Formal consensus on fast-track hip and knee arthroplasty: ESSKA/EKA, EHS and APAS recommendations for optimised recovery pathways in joint replacement surgeries

This international formal consensus aims to establish a unified, evidence-based approach to perioperative care by promoting the adoption of fast-track surgery or enhanced recovery after surgery (ERAS) protocols, informing healthcare professionals and administrators about optimal perioperative management of arthroplasty and facilitating broader implementation. A multidisciplinary panel of 106 experts contributed across a Steering Group (n = 22), a Rating Group (n = 35) and a Peer Review group (n = 49). The Steering Group developed 37 questions and corresponding statements based on the literature review and expert opinion. Statements were graded from A (high-level evidence) to D (expert opinion). An independent Rating Group evaluated each statement on a 1-9 Likert scale across two rounds using the Formal Consensus methodology. Statements were iteratively revised and finalised through consensus and joint discussion. The final document was assessed by an international Peer Review Group to ensure transnational applicability. Out of 37 questions, a total of 63 statements were developed. Following a set of general statements outlining the principles and overall goals of fast-track total knee arthroplasty (TKA) and total hip arthroplasty (THA), the recommendations addressed and optimised the three key phases of perioperative care: preoperative, intraoperative and postoperative management. Of the 63 statements, 39 were graded A or B and 24 as C or D. Mean agreement scores ranged from 7.7 to 8.9. Overall, 56 statements were considered appropriate with strong agreement and 7 with relative agreement. The Peer Review Group supported the overall statements, providing feedback to clarify specific recommendations and to highlight regional differences in implementation, which were incorporated into the final document. This consensus endorses the adoption of structured fast-track or enhanced recovery programs as a patient-centred approach to perioperative care in total hip and knee arthroplasty. The aim is to improve the quality of care by reducing morbidity, optimising pain management, shortening hospital stay and enhancing patient satisfaction. While not intended to replace clinical judgement, it provides a pragmatic framework to guide decision-making, promote consistency and facilitate safe early mobilisation and discharge. Level I.