BACKGROUND : A structured approach to perioperative patient management based on an enhanced recovery
pathway protocol facilitates early recovery and reduces morbidity in high income countries. However, in low- and
middle-income countries (LMICs), the feasibility of implementing enhanced recovery pathways and its influence on
patient outcomes is scarcely investigated. To inform similar practice in LMICs for total hip and knee arthroplasty, it is
necessary to identify potential factors for inclusion in such a programme, appropriate for LMICs.
METHODS : Applying a Delphi method, 33 stakeholders (13 arthroplasty surgeons, 12 anaesthetists and 8
physiotherapists) from 10 state hospitals representing 4 South African provinces identified and prioritised i) risk
factors associated with poor outcomes, ii) perioperative interventions to improve outcomes and iii) patient and
clinical outcomes necessary to benchmark practice for patients scheduled for primary elective unilateral total hip
and knee arthroplasty.
RESULTS : Thirty of the thirty-three stakeholders completed the 3 months Delphi study. The first round yielded i) 36
suggestions to preoperative risk factors, ii) 14 (preoperative), 18 (intraoperative) and 23 (postoperative) suggestions
to best practices for perioperative interventions to improve outcomes and iii) 25 suggestions to important
postsurgical outcomes. These items were prioritised by the group in the consecutive rounds and consensus was
reached for the top ten priorities for each category.
CONCLUSION : The consensus derived risk factors, perioperative interventions and important outcomes will inform the
development of a structured, perioperative multidisciplinary enhanced patient care protocol for total hip and knee
arthroplasty. It is anticipated that this study will provide the construct necessary for developing pragmatic
enhanced care pathways aimed at improving patient outcomes after arthroplasty in LMICs.