Fast Track surgery from the orthopedic point of view How to apply FTS in orthopedics specially in Arthroplasty surgery. Evidence based practice in orthopedics

1. Fast Track Surgery
In orthopedics
By
Abdullah Ahmed Nada, MSc
Assistant lecturer, Orthopedic department, Tanta school of
medicine
Acknowledgement
Prof. Dr Wael Samir

2. Learning outcomes
• Definition of fast track surgery
• Components of fast track surgery
• How to apply in orthopedics

3. Introduction
• Perioperative protocol
• Also called ERAS ( Enhanced Recovery After
Surgery)
• The term was first used by Preofessor Henrik
Kehlet (Denmark) In 1990 (Gastroenterologist
surgeon)

4. Importance

5. Ultimate Aim
• Enhance the patient satisfaction
Pain and Stress free operations
Enhanced recovery
• Lower rate of complications
• Reduced duration of hospitalization 2-4 days (
reducing the cost)

6. How ? Components
Preoperative Operative Postoperative

8. Members of FTS program
Multidisciplinary
• Nurses
• Dietitians
• Pain team
• Surgeons
• Physiotherapists
• Hospital management

9. From the orthopedic point of view
LIS Blood
Pain

11. From the orthopedic point of view
LIS Blood
Pain

12. Pain
• Multimodal pain management approach
• Synergistic effect
• Lower doses
• Less complications
• More effective action

13. Multimodal Appraoch
• Pre-emptive analgesia or Preventive analgesia
• Spinal Epidural anethesia
• Surgical site infiltration using bupivocaine
• Local nerve block
• PCA (patient controlled analgesia )
• Acetaminophen + Ketorolac IV

15. Pre-emptive analgesia
• Analgesics before incision >
• Preoperative only?
Decrease postop pain
reduce analgesics consumption
Prevent central sensitization ??
BUT
Limited effect
Shorter duration
Not cover postop inflammatory phase

16. 2001

17. Recommended multimodal Protocol
• Preoperative weaning of narcotics
• Pre-emptive analgesia (within 2 hours pre
surgery)
Acetaminophen (paracetamol) 1000 (liver
disease)
Pregabalin 75 (Delirium)
Celecoxib (drug allergy)

18. From the orthopedic point of view
LIS
Pain
Blood

19. Bleeding
• Preoperative Hb level
• 90% chance of transfusion with preoperative
Hb less than 10g/dl
• 15-25% chance with preop Hb 10-13g/dl

20. Preop transfusion thresholds
• Lower limit of 10g/dl is recommended before major
orthopedic surgery
• Little evidence supports that
• Risk benefit relationship (transfusion complications)
• Lower than 7g/dl with clinical indicators (symptomatic)
• Less than 8-9g/dl for elderly, cardiac, peripheral
vascular disease

21. Prevention of bleeding
• Avoid Cefoperazone / Sulbactam (Salbin) 
reported to decrease Hb
• Epidural anethesia > hypotension
• Avoid hypothermia
• IV Tranexamic acid 1g/100 ml saline with
induction
• Smaller incisions ?
• Electrocautery
• IV Tranxamic acid 1/100 ml saline at start of
closure

22. Level 1
Evidence
trials

23. Drains?

24. Meta-analysis of three studies

25. Drains in practice?
• The routine use of a suction drain is unnecessary after
an uncomplicated total joint arthroplasty *
• There is insufficient evidence from randomised
controlled trials (RCTs) to support the routine use of
closed suction drainage in orthopaedic surgery.*
• Despite the paucity of clinical evidence demonstrating
any benefit supporting their use, drains continue to be
placed after elective orthopaedic procedure*
• Wound compression, Clamping (3-4 hours)

27. Clamping

29. Removal of drains
• Generally, drains should be removed once the drainage has
stopped or becomes less than about 25 ml/day
• If output seems excessive, the drain can be clamped, and a
compressive dressing may be applied for 30 to 45 minutes.
On postoperative day 1, the surgical drain is removed
regardless of output.
• Risk benefit relationship
• Early removal may decrease the risk of some complications,
especially infection *

30. Anticoagualtion
• Prophylaxis should be continued at least 10–14 days, and considered for
up to 35 days postoperatively.
• Screening asymptomatic patients for VTE with Doppler/Duplex ultrasound
is not recommended.*
• IVC filter placement is not recommended in patients with
contraindications to other treatments *
• Increasing the VTE prophylaxis dose of LMWH by 30% may be appropriate
in morbidly obese patients (BMI >40 kg/m2) *
• Decreasing VTE prophylaxis dose of enoxaparin may also be appropriate in
patients with low body weight (<45 kg for women and <57 kg for men)

32. From the orthopedic point of view
Blood
Pain
LIS

33. Less Invasive surgery
• Minimal Skin and soft tissue dissection
without major increase in difficulty and /or
time of operation.
• Not defined by length of the exposure

37. Is Fast Track Surgery safe and
effective ?
Evidence?

39. Safe?
• Available Evidence suggests that FTS protocols
are as safe as conventional treatments
regimes

40. Systematic Review

42. Effective?,, Yes It is
• Reduce length of hospital stay
• Reduce the cost
• No increase in readmission rates, morbidity
and mortality

43. Level 1 evidence study, on 150 patients

44. • In summary :
Saves money
Saves Resources
Saves Time
No increased complication risk

45. Take home messages
• Fast track surgery is a perioperative,
Multidisciplinary protocol, safe and effective
• Multimodal analgesics pre, intra and
postoperative
• Blood transfusion if less than 7,, 9 in elderly,
cardiac
• Prevent intraoperative bleeding ,,Tranexamic acid
role, drains role
• Less invasive surgery,,,smaller not always better

46. References
• Parker MJ, Roberts C; Closed suction surgical wound drainage after orthopaedic
surgery. Cochrane Database Syst Rev. 2001(4):CD001825.
• Parker MJ, Livingstone V, Clifton R, et al; Closed suction surgical wound drainage
after orthopaedic surgery. Cochrane Database Syst Rev. 2007 Jul 18(3):CD001825.
• Clifton R, Haleem S, McKee A, et al; Closed suction surgical wound drainage after
hip fracture surgery: a systematic review and meta-analysis of randomised
controlled trials. Int Orthop. 2007 Aug 9.
• Clifton R, Haleem S, McKee A, et al; Closed suction surgical wound drainage after
anterior cruciate ligament reconstruction: a systematic review of randomised
controlled trials. Knee. 2007 Oct14(5):348-51. Epub 2007 Jul 31.
• Gaines RJ, Dunbar RP; The use of surgical drains in orthopedics. Orthopedics. 2008
Jul31(7):702-5
• Guyot A, Layer G; MRSA - 'bug-bear' of a surgical practice: reducing the incidence
of MRSA surgical site infections. Ann R Coll Surg Engl. 2006 Mar88(2):222
• Falck-Ytter Y, Francis CW, Johanson NA et al. Prevention of VTE in orthopedic
surgery patients. Antithrombotic therapy and prevention of thrombosis, 9th ed:
American College of Chest Physicians. Chest 2012;141(2)(Suppl):e278s–e325s
• Nutescu EA, Spinler SA, Wittkowsky A, Dager WE. Low-molecular-weight heparins
in renal impairment and obesity: available evidence and clinical practice
recommendations across medical and surgical settings. Ann Pharmacother.
2009;43:1064–83

47. • Glassou EN, Pedersen AB, Hansen TB. Risk of re-admission, reoperation, and
mortality within 90 days of total hip and knee arthroplasty in fast-track
departments in Denmark from 2005 to 2011. Acta Orthop. 2014;85(5):493–500.
• Tucci G, Amorese V, Romanini E. Closed suction drainage after orthopaedic
surgery: Evidence versus practice. J Orthop Traumatol. 2006;7(1):29–32.
• Murphy JP, Scott JE. The effectiveness of suction drainage in total hip arthroplasty.
J R Soc Med [Internet]. 1993;86(7):388–9. Available from:
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• Choudhari P, Padia D. Role of Drainage Clamping For the Control of Blood Loss in
Cemented Bipolar Hemiarthroplasty. 2015;3(8):28–30.
• Jeon YS, Park JS, Kim MK. Optimal release timing of temporary drain clamping after
total knee arthroplasty. J Orthop Surg Res. Journal of Orthopaedic Surgery and
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• Stucinskas J, Tarasevicius S, Cebatorius A, Robertsson O, Smailys A, Wingstrand H.
Conventional drainage versus four hour clamping drainage after total knee
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