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. 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

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

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: 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

Background. Evidence from recent trials has supported the efficacy of periarticular analgesic injection for pain control following total knee arthroplasty (TKA). However, no randomized controlled trial has compared the efficacy of periarticular analgesic injection with that of other regimens for simultaneous bilateral TKA. Methods. We conducted a randomized controlled trial in which patients scheduled for simultaneous bilateral TKA were randomly assigned to receive periarticular analgesic injection or epidural analgesia. In the periarticular analgesic injection group, the injection contained 7.5 mg/ml ropivacaine 40 ml, 10 mg/ml morphine hydrochloride hydrate 1.0 ml, 1.0 mg/ml epinephrine 0.6 ml, methylprednisolone 80 mg, and ketoprofen 50 mg. These agents were mixed with normal saline to a combined volume of 120 ml. The 60 ml of the cocktail was injected into each knee. In the epidural analgesia group, the catheter was placed at the L2–3 or L3–4 level, and connected to an infusion pump delivering continuous infusion (flow rate: 4 ml/h) of 100 ml of 2 mg/ml ropivacaine plus 1.0 ml of 10 mg/ml morphine hydrochloride hydrate. Surgery was managed under spinal anaesthesia. Surgical techniques and postoperative medication protocols were identical in both groups. The primary endpoint was postoperative pain at rest, quantified as the area under the curve (AUC) of the score on a visual analogue scale. Results. Seventy-one patients with 142 knees were randomly assigned to receive periarticular analgesic injection or epidural analgesia. The flow chart presented in Figure 1 outlines the trial. The periarticular analgesic injection group had a significantly lower AUC at 4–24 hour compared with the epidural analgesia group (174.9 ± 181.5 versus 360.4 ± 360.6; p = 0.0073), while no difference in the AUC was noted at 24–72 hour (1388.1 ± 727.2 versus 1467.3 ± 810.1; p = 0.67). The consumption of diclofenac sodium suppositories as rescue analgesia was significantly lower in the periarticular analgesic injection group than in the epidural analgesia group on the night of surgery (0.16 ± 0.4 versus 0.70 ± 0.9; p = 0.0013). The incidence of nausea on the night of surgery and postoperative day 1 and that of pruritus were significantly lower in the periarticular analgesic injection group than in the epidural analgesia group (7.4 % versus 45.5 %; p = 0.0031, 7.4 % versus 54.5 %; P = 0.0003, and 0 % versus 15.2 %; p = 0.014, respectively). Conclusions. Compared with epidural analgesia, periarticular analgesic injection following simultaneous bilateral TKA was associated with better postoperative pain relief and decreased opioid-related side-effects. Periarticular analgesic injection is preferable to epidural analgesia for postoperative pain relief after simultaneous bilateral TKA

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

Total knee arthroplasty (TKA) is done primarily for pain relief, and function improves when there is less pain. Greater understanding of the biomechanical functioning of the knee has led to an improvement in prosthetic implants. Surgical technique, which plays an important role in the overall outcome of TKA, has also improved over the years. Simultaneous bilateral total knee arthroplasty (SBTKA) is one of the latest techniques employed by arthroplasty surgeons. SBTKA has advantages and disadvantages, and there are clearly diverse reactions to it from surgeons treating patients with bilateral osteoarthritis. We reviewed 87 patients who underwent SBTKA and compared complications, costs and functional results with those of patients who underwent staged TKA. The same surgeon performed all the operations. There was strict adherence to a consistent preoperative, intraoperative and postoperative protocol. Our results showed that the complications of SBTKA are not significantly different from of staged TKA. SBTKA is definitely more cost-effective, and rehabilitation and function were the same as in patients who had a staged procedure

Today the use of pneumatic tourniquet is commonly accepted in total knee arthroplasty (TKA) to reduce perioperative blood loss. There are a few prospective randomised and nonrandomised studies that compare the effect of tourniquet release timing in cementless or cemented unilateral TKA. However, many of these studies show an inadequate reporting and methodology. This randomized prospective study was designed to investigate the efficiency of tourniquet release timing in preventing perioperative blood loss in a simultaneous bilateral TKA study design. To our knowledge, this is the first study of its kind, in which the effect of tourniquet release timing on perioperative blood loss was investigated in simultaneous bilateral cemented TKA. In 20 patients (40 knees) one knee was operated with tourniquet release and hemostasis before wound closure, and the other knee with tourniquet release after wound closure and pressure dressing. To determine the order of tourniquet release technique for simultaneous bilateral TKA, patients were randomized in two groups: ‘Group A’ first knee with tourniquet release and hemostasis before wound closure, and ‘Group B’ second knee with tourniquet release and hemostasis before wound closure. The blood loss was recorded 48 hours postoperative for each technique. We found no significant difference in total blood loss between both techniques (p =.930), but a significant difference in operating time (p =.035). There were no postoperative complications at a follow-up of 6 month. Other studies report an increase the blood loss in early tourniquet release and an increase the risk of early postoperative complications in deflation of tourniquet after wound closure. In this study we found no significant difference in perioperative blood loss and no increase of postoperative complications. Therefore, we recommend a tourniquet release after wound closure to reduce the duration of TKA procedure and to avoid possible risks of extended anaesthesia

Introduction. Total knee arthroplasty (TKA) is an effective surgical intervention, which alleviates pain and improves function and health-related quality of life in patients with end-stage arthritis of the knee joint. With improvements in anesthesia, general health care, and surgical techniques, this procedure has become widely accepted for use in very elderly patients. However, many elderly patients tend to have compromised function and low reserve capabilities of organs and are therefore likely to develop various complications during the perioperative period. Thus, elderly patients often hesitate to undergo simultaneous bilateral TKA (SBTKA). Our purpose was to report the short-term results and clinical complications of octogenarians undergoing SBTKA. Materials and Methods. Between 2015 and 2016 all patients greater than 80years of age who underwent SBTKA by a single surgeon were retrospectively evaluated demographics, comorbidity, complications, and 30days mortality following SBTKA. Arthroplasty was performed sequentially under general anesthesia by one team led by primary surgeon. After the first knee, the patient's cardiopulmonary status was assessed by anesthesiology to determine whether or not to begin the second side. Cardiopulmonary decompensation, such as significant shifts in heart rate, oxygen saturation or blood pressure, was not showed. Then the second procedure was undertaken. Inclusion criteria of this study was underlying diseases were osteoarthritis. Exclusion criteria were (1) previous knee surgery; (2) underlying diseases were osteonecrosis, rheumatoid arthritis, fracture, and others. Fifty-seven patients with an average age of 82.7years were identified. The results of these procedures were retrospectively compared with those of patients greater than 80years of age of 89 patients unilateral TKA (UTKA) that had been performed by the same surgeon. Results. The study groups did not differ significantly with regard to age, gender, or body mass index. The mean age was 82.7years with a mean body mass index of 25.8 for the SBTKA group, compared with 84.0years with a mean body mass index of 24.9 for the UBTKA group. The length of hospital stay was longer in SBTKA groups. There was no serious complication. No deaths, no pulmonary embolisms and no nerve paralysis occurred within 30days in both groups. There was one wound problem in SBTKA group, compared 10 wound problem in UBTKA group; this difference was significant. Three deliriums occurred in SBTKA group, compared 13 deliriums in UBTKA group; this difference was significant. Minor complications included urinary tract infection, decubitus ulcer, transfusion reaction and ileus were noted seven in SBTKA group, compared in 11 UBTKA group; this difference was not significant. Conclusions. Complications and mortality are not higher for SBTKA compared to UTKA, SBTKA can be a safe and effective option for octogenarians

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

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

Total Knee Arthroplasty (TKA) has been widely performed and successful clinical outcomes have been achieved for the patients with knee osteoarthritis which is generally known to cause ADL problem. Clinical and radiographic evaluations are commonly used when evaluating postoperative outcomes, among which kinetic analysis and gait analysis are considered essential to investigate the more detailed effect of the treatment. There is a controversy whether performing TKA on both knees simultaneously is appropriate in treating patients with bilateral knee osteoarthritis, in terms of the speed and effectiveness of gait recovery. In this study, we reviewed the significance of performing simultaneous bilateral TKA, by the results of preoperative and postoperative gait analysis. Materials and Methods: Total of eight patients, all female and diagnosed of bilateral knee osteoarthritis, were treated with TKA and reviewed. Mean age was 70 years old (60–74). For prosthesis, we used Scorpio NRG PS, and ADVANCE, with cementation for all. No patella was replaced. Some had unilateral TKA, and some were treated bilaterally as needed. We examined distance factors (step length and step width), gait velocity, and gait barycentric factors (single-support phase and Ratio of center of gravity maximum values). We performed the analysis preoperatively, postoperatively at 1 month, 3 months, and 6 months. We used the floor pressure gauge (NITTA CORPORATION) and the three-dimensional motion analysis device (DITECT Co. Ltd) for the analysis. Results: During the six-month follow-ups, six cases were unilateral TKA and two were treated bilaterally. Increase in step length was seen in the unilateral cases, and it decreased in the bilateral cases. Step width decreased in five cases, two cases showed no change, and increased in one case. Gait velocity had increased in all cases. Single-support phase was close to 1 for all the cases. Ratio of center of gravity maximum values, which indicates the movement of centroid during ambulation, the ratio went up for unilateral cases while it showed no change in the bilateral cases. Discussion: Quantitative studies of gait analysis have reported that gait condition had improved after TKA. However, some reported that the gait impairment had remained. Unilateral TKA group showed gait restoration, whereas gait abnormality in either leg was seen in the bilateral group. Gait analysis is effective in determining whether surgeons should perform unilateral TKA or bilateral TKA to the patients with bilateral knee osteoarthritis. Among the gait analysis factors, we consider that Ratio of center of gravity maximum values shows effectively the improvement of the treated knee, gait, and the condition of contralateral knee

Aim: To identify the local and systemic morbidity of simultaneous sequential bilateral total knee arthroplasty in a large patient population and to undertake a comparative statistical analysis with a group of matched patients who underwent staged bilateral total knee replacement during the same period. Methods: Theatre records at two regional district general hospitals were scrutinised to identify all patients who had undergone simultaneous sequential and staged bilateral total knee arthroplasty over a three year period. Patient case notes and hospital charts were retrospectively reviewed to obtain several outcome measures to allow subsequent risk factor assessment. Results: 134 patients with 268 primary knee arthroplasties undergoing a simultaneous procedure were identified. The average age was 70 with a minimum follow up of 12 months. The study results revealed 1.5% mortality, 5.2% local complication and 14.9% systemic complication rates and this increased with age. During the same period 34 patients (68 knees) who had undergone staged procedures at least 3 months apart were also identified. Statistically significant findings between both groups included the reduced length of hospital stay, a 3-fold increase in the requirement for banked blood (particularly when either suction drainage or low molecular weight heparin thromboprophylaxis was used) and a higher degree of intra operative instability in those undergoing simultaneous bilateral total knee replacement. Conclusions: Patients can continue to enjoy the benefits of simultaneous bilateral knee arthroplasty, however, extreme caution must be taken in selection of patients over 75 years, high dependency facilities must be available and an acceptable alternative to banked blood transfusion needs to be used

INTRODUCTION: Many orthopaedic device companies now offer a high flexion (HF) choice within their knee Arthroplasty portfolios. Early published results are mixed between standard (STD) and HF knee devices despite claims of increased flexion with the HF offerings. The purpose of this randomized, controlled, simultaneous, bilateral study was to compare two coronally conforming rotating platform devices to determine if flexion differences were attributed to implant design. METHODS: Ninety-three subjects underwent simultaneous bilateral TKA across 8 centers. The HF device was randomly assigned to one side and the contralateral leg received the STD device. Average age was 61 years, 99% were diagnosed with osteoarthritis, 66% were females, average BMI was 32 and range of motion was measured by subjective expectations versus satisfaction. RESULTS: The HF design had statistically better single leg active flexion (SLAF) 12 months after surgery compared to the STD. Consistent with Gupta et. al, in a subgroup with pre-op flexion < 120 degrees in both knees, the HF device was statistically superior in passive flexion, ROM, and SLAF by between 1.8 and 4.5 degrees at 6 months, 12 months, and longitudinally over all postoperative intervals using raw degrees, improvement from pre-op, and adjusting for potentially confounding variables. 57% of subjects preferred their HF knee 6 months postoperatively, although there was no difference in preference at 12 months. DISCUSSION: The simultaneous bilateral design of this study necessitates that subjects act as their own control eliminating most confounding variables. Gains in postoperative flexion, although small, were superior in the HF TKA group and were greater in those subjects with less than 120 degrees of preoperative flexion, suggesting the ideal candidate for a HF TKA is one with lesser preoperative flexion

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

Bilateral one stage total knee replacement (TKR) has a number of advantages. There is one operative procedure and anesthetic and overall recovery time is significantly reduced. It is a more cost-effective procedure in that acute hospital stay is less and although rehabilitation time is greater in the short term, overall it is less. Additionally, if there is a bilateral flexion contracture present there is an inevitable loss of extension if a single knee is operated upon as this knee will assume the position of the unoperated knee. Patients greatly prefer having both knees corrected at one operative setting rather than having to have the inconvenience and pain associated with a second operative procedure at three to six months after the first one.

There are potential disadvantages to a one stage procedure. One concern has been that there is more peri-operative morbidity associated with one stage bilateral total knee replacement. In a review of 501 patients undergoing bilateral one stage total knee replacement at the Hospital for Special Surgery (HSS) there were no peri-operative deaths, myocardial infarctions or cerebrovascular accidents. There were arrhythmias present in 5% of patients. Fat emboli were present in 3% and 2 patients (0.4%) had pulmonary emboli. The average transfusion requirement was 2.6 units and allogeneic blood was required in 42%. There were 2 deep infections, 3 hematomas and 5 patients with delayed wound healing There was an increased incidence of major complications in patients with ASA classification 3 and with increasing age over 70 years.

New data indicates peri-operative administration of hydrocortisone may mitigate lung injury as demonstrated by reduction in cytokine and desmosine levels in a randomised trial. There was also a trend toward less need for narcotic medication and better range of motion in the steroid treated group

Patient selection is important and all patients are screened pre-operatively by an internist and anesthesiologist. In over 3000 bilateral TKRs at HSS infection rate and mortality were lower than in the unilateral total knee replacement patients. Much of this is due to patient selection criteria. All patients underwent the procedure with epidural anesthesia with post-operative epidural PCA for 48 hours. All patients are discharged on warfarin and spend the operative night in the recovery room. The procedure has acceptable morbidity and great advantage in properly selected patients.

Bilateral one stage total knee replacement has a number of advantages. There is one operative procedure and anesthetic and overall recovery time is significantly reduced. It is a more cost effective procedure in that acute hospital stay is less and although rehabilitation time is greater in the short term overall it is less. Additionally if there is a bilateral flexion contracture present there is an inevitable loss of extension if a single knee is operated upon as this knee will assume the position of the unoperated knee. Patients greatly prefer having both knees corrected at one operative setting rather than having to have the inconvenience and pain associated with a second operative procedure at three to six months after the first one.

There are potential disadvantages to a one stage procedure. One concern has been that there is more peri-operative morbidity associated with one stage bilateral total knee replacement. In a review of 501 patients undergoing bilateral one stage total knee replacement at the Hospital for Special Surgery there were no peri-operative deaths, myocardial infarctions or cerebrovascular accidents. There were arrhythmias present in 5% of patients. Fat emboli were present in 3% and 2 patients (0.4%) had pulmonary emboli. The average transfusion requirement was 2.6 units and allogeneic blood was required in 42%. There were 2 deep infections, 3 hematomas and 5 patients with delayed wound healing. There was an increased incidence of major complications in patients with ASA classification 3 and with increasing age over 70 years.

New data indicates peri-operative administration of hydrocortisone my mitigate lung injury as demonstrated by reduction in cytokine and desmosine levels in a randomised trial. There was also a trend toward less need for narcotic medication and better range of motion in the steroid treated group

Patient selection is important and all patients are screened pre-operatively by an internist and anesthesiologist. In over 3000 bilateral TKR at HSS infection rate and mortality were lower than in the unilateral total knee replacement patients. Much of this has is due to patient selection criteria. All patients underwent the procedure with epidural anesthesia with post-operative epidural PCA for 48 hours. All patients are discharged on warfarin and spend the operative night in the recovery room. The procedure has acceptable morbidity and great advantage in properly selected patients.