Efficacy and safety of Enhanced Recovery After Surgery (ERAS) in hemiarthroplasty for hip fracture patients: a systematic review and meta-analysis

Hip fractures pose a significant healthcare challenge for the elderly, with hemiarthroplasty being a standard surgical intervention. Traditional perioperative care often results in prolonged recovery and increased complications. Enhanced Recovery After Surgery (ERAS) protocols have demonstrated efficacy in elective surgeries, yet their safety and effectiveness in the frailer population undergoing hemiarthroplasty for hip fractures require further systematic evaluation. Following PRISMA guidelines, a systematic review and meta-analysis was conducted. Databases were searched from inception until November 2025. Studies comparing ERAS protocols (comprising at least three core components) with conventional care in adults undergoing hemiarthroplasty for acute hip fractures were included. Outcomes included length of hospital stay (LOS), complications, pain, functional scores, and other relevant endpoints. Study quality was assessed, and meta-analyses were performed using RevMan 5.4. Eight studies (5 case-control, 3 RCTs) with 46–118 participants were included. The ERAS group showed a significantly shorter LOS (MD = − 2.38 days, 95% CI: − 3.57 to − 1.19, P < 0.0001), lower postoperative pain VAS scores (MD = − 0.87, 95% CI: − 1.34 to − 0.39, P = 0.0003), higher Harris Hip Scores (MD = 5.05, 95% CI: 1.55 to 8.55, P = 0.005), reduced overall complication rates (OR = 0.23, 95% CI: 0.14 to 0.38, P < 0.00001), and lower transfusion rates (OR = 0.38, 95% CI: 0.22 to 0.66, P = 0.0006) compared to the control group. Reduction in intraoperative blood loss was not statistically significant (MD = − 34.53 mL, P = 0.08). Significant heterogeneity was observed for some outcomes, likely due to variations in ERAS implementation intensity. The methodological quality of included studies ranged from moderate to low. ERAS protocols in hemiarthroplasty for hip fracture patients are associated with improved recovery outcomes, likely due to multimodal interventions that mitigate perioperative stress and break the cycle of recovery hindrance. Heterogeneity suggests a dose–response relationship between protocol completeness and clinical benefit. While current evidence supports ERAS adoption, future research should prioritize protocol standardization, exploration of underlying mechanisms, and assessment of long-term and cost-effectiveness outcomes.