Enhanced Recovery After Primary Total Hip and Knee Arthroplasty

Abstract

Background:Enhanced Recovery After Surgery (ERAS) has become increasingly implemented to reduce costs, to increase efficiency, and to optimize patient outcomes after a surgical procedure. This study aimed to systematically review the effect of ERAS after primary elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) on hospital length of stay, total procedure-related morbidity, and readmission.Methods:A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and with guidance from the Cochrane Handbook for Systematic Reviews of Interventions. MEDLINE, Embase, and Cochrane databases were searched from inception (1946 for MEDLINE and 1974 for Embase; Cochrane is a composite of multiple databases and thus does not report a standard inception date) until January 15, 2020. Prospective nonrandomized cohort studies and randomized controlled trials comparing adult patients undergoing elective primary THA or TKA with ERAS or traditional protocols were included. Articles examining outpatient, nonelective, or revision surgical procedures were excluded. Two reviewers independently assessed the risk of bias and extracted data. The primary outcome was length of stay. The secondary outcomes included total procedure-related morbidity and readmission.Results:Of the 1,018 references identified (1,017 identified through an electronic search and 1 identified through a manual search), 9 individual studies met inclusion criteria. Data were reported from 7,789 participants, with 2,428 receiving ERAS and 5,361 receiving traditional care. Narrative synthesis was performed instead of meta-analysis, given the presence of moderate to high risk of bias, wide variation of ERAS interventions, and inconsistent methods for assessing and reporting outcomes among included studies. Adherence to ERAS protocols consistently reduced hospital length of stay. Few studies demonstrated reduced total procedure-related morbidity, and there was no significant effect on readmission rates.Conclusions:ERAS likely reduced the length of stay after primary elective THA and TKA, with a more pronounced effect in selected healthier patient populations. We found minimal to no impact on perioperative morbidity or readmission. The quality of existing evidence was limited because of study heterogeneity and a significant risk of bias. Further high-quality research is needed to definitively assess the impact of ERAS on total joint arthroplasty.Level of Evidence:Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Comparison of serum inflammatory indicators and radiographic results in MAKO robotic-assisted versus conventional total knee arthroplasty for knee osteoarthritis: a retrospective study of Chinese patients

“…Patients in both groups received the same treatment, which included an intravenous injection and topical infusion of tranexamic acid [ 12 ]. Postoperatively, both groups adopted the clinical pathway of Enhanced Recovery After Surgery (ERAS) [ 13 ]. Anti-infectives, analgesics and anticoagulants were administered to patients in both groups.…”

Introduction of an enhanced recovery programme for total shoulder arthroplasty: report of a novel pathway

“… 4 5 A 2016 systematic review and meta-analysis of ER in total hip arthroplasty (THA) and total knee arthroplasty (TKA) showed significantly reduced LOS without significantly impacting 30-day readmission rates or complication rates. 6 A more recent systematic review and narrative synthesis in 2021 7 of THA and TKA also found that adherence to ER protocols consistently reduced LOS. Moderate confidence in the results of these reviews is suggested using AMSTAR-2 (A MeaSurement Tool to Assess systematic Reviews-2).…”

Preoperative optimisation in fast-track and enhanced recovery after surgery (ERAS) programs for total hip and knee joint replacement: a systematic review protocol

“…10-14 Thus, some studies have investigated pre-operative interventions that aim to optimise THR/TKR outcomes via targeting known modifiable risk factors. 15-17…”

“…29 30 A recent systematic review has shown that ERAS protocols significantly reduce the length of hospital stay after THR and TKR, and treatment costs, although the effect on mortality rate remains unclear. 15 However, pre-operative optimisation was not embedded in all included studies and the intervention details (i.e., type, duration, frequency of interventions) were not clearly revealed. Similarly, a recent consensus statement for perioperative care in THR and TKR provided recommendations for pre-operative optimisation but the details of the interventions were absent, 31 and some recommendations (i.e., cessation of alcohol consumption and smoking) were not based on data from fully implemented ERAS for THR/TKR.…”

“…[10][11][12][13][14] Thus, some studies have investigated pre-operative interventions that aim to optimise THR/TKR outcomes via targeting known modifiable risk factors. [15][16][17] The concept of pre-operative multimodal/multidisciplinary optimisation is not new, and the scope has expanded to incorporate principles of shared decision making. [18][19][20][21][22][23] Although relatively sparse compared with other surgical specialities, optimisation programs for THR and TKR, such as pre-operative rehabilitation (prehabilitation), fast-track or enhanced recovery after surgery (ERAS) protocols have been developed and tested.…”