Enhanced recovery after surgery in pediatric orthopedics (ERAS-PO)

Enhanced recovery after surgery in pediatric orthopedics (ERAS-PO)

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ARTICLE IN PRESS

OTSR-2340; No. of Pages 7

Orthopaedics & Traumatology: Surgery & Research xxx (2019) xxx–xxx

Contents lists available at ScienceDirect

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Review article

Enhanced recovery after surgery in pediatric orthopedics (ERAS-PO) Christophe Garin Chirurgie orthopédique pédiatrique, hôpital femme-mère-enfant, hospices civils de Lyon, 59, boulevard Pinel, 69677 Bron, France

a r t i c l e

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Article history: Received 30 November 2018 Accepted 2 May 2019 Available online xxx Keywords: Enhanced recovery after surgery Therapeutic education Parent-child duo Cost-effectiveness analysis

a b s t r a c t “Enhanced recovery after surgery” is now the official term: ERAS. Patients come to a specialized center for surgery, and early recovery is ensured by minimizing the impact of surgical stress, controlling pain and stimulating autonomy. Patient information and education concerning the process and care organization enable short hospital stay with early discharge. The expected benefits are fewer postoperative complications and shorter hospital stay. There is nothing to prevent this kind of program being implanted for children, so long as age and the parent-child relationship are taken into account. Lessons should be drawn from existing pediatric therapeutic education programs, to adapt information and training to the child’s cognitive, motor and psycho-affective development. Setting up an ERAS program is the result firstly of medical and surgical reflection. All healthcare actors need to be actively involved, to set up a management program for the parent-child duo. Implementation, monitoring and assessment are the responsibilities of the physicians who initiate the program. Fewer postoperative complications, with earlier discharge and rehabilitation, should reduce costs and improve patient management in hospital. Such is, indeed, usually the case, but unfortunately drastic health expenditure curbs greatly attenuate the expected benefit in terms of care organization and cost savings. © 2019 Published by Elsevier Masson SAS.

1. Introduction

2. What is enhanced recovery after surgery?

The earlier model of “Fast Track Surgery” has developed into “Enhanced Recovery After Surgery” (ERAS), which is now the accepted term, no longer specifically referring to quick discharge from the care unit. In the literature, there are also the terms “Accelerated Recovery Protocol” and “Accelerated Discharged Protocol”, all testifying to a progression in ideas or at least a challenge to preconceptions, resulting from sharing patient information and education. Pediatric orthopedic surgery aims to restore function, as well as possible and as quickly as possible. Assessment of results, quality of life and recovery has improved management, and surgery has come to be guided by quality of outcome. We can claim to practice “quality recovery after surgery”, rapidity being a consequence of improved management. The present study aimed to define ERAS, and to confirm that it is applicable in children. How should an ERAS program be set up? Are there economic and organizational benefits for the health system? These are questions we shall seek to answer, in the hope that this may encourage all of us to launch into an ERAS program.

2.1. Definition

E-mail address: [email protected]

The principle of enhanced recovery after surgery consists of associating various medical and surgical techniques in a standardized multidisciplinary program for patients undergoing scheduled surgery in a formalized care setting, so as to allow fast postoperative recovery [1]. The French Health Authority (HAS) gave a broader definition in 2016: ERAS is a global patient management approach allowing earlier recovery of capacities after surgery. It is intended in the long run to be applicable to all patients [2]. Karem Slim’s book confirmed the feasibility of including intensive care and emergency patients in an ERAS program [3]. Briefly, an ERAS program consists of: • minimizing the consequences of surgical stress by controlling pain and stimulating autonomy; • informing and educating the patient concerning the process; • and planning care organization and discharge. The expected consequences are: fewer postoperative complications and shorter hospital stay.

https://doi.org/10.1016/j.otsr.2019.05.012 1877-0568/© 2019 Published by Elsevier Masson SAS.

Please cite this article in press as: Garin C. Enhanced recovery after surgery in pediatric orthopedics (ERAS-PO). Orthop Traumatol Surg Res (2019), https://doi.org/10.1016/j.otsr.2019.05.012

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2.2. History In Europe in the 1990s, Henrik Kehlet, a Danish digestive surgeon, laid the foundations of Fast Track Surgery in colorectal procedures [1]. The first question arising is: Why is the patient still admitted to hospital? The answer is obviously multifactorial, and ERAS deals with all of these factors. It consists firstly of combating clinical and organizational preconceptions. The patient is still admitted, because he or she is suffering, under drainage, with uncertain transit and impaired autonomy–and discharge is complicated. 2.3. Concept ERAS is a healthcare pathway organized to ensure global patient management from preoperative consultation to postoperative discharge. This involves all healthcare personnel (surgeons, anesthetists, paramedics)–and also the patient. This is the originality of ERAS: the patients was already at the center, but now becomes a fully fledged actor in the healthcare process. Once information has been provided (as is now mandatory in France, following the “Kouchner law” of 2002) [4], the patient enters a stage of training or education, as compliance works best with understanding. 2.4. Aim The aim is to recover complete active autonomy, as soon as possible after surgery, so as to reduce complications and hospital stay. The literature on adult colorectal cancer tends to show that ERAS reduces postoperative complications rates and thus hospital stay; in pediatrics, and especially pediatric orthopedics, however, there is no established evidence. PubMed contains only 2 articles using the term “enhanced recovery” in idiopathic childhood and adolescent scoliosis surgery [5,6]. In adult orthopedics, there are many more articles on ERAS in hip and knee replacement, tending to show the contribution of such rapid rehabilitation programs to reducing postoperative complications rates and conventional hospital stay [7]. Although shorter hospital stay is one consequence of ERAS, in orthopedics recovery of autonomy may be a good indicator of overall quality of care. 2.5. Patient therapeutic education By definition, patient therapeutic education consists of: • setting up a structured process of skill acquisition for the patient so as actively to adopt pro-health behavior; • helping the patient enhance self-care skills; • and supplementing the mandatory necessary information on surgery, so that the patient becomes an active participant in the care process. Established by the WHO in 1998 and by the French Health Authority in 2007 for chronic diseases [8], patient therapeutic education programs are available to pediatric orthopedic patients with idiopathic scoliosis with a view to improving quality of life with the disease. The 2009 health law helped launch patient therapeutic education in France, demonstrating official interest and the importance given to patient education and information. Patient therapeutic education can obviously be integrated in an ERAS program.

Pediatric patient therapeutic education must meet certain precise criteria [9]: • trained and qualified educators in a formalized and assessed patient therapeutic education program; • originally targeting medical pathologies such as diabetes, kidney failure or hemophilia, patient therapeutic education is available in pediatric orthopedics exclusively for idiopathic scoliosis, due to its chronic nature and potential impact in adulthood. Patient therapeutic education programs require assessment of practices, but open up possibilities for funding to set up and continue the program. However, it remains possible to educate patients without a formalized patient therapeutic education protocol [10]. 2.6. Day-surgery Day-surgery is a form of care defined by regulations as an alternative to conventional hospital admission (Decree n◦ 92 1100–1101 of October 2, 1992, Order of November 12, 1992). By definition, day-surgery concerns procedures allowing admission for less than 12 h. The procedures are identical to those used in conventional admission: it is the patient who is “out”, with specific anesthesia and pain management [11–13]. ERAS and day-surgery have a lot in common: type of procedure, pre-selected eligibility, and predefined pre-, intra- and postoperative clinical pathway. According to Karem Slim [3], day-surgery is official policy (French regional care system “SROS PRS” 2011–2016), whereas ERAS is above all medically motivated. According to Frédéric Bizard of Science Po, Paris, day-surgery and conventional admission within an ERAS program are governed by the same criteria: from passive patients undergoing surgery, the progression is toward an active patient playing an active role in surgery so as to maximize recovery quality and well-being; these are the final objectives of ERAS and its raison d’être; outpatient management may be the final step in an ERAS program. The law seems to be of the same opinion according to an Order of December 8, 2015 entitled “Enhanced recovery after surgery: a novel approach in surgery that may hasten the switch to day care” [14]. France is lagging behind other European countries in this area, but is determined to catch up. For any given procedure, one can imagine not suddenly switching over to day care but progressively optimizing hospital stay toward ever earlier discharge. Such a trend has been clearly reported in hip and knee replacement [15]. One may indeed wonder whether there is any big difference between discharge at day 0 or D2 or 3. The pathway differs, but the ultimate objective is discharge at the right time. According to Karem Slim [3], we should stop dichotomizing between out- and in-patient management and rather define clinical and healthcare pathways along which each individual patient enters according to the particular procedure and comorbidity profile; this would, obviously, impact length of hospital stay. The author calls this new paradigm “hospitalization 2.0”. 3. Is rapid or enhanced recovery after surgery applicable to children? ERAS programs were designed for adult patients, but there is no reason not to apply them in children, so long as patient age is taken into account and also the parent-child duo, which is central. We should take our inspiration from the existing pediatric patient education programs [9], adapting the information and training content to the child’s cognitive, motor and psycho-affective development.

Please cite this article in press as: Garin C. Enhanced recovery after surgery in pediatric orthopedics (ERAS-PO). Orthop Traumatol Surg Res (2019), https://doi.org/10.1016/j.otsr.2019.05.012

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What characterizes the passage from childhood to adulthood is the progressive acquisition of autonomy in dealing with the illness and treatment. There has to be a gradual transfer of skills from parents to child (WHO 1998). What are the key points here? The role of the school: Teachers should be called in to help design and set up a pediatric orthopedic ERAS program. There will thus be several levels, or education programs, in pediatrics. Objectives should be set, to strengthen motivation:

In practice, it is best to begin with frequent and, above all, scheduled procedures. It is important to progress from simple to complex. ERAS programs concern not only healthcare protocols and clinical pathways; the organizational aspect (theater, in-patient department, paramedical staff) is essential for a sustainable program. For example, in our specialty, posterior fusion for idiopathic scoliosis, thoracoplasty and hip dysplasia surgery are particularly well suited to the ERAS approach.

• learning to listen: a psychologist may be called in here; • learning self-care: techniques, check-up, etc.; • accompanying the parents as disease progresses and the child may sometimes refuse treatment; • taking account of the parents’ feelings of guilt and possible overprotectiveness.

4.1.2. Nurses, from consultation to hospital stay Nurses are involved in drawing up but, above all, in implementing the program along the whole pathway from preoperative consultation to discharge. The chief nurses on the ward play a very important role in motivating care-staff to adhere to the new charge book.

We need to be able to adapt to the competencies of the child or adolescent and to the functioning of the family unit. The first step in the process is an educational diagnosis, as in a patient education program: resources and support differ greatly from child to child, according to the social context and, of course, to the pathology in question. Adult patient education programs are all the same, whereas for children the program comprises several sessions according to age. Three age-groups are usually distinguished: < 6, 6–10 and > 11 years into adolescence. The child’s dependence on adults has to be taken into account; care-providers need to be aware of and able to manage the functioning of the parent-child duo. The needs of both child and parent have to be examined. The process consists in transferring skills from parent to child. Therapeutic education programs for children exist, but have yet to be integrated in a pediatric orthopedic ERAS design, and everything remains to be done. A question that arises is whether there is an age limit for pediatric orthopedic ERAS. Obviously, the child needs to have a certain level of understanding (the “age of reason”) to be able to follow an education program in the ERAS context. For the parents, there is no child age limit, as they can stand in and accompany their child as he or she progresses.

4.1.3. Physiotherapists Physiotherapists have a central place in pediatric orthopedic departments, drawing up the pre- and postoperative physiotherapy programs, in hospital and after discharge. 4.1.4. The patient In ERAS programs, the patient becomes an informed actor in his or her care process, with a primordial role for success of treatment (Fig. 1). Information may be delivered in various forms: oral, written, or the preoperative brochure [published by the French Society of Pediatric Orthopedics (SOFOP)] describing not only the operation but also the stages of hospital stay enabling early discharge. Video supports can be useful. In idiopathic scoliosis, good use can be made of the therapeutic education programs already available to many patients. In pediatrics, informing the parent-child duo, each at its own level, may require two distinct education programs: one adapted to the parents and the other to the child’s age. “Corresponding” patients should also be involved: patients who have been operated on and volunteer to share their experience of surgery and the clinical pathway. Obviously, the quality of the testimony needs to be checked in advance. 4.2. How to set up an ERAS program

4. How to set up an ERAS program 4.1. Actors and roles

Setting up and launching an ERAS program begins with a phase of medical and surgical reflection.

4.1.1. The medical-surgical pair (surgeons and anesthetists) They initiate the process of reflection on setting up the ERAS program, selecting a pathology and the surgical procedure.

4.2.1. Choice of type of surgery In principle, most scheduled procedures in pediatric orthopedics are suited to ERAS.

Fig. 1. The patient becomes one of the actors in the healthcare pathway, alongside the surgeon, anesthetist and care-staff, thanks to clear, standardized information. The objectives involve both patients and staff.

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In practice, it is best to begin gradually, with a frequent procedure in a straightforward case. The medical-surgical team first conducts an initial assessment, then sets objectives; choice of patients, hospital stay, and discharge home. 4.2.1.1. For the surgeon. Surgical practice has to be reviewed from scratch. After analysis of the literature founded on evidence-based medicine (EBM), all the components of the procedure need reviewing and validating: What approach, preferably minimally invasive? • • • •

Fixation material: is drainage required? How can operating time be optimized? How to manage blood loss? What are the possibilities for early mobilization?

The GRACE platform (www.grace-asso.fr) of the French ERAS group can also be used, to download ERAS protocols for adaptation. 4.2.3. Protocol launch This requires a leader to monitor the first procedures, from admission to discharge. After a few weeks, those involved in the project will meet to identify and correct teething problems and overcome any initial resistance to change. 4.2.4. Implementation Here again, the GRACE audit protocols can be useful. A well-composed protocol and high motivation are not enough to ensure good implementation. An implementation strategy is needed, to deal with hindrances, which come mainly from the carestaff and hospital structures, but also sometimes from the patient [19].

4.2.1.2. For the anesthetist. The process is the same, and may lead to changes in protocol:

5. Our ERAS experience with children with scoliosis treated by posterior vertebral fusion

• no preoperative fasting; • early return to feeding, without nasogastric tube; • minimal intensive care, thanks to reduced blood loss by every means available: Cell-Saver® , controlled hypotension and tranexamic acid.

Idiopathic scoliosis is a frequent indication in pediatric orthopedic surgery, and is well suited to ERAS. In our department, setting up ERAS was facilitated by physicians being already involved in the French “T2A” activity-based budgeting system and aware of the importance of ICD-10 coding. Upstream, therapeutic education had already been set up for children with idiopathic scoliosis undergoing orthopedic treatment.

4.2.1.3. Postoperative analgesia protocol. So far as possible, morphine derivatives and locoregional anesthesia are eschewed, as paresis hinders early mobilization [16,17]. The protocol can be revised after analysis of the first patients. 4.2.2. Reflection by physicians and care-staff This second phase serves to motivate all those involved along the care pathway and, after validation, to set up the pre- and postoperative protocols, with precise objectives during hospital stay: pain management, early mobilization, and early return to feeding. The care pathway has to be organized, possibly with a booklet given and explained to the patient at the preoperative consultation. A therapeutic education program can then be drawn up or adapted to the selected pathology; this will be included in the patient’s booklet “Patient and family” should consistently receive the same message throughout the pathway, to reassure them and help them integrate all the phases of treatment. “Pre-habilitation” (the pathway leading up to surgery) should be organized: preoperative examinations, pre-anesthesia consultation, and physical preparation and preoperative physiotherapy [16]. Discharge: a discharge protocol is drawn up, aiming at discharge home rather than to a follow-up center. Discharge should be as early as possible, resulting from effective overall management and respecting the individual patient objectives. Care-givers validate predefined discharge criteria (possibly based on day-surgery). The patient is informed of and should agree to the discharge. Discharge criteria are clinical and biological: pain control, functional objectives, restored transit, and oral medication [18]. Post-discharge risk management: Depending on the parentchild duo, a home nurse and physiotherapist may or may not be needed. Referral to a follow-up center is reserved to cases in which parents are incompetent or absent. After discharge, the patient has to be checked on by telephone and/or text messaging. Online devices can also be used via platforms sending questionnaires to check home rehabilitation. All these digital data have to be protected the data protection regulations of the CNIL (Commission Nationale Informatique et Liberté) national data protection commission.

5.1. Medical-surgical reflection 1. Surgically, we kept the classical approach, rasping the posterior vertebral bone, although other approaches are also possible: transmuscular, thoracic extension of the Whiltse approach [20]. We try to perform two-operator surgery, with precise preoperative ® planning, including pre-formed stems, Cell Saver and tranexamic acid. Drainage, if any, is simply subcutaneous by 24 hours’ siphoning. Intraoperative somesthetic and motor evoked potential somesthesic evoked potential/motor evoked potential (SEP/MEP) monitoring is systematic. 2. Anesthesiologically, as SEP/MEP monitoring is systematic, we did not modify anesthesia but adapted postoperative analgesia, using 1 or 2 peridural injections for a maximum 1 or 2 days, with oral relay. Preoperative fasting is not required; there is no nasogastric intubation or catheter. 3. Postoperatively, the patient is raised and fed on day 0 or +1 and returns to the department on day 1 or 2 with oral analgesics. Scoliosis surgery is followed by a stay in intensive care, which is financially useful but has the drawback of being administratively under anesthesiology and not pediatric orthopedics; at the beginning of our experience, decisions were applied variably, delaying IC discharge and thus postoperative rehabilitation. Discharge home is at D4 or D5. 5.2. Writing and setting up care protocols. Impact on care organization and treatment Preparation meetings were held with representatives of each category of personnel involved in the patients’ care pathway: secretary, consultation nurse, chief ward nurse, physiotherapist, anesthesiologist and surgeon. It is very important to alter care organization no more than marginally. The project to improve care is a choice made by the team, and gives rise to no extra funding. Thus, several meetings are needed until everyone is in agreement, so as to reassure those involved and overcome resistance to change.

Please cite this article in press as: Garin C. Enhanced recovery after surgery in pediatric orthopedics (ERAS-PO). Orthop Traumatol Surg Res (2019), https://doi.org/10.1016/j.otsr.2019.05.012

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5.3. Early assessment of protocol application and correction of initial dysfunctions There are 4 important steps: secretariat, consultation nurse, departmental chief nurse and relations with the postoperative care unit. The secretariat fixes the dates for surgery and anesthesiology consultation, organizes peroperative complementary examinations (MRI, neurology, dynamic X-ray) and preoperative physiotherapy. The consultation nurse and/or specialized “gypsotherapist” orthopedic nurse play an educational role, putting the family in touch with “corresponding” patients, and making sure that the care pathway is properly understood by child and parents. The chief nurse motivates the departmental care-staff and ensures timing along the pathway. He or she receives the patient on the day before surgery and organizes discharge home from the postoperative care unit. Preoperative consultation: The surgeon explains the surgical procedure and the hospital process, the objectives to be attained to enable autonomous return home, and the preoperative preparation. It is important to use simple language that the parents and child are going to be able to understand, and that all those involved keep to the same message throughout the therapeutic pathway; this is reassuring for the patient. 5.4. Short-term results A department audit held before the protocol was introduced found a mean hospital stay for idiopathic scoliosis of 8.3 days, compared to a national average of 10.2 days. Assessment after the first 30 ERAS procedures found significantly shorter hospital stay (mean, 5 days) and operative time (mean, 160 min). Otherwise, the two cohorts were identical in terms of type of patient and results: blood loss, Cobb angle and complications rate. Only the shorter hospital stay can be attributed to the ERAS protocol. Shorter operative time was due rather to procedure being performed by 2 senior surgeons using pre-formed stems. A longerterm study will be needed to assess the real benefit of ERAS in this surgery. Time to return to school and pain duration and intensity at home were also identical; for the first 4 days (including the day of surgery itself), pain seemed less well controlled, which is a limiting factor [21].

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directly bound to activity as regards to hospital stay, consultations, outpatient care and emergency care. The system was introduced gradually, but since 2008 it has been the sole means of health center funding. On the PMSI system, information collected for each admission classifies patients by disease-related group (DRG). For each admitted patient, at discharge, a report detailing acts and diagnoses performed during hospital stay is collected. That report, named “standardized discharge summary”, allows classification of hospital stay according to DRG. Each DRG is associated with a socalled “stay-related group”, for which there may be an upper limit (longer stays giving rise to a daily supplement) and a lower limit (shorter stays giving rise to a fixed amount being subtracted). What then is the medico-economic impact in this context? If mean hospital stay shortens for a given category, profit increases and the availability of conventional hospital beds increases, enabling the number of admissions in one specialty or another to be increased. There is thus a gain in productivity (Fig. 2). Apart from its proven benefit for the patient, with shorter hospital stay and better recovery, ERAS also provides social benefit, reducing healthcare costs. In those countries in which it is widely implemented, it reduces the number of surgery beds required to meet the needs of the population, by reducing mean hospital stay without transferring costs to community health services and rehabilitation units. The resources thus freed can be allocated to other health needs. This means reorganizing the health system so as to redistribute actors: for example, by reducing the number of followup units and thus freeing nursing time which can be allocated to home care, reducing health insurance costs. Savings can also be reallocated to other health or social needs according to health policy. Seen like this, ERAS constitutes a virtuous circle. In France, however, the “National Health Insurance Costs Target” (Objectif National des Dépenses d’Assurance Maladie: ONDAM) now sets health expenditure in a mandatory fashion. Briefly, on the one hand the T2A system enhances “productivity” while on the other hand spending limits are set in concrete. At the same time, hospital activity and healthcare demand are increasing faster than expenditure, due to population aging and the cost of medical research [25]. There is thus a decrease in funding per DRG; the more efficient you get, the lower the budget. We can thus conclude, in agreement with Véronique Faujour [26], that the cost saving associated with ERAS is slight and that all that can be expected is benefit for the patient and improved hospital department functioning. That certainly seems to be true for the patient; but for healthcare staff, are their efforts repaid? In terms of working conditions and salaries, that remains to be seen.

6. Does ERAS provide benefit for the health system? 6.1. Economic It is easy to imagine that improved peri-operative management, with fewer complications, shorter hospital stay and discharge preferentially home, should allow ERAS to save costs [22]. The literature on medico-economic analyses of ERAS simply compares direct costs, and argues in favor of ERAS [23,24]. Indirect costs, such as sick leave, hospital workload, change in postoperative treatment, impact on community care etc., are not taken into account. Moreover, heath systems differ from one country to another, as do health insurance systems. It is thus difficult to draw any clear conclusion. So, what about France? Since 2004, health budgeting in France has used the so-called “T2A” activity-based system: resources are allocated to public or private health structures according to the type and volume of activity as measured on the PMSI (Programme de Médicalisation du Système d’Information) medical information database. Funding is

6.2. Is there short, medium and long-term improvement in surgical results? This is very clearly the stated objective of ERAS programs, and would seem to be the case in the short-term, according to reports in digestive surgery [27] and orthopedic surgery for adults. Especially in orthopedic surgery for adults, ERAS does seem to reduce postoperative complications rates and improve functional rehabilitation [28]. The same should go for pediatric orthopedics, but the literature is sparse and it is still too early to give any definitive answers. In the medium to long-term, benefit is more difficult to establish, whether in terms of functional outcome for the patient or of the health system. There are no randomized studies in pediatric orthopedic surgery with sufficient follow-up to determine whether these rehabilitation programs provide benefit or at least improve functional results.

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Fig. 2. The “T2A” activity-based funding system. When hospital stay for a given procedure decreases, hospital time is freed up, and the number of admissions and bedoccupation rate can be increased. Income increases with equivalent overheads. MHS: mean hospital stay; SDS: standardized discharge summary: DRG: disease-related group.

In posterior vertebral fusion for idiopathic scoliosis, it does seem to be the case, but longer follow-up will be required to confirm this [29]. 7. Conclusions The idea of ERAS is to combat surgical preconceptions and implement evidence-based medicine founded on precise and evolving protocols. ERAS is thus the result of constant progress in surgery. It benefits the care-givers, who are led to review their practices, and benefits the patient, who is better informed in making choices. The patient/client now wishes to be actively involved in treatment, as the information available to him or her is increasingly complete. Most surgeons concerned to improve and assess their practices actually implement ERAS without having consciously formulated the idea. ERAS is set to become the new normal, with shorter hospital stay, and physicians who are also technicians, organizers and economists, backed up by teams whose functions are probably also set to evolve. ERAS will also affect healthcare organization outside the hospital setting: “connected ERAS”, changing the medical, social and economic environment in depth. Disclosure of interest The author declares that he has no competing interest. Funding None. References [1] Bardam L, Funch-Jensen P, Jensen P, Crawford ME, Kehlet H. Recovery after laparoscopic colonic surgery with epidural analgesia, and early oral nutrition and mobilisation. Lancet 1995;345:763–4. [2] Haute Autorité de Santé. Programmes de récupération amélioréé après chirurgie (RRAC), synthèse du rapport d’orientation; 2016. www.has-sante.fr. [3] Slim K. Réabilitation améliorée après chirurgie. Elsevier Masson; 2018. [4] Loi n◦ 2002-303 of March 4 2002 https://www.legifrance.gouv.fr/affichTexte.do ?cidTexte=JORFTEXT.

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Please cite this article in press as: Garin C. Enhanced recovery after surgery in pediatric orthopedics (ERAS-PO). Orthop Traumatol Surg Res (2019), https://doi.org/10.1016/j.otsr.2019.05.012

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ARTICLE IN PRESS C. Garin / Orthopaedics & Traumatology: Surgery & Research xxx (2019) xxx–xxx

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Please cite this article in press as: Garin C. Enhanced recovery after surgery in pediatric orthopedics (ERAS-PO). Orthop Traumatol Surg Res (2019), https://doi.org/10.1016/j.otsr.2019.05.012