Enhanced recovery programmes for lower limb arthroplasty in the UK

Introduction: Enhanced Recovery Programmes (ERPs) reduce patient morbidity and mortality and provide significant cost savings by reducing length of stay (LOS). Currently no uniform ERP guidelines exist for lower limb arthroplasty in the UK and this study aimed to identify variations in ERPs across the NHS and determine adherence to local policy. Materials and Methods: Directed through BONE (British Orthopaedic Network Environment, an online system from BOTA), NHS hospitals offering elective TKA (23 centres) or THA (22 centres) contributed details of their ERPs and performed an audit (15 patients/centre) to assess compliance. Results: Contrasting content and detail of ERPs was noted across centres. Adherence to ERPs varied significantly (40-100% for TKA, range 17-94% for THA). Analysis identified perioperative use of dexamethasone, tranexamic acid, and early mobilisation for TKA and procedures performed in teaching hospitals for THA, as being associated with a reduced length of stay. Discussion: There is no consensus regarding the ERP gold standard with protocols contradicting the evidence base. Despite meta-analysis questioning efficacy of pre-operative education it continues to be commissioned. Conversely, utilisation of drugs such as tranexamic acid and dexamethasone remains suboptimal despite evidence of efficacy. This study highlights variation in practice and poor compliance with local ERPs in the NHS. Considering proven benefits of ERPs, evidence-based guidelines in the context of local skillsets should be established to optimise the patient care pathway