Simultaneous Bilateral Arthroplasty Research Articles

Simultaneous bilateral arthroplasty of the hip by anterior approach. A case report

Simultaneous bilateral arthroplasty of the hip by anterior approach. A case report

A Time-Driven Activity-Based Costing Analysis of Simultaneous Versus Staged Bilateral Total Hip Arthroplasty and Total Knee Arthroplasty

BackgroundAlthough studies have compared the claims costs of simultaneous and staged bilateral total hip arthroplasty (THA) and total knee arthroplasty (TKA), whether a simultaneous procedure is cost-effective to the facility remains unknown. This study aimed to compare facility costs and perioperative outcomes of simultaneous vs staged bilateral THA and TKA. MethodsWe reviewed a consecutive series of 560 bilateral THA (170 staged and 220 simultaneous) and 777 bilateral TKA (163 staged and 451 simultaneous). Itemized facility costs were calculated using time-driven activity-based costing. Ninety-day outcomes were compared. Margin was standardized to unadjusted Medicare Diagnosis Related Group payments (simultaneous, $18,523; staged, $22,386). Multivariate regression was used to determine the independent association between costs/clinical outcomes and treatment strategy (staged vs simultaneous). ResultsSimultaneous bilateral patients had significantly lower personnel, supply, and total facility costs compared with staged patients with no difference in 90-day complications between the groups. Multivariate analyses showed that overall facility costs were $1,210 lower in simultaneous bilateral THA (P < .001) and $704 lower in TKA (P < .001). Despite lower costs, margin for the facility was lower in the simultaneous group ($6,569 vs $9,225 for THA; $6,718 vs $10,067 for TKA; P < .001). ConclusionSimultaneous bilateral TKA and THA had lower facility costs than staged procedures because of savings associated with a single hospitalization. With the increased Medicare reimbursement for 2 unilateral procedures, however, margin was higher for staged procedures. In the era of value-based care, policymakers should not penalize facilities for performing cost-effective simultaneous bilateral arthroplasty in appropriately selected patients.

Одноэтапное билатеральное тотальное эндопротезирование тазобедренных суставов.Современные представления и наш опыт

Summary. Relevance. Total hip arthroplasty remains one of the most successful and cost-effective surgical interventions in modern medicine. This is proven by the ever-growing number of total arthroplasties worldwide, which reached 650,000 implantations in Europe only in 2018. In 2024, this number is expected to be 730,000 [1]. According to experts, from 15 to 25 percent of patients need a bilateral procedure [2, 8]. The experience of our Center allows us to recommend a successful one-stage replacement of both hip joints for patients with a number of medical and social comorbidities. Objective. The study is set out to highlight the possibilities of performing simultaneous bilateral arthroplasty of the hip joint in a group of patients with bilateral joint damage, as well as to substantiate the economic, medical and social benefits of this surgical intervention. Materials and Methods. We have analyzed the data from publications of our foreign colleagues. We also present our own observations – more than 100 cases over the past 11 years (2008-2019). Results. Based on data from foreign publications and our own observations, the undoubted advantages, features and limitations of this type of surgical intervention are shown. Complex cases of bilateral joint damage and the results of one-stage surgical treatment have been demonstrated. Conclusions. One-stage bilateral hip arthroplasty is the method of choice for symmetric lesions and should take its rightful place in the arsenal of modern orthopedics clinics. We continue to advocate simultaneous bilateral hip replacement for a selected group of healthy patients ≤65 years old. Thoughtful preoperative planning, surgical intervention lasting up to 90 minutes on each joint, careful postoperative monitoring, strictly controlled prevention of thromboembolic complications and active postoperative rehabilitation provide our patients with quick and safe functional recovery.

Postoperative Blood Use Following Elective Total Hip and Total Knee Arthroplasty

Abstract 1181Use of allogeneic blood in elective procedures should be minimized due to risks of transfusion, potential adverse impact on outcomes, inconvenience to the patient, high cost and limited supply of blood. The purpose of this study was to examine the rate of transfusion following elective total hip (THA) and total knee arthroplasties (TKA) within a preoperative and perioperative blood management program and to examine the relationship between clinical and surgical parameters and blood transfusion. Methods:This was a secondary analysis of prospectively collected data of all consented patients who had undergone joint arthroplasty surgery between January and December, 2011. All patients attended a preoperative clinic 7–14 days prior to their surgery. The preoperative hemoglobin (Hgb) was measured. Transfusion rate was calculated for type of surgery (primary vs. revision and unilateral vs. bilateral). Impact of preoperative Hgb, age, sex, Body Mass Index (BMI), estimated blood loss, type of anaesthetic, type of anticoagulant (rivaroxaban vs. no rivaroxaban), surgeon and drop in hemoglobin (preoperative hemoglobin minus lowest post-operative hemoglobin documented on postoperative day 1, 2 or 3) were examined. Descriptive statistics examined the rate of transfusion in different procedures. Univariate analysis examined the relationship between each factor and having a transfusion. Stepwise logistic regression examined the impact of all factors together. Statistical significance was set at p<0.05. Results:1605 patients [989 females (62%), mean age 66 (SD:11)] had surgery during 2011. Primary TKA: Unilateral 821 (51%), Bilateral TKA: 41 (3%), Revision TKA: 91 (6%), Primary THA: 588 (37%), Bilateral THA: 4 (0.02%), Revision THA: 60 (4%). Four percent (4%) of females had an Hgb <120 mg/L and 3% of males had an Hgb <130 mg/L at the preoperative visit. There were 1555 cases done under regional anaesthesia (spinal or epidural) and 129 cases received a general anaesthetic. Sixty-seven patients (4%) had a blood transfusion while in hospital. Thirty percent (30%) of the transfused women and 9% of the men had a low pre-operative Hgb. THA procedures required more transfusions than TKA (p=0.0012). Transfusion was associated with the following individual factors: age ≥ 80 years, female sex, low BMI (<18.5), increased estimated blood loss, larger drop in hemoglobin, type of anticoagulant (4% in rivaroxaban vs. 8% in non-rivaroxaban), revision surgery (vs. primary), simultaneous bilateral arthroplasty, general anesthesia (vs. spinal), and surgeon. Stepwise logistic regression analysis maintained the intra-operative blood loss, drop in Hgb, female sex, and age as significant independent factors in explaining the variation in blood transfusion. Discussion:This study was carried out in an independent orthopaedic facility for elective joint surgery. All patients are assessed medically prior to surgery and advised to take supplemental iron for 2 months prior to surgery. Four percent of females and 3% of males were found to be anemic preoperatively. Patients are admitted the morning of their surgery. Approximately 97% of the consented patients had a regional anesthetic (spinal and/or epidural) with sedation. Patients are transferred into the operating room after the anaesthetic was administered. Surgery is carried out without the routine use of cell saver, tranexamic acid or drains. Approximately 50% of the surgeons deflate the tourniquet in a total knee arthroplasty prior to closure of the capsule. Thromboprophylaxis is initiated with rivaroxaban 10 mg on postoperative day 1. The general transfusion trigger for symptomatic patients is a hemoglobin of 80 g/L. Transfusions can be ordered by staff surgeon, hospitalist, medical consultant or Orthopaedic fellow. The blood bank does not group and screen patients scheduled for routine primary total hip or total knee arthroplasty. Following these practices, we observed a transfusion rate for primary THA of 5% and primary TKA of 3% while using rivaroxaban for thromboprophylaxis starting on postoperative day 1. Conclusion:The present study confirmed that intra-operative blood loss, drop in the hemoglobin, being a female, and older than 80 years of age as risk factors in relation to need for blood transfusion following elective total joint arthroplasty. Transfusion rates were not higher when rivaroxaban was used for thromboprophylaxis. Disclosures:Murnaghan:Bayer Healthcare: Honoraria, Research Funding. Off Label Use: Rivaroxaban was used perioperatively for thromboprophylaxis. Our protocol gave the intial dose on postoperative day 1 rather than the 6–10 hours post-operatively recommended by the manufacturer in product monograph. Gollish:Bayer Healthcare: Honoraria, Research Funding.

Surgical practices in total knee arthroplasty in Turkey

The aim of this study was to determine the current practices in the total knee arthroplasty (TKA) and the differences of practice among the orthopedic surgeons in Turkey. Data in this cross-sectional and descriptive study was collected through a questionnaire from 76 orthopaedic surgeons performing TKA. The questionnaire form contained 57 questions under four main headings, covering the professional properties of the surgeon, pre-surgery approach, surgical technique applied for TKA and the surgical details peculiar to the technique with solutions applied for complication scenarios, and finally the postoperative approach. It was determined that 39.7% of the TKA applications were performed in operating theatres without laminar airflow or HEPA filters. Nearly 1/5 of the surgeons used more than one antibiotic for prophylaxis, and more than 85% continued prophylaxis use over 3 days. Low-molecular-weight heparin was the most commonly used method for thromboprophylaxis. 94.67% of the surgeons used only the cemented technique in primary TKA. 44% indicated that they performed simultaneous bilateral arthroplasty, 89% did not use any scoring system and 72.37% preferred fixed-bearing and posterior-cruciate-retaining type prosthesis. Results showed no standardization in TKA surgery among surgeons in Turkey, and important educational deficiencies were noted.

A Population-Based Comparison of the Incidence of Adverse Outcomes After Simultaneous-Bilateral and Staged-Bilateral Total Knee Arthroplasty

It is unclear whether simultaneous-bilateral total knee arthroplasty is as safe as staged-bilateral arthroplasty is. We are aware of no randomized trials comparing the safety of these surgical strategies. The purpose of this study was to retrospectively compare these two strategies, with use of an intention-to-treat approach for the staged-bilateral arthroplasty cohort. We used linked hospital discharge data to compare the safety of simultaneous-bilateral and staged-bilateral knee arthroplasty procedures performed in California between 1997 and 2007. Estimates were generated to take into account patients who had planned to undergo staged-bilateral arthroplasty but never underwent the second procedure because of death, a major complication, or elective withdrawal. Hierarchical logistic regression modeling was used to adjust the comparisons for patient and hospital characteristics. The principal outcomes of interest were death, a major complication involving the cardiovascular system, and a periprosthetic knee infection or mechanical malfunction requiring revision surgery. Records were available for 11,445 simultaneous-bilateral arthroplasty procedures and 23,715 staged-bilateral procedures. On the basis of an intermediate estimate of the number of complications that occurred after the first procedure in a staged-bilateral arthroplasty, patients who underwent simultaneous-bilateral arthroplasty had a significantly higher adjusted odds ratio (OR) of myocardial infarction (OR = 1.6, 95% confidence interval [CI] = 1.2 to 2.2) and of pulmonary embolism (OR = 1.4, 95% CI = 1.1 to 1.8), similar odds of death (OR = 1.3, 95% CI = 0.9 to 1.9) and of ischemic stroke (OR = 1.0, 95% CI = 0.6 to 1.6), and significantly lower odds of major joint infection (OR = 0.6, 95% CI = 0.5 to 0.7) and of major mechanical malfunction (OR = 0.7, 95% CI = 0.6 to 0.9) compared with patients who planned to undergo staged-bilateral arthroplasty. The unadjusted thirty-day incidence of death or a coronary event was 3.2 events per thousand patients higher after simultaneous-bilateral arthroplasty than after staged-bilateral arthroplasty, but the one-year incidence of major joint infection or major mechanical malfunction was 10.5 events per thousand lower after simultaneous-bilateral arthroplasty. Simultaneous-bilateral total knee arthroplasty was associated with a clinically important reduction in the incidence of periprosthetic joint infection and malfunction within one year after arthroplasty, but it was associated with a moderately higher risk of an adverse cardiovascular outcome within thirty days. If patients who are at higher risk for cardiovascular complications can be identified, simultaneous-bilateral knee arthroplasty may be the preferred surgical strategy for the remaining lower-risk patients.

Contemporary Total Hip Arthroplasty with and without Cement in Patients with Osteonecrosis of the Femoral Head

We previously evaluated ninety-eight consecutive patients (148 hips) at mean of 9.3 years after total hip arthroplasty; the mean age at the time of the index surgical procedure was 47.3 years. Fifty patients (100 hips) had simultaneous bilateral arthroplasty with a cemented stem in one hip and a cementless stem in the contralateral hip. Forty-eight patients (forty-eight hips) had unilateral hip arthroplasty with a cementless stem. All patients had a cementless acetabular component. In our first report, we found no difference in clinical results, as measured with the Harris hip score and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), between the cementless and cemented stems. One hip (2%) in the hybrid group (a cementless cup and a cemented stem) had revision because of infection and two hips (2%) in the fully cementless group had revision of the femoral component because of a periprosthetic fracture. Between the time of follow-up in that study (at a mean of 9.3 years) and the time of follow-up in the present study (at a mean of 17.3 years), twenty-two revisions of acetabular components were performed, with eight in the hybrid group and fourteen in the fully cementless group. There was no difference in clinical results, as measured with the Harris hip score and the WOMAC, between the hybrid and fully cementless groups. At the time of the present review, forty (83%) of forty-eight acetabular components in the hybrid group and eighty (85%) of ninety-four acetabular components in the fully cementless group were intact. Most of the femoral components (98%) in both groups were intact. Wear and periacetabular osteolysis were the causes of failure in the hips requiring revision.

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.

Who Needs Autologous Blood Donation in Joint Replacement?

Conflicting results are available about the efficacy of routine preoperative autologous donation (PAD) in reducing allogenic blood transfusion during total joint arthroplasty (TJA). This study aimed to determine if PAD is effective in reducing the need for allogenic transfusion after TJA. For this retrospective study, data on 409 patients who received total knee arthroplasty (TKA) and 513 who underwent total hip arthroplasty (THA) from January to June 2005 were evaluated. It is our institutional policy to offer preoperative donation to all patients. Based on patient decision, preoperative hemoglobin, and other factors, PAD may or may not take place. Five hundred forty-six (61%) patients donated on average 1.3 units (range, 1 to 2) of blood. Autologous and allogenic transfusions were respectively performed in 91% (514 patients) and 24% of our cohort. The rate of allogenic transfusion after TKA was lower in the PAD group at 21% versus 27% among the nondonors, although it was not statistically significant (p = 0.10). The allogenic transfusion rate after THA was significantly lower among autologous donors (16% versus 34%, p = 0.003). Advanced age, lower body mass index, simultaneous bilateral arthroplasty, and lower preoperative hemoglobin were independently associated with increased allogenic blood transfusion. PAD seems to be effective in reducing allogenic transfusions after THA but not TKA.

Predicting Pain After Total Knee Arthroplasty

Six hundred twenty-two primary total knee arthroplasties were studied prospectively in 512 patients. A group with no pain and one with severe pain at 5 years were statistically compared. The following were significant predictors of poor pain outcomes: age below 60 (17%) compared with above 60 (7%, P < .05). The first knee was most likely to be in the poor outcome group (13%) compared with the second knee (6%). In contrast, patients who underwent simultaneous bilateral arthroplasty faired better (2%, P < .01). Performing lateral release and sacrificing the posterior cruciate ligament also significantly predicted for poor pain outcomes but may have been influenced by selection bias. We conclude that avoiding surgery in patients younger than 60 and choosing a simultaneous approach to bilateral disease reduce the chance of poor pain outcomes.

Simultaneous bilateral total knee arthroplasties: who decides?

The purpose of the current retrospective review was to compare the results of 1498 patients having 1090 simultaneous bilateral total knee arthroplasties and 958 unilateral total knee arthroplasties in a 3-year period, focusing on perioperative complications, length of hospital stay, and discharge disposition. Gender, age, diagnosis, and weight were similar between the groups. Patients undergoing simultaneous bilateral total knee arthroplasties had statistically significant higher amounts of intraoperative blood loss, with more patients requiring blood transfusion, and a higher average number of units of blood transfused compared with patients undergoing unilateral total knee arthroplasty. Overall, a significantly higher incidence of gastrointestinal complications was reported in patients who had simultaneous bilateral knee arthroplasties compared with patients who had unilateral knee arthroplasty. Comparing age subgroups within the unilateral group revealed significantly higher incidences of pulmonary, neurologic, cardiac, and genitourinary complications among patients 80 years or older versus patients younger than 80 years. Patients having simultaneous bilateral arthroplasties who were 80 years or older had significantly higher incidences of pulmonary, neurologic, and cardiac complications than patients younger than 80 years in that same group. These results suggest that age, not procedure, has a more significant role in the perioperative morbidity of total knee arthroplasty. Based on the results from the current study and previous literature documenting patient preference, patient satisfaction, efficacy, and outcomes comparable with those of patients having unilateral total knee arthroplasty, the authors continue to offer patients the option of simultaneous bilateral total knee arthroplasties.

Thirty-day mortality after total knee arthroplasty.

There have been sporadic reports on perioperative mortality associated with total knee arthroplasty. The purpose of this study was to determine risk factors for such mortality. A computer-assisted review of the records of 22,540 consecutive patients who had undergone total knee arthroplasty between 1969 and 1997 was performed to identify all patients who had died within thirty days after the procedure. A detailed analysis of the medical, surgical, anesthetic, and pathological records of the patients was performed, and the mortality was determined according to age, gender, diagnosis, and fixation method. The rate of mortality within thirty days after the operation was 0.21% (forty-seven of 22,540). All deaths occurred in the group of 18,810 patients who had received a cemented implant, and no deaths occurred among the 3730 patients who had received an uncemented implant (p < 0.0001). The mortality rate was 0.24% (forty-three of 18,165) after primary arthroplasty and 0.09% (four of 4375) after revision arthroplasty (p < 0.0003). Three patients (0.01%) died during the operation. Forty-three of the forty-seven patients who died had a history of preexisting cardiovascular and/or pulmonary disease. Simultaneous bilateral total knee arthroplasty was associated with a significantly higher rate of perioperative mortality (p < 0.002). Factors that were associated with a significantly increased mortality after total knee arthroplasty included an age of more than seventy years, primary (as compared with revision) knee surgery, use of a cemented prosthesis, preexisting cardiopulmonary disease, and simultaneous bilateral arthroplasty.

Outcome Implications for the Timing of Bilateral Total Knee Arthroplasties

Health Care Financing Administration data from 1985 to 1990 revealed 339,152 total knee arthroplasties of which 62,730 (18.6%) were bilateral procedures (simultaneous 112,922; staged 6 weeks, 4354; staged 3 months, 4524; staged 6 months, 9829; and staged 1 year 31,401). Medicare beneficiaries undergoing bilateral procedures were an average of 73 years of age; demographics revealed that among the various simultaneous and staged groups 57% to 69% were females, 90% were white, 85% to 90% had a diagnosis of osteoarthritis, and 30% to 40% were performed in rural hospitals. Between 1985 and 1990, surgical and vascular complications ranged from 2.4% to 4% and 4.1% to 6.8%, respectively, for all types of bilateral staged and simultaneous total knee arthroplasties. All differences were statistically significant. After controlling statistically for demographic variables and diagnoses, a surrogate for case mix, it was found that individuals electing simultaneous bilateral arthroplasties experienced twice the number of intensive care days than those choosing staged procedures. Days in the intensive care unit were double when done simultaneously instead of staged (0.48 versus 0.21). Nosocomial infections were similar within groups (10% versus 13%); however, wound infections were nearly half when done simultaneously (0.5% versus 1%) versus in a staged fashion. Length of stay and cost were much less for the simultaneous procedure group who were sicker as measured by the number of diagnoses. Mortality at 30 days was highest for the simultaneous procedure group (.99%) versus staged 3 or 6 months (0.30%); however, by 2 years it was close to 4% for all groups. Staging the procedure 3 to 6 months seems to offer the fewest disadvantages, is only slightly more expensive, and has the lowest mortality rate.