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Simultaneous Bilateral vs Unilateral Simultaneous Bilateral vs Unilateral TKRTKR

Complications & Analysis of the Patient’s Complications & Analysis of the Patient’s PerspectivePerspective

Chloe Donovan RNChloe Donovan RN

David A Parker FRACSDavid A Parker FRACS

AOA Annual Scientific MeetingAdelaide, 2010

Sydneyortho.com.au/sori_pageSydneyortho.com.au/sori_page

Conflict of InterestConflict of Interest

There is no conflict of interest in There is no conflict of interest in this research projectthis research project


Bilateral Knee OABilateral Knee OA

Common presentationCommon presentation

Simultaneous vs StagedSimultaneous vs Staged

ConsiderationsConsiderations Risks / ComplicationsRisks / Complications RehabilitationRehabilitation ComorbiditiesComorbidities Patient’s desires / concernsPatient’s desires / concerns

““Will I have a leg to stand on afterwards?”Will I have a leg to stand on afterwards?”


Bilateral TKR: LiteratureBilateral TKR: Literature

Several studiesSeveral studies

Variable resultsVariable results Increased morbidityIncreased morbidity

• Patil et al 2008, Fabi et al 2010, Qian et al 2008Patil et al 2008, Fabi et al 2010, Qian et al 2008

Increased mortalityIncreased mortality• Mangaleshkar 2001, Stafansdottir 2008Mangaleshkar 2001, Stafansdottir 2008

No increased riskNo increased risk• Taylor et al 2010, Leonard et al 2003Taylor et al 2010, Leonard et al 2003


Bilateral TKR: LiteratureBilateral TKR: Literature

LimitationsLimitations Heterogeneous groupsHeterogeneous groups Many fail to compare to 2 x Many fail to compare to 2 x

UnilateralUnilateral Lack of attention to other aspects Lack of attention to other aspects

of patient outcomesof patient outcomes• Leonard et al 2003: Increased patient Leonard et al 2003: Increased patient

satisfaction with Bilateral proceduressatisfaction with Bilateral procedures


Study AimsStudy Aims

Comparison of:Comparison of: UnilateralUnilateral Staged BilateralStaged Bilateral Simultaneous BilateralSimultaneous Bilateral

Analysis of:Analysis of: ComplicationsComplications OutcomesOutcomes Patient Satisfaction & PerspectivePatient Satisfaction & Perspective


Indications for Simultaneous Indications for Simultaneous BTKRBTKR

Each Knee independently Each Knee independently meets appropriate criteria for meets appropriate criteria for TKRTKR

Medically fit (Physician review)Medically fit (Physician review)

Patient elects surgeryPatient elects surgery

Especially significant fixed Especially significant fixed deformitiesdeformities


Simultaneous Bilateral TKRSimultaneous Bilateral TKR

Commence with most Commence with most symptomaticsymptomatic

11stst completed, tourniquet completed, tourniquet deflated, extensor deflated, extensor mechanism closed, before 2mechanism closed, before 2ndnd startedstarted

Computer Navigation routineComputer Navigation routine


MethodsMethods

Single SurgeonSingle Surgeon

Consecutive SeriesConsecutive Series 205 patients / 329 TKR205 patients / 329 TKR Dec 2004 to June 2009Dec 2004 to June 2009 Minimum 1 yr followupMinimum 1 yr followup 3 Groups3 Groups

• 89 Simultaneous BTKR (2.1years)89 Simultaneous BTKR (2.1years)• 81 Unilateral TKR (3.2 years)81 Unilateral TKR (3.2 years)• 35 Staged Bilateral TKR (4 year)35 Staged Bilateral TKR (4 year)


Methods: Data CollectionMethods: Data Collection

Ethics approval via NSHHREC Ethics Ethics approval via NSHHREC Ethics committeecommittee

Retrospective ReviewRetrospective Review Prospective Database (Socrates)Prospective Database (Socrates)

• Oxford, KSCRS, WOMAC, SF-36Oxford, KSCRS, WOMAC, SF-36 Hospital RecordsHospital Records

Patient Satisfaction QuestionnairePatient Satisfaction Questionnaire Self - administeredSelf - administered


Methods:Methods:Patient Patient QuestionnaireQuestionnaire


Results: Patient Results: Patient DemographicsDemographics

n=81

n=35 n=89 n=51 n=31 n=62

* Significantly different to Simultaneous group (p<0.05)

*


Results: Complication Rate Results: Complication Rate (%) (%)

Unilateral

Staged

Simultaneous

P-value

Retention 3.3 6.9 5.7 0.59

Postop delirium

11.7 10.7 5.7 0.23

VTE 8.3 3.4 4.6 0.66

Blood Tx 10.0 3.4 10.3 0.45

ICU 3.3 0.0 6.9 0.47

Other 3.3 3.4 2.3 0.74


OxfordOxford


WOMACWOMAC


Range of MotionRange of Motion


Results: SF36 – Physical Results: SF36 – Physical ScoreScore

n=67

n=50

n=33

n=27

n=68

n=53

*

* Significantly different to pre-op (p<0.05)

† Significantly different to Staged (p<0.05)


Results: SF36 – Mental Results: SF36 – Mental ScoreScore

n=67

n=50

n=33

n=27

n=68

n=53

*

* Significantly different to Staged (p<0.05)


Results: Patient Results: Patient SatisfactionSatisfaction

* Significantly different to Unilateral and Staged (p<0.05)

*


DiscussionDiscussion

Bilateral Simultaneous TKRBilateral Simultaneous TKR ControversialControversial

• Increased morbidity / mortalityIncreased morbidity / mortality• Inconsistencies in literatureInconsistencies in literature

Minimal investigation into patients’ Minimal investigation into patients’ perspectiveperspective

Potential benefits for the patientPotential benefits for the patient• Rehabilitation & Clinical OutcomeRehabilitation & Clinical Outcome• Efficiency / Costs / ExpedienceEfficiency / Costs / Expedience


DiscussionDiscussion

Current investigationCurrent investigation No increase in morbidity / mortalityNo increase in morbidity / mortality Equivalent or better functional outcomesEquivalent or better functional outcomes Improved patient satisfactionImproved patient satisfaction Negative preconceptions proved incorrectNegative preconceptions proved incorrect Effect of better preop SF36 mental scores Effect of better preop SF36 mental scores

LimitationsLimitations Differences in groups (not RCT)Differences in groups (not RCT) Questionnaire not validatedQuestionnaire not validated


ConclusionConclusion

Bilateral Simultaneous TKRBilateral Simultaneous TKR Bilateral advanced OABilateral advanced OA

• Especially significant fixed deformitiesEspecially significant fixed deformities Healthy patients (Physician approval)Healthy patients (Physician approval) Patient requestPatient request

Further studyFurther study Increasing databaseIncreasing database Development & Validation of Development & Validation of

questionnairequestionnaire


ThankyouThankyou

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page bilateral tkr

staged bilateral tkr

bilateral procedures

fabi et

qian et

increased patient satisfaction

simultaneous btkr

increased risk taylor