Open access peer-reviewed chapter
Preoperatively, intra-perioperative and postoperative ERAS interventions.
Abstract
Enhanced recovery after surgery (ERAS) protocols have been recently studied and introduced in order to provide and develop peri-operative multidisciplinary programs able to shorten length of hospital stay (LOS), reduce complications, readmissions and costs for patients undergoing major surgery. The number of patients requiring and undergoing total knee replacement and total hip replacement surgery has been increasing for years; however individualized and standardized rehabilitation protocols after surgery are still lacking in most centers. Postoperative joint function, pain control, patient satisfaction, shortest possible length of stay and better quality of life are uppermost priorities for results related to patients undergoing joint replacement surgery. Therefore the knowledge and possibly the implementation of such protocols should be taken into account by all institution. In fact, by utilizing ERAS protocols, the orthopedic surgeons would be able to deliver not just good results strictly related to the surgery itself, but also provide good results in terms of pain, function, mobility, patients’ satisfaction, and complications compared to patients undergoing routine rehabilitation. There is enough scientific evidence that ERAS protocols should be seen as a valuable and efficient aid for the orthopedic surgeons and a safe and effective option of the patient after joint arthroplasty surgery.
Keywords
- ERAS
- joint reconstruction
- joint arthroplasty
- hip replacement
- knee replacement
- rehabilitation
1. Introduction
Enhanced recovery after surgery (ERAS) protocols have been initially studied and proposed by the Danish surgeon H. Kehlet in the 1990s. The original idea was to implement a number of measures with regards to perioperative treatments and rehabilitation, basing his research on the scientific evidence available at that time. The final aim was to improve clinical and functional results and accelerate the recovery process together with patient satisfaction and quality of life. Perhaps these goals do not differ much from the ones looked for these days. The good results of ERAS programs have attracted growing acceptance and worldwide adoption [1, 2, 3].
ERAS protocols have been successfully proposed and introduced in several specialties and related surgical options. Results have been reported to be good overall in most specialties. ERAS was initially centered on abdominal and colorectal surgery patients but its use was then extended to many other specialties, including orthopedic surgery (mainly total hip and knee replacement surgery) [1, 2]. The focus of our chapter is on ERAS protocols for hip or knee replacement surgery and therefore we will keep our attention strictly on these areas.
The basic principles of ERAS protocols are shared among researchers and clinicians: using the least invasive surgical practices; reducing complications; reducing costs; reducing length of stay at hospitals; improving patients’ satisfaction and postoperative quality of life; fastest possible recovery; better clinical and functional outcomes; better postoperative pain control. Good results have been achieved due to substantial improvements in the fields of orthopedic surgical techniques and anesthetic management strategies. With regards to costs, it must be said that a huge burden is linked to the postoperative care after joint replacement surgery. In fact, a relevant amount of money is spent on physical and occupational therapy, nutrition and social services [1, 2, 3].
The combination of interventions included in these protocols are thought to reduce the post-op surgical stress response and overall optimize the perioperative wellbeing of the patients undergoing hip and knee arthroplasty surgery. In fact, major orthopedic surgeries are naturally followed by a pathophysiologic catabolism e slow recovery and the proposed interventions must overcome these adverse factors [1, 4].
Recent high level of evidence research reported that the measures used to analyze the outcomes have initially been related to costs, length of stay, readmission rates and complication rates. More recently further attention has been given to more subjective outcome measures, such as patient reported outcome measures (PROMs) which include satisfaction and quality of life (QoL) scores, meaning that the patient experience is these days considered as important as clinical related aspects as indicators of quality. In some countries (e.g. United Kingdom, United States) PROMs are standardly recorded for patients undergoing elective hip and knee replacement procedures [4, 5]. The use of national joint registries have certainly helped researchers and clinicians in carrying out relevant research on this topic [6].
It has been well reported that the demographic changes in the last few decades (significant and progressive age of the populations) make us predict that total primary hip replacements (THR) and total knee replacements (TKR) will keep increasing in numbers. Patients do not just evaluate results strictly related to the surgical procedures but their dissatisfaction could be related to chronic pain or limitation of function postoperatively [5, 6]. Therefore these two aspects must be particularly looked after when performing such type of surgery and a multidisciplinary approach and interventions seem to be the perfect strategy in order to obtain the best possible objective and subjective outcomes [1, 5, 6].
Despite a huge number of studies have been published on ERAS programs (some of which with high level of evidence), it has been reported overall inconsistent data availability on the efficacy and reproducibility of ERAS protocols and their real impact on early postoperative pain. The most recent literature reviews reveals a certain amount of uncertainty and show the need for further research and meta-analysis on this field in order to uniformly utilize and access these programs and create share-standardized knowledge among orthopedic surgeons around the world [1, 2, 5, 6].
Our aim was to provide all the relevant up to date information on ERAS protocols in relation to hip and knee replacement surgery, highlighting the most current known aspects and concepts, the weaknesses, potential room for improvement, the available most recent scientific evidence and suggesting future research directions and trends.
A literature review was performed using the following search database: Pubmed, Embase and Cochrane. Relevant key words were searched: “ERAS”, “Enhanced Recovery After Surgery”, “ERAS Orthopedic”, “ERAS knee surgery”, “ERAS hip surgery”, “ERAS joint arthroplasty”, “ERAS joint replacement”, “ERAS hip replacement”, “ERAS knee replacement”. All articles were scrutinized and 40 papers were finally included.
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2. Enhanced recovery after surgery (ERAS) in hip and knee replacement surgery
Enhanced recovery after surgery (ERAS) protocols in joint arthroplasty surgery are programs based on scientific evidence aimed to deliver a standardized, multimodal and multidisciplinary perioperative management which should provide a quicker and more efficient recovery after surgery as well as the best possible clinical and functional outcomes. This approach should indirectly guarantee reduced complication rates, shorter length of stay, better patient satisfaction. In simple words these protocols are built to target the main factors that could delay the postoperative recovery [1, 2, 3, 4, 5, 6, 7].
Many articles with different level of evidence have been published over the last few decades, proposing internationally standardized ERAS programs. However, at the same time, many institutions have developed their own individualized programs after considering their own specific financial burden and particular types of surgery. With regards to orthopedic surgery, there is clear evidence that ERAS programs improve both hospital and patient outcomes [7, 8].
The studied ERAS interventions for primary THR and TKR that have been reported (in different combinations) are as follows: least invasive surgical approach, spinal anesthesia, intraoperative and postoperative local infiltration analgesia, femoral blocks, patients’ education before undergoing surgery (related to pain management, gait training such as walking with crutches and specific exercises), pre-op non-steroid-anti-inflammatory-drugs, intravenous application of a steroid, patient-controlled analgesia, continuous femoral nerve block, tranexamic acid intravenously as well as topically or intra-articularly, no use of wound drains, first mobilization 2–4 hours after surgery, intensive physiotherapy by special trained therapists, immediate full weight bearing allowed, adequate analgesia, nutrition support for specific conditions (such as anti-anemic or hypoproteinemia therapy, postoperative nutrition supplement, ice therapy [1, 4, 5, 6].
The relevant outcomes measures reported in different combinations in ERAS protocols are: length of incision, length of stay, operation time, intraoperative blood loss, pre and post-op hemoglobin, pre and post-op albumin, costs, readmission rates, complications rates, patient reported outcome measures (PROMs), range of motion (ROM), numerical Rating Scale (NRS), Lysholm score, Oxford Knee Score (OKS), wound delayed healing, surgical site infection, use of pre and post-op opioids, Harris Hip Score, Oxford Hip Score [1, 4, 5, 6].
The common interventions used in orthopedic ERAS programs have been divided into those performed in the preoperative, intraoperative, and postoperative phases of care [7, 8, 9, 10].
2.1 Pre-operative phase
Several systematic reviews have reported that preoperative patient education could be beneficial for patients undergoing orthopedic surgery as it could reduce preoperative anxiety. However, his positive effects on independently improving the postoperative outcomes is doubtful. These findings have been however described by not sufficiently powered studies and therefore the need for further randomized controlled studies has been advocated. Certainly preoperative education could not be harmful and could provide good support and counseling for the patients. Preoperative education may represent a useful adjunct, with low risk of undesirable effects, particularly in certain patients, for example people with depression, anxiety or unrealistic expectations, who may respond well to preoperative education that is stratified according to their physical, psychological and social need [9, 10].
The multidisciplinary team delivering an ERAS program should take into account the preoperative risk factors that could lead to delayed recovery or, even worse, complications. All specific individual factors should be identified and analyzed. This is supported by the ERAS evidence-based literature [8, 10].
Smoking has been found as a factor able to increase the length of stay, postoperative mortality and complication rate. ERAS protocols should include a smoke cessation program, to be started at least 4 weeks before surgery. The evidence related to these aspects is level 1 and 2 [10, 11, 12, 13]. Similar findings were highlighted with regards to alcohol consumption. Again, studies showed that patients who misused alcohol had increased complication rates and longer length of stay. Therefore, an alcohol cessation intervention is recommended before orthopedic surgery [9, 14].
Another aspect to be considered preoperatively is the hematic levels of hemoglobin and hematocrit. It has been shown that anemia could cause an increased risk of transfusion, length of stay, infection, morbidity, and readmission rates. To battle this issue, some ERAS protocols have included the use of preoperative iron or erythropoietin therapy and postoperative re-transfusion of salvaged cells. The cause of the anemia must also be investigated and managed [9, 15, 16].
Despite the current evidence does not fully support the use of carbohydrate loading, few studies have reported its benefits in the perioperative period as it could potentially reduce the preoperative hunger and nausea and the postoperative pain and glucose metabolism. However, it is clear that further studies are needed in order to provide high level of evidence [9, 17, 18].
Differently, there is strong evidence on the timing of intake of clear fluids (until 2 hours before the anesthesia induction) and solid food (up to 6 hours before the anesthesia induction). Factors such as timing of surgery with regards to the operating list and individual aspects should be considered by the anesthetist [9, 19].
Preoperative physiotherapy has been widely and commonly considered very important for patients undergoing joint replacement surgery. However, there is little evidence that it could expedite recovery and discharge. It seems that preoperative physiotherapy could particularly help patients in the first post-op days, whilst his efficacy on the medium and long term is doubtful [9, 20, 21].
Pre-existing conditions such as coronary artery disease, hypertension, chronic obstructive pulmonary disease, diabetes and organ dysfunction are strong determining factors of postoperative complications and duration of hospital stay. It is crucial to meet with patients several weeks before their scheduled surgery. It allows the preoperative team to optimize any organ dysfunction, address issues that may cause any potential risk, and to optimize preoperative anemia. It also gives the opportunity to initiate alcohol and smoking cessation programs if indicated (Table 1) [7, 22].
| ERAS interventions | ||
|---|---|---|
| Preoperative | Intra-perioperative | Postoperative |
| Patient education | Sedative or anxiolytic drugs | To manage nausea and vomiting |
| Preoperative risk factors | Neuraxial anesthesia | Multimodal analgesia approach |
| Smoking cessation | Opioids in spinal anesthesia | PCA and as required opioids |
| Avoid alcohol consumption | Local infiltration analgesia or nerve blocks | Antibiotic/antiseptic prophylaxis |
| Hematic levels of hemoglobin | Venous thromboembolism prophylaxis | Venous thromboembolism prophylaxis |
| Carbohydrate loading | Minimally invasive surgical technique | Early mobilization |
| Timing of intake of clear fluids | Maintaining normothermia through forced air warming | Tailored rehab approach to patients |
| Preoperative physiotherapy | Optimal intraoperative fluid balance | No use of tourniquet |
| Considerations of pre-existing conditions | Blood conservation | No use of drains |
| Intravenous or infiltrative tranexamic acid | No urinary catheter when possible | |
| Postoperative nutritional care | ||
Table 1.
2.2 Peri-operative phase
Most of the aspects related to this phase are anesthesia related. There are minimal data supporting the use of sedative or anxiolytic drugs used before the anesthesia takes places. Even if their use could help the patient to feel more comfortable and less stressed in proximity of the anesthetic and surgical procedure, they could cause side effects such as sedation [23].
Standardized anesthetic protocols should be used and integrated in ERAS protocols. Most of recent high level of evidence studies have favored the use of neuraxial anesthesia over general anesthesia. In fact, relevant literature fully support neuraxial anesthesia and its advantages in terms of reduced complications and better results [9, 24, 25].
Despite the adjunct of opioids to local anesthetic in spinal anesthesia could cause an increased risk of urinary retention and respiratory depression, a low opioids dose could lower these risks and at the same time reinforce the effect of the anesthetic on pain. However, their use is still debated, as the related side effects are relatively common and potentially very dangerous [9, 26].
The use of local infiltration analgesia or nerve blocks is still debated. It is unclear whether one technique is superior over the other. Moreover, there are studies reporting similar results with a postoperative wound infusion catheter technique, as long as multimodal, oral non-opioid analgesia [26, 27]. There are several nerve block techniques that may be used. Some studies have reported good results with femoral nerve blockade, which is probably the most used technique for total knee replacements. The Hunter Canal block is an alternative to the femoral nerve block and is proposed to offer better preserved quadriceps muscle strength and mobilization ability in the 48 hours post-surgery. Differently, no significant advantages have been proved to be given by sciatic nerve blocks [9, 26, 27, 28, 29].
The opoioid crisis seen worldwide has prompted a multimodal approach to pain management in the preoperative, perioperative, and postoperative periods. For example, NSAIDs, acetaminophen, preoperative bupivicane, adenosine, magnesium, clonidine, and venlafaxine have all been effective analgesics in patients undergoing orthopedic surgery (and other types of surgery too). There is also evidence that sedatives and anxiolytics can be avoided with appropriate preoperative counseling, whereas histamine H2 blockers and proton pump inhibitor prophylaxis can be used in patients who have had a shortened fasting period [7, 9].
There is evidence suggesting that regional anesthesia confers a greater advantage in total joint arthroplasty from a physiological standpoint. It is sufficient for surgery, provides a sympathetic block, inhibits stress hormone release, and decreases insulin resistance. Reduced length of stay is also associated with the use of neuraxial anesthesia as opposed to general anesthesia. Epidurals in major open surgeries have been shown to decrease respiratory complications and decrease bowel ileus as opposed to general anesthesia with concurrent opioid use. Many ERAS protocols advocate a multimodal approach to pain management to limit opioid use. Additionally, neuraxial techniques have been shown to blunt the stress response and decrease length of stay, which are all important in extended recovery programs [7, 9, 30].
Aspects related to venous thromboembolism (VTE) prophylaxis characterized both the pre, peri and postoperative phase. Unfractionated and low molecular weight heparin is the most common prophylaxis strategy used internationally. Surgical societies all over the world have follow their own recommendations. VTE prophylaxis is usually recommended for at least 14 days post-op. Most of societies recommend against the use of VTE prophylaxis 12 hours prior to insertion or removal of a catheter (Table 1) [7, 30].
2.3 Intra-operative phase
The general aim of the multidisciplinary ERAS team during the intra-operative phase is to reduce the physical stress of the surgery. The trauma-induced physiological responses should be kept under controlled and reduced to the lesser possible level. As mentioned in the previous section, neuraxial anesthesia has always been preferred and considered superior to general anesthesia in ERAS protocols. Local infiltration analgesia (LIA) is administered by surgeons intraoperatively, in and around the joint. Ropivacaine is most commonly used as local anesthetic, mixed with epinephrine and/or steroids. LIA is more useful when used in total knee arthroplasty. It provides postoperative pain relief 6–12 h after total knee arthroplasty. However, when used in total hip arthroplasty, it has no analgesic effect [7, 31].
The orthopedic surgeons themselves obviously play an important role in this “game”. The most minimally invasive surgical technique should be planned and performed by the surgeons. Major orthopedic surgery does not often allow room for small surgical wounds, but a big effort should be made in order to use the least invasive approach and protect relevant anatomical structures throughout the entire procedure. This is thought to reduce the physical stress of the surgery, complications, wound healing and pain levels [1, 2, 7, 9].
Other precautions that should attract the attention of the surgical and anesthetic team are: maintaining normothermia through forced air warming (this is associated with reduced infections, coagulopathy, blood transfusion rate, and cardiovascular complications, mainly because of reduced cortisol and catecholamine release; several associations recommends the pre-warming of patients and to maintain the active warming of all adults undergoing surgery throughout the intraoperative phase); optimal intraoperative fluid balance (this assures a better tissue oxygenation and a quicker wound healing process); blood conservation strategies (preoperative anemia should be investigated and corrected through the use of iron supplements or erythropoietin; blood salvage techniques should be utilized in surgical theaters, allowing a reduced need for allogeneic transfusions; the use of intravenously or infiltrative tranexamic acid, an antithrombotic drug able to reduce blood loss and the need for blood transfusions) (Table 1) [7, 9, 30, 32].
2.4 Post-operative phase
Postoperative nausea and vomiting can cause significant discomfort to patients in the first days after surgery and determining prolonged length of stay and delayed rehabilitation progress. Therefore, the use of dopamine antagonists, serotonin antagoinists and corticosteroids (or a combination of these) should be taken into account by the multidisciplinary team.
A multimodal analgesia approach (mainly non-opioid oral analgesia) is recommended and advocated. In fact, a combination of different analgesics classes together with the use of different modes of action is associated with better pain control and reduced need for the use of opioids. Paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) are the mainstay. Optimal pain management is a prerequisite of ERAS and alternative analgesic drugs (such as glucocorticoids, gabapentinoids and ketamine) have been described for hip and knee replacement. In the postoperative phase, several combination of epidural analgesia, continuous or patient-controlled, peripheral nerve blocks, single injection or continuous, acetaminophen, NSAIDs, gabapentin, and ketamine, have all been used for the same purpose [7, 9, 33, 34].
The use of opioids should be limited but their used has been reported in some centers using ERAS protocols, despite their well-known potential side effects. They are often used with a “as required” modality in the very few hours/days after surgery. Different opioids have been studied, among which oxycodone and sulfentanil. Initially a PCA (patient controlled analgesia) regime could be initiated, to be then switched to oral medications [7, 9, 35].
There is currently no universal internationally defined guideline for antibiotic/antiseptic prophylaxis for hip and knee replacement, with differing national and local policies in existence. However, a recent consensus paper does present recommendations for type, timing, dosing, and repetition of antimicrobials [36, 37].
Deep venous thrombosis (DVT) and pulmonary embolism (PE) are two of the most common and impactful complications following THR and TKR surgery. Again, there is no universal international consensus with regards to type and timing of prophylaxis. A minimum of 14 days of antithrombotic prophylaxis (up to 4–5 weeks) is usually recommended. Early mobilization and a tailored approach are certainly the new trends in this field, but further evidence is needed in order to validate the current research [1, 2, 7, 9].
Other aspects that should attract the attention of the surgical and anesthetic team are: the use of tourniquet for TKR surgery (many recent studies discourage its use as it could increase the risk of wound complications, DVT and slower functional recovery); the use of drains (recent studies have shown no advantages with its use as their use could cause increased risk of wound infections, hematomas and wound healing complications); the use of indwelling urinary catheters (despite being routinely utilized, recent high level of evidence studies reported increased incidence of renal and urological complications against no evidence of benefits by the use of urinary catheters); postoperative nutritional care (early return to normal diet is encouraged in most of ERAS protocols, despite the absence of high level of evidence) [7, 9, 35, 38, 39].
A mainstay of ERAS protocols is certainly early mobilization following surgery. Patients should be mobilized as soon as possible following surgery. It has been well studied and proved that prolonged bed rest postoperatively is associated with increased risk of thromboembolism, pulmonary complications, insulin resistance, and delayed wound healing. There are centers reporting patients’ discharge within 48–72 hours after surgery, with the support of studies with level 1 evidence. A well trained and specialized team of physiotherapists are necessary in order to achieve such good results, in the few hours/days after surgery as well as in the following weeks. A preoperative assessment to identify the patient’s expectations and the goals of rehabilitation and a tailored approach in the postoperative phase are the keys for the best possible results (Table 1) [7, 9].
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3. Discussion and conclusions
ERAS protocols are a combination of interventions based on the most scientific evidence and characterized by a tailored approach for each patient. This approach was initially hypothesized and introduced in abdominal surgery, and then adopted in orthopedic surgery for elective hip and knee arthroplasty [1, 2, 3, 4, 5, 6, 7, 8, 9].
The use of ERAS programs has demonstrated to provide excellent results with regards to both clinical-functional outcomes and the subjective patient experience before, during and after joint arthroplasty surgery. The most relevant positive aspects of ERAS protocols related to orthopedic surgery studied and recorded are: using the least invasive surgical practices; reducing complications; reducing costs; reducing length of stay at hospitals; improving patients’ satisfaction and postoperative quality of life; fastest possible recovery; better clinical and functional outcomes; better postoperative pain control [1, 2, 3, 4, 7, 8, 9].
The ERAS pathway consists of a selected number of interventions divided into those performed preoperatively, intraoperatively, and postoperatively (Table 1). All of them play a relevant and complementary role for the common aim to achieve the best possible objective and subjective outcome [7, 9].
Despite their great success and high level of evidence from a scientific point of view, ERAS programs are not routinely used and their widespread use is far from being achieved. Researchers attribute the responsibility for the latter issue to several factors: not satisfactory surgical team education and patients’ education; difficulties in changing the traditional practice; potential costs of ERAS implementations (education, rehabilitation centers, equipment, size of the team looking after patients, etc.…). One could argue that these issues could be counterbalanced, point by point, by the improvements that could be achieved through the use of ERAS implementations. Despite any positive considerations, ERAS protocols are adapted in very few specialized orthopedic centers around the globe [1, 2, 4, 7, 9].
This chapter summarizes the available evidence and the current knowledge and implementations of ERAS programs for patients undergoing elective THR and TKR. It is evident that a very early discharge (1–3 days) is possible and safe for such patients if ERAS protocols are put in place. Several studies have proposed a number of implementations in relation to ERAS programs: this chapter has widely considered all of them and outlined a useful summary to be utilized by the clinicians dealing with this cohort of patients, after having carefully considered the level of evidence of such studies and not included low level of evidence results.
Our aim is to explain in the most simple and clear way how ERAS programs works and highlight their potential advantages compared to more traditional practice. This should work as a starting point for the clinicians working with THR and TKR patients and as a trigger for reflection on the current practice, in order to find room for improvements. A more broad application (worldwide) of the ERAS implementations could generate further data and evidence, with the final result of better understanding, more standardization and wide international consensus. There are areas that particularly need further research more than the others, such as how to reduce pain and improve function, specific aspects of the post-op inflammatory response, specific aspects related to patients’ morbidity (chronic disease, psychiatric disorders, etc.…) [1, 2, 7, 9, 15, 23].
We believe that ERAS in joint replacement surgery is safe and cost effective, and its use should be widely promoted [1, 2, 7, 9, 40]. His use could be applicable to both younger and older patients as research shows its efficacy in providing good clinical-functional results, quicker recovery, low morbidity, low complications rates, shorter length of stay, quick return to independency in the daily activities and better experience for the patients [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 40].
Future research is needed in order to achieve better standardization and high level of evidence for all aspects related to ERAS, including patient experience and subjective results. In fact, the quality of existing evidence is limited due to several aspect, among which heterogeneity of the studies and significant risk of bias. Moreover, further progress should be specifically made in the application of ERAS protocols in THR and TKR surgery, to highlight specific considerations and improvements related to this cohort of patients and the performed surgery.
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4. Take home messages
The number of patients requiring and undergoing total knee replacement and total hip replacement surgery has been increasing for years; however individualized and standardized rehabilitation protocols after surgery are still lacking in most Orthopedic centers.
Enhanced recovery after surgery (ERAS) protocols have been recently studied and wildly introduced in order to provide and develop peri-operative multidisciplinary programs able to shorten length of hospital stay (LOS), reduce complications, readmissions and costs for patients undergoing major surgery. The knowledge and possibly the implementation of such protocols should be taken into account by all institutions.
The use of ERAS protocols in hip and knee replacement surgery can allow good clinical-functional results, better pain control, quicker recovery, low morbidity, low complications rates, shorter length of stay, quick return to independency in the daily activities and better experience for the patients with better patient satisfaction.
There is enough scientific evidence that ERAS protocols should be seen as a valuable and efficient aid for the orthopedic surgeons and a safe and effective option of the patient after joint arthroplasty surgery.
We believe that ERAS in joint replacement surgery is safe and cost effective, and its use should be widely promoted
Future research is needed in order to achieve better standardization and high level of evidence for all aspects related to ERAS.
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Appendices and nomenclature
enhanced recovery after surgery | |
length of stay | |
patient reported outcome measures | |
total hip replacements | |
total knee replacement | |
range of motion | |
numerical Rating Scale | |
Oxford Knee Score | |
venous thromboembolism | |
non-steroidal anti-inflammatory drugs | |
patient controlled analgesia | |
Deep venous thrombosis | |
pulmonary embolism |
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