OBJECTIVEEnhanced recovery after surgery (ERAS) is a multidimensional approach to improving the care of surgical patients using subspecialty- and procedure-specific evidence-based protocols. The literature provides evidence of the benefits of ERAS implementation, which include expedited functional recovery, decreased postoperative morbidity, reduced costs, and improved subjective patient experience. Although extensively examined in other surgical areas, ERAS principles have been applied to spine surgery only in recent years. The authors examine studies investigating the application of ERAS programs to patients undergoing spine surgery.METHODSThe authors conducted a systematic review of the PubMed and MEDLINE databases up to November 20, 2018.RESULTSTwenty full-text articles were included in the qualitative analysis. The majority of studies were retrospective reviews of nonrandomized data sets or qualitative investigations lacking formal control groups; there was 1 protocol for a future randomized controlled trial. Most studies demonstrated reduced lengths of stay and no increase in rates of readmissions or complications after introduction of an ERAS pathway.CONCLUSIONSThese introductory studies demonstrate the potential of ERAS protocols, when applied to spine procedures, to reduce lengths of stay, accelerate return of function, minimize postoperative pain, and save costs.

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Enhanced recovery after spine surgery: a systematic review

Background There are few studies detailing the incidence, patient outcomes and prognostic factors for chondrosarcomas (CS). Those that do exist have small sample sizes and/or use older datasets. The purpose of this study was to determine the incidence, overall survival (OS) and prognostic factors for OS of CS patients, as well as investigate the efficacy of curettage. Methods We analyzed data of 2186 patients diagnosed with chondrosarcomas between ’89-‘13 from the Netherlands Cancer Registry. The effect of risk factors on OS was assessed with a multivariate Cox regression. Median Follow-up was determined with reversed Kaplan-Meier. OS was estimated using Kaplan-Meier method. Results The relative incidence of CS was 2.88 per million citizens between ’89-’96, 4.15 between ’96-‘04 and 8.78 between ’05-’13. Most of the increase in incidence came from atypical cartilaginous tumours/grade I chondrosarcoma (ACT/CS I). The 3-, 5- and 10-years survival were, respectively, 96%, 93% and 88% for ACT/CS I, 82%, 74% and 62% for grade II CS and 38%, 31% and 26% for grade III CS. Prognostics factors significantly associated with OS were age, histological grade, year of diagnosis, tumour location and size. Conclusion The incidence of CS, and especially ACT/CS I, has increased over time, which could be driven by both an ageing population and increased diagnostic imaging. With the increased number of diagnosed ACT/CS I, the number of preventative curettages of this tumour has also increased. Despite the supposed preventative character of this treatment, the incidence of high-grade CS did not decrease.

https://scholarlypublications.universiteitleiden.nl/access/item%3A3005260/view

Incidence, outcomes and prognostic factors during 25 years of treatment of chondrosarcomas.

The enhanced recovery after surgery (ERAS) concept, sometimes referred to as "fast track", "accelerated," or "Rapid Recovery" surgery, was first introduced in 1997. The concept of ERAS targets factors that delay postoperative recovery such as surgical stress and organ dysfunction. ERAS protocols or programs are a care package of evidence-based interventions used in a multimodal and coordinated clinical care pathway. They represent a multidisciplinary approach directed to reducing postoperative complications, shortening length of hospital stay, improving patient satisfaction, and accelerating recovery. ERAS was initially centered on abdominal and colorectal surgery patients; however, ERAS protocols have been widely extended to include other specialties. Orthopedic surgery, particularly elective hip and knee arthroplasty is one of such areas where ERAS principles have been adopted. It has been associated with reduced length of hospital stay, readmission rate, and improved functional recovery. The common interventions used in orthopedic ERAS programs have been divided into those performed in the preoperative, intraoperative, and postoperative phases of care. A PubMed literature search was performed for articles that included the terms enhanced recovery and orthopedic surgery. In this article, we summarized the clinical application of ERAS and highlighted the key elements that characterize an enhanced recovery program.

Enhanced recovery pathways in orthopedic surgery

OBJECTIVEEndoscopic skull base surgery (ESBS) is a relatively recent addition to the neurosurgical armamentarium. As with many new approaches, there has been significant controversy regarding its value compared with more traditional approaches to ventral skull base pathology. Although early enthusiasm for new approaches that appear less invasive is usually high, these new techniques require rigorous study to ensure that widespread implementation is in the best interest of patients.METHODSThe authors compared surgical results for ESBS with transcranial surgery (TCS) for several different pathologies over two different time periods (prior to 2012 and 2012-2017) to see how results have evolved over time. Pathologies examined were craniopharyngioma, anterior skull base meningioma, esthesioneuroblastoma, chordoma, and chondrosarcoma.RESULTSESBS offers clear advantages over TCS for most craniopharyngiomas and chordomas. For well-selected cases of planum sphenoidale and tuberculum sellae meningiomas, ESBS has similar rates of resection with higher rates of visual improvement, and more recent results with lower CSF leaks make the complication rates similar between the two approaches. TCS offers a higher rate of resection with fewer complications for olfactory groove meningiomas. ESBS is preferred for lower-grade esthesioneuroblastomas, but higher-grade tumors often still require a craniofacial approach. There are few data on chondrosarcomas, but early results show that ESBS appears to offer clear advantages for minimizing morbidity with similar rates of resection, as long as surgeons are familiar with more complex inferolateral approaches.CONCLUSIONSESBS is maturing into a well-established approach that is clearly in the patients' best interest when applied by experienced surgeons for appropriate pathology. Ongoing critical reevaluation of outcomes is essential for ensuring optimal results.

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Lessons learned in the evolution of endoscopic skull base surgery.

OBJECTIVEThe aims of enhanced recovery after surgery (ERAS) are to improve surgical outcomes, shorten hospital stays, and reduce complications. The objective of this study was to introduce ERAS with biportal endoscopic transforaminal lumbar interbody fusion (TLIF) and to investigate the clinical results.METHODSPatients were divided into two groups based on the fusion procedures. Patients who received microscopic TLIF without ERAS were classified as the non-ERAS group, whereas those who received percutaneous biportal endoscopic TLIF with ERAS were classified as the ERAS group. The mean Oswestry Disability Index (ODI) and visual analog scale (VAS) scores were compared between the two groups. In addition, demographic characteristics, diagnosis, mean operative time, estimated blood loss (EBL), fusion rate, readmissions, and complications were investigated and compared.RESULTSForty-six patients were grouped into the non-ERAS group (microscopic TLIF without ERAS) and 23 patients into the ERAS group (biportal endoscopic TLIF with ERAS). The VAS score for preoperative back pain on days 1 and 2 was significantly higher in the non-ERAS group than in the ERAS group (p 0.05). Readmission was required in 2 patients who were from the non-ERAS group. Postoperative complications occurred in 6 cases in the non-ERAS group and in 2 cases in the ERAS group.CONCLUSIONSPercutaneous biportal endoscopic TLIF with an ERAS pathway may have good aspects in reducing bleeding and postoperative pain. Endoscopic fusion surgery along with the ERAS concept may help to accelerate recovery after surgery.

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Clinical results of percutaneous biportal endoscopic lumbar interbody fusion with application of enhanced recovery after surgery.

Objectives To collect data of randomised controlled trials (RCTs) and clinical controlled trials (CCTs) for evaluating the effects of enhanced recovery after surgery on postoperative recovery of patients who received total hip arthroplasty (THA) or total knee arthroplasty (TKA). Methods Relevant, published studies were identified using the following key words: arthroplasty, joint replacement, enhanced recovery after surgery, fast track surgery, multi-mode analgesia, diet management, or steroid hormones. The following databases were used to identify the literature consisting of RCTs or CCTs with a date of search of 31 December 2016: PubMed, Cochrane, Web of knowledge, Ovid SpringerLink and EMBASE. All relevant data were collected from studies meeting the inclusion criteria. The outcome variables were postoperative length of stay (LOS), 30-day readmission rate, and total incidence of complications. RevMan5.2. software was adopted for the meta-analysis. Results A total of 10 published studies (9936 cases) met the inclusion criteria. The cumulative data included 4205 cases receiving enhanced recovery after surgery (ERAS), and 5731 cases receiving traditional recovery after surgery (non-ERAS). The meta-analysis showed that LOS was significantly lower in the ERAS group than in the control group (non-ERAS group) (p Conclusions ERAS significantly reduces LOS and incidence of complications in patients who have had THA or TKA. However, ERAS does not appear to significantly impact 30-day readmission rates.

https://pmj.bmj.com/content/postgradmedj/93/1106/736.full.pdf

Enhanced recovery after surgery for hip and knee arthroplasty: a systematic review and meta-analysis.

Background The surgical choice for grade 1 chondrosarcoma has been debated for decades. Intralesional resection can minimize the damage caused by surgery and offer better functional outcome. However, controversy remains about whether it will result in higher rates of local recurrence and metastasis, fewer complications, and better functional outcome compared with resection with wide margin. This systematic review and updated meta-analysis therefore compared intralesional resection and resection with wide margin in terms of local recurrence, metastasis, complications, and functional outcome. Methods Medline, Embase, and the Cochrane Library were comprehensively searched in December 2016 to identify studies comparing intralesional resection and resection with wide margin for central grade 1 chondrosarcoma. Data of interest were extracted and analyzed using Review Manager 5.3. Results Ten studies involving 394 patients were included, with 214 patients who had intralesional resection and 180 patients who had resection with wide margin for grade 1 chondrosarcoma. Intralesional resection was associated with lower complication rates (P  Conclusion Intralesional resection provides lower complications and better functional outcome with no significant increase in the risk of recurrence and metastasis. We think it is a suitable treatment for central grade 1 chondrosarcoma.

Is intralesional resection suitable for central grade 1 chondrosarcoma: A systematic review and updated meta-analysis.

Controversy still exists regarding positioning of the knee in flexion or in extension after total knee arthroplasty (TKA) impacts treatment outcomes. In this meta-analysis, we evaluated if a postoperative knee position regime could positively affect the rehabilitation. A comprehensive search for randomized controlled trials (RCTs) assessing the effect of knee positioning after TKA was conducted. The outcomes of interest were blood loss and range of motion (ROM); total calculated blood loss (CBL), drainage volume, hidden blood loss (HBL), decline of hemoglobin level and requirement for blood transfusion. Ten RCTs involving 962 knees were eligible for meta-analysis. Positioning the knee in flexion after TKA was significantly associated with lesser CBL (P < 0.00001), less HBL (P < 0.00001) and decreased requirement for blood transfusion (P = 0.06). On subgroup analyses, the flexion group was found to have significantly less decrease in hemoglobin level 48 h to 6 days after surgery (P = 0.003), while no significant difference was noted at 24 h after surgery (P = 0.29). Further,a superior ROM was observed in flexion group (5–7 days after surgery) (P = 0.002), while there was no significant difference at 6 weeks. No significant inter-group difference in wound drainage was observed at 24 h after surgery. Positioning the knee in flexion in the early postoperative stage was associated with significantly lesser CBL, lesser HBL, decreased requirement for blood transfusion and better ROM at least in the early postoperative period, which may contribute to early rehabilitation. However, no significant difference was found in ROM at 6 weeks.

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Impact of flexion versus extension of knee position on outcomes after total knee arthroplasty: a meta-analysis

Although total joint replacement (TJR) procedures are efficacious, perioperative high‐dose factors replacement therapy (FRT) to avoid catastrophic bleeding represents a significant hurdle, particularly for patients with multiple joint affection. Double simultaneous bilateral TJRs were reported as safe and cost‐effective. However, little is known about multiple TJRs. The feasibility and effects remain debatable. Surgeons need to weigh the high cost of FRT against safety. Accordingly, we aimed to evaluate the clinical outcomes and cost‐effectiveness of single‐anesthetic multiple‐joint procedures of lower limbs in end‐stage hemophilic arthropathy.

https://onlinelibrary.wiley.com/doi/pdfdirect/10.1111/os.13743

A Retrospective, Long‐term Follow‐up of the Clinical Outcomes and Cost‐effectiveness of Single‐anesthetic Multiple Total Joint Procedures in Hemophilic Arthropathy

Chao Jiang

Papers

Enhanced recovery after surgery for hip and knee arthroplasty: a systematic review and meta-analysis.

Is intralesional resection suitable for central grade 1 chondrosarcoma: A systematic review and updated meta-analysis.

Impact of flexion versus extension of knee position on outcomes after total knee arthroplasty: a meta-analysis

A Retrospective, Long‐term Follow‐up of the Clinical Outcomes and Cost‐effectiveness of Single‐anesthetic Multiple Total Joint Procedures in Hemophilic Arthropathy