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

Hip and knee arthroplasty in one surgical session: early morbi-mortality study

INTRODUCTION

Bilateral prosthetic hip or knee replacement in one surgical session is a procedure that has been widely validated in the literature, whereas hip and knee replacement in one surgical session remains poorly documented. This study reports on the results of these procedures by analyzing early post-operative complications in a retrospective multicenter study.

MATERIAL AND METHODS

Between 2009 and 2023, 51 patients underwent hip and knee replacement surgery in a single surgical session at 4 French centers. They were 24 men and 27 women, with a mean age of 68.8 years (36-87); 7 patients were ASA 1, 30 were ASA 2 and 14 ASA 3. Prosthetic hip replacement was always performed first, associated 33 times with the ipsi-lateral knee and 18 times with the contralateral knee. All early complications, within the first 90 days post-operatively, were recorded: death, phlebitis, pulmonary embolism, myocardial infarction, surgical site infection (SSI), knee stiffness treated by mobilization under general anesthesia, urinary tract infection, acute urine retention or any other adverse event related to care. Transfusion rates were also reported.

RESULTS

The rate of early complications was 9.8% (5/51). No deaths, no phlebitis, no pulmonary embolism and no SSI were observed. Complications included one myocardial infarction, one urinary tract infection, one superficial infection, one haematoma treated by surgical evacuation and one recurrent instability requiring revision surgery (hip arthroplasty). The transfusion rate was 17.6% (9/51). The complication rate of ASA 3 patients was higher than that of ASA 1 and 2 patients, while there was no difference related to age or BMI.

DISCUSSION

Our results confirm the feasibility of single-stage hip and knee replacement, with a low complication rate in ASA 1 and 2 patients. This study adds to the few published works on the subject and reports comparable results. The small sample size and the heterogeneity of patients and centers limit the scope of the results, these limitations being relative to the volume expected for a rare procedure.

CONCLUSION

Single-session hip and knee arthroplasty should be reserved for patients selected according to comorbidities: ASA score, age and body mass index. ASA 3 patients have a higher risk of complications.

LEVEL OF EVIDENCE

IV; retrospective.

Complications following single-stage bilateral total knee arthroplasty and unilateral procedures: experience of a high-volume community hospital

INTRODUCTION

The safety of single-stage bilateral total knee arthroplasty (SSBTKA) compared to unilateral total knee arthroplasty (TKA) remains controversial. The present study compares the 90-day postoperative complications encountered following SSBTKA and unilateral TKA in an unselected cohort of patients performed at a high-volume community hospital.

MATERIALS AND METHODS

The perioperative electronic medical records of an unselected consecutive cohort of 1032 patients (1345 knees) having undergone unilateral or SSBTKA were reviewed. Ninety-day postoperative complications or need for additional procedures were compared between unilateral and SSBTKA groups.

RESULTS

A total of 719 and 313 patients underwent unilateral and SSBTKA, respectively. There were no significant differences in age or BMI between groups. Patients undergoing SSBTKA were more likely to be male (p = 0.019), have longer lengths of stay (p < 0.001) and were less likely to discharge directly home (13.1%) compared to unilateral patients (80.9%) (p < 0.001). Patients undergoing SSBTKA were more likely to require a transfusion (14.7%) compared to unilateral patients (2.2%) (p < 0.001). Interestingly, mortality rate following unilateral TKA (1.7%) was significantly higher than SSBTKA (0.0%) (p = 0.013). There were no significant differences regarding other complications or need for additional procedures within 90 days following surgery.

CONCLUSION

SSBTKA did not result in greater complications when compared to unilateral TKA in this particular cohort. As expected, transfusion rates will likely be higher and there will be a greater need for acute inpatient care following surgery for SSBTKA patients.

Same-day bilateral total knee replacement versus unilateral total knee replacement: A comparative study

INTRODUCTION

Bilateral total knee arthroplasty (TKA) in a single session is rarely done in France, mainly due to the increased risk of perioperative and late complications. The primary objective of this study was to compare the complication rates of same-day bilateral TKA (TKA bilat) with that of unilateral TKA (TKA unilat). The hypothesis was bilateral TKA increases the rate of early and late complications in a group of selected patients (ASA 1 or 2, less than 80 years of age).

MATERIAL AND METHODS

Retrospective comparative study of 91 bilat TKA and 182 unilat TKA cases operated on between 2009 and 2016 (1 bilat TKA paired with 2 controls). The patients were matched based on age, sex, indication and ASA score. The minimum follow-up was 2 years. Mortality along with early and late complications were documented. The secondary endpoints were implant survival, functional outcomes, and patient satisfaction.

RESULTS

The early mortality rate was zero in both groups. The early complication rate was lower in the bilat TKA group (9%) than in the unilat TKA group (22%) (p<0.001). The late complications did not differ between groups. Implant survival at 5 years was 99% (95% CI=[95.6-99.7]) in the bilat TKA group and 97% (95% CI=[92.8-98.8]) in the unilat TKA group. The autologous blood transfusion rate was 33% in the bilat TKA group and 2.2% in the unilat TKA group (p<0.001). There was no difference between groups in the satisfaction rate or the KOOS and New IKS scores. A larger share of patients in the unilat TKA group (54%) said they had forgotten about their knee than in the bilat TKA group (43%) (p=0.036).

DISCUSSION

There were few early complications in the bilat TKA group. There was no significant difference in the number of late complications, survival, functional scores, or patient satisfaction between the two groups. The transfusion rate was higher in the bilat TKA group, while the forgotten knee rate was higher in the unilat TKA group.

CONCLUSION

Our hypothesis was not confirmed: in the context of this study, in patients who are ASA 1 or 2, and less than 80 years old, same-day bilateral TKA does not increase the complication rate relative to unilateral TKA.

LEVEL OF EVIDENCE

III, comparative study of continuous paired cases.

Does Resident Participation Influence Surgical Time and Clinical Outcomes? An Analysis on Primary Bilateral Single-Staged Sequential Total Knee Arthroplasty

Background

Although several studies have indirectly compared teaching and nonteaching hospitals, results are conflicting, and evaluation of the direct impact of trainee involvement is lacking. We investigated the direct impact of resident participation in primary total knee arthroplasties (TKAs).

Material and methods

Fifty patients undergoing single-staged sequential bilateral primary TKAs were evaluated. The more symptomatic side was performed by the attending surgeon first, followed by the contralateral side performed by a chief resident under direct supervision and assistance of the same attending surgeon. Surgery was subdivided into 8 critical steps on both sides. The overall time and critical stepwise surgical time and short-term clinical outcomes were then compared between the 2 sides.

Results

The attending surgeon completed the surgery (skin incision to dressing) significantly faster than the resident (70.2 vs 96.9 minutes) by a mean of 26.7 minutes (P < .05) and was also faster in all steps. The most significant differences in time were in “exposure” (9.5 vs 16.5 minutes) and “closure” steps (13.2 vs 24.9 minites), all P < .001. Adverse events occurred in 7 patients; 5 of these resolved uneventfully. There were no significant differences in surgical complications, objective outcome scores, or patient satisfaction scores between both sides.

Conclusion

Resident participation in TKA increased operative time without jeopardizing short-term patient clinical outcomes, satisfaction, and complications. This may alleviate concerns from patients and policymakers about TKA in an academic setting. Surgical “exposure” and “closure” were the most prolonged steps for the residents, and they may benefit with more focus and/or simulation studies during training.

Total knee replacement in osteoarthritis patients on reducing the risk of major adverse cardiac events: a 18-year retrospective cohort study

OBJECTIVES

Osteoarthritis (OA) is a common degenerative joint disease, and total knee replacement (TKR) is a successful surgical intervention for knee OA treatment. However, the risks of mortality and major cardiovascular events (MACEs) in patients receiving TKR remain unclear. This study investigated the risks of mortality and MACEs in knee OA patients who received TKR.

METHODS

For this population-based cohort study, the Longitudinal Health Insurance Database 2000 was used. Two million individuals with knee OA defined by ICD-9-CM codes who received physical therapy between 1999 and 2017 were selected. For propensity score matching (PSM), we considered the year of knee OA diagnosis, demographics, comorbidities, co-medications, and knee OA-related hyaluronic acid or physical therapy at baseline. After PSM, regression analyses were performed to assess the association of mortality or MACEs with TKR and non-TKR individuals.

RESULTS

We identified patients (n = 189,708) with a new diagnosis of knee OA between 2000 and 2017. In total, 10,314 propensity-score-paired TKR and non-TKR individuals were selected. The PSM cohort algorithm revealed that the risk of mortality or MACEs was lower in the TKR group (adjusted hazard ratio: 0.791; 95% confidence interval: 0.755-0.830) than in the non-TKR group.

CONCLUSIONS

Patients with knee OA who received TKR had decreased risks of mortality and MACEs than those who did not receive TKR. Moreover, the TKR group received a reduced dosage of nonsteroidal anti-inflammatory drugs at the 1-year follow-up.

One stage bilateral unicompartmental knee replacement: Similar early clinical outcome with shorter rehabilitation and better resources utilization compared with two stage

Introduction:

There are a lot of debates on the advantages and safety profile of one stage bilateral knee arthroplasty. Most of the studies focus on total knee replacement, and it may not be applied directly to unicompartmental knee replacement (UKR). We would like to compare the early results of one and two stage bilateral UKR in our center.

Methods:

This is a retrospective review of all the bilateral medial UKR done in our center in 2018–2019. Patients’ demographic data, operative time, postoperative blood, length of stay (LOS) and complications were recorded. The number of admissions, pre-operative assessment sessions (PAS), and weeks of post-operative physiotherapy were analyzed. Clinical outcome was measured by Knee society knee score and range of motion (ROM).

Results:

Our center performed 97 UKR in 2018–2019, with 50 UKR performed in 25 patients, among which 16 received one stage while 9 received two stage bilateral UKR. Both groups had similar mean age, BMI, sex ratio, ASA grading, pre-operative knee score and ROM. Patient in the one stage group required only 1 PAS/admission/operation to treat both knees with a mean LOS of 7.3 days and 7.8 weeks of physiotherapy, while those in the two stage group required 2 PAS/admissions/operations with a mean cumulative LOS of 9.8 days and 14.1 weeks of physiotherapy. The mean cumulative operative time was similar for both groups but the one stage group only required 1 operative session. There was no difference in blood loss and there was no transfusion or complication. The post-operative knee score and ROM at 3 and 6 months were similar for both groups.

Conclusion:

In suitable patients with bilateral medial OA knee, one stage bilateral UKR offers simliar early clinical outcome with shorter rehabilitation duration but without increasing complications compared with two stage. Resources can therefore be better utilized.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

IV, retrospective case series.

Knee surgery trends and projections in France from 2008 to 2070

INTRODUCTION

Knee surgery makes up a large share of the orthopedic surgery practice. Data on how this activity has changed over time is not available in France, thus we wanted to do a study to determine 1) how many knee surgeries were performed in France in 2018, 2) how this changed between 2012 and 2018, and 3) how it is projected to change by 2070. The hypothesis is that the number of knee surgeries will increase over the next 50 years.

METHODS

This was an epidemiology study analysing coding data for surgical procedures in France between 2012 and 2018. Two scenarios were defined to assess the change over time: the first only considered population growth and how the age distribution changes over time, and the second extrapolated the trends observed over the past few years.

RESULTS

In 2018, 321,179 procedures were coded as a main knee surgery procedure. The three most frequent were primary knee arthroplasty with 113,600 procedures (31.2% of procedures) then meniscus surgery (110,510 procedures or 30.3%) and then ligament surgery (57,053 procedures or 15.7%). The number of primary knee arthroplasty procedures increased by 32.2% between 2012 and 2018. Between 2018 and 2050, the different scenarios suggested an increase of 30.8% to 152.8%. The number of ligament surgery procedures increased by 17.3% between 2012 and 2018. Between 2018 and 2050, an increase of 1.2% to 49.2% is expected. The number of meniscus procedures decreased by 14.2% between 2012 and 2018. Between 2018 and 2050, scenario 1 projects a 5.6% increase and scenario 2 a 73.6% reduction.

DISCUSSION

The number of knee surgery procedures per year has increased over the past few years in France and should continue to increase.

LEVEL OF EVIDENCE

IV, descriptive epidemiology study.

Is the economic and social cost of one-stage bilateral hip resurfacing lower than two-stage procedures? Retrospective case-control study of 260 hips

BACKGROUND

Studies on the economic impact of medical practices and estimates of intra- and extra-hospital costs have an important role in controlling healthcare spending. But few studies of this nature have been done for bilateral surgery in a single operative session. This led us to carry out a health economics study to determine whether (1) bilateral hip resurfacing arthroplasty (HRA) performed in one stage instead of two stages will reduce the health care expenditures (costs of hospitalization, medical leave, rehabilitation), (2) it is equally safe for the patient. Hypothesis One-stage bilateral HRA is less costly for the health care system than two-stage bilateral resurfacing.

METHODS

This was a single-center, single-surgeon retrospective cohort study comparing patients who underwent bilateral HRA in one stage (53 cases) or in two stages (77 cases). We determined the intra-hospital costs based on the French National Cost Scales and the extra-hospital costs (medical leave and rehabilitation), perioperative data (blood loss, operation time, duration of narcotic analgesic use, medical and surgical complications) and the outcomes with a mean follow-up of 4.8 years [1.7-10.1].

RESULTS

The total costs for the one-stage group (€16,840.94±7042.7) were significantly less than those of the two-stage group (€19,335.0±7296.9) (p=0.0101). The two groups were comparable except for the one-stage group having more primary hip osteoarthritis indications (72% (38/53)) than the two-stage group (49% (38/77)) (p=0.0111). The main differences between groups was the cost and duration of hospitalization, with cost of €10,546.06±2049.47 and average length of stay (ALS) of 9.83±2.19 days in the one-stage group and €13,569.49±2186.30, ALS=15.04±3.15 days in the two-stage group (p<0.0001). There was no significant difference in the length of medical leave: 67.15±50.36 (0-180) days for the one-stage group and 97.89±108.39 (0-730) days for the two-stage group (p=0.1933).

CONCLUSION

Performing bilateral HRA during a single hospital stay results in lower health care expenditures than performing it during two separate hospital stays. Similar studies on other surgical procedures could help to promote the simultaneous nature of bilateral procedures and reset the current pricing, which is currently too low in the French health care system.

LEVEL OF EVIDENCE

III, Retrospective case-control study.