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Review Article 


Muath Abdulghani Alturkistani et al, 2019;3(1):108–112.

International Journal of Medicine in Developing Countries

Enhanced recovery experience after orthopedic surgery: a systematic review of patient-reported outcomes

Muath Abdulghani Alturkistani1*, Ali Mohammed Alahmari2, Hussam Hussain Alhumaidi3, Mohammed Muteb Alharbi4, Alhanouf Adnan Alqernas5, Noor Sayed Alsharkhat1, Abdullah Khalaf Alshammari1, Faisal Khalaf Alshammari1

Correspondence to: Muath Abdulghani Alturkistani

*Al-Bashir Hospital, Amman, Jordan.

Email: muath_tu [at] hotmail.com

Full list of author information is available at the end of the article.

Received: 16 December 2018 | Accepted: 31 December 2018


ABSTRACT

Enhanced recovery after surgery (ERAS) is an application that aims to improve the care of elective surgical patients. Evidence-based medical interventions were used to reduce postoperative physical and psychological trauma and stress, and thus accelerate the recovery process. This study was done to evaluate the outcome of the enhanced orthopedic recovery after the surgery program at Al-Bashir Hospital in 2018 for the total hip and total knee arthroplasty patients. The analytical description methodology was adopted by conducting a questionnaire as the study tool. The study sample consisted of 20 patients. There was a statistically significant difference at the level of significance (p = 0.05) of the orthopedic ERAS program for the total hip and total knee arthroplasty patients upon the length of stay (LOS) (in the hospital) and complication rates. Significant progress has been found in the program of ERAS after joint arthroplasty. ERAS significantly reduced LOS and complications rates after joint arthroplasty.


Keywords:

Enhanced recovery after surgery, perioperative care length of hospital stay (LOS), orthopedic surgery, complications.

Introduction

Osteoarthritis is defined as a chronic disease caused by articular cartilage damage and destruction. The surgery of total hip replacement has proved to be a sustainable, reliable, valid, and reproducible method of treatment for this disease process [1].

Health-related quality of life assessments has suggested that the return to function after arthroplasty, and particularly after primary total hip replacement, is excellent and that the money spent on these procedures is justified. With the impact of arthritis on the rise, it is expected that the frequency of total hip replacements to rise by 174% by 2030, putting these surgeries and the approach toward them in the spotlight [2].

Length of stay (LOS) after total hip replacement varies across the literature, ranging between 1 and 21 days. The trend is that of a decreasing LOS. Traditionally, in South Africa, the teaching and protocols followed were that of a longer LOS ranging between 4 and 7 days, with delayed and prolonged hospital mobilization and rehabilitation. While this is still an accepted method of treatment with excellent outcomes, very little attention is given to new or alternative protocols [3].

Enhanced recovery after surgery (ERAS) is an application that aims to improve the care of elective surgical patients. Evidence-based medical interventions were used to reduce postoperative physical and psychological trauma and stress, and thus accelerate the recovery process [4].

The primary goal is diminishing trauma and stress by shortening LOS using the least invasive surgical practices, improving patient satisfaction, thereby reducing postoperative complications, saving costs, and promoting faster recovery. Its earliest use in orthopedic surgery achieved satisfactory results. Recently, improvements in orthopedic surgical techniques and anesthesia parameters have produced exciting clinical results in enhancing postoperative recovery, particularly in joint surgery patients [5].

Figure 1. Surgical procedures distributions of both total hip and total knee arthroplasty for the patients.

ERAS seeks to optimize perioperative wellbeing by reducing the surgical stress response. To date, the outcome of ERAS pathways has been measured using a LOS (in the hospital), readmission, and complication rates [6]. However, there is now a drive to capture the patient’s perspective, and patient-reported outcome measures (PROMs) had been used to do this. PROMs are validated tests of any aspect of health that come from the patients themselves [7].

ERAS is a method of streamlining the patient’s journey pre-operatively and post-operatively for enhancing the patient recovery. The technique has been supported in other specialties, given its potential to minimize the duration of hospitalization, hasten recovery and improve patient’s awareness. ERAS is of particular interest in orthopedic surgery, where patients who often have multiple complications could gain substantial benefits from more efficient management [8].

ERAS providers are encouraged to estimate the actual benefit of ERAS according to the patient’s opinion by using patient-generated data alongside traditional measures such as LOS. They include satisfaction and quality of life scores [9]. Their collection for total elective hip and total knee arthroplasty patients have been mandatory at Al-Bashir Hospital in 2018. Patient experience is another aspect of the patient’s perspective and is considered to have equal standing alongside clinical effectiveness and patient safety as an indicator of quality [9].

It was reported that ERAS protocols produce marked 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 replacement cases. ERAS represents the next step in the evolution of standardized care. Reports of full ERAS pathways for hip or knee surgeries are lacking [5].

Table 1. Demographical characteristics of the study sample.

Variable Frequency
Gender Male 13
Female 7
Total 20
Age 10–20 years 3
21–30 years 4
31–40 years 5
Over 40 years 8
Total 20

It was indicated that ERAS is a program that aims to improve the care of elective surgical patients. Accelerated care pathways are delivered for reducing lengths of hospital stay, improved quality of treatment, and better outcomes. These programs have gained considerable popularity in orthopedics recently. However, their widespread adoption needs to be seen [10].

By evaluating the benefits of ERAS program across three hospitals in Victoria, Christelis et. al. [11] found that for ERAS patients, when compared with existing-practice patients’ LOS, there was a marked enhancement in the proportion of patients ready for discharge on Day 3 after the surgery. There were various indicators of processes and outcomes of care, involving enhanced patient awareness, earlier ambulation, reduced fasting times, less blood loss, better analgesia, and improved overall quality of recovery [11]. The aim of the present study was to evaluate the effects of ERAS orthopedic surgery at Al-Bashir Hospital.

Subjects and Methods

The present study sample was conducted by a questionnaire between January and June 2018, from the total hip and total knee arthroplasty patients at Al-Bashir Hospital (Figure 1). The study sample size was 20 patients; and Table 1 shows the demographical characteristics of the study sample.

The questionnaire of the current study was performed in two parts and as follows: Part I included the information related to the respondents and their demographic data; gender and age, whereas part II included two dimensions; LOS and the complication rates.

The questionnaire paragraphs were built upon the five-point Likert scale; to measure the variables of the study, and for the analysis, the weights of the answers were distributed as shown in Figure 2.

Figure 2. Graphics distribution of the response options in the questionnaire according to the five-point Likert scale.

Study Results and Findings

The arithmetical means and standard deviation values of the items in light of the responses obtained ranged from 3.63 to 4.33. These mean values indicated the approval of the sample to the pieces measuring the attitudes toward the LOS as the values all exceed the default meaning. More specifically, the item stating that “Medical staff response is slow during postoperative treatment” obtained the highest mean with 4.33, with a standard deviation of 0.587. Meanwhile, the item stating that “I am the one who chose to leave the hospital after the operation on my own although it must take me longer” obtained the lowest mean value of 3.63, with a standard deviation of 0.901, as shown in Table 2.

On the whole, the average value of arithmetic mean for all the responses was 4.09, with a standard deviation of 0.708, which shows the general approval of the sample study to the items measuring the variable and their positive attitude toward them.

The arithmetical means and standard deviation values of the items in light of the responses obtained ranged from 3.12 to 4.01. These mean values indicated the approval of the sample to the items measuring the attitudes toward the complication rates as the values all exceeds the default meaning. More specifically, the item stating that “I had postoperative complications caused by neglect of the nursing staff” obtained the highest mean with 4.01, with a standard deviation of 0.552. Meanwhile, the item stating that “I had postoperative complications caused by the inadequacy of the medical staff” obtained the lowest mean value of 3.12, with a standard deviation of 0.923, as shown in Table 3.

On the whole, the average value of arithmetic mean for all the responses was 3.60, with a standard deviation of 0.662, which shows the general approval of the sample study to the items measuring the variable and their positive attitude toward them.

Discussion

ERAS is defined as an evidence-based multimodal perioperative program focused on the promotion of returning to function and stress reduction. ERAS has been performed to lower both recovery time and postoperative complication rates while being cost-effective at the same time. It fundamentally shifts the traditional patient care in surgical wards to one that standardizes it, based on published evidence [2].

The purpose of ERAS in the perioperative arthroplasty period is to reduce the hospitalization time without increasing complications and readmission. ERAS program in the perioperative period of arthroplastic surgeries effects include [12]; preoperative oral carbohydrate, shortening fasting time, perioperative nutritional support, anesthesia management, greater patient education, optimization of anesthesia, early postoperative feeding, restrictive infusion, and minimally invasive surgery. Blood management includes controlled hypotension, anemia management, application of tranexamic acid, prevention of infection, and venous thromboembolism. Optimization of analgesic regimen includes preemptive analgesia, postoperative multimode analgesia, peripheral nerve block, local infiltration anesthesia; optimization of a tourniquet, drainage tube, and catheter; prevention of nausea and vomiting, sleep management; follow-up management after discharge and functional recovery exercise [12].

Table 2. Arithmetic means, standard deviations, rank, and level of the sample responses and attitudes toward the LOS (in the hospital).

No. Statement AM SD Rank Level
1 Residence in the hospital was too short 4.29 0.669 2 High
2 Medical staff response is slow during postoperative treatment 4.33 0.587 1 High
3 Postoperative complication increases hospital stay 4.21 0.627 5 High
4 The reason for shortening the hospital stay is to provide a bed for another patient 4.24 0.620 4 High
5 I am the one who chose to leave the hospital after the operation on my own, although it must take me longer 3.63 0.901 7 Medium
6 I think the period I spent in the hospital after the surgery was adequate and appropriate 3.65 0.948 6 Medium
7 The reason for shortening the LOS in the hospital is the end of the treatment process 4.25 0.604 3 High
General average 4.09 0.708 High

AM = arithmetic mean; SD = standard deviation.

Table 3. Arithmetic means, standard deviations, rank, and level of the sample responses and attitudes toward the complication rates.

No. Statement AM SD Rank Level
1 The cause of my complications after surgery is the poor management
of the treatment
3.70 0.561 3 High
2 I did not have complications after surgery 3.55 0.587 4 Medium
3 Postoperative complications were limited to pain only 3.89 0.624 2 High
4 Postoperative complications led to new surgical intervention 3.34 0.724 5 Medium
5 I had postoperative complications caused by neglect of the nursing
staff
4.01 0.552 1 High
6 I had postoperative complications caused by the inadequacy of the
medical staff
3.12 0.923 6 Medium
General average 3.60 0.662 Medium

AM = arithmetic mean; SD = standard deviation.

Previous studies found that the LOS of the ERAS groups had different degrees of reductions in the perioperative period after a series of optimization schemes for joint replacement as compared with the LOS of the non-ERAS group [5].

ERAS protocols reduce the LOS without an increase in readmission or complication rate, results in significant cost savings, post-operative complications are still an issue that continues to find ways to overcome [13].

LOS decreased markedly after the performance of ERAS, from 5.1 to 4.2 days in the colorectal resection group and 3.6 to 3.2 days in the hip fracture group. Complication rates decreased from 18.1% to 14.7% and from 30.8% to 24.9%, respectively. Early ambulation rates increased substantially, from 22.3% to 56.5% and from 2.8% to 21.2%, respectively [14].

Traditionally, LOS after arthroplastic surgeries ranged between 4 and 7 days. This period was necessary for achieving adequate mobility and due to the concerns about high rates of complications in the post-operative period. Parvizi stated that the vast majority of difficulties in arthroplastic surgeries are found to be within the first 4 days, encouraging many surgeons to supervise patients for longer in the hospital [15,16].

Conclusion

Significant progress has been found in the program of ERAS after joint arthroplasty. Decades of research have improved patient safety, reduced the LOS, improved outcomes, and complication rates. Additional studies are needed to confirm that the ERAS applications benefit knee and hip arthroplasty patients. It should focus on determining which components contribute to enhanced recovery, and via what mechanism. Studies on individual parts of ERAS and pathways implemented in totality need to be accompanied by an audit of practices and processes. ERAS significantly reduced LOS and complications rates after joint arthroplasty.

List of Abbreviations

ERAS Enhanced recovery after surgery

LOS Length of stay

PROM patient-reported outcome measures


Consent for publication

Not applicable.


Funding

None.


Declaration of conflicting interests

The authors declare that there is no conflict of interest regarding the publication of this article.


Ethical approval

Not applicable.


Author details

Muath Abdulghani Alturkistani1, Ali Mohammed Alahmari2, Hussam Hussain Alhumaidi3, Mohammed Muteb Alharbi4, Alhanouf Adnan Alqernas5, Noor Sayed Alsharkhat1, Abdullah Khalaf Alshammari1, Faisal Khalaf Alshammari1

  1. Al-Bashir Hospital, Amman, Jordan
  2. King Fahad Armed Forces Hospital, Abha, Saudi Arabia
  3. King Fahad University Hospital, Khobar, Saudi Arabia
  4. King Fahad Medical City, Riyadh, Saudi Arabia
  5. College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia

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  12. Melnyk M, Casey RG, Black P, Koupparis AJ. Enhanced recovery after surgery (ERAS) protocols: Time to change practice?. Can Urol Assoc J. 2011;5(5):342–8. https://doi.org/10.5489/cuaj.693
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How to Cite this Article
Pubmed Style

Alturkistani MA, Alahmari AM, Alhumaidi HH, Alharbi MM, Alqernas AA, Alsharkhat NS, Alshammari AK, Alshammari FK. Enhanced Recovery Experience After Orthopaedic Surgery: A Systematic Review of Patient-Reported Outcomes. IJMDC. 2019; 3(1): 108-112. doi:10.24911/IJMDC.51-1544989841


Web Style

Alturkistani MA, Alahmari AM, Alhumaidi HH, Alharbi MM, Alqernas AA, Alsharkhat NS, Alshammari AK, Alshammari FK. Enhanced Recovery Experience After Orthopaedic Surgery: A Systematic Review of Patient-Reported Outcomes. https://www.ijmdc.com/?mno=21793 [Access: January 28, 2022]. doi:10.24911/IJMDC.51-1544989841


AMA (American Medical Association) Style

Alturkistani MA, Alahmari AM, Alhumaidi HH, Alharbi MM, Alqernas AA, Alsharkhat NS, Alshammari AK, Alshammari FK. Enhanced Recovery Experience After Orthopaedic Surgery: A Systematic Review of Patient-Reported Outcomes. IJMDC. 2019; 3(1): 108-112. doi:10.24911/IJMDC.51-1544989841



Vancouver/ICMJE Style

Alturkistani MA, Alahmari AM, Alhumaidi HH, Alharbi MM, Alqernas AA, Alsharkhat NS, Alshammari AK, Alshammari FK. Enhanced Recovery Experience After Orthopaedic Surgery: A Systematic Review of Patient-Reported Outcomes. IJMDC. (2019), [cited January 28, 2022]; 3(1): 108-112. doi:10.24911/IJMDC.51-1544989841



Harvard Style

Alturkistani, M. A., Alahmari, . A. M., Alhumaidi, . H. H., Alharbi, . M. M., Alqernas, . A. A., Alsharkhat, . N. S., Alshammari, . A. K. & Alshammari, . F. K. (2019) Enhanced Recovery Experience After Orthopaedic Surgery: A Systematic Review of Patient-Reported Outcomes. IJMDC, 3 (1), 108-112. doi:10.24911/IJMDC.51-1544989841



Turabian Style

Alturkistani, Muath Abdulghani, Ali Mohammed Alahmari, Hussam Hussain Alhumaidi, Mohammed Muteb Alharbi, Alhanouf Adnan Alqernas, Noor Sayed Alsharkhat, Abdullah Khalaf Alshammari, and Faisal Khalaf Alshammari. 2019. Enhanced Recovery Experience After Orthopaedic Surgery: A Systematic Review of Patient-Reported Outcomes. International Journal of Medicine in Developing Countries, 3 (1), 108-112. doi:10.24911/IJMDC.51-1544989841



Chicago Style

Alturkistani, Muath Abdulghani, Ali Mohammed Alahmari, Hussam Hussain Alhumaidi, Mohammed Muteb Alharbi, Alhanouf Adnan Alqernas, Noor Sayed Alsharkhat, Abdullah Khalaf Alshammari, and Faisal Khalaf Alshammari. "Enhanced Recovery Experience After Orthopaedic Surgery: A Systematic Review of Patient-Reported Outcomes." International Journal of Medicine in Developing Countries 3 (2019), 108-112. doi:10.24911/IJMDC.51-1544989841



MLA (The Modern Language Association) Style

Alturkistani, Muath Abdulghani, Ali Mohammed Alahmari, Hussam Hussain Alhumaidi, Mohammed Muteb Alharbi, Alhanouf Adnan Alqernas, Noor Sayed Alsharkhat, Abdullah Khalaf Alshammari, and Faisal Khalaf Alshammari. "Enhanced Recovery Experience After Orthopaedic Surgery: A Systematic Review of Patient-Reported Outcomes." International Journal of Medicine in Developing Countries 3.1 (2019), 108-112. Print. doi:10.24911/IJMDC.51-1544989841



APA (American Psychological Association) Style

Alturkistani, M. A., Alahmari, . A. M., Alhumaidi, . H. H., Alharbi, . M. M., Alqernas, . A. A., Alsharkhat, . N. S., Alshammari, . A. K. & Alshammari, . F. K. (2019) Enhanced Recovery Experience After Orthopaedic Surgery: A Systematic Review of Patient-Reported Outcomes. International Journal of Medicine in Developing Countries, 3 (1), 108-112. doi:10.24911/IJMDC.51-1544989841