Enhanced Recovery After Surgery (ERAS) Protocols in Orthopaedic Surgery: Opioids or Not Opioids?

Enhanced Recovery After Surgery (ERAS) protocols have transformed perioperative care in orthopaedic surgery, emphasising streamlined patient pathways for improved outcomes and treatment of chronic pain. Traditionally, opiates have been pivotal in managing postoperative (PO) pain and their efficacy in providing essential relief during the recovery phase is well-established. However, the evolving landscape of perioperative care, coupled with the opioid crisis and their association with chronic pain, has prompted a re-evaluation of their role. Orthopaedic ERAS protocols emphasise a multimodal approach to pain management, advocating for a reduction in opioid reliance. Alternative analgesic strategies, such as regional nerve blocks and non-opioid medications, are integrated into these protocols. Studies comparing opiates and opioid-free analgesia in orthopaedic ERAS are limited, making it challenging to establish a standardised approach. Some evidence suggests that opioid-free strategies, in some operating settings, may lead to improved recovery outcomes, reduced PO pain, and lower opioid consumption. However, in orthopaedics, evidence is inconclusive, necessitating further exploration. This review provides an overview of the development and multifaceted nature of ERAS protocols, which encompass a holistic approach to perioperative pain management and sustained pain relief, all while aiming to reduce the risks associated with opioid use. Striking the optimal balance between pain control and patient safety remains a priority, with the need for continued exploration and refinement of clinical guidelines in orthopaedics.