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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 14  |  Issue : 1  |  Page : 13-17

A retrospective study to compare early outcomes of bilateral total knee replacement done in single sitting versus double sitting


Department of Orthopaedics, Pt. B.D.S. PGIMS, Rohtak, Haryana, India

Date of Submission24-Aug-2021
Date of Acceptance08-Dec-2021
Date of Web Publication15-Jun-2022

Correspondence Address:
Dr. Jitendra Wadhwani
6/CH, Medical Enclave, PGIMS Campus, Rohtak - 124 001, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_78_21

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  Abstract 


Aim: We aimed to conduct a study comparing early outcomes of bilateral total knee replacement (BTKR) done in single sitting versus double sitting. Materials and Methods: The study included 58 patients who were already operated case of BTKR done in single sitting (sequential BTKR) – Group I (n = 30) and double sitting (staged BTKR) – Group II (n = 27), during time period April 2016 to May 2019. At follow-up, functional outcome in both the groups was assessed by Knee Injury and Osteoarthritis (OA) Outcome Score, Western Ontario and McMaster Universities OA Index score, and Visual Analog Scale scores. Results: The mean age in Group I was 64.5 ± 10.52 years and in Group II was 63.92 ± 5.76 years. The mean body mass index (BMI) in Group I was 28.42 ± 1.365 kg/m2, whereas the mean BMI in Group II was 29.19 ± 1.898 kg/m2. The mean length of hospital stay in Group I was 15.23 ± 2.921 days as compared to 23.69 ± 5.259 days in Group II. There was no mortality in both the groups within 90 days after operation in both the groups. There was significantly less requirement of hospital stay in Group I as compared to Group II (P = 0.001, Mann–Whitney U-test). Conclusion: We found that the single sitting BTKR is cost-effective and a relatively safe surgery. There was significantly lower length of hospital stay in single sitting BTKR along with no major complication in our study. Thus we advocate BTKR as a single sitting surgery with proper patient selection and preanesthetic workup.

Keywords: Bilateral total knee replacement, body mass index, Knee Injury and Osteoarthritis Outcome Score, osteoarthritis, sequential bilateral total knee replacement, staged bilateral total knee replacement, Visual Analog Scale, Western Ontario and McMaster Universities Osteoarthritis Index


How to cite this article:
Wadhwani J, Siwach R, Sihag R, Kamboj P, Siwach K. A retrospective study to compare early outcomes of bilateral total knee replacement done in single sitting versus double sitting. J Orthop Traumatol Rehabil 2022;14:13-7

How to cite this URL:
Wadhwani J, Siwach R, Sihag R, Kamboj P, Siwach K. A retrospective study to compare early outcomes of bilateral total knee replacement done in single sitting versus double sitting. J Orthop Traumatol Rehabil [serial online] 2022 [cited 2022 Oct 2];14:13-7. Available from: https://www.jotr.in/text.asp?2022/14/1/13/347374




  Introduction Top


Aging is associated with progressive destruction of joints and leading to osteoarthritis (OA) which a common progressive disorder is seen in nearly 30% of individuals with age more than 60 years.[1] Pain, decreased joint function, decreased range of motion along with stiffness, and deformities are common symptoms associated with OA. Joint space narrowing, marginal osteophytes, subchondral cysts, and sclerosis are primary signs visible on standard radiographs of osteoarthritic joint.[2] The severity of OA is classified on radiographs using Kellgren and Lawrence system.[3] In end stage of arthritis, total knee replacement (TKR) is the best available solution for the disease management. It is not very uncommon to see bilateral involvement of knee joints in patients with OA, who frequently require bilateral knee replacement for severe joint disease.[4] Bilateral TKR (BTKR) depending upon the pattern of surgical protocol can be classified, as depicted in [Table 1]. For the sake of proper comparison, we have defined two basic surgical protocols as:
Table 1: Classification of bilateral total knee replacement

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Single sitting bilateral total knee replacement

In single sitting BTKR, both knees are draped simultaneously after completion of surgery on one side and surgery was started on the other side (sequential BTKR).[5]

Double sitting bilateral total knee replacement

In double sitting, knee replacement surgery was performed in staged manner in single hospitalization with an interval of minimum 7 days (staged BTKR).[6]

OA broadly can be managed with surgical and conservative options. The conservative noninvasive management is beneficial in patients with Kellgren and Lawrence[3] Grade 1–2. Invasive procedures (intra-articular injections, arthroscopic joint debridement, high tibial osteotomy, unicondylar knee arthroplasty, and TKR) are required for higher grades of OA (Grades 3 and 4).[6],[7],[8] It is the decision of operating surgeon and patient to have the procedure for bilateral involvement with simultaneous BTKR or staged BTKR with a certain time interval between the two procedures; there is controversy about this decision in the literature.[4],[5],[6],[9] Simultaneous BTKR performed using proper patient selection and perioperative care measures can successfully treat patients with bilateral arthritis of knee joints.[8] In the literature, there is still a controversy regarding use of single sitting BTKR versus double sitting BTKR as better treatment protocol.[4],[5],[6],[9] Therefore, we aim to conduct a retrospective analysis for comparing early outcome of BTKR done in single sitting versus double sitting with a null hypothesis that simultaneous BTKR is not better than staged BTKR.


  Materials and Methods Top


A retrospective study was conducted at author's tertiary care hospital to evaluate the clinical and radiological outcome in single sitting (Group I) BTKR versus double sitting (Group II) BTKR operated from April 2016 to May 2019. The study was approved by institutional review board and ethical committee. The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments. Written informed consent was taken for surgery from all the patients included in the study. Patients already operated for BTKR either in single or double sitting during 3-year period from April 2016 to May 2019 with minimum duration since surgery of 6 months were included in the study. Patients with psychiatric illness and patients having secondary trauma after surgery were excluded from the study. The intraoperative and postoperative data of patients were obtained from hospital records available at the institution. The data were assessed for the demographic as well as clinical aspects. The demographic details such as age, sex, and body mass index (BMI) were assessed. The clinical details such as mean hospital stay, blood loss, complications, and blood transfusions were assessed. All surgeries taken into account were performed by single surgeon (RCS) and were done with standard surgical technique of anterior referencing. All TKR implants used were of posterior cruciate ligament stabilizing type. All surgeries were done under tourniquet control, and we used topical tranexamic acid at the time of wound closure to prevent blood loss. Complications were defined as local, pertaining to the operative site, or systemic, relating to the patients' general medical condition. Patients were called for the evaluation in the outpatient department and were also interviewed telephonically for assessment. We divided the complications for better evaluation into intraoperative, immediate, postoperative, and late complications. The Knee Injury and OA Outcome Score (KOOS), Western Ontario and McMaster Universities OA Index (WOMAC) score, and Visual Analog Scale (VAS) were used for the evaluation of the patients at final follow-up by author (RS).[10],[11],[12] There was no difference in postoperative rehabilitation protocol of both the groups. Radiological assessment was based on anteroposterior standing and lateral 45° flexion radiographs of bilateral knees.

Statistical analysis

The data were coded and entered into Microsoft Excel spreadsheet. Analysis was done using SPSS version 20 (IBM SPSS Statistics Inc., Chicago, Illinois, USA) Windows software program. Descriptive statistics included computation of percentages, means, and standard deviations. The Mann–Whitney U-test (for quantitative data to compare two independent groups) and Wilcoxon signed-rank test (for quantitative data to compare before and after observations) were used for quantitative data comparison of all clinical indicators. Chi-square test and Fisher's exact test were used for qualitative data whenever two or more than two groups were used to compare. Level of significance was set at P ≤ 0.05. Power analysis was done for minimum sample size calculation with a power of 80%. The minimum sample size required was 20 in each group.


  Results Top


The number of patients operated in single sitting (Group I) and double sitting (Group II) was 30 and 27, respectively, from April 2016 to May 2019. The mean age in Group I was 64.5 ± 10.52 years and in Group II was 63.92 ± 5.76 years (P = 0.8). In Group I, 20 (66.66%) patients were females, whereas in Group II, 8 (70.37%) were females (P = 0.78). The mean BMI in Group I was 28.42 ± 1.365 kg/m2, whereas the mean BMI in Group II was 29.19 ± 1.898 kg/m2 (P = 0.78). The mean length of hospital stay in BTKR in Group I was less 15.23 ± 2.921 days as compared to Group II 23.69 ± 5.259 days (P = 0.001, MannWhitney U-test). There was no mortality in both the groups within 90 days after operation. In the present study, the mean VAS score in Group I was 1.35 ± 3.019, whereas in Group II, it was 2.12 ± 4.727 (P = 0.48, Mann–Whitney U-test). The mean KOOS score in Group I was 82.46 ± 2.42, whereas in Group II, it was 80.69 ± 4.27 (P = 0.07, Mann–Whitney U-test). The mean WOMAC score in Group I was 19.15 ± 2.588, whereas in Group II, it was 19.73 ± 5.303 (P = 0.62, Mann–Whitney U-test). The mean blood loss in drain after surgery in Group I was 605.00 ± 87.45 ml. In Group II, the mean blood loss in drain after first surgery was 333.15 ± 68.37 ml and after second surgery was 365.38 ± 84.58 ml. As per medical record, the preoperative hemoglobin (Hb) in Group I was 12.76 g/dl and postoperative Hb was 10.5 g/dl (P = 0.001, Wilcoxon signed-rank test). After first surgery in Group II, the preoperative Hb was 13.57 g/dl and postoperative Hb was 12.12 g/dl (P = 0.001, Wilcoxon signed-rank test). In second surgery of Group II, the preoperative Hb was 12.16 g/dl and postoperative Hb was 11.24 g/dl (P = 0.009, Wilcoxon signed-rank test). The mean unit of blood transfused in Group I intraoperatively was 0.40 ± 0.498 unit and postoperatively was 1.03 ± 0.320 units. The mean unit of blood transfused in Group II intraoperatively was 0.11 ± 0.320 unit and postoperatively was 0.93 ± 0.385 unit. The mean duration of surgery in Group I was 129.83 ± 10.706 min. In Group II, the mean duration of first surgery was 67.50 ± 5.701 min and of second surgery was 68.46 ± 5.791 min. The mean interval between two surgeries in Group II was 8.23 ± 2.35 days (range, 7–15 days). The comorbidities before operation were compared in both the groups as per [Table 2]. Postoperative complications were compared as per [Table 3] and [Table 4]. The mean follow-up in Group I was 30.66 ± 11.302 months (range, 24–28 months), whereas in Group II, it was 13.08 ± 4.041 months (range, 7–20 months) (P = 0.001, Mann–Whitney U-test).
Table 2: Distribution by comorbidity before operation

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Table 3: Comparison of early complications

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Table 4: Complications

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  Discussion Top


Higher OA grade of Kellgren and Lawrence system (Grade 4) is an indication for TKR, and satisfactory results in bilateral OA knee patients are difficult to attain without BTKR.[3] Patients with bilateral disease who wish to undergo surgery must decide whether they want a single anesthesia and surgery or separate surgeries and hospitalizations for both knees. This decision is affected by patient's needs and expectations and their physician recommendation considering patient comorbidities. Although simultaneous BTKR has several advantages, there is still concern and controversy about the safety of this operation due to higher risk of perioperative complications mentioned in the literature.[13],[14],[15]

The results of our study suggest that there are no significant differences in major and minor complications following simultaneous BTKR and staged BTKR. There was no mortality in any group within 90 days after surgery. This is similar to other previous case–control studies and suggests that the simultaneous bilateral TKR procedure may be as safe as the staged bilateral procedure.[16],[17] We also found a higher deep infection (3.33%) in the staged BTKR group and no deep infection in the simultaneous BTKR group which is nonsignificant (P = 0.28). The higher rate of minor complication in the staged BTKR group may be due to the additional risk of the second procedure when compared to simultaneous BTKR surgery. Although staged appropriately, the second TKR might carry the same risk as the first. Simultaneous BTKR during a single session of anesthesia offers several potential advantages, including less hospital stay, faster functional recovery, cost-effectiveness, less infection risk, and lower risk of mechanical failure within the 1st year after TKR.[18]

According to some authors, simultaneous BTKR is associated with an increased risk of perioperative cardiac and pulmonary complications.[19],[20] Simultaneous bilateral TKR is found to have twice greater risk of cardiovascular complications than single unilateral TKR and a 1.6 times greater risk compared to staged bilateral TKR.[17],[18] There is literature supporting simultaneous BTKR too, considering it to be a safer surgery.[21],[22],[23] Hardaker et al. did evaluation and comparison of the perioperative safety between single sitting versus double sitting BTKR. There was no difference in complication rates between the two groups.[21] Morrey et al. and Kim et al. also did comparison between these two BTKR methodologies and found no differences in complications, outcomes, and perioperative mortality.[22],[23]

There were no significant differences in readmission rates and mortality between simultaneous and staged BTKR. Readmission post TKR can be due to medically related complications such as infection and deep venous thrombosis. There is no postoperative deep venous thrombosis and cardiac complications after the simultaneous procedure which is in contrast to previous findings[24],[25] and probably reflecting early mobilization on the 2nd postoperative day of surgery[19] or can be due to smaller study population size in our tertiary care center. The mean follow-up in Group I was 30.66 ± 11.302 months, whereas in Group II, it was 13.08 ± 4.041 months. There was a significant difference in follow-up time which can affect the outcome measures. There was significantly higher follow-up period of Group I patients as in our institute we used to follow single sitting BTKR protocols in most of our patients. This should not cause any bias in our study as there were very little/insignificant late complications (>1 year after surgery) noted in both the groups.

Ekinci et al. conducted a study in which blood unit transfused in the simultaneous BTKR and unilateral TKR groups was 3.3 ± 0.91 (range, 2–6) and 2.3 ± 0.69 (range, 1–4).[26] Forster et al. conducted a study in which blood unit transfused in the simultaneous BTKR and staged BTKR groups was 6 (range, 3–9) and 5.8 (range, 4–8), respectively.[27] In a study by Horne et al., the blood unit transfused in simultaneous BTKR was 4 (range, 2–6).[28] In a study by Stubb et al., the blood unit transfused in the simultaneous BTKR and staged BTKR groups was 3.59 and 2.14 units, respectively.[29] The blood requirement in our studies is less than these studies probably due to the use of topical tranexamic acid in our studies. However, the higher rate of blood transfusion leads to increased transmission rate of blood-borne diseases such as HIV and HCV.

The potential economic benefit of simultaneous BTKR can be significant. Single anesthetic session resulted in shorter hospital stay and shorter rehabilitation time in the simultaneous BTKR group compared to the staged BTKR group.[30] In our series, the mean length of hospital stay for the simultaneous BTKR and staged BTKR groups was 15.23 ± 2.921 days and 23.69 ± 5.259 days, respectively. Therefore, if TKR is required for both knees, simultaneous bilateral surgery is more advantageous financially because it reduces the length of hospital stay. Simultaneous BTKR offers the potential benefits in decreasing overall cost, decreasing the number of anesthetic administrations, and good functional recovery of both knees simultaneously.

The retrospective nature of the study and small number of patients in both the BTKR groups are limitations of our study. Direct cost–benefit analysis was not done between the study groups, but length of hospital stay can give an idea about the approximate cost incurred. Statistically proven results are strengths of our study design.


  Conclusion Top


We found that the single sitting BTKR is a relatively safe surgery. There was significantly lower length of hospital stay in single sitting BTKR along with no major complication in our study. Thus, we advocate BTKR as a single sitting surgery with proper patient selection and preanesthetic workup.

Acknowledgment

We would like to thank Dr. Virender Kumar for assistance in planning of the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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