1
|
Wu CJ, Penrose C, Ryan SP, Bolognesi MP, Seyler TM, Wellman SS. Subsequent total joint arthroplasty: Are we learning from the first stage? World J Orthop 2024; 15:230-237. [PMID: 38596183 PMCID: PMC10999970 DOI: 10.5312/wjo.v15.i3.230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 01/15/2024] [Accepted: 02/02/2024] [Indexed: 03/15/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Christine Jiang Wu
- Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC 27710, United States
| | - Colin Penrose
- Department of Orthopaedic Surgery, Midwest Center for Joint Replacement, Indianapolis, IN 46241, United States
| | - Sean Patrick Ryan
- Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC 27710, United States
| | - Michael Paul Bolognesi
- Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC 27710, United States
| | - Thorsten Markus Seyler
- Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC 27710, United States
| | - Samuel Secord Wellman
- Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC 27710, United States
| |
Collapse
|
2
|
Kazubski K, Tomczyk Ł, Bobiński A, Morasiewicz P. Prognostic Factors in Staged Bilateral Total Knee Arthroplasty-A Retrospective Case Series Analysis. J Clin Med 2023; 12:jcm12103547. [PMID: 37240651 DOI: 10.3390/jcm12103547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 05/12/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Bilateral osteoarthritis of the knee is an indication for a bilateral total knee replacement (TKR) procedure. The goal of our study was to assess the sizes of the implants used during the first and second stages of TKR procedures in order to compare their size and identify the prognostic factors for the second procedure. METHODS We evaluated 44 patients who underwent staged bilateral TKR procedures. We assess the following prognostic factors from the first and second surgery: duration of anesthesia, femoral component size, tibial component size, duration of hospital stay, tibial polyethylene insert size, and the number of complications. RESULTS All assessed prognostic factors did not differ statistically between the first and second TKR. A strong correlation was found between the size of femoral components and the size of tibial components used during the first and second total knee arthroplasty. The mean duration of the hospital stay associated with the first TKR surgery was 6.43 days, whereas the mean duration of the second hospital stay was 5.5 days (p = 0.211). The mean sizes of the femoral components used during the first and second procedures were 5.43 and 5.2, respectively (p = 0.54). The mean sizes of the tibial components used during the first and second TKR procedures were 5.36 and 5.25, respectively (p = 0.382). The mean sizes of the tibial polyethylene inserts used during the first and second procedures were 9.45 and 9.34 (p = 0.422), respectively. The mean duration of anesthesia during the first and second knee arthroplasty was 117.04 min and 118.06 min, respectively (p = 0.457). The mean rates of recorded complications associated with the first and second TKR procedures were 0.13 and 0.06 per patient (p = 0.371). CONCLUSIONS We observed no differences between the two stages of treatment in terms of all analyzed parameters. We observed a strong correlation between the size of femoral components used during the first and second total knee arthroplasty. We noted a strong correlation between the size of tibial components used during the first and second procedure. Slightly weaker prognostic factors include the number of complications, duration of anesthesia and tibial polyethylene insert size.
Collapse
Affiliation(s)
- Krystian Kazubski
- Department of Orthopaedic and Trauma Surgery, University Hospital in Opole, Institute of Medical Sciences, University of Opole, Witosa 26, 45-401 Opole, Poland
| | - Łukasz Tomczyk
- Department of Food Safety and Quality Management, Poznan University of Life Sciences, Wojska Polskiego 28, 60-637 Poznan, Poland
| | - Andrzej Bobiński
- Department of Orthopaedic and Trauma Surgery, University Hospital in Opole, Institute of Medical Sciences, University of Opole, Witosa 26, 45-401 Opole, Poland
| | - Piotr Morasiewicz
- Department of Orthopaedic and Trauma Surgery, University Hospital in Opole, Institute of Medical Sciences, University of Opole, Witosa 26, 45-401 Opole, Poland
| |
Collapse
|
3
|
Lee KH, Chang WL, Tsai SW, Chen CF, Wu PK, Chen WM. The impact of Charlson Comorbidity Index on surgical complications and reoperations following simultaneous bilateral total knee arthroplasty. Sci Rep 2023; 13:6155. [PMID: 37061607 PMCID: PMC10105729 DOI: 10.1038/s41598-023-33196-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 04/08/2023] [Indexed: 04/17/2023] Open
Abstract
Simultaneous bilateral total knee arthroplasty (TKA) might be associated with higher postoperative morbidity and mortality rates compared with staged bilateral TKA. However, risk factors for surgical complications and reoperations following simultaneous bilateral TKA remain elusive. We conducted this retrospective, single-surgeon case series from 2010 through 2019. A total of 1561 patients who underwent simultaneous bilateral TKA procedures were included. The outcome domains included 30-day and 90-day readmission events for medical or surgical complications and 1-year reoperation events. We performed logistic regression analysis and backward stepwise selection to identify possible risk factors, including age, sex, body mass index, diabetes mellitus (DM), rheumatoid arthritis, American Society of Anesthesiologist (ASA) classification, Charlson Comorbidity Index (CCI), receiving venous thromboembolism (VTE) prophylaxis, or blood transfusion. The overall 30-day, 90-day readmission, and 1-year reoperation rates were 2.11%, 2.88%, and 1.41%, respectively. Higher CCI score (CCI = 4+) was a risk factor for 90-day readmission (aOR: 2.783; 95% CI 0.621-12.465), 90 day readmission for surgical complications (aOR: 10.779; 95% CI 1.444-80.458), and 1 year reoperation (aOR: 4.890; 95% CI 0.846-28.260). Other risk factors included older age, higher ASA level, DM, and receiving VTE prophylaxis. In conclusion, high CCI scores were associated with increased risks of surgical complications and reoperations following simultaneous bilateral TKA procedures.
Collapse
Affiliation(s)
- Kun-Han Lee
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Beitou District, Taipei, 112, Taiwan
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wei-Lin Chang
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Beitou District, Taipei, 112, Taiwan
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shang-Wen Tsai
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Beitou District, Taipei, 112, Taiwan.
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Cheng-Fong Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Beitou District, Taipei, 112, Taiwan
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Po-Kuei Wu
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Beitou District, Taipei, 112, Taiwan
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wei-Ming Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Beitou District, Taipei, 112, Taiwan
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| |
Collapse
|
4
|
Wang KY, LaVelle MJ, Gazgalis A, Bender JM, Geller JA, Neuwirth AL, Cooper HJ, Shah RP. Bilateral Total Knee Arthroplasty: Current Concepts Review. JBJS Rev 2023; 11:01874474-202301000-00011. [PMID: 36722826 DOI: 10.2106/jbjs.rvw.22.00194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
» 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.
Collapse
Affiliation(s)
- Kevin Y Wang
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
| | | | | | | | | | | | | | | |
Collapse
|
5
|
Agarwal AR, Gu A, Wang KY, Harris AB, Campbell JC, Thakkar SC, Golladay GJ. Interval Time of at Least 6 Weeks Between Bilateral Total Knee Arthroplasties is Associated With Decreased Postoperative Complications. J Arthroplasty 2022; 38:1063-1069. [PMID: 36566996 DOI: 10.1016/j.arth.2022.12.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 12/17/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Amil R Agarwal
- Department of Orthopaedic Surgery, George Washington University Hospital, Washington, District of Columbia; Department of Orthopaedic Surgery, Adult Reconstruction Division, Johns Hopkins University, Columbia, Maryland
| | - Alex Gu
- Department of Orthopaedic Surgery, George Washington University Hospital, Washington, District of Columbia
| | - Kevin Y Wang
- Department of Orthopaedic Surgery, Adult Reconstruction Division, Johns Hopkins University, Columbia, Maryland
| | - Andrew B Harris
- Department of Orthopaedic Surgery, Adult Reconstruction Division, Johns Hopkins University, Columbia, Maryland
| | - Joshua C Campbell
- Department of Orthopaedic Surgery, George Washington University Hospital, Washington, District of Columbia
| | - Savyasachi C Thakkar
- Department of Orthopaedic Surgery, Adult Reconstruction Division, Johns Hopkins University, Columbia, Maryland
| | - Gregory J Golladay
- Department of Orthopedic Surgery, Virginal Commonwealth University Medical Center Orthopaedics, Richmond, Virginia
| |
Collapse
|
6
|
Kelly MJ, Quinlan JF, Frampton C, Matheson JA. Medium-term outcomes in single anaesthetic bilateral total knee replacement surgery: a single surgeon series. Arch Orthop Trauma Surg 2022; 142:2857-2863. [PMID: 34495363 DOI: 10.1007/s00402-021-04151-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 08/30/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The lifetime risk of developing symptomatic knee osteoarthritis (OA) is estimated to be 45%, with up to two thirds of patients presenting with bilateral knee symptoms. Patients presenting with end stage bilateral knee OA may benefit from single anaesthetic bilateral total knee replacement (SABTKR). Our study aim was to compare the outcomes of SABTKR with unilateral total knee arthroplasty (TKA) in a single surgeon series over a 20 year period. METHODS We performed a retrospective review of a single surgeon's data from the New Zealand Joint Registry (NZJR) over a 20-year period from January 1999 to December 2018. This review reports on patient demographics, functional outcomes, revision rates and mortality rates. RESULTS 1225 total knee replacements were performed by the senior author (995 TKAs and 115 patients underwent SABTKRs) over the 20 year period reviewed. The mean ages of the TKA and SABTKR groups were 67.7 and 66.7 years, respectively. There was 16.9% mortality rate for the TKA group versus 7.8% in SABTKR group. There were no revisions in the SABTKR group versus 17 revisions in the TKA group representing a revision rate of 0.23/100 component years which can be viewed against a 20 year revision rate of 0.48/100 component years (p < 0.05) for all comers in the NZJR. CONCLUSION This NZJR study demonstrates excellent medium term survival outcomes for selected patients having simultaneous bilateral total knee replacements.
Collapse
Affiliation(s)
- M J Kelly
- Tallaght University Hospital, Tallaght, Dublin 24, Ireland.
| | - J F Quinlan
- Tallaght University Hospital, Tallaght, Dublin 24, Ireland
- Dunedin Public and Mercy Hospitals, Suite 3, Marinoto Clinic, Otago, Dunedin, New Zealand
| | - C Frampton
- New Zealand National Joint Registry, Christchurch Public Hospital, Christchurch, New Zealand
| | - J A Matheson
- Dunedin Public and Mercy Hospitals, Suite 3, Marinoto Clinic, Otago, Dunedin, New Zealand
| |
Collapse
|
7
|
Pumo TJ, Emara AK, Jin Y, Klika AK, Piuzzi NS. Staged Versus Simultaneous Bilateral Knee Arthroplasty: Does Minimal Cost Difference Justify Risks? J Arthroplasty 2022; 37:1776-1782.e4. [PMID: 35398227 DOI: 10.1016/j.arth.2022.03.087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/11/2022] [Accepted: 03/31/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Simultaneous bilateral total knee arthroplasty (BTKA) is associated with a higher risk but can be perceived to afford faster improvement and mitigated costs versus staged BTKA. We aimed to explore (1) health care utilization, (2) surgical supply costs of simultaneous BTKA; and (3) 1-year improvement in patient-reported pain, function, and quality of life (QOL) versus staged BTKA. METHODS A prospective cohort of 198 simultaneous and 625 staged BTKAs was obtained (2016-2020). Simultaneous BTKA cohort was propensity score-matched (1:2) to a similar group of staged patients (simultaneous = 198 versus staged = 396). Outcomes included length of stay, discharge disposition, 90-day readmission, 1-year reoperation, surgical episode supply cost, Knee Injury and Osteoarthritis Outcome Score (KOOS)-pain, KOOS-Physical Function Short Form, and KOOS-QOL. Rates of attaining minimal clinically important difference and Patient Acceptable Symptomatic State were calculated. RESULTS Compared to both staged BTKA surgeries combined, simultaneous BTKA demonstrated shorter median net length of stay (2.00 [2.00, 3.00] days versus 2.00 [2.00, 4.00] days; P < .001) but higher rates of nonhome discharge (n = 56 [28.3%] versus n = 32 [4.04%]; P < .001), 90-day readmission (n = 20 [10.1%] versus n = 48 [6.06%]; P = .047) and similar reoperation rates (P = .44). Simultaneous BTKA afforded slight reduction in net surgical cost compared to that of both staged BTKAs combined ($643; P = .028). There was no significant difference in 1-year improvement and minimal clinically important difference attainment rates with simultaneous versus staged BTKA for KOOS-pain (P = .137 and P = .99), KOOS-QOL (P = .095 and P = .81), or KOOS-Physical Function Short Form (P = .75 and P = .49, respectively) or Patient Acceptable Symptomatic State (P = .12). CONCLUSION Staged BTKA is associated with similar 1-year pain, function, and QOL at a better safety profile and minimal surgical supply cost increase compared to simultaneous BTKA.
Collapse
Affiliation(s)
- Thomas J Pumo
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ahmed K Emara
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Yuxuan Jin
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Alison K Klika
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | -
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
8
|
Simultaneous Bilateral Total Knee Arthroplasty in Elderly: Are There Factors that Can Influence Safety and Clinical Outcome? Adv Orthop 2022; 2022:1989822. [PMID: 36046489 PMCID: PMC9420611 DOI: 10.1155/2022/1989822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 07/25/2022] [Accepted: 07/30/2022] [Indexed: 11/18/2022] Open
Abstract
Objective The aim of this study was to look for preoperative patients' related factors correlating with worse clinical outcomes in a cohort of elderly patients undergoing simultaneous bilateral total knee arthroplasty (SiBTKA) to search for risk factors, which may influence clinical outcomes and safety. Subjects and Methods. The hospital database was mined searching for patients older than 70 years that underwent SiBTKA for severe bilateral knee osteoarthritis (OA) between 2012 and 2016. Preoperative clinical information, Oxford Knee Score (OKS), and Knee Injury and Osteoarthritis Outcome Score (KOOS) prior to surgery were recorded. The OKS and the KOOS were submitted again after a minimum of 5 years of follow-up (FU). Results An improvement was observed in all clinical scores at last FU. The major complication rate was 5.4%. No patients' clinical data showed correlation with perioperative complications or need for transfusions. Functional scores at the last FU were negatively affected by age at surgery and positively affected by preoperative clinical scores. Discussion. In the setting of severe symptomatic bilateral knee OA, SiBTKA seems to be effective in improving symptoms at midterm follow-up, with acceptable rates of perioperative complications in patients older than 70. Higher age at surgery and lower preoperative functional scores are associated with worse clinical outcomes at FU. This could assist surgeons in advising patients that delay of surgical treatment could worsen outcomes.
Collapse
|
9
|
Simultaneous bilateral total knee arthroplasty has higher in-hospital complications than both staged surgeries: a nationwide propensity score matched analysis of 38,764 cases. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2022; 33:1057-1066. [PMID: 35377079 DOI: 10.1007/s00590-022-03248-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 03/09/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE To investigate (1) healthcare utilization, (2) in-hospital metrics and (3) total in-hospital costs associated with simultaneous versus staged BTKA while evaluating staged BTKA as a single process consisting of two combined episodes. METHODS The national readmissions database was reviewed for simultaneous and staged (two primary unilateral TKAs12 months apart) BTKA patients (2016-2017). A total of 19,382 simultaneous BTKAs were identified, and propensity score matched (1:1) to staged BTKA patients (19,382 patients; 38,764 surgeries) based on demographics, comorbidities, and socioeconomic determinants. Outcomes included healthcare utilization [length of stay (LOS) and discharge disposition], in-hospital periprosthetic fractures, non-mechanical complications, and costs. Staged BTKA was evaluated as one process consisting of two episodes. For each staged patient, continuous outcomes were evaluated via the sum of both episodes. Categorical outcomes were added, and percents were expressed relative to total number of surgeries (n = 38,764). RESULTS Simultaneous BTKA had longer LOS (5.0 days ± 4.7 vs. 4.5 days ± 3.5; p < 0.001), higher non-home discharge [36.9% (n = 7150/19,382) vs. 13.6% (n = 5451/38,764)], in-hospital periprosthetic fractures [0.13% (26/19,382) vs. 0.08% (31/38,764); p = 0.049], any non-mechanical complication [33.76% (6543/19,382) vs.15.93% (6177/38,764); p < 0.0001], hematoma/seroma formation [0.11% (22/19,382) vs. 0.05% (20/38,764); p = 0.0088], wound disruption [0.08% (16/19,382) vs. 0.04% (16/38,764); p = 0.0454], and any infection [1.13% (219/19,382) vs. 0.50% (194/38,764); p < 0.0001]. Average in-hospital costs for the two staged BTKA episodes combined were $5006 higher than those of simultaneous BTKA ($28,196 ± $18,488 vs. $33,202 ± $15,240; p < 0.001). CONCLUSION Simultaneous BTKA had higher healthcare utilization and in-hospital complications than both episodes of staged BTKA combined, with a minimal in-hospital cost savings. Future studies are warranted to further explore patient selection who would benefit from BTKA.
Collapse
|
10
|
Abstract
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.
Collapse
Affiliation(s)
- Gerard A Sheridan
- Division of Lower Limb Reconstruction and Oncology, The University of British Columbia, Vancouver, Canada
| | - Rotem Moshkovitz
- Division of Lower Limb Reconstruction and Oncology, The University of British Columbia, Vancouver, Canada
| | - Bassam A Masri
- Division of Lower Limb Reconstruction and Oncology, The University of British Columbia, Vancouver, Canada
| |
Collapse
|
11
|
Remily EA, Wilkie WA, Mohamed NS, Pastore M, Viola A, Cho AH, Nace J, Delanois RE. Trends of Obese and Morbidly Obese Patients in Same-Day Bilateral Total Knee Arthroplasty from 2009 to 2016. J Knee Surg 2021; 34:1275-1283. [PMID: 32259850 DOI: 10.1055/s-0040-1708038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
As obesity in the United States increases, the proportion of obese and morbidly obese patients undergoing same-day bilateral total knee arthroplasty (sd-BTKA) remains unknown. Therefore, this study analyzed: (1) incidence, (2) patient demographics, (3) patient course, and (4) patient outcomes in obese and morbidly obese patients undergoing sd-BTKA in the United States from 2009 to 2016. The National Inpatient Sample was queried for all sd-BTKA patients from 2009 to 2016, yielding 39,901 obese and 20,394 morbidly obese patients. Analyzed variables included overall incidence, age, length of stay (LOS), sex, race, payer, Charlson comorbidity index (CCI) status, disposition, complications, location/teaching status, region of hospital, costs, and charges. Categorical variables were evaluated with chi-square analysis, while continuous variables were analyzed by Student's t-tests. Overall, the number of sd-BTKAs decreased over the study period, although the proportion of both obese and morbidly obese patients increased (p < 0.001 for all). The most common CCI status, 3 + , decreased in proportion for both groups (p < 0.001 for all). Hospital costs decreased and charges increased for both groups (p < 0.001 for all). Mean LOS decreased and patients were most commonly discharged to skilled nursing facilities, although these proportions decreased (p < 0.001 for all). Respiratory failures (p < 0.001 for all) increased for both groups, while proportion of deep vein thromboses and hematomas/seromas (p < 0.001 for all) increased for obese patients and proportion of pulmonary emboli (p < 0.001) increased for morbidly obese patients. The results of this study appear to portray improving optimization and patient selection of higher body mass index (BMI) individuals undergoing this procedure. More information is needed comparing the safety of the sd-BTKA across patients of all BMI groups.
Collapse
Affiliation(s)
- Ethan A Remily
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Wayne A Wilkie
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Nequesha S Mohamed
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Mark Pastore
- Department of Orthopaedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - Anthony Viola
- Department of Orthopaedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - Abraham H Cho
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - James Nace
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| |
Collapse
|
12
|
Warren JA, Siddiqi A, Krebs VE, Molloy R, Higuera CA, Piuzzi NS. Bilateral Simultaneous Total Knee Arthroplasty May Not Be Safe Even in the Healthiest Patients. J Bone Joint Surg Am 2021; 103:303-311. [PMID: 33369981 DOI: 10.2106/jbjs.20.01046] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Bilateral total knee arthroplasty (TKA) has been shown to increase both mortality and complications, but has potential benefits including decreased length of stay, rehabilitation time, and costs. The purpose of this study was to use data from a nationally representative database to identify if there is a population of patients undergoing TKA in whom bilateral TKA can be safely performed, by comparing 30-day mortality and complication rates with those of patients undergoing unilateral TKA. METHODS The National Surgical Quality Improvement Program (NSQIP) was queried to compare 30-day rates of mortality and any complication between bilateral TKA and unilateral TKA. A total of 8,291 patients who underwent bilateral TKA were matched 1:1 with a unilateral TKA control cohort (n = 315,219) by morbidity probability, which is a cumulative variable encompassing demographic characteristics, comorbidities, and laboratory values. Patients were divided into quartiles based on morbidity probability. Binary logistic regression comparing bilateral TKA and unilateral TKA for the same quartiles was performed to establish if any population could safely have bilateral TKA performed. RESULTS Bilateral TKA had an increased risk for all complications (p < 0.001) and major complications (p < 0.001) when compared with unilateral TKA regardless of health status. For all complications, there was a greater than threefold increase for the first quartile (healthiest patients) (p < 0.001), a greater than fourfold increase for the second and third quartiles (p < 0.001), and a greater than threefold increase for the fourth quartile (least healthy patients) (p < 0.001). For major complications, there was a greater than twofold increase for the first quartile (p = 0.001) and the second quartile (p < 0.001), an almost threefold increase for the third quartile (p < 0.001), and a 57% increase for the fourth quartile (p = 0.005). CONCLUSIONS This study will assist shared decision-making between orthopaedic surgeons and patients by suggesting that bilateral TKA may not be as safe an option for even healthy individuals compared with unilateral TKA. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Jared A Warren
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ahmed Siddiqi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Viktor E Krebs
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Robert Molloy
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Carlos A Higuera
- Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
13
|
|
14
|
Abstract
Because value in healthcare has shifted to a measurement of quality relative to the cost, a greater emphasis exists on improving clinical and functional outcomes and patient satisfaction. Despite advances in implant design, surgical technique, and postoperative rehabilitation, multiple studies demonstrate that nearly 20% of patients remain dissatisfied with their overall outcomes after primary total knee arthroplasty (TKA). Because implant positioning, alignment, and equal soft-tissue balance are critical for a successful TKA, malalignment in the coronal, sagittal, and rotational planes continue to increase failure rates and cause poor clinical outcomes. Robotic-assisted TKA has gained momentum within the past 10 years to better control surgical variables by mitigating technical errors caused by insecure cutting guides and imprecise bone cuts. Contemporary robotic platforms have evolved along with our ability to collect high-quality patient-reported outcome measures data, and this combination is proving the clinical effectiveness. This comprehensive review investigates the advent of robotic-assisted TKA including advantages, disadvantages, historical, and commercially available newer generation systems, clinical outcomes, and cost analysis to better understand the potential added value of this technology.
Collapse
|
15
|
Remily EA, Mohamed NS, Wilkie WA, Smith T, Judice A, Forte S, Nace J, Delanois RE. Obesity and its effect on outcomes in same-day bilateral total knee arthroplasty. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:936. [PMID: 32953736 PMCID: PMC7475448 DOI: 10.21037/atm-20-806] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Background The niche surgery of same-day bilateral total knee arthroplasty (sd-BTKA) continues to create debate amongst specialists in arthroplasty. To date, there is a significant lack of literature on obese patients undergoing sd-BTKA, and no study has evaluated outcomes of this procedure when compared to non-obese patients. Therefore, this study will perform a retrospective analysis to compare (I) incidence, (II) demographics, and (III) complications of sd-BTKA in non-obese, obese, and morbidly obese patients in the United States from 2009 to 2016. Methods The National Inpatient Sample (NIS) database was queried for all individuals that underwent sd-BTKA from 2009 to 2016. This returned 184,844 non-obese patients, 39,901 obese patients, and 20,394 morbidly obese patients. Analyzed variables included mean age, mean length of stay (LOS), race, payer, age-adjusted Charlson Comorbidity Index score, discharge disposition, hospital charges, hospital costs, and complications. Chi-square analyses and analyses of variance were utilized to assess categorical and continuous variables, respectively. Results Non-obese patients most commonly underwent sd-BTKA over the course of the study. As weight status increased, mean age decreased and the proportion of females, LOS, hospital charges and costs, and proportion of discharges to skilled nursing facilities increased. Regression analysis demonstrated obese and morbidly obese cohorts were at an overall increased odds for experiencing complications. Specifically, obese patients were at increased risk for pulmonary emboli, periprosthetic joint infections, and respiratory failures, while morbidly obese patients are at increased risk for pulmonary emboli, respiratory failures, and urinary tract infections. Conclusions Surgeons should thoroughly evaluate the risks and benefits of performing sd-BTKA on obese and morbidly obese patients, as both confer higher overall complication rates and increased length of stay. More research is necessary to characterize the cost analysis of this procedure, as health care models continue to transition to more cost-effective procedures.
Collapse
Affiliation(s)
- Ethan A Remily
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Nequesha S Mohamed
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Wayne A Wilkie
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Tyler Smith
- Department of Orthopaedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, USA
| | - Anthony Judice
- Department of Orthopaedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, USA
| | - Salvador Forte
- Department of Orthopaedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, USA
| | - James Nace
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| |
Collapse
|