Key Elements of Enhanced Recovery after Total Joint Arthroplasty: A Reanalysis of the Enhanced Recovery after Surgery Guidelines

Abstract

Recent guidelines have produced a consensus statement for perioperative care in hip and knee replacement. However, there is still a need for reanalysis of the evidence and recommendations. Therefore, we retrieved and reanalyzed the evidence of each recommended components of enhanced recovery after surgery (ERAS) based on the guidelines of total joint arthroplasty. For each one, we included for the highest levels of evidence and those systematic reviews and meta‐analyses were preferred. The full texts were analyzed and the evidence of all components were summarized. We found that most of the recommended components of ERAS are supported by evidence, however, the implementation details of each recommended components need to be further optimized. Therefore, implementation of a full ERAS program may maximize the benefits of our clinical practice but this combined effect still needs to be further determined.

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

“…Furthermore, only two studies 13 , 36 supported the use of specific surgical approaches and reduced or abandoned the use of tourniquets and drains. Though surgical approach is hotly discussed in TJA, the preferred surgical approach was not highlighted or recommended in the guidelines as well as recent publications 6 , 10 ; of which, subvastus approach for TKA was reported to have increased ROM at 6 months post‐surgery and short‐term recovery favors limited incision over standard incision for THA. 49 , 50 Thus, the surgical approach that could support ERAS still remains controversial.…”

“…Others found that the ERAS pathway reduced LOS after primary TJA but had minimal to no impact on perioperative complications 9 . In addition, the performance and importance of individual components in TJA remain controversial, and the available evidence in the literature has not been systematically reviewed until now 10 . Therefore, the aims of this study are (1) to reanalyze the contemporary performance and clinical outcomes of ERAS in TJA and (2) to evaluate the current usage of ERAS components in TJA and determine the “active” components.…”

Multidisciplinary approach toward enhanced recovery after surgery for total knee arthroplasty improves outcomes

“…Although ERAS protocols have been shown to decrease mortality, need for blood and blood component transfusion, complication rate, and length of stay, studies have identified at least 17 specific elements, and optimizing their usage in clinical scenarios would be guided by future studies[ 36 ]. These elements comprise preoperative components of (1) “preoperative information, education and counseling”; (2) “preoperative optimization of smoking, alcohol consumption and anemia”; and (3) optimum preoperative fasting[ 36 ].…”

“…Although ERAS protocols have been shown to decrease mortality, need for blood and blood component transfusion, complication rate, and length of stay, studies have identified at least 17 specific elements, and optimizing their usage in clinical scenarios would be guided by future studies[ 36 ]. These elements comprise preoperative components of (1) “preoperative information, education and counseling”; (2) “preoperative optimization of smoking, alcohol consumption and anemia”; and (3) optimum preoperative fasting[ 36 ]. The intraoperative components include: (1) A standardized anesthesia protocol; (2) local anesthetic infiltration and specific nerve blocks; (3) prevention of postoperative nausea and vomiting; (4) reducing perioperative blood loss with use of tranexamic acid; (5) perioperative analgesia including use of paracetamol; (6) ensuring normothermia; (7) optimum antibiotic prophylaxis; (8) perioperative fluid management; and (9) modulating surgical factors[ 36 ].…”

“…These elements comprise preoperative components of (1) “preoperative information, education and counseling”; (2) “preoperative optimization of smoking, alcohol consumption and anemia”; and (3) optimum preoperative fasting[ 36 ]. The intraoperative components include: (1) A standardized anesthesia protocol; (2) local anesthetic infiltration and specific nerve blocks; (3) prevention of postoperative nausea and vomiting; (4) reducing perioperative blood loss with use of tranexamic acid; (5) perioperative analgesia including use of paracetamol; (6) ensuring normothermia; (7) optimum antibiotic prophylaxis; (8) perioperative fluid management; and (9) modulating surgical factors[ 36 ]. The postoperative interventions include: (1) Thromboprophylaxis; (2) postoperative nutrition; (3) early mobilization; (4) criteria-based discharge; and (5) continuous audit and improvement[ 36 ].…”