Impact of enhanced recovery pathways on safety and efficacy of hip and knee arthroplasty: A systematic review and meta-analysis

Table 1 Characteristics of the included studies, patient demographics, ERP versus regular pathways, and outcome

Author/year	Procedure	Study design	Country/setting	ERP/regular pathway	Number participants ERP/regular pathway	Participants characteristics ERP/regular pathway	Outcome
Arshi et al[42]; 2017	TKA	Retrospective cohort	United States; Humana subset of the pearl-diver patient record database	Outpatient/inpatient	n = 133.342; 4.391/128.951	Age: (70-74), modus 65-69; Men-women: (1.560-2.831)/(46.805-82.146)	LoS, (S)AE
Auyong et al[36]; 2015	TKA	Retrospective cohort	United States; Medical center	Updated ERAS/ERAS	n = 252; 126/126	Age: 66.02 (10.02)/68.44 (9.98); Men-women: (44-82)/(41-85); BMI: 31.88 (7.629)/31.3 (6.562)	LoS, (S)AE, functional recovery, PROMs, readmission
Basques et al[43]; 2017	THA; TKA	Retrospective matched cohort	United States; NSQIP database	Same day/inpatient	n = 177.818, 1.236/176.582; THA: n = 63.360, 368/368; TKA: n = 110.410, 608/608; UKA: n = 4.048, 260/260	Age: Most between 65-74; Men-women: (46.6%-53.4%)/(39.8%-60.2%); BMI: Most between 25-29.9	LoS, (S)AE, readmission
Bertin et al[26]; 2005	THA	Pilot study, retrospectively chosen control group	United States; Hospital	Outpatient/existing protocol	n = 20; 10/10	Age: 62/63; Men-women: (6-4)/(5-5); BMI: 30.024/29.64	LoS, (S)AE, costs
Bovonratwet et al[44]; 2017	TKA	Retrospective cohort	United States; NSQIP database	Outpatient/inpatient	n = 112.922; 642/112.280	Age: 64/67; Men-women: (265-377)/(41.821-70.459); BMI: 32/33	LoS, (S)AE, readmission
Bovonratwet et al[45]; 2017	UKA	Cohort	United States; NSQIP database	Outpatient/inpatient	n = 5880; 568/5312	Age: 62.9/63.7; Men-women: (284-284)/(2501-2811); BMI: 31.5/31.6	LoS, (S)AE, readmission
Brunenberg et al[27]; 2005	THA; TKA	Before-after trial	Netherlands; University hospital	Joint recovery programme/usual care	n = 160; THA: n = 98, 48/50; TKA: n = 62, 30/32	Age: 64.4 (28-87); THA: Age 63.38 (11.48)/ 65.4 (13.04), Men-women% (35.4-64.6)/(24-76); TKA: Age 64.9(9.43)/63.94 (12.6), Men-women % (33.3-66.7)/(31.3-68.7)	LoS, functional recovery; PROMs; costs
Castorina et al[58]; 2017	TKA	Retrospective observational cohort study	Italy; Orthopedics traumatology and rehabilitation unit	Fast track/traditional group	n = 132; 95/37	Age: 71.1 (7.77)/74.62 (± 6.42)	Functional recovery; (S)AE
Courtney et al[46]; 2017	THA; TKA	Retrospective cohort	United States; NSQIP database	Outpatient/inpatient	n = 169.406; 1220/168.186	Age: 63.1/65.9; Men-women: (539-681)/(67.687-100.499); BMI: 32.1/31.7	LoS, (S)AE, readmission
Courtney et al[59]; 2018	TKA	Retrospective cohort	United States; NSQIP database	Outpatient/short stay/LOS ≥ 2 d	n = 49.136; 365/3033/45.738		LoS, (S)AE, readmission
den Hertog et al[7]; 2012	TKA	Randomized prospective study	Germany; Hospital	Fast-track group/standard care re-habilitation	n = 147 (ITT), 74/73; n = 140 (PP), 71/69	Age: 66.58 (8.21)/68.25 (7.91); Men-women: (23-51)/(20-53); BMI: 31.17 (5.82)/30.38 (6.05)	LoS, (S)AE, functional recovery, PROMs
Dowsey et al[28]; 1999	THA; TKA	Prospective randomized controlled study	Australia; Tertiary hospital	Clinical pathway/control	n = 163; 92/71	Age: 64.2/68.2; Men-women: 56/107	LoS, (S)AE, functional recovery, readmission
Featherall et al[60]; 2018	THA	Cohort	United States; Clinic	Full protocol/transition cohort/Pre-protocol	n = 6090; 2081/2009/2000	Age: 63.77 (11.72)/64.09 (12.04)/64.03 (12.09); Men-women: (1033-1048)/(983-1026)/(960-1040); BMI: 30.13 (6.17)/ 29.93 (6.19)/ 30.09 (6.38)	LoS, (S)AE, cost
Gauthier-Kwan et al[61]; 2018	TKA	Prospective comparative cohort	Canada; Hospital	Outpatient/inpatient	n = 86; 43/43	Age: 62.5 (50.4-75), 62.5 (51.2-74); Men-women: (29-14)/(22-21); BMI: 28.6 (23.7-35.8)/30.4 (23.5-41.6)	LoS, (S)AE, readmission, functional outcome, PROMs
Gooch et al[35]; 2012	THA; TKA	RCT	Canada; Bone and Joint Health Institute	New clinical pathway/standard care	n = 1570, 1066 (THA: 615; TKA: 451)/504 (THA: 278; TKA: 226)	Age: 69 (11.1)/69 (10.4); Men-women%: (39.6-60.4)/(40.1-59.9); BMI: 29.5 (5.6)/29.4 (5.4)	(S)AE, functional recovery, PROMs
Goyal et al[38]; 2017	THA	Prospective randomized study	United States; Two reconstruction centres	Outpatient/inpatient	n = 220; 112/108	Age: 59.8 (8.5) (59.3) (27-74)/60.2 (8.9) (61) (34-74); Men-women: (59-53)/(58-50); BMI: 27.6 (4.1) (27.1) (18-38.4)/ 28.3 (4.7) (27.7) (18.4-39.9)	LoS, (S)AE, readmission, functional recovery, PROMs
Gwynne-Jones et al[47]; 2017	THA; TKA	Matched cohort study	New Zealand; Hospital	Post ERAS/pre ERAS	n = 1035, 528/507; THA: 318/314; TKA: 210/193	THA: Age 68.3 (11.8)/66.8 (11.8), Men-women (146-172)/(146-168); TKA: Age 70.4 (8.9)/69.8 (9.0), Men-women: 107-103/83-110	LoS, (S)AE, readmission, PROMs
Ho et al[30]; 2007	TKA	Randomized controlled trial; retrospective cost analysis	United States; Tertiary teaching hospital	Critical pathway/no uniform CP	n = 90; 3 cohorts: 30/30/30	Age: 66/67/68; Men-women: (14-16)/(14-16)/(14-16); Weight: 89/91/88	LoS, (S)AE, costs
Hoorntje et al[48]; 2017	UKA	Case control study	Netherlands; Hospital	Outpatient/fast-track	n = 40; 20/20	Age: 62.2 (5.5)/63.8 (7.5); Men-women: (10-10)/(7-13); BMI: 27.8 (3.7)/30.5 (7.0)	LoS, PROMs
Huang et al[49]; 2017	TKA	Prospective case control study	Canada; Tertiary academic medical centre	Same day discharge/inpatient	n = 40; 20/20	Age: 58.5 (5.6)/61.5 (5.9); Men-women: (14-6)/(14-6); BMI: 29.0 (3.7)/30.6 (5.3)	LoS, (S)AE, readmission, cost
Ismail A et al[39]; 2016	TKA	Non-randomized control trial	Malaysia; University hospital	CP/control	n = 152; 73/79	Age: 66.1/64.7	LoS, (S)AE, readmission
Jimenez Muñoz et al[29]; 2006	THA	Prospective follow-up study	Spain; University general hospital	After CP/prior CP	n = 487; 384/98; 309/75	Not present	LoS, (S)AE
Klapwijk et al[50]; 2017	THA	Prospective cohort	Netherlands; Hospital	Outpatient/inpatient	n = 94; 42/52	Age: 61 (41-78)/68 (48-82); Men-women: (17-25)/(21-31); BMI: 29 (20-35) /26 (18-39)	LoS, (S)AE, functional recovery, PROMs
Klingenstein et al[51]; 2017	TKA	Retrospective cohort	United States; Joint replacement centre	Short stay/traditional stay	n = 2287; 1502/785	Age: 71.7 (5.4)/73.3 (6.1); Men-women%: (39-61)/(25-75); BMI ≥ 30 (%): 50/57	LoS, (S)AE, readmission
Kolisek et al[31]; 2009	TKA	Prospective matched cohort	United States; Hospital	Outpatient/conventional inpatient stay	n = 128; 64/64	Age: 55 (42-64)/55 (42-63); Men-women: (40-24)/(40-24); BMI: 30.8 (24.3-38)/30.8(24.2-37.8)	LoS, (S)AE, functional recovery, PROMs, readmission
Kort et al[3]; 2017	UKA	Case control study	Netherlands; Hospital	Outpatient/rapid recovery	n = 40; 20/20	Age: 60.5 (5.65)/61.2 (5.15); Men-women: (13-7)/(11-9); BMI: 29.1 (3.85)/27.7 (3.27)	LoS, (S)AE, readmission, PROMs
Larsen et al[52]; 2017	THA	Observational cohort	Denmark; Orthopedic clinic	Day case (< 12 h)/standard 2-d	n = 56; 20/36	Age: 64.6; Men-women: 15-5; BMI: 28.8 (23.8-33.7)	LoS, (S)AE, readmission, PROMs
Lovecchio et al[40]; 2016	THA; TKA	Propensity score matched study	United States; NSQIP database	Outpatient/fast-track inpatients	n = 1968, 492/1476; THA/TKA: (183-585)/(309-891)	Age: Most between 60 to 69; Men-women: (217-275)/(664-812); BMI between 25-30	LoS, (S)AE, readmission
Maempel et al[41]; 2016	THA	Prospective cohort	United Kingdom; Hospital	ERP/traditional rehabilitation	n = 1161; 550/611	Age: 64 (18-94)/66 (23-90); Men-women: (212-338)/(242-369); BMI: 30 (7)/29 (7)	LoS, (S)AE, functional recovery, PROMs
Maempel et al[37]; 2015	TKA	Non-randomized prospective cohort	United Kingdom; Arthroplasty clinic	ERP/traditional rehabilitation	n = 165; 84/81	Age: 69.8 (8.9)/70.1 (10.5); Men-women: (42-42)/(37-44); BMI: 32.4 (22.6-46.6)/31.8 (20.5-41.9)	LoS, (S)AE, functional recovery
Malviya et al[34]; 2011	THA; TKA	Observational study	United Kingdom; Hospital	ERP/traditional pathway	n = 4500; 1500 (THA: 630; TKA: 870)/3000 (THA: 1368; TKA: 1632)	Age: 68/69; Men-women: (711-789)/(1482-1518)	LoS, (S)AE, readmission
Nelson et al[54]; 2017	THA	Retrospective cohort, data prospectively collected	United States; NSQIP database	Outpatient/inpatient	n = 63.844; 420/63.424	Age: 62/65; Men-women: (222-198)/(28.587-34.833); BMI most between 25-30	LoS, (S)AE, readmission
Pamilo et al[62]; 2018	TKA	Retrospective cohort	Finland; Finnish Hospital Discharge Register	Fast-track CP/non-fast-track	n = 4256, 2310/1946; Hospital A: 624/437	Age and sex: No statistically significant difference between CP’s	LoS, (S)AE, readmission
Renkawitz et al[32]; 2010	TKA	Prospective parallel group design	Germany; Orthopaedic university medical centre	Optimized accelerated CP/standard CP	n = 143; 67/76	Age: 67 (9)/68.1 (11.1); Men-women: (14-53)/(23-53); BMI: 31.4 (5.1)/30.7 (5.6)	LoS, (S)AE, readmission, functional recovery
Richter et al[55]; 2017	UKA	Retrospective chart review	United States; Surgical outpatient center	Outpatient/inpatient	n = 22; 12/10	Age: 67.2 (9.2)/64.5 (9.8); Men-women: (7-5)/(8-2); BMI: 28.7 (5.1)/25.8 (8.1)	LoS, (S)AE, readmission, cost
Schotanus et al[69]; 2017	TKA; UKA	Case control study	Netherlands; Hospital	Outpatient/ERP	n = 361; 94/267	Age: 63.4 (8.0)/68.4 (9.0); Men-women: (49-45)/(94-173); BMI: 28.25 (3.68)/29.49 (5.05)	LoS, PROMs
Toy et al[63]; 2018	THA	Retrospective cohort	United States; Ambulatory surgery centers	Later outpatient pathway/initial outpatient pathway	n = 145; 72/73	Age: 55 (27-70); Men-women: 76-49; BMI: 29.7 (19.6-43)	LoS, (S)AE, readmission
Wilche et al[57]; 2017	THA; TKA	Retrospective review	Spain; Hospital	Fast-track recovery/conventional recovery	n = 200; THA: 50/50; TKA: 50/50	Age: 69.24 (9.64)/73.07 (8.33); Men-women: (40-60)/(40-60)	LoS, (S)AE, readmission, cost

Age in years, mean ± SD (median) (range); Weight in kg. BMI: Body mass index; NSQIP: National Surgical Quality Improvement Program; THA: Total hip arthroplasty; TKA: Total knee arthroplasty; CP: Clinical pathway; UKA: Unicompartmental knee arthroplasty; Los: Length of hospital stay; (S)AE: (Serious) adverse events; PROMS: Patient reported outcome measures; ERP: Enhanced recovery pathways; ERAS: Enhanced Recovery After Orthopedic Surgery; RCT: Randomized controlled trial.