Simultaneous vs. Staged Bilateral TKR By: Reese Wilmoth Question - PowerPoint PPT Presentation

Simultaneous vs. Staged Bilateral TKR By: Reese Wilmoth

Question “For a 64 year old male patient, does simultaneous bilateral total knee replacement (Both knees replaced at the same time) or staged bilateral total knee replacement (surgeries usually 4-6 weeks apart) provide better functional outcomes 12 months from initial surgery?”

Patient Details/history : Demographics - Mr. O is a 64 year old Caucasian Male. - Lives with wife in 1 story home, 8 stairs to enter, handrail on left. - Community Ambulator prior to surgery, no fall history - Retired

Patient Details/history : Comorbidities - Hypertension - Hyperlipidemia - Gilbert’s Syndrome - liver has difficulty processing bilirubin - Mild Anxiety - Gastroesophageal Reflux Disease - Prior abdominal surgery - procedure unlisted

PT Diagnosis and Prognosis Diagnosis - Degenerative Joint Disease → Bilateral primary osteoarthritis of knees Mr. O underwent simultaneous bilateral total knee arthroplasty and was evaluated by PT post of Day 0. Prognosis - Good due to age, few comorbidities, and motivation to improve.

Pathology Osteoarthritis - Wearing down of protective cartilage at the ends of bones over time. - Estimated 693,000 Total knee replacements in adults 45 years old and older in 2010 alone (Brooks, 2015)

Initial PT Evaluation (post op day 0) - Alert and Oriented x 4 - Pain- 3/10 in supine, 5/10 with movement , Bilateral Femoral Nerve Block in place (On Q) - Weakness, dulled sensation, Decreased ROM, Decreased Mobility. - MOD A x 2 to reach EOB, pt reported he felt Dizzy

Initial PT Evaluation Continued AROM - Knee Flexion - Right= 80 degrees, Left = 80 degrees - Knee Extension - Right = -23 degrees, Left = -25 degrees - Bed Mobility - Supine to sit - Mod A x 2 and additional time - Sit to Supine - Mod A x 2 and additional time - Scooting- supervision. - Sit to stand - not tested due to pain and patient fatigue post op day 0. - Sitting Balance - in tact - Returned to bed due to post surgical fatigue

PT eval continued post op day 1 - Demonstrated understanding of TKR basic exercise program. - Sit to stand - Max A x 2 with bed elevated and RW. - Stand to sit - Max A x 2 - Static balance - Standing= impaired with support. sitting - in tact without support - Dynamic Balance - standing = poor, sitting - constant support. - Pt ambulated 1 ft with immobilizers, gait belt, RW and Max A x 2, antalgic gait, decreased step clearance. - Patient highly motivated and expressed desire to move to IP rehab.

Outcome Measures performed (post op day 1) Tinetti Test (Balance) performed - total score = 1 Score of 1-5 = 80-99% impaired Mean Score for patient age group (65-79) = 26.21 Scoring - < 19 - High Fall risk - 19-24 = Moderate Fall Risk - > 24-28 = Low Fall risk

Plan of Care and Patient Goals Plan of Care - patient to be seen by PT BID for gait training, therapeutic exercise, Bed Mobility Training, Transfer Training, Neuromuscular Re-education, CPM, Patient and Family Education/training, and therapeutic activity. Patient Goal(s) - “I want to go home”

PT goals and Plan of Care Physical Therapy Goals 1. Patient will move from supine to sit and sit to supine, scoot up and down in bed with independence within 4 days 2. Patient will perform sit to stand with modified independence within 4 days 3. Patient will ambulate with modified independence 100 ft with least restrictive device within 4 days. 4. Patient will ascend/descend 8 stairs with one handrail and minimal assistance/contact guard within 4 days 5. Patient will demonstration AROM 0-90 degrees in operative joints within 4 days.

Intervention and Outcomes - Interventions - Ankle Pumps, Quad sets, hamstring sets, Short Arc Quads, Knee Extension Stretch, Heel slides, Long arc quads, Knee flexion stretch, straight leg raises - All exercises 2 sets of 10 reps, 2 times each day. - Patient was discharged to Inpatient Rehab Facility post op day 4

Seol, J., Seon, J., & Song, E. (2016). Comparison of postoperative complications and clinical outcomes between simultaneous and staged bilateral total knee arthroplasty. Journal of Orthopaedic Science, 21 (6), 766-769. doi:10.1016/j.jos.2016.07.023 Purpose - to compare post-op complication rate and clinical outcomes of simultaneous vs. staged Bilateral TKA.

Proposed Advantages of Simultaneous TKA - Shorter hospital stay - Less anesthesia time - Decreased rehab time - Decreased hospital cost to patient No evidence based guideline for which is better

Methods - 1,074 patients who underwent simultaneous (759) or staged (315) bilateral TKA from 2004-2013 - Retrospectively compared postop complication rate, length of stay in hospital, functional outcome - Clinical Outcome evaluated using Knee Society Score, WOMAC, ROM. - Inclusion criteria - OA exceeding grade III. - Exclusion Criteria - revision TKA, previous knee infection, trauma requiring surgery. - Follow up at 3,6,12 months and yearly thereafter.

Demographic characteristics of patients Simultaneous Staged - Age - 68.3 years - Age - 66 years - BMI 25.3 - BMI - 25.9 - ASA class (1-5) - 2.0 - ASA class - 2.3 - WOMAC score - 69.1 - WOMAC - 66.7

Results - Staged group had significantly longer hospital stays (34 vs 18 days). - Knee society scores (KSS) significantly improved in both groups, no significant difference. - WOMAC scores significantly improved in both, no significant difference. - ROM improved significantly in both, no significant difference. - 66 complications (8.7%) in simultaneous. - 43 complications (13.7%) in staged. - Major complication rate slightly higher in simultaneous but was not statistically significant - Minor complication rate was significantly higher in staged group.

Major vs. Minor Complications Major Minor - Myocardial Infarction - Superficial Infection - Pulmonary Embolism - DVT - Deep Infection - Confusion - CVA - Pneumonia - UTI

Discussion - Some earlier studies have reported an increase in CV risk with simultaneous TKA - No difference in clinical outcomes - No difference in major complications - Higher risk for minor complications with staged TKA - likely attributed to having to undergo a second surgery. - In a time of cost containment, Simultaneous TKA could be very financially beneficial. - Limitations - retrospective nonrandomized study, sample size (all done by same surgeon)

Bohm, E. R., Molodianovitsh, K., Dragan, A., Zhu, N., Webster, G., Masri, B., . . . Dunbar, M. (2016). Outcomes of unilateral and bilateral total knee arthroplasty in 238,373 patients. Acta Orthopaedica, 87 (Sup1), 24-30. doi:10.1080/17453674.2016.1181817 Purpose - To examine the outcomes of patients undergoing staged vs. bilateral total knee arthroplasty.

Methods - Demographic, clinical, and outcome data was collected for TKA (206,771 unilateral, 6,349 simultaneous bilateral, 25,253 stage bilateral). - Canadian Hospital Morbidity Database 2006-2013 - Outcomes compared - blood transfusion during stay, length of stay, complications, discharge disposition, percentage revised, inpatient mortality.

Results - Simultaneous were younger, more often male, and had less comorbidities than staged or unilateral. - Simultaneous had a shorter IP length of stay - but more often discharged to rehab facility. Staged was more likely to be discharged home. - Simultaneous had higher rates of blood transfusion, cardiac complications (compared to both groups) - Simultaneous had lower frequency of knee infection compared to staged, higher pulmonary embolism compared to unilateral.

Results - continued - Staged group had lowest IP mortality rate- could be underestimated since it did not include mortality after first TKA. - Unilateral group had highest revision at 3 years. - Male, >75 years old, 1 or more comorbidity - all increased odds of cardiac complication, pulmonary embolism, knee infection, in hospital mortality.

Discussion - Seeing a significant drop in simultaneous TKA in canada from 2006-2013 - Simultaneous group was younger (64 vs 68) and cause a selection bias and contributing to better outcomes for the simultaneous group. - Cardiac Complication and pulmonary embolism differences are in contrast to current meta analyses. (selection criteria, confounding factors) - Lower frequency of knee infections in simultaneous group (consistent with other studies) - Weaknesses- retrospective study, underestimated mortality for staged because those who planned staged but died before the second stage were included in unilateral group.

Conclusion/application to patient - Many advantages to simultaneous TKR if the patient is younger than 75 and has 1 or less comorbidities (decreased chance of cardiac complications). - Mr. O is young and has few comorbidities so he is an excellent candidate for a simultaneous bilateral knee replacement. - A good extension of my question would be to look into more of the prognostic factors that would impact a simultaneous TKR.

Possible difference In the 2nd study, staged TKR were an average of 3 months apart. In the first study they were an average of 34.4 days apart.