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Sustich SJ, Stambough JB, Hui R, Siegel ER, Barnes CL, Mears SC. Postoperative Opioid Consumption is Greater after Simultaneous versus Staged Bilateral Total Knee Arthroplasty. J Knee Surg 2024; 37:436-443. [PMID: 37852291 DOI: 10.1055/s-0043-1775872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
Increased exposure to opioids around total knee arthroplasty (TKA) can lead to a risk of long-term dependence. We hypothesized that performing simultaneous bilateral total knee arthroplasty (simBTKA) over staged surgery (staged bilateral total knee arthroplasty [stgBTKA]) may decrease the total amount of opiates used. We retrospectively reviewed 29 patients who underwent simBTKAs performed between February 2015 and November 2020 and identified 23 that did not use opioids ≤90 days prior to surgery. These were frequency matched for gender and body mass index to 50 stgBTKAs completed within 6 months who also were opioid-free ≤90 days prior to their first surgery. Using our state's prescription database, we reviewed postsurgery opioid refills and morphine milligram equivalents (MMEs) for the two groups and compared their initial MME prescription at discharge and their total MME consumption 6 months postoperatively. Total MME consumption for the stgBTKA group included all prescriptions following the first and 6 months after the second surgery, whereas for the simBTKA group, total consumption included the 6 months after their two same-day surgeries. The simBTKA group had more MMEs prescribed initially (median = 375) than did the stgBTKA group after second surgery (median = 300; p < 0.007), larger postoperative-refill MMEs in the first 30 days (median = 300) than stgBTKA (median = 0; p = 0.221) and increased total MME consumption 6 months after surgery (median = 675) compared with stgBTKA after second surgery (median = 450; p = 0.077). However, both groups had similar monthly consumptions rates, with medians I MMEs/month of 112 for simBTKA versus 96 for stgBTKA (p = 0.585). Our results suggest there is no significant difference in opioid consumption between simBTKA and stgBTKA. In fact, we found that simBTKA patients received larger opioid amounts in the immediate postoperative period as well as slightly larger amounts at 30 days.
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Affiliation(s)
- Sara J Sustich
- Department of Orthopedic Surgery, University of Oklahoma, Oklahoma City, Oklahoma
| | - Jeffrey B Stambough
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Ryan Hui
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Eric R Siegel
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - C Lowry Barnes
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Simon C Mears
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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Kaneko T, Matsudaira K, Nakamura S, Hayakawa K, Tokimura F, Miyazaki T. Clinical and safety outcomes of simultaneous bilateral total knee arthroplasty for Japanese octogenarian patients: a retrospective analysis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:155-160. [PMID: 37378735 DOI: 10.1007/s00590-023-03634-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 06/21/2023] [Indexed: 06/29/2023]
Abstract
PURPOSE The demand for simultaneous bilateral total knee arthroplasty (SiBTKA) in older adults is expected to increase with an aging population, thus necessitating evaluating its efficacy and safety. However, there is limited information regarding the clinical outcomes of SiBTKA in older adults, particularly in octogenarians. We aimed to assess the clinical outcomes and safety of SiBTKA in Japanese patients aged ≥ 80 years. METHODS Of the 176 consecutive knees that underwent SiBTKA between July 2016 and January 2022 at our hospital, 172 were selected. They were divided into two groups according to the patient age as follows: the octogenarian group (≥ 80 years, 74 knees) and the younger control group (< 80 years, 98 knees). In addition, we assessed their preoperative clinical information, clinical outcomes using the Knee Society Score for knee (KSS-K) and function (KSS-F), and the incidence of early (≤ 90 days) and late (> 90 days) postoperative complications. RESULTS The mean follow-up period was 3.5 years. The KSS-K scores of both groups improved postoperatively than that preoperatively. Both preoperative and postoperative KSS-F scores were lower in the octogenarians; however, their improvement rates were similar to those of the younger controls. We observed no significant intergroup differences in early or late postoperative complications, including infection, systemic complications, periprosthetic fractures, aseptic loosening, and mortality. CONCLUSION SiBTKA for octogenarians had clinical outcomes and postoperative complication incidence similar to that for younger controls. Therefore, SiBTKA may be a safe and effective treatment option for octogenarians with painful bilateral knee deformities.
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Affiliation(s)
- Taizo Kaneko
- Department of Orthopaedic Surgery, Tokyo Metropolitan Institute for Geriatrics and Gerontology, Sakae-cho 35- 2, Itabashi-ku, Tokyo, 173-0015, Japan.
| | - Kyoko Matsudaira
- Department of Orthopaedic Surgery, Tokyo Metropolitan Institute for Geriatrics and Gerontology, Sakae-cho 35- 2, Itabashi-ku, Tokyo, 173-0015, Japan
| | - Shinya Nakamura
- Department of Orthopaedic Surgery, Tokyo Metropolitan Institute for Geriatrics and Gerontology, Sakae-cho 35- 2, Itabashi-ku, Tokyo, 173-0015, Japan
| | - Kentaro Hayakawa
- Department of Orthopaedic Surgery, Tokyo Metropolitan Institute for Geriatrics and Gerontology, Sakae-cho 35- 2, Itabashi-ku, Tokyo, 173-0015, Japan
| | - Fumiaki Tokimura
- Department of Orthopaedic Surgery, Tokyo Metropolitan Institute for Geriatrics and Gerontology, Sakae-cho 35- 2, Itabashi-ku, Tokyo, 173-0015, Japan
| | - Tsuyoshi Miyazaki
- Department of Orthopaedic Surgery, Tokyo Metropolitan Institute for Geriatrics and Gerontology, Sakae-cho 35- 2, Itabashi-ku, Tokyo, 173-0015, Japan
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Tong SX, Li RS, Wang D, Xie XM, Ruan Y, Huang L. Artificial intelligence technology and ultrasound-guided nerve block for analgesia in total knee arthroplasty. World J Clin Cases 2023; 11:7026-7033. [PMID: 37946775 PMCID: PMC10631398 DOI: 10.12998/wjcc.v11.i29.7026] [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: 08/15/2023] [Revised: 09/14/2023] [Accepted: 09/22/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Knee diseases are more common in middle-aged and elderly people, so artificial knee replacement is also more used in middle-aged and elderly people. Although the patient's pain can be reduced through surgery, often accompanied by moderate pain after surgery and neutralization, which not only increases the psychological burden of the patient, but also greatly reduces the postoperative recovery effect, and may also lead to the occurrence of postoperative adverse events in severe cases. AIM To investigate the analgesic effect of artificial intelligence (AI) and ultrasound-guided nerve block in total knee arthroplasty (TKA). METHODS A total of 92 patients with TKA admitted to our hospital from January 2021 to January 2022 were opted and divided into two groups according to the treatment regimen. The control group received combined spinal-epidural anesthesia. The research group received AI technique combined with ultrasound-guided nerve block anesthesia. The sensory block time, motor block time, visual analogue scale (VAS) at different time points and complications were contrasted between the two groups. RESULTS The time of sensory block onset and sensory block perfection in the research group was shorter than those in the control group, but the results had no significant difference (P > 0.05). Duration of sensory block in the research group was significantly longer than those in the control group (P < 0.05). The time of motor block onset and motor block perfection in the research group was shorter than those in the control group, but the results had no significant difference (P > 0.05). Duration of motor block in the research group was significantly longer than those in the control group. The VAS scales of the research group were significantly lower than that of the control group at different time points (P < 0.05). The postoperative hip flexion and abduction range of motion in the research group were significantly better than those in the control group at different time points (P < 0.05). The incidence of complications was significantly lower in the research group than in the control group (P = 0.049). CONCLUSION In TKA, the combination of AI technology and ultrasound-guided nerve block has a significantly effect, with fewer postoperative complications and significantly analgesic effect, which is worthy of application.
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Affiliation(s)
- Sheng-Xiong Tong
- Department of Pain Management, Wuhan First Hospital, Wuhan 430033, Hubei Province, China
| | - Ren-Song Li
- Department of Orthopaedics, Wuhan Wuchang Hospital, Wuhan 430063, Hubei Province, China
| | - Dan Wang
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Xiao-Meng Xie
- Department of Nursing, Huanggang Central Hospital, Huanggang 438000, Hubei Province, China
| | - Yuan Ruan
- Department of Orthopaedics, Huanggang Central Hospital, Huanggang 438000, Hubei Province, China
| | - Lin Huang
- Department of Orthopaedics, Huanggang Central Hospital, Huanggang 438000, Hubei Province, China
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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.
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Affiliation(s)
- Kevin Y Wang
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
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No Difference in Perioperative Complications for Bilateral Total Knee Arthroplasty Staged at 1 Week Compared With Delayed Staging. J Am Acad Orthop Surg 2022; 30:992-998. [PMID: 35916881 DOI: 10.5435/jaaos-d-22-00135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 05/04/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Controversy exists regarding the safety of simultaneous bilateral total knee arthroplasty (TKA) versus two TKA procedures staged months apart in patients with bilateral knee arthritis. Here, we investigated a third option: bilateral TKA staged 1 week apart. In this study, we examined the rate of complications in patients undergoing bilateral TKA staged at 1 week compared with longer time intervals. METHODS A retrospective review of 351 consecutive patients undergoing bilateral TKA at our institution was conducted. Patients underwent a 1-week staged bilateral procedure with planned interim transfer to a subacute rehabilitation facility (short-staged) or two separate unilateral TKA procedures within 1 year (long-staged). Binary logistic regression was used to compare outcomes while controlling for year of surgery, patient age, body mass index, and Charlson Comorbidity Index. RESULTS Two hundred four short-staged and 147 long-staged bilateral TKA patients were included. The average interval between procedures in long-staged patients was 200.9 ± 95.9 days. Patients undergoing short-staged TKA had a higher Charlson Comorbidity Index (3.0 ± 1.5 versus 2.6 ± 1.5, P = 0.017) with no difference in preoperative hemoglobin ( P = 0.285) or body mass index ( P = 0.486). Regression analysis demonstrated that short-staged patients had a higher likelihood of requiring a blood transfusion (odds ratio 4.015, P = 0.005) but were less likely to return to the emergency department within 90 days (odds ratio 0.247, P = 0.001). No difference was observed in short-term complications ( P = 0.100), 90-day readmissions ( P = 0.250), or 1-year complications ( P = 0.418) between the groups. CONCLUSION Bilateral TKA staged at a 1-week interval is safe with a comparable complication rate with delayed staged TKA, but allows for a faster total recovery time. LEVEL OF EVIDENCE Level III.
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Klasan A, Putnis SE, Yeo WW, Myat D, Fritsch BA, Coolican MR, Parker DA. Should Sequential Bilateral Total Knee Arthroplasty Be Limited to Patients Younger than 80? A Two-Arm Propensity Matched Study. J Knee Surg 2021; 34:1579-1586. [PMID: 32450604 DOI: 10.1055/s-0040-1712100] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Despite multiple studies, there remains a debate on the safety of bilateral total knee arthroplasty (BTKA) in the average age patient, with a paucity of data on the outcome of BTKA in an elderly population. This study included 89 patients aged 80 years and older undergoing sequential BTKA over 14 years were identified in a prospectively collected database. Two matched comparison groups were created: patients under 80 undergoing sequential BTKA and patients over 80 undergoing unilateral TKA (UTKA). An analysis of complications, mortality, revision, and patient-reported outcome measures was performed. Mean age of the elderly cohorts was similar: 82.6 for BTKA and 82.9 for UTKA. The average age BTKA cohort had a mean age of 69.1. Complication rates were higher in bilateral cohorts, more so in the elderly BTKA cohort. Pulmonary embolism (PE) was observed in bilateral cohorts only. In these patients, history of PE and ischemic heart disease was a strong predictive factor for developing a major complication. There was no difference in revision rates and infection rates between the three cohorts, and no difference in patient survivorship between the two elderly cohorts. Through the combination of low revision and high survivorship rates and comparable clinical outcomes, this article demonstrates that simultaneous BTKA is an appropriate option to consider for an elderly patient, with proper patient selection and perioperative management. The demonstrated risk groups show that emphasis on patient selection should be focused on medical history rather than chronological age.
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Affiliation(s)
- Antonio Klasan
- Sydney Orthopaedic Research Institute, Chatswood, New South Wales, Australia
| | - Sven Edward Putnis
- Sydney Orthopaedic Research Institute, Chatswood, New South Wales, Australia
| | - Wai Weng Yeo
- Department of Medicine, University of New South Wales, Sydney, Australia
| | - Darli Myat
- Sydney Orthopaedic Research Institute, Chatswood, New South Wales, Australia
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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.
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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
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Simultaneous single-stage versus two-staged bilateral total knee arthroplasty: a prospective comparative study. INTERNATIONAL ORTHOPAEDICS 2020; 44:1305-1310. [PMID: 32458035 DOI: 10.1007/s00264-020-04642-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 05/18/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE The study aims to prospectively compare peri-operative morbidity and mortality of simultaneous single-stage bilateral total knee arthroplasty (SS BLTKA) with two-staged bilateral total knee arthroplasty (TS BLTKA) performed within 12 months of the first surgery. We hypothesized that SS BLTKA is as safe as TS BLTKA. METHODS Patients with a minimum follow-up of 12 months were included in this study. Oxford knee score and quality of life index SF12 was compared between the 2 groups at six weeks and six month follow-up. RESULTS SS BLTKA included 250 patients and TS BLTKA included 210 patients. The minimum time interval between two operations was three weeks (mean 1.6 months, range 3 weeks-12 months). There was no significant difference between the 2 groups in peri-operative mortality, surgical site infection, major peri-operative complications. There was no difference between the 2 groups in the Oxford knee score and quality of life index SF12 at 6-month follow-up. There was no difference in the range of knee flexion between the 2 groups at six months. Post-operative haemoglobin drop was significantly more in SS BLTKA patients and consequently, blood transfusion requirement was significantly higher in SS BLTKA. There was a significantly higher length of hospital stay and duration of surgery in TS BLTKA group. CONCLUSION There does not appear to be a difference in complication rates between the 2 groups. SS BLTKA seems to be a logical choice if both knees have severe osteoarthritis. Patients with severe cardiopulmonary compromise were excluded, and a unilateral procedure may be preferred in them.
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Mhaskar VA, Maheshwari J, Ugrasen H. Bilateral HTO in same sitting: Perioperative challenge or feasible option? ACTA ACUST UNITED AC 2020. [DOI: 10.1016/j.jajs.2020.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Womble TN, King JD, Hamilton DH, Shrout M, Jacobs CA, Duncan ST. Greater Rates of Acute Kidney Injury in African American Total Knee Arthroplasty Patients. J Arthroplasty 2019; 34:1240-1243. [PMID: 30824293 PMCID: PMC6536310 DOI: 10.1016/j.arth.2019.01.058] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 01/07/2019] [Accepted: 01/24/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND This retrospective study compared the change in serum creatinine between African American and Caucasian total knee arthroplasty (TKA) patients. The authors hypothesized that African Americans would demonstrate significantly greater change, and that a significantly greater proportion would demonstrate creatinine changes consistent with acute kidney injury (AKI). METHODS Primary TKAs performed at a single institution between July 2011 and June 2016 were identified: 1035 primary TKAs met inclusion and exclusion criteria (110 African American, 925 Caucasian, excluding Hispanic and Asian patients). None were excluded based on gender, age, body mass index, preoperative diagnosis, or comorbidities. All patients had preoperative and postoperative creatinine levels available in the electronic medical records. Each patient received the same preop and postop protocol for nonsteroidal anti-inflammatory drug use along with other drugs administered including anesthesia. All patients received 1 g of intravenous vancomycin with some patients additionally receiving 1 g of vancomycin powder administered locally at the end of surgery. All patients were controlled for fluid intake and blood loss, along with no patient receiving a transfusion or intravenous contrast. Patient demographics and preoperative/postoperative serum creatinine were recorded and then analyzed for presence of AKI (≥0.3 mg/dL). Preoperative/postoperative serum creatinine concentrations were compared between African American and Caucasian patients using 2 × 2 repeated measures analysis of variance. Prevalence of patients in each group demonstrating AKI was calculated using Fisher's exact test. RESULTS African American patients had significantly greater serum creatinine preoperatively (1.00 ± 0.26 vs 0.90 ± 0.22, P < .001) and a significantly greater increase postoperatively (0.10 vs 0.03, P < .001). A significantly greater number of African American patients demonstrated AKI (10.9% vs 5.1%, P = .03). Furthermore, a significantly greater number of African American patients stayed in the hospital an additional 2 or more days for renal issues (2.7% vs 0.4%, P = .03). CONCLUSION Altered renal function was significantly more common in African American TKA patients. Future studies are necessary to determine if tailoring anti-inflammatories, perioperative medications, and preoperative comorbidities reduce the risk of renal injury and/or a longer hospital stay for this subset of patients.
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Simultaneous, same-anaesthetic bilateral total knee arthroplasty has low mortality and complication rates. Knee Surg Sports Traumatol Arthrosc 2018; 26:3395-3402. [PMID: 29574549 DOI: 10.1007/s00167-018-4908-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 03/20/2018] [Indexed: 01/13/2023]
Abstract
PURPOSE The benefits of simultaneous bilateral total knee arthroplasty (SBTKR) include reduced hospital costs, single anaesthetic exposure and in many cases is also the patient's preference. Despite these potential benefits, risk-adversity with respect to assumed complications and mortality make it difficult for the orthopaedic surgeon and patient to make an informed decision. This study aimed to address the inconsistencies and lack of consensus in previous literature regarding the short-term complications and clinical safety of SBTKR in patients with end-stage knee osteoarthritis (OA). METHODS A cohort of 950 knees (475 patients) undergoing surgery between 2008 and 2013 was extracted from a prospectively collected clinical database and retrospectively linked to the Australian Joint Replacement Registry and hospital records. Patients underwent sequential SBTKR by their treating surgeon under one anaesthetic. Basic demographic data and outcome data including complications and mortality were collected. All data were analyzed using descriptive statistics only. RESULTS A total of 413 patients and 826 knees were included. The average age of the cohort was 70 years with range between 46 and 88 years. 50% of patients were female. The overall mortality rate during the study follow-up period was 1.9%, with an average time to death postoperatively of 23.8 months. There were no cases of acute postoperative mortality (< 6 weeks). Medical complication rates were low. CONCLUSIONS In contrast to the higher mortality and complication rates suggested in previous literature, this study has demonstrated that SBTKR is safe, with low mortality and complication rates under the current surgical protocol. LEVEL OF EVIDENCE IV.
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Patrick MR, Parvataneni HK, Bohannon DS, Boezaart AP. Early Experience with Bilateral Continuous Femoral Nerve Block and Single-Injection Spinal Anesthesia for Bilateral Total Knee Arthroplasty: A Case Series. PAIN MEDICINE 2018; 19:1839-1847. [PMID: 29190367 DOI: 10.1093/pm/pnx246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Objective Total knee arthroplasty (TKA) is a commonly performed surgery in the United States, with demand for unilateral and simultaneous bilateral TKAs (BTKAs) expected to increase significantly over the coming decades. This study reports the authors' early experience in a consecutive series of simultaneous BTKAs performed under regional anesthesia and mild sedation. Methods In this retrospective case series, the authors examined all simultaneous BTKAs performed over two years by a single surgeon. Only patients receiving bilateral continuous femoral nerve blockade (CFNB) and single-injection sciatic nerve blockade in combination with single-injection subarachnoid block were included in the study. Of the 32 patients who underwent BTKAs during this period, 25 met the inclusion criteria. The patient's anesthesia records, physician notes, nursing notes, pharmacy records, and physical therapy records were then reviewed systematically to create a database of information. Results Only one of 25 patients required conversion to general anesthesia during surgery. There were no major perioperative complications. The average Defense and Veterans Pain Rating Scale score immediately postoperation was 0.6/10, and the average daily score remained below 3.5/10 throughout the hospital stay. The use of bilateral CFNB did not prevent patients from ambulating during physiotherapy. Conclusions This early retrospective case series suggests that it is feasible to effectively manage the postoperative pain associated with BTKA with staged bilateral CFNB and single-injection sciatic nerve blockage in combination with single-injection subarachnoid block as the sole anesthetic technique without negatively influencing early ambulation.
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Affiliation(s)
| | | | - Donald S Bohannon
- Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - André P Boezaart
- Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
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Sobh AH, Siljander MP, Mells AJ, Koueiter DM, Moore DD, Karadsheh MS. Cost Analysis, Complications, and Discharge Disposition Associated With Simultaneous vs Staged Bilateral Total Knee Arthroplasty. J Arthroplasty 2018; 33:320-323. [PMID: 28988612 DOI: 10.1016/j.arth.2017.09.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 08/24/2017] [Accepted: 09/02/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Simultaneous vs staged bilateral total knee arthroplasty (BTKA) has long been debated. The primary objective of this study was to compare actual hospital costs and complication rates in patients undergoing simultaneous BTKA (simBTKA) and staged BTKA (staBTKA) at a single institution. METHODS A total joint arthroplasty database from a single hospital was used to identify all patients who underwent primary BTKA from 2013 to 2016 and divided into simultaneous and staged groups. StaBTKA patients were included if both procedures were performed within 1 year by the same surgeon. The combined total hospital cost of both procedures was used, and inpatient rehabilitation (IPR) costs were added for all patients discharged to IPR. RESULTS There were 225 simBTKA and 337 staBTKA patients. SimBTKA patients were younger (61 ± 8 vs 66 ± 8 years, P < .001), had lower body mass index (31.3 ± 5.9 vs 34.0 ± 7.2, P < .001), were more predominately male (48% vs 38%, P = .029), and more likely to require IPR as compared with staBTKA patients. There was no difference in total hospital cost for simBTKA as compared with staBTKA ($24,596 ± $5652 vs $24,915 ± $5756, P = .586). Complications were more prevalent in the simBTKA group, including venous thromboembolism (5.4% vs 1.4%, P = .006) and blood transfusions (15.8% vs 6.2%, P < .001). CONCLUSION There were higher complication rates with no significant cost savings in actual hospital costs associated with simBTKA, when accounting for the cost of IPR, as compared with staBTKA. The total cost analysis of simBTKA vs staBTKA, using actual cost data, merits further evaluation.
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Affiliation(s)
- Ali H Sobh
- Beaumont Health System, Department of Orthopaedic Surgery, Royal Oak, Michigan
| | - Matthew P Siljander
- Beaumont Health System, Department of Orthopaedic Surgery, Royal Oak, Michigan
| | - Anthony J Mells
- Beaumont Health System, Department of Orthopaedic Surgery, Royal Oak, Michigan
| | - Denise M Koueiter
- Beaumont Health System, Department of Orthopaedic Surgery, Royal Oak, Michigan
| | - Drew D Moore
- Beaumont Health System, Department of Orthopaedic Surgery, Royal Oak, Michigan
| | - Mark S Karadsheh
- Beaumont Health System, Department of Orthopaedic Surgery, Royal Oak, Michigan
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Qi Y, Tie K, Wang H, Pan Z, Zhao X, Chen H, Chen L. Perioperative comparison of blood loss and complications between simultaneous bilateral and unilateral total knee arthroplasty for knee osteoarthritis. Knee 2017; 24:1422-1427. [PMID: 28974399 DOI: 10.1016/j.knee.2017.06.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 12/16/2016] [Accepted: 06/13/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE This study aimed to compare the blood loss and complications between simultaneous bilateral total knee arthroplasty (SBTKA) and unilateral total knee arthroplasty (UTKA). METHODS This study included 54 SBTKAs and 70 UTKAs performed between 2013 and 2014. Groups were compared with respect to blood loss, hemoglobin, hematocrit, D-dimer, blood transfusion, and complications. RESULTS Hemoglobin between the groups was not significantly different (P>0.05). In the SBTKA group, the hematocrit on the 3rd postoperative day was lower (P<0.05), and the D-dimer on the 1st postoperative day was higher (P<0.05) than in the UTKA group. The total drain output of the UTKA group was not significantly different from any unilateral side of the SBTKA group (P<0.05). The mean autologous red blood cell (RBC) transfusion requirements were not significantly different between the two groups. However, the mean allogeneic RBC transfusion requirement was higher in the SBTKA group than in the UTKA group (P<0.001). The total drainage of the SBTKA group was significantly more than the UTKA group, but the total drain output of the UTKA group was not significantly different from any unilateral side of the SBTKA group (P>0.05). Also, the mean allogeneic RBC transfusion requirement was higher in the SBTKA group than in the UTKA group (P<0.001). CONCLUSION This study demonstrates that the rate of complication between SBTKA and UTKA is similar. The total drainage and transfusion of SBTKA are not twice that of UTKA, and after treatment, hemoglobin could be increased to a similar level. Thus, SBTKA is an effective and safe option.
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Affiliation(s)
- Yongjian Qi
- Department of Orthopaedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
| | - Kai Tie
- Department of Orthopaedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
| | - Hua Wang
- Department of Orthopaedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
| | - Zhengqi Pan
- Department of Orthopaedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
| | - Xinyu Zhao
- Department of Orthopaedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
| | - Heqiang Chen
- Department of Orthopedic Surgery, Yichang Central People's Hospital, Yichang 443003, China
| | - Liaobin Chen
- Department of Orthopaedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan 430071, China.
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16
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Thiam D, Teh DJW, Bin Abd Razak HR, Tan AHC. Improvement in health-related quality of life after unilateral total knee arthroplasty in patients with bilateral knee osteoarthritis. J Orthop Surg (Hong Kong) 2016; 24:294-297. [PMID: 28031493 DOI: 10.1177/1602400304] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE To review the outcome of unilateral total knee arthroplasty (TKA) in patients with bilateral knee osteoarthritis (OA) to determine whether unilateral TKA can achieve good health-related quality of life (HRQoL). METHODS Records of 68 women and 25 men with severe bilateral knee OA who underwent unilateral TKA on the more symptomatic knee by a single surgeon and did not return for the second TKA within 2 years were reviewed. Outcome at 6 months and 2 years was assessed using the mental and physical component summary (MCS and PCS) of the Short-Form 36 (SF-36) for HRQoL as well as the Oxford Knee Score (OKS) and Knee Society Score (KSS) for knee-specific outcome. RESULTS The SF-36, OKS, and KSS improved significantly after unilateral TKA. Respectively for MCS and PCS of SF-36, OKS, and KSS knee and function scores, 65%, 89%, 98%, 98%, and 98% of patients reported absolute improvement at 2 years. Respectively for PCS, OKS, and KSS function score that a minimal clinically important difference (MCID) was established, 77%, 96%, and 80% of patients achieved MCID at 2 years. CONCLUSION Unilateral TKA achieves good outcome in HRQoL at 2 years in patients with bilateral knee OA.
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Affiliation(s)
- Desmond Thiam
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Daniel Jing Wen Teh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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17
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Outcomes of Inpatient Rehabilitation in Patients With Simultaneous Bilateral Total Knee Arthroplasty. PM R 2016; 8:761-6. [DOI: 10.1016/j.pmrj.2015.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 11/06/2015] [Accepted: 11/07/2015] [Indexed: 11/21/2022]
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Kandemir T, Muslu S, Kalaycı D, Kandemir E. Effects of Systemic Disorders on Postoperative Complications After Simultaneous Bilateral Total Knee Replacement. Turk J Anaesthesiol Reanim 2016; 43:169-73. [PMID: 27366490 DOI: 10.5152/tjar.2015.48378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 07/21/2014] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE The aim of the present study was to retrospectively evaluate the association between accompanying systemic disorders and major complications developing in the early postoperative period in patients who underwent simultaneous bilateral total knee arthroplasty with combined spinal and epidural anaesthesia. METHODS In the present study, the medical records of a total of 456 patients were analyzed. Preoperative data, including the American Society of Anesthesiologists physical status and presence of coronary artery disease (CAD), chronic pulmonary disease, diabetes mellitus (DM), hypertension and renal insufficiency were recorded. Furthermore, the data related to major complications, such as cardiac complications, respiratory complications, acute myocardial infarction (AMI), thromboembolism, cerebrovascular accident (CVA), confusion, acute renal failure (ARF), shock and cardiopulmonary arrest were recorded. RESULTS We found that the frequency of complications markedly increased in the presence of concurrent DM and hypertension, or DM, hypertension and CAD, or DM and CAD. Further, 0.2% of the patients developed AMI, 3.3% developed cardiac complications, 2.2% developed respiratory complications, 0.9% developed thromboembolism, 0.2% developed CVA, 2% developed confusion and 0.4% developed cardiac arrest and shock in the first week after the operation. The frequency of cardiac and pulmonary complications and confusion was higher in patients aged above 65 years compared to patients below 65 years. CONCLUSION We observed that the frequency of cardiac and pulmonary complications and confusion in the early postoperative period was markedly higher in patients aged above 65 years and in patients with concurrent DM and cardiovascular comorbidities.
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Affiliation(s)
- Tünay Kandemir
- Department of Anaesthesia, Dr. Abdurrahman Yurtaslan Oncology Training and Research Hospital, Ankara, Turkey
| | - Selda Muslu
- Department of Anaesthesia, Dr. Abdurrahman Yurtaslan Oncology Training and Research Hospital, Ankara, Turkey
| | - Dilek Kalaycı
- Department of Anaesthesia, Dr. Abdurrahman Yurtaslan Oncology Training and Research Hospital, Ankara, Turkey
| | - Erbin Kandemir
- Department of Anaesthesia, Dr. Abdurrahman Yurtaslan Oncology Training and Research Hospital, Ankara, Turkey
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Scott JE, Mathias JL, Kneebone AC. Incidence of delirium following total joint replacement in older adults: a meta-analysis. Gen Hosp Psychiatry 2015; 37:223-9. [PMID: 25774049 DOI: 10.1016/j.genhosppsych.2015.02.004] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 02/13/2015] [Accepted: 02/17/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Delirium is common in older adults following total joint replacement (TJR) of the hip and knee. However, reports of the incidence of delirium vary widely, limiting their usefulness. The current meta-analysis therefore examined (1) the incidence of delirium in older patients who underwent TJR and (2) whether these rates vary according to the (a) joint (hip/knee replacement), (b) inclusion/exclusion of patients who underwent simultaneous bilateral surgery, (c) inclusion/exclusion of patients with preexisting cognitive impairments, (d) type of anesthesia (regional/general), (e) method/frequency of assessment, and (f) postoperative interval. METHOD Data from 24 studies (2,895 patients) that measured postsurgical delirium following TJR were analyzed. Mean weighted proportions were calculated using a random-effects model to assess the overall incidence of delirium and whether the rate varied according to the aforementioned variables. RESULTS Overall, 17% of patients who underwent TJR developed delirium during hospital admission. Individual estimates varied from 0% to 82%, but this variability was not adequately explained by the variables that were examined. CONCLUSIONS Delirium is relatively common following TJR; however, it remains unclear why individual estimates vary so widely. Health professionals working with these patients should remain alert to the presentation, diagnosis and management of delirium to optimize postsurgical outcomes.
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Affiliation(s)
- J E Scott
- School of Psychology, University of Adelaide, South Australia, Australia 5005.
| | - J L Mathias
- School of Psychology, University of Adelaide, South Australia, Australia 5005.
| | - A C Kneebone
- Department of Clinical Psychology, Flinders Medical Centre, South Australia, Australia 5042; School of Psychology, University of Adelaide, South Australia, Australia 5005.
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Meehan JP, Blumenfeld TJ, White RH, Kim J, Sucher M. Risks and Benefits of Simultaneous Bilateral Total Knee Arthroplasty. JBJS Rev 2015; 3:01874474-201502000-00003. [DOI: 10.2106/jbjs.rvw.n.00019] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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21
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Choi YJ, Lee HI, Ra HJ, Hwang DY, Kim TK, Shim SJ. Perioperative Risk Assessment in Patients Aged 75 Years or Older: Comparison between Bilateral and Unilateral Total Knee Arthroplasty. Knee Surg Relat Res 2014; 26:222-9. [PMID: 25505704 PMCID: PMC4258489 DOI: 10.5792/ksrr.2014.26.4.222] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 10/11/2014] [Accepted: 10/14/2014] [Indexed: 11/03/2022] Open
Abstract
PURPOSE The purpose of this study is to evaluate the risk of sequential bilateral total knee arthroplasty (TKA) under 1 anesthesia in patients 75 years or older. MATERIALS AND METHODS Patients aged 75 years or older who underwent sequential bilateral TKA (bilateral group, n=159) and unilateral TKA (unilateral group, n=159) between 2002 and 2012 were selected. All patients were evaluated for underlying medical diseases, such as cardiac, pulmonary, and renal problems, and high-risk patients were recommended to postpone the surgery. We compared the underlying diseases, major postoperative complications, and the length of hospital stay between bilateral and unilateral groups. RESULTS The prevalence of underlying diseases of the bilateral group was 74.8% and major complications occurred in 6 patients (3.8%). The prevalence of underlying diseases of the unilateral group was 52.4% and complications were observed in 4 patients (2.4%). Although the complication rate of the bilateral group was slightly higher than that of the unilateral group, the difference was not statistically meaningful (p=0.204). The length of hospital stay was 21.9 days for the bilateral group and 24.9 days for the unilateral group. CONCLUSIONS There was no significant difference in postoperative complications between groups. The result shows that bilateral TKA can be relatively safe compared with unilateral TKA in patients 75 years or older. However, careful selection of low-risk patients is advised.
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Affiliation(s)
- Young-Joon Choi
- Department of Orthopaedic Surgery, Gangneung Asan Hospital, Ulsan University College of Medicine, Gangneung, Korea
| | - Hyun-Il Lee
- Department of Orthopaedic Surgery, Gangneung Asan Hospital, Ulsan University College of Medicine, Gangneung, Korea
| | - Ho Jong Ra
- Department of Orthopaedic Surgery, Gangneung Asan Hospital, Ulsan University College of Medicine, Gangneung, Korea
| | - Do-Yon Hwang
- Department of Orthopaedic Surgery, Gangneung Asan Hospital, Ulsan University College of Medicine, Gangneung, Korea
| | - Tae-Kyung Kim
- Department of Orthopaedic Surgery, Gangneung Asan Hospital, Ulsan University College of Medicine, Gangneung, Korea
| | - Sang-Jun Shim
- Department of Orthopaedic Surgery, Gangneung Asan Hospital, Ulsan University College of Medicine, Gangneung, Korea
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22
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Is bilateral total knee arthroplasty staged at a one-week interval safe? A matched case control study. J Arthroplasty 2014; 29:1946-9. [PMID: 24953946 DOI: 10.1016/j.arth.2014.05.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 05/04/2014] [Accepted: 05/10/2014] [Indexed: 02/01/2023] Open
Abstract
Controversy surrounds the safety of bilateral total knee arthroplasty (TKA) and whether staging the procedures one week apart represents a safer option. A consecutive series of 234 patients underwent either a simultaneous (103 patients) or staged bilateral TKA (131 patients) from 2007 to 2012 and were compared to a matched control group of unilateral TKA (131 patients). Staged patients had no difference in one-year complication rate when compared to simultaneous bilateral TKA and the matched unilateral TKA control group (15% vs. 19% vs. 15%, P=0.512). There was also no difference in perioperative complications (10% vs. 14% vs. 7%, P=0.231) or 90-day readmissions (8% vs. 4% vs. 4%, P=0.295). In selected patients with bilateral knee OA, TKA staged at a one-week interval is a safe alternative.
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23
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Gallagher TK, McErlean S, O'Farrell A, Hoti E, Maguire D, Traynor OJ, Conlon KC, Geoghegan JG. Incidence and risk factors of delirium in patients post pancreaticoduodenectomy. HPB (Oxford) 2014; 16:864-9. [PMID: 24750484 PMCID: PMC4159461 DOI: 10.1111/hpb.12266] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 03/06/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Post-operative delirium is an important and common complication of major abdominal surgery characterized by acute confusion with fluctuating consciousness. The aim of this study was to establish the incidence of post-operative delirium in patients undergoing a pancreaticoduodenectomy and to determine the risk factors for its development. METHODS From a prospectively maintained database, a retrospective cohort analysis was performed of 50 consecutive patients who underwent a pancreaticoduodenectomy at the National Surgical Centre for Pancreatic Cancer in St. Vincent's University Hospital, Dublin and whose entire post-operative stay was in this institution, between July 2011 and December 2012. Two independent medical practitioners assessed all data and delirium was diagnosed according to criteria of the Diagnostic and Statistical Manual Disorder (DSM), fourth edition. Univariate and multivariate analyses were performed. RESULTS Seven patients (14%) developed post-operative delirium. The median onset was on the second post-operative day. Older age was predictive of an increased risk of delirium post-operatively. Those who developed delirium had a significantly increased length of stay (LOS) as well as a significantly increased risk of developing at least a grade 3 complication (Clavien-Dindo classification). CONCLUSION This study demonstrates that post-operative delirium is associated with a more complicated recovery after a pancreaticoduodenectomy and that older age is independently predictive of its development. Focused screening may allow targeted preventative strategies to be used in the peri-operative period to reduce complications and costs associated with delirium.
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Affiliation(s)
- Tom K Gallagher
- Correspondence, Tom K. Gallagher, Department of Hepatobiliary & Pancreatic Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland. Tel: +44 781 606 5765. Fax: +353 1 2837724. E-mail:
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Kotekar N, Kuruvilla CS, Murthy V. Post-operative cognitive dysfunction in the elderly: A prospective clinical study. Indian J Anaesth 2014; 58:263-8. [PMID: 25024467 PMCID: PMC4090990 DOI: 10.4103/0019-5049.135034] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background and Aims: Aging population is a major demographic trend worldwide. Globally, 50% of all the elderly individuals are estimated to undergo atleast one surgical procedure and post-operative cognitive dysfunction (POCD) is one of the most common and often poorly understood post-operative complications in this section of the population. This randomised prospective study was conducted to assess the post-operative cognitive status in the elderly undergoing non-cardiac surgery, evaluate the cognitive parameters affected, evaluate the potential risk factors and thereby analyse the potential for implementation of preventive strategies. Methods: This study was conducted on 200 patients aged 60 years or older scheduled for elective non-cardiac surgeries. The baseline cognitive status of the patients was assessed 2 days prior to the date of the surgery. The post-operative cognitive status was assessed on the 3rd day, 7th day and after 1 month. Statistical analysis was performed using SAS and SPSS. Results: The incidence of POCD showed a gradual decline from postoperative day 3 to 30. Females were found to be at significant risk in developing POCD. Advancing age and level of education emerged as dominant factors, while type of anaesthesia, duration of surgery, and presence of coexisting comorbidities had no influence on the incidence of cognitive dysfunction. Conclusion: POCD is a definite complication after surgery and anaesthesia in the elderly population. Gender emerged as a significant risk factor with increasing age as a dominating factor contributing to POCD.
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Affiliation(s)
- Nalini Kotekar
- Department of Anaesthesiology, JSS Medical College, Mysore, Karnataka, India
| | | | - Vishakantha Murthy
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN 55905, USA
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25
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Odum SM, Springer BD. In-Hospital Complication Rates and Associated Factors After Simultaneous Bilateral Versus Unilateral Total Knee Arthroplasty. J Bone Joint Surg Am 2014; 96:1058-1065. [PMID: 24990970 DOI: 10.2106/jbjs.m.00065] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Data comparing complication rates following simultaneous bilateral total knee arthroplasty with those of unilateral total knee arthroplasty are conflicting. The purpose of this study was to compare in-hospital complication rates following simultaneous bilateral versus unilateral total knee arthroplasty and to determine factors associated with in-hospital complication rates in a large cohort of patients identified from the Nationwide Inpatient Sample (NIS). METHODS The 2004 to 2007 NIS data set was used to identify 407,070 total knee arthroplasties: 24,574 simultaneous bilateral and 382,496 unilateral total knee arthroplasties. Complications, based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes, were categorized as none, minor, major, or mortality. Covariates included comorbidities, demographic information, payer type, and hospital total knee arthroplasty volume. Multiple logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS Simultaneous bilateral total knee arthroplasty was associated with significantly higher odds of an in-hospital complication compared with unilateral total knee arthroplasty: OR, 1.51 (95% CI, 1.42 to 1.62) for minor complication; OR, 1.30 (95% CI, 1.14 to 1.47) for major complication; and OR, 2.51 (95% CI, 1.66 to 3.80) for mortality. Patients with greater numbers of medical comorbidities were more likely to have an in-hospital complication. Compared with whites, African-American and Asian/Pacific Islander groups had significantly higher odds of a minor complication. Female patients were less likely than male patients to have an in-hospital complication. Patients who were less than sixty-five years old at the time of surgery had significantly reduced odds of a minor complication and mortality compared with patients who were seventy-five years of age or older. Compared with hospitals with a very-high volume of total knee arthroplasty procedures performed (≥850), lower-volume hospitals had significantly increased odds of minor complications and mortality. CONCLUSIONS While complication rates following either unilateral or simultaneous bilateral total knee arthroplasty are low, simultaneous bilateral total knee arthroplasty was associated with higher odds of in-hospital complications, including mortality, compared with unilateral total knee arthroplasty. Patient demographic information, preoperative health status, payer type, and hospital total knee arthroplasty volume were all significant factors in complication rates following bilateral total knee arthroplasty. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Susan M Odum
- OrthoCarolina Research Institute, Inc., 2001 Vail Avenue, Suite 300, Charlotte, NC 28207. E-mail address:
| | - Bryan D Springer
- OrthoCarolina Hip and Knee Center, 2001 Vail Avenue, Suite 200-A, Charlotte, NC 28207. E-mail address:
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Madsen AA, Taylor BC, Dimitris C, Hansen DC, Steensen RA, Gaines ST. Safety of bilateral total knee arthroplasty in morbidly obese patients. Orthopedics 2014; 37:e252-9. [PMID: 24762152 DOI: 10.3928/01477447-20140225-57] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 11/01/2013] [Indexed: 02/03/2023]
Abstract
There has been an increase in the prevalence of morbid obesity and the demand for total knee arthroplasty (TKA). Physicians must help patients with bilateral knee arthritis to make informed decisions regarding whether to undergo staged, sequential, or simultaneous TKA. The purpose of this study was to evaluate the perioperative complications of 2-team simultaneous bilateral TKA in the morbidly obese. The authors performed a retrospective review of the records at a single tertiary hospital from 1997 to 2007 and identified 35 morbidly obese (body mass index [BMI] greater than 40 kg/m(2)) patients who had undergone unilateral TKA, as well as 42 morbidly obese and 79 nonobese (BMI less than 30 kg/m(2)) patients who underwent simultaneous bilateral TKA. Clinical, operative, and postoperative variables and complication rates were recorded. Clinical variables were similar between the morbidly obese TKA patients. The bilateral group had significantly increased operative times (132.4 vs 115.5 minutes; P<.01), intravenous fluids (2556.1 vs 2114.7 mL; P=.03), percentage transfused (64.2% vs 11.4%; P<.01), days in the hospital (3.6 vs 3.2 days; P=.03), and discharge rates to rehabilitation facility (72.7% vs 48.6%; P=.01). Major and minor complications were few and comparable, with the need for manipulation under anesthesia in unilateral TKA (11.4%; P=.04) as the only significant difference between groups, including when comparing bilateral nonobese TKAs with bilateral morbidly obese TKAs. The authors feel that morbidly obese patients may undergo 2-team simultaneous bilateral TKA after careful discussion regarding some of the differences in short-term outcomes.
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MESH Headings
- Aged
- Arthroplasty, Replacement, Knee/adverse effects
- Arthroplasty, Replacement, Knee/methods
- Female
- Humans
- Male
- Middle Aged
- Obesity, Morbid/complications
- Obesity, Morbid/diagnosis
- Obesity, Morbid/surgery
- Osteoarthritis, Knee/complications
- Osteoarthritis, Knee/diagnosis
- Osteoarthritis, Knee/surgery
- Patient Safety
- Prosthesis-Related Infections/diagnosis
- Prosthesis-Related Infections/etiology
- Prosthesis-Related Infections/prevention & control
- Retrospective Studies
- Surgical Wound Infection/diagnosis
- Surgical Wound Infection/etiology
- Surgical Wound Infection/prevention & control
- Treatment Outcome
- Venous Thrombosis/diagnosis
- Venous Thrombosis/etiology
- Venous Thrombosis/prevention & control
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Spicer E, Thomas GR, Rumble EJ. Comparison of the major intraoperative and postoperative complications between unilateral and sequential bilateral total knee arthroplasty in a high-volume community hospital. Can J Surg 2013; 56:311-7. [PMID: 24067515 DOI: 10.1503/cjs.012912] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) is a common surgical treatment for arthritis. In the event of bilateral knee symptoms, a patient may elect for bilateral TKA (BTKA) under 1 anesthetic or 2 separate unilateral TKAs (UTKA). Controversy exists in the literature regarding the safety of BTKA versus UTKA. We compared the rate of major intraoperative and postoperative complications for BTKA versus UTKA at a high-volume community hospital. METHODS We compared 373 patients who underwent BTKA with 966 who underwent UTKA between May 2008 and May 2011. Health records were used to determine patient characteristics and major intraoperative and postoperative complications. The BTKA and UTKA cohorts were matched for demographic characteristics and comorbidities with the exception of previous transient ischemic attack and previous knee surgery (UTKA > BTKA). RESULTS Rates of intraoperative and postoperative complications, including cardiovascular, thromboembolic and neurologic complications; deep wound infections; and mortality, did not differ significantly between groups. Bilateral TKA was associated with a greater proportion of patients requiring blood transfusion than UTKA (29.8% v. 8.9%, p < 0.001). Among those transfused, there was no significant difference between the groups in the mean number of units required (1.72 ± 0.77 v. 1.53 ± 0.85 units, p = 0.68). CONCLUSION Bilateral TKA was not associated with statistically greater rates of intraoperative and postoperative complications than UTKA, barring the proportion of patients requiring transfusion. Our results support the use of BTKA to treat bilateral knee arthritis in a high-volume community hospital setting.
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Affiliation(s)
- Erin Spicer
- From the Faculty of Medicine, University of Toronto, Toronto, Ont. and the Division of Orthopaedic Surgery, North York General Hospital, Toronto, Ont
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Fu D, Li G, Chen K, Zeng H, Zhang X, Cai Z. Comparison of clinical outcome between simultaneous-bilateral and staged-bilateral total knee arthroplasty: a systematic review of retrospective studies. J Arthroplasty 2013; 28:1141-7. [PMID: 23518424 DOI: 10.1016/j.arth.2012.09.023] [Citation(s) in RCA: 110] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2012] [Revised: 09/15/2012] [Accepted: 09/29/2012] [Indexed: 02/01/2023] Open
Abstract
The purpose of this study is to conduct a systematic review assessing the clinical outcome associated with Simultaneous bilateral and staged bilateral total knee arthroplasty (TKA). A literature search for eligible studies was conducted. Eighteen retrospective comparative studies were included. Pooled results showed that the prevalence of mortality at 30 days postoperatively, pulmonary embolism, blood transfusion rate were significantly higher in simultaneous TKA group. A significantly lower rate of deep infection and revision were found in simultaneous TKA. No significant difference was seen in regard to neurological complications, deep-vein thrombosis, cardiac complications, superficial infection. Compared with staged bilateral TKA, simultaneous bilateral TKA is associated with higher rates of mortality, pulmonary embolism and blood transfusion, while decreasing the risk of deep infection and revision rate.
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Affiliation(s)
- Dong Fu
- The tenth People's Hospital affiliated with Tong Ji University, Shanghai, People's Republic of China
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29
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Gurunathan U. Perioperative considerations of bilateral total knee replacement: a review. J Clin Anesth 2013; 25:232-9. [DOI: 10.1016/j.jclinane.2013.01.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Revised: 01/25/2013] [Accepted: 01/29/2013] [Indexed: 01/29/2023]
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30
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Trojani C, Bugnas B, Blay M, Carles M, Boileau P. Bilateral total knee arthroplasty in a one-stage surgical procedure. Orthop Traumatol Surg Res 2012; 98:857-62. [PMID: 23146285 DOI: 10.1016/j.otsr.2012.08.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Revised: 08/02/2012] [Accepted: 08/30/2012] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Bilateral total knee arthroplasty (TKA) in a one-stage surgical procedure has the advantage of a single hospital stay, shorter rehabilitation, and reduced patient management costs. However, until now the use of this strategy has been limited by the fear of a higher rate of perioperative complications. The hypothesis of this study was that in selected patients, this management strategy would not result in any serious complications. MATERIALS AND METHODS This prospective 24-month pilot study was performed in a continuous series of patients without a control group. Inclusion criteria were bilateral non-infectious gonarthropathy, in patients classified as American Society of Anesthesiology (ASA) 1 or 2 and presenting with a preoperative hemoglobin level of at least 13g/dL. All patients underwent a pre- and postoperative evaluation using the International Knee Society (IKS) and Knee Injury and Osteoarthritis Score (KOOS) scores. RESULTS Thirty patients were included in the study (25 women, mean age 70.3years old [32 to 88years]; five ASA 1 and 25 ASA 2). All patients were followed-up and evaluated for a mean 18months (6 to 30months). Three deep vein thromboses, one cardiopulmonary accident and three confusional states were reported, but there were no perioperative deaths, pulmonary embolisms, nosocomial infections or revision procedures. At 18months follow-up the IKS score had improved from 98 (33-139) preoperatively to 169 (62-200) postoperatively. The five items of the KOOS score improved significantly. DISCUSSION This preliminary series confirms that bilateral total knee replacement in a one-stage surgical procedure is a reliable alternative to a two-stage procedure in ASA 1 and 2 patients. Because of the savings in health costs with this strategy, public healthcare authorities should provide support by creating and sponsoring a specific group for further study. LEVEL OF EVIDENCE 4, prospective, no control group.
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Affiliation(s)
- C Trojani
- Department of Orthopaedic surgery and sport traumatology, hôpital de l'Archet II, 151 route de Saint-Antoine-de-Ginestière, Nice, France.
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Cardiovascular disease predicts complications following bilateral total knee arthroplasty under a single anesthetic. Knee 2012; 19:580-4. [PMID: 22032866 DOI: 10.1016/j.knee.2011.09.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2011] [Revised: 09/06/2011] [Accepted: 09/18/2011] [Indexed: 02/02/2023]
Abstract
INTRODUCTION This study evaluated the rate of perioperative complications of single anesthetic bilateral total knee arthroplasties (TKA) compared with staged procedures. METHODS The records of all single anesthetic bilateral TKA performed between 1997 and 2007 at one large community hospital and one university hospital were retrospectively reviewed. Complete demographic data, preoperative co-morbidities and complications for 156 patients were compared to a matched staged bilateral TKA (n=78) cohort. RESULTS In the single anesthetic bilateral TKA cohort, cardiovascular disease predicted postoperative myocardial (p<0.01, Odds Ratio - 67.6), need for ICU admission (p<0.01, Odds Ratio - 88.8), and days spent in ICU (p<0.01), while cardiovascular disease did not significantly predict postoperative MI in the staged bilateral (p=0.99, OR - 0). CONCLUSION Patients with cardiovascular disease are at higher risk for perioperative MI after single anesthetic bilateral TKA.
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Abstract
Postoperative cognitive dysfunction (POCD) refers to a postoperative decline in cognitive function compared with preoperative cognitive function. Diagnosis requires pre- and postoperative testing, the latter of which is usually performed both 7 days and 3 months postoperatively. Although several risk factors for POCD have been described, age is the only consistently reported risk factor. Postoperative cognitive dysfunction is often transient. It may last several months, and is associated with leaving the labor market prematurely and increased mortality. As the pathophysiology of POCD is still a matter of debate and is likely to be multifactorial, there are no widely accepted prophylactic and therapeutic interventions. In this article, we discuss POCD's definition, risk factors, long-term significance, and pathophysiology. We also present data on prophylactic interventions that have been investigated in clinical trials.
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Affiliation(s)
- Christoph S Burkhart
- Department of Anesthesia and Intensive Care Medicine, University Hospital Basel, Basel, Switzerland.
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Dimitris CN, Taylor BC, Mowbray JG, Steensen RN, Gaines ST. Perioperative morbidity and mortality of 2-team simultaneous bilateral total knee arthroplasty. Orthopedics 2011; 34:e841-6. [PMID: 22146199 DOI: 10.3928/01477447-20111021-02] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Total knee arthroplasty (TKA) has a well-established track record for relieving pain associated with arthritis of the knee joint. The total rate of bilateral TKA has doubled over the past 2 decades, and the rate in women has tripled over that same time period. In patients with bilateral knee arthritis, a decision must be made whether to operate at 2 different settings (staged), a single setting with 1 surgeon (sequential simultaneous), or a single setting with 2 surgeons (2-team simultaneous). The purpose of this study was to examine the perioperative morbidity and mortality of 2-team simultaneous bilateral TKA. Two hundred twenty-seven consecutive 2-team simultaneous bilateral TKA and 216 consecutive unilateral TKA patients were reviewed. Major (deep infection, death, cerebrovascular accident, myocardial infarction, pulmonary embolism, revision within the 1-year follow-up) and minor (all other) complications were compared. No deaths occurred, and the major and minor complication rates were not statistically significantly different between the 2 groups, but a trend toward higher rates of both major and minor complications existed in the bilateral TKA group. Two-team simultaneous bilateral TKA offers the potential benefits of decreased overall recovery time, decreased overall cost, decreased number of anesthetic administrations, and simultaneous correction of significant deformity. It remains an appropriate option in select patients.
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Affiliation(s)
- Craig N Dimitris
- Department of Orthopaedic Surgery, Mount Carmel West Hospital, 793 W State St, Columbus, OH 43222, USA.
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Kim S, Meehan JP, White R. Operative risk of staged bilateral knee arthroplasty is underestimated in retrospective studies. J Arthroplasty 2011; 26:1198-204. [PMID: 21392934 DOI: 10.1016/j.arth.2011.01.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Accepted: 01/02/2011] [Indexed: 02/01/2023] Open
Abstract
To find a safer surgical option, a number of studies have compared postoperative complications after bilateral total knee arthroplasty vs staged total knee arthroplasty (STKA) by contrasting postoperative complications collected retrospectively. However, we believe that a comparison based on retrospective studies could be biased. The purpose of this study was to demonstrate the misclassification bias associated with a retrospective study in comparing operative outcomes. Our analysis indicates that any conclusions based simply on retrospective analysis of subjects who successfully completed STKA is biased because it includes only cases that recovered after the first operation, rather than all of the patients who had planned STKA. In the absence of a prospective study to date, published studies should be interpreted with caution.
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Affiliation(s)
- Sunny Kim
- Department of Orthopaedic Surgery, University of California, Davis, USA
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Mortality and morbidity associated with simultaneous bilateral or staged bilateral total knee arthroplasty: a meta-analysis. Arch Orthop Trauma Surg 2011; 131:1291-8. [PMID: 21359869 DOI: 10.1007/s00402-011-1287-4] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2010] [Indexed: 02/09/2023]
Abstract
OBJECTIVE To evaluate the mortality and postoperative morbidity associated with simultaneous bilateral or staged bilateral total knee arthroplasty (TKA). METHODS We identified eligible studies in PubMed (1980-2010), OVID MEDLINE (1980-2010) and the Cochrane library. Data were extracted and evaluated by two reviewers independently. Data analyses were conducted with Stata 10.0. RESULTS Fourteen studies met our inclusion criteria. Combined results showed that the prevalence of mortality [OR = 3.202, 95% CI (1.852-5.537)], mortality at 30 days postoperatively [OR = 5.564, 95% CI (2.392-12.939)] and neurological complications [OR = 2.906, 95% CI (1.200-7.037)] were significantly higher in the population who had undergone simultaneous TKA compared with those who had undergone staged TKA. The prevalence of infection, pulmonary embolism, deep-vein thrombosis, and cardiac complications between the two populations was not significantly different. CONCLUSION Compared with staged bilateral TKA, simultaneous bilateral TKA might carry a higher potential risk of postoperative complications. Patients should be aware of this information when deciding whether to proceed with simultaneous bilateral TKA. The poor quality of the studies calls into question the robustness of the analyses.
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Fabi DW, Mohan V, Goldstein WM, Dunn JH, Murphy BP. Unilateral vs bilateral total knee arthroplasty risk factors increasing morbidity. J Arthroplasty 2011; 26:668-73. [PMID: 20875943 DOI: 10.1016/j.arth.2010.07.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2010] [Accepted: 07/18/2010] [Indexed: 02/01/2023] Open
Abstract
Because surgeons are electing to perform simultaneous bilateral total knee arthroplasty (TKA), it is important to identify which patients are at increased risk. We performed a retrospective cohort analysis of 150 patients with unilateral TKA vs 150 patients with simultaneous bilateral TKA. The bilateral group demonstrated a 2.1 times greater mean overall complication rate as well as increased transfusion rates. Patients older than 70 years exhibited significantly higher complication rates. Having a preexisting pulmonary disorder in the bilateral cohort carried nearly a 3-fold risk of complications. Patients with body mass indices greater than 30 displayed a complication rate of 0.97 in the bilateral group as opposed to 0.44 in the control group. Our study demonstrated that age, body mass index, and a preexisting pulmonary disorder resulted in increased complications.
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Affiliation(s)
- David W Fabi
- Department of Orthopaedic Surgery, University of Illinois, Chicago, Illinois, USA
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Rosenbaum AJ, Luciano JA, Marburger R, Hume E. Acute kidney injury in the setting of knee arthroplasty: a case report and discussion investigating Angiotensin-converting enzyme inhibitors as the culprit. HSS J 2011; 7:183-6. [PMID: 22754420 PMCID: PMC3145861 DOI: 10.1007/s11420-010-9189-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Accepted: 10/22/2010] [Indexed: 02/07/2023]
Abstract
Total knee arthroplasty (TKA) has become the predominant treatment modality for severe degenerative joint disease. With recent advancements in surgical and anesthetic technique, patients with severe comorbidities are able to have this procedure; they would have been precluded from TKA only a matter of years ago. Although many studies have investigated risk factors and the causes of perioperative morbidity and mortality in the arthroplasty patient, few have linked risk factors with specific outcomes. We present a case report that illustrates the link between the use of angiotensin-converting enzyme inhibitors and the development of postoperative acute kidney injury. While this relationship has been extensively studied in cardiac and gastric bypass patient populations, it has never been examined in the setting of joint replacement.
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Affiliation(s)
| | - Jason A. Luciano
- Division of Trauma and General Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - Robert Marburger
- Department of Orthopaedic Surgery, Cooper University Hospital, Camden, NJ USA
| | - Eric Hume
- Department of Orthopaedic Surgery, Cooper University Hospital, Camden, NJ USA
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Kim SY, An YJ, Kim SH, Kim HK, Park JS, Shin YS. The effect of postoperative pain on postoperative blood loss after sequential bilateral total knee arthroplasty. Korean J Anesthesiol 2011; 60:98-102. [PMID: 21390164 PMCID: PMC3049889 DOI: 10.4097/kjae.2011.60.2.98] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Revised: 07/23/2010] [Accepted: 07/27/2010] [Indexed: 12/05/2022] Open
Abstract
Background Bilateral total knee arthroplasty is generally accompanied by a significant amount of blood loss. We investigated the relationship between the intensity of pain and the amount of blood loss in the early postoperative period after bilateral total knee arthroplasty. Methods A prospective study was conducted on 91 patients who underwent elective sequential bilateral total knee arthroplasty for osteoarthritis. All patients received combined spinal and epidural anesthesia. Patients were divided into three groups based on their scores on the verbal numerical rating scale (VNRS) for pain at 6 hours postoperatively. The VNRS was classified as follows; mild pain (n = 34, VNRS score 0-4), moderate pain (n = 24, VNRS score 5-6), and severe pain (n = 33, VNRS score 7-10). We compared the mean arterial pressures and the amount of blood loss during the first 24 postoperative hours in the three groups. Factors influencing postoperative blood loss were analyzed. Results Postoperative mean arterial pressures and blood loss were not different among the groups. Of the factors examined, the amount of postoperative blood loss was only dependent on the amount of intraoperative blood loss (P = 0.001). Conclusions Early postoperative pain has no effect on postoperative blood pressure and the amount of blood loss after bilateral total knee arthroplasty. For postoperative blood loss, intraoperative blood loss is the main determinant.
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Affiliation(s)
- So Yeon Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
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Taylor BC, Dimitris C, Mowbray JG, Gaines ST, Steensen RN. Perioperative safety of two-team simultaneous bilateral total knee arthroplasty in the obese patient. J Orthop Surg Res 2010; 5:38. [PMID: 20565781 PMCID: PMC2896355 DOI: 10.1186/1749-799x-5-38] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2009] [Accepted: 06/17/2010] [Indexed: 11/13/2022] Open
Abstract
Background Although the rates of perioperative morbidity and mortality with simultaneous bilateral total knee arthroplasty remain a concern, multiple studies have shown the procedure to be safe in selected patient populations. Evidence also remains mixed regarding the outcomes of total knee arthroplasty in obese patients. The purpose of this paper is to compare the rates of perioperative morbidity and mortality in consecutive obese patients undergoing two-team simultaneous bilateral total knee arthroplasty and unilateral total knee arthroplasty. Methods The records on all two-team simultaneous total knee arthroplasties and unilateral total knee arthroplasties from October 1997 to December 2007 were reviewed. A total of 151 patients with a body mass index (BMI) >30 undergoing two-team simultaneous total knee arthroplasty and 148 patients with a BMI >30 undergoing unilateral total knee arthroplasty were retrospectively reviewed and analyzed to determine perioperative morbidity and mortality as well as one-year mortality rates. Results Preoperative patient characteristics did not show any significant differences between groups. The simultaneous bilateral group had significantly longer operative times (127.4 versus 112.7 minutes, p < 0.01), estimated blood loss (176.7 versus 111.6 mL, p = 0.01), percentage of patients requiring blood transfusion (64.9% versus 13.9%, p < 0.01), length of hospital stay (3.72 versus 3.30 days, p < 0.01), and percentage of patients requiring extended care facility usage at discharge (63.6% versus 27.8%, p < 0.01). No significant difference between unilateral and bilateral groups was seen in regards to total complication rate, major or minor complication subgroup rate, or any particular complication noted. Doubling the variables in the unilateral group for a staged total knee arthroplasty scenario did create significant increases over the simultaneous data in almost every data category. Conclusions Two-team simultaneous total knee arthroplasty appears to be safe in obese patients, with similar complication rates as compared to unilateral procedures. Two-team simultaneous total knee arthroplasty also appears to have potential benefits over a staged procedure in the obese patient, although more study is required regarding this topic.
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Affiliation(s)
- Benjamin C Taylor
- Department of Orthopaedic Surgery, Mount Carmel Medical Center, MSB 3rd Floor, 793 W, State Street, Columbus, Ohio, 43222, USA.
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Yoon HS, Han CD, Yang IH. Comparison of simultaneous bilateral and staged bilateral total knee arthroplasty in terms of perioperative complications. J Arthroplasty 2010; 25:179-85. [PMID: 19195827 DOI: 10.1016/j.arth.2008.11.103] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2008] [Accepted: 11/30/2008] [Indexed: 02/01/2023] Open
Abstract
We compared bilateral total knee arthroplasty (TKA) performed at a single session vs those performed at 2 separate sessions with respect to complications, amount of blood loss, and length of hospital stay. Study participants included 119 consecutive patients undergoing simultaneous bilateral TKA and an additional 119 patients undergoing staged bilateral TKA. Systemic complication in the simultaneous bilateral TKA was significantly higher statistically than that in the staged bilateral TKA. Therefore, performing simultaneous bilateral TKA in elderly or high-risk patients results in a significantly higher rate of systemic complications. Simultaneous bilateral TKA is a relatively safe and beneficial procedure with a minimal increase in the risk of systemic complications. However, this procedure should be conducted carefully, particularly in elderly and high-risk patients.
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Affiliation(s)
- Hang-Seob Yoon
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
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Noble J, Goodall JR, Noble DJ. Simultaneous bilateral total knee replacement: a persistent controversy. Knee 2009; 16:420-6. [PMID: 19464899 DOI: 10.1016/j.knee.2009.04.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2008] [Revised: 04/03/2009] [Accepted: 04/21/2009] [Indexed: 02/02/2023]
Abstract
The benefits and risks of Simultaneous Bilateral Total Knee Replacement (SBTKR) remain controversial. A review of the English speaking literature was undertaken and found that many papers took staunch positions either for or against the procedure. It was also noted that earlier papers supporting SBTKR suggested cost benefits. There was a huge disparity in the incidence of mortality and morbidity and it was not possible to compare many papers, because in some medically frail patients were excluded from the SBTKR cohorts. In large published series the proportion of patients having a SBTKR varied between 3% and 70%. Many, but not all, series highlighted age and co-morbidity as risk factors. Overall there was no clear case for or against SBTKR. The evidence suggested that careful preoperative assessment and patient selection on a strict protocol were essential. The procedure should be confined to hospitals where high dependency nursing is readily available and the literature indicated that the risk is less in high through-put units. By refining preoperative assessment and preparation it can be a safe and effective procedure in an appropriate clinical setting for postoperative care.
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Affiliation(s)
- J Noble
- University of Manchester, Manchester, UK
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Efficiency of autologous blood donation in combination with a cell saver in bilateral total knee arthroplasty. HSS J 2009; 5:45-8. [PMID: 19083062 PMCID: PMC2642542 DOI: 10.1007/s11420-008-9101-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2008] [Accepted: 10/22/2008] [Indexed: 02/07/2023]
Abstract
The increased blood loss and resulting need for allogenic blood has been a major concern of one-stage bilateral total knee arthroplasty (TKA). One hundred eighteen consecutive patients donating either 2 units (87 patients) or 3 units (31 patients) of autologous blood prior to one-stage bilateral TKA were retrospectively evaluated to determine: (1) how many patients received allogenic transfusion; (2) what percentage of autologous blood was wasted; and (3) whether donating 2 or 3 units of autologous blood before surgery is more cost-effective. Fifteen patients in the 2-units donation group (17.2%) and one patient in the 3-units donation group (3.2%) required allogenic blood transfusions. In the 2-units group, 37.9% of the patients wasted 21.8% of predonated autologous blood, and in the 3-units group, 64.5% of the patients wasted 32.3% of predonated autologous blood. The estimated cost for patients donating 2 or 3 units of blood was $1,814.17 and $1,996.10, respectively. Donating 2 units of autologous blood is more cost-effective; however, patients donating 3 units of blood required less allogenic blood.
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Patil N, Wakankar H. Morbidity and mortality of simultaneous bilateral total knee arthroplasty. Orthopedics 2008; 31:780-9; quiz 790-1. [PMID: 18714773 DOI: 10.3928/01477447-20080801-23] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Nilesh Patil
- Stanford Medical Center, 300 Pasteur Dr, Palo Alto, CA 94305, USA
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Does different time interval between staggered bilateral total knee arthroplasty affect perioperative outcome? A retrospective study. J Arthroplasty 2008; 23:539-42. [PMID: 18514871 DOI: 10.1016/j.arth.2007.05.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2006] [Accepted: 05/17/2007] [Indexed: 02/01/2023] Open
Abstract
Staggered bilateral total knee arthroplasty (BTKA) performed 4 to 7 days apart has been shown to have fewer postoperative complications than sequential or staged BTKA. However, there has been no comparison of staggered BTKA with different intervals. A retrospective study involving 79 patients who underwent BTKA from 2002 to 2004 was performed to determine whether the interval between each TKA influenced the clinical outcome. Staggered operations performed 2 days (n = 46) or 7 days (n = 33) apart had similar incidence of major (acute myocardial infarction, pulmonary embolism, etc) and minor complications (transient hypotension or low Sp(o)(2)) throughout hospitalization. Perioperative complications in the first and second TKAs were similar when TKAs were performed with a 2- or a 7-day interval.
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Hu J, Guo D, Lü Z, Liu J, Yu X, Zhang Z. The clinical comparison of simultaneous bilateral total knee arthroplasty in treatment of osteoarthritis. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/s1007-4376(08)60059-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Peak EL, Hozack WJ, Sharkey PF, Parvizi J, Rothman RH. One-stage bilateral total joint arthroplasty: a prospective, comparative study of total hip and total knee replacement. Orthopedics 2008; 31:131. [PMID: 19292211 DOI: 10.3928/01477447-20080201-26] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This prospective study compared the incidence of minor and major complications in 50 patients (100 joints) undergoing bilateral total knee arthroplasty (TKA) with 50 patients (100 joints) undergoing bilateral total hip arthroplasty (THA). Gender, comorbidities, American Society of Anesthesiologists scores, and body mass indices were similar in both groups. There was no difference in preoperative hemoglobin, operative time, anesthetic management, postoperative surveillance, and hemoglobin at discharge. However, the need for allogenic blood transfusion, despite preoperative autologous blood donation and retransfusion, was high for both groups (34% for bilateral TKA and 20% for bilateral THA. Bilateral THA patients had lower rates of total major and minor complications than bilateral TKA patients. Although cementless bilateral THA and cemented bilateral TKA can be performed efficiently and with relative safety in a select group of patients, the high rate of minor complications and in particular the need for allogenic transfusion in both groups is concerning and should be discussed with patients before surgery.
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Affiliation(s)
- E Louis Peak
- Department of Orthopedic Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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Restrepo C, Parvizi J, Dietrich T, Einhorn TA. Safety of simultaneous bilateral total knee arthroplasty. A meta-analysis. J Bone Joint Surg Am 2007; 89:1220-6. [PMID: 17545424 DOI: 10.2106/jbjs.f.01353] [Citation(s) in RCA: 122] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The safety of simultaneous bilateral total knee replacement remains controversial. Some studies have demonstrated a higher rate of serious complications, including death, following bilateral procedures, whereas others have suggested no increase in the complication rate. The objective of this meta-analysis was to compare the safety of simultaneous bilateral total knee replacement with that of staged bilateral and unilateral total knee replacements. METHODS A computerized literature search was conducted to identify all citations, from 1966 to 2005, concerning bilateral total knee replacement. All of the English-language abstracts were obtained. A multistage assessment was then performed to identify articles fulfilling the inclusion criteria for the study. All randomized, prospective studies reporting the outcome of bilateral total knee replacement were included. The details of the reported data were extracted, and an extensive analysis of relevant variables was carried out. RESULTS One hundred and fifty published articles were identified, and eighteen that included a total of 27,807 patients (44,684 knees) were included in the meta-analysis. There were 10,930 unilateral total knee replacements, 16,419 simultaneous bilateral total knee replacements, and 458 staged bilateral total knee replacements with at least three months between the operative procedures. The prevalences of pulmonary embolism (odds ratio = 1.8), cardiac complications (odds ratio = 2.49), and mortality (odds ratio = 2.2) were higher after simultaneous bilateral total knee replacement. The prevalence of deep venous thrombosis was lower after simultaneous bilateral total knee replacement, but this difference was not significant. The complication rates after the staged bilateral total knee replacements were similar to those in the patients who had undergone unilateral total knee replacement only. CONCLUSIONS Compared with staged bilateral or unilateral total knee replacement, simultaneous bilateral total knee replacement carries a higher risk of serious cardiac complications, pulmonary complications, and mortality. The period of time between staged procedures that would eliminate these increased risks could not be determined from this study. LEVEL OF EVIDENCE Therapeutic Level III.
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Affiliation(s)
- Camilo Restrepo
- Department of Orthopedic Surgery, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania 19107, USA
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Huotari K, Lyytikäinen O, Seitsalo S. Patient outcomes after simultaneous bilateral total hip and knee joint replacements. J Hosp Infect 2007; 65:219-25. [PMID: 17275961 DOI: 10.1016/j.jhin.2006.10.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2006] [Accepted: 10/31/2006] [Indexed: 11/20/2022]
Abstract
Simultaneous arthroplasties are increasingly being performed during one single anaesthetic event. No national nosocomial surveillance systems have yet reported data on this issue. We compared patient populations undergoing bi- and unilateral total hip (THA) and total knee (TKA) arthroplasties in terms of two outcome variables, deep surgical site infections (SSI) and mortality, by analysing surveillance data from the Finnish Hospital Infection Programme (SIRO). A total of 8201 patients underwent 9831 total arthroplasties during 2001-2004. Of the prosthetic joints, 7.2% were inserted in a bilateral operation (range by hospital, 0.6-19.2%; range by procedure type, 5.2-9.9%). Patients who underwent bilateral operations were younger; more often males, and their ASA score was lower than those who underwent unilateral procedures. The rate of deep SSI in bi- and unilateral THAs and in bi- and unilateral TKAs was 0, 0.5, 1.0 and 0.9%, respectively. Following bilateral operations, four deep SSIs were detected, all from bilateral TKAs, three of which were on the second operative side. In these three cases, single doses of antimicrobial prophylaxis were administered 115, 155 and 218 min before incision (median time in unilateral operations: 47 min). According to multi-variate analysis, bilateral operations were not an independent risk factor for deep SSIs. Mortality did not differ between bi- and unilateral THAs or TKAs. Our surveillance data indicate that simultaneous bilateral surgery did not increase the risk of deep SSIs or death after THA and TKA. Bilateral operations may, however, require specific guidelines regarding antimicrobial prophylaxis.
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Affiliation(s)
- K Huotari
- National Public Health Institute, Helsinki, Finland.
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Shah K, Smith J, Jones B, Hullin M. Bilateral total knee replacement under a single anaesthetic, using a cementless implant is not unsafe. Knee Surg Sports Traumatol Arthrosc 2007; 15:269-75. [PMID: 16937151 DOI: 10.1007/s00167-006-0196-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2006] [Accepted: 08/01/2006] [Indexed: 10/24/2022]
Abstract
Bilateral knee replacement under single anaesthetic is not a common procedure. There is a general agreement that this is associated with greater morbidity and mortality. However, there is a suggestion in literature that using a cementless implant could reduce this risk. We wanted to make a prospective comparison of safety and clinical results, between unilateral and bilateral cementless knee replacements performed under a single anaesthetic. A prospective non-randomised matched cohort study on 87 consecutive patients who had bilateral simultaneous/sequential knee replacement and 174 consecutive patients who had unilateral knee replacement between the period of 1997 and 2002 were included in this study. All patients had a cementless mobile-bearing implant. All patients had an independent objective assessment at follow-up. There was no significant difference between the two groups in terms of age, sex, primary diagnosis (osteoarthritis or rheumatoid arthritis), co-morbidity, ASA grade, average range of motion and average American knee society score and post-operative surgical complications. There was one early death in the bilateral group, and three in the unilateral group. The clinical results of bilateral group were as good as the unilateral group. Our study showed that in terms of postoperative medical and surgical complications, bilateral simultaneous/sequential knee replacement using a cementless mobile-bearing implant is as safe as a unilateral knee replacement. With careful patient selection, bilateral knee replacement under a single anaesthetic would be a suitable option for patients who present with bilateral symptomatic arthritis of the knee.
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Affiliation(s)
- Kalpesh Shah
- Southern General Hospital, Flat 1, 87 Cleveden Road, Glasgow, G12 0JN, UK.
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