The safety and cost-analysis of simultaneous versus staged bilateral total knee arthroplasty in a Taiwan population

The purpose of this study was to investigate the safety of Simultaneous, bilateral TKA (SiTKA). Furthermore, we also assessed the cost reduction of SiTKA in comparison with Staged, bilateral TKA (StTKA). We retrospectively review all patients that underwent SiTKA or StTKA due to osteoarthritis (OA) or spontaneous osteonecrosis of the knee (SONK).We assessed length of stay, transfusion rate, early postoperative complications, 30-day and 90-day readmission rate, 1-year reoperation rate and the indication for reoperation. Furthermore, we analyzed the total cost of the two groups, reimbursement from the national health insurance (NHI), cost of the procedures, and net income from each case. A total of 2016 patients (1565 SiTKA and 451 StTKAs) were included in this study. There were no significant differences in terms of complication rates, 30-day and 90-day readmission, and 1-year reoperations between the two groups. The total length of stay was on average 5.0 days longer for StTKA (p<0.01). In terms of cost, all categories of medical costs were significantly lower in SiTKA, while the net hospital income was significantly higher for StTKA. In conclusion, SiTKA and StTKA have similar postoperative complication, readmission and reoperation rates, while SiTKA significantly reduces medical expenses for the patient and NHI. Level of evidence: level III, retrospective cohort study

Simultaneous bilateral total knee arthroplasty

Aims Simultaneous bilateral total knee arthroplasty (TKA) has been used due to its financial advantages, overall resource usage, and convenience for the patient. The training model where a trainee performs the first TKA, followed by the trainer surgeon performing the second TKA, is a unique model to our institution. This study aims to analyze the functional and clinical outcomes of bilateral simultaneous TKA when performed by a trainee or a supervising surgeon, and also to assess these outcomes based on which side was done by the trainee or by the surgeon. Methods This was a retrospective cohort study of all simultaneous bilateral TKAs performed by a single surgeon in an academic institution between May 2003 and November 2017. Exclusion criteria were the use of partial knee arthroplasty procedures, staged bilateral procedures, and procedures not performed by the senior author on one side and the trainee on another. Primary clinical outcomes of interest included revision and re-revision. Primary functional outcomes included the Oxford Knee Score (OKS) and patient satisfaction scores. Results In total, 315 patients (630 knees) were included for analysis. Of these, functional scores were available for 189 patients (378 knees). There was a 1.9% (n = 12) all-cause revision rate for all knees. Overall, 12 knees in ten patients were revised, and both right and left knees were revised in two patients. The OKS and patient satisfaction scores were comparable for trainees and supervising surgeons. A majority of patients (88%, n = 166) were either highly likely (67%, n = 127) or likely (21%, n = 39) to recommend bilateral TKAs to a friend. Conclusion Simultaneous bilateral TKA can be used as an effective teaching model for trainees without any significant impact on patient clinical or functional outcomes. Excellent functional and clinical outcomes in both knees, regardless of whether the performing surgeon is a trainee or supervising surgeon, can be achieved with simultaneous bilateral TKA. Cite this article: Bone Jt Open 2022;3(1):29–34.

Comparison of functional outcome of simultaneous and staged bilateral total knee arthroplasty : systematic review of literature

Safety of simultaneous bilateral TKA (simBTKA) and staged BTKA (staBTKA) have been compared in previous systematic reviews but functional outcome remains neglected aspect of the debate. We performed a systematic review of contemporary literature to compare the functional outcome of simBTKA and staBTKA. We searched PubMed/MEDLINE, EMBASE and Cochrane Central Database to identify all articles published between 2000 and July 2020 that evaluated the outcome of patients undergoing BTKA either in simultaneous or staged manner. Ten articles were identified which met the inclusion criteria. Functional outcome was reported in terms of Knee Society score (KSS), range of motion (ROM), Oxford Knee Score (OKS) and Western Ontario and McMaster University score (WOMAC) in seven, five, four and two studies respectively. KSS gained on average 66.6 points (47.5-95.3) for simBTKA and 65.1 points (44.4-97.2) for staBTKA without significant difference between two groups. There was no difference in post-operative ROM (maximum post-operative flexion being 124.4 and 125.1 for simBTKA and staBTKA groups respectively). Mean improvement in OKS ranged from 20 to 32.6 for simBTKA and 21.6 to 33.1 for staBTKA. There was moderate evidence to suggest that both simultaneous BTKA and staged BTKA produce equivalent improvement in functional scores.

Simultaneous Bilateral Traumatic Tibial Post Fracture in Total Knee Arthroplasties: A Case Report

Fracture of tibial post after a posterior stabilized total knee arthroplasty (TKA) is an uncommon complication. We report a case of a patient who presented with simultaneous bilateral TKA tibial post fractures after a fall from height. To our knowledge, this is the first report of bilateral traumatic TKA tibial post fractures. We also demonstrate the utility of MRI scans in diagnosing this injury; an imaging modality which may not be considered by most surgeons due to metal artifact. There are also implications regarding the availability of prosthetic components after a TKA design is no longer marketed.

Differences in time to return to work among patients undergoing simultaneous versus staged bilateral total knee arthroplasty

Aims Many patients undergoing total knee arthroplasty (TKA) have severe osteoarthritis (OA) in both knees and may consider either simultaneous or staged bilateral TKA. The implications of simultaneous versus staged bilateral TKA for return to work are not well understood. We hypothesized that employed patients who underwent simultaneous bilateral TKA would have significantly fewer days missed from work compared with the sum of days missed from each operation for patients who underwent staged bilateral TKA. Methods The prospective arthroplasty registry at the Hospital for Special Surgery was used. Baseline characteristics and patient-reported outcome scores were evaluated. We used a linear regression model, adjusting for potential confounding variables including age, sex, preoperative BMI, and type of work (sedentary, moderate, high activity, or strenuous), to analyze time lost from work after simultaneous compared with staged bilateral TKA. Results We identified 152 employed patients who had undergone simultaneous bilateral TKA and 61 who had undergone staged bilateral TKA, and had completed the registry’s return to work questionnaire. The simultaneous group missed a mean of 46.2 days (SD 29.1) compared with the staged group who missed a mean total of 68.0 days of work (SD 46.1) when combining both operations. This difference was statistically significant (p < 0.001). In multivariate mixed regression analysis adjusted for age, sex, BMI, American Society of Anesthesiologists status, and type of work, the simultaneous group missed a mean of 16.9 (SD 5.7) fewer days of work compared with the staged group (95% confidence interval 5.8 to 28.1; p = 0.003). Conclusion Employed patients undergoing simultaneous bilateral TKA missed a mean of 17 fewer days of work as a result of their surgical treatment and rehabilitation compared with those undergoing staged bilateral TKA. This information may be useful to surgeons counselling employed patients with bilateral OA of the knee who are considering surgical treatment. Cite this article: Bone Joint J 2021;103-B(6 Supple A):108–112.

Percutaneous periarticular analgesic injection at one day after simultaneous bilateral total knee arthroplasty: an open-label randomized control trial

Background The postoperative pain after total knee arthroplasty (TKA) remains a critical issue. The aim of this study was to assess the clinical effectiveness of percutaneous periarticular injection at 1 day following simultaneous bilateral TKA. Methods A total of 88 knees in 44 patients who underwent simultaneous bilateral TKA were randomly assigned to receive a percutaneous periarticular injection at 1 day following surgery (n = 22 patients) or no injection (n = 22 patients). In the additional injection group, we injected a solution including methylprednisolone, ropivacaine, and epinephrine into the muscle belly of the vastus medialis at 1 day after surgery. In both groups, patients received an intraoperative periarticular multi-drug injection and postoperative intravenous and oral nonsteroidal anti-inflammatory drugs. The primary outcome measure was the postoperative pain at rest using a visual analog scale (VAS) and analyzed with Student’s t test. Results Compared to the no additional injection group, the additional periarticular injection group had significantly lower VAS score at 8:00 PM postoperative day 1, 6:00 AM postoperative day 2, 12:00 PM postoperative day 2, 6:00 AM postoperative day 5, 12:00 PM postoperative day 5, and 8:00 PM postoperative day 5 (p < 0.05). The rate of complication did not differ between groups (p > 0.05). Conclusion Additional percutaneous periarticular injection at 1 day following TKA adding to intraoperative periarticular injection provided better postoperative pain relief. Trial registration Registered at the University Hospital Medical Information Network (registration number: UMIN000029759).

Identifying factors predicting prolonged rehabilitation after simultaneous bilateral total knee arthroplasty: a retrospective observational study

Background Rehabilitation is an effective procedure for promoting functional recovery after simultaneous bilateral total knee arthroplasty (TKA); however, it has been cited as a significant economic burden of medical care. We hypothesized that preoperative factors, including age, sex, body mass index, living alone, the knee society function score (KSS), the American society of anesthesiologists (ASA) class, hemoglobin (Hb), albumin level, mean range of motion, and the Kellgren–Lawrence grade, would predict prolonged rehabilitation utilization. Methods In total, 191 patients undergoing simultaneous bilateral TKA in a single hospital were enrolled. The successful compliance group included patients who completed their rehabilitation program and could return to their residence within 3 weeks after surgery (n = 132), whereas the delayed group included the remaining patients (n = 59). Logistic regression analysis was performed using preoperative factors. A prediction scoring system was created using the regression coefficients from the logistic regression model. Results Logistic regression analysis revealed that age (β = − 0.0870; P < 0.01) and Hb (β = 0.34; P < 0.05) were significantly associated with prolonged rehabilitation programs, whereas body mass index, living alone, KSS score, and ASA class were not significantly associated with successful completion of rehabilitation programs; however, these factors contributed to the prediction scoring formula, which was defined as follows: $$ {\displaystyle \begin{array}{l}\mathrm{Score}=10-\left(0.09\times \mathrm{age}\right)-\left(0.09\times \mathrm{body}\ \mathrm{mass}\ \mathrm{index}\right)-\left(0.56\times \mathrm{living}\ \mathrm{alone}\ \right[\mathrm{alone}:1,\\ {}\mathrm{others}:0\left]\right)+\left(0.03\times \mathrm{KSS}\ \mathrm{stairs}\right)+\left(0.34\times \mathrm{Hb}\right)-\left(1.1\times \mathrm{ASA}\ \mathrm{class}\right).\end{array}} $$ Score = 10 - 0.09 × age - 0.09 × body mass index - ( 0.56 × living alone [ alone : 1 , others : 0 ] ) + 0.03 × KSS stairs + 0.34 × Hb - 1.1 × ASA class . The C-statistic for the scoring system was 0.748 (95% confidence interval, 0.672–0.824). The positive and negative likelihood ratios were 2.228 (95% CI, 1.256–3.950) and 0.386 (95% CI, 0.263–0.566), respectively. These results showed an increase of 15–20% and a decrease of 20–25% in the risk of prolonged rehabilitation. The optimal cutoff point for balancing sensitivity and specificity was 3.5, with 66.6% sensitivity and 78.0% specificity. Conclusions Older age and lower preoperative Hb were significantly associated with prolonged rehabilitation programs. We defined a new scoring formula using preoperative patient factors to predict prolonged rehabilitation utilization in patients undergoing simultaneous bilateral TKA.

Risk of stroke after unilateral or bilateral TKA (simultaneous and staged without discharge) in 327,438 matched patients using data from the National Health Insurance Claims for South Korea

Background: Limited data is available regarding the incidence rate and risk factors for stroke associated with unilateral total knee arthroplasty (TKA) and bilateral TKA. This study aims to investigate the incidence rate and risk factors of stroke in patients treated with bilateral TKA compared with patients with unilateral TKA.Methods: In this retrospective nationwide cohort study, we compared patients undergoing unilateral TKA or bilateral TKA using data from the Korean National Health Insurance claims database between January 1, 2009 and August 31, 2017 and included patients older than 40 years of age who underwent primary TKA by the index date as documented primary diagnosis and first additional diagnosis without a history of stroke during the preceding 1 year. We used matched Cox regression models to compare the incidence rate and risk factors of newly acquired stroke among patients treated with unilateral TKA or bilateral TKA after propensity score (PS) matching.Results: In the present study, 163,719 patients who received unilateral TKA were matched to 163,719 patients with bilateral TKA (simultaneous and staged without discharge) based on PS. The risk of stroke during the study period was lower in patients treated with bilateral TKA than in patients with unilateral TKA (adjusted hazard ratio [HR] 0.79; P<0.001). Patients who received bilateral TKA were at decreased risk of stroke when the following variables were present: advanced age (70-79 years, HR 0.76; P<0.001), female sex (HR 0.75; P<0.001), rural area (HR 0.77; P<0.001), small- or medium-sized hospital (HR 0.75; P<0.001), health insurance (HR 0.77; P<0.001), history of hypertension drug use (HR 0.75; P<0.001), congestive heart failure (HR 0.70; P=0.032), connective tissue disease (HR 0.71; P=0.01), diabetes (HR 0.77; P<0.001), and diabetes with complication (HR 0.76; P=0.034).Conclusions: The risk of stroke was lower in patients treated with bilateral TKA (simultaneous and staged without discharge) than in patients with unilateral TKA. Patients treated with bilateral TKA were at decreased risk of stroke when the following variables were present: age (70-79 years), female sex, health insurance, history of hypertension drug use, and comorbidities, such as congestive heart failure, connective tissue disease, and diabetes. More importantly, we do state that those with simultaneous bilateral TKA and staged bilateral TKA without discharge could have been healthier. This is precisely what the guidelines will implement by South Korea for patient selection aim to do and our data show that the risk of stroke is not increased in selected patients undergoing simultaneous bilateral TKA (SiBTKA) and staged bilateral TKA (StBTKA) without discharge.

Identifying Factors Predicting Prolonged Rehabilitation After Simultaneous Bilateral Total Knee Arthroplasty: A Retrospective Observational Study

Background: Rehabilitation is an effective procedure for promoting functional recovery after simultaneous bilateral total knee arthroplasty (TKA); however, it has been cited as the single largest economic burden of medical care spending. Risk factors affecting prolonged rehabilitation utilization after simultaneous bilateral TKA have not been identified. We hypothesized that preoperative factors, including age, sex, body mass index, living alone, the knee society function score (KSS), the American society of anesthesiologists (ASA) grade, hemoglobin (Hb), albumin level, mean range of motion, and the Kellgren–Lawrence grade, would predict prolonged rehabilitation utilization.Methods: A total of 191 patients undergoing simultaneous bilateral TKA in a single hospital were enrolled. The successful compliance group included patients who completed their rehabilitation program and were able to return to their residence within 3 weeks after surgery (n=132), whereas the delayed group included the remaining patients (n=59). Logistic regression analysis was performed using preoperative factors. A prediction scoring system was created using the regression coefficients from the logistic regression model.Results: Logistic regression analysis revealed that age (β=-0.0870; P<0.01) and Hb (β=0.34; P<0.05) were significantly associated with prolonged rehabilitation programs, whereas body mass index (BMI), living alone, the KSS score, and the ASA class were not significantly associated with successful completion of rehabilitation programs; however, these factors contributed to the prediction scoring formula, which was defined as: score = 10 – (0.09×age) – (0.09×body mass index) – (0.56×living alone [alone: 1, others: 0]) + (0.03×KSS stairs) + (0.34×Hb) – (1.1×ASA class). The C-statistic for the scoring system was 0.748 (95% confidence interval, 0.672–0.824). The optimal cutoff point for balancing sensitivity and specificity was 3.5, with 66.6% sensitivity and 78.0% specificity.Conclusions: Older age and lower preoperative Hb were significantly associated with prolonged rehabilitation programs. We defined a new scoring formula using preoperative patient factors to predict prolonged rehabilitation utilization in patients undergoing simultaneous bilateral TKA.