Clinical Outcomes and Complication Rates in Fast-Track Versus Routine after Total Knee Arthroplasty: A Systematic Review and Meta-analysis

Abstract

Objectives: Fast-track or enhanced recovery after surgery (ERAS) pathways have been increasingly adopted in total knee arthroplasty (TKA) to optimize perioperative care, yet their comparative effectiveness and safety relative to routine pathways remain incompletely defined. This systematic review and meta-analysis compared the effects of fast-track versus routine perioperative care on length of hospital stay (LOS), postoperative pain, complications, and readmissions in patients undergoing primary TKA. Methods: A systematic search of PubMed, Embase, Cochrane Library, Scopus, and Web of Science was performed from inception to January 2025 using MeSH terms. Primary outcomes were LOS and postoperative pain, with complications and readmissions assessed as secondary outcomes. Risk of bias was assessed using Cochrane RoB 2 for RCTs and ROBINS-I for non-randomized studies. A random-effects meta-analysis was conducted due to anticipated heterogeneity. Results: Nine studies (total 2607 patients) met inclusion criteria. Fast-track care significantly reduced LOS (WMD: -2.41 days, 95% CI: -3.18 to -1.64). Postoperative pain was slightly higher in the fast-track group at 24h (MD: 0.98, 95% CI: -0.1 to 2.05) and at 2 weeks (MD: 0.33, 95% CI: -0.04 to 0.7), neither reaching statistical significance. Methodological quality was limited, with moderate to serious risk of bias in non-randomized studies and high risk of bias in all randomized trials. Conclusion: Overall, the available evidence suggests that fast-track rehabilitation following TKA substantially reduces hospitalization without clinically meaningful or sustained increases in postoperative pain. These findings support the use of fast-track pathways to enhance perioperative efficiency in TKA, while highlighting the need for higher-quality randomized studies to better define their effects on pain and safety outcomes.