The outcomes of total hip replacement have improved dramatically with the adoption of improved surgical techniques, aggressive pain interventions, and interventions that aid in recovery. These recovery interventions include preoperative education by a multidisciplinary team, multimodal pain interventions, and recovery promotion programs. The current economic climate and tight fiscal budgets require minimizing healthcare costs while reducing hospitalization dates. This forces hospitals to ensure excellent clinical outcomes while promoting early functional recovery and shorter hospitalization dates. In this review, researchers present a series of common interventions and modalities based on evidence-based medicine. These include: preoperative patient education, hyperalgesia, local infiltration for pain relief, preoperative nutrition, application of pulsed electromagnetic fields, perioperative rehabilitation, wound dressings, different surgical techniques, minimally invasive surgery, and rapid arthroplasty components. When conservative treatment fails, total hip replacement surgery can be effective in improving the quality of life of patients with osteoarthritis of the hip. According to the 2012 annual report of the National Artificial Joint Registry of England and Wales, 71,672 total hip replacements were performed in 2011. This is a significant increase from 560,000 cases in 2005. Since the 1990s, a variety of multimodal techniques have been proposed to enhance surgical efficacy and promote postoperative recovery. This has led to the development of several new phrases: “fast track”, “rapid recovery”, and “enhanced recovery program (ERP)”. In 1997, a clinical pathway was proposed in Copenhagen to promote recovery after colorectal surgery using ERP, which was subsequently adopted by orthopedic surgeons. The use of ERP has dramatically reduced the complication rate, mortality rate, and length of hospitalization for patients after total hip replacement. Hospitals in the United Kingdom have also adopted the principles of ERP. In this review, researchers propose a series of common interventions and modalities based on evidence-based medicine. The aim is to promote recovery, reduce hospitalization time, and achieve better functional outcomes. MATERIALS AND METHODS: The researchers searched medical databases such as MEDLINE,, EMBASE, AMED and Cochrane library for research papers published in the last decade. Relevant content on the web was also searched. The keywords used included: enhanced recovery, facilitated recovery, rapid process, rapid recovery, total hip replacement, and total hip arthroplasty. All studies on ERP and total hip replacement were extracted, excluding non-English literature. Results: Different interventions could be used and integrated into one clinical pathway. Nonsurgical interventions: Preoperative patient education: preoperative education allows patients to actively participate in the recovery process and enables them to rationalize their postoperative expectations, thus contributing to the promotion of early recovery and early discharge. Because for some patients, treatment that does not achieve the desired outcome is judged by them to be unsatisfactory, detailed preoperative education can improve patient-reported outcomes metrics (PROMs). The discrepancy between patient expectations and physician expectations was demonstrated in a controlled study in which a survey found that patients’ ability to participate in physical activity after surgery was lower than they expected. Individualized preoperative education by telephone or face-to-face can shorten the one-day hospital stay for total hip replacement patients. A randomized controlled study compared a standard multidisciplinary preoperative talk with the usual verbal communication. The former was found to reduce patients’ preoperative anxiety and pain, but the postoperative differences between the two groups were not statistically significant.Daltroy et al. concluded that preoperative education shortens hospitalization time, postoperative medical expenses, and reduces postoperative anxiety. A further study combined preoperative and postoperative education with home follow-up as a test group compared to patients who underwent traditional recovery. Patients in the trial group had an almost 4-day shorter hospital stay and achieved higher Oxford Hip Scores. Preoperative education is effective in reducing hospitalization time, but the cost of multidisciplinary education is initially higher. The cost of total hip replacement varies by country and region. However, reducing the length of stay by one day reduces the cost of hospitalization by approximately £260. It also increases the number of patients seen, which reduces waiting lists and increases income. When looking at the economic advantages of preoperative education, it is necessary to calculate the cost of carrying out this measure. Preoperative hemoglobin level: The level of hemoglobin can influence the duration of hospitalization after total hip replacement. Postoperative blood transfusions in symptomatic patients with or without hemoglobin below 8 g/dl significantly prolonged hospitalization, and Dwer et al. found that patients with hemoglobin above 14 g/dl had significantly shorter hospital stays than patients below that level when treated with ERP. One study found that adjusting a patient’s preoperative hemoglobin level to greater than 12 g/dl reduced the chance of postoperative blood transfusion and shortened the length of hospital stay. By screening patients with low preoperative ferritin and hemoglobin and administering iron supplementation and transfusion therapy, the average length of hospital stay for patients with total hip replacement was reduced from 6 days (5 to 8) to 5 days (3 to 7). A number of measures were taken to reduce intraoperative bleeding in these patients: the use of tranexamic acid, spinal anesthesia, intraoperative blood recovery, and controlled hypotension. Singh et al. compared intraoperative bleeding, postoperative hemoglobin reduction levels, and length of hospital stay in patients divided into a cyclamic acid group and a non-cyclamic acid group. It was found that cyclomethionine significantly reduced intraoperative bleeding and postoperative hemoglobin reduction levels, but there was no statistical difference in the length of hospital stay between the two groups. Preoperative Patient Nutrition: Malnutrition can lead to infection, delayed healing, sepsis, prolonged hospitalization, and increased mortality. Malnutrition can be corrected by preoperative nutritional assessment. Low albumin and transferrin levels are associated with prolonged recovery time and hospitalization. Triceps skinfold thickness is inversely related to the risk of postoperative infection. Obesity similarly affects perioperative outcomes. For example, increased body mass index prolongs operative time, increases intraoperative blood loss, wound hematoma, and the need for intraoperative blood transfusion. However, increased body mass index did not prolong postoperative recovery or hospitalization. Obesity is more prevalent in patients requiring total hip replacement and can increase the incidence of short- and long-term complications and the cost of care. These patients are often advised to lose weight or referred to a bariatric specialist. There is evidence that preoperative weight loss reduces the incidence of total hip replacement complications. Although weight loss aids in recovery, obese patients can suffer from nutritional deficiencies as well as malnutrition, especially after bariatric surgery. Intentional weight loss can lead to weight gain after total hip replacement. It is recommended to seek help from a bariatric specialist for effective strategies to manage preoperative and postoperative weight. Dwyer et al. used patients who consumed a large number of calories as part of an ERP 48 hours prior to surgery as a test group and compared them with patients who did not undergo an ERP. The average length of hospitalization for the test group was 5.3 days compared to 8.3 days for the control group. The researchers shortened the fasting time to two to three hours. If a six-hour preoperative fast was required, then patients were preloaded with a large intake of carbohydrates. Hyperalgesia: Pain and loss of function are the main indications for transcatheter total hip replacement. Therefore, postoperative pain, especially prolonged pain, decreases patient satisfaction. Pain likewise limits activity as well as delays functional recovery. However, studies on the effect of pain and pain relief on length of hospitalization have yielded mixed results. Although aggressive pain interventions have been reported to significantly reduce the length of hospital stay, they are not widely recognized. Understanding the physiologic mechanisms of pain is key to effective pain interventions. Hyperalgesia refers to the fact that the same dose of analgesic is more effective when given pre-injury than post-injury. Unfortunately, research in this area is subject to many confounding factors. Intravenous anesthetics delay recovery and decrease patient satisfaction. One strategy is to avoid using them with opioids and to use NSAIDs as an option. However, NSAIDs have their own drawbacks, such as: inhibition of bone anabolism, effects on renal function, platelet dysfunction, and gastric ulcers. These risks, as well as the risk of heart failure, are particularly prominent in patients with coexisting heart disease. Therefore, particular caution should be exercised when treating such patients with NSAIDs. With the large number of research papers demonstrating the effectiveness of NSAIDs in supra-analgesia being retracted by the authors, their validity has been questioned. Lunn et al. concluded that high preoperative doses of methylprednisolone helped to reduce pain in the first 24 hours after surgery, but had no effect on recovery or time to discharge. Local infiltration anesthesia: This therapeutic measure consists of intraoperative pharmacological infiltration anesthesia and administration of pills through an intra-articular catheter in the postoperative period. Kerr and Kohan first proposed local infiltration anesthesia as part of the principles of multimodal pain intervention and early mobility after joint replacement. They reported cases with good pain control and few narcotic-related complications. Activity was initiated four to six hours postoperatively and discharged the next day.Kang’s scholars randomized 82 patients who underwent hemiarthroplasty due to hip fracture into two groups. The test group received supra-anesthesia and local infiltration anesthesia and the control group received only supra-anesthesia. Patients in the test group had significantly less pain from 1 to 4 days after surgery, but there was no difference between the two groups at 7 days after surgery. The trial group had an overall decrease in the use of anesthetics and an increase in satisfaction at the time of discharge. Other studies have reported similar results, but some have concluded that no convincing evidence exists to demonstrate that local infiltration anesthesia reduces length of stay. This is in contrast to Andersen et al, who concluded that a significant reduction in hospitalization time could be achieved. In randomized studies, intraoperative local infiltration anesthesia appeared to reduce pain and decrease the use of analgesics only 6 to 12 hours after surgery. In a randomized controlled trial, local infiltration anesthesia was compared with placebo. Local infiltration anesthesia did not further reduce pain when combined with multimodal analgesia with paracetamol, celecoxib, and nogabapentin after total hip replacement. This phenomenon was also found in other randomized controlled trials in patients undergoing bilateral total hip replacement according to the ERP principle. In randomized controlled trials of local infiltration anesthesia alone and placebo, morphine use was reduced in patients in the local infiltration anesthesia group, although pain scores were the same for both. Local infiltration anesthesia reduced pain to the same extent as epidural anesthesia, but the former had significantly lower narcotic use and a two-day shorter hospital stay. Its effect was comparable to epidural morphine analgesia, but the incidence of nausea and vomiting was lower. Postoperatively, local injection of analgesic pills through the wound drain was definitively effective. Table 1, Different principles of using local infiltration anesthesia in the literature; various analgesic drugs and their doses. (PCA: Patient Controlled Analgesia; LOS, length of stay) American Society of Anesthesiologists (ASA) score: a study comparing patients who underwent total hip replacement according to ERP principles with patients who recovered according to traditional principles found that the length of stay was significantly shorter in patients with an ASA score of 1 (from 5 days to 3.2 days.) Dwyer et al. when comparing patients with ASA scores of 1 and 2 with found similar results when comparing patients with scores up to 3. A study of correlates of length of stay included patients who underwent total knee or total hip replacement according to ERP principles. The results of the study found that patients with ASA scores of 1 and 2 had a 60% and 20% chance of having a hospital stay of less than 3 days, respectively, when compared to those with a score of 3. Pulsed Electromagnetic Fields (PEMF): PEMF promotes bone repair and growth and produces an adenylate stimulant-like effect, acting on the A2a receptor of inflammatory cells to reduce the inflammatory response. Safe and without invasive complications, PEMF produces strong anti-inflammatory effects; reduces joint swelling; reduces the use of NSAIDs; and accelerates recovery. This treatment is easily accepted by patients. There is a lack of evidence that PEMF is effective in total knee replacement. A randomized controlled trial of revision total hip replacement patients found that PMEF was beneficial in promoting functional recovery and bone recovery. In 1988, Heylings and McMillin reported that preoperative application of PMEF to patients awaiting total hip replacement helped reduce pain and improve function. They found that all patients who underwent at least three courses of PMEF and had increased mobility had significant pain relief, decreased use of pain medication, and better sleep. They advocate the use of this non-toxic, non-invasive treatment prior to surgery to increase mobility and improve comfort for faster recovery. Preoperative rehabilitation programs: a team that includes multidisciplinary personnel – surgeon, anesthesiologist, physical therapist, occupational therapist, and patient – is very important. This has been explored since the 1990s; in 2002, Kehlet and Wilmore reported combining various strategies to improve surgical outcomes, and Malviya et al. achieved better clinical outcomes by incorporating behavioral, pharmacological, and procedural changes to the original program. These changes included: detailed patient and staff education based on “recovery promotion” principles; preoperative gabapentin and dexamethasone; same-day postoperative activity; low-dose spinal anesthesia; and the use of tranylcypromine during the induction period of anesthesia. Perioperative rehabilitation reduces the length of hospital stay in patients with an ASA score of 3, preoperative hemoglobin less than 14 g/dl, and a body mass index greater than 30 kg/m². Highly organized and modular multidisciplinary teams are more likely to promote recovery and reduce hospital length of stay, a view supported by Laren, Hansen, and Soballe, in particular a 3.1-day reduction in mean hospital length of stay in patients with total hip replacement and significantly higher health-related quality of life scores. There have been calls for a change in high-intensity physical therapy early after total hip replacement, but a 2009 systematic review did not find sufficient evidence to support this view. Numerous studies have shown that coordinated application of perioperative rehabilitation programs reduces hospital length of stay (Table 2). However, a review of preoperative rehabilitation measures in older adults did not find a significant effect, leaving scholars unsure whether rehabilitation can definitively achieve improved function, quality of life, and surgical outcomes. POSTOPERATIVE HIP PREVENTIVE MEASURES: In a prospective randomized controlled study, unrestricted patients in the early rehabilitation group slept on their backs or sides without pillows between their legs. These patients were allowed to ride in a car, use a normal-height toilet, and sleep in any position. The patients in their control group followed standard rehabilitation rules and did all relevant prophylaxis. No dislocations occurred in either group, but patients in the unrestricted group recovered more quickly. Each patient spent about$655 on somatic aids and precautions. Other studies have found that no restrictions can be used when an anterior or anterolateral approach is used.26 The incidence of early dislocation did not increase in the 1212 patients, and the incidence of dislocation at an average of 5 days (3 to 12) postoperatively was 0.15% (4 hips).Mauerhan et al. found that shorter lengths of stay were associated with higher rates of dislocation when measures to reduce hospitalization were used. Dressings: Dressings protect healing tissues, allow incision assessment, absorb exudate, and relieve pain. Adhesive dressings have raised concerns due to their short duration of action, frequent changes, and disadvantages such as causing skin blisters. Although no unidentified evidence has been found to support any one dressing, guidelines from the National Institute for Health and Clinical Research recommend the use of island interactive dressings. A group of 100 patients was prospectively grouped at a district hospital to compare the difference between the two dressings as part of an ERP. The use of traditional adhesive dressings required more frequent changes than the use of modern plastic film dressings with built-in absorbent pads. The former likewise significantly reduced the occurrence of blisters. There was no statistical difference in the length of hospitalization between the two groups. However, 75% of patients using modern dressings were discharged on the fourth postoperative day, compared with the traditional group on the sixth day. Surgical Interventions: Traditional versus Minimally Invasive Surgery (MIS) : Minimally invasive total hip replacement is defined as an incision length of 10 to 12 cm. reported to have the advantages of reduced soft tissue damage, reduced postoperative pain, smaller scars, better mobility, shorter hospital stay and fewer blood transfusions. Some of the so-called MIS utilize special equipment to reduce the length of the incision based on the standard posterior approach; while others use a new improved approach. Compared with the traditional approach, the small incision posterior approach has the advantages of significantly reducing blood loss and shortening hospitalization time. There are two types of MIS for total hip replacement: a single incision; and a double incision. Comparison of the two approaches revealed that patients with double incision had significantly earlier walking time, shorter hospitalization time, and longer operation time. However, more complications occurred in this group of patients and it is no longer respected by surgeons. Currently, interest lies in the anterior hip incision, an approach that is thought to reduce soft tissue damage and thus shorten recovery time. Complications include injury to the lateral femoral cutaneous nerve, dislocation, and component misalignment. A recent meta-analysis found the following advantages of MIS for total hip replacement compared to conventional surgery: shorter hospital stay (1 day), less pain at discharge (50%), less bleeding, and higher Harris Hip Score at three months postoperatively. There were no significant differences in complications between the two groups. In a 2009 systematic review, Cheng et al. found no clinical or imaging differences between the two groups. Another 2011 systematic review that included 28 fully randomized and semi-randomized controls found an increased incidence of lateral femoral cutaneous nerve in total hip replacement MIS. However, there was no difference in blood loss or hip scores at final follow-up (6 weeks to 5 years); there were no imaging differences compared with the conventional group. Fast-access total hip replacement components: these are designed to provide ERP for total hip replacement patients with devices customized to the goal of rapid recovery. An excellent model was produced in Denmark that has an easy assembly process and contains a care plan emphasizing fast-track recovery, predetermined discharge criteria, and clear information about the length of hospital stay. Cyclomethionine was injected 15 minutes before making the skin incision, local infiltration anesthesia was applied intraoperatively, and local infiltration anesthesia was maintained with a wound catheter at 24 hours postoperatively. Gabapentin and COX-2 blockers were given on the day of surgery and for the next 7 days. Table 2, Components using rehabilitation-promoting protocols (LOS, length of stay; LIA, local infiltration anesthesia) DISCUSSION: ERPs have been widely adopted in total hip replacement. The multimodal pathways and facilitated rehabilitation programs discussed in this article appear to enhance patient care as well as enhance function while reducing patient length of stay. The concept of day-case total hip replacement should probably be utilized in some specific patients within two years, especially given the apparent reduction in mortality with ERPs. The review highlights the potential benefits to patients as they learn about their treatment procedures. For example, optimization of their nutritional and somatic status; knowledge of the expected outcomes that can be achieved with surgery; reduced risk of surgery; and accelerated recovery and early discharge. Despite the many proposed pathways, there are few multicenter randomized controlled trials comparing the results of these specialized centers with traditional treatment modalities. The implementation of EPRs will require changes in healthcare facilities and technology.