Simultaneous Bilateral Total Knee Arthroplasty Becomes Safer after Institution of Optimal Perioperative Management: A Longitudinal Cohort Study

Abstract

Simultaneous bilateral total knee arthroplasty (SBTKA) increases the rates of procedure-related complications and mortality compared with unilateral TKA. There are no well-defined guidelines for selecting patients to avoid mortality and proposing an upgrade treatment to decrease complication rates. This study aimed to evaluate whether optimal perioperative management could improve the safety of SBTKA. From 2005 to 2017, 1,166 cases of SBTKA were identified from 14,209 TKA procedures. We retrospectively examined the SBTKA patients' demographics, comorbidity profiles, procedure-related complications, and perioperative management during two time periods. Optimal perioperative workup for managing SBTKA significantly decreased the incidences of major complication from 6.2 to 2.4% (p = 0.001) and minor complications from 28.9 to 21.5% (p = 0.004) during period I and period II, respectively. The efficiency of less tourniquet use along with intraarticular tranexamic acid injection was demonstrated by the decreases of hemoglobin (Hb) change in the first 2 days after surgery (p = 0.005) and blood transfusion requirement (p = 0.035) during the SBTKA. Furthermore, the less tourniquet use group had less thigh pain (visual analog scale decreased from 6.0 to 4.2, p = 0.003), shorter duration of hospital stay (decreased from 7.8 to 7.1, p < 0.001), and lower coagulation time (decrease from 3.5 to 2.9, p < 0.001) than the routine tourniquet use group. Patient's screening must be performed carefully for cardiopulmonary compromise in patients aged >80 years and with an American Society of Anesthesiologists score of 3. Additionally, hospitalists should consider developing methods for the eligibility, testing, and perioperative monitoring of patients who undergo SBTKA with the aim of avoiding complications and improving outcomes.

The safety and cost-analysis of simultaneous versus staged bilateral total knee arthroplasty in a Taiwan population

“…Recent studies suggest that careful selection of patients can reduce complications to similar rates. 7,11,15,16 For instance, patients who are older and/or have concomitant cardiopulmonary conditions, who are morbidly obese (BMI >40 kg/m 2 ) or have higher ASA scores should be treated with caution, due to a relatively higher risk of surgical complications. 8,[17][18][19] Interestingly, SiTKA is considered a safe procedure in patients with conditions such as rheumatoid arthritis, end-stage hemophilic arthropathy, and moderate obesity (BMI 30-35 kg/m 2 ), all conditions previously considered risk factors for postoperative complications in unilateral TKA.…”

“…26 The use of intraoperative tranexamic acid via the intravenous or intraarticular route can also effectively reduce blood loss. 16 At our institution, based on preference, the surgeon may use one or more of these methods. Therefore, although SiTKA involves substantial blood loss and higher rates of transfusion, the overall rate of adverse reactions is minimal.…”

The safety and cost-analysis of simultaneous versus staged bilateral total knee arthroplasty in a Taiwan population

“…Recent studies have suggested that careful selection of patients can reduce complications to similar rates. [3,11,27,28] For instance, patients that are older and/or have concomitant cardiopulmonary conditions, morbidly obese (BMI>40 kg/m 2 ), and higher ASA scores should be treated with caution due to a relatively higher risk for surgical complications. [7,9,10,24] Interestingly, SiTKA is considered to be a safe procedure in patients with conditions such as rheumatoid arthritis, end-stage hemophilic arthropathy, and moderate obesity (BMI 30-35 kg/m 2 ) which were previously thought as risk factors for postoperative complications in unilateral TKA.…”

“…[22] Furthermore, the use of intraoperative tranexamic acid via intravenous or intraarticular route have been also shown to effectively reduce blood loss. [3] In our institution, one or a combination of the above methods are currently in practice and is dependent on the surgeon's preference. Therefore, although there is substantial blood loss and higher rates for transfusion, the overall rate of adverse reactions is minimal.…”