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

Acta Orthop. 2014 Feb;85(1):26-31. doi: 10.3109/17453674.2013.874925. Epub 2013 Dec 20.


Background and purpose: Enhanced Recovery (ER) is a well-established multidisciplinary strategy in lower limb arthroplasty and was introduced in our department in May 2008. This retrospective study reviews short-term outcomes in a consecutive unselected series of 3,000 procedures (the "ER" group), and compares them to a numerically comparable cohort that had been operated on previously using a traditional protocol (the "Trad" group).

Methods: Prospectively collected data on surgical endpoints (length of stay (LOS), return to theater (RTT), re-admission, and 30- and 90-day mortality) and medical complications (stroke, gastrointestinal bleeding, myocardial infarction, and pneumonia within 30 days; deep vein thrombosis and pulmonary embolism within 60 days) were compared. Results ER included 1,256 THR patients and 1,744 TKR patients (1,369 THRs and 1,631 TKRs in Trad). The median LOS in the ER group was reduced (3 days vs. 6 days; p = 0.01). Blood transfusion rate was also reduced (7.6% vs. 23%; p < 0.001), as was RTT rate (p = 0.05). The 30-day incidence of myocardial infarction declined (0.4% vs. 0.9%; p = 0.03) while that of stroke, gastrointestinal bleeding, pneumonia, deep vein thrombosis, and pulmonary embolism was not statistically significantly different. Mortality at 30 days and at 90 days was 0.1% and 0.5%, respectively, as compared to 0.5% and 0.8% using the traditional protocol (p = 0.03 and p = 0.1, respectively).

Interpretation: This is the largest study of ER arthroplasty, and provides safety data on a consecutive unselected series. The program has achieved a statistically significant reduction in LOS and in cardiac ischemic events for our patients, with a near-significant decrease in return to theater and in mortality rates.

Publication types

  • Multicenter Study

MeSH terms

  • Aged
  • Arthroplasty, Replacement, Hip / adverse effects*
  • Arthroplasty, Replacement, Hip / methods
  • Arthroplasty, Replacement, Hip / mortality
  • Arthroplasty, Replacement, Hip / rehabilitation
  • Arthroplasty, Replacement, Knee / adverse effects*
  • Arthroplasty, Replacement, Knee / methods
  • Arthroplasty, Replacement, Knee / mortality
  • Arthroplasty, Replacement, Knee / rehabilitation
  • Cardiovascular Diseases / etiology
  • Clinical Protocols
  • Delivery of Health Care / organization & administration*
  • England / epidemiology
  • Female
  • Humans
  • Length of Stay / statistics & numerical data
  • Male
  • Middle Aged
  • Patient Care Team / organization & administration
  • Patient Readmission / statistics & numerical data
  • Perioperative Care / methods
  • Program Evaluation
  • Reoperation / statistics & numerical data
  • Retrospective Studies
  • Treatment Outcome