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
ARTICLE HIGHLIGHTS
Research background

Over the past 20 years, clinical pathways (CPs) for total knee and hip arthroplasty have been evolved and optimized. Based on novel evidence and new standards, at this moment we can safely discharge patients on the day of surgery. Whereas in the past, 2-wk bed rest was the standard.

Research motivation

A clinical pathway is a stochastic process that needs to be updated with the latest evidence so the hospital, orthopedic surgeon, and other staff involved in this multidisciplinary approach will be satisfied, with financial benefits for the hospital and improved outcome for the patients. Although, these days in modern medicine, orthopedic surgeons, nurses and hospital staff still needs to be convinced by these optimized CPs. For this reason, we did this systematic review and meta-analysis.

Research objectives

The aim of the present review was to compare the effect of enhanced recovery pathways with regular pathways for adult patients with elective hip and/or knee arthroplasty for (serious) adverse events [(S)AEs], readmission rate, length of hospital stay (LoS), clinician-derived clinical outcomes, patient reported outcome measures (PROMs), and costs.

Research methods

A systematic literature search was conducted in EMBASE, PubMed, Cochrane Library, Web of Science, and CINAHL. All relevant studies were considered for analysis based on the defined eligibility criteria. For the included studies, the risk of bias was assessed. Data for sensitivity analysis were pooled for (S)AE and readmission. A qualitative analysis was performed for the results of LoS, clinician-derived outcome, PROMs, and costs.

Research results

A total of 40 studies were included, 34 in meta-analysis and 40 in qualitative analysis, with data of more than 2 million patients. The meta-analysis presented less (S)AEs in patients following the enhanced recovery pathways (ERP), with fewer readmissions when compared to the regular pathways. The readmission rate was statistically different in favor for the knee arthroplasties without heterogeneity. A reduced LoS was found in all ERP, and in half of these studies, this reduction was statistically significant. The implementation of CPs for hip and knee arthroplasty was associated with similar or improved outcome for clinician-derived outcome and PROMs. ERP were reported to be cost effective. The overall outcomes of all studies reported using Grading of Recommendation, Assessment, Development and Evaluation, presented moderate or high quality of evidence.

Research conclusions

The implementation of ERP for hip and/or knee arthroplasty results in improved clinical and patient related outcomes with financial benefits, compared to regular pathways.

Research perspectives

Based on the results presented, we recommend orthopedic surgeons worldwide, to keep optimizing their standard pathway with the latest evidence. This paper highlights the importance that regular pathways for hip and knee arthroplasty continuously need to be updated according to the latest scientific evidence, which can result in improved clinical outcomes with satisfied patients and financial benefits for patients, healthcare organizations, and hospital management. In this context, high-quality care for hip and/or knee arthroplasty can be achieved.