Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Multicenter Study
. 2020 Apr 1;155(4):e196024.
doi: 10.1001/jamasurg.2019.6024. Epub 2020 Apr 15.

Association Between Use of Enhanced Recovery After Surgery Protocol and Postoperative Complications in Total Hip and Knee Arthroplasty in the Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol in Elective Total Hip and Knee Arthroplasty Study (POWER2)

Javier Ripollés-Melchor  1   2   3   4 , Ane Abad-Motos  1   2   3   4 , Yolanda Díez-Remesal  5 , Marta Aseguinolaza-Pagola  6 , Lidia Padin-Barreiro  7 , Rubén Sánchez-Martín  8 , Margarita Logroño-Egea  9 , Juan C Catalá-Bauset  10 , Silvia García-Orallo  11 , Elvira Bisbe  12 , Nuria Martín  13 , Alejandro Suárez-de-la-Rica  3   4   14 , Ana B Cuéllar-Martínez  4   15 , Silvia Gil-Trujillo  16 , Juan Carlos Estupiñán-Jiménez  17 , Marta Villanova-Baraza  18 , Cristina Gil-Lapetra  19 , Pilar Pérez-Sánchez  20 , Nicolás Rodríguez-García  21 , Alvaro Ramiro-Ruiz  4   22 , Carla Farré-Tebar  23 , Alejandro Martínez-García  24 , Pedro Arauzo-Pérez  25 , Cristina García-Pérez  26 , Alfredo Abad-Gurumeta  1   2   4 , María A Miñambres-Villar  27 , Alberto Sánchez-Campos  28 , Ignacio Jiménez-López  29 , José M Tena-Guerrero  30 , Oliver Marín-Peña  31 , Míriam Sánchez-Merchante  32 , Ubaldo Vicente-Gutiérrez  33 , María C Cassinello-Ogea  34 , Carlos Ferrando-Ortolá  3   4   13 , Héctor Berges-Gutiérrez  35 , Jesús Fernanz-Antón  36 , Manuel A Gómez-Ríos  37 , Daniel Bordonaba-Bosque  38 , José M Ramírez-Rodríguez  3   4   38   39 , José Antonio García-Erce  3   4   40 , César Aldecoa  3   4   41 ; Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol in Elective Total Hip and Knee Arthroplasty (POWER2) Study Investigators Group for the Spanish Perioperative Audit and Research Network (REDGERM)
Affiliations
Multicenter Study

Association Between Use of Enhanced Recovery After Surgery Protocol and Postoperative Complications in Total Hip and Knee Arthroplasty in the Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol in Elective Total Hip and Knee Arthroplasty Study (POWER2)

Javier Ripollés-Melchor et al. JAMA Surg. .

Abstract

Importance: The Enhanced Recovery After Surgery (ERAS) care protocol has been shown to improve outcomes compared with traditional care in certain types of surgery.

Objective: To assess the association of use of the ERAS protocols with complications in patients undergoing elective total hip arthroplasty (THA) and total knee arthroplasty (TKA).

Design, setting, and participants: This multicenter, prospective cohort study included patients recruited from 131 centers in Spain from October 22 through December 22, 2018. All consecutive adults scheduled for elective THA or TKA were eligible for inclusion. Patients were stratified between those treated in a self-designated ERAS center (ERAS group) and those treated in a non-ERAS center (non-ERAS group). Data were analyzed from June 15 through September 15, 2019.

Exposures: Total hip or knee arthroplasty and perioperative management. Sixteen individual ERAS items were assessed in all included patients, whether they were treated at a center that was part of an established ERAS protocol or not.

Main outcomes and measures: The primary outcome was postoperative complications within 30 days after surgery. Secondary outcomes included length of stay and mortality.

Results: During the 2-month recruitment period, 6146 patients were included (3580 women [58.2%]; median age, 71 [interquartile range (IQR), 63-76] years). Of these, 680 patients (11.1%) presented with postoperative complications. No differences were found in the number of patients with overall postoperative complications between ERAS and non-ERAS groups (163 [10.2%] vs 517 [11.4%]; odds ratio [OR], 0.89; 95% CI, 0.74-1.07; P = .22). Fewer patients in the ERAS group had moderate to severe complications (73 [4.6%] vs 279 [6.1%]; OR, 0.74; 95% CI, 0.56-0.96; P = .02). The median overall adherence rate with the ERAS protocol was 50.0% (IQR, 43.8%-62.5%), with the rate for ERAS facilities being 68.8% (IQR, 56.2%-81.2%) vs 50.0% (IQR, 37.5%-56.2%) at non-ERAS centers (P < .001). Among the patients with the highest and lowest quartiles of adherence to ERAS components, the patients with the highest adherence had fewer overall postoperative complications (144 [10.6%] vs 270 [13.0%]; OR, 0.80; 95% CI, 0.64-0.99; P < .001) and moderate to severe postoperative complications (59 [4.4%] vs 143 [6.9%]; OR, 0.62; 95% CI, 0.45-0.84; P < .001) and shorter median length of hospital stay (4 [IQR, 3-5] vs 5 [IQR, 4-6] days; OR, 0.97; 95% CI, 0.96-0.99; P < .001).

Conclusions and relevance: An increase in adherence to the ERAS program was associated with a decrease in postoperative complications, although only a few ERAS items were individually associated with improved outcomes.

PubMed Disclaimer

Conflict of interest statement

Conflict of Interest Disclosures: Dr Ripollés-Melchor reported receiving personal fees from Edwards Lifesciences and Fresenius Kabi outside the submitted work. Dr Bisbe reported receiving personal fees from Vifor Pharma outside the submitted work. Dr Abad-Gurumeta reported receiving personal fees from Merck & Co, Ferrer Pharmaceuticals, Braun PharmaCare, Panamericana Editorial, 3M Company, Rovipharm, and Altan Pharma Ltd outside the submitted work. Dr Jiménez-López reported receiving personal fees from Edwards Lifesciences outside the submitted work. Dr Marin-Peña reported receiving personal fees from Johnson & Johnson, 3M Company, and Stryker Corporation outside the submitted work. Dr Cassinello-Ogea reported receiving personal fees from Vifor Pharma outside the submitted work. Dr García-Erce reported receiving personal fees from Alexion Pharmaceuticals, Inc, Amgen, Inc, Braun PharmaCare, Celgene Corporation, Ferrer Pharmaceuticals, GlaxoSmithKline, Inmucor, Jansen Pharmaceutica, Novartis International AG, Octapharma AG, Sanofi, Sandoz, Inc, Terumo Corporation, Vifor Pharma, and Zambon and nonfinancial support from Vifor Pharma outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. STROBE Flow Diagram for Included Patients
Figure 2.
Figure 2.. Postoperative Outcomes and Enhanced Recovery After Surgery (ERAS) Adherence
Patients are stratified by complications, type of complication, and other secondary outcomes and by quartile of adherence to the ERAS protocol. Surgical complications included all postoperative complications as defined by protocol according to the standards for definitions and use of outcome measures for clinical effectiveness research in perioperative medicine: European Perioperative Clinical Outcome (EPCO) definitions, the standardized list, definitions, and the stratification developed by the Hip Society, the standarized list and definitions of the Knee Society, and the Standardized Bleeding Definitions for Cardiovascular Clinical Trials. IQR indicates interquartile range; LOS; length of stay; and OR, odds ratio. aUnless otherwise indicated, data are expressed as number (percentage) of patients.
Figure 3.
Figure 3.. Bubble Plot of the Rate of Postoperative Complications vs Length of Stay, Number of Participating Patients, and Rate of ERAS Program Adherence
For each hospital, the plot shows the mean percentage of adherence to the Enhanced Recovery After Surgery (ERAS) program (bubble color), the mean length of hospital stay, and percentage of patients who have postoperative complications. The bubble diameter indicates the number of patients that the hospital contributed to the study.
See this image and copyright information in PMC

References

    1. Weiser TG, Regenbogen SE, Thompson KD, et al. . An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet. 2008;372(9633):-. doi:10.1016/S0140-6736(08)60878-8 - DOI - PubMed
    1. Kurtz SM, Lau E, Ong K, Zhao K, Kelly M, Bozic KJ. Future young patient demand for primary and revision joint replacement: national projections from 2010 to 2030. Clin Orthop Relat Res. 2009;467(10):2606-2612. doi:10.1007/s11999-009-0834-6 - DOI - PMC - PubMed
    1. Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries. Br J Anaesth. 2017;119(3):553. doi:10.1093/bja/aew472 - DOI - PMC - PubMed
    1. Bozic KJ, Grosso LM, Lin Z, et al. . Variation in hospital-level risk-standardized complication rates following elective primary total hip and knee arthroplasty. J Bone Joint Surg Am. 2014;96(8):640-647. doi:10.2106/JBJS.L.01639 - DOI - PubMed
    1. Maradit Kremers H, Larson DR, Crowson CS, et al. . Prevalence of total hip and knee replacement in the United States. J Bone Joint Surg Am. 2015;97(17):1386-1397. doi:10.2106/JBJS.N.01141 - DOI - PMC - PubMed

Publication types