Systematic Reviews
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. Mar 18, 2022; 13(3): 307-328
Published online Mar 18, 2022. doi: 10.5312/wjo.v13.i3.307
Impact of enhanced recovery pathways on safety and efficacy of hip and knee arthroplasty: A systematic review and meta-analysis
Marion JLF Heymans, Nanne P Kort, Barbara AM Snoeker, Martijn GM Schotanus
Marion JLF Heymans, Zuyderland Academy, Zuyderland Medical Center, Sittard 6155 NH, Netherlands
Nanne P Kort, Department of Orthopedic Surgery, Cortoclinics, Schijndel 5482 WN, Netherlands
Barbara AM Snoeker, Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam Medical Center, University of Amsterdam, Amsterdam 1105 AZ, Netherlands
Martijn GM Schotanus, Department of Orthopaedic Surgery and Traumatology, Zuyderland Medical Center, Sittard-Geleen 6162 BG, Limburg, Netherlands
Martijn GM Schotanus, Care and Public Health Research Institute, Maastricht University Medical Centre, Faculty of Health, Medicine & Life Sciences, Maastricht 6229 ER, Limburg, Netherlands
Author contributions: Heymans MJ designed the study, gathered and analyzed the data, wrote the initial draft of the manuscript, and managed the study; Kort NP is initiator of pathway optimization; Snoeker BA ensured the accuracy of the data; Schotanus MG conceived the study, analyzed the data, and wrote the manuscript; Kort NP, Snoeker BA, and Schotanus MG revised the manuscript; and all authors read and approved the final manuscript.
Conflict-of-interest statement: One author (Kort NP) is a paid consultant for Stryker and Zimmer-Biomet. The other authors declare that they have no conflicts of interest to disclose.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to PRISMA 2009.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Marion JLF Heymans, MSc, Research Scientist, Zuyderland Academy, Zuyderland Medical Center, Dr H. van der Hoffplein 1, Sittard 6155 NH, Netherlands. m.heymans@zuyderland.nl
Received: March 25, 2021
Peer-review started: March 25, 2021
First decision: July 28, 2021
Revised: August 25, 2021
Accepted: January 19, 2022
Article in press: January 19, 2022
Published online: March 18, 2022
Abstract
BACKGROUND

Over the past decades, clinical pathways (CPs) for hip and knee arthroplasty have been strongly and continuously evolved based on scientific evidence and innovation.

AIM

The present systematic review, including meta-analysis, aimed to compare the safety and efficacy of enhanced recovery pathways (ERP) with regular pathways for patients with hip and/or knee arthroplasty.

METHODS

A literature search in healthcare databases (Embase, PubMed, Cochrane Library, CINAHL, and Web of Science) was conducted from inception up to June 2018. Relevant randomized controlled trials as well as observational studies comparing ERP, based on novel evidence, with regular or standard pathways, prescribing care as usual for hip and/or knee arthroplasty, were included. The effect of both CPs was assessed for (serious) adverse events [(S)AEs], readmission rate, length of hospital stay (LoS), clinician-derived clinical outcomes, patient reported outcome measures (PROMs), and financial benefits. If possible, a meta-analysis was performed. In case of considerable heterogeneity among studies, a qualitative analysis was performed.

RESULTS

Forty studies were eligible for data extraction, 34 in meta-analysis and 40 in qualitative analysis. The total sample size consisted of more than 2 million patients undergoing hip or knee arthroplasty, with a mean age of 66 years and with 60% of females. The methodological quality of the included studies ranged from average to good. The ERP had lower (S)AEs [relative risk (RR): 0.9, 95% confidence interval (CI): 0.8-1] and readmission rates (RR: 0.8, 95%CI: 0.7-1), and reduced LoS [median days 6.5 (0.3-9.5)], and showed similar or improved outcomes for functional recovery and PROMs compared to regular pathways. The analyses for readmission presented a statistically significant difference in the enhanced recovery pathway in favor of knee arthroplasties (P = 0.01). ERP were reported to be cost effective, and the cost reduction varied largely between studies (€109 and $20573). The overall outcomes of all studies reported using Grading of Recommendation, Assessment, Development and Evaluation, presented moderate or high quality of evidence.

CONCLUSION

This study showed that implementation of ERP resulted in improved clinical and patient related outcomes compared to regular pathways in hip and knee arthroplasty, with a potential reduction of costs.

Keywords: Hip arthroplasty, Knee arthroplasty, Joint arthroplasty, Clinical pathway, Enhanced recovery pathway, Systematic review, Meta-analysis

Core Tip: Enhanced recovery pathways for hip and knee arthroplasty help the patient and the multidisciplinary team to achieve the best possible results. Based on the results presented, it may help health care providers to make informed decisions regarding the optimization of currently used regular pathways. We strongly recommend orthopedic surgeons worldwide to keep up-to-date with the latest literature and to optimize their regular pathway with the latest evidence. This study involves an extensive literature search for care pathways for hip and knee arthroplasty, and the effects on multiple outcomes have been analyzed in terms of (serious) adverse events, readmissions, length of hospital stay, functional recovery, patient reported outcome measures, and costs.