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

doi:10.5312/wjo.v13.i3.307

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World J Orthop. Mar 18, 2022; 13(3): 307-328
Published online Mar 18, 2022. doi: 10.5312/wjo.v13.i3.307

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.

Table 2 Pre-, peri-, and post-operative management during enhanced recovery pathways

Author	Year	ERP			Preoperative					Peri-operative							Post-operative
Author	Year	Pre-operative	Peri-operative	Post-operative	Education	Outpatient consultation	Discharge planning	Physiotherapy	Pre-assessment outpatient clinic	Day of surgery admission	Pre-medication	Optimal hydration	Neuraxial-regional anaesthesia	Multimodal blood loss reduction	+/- peri articular injection	Avoid surgical drains	Multi-modal analgesia regimen	Day of surgery mobilisation	Venous thromboembolic prophylaxis	Rehabilitation programme	Early discharge home
Arshi et al[42]	2017			X																	X
Auyong et al[36]	2015	X	X	X	X						X		X				X	X			X
Basqueset al[43]	2017			X																	X
Bertinet al[26]	2005	X	X	X				X			X		X							X	X
Bovonratwetet al[44]	2017			X																	X
Bovonratwetet al[45]	2017			X																	X
Brunenberget al[27]	2005	X		X	X				X											X
Castorinaet al[58]	2017	X	X	X									X				X
Courtneyet al[46]	2017			X																	X
Courtneyet al[59]	2018			X																	X
den Hertoget al[7]	2012	X		X														X		X	X
Dowseyet al[28]	1999		X	X
Featherallet al[60]	2018	X	X	X					X						X		X			X
Gauthier-Kwanet al[61]	2018	X	X	X	X						X		X				X			X	X
Goochet al[35]	2012	X	X	X	X	X	X	X			X		X					X		X
Goyalet al[38]	2017			X													X				X
Gwynne-Jones et al[47]	2017	X	X	X	X					X	X		X	X				X		X
Ho et al[30]	2007	X	X
Hoorntjeet al[48]	2017	X	X	X								X								X	X
Huanget al[49]	2017	X	X	X		X				X					X					X
Ismail A et al[39]	2016
Jimenez Muñoz et al[29]	2006			X																X	X
Klapwijket al[50]	2017	X	X	X	X						X		X			X		X
Klingensteinet al[51]	2017			X																	X
Koliseket al[31]	2009	X		X														X		X	X
Kortet al[3]	2017	X	X	X			X	X		X	X									X	X
Krummenaueret al[33]	2011	X		X	X	X														X
Larsenet al[52]	2017	X		X	X													X
Lovecchioet al[40]	2016			X																	X
Maempelet al[41]	2016	X	X	X	X	X	X	X					X					X
Maempelet al[37]	2015	X	X	X		X				X			X					X
Malviyaet al[34]	2011	X	X	X	X				X		X		X					X
Molloyet al[53]	2017
Nelsonet al[54]	2017			X																	X
Pamiloet al[62]	2018	X			X	X
Renkawitzet al[32]	2010	X	X	X	X	X			X									X		X
Richteret al[55]	2017			X																	X
Schotanuset al[69]	2017	X	X	X			X			X								X
Toyet al[63]	2018	X				X
Wilcheset al[57]	2017	X	X	X	X				X		X	X	X	X				X		X

ERP: Enhanced recovery pathways.

Table 3 Grading of Recommendation, Assessment, Development and Evaluation evidence profile: Enhanced recovery pathways compared to regular pathways for hip and knee arthroplasty

Quality assessment							No. of patients		Effect		Quality	Importance
Quality assessment							No. of patients		Effect				No. of studies
Design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	(S)AE	Control	Relative (95%CI)	Absolute
Functional recovery (follow-up 24 mo)
12	Randomised trials	No serious risk of bias	Serious¹	No serious indirectness	No serious imprecision	None	0/2289 (0%)	0/1802 (0%)	Not pooled	Not pooled	Moderate	Important
12	Randomised trials	No serious risk of bias	Serious¹	No serious indirectness	No serious imprecision	None		0%	Not pooled	Not pooled	Moderate	Important
PROMs (follow-up 24 mo; Better indicated by lower values)
15	Randomised trials	No serious risk of bias	Serious²	No serious indirectness	No serious imprecision	None	2966	2388	-	Not pooled	Moderate	Important
LoS (follow-up 24 mo; Better indicated by lower values)
38	Randomised trials	No serious risk of bias	No serious inconsistency	No serious indirectness	No serious imprecision	None	997447	1573895	-	MD 2.45 lower (3.42 to 1.48 lower)	High	Important
(S)AEs
34	Randomised trials	No serious risk of bias	No serious inconsistency	Serious³	No serious imprecision	None	2103/18344 (11.5%)	83989/540864 (15.5%)	RR 0.91 (0.78 to 1.06)	14 fewer per 1000 (from 34 fewer to 9 more)	Moderate	Important
34	Randomised trials	No serious risk of bias	No serious inconsistency	Serious³	No serious imprecision	None		11.7%	RR 0.91 (0.78 to 1.06)	11 fewer per 1000 (from 26 fewer to 7 more)	Moderate	Important
Readmission (follow-up 24 mo)
23	Randomised trials	No serious risk of bias	No serious inconsistency	No serious indirectness	Serious⁴	None	273/9846 (2.8%)	8360/406167 (2.1%)	RR 0.83 (0.65 to 1.07)	3 fewer per 1000 (from 7 fewer to 1 more)	Moderate	Important
23	Randomised trials	No serious risk of bias	No serious inconsistency	No serious indirectness	Serious⁴	None		2.7%	RR 0.83 (0.65 to 1.07)	5 fewer per 1000 (from 9 fewer to 2 more)	Moderate	Important

¹Different outcomes for functional recovery: HHS [with/without range of motion (ROM), pain], American Knee Society Score, ROM.

²Different patient reported outcome measures: SF-36, WOMAC, KATZ.

³No clear distinction between adverse event (AE) and serious AE.

⁴Wide confidence interval.

(S)AE: (Serious) adverse event; CI: Confidence interval; PROMS: Patient reported outcome measures; LoS: Length of hospital stay; RR: Relative risk.

Citation: Heymans MJ, Kort NP, Snoeker BA, Schotanus MG. Impact of enhanced recovery pathways on safety and efficacy of hip and knee arthroplasty: A systematic review and meta-analysis. World J Orthop 2022; 13(3): 307-328
URL: https://www.wjgnet.com/2218-5836/full/v13/i3/307.htm
DOI: https://dx.doi.org/10.5312/wjo.v13.i3.307