Table 2.
Summary of Reviewed TKA/THA Protocol Components, Outcomes, and Literature/Guideline Support.a
| Component “Bin” | Outcome(s) | Studies | Population Studied | Evidence | Guideline Support |
|---|---|---|---|---|---|
| Preoperative management | |||||
| Risk factor assessment | |||||
| Anemia | ↑ Postop transfusion, +/− LOS, infection, mortality; iron, Epo, preop donation → ↓ postop transfusion, +/− LOS, readmission | 2 SR, 2 RCT, 9 Obs | TKA/THA | + | NA |
| Diabetes | ↑ Infections (wound, UTI, and respiratory), ↑ pain, ↓ functional improvement | 1 SR, 13 Obs | TKA/THA | +++ | √√√ |
| Smoking | Cessation → ↓ Complications (wound, CV, and reoperation), ↓ pain | 2 RCT, 5 Obs | TKA/THA, spine, other surgical procedures | +++ | √ |
| Obesity | ↑ Implant failure/reoperation, superficial and deep SSI, DVT, reduced functional scores | 5 SR, 23 Obs | TKA/THA | +++ | √√√ |
| Malnutrition | ↑ LOS, wound complications | 9 Obs | TKA/THA | + | NA |
| Immune modulators | No consistent findings | 1 RCT, 5 Obs | TKA/THA | +/− | √ |
| Opiates/drug abuse | ↑ Opioid dependence postoperatively | 6 Obs | TKA/THA | + | √ |
| Preoperative education | ↓ LOS for TKA | 4 SR, 6 Obs | TKA/THA | +/− | NA |
| Preoperative bathing/ decolonization | ↓ SSI | 1 RCT, 3 Obs | TKA/THA | +++ | √√√ |
| Preoperative VTE prophylaxis | No difference in VTE vs postoperative initiation | 2 SR, 5 RCT | TKA/THA | +/− | √ |
| Intraoperative management | |||||
| Drains | No benefit; may ↑ complications/costs | 2 SR, 3 RCT, 7 Obs | TKA/THA | − | √√√ |
| Postoperative management | |||||
| Early mobilization | ↓ LOS | 1 SR, 1 RCT | TKA/THA | +++ | √√√ |
| Continuous passive motion | No effect | 1 SR, 2 RCT | TKA | − | √√√ |
| Extended duration VTE prophylaxis | ↓ Overall VTE rate, ↓DVT | 5 SR, 1 RCT | TKA/THA | + | √ |
| Early oral alimentation and enhanced nutrition | No effect | 1 SR | HFS | +/− | NA |
| Discharge planning/ discharge criteria | No consistent findings | 1 SR, 1 RCT, 7 Obs | TKA/THA | +/− | NA |
Abbreviations: CV, cardiovascular; DVT, deep vein thrombosis; EPO, erythropoietin; HFS, hip fracture surgery; LOS, length of stay; Obs, observational study; RCT, randomized clinical trial; SR, systematic review; SSI, surgical site infection; THA, total hip arthroplasty; TKA, total knee arthroplasty; UTI, urinary tract infection; VTE, venous thromboembolism.
aEvidence grading: +++, consistent evidence across studies showed benefit (interventions) or impact (risk assessment); +, evidence was either mixed with the majority favoring benefit/impact or little evidence existed in only one direction; +/−, evidence either did not exist or existed in both directions without one direction being favored; −, evidence showed no effect of a given practice or the intervention’s harms outweighed its benefits. Consistency with clinical guidelines: √√√, all guidelines supported a given practice or the guidelines cited strong evidence of support; √, some, but not all, guidelines supported a given practice or guidelines cited weak evidence or expert opinion.