Enhanced recovery after surgery protocols in lower extremity joint arthroplasty: using observational data to identify the optimal combination of components

Abstract Background Enhanced Recovery after Surgery (ERAS) protocols are increasingly used in orthopedic surgery. Data is lacking on which combinations of ERAS components are 1) the most commonly used and 2) the most effective in terms of outcomes. Methods This retrospective cohort study utilized claims data (Premier Healthcare, n=1,539,432 total joint arthroplasties, 2006-2016. Eight ERAS components were defined: A) regional anesthesia, B) multimodal analgesia, C) tranexamic acid, D) antiemetics on day of surgery, E) early physical therapy, and avoidance of F) urinary catheters, G) patient-controlled analgesia, and H) drains. Outcomes were length of stay, ‘any complication’, and hospitalization cost. Mixed-effects models measured associations between the most common ERAS combinations and outcomes. Odds ratios (OR) and 95% confidence intervals (CI) are reported. Results In 2006-2012 and 2013-2016, the most common ERAS combinations were B/D/E/F/G/H (20%, n=172,397) and B/C/D/E/F/G/H (17%, n=120,266), respectively. The only difference between the most commonly used ERAS combinations over the years is the addition of C (addition of tranexamic acid to the protocol). The most pronounced beneficial effects in 2006-2012 were seen for combination A/B/D/E/F/G/H (6% of cases, versus less prevalent ERAS combinations) for the outcome of ‘any complication’: OR 0.87 CI 0.83-0.91; p Conclusion Despite varying ERAS protocols, maximum benefits in terms of complication reduction differed minimally. Further study may elucidate the balance between an increasing number of ERAS components and incremental benefits realized. Level of Evidence III