Bilateral simultaneous knee arthroplasty shows comparable early outcome and complication rate as staged bilateral knee arthroplasty for patients scored ASA 1-3 if performed by a high-volume surgeon: a retrospective cohort study of 127 cases.

BACKGROUND AND PURPOSE: The study compares early outcomes after simultaneous and staged knee arthroplasty in patients with bilateral knee osteoarthritis (OA) to evaluate whether simultaneous bilateral TKA shows comparable early outcomes and complication rates to staged bilateral TKA. METHODS: A retrospective cohort study including all patients scheduled for primary TKA for bilateral knee OA (n = 127) was conducted. Patients received either simultaneous (n = 53, 41.7%) or staged (n = 74, 58.3%) bilateral TKA by a single, high-volume surgeon-depending on their individual preference. Demographic data, haemoglobin drop (Hb), length of stay (LOS), operation time, 30-day complication rate and achievement of rehabilitation key points were evaluated. RESULTS: There was no difference between the groups concerning age, sex, BMI or complication rate. ASA scoring was better in the simultaneous group [2.2, (15.1% ASA 1, 49.1% ASA 2, 35.8% ASA 3) vs. 2.4 (2.7% ASA 1, 51.4% ASA 2, 45.9% ASA 3)]. Average LOS was 7.8 ± 2.1 days for simultaneous TKA, 7.4 ± 1.7 days for single procedure of staged group (p < 0.453) and 14.7 ± 3.1 days if combined (p < 0.001). Cumulative Hb loss was significantly higher in the staged group (3.8 ± 1.2 g/dl vs. 2.4 ± 0.8 g/dl, p < 0.001). Detailed comparison of early outcome parameters between staged and simultaneous procedure depending on ASA score only revealed slightly slower assessment of stairs (p < 0.001) and increased Hb drop per surgery in case of simultaneous procedure (p < 0.011) if ASA score was ≥ 2. Only patients scored ASA 3 demonstrated a significant longer LOS per procedure in simultaneous group (8.5 ± 2.4 vs.7.3 ± 1.6 days, p = 0.034). INTERPRETATION: Simultaneous bilateral TKA results in comparable early outcome and complication rate than staged bilateral procedure-even for patients scored ASA 3. LEVEL OF EVIDENCE: Level IV.

Bilateral simultaneous hip arthroplasty shows comparable early outcome and complication rate as staged bilateral hip arthroplasty for patients scored ASA 1-3 if performed by a high-volume surgeon.

PURPOSE: The aim of this study was to compare early outcomes after simultaneous and staged hip arthroplasty (THA) in patients with bilateral symptomatic pathology. METHODS: We conducted a retrospective cohort study including all patients scheduled for primary THA for bilateral hip osteoarthritis (OA, n = 290). Patients either received simultaneous (n = 152, 52.4%) or staged (n = 138, 47.6%) bilateral THA based on individual preference. All operations (n = 428) were performed by one single, high-volume surgeon. Demographic data (e.g., age, ASA score) as well as perioperative parameters (haemoglobin drop (Hb), red blood cell transfusion, length of stay (LOS), operation time, six week complication rate and achievement of inpatient rehabilitation key points) were evaluated. RESULTS: Patients in the simultaneous bilateral THA group were younger (62.8 ± 8.9 vs. 65 ± 9.7 years, p = 0.022) and had lower ASA scores (1.8, (34.2% ASA 1, 55.3% ASA 2, 37.2% ASA 3) vs. 2.0 (18.8% ASA 1, 61.6% ASA 2, 19.6% ASA 3)) than the staged group. While the average LOS was 7.1 ± 1.7 days for simultaneous bilateral THA, the combined LOS for the staged group was 12.9 ± 2.4 days (p < 0.001). The cumulative operation time in the simultaneous bilateral THA group was 61.1 ± 11.5 min and 57.6 ± 7.3 min in the staged group (p < 0.015). Cumulative Hb loss was significantly higher in the staged group (2.1 ± 7.2 g/dl vs. 3.7 ± 1.3 g/dl, p < 0.001). No significant differences were found concerning the complication rate or early inpatient rehabilitation. CONCLUSION: Simultaneous bilateral hip arthroplasty in patients with symptomatic bilateral hip osteoarthritis is as safe and successful as a staged procedure if performed by a high-volume surgeon.

The Safety of Bilateral Simultaneous Hip and Knee Arthroplasty versus Staged Arthroplasty in a High-Volume Center Comparing Blood Loss, Peri- and Postoperative Complications, and Early Functional Outcome.

PURPOSE: In recent years, there has been increasing interest in the use of simultaneous hip and knee arthroplasty compared to staged procedures in patients with bilateral pathology. The aim of this study was to compare simultaneous and staged hip and knee arthroplasty in patients with bilateral pathology by assessing the transfusion rate, postoperative hemoglobin drop, length of stay (LOS), in-hospital complications, 30-day readmissions and early functional outcome. METHODS: We conducted a retrospective cohort study that included all patients who were undergoing primary TKA, THA and UKA by a single surgeon in a high-volume arthroplasty center between 2015 and 2020 as simultaneous or staged procedures. Staged bilateral arthroplasties were performed within 12 months and were stratified by the time between procedures. Data were acquired through the electronic files at the Orthopädische Chirurgie München (OCM). For functional outcome, the ability of the patients to walk independently on the ward was compared with the ability to walk a set of stairs alone, which was recorded daily by the attending physiotherapist. RESULTS: In total n = 305 patients were assessed for eligibility and included in this study. One hundred and forty-five patients were allocated to the staged arthroplasty group. This group was subdivided into a hip and a knee group, whereas the knee group was split into TKA and UKA. The second staged procedure was performed within 12 months of the first procedure. One hundred and sixty patients were allocated to the simultaneous arthroplasty group. This group was also subdivided into a hip and knee group, whereas the knee group was split again into a TKA and UKA group. No statistical difference was found between the two groups regarding demographic data. Primary outcome measurements: There was no significant difference in the transfusion rate or complication rate. Secondarily, no statistically significant difference was found between the postoperative hemoglobin drop and the functional outcome, or in the length of stay (LOS) between both groups. Walking the stairs showed a significant difference in the knee group. CONCLUSIONS: There were no significant differences observed in the transfusion rate in-hospital complications, or readmission rate between both groups. The early functional outcome showed no significant difference in mobility for all groups. Simultaneous arthroplasty for knee or hip is as safe as a staged procedure, with no higher risk for the patient, in a specialized high-volume center. LEVEL OF EVIDENCE: Level IV.

Discrepancy of Trial Rasp and Femoral Stem Relative Position Within the Femoral Canal of a Coated Tapered System: An Intraoperative, Intrapatient Controlled Study.

BACKGROUND: For a successful total hip arthroplasty, the final position of the trial rasp should be adopted by the femoral stem to achieve correct positioning. This study aimed to characterize the discrepancy of the stem and rasp position in vivo of a widely used dual-tapered straight stem with rectangular cross section that is known to have an oversized stem with respect to the rasp. METHODS: The distances between the tip of the greater trochanter and the shoulder of the implant and rasp were measured on 39 intraoperatively acquired fluoroscopic image pairs. Leg-length discrepancy was also measured clinically before and after surgery. RESULTS: A paired t-test showed a significant average protrusion of the femoral stem with respect to the final rasp position of 2.63 mm (standard deviation = 2.3 mm, P < .001), while 88% of the cases had no leg-length discrepancy after surgery. The quantified stem protrusion was statistically significant but did not reach clinical relevance and was easily mitigated in our study. CONCLUSIONS: The quantified stem protrusion appears to be clinically manageable, as only 2 cases required attenuation of stem positioning: in one case by the use of a femoral head with a shorter neck and in the other case by rerasping the femoral bed. Neither case was associated with the most extreme differences in position of the stem with respect to the final rasp. In addition, the used stem shows good overall outcomes in other studies. It appears that factors other than stem and rasp position play a critical role to the surgeon and for total hip arthroplasty success.

Is changing the postoperative pain management in total knee arthroplasty from femoral nerve block to local infiltration analgesia successful? Retrospective trial with the first and last 100 patients.

PURPOSE: In recent years, there has been an increasing interest in local infiltration analgesia (LIA) as a technique to control postoperative pain. We compared this technique to the gold standard the 3 in 1 femoral nerve block (FNB) in postoperative pain management after total knee arthroplasty (TKA) in a large patient population. This trial analyzes in the early postoperative phase the pain, range of motion, and consumption of pain medications after TKA. METHODS: We conducted a retrospective trial that included all patients who were undergoing primary TKA by one single surgeon in a high-volume arthroplasty center in 2015. Patients who have secondary osteoarthritis due to rheumatoid arthritis or previous knee arthrotomy, as well as revision cases, were excluded. The included patients were divided into 2 groups according to the applied pain management (group 1 FNB, group 2 LIA). Concerning the LIA group, a modified form of composition compared to the first describer without the use of adrenaline was carried out. Post-operative additional pain medications were given on a fixed scheme to the patient. The primary outcome was pain at rest over 7 days after surgery labeled by the numeric pain rating scale (NRS). The secondary outcome measures were the total amount of opioid consumption over the hospital stay and the additional need for non-opioid medication. The conversion of the opiate medications on the morphine preparation was carried out according to the conversion data from the literature. For functional recovery, we compared the range of motion in both groups, which was recorded from the second postoperative day by the attending physiotherapist. RESULTS: In total, 202 patients were assessed for eligibility and included in this clinical trial. Hundred patients were allocated to the continuous FNB group (group 1) and 102 patients to the LIA group (group 2). No statistical difference was found between the two groups regarding demographic data. Primary outcome measurements: The LIA group had a significantly lower NRS score than the continuous FNB group for the measurement in the morning on days 1, 2, and 3 after surgery (day 1, 1.5; day 2, 1.6; day 3, 1.3; p < 0.05). Secondary outcome measurements: The total volume of morphine consumption for the first six postoperative days was significantly lower in the LIA group than the FNB group (FNB 159.8 vs. LIA 96.07). There is also a significant difference between the total morphine consumption of both groups in the direct postoperative course with respect to time and group (two way ANOVA, p < 0.05) On the day of the operation and on the first postoperative day, the intake of additional non-opioids in the LIA group was also significantly reduced compared to the FNB group. No significant difference was observed on the second to sixth postoperative day concerning an additional consumption of non-opioid medications. In terms of range of motion, the LIA group showed a higher active range of motion at the operated extremity than the FNB group during the hospital stay. CONCLUSION: The local intraarticular infiltration therapy (LIA) is a sufficient alternative to regional anesthesia avoiding the known risks of regional procedures. The results of this study reflect the efficiency of this pain management with a lower consumption of analgesics, identical to reduced postoperative pain ratings and an improved ROM in the first postoperative days. LEVEL OF EVIDENCE: Retrospective trial.

[Perioperative Management in Total Knee Arthroplasty]. / Perioperatives Management in der Knieendoprothetik.

The themes of this paper are the clinical relevance and technique of perioperative management in total knee arthroplasty. Due to the number of unsatisfied patients after knee arthroplasty, optimisation of processes seems to be necessary. Beside patient preparation and rehabilitation, the surgical technique and implant choice in perioperative management are important. This means the use of tourniquet and drains, the application of tranexamic acid and pain management. These items are presented and discussed in detail in this paper.

Wedge volume and osteotomy surface depend on surgical technique for distal femoral osteotomy.

PURPOSE: Biplanar distal femoral osteotomy (DFO) is thought to promote rapid bone healing due to the increased cancellous bone surface compared to other DFO techniques. However, precise data on the bone surface area and wedge volume resulting from both open- and closed-wedge DFO techniques remain unknown. We hypothesized that biplanar rather than uniplanar DFO better reflects the ideal geometrical requirements for bone healing, representing a large cancellous bone surface combined with a small wedge volume. METHODS: Femoral saw bones were assigned to 4 different groups of varization distal femur osteotomies: group 1, lateral open-wedge uniplanar DFO; group 2, medial closed-wedge uniplanar DFO; group 3, lateral open-wedge biplanar DFO; and group 4, medial closed-wedge biplanar DFO. Bone surface areas of all osteotomy planes were quantified. Wedge volumes were determined using a prism-based algorithm, applying standardized wedge heights of 5, 10 and 15 mm. RESULTS: The biplanar osteotomy techniques (groups 3 and 4) created significantly larger femoral surface compared to the uniplanar groups (groups 1 and 2) (p = 0.036). Bone surfaces after the lateral biplanar open-wedge technique (group 3) were slightly larger than the medial biplanar closed-wedge technique (group 4) and biplane techniques significantly larger than the uniplanar techniques (groups 1 and 2). Wedge volumes were significantly higher in the lateral uniplanar open-wedge (group 1) and biplanar open-wedge (group 3) techniques compared to the closed-wedge techniques (groups 2 and 4) that have nearly absent wedge volumes. CONCLUSION: Bone geometry following DFO suggests that the medial biplanar closed-wedge technique simultaneously creates smaller wedge volume and larger bone surface areas compared to the lateral biplanar open-wedge and the uniplanar DFO techniques. The horizontal cuts of the biplane DFO techniques are positioned behind the trochlear area in better healing metaphysial bone, which further enhances bone healing potential. Although this idealized geometric view on bony geometry excludes all biological factors that influence bone healing, the current data confirm the general rule for osteotomy techniques: reducing the amount of slow gap healing and wedge volumes and simultaneously increasing the area of faster contact healing by larger bone surface areas may be beneficial for osteotomy healing.