Stepwise Adoption of a Postoperative ERAS Pathway in Microsurgical Lower Extremity Reconstruction: Faster Recovery and Stable Outcomes.

Abstract

Despite increasing emphasis on early postoperative recovery, lower extremity microsurgical reconstruction has been overlooked, likely due to concerns of high complication rates and the challenges of a gravity-dependent, weight-bearing region. This study evaluated the feasibility and outcomes of stepwise ERAS protocol implementation in this setting. A retrospective review was conducted of consecutive lower extremity free flap reconstructions from January 2020 to February 2024, during which postoperative management evolved stepwise toward early recovery. Patients were categorized into three cohorts-pre-ERAS, transition, and ERAS. In the ERAS cohort, oral intake resumed on POD 1 morning, wheelchair-assisted ambulation began that afternoon, and discharge was targeted for POD 5. Postoperative course and complication rates were compared, and the independent association of ERAS implementation was assessed. In total, 240 flaps in 224 patients were included: 66 pre-ERAS, 123 transition, and 51 ERAS. Following full protocol adoption, median nil per os (NPO) duration decreased from 24.9 to 12.7 hours, bed rest from 4.0 to 1.0 day, and length of stay (LOS) from 11.5 to 7.0 days. Flap- and donor-site complication rates also declined significantly over time. On multivariable analysis, ERAS implementation was associated with shorter NPO duration and reduced bed rest, without an increase in flap-related complications. The reduction in LOS associated with ERAS implementation was particularly pronounced in patients with ASA class <3 or those undergoing oncologic reconstruction. Stepwise adoption of an ERAS-based protocol in microsurgical lower extremity reconstruction might be feasible and effective, promoting early recovery without increasing complication risk.