Perioperative Acupuncture: A Novel and Necessary Addition to ERAS Pathways for Total Joint Arthroplasty

Introduction

As the demand for total joint arthroplasty (TJA) continues to rise, the challenge to provide high-quality, cost-effective care is rising in parallel. In addition to the imperative to improve patient outcomes, economic forces incentivize physicians and health care systems to reward the provision of efficient, high-quality care [1].

For patients undergoing TJA, enhanced recovery after surgery (ERAS) has long been a care model that has demonstrated improved patient outcomes and reduced lengths of stay and care costs [11,12,14]. In more than 20 years since the first descriptions of ERAS concepts, procedure-specific pathways have been developed across and within most surgical subspecialties. Developing a pathway requires an examination of the evidence for interventions and determining which benefit outcomes and which do not; care components are included (and eliminated) accordingly. Care delivery is classically divided into preoperative, intraoperative, and postoperative phases of care, and compliance with individual components of care is assessed and used to improve individual and system practice. Finally, ongoing analyses of the efficacy of the pathway and individual care items are needed to reflect the most up-to-date standards of care.

Despite this quest for continual improvement, few novel interventions for ERAS pathways for TJA have been described in recent years. Acupuncture is an exception to this rule. As a low-risk intervention, acupuncture positively affects multiple aspects of perioperative care that ERAS seeks to improve—potentially making acupuncture an ideal addition. Interestingly, in contrast to other interventions, acupuncture has been shown to have value across all phases of the perioperative trajectory. In this article, we review the literature that supports incorporating acupuncture into ERAS pathways for TJA and suggest the barriers to adoption that will need to be crossed to expand the potential benefits of acupuncture to more patients.

The Preoperative Phase

Preoperative preparation and optimization of patients for surgery is a key to ERAS care. Preoperative goals include weight loss, smoking cessation, anxiety management, and opioid weaning. Acupuncture has been shown to lower short-term tobacco craving and to decrease plasma carbon dioxide levels [22]. In addition to representing a specific benefit for surgical patients who continue to smoke, it may also benefit any patient preparing to undergo anesthesia.

Evidence also suggests that weight loss can be facilitated by acupuncture. In a recent randomized controlled trial (RCT) of 84 patients with a body mass index ≥24, patients randomized to receive active acupuncture for 10 days lost a small but statistically greater amount of weight compared with patients randomized to sham acupuncture [4]. Impressively, the difference in weight loss between the groups was sustained at 3-month follow-up.

Some of the best evidence to support the benefits of acupuncture is derived from its effects on anxiety. A systematic review of 27 studies/1782 participants concluded that acupuncture relieved symptoms of generalized anxiety disorder, with an improved safety benefit, compared with other treatments [9]. Although encouraging, the authors urged caution in interpretation due to unclear bias in the included studies and called for larger randomized studies to confirm the effects. Similarly, acupuncture has been shown to mitigate presurgical anxiety when performed in 2 sessions, at 24 hours and 2 hours prior to anesthetic induction for laparoscopic gynecology surgery [24].

The Intraoperative Phase

The ERAS protocols emphasize multimodal, opioid-sparing, and anesthetic-sparing approaches to care. Using combinations of interventions and techniques facilitates rapid emergence from anesthesia and contributes to satisfactory pain control and minimization of opioid-related side effects. Emerging evidence exists to support the role and value of intraoperative acupuncture as complementary to these goals. For example, for surgeries performed under general anesthesia, acupuncture lowers anesthetic requirements and reduces the time to spontaneous eye opening, to extubation, and to following commands, compared with sham or control among patients undergoing ophthalmic surgeries [7].

A major focus of research on the benefits of intraoperative acupuncture has been directed toward preventing postoperative pain and reducing opioid consumption. Acupuncture has been demonstrated to do both in a wide range of procedures, including oocyte retrieval, tonsillectomy, and orthopedic surgery [2,3,10,17,20]. In a pair of articles, Usichenko et al [18,19] randomized patients to receive semipermanent auricular needles versus sham and demonstrated significant reductions in intraoperative fentanyl and postoperative analgesic requirements among patients undergoing total hip arthroplasty. More recently, at HSS, clinical studies of the addition of acupuncture to institutional ERAS pathways have found significant decreases in opioid consumption among patients undergoing total knee arthroplasty and decreased incidence of rescue nerve block performance after surgery for anterior cruciate ligament injury [2,3].

The Postoperative Phase

The clinical gains afforded by ERAS care is arguably best demonstrated in the early postoperative period, when ERAS interventions target the physiological derangements that may limit prompt hospital discharge. Despite significant improvements over time and across surgical subtypes, the factors limiting satisfactory recovery and prompt hospital discharge include postoperative nausea and vomiting (PONV), ileus, suboptimal pain management, and high opioid requirements. Acupuncture has evidence of efficacy in each of these domains.

Despite early adoption of ERAS protocols for gastrointestinal surgery, postoperative ileus remains a leading complication. In a recent well-designed, multicenter RCT, 249 patients received either auricular or sham acupuncture within a comprehensive ERAS pathway for colorectal surgery [21]. Impressively, 4 daily sessions of acupuncture, starting at postoperative day 1, shortened the time to recovery of gastrointestinal function. Among patients who developed ileus, acupuncture shortened its duration and reduced the risk of prolonged ileus. These results suggest that acupuncture may be a useful adjunct to standard care for ileus prevention in other surgeries with risk for postoperative ileus. In orthopedics, patients undergoing spine surgery through anterior or lateral abdominal wall approaches may represent an ideal population in which to investigate risk modification.

Pain management plays a fundamental role in ERAS pathways and a reasonable body of evidence suggests that acupuncture can improve acute pain. In an early meta-analysis, 15 high-quality RCTs that compared acupuncture versus sham control in the management of acute postoperative pain were grouped and analyzed [16]. The authors found that using acupuncture as an adjunct significantly reduced postoperative pain scores and opioid consumption. These results have been confirmed in a subsequent meta-analysis of 13 RCTs/806 patients in which a mean decrease in pain scores was found among patients who received auricular therapy compared with sham therapy [23].

Furthermore, PONV has a significant negative impact on both prompt discharge after surgery and patient satisfaction. In addition to indirect effects on PONV through an opioid-sparing capacity, acupuncture also has direct anti-emetogenic effects [6,8]. An updated Cochrane review, including 59 trials/7667 subjects, reported that PC6 acupoint stimulation was associated with a significant reduction in the risk of PONV and the need for rescue antiemetics, compared with sham treatment [8]. However, the review also included comparison with standard antiemetic medications and found no difference between the 2 interventions although combination therapy was more effective than antiemetics alone. These data are included in at least 1 major anesthetic society guideline, with a call for further research before recommending adoption due to overall low-quality evidence informing the topic [6].

The prototypical end point for measuring ERAS efficacy is hospital and/or postanesthesia care unit (PACU) length of stay. Given the evidence reviewed here that acupuncture can improve pain and minimize early complications, it would be predicted that acupuncture can also shorten length of stay. Although there is scant evidence to support this hypothesis, one RCT randomized 75 women undergoing laparoscopic gynecology surgery to acupuncture or sham. The authors found a 16-minute difference (which was significant) in the time from extubation to ready-for-discharge from the PACU among patients who received acupuncture [5].

Barriers to Widespread Adoption

The first barrier to adoption of acupuncture in clinical practice is that practitioners need to be licensed and confident in their abilities to perform the procedure. The investment in licensure is not insignificant. Requirements to practice acupuncture as part of anesthesia care vary from state to state, but New York State requires 300 hours of training for certification.

Second, awareness of the evidence that supports acupuncture and the quality of evidence informing practice need to be improved. In addition, the mechanisms by which acupuncture improves outcomes are not clear; this needs to be elucidated. Apart from addressing PONV, acupuncture is not mentioned or recommended in major society guidelines as a preventive or treatment strategy for pain or as a potential component of ERAS pathways [6]. This is challenging, given that the evidence to support acupuncture reviewed here is not substantially weaker than other interventions that feature prominently in ERAS care pathways. A salient example is the zeal with which novel fascial plane blocks have been formally adopted into ERAS care, despite modest evidence for improved outcomes [13].

Finally, cost is a major barrier to adoption. In anesthesia practice, an acupuncture session should cost an estimated 6 anesthesia time units (TU), but given the rarity of perioperative acupuncture treatments, payment has not been standardized and not all insurance companies reimburse for services [15]. Costs may additionally or alternatively be offset by savings that result from improved outcomes and shorter length of hospital stay, but this is speculative, given that cost-effectiveness studies are not yet in evidence and urgently need to be conducted.

Conclusions

To reduce perioperative morbidity and improve outcomes, ERAS protocols emphasize multimodal, multidisciplinary care, which relies on evidence-based interventions implemented throughout the perioperative period. Acupuncture is emerging as a technique with similar benefits for patients and health care systems when used at parallel timepoints. Whether acupuncture should replace or complement other ERAS interventions for TJA is unclear. However, emerging evidence is encouraging and suggests several temporal opportunities to provide acupuncture to target aspects of recovery and complications.

Currently, no formal ERAS protocols for TJA incorporate perioperative acupuncture. Developing—and validating—a preliminary fast-track protocol for these surgeries may have a significant impact on reducing recovery time and improving the rate at which TJA may be moved to the outpatient setting. The prospect of incorporating intraoperative acupuncture as an adjunct into ERAS protocols is appealing, given its safety profile, ease of administration, potential for cost savings, and the growing evidence supporting efficacy. Further studies will clarify whether perioperative acupuncture can reduce hospital length of stay and postoperative opioid consumption and evaluate the procedure-specific role of perioperative acupuncture in improving recovery after TJA.

Supplemental Material

sj-docx-1-hss-10.1177_15563316231204308 – Supplemental material for Perioperative Acupuncture: A Novel and Necessary Addition to ERAS Pathways for Total Joint Arthroplasty

Supplemental material, sj-docx-1-hss-10.1177_15563316231204308 for Perioperative Acupuncture: A Novel and Necessary Addition to ERAS Pathways for Total Joint Arthroplasty by Stephanie I. Cheng, Cephas P. Swamidoss and Ellen M. Soffin in HSS Journal®

Supplemental Material

sj-docx-2-hss-10.1177_15563316231204308 – Supplemental material for Perioperative Acupuncture: A Novel and Necessary Addition to ERAS Pathways for Total Joint Arthroplasty

Supplemental material, sj-docx-2-hss-10.1177_15563316231204308 for Perioperative Acupuncture: A Novel and Necessary Addition to ERAS Pathways for Total Joint Arthroplasty by Stephanie I. Cheng, Cephas P. Swamidoss and Ellen M. Soffin in HSS Journal®

Supplemental Material

sj-docx-3-hss-10.1177_15563316231204308 – Supplemental material for Perioperative Acupuncture: A Novel and Necessary Addition to ERAS Pathways for Total Joint Arthroplasty

Supplemental material, sj-docx-3-hss-10.1177_15563316231204308 for Perioperative Acupuncture: A Novel and Necessary Addition to ERAS Pathways for Total Joint Arthroplasty by Stephanie I. Cheng, Cephas P. Swamidoss and Ellen M. Soffin in HSS Journal®