3.2. Duration of the surgical procedure

antibiotics. Current literature suggested that systemic administration of prophylactic antibi-

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

With the revolutionary advances in the surgical and anesthetic fields, many surgical procedures are now routinely performed on outpatient basis. Currently, with the combination of multiple strategies that target at minimizing surgical stress, many orthopedic surgeons are now applying the concepts of fast track program to their clinical practice. Fast track knee arthroplasty or even outpatient joint arthroplasty is increasingly performed. To reach the goal of fast track, there are 5 major strategies to be aware of: anesthesia approach, duration of the surgical procedure, minimally invasive surgical approach, blood management, and the main-

The potential impact of different types of anesthetic technique administered during TKA on postoperative outcome remains controversial. Different anesthesia approaches may affect the incidence of surgical site infection, urinary retention, and also pose different impact on medical cost. There are two anesthetic techniques that are often used in TKA, general anesthesia and spinal anesthesia. In current literature, spinal anesthesia is a more recommended anesthetic approach as it is associated with more favorable postoperative outcomes, lower complication rate and lower 30-day mortality. Patients receiving spinal anesthesia are observed to experience shorter length of hospital stay, lower rate of pulmonary embolism, pneumonia, cerebro-

Regional anesthesia also plays a role in fast track program. Peripheral nerve blocks such as femoral nerve blocks and adductor canal blocks are often used in TKA in assistance with spinal or general anesthesia. It is assumed that peripheral nerve blocks provide supplemental anesthesia and analgesia effect during the perioperative and postoperative periods. Reported benefits include shorter length of hospital stay, less opioid consumption and earlier participation in physical therapy [18–20]. Reduced risk of hypotension and urinary retention were also observed in patients receiving regional anesthesia comparing with patients receiving epidural anesthesia. Local infiltration anesthesia (LIA) has been gaining focus in recent years, as several wellconducted studies had indicated the potential benefits postoperatively [21, 22]. LIA consists of a

vascular events, acute renal failure and the need for blood transfusion [16, 17].

is potential benefit of continuing the analgesics during operation remain debating issues.

otics should be given within 60 min of surgical incision [14].

2.3.2. Preemptive analgesia

116 Primary Total Knee Arthroplasty

tenance of normothermia.

3.1. Anesthesia approach

3. Intraoperative management

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 complications [23].

### 3.3. Minimally invasive surgical approach

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 subvastus approach [24, 25].

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 knee arthroplasty.

#### 3.4. Blood management strategy

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 hospital stay, and local swelling.

Antifibrinolytic agents such as tranexamic acid (TXA) decreased the rate of fibrinolysis and therefore stabilizes fibrosis clot [30]. It can be administrated by oral, intra-venous, intramuscular, or intra-articular. Current literature had shown the effect of reducing blood loss, less reduction of postoperative hemoglobin and less swelling with strong evidence [31–33]. In addition, there's no increased risk for deep vein thrombosis (DVT) among related studies.

4.3. Thromboprophylaxis

to 12 hours after surgery [38].

acute pain after surgery [42, 43].

4.5. Ambulation and exercise

its sequelae [45, 46].

adverse physiological and psychological responses [39, 40].

4.4. Pain relief

Patients who undergo TKA are at high risk of venous thromboembolism(VTE) as the incidence of symptomatic and asymptomatic VTE is 10% and 40–60%, respectively [36, 37]. After admission, a complete assessment of VTE risk is performed. Thromboprophylaxis measures include general, mechanical and pharmacological strategies. General thromboprophylaxis including avoidance of dehydration, early mobilization and lower limb range of motion exercises are applied to patients at any risk. Mechanical thromboprophylaxis including stockings or intermittent pneumatic calf compression are used during operation. While pharmacological strategies, for instance, low molecular weight heparins should be started 6

Fast Track Surgery Program in Knee Replacement http://dx.doi.org/10.5772/intechopen.74026 119

TKA is often associated with moderate to severe postoperative pain during the early postoperative period. Effective pain management following total knee arthroplasty is critical for which enables early mobilization, ambulation and even patients' satisfaction via the reduced

In traditional clinical practice, opiates play a major role in postoperative pain management. However, despite the strong analgesic effect of opiates, there are a number of associated adverse effects, e.g., nausea, vomiting, or risk of addiction. The associated adverse effects could further delay the recovery of the patients and increase the overall healthcare expenditure. Current literatures recommend the application of opioid sparing regimen with multimodal analgesics. It was proven to provide adequate pain control and avoidance of opioid-related adverse effects. Combination analgesics such as paracetamol, NSAIDs, COX-2 inhibitors, neuropathic medication or NMDA antagonist block different pathways of pain to optimize analgesic efficacy [41]. Combination therapy also reduces the required dose of individual medication which further lowers the incidence of medication adverse events. Other alternative modalities such as cryotherapy, through the application of cool water to the surgical site or transcutaneous electrical nerve stimulation (TENS) are also taken into consideration, as studies have shown to reduce the

Early ambulation and exercise should be valued as an important part of the fast track program as it provides a range of health benefits [44]. Current literature suggests that rehabilitation and physical therapy initiated on the day of surgery. Early mobilization potentially prevents complications such as venous thromboembolism, atelectasis, urinary tract infection, stroke,…, etc., [45]. Furthermore, it was reported by related studies to reduce length of hospital stay, post-operative morbidity and mortality, improved patient satisfaction, and reduced VTE and

#### 3.5. Maintenance of normothermia

Maintenance of intraoperative normothermia (defined as a condition of normal core body temperature around 36.5 to 37.5C) is recommended in current surgical guidelines (AHRQ, WHO, and SCIP) in order to minimize the incidence of complications. Although most surgical guidelines recommend maintaining patients in a normothermia status, the role is still controversial and unclear as these guidelines are often based on limited evidence outside the field of orthopedics. Several studies have suggested that perioperative hypothermia may increase perioperative blood loss, transfusion rate, risk of surgical site infection or the incidence of cardiovascular morbidities.

Patients who underwent general anesthesia or experienced longer operating time were at higher risk of who developing hypothermia. However, some studies showed the contrary result. Even though hypothermia increases the amount of estimated blood loss, it did not increase transfusion rate, postoperative complications, length of hospital stay or the rate of 30-day readmission [34]. In general, it is still recommended that patients' core temperature should be constantly monitored throughout the operation to maintain normothermia status.
