Title: Perioperative Complications in Simultaneous Bilateral versus Unilateral Total Knee Arthroplasty

Authors: Mohamed S. Kabil, MSc; Mohsen A. Mashour, MD; El Sayed Mohameady Ibrahim, MD

Affiliation: Orthopedics Specialist, Agoza Hospital

Corresponding Author: Mohamed Solyman Kabil

Email: Muhammad.Suleiman21@fmed.bu.edu.eg

Phone: +20 1006388415

Background: Single-stage bilateral total knee arthroplasty (SB-TKA) has been shown to have economic benefits but may also lead to perioperative complications. Currently, there is no clear guideline for choosing between single-stage and staged procedures, and further research is needed to address this gap.

Objective: This study aims to compare perioperative outcomes of unilateral total knee arthroplasty (U-TKA) versus SB-TKA in patients with bilateral knee osteoarthritis.

Methods: A prospective cohort analysis was conducted on 30 patients with bilateral knee osteoarthritis. Group A underwent SB-TKA, while Group B underwent U-TKA. Cruciate retaining design.

Results: Preliminary one-year follow-up data for 30 cases, average age 58 years old showed lower rates of perioperative complications in Group B (U-TKA) compared to Group A (SB-TKA) (p < .05). Two cases in Group B required revisions, while seven cases in Group A needed blood transfusions, two were admitted to ICU, and three had superficial wound infections.

Conclusion: These preliminary findings suggest that U-TKA may have lower perioperative complication rates than SB-TKA. However, further investigation with a longer follow-up period is required to confirm these results. This study highlights the need for continued research to guide procedure selection for patients with bilateral knee osteoarthritis.
Keywords:
TKA, SB-TKA, U-TKA-, Perioperative complications, Economic benefits

Background: Performing bilateral simultaneous total knee replacement (TKR) poses some hazard on specific patients mainly due to the longer operative times. In this study, advocate for the use of patient-specific instrumentation (PSI) in patient performing bilateral simultaneous TKR as they are less prone to long operative times.
Methods: After obtaining ethical approval and collecting informed consent, the data for this study were collected prospectively using the Egyptian Community Arthroplasty Registry. We included patients undergoing TKR regardless of their age, sex, cause of TKR, and other basic characteristics. However, we only included patients who performed bilateral simultaneous TKR using PSI. We dichotomized the patients depending on age (younger than 60 years and 60 years or older). Correlations were performed using a two-sample t-test.
Results: The finally included knees were 484 of 242 patients. The number of female knees was 388 (80.2%). The mean age and BMI were 62.4 (SD=9.2) years and 33.5 (SD=7.3) Kg/m2, respectively. There was not enough statistical evidence to suggest that the improvement in knee society score was better in any of the two age groups (p>0.05).
Conclusion: We believe that performing bilateral simultaneous PSI may offer better chances to the elderly with comorbidities who will not stand a chance of having their bilateral surgeries performed using the conventional approach. However, further studies are required to define the criteria for bilateral simultaneous TKR when using PSI.

Purpose
Robotic knee arthroplasty procedures have become the new trend that attracted many orthopedic surgeons worldwide; it was hypothesized that robotics is associated with the improvement of accuracy of prosthesis position and alignment restoration.
This study aimed to provide high evidence-based comparison between the robotic total and conventional knee replacements in terms of radiological and functional outcomes.
Methods
PRISMA guidelines were followed in our literature review while conducting this meta-analysis. We only included English literature using keywords; Arthroplasty, Total knee, Robotic knee, conventional knee, jig-based knee using Pub Med, Medline, CINAHL, Cochrane, Embase, and Google Scholar databases. Randomized control trials were only included in the analysis after assuring their homogeneity. Analysis of different variables like knee range of motion, KSS, Oxford knee, WOMAC, HSS Knee scores, complications and radiological alignment.
Results
Our search yielded 8 randomized control trials that were qualified to our analysis. 2002 knees have been included in the study; 1005 knees were implanted using robotic arms while the other 997 were done using jig-based knee systems. Although we were not able to identify any statistically significant superiority of either technique when it comes to patients reported outcomes and complications, robotic knees were significantly better in the post operative range of motion, mechanical and anatomical axes restorations and femoral prosthesis position.
Conclusion
According to our meta-analysis, both robotic and jig based total knee techniques were equivalent in patient’s reported outcomes and tibial tray position, however robotic knees were better in post-operative range of motion and alignment restoration.

Introduction: Total knee replacements aim for early mobilization for improved longer term outcomes. This is largely limited by pain control in the immediate post-operative period. The modality of local infiltration analgesia (LIA) improves pain control but requires the combination of Adrenaline, Ketorolac, and Ropivacaine which takes up time and manpower. An alternative would be to use pre-diluted Ropivacaine which requires less steps and time. Aim: This study prospectively compares the efficacy of using the conventional LIA cocktail vs pre-diluted Ropivacaine with IV Parecoxib and assesses if the difference (or lack thereof) in post-operative pain control will be suitable given the logistical efficiency of pre-diluted Ropivacaine LIA intra-operatively. Methods: Patients with inflammatory arthritis and contraindication to NSAIDs were excluded. LIA was given at same stages of surgery and weight adjusted. Patients were given either the full cocktail or LIA ropivacaine with IV Parecoxib. VAS scores were collected from post-operative Physiotherapy assessments on day 0/1. Results: A total of 37 patients (19 cocktail and 18 pure Ropivacaine) with an average age of 68.2 years. Average length-of-stay of 1.89 days. The mean VAS for cocktail was 2.32±0.930 compared to 4.44±0.940 for pure Ropivacaine (p=0.007). Use of pre-diluted Ropivacaine during TKR with IV Parecoxib anecdotally reduced the need for manpower/time. Discussion and Conclusion: Conventional cocktail had significantly better pain scores immediately post-op despite needing more time to prepare. Peri-operative analgesia for TKR continues to balance between efficiency vs efficacy. It would be prudent to explore whether this would affect patient outcomes beyond immediate post-op.

It might be difficult to identify and manage infections following total knee and total hip arthroplasty. To prevent infection in our trial, we followed a specific strategy for all arthroplasty patients. A 500-case retrospective analysis was conducted to evaluate our technique for preventing infection. The research included 33 patients with total hip arthroplasty, 432 with original total knee replacement, 13 with bilateral primary knee replacement, and 9 with total knee revision. The protocol for the prevention of infection was divided into preoperative measures (elimination of any septic focus, three showers with for the patient, antibiotic during induction), intraoperative measures (sterile helmet for the surgeons and nurses, double gloves technique, complete disposable draping, use of pulsatile wash, Betadine film scrubbing the patient), and postoperative measures (removal of any septic focus, three showers Cleanse with hydrogen peroxide, then with three litres of regular saline. Change gloves after draping, change gloves before to applying the prosthesis, and administer an antibiotic spray once the wound has been closed. Dressing using silver nitrate dressing, reducing tourniquet duration, and haemostasis) as well as postoperative measures (Wound exposure after 2 w of surgery. Antibiotics for 5 days, CBC after 24 hours of surgery, If HB below 10: give blood transfusion). The data revealed that just one case was infected after two years of follow-up, while 499 cases exhibited no evidence of illness; therefore, the infection rate in our institution is 0.2%. Our strategy was successful in preventing infection during arthroplasty procedures.

Hemophilia A is a genetic disorder involving a deficiency of clotting factor VIII. recurrent hemarthrosis of major joints is often a common occurrence due torepeated trauma. That usually leads to hemophilic arthropathy, Therefore, orthopaedic adult reconstructive surgeons increasingly encounter hemophilic arthropathy in young adults and consider treating with total joint arthroplasty. In this report, the authors describe a patient with hemophilia A and severe knee osteoarthritis, who was treated with primary semiconstrained total knee arthroplasty. This rare case is an opportunity to explore a variety of unique clinical scenarios specific to patients with hemophilia, including the maintenance of optimal factor VIII levels through clotting factor infusions and prevention of a venous thromboembolic event.

Introduction: Robotic-assisted surgery is increasingly being adopted in TKA to improve accuracy of bony cuts and gap balancing. CORI is an imageless, intraoperative mapping robotic system recently launched. This study aims to analyze CORI's accuracy in achieving planned alignment, component positioning and gap balancing in TKA. Method: Patients undergoing TKA utilizing CORI in the study period were included. Mechanical alignment and component positioning was measured on postoperative radiographs. The accuracy was analyzed by the number of outliers (±3°) for the achieved mechanical alignment and component positioning as compared to planned alignment and component positioning. The gap balancing achieved was quantified by CORI robotic system and was recorded. Medio-lateral gap in flexion and extension within 2mm was considered as precise. Results: Overall number of outliers (±3°) for HKA angle in 300 knees were 19 (6.3%) The outliers in varus knees were 14 out of 280 (5%) and in valgus knee were 5 out of 20 (25%) which was statistically significant (p =0.0004). The outliers for α, β, and γ angles were 8.33%, 4% and 8.66% respectively. Gap balancing was accurate in all knees. Conclusion: The novel burr based CORI system has overall accuracy of 93.70 %. The system was not very accurate for achieving planned alignment in valgus knees and had significantly higher number of outliers as compared to the varus knees (p < 0.0001). This system had more than 90% accuracy for component positioning, had no femoral notching or over-hangs and 100% accuracy for gap balancing in the stipulated range.

Introduction: use of tourniquet in total knee replacement helps in providing a bloodless field for surgery but has many disadvantages in postoperative period. Methods: a prospective study of 217 (grade 3 OA) knee replacement surgeries without patella resurfacing were conducted between 2015 to 2019. Surgeries performed on odd days of the week(mon,wed,fri) were performed with tourniquet n= 89 called as gp1), whereas surgeries performed on even days(tue,thu,sat) were performed without torniquet (n=128 called as gp2). The blood loss intraoperatively was assessed by weighing the mops used. Suction was not used in all cases during the study. VTE prophylaxis was as per standard protocol in all cases Drain collection at 72 hours was noted. OKS and VAS were used preoperatively and at every 3-week intervals till 6 months to assess outcome. Results: blood loss was almost similar in both groups at about 800ml in gp1 to 820ml in gp2. Knee score was better in gp1 but return to activity was similar in both groups. Quads weakness was seen in 15.7%(n=14) of patients in gp1 with grade 1 decrease. Dvt was seen in 1 case of gp1. Wound complications were not seen in both groups. Conclusion: tourniquet use helps in faster surgical time, but has a few risks in postoperative period. Outcome may be similar but detailed evaluation of the kinematics is required to assess the actual muscle wasting.

Introduction: The Oxford Unicompartmental Knee Replacement (OUKR) is the most commonly used UKR globally. Instrumentation modifications have resulted in significant outcome improvements for OUKR patients over 40 years of use. This study aimed to assess surgeons’ views of the OUKR instrumentation with a survey. Methodology: An anonymous online survey was developed to collect demographic information on OUKR user experience and caseload. Surgeons were also asked to identify instruments that need improvement for each step of the operation and asked what new instruments and/or technology may improve the procedure. The survey was distributed via email and social media. Inclusion criteria was any surgeon that had completed at least one OUKR. Results: 104 responses from OUKR users (87 orthopaedic consultants and 17 other users) were received. On average, the users had 8.6 years (95%CI=1.4) of OUKR experience and performed 51 OUKRs per year (95%CI=14), which comprised 37% (95%CI=5.3) of their knee replacement caseload. Instruments used for tibial resection (50%), femoral preparation (35%), and tibial keel slot preparation (29%) were identified as requiring improvement by the greatest proportion of surgeons. 62% of surgeons believed technology would improve the OUKR procedure, with robotics and navigation the preferred assistance types. Conclusions: Based on surgeon feedback, mechanical instruments for OUKR tibial resection to assist the vertical cut, femoral preparation to facilitate accurate drill guide placement, and the tibial keel slot saw and template need to be optimised. The implementation of assistive technology for OUKR should also be investigated, specifically for tibial and femoral component positioning.