A comparison of two rehabilitation protocols after simultaneous bilateral total knee arthroplasty: a controlled, randomized study

One-session bilateral total knee replacement: Late complications and survivorship

INTRODUCTION

The early morbidity and mortality of one-session bilateral total knee arthroplasty (1-session BTKA) has been reported in the medical literature. However, there is less information about the long-term clinical impact of this strategy. The aim of this study was to report on the late complications (>90 days), clinical outcomes (KOOS and new KSS) along with the survivorship of 1-session BTKA. We hypothesised that 1-session BTKA will cause few late complications and that the implant survival will meet the criteria of the National Institute for Health and Clinical Excellence (NICE).

METHODS

This single-centre retrospective study analysed a cohort of ASA-1 and ASA-2 patients who underwent 1-session BTKR over an 8-year period (2009 to 2016). The cohort consisted of 116 patients (66% women, 34% men) with mean age at inclusion of 69 years (32-85 years); 22% of patients were ASA-1 and 78% were ASA-2. The implant-related, infection-related or mechanical complications that occurred more than 90 days after the operation, the clinical outcomes (KOOS and New KSS) and radiological outcomes, along with the survivorship were determined during the scheduled follow-up visits at 3 months, 6 months and 1 year postoperative and during the long-term follow-up or during an intercurrent event.

RESULTS

No patients were lost to follow-up. Fifteen complications occurred (6.5%): four infections, four patellar problems (three cases of clunk syndrome and one of patellofemoral pain), four cases of stiffness, two of unexplained pain and one femoral periprosthetic fracture. Eight patients were readmitted to the hospital (7%); seven were reoperated (3%) and two implants were revised (1%). The functional outcomes (KOOS and New KSS) were significantly improved and 87% of patients were satisfied or very satisfied with this procedure. At a mean follow-up of 5 years, the survivorship estimated using the Kaplan-Meier method was 98.4% (95% CI: 0.933-0.996).

CONCLUSION

Performing 1-session BTKA is a reliable strategy as it produces a low rate of late complications, excellent medium-term functional outcomes and survivorship that meets NICE criteria, thus confirming our hypothesis.

LEVEL OF EVIDENCE

IV, retrospective case series.

Early morbidity and mortality after single-stage bilateral total knee replacement

INTRODUCTION

Single-stage bilateral total knee replacement (TKR) has the advantages of requiring only one hospital stay and one anesthesia session, having a shorter rehabilitation period, and reducing the cost of patient care. However, this strategy is controversial because of the perioperative risk. We hypothesized that this strategy did not cause early perioperative mortality and that the early morbidity and readmission rates would be low when patients are selected based on their ASA score.

METHODS

This single-center retrospective study analyzed a cohort of ASA-1 and ASA-2 patients who underwent single-stage bilateral TKR over an 8-year period (2009 to 2016). The study cohort consisted of 116 patients, mainly women with mean age of 69 years at inclusion; 22.4% of patients were ASA-1 and 77.6% were ASA-2. Death and early complications during the first 90 days postoperative, the early readmission rate and the blood-sparing strategy were analyzed using the clinical and paraclinical data collected during the hospital stay, during the convalescent care center stay, and during the follow-up visits at 6 weeks and 3 months postoperative. The analysis was completed using the intrahospital software Clinicom, which allowed us to trace all the events and episodes for each patient.

RESULTS

The early mortality rate was 0%. There were five major complications (4.3%) and thirteen minor complications (11%). The early readmission rate was 5.2%. Homologous blood transfusion was performed in 36% of patients. Administration of tranexamic acid reduced this rate to 24.3% versus 44% in patients not taking it (p=0.06).

CONCLUSION

The perioperative mortality in this selected population is zero and the early morbidity is acceptable. The early readmission rate is also low. Thus proposing single-stage bilateral TKR to patients meeting the criteria defined in this study is a valid strategy.

LEVEL OF EVIDENCE

IV, retrospective cohort study.

Bilateral total knee arthroplasty in a one-stage surgical procedure

INTRODUCTION

Bilateral total knee arthroplasty (TKA) in a one-stage surgical procedure has the advantage of a single hospital stay, shorter rehabilitation, and reduced patient management costs. However, until now the use of this strategy has been limited by the fear of a higher rate of perioperative complications. The hypothesis of this study was that in selected patients, this management strategy would not result in any serious complications.

MATERIALS AND METHODS

This prospective 24-month pilot study was performed in a continuous series of patients without a control group. Inclusion criteria were bilateral non-infectious gonarthropathy, in patients classified as American Society of Anesthesiology (ASA) 1 or 2 and presenting with a preoperative hemoglobin level of at least 13g/dL. All patients underwent a pre- and postoperative evaluation using the International Knee Society (IKS) and Knee Injury and Osteoarthritis Score (KOOS) scores.

RESULTS

Thirty patients were included in the study (25 women, mean age 70.3years old [32 to 88years]; five ASA 1 and 25 ASA 2). All patients were followed-up and evaluated for a mean 18months (6 to 30months). Three deep vein thromboses, one cardiopulmonary accident and three confusional states were reported, but there were no perioperative deaths, pulmonary embolisms, nosocomial infections or revision procedures. At 18months follow-up the IKS score had improved from 98 (33-139) preoperatively to 169 (62-200) postoperatively. The five items of the KOOS score improved significantly.

DISCUSSION

This preliminary series confirms that bilateral total knee replacement in a one-stage surgical procedure is a reliable alternative to a two-stage procedure in ASA 1 and 2 patients. Because of the savings in health costs with this strategy, public healthcare authorities should provide support by creating and sponsoring a specific group for further study.

LEVEL OF EVIDENCE

4, prospective, no control group.