J Orthop Sci (1996) 1:351-355
thopaedic Science The JapaneseOrthopaedicAssociation
Original articles Simultaneous bilateral total knee arthroplasty JUNNOSUKE RYU, SHU SAITO, and TAKAHITOHONDA Department of Orthopaedic Surgery, Nihon University School of Medicine, 30-10yaguchi Kamimachi, Itabashi-ku, Tokyo 173, Japan
Abstract: Total knee arthroplasty (TKA) was performed simultaneously on both knees by two teams in a single procedure. The study population consisted of 74 patients (148 knee joints) with osteoarthritis (OA) or rheumatoid arthritis (RA). The peri- and postoperative results were compared with those in a group of 22 OA and RA patients (44 knee joints) who underwent staged operation during one hospital stay. Comparisons were made of functional score and range of motion (ROM) before and after operation, mean total blood loss, operative time, duration of hospital stay, and operative and postoperative complications. The simultaneous performance of bilateral procedures did not influence the functional score, ROM after operation, or mean intra- and postoperative blood loss. Nor was the incidence of operative and postoperative complications increased compared with that in the staged operation group. The operative time in the simultaneous TKA group was significantly shorter than the time that would have been required had separate procedures been performed on both knees. Simultaneous bilateral TKA is beneficial for the patient. Key words: total knee arthroplasty, simultaneous bilateral replacement, rheumatoid arthritis, osteoarthritis
during the same hospitalization, or during separate hospitalizations. In patients who have undergone bilateral T K A on different days, the recovery of knee function often requires prolonged hospital stay and long-term rehabilitation. In addition there is the attendant morbidity and risk associated with two separate operations and with the anesthesia. A number of authors have reported simultaneous bilateral TKA. 1,3,5-11 Soundry et al. 9 have reported identical clinical results and similar incidence of complications in patients who underwent unilateral, bilateral one-stage, and bilateral staged TKA. McLaughlin et al. 6 conducted a study of the relative safety of simultaneous (two-team), sequential, and staged TKA, and concluded that there were fewer complications and significantly shorter hospitalizations in patients who underwent simultaneous bilateral TKA. Although the bilateral one-stage technique has several advantages, it usually takes 3-4h. Since July 1984, we have been performing bilateral TKA, using two surgical teams, in order to reduce the operative time. We report the postoperative results and the advantages and disadvantages of simultaneously performed bilateral TKA.
The bilateral knee joints are sometimes involved in both rheumatoid arthritis (RA) and osteoarthritis (OA). These patients are often unable to walk because of deformities, instability, and pain in the knees. Bilateral total knee arthroplasty ( T K A ) can be performed either simultaneously, or in stages on different days
Offprint requests to: J. Ryu Received for publication on March 19, 1996; accepted on July 23, 1996
Materials and m e t h o d s
Patient population Between January, 1984 and December, 1993, T K A was performed in 212 patients (332 knees) at Itabashi Hospital of Nihon University. Ninety-two of these patients underwent unilateral T K A and in 120 patients (240 knees), bilateral T K A was performed. In 79 of these patients (158 knees), the bilateral T K A was carried out simultaneously. Follow-up data were available for 113 patients (226 joints) who underwent bilateral TKA. This population
J. Ryu et al.: Simultaneous bilateral knee arthroplasty
Table 1. Characteristics of patients in whom bilateral total knee arthroplasty (TKA) was performed
Patients (n) Knees (n) Age (years, mean) Female:Male RA:OA Follow-up period (years, mean)
74 148 64.3 (39-85) 65:9 46:28 5.4 (2.4-8.7)
22 44 64.1 (50-71) 18:4 14:8 6.2 (2-9.4)
Numbers in parentheses indicateranges. Group I, Simultaneousbilateral TKA; Group II, stagedbilateral TKA. RA, rheumatoidarthritis; OA, osteoarthritis
included patients treated by each of the three methods. Seven patients dropped out of the study, 4 because of unrelated deaths, and 3 who were lost to follow-up. Simultaneous bilateral TKA (group I) was indicated when the patient had destructive changes in both knees, was considered physically able to withstand the simultaneous bilateral TKA procedure, and expressed a preference for this approach. Group I consisted of 74 patients (148 knees), 65 women (130 knees) and 9 men (18 knees). Forty-six patients had rheumatoid arthritis (RA) (92 joints) and 28 patients had osteoarthritis (OA) (56 joints). Age at the time of operation ranged from 39 to 85 years (mean, 64.3 years). The follow-up period ranged from 2 years and 5 months to 8 years and 8 months (mean, 5.4 years) (Table 1). The prostheses used in this group were: the AXIOM (Orthomet, Minneapolis, MN, USA) (n -- 50 joints), AMK (DePuy, Warsaw, IN, USA) (n = 44), Miller-Galante (MG, Zimmer, Warsaw, IN, USA) (n = 34), [MGI (n = 24) and MGII (n = 10)], and several other surface replacement type prostheses (n = 20). Components were fixed with bone cement in 104 joints (70%), and without cement in 44 joints (30%). The group that underwent staged TKA during one hospitalization (group II) consisted of 22 patients (44 joints). The indications for the staged operation included mental or physical inability to tolerate the sameday operation. The physical contraindications included uncontrolled hypertension or diabetes, severe heart disease, renal insufficiency, and liver dysfunction. The group consisted of 18 women and 4 men; 14 patients had RA and 8 had OA. Age at time of operation ranged from 50 to 75 years (mean, 64.1 years). The follow-up period ranged from 2 years to 9 years and 5 months (mean, 6.2 years). The prostheses used in this group were: MG (n = 20) [MGI (n = 16) and MGII (n = 4)], Kinematic stabilizer (Howmedica, Rutherford, N J, USA) (n = 12), and other types of surface replace-
ment prostheses (n = 12). Bone cement was used for fixation of components in 34 joints (77%). Cementless fixation was chosen in 10 joints (23%). All patients (groups I and II) were hospitalized 1 week before the scheduled date of surgery to permit thorough preoperative medical evaluation.
Operative method The patients, received combined (spinal and epidural) anesthesia, and the operative procedure was performed in a clean room by two surgical teams, each of which included a surgeon and one assistant. The chief surgeon, who was on the first team, started the operation on one side; an air tourniquet was used. Twenty to 30min later, the second team started the procedure on the other side, also using an air tourniquet. A time lag of 20-30 min was maintained throughout the operation, so that the chief surgeon could constantly supervise progress on both knees. To avoid stress to the cardiovascular system, the tourniquets on the two knees were applied and released at intervals of 15-20rain. The tourniquets were released for 10rain so that hemostasis could be achieved. They were then, reapplied to protect against further bleeding from bone prior to skin closure. Epidural anesthesia was maintained continuously for 3 or 4 days postoperatively to avoid postoperative pain in the two knees. For hemostasis, when the TKA was completed and the wound bandaged, 50cc of saline, containing epinephrine (1:200000) and 0.5g antibiotic (Flomoxef sodium, Flumarin, Shionogi, Osaka, Japan) was injected into the knee via the drain. The drain was clamped for 20h (overnight) (drain clamp method). It was then unclamped to begin aspiration. The drain was retained for 48 h after surgery. This procedure was employed in all patients. The operative schedule in group II consisted of unilateral TKA on each knee, with a 3- to 4-week interval
J. Ryu et al.: Simultaneous bilateral knee arthroplasty between the first and second surgeries; these were carried out during the same hospital stay. In both group I and group II, a regimen of continuous passive motion (CPM) was begun 3 days after operation. After 2 weeks (with cement fixation) or 3 weeks (without cement), full weight-bearing and ambulation exercises were begun. The postoperative rehabilitation schedules and exercises were the same in the two groups and were continued for 3 - 4 weeks. Follow-up examinations were p e r f o r m e d at 3- to 4-month intervals after the patients were discharged from hospital.
Methods of assessment Comparisons were made between groups I and II. K n e e function, based on the functional evaluation score established by the Hospital for Special Surgery, 4 was assessed before and after the operation. The range of motion ( R O M ) before and after surgery, the total volu m e of blood loss during and after the operation, the operative time, the duration of hospital stay, and the incidence of complications were c o m p a r e d in the two groups. T h e significance of differences between the val-
353 ues in groups I and II for the knee function score, R O M , the total volume of blood toss, the operative time, and hospital stay was evaluated using the unpaired t-test. The incidence of complications was assessed by Fisher's exact probability test. A probability(P) value of less than 0.05 was considered significant.
The m e a n functional evaluation score in group I was 41.2 points before surgery and 84.3 points at follow-up; i.e., there was a 43.1 point gain after operation, with rehabilitation. In group II, the m e a n scores were 41 and 82.4 points, respectively, with a 41.4 point gain at follow-up (Table 2). The m e a n postoperative score in group I was not significantly different from that in group II. The m e a n pre- and postoperative R O M values in group I were 101 and 109 degrees, respectively, and values in group II were 97 and 110 degrees, respectively. The m e a n R O M before and after operation did not differ in the two groups.
Table 2. Functional score and range of motion before and after total knee arthroplasty
Group I (148 knees of 74 patients)
Group II (44 knees of 22 patients)
Functional Score (points) Preop 41.2 _+ 13.2 (14-65) Postop 84.3 -+ 5.6 (73-94)
41 _+ 11.7 (17-66) 82.4 -+ 5.9 (70-92)
NS (P = 0.972) NS (P = 0.468)
Range of motion (degrees) Preop 101 _+ 25.0 (50-140) Postop 109 -+ 15.1 (75-135)
97 -+ 25.7 (40-140) 110 _+ 26.7 (45-135)
NS (P = 0.726) NS (P = 0.919)
NS, Not significant. Knee scores assessed based on functional evaluation score established by the Hospital for Special Surgery4. Numbers in parentheses indicate ranges. Values are means _+ SD. Group I, Simultaneous bilateral TKA; group II, Staged bilateral TKA
Table 3. Blood loss during and after operation
Group I Both knees
Group II Both knees
During op (ml) After op (ml)
122 _+ 50.5 (60-250) 355 +_ 119.9 (110-550)
164 -+ 57.6 (115-320) 420 -+ 154.1 (150-640)
NS (P =0.1) NS (P = 0.306)
477 +- 147.5 (120-680)
584 _+ 151.8 (180-820)
NS (P = 0.127)
NS, Not significant. Numbers in parentheses indicate ranges. Values are means _+SD. Group I, Simultaneous bilateral TKA; Group II, Staged bilateral TKA
J. Ryu et al.: Simultaneous bilateral knee arthroplasty
Table 4. Operative time and duration of hospital stay
Operative time (min) Hospital stay (days)
Group I Both knees
Group II Both knees
153 • 29.6 (95-180) 48.5 • 13.1 (42-79)
185 • 28.1 (P = 0.023)* (135-240) 78 • 10.6 (P = 0.00003)* (66-101)
*Significant. Numbers in parentheses indicate ranges. Values are means + SD. Group I, Simultaneous bilateral TKA; Group II, staged bilateral TKA
The mean total (intra- and postoperative) blood loss for both knees for each group is shown in Table 3. In group I, blood loss during and after the operation was 477ml for both knees, whereas the blood loss for the two knees in group II was 584ml (Table 3). Blood transfusion was necessary for only two patients(3%), who had RA, in group I and for one patient(4.5%), who had RA, in group II. The operative time in group I was 32 min less than the duration of the bilateral T K A in group II (Table 4). The hospital stay in group I was also shorter than that in group II. In one patient in group I, the operation was abandoned. In two other patients in this group, it was decided, intraoperatively, to perform unilateral T K A because of cardiopulmonary problems which developed during the operation. For analysis, these three patients were excluded from group I. No other noteworthy intraoperative complications were recognized in either group I or group II. Postoperative complications were seen in only a few patients. These included delayed wound healing, deep infection, loosening of the prosthesis, and patellar prob-
lems. Cardiopulmonary complications and renal insufficiency were not seen. There were no significant differences between groups I and II with respect to complications (Table 5).
Discussion Until about 15 years ago, it was necessary for patients with severe bilateral knee joint destruction to undergo separate T K A operations at intervals of 3 months. After they had undergone the operation on one knee, however, severe pain and disability in the other knee often prevented effective postoperative rehabilitation or sufficient improvement in the activities of daily living. Furthermore, repetition of hospitalization, anesthesia, operation, and rehabilitation imposed severe physical, mental, and economic burdens. Against this background we began performing two separate TKAs on some of our patients at 3- to 4-week intervals during the same hospitalization. However, the two operations still entailed repeated anesthesia, operation, and rehabilitation. For this reason, we introduced simultaneous bilat-
Table 5. Complications during and after total knee arthroplasty
Medical complications Pulmonary embolism Myocardial infarction Transient confusion Fat embolism Surgical complications Delayed wound healing Deep infection Loosening of prosthesis Patellar problems
n = 74 patients 0 0 1 (1.4%) 0 n = 148 knees 4 (2.7%) 2 (1.4%) 0 9 (6%)
n = 22 patients 0 0 0 (P = 0.771) 0 n = 44 knees 2 (4.5%) (P = 0.417) 1 (2.3%) (P = 0.544) 1 (2.3%) (P = 0.229) 4 (9%) (P =0.344)
Group I, Simultaneous bilateral TKA; group II, staged bilateral TKA
J. Ryu et al.: Simultaneous bilateral knee arthroplasty eral T K A . Stanley et al. 1~studied 100 T K A surgeries in patients with R A and c o m p a r e d simultaneous bilateral surgery with staged bilateral replacement. All patients showed postoperative i m p r o v e m e n t of function. H o w ever, in those who had staged surgery, m a x i m u m benefit was achieved only after the second T K A . The complication rate was no greater for simultaneous surgery. Accordingly, these authors advocate simultaneous T K A for those patients who require bilateral replacement. Morrey et al. 7 have reported that the incidence of morbidity and m o r t a l i t y associated with simultaneous bilateral T K A is no greater than that found when the procedure is p e r f o r m e d during the same hospitalization or during separate hospitalizations. W a p n e r et al. 11 and Gradillas and g o l z 3 have recomm e n d e d staged bilateral T K A because of the decreased incidence of deep venous thrombosis and p u l m o n a r y embolism. D o r r et al. z have reported fat embolism in 12% of patients after bilateral T K A p e r f o r m e d with intramedullary instrumentation. On the other hand, Ritter and Meding, 8 who reported a comparison of 132 patients who underwent simultaneous bilateral T K A and 77 patients who underwent the unilateral procedure, found that bilateral T K A , as a single procedure, did not increase the risk of complications in the postoperative or follow-up period. It was noted that bilateral T K A as a single procedure decreased the risk of phlebitis and p u l m o n a r y embolism. Our study revealed no significant differences between the two groups of patients with respect to functional score, postoperative R O M , or operative and postoperative complications. No serious complications, such as p u l m o n a r y embolism or deep venous thrombosis, were noted in either group after surgery. Simultaneous bilateral T K A has considerable advantages. A single operation is performed, with minimization of the attendant risk of anesthesia. The hospital stay is shorter and the costs are lower (less than twice the cost for unilateral T K A ) . Moreover, a simultaneous operation by two surgical teams requires a shorter operative time than that one t e a m for two operations. The disadvantages associated with simultaneous bilateral T K A include considerably greater blood loss during and after the operation than occurs with the unilateral procedure, postoperative pain in both knees rather than one knee, the potential for interference with the other surgical field and for confusion at the operating table, and the requirement for four surgeons to carry out the procedure. In our patients, blood transfusion was seldom necessary because we used the drain clamp
355 m e t h o d to prevent excess bleeding after the operation. As epidural anesthesia was employed continuously from the time of operation for 3 or 4 days postoperatively, the patients did not have intolerable pain in either knee after the operation. The t e a m m e m b e r s are now experienced with this procedure, and there is now no confusion at the operating table. The advantages of the procedure, we believe, outweigh the disadvantages and we therefore plan to continue performing simultaneous bilateral T K A in carefully selected patients who have destructive changes in both knees, for which T K A is indicated; who are considered physically and mentally able to withstand this T K A procedure; and who express a preference that the operation be p e r f o r m e d at a single surgery. Simultaneous bilateral T K A p e r f o r m e d under single anesthesia does not involve serious disadvantages compared with unilateral T K A . The operative m e t h o d has the advantages of a single anesthesia, less total operative time, shorter hospital stay, and lower total cost of treatment. With careful, and appropriate determinations of the indications, we r e c o m m e n d this m e t h o d in appropriate candidates.
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