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Enhanced recovery programmes in knee arthroplasty: current concepts
  1. Robert M Middleton1,
  2. Alexander G Marfin2,
  3. Abtin Alvand1,
  4. Andrew J Price1
  1. 1 Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
  2. 2 Nuffield Department of Anaesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
  1. Correspondence to Robert M Middleton, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK; rob.middleton{at}


The concept of a multimodal approach to improve the care of surgical patients was first proposed by Kehlet in the 1990s. Measures to optimise the surgical patient, and minimise perioperative stresses, aimed to improve postoperative outcomes. Although originally introduced in colorectal surgery, these ‘enhanced recovery programmes’ have now seen widespread uptake in multiple surgical specialities, including orthopaedics. Patients undergoing knee arthroplasty are well suited to an enhanced recovery approach. These programmes optimise the patient at each stage of the surgical journey, including preoperative optimisation of fitness, perioperative anaesthetic and surgical techniques and finally postoperative rehabilitation and discharge plans. The available evidence supports a number of improvements after programme introduction, including shorter length of stay, morbidity and economics. However, the impact on other outcomes is less clear. One of the issues in the field is a lack of consensus on what interventions an enhanced recovery programme should contain and the specifics of these interventions. As a result, individual units develop their own programmes, making the interpretation and comparison of their impact difficult. This article discusses interventions that could be considered for inclusion in an enhanced recovery programme for knee arthroplasty.

  • knee
  • total joint replacement
  • enhanced recovery
  • anaesthesia
  • orthopaedics
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  • Contributors RM drafted the manuscript, with critical review and revisions by AM, AA and AP. All authors reviewed and approved the submitted article.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Commissioned; externally peer reviewed.

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