Simultaneous bilateral total knee arthroplasties: who decides?

The purpose of the current retrospective review was to compare the results of 1498 patients having 1090 simultaneous bilateral total knee arthroplasties and 958 unilateral total knee arthroplasties in a 3-year period, focusing on perioperative complications, length of hospital stay, and discharge disposition. Gender, age, diagnosis, and weight were similar between the groups. Patients undergoing simultaneous bilateral total knee arthroplasties had statistically significant higher amounts of intraoperative blood loss, with more patients requiring blood transfusion, and a higher average number of units of blood transfused compared with patients undergoing unilateral total knee arthroplasty. Overall, a significantly higher incidence of gastrointestinal complications was reported in patients who had simultaneous bilateral knee arthroplasties compared with patients who had unilateral knee arthroplasty. Comparing age subgroups within the unilateral group revealed significantly higher incidences of pulmonary, neurologic, cardiac, and genitourinary complications among patients 80 years or older versus patients younger than 80 years. Patients having simultaneous bilateral arthroplasties who were 80 years or older had significantly higher incidences of pulmonary, neurologic, and cardiac complications than patients younger than 80 years in that same group. These results suggest that age, not procedure, has a more significant role in the perioperative morbidity of total knee arthroplasty. Based on the results from the current study and previous literature documenting patient preference, patient satisfaction, efficacy, and outcomes comparable with those of patients having unilateral total knee arthroplasty, the authors continue to offer patients the option of simultaneous bilateral total knee arthroplasties.     

同期双侧与单侧全膝关节置换治疗膝骨关节炎的比较

[目的]比较同期双侧与单侧全膝关节置换术的安全性及临床疗效.[方法]回顾性分析2000年5月～2009年5月,因骨关节炎行硬膜外麻醉下初次全膝关节置换术患者705例,按同期双侧置换(268例)和单侧置换(437例)分为两组,比较两组患者的围手术期并发症、术后失血量、输血量、住院时间、费用与KSS临床及功能评分等各项指标.[结果]存在围手术期并发症的患者比例,双侧组(15.6％)高于单侧组(7.8％),其中心血管系统并发症发生率双侧组(7.3％)高于单侧组(3.2％).感染、死亡、肺栓塞等围手术期并发症发生率,两组之间差异无统计学意义.术后失血量及输血量双侧组高于单侧组.术后2年KSS临床评分两组间差异无统计学意义,KSS功能评分,双侧组高于单侧组,差异有统计学意义.[结论]对于双侧膝骨关节炎的患者,在硬膜外麻醉下行同期双侧全膝关节置换术经济、高效,且有理想的手术疗效.术前应对患者做全面健康评估,对存在严重合并症,尤其是心血管系统疾病患者,应尽量避免行同期双侧全膝关节置换术.     

Simultaneous bilateral,staged bilateral,and unilateral total knee arthroplasty. A survival analysis

BACKGROUND: The rates of perioperative morbidity and mortality are areas of concern associated with simultaneous bilateral total knee replacement. The purpose of this paper was to compare the rates of morbidity and mortality and the clinical outcome in large groups of consecutive patients undergoing simultaneous bilateral total knee replacement, unilateral total knee replacement, or staged bilateral total knee replacement. METHODS: A total of 6200 total knee replacements, performed in 3998 patients between 1983 and 2000, consisted of 2050 simultaneous bilateral, 1796 unilateral, and 152 staged bilateral total knee replacements. A review of each group was conducted to compare the rates of morbidity and mortality, the survival of the prosthesis, and the clinical outcome. Kaplan-Meier survival analyses were performed with failure defined as revision because of aseptic loosening and as patient death. Complications and Knee Society scores were compared throughout the fifteen-year follow-up period (average, 4.3 years of follow-up). RESULTS: The unilateral group had significantly lower Knee Society scores than the simultaneous bilateral group (p < 0.0001 up to twelve years, and p = 0.0067 at fifteen years) across all postoperative time-intervals. The percentage of patients who had thrombophlebitis was significantly higher in the simultaneous bilateral group (0.9%) than in the unilateral group (0.3%) (p = 0.0326). No significant differences were found with regard to prosthetic failure, cardiac complications, and the rates of death in the three groups. Ten years postoperatively, the simultaneous bilateral group had a significantly higher rate of patient survival than did the unilateral group (78.6% compared with 72.0%) (p = 0.0062). CONCLUSIONS: The significantly higher rate of thrombophlebitis in the simultaneous bilateral group compared with that in the unilateral group may represent a greater risk to those patients. However, we believe that when there are adequate indications for bilateral total knee replacement, simultaneous bilateral arthroplasty is beneficial to patients, with a minimal increase in the risk of death or other complications compared with that associated with unilateral and staged procedures.     

Is obesity a contraindication to bilateral total knee arthroplasties under one anesthetic?

Three-hundred sixteen patients who underwent 405 primary knee replacements between January 1994 and June 1999 were reviewed for the incidence of local wound and systemic complications after unilateral and simultaneous bilateral total knee arthroplasties. A body mass index of 30 or greater was used to define obesity, and patients were divided into four groups based on obesity and whether they were undergoing unilateral or bilateral total knee arthroplasties. Preoperative and postoperative knee scores were not significantly different for any patient group. Local wound complication rates did not differ between any of the study groups. Patients who were not obese who underwent unilateral total knee arthroplasty had lower systemic complication rates (3%) than the other groups; however, there was no significant difference in complication rates between patients with obesity who underwent unilateral or simultaneous bilateral total knee arthroplasties. Based on these findings, obesity does not seem to be a contraindication to bilateral total knee arthroplasties under one anesthetic.     

Perioperative safety of two-team simultaneous bilateral total knee arthroplasty in the obese patient

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.     

The relative safety of one-stage bilateral total knee arthroplasty

Patients with osteoarthritis of the knee often require bilateral knee replacement before fulfilling their full ambulatory potential. Despite extensive research there is considerable debate about the risks of performing simultaneous bilateral knee replacements under the same anaesthetic. Our aim was to compare the relative short-term morbidity of one-stage bilateral with unilateral total knee arthroplasty in a retrospective, consecutive cohort of patients. Seventy-two bilateral knee replacements were case-matched for age and gender with 144 unilateral knees. One-stage bilateral arthroplasty was associated with increased morbidity with respect to wound (6.0 vs 0.7%; p = 0.003) and deep prosthetic (3.5% vs 0.7 %; p = 0.02) infections, cardiac complications (3.5% vs 0.7%; p = 0.04) and chest infections (7.0% vs 1.4%; p = 0.04). No differences were observed in the mortality rates (p = 0.30) and risk of thrombo-embolism (p = 0.70). We conclude that one-stage bilateral total knee arthroplasty is associated with increased morbidity compared with unilateral knee replacement.     

Cost comparison between bilateral simultaneous,staged, and unilateral total joint arthroplasty

A hospital-based computer system was used to compare the inpatient costs of performing bilateral simultaneous sequential, staged, and unilateral total hip and knee arthroplasties. Bilateral simultaneous sequential total knee arthroplasty was 36% less costly than 2 unilateral total knee arthroplasties. Bilateral simultaneous sequential total hip arthroplasty saved 25% over the costs of performing 2 unilateral hip arthroplasties. Prosthetic costs range between 28% and 43% of the total costs of hospitalization. There was a significant correlation between hospital length of stay, morbidity, and total costs, but no correlation with patient age and sex except in the unilateral knee patients. Bilateral simultaneous sequential joint arthroplasty can save more than $10,000 for each total knee patient and more than $8,000 for each total hip patient.     

Perioperative morbidity and mortality of 2-team simultaneous bilateral total knee arthroplasty

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.     

一期双膝关节与单膝关节置换术围手术期并发症比较

目的 比较一期双膝关节与单膝关节置换术的围手术期并发症.方法 1996年10月至2006年10月,行初次全膝关节置换术的患者497例,男112例,女385例;年龄24～86岁,平均66岁;行一期双膝关节置换术171例,单膝关节置换术326例.比较两组患者的术前合并症、围手术期并发症等.结果 两组患者平均年龄、性别比例及术前合并症比较,差异均无统计学意义.一期双膝关节置换术后平均出血量为1050.90 ml(963.36～1138.44 ml),输血量为400～2800 ml;单膝关节置换术后平均出血量为466.75 ml(444.85～488.65 ml),输血量为0～1200 ml.一期双膝关节置换术与单膝关节置换术后出血量及输血量比较,差异有统计学意义.围手术期深静脉血栓形成和肺栓塞的发生率、消化系统并发症的发生率、浅表伤口愈合不良的发生率及术后2年深部感染的发生率比较,差异无统计学意义.一期双膝关节置换术与单膝关节置换术相比,术后心血管系统并发症(P=0.0003)及神经系统并发症(P=0.0356)的发生率增高.结论 术前对患者进行全面的健康评估,积极治疗术前合并症,对降低一期双膝关节置换术的风险至关重要.当患者术前存在心脑血管合并症时,应避免采用一期双膝关节置换术.对于存在高风险的患者,术前应向其充分交待手术风险及术中有临时决定改为分期手术的可能.     

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.     

一期与分期双膝关节置换术围手术期风险的比较研究

目的 比较一期双膝关节置换术与分期双膝关节置换术的围手术期并发症的发生率,评价一期双膝关节置换术的安全性.方法 回顾性分析1996年10月至2006年10月接受双膝初次全膝关节置换术的219例患者的临床资料,其中一期双膝关节置换术171例,分期双膝关节置换术48例(B组),按B组年龄性别构成从前者171例患者中1:1匹配抽取48例为A组,与B组进行比较.比较两组术前全身合并症和术后围手术期并发症(B组统计两次手术的累加值)发生情况.结果 匹配后A组和B组的术前全身合并症情况比较差异无统计学意义(P＞0.05),但围手术期A组的心脑血管并发症的发生率较B组增高,差异具有统计学意义(P＜0.05).结论 一期双膝关节置换术前应仔细评估术前全身状况,充分说明手术风险,并积极预防围手术期并发症的发生.     

Thirty-day mortality after total knee arthroplasty

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

Complications and mortality associated with bilateral or unilateral total knee arthroplasty

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

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.     

A comparison of bilateral uncemented total knee arthroplasty: simultaneous or staged?

In a series of 1304 patients (1867 knees), the results of simultaneous and staged bilateral total knee arthroplasty were compared with each other and with unilateral total knee arthroplasty. The bilateral procedures had a significantly higher rate of complications than unilateral procedures, almost entirely because of thromboembolic problems. However, this did not correspond to an increase in mortality. If a bilateral procedure was indicated, then a simultaneous procedure had no increased risk over a staged procedure. There was no increase in cardiovascular complications, the rate of deep-vein thrombosis or pulmonary embolism or mortality. The rate of infection was lower with a bilateral procedure and the overall revision rate was less than 1% in all groups. The prosthesis functioned as well in all groups in the medium and longer term periods.We feel that simultaneous bilateral total knee arthroplasty is a safe and successful procedure when compared with a staged bilateral procedure. It also has the added benefit of single anaesthetic, reduced costs and decreased total recovery time when compared to a staged bilateral procedure. For these reasons it should be considered as an option in the presence of bilateral knee joint disease.     

Safety and efficacy of bilateral total knee arthroplasty

Recent studies have reported increased morbidity associated with bilateral simultaneous total knee arthroplasty (TKA). The purpose of this study was to evaluate the morbidity and clinical outcome associated with simultaneous bilateral TKA in contrast to unilateral TKA. All primary TKAs, either unilateral or simultaneous bilateral, performed between May 1988 and July 1993 were retrospectively reviewed. Patients were evaluated using Knee Society scores both before surgery and a minimum of 6 months after surgery. In addition to routine demographics, patients were evaluated for the incidence of both local wound and systemic complications. It is concluded that performing simultaneous bilateral TKA does not result in any significant increase in patient morbidity or compromise in postoperative function when compared with unilateral TKA.     

Total knee arthroplasty in patients with liver cirrhosis

BACKGROUND: Patients with liver cirrhosis have an increased risk of surgical morbidity and mortality. We are aware of no study that has investigated the risks and outcomes of elective orthopaedic procedures in these patients. The purposes of the present study were to review the results of total knee arthroplasty in patients with cirrhosis and to identify risk factors leading to poor results. METHODS: Fifty-one patients with cirrhosis who had undergone sixty total knee arthroplasties for osteoarthritis were studied. The medical records and laboratory data were collected retrospectively. All data were compared with those for matched patients without cirrhosis. Forty-two patients (fifty-one knees) with complete follow-up were evaluated with regard to complications, mortality, and factors leading to poor results. RESULTS: Total knee arthroplasty was associated with significantly more blood loss, a longer hospital stay, more complications, and a higher mortality rate in patients with cirrhosis as compared with control patients (p 相似文献   

Are Postoperative Complications More Common with Single-Stage Bilateral (SBTKR) Than with Unilateral Knee Arthroplasty: Guidelines for Patients Scheduled for SBTKR

A significant number of patients with degenerative arthritis of the knee require bilateral knee arthroplasty. Single-stage bilateral total knee arthroplasty (SBTKR) has been associated with increased patient morbidity and mortality. At our institution, the following steps have been taken to minimize the risks to patients undergoing this procedure: regional anesthesia and analgesia, invasive monitoring, postoperative observation in an intensive care unit setting, and aggressive management of hemodynamic aberrations. We reviewed the medical records of 462 sequential total knee arthroplasty patients, consisting of 169 SBTKR and 293 unilateral total knee arthroplasty (UTKR) cases. A total of 122 patients from each group were matched for age, weight, and a history of ischemic heart disease and hypertension. Patients for SBTKR exhibited a significantly higher incidence of fat embolism syndrome and cardiac arrhythmias than UTKR patients. There were no deaths in either group and the incidence of other serious postoperative complications was low and similar between the two groups. Elderly patients (∼75 years old) had more postoperative complications. With aggressive clinical management SBTKR can be safely performed in selected patients. Guidelines for the selection of these patients are presented.     

Safety of simultaneous bilateral total knee arthroplasty. A meta-analysis

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.     

Simultaneous revision and contralateral primary total knee arthroplasty

BACKGROUND: There is controversy regarding whether simultaneous or staged bilateral total knee arthroplasty should be performed in patients with bilateral gonarthrosis. In addition, revision total knee arthroplasties have been less successful than primary arthroplasties. The purpose of this study was to evaluate the results of simultaneous revision and contralateral primary total knee arthroplasties performed during the same setting. METHODS: The study cohort included 150 knees in seventy-five patients who had undergone revision arthroplasty because of aseptic failure of a total knee arthroplasty and a contralateral primary arthroplasty for severe gonarthrosis under the same anesthetic. The study group was compared with a control group of sixty patients who had severe arthritis in one knee and had undergone unilateral revision total knee arthroplasty on the contralateral side. The duration of follow-up averaged five years in the group treated with the simultaneous arthroplasties and eight years in the control group. Clinical and radiographic results were evaluated with the Knee Society rating system. RESULTS: In the study group, the average knee score improved by 48 points on the side of the primary arthroplasty and by 37 points on the side of the revision. At the last follow-up visit, most (sixty-five) of the seventy-five patients stated that the knee with the revision felt better than the knee with the simultaneously performed primary arthroplasty. In the control group, the average knee score improved by 30 points on the side of the revision arthroplasty. However, forty-five of the sixty patients had a primary total knee arthroplasty on the contralateral side within two years after the index revision arthroplasty; by four years, all sixty patients had undergone a contralateral primary arthroplasty. CONCLUSIONS: We found a favorable outcome in patients who had undergone simultaneous revision and contralateral primary total knee arthroplasties. Despite a lower mean knee score and less motion, most patients seemed to prefer the knee with the revision arthroplasty to the knee with the primary procedure. These results suggest that this combined procedure is a safe and favorable alternative to a staged procedure consisting of revision and subsequent contralateral primary total knee arthroplasty.