*6.2.5 Surgical factors*

Surgical approaches may play a role in ERAS THA and TKA however, the advantages or shortcomings between different approaches in both hip and knee arthroplasty in controversial in the literature. This will not be discussed in details, however, there is no conclusive evidence that surgical approach affect post-operative outcomes [8].

Tourniquet free TKR has recently gained popularity, a systematic review with meta-analysis conducted by Smith and Hing showed tourniquet does reduce intraoperative blood loss however increases rates of haematoma, blisters, superficial wound complications, VTE and pulmonary embolism [65]. Furthermore, the use of knee tourniquet has been shown to negatively affect strength with no impact on range of motion [8]. We do not use a tourniquet. We do not apply but not inflate the tourniquet as this technique often creates a venous tourniquet, making surgery more difficult.

The use of the routine post-operative drain shows no improvement for complications including wound infections, haematomas and healing complications [8] and may increase blood loss and transfusion rate [66]. We do not use drain tubes for primary arthroplasty.
