Bilateral Simultaneous Total Knee Arthroplasty: A Patient-Matched Retrospective Observational Study

Comparison of safety and efficiency between sequential simultaneous bilateral and staged bilateral total knee arthroplasty at a high-volume center: a retrospective cohort study

The treatment strategy remains controversial for bilateral end-stage osteoarthritis, particularly with regard to patient safety. The aim of this study was to compare the safety and clinical results of sequential simultaneous bilateral total knee arthroplasty (ssBTKA) and staged bilateral total knee arthroplasty (staBTKA). Patients who underwent either simultaneous (n=168) or staged (n=63) bilateral total knee arthroplasty in a single center between February 2017 and April 2021 were identified retrospectively. Data related to age, gender, body mass index, ASA score, comorbidities, operative time, transfusion rate, length of stay, knee range of motion (ROM), Knee Society Score (KSS), complications, and mortality rates were evaluated. Mean follow-up duration was 39.0±14.7 months. Preoperative characteristics were similar among cohorts. Transfused units were significantly higher in the ssBTKA group (p<0.001). Operative time and length of stay were significantly higher in the staBTKA group (respectively, p<0.001 and p=0.004). Complication rates (except superficial infection rate which was significantly higher in the staBTKA group), revision rates, mortality rates and functional outcomes were statistically similar between the groups (p>0.05). Presence of preoperative coronary artery disease comorbidity was significantly associated with increased postoperative myocardial infarction risk (p=0.001). ssBTKA provided similar functional results, shorter cumulative hospital stay and shorter operative time without increasing complications and mortality rates compared to staBTKA procedure. For patients with pre-existing coronary artery disease, a more cautious approach should be preferred to decrease complications.

The mid-term outcomes of mobile bearing unicompartmental knee arthroplasty versus total knee arthroplasty in the same patient

Objective

To compare the mid-term outcomes of unicompartmental knee arthroplasty (UKA) that was performed in one knee and total knee arthroplasty (TKA) performed in the other knee in the same stage.

Methods

This is a retrospective study. A total of 63 patients (126 knees) scheduled for one-stage knee surgery due to osteoarthritis of both knees were selected, and all patients underwent one-stage mobile platform UKA and TKA of the other knee. Differences in general clinical data, functional recovery, complications, and prosthesis revision rates were assessed after UKA and TKA, respectively. The evaluation indicators for knee joint function recovery included the hospital for special surgery knee score (HSS), Joint Forgotten Score (JFS), Knee Injury and Osteoarthritis Outcome Score (KOOS), and Visual analog scale (VAS). Patient preference between UKA and TKA was also recorded.

Results

During a mean follow-up of 76.95 months (range, 65.00 to 87.00 months), there were no significant differences in postoperative complications between the two groups (P = 0.299); however, the prosthesis revision rate was higher in the UKA group than in the TKA group (P = 0.023). The incision length, operation time, blood loss, and postoperative drainage volume in the UKA group were significantly (P < 0.001) lower than those in the TKA group: JFS, ROM, and VAS in the UKA group were higher than those in the TKA group (P < 0.001, P = 0.023, P = 0.032), HSS and KOOS in TKA group were significantly (P < 0.001) higher than those in UKA group. At the last follow-up, 40% and 24% of patients preferred TKA and UKA, respectively.

Conclusions

TKA was found to be superior to UKA in terms of HSS, KOOS, and VAS, while UKA had more significant advantages in terms of less surgical trauma, better ROM, and higher JFS. Complications were not different between groups, but UKA had a higher rate of prosthesis revision. After a follow-up of at least 5 years, more patients preferred TKA.

A artroplastia total de joelhos bilateral simultânea pode ser segura

Objetivos Os objetivos deste estudo foram analisar a segurança da artroplastia total bilateral de joelho simultânea (ATJBS) e investigar a satisfação dos pacientes com o procedimento realizado de forma concomitante.

Métodos Em um estudo prospectivo, avaliamos 45 pacientes submetidos à ATJBS feita por duas equipes cirúrgicas. A idade média dos pacientes foi 66,9 anos, sendo 33 do gênero feminino (73,3%) e 12 (26,6%) do gênero masculino. No período intra- e pós-operatório foi seguido um protocolo de medidas visando a segurança do procedimento. Avaliamos o tempo de cirurgia, a perda sanguínea pelo hematócrito (Ht) e hemoglobina (Hb), obtidos no primeiro dia de pós-operatório, a porcentagem de pacientes que receberam transfusão de concentrado de hemácias e quantidade de unidades que foram necessárias. Verificamos as complicações no período perioperatório e, ao final de três meses, inquirimos aos pacientes sobre a preferência entre o procedimento simultâneo ou estagiado.

Resultados O tempo médio de cirurgia foi de 169 minutos; no pós-operatório houve um decréscimo médio de 28,2% do Ht e de 27,0% da Hb. Ao todo, 16 pacientes (35,5%) receberam transfusão de concentrado de hemácias (média de 1,75 unidades por paciente que precisou de reposição). Tivemos 12 complicações menores (26,6%) e 2 complicações maiores (4,4%); além disso, nenhum paciente teve o diagnóstico clínico de trombose venosa profunda e não houve mortes.

Conclusões A ATJBS pode ser considerada um procedimento seguro, se realizada em pacientes selecionados e com um protocolo de cuidados para prevenir complicações. Esse procedimento teve a aprovação unânime dos pacientes.

Development and validation of a nomogram to predict complications in patients undergoing simultaneous bilateral total knee arthroplasty: A retrospective study from two centers

Purpose

Complications were significantly increased 30 days after Simultaneous bilateral total knee arthroplasty (SBTKA). In this study, an individualized nomogram was established and validated to predict the complications within 30 days after SBTKA.

Methods

The general data of 861 patients (training set) who received SBTKA in The Affiliated Hospital of Qingdao University between January 1, 2012 and March 31, 2017 were retrospectively analyzed. All patients were divided into complication group (n = 96) and non-complication group (n = 765) according to the incidence of complications within 30 years after SBTKA. Independent risk factors for postoperative SBTKA complications were identified and screened by binary logistic regression analyses, and then a nomogram prediction model was constructed using R software. The area under curve (AUC), calibration curve, and decision curve analysis (DCA) were selected to evaluate the line-chart. Meanwhile, 396 patients receiving SBTKA in the Third Hospital of Hebei Medical University who met the inclusion and exclusion criteria (test set) were selected to verify the nomogram.

Results

Five independent predictors were identified by binary logistic regression analyses and a nomogram was established. The AUC of this nomogram curve is 0.851 (95% CI: 0.819–0.883) and 0.818 (95% CI: 0.735–0.900) in the training and testing sets, respectively. In the training set and test set, calibration curves show that nomogram prediction results are in good agreement with actual observation results, and DCA shows that nomogram prediction results have good clinical application value.

Conclusion

Older age, lower preoperative hemoglobin level, higher preoperative blood urea nitrogen (BUN) level, longer operation time, ASA grade ≥ III are independent predictors of SBTKA complications within 30 days after surgery. A nomogram containing these five predictors can accurately predict the risk of complications within 30 days after SBTKA.

The BTK Safety Score: A Novel Scoring System for Risk Stratifying Patients Undergoing Simultaneous Bilateral Total Knee Arthroplasty

Selection of appropriate candidates for simultaneous bilateral total knee arthroplasty (si-BTKA) is crucial for minimizing postoperative complications. The aim of this study was to develop a scoring system for identifying patients who may be appropriate for si-BTKA. Patients who underwent si-BTKA were identified in the National Surgical Quality Improvement Program database. Patients who experienced a major 30-day complication were identified as high-risk patients for si-BTKA who potentially would have benefitted from staged bilateral total knee arthroplasty. Major complications included deep wound infection, pneumonia, renal insufficiency or failure, cerebrovascular accident, cardiac arrest, myocardial infarction, pulmonary embolism, sepsis, or death. The predictive model was trained using randomly split 70% of the dataset and validated on the remaining 30%. The scoring system was compared against the American Society of Anesthesiologists (ASA) score, the Charlson Comorbidity Index (CCI), and legacy risk-stratification measures, using area under the curve (AUC) statistic. Total 4,630 patients undergoing si-BTKA were included in our cohort. In our model, patients are assigned points based on the following risk factors: +1 for age ≥ 75, +2 for age ≥ 82, +1 for body mass index (BMI) ≥ 34, +2 for BMI ≥ 42, +1 for hypertension requiring medication, +1 for pulmonary disease (chronic obstructive pulmonary disease or dyspnea), and +3 for end-stage renal disease. The scoring system exhibited an AUC of 0.816, which was significantly higher than the AUC of ASA (0.545; p < 0.001) and CCI (0.599; p < 0.001). The BTK Safety Score developed and validated in our study can be used by surgeons and perioperative teams to risk stratify patients undergoing si-BTKA. Future work is needed to assess this scoring system's ability to predict long-term functional outcomes.

Comparison of functional outcome of simultaneous and staged bilateral total knee arthroplasty : systematic review of literature

Safety of simultaneous bilateral TKA (simBTKA) and staged BTKA (staBTKA) have been compared in previous systematic reviews but functional outcome remains neglected aspect of the debate. We performed a systematic review of contemporary literature to compare the functional outcome of simBTKA and staBTKA. We searched PubMed/MEDLINE, EMBASE and Cochrane Central Database to identify all articles published between 2000 and July 2020 that evaluated the outcome of patients undergoing BTKA either in simultaneous or staged manner. Ten articles were identified which met the inclusion criteria. Functional outcome was reported in terms of Knee Society score (KSS), range of motion (ROM), Oxford Knee Score (OKS) and Western Ontario and McMaster University score (WOMAC) in seven, five, four and two studies respectively. KSS gained on average 66.6 points (47.5-95.3) for simBTKA and 65.1 points (44.4-97.2) for staBTKA without significant difference between two groups. There was no difference in post-operative ROM (maximum post-operative flexion being 124.4 and 125.1 for simBTKA and staBTKA groups respectively). Mean improvement in OKS ranged from 20 to 32.6 for simBTKA and 21.6 to 33.1 for staBTKA. There was moderate evidence to suggest that both simultaneous BTKA and staged BTKA produce equivalent improvement in functional scores.

Safety and efficacy of sequential simultaneous bilateral total knee arthroplasty: A single centre retrospective cohort study

BACKGROUND

Simultaneous bilateral total knee arthroplasty (TKA) is a promising option for patients with bilateral arthritis of the knee because of the requirement of a single hospitalization and anesthetic regimen, reduced overall hospital stay, lower overall costs, and quicker recovery compared to staged bilateral TKA. However, there are conflicting reports on the safety of the procedure, with little data available in the Indian setting. Herein, we compared the efficacy and safety of sequential simultaneous bilateral TKA (SSBTKA) with those of unilateral TKA (UTKA).

METHODS

This retrospective analysis included cases of SSBTKA (n = 380, 760 knees) and UTKA (n = 754) performed by the same surgeon and followed up for a minimum duration of 1 year. The functional outcomes (postoperative changes in Oxford Knee Score [OKS] and Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]), length of hospital stay (LOS), complications, and rates of revision and mortality were compared between the two groups.

RESULTS

The mean follow-up durations were 40.59 and 36.69 months for the UTKA and SSBTKA groups, respectively. The LOS was significantly longer in the SSBTKA group than in the UTKA group (Median [Interquartile range]: 4[1] vs. 3[0], p < 0.001). The OKS and WOMAC scores increased with time in both groups. The improvements in each of these scores at 3, 6, and 12 months postoperatively were either statistically similar between the two groups or, if statistically different, the differences were too small to be clinically meaningful. Blood transfusions (4% [SSBTKA] vs.0.3% [UTKA], p < 0.001), cardiac complications (1.6% vs. 0.4%, p = 0.034), urine retention (3.7% vs. 1.2%, p = 0.005), and deep infection (0.8% vs. 0%, p = 0.015) were significantly more frequent in the SSBTKA group. None of the patients in the UTKA group had to undergo revision surgery, whereas in the SSBTKA group, 2 (0.6%) patients underwent revision TKA. The overall mortality rates were low in both groups (0.8% [SSBTKA] and 0.3% [UTKA]), with no significant between-group difference (p = 0.209).

CONCLUSION

The functional outcomes and mortality rates associated with SSBTKA are comparable to those associated with UTKA. The risk of complications and the need for revision, although higher with SSBTKA, the actual numbers are low enough to justify its use. Although the LOS in SSBTKA is longer than that in UTKA, it is likely to be shorter than the cumulative LOS for two UTKA procedures (i.e. a staged bilateral TKA). Thus, SSBTKA appears to be a safe and effective choice for appropriately selected patients.

Component Alignment in Simultaneous Bilateral versus Unilateral Total Knee Arthroplasty

Purpose

The purpose of this study was to investigate differences in component alignment between first and second knees in simultaneous bilateral total knee arthroplasty (SBTKA) and unilateral TKA (UTKA).

Materials and Methods

274 SBTKAs and 198 UTKAs were included in study. Patients were divided into three groups as SBTKA on the right knee (group A), SBTKA on the left knee (group B) and UTKA (group C). Femoral and tibial component alignment was checked in both coronal plane (alpha [α] and beta [β] angles) and sagittal plane (gamma [γ] and delta [δ] angles) radiographs.

Results

There were no statistically significant differences among groups in the preoperative anatomical varus angle and Kellgren–Lawrence gonarthrosis classification grade (p=0.139 and p=0.329, respectively). In the coronal plane, the alignment of femoral component (α angle) and tibial component (β angle) was similar in all three groups (α angle, 95.01 vs. 95.14 vs. 94.9, p=0.945; β angle, 90.03 vs. 89.67 vs. 89.98, p=0.483). The sagittal plane alignment of femoral component (γ angle) and tibial component (δ angle) did not show significant differences (γ angle, 7.04 vs. 6.98 vs. 7.00, p=0.132; δ angle, 86.56 vs. 87.41 vs. 86.73, p=0.610).

Conclusions

The angular alignment of components was similar between SBTKA and UTKA.