Ssrrhcap Deiarrmenr, Je enhce renerap ho ihrap, Je enhce, Spovenha Correspondence: Tomaž Shpve rer, e: romaz. hpve rer@ b-je. h Key words: enhanced recovery afer srrery; nee; hhi; arrhroipa ry Recehved: 13. 1. 2018 Acceired: 7. 2. 2019 Enhanced recovery after surgery for hip and knee arthroplasty: Our experiences at the department of orthopedic surgery in GH Jesenice TomažSilvester, BlažKacijan Abstract Population ageing has led to a growing number of total joint arthroplasty procedures in patients with degenerative joint diseases. At the same time, the financial resources for healthcare budget are limited or even decreasing. The enhanced recovery after surgery (ERAS) protocol can de­crease patients` length of stay (LOS) without compromising the quality of treatment, thus being beneficial both for the patients and the hospital budget. ERAS protocol for patients undergoing primary total knee or hip arthroplasty was partially im­plemented at the Jesenice General Hospital in 2014. It was then optimised and upgraded with preoperative education for patients and their relatives, with all patients treated according to the comprehensive ERAS protocol since 2015. Analysed outcome measures included LOS and readmissions in the first 30 days after discharge. Before the implementation of ERAS, the median LOS in 2013 and 2014 was 6.45 and 6.4 days, respectively. This was significantly reduced after ERAS implementation, with the median LOS of 4.4 days in 2015 and 2016, and 3.5 days in 2017. Readmission rate in the first 30 days after discharge showed no significant differences before and after the implementation of the ERAS protocol. The ERAS protocol has been successfully and effectively implemented by our department, with LOS being significantly reduced without an increase in the rate of postoperative complications. This was achieved with several multidisciplinary changes before (preoperative education) and during hospitalisation, with peri- and postoperative optimisation of blood management (regular use of tranexamic acid), pain control (multimodal opioid sparing analgesia) and especially with optimisation in physiotherapy. Cite as: Shpverer T, Kachjan B .[Enhanced recovery afer srrery or hhi and nee arrhroipary: Osr exierhence arrhe deiarrmenr o orrhoiedhc srrery hn GH JeenhceH. Zdrav Vern. 2019;88(5–6):225–34. DOI: 10.6016/ZdravVe rn.2691 1 Introduction 1.1 Total joint arthroplasty surgery Population ageing has led to a grow­ing number of patients with degen­erative joint diseases. However, their demands and expectations for a better quality of life in more advanced age have been growing. Total joint arthroplasty surgery is regarded as one of the most successful and routinely performed pro­cedures of the 20th century, as it is used to effectively eliminate pain, restore mo­bility and correct joint deformity, thus improving the patient’s quality of life (1). In Slovenia, approximately 3,500 prima­ry hip endoprosthesis and 2,200 prima­ry knee endoprosthesis are implanted every year, i.e. a total of approximately 5,700 procedures (2). Some 450 of these implantations are performed in Jesenice General Hospital every year. The growing number of total major joint arthroplas-ties represents an increasing financial burden for the healthcare budget both at the hospital and state levels. Combined with the patients’ expressed desire for re­covery in the home environment and its confirmed effectiveness, this had led to the concept of enhanced recovery after surgery (ERAS), without compromising the quality of treatment. 1.2 Enhanced recovery after surgery (ERAS) KSPO (angl. Fast-track surgery ali enhanced recovery after surgery, ERAS) je večdisciplinaren, na dokazih temelječ koncept, s katerim učinkovito in brez ogrožanja bolnika skrajšamo ležalno dobo po operaciji (3-5). The concept was developed by Danish surgeon Henrik Kehlet, who initially introduced ERAS into the field of colorectal surgery. In the last decade, its implementation in ortho­pedic surgery, especially in major joint arthroplasty, has become increasingly widespread. The basic principles of ERAS are to improve preoperative preparation, and reduce physical stress during surgery and postoperative discomfort, result­ing in earlier mobility and hospital dis­charge. Achieving this goal requires the coordinated effort of a multidisciplinary team consisting of orthopedic surgeons, anesthesiologists, physiotherapists, nurs­es and other nursing staff, while equally including the patient in the process (6). The ERAS concept is used to effective­ly reduce the number of perioperative complications, shorten the time needed for full recovery, as well as reduce mor­bidity and mortality of patients in the postoperative period (7). This shortens length of stay and ultimately reduces the cost of treatment (8,9). 2 The concept of enhanced recovery after surgery at the department of orthopaedic surgery at Jesenice GH The implementation of ERAS ele­ments was gradually initiated in 2014 for patients undergoing primary knee and hip joint arthroplasty. The concept was then upgraded, standardized and fully implemented in 2015. Successful imple­mentation of the ERAS concept requires collaboration within a multidisciplinary team and strict adherence to the pro­tocol to ensure high-quality treatment of the highest professional standard. Preoperative evaluation of patients un­dergoing total knee and hip joint arthro­plasty at the orthopedic department of Jesenice GH follows a protocol consist­ing of the following key elements: • optimization of the process of edu­ cating and informing the patient and their relatives, • optimization of anesthetic techniques and fluid balance, • optimization of pain management, • optimization of transfusion therapy, • optimization of physiotherapy and rehabilitation, • reduction of cognitive impairment af­ter surgery, and • strict compliance with functional cri­teria for hospital discharge. 2.1 Optimisation of the process of educating and informing the patient and their next of kin By properly educating the patient be­fore surgery, they are informed of the events before, during and after surgery, thereby reducing the patient’s anxiety, while contributing to a shorter recov­ery period and better treatment out­come (10). The process of education begins be­fore admission to hospital. A so-called preoperative school for patients under­going total knee and hip joint arthroplas­ty is organized almost every week. The orthopedic surgeon, anesthesiologist, floor nurse, dietitian, and clinical case coordinator present the entire course of treatment to the patient and their next of kin. They also address any questions or doubts that arise at this time. One of the more important pieces of information is also the length of stay. Thereby, pa­tients are fully informed when admitted to hospital and at ease concerning their treatment. REVIEW ARTICLE 2.2 Optimisation of anesthetic techniques and fluid balance Studies report conflicting results re­garding the choice of the optimal anes­thetic technique within the ERAS con­cept. Results of some studies, particularly less recent ones, support the use of spinal anesthesia (11). Some recent studies give somewhat preference to general anes­thesia (12). Nevertheless, due to the lack of large-scale randomized studies, there are no clear recommendations concern­ing the choice of anesthesia techniques within the ERAS. In Jesenice GH, spinal anesthesia is generally used as the technique of choice in patients undergoing total knee or hip joint arthroplasty. A femoral nerve block is supplemented to SA preoperatively in patients undegoing total knee arthro­plasty, in order to provide additional an­algesia. In case of any contraindications, general anesthesia combined with femo­ral nerve block is used instead of spinal anesthesia in patients undergoing knee arthroplasty. Patients are admitted on the day of surgery and should be fasted, mainly due to the possibility of general anes­thesia in case of spinal anesthesia fails or is impossible. Patients undergo rou­tine examinations prior to admission, including basic laboratory blood tests and coagulogram, chest radiograph and an electrocardiogram. During the prean­esthesia evaluation, the anesthetist may order additional tests if necessary. 2.3 Optimisation of pain management Optimal pain management after knee and hip joint arthroplasty is important for early mobilisation and rehabilitation, which will contribute to early hospital discharge (13). This is achieved through a multimodal pain prevention approach, comprising: • a high dose of glucocorticoid 1-2 hours before the start of the pro­cedure (20 mg dexamethasone or 125 mg methylprednisolone), which effectively reduces postoperative pain and improves postoperative recov­ery (14), • local infiltration analgesia with a mix­ture of ropivacaine and noradrena­line (250 mg ropivacaine and 0.5 mg noradrenaline in 100 ml of saline), which effectively relieves pain in the early postoperative period and re­duces the need for pain relief with systemic analgesics, especially in pa­tients undergoing total knee arthro­plasty (15), • postoperative pain relief with a com­bination of paracetamol and non-steroidal anti-inflammatory medica­tion. Opioid analgesics are avoided and are administered only for break­through pain relief. Patients receive intravenous analgesic therapy for the first 24 hours and then change to per os analgesia. 2.4 Optimisation of transfusion therapy Minor blood loss during surgery re­duces the need for postoperative blood transfusion and significantly contributes to early recovery and rehabilitation after total knee or hip joint arthroplasty (16). In order to reduce blood loss during surgery and prevent postoperative ane­mia, patients without known contrain­dications receive 1 g of antifibrinolytic agent (tranexamic acid) intravenously once anesthesia is induced and the sec­ond time upon arrival at the ward after surgery. There are different routes of administration of tranexamic acid (in­travenous, topical, per os). However, studies have not shown significantly different outcomes based on the route of administration (17). Research shows that tranexamic acid effectively reduces perioperative blood loss and the need for postoperative blood transfusion in patients who have undergone total joint arthroplasty (18). Since the introduction of tranexamic acid therapy at our de­partment, we have noticed a significant­ly lower rate of postoperative anemia, virtually eliminating the need for blood product therapy. Routine reservation of red blood cell concentrates before sur­gery is not necessary either. In the event of good hemostasis, postoperative an-tithrombotic prophylaxis is introduced approximately 12 hours after surgery; in­itially with low-molecular-weight hepa­rin applications, and converting to oral anticoagulant therapy in the following days. This therapy is continued for 15 days in patients after total knee arthro­plasty and for 30 days in patients after total hip arthroplasty. Patients who have risk factors for thrombotic complications (history of thrombotic events: CVI, PE, DVT, MI, atrial fibrillation …) are treated accord­ing to the latest joint guidelines of AAOS (American Academy of Orthopaedic Surgeons) and ASRA (American Society of Regional Anesthesia and Pain Medicine) (17). 2.5 Optimization of physiotherapy and rehabilitation Early mobilization of patients after surgery is an important element of the ERAS concept. With good pain manage­ment, mobilization of patients after total hip or knee arthroplasty is possible on the day of surgery.At Jesenice GH, this is not feasible yet due to the lack of physio­therapy staff. At our hospital, the patient 8 Pred uvedbo KSPO p < 0,01 7 6,45 6,4 6 Po uvedbi KSPO Dnevi 5 4,4 4,4 4 3,5 3 2 2013 2014 2015 2016 2017 Leto Figure 1:Patients’ length of stay following total hip arthroplasty before and after the introduction of enhanced recovery after surgery (ERAS) in days. Numerical data are expressed as median value and the first and third quartile The p-value between the groups before and after the introduction of ERAS (Mann-Whitney U test) begins the process of mobilization and physiotherapy on the morning following their procedure. 2.6 Reduction of postoperative delirium and cognitive impairment Postoperative delirium and cognitive impairment are frequently reported in literature on endoprosthetic reconstruc­tion surgery. They are associated with the duration of hospitalization. Risk fac­tors include pain, use of opioid analge­sics, sleep disorders, and postoperative inflammatory response (19). Applying the ERAS concept, the incidence of post­operative delirium and cognitive im­pairment is significantly reduced, since the aim of the ERAS protocol itself is to shorten the length of stay and to avoid potential risk factors (20). 2.7 Strict compliance with functional criteria for hospital discharge The patient is discharged to home care when they meet the functional cri­teria for discharge. These are achieved considerably faster by following the aforementioned elements. The function­al criteria include: • consent to discharge (both by the pa­tient and the orthopedic surgeon) • appropriate pain prevention • familiarization with the process of medication cessation, • awareness of restrictions, • the ability to properly stand up from a supine and seated position, • safe walking with or without a mobil­ity aid, • the ability to ascend and descend stairs, if necessary, 8 Pred uvedbo KSPO 7 6 Po uvedbi KSPO 5 4 Dnevi 3 2 2013 2014 2015 2016 2017 Leto Figure 2:Length of stay following total knee arthoplasty before and after the introduction of enhanced recovery after surgery (ERAS) in days Numerical data are expressed as median value and the first and third quartile The p-value between the groups before and after the introduction of ERAS (Mann-Whitney U test) . • the ability to continue specific exer-The basis for protocol adherence is cises at home, the clinical pathway for total knee and • self-reliance regarding personal hy-hip joint arthroplasty. This is a document giene and that accompanies the patient from hospi- • surgical wound with no signs of in-tal admission to discharge, documenting fection. all events concerning this patient. Only deviations from the standard course of Table 1: The number of patients who underwent primary total hip arthroplasty between 2013 and 2017. Table 2:The number of patients who underwent primary total knee arthroplasty between 2013 and 2017. treatment, nursing care and physiothera­py of the patient are recorded separately. 3 Experience in enhanced recovery after surgery at the department of orthopaedic surgery at Jesenice GH We wanted to verify the safety and efficacy of the implementation of the ERAS concept in patients undergoing primary knee and hip joint arthroplas­ty. Therefore, we analysed patients who underwent primary total knee and hip arthroplasty between 2013 and 2017. We divided patients into two groups. The first group comprised patients treated before the full implementation of the ERAS concept (in 2013 and 2014). The second group comprised patients treated according to the ERAS principles (from 2015 to 2017). We compared the two groups in terms of in-hospital length of stay as well as the incidence and cause of readmission within 30 days of hospi­tal discharge.We also examined the need for postoperative blood product therapy. Between 1 January 2013 and 31 December 2017, 982 primary knee and 851 primary hip arthroplasty procedures were performed. The number of proce­dures in the years before and after the introduction of ERAS is shown in Table 1 in Table 2, respectively. The mean age of the patients in this period was 68 years and 5 months for primary total hip ar­throplasty and 70 years and 1 month for primary total knee arthroplasty. Table 3:Readmission in 30 days following discharge from hospital after primary total hip and knee arthroplasty AMI – acute myocardial infarction A comparison of patient’s length of stay following primary total hip and knee arthroplasty before and after the introduction of ERAS is shown in Figure 1 and Figure 2. We also examined the need for blood product therapy. Prior to the introduc­tion of ERAS, blood product therapy was required in 5.8% of patients. The propor­tion of patients requiring blood product therapy decreased significantly to 2.9% after complete implementation of ERAS (p < 0.05). The frequency of readmission within the first 30 days of discharge and the cause for readmission is presented in Table 3. 4 Discussion The approach to the ERAS principle should be multidisciplinary, with coop­eration between surgeons, anesthesiol­ogists, nurses, physical therapists and others. A coordinated effort between members of this team is necessary to achieve the optimal effect, which is fa­cilitated by standardizing hospital treat­ment. In this respect, a treatment proto­col containing the elements of the ERAS concept is important. The protocols used by hospitals to implement the ERAS con­cept differ slightly. Nonetheless, they all follow the same basic set of ERAS prin­ciples (6,23,24). The protocol used at the orthopedic department of Jesenice GH is in most aspects comparable to the pro­tocols of other major orthopedic centers that have successfully implemented the ERAS concept. The clinical pathway pro­vides the basis for adherence to protocol and procedure standardization with­in the ERAS concept. Our department was the first in Slovenia to implement a clinical pathway for patients undergoing knee and hip joint arthroplasty. The pur­pose of a clinical pathway is to use stand­ardized and streamlined procedures and protocols to improve the quality of treat­ment, minimize unnecessary deviations in patient treatment, and consequently reduce treatment costs. One of the differences observed with regard to the protocols used in other centers is the time needed to achieve postoperative patient mobilization. In certain centers, this is achieved in the first hours after the procedure, which is not yet feasible at our department due to organizational and personnel issues. In the future, we wish to make progress in this respect and follow the relevant trends relying on ERAS concepts. Additionally, our protocol differs from the rest with regard to the anes­thesia technique used during total knee arthroplasty, as we use the femoral nerve block to extend the analgesic effect. A possible complication of performing the femoral nerve block is the weakening of the quadriceps muscle, which can lead to falls while attempting mobilization and may prolong the time needed for ver­ticalization of the patient (25). Studies show that the efficacy of perioperative local infiltration analgesia is comparable to that of the femoral nerve block (26,27). Therefore, further research is needed to determine the feasibility of the femoral nerve block. The introduction of physi­otherapy and mobilization on the day of surgery would enable the femoral nerve block procedure to discontinue. The successful implementation of the ERAS concept and the subsequent reduction of the length of stay allows for more procedures to be performed. Since the introduction of the ERAS con­cept, certain other centers have seen an increase in the number of performed procedures too (24). Following the in­troduction of the ERAS concept at the orthopedic department of Jesenice GH, we have observed the potential for in­creasing the number of total knee and hip joint arthroplasties. However, an in­crease also depends on adequate infra­structure and staff policy, and above all on the financial resources allocated to this purpose. Although we have not conducted a thorough analysis of the reduction in treatment costs following the introduc­tion of the ERAS concept, published studies have reported a reduction in the total cost of treatment (8,9). The cost of an inpatient day is EUR150 per patient, which indicates that reducing the length of stay of 400 patients by two days trans­lates into EUR120,000 in annual savings. However, an analysis of the cost reduc­tion in patient treatment should not be limited to the incidence of hospital re­admissions, as the number of specialist reexaminations at the emergency care department following hospital discharge into home care should also be consid­ered. These are relatively common in patients following total knee or hip joint arthroplasty, though in most cases un­necessary and rarely leading to hospital readmission (28,29). With proper pa­tient education and comprehensive in­formation on the course of treatment, which should continue even after hos- References pital discharge, unnecessary visits to the emergency care facilities can be reduced to some extent. Further research is need­ed to thoroughly clarify this issue. In order to maintain adequate qual­ity of treatment, it is essential to moni­tor the quality indicators concerning the primary total joint arthroplasty surgery procedure. These include hospital re­admission within 30 days after surgery, early periprosthetic infection and me­chanical complications (prosthesis dislo­cation, loosening) (21,22). Conscientious adherence to the ERAS concept has led to a reduction in the length of stay, with no observable increase in the number of perioperative complications or hospital readmissions. 5 Conclusion Despite the relatively short amount of time since the introduction of the ERAS protocol for primary total knee and hip joint arthroplasty, we have observed a significant reduction in the length of stay, without observing an increased number of complications or postopera­tive readmissions to hospital. 1. lee K, Goodman SB. Csrrenr rare and srsre o johnr reipacemenr hn rhe hhiand nee. Exierr Rev Med Devhce . 2008 May;5(3):383–93. 2. Mavčhč B. Porrebe io endoirorezah op a hn opena v Spovenhjh do pera 2050. Med Razrp. 2016;55(1):5–12. 3. KehperH, Whpmore DW. Evhdence-baed srrhcapcare and rhe evopsrhon o ar-rrac srrery. Ann Ssrr. 2008 Asr;248(2):189–98. 4. MaemiepJF, CpemenrND, Bappanryne JA, Dsnran E. Enhanced recovery irorramme afer roraphhiarrhro­ipary can re sprhn redsced penrrh oho ihrap ray whrhosrcomiromh hnr sncrhonaposrcome. Bone Johnr J. 2016 Air;98-B(4):475–82. 5. den Harror yM, Marhhj en NM, Vehmehjer SB. Redsced penrrh oho ihrapray afer rhe hnrrodscrhon oa raihd recovery irorocop or irhmary THA irocedsre. Acra Orrhoi. 2013 Ocr;84(5):444–7. 6. Ppace K, Scorr NB. Enhanced revcovery or power phmb arrhroipa ry. Conrhn Edsc Anae rh Crhr Care Pahn. 2014;4(3):95–9. 7. Mapvhya A, Marrhn K, Harier I, Mspper SD, Emmer on KP, Parrhnrron PF, erap. Enhanced recovery irorram or hhi and nee reipacemenr redsce dearh rare. Acra Orrhoi. 2011 Ocr;82(5):577–81. 8. Srower MD, lemans DP, HhppAG. Heaprh economhc hn enhanced recovery afer srrery irorram. Can J Anae rh. 2015 Feb;62(2):219–30. 9. Thanh NX, ChscAW, WaypaT, lawrence J, Farh P, ljsnrqvh rO, erap. An economhc evapsarhon orhe En­hanced Recovery Afer Ssrrery (ERAS) msprh hre hmipemenrarhon irorram or coporecrap srrery hn Apberra. Can J Ssrr. 2016 Dec;59(6):415–21. 10.McDonapd S, Pare MJ, Berhnrer K, Wa ha J, Sirowon A. Preoierarhve edscarhon or hhi or nee reipace­menr. Cochrane Daraba e Sy r Rev. 2014 May;(5):CD003526. 11. Rodrer A, Wap er N, SchsrS, McKee A, KehperH, van ZsnderrA, erap. Redscrhon oioroierarhve morraphry and morbhdhry whrh eihdsrapor ihnapanaerhe ha: re spr rom overvhew orandomh ed rrhap . BMJ. 2000 Dec;321(7275):1493. 12.Harren A, KehperH, To vhr-laren S. Recovery afer roraphnrravenos renerapanaerhe ha or ihnapanae -rhe ha or rorap nee arrhroipary: a randomhzed rrhap. Br J Anaerh. 2013 Sei;111(3):391–9. 13.lamiporJD, Warner ER, MannhnrDW. Msprhmodapiahn manaremenrhn rorap nee arrhroipary: a iro iec­rhve randomhzed conrropped rrhap. J Arrhroipa ry. 2014 Feb;29(2):329–34. 14. lsnn TH, Ander en lO, Krh ren en BB, Hs red H, Gaarn-lar en l, Bandhopm T, er ap. Effecr o hhrh-do e ireoierarhve merhypirednh opone on recovery afer roraphhiarrhroipary: a randomhzed, dosbpe-bphnd, ipa­cebo-conrropped rrhap. Br J Anae rh. 2013 Jan;110(1):66–73. 15.Anderen lO, KehperH. Anapre hc effhcacy opocaphn hprrarhon anapre ha hn hhiand nee arrhroipary: a y -remarhc revhew. Br J Anae rh. 2014 Sei;113(3):360–74. 16.Hs red H, Hopm G, Jacoben S. Predhcroropenrrh o ray and iarhenrarh acrhon afer hhiand nee re-ipacemenr srrery: ar-rrac exierhence hn 712 iarhenr. Acra Orrhoi. 2008 Air;79(2):168–73. 17. Fhpphnrham yA, Ramsmar DB, Jevevar DS, yare AJ, BhnhSA, Cpare HD, erap. Tranexamhc Achd Ue hn Torap JohnrArrhroipary: The CphnhcapPracrhce GshdephneEndored by rhe Amerhcan A ocharhon oHhiand Knee Ssrreon , Amerhcan Sochery o RerhonapAnerhe ha and Pahn Medhchne, Amerhcan Academy o Orrhoiaedhc Ssrreon , Hhi Sochery, and Knee Sochery. J Arrhroipary. 2018 Ocr;33(10):3065–9. 18.Dannhnrer T, Memrosdh SG. Tranexamhc achd and orrhoiedhc srrery-rhe earch or rhe hopy rrahpobpood con ervarhon. Ann Tran p Med. 2015 Air;3(6):77. 19.Kren l, Rams en lS, Kehper H. New hn hrhrhnro rhe iarhoihy hopory oioroierarhve cornhrhve dy- sncrhon. Acra Anaerhe hop Scand. 2010 Sei;54(8):951–6. 20.Kren l, Rams en lS, Hanen TB, Boro S, Sobappe K, KehperH. Dephrhsm afer ar-rrac hhiand nee ar­rhroipa ry. Br J Anae rh. 2012 Air;108(4):607–11. 21.Hs red H, Orre KS, Krh renen BB, OrneT, KehperH. Readmh honafer ar-rrachhiand nee arrhroipa -ry. Arch Orrhoi Trasma Ssrr. 2010 Sei;130(9):1185–91. 22.Gpa os EN, Pederen AB, Hanen TB. Rh ore-admh hon, reoierarhon, and morraphry whrhhn 90 dayo roraphhiand nee arrhroipary hn ar-rracdeiarrmenrhn Denmar rom 2005 ro 2011. Acra Orrhoi. 2014 Sei;85(5):493–500. 23.Chrh reph 1, Wappace S, Sare C, BabhrsU, lhew S, Dsrap3, erap. An enhanced recovery afer srrery irorram or hhi and nee arrhroipary. Med J As r. 2015;202(7):363-368. 24.Whnrher SB, Fo OA, Wh TS, Davh SP, EnrdapM, Je en V, erap. 1-year oppow-sio920 hhiand nee arrhro­ipary iarhenr afer hmipemenrhnrar-rrac. Acra Orrhoi. 2015 Feb;86(1):78–85. 25. Sharma S, Iorho R, SiechrlM, Davhe -leihe S, Heapy Wl. Comiphcarhon o emorapnerve bpoc or rorap nee arrhroipary. Cphn Orrhoi Repar Re . 2010 Jan;468(1):135–40. 26.ysn XD, yhn Xl, JhanrJ, TenryJ, DonrHT, An lP, erap. locaphn hprrarhon anapre ha ver s emorapnerve bpoc hn rorap nee arrhroipary: a mera-anapy h . Orrhoi Trasmarop Ssrr Re. 2015 Sei;101(5):565–9. 27. ApbrechrE, Gsyen O, Jacor-Gshpparmod A, Khr ham KR. The anapre hc effhcacy o pocaphn hprrarhon anapre ha v emorapnerve bpoc afer rorap nee arrhroipary: a yremarhc revhew and mera-anapy h . Br J Anaerh. 2016 May;116(5):597–609. 28.Ro man SR, Reb CW, Danow hRM, Mapren orr MG, MarhanhJK, lonner JH. Sepecrhve Earpy Ho ihrapDh -charre Doe NorIncreae Readmh hon bsrUnnece ary Rersrn ro rhe Emerrency DeiarrmenrI Exce hve Acro Grosi Afer Prhmary Torap Knee Arrhroipary. J Arrhroipary. 2016 Jsn;31(6):1175–8. 29.Shbha US, MandepbparrAE, Cappanan MA, MacDonapd JH, KhnrPJ. Inchdence, rh acror, and cor or ho ihrap rersrn afer rorap johnr arrhroiparhe. J Arrhroipary. 2017 Feb;32(2):381–5.