{'fraction_non_alphanumeric': 0.015498330948974726, 'fraction_numerical': 0.003814973772055317, 'mean_word_length': 5.788025889967638, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Does Anesthetic Technique Influence the Incidence of Surgical Site Infection in Total Joint Arthroplasty?

The current health care environment rewards health systems for the delivery of high-value care. Anesthetic departments may struggle to identify high-value practices because of the lack of granular tools to define and measure characteristics related to quality and costs. Therefore, we are immediately drawn to anesthetic techniques that might be associated with reduced complications and reduced costs. In this issue of Regional Anesthesia and Pain Medicine, Zorilla-Vaca and colleagues synthesize data comparing neuraxial and general anesthetic techniques and their effects on the rate of surgical site infection (SSI) in patients undergoing knee or hip arthroplasty. Although not nearly as associated with mortality as other hospital-acquired infections, SSIs are costly to both the patient and the health system, potentially leading to prolonged length of stay, unplanned readmissions, or reoperation. Over the years, many investigators have compared outcomes after regional versus general anesthesia for a myriad of surgeries and patient cohorts. Regional anesthesiologists have long sought to place ourselves and our preferred techniques at the forefront of strategies to reduce perioperative morbidity and mortality. Following the relatively small 1987 study by Yeager and colleagues, in which mortality was less common in high-risk surgery patients receiving epidural analgesia, various studies (only a very few of which we mention here) have suggested that regional anesthetic techniques can reduce the inflammatory changes associated with surgery, enhance functional recovery, improve cardiopulmonary and gastrointestinal function, optimize coagulation profiles, and reduce the incidence of cancer recurrence. Given the potential devastating impact of SSIs after total joint arthroplasty, it is exciting to consider whether specific anesthetic techniques beyond maintaining normothermia and timely antibiotic administration might reduce the likelihood of SSI. Zorilla-Vaca and colleagues combined 13 studies with a total patient population of 362,029 in a meta-analytic technique and determined that neuraxial anesthesia was associated with a reduced incidence of SSI in patients undergoing hip or knee arthroplasty. However, given that these results support many of our preconceived beliefs, we are obligated to scrutinize them carefully. The authors acknowledge the lack of randomized controlled trials in their analysis as a limitation to their findings. Because of the constant threat from unmeasured and unadjusted confounding, randomized trials and ultimately meta-analysis are necessary if we wish to definitively identify an impact of a specific anesthetic type on SSI. Although several biologically plausible theories linking neuraxial anesthetics to infection prevention have been suggested, such as improved tissue oxygenation and reductions in inflammation, no definitive mechanisms have been elucidated. The provision of an anesthetic, whether general or neuraxial, has become so safe that we expect our patients to emerge with few or no adverse effects. Serious complications directly attributable to anesthesia are now rare. As a consequence, simply ushering patients through an anesthetic and delivering them to the recovery room seemingly unharmed and in their preoperative state of health may no longer be sufficient tomeasure anesthesia quality. New expectations for good anesthetic practice include an anesthetic specifically tailored to a patient's conditions and surgical intervention, chosen using valid medical evidence, and with an eye toward enhanced recovery. As suggested in 2009, an “exciting new dimension of anesthesia” includes the exploration of long-term consequences and those outside the immediate perioperative period. Zorilla-Vaca and colleagues have provided us with yet another good reason to prefer neuraxial rather than general anesthesia for total joint arthroplasty. We eagerly await future investigations that will confirm this outcome benefit and provide us with a definitive mechanistic explanation for these very welcome findings.