Enhanced recovery pathways in total hip and knee arthroplasty: impact on length of stay, complications, and long-term patient-reported outcomes: a systematic review and meta-analysis

Introduction Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are effective, but recovery involves pain and reduced mobility. Enhanced Recovery After Surgery (ERAS) pathways combine perioperative interventions to accelerate recovery, but evidence versus conventional care is inconsistent. Objective To evaluate ERAS pathways versus conventional perioperative care in adults undergoing elective primary THA or TKA. Methods PubMed/MEDLINE, Web of Science, and Google Scholar were searched from inception to August 2026. Randomized controlled trials and comparative cohort studies comparing a multimodal ERAS pathway (≥3 components) with conventional care were eligible. Four reviewers extracted data independently. Risk of bias was assessed using RoB 2 and ROBINS-I. Random-effects meta-analysis was performed, and certainty of evidence was rated using GRADE. Results Twenty-six studies were included (sample sizes 24 to 1,540,462). ERAS shortened length of stay (LOS) in nearly every study; the pooled mean difference was −3.61 days (95% confidence interval [CI], −5.22 to −1.99; I²=97.0%). The reduction was significant for TKA (−3.98 days; 95% CI, −7.04 to −0.92) but not for THA. Overall complications showed a non-significant trend favoring ERAS (risk ratio 0.82; 95% CI, 0.65–1.04), driven mainly by minor (Clavien-Dindo grade 1–2) events. Readmissions, transfusion, and opioid requirements did not differ significantly. Conclusion ERAS pathways are associated with a clinically important reduction in LOS, particularly for TKA. A reduction in perioperative morbidity is plausible but unconfirmed. Evidence on readmissions, opioid use, and long-term patient-reported outcomes is limited and of low certainty. Well-designed multicenter randomized trials with standardized long-term outcome reporting are needed.