Enhanced Recovery after Total Joint Arthroplasty (TJA): A Contemporary Systematic Review of Clinical Outcomes and Usage of Key Elements

Abstract

Background Enhanced recovery after surgery (ERAS) is a pathway designed to improve the care of surgical patients and achieve early recovery. The clinical outcomes and usage of key elements of ERAS pathways in total joint arthroplasty (TJA) need further reanalysis. This article aims to provide an overview of the latest clinical outcomes and current usage of key elements of ERAS pathways in TJA. Methods We undertook a systematic review of the PubMed, OVID, and EMBASE databases in February 2022. Studies investigating the clinical outcomes and usage of key elements of ERAS in TJA were included. The components of successful ERAS programs and their usage were further determined and discussed. Results Twenty‐four studies involving 216,708 patients assessed ERAS pathways for TJA. A total of 95.8% (23/24) of studies reported a reduced length of stay (LOS), followed by reduce overall opioid consumption or pain (87.5% [7/8]), save costs (85.7% [6/7]), improvements in patient‐reported outcomes or functional recovery (60% [6/10]), and reduced incidence of complications (50% [5/10]). In addition, preoperative patient education (79.2% [19/24]), anesthetic protocol (54.2% [13/24]), use of local anesthetics for infiltration analgesia or nerve blocks (79.2% [19/24]), perioperative oral analgesia (66.7% [16/24]), perioperative surgical factors including reduced use of tourniquets and drains (41.7% [10/24]), use of tranexamic acid (41.7% [10/24]) and early mobilization (100% [24/24]) were contemporary comparatively “active” components of ERAS. Conclusions ERAS for TJA has favorable clinical outcomes in terms of reducing LOS and overall pain, saving costs, accelerating functional recovery, and reducing complications, although the evidence is still low in quality. In the current clinical scenario, only some “active” components of the ERAS program are widely used.

Prevalence and Clinical Burden of Venous Thromboembolic Events (VTEs) in Contemporary Total Knee Arthroplasties (TKAs) in US Hospitals

“…Patients who are partially or fully functionally dependent or require active support face challenges with mobility, leading to prolonged periods of immobilization and increased DVT risk post-TKA [29][30][31]. Our study revealed that being partially or completely dependent on preoperative mobilization can elevate DVT risk by a factor of 5, emphasizing the need for interventions like physical therapy and early ambulation programs to mitigate this risk among vulnerable TKA patients [32,33]. Furthermore, there is a growing interest in the literature regarding the relationship between patient mobilization and pulmonary embolism (PE) risk [18,34,35].…”

Causes and risk factors for same-day discharge failure after total hip and knee arthroplasty: a meta-analysis

“…All the factors studied in this meta-analysis could be considered and influenced the Enhanced Recovery After Surgery (ERAS) protocol, which is a comprehensive approach designed to optimize the care of surgical patients by implementing evidence-based strategies before, during, and after surgery 30 . It has been observed that only some components of the ERAS program are widely implemented in current clinical practice 30 . This approach aims to minimize surgical stress, maintain physiological function, and accelerate recovery to improve outcomes and reduce hospital stay 30 .…”

“…It has been observed that only some components of the ERAS program are widely implemented in current clinical practice 30 . This approach aims to minimize surgical stress, maintain physiological function, and accelerate recovery to improve outcomes and reduce hospital stay 30 . ERAS protocols in joint replacement surgery have been associated with a reduced length of hospital stay, decreased pain, cost savings, improved patient-reported outcomes, and decreased incidence of complications, although the quality of evidence remains low 30 .…”

“…This approach aims to minimize surgical stress, maintain physiological function, and accelerate recovery to improve outcomes and reduce hospital stay 30 . ERAS protocols in joint replacement surgery have been associated with a reduced length of hospital stay, decreased pain, cost savings, improved patient-reported outcomes, and decreased incidence of complications, although the quality of evidence remains low 30 . Some of the recommendations of this protocol include preoperative education, optimization of certain factors (smoking, alcohol, anemia), preoperative fasting, standard anesthesia protocols, use of local anesthetics for pain control, prevention of nausea and vomiting, management of perioperative blood loss with tranexamic acid, oral analgesia, maintenance of normothermia, antimicrobial and antithrombotic prophylaxis, perioperative surgical factors, fluid management, postoperative nutritional care, and early mobilization 31 .…”

Pre-emptive infiltration with betamethasone and ropivacaine for postoperative pain in laminoplasty and laminectomy (PRE-EASE): a prospective randomized controlled trial

“…LIA has also been described by Chen et al . 37 to have several advantages over nerve block such as, the absence of motor blockade and interference on muscle strength leading to early mobilization and recovery for enhanced recovery after surgery (ERAS) following total joint arthroplasty. However, the addition of corticosteroids to LIA was not explored in this review, which we believe to have added benefits to this simple and inexpensive regional anesthesia technique.…”