BACKGROUND: The Enhanced Recovery After Surgery (ERAS) program has significantly reduced complication rates and hospital length of stay (LOS) for various surgical procedures. A key aspect is the reduction of pre-operative fasting through carbohydrate-loading protocols. There is limited research on the effects of pre-operative carbohydrate loading in elective lower limb arthroplasty. This systematic review and meta-analysis evaluates the impact of pre-operative carbohydrate loading on LOS, pain scores, postoperative nausea and vomiting, patient-reported outcome measures (PROMs), and patient experience in lower limb arthroplasty surgery. METHODS: The MEDLINE, Embase, CINAHL, and Cochrane Central databases underwent a comprehensive search from their inception to July 01, 2023, with an update conducted on April 01, 2024. Inclusion criteria encompassed high-quality research as determined by the AMPQQ assessment tool, focusing on preoperative carbohydrate drink loading in hip and knee arthroplasty. The review was prospectively registered on PROSPERO
registration number CRD42023420618. RESULTS: 1686 articles were identified. 281 duplicates were removed and 1379 articles rejected based on title and abstract review. 26 articles underwent a full-text review. A final evaluation was conducted, which included 10 articles meeting the inclusion criteria. These articles, published between 2001 and 2022, encompassed 756 patients (57-71.9 years old). While some studies indicated the potential benefits of carbohydrate loading in reducing the length of hospital stay (LOS), our meta-analysis did not demonstrate a statistically significant LOS reduction within the intervention group (mean difference of 0.47 days (95 % CI -0.98 to 0.04, p = 0.07). Furthermore, no statistically significant differences were observed in pain scores (VAS) at 24 h (p = 0.37) or in postoperative nausea and vomiting (p = 0.42) between the two groups. However, there is a possibility of improvement in anxiety levels, postoperative thirst, and hunger with carbohydrate drink loading. CONCLUSION: LOS trended towards favouring pre-operative carbohydrate loading in lower limb arthroplasty surgery, however, there was significant heterogeneity within included studies. Further high-powered, multicentered studies are required to analyse whether carbohydrate drink loading is superior to 'nil by mouth' protocols.