Bilateral vs Unilateral Total Knee Arthroplasty: Racial Variation in Utilization and In-Hospital Major Complication Rates

BackgroundWe sought to examine bilateral total knee arthroplasty (BTKA) vs unilateral TKA (UTKA) utilization and in-hospital complications comparing African Americans (AAs) and Whites.MethodsIn this retrospective analysis of patients ≥50 years who underwent elective primary TKA, the (2007-2016) database of the Healthcare Cost and Utilization Project (National Inpatient Sample) was used. We computed differences in temporal trends in utilization and major in-hospital complication rates of BTKA vs UTKA comparing AAs and Whites. We performed multivariable logistic regression models to assess racial differences in trends adjusting for individual-, hospital- and community-level variables. Discharge weights were used to enable nationwide estimates. We used multiple imputation procedures to impute values for 12% missing race information.ResultsAn estimated 276,194 BTKA and 5,528,429 UTKA were performed in the US. The proportion of BTKA among all TKAs declined, and AAs were significantly less likely to undergo BTKA compared to Whites throughout the study period (trend P = .01). In-hospital complication rates for UTKA were higher in AAs compared to Whites throughout the study period (trend P < .0001). However, for BTKA, the in-hospital complication rates varied between Whites and AAs throughout the study period (trend P = .09).ConclusionIn this nationwide sample of patients who underwent total knee arthroplasty from 2007 to 2016, the utilization of BTKA was higher in Whites compared to AAs. On the other hand, while AAs have consistently higher in-hospital complication rates in UTKA over the time period, this pattern was not consistent for BTKA.     

Should we use similar perioperative protocols in patients undergoing unilateral and bilateral one-stage total knee arthroplasty?

BACKGROUNDBilateral one-stage total knee arthroplasty (BTKA) is now in greater use as an alternative option for patients with bilateral end-stage knee arthropathy. However, postoperative pain and disablement during convalescence from BTKA, and procedure-related complications have been concerning issues for patients and surgeons. Although some studies reported that BTKA in selected patients is as safe as the staged procedure, well-defined guidelines for patient screening, and perioperative care and monitoring to avoid procedure-related complications are still controversial.AIMTo compare the perioperative outcomes including perioperative blood loss (PBL), cardiac biomarkers, pain intensity, functional recovery, and complications between unilateral total knee arthroplasty (UTKA) and BTKA performed with a similar perioperative protocol. METHODSWe conducted a retrospective study on consecutive patients undergoing UTKA and BTKA that had been performed by a single surgeon with identical perioperative protocols. The exclusion criteria of this study included patients with an American Society of Anesthesiologists score > 3, and known cardiopulmonary comorbidity or high-sensitivity Troponin-T (hs-TnT) > 14 ng/L. Outcome measures included visual analogue scale (VAS) score of postoperative pain, morphine consumption, range of knee motion, straight leg raise (SLR), length of stay (LOS), and serum hemoglobin (Hb) and hs-TnT monitored during hospitalization. RESULTSOf 210 UTKA and 137 BTKA patients, those in the BTKA group were younger and more predominately female. The PBL of the UTKA vs BTKA group was 646.45 ± 272.26 mL vs 1012.40 ± 391.95 mL (P < 0.01), and blood transfusion rates were 10.48% and 40.88% (P < 0.01), respectively. Preoperative Hb and body mass index were predictive factors for blood transfusion in BTKA, whereas preoperative Hb was only a determinant in UTKA patients. The BTKA group had significantly higher VAS scores than the UTKA group at 48, 72, and 96 h after surgery, and also had a significantly lower degree of SLR at 72 h. The BTKA group also had a significantly longer LOS than the UTKA group. Of the patients who had undergone the procedure, 5.71% of the UTKA patients and 12.41% of the BTKA patients (P = 0.04) had hs-TnT > 14 ng/L during the first 72 h postoperatively. However, there was no difference in other outcome measures and complications. CONCLUSIONFollowing similar perioperative management, the blood transfusion rate in BTKA is 4-fold that required in UTKA. Also, BTKA is associated with higher pain intensity at 48 h postoperatively and prolonged LOS when compared to the UTKA. Hence, BTKA patients may require more extensive perioperative management for blood loss and pain, even if having no higher risk of complications than UTKA.     

Comparing the Safety and Outcome of Simultaneous and Staged Bilateral Total Knee Arthroplasty in Contemporary Practice: A Systematic Review of the Literature

BackgroundAlthough a variety of studies have assessed the outcomes of simultaneous bilateral total knee arthroplasty (BTKA) and staged BTKA, there remains no definitive conclusion regarding the superiority of one technique in terms of safety.MethodsThe US National Library of Medicine (PubMed/MEDLINE), EMBASE, and the Cochrane Database of Systematic Reviews were queried utilizing keywords pertinent to BTKA, simultaneous and staged, and clinical or functional outcomes. In order to examine the contemporary relevant literature, studies published prior to 2009 were excluded from our search.ResultsIn total, 19 articles met the inclusion criteria and were included in this analysis. The overall quality of the studies included in this review was rated as moderate. Seven of the 19 studies reported no significant differences between the 2 groups in regards to baseline clinical and demographic characteristics (comorbidity index, American Society of Anesthesiologists grade, preoperative clinical subjective scores). Nearly all from these 7 studies with comparable initial characteristics documented no significant differences in the overall complication rates between the 2 groups in addition to no difference in mortality rate, cardiac complications, revision rate, thromboembolic events, and functional outcomes.ConclusionIn contemporary studies involving comparable baseline demographics (including comorbidity index, American Society of Anesthesiologists grade), there was moderate evidence to show that simultaneous BTKA is as safe as the staged BTKA.     

Staged Versus Simultaneous Bilateral Knee Arthroplasty: Does Minimal Cost Difference Justify Risks?

BackgroundSimultaneous bilateral total knee arthroplasty (BTKA) is associated with a higher risk but can be perceived to afford faster improvement and mitigated costs versus staged BTKA. We aimed to explore (1) health care utilization, (2) surgical supply costs of simultaneous BTKA; and (3) 1-year improvement in patient-reported pain, function, and quality of life (QOL) versus staged BTKA.MethodsA prospective cohort of 198 simultaneous and 625 staged BTKAs was obtained (2016-2020). Simultaneous BTKA cohort was propensity score-matched (1:2) to a similar group of staged patients (simultaneous = 198 versus staged = 396). Outcomes included length of stay, discharge disposition, 90-day readmission, 1-year reoperation, surgical episode supply cost, Knee Injury and Osteoarthritis Outcome Score (KOOS)-pain, KOOS-Physical Function Short Form, and KOOS-QOL. Rates of attaining minimal clinically important difference and Patient Acceptable Symptomatic State were calculated.ResultsCompared to both staged BTKA surgeries combined, simultaneous BTKA demonstrated shorter median net length of stay (2.00 [2.00, 3.00] days versus 2.00 [2.00, 4.00] days; P < .001) but higher rates of nonhome discharge (n = 56 [28.3%] versus n = 32 [4.04%]; P < .001), 90-day readmission (n = 20 [10.1%] versus n = 48 [6.06%]; P = .047) and similar reoperation rates (P = .44). Simultaneous BTKA afforded slight reduction in net surgical cost compared to that of both staged BTKAs combined ($643; P = .028). There was no significant difference in 1-year improvement and minimal clinically important difference attainment rates with simultaneous versus staged BTKA for KOOS-pain (P = .137 and P = .99), KOOS-QOL (P = .095 and P = .81), or KOOS-Physical Function Short Form (P = .75 and P = .49, respectively) or Patient Acceptable Symptomatic State (P = .12).ConclusionStaged BTKA is associated with similar 1-year pain, function, and QOL at a better safety profile and minimal surgical supply cost increase compared to simultaneous BTKA.     

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.     

Trends in Same-Day Bilateral Total Knee Arthroplasty

Between 2000 and 2009 demographics, comorbidity, complications, and 30-day mortality following same-day BTKA (SBTKA) in two high-volume institutions were obtained. Two 5-year periods were created to facilitate trend analysis. The percentage of SBTKA decreased by 36.2% in the latter period. A decline in mean age reflected mainly by a 50% decrease in patients > 75 years was observed. The average LOS decreased (5.7 vs. 4.5 days). Overall, selected patients were healthier in the second period. The prevalence of CAD and obesity decreased, whereas hypercholesteremia increased. The overall complication rate decreased by 55.5%; reduction in cardiac adverse events and acute posthemorrhagic anemia was observed. The rate of PE and 30-day mortality was unchanged with time. A need for more selective preoperative screening for potential candidates of SBTKAs is indicated.     

Improvement in Sleep Patterns After Hip and Knee Arthroplasty: A Prospective Study in 780 Patients

BackgroundThis study assessed change in sleep patterns before and after total hip arthroplasty (THA) and total knee arthroplasty (TKA) and its relationship to patient-reported outcome measures (PROMs).MethodsBetween July 2016 and June 2018, surgical data and PROMs were collected on 780 subjects before and 12 months after THA or TKA. PROMs included Knee Injury and Osteoarthritis Outcome Score, Hip Disability and Osteoarthritis Outcome Score, patient satisfaction, and 2 questions from the Pittsburgh Sleep Quality Index.ResultsBefore surgery, 35% (270 of 780) reported poor quality sleep. Sleep quality and duration were worse in females over males, and in THA patients (39%) over TKA patients (30%; P = .011). Of those reporting bad sleep, 74% (201 of 270) were improved after arthroplasty. Satisfaction was higher in subjects reporting good sleep quality (626 of 676; 93%) compared with those reporting bad sleep quality (67 of 86; 78%) (P = .001). Sleep was positively correlated with better Hip Disability and Osteoarthritis Outcome Score/Knee Injury and Osteoarthritis Outcome Score (r = 0.2-0.3).ConclusionImprovement in sleep quality and duration can be expected after THA and TKA and is associated with better outcome scores and satisfaction.     

Negative Association of Subclinical Hypothyroidism on Improvement in Patient-Reported Outcomes After Total Knee Arthroplasty

BackgroundThe purpose of this study is to analyze the potential influence of subclinical hypothyroidism (SCH) on improvement in patient-reported outcome measures following primary total knee arthroplasty.MethodsA prospective, comparative cohort study between 92 SCH and 90 euthyroid patients was performed. Patients were followed up to 5 postoperative years. Patient-reported outcome measure was assessed by the Western Ontario and McMaster Universities Osteoarthritis Index questionnaire. The Knee Society Scores were used for functional evaluation, and 5-point Likert scale for patient satisfaction. The Hospital Anxiety and Depression scale was also used.ResultsAll outcome scores significantly improved from preoperative to final follow-up in both groups (P = .001). There were no significant differences between groups in Knee Society Scores (P = .057) at the final follow-up, but Western Ontario and McMaster Universities Osteoarthritis Index scores were significantly lower in the SCH group (P = .015). Likewise, the patient satisfaction rate was significant lower in the SCH group (0.010).ConclusionSCH patients have a slower functional recovery than euthyroid patients, and trended toward lower improvements in patient-reported scores. Depression was the most important negative factor. The findings of this study can provide the surgeon with an important information for better counseling the SCH patients.     

Does Different Time Interval Between Staggered Bilateral Total Knee Arthroplasty Affect Perioperative Outcome? A Retrospective Study

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.     

Simultaneous Bilateral Knee Arthroplasty in Octogenarians: Can It Be Safe and Effective?

Simultaneous bilateral knee arthroplasty (SBTKA) in octogenarians is controversial. Our purpose was to review the outcomes of octogenarians undergoing SBTKA. All patients greater than 80 years of age who underwent SBTKA by a single surgeon were retrospectively evaluated. Fifty-six patients with an average age of 82.5 years were identified. Twelve postoperative complications occurred. Three were serious; two non-fatal PEs and one wound debridement. Minor complications included UTI, decubitus ulcer, DVT, confusion, transfusion reaction and ileus. Average postoperative survival was 7.4 years. No deaths occurred within 30 days postoperatively. Simultaneous bilateral total knee arthroplasty can be a safe and effective option for octogenarians. Complications and mortality are not higher for SBTKA compared to UTKA in this population.     

Natural Language Processing of Patient-Experience Comments After Primary Total Knee Arthroplasty

BackgroundThere is interest in improving patient experience after total knee arthroplasty (TKA) due to recent shifts toward value-based medicine. Patient narratives are a valuable but unexplored source of information.MethodsRecords of 319 patients who had undergone primary TKA between August 2016 and August 2019 were linked with vendor-supplied patient satisfaction data, which included patient comments and the Press Ganey satisfaction survey. Using machine-learning-based natural language processing, 1048 patient comments were analyzed for sentiment and classified into themes. Postoperative outcomes, patient-reported outcome measures, and traditional measures of satisfaction were compared between patients who provided a negative comment vs those who did not (positive, neutral, mixed grouped together). Multivariable regression was used to determine perioperative variables associated with providing a negative comment.ResultsOf the 1048 patient comments, 25% were negative, 58% were positive, 8% were mixed, and 9% were neutral. Top 2 themes of negative comments were room condition (25%) and inefficient communication (23%). There were no differences in most of the studied outcomes (eg, peak pain intensity, length of stay, or Knee Injury and Osteoarthritis Outcome Score Junior and pain scores at 6-week follow-up) between the 2 cohorts (P > .05). However, patients who made negative comments were less likely to highly recommend their hospital care to peers (P < .001). Finally, patients who had higher American Society of Anesthesiologists Score and those who received a scopolamine patch were more likely to provide negative comments (P < .05).ConclusionAlthough the current study showed that patient satisfaction might not be a proxy for traditional objective perioperative outcomes, efforts to improve the nontechnical aspects of medicine are still crucial in providing patient-centered care.     

Cost Analysis,Complications, and Discharge Disposition Associated With Simultaneous vs Staged Bilateral Total Knee Arthroplasty

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.

Interval Between Staged Bilateral Total Knee Arthroplasties Does Not Affect Early Medical or Surgical Complications

BackgroundThe purpose of this study is to evaluate early postoperative surgical and medical complications in patients undergoing staged bilateral total knee arthroplasty (TKA) and determine if the interval to the second stage influences the risk of complications.MethodsA retrospective review was performed from 2016 through 2018 of all staged bilateral primary TKA procedures, yielding a cohort of 1005 patients (2010 TKAs). Four groups were created based on the timing of the second stage: 3 to 6 weeks, 7 to 12 weeks, 13 to 24 weeks, and >24 weeks. Clinical data compared between groups included demographics, knee range of motion, University of California, Los Angeles (UCLA) activity score, Knee Society pain score, Knee Society clinical score, and Knee Society functional score. Postoperative complications within 90 days were evaluated, with complications after the second knee being the primary outcome.ResultsThe mean follow-up after second stage was 10.7 months (range, 3 to 37 months). No significant differences were found between groups in the range of motion, Knee Society pain, Knee Society clinical score, Knee Society functional score, or University of California Los Angeles activity score in either the first or second knee. After the first knee surgery, medical complications were highest in the >24-week group. After the second knee, there were no significant difference in manipulation (P = .9), wound complications (P = .7), venous thromboembolism (P = .8), or other medical complications (P = 1) based on the interval duration.ConclusionThe interval between staged TKA did not affect early medical or surgical complications after the second stage. Early clinical and function results were not different based on timing of the second surgery.     

Satisfaction With the Process vs Outcome of Care in Total Hip and Knee Arthroplasty

BackgroundPatient satisfaction, with both process of care and outcome of care, is critical for measuring the quality and value of elective procedures such as arthroplasty. The purpose of this study is to evaluate the correlation between early postoperative satisfaction with the process of care and 2-year satisfaction with the outcome of care after total hip arthroplasty (THA) and total knee arthroplasty (TKA).MethodsWe retrospectively analyzed data from institutional arthroplasty registries. Satisfaction with the outcome of care was measured on a scale of 0-100 by a previously validated questionnaire administered 2 years postoperatively. Patient satisfaction with the process of care was measured by the Press Ganey (PG) inpatient survey, also scored 0-100. We examined the correlation between these 2 measures of satisfaction in patients who underwent primary THA or TKA.ResultsIn total, 721 TKA patients and 760 THA patients underwent surgery and completed both the PG survey and 2-year satisfaction questionnaire. The mean age was 65.1 years with a mean body mass index of 28.8 and 56% were female. The mean PG survey score for the entire cohort was 95.6. The mean 2-year satisfaction score was 90.3. The Spearman correlation coefficient between the PG survey and the 2-year satisfaction survey was 0.23 for TKA patients (P < .001) and 0.13 for THA patients (P < .001).ConclusionWe found a weak correlation between the measurement of satisfaction with the process of care surrounding hip and knee arthroplasty using the PG survey and measurement of satisfaction with the outcome of care after arthroplasty using a validated 2-year satisfaction instrument.     

Early Identification of Patient Satisfaction Two Years After Total Knee Arthroplasty

BackgroundThere are numerous reports of poor satisfaction after total knee arthroplasty (TKA), yet there is little known about when to use evidence-based models of care to improve patient outcomes.ObjectiveThis study aimed to characterize longitudinal changes in patient-reported satisfaction after TKA and to identify factors for early identification of poor satisfaction.MethodsFor a cohort of primary TKA surgeries (n = 86), patient-reported outcomes were captured one week before TKA and 6 weeks, 12 weeks, 6 months, and 1 and 2 years after TKA. “Satisfied” versus “not fully satisfied” patients were defined using a binary response (≥90 vs <90) from a 100-point scale. Wilcoxon signed-rank tests identified changes in satisfaction between follow-up times, and longitudinal analyses examined demographic and questionnaire factors associated with satisfaction.ResultsImprovements in satisfaction occurred within the first 6 months after TKA (P ≤ 0.01). Preoperative patient-reported outcome measures alone were not predictive of satisfaction. Key factors that improved longitudinal satisfaction included higher Oxford Knee Scores (odds ratio (OR) = 2.1, P < .001), general health (EQ-VAS, OR = 1.3, P = .03), and less visual analog scale pain (VAS; OR = 1.7, P < .001). Differences in these factors between satisfied and not fully satisfied patients were identified as early as 6 weeks after surgery.ConclusionVisibly different satisfaction profiles were captured among satisfied and not fully satisfied patient responses, with differences in patient-perceived joint function, general health, and pain severity occurring as early as 6 weeks after surgery. This study provides metrics to support early identification of patients at risk of poor TKA satisfaction, enabling clinicians to apply timely targeted treatment and support interventions, with the aim of improving patient outcomes.     

Ninety-Day Morbidity and Mortality in Risk-Screened and Optimized Patients Undergoing Two-Team Fast-Track Simultaneous Bilateral TKA Compared With Unilateral TKA—A Prospective Study

Background

Simultaneous bilateral total knee arthroplasty (SBTKA) offers significant socioeconomic benefits. However, retrospective studies and public health data show increased mortality and morbidity rates in patients undergoing SBTKA compared with those undergoing unilateral TKA (UTKA), and there have been recommendations against the use of SBTKA. High-volume centers, which feature careful patient selection and fast-tracked surgery, continue to perform SBTKA and have published their results in favor of the procedure. However, the quality of evidence remains poor.

Simultaneous Bilateral Total Knee Arthroplasty Is Associated With Shorter Length of Stay but Increased Mortality Compared With Staged Bilateral Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

BackgroundPrimary total knee arthroplasty (TKA) is associated with high patient satisfaction. However, controversy remains regarding the safety and efficacy of conducting simultaneous bilateral (simBTKA) versus staged bilateral TKA (staBTKA). The objective of this systematic review and meta-analysis was to evaluate the current evidence for simBTKA versus staBTKA and compare clinical outcomes including mortality, complications and length of stay (LOS).MethodsA search was performed of PubMed, MEDLINE, EMBASE and Cochrane central databases between January 2000 and March 2020. Search terms included “simultaneous,” “staged,” and “bilateral TKA.” Inclusion criteria comprised studies comparing outcomes of simBTKA versus staBTKA. Quality of included studies was assessed and meta-analyses of pooled data was conducted.Results29 articles published between 2001 and 2020 were included in qualitative synthesis from 927 potentially relevant titles, comprising 257,284 patients. 104,207 patients underwent simBTKA and 153,632 patients underwent staBTKA. simBTKA was associated with significantly increased 90-day mortality rate (P < .00001, OR 2.24, 95% CI 1.79-2.81), increased incidence of pulmonary embolism (P < .00001, OR 1.69, 95% CI 1.51-1.89), venous thrombosis (P < .00001, OR 1.33, 95% CI 1.23-1.43), and neurological complications (P = .002, OR 1.42, 95% CI 1.13-1.77). Incidence of superficial and deep infection was significantly increased with staBTKA (P = .02, P < .00001 respectively). Revision rate within one year was equivocal. Mean LOS was 2.1 days shorter for simBTKA.ConclusionSimBTKA was associated with decreased incidence of infection and LOS but increased incidence of 90-day mortality, venous thromboembolism and neurological complications. Revision rates were equivocal. Patients should be selected and counseled based on the risks respective to each strategy.     

Blood Transfusion can be Avoided in Single-Anesthetic Bilateral Total Knee Arthroplasty

BackgroundFemale gender and surgical drain use have been associated with an increased transfusion risk following single-anesthetic bilateral total knee arthroplasty (SBTKA). This study evaluated allogenic blood transfusion rates among female and male patients undergoing SBTKA with intraoperative tourniquet, tranexamic acid and contemporary blood transfusion thresholds but without surgical drain use.MethodsWe performed a retrospective electronic medical record review for 125 consecutive patients undergoing SBTKA (250 knees) between May 1, 2015 and July 10, 2021. Patient demographic characteristics (age, gender, body mass index, American Society of Anesthesiologists), preoperative and postoperative hemoglobin levels, perioperative transfusions, operative time, and hospital length of stay were compared between 76 female (60.8%) and 49 male (39.2%) patient cohorts using paired Student’s t-test or Fisher’s exact test with a P value <.05 for significance.ResultsNo patient in either gender-based cohort received a perioperative allogeneic or autologous blood transfusion (P = 1). There were no significant differences in patient demographic features or medical comorbidities. Male patients had significantly higher mean preoperative (14.7 versus 13.7 g/dL, P < .01) and postoperative (12.7 versus 11.8 g/dL, P < .01) hemoglobin levels and a shorter mean hospital length of stay (2.5 versus 3.0 days, P < .01). There was no difference in the mean operative time (154.7 versus 150.7 minutes, P = .34) or change in the hemoglobin level (2.1 versus 1.9 g/dL, P = .27).ConclusionSBTKA can be performed with a limited risk of perioperative transfusion with a combination of intraoperative tourniquet, tranexamic acid, conservative blood transfusion criteria, and avoidance of postoperative drain use. Study results were not influenced by patient gender.Level of evidenceThis is a level III, retrospective cohort study.