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


Postoperative Nausea and Vomiting (PONV)

Postoperative nausea and vomiting (PONV) can be influenced by a multitude of perioperative factors and should be treated accordingly to prevent patient morbidity and associated prolonged LOS.[13,55] The avoidance or limited usage of opioid analgesics aid in reducing PONV.[28] In a recent meta-analysis, dexamethasone administration preoperatively was found to reduce postoperative pain, opioid consumption, PONV, and LOS (decreased by 24 hr)[56,57] A single 10 mg dose of dexamethasone at induction is most quoted in the literature; however, multiple postoperative doses have also shown benefit.[56] Dexamethasone's significant reduction in PONV is well known,[42,58] but its hyperglycemia effects on poorly controlled diabetics must be considered,[59] especially the association of perioperative hyperglycemia with periprosthetic joint infection.[5,60] Currently, a recommendation for the routine use of dexamethasone in diabetics cannot be concluded and the decision must be made on a case-by-case basis. Regarding anesthesia, minimizing general anesthesia and relying instead on neuraxial and regional blocks will help reduce PONV associated with volatile anesthetic agents and opioids.[42] Antiemetic drug therapy, such as dopamine antagonists (i.e., metoclopramide), serotonin antagonists (i.e., ondansetron), and anticholinergics (i.e., scopolamine) may also be utilized for treatment or prophylaxis of nausea after TJA.

Some known patient risk factors for PONV include female gender, history of motion sickness, and being a non-smoker.[61] Surgical factors include increased duration of surgery and use of volatile anesthetics.[28] If a patient is deemed at-risk, then prophylactic treatment with antinausea medication should be strongly considered. Adequate perioperative hydration can also reduce PONV. This provides further justification to allow clear fluids up to 2 hr before initiation of anesthesia and maintaining intraoperative euvolemia.[6] Preoperative carbohydrate loading was shown to reduce PONV by Bilku et al.;[62] however, it is still uncertain if is related to the carbohydrate-rich nature or simply the fluid volume.

A concerted effort should be made to optimize hydration, anesthetic, glucocorticoids, and antiemetic drug therapy to reduce PONV to promote early mobilization and discharge.

Postoperative Analgesia

Postoperative pain control is central to any ERAS protocol to reduce distress and promote early mobilization. The goal for pain management is to be proactive rather than reactive which further prioritizes preoperative analgesia. Using multimodal drug therapy aims to reduce dependence on postoperative opioids, which can have unwanted side effects of drowsiness, respiratory depression, nausea, urinary retention, and additional risks.[13] However, the efficacy of short-acting opioids for pain control after TKA is well established and should be appropriately used. The optimal medication, dosage, and duration of opioid treatment has not been well established and is highly dependent on surgeon, procedure, and demographic variations. However, clinical practice guidelines put forth by AAHKS, ASRA, AAOS, Hip Society, and Knee Society provided guidance with moderate strength that prescribing lower quantities of opioid pills at discharge may lead to equivalent patient-reported outcomes, pain relief, reduced opioid consumption, and few unused pills after TJA.[63] This recommendation is supported by an RCT by Hannon et al.,[64] which randomized 304 patients into a cohort that received 30 oxycodone pills after TJA versus a cohort that received 90 oxycodone pills. In the first 30 days, the 30-pill group had 15 unused pills, and the 90-pill group at 73 unused pills.[64]

Postoperative NSAIDs or selective cyclooxygenase-2 (COX-2) inhibitors have shown to reduce opioid consumption and improve ROM after joint replacement surgery,[65] but as mentioned previously, the gastric and renal side effect profile must be considered. The benefits are seen when administered for a short course (10 to 14 days) postoperatively.[5] Continuing oral acetaminophen at doses up to 3000 mg per day postoperatively has synergistic analgesic effects with NSAIDs[66] without significant side effects. Ample patient education should be provided not to exceed 4000 mg in 24 hr especially if concomitantly being given with a medication like Norco or Percocet which combines acetaminophen with an opioid. Gabapentinoids must be used with caution because of sedation and dizziness and has not gained universal acceptance for ERAS protocols.

Early Mobilization

Early mobilization after joint arthroplasty is widely supported in the literature. In addition to reducing the incidence of DVT,[67] pulmonary complications, and insulin resistance,[42] early gait training after TKA can significantly improve knee ROM, pain scores, and functional scores.[23,68] A recent systematic review of RCTs demonstrated early mobilization can independently reduce LOS by 1.8 days without an increase in negative outcomes.[69]

A robust multimodal analgesic protocol is perhaps the most critical component of a successful ERAS pathway to early mobilization;[23,42] however, each element of the program plays a key role. The goal is to initiate physical therapy on postoperative day 0 as early as 2 to 6 hr after surgery.[42] This requires close logistical coordination with the facility's rehabilitation team identifying clear goals and expectations for patient activity. Once therapy is initiated, objective discharge criteria must be defined within the ERAS pathway to promote home discharge. Typical functional goals include the ability to ambulate independently, rise and sit from chair or toilet, and dress independently.[13]

Venous Thromboembolism Prophylaxis

Although relatively uncommon, VTE is the second leading cause of mortality after TJA.[70] DVT is potentially preventable with the judicious use of chemoprophylaxis, pneumatic compression devices, and early mobilization. However, this must be weighed with the potential complications associated with excessive bleeding including wound complications, hematoma, secondary infection, and need for reoperation.[71] Aspirin has gained recent popularity over established warfarin, enoxaparin, and low-molecular-weight heparin (LMWH) agents; however, a closer look at the current literature is necessary to justify this shift.[70,71]

A recent meta-analysis by Farey et al.[70] sought to compare aspirin to enoxaparin for VTE prophylaxis after TJA. They reported on incidence of VTE and mortality rates in addition to bleeding complications up to 3 mo postoperatively of 1,507 patients over four large trials. They did not find any significant difference in VTE rates, mortality, or bleeding complications between aspirin and enoxaparin. The study was limited by the moderate-to-low quality evidence available and concluded that more high-quality RCTs were needed to promote the use of aspirin routinely for TJA.[70] Similarly, three other clinical studies published in 2019 demonstrated comparable clinical VTE outcomes with aspirin to stronger anticoagulants however these were retrospective studies fraught with bias.[71–74]

A multi-institution randomized trial, PEPPER (pulmonary embolism prevention after hip and knee replacement) trial, is currently underway to compare the three most common North American VTE prophylaxis agents: aspirin, warfarin, and rivaroxaban. This large trial will involve an estimated 20,000 participants with an expected completion of February 2023 and should provide quality evidence in this matter.

Endorsed by both the AAOS and American College of Chest Physicians (AACP), it is currently recommended that all patients undergoing primary TJA should receive some form of chemoprophylaxis for at least 10 to 14 days,[75] with consideration of using a stronger anticoagulant (such as LMWH) for higher risk patients.[28] Furthermore, mechanical prophylaxis with a pneumatic compression device should be routinely applied while inpatient because of its VTE protection and lack of known complications.[76]