Different clinical outcomes on the second side after staged total knee replacement. A systematic review

Kinematic Alignment Technique Outperforms Mechanical Alignment in Simultaneous Bilateral Total Knee Arthroplasty: A Randomized Controlled Trial

BACKGROUND

The 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.

METHODS

In 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.

RESULTS

At 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.

CONCLUSIONS

The 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 EVIDENCE

I.

Subsequent total joint arthroplasty: Are we learning from the first stage?

BACKGROUND

With the increasing incidence of total joint arthroplasty (TJA), there is a desire to reduce peri-operative complications and resource utilization. As degenerative conditions progress in multiple joints, many patients undergo multiple procedures.

AIM

To determine if both physicians and patients learn from the patient's initial arthroplasty, resulting in improved outcomes following the second procedure.

METHODS

The institutional database was retrospectively queried for primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). Patients with only unilateral THA or TKA, and patients undergoing same-day bilateral TJA, were excluded. Patient demographics, comorbidities, and implant sizes were collected at the time of each procedure and patients were stratified by first vs second surgery. Outcome metrics evaluated included operative time, length of stay (LOS), disposition, 90-d readmissions and emergency department (ED) visits.

RESULTS

A total of 642 patients, including 364 undergoing staged bilateral TKA and 278 undergoing bilateral THA, were analyzed. There was no significant difference in demographics or comorbidities between the first and second procedure, which were separated by a mean of 285 d. For THA and TKA, LOS was significantly less for the second surgery, with 66% of patients having a shorter hospitalization (P < 0.001). THA patients had significantly decreased operative time only when the same sized implant was utilized (P = 0.025). The vast majority (93.3%) of patients were discharged to the same type of location following their second surgery. However, when a change in disposition was present from the first surgery, patients were significantly more likely to be discharged to home after the second procedure (P = 0.033). There was no difference between procedures for post-operative readmissions (P = 0.438) or ED visits (P = 0.915).

CONCLUSION

After gaining valuable experience recovering from the initial surgery, a patient's perioperative outcomes are improved for their second TJA. This may be the result of increased confidence and decreased anxiety, and it supports the theory that enhanced patient education pre-operatively may improve outcomes. For the surgical team, the second procedure of a staged THA is more efficient, although this finding did not hold for TKA.

First knee for pain and function versus second knee for quality of life

Aims

The aim of this study was to describe and compare joint-specific and generic health-related quality of life outcomes of the first versus second knee in patients undergoing staged bilateral total knee arthroplasty (BTKA) for osteoarthritis.

Methods

This retrospective cohort study used Australian national arthroplasty registry data from January 2013 to January 2021 to identify participants who underwent elective staged BTKA with six to 24 months between procedures. The primary outcome was Oxford Knee Score (OKS) at six months postoperatively for the first TKA compared to the second TKA, adjusted for age and sex. Secondary outcomes compared six-month EuroQol five-dimension five-level (EQ-5D-5L) domain scores, EQ-5D index scores, and the EQ visual analogue scale (EQ-VAS) between knees at six months postoperatively.

Results

The cohort included 635 participants (1,270 primary procedures). Preoperative scores were worse in the first knee compared to the second for all instruments; however, comparing the first knee at six months postoperatively with the second knee at six months postoperatively, the mean between-knee difference was minimal for OKS (-0.8 points; 95% confidence interval (CI) -1.4 to -0.2), EQ-VAS (3.3; 95% CI 1.9 to 4.7), and EQ-5D index (0.09 points; 95% CI 0.07 to 0.12). Outcomes for the EQ-5D-5L domains 'mobility', 'usual activities', and 'pain/discomfort' were better following the second TKA.

Conclusion

At six months postoperatively, there were no clinically meaningful differences between the first and second TKA in either the joint-specific or overall generic health-related quality of life outcomes. However, individual domain scores assessing mobility, pain, and usual activities were notably higher after the second TKA, likely reflecting the cumulative improvement in quality of life after both knees have been replaced.

Outcomes after bilateral shoulder arthroplasty: a systematic review

The purpose of this systematic review was to report outcomes after bilateral shoulder arthroplasty including bilateral total shoulder arthroplasty (TSA), bilateral reverse shoulder arthroplasty (RSA), and ipsilateral TSA with contralateral RSA (TSA/RSA). Two reviewers independently performed a PRISMA-guided systematic search using MEDLINE/PubMed, Embase, and Cochrane Database of Systematic Reviews up to May 11, 2021. The databases were queried using the following search terms: (["bilateral" OR "contralateral"] AND "shoulder" AND ["arthroplast∗" OR "replacement"]). A total of 486 titles/abstracts were screened for eligibility and 19 studies were included in the final analysis. Risk of bias was assessed using Methodological Index for Nonrandomized Studies and Modified Coleman Methodology scores. Analysis compared overall results for bilateral shoulder arthroplasty and sub-group analyses compared TSA (all shoulders from bilateral TSA patients and the TSA shoulder in TSA/RSA patients) to RSA (all shoulders from bilateral RSA patients and the RSA shoulder in TSA/RSA patients), first shoulder arthroplasty to second contralateral shoulder arthroplasty, and interval between arthroplasty (IBA) <20 months to IBA ≥20 months. Nineteen studies analyzed bilateral TSA (n = 3), bilateral RSA (n = 7), and TSA/RSA (n = 8). The mean Methodological Index for Nonrandomized Studies was 18 and mean Modified Coleman Methodology Score was 74, with 63.2% of studies demonstrating level III evidence. A total of 2729 patients (30.4% male; mean age 72.2 years, mean follow-up 47.3 months, mean IBA 20 months) were analyzed. Postoperative forward flexion (142.0° vs. 129.6°), external rotation (ER) (42.5° vs. 25.6°), and internal rotation (60% reaching T12-T8 vs 85.7% reaching L3-L1) were higher for TSA when compared to RSA. Patient reported outcome measures such as Constant-Murley (73.2 vs. 59.2), American Shoulder and Elbow Surgeons (87.9 vs. 77.7), and Single Assessment Numeric Evaluation (SANE) (86.9 vs. 67.8) were higher for TSA when compared to RSA. Patients with IBA ≥20 months demonstrated greater ER and patient satisfaction than patients with IBA <20 months. Postoperative complication rates were 15.1% for TSA and 10.6% for RSA, while reoperation and revision rates were 13.7% for TSA and 7.1% for RSA. Bilateral shoulder arthroplasty results in improvements in motion, strength, pain, function, and high satisfaction. Bilateral TSA is associated with greater improvement in motion and function than bilateral RSA but higher complication, reoperation, and revision rates. IBA ≥20 months is associated with greater ER and satisfaction than IBA <20 months.

Interval Time of at Least 6 Weeks Between Bilateral Total Knee Arthroplasties is Associated With Decreased Postoperative Complications

BACKGROUND

Staged, bilateral total knee arthroplasty (TKA) has an increased risk of complications if the second procedure is performed before physiologic recovery from the first. The aims of this study were to 1) determine whether there is a time-dependent relationship between TKA staging and rates of revisions and complications and 2) identify data-driven time intervals that reduce risk of revisions and complications.

METHODS

Data were collected from a national insurance database from 2015 to 2018. Staged intervals were initially assessed using fixed 6-week intervals. Stratum-specific likelihood ratio analyses were subsequently conducted to observe data-driven staging thresholds. Bivariate and multivariable regression analyses were conducted to determine the associations between the time intervals and 2-year rates of revision surgery and 90-day major complications. We included 25,527 patients undergoing staged bilateral TKA.

RESULTS

In comparison to the shortest fixed time interval (1-6 weeks), as the staging interval increased the odds of 2-year all-cause revision and 90-day major complications significantly decreased (P < .05 for all). Stratum-specific likelihood ratio analysis identified 3 data-driven staging categories 1-5, 6-17, and 18-24 weeks that maximized the difference in both 2-year rates of revision and 90-day major complications.

CONCLUSION

Our data showed a time-dependent relationship between the timing of TKA stages and complications. If staging is considered, a delayed interval of at least 6 weeks between procedures may significantly reduce revision and major complications.

LEVEL OF EVIDENCE

Level III Therapeutic Study.

Are Functional Outcomes of a Total Hip Arthroplasty Predictive of a Contralateral Total Hip Arthroplasty: A Retrospective Cohort Study

BACKGROUND

Current literature suggests that 8%-35% of patients undergoing total hip arthroplasty (THA) undergo a subsequent contralateral THA. This study aims to determine if functional outcomes after primary THA predict outcomes in the subsequent primary THA of the contralateral side.

METHODS

A retrospective cohort of patients undergoing staged bilateral primary THA was reviewed. The Oxford Hip Score (OHS) was utilized as the functional outcome measurement tool and was assessed preoperatively and at one year postoperatively. The minimal clinically important difference (MCID) was assessed. Based on the first-side THA one-year outcomes, the odds of maintaining an MCID, or not, for the second-side THA were determined.

RESULTS

The study cohort consisted of 551 patients and 1102 primary THAs. The average postoperative OHSs were similar after the first and second THA. Patients achieving the MCID with the first-side surgery were 2.6 times (95% confidence interval 1.0 to 6.64, P = .04) more likely to achieve the MCID for the second-side surgery than patients failing to reach the MCID for their first-side surgery. After the first THA, 29 (5.3%) patients failed to reach the predefined MCID for the OHS compared with 54 (9.8%) patients undergoing their second THA (odds ratio: 1.96 [95% confidence interval: 1.23 to 3.1], χ² = 8.14, P = .005).

CONCLUSIONS

Functional outcomes after the first THA are predictive of functional outcomes of the second THA. Patients are more likely to achieve a clinically significant improvement after their first THA related to higher preoperative OHSs before the second THA.

Are patient-reported outcomes the same following second-side surgery in primary hip and knee arthroplasty?

Aims

Up to one in five patients undergoing primary total hip (THA) and knee arthroplasty (TKA) require contralateral surgery. This is frequently performed as a staged procedure. This study aimed to determine if outcomes, as determined by the Oxford Hip Score (OHS) and Knee Score (OKS) differed following second-side surgery.

Methods

Over a five-year period all patients who underwent staged bilateral primary THA or TKA utilizing the same type of implants were studied. Eligible patients had both preoperative and one year Oxford scores and had their second procedure completed within a mean (2 SDs) of the primary surgery. Patient demographics, radiographs, and OHS and OKS were analyzed.

Results

A total of 236 patients met the inclusion criteria, of which 122 were THAs and 114 TKAs. The mean age was 66.5 years (SD 9.4), with a 2:1 female:male ratio. THAs showed similar significant improvements in outcomes following first- and second-side surgery, regardless of sex. In contrast for TKAs, although male patients demonstrated the same pattern as the THAs, female TKAs displayed significantly less improvement in both OKS and its pain component following second-side surgery.

Conclusion

Female patients undergoing second-side TKA showed less improvement in Oxford and pain scores compared to the first-side. This difference in outcome following second-side surgery did not apply to male patients undergoing TKA, or to either sex undergoing THA.

Cite this article: Bone Jt Open 2021;2(4):243–254.

Interval Between Staged Bilateral Total Knee Arthroplasties Does Not Affect Early Medical or Surgical Complications

BACKGROUND

The purpose of this study is to evaluate early postoperative surgical and medical complications in patients undergoing staged bilateral total knee arthroplasty (TKA) and determine if the interval to the second stage influences the risk of complications.

METHODS

A retrospective review was performed from 2016 through 2018 of all staged bilateral primary TKA procedures, yielding a cohort of 1005 patients (2010 TKAs). Four groups were created based on the timing of the second stage: 3 to 6 weeks, 7 to 12 weeks, 13 to 24 weeks, and >24 weeks. Clinical data compared between groups included demographics, knee range of motion, University of California, Los Angeles (UCLA) activity score, Knee Society pain score, Knee Society clinical score, and Knee Society functional score. Postoperative complications within 90 days were evaluated, with complications after the second knee being the primary outcome.

RESULTS

The mean follow-up after second stage was 10.7 months (range, 3 to 37 months). No significant differences were found between groups in the range of motion, Knee Society pain, Knee Society clinical score, Knee Society functional score, or University of California Los Angeles activity score in either the first or second knee. After the first knee surgery, medical complications were highest in the >24-week group. After the second knee, there were no significant difference in manipulation (P = .9), wound complications (P = .7), venous thromboembolism (P = .8), or other medical complications (P = 1) based on the interval duration.

CONCLUSION

The interval between staged TKA did not affect early medical or surgical complications after the second stage. Early clinical and function results were not different based on timing of the second surgery.

Patients undergoing staged bilateral knee arthroplasty are less aware of their kinematic aligned knee compared to their mechanical knee

OBJECTIVE

To compare knee joint awareness following kinematic alignment (KA) TKA in patients who had previously undergone mechanical alignment (MA) on their contralateral knee.

METHODS

We performed a retrospective study of all consecutive patients who underwent staged bilateral TKA, the first using MA technique and the second utilizing the KA technique, without patient specific instrumentations. Primary outcome was assessed by the Forgotten Joint Score (FJS) with a minimum 1-year follow-up. Differences between knees were also assessed by three predefined key questions. Secondary outcome were differences in knee alignment assessed by long standing x-rays.

RESULTS

Overall, 38 patients (76 knees) met inclusion criteria and were included in the analysis. The mean time for follow up was significantly shorter (P < 0.01) in the KA knees (1.8 years, SD 0.3) compared to the MA knees (3.1 years, SD 0.8). Nonetheless, patients were significantly less aware of their KA knees compared to their MA knees; median FJS scores were 74.0 for the KA group (IQR¼ 54.5-92.0) and 67.0 for the MA group (IQR¼ 43.7-88.0) (p = 0.01). Overall, 31 patients (81.6%) preferred their KA knee over their MA knee 6 (15.8%) (p < 0.001). KA bone cuts resulted in net varus of the medial proximal tibia (86.9, SD 2.0) and valgus of the distal femur (86.6, SD 2.8). However, the overall alignment was similar (femorotibial angle 5.4 ± 2.3 vs. 4.7 ± 2.4, p = 0.45).

CONCLUSIONS

Patients who underwent staged bilateral knee arthroplasty were less aware of the knee that was kinematically aligned compared to the knee that was mechanically aligned. Future studies should focus on the long-term survivorship of KA TKA.

Outcomes of a First Total Knee Arthroplasty Are Associated With Outcomes of the Subsequent Contralateral Total Knee Arthroplasty

BACKGROUND

To determine if preoperative characteristics and postoperative outcomes of a first total knee arthroplasty (TKA) were predictive of characteristics and outcomes of the subsequent contralateral TKA in the same patient.

METHODS

Retrospective administrative claims data from (SPARCS) database were analyzed for patients who underwent sequential TKAs from September 2015 to September 2017 (n = 5,331). Hierarchical multivariable Poisson regression (length of stay [LOS]) and multivariable logistic regression (all other outcomes), controlling for sex, age, and Elixhauser comorbidity scores were performed.

RESULTS

The cohort comprised 65% women, with an average age of 66 years and an average duration of 7.3 months between surgeries (SD: 4.7 months). LOS was significantly shorter for the second TKA (2.6 days) than for the first TKA (2.8 days; P < .001). Patients discharged to a facility after their first TKA had a probability of 76% of discharge to facility after the second TKA and were significantly more likely to be discharged to a facility compared with those discharged home after the first TKA (odds ratio [OR]: 63.7; 95% confidence interval [CI]: 52.1-77.8). The probability of a readmission at 30 and 90 days for the second TKA if the patient was readmitted for the first TKA was 1.0% (OR: 3.70; 95% CI: 0.98-14.0) and 6.4% (OR: 9; 95% CI: 5.1-16.0), respectively. Patients with complications after their first TKA had a 27% probability of a complication after the second TKA compared with a 1.6% probability if there was no complication during the first TKA (OR: 14.6; 95% CI: 7.8.1-27.2).

CONCLUSION

The LOS, discharge disposition, 90-day readmission rate, and complication rate for a second contralateral TKA are strongly associated with the patient's first TKA experience. The second surgery was found to be associated with an overall shorter LOS, fewer readmissions, and higher likelihood of home discharge.

LEVEL OF EVIDENCE

Level 3-retrospective cohort study.

Contralateral knee pain reduces the rate of patient satisfaction but does not clinically impair the change in WOMAC score after total knee arthroplasty

Aims

The primary aim of this study was to assess whether pain in the contralateral knee had a clinically significant influence on the outcome of total knee arthroplasty (TKA) according to the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. Secondary aims were to: describe the prevalence of contralateral knee pain; identify if it clinically improves after TKA; and assess whether contralateral knee pain independently influences patient satisfaction with their TKA.

Methods

A retrospective cohort of 3,178 primary TKA patients were identified from an arthroplasty database. Patient characteristics, comorbidities, and WOMAC scores were collected preoperatively and one year postoperatively for the index knee. In addition, WOMAC pain scores were also collected for the contralateral knee. Overall patient satisfaction was assessed at one year. Preoperative contralateral knee pain was defined according to the WOMAC score: minimal (> 78 points), mild (59 to 78), moderate (44 to 58), and severe (< 44). Multivariate regression analysis was used to adjust for confounding.

Results

According to severity there were 1,425 patients (44.8%) with minimal, 710 (22.3%) with mild, 518 (16.3%) with moderate, and 525 (16.5%) with severe pain in the contralateral knee. Patients in the severe group had a greater clinically significant improvement in their functional WOMAC score (9.8 points; p < 0.001). Only patients in the moderate (22.9 points) and severe (37.8 points) groups had a clinically significant improvement in their contralateral knee pain (p < 0.001), but they were significantly less likely to be satisfied with their TKA (moderate: odds ratio (OR) 0.64, 95% confidence interval (CI) 0.4 to 0.92, p = 0.022; severe: OR 0.57, 95% CI 0.39 to 0.82, p = 0.002).

Conclusion

Contralateral knee pain did not impair improvement in the WOMAC score after TKA, and patients with the most severe contralateral knee pain had a clinically significantly greater improvement in their functional outcome. More than half the patients presenting for TKA had mild-to-severe contralateral knee pain, most of whom had a clinically meaningful improvement but were significantly less likely to be satisfied with their TKA. Cite this article: Bone Joint J. 2020;102-B(1):125–131