Simultaneous Bilateral vs Unilateral TKR Complications & Analysis of the Patient’s Perspective Chloe Donovan RN David A Parker FRACS

SORI Sydney Australia www.sori.com.au

AOA Annual Scientific Meeting Adelaide, 2010

Conflict of Interest

 There is no conflict of interest in this research project Sydneyortho.com.au/sori_page

Bilateral Knee OA

 Common presentation  Simultaneous vs Staged  Considerations    Risks / Complications Rehabilitation Comorbidities  Patient’s desires / concerns “ Will I have a leg to stand on afterwards?” Sydneyortho.com.au/sori_page

Bilateral TKR: Literature

 Several studies  Variable results   Increased morbidity • Patil et al 2008, Fabi et al 2010, Qian et al 2008 Increased mortality • Mangaleshkar 2001, Stafansdottir 2008  No increased risk • Taylor et al 2010, Leonard et al 2003 Sydneyortho.com.au/sori_page

Bilateral TKR: Literature

 Limitations    Heterogeneous groups Many fail to compare to 2 x Unilateral Lack of attention to other aspects of patient outcomes • Leonard et al 2003: Increased patient satisfaction with Bilateral procedures Sydneyortho.com.au/sori_page

Study Aims

 Comparison of:    Unilateral Staged Bilateral Simultaneous Bilateral  Analysis of:    Complications Outcomes Patient Satisfaction & Perspective Sydneyortho.com.au/sori_page

Indications for Simultaneous BTKR

 Each Knee independently meets appropriate criteria for TKR  Medically fit (Physician review)  Patient elects surgery  Especially significant fixed deformities Sydneyortho.com.au/sori_page

Simultaneous Bilateral TKR

 Commence with most symptomatic  1 st completed, tourniquet deflated, extensor mechanism closed, before 2 nd started  Computer Navigation routine Sydneyortho.com.au/sori_page

Methods

 Single Surgeon  Consecutive Series     205 patients / 329 TKR Dec 2004 to June 2009 Minimum 1 yr followup 3 Groups • • 89 Simultaneous BTKR (2.1years) 81 Unilateral TKR (3.2 years) • 35 Staged Bilateral TKR (4 year) Sydneyortho.com.au/sori_page

Methods: Data Collection

 Ethics approval via NSHHREC Ethics committee  Retrospective Review   Prospective Database (Socrates) • Oxford, KSCRS, WOMAC, SF-36 Hospital Records  Patient Satisfaction Questionnaire  Self - administered Sydneyortho.com.au/sori_page

Methods: Patient Questionnaire

Sydneyortho.com.au/sori_page

Results: Patient Demographics

* 90 80 70 60 50 40 30 20 10 0 n=81 Unilateral

Age

n=35 Staged n=89 Simultaneous 25 20 15 50 45 40 35 30 * Significantly different to Simultaneous group (p<0.05) n=51 Unilateral

BMI

n=31 Staged n=62 Simultaneous Sydneyortho.com.au/sori_page

Results: Complication Rate (%)

Retention Postop delirium VTE Blood Tx ICU Other

Unilateral Staged Simultaneous P-value

3.3

6.9

5.7

0.59

11.7

8.3

10.7

3.4

5.7

4.6

0.23

0.66

10.0

3.3

3.3

3.4

0.0

3.4

10.3

6.9

2.3

0.45

0.47

0.74

Sydneyortho.com.au/sori_page

Oxford

50 45 40 35 30 25 20 15 10 5 0 Unilateral Pre-Op Post-Op Staged Simultaneous Sydneyortho.com.au/sori_page

WOMAC

30 20 10 0 70 60 50 40 Unilateral Pre-Op Post-Op Staged Simultaneous Sydneyortho.com.au/sori_page

Range of Motion

60 40 20 0 140 120 100 80 Unilateral Staged Pre-Op Post-Op Simultaneous Sydneyortho.com.au/sori_page

Results: SF36 – Physical Score

60 * * * † 50 40 30 Pre-op Post-op 20 10 n=67 n=50 0 Unilateral * Significantly different to pre-op (p<0.05) n=33 n=27 n=68 n=53 Staged Simultaneous † Significantly different to Staged (p<0.05) Sydneyortho.com.au/sori_page

Results: SF36 – Mental Score

70 60 50 40 30 20 10 n=67 n=50 0 Unilateral * Significantly different to Staged (p<0.05) n=33 n=27 Staged * n=68 n=53 Simultaneous Pre-op Post-op Sydneyortho.com.au/sori_page

Results: Patient Satisfaction

2 0 6 4 12 10 8 * Unilateral Staged * Significantly different to Unilateral and Staged (p<0.05) Simultaneous Sydneyortho.com.au/sori_page

Discussion

 Bilateral Simultaneous TKR    Controversial • Increased morbidity / mortality • Inconsistencies in literature Minimal investigation into patients’ perspective Potential benefits for the patient • Rehabilitation & Clinical Outcome • Efficiency / Costs / Expedience Sydneyortho.com.au/sori_page

Discussion

 Current investigation      No increase in morbidity / mortality Equivalent or better functional outcomes Improved patient satisfaction Negative preconceptions proved incorrect Effect of better preop SF36 mental scores  Limitations   Differences in groups (not RCT) Questionnaire not validated Sydneyortho.com.au/sori_page

Conclusion

 Bilateral Simultaneous TKR    Bilateral advanced OA • Especially significant fixed deformities Healthy patients (Physician approval) Patient request  Further study  Increasing database  Development & Validation of questionnaire Sydneyortho.com.au/sori_page

Thankyou

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