Update on Current Enhanced Recovery After Surgery (ERAS) Pathways for hip and Knee Arthroplasty

A Review of the Literature

Om V. Patel, MD; Giles R. Scuderi, MD


Curr Orthop Pract. 2022;33(2):178-185. 

In This Article

Abstract and Introduction


Enhanced recovery after surgery (ERAS) pathways for total hip and knee arthroplasty require continuous, comprehensive updates with the most current evidence-based guidelines. Guidelines are rapidly evolving in this topic because of interest in rapid recovery and outpatient total joint arthroplasty. This review article summarizes current literature to provide recommendations involving preoperative patient education and patient optimization, preoperative fasting and carbohydrate loading, analgesia, mode of anesthesia, intraoperative temperature management, hemostasis, postoperative nausea and vomiting management, early mobilization, and thromboprophylaxis. By promoting consensus, the authors aim to improve ERAS utilization and ultimately improve patient outcomes while also decreasing lengths of stay.


Enhanced recovery after surgery (ERAS) is gaining popularity in hip and knee arthroplasty as joint replacement volumes continue to increase at rapid rates. Some projections anticipate total hip (THA) and total knee (TKA) arthroplasty to increase by 174% and 673%, respectively from 2015 to 2030.[1] Simultaneously, value-based care that focuses on improving outcomes and patient satisfaction while also reducing costs is becoming increasingly important. This highlights the importance of instituting and maintaining an exemplar ERAS protocol.

ERAS programs were developed with the goal of maintaining the patient's normal physiology and optimizing their outcomes without increasing postoperative complications. This is achieved by a multifaceted comprehensive approach that impacts the physical and mental aspects of surgery. The tenets of ERAS include preoperative education and counseling, patient optimization, nutritional strategies, regional anesthesia, multimodal pain management, venous thromboembolism (VTE) prophylaxis, and early mobilization (Table 1).

Broad components of ERAS include evidence-based clinical protocols, encouragement of patient engagement, and optimization of care pathways.[2] Adherence to the components of an ERAS program is critical to its success because it has been shown that the greater use of ERAS components in hip and knee arthroplasty is associated with fewer complications and shorter hospital stays.[3] An adherence of greater than 62.5% was associated with a decrease in postoperative complications a multihospital study of 6000 joint arthroplasty patients.[4] Perhaps the best way to improve adherence is through consensus utilizing evidence-based medicine. The goal of this review was to provide an update to the current ERAS pathways and recommendations for total hip and knee arthroplasty based on current available literature. Institutional board of review approval was not required for this review of literature.