Simultaneous Bilateral Knee Replacement The Barwon Health Experience

Morrison SG Thomson AA

Page RS Barwon Orthopaedic Research Unit

Conflicts of Interest✚ None to declare

Background✚ Patients requiring TKR often suffer from bilateral disease✚ Hence require both TKRs, prior to full pain relief and functional restoration

✚ Postulated benefits of bilateral simultaneous TKR (BTKR):✚ Patient benefits✚ System benefits

✚ Postulated disadvantages of BTKR:✚ Greater medical + surgical insult✚ Increased complication rates✚ Poorer outcomes

Background✚ Barwon Health Orthopaedic Unit performs BTKR

✚ Anecdotally unique for a Victorian health service

✚ Study Aim to compare BTKR with STKR, with regards to:✚ Length of Stay (LOS)✚ Transfusion Rates✚ Complications✚ Outcomes (ROM + KSS)

Methods✚ Retrospective Cohort Study✚ Prospective ethical approval (BORU Arthroplasty Register Approval 12/95). ✚ Socrates™ and Filemaker Pro (HREC prospective databases)✚ Inclusion

✚ All patients undergoing BTKR (simultaneous knee replacement by two surgeons and two registrars)✚ All patients undergoing STKR (Two procedures with 24 months, with bilateral disease at initial assessment)

✚ Exclusion✚ Previous major knee surgery (eg. HTO, UKR)✚ Siimultaneous major knee procedure

Methods✚ Patients offered BTKR if deemed appropriate by surgical and anaesthetic teams

✚ Patients who declined BTKR were offered STKR

✚ Standard unit protocols adhered to

✚ Peri-operative antibiotic and VTE prophylaxis

✚ Post-operative rehabilitation

Methods✚ Filemaker Pro + Medical Records

✚ Demographics Charlson Comorbidty Index (CCI)

✚ Complications Transfusion, Surgical site infection, DVT, PE, AMI, re-operation, revision, acute renal failure, nerve palsy, death

✚ Length of Stay Acute Ward, Rehabilitation

✚ Socrates™ (Pre-Op, 12-18 month review)✚ Range of Motion ✚ Knee Society Score✚ Knee Society Score (Function) obtained at pre-operative assessment, and 7-18 months post-operatively

✚ Complications analysis per patient✚ Outcomes analysis per knee✚ Mann-Whitney U test utilised given different group sizes

Results:Demographics

Results:Length of Stay

Results:

ComplicationsBTKR STKR

AMI 1 0

Infection (Superficial/Deep)

2/1 3/0

Transfusion 2.0 1.3 (p=0.144)

Death (within 6 months) 0 0

Re-operation 1 x revision (aseptic loosening )1 x infection (req. open washout)

1 x haematoma (req. evacuation)1 x periprosthetic fracture

Results:Functional Outcomes

Results:Functional Outcomes

Results:Functional Outcomes

Results:SummaryNo difference with regard to:✚ Complication Rates✚ Death

Functional Benefits:✚ Increased KSS (Function) score post-operatively for BTKR knees✚ Greater increase in KSS and KSS (Function) score post-operatively for BTKR Knees

System Benefits:✚ Shorter cumulative acute inpatient stay for BTKR patients

Discussion:ComplicationsRetrospective Cohort Studies

Brotherton (1986) BTKR less costly, less bed days, vs. STKR (n = 18/29)Parvizi (2001) Mortality BTKR 0.49%, UTKR 0.17% (n = 2691/19861)Luscombe (2007) Increased morbidity, not mortality BTKR (n = 72/144)Yoon (2010) Systemic complications higher in BTKR (n = 119/119)Fabi (2011) Complications 2 x, 4 x Blood Tx

(n = 150/150)(Complic 8 x if pulmonary disease)

Husted (2011) BTKR longer LOS, more Tx, same outcome (n = 150/271)Peskun (2012) IHD + COAD risk factors for complications (n = 78/156)

Prospective Cohort studies

Kim (2009) No overall differences between groups (n = 2385/719)Lane (1997) BTKR longer stays, more Tx

(n = 100/100)Low cost/benefit (vs. UTKR)

Discussion:Complications Population StudiesRitter (1997) BTKR mortality higher, cost/LOS less(n = 112 922)

Recommend 3-6 months gapMemtsoudis (2008) BTKR higher mortality (0.5% vs 0.3%) (n = 153 259/ 3 672 247)

BTKR higher complications (12.2% vs 8.2%)Memtsoudis (2009) BTKR 2 x mortality (0.41% vs 0.30%)(n = 43 350/626 439)

BTKR < 2 x complications (9.45% vs 0.14%)Meehan (2011) BTKR inc. AMI, PE

(n = 11 445/23 715)CVA, Death, similarBTKR Infection, ‘mechanical malfunction’ lower

Registry StudiesStefansdottir (2008) BTKR mortality 7.5x higher than after 2nd STKR (n = 1139/3432)

“It is safer to operate on one knee at a time” Hooper (2009) BTHR + BTKR

(n= 8144)Age + inflammatory disease different between groupsSimilar outcomes

Discussion:ComplicationsMeta-analyses

Restrepo (2007) TKR vs. UKR (n = 18 articles, 27 807 patients)

1.8 x PE, 2.49 x Cardiac, 2.2 x Mortality

Hu (2011) BTKR 3.2 x Mortality (n = 14 articles, 4320/11 243 patients)

Discussion:Functional Outcomes

Husted (2011) ROM and pain similar at 3 months (n = 150 / 271)

Fewer BTKR patients using walking aidsFinal satisfaction, pain, return to employment similar

Kim (2008) No difference in final KSS (n = 2385 / 719)

Discussion:AOANJRRRevision Rates of Bilateral Primary Total Knee Replacement by Bilateral Status

Rev / 100 Obs. yearsBTKR (Same Day, Two Surgeons) n = 480 0.54 (0.28-0.94)BTKR (Same Day, Same Surgeon) n = 16682 0.59 (0.53-0.66)STKR (Within Six Months) n = 16 924 0.48 (0.43-0.53) STKR (Over Six Months) n = 81 236 0.62 (0.57-0.61)BTKR (Same Day, Unkn. Surgeons) n = 10 014 0.54 (0.48-0.61)

Discussion:AOANJRR

Cumulative Percent Revision of BTKR by Bilateral Status

BTKR (Different Surgeons) vs. STKR (<6 months) HR 1.24 (9.70-2.20, p=0.469)BTKR (Same Surgeon) vs. STKR (<6 months) HR 1.06 (0.91-1.24, p=0.441)BTKR (Same Surgeon) vs. BTKR (Diff. Surgeon) HR 1.16 (0.65-2.07) p=0.605)

Mortality (Rate / 100 person yrs) Standardised

MortalityBTKR (Different Surgeons) 2.97 (2.06-4.15) 3.3BTKR (Same Surgeon) 1.14 (1.02-1.28) 1.7STKR (<6 months) 1.78 (1.65–1.91) 4.4

 

Cum

ulati

ve P

erce

nt R

evisi

on

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

Years Since Primary Procedure

0 1 2 3 4 5 6 7 8 9 10 11

Same Day Bilateral TKA by Different Surgeons vs

Bilateral TKA within 6 months

Entire Period: HR=1.24 (0.70, 2.20),p=0.469

Same Day Bilateral TKA by the Same Surgeon vs

Bilateral TKA within 6 months

Entire Period: HR=1.06 (0.91, 1.24),p=0.441

Same Day Bilateral TKA by Different Surgeons vs

Same Day Bilateral TKA by the Same Surgeon

Entire Period: HR=1.16 (0.65, 2.07),p=0.605

HR - adjusted for age and genderSame Day Bilateral TKA by Different SurgeonsSame Day Bilateral TKA by the Same SurgeonBilateral TKA within 6 months

Source: AOANJRR (Request 1017)

Discussion:Patient SelectionMemsoudis (2008) BTKR, Male, Age, IHD = independent risk factors for mortality

Discussion:Patient Selection✚ Insidious onset✚ Pain on activity, night pain✚ Antalgic✚ Apprehension with passive IR of hip✚ Groin pain on SLR

✚ DDx✚ Transient Osteoporosis

Jules-Elysee (2012)

Discussion: Limitations✚ Retrospective✚ Heterogeneous practice

✚ Incomplete outcome data 16/52 (30%) of STKR knees had both pre/post KSS scores

23/52 (44%) of STKR knees had both pre/post ROM

✚ Statistical challenges of comparing BTKR, UTKR, and STKR (without ITT)

Conclusions:Further Considerations✚ Resource Usage

✚ Pre-admission process✚ Theatre time✚ Theatre staff✚ Recovery LOS✚ ICU

✚ Surgical Process✚ Distraction✚ Medicolegal considerations

Conclusions:Recommendations✚ Improved data collection/follow up

✚ Physiotherapist-run joint clinic✚ Data entry

✚ Standarised patient selection criteria✚ Orthopaedic Unit✚ Anaesthetic Unit

Conclusion✚ Analysis of current practice✚ No increase in complications observed✚ Functional outcomes similar✚ Less acute bed days used✚ Number may limit extrapolation of findings

Thank you

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