Perioperative considerations of bilateral total knee replacement: a review

Bilateral simultaneous hip and knee replacement: an epidemiological nationwide study from 2001 to 2016

BACKGROUND

Several studies have compared the pros and cons of simultaneous bilateral versus staged bilateral hip and knee replacement but the outcomes of these two surgical options remains a matter of controversy. This study aimed to evaluate demographic features, incidence and hospitalization rates of bilateral one stage total hip and knee arthroplasty in Italy.

METHODS

The Italian Ministry of Health's National Hospital Discharge Reports (SDO) were used to gather data. This study referred to the adult population (+ 20 years of age) from 2001 to 2015 for hip arthroplasty and from 2001 to 2016 for knee arthroplasty.

RESULTS

Overall, 1,544 bilateral simultaneous hip replacement were carried out. The incidence rate was 0.21 cases per 100,000 adult Italian residents. Male/female ratio was 1.1. The average days of hospital stay was 11.7 ± 11.8 days. The main primary codified diagnosis was: osteoarthrosis, localized, primary, pelvic region and thigh (ICD code: 715.15). 2,851 bilateral simultaneous knee replacement were carried out. The incidence rate was 0.37 cases per 100,000 adult Italian residents. Male/female ratio was 0.6. The average days of hospital stay was 7.7 ± 5.8 days. The main primary codified diagnosis was: osteoarthrosis, localized, primary, lower leg (ICD code: 715.16).

CONCLUSIONS

The burden of hip and knee osteoarthrosis as a leading cause of bilateral joint replacement is significant in Italy. The national registers' longitudinal analysis may provide data for establishing international guidelines regarding the appropriate indications for one stage bilateral simultaneous hip or knee replacement versus two stage.

Comparative Analysis of Short-Term and Long-Term Clinical Efficacy of Mesenchymal Stem Cells from Different Sources in Knee Osteoarthritis: A Network Meta-Analysis

Background

Joint articular injection of mesenchymal stem cells (MSCs) has emerged as a novel treatment approach for osteoarthritis (OA). However, the effectiveness of MSCs derived from different sources in treating OA patients remains unclear. Therefore, this study aimed to explore the differences between the effectiveness and safety of different sources of MSCs.

Materials and Methods

For inclusion consideration, we searched trial registries and published databases, including PubMed, Cochrane Library, Embase, and Web of Science databases. Revman (V5.3), STATA (V16.0), and R (V4.0) were utilized for conducting data analysis, while the Cochrane Risk of Bias Tool was employed for assessing the quality of the studies. We derived outcome measures at 6 and 12 months based on the duration of study follow-up, including visual analog scale (VAS) score, WOMAC score, WOMAC pain, WOMAC Functional Limitation, and WOMAC stiffness. The evaluation time for short-term effectiveness is set at 6 months, while 12 months is utilized as the longest follow-up time for most studies to assess long-term effectiveness.

Results

The evaluation of literature quality showed that the included studies had excellent methodological quality. A meta-analysis revealed that different sources of MSCs improved knee function and pain more effectively among patients suffering from knee OA (KOA) than controls. The results of the network meta-analysis showed the following: short-term functional improvement (the indexes were evaluated after 6 months of follow-up) (WOMAC total score: bone marrow-derived MSC (BMMSC) vs. adipose-derived MSC (ADMSC) (mean difference (MD) = -20.12, 95% confidence interval (CI) -125.24 to 42.88), umbilical cord-derived MSC (UCMSC) (MD = -7.81, 95% CI -158.13 to 74.99); WOMAC stiffness: BMMSC vs. ADMSC (MD = -0.51, 95% CI -7.27 to 4.29), UCMSC (MD = -0.75, 95% CI -9.74 to 6.63); WOMAC functional limitation: BMMSC vs. ADMSC (MD = -12.22, 95% CI -35.05 to 18.86), UCMSC (MD = -9.31, 95% CI -44.26 to 35.27)). Long-term functional improvement (the indexes were evaluated after 12 months of follow-up) (WOMAC total: BMMSC vs. ADMSC (MD = -176.77, 95% CI -757.1 to 378.25), UCMSC (MD = -181.55, 95% CI -937.83 to 541.13); WOMAC stiffness: BMMSC vs. ADMSC (MD = -0.5, 95% CI -26.05 to 18.61), UCMSC (MD = -1.03, 95% CI -30.44 to 21.69); WOMAC functional limitation: BMMSC vs. ADMSC (MD = -5.18, 95% CI -316.72 to 177.1), UCMSC (MD = -8.33, 95% CI -358.78 to 218.76)). Short-term pain relief (the indexes were evaluated after 6 months of follow-up) (VAS score: UCMSC vs. BMMSC (MD = -10.92, 95% CI -31.79 to 12.03), ADMSC (MD = -14.02, 95% CI -36.01 to 9.81), PLMSC (MD = -17.09, 95% CI -46.31 to 13.17); WOMAC pain relief: BMMSC vs. ADMSC (MD = -11.42, 95% CI -39.52 to 11.77), UCMSC (MD = -6.73, 95% CI -47.36 to 29.15)). Long-term pain relief (the indexes were evaluated after 12 months of follow-up) (VAS score: BMMSC vs. UCMSC (MD = -4.33, 95% CI -36.81 to 27.08), ADMSC (MD = -11.43, 95% CI -37.5 to 13.42); WOMAC pain relief: UCMSC vs. ADMSC (MD = 0.23, 95% CI -37.87 to 38.11), BMMSC (MD = 5.89, 95% CI -25.39 to 51.41)). According to the GRADE scoring system, WOMAC, VAS, and AE scores were of low quality.

Conclusion

Meta-analysis suggests MSCs can effectively treat KOA by improving pain and knee function compared to control groups. In terms of functional improvement in KOA patients, both short-term (6-month follow-up) and long-term (12-month follow-up) results indicated that while the differences between most treatments were not statistically significant, bone marrow-derived MSCs may have some advantages over other sources of MSCs. Additionally, BM-MSCs and UC-MSCs may offer certain benefits over ADMSCs in terms of pain relief for KOA patients, although the variances between most studies were not statistically significant. Therefore, this study suggests that BM-MSCs may present clinical advantages over other sources of MSCs.

Data-driven preoperative hemoglobin thresholds in patients undergoing Bilateral simultaneous total Knee arthroplasty are similar to patients undergoing unilateral total Knee arthroplasty

INTRODUCTION

Preoperative anemia is a risk factor for transfusions and complications following total knee arthroplasty (TKA). Bilateral TKA (bTKA) is more extensive compared to unilateral TKA (uTKA) and a higher preoperative hemoglobin threshold may be warranted. We hypothesized that the optimal hemoglobin cutoff value which predicts the need for postoperative transfusion would be higher for bTKA than uTKA.

METHODS

We conducted a case control study using a national database and identified patients undergoing primary TKA from 2010-2020. 1:1, nearest-neighbor propensity-score matching was used to create a cohort of patients undergoing uTKA matched with patients undergoing bTKA based on age, gender, Charlston Comorbidity Index (CCI), and American Society of Anesthesiology (ASA) classification. After 2015, NSQIP discontinued collection of the variables MI, angina, and hemiplegia. Thus, the accuracy of CCI, which was used as a matching variable, will be less accurate after 2015. To explore this limitation further, a sensitivity analysis was performed excluding data after 2015 and there was no change in the significance of our primary outcomes. Hemoglobin thresholds which maximally predict postoperative transfusion risk and 30-day complications were identified using Youden's index. Significance was considered if 95% CI's were non-overlapping.

RESULTS

9,891 patients were included in each of the bTKA and uTKA cohorts with successful 1:1 matching (p > 0.05 for all criteria). 3.216 (16 %) of patients received a transfusion in the postoperative period. Hemoglobin values which predict postoperative transfusions were not significantly different between uTKA and bTKA for both female and male groups. In females, the preoperative hemoglobin threshold was 12.8 g/dL (95 % CI: 12.2-13.3) in patients undergoing bTKA and 12.7 g/dL (95 % CI: 12.2 - 13.2) in uTKA. In males, the threshold was 13.9 (95 % CI: 13.7-14.2) in patients undergoing bTKA and 13.1 g/dL (95 % CI: 12.5-13.8) in patients undergoing uTKA.

CONCLUSIONS

Preoperative hemoglobin values which maximally predict postoperative transfusion risk following uTKA and bTKA are similar without significant differences.

Bilateral Total Knee Arthroplasty: Current Concepts Review

»

Bilateral total knee arthroplasty (BTKA) is an effective surgical treatment for bilateral knee arthritis and can be performed as a simultaneous surgery under a single anesthetic setting or as staged surgeries on separate days.

»

Appropriate patient selection is important for simultaneous BTKA with several factors coming into consideration such as age, comorbidities, work status, and home support, among others.

»

While simultaneous BTKA is safe when performed on appropriately selected patients, current evidence suggests that the risk of complications after simultaneous BTKA remains higher than for staged BTKA.

»

When staged surgery is preferred, current evidence indicates that complication risks are minimized if the 2 knees are staged at least 3 months apart.

»

Simultaneous BTKA is the economically advantageous treatment option relative to staged BTKA, primarily because of shorter total operative time and total hospital stay.

Simultaneous bilateral total knee arthroplasty : similar outcomes for trainees and trainers

Aims

Simultaneous bilateral total knee arthroplasty (TKA) has been used due to its financial advantages, overall resource usage, and convenience for the patient. The training model where a trainee performs the first TKA, followed by the trainer surgeon performing the second TKA, is a unique model to our institution. This study aims to analyze the functional and clinical outcomes of bilateral simultaneous TKA when performed by a trainee or a supervising surgeon, and also to assess these outcomes based on which side was done by the trainee or by the surgeon.

Methods

This was a retrospective cohort study of all simultaneous bilateral TKAs performed by a single surgeon in an academic institution between May 2003 and November 2017. Exclusion criteria were the use of partial knee arthroplasty procedures, staged bilateral procedures, and procedures not performed by the senior author on one side and the trainee on another. Primary clinical outcomes of interest included revision and re-revision. Primary functional outcomes included the Oxford Knee Score (OKS) and patient satisfaction scores.

Results

In total, 315 patients (630 knees) were included for analysis. Of these, functional scores were available for 189 patients (378 knees). There was a 1.9% (n = 12) all-cause revision rate for all knees. Overall, 12 knees in ten patients were revised, and both right and left knees were revised in two patients. The OKS and patient satisfaction scores were comparable for trainees and supervising surgeons. A majority of patients (88%, n = 166) were either highly likely (67%, n = 127) or likely (21%, n = 39) to recommend bilateral TKAs to a friend.

Conclusion

Simultaneous bilateral TKA can be used as an effective teaching model for trainees without any significant impact on patient clinical or functional outcomes. Excellent functional and clinical outcomes in both knees, regardless of whether the performing surgeon is a trainee or supervising surgeon, can be achieved with simultaneous bilateral TKA.

Cite this article: Bone Jt Open 2022;3(1):29–34.

Should Sequential Bilateral Total Knee Arthroplasty Be Limited to Patients Younger than 80? A Two-Arm Propensity Matched Study

Despite multiple studies, there remains a debate on the safety of bilateral total knee arthroplasty (BTKA) in the average age patient, with a paucity of data on the outcome of BTKA in an elderly population. This study included 89 patients aged 80 years and older undergoing sequential BTKA over 14 years were identified in a prospectively collected database. Two matched comparison groups were created: patients under 80 undergoing sequential BTKA and patients over 80 undergoing unilateral TKA (UTKA). An analysis of complications, mortality, revision, and patient-reported outcome measures was performed. Mean age of the elderly cohorts was similar: 82.6 for BTKA and 82.9 for UTKA. The average age BTKA cohort had a mean age of 69.1. Complication rates were higher in bilateral cohorts, more so in the elderly BTKA cohort. Pulmonary embolism (PE) was observed in bilateral cohorts only. In these patients, history of PE and ischemic heart disease was a strong predictive factor for developing a major complication. There was no difference in revision rates and infection rates between the three cohorts, and no difference in patient survivorship between the two elderly cohorts. Through the combination of low revision and high survivorship rates and comparable clinical outcomes, this article demonstrates that simultaneous BTKA is an appropriate option to consider for an elderly patient, with proper patient selection and perioperative management. The demonstrated risk groups show that emphasis on patient selection should be focused on medical history rather than chronological age.

Complications Associated With Same-Day Bilateral Total Knee Arthroplasties

Same-day bilateral total knee arthroplasties (SBTKAs) are associated with shorter rehabilitation and lower cost. However, controversy surrounding the safety of SBTKAs exists. Recent studies are lacking to determine whether patient selection has brought SBTKA in line with unilateral total knee arthroplasty (UTKA). Therefore, the authors evaluated and compared patient characteristics, hospital characteristics, and inpatient course between UTKA and SBTKA from 2009 to 2016. The National Inpatient Sample was queried from 2009 to 2016 for UTKA and SBTKA patients. Of the 5,329,466 patients identified, 5,084,328 (95.4%) patients received UTKAs and 245,138 (4.6%) patients underwent SBTKAs. Incidence, rate, patient and hospital characteristics, health status, length of stay (LOS), discharge disposition, hospital charges, hospital costs, and complications were analyzed and statistically compared. The incidence (-1.4%) and rate (15.8%) of SBTKAs decreased (both P<.001). The SBTKA cohort had more patients who were younger, male, White, obese, healthier, and using private insurance (P<.001 for all). The SBTKA cohort had longer LOS, a higher proportion of discharges to skilled nursing facilities, higher cost and charges, and more complications, including deep venous thromboses/pulmonary emboli (DVT/PE) and transfusions (P<.001 for all). Conversely, SBTKA was associated with fewer myocardial infarctions (P<.001). Although improved from previous literature, SBTKA is still associated with longer LOS, higher cost and charges, and more complications, including DVT/PE and transfusions, although with a lower rate of myocardial infarction. However, studies are needed to determine whether the risk of 1 SBTKA outweighs the cumulative risk of staged UTKAs. [Orthopedics. 2021;44(3):e407-e413.].

Single-stage bilateral tibial tuberosity advancement for treatment of bilateral canine cranial cruciate ligament deficiency

Objective: To report complications in dogs with naturally occurring cranial cruciate ligament rupture following single-stage bilateral tibial tuberosity advancement (SS-BTTA) procedures, and to compare these complications to a population of dogs undergoing unilateral tibial tuberosity advancement (UTTA).

Methods: Medical records and radiographs of client-owned dogs treated with tibial tuberosity advancement between August 2008 and December 2011 were reviewed. Forty-four client-owned dogs with bilateral cranial cruciate ligament rupture that underwent SS-BTTA procedures and 82 client-owned dogs that underwent UTTA proced -ures were randomly selected from our hospital population. Complications were recorded and analysed. Major complications were defined as fractures or any complication requiring a second surgery. Minor complications were any problem identified that did not require surgical management.

Results: Incidence for major and minor complications in the UTTA group was 2.3% and 24.4%, respectively. Incidence for major and minor complications in the SS-BTTA group was 12.5% and 26.1%, respectively. Single-stage bilateral tibial tuberosity advancement procedures had a four- to five-fold increase in odds of a major complication (p <0.050) compared to UTTA.

Clinical significance: The findings of our study indicate that SS-BTTA procedures are associated with an increased risk of major complications compared to UTTA procedures.

Staging Bilateral Total Knee Arthroplasty During the Same Hospitalization: The Impact of Timing

The concept of staging during the same hospitalization for bilateral total knee arthroplasty (BTKA) has emerged as a practice to minimize perioperative risks, although with few data providing an evidence base. A total of 41,664 BTKA patients from Nationwide Inpatient Sample data between 1998 and 2010 were identified, and categorized into three groups, same day, staging 1-3 days, and staging 4-7 days BTKA. Staging BTKA 1-3 days apart was associated with increased rates for complications compared to same day BTKA, while staging 4-7 days BTKA was associated with similar complication profiles compared to same day BTKA. Our study suggests that same day BTKA for selective patient population is preferable, and staging BTKA either 1-3 days or 4-7 days apart should be discouraged.

Effects of anesthetic technique on blood loss and complications after simultaneous bilateral total knee arthroplasty

AIMS

Anesthetic technique affects perioperative outcomes, but less was known in simultaneous bilateral total knee arthroplasty (BTKA). A single center, retrospective analysis was carried out to prove the hypothesis that utilization of regional anesthesia would result in favorable perioperative outcomes.

METHODS

Medical records of patients admitted for simultaneous BTKA between 2004 and 2013 were analyzed. Two groups, the general anesthesia (GA) and regional anesthesia (RA) group, were identified. Patient preoperative characteristics were compared. Perioperative outcomes measured included blood loss, transfusion requirement, length of hospitalization, operating time, and 30-day perioperative complications.

RESULTS

A total of 513 patients were identified, 54.6% were performed under GA, and 45.4% under RA. Patient characteristics were similar between the two groups, except that patients operated under GA were younger than those under RA. RA was associated with significantly less perioperative blood loss (981 vs. 1075 mL, p = 0.017) and 30-day complications (6.4 vs. 13.2%, p = 0.016). Systemic and organ specific infections were particularly lower in the RA group (0.4 vs. 3.9%, p = 0.009). Transfusion requirement, length of hospitalization, and operating time were similar between the two groups. After correcting for covariates, RA offered a 92 mL (p = 0.023) reduction in blood loss and 49% less overall complications (p = 0.047), compared to GA.

CONCLUSION

Patients who underwent simultaneous BTKA under RA had lesser blood loss and lower complication rate than GA. The impact of RA can be further exploited to improve perioperative outcomes of simultaneous BTKA in addition to various other interventions.