Enhanced Recovery After Surgery (ERAS) Pathways in Elective Total Joint Arthroplasty

Enhanced recovery after surgery (ERAS) protocols are increasingly used in total hip and knee arthroplasty to improve outcomes, reduce complications, and shorten hospital stays. This involves a multidisciplinary, evidence-based approach covering the preoperative to postoperative period. This review explores the current literature on ERAS implementation in elective total hip arthroplasty (THA) and total knee arthroplasty (TKA), focusing on clinical outcomes such as length of stay (LOS), opioid use, complications/readmissions, and other key components such as anesthetic standardization, use of opioid-sparing analgesia agents, early mobilization, and patient satisfaction. We performed a literature search of PubMed, Embase, and Google Scholar databases (last searched May 2025) for studies evaluating the use of ERAS protocols in elective THA and TKA. Relevant articles, including clinical trials, observational studies, case series, case reports, and review articles, were identified without geographic restrictions, limited to English-language publications from 2000 to 2025. Key search terms included "enhanced recovery after surgery," "ERAS," "fast-track," "rapid recovery," "total joint arthroplasty," "total knee replacement," "total hip replacement," and "outcomes." The selection of articles was based on relevance to the topic, emphasizing clinical outcomes. No formal quantitative synthesis was performed, given the narrative scope. The included literature (spanning approximately 294,000 patients across multiple studies) consistently demonstrates that ERAS pathways significantly reduce LOS by one to three days without increasing readmission or complication rates. Multimodal, opioid-sparing analgesia regimens lead to superior pain control and reduced opioid exposure, enhancing early mobilization and minimizing adverse effects. Functional recovery is accelerated, with many ERAS patients ambulating within hours of surgery. Patient-reported outcomes and satisfaction are high, and early quality-of-life improvements are commonly observed. ERAS implementation results in substantial cost savings from a systems perspective, largely due to shorter inpatient stays and fewer postoperative complications. The evolution of ERAS has also facilitated the growth of outpatient (same-day discharge) arthroplasty in appropriately selected patients. ERAS in total joint arthroplasty (TJA) represents a paradigm shift in perioperative care, combining safety, efficiency, and patient-centred recovery. Its implementation leads to improved clinical outcomes and enhanced healthcare value, supporting its continued expansion and adoption as a global standard of care in hip and knee arthroplasty.