Lin C, Nagdev T, Zhu DA, Nair GS, Cheng S, Kumar K. High efficiency pathway for lower limb orthopedic surgery: A matched historic cohort study. World J Orthop 2025; 16(10): 109196 [DOI: 10.5312/wjo.v16.i10.109196]
Corresponding Author of This Article
Cheng Lin, Associate Professor, FRCPC, Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine, Western University, 800 Commissioners Road East, London N6A 5W9, Ontario, Canada. cheng.lin@lhsc.on.ca
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Anesthesiology
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Retrospective Study
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This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Oct 18, 2025 (publication date) through Oct 26, 2025
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World Journal of Orthopedics
ISSN
2218-5836
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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA
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Lin C, Nagdev T, Zhu DA, Nair GS, Cheng S, Kumar K. High efficiency pathway for lower limb orthopedic surgery: A matched historic cohort study. World J Orthop 2025; 16(10): 109196 [DOI: 10.5312/wjo.v16.i10.109196]
World J Orthop. Oct 18, 2025; 16(10): 109196 Published online Oct 18, 2025. doi: 10.5312/wjo.v16.i10.109196
High efficiency pathway for lower limb orthopedic surgery: A matched historic cohort study
Cheng Lin, Tripti Nagdev, Dan Annie Zhu, Gopakumar S Nair, Sonny Cheng, Kamal Kumar
Cheng Lin, Gopakumar S Nair, Kamal Kumar, Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine, Western University, London N6A 5W9, Ontario, Canada
Tripti Nagdev, Department of Anesthesia, McMaster University, Hamilton L8R2K3, Ontario, Canada
Dan Annie Zhu, Department of Anesthesia, Western University, London N6A 5W9, Ontario, Canada
Sonny Cheng, Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine & Dentistry, LHSC/Western University, London N6A 5W9, Ontario, Canada
Co-first authors: Cheng Lin and Kamal Kumar.
Author contributions: Lin C contributed to the conception and design of the study, data analysis and manuscript writing; Nagdev T and Zhu DA assisted in data collection and manuscript reviewing; Cheng S, Nair GS, Kumar K reviewed and revised the final manuscript. Lin C and Kumar K contributed equally to this work as co-first authors.
Institutional review board statement: The study was approved by Health Sciences Research Ethics Board at Western University (ID 113648).
Informed consent statement: Health Sciences Research Ethics Board at Western University (ID 113648) waived the requirement for informed consent.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: No additional data are available.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Cheng Lin, Associate Professor, FRCPC, Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine, Western University, 800 Commissioners Road East, London N6A 5W9, Ontario, Canada. cheng.lin@lhsc.on.ca
Received: May 8, 2025 Revised: June 12, 2025 Accepted: September 19, 2025 Published online: October 18, 2025 Processing time: 161 Days and 16 Hours
Abstract
BACKGROUND
In 2017, our institution implemented a high efficiency (HE) pathway for lower limb orthopedic surgery. The employed strategy included patient selection, surgical instrument standardization, preoperative surgical nerve blocks, avoidance of general anesthesia and bypassing phase one recovery. We conducted a historic cohort study whose primary outcome was the postoperative recovery time between the HE and traditional (T) pathway.
AIM
To determine whether the implementation of a HE pathway was correlated with a reduction in postoperative recovery time.
METHODS
Patients who had unilateral elective lower limb orthopedic procedures through the T and HE pathway were screened between 2017 to 2019. Patients were at least 18 years old, and American Society of Anesthesiologists (ASA) Physical Status I to III without major systemic comorbidities were included. Propensity score was generated using multivariable regression taking age, body mass index, sex, ASA class and surgical type as covariates using nearest neighbour methods between the two pathways. Mann Whitney U test were used to analyzed total postoperative time.
RESULTS
There was an associated reduction in total postoperative recovery time of 63 minutes (95%CI: -69 to -57) in the HE group. The operating room time and total length of stay also had an associated decrease of 20 minutes (95%CI: -23 to -17) and 84 minutes (95%CI: -92 to -75) respectively.
CONCLUSION
Utilizing multifaceted strategies to improve perioperative efficiency was associated with a reduction in the postoperative recovery time in our retrospective study. This model can be a potential strategy to deal with surgical backlog in the face of ongoing human resource challenges.
Core Tip: This study shows that adopting a high-efficiency approach for lower limb orthopedic surgery, by selecting appropriate patients, using standardized instruments, applying regional anesthesia, and bypassing phase one recovery, significantly shortens postoperative recovery time, reduces operating room duration, and decreases total hospital stay. This model provides a practical and scalable way to enhance perioperative care and tackle surgical backlogs in the face of ongoing constraints in healthcare resources.
