Simultaneous Bilateral vs Unilateral TKR Complications & Analysis of the Patient’s Perspective
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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
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Conflict of InterestConflict of Interest
There is no conflict of interest in There is no conflict of interest in this research projectthis research project
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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?”
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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
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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
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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
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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
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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
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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)
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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
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Methods:Methods:Patient Patient QuestionnaireQuestionnaire
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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)
*
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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
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OxfordOxford
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WOMACWOMAC
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Range of MotionRange of Motion
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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)
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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)
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Results: Patient Results: Patient SatisfactionSatisfaction
* Significantly different to Unilateral and Staged (p<0.05)
*
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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
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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
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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
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ThankyouThankyou