Effects of Enhanced Recovery After Surgery in Total Knee Arthroplasty for Patients Older Than 65 Years

Abstract

Objectives To explore the safety and efficacy of the enhanced recovery after surgery (ERAS) program for elderly total knee arthroplasty (TKA) patients. Methods A prospective controlled study was conducted for patients older than 65 years, who would undergo unilateral TKA with a minimum follow‐up of 2 years. Patients were divided into an ERAS group (n = 106) and a traditional group (n = 141) based on the patients’ willingness to participate in the ERAS program. Baseline parameters of American Society of Anesthesiologists classification and comorbidity were recorded. Complication, mortality, knee function assessment using knee society score and knee range of motion, and perioperative clinical outcomes were compared between the two groups. Results There were no significant differences between the two groups in terms of baseline parameters. Although no significant differences were found in postoperative nausea and vomiting, urinary tract infection, deep venous thrombosis, pulmonary embolism, wound delayed healing, superficial infection, and deep infection, there were significantly fewer total complications in the ERAS group (26/106 vs 52/141; P = 0.039). No significant difference was found in short‐term mortality (1/106 vs 3/141; P = 0.836) between the two groups. There were no significant differences in preoperative visual analogue scale (VAS), knee society score (KSS), and range of motion (ROM) between the two groups. Lower VAS scores were found in the ERAS group at time of postoperative day (POD) 1 (P = 0.012) and POD 5 (P = 0.020); no significant differences were observed at time of postoperative month (POM) 1 and final follow‐up. Higher KSS scores were found in the ERAS group at time of POD 1 (P = 0.013), and POD 5 (P = 0.011), no significant differences were observed at time of POM 1 and final follow‐up. Increased ROM degree was found in the ERAS group at time of POD 1 (P = 0.021); no significant differences were observed at time of POD 5, POM 1 and final follow‐up. Decreased intraoperative blood loss (P < 0.001), total blood loss (P < 0.001), transfusion rate (P = 0.004), and length of stay (P < 0.001) were found in the ERAS group; no significant differences were found in operative time and hospitalization costs between the two groups. Conclusion The ERAS program is safer and more efficacious in elderly TKA patients compared to the traditional pathway. It could effectively relieve perioperative pain and improve joint function, and reduce blood transfusion, length of stay, and total complications without increasing short‐term mortality.

Core Outcome Measurement Instruments for Clinical Trials of Total Knee Arthroplasty: A Systematic Review

“…Reliability parameters were reported in 11 (85%) instruments. The KOOS [ 55 ], OKS [ 13 , 30 ], HSS [ 51 , 69 ], GDS [ 73 ], HADS [ 10 , 17 , 52 , 82 , 87 ], PCS [ 82 ] and NRS pain [ 83 ] had positive ratings in terms of the intra-class correlation coefficient (ICC), generally ranging from 0.7 to 0.9, based on some studies. However, the WOMAC [ 63 ], SF-36 [ 62 ], and SF-12 [ 62 ] had indeterminate ratings based on several studies.…”

“…The KSS [29,70] and PCS [82] received indeterminate ratings mostly due to the lack of pre-defined hypotheses and confirmation of less than 75% of the hypotheses. Finally, the HSS [51,69] and STAI [72] obtained negative assessments.…”

“…Based on more than one study, the KOOS [37,40,73,78,79], WOMAC [8,18,34,63,79,89], OKS [30,42,90], SF-36 [7,8,27,34,35,75,88], and SF-12 [7,28,34,38,88] had positive ratings. The HADS [10,17,52,82,87] and HSS [51,69] had indeterminate ratings in nearly all studies because some subscales did not meet the 15% cut-off point.…”

Enhanced recovery after surgery on multiple clinical outcomes

“…[ 90 , 93 – 95 ] In THA and TKA, the prevalence of complications was 24.5% in ERAS group whilst 36.9% in the traditional group ( P = .039). [ 94 ] In addition, the rate of readmission for THAs performed under the ERAS pathway was almost one-third of that of traditional care. [ 90 ] What is more, the 30-days and 90-days mortality were reduced both in THA and TKA, [ 93 , 95 ] and the reduction is 0.5% to 0.1% ( P = .02), 0.8% to 0.2%, ( P = .01) respectively.…”

“…[ 95 ] Although the ERAS group had a higher prevalence of co-morbidities such as hypertension, ischemic heart disease, chronic obstructive pulmonary disease (COPD) and type-2 diabetes, cardiac ischemic events were lesser in the postoperative compared with traditional group. [ 95 ] In the latest paper, the morbidity was also reduced in the TKA for patients older than 65 years [ 94 ] but the mortality was similar in the control group. So the ERAS pathways are safe and effective in orthopedic surgery.…”