The aim of this study was to evaluate the impact of fast-track procedures (FTPs) on length of hospital stay after primary total knee arthroplasty (TKA) in a prospective, national, multicentric analysis. The innovative point was that no patient selection was used. The hypothesis was that FTPs reduce hospital stay after primary TKA for non-traumatic conditions compared with the national database.
An observational prospective study was conducted in ten centres throughout France. A total of 839 patients included in FTPs were followed up for three months. The average LOS, direct return home rate, unscheduled re-admission rate, and re-intervention rate were compared with those in the national database (93,329 TKAs). Knee society and Oxford score were collected.
The mean LOS was 4.4 ± 3.3 days, while the national base LOS was 6.4 ± 3.1 days (p < 0.001). A total of 560 patients (66.7%) were able to return home, compared with 47,617 (49.6%) in the national database (p < 0.001). Thirty-five patients (4.2%) were re-admitted within 90 days of the intervention, compared with 10,399 (10.8%) in the national database (p < 0.001). Seventeen patients (2.0%) were re-operated upon within 90 days after the TKA, compared with 529 (0.5%) in the national database (p < 0.05).
The FTPs used by unselected patients allowed a significant decrease in the mean LOS and in the rate of re-admission and a significant increase of the rate of direct home return after primary TKA compared with the national database. The significant increase in the re-operation rate warrants further investigation. However, FTP should become the standard of care after this intervention.
This is a preview of subscription content, log in to check access.
Buy single article
Instant access to the full article PDF.
Price includes VAT for USA
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
This is the net price. Taxes to be calculated in checkout.
Berger RA, Sanders SA, Thill ES, Sporer SM, Della VC (2009) Newer anesthesia and rehabilitation protocols enable outpatient hip replacement in selected patients. Clin Orthop Relat Res 467:1424–1430. https://doi.org/10.1007/s11999-009-0741-x
Husted H, Holm G (2006) Fast track in total hip and knee arthroplasty--experiences from Hvidovre University Hospital, Denmark. Injury 37(Suppl 5):S31–S35
Husted H, Jensen CM, Solgaard S, Kehlet H (2012) Reduced length of stay following hip and knee arthroplasty in Denmark 2000-2009: from research to implementation. Arch Orthop Trauma Surg 132:101–104. https://doi.org/10.1007/s00402-011-1396-0
Jørgensen CC, Kehlet H (2013) Role of patient characteristics for fast-track hip and knee arthroplasty. Br J Anaesthesia 110:972–980. https://doi.org/10.1093/bja/aes505
Jansson MM, Harjumaa M, Puhto AP, Pikkarainen M (2019) Healthcare professionals’ perceived problems in fast-track hip and knee arthroplasty: results of a qualitative interview survey. J Orthop Surg Res 14:294. https://doi.org/10.1186/s13018-019-1334-3
Memtsoudis SG, Fiasconaro M, Soffin EM, Liu J, Wilson LA, Poeran J, Bekeris J, Kehlet H (2020) Enhanced recovery after surgery components and perioperative outcomes: a nationwide observational study. Br J Anaesth 124:638–647. https://doi.org/10.1016/j.bja.2020.01.017
Beverly A, Kaye AD, Ljungqvist O, Urman RD (2017) Essential elements of multimodal analgesia in enhanced recovery after surgery (ERAS) guidelines. Anesthesiol Clin 35:e115–e143. https://doi.org/10.1016/j.anclin.2017.01.018
Golladay GJ, Balch KR, Dalury DF, Satpathy J, Jiranek WA (2017) Oral multimodal analgesia for total joint arthroplasty. J Arthroplast 32:S69–S73. https://doi.org/10.1016/j.arth.2017.05.002
De Oliveira GS Jr, Almeida MD, Benzon HT, McCarthy RJ (2011) Perioperative single dose systemic dexamethasone for postoperative pain: a meta-analysis of randomized controlled trials. Anesthesiology 11:575–588. https://doi.org/10.1097/ALN.0b013e31822a24c2
Antoni M, Jenny JY, Noll E (2014) Postoperative pain control by intra-articular local anesthesia versus femoral nerve block following total knee arthroplasty: impact on discharge. Orthop Traumatol Surg Res 100:313–316. https://doi.org/10.1016/j.otsr.2013.12.022
Kuang MJ, Ma JX, Fu L, He WW, Zhao J, Ma XL (2017) Is adductor canal block better than femoral nerve block in primary total knee arthroplasty? A GRADE analysis of the evidence through a systematic review and meta-analysis. J Arthroplast 32:3238–3248.e3. https://doi.org/10.1016/j.arth.2017.05.015
Guerra ML, Singh PJ, Taylor NF (2015) Early mobilization of patients who have had a hip or knee joint replacement reduces length of stay in hospital: a systematic review. Clin Rehabil 29:844–854. https://doi.org/10.1177/0269215514558641
Dripps RD, Lamont A, Eckenhoff JE (1961) The role of anesthesia in surgical mortality. JAMA 178:261–266
Insall JN, Dorr LD, Scott RD, Scott WN (1989) Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res 248:13–14
Jenny JY, Diesinger Y (2011) Validation of a French version of the Oxford knee questionnaire. Orthop Traumatol Surg Res 97:267–271. https://doi.org/10.1016/j.otsr.2010.07.009
Agence technique de l’information sur l’hospitalisation (ATIH): Base nationale PMSI-MCO, Paris, 2017
Fransen BL, Hoozemans MJM, Argelo KDS, Keijser LCM, Burger BJ (2018) Fast-track total knee arthroplasty improved clinical and functional outcome in the first 7 days after surgery: a randomized controlled pilot study with 5-year follow-up. Arch Orthop Trauma Surg 138:1305–1316. https://doi.org/10.1007/s00402-018-3001-2
Venclauskas L, Llau JV, Jenny JY, Kjaersgaard-Andersen P, Jans Ø, ESA VTE Guidelines Task Force (2018) European guidelines on perioperative venous thromboembolism prophylaxis: day surgery and fast-track surgery. Eur J Anaesthesiol 35:134–138. https://doi.org/10.1097/EJA.0000000000000706
Andersen LØ, Kehlet H (2014) Analgesic efficacy of local infiltration analgesia in hip and knee arthroplasty: a systematic review. Br J Anaesth 113:360–374. https://doi.org/10.1093/bja/aeu155
Søreide E, Ljungqvist O (2006) Modern preoperative fasting guidelines: a summary of the present recommendations and remaining questions. Best Pract Res Clin Anaesthesiol 20:483–491
Brandal D, Keller MS, Lee C, Grogan T, Fujimoto Y, Gricourt Y, Yamada T, Rahman S, Hofer I, Kazanjian K, Sack J, Mahajan A, Lin A, Cannesson M (2017) Impact of enhanced recovery after surgery and opioid-free anesthesia on opioid prescriptions at discharge from the hospital: a historical-prospective study. Anesth Analg 125:1784–1792. https://doi.org/10.1213/ANE.0000000000002510
Lunn TH, Kristensen BB, Andersen LØ, Husted H, Otte KS, Gaarn-Larsen L, Kehlet H (2011) Effect of high-dose preoperative methylprednisolone on pain and recovery after total knee arthroplasty: a randomized, placebo-controlled trial. Br J Anaesth 106:230–238. https://doi.org/10.1093/bja/aes345
Gholson JJ, Pugely AJ, Bedard NA, Duchman KR, Anthony CA, Callaghan JJ (2016) Can we predict discharge status after total joint arthroplasty? A calculator to predict home discharge. J Arthroplast 31:2705–2709. https://doi.org/10.1016/j.arth.2016.08.010
Keswani A, Tasi MC, Fields A, Lovy AJ, Moucha CS, Bozic KJ (2016) Discharge destination after total joint arthroplasty: an analysis of postdischarge outcomes, placement risk factors, and recent trends. J Arthroplast 31:1155–1162. https://doi.org/10.1016/j.arth.2016.02.053
Fu MC, Samuel AM, Sculco PK, MacLean CH, Padgett DE, McLawhorn AS (2017) Discharge to inpatient facilities after total hip arthroplasty is associated with increased postdischarge morbidity. J Arthroplast 32:S144–S149.e1. https://doi.org/10.1016/j.arth.2017.03.044
Klapwijk LC, Mathijssen NM, Van Egmond JC, Verbeek BM, Vehmeijer SB (2017) The first 6 weeks of recovery after primary total hip arthroplasty with fast track. Acta Orthop 88:140–144. https://doi.org/10.1080/17453674.2016.1274865
Berg U, W-Dahl A, Rolfson O, Nauclér E, Sundberg M, Nilsdotter A (2020) Influence of fast-track programs on patient-reported outcomes in total hip and knee replacement (THR/TKR) at Swedish hospitals 2011–2015: an observational study including 51,169 THR and 8,393 TKR operations. Acta Orthopaedica 91
Berg U, Bülow E, Sundberg M, Rolfson O (2018) No increase in readmissions or adverse events after implementation of fast-track program in total hip and knee replacement at 8 Swedish hospitals: an observational before-and-after study of 14,148 total joint replacements 2011-2015. Acta Orthop 89:522–527. https://doi.org/10.1080/17453674.2018.1492507
Sutton JC 3rd, Antoniou J, Epure LM, Huk OL, Zukor DJ, Bergeron SG (2016) Hospital discharge within 2 days following total hip or knee arthroplasty does not increase major-complication and readmission rates. J Bone Joint Surg Am 98:1419–1428. https://doi.org/10.2106/JBJS.15.01109
Zhu S, Qian W, Jiang C, Ye C, Chen X (2017) Enhanced recovery after surgery for hip and knee arthroplasty: a systematic review and meta-analysis. Postgrad Med J 93:736–742. https://doi.org/10.1136/postgradmedj-2017-134991
Khan SK, Malviya A, Muller SD, Carluke I, Partington PF, Emmerson KP, Reed MR (2014) Reduced short-term complications and mortality following enhanced recovery primary hip and knee arthroplasty: results from 6,000 consecutive procedures. Acta Orthop 85:26–31. https://doi.org/10.3109/17453674.2013.874925
Andreasen SE, Holm HB, Jørgensen M, Gromov K, Kjærsgaard-Andersen P, Husted H (2017) Time-driven activity-based cost of fast-track total hip and knee arthroplasty. J Arthroplast 32:1747–1755. https://doi.org/10.1016/j.arth.2016.12.040
Stowers MD, Manuopangai L, Hill AG, Gray JR, Coleman B, Munro JT (2016) Enhanced recovery after surgery in elective hip and knee arthroplasty reduces length of hospital stay. ANZ J Surg 86:475–479. https://doi.org/10.1111/ans.13538
Weiser MC, Kim KY, Anoushiravani AA, Iorio R, Davidovitch RI (2018) Outpatient total hip arthroplasty has minimal short-term complications with the use of institutional protocols. J Arthroplast 33:3502–3507. https://doi.org/10.1016/j.arth.2018.07.015
Deng QF, Gu HY, Peng WY, Zhang Q, Huang ZD, Zhang C, Yu YX (2018) Impact of enhanced recovery after surgery on postoperative recovery after joint arthroplasty: results from a systematic review and meta-analysis. Postgrad Med J 94:678–693. https://doi.org/10.1136/postgradmedj-2018-136166
Shah A, Memon M, Kay J, Wood TJ, Tushinski DM, Khanna V, McMaster Arthroplasty Collective (MAC) group (2019) Preoperative patients factors affecting length of stay following total knee arthroplasty : a systematic review and meta-analysis. J Arthroplast 34:2124–2165.e1. https://doi.org/10.1016/j.arth.2019.04.048
The authors thank the other colleagues who participated in the data collection: Nicolas BONIN, Marc-Pierre HENRY, and Philippe TRACOL. The authors also thank Estelle VOYOT for extracting the data from the ATIH database.
Conflict of interest
JYJ: Royalties from B-Braun, paid consultant for FH Orthopedics, member of board of CAOS-International and ISTA
CC: Nothing to disclose
PB: Paid consultant for Smith-and-Nephew and Zimmer
JC: Paid consultant for DePuy
PH: Nothing to disclose
CS: Paid consultant for FH Orthopedics
ADL: Paid consultant for Microport Orthopedics, member of board of SFHG
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Level of evidence: II (prospective comparative cohort study)
About this article
Cite this article
Jenny, J., Courtin, C., Boisrenoult, P. et al. Fast-track procedures after primary total knee arthroplasty reduce hospital stay by unselected patients: a prospective national multi-centre study. International Orthopaedics (SICOT) (2020). https://doi.org/10.1007/s00264-020-04680-0
- Total knee arthroplasty
- Fast-track procedure