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


Preoperative Education, Counseling, and Expectations

Objective evidence correlating preoperative education and counseling to improved outcomes is lacking. However, many systematic reviews have reported decreased patient anxiety and emotional stress with implementation of patient engagement protocols, especially in those with preexisting anxiety, depression, and unrealistic expectations.[5] Patient engagement includes education, expectation management, portraying confidence, and providing appropriate motivation and support.[2] Expectations were found to be discordant between patients and surgeons, with up to 52% of patients displaying greater expectations than their surgeon regarding postoperative pain, function, and expected level of activity.[6] Although realistic expectations have not been correlated with better outcomes, it has been associated with improved patient satisfaction scores.[7]

Most surgeons routinely implement some form of basic education during their clinical visit when discussing risks, benefits, and expectations of the planned procedure. The extent, however, is variable from surgeon to surgeon. Time, cost, and coordination are real barriers associated with improving preoperative education. To provide further education, several variations of joint replacement courses are offered and are sometimes coordinated by large specialty groups or hospitals. Studies do show objective benefit such as a 27% reduction in hospital costs and decreased hospital length of stay (LOS) in addition to improved patient satisfaction with these courses.[8] The recent advent of web-based platforms and apps provides a promising solution to the issue of time, cost, and coordination by creating a platform for nearly limitless information away from clinical time. A recent randomized control trial found that interactive web-based education improved patient satisfaction scores after outpatient orthopaedic surgery.[9] It is too early to recommend for or against the implementation of a web-based education and tracking tool for joint arthroplasty; however, interest is gaining.

A commonly overlooked aspect of preoperative education is determination of home social support. Identifying at-risk individuals and coordinating care preoperatively could decrease social barriers to discharge leading to decreased LOS, readmissions, costs, and adverse outcomes associated with discharge to extended care facilities.[10] Furthermore, patient expectations greatly influence discharge disposition,[11] highlighting the importance of education. Preoperative education component of an ERAS pathway inherently holds minimal patient risk and thus should be incorporated when feasible.

Patient Optimization

Strategies to identify and address modifiable patient risk factors is essential to a successful ERAS program and can help reduce complications and LOS.[12] Table 2 provides a summary of modifiable risk factors and recommended interventions to optimize the patient before total joint arthroplasty (TJA). Although some institutions have placed "hard stops" on specific patient conditions, such as body mass index (BMI) or hemoglobin (Hgb) A1c, it is prudent to assess each patient individually, identify the factors, and include the patient in a shared decision-making plan.

Preoperative Fasting and Carbohydrate Loading

The classic notion to begin fasting the midnight before surgery to prevent pulmonary complications has been challenged by a multitude of studies. The most recent consensus statement put forth in 2020 by the ERAS Society recommends intake of clear fluids until 2 hr before the induction of anesthesia and a 6-hour fast for solids. This was given a strong recommendation based on a moderate level of evidence.[13] This recommendation also was supported by the most recent practice guidelines of The American Society of Anesthesiologists set forth in March 2017.[14]

Carbohydrate loading with a clear, carbohydrate-rich supplement 2 to 3 hr prior to surgery has shown benefits of accelerated recovery after colorectal surgery;[15,16] however, this has not been seen clearly in joint arthroplasty because of a lack of literature.[17] Surgery induces physiological stress which promotes peripheral insulin resistance. It is believed that preoperative glucose loading in the form a carbohydrate-rich drink induces an insulin response to protect against perioperative hyperglycemia. Hyperglycemia, in turn, may lead to postoperative complications and prolonged recovery.[18] Aside from reducing insulin resistance, carbohydrate loading leads to general patient satisfaction including reduced thirst, hunger, and anxiety which can improve a patient's overall wellbeing.[19] There is question of whether it is the carbohydrate-rich nature of the drink that allows for improved recovery or simply the fluid volume status of the patient that confers benefit. A recent meta-analysis by Amer et al.[20] involving 43 randomized controlled trials (RCT) did show decreases LOS for patients receiving high-dose and low-dose carbohydrate-rich supplements (0.4 days and 0.2 days, respectively) when compared with fasting (no oral supplement). However, when comparing patients receiving the carbohydrate-rich supplements with either water or placebo supplements, they found no significant decrease in LOS. They did not show any differences in their secondary outcomes including aspiration pneumonitis, vomiting, and insulin resistance or sensitivity. It is important to note that this study did have limitations of low-to-moderate quality trials incorporated in the analysis.[20]

There is no consensus for carbohydrate-rich supplements preoperatively for patients with diabetes mellitus type 2. However, carbohydrate-rich drinks should be avoided in type 1 diabetics due to the inherent lack of insulin.[19] At this point, perioperative glucose monitoring remains imperative for all diabetics.[21]

There appears to be clear benefit for improved recovery with carbohydrate-rich supplements in other surgical specialties; however, limited high-quality evidence exists in joint arthroplasty. The low-risk profile and potential benefits, however, suggest preoperative supplement may have a role.[17] Multiple studies are currently underway, including a prospective randomized trial being performed at Henry Ford Hospital to determine the effects of a preoperative carbohydrate rich drink on postoperative nausea and vomiting (PONV) which could provide further insight.

Preoperative Analgesia

Multimodal nonopioid analgesia is one of the cornerstones of a successful ERAS pathway for hip and knee arthroplasty.[22] Combining different classes of analgesics perioperatively (including but not limited to Tylenol, NSAIDs, Gabapentinoids, and glucocorticoids) can effectively and synergistically limit postoperative opioid consumption and limit the known side effects and addiction potential.[13,23]

The use of oral or intravenous (IV) acetaminophen within an ERAS pathway comes with strong recommendation from the ERAS Society. In a recent study by Sinatra et al.,[24] a 24-hour reduction in pain and morphine consumption for both hip and knee arthroplasty with continuous acetaminophen administration was reported. Acetaminophen has an excellent safety profile with minimal adverse reactions or drug-to-drug interactions making it an ideal additive for a multi-modal pathway.[24] In regard to IV versus oral, a recent RCT by Hickman et al.[25] found no significant difference between the two for hip and knee arthroplasty.

The appropriate use of NSAIDs in multimodal analgesia is a central tenant with level-1 evidence demonstrating its analgesic and opioid-sparing effects after arthroplasty.[13,26] However, unlike acetaminophen, NSAIDs do carry a risk profile of potential bleeding complications, gastric ulceration, and renal toxicity[27] and thus should be administered cautiously in a patient-specific manner. The fear of NSAIDs leading to prosthetic loosening has not been borne in the literature, and they should not be withheld because of its superior analgesic qualities.[13]

Gabapentinoids have shown mixed results at reducing postoperative pain and opioid consumption and are not without adverse side effects, most notably sedation.[28,29] Several studies specifically looking at the use of gabapentin after THA failed to show a decrease in opioid consumption.[21] Further evidence is needed to support the use of gabapentinoids after joint arthroplasty.

Adjunct peripheral nerve blocks (PNB) are gaining in popularity for TJA. The efficacy of an ultrasound-guided block is highly operator-dependent both in terms of technique and composition. The current evidence suggests that adductor canal blocks (ACB) for TKA are superior to femoral nerve blocks at providing effective pan relief while also allowing for early postoperative mobilization.[28,29] Seangleulur et al.[30] recently performed a systematic review comparing postoperative analgesic effects of periarticular injections (PAI) versus placebo or no injection and found PAI patients to have lower pain scores, opioid consumption, PONV, shorter LOS and improved knee ROM. It is important to note that PAI composition (medication, dose, injection technique, etc.) are highly variable in publications; however, most "cocktails" consist of a dilute local anesthetic with adjuvants such as epinephrine, ketorolac, clonidine, corticosteroids, and morphine.[31] No consensus exists on the ideal "cocktail" thus it varies based on surgeon preference. A recent meta-analysis by Sardana et al.[32] in 2019 comparing ACB to intraoperative PAI found that PAI could lead to greater reduction in pain and opioid consumption when compared with ACB. However, the authors could not determine whether combining both ACB and PAI was conclusively beneficial based on this meta-analysis.[32] In reality, both PAI and ACB blocks should be utilized if feasible because of minimal cost, time, and morbidity associated with these interventions when compared with the potential benefits.

Local infiltration of liposomal bupivacaine in PAIs comes with mixed recommendations.[33,34] A recent RCT by Mont et al.[35] compared PAI with and without the addition of liposomal bupivacaine and reported significantly improved pain and reduction in opioid consumption after surgery. However, a more recent systematic review of 17 studies by Yayac et al.[36] concluded that the overall improvement in pain control was not clinically significant and did not offer the benefit of opioid reduction. Given the paucity of mixed literature, the authors of this review do not recommend for or against routine use of liposomal bupivacaine as a component of PAIs.

Cryotherapy has been shown to have some beneficial qualities in postoperative pain management[37] and possibly blood conservation;[38] however, level-1 studies are lacking to provide a definitive recommendation.