Early mobilization after total hip or knee arthroplasty: a substudy of the POWER.2 study

Ripollés-Melchor, Javier; Aldecoa, César; Fernández-García, Raquel; Varela-Durán, Marina; Aracil-Escoda, Norma; García-Rodríguez, Daniel; Cabezudo-de-la-Muela, Lucia; Hormaechea-Bolado, Lucía; Nacarino-Alcorta, Beatriz; Hoffmann, Rolf; Lorente, Juan V.; Ramírez-Rodríguez, José M.; Abad-Motos, Ane; ,

doi:10.1016/j.bjane.2021.05.008

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Brazilian Journal of Anesthesiology

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Sumário

Original Investigation • Braz. J. Anesthesiol. 73 (1) • Jan-Feb 2023 • https://doi.org/10.1016/j.bjane.2021.05.008 copy

Early mobilization after total hip or knee arthroplasty: a substudy of the POWER.2 study

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Background

Early mobilization after surgery is a cornerstone of the Enhanced Recovery After Surgery (ERAS) programs in total hip arthroplasty (THA) or total knee arthroplasty (TKA). Our goal was to determine the time to mobilization after this surgery and the factors associated with early mobilization.

Methods

This was a predefined substudy of the POWER.2 study, a prospective cohort study conducted in patients undergoing THA and TKA at 131 Spanish hospitals. The primary outcome was the time until mobilization after surgery as well as determining those perioperative factors associated with early mobilization after surgery.

Results

A total of 6093 patients were included. The median time to achieve mobilization after the end of the surgery was 24 hours [16-30]. 4,222 (69.3%) patients moved in ≤ 24 hours after surgery. Local anesthesia [OR = 0.80 (95% confidence interval [CI]: 0.72-0.90); p= 0.001], surgery performed in a self-declared ERAS center [OR = 0.57 (95% CI: 0.55-0.60); p< 0.001], mean adherence to ERAS items [OR = 0.93 (95% CI: 0.92-0.93); p< 0.001], and preoperative hemoglobin [OR = 0.97 (95% CI: 0.96-0.98); p< 0.001] were associated with shorter time to mobilization.

Conclusions

Most THA and TKA patients mobilize in the first postoperative day, early time to mobilization was associated with the compliance with ERAS protocols, preoperative hemoglobin, and local anesthesia, and with the absence of a urinary catheter, surgical drains, epidural analgesia, and postoperative complications. The perioperative elements that are associated with early mobilization are mostly modifiable, so there is room for improvement.

Keywords
Total hip arthroplasty; Total knee arthroplasty; Enhanced Recovery After Surgery (ERAS); Early mobilization; Local anesthesia

	[ALL]	THA	TKA
	n = 6093	n = 2280	n = 3813
Age n, %
(18,63)	1535 (25.2%)	894 (39.2%)	641 (16.8%)
(63,71)	1762 (28.9%)	540 (23.7%)	1222 (32.0%)
(71,76)	1324 (21.7%)	377 (16.5%)	947 (24.8%)
(76,95)	1472 (24.2%)	469 (20.6%)	1003 (26.3%)
Sex n, %
Female	3556 (58.4%)	1035 (45.4%)	2521 (66.1%)
Male	2537 (41.6%)	1245 (54.6%)	1292 (33.9%)
BMI kg.m^-2, n, %
(15.9,25)	921 (15.5%)	517 (23.3%)	404 (10.9%)
(25,30)	2341 (39.5%)	955 (43.0%)	1386 (37.4%)
(30,35)	1787 (30.1%)	526 (23.7%)	1261 (34.0%)
(35,110)	883 (14.9%)	224 (10.1%)	659 (17.8%)
ASA Score n, %
ASA I	388 (6.4%)	233 (10.2%)	155 (4.1%)
ASA II	4101 (67.3%)	1486 (65.2%)	2615 (68.6%)
ASA III	1561 (25.6%)	534 (23.4%)	1027 (26.9%)
ASA IV	42 (0.7%)	26 (1.1%)	16 (0.4%)
Ex-smoker n, %	996 (16.4%)	425 (18.7%)	571 (15.0%)
Smoker n, %	695 (11.4%)	375 (16.5%)	320 (8.4%)
Frailty median, IQR	3.0 [2.0;3.0]	3.0 [2.0;3.0]	3.0 [3.0;4.0]
Hypertension n, %	3614 (72.8%)	1126 (67.5%)	2488 (75.5%)
Ischemic heart disease n, %	356 (7.2%)	117 (7.0%)	239 (7.3%)
Heart failure n, %	156 (2.6%)	56 (2.5%)	100 (2.6%)
Cirrhosis n, %	52 (1.0%)	19 (1.1%)	33 (1.0%)
Stroke n, %	287 (5.8%)	106 (6.4%)	181 (5.5%)
Atrial fibrillation n, %	416 (6.8%)	147 (6.4%)	269 (7.1%)
COPD n, %	690 (13.9%)	261 (15.6%)	429 (13.0%)
Chronic kidney disease n, %	328 (6.6%)	102 (6.1%)	226 (6.9%)
Peripheral vasculopathy n, %	280 (4.6%)	103 (4.5%)	177 (4.6%)
Dementia n, %	66 (1.1%)	20 (0.9%)	46 (1.2%)
Preoperative hemoglobin g.dL^-1 (Median, IQR)	14.0 [13.1;15.0]	14.3 [13.3;15.2]	13.9 [13.0;14.8]
Preoperative creatinine mg.dL^-1 (Median, IQR)	0.8 [0.7;1.0]	0.8 [0.7;1.0]	0.8 [0.7;0.9]
Preoperative RBC transfusion n, %	7 (0.1%)	6 (0.3%)	1 (< 0.1%)
General anesthesia n, %	456 (7.5%)	258 (11.3%)	198 (5.2%)
Epidural anesthesia n, %	386 (6.3%)	60 (2.6%)	326 (8.5%)
Regional anesthesia n, %	925 (15.2%)	156 (6.8%)	769 (20.2%)
Local anesthesia n, %	233 (3.8%)	14 (0.6%)	219 (5.7%)
Spinal anesthesia n, %	5629 (92.4%)	2039 (89.4%)	3590 (94.2%)
Intrathecal morphine administration n, %	435 (7.7%)	158 (7.7%)	277 (7.7%)
Urinary drain n, %	1388 (22.8%)	533 (23.4%)	855 (22.4%)
Surgical drains n, %	4290 (70.4%)	1454 (63.8%)	2836 (74.4%)
Time of surgery, minutes (Median IQR)	90.0 [75.0;110.0]	90.0 [70.0;110.0]	90.0 [75.0;110.0]
Tourniquet time, minutes (Median, IQR)	80.0 [65.0;95.0]	. [.;.]	80.0 [65.0;95.0]
Intraoperative RBC transfusion n, %	60 (1.0%)	47 (2.1%)	13 (0.3%)
Bleeding, mL (Median IQR)	200.0 [100.0;350.0]	300.0 [200.0;500.0]	150.0 [50.0;300.0]
Tranexamic acid administration	4495 (74.1%)	1591 (70.2%)	2904 (76.4%)
ERAS center n, %	1558 (25.6%)	577 (25.3%)	981 (25.7%)
ERAS mean compliance (Medan, IQR)	8.0 [7.0;10.0]	8.0 [7.0;10.0]	9.0 [7.0;10.0]
Postoperative hemoglobin, g.dL^-1 (Median, IQR)	11.5 [10.5;12.5]	11.5 [10.4;12.6]	11.5 [10.6;12.5]
Postoperative complications n, %	673 (11.0%)	272 (11.9%)	401 (10.5%)
Moderate-severe postoperative complications n, %	347 (5.7%)	149 (6.5%)	198 (5.2%)
Level of care after surgery
Ward/ Post-anesthetic care unit n, %	5692 (93.4%)	2160 (94.7%)	3532 (92.6%)
ICU level 1 n, %	373 (6.1%)	110 (4.8%)	263 (6.9%)
ICU level 2 n, %	28 (0.5%)	10 (0.4%)	18 (0.5%)
Postoperative RBC transfusion n, %	438 (7.2%)	209 (9.2%)	229 (6.0%)
LOS, days, (Median, IQR)	4.0 [3.0;6.0]	4.0 [3.0;6.0]	4.0 [3.0;6.0]

	ALL				THA				TKA
Time to mobilization (hours)		Median (IQR)	OR (univariable)	OR (multivariable)		Median (IQR)	OR (univariable)	OR (multivariable)		Median (IQR)	OR (univariable)	OR (multivariable)
Age	[18,63]	24.00 (16.00 to 28.00)	•	•	[18,63]	24.00 (18.00 to 28.00)	•	•	[18,63]	24.00 (13.00 to 28.00)	•	•
	(63,71]	24.00 (15.00 to 30.00)	1.004 (0.962-1.048, p = 0.8441)	1.007 (0.962-1.055, p = 0.7581)	(63,71]	24.00 (18.00 to 30.00)	1.019 (0.955-1.086, p = 0.5764)	1.028 (0.959-1.101, p= 0.4435)	(63,71]	24.00 (13.00 to 30.00)	1.021 (0.960-1.086, p= 0.5143)	1.018 (0.956-1.083, p= 0.5820)
	(71,76]	24.00 (17.00 to 30.25)	1.047 (1.001-1.096, p = 0.0470)	1.031 (0.982-1.083, p = 0.2128)	(71,76]	24.00 (20.00 to 36.00)	1.103 (1.028-1.184, p = 0.0064)	1.112 (1.029-1.200, p = 0.0069)	(71,76]	24.00 (16.00 to 30.00)	1.049 (0.984-1.119, p = 0.1450)	1.016 (0.952-1.084, p = 0.6411)
	(76,95]	24.00 (16.00 to 32.00)	1.047 (1.001-1.094, p = 0.0448)	1.019 (0.971-1.071, p = 0.4432)	(76,95]	24.00 (20.00 to 30.00)	1.063 (0.994-1.136, p = 0.0726)	1.029 (0.953-1.110, p = 0.4708)	(76,95]	24.00 (15.00 to 34.50)	1.062 (0.997-1.132, p = 0.0636)	1.028 (0.963-1.098, p = 0.4088)
Sex	Female	24.00 (16.00 to 30.00)	•	•	Female	24.00 (20.00 to 35.50)	•	•	Female	24.00 (14.00 to 30.00)	•	•
	Male	24.00 (16.00 to 29.00)	0.971 (0.941-1.003, p = 0.0720)	0.973 (0.938-1.008, p = 0.1331)	Male	24.00 (18.00 to 28.00)	0.935 (0.890-0.982, p = 0.0071)	0.941 (0.889-0.997, p = 0.0385)	Male	24.00 (15.00 to 29.00)	0.976 (0.935-1.019, p = 0.2719)	0.970 (0.926-1.017, p = 0.2062)
BMI	[15.9,25)	24.00 (16.00 to 30.00)	•	•	[15.9,25)	24.00 (20.00 to 32.00)	•	•	[15.9,25)	24.00 (12.00 to 27.00)	•	•
	[25,30)	24.00 (16.00 to 30.00)	0.984 (0.939-1.032, p = 0.5038)	•	[25,30)	24.00 (18.00 to 28.50)	0.951 (0.893-1.014, p = 0.1212)	•	[25,30)	24.00 (15.00 to 30.00)	1.045 (0.973-1.123, p = 0.2260)	•
	[30,35)	24.00 (16.00 to 30.00)	0.980 (0.933-1.029, p = 0.4131)	•	[30,35)	24.00 (19.00 to 30.00)	0.958 (0.892-1.030, p = 0.2455)	•	[30,35)	24.00 (15.00 to 30.00)	1.041 (0.969-1.120, p = 0.2743)	•
	[35,110)	24.00 (18.00 to 36.00)	1.022 (0.966-1.082, p = 0.4425)	•	[35,110)	24.00 (20.00 to 36.00)	1.004 (0.916-1.100, p = 0.9264)	•	[35,110)	24.00 (16.00 to 36.00)	1.088 (1.005-1.178, p = 0.0370)	•
ASA	ASA I	24.00 (12.00 to 24.00)	•	•	ASA 1	24.00 (12.00 to 24.00)	•	•	ASA 1	22.00 (11.00 to 24.00)	•	•
	ASA II	24.00 (16.00 to 29.00)	1.135 (1.060-1.217, p = 0.0003)	1.505 (1.171-1.978, p = 0.0022)	ASA 2	24.00 (19.00 to 30.00)	1.149 (1.053-1.255, p = 0.0019)	1.546 (1.110-2.240, p = 0.0148)	ASA 2	24.00 (14.00 to 28.00)	1.161 (1.041-1.300, p = 0.0087)	1.442 (1.007-2.166, p = 0.0602)
	ASA III	24.00 (19.00 to 36.00)	1.248 (1.161-1.342, p < 0.0001)	1.570 (1.219-2.068, p = 0.0008)	ASA 3	24.00 (23.00 to 36.00)	1.261 (1.147-1.388, p < 0.0001)	1.643 (1.174-2.389, p = 0.0061)	ASA 3	24.00 (18.00 to 36.00)	1.280 (1.143-1.438, p < 0.0001)	1.490 (1.038-2.242, p = 0.0417)
	ASA IV	24.00 (24.00 to 48.00)	1.409 (1.170-1.684, p = 0.0002)	1.587 (1.170-2.183, p = 0.0036)	ASA 4	26.00 (24.00 to 48.00)	1.411 (1.122-1.753, p = 0.0025)	1.606 (1.084-2.443, p = 0.0219)	ASA 4	24.00 (24.00 to 36.00)	1.402 (1.020-1.882, p = 0.0303)	1.510 (0.945-2.466, p = 0.0908)
Ex-smoker	Exsmoker	24.00 (16.00 to 30.00)	0.987 (0.946-1.030, p = 0.5544)	•	Exsmoker	24.00 (18.00 to 30.00)	0.990 (0.928-1.055, p = 0.7527)	•	Exsmoker	24.00 (15.00 to 28.00)	0.975 (0.921-1.033, p = 0.3941)	•
Smoker		24.00 (16.00 to 26.00)	0.948 (0.901-0.997, p = 0.0387)	•		24.00 (18.00 to 28.00)	0.928 (0.865-0.994, p = 0.0343)	•		24.00 (15.00 to 26.00)	0.947 (0.878-1.020, p = 0.1518)	•
Frailty	[1,8]	24.00 (16.00 to 30.00)	1.017 (1.001-1.033, p = 0.0352)	0.998 (0.980-1.015, p = 0.7967)	[1,7]	24.00 (18.00 to 30.00)	1.040 (1.017-1.062, p = 0.0005)	1.010 (0.983-1.036, p = 0.4767)	[1,8]	24.00 (14.00 to 30.00)	1.000 (0.979-1.022, p = 0.9707)	0.985 (0.961-1.008, p = 0.1963)
Hypertension		24.00 (16.00 to 30.00)	1.027 (0.988-1.068, p = 0.1841)	•		24.00 (20.00 to 30.00)	0.983 (0.926-1.043, p = 0.5626)	•		24.00 (15.00 to 30.00)	1.066 (1.013-1.122, p = 0.0148)	•
Ischemic heart disease		24.00 (20.75 to 36.00)	1.086 (1.017-1.157, p = 0.0125)	1.011 (0.950-1.074, p = 0.7360)		24.00 (24.00 to 36.00)	1.113 (1.001-1.234, p = 0.0452)	1.018 (0.920-1.125, p = 0.7248)		24.00 (20.00 to 36.00)	1.072 (0.987-1.162, p = 0.0934)	1.018 (0.941-1.099, p = 0.6565)
Heart Failure		24.00 (18.00 to 31.25)	1.059 (0.960-1.164, p = 0.2444)	•		24.00 (18.00 to 28.25)	1.008 (0.857-1.176, p = 0.9221)	•		24.00 (17.50 to 36.00)	1.091 (0.964-1.228, p = 0.1614)	•
Cirrhosis		24.00 (19.75 to 28.00)	0.965 (0.809-1.141, p = 0.6880)	•		24.00 (20.00 to 28.00)	0.850 (0.630-1.117, p = 0.2652)	•		24.00 (19.00 to 36.00)	1.033 (0.827-1.271, p = 0.7656)	•
Stroke		24.00 (18.50 to 36.00)	1.044 (0.970-1.121, p = 0.2476)	•		24.00 (22.25 to 45.00)	1.070 (0.956-1.195, p = 0.2331)	•		24.00 (18.00 to 36.00)	1.024 (0.931-1.124, p = 0.6237)	•
Atrial Fibrillation		24.00 (18.00 to 36.00)	1.071 (1.008-1.137, p = 0.0253)	0.992 (0.936-1.052, p = 0.7969)		24.00 (21.00 to 42.00)	1.068 (0.968-1.176, p = 0.1822)	0.964 (0.877-1.058, p = 0.4398)		24.00 (17.00 to 36.00)	1.075 (0.995-1.159, p = 0.0647)	1.004 (0.932-1.080, p = 0.9154)
CPOD		24.00 (18.00 to 28.00)	1.012 (0.963-1.063, p = 0.6246)	•		24.00 (20.00 to 28.00)	1.007 (0.932-1.087, p = 0.8511)	•		24.00 (17.00 to 28.00)	1.011 (0.948-1.078, p = 0.7386)	•
Chronic kidney disease		24.00 (17.75 to 36.00)	1.047 (0.978-1.120, p = 0.1845)	1.054 (0.988-1.124, p = 0.1097)		24.00 (24.00 to 47.50)	1.173 (1.050-1.305, p = 0.0042)	1.105 (0.993-1.225, p = 0.0630)		24.00 (12.00 to 36.00)	0.990 (0.907-1.078, p = 0.8116)	1.044 (0.961-1.131, p = 0.3057)
Peripheral vascular disease		24.00 (19.75 to 37.00)	1.092 (1.016-1.173, p = 0.0155)	1.062 (0.994-1.134, p = 0.0713)		24.00 (24.00 to 29.50)	1.019 (0.905-1.144, p = 0.7496)	0.985 (0.885-1.094, p = 0.7864)		24.00 (18.00 to 48.00)	1.138 (1.039-1.245, p = 0.0050)	1.097 (1.009-1.191, p = 0.0282)
Dementia		24.00 (12.00 to 29.50)	0.947 (0.808-1.102, p = 0.4919)	•		25.50 (24.00 to 31.50)	1.112 (0.857-1.413, p = 0.4067)	•		24.00 (12.00 to 24.00)	0.877 (0.715-1.062, p = 0.1924)	•
Preoperative hemoglobin (g.dL^-1)	[8,18.7]	24.00 (16.00 to 30.00)	0.981 (0.970-0.992, p = 0.0006)	0.999 (0.986-1.012, p = 0.8374)	[8,18.7]	24.00 (19.00 to 30.00)	0.971 (0.956-0.987, p = 0.0004)	1.004 (0.984-1.024, p = 0.7258)	[8.7,18.7]	24.00 (15.00 to 30.00)	0.985 (0.971-1.000, p = 0.0528)	0.998 (0.981-1.014, p = 0.7811)
Preoperative Creatinine (mg.dL^-1)	[0.15,14.3]	24.00 (16.00 to 30.00)	1.035 (0.990-1.077, p = 0.1071)	•	[0.28,3.72]	24.00 (18.00 to 30.00)	1.065 (0.966-1.173, p = 0.2024)	•	[0.15,14.3]	24.00 (14.00 to 30.00)	1.028 (0.976-1.076, p = 0.2584)	•
Preoperative RBT transfusion		48.00 (48.00 to 48.50)	1.860 (1.300-2.561, p = 0.0003)	1.216 (0.870-1.654, p = 0.2329)		48.00 (48.00 to 48.75)	2.088 (1.471-2.859, p < 0.0001)	1.344 (0.961-1.837, p = 0.0736)		2.00 (2.00 to 2.00)	0.078 (NA-1.050, p = 0.2624)	0.070 (0.000-0.792, p = 0.1898)
General anesthesia		24.00 (18.00 to 30.00)	1.032 (0.973-1.093, p = 0.2953)	•		24.00 (19.00 to 29.50)	0.994 (0.919-1.074, p = 0.8813)	•		24.00 (17.00 to 36.00)	1.054 (0.963-1.151, p = 0.2467)	•
Epidural anesthesia		31.00 (24.00 to 48.00)	1.433 (1.357-1.512, p < 0.0001)	1.271 (1.203-1.343, p < 0.0001)		30.00 (24.00 to 48.00)	1.434 (1.258-1.627, p < 0.0001)	1.362 (1.177-1.568, p < 0.0001)		31.00 (24.00 to 48.00)	1.467 (1.380-1.559, p < 0.0001)	1.285 (1.207-1.366, p < 0.0001)
Regional anesthesia		24.00 (18.00 to 36.00)	1.016 (0.973-1.061, p = 0.4769)	0.981 (0.939-1.024, p = 0.3888)		24.00 (24.00 to 48.00)	1.168 (1.066-1.278, p = 0.0008)	1.126 (1.020-1.240, p = 0.0171)		24.00 (16.00 to 30.00)	0.997 (0.947-1.048, p = 0.8950)	0.974 (0.926-1.024, p = 0.3009)
Local anesthesia		7.00 (5.00 to 24.00)	0.543 (0.487-0.604, p < 0.0001)	0.805 (0.722-0.894, p = 0.0001)		7.00 (4.25 to 23.75)	0.547 (0.347-0.812, p = 0.0052)	0.862 (0.558-1.263, p = 0.4750)		8.00 (5.00 to 24.00)	0.549 (0.490-0.614, p < 0.0001)	0.830 (0.739-0.929, p = 0.0014)
Spinal anesthesia		24.00 (16.00 to 30.00)	0.933 (0.881-0.988, p = 0.0167)	0.976 (0.922-1.035, p = 0.4207)		24.00 (18.00 to 30.00)	0.959 (0.887-1.038, p = 0.2963)	1.062 (0.977-1.156, p = 0.1590)		24.00 (14.00 to 30.00)	0.921 (0.848-1.002, p = 0.0517)	0.952 (0.878-1.033, p = 0.2295)
Urinary drain		24.00 (22.00 to 48.00)	1.252 (1.209-1.296, p < 0.0001)	1.068 (1.029-1.107, p = 0.0004)		24.00 (24.00 to 48.00)	1.225 (1.160-1.293, p < 0.0001)	1.070 (1.008-1.136, p = 0.0270)		24.00 (20.00 to 48.00)	1.268 (1.213-1.327, p < 0.0001)	1.069 (1.020-1.119, p = 0.0050)
Surgical drains		24.00 (20.00 to 36.00)	1.372 (1.324-1.423, p < 0.0001)	1.203 (1.158-1.249, p < 0.0001)		24.00 (24.00 to 39.75)	1.377 (1.307-1.451, p < 0.0001)	1.300 (1.228-1.377, p < 0.0001)		24.00 (18.00 to 36.00)	1.395 (1.328-1.467, p < 0.0001)	1.163 (1.105-1.224, p < 0.0001)
Time of surgery (minutes)	[30,300]	24.00 (16.00 to 30.00)	1.002 (1.002-1.003, p < 0.0001)	1.001 (1.000-1.001, p = 0.0415)	[30,270]	24.00 (18.00 to 30.00)	1.002 (1.001-1.003, p < 0.0001)	1.001 (1.000-1.001, p = 0.1544)	[35,300]	24.00 (15.00 to 30.00)	1.002 (1.002-1.003, p < 0.0001)	1.001 (1.000-1.001, p = 0.0688)
RBC transfusion		24.00 (12.00 to 48.00)	1.242 (1.074-1.427, p = 0.0028)	1.089 (0.940-1.255, p = 0.2445)		24.00 (24.00 to 48.00)	1.351 (1.160-1.562, p = 0.0001)	1.068 (0.910-1.247, p = 0.4103)		6.00 (4.00 to 21.00)	0.717 (0.462-1.051, p = 0.1106)	0.930 (0.629-1.316, p = 0.6986)
Bleeding (mL)	[0,2640]	24.00 (17.00 to 32.00)	1.000 (1.000-1.000, p = 0.7483)	•	[0,2640]	24.00 (20.00 to 31.00)	1.000 (1.000-1.000, p = 0.5721)	•	[0,1800]	24.00 (15.00 to 36.00)	1.000 (1.000-1.000, p = 0.0938)	•
Tranexamic acid administration		24.00 (15.00 to 28.00)	0.898 (0.868-0.930, p < 0.0001)	1.015 (0.978-1.053, p = 0.4369)		24.00 (18.00 to 30.00)	0.896 (0.850-0.944, p < 0.0001)	1.030 (0.973-1.091, p = 0.3122)		24.00 (14.00 to 28.00)	0.906 (0.865-0.949, p < 0.0001)	1.014 (0.967-1.063, p = 0.5678)
ERAS center		12.00 (6.00 to 24.00)	0.540 (0.518-0.562, p < 0.0001)	0.573 (0.547-0.601, p < 0.0001)		16.00 (6.00 to 24.00)	0.566 (0.531-0.603, p < 0.0001)	0.608 (0.564-0.654, p < 0.0001)		12.00 (5.00 to 22.00)	0.524 (0.496-0.552, p < 0.0001)	0.556 (0.523-0.590, p < 0.0001)
ERAS adherence	²2 Kehlet H. Enhanced Recovery After Surgery (ERAS): good for now, but what about the future? Can J Anaesth. 2015;62:99-104.,¹⁶16 Goodnough LT, Maniatis A, Earnshaw P, et al. Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines. Br J Anaesth. 2011;106:13-22.	24.00 (16.00 to 30.00)	0.927 (0.922-0.933, p < 0.0001)	•	²2 Kehlet H. Enhanced Recovery After Surgery (ERAS): good for now, but what about the future? Can J Anaesth. 2015;62:99-104.,¹⁶16 Goodnough LT, Maniatis A, Earnshaw P, et al. Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines. Br J Anaesth. 2011;106:13-22.	24.00 (18.00 to 30.00)	0.945 (0.936-0.954, p < 0.0001)	•	²2 Kehlet H. Enhanced Recovery After Surgery (ERAS): good for now, but what about the future? Can J Anaesth. 2015;62:99-104.,¹⁶16 Goodnough LT, Maniatis A, Earnshaw P, et al. Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines. Br J Anaesth. 2011;106:13-22.	24.00 (15.00 to 30.00)	0.916 (0.908-0.923, p < 0.0001)	•
Postoperative Hemoglobin	[1,17.3]	24.00 (16.00 to 30.00)	0.969 (0.959-0.978, p < 0.0001)	•	[1.4,17]	24.00 (19.00 to 30.00)	0.951 (0.937-0.966, p < 0.0001)	•	[1,17.3]	24.00 (14.75 to 30.00)	0.980 (0.968-0.993, p = 0.0019)	•
Postoperative complications		24.00 (24.00 to 48.00)	1.331 (1.254-1.411, p < 0.0001)	1.213 (1.137-1.293, p < 0.0001)		24.00 (24.00 to 48.00)	1.267 (1.158-1.383, p < 0.0001)	1.096 (0.985-1.217, p = 0.0895)		24.00 (24.00 to 48.00)	1.374 (1.269-1.484, p < 0.0001)	1.281 (1.181-1.387, p < 0.0001)
Level of care	Ward	24.00 (16.00 to 30.00)	•	•		24.00 (18.00 to 30.00)	•	•		24.00 (14.00 to 28.00)	•	•
	Level 1 Critical care	24.00 (24.00 to 40.00)	1.164 (1.095-1.237, p < 0.0001)	1.091 (1.026-1.159, p = 0.0055)		24.00 (24.00 to 36.00)	1.146 (1.028-1.274, p = 0.0130)	1.065 (0.952-1.188, p = 0.2624)		24.00 (20.00 to 40.00)	1.181 (1.096-1.271, p < 0.0001)	1.113 (1.033-1.198, p = 0.0046)
	Level 2 critical care	28.50 (23.75 to 48.00)	1.445 (1.184-1.743, p = 0.0002)	1.274 (1.035-1.548,p = 0.0182)		38.00 (24.00 to 48.00)	1.534 (1.118-2.044, p = 0.0053)	1.252 (0.898-1.693, p = 0.1633)		28.50 (22.25 to 48.00)	1.396 (1.074-1.776, p = 0.0092)	1.304 (0.997-1.671, p = 0.0435)
Postoperative RBC transfusion		24.00 (24.00 to 48.00)	1.272 (1.204-1.343, p < 0.0001)	1.074 (1.010-1.142, p = 0.0225)		24.00 (24.00 to 48.00)	1.269 (1.174-1.369, p < 0.0001)	1.072 (0.974-1.179, p = 0.1519)		24.00 (24.00 to 48.00)	1.262 (1.168-1.362, p < 0.0001)	1.078 (0.994-1.167, p = 0.0680)
LOS	[1,30]	24.00 (16.00 to 30.00)	1.014 (1.011-1.016, p < 0.0001)	•	[1,30]	24.00 (18.00 to 30.00)	1.014 (1.010-1.017, p < 0.0001)	•	[1,30]	24.00 (14.00 to 30.00)	1.014 (1.011-1.017, p < 0.0001)	•

	All			THA				TKA
	≤ 24	> 24	OR	p. ratio	≤ 24	> 24	OR	p. ratio	≤ 24	> 24	OR	p. ratio
	n = 4222	n = 1871			n = 1538	n = 742			n = 2684	n = 1129
Age
[18,63]	1090 (25.8%)	445 (23.8%)	Ref.	Ref.	630 (41.0%)	264 (35.6%)	Ref.	Ref.	460 (17.1%)	181 (16.0%)	Ref.	Ref.
(63,71]	1239 (29.3%)	523 (28.0%)	1.03 [0.89;1.20]	0.664	367 (23.9%)	173 (23.3%)	1.13 [0.89;1.42]	0.319	872 (32.5%)	350 (31.0%)	1.02 [0.83;1.26]	0.856
(71,76]	902 (21.4%)	422 (22.6%)	1.15 [0.98;1.34]	0.095	234 (15.2%)	143 (19.3%)	1.46 [1.13;1.88]	0.004	668 (24.9%)	279 (24.7%)	1.06 [0.85;1.33]	0.599
(76,95]	991 (23.5%)	481 (25.7%)	1.19 [1.02;1.39]	0.029	307 (20.0%)	162 (21.8%)	1.26 [0.99;1.60]	0.059	684 (25.5%)	319 (28.3%)	1.18 [0.95;1.47]	0.125
Sex
Female	2435 (57.7%)	1121 (59.9%)	Ref.	Ref.	666 (43.3%)	369 (49.7%)	Ref.	Ref.	1769 (65.9%)	752 (66.6%)	Ref.	Ref.
Male	1787 (42.3%)	750 (40.1%)	0.91 [0.82;1.02]	0.102	872 (56.7%)	373 (50.3%)	0.77 [0.65;0.92]	0.004	915 (34.1%)	377 (33.4%)	0.97 [0.84;1.12]	0.679
BMI
[15.9,25)	620 (15.2%)	301 (16.4%)	Ref.	Ref.	328 (21.9%)	189 (26.0%)	Ref.	Ref.	292 (11.2%)	112 (10.1%)	Ref.	Ref.
[25,30)	1640 (40.1%)	701 (38.1%)	0.88 [0.75;1.04]	0.128	665 (44.5%)	290 (39.9%)	0.76 [0.60;0.95]	0.016	975 (37.6%)	411 (36.9%)	1.10 [0.86;1.41]	0.455
[30,35)	1251 (30.6%)	536 (29.1%)	0.88 [0.74;1.05]	0.153	361 (24.1%)	165 (22.7%)	0.79 [0.61;1.03]	0.077	890 (34.3%)	371 (33.3%)	1.09 [0.85;1.40]	0.515
[35,110)	581 (14.2%)	302 (16.4%)	1.07 [0.88;1.30]	0.494	142 (9.5%)	82 (11.3%)	1.00 [0.72;1.39]	0.987	439 (16.9%)	220 (19.7%)	1.31 [1.00;1.72]	0.053
ASA Score
ASA 1	293 (6.9%)	95 (5.1%)	Ref.	Ref.	176 (11.5%)	57 (7.7%)	Ref.	Ref.	117 (4.4%)	38 (3.4%)	Ref.	Ref.
ASA 2	2882 (68.3%)	1219 (65.2%)	1.30 [1.03;1.67]	0.028	1019 (66.3%)	467 (62.9%)	1.41 [1.03;1.96]	0.030	1863 (69.4%)	752 (66.6%)	1.24 [0.86;1.83]	0.256
ASA 3	1023 (24.2%)	538 (28.8%)	1.62 [1.26;2.10]	< 0.001	329 (21.4%)	205 (27.6%)	1.92 [1.36;2.73]	< 0.001	694 (25.9%)	333 (29.5%)	1.47 [1.01;2.20]	0.046
ASA 4	23 (0.5%)	19 (1.0%)	2.54 [1.31;4.89]	0.006	13 (0.8%)	13 (1.8%)	3.07 [1.33;7.13]	0.009	10 (0.4%)	6 (0.5%)	1.86 [0.59;5.43]	0.280

Ex-smoker	706 (16.7%)	290 (15.5%)	0.89 [0.77;1.04]	0.137	290 (18.9%)	135 (18.2%)	0.91 [0.72;1.15]	0.443	416 (15.5%)	155 (13.7%)	0.85 [0.70;1.04]	0.119
Smoker	503 (11.9%)	192 (10.3%)	0.83 [0.69;0.99]	0.038	268 (17.5%)	107 (14.5%)	0.78 [0.61;1.00]	0.053	235 (8.8%)	85 (7.5%)	0.83 [0.64;1.07]	0.154
Frailty	3.0 [2.0;3.0]	3.0 [2.0;4.0]	1.06 [1.01;1.12]	0.031	3.0 [2.0;3.0]	3.0 [2.0;4.0]	1.15 [1.06;1.24]	0.001	3.0 [2.0;4.0]	3.0 [3.0;4.0]	1.00 [0.93;1.08]	0.963
Hypertension	2483 (72.6%)	1131 (73.3%)	1.04 [0.91;1.19]	0.566	755 (68.1%)	371 (66.4%)	0.93 [0.75;1.15]	0.481	1728 (74.7%)	760 (77.3%)	1.15 [0.97;1.38]	0.111
Ischemic heart disease	229 (6.7%)	127 (8.2%)	1.25 [1.00;1.57]	0.053	69 (6.2%)	48 (8.6%)	1.42 [0.96;2.07]	0.079	160 (6.9%)	79 (8.0%)	1.18 [0.89;1.55]	0.259
Heart failure	109 (2.6%)	47 (2.5%)	0.97 [0.68;1.37]	0.883	39 (2.5%)	17 (2.3%)	0.91 [0.50;1.59]	0.737	70 (2.6%)	30 (2.7%)	1.02 [0.65;1.56]	0.920
Cirrhosis	35 (1.0%)	17 (1.1%)	1.08 [0.59;1.92]	0.788	13 (1.2%)	6 (1.1%)	0.93 [0.32;2.39]	0.881	22 (1.0%)	11 (1.1%)	1.19 [0.55;2.42]	0.650
Stroke	196 (5.7%)	91 (5.9%)	1.03 [0.80;1.33]	0.803	67 (6.0%)	39 (7.0%)	1.17 [0.77;1.75]	0.460	129 (5.6%)	52 (5.3%)	0.95 [0.67;1.31]	0.748
Atrial fibrillation	281 (6.7%)	135 (7.2%)	1.09 [0.88;1.35]	0.424	92 (6.0%)	55 (7.4%)	1.26 [0.89;1.78]	0.196	189 (7.0%)	80 (7.1%)	1.01 [0.76;1.32]	0.955
COPD	488 (14.3%)	202 (13.1%)	0.91 [0.76;1.08]	0.274	183 (16.5%)	78 (14.0%)	0.82 [0.61;1.09]	0.176	305 (13.2%)	124 (12.6%)	0.95 [0.76;1.19]	0.659
Chronic kidney disease	219 (6.4%)	109 (7.1%)	1.11 [0.87;1.41]	0.380	59 (5.3%)	43 (7.7%)	1.48 [0.98;2.23]	0.061	160 (6.9%)	66 (6.7%)	0.97 [0.72;1.30]	0.840
Peripheral vascular disease	181 (4.3%)	99 (5.3%)	1.25 [0.97;1.60]	0.087	70 (4.6%)	33 (4.4%)	0.98 [0.63;1.48]	0.920	111 (4.1%)	66 (5.8%)	1.44 [1.05;1.96]	0.025
Dementia	45 (1.1%)	21 (1.1%)	1.06 [0.62;1.76]	0.833	9 (0.6%)	11 (1.5%)	2.55 [1.04;6.42]	0.041	36 (1.3%)	10 (0.9%)	0.67 [0.31;1.30]	0.242
Preoperative Hemoglobin	14.1 [13.2;15.0]	14.0 [13.0;14.9]	0.94 [0.90;0.97]	0.001	14.4 [13.4;15.3]	14.1 [13.0;15.0]	0.89 [0.84;0.94]	<0.001	14.0 [13.1;14.9]	13.9 [13.0;14.8]	0.97 [0.92;1.02]	0.187
Preoperative creatinine	0.8 [0.7;1.0]	0.8 [0.7;1.0]	1.06 [0.91;1.24]	0.466	0.8 [0.7;1.0]	0.8 [0.7;1.0]	1.02 [0.72;1.45]	0.924	0.8 [0.7;0.9]	0.8 [0.7;1.0]	1.07 [0.90;1.28]	0.451
Preoperative RBC	1 (< 0.1%)	6 (0.3%)	12.15 [2.00;314.42]	0.005	0 (0.0%)	6 (0.8%)	. [.;.]	.	1 (< 0.1%)	0 (0.0%)	. [.;.]	.
General anesthesia	310 (7.3%)	146 (7.8%)	1.07 [0.87;1.31]	0.527	177 (11.5%)	81 (10.9%)	0.94 [0.71;1.24]	0.681	133 (5.0%)	65 (5.8%)	1.17 [0.86;1.59]	0.310
Epidural anesthesia	184 (4.4%)	202 (10.8%)	2.66 [2.16;3.27]	0.000	30 (2.0%)	30 (4.0%)	2.12 [1.26;3.56]	0.005	154 (5.7%)	172 (15.2%)	2.95 [2.35;3.72]	0.000
Regional anesthesia	614 (14.5%)	311 (16.6%)	1.17 [1.01;1.36]	0.038	93 (6.0%)	63 (8.5%)	1.44 [1.03;2.01]	0.033	521 (19.4%)	248 (22.0%)	1.17 [0.98;1.38]	0.074
Local anesthesia	199 (4.7%)	34 (1.8%)	0.38 [0.26;0.54]	< 0.001	12 (0.8%)	2 (0.3%)	0.37 [0.05;1.36]	0.147	187 (7.0%)	32 (2.8%)	0.39 [0.26;0.56]	< 0.001
Spinal anesthesia	3911 (92.6%)	1718 (91.8%)	0.89 [0.73;1.09]	0.272	1371 (89.1%)	668 (90.0%)	1.10 [0.83;1.47]	0.523	2540 (94.6%)	1050 (93.0%)	0.75 [0.57;1.00]	0.053
Intrathecal morphine	258 (6.6%)	177 (10.3%)	1.63 [1.33;1.99]	< 0.001	98 (7.1%)	60 (9.0%)	1.28 [0.91;1.79]	0.150	160 (6.3%)	117 (11.1%)	1.86 [1.45;2.39]	< 0.001
Urinary drain	827 (19.6%)	561 (30.0%)	1.76 [1.55;1.99]	0.000	311 (20.2%)	222 (29.9%)	1.68 [1.38;2.06]	< 0.001	516 (19.2%)	339 (30.0%)	1.80 [1.54;2.11]	< 0.001
Surgical drains	2802 (66.4%)	1488 (79.5%)	1.97 [1.73;2.24]	0.000	896 (58.3%)	558 (75.2%)	2.17 [1.79;2.64]	< 0.001	1906 (71.0%)	930 (82.4%)	1.91 [1.60;2.27]	< 0.001
Time of surgery	90.0 [72.0;110.0]	90.0 [75.0;120.0]	1.01 [1.00;1.01]	< 0.001	90.0 [70.0;110.0]	90.0 [75.0;118.0]	1.01 [1.00;1.01]	< 0.001	90.0 [75.0;110.0]	95.0 [80.0;120.0]	1.01 [1.00;1.01]	< 0.001
Tourniquet time	78.0 [63.0;92.0]	80.0 [68.0;99.0]	1.01 [1.01;1.01]	< 0.001	.	.	.	.	78.0 [63.0;92.0]	80.0 [68.0;99.0]	1.01 [1.01;1.01]	< 0.001
Intraoperative RBC	35 (0.8%)	25 (1.3%)	1.62 [0.96;2.71]	0.072	25 (1.6%)	22 (3.0%)	1.85 [1.02;3.31]	0.041	10 (0.4%)	3 (0.3%)	0.74 [0.16;2.46]	0.643
Bleeding	200.0 [100.0;350.0]	200.0 [100.0;350.0]	1.00 [1.00;1.00]	0.789	300.0 [200.0;500.0]	300.0 [200.0;500.0]	1.00 [1.00;1.00]	0.963	150.0 [50.0;300.0]	120.0 [50.0;300.0]	1.00 [1.00;1.00]	0.088
Tranexamic acid administration	3203 (76.3%)	1292 (69.2%)	0.70 [0.62;0.79]	< 0.001	1108 (72.8%)	483 (65.1%)	0.70 [0.58;0.84]	< 0.001	2095 (78.4%)	809 (71.8%)	0.70 [0.60;0.83]	< 0.001
ERAS center	1406 (33.3%)	152 (8.1%)	0.18 [0.15;0.21]	0.000	517 (33.6%)	60 (8.1%)	0.17 [0.13;0.23]	0.000	889 (33.1%)	92 (8.1%)	0.18 [0.14;0.22]	0.000
ERAS mean compliance	9.0 [7.0;11.0]	8.0 [6.0;9.0]	0.80 [0.78;0.82]	< 0.001	9.0 [7.0;11.0]	7.0 [6.0;9.0]	0.82 [0.79;0.85]	< 0.001	9.0 [8.0;11.0]	8.0 [6.0;9.0]	0.79 [0.77;0.82]	< 0.001
Postoperative hemoglobin, g.dL^-1 (mean, IQR)	11.6 [10.6;12.6]	11.3 [10.3;12.4]	0.91 [0.88;0.94]	< 0.001	11.6 [10.5;12.7]	11.2 [10.0;12.3]	0.85 [0.80;0.90]	< 0.001	11.6 [10.6;12.5]	11.4 [10.4;12.4]	0.95 [0.91;0.99]	0.027
Postoperative complications	403 (9.5%)	270 (14.4%)	1.60 [1.35;1.88]	< 0.001	150 (9.8%)	122 (16.4%)	1.82 [1.41;2.35]	< 0.001	253 (9.4%)	148 (13.1%)	1.45 [1.17;1.80]	0.001
Moderate to severe postoperative complications	193 (4.6%)	154 (8.2%)	1.87 [1.50;2.33]	< 0.001	85 (5.5%)	64 (8.6%)	1.61 [1.15;2.26]	0.006	108 (4.0%)	90 (8.0%)	2.07 [1.54;2.76]	< 0.001
Postoperative care:
Ward	3984 (94.4%)	1708 (91.3%)	Ref.	Ref.	1468 (95.4%)	692 (93.3%)	Ref.	Ref.	2516 (93.7%)	1016 (90.0%)	Ref.	Ref.
ICU level 1	227 (5.4%)	146 (7.8%)	1.50 [1.21;1.86]	< 0.001	66 (4.3%)	44 (5.9%)	1.42 [0.95;2.09]	0.087	161 (6.0%)	102 (9.0%)	1.57 [1.21;2.03]	0.001
ICU level 2	11 (0.3%)	17 (0.9%)	3.59 [1.68;7.97]	0.001	4 (0.3%)	6 (0.8%)	3.14 [0.87;12.82]	0.081	7 (0.3%)	11 (1.0%)	3.86 [1.50;10.68]	0.005
Postoperative RBC	240 (5.7%)	198 (10.6%)	1.96 [1.61;2.39]	< 0.001	106 (6.9%)	103 (13.9%)	2.18 [1.63;2.90]	< 0.001	134 (5.0%)	95 (8.4%)	1.75 [1.33;2.29]	< 0.001
LOS	4.0 [3.0;6.0]	5.0 [4.0;7.0]	1.03 [1.02;1.04]	< 0.001	4.0 [3.0;6.0]	5.0 [4.0;7.0]	1.03 [1.01;1.04]	< 0.001	4.0 [3.0;6.0]	5.0 [4.0;7.0]	1.02 [1.01;1.04]	< 0.001

Sociedade Brasileira de Anestesiologia (SBA) Rua Professor Alfredo Gomes, 36, Botafogo , cep: 22251-080 - Rio de Janeiro - RJ / Brasil , tel: +55 (21) 97977-0024 - Rio de Janeiro - RJ - Brazil
E-mail: editor.bjan@sbahq.org

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[1] * Corresponding author. E-mail:ripo542@gmail.com (J.Ripollés-Melchor).