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British Journal of Anaesthesia, 117 (S3): iii62iii72 (2016)

doi: 10.1093/bja/aew362
Review Article

Enhanced recovery after surgery for primary hip and


knee arthroplasty: a review of the evidence
E. M. Soffin* and J. T. YaDeau

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Department of Anesthesiology, Hospital for Special Surgery, Weill Cornell Medical College, 535 East
70th Street, New York, NY 10021, USA

*Corresponding author. E-mail: soffine@hss.edu

Abstract
Enhanced recovery after surgery (ERAS) protocols produce significant clinical and economic benefits in a range of surgical
subspecialties. There is a long tradition of applying clinical pathways to the perioperative care of joint arthroplasty patients.
Enhanced recovery after surgery represents the next step in the evolution of standardized care. To date, reports of full ERAS
pathways for hip or knee arthroplasty are lacking. In this narrative review, we present the evidence base that can be usefully
applied to constructing ERAS pathways for hip or knee arthroplasty. The history and rationale for applying ERAS to joint
arthroplasty are explained. Evidence demonstrates improved outcomes after joint arthroplasty when a standardized ap-
proach to care is implemented. The efficacy of individual ERAS components in hip or knee replacement is considered,
including preoperative education, intraoperative anaesthetic techniques, postoperative analgesia, and early mobilization
after joint arthroplasty. Interventions lacking high-quality evidence are identified, together with recommendations for fu-
ture research. Based on currently available evidence, we present a model ERAS pathway that can be applied to perioperative
care of patients undergoing hip or knee arthroplasty.

Key words: arthroplasty; hip; knee; replacement

Enhanced recovery after surgery (ERAS) is rapidly becoming fa- consistently been associated with superior recovery, decreased
miliar to anaesthetists. Perioperative programmes incorporating morbidity, reduced hospital length of stay, and cost savings.2
multimodal, evidence-based interventions have come to be The clinical and economic gains that can be achieved with ERAS
known as fast-track or ERAS pathways. Enhanced recovery after have been demonstrated across a range of surgical specialties,
surgery was pioneered by Henrik Kehlet in the 1990s as an effort including gynaecological oncology, urology, vascular, and thor-
to improve recovery after colorectal surgery.1 Kehlet hypothe- acic surgery.3
R
sized that surgical stress, metabolic and endocrine derange- According to the ERASV Society, there are 20 components of
ments, and prolonged immobilization contribute to organ care that influence the stress response and enhance recovery. It
dysfunction: pain, nausea, vomiting, ileus, fatigue, and cogni- can quickly be appreciated that designing and implementing an
tive disturbance. The extent of organ dysfunction thus deter- ERAS protocol is a multidisciplinary endeavour. Accordingly, an
mines recovery. According to ERAS concepts, it is unlikely that ERAS team should comprise expertise from surgery, anaesthesia,
any single surgical technique, anaesthetic intervention, or nursing, physical therapy, and nutrition. The team has primary
medication can significantly reduce organ dysfunction. Rather, responsibility for reviewing the available literature and for for-
recovery is facilitated by a multimodal approach directed to- mulating and delivering the protocol. Once implemented, a key
wards global modulation of the surgical stress response. plank in any ERAS platform is audit, with continuous evaluation
Enhanced recovery after surgery in colorectal surgery has of component efficacy and institutional compliance (Fig. 1).

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iii62
ERAS for hip and knee arthroplasty | iii63

surgery, particularly elective hip and knee arthroplasty. In one


Editors key points of the earliest examples, Sharrock and colleagues5 applied a
bundle of interventions to patients undergoing hip or knee re-
Enhanced recovery after surgery (ERAS) protocols exist
placement: epidural anaesthesia replaced general anaesthesia,
for a range of procedures, but are just being developed
invasive haemodynamic monitors became routine, high-risk
for orthopaedic surgery. patients received postoperative intensive care monitoring, post-
Standardized approaches to perioperative management
operative epidural analgesia was used, pulse oximetry was
in joint arthroplasty show efficacy for several individual introduced, and postoperative patients routinely received sup-
ERAS components. plemental oxygen. Although no changes were reported in surgi-
Further work to develop and implement the optimal
cal technique, the mortality rate for total knee arthroplasty
components into a coherent ERAS protocol is indicated. decreased from 0.44 to 0.07%.
Sharrocks work can be viewed as an early model for ERAS in
orthopaedic surgery. A more recent precursor of ERAS for joint
arthroplasty was the development of clinical pathways.6 7
Confusion exists about what constitutes ERAS vs other path- Although no two pathways are the same, each includes a range
ways of clinical care (Table 1). There is no internationally ac- of pre-, intra-, and postoperative components and interven-
cepted definition of what constitutes a clinical pathway.4 Like tions. Chief among these are preoperative patient education,
ERAS, clinical pathways ensure an evidence-based set of patient provision of adequate multimodal analgesia, and early mobil-
orders and interventions, so that the most important elements

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ization after surgery. A significant body of work on the efficacy
of care are consistently delivered. It is the inclusion of audit that of joint arthroplasty pathways has been published by Hebl and
most distinguishes an ERAS protocol from a clinical pathway. colleagues at the Mayo Clinic. The Mayo Clinics Total Joint
Enhanced recovery after surgery mandates collection and ana- Regional Anesthesia Clinical Pathway includes regional anaesthe-
lysis of outcomes and compliance. Enhanced recovery after sur- sia techniques (peripheral nerve blocks and catheters),
gery also stresses refining components of the pathway based on pre-emptive analgesia, and postoperative opiate-sparing multi-
evolving evidence. In this way, ERAS can be viewed not only as a modal analgesia. Patients who have surgery on the pathway ex-
package of evidence-based interventions, but also as a process perience superior analgesia, fewer opioid-related side-effects,
to facilitate consensus and research. fewer postoperative complications, shorter length of stay, and
greater cost savings.811
A major limitation to comparing the effectiveness of one
Outcomes in orthopaedic surgery clinical pathway with another is that a pathway is not a stand-
Despite widespread success in multiple surgical subspecialties, ardized intervention. Accordingly, comparative research has
ERAS remains formally understudied and under-reported in the focused on the concept of pathways, rather than the compo-
orthopaedic surgery literature. Nonetheless, there is persuasive nents themselves. A systematic review of clinical pathways
evidence that ERAS concepts can also be applied to orthopaedic used in joint replacement surgery included 22 studies totalling

PREOPERATIVE INTRAOPERATIVE POSTOPERATIVE

AUDIT

Education Regional anaesthesia (spinal, Multimodal opioid-sparing


Nutrition: carbohydrate loading CSE, PNB, LIA) analgesia: lumbar epidural,
Nutrition: liberal fasting Short-acting sedative-hypnotic NSAIDs, acetaminophen
Optimization: detect and correct agents
PONV prophylaxis
anaemia Goal: normothermia
Early mobilization
Active prewarming Goal: normovolaemia
Early oral intake
Pre emptive oral analgesia Blood conservation
Antibiotic prophylaxis

Fig 1 A recommended protocol for ERAS for total joint arthroplasty. This diagram highlights the multimodal, multidiscliplinary nature of ERAS protocols. Audit is
required and is a key driver of continuous evaluation and refining of the components of care. CSE, combined spinalepidural; ERAS, enhanced recovery after sur-
gery; LIA, local infiltration anaesthesia; NSAID, non-steroidal anti-inflammatory; PNB, peripheral nerve block; PONV, postoperative nausea and vomiting.
iii64 | Soffin and YaDeau

Table 1 Features distinguishing clinical pathways from ERAS protocols. The ERAS protocols encompass the entire perioperative phase, in-
clude a broad, coordinated care team, and emphasize assessing the delivery of best practice. ERAS, enhanced recovery after surgery

Feature Clinical pathway ERAS

Evidence based Yes Yes


Purpose Support decision-making in patient care Provide multidisciplinary plan of care
Components and interventions Often restricted Global
Outcome criteria Not defined Defined
Variance/deviations Not applicable Documented and analysed by audit process

6316 patients.6 Compared with standard care, patients on a clin- attempt to present major areas of disagreement and suggest
ical pathway had significantly fewer postoperative complica- reasonable ways forward. Future audit and research could prof-
tions [specifically, deep vein thrombosis (DVT), pulmonary itably investigate ERAS protocols for joint arthroplasty based on
embolism (PE), requirement for manipulation, superficial and these components, both to document outcomes and to refine
deep infections, and decubitus ulcers], shorter hospital length of the choice of components.

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stay, and lower hospital costs.
Despite the derived benefits, the lack of standardization of
clinical pathways inhibits full investigation and refinement of
Preoperative education and counselling
the individual components of care. Ultimately, this could pro- Anticipation of surgery can lead to anxiety and fear for many
duce a ceiling effect on their clinical and economic advantages. patients. An early study found that explicit pre-anaesthesia
Thus, we would advocate a shift towards adopting ERAS prin- education significantly relieved anxiety and emotional stress
ciples in the ongoing development of pathways of care in ortho- before hip or knee replacement.22 Preoperative education con-
paedic surgery. This is confirmed by several studies comparing tributes to higher patient confidence, greater patient satisfac-
ERAS pathways with usual care in patients undergoing primary tion, and early recovery and discharge.23 It is essential that a
hip or knee replacement. In a comparison of 1500 patients on an preoperative education programme should establish achievable
ERAS pathway with 3000 patients on a traditional protocol for goals for postoperative oral intake, analgesia, physical therapy,
hip or knee arthroplasty,12 ERAS effected significant reductions and mobilization.
in both postoperative transfusion requirements and 90 day mor- Two Cochrane systematic reviews explored the effect of
tality. The median length of stay was reduced from 6 to 3 days, preoperative education on outcomes after hip or knee
saving 5418 bed days, with no change in readmission rates. arthroplasty.24 25 Overall, there is little evidence to support the
Enhanced recovery after surgery also seems to be safe and ef- use of structured preoperative education to reduce postopera-
fective for joint arthroplasty regardless of age, preoperative tive adverse events, improve pain, facilitate functional recovery,
functional status, or co-morbidities.13 Moreover, ERAS produced or reduce length of hospital stay. However, a significant reduc-
the most marked decrease in length of stay in patients aged 85 tion in preoperative anxiety can be achieved. Preoperative edu-
yr or older, without any increase in morbidity and mortality.14 cation may most benefit patients with depression, anxiety,
In a review of factors contributing to poor physical and cognitive unrealistic expectations, or those with limited social support.
function after total hip or knee arthroplasty,15 key ERAS con- Generalizability of the Cochrane review findings might be
cepts were already being successfully applied to elective joint limited because the majority of the included trials16 were con-
arthroplasty. Thus, future efforts should be directed towards sidered inadequately blinded, although designing an adequately
modulating the stress response during the immediate recovery blinded educational intervention is challenging. The majority of
phase and optimizing postdischarge function. the included studies also failed to report sufficient data to ana-
Although initially adopted in orthopaedic surgery for pri- lyse the major outcomes of the reviews (including pain, func-
mary hip and knee replacement, ERAS is increasingly being tion, quality of life, and postoperative anxiety). Future trials
applied to other orthopaedic procedures. A full review is beyond should be adequately standardized and powered in order to ex-
the scope of the present article, but ERAS success has been re- plore the impact of preoperative education on outcomes. This is
ported for revision joint arthroplasty,16 total shoulder replace- confirmed by a small study of 53 patients undergoing primary
ment,17 and repair of fractured neck of femur.1821 hip or knee arthroplasty.26 Watching a series of presurgery edu-
cational videos on YouTube was associated with significant im-
provement in generalized anxiety scores, particularly in
Evidence to support individual ERAS
patients with high preoperative anxiety.
components in total joint arthroplasty
Studies implementing ERAS pathways for joint replacement in
totality are sparse. However, individual components of typical
Preoperative fasting and carbohydrate loading
ERAS protocols have been investigated separately. The remain- Enhanced recovery after surgery has challenged the time-hon-
der of this review summarizes the current state of knowledge oured tradition of fasting from midnight to avoid pulmonary as-
regarding components that are classically included in ERAS piration during elective surgery. Several systematic reviews
protocols and that can be applied usefully to total joint arthro- found no evidence to support a safety benefit of prolonged
plasty. For many clinical choices controversy reigns, but cre- fasting.27 28 Enhanced recovery after surgery consensus guide-
ation of an ERAS programme necessitates making a series of lines now permit intake of clear fluids until 2 h before induction
difficult choices in the face of uncertainty. In this article, we of anaesthesia and a 6 h fast for solid foods.29 The safety of a
ERAS for hip and knee arthroplasty | iii65

2 h-clear/6 h-solids fast is also upheld in obese and morbidly A body of evidence demonstrates a higher incidence of post-
obese cohorts,30 and in patients with uncomplicated diabetes operative complications when primary hip or knee arthroplasty
mellitus.31 A more conservative fast is recommended for dia- is performed under general compared with neuraxial/regional
betic patients with gastroparesis.32 In addition to liberalized anaesthesia. Pulmonary compromise, pulmonary embolus,
fasting guidelines, ERAS protocols recommend that patients need for transfusion, renal injury, infection, length of stay, and
consume up to 300 ml of a clear carbohydrate-rich drink 23 h 30 day mortality are all significantly lower after neuraxial anaes-
before surgery, with the goal of presenting the patient for sur- thesia.4244 Others suggest that outcomes are equivalent be-
gery in a metabolically fed state.29 A patient in an anabolic tween techniques.45 46 These results are difficult to reconcile
state undergoes less postoperative nitrogen and protein loss33 because there are multiple sources of potential bias. Registry-
and maintains more lean muscle mass.34 These concepts are based data are subject to selection bias, and older, outdated
supported by several randomized controlled trials, indicating modes of general anaesthesia could contribute to the appear-
accelerated recovery after colorectal surgery when patients re- ance of neuraxial superiority. In contrast, randomized con-
ceive preoperative carbohydrate loading.35 36 trolled trials (and the resultant meta-analyses) have their own
There are limited data specifically exploring the role of meta- sources of bias, including difficulty in generalizing results from
bolic state and recovery after joint arthroplasty. In a recent pilot (often) healthy study subjects to the much less selected patients
study, 32 patients undergoing primary hip arthroplasty were found in everyday clinical practice.
randomized to usual care or a package of nutritional interven- A recent study comparing total i.v. anaesthesia vs spinal an-
tions, including preoperative supplementation and carbohy- aesthesia for total knee arthroplasty found a 6 h reduction in
drate drink.37 Length of hospital stay and C-reactive protein

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length of stay and less nausea, dizziness, and orthostatic in-
were both significantly reduced in the intervention arm. There stability in the total i.v. anaesthesia group.47 This study has
were no differences in complications between the groups. been criticized for suboptimal analgesic design of the neuraxial
Another study randomized 29 patients to carbohydrate-rich group.48 Reduced length of hospital stay is otherwise consist-
drink 2 h before primary hip arthroplasty vs no beverage.38 The ently associated with the use of a neuraxial compared with a
primary outcome was metabolic state, as determined by general anaesthetic. The most recent meta-analysis of 29 stud-
insulin-like growth factor-1 concentrations. Compared with pla- ies, including 10 488 patients, showed that neuraxial anaesthe-
cebo, patients who received the carbohydrate beverage had sig- sia reduces length of stay by almost half a day compared with
nificantly higher insulin-like growth factor-1 at 5 days and general anaesthesia.46 Multi-institutional retrospective studies
2 months after surgery, which was interpreted as evidence of associated the use of general anaesthesia with an 8.5-fold
anabolic status. Higher insulin-like growth factor-1 did not increased risk of moderate to severe postoperative pain49 and a
translate into long-term changes in body composition. There 2.5-fold increased risk of persistent postsurgical pain, for hip
was a trend toward more fat loss in patients who underwent and knee arthroplasty.50 These data provide additional motiv-
surgery later in the day, ostensibly because of prolonged fasting ation to use neuraxial anaesthesia.
and catabolic state.
Others have argued that it is not the carbohydrate content of
the beverage that confers a protective benefit, but the volume Preventing and treating postoperative nausea
status of the patient at the time of induction of anaesthesia.39 and vomiting
To test this, 66 patients were randomized to fasting, water, or a
Postoperative nausea and vomiting (PONV) can be more dis-
carbohydrate drink before total hip arthroplasty under spinal
tressing than pain.51 Risk factors include female sex, non-
anaesthesia. There were no differences between the three
smoking status, a history of motion sickness or previous PONV,
groups in any markers of catabolism (insulin resistance, glucose
and predicted requirement for postoperative opioids.52 The best
clearance, or cortisol concentrations) or haemodynamic status.
way to manage PONV is probably to avoid general anaesthesia
However, patients in the fasting group received 10% more intra-
and to minimize opioids, as discussed elsewhere in this review.
operative i.v. colloids.
Based on the criteria of Apfel and colleagues,52 patients at mod-
Taken together, there are currently insufficient data to make
erate risk of PONV (i.e. two risk factors) should receive prophy-
a decision for or against preoperative carbohydrate supplemen-
laxis with dexamethasone at induction or a serotonin receptor
tation for joint arthroplasty. It is unclear whether supplementa-
antagonist at the end of surgery. High-risk individuals (three or
tion contributes to (i) a metabolically fed state during surgery,
more factors) should receive both dexamethasone at the begin-
and (ii) whether that state contributes to improved outcomes.
ning of surgery and a serotonin receptor antagonist at the end
The available evidence is from small trials of hip arthroplasty
of surgery.
patients. The methods used for assessing anabolic/catabolic
Forgoing dexamethasone prophylaxis in a diabetic patient
state are inconsistent and not without controversy.39 However,
should be decided on an individual basis, after balancing the in-
the risk vs benefit of liberal fasting and carbohydrate loading be-
dividual risk of PONV with hyperglycaemia. Dexamethasone in-
fore elective colorectal surgery suggests that similar concepts
creases blood glucose in both diabetic and non-diabetic patients
could be applied safely and effectively to elective joint
in a dose-dependent fashion, but evidence of an association
replacement.
with complications is currently lacking.53 54 Furthermore, the
peak hyperglycaemia is limited in diabetic patients and can
probably be managed effectively with perioperative insulin.55
Standardized anaesthetic protocol
There is a physiological argument that regional anaesthesia is
the optimal ERAS technique for hip and knee replacement.
Postoperative analgesia
Neuraxial anaesthesia is sufficient for surgery, provides a sym- Enhanced recovery after surgery protocols advocate multi-
pathetic block, inhibits stress hormone release, and attenuates modal, opioid-sparing techniques as the basis for postoperative
postoperative insulin release.40 41 pain control.29 For this reason, use of epidural analgesia,
iii66 | Soffin and YaDeau

peripheral nerve block, acetaminophen, and non-steroidal anti- The role of additional oral adjuvants for multimodal anal-
inflammatory drugs feature prominently. General anaesthesia gesia is unclear. A meta-analysis found opioid sparing from
and subsequent monotherapy with i.v. opioids are not corre- gabapentin for knee arthroplasty.81 The anticonvulsant prega-
lated with optimal analgesia after total knee replacement.56 balin has been studied, with mixed evidence that perioperative
Non-steroidal anti-inflammatory drugs57 58 and acetamino- pregabalin reduces opioid consumption and prevents chronic
phen59 60 are opioid sparing and promote efficient postoperative neuropathic pain after total knee82 83 or total hip arthroplasty.84
analgesia, but on their own are typically insufficient. There are However, in conjunction with an epidural, adductor canal block,
several reasonable choices for initial postoperative analgesic and multimodal oral analgesia after knee arthroplasty, pregaba-
therapy: patient-controlled epidural analgesia, peripheral nerve lin was associated with increased sedation, lower patient satis-
block (either single injection or continuous), and peri-articular faction, and no benefit on pain scores.85 There is recent interest
injection/local infiltration analgesia. All three of these choices in gabapentinoids as adjuncts to prevent PONV after joint
have ardent advocates; some institutions favour combinations arthroplasty by virtue of the opioid-sparing effect. Some meta-
of all. Unfortunately, many studies compare an advanced anal- analyses show that gabapentinoids reduce nausea after hip83 or
gesic modality with systemic opioids; direct head-to-head com- knee86 replacement, although there was no effect on the inci-
parisons are less common.61 dence of vomiting in either study. Another meta-analysis failed
Excellent analgesia can be achieved by continuous epidural to find any protective PONV effect of gabapentin after knee
local anaesthetic with or without opioids after knee or hip re- arthroplasty.87 These benefits need to be balanced against the
placement.62 It is important to avoid high concentrations of epi- risk of sedation or dizziness from gabapentinoids.

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dural local anaesthetics, so as to reduce side-effects. Addition of The antidepressant duloxetine, when added to a compre-
an opioid (fentanyl or hydromorphone) or clonidine allows very hensive postoperative analgesic regimen, also failed to affect
low concentrations of local anaesthetic to be used, but the addi- pain scores after knee arthroplasty.88 However, duloxetine sub-
tives have their own side-effects.63 stantially reduced both opioid use and nausea. It is possible that
Continuous peripheral nerve catheters have become a popu- the baseline analgesic regimen used in these latter two studies87
88
lar and effective technique for extended analgesia after knee was so effective that the benefits of duloxetine and pregabalin
arthroplasty.64 65 Femoral nerve continuous catheters provide were not revealed; future studies in institutions that do not use
analgesia comparable to an epidural, but with potentially fewer comprehensive multimodal pain therapy regimens may provide
side-effects.66 The adductor canal catheter has recently attained insight.89
prominence. Several recent trials show that adductor canal
catheters and femoral catheters provide equivalent analgesia
without quadriceps weakness.6770 Early mobilization
Combination of epidural analgesia and a single-injection
Early mobilization is a key component of ERAS programmes.
nerve block has been advocated as a way to improve analgesia
Adverse physiological effects of prolonged bed rest include
for knee arthroplasty, with reduced pain scores with therapy
increased insulin resistance, myopathy, reduced pulmonary
and improved physical therapy outcomes.71 Adductor canal
function, impaired tissue oxygenation, and increased risk of
block combined with epidural analgesia provides analgesia
thromboembolism.90 Safe and effective analgesia is a prerequis-
similar to the combination of femoral nerve block plus epidural
ite to encourage postoperative mobilization.91 There is good evi-
analgesia but without the quadriceps weakness that can limit
dence that early mobilization facilitates recovery after hip and
rehabilitation and contribute to falls.72 If longer-duration nerve
knee arthroplasty. A recent meta-analysis shows a significant
block is desired, adjuvants such as dexamethasone can be con-
reduction in length of stay (by 1.8 days) when patients ambulate
sidered,73 but adjuvants are not without controversy.
within 24 h of surgery.92 Early mobilization after knee arthro-
Local infiltration analgesia (LIA) is a recent technique for
plasty is also associated with improved functional recovery93
early postoperative analgesia after knee arthroplasty.74 Local in-
and lower incidence of DVT.94 95
filtration analgesia is administered by surgeons and does not re-
Despite these benefits, it is unknown whether early mobil-
quire the ongoing management that is found with epidural or
ization is associated with other complications after joint arthro-
peripheral nerve catheters. Local infiltration analgesia provides
plasty, including loosening, dislocation, and bleeding.
612 h of pain relief after knee arthroplasty,74 so patients benefit
High-quality studies of postdischarge rehabilitation are also
from multimodal analgesia and scheduled oral opioids. Many of
lacking, including the ideal composition and duration of a
the early studies that promoted use of LIA compared LIA with
course of treatment.
opioids only and did not compare LIA with other regional anaes-
thesia modalities.61 Comparison of LIA for knee arthroplasty
with epidural analgesia (with single-injection femoral nerve
block) revealed that LIA was not superior on readiness for dis-
Maintaining normothermia
charge, but LIA was associated with increased pain and Multiple series suggest that normothermia should be targeted
increased opioid usage.75 Local infiltration analgesia for hip as part of the anaesthetic care of the joint arthroplasty patient.
arthroplasty (compared with epidural analgesia) gave similar re- Maintaining perioperative normothermia with forced-air heat-
sults, with failure to improve readiness for discharge, higher ing has been firmly established to reduce infection,96 cardiac
pain scores, and increased opioid usage.76 The ideal compos- complications,97 coagulopathy, and transfusion requirements.98
ition of the LIA is unclear, but use of liposomal bupivacaine ap- Aggressive warming reduced intraoperative blood loss during
pears to be worse than use of plain bupivacaine.77 There is a total hip arthroplasty99 and was associated with reduced opioid
growing body of literature addressing the role of LIA vs periph- need and greater satisfaction after total knee arthroplasty.100
eral nerve block.7880 As with epidural analgesia, it is possible Active intraoperative warming before tourniquet deflation pre-
that the future of LIA research and practice involves advances vented subsequent hypothermia in elderly patients undergoing
in multimodal analgesia and combination with single-injection primary knee replacement under general anaesthesia.101
peripheral nerve block. Prewarming the operating room before total hip or knee
ERAS for hip and knee arthroplasty | iii67

replacement seems to be a less effective strategy and did not for reduced postoperative infection, organ complications, and
prevent intraoperative hypothermia in hip or knee risk of blood transfusion in the GDFT group compared with con-
replacement.102 trol. Unlike other surgical subspecialties, in elective joint re-
One argument against maintaining normothermia is the placement the role, type, and volume of i.v. fluids have not been
possible neuroprotective effect of mild hypothermia. Short- investigated. The effects of i.v. fluid on postsurgical outcomes
term postoperative cognitive impairment has been associated are likewise unknown. These topics are ripe for future
with warmer temperatures in elderly patients after knee re- investigation.
placement.103 The long-term effects of mild hypothermia for
joint replacement, who might benefit, and how to risk stratify
patients are intriguing avenues for research. In the interim, Blood conservation
there are sufficiently described benefits of normothermia to rec-
A conservative blood management strategy is crucial to the suc-
ommend a normothermic goal as part of ERAS protocols.
cess of an ERAS programme. Allogeneic blood transfusion is
associated with immunomodulation and volume overload.111
112
On the contrary, transfusion and anaemia are both associ-
Antimicrobial prophylaxis ated with increased incidence of infection, increased length of
Infection after joint arthoplasty is a serious complication that stay, and higher mortality after joint arthroplasty.111113 Risk
can be difficult to treat.104 There is currently no defined factors associated with allogeneic transfusion after knee re-
guideline for antibiotic/antiseptic prophylaxis for joint replace- placement include age >75 yr, male sex, hypertension, and

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ment.105 The Agency for Healthcare Research and Quality- BMI <27 kg m2.114 115 The presence of more than one risk factor
recommended regimen for patients undergoing primary hip significantly increases the likelihood of transfusion, suggesting
and knee arthroplasty is cefazolin.106 Clindamycin and vanco- that correction of preoperative anaemia is particularly import-
mycin should be reserved as alternative agents, if there is a ant in patients with multiple risk factors.116 Options to increase
cephalosporin allergy or surveillance data indicating causative preoperative haemoglobin include iron supplements117 and
organisms. Intranasal mupirocin is recommended for all pa- erythropoietin.118 Both are associated with a lower requirement
tients with documented S. aureus colonization. for transfusion after hip and knee arthroplasty.
Recent evidence from a large systematic review and meta- There are several strategies for intraoperative blood conser-
analysis indicated that systemic antibiotic prophylaxis before vation. Hypotensive epidural anaesthesia for primary hip
hip replacement significantly reduced the incidence of infec- arthroplasty minimizes blood loss119 without increasing compli-
tion.105 For all other outcomes, including infection after knee re- cations, including stroke and myocardial infarction120 or renal
placement, there were no differences found in any comparisons injury.121 Blood salvage techniques minimize the effects of
made, including timing, route of administration, or dose of anti- acute blood loss during both total hip122124 and total knee
biotic studied. Overall, the quality of data was considered poor, arthroplasty.125127 However, blood salvage did not eliminate
with unclear or high risk of bias, and the majority of the studies the need for allogeneic transfusion, especially in patients with
(20 out of 30) were >20 yr old; importantly, patient characteris- low preoperative haemoglobin. Pharmacological interven-
tics, selection, optimization, and surgical and anaesthetic tech- tionsspecifically, the antifibrinolytic tranexamic acidhave
niques have changed dramatically during this time. The supplanted cell salvage techniques in recent years,128 with mul-
authors end with a call to replicate some of the trials using large tiple publications demonstrating both clinical and cost efficacy
registries and taking into account local resistance patterns. in hip,129 130 knee,131133 and bilateral total knee arthroplasty.134
They consider this especially important in primary knee arthro- Tranexamic acid reduces blood loss and the risk of transfusion
plasty, where no historic placebo comparator trials exist. irrespective of the route of administration (i.v.135 or topical136).
Antibiotic-loaded bone cement might reduce infection rates The benefits afforded by tranexamic acid are achieved without
after joint arthroplasty. The evidence is more robust in hip com- significant increase in side-effects, including DVT, PE, stroke,
pared with knee arthroplasty.107 108 A recent systematic review myocardial infarction, or seizure.131 133 137
and meta-analysis concluded that there is a paucity of well-con-
ducted trials, and evidence of the protective effect is insufficient
to recommend routine use in primary knee replacement.109 Venous thromboembolism prophylaxis
Additional research into the role of antibiotic-loaded bone ce-
Current guidelines from the American College of Chest
ment should also address concerns about patient safety, risk of
Physicians (ACCP) recommend routine use of anticoagulants to
antibiotic-resistant microorganisms, and increased cost.
prevent clinical and radiographic DVT and PE after joint arthro-
plasty.138 Choices reviewed in the most recent guidelines in-
clude low-molecular-weight heparin (LMWH), a direct oral
Intravenous fluid therapy anticoagulant (DOAC; either a direct thrombin inhibitor or factor
Goal-directed fluid therapy (GDFT) is a prominent component of Xa inhibitor), low-dose unfractionated heparin, a vitamin K an-
ERAS protocols in multiple surgical specialties.29 However, in tagonist (usually warfarin), aspirin, and an intermittent pneu-
contrast to colorectal surgery, GDFT might be less important for matic compression device. The minimal recommended
elective joint replacement. Blood and fluid losses are likely to be duration of thromboprophylaxis is 1014 days; however, the
low, and the chance of early oral intake likely to be high. Thus, ACCP guidelines now suggest this could be extended up to 35
intraoperative fluid regimens can be more restrictive for hip or days.138
knee replacement. In any event, there are limited data exploring An alternative view, promulgated by the American Academy
GDFT in hip or knee replacement. A recent trial randomized 120 of Orthopaedic Surgeons, is that the ACCP guidelines focus in-
patients to no-protocol (control, n 40), conservative (n 40), or appropriately on prophylaxis that is effective for prevention of
GDFT using a non-invasive arterial pressure monitoring device DVT, as a surrogate for PE.139 The American Academy of
based on pulse pressure variation.110 Results were significant Orthopaedic Surgeons considers symptomatic PE, fatal PE, or
iii68 | Soffin and YaDeau

death as the primary outcomes of importance after hip or knee improvements seen in other surgical subspecialties, further
replacement. Some authors have criticised the premise that evaluation and adoption of ERAS pathways should be a priority
venographic evidence of DVT is equivalent to symptomatic, for joint arthroplasty care teams.
fatal PE, because there does not appear to be a direct correlation
between DVT and PE.140 For example, DVT is two- to three-fold
more common after knee replacement compared with hip re-
Authors contributions
placement, yet total knee arthroplasty is associated with a E.M.S. and J.T.Y. contributed equally to conceiving the idea, col-
reduced incidence of PE, compared with total hip arthro- lecting data, and drafting and revising the manuscript.
plasty.141 Additionally, all-cause mortality is higher in patients
taking potent anticoagulants (LMWH or DOAC) than in patients
receiving aspirin or warfarin, and clinically significant PE
Declaration of interest
occurred despite the use of anticoagulants.142 None declared.
Other data suggest that DOACs might be superior to LMWH
after hip or knee arthroplasty. For example, RECORD (Regulation
of Coagulation in ORthopaedic surgery to prevent Deep vein
Funding
thrombosis and pulmonary embolism) consisted of four double- This work was supported by the Department of Anesthesiology,
blind, randomized studies comparing oral rivaroxaban (factor Hospital for Special Surgery, New York, NY.
Xa inhibitor) with LMWH.143 Two studies were performed in pa-

Downloaded from http://bja.oxfordjournals.org/ by guest on December 23, 2016


tients undergoing total hip arthroplasty and two in total knee
arthroplasty. A pooled analysis of all four studies found that
References
rivaroxaban reduced the primary composite end point of venous 1. Kehlet H. Multimodal approach to control postoperative
thromboembolism (VTE) and all-cause mortality, although the pathophysiology and rehabilitation. Br J Anaesth 1997; 78:
majority of the effect was via a reduction in asymptomatic VTE. 60617
There was a small but significant increase in clinically relevant 2. Geltzeiler CB, Rotramel A, Wilson C, Deng L, Whiteford MH,
bleeding events, but fewer serious adverse events compared Frankhouse J. Prospective study of colorectal enhanced re-
with LMWH regimens. covery after surgery in a community hospital. JAMA Surg
Another key difference between the two sets of guidelines is 2014; 149: 95561
that the American Academy of Orthopaedic Surgeons places 3. Melnyk M, Casey RG, Black P, Koupparis J. Enhanced recov-
higher priority on wound complications, bleeding complica- ery after surgery (ERAS) protocols: time to change practice?
tions, and other adverse events that are exacerbated by chemo- Can Urol Assoc J 2011; 5: 3428
prophylaxis, compared with the ACCP. These differences lead to 4. Kinsman L, Rotter T, James E, Snow P, Willis J. What is a
different trials being included in the systematic reviews upon clinical pathway? Development of a definition to inform
which the recommendations are made by the two associations. the debate. BMC Med 2010; 8: 31
The safety of initiating VTE prophylaxis with concurrent epi- 5. Sharrock NE, Cazan MG, Hargett MJ, Williams-Russo P,
dural analgesia must be considered in ERAS for joint arthro- Wilson PD Jr. Changes in mortality after total hip and knee
plasty. The incidence of clinically significant bleeding arthroplasty over a ten-year period. Anesth Analg 1995; 80:
associated with neuraxial block and VTE thromboprophylaxis is 2428
unknown, but may be as high as 1:3000 in some populations.144 6. Barbieri A, Vanhaecht K, Van Herck P, et al. Effects of clinical
According to American Society of Regional Anesthesia and Pain pathways in the joint replacement: a meta-analysis. BMC
Medicine guidelines, prophylactic LMWH should be given no Med 2009; 7: 32
less than 12 h before insertion or removal of an epidural cath- 7. Duggal S, Flics S, Cornell CN. Introduction of clinical path-
eter.144 American Society of Regional Anesthesia and Pain ways in orthopedic surgical care: the experience of the hos-
Medicine guidelines consistently recommend against twice pital for special surgery. In: CR MacKenzie, CN Cornell, SG
daily LMWH dosing in the presence of an epidural catheter. The Memtsoudis, eds. Perioperative Care of the Orthopedic Patient.
American Society of Regional Anesthesia and Pain Medicine New York: Springer, 2014; 36571
additionally recommends withholding DOACs 35 days before 8. Hebl JR, Kopp SL, Ali MH, et al. A comprehensive anesthesia
performing a neuraxial block (depending on the drug), and wait- protocol that emphasized peripheral nerve blockade for
ing 6 h after oral administration (for all DOACs) for removal or total knee and total hip arthroplasty. J Bone Joint Surg Am
manipulation of an epidural catheter. 2005; 87 (Suppl 2): 6371
9. Hebl JR, Dilger JA, Byer DE, et al. A pre-emptive multimodal
pathway featuring peripheral nerve block improves peri-
operative outcomes after major orthopedic surgery. Reg
Conclusions Anesth Pain Med 2008; 33: 5107
Significant progress has been made in the application of ERAS 10. Duncan CM, Hall Long K, Warner DO, et al. The economic
to hip and knee arthroplasty. Decades of research have im- implications of a multimodal analgesic regimen combined
proved patient safety, improved outcomes, reduced length of with minimally invasive orthopedic surgery: a comparative
hospital stay, and effected cost savings. However, there is still cost study. J Anesth Clin Res 2010; 1: 101
significant work to be done. Additional evidence is needed to 11. Duncan CM, Moeschler SM, Horlocker TT, Hanssen AD,
confirm that adoption of ERAS protocols benefits hip and knee Hebl JR. A self-paired comparison of perioperative out-
arthroplasty patients. Future research should focus on under- comes before and after implementation of a clinical path-
standing which components contribute to improved recovery, way in patients undergoing total knee arthroplasty. Reg
and via what mechanism. Studies on individual components of Anesth Pain Med 2013; 38: 5338
ERAS and pathways implemented in totality need to be accom- 12. Malviya A, Martin K, Harper I, et al. Enhanced recovery pro-
panied by audit of practices and processes. Given the significant gram for hip and knee replacement reduces death rate. A
ERAS for hip and knee arthroplasty | iii69

study of 4500 consecutive primary hip and knee replace- no effect on gastric fluid volume and pH in fasting and non-
ment. Acta Orthop 2011; 82: 57781 fasting obese patients. Can J Anaesth 2004; 51: 1115
13. Jrgensen CC, Kehlet H. On behalf of the Lundbeck 31. Breuer JP, von Dossow V, von Heymann C, et al.
Foundation Centre for Fast-track hip and knee replacement Preoperative oral carbohydrate administration to ASA III-IV
collaborative Group. Role of patient characteristics for fast- patients undergoing elective cardiac surgery. Anesth Analg
track hip and knee arthroplasty. Br J Anaesth 2013; 110: 2006; 103: 1099108
97280 32. Kong MF, Horowitz M. Diabetic gastroparesis. Diabet Med
14. Starks I, Wainwright TW, Lewis J, Lloyd J, Middleton RG. 2005; 22(Suppl 4): 138
Older patients have the most to gain from orthopaedic 33. Svanfeldt M, Thorell A, Hausel J, et al. Randomized clinical
enhanced recovery programmes. Age Ageing 2014; 43: 6428 trial of the effect of preoperative oral carbohydrate treat-
15. Aasvang EK, Luna IE, Kehlet H. Challenges in postdischarge ment on postoperative whole-body protein and glucose
function and recovery: the case of fast-track hip and knee kinetics. Br J Surg 2007; 94: 134250
arthroplasty. Br J Anaesth 2015; 115: 8616 34. Yuill KA, Richardson RA, Davidson H, Garden OJ, Parks RW.
16. Winther SB, Foss OA, Wik TS, et al. 1-year follow-up of 920 The administration of an oral carbohydrate-containing
hip and knee Arthroplasty patients after implementing fluid prior to major elective upper-gastrointestinal surgery
fast-track. Acta Orthop 2015; 86: 7885 preserves skeletal muscle mass postoperatively: a rando-
17. Goon AK, Dines DM, Craig EV, et al. A clinical pathway for mised clinical trial. Clin Nutr 2005; 24: 327
total shoulder arthroplasty A pilot study. HSS Jl 2014; 10: 35. Nygren JT, Thorell AL, Ljungqvist O. Preoperative oral

Downloaded from http://bja.oxfordjournals.org/ by guest on December 23, 2016


1006 carbohydrate nutrition: an update. Curr Opin Clin Nutr Metab
18. Pederson SJ, Borgbjerg FM, Schousboe B, et al. A comprehen- Care 2001; 4: 2559
sive hip fracture program reduces complication rates and 36. Noblett SE, Watson DS, Huong H, Davison B, Hainsworth PJ,
mortality. J Am Geriatr Soc 2008; 56: 18318 Horgan AF. Pre-operative oral carbohydrate loading in colo-
19. Macfie D, Zadeh RA, Andrews M, Crowson J, Macfie J. rectal surgery: a randomized controlled trial. Colorectal Dis
Perioperative multimodal optimisation in patients undergo- 2006; 8: 5639
ing surgery for fractured neck of femur. Surgeon 2012; 10: 904 37. Alito MA, de Aguilar-Nascimento JE. Multimodal periopera-
20. Gupta A. The effectiveness of geriatrician-led comprehen- tive care plus immunonutrition versus traditional care in
sive hip fracture collaborative care in a new acute hip unit total hip arthroplasty: a randomized pilot study. Nutr J 2016;
based in a general hospital setting in the UK. J R Coll 15: 34
Physicians Edinb 2014; 44: 206 38. Aronsson A, Al-Ani NA, Brismar K, Hedstrom M. A
21. Wainwright TW, Middleton RG. PO019 What is the potential carbohydrate-rich drink shortly before surgery affected
effect on national bed capacity if ERAS was applied to all IGF-I bioavailability after a total hip replacement. A double-
fractured neck of femur patients? Abstracts of the World blind placebo controlled study on 29 patients. Aging Clin Exp
Congress of Enhanced Recovery After Surgery and Res 2009; 21: 97101
Perioperative Medicine, Washington, DC, USA, 912 May 39. Ljunggren S, Hahn RG. Oral nutrition or water loading be-
2015. Can J Anesth/J Can Anest 2015; 62: 683720 fore hip replacement surgery: a randomized clinical trial.
22. Bondy LR, Sims N, Schroeder DR, Offord KP, Narr BJ. The ef- Trials 2012; 13: 97
fect of anesthetic patient education on preoperative patient 40. Halter JB, Pflug AE. Effects of anesthesia and surgical stress
anxiety. Reg Anesth Pain Med 1999; 24: 15864 on insulin secretion in man. Metabolism 1980; 29(11 Supp 1):
23. Halaszynski TM, Juda R, Silverman DG. Optimizing postop- 11247
erative outcomes with efficient preoperative assessment 41. Riis J, Lomholt B, Haxholdt O, et al. Immediate and long-term
and management. Crit Care Med 2004; 32(Suppl): S7686 mental recovery from general versus epidural anesthesia in
24. McDonald S, Hetrick S, Green S. Pre-operative education for elderly patients. Acta Anaesthesiol Scand 1983; 27: 449
hip or knee replacement. Cochrane Database Syst Rev 2004; 42. Hu S, Zhang Z-Y, Hua Y-Q, Li J, Cai Z-D. A comparison of re-
2004(1): CD003526 gional and general anesthesia for total replacement of the
25. McDonald S, Page MJ, Beringer K, et al. Preoperative educa- hip or knee: a meta-analysis. J Bone Joint Surg Br 2009; 91:
tion for hip or knee replacement. [update of: Cochrane 93542
Database Syst Rev. 2004(1):CD003526]. Cochrane Database 43. Stundner O, Chiu Y-L, Sun X, et al. Comparative periopera-
Syst Rev 2014; 13: CD003526 tive outcomes associated with neuraxial versus general an-
26. OConnor MI, Brennan K, Kazmerchak S, Pratt J. YouTube esthesia for simultaneous bilateral total knee arthroplasty.
videos to create a Virtual Hospital Experience for hip and Reg Anesth Pain Med 37: 63844
knee replacement patients to decrease preoperative anx- 44. Memtsoudis SG, Stundner O, Rasul R, et al. Sleep apnea and
iety: a randomized trial. Interact J Med Res 2016; 5: e10 total joint arthroplasty under various types of anesthesia: a
27. Brady M, Kinn S, Stuart P. Preoperative fasting for adults to population-based study of perioperative outcomes. Reg
prevent perioperative complications. Cochrane Database Syst Anesth Pain Med 2013; 38: 27481
Rev 2003; 2003(4): CD004423 45. Crowley C, Dowsey MM, Quinn C, Barrington M, Choong PF.
28. Ljungqvist O, Sreide E. Preoperative fasting. Br J Surg 2003; Impact of regional and local anaesthetics on length of stay
90: 4006 in knee arthroplasty. ANZ J Surg 2012; 82: 20714
29. Lassen K, Soop M, Nygren J, et al. Consensus review of opti- 46. Johnson RL, Kopp SL, Burkle CM, et al. Neuraxial vs general
mal perioperative care in colorectal surgery. Enhanced anaesthesia for total hip and total knee arthroplasty: a sys-
Recovery After Surgery (ERAS) Group recommendations. tematic review of comparative-effectiveness research. Br J
JAMA Surg 2009; 144: 9619 Anaesth 2016; 116: 16376
30. Maltby JR, Pytka S, Watson NC, Cowan RA, Fick GH. 47. Harsten A, Kehlet H, Ljung P, Toksvig-Larsen S. Total intra-
Drinking 300 mL of clear fluid two hours before surgery has venous general anaesthesia vs. spinal anaesthesia for total
iii70 | Soffin and YaDeau

hip arthroplasty: a randomised controlled trial. Acta 65. Ilfeld BM. Continuous peripheral nerve blocks: an update of
Anaesthesiol Scand 2015; 59: 298309 the published evidence and comparison with novel, alter-
48. McCartney CJL, Choi S. Does anaesthetic technique really native analgesic modalities. Anesth Analg 2016; in press
matter for total knee arthroplasty? Br J Anaesth 2013; 111: 66. Barrington MJ, Olive D, Low K, Scott DA, Brittain J, Choong P.
3313 Continuous femoral nerve blockade or epidural analgesia
49. Liu SS, Buvanendran A, Rathmell JP, et al. Predictors for after total knee replacement: a prospective randomized
moderate to severe acute postoperative pain after total hip controlled trial. Anesth Analg 2005; 101: 18249
and knee replacement. Int Orthop 2012; 36: 22617 67. Elkassabany NM, Antosh S, Ahmed M, et al. The risk of falls
50. Liu SS, Buvanendran A, Rathmell JP, et al. A cross-sectional after total knee arthroplasty with the use of a femoral nerve
survey on prevalence and risk factors for persistent post- block versus an adductor canal block: a double-blinded
surgical pain 1 year after total hip and knee replacement. randomized controlled study. Anesth Analg 2016; 122:
Reg Anesth Pain Med 2012; 37: 41522 1696703
51. Van den Bosch JE, Bonsel GJ, Moons KG, Kalkman CJ. Effect 68. Shah NA, Jain NP. Is continuous adductor canal block better
of postoperative experiences on willingness to pay to avoid than continuous femoral nerve block after total knee
postoperative pain, nausea, and vomiting. Anesthesiology arthroplasty? Effect on ambulation ability, early functional
2006; 104: 10339 recovery and pain control: a randomized controlled trial. J
52. Apfel CC, Kranke P, Eberhart LH, Roos A, Roewer N. Arthroplasty 2014; 29: 22249
Comparison of predictive models for postoperative nausea 69. Machi AT, Sztain JF, Kormylo NJ, et al. Discharge readiness

Downloaded from http://bja.oxfordjournals.org/ by guest on December 23, 2016


and vomiting. Br J Anaesth 2002; 88: 23440 after tricompartment knee arthroplasty: adductor canal
53. Low Y, White WD, Habib AS. Postoperative hyperglycemia versus femoral continuous nerve blocks. A dual-center,
after 4- vs 8-10-mg dexamethasone for postoperative nau- randomized trial. Anesthesiology 2015; 123: 44456
sea and vomiting prophylaxis in patients with type II dia- 70. Jaeger P, Zaric D, Fomsgaard JS, et al. Adductor canal block
betes mellitus: a retrospective database analysis. J Clin versus femoral nerve block for analgesia after total knee
Anesth 2015; 27: 58994 arthroplasty: a randomized, double-blind study. Reg Anesth
54. Tien M, Gan TJ, Dhakal I, et al. The effect of anti-emetic Pain Med 2013; 38: 52632
doses of dexamethasone on postoperative blood glucose 71. YaDeau JT, Cahill JB, Zawadsky MW, et al. The effects of
levels in non-diabetic and diabetic patients: a prospective femoral nerve blockade in conjunction with epidural anal-
randomised controlled study. Anaesthesia 2016; 71: 103743 gesia after total knee arthroplasty. Anesth Analg 2005; 101:
55. Abdelmalak BB, Bonilla AM, Yang D, et al. The hypergly- 8915
cemic response to major noncardiac surgery and the added 72. Kim DH, Lin Y, Goytizolo EA, et al. Adductor canal block ver-
effect of steroid administration in patients with and with- sus femoral nerve block for total knee arthroplasty: a pro-
out diabetes. Anesth Analg 2013; 116: 111622 spective, randomized, controlled trial. Anesthesiology 2014;
56. Wang H, Boctor B, Verner J. The effect of single-injection 120: 54050
femoral nerve block on rehabilitation and length of hospital 73. Choi S, Rodseth R, McCartney CJL. Effects of dexametha-
stay after total knee replacement. Reg Anesth Pain Med 2002; sone as a local anaesthetic adjuvant for brachial plexus
27: 13944 block: a systematic review and meta-analysis of random-
57. Buvanendran A, Kroin JS, Tuman KJ, et al. Effects of peri- ized trials. Br J Anaesth 2014; 112: 42739
operative administration of a selective cyclooxygenase 2 in- 74. Kehlet H, Andersen L&Oslash;. Local infiltration analgesia
hibitor on pain management and recovery of function after in joint replacement: the evidence and recommenda-
knee replacement: a randomized controlled trial. JAMA tions for clinical practice. Acta Anaesthesiol Scand 2011; 55:
2003; 290: 24118 77884
58. Kazerooni R, Tran MH. Evaluation of celecoxib addition to 75. YaDeau JT, Goytizolo EA, Padgett DE, et al. Analgesia after
pain protocol after total hip and knee arthroplasty stratified total knee replacement: local infiltration versus epidural
by opioid tolerance. Clin J Pain 2015; 31: 9038 combined with a femoral nerve blockade: a prospective,
59. Apfel CC, Jahr JR, Kelly CL, Ang RY, Oderda GM. Effect of i.v. randomised pragmatic trial. Bone Joint J 2013; 95-B: 62935
acetaminophen on total hip or knee replacement surgery: a 76. Jules-Elysee KM, Goon AK, Westrich GH, et al. Patient-con-
case-matched evaluation of a national patient database. trolled epidural analgesia or multimodal pain regimen with
Am J Health Syst Pharm 2015; 72: 19618 periarticular injection after total hip arthroplasty: a
60. Gupta A, Abubaker H, Demas E, Ahrendtsen BS. A random- randomized, double-blind, placebo-controlled study. J Bone
ized trial comparing the safety and efficacy of intravenous Joint Surg Am 2015; 97: 78998
ibuprofen versus ibuprofen and acetaminophen in knee or 77. Bagsby DT, Phillip HI, Meneghini RM. Liposomal bupivacaine
hip arthroplasty. Pain Physician 2016; 19: 34956 versus traditional periarticular injection for pain control after
61. McCartney CJL, McLeod GA. Local infiltration analgesia for total knee arthroplasty. J Arthroplasty 2014; 29: 168790
total knee arthroplasty. Br J Anaesth 2011; 107: 4879 78. Fan L, Zhu C, Zan P, et al. The comparison of local infiltra-
62. Choi PT, Bhandari M, Scott J, Douketis J. Epidural analgesia tion analgesia with peripheral nerve block following total
for pain relief following hip or knee replacement. Cochrane knee arthroplasty (TKA): a systematic review with meta-
Database Syst Rev 2003; 2003(3): CD003071 analysis. J Arthroplasty 2015; 30: 166471
63. Liu SS, Bae JJ, Bieltz M, Wukovits B, Ma Y. A prospective sur- 79. Jimenez-Almonte JH, Wyles CC, Wyles SP, et al. Is local infil-
vey of patient-controlled epidural analgesia with bupiva- tration analgesia superior to peripheral nerve blockade for
caine and clonidine after total hip replacement: a pre- and pain management after THA: a network meta analysis. Clin
postchange comparison with bupivacaine and hydromor- Orthop Relat Res 2016; 474: 495516
phone in 1,000 patients. Anesth Analg 2011; 113: 12137 80. Yun XD, Yin XL, Jiang J, et al. Local infiltration analgesia ver-
64. Ilfeld BM. Continuous peripheral nerve blocks: a review of sus femoral nerve block in total knee arthroplasty: a meta-
the published evidence. Anesth Analg 2011; 113: 90425 analysis. Orthop Traumatol Surg Res 2015; 101: 5659
ERAS for hip and knee arthroplasty | iii71

81. Han C, Li XD, Jiang HQ, Ma JX, Ma XL. The use of gabapentin 98. Schmied H, Kurz A, Sessler DI, Kozek S, Reiter A. A mild
in the management of postoperative pain after total knee hypothermia increases blood loss and transfusion require-
arthroplasty: a PRISMA-compliant meta-analysis of ments during total hip arthroplasty. Lancet 1996; 347:
randomized controlled trials. Medicine 95: e3883 28992
82. Buvanendran A, Kroin JS, Della Valle CJ, Kari M, Moric M, 99. Winkler M, Akca O, Birkenberg B, et al. Aggressive warming
Tuman KJ. Perioperative oral pregabalin reduces chronic reduces blood loss during hip arthroplasty. Anesth Analg
pain after total knee arthroplasty: a prospective, random- 2000; 91: 97884
ized, controlled trial. Anesth Analg 2010; 110: 199207 100. Benson EE, McMillan DE, Ong B. The effects of active warm-
83. Mao Y, Wu L, Ding W. The efficacy of preoperative adminis- ing on patient temperature and pain after total knee arthro-
tration of gabapentin/pregabalin in improving pain after plasty. Am J Nurs 2012; 112: 2633
total hip arthroplasty: a meta-analysis. BMC Musculosk 101. Kim YS, Jeon YS, Lee JA, et al. Intra-operative warming with
Disord 2016; 17: 373 a forced-air warmer in preventing hypothermia after tour-
84. Clarke H, Page GM, McCartney CJ, et al. Pregabalin reduces niquet deflation in elderly patients. J Int Med Res 2009; 37:
postoperative opioid consumption and pain for 1 week after 145764
hospital discharge but does not affect function at 6 weeks 102. Deren ME, Machan JT, DiGiovanni CW, Ehrlich MG,
or 3 months after total hip arthroplasty. Br J Anaesth 2015; Gillerman RG. Prewarming operating rooms for prevention
115: 90311 of intraoperative hypothermia during total knee and hip
85. YaDeau JT, Lin Y, Mayman DJ, et al. Pregabalin and pain arthroplasties. J Arthroplasty 2011; 26: 13806

Downloaded from http://bja.oxfordjournals.org/ by guest on December 23, 2016


after total knee arthroplasty: a double-blind, randomized, 103. Salazar F, Don ~ ate M, Boget T, et al. Intraoperative warming
placebo-controlled, multidose trial. Br J Anaesth 2015; 115: and post-operative cognitive dysfunction after total knee
28593 replacement. Acta Anaesthesiol Scand 2011; 55: 21622
86. Hamilton TW, Strickland LH, Pandit HG. A meta-analysis on 104. Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infec-
the use of gabapentinoids for the treatment of acute post- tions. N Engl J Med 2004; 351: 164554
operative pain following total knee arthroplasty. J Bone Joint 105. Voigt J, Mosier M, Darouiche R. Systematic review and
Surg Am 2016; 98: 134050 meta-analysis of randomized controlled trials of antibiotics
87. Zhai L, Song Z, Liu K. The effect of gabapentin on acute and antiseptics for preventing infection in people receiving
postoperative pain in patients undergoing total knee primary total hip and knee prostheses. Antimicrob Agents
arthroplasty: a meta-analysis. Medicine 2016; 95: e3673 Chemother 2015; 59: 6696707
88. YaDeau JT, Brummett CM, Mayman DJ, et al. Duloxetine and 106. Bratzler DW, Dellinger EP, Olsen KM. Clinical guidelines for
subacute pain after knee arthroplasty when added to a multi- antimicrobial prophylaxis in surgery. Am J Health Syst Pharm
modal analgesic regimen: a randomized, placebo-controlled, 2013; 70: 195283
triple-blinded trial. Anesthesiology 2016; 125: 56172 107. Engester LB, Espehaug B, Lie SA, Furnes O, Havelin LI.
89. Jacobs MB, Cohen SP. Duloxetine for subacute pain manage- Does cement increase the risk of infection in primary total
ment after total knee arthroplasty. Anesthesiology 2016; 125: hip arthroplasty? Revision rates in 56,275 cemented and
4546 uncemented primary THAs followed for 016 years in the
90. Kehlet H, Wilmore DW. Multimodal strategies to improve Norwegian Arthroplasty Register. Acta Orthop 2006; 77:
surgical outcome. Am J Surg 2002; 183: 63041 3518
91. Mudambai SC, Kim TE, Howard SK, et al. Continuous ad- 108. Dale H, Hallan G, Espehaug B, Havelin LI, Engester LB.
ductor canal blocks are superior to continuous femoral Increasing risk of revision due to deep infection after hip
nerve blocks in promoting early ambulation after TKA. Clin arthroplasty. Acta Orthop 2009; 80: 63945
Orthop Relat Res 2014; 472: 137783 109. Hinarejos P, Guirro P, Puig-Verdie L, et al. Use of antibiotic-
92. Guerra ML, Singh PJ, Taylor NF. Early mobilization of pa- loaded cement in total knee arthroplasty. World J Orthop
tients who have had a hip or knee joint replacement re- 2015; 6: 87785
duces length of stay in hospital: a systematic review. Clin 110. Benes J, Haidingerova L, Pouska J, et al. Fluid management
Rehabil 2015; 29: 84454 guided by a continuous non-invasive arterial pressure de-
93. Pua YH, Ong PH. Association of early ambulation with vice is associated with decreased postoperative morbidity
length of stay and costs in total knee arthroplasty: retro- after total knee and hip replacement. BMC Anesthesiol 2015;
spective cohort study. Am J Phys Med Rehabil 2014; 93: 15: 148
96270 111. Bernard AC, Davenport DL, Chang PK, Vaughan TB,
94. Pearse EO, Caldwell BF, Lockwood RJ, Hollard J. Early mobil- Zwischenberger JB. Intraoperative transfusion of 1 U to 2 U
ization after conventional knee replacement may reduce packed red blood cells is associated with increased 30-day
the risk of postoperative venous thromboembolism. J Bone mortality, surgical-site infection, pneumonia, and sep-
Joint Surg Br 2007; 89: 31622 sis in general surgery patients. J Am Coll Surg 2009; 208: 9317
95. Chandrasekaran S, Ariaretnam SK, Tsung J, Dickison D. 112. Bower WF, Jin L, Underwood MJ, Lam YH, Lai PB. Peri-opera-
Early mobilization after total knee replacement reduces the tive blood transfusion increases length of hospital stay and
incidence of deep venous thrombosis. ANZ J Sug 2009; 79: number of postoperative complications in non-cardiac sur-
5269 gical patients. Hong Kong Med J 2010; 16: 11620
96. Scott EM, Buckland R. A systematic review of intraoperative 113. Greenky M, Gandhi K, Pulido L, Restrepo C, Parvizi J.
warming to prevent postoperative complications. AORN J Preoperative anemia in total joint arthroplasty: is it associ-
2006; 83: 1090104 1107-1113. ated with periprosthetic joint infection? Clin Orthop Relat Res
97. Frank SM, Fleisher LA, Breslow MJ, et al. Perioperative main- 2012; 470: 2695701
tenance of norothermia reduces the incidence of morbid 114. Bong MR, Patel V, Chang E, Issack PS, Hebert R, Di Cesare PE.
cardiac events: a randomized clinical trial. JAMA 1997; 277: Risks associated with blood transfusion after total knee
112734 arthroplasty. J Arthroplasty 2004; 19: 2817
iii72 | Soffin and YaDeau

115. Pierson JL, Hannon TJ, Earles DR. A blood-conservation al- 131. Wei Z, Liu M. The effectiveness and safety of tranexamic
gorithm to reduce blood transfusions after total hip and acid in total hip or knee arthroplasty: a meta-analysis of
knee arthroplasty. J Bone Joint Surg Am 2004; 86: 15128 2720 cases. Transfus Med 2015; 25: 15162
116. Pola E, Papaleo P, Santoliquido A, Gasparini G, Aulisa L, De 132. Zhang H, Chen J, Chen F, Que W. The effect of tranexamic
Santis E. Clinical factors associated with an increased risk acid on blood loss and use of blood products in total knee
of perioperative blood transfusion in nonanemic patients arthroplasty: a meta-analysis. Knee Surg Sports Traumatol
undergoing total hip arthroplasty. J Bone Joint Surg Am 2004; Arthrosc 2012; 20: 174252
86: 5761 133. Yang ZG, Chen WP, Wu LD. Effectiveness and safety of
117. Cuenca JI, Garca-Erce JA, Martnez F, Cardona R, Perez- tranexamic acid in reducing blood loss in total knee
Serrano L, Mun ~ oz M. Preoperative haematinics and transfu- arthroplasty: a meta-analysis. J Bone Joint Surg Am 2012; 94:
sion protocol reduce the need for transfusion after total 11539
knee replacement. Int J Surg 2007; 5: 8994 134. He P, Zhang Z, Li Y, Xu D, Wang H. Efficacy and safety of
118. Spahn D. Anaemia and patient blood management in hip tranexamic acid in bilateral total knee replacement: a
and knee surgery. Anaesthesiology 2010; 113: 48295 meta-analysis and systematic review. Med Sci Monit 2015;
119. Sharrock NE, Mineo R, Urquhart B, Salvati EA. The effect of 21: 363442
two levels of hypotension on intraoperative blood loss dur- 135. Fu DJ, Chen C, Guo L, Yang L. Use of intravenous tranexamic
ing total hip arthroplasty performed under lumbar epidural acid in total knee arthroplasty: a meta-analysis of random-
anesthesia. Anesth Analg 1993; 76: 5804 ized controlled trials. Chin J Traumatol 2013; 16: 6776

Downloaded from http://bja.oxfordjournals.org/ by guest on December 23, 2016


120. Sharrock NE, Mineo R, Urquharat B. Haemodynamic effects 136. Alshryda S, Sukeik M, Sarda P, Blenkinsopp J, Haddad FS,
and outcome analysis of hypotensive extradural anaesthe- Mason M. A systematic review and meta-analysis of the
sia in controlled hypertensive patients undergoing total hip topical administration of tranexamic acid in total hip and
arthroplasty. Br J Anaesth 1991; 67: 1725 knee replacement. Bone Joint J 2014; 96-B: 100515 Aug
121. Sharrock NE, Beksac B, Flynn E, Go G, Della Valle AG. 137. Poeran J, Rasul R, Suzuki S, et al. Tranexamic acid use
Hypotensive epidural anaesthesia in patients with pre- and postoperative outcomes in patients undergoing
operative renal dysfunction undergoing total hip replace- total hip or knee arthroplasty in the United States: retro-
ment. Br J Anaesth 2006; 96: 20712 spective analysis of effectiveness and safety. BMJ 2014; 349:
122. del Trujillo MM, Carrero A, Mun ~ oz M. The utility of the peri- g4829
operative autologous transfusion system OrthoPAT in total 138. Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of
hip replacement surgery: a prospective study. Arch Orthop VTE in Orthopedic Surgery Patients. Antithrombotic ther-
Trauma Surg 2008; 128: 10318 apy and prevention of thrombosis, 9th ed: American College
123. Smith LK, Williams DH, Langkamer VG. Post-operative of Chest Physicians Evidence-Based Clinical Practice
blood salvage with autologous retransfusion in pri- Guidelines. Chest 2012; 141(2 Suppl): e278S325S
mary total hip replacement. J Bone Joint Surg Br 2007; 89: 139. American Academy of Orthopaedic Surgeons. Preventing
10927 venous thromboembolic disease in patients undergoing
124. Moonen AF, Knoors NT, van Os JJ, Verburg AD, Pilot P. elective hip and knee arthroplasty. Evidence based guide-
Retransfusion of filtered shed blood in primary total hip line and evidence report. 2011. Available at www.aaos.org/
and knee arthroplasty: a prospective randomized clinical researchguidelines/VTE/VTE_full_guideline.pdf (accessed
trial. Transfusion 2007; 47: 37984 22 October 2016)
125. Shenolikar A, Wareham K, Newington D, Thomas D, 140. Callaghan JJ, Dorr LD, Engh GA, et al. Prophylaxis for
Hughes J, Downes M. Cell salvage auto transfusion in total thromboembolic disease. Recommendations from the
knee replacement surgery. Transfus Med 1997; 7: 27780 American College of Chest Physiciansare they appropri-
126. Thomas D, Wareham K, Cohen D, Hutchings H. Autologous ate for orthopaedic surgery? J Arthroplasty 2005; 20: 2734
blood transfusion in total knee replacement surgery. Br J 141. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous
Anaesth 2001; 86: 66973 thromboembolism. The seventh ACCP conference on antith-
127. Mun ~ oz M, Ariza D, Garcera  n MJ, Go  mez A, Campos A. rombotic and thrombolytic therapy. Chest 2004; 12: 338S
Benefits of postoperative shed blood reinfusion in patients 142. Sharrock NE, Della Valle AG, Go G, Lyman S, Salvati EA.
undergoing unilateral total knee replacement. Arch Orthop Potent anticoagulants are associated with a higher all-
Trauma Surg 2005; 125: 3859 cause mortality rate after hip and knee arthroplasty. Clin
128. Oremus K, Sostaric S, Trkulja V, Haspl M. Influence of tran- Orthop Relat Res 2008; 466: 71421
examic acid on postoperative autologous blood retrans- 143. Turpie AGG, Lassen MR, Eriksson BI, et al. Rivaroxaban for
fuion in primary total hip and knee arthroplasty: a the prevention of venous thromboembolism after hip or
randomized controlled trial. Transfusion 2014; 54: 3141 knee arthroplasty. Pooled analysis of four studies. Thromb
129. Zhou XD, Tao LJ, Li J, Wu LD. Do we really need tranexamic Haemost 2011; 105: 44453
acid in total hip arthroplasty? A meta-analysis of nineteen 144. Horlocker TT, Wedel D, Rowlingson J, et al. Regional anesthe-
randomized controlled trials. Arch Orthop Trauma Surg 2013; sia in the patient receiving antithrombotic or thrombolytic
133: 101727 therapy: American Society of Regional Anesthesia and Pain
130. Sukeik M, Alshryda S, Haddad FS, Mason JM. Systematic re- Medicine Evidence-Based Guidelines (Third Edition). Reg
view and meta-analysis of the use of tranexamic acid in Anesth Pain Med 2010; 35: 64101
total hip replacement. J Bone Joint Surg Br 2011; 93: 3946

Handling editor: Hugh Hemmings

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