Simultaneous bilateral total knee arthroplasties: who decides?

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.

Background &amp; Objective: Local infiltration of knee joints during knee joint surgery has been used for postoperative analgesia with preservation of motor function of quadriceps muscle, which helps in early mobilization. Femoral nerve block has been incriminated with paralyses of vastus medialis muscle. We aimed to compare postoperative analgesia between femoral nerve block and local infiltration in patients undergoing unilateral total knee arthroplasty (TKA).Methodology: After obtaining institutional ethical approval and written informed consent from the patients, this randomized controlled trial was conducted at Department of Anesthesia at Teerthankar Mahaveer Medical College &amp; Research Centre between July - December 2018. The study was conducted on 60 patients of ASA I and II, undergoing unilateral total TKA. Patients were randomly divided into two groups: Group FB patients underwent femoral nerve block, and Group LI patients underwent local infiltration analgesia. Sedation score, numeric rating scale, motor power and frequency of nausea/vomiting were recorded and statistical analysis done.Results: We observed better pain relief in patients which received femoral nerve block as compared to local infiltration analgesia (p &lt; 0.001). Sedation score was higher in Group LI and was statistically significant between the two groups at 4th, 12th, and 48th hour (p &lt; 0.05). Group FB patients were associated with higher muscle power grades (p &lt; 0.001) as compared to local infiltration analgesia patients. Fentanyl demand was observed to be lesser in Group FB as compared to Group LI (p &lt; 0.001).Conclusion: The study concludes that femoral nerve block produces better pain reliefin patients posted for unilateral knee arthroplasty as compared to local infiltration ofthe local anesthetic solution. However, there is gross reduction in range of motion withfemoral nerve block.Citation: Varshney RK, Prasad MK, Garg M. Comparison of continuous femoral nerve block with local infiltration for postoperative analgesia in unilateral total knee arthroplasty - a randomized controlled trial. Anaesth pain &amp; intensive care 2019;23(3):268-273

It was with great interest that we read the recent article by Spicer, Thomas and Rumble,1 which provides an insight into the safety of unilateral total knee arthroplasty (UTKA) versus sequential or simultaneous bilateral total knee arthroplasty (BTKA) in a high-volume community hospital. The authors excluded from their study patients who underwent staged TKA, defined as “2 distinct surgeries on both knees within a 1-year period.” Instead, candidates with bilateral knee symptoms who were deemed eligible for surgery were given the option of BTKA or 2 UTKAs.1 In our experience with patients who present with bilateral fixed flexion knee deformities, even if a UKTA is initially successful, it may develop stiffness and adopt the fixed flexion of the contralateral knee if the latter is not likewise replaced within a few months. Residual flexion contractures after knee replacement have been associated with poor outcomes.2 The limitation of movement and impact on quality of life caused by a residual flexion contracture3 should be considered a complication in itself. This complication might be avoided by performing a BTKA or careful pre- and postoperative management to safely complete staged TKA procedures in considerably less than 1 year. Although it seems reasonable that “individuals who decline the second operation may have been better served by a 1-step BTKA,”1 the alternative is perhaps more relevant to orthopedic departments where there is less experience and expertise in performing BTKAs. The merits of BTKA versus staged TKA have been extensively discussed in the literature. Reduced costs, single anesthetic and decreased total recovery time have been highlighted as advantages of BTKA,4 but an increased risk of serious postoperative complications have also been reported.5 We hope that future studies will continue to objectively evaluate the risks and benefits of each, and identify which patients might be more suited to a particular method.

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

Patellar resurfacing versus nonresurfacing in total knee arthroplasty for osteoarthritis: experience at a tertiary care institution in Pakistan Akil Fazal1, Riaz H Lakdawala21Clinical Fellow, NYU Hospital for Joint Disease, New York, US; 2Associate Professor and Chief, Section of Orthopedics, Department of Surgery, The Aga Khan University Hospital, Karachi, PakistanObjective: To determine the effect of patellar resurfacing in patients offered total knee arthroplasty for osteoarthritis.Design: Randomized control study.Place and duration of study: The Aga Khan University Hospital, Karachi, Pakistan from January 3, 2005 to January 9, 2010.Patients and methods: Patients undergoing primary total knee arthroplasty for osteoarthritis were assigned to either the patellar resurfacing or nonresurfacing arm using systematic sampling. This consisted of patients undergoing unilateral and bilateral knee arthroplasty. Preoperatively, Knee Society Knee and Function Scores were calculated. After a minimum of 3 years postoperatively Knee Society Knee and Function Scores as well as the Clinical Anterior Knee Pain Rating were calculated and analysis done to check for differences.Results: Seventy-five patients were recruited in each arm; 135 patients had bilateral and 15 had unilateral knee arthroplasty. The mean preoperative knee score was 40.4 for the resurfacing group and 40.60 for the nonresurfacing group (P = 0.45). This improved postoperatively to 93.67 and 94.23 respectively, with no difference between the two groups (P = 0.67). The mean preoperative function score was 45.50 for resurfaced patellae and 45.83 for nonresurfaced. This improved to 89.67 and 90.50, respectively, again with no difference (P = 0.51). Postoperative Clinical Anterior Knee Pain Rating was a mean of 0.1 for resurfaced and 0.13 for nonresurfaced patellas, with no difference on analysis (P = 0.06). However, patients who had bilateral knee arthroplasty had a slightly higher Clinical Anterior Knee Pain Rating than those who had single knee surgery (P = 0.046) irrespective of whether the patellar was resurfaced or not.Conclusion: In patients undergoing primary Total Knee Arthroplasty for osteoarthritis, there is no added advantage of performing resurfacing of the patellar at 3 years of follow-up.Keywords: patellar, patellar ligament, patellofemoral pain syndrome, arthroplasty subchondral, arthroplasy replacement knee, osteoarthritis knee, Pakistan

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 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.

The incidence of complications, the need for secondary surgical procedures, and the mortality rate associated with bilateral replacement of the knee performed simultaneously, performed during the same hospitalization, or performed during separate hospitalizations were compared with those after unilateral replacement of the knee. The incidence of complications after 290 simultaneous bilateral procedures was 9.3 per cent, which compares favorably both with the incidence of 7.0 per cent after 228 bilateral procedures that were done during the same hospitalization and incidence of the 12.0 per cent after 234 bilateral procedures that were performed during separate hospitalizations. The incidence for each of these groups compares favorably with the incidence of complications of 11.0 per cent after 501 unilateral procedures. The incidence of reoperation was 2.4, 4.8, 8.5, and 5.6 per cent, respectively, in the four groups, and the incidence of mortality was 5.5, 0.9, 3.8, and 7.0 per cent. None of these differences were statistically significant. These data indicate that the incidence of morbidity and mortality that is associated with simultaneous bilateral total knee arthroplasty is no greater than when the procedure is performed during the same hospitalization or separate hospitalizations.

Peripheral nerve block (PNB) for patients with total knee arthroplasty (TKA) is one of the recommended interventions in ERAS protocols. However, most existing studies involved unilateral TKA (UTKA). As such, this study aimed to evaluate the effectiveness of PNB in terms of immediate postoperative analgesia, length of hospital stays (LOS), and early functional outcomes in both UTKA and simultaneous bilateral TKAs (BTKAs). We reviewed 236 patients who underwent primary TKA with PNB, with 138 and 98 being UTKA and BTKAs, respectively; those in the PNB group underwent femoral nerve and adductor canal block. The matched control and PNB groups—who received intravenous/epidural patient-controlled analgesia (IVPCA/PCEA) alone or IVPCA in addition to PNB after surgery, respectively—were compared. The VAS scores at rest until 48 h after surgery were significantly lower in PNB groups compared to those in the IVPCA groups. At 0– 6 h of activity, VAS scores of the UTKA with PNB group were also lower than the IVPCA group. Compared to PCEA groups, VAS scores at 0–6 h of activity were higher in both the UTKA and BTKAs with PNB groups. However, at 24–48 h at rest, the scores of those in the UTKA with PNB group were lower than those in the PCEA group. The control and experimental UTKA and BTKAs groups had similar LOS and functional outcomes at 90 days postoperatively. In primary TKA, PNB has great analgesic effects for immediate postoperative pain control, and represents a similar analgesic effect to epidural PCA.

The purpose of this paper is to assess the morbidity, mortality, and clinical outcome of simultaneous bilateral total knee arthroplasty. We reviewed 4100 simultaneous bilateral total knee replacements. The knees were subjected to two Kaplan-Meier survival analyses, with failure equal to revision for aseptic loosening and failure equal to patient death. Complications and Knee Society scores were considered. The average Knee Society knee score was 90 points 3 years postoperatively and 87 points 10 years postoperatively. The complication rates were as follows: deep infection (0.8%), superficial infection (0.3%), cardiac (6 arrhythmia, 5 congestive heart failure, 1 cardiac insufficiency, 3 complete heart block, 2 myocardial infarction and cardiac arrest, and 14 myocardial infarction only) (1.5%), intestinal ileus (0.5%), gastrointestinal ulcer (0.4%), thrombophlebitis (0.9%), cerebrovascular accident (0.3%), and urinary (1 BPH-obstruction, 4 renal failure, 2 transurethral resection of the prostate, 16 urinary tract infection, and 2 urinary retention/incontinence) (1.2%). The 10-year prosthesis survival probability was 98.3%. The 10-year patient survival probability was 78.6%. Twenty-five (1.2%) patients died within the first postoperative year. The patients who died within 1 year postoperatively were older than the rest of the group. Higher age and male gender were factors related to increased mortality. The complication rates and clinical outcomes were similar to unilateral total knee arthroplasty. With regard to death early in the postoperative course, simultaneous bilateral total knee arthroplasty may pose a greater risk to the patient than a unilateral procedure. However, the early deaths may be related to older age at the time of surgery.

Objective To explore the effects of retention catheterization on urinary irritation symptoms in patients received general anesthesia unilateral total knee arthroplasty (TKA). Methods Totally 95 patients scheduled to unilateral primary TKA were randomized into two groups: the non-indwelling urinary catheter (NIC) group and the indwelling urinary catheter (IC) group. In IC group (n=48), catheter was removed within 24 hours. All patients were under the monitoring for urinary retention, urinary irritation, urinary tract infections and comfort scale. Results There were 3 cases of urinary retention and no cases of urinary irritation in the NIC group, while there was 1 case of urinary retention and 5 cases of urinary irritation. There was no significant difference between IC group and NIC group in urinary retention and urinary tract infections (P>0.05). No urinary tract infection cases in two groups. The score of sedative degree of patients in the NIC group was (3.89±0.31), and was (4.06±0.24) in the IC group (t=-2.941, P<0.05). Conclusions The risk of urinary irritation was higher in IC group than in NIC group when received total anesthesia in TKA. Indwelling urinary catheter is not routinely needed in TKA, non-indwelling urinary catheter can contribute to increasing the comfort of surgery. Key words: Total knee arthroplasty; General anesthesia; Indwelling urinary catheter; Urinary irritation; Urinary retention

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.

Objectives:We asked whether tranexamic acid administration could reduce blood loss and blood transfusion requirements after simultaneous bilateral total knee arthroplasty (TKA). This study examined the role of different method of tranexamic acid administration in TKA.Methods:The study enrolled 81 patients who underwent simultaneous bilateral total knee replacement in a prospective, randomized, double-blind study. The patients who were randomized into the TXA group received both intravenous and intra-articular TXA. The control group did not receive TXA. The anesthetist, surgeon, and observer were blinded to the study group (double-blinded). TXA was administered as a bolus dose of 15 mg/kg 10 min before the inflation of the tourniquet on the first side. This was followed by continued intra-articular administration of 3 g at 10 min before the deflation of the tourniquet. Intravenous infusion of 10 mg/kg/h was continued for the next 3 h. Equal volumes of placebo were administered at the same rate and by the same route. We measured volume of drained blood 48 hours postoperatively, decrease in hemoglobin levels 12 hours postoperatively, amount of blood transfused, and number of patients requiring allogenic blood transfusion (BT).Results:Mean (± SD) postoperative volume of drained blood was lower in the group receiving tranexamic acid (509.39 ± 224.97mL) than in control subjects (961.37 ± 427.99mL). The mean hemoglobin decrease 12 hours postoperatively was lower in patients receiving tranexamic acid (2.07 ± 1.11g/dL) than in control subjects (3.21 ± 1.05g/dL). The amount of blood transfused and number of patients requiring blood transfusion were lower in patients receiving tranexamic acid than in control subjects.Conclusion:This prospective randomized study showed that during simultaneous bilateral TKA, TXA reduced blood loss and helped to reduce the BT amount and frequency with negligible side effects. With regard to the administration route, combined intravenous–intra-articular administration of TXA significantly reduces blood loss and the need for BT associated with bilateral simultaneous total knee replacement without enhancing the risk of deep vein thrombosis.

There have been sporadic reports on perioperative mortality associated with total knee arthroplasty. The purpose of this study was to determine risk factors for such mortality. A computer-assisted review of the records of 22,540 consecutive patients who had undergone total knee arthroplasty between 1969 and 1997 was performed to identify all patients who had died within thirty days after the procedure. A detailed analysis of the medical, surgical, anesthetic, and pathological records of the patients was performed, and the mortality was determined according to age, gender, diagnosis, and fixation method. The rate of mortality within thirty days after the operation was 0.21% (forty-seven of 22,540). All deaths occurred in the group of 18,810 patients who had received a cemented implant, and no deaths occurred among the 3730 patients who had received an uncemented implant (p < 0.0001). The mortality rate was 0.24% (forty-three of 18,165) after primary arthroplasty and 0.09% (four of 4375) after revision arthroplasty (p < 0.0003). Three patients (0.01%) died during the operation. Forty-three of the forty-seven patients who died had a history of preexisting cardiovascular and/or pulmonary disease. Simultaneous bilateral total knee arthroplasty was associated with a significantly higher rate of perioperative mortality (p < 0.002). Factors that were associated with a significantly increased mortality after total knee arthroplasty included an age of more than seventy years, primary (as compared with revision) knee surgery, use of a cemented prosthesis, preexisting cardiopulmonary disease, and simultaneous bilateral arthroplasty.

The aim of this study was to compare quadriceps femoris muscle performance parameters of patients who underwent unilateral and bilateral total knee arthroplasty (TKA). The study included 80 patients. Thirty-five underwent unilateral primary TKA (35 females; mean age: 67.11 ± 3.97 years) and 45 underwent bilateral primary TKA (2 males, 43 females; mean age: 67.12 ± 7.32 years). Patients were evaluated in terms of performance parameters including stand-up time, rising index, standing postural sway velocity, and symmetries of body weight distribution on the extremities while standing up using a Balance Master® balance and performance instrument in the postoperative 6th and 12th month. No significant difference was determined in body weight symmetry ratios between the operated and non-operated extremity in unilateral TKA patients in the 6th and 12th month sit-to-stand test (p>0.05) whereas there was a significant difference in bilateral TKA patients (p<0.05). There was no significant difference between unilateral and bilateral TKA patients in terms of time needed for standing up, rising index and gravity sway velocity at the postoperative 6th month and 12th month (p>0.05). Bilateral TKA patients stood up in a shorter time than unilateral TKA patients (p<0.05) although the degree of body sway was higher after standing up (p<0.05). Bilateral TKA patients should be encouraged to focus on exercises with non-dominant limbs and to use them more while physiotherapy and rehabilitation programs including physical performance activities are planned.