Simultaneous Total Knee Arthroplasty Research Articles

No difference in early functional outcomes for mini-midvastus and limited medial parapatellar approaches in navigation-assisted total knee arthroplasty: a prospective randomized clinical trial

Patients desire less pain and faster recovery of range of knee motion after total knee arthroplasty (TKA). While minimal invasive surgery (MIS) TKA appears to meet these needs, concerns exist regarding component malpositioning. Navigation systems can reduce the incidence of component misalignment. The present prospective randomized study compared limited medial parapatellar (LMPP) and mini-midvastus (MMV) approaches in 30 patients who had bilateral simultaneous primary TKAs. Each patient underwent LMPP on one knee and MMV on the other. Both approaches were navigation-assisted. We primarily analyzed postoperative pain (using visual analog scores), range of knee motion, and hospital for special surgery (HSS) scores in the first 6 postoperative months (i.e., the early postoperative period), and secondarily analyzed perioperative parameters and radiographic outcomes. The LMPP and MMV approaches were found to be similar in terms of pain measured at postoperative 3 days, 1, 2 weeks, 1, 3, and 6 months (P = NS). Similarly, the 2 approaches were found to be similar in terms of range of motion measured at 1, 2 weeks, 1, 3, and 6 months (P = NS), and in terms of HSS scores measured at 1, 3, and 6 months (P = NS). There were also no differences between groups in terms of total blood loss, approach preferred by patients, and radiographic component positioning. The present study found that navigation-assisted MMV and navigation-assisted LMPP resulted in similar outcomes in terms of pain, ROM, HSS score, and radiologic outcomes over the first six postoperative months. We recommend the LMPP approach over the MMV approach in navigation-assisted MIS TKA because it is more familiar to surgeons and is easier to convert to the conventional approach where necessary.

Bilateral simultaneous total knee arthroplasty in severely deformed knees: use of an evidence-based rehabilitation programme

Post-operative rehabilitation after staged total knee arthroplastiess (TKAs) in severely deformed bilateral knee disease can be a very difficult task. At the same time, the safety of simultaneous (one stage) bilateral TKA remains controversial and highly debatable. We wish to report our experience with simultaneous bilateral conventional TKAs for all severely deformed knees, followed by a carefully planned, evidence-based rehabilitation programme. Simultaneous bilateral TKA in severely deformed knees is safe and very effective, provided attention to details of rehabilitation and overall multidisciplinary medical care is exercised.

Visual Loss After Orthopedic Procedures

Perioperative visual loss (PVL) is a very rare and unpredictable complication of surgery performed at distance from the visual pathways, mostly after spine or cardiac procedures. We report 6 consecutive patients with PVL after routine orthopedic procedures (osteosynthesis for complex fracture of the femur [2], total hip arthroplasty [2], hip prosthesis arthroplasty [1], bilateral simultaneous total knee arthroplasty [1]) and reviewed the literature on the subject. An ischemic optic neuropathy was diagnosed in all cases, and visual loss was bilateral in 5 of 6 patients. Partial visual improvement occurred in only 3 of 11 eyes. No specific therapy is available for PVL. Postoperative visual disturbances should prompt without delay an ophthalmic evaluation because emergent correction of anemia, systemic hypotension, or hypovolemia might improve visual prognosis of PVL.

Perioperative safety of two-team simultaneous bilateral total knee arthroplasty in the obese patient

BackgroundAlthough the rates of perioperative morbidity and mortality with simultaneous bilateral total knee arthroplasty remain a concern, multiple studies have shown the procedure to be safe in selected patient populations. Evidence also remains mixed regarding the outcomes of total knee arthroplasty in obese patients. The purpose of this paper is to compare the rates of perioperative morbidity and mortality in consecutive obese patients undergoing two-team simultaneous bilateral total knee arthroplasty and unilateral total knee arthroplasty.MethodsThe records on all two-team simultaneous total knee arthroplasties and unilateral total knee arthroplasties from October 1997 to December 2007 were reviewed. A total of 151 patients with a body mass index (BMI) >30 undergoing two-team simultaneous total knee arthroplasty and 148 patients with a BMI >30 undergoing unilateral total knee arthroplasty were retrospectively reviewed and analyzed to determine perioperative morbidity and mortality as well as one-year mortality rates.ResultsPreoperative patient characteristics did not show any significant differences between groups. The simultaneous bilateral group had significantly longer operative times (127.4 versus 112.7 minutes, p < 0.01), estimated blood loss (176.7 versus 111.6 mL, p = 0.01), percentage of patients requiring blood transfusion (64.9% versus 13.9%, p < 0.01), length of hospital stay (3.72 versus 3.30 days, p < 0.01), and percentage of patients requiring extended care facility usage at discharge (63.6% versus 27.8%, p < 0.01). No significant difference between unilateral and bilateral groups was seen in regards to total complication rate, major or minor complication subgroup rate, or any particular complication noted. Doubling the variables in the unilateral group for a staged total knee arthroplasty scenario did create significant increases over the simultaneous data in almost every data category.ConclusionsTwo-team simultaneous total knee arthroplasty appears to be safe in obese patients, with similar complication rates as compared to unilateral procedures. Two-team simultaneous total knee arthroplasty also appears to have potential benefits over a staged procedure in the obese patient, although more study is required regarding this topic.

Bilateral Total Knee Arthroplasty in Patients 70 Years and Older

Recently an increase has been shown in perioperative morbidity and mortality in patients older than 70 years undergoing sequential or simultaneous total knee arthroplasty (TKA) using 1 anesthetic. This study prospectively compared perioperative morbidity, mortality, and functional outcomes in patients 70 years and older undergoing sequential bilateral TKA under 1 anesthetic vs a control undergoing only unilateral TKA. Seventy patients (140 knees), 70 years and older, who underwent sequential bilateral TKA under 1 anesthetic were matched with a control series of 312 patients undergoing unilateral TKA during the same time period. All patients were evaluated pre- and postoperatively at regular time intervals. No mortalities were noted in either group. Perioperative complication rates were not statistically different between groups. Knee Society scores and SF-36v2 scores were better at 6-month and 1-year follow-up in the sequential bilateral knee group. Results from this study were not as expected based on previous reports in the literature. Although functional outcomes in this study were consistent with previous reports, patients did not demonstrate the expected difference in complications. This study is the first prospective study looking specifically at patients 70 years and older undergoing unilateral vs bilateral TKA under 1 anesthetic. According to our data, age alone is not a reason to exclude patients from sequential bilateral TKA under 1 anesthetic.

Prevalence of Osteolysis After Simultaneous Bilateral Fixed- and Mobile-Bearing Total Knee Arthroplasties in Young Patients

This study aimed to evaluate the clinical and radiographic results and to document the prevalence of osteolysis associated with fixed-bearing (anatomic modular knee) and mobile-bearing (low contact stress) total knee arthroplasties (TKAs) in 61 patients younger than 55 years who had bilateral simultaneous primary TKAs. Forty-five patients were female and 16 patients were male. The mean age of the patients was 48.3 years (range, 34-55 years). The mean postoperative Knee Society knee and functional score were similar in both groups (91 and 90 points and 85 and 86 points, respectively). Three knees (5%) in each group were revised for wear of the tibial bearing, and 1 knee (2%) in the mobile-bearing TKA was revised for dislocation of the meniscal bearing. Osteolysis was identified in both radiographs and computed tomography scans in 6 knees (10%) in the anatomic-modular-knee group and 4 knees (7%) in the low-contact-stress group.

Postoperative Wound Breakdown Caused by Pyoderma Gangrenosum After Bilateral Simultaneous Total Knee Arthroplasty

Pyoderma gangrenosum is a noninfective necrosis of dermal tissues. Rarely, it occurs after surgery or trauma. However, lack of awareness and its striking similarity to a clinical picture of sepsis usually delay diagnosis and initiation of the correct management. We describe a unique case of its occurrence in both surgical wounds after bilateral total knee arthroplasty and discuss the differential diagnoses and management.

Unilateral Tibial Polyethylene Liner Failure in Bilateral Total Knee Arthroplasty—Bilateral Retrieval Analysis at 8 Years

This is a report of a unique case of bilateral simultaneous total knee arthroplasties in which one tibial liner failed dramatically, whereas the other liner showed minimal evidence of wear. This unique case allows isolation of component factors as the primary contributing etiology to failure. The differentiating characteristic was the method of sterilization and the shelf life of the polyethylene liner. The insert that showed minimal wear was sterilized with γ radiation in a barrier package and had a shelf life of less than 1 year, whereas the insert that failed dramatically was sterilized in air and had a shelf life of more than 5 years. This case provides a dramatic example of the potential detrimental effects of manufacturing details on the performance of orthopedic implants, particularly polyethylene inserts.

Patient Perspectives on Currently Controversial Issues in Total Knee Arthroplasty

Purpose : To examined the level of patient knowledge and their perspectives about the controversial issues in total knee arthroplasty (TKA), and to evaluate the effect of a relevant explanation about the issues on the patient preferences for their particular option. Materials and Methods : One hundred patients who visited our clinic and decided to undergo TKA were asked to complete a questionnaire asking about their knowledge and preference for 4 controversial issues: 1) surgical timing of the bilateral TKAs, 2) use of computer assisted surgery, 3) use of minimal invasive surgery, and 4) use of ceramic femoral component. The patients completed the same questionnaire after the advantages and disadvantages of each option had been explained using an explanatory document designed based upon what was documented in the literature. Results : The patients were not well-informed about the issues and received their information through a non-professional source. The patients tended to prefer new options with claimed promises before an explanation. The patients preferred the options with safety, accuracy, and proven evidence after an explanation. Male patients tended to prefer simultaneous TKAs more than female patients. Younger patients preferred ceramic femoral component claimed to have better longevity more than older patients did. Conclusion : This study demonstrates that patients’ knowledge of the current controversial issues is very limited, and that patient preferences would be significantly changed if they were given an explanation from a physician. Balanced information should be given to patients in order for them to reach a fair decision.

Zone 4 Femoral Radiolucent Lines in Hybrid versus Cemented Total Knee Arthroplasties

Aseptic loosening of the femoral component is an infrequent but important cause of failure in total knee arthroplasties. Inadequate support in the posterior femoral condylar region (radiographic Zone 4) has been associated with loosening. This zone also has been implicated as a site for ingress of wear debris particles leading to osteolysis. We determined the prevalence of Zone 4 radiolucent lines using fluoroscopy to obtain true lateral radiographs in a series of patients who had bilateral simultaneous total knee arthroplasties with a cemented femur on one side and a cementless porous ingrowth femur on the other. We hypothesized that cementless fixation would yield fewer Zone 4 radiolucent lines than cemented fixation. At an average 7.6 +/- 4.4 years followup, 11 of 16 patients (69%) with cemented femoral fixation had Zone 4 radiolucent lines, whereas none of the patients with cementless prostheses had radiolucent lines. Three of 11 radiolucent lines (27%) were progressive. Knee Society scores were similar for both groups. No femoral components in either group were clinically loose. When excellent initial stability was obtained, cementless femoral fixation yielded fewer Zone 4 radiolucent lines compared with cemented fixation. Therapeutic study, Level III (retrospective comparative study). See the Guidelines for Authors for a complete description of levels of evidence.

Complications and outcomes of single‐stage bilateral total knee arthroplasty

A recent literature review by the senior authors of this study revealed that simultaneous bilateral knee arthroplasty is uncommon and controversial. Reported complications include myocardial infarction, deep venous thrombosis, pulmonary embolus, thromboembolic complications, pseudo-obstruction, postoperative ileus and death. This present study was designed to identify complications of single-stage bilateral total knee arthroplasty to compare with reports in the international literature. A retrospective study of 40 cases of simultaneous total knee arthroplasty carried out by the senior authors at Wellington over the last 10 years, examined details of surgery, anaesthesia, preoperative and postoperative management to identify the occurrence of complications. Thirty-one patients completed an Oxford Knee Score, a EuroQuol-5 Dimension (EQ-5D) questionnaire and reported their experience of the bilateral procedure. Complications reported in the international literature did not occur in the patients studied. Complications that did occur included urinary retention, wound infections and oedema of the limbs or knees. The mean Oxford Knee Score was 20.79. In 2003 the New Zealand national mean for primary total knee arthroplasty was 23.35. The EQ-5D revealed high patient satisfaction and good functional status. While the outcomes and cost benefits of single stage bilateral replacement are established, the risk of complications remains. This study establishes the low complication rate associated with this procedure in the senior authors' hands, and documents the high patient satisfaction. The study demonstrates that, in selected patients, simultaneous bilateral knee replacement surgery can be performed with good outcomes without a definite increase in perioperative risk.

Debate: Bilateral Simultaneous Total Knee Arthroplasty

Controversy persists regarding the value of doing bilateral simultaneous total knee arthroplasty. Advocates of this procedure focus on economic costs, patient satisfaction, and quicker return to function as compared with bilateral staged total knee arthroplasty. Those in opposition focus on increased complication rates that question the overall safety of this operative procedure. The purpose of this discussion is to review the orthopaedic literature, concentrating on the reported advantages and disadvantages of bilateral simultaneous total knee arthroplasty in hopes of providing the surgeon with information valuable in determining the safety and efficacy of this procedure.

Advanced osteoarthritic knee with neglected patellar tendon rupture treated with total patellectomy and total knee arthroplasty

Loss of the knee extensor mechanism results in a change of normal knee joint alignment and functional anteroposterior instability. In patients with neglected or chronic patellar tendon rupture, advanced degenerative change of the knee joints may develop at the later stage. We present a case of a 64-year-old man with chronic left patellar tendon rupture and 10-cm proximal patella migration associated with advanced osteoarthritis of the knee. Total patellectomy and simultaneous total knee arthroplasty (TKA) relieved his symptoms and disability successfully. His left knee still did well at 7-year follow-up.

Metal-backed patellar component failure in total knee arthroplasty presenting as a giant calf mass

Failure of total knee arthroplasty (TKA) caused by wear of the polyethylene-bearing surface of a metal-backed tibial platform or a metal-backed patellar component is a recognized complication. We present a case of a 78-year-old woman with a cystic mass in the left calf caused by metal wear debris from the failure of a Miller-Galante I TKA. The patient received a left TKA to treat advanced osteoarthritis in July 1990 and was lost to follow-up immediately after the operation. In December 1998, she presented at our clinic 2 days before admission, when an originally silent mass over the calf turned intolerably painful. A series of examinations revealed a calf mass caused by wear debris of total knee prosthesis and subsequent inflammation of the knee joint. Curettage of the cyst and simultaneous revision TKA were successful in relieving her symptoms. Copyright 2003, Elsevier Science (USA). All rights reserved.

Incidence of fat embolism syndrome after cemented or cementless bilateral simultaneous and unilateral total knee arthroplasty

This prospective study enrolled 100 patients undergoing unilateral total knee arthroplasty (TKA) and 100 patients undergoing bilateral simultaneous TKA. Bilateral simultaneous TKAs were done under 1 anesthesia with one side immediately following the other. To determine hemodynamic changes and to detect fat and bone marrow embolization, arterial and right atrial blood samples were obtained before insertion (baseline) and 1, 3, 5, and 10 minutes after insertion of the femoral alignment rod. Arterial and right atrial blood samples were obtained 1, 3, 5, and 10 minutes after insertion of the tibial component broach. Blood samples were obtained at 24 and 48 hours after the operation. Arterial blood pressure, heart rate, right atrial pressure, arterial oxygen tension, and carbon dioxide tension were monitored at corresponding times. The presence of fat was determined with oil red O fat stain, and the presence of cellular contents of bone marrow was determined with Wright-Giemsa stain. Fat embolism was found in 65 patients (65%) with a bilateral TKA and 46 patients (46%) with a unilateral TKA. Bone marrow cell embolism was found in 12 patients (12%) with a bilateral TKA and in 4 patients (4%) with a unilateral TKA. Six patients with positive bone marrow cells (2 patients with a unilateral TKA and 4 patients with a bilateral TKA) had neurologic manifestations.

Simultaneous management of ipsilateral gonarthritis and ununited tibial stress fracture: Combined total knee arthroplasty and internal fixation

Nonunion of a proximal tibial stress fracture is rare and can be difficult to manage, especially if associated with ipsilateral gonarthritis. Three patients with nonunion of a proximal tibial stress fracture adjacent to an arthritic knee joint were managed by performing simultaneous total knee arthroplasty and internal fixation of the fracture site. The technique involved performing a total knee arthroplasty with angular correction at the site of the extra-articular and intra-articular deformity, bone grafting of the nonunion site, and stabilization of the fracture with a long uncemented intramedullary stemmed tibial component and a unicortical plate. Fibular ostectomy was required during the index surgery in 2 cases to achieve the desired angular correction. In all 3 patients, healing of the nonunion site and limb realignment was achieved. There were no complications or infections associated with the surgery. All patients progressed to full weight bearing at 3 months and had clinical and radiographic union of the nonunion site at 6 months.

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.

Safety and efficacy of bilateral total knee arthroplasty

Recent studies have reported increased morbidity associated with bilateral simultaneous total knee arthroplasty (TKA). The purpose of this study was to evaluate the morbidity and clinical outcome associated with simultaneous bilateral TKA in contrast to unilateral TKA. All primary TKAs, either unilateral or simultaneous bilateral, performed between May 1988 and July 1993 were retrospectively reviewed. Patients were evaluated using Knee Society scores both before surgery and a minimum of 6 months after surgery. In addition to routine demographics, patients were evaluated for the incidence of both local wound and systemic complications. It is concluded that performing simultaneous bilateral TKA does not result in any significant increase in patient morbidity or compromise in postoperative function when compared with unilateral TKA.

Simultaneous bilateral total knee arthroplasty

Total knee arthroplasty (TKA) was performed simultaneously on both knees by two teams in a single procedure. The study population consisted of 74 patients (148 knee joints) with osteoarthritis (OA) or rheumatoid arthritis (RA). The peri- and postoperative results were compared with those in a group of 22 OA and RA patients (44 knee joints) who underwent staged operation during one hospital stay. Comparisons were made of functional score and range of motion (ROM) before and after operation, mean total blood loss, operative time, duration of hospital stay, and operative and postoperative complications. The simultaneous performance of bilateral procedures did not influence the functional score, ROM after operation, or mean intra- and postoperative blood loss. Nor was the incidence of operative and postoperative complications increased compared with that in the staged operation group. The operative time in the simultaneous TKA group was significantly shorter than the time that would have been required had separate procedures been performed on both knees. Simultaneous bilateral TKA is beneficial for the patient.

Clinical, Roentgenographic, and Scintigraphic Results After Interruption of the Superior Lateral Genicular Artery During Total Knee Arthroplasty

Forty-eight patients treated by primary bilateral simultaneous total knee arthroplasty, in which one knee had a lateral release and the other did not, were evaluated clinically and roentgenographically from one to 12 years postoperatively. Thirty of these patients also had a technetium-99 bone scan. Mean clinical scores at the last follow-up examination were 90 for both groups. Roentgenographically, there were no subluxations, dislocations, or fractures in either group. There were two metal-backed patellae (one in each group) with signs of polyethylene wear and developed debris. Bone scans showed no difference between the two groups and no signs of osteonecrosis of the patella.