2.2. Preoperative patient education

post-operative recovery [1, 2]. FT refers to a standardized, evidence-base and multimodal strategy to surgery [3]. It aims at early recovery, early discharge with better prognosis and less complications. Outpatient surgical pathways even go one step further and aim for same day of

This concept was pioneered by Professor Henrik Kehlet in the early 1990s and firstly applied in the colorectal surgery [4]. It is then expanded to many surgical fields, e.g., gynecologic, urologic, cardiovascular or orthopedic surgery. Over the past decades, it has been proven an effective and beneficial program for not only patients but also surgeons as well as the health insurance system. As increasing elderly population and increasing incidence of osteoarthritis, the growth of requirement of knee arthroplasty is to be expected [5]. However, the difficulty in economic health care along with increasing financial pressure has reinforced the necessity of putting FT into the focus. An increasing number of knee surgeons have already introduced fast track surgery for patients undergoing knee arthroplasty. It is carried out by the fast track team which composed of anesthetists, surgeons, pain specialist, physiotherapists, and nurses [6].The main strategy consists of five strands: careful patient selection, improving preoperative care, minimizing perioperative stress, decreasing postoperative discomfort, and improving postoperative recovery, thus leading to potentially lower mortality and morbidity as well as optimizing patient satisfaction. To make the FT program and related approaches easily-understood, we classified it into 3 phases according to the proceeding of operation: the pre-, intra- and post-

The challenge for the patients begins with the initial consultation and the decision to undergo total knee arthroplasty (TKA). It is important to select appropriate candidates and optimize

admission and discharge of the patient undergoing selective operations.

operative management. (Figure 1).

Figure 1. Algorithm of fast track TKA surgery.

114 Primary Total Knee Arthroplasty

2. Preoperative management

Adequate patient education is required to prevent patients or their family from holding unrealistic expectation. Surgeon should notify patients of what will happen during their inpatient stay, associated risks and the postoperative recovery plan. Some educational class illustrating the whole procedure and related impacts are therefore arranged for the candidates for TKA. In addition, the identification of assistive care companion at home is important to clarify the availability and ability of nursing after discharge, leading to the reduced anxiety of the patients for the coming surgical interventions. Through sufficient patient education and discussion, less anxiety with enhanced patient compliance could be expected [9].

#### 2.3. Preoperative preparation

#### 2.3.1. Infectious prophylaxis

One of the great challenge for orthopedic surgeon was avoiding the prosthetic joint-associated infections [10]. Several patients' preoperative conditions are considered as risk factors for increasing the rate of infection after TKA. Risk factors include old age, poor nutritional status, extreme body mass index, smoking, rheumatoid arthritis or diabetes mellitus [11–13]. Previous histories of trauma, steroid injection, or infection elsewhere in the body are also associated with increasing rates of infection. According to the Surgical Care Improvement Project initiated in 2004, rate of wound infections was reduced by the administration of prophylactic antibiotics. Current literature suggested that systemic administration of prophylactic antibiotics should be given within 60 min of surgical incision [14].

mixture of medications that include long-acting anesthetic, NSAIDs and epinephrine. Regimen varies from institution to institution. It is injected to the posterior capsule, collateral ligaments, capsular incision, quadriceps muscle tendon, and the adjacent subcutaneous tissues. Significant reduction in opioid consumption, improvement in pain VAS score and patient satisfaction are

Fast Track Surgery Program in Knee Replacement http://dx.doi.org/10.5772/intechopen.74026 117

The duration of the surgical procedure should be minimized as short as possible. However, the delay in operation duration is frequently reported with revision surgeries, the use of computer navigation and inexperienced surgeons. Prolonged operative time may be highly associated with the increase rate of surgical site infection, deep wound infection and other associated

Minimally invasive approach for total knee arthroplasty was introduced in 1990s, and popularized in recent 10 years. The minimally invasive approach allowed smaller wound incision, less soft tissue trauma, less invasion to muscle, especially vastus medialis obliquus (VMO). Minimally invasive approach has transformed from conventional parapatellar approach, and later converted to sub-vastus approach, which boasted no invasion to VMO, and had less soft tissue damage during the procedure. However, with VMO preserved the surgical field clearance decrease and may lead to difficulties in prosthesis sizing, and placement. Mini-midvastus approach was then introduced, and was shown to have similar outcomes comparing to sub-

Through minimal invasive approach, extensor muscles were maximally preserved. Large scale of RCTs showed the better short-term outcomes including better knee flexion/ extension torque, faster days to raise leg, greater range of motion, higher in knee society score (KSS), less total estimated blood loss and less postoperative pain [26, 27]. However, minimal invasive approach may also contribute to longer tourniquet time and operating time, as well as wound complication. In term of long term outcomes and longevity, there is still insufficient evidence to declare that minimal invasive approach had long term advantages over conventional total

Perioperative blood loss of TKA can be significant. It could lead to resultant anemia which leads to further need of blood transfusion associated morbidity and mortality [28]. Therefore, it is always an important issue to avoid massive blood loss during and after TKA procedure.

During TKA, a pneumatic tourniquet is commonly used to provide clear surgical field and significantly reduces blood loss and surgical time [29]. However, no significant difference was shown for postoperative knee-extension strength, hemoglobin level, pain, nausea, length of

observed in patients receiving LIA [21, 22].

3.2. Duration of the surgical procedure

3.3. Minimally invasive surgical approach

complications [23].

vastus approach [24, 25].

knee arthroplasty.

3.4. Blood management strategy

hospital stay, and local swelling.

#### 2.3.2. Preemptive analgesia

Analgesia given prior to surgery is assumed to prevent peripheral and central sensitization. Preemptive medications such as NSAIDs, COX-2 inhibitors, and the neuropathic agent gabapentin and pregabalin have all shown promising result in reducing the magnitude and duration of postoperative pain [15]. However, the optimal dose, timing of administration, and whether there is potential benefit of continuing the analgesics during operation remain debating issues.
