Table 1 Strategies of the ERAS program for TKA

Patients’ education

 Inform detailed treatment process and rehabilitation plan

 Continue knee joint functional exercise every hour during the day

Nutritional support and diet managements

 Take high-protein dietary for at least 2 days before surgery

 Individualized diet management on day of surgery: individually preoperative fasting and water-deprivation according to the operation time, oral carbohydrate solution 2 h before surgery, and early postoperative feeding on day of surgery.

General anesthesia

Restrictive fluid management

 Intravenous crystalloid fluid volume controls in about 1500 ml on day of surgery

Minimally invasive operation

 A middle skin incision, a standard medial parapatellar approach, and a measured resection technique.

Blood managements

 Erythropoietin and chalybeate were used in patients with anemia (hemoglobin: male < 130 g/L; female < 120 g/L)

 Controlled hypotension (mean arterial pressure: 70 to 80 mmHg) during operation

 Tranexamic acid (TXA) utilization: a dose of 20 mg/kg intravenous TXA (IV-TXA) was given before incision, another two doses of 10 mg/kg or 1 g IV-TXA 3 and 6 h later.

Pain managements

 Preventive analgesia with celecoxib orally preoperatively

 Local infiltration of 80 mL 2.5% ropivacaine before incision closure

 A standard regimen of oral nonsteroidal anti-inflammatory drugs (NSAIDs) after surgery, oral oxycodone as needed.

No allogenic blood transfusion

No tourniquet during operation

No urine catheter before surgery, catheter would be used for postoperative uroschesis.

No drainage tube or early removal of drainage tube after surgery

Antithrombotic prophylaxis

 Low-molecular-weight heparin daily, starting 6 h postoperatively and given until discharge, then oral rivaroxaban 5 or 10 mg daily for 10 days.

Prevention of postoperative nausea and vomiting

 Oral mosapride 5 mg 2 h before surgery and postoperatively three times a day

 Dexamethasone 10 mg intravenous injection during operation and a repeat dose was given 4 to 6 h after surgery

Start rehabilitation and mobilization on day of surgery

 Perform ankle flexion and extension exercises in bed immediately after surgery, then progressive ambulation exercises with full weight bearing on the first or second postoperative day with the assistance of a walker or crutches.

Discharge criteria

 Be self-dependent, able to walk with crutches or better, able to achieve 100° active knee flexion or better and − 5° to 0° extension.