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Comparison of postoperative complications and clinical outcomes between simultaneous and staged bilateral total knee arthroplasty
Journal of Orthopaedic Science xxx (2016) 1e4
Contents lists available at ScienceDirect
Journal of Orthopaedic Science journal homepage: http://www.elsevier.com/locate/jos
Original article
Comparison of postoperative complications and clinical outcomes between simultaneous and staged bilateral total knee arthroplasty Jong-Hwan Seol, Jong-Keun Seon, Eun-Kyoo Song* Department of Orthopedic Surgery, Center for Joint Disease, Chonnam National University Hwasun Hospital, Hwasun, South Korea
a r t i c l e i n f o
a b s t r a c t
Article history: Received 27 July 2015 Received in revised form 11 July 2016 Accepted 30 July 2016 Available online xxx
Background: Controversy exists regarding the safety of simultaneous vs. staged bilateral total knee arthroplasty (TKA). The purpose of this study was to compare postoperative complication rate and clinical outcomes of simultaneous vs. staged bilateral TKA. Methods: A consecutive series of 1074 patients who underwent either simultaneous (759 patients) or staged bilateral (315 patients) TKA from 2004 to 2013 were enrolled in this study. Postoperative complications were categorized as minor or major. Clinical outcome was evaluated at the last follow-up using Knee Society Score (KSS), Western Ontario and McMaster Universities Arthritis Index (WOMAC), and range of motion (ROM). Results: Major complication rate was not statistically different between the two groups. However, minor complication rate was significantly (p < 0.05) higher in the staged TKA group compared to that in the simultaneous TKA group. The median length of stay (LOS) in hospital was 18.0 days after simultaneous TKA vs. cumulated LOS of 34.1 days in the staged group (p < 0.05). Clinical outcome results revealed that there was no significant difference in KSS, WOMAC scores, or ROM between the two groups. Conclusions: Therefore, simultaneous bilateral TKA has some advantage such as less length of stay in hospital compared to staged bilateral TKA. However, this procedure should be conducted very carefully, particularly in high-risk patients. © 2016 Published by Elsevier B.V. on behalf of The Japanese Orthopaedic Association.
1. Introduction Total knee arthroplasty (TKA) is widely used to relieve pain and restore function in patients with end-stage arthritis of the knee. In many patients, osteoarthritis affects joint bilaterally, causing pain and deformity to both knee joints. Bilateral surgery may be required for those with severe arthritic involvement of both knees. Both patient and surgeon must decide whether to treat arthritis with simultaneous bilateral TKA or staged bilateral TKA with a certain time interval between the two procedures, although the decision to undertake bilateral TKA as a simultaneous or staged procedure is controversial [1]. The advantages of simultaneous bilateral TKA conducted under a single anesthetic compared to staged bilateral TKA include: 1) decreased overall length of hospitalization, 2) less anesthesia time,
3) decreased rehabilitation time, and 4) decreased hospital cost to the patient [2]. However, increase in postoperative morbidity and mortality related to simultaneous bilateral TKA has been a concern. Several studies have reported increased complication rate following simultaneous bilateral TKA compared to staged or unilateral TKA [3]. However, other evidence suggests that there is no difference in complication rates between procedures [4]. In addition, there is no evidence-based guideline regarding the optimal choice between simultaneous and staged bilateral TKA. To determine whether to undertake simultaneous bilateral TKA or staged bilateral TKA, we retrospectively compared postoperative complication rate, length of stay in hospital, and functional outcome of patients who underwent simultaneous bilateral TKA compared to those who underwent staged bilateral TKA. 2. Material and method
* Corresponding author. Department of Orthopedic Surgery, Center for Joint Disease, Chonnam National University Hwasun Hospital, 322 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeonnam 519-809, South Korea. Fax: þ82 62 379 7681. E-mail address: [email protected] (E.-K. Song).
Institutional review board approval was obtained for this study. Surgical records from a single institution were reviewed. We retrospectively reviewed the department's arthroplasty database for all patients who underwent simultaneous or staged bilateral
http://dx.doi.org/10.1016/j.jos.2016.07.023 0949-2658/© 2016 Published by Elsevier B.V. on behalf of The Japanese Orthopaedic Association.
Please cite this article in press as: Seol J-H, et al., Comparison of postoperative complications and clinical outcomes between simultaneous and staged bilateral total knee arthroplasty, Journal of Orthopaedic Science (2016), http://dx.doi.org/10.1016/j.jos.2016.07.023
2
J.-H. Seol et al. / Journal of Orthopaedic Science xxx (2016) 1e4
TKA by a single surgeon between May 2004 and July 2013. Inclusion criterion was bilateral osteoarthritis exceeding grade III based on Kellgren and Lawrence classification. Exclusion criteria comprised revision TKA or previous knee infection and trauma requiring surgery. A total of 1074 patients underwent bilateral TKR. Of these patients, 759 underwent simultaneous bilateral TKA, and 315 patients underwent staged bilateral TKA. The decision to proceed with a staged or simultaneous procedure was made between the patient and surgeon based upon the patient's medical comorbidities, and preference of the patient. We exclude the patients at a high risk (ASA score 4) from the group of the simultaneous procedure. Mean interval between the first and the second operation for the staged bilateral group was 36.6 days. Patient demographic data, ASA score, and preoperative medical comorbidities were documented from the medical record. Demographic characteristics of patients are shown in Table 1. The two groups did not differ statistically with respect to age, gender, BMI, range of motion, or functional score. Functional outcome was evaluated pre-operatively using Knee Society Score (KSS) and Western Ontario and McMaster Universities Arthritis Index (WOMAC) (Table 1). There was no significant difference between the two groups with respect to number or type of preoperative medical conditions (Table 2). All patients received a standard preoperative assessment of comorbidities. When a patient was found to have high risk, we consulted with internist in related areas and performed additional evaluation and applied internal treatment. One single senior surgeon operated on patients in both groups. A general anesthetic was used in all but a limited number of cases in which the surgery was performed under spinal or epidural anesthesia. We used a midline longitudinal skin incision and medial para-patellar arthrotomy for all TKA. An intramedullary technique was used for placement of femoral guides. Intra- or extramedullary technique was used on tibia at surgeon's discretion. The decisions on whether to resurface the patella and retain the posterior cruciate ligament (PCL) were made intraoperatively. Polymethylmethacrylate cement was used for fixation of all components. All patients started active or passive joint movements from the day after the surgery. Full weight bearing with a crutch or a walker was started from the 2nd or the 3rd day after surgery depending on the patients' compliance. Rehabilitation was similar to each other in both groups. Patients were followed up at months 3, 6, and 12, and yearly thereafter. At the time of the last follow-up, clinical outcome was evaluated and documented by an independent observer who was not aware of the surgical method. The clinical outcome was evaluated by assessing the passive range of motion (ROM), the Knee Society Score (KSS), Western Ontario, and McMaster Universities Osteoarthritis Index (WOMAC). Table 1 Demographic characteristics of patients used in this study.
Age (years) Gender (male/female) BMI (kg/m2) ASA class ROM Extension Flexion KSS WOMAC score Follow-up period (months)
Simultaneous bilateral TKA group (n ¼ 759)
Staged TKA group (n ¼ 315)
p Value
68.3 ± 4.1 43/716 25.3 ± 3.4 2.0 ± 0.3
66.0 ± 4.1 25/290 25.9 ± 3.3 2.3 ± 0.5
p > 0.05
6.3 ± 8.4 127.2 ± 13.4 46.1 ± 8.2 69.1 ± 9.1 51 ± 7.2
7.2 ± 6.8 126.8 ± 11.2 48.3 ± 9.2 66.7 ± 10.4 53 ± 8.1
Abbreviation: ASA, American Society of Anesthesiologists; BMI, body mass index; KS, knee society score; WOMAC, Western Ontario and McMaster University osteoarthritis index; TKA, total knee arthroplasty.
The following data were obtained and analyzed from medical records of patients in our institute regarding major complications, minor complications, and length of hospital stay. All postoperative complications were categorized as either major or minor. Major complications included deep infections, pulmonary embolism, cerebrovascular accident and myocardial infarction within one year of follow-up period. All other complications were considered minor. Complications evaluation was based on the patient's symptoms. Additional tests were performed when the patients complain the symptom. Postoperative complication rate was analyzed using Chi-Square test. Clinical results were analyzed using unpaired t-test. All analysis was done using SPSS software (SPSS for Windows Release 12.0, Chicago, Ill). Statistical significance was considered when p value was less than 0.05. 3. Result The mean length of hospital stay in the staged bilateral group was calculated as the sum of two hospital stays. Patients in the staged bilateral TKA group had a significantly (p < 0.05) longer length of stay compared to patients in the simultaneous bilateral TKA group (34.1 ± 13.0 vs. 18.0 ± 5.1, Table 3). At the last follow-up, the mean KS scores in both groups were significantly (p < 0.05) improved score compared to the mean preoperative KS scores. However, there was no significant difference in KS scores between the two groups (Table 3). The average WOMAC scores in both groups were significantly (p < 0.05) improved compared to the preoperative values. Again, there was no significant difference in WOMAC scores between the two groups (Table 3). Similarly, the range of motion scores were not different between the two groups (Table 3). A total of 66 (8.7%) complications occurred in the simultaneous bilateral TKA compared to 43 (13.7%) complications in the staged bilateral TKA. Major complication rate was slightly higher in the simultaneous bilateral group, but without statistical significance (p ¼ 0.883). Minor complication rate was significantly (p < 0.05) higher in staged TKA group compared to simultaneous TKA group (Table 4). 4. Discussion Many cases of osteoarthritis become bilateral, resulting in destructive changes and severe deformation of the knee joints. Satisfactory results are difficult to attain without total arthroplasty of both knee joints. Patients with bilateral disease who wish to undergo surgery must decide whether they want a single anesthesia and surgery or separate surgeries and hospitalizations. This decision is affected by patients' needs and expectations and their physicians' recommendation considering patient comorbidities. The question of safety in simultaneous bilateral TKA remains controversial [5]. Although simultaneous bilateral TKA has several advantages, there is still concern about the safety of this operation because it might be associated with a higher risk of perioperative complications [6,7]. In spite of these concerns, simultaneous bilateral TKA is routinely performed. However, there is little information about the epidemiology of simultaneous bilateral TKA. The purpose of this study was to provide insights regarding the benefits and risks associated with surgical techniques used for the treatment of bilateral degenerative knee conditions. This study focuses on the incidence of perioperative complications and functional outcomes following simultaneous or staged bilateral TKA. The results of our study suggest a decreased risk of minor complications following simultaneous procedures within one year follow-up period. Our results also suggest that the two procedures
Please cite this article in press as: Seol J-H, et al., Comparison of postoperative complications and clinical outcomes between simultaneous and staged bilateral total knee arthroplasty, Journal of Orthopaedic Science (2016), http://dx.doi.org/10.1016/j.jos.2016.07.023
J.-H. Seol et al. / Journal of Orthopaedic Science xxx (2016) 1e4 Table 2 Comparison of pre-existing medical conditions between the simultaneous bilateral TKA group and the staged bilateral TKA group. Simultaneous bilateral TKA group (n ¼ 759)
Staged bilateral TKA group (n ¼ 315)
Cardiovascular condition Hypertension CAOD CHF Arrhythmia
414 26 7 33
217 18 11 11
Pulmonary disease Diabetes mellitus Hypothyroidism CKD CVA
13 125 26 33 26
11 39 4 7 18
Comorbidity
Abbreviations: CAOD, coronary artery obstructive disease; CHF, congestive heart failure; CKD, chronic kidney disease; CVA, cerebral vascular accident.
Table 3 Comparison of the two groups with respect to length of hospital stay and postoperative clinical outcomes. Simultaneous bilateral TKA group (n ¼ 759) Length of hospital stay ROM Extension Flexion KS score WOMAC score
Staged TKA group (n ¼ 315)
p Value
18.0 ± 5.1
34.1 ± 13.0
<0.05
1.9 ± 3.2 126.3 ± 10.3
1.5 ± 2.6 126.6 ± 10.1
>0.05 >0.05
93.6 ± 1.6 12.5 ± 2.2
92.7 ± 1.1 13.9 ± 1.1
>0.05 >0.05
Table 4 Major and minor complications. Complication
Simultaneous bilateral TKA group (n ¼ 759)
Staged TKA group (n ¼ 315)
p Value
Major Myocardial infarction Pulmonary embolism Deep infection Cerebrovascular accident
18 (2.4%) 5 0 5 8
7 (2.2%) 2 0 3 2
0.883
Minor Superficial infection DVT Confusion Pneumonia Urinary tract infection Transient acute renal failure
48 (6.3%) 9 2 12 7 16 2
36 (11.4%) 14 0 4 4 6 8
Total
66 (8.7%)
43 (13.7%)
0.014
are comparable with regards to major complication. More specifically, there was no significant difference in cardiac complications, pulmonary embolism, or deep infection between the two procedures. The higher rate of minor complication in the staged group may be due to the additional risk of the 2nd procedure when compared to simultaneous surgery. Although staged appropriately, the second TKA might carry the same risk as the first. Performing simultaneous bilateral TKAs eliminates one of these risks. Simultaneous bilateral TKA during a single session of anesthesia offers several potential advantages, including reduced duration of hospitalization, faster functional recovery, reduced cost, lower risk of infection, and lower risk of mechanical failure within the first year after TKA [8].
3
According to other authors, simultaneous bilateral TKA is associated with an increased risk of perioperative cardiac and pulmonary complications [9,10]. Simultaneous bilateral TKA is reportedly to be associated with a 2-fold greater risk of cardiovascular complications than single unilateral TKA [9] and a 1.6-fold greater risk compared to staged bilateral TKA [8]. However, several series have reported that simultaneous bilateral TKA is safer. One of the earliest series by Hardaker et al. [11] compared the perioperative safety of simultaneous bilateral TKA and that of staged TKA. They found no differences in complication rates or outcomes. Morrey et al. [12] retrospectively studied 290 simultaneous bilateral TKAs and compared them with staged bilateral TKAs. They found similar rates of complications and mortality between the two groups. Recent studies continue to demonstrate increased complications from bilateral TKAs under the same anesthetics [13,14], whereas others show comparable safety profiles with good outcomes [15]. Kim et al. [16] found no significant difference in overall number of complications or perioperative mortality in simultaneous bilateral TKA group compared to unilateral TKA group. The two groups were similar in preoperative ASA classification, which was used as a surrogate for operative risk. Another recent study by Hutchinson et al. [17] compared the outcomes of patients who underwent either simultaneous bilateral, staged bilateral, or unilateral TKA. A higher rate of overall complications was observed in patients undergoing bilateral procedure compared to unilateral. However, when the simultaneous group was compared to the staged group, they saw no difference in perioperative morbidity or mortality. Between the two groups in our study, patients who underwent staged procedures had the same prevalence of preexisting medical comorbidities. Although we found that minor complication rates were higher in patients with staged TKA compared to simultaneous TKA, no difference was observed in clinical outcomes. In a time of cost containment, the potential economic benefit of simultaneous bilateral TKA can be significant. Single anesthetic session resulted in shorter hospital stay and shorter rehabilitation time in the simultaneous TKA group compared to the staged TKA group [18e21]. In our series, the mean length of hospital stay for the simultaneous bilateral patients was 18.0 days (range, 13e28 days), which is only around 53% of the 34.1 days (range, 25e41 days) for the staged bilateral patients. Therefore, if TKA is required for both knees, simultaneous bilateral surgery is more advantageous financially because it reduces the length of hospital stay. Simultaneous bilateral TKA offers the potential benefits in decreasing overall cost, decreasing the number of anesthetic administrations, and resulting in function recovery of both knees. The limitations of this study include a retrospective design and the use of observable data. The results of the present study must be interpreted with great caution due to its non-randomized retrospective design. In addition, patient selection criteria remain an issue of concern for simultaneous bilateral TKA. However, in these retrospective studies, the true patient selection criteria and associated selection bias are unclear. In the present study, all patients were assessed for preoperative operative risk. Some high risk patients have canceled TKA. Some patients primarily scheduled to undergo the simultaneous procedure switched to staged procedure. And we need more samples for statistically significant difference between two groups, because major complication does not occur frequently. If we want the appropriate statistical power analysis, this study needs more sample size in major complication. However, this study has only 759 cases in simultaneous bilateral TKA group and 315 cases in staged TKA group. So to obtain a statistical power analysis (usually 80e90%, thus leading to false rejection of true effects in 10e20% of the cases), each group has a sample size about at least 1300 cases. But we did not compare the sample size of the extent. Likewise, the other study of Chen et al.
Please cite this article in press as: Seol J-H, et al., Comparison of postoperative complications and clinical outcomes between simultaneous and staged bilateral total knee arthroplasty, Journal of Orthopaedic Science (2016), http://dx.doi.org/10.1016/j.jos.2016.07.023
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J.-H. Seol et al. / Journal of Orthopaedic Science xxx (2016) 1e4
[22] and Chan et al. [23] showed similar frequency of major complication with our study and we made comparison between two groups. And Yoon et al. [13] also showed that less sample size and similar complication rate. These studies mentioned about minimizing the biases coming from similarities lend statistical power to their result. Our study shows low frequency of major complication which might give limitation, but it wasn't a difference compared with other study. 5. Conclusion Our data showed that simultaneous bilateral TKA had similar complication rate as staged bilateral TKA. However, simultaneous bilateral TKA remains a safe option for appropriately motivated patients. Simultaneous bilateral TKA offers the potential benefits in decreasing the overall recovery time, decreasing the overall cost, decreasing the number of anesthetic administrations. Our study results confirm that simultaneous bilateral TKA has some advantage such as less length of stay in hospital. However, this procedure should be conducted carefully, particularly in patients who are at higher risk for cardiovascular complications. For the remaining lower-risk patients, simultaneous-bilateral knee arthroplasty may be the preferred surgical strategy. Conflict of interest The authors declare that they have no conflict of interest. References [1] Patil N, Wakankar H. Morbidity and mortality of simultaneous bilateral total knee arthroplasty. Orthopedics 2008 Aug;31(8):780e9. [2] Stubbs G, Pryke SE, Tewari S, Rogers J, Crowe B, Bridgfoot L, Smith N. Safety and cost benefits of bilateral total knee replacement in an acute hospital. ANZ J Surg 2005 Sep;75(9):739e46. [3] Ritter MA, Meding JB. Bilateral simultaneous total knee arthroplasty. J Arthroplasty 1987;2(3):185e9. [4] Health Care Utilization Project. Comorbidity software, version 3.6. 2011. http://www.hcupus.ahrq.gov/toolssoftware/comorbidity/comorbidity.jsp [accessed 17.03.11]. [5] Dennis DA. Debate: bilateral simultaneous total knee arthroplasty. Clin Orthop Relat Res 2004 Nov;428:82e3. [6] Parvizi J, Rasouli MR. Simultaneous-bilateral TKA: double troubledaffirms. J Bone Jt Surg Br 2012 Nov;94:90e2.
[7] Sculco TP, Sculco PK. Simultaneous-bilateral TKA: double troubledopposes. J Bone Jt Surg Br 2012 Nov;94:93e4. [8] Meehan JP, Danielsen B, Tancredi DJ, Kim S, Jamali AA, White RH. A population-based comparison of the incidence of adverse outcomes after simultaneous-bilateral and staged-bilateral total knee arthroplasty. J Bone Jt Surg Am 2011 Dec 7;93(23):2203e13. [9] Restrepo C, Parvizi J, Dietrich T, Einhorn TA. Safety of simultaneous bilateral total knee arthroplasty. A meta-analysis. J Bone Jt Surg Am 2007 Jun;89(6): 1220e6. [10] Memtsoudis SG, Hargett M, Russell LA, Parvizi J, Cats-Baril WL, Stundner O, Sculco TP. Consensus statement from the consensus conference on bilateral total knee arthroplasty group. Clin Orthop Relat Res 2013 Aug;471(8): 2649e57. [11] Hardaker Jr WT, Ogden WS, Musgrave RE, Goldner JL. Simultaneous and staged bilateral total knee arthroplasty. J Bone Jt Surg Am 1978 Mar;60(2): 247e50. [12] Morrey BF, Adams RA, Ilstrup DM, Bryan RS. Complications and mortality associated with bilateral or unilateral total knee arthroplasty. J Bone Jt Surg Am 1987 Apr;69(4):484e8. [13] Yoon HS, Han CD, Yang IH. Comparison of simultaneous bilateral and staged bilateral total knee arthroplasty in terms of perioperative complications. J Arthroplasty 2010 Feb;25(2):179e85. [14] Oakes DA, Hanssen AD. Bilateral total knee replacement using the same anesthetic is not justified by assessment of the risks. Clin Orthop Relat Res 2004 Nov;428:87e91. [15] Shin YH, Kim MH, Ko JS, Park JA. The safety of simultaneous bilateral versus unilateral total knee arthroplasty: the experience in a Korean hospital. Singapore Med J 2010 Jan;51(1):44e9. [16] Kim YH, Choi YW, Kim JS. Simultaneous bilateral sequential total knee replacement is as safe as unilateral total knee replacement. J Bone Jt Surg Br 2009 Jan;91(1):64e8. [17] Hutchinson JR, Parish EN, Cross MJ. A comparison of bilateral uncemented total knee arthroplasty: simultaneous or staged? J Bone Jt Surg Br 2006 Jan;88(1):40e3. [18] Brotherton SL, Roberson JR, de Andrade JR, Fleming LL. Staged versus simultaneous bilateral total knee replacement. J Arthroplasty 1986;1(4):221e8. [19] March LM, Cross M, Tribe KL, Lapsley HM, Courtenay BG, Cross MJ, Brooks PM, Cass C, Coolican M, Neil M, Pinczewski L, Quain S, Robertson F, Ruff S, Walter W, Zicat B. Two knees or not two knees? Patient costs and outcomes following bilateral and unilateral total knee joint replacement surgery for OA. Osteoarthritis Cartil 2004 May;12(5):400e8. [20] Reuben JD, Meyers SJ, Cox DD, Elliott M, Watson M, Shim SD. Cost comparison between bilateral simultaneous, staged, and unilateral total joint arthroplasty. J Arthroplasty 1998 Feb;13(2):172e9. [21] Macario A, Schilling P, Rubio R, Goodman S. Economics of one-stage versus two-stage bilateral total knee arthroplasties. Clin Orthop Relat Res 2003 Sep;414:149e56. [22] Chen JY, Lo NN, Jiang L, Chong HC, Tay DK, Chin PL, Chia SL, Yeo SJ. Simultaneous versus staged bilateral unicompartmental knee replacement. Bone Jt J 2013 Jun;95-B(6):788e92. [23] Chan WC, Musonda P, Cooper AS, Glasgow MM, Donell ST, Walton NP. Onestage versus two-stage bilateral unicompartmental knee replacement: a comparison of immediate post-operative complications. J Bone Jt Surg Br 2009 Oct;91:1305e9.
Please cite this article in press as: Seol J-H, et al., Comparison of postoperative complications and clinical outcomes between simultaneous and staged bilateral total knee arthroplasty, Journal of Orthopaedic Science (2016), http://dx.doi.org/10.1016/j.jos.2016.07.023
Contents lists available at ScienceDirect
Journal of Orthopaedic Science journal homepage: http://www.elsevier.com/locate/jos
Original article
Comparison of postoperative complications and clinical outcomes between simultaneous and staged bilateral total knee arthroplasty Jong-Hwan Seol, Jong-Keun Seon, Eun-Kyoo Song* Department of Orthopedic Surgery, Center for Joint Disease, Chonnam National University Hwasun Hospital, Hwasun, South Korea
a r t i c l e i n f o
a b s t r a c t
Article history: Received 27 July 2015 Received in revised form 11 July 2016 Accepted 30 July 2016 Available online xxx
Background: Controversy exists regarding the safety of simultaneous vs. staged bilateral total knee arthroplasty (TKA). The purpose of this study was to compare postoperative complication rate and clinical outcomes of simultaneous vs. staged bilateral TKA. Methods: A consecutive series of 1074 patients who underwent either simultaneous (759 patients) or staged bilateral (315 patients) TKA from 2004 to 2013 were enrolled in this study. Postoperative complications were categorized as minor or major. Clinical outcome was evaluated at the last follow-up using Knee Society Score (KSS), Western Ontario and McMaster Universities Arthritis Index (WOMAC), and range of motion (ROM). Results: Major complication rate was not statistically different between the two groups. However, minor complication rate was significantly (p < 0.05) higher in the staged TKA group compared to that in the simultaneous TKA group. The median length of stay (LOS) in hospital was 18.0 days after simultaneous TKA vs. cumulated LOS of 34.1 days in the staged group (p < 0.05). Clinical outcome results revealed that there was no significant difference in KSS, WOMAC scores, or ROM between the two groups. Conclusions: Therefore, simultaneous bilateral TKA has some advantage such as less length of stay in hospital compared to staged bilateral TKA. However, this procedure should be conducted very carefully, particularly in high-risk patients. © 2016 Published by Elsevier B.V. on behalf of The Japanese Orthopaedic Association.
1. Introduction Total knee arthroplasty (TKA) is widely used to relieve pain and restore function in patients with end-stage arthritis of the knee. In many patients, osteoarthritis affects joint bilaterally, causing pain and deformity to both knee joints. Bilateral surgery may be required for those with severe arthritic involvement of both knees. Both patient and surgeon must decide whether to treat arthritis with simultaneous bilateral TKA or staged bilateral TKA with a certain time interval between the two procedures, although the decision to undertake bilateral TKA as a simultaneous or staged procedure is controversial [1]. The advantages of simultaneous bilateral TKA conducted under a single anesthetic compared to staged bilateral TKA include: 1) decreased overall length of hospitalization, 2) less anesthesia time,
3) decreased rehabilitation time, and 4) decreased hospital cost to the patient [2]. However, increase in postoperative morbidity and mortality related to simultaneous bilateral TKA has been a concern. Several studies have reported increased complication rate following simultaneous bilateral TKA compared to staged or unilateral TKA [3]. However, other evidence suggests that there is no difference in complication rates between procedures [4]. In addition, there is no evidence-based guideline regarding the optimal choice between simultaneous and staged bilateral TKA. To determine whether to undertake simultaneous bilateral TKA or staged bilateral TKA, we retrospectively compared postoperative complication rate, length of stay in hospital, and functional outcome of patients who underwent simultaneous bilateral TKA compared to those who underwent staged bilateral TKA. 2. Material and method
* Corresponding author. Department of Orthopedic Surgery, Center for Joint Disease, Chonnam National University Hwasun Hospital, 322 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeonnam 519-809, South Korea. Fax: þ82 62 379 7681. E-mail address: [email protected] (E.-K. Song).
Institutional review board approval was obtained for this study. Surgical records from a single institution were reviewed. We retrospectively reviewed the department's arthroplasty database for all patients who underwent simultaneous or staged bilateral
http://dx.doi.org/10.1016/j.jos.2016.07.023 0949-2658/© 2016 Published by Elsevier B.V. on behalf of The Japanese Orthopaedic Association.
Please cite this article in press as: Seol J-H, et al., Comparison of postoperative complications and clinical outcomes between simultaneous and staged bilateral total knee arthroplasty, Journal of Orthopaedic Science (2016), http://dx.doi.org/10.1016/j.jos.2016.07.023
2
J.-H. Seol et al. / Journal of Orthopaedic Science xxx (2016) 1e4
TKA by a single surgeon between May 2004 and July 2013. Inclusion criterion was bilateral osteoarthritis exceeding grade III based on Kellgren and Lawrence classification. Exclusion criteria comprised revision TKA or previous knee infection and trauma requiring surgery. A total of 1074 patients underwent bilateral TKR. Of these patients, 759 underwent simultaneous bilateral TKA, and 315 patients underwent staged bilateral TKA. The decision to proceed with a staged or simultaneous procedure was made between the patient and surgeon based upon the patient's medical comorbidities, and preference of the patient. We exclude the patients at a high risk (ASA score 4) from the group of the simultaneous procedure. Mean interval between the first and the second operation for the staged bilateral group was 36.6 days. Patient demographic data, ASA score, and preoperative medical comorbidities were documented from the medical record. Demographic characteristics of patients are shown in Table 1. The two groups did not differ statistically with respect to age, gender, BMI, range of motion, or functional score. Functional outcome was evaluated pre-operatively using Knee Society Score (KSS) and Western Ontario and McMaster Universities Arthritis Index (WOMAC) (Table 1). There was no significant difference between the two groups with respect to number or type of preoperative medical conditions (Table 2). All patients received a standard preoperative assessment of comorbidities. When a patient was found to have high risk, we consulted with internist in related areas and performed additional evaluation and applied internal treatment. One single senior surgeon operated on patients in both groups. A general anesthetic was used in all but a limited number of cases in which the surgery was performed under spinal or epidural anesthesia. We used a midline longitudinal skin incision and medial para-patellar arthrotomy for all TKA. An intramedullary technique was used for placement of femoral guides. Intra- or extramedullary technique was used on tibia at surgeon's discretion. The decisions on whether to resurface the patella and retain the posterior cruciate ligament (PCL) were made intraoperatively. Polymethylmethacrylate cement was used for fixation of all components. All patients started active or passive joint movements from the day after the surgery. Full weight bearing with a crutch or a walker was started from the 2nd or the 3rd day after surgery depending on the patients' compliance. Rehabilitation was similar to each other in both groups. Patients were followed up at months 3, 6, and 12, and yearly thereafter. At the time of the last follow-up, clinical outcome was evaluated and documented by an independent observer who was not aware of the surgical method. The clinical outcome was evaluated by assessing the passive range of motion (ROM), the Knee Society Score (KSS), Western Ontario, and McMaster Universities Osteoarthritis Index (WOMAC). Table 1 Demographic characteristics of patients used in this study.
Age (years) Gender (male/female) BMI (kg/m2) ASA class ROM Extension Flexion KSS WOMAC score Follow-up period (months)
Simultaneous bilateral TKA group (n ¼ 759)
Staged TKA group (n ¼ 315)
p Value
68.3 ± 4.1 43/716 25.3 ± 3.4 2.0 ± 0.3
66.0 ± 4.1 25/290 25.9 ± 3.3 2.3 ± 0.5
p > 0.05
6.3 ± 8.4 127.2 ± 13.4 46.1 ± 8.2 69.1 ± 9.1 51 ± 7.2
7.2 ± 6.8 126.8 ± 11.2 48.3 ± 9.2 66.7 ± 10.4 53 ± 8.1
Abbreviation: ASA, American Society of Anesthesiologists; BMI, body mass index; KS, knee society score; WOMAC, Western Ontario and McMaster University osteoarthritis index; TKA, total knee arthroplasty.
The following data were obtained and analyzed from medical records of patients in our institute regarding major complications, minor complications, and length of hospital stay. All postoperative complications were categorized as either major or minor. Major complications included deep infections, pulmonary embolism, cerebrovascular accident and myocardial infarction within one year of follow-up period. All other complications were considered minor. Complications evaluation was based on the patient's symptoms. Additional tests were performed when the patients complain the symptom. Postoperative complication rate was analyzed using Chi-Square test. Clinical results were analyzed using unpaired t-test. All analysis was done using SPSS software (SPSS for Windows Release 12.0, Chicago, Ill). Statistical significance was considered when p value was less than 0.05. 3. Result The mean length of hospital stay in the staged bilateral group was calculated as the sum of two hospital stays. Patients in the staged bilateral TKA group had a significantly (p < 0.05) longer length of stay compared to patients in the simultaneous bilateral TKA group (34.1 ± 13.0 vs. 18.0 ± 5.1, Table 3). At the last follow-up, the mean KS scores in both groups were significantly (p < 0.05) improved score compared to the mean preoperative KS scores. However, there was no significant difference in KS scores between the two groups (Table 3). The average WOMAC scores in both groups were significantly (p < 0.05) improved compared to the preoperative values. Again, there was no significant difference in WOMAC scores between the two groups (Table 3). Similarly, the range of motion scores were not different between the two groups (Table 3). A total of 66 (8.7%) complications occurred in the simultaneous bilateral TKA compared to 43 (13.7%) complications in the staged bilateral TKA. Major complication rate was slightly higher in the simultaneous bilateral group, but without statistical significance (p ¼ 0.883). Minor complication rate was significantly (p < 0.05) higher in staged TKA group compared to simultaneous TKA group (Table 4). 4. Discussion Many cases of osteoarthritis become bilateral, resulting in destructive changes and severe deformation of the knee joints. Satisfactory results are difficult to attain without total arthroplasty of both knee joints. Patients with bilateral disease who wish to undergo surgery must decide whether they want a single anesthesia and surgery or separate surgeries and hospitalizations. This decision is affected by patients' needs and expectations and their physicians' recommendation considering patient comorbidities. The question of safety in simultaneous bilateral TKA remains controversial [5]. Although simultaneous bilateral TKA has several advantages, there is still concern about the safety of this operation because it might be associated with a higher risk of perioperative complications [6,7]. In spite of these concerns, simultaneous bilateral TKA is routinely performed. However, there is little information about the epidemiology of simultaneous bilateral TKA. The purpose of this study was to provide insights regarding the benefits and risks associated with surgical techniques used for the treatment of bilateral degenerative knee conditions. This study focuses on the incidence of perioperative complications and functional outcomes following simultaneous or staged bilateral TKA. The results of our study suggest a decreased risk of minor complications following simultaneous procedures within one year follow-up period. Our results also suggest that the two procedures
Please cite this article in press as: Seol J-H, et al., Comparison of postoperative complications and clinical outcomes between simultaneous and staged bilateral total knee arthroplasty, Journal of Orthopaedic Science (2016), http://dx.doi.org/10.1016/j.jos.2016.07.023
J.-H. Seol et al. / Journal of Orthopaedic Science xxx (2016) 1e4 Table 2 Comparison of pre-existing medical conditions between the simultaneous bilateral TKA group and the staged bilateral TKA group. Simultaneous bilateral TKA group (n ¼ 759)
Staged bilateral TKA group (n ¼ 315)
Cardiovascular condition Hypertension CAOD CHF Arrhythmia
414 26 7 33
217 18 11 11
Pulmonary disease Diabetes mellitus Hypothyroidism CKD CVA
13 125 26 33 26
11 39 4 7 18
Comorbidity
Abbreviations: CAOD, coronary artery obstructive disease; CHF, congestive heart failure; CKD, chronic kidney disease; CVA, cerebral vascular accident.
Table 3 Comparison of the two groups with respect to length of hospital stay and postoperative clinical outcomes. Simultaneous bilateral TKA group (n ¼ 759) Length of hospital stay ROM Extension Flexion KS score WOMAC score
Staged TKA group (n ¼ 315)
p Value
18.0 ± 5.1
34.1 ± 13.0
<0.05
1.9 ± 3.2 126.3 ± 10.3
1.5 ± 2.6 126.6 ± 10.1
>0.05 >0.05
93.6 ± 1.6 12.5 ± 2.2
92.7 ± 1.1 13.9 ± 1.1
>0.05 >0.05
Table 4 Major and minor complications. Complication
Simultaneous bilateral TKA group (n ¼ 759)
Staged TKA group (n ¼ 315)
p Value
Major Myocardial infarction Pulmonary embolism Deep infection Cerebrovascular accident
18 (2.4%) 5 0 5 8
7 (2.2%) 2 0 3 2
0.883
Minor Superficial infection DVT Confusion Pneumonia Urinary tract infection Transient acute renal failure
48 (6.3%) 9 2 12 7 16 2
36 (11.4%) 14 0 4 4 6 8
Total
66 (8.7%)
43 (13.7%)
0.014
are comparable with regards to major complication. More specifically, there was no significant difference in cardiac complications, pulmonary embolism, or deep infection between the two procedures. The higher rate of minor complication in the staged group may be due to the additional risk of the 2nd procedure when compared to simultaneous surgery. Although staged appropriately, the second TKA might carry the same risk as the first. Performing simultaneous bilateral TKAs eliminates one of these risks. Simultaneous bilateral TKA during a single session of anesthesia offers several potential advantages, including reduced duration of hospitalization, faster functional recovery, reduced cost, lower risk of infection, and lower risk of mechanical failure within the first year after TKA [8].
3
According to other authors, simultaneous bilateral TKA is associated with an increased risk of perioperative cardiac and pulmonary complications [9,10]. Simultaneous bilateral TKA is reportedly to be associated with a 2-fold greater risk of cardiovascular complications than single unilateral TKA [9] and a 1.6-fold greater risk compared to staged bilateral TKA [8]. However, several series have reported that simultaneous bilateral TKA is safer. One of the earliest series by Hardaker et al. [11] compared the perioperative safety of simultaneous bilateral TKA and that of staged TKA. They found no differences in complication rates or outcomes. Morrey et al. [12] retrospectively studied 290 simultaneous bilateral TKAs and compared them with staged bilateral TKAs. They found similar rates of complications and mortality between the two groups. Recent studies continue to demonstrate increased complications from bilateral TKAs under the same anesthetics [13,14], whereas others show comparable safety profiles with good outcomes [15]. Kim et al. [16] found no significant difference in overall number of complications or perioperative mortality in simultaneous bilateral TKA group compared to unilateral TKA group. The two groups were similar in preoperative ASA classification, which was used as a surrogate for operative risk. Another recent study by Hutchinson et al. [17] compared the outcomes of patients who underwent either simultaneous bilateral, staged bilateral, or unilateral TKA. A higher rate of overall complications was observed in patients undergoing bilateral procedure compared to unilateral. However, when the simultaneous group was compared to the staged group, they saw no difference in perioperative morbidity or mortality. Between the two groups in our study, patients who underwent staged procedures had the same prevalence of preexisting medical comorbidities. Although we found that minor complication rates were higher in patients with staged TKA compared to simultaneous TKA, no difference was observed in clinical outcomes. In a time of cost containment, the potential economic benefit of simultaneous bilateral TKA can be significant. Single anesthetic session resulted in shorter hospital stay and shorter rehabilitation time in the simultaneous TKA group compared to the staged TKA group [18e21]. In our series, the mean length of hospital stay for the simultaneous bilateral patients was 18.0 days (range, 13e28 days), which is only around 53% of the 34.1 days (range, 25e41 days) for the staged bilateral patients. Therefore, if TKA is required for both knees, simultaneous bilateral surgery is more advantageous financially because it reduces the length of hospital stay. Simultaneous bilateral TKA offers the potential benefits in decreasing overall cost, decreasing the number of anesthetic administrations, and resulting in function recovery of both knees. The limitations of this study include a retrospective design and the use of observable data. The results of the present study must be interpreted with great caution due to its non-randomized retrospective design. In addition, patient selection criteria remain an issue of concern for simultaneous bilateral TKA. However, in these retrospective studies, the true patient selection criteria and associated selection bias are unclear. In the present study, all patients were assessed for preoperative operative risk. Some high risk patients have canceled TKA. Some patients primarily scheduled to undergo the simultaneous procedure switched to staged procedure. And we need more samples for statistically significant difference between two groups, because major complication does not occur frequently. If we want the appropriate statistical power analysis, this study needs more sample size in major complication. However, this study has only 759 cases in simultaneous bilateral TKA group and 315 cases in staged TKA group. So to obtain a statistical power analysis (usually 80e90%, thus leading to false rejection of true effects in 10e20% of the cases), each group has a sample size about at least 1300 cases. But we did not compare the sample size of the extent. Likewise, the other study of Chen et al.
Please cite this article in press as: Seol J-H, et al., Comparison of postoperative complications and clinical outcomes between simultaneous and staged bilateral total knee arthroplasty, Journal of Orthopaedic Science (2016), http://dx.doi.org/10.1016/j.jos.2016.07.023
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J.-H. Seol et al. / Journal of Orthopaedic Science xxx (2016) 1e4
[22] and Chan et al. [23] showed similar frequency of major complication with our study and we made comparison between two groups. And Yoon et al. [13] also showed that less sample size and similar complication rate. These studies mentioned about minimizing the biases coming from similarities lend statistical power to their result. Our study shows low frequency of major complication which might give limitation, but it wasn't a difference compared with other study. 5. Conclusion Our data showed that simultaneous bilateral TKA had similar complication rate as staged bilateral TKA. However, simultaneous bilateral TKA remains a safe option for appropriately motivated patients. Simultaneous bilateral TKA offers the potential benefits in decreasing the overall recovery time, decreasing the overall cost, decreasing the number of anesthetic administrations. Our study results confirm that simultaneous bilateral TKA has some advantage such as less length of stay in hospital. However, this procedure should be conducted carefully, particularly in patients who are at higher risk for cardiovascular complications. For the remaining lower-risk patients, simultaneous-bilateral knee arthroplasty may be the preferred surgical strategy. Conflict of interest The authors declare that they have no conflict of interest. References [1] Patil N, Wakankar H. Morbidity and mortality of simultaneous bilateral total knee arthroplasty. Orthopedics 2008 Aug;31(8):780e9. [2] Stubbs G, Pryke SE, Tewari S, Rogers J, Crowe B, Bridgfoot L, Smith N. Safety and cost benefits of bilateral total knee replacement in an acute hospital. ANZ J Surg 2005 Sep;75(9):739e46. [3] Ritter MA, Meding JB. Bilateral simultaneous total knee arthroplasty. J Arthroplasty 1987;2(3):185e9. [4] Health Care Utilization Project. Comorbidity software, version 3.6. 2011. http://www.hcupus.ahrq.gov/toolssoftware/comorbidity/comorbidity.jsp [accessed 17.03.11]. [5] Dennis DA. Debate: bilateral simultaneous total knee arthroplasty. Clin Orthop Relat Res 2004 Nov;428:82e3. [6] Parvizi J, Rasouli MR. Simultaneous-bilateral TKA: double troubledaffirms. J Bone Jt Surg Br 2012 Nov;94:90e2.
[7] Sculco TP, Sculco PK. Simultaneous-bilateral TKA: double troubledopposes. J Bone Jt Surg Br 2012 Nov;94:93e4. [8] Meehan JP, Danielsen B, Tancredi DJ, Kim S, Jamali AA, White RH. A population-based comparison of the incidence of adverse outcomes after simultaneous-bilateral and staged-bilateral total knee arthroplasty. J Bone Jt Surg Am 2011 Dec 7;93(23):2203e13. [9] Restrepo C, Parvizi J, Dietrich T, Einhorn TA. Safety of simultaneous bilateral total knee arthroplasty. A meta-analysis. J Bone Jt Surg Am 2007 Jun;89(6): 1220e6. [10] Memtsoudis SG, Hargett M, Russell LA, Parvizi J, Cats-Baril WL, Stundner O, Sculco TP. Consensus statement from the consensus conference on bilateral total knee arthroplasty group. Clin Orthop Relat Res 2013 Aug;471(8): 2649e57. [11] Hardaker Jr WT, Ogden WS, Musgrave RE, Goldner JL. Simultaneous and staged bilateral total knee arthroplasty. J Bone Jt Surg Am 1978 Mar;60(2): 247e50. [12] Morrey BF, Adams RA, Ilstrup DM, Bryan RS. Complications and mortality associated with bilateral or unilateral total knee arthroplasty. J Bone Jt Surg Am 1987 Apr;69(4):484e8. [13] Yoon HS, Han CD, Yang IH. Comparison of simultaneous bilateral and staged bilateral total knee arthroplasty in terms of perioperative complications. J Arthroplasty 2010 Feb;25(2):179e85. [14] Oakes DA, Hanssen AD. Bilateral total knee replacement using the same anesthetic is not justified by assessment of the risks. Clin Orthop Relat Res 2004 Nov;428:87e91. [15] Shin YH, Kim MH, Ko JS, Park JA. The safety of simultaneous bilateral versus unilateral total knee arthroplasty: the experience in a Korean hospital. Singapore Med J 2010 Jan;51(1):44e9. [16] Kim YH, Choi YW, Kim JS. Simultaneous bilateral sequential total knee replacement is as safe as unilateral total knee replacement. J Bone Jt Surg Br 2009 Jan;91(1):64e8. [17] Hutchinson JR, Parish EN, Cross MJ. A comparison of bilateral uncemented total knee arthroplasty: simultaneous or staged? J Bone Jt Surg Br 2006 Jan;88(1):40e3. [18] Brotherton SL, Roberson JR, de Andrade JR, Fleming LL. Staged versus simultaneous bilateral total knee replacement. J Arthroplasty 1986;1(4):221e8. [19] March LM, Cross M, Tribe KL, Lapsley HM, Courtenay BG, Cross MJ, Brooks PM, Cass C, Coolican M, Neil M, Pinczewski L, Quain S, Robertson F, Ruff S, Walter W, Zicat B. Two knees or not two knees? Patient costs and outcomes following bilateral and unilateral total knee joint replacement surgery for OA. Osteoarthritis Cartil 2004 May;12(5):400e8. [20] Reuben JD, Meyers SJ, Cox DD, Elliott M, Watson M, Shim SD. Cost comparison between bilateral simultaneous, staged, and unilateral total joint arthroplasty. J Arthroplasty 1998 Feb;13(2):172e9. [21] Macario A, Schilling P, Rubio R, Goodman S. Economics of one-stage versus two-stage bilateral total knee arthroplasties. Clin Orthop Relat Res 2003 Sep;414:149e56. [22] Chen JY, Lo NN, Jiang L, Chong HC, Tay DK, Chin PL, Chia SL, Yeo SJ. Simultaneous versus staged bilateral unicompartmental knee replacement. Bone Jt J 2013 Jun;95-B(6):788e92. [23] Chan WC, Musonda P, Cooper AS, Glasgow MM, Donell ST, Walton NP. Onestage versus two-stage bilateral unicompartmental knee replacement: a comparison of immediate post-operative complications. J Bone Jt Surg Br 2009 Oct;91:1305e9.
Please cite this article in press as: Seol J-H, et al., Comparison of postoperative complications and clinical outcomes between simultaneous and staged bilateral total knee arthroplasty, Journal of Orthopaedic Science (2016), http://dx.doi.org/10.1016/j.jos.2016.07.023