Key Components, Current Practice and Clinical Outcomes of ERAS Programs in Patients Undergoing Orthopedic Surgery: A Systematic Review

Enhanced recovery after surgery (ERAS) protocols have led to improvements in outcomes in several surgical fields, through multimodal optimization of patient pathways, reductions in complications, improved patient experiences and reductions in the length of stay. However, their use has not been uniformly recognized in all orthopedic fields, and there is still no consensus on the best implementation process. Here, we evaluated pre-, peri-, and post-operative key elements and clinical evidence of ERAS protocols, measurements, and associated outcomes in patients undergoing different orthopedic surgical procedures. A systematic literature search on PubMed, Scopus, and Web of Science Core Collection databases was conducted to identify clinical studies, from 2012 to 2022. Out of the 1154 studies retrieved, 174 (25 on spine surgery, 4 on thorax surgery, 2 on elbow surgery and 143 on hip and/or knee surgery) were considered eligible for this review. Results showed that ERAS protocols improve the recovery from orthopedic surgery, decreasing the length of hospital stays (LOS) and the readmission rates. Comparative studies between ERAS and non-ERAS protocols also showed improvement in patient pain scores, satisfaction, and range of motion. Although ERAS protocols in orthopedic surgery are safe and effective, future studies focusing on specific ERAS elements, in particular for elbow, thorax and spine, are mandatory to optimize the protocols.

Society for Obstetric Anesthesia and Perinatology: Consensus Statement and Recommendations for Enhanced Recovery After Cesarean

The purpose of this article is to provide a summary of the Enhanced Recovery After Cesarean delivery (ERAC) protocol written by a Society for Obstetric Anesthesia and Perinatology (SOAP) committee and approved by the SOAP Board of Directors in May 2019. The goal of the consensus statement is to provide both practical and where available, evidence-based recommendations regarding ERAC. These recommendations focus on optimizing maternal recovery, maternal-infant bonding, and perioperative outcomes after cesarean delivery. They also incorporate management strategies for this patient cohort, including recommendations from existing guidelines issued by professional organizations such as the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists. This consensus statement focuses on anesthesia-related and perioperative components of an enhanced recovery pathway for cesarean delivery and provides the level of evidence for each recommendation.

Mobilization after joint arthroplasty surgery: who benefits from standing within 12 hours?

BACKGROUND

Early mobilization following joint arthroplasty surgery has been shown to be beneficial for patients, but it is unclear whether it is associated with a shorter length of stay (LOS) for both hip and knee arthroplasty (KA) patients.

METHODS

We undertook a retrospective observational study, reviewing the case notes of 386 patients admitted to an enhanced recovery programme for total hip (THA) or total/unicompartmental KA. We evaluated the influence of early mobilization on LOS, adjusting for possible confounders, stratifying by surgery type.

RESULTS

THA patients first mobilized within 12 h of returning to the acute orthopaedic ward following surgery had a significantly shorter mean LOS (mean = 3.6, standard deviation = 1.1) than THA patients who first mobilized 12 or more hours (mean = 4.1, standard deviation = 1.2), P = 0.004. There was no statistical significant difference in the mean LOS between the KA patients mobilized earlier or later.

CONCLUSION

Early mobilization as part of an enhanced recovery programme was associated with decreased LOS for patients having THA; however, this was not the case for KA patients.

Assessment of Psychological Factors in Short-Stay Total Hip Arthroplasty Protocol

BACKGROUND

Several variables are known to correlate with the successful completion of short-stay total hip arthroplasty (THA) protocols. The role of psychological factors remains unclear. We investigated the interaction between patient-reported measures of psychological fitness and successful completion of a short-stay THA protocol.

METHODS

We performed a prospective cohort study of patients undergoing elective anterior total hip arthroplasty enrolled in a short-stay protocol (success defined as LOS ≤1 midnight versus failed, LOS >1 midnight). Psychological fitness was measured using the Patient-Reported Outcomes Measurement Information System (PROMIS) domains for self-efficacy, depression, anxiety, emotional support, and the ability to participate in social roles. PROMIS scores, patient demographics, and surgical factors were assessed for a relationship with failure to complete short-stay protocol.

RESULTS

Patients that failed to complete the short-stay protocol had higher mean pre-operative PROMIS depression scores (50.8 vs 47.1, P = .025) and anxiety scores (53.6 vs 49.2, P = .008) and higher postoperative PROMIS depression (48.19 vs 43.49, P = .003) and anxiety scores (51.7 vs 47.1, P = .01). Demographic and surgical variables did not correlate with the successful completion of the short-stay protocol. That seventy-six percent of the patients did not adhere to the short-stay protocol was due to the inability to complete a physical therapy standardized safety assessment.

CONCLUSION

Higher levels of preoperative and postoperative anxiety and depression in otherwise psychologically healthy patients, is associated with an increased risk of failure to complete a short-stay protocol following THA. Targeted interventions are needed to facilitate rapid recovery in patients with psychological barriers to early mobilization.

Accelerated rehabilitation versus conventional rehabilitation in total hip arthroplasty (ARTHA): a randomized double blinded clinical trial

OBJECTIVES

compare an accelerated physiotherapeutic protocol to a conventional physiotherapeutic protocol in total hip arthroplasty patients.

METHODS

a randomized double blinded clinical trial performed from August 2013 to November 2014. Forty-eight patients diagnosed with hip osteoarthritis submitted to a total hip arthroplasty surgery. An accelerated rehabilitation physiotherapy applied three times a day and start gait training on the first day or standard physiotherapy applied once a day and start gait training on the second or third day of hospitalization. The Merle dAubigné and Postel score (mobility, pain and gait), muscle strength force, range of motion, in hospital stay and time to start of gait training, were the outcomes.

RESULTS

the mean age was 64.46 years (10.37 years standard deviation). No differences were observed in age in different genders, and the two randomization groups were homogeneous. In hospital stay was lower in the intervention group compared to the control group, 3 (3-4) days [median (interquartile range)] versus 4 (4-5) days. Time to the start of gait training was early in the intervention group compared to the control group, 1 (1-1) days versus 2 (2-2) days. Higher muscle strength values were observed in the postoperative results in the intervention group compared to the control group for internal rotation, external rotation and abduction.

CONCLUSIONS

an accelerated physiotherapeutic protocol should be encouraged, because it shows favourable results in gait, muscle strength and length of hospital stay, even upon hospital discharge.

Introducing enhanced recovery after surgery in a high-volume orthopaedic hospital: a health technology assessment

BACKGROUND

The number of patients undergoing joint arthroplasty is increasing worldwide. An Enhanced Recovery After Surgery (ERAS) pathway for hip and knee arthroplasty was introduced in an Italian high-volume research hospital in March 2018.

METHODS

The aim of this mixed methods observational study is to perform a health technology assessment (HTA) of the ERAS pathway, considering 938 procedures performed after its implementation, by means of a hospital-based approach derived from the EUnetHTA (European Network for Health Technology Assessment) Core Model. The assessment process is based on dimensions of general relevance, safety, efficacy, effectiveness, economic and financial impact, equity, legal aspects, social and ethical impact, and organizational impact. A narrative review of the literature helped to identify general relevance, safety and efficacy factors, and a set of relevant sub-dimensions submitted to the evaluation of the professionals who use the technology through a 7-item Likert Scale. The economic and financial impact of the ERAS pathway on the hospital budget was supported by quantitative data collected from internal or national registries, employing economic modelling strategies to identify the amount of resources required to implement it.

RESULTS

The relevance of technology under assessment is recognized worldwide. A number of studies show accelerated pathways to dominate conventional approaches on pain reduction, functional recovery, prevention of complications, improvements in tolerability and quality of life, including fragile or vulnerable patients. Qualitative surveys on clinical and functional outcomes confirm most of these benefits. The ERAS pathway is associated with a reduced length of stay in comparison with the Italian hospitalization average for the same procedures, despite the poor spread of the pathway within the country may generate postcode inequalities. The economic analyses show how the resources invested in training activities are largely depreciated by benefits once the technology is permanently introduced, which may generate hospital cost savings of up to 2054,123.44 € per year.

CONCLUSIONS

Galeazzi Hospital's ERAS pathway for hip and knee arthroplasty results preferable to traditional approaches following most of the HTA dimensions, and offers room for further improvement. The more comparable practices are shared, the before this potential improvement can be identified and addressed.

Influence of fast-track programs on patient-reported outcomes in total hip and knee replacement (THR/TKR) at Swedish hospitals 2011-2015: an observational study including 51,169 THR and 8,393 TKR operations

Background and purpose - Fast-track care programs have been broadly introduced at Swedish hospitals in elective total hip and knee replacement (THR/TKR). We studied the influence of fast-track programs on patient-reported outcomes (PROs) 1 year after surgery, by exploring outcome measures registered in the Swedish arthroplasty registers.Patients and methods - Data were obtained from the Swedish Knee and Hip Arthroplasty Registers and included TKR and THR operations 2011-2015 on patients with osteoarthritis. Based on questionnaires concerning the clinical pathway and care programs at Swedish hospitals, the patients were divided in 2 groups depending on whether they had been operated in a fast-track program or not. PROs of the fast-track group were compared with not fast-track using regression analysis. EQ-5D, EQ VAS, Pain VAS, and Satisfaction VAS were analyzed for both THR and TKR operations. The PROMs for TKR also included KOOS.Results - The differences of EQ-5D, EQ VAS, Pain VAS, and Satisfaction VAS 1 year after surgery were small but all in favor of fast-track for both THR and TKR, also in subscales of KOOS for TKR except KOOS QoL. However, the effect sizes as measured by Cohens' d formula were < 0.2 for all PROs, in both THR and TKR.Interpretation - Our results indicate that the fast-track programs may be at least as good as conventional care from the perspective of PROs 1-year postoperatively.

A cost-effectiveness analysis after implementation of a fast-track protocol for total knee arthroplasty

BACKGROUND

Since the introduction of arthroplasty fast-track protocols, many studies have investigated their effect on complications and length of hospital stay. However, few fast-track studies have examined the long-term effects on cost and health-related quality of life after total knee arthroplasty (TKA). This study aimed to specifically analyze, after implementation of fast-track TKA, cost-effectiveness with functional outcome, length of stay, thromboembolic complications, medical costs, and quality of life after 12 months.

METHODS

A retrospective cohort of 403 TKA patients treated by a fast-track pathway were compared with 283 patients in a non-fast-track pathway. Length of stay and thromboembolic complications were registered postoperatively. Healthcare costs were based on hospital production costs and calculated on average. Costs were compared with EQ-5D questionnaires to derived quality-adjusted life year (QALY) scores.

RESULTS

No between-protocol differences were found in functional outcome and quality of life after TKA. The fast-track protocol reduced the length of stay from a median five days to median three days, and did not influence the thromboembolic complication rate (2.6%). After one-year follow-up for fast-track pathway patients, QALY was 0.85 vs. 0.84 for non-fast-track. A reduction of 268,- euro per patient was calculated in favor of the fast-track protocol.

CONCLUSION

Fast-track protocol implementation is a cost-effective strategy for patients undergoing TKA, with high QALY and reduced costs. Fast-track TKA treatment is safe, with low thromboembolic complications. This is the first study to measure fast-track implementation effects on functional outcome and quality of life up to 12 months postoperatively, and calculate equivalent QALYs for both groups.

LEVEL OF EVIDENCE

Level III.

[Enhanced recovery after robotic partial nephrectomy: Evaluation of patient's satisfaction]

INTRODUCTION

Several enhanced recovery protocols after surgery showed a benefit for postoperative recovery and reduction of hospital lengths of stay. Very few studies evaluated patient's satisfaction about these enhanced recovery protocols. The aim of this study was to evaluate patient's satisfaction about our enhanced recovery protocol for robotic-assisted partial nephrectomy (RAPN).

METHODS

A validated survey EORTC In PATSAT32 with a specific questionnaire about protocol was sent to the first patients included in the enhanced recovery protocol for RAPN. The survey was sent after the postoperative consultation at postoperative day 30. Responses were anonymous. Satisfaction's scores for EORTC questionnaire were calculated for each dimension with Likert's method. Scores were transformed linearly into a scale ranging from 0 to 100, where 100 represent the highest level of care satisfaction (EORTC method).

RESULTS

A total of 21 patients (50%) returned the completed questionnaire. The overall satisfaction score was 75.1% (37.3; 100) in the EORTC survey. In total, 71.4% of patients (n=15) were satisfied with the discharge at postoperative day 2 (POD2) and 5 patients (23.8%) found this premature. None of the patients had a negative impression on the clinical pathway. The average overall evaluation on the protocol by patients, on a satisfaction scale of 1 to 10 was 8.9/10.

CONCLUSION

In this study, patients included in the enhanced recovery protocol after RAPN were very satisfied with their pre-, per- and postoperative care. Given patients satisfaction, reduction of LOS, patient's safety and the medicoeconomic advantage, these enhanced recovery protocol have become a priority to develop and evaluate. More large studies are needed to assess the patient's experience with these clinical pathways.

LEVEL OF EVIDENCE

4.

Experiences of pre- and postoperative information among patients undergoing knee arthroplasty: a systematic review and narrative synthesis

Purpose: The aim of this review was to identify and synthesize knowledge of how patients undergoing knee arthroplasty experience pre- and postoperative information provided by healthcare professionals.Materials and methods: A systematic review and narrative synthesis was conducted in accordance with Popay et al.'s guidelines which involve 1) developing a preliminary synthesis; 2) exploring relationships; and 3) assessing the robustness of the synthesis. Qualitative and quantitative studies were considered for inclusion, and a systematic, extensive search was conducted in scientific databases.Results: A total of 31 studies were included in this review. The analysis resulted in five synthesized themes: 1) Support in the decision to undergo surgery; 2) Confidence versus uncertainty in the preparation for surgery; 3) Prerequisites for feeling secure before discharge; 4) Struggling through rehabilitation at home; and 5) Unmet expectations and endeavoring to accept realities.Conclusions: The findings illustrate the complexities of patients' experiences of information from healthcare professionals and its significance for how they manage challenges throughout the surgical care pathway. Information from healthcare professionals influences patients' knowledge, skills and confidence in the journey through knee arthroplasty. Therefore, it is important that healthcare professionals recognize patients' support requirements and adapt information to their individual needs.Implications for rehabilitationHealthcare professionals should encourage more dialog with patients and adapt information to their individual circumstances and needs throughout the surgical care pathway.It is important that healthcare professionals provide ongoing information and repeat information throughout the entire surgical care pathway in order to facilitate predictability and improve patients' ability to comprehend and assimilate information.Improved access to information and advice from healthcare professionals following knee arthroplasty will offer patients reassurance and increase their confidence in managing postoperatively at home.Patients who require enhanced information and guidance from healthcare professionals need to be identified in order to support their progress and achieve the best possible postoperative outcomes.

Sciatic nerve block or not for outpatient total knee arthroplasty? Study protocol for a randomized controlled trial

Background

The number of patients operated on for total knee arthroplasty (TKA) is growing worldwide. Outpatient surgery is defined by a length of stay (LOS) in the hospital of less than 12 h. This can be limited for TKA, with the efficient management of pain and perioperative complications, such as blood loss, affecting a safe hospital discharge. Outpatient TKA with a suitable protocol, including multimodal measures, could improve the success rate of this procedure. Among the main measures, single-shot sciatic nerve block in association with continuous femoral nerve block for pain control needs to be evaluated in outpatient TKA. Furthermore, to promote the safety of the postoperative period and to accelerate rehabilitation, patients who undergo ambulatory TKA could be discharged to a rehabilitation center on the day of surgery to screen adverse events and to optimize the rehabilitation process. This study is designed to assess the benefits of sciatic nerve block in postoperative pain relief for outpatient TKA.

Methods/design

This randomized prospective controlled study will be conducted in the knee unit of the teaching hospital of the Nice university and will include 40 patients undergoing primary unilateral outpatient TKA, discharged the day of surgery to a private rehabilitation center for enhanced recovery after surgery, after a hospital stay of less than 12 h. Before surgery, all patients will receive a continuous femoral nerve block with 2 mg/ml ropivacaine 20 ml, and then patients will be randomly assigned to receive or not receive a single-shot sciatic nerve block with 2 mg/ml ropivacaine, 20 ml. The primary outcome measure is the success rate of outpatient TKA. This rate is defined by patients discharged from the hospital to a rehabilitation center the day of surgery with no re-hospitalization due to insufficient pain control before the fifth postoperative day. Secondary outcomes include the incidence of major and minor adverse events during the first five postoperative days and measurement of the quality of recovery using the Knee injury and Osteoarthritis Outcome Score and the new International Knee Society scores plus the Quality of Recovery-40 questionnaire.

Discussion

The assessment of anesthesia and rehabilitation protocols enabling major orthopedic surgery, such as TKA, is necessary. This randomized controlled study will address the hypothesis that a suitable multimodal protocol including sciatic nerve block could improve pain control and thus improve the success rate of outpatient TKA.

Trial registration

EudraCT, 2016-000226-19. Registered on 15 April 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3142-1) contains supplementary material, which is available to authorized users.

No increase in readmissions or adverse events after implementation of fast-track program in total hip and knee replacement at 8 Swedish hospitals: An observational before-and-after study of 14,148 total joint replacements 2011-2015

Background and purpose - Fast-track care programs in elective total hip and knee replacement (THR/TKR) have been introduced in several countries during the last decade resulting in a significant reduction of hospital stay without any rise in readmissions or early adverse events (AE). We evaluated the risk of readmissions and AE within 30 and 90 days after surgery when a fast-track program was introduced in routine care of joint replacement at 8 Swedish hospitals. Patients and methods - Fast-track care programs were introduced at 8 public hospitals in Västra Götaland region from 2012 to 2014. We obtained data from the Swedish Hip and Knee Arthroplasty Registers for patients operated with THR and TKR in 2011-2015. All readmissions and new contacts with the health care system within 3 months with a possible connection to the surgical intervention were requested from the regional patient register. We compared patients operated before and after the introduction of the fast-track program. Results - Implementation of the fast-track program resulted in a decrease in median hospital length of stay (LOS) from 5 to 3 days in both THR and TKR. The total readmission rate <90 days for THR was 7.2% with fast-track compared with 6.7% in the previous program, and for TKR 8.4% in both groups. Almost half of the readmissions occurred without any AE identified. There was no statistically significant difference concerning readmissions or AE when comparing the programs. Interpretation - Implementation of a fast-track care program in routine care of elective hip and knee replacement is effective in reducing hospital stay without increasing the risk of readmissions or adverse events within 90 days after surgery.

Length of stay and its impact upon functional outcomes following lower limb arthroplasty

PURPOSE

The aim was to investigate the interplay between patient characteristics and (1) length of hospital stay and (2) one-year patient-reported outcome following total knee and hip arthroplasty.

METHODS

Event (survival) analysis and structural equation modelling were performed for 1001 patients undergoing knee (n = 566) and hip (n = 435) arthroplasty in a single institution.

RESULTS

Age, body mass index and co-morbidities were independent predictors of length of stay in both event analysis and structural equation modelling. These patient characteristics and type of arthroplasty had both small direct and indirect effects on patient-reported outcome measures at one year. Length of stay had a small effect (<2 %) in SF-36 scores at one year.

CONCLUSION

Predictors that influence length of stay also impact on one-year post-operative outcome and therefore should be taken into account during patient selection and discharge planning.

LEVEL OF EVIDENCE

Retrospective cohort study, Level III.

A Patient-Focused Technology-Enabled Program Improves Outcomes in Primary Total Hip and Knee Replacement Surgery

Background:

A patient-engagement and pathway-management program for patients undergoing primary total hip and knee replacement was evaluated. Health-service and multimedia features supported by technology were integrated with existing enhanced recovery after surgery (ERAS) practices. The primary objective was to demonstrate the impact on length of stay. The secondary objective was to assess the impact on clinical, patient-focused, and financial outcomes.

Methods:

Two thousand and eighty consecutive patients undergoing primary total hip replacement (n = 1,034) and total knee replacement (n = 1,046) were classified into “pre-program” (retrospectively assessed [n = 1,038]) and “program” (prospectively assessed [n = 1,042]) cohorts. Patients in the program cohort were subdivided according to those who were eligible for criteria-based outreach support (OS) (n = 401) and those who were ineligible for this service (NOS) (n = 641). Clinical outcomes were assessed for all patients, and patient-focused outcomes were assessed for a subset (n = 223).

Results:

The mean reduction in length of stay ranged from 20% (1.2 days) to 42% (2.5 days) following total hip replacement and from 9% (0.6 day) to 31% (2 days) following total knee replacement (p < 0.001). Clinical outcomes (readmissions, complications, emergency department re-attendance rates) were not significantly negatively impacted. The Oxford Hip Score had numerically larger improvement after total hip replacement in the OS group than in the pre-program group (4.1-point increase), and the Oxford Knee Score had numerically larger improvement after total knee replacement in the NOS group than in the pre-program group (0.8-point increase). The patients in the program cohort (either OS or NOS) rated overall health gain as higher than those in the pre-program cohort (gain in numerical rating scale, 1.4 points for patients managed with total hip replacement, 0.6 points for patients managed with total knee replacement). Older patients and those with higher comorbidity indices benefited most with respect to length of stay and multiple clinical outcomes. Patient experience was significantly improved across domains (p < 0.001 to p = 0.003). Potential savings for patients managed with total hip replacement (£401.64 [$267.76] per patient) exceeded estimated program charges of £50 [$33.33] to £60 [$40] per patient, whereas the potential savings for patients managed with total knee replacement (£76.67 [$51.11] per patient) were sufficient to achieve a reduction of total system costs.

Conclusions:

Technology-enabled programs may deliver enhanced care at lower costs for patients undergoing lower-limb arthroplasty. Shorter durations of inpatient stay without a negative impact on clinical outcomes and improved patient-focused outcomes and experience can deliver substantial value that can be especially beneficial for older patients and those with greater medical complexity.

Level of Evidence:

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Fast-track recovery technique applied to primary total hip and knee replacement surgery. Analysis of costs and complications

PURPOSE

To determine the cost reduction and complication rates of using an enhanced recovery pathway (Fast-track) when compared to traditional recovery in primary total hip replacement (THR) and total knee replacement (TKR), as well as to determine if there were significant differences in complication rates.

MATERIAL AND METHODS

Retrospective review of 100 primary total arthroplasties using the Fast-track recovery system and another 100 using conventional recovery. Gender, Charlston comorbidity index, ASA score, length of stay and early complications were measured, as well in-hospital complications and those in the first six months, re-admissions and transfusion rates. The total and daily cost of stay was determined and the cost reduction was calculated based on the reduction in the length of stay found between the groups.

RESULTS

Both groups where comparable as regards age, gender, ASA score, and Charlston index. The mean reduction in length of stay was 4.5 days for TKR and 2.1 days for THR. The calculated cost reduction was 1266 euros for TKR and 583 euros for THR. There were no statistically significant differences between groups regarding in-hospital complications, transfusion requirements, re-admissions and complication rates in the first six months.

DISCUSSION

There are few publications in the literature reviewed that analyse the cost implications of using fast-track recovery protocols in arthroplasty. Several published series comparing recovery protocols found no significant differences in complication rates either. The use of a fast-track recovery protocol resulted in a significant cost reduction of 1266 euros for the TKR group and 583 for the THR group, without affecting complication rates.

Risk of re-admission, reoperation, and mortality within 90 days of total hip and knee arthroplasty in fast-track departments in Denmark from 2005 to 2011

PURPOSE

To compare the risks of re-admission, reoperation, and mortality within 90 days of surgery in orthopedic departments with well-documented fast-track arthroplasty programs with those in all other orthopedic departments in Denmark from 2005 to 2011.

METHODS

We used the Danish hip and knee arthroplasty registers to identify patients with primary total hip arthroplasty or total knee arthroplasty. Information about re-admission, reoperation, and mortality within 90 days of surgery was obtained from administrative databases. The fast-track cohort consisted of 6 departments. The national comparison cohort consisted of all other orthopedic departments. Regression methods were used to calculate relative risk (RR) of adverse events, adjusting for age, sex, type of fixation, and comorbidity. Cohorts were divided into 3 time periods: 2005-2007, 2008-2009, and 2010-2011.

RESULTS

79,098 arthroplasties were included: 17,284 in the fast-track cohort and 61,814 in the national cohort. Median length of stay (LOS) was less for the fast-track cohort in all 3 time periods (4, 3, and 3 days as opposed to 6, 4, and 3 days). RR of re-admission due to infection was higher in the fast-track cohort in 2005-2007 (1.3, 95% CI: 1.1-1.6) than in the national cohort in the same time period. This was mainly due to urinary tract infections. RR of re-admission due to a thromboembolic event was lower in the fast-track cohort in 2010-2011 (0.7, CI: 0.6-0.9) than in the national cohort in the same time period. No differences were seen in the risk of reoperation and mortality between the 2 cohorts during any time period.

INTERPRETATION

The general reduction in LOS indicates that fast-track arthroplasty programs have been widely implemented in Denmark. At the same time, it appears that dedicated fast-track departments have been able to optimize the fast-track program further without any rise in re-admission, reoperation, and mortality rates.