Fast-track hip and knee arthroplasty...how fast?

Fast-track (or enhanced recovery after surgery [ERAS]) programmes for total hip arthroplasty and knee have evolved over the past 20 yr.1Kehlet H. arthroplasty.Lancet. 2013; 381: 1600-1602Abstract Full Text PDF PubMed Scopus (221) Google Scholar Their development has been driven by questions, ‘Can operation be done as an outpatient procedure?’ if not, ‘Why is patient in hospital?’ based upon analysis modification of undesirable pathophysiological responses that delay recovery.2Wainwright T.W. Kehlet — we reached goal?.Acta Orthop. 2019; 90: 3-5Crossref (25) The data confirm fast-track approaches can improve clinical economic outcomes; however, their implementation not universal.2Wainwright Scholar,3Memtsoudis S.G. Fiasconaro M. Soffin E.M. et al.Enhanced components perioperative outcomes: a nationwide observational study.Br J Anaesth. 2020; 124: 638-647Abstract Although length hospital stay (LOS) reduced 10 yr within English NHS, national mean LOS remains 4–5 days rates continue to low (data from Hospital Episode Statistics at https://digital.nhs.uk/data-and-information/data-tools-and-services/data-services/hospital-episode-statistics). In contrast, Denmark4Petersen P.B. Jorgensen C.C. Temporal trends readmissions arthroplasty.Dan Med J. 66: A5553PubMed USA,5Liu Elkassabany N. Poeran al.Association between same day discharge risks cardiac/pulmonary complications readmission: population-based study.BMJ Open. 9e031260Crossref (12) about 2 both arthroplasty, now well established selected patients many international centres.6Vehmeijer S.B.W. Husted Outpatient arthroplasty.Acta 2018; 89: 141-144Crossref (42) Importantly, definition these settings should include overnight stay, which contrast other reports using less than 23 h stay,6Vehmeijer thereby adding some confusion when interpreting data. concept new. Studies demonstrating its feasibility were first published more ago. More recently, preliminary observations support such approach feasible ∼15% unselected cohorts socialised healthcare system, with no apparent increase or re-admissions.7Gromov K. Petersen al.Complications following arthroplasty: prospective 2-center study matched controls.Acta 281-285Crossref (30) therefore attractive context policy changes advocating value-based care models, particularly given additional capacity benefits it offers, although benefit may variable depend on local factors.6Vehmeijer However, recent studies USA Canada American College Surgeons National Surgical Quality Improvement Program (NSQIP) database shown associated higher odds major minor complications5Liu Scholar,8Nowak L.L. Schemitsch E.H. Same-day delayed are worse outcomes arthroplasty.Bone Joint 101-b: 70-76Crossref (14) compared discharged one-night stay5Liu 1–2 stay.8Nowak study5Liu very large comprehensive evaluation population includes propensity accounting comorbidities amongst 226 481 140 557 patients, focus safety arthroplasty. A smaller (n=4391) US private insurance also showed risk surgical medical standard inpatient arthroplasty.9Arshi A. Leong N.L. D’Oro al.Outpatient complications.J Bone Surg Am. 2017; 99: 1978-1986Crossref (39) several limitations, including residual confounding, findings nevertheless important reminder equate optimised every patient, ERAS protocols ‘first better – then faster’.2Wainwright Consequently, there need improved prediction methods safe procedures.10Johnson D.J. Castle J.P. Hartwell M.J. D’Heurle A.M. Manning D.W. Risk factors greater Ttan 24-hour primary arthroplasty.J Arthroplasty. 35: 633-637Abstract (7) Within programme, high-risk planned longer best means accelerating reducing complications, re-admissions, morbidity.2Wainwright prudent keep specific even though they meet conventional criteria. This especially case discharging home evening instead next morning still determined vs perspective.6Vehmeijer apparently settings, generalisable data, complete post-discharge issues emergency department general practitioner visits use skilled nursing facilities, etc. Before widespread recommendations practical caveats considered. Firstly, value change practice only investigated existing justification units without properly implemented programme. Secondly, difficult implement ambulatory centres (ASC). suggest programme performed successfully settings.11Sershon R.A. McDonald 3rd, J.F. Ho Goyal Hamilton W.G. center setting: revisions, readmissions.J 34: 2861-2865Abstract (15) addition contextual factors, most challenge future improvement setting understanding control pain relief, inflammatory orthostatic intolerance, optimal blood management, prevention cognitive dysfunction.12Kehlet Enhanced postoperative recovery: good afar, but far good?.Anaesthesia. 75: e54-e61PubMed Future optimisation reduction post-surgical sequelae represent prerequisite further increased There able identify complication re-admission preoperatively before discharge. Of special importance will ways predict high responders12Kehlet so related pathophysiology modified facilitate rehabilitation strategies.2Wainwright Nevertheless, high-performing centres, natural evolution, results led enthusiasm across systems, industry, media. remain prolong modestly. apply sites already successful protocol, where possible lead re-admissions morbidities. addition, facilities secondary cost challenges. To summarise, delicate balance evidence moving too fast promising fact revision being seen. We mindful ‘walk run’ remember order enhance recovery, meaning better, faster’. authors declare conflicts interest.