Modernizing Total Hip Arthroplasty Perioperative Pathways: The Implementation of ERAS-Outpatient Protocol

Abstract

Pressure to reduce healthcare costs, limited hospital availability along with improvements in surgical technique and perioperative care motivated many centers to focus on outpatient pathway implementation. However, in many short-stay protocols, the focus has shifted away from aiming to reduce complications and improved rehabilitation, to using length of stay as the main factor of success. To improve patient outcomes and maintain safety, the best way to implement a successful outpatient program would be to combine it with the principles of enhanced recovery after surgery (ERAS), and to improve patient recovery to a level where the patient is able to leave the hospital sooner. This article delivers a case for modernizing total hip arthroplasty perioperative pathways by implementing ERAS-outpatient protocols.

A low dislocation rate after revision total hip arthroplasty performed through the anterior approach

“…As these complications happened in two obese patients, we strongly believe that care must be taken when rTHA is done in this patient population. Preoperative aqueous chlorhexidine gluconate (4%) shows, the day before the operation, appropriate antibiotic prophylaxis before incision and daily wound care are essential to reduce this risk [26][27][28].…”

Fast Track Protocols and Early Rehabilitation after Surgery in Total Hip Arthroplasty: A Narrative Review

“…Moreover, people with serious coagulation disorders or systemic diseases that may call for intensive care, numerous transfusions, or dialysis must be removed from the program. Another reason for exclusion could be the lack of nearby medical services or transportation issues since social and logistical support is of paramount importance in the period close to surgery to ensure a consonant rehabilitation pathway [ 24 ].…”

“…Traditionally, patients referred to a Fast Track protocol were young and fit. However, these limitations have been progressively overcome because of the implementation of minimally invasive surgical techniques and optimized anesthesiologic procedures; therefore, more patients are nowadays considered suitable for ERAS protocols in THA [ 24 ]. Ultimately, the objective is to select a patient that is functionally healthy pre-operatively, regardless of sex and age, that can withstand the surgery that is planned with minimal biological stress [ 24 ].…”

“…However, these limitations have been progressively overcome because of the implementation of minimally invasive surgical techniques and optimized anesthesiologic procedures; therefore, more patients are nowadays considered suitable for ERAS protocols in THA [ 24 ]. Ultimately, the objective is to select a patient that is functionally healthy pre-operatively, regardless of sex and age, that can withstand the surgery that is planned with minimal biological stress [ 24 ]. Overall, the standard inclusion criteria for THA surgery include primary surgery, ASA I-II, BMI <35, no pulmonary or cardiac functional limitation, previous normal hematocrit, no history of pulmonary embolism or deep vein thrombosis within the last six months, a limited requirement for urinary catheter positioning, preoperative normal cognitive function, and adequate home support [ 25 , 26 ].…”

“…Diabetes is a common comorbidity among obese patients. A pre-operative work-up is of the utmost importance in trying to reduce HbA1c below the 8% threshold associated with a higher incidence of wound complications and infections [ 24 ].…”