Simultaneous Bilateral vs Unilateral TKR Complications & Analysis of the Patient’s Perspective

1. Simultaneous Bilateral vs Unilateral TKRComplications & Analysis of the Patient’s Perspective Chloe Donovan RN David A Parker FRACS AOA Annual Scientific Meeting Adelaide, 2010

2. Conflict of Interest • There is no conflict of interest in this research project

3. Bilateral Knee OA • Common presentation • Simultaneous vs Staged • Considerations • Risks / Complications • Rehabilitation • Comorbidities • Patient’s desires / concerns “Will I have a leg to stand on afterwards?”

4. Bilateral TKR: Literature • Several studies • Variable results • Increased morbidity • Patil et al 2008, Fabi et al 2010, Qian et al 2008 • Increased mortality • Mangaleshkar 2001, Stafansdottir 2008 • No increased risk • Taylor et al 2010, Leonard et al 2003

5. Bilateral TKR: Literature • Limitations • Heterogeneous groups • Many fail to compare to 2 x Unilateral • Lack of attention to other aspects of patient outcomes • Leonard et al 2003: Increased patient satisfaction with Bilateral procedures

6. Study Aims • Comparison of: • Unilateral • Staged Bilateral • Simultaneous Bilateral • Analysis of: • Complications • Outcomes • Patient Satisfaction & Perspective

7. Indications for Simultaneous BTKR • Each Knee independently meets appropriate criteria for TKR • Medically fit (Physician review) • Patient elects surgery • Especially significant fixed deformities

8. Simultaneous Bilateral TKR • Commence with most symptomatic • 1st completed, tourniquet deflated, extensor mechanism closed, before 2nd started • Computer Navigation routine

9. Methods • Single Surgeon • Consecutive Series • 205 patients / 329 TKR • Dec 2004 to June 2009 • Minimum 1 yr followup • 3 Groups • 89 Simultaneous BTKR (2.1years) • 81 Unilateral TKR (3.2 years) • 35 Staged Bilateral TKR (4 year)

10. Methods: Data Collection • Ethics approval via NSHHREC Ethics committee • Retrospective Review • Prospective Database (Socrates) • Oxford, KSCRS, WOMAC, SF-36 • Hospital Records • Patient Satisfaction Questionnaire • Self - administered

11. Methods:Patient Questionnaire

12. Results: Patient Demographics * n=81 n=89 n=51 n=31 n=62 n=35 * Significantly different to Simultaneous group (p<0.05)

13. Results: Complication Rate (%)

14. Oxford

15. WOMAC

16. Range of Motion

17. Results: SF36 – Physical Score * n=67 n=50 n=33 n=27 n=68 n=53 * Significantly different to pre-op (p<0.05) † Significantly different to Staged (p<0.05)

18. Results: SF36 – Mental Score * n=50 n=33 n=27 n=68 n=53 n=67 * Significantly different to Staged (p<0.05)

19. Results: Patient Satisfaction * * Significantly different to Unilateral and Staged (p<0.05)

20. Discussion • Bilateral Simultaneous TKR • Controversial • Increased morbidity / mortality • Inconsistencies in literature • Minimal investigation into patients’ perspective • Potential benefits for the patient • Rehabilitation & Clinical Outcome • Efficiency / Costs / Expedience

21. Discussion • Current investigation • No increase in morbidity / mortality • Equivalent or better functional outcomes • Improved patient satisfaction • Negative preconceptions proved incorrect • Effect of better preop SF36 mental scores • Limitations • Differences in groups (not RCT) • Questionnaire not validated

22. Conclusion • Bilateral Simultaneous TKR • Bilateral advanced OA • Especially significant fixed deformities • Healthy patients (Physician approval) • Patient request • Further study • Increasing database • Development & Validation of questionnaire

23. Thankyou