Retrospective Cohort Study
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. Jan 18, 2022; 13(1): 58-69
Published online Jan 18, 2022. doi: 10.5312/wjo.v13.i1.58
Should we use similar perioperative protocols in patients undergoing unilateral and bilateral one-stage total knee arthroplasty?
Artit Laoruengthana, Piti Rattanaprichavej, Parin Samapath, Bhuwad Chinwatanawongwan, Pariphat Chompoonutprapa, Krit Pongpirul
Artit Laoruengthana, Piti Rattanaprichavej, Parin Samapath, Bhuwad Chinwatanawongwan, Pariphat Chompoonutprapa, Department of Orthopaedics, Naresuan University, Mueang 65000, Phitsanulok, Thailand
Krit Pongpirul, Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
Author contributions: Laoruengthana A contributed to the conception and design of the study, and performed the operation as the surgeon; Rattanaprichavej P, Samapath P, Chinwatanawongwan B, and Chompoonutprapa P collected the required data; Laoruengthana A and Rattanaprichavej P wrote and completed the manuscript; Laoruengthana A, Rattanaprichavej P, and Pongpirul K were responsible for data interpretation and performed the statistical analysis; all authors have read and approved the manuscript.
Institutional review board statement: The study was reviewed and approved by the Naresuan University Institutional Review Board (No. 756/2017).
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: The authors declare that they have no competing interests related to the study design, data collection, and interpretation of results presented in this manuscript.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Piti Rattanaprichavej, MD, Associate Professor, Director, Lecturer, Surgeon, Department of Orthopaedics, Naresuan University, 99 Moo 9, Mueang 65000, Phitsanulok, Thailand. pt-rp@hotmail.com
Received: April 28, 2021
Peer-review started: April 28, 2021
First decision: October 17, 2021
Revised: October 28, 2021
Accepted: December 25, 2021
Article in press: December 25, 2021
Published online: January 18, 2022
Processing time: 263 Days and 19.5 Hours
Abstract
BACKGROUND

Bilateral one-stage total knee arthroplasty (BTKA) is now in greater use as an alternative option for patients with bilateral end-stage knee arthropathy. However, postoperative pain and disablement during convalescence from BTKA, and procedure-related complications have been concerning issues for patients and surgeons. Although some studies reported that BTKA in selected patients is as safe as the staged procedure, well-defined guidelines for patient screening, and perioperative care and monitoring to avoid procedure-related complications are still controversial.

AIM

To compare the perioperative outcomes including perioperative blood loss (PBL), cardiac biomarkers, pain intensity, functional recovery, and complications between unilateral total knee arthroplasty (UTKA) and BTKA performed with a similar perioperative protocol.

METHODS

We conducted a retrospective study on consecutive patients undergoing UTKA and BTKA that had been performed by a single surgeon with identical perioperative protocols. The exclusion criteria of this study included patients with an American Society of Anesthesiologists score > 3, and known cardiopulmonary comorbidity or high-sensitivity Troponin-T (hs-TnT) > 14 ng/L. Outcome measures included visual analogue scale (VAS) score of postoperative pain, morphine consumption, range of knee motion, straight leg raise (SLR), length of stay (LOS), and serum hemoglobin (Hb) and hs-TnT monitored during hospitalization.

RESULTS

Of 210 UTKA and 137 BTKA patients, those in the BTKA group were younger and more predominately female. The PBL of the UTKA vs BTKA group was 646.45 ± 272.26 mL vs 1012.40 ± 391.95 mL (P < 0.01), and blood transfusion rates were 10.48% and 40.88% (P < 0.01), respectively. Preoperative Hb and body mass index were predictive factors for blood transfusion in BTKA, whereas preoperative Hb was only a determinant in UTKA patients. The BTKA group had significantly higher VAS scores than the UTKA group at 48, 72, and 96 h after surgery, and also had a significantly lower degree of SLR at 72 h. The BTKA group also had a significantly longer LOS than the UTKA group. Of the patients who had undergone the procedure, 5.71% of the UTKA patients and 12.41% of the BTKA patients (P = 0.04) had hs-TnT > 14 ng/L during the first 72 h postoperatively. However, there was no difference in other outcome measures and complications.

CONCLUSION

Following similar perioperative management, the blood transfusion rate in BTKA is 4-fold that required in UTKA. Also, BTKA is associated with higher pain intensity at 48 h postoperatively and prolonged LOS when compared to the UTKA. Hence, BTKA patients may require more extensive perioperative management for blood loss and pain, even if having no higher risk of complications than UTKA.

Keywords: Bilateral one-stage total knee arthroplasty; Unilateral total knee arthroplasty; Blood loss; Postoperative pain; High-sensitivity Troponin-T; Cardiovascular events

Core Tip: The safety of bilateral one-stage total knee arthroplasty (BTKA) is still debated because of greater blood loss, higher risk of cardiovascular events, increased postoperative pain, and longer disablement period than unilateral total knee arthroplasty (UTKA). After comparing consecutive patients underwent BTKA and UTKA with similar perioperative management, we found that the blood transfusion rate in the BTKA is 4-fold than UTKA. Moreover, BTKA is associated with significantly higher pain intensity at 48 h postoperatively and prolonged hospitalization. Although our study demonstrated that BTKA is a safe procedure in selected patients, extensive perioperative management for blood loss and pain is mandatory for BTKA patients.