This decade saw the introduction of
fast-track programs — streamlined perioperative practices
— in many areas of specialty surgery. Members of the European orthopaedic
community told Orthopaedics Today Europe that Henrik Kehlet, MD,
who has worked with the Danish government to implement accelerated surgical
tracks in various specialties, is considered the “father” of
Testament to Kehlet’s influence on the steady
adoption of this innovative approach in orthopaedics is the growing body of
documented clinical and economic advantages of fast-track total joint
arthroplasty (TJA) protocols, which typically incorporate in-depth patient
education and a rapid resumption of activities of daily living. Due to his
work, Denmark has become one of the leaders in TJA rapid rehabilitation, with
several centers now following these protocols. Yet, some surgeons said that
centers in other countries still have not adopted them, mostly due to
differences in culture,
Klaus-Peter Günther, MD, of Dresden, Germany, said
in his experience he has seen higher than anticipated start-up costs associated
with writing the new protocols, training the staff to use them and related
activities, which he said are typically not mentioned in the cost-benefit
Furthermore, “Not all patients want fast-track
surgery,” Günther, an Orthopaedics Today Europe
Editorial Board member, said, noting it is not for everyone. Only up to 60% of
patients at Günther’s large referral center meet fast-track inclusion
criteria. Also, long-term data are needed for this approach. “Surgeons are
expecting the same long-term outcomes, but no one knows yet whether they will
be the same.”
Henrik Husted, MD, and a nurse colleague
developed the initial fast-track joint arthroplasty program used at Hvidovre
Hospital in Denmark, as a safe and proven multidisciplinary approach to these
Image: Susanne Østergaard,
Danish TJA surgeon Henrik Husted, MD, whose patients all
undergo rapid rehabilitation, said it has positively impacted their level of
satisfaction and length of stay (LOS) following total hip arthroplasty (THA) or
total knee arthroplasty (TKA). In fact, based on the literature, patients in
Europe, North America and elsewhere may be permitted to be discharged within 24
to 72 hours because they underwent fast-track surgery.
“It is an optimization of both logistical and
clinical features,” Husted said. “Of course, we have been focusing
intensely on pain treatment and
In 2003, when THA and TKA LOS was averaging 13.3 days at
Hvidovre Hospital in Copenhagen, Husted and a nurse developed a fast-track
rehabilitation system which led to an average LOS of 1.5 days at the
institution. The system Husted introduced has since expanded to include
physiotherapists, anesthesiologists and members of other disciplines on the
fast-track team and incorporates features of a commercially available Rapid
Recovery program (Biomet), he said.
The THA rapid recovery program used since 2000 at
Reinier de Graaf Hospital in the Netherlands has achieved equally dramatic
results, with LOS steadily decreasing. Its early results published in
Injury showed 92% of patients were discharged by the fifth
postoperative day with discharges for those with wound problems or suspected
superficial infections slightly delayed.
In June the hospital-wide LOS was 4.8 days, with shorter
stays in the orthopaedic department. This was attributed to changed pain
control techniques and operational improvements.
“Rapid recovery is more a philosophy than an actual
rigid program. It is a continued willingness to improve care around the
orthopaedic patient,” said Peter Pilot, PhD, senior scientist in the
orthopaedic department at the hospital.
For rapid recovery to work, “the borders between
orthopaedics and anesthetics should disappear,” he said. “From day
one we tried to walk this path together with our anesthetic colleagues. This is
really essential,” Pilot said.
In 2006 Reinier de Graaf Hospital officials met with
Kehlet and other experts about changes they might implement to increase quality
of care and take orthopaedic rapid recovery to the next level. As a result, 2
years ago the six orthopaedic surgeons at the hospital’s Delft location
implemented a new pain protocol supported by the anesthesiologists, Pilot told
Orthopaedics Today Europe.
“The major gain of the program is the huge
reduction in postoperative nausea and vomiting, which were reduced by
two-thirds,” he said. This and other aspects of the protocol help reduce
surgical stress, allowing patients to safely and more quickly resume normal
Now, 10 years after they started their program, he and
others at Reinier de Graaf Hospital are focused on better mobilizing patients
the day of surgery. Despite the challenges that are posed with patients
operated on late in the day needing to be mobilized at night when physical
therapists do not typically work, Pilot indicated that with time and
cooperation the changes will be implemented.
Focusing on the patient
A modified, more-extensive patient education experience
has been essential to all these programs, especially those that address and
positively impact THA and TKA candidates’ expectations.
In a classroom setting, patients at Husted’s
hospital get important information from doctors, nurses and anesthesiologists,
including what is expected of them during recovery, and a timeline for the
recovery. They also meet a patient who underwent surgery on the previous day.
According to Husted, patients should be motivated to
participate in their recovery. Following their being educated on the fast-track
system, “they really want to do this and they understand why we want to do
In addition to providing similar preoperative education,
Ajay Malviya, MD, and other orthopaedists at Northumbria Healthcare NHS
Foundation Trust in Newcastle-upon-Tyne, England, as well as the nurses and
health care staff repeatedly emphasize fast-track principles in discussions
with patients, saying they can go home in 2 or 3 days depending on how they are
“The same message is passed on by various team
members so [patients] believe that, yes, it is possible. I think the first
thing for them to believe is it is possible,” said Malviya, who reported
positive early clinical results and cost effectiveness with a fast-track
protocol at the 2010 Annual Meeting of the American Academy of Orthopaedic
At hospitals where fast-track protocols have been
adopted, the majority, if not all, of the patients undergoing THA and TKA
benefit from these new procedures. Husted and colleagues apply their protocol
across the board, and are now also studying results in patients who discontinue
deep venous thrombosis (DVT) prophylaxes at discharge because the early
mobilization may be an effective antithrombotic method. They expect to
elucidate outcome differences in those who receive DVT therapy for the
mandatory amount of time in Denmark — 10 postoperative days with TKA, 35
days minimum for THA — and those under the fast-track system.
Husted explained that because every patient in his joint
arthroplasty ward stands to benefit from the protocol, it is used in bilateral
and revision cases as well, eliminating the time and cost of selecting the
“best” patients, special anesthesia or pain medications on a per-case
“This gives the patient the best treatment
available, and also optimizes the logistics … It is our philosophy that
every patient would benefit. We call it fast-track, but it should actually be
called ‘best-track’ or ‘right-track’ because it is what we
do. It is giving the patient the best available documented treatment, including
mobilization, pain treatment, care and so forth,” he said.
According to Malviya, “Any surgery with accelerated
rehabilitation that leads to early discharge and improves the patient
experience is a fast-track surgery.”
recovery is more a philosophy than an actual rigid program. It is a continued
willingness to improve care around the orthopaedic patient. ”
— Peter Pilot, PhD
To meet those endpoints, he uses a modified anesthesia
protocol involving local spinal anesthetic supplemented with light general
anesthesia obviating the need for intrathecal opioids which may be associated
with postoperative nausea and vomiting and grogginess, both of which can
inhibit same-day mobilization.
Pain management for THA and TKA cases improved at
Malviya’s center once he and his colleagues started infiltrating layers of
wound, from the capsule to the subcutaneous layer, with 100 mL levobupivacaine,
0.125% concentration. Subsequently, as a later supplement they leave an
epidural catheter in the joint for introducing boluses of gabapentin or
OxyContin (oxycodone; Purdue Pharma), sometimes followed by tramadol. Patients
having morning surgery receive a dose of gabapentin the previous night.
“The advantage of all these is they are not strong
opioids so they avoid the effect of the opioid, like the sedative effect,”
Malviya said. “That will help us get the patients up the same day after
This accelerated rehabilitation protocol is for all
comers, including those not expected to rehabilitate quickly. “It has a
definite beneficial effect even in the relatively ill patients because it takes
away the anesthesia stress of the operation, so it helps them. We have shown
actually that even the outliers — the patients who stayed beyond 15 days
before we introduced the protocol — are significantly reduced,” said
Malviya, whose hospital started using the protocol once physicians, nurses,
physiotherapists, occupational therapists and others observed it in use at
Golden Jubilee National Hospital in Clydebank, Scotland.
The bottom line
From an administrative standpoint, the rapid
rehabilitation programs used at Hvidovre Hospital met economic and patient care
goals, according to Vice Director Torben Mogensen, MD. Seeing the improved
physical status of patients and their earlier discharge after colonic surgery
was the impetus for adopting these practices in orthopaedics, he said.
“We have seen a low complication rate and high
patient satisfaction with the treatments,” which was evident right after
implementing rapid recovery in THA and TKA, Mogensen said.
Reducing the surgical waiting list was yet another
reason to adopt fast-track orthopaedic protocols since Danish law made public
hospitals pay to send patients to private hospitals if they could not treat
them within 1 month. The waiting list, which was 6 months long in 2003 when the
program began, no longer exists. “Now we don’t send any patients to
the private hospital,” according to Mogensen.
The short 2- to 3-day surgical stays sometimes mean
empty beds on the arthroplasty ward come Friday or Saturday, but foot and ankle
surgery patients may use them. To resolve that issue in the orthopaedic and
gastric surgery wards, he said more major procedures are performed Monday to
Wednesday. Straightforward ones are done Thursday or Friday so that the beds
are closed down Friday evening or Saturday morning.
Recently the Hvidovre Hospital emergency department
staff started delving into fast-track practices so that a 21-day LOS for hip
fracture patients is down to 9 to 11 days. “With fragile patients who have
many comorbidities, I think it was important to use it in the emergency
department,” Mogensen said, noting that reducing morbidity and mortality
Luigi Zagra, MD, in the Hip Department at Istituto
Ortopedico Galeazzi in Milan, Italy, is in favor of using accelerated
rehabilitation, but explained to Orthopaedics Today Europe that
the obstacles to adopting them in his region are great.
He said patients from throughout Italy who are referred
to his department in the northern part of the country for treatment cannot be
quickly discharged to home if they require medically supervised postoperative
rehabilitation. Therefore, they would not be fast-track candidates. For local
patients, two factors impact the speed of rehabilitation.
“It depends on the patient and, here, it depends a
lot on the family organization,” said Zagra, an Orthopaedics Today
Europe Editorial Board member, whose patients are discharged to home
within 5 or 6 days of surgery — excluding older patients, who may stay in
the orthopaedic or rehabilitation department up to 3 weeks.
But Zagra’s patients often feel they need to stay
longer. “In Italy, there is sort of an environment that favors having
rehabilitative care at the hospital or going home and having someone come and
help you,” he said.
Many countries’ reimbursement systems are
unfavorable for fast-track surgery. In others the government has to make key
changes to implement it, Pilot said. He urged those considering implementing
rapid recovery protocols to visit one of the Biomet Rapid Recovery board’s
orthopaedic surgeons and their anesthesiologists. Pilot, Husted, Kehlet and
other board members agree that “seeing is believing” when it comes to
rapid recovery. – by Susan M. Rapp
- Husted H, Holm G, Jacobsen S. Predictors of length of stay and
patient satisfaction after hip and knee replacement surgery: fast-track
experience in 712 patients. Acta Orthop 2008;79:168-173.
- Kehlet H, Søballe K. Fast-track hip and knee replacement
— what are the issues? Acta Orthop. 2010;81(3):271-272.
- Malviya A, Reed MR. Fast track protocol leads to reduction in
mortality and morbidity following joint replacement. Paper #631. Presented at
the 2010 Annual American Academy of Orthopaedic Surgeons Meeting. March 9-13,
2010. New Orleans, U.S.A.
- Pilot P, Bogie R. Draijer WF, et al. Experience in the first four
years of rapid recovery; is it safe? Injury. 2006; 37 Suppl
- Klaus-Peter Günther, MD, can be reached at University
Carl-Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany;
- Henrik Husted, MD, and Torben Mogensen, MD, are at Hvidovre
University Hospital, 2650 Hvidovre, Denmark. Husted can be reached at
+45-3632-6297; e-mail: email@example.com.
Mogensen can be reached at +45-3632-2504; e-mail:
Husted is a member of the Biomet Rapid Recovery board.
- Ajay Malviya, MD, can be reached at Northumbria Healthcare NHS
Foundation Trust, 81 Daylesford Drive, Newcastle upon Tyne, NE3 1TW, United
Kingdom; +44-191-285-9890; e-mail: firstname.lastname@example.org.
- Peter Pilot, PhD, can be reached in the Department of Orthopaedics
at Reinier de Graaf Hospital, Delft, the Netherlands; +31-15-2603257; e-mail:
P.Pilot@rdgg.nl. His institution received
support from Biomet, Zimmer, AstraZeneca and Astratech.
- Luigi Zagra, MD, can be reached at Istituto Ortopedico Galeazzi
IRCCS, Milan, Italy; +39-3498838269; e-mail:
What factors have impacted your decision for or against adopting
fast-track TJA protocols?
Today, TJA is a standardized procedure performed the same way in every
part of the world. On the contrary, however, postoperative regimens now vary
according to the local situation.
My personal experience with the so-called “fast-track”
procedure was limited to a small number of patients, after which I decided to
abandon it. The main reason was that patients after a course of
“fast-track” rehabilitation did not do better than patients who
followed a traditional postoperative regimen of rehabilitation. Some had
slightly earlier weight-bearing but, on the whole, this was offset by the
difficulty of organizing the rehabilitation in the first place and the fact
that the final result was identical.
Other reasons associated with our discontinuation of fast-track
procedures were that our patients prefer to remain in the hospital in the
postoperative period because they feel more protected and happier. I am much
more comfortable knowing I can follow the patients’ progress every day
while they are in the hospital, possibly correcting any little problems they
have as they develop.
Finally, from a medicolegal point of view, it is quite dangerous in my
country to dismiss a patient on the same day of the operation or even 2 or 3
days afterwards because if something happens, especially in older patients,
such as a serious complication, we would be immediately sent to the court to
deal with it legally.
Roberto Binazzi, MD, is the Chairman of the
Department of Orthopaedics and Hip Surgery, University of Bologna, Italy.
Need to reduce wait lists
The Swedish government has implemented a national maximum waiting-time
guarantee of 3 months from the time the patient is put on the waiting list for
surgery until the operation is performed. This has led us to improve
accessibility and put the patient’s needs and wishes first. We perform a
vast majority of our joint arthroplasties in a smaller specialized elective
surgery hospital outside of the university, but in direct cooperation with the
university hospital. This has helped us to streamline the joint arthroplasty
process and, notably, to shorten the waiting list. Furthermore, it seems that
all the personnel involved in this process are working with growing enthusiasm
and pride in the positive results.
I think we must consider how we spend the often limited health care
budget in order to make it as efficient and as cost-effective as possible. We
must, however, never forget that our primary goal is to provide our patients
with the best possible care and highest quality results. I believe a fast-track
joint arthroplasty protocol can serve all these purposes. We have shown that
with the patients better prepared before an operation and with a more focused
and efficient pre- and postoperative care protocol, they become better
mobilized and can get home earlier, in better condition and hopefully with less
risk of complications. This can be done without ever endangering the quality
and longevity of the joint arthroplasty.
Not only does an effective fast-track joint arthroplasty protocol cut
the direct hospital treatment costs, but socio-economic gains are probably
considerably larger by indirect earnings from patients’ earlier re-entry
into a normal healthy life situation.
Gunnar Flivik, MD, PhD, is in the Department of
Orthopedics, Skane University Hospital, Lund University, Sweden.