1. Introduction

A Fast-track (FT) program, or more precisely named enhanced recovery after surgery (ERAS) is a well-established approach for patients undergoing selective operations that target enhanced

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and eproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

every facet of their condition [7]. There are several key factors that should be considered to

Fast Track Surgery Program in Knee Replacement http://dx.doi.org/10.5772/intechopen.74026 115

The preoperative assessment should always start with a thorough history taking. Patients often reported pain, functional deficit, or other instability symptoms. The location, duration, severity, character, alleviating and aggravating factors should be obtained in detail. The patients' baseline activity level and past medical history including underlying systemic disease, surgical history, anesthetic history, allergic history, social history and current medication should be recorded. Identification of the unfavorable conditions such as preoperative anemia or coagulopathy is important to reduce the potential complications and comorbidities. Also, previous surgical and non-surgical treatment should be documented. Patient's occupation,

Complete physical examination is mandatory, including gait observation, inspection, palpation, measurement of range of motion, contractures and ligament stability. Gait observation is mainly looking for the presence of antalgic gait pattern and the requirement of walking aids. Inspection of the patients includes skin change, swelling, and associated deformity of the knee. Following palpation should identify the area of tenderness, severity of effusion, crepitus and patellar tracking. Measurement of range of motion, contractures and ligament stability are also

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

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

discussion, less anxiety with enhanced patient compliance could be expected [9].

minimize the risks of complications and comorbidities [8].

leisure hobbies and expectation toward surgical outcomes are inquired.

2.1. Preoperative patient assessment

2.2. Preoperative patient education

2.3. Preoperative preparation

2.3.1. Infectious prophylaxis

needed.

Figure 1. Algorithm of fast track TKA surgery.

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 admission and discharge of the patient undergoing selective operations.

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 postoperative management. (Figure 1).
