Comparing Anterior Versus Posterior Size Referencing in Patients Undergoing Simultaneous Bilateral Total Knee Arthroplasty: One Technique Per Knee.

Anterior referencing and posterior referencing are two major techniques for positioning femoral components and balancing the sagittal plane during total knee arthroplasty (TKA). The purpose of this study was to evaluate the changes in medial and lateral posterior condylar offset (PCO) after bilateral TKA using anterior referencing (AR) or posterior referencing (PR) systems and compare the effect of the PCO changes on knee flexion. Twenty female patients (mean age, 68.6years) underwent bilateral TKA using the AR technique in one knee and the PR technique in the contralateral knee. Three-dimensional reconstructed computed tomographic images from the sagittal plane were used to evaluate PCO before and after arthroplasty. Knee Society scores and range of motion were evaluated postoperatively at a mean of 2.9years. Postoperative medial and lateral PCOs were significantly greater (p<0.001 and p=0.048, respectively) in the AR group (30.9±2.2 and 29.1±1.5mm, respectively) than those in the PR group (29.1±2.7 and 27.3±2.3mm, respectively). In addition, the degree of change in the PCO after TKA was greater in the AR group than in the PR group. On the final follow-up, no differences in the degree of knee flexion were observed between the two groups (124.7° for AR and 124.5° for PR). Knee Society scores were similar in the two groups both preoperatively and postoperatively. On the final follow-up, individual changes in the medial and lateral PCO were not associated with changes in the knee flexion angle. Restoration of PCO after TKA was more accurate with the PR technique than with the AR technique. However, the postoperative differences in PCO showed no correlation with changes in knee flexion 2years after PCL-substituting TKA. Therapeutic study, Level I.

This study aimed to evaluate the annual trends of transfusion rates and utilization of blood management agents in total knee arthroplasty (TKA) based on the operation type and to analyze the risk factors of transfusion after TKA. Using the Korean National Insurance claims database of 797,106 primary and revision TKAs between January 2008 and October 2019, data on the patients' characteristics, comorbidities, utilization of transfusion, and blood management agents were collected. The patients were categorized into three groups based on the operation type: primary, revision, and simultaneous bilateral TKA. The transfusion rate and utilization of blood management agents (intraoperative tranexamic acid [TXA] and preoperative iron supplements) were compared, and the risk factors for transfusion were evaluated. After excluding the inaccurate data, 730,554 arthroplasties (636,292 primary, 10,540 revision, and 41,861 simultaneous bilateral TKAs) were identified. The transfusion rates of primary, revision, and simultaneous bilateral TKAs in 2019 were 64.0%, 67.7%, and 68.9%, respectively, which were significantly decreased compared with 83.2%, 88.0%, and 92.5% in 2008, respectively (p < 0.001). Conversely, the utilization of intraoperative TXA and preoperative iron supplements was significantly increased from 4.6% and 13.8%, respectively, in 2008 to 52.4% and 27.0%, respectively, in 2019 (p < 0.001). The utilization of intraoperative TXA and preoperative iron supplements significantly lowered the risk of transfusion after TKA (odds ratio [OR], 0.20; p < 0.001 and OR, 0.71; p < 0.001). The transfusion rate after TKA decreased gradually from 83.5% to 64.5% between 2008 and 2019 in South Korea corresponding with the increased utilization of blood management agents. Therefore, consistent attention to patient blood management should be emphasized to reduce the transfusion rate after TKA.

BackgroundSimultaneous bilateral total knee arthroplasty (TKA) is an effective treatment option and safe for properly selected patients. The purpose of this study was to evaluate whether patients have different satisfaction levels between the first and second knee in the early stage after simultaneous bilateral TKA.MethodsWe retrospectively reviewed 46 patients who underwent simultaneous bilateral TKA by a single surgeon in our department between March 2013 and March 2015. The surgeon typically performed first-side TKA (right knee), followed by TKA on the left knee. Tranexamic acid (TXA) (10 mg/kg) was given intravenously, and the tourniquet was released after wound closure. The preoperative KSS, ROM, and pain visual analog scale (VAS); the objective parameters including drainage volume and swelling evaluated by the circumference of the 10 cm above the patella; and the preoperative and postoperative (1st, 3rd, and 7th days) subjective parameters including pain, satisfaction VAS, and patient satisfaction of the first and second surgeries for each knee were analyzed.ResultsIn simultaneous bilateral TKA, compared with the second-side TKA (left knee), the first-side TKA (right knee) had a lower mean drainage volume (p < 0.05), but the swelling of the knee was higher on the 1st, 3rd, and 7th postoperative days (p < 0.05). Moreover, the first-side TKA was scored lower in satisfaction VAS but higher in pain VAS at the 1st, 3rd, and 7th postoperative days. The patient satisfaction scores indicated 2 (4.4%) of the 46 patients scored first-side TKA higher than second-side TKA, 34 (73.9%) of the 46 patients scored second-side TKA higher than first-side TKA, and 10 (21.7%) of the 46 patients scored their satisfaction as the same for both knees.ConclusionsThis research study found that there was better patient satisfaction with the second knee in the early stage after simultaneous bilateral TKA, which may provide some considerations for surgeons choosing simultaneous bilateral total knee arthroplasty for patients with osteoarthritis in both knees.

The aim of this study was to determine whether closed suction drain (CSD) use influences recovery of quadriceps strength and to examine the effects of drain use on secondary outcomes: quadriceps activation, intra-articular effusion, bioelectrical measure of swelling, range of movement (ROM), pain, and wound healing complications. A total of 29 patients undergoing simultaneous bilateral total knee arthroplasty (TKA) were enrolled in a prospective, randomized blinded study. Patients were randomized to receive a CSD in one limb while the contralateral limb had the use of a subcutaneous drain (SCDRN) without the use of suction ('sham drain'). Isometric quadriceps strength was collected as the primary outcome. Secondary outcomes consisted of quadriceps activation, intra-articular effusion measured via ultrasound, lower limb swelling measured with bioelectrical impendence and limb girth, knee ROM, and pain. Outcomes were assessed preoperatively and postoperatively at day two, two and six weeks, and three months. Differences between limbs were determined using paired Student's t-tests or Wilcoxon's signed-rank tests. No significant differences were identified between limbs prior to surgery for the primary or secondary outcomes. No significant differences in quadriceps strength were seen between CSD and SCDRN limbs at postoperative day two (p = 0.09), two weeks (primary endpoint) (p = 0.7), six weeks (p = 0.3), or three months (p = 0.5). The secondary outcome of knee extension ROM was significantly greater in the CSD limb compared with the SCDRN (p = 0.01) at two weeks following surgery, but this difference was absent at all other intervals. Secondary outcomes of quadriceps activation, intra-articular effusion, lower limb swelling, and pain were not found to differ significantly at any timepoint following surgery. The use of CSD during TKA did not influence quadriceps strength, quadriceps activation, intra-articular effusion, lower limb swelling, ROM, or pain. These results have limited drain use by the authors in primary uncomplicated TKA. Cite this article: Bone Joint J 2019;101-B (7 Supple C):84-90.

BACKGROUND: Advanced knee osteoarthritis (OA) is a common clinical problem requiring knee arthroplasty. X-ray can be used to diagnose knee osteoarthritis. Total knee arthroplasty of the two knees can be done simultaneously or staged in two different sessions. AIM: To assess simultaneous bilateral total knee arthroplasty based on complications and patient satisfaction and compare the results to those in the literature to provide a clear guideline for appropriate choice for patients. MATERIALS AND METHODS: A prospective cohort study was conducted in Ain Shams University Hospital in Cairo and Taiba Hospital in Kuwait on 45 cases who suffered from advanced bilateral knee osteoarthritis and underwent simultaneous bilateral total knee arthroplasty between August 2018 and October 2020. RESULTS: The study was conducted on 45 patients aged 47–75 years (mean age: 64.29±6.23 years). There were 41 females (91.1%) and 4 males (8.9%). Pre- and postoperative patient satisfaction was 15.24±2.45 and 32.18±4.08, respectively, with a mean difference of 16.93. Moreover, the pre- and postoperative objective knee score and Knee Society Scoring System, were 58.90±6.28 and 82.62±5.70, respectively. Additionally, the pre- and postoperative functional knee score were 51.39±8.67 and 73.80±7.75, respectively. Four patients (8.9%) had complications: 3 (6.7%) had superficial infection and 1 (2.2%) had acute coronary syndrome. CONCLUSION: Simultaneous bilateral total knee arthroplasty can be safe and have low mortality and complication rates with careful preoperative patient selection.

To evaluate the difference in post-operative knee awareness between knees in patients undergoing bilateral simultaneous total knee arthroplasty (TKA) and to assess factors predicting high or low knee awareness. This study was conducted on 99 bilateral simultaneous TKAs performed at our institution from 2008 to 2012. All patients received one set of questionnaires [Forgotten Joint Score (FJS) and Oxford Knee Score (OKS)] for each knee. Based on the FJS, the patients' knees were divided into two groups: "best" and "worst" knees. The median of the absolute difference in FJS and OKS within each patient was calculated. Multivariate linear regression was performed to identify factors affecting FJS. The difference between knees was 1 point (CI 0-5) for the FJS and 1 point (CI 0-2) for the OKS. The FJS for females increased (decreasing awareness) with increasing age. Males had the highest FJS (lowest awareness) at the age of 67. An increase in the FJS (lower knee awareness) of 12.0 points was found for Kellgren-Lawrence (K-L) grades 3+4 compared with K-L grades 1+2. A preoperative anatomical alignment of 3° valgus resulted in the lowest FJS (highest knee awareness) with decreasing knee awareness for decreasing tibio-femoral angles. Post-operative alignment did not significantly affect FJS. Knee awareness did not differ significantly between the "best" and the "worst" knee. Bilateral simultaneous TKA can be performed without compromising the result in one of the knees. Knee awareness after primary TKA was influenced by age, gender, preoperative knee alignment, and severity of OA. III.

The purpose of the current retrospective review was to compare the results of 1498 patients having 1090 simultaneous bilateral total knee arthroplasties and 958 unilateral total knee arthroplasties in a 3-year period, focusing on perioperative complications, length of hospital stay, and discharge disposition. Gender, age, diagnosis, and weight were similar between the groups. Patients undergoing simultaneous bilateral total knee arthroplasties had statistically significant higher amounts of intraoperative blood loss, with more patients requiring blood transfusion, and a higher average number of units of blood transfused compared with patients undergoing unilateral total knee arthroplasty. Overall, a significantly higher incidence of gastrointestinal complications was reported in patients who had simultaneous bilateral knee arthroplasties compared with patients who had unilateral knee arthroplasty. Comparing age subgroups within the unilateral group revealed significantly higher incidences of pulmonary, neurologic, cardiac, and genitourinary complications among patients 80 years or older versus patients younger than 80 years. Patients having simultaneous bilateral arthroplasties who were 80 years or older had significantly higher incidences of pulmonary, neurologic, and cardiac complications than patients younger than 80 years in that same group. These results suggest that age, not procedure, has a more significant role in the perioperative morbidity of total knee arthroplasty. Based on the results from the current study and previous literature documenting patient preference, patient satisfaction, efficacy, and outcomes comparable with those of patients having unilateral total knee arthroplasty, the authors continue to offer patients the option of simultaneous bilateral total knee arthroplasties.

The safety and efficacy of simultaneous or staged bilateral total knee arthroplasty have long been debated among orthopaedic surgeons. Advocates for simultaneous bilateral total knee arthroplasty posit that the benefits of decreased costs and recovery time, with no difference in functional outcomes, outweigh the economic costs of potential complications. The purpose of the study was to conduct a cost-utility analysis comparing simultaneous bilateral total knee arthroplasty with staged bilateral total knee arthroplasty. A Markov model was designed to compare the cost-effectiveness of simultaneous bilateral total knee arthroplasty with that of staged bilateral total knee arthroplasty. Nationwide Inpatient Sample data sets from 2004 to 2007 were used to identify 24,574 simultaneous and 382,496 unilateral procedures. On the basis of the codes of the International Classification of Diseases, Ninth Revision, Clinical Modification, perioperative complications were categorized as minor, major, and mortality, and respective probability values were calculated. Nationwide Inpatient Sample data were used to determine hospital costs conditional on procedure type and complications. Rehabilitation costs, anesthesia costs, and heath utilities were estimated from the literature. To minimize selection bias, propensity score matching was used to match the groups on comorbid conditions, socioeconomic variables, and hospital characteristics. Using the matched sample, all complication rates were higher for the staged group. The estimated mean cost (in 2012 U.S. dollars) was $43,401 for simultaneous bilateral total knee arthroplasty compared with $72,233 for staged bilateral total knee arthroplasty. The quality-adjusted life years gained were 9.31 for simultaneous bilateral total knee arthroplasty and 9.29 for staged bilateral total knee arthroplasty. On the basis of these matched results, simultaneous bilateral total knee arthroplasty dominated staged bilateral total knee arthroplasty with lower costs and better outcomes. On the basis of this analysis, simultaneous bilateral total knee arthroplasty is more cost-effective than staged bilateral total knee arthroplasty, with lower costs and better outcomes for the average patient. These data can inform shared medical decision-making when bilateral total knee arthroplasty is indicated.

Comparison of Gap Balancing vs Measured Resection Technique in Patients Undergoing Simultaneous Bilateral Total Knee Arthroplasty: One Technique per Knee

The clinical comparison of simultaneous bilateral total knee arthroplasty in treatment of osteoarthritis

AIMTo determine social, logistical and demographic factors that influence time to discharge in a short stay pathway (SSP) by following total knee arthroplasty (TKA).METHODSThe study included primary TKA’s performed in a high-volume arthroplasty center from January 2016 through December 2016. Potential variables associated with increased hospital length of stay (LOS) were obtained from patient medical records. These included age, gender, race, zip code, body mass index (BMI), number of pre-operative medications used, number of narcotic medications used, number of patient reported allergies (PRA), simultaneous bilateral surgery, tobacco use, marital status, living arrangements, distance traveled for surgery, employment history, surgical day of the week, procedure end time and whether the surgery was performed during a major holiday week. Multivariate step-wise regression determined the impact of social, logistical and demographic factors on LOS.RESULTSEight hundred and six consecutive primary SSP TKA’s were included in this study. Patients were discharged at a median of 49 h (post-operative day two). The following factors increased LOS: Simultaneous bilateral TKA [46.1 h longer (P < 0.001)], female gender [4.3 h longer (P = 0.012)], age [3.5 h longer per ten-year increase in age (P < 0.001)], patient-reported allergies [1.1 h longer per allergy reported (P = 0.005)], later procedure end-times [0.8 h longer per hour increase in end-time (P = 0.004)] and Black or African American patients [6.1 h longer (P = 0.047)]. Decreased LOS was found in married patients [4.8 h shorter (P = 0.011)] and TKA’s performed during holiday weeks [9.4 h shorter (P = 0.011)]. Non-significant factors included: BMI, median income, patient’s living arrangement, smoking status, number of medications taken, use of pre-operative pain medications, distance traveled to hospital, and the day of surgery.CONCLUSIONThe cost of TKA is dependent upon LOS, which is affected by multiple factors. The clinical care team should acknowledge socio-demographic factors to optimize LOS.

Racial and ethnic disparities in total joint replacements have been documented. Our objective was to determine the rates of total joint replacements for Alaska Native/American Indian (AN/AI) individuals compared with non-AN/AI individuals in Alaska and investigate the differences in characteristics and outcomes by race. We used hospital discharge data from the Alaska Health Facilities Data Reporting Program from 2015 to 2018. We identified people with an inpatient primary or revision total knee arthroplasty (TKA) or total hip arthroplasty (THA). We determined the population proportion of each procedure, age-adjusted rates by race, age-specific rates, and multivariable adjusted rate ratios for TKA or THA. We compared the characteristics of people undergoing primary TKA and THA by race. In 2,195,806 person-years, there were 8,131 arthroplasty procedures (4,594 primary TKAs, 2,791 primary THAs, 378 revision TKAs, and 368 revision THAs). Primary TKAs and THAs were less likely in people of AN/AI or "Other" race compared with people of White race, with some heterogeneity in the "Other" race category. In multivariable models, the adjusted rate ratio for AN/AI compared with White race for TKA was 0.70 (95% confidence interval [CI] 0.60-0.82) and for THA was 0.69 (95% CI 0.55-0.85). AN/AI individuals undergoing TKA and THA were more likely to reside in rural locations, be younger than 65 years, have longer hospital stay, and discharge to home. This study confirmed the existence of racial disparities in TKA and THA in Alaska. There may be many underlying causes, and future research should focus on improving access to care.

Objective To compare the differences of safety and clinical efficacy between simul-taneous bilateral total knee arthroplasty（ BTKA）and staged bilateral total knee arthroplasty. Methods The clinical data of 45 patients with BTKA,from Jan 2010 to Mar 2013 were retrospectively analyzed. They were divided into group A and group B,the patients in group A were given bilateral total knee ar-throplasty simultaneously,and the patients in group B were given bilateral total knee arthroplasty at different time（ interval time of surgery was 1 to 6 months）. The general information,preoperative complications,early postoperative complications and knee function recovery indicators of the two groups were compared. Results There were no significant differences in the sex ratio,age and body mass index between the two groups. The incidence of complications in group B was higher than that in group A. The incidence of early postoperative complication in group A was higher than that in group B. The early postoperative complications including cardiovascular complications,thrombosis,fever and psychiatric disorder. The infection around joint didn’t appear in either groups. And no patient died until the end of the follow-up. After follow-up of 6 months,there was no significant difference in HSS score of knee joint function between the two groups（ P〉0 . 05 ）. Conclusions Simultaneous BTKA can significantly shorten the hospitalization time and recovery time of lower limb function,but has higher incidence of early postoperative complication and big risk. The detailed body condition of patients need to be evaluated before operation. If the patients are selected reasonably and the preoperative preparation is perfect,simultaneous BTKA and staged BTKA has the same safety,reliability and satisfactory effect. Key words: Total knee arthroplasty; Simultaneous; Staged; Osteoarthritis

Total knee arthroplasty (TKA) is a common procedure for end-stage knee osteoarthritis. The comparative safety and functional outcomes of simultaneous bilateral TKA (SBTKA) versus unilateral TKA (UTKA) remain uncertain. This systematic review evaluated the complication rate, range of motion (ROM), functional recovery, and health-related quality of life (HRQoL) in patients who underwent SBTKA or UTKA. We performed a comprehensive literature search identifying 52 studies, including 5,859,125 patients who underwent SBTKA or UTKA. Outcomes assessed included complications, mortality, and readmission rates from the in-hospital period to 90 days, as well as lengths of stay (LOS), ROM, Knee Society Score (KSS), Oxford Knee Score (OKS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and physical and mental HRQoL scores. Meta-analyses were conducted using random-effects models. Risk ratios (RR) and mean differences (MD) were calculated for dichotomous and continuous outcomes, respectively. Patients who underwent SBTKA had a longer LOS (mean 0.8 days; 95% confidence interval [CI]: 0.3 to 1.3; P = 0.003) and higher complication rates (RR 1.42; 95% CI: 1.21 to 1.67; P < 0.001) compared with patients who underwent UTKA. Mortality (RR 1.12; 95% CI: 0.79 to 1.59; P = 0.55) and readmission (RR 1.13; 95% CI: 0.91 to 1.41; P = 0.29) were similar between groups. Functional outcomes, including ROM, KSS, and OKS, as well as HRQoL scores, were broadly comparable, with possible improvements in two-year KSS favoring SBTKA. Compared with UTKA, SBTKA is associated with a higher risk of complications and a longer LOS, while functional outcomes, range of motion, and health-related quality of life appear comparable between the two groups. Further high-quality studies are needed to clarify long-term outcomes and guide patient selection.

To compare the outcome after simultaneous bilateral total knee arthroplasty (TKA) with or without an intra-articular tranexamic acid (TXA) wash in terms of blood loss, haemoglobin change, and transfusion requirement. 35 women and 10 men (mean age, 67.5 years) who underwent primary simultaneous bilateral TKA by a single senior surgeon were compared with 45 matched controls. In the TXA group, 1500 mg of TXA diluted in 100 ml of 0.9% sodium chloride was administered as a wash after cementing of implant and before closure of the retinaculum. At least 5 minutes of contact time was allowed before wound closure and tourniquet deflation. No drain was used. No patients had thromboembolic complication. Compared with controls, the TXA group had lower perioperative blood loss (920 vs. 657 ml, p=0.001), total blood loss (997 vs. 679 ml, p<0.001), blood transfusion rate (60% vs. 37.8%, p=0.035), percentage of patients requiring more than one blood unit (24.4% vs. 8.9%, p=0.048), and length of hospitalisation (6 vs. 4 days, p<0.001). Nonetheless, the 2 groups were comparable in blood units and volume transfused. An intra-articular TXA wash during simultaneous bilateral TXA reduced total blood loss and resulted in a difference of 22.2% in blood transfusion rate and a 2-day reduction in the length of hospital stay.