Abstract
BackgroundThe benefits of combining enhanced recovery after surgery (ERAS) interventions with an outpatient program for total hip/knee arthroplasty (THA/TKA) are uncertain. This study's main objective was to evaluate adverse events with an ERAS-outpatient compared to standard-inpatient care and secondary objectives were to compare pain, functional recovery, PROMs and satisfaction. HypothesisThe ERAS-outpatient program would result in reduced adverse events compared to standard-inpatient care. MethodsAn ambidirectional single subject cohort study was conducted on 48 consecutive patients who experienced both a standard-inpatient and an ERAS-outpatient THA/TKA (contralaterally). Adverse event rate according to the Clavien-Dindo scale, the Comprehensive Complications Index (CCI) and the number of unplanned episodes of care were assessed. Postoperative pain on a numeric rating scale, opioid consumption in morphine milligram equivalents, functional recovery, patient reported outcome measures (PROMs) (WOMAC, KOOS, HOOS, Forgotten Joint Score and Patient Joint Perception) and patients’ satisfaction were also evaluated. ResultsFollowing the ERAS-outpatient surgery, complication rates were reduced by more than 50% (2.1 vs. 4.4, p<0.001), CCI was significantly lower (12.3 vs. 19.1, p<0.001), and similar unplanned episodes of care were observed (p>0.999). In the first 8 postoperative hours, perceived pain was similar (p>0.805) while opioid consumption was significantly reduced (9.3 vs. 26.5, p<0.001). Patients walked, climbed stairs, showered, performed activities of daily living, practised sports, went back to work sooner (p<0.001), but PROMs were similar between groups at the last follow-up (p>0.188). Patients were more satisfied of the ERAS-outpatient pathway and recommended it significantly more (p<0.002). ConclusionCompared to the conventional inpatient care, the ERAS-outpatient program proved to be safer, enable faster functional recovery, and improve patients’ satisfaction which highlight the importance of following ERAS principles when implementing an outpatient THA/TKA program. Level of evidenceIII; Ambidirectional Cohort study.
Highlights
In response to financial pressure and, more recently, to resume elective surgery in the pandemic period, there has been a shift toward using outpatient protocols for patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA).[1]
We hypothesized that the ERASoutpatient protocol would result in reduced adverse event rate, reduced pain and opioid consumption, faster functional recovery, improved PROMs and increased satisfaction when compared with standard care
We found that compared to STD-inpatient practice, enhanced recovery after surgery (ERAS)-outpatient program reduced complications by half while not resulting in more unplanned episodes of care
Summary
In response to financial pressure and, more recently, to resume elective surgery in the pandemic period, there has been a shift toward using outpatient protocols for patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA).[1]. Some studies suggested that immediate postoperative pain was better controlled by ERAS interventions[2,7] while others found no difference.3 8Some studies showed faster recovery in the first few days[7] and better functional outcomes 3-6-12 months after surgery[9,10,11] while others found no difference at all.[12,13] Improved patient satisfaction regarding the fast track pathway is controversial.[14] the primary study objective was to compare adverse event rate (complication and unplanned episode of care) and secondly to compare pain management, functional recovery, PROMS and satisfaction in patients who experienced both our ERAS-outpatient protocol and standard-inpatient care. The primary objective was to compare adverse event rate and secondly to compare pain management, functional recovery, PROMs and satisfaction in patients who experienced both an ERAS-outpatient protocol and standard-inpatient care
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