Single-stage Bilateral Total Knee Arthroplasty Research Articles

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.

Complications following single-stage bilateral total knee arthroplasty and unilateral procedures: experience of a high-volume community hospital.

The safety of single-stage bilateral total knee arthroplasty (SSBTKA) compared to unilateral total knee arthroplasty (TKA) remains controversial. The present study compares the 90-day postoperative complications encountered following SSBTKA and unilateral TKA in an unselected cohort of patients performed at a high-volume community hospital. The perioperative electronic medical records of an unselected consecutive cohort of 1032 patients (1345 knees) having undergone unilateral or SSBTKA were reviewed. Ninety-day postoperative complications or need for additional procedures were compared between unilateral and SSBTKA groups. A total of 719 and 313 patients underwent unilateral and SSBTKA, respectively. There were no significant differences in age or BMI between groups. Patients undergoing SSBTKA were more likely to be male (p = 0.019), have longer lengths of stay (p < 0.001) and were less likely to discharge directly home (13.1%) compared to unilateral patients (80.9%) (p < 0.001). Patients undergoing SSBTKA were more likely to require a transfusion (14.7%) compared to unilateral patients (2.2%) (p < 0.001). Interestingly, mortality rate following unilateral TKA (1.7%) was significantly higher than SSBTKA (0.0%) (p = 0.013). There were no significant differences regarding other complications or need for additional procedures within 90days following surgery. SSBTKA did not result in greater complications when compared to unilateral TKA in this particular cohort. As expected, transfusion rates will likely be higher and there will be a greater need for acute inpatient care following surgery for SSBTKA patients.

Do older patients fare worse following unilateral or single stage bilateral total knee arthroplasty?

The safety and benefits of single stage bilateral total knee arthroplasty (SSBTKA) among older patients as compared to unilateral TKA remains controversial. This study aimed to evaluate the influence of age and comorbidities on complications and early outcomes for unilateral and BTKA in patients over and under 70years of age. This prospective study compared postoperative complications and early patient-reported outcomes at 6weeks of 142 unilateral TKA patients (N = 75, ≤ 70; N = 67, > 70) and 89 SSBTKA patients (N = 48, ≤ 70; N = 41, > 70). Patients completed the KOOS JR and PROMIS Global Mental (GMH) and Global Physical Health (GPH) surveys. Knee Society Scores for Knee (KSS-K) and Function (KSS-F) were completed in the clinic. Parametric tests were performed for comparisons of unilateral and BTKA outcomes and complications for patients over and under 70. While patient demographics were similar, patients > 70 had more comorbidities than patients ≤ 70 (p < 0.004). There were no significant differences in postoperative complications or readmissions between age groups or procedures. Unilateral TKA patients > 70 had significantly lower pre- (p < 0.001) and post-operative (p = 0.011) KSS-F scores compared to those ≤ 70. SSBTKA patients > 70 had significantly higher preoperative GMH (p = 0.029), postoperative KSS-K (p = 0.027), KOOS JR scores (p = 0.039) and satisfaction (p = 0.048) compared to those ≤ 70. Age did not influence the risk of early postoperative complications. Additionally, the greater improvements in KOOS JR and higher patient satisfaction for SSBTKA patients > 70 suggests that SSBTKA may meet elderly patient expectations and should not necessarily be discouraged due to safety concerns.

Long Term Outcomes of Single Staged Sequential Bilateral Total Knee Replacement in Patients aged 60 years or above

Objective: To determine the long-term outcomes of single staged bilateral total knee arthroplasty in patients of geriatric age group.Methods: This single-center retrospective study was carried out at Liaquat National Hospital Karachi, Pakistan. Data of 2001 to 2010 were retrieved from the medical records. All geriatric age group patients above 60 years irrespective of comorbidity status, underwent single-stage bilateral total knee arthroplasty were consecutively included. Pre-operative diagnoses such as primary osteoarthritis, post-traumatic arthritis and rheumatoid arthritis were noted. The minimum follow-up time period was 10 years. Long term outcome such as knee society score, adverse event, and need of revision surgery were noted.Results: Of 96 patients, the median age was 69.0 (65.0-76.0) years. There were 44 (45.8%) males and 52 (54.2%) females. Primary osteoarthritis was the most common primary diagnosis, i.e., 66 (68.8%) followed by rheumatoid arthritis in 24 (25.0%), and post-traumatic arthritis in 6 (6.3%) patients. Most of the patients had moderate Charlson Comorbidity Index score, i.e., 70 (72.9%) while Knee Society Score showed that 41 (40%) reported excellent outcome. Need of revision surgery was reported by 6 (6.3%) patients. Adverse events were reported by 11 (11.5%) patients. A significant median difference of Knee Society Score was found among patients with diabetes mellitus (p-value &lt;0.001) and pre-operative diagnosis (p-value &lt;0.001).Conclusion: The long-term outcome of patients underwent bilateral total knee arthroplasty was found satisfactory. It is likely that total knee arthroplasty is widely regarded as the best option for treating end-stage knee osteoarthritis.

Accuracy of different navigation systems for femoral and tibial implantation in total knee arthroplasty: a randomised comparative study.

It remains to be established whether optical computed tomography (CT)-free and acceleration-based navigation systems differ in terms of implantation accuracy and clinical outcomes for total knee arthroplasty. This randomised prospective study compared the implantation accuracy of these two navigation systems in total knee arthroplasty. Optical CT-free navigation (ExactechGPS) or acceleration-based navigation (KneeAlign2) was randomly assigned to the left or right knee of 45 patients who underwent a single-stage bilateral total knee arthroplasty: the ExactechGPS (n = 45) and KneeAlign2 groups (n = 45) were compared. Component alignments were evaluated using three-dimensional computed tomography and radiography at pre- and post-surgery. Implantation accuracy of the component alignment, proportion of outliers, postoperative range of motion, and Japanese Orthopaedic Association (JOA) score were compared between the systems. The implantation accuracies of the lower-extremity mechanical alignment, coronal femoral component angle, coronal tibial component angle, sagittal femoral component, axial femoral angle, and axial tibial angle had no significant difference between the groups. The implantation accuracy of the sagittal tibial component angle was superior in the ExactechGPS than the KneeAlign2 group (1.3° vs. 1.8°, P = 0.034). The proportions of outliers, range of motion, and JOA score had no significant difference between the groups. In the tibial sagittal plane, there was a significant difference in the implantation accuracy, but its difference did not affect the clinical outcomes. Both navigation systems have clinically acceptable implantation accuracy.

Simultaneous single-stage versus two-staged bilateral total knee arthroplasty: a prospective comparative study.

The study aims to prospectively compare peri-operative morbidity and mortality of simultaneous single-stage bilateral total knee arthroplasty (SS BLTKA) with two-staged bilateral total knee arthroplasty (TS BLTKA) performed within 12months of the first surgery. We hypothesized that SS BLTKA is as safe as TS BLTKA. Patients with a minimum follow-up of 12months were included in this study. Oxford knee score and quality of life index SF12 was compared between the 2 groups at six weeks and six month follow-up. SS BLTKA included 250 patients and TS BLTKA included 210 patients. The minimum time interval between two operations was three weeks (mean 1.6months, range 3weeks-12months). There was no significant difference between the 2 groups in peri-operative mortality, surgical site infection, major peri-operative complications. There was no difference between the 2 groups in the Oxford knee score and quality of life index SF12 at 6-month follow-up. There was no difference in the range of knee flexion between the 2 groups at six months. Post-operative haemoglobin drop was significantly more in SS BLTKA patients and consequently, blood transfusion requirement was significantly higher in SS BLTKA. There was a significantly higher length of hospital stay and duration of surgery in TS BLTKA group. There does not appear to be a difference in complication rates between the 2 groups. SS BLTKA seems to be a logical choice if both knees have severe osteoarthritis. Patients with severe cardiopulmonary compromise were excluded, and a unilateral procedure may be preferred in them.

Functional outcome of bilateral total knee arthroplasty: A two-year prospective study

The wider adoption of simultaneous bilateral TKA has been limited due to the reports of the associated risk of mortality and perioperative complications. The present study evaluated the safety of single-stage bilateral total knee arthroplasty, in terms of perioperative morbidity, mortality and clinical outcomes of the procedure. The two-year prospective study was conducted on 100 knees of fifty patients who visited the Department of orthopaedics of a super speciality hospital, based in India. Detailed history was collected and clinical examination of the knees was performed in all the patients. Pre-and postoperative knee scores were calculated using modified Install’s knee society scoring system. Postoperative knee society score was recorded up to 12 months of follow-up. Perioperative complications were noted in 8 subjects. Groups with and without complications were compared for various assessed variables, and the correlation between hospital stay and different demographic and clinical variables were studied by Spearman correlation. Out of the 50 subjects who underwent bilateral TKA, perioperative complications were noted in 16% of the subjects. Major complications like DVT, pulmonary embolism, myocardial infarction and death were not reported in any of the cases. A significant number of patients (37.5%) belonging to the complication group underwent secondary procedures. The duration of hospital stay was found to be significantly associated with comorbidities, and perioperative complications. Simultaneous bilateral TKA is a safe procedure, providing satisfactory functional outcomes. Comorbidities of the patients has been noted as the major factor contributing to increased hospital stay

Impact of oxidative stress on early postoperative knee function and muscle injury biochemical markers: Is it possible to create an ischemic preconditioning effect in sequential ischemic surgical procedures?

Simultaneous bilateral total knee arthroplasty (TKA) with prolonged tourniquet time has the potential to trigger ischemia-reperfusion injury, which can adversely affect knee function. Studies suggest that the magnitude of injury is less if it occurs following an ischemic event which takes place in another part of the body, known as ischemic preconditioning (IPC). The purpose of this study was to investigate the impact of oxidative stress on muscle injury and knee function and to elucidate if potential IPC effect can attenuate ischemia-reperfusion injury metabolites and prevent poor functional outcomes in single-stage bilateral TKA. Thirty patients who underwent single-stage bilateral TKA under tourniquet were enrolled in the study. All procedures were initiated from the right limb. Upon completion of the procedure, the left tourniquet was inflated 20 minutes after the first tourniquet was deflated. The tourniquet time was noted. Pre- and postoperative levels of malondialdehyde (MDH), creatine kinase (CK), and lactate dehydrogenase (LDH) were evaluated. Knee function was assessed postoperatively at 1 month using WOMAC score. Postoperative levels of MDH, CK, and LDH were significantly increased in both extremities compared to preoperative levels. Serum MDH, CK, and LDH levels were not found to be correlated with tourniquet time for either extremity. Compared to the left extremity, the right extremity revealed increased postoperative oxidative stress, which was indicated by elevated serum MDH, CK, and LDH levels. Although tourniquet time and postoperative serum MDH, CK, and LDH levels were not found to be correlated with WOMAC index in either knee, the average change in WOMAC score at 1 month postoperatively was found to be higher in the left knee compared to the right. The biochemical and functional outcomes can be attributed to potential IPC effect. During bilateral TKA, a 20-minute interval between tourniquets can create IPC effect and attenuate the magnitude of ischemia-reperfusion injury, preserving better functional outcomes.

Polysaccharide hemostatic system reduces blood loss in high-body-mass-index patients undergoing simultaneous bilateral total knee arthroplasty

BackgroundTo investigate the efficacy of a topically applied hemostatic agent used to reduce blood loss in patients undergoing simultaneous bilateral total knee arthroplasty (TKA). MethodsThirty-two patients (5 male, 27 female) mean age 65 ± 9.3 (46–80) undergoing single-stage bilateral TKA were enrolled in the study and divided in two groups. Groups 1 and 2 consisted of patients with body mass index (BMI) <30 and >30, respectively. Polysaccharide hemostatic agent (PHA; 3g) was applied topically to the right knees of each patient intraoperatively. The left knees were used as controls. A negative suction drain was used and the effect of PHA and BMI on postoperative bleeding was evaluated. ResultsBlood loss was significantly higher (p = 0.027, r = 0.397) for patients with higher BMI. Treatment by local application of PHA to potential bleeding sites significantly reduced blood loss—314 ± 151ml (50–600) for the right knees versus 468 ± 140ml (150-700) for the left knees (p = 0.007) in group 1; 420 ± 251 ml (100–900) for the right knees versus 620 ± 229ml (350–1125) for the left knees (p = 0.036) in group 2. Blood loss reduction between the right and left knees was no different between the two groups (p = 0.173). ConclusionsBy reducing blood loss and the need for postoperative blood transfusion in patients with high BMI, PHA can be of value as adjuvant therapy in new blood-management procedures in major joint-replacement surgery.

Dénervation patellaire dans la prothèse totale du genou sans resurfaçage patellaire : une étude prospective, randomisée, contrôlée

Summary Background Anterior knee pain is still a major problem in total knee arthroplasty (TKA). Although the most widely accepted opinion is that anterior knee pain is often associated with a patellofemoral etiology, there is no clear consensus as to etiology or treatment. Disabling pain receptors by electrocautery could theoretically achieve denervation of the anterior knee region. The present prospective randomized controlled study aimed to evaluate results after patellar denervation with electrocautery in TKA at a minimum follow-up of 2 years. Hypothesis Patellar denervation provides some benefit in terms of pain and clinical outcomes after TKA without patellar resurfacing. Patients and methods Clinical and radiological results for 35 patients with single-stage bilateral TKA (70 knees; 26 women, nine men; mean age, 68 years [range, 58 to 77 years]) were reviewed. In addition to removal of all osteophytes, patellar denervation by electrocautery was performed on one patella; and debridement alone, removing all osteophytes, was performed on the contralateral patella, as a control. KSS score and a visual analog scale (VAS) were used to assess pre- and postoperative anterior knee pain. Results Mean follow-up was 36 months (24 to 60 months). No revisions or re-operations were performed. There were no patellar fractures. On all parameters (KSS score, range of motion and VAS), there was a statistically significant pre- to postoperative difference in favor of the denervation group. Discussion Patellar denervation with electrocautery can reduce anterior knee pain, with satisfactory clinical and radiological outcome, in TKA without patellar resurfacing. Level of evidence Level II: low-powered prospective randomized trial.

Patellar denervation in total knee arthroplasty without patellar resurfacing: A prospective, randomized controlled study

Anterior knee pain is still a major problem in total knee arthroplasty (TKA). Although the most widely accepted opinion is that anterior knee pain is often associated with a patellofemoral etiology, there is no clear consensus as to etiology or treatment. Disabling pain receptors by electrocautery could theoretically achieve denervation of the anterior knee region. The present prospective randomized controlled study aimed to evaluate results after patellar denervation with electrocautery in TKA at a minimum follow-up of 2 years. Patellar denervation provides some benefit in terms of pain and clinical outcomes after TKA without patellar resurfacing. Clinical and radiological results for 35 patients with single-stage bilateral TKA (70 knees; 26 women, nine men; mean age, 68 years [range, 58 to 77 years]) were reviewed. In addition to removal of all osteophytes, patellar denervation by electrocautery was performed on one patella; and debridement alone, removing all osteophytes, was performed on the contralateral patella, as a control. KSS score and a visual analog scale (VAS) were used to assess pre- and postoperative anterior knee pain. Mean follow-up was 36 months (24 to 60 months). No revisions or re-operations were performed. There were no patellar fractures. On all parameters (KSS score, range of motion and VAS), there was a statistically significant pre- to postoperative difference in favor of the denervation group. Patellar denervation with electrocautery can reduce anterior knee pain, with satisfactory clinical and radiological outcome, in TKA without patellar resurfacing. Level II: low-powered prospective randomized trial.

Ergebnisse einzeitiger vs. zweizeitiger bilateraler Knietotalendoprothetik

The total knee arthroplasty (TKA) is a successful procedure. In cases of bilateral knee osteoarthritis, advantages of single stage TKA vs. two-stage TKA as well as the gap between the procedures in case of two-stage TKA are discussed controversially. The aim of the present study is to compare the clinical and radiographic results of single stage bilateral TKA and two-stage bilateral TKA. In cases of two-stage TKA the dependency on the gap between surgeries was determined. In this retrospective study 43 patients with single stage TKA and 35 patients after two-stage TKA with a maximum of 12 months between surgeries were included. Follow-up was in mean 31 ± 15 months. For clinical and radiological evaluation the Knee Society score (KSS) and Stolzalpen knee score were used. Quality of life was measured by the SF-36 score. The pain was determined using a visual analogue scale (VAS). Radiological evaluation was done by use of Knee Society roentgenographic evaluation and scoring system. The overall hospital stay for patients with two-stage TKA (26 ± 5 days) was twice as long as for patients with single stage TKA (14 ± 4 days). Patients with single stage bilateral TKA had a significantly higher KSS level (186 ± 19 points) than patients after two-stage bilateral TKA (179 ± 22 points). Within the two-stage group the best range of motion was achieved by patients with a gap of 4 to 6 months between surgeries and a decreased point value was measured in patients with a gap of 10 to 12 months between TKAs. Using the VAS patients with simultaneous bilateral TKA had significantly increased pain levels during passive motion. Within the two-stage group there were no differences in VAS. The results of Stolzalpen knee score were comparable in both groups. The analysis of radiological measurements showed a significantly higher number of radiolucent lines (1 mm) in patients with single stage TKA without any clinical relevance or progress in follow-up. Patients with single stage bilateral TKA had a higher complication rate than patients with a two-stage procedure. In the single stage group 6 patients had to be revised because of fracture, dislocation, peroneal nerve palsy, patella lateralisation or loosening. In the two-stage group only one patient had to be revised due to a quadriceps tendon rupture caused by a fall at day one after surgery. Analysis of clinical and radiological results shows only marginal differences between the two groups. In two-stage procedures functional results were best when the second surgery was done 4 to 6 months after the first procedure. Single stage TKA had a significantly higher complication rate. However, patient and surgeon should make the decision for single or two-stage bilateral TKA individually.

Total Diz Artroplastisinde Midvastus Yaklaşımına Karşılık Medial Parapatellar Yaklaşım: Erken Fonksiyonel Sonuçların Karşılaştırılması

Objective: The purpose of this study was to compare the early outcomes of total knee arthroplasty (TKA) using midvastus (MV) versus medial parapatellar (MPP) approaches on both knees. Material and Methods: Fifty two consecutive patients (104 knees) who underwent single-stage bilateral TKA performed by two surgeons between August 2004 and December 2007 were evaluated retrospectively at a minimum follow-up duration of two years. Patients were divided into two groups. In the MV group, consisted of 27 patients, a midvastus approach was performed on both knees. Besides, in the MPP group, consisted of 25 patients, a medial parapatellar approach was performed on both knees. Results: Mean follow-up duration was 40.2 months (27-66 months) and 42.3 months (25-61 months) for the MV and MPP groups, respectively. The Knee Society Clinical Rating System (knee and function score), the range of motion, patellofemoral pain questionnaire, patient satisfaction questionnaire and radiography were used for the evaluation of both groups. Lateral retinacular release (LRR) was performed on four knees in the MPP group whereas it was not used in the MV group. There was a significant difference between the two groups with regard to the rate of LRR (p= 0.034). Axial radiographs revealed that six patellas in the MPP group, but only one in the MV group exhibited lateral displacement postoperatively (p= 0.039). Conclusion: The preservation of normal patellar tracking is important for TKA. In this study, the midvastus approach required significantly less LRR as compared to the medial parapatellar approach.

Are Postoperative Complications More Common with Single-Stage Bilateral (SBTKR) Than with Unilateral Knee Arthroplasty: Guidelines for Patients Scheduled for SBTKR

A significant number of patients with degenerative arthritis of the knee require bilateral knee arthroplasty. Single-stage bilateral total knee arthroplasty (SBTKR) has been associated with increased patient morbidity and mortality. At our institution, the following steps have been taken to minimize the risks to patients undergoing this procedure: regional anesthesia and analgesia, invasive monitoring, postoperative observation in an intensive care unit setting, and aggressive management of hemodynamic aberrations. We reviewed the medical records of 462 sequential total knee arthroplasty patients, consisting of 169 SBTKR and 293 unilateral total knee arthroplasty (UTKR) cases. A total of 122 patients from each group were matched for age, weight, and a history of ischemic heart disease and hypertension. Patients for SBTKR exhibited a significantly higher incidence of fat embolism syndrome and cardiac arrhythmias than UTKR patients. There were no deaths in either group and the incidence of other serious postoperative complications was low and similar between the two groups. Elderly patients (approximately 75 years old) had more postoperative complications. With aggressive clinical management SBTKR can be safely performed in selected patients. Guidelines for the selection of these patients are presented.

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.

Comparative outcomes of total joint arthroplasty

A prospective pre- and postoperative general health/quality-of-life factor comparison, using the Rand SF-36 Health Status Questionnaire (TyPE Specification, Quality Quest [Health Outcomes Institute, Minneapolis, MN]), was carried out on a consecutive series of patients with diagnosed osteoarthritis undergoing total hip and knee arthroplasty between March 1991 and March 1994. Study groups consisted of 85 total hip arthroplasty patients, 93 total knee arthroplasty patients, and 65 single-stage bilateral total knee arthroplasty patients, all treated at the same specialty hospital, under the care of three senior orthopaedic surgeons. The average patient age was 69 years. Significant improvements in quality-of-life measures including physical functioning, social functioning, role functioning/physical problem, role functioning/emotional problem, mental health, energy/fatigue, pain, and change in health were noted in all hip and knee arthroplasty patients 6 months, 1 year, and 2 years after surgery ( P < .05). There appeared to be no significant differences in quality-of-life measures between hip and knee arthroplasty patients. Results therefore indicate that total hip and knee arthroplasty significantly improve the functional status and quality of life among patients suffering from osteoarthritis.