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Residency Applicants: Your Guide to the MyERAS Impactful Experiences Section

• by Dr. Mike Ren
• Aug 22, 2023
• Reviewed by: Amy Rontal, MD

The Electronic Residency Application Service® (ERAS) has been an essential tool in the medical community for decades as it introduced a digital platform that streamlined the application journey into residency, replacing traditional paper-based submissions with a centralized electronic system. While the landscapes of both medicine and technology have seen substantial changes over the past 20 years, the ERAS application itself has remained relatively consistent. Behind the scenes, however, there have always been discussions of rolling out enhancements and refinements to ensure the platform’s efficacy in a dynamic healthcare environment.

As was the case for many things, the catalyst for change was COVID. The pandemic altered the residency application process drastically, and resulted in a number of changes to the new ERAS application. As a result, the refresh to the 2024 ERAS application includes various things from program signaling to geographic preferences and an updated impactful experiences section. In this post, we’ll focus on the latter. I’ll explain the changes to the impactful experiences section that are in the 2024 MyERAS application , and give you some tips on how to fill out this revised portion of your application.

Tips for Completing the Revised MyERAS 2024 Impactful Experiences Section

Recent changes to the myeras application.

In prior iterations of ERAS, applicants listed their various experiences based on the three categories of work, volunteer activity, and research experience. Applicants would list start/end dates, amount of time allocated for each activity, as well as a brief description of the experience itself. 

Over the years, problems became evident with this model. One major issue was that applicants would word-vomit all sorts of random experiences, some totally irrelevant to medicine or their application all together. While not always a negative, as residency programs and directors want diverse applicants with varied experiences, they also want to see meaningful experiences that contributed to your growth as an applicant. Listing dozens of extraneous activities and extracurriculars is of no help in that regard. 

What’s new for the 2023 cycle?

The MyERAS application has a revised “impactful experiences” section where applicants can now list as many as 10 experiences that best communicate who they are and what is most important to them. For each experience, applicants are able to provide descriptive information such as a position title, start/end dates, location/setting of the experience, and describe it within 1020 characters. Moreover, from those 10, applicants will be able to describe up to three “most meaningful experiences,” in which they are prompted to write a brief reflection on the experience and explain how it influenced them.

Needless to say, it’s important to complete this new “impactful experiences” section in a way that program directors find compelling. Failing to do so can have a serious impact on your application. Here are some pointers for getting this crucial portion of your application done in a way that’ll make your application stand out. 

11 Tips for the MyERAS Impactful Experiences Section

1. use all 10 slots..

Applicants should optimize the use of application space and utilize all 10 experiences in order to showcase their dedication to the practice of medicine outside of generic clinical rotations and coursework, or alternatively, list life experiences that have led them to pursue a career in the medical field.  

2. List a variety of experiences.

As a residency counselor, I’m looking for   a variety of experiences, from community service to research and education, to clinical skills and entrepreneurship. In the 2024 MyERAS application there are new experience types to choose from, and the opportunity to discuss them in a way that supports a holistic view of each student’s experiences.

In the “three most meaningful experiences” section, applicants are encouraged to explain any challenges or hardships that influenced their journey to residency. The following examples from the AAMC can help you determine the kinds of experiences that are appropriate to share on your MyERAS application. Please keep in mind that this is not a complete list, but some good things to share include:

• – Family background (e.g., the first generation to graduate college)
• – Financial background (e.g., low-income family, work study to pay for college or medical school)
• – Community setting (e.g., food scarcity, low health literacy, lack of access to medical care)
• – Educational experiences (e.g., limited educational opportunities, limited access to advisors or mentors)
• – Other general life circumstances (e.g., loss of a family member, serving as a caregiver while working or in school)

You can include various experiences, some related to medicine and some not. The purpose of this section is to showcase who you are, not only as a future resident physician, but also as a young adult with interests and hobbies. Show me everything from your capacity for research and impact in the community to your work experience and teaching skills.

3. Use your slots wisely. 

Now, I know what you’re thinking, as the majority of applicants I’ve worked with have a host of experiences that could extend well beyond the mere ten slots in the experiences section of the 2024 application. The idea is for applicants to selectively place experiences that best demonstrate who they are to the programs. Program directors don’t need to read about your job as a movie attendant during freshman year of high school. You’d be surprised by the extraneous details that end up on some applications!

Also, it’s wise to combine multiple experiences in one meaningful entry to save space. For example, instead of listing the three various allergy clinics you volunteered at, combine them into a singular, meaningful experience of patient care and how it helped you realize your love for pediatric allergy and immunology. This helps convey what is essential to you as a physician and reflects your priorities. Furthermore, the brevity will help the program director better understand you as an applicant. 

4. Paint a picture. 

Program directors already have your scores, clinical grades, and objective data. The impactful experiences section, along with letters of recommendation and your ERAS personal statement , will paint a picture of who you are as an applicant, and more importantly, as an individual. This is a great opportunity to exhibit your perseverance and problem-solving skills to overcome obstacles.  

Please note that the experiences described can be from any point in time—they do not have to be during medical school or related to the field of medicine. This section is designed to give you the opportunity to provide additional information about your background or life experiences that is not captured elsewhere in the application.

For each experience, we want applicants to provide a brief description outlining the role, their responsibilities, and their contributions. This is also an opportunity to reflect on how you’ve grown as a result of the experience, and how it impacts your work as a doctor. Elaborate on what you learned and the insights you gained.

5. Know what program directors can see.

You may be wondering what the program directors have access to. 

From AAMC: “ All selected, most meaningful, and/or impactful experiences entered into your MyERAS application will be seen by programs across all specialties to which you apply. When viewing your application, programs will see experiences listed by experience type and then in chronological order with most meaningful experiences above all experiences. Additionally, programs can sort experience types, focus on certain areas, and key characteristics to help identify applicants who align with their mission.”

6. Avoid repeating yourself.

Try not to repeat experiences or mention similar things in this section that are elsewhere on your application (such as in your personal statement). When possible, combine multiple interchangeable experiences into a singular, meaningful one. This prevents your application from seeming too repetitive.

7. Find a connection.

In some cases, you might be able to link specific impactful experiences with the letters of recommendation you submit. This can help corroborate the information you provide and strengthen your overall application! 

8. Demonstrate desired qualities. 

Use the impactful experiences section to showcase qualities and attributes that make you a well-rounded and capable candidate, such as teamwork, communication skills, adaptability, and a commitment to patient care. 

9. Maximize the impact of the experience.

If a major experience played a role in influencing your choice of medical specialty, explain how it shaped your decision in detail.

10. Be sure to review and edit!

Like other sections of your MyERAS application, take time to review and edit your impactful experiences. Ensure that your descriptions are clear, concise, and effectively convey the significance of each experience. And please note that as the application process may change over time, refer to the official ERAS website for the most current and accurate instructions.

11. Take this section seriously. It matters!

Each year, the AAMC conducts a survey of program directors in which they answer questions about how they used the information in the application. The significance of the impactful experiences section for an application is evident.

But don’t just take my word for it. Here’s the data regarding the experiences section from a survey of the 2022 ERAS application cycle:

About 51%-81% of respondents, by specialty, used information from the applicants’ five most meaningful past experiences.

Further Reading

The impactful experiences section in MyERAS is where applicants can highlight moments in their life that have had a significant impact on their personal and professional development. This section allows them to showcase experiences that have shaped their journey through healthcare thus far, and illustrate to residency program directors the diverse backgrounds, skills, and qualities they bring into intern year. This helps PDs evaluate an applicant’s suitability for their programs.

Put your best foot forward and carefully consider how to complete the impactful experiences section of the MyERAS application. Take note of the changes that have been made to this section, and use these tips to complete it in a way that makes it more likely you’ll land your dream residency!

For more residency tips from Blueprint tutors (for free!), check out these other posts on the blog:

• How to Explain Educational Gaps on Your Residency Application
• Navigating the ERAS Residency Application: The Ultimate Guide
• What’s It Like Working With a Medical Residency Consultant?

About the Author

Mike is a driven tutor and supportive advisor. He received his MD from Baylor College of Medicine and then stayed for residency. He has recently taken a faculty position at Baylor because of his love for teaching. Mike’s philosophy is to elevate his students to their full potential with excellent exam scores, and successful interviews at top-tier programs. He holds the belief that you learn best from those close to you in training. Dr. Ren is passionate about his role as a mentor and has taught for much of his life – as an SAT tutor in high school, then as an MCAT instructor for the Princeton Review. At Baylor, he has held review courses for the FM shelf and board exams as Chief Resident.   For years, Dr. Ren has worked closely with the office of student affairs and has experience as an admissions advisor. He has mentored numerous students entering medical and residency and keeps in touch with many of them today as they embark on their road to aspiring physicians. His supportiveness and approachability put his students at ease and provide a safe learning environment where questions and conversation flow. For exam prep, Mike will help you develop critical reasoning skills and as an advisor he will hone your interview skills with insider knowledge to commonly asked admissions questions.

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MyERAS Application: How to Fill Out the Experiences Section

• 3 May, 2021
• ERAS Application
• No Comments

Advice for Completing the Experiences Section of the MyERAS Application

The MyERAS Common Application (Now called the MyERAS Application) is a section of your ERAS account that is meant to cover all the basic information programs would need to know about your personal and professional background. If programs want, they can also view the ERAS Common Application as a Curriculum Vitae (CV).  

One of the most important and most difficult sections of the MyERAS Application to fill out is the Experiences section. This is where you will break up your experiences (clinical, work, teaching, research, extracurriculars, and volunteer) into three categories: work, research, and volunteer.

You can, and should, include all of your relevant experiences to prove to residency programs you are medically relevant and ready to train in a residency. It also doesn’t just have to be clinical training. According to ERAS:

Adding Experiences

Each experience you add includes the following sections:

• Work – any clinical or teaching positions (paid or unpaid), and (maybe) your clinical rotations**
• Research – research positions
• Volunteer – unpaid or extracurricular activities
• Organization
• Supervisor – Who did you report to (if applicable)?
• Location: Country, State (if in the US), City
• Average Hours/Week
• Description
• Reason for Leaving (only include if there was an outstanding reason)
• Dates of Experience

**A note about including your clinical rotations.** According to the ERAS Helpdesk, you can choose to include clinical rotations, but this is entirely up to you as a residency applicant. Here are suggestions for including clinical rotations:

• However, if these are included on your MSPE in detail , rotations can come off as redundant
• Ask your medical school if you can review your MSPE to see what amount of detail it has for your clinical rotations
• Older candidates (+5 years since medical school) or International Medical Graduates (IMGs) should pick their most relevant and recent experience as opposed to using medical school clinical rotations, especially if they were completed outside of the US. Use your experiences to make sure there are no professional gaps.

More Tips for the Experiences Section

• Include any medical or professional skills you learned or improved such as taking patient history or inserting a catheter for the first time  
• If you know or have an idea of the language used in your Letters of Recommendation you can integrate those details into your descriptions
• Don’t repeat anything that was said in another section of your residency application such as your Personal Statement
• Include experiences from all medical specialties you have worked in. While your Personal Statements and Letters of Recommendation should be specialty specific, you want to include all of your medically relevant experiences in the MyERAS Application.
• Take your time. Do not rush your application and make costly mistakes! All applications certified before the date programs have access to them are time stamped with the same date.
• Proofread proofread proofread before you “Certify.” Make sure each experience is filled out properly with no grammatical mistakes, spelling errors, or typos. Remember that the MyERAS interface does not have a spell checker. So, copy and past your written sections into a word processor to check for you. If you want to ensure the quality of your MyERAS Application is as strong as possible, consider signing up for a Residency Experts package where you’ll have the benefit of editing and optimization by a residency expert. Once you “Certify,” your experiences will be locked in and no further changes will be allowed .

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• Residency Application

Master the ERAS Experience Section with MD Tips and Examples

Featured Expert: Dr. Monica Taneja, MD

ERAS Experience section examples can be a great guide to planning your own experience descriptions. Whether you are applying to the most competitive or least competitive residencies , your applications must be outstanding. The Experience section of your application is a great opportunity to provide program directors and faculty with the skills and aptitudes you developed throughout your medical school journey. In this blog, learn tips to create your ERAS experience entries and read excellent ERAS Experience section examples that you can use to inspire your own!

>> Want us to help you get accepted? Schedule a free strategy call here . <<

Article Contents 8 min read

What should you include on the eras experience section.

The ERAS Experience section is part of your residency CV . You can fill in up to 10 experiences and designate 3 of them as the “most meaningful”. You can also share any significant obstacles you faced and overcame in medical school in the “impactful experiences” category.

However, remember our golden rule – quality always trumps quantity. Focus on including experiences that were truly meaningful to your growth as an individual and a professional.

“I started by compiling a list of all my experiences through medical school. Then, I categorized them as volunteering, work, or research. I pared down my list in order to focus on the most important experiences to me, and to ensure that the reader wouldn’t have application reading fatigue as often times experiences just get glanced over.” – Dr. Monica Taneja, MD, Harvard South Shore, Psychiatry.

Remember that you can recycle some of your most notable experiences from your medical school application, and any activities you completed during a post-bacc program or special master’s program !

“I reused things from my medical school application. I included all of my research achievements which spanned from undergraduate through medical school. I also included items that occurred in my Master’s program before starting medical school which I completed after starting medical school.”

Aim to include any paid or unpaid clinical or teaching positions you may have. This can include clinical positions you held throughout your years in medical school or your role as an MCAT tutor for medical school applicants. 

And if you are wondering whether your clinical rotations and electives can be included in your ERAS Experience section, you are not alone. Technically, you can include these experiences. However, you should base your decision to include or exclude them based on your status as an applicant. What do we mean by this?

If you are still in 3rd or 4th year of med school figuring out how to prepare for residency applications , you most likely do not have much experience outside of your rotations and clerkships. So it would make sense that your experiences in rotations can be considered as some of the most important, formative activities on your journey to becoming a doctor. In this case, you can include a description of your experience in a specific rotation that solidified your decision to pursue your chosen specialty, for example. However, you can include your experiences from all the medical specialties you worked in.

Showing genuine interest in your specialty is key in making a strong impression to residency programs, Dr. Taneja says:

“Psychiatry specifically focuses on a holistic view of applicants and creating cohesive residency classes. I showed preparedness and interest in psychiatry by engaging in research and taking advantage of unique psychiatry rotations offered at my medical school. These both gave me plenty of stories to talk about how I validated the field and showcase how I see my career progressing in psychiatry.”

Eras research experiences.

For the Experience section, you need to include research activities you participated in, i.e., positions you held, such as assistant, investigator, technician, and so on.

“We were provided a good database of research opportunities within our medical school. When I started medical school, I also looked at National Research fellowships that I could pursue during the summer between 1st and 2nd year. I really didn't seek out work, other than paid research, during medical school and most of my true work experience was from before medical school.” – Dr. Monica Taneja, MD.

Right off the bat let’s make it clear that the research activities you are to include in the ERAS Experience section and your publications are not the same. You will actually have a whole separate section to include your publications in the ERAS application.

“I think that there are some specialties where showing your dedication is very important and one of the easiest ways to do this is through publications and presentations. There are also usually opportunities to spearhead an interest group within your medical school.” – Dr. Taneja, MD

Eras volunteer experiences.

ERAS encourages all applicants to include their unpaid and extracurriculars in the volunteer category of the ERAS Experience section. This means that if you have many clinical experiences that you want to include in the Experience section, you can divide them up between the clinical category and the volunteer category, but make sure to only include unpaid experiences in the latter.

Dr. Taneja says she found plenty of volunteering opportunities locally, but don’t hesitate to search for more opportunities online.

“For volunteering, my institution provided a list of local organizations that often had medical student participation. Beyond that, I did a fair amount of online volunteering as well.”

International experiences.

However, if you are an international medical graduate with experience in another country or a medical grad who took a gap year before residency , including your clinical rotations may be a faux pas. Firstly, because they may seem outdated, and you are encouraged to include your most recent experiences in the ERAS Experience section. Try to include any IMG clinical experience you gained in US.

For our admissions expert Dr. Terrell Coring, MD, clinical exposure in the US was built into his medical school program at Ross University School of Medicine :

“I attended a medical school that contracted with US hospital systems for clinical experiences. Therefore, these US clinical experiences were built into the program within my medical school. These clinical experiences within the US allowed for great letters of recommendation and great opportunities to network to increase my chances of matching within that health system.”

On the other hand, if you’re a US med student who’s interested in gaining some international experience, this is more than possible, too!

“[As a med student] I could easily set up rotations within South Africa in my final year as a medical student, and I had several colleagues complete rotations in clinics abroad, such as in Kenya and Guatemala, without issue … My advice is that if international or global health is something you are interested in, make sure you research which specific area you are dedicated to ahead of time to ensure that this is an option for you.” – Dr. Shaughnelene Smith, DO, Kansas City University School of Osteopathic Medicine.

The format of this residency application section is very similar to that of the AMCAS Work and Activities section or of the TMDSAS Employment and Activities section, or the Experience Section of the AACOMAS application system. And if you applied to medical schools in Canada , most of you filled out some form of description of your experiences, skills, and extracurriculars.

The selected experiences section has two parts:

• Up to 10 experiences that demonstrate who you are and what your passions are. For each entry, you’ll include a description, position title, organization name, start and end dates, frequency, location and setting.
• Your 3 Most Meaningful Experiences. From your 10 selected experiences, select 3 that had the biggest impact on you.

Your description is the most important part of every entry. You are given 1,020 characters to describe the activity and your responsibilities and 300 characters for the 3 most meaningful entries.

Your description must concisely demonstrate what position you held, what your responsibilities were, what kind of impact you had, and what you accomplished in this role. Make sure to dedicate some space to discuss what you learned from this experience and why it was so significant in your journey to residency. Include solid examples of how and why you learned your skills. For example, if your clinical experience taught you how to read patient histories and lab results, make sure to describe under what circumstances you learned this skill:

\u201c As part of my duties at Y Hospital, I assisted Dr. X in patient roundings. I reviewed patient histories and recent lab results, such as blood and urine tests. As my expertise grew, Dr. X delegated to me more duties, including review of results of other medical procedures, such as x-rays, CT scans, and electrocardiograms. I participated in organizing treatment plans with the patients and their families. \u201d ","label":"Example","title":"Example"}]" code="tab2" template="BlogArticle">

And while not all of your experiences have to be medically related, the characteristics you developed and lessons you learned should be applicable to medicine. For example, if you were a part of your med school's student council, committee, or organized a fundraiser, your description of this activity should include what kind of leadership lessons you learned, what organizational qualities you developed, and so on.

Interested in 7 tips to make your ERAS Application stand out:

Additional Tips for Your ERAS Experience Section

1. do not repeat yourself.

Your residency applications are meant to demonstrate the diversity of your experiences, your versatility, and your curiosity, among other qualities. Do not write about the same experiences in all your residency components. While it's expected that you will have some overlap between your residency CV and MSPE , try not to discuss the same experiences in your residency personal statement .

Additionally, keep in mind that you may be able to complete the Supplemental ERAS Application , in which you can further discuss your most important activities. Do not feel the need to emphasize the same activities and qualities over and over again to make the right impression – you will have plenty of opportunities to discuss a variety of experiences that demonstrate your strengths.

2. Do Not be Afraid to be Yourself

If you were involved in activities that were not necessarily related to medicine, like music, art, sports, etc., do not be afraid to include these activities in the Experience Section. You can and should include these if they have been especially formative in your life and taught you skills and lessons important for your medical career. For example, if you were a captain of a soccer team while studying in medical school, you should be proud of your time management skills and leadership skills.

Additionally, keep in mind that it is experiences and skills like these that often grab the reader’s attention. While most of your residency application should focus on the story of your journey to residency and how you chose your medical specialty , there is space to discuss other aspects of your life that enriched this journey.

3. Start Early

We may sound like a broken record with this advice, but rushing your applications is one of the biggest mistakes you can make as a candidate. Choosing which experiences to include and crafting your descriptions is time-consuming! Do not think you can do this in a week. Give yourself at least 5-6 weeks to narrow down a list of experiences and craft compelling descriptions of each activity.

4. Proofread

Another piece of advice that may seem trivial, but following it is essential for your success. Your residency application components must be near-perfect. Any typos, errors, and mistakes will hinder the impression you make with your application. Triple-check any of your components to make sure there are no errors.

Since we strongly encourage you to write in full sentences to add that extra bit of competitive edge to your entries, our descriptions will also be written in complete sentences.

Dates of experience: 09\/01\/20xx \u2013 05\/31\/20xx ","label":"Volunteer Experience Example","title":"Volunteer Experience Example"}]" code="tab1" template="BlogArticle">

The ERAS Experience section is a part of your residency CV. It’s meant to demonstrate which experiences and activities made the most impact on your choice of career and specialty.

You can include experiences from these three categories: work, research, volunteer. Note that you will have a separate section for publications in the CV, so for the Experience section, only include positions you held, not publications.

You will have 1,020 characters to describe the activity and 300 characters for your 3 “most meaningful” entries. Your descriptions should be informative, but concise.

While it is certainly allowed, we would advise writing your descriptions in short, concise sentences to show off your written communication and organizational skills.

You can include up to 10 selected experiences and 3 most meaningful, chosen from the original 10.

You can, but try not to. Use this opportunity to showcase a variety of your involvements and show that you are a versatile candidate with a variety of experiences. 

ERAS Experience section examples are a great way to start your research. Check out how others have structured and described their activities. Examples can help you decide not only how to write about your activities, but how to choose which ones to include.

Yes, you can. However, keep in mind that you are still applying to medical residency, so your descriptions should aim to emphasize skills, characteristics, and lessons you learned that would be valuable for a physician.

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Have a question ask our admissions experts below and we'll answer your questions.

ANDRES FERNANDEZ

Hi. I need help in how to add my publications at ERAS? I have one plublications and 4 posters. Thanks

BeMo Academic Consulting

Hello Andres, please reach out to us to see how we can help you with the Experience Section. 

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Key Components, Current Practice and Clinical Outcomes of ERAS Programs in Patients Undergoing Orthopedic Surgery: A Systematic Review

Francesca salamanna.

1 Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; [email protected] (F.S.); [email protected] (D.C.); [email protected] (A.V.); [email protected] (M.F.)

Deyanira Contartese

Silvia brogini, andrea visani, konstantinos martikos.

2 Spine Surgery Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; [email protected] (K.M.); [email protected] (C.G.); [email protected] (A.G.)

Cristiana Griffoni

Alessandro ricci.

3 Anesthesia-Resuscitation and Intensive Care, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; [email protected]

Alessandro Gasbarrini

Milena fini, associated data.

Not applicable.

Enhanced recovery after surgery (ERAS) protocols have led to improvements in outcomes in several surgical fields, through multimodal optimization of patient pathways, reductions in complications, improved patient experiences and reductions in the length of stay. However, their use has not been uniformly recognized in all orthopedic fields, and there is still no consensus on the best implementation process. Here, we evaluated pre-, peri-, and post-operative key elements and clinical evidence of ERAS protocols, measurements, and associated outcomes in patients undergoing different orthopedic surgical procedures. A systematic literature search on PubMed, Scopus, and Web of Science Core Collection databases was conducted to identify clinical studies, from 2012 to 2022. Out of the 1154 studies retrieved, 174 (25 on spine surgery, 4 on thorax surgery, 2 on elbow surgery and 143 on hip and/or knee surgery) were considered eligible for this review. Results showed that ERAS protocols improve the recovery from orthopedic surgery, decreasing the length of hospital stays (LOS) and the readmission rates. Comparative studies between ERAS and non-ERAS protocols also showed improvement in patient pain scores, satisfaction, and range of motion. Although ERAS protocols in orthopedic surgery are safe and effective, future studies focusing on specific ERAS elements, in particular for elbow, thorax and spine, are mandatory to optimize the protocols.

1. Introduction

1.1. eras in orthopedic surgery.

Currently, orthopedic surgery remains one of the most common hospital surgeries in the world with an ever-growing burden in low- and middle-income countries. The number of orthopedic procedures performed worldwide totaled approximately 22.3 million in 2017 [ 1 ]. Additionally, the rising life expectancy in association with the shorter disease-free life expectancy (62.6 years in males and 64.4 years in females) will lead to an ever-increasing growth in the number of these procedures [ 2 ]. As demand for orthopedic surgical procedures has increased considering the recent advances in surgical and anesthesiologic techniques, the clinical pathways and care programs have undergone considerable changes influenced by the concept of ERAS programs [ 3 ]. ERAS aims to enhance the recovery from orthopedic surgery, also decreasing the length of hospital stays (LOS) and the readmission rates after surgery [ 3 ]. The reductions in LOS and readmission lead, in turn, to cost cutting and to a lower risk of nosocomial infections and thromboembolic events, as well as to a reduction in perioperative complications [ 3 , 4 ].

1.2. ERAS Protocols

ERAS protocols were introduced more than 20 years ago by Henrik Kehlet, providing the involvement of a multidisciplinary team made up of orthopedic surgeons, nursing staff, anesthesiologists, internists, physiatrists, physiotherapists, and nutritionists [ 5 ]. The procedures manage the patients’ care using a multi-modal approach that includes patient selection, patient-specific education and information on the preoperative, perioperative, and postoperative steps, improvements in surgical and anesthetic practices, advances in post-operative multi-modal analgesia, early rehabilitation and ambulation, early nutrition hydration, and discharge within 24 h post-surgery [ 6 , 7 ]. Preoperative patient education is of key importance in orthopedic care programs, particularly in ERAS programs, although its real impact with respect to traditional (standard) care in terms of anxiety, postoperative pain management, function, quality of life and complications is not yet clear [ 8 , 9 ]. Nevertheless, several studies recognized that satisfactory patient information is a critical element for early discharge and managing daily home life in ERAS programs, also supporting the value of multimodal education of the patient [ 10 , 11 ]. Additional key issues in ERAS programs in orthopedic surgery include effective pain treatment and management, which undoubtedly influence an early hospital discharge and a fast recovery period at home [ 10 , 12 ]. However, some studies evaluating the discharge procedure and patients’ experiences after hospital discharge showed that the early discharge, especially in elderly patients, may be stressful in terms of managing daily life and rehabilitation [ 10 , 11 , 12 , 13 ]. Although this type of ERAS pathway has undeniable advantages and represents the standard of care in many institutions, to date, the clinical effectiveness of ERAS procedures has not been homogeneously recognized or accepted for all orthopedic areas, and there is still significant work and research to be done [ 14 , 15 , 16 ]. In addition, the ERAS pathways are always undergoing improvement, thanks to the constant contribution that can derive from multiple perspectives such as that of the patient, the surgeon, or the hospital unit with the aim of improving the protocols. Continuous evidence-based revisions for ERAS use in different orthopedic areas are mandatory to properly update orthopedic surgeons and their staff on the use of these ERAS pathways and on their potential advantages over standard/traditional protocols in terms of safety and efficacy. In addition, within an optimized and clear ERAS protocol, selected high-risk patients may benefit from a planned longer stay in hospital as the best means of accelerating recovery and reducing complications, readmissions, and morbidity, and allowing the medical staff to monitor patients for longer periods of time. Thus, to highlight recent improvements in the preoperative, perioperative, and postoperative ERAS components and their clinical evidence in patients undergoing different types of orthopedic surgery, we carried out a systematic review to provide an evidenced-based assessment of specific interventions, measurement, and associated clinical outcomes linked to ERAS pathways in the orthopedic field.

2. Materials and Methods

2.1. eligibility criteria.

The PICOS framework (population, intervention, comparison, outcomes, study design) [ 17 ] was used to formulate the questions for this study: (1) patients undergoing orthopedic surgery (population) submitted to, (2) ERAS pathways (interventions), (3) with or without a comparison group (standard protocol) (comparisons), (4) that reported preoperative, perioperative, and postoperative key components and clinical outcomes of the ERAS protocols (outcomes), in (5) randomized, non-randomized, controlled, non-controlled, retrospective, and prospective studies (study design). The focused question was “What are the preoperative, perioperative, and postoperative key components and the clinical outcomes of ERAS interventions in patients undergoing orthopedic surgery?”. Studies from 1 August 2011 to 1 August 2021, were included in this review if they met the PICOS criteria.

We excluded studies (1) in which the use of an ERAS protocol was declared but which then did not follow any of the indications of an ERAS protocol, and studies that evaluated (2) surgeries other than orthopedic ones, (3) patients undergoing orthopedic surgery with other concomitant severe pathological conditions (e.g., tumor, metastases, diabetes, rare neurological diseases, opioid use disorders), (4) different surgeries within a single ERAS protocol, (5) novel intervention/drugs/therapies not associated with ERAS protocols, and (6) articles with incorrect or incomplete data, or articles whose data could not be extracted. Additionally, we excluded abstracts, protocol studies, editorials, pilot studies, case reports or series, animal experiments, letters, comments to editors, reviews, meta-analyses, book chapters and articles not written in English.

2.2. Information Source and Search Strategies

Our literature review involved a systematic search conducted on 1 August 2021. We performed our review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement [ 18 ]. The search was carried out on PubMed, Scopus, and Web of Science Core Collection databases to identify studies that evaluated preoperative, perioperative, and postoperative key components and clinical evidence of ERAS protocols in orthopedic surgery. The search was conducted combining the terms (orthopedic disorders OR orthopedic surgery) AND (fast-track OR enhanced recovery after surgery OR enhanced recovery programs); for each of these terms, free words and controlled vocabulary specific to each bibliographic database were combined using the operator “OR”. The combination of free-vocabulary and/or medical subject headings (MeSH) terms for the identification of studies in PubMed, Scopus and Web of Science Core Collection are reported in Table S1 (Supplementary Materials) .

2.3. Selection Process

Possible relevant articles were screened using titles and abstracts by three reviewers (DC, FS, SB). After screening the titles and abstracts, articles were submitted to a public reference manager (Mendeley Desktop 1.19.8) to eliminate duplicates. Three reviewers (DC, FS, SB) performed 100% double title and abstract screening independently with inter-reviewer agreement of 90.1%. Studies that did not meet the inclusion criteria were excluded from full text review, and any disagreement was resolved through discussion until a consensus was reached, or with the involvement of a fourth reviewer (MF). Subsequently, the studies were subjected to full text review by three reviewers independently (DC, FS, SB). Disagreements after full text review were resolved through discussion, and the remaining studies were included in the final stage of data extraction. The inter-reviewer agreement for the final stage of data extraction was 95.3%.

2.4. Assessment of Methodological Quality

Two reviewers (DC, FS) independently assessed the methodological quality of selected studies. In case of disagreement, they attempted to reach consensus; if this failed, a third reviewer made the final decision (MF). The methodological quality of the studies was assessed using the quality assessment tools of the National Heart, Lung, and Blood Institute (NHLBI) [ 19 ] ( Table S2, Supplementary Materials ).

2.5. Data Collection Process and Synthesis Methods

The data extraction and synthesis process commenced with cataloguing the studies in detail. Subsequently, to increase validity and avoid potentially omitting findings for the synthesis, three authors (DC, FS, SB) extracted the data and generated tables taking into consideration the study design, pathological condition, patient numbers, ages and genders, surgical procedures, follow-up and outcomes/endpoints ( Tables S3–S6 , Supplementary Materials ). Another table included ERAS protocols (preoperative, perioperative, postoperative) ( Table S7, Supplementary Materials ). Finally, a supplementary table ( Table S8, Supplementary Materials ) with a numerical designation of positive, neutral and negative outcomes for each study was reported.

3.1. Study Selection and Characteristics

The initial literature search retrieved 1154 studies. Of those, 763 studies were identified using PubMed and 263 using Scopus, and 128 were found in the Web of Science Core Collection. Articles were submitted to a public reference manager to eliminate duplicate articles. The resulting 930 articles were screened for titles and abstracts, and 229 articles were then reviewed to establish whether the publication met the inclusion criteria. Finally, 174 (two on elbow orthopedic surgery, four on thorax orthopedic surgery, 25 on spine orthopedic surgery, and 143 on hip and/or knee orthopedic surgery, of which 52 were only on knee, 39 only on hip, and 52 on both knee and hip) were considered eligible for this review. Search research and study inclusion and exclusion criteria are detailed in Figure 1 .

PRISMA 2020 flow diagram for the selection of studies.

Of these articles, 82 were retrospective cohort studies (one on elbow, four on thorax, 18 on spine, 59 on knee and/or hip), 68 were prospective cohort studies (two of which were with a retrospective, historical cohort as control; six on spine, 62 on knee and/or hip) and 24 were randomized clinical trials (RCT) (one on elbow, one on spine, 22 on knee and/or hip) ( Figure 2 ).

ERAS study characteristics, numbers, and types.

3.2. Assessment of Methodological Quality

The quality assessment for the two studies on orthopedic elbow surgery was strong for the single RCT and moderate for the one retrospective study, with weaknesses in the patient’s eligibility, sample size justification, blinded assessor, and potential confounding variables. Regarding the four studies on orthopedic thorax surgery, three studies were classified as moderate and one as weak, with weaknesses in, sample size justification, blinded assessor, and potential confounding variables examination. In the quality assessment of the 25 studies on orthopedic spine surgery, 12% of the studies were rated strong, 80% were rated moderate, and 8% were rated weak. Methodological weaknesses that led to study quality scores of moderate or weak often included the lack of a sample size justification and/or lack of variance and effect estimates, the lack of ERAS results evaluation more than once over time, the lack of blinded assessor and the lack of measurement of potential confounding variables. For the 143 studies on hip and/or knee orthopedic surgery, 39.2% were rated strong, 40.5% as moderate, and 20.3% as weak. The quality scores of moderate or weak studies included lack of a sample size justification and/or lack of variance and effect estimates, lack of ERAS results evaluation more than once over time, lack of blinded assessor and lack of measurement of potential confounding variables. Risks of bias assessments for each study are summarized in Table S2 (Supplementary Materials) .

3.3. Study Results and Synthesis

3.3.1. types of orthopedic surgery in eras protocols.

Of the 174 articles on ERAS selected and included in this review, 36.2% had a comparison with a standard/traditional protocol (non-ERAS), while all the others (64%) evaluated different ERAS protocols in patients undergoing orthopedic surgery. Of the 174 articles, 1.1% were on elbow orthopedic surgery, 2.3% on thorax orthopedic surgery, 14.4% on spine orthopedic surgery, and 82.2% on hip and/or knee orthopedic surgery. These data highlighted that the highest percentage of articles on ERAS were on total and mono-compartmental hip arthroplasty and knee arthroplasty, mainly performed due to osteoarthritis (OA) (62.2%) but, in some cases, also for fractures, avascular necrosis and revision surgery. However, it was also shown that ERAS programs are starting to apply to other orthopedic surgical specialties such as for spine, principally for spinal stenosis (36%), spinal scoliosis and deformities (32%) and adolescent idiopathic scoliosis (16%). Four articles on thorax orthopedic surgery were also present and used ERAS protocols for pectus deformities (n = 3) and for traumatic rib fracture (n = 1). Finally, two studies on ERAS protocols were present for patients with elbow post-traumatic stiffness and with elbow primary or secondary OA.

3.3.2. Key Components in ERAS Protocols

Preoperative.

Preoperative ERAS components are defined in this review as interventions that occur any time before the day of surgery, elements planned to optimize the patient’s condition prior to surgery. They also include advice about behavioral health and psychology referral to guide patients’ expectations as well as to inform them on the risks about intra- and postoperative pathways. Below are reported the preoperative ERAS components for the different orthopedic specialties ( Figure 3 ).

Pre-, peri- and postoperative elements of ERAS procedures.

• - Elbow: In elbow orthopedic surgery, the most common preoperative interventions were patient education and the provision of information (on the surgical procedure, analgesia, anesthesia, LOS, and physiotherapy) (100%).
• - Thorax: The most common preoperative interventions reported in thorax orthopedic surgery were patient education and the provision of information (50%). Supplementary pre-emptive interventions were analgesia and multimodal pain management (50%) (defined as the use of one or more analgesic modes, such as acetaminophen, pregabalin, gabapentin, ketamine, non-steroidal anti-inflammatory drugs (NSAIDs), and cyclooxygenase (COX)-2 inhibitors)), clear fluid fasting (25%), physiotherapy (25%) and nausea and vomiting prophylaxis (25%).
• - Spine: In spine orthopedic surgery, among the principal interventions of ERAS protocol were patient education and the provision of information associated with a multidisciplinary consultation (geriatric, psychological, nutritional, behavioral health) (88%). Clear fluid and solid fluid fasting for 2–6 h before surgery (48%), pre-emptive analgesia and multimodal pain management (32%), antimicrobial/antibiotic prophylaxis (32%), nausea and vomiting prevention (20%), thromboprophylaxis (16%), tranexamic acid (TXA) (including oral or parenteral formulations) used to minimize bleeding (8%) and physiotherapy (4%) were other key interventions in spine orthopedic surgery.
• - Hip and/or knee: For hip and/or knee orthopedic surgery, the most common pre-operative interventions were patient education, the provision of information, and multidisciplinary consultation (43.3%), followed by pre-emptive analgesia and multimodal pain management (30%), comorbidities assessment (21.7%), antimicrobial/antibiotic prophylaxis (9.7%), clear fluid and solid fluid fasting for 2–6 h before surgery (8.3%), TXA use (7%) and thromboprophylaxis (4.9%).

Perioperative

Perioperative ERAS components/elements refer to all the interventions that occur from surgery until patient transfer to the post-anesthesia care unit (PACU). Below, and in Figure 3 , are reported the perioperative ERAS components for the different orthopedic specialties ( Figure 3 ).

• - Elbow: In elbow orthopedic surgery frequent perioperative interventions were local anesthesia (50%), antimicrobial/antibiotic prophylaxis (50%), TXA use (50%) and avoidance of catheter/drain (50%).
• - Thorax: The most common perioperative interventions in thorax surgery included local anesthesia (50%), avoidance of catheter/drain (50%), antibiotic/antimicrobial prophylaxis (50%), fluid management (50%) and multimodal pain management (50%).
• - Spine: For spine surgery, perioperative components were multimodal analgesia and pain management (68%), local anesthesia (56%), normothermia/normovolemia maintenance (32%), TXA use (28%), antimicrobial/antibiotic prophylaxis (28%), postoperative nausea and vomiting prophylaxis (24%), transfusion control (20%) and avoidance of catheter/drain (20%).
• - Hip and/or knee: For hip and/or knee orthopedic surgery, the most common perioperative elements were local anesthesia (70%), multimodal pain management (55.2%), TXA use (36%), avoidance of catheter/drain (23%), intraoperative fluid management (14%), thromboprophylaxis (10.4%), compression bandage use (7%) and antimicrobial/antibiotic prophylaxis (5.6%).

Postoperative

Postoperative ERAS components are defined as interventions that occur during and after admission to the recovery area. Below, and in Figure 3 , are described the postoperative ERAS components for the different orthopedic specialties ( Figure 3 ).

• - Elbow: The principal postoperative elements were early mobilization and rehabilitation/physiotherapy within 24 h (100% of studies) and multimodal analgesia and pain management (50%).
• - Thorax: In thorax surgery, key postoperative elements were represented by multimodal analgesia and pain management (75% of studies), early mobilization and rehabilitation/physiotherapy (50%), early nutrition (50%), catheter/drain removal within 24 h after surgery (25%) and nausea and vomiting prophylaxis (25%)
• - Spine: In spine surgery, postoperative elements were multimodal analgesia and pain management (84% of studies), early mobilization and rehabilitation/physiotherapy (64%), early nutrition (64%), catheter/drain removal within 24 h after surgery (32%), nausea and vomiting prophylaxis (12% in spine), thromboprophylaxis (12% spine), patient satisfaction survey (12%) and normothermia (4%).
• - Hip and/or knee: Principal postoperative elements were early mobilization and rehabilitation/physiotherapy (82% of studies), multimodal analgesia and pain management (61%), thromboprophylaxis (22.3%), early nutrition (7%), catheter/drain removal within 24 h after surgery (7%) and antimicrobial/antibiotic prophylaxis (5%).

3.4. Outcomes and Clinical Evidence of ERAS Protocols

All of the studies examined in this review confirmed the safety and efficacy of ERAS protocols in orthopedic surgery, showing an enhancement in the recovery from orthopedic surgery.

The primary outcomes in studies on elbow orthopedic surgery were a LOS reduction (50%), decrease in postoperative pain score (50%), especially in the first days after surgery, an abatement in drain removal time (50%), and an improvement in range of motion after ERAS pathway (50%).

Similarly, studies on thorax orthopedic surgery reported a significantly reduced LOS at 3 days after ERAS protocol, in patients undergoing minimally invasive repair of pectus excavatum (50%). Furthermore, a reduction in opioid consumption (50%), catheter removal time (50%), postoperative pain score (50%) and intraoperative time (25%), without an increase in the complication and readmission rate, was also noted after ERAS protocol.

In spine orthopedic surgery studies, a LOS of 1–3 days was observed for spinal deformities such as scoliosis and radiculopathy, while a LOS of 5–10 days was detected for lumbar stenosis or spondylolisthesis. Sixteen percent of studies also reported a significant reduction in intra-operative time after ERAS protocol. A reduction in catheter and drain removal time (12%), opioid consumption (12%), total health costs (16%), blood transfusion rate (8%), intraoperative blood loss (24%), postoperative pain score (24%), and complication and readmission rate (24%) were also detected in studies on spine orthopedic surgery. Finally, better functional recovery and early food recovery were observed in 20% and 12% of studies, respectively.

Concerning hip and/or knee orthopedic surgery, the most common reported outcomes were reductions in LOS (66.4%), postoperative pain score (25.2%), complication rate (16.8%) and bleeding rate/transfusion (13.3%), an increase in range of motion/walking anatomy/extension/flexion (13.3%), a reduction in readmission rate (9.8%) and opioid consumption (8.3%), a reduction in circulating markers of inflammation, anemia and endothelial activation (C-reactive protein, hemoglobin, tumor necrosis factor alpha) (8.3%), an increase in patient satisfaction (5.6%), and a reduction in intraoperative time (4.2%).

Almost all of the studies on elbow, thorax, spine and hip and/or knee orthopedic surgery that evaluated an ERAS vs. more conventional (non-fast track) (36%) protocol reported a significantly reduced LOS, without increasing complications or readmission rates in patients treated with ERAS regardless of follow-up (from 12 h to 5 years), surgical approach used, as well as surgeon. Only one study on spinal surgery did not find a significant change in LOS compared with the standard non-ERAS group [ 20 ]. In this study, an overall LOS increase, due to 5 h of observation in the PACU for a potential respiratory compromise, was detected. However, a variation in mean/median LOS, ranging from several hours to several days after surgery (from 12 h to 5.3 days), was observed between all the analyzed studies. Despite these variations, in all studies, the LOS reduction in the ERAS group was associated with a reduction in post-operative pain, bleeding rate and transfusion rate. The pain reduction during these ERAS pathways were associated with pre-emptive analgesia, perioperative local infiltration of analgesics (LIA) and post-operative analgesia. Several opioid-sparing agents were also used for pain relief in almost all studies. Specifically, paracetamol and NSAIDs were the most used. Analgesic protocols not only reduced the opioid requirements but also helped to reduce post-operative nausea-vomiting, post-operative stress, and the risk of complications. A reduction in transfusion rate with ERAS protocols vs. standard non-ERAS protocols was also seen in all of the studies that evaluated this element; this aspect was due not only to the optimization of hemoglobin mass performed in the preoperative phase but also to the prevention of perioperative blood loss. The main blood-saving strategy applied in this review was the TXA use. Depending on the study, TXA, an antifibrinolytic medication that stops the breakdown of fibrin clots by inhibiting activation of plasminogen, plasmin, and tissue plasminogen activator, was used in pre-, peri-, and post-operative phases. Several analyzed studies also evaluated different doses and administration routes (oral vs. intra-articular) of TXA, showing no differences with respect to blood loss and related thromboembolic events [ 21 , 22 , 23 ]. These ERAS elements not only improved the treatment management of the patients, increasing their satisfaction, but also aided the range of motion and return of function in all of the examined studies that evaluated these parameters (14.2%). Post-operatively, standard physiotherapy (kinesiotherapy) as well as other methods, including electrical stimulation, were also applied to strengthen the muscles, increase the range of motion, reduce swelling, and enhance independent gait, as it is known that early and persistent muscle loss occurs after these interventions, impairing balance and walking ability. The improvements in range of motion and return of function were undoubtedly helped by the early mobilization, but also by pain management as well as by the information and support given to the patients by the interdisciplinary team, because it increased their sense of self-efficacy, security, and satisfaction. Paradoxically, in their analysis 90 days after hip and knee arthroplasty, Jørgensen et al. found that fall-related hospital readmissions were due to physical activity and extrinsic factors other than surgery because of patient success and intent to return to a normal level of activity [ 24 ]. As emerged from all of the studies examined in this review, in turn, all of these interventions reduce the LOS as patients could be discharged sooner without increasing the risk of complications (References [ 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 , 106 , 107 , 108 , 109 , 110 , 111 , 112 , 113 , 114 , 115 , 116 , 117 , 118 , 119 , 120 , 121 , 122 , 123 , 124 , 125 , 126 , 127 , 128 , 129 , 130 , 131 , 132 , 133 , 134 , 135 , 136 , 137 , 138 , 139 , 140 , 141 , 142 , 143 , 144 , 145 , 146 , 147 , 148 , 149 , 150 , 151 , 152 , 153 , 154 , 155 , 156 , 157 , 158 , 159 , 160 , 161 , 162 , 163 , 164 , 165 , 166 , 167 , 168 , 169 , 170 , 171 , 172 , 173 , 174 , 175 , 176 , 177 , 178 , 179 , 180 , 181 , 182 , 183 , 184 , 185 , 186 , 187 , 188 , 189 , 190 , 191 , 192 ] are cited in the Supplementary Materials ).

4. Discussion

The ERAS philosophy focuses on patient experience, multidisciplinary teamwork (among surgeons, anesthesiologists, nurses, and physical therapists), evidence-based data gathering, and an iterative review process to improve protocol details across preoperative, perioperative, and postoperative phases [ 4 , 193 ]. Although the concept of ERAS was widely examined in orthopedic hip and/or knee replacement, its use in other orthopedic surgery has been employed only in recent years [ 194 , 195 ]. This aspect was specifically highlighted in this review where the presence of studies on ERAS in the elbow, thorax and spine emerged starting from 2018–2019, while numerous studies on ERAS in hip and/or knee replacement were present already in 2011. Although ERAS protocols seem to be well established and studied for specific orthopedic fields, this review highlighted the presence of numerous preliminary cohort studies lacking formal control groups (only 36.2% of the analyzed studies had a control group) and nonrandomized data sets as well as showing differences in postoperative follow-up, variability in operation and surgical indication in most of the studies, also for hip and/or knee replacement surgery [ 194 ].

A critical aspect that should be addressed with ERAS protocols would be to know which of the many elements really have an impact, thus, to understand if any of these elements may be skipped without resulting in inferior results, to further improve clinical outcomes and cost-efficacy of the protocol. However, it is important to underline that individual elements may not necessarily have significant benefits when studied in isolation, but their combination with other elements of the pathway is thought to have a synergistic effect. In this review, most impactful ERAS elements seemed to be patient education, NSAIDs with minimization of opioid use, local anesthesia, thromboprophylaxis, antibiotic prophylaxis, urinary catheters and drainage avoidance or removal within 24 h after surgery, TXA use and early mobilization within 24 h after surgery. The combined effects of these interventions have been shown to improve patient recovery with shorter LOS and decreases in hospital infections, complications, readmission rates and pain scores, with an increase in patients’ satisfaction due also to their active role and commitment. These aspects also lead to total cost savings, which accompany streamlined and less invasive methods. In this context, it is important to underline that, to date, ERAS costs have been estimated only in studies on THA and TKH surgery, and all indicated a reduction in medical costs compared with standard care with a prolonged LOS [ 29 , 66 , 188 ]. A recent study by Jansen et al. [ 195 ] also conduct a full economic evaluation with a cost-effectiveness analysis by using functional outcomes, LOS, thromboembolic complications, healthcare costs, and quality of life in TKA patients 12 months after surgery. Results showed a mean reduction in costs of EUR 268 per patient in favor of ERAS protocols, mostly due to the shorter LOS, which resulted in lower costs associated with nursing staff [ 195 ]. However, in general, and also in view of these cost analyses, it is difficult to extrapolate those elements that are less influential than others, also considering that good-quality data were not always available; thus, no recommendation can currently be made because either equipoise exists or there is a paucity of evidence. Stronger recommendations could be obtained from the 24 RCTs examined in this review, one on elbow, one on spine and 22 on hip and/or knee replacement surgery. In these RCTs, patient education and pre-emptive anesthetics and analgesics were the main pre-operative ERAS elements. A preoperative ERAS element of key importance little considered in these studies was the nutritional status [ 196 ]. in only two RCTs, it was reported that carbohydrate loading with a clear carbohydrate liquid 2 h prior to surgery was used in order to present the patient to surgery in a metabolically fed state leading to less postoperative protein loss and preservation of muscle mass [ 196 ]. This is probably due to the fact that this ERAS element requires special attention for those patients with specific comorbidities, such as obesity and diabetes, pathological conditions more common in aged patients [ 196 ]. Considering the intra-operative elements in the 24 RCTs, neuraxial anesthesia was frequently preferred to general anesthesia as well as multimodal analgesia, TXA use and urinary catheters and drainage avoidance or removal within 24 h after surgery. Although normothermia has been considered part of the anesthetic management in ERAS programs, no RCTs considered this aspect [ 3 , 196 , 197 ]. Hypothermia is common in patients who have undergone orthopedic surgery and may increase infection, coagulopathy, blood transfusion rate, cardiovascular complications, and opioid need, which may adversely affect the postoperative outcome [ 196 ]. Finally, in the post-operative phase, the main ERAS elements used in this RCT were early mobilization, opioid-sparing multimodal analgesia and thromboprophylaxis. Additoinally, as a post-operative element, no studies investigated the direct relationship between postoperative nutritional supplementation and accelerating the achievement of discharge criteria. However, encouraging patients to eat and drink as soon as possible is considered an essential component of the ERAS protocol, as returning to normal food intake can help patients return to normal behavior [ 3 , 196 , 197 ]. Considering all of these aspects of ERAS in orthopedic surgery, more investigations are mandatory to adapt and/or adjust several elements of the protocol [ 195 ]. Recently, under the impetus of the ERAS ® society, a multidisciplinary guideline development group was constituted by bringing together international experts involved in the practice of ERAS in spine surgery. This group identified 22 ERAS items specifically for lumbar fusion [ 197 ]. However, ERAS recommendations/guidelines also for other spinal procedures, cervical spine surgery, anterior or combined approaches, complex deformities, scoliosis, etc., and other orthopedic specialties are necessary.

Other critical key points to consider are whether further advances and implementations can be made to further reduce the risk of complications and, as the global trend is to shift to outpatient surgery, whether such orthopedic ERAS protocols can be performed on an ambulatory or semi-ambulatory basis without any increased risk of morbidity or cardiopulmonary and thromboembolic complications, as well as cognitive dysfunctions, especially in geriatric patients that have specific needs for rehabilitation. Last but not least, another important factor that emerged from the analyzed studies is the need for a unique, well-defined and updated guideline in every step and, importantly, a coordinated interaction between all the subjects involved, beginning from the very first ambulance’s intervention to the patient’s call. Based on these open questions, rigorous RCTs may serve to provide robust evidence and establish the efficacy of enhanced-recovery programs for particular patient populations and procedures within orthopedic surgery.

4.1. Limitation and Strengths

A methodological limitation of this review is correlated with the quality of the studies that were included. Most of these studies were retrospective studies, which are more likely subjected to biases than prospective randomized controlled trials. As highlighted by the quality assessment conducted, the moderate and weak scores were mainly associated with lack of a sample size justification and lack of blinded assessor or other potential confounding variables that could limit the validity of the review’s conclusions. On the other hand, to overcome these potential biases, the strength of this review stands in the development of an explicit and well-designed research protocol centered on a researchable and clinically relevant question that provide a clear description of the eligibility criteria such as population, intervention and outcomes of interest, the definition of explicit but also broad inclusion and exclusion criteria as well as the selection process. All of these methodological aspects were focused on extracting the best available evidence relevant to the review question. Additionally, as a patient-centered approach and evidence-based intervention, safety aspects following ERAS include morbidity and mortality, the first in the form of complications and readmissions. To the authors’ best knowledge, no disadvantages specifically related to the ERAS protocol in orthopedic surgery have been reported in the literature analyzed. However, several potential disadvantages should be assessed, such as the most demanding preoperative phase for the healthcare professional and for the patient, a phase that requires continuous multidisciplinary communication and collaboration. Furthermore, it would be essential to evaluate the real cost-effectiveness of ERAS protocol, examining and balancing the costs of all additional interventions with the specific patient advantages. Finally, the degree of independence of patients and the satisfaction associated with the shorter hospital stay should be analyzed in greater detail.

4.2. Future Prospects

Future studies focused on the elements of ERAS specific to orthopedic interventions, in particular for elbow, thorax and spine, may serve to optimize the protocol. Another critical key point to consider is whether further advances and implementations can be made to reduce even more the risk of complications and, as the global trend is to shift to outpatient surgery, whether such orthopedic ERAS protocols can be performed on an ambulatory or semi-ambulatory basis without any increased risk of morbidity or cardiopulmonary and thromboembolic complications, as well as cognitive dysfunctions, especially in geriatric patients that have specific needs for rehabilitation. Finally, another important factor that emerged from the analyzed studies is the need for a unique, well-defined and updated guideline in every step and, importantly, a coordinated interaction between all of the subjects involved, beginning from the very first ambulance’s intervention to the patient’s call. Based on these open questions, rigorous RCTs may serve to provide robust evidence and establish the efficacy of ERAS programs for particular patient populations and procedures within orthopedic surgery.

Supplementary Materials

The following supporting information can be downloaded at: www.mdpi.com/article/10.3390/jcm11144222/s1 . Table S1: Search terms used in PubMed, Scopus, and Web of Science Core Collection; Table S2: National Heart, Lung, and Blood Institute (NHLBI) quality assessment tool; Table S3: Basic characteristics of included studies from the literature on spine orthopedic surgery; Table S4: Basic characteristics of studies from the literature on thorax orthopedic surgery; Table S5: Basic characteristics of studies from the literature on elbow orthopedic surgery; Table S6: Basic characteristics of studies from the literature on hip and/or knee orthopedic surgery; Table S7. Fast-track components of included literatures studies on orthopedic surgery; Table S8. Designation of positive, neutral and negative outcome for each examined study. (References [ 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 , 106 , 107 , 108 , 109 , 110 , 111 , 112 , 113 , 114 , 115 , 116 , 117 , 118 , 119 , 120 , 121 , 122 , 123 , 124 , 125 , 126 , 127 , 128 , 129 , 130 , 131 , 132 , 133 , 134 , 135 , 136 , 137 , 138 , 139 , 140 , 141 , 142 , 143 , 144 , 145 , 146 , 147 , 148 , 149 , 150 , 151 , 152 , 153 , 154 , 155 , 156 , 157 , 158 , 159 , 160 , 161 , 162 , 163 , 164 , 165 , 166 , 167 , 168 , 169 , 170 , 171 , 172 , 173 , 174 , 175 , 176 , 177 , 178 , 179 , 180 , 181 , 182 , 183 , 184 , 185 , 186 , 187 , 188 , 189 , 190 , 191 , 192 ] are cited in the Supplementary Materials).

Funding Statement

This work was supported by grants from IRCCS Istituto Ortopedico Rizzoli (Ricerca Corrente) and by 5 × 1000, 2018 project entlited “Percorso di rapida ripresa post-operatoria (ERAS) nella scoliosi idiopatica adolescenziale” (PRWEB: 2020/730420).

Author Contributions

Conceptualization, F.S. and D.C. and M.F.; methodology, F.S., D.C. and S.B.; validation, C.G., A.V. and K.M.; formal analysis, F.S., D.C., S.B. and C.G.; investigation, F.S. and D.C.; data curation, C.G. and K.M.; writing—original draft preparation, F.S., D.C. and S.B.; writing—review and editing, F.S., D.C. and S.B.; visualization, F.S., D.C., S.B., A.V., C.G., K.M., C.G., A.R., A.G. and M.F.; supervision, M.F. and A.G. All authors have read and agreed to the published version of the manuscript.

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