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Original Investigation
February 12, 2020

Association Between Use of Enhanced Recovery After Surgery Protocol and Postoperative Complications in Total Hip and Knee Arthroplasty in the Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol in Elective Total Hip and Knee Arthroplasty Study (POWER2)

Javier Ripollés-Melchor, MD1,2,3,4; Ane Abad-Motos, MD1,2,3,4; Yolanda Díez-Remesal, MD, PhD5; et al Marta Aseguinolaza-Pagola, MD6; Lidia Padin-Barreiro, MD7; Rubén Sánchez-Martín, MD8; Margarita Logroño-Egea, MD9; Juan C. Catalá-Bauset, MD10; Silvia García-Orallo, MD11; Elvira Bisbe, MD, PhD12; Nuria Martín, MD13; Alejandro Suárez-de-la-Rica, PhD3,4,14; Ana B. Cuéllar-Martínez, MD4,15; Silvia Gil-Trujillo, MD16; Juan Carlos Estupiñán-Jiménez, MD17; Marta Villanova-Baraza, MD18; Cristina Gil-Lapetra, MD19; Pilar Pérez-Sánchez, MD20; Nicolás Rodríguez-García, MD21; Alvaro Ramiro-Ruiz, MD4,22; Carla Farré-Tebar, MD23; Alejandro Martínez-García, MD24; Pedro Arauzo-Pérez, MD25; Cristina García-Pérez, MD26; Alfredo Abad-Gurumeta, MD, PhD1,2,4; María A. Miñambres-Villar, MD27; Alberto Sánchez-Campos, MD28; Ignacio Jiménez-López, MD, PhD29; José M. Tena-Guerrero, MD30; Oliver Marín-Peña, MD, PhD31; Míriam Sánchez-Merchante, MD32; Ubaldo Vicente-Gutiérrez, MD33; María C. Cassinello-Ogea, MD, PhD34; Carlos Ferrando-Ortolá, MD, PhD3,4,13; Héctor Berges-Gutiérrez, MD35; Jesús Fernanz-Antón, MD36; Manuel A. Gómez-Ríos, MD37; Daniel Bordonaba-Bosque, MD, PhD38; José M. Ramírez-Rodríguez, MD, PhD3,4,38,39; José Antonio García-Erce, PhD3,4,40; César Aldecoa, MD, PhD3,4,41; for the Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol in Elective Total Hip and Knee Arthroplasty (POWER2) Study Investigators Group for the Spanish Perioperative Audit and Research Network (REDGERM)
Author Affiliations
  • 1Department of Anaesthesia and Critical Care, Infanta Leonor University Hospital, Madrid, Spain
  • 2School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
  • 3Spanish Perioperative Audit and Research Network (REDGERM)
  • 4Grupo Español de Rehabilitación Multimodal, Enhanced Recovery After Surgery Spain Chapter, Madrid
  • 5Department of Anaesthesia and Critical Care, Ramón y Cajal University Hospital, Madrid, Spain
  • 6Department of Anaesthesia, Donostia University Hospital/Donostia Unibertsitate Ospitalea, San Sebastián, Spain
  • 7Department of Anaesthesia, Complejo Hospitalario Universitario De Vigo–Eoxi Vigo, Vigo, Spain
  • 8Department of Anaesthesia, Hospital Universitario Clínico San Carlos, Madrid, Spain
  • 9Department of Anaesthesia, Hospital Universitario de Álava, Vitoria-Gasteiz, Spain
  • 10Department of Anaesthesia, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
  • 11Department of Anaesthesia, Hospital Universitario Sierrallana, Torrelavega, Spain
  • 12Department of Anaesthesia, Hospitales del Parc de Salut Mar, Barcelona, Spain
  • 13Department of Anaesthesia, Hospital Clínic de Barcelona, Barcelona, Spain
  • 14Department of Anaesthesia and Critical Care, La Paz University Hospital, Madrid, Spain
  • 15Department of Anaesthesia and Critical Care, Hospital Universitario Central de Asturias, Oviedo, Spain
  • 16Department of Anaesthesia, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
  • 17Department of Anaesthesia, Hospital Universitario Rey Juan Carlos, Móstoles, Spain
  • 18Department of Anaesthesia, Hospital de Mataró, Mataró, Spain
  • 19Department of Anaesthesia, Hospital Universitario de Fuenlabrada, Fuenlabrada, Spain
  • 20Department of Anaesthesia, Hospital de Galdakao-Usansolo, Bizkaia, Spain
  • 21Department of Anaesthesia, Hospital de La Cruz Roja, Gijón, Spain
  • 22Department of Anaesthesia, Hospital Universitario 12 de Octubre, Madrid, Spain
  • 23Department of Anaesthesia, Althaia Xarxa Assistencial Universitària de Manresa, Barcelona, Spain
  • 24Department of Anaesthesia, Hospital Universitario de Jaén, Jaén, Spain
  • 25Department of Anaesthesia, Hospital Quirón, Zaragoza, Spain
  • 26Department of Anaesthesia, Hospital Universitario de Léon, Léon, Spain
  • 27Department of Anaesthesia, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
  • 28Department of Anaesthesia, Hospital Universitario de Cruces, Bilbao, Spain
  • 29Department of Anaesthesia, Hospital Universitario Virgen del Rocío, Sevilla, Spain
  • 30Department of Anaesthesia, Complejo Hospitalario de Mérida, Mérida, Spain
  • 31Department of Orthopedia, Infanta Leonor University Hospital, Madrid, Spain
  • 32Department of Anaesthesia, Hospital Universitario Fundación Alcorcón, Alcorcón, Spain
  • 33Department of Anaesthesia, Clínica Santa Cristina, Albacete, Spain
  • 34Department of Anaesthesia, Hospital Universitario Miguel Servet, Zaragoza, Spain
  • 35Department of Anaesthesia, Hospital Universitario Virgen Macarena, Sevilla, Spain
  • 36Department of Anaesthesia, Hospital Sant Joan Despí Moisès Broggi, Sant Joan Despí, Spain
  • 37Department of Anaesthesia, Complejo Hospitalario Universitario de A Coruña, Coruña, Spain
  • 38Instituto Aragonés de Ciencias de la Salud, Zaragoza, Spain
  • 39Department of Surgery, Lozano Blesa University Hospital, Zaragoza, Spain
  • 40Blood and Tissue Bank of Navarra, Servicio Navarro de Salud-Osasunbidea, Pamplona, Navarra, Spain
  • 41Department of Anaesthesia and Perioperative Medicine, Río Hortega University Hospital, Valladolid, Spain
JAMA Surg. Published online February 12, 2020. doi:10.1001/jamasurg.2019.6024
Key Points

Question  How frequent are complications after total hip and knee arthroplasty procedures and how are the Enhanced Recovery After Surgery (ERAS) protocols associated with them?

Findings  In this large, multicenter cohort study that included 6146 patients in 131 hospitals, 680 (11.1%) presented with postoperative complications and 352 (5.7%) presented with complications graded as moderate to severe. Patients who had greater compliance with the ERAS items had fewer postoperative complications, regardless of whether or not the center had an established ERAS protocol.

Meaning  Although only a few perioperative interventions were associated with decreased complications, greater adherence with the set of ERAS measures was associated with a decrease in postoperative complications at 30 days of follow-up.


Importance  The Enhanced Recovery After Surgery (ERAS) care protocol has been shown to improve outcomes compared with traditional care in certain types of surgery.

Objective  To assess the association of use of the ERAS protocols with complications in patients undergoing elective total hip arthroplasty (THA) and total knee arthroplasty (TKA).

Design, Setting, and Participants  This multicenter, prospective cohort study included patients recruited from 131 centers in Spain from October 22 through December 22, 2018. All consecutive adults scheduled for elective THA or TKA were eligible for inclusion. Patients were stratified between those treated in a self-designated ERAS center (ERAS group) and those treated in a non-ERAS center (non-ERAS group). Data were analyzed from June 15 through September 15, 2019.

Exposures  Total hip or knee arthroplasty and perioperative management. Sixteen individual ERAS items were assessed in all included patients, whether they were treated at a center that was part of an established ERAS protocol or not.

Main Outcomes and Measures  The primary outcome was postoperative complications within 30 days after surgery. Secondary outcomes included length of stay and mortality.

Results  During the 2-month recruitment period, 6146 patients were included (3580 women [58.2%]; median age, 71 [interquartile range (IQR), 63-76] years). Of these, 680 patients (11.1%) presented with postoperative complications. No differences were found in the number of patients with overall postoperative complications between ERAS and non-ERAS groups (163 [10.2%] vs 517 [11.4%]; odds ratio [OR], 0.89; 95% CI, 0.74-1.07; P = .22). Fewer patients in the ERAS group had moderate to severe complications (73 [4.6%] vs 279 [6.1%]; OR, 0.74; 95% CI, 0.56-0.96; P = .02). The median overall adherence rate with the ERAS protocol was 50.0% (IQR, 43.8%-62.5%), with the rate for ERAS facilities being 68.8% (IQR, 56.2%-81.2%) vs 50.0% (IQR, 37.5%-56.2%) at non-ERAS centers (P < .001). Among the patients with the highest and lowest quartiles of adherence to ERAS components, the patients with the highest adherence had fewer overall postoperative complications (144 [10.6%] vs 270 [13.0%]; OR, 0.80; 95% CI, 0.64-0.99; P < .001) and moderate to severe postoperative complications (59 [4.4%] vs 143 [6.9%]; OR, 0.62; 95% CI, 0.45-0.84; P < .001) and shorter median length of hospital stay (4 [IQR, 3-5] vs 5 [IQR, 4-6] days; OR, 0.97; 95% CI, 0.96-0.99; P < .001).

Conclusions and Relevance  An increase in adherence to the ERAS program was associated with a decrease in postoperative complications, although only a few ERAS items were individually associated with improved outcomes.

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