Fast-track procedures after primary total knee arthroplasty reduce hospital stay by unselected patients: a prospective national multi-centre study



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.


  1. 1.

    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.

    Article  PubMed  PubMed Central  Google Scholar 

  2. 2.

    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

    Article  Google Scholar 

  3. 3.

    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.

    Article  PubMed  Google Scholar 

  4. 4.


  5. 5.

    Jørgensen CC, Kehlet H (2013) Role of patient characteristics for fast-track hip and knee arthroplasty. Br J Anaesthesia 110:972–980.

    Article  Google Scholar 

  6. 6.

    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.

    Article  PubMed  PubMed Central  Google Scholar 

  7. 7.

    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.

    CAS  Article  PubMed  Google Scholar 

  8. 8.

    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.

    Article  PubMed  Google Scholar 

  9. 9.

    Golladay GJ, Balch KR, Dalury DF, Satpathy J, Jiranek WA (2017) Oral multimodal analgesia for total joint arthroplasty. J Arthroplast 32:S69–S73.

    Article  Google Scholar 

  10. 10.

    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.

    CAS  Article  Google Scholar 

  11. 11.

    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.

    CAS  Article  PubMed  Google Scholar 

  12. 12.

    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.

    Article  Google Scholar 

  13. 13.

    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.

    Article  PubMed  Google Scholar 

  14. 14.

    Dripps RD, Lamont A, Eckenhoff JE (1961) The role of anesthesia in surgical mortality. JAMA 178:261–266

    CAS  Article  Google Scholar 

  15. 15.

    Insall JN, Dorr LD, Scott RD, Scott WN (1989) Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res 248:13–14

    Google Scholar 

  16. 16.

    Jenny JY, Diesinger Y (2011) Validation of a French version of the Oxford knee questionnaire. Orthop Traumatol Surg Res 97:267–271.

    Article  PubMed  Google Scholar 

  17. 17.

    Agence technique de l’information sur l’hospitalisation (ATIH): Base nationale PMSI-MCO, Paris, 2017

  18. 18.

    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.

    Article  PubMed  PubMed Central  Google Scholar 

  19. 19.

    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.

    Article  PubMed  Google Scholar 

  20. 20.

    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.

    CAS  Article  PubMed  Google Scholar 

  21. 21.

    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

    Article  Google Scholar 

  22. 22.

    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.

    Article  PubMed  Google Scholar 

  23. 23.

    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.

    CAS  Article  PubMed  Google Scholar 

  24. 24.

    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.

    Article  Google Scholar 

  25. 25.

    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.

    Article  Google Scholar 

  26. 26.

    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.

    Article  Google Scholar 

  27. 27.

    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.

    Article  PubMed  PubMed Central  Google Scholar 

  28. 28.

    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

  29. 29.

    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.

    Article  PubMed  PubMed Central  Google Scholar 

  30. 30.

    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.

    Article  PubMed  Google Scholar 

  31. 31.

    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.

    Article  PubMed  PubMed Central  Google Scholar 

  32. 32.

    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.

    Article  PubMed  PubMed Central  Google Scholar 

  33. 33.

    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.

    Article  Google Scholar 

  34. 34.

    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.

    Article  PubMed  Google Scholar 

  35. 35.

    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.

    Article  Google Scholar 

  36. 36.

    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.

    Article  PubMed  Google Scholar 

  37. 37.

    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.

    Article  Google Scholar 

Download references


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.

Author information





JYJ designed the study, monitored data collection, performed data analysis, drafted the manuscript, and wrote the final manuscript. CC performed literature analysis. ADL designed the study and monitored data collection. All authors performed data collection in their own center. All authors reviewed the drafted manuscript. All authors read and accepted the final manuscript.

Corresponding author

Correspondence to Jean-Yves Jenny.

Ethics declarations

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

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Level of evidence: II (prospective comparative cohort study)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

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).

Download citation


  • Total knee arthroplasty
  • Fast-track procedure