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Pros and Cons of Fast-track Total Knee Arthroplasty

E. Carlos Rodriguez-Merchan

E. Carlos Rodriguez-Merchan, Department of Orthopaedic Surgery, “La Paz” University Hospital, Madrid, Spain; and Department of Orthopaedic Surgery, School of Medicine, “Autonoma” University, Madrid, Spain

Correspondence to: E. Carlos Rodriguez-Merchan, MD, PhD, Department of Orthopaedic Surgery, “La Paz” University Hospital, Madrid, Spain; and Department of Orthopaedic Surgery, School of Medicine, “Autonoma” University, Madrid, Spain
Email: ecrmerchan@gmx.es
Telephone: +34-91-5712871
Fax: +34-91-5712871
Received: January 10, 2014
Revised: February 9, 2015
Accepted: February 12, 2015
Published online: June 23, 2015

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.

© 2015 The Authors. Published by ACT Publishing Group Ltd.

Key Words: Total knee arthroplasty; Fast-track; Pros; Cons; Economical impact; Health system

Rodriguez-Merchan EC. Pros and Cons of Fast-track Total Knee Arthroplasty. International Journal of Orthopaedics 2015; 2(3): 270-279 Available from: URL: http://www.ghrnet.org/index.php/ijo/article/view/1255

Introduction

Total knee arthroplasties (TKAs) have been used for at least thirty years, but surgeons are of course always trying to improve their results and decrease length of stay (LOS)[1].

Fast-track defined as a hospitalization which provides the best possible evidence-based treatment and a hospital stay of maximum 3 days, uses fewer clinical resources with the aim of decrease perioperative morbidity and LOS[2]. The treatment concept called “fast-track” is based on information, motivation and logistics and the use of available evidence-based interventions within all aspects of treatment, care, rehabilitation, anesthesia, pain management, etc. The ultimate goal is to reduce the need for hospitalization to a maximum of 3 days without additional resources - while maintaining a very high patient satisfaction and very few complications.

The purpose of this review is to analyze whether fast-track TKA should be the default mode of care and to clarify whether it is justifiable in all kind of patients.

Methods

A review was performed on the role of fast-track TKA. The search engines were MEDLINE (PubMed), Google Scholar and the Cochrane Library, and the final date was 22 August 2014. The keywords used were: TKA and fast-track, and TKR and fast-track. 919 articles were found. Of these, twenty-seven were selected and reviewed because they were deeply focused on the aforementioned questions[1-27]. Of them, only four have been included in the Cochrane Library because of their high grade of evidence[3-6].

Results

The types of studies reported have a low level of evidence (levels III and IV). Most of them are prospective case series (level IV).

A number of topics have been analyzed in the literature of fast-track TKA: preoperative anemia[7], intraoperative fibrin sealant[6], type of anesthesia[4,8], pain[9-11], postoperative rehabilitation[3,5,12,13], risk of postoperative deep vein thrombosis (DVT)[14,15], postoperative delirium[16,17], outcome[1,18], length of stay (LOS) in hospital[2,19-21], fast-track in special situations (elderly patients with comorbidities[16], bilateral TKA[22,23], and revision TKA[24].

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[7].

In a randomized, double-blind, placebo-controlled study, local fibrin sealant in fast-track TKA did not reduced drain output when used with a tourniquet, tranexamic acid, and a femoral bone plug[6].

Regarding the role of anesthesia, a study with high grade of evidence compared the effects of general anesthesia (GA) and spinal anesthesia (SA) in patients undergoing fast-track TKA[4]. In the GA group LOS was shorter (46 vs 52 h). Moreover, patients in the GA group needed fewer PCA (patient-controlled analgesia) and less morphine, and they were able to walk earlier. In another report more than eighty-five per cent of patients operated with fast-track TKA under low-dose spinal anesthesia were discharged from the post-anesthesia care unit in 15 minutes[25].

The influence of pain on functional recovery after the first postop day in fast-track TKA is small, thereby allowing early rehabilitation and physiotherapy[9]. It has been reported that in 5 to 9 days postoperative pain returns to preoperative levels[10]. A randomized study compared a multimodal analgesic regimen with PCA[11]. Patients in one group received either periarticular injection before wound closure (30cc 0.5% bupivacaine, 10 mg MSO4, 15 mg ketorolac) and multimodal analgesics (oxycodone, tramadol, ketorolac; narcotics as needed). In the other group hydromorphine PCA was used. VAS scores, narcotic usage and adverse effects were fewer in the multimodal group. Satisfaction scores were also better.

Some authors have proposed fast-track physiotherapy to diminish the early loss of muscle strength and function after TKA[12]. A prospective randomized study included in the Cochrane Library demonstrated that fast-track rehabilitation and physiotherapy after TKA yielded better WOMAC index scores, fewer consumption of analgesic drugs and rate of adverse events, and shorter LOS (6.75 vs 13.20)[3]. Implementation of fast-track rehabilitation was highly recommended. Six months after fast-track TKA no differences have been found between a supervised home-training program and a group-based rehabilitation program regarding physical function and quality of life of patients[5].

The risk of clinical deep vein thrombosis (DVT), and of fatal and non-fatal pulmonary embolism (PE) after fast-track TKA is not higher that after standard TKA[14]. In-hospital prophylaxis only has been shown to be safe in fast-track TKA patients with LOS of ≤5 days[15].

Fast-track TKR with multimodal opioid-sparing analgesia has been associated with lack of postoperative delirium in elderly patients[16,17].

Operations at the beginning of the week and lack of blood transfusion have been associated with shorter LOS (maximum 5 days) but similar readmission rates[19]. Fast-track TKA has been successfully implemented in Denmark with a reduction in LOS from 10-11 days on average in 2000 to 4 days on average in 2009[2]. Fast-track TKA allowed enhanced recovery and better functional outcomes. That is why fast-track TKA units have been recommended[1].

Fast-track TKA with LOS of ≤4 days and discharge to home has shown to be feasible and safe, including in elderly patients with comorbidities[25]. More than 75% of patients aged over 80 year or with comorbidities had an LOS ≤4 days. Mortality and readmission rate were 0.22% and 6.6%, respectively, at 30 days and 0.42% and 9.3% at 90 days.

Bilateral simultaneous TKA has been performed as a fast-track procedure with excellent results[22]. The results from a study indicated that bilateral simultaneous TKA can safely be carried out[23].

Patients undergoing fast-track revision TKA for aseptic loosening showed similar results that primary TKA regarding LOS, morbidity, and satisfaction[24].

There are some patient´s characteristics that influence the result, LOS, and patient satisfaction in fast-track TKA[13]. They are: age, sex, co-morbidity, preoperative use of walking aids, pre- and postoperative hemoglobin levels, the need for blood transfusion, ASA (American Society of Anesthesia) score, and time between the procedure and mobilization. It has been reported that fast-track TKA yields similar or better results that the standard classical TKA[1,26,27]. Table 1 summarizes main data and results of the review of the literature of fast-track TKA.

Discussion

The purpose of this article was to review the literature with the aim of answering the following questions: (1) Should fast-track TKA be the default, used unless contra-indicated; (2) Is it justifiable in all kind of patients and circumstances?

The quality of studies reported so far on the topic is poor (low level of evidence, levels III and IV). Most of them are prospective case series (level IV).

A number of topics have been analyzed in the literature of fast-track TKA: the importance of preoperative anemia[17], the potential role intraoperative fibrin sealant[26], the importance of the type of anesthesia[3,24], the role of pain control[9-11], postoperative rehabilitation[3,5,12,13], the risk of postoperative DVT[14,15] and postoperative delirium[16,17], the outcome[1,18], the length of stay in hospital[2,19-21], and the role of fast-track in special situations (elderly patients with comorbidities[25], bilateral TKA[22,23], and revision TKA[24].

Preoperative anemia in fast-track TKA has been associated with transfusion and increased postoperative morbidity[7]. Local fibrin sealant in fast-track TKA neither reduced drain output nor facilitated early functional recovery[6].

General anesthesia in fast-track TKA yields better results than spinal anesthesia[4]. More than eighty-five per cent of patients achieved pre-defined post-anesthesia care unit discharge criteria in 15 minutes[8]. A multimodal analgesic regimen on postoperative pain is paramount in fast-track TKA[11].

Fast-track rehabilitation and physiotherapy after TKA yielded better results that standard rehabilitation regarding muscle strength, function after surgery, LOS and consumption of analgesic drugs[3,12]. However, no differences have been found between a supervised home-training program and a group-based rehabilitation program six months after the procedure[5].

There are several patient characteristics that influence the postoperative outcome, the LOS, and patient satisfaction in fast-track TKA[13]. They are: age, sex, co-morbidity, preoperative use of walking aids, pre- and postoperative hemoglobin levels, the need for blood transfusion, ASA score, and time between surgery and mobilization.

The risk of clinical DVT, and of fatal and non-fatal PE after fast-track TKA are similar to the risk of other published regimens with extended prophylaxis (up to 7 weeks) and hospitalization up to 11 days[14]. In-hospital prophylaxis only has been found to be safe in fast-track TKA patients with LOS of ≤5 days[15].

In elderly patients, multimodal opioid-sparing analgesia is associated with lack of postoperative delirium and a reduction of the prevalence of postoperative cognitive decline after fast-track TKA[16,17]. It has also been reported that fast-track TKA yields similar or better results that the standard classical track[21,26,27].

Operations at the beginning of the week and lack of blood transfusion have been associated with shorter LOS. Fast-track TKA can be carried out in unselected without a higher rate of readmissions[19].

Fast-track TKA has been successfully implemented in the orthopedic departments in Denmark[1,2]. Reduction in LOS was from 10-11 days on average in 2000 to 4 days on average in 2009. Fast-track TKA resulted in better recovery, lower LOS, and better functional outcomes.

A prospective study on patients´ characteristics and comorbidity in unselected patients undergoing fast-track TKA with a follow-up of 90 days showed that more than 75% of those aged over 80 year or with comorbidities had an LOS ≤4 days[16]. Mortality and readmission rate were 0.22% and 6.6%, respectively, at 30 days and 0.42% and 9.3% at 90 days. Readmissions were similar in all kind of patients. Fast-track TKA with LOS of ≤4 days and discharge to home proved to be feasible and safe, including in elderly patients with comorbidities[25].

Bilateral simultaneous fast-track TKA has been performed with excellent results[22,23]. Patients undergoing fast-track revision TKA for aseptic loosening showed similar results that those undergoing primary fast-track TKA regarding LOS, morbidity, and satisfaction[24].

To get quick rehabilitation and discharge, a fast-track TKA unit needs both logistical (homogenous entities, regular staff, high continuity, using more time on and up to date information including expectations on a short stay, functional discharge criteria) and clinical features (multimodal opioid-sparing analgesia, early mobilization and discharge when criteria were met)[20]. The aforementioned features expected will reduce LOS, with similar or improved patient satisfaction. The literature supports the implementation of fast-track TKA in nearly all kind of patients and circumstances[2,14,19,20,22,24,26].

In conclusion, fast-track TKR 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 TKR 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.

CONFLICT OF INTEREST STATEMENT

There are no conflicts of interest with regard to the present study.

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Peer reviewers: Kaiyu Zhang, Bioengineering Department, Imperiao College London, South Kensington Campus, SW7 2AZ, The United Kingdom; Michele D’Arienzo, MD, Professor, Clinica Ortopedica e Traumatologica, Dipartimento di Discipline Chirurgiche, Oncologiche e Stomatologiche, Università degli Studi di Palermo, Via del Vespro, 90100, Palermo, Italy.

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