Pros and Cons of Fast-track Total Knee Arthroplasty

Abstract

Background: Existing literature emphasizes the benefits of fast-track total knee arthroplasty (TKA), mainly because this diminishes the length of stay (LOS) in hospital. Fast-track is defined as a hospitalization which provides the best possible evidence-based treatment and a hospital stay of maximum 3 days. However, many authors still don´t use fast-track TKA due to its potential risks, mainly in elderly patients with comorbidities and some special circumstances (bilateral TKA in one stage, revision TKA). Questions: (1) Should fast-track TKA be the default, used unless contra-indicated; (2) Is it justifiable in all kind of patients and circumstances? Methods: A Cochrane Library, PubMed (MEDLINE) and Google Scholar search related to the results of fast-track TKA and the justification of fast-track TKA in all kind of patients was systematically analyzed. The keywords used were: TKA and fast-track, and TKR and fast-track. The main criteria for selection were that the articles were focused in the aforementioned questions. Results: 919 articles were found, with 27 meeting the selection criteria. Of them, only four have been included in the Cochrane Library because of their high grade of evidence. Many authors agree on that fast-track TKA yields similar or better results than the classical standard-track. The four articles included in the Cochrane Library have shown that patients undergoing fast-track TKA recover better after general anesthesia than after spinal anesthesia, that fibrin sealant (fibrin blue) is not beneficial in diminishing drain output or in improving functional recovery, and that fast-track rehabilitation reduces the consumption of analgesic drugs and LOS. Conclusion: Fast-track TKA should be used in all kind of patients, although the procedures for patients having different age/gender/preconditions would be different. In fact, preoperative anemia in fast-track TKA is associated with an increased risk of receiving transfusion during admission, increased risk of readmission within 90 days from the procedure, and increased risk of LOS of more than 5 days.