Bilateral Total Knee Arthroplasty Research Articles

The interval between staged bilateral total knee arthroplasties does not affect early complications of the second knee or long-term function of the first and second knees

BackgroundThis study explored the optimal time interval between staged bilateral total knee arthroplasty (BTKA) to minimize early complications of the second TKA and maximise the long-term function of the first and second knees.MethodsWe retrospectively reviewed 266 patients who underwent staged BTKA between 2013 and 2018. Groups 1–4 had time intervals between BTKAs of 1–6, 6–12, 12–18, and 18–24 months, respectively. Demographics, postoperative complications within 90 days of the second TKA, Knee Society Score (KSS), and Western Ontario and McMaster Universities Arthritis Index (WOMAC) score were compared among the groups.ResultsIn total, 54, 96, 75, and 41 patients were assigned to groups 1–4, respectively. Although group 1 had the highest overall complication rate (11.11%), there was no significant difference in the complication rate among the four groups. Also, no significant differences were found among the four groups in functional and patient-reported outcomes, in either the first or second knee at 5 years postoperatively, including KSS-knee, KSS-function, WOMAC-pain, WOMAC-stiffness, and WOMAC-physical function. The interval between BTKA did not influence complications or the function of the second knee. The TKA type (posterior-stabilised vs. medial-pivot) and age did not correlate significantly with any scores.ConclusionsThere was no group difference in early complications of the second TKA, and postoperative function was equivalent between the two knees and did not vary by the interval between surgeries. The results of this study give surgeons and patients more choices. If patients cannot tolerate severe symptoms in the contralateral knee after the first TKA, the second TKA should be performed as early as possible. If knee joint function is not well recovered after the first TKA, and patients are anxious to undergo the second TKA, surgeons can advise patients to postpone the operation based on these results.

Comparison of bilateral cementless total knee arthroplasty results between patients in different BMI groups.

The aim of this study was to compare the results of cementless bilateral total knee arthroplasty (TKA) between individuals in different obesity groups. This was a retrospective cohort study. Patients with a body mass index (BMI) greater than 25 who underwent bilateral TKA for gonarthrosis between 2014 and 2020 and completed a minimum follow-up of 24 months were included. Age, sex, height, weight, BMI, operation time, length of stay, patient satisfaction, knee scores and complications were compared. Patients with missing data, who were followed for less than 24 months or had postoperative fractures around the knee were excluded. There was a significant difference between the groups in terms of operation time (Class III > overweight > Class II > Class I p < 0.001). There was a significant difference in complications between the groups (Class III > Class I > Class II > overweight p = 0.010). According to our pairwise comparison, complications were more common in the class III group than in the overweight group. Knee score (KS) and function score (FS) increased significantly after surgery in all groups (p < 0.001), with no difference in FS (p = 0.448). Knee score changes were greater in the overweight and class I groups (p < 0.001). There was a significant interaction between both KS and FS and person satisfaction (p < 0.001). Cementless TKA improved KS and FS in all obesity groups, yielded high patient satisfaction. Although the incidence of complications was higher in the morbidly obese patients than in the overweight patients, the difference was not significant. Patients with morbid obesity should be informed about related risks before planning cementless TKA.

Pain management In Total Knee Arthroplasty: Which helps in better post-operative outcomes?

Background: Individuals exhibit variations in pain perception and pain threshold, and these differences exist between the right and left limbs, resulting in biases related to inter-cerebral pain variability and inter-patient pain variability. Currently, there is limited available data comparing adductor canal block (ACB) with femoral nerve block (FNB) in individuals who have undergone bilateral total knee arthroplasty (TKA). Methods: We conducted a prospective, non-randomized, controlled study involving patients scheduled for bilateral total knee arthroplasty (TKA) under central neuraxial anesthesia. Following surgery, patients received intermittent 12-hourly boluses of 15 mL ropivacaine 0.5% through two distinct peripheral nerve blocks (adductor canal block - ACB and femoral nerve block - FNB) in either of the lower limbs. The primary objective was to evaluate the postoperative Visual Analog Scale (VAS) score, while the secondary outcomes included the assessment of quadriceps muscle strength and the degree of flexion at the knee joint. Results: Out of the 70 patients evaluated for eligibility, 63 were enrolled, and 60 were included in the final analysis. Visual Analog Scale (VAS) scores after both blocks during periods of rest at 30 minutes, 6 hours, 12 hours, and 48 hours post-operatively did not exhibit any significant differences. However, VAS scores during rest at 24 hours and during exercise at 24 hours and 48 hours demonstrated a notable disparity. Furthermore, there was a significant difference in favour of adductor canal block (ACB) over femoral nerve block (FNB) regarding quadriceps muscle strength and the degree of knee flexion at 24 hours and 48 hours post-operatively. Conclusions: Adductor canal block (ACB) delivers comparable pain relief to femoral nerve block (FNB) both at rest and during passive exercise for up to 48 hours after surgery. ACB notably maintains the motor strength of quadriceps muscles when contrasted with FNB, and this preservation comes without introducing any additional complications.

Operating room efficiency for a high-volume surgeon in simultaneous bilateral robotic-assisted total knee arthroplasty: a prospective cohort study.

Robotic-assisted total knee arthroplasty (RATKA) has been shown to achieve more accurate component positioning and target alignment than conventional jig-based instrumentation; however, concerns remain regarding its adoption since it is associated with steep learning curves, higher operational costs, and increased surgical time. This study aims to compare the operating times of three cohorts of patients undergoing simultaneous bilateral TKA, i.e., first 50 RATKA, last 50 RATKA (at the end of 1year), and 50 conventional TKA. This prospective cohort study was conducted at a single high-volume tertiary care center by a single experienced surgeon on 150 patients (300 knees), who were allotted into three equal cohorts of 50, between February 2020 and December 2021. Simultaneous bilateral TKAs were done in all three groups and operative times recorded. We describe the technique for optimizing the surgical time of SB-RATKA for efficient operative room logistics. The operating times of the two robotic-assisted TKA cohorts were compared with the operating times of the conventional SB-TKA cohort. The mean age of the study population was 59(±6.2) years with the majority of females (82%). The mean coronal deformity was comparable between the cohorts. The mean operating time in the conventional CTKA, initial 50 RATKA, and final 50 RATKA cohorts were 115.56 (±10.7), 127.8 (±26), and 91.66 (±13.5) min, respectively, all of which showed a statistically significant difference (p<0.001). The mean operating times of the final 50 RATKA at the end of 1year improved by about 36min with all the SB-RATKA cases being completed in under 120min. The efficiency of SB-RATKA improved significantly with time and experience, resulting in shorter operational times within a year, revealing the potential of robotic-assisted surgery to surpass conventional approaches in TKA in terms of operating room efficiency.

Incidence of deep venous thrombosis in patients with hemophilia undergoing bilateral simultaneous total knee arthroplasty: a retrospective cohort study

BackgroundHemophilic arthropathy usually affects the knees bilaterally. In order to reduce costs and improve rehabilitation, bilateral simultaneous total knee arthroplasty (TKA) can be performed. However, pharmacological prophylaxis for deep venous thrombosis (DVT) remains controversial in patients with severe hemophilia. The purpose of this study was to establish the incidence of DVT in severe hemophilia A patients undergoing bilateral simultaneous TKA without pharmacological thromboprophylaxis.MethodsConsecutive patients with severe hemophilia A undergoing bilateral simultaneous TKA at a single center between January 2015 and December 2020 were retrospectively reviewed. All patients received a modified coagulation factor substitution regimen. Tranexamic acid (TXA) was used for hemostasis in all patients during surgery. All patients followed a standardized postoperative protocol with routine mechanical thromboprophylaxis, and none received anticoagulation. D-dimer was measured preoperatively, on the day of the operation and on postoperative days 1, 7 and 14. Ultrasound (US) of the lower extremities was performed before (within 3 days of hospitalization) and after surgery (days 3 and 14) to detect asymptomatic DVT. Patients were followed up until 2 years after surgery for the development of symptomatic DVT or pulmonary embolism (PE).Results38 male patients with severe hemophilia A underwent 76 simultaneous TKAs. Mean (± standard deviation) age at the time of operation was 41.7 (± 17.1) years. Overall, 47.3% of patients had D-dimer concentrations above the threshold 10 µg/mL on day 7 and 39.5% on day 14. However, none of the patients had DVT detected on postoperative US, nor developed symptomatic DVT or PE during the 2-year follow-up.ConclusionsThe risk of DVT in patients with severe hemophilia A after bilateral simultaneous TKA is relatively low, and routine pharmacological thromboprophylaxis may not be needed.

Association of Surgical Adhesive and Glue System With Incidence of Allergic Dermatitis Post Unilateral and Staged Bilateral Total Knee Arthroplasty.

Background Skin closure is an important step in total knee arthroplasty (TKA). Several techniques are described in the literature with emerging interest in skin adhesives. This study aims to highlight the adverse reactions related to skin adhesives and to identify potential risk factors. Methods A retrospective review of 250 patients (295 knees, 45 being staged bilateral TKA) who underwent TKA was conducted at our facility. All patients underwent the same perioperative protocol with application of surgical glue over the wound edges.Postoperative adverse reactions were classified as allergic dermatitis (AD), cellulitis, and superficial infection. Results Incidence of adverse reactions in the form of AD was noted in 4.8% of patients. Demographics and comorbidities had no influence on this occurrence (p>0.05). However, in patients who had bilateral staged TKA, AD manifested after performing the second contralateral TKA in 22% of patients. This incidence of AD was significantly higher when compared to those who had single unilateral TKA (p =0.001) Conclusion The theory of allergic sensitization may explain the higher incidence of AD in bilateral staged TKA due to prior exposure to glue components in the first knee; thus, we recommend avoiding its use if there was previous exposure.

Staged Bilateral Total Knee Arthroplasty: Differing Results Comparing the First and Second Knees

BackgroundPatients often prefer one knee over the other following staged bilateral total knee arthroplasty (BTKA). Our study compared patient-reported outcomes scores of each knee following BTKA and identified factors that may contribute to the identified discrepancies. MethodsAll patients who underwent staged BTKA between July 2014 and August 2022 were identified. The patient-reported outcomes were collected preoperatively and at 2 weeks, 6 weeks, 1 year, and 2 years postoperatively. Each knee’s results were compared using paired t-tests and McNemar tests. Preoperative Kellgren-Lawrence Grade (KLG), postoperative range of motion (ROM), reoperation rates, and manipulations under anesthesia (MUAs) were collected. Results were stratified based on time between TKAs (< 3 months, 3 to 12 months, 1 to 2 years, and > 2 years). ResultsThere were 911 patients who underwent staged BTKA, with a mean 4.1-year follow-up. The ROM, patient satisfaction, MUAs, and reoperations were not significantly different between knees. Comparing the KLG of the first and second knees, 71% had the same KLG for both knees, 21% had a lower KLG, and 7% of the second knees had a higher KLG. The first knee had greater pain reduction (−10.6 at 2 weeks, −27.4 at 6 weeks) compared to the second (9.3 at 2 weeks, −8.1 at 6 weeks) (P < .0001) and better improvement in Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) score (8.5 at 2 weeks, 16.9 at 6 weeks) compared to the second (−5.8 at 2 weeks, 5.0 at 6 weeks) (P < .0001). The 1-year outcomes between first and second knees, or recovery curves, were not different when stratifying by time between TKAs. ConclusionsThe second knee in a staged BTKA has less delta improvement in KOOS JR and pain scores at early follow-up, likely due to higher starting KOOS JR and Patient-Reported Outcomes Measurement Information System scores, despite similar final patient satisfaction and clinical outcome measures. Lower KLG in the second total knee arthroplasty (TKA) may contribute to these findings. An MUA after the first TKA is highly predictive of an MUA after the second TKA.

Deficient gait function despite effect index of the Western Ontario and McMaster university osteoarthritis index score considered cured one year after bilateral total knee arthroplasty

BackgroundTo clarify the value of gait analysis and its consistency with traditional scoring scales for the evaluation of knee joint function after total knee arthroplasty (TKA).MethodsThis study included 25 patients with knee osteoarthritis (KOA) who underwent bilateral TKA, and 25 conditionally matched healthy individuals, categorised into the experimental and control groups, respectively. Patients in the experimental group underwent gait analysis and Western Ontario and McMaster University Osteoarthritis Index (WOMAC) evaluation before and 1 year after TKA. Weight-bearing balance and walking stability were assessed using discrete trends of relevant gait indicators. Pearson’s correlation analysis was performed on the gait and WOMAC score data of the experimental group before and after TKA.ResultsOne year after TKA, patients’ gait indices (except gait cycle) were significantly better than before surgery, but significantly worse than that of the control group (P < 0.01). The shape of patients’ plantar pressure curves did not return to normal. Additionally, the discrete trend of related gait indicators reflecting weight-bearing balance and walking stability were smaller than before TKA, but still greater than that of the control group. The WOMAC scores of patients 1 year after TKA were significantly lower than those before TKA (P < 0.001), and the efficacy index was > 80%. The WOMAC scores and gait analysis results were significantly correlated before TKA (P < 0.05).ConclusionsGait analysis should be used in conjunction with scoring scales to assess joint functions.

A comprehensive comparative study on mid-term clinical and functional outcomes in Indian patients following bilateral total knee arthroplasty: assessing the impact of body mass index on post-total knee arthroplasty results

Background: Limited research exists on Indian obese patients undergoing simultaneous bilateral total knee arthroplasty (bTKA), necessitating a comprehensive and comparative analysis with non-obese counterparts. This study presents an observational and prospective assessment of Indian patients who underwent cruciate retaining/posterior stabilized (CR/PS) metal-backed implant surgeries from 2016 to 2019. Methods: The study encompassed 190 patients (380 knees) undergoing bTKA, classified by World Health Organization (WHO) weight stratification: normal weight (cohort 1, n=51), overweight (cohort 2, n=85), and obese (cohort 3, n=54). Primary endpoints were implant survivorship and revision rates, with secondary endpoints including range of motion (ROM), knee society score (KSS), Western Ontario and McMaster Universities osteoarthritis index (WOMAC), and SF-36 scores. Results: Female representation dominated all groups (88.24%, 87.06%, and 90.74%). End-stage osteoarthritis occurred in 94.12%, 96.47%, and 98.15%, respectively. Over the 3-year follow-up, four fatalities occurred, with 186 patients completing the study. ROM showed significant improvement after three years, with baseline values increasing from 93.29°±18.29° (cohort 1) to 123.97°±2.28°, 122.86°±5.03°, and 122.67°±4.77°, respectively (p&lt;0.001). KSS demonstrated substantial improvement (cohort 1: 89.87±6.48, cohort 2: 90.47±8.40, cohort 3: 90.52±8.07) after three years. A 100% success rate and no revisions indicated implant durability. WOMAC and SF-36 questionnaires exhibited significant improvements in pain, stiffness, and overall well-being (p&lt;0.001) after bTKA. Conclusions: This mid-term CR/PS knee survival analysis underscores 100% implant functionality, improved knee function, and enhanced quality of life for all patients, irrespective of their body mass index (BMI). Simultaneous bilateral TKA with CR/PS implants demonstrates favourable outcomes, affirming its efficacy as a viable treatment option.

The Impact of Preoperative Medical Evaluation in an Orthopaedic Perioperative Medical Clinic on Total Joint Arthroplasty Outcomes: An Observational Study.

A preoperative medical evaluation (PME) in total joint arthroplasty (TJA) is routine despite considerable variation and uncertainty regarding its benefits. The orthopaedic department in our academic health system established a perioperative medical clinic (PMC) to standardize perioperative management and to study the effect of this intervention on total hip arthroplasty (THA) and total knee arthroplasty (TKA) outcomes. This observational study compared the impact of a PME within 30 days prior to surgery at the PMC (Periop30) versus elsewhere ("Usual Care") on postoperative length of stay (LOS), extended LOS (i.e., a stay of >3 days), and Patient-Reported Outcomes Measurement Information System-10 (PROMIS-10) Global Physical Health (GPH) score improvement in TJA. We stratified adult patients (≥18 years of age) who underwent primary TJA between January 2015 and December 2020 into Periop30 or Usual Care. We utilized univariate tests (a chi-square test for categorical variables and a t test for continuous variables) to assess for differences in patient characteristics. For both TKA and THA, LOS was assessed with use of multivariable negative binomial regression models; extended LOS, with use of binary logistic regression; and PROMIS-10 GPH score, with use of mixed-effects models with random intercept and slope. Interaction terms between the focal predictor (Periop30, yes or no) and year of surgery were included in all models. Periop30 comprised 82.3% of TKAs (1,911 of 2,322 ) and 73.8% of THAs (1,876 of 2,541). For THA, the Periop30 group tended to be male (p = 0.005) and had a higher body mass index (p = 0.001) than the Usual Care group. The Periop30 group had a higher rate of staged bilateral THA (10.6% versus 7.5%; p = 0.028) and a lower rate of simultaneous bilateral TKA (5.1% versus 12.2%; p < 0.001) than the Usual Care group. Periop30 was associated with a lower mean LOS for both TKA (43.46 versus 54.15 hours; p < 0.001) and THA (41.07 versus 57.94 hours; p < 0.001). The rate of extended LOS was lower in the Periop30 group than in the Usual Care group for both TKA (15% versus 26.5%; p < 0.001) and THA (13.3% versus 27.4%; p < 0.001). There was no significant difference in GPH score improvement between Periop30 and Usual Care for either TKA or THA. Periop30 decreased mean LOS and the rate of extended LOS for TJA without an adverse effect on PROMIS-10 GPH scores. Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Subsequent total joint arthroplasty: Are we learning from the first stage?

With the increasing incidence of total joint arthroplasty (TJA), there is a desire to reduce peri-operative complications and resource utilization. As degenerative conditions progress in multiple joints, many patients undergo multiple procedures. To determine if both physicians and patients learn from the patient's initial arthroplasty, resulting in improved outcomes following the second procedure. The institutional database was retrospectively queried for primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). Patients with only unilateral THA or TKA, and patients undergoing same-day bilateral TJA, were excluded. Patient demographics, comorbidities, and implant sizes were collected at the time of each procedure and patients were stratified by first vs second surgery. Outcome metrics evaluated included operative time, length of stay (LOS), disposition, 90-d readmissions and emergency department (ED) visits. A total of 642 patients, including 364 undergoing staged bilateral TKA and 278 undergoing bilateral THA, were analyzed. There was no significant difference in demographics or comorbidities between the first and second procedure, which were separated by a mean of 285 d. For THA and TKA, LOS was significantly less for the second surgery, with 66% of patients having a shorter hospitalization (P < 0.001). THA patients had significantly decreased operative time only when the same sized implant was utilized (P = 0.025). The vast majority (93.3%) of patients were discharged to the same type of location following their second surgery. However, when a change in disposition was present from the first surgery, patients were significantly more likely to be discharged to home after the second procedure (P = 0.033). There was no difference between procedures for post-operative readmissions (P = 0.438) or ED visits (P = 0.915). After gaining valuable experience recovering from the initial surgery, a patient's perioperative outcomes are improved for their second TJA. This may be the result of increased confidence and decreased anxiety, and it supports the theory that enhanced patient education pre-operatively may improve outcomes. For the surgical team, the second procedure of a staged THA is more efficient, although this finding did not hold for TKA.

Computer-Assisted Surgery in Total Knee Arthroplasty: Our Experience.

Total knee arthroplasty (TKA) is a reliable orthopedic procedure for knee osteoarthritis with long-term success rates of 90% after 15years. Computer-assisted surgery (CAS) has been developed to improve the accuracy of the alignment and orientation of the components in TKA. A prospective study involving 103 subjects who underwent CAS-TKA was conducted over a 3-year period. Subjects were assessed for pre- and post-operative varus and valgus deformity, BMI, comorbidities, and Knee Society Score (KSS). Outcome measures of post-operative KSS, post-operative alignment, and hospital stay were examined by Spearman correlation coefficients. Categorical outcomes of complication and secondary procedures were compared by chi-squared test and odds ratio. The study considered 103 TKA patients with a mean ± SD age of 63.7 ± 8.4years (33-88years). Unilateral knee replacement was performed on 56 patients (54.3%) and remaining 47 (45.6%) had simultaneous bilateral TKA. Forty (34.8%) patients were obese, and severe pre-operative deformity (> 15°) was observed in 47 (31.3%) patients. Mean coronal alignment of the knee joint was 91.33° (SD: 90.69° valgus-88.92° varus). The mean post-operative KSS noted in obese and non-obese subjects were 93.43 (84-98) and 94.76 (85-98) respectively. Post-operative KSS for knees with severe deformity was 94.08 (80-98), while it was 95.76 (83-98) in those with mild to moderate deformities. The study confirms that navigation in CAS-TKA consistently achieved coronal alignment of the knee joint within ± 3°, irrespective of the patient BMI and degree of deformity.

First knee for pain and function versus second knee for quality of life.

The aim of this study was to describe and compare joint-specific and generic health-related quality of life outcomes of the first versus second knee in patients undergoing staged bilateral total knee arthroplasty (BTKA) for osteoarthritis. This retrospective cohort study used Australian national arthroplasty registry data from January 2013 to January 2021 to identify participants who underwent elective staged BTKA with six to 24 months between procedures. The primary outcome was Oxford Knee Score (OKS) at six months postoperatively for the first TKA compared to the second TKA, adjusted for age and sex. Secondary outcomes compared six-month EuroQol five-dimension five-level (EQ-5D-5L) domain scores, EQ-5D index scores, and the EQ visual analogue scale (EQ-VAS) between knees at six months postoperatively. The cohort included 635 participants (1,270 primary procedures). Preoperative scores were worse in the first knee compared to the second for all instruments; however, comparing the first knee at six months postoperatively with the second knee at six months postoperatively, the mean between-knee difference was minimal for OKS (-0.8 points; 95% confidence interval (CI) -1.4 to -0.2), EQ-VAS (3.3; 95% CI 1.9 to 4.7), and EQ-5D index (0.09 points; 95% CI 0.07 to 0.12). Outcomes for the EQ-5D-5L domains 'mobility', 'usual activities', and 'pain/discomfort' were better following the second TKA. At six months postoperatively, there were no clinically meaningful differences between the first and second TKA in either the joint-specific or overall generic health-related quality of life outcomes. However, individual domain scores assessing mobility, pain, and usual activities were notably higher after the second TKA, likely reflecting the cumulative improvement in quality of life after both knees have been replaced.

Comparison of blood loss between intra-articular microporous polysaccharide hemospheres powder and tranexamic acid following primary total knee arthroplasty

Total knee arthroplasty (TKA) is associated with substantial blood loss and tranexamic acid (TXA) effectively reduces postoperative bleeding. Although it is known that there is no difference between intravenous or intra-articular (IA) injection, the general interest is directed towards topical hemostatic agents regarding thromboembolic events in high-risk patients. This study aimed to compare the blood conservation effects of IA MPH powder and TXA in patients undergoing primary TKA. We retrospectively analyzed 103 patients who underwent primary TKA between June 2020 and December 2021. MPH powder was applied to the IA space before capsule closure (MPH group, n = 51). TXA (3 g) was injected via the drain after wound closure (TXA group, n = 52). All patients underwent drain clamping for three postoperative hours. The primary outcome was the drain output, and the secondary outcomes were the postoperative hemoglobin (Hb) levels during the hospitalization period and the perioperative blood transfusion rates. An independent Student’s t-test was used to determine differences between the two groups. The drain output in the first 24 h after surgery was significantly higher in the MPH group than in the TXA group. The postoperative Hb levels were significantly lower in the MPH group than in the TXA group. In patients with simultaneous bilateral TKA, there was a significant difference in the blood transfusion volumes and the rates between groups. It is considered that IA MPH powder cannot replace IA TXA because of an inferior efficacy in reducing blood loss and maintaining postoperative Hb levels in the early postoperative period after primary TKA. Moreover, in the case of simultaneous bilateral TKA, we do not recommend the use of IA MPH powder because it was notably less effective in the field of transfusion volume and rate.

Comparison of Short-term Results: Robotic-assisted vs. Conventional Bilateral Total Knee Arthroplasty

Introduction: Robotic-assisted total knee arthroplasty is becoming widely accepted as a method to improve intra-operative measures and post-operative functional outcomes. While there is a large body of evidence supporting robotic-assisted unilateral total knee arthroplasty (TKA), few studies have examined the outcomes of this technology in simultaneous bilateral TKA procedures. Thus, the purpose of the study is to compare the clinical outcomes between patients undergoing simultaneous robot-assisted bilateral total knee arthroplasty (raTKA) versus conventional bilateral total knee arthroplasty (convTKA). Methods: We retrospectively reviewed 140 simultaneous bilateral TKA cases (61 conventional, 79 robot-assisted) performed by a single surgeon in a single institution from January 1, 2015 to December 11, 2020. The institution’s electronic medical records were reviewed for patient demographic information, operative data, and post-operative complications. Outcomes Based Electronic Research Database (OBERD) records were reviewed for patient-reported outcomes (Oxford Knee Score and SF-12 Version 1) preoperatively and postoperatively at 6 months, 1 year, and 2 years. Results: Both raTKA and convTKA groups exhibited clinically relevant improvements beyond the minimally clinically important difference (MCID) in SF-12 physical and Oxford Knee Scores at 6 months, 1 year, and 2 years post-surgery. There were no statistically significant differences found between the two groups in terms of postoperative SF-12 scores, Oxford Knee Scores, complications, or revision rates. The raTKA group had a longer length of stay (2.6 versus 2.2 days, P=0.001) and a significantly different discharge disposition with more patients entering acute rehab compared to the convTKA group (20 versus 7 patients respectively, P=0.031). Conclusion: Robotic-assisted total knee arthroplasty has a non-inferior impact on short-term patient outcomes compared to conventional methods in patients undergoing simultaneous bilateral total knee arthroplasty. Level of evidence: III

Moving a skin incision to lateral side of tibial tubercle reduces the risk of persistent skin numbness compared with a regular midline one: A randomized paired study in bilateral total knee arthroplasty

BackgroundThe midline incision during total knee arthroplasty (TKA) is known to damage the infrapatellar branch of the saphenous nerve (IPBSN), leading to lateral flap numbness. The aim was to evaluate the rate of persistent skin numbness (RSN) and area of skin numbness (AON) after a lateral-based skin incision compared with the standard midline incision in bilateral TKA patients. MethodsThirty-six patients undergoing bilateral TKA were included and randomly assigned to receive the lateral skin incision (lateral side of the tibial tubercle) on one knee and the standard midline incision on the contralateral. All other surgical steps were identical. Primary outcomes were the RSN at 1 year and the AON at 6 weeks, 3, 6, and 12 months postoperatively. Kneeling ability test (KAT), operative time, and length of incision were also recorded. ResultsThe lateral incision had half the RSN at 12 months compared to the midline incision (25% vs 53%; p = 0.01). The median AON at 1-year after surgery was 0 [0–0.5] cm2 in lateral incision vs 4 [0–7.5] cm2 in midline group (p < 0.001). KAT was minimally better in the lateral group at 110° of kneeling between 6-month to 1-year. Operative time and length of incision were similar between both groups. ConclusionThe lateral skin incision reduced RSN by approximately 50% compared with the midline incision. The AON in lateral incision was 4 cm2 smaller than midline at 1-year after surgery. Moving a skin incision more lateral may be considered to minimize the numbness after TKA.

Kinematic Alignment Technique Outperforms Mechanical Alignment in Simultaneous Bilateral Total Knee Arthroplasty: A Randomized Controlled Trial

BackgroundThe aim of this study was to compare the clinical results of kinematic alignment (KA) with those of mechanical alignment (MA) in single-stage bilateral total knee arthroplasty. MethodsIn this double-blinded randomized controlled trial, 65 patients who had bilateral knee osteoarthritis underwent simultaneous bilateral total knee arthroplasty. One knee was randomly selected to be operated on with the calipered-KA technique and the other with MA. The participants were assessed via the Oxford Knee Score, Western Ontario and McMaster Universities Osteoarthritis Index questionnaire, and visual analog scale before the surgery and the same plus the Forgotten Joint Score at their last follow-up visit, 2 years postoperatively. Maximum knee flexion and the time reaching maximum knee flexion, named the recovery time, were also recorded. Hip-knee-ankle angle, medial proximal tibial angle, and lateral distal femoral angle were measured before and after the surgery using 3-joint-view radiographs. ResultsAt 2 years, there were significant differences between the KA and MA techniques in terms of duration of surgery, recovery time, and final Western Ontario and McMaster Universities Osteoarthritis Index, Forgotten Joint Score, and maximum flexion range in favor of KA (P < .05), but no significant difference in visual analog scale score or Oxford Knee Score. In patients who have a preferred knee, the KA knee was preferred over the MA knee by most patients. No prosthetic failure or revision was reported in either group. ConclusionsThe KA technique yields acceptable functional outcomes compared to the MA technique. The KA technique was associated with a shorter surgery time, a faster recovery time, and higher patient satisfaction in 2-year follow-ups. Larger multicenter studies with longer follow-ups are warranted to confirm these findings. Level of EvidenceI.

Efficacy of a Combined Periarticular and Intraosseous Multimodal Analgesic Injection Technique in Simultaneous Bilateral Total Knee Arthroplasty: A Randomized Controlled Trial.

Introduction Early postoperative pain poses a challenge for surgeons to manage after total knee arthroplasty (TKA). Various techniques have been employed to optimize pain reduction, including Periarticular Multimodal Analgesia (PMA), recognized as a safe and effective method. Our study aims to enhance PMA through a combined intraosseous injection (PMA-I) and compare it with standard PMA. Methods Forty patients undergoing simultaneous bilateral TKA surgery were enrolled. Patients were randomized to receive PMA-I on one side of the knee, while the contralateral knee received standard PMA. Pain scores, bleeding, and range of motion (ROM) were assessed in both groups. Results The PMA-I group demonstrated statistically significant lower visual analog scale (VAS) scores at all postoperative time points, except at 48 hours, where the difference was not statistically significant. Postoperative bleeding and ROM did not significantly differ between groups. Conclusion PMA-I demonstrated both statistically and clinically significant reduction in early post-TKA pain, without additional costs, providing a technique that can be used to optimize postoperative pain control in TKA.

Comparison of the effect of open-box versus closed-box prostheses on blood loss following total knee arthroplasty: a meta-analysis

Purpose: Postoperative blood loss is a common complication following total knee arthroplasty (TKA). The authors aimed to analyze the significance of open versus closed-box prostheses in reducing blood loss after TKA. Methods: PubMed, Cochrane, Scopus, and Web of Science were searched. Observational studies and clinical trials comparing the effect of open-box versus closed-box prostheses on blood loss following TKA were included. The primary outcome was total blood loss following TKA. Secondary outcomes included average transfused units and total operation time. Continuous data were represented as mean difference (MD) and CI, while dichotomous data were presented as odds ratio (OR) and CI. RevMan software version 5.4 was used to conduct the analysis. Results: Four studies with a total number of 687 patients were included. The pooled analysis showed a statistically significant association between closed-box and decreased total blood loss following TKA compared with open-box (MD=173.19, 95% CI=88.77–257.61, P value &lt;0.0001). Similar findings were reported in unilateral TKA (MD=190.63, 95% CI=70.91–310.35, P value=0.002), and bilateral TKA (MD=160.79, 95% CI=61.70–359.86, P value=0.001). There was no significant difference between open and closed-box regarding average transfused units (MD=0.02, 95% CI=−0.07–0.11, P value=0.68), blood transfusion rate (OR=1.38, 95% CI=0.85–2.26, P value=0.20), length of stay (MD=0.06, 95% CI=−0.27 to 0.38, P value=0.74), and total operation time (MD=1.08, 95% CI=−4.62 to 6.79, P value=0.71). Conclusion: Closed-box reduces the total blood loss following unilateral and bilateral TKA. More studies are warranted to explore the benefits of Closed-box in patients with high bleeding susceptibility.

Duloxetine as an Analgesic in Patients Who Do Not Have Central Sensitivity Undergoing Single-Setting, Bilateral Total Knee Arthroplasty: A Prospective, Double-Blinded, Randomized, Placebo-Controlled Trial

BackgroundPain control and patient satisfaction after total knee arthroplasty (TKA) have room for improvement. While studies have reported better analgesic outcomes with antidepressants like duloxetine in patients who do not have central sensitivity (CS), we undertook this trial to determine the short and midterm analgesic role of low-dose duloxetine in patients who do not have CS. MethodsThis prospective, double-blinded, randomized, placebo-controlled trial was conducted in 106 patients undergoing single-setting, bilateral TKA under spinal anesthesia. There were 2 matched groups, with one given 20 mg of duloxetine and the other given a placebo (similar in appearance and weight) from preoperative day 2 to postoperative day 28. Follow-ups were scheduled at 48-hours, 1-week, 2-weeks, 4-weeks, and 3-months. Pain was measured using a visual analogue scale at rest and visual analogue scale at mobilization (mVAS). Secondary measures included additional non-steroidal anti-inflammatory drug consumption, patient satisfaction, and safety profile. ResultsThe visual analogue scale at rest in the duloxetine group was better in the first 48 hours (6.38 ± 1.32 versus 7.02 ± 0.99; P = .017), 1-week (4.76 ± 1.24 versus 5.89 ± 1.06; P < .001), and 2-weeks (3.34 ± 1.19 versus 4.26 ± 1.02; P < .001) follow-up. The mVAS remained significantly higher in the duloxetine group in the first 48 hours (7.23 ± 1.12 versus 8.21 ± 0.69; P < .001), 1-week (5.83 ± 1.11 versus 6.82 ± 0.92; P < .001), and 2 weeks (3.70 ± 0.89 versus 4.60 ± 1.03; P < .001) follow-up. Both outcomes became comparable from 4-week follow-up onward. Patient satisfaction (8.44 ± 1.68 versus 7.17 ± 1.04; P < .001) and additional non-steroidal anti-inflammatory drug consumption (2,770 ± 533.05 versus 3,566.04 ± 464.54; P < .001) were better in the duloxetine group, with a comparable safety profile. ConclusionsIn patients who did not have CS, persistent pain after bilateral TKA can be managed safely and successfully by a daily dose of 20 mg Duloxetine, improving patient satisfaction and analgesic consumption in the acute postoperative phase.