Single-stage bilateral cemented total hip replacement: is it safe and effective?

Concerns regarding single-stage bilateral total hip arthroplasty (THA) remain among orthopaedic surgeons in the UK, primarily with regard to rehabilitation, function, and complications. Between 1998 and 2002, 1,215 patients had a primary THA in our centre. We reviewed prospectively collected data on 264 of these patients who had symptoms from both hips. Of these patients, 49 had a bilateral THA at the same operation and 215 had a unilateral THA. We compared these two groups and found that, pre-operatively, there were no significant differences in sex, body mass index, American Society of Anesthesiologists scores, smoking history, or overall Harris Hip Score (HHS). The patients in the bilateral group were significantly younger. Our results showed no significant differences in complications between the two groups in terms of death, infection, dislocation, or revision at 6 months. Postoperative HHSs at 6 months were almost the same, again with no significant difference. Length of stay was increased for the group having single-stage bilateral THA, but even when corrected for age, was significantly shorter than twice as long at 173%. We did see an increased risk of blood transfusion in the bilateral group, 78% of patients requiring blood, against 22% of patients having a unilateral THA. We know from previous studies that single-stage bilateral THA is cheaper and the benefits to the patient are many. We therefore conclude that single-stage bilateral THA should be taken up more widely in the UK in a selected, generally younger patient group.     

Bilateral Total Joint Arthroplasty : The Early Results from the New Zealand National Joint Registry

This study evaluated the mortality rate, major complications, and early outcomes of single anesthetic bilateral total hip and knee arthroplasty compared with unilateral and staged procedures. A total of 37 828 total hip and knee arthroplasties were evaluated with 6-month Oxford 12 scores. Major complications and mortality rates were recorded. Analysis of variance tables were used for statistical analysis. The single anesthetic bilateral group were significantly younger (P < .001), with their age-adjusted postoperative Oxford 12 scores significantly better (P < .001) than the other 2 groups. The surgeons involved, in general, performed more than 25 total knee and hip arthroplasties per year. There was 1 death within the first 6 months occurring in the staged bilateral group and was unrelated to the surgery. The complication rate as reported by patients was low in all groups, and there was no significant difference. The results show that, in selected patients, single anesthetic bilateral total knee or hip arthroplasty is a safe, low-risk procedure with very good patient-generated outcome scores at 6 months when performed by an experienced surgeon.     

一期采用髋关节前路切口行双侧人工全髋关节置换术治疗双侧股骨头缺血性坏死

[摘要]目的探讨一期采用髋关节前路行双侧全髋关节置换术（totalhipreplacement,THR）治疗双侧股骨头缺血性坏死的临床疗效。方法2005年5月一2010年11月一期采用髋关节前路行双侧THR治疗双侧股骨头缺血性坏死23例46髋,观察术后髋关节功能和并发症。结果23例均获得随访,随访时间3～41个月。根据Harris评分系统评定,优良率91．3％（42／46）。结论一期采用髋关节前路行双侧THR治疗双侧股骨头缺血性坏死临床疗效满意。     

Complications and outcomes of single-stage bilateral total knee arthroplasty

BACKGROUND: A recent literature review by the senior authors of this study revealed that simultaneous bilateral knee arthroplasty is uncommon and controversial. Reported complications include myocardial infarction, deep venous thrombosis, pulmonary embolus, thromboembolic complications, pseudo-obstruction, postoperative ileus and death. This present study was designed to identify complications of single-stage bilateral total knee arthroplasty to compare with reports in the international literature. METHODS: A retrospective study of 40 cases of simultaneous total knee arthroplasty carried out by the senior authors at Wellington over the last 10 years, examined details of surgery, anaesthesia, preoperative and postoperative management to identify the occurrence of complications. Thirty-one patients completed an Oxford Knee Score, a EuroQuol-5 Dimension (EQ-5D) questionnaire and reported their experience of the bilateral procedure. RESULTS: Complications reported in the international literature did not occur in the patients studied. Complications that did occur included urinary retention, wound infections and oedema of the limbs or knees. The mean Oxford Knee Score was 20.79. In 2003 the New Zealand national mean for primary total knee arthroplasty was 23.35. The EQ-5D revealed high patient satisfaction and good functional status. CONCLUSIONS: While the outcomes and cost benefits of single stage bilateral replacement are established, the risk of complications remains. This study establishes the low complication rate associated with this procedure in the senior authors' hands, and documents the high patient satisfaction. The study demonstrates that, in selected patients, simultaneous bilateral knee replacement surgery can be performed with good outcomes without a definite increase in perioperative risk.     

Prevalence of fat embolism following bilateral simultaneous and unilateral total hip arthroplasty performed with or without cement : a prospective,randomized clinical study

BACKGROUND: Controversy exists regarding the safety of bilateral simultaneous total hip arthroplasty, in part because of the potentially higher prevalence of pulmonary fat embolism. The purpose of the present study was to determine if unilateral and bilateral simultaneous total hip arthroplasty procedures resulted in different prevalences of fat embolization, different degrees of hemodynamic compromise, or different levels of hypoxemia or mental status changes. METHODS: One hundred and fifty-six consecutive patients undergoing primary total hip arthroplasty were prospectively enrolled in the study. The study group included fifty patients undergoing bilateral simultaneous total hip arthroplasty and 106 patients undergoing unilateral total hip arthroplasty. One hundred hips were treated with a cemented stem, and 106 were treated with a cementless stem. Arterial and right atrial blood samples were obtained before implantation (baseline); at one, three, five, and ten minutes after implantation of the acetabular and femoral components; and at twenty-four and forty-eight hours after the operation. Arterial blood pressure, right atrial pressure, arterial oxygen tension, and carbon-dioxide tension were also monitored at these times. The presence of lipid and cellular contents of bone marrow was determined. RESULTS: The prevalence of fat embolism was not significantly different between the groups managed with bilateral and unilateral total hip arthroplasty or between the groups managed with cemented and cementless stems. Similarly, the prevalence of bone-marrow-cell embolization was not significantly different between the groups managed with bilateral and unilateral total hip arthroplasty or between the groups managed with cemented and cementless stems. Patients with bone-marrow-cell embolization had a significantly lower arterial oxygen tension (p = 0.022) and oxygen saturation (p = 0.017) than did patients without bone-marrow-cell embolization on the first postoperative day. Four patients with bone-marrow cells in the blood samples that were obtained from the right atrium on the first postoperative day had development of diffuse encephalopathy with confusion and agitation that lasted for about twenty-four hours. CONCLUSIONS: The prevalence of fat and bone-marrow-cell embolization was similar in the groups managed with bilateral simultaneous and unilateral total hip arthroplasty as well as in the groups managed with cemented and cementless stems.     

Simultaneous bilateral total hip arthroplasty in sickle cell disease

Simultaneous bilateral uncemented total hip arthroplasty for avascular necrosis of the femoral head resulting from sickle cell disease was performed in 18 consecutive patients (36 hips). The patients were followed 2 to 10 years (mean, 5.7 years). All patients showed improvement in postoperative hip scores compared with preoperative scores for pain, range of motion, and function. There were 2 immediate postoperative complications related to sickling of red blood cells. One intraoperative fracture of the proximal femur occurred. There was 1 superficial and 1 deep infection. There was no femoral stem loosening, but 1 protrusio acetabuli occurred. One acetabular cup was revised for instability. Heterotopic ossification developed in 2 patients. Simultaneous bilateral total hip arthroplasty in sickle cell disease is a good option in a select group of patients with adequate hydration and ventilation in the perioperative and postoperative periods.     

Comparative outcomes of total joint arthroplasty

A prospective pre- and postoperative general health/quality-of-life factor comparison, using the Rand SF-36 Health Status Questionnaire (TyPE Specification, Quality Quest [Health Outcomes Institute, Minneapolis, MN]), was carried out on a consecutive series of patients with diagnosed osteoarthritis undergoing total hip and knee arthroplasty between March 1991 and March 1994. Study groups consisted of 85 total hip arthroplasty patients, 93 total knee arthroplasty patients, and 65 single-stage bilateral total knee arthroplasty patients, all treated at the same specialty hospital, under the care of three senior orthopaedic surgeons. The average patient age was 69 years. Significant improvements in quality-of-life measures including physical functioning, social functioning, role functioning/physical problem, role functioning/emotional problem, mental health, energy/fatigue, pain, and change in health were noted in all hip and knee arthroplasty patients 6 months, 1 year, and 2 years after surgery (P < .05). There appeared to be no significant differences in quality-of-life measures between hip and knee arthroplasty patients. Results therefore indicate that total hip and knee arthroplasty significantly improve the functional status and quality of life among patients suffering from osteoarthritis.     

同期双侧人工全髋关节置换术15例

目的探讨同期双侧人工全髋关节置换术的疗效。方法1999年8月～2004年3月，对15例（30髋）患者行双侧全髋关节置换术。其中男11例（22髋），女4例（8髋）；年龄35～70岁；病程1～50年（平均4．8年）。术前髋关节Harris评分12～45分，平均27分。其中5例采用Smith—Peterso切口，10例采用后路Morre切口。结果手术时间3h25min～5h，平均4h10min。术中输血400～2400ml，平均1160ml。15例均获随访3～35个月，平均18个月，髋关节术后Harris评分70～100分，平均86分，较术前平均提高59分（27～86分），差异有统计学意义（P〈0．05）。除1例患者于术后1个月因“心肌梗死”死亡外，其余患者术后均无感染、肺栓塞、深静脉栓塞、假体松动、下沉及脱位等并发症发生。患者均能独立行走，自理生活。结论同期双侧人工全髋关节置换术是一种安全有效的手术，但在选择病例时应慎重，并须作好充分的术前准备。     

One-stage bilateral total hip arthroplasty a simultaneous procedure in 79 patients

The authors retrospectively studied 79 patients who had undergone simultaneous bilateral total hip arthroplasty during the period 1982 to 1994. Forty one patients were examined clinically and radiographically at least 5 years postsurgery. The procedure was associated with few early postoperative complications and so far excellent results at 7.5 years with regard to patient satisfaction, Hip Functional Index and survival of the prostheses. It is concluded, that in selected patients with bilateral hip disease necessitating bilateral hip replacement, the bilateral operation may be advantageously carried out in one session.     

Medical Clearance Risk Rating as a Predictor of Perioperative Complications After Total Hip Arthroplasty

Hip arthroplasty has become the standard treatment of end-stage osteoarthritis. However, postoperative complications are the risks associated with joint arthroplasty, which most significantly impact patient results and the total cost of care. Currently, no predictive system has been developed for categorizing levels of risk for the development of postoperative complications in patients undergoing total hip arthroplasty. We examined the association between the medical clearance risk rating by the physician performing the preoperative clearance examination and postoperative complications after total hip arthroplasty. We have demonstrated a significant association between the medical clearance risk rating and postoperative urinary track infection, and the American Society of Anesthesiologist score but no significant association to other complications. This study presents a predictive patient characteristic that may help us identify among our patients the ones that may benefit from a personally tailored preoperative planning and evaluation but demonstrates further work is necessary to better predict the risk of complications after total hip arthroplasty.     

Simultaneous bilateral versus unilateral total hip arthroplasty an outcomes analysis

This study compared the morbidity, mortality, and outcomes of 900 simultaneous bilateral total hip arthroplasties in 450 patients and 450 unilateral total hip arthroplasties. Pulmonary complications were significantly higher in the simultaneous bilateral group (1.6% vs 0.7%; P < .0312). Fourteen (3.1%) patients in the simultaneous bilateral group and 18 (4%) patients in the unilateral group died within the first postoperative year. Patients with mortality in the first postoperative year were significantly older (69.8 vs 62.3 years; P < .0012). Long-term patient survival, the prosthetic survival, and functional outcomes were not significantly different between groups. Simultaneous bilateral total hip arthroplasty has advantages where both hips are symptomatic and has less risk in younger patients with understanding of the increased risk of pulmonary complications.     

低蛋白血症延长髋膝关节置换患者住院日

目的 探讨术前低蛋白血症和初次髋膝关节置换术住院时长的相关性.方法 回顾性分析2017年8月至2019年1月在南京鼓楼医院运动医学与成人重建外科行初次人工关节置换术的患者资料,排除掉资料不全、围手术期对并发症进行过针对治疗、一期行双侧关节置换、行翻修手术、血友病性关节炎等病人,共纳入男253例,女640例,年龄范围19...     

Noncompliance in the inpatient administration of enoxaparin in conjunction with epidural or spinal anesthesia

Deep venous thrombosis is 1 of the most common postoperative complications resulting in significant mortality and morbidity in patients undergoing total hip and total knee arthroplasty. Research has shown that the effectiveness and safety of low-molecular-weight heparins depend on the timeliness of their administration, particularly when used in conjunction with spinal or epidural anesthesia, both of which are effective and safe treatment modalities for knee and hip arthroplasty. The focus of this study was to examine the compliance with current protocols in the administration of enoxaparin (Lovenox) to patients who had undergone total joint arthroplasty. We reviewed the perioperative management of patients who had a total hip or total knee arthroplasty in which there was the combined use of epidural or spinal anesthesia and enoxaparin. Our results show a 52% (26 of 50) noncompliance rate in the administration of enoxaparin as compared with the published protocol for using this treatment modality safely and effectively.     

Postoperative ileus in the lower extremity arthroplasty patient

Postoperative ileus is a recognized complication of lower extremity surgery. In a review of 21,589 patients who underwent either total hip or total knee arthroplasty between 1988 and 1997, 0.32% developed postoperative ileus. The ileus lasted >3 days in 46% of patients. The purpose of this study was to investigate the risk factors associated with ileus during 3 days after total joint arthroplasty. The average age of the patients with prolonged ileus was 69.1 years, and 70% were male. The development of a prolonged ileus was associated significantly with younger age (P<.005) and male gender (P<.02). In total knee arthroplasty, more cases of postoperative ileus were seen in bilateral surgery. Patients who are younger, male, and undergoing bilateral total knee arthroplasty are at an increased risk of having a more prolonged postoperative ileus and should be monitored closely.     

Total joint arthroplasty for steroid-induced osteonecrosis in cardiac transplant patients

Ten cardiac transplant patients have had bilateral total hip or knee surgery for treatment of osteonecrosis secondary to corticosteroid immunosuppression. Nine had bilateral total hip arthroplasty and one had bilateral total knee arthroplasty for osteonecrosis of the tibial plateaus. The only immediate postoperative complication was in a single hip patient who had a nonfatal pulmonary embolism. Two patients died from cardiovascular causes; the remaining eight had excellent results from arthroplasty, with an average Harris hip rating of 95 at a mean follow-up period of 34 months. No patient had required revision surgery and radiographic follow-up examination has revealed no evidence of loosening of any of these cemented arthroplasties. One patient developed a late hematogeneous sepsis of one hip seven years after replacement from atypical mycobacterium three months following renal transplantation, which was done 11 years after cardiac transplantation. Total joint arthroplasty has resulted in excellent clinical and radiologic results in this patient population. Despite the increased risks of major surgery in these immunocompromised transplant recipients, total joint arthroplasty appears to be a safe and effective method of treatment of osteonecrosis of the hip.     

初次全髋关节置换术后6年以上随访的临床疗效分析

目的评价初次全髋关节置换（THA）术后6年以上的临床疗效及术后的各种并发症。方法自2001年1月至2005年1月,本中心共对北京地区210例225侧髋关节进行初次THA。其中单侧髋关节置换术195例,双髋同时置换术15例。半髋置换10例,全髋关节置换术215例。骨水泥固定假体18例,非骨水泥固定假体207例。围手术期及术后处理基本一致。术后定期随访,最新的随访时间平均为6.5年（5.5~8.5年）。结果围手术期并发症包括：术中股骨干骨折6例;下肢深静脉血栓28例,无肺栓塞病例;术后伤口感染4例;术后4周内脱位3例;术后出现一过性意识障碍3例。术后平均6.5年时176例183髋得到随访,34例42髋失访。远期感染病例1例,脱位2例,股骨干骨折4例。Harris评分由术前平均40.6分（-12~59分）提高到术后平均80.4分（75~94分）。其中152例评分〉80分,19例评分位于70~80分之间,5例评分〈70分。影像学检查3例髋臼假体、4例6髋股骨假体周围出现小范围的透亮线,2例3髋发现位于髋关节周围的异位骨化。其余X线片示髋臼和股骨柄假体位置满意,无松动和感染征象。结论 THA是治疗各种晚期重度髋关节疾病很好的方法,6年以上的临床效果良好,并发症少。     

Heterotopic bone formation following hip arthroplasty: A retrospective study of 65 bilateral cases

Heterotopic bone formation after two-stage bilateral cemented total hip arthroplasty was evaluated in 65 patients (23 women and 42 men) who had not received treatment with anti-inflammatory drugs in the immediate postoperative weeks. The mean age at the first operation was 65 years, and the median interval between the two arthroplasties was 3 months. Fifty-two patients developed heterotopic ossification after the initial hip arthroplasty. Of these patients, 40 also developed ossifications after contralateral hip arthroplasty. Out of 11 males developing Grade-III heterotopic ossification after the initial hip arthroplasty, 8 also developed Grade-III ossification after contralateral hip arthroplasty. Two females developed Grade-III ossification after the initial arthroplasty, but neither of them developed a Grade-III lesion after contralateral total hip arthroplasty. Males with Grade-III heterotopic ossification after the initial hip arthroplasty were shown to be at a high risk of developing the same severe lesion after contralateral total hip arthroplasty, making them candidates for postoperative prophylaxis.     

Preoperative lower limb venography in patients undergoing total hip arthroplasty

Using bilateral ascending venography, the authors examined 93 consecutive patients undergoing total hip arthroplasty for the presence of asymptomatic preoperative leg vein thrombosis. Radiologic abnormalities were seen in only four patients, and this was not statistically significant (P greater than .1). There were no complications from the procedure. It is suggested that routine preoperative screening for deep vein thrombosis prior to hip arthroplasty is unnecessary but may be appropriate in patients at particularly high risk for thromboembolic complications.     

Heterotopic bone formation following hip arthroplasty. A retrospective study of 65 bilateral cases

Heterotopic bone formation after two-stage bilateral cemented total hip arthroplasty was evaluated in 65 patients (23 women and 42 men) who had not received treatment with antiinflammatory drugs in the immediate postoperative weeks. The mean age at the first operation was 65 years, and the median interval between the two arthroplasties was 3 months. Fifty-two patients developed heterotopic ossification after the initial hip arthroplasty. Of these patients, 40 also developed ossifications after contralateral hip arthroplasty. Out of 11 males developing Grade-III heterotopic ossification after the initial hip arthroplasty, 8 also developed Grade-III ossification after contralateral hip arthroplasty. Two females developed Grade-III ossification after the initial arthroplasty, but neither of them developed a Grade-III lesion after contralateral total hip arthroplasty. Males with Grade-III heterotopic ossification after the initial hip arthroplasty were shown to be at a high risk of developing the same severe lesion after contralateral total hip arthroplasty, making them candidates for postoperative prophylaxis.     

Drainage versus nondrainage in simultaneous bilateral total hip arthroplasties

A prospective study of 48 patients (96 hips) who had undergone primary simultaneous bilateral total hip arthroplasty was conducted to assess the effect of postoperative suction drainage on wound healing and infection. A suction drain was placed by randomization of the drained versus undrained side. The same surgical technique was used in all total hip arthroplasty wounds. Statistical analysis of the results showed significant differences with respect to drainage from the wound, soaked dressings requiring reinforcements, ecchymosis, and erythema about the wound in the group without drainage. There was no specific correlation between the incidence of wound complications and infection after total hip arthroplasty and the use or nonuse of closed-suction drainage. The hip score and range of motion of the hip were unaffected by the use or nonuse of the drains. The cost of 1 set of hemovac drains is $135 and the cost for 4–5 dressings and bed sheet changes is about $50. Although the hemovac is more expensive, the authors recommend the routine use of suction drains for wounds after primary total hip arthroplasty to reduce drainage, soaked dressings requiring reinforcement, ecchymosis and erythema around the wound, and psychological impact on the patient's fear of bleeding.