Effects of Enhanced Recovery After Surgery (ERAS) on Perioperative Outcomes in Shoulder Arthroplasty

Background and objective Enhanced Recovery After Surgery (ERAS) is a multidisciplinary, evidence-based management pathway to decrease length of stay (LOS) and complication rates. However, there is minimal research on ERAS regarding total shoulder arthroplasties (TSA). This study aimed to analyze the effects of the ERAS protocol on perioperative outcomes in patients who underwent elective, inpatient TSAs.  Methods A retrospective analysis was conducted using the Premier Health Database. Patients who underwent an elective anatomic TSA (aTSA) or reverse TSA (rTSA) were categorized into 'Low ERAS', 'Medium ERAS', or 'High ERAS' based on the number of billable ERAS criteria. Mixed model logistic regressions yielded odds ratios (ORs) and 95% confidence intervals (CIs). An area under the receiver operating characteristic curve (AUROC) and a Youden index were calculated to determine the optimal cutoff point for the best predictive model. Results A total of 74,158 patients were identified. Of them, 15,285 (20.6%) patients were 'High ERAS', 21,809 (29.4%) were 'Medium ERAS', and 37,064 (50.0%) were 'Low ERAS.' 'High ERAS' patients had significantly decreased ORs of experiencing any complication (OR=0.78, p<0.001), cardiopulmonary complications (OR=0.75, p<0.001), in-hospital mortality (OR=0.054, p=0.0040), and blood transfusions (OR=0.58, p<0.0001), and a shorter LOS from 2.19 days to 1.84 days (p<0.0001). The AUROC for the number of ERAS criteria received and in-hospital mortality was 0.75 with an optimal cutoff point of four ERAS criteria.  Conclusions TSAs are not an exception to the promising benefits of the ERAS protocol. Efforts should be made to create an official ERAS protocol in TSAs and help hospitals allocate resources to make its implementation possible.