Impact of enhanced recovery pathways on safety and efficacy of hip and knee arthroplasty: A systematic review and meta-analysis

Marion J. L. F. Heymans, Nanne P. Kort, Barbara A. M. Snoeker, Martijn G. M. Schotanus

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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.
Original languageEnglish
Pages (from-to)307-328
Number of pages22
JournalWorld journal of orthopedics
Issue number3
Publication statusPublished - 18 Mar 2022


  • Clinical pathway
  • Enhanced recovery pathway
  • Hip arthroplasty
  • Joint arthroplasty
  • Knee arthroplasty
  • Meta-analysis
  • Systematic review

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