Retrospective analysis of Clinical Outcomes and Complications of One-stage versus Two-staged Bilateral Total Knee Arthroplasty.
2 Department of Orthopaedics, National Orthopaedic Hospital Dala, Kano, Nigeria, Email: firstname.lastname@example.org
Received: 04-Aug-2023, Manuscript No. jotsrr-23- 109281; Editor assigned: 06-Aug-2023, Pre QC No. jotsrr-23-109281 (PQ); Accepted Date: Aug 20, 2023 ; Reviewed: 14-Aug-2023 QC No. jotsrr-23-109281 (Q); Revised: 16-Aug-2023, Manuscript No. jotsrr-23-109281 (R); Published: 23-Aug-2023
This open-access article is distributed under the terms of the Creative Commons Attribution Non-Commercial License (CC BY-NC) (http://creativecommons.org/licenses/by-nc/4.0/), which permits reuse, distribution and reproduction of the article, provided that the original work is properly cited and the reuse is restricted to noncommercial purposes. For commercial reuse, contact email@example.com
Introduction: The safety of single staged bilateral TKA has been issue of debates due to concerns of morbidity and mortality. The advantages attributed to one-stage bilateral TKA include shorter recovery time, shorter hospital stay and perhapsreduced total cost of treatment. The aim of thisstudy was to analyze the clinical outcomes and complications following one-stage versus two-staged bilateral TKA for severe osteoarthritis of both knees.
Methods: This retrospective comparative analysis was carried out between January 2018 and December 2022 at a government orthopaedic referral hospital in Nigeria. Clinical outcomes using KSS scoring system and rate of complications were recorded. Patients’ satisfaction using Likert scale was also documented. The statistical analysis was performed using SPSS version 23.0.
Result: There was no significant difference between the postoperative KSS in the two groups (p = 0.717) The mean postoperative KSS in OS and TS groups were 97.78 ± 1.78 and 97.76 ± 1.74 respectively. Postoperative complications do not also significantly differ in the two groups (P=0.712)
Conclusion: In properly selected cases, one-stage bilateral TKA has the same good outcome and excellent patients’satisfaction as two-staged procedure without significant increase in complication rates.
Bilateral total knee replacement, one stage, two stage
Total Knee Arthroplasty (TKA) is a cost-effective elective orthopaedic procedure that provides significant pain relief and improved quality of life for patients with severe osteoarthritis of the knee . In these patients, unilateral TKA can significantly affect rehabilitation, and this may result in poor outcome . The safety of single staged bilateral TKA has been issue of debates due to concerns of increased morbidity and mortality [3-5]. Bilateral TKA can be done as one-stage or two- staged surgery. The advantages that have been attributed to one-stage TKA include shorter recovery time, shorter hospital stay and perhaps reduced total cost of treatment [6,7]. However, opponents of one-stage surgery reported a greater risk of postoperative complications [8-10].
Total knee replacement has become a routine procedure in most orthopaedic hospitals in Nigeria. To the best of our knowledge, there is scarcity of published studies about bilateral TKA in Nigeria. The aim of this study therefore was to analyze the clinical outcomes and complications following one-stage versus two-staged bilateral TKA for severe osteoarthritis of both knees. Our hypotheses were that the clinical outcomes of one-stage bilateral TKA would be poorer, and the rate of complication would be higher than two-staged bilateral TKA.
Materials and Methods
This retrospective comparative analysis was carried out between January 2018 and December 2022 at a government orthopaedic referral hospital in Northern Nigeria. The study was performed after approval from Hospital Research Ethics Committee (HREC). Patients’ information was retrieved from the hospital electronic medical record. Patients were also contacted on the phone where necessary for additional information.
The study involved all consecutive patients with bilateral severe osteoarthritis of the knees who had bilateral TKA either as one or two- staged surgery within the study period. The inclusion criteria were: Adult patients males and females aged 50 years and above with severe osteoarthritis of both knees who had bilateral TKA and were followed up for a minimum of 1 year. The decision to do one or two-staged surgery was based on the surgeon and anaesthetist assessment for fitness for the surgery. The exclusion criteria were patients less than 50 years of age, unilateral osteoarthritis, patients with a history of myocardial infarction, severe obesity, significant history of smoking, poorly controlled diabetes, and revision TKA. Patients were divided into two groups: One-Stage (OS) and Two-Stage (TS) groups.
Clinical outcomes using Knee Society Scoring system and rate of complications were recorded. Patients’ satisfaction using Likert scale was also documented. The statistical analysis was performed using SPSS version 23.0 (SPSS Inc., Chicago, IL, USA). Means, ranges, and standard deviation were calculated for quantitative variables and compared using Student’s t tests. Frequencies were calculated for qualitative variables and compared using Chi-square. The results were considered statistically significant at p<0.05.
A total of 291 bilateral TKA were performed by four surgeons during the study period. One hundred and ninety-five patients in Two-Staged procedure (TS group) and ninety-six patients in One-Stage procedure (OS group) were followed up for a minimum of 12 months. The mean ages of patients in OS and TS groups were 63.73 years ± 7.03 years and 62.39 years ± 7.46 years respectively. More females were operated in both groups. There was no significant difference in the demographic characteristics of both groups (Table 1).
Table 1. Demographic characteristics of patients in One-stage and Two-staged groups
|Age (year)||63.73 ± 7.03||62.39 ± 7.46||0.078|
|Male||26 (27.1%)||43 (22.1%)||
|Female||70 (72.9%)||152 (77.9%)|
|BMI (Kg/m2)||33.63 ± 5.91||34.18 ± 5.60||0.94|
|Nil||34 (35.4%)||63 (32.3%)||
|DM||22 (22.9%)||32 (16.4%)|
|Cardiac dx||40 (41.7%)||77 (39.5%)|
|DM + Cardiac||34 (35.4%||23 (11.8%)|
There was no significant difference between the postoperative KSS in the two groups (p=0.717). The mean postoperative KSS in OS and TS groups were 97.78 ± 1.78 and 97.76 ± 1.74 respectively. Postoperative complications do not significantly differ in the two groups (P=0.712). Table 2 below shows the postoperative complications in the OS and TS groups.
Table 2. Postoperative Complications in one-stage and two-staged bilateral total knee replacement
|Complications||One-stage (n = 95)||Two-staged (n = 195)||p-value|
|Mortality||2 (2.1%)||1 (0.5%)||
|Deep Venous Thrombosis||1 (1.0%)||1 (0.5%)|
|Deep Surgical Site Infection||0 (0%)||1 (0.5%)|
|Chronic Knee Pain||1 (1.0%)||0 (0%)|
|4 (4.2%)||3 (2%)||
The safety of one-stage bilateral TKA has been a topic for discussion for a while in orthopaedic surgery due to documented relative increased postoperative morbidity and mortality [3, 4]. There are however some advantages of single stage procedure especially when cases are well selected. One stage bilateral TKA requires only one anaesthetic session and one hospital admission. It also aids quick rehabilitation in patients with severely deformed bilateral knees, thereby leading to a better outcome. In our setting, we regularly do bilateral arthroplasty under the same anaesthesia for selected cases. Some of the exclusion criteria include patients with more than one comorbidity, morbid obesity, complex primary TKR and revision TKR among others (Table 3).
Table 3. Patients satisfaction (using Liker type scale) after one-stage versus two-staged bilateral TKA
|Very Satisfied||63 (65.6%)||108 (55.4%)||
|Satisfied||31 (32.3%)||85 (43.6%)|
|Neutral||0 (0%)||0 (0%)|
|Dissatisfied||2 (2.1%)||2 (1%)|
|Very Dissatisfied||0 (0%)||0 (0%)|
|96 (100%)||195 (100%)||
At 12 months postoperative, we did not find significant difference in terms of knee functions between the patient who had bilateral TKA as one-stage procedure and those who had bilateral TKR as a two- staged procedure. Patients were also similarly satisfied with the surgery. Although there were selection criteria for patients operated on one- stage procedure, the preoperative demographic characteristics of the patients in both groups do not significantly differ.
Similarly, postoperative complications in one-stage and two-staged bilateral TKR are not significantly different (p =0.842). This might be because there is a difference in the number of patients in each cohort (195 in two-stage group, 96 in one-stage group) and because there was no randomization into each group, though there was no significant difference in demographics of both groups.
Two patients died in one stage group. The first died 3 days postoperative due to pulmonary embolism while the other died from diabetes complications 3 months after surgery. In the two-staged group, one patient died of cardiac arrest 12 hours postoperative. One patient in one- stage group developed chronic knee pain which persisted even after 1 year postoperative. She was 66 years old woman with severe deformities of both knee and feet due to rheumatoid arthritis. Other complications noted were prosthetic joint infection and deep veinous thrombosis. The insignificant difference in complication rates noted in our study is consistent with previous other studies by Hadley et al , Hooper et al , and Fortin et al [11-13] . On the contrary, studies have also shown that one-stage bilateral TKA is more prone to postoperative complications compared with staged surgery. Fu D et al in a systematic review found that simultaneous bilateral TKA had higher rates of mortality, pulmonary embolism, and blood transfusion rates . Similarly, Bolognesi et al found higher mortality and myocardial infarction rates for simultaneous bilateral TKA but no significant difference in infection and revision rates . Lack of difference in complication rates of our study may be due selection of patients for one-stage group. Other complication that has been previously noted with TKR is fat embolism . We did not find any patient in either group with this complication in our study.
This study has several limitations. Different surgeons operated on the patients, though they follow the same hospital protocol for patient care. There w as n o r andomization o f t he s ubjects i nto t he g roups, i nstead there were definite criteria preoperatively for selecting patients into one-stage surgery. In addition, there was disparity in the numbers of patients in each group, though there was no significant difference in the demographic characteristics of the patients in the two groups. Finally, this is a retrospective study, with all the limitations associated with it.
In conclusion, for properly selected cases, one-stage bilateral TKA has the same good outcome and excellent patients’ satisfaction as two- staged procedure without significant increase in complication rates.
- Rissanen P, Aro S, Slätis P, et al. Health and quality of life before and after hip or knee arthroplasty. The Journal of arthroplasty. 1995 Apr 1;10(2):169-75. [Google Scholar] [Cross ref]
- Jain S, Wasnik S, Mittal A, et al Simultaneous bilateral total knee replacement: a prospective study of 150 patients. Journal of Orthopaedic Surgery. 2013 Apr;21(1):19-22. [Google Scholar] [Cross ref]
- Patil N, Hemant Wakankar MS. Morbidity and mortality of simultaneous bilateral total knee arthroplasty. Orthopedics (Online). 2008 Aug 1;31(8):780. [Google Scholar] [Cross ref]
- Restrepo C, Parvizi J, Dietrich T, et al Safety of simultaneous bilateral total knee arthroplasty: a meta-analysis. JBJS. 2007 Jun 1;89(6):1220-6. [Google Scholar] [Cross ref]
- Noble J, Goodall JR, Noble DJ. Simultaneous bilateral total knee replacement: a persistent controversy. The Knee. 2009 Dec 1;16(6):420-6. [Google Scholar] [Cross ref]
- Macario A, Schilling P, Rubio R, et al. Economics of one-stage versus two-stage bilateral total knee arthroplasties. Clinical Orthopaedics and Related Research®. 2003 Sep 1;414:149-56. [Google Scholar] [Cross ref]
- Trojani C, Bugnas B, Blay M. Bilateral total knee arthroplasty in a one-stage surgical procedure. Orthopaedics & Traumatology: Surgery & Research. 2012 Dec 1;98(8):857-62. [Google Scholar] [Cross ref]
- Stefánsdóttir A, Lidgren L, Robertsson O. Higher early mortality with simultaneous rather than staged bilateral TKAs: results from the Swedish Knee Arthroplasty Register. Clinical orthopaedics and related research. 2008 Dec;466(12):3066-70. [Google Scholar] [Cross ref]
- Walmsley P, Murray A, Brenkel IJ. The practice of bilateral, simultaneous total knee replacement in Scotland over the last decade. Data from the Scottish Arthroplasty Project. The Knee. 2006 Mar 1;13(2):102-5. [Google Scholar] [Cross ref]
- Barrett J, Baron JA, Losina E, et al. Bilateral total knee replacement: staging and pulmonary embolism. JBJS. 2006 Oct 1;88(10):2146-51. [Google Scholar] [Cross ref]
- Day M, Schwarzkopf MR, Smith A, et al. Is simultaneous bilateral total knee arthroplasty (BTKA) as safe as staged BTKA?. Am J Orthop. 2017 Jul;46(4):E224-9. [Google Scholar] [Cross ref]
- Hooper GJ, Rothwell AG, Hooper NM, et al. The relationship between the American Society of Anesthesiologists physical rating and outcome following total hip and knee arthroplasty: an analysis of the New Zealand Joint Registry. JBJS. 2012 Jun 20;94(12):1065-70. [Google Scholar] [Cross ref]
- Fortin PR, Penrod JR, Clarke AE, et al. Timing of total joint replacement affects clinical outcomes among patients with osteoarthritis of the hip or knee. Arthritis & Rheumatism. 2002 Dec;46(12):3327-30. [Google Scholar] [Cross ref]
- Fu D, Li G, Chen K, et al. Comparison of clinical outcome between simultaneous-bilateral and staged-bilateral total knee arthroplasty: a systematic review of retrospective studies. The Journal of arthroplasty. 2013 Aug 1;28(7):1141-7. [Google Scholar] [Cross ref]
- Bolognesi MP, Watters TS, Attarian DE, et al. Simultaneous vs staged bilateral total knee arthroplasty among Medicare beneficiaries, 2000–2009. The Journal of arthroplasty. 2013 Sep 1;28(8):87-91. [Google Scholar] [Cross ref]
- Figueroa D, Figueroa F, Mena RC, et al. Cerebral and pulmonary fat embolism after unilateral total knee arthroplasty. Arthroplasty Today. 2019 Dec 1;5(4):431-4. [Google Scholar] [Cross ref]