Update on ERAS Pathways for Hip and Knee Arthroplasty

In This Article

Abstract and Introduction

Abstract

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.

Introduction

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.

Table 1. Components of enhanced recovery after surgery (ERAS)
Surgical phase	Intervention
Preoperative phase
Education	Preoperative education, counseling, and education
Optimization	Tobacco cessation at least 6 to 8 wk prior to surgery
	Alcohol cessation for at-risk drinkers
	Identification and correction of anemia
	Identification and management of medical comorbidities
Fasting guidelines	Light solid meal up to 6 hr before surgery
	Clear liquids up to 2 hr prior to surgery
	Clear carbohydrate liquid supplement 2 hr prior to surgery (avoid in type-1 diabetics)
Analgesia	Multimodal analgesia (acetaminophen, NSAIDs)
Intraoperative phase
Anesthesia	Regional anesthesia or modern general anesthesia
Antibiotic therapy	Weight-adjusted antibiotic dosage (preferably first-generation cephalosporin)
Hemostasis	Use of tranexamic acid
Temperature	Maintenance of normothermia
Postoperative phase
Early mobilization	Initiate ambulation as early as possible following surgery
	Establish objective discharge criteria to promote discharge to home
Analgesia	Multimodal pain management
Avoid nausea and vomiting	Intraoperative dexamethasone
	Optimize oral hydration (consider carbohydrate drinks)
	Use of antiemetic medication
VTE prophylaxis	Chemoprophylaxis
	Pneumatic compression devices
	Early mobilization

NSAIDs, nonsteroidal anti-inflammatory drugs; VTE, venous thromboembolism.

Table 2. Modifiable risk factors and optimization
Condition or risk factor	Optimization
Diabetes mellitus	Check HgbA1c and fasting blood glucose
	Tight glycemic control
Obesity	Calculate the BMI and consider weight reduction program if not ideal
Malnutrition	Nutritional screening, education and supplementation if needed
Smoking	Tobacco cessation at least 6 to 8 wk prior to surgery
Anemia	Check hemoglobin and hematocrit
	Determine etiology of anemia and correct prior to surgery
Rheumatoid arthritis	DMARDs continue through surgery
	Biologic agents: stop prior to surgery and schedule at the end of dosing cycle
	Resume after a minimum of 14 days after surgery in the absence of wound problem