Enhanced recovery after surgery for major orthopedic surgery: a narrative review

Abstract

Background With increasing interest in enhanced recovery after surgery (ERAS), the literature on ERAS in orthopedic surgery is also rapidly accumulating. This review article aims to (1) summarize the components of the ERAS protocol applied to orthopedic surgery, (2) evaluate the outcomes of ERAS in orthopedic surgery, and (3) suggest practical strategies to implement the ERAS protocol successfully. Main body Overall, 17 components constituting the highly recommended ERAS protocol in orthopedic surgery were identified. In the preadmission period, preadmission counseling and the optimization of medical conditions were identified. In the preoperative period, avoidance of prolonged fasting, multimodal analgesia, and prevention of postoperative nausea and vomiting were identified. During the intraoperative period, anesthetic protocols, prevention of hypothermia, and fluid management, urinary catheterization, antimicrobial prophylaxis, blood conservation, local infiltration analgesia and local nerve block, and surgical factors were identified. In the postoperative period, early oral nutrition, thromboembolism prophylaxis, early mobilization, and discharge planning were identified. ERAS in orthopedic surgery reduced postoperative complications, hospital stay, and cost, and improved the patient outcomes and satisfaction with accelerated recovery. For successful implementation of the ERAS protocol, various strategies including the standardization of care system, multidisciplinary communication and collaboration, ERAS education, and continuous audit system are necessary. Conclusion The ERAS pathway enhanced patient recovery with a shortened length of stay, reduced postoperative complications, and improved patient outcomes and satisfaction. However, despite the significant progress in ERAS implementation in recent years, it has mainly focused on major surgeries such as arthroplasty. Therefore, further efforts to apply, audit, and optimize ERAS in various orthopedic surgeries are necessary.

Key Components, Current Practice and Clinical Outcomes of ERAS Programs in Patients Undergoing Orthopedic Surgery: A Systematic Review

“…In these RCTs, patient education and pre-emptive anesthetics and analgesics were the main pre-operative ERAS elements. A preoperative ERAS element of key importance little considered in these studies was the nutritional status [ 196 ]. in only two RCTs, it was reported that carbohydrate loading with a clear carbohydrate liquid 2 h prior to surgery was used in order to present the patient to surgery in a metabolically fed state leading to less postoperative protein loss and preservation of muscle mass [ 196 ].…”

“…A preoperative ERAS element of key importance little considered in these studies was the nutritional status [ 196 ]. in only two RCTs, it was reported that carbohydrate loading with a clear carbohydrate liquid 2 h prior to surgery was used in order to present the patient to surgery in a metabolically fed state leading to less postoperative protein loss and preservation of muscle mass [ 196 ]. This is probably due to the fact that this ERAS element requires special attention for those patients with specific comorbidities, such as obesity and diabetes, pathological conditions more common in aged patients [ 196 ].…”

“…in only two RCTs, it was reported that carbohydrate loading with a clear carbohydrate liquid 2 h prior to surgery was used in order to present the patient to surgery in a metabolically fed state leading to less postoperative protein loss and preservation of muscle mass [ 196 ]. This is probably due to the fact that this ERAS element requires special attention for those patients with specific comorbidities, such as obesity and diabetes, pathological conditions more common in aged patients [ 196 ]. Considering the intra-operative elements in the 24 RCTs, neuraxial anesthesia was frequently preferred to general anesthesia as well as multimodal analgesia, TXA use and urinary catheters and drainage avoidance or removal within 24 h after surgery.…”

“…Considering the intra-operative elements in the 24 RCTs, neuraxial anesthesia was frequently preferred to general anesthesia as well as multimodal analgesia, TXA use and urinary catheters and drainage avoidance or removal within 24 h after surgery. Although normothermia has been considered part of the anesthetic management in ERAS programs, no RCTs considered this aspect [ 3 , 196 , 197 ]. Hypothermia is common in patients who have undergone orthopedic surgery and may increase infection, coagulopathy, blood transfusion rate, cardiovascular complications, and opioid need, which may adversely affect the postoperative outcome [ 196 ].…”

“…Although normothermia has been considered part of the anesthetic management in ERAS programs, no RCTs considered this aspect [ 3 , 196 , 197 ]. Hypothermia is common in patients who have undergone orthopedic surgery and may increase infection, coagulopathy, blood transfusion rate, cardiovascular complications, and opioid need, which may adversely affect the postoperative outcome [ 196 ]. Finally, in the post-operative phase, the main ERAS elements used in this RCT were early mobilization, opioid-sparing multimodal analgesia and thromboprophylaxis.…”