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Simultaneous Bilateral Knee Replacement The Barwon Health Experience

Simultaneous Bilateral Knee Replacement The Barwon Health Experience. Morrison SG Thomson AA Page RS Barwon Orthopaedic Research Unit. Conflicts of Interest. None to declare . Background. Patients requiring TKR often suffer from bilateral disease

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Simultaneous Bilateral Knee Replacement The Barwon Health Experience

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  1. Simultaneous Bilateral Knee Replacement The Barwon Health Experience Morrison SG Thomson AA Page RS BarwonOrthopaedic Research Unit

  2. Conflicts of Interest • None to declare

  3. Background • Patients requiring TKR often suffer from bilateral disease • Hence require both TKRs, prior to full pain relief and functional restoration • Postulated benefits of bilateral simultaneous TKR (BTKR): • Patient benefits • System benefits • Postulated disadvantages of BTKR: • Greater medical + surgical insult • Increased complication rates • Poorer outcomes

  4. Background • Barwon Health Orthopaedic Unit performs BTKR • Anecdotally unique for a Victorian health service • Study Aim to compare BTKR with STKR, with regards to: • Length of Stay (LOS) • Transfusion Rates • Complications • Outcomes (ROM + KSS)

  5. Methods • Retrospective Cohort Study • Prospective ethical approval (BORU Arthroplasty Register Approval 12/95). • Socrates™ and Filemaker Pro (HREC prospective databases) • Inclusion • All patients undergoing BTKR (simultaneous knee replacement by two surgeons and two registrars) • All patients undergoing STKR (Two procedures with 24 months, with bilateral disease at initial assessment) • Exclusion • Previous major knee surgery (eg. HTO, UKR) • Siimultaneous major knee procedure

  6. Methods • Patients offered BTKR if deemed appropriate by surgical and anaesthetic teams • Patients who declined BTKR were offered STKR • Standard unit protocols adhered to • Peri-operative antibiotic and VTE prophylaxis • Post-operative rehabilitation

  7. Methods • Filemaker Pro + Medical Records • Demographics CharlsonComorbidty Index (CCI) • Complications Transfusion, Surgical site infection, DVT, PE, AMI, re-operation, revision, acute renal failure, nerve palsy, death • Length of Stay Acute Ward, Rehabilitation • Socrates™ (Pre-Op, 12-18 month review) • Range of Motion • Knee Society Score • Knee Society Score (Function) obtained at pre-operative assessment, and 7-18 months post-operatively • Complications analysis per patient • Outcomes analysis per knee • Mann-Whitney U test utilised given different group sizes

  8. Results:Demographics

  9. Results:Length of Stay

  10. Results:Complications

  11. Results:Functional Outcomes

  12. Results:Functional Outcomes

  13. Results:Functional Outcomes

  14. Results:Summary No difference with regard to: • Complication Rates • Death Functional Benefits: • Increased KSS (Function) score post-operatively for BTKR knees • Greater increase in KSS and KSS (Function) score post-operatively for BTKR Knees System Benefits: • Shorter cumulative acute inpatient stay for BTKR patients

  15. Discussion:Complications Retrospective Cohort Studies Brotherton (1986) BTKR less costly, less bed days, vs. STKR (n = 18/29) Parvizi (2001) Mortality BTKR 0.49%, UTKR 0.17% (n = 2691/19861) Luscombe (2007) Increased morbidity, not mortality BTKR (n = 72/144) Yoon (2010) Systemic complications higher in BTKR (n = 119/119) Fabi (2011) Complications 2 x, 4 x Blood Tx (n = 150/150) (Complic 8 x if pulmonary disease) Husted (2011) BTKR longer LOS, more Tx, same outcome (n = 150/271) Peskun (2012) IHD + COAD risk factors for complications (n = 78/156) Prospective Cohort studies Kim (2009) No overall differences between groups (n = 2385/719) Lane (1997) BTKR longer stays, more Tx (n = 100/100) Low cost/benefit (vs. UTKR)

  16. Discussion:Complications Population Studies Ritter (1997) BTKR mortality higher, cost/LOS less (n = 112 922) Recommend 3-6 months gap Memtsoudis (2008) BTKR higher mortality (0.5% vs 0.3%) (n = 153 259/ 3 672 247) BTKR higher complications (12.2% vs 8.2%) Memtsoudis (2009) BTKR 2 x mortality (0.41% vs 0.30%) (n = 43 350/626 439) BTKR < 2 x complications (9.45% vs 0.14%) Meehan (2011) BTKR inc. AMI, PE (n = 11 445/23 715) CVA, Death, similar BTKR Infection, ‘mechanical malfunction’ lower Registry Studies Stefansdottir (2008) BTKR mortality 7.5x higher than after 2nd STKR (n = 1139/3432) “It is safer to operate on one knee at a time” Hooper (2009) BTHR + BTKR (n= 8144) Age + inflammatory disease different between groups Similar outcomes

  17. Discussion:Complications Meta-analyses Restrepo (2007) TKR vs. UKR (n = 18 articles, 27 807 patients) 1.8 x PE, 2.49 x Cardiac, 2.2 x Mortality Hu (2011) BTKR 3.2 x Mortality (n = 14 articles, 4320/11 243 patients)

  18. Discussion:Functional Outcomes Husted (2011) ROM and pain similar at 3 months (n = 150 / 271) Fewer BTKR patients using walking aids Final satisfaction, pain, return to employment similar Kim (2008) No difference in final KSS (n = 2385 / 719)

  19. Discussion:AOANJRR Revision Rates of Bilateral Primary Total Knee Replacement by Bilateral Status Rev / 100 Obs. years BTKR (Same Day, Two Surgeons) n = 480 0.54 (0.28-0.94) BTKR (Same Day, Same Surgeon) n = 16682 0.59 (0.53-0.66) STKR (Within Six Months) n = 16 924 0.48 (0.43-0.53) STKR (Over Six Months) n = 81 236 0.62 (0.57-0.61) BTKR (Same Day, Unkn. Surgeons) n = 10 014 0.54 (0.48-0.61)

  20. Discussion:AOANJRR Cumulative Percent Revision of BTKR by Bilateral Status BTKR (Different Surgeons) vs. STKR (<6 months) HR 1.24 (9.70-2.20, p=0.469) BTKR (Same Surgeon) vs. STKR (<6 months) HR 1.06 (0.91-1.24, p=0.441) BTKR (Same Surgeon) vs. BTKR (Diff. Surgeon) HR 1.16 (0.65-2.07) p=0.605) Mortality (Rate / 100 person yrs) Standardised Mortality BTKR (Different Surgeons) 2.97 (2.06-4.15) 3.3 BTKR (Same Surgeon) 1.14 (1.02-1.28) 1.7 STKR (<6 months) 1.78 (1.65–1.91) 4.4 Source: AOANJRR (Request 1017)

  21. Discussion:Patient Selection Memsoudis (2008) BTKR, Male, Age, IHD = independent risk factors for mortality

  22. Discussion:Patient Selection • Insidious onset • Pain on activity, night pain • Antalgic • Apprehension with passive IR of hip • Groin pain on SLR • DDx • Transient Osteoporosis Jules-Elysee (2012)

  23. Discussion: Limitations • Retrospective • Heterogeneous practice • Incomplete outcome data 16/52 (30%) of STKR knees had both pre/post KSS scores 23/52 (44%) of STKR knees had both pre/post ROM • Statistical challenges of comparing BTKR, UTKR, and STKR (without ITT)

  24. Conclusions:Further Considerations • Resource Usage • Pre-admission process • Theatre time • Theatre staff • Recovery LOS • ICU • Surgical Process • Distraction • Medicolegal considerations

  25. Conclusions:Recommendations • Improved data collection/follow up • Physiotherapist-run joint clinic • Data entry • Standarised patient selection criteria • Orthopaedic Unit • Anaesthetic Unit

  26. Conclusion • Analysis of current practice • No increase in complications observed • Functional outcomes similar • Less acute bed days used • Number may limit extrapolation of findings

  27. Thank you

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