Fast-track hip and knee replacement — what are the issues?

Surgical injury is followed by pain, stress-induced catabolism, impairment of organ function, and a risk of thromboembolism and impaired cognitive function. These events may contribute to complications, a need for prolonged hospitalization, postoperative fatigue, delayed convalescence, and the need for rehabilitation. Optimization of the individual care components in perioperative care (the fast-track methodology) reduces the need for hospitalization, morbidity, and prolonged convalescence, with subsequent economic savings (Kehlet and Wilmore 2008). Correspondingly, improvement in perioperative care has led to a reduced stay in hospital after total hip arthroplasty (THA) and total knee arthroplasty (TKA), which is now only about 3 days in many centers.

The main question that remains to be answered is whether further improvement can be made and whether these operations can be performed on an ambulatory or semi-ambulatory basis without any increased risk of morbidity or cardiopulmonary and thromboembolic complications, long-term cognitive dysfunction, pain, and need for rehabilitation. Thus, a multidisciplinary collaboration has been established in 5 dedicated public Danish hospitals with established fast-track THA and TKA in order to optimize perioperative care to require only 1–2 days of hospitalization with no increase in post-discharge pain, morbidity, and rehabilitation requirements (Figure). To this end, we concentrated on perioperative pain management, optimization of transfusion strategies, strategies for postoperative rehabilitation, requirements for postoperative thromboembolic prophylaxis, and safety aspects (re-admissions, hip dislocation, and knee stiffness).