Bilateral total knee arthroplasties: a call for practice guidelines

Improving Safety of Bilateral Knee Arthroplasty: Impact of Selection Criteria on Perioperative Outcome

Background: Bilateral total knee arthroplasty (BTKA) procedures are associated with an increased risk of complications when compared with unilateral approaches. In 2006, in an attempt to reduce this risk, our institution implemented selection criteria that specified younger and healthier patients as candidates for BTKA. Questions/Purpose: We sought to investigate the effect of these selection criteria on perioperative outcomes. Methods: In a retrospective cohort study, we used institutional data to identify patients who underwent BTKA between 1998 and 2014. Patients were divided into 2 groups: those who underwent surgery before the 2006 introduction of our selection criteria (1998-2006) and those who underwent surgery after (2007-2014). Groups were compared in terms of demographics, comorbidity burden, and incidence of perioperative complications. Regression analysis was performed, calculating incidence rate ratios to evaluate changes in complication rates. Results: Before the selection criteria were implemented in 2006, patients who underwent BTKA were older and had a higher comorbidity burden. The rate of major complications per 1000 hospital days decreased from 31.5 in 1998 to 7.9 in 2014. A reduction in cardiac complications was the most significant contributor to this decrease in major complications. Conclusion: After stringent criteria for BTKA candidates were implemented at our institution, selection of younger patients with lower comorbidity burden was accompanied by a reduction in the incidence of operative complications. This suggests that introducing such criteria can be associated with a reduction in adverse perioperative outcomes.

Integrative Review for Patients With Bilateral Total Knee Replacement: A Call for Nursing Practice Guidelines

BACKGROUND

The aim of this joint project between the National Association of Orthopaedic Nurses and the Association of Rehabilitation Nurses was to develop nursing practice guidelines for patients who experience bilateral knee arthroplasty (BTKA) across the continuum of care. No guidelines existed and an integrative review was completed to address this gap.

METHODS

An integrative review of refereed quantitative and qualitative research in published and gray literature was completed to answer the clinical questions: (1) What is the scope of evidence-based nursing interventions for patients undergoing BTKA? (2) What are patients' experiences with BTKA across the care continuum? The scope of the literature search was patients with bilateral and unilateral total knee arthroplasty. An evidence-based system was used to rate the strength of studies that met the criteria for inclusion in this review.

RESULTS

The search method identified 588 potential titles but the analysis of the abstracts supported only 128 studies for possible inclusion in this project. The authors independently reviewed these studies and concluded that 126 studies did not meet the inclusion criteria and 2 quantitative studies were eligible for inclusion.

CONCLUSIONS

Understanding which interventions are most effective for pain management, functional gains, quality of life, and other nurse-sensitive outcomes is best derived from empirical studies. Most likely, BTKA nursing care is being guided by clinical experts and not by empirical nursing evidence. In the absence of empirical evidence, it is feasible that nurses can extrapolate findings from other studies to guide and support the care of BTKA patients. Research recommendations include the exploration of early mobilization interventions, development of nursing care bundles, and evaluation of patient-centered outcomes at the points of transitional care.

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.