Original Article
311
Staged Bilateral Total Knee Arthroplasty: Time of the Second Side Antonia F. Chen, MD, MBA1 Mohammad R. Rasouli, MD1 Mitchell G. Maltenfort, PhD1 Javad Parvizi, MD, FRCS1 1 Department of Orthopaedic Surgery, Rothman Institute at Thomas
Jefferson University Hospital, Philadelphia, Pennsylvania
David N. Vegari, MD1
Ronald C. Huang, MD1
Address for correspondence Javad Parvizi, MD, FRCS, Department of Orthopaedic Surgery, Rothman Institute, 125 S. 9th Street, Suite 1000, Philadelphia, PA 19107 (e-mail: [email protected]).
Abstract
Keywords
► staged ► bilateral total knee arthroplasty ► complications ► periprosthetic joint infection
The purpose of this study was to determine if there was a safe time frame for performing the second total knee arthroplasty (TKA) in staged bilateral TKAs. Retrospectively, 589 TKAs were studied at a single institution from January 2000 to June 2012. Patients were excluded if they underwent simultaneous or staggered bilateral TKA during the same hospitalization. Patients were included if they underwent bilateral staged TKA during a different hospitalization within 21 to 90, 91 to 180, 181 to 270, and 271 to 360 days after the first TKA. In-hospital complications were determined using International Classification of Diseases, Ninth Revision codes for cardiac, pulmonary, urinary, deep vein thrombosis, wound complications, mechanical complications, and wound infections. Periprosthetic joint infection (PJI) was determined by hospital readmission records. There were 29 postoperative complication events (4.9%) and there was no difference between time groups and complications. The highest rates of PJI occurred when the second TKA was performed after 271 to 360 days (3.6%), followed by the early postoperative period after 21 to 90 days (2.7%). We could not identify a time frame for performing the second TKA in staged bilateral TKAs to reduce complications. A signal from the study suggests that complications, particularly PJI, may be lower if the second TKA is performed more than 90 days and less than 270 days after the first TKA, although this finding was not significant.
As the population ages and life expectancy increases, the number of patients who undergo total knee arthroplasty (TKA) has grown with time.1 With it, there are an increasing number of patients who receive bilateral TKAs, as there is increased risk of developing bilateral knee osteoarthritis (OA) after the development of unilateral OA.2 Bilateral TKAs can be performed simultaneously during the same hospital stay, staggered within the same hospital stay, or staged over different hospital visits. There has been considerable debate on the ideal bilateral TKA procedure to perform while evaluating complication rates, costs, and outcomes. Previous studies have compared the outcome and complications of staged bilateral TKAs and simultaneous bilateral
TKA. Simultaneous TKA has been shown to have an increased blood loss,3 mortality,4,5 and medical complications,6,7 especially cardiovascular complications8,9 and pulmonary embolism.4 On the other hand, simultaneous TKA has been found to cost less,10,11 have a lower risk of periprosthetic joint infection (PJI), and decreased risk of need for revision.8 Another study determined that there were no differences in complications between simultaneous and staged bilateral TKAs.12 On the contrary, one study found that staged bilateral TKA are more expensive and have worse outcomes13 and that staged bilateral TKA can have greater thromboembolic events14 and higher infection rates.15 However, there may be fewer complications associated with staged bilateral TKA
received February 25, 2014 accepted after revision May 21, 2014 published online July 28, 2014
Copyright © 2015 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1384215. ISSN 1538-8506.
Downloaded by: Collections and Technical Services Department. Copyrighted material.
J Knee Surg 2015;28:311–314.
Staged Bilateral Total Knee Arthroplasty
Chen et al.
and this procedure may be performed in patients with more comorbidities.16 While other studies have been performed evaluating the time frame to stagger bilateral TKAs within the same hospital visit,17–19 a meta-analysis evaluating the safety of simultaneous bilateral TKA was unable to determine a safe time period between staged procedures that could decrease risks.20 To date, there has been no study conducted that has evaluated a safe time frame after the index TKA to perform the second TKA to minimize complications. Thus, the purpose of our study was to determine if there was a safe time frame for performing the second TKA in bilateral TKAs to minimize complications.
Patients and Methods After approval by the institutional review board, we retrospectively reviewed our prospectively collected electronic total joint arthroplasty database to identify patients who underwent staged bilateral TKA between January 2000 and June 2012. Patients who were coded twice for primary TKA (International Classification of Diseases, Ninth Revision [ICD9] code of 81.54) were identified. Patients who had simultaneous bilateral TKA or staged bilateral TKA during the same hospitalization were excluded and only patients who had the second knee replaced within 360 days after the first knee, but not during the same hospitalization, were included in the study. We divided patients into the following groups, based on the time interval between stages: 21 to 90, 91 to 180, 181 to 270, and 271 to 360 days after the first TKA. Demographic information including age, gender, Charlson comorbidity index (CCI), and body mass index (BMI) was obtained for the patients included in this study. CCI is frequently used to assess underlying comorbidities and was originally designed to determine the risk of 10-year mortality.21 CCI consists of 17 weighted medical conditions, including cardiac, pulmonary, renal, vascular, neurological, hepatic, gastrointestinal, endocrine, oncologic, rheumatologic, and immunocompromised diseases.22 We queried our institutional database using ICD-9 codes to identify comorbidity items, which have previously been described.22 Raw scores were then adjusted for age, as 1 point was added for each decade after the age of 40 years. In-hospital complications were identified using the same coding system as has been previously described.8 The following ICD-9 codes were used to identify complications: cardiac, deep vein thrombosis, pulmonary including pulmonary embolism, urinary, mechanical complications, wound infections with associated revision codes, and wound complications. PJI was defined using the Musculoskeletal Infection Society criteria23 and PJI patients were determined by hospital readmission for infection. The rate of all complications was compared with the specified time intervals using Fisher exact test. The effect of the time intervals between TKA stages on the rate of complication was assessed using logistic regression analysis, controlling for age, gender, BMI, and CCI. A post hoc power analysis was performed assuming a randomized experiment The Journal of Knee Surgery
Vol. 28
No. 4/2015
using a one-tailed Fisher exact test assuming 80% power and a type I error rate of 5%. All analyses were performed using R 3.0.2 (R Foundation for Statistical Computing, Vienna, Austria) using the RMS package for logistic regression analysis, and p values < 0.05 were considered to be statistically significant.
Results A total of 589 patients including 374 females (63.5%) who underwent staged bilateral TKA were included in this study. The mean age and BMI of the patients were 65.8 10.1 years and 34.0 7.5 kg/m2, respectively. The majority of patients (579, 98.3%) had CCI 3. In our patient population, 13% (n ¼ 27) of the second TKA were performed 21to 90 days after the index procedure, 32% (n ¼ 191) were performed after 91 to 180 days, 27% (n ¼ 157) were performed after 181 to 270 days, and 28% (n ¼ 167) were performed after 271 to 360 days. A total of 29 complication events were identified after the second TKA, resulting in a 4.9% rate of postoperative complications. Urinary complications were the most frequent (n ¼ 15, 51.7%), followed by pulmonary (n ¼ 6, 20.7%), then mechanical complications of the implant (n ¼ 4, 13.8%). ►Fig. 1 depicts the frequency of complications at various time intervals. There was no statistically significant difference between various time groups and the rate of complications (p ¼ 0.90). Using our institution’s hospital readmission database, 14 PJI cases were identified. The highest rates were identified in the group where the second TKA was performed after 271 to 360 days (3.6%), followed by the second TKA performed in the early postoperative period after 21 to 90 days (2.7%). ►Fig. 2 demonstrates the frequency of these PJI at various time periods. Using logistic regression analysis, the time interval between TKA stages was not a predictor of complications (►Table 1).
Discussion Bilateral TKA is an increasingly popular surgical intervention because the likelihood of developing bilateral knee OA increases with the development of OA in one knee.2,24 Bilateral TKAs can be performed simultaneously, in a staggered fashion during the same hospital stay, or in a staged manner during different hospital stays. A previous study determined that staged bilateral TKAs have higher infection rates than unilateral TKAs.15 However, there has been no study till date evaluating a safe time frame to perform the second TKA to minimize risk of PJI. Therefore, the purpose of our study was to establish a safe time frame to minimize complications for performing the second procedure in patients undergoing bilateral TKAs. Based on the results of this study, there was no difference between various time groups and the rate of complications. Thus, based on all complications determined by the ICD-9 codes included in our study, we could not identify a safe time frame for performing the second TKA. There were less PJIs
Downloaded by: Collections and Technical Services Department. Copyrighted material.
312
Staged Bilateral Total Knee Arthroplasty
Chen et al.
313
Table 1 Results of multivariate analysis to identify predicators of complications. The time interval between stages was not a predictor of complication OR
95% CI
p-Value
Time interval between TKA stages (d)
1.00
1.00–1.01
0.31
Males
0.95
0.41–2.17
0.90
BMI (kg/m2)
1.07
1.02–1.13
0.01
Charlson comorbidity index
1.12
0.76–1.64
0.56
Age (y)
1.03
0.98–1.07
0.26
Fig. 1 Frequency of complications in different time intervals. DVT, deep venous thrombosis.
when the second TKA was performed between 90 and 270 days after the first TKA in a staged bilateral TKA procedure, but the finding was not statistically significant. A previous meta-analysis comparing simultaneous bilateral TKA, staged bilateral TKA, and unilateral TKA determined that staged bilateral TKAs have higher pulmonary and cardiac complications, as well as higher mortality.20 The study concluded
Fig. 2 Rate of readmission due to periprosthetic joint infection (PJI) in different time intervals.
that determining the period of time between staged bilateral TKAs to reduce these complications would be beneficial. Our study sought to determine this time frame and found that there was no difference in pulmonary and cardiac complications when staged bilateral TKAs were performed within 1 year of each other. A study conducted by Ritter et al in the Medicare population found similar results when comparing simultaneous versus bilateral staged TKAs performed in the following intervals: within 6 weeks, between 6 weeks and 3 months, between 3 and 6 months, and between 6 months and 1 year.25 This study evaluated complications (postoperative wound infection, mechanical complication of orthopedic devices, wound dehiscence, and postoperative hemorrhage), mortality, and hospital charges as endpoints. Similar to our study, the authors demonstrated that there was no difference in complications between the different time intervals, but the study demonstrated that staging the second TKA 3 to 6 months after the first TKA had the lowest mortality rate and was only slightly more expensive than performing simultaneous bilateral TKA.25 Of note, this study found no differences in wound infection between all-time groups of staged bilateral TKAs performed within 1 year of the index. While our study demonstrated differences in PJI based on the time frame of the second TKA, there were limitations to our study. First, we had an underpowered sample size and we could not determine a safe time frame for performing the second TKA in a patient undergoing bilateral staged TKA. A post hoc power analysis was performed and demonstrated that we had an undersized patient population. To show that complications within 90 days (2.7%) were less than those at 90þ days (4.9% overall), we would need 1,041 per group for a total of 2,082 patients. Second, if patients were admitted to other hospitals, their complications may not have been captured. Finally, there are limitations with using the ICD-9 coding system, such as not including complications outside of the scope of our study and the lack of clinical specificity for describing the complexity or severity of different disease conditions. Despite these limitations, our study suggests that there are no differences in complications determined by the time frame that staged bilateral TKAs are performed. Further studies are The Journal of Knee Surgery
Vol. 28
No. 4/2015
Downloaded by: Collections and Technical Services Department. Copyrighted material.
Abbreviations: BMI, body mass index; CI, confidence interval; OR, odds ratio; TKA, total knee arthroplasty.
Staged Bilateral Total Knee Arthroplasty
Chen et al.
needed to determine if a more specific time frame exists for performing staged TKAs based on other parameters.
13 Odum SM, Troyer JL, Kelly MP, Dedini RD, Bozic KJ. A cost-utility
14
References 1 Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary
2
3
4
5
6
7
8
9
10
11
12
and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007;89(4):780–785 Felson DT, Zhang Y, Hannan MT, et al. The incidence and natural history of knee osteoarthritis in the elderly. The Framingham Osteoarthritis Study. Arthritis Rheum 1995;38(10):1500–1505 Jankiewicz JJ, Sculco TP, Ranawat CS, Behr C, Tarrentino S. Onestage versus 2-stage bilateral total knee arthroplasty. Clin Orthop Relat Res 1994;(309):94–101 Fu D, Li G, Chen K, Zeng H, Zhang X, Cai Z. Comparison of clinical outcome between simultaneous-bilateral and staged-bilateral total knee arthroplasty: a systematic review of retrospective studies. J Arthroplasty 2013;28(7):1141–1147 Hu J, Liu Y, Lv Z, Li X, Qin X, Fan W. Mortality and morbidity associated with simultaneous bilateral or staged bilateral total knee arthroplasty: a meta-analysis. Arch Orthop Trauma Surg 2011;131(9):1291–1298 Memtsoudis SG, Hargett M, Russell LA, et al; Consensus Conference on Bilateral Total Knee Arthroplasty Group. Consensus statement from the consensus conference on bilateral total knee arthroplasty group. Clin Orthop Relat Res 2013;471(8):2649–2657 Yoon HS, Han CD, Yang IH. Comparison of simultaneous bilateral and staged bilateral total knee arthroplasty in terms of perioperative complications. J Arthroplasty 2010;25(2):179–185 Meehan JP, Danielsen B, Tancredi DJ, Kim S, Jamali AA, White RH. A population-based comparison of the incidence of adverse outcomes after simultaneous-bilateral and staged-bilateral total knee arthroplasty. J Bone Joint Surg Am 2011;93(23):2203–2213 Peskun C, Mayne I, Malempati H, Kosashvili Y, Gross A, Backstein D. Cardiovascular disease predicts complications following bilateral total knee arthroplasty under a single anesthetic. Knee 2012; 19(5):580–584 Hutchinson JR, Parish EN, Cross MJ. A comparison of bilateral uncemented total knee arthroplasty: simultaneous or staged? J Bone Joint Surg Br 2006;88(1):40–43 Stubbs G, Pryke SE, Tewari S, et al. Safety and cost benefits of bilateral total knee replacement in an acute hospital. ANZ J Surg 2005;75(9):739–746 Liu TK, Chen SH. Simultaneous bilateral total knee arthroplasty in a single procedure. Int Orthop 1998;22(6):390–393
The Journal of Knee Surgery
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16
17
18
19
20
21
22
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analysis comparing the cost-effectiveness of simultaneous and staged bilateral total knee arthroplasty. J Bone Joint Surg Am 2013; 95(16):1441–1449 Soudry M, Binazzi R, Insall JN, Nordstrom TJ, Pellicci PM, Goulet JA. Successive bilateral total knee replacement. J Bone Joint Surg Am 1985;67(4):573–576 Poultsides LA, Memtsoudis SG, Vasilakakos T, et al. Infection following simultaneous bilateral total knee arthroplasty. J Arthroplasty 2013; 28(8, Suppl)92–95 Pavone V, Johnson T, Saulog PS, Sculco TP, Bottner F. Perioperative morbidity in bilateral one-stage total knee replacements. Clin Orthop Relat Res 2004;(421):155–161 Wu CC, Lin CP, Yeh YC, Cheng YJ, Sun WZ, Hou SM. Does different time interval between staggered bilateral total knee arthroplasty affect perioperative outcome? A retrospective study. J Arthroplasty 2008;23(4):539–542 Forster MC, Bauze AJ, Bailie AG, Falworth MS, Oakeshott RD. A retrospective comparative study of bilateral total knee replacement staged at a one-week interval. J Bone Joint Surg Br 2006; 88(8):1006–1010 Sliva CD, Callaghan JJ, Goetz DD, Taylor SG. Staggered bilateral total knee arthroplasty performed four to seven days apart during a single hospitalization. J Bone Joint Surg Am 2005; 87(3):508–513 Restrepo C, Parvizi J, Dietrich T, Einhorn TA. Safety of simultaneous bilateral total knee arthroplasty. A meta-analysis. J Bone Joint Surg Am 2007;89(6):1220–1226 Charlson M, Szatrowski TP, Peterson J, Gold J. Validation of a combined comorbidity index. J Clin Epidemiol 1994;47(11): 1245–1251 Sundararajan V, Henderson T, Perry C, Muggivan A, Quan H, Ghali WA. New ICD-10 version of the Charlson comorbidity index predicted in-hospital mortality. J Clin Epidemiol 2004;57(12): 1288–1294 Parvizi J, Zmistowski B, Berbari EF, et al. New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res 2011;469(11): 2992–2994 Marmon AR, Zeni JA Jr, Snyder-Mackler L. Perception and presentation of function in patients with unilateral versus bilateral knee osteoarthritis. Arthritis Care Res (Hoboken) 2013;65(3):406–413 Ritter M, Mamlin LA, Melfi CA, Katz BP, Freund DA, Arthur DS. Outcome implications for the timing of bilateral total knee arthroplasties. Clin Orthop Relat Res 1997;(345):99–105
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Staged Bilateral Total Knee Arthroplasty: Time of the Second Side Antonia F. Chen, MD, MBA1 Mohammad R. Rasouli, MD1 Mitchell G. Maltenfort, PhD1 Javad Parvizi, MD, FRCS1 1 Department of Orthopaedic Surgery, Rothman Institute at Thomas
Jefferson University Hospital, Philadelphia, Pennsylvania
David N. Vegari, MD1
Ronald C. Huang, MD1
Address for correspondence Javad Parvizi, MD, FRCS, Department of Orthopaedic Surgery, Rothman Institute, 125 S. 9th Street, Suite 1000, Philadelphia, PA 19107 (e-mail: [email protected]).
Abstract
Keywords
► staged ► bilateral total knee arthroplasty ► complications ► periprosthetic joint infection
The purpose of this study was to determine if there was a safe time frame for performing the second total knee arthroplasty (TKA) in staged bilateral TKAs. Retrospectively, 589 TKAs were studied at a single institution from January 2000 to June 2012. Patients were excluded if they underwent simultaneous or staggered bilateral TKA during the same hospitalization. Patients were included if they underwent bilateral staged TKA during a different hospitalization within 21 to 90, 91 to 180, 181 to 270, and 271 to 360 days after the first TKA. In-hospital complications were determined using International Classification of Diseases, Ninth Revision codes for cardiac, pulmonary, urinary, deep vein thrombosis, wound complications, mechanical complications, and wound infections. Periprosthetic joint infection (PJI) was determined by hospital readmission records. There were 29 postoperative complication events (4.9%) and there was no difference between time groups and complications. The highest rates of PJI occurred when the second TKA was performed after 271 to 360 days (3.6%), followed by the early postoperative period after 21 to 90 days (2.7%). We could not identify a time frame for performing the second TKA in staged bilateral TKAs to reduce complications. A signal from the study suggests that complications, particularly PJI, may be lower if the second TKA is performed more than 90 days and less than 270 days after the first TKA, although this finding was not significant.
As the population ages and life expectancy increases, the number of patients who undergo total knee arthroplasty (TKA) has grown with time.1 With it, there are an increasing number of patients who receive bilateral TKAs, as there is increased risk of developing bilateral knee osteoarthritis (OA) after the development of unilateral OA.2 Bilateral TKAs can be performed simultaneously during the same hospital stay, staggered within the same hospital stay, or staged over different hospital visits. There has been considerable debate on the ideal bilateral TKA procedure to perform while evaluating complication rates, costs, and outcomes. Previous studies have compared the outcome and complications of staged bilateral TKAs and simultaneous bilateral
TKA. Simultaneous TKA has been shown to have an increased blood loss,3 mortality,4,5 and medical complications,6,7 especially cardiovascular complications8,9 and pulmonary embolism.4 On the other hand, simultaneous TKA has been found to cost less,10,11 have a lower risk of periprosthetic joint infection (PJI), and decreased risk of need for revision.8 Another study determined that there were no differences in complications between simultaneous and staged bilateral TKAs.12 On the contrary, one study found that staged bilateral TKA are more expensive and have worse outcomes13 and that staged bilateral TKA can have greater thromboembolic events14 and higher infection rates.15 However, there may be fewer complications associated with staged bilateral TKA
received February 25, 2014 accepted after revision May 21, 2014 published online July 28, 2014
Copyright © 2015 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1384215. ISSN 1538-8506.
Downloaded by: Collections and Technical Services Department. Copyrighted material.
J Knee Surg 2015;28:311–314.
Staged Bilateral Total Knee Arthroplasty
Chen et al.
and this procedure may be performed in patients with more comorbidities.16 While other studies have been performed evaluating the time frame to stagger bilateral TKAs within the same hospital visit,17–19 a meta-analysis evaluating the safety of simultaneous bilateral TKA was unable to determine a safe time period between staged procedures that could decrease risks.20 To date, there has been no study conducted that has evaluated a safe time frame after the index TKA to perform the second TKA to minimize complications. Thus, the purpose of our study was to determine if there was a safe time frame for performing the second TKA in bilateral TKAs to minimize complications.
Patients and Methods After approval by the institutional review board, we retrospectively reviewed our prospectively collected electronic total joint arthroplasty database to identify patients who underwent staged bilateral TKA between January 2000 and June 2012. Patients who were coded twice for primary TKA (International Classification of Diseases, Ninth Revision [ICD9] code of 81.54) were identified. Patients who had simultaneous bilateral TKA or staged bilateral TKA during the same hospitalization were excluded and only patients who had the second knee replaced within 360 days after the first knee, but not during the same hospitalization, were included in the study. We divided patients into the following groups, based on the time interval between stages: 21 to 90, 91 to 180, 181 to 270, and 271 to 360 days after the first TKA. Demographic information including age, gender, Charlson comorbidity index (CCI), and body mass index (BMI) was obtained for the patients included in this study. CCI is frequently used to assess underlying comorbidities and was originally designed to determine the risk of 10-year mortality.21 CCI consists of 17 weighted medical conditions, including cardiac, pulmonary, renal, vascular, neurological, hepatic, gastrointestinal, endocrine, oncologic, rheumatologic, and immunocompromised diseases.22 We queried our institutional database using ICD-9 codes to identify comorbidity items, which have previously been described.22 Raw scores were then adjusted for age, as 1 point was added for each decade after the age of 40 years. In-hospital complications were identified using the same coding system as has been previously described.8 The following ICD-9 codes were used to identify complications: cardiac, deep vein thrombosis, pulmonary including pulmonary embolism, urinary, mechanical complications, wound infections with associated revision codes, and wound complications. PJI was defined using the Musculoskeletal Infection Society criteria23 and PJI patients were determined by hospital readmission for infection. The rate of all complications was compared with the specified time intervals using Fisher exact test. The effect of the time intervals between TKA stages on the rate of complication was assessed using logistic regression analysis, controlling for age, gender, BMI, and CCI. A post hoc power analysis was performed assuming a randomized experiment The Journal of Knee Surgery
Vol. 28
No. 4/2015
using a one-tailed Fisher exact test assuming 80% power and a type I error rate of 5%. All analyses were performed using R 3.0.2 (R Foundation for Statistical Computing, Vienna, Austria) using the RMS package for logistic regression analysis, and p values < 0.05 were considered to be statistically significant.
Results A total of 589 patients including 374 females (63.5%) who underwent staged bilateral TKA were included in this study. The mean age and BMI of the patients were 65.8 10.1 years and 34.0 7.5 kg/m2, respectively. The majority of patients (579, 98.3%) had CCI 3. In our patient population, 13% (n ¼ 27) of the second TKA were performed 21to 90 days after the index procedure, 32% (n ¼ 191) were performed after 91 to 180 days, 27% (n ¼ 157) were performed after 181 to 270 days, and 28% (n ¼ 167) were performed after 271 to 360 days. A total of 29 complication events were identified after the second TKA, resulting in a 4.9% rate of postoperative complications. Urinary complications were the most frequent (n ¼ 15, 51.7%), followed by pulmonary (n ¼ 6, 20.7%), then mechanical complications of the implant (n ¼ 4, 13.8%). ►Fig. 1 depicts the frequency of complications at various time intervals. There was no statistically significant difference between various time groups and the rate of complications (p ¼ 0.90). Using our institution’s hospital readmission database, 14 PJI cases were identified. The highest rates were identified in the group where the second TKA was performed after 271 to 360 days (3.6%), followed by the second TKA performed in the early postoperative period after 21 to 90 days (2.7%). ►Fig. 2 demonstrates the frequency of these PJI at various time periods. Using logistic regression analysis, the time interval between TKA stages was not a predictor of complications (►Table 1).
Discussion Bilateral TKA is an increasingly popular surgical intervention because the likelihood of developing bilateral knee OA increases with the development of OA in one knee.2,24 Bilateral TKAs can be performed simultaneously, in a staggered fashion during the same hospital stay, or in a staged manner during different hospital stays. A previous study determined that staged bilateral TKAs have higher infection rates than unilateral TKAs.15 However, there has been no study till date evaluating a safe time frame to perform the second TKA to minimize risk of PJI. Therefore, the purpose of our study was to establish a safe time frame to minimize complications for performing the second procedure in patients undergoing bilateral TKAs. Based on the results of this study, there was no difference between various time groups and the rate of complications. Thus, based on all complications determined by the ICD-9 codes included in our study, we could not identify a safe time frame for performing the second TKA. There were less PJIs
Downloaded by: Collections and Technical Services Department. Copyrighted material.
312
Staged Bilateral Total Knee Arthroplasty
Chen et al.
313
Table 1 Results of multivariate analysis to identify predicators of complications. The time interval between stages was not a predictor of complication OR
95% CI
p-Value
Time interval between TKA stages (d)
1.00
1.00–1.01
0.31
Males
0.95
0.41–2.17
0.90
BMI (kg/m2)
1.07
1.02–1.13
0.01
Charlson comorbidity index
1.12
0.76–1.64
0.56
Age (y)
1.03
0.98–1.07
0.26
Fig. 1 Frequency of complications in different time intervals. DVT, deep venous thrombosis.
when the second TKA was performed between 90 and 270 days after the first TKA in a staged bilateral TKA procedure, but the finding was not statistically significant. A previous meta-analysis comparing simultaneous bilateral TKA, staged bilateral TKA, and unilateral TKA determined that staged bilateral TKAs have higher pulmonary and cardiac complications, as well as higher mortality.20 The study concluded
Fig. 2 Rate of readmission due to periprosthetic joint infection (PJI) in different time intervals.
that determining the period of time between staged bilateral TKAs to reduce these complications would be beneficial. Our study sought to determine this time frame and found that there was no difference in pulmonary and cardiac complications when staged bilateral TKAs were performed within 1 year of each other. A study conducted by Ritter et al in the Medicare population found similar results when comparing simultaneous versus bilateral staged TKAs performed in the following intervals: within 6 weeks, between 6 weeks and 3 months, between 3 and 6 months, and between 6 months and 1 year.25 This study evaluated complications (postoperative wound infection, mechanical complication of orthopedic devices, wound dehiscence, and postoperative hemorrhage), mortality, and hospital charges as endpoints. Similar to our study, the authors demonstrated that there was no difference in complications between the different time intervals, but the study demonstrated that staging the second TKA 3 to 6 months after the first TKA had the lowest mortality rate and was only slightly more expensive than performing simultaneous bilateral TKA.25 Of note, this study found no differences in wound infection between all-time groups of staged bilateral TKAs performed within 1 year of the index. While our study demonstrated differences in PJI based on the time frame of the second TKA, there were limitations to our study. First, we had an underpowered sample size and we could not determine a safe time frame for performing the second TKA in a patient undergoing bilateral staged TKA. A post hoc power analysis was performed and demonstrated that we had an undersized patient population. To show that complications within 90 days (2.7%) were less than those at 90þ days (4.9% overall), we would need 1,041 per group for a total of 2,082 patients. Second, if patients were admitted to other hospitals, their complications may not have been captured. Finally, there are limitations with using the ICD-9 coding system, such as not including complications outside of the scope of our study and the lack of clinical specificity for describing the complexity or severity of different disease conditions. Despite these limitations, our study suggests that there are no differences in complications determined by the time frame that staged bilateral TKAs are performed. Further studies are The Journal of Knee Surgery
Vol. 28
No. 4/2015
Downloaded by: Collections and Technical Services Department. Copyrighted material.
Abbreviations: BMI, body mass index; CI, confidence interval; OR, odds ratio; TKA, total knee arthroplasty.
Staged Bilateral Total Knee Arthroplasty
Chen et al.
needed to determine if a more specific time frame exists for performing staged TKAs based on other parameters.
13 Odum SM, Troyer JL, Kelly MP, Dedini RD, Bozic KJ. A cost-utility
14
References 1 Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary
2
3
4
5
6
7
8
9
10
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