Bilateral Knee Replacement Research Articles

Total knee arthroplasty and posterior tibial slope

Background: Total knee arthroplasty has been considered as a standard procedure for intractable pain in the end-stage degenerative arthritis of the knee and maintaining range of motion (ROM) to facilitate the ability to perform daily living activities. A majority of studies have reported that the influence of PTS on the range of motion, however controversy exists. Methods: Two hundred patients (400 knees) who underwent simultaneous or staged bilateral knee replacements and who met our inclusion criteria were included for this study. The pre-operative and post-operative knee ROM and PTS were recorded for each patient. Patients followed up at regular interval with minimum follow up of one year. Results: 200 patients that is, 400 knees who underwent posteriorly stabilised TKA were considered. Respective mean ROM and PTS were 106 0 and 7.8 0 preoperatively and 128 0 and 5.7 0 postoperatively. We divided the patients in to group A (post-operative PTS ≤8 0 ) 346 knees, and group B (postoperative PTS >8 0 ) 54 knees and analysed the relation between PTS and ROM. Conclusions: Change in PTS does not have influence on postoperative ROM in posteriorly stabilised TKA. Preoperative range of motion has got significant effect on post op range of motion following TKA.

Pain, fear of falling and stair climbing ability in patients with knee osteoarthritis before and after knee replacement: 6 month follow-up study

(1) to evaluate the change in time of pain, stair climbing ability and fear of falling (FOF), (2) to determine the association between pain, stair climbing ability and FOF for patients with knee osteoarthritis (OA) following the knee replacement over the course of six months, (3) and to compare the results with healthy controls in terms of stair climbing ability and FOF. Fifteen female healthy controls and 21 female consecutive subjects who were scheduled to undergo primary bilateral knee replacement for the treatment of knee OA were involved. Pain, stair climbing ability and FOF were assessed with a numerical pain rating scale, Going up and Down Scale (GUDS) and Tampa Scale for Kinesiophobia (TSK) at pre-surgery and discharge. After discharge, patients were asked to answer the outcome measures at 2, 4, 8, 12 and 26 week by phone. Patients had significantly improvement in the postoperative 26-week scores of pain (p< 0.001), stair ability (p< 0.001), and FOF (p=0.006) compared with the preoperative scores. There was also decreased pain at 4.week, improved stair ability at 8.week, and delayed improvement at FOF in patients. While patients had significantly worse stair ability than controls preoperatively (p< 0.001), the difference was not significant at postoperative 26-week (p=0.561). A positive significant correlation was found between the stair ability, FOF and pain scores (p< 0.001). It would be reasonable to consider that FOF control is potentially useful for preventing severe functional limitation in stair climbing for subsequent knee OA before and early after the surgery.

Does Chondrocalcinosis Affect Knee Society Scores and Range of Motion After TKA?

Chondrocalcinosis is manifested by crystalline deposits of calcium commonly found during primary TKA for osteoarthritis. Its frequency among patients undergoing TKA is poorly defined, as is its influence on pain or function after TKA. The purposes of this study are to (1) determine the prevalence of chondrocalcinosis in patients undergoing TKA for osteoarthritis; (2) evaluate the effect of chondrocalcinosis on ROM and The Knee Society scores; (3) determine if patients with chondrocalcinosis and severe synovitis who underwent synovectomy are at risk for lower postoperative Knee Society scores and less ROM; and (4) assess if chondrocalcinosis is associated with increased rates of revision surgery. We retrospectively reviewed the medical records of 1500 primary TKAs performed by one surgeon. The minimum followup for patients was 24months (average, 57months; range, 24-120months). There were 511 men and 934 women with an average age of 70years. Fifty-five patients underwent bilateral knee replacements. Crystal deposition was graded prospectively during surgery using a subjective visual scale. A thorough synovectomy was performed on patients with severe synovitis and apparent crystalline deposition suggestive of calcium pyrophosphate dihydrate (CPPD) deposition (n=50). The Knee Society scores, ROM, and revision rates were compared between patients with visible chondrocalcinosis with those without and between patients with mild chondrocalcinosis with those with severe chondrocalcinosis. Chondrocalcinosis was found in 173 male patients (34%) undergoing TKAs during this period compared with 224 female patients (24%) (p<0.001). The Knee Society scores for knee rating and function were similar in patients with or without chondrocalcinosis undergoing TKA. However, patients with visible CPPD deposition who underwent synovectomy for proliferative synovitis had diminished final ROM and Knee Society knee rating scores (107(o) versus 115(o) knee flexion, p<0.001 and 87 versus 94 points, p=0.001). We cannot determine whether this result is because of the synovectomy or severity of the disease, and therefore we cannot recommend a synovectomy at this time. Revision rates were no different among patients with chondrocalcinosis compared with those without it (3.6% versus 2.2%, p=0.2). Chondrocalcinosis is common among patients undergoing TKA for osteoarthritis. The presence of CPPD deposition does not appear to affect the ROM and Knee Society scores of patients with CPPD but without severe synovitis. However, patients with severe synovitis and visible CPPD who underwent thorough synovectomy may be at risk for having decreased postoperative ROM and pain develop. Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Simultaneousversusstaged bilateral unicompartmental knee replacement

We prospectively followed 171 patients who underwent bilateral unicompartmental knee replacement (UKR) over a period of two years. Of these, 124 (72.5%) underwent a simultaneous bilateral procedure and 47 (27.5%) underwent a staged procedure. The mean cumulative operating time and length of hospital stay were both shorter in the simultaneous group, by 22.5 minutes (p < 0.001) and three days (p < 0.001), respectively. The mean reduction in haemoglobin level post-operatively was greater by 0.15 g/dl in the simultaneous group (p = 0.023), but this did not translate into a significant increase in the number of patients requiring blood transfusion (p = 1.000). The mean hospital cost was lower by $8892 in the simultaneous group (p < 0.001). There was no significant difference in the rate of complications between the groups, and at two-year follow-up there was no difference in the outcomes between the two groups. We conclude that simultaneous bilateral UKR can be recommended as an appropriate treatment for patients with bilateral medial compartment osteoarthritis of the knee.

Quantitative computed tomography assessment of bone mineral density after 2 years’ oral bisphosphonate treatment in postmenopausal osteoarthritis patients who underwent total knee arthroplasty

To identify the effects of two years' oral bisphosphonate (alendronate) treatment in patients who underwent total knee arthroplasty (TKA); to determine whether significant responses seen after the first year of treatment changed during the second year. Additionally, the study tried to identify factors relating to bone mineral density (BMD) changes. This was a prospective 2-year follow-up study of a previous 1-year report of postmenopausal women with knee osteoarthritis who underwent primary unilateral or staged bilateral TKA, after which they received 70 mg alendronate orally once-weekly. BMD was measured using quantitative computed tomography (QCT) on lumbar vertebrae at baseline (pre-TKA) and at 12 and 24 months. Factors associated with BMD changes were determined by regression analysis. Sixty-one patients entered the second year and continued treatment for ≥ 24 months. Mean vertebral QCT BMDs at baseline and after 12 and 24 months' alendronate treatment were 71.8 mg/ml (41.9-97.5 mg/ml), 69.3 mg/ml (31.4-103.9 mg/ml), and 72.7 mg/ml (33.1-136.1 mg/ml), respectively. Patients undergoing bilateral TKA and who had more severe OA at baseline (bilateral severe [grade 4] OA) had a lower BMD response after 2 years' bisphosphonate treatment, compared with patients with less severe unilateral knee OA who underwent unilateral TKA. Improvements were, however, seen compared with year 1 levels. Low BMI was associated with BMD nonresponse. Patients with bilateral severe OA (grade 4) requiring bilateral knee replacement are at greater risk of nonresponse after 2 years' oral alendronate treatment. A longer duration of treatment may be necessary in these patients.

Bilateral knee replacements for treatment of acute septic arthritis in both knees

A case report of bilateral acute septic arthritis of knees is presented, which was managed with staged total knee replacements for both knees. A literature review on septic arthritis treated with knee arthroplasty is also presented.

Knee Sports Injury Is Associated with an Increased Prevalence of Unilateral Knee Replacement: A Case-Controlled Study

Injury to the knee during athletics is common and may limit future sports participation, but its long-term effects on patients are less well characterized. Examining the development of end-stage osteoarthritis (OA) in these patients may help better clarify this relationship. We hypothesize that sports-related knee injuries are associated with subsequent unilateral knee OA and need for total knee arthroplasty (TKA) relative to bilateral knee replacement. We present a single-hospital case-control study of 124 consecutive patients undergoing primary TKA over a 6-month period for end-stage OA. Patients were interviewed at the time of surgery using a standardized questionnaire to detect and characterize a history of athletic knee injury. The presence of contralateral knee arthritis based on preoperative assessment was noted for all patients. A control population was derived from patients with diagnosed or known bilateral OA undergoing TKA. Patients were all assessed for exposure to earlier sports or athletic injury. Prestudy power analysis and uni- and multivariate statistical analyses were performed. Of the 124 patients, 27 (22%) recorded a history of athletic knee injury. Evidence of bilateral significant knee OA was found in 73 patients and unilateral arthritis in 51 patients. Patients with unilateral OA were found to have an increased likelihood of previous athletic injury relative to those with bilateral disease (odds ratio: 6.08, p = 0.0001). There is a significant prevalence of sports-related injuries in patients with unilateral knee OA. This study suggests that patients with such injuries may develop arthritis via a different process, sports-related trauma, than patients with bilateral nontraumatic OA.

Staged bilateral knee replacements

It is a shame that Gabr et al did not include any reference to age or employment in their paper. Employment is surely one of the most important functional outcomes for many knee replacement patients and, as retirement ages rise, will become more so. Staged bilateral replacements might be thought to increase the duration of sickness absence from work and potentially push this to the point where patients end up on unpaid leave or even unemployed. However, if staging the procedure improves rehabilitation and reduces the proportion of working age patients who do not recover sufficiently to return to work, it might be advantageous economically. Clinical specialists should move towards considering return to an economically productive life as the desired end point to their interventions and therefore an important outcome to measure in studies of functional impact of surgery.

An RCT on the effects of topical CGP on surgical wound appearance and residual scarring in bilateral total-knee arthroplasty patients

To test the hypothesis that topically applied calcium glycerophosphate (CGP) would improve the appearance of the wound following bilateral knee replacement. Healthy patients, aged 45-75 years, scheduled for bilateral total-knee replacement surgery were recruited into the study. One knee was randomly assigned to the treatment group, while the contralateral knee was designated the control (standard care). Subjects were instructed to apply a preparation of 10% CGP in an aqueous lotion to the treated knee once daily for 42 days, starting at the third postoperative day. Functional sealing and cosmetic appearance of the incision were evaluated by two surgeons by direct examination of the patient and then by two experienced assessors from photographs. The investigators qualitatively scored the intensity and extent of erythema along the incision and over the entire knee, the appearance of visible oedema along the incision and over the knee, and the overall clinical impression of wound healing. All four assessors were blinded to the subjects' allocation and the latter two assessors to the initial investigators' assessments. Subjects were also followed up for an additional 46 weeks, giving a total study duration of 12 months. Twenty patients completed the study. Statistical analysis showed that both the area and intensity of erythema along the incision were significantly reduced in the treated vs untreated knee over the entire study period. The analysis further showed that treatment significantly reduced oedema, both along the incision and across the entire knee. The differences were most marked at the seventh postoperative day and diminished with time. No adverse effects were observed for any patient, in either treated or untreated knees. These data demonstrate that postoperative application of 10% CGP could improve the appearance of the wound following total knee arthroplasty.

Functional outcome of staged bilateral knee replacements

The aim of this study was to compare the functional outcome between the first and second knee replacement in patients undergoing staged bilateral total knee arthroplasty. We identified 64 patients who had bilateral knee replacements and had at least one year of postoperative outcome studies. Data on pain scores, walking ability, use of walking aids, range of movement, instability, muscle strength, WOMAC® (Western Ontario and McMaster Universities) scores, SF-12 (Short Form 12) scores, American Knee Society radiological scores and length of hospital stay (LOS) were recorded. The difference in data between the first and second knee was assessed. Groups remained statistically comparable between the first and second operation. Four outcomes showed a significant difference between the second and first knee. The mean score for postoperative walking ability was 4.83 (second knee) vs 4.51 (first knee) (p =0.03). The mean score for postoperative walking aid requirement was 5.73 (second knee) vs 5.46 (first knee) (p=0.01). The mean postoperative SF-12 score was 54.26 (second knee) vs 52.45 (first knee) (p=0.04). The mean LOS was 4.73 days (second knee) vs 6.16 days (first knee) (p =0.05). All other data comparisons were statistically insignificant. Patients have a reduced LOS and continue to improve after the second procedure with regards to walking ability, use of walking aids and psychological wellbeing.

A middle-aged woman with nausea, weight loss, and orthostatic hypotension

A 54-year-old, right-handed, Caucasian woman presented with intermittent nausea, vomiting, and orthostatic hypotension of 1 year duration. Following every meal, she would belch and vomit nonbloody undigested food. She reported constipation and fatigue and felt lightheaded and occasionally lost consciousness on standing. She denied visual changes, dysphagia, dysarthria, weakness, involuntary movement, or loss of urinary or fecal continence. She denied fever, chill, dysuria, diarrhea, or coughing. At one point, she was hospitalized for rehydration every 2 weeks. She had lost nearly 80 pounds over the prior year. She had a history of osteoarthritis with bilateral knee replacements. Her current medications were lansoprazole, midodrine hydrochloride, fludrocortisone acetate, and metoclopramide without significant relief. Her family history was remarkable for cancer and a brother had Down syndrome. She previously worked as a draftsman. She did not use tobacco or recreational drugs and rarely drank alcohol. General examination was significant for orthostasis. Supine blood pressure was 143/89 mm Hg with heart rate of 88 beats per minute. Upon standing, her blood pressure dropped to 63/44 mm Hg with heart rate increasing to 102 beats per minute. Mental status, language, and cranial nerve examination were normal. Sensation to vibration and pinprick was decreased distally in the lower extremities bilaterally. Light touch and temperature sensation were normal. Romberg sign was negative. Muscle strength and tone was normal in all extremities. Deep tendon reflexes were intact in biceps, triceps, brachioradialis, and patellar but absent at the Achilles. Plantar responses were flexor. Limb coordination was normal. She could stand without assistance for only under 1 minute before becoming lightheaded, requiring sitting. Extensive gastrointestinal workup at different hospitals including mesenteric lymph node biopsy led to the diagnosis of sclerosing mesenteritis. Treatment with prednisone provided only transient relief. Her endocrine evaluation did not reveal a cause for the orthostasis. Transthoracic …

Limb Alignment Improves with Computer-Assisted Navigation in Total Knee Replacement, But Questions Remain

The value of intraoperative computer navigation during total knee arthroplasty has been debated for more than a decade. Despite substantial research, contradictory results and reservations about the cost and efficacy of the technology have contributed to the failure of computer navigation to become the accepted standard for establishing limb alignment during knee replacement surgery. In their paper, Zhang and colleagues report the results of a well-designed, prospective, randomized study that was conducted to compare the short-term clinical and radiographic results of total knee arthroplasty performed with computer navigation with the results of total knee arthroplasty performed with conventional mechanical instruments. The authors attempted to control for as many variables as possible by studying patients with bilateral knee arthritis who were undergoing simultaneous bilateral knee replacement. For each patient, both the order of the surgery and the knee that was assigned to the computer-navigation group were selected by randomization. During the follow-up period, the clinician, radiologist, and patient were blinded with regard to the type of procedure that had been performed on each knee. The outcomes recorded included overall limb alignment on full-length radiographs; various parameters of prosthetic positioning on both standard radiographs and …

Use of Tranexamic acid is a cost effective method in preventing blood loss during and after total knee replacement

Background & PurposeAllogenic blood transfusion in elective orthopaedic surgery is best avoided owing to its associated risks. Total knee replacement often requires blood transfusion, more so when bilateral surgery is performed. Many strategies are currently being employed to reduce the amount of peri-operative allogenic transfusions. Anti-fibrinolytic compounds such as aminocaproic acid and tranexamic acid have been used systemically in perioperative settings with promising results. This study aimed to evaluate the effectiveness of tranexamic acid in reducing allogenic blood transfusion in total knee replacement surgery.MethodologyThis was a retrospective cohort study conducted on patients undergoing total knee replacement during the time period November 2005 to November 2008. Study population was 99 patients, of which 70 underwent unilateral and 29 bilateral knee replacement. Forty-seven patients with 62 (49.5%) knees (group-I) had received tranexamic acid (by surgeon preference) while the remaining fifty-two patients with 66 (51.5%) knees (group-II) had did not received any tranexamic acid either pre- or post-operatively.ResultsThe mean drop in the post-operative haemoglobin concentration in Group-II for unilateral and bilateral cases was 1.79 gm/dl and 2.21 gm/dl, with a mean post-operative drainage of 1828 ml (unilateral) and 2695 ml (bilateral). In comparison, the mean drop in the post-op haemoglobin in Group-I was 1.49 gm/dl (unilateral) and 1.94 gm/dl (bilateral), with a mean drainage of 826 ml (unilateral) and 1288 ml (bilateral) (p-value < 0.001).InterpretationTranexamic acid is effective in reducing post-operative drainage and requirement of blood transfusion after knee replacement.

A patient with ‘spontaneous’ heparin-induced thrombocytopenia and thrombosis after undergoing knee replacement

Exogenous heparin exposure is the major risk factor for heparin-induced thrombocytopenia and thrombosis (HITT). To date, only five cases of 'spontaneous' HITT have been reported in the literature. We report the case of a 60-year-old man who developed severe thrombocytopenia (15 000/μl) and bilateral deep venous thromboses 10 days after bilateral knee replacement. There was no evidence of heparin exposure upon review of the patient's preoperative and postoperative medication history. Heparin: platelet factor-4 (PF4) antibodies were positive as was the serotonin release assay. Anticoagulation with argatroban along with prednisone and intravenous immune globulin were administered. Anticoagulation with argatroban was bridged to warfarin once his platelet count reached 100 000/μl, and he was continued on oral prednisone taper. Heparin: PF4 antibodies were negative 3 months after the event. Six months later, Doppler ultrasound revealed deep vein thrombosis. This case represents a third 'spontaneous' episode of HITT in the context of knee replacement surgery without heparin administration. It is unclear whether these cases are a result of exposure to a heparin-like proteoglycan such as chondroitin sulfate during surgery that binds PF4, or whether the perioperative pro-inflammatory milieu is the inciting event. Further consideration of precipitating events in these individuals merits further investigation and may lead to valuable insight into the pathophysiology of heparin-independent PF4-related thrombocytopenia and thrombosis.

Central Versus Lower Body Obesity Distribution and the Association With Lower Limb Physical Function and Disability

To determine whether fat distribution in obese adults is significantly associated with decreased function and increased disability. Cross-sectional epidemiologic analysis. Multicenter, community-based study. Multicenter Osteoarthritis Study participants included adults ages 50-79 years at high risk of developing or already possessing knee osteoarthritis. A total of 549 men and 892 women from the Multicenter Osteoarthritis Study who had a body mass index ≥ 30 kg/m² and who underwent dual energy x-ray absorptiometry (DEXA) scans were included in these analyses. Exclusion criteria included bilateral knee replacements, cancer, or other rheumatologic disease. Body fat distribution was determined using baseline DEXA scan data. A ratio of abdominal fat in grams compared with lower limb fat in grams (trunk:lower limb fat ratio) was calculated. Participants were divided into quartiles of trunk:lower limb fat ratio, with highest and lowest quartiles representing central and lower body obesity, respectively. Backward elimination linear regression models stratified by gender were used to analyze statistical differences in function and disability between central and lower body obesity groups. Lower limb physical function measures included 20-meter walk time, chair stand time, and peak knee flexion and extension strength. Disability was assessed using the Late Life Function and Disability Index. Trunk:lower limb fat ratio was not significantly associated with physical function or disability in women or men (P value .167-.972). Total percent body fat (standardized β = -0.1533 and -0.1970 in men and women, respectively) was a better predictor of disability when compared with trunk:lower limb fat ratio (standardized β = 0.0309 and 0.0072). Although fat distribution patterns may affect clinical outcomes in other areas, lower limb physical function and disability do not appear to be significantly influenced by the distribution of fat in obese older adults with, or at risk for, knee osteoarthritis. These data do not support differential treatment of functional limitations based on fat distribution.

Closed-chain exercise after simultaneous bilateral knee replacement surgery: A case report

ABSTRACTThe purpose of this case report was to present a method for assessing entire lower extremity performance and describe a Medical Exercise Therapy (MET) training program early after simultaneous bilateral total knee replacement (TKR). We also documented perceived function, mobility, and weight-bearing ability during functional tasks. The patient was a 50-year-old male who underwent a simultaneous bilateral procedure and began physical therapy (PT) 16 days postsurgery. Lower extremity performance (weight, repetitions, and load*volume) was assessed weekly using a one-legged horizontal press. Perceived physical abilities, mobility, and body weight placed over each limb during a sit to stand and a squat at two different flexion angles were assessed. At discharge load*volume for the weakest limb was 87% of the strongest side. At discharge, sit-to-stand, and 30 and 60 degree squat asymmetry ranged from 4% to 6%. Perceived abilities and mobility improved from initial visit to discharge. The patient was able to tolerate the closed-chain assessment of lower extremity performance and MET training program early after surgery. The patient made improvements in all functional tests and more importantly maintained a fairly equal distribution of body weight over both limbs during functional activities.

Outcome of Staged Bilateral Knee Replacement

Outcome of Staged Bilateral Knee Replacement

Sudden Sensorineural Deafness after Unilateral Total Knee Replacement

We present a report of an individual who sustained a sudden onset of sensorineural hearing loss following a unilateral total knee replacement. Phillips et al reported a case in 2003 from the same hospital, following bilateral simultaneous knee replacements.(1) It was previously concluded that the most probable cause of the hearing loss was fat embolism.This is the first recorded case of a sudden bilateral hearing loss following a unilateral knee replacement. We conclude that a prospective investigation of the incidence of hearing loss after joint replacement is may be warranted.

A 47-Year-Old Woman With Rheumatoid Arthritis and Dyspnea on Exertion

A 47-year-old white woman came to the clinic complaining of dyspnea on exertion for the past few weeks. She had a cough with scanty whitish expectoration during the first week of her illness. She had rheumatoid arthritis (RA) for 34 years, and had been treated with corticosteroids, methotrexate, infliximab, and etanercept. Her condition had been stabilized for the past 5 years. Her medical history included thalassemia, gastroesophageal reflux disease, hypertension, hysterectomy, and bilateral knee replacements.

Absence of Heart Failure in Severe Cardiac and Autonomic Amyloidosis: The Essential Role of Sympathetic Activation and Venous Tone in the Development of the Congestive Heart Failure Syndrome

Heart failure is a complex clinical syndrome that requires the interaction of many organ systems for its development, including the heart, renal, and neuroendocrine systems. The heart may be severely abnormal yet symptoms of heart failure may not develop. The present case illustrates, by its absence, the essential role of neuroendocrine sympathetic activation and venous tone in the development of the congestive heart failure syndrome.