The concept of fast-track or rapid recovery
surgery has evolved during the past 2 decades and has recently been applied and
developed in total hip and knee arthroplasty settings with evidence-based
support of its benefits; however, the widespread implementation of this
approach in major joint arthroplasty settings has not occurred.
Fast-track surgery is a package of care management that aims to
reduce morbidity to deliver a pain and risk free procedure that significantly
reduces the number of days a patient is in the hospital, said Henrik
Kehlet, MD, PhD, of Rigshospitalet Copenhagen University, Denmark, who has been
called the pioneer of fast-track surgery.
Peter Pilot, PhD, of Reinier de Graaf Hospital in the Netherlands,
defined the rapid recovery multi-modal approach as, the use of a critical
care pathway, combining perioperative pain management with a shift from general
to local anaesthesia and opioid sparing, besides careful fluid management and a
restrictive transfusion policy. [This] is the best option for most
Speakers at a rapid recovery symposium held in Barcelona late last year
addressed key practical issues, such as early mobilization, surgical
traditions, pharmacologic interventions and program implementation.
Henrik Husted, MD, of Hvidovre University Hospital in Denmark, presented
data from his center. Since 2003, all total hip arthroplasty (THA) and total
knee arthroplasty (TKA) patients there have been fast-tracked. Patients are
mobilized within 2 hours after surgery and deep venous thrombosis (DVT)
prophylaxis is initiated 6 hours after surgery and discontinued upon discharge.
Data from a series of 1,977 operations performed from 2004 to 2008
showed three deaths possibly related to clotting episodes. Results from the
last 2 years showed that the risk of pulmonary embolism was 0.30% after TKA and
0% after THA.
We found a low risk of clinically symptomatic VTE [venous
thromboembolism] and deaths potentially related to the operation. Early
mobilization may play an important role in the reduction of VTE and our study
appears to confirm this, Husted said. He added that recommendations to
provide extended thromboprophylaxis following discharge should be considered in
context of the time of first mobilization.
A discussion following a presentation by Husted addressed several
traditional THA and TKA techniques and their influence on outcome in relation
to infection, the need for blood transfusion, length of stay, pain and DVT.
The faculty concluded the following traditions were unsupported by
evidence of beneficial outcome: hair removal, plastic drapes, pre-emptive
analgesia, tourniquets (except for better visibility during surgery), drains,
continuous passive motion, urinary catheters, bed rest and compression
Pilot added, There is insufficient evidence from randomized trials
to support the routine use of closed suction drainage in orthopaedic
surgery, noting that drains do not reduce joint effusion or have any
effect on wound healing although they do reduce hematoma formation.
Readmission rates, complications
To address concerns as to whether fast-track surgery and reduced length
of stay leads to an increase in readmissions, Husted presented data from his
unit based on a series of fast-track THA and TKA with varying lengths of stay.
As average length of stay has decreased from 6 to 3 days over the past 6 years,
he reported no increase in readmissions and complications.
Specifically, dislocation following THA does not increase
on the contrary and neither does manipulation after TKA, he
Trauma and Orthopaedics Consultant, Mike Reed, MBBS, MD, FRCS, FRCS(Tr
& Orth), from Wansbeck General Hospital in Northumberland, U.K., also
presented data that showed fast-track joint replacement surgery reduces early
complications. Based on an evaluation of 5,000 consecutive unselected total hip
and knee patients, Reed explained that the 2,060 patients who underwent a rapid
recovery protocol experienced an average reduced length of stay of 4.7 days
compared to an average 8.5 days for patients who underwent a traditional
Moreover, he reported a significant reduction in death rate amongst the
fast-track group (0.5% vs. 0.14%) and blood transfusion requirement was reduced
from 22.8% to 9.8%. Gastrointestinal bleeding was also significantly reduced
from 0.6% to 0.2%. There was a trend towards a decreased rate of 30-day
myocardial infarction, stroke and 60-day DVT.
David Houlihan-Burne, BSc(Hons), MBBS(Hons), MRCS, FRCS(Orth), of
Hillingdon Hospital in London, presented his take on the role of the quality
road map to help implement rapid recovery programs.
Breaking down traditional barriers for implementation, including
the ability to work closely with management and interdepartmental relationships
between anaesthetists and surgeons is paramount to the successful launch and
perseverance of these programs, Houlihan-Burne said, and advised those
wishing to implement a rapid recovery program to approach it with small,
stepwise changes in mind.
If you need to change something big, you need to change small
things first and systematically. Set out with a clear aim, implement change
strategies and then keep measuring what you are doing to be clear on the
improvements any changes are bringing, he added.
- Kehlet H, Wilmore DW. Evidence-based surgical care and the
evolution of fast-track surgery. Ann Surg. 2008; 248:189-198.
- Rapid Recovery Symposium 2010. November 4-5, 2010. Barcelona.
- David Houlihan-Burne, BSc(Hons), MBBS(Hons), MRCS, FRCS(Orth), can
be reached at Hillingdon Hospital, London, U.K.; +44 1895 279190; e-mail:
- Henrik Husted, MD, can be reached at Hvidovre University Hospital,
2650 Hvidovre, Denmark; +45-3632-6297; e-mail:
- Henrik Kehlet, MD, PhD, can be reached at Rigshospitalet Copenhagen
- Peter Pilot, PhD, can be reached in the Department of Orthopaedics
at Reinier de Graaf Hospital, Delft, the Netherlands; +31-15-2603257; e-mail:
- Mike Reed, MBBS, MD, FRCS, FRCS(Tr & Orth), can be reached at
Wansbeck General Hospital, Northumberland, U.K.; +44 1670 529191; e-mail:
- Disclosures: All symposium speakers have received funding
for their presentations. Houlihan-Burne, Husted, Kehlet and Pilot are members
of the Biomet Rapid Recovery advisory board and have received benefits for
personal or professional use. The Rapid Recovery Symposium 2010 was funded by