Empower Mobility With ERAS

Cutting-edge multimodal anesthesia techniques and holistic care endeavor to make total joints a much smoother ride for patients.

For decades, patients heading into joint replacement surgery have heard their procedure should be a simple, no-frills affair, only to experience a much different reality. In 2025, however, the buzz surrounding these cases is entirely positive for a growing number of patients, and one of the big reasons why is the wide embrace within the orthopedic specialty of multimodal anesthesia and Enhanced Recovery After Surgery (ERAS) protocols.

ERAS protocols optimize surgical outcomes and patient recovery across a range of procedures. Under ERAS, anesthesia providers can adjust strategies for orthopedic and joint replacement procedures to better manage pain, reduce the risk of blood clots, optimize nutrition, reduce fluid retention and facilitate movement.

When applied properly, the ERAS-based approach improves cognitive function, allowing for earlier mobility following surgery, decreased physical and emotional side effects, and improved pain control.

What is ERAS?

It’s challenging to pinpoint when the shift to this evidence-based practice began, but ERAS — a multidisciplinary approach to improve recovery following surgery — has been an unbridled success. A typical hospital-based ERAS conduction team consists of surgeons, anesthesia providers, a coordinator and various staff from different hospital units whose treatment of the patient unwaveringly depends on published evidence.

When the ERAS Society began in 2001, a guiding principle for its founding members was to transition from treatment based on tradition to evidence-based treatment. In the nearly quarter-century since its formation, the ERAS Society has officially arrived as a thought leader in the creation of surgical recovery protocols.

Further advancements, including the popularization of minimally invasive surgical techniques, thorough patient education before surgery and deeper research into avoidance of presurgical fasting, have elevated the reputation of ERAS to the point that hospitals now consistently review and update their guidelines based on the latest ERAS protocols.

Many healthcare professionals believe no practice area has seen as much impact from ERAS as anesthesia.

Anesthesia, ERAS and joint replacements

The evolution of the anesthesia provider’s ERAS-driven role is most evident in joint replacement surgeries. Procedures to address the hip and knee specifically are historically among the most rehab-intensive surgeries in orthopedics.

Over the past quarter-century, however, scientific advances and recovery protocols have combined to turn what was often a life-altering operation into a same-day return home after an outpatient procedure. It’s no accident that this timeframe coincides with the rise of ERAS.

The field of orthopedic anesthesia has emerged as one of the fastest-growing specialties in medicine in both hospital and outpatient settings. Meanwhile, patient care is becoming increasingly individualized, with greater thought and priority placed upon the patient’s post-surgical recovery.

Just a couple decades ago, in a pre-ERAS world, a joint replacement procedure could involve a prior-day admission leading to a week-long (or more) hospital stay, extended fasting and repeated blood transfusions. While one of the greatest lessons of ERAS is that there’s no such thing as a typical patient, the orthopedic surgery patient experience in 2025 often includes the following advancements:

• The patient is encouraged to drink some type of clear liquid — Gatorade, tea or black coffee — before leaving home. The drink can be consumed about two hours before the procedure, with solid foods permitted for patients ages 13 and older up to eight hours before surgery.

• Rather than traveling to a hospital, the patient reports to a specialized, state-of-the-art surgical center. Improved quality and reduced costs are a few benefits to the patient, but surgeons also enjoy the greater scheduling flexibility of ASCs combined with an enhanced ability to rely upon specialized staff.

• Avoidance of general anesthetic. Again, the shift away from a one-size-fits-all approach means that doctors and anesthesia providers can offer a range of best practices in anesthesia for highly active competitive athletes to those well into their 80s and 90s. The modern-day preference is an avoidance of general anesthesia due to the potential for side effects that can slow recovery. ERAS protocol calls for preoperative, non-opioid pain medications (known as multimodal pain management), along with regional anesthesia such as an ultrasound-guided peripheral nerve block with lasting effects of up to 18 to 20 hours combined with intraoperative spinal anesthesia for motor block and to provide sufficient sedation during the surgery.

When regional anesthetic is contraindicated, as it may be in patients with a history of spinal surgeries, specific allergies, bleeding disorders or certain heart conditions, general anesthesia remains an option.

Benefits of ERAS and regional anesthesia

Regional anesthesia affects the patient’s post-surgical experience more than it does the procedure itself. Some of its main benefits include:

• Improved cognitive function. Current research shows mixed results on the effects of anesthesia on cognitive decline. Conventional wisdom maintains no significant difference in cognitive function between patients receiving general anesthesia and those receiving regional anesthesia.

Some studies, however, show that in patients receiving total knee replacements, at least 25% of adults 60 and older showed functional network decline. Specifically, one study (osmag.net/cognitive) found that patients receiving general anesthesia experienced higher postoperative cortisol levels than those receiving regional anesthesia, suggesting a need to mitigate stress factors in patients who receive general anesthesia.

• Early mobility. This is generally defined as having the patient up and moving within 24 hours of surgery. Today’s gold standard is same-day mobility. These quick turnaround times reduce complications including deep vein thrombosis, pulmonary embolism and pneumonia, while shortening recovery and improving patient-reported outcomes.

Advanced pain management techniques enable many patients to begin physical therapy the same day as surgery, leading to early discharges and increased satisfaction.

• Reduced nausea and vomiting. A peripheral nerve block impacts only the sensory nerves of the affected area to offer targeted pain relief, reducing the need for opioid-based medications and thus reducing the risk of postoperative nausea or vomiting (PONV). Multimodal pain-relieving medications also reduce the risk of PONV.

• Reduced bleeding and transfusion rate. This is accomplished via the use of tranexamic acid, an antifibrinolytic medication that stops the breakdown of fibrin clots by inhibiting the activation of plasminogen, plasmin and tissue plasminogen activator. It is used in pre-, intra- and postoperative phases unless contraindicated.

ERAS outcomes

Success with ERAS protocols depends on thorough coordination of the surgical team, attending physicians, the anesthesia provider and nursing personnel. It also requires the full investment of proactive patients and the people attending to them after they return home. When all involved parties work together using a single strategy with the same outcome in mind, it greatly reduces the stress on the patient — one of the highest risk factors after major surgery.

It’s easy to see a correlation between the implementation of ERAS and the improvement of total hip and knee arthroplasties.

Same-day surge

The 2023 Annual Report from the American Joint Replacement Registry took data from 3.1 million procedures performed between 2012 and 2022, representing a nearly 25% uptick in total procedures from its prior report.

The report indicated that patient-reported outcome measures (PROMs) are fast becoming the primary means of evaluating the effectiveness of a procedure. By the end of 2022, 496 participating sites submitted PROMs — a 24% increase from the previous year. The data revealed that 86% of patients reported a meaningful improvement following total knee arthroplasty. In 2023, ASCs reported more than 42,000 cases, an 84% increase over the previous year. Perhaps most importantly, over 92% of patients were discharged to their homes following elective total hip arthroplasty, with only 8% discharged to skilled nursing facilities.

The implications of ERAS expand beyond total hip and knee arthroplasties into other areas of orthopedic surgery. Researchers studied 323 adults with ankle fractures across a dozen centers and another 323 adults with distal radial fractures from 13 centers in 2017 and 2018. They divided them into an ERAS group and a traditional group. The ERAS group displayed higher satisfaction levels at discharge and six months post-operation. ERAS patients with ankle fractures also spent less time in bed and had shorter hospital stays than their traditional-approach cohorts, with no increase in complications or decrease in function.

This research suggests the role of ERAS is imperative in speeding up discharges while improving patient recoveries and satisfaction levels postoperatively. The best part? We’ve only scratched the surface of what’s ultimately possible. OSM