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

Introduction. Bilateral TKA is proven to be safe in a select group of patients. Patients with symptomatic bilateral knee arthritis who are not candidates for simultaneous bilateral TKA are subjected to staged surgery. The main objective of this study is to determine the safe window when second TKA can be performed in patients requiring bilateral TKA. Methods. Retrospective study includes bilateral TKA cases performed in a single institution between 2000–2018. A cohort of simultaneous bilateral TKA (n=2728) was compared to cohort of staged bilateral TKA (n=1660). Outcomes in terms of complications, reoperation, 30 days readmission and cumulative revision rates were compared between the two groups using both non-adjusted and adjusted models. Results. In-hospital complication rates were lower in the staged TKA group in both adjusted model (OR 0.59:0.48 – 0.72)(p <0.001), and unadjusted model (OR 0.54:0.47–0.63)(p<0.001). Although DVT rates were similar between both groups, odds of PE were higher in the simultaneous BTKA group (1.91% vs 0.54%)(p< 0.001). No statistically significant difference was found in reoperation rate between the groups both in the adjusted and unadjusted analyses. All causes revision rate in simultaneous TKA was significantly higher at 6.41% vs 2.35% for the staged TKA gr (OR 0.35 P<0.001). However, revision due to deep infection was higher in the staged group. No difference in complication rate after the 2. nd. surgery was detected when staging TKA was done less than 90 days apart compared to staging > 90 days (80.2% vs 79 %)(p=0.885). Conclusion. This single institution study demonstrates that bilateral TKA performed under the same anesthesia is associated with more complications and revisions than when compared to staged bilateral TKA. Furthermore, performing the second stage TKA under 90 days after the 1. st. TKA was not associated with more complications. Therefore performing simultaneous BTKA, simply for convenience, is not warranted

Introduction. A large proportion of patients undergoing total knee arthroplasty (TKA) have severe osteoarthritis in both knees and may consider either simultaneous or staged bilateral TKA. The implications of staged versus simultaneously 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 to the sum of days missed from each surgery for patients who underwent staged bilateral TKA. Methods. The prospective arthroplasty registry at Hospital for Special Surgery was utilized. We identified 61 employed patients who had undergone staged bilateral TKA and 152 employed patients who had undergone simultaneous bilateral TKA and had completed the registry's return to work questionnaire. Baseline characteristics and patient reported outcome scores were evaluated. We used a linear regression model, adjusting for potential confounders including age, sex, pre-op BMI, and work type (sedentary, moderate, high activity, or strenuous), to analyze workdays lost after staged versus simultaneous bilateral TKA. Results. Staged patients missed a mean total of 67.9±46.1 days of work across both TKA surgeries, compared to 46.5±29.0 days missed in the simultaneous group (p<0.001). In multivariate mixed regression analysis, adjusted for age, sex, BMI, ASA status, and work type, the staged group missed 16.9±5.7 more days of work compared to the simultaneous group (95%CI 5.8 to 28.1, p=0.003). Compared to sedentary work type, patients with high or strenuous work activity missed 19.4±9.4 (p=0.040) more total work days. Conclusions. Employed patients undergoing simultaneous bilateral TKA missed 17 fewer days of work over the course of their surgical treatment and rehabilitation compared to those undergoing staged bilateral TKA. This information may be useful to surgeons counseling patients with bilateral knee osteoarthritis about staged versus simultaneous bilateral surgery

Abstract. Introduction. Multiple strategies, used either in isolation or combination, are available to reduce the need for post-operative blood transfusion in joint replacements. Amongst them, the use of tranexamic acid (TXA) has been rising and this study was conducted to compare the efficacy of topical and intravenous TXA in bilateral total knee replacement patients. Materials and methods. Randomised prospective study with 120 patients (male: female: 25:95) undergoing bilateral TKA. Patients were divided into two groups A and B after computer randomization, who received intravenous or topical (intra-articular) TXA respectively. Results. The average haemoglobin loss in intravenous group was 90.2379 g/L as compared to 39.137 g/L in topical group (p < 0.005). Moreover, there was reduction in blood loss in topical (330.1602 ml) as compared to intravenous group (764.9622 ml). The blood transfusion rate was more for the intravenous group (average 1.73 units) than for the topical group (average 0.75, unit). WOMAC score at 6 weeks in the intravenous group was 12.50, and in the topical group was 7.23 (p value < 0.001). Conclusion. Topical TXA is better than intravenous TXA for reduction of blood loss, which also reduces the need for blood transfusion in bilateral TKA patients

Introduction. Patient self-reported outcome scales have recently been used to evaluate total knee arthroplasty (TKA) outcomes. Many follow-up studies have been conducted on patients undergoing TKA; however, they have mostly reported outcomes after unilateral TKA. We believe that a longitudinal study after bilateral TKA will be more useful in evaluating the quality of life (QOL) of such patients. Objectives. The objective of this study was to longitudinally evaluate QOL using the Japanese Knee Osteoarthritis Measure (JKOM). Objective outcomes were assessed using the Knee Society Score (KSS) and the Timed Up and Go test (TUG) for more than 5 years after bilateral TKA. Furthermore, QOL and objective outcomes were compared between younger (age ≤ 80 years at the final follow-up point) and older (age > 80 years) age groups. Methods. In total, 109 patients underwent two-staged bilateral TKAs for varus knee osteoarthritis at our clinic between October 2006 and March 2013. Of these patients, 78 were evaluated preoperatively (Pre) and at 1, 3 and 5 years or more (average, 6.7 years; range, 5–10 years) after bilateral TKAs using JKOM, KSS and TUG. The average patient age at the time of the first and the contralateral TKAs was 73.3 (range, 61–85) years and 74.0 (range, 62–85) years, respectively. The average patient age at the final follow-up point among younger (36 patients) and older (42 patients) age groups was 75.8 (range, 67–80) years and 84.7 (range: 81–92) years, respectively. The outcomes at each evaluation point were compared using Steel–Dwass test. A comparison of the JKOM scores and objective outcomes between the younger and older age groups was performed using Mann–Whitney U-test. P values < 0.05 were considered significant. Results. A significant improvement in the JKOM score was observed between ‘Pre’ and ‘1 year after bilateral TKA’; the improvement was maintained until the final follow-up point. All four subscales in JKOM showed the same improvement as JKOM itself. Furthermore, significant improvements in the total KSS, knee and function scores were observed between ‘Pre’ and ‘1 year after bilateral TKA’; the improvement was maintained until the final follow-up point. A significant improvement in the TUG scores was observed between ‘Pre’ and ‘1 year after bilateral TKA’; although the improvement was maintained for 3 years, there was a small but significant deterioration at the final follow-up point. Although the average age difference between the two groups was 8.9 years, no significant differences were found in the JKOM and objective outcome scores between the younger and older age groups. Conclusions. This is the first longitudinal mid-term follow-up study to evaluate QOL after bilateral TKAs. The JKOM and objective outcome scores reached a plateau 1 year after bilateral TKA, and the improvement was maintained for an average of 6.7 years; however, TUG scores showed a small deterioration at the final follow-up point. The improvement in the JKOM and objective outcome scores maintained by the older age group was equivalent to that by the younger one

Introduction. At a time when many surgeons are reluctant to perform a unilateral TKA in the obese patient, little is written on the safety and efficacy of bilateral simultaneous TKA in this same patient population. While these potential benefits are attractive to patients, surgeons may be hesitant to perform bilateral TKA due to the greater physical demand placed on the patient, and a potential increase in postoperative complication. The primary aim of this study was to analyze the impact of obesity on clinical outcomes and complication rates of patients undergoing bilateral TKA under one anesthetic. Materials and Methods. The clinical outcomes of 133 patients (266 knees) who underwent bilateral TKA between 2013 and 2016 were reviewed. The procedures were performed by three separate surgeons across three major academic institutions. ASA scores, tourniquet time, operative time, blood loss, length of stay, readmission, and postoperative complications were compared between different BMI categories of less than 30 kg/ m2, 30–34.99 kg/ m2, 35–39.99 kg/ m2and above 40 kg/ m2. Results. There were 83 females and 50 males who underwent bilateral TKA identified, with an average age of 60.17 years. The average LOS was 5 days and there was no significant impact of BMI on the length of stay or blood loss. 31 out of 133 patients experienced either a minor or major complication postoperatively (Table 1). Obese patients experienced more complications than non-obese patients. Specifically, patients identified as morbidly obese experienced a complication rate of 44.4%. This was significantly higher than the complication rate in the non-obese (less than 30 kg/ m2) patient cohort, 20.8% (p=.034). Of the 31 complications, 10 patients required a return to the operating room for a manipulation under anesthesia. There was no significant difference in the manipulation rate for the obese and non-obese patient. As BMI increased; postoperative ROM displayed a trend in the negative direction (Table 2). On average, obese patients had significantly higher ASA scores, with only 13.8% of patients with a BMI below 30 assigned an ASA score of 3 in comparison to 50% of patients with a BMI of 40 and above (p= .013) (Table 3). Higher BMI was significantly correlated with longer operative times (p=.002). Conclusion. Similar to numerous unilateral TKA studies in the obese patient, greater complication rates in the obese patient population were noted. The majority of complications that occurred within the time of this study were minor and did not affect the outcome of the procedure. Surgeons should carefully analyze the comorbidities of patients with a BMI above 40 kg/m2 such as cardiac history, diabetes mellitus, and smoking status when considering operating on morbidly obese patients and take steps to address these comorbidities and maximize the patient prior to surgery. For any figures or tables, please contact authors directly

For 3 decades surgeons have vigorously debated whether it is reasonable to offer simultaneous bilateral total knee replacement (TKA) to patients. Even after this substantial period of time there remain no randomised clinical trials that have addressed this issue and thus, it remains difficult to fully evaluate both the relative risks and the absolute risks of bilateral simultaneous versus staged bilateral knee replacement. What has emerged over the past couple of decades, however, is an understanding that there is a subset of patients with substantial comorbidities such as pre-existent cardiac disease and advanced age for whom bilateral simultaneous knee replacement seems unwise. For younger or otherwise healthy patients the debate continues in 2016 and seems to be focused less on the data itself than on how individual surgeons come to reconcile the differences between Relative Risk and Absolute Risk. When data is pooled from multiple retrospective studies of simultaneous versus staged bilateral TKA there are 2 clear trends that appear in the data. First, the relative risk of certain substantial complications (cardiac, thromboembolic, neurologic, gastrointestinal, and death) seems to be higher after simultaneous bilateral TKA than after staged bilateral TKA. Oakes and Hanssen highlighted these differences in Relative Risk noting that for each of those 5 outcomes there was a 2 to 5 times greater incidence of these complications after bilateral versus unilateral TKA. At the same time, however, it is clear that for most medically uncomplicated patients the Absolute Risk of a major complication is still fairly low — it is likely that >93% of such patients can undergo simultaneous bilateral TKA without encountering a major complication. Individual surgeons and individual patients often view those kinds of statistics in markedly disparate ways. One set of surgeons and patients will view the Relative Risk as most important and be decidedly concerned about the 2–5 times higher risk of certain complications. Another set of patients and surgeons will look at the Absolute Risk as most important and determine that it is decidedly most likely (>93%) that an individual healthy patient will make it through bilateral simultaneous TKA without major medical complications. Overall the conclusions of Oakes and Hanssen from a decade ago remain relevant in 2016: the overall risk of a peri-operative complication is higher with simultaneous bilateral TKA … and this is particularly true for the risk of peri-operative death. While some surgeons and some patients will decide that the increases in Relative Risk is offset by the fairly low Absolute Risk of complications and thus, feel comfortable with bilateral simultaneous TKA, other patients and other surgeons will not

Introduction. Bilateral total knee arthroplasty (TKA) can be performed under a single-anesthetic (SA) or staged under a two-anesthetic (TA) technique. Recently, our institution began piloting a two-surgeon team SA method for bilateral TKA. The purpose of this study was to compare the inpatient costs and clinical outcomes in the first 90 days after surgery between the team SA, single-surgeon SA, and single-surgeon TA approaches for bilateral TKA. Methods. All primary TKA performed from 2007–2017 by the two participating surgeons for each of the 3 groups of interest were identified: team SA (N=42 patients; 84 knees), single-surgeon SA (N=146 patients; 292 knees), single-surgeon TA (N=242 patients; 484 knees). No patients were lost to follow-up. Results. Median hospital cost (per TKA) for the episode(s) of care was as follows: team SA $20,962, single-surgeon SA $22,057, single-surgeon TA $31,145 (p<0.001 overall; p=0.0905 team SA vs single-surgeon SA). Rate of 90-day complications was 2.4% for team SA, 11.0% for single-surgeon SA, and 8.3% for single-surgeon TA (p=0.2090). Discharge to skilled nursing facilities or rehab was as follows: team SA 31%, single-surgeon SA 53% and single-surgeon TA after the second operation 34% (p<0.001). Conclusions. This pilot project suggests that team SA bilateral TKA is a potentially cost-effective option with fewer complications compared to single-surgeon SA bilateral TKA. The less frequent disposition to skilled nursing facilities in the team SA group in conjunction with more efficient OR utilization may further enhance the financial benefits

Background:. A large percentage of the patients who present for unilateral TKA have bilateral disease. Performing simultaneous, bilateral TKA has been debated and currently there is no consensus on the risks and benefit of this approach. In addition, specific selection criteria have not been defined to more accurately identify which patients are potentially appropriate candidates for this approach. Objectives:. The purpose of this study was to evaluate the clinical outcomes and peri-operative complications in simultaneous, bilateral TKA's using pre-operative patient selection criteria. Methods:. A retrospective analysis of 117 consecutive patients, (234 knees), was performed between February 2008 and March 2012 who underwent simultaneous, bilateral TKA performed by one surgeon under a single anesthetic. Pre-operative selection criteria were used for all patients to qualify for a simultaneous bilateral approach. This included the following: . 1). BMI less than 34,. 2). Minimum arc of motion to 100 degrees flexion,. 3). Flexion contracture less than 10 degrees,. 4). Varus or valgus alignment less than 10 degrees,. 5). No prior history of cardiovascular disease. 6). Age Less than 70 years old. Clinical outcomes were assessed including anesthesia type, tourniquet time, length of stay, transfusion rate, pre- op hemoglobin, post-op hemoglobin, pre-op range of motion, post-op range of motion, DVT and PE. Knee Society Score (KSS) and Functional KSS were assessed pre-operatively and 1 year post-operatively. Anatomic and mechanical axis evaluation was also performed on all patients with long standing radiographs pre and post operatively. A control group of 573 consecutive patients undergoing unilateral total knee arthroplasty during this same time period were identified and matched for the year of surgery, and prosthesis type. The same selection criteria were used for the control group and the same data points were evaluated. Results:. One hundred and seventeen consecutive patients, (234 knees), undergoing simultaneous, bilateral TKA were reviewed. There were no DVT's, or PE's. Nineteen percent required a transfusion for post-operative anemia. There were no cases of deep infection. Average pre-op KSS score was 49, with a post KSS score of 89 at an average follow-up of 1 year. Average pre-op Functional KSS score was 52, with an average post-op Functional KSS score of 91. Average ROM at one year post-op was 0 degrees of extension and 123 degrees of flexion. Average anatomic axis was 6 degrees valgus with a neutral mechanical axis restored in all patients. The clinical outcomes of the control group were comparable, with no statistically significant increase in the incidence of perioperative complications between the study group and the control group. Conclusion:. When the degenerative process involves both knees with comparable severity, the decision to perform total knee arthroplasty on one knee at a time with a staged approach, verses a simultaneous bilateral approach, has been challenging for many surgeons. There have been previous reports of increased perioperative complications associated with bilateral total knee arthroplasty, including increased risks of cardiovascular, neurological complications, as well as the increased demands on rehabilitation. Similarly, benefits of simultaneous bilateral total knee arthroplasty have also been identified such as, shortened rehabilitation, improved patient satisfaction, and decreased costs both to the patient and the hospital system. Using pre-operative patient selection criteria, the decision process in determining which patients are appropriate candidates for a bilateral approach can be facilitated, with clinical outcomes comparable to unilateral total knee arthroplasty

(Introduction). In Total Knee Arthroplasty (TKA), closed drains have been conventionally used to prevent hematoma. Recently reported “no-drain” methods have been demonstrated to be safe and effective, especially for decreasing hemorrhage. However, there has been no report of a major study on a no-drain method in simultaneous bilateral TKA, only a few small studies. Therefore, this study evaluated the efficacy of no-drain placement in simultaneous bilateral TKA. (Methods). Our study included 75 patients (150joints) with preoperative hemoglobin(Hb) level of at least 11.0 g/dl who underwent simultaneous bilateral TKA performed by the same surgeon in our department between January 2012 and December 2013. There were 12men and 63women, of average age 70.7 ± 7.9years (mean ± SD) and BMI 25.6± 3.8 (mean ± SD). Among them 72 patients had knee osteoarthritis and 3 patients had rheumatoid arthritis. The patella was not replaced in any of the cases. TKAs were performed separately on each knee. A tourniquet was applied between the initial skin incision and the postoperative dressing, and 1000 mg of tranexamic acid was injected into each joint after wound closure. (Results). The surgical time per patient was 136.6 ± 30.3 minutes (mean ± SD). The Hb levels (mean ± SD) were 13.0 ± 1.1 g/dl before surgery, 10.9 ± 1.2 g/dl on the day after surgery. The estimated total blood loss until the day after surgery was 558.4 ± 253.9 ml (mean ± SD). No patient experienced hypotension requiring vasopressor or rapid fluid therapy between the end of surgery and the day after surgery, and no complication caused by a sudden change of hemodynamics was found in any case of bilateral TKA. A gait training/range of motion exercise while bearing full load of the body weight was initiated from the day after surgery. This allowed patients to be discharged from our hospital in an average of 6.1days (range 5–11days)after surgery. There were no serious complications that occurred within three months after surgery. (Discussion). In cases of TKA with closed drain, even in unilateral surgery, excessive hemorrhage may be discharged through drain tubes for the first few hours after surgery. Hypotension caused by postoperative sudden hemorrhage or burden on the cardiovascular system seem to be major issues. In this study, simultaneous bilateral TKA were performed without suction drainage. The estimated blood loss until the day after surgery was approximately 560 ml. As sudden hypotension causing shock was not found, the post-operative hemorrhage seemed to have gradually progressed naturally. So we did not need the blood transfusion or rapid fluid therapy to any patient. This is one of the advantage of no-drainage method. (Conclusion). The simultaneous bilateral TKA without drain placement can be applied safely

BACKGROUND. This study aims to identify recent trends in discharge disposition following bilateral total knee arthroplasty (TKA) as well as factors that predispose patients to enter inpatient rehabilitation facilities (IRF) or skilled nursing facilities (SNF) versus home-rehabilitation (HR). The goal was to identify risk factors that predispose prolonged hospital stays and identify changes in management over time that may be responsible for decreased length of stay (LOS) and a HR program. METHODS. A retrospective cohort study design was used to collect and analyze clinical and demographic data for 404 consecutive bilateral primary total knee arthroplasty (TKA) procedures. Patients who underwent elective primary bilateral total knee arthroplasty from 2011 to 2016 were identified from hospital records at a single institution. Clinical and demographic data including sex, age, and disposition were analyzed. RESULTS. 404 bilateral TKAs were performed by 17 surgeons at a single institution from 2011 to 2016. The average age for bilateral TKA was 63y (31.4–86.6) and 59% were females (239/404). From 2011 to 2016, an increase of 61% (10% to 71%) was noted with regards to home discharge (22.035, <0.001), as well as an increase in the ratio of males being discharged home vs IRF/SNF (1.04 vs 2.4; 2.304, 0.008). Univariate analysis for factors associated with home discharge showed significance for age <60y (3.781, <0.001), age >70 (0.118, 0.001), the use of TXA (3.52, <0.001), type of implant (6.055, <0.001), low postoperative Hg (0.333, <0.001), and yearly trend (Pearson: 0.322, <0.001). Factors associated with prolonged LOS included age <60y (0.641, 0.029), age >70 (1.723, 0.032), active cancer (0.256, 0.027), low postoperative Hg (1.674, 0.020), and postoperative transfusion (1.667, 0.015). Multivariate regression for factors associated with a home discharge showed aggregate significance for BMI <25 (0.886, 0.024), use of TXA (1.139, <0.001), type of implant (1.310, 0.008), age <60 (0.956, 0.004), and age >70 (−1.627, 0.036). Multivariate logistic regression for factors associated with a prolonged LOS showed aggregate significance for active cancer (−1.654, 0.015), postoperative transfusion (0.485, 0.023), and age >70 (0.600, 0.024). CONCLUSION. There has been a significant trend towards postoperative home-rehabilitation programs rather than inpatient rehabilitation following bilateral total knee arthroplasty. There has also been a trend towards an increasing age for those undergoing bilateral total knee arthroplasty. Factors predisposing patients towards non-home discharge disposition include increased age and female gender. The increased use of both TXA and patient specific implants has led to a decrease in operative time and postoperative transfusion rates, and thus a decrease in the overall length of inpatient hospital stay

Introduction and Aims: Single-stage bilateral total knee arthroplasty is an uncommon and often controversial procedure. Recent reports have refined the data relative to bilateral total knee arthroplasty and complications, which include myocardial infarction, deep vein thrombosis, pulmonary embolus and death. Method: A retrospective study of the cases of total knee arthroplasty performed by the senior authors in the last 10 years examines details of surgery and anaesthesia, pre- and post-operative management to identify the occurrence of complications. Patients also completed an Oxford Knee Score and a questionnaire relating to their experience of having a bilateral procedure. Results: While the outcomes and cost benefits of single-stage bilateral replacement are established, the risk of complications remains. This study establishes the low complication rate associated with this procedure in the senior author’s hands and documents the high patient satisfaction from it. Conclusion: The study demonstrates that, in selected patients, simultaneous bilateral knee replacement surgery can be performed with good outcomes without a definite increase in peri-operative risk

Single-stage bilateral total knee arthroplasty is an uncommon and often controversial procedure. Recent reports have refined the data relative to bilateral total knee arthroplasty and complications which include myocardial infarction, deep vein thrombosis, pulmonary embolus and death. Less significant complications, including post-operative ileus and pseudo-obstruction are also more common following bilateral replacement. A retrospective study of the cases of total knee arthroplasty performed by the senior authors in the last ten years, examines details of surgery and anaesthesia, pre and post-operative management to identify the occurrence of complications. Patients also completed an Oxford Knee Score and a questionnaire relating to their experience of having a bilateral procedure. While the outcomes and cost benefits of single stage bilateral replacement are established, the risk of complications remains. This study establishes the low complication rate associated with this procedure in the senior authors’ hands, and documents the high patient satisfaction from it. The study demonstrates that, in selected patients, simultaneous bilateral knee replacement surgery can be performed with good outcomes without a definite increase in perioperative risk

Background. Bilateral leg alignment should be equal for preventing leg length discrepancy and diminishing limping in walking. The candidates for total knee arthroplasty (TKA) sometimes image bilateral TKA seems to get completely same shape and alignment of legs. The query that bilateral TKA, staged in a day and by one surgeon, has an advantage to reconcile one side alignment and component setting to another side, was investigated. Materials and methods. This retrospective investigation enrolled 408 knees of 204 patients (74 years old on average) underwent one day TKA and 48 knees of 24 cases (73 years old on average) underwent two days TKA. There were no history of trauma and surgery on both legs and no other obvious features. All components were same (Vanguard PS TKA, Biomet Inc. Warsaw IN). Surgical procedure is single (modified gap technique) with intramedullar rod for the femur and extramedullar system for the tibia without navigation system and patient specific instrumentation (PSI). Postoperative femorotibial angle (FTA), α, β, γ, δ angles were computed and the absolutes of differences between right and left were analyzed. (two sample t test). Results. Differences of postoperative FTA were 2.4 +/− 1.9 deg in one day, and 3.6 +/− 3.9 deg. in two days (p<0.05). Differences of α angle were 1.7 +/− 1.3 deg. in one day TKA and 2.5 +/− 3.4 deg. in two days TKA (p<0.05), β angle were 1.8 +/− 1.6 deg. and 1.7 +/− 1.4 deg. (ns), γ angle were 3.0 +/− 3.9 deg. and 3.0 +/− 2.6 deg. (ns), δ angle were 2.6 +/− 2.2 deg. and 2.7 +/− 2.5 deg. (ns) respectively. Discussion. Large volume surgeons purposely do fine adjustment of coronal alignment during operation even if they employ navigation system or PSI. The only landmark for the adjustment of the femur is impalpable femoral head that makes the adjustment difficult although there are several landmarks for the adjustment of the tibia that makes the adjustment reliable. The substitute method for the femoral adjustment is still inaccurate. Several factors such as more range of motion should be considered in sagittal alignment. The differences are wider in sagittal alignment as a result. In summary, bilateral TKA can reconcile one side alignment to other at coronal femoral alignment

Introduction. A large proportion of patients with osteoarthritis of the knee, present with bilateral symptoms at the outpatient department. A simultaneous total knee arthroplasty (TKA) procedure is available for such patients. The first operation in a simultaneous surgery may provide information to the operator to determine component size, soft tissue balancing, and estimate gap size for the second operation, while the second team usually conducts an operation in a confined space on the contralateral side during closure for the first operation, which can disturb cooperation during the second operation and may lead to more intra-operative surgical errors. We hypothesized that the circumstances of the two consecutive operations of a simultaneous bilateral TKA are different, could lead to different outcomes of overlapping bilateral TKAs. We therefore addressed the following research questions to determine whether there would be differences in short-term clinical outcomes, radiographic results, and implanted component size between the two sides. Methods. A retrospective review of 451 consecutive patients, who underwent simultaneous bilateral TKA between January 2011 and April 2012, was conducted. Bilateral TKAs were performed with the senior surgeon conducting the main procedure (from skin incision to implantation of first prosthesis until prior closure of the first knee) on the right side first and subsequently the left side with a second team. At 1 year after surgery, clinical outcome scores (the Knee Society Knee and Function scores, WOMAC score), radiologic findings were evaluated and clinical results as postoperative blood loss, operation time were compared between bilateral sides. Results. A greater incidence (16.1%) of outliers during postoperative coronal limb alignment (>±3o) were identified in the second TKA than those in the first TKA (9.0%) (p =0.003). Multivariate analysis for the association of outlier rates in the second TKA relative to the first revealed a significance for severity of the preoperative deformity (pre-op. coronal limb alignment, p = 0.002) and decreased ROM (p = 0.042) from the GEE analysis. The second knee also showed more blood loss (735 vs. 656mL), and longer operation time (61, 58 minutes respectively), as compared to the first TKA, while no significant differences in clinical outcomes. Discussion and Conclusion. There were no significant differences in the clinical outcomes even though few distinct outcomes due to different circumstances of the surgery. Awareness of these findings can help the continued success of bilateral TKA in an increasing patient population

Introduction: Morbidity and mortality are major concerns after simultaneous bilateral TKA. This paper reviews the results of patients who had simultaneous bilateral TKA (558 patients) and compares it to the results of single TKA (485 patients) carried out by the same surgeon in the same institution using same intra operative and post operative protocols. Material and methods: 558 patients underwent simultaneous bilateral TKA while 485 underwent single TKA carried out by the same surgeon. The pre-op medical evaluation was carried out by a special multidisciplinary medical team. The decision to proceed with simultaneous TKA was made based on the clinical findings pre operatively. There were no additional special cares for the simultaneous group (central or arterial line) during surgery. Post op protocols were the same for both groups. Results: Blood transfusion was higher in the simultaneous knee surgeries (71%) as compared to (34 %) in a single knee group. We had 8 unscheduled ICU admission in the simultaneous group compared to 2 in the individual. Surprisingly DVT was less common in the simultaneous group. We had one death in the simultaneous group. The average knee score and average range of motion were the same in both groups. Discussion and conclusion: Simultaneous bilateral TKA is safe. It is more economical and convenient, especially for patients who travel for the surgery. A special multidisciplinary task force is recommended to make the simultaneous knee surgery safe

Introduction. Peri-articular local anesthetic injections reduce post-operative pain in total knee arthroplasty and assist recovery. It is inconclusive whether intra-operative injection of peri-articular morphine is locally effective. The aim of this study is whether the addition of morphine to peri-articular injections in only unilateral knee improves post-operative pain, range of motion, swelling in patients with simultaneous bilateral total knee arthroplasty. Materials and Methods. A prospective single-center double-blinded randomized controlled trial was undertaken to assess the local efficacy of adding morphine to intra-operative, peri-articular anesthesia in simultaneous bilateral total knee arthroplasty. Twenty eight patients with 56 TKAs were randomly divided into 2 groups, unilateral TKA with intraoperative peri-articular injection with adding morphine and the other side TKA without adding morphine. The morphine group received an intraoperative, peri-articular injection of local anesthetic (Ropivacaine 150mg), epinephrine (50μg), ketoprofen (25mg) and methylpredonisolone sodium (20mg) plus 0.1mg/kg of morphine. The no-morphine group received the same amount of local anesthetic, epinephrine, ketoprofen and methylpredonisolone sodium without morphine. The operating surgeon, operating staff, patients, physiotherapists, ward nursing staff and data collectors remained blinded for the duration of study. All surgeries were performed by the same operating team. A standard medial parapatellar approach was used in all operations. Post-operative analgesia was standardized to all participants with celecoxib daily for 3 weeks. Primary outcomes included visual analog pain scores (VAS), ROM and swelling of the thigh. Secondary outcomes included WOMAC and adverse outcomes. Result. There were no significant differences between two groups for pre-operative ROM, pre-operative pain VAS or the circumference of the thigh. There were no statistically significant differences in primary and secondary outcomes between two groups (Figure 1, 2, 3). Discussion. Multiple studies have demonstrated the clinical efficacy of multimodal peri-articular injection of analgesics in TKA for pain relief. However, the opioids often lead to nausea as an adverse effect, which is reported from 25% to 56%. The mechanism of pain relief by morphine is mainly the efficacy through the opioid receptor in central nerve system, and the other mechanism through local opioid receptor (μ-receptor) is rarely revealed for pain relief. Our study used morphine in unilateral TKA and no-morphine in the other side TKA and showed no significant difference in primary and secondary outcomes. These results revealed that the efficacy for pain relief in peri-articular injection without morphine is the same as that in no-morphine group. In conclusion, adding morphine in peri-articular injection could not be locally effective for pain relief

Approximately 20% of patients undergoing primary unilateral total knee arthroplasty complain of severe pain in the contralateral knee, and 10% of patients who have had a primary total knee (TKA) undergo contralateral surgery within 1 year. The number of patients suitable for primary TKA is rising, and so is the need for simultaneous bilateral TKA (BTKA) procedures. The advantages of single-stage BTKA include its low complication rates, high patient satisfaction, and cost-effectiveness. Others believe that there is increased morbidity and mortality. The goal of reducing the exposure to repeated anaesthesia, total hospitalization and recovery time, and cost, while maintaining patient safety, is a laudable one. Our data suggest that bilateral TKA patients have a lower total operating time, use less pain medication, have a shorter hospital stay and lower overall treatment costs. The cohort of patients selected for bilateral surgery in our unit is younger and has fewer comorbidities than unilateral controls. They have a high satisfaction rate and no increase in complication or readmission rates. We have seen a higher blood transfusion rate but no increase in cardiac, thromboembolic or septic complications. The key to BTKA is patient selection and the implementation of efficient care and surgical pathways that includes a thorough pre-assessment, careful education and well-resourced aggressive post-operative physiotherapy. When appropriately applied, the benefits include a shorter overall recovery time and an accelerated return to everyday life and work

Objective: The aim of this study was to evaluate the safety and efficacy of sequential bilateral total knee arthroplasty (TKA) for patients with rheumatoid arthritis (RA), in comparison with staged bilateral and unilateral TKA. Patients and Methods: Between July 2000 and June 2005, 340 TKA were performed in our department. We investigated retrospectively the clinical data of each patient, including the peri-operative data such as the surgical time, the amount of haemorrhage and postoperative adverse events. We also examined the clinical outcome before and after bilateral TKA by using the Japanese Orthopaedic Association (JOA) evaluation chart of knee joint function (JOA score). Results: We have done sequential bilateral TKA for 60 knees of 30 patients (group A), staged bilateral TKA for 26 knees of 13 patients (group B) and unilateral TKA for 254 knees (group C). Before TKA, the mean JOA score were 44.9, 40.1, 46.4 points, and the mean range of motion of affected knees were 14.6–113.6°, 27.9–89.6°, 14.1–116.9° in group A, B and C, respectively, indicating that group B included more severe cases. Whereas the mean surgical time were 136.4, 158.4, 154.3 minutes, the mean amount of peri-operative haemorrhage were 414.6, 273.4, 277.7 ml in group A, B and C, respectively. Although we experienced 1 case with symptomatic pulmonary embolism in group A, which was successfully treated, there was none of cases with death within 1 month of surgery or early-phase infection. The JOA score at final follow-up (the mean follow-up period was 1 year and 8 months) were 91.1 and 86.9 points in group A and B, respectively, showing good results in both groups. Conclusion: In short-term data, sequential bilateral TKA was successfully performed and beneficial approach to patients with RA. The intensive pre- and post-operative management could be essential for good clinical outcome. Further improvement should be needed to perform this procedure more safely and prevent complications, especially serious cardiopulmonary events

Introduction. The purpose of this study was to determine the efficacy of a multi-modal blood conservation protocol that involved pre–operative autologous blood donations (2 units) in conjunction with erythropoietin supplementation as well as intra-operative conservation modalities. Methods. A retrospective chart review of 90 patients with simultaneous bilateral total knee arthroplasty done between 2006–2009 by one of the 3 senior authors was performed. Patients donated two units of blood 4 weeks prior to surgery and also received erythropoietin injections (40,000 units: 3 weeks, 2 weeks and 1 week prior to surgery). Intra- operative blood management included use of pneumatic tourniquet, re-infusion drains, local epinephrine injections and fibrin spray. Post-operatively, autologous transfusions were provided based on symptoms. Pre-donation blood levels, peri-operative hemoglobin and hematocrit levels along with transfusion records were assessed. Results. The mean pre-donation hemoglobin was 13.1 g/dL. After 2 units of autologous blood donation and procrit injections, the mean preoperative hemoglobin was 13.0 g/dL. The mean hemoglobin dropped to 9.8 g/dL on postoperative day 3. The mean drop in hemoglobin from preadmission testing was 3.3 g/dl. Overall, 30% patients required autologous blood transfusion and no patients required allogenic transfusion. Conclusion. This multi-modal protocol was effective in not only avoiding allogeneic transfusions following bilateral TKA but also resulted in high blood levels at the time of discharge. This protocol was effective in eliminating allogenic transfusions and maintaining blood levels