Enhanced recovery after surgery: Singapore General Hospital arthroplasty experience

INTRODUCTION Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are effective treatments for end-stage osteoarthritis of the knee and hip, with increasing demand for these surgeries being projected to rise substantially along with the cost to the healthcare system.[1] In the past, a week-long hospitalisation after TKA was the norm as there had been concerns that reduction in length of stay (LOS) would correspond with increase in postoperative complications.[2] Enhanced recovery after surgery (ERAS) or fast-track surgery has evolved over the decades and has been proven effective across a range of procedures to reduce the LOS and morbidity, without an increase in readmission rates or safety issues.[3,4] Its applicability for postoperative care and recovery for patients undergoing major orthopaedic arthroplasty procedures (THA and TKA) has also grown over the years.[5] The drive to implement ERAS protocols and day surgery arthroplasties has particularly grown during the coronavirus disease 2019 (COVID-19) pandemic to ensure business continuity in the setting of shortage of hospital beds and resources globally[6,7] and locally.[8] DISCUSSION The proponents of ERAS believe that perioperative care is equally important as TKA and THA procedures in dictating patient outcomes, and detailed guidelines have been recommended by the ERAS Society to help guide surgical centres in this transition.[9] The ERAS protocols were implemented with the aim to reduce average LOS for patients undergoing TKA with less than 5 days inpatient stay. Some studies in the literature[10,11] show that the mean LOS in ERAS TKA has safely shortened from 4–5 days to 3 days. In 2019, Singapore General Hospital (SGH) launched the ERAS pathway for patients undergoing TKA and started to offer TKA as a day surgery procedure in August 2020 during the height of the COVID-19 pandemic, whereby majority of the healthcare resources were diverted towards the fight of the pandemic.[12,13,14] This was to allow continuation of musculoskeletal care and elective procedures, such as TKA, to reduce utilisation of inpatient hospital bed as well as minimise potential patient COVID-19 exposure in the hospital setting after surgery. The ERAS day surgery TKA protocol refers to expedited discharge either on the day of surgery or on postoperative day (POD) 1, with patients being discharged within 23 h after surgery. These patients were considered to have successfully cleared the ERAS TKA protocol after they were cleared by the primary surgeon and the physiotherapist. Recommendations from the ERAS Society consensus statement were implemented in line with hospital guidelines. Preoperatively, patients received counselling on their surgery and the expected recovery progress by both the primary surgeon and the physiotherapist. Patients were evaluated by an anaesthetist, and smoking cessation advice was given as required. Preoperative anaemia screening was performed and patients were started on iron supplementation if indicated. All patients underwent physiotherapy review before operation and received prehabilitation. Perioperatively, patients were fasted for at least 6 h before the operation, with clear fluids allowed until 2 h before induction. A carbohydrate drink consisting of 50 g of glucose was given 2 h before surgery with oral preemptive analgesia (etoricoxib 120 mg and omeprazole 20 mg if no contraindications) (body mass index [BMI] >35 kg/m2, history of gastrointestinal reflux, diabetes mellitus). Intraoperatively, all cases were planned for spinal anaesthesia unless contraindicated (e.g. previous spinal instrumentation). No femoral nerve block was given. Intravenous (IV) cefazolin was given at the start of surgery and IV clindamycin was given for patients with penicillin allergy. The use of tourniquet was left to the preference of the individual surgeons. For postoperative nausea and vomiting prophylaxis, all patients received IV dexamethasone 8 mg at the start of surgery and IV ondansetron 8 mg at the end of surgery. All patients received a periarticular infiltration of ketorolac, shincort, vancomycin and morphine, as well as an adductor canal block given intraoperatively by the surgeon. Topical tranexamic acid was applied before knee capsular closure. Postoperatively, patient-controlled analgesia (e.g., morphine) and epidurals were not used. Patients were given a combination of oral analgesia (paracetamol, etoricoxib, pregabalin and tramadol) for pain control. Oral aspirin was started on POD 1 for 1–2 weeks, and patients underwent physiotherapy for ambulation on the same day after surgery. In addition, the protocol at SGH comprises home visit by a physiotherapist at the first week after surgery and home visit by a nurse at the second week after surgery. There was a steady increase in the proportion of ERAS TKA between 2020 and 2021, with more than 20% of TKAs performed as ERAS for 2021. During the period from August 2020 to July 2021, there were 738 patients who underwent unilateral TKA at SGH, with 342 ERAS day surgeries (aiming for discharge within 23 h) and 396 conventional TKAs (discharge after 23 h). The inclusion criteria were (a) American Society of Anesthesiologists (ASA) ≤3 and (b) patient who agreed to be discharged home. Patients who declined discharge within 23 h were enrolled for conventional TKA. There were 92.4% of patients in the ERAS day surgery group, who were successfully discharged home within 23 h, leading to a significant shorter mean LOS of 1.13 (±1.0) days compared to 4.12 (±3.3) days in the conventional group (P < 0.005). Some of the common reasons for patients failing ERAS day surgery TKA protocol and getting discharged after 23 h included decision to transfer to step-down facility (community hospital), postoperative nausea and vomiting, acute urinary retention and inadequate pain control. Patients who underwent ERAS day surgery compared to conventional TKA inpatient group had significantly better preoperative patient-reported outcome measure scores (PROMs) in terms of knee society scores, Oxford knee scores and Short Form-36 scores (P < 0.05). Both groups had postoperative improvement of PROMs well above the minimal clinically important difference at 6 months follow-up. There was no increase in the rates of 30-day readmission and complications (readmission rate 2.6% in ERAS day surgery vs. 2.5% in conventional group, P = 0.928; infection 1.5% vs. 0.8%, P = 0.357; reoperation 0.9% vs. 0.5%, P = 0.130). There were no significant associations between age, gender, Charlson comorbidity index, ASA classification, BMI and the successful completion of ERAS day surgery TKA as compared to those who did not manage to be discharged within 23 h. There were also no differences in PROMs for patients who did not manage to be discharged within 23 h compared to that of those who underwent ERAS day surgery TKA at 6 months follow-up. These results are promising in terms of promoting ERAS day surgery TKA as a safe standard of care model for patients to be discharged in an expedited and timely manner with no compromise in patient outcomes and complication rates, and also to encourage inclusion of more patients into this pathway, especially in view of the rapidly ageing population in Singapore. It is also more cost-efficient for both the patients and health care as the median cost of ERAS TKA is significantly lower than that of non-ERAS TKA cases. This is largely due to the savings in hospital room charges, daily treatment fees and services due to the shorter LOS for ERAS TKA patients. In SGH, before ERAS TKA, day surgery THA was performed through the direct anterior approach, with up to 82% of patients being discharged within the same day of surgery with satisfactory results postoperatively and no major complications observed.[15] Subsequently, posterior approach day surgery THA was offered to patients at SGH. There are approximately 100 cases of ERAS posterior approach THA. We are still working on preliminary data analysis, and future studies will report on the clinical outcomes of all ERAS THA, including our results between the traditional posterior approach and the direct anterior approach THA, which is gaining popularity in many orthopaedic surgery centres.[16] We anticipate that there will be increasing number of patients who will be able to benefit from the ERAS protocol for total joint arthroplasties (TKA and THA) to safely reduce the length of inpatient stay without compromising on clinical outcomes and complication rates. TAKE HOME MESSAGES Successful ERAS protocols involve a multidisciplinary approach for patient care. ERAS protocols can be safely implemented for day surgery total join arthroplasty. The THA and TKA patients can safely have shorter LOS without compromising on outcomes and with no increased risk of complications. With increasing number of patients undergoing ERAS inpatient and day surgery total joint arthroplasty, more concrete findings and reports can be published in the upcoming years. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.