Enhanced recovery care versus traditional non-ERAS care following osteotomies in developmental dysplasia of the hip in children: a retrospective case-cohort study

Based on the ERAS protocol adopted in the pediatric surgery and orthopaedics department, an ERAS protocol for pediatric orthopaedic surgery was developed following a series of discussions with experts from pediatric orthopaedic surgery, anesthesiology, pediatrics, and nurses from both the ward and operating room (OR). The protocol was then implemented for DDH patients undergoing surgical treatment from January 1, 2016.

The ERAS protocol for DDH osteotomies surgery included the following elements (Tables 1 and 2): preoperative education and counselling, antimicrobial prophylaxis, multimodal analgesia, postoperative nausea and vomiting (PONV) prophylaxis, early oral food intake, less daily intravenous infusion volume, early removal of wound drainage and urinary catheters, early mobilization, and discharge criteria. Preoperative education and counselling included the aim and procedures of the ERAS protocol, pain coping strategies, the parental expectation of this surgery, discharge criteria, and a follow-up plan. The fasting guideline requires cessation of clear fluid for at least 2 h as well as solid foods for 6 h before anaesthesia [17]. The temperature of the operative room was controlled at 24 degrees, and warm fluids were used. Patients were administered with multimodal analgesia postoperatively including local infiltration of ropivacaine (2.0 mg/ml) around the incision, analgesia infusion pump based on the parental requirements, intravenous nonsteroidal anti-inflammatory (flurbiprofen, 2 mg/Kg) for 3 days, and then oral dexibuprofen oral suspension if necessary. The regular diet was advised after the patient fully recovered from the anaesthesia. A lower intravenous infusion volume was defined as less than 300 ml/d after surgery. The Foleys catheter was removed within 24 h postoperatively. The drainage tube was recommended to be removed within 48 h postoperatively. Early mobilization, including the on-bed movement of the healthy leg and upper extremities on postoperative day (POD) 1. The antithrombotic prophylaxis was not necessary since children were at low risk of deep venous thrombosis (DVT). Discharge criteria were as follows: a visual analogue scale (VAS) score of < 3 points with or without the use of oral analgesia; normal diet, no need for intravenous fluid; normal body temperature, no evidence of wound infection with normal complete blood count and C-reactive protein level; and no serious complications. We encouraged patient discharge once the discharge criteria were met.

The hospital medical records of DDH patients receiving unilateral osteotomies in our institution were retrospectively reviewed. We included 82 patients in the traditional non-ERAS group or control group who underwent DDH surgery just prior to the implementation of the ERAS protocol (from January 2014 to December 2015). The ERAS group consisted of 86 patients who underwent DDH surgery after the implementation of the ERAS protocol (from January 2016 to December 2017).

The inclusion criteria were: 1) Patients aged between 1.5 years and 6 years received DDH surgery (PO + PFO) after failed nonoperative management, and 2) Unilateral single-stage surgery for bilateral DDH. The exclusion criteria were: 1) Patients with prior neuromuscular disease, cerebral palsy, scoliosis and hyperlaxity, and 2) Patients over the age of 6 years.

This study is approved by the Ethics Committee of Tongji Medical College, Huazhong University of Science and Technology.

All the patients underwent PO + PFO (See Fig. 1). Pelvic osteotomy (PO) is meant for increasing the acetabular coverage on the femoral head. Acetabuloplasty offers a higher rate of correction of acetabular dysplasia in comparison with reorientation osteotomies [18].

Pemberton osteotomy has been a preferred method of pelvic osteotomy in our institution. Proximal femoral osteotomies (PFO) are designed to reorient the femoral head by derotation and increasing the varus in order to stabilize and stimulate acetabular development [19, 20]. Pediatric hip plate (PHP) system is used to fixate the osteotomy at the femoral side.

After the surgery, all patients were immobilized in Spica cast for 4–6 weeks until the first out-patient visit.

Physiological function outcome indicators, such as the first time that the patient was able to eat, defecate, as well as the removal time of the Foleys catheter and drainage tubes, and duration of hospital stay were recorded.

The postoperative pain response after surgery was recorded, including the average VAS score, the highest VAS score, and the frequency of break-out pain (VAS ≥ 4). The incidence of all postoperative complications, including nausea, vomiting and fever, were recorded.

Demographic data are shown in Table 3. There were no significant differences in age, sex, surgical duration, intraoperative blood loss, and other comorbidities between the ERAS group and traditional non-ERAS group.

The removal of Foleys and drainage tubes were significantly earlier in the ERAS group than that in the traditional non-ERAS group (Table 4). The mean duration of hospital stay was significantly reduced from 10.0 ± 3.1 in the traditional non-ERAS group to 6.0 ± 0.8 days in the ERAS(P < 0.001).

The average VAS score in the first 3 days was better in the ERAS group than the traditional non-ERAS group (2.9 ± 0.8 vs. 4.0 ± 0.8, P < 0.001), and maximum VAS score (4.1 ± 0.8 vs. 4.9 ± 0.8, P < 0.001) (Table 5). However, there was no significant difference in the frequency of break-out pain (VAS > 4) between two groups (29.5 ± 6.3 vs.30.6 ± 6.5, P = 0.276).

Table 6 shows the surgery-related complications in both groups. There were no serious complications observed in this study. PONV was more common in the ERAS group as we used opiates as analgesics in the infusion pump. However, fever was less in the ERAS group, and no patients had postoperative urinary tract infection.

Compliance with the core components of the ERAS protocol (Table 2) is shown in Table 7. During the perioperative period, the fasting time before surgery was shortened in the ERAS group. The application of local analgesia, oral analgesia, PONV prophylaxis was well executed in the ERAS group. Because of the possible adverse reactions of opiates (Sufentanil or Oxycodone), the application of analgesia infusion pump was not well executed. In all patients, oral Dexibuprofen was given whenever necessary. Compliance of early removal of the Foleys catheter and drainage tubes in the ERAS group was 100 and 95.3% respectively. The most common cause of delayed removal of drainage catheters was high drainage volume on POD2, which may increase the risk of postoperative hematoma and local infection. Compliance with early regular diet was 95.3%.