Orthopaedics

Current status

The first orthopaedic surgeries to use enhanced recovery pathways were total hip arthroplasty (THA) and total knee arthroplasty (TKA).  These procedures were chosen as they were high volume, had long hospital length of stays, and carried high costs. Enhanced recovery pathways were first widely adopted in countries such as Denmark and the United Kingdom (UK) through the use of centrally organised improvement programs. Their success led to international spread, and enhanced recovery is now broadly accepted as best practice for hip and knee arthroplasty surgeries.

Enhanced recovery pathways aim to reduce a patient’s recovery time following surgery, and improve patient outcomes. To do this, orthopaedic enhanced recovery pathways encourage the patient to be active in the process of their recovery. Multi-disciplinary teams focus on combining the evidence-based clinical steps with the required process and system changes, so that care is consistent for each patient.  Logistical processes as well as clinical steps are optimised for each patient, so that post-operative recovery is quickened, and complications, adverse events and morbidity are reduced.

The over-arching principles of an orthopaedic ERAS pathway can be divided into four stages.  At the pre-operative stage the focus is on optimisation of pre-operative physical and psychological, such as the identification and management of anaemia, and use of pre-operative education and counselling. Additionally, pre-emptive organisation of discharge arrangements is important. Intra-operatively, atraumatic surgical techniques are used; anaesthesia and analgesia protocols are standardised, multimodal opioid sparing analgesia regimes are adopted; blood loss is spared; normovolemia and normothermia are promoted, and hypoxia prevented. Post-operatively, early ambulation with effective analgesia is essential (avoiding opioids where feasible); catheters, drains and drips are not used or removed as soon as possible; and patients are encouraged to eat and drink early, and wash, dress and socialise as soon as possible.  All patients are discharged home, using agreed criteria managed by the multi-disciplinary team; with clear instructions and support on progressing independently.

ERAS pathways have been so successful in reducing length of stay that there is now a growing trend and evidence for outpatient surgery for THA and TKA. Currently, outpatient arthroplasty can be a safe and effective procedure for carefully selected patients, however more research is required in order to critically examine its safety and potential cost-savings for all patients.

Future directions

Whilst outcomes have improved dramatically in the last ten years, challenges remain in order to achieve widespread adoption and implementation of what is already known, and there are future research challenges in order to improve our understanding of the pathophysiology of factors effecting recovery, such as the inflammatory response and pain, and the most effective rehabilitation regimes. The ERAS Society Guidelines, in both hip and knee, and also lumbar spine fusion, will hopefully help to bridge both the implementation gap for those new to enhanced recovery, and help to consolidate the current heterogeneous evidence base, where direct comparison of enhanced recovery components is difficult with so many differences in the pathways currently used.

In addition, the application and development of enhanced recovery in other elective and emergency orthopaedic procedures (such as hip fracture and shoulder arthroplasty) is an exciting and emerging area that looks set to bring the benefits of enhanced recovery to even more orthopaedic patients.