Implementation of an Enhanced Recovery After Surgery Protocol for Temporomandibular Joint Replacement: A Retrospective Cohort Study.

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols are guidelines designed to improve postoperative outcomes for patients. Although ERAS protocols are associated with improved outcomes in orthognathic, head and neck cancer, and maxillofacial trauma surgeries, their utility following temporomandibular joint replacement (TMJR) remains unclear.

PURPOSE: The purpose of this study was to measure the association between implementation of an ERAS protocol following TMJR and postoperative opioid use, pain scores, and hospital length of stay (LOS).

STUDY DESIGN, SETTING, AND SAMPLE: The researchers implemented a retrospective cohort study. Patients who received unilateral or bilateral TMJR between 2017 and 2022 at the Hospital of the University of Pennsylvania were identified through review of the electronic medical record. The inclusion criteria were all patients who underwent TMJR Current Procedural Terminology (CPT) code 21243) during the study period. The exclusion criteria were patients who underwent concomitant orthognathic surgery, those with postoperative complications resulting in prolonged hospital stays or ICU admission, and patients unable to provide pain scores.

PREDICTOR VARIABLE: The predictor variable was ERAS status, categorized as ERAS (2019 to 2022) versus non-ERAS (2017 to 2018).

MAIN OUTCOME VARIABLE: The primary outcome variable was postoperative opioid use measured in morphine milligram equivalents (MME) calculated from postanesthesia care unit (PACU) arrival to hospital discharge. Secondary outcomes were LOS measured in days, and pain scores measured using the numeric rating scale.

COVARIATES: Covariates were age, sex, TMJR laterality (unilateral or bilateral), and previous narcotic use (opioid naïve vs tolerant).

ANALYSES: Analysis included independent t tests comparing continuous outcomes (MME, LOS, and pain). χ2 tests were used to evaluate categorical variables. A linear regression model was used to adjust for covariates. Statistical significance was determined at P ≤ .05.

RESULTS

A total of 229 subjects (mean age 49 ± 15 years; 200 [87.3%] female) were included, with 171 (74.7%) in the ERAS group and 58 (25.3%) in the non-ERAS group. In bivariate analysis, the ERAS group demonstrated lower postoperative opioid use compared to the non-ERAS group (34.0 ± 33.5 vs 44.1 ± 39.0 MME; P = .03). After adjusting for opioid tolerance in a linear regression model, this association remained statistically significant (P < .001). There were no significant differences in hospital LOS (1.48 ± 0.6 vs 1.52 ± 0.7 days; P = .8) or adjusted pain scores (P = .06).

CONCLUSIONS AND RELEVANCE: Implementation of an ERAS protocol was associated with reduced postoperative opioid use without adversely affecting pain scores or LOS. These findings support the use of ERAS pathways in TMJR recovery.