Stage Bilateral Total Knee Arthroplasty Research Articles

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.

Outcome of Midvastus versus Subvastus Approach in Single Stage Bilateral Total Knee Arthroplasty

Objective: To compare midvastus and subvastus approach regarding operative parameters(lateral retinacular release, operative time, neurovascular injury) and outcome (Knee Society Score, Straight Leg Raise) at 12 weeks in single stage bilateral total knee arthroplasty. Study Design: Randomized clinical trial study Place and Duration of Study: Institute of Orthopaedic Surgery and South City Hospital Karachi from 1st January 2016 to 31st December 2018. Methodology: Fifty two patients of both genders ofmore than 50 years with osteoarthritis grade III or IV and bony changes confirmed by AP and lateral radiographs of knee were included. Patients with previous knee surgeries including high tibial osteotomy, deformities &gt;20°(on mechanical axis), any neuromuscular problem and BMI ≥30 were excluded. Final assessment was done at 12 weeks. Isometric quadriceps strength was assessed by holding of contraction in seconds during the lifting (10cm above the plinth) phase of SLR (patient lying supine).Knee score (preoperative and final follow-up) was performed by Knee Society Score. Results: Thirty five were females and 21 males with mean age 65.3 years (50-78 years). Mean body mass index was 27.8 Kg/m2 (26.4-29.9). In midvastus TKR, the mean operative time was 61.7 minutes (range 52-70) whereas the same was 68.3 minutes (range 58-74) in subvastus TKR with p value 0.002. Rate of lateral retinacular release (LLR) was significantly (p=0.011) different between the midvastus TKR 5 (8.9%) and subvastus TKR 11 (19.6%). Neither group had neurovascular injury or early infection of the knee. Active SLR in subvastus group was achieved in shorter time (mean 3.1 days) as compared to midvastus group (mean 4.7 days). There was no difference (p=0.173) in isometric quadriceps strength at 12 weeks between subvastus TKR (mean 18 seconds) and midvastus TKR (mean 17 seconds). Knee society pain and functional scores were comparable between the two approaches at final follow up. Conclusion: Subvastus exposure has advantage of achieving active straight leg raise earlier while midvastus has lower frequency of lateral retinacular release. No difference in hospital stay and postoperative pain scores. Both subvastus and midvastus approaches are safe and offer comparable Knee Society Score outcomes. Keywords: Midvastus, Subvastus, Total knee arthroplasty, Knee Society Score, Straight leg raise

Bilateral Simultaneous vs Staged Total Knee Arthroplasty: Minimal Difference in Perioperative Risks

BackgroundWith the rising utilization of total joint arthroplasty, the role of simultaneous-bilateral surgery will have an expanding impact. The purpose of this study is to examine the risks of perioperative complications with this approach in total knee arthroplasty (TKA), to inform shared decision-making. MethodsWe reviewed national hospital discharge data from 2005 to 2014 to compare outcomes between simultaneous-bilateral TKAs (sim-BTKAs) and staged-bilateral TKAs (staged-BTKAs). Hierarchical logistic regression analyses were used to adjust for confounders. Outcomes analyzed included mortality, various medical complications, knee infection, and mechanical complications. ResultsThis study analyzed 27,301 sim-BTKAs and 45,419 staged-BTKAs. Patients who underwent simultaneous surgery had a statistically significant higher adjusted odds of mortality, cardiac events, thromboembolic events, and complications involving the urinary and digestive systems, and a lower adjusted odds of deep knee infection and hematoma. Thirteen of the 14 complications had overall incidences less than 2% and 1 outcome had an incidence of 3%. The absolute between-group risk difference for any complication was 1% or less. ConclusionSim-BTKAs have a statistically significant increased odds of multiple complications compared to staged-BTKAs. However, the absolute risk differences between these options are minimal and the occurrence of any complication is low. Level of EvidenceTherapeutic Level III.

Severe Bilateral Fixed Flexion Deformity—Simultaneous or Staged Total Knee Arthroplasty?

Outcomes of 29 simultaneous (SimBTKA) and 38 staged bilateral total knee arthroplasty (StaBTKA) subjects with severe (≥16°) bilateral fixed flexion deformity (FFD) were retrospectively investigated. SimBTKA patients were significantly younger (63 ± 8 vs 68 ± 7, P > .01). At 2 years, SimBTKA subjects had significantly better residual FFD (2.5° ± 5.1° vs 5.4° ± 6.6°, P = .02) and Knee Society function score (75.7 ± 25.7 vs 69.3 ± 24.1, P = .02). However, Knee Society knee scores, Oxford Knee Scores, and Short Form-36 scores were similar. These suggest no large clinical advantage of SimBTKA over StaBTKA. We feel that severe bilateral FFD is not an absolute indication for SimBTKA.

A Comparative Study of Subcutaneous versus Intra-Articular Indwelling Closed Suction Drainage after Total Knee Arthroplasty

Purpose: The aim of this study was to compare the drainage amount, total blood loss, and clinical results between two different positions of suction drainage after total knee arthroplasty. Materials and Methods: A total of 100 patients who underwent one stage bilateral total knee arthroplasty were enrolled. In experiment 1 with 50 patients, we compared the drainage amount, pain, range of motion, and complications of the leg whose suction drain was inserted into the joint cavity with those of the contralateral leg whose suction drain was inserted in subcutaneous tissue. Another 50 patients of experiment 2 had suction drainage in the joint cavity of both legs and the total blood loss (sum of drainage output, exudates, and hematoma of subcutaneous tissue and joint) was calculated and compared with that of experiment 1. Results: In experiment 1, the drainage amount was less in the leg with suction drainage in subcutaneous tissue compared with the contralateral leg with suction drainage in the joint cavity (p<0.001). However, the postoperative joint pain was significantly different only on post-operative day 2 between two legs. In experiment 2, there was no significant difference in the total blood loss between the two groups. Conclusion: Although the drainage amount was less in the leg whose suction drain was kept in subcutaneous tissue compared with the contralateral leg whose suction drain was in the joint cavity, the total blood loss and the clinical results were not significantly different according to the position of the suction drain. Therefore, we can conclude that the subcutaneous position of the suction drain did not yield superior results.

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

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

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.

Tranexamic acid for control of blood loss in bilateral total knee replacement in a single stage

Background:Tranexamic acid (TEA) reduces blood loss and red cell transfusions in patients undergoing unilateral total knee arthroplasty (TKA). However, there is not much literature regarding the use of TEA in patients undergoing bilateral TKA in a single stage and the protocols for administration of TEA in such patients are ill-defined.Materials and Methods:We carried out a case control study evaluating the effect of TEA on postoperative hemoglobin (Hb), total drain output, and number of blood units transfused in 52 patients undergoing bilateral TKA in a single stage, and compared it with 56 matched controls who did not receive TEA. Two doses of TEA were administered in doses of 10 mg / kg each (slow intravenous (IV) infusion), with the first dose given just before tourniquet release of the first knee and the second dose three hours after the first one.Results:A statistically significant reduction in the total drain output and requirement of allogenic blood transfusion in cases who received TEA, as compared to the controls was observed. The postoperative Hb and Hb at the time of discharge were found to be lower in the control group, and this result was found to be statistically significant.Conclusion:TEA administered in patients undergoing single stage bilateral TKA helped reduce total blood loss and decreased allogenic blood transfusion requirements. This might be particularly relevant, where facilities such as autologous reinfusion might not be available.

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.

Comparative study of one stage bilateral total knee arthroplasty with or without drainage

To compare the impact of rehabilitative process of placing drainage versus no drainage during total knee arthroplasty (TKA). A prospective study was performed in 30 osteoarthritic patients who underwent one-stage bilateral TKA between October 2007 and December 2008. For every patient, drainage was randomly placed intra-operatively only on one knee side. Pain VAS scores, extremity swelling, incision healing, recovery of knee joint flexion and extension function and early postoperative complications were compared statistically as a self-control study. All patients were followed up for at least one month. Comparing drainage side with non-drainage side, the mean pain VAS scores at Day 3 post-operation were 4.7 +/- 1.8 and 4. 9 +/- 1.9 respectively; the mean extremity swelling differences of supra patellar (infra patellar) perimeter at Day 6 post-operation were 1.8 +/- 1.7 (0.7 +/- 1.0) cm and 1.7 +/- 1.3 (1.0 +/- 1.0) cm respectively; the mean flexion (extension) differences at Day 30 post-operation were 12.5 +/- 21.6 (4.4 +/- 6.9) degrees and 11.7 +/- 23.9 (4.2 +/- 6.4) degrees respectively. There was no obvious statistical difference between placing drainage and no drainage in all the above aspects (paired t-test, P > 0.05). There was also no statistical difference of early postoperative complications between two groups (exact Fisher test, P > 0.05). For unsophisticated TKA, placing drainage had no effect upon reducing the pain, extremity swelling and incision exudation. It also had no effect upon reducing the incidence of hematoma to prevent early infections and promoting rehabilitation. Comparing with no drainage, placing drainage had no obvious advantage. On the contrary, it might complicate the surgical steps and increase the chances of post-operative hemorrhage and retrograde infections. Thus no drainage is recommended in such a kind of operation.