Bilateral Knee Arthroplasty Research Articles

Increased Risk of Bilateral Infection

Hypothesis: Simultaneous bilateral endoprosthetic total hip or knee arthroplasty (as in the current article) is in theory inevitably associated with an increased rate of bilateral infections. Reasoning: A department specific risk of infection due to surgery—for example, 5/1000—for endoprosthetic total hip or knee arthroplasty means that even for simultaneous bilateral surgery, such a risk of infection exists (if not even a higher risk, which we will not consider here). If one furthermore assumes that in case of surgery both surgical sites may be affected—the current article does not provide any information in this respect—then the risk of bilateral infection may be 5/1000 if all cases of infection are always bilateral or, for example, 5/10 000 if only one in 10 cases of infection is bilateral. In two-stage surgery (with an interval of several weeks between procedures) the risk per intervention is 5/1000. Both interventions combined have a risk of infection of 2×5/1000=10/1000 for an infection to affect one joint. The probability that in a two-stage procedure (with an interval of several weeks between procedures) both joints become infected is 5/1000×5/1000=25/1000 000. In order to be able better to balance these very divergent surgical risks it would be necessary to obtain detailed data on the bilateral proportion of infections in the group of patients having had simultaneous surgery. Unrelated to that, statistical probability in simultaneous bilateral surgery works against the surgeon, which is why I personally do not recommend this procedure to my patients.

Patellar resurfacing versus nonresurfacing in total knee arthroplasty for osteoarthritis: experience at a tertiary care institution in Pakistan

Patellar resurfacing versus nonresurfacing in total knee arthroplasty for osteoarthritis: experience at a tertiary care institution in Pakistan Akil Fazal1, Riaz H Lakdawala21Clinical Fellow, NYU Hospital for Joint Disease, New York, US; 2Associate Professor and Chief, Section of Orthopedics, Department of Surgery, The Aga Khan University Hospital, Karachi, PakistanObjective: To determine the effect of patellar resurfacing in patients offered total knee arthroplasty for osteoarthritis.Design: Randomized control study.Place and duration of study: The Aga Khan University Hospital, Karachi, Pakistan from January 3, 2005 to January 9, 2010.Patients and methods: Patients undergoing primary total knee arthroplasty for osteoarthritis were assigned to either the patellar resurfacing or nonresurfacing arm using systematic sampling. This consisted of patients undergoing unilateral and bilateral knee arthroplasty. Preoperatively, Knee Society Knee and Function Scores were calculated. After a minimum of 3 years postoperatively Knee Society Knee and Function Scores as well as the Clinical Anterior Knee Pain Rating were calculated and analysis done to check for differences.Results: Seventy-five patients were recruited in each arm; 135 patients had bilateral and 15 had unilateral knee arthroplasty. The mean preoperative knee score was 40.4 for the resurfacing group and 40.60 for the nonresurfacing group (P = 0.45). This improved postoperatively to 93.67 and 94.23 respectively, with no difference between the two groups (P = 0.67). The mean preoperative function score was 45.50 for resurfaced patellae and 45.83 for nonresurfaced. This improved to 89.67 and 90.50, respectively, again with no difference (P = 0.51). Postoperative Clinical Anterior Knee Pain Rating was a mean of 0.1 for resurfaced and 0.13 for nonresurfaced patellas, with no difference on analysis (P = 0.06). However, patients who had bilateral knee arthroplasty had a slightly higher Clinical Anterior Knee Pain Rating than those who had single knee surgery (P = 0.046) irrespective of whether the patellar was resurfaced or not.Conclusion: In patients undergoing primary Total Knee Arthroplasty for osteoarthritis, there is no added advantage of performing resurfacing of the patellar at 3 years of follow-up.Keywords: patellar, patellar ligament, patellofemoral pain syndrome, arthroplasty subchondral, arthroplasy replacement knee, osteoarthritis knee, Pakistan

Ogilvie’s syndrome following bilateral knee arthroplasty: a case report

Ogilvie's syndrome, also known as acute colonic pseudo-obstruction, is an uncommon but severe postoperative complication of total hip and knee arthroplasty. This syndrome should be borne in mind after arthroplasty surgery. We present a case of this serious postoperative complication and aim to identify the risk factors and alert surgeons to the possibility and appropriate management of Ogilvie's syndrome.

The use of computer-assisted orthopaedic surgery in complex cases of hip and knee arthroplasty: experience from a developing country

The technology of computer-assisted orthopaedic surgery (CAOS) has been used in many developed countries for the last two decades. Initially, it was thought that CAOS would be the standard in surgical practice, but so far its clinical application has been limited due to the involved cost and complexity. The cost-effectiveness of CAOS techniques has also been questioned. Therefore, it is expected that the application of CAOS in developing countries would be more limited for the same reasons. Herein, the author presents a surgical experience of using different CAOS techniques in Egypt. Computer-assisted templating software was used in complex and neglected cases of hip arthritis and in cases of leg length discrepancy. Navigation techniques were employed in knee arthroplasty in patients with extraarticular deformities. Computer-assisted patient-specific instruments were used for bilateral simultaneous knee arthroplasty in medically unfit patients and in patients with severe articular deformities. Contrary to expectations, the experience proved that CAOS is more useful and possibly cost-effective when used in hip and knee arthroplasty for complex and neglected cases in developing countries.

Bilateral Endoprosthetic Total Hip or Knee Arthroplasty

More than 300 000 joint replacement operations are performed in Germany every year, and the number is rising. In this article, we consider the question of simultaneous bilateral joint replacement at the hips or knees. Such procedures are indicated in patients suffering from bilateral, symptomatic arthrosis. The article is based on a selective review of the relevant literature, and on the authors' own prospective comparative study of simultaneous bilateral hip replacement. The morbidity and mortality of simultaneous bilateral hip arthroplasty are no different than those of a unilateral procedure. Rehabilitation is easier when both joints are replaced at the same time. Simultaneous bilateral knee arthroplasty has comparable morbidity to a unilateral procedure, but a slightly higher mortality (0.30% vs. 0.14%). Allogenic blood transfusion is more likely to be needed in a bilateral procedure, particularly of the knees. Simultaneous bilateral arthroplasty of either the hips or the knees in one surgical procedure is better than two-staged arthroplasty during a single hospital stay. Simultaneous bilateral hip arthroplasty is safer for the patient and facilitates rehabilitation, regardless of the patient's age and ASA status (ASA, American Society of Anesthesiologists). With regard to the knees, there are two additional issues, namely the more frequent need for transfusion and somewhat higher mortality of a simultaneous bilateral procedure. Therefore, we recommend simultaneous bilateral knee arthroplasty only for patients in ASA classes 1 and 2. Simultaneous bilateral arthroplasty of either the hip or knee incurs lower costs than two separate operations.

Unicompartmental and Total Knee Arthroplasty in the Same Patient

This prospective randomized study compared the clinical and radiographic outcomes of unicompartmental knee arthroplasty versus total knee arthroplasty. The group consisted of 34 patients (19 males and 15 females), who had a mean age of 73 years (range, 49 to 86 years), and who fit the criteria for bilateral unicompartmental knee arthroplasty. Each patient received a unicompartmental prosthesis in one knee and a total knee arthroplasty in the other during a single anesthetic session. At a mean follow-up of 5 years (range, 24 to 89 months), the Knee Society pain and function scores were similar for both groups. There were no radiographic failures. Survivorship of the unicompartmental group was 85% compared with 100% in the total knee group (p = 0.05). All of the prostheses that failed had an all-polyethylene tibial component. These results suggest that unicompartmental knee arthroplasty may not offer similar survivorship when compared with total knee arthroplasty.

Are both the knees of the same size? Analysis of component asymmetry in 289 bilateral knee arthroplasties

Background:Variations in the anatomy of knee are well described, however the true incidence of component asymmetry in bilateral total knee arthroplsties is rarely reported. Incidence of component asymmetry in bilateral total knee arthroplasties (TKA) was retrospectively analysed in 289 cruciate retaining total knee arthroplasties.Materials and Methods:Medical records of these 289 patients were evaluated for the incidence of asymmetry of either femoral or tibial components. Clinical outcomes were compared between the cases of asymetrical components to that of symmetrical components.Results:Incidence of femoral component asymmetry was found to be 9.2% and tibial component asymmetry to be 8.7%. Of 289 cases, TKA 178 were done in a single day (group A), while 111 were done at 2- to 3-day intervals (group B). Asymmetric and symmetric knees were equally distributed among both groups, male and female patients in both groups, and the incidence of component asymmetry was similar between all four different implants – Optetrak-CR (Exactech, Gainesville, FL, USA), Nexgen-CR (Zimmer, Warsaw, IN, USA), PFC-Sigma CR (DePuy, Warsaw, IN, USA), Genesis II CR (Smith and Nephew, Memphis, TN, USA) we used. The pre- and postoperative range of motion and pre- and postoperative knee society scores were compared between the symmetric and asymmetric cases in both the groups and the difference was found to be insignificant.Conclusion:We conclude that incidence of component asymmetry in bilateral total knee arthroplasty is around 9 % and independent sizing of both knees during bilateral arthoplasty is recommended rather than simply relying on the contralateral knee measurements.

Bilateral Simultaneous Total Hip Arthroplasty in a Fast Track Setting

Simultaneous bilateral hip arthroplasty has been reported to have varying results in the literature when performed using conventional postoperative care. Unilateral hip and knee arthroplasty as well as bilateral simultaneous knee arthroplasty may be associated with reduced length of stay and low complication rates when performed in a fast-track setting. We believed it would be useful to assess hip arthroplasty in this context, and we report 50 consecutive fast-track simultaneous bilateral hip arthroplasty procedures. The median length of stay was 4 days. Mortality within 90 days was 4% and 8% required a further operative procedure. The overall complication rate was 22%. 55% of the complications were considered to be caused by failures in surgical technique and 45% by other factors. Bilateral simultaneous hip arthroplasty may have a high complication rate in a fast-track setting and further evaluation may be warranted.

Operative Risk of Staged Bilateral Knee Arthroplasty is Underestimated in Retrospective Studies

To find a safer surgical option, a number of studies have compared postoperative complications after bilateral total knee arthroplasty vs staged total knee arthroplasty (STKA) by contrasting postoperative complications collected retrospectively. However, we believe that a comparison based on retrospective studies could be biased. The purpose of this study was to demonstrate the misclassification bias associated with a retrospective study in comparing operative outcomes. Our analysis indicates that any conclusions based simply on retrospective analysis of subjects who successfully completed STKA is biased because it includes only cases that recovered after the first operation, rather than all of the patients who had planned STKA. In the absence of a prospective study to date, published studies should be interpreted with caution.

Bilateral total knee arthroplasty in a patient with hemophilia A, high inhibitor titre and aneurysma spurium of the popliteal artery

The authors report on bilateral simultaneous knee arthroplasty in a 40-year-old male patient with haemophilia A, high inhibitor titre and an aneurysma spurium of the right popliteal artery. Both knees showed a fixed flexion deformity of 20 degrees. To build up haemostasis, treatment with activated prothrombin complex concentrate (APCC) and recombinant activated factor seven (rFVIIa) was initiated preoperatively. A tourniquet was used on both sides during the operation and factor VIII (FVIII) was administered to further correct coagulopathy. On the eleventh postoperative day the patient complained of increasing pain and pressure in the right knee. An ultrasound suggested aneurysm, which was confirmed by substraction angiography. Under the protection of rFVIIa the aneurysm could be coiled and further rehabilitation was uneventful. At one year post-op the patient presented a range of motion of 90/5/0 degrees for both knees and had returned to full time office work. This case indicates that haemophiliacs with high antibody titre and destruction of both knees can be operated on in one session in order to diminish the operative risk of two consecutive surgical procedures, thus allowing an effective rehabilitation programme. Because of the significant frequency of popliteal aneurysms, preoperative angiography is recommended.

Incorrect Use of the Student t Test in Randomized Trials of Bilateral Hip and Knee Arthroplasty Patients

The statistical analysis of a study's results is critical to its interpretation. Often confused, 2 types of t tests exist for dependent or independent samples. We reviewed randomized controlled trials that included patients undergoing bilateral total hip or knee arthroplasty (dependent samples) that used the t test for analysis. Our inclusion criteria resulted in 40 studies for review, 10 of which combined both unilateral and bilateral patients. Of the 30 studies that compared a pure sample of only bilateral patients, 18 (60%) incorrectly used the independent t test. Of the 10 studies with mixed samples, 8 (80%) used the independent t test. The extent to which the incorrect use of this statistical test led to misleading conclusions is uncertain; however, our findings highlight the misuse of statistical tests in the arthroplasty literature.

Don't Patients Have Two Knees?

The article by Dr. Memtsoudis et al. describing perioperative outcomes after unilateral knee arthroplasty (UKA) and bilateral knee arthroplasty (BKA) uses the technique of using a large database, the Nationwide Inpatient Sample (NIS), to undertake as described in the accompanying editorial a form of “comparative effective research.”1,2In their introduction, the authors state that to date, one of the major limitations of studies comparing UKA with BKA has been their small sample sizes. To avoid this problem, the authors use a large database to compare the outcomes of UKA versus BKA. However, in designing a study using a large database, it is important to define the population groups under study accurately.In the total knee population, the authors defined a population of 670,305 admissions between 1998 and 2006 (9-yr period) requiring knee arthroplasty. In the “Materials and Methods,” the authors state that the NIS database contains information from approximately 8 million admissions per year. By using this number, we calculated that knee arthroplasty represented 0.93% of all admissions (670,305/72 million). Can the authors define the actual percentage that knee arthroplasty represents of all NIS database hospital admissions and more importantly of all NIS database surgical admissions for the period 1998–2006? Do the authors believe that this incidence is representative of the general population, and if not, how would this alter their results?In the authors' article, the only significant benefit to the BKA group in this NIS population was the incidence of device-related complication, which was 0.52% in the BKA group compared with 0.86% in the UKA group. How do the authors account for this difference?Of the 670,305 patients, 626,601 (93.75%) underwent UKA as defined by the code 81.55. This code does not differentiate between a first UKA and a second opposite-side UKA. In the BKA group, both knees require arthroplasty. Thus, should the authors include only patients who have undergone two UKA knee arthroplasties (opposite side) in the control group? If the control group consists of patients who have undergone two UKAs, should the morbidity of the two UKAs be combined? If the patient had the first UKA and then decided, for whatever the reason, not to have the second opposite-side UKA, should this be classified as a complication of the first UKA?In the article, the authors refer to four different groups in the BKA population. The first is the total BKA population of 43,703 (6.52% of 670,305). The second is a subtotal BKA population of 34,015 patients (the total BKA group minus a group of 9,688 [22.3%] that could not be defined). The third and fourth are subgroups and consist of simultaneous BKAs 25,443 (74.8% of 34,015) and staged BKAs of 8571 (25.2% of 34,015). Except for the length of stay, the authors refer to percentages and not actual “n” values in most of the results, and without stating which of the BKA groups, it makes it difficult to discern the actual values. Can the author supply the reader with actual value for mortality in the simultaneous BKA group and how this compares directly with the UKA group?Based on the NIS database and the definitions used by the authors, the number of patients required to undergo BKA compared with UKA to cause one additional mortality is 625, that is, 625 people need to undergo BKA to cause one additional death that would not have occurred if they had only received a UKA. The evidence as demonstrated by the authors may be compelling; however, their results are based on how the authors defined the BKA and UKA groups and the NIS database studied.*Mayo Clinic, Jacksonville, Florida. bharrison@mayo.edu

Patella in total knee arthroplasty: to resurface or not to—a cohort study of staged bilateral total knee arthroplasty

The aim of this study was to assess medium term results of patellar resurfacing in total knee arthroplasty, specifically looking at anterior knee pain, patellofemoral function and need for reoperation. A prospective cohort study was conducted with patients undergoing staged bilateral knee arthroplasty with the patella being resurfaced only on one side. This was due to change in the clinical practice of the senior author. Sixty patients were reviewed clinically and radiologically on a regular basis. The surgery was either performed or supervised by the senior author in all cases. All patients received the cemented press-fit condylar© prosthesis. The Knee Society clinical rating system was used. Scores were recorded pre-operatively and post-operatively at three months, one year, two years and three yearly thereafter. The mean age of patients in the study group was 75 years (range: 62-89 years). There were 42 women and 18 men in the study. The mean duration of follow-up was 4.5 years (range: 2-12 years). There was no significant difference in the pre-operative scores in both groups. There were significantly better scores (p < 0.05) on the resurfaced side as compared to the non-resurfaced side at final follow-up. No revision was carried out for patellofemoral complications on the resurfaced side. Four patients required revision in the form of patellar resurfacing on the non-resurfaced side for persistent anterior knee pain. Patellar resurfacing is recommended in total knee arthroplasty for better functional outcome with regards to anterior knee pain and patellofemoral function.

Adult presentation of Stickler syndrome type III

Few clinical cases have been published on Stickler syndrome type III, and all describe the pediatric presentation. We describe an adult presentation of the syndrome in a 67-year-old woman and provide a report on the clinical and radiographic features supporting diagnosis. A chart review and updated investigations were performed to elucidate the presenting history and disease progression in the patient. Clinically, the patient was 42 years old when she presented with a 22-year history of bilateral knee pain and atypical osteoarthritis (OA) of an inflammatory but non-erosive character. The patient also reported increasing hearing loss for high-pitched frequencies. Radiography/X-rays at age 42 years showed severe, non-erosive tri-compartmental OA changes. Atypical destructive changes were identified in the small joints. The son of the patient developed left knee pain and bilateral knee swelling since the age of 9 years. He was diagnosed with early-onset OA and also underwent bilateral knee arthroplasties in his third decade, similar to his mother. The grandson presented at age 4 years, with recurrent, acute episodes of pain and swelling in his ankles and knees and was diagnosed with pediatric OA. A mutation of the COL11A2 gene was confirmed in the patient at aged 63 years. This is the first clinical case report on the adult presentation of Stickler syndrome type III. In particular, early-onset OA or an unrecognized skeletal dysplasia can be considered as rationale for genetic testing, screening, and surveillance of both past and present family members of an affected patient.

Analgesic efficacy of subcutaneous local anaesthetic wound infiltration in bilateral knee arthroplasty: a randomised, placebo-controlled, double-blind trial

High-volume wound local infiltration analgesia is effective in knee arthroplasty, but the analgesic efficacy of subcutaneous wound infiltration has not been evaluated. In a randomised, double-blind, placebo-controlled trial in 16 patients undergoing bilateral knee arthroplasty with high-volume local infiltration analgesia in the deeper layers, saline or ropivacaine 2 mg/ml was infiltrated into the subcutaneous part of the wound in each knee along with the placement of multi-fenestrated catheters in the subcutaneous wound layers in both knees. Pain was assessed for 6 h post-operatively and for 3 h after a bolus injection given through the catheter 24 h post-operatively. Visual analogue scale (VAS) pain scores were significantly lower from the knee infiltrated with ropivacaine compared with the knee infiltrated with saline in the subcutaneous layer of the wound, at rest (P<0.02), with flexion of the knee (P<0.04) and when the leg was straight and elevated (P<0.04). Twenty-four hours post-operatively, a decline in the VAS pain scores was observed in both groups, with no statistically significant difference between injection of ropivacaine or saline in the subcutaneously placed catheters (P>0.05). As part of a total wound infiltration analgesia intraoperative subcutaneous infiltration with ropivacaine in bilateral total knee arthroplasty is effective in early post-operative pain management, while a post-operative subcutaneous bolus administration through a multiholed catheter 24 h post-operatively did not show improved analgesia compared with the administration of saline.

Devastating Ochronotic Arthropathy With Successful Bilateral Hip and Knee Arthroplasties

Ochronotic arthropathy is a manifestation of long-standing alkaptonuria, a rare hereditary metabolic disorder characterized by the absence of the enzyme homogentisic acid oxidase. We describe a patient who developed rapidly progressive destructive ochronotic arthropathy in his knee and hip joints and underwent successful bilateral total knee and hip arthroplasties.

High‐volume infiltration analgesia in total knee arthroplasty: a randomized, double‐blind, placebo‐controlled trial

High-volume infiltration analgesia may be effective with a low risk of side effects in hip and knee arthroplasty. The present placebo-controlled study was carried out to evaluate the analgesic effect of high-volume infiltration analgesia in bilateral total knee arthroplasty, along with a detailed description of the infiltration technique. In a randomized, double-blind, placebo-controlled trial in 12 patients undergoing bilateral knee arthroplasty, saline or high-volume (170 ml) ropivacaine (0.2%) with epinephrine was infiltrated around each knee, with repeated doses administered through an intra-articular catheter for 24 h and pain and opioid requirements assessed for 48 h in a fast-track setting. Pain at rest and during movement was significantly reduced for up to 32 h with the high-volume local anesthetic infiltration technique. No major side effects were observed. The median hospital stay was 4 days. High-volume infiltration analgesia is effective in knee arthroplasty and, due to its simplicity, may be preferable compared with other analgesic techniques in knee arthroplasty.

Conversion of bilateral hip and knee ankylosis to total joint replacements

We present a 25-year-old patient with juvenile rheumatoid arthritis and ankylosis of both hips and both knees treated by staged bilateral hip and knee arthroplasty. She was followed up for 18 months. We discuss the pre-operative planning, surgical details and post-operative rehabilitation.

Results of bilateral combined hip and knee arthroplasty in very young patients with juvenile rheumatoid arthritis

We evaluated the long-term outcomes for combined, bilateral total knee and hip arthroplasty performed on a group of very young patients with juvenile rheumatoid arthritis. Six consecutive patients with a mean age of 14 years at the time of hip replacement and 16 years at knee replacement were analyzed. Five of the six patients were wheelchair dependent pre-operatively. All knee components had uncemented fixation, while the hip replacements were a mixed group of cemented and uncemented prostheses. Clinical and radiographic follow-up at a mean duration of 13.8 years for the hips and 17.3 years for the knees demonstrated four of the six patients were unlimited community ambulators, one a limited community ambulator and the remaining patient a household ambulator. Failure, defined as revision of any of the components or definite radiographic loosening, occurred in three knees (two patients) and five hips (three patients). These good long-term functional results in a relatively very young population indicate that an early and aggressive approach to multiple joint disease is an appropriate option at a young age for patients with juvenile rheumatoid arthritis with severe disability and pain refractory to conservative management.

Staged Bilateral Hip or Knee Arthroplasties

To compare the operating time, amount of blood transfused, length of hospital stay, and early complications (within 6 months) between 2-week staged bilateral arthroplasties and matched randomised controls undergoing unilateral arthroplasties. From October 1992 to October 2000, 90 patients who underwent bilateral hip or knee arthroplasties with a 2-week interval were compared with matched randomised controls undergoing unilateral arthroplasties. A single surgeon performed all procedures. After the match-up process, 30 pairs of patients were included in the analysis. There were no significant differences in the operating times, amount of blood transfused, and early complication rates. The mean difference in length of hospital stay was significant (t=-3.552, df=29, p<0.001). Compared to staged procedures with an interval months apart, staged sequential arthroplasty with a 7- to 10-day interval during one hospital admission is more efficient, as it facilitates earlier rehabilitation without higher complication rates, and entails shorter hospital stays.