ERAS for Total Joint Arthroplasty: Past, Present and Future By Ellen M. Soffin, MD, PhD; Alana E. Sigmund, MD, FHM & Chad M. Craig, MD, FACP I n the companion article in this edition, we speculate whether Enhanced Recovery After Surgery (ERAS) protocols can be usefully applied to patients undergoing spine surgery. If ERAS for spine represents an emerging concept in orthopedic surgery, ERAS for total joint arthroplasty (TJA) represents the proof of concept. In contrast to spine surgery, elective hip and knee arthroplasty are high-volume, highly standardized surgical procedures typically performed in medically optimized patients. These conditions facilitate the implementation of clinical pathways or fast-track programs which lead directly to reductions in length of stay and improved outcomes. For more than 30 years, there has been compelling evidence to support the use of packages of care to improve recovery after TJA. At Hospital for Special Surgery, Sharrock et al. transformed the care of our TJA patients by incorporating standardized perioperative interventions: universal receipt of epidural anesthesia, invasive goal-directed hemodynamic monitoring, epidural analgesia, pulse oximetry, and post-operative supplemental oxygen, with ICU-level of care for high-risk patients.1 These changes effected a reduction in mortality after total knee arthroplasty from 0.44% to 0.07% over a 10-year period. Importantly, there were no major changes in surgical technique over this interval, suggesting the bundle of interventions led to improved outcomes. More modern fast track protocols reliably demonstrate cost savings and reductions in lengthof-stay – often with discharge to home and without increased complications or readmission.2-6 . The Hospital for Special Surgery clinical pathways for total hip or knee arthroplasty feature pre-operative patient education and discharge planning, pre-emptive analgesia, post-operative nausea and vomiting prophylaxis, regional analgesia techniques, and early mobilization. Patients following these pathways achieve reduced length of stay, superior pain control, and shortened time to functional recovery.7-9 Finally, in a recent study of patients undergoing primary total hip arthroplasty, comparing patients in an enhanced recovery program to patients in the hospital’s standardcare program, the enhanced recovery group showed a decreased length of stay of 1.5 days with no increase in post-operative complications.10 program, patients underwent pre6 operative assessment by a physical therapist, and were educated about the planned day of discharge, wound care and physical therapy, They also received necessary equipment prior to admission, received spinal anesthesia, and also participated in early mobilization. A similar, although smaller, study in total knee arthroplasty showed similar results.11 In this While package of care studies in TJA show benefit for patients, they also have revealed that the two major approaches to standardized care in TJA, ERAS and clinical pathways, have basic differences in form and content. In contrast to ERAS in other surgical subspecialties, the majority of published pathways for TJA comprise intraoperative anesthesia, post-operative analgesia, and early mobilization as the basis of the care trajectory. Standardized ERAS components, including pre-operative education and nutritional optimization, goal directed fluid therapy (GDFT) and audit are often conspicuous by their absence in TJA. A recent review of ERAS for TJA suggests that despite the established success of clinical pathways, there remain major opportunities to apply ERAS principles to patients undergoing elective joint replacement.12 Although ASER ALERT • VOLUME 1, ISSUE 1 • aserhq.org
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