TKR JOURNAL simultaneous vs staged total knee replacement

simultaneous vs staged total knee replacement

1. COMPARISION OF SAFETY PROFILE OF BILATERAL SIMULTANEOUS VERSUS STAGGERED TOTAL KNEE REPLACEMEMT:RCT PRESENTER:DR.GEETHIKA 2 ND YEAR POSTGRADUATE MODERATOR:DR.VIJAYABUSHANAM PROFESSOR

2. JOURNAL OF ARTHROPLASTY JUNE 14 TH 2025 KUSHAL HIPPALGAONKAR,A.V.GURAVA REDDY HYDERABAD,INDIA

3. REMEMBER-5mins Definitions of simultaneous, staggered , staged procedure UNDERSTAND-10mins Intraoperative complications and their pathophysiology EVALUATE-10mins Effectiveness of simultaneous and staggered procedure CREATE-20mins Journal proper TOTAL-45MIN SPECIFIC LEARNING OBJECTIVES

4. INTRODUCTION SIMULTANEOUS -one procedure under the same anaesthesia STAGGERED -two separate procedures during a single hospitalization within 72hrs STAGED -two unilateral Total knee arthroplasty surgeries in two hospital admissions separated by several weeks to months

5. COMPLICATIONS PERIOPERATIVE COMPLICATIONS Pulmonary embolism Deep vein thrombosis(DVT) Cardiovascular events Hypotension Arrhythmias Desaturation

6. POSTOPERATIVE COMPLICATIONS Cardiopulmonary complications Neurological complications Drop in haemoglobin level Blood loss Blood transfusions associated with fever,hypotension

7. THROMBOEMBOLISM Thrombi in Popliteal vein is more likely to cause PE than that in calf veins. Various risk factors have been associated with development of DVT and Thromboembolism Prophylaxis measures have significantly reduced the incidence.

8. RISK FACTORS Age: >40yrs H/o Stroke Nephrotic syndrome Cancer Prolonged immobility Previous Thromboembolism Chronic heart failure Inflammatory bowel disorder Obesity ,Varicose vein Smoking Hypertension , DM

9. VIRCHOW TRAID

10. HYPOTENSION

11. CARDIOVASCULAR EVENTS

12. JOURNAL OF BONE AND JOINT SURGERY 2007 BOSTON

13. CARDIAC EVENTS WITH SIMULTANEOUS BILATERAL TOTAL KNEE REPLACEMENT

14. INTERNATIONAL JOURNAL OF RESEARCH IN ORTHOPAEDICS DATE:JUNE 2020 A.V.GURAVA REDDY HYDERABAD

15. Study of 234,divided into simultaneous,staged,staggered

16. WOMAC INDEX FOR FUNCTIONAL OUTCOME PARAMETRS Pain Stiffness Difficulty while standing,taking stairs,walking on even floor,sitting

17. OXFORD KNEE SCORE

18. JOURNAL PROPER

19. JOURNAL OF ARTHROPLASTY JUNE 14 TH 2025 KUSHAL HIPPALGAONKAR,A.V.GURAVA REDDY HYDERABAD,INDIA

20. INTODUCTION Total knee arthroplasty (TKA) remains the gold standard surgical intervention for patients who have debilitating bilateral knee osteoarthritis (OA), markedly enhancing quality of life by alleviating pain and improving functional mobility.

21. As the prevalence of bilateral knee OA has risen in conjunction with an aging global population, so too has the need to optimize the surgical strategies for treating bilateral knee OA, specifically weighing the benefits and risks of simultaneous , staggered and staged procedures. 

22. AIM This study aimed to clarify the outcomes of simultaneous versus staggered bilateral TKA through a randomized controlled trial. The primary objectives are to assess patient safety by examining intraoperative , perioperative and 90-day complication rates. The secondary objectives include assessing the need for blood transfusions and length of hospital stay.

23. STUDY DESIGN This was a single- center , prospective, randomized control trial of patients who had bilateral primary OA of the knees, randomized to undergo either simultaneous bilateral TKA or staggered bilateral TKA to compare the safety profile of both approaches. Time period-January 1, 2023 and September 30, 2023

24. INCLUSION CRITERIA Age <65years Optimized medical conditions(hypertensive or diabetes patient on medication,HbA1C<8%) BMI<30 ASA class-1/2 A vailability of comprehensive intensive care unit support, effective pain management,good rehabilitation services, and alignment with patient and family preferences for staggered surgery.

25. EXCLUSION CRITERIA Age>66years History of previous knee surgeries; secondary knee arthritis due to inflammatory arthropathy or post-traumatic arthritis; History of intraarticular injections within 3 months of presentation ASA class III and above DVT,Pulmonary thromboembolism Uncontrolled hypertension,diabetes,immunocompromised patients

26. SAMPLE SIZE AND RANDOMIZATION

27. RESULTS Blood transfusion requirements and length of hospital stay were notably higher in the staggered TKA group. These results suggest that, while staggered procedures may necessitate more intensive postoperative care, the general safety profile regarding complication rates remains similar for both surgical approaches.

28. DISCUSSION The decision to opt for either simultaneous or staggered TKA should be tailored to individual patient characteristics, balancing the risks associated with extended hospitalization and increased transfusion needs with the benefits of each approach.

29. This approach of performing a staggered TKA is particularly relevant in the Asian scenario due to patient preferences comfort, lack of insurance coverage to perform TKA on both knees in one sitting, affordability concerns due to insurance limitations and the convenience of addressing both knees within a single hospital admission

30. The staggered bilateral TKA group required significantly more intraoperative and postoperative blood transfusions compared to the simultaneous bilateral TKA group. This increased need for blood transfusions in the staggered group may be attributed to the cumulative effect of two separate surgeries and anaesthetic exposures.

31. A study done by Maniar et al. found that interleukin 6 showed a sharp rise from a preoperative median value of 6 pg /mL to a peak median value of 133 pg /mL at 12 hours postoperatively. At 4 days, it had declined to a median value of 22 pg / mL. This heightened response may explain the increased likelihood of complications,thus supporting the practice of performing the second TKA surgery after 72 hours (day three) in a staggered bilateral TKA.

32. The length of hospital stay was significantly shorter for patients undergoing simultaneous bilateral TKA compared to those undergoing staggered bilateral TKA This reduction in hospitalization time for simultaneous bilateral TKA patients supports the notion that simultaneous procedures are more cost-effective due to decreased resource utilization

33. The primary advantage of staggered TKA is its suitability for patients who have severe bilateral OA in Asian countries, which are often associated with major delays in insurance processing after surgery, wide variation in pricing between government and private institutes, and also among patients who are unfit for a simultaneous TKA

34. In conclusion, this randomized controlled trial demonstrates that staggered bilateral TKA, performed within the same hospital admission with a 72-hour interval, is non-inferior to simultaneous bilateral TKA regarding complication profiles, provided appropriate patient selection criteria are followed. However, staggered TKA has a notably higher transfusion requirement, which should be clearly communicated to patients preoperatively.

35. REFERENCES Raynauld JP, Martel-Pelletier J, Dorais M, Haraoui B, Choquette D, Abram F,et al. Total knee replacement as a knee osteoarthritis outcome: predictors derived from a 4-year long-term observation following a randomized clinical trial using chondroitin sulfate . Cartilage 2013;4:219. https:// doi.org /10.1177/1947603513483547. Khanna V, Gurava Reddy AV, Daultani D, Sankineani SR, Khanna J,Annapareddy A, et al. When can I go home after my knee replacement?Factors affecting the duration of in-hospital stay after knee replacement. Eur Orthop Surg Traumatol 2019;29:1719—28. https:// doi.org /10.1007/s00590019-02485-5.

36. Adili A, Bhandari M, Petruccelli D, De Beer J. Sequential bilateral total knee arthroplasty under 1 anesthetic in patients > or = 75 years old: complications and functional outcomes. J Arthroplasty. 2001;16:271-8. Ritter M, Mamlin LA, Melfi CA, Katz BP, Freund DA, Arthur DS. Outcome impli - cations for the timing of bilateral total knee arthroplasties. Clin Orthop Relat Res. 1997;345:99-105.

37. MCQ’S

38. Which of the following is a major concern with simultaneous bilateral TKA in high-risk patients? A. Faster wound healing B. Decreased thromboembolic risk C. Increased cardiopulmonary complications D. Reduced length of stay

39. Correct Answer: C Simultaneous procedures may increase cardiovascular or pulmonary risk, especially in older or comorbid patients.

40. Simultaneous bilateral TKA is typically avoided in which type of patient? A. Age under 60 B. ASA (American Society of Anesthesiologists) grade I C. Obese patient with uncontrolled diabetes D. Patient with bilateral knee osteoarthritis

41. Correct Answer: C High-risk comorbidities like obesity and uncontrolled diabetes increase complication risk.

42. Compared to staged bilateral TKA, simultaneous bilateral TKA is associated with: A. Lower total cost of care B. Lower overall functional improvement C. Increased rate of revision surgeries D. Shorter operative time per knee

43. Correct Answer: A Simultaneous procedures are generally more cost-effective than two separate surgeries.

44. What is the primary reason for choosing a staged (staggered) bilateral total knee replacement over a simultaneous procedure? A. Reduced rehabilitation time B. Improved range of motion C. Lower perioperative risk in high-risk patients D. Better cosmetic outcome

45. Correct Answer: C Staged procedures are safer for patients with significant comorbidities or poor cardiopulmonary reserve.

46. THANK YOU