Reduced short-term complications and mortality following Enhanced Recovery primary hip and knee arthroplasty: results from 6,000 consecutive procedures

Figures & data

Table 1. Protocols followed during the different periods in this study. Adapted from Malviya et al. 2011

	Trad	ER
Pharmacological	General anesthesia, spinal or epidural according to anesthetist’s preference and patient consent	Low-dose spinal anesthesia without any intrathecal opioids with Propofol +/- Ketamine, and Paracetamol +/- Parecoxib
	Patient-controlled intravenous analgesia	Local anesthetic: intraoperative infiltration and postoperative infusion
	No thrombomodulator	Tranexamic acid
Procedural	Intravenous fluids continuing until next day	Judicious intraoperative fluid and vasopressor administration
	Perioperative urinary catheterization	Catheterization only if indicated
	Mobilization next day	Same-day mobilization
Behavioral	Generic patient and staff education	Patient and staff education on ER principles

This schematic diagram shows the patient’s progression through different components of the Enhanced Recovery program.

Table 2. A comparison of demographics and comorbidities between the two cohorts

	Trad	% (CI)	ER	% (CI)	p-value
Demographics
Mean age (SD)	69 (10)		68 (10)		0.05
Male gender	1,482	49.4 (46.9–51.9)	1,390	46.3 (43.8–48.9)	0.02
No. of TKAs	1,631	54.4 (51.8–56.9)	1,744	58.1 (55.6–60.6)	0.003
Comorbidities
Hypertension	936	31.2 (28.9–33.6)	1,409	46.9 (44.5–49.5)	< 0.001
Atrial fibrillation	143	4.8 (3.8–6.0)	162	5.4 (4.4–6.7)	0.3
Ischemic heart disease	213	7.1 (5.9–8.5)	249	8.3 (7.0–9.8)	0.09
Diabetes mellitus
insulin-dependent	21	0.7 (0.4–1.3)	33	1.1 (0.7–1.8)	0.1
non-insulin-dependent	212	7.1 (5.8–8.5)	293	9.7 (8.4–11.4)	< 0.001
Chronic obstructive
pulmonary disease	87	2.9 (2.2–3.9)	133	4.4 (3.5–5.6)	0.002
Alzheimer	7	0.2 (0.1–0.7)	9	0.3 (0.1–0.8)	0.8

Table 3. A comparison of surgical endpoints and medical complications in the 2 cohorts

	Trad	% (CI)	ER	% (CI)	p-value
LOS in days,
median (range)	6 (1–125)		3 (0–82)		0.01
Blood transfusion ^a	230/1,000	23 (20.5–25.7)	228/3,000	7.6 (6.4–9.1)	< 0.001
Re-admission	141	4.7 (3.8–5.9)	139	4.6 (3.7–5.8)	1.0
RTT (30-day)	60	2.0 (1.4–2.8)	40	1.3 (0.8–2.1)	0.05
Stroke (30-day)	14	0.5 (0.2–0.9)	7	0.2 (0.1–0.7)	0.2
GI bleed (30-day)	18	0.6 (0.3–1.2)	11	0.4 (0.2–0.9)	0.3
MI (30-day)	26	0.9 (0.5–1.5)	12	0.4 (0.2–0.9)	0.03
DVT (60-day)	23	0.8 (0.4–1.4)	14	0.5 (0.2–0.9)	0.2
PE (60-day)	36	1.2 (0.7–1.9)	32	1.1 (0.6–1.7)	0.7
Pneumonia (30-day)	29	0.9 (1.4–2.8)	36	1.2 (0.7–1.9)	0.5
Death (30-day)	16	0.5 (0.2–1.1)	5	0.2 (0.04–0.6)	0.03
Death (90-day)	25	0.8 (0.5–1.5)	14	0.5 (0.2–0.9)	0.1

LOS: length of stay; RTT: return to theater; GI: gastrointestinal; MI: myocardial infarction; DVT: deep vein thrombosis; PE: pulmonary embolism.

^a The transfusion policy changed in June 2007; thus, transfusion data are presented only for the last 1,000 traditional (Trad) arthroplasties, as compared to those for 3,000 ER procedures.

Malviya A, Martin K, Harper I, Muller SD, Emmerson KP, Partington PF, Reed MR. Enhanced recovery program for hip and knee replacement reduces death rate. Acta Orthop 2011; 82 (5): 577-81.

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