The Journal of Arthroplasty xxx (2013) xxx–xxx
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
Simultaneous Bilateral Knee Arthroplasty in Octogenarians: Can It Be Safe and Effective? Catherine W. Cahill, MD a, Ran Schwarzkopf, MD b, Sumi Sinha, MS c, Richard D. Scott, MD d a
Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas University of California, Irvine, California Harvard Medical School, Boston, Massachusetts d Department of Orthopedic Surgery, New England Baptist Hospital, Harvard Medical School, Roxbury Crossing, Massachusetts b c
a r t i c l e
i n f o
Article history: Received 15 August 2013 Accepted 29 October 2013 Available online xxxx Keywords: simultaneous bilateral total knee arthroplasty octogenarians complications
a b s t r a c t Simultaneous bilateral knee arthroplasty (SBTKA) in octogenarians is controversial. Our purpose was to review the outcomes of octogenarians undergoing SBTKA. All patients greater than 80 years of age who underwent SBTKA by a single surgeon were retrospectively evaluated. Fifty-six patients with an average age of 82.5 years were identified. Twelve postoperative complications occurred. Three were serious; two nonfatal PEs and one wound debridement. Minor complications included UTI, decubitus ulcer, DVT, confusion, transfusion reaction and ileus. Average postoperative survival was 7.4 years. No deaths occurred within 30 days postoperatively. Simultaneous bilateral total knee arthroplasty can be a safe and effective option for octogenarians. Complications and mortality are not higher for SBTKA compared to UTKA in this population. © 2013 Elsevier Inc. All rights reserved.
With the aging population, an increasing number of octogenarians will present as potential candidates for total knee arthroplasty (TKA). The efficacy of TKA in this population has been well established [1–4]. Octogenarians report reliable improvements in pain and function, have equal if not improved satisfaction compared to a younger cohort and can be expected to have their implants survive them [1–3,5]. In regards to safety, however, several authors have pointed out the increased number of postoperative complications in this group [2,6–8]. Many of these octogenarians will have bilateral disease and require bilateral arthroplasties. Most surgeons will recommend sequential surgery spaced months apart because of the higher risk profile for this age group as well as for bilateral procedures in any age group [9–13]. Complications for the elderly include higher mortality, postoperative confusion, cardiopulmonary events and genitourinary dysfunction [2,6,7]. Complications associated with simultaneous bilateral TKA (SBTKA) include higher mortality in some series, cardio-pulmonary complications and greater blood loss and transfusion requirements [11–13]. In addition, a recent consensus article commented that age N 75 should be an exclusionary criteria for SBTKA [14]. Several series, however, report outcomes of SBTKA that are equivalent to staged arthroplasties with no increase in serious complications [15–18].
The Conflict of Interest statement associated with this article can be found at http:// dx.doi.org/10.1016/j.arth.2013.10.026. Reprint requests: Catherine Cahill, MD, Department of Orthopedic Surgery, Baylor College of Medicine, 1 Baylor Plaza, Suite 1325, Houston, TX 77030.
The purpose of our study was to retrospectively review the results of a selected group of octogenarians who underwent SBTKA to determine if this procedure could be both safe and effective in this age group. We hypothesize that a properly selected octogenarian patient cohort undergoing SBTKA will not have a higher complication rate than patients undergoing TKA. Materials and Methods All patients who underwent SBTKA between 1990 and 2010 and were over the age of 80 years on the day of surgery were identified retrospectively. All patients underwent SBTKA at a single orthopedic specialty hospital by a single surgeon. All patients had bilateral knee pain or deformity with evidence of end stage osteoarthritis amenable to total knee arthroplasty and who requested simultaneous bilateral procedures. Exclusion criteria included preoperative cardiopulmonary disease, specifically, congestive heart failure, moderate or severe COPD, arrhythmias or valvular dysfunction. Individual patient charts were reviewed to obtain demographics, comorbidities, knee society scores, complications and survival. IRB approval was obtained according to our institutional requirements. Demographic data were collected including: age, sex, height, and weight. History of diabetes, CAD, CHF, arrhythmias, prior myocardial infarction, valvular heart disease, stroke, dementia, COPD, genitourinary dysfunction and endocrinopathies were sought from records to determine preoperative comorbidities. All complications were recorded. Thirty-day mortality, deep wound infections, return to the operating room for any reason, pulmonary embolus, cerebrovascular accidents and postoperative MI were considered major complications.
0883-5403/0000-0000$36.00/0 – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.arth.2013.10.026
Please cite this article as: Cahill CW, et al, Simultaneous Bilateral Knee Arthroplasty in Octogenarians: Can It Be Safe and Effective?, J Arthroplasty (2013), http://dx.doi.org/10.1016/j.arth.2013.10.026
2
C.W. Cahill et al. / The Journal of Arthroplasty xxx (2013) xxx–xxx
Minor complications included any other perioperative adverse event related to the surgery. Mortality was specifically sought and a combination of chart review, phone calls and social security databases was used to confirm date of death. Patients lost to follow up without a confirmed death date or to be living were excluded past their most recent office follow up for survival data analysis. Knee society scores were calculated preoperatively and at most recent patient follow up based on data collected from the primary surgeon at office visits. Prescreening was undertaken, as is standard practice and included medical clearance. Patients with significant cardiac history did not undergo SBTKA and were treated with staged UTKA even if approved for elective TKA. Arthroplasty was performed sequentially under the same anesthetic by one team led by the primary surgeon. After the first knee, the patient’s cardiopulmonary status was assessed by anesthesiology to determine whether or not to begin the second side. If the patient showed no signs of cardiopulmonary decompensation, evidenced by significant shifts in heart rate, oxygen saturation or blood pressure, then the second procedure was undertaken. No patients originally scheduled for bilateral procedures had the second side aborted after assessment. Surgical technique included intramedullary femoral and extramedullary tibial guides. Prophylaxis for DVT consisted of warfarin therapy initiated the night before surgery and continued for 4 weeks postoperatively with the goal INR between 1.8 and 2.2. Results Fifty-six patients were identified for inclusion in the study. Of the 56 patients, 11 were excluded from outcome data due to inadequate clinical information or follow up less than 6 months. All but one of the patients excluded from outcome data had confirmed dates of death so were included in survival analysis. The remaining patient was international and underwent follow up in their home country and was excluded from all analysis. Of the remaining 45 patients, 17 were male and 28 were female. Average age was 82.5 years with the eldest being 90 at the time of surgery. Average BMI for the group was 27 and the maximum was 36. Follow up for our group of 45 patients ranged from 10 months to 10 years and averaged 4.5 years. Preoperative knee and functional scores averaged 70 and 62 respectively and improved to 97 and 89 after surgery assessed at postoperative office visits. Improvement was statistically significant, (P b 0.0001). Survival data were sought for all 56 patients and could be obtained for 55. Through 1 year, it was 98%, with one death occurring at 11 months postoperatively due to complications of ALS diagnosed 6 months after the total knee arthroplasty. The average life expectancy after surgery for patients with confirmed dates of death in our cohort with an average age of 82 was 7.4 years, SD ± 3.6. For females and males the averages were 6.9 and 8.0 years respectively, and if patients still surviving were included that rose to 7.6 and 8.7 years. No deaths were related to the total knee arthroplasty or postoperative complications. A survival curve for patients with confirmed dates of death was plotted (Fig. 1). There was 100% survival of the prosthetic components, with revision for any reason as an end point, in this cohort. Complications occurred in 12 patients (27%) (Table 1). Major complications occurred in 3 patients (7%) and included 2 non-fatal pulmonary emboli and 1 return to the operating room to resolve superficial wound infection. Other complications included urinary tract infection, confusion, neuropathy, new onset atrial fibrillation, ileus and sacral decubitus ulcer. Each minor complication occurred once except UTI and decubitus ulcers which occurred in 2 patients, and confusion which was significant, occurred in 2 patients as well (4%). None of the postoperative confusion resulted in permanent mental status change. Complications were not associated statistically with any of the preoperative comorbidities which were recorded.
Fig. 1. SBTKA in octogenarians survival curve.
We asked surviving patients and/or family to retrospectively reevaluate the decision they made to undergo SBTKA. Of the 26 patients surveyed, 21 responded. Of those, 19 rated their satisfaction with surgical outcome as excellent, and 2 rated it as good. All but two patients said they would choose SBTKA again. One patient thought the rehab kept them away from home longer and would have preferred to have had them staged, and one patient felt that staged TKA would have been less painful.
Discussion Octogenarians are a growing segment of the population and as such are presenting much more frequently for orthopedic consultation regarding knee arthritis. According to the United States Social Security Administration the life expectancy of a male and female aged of 82 years old is 7.1 and 8.5 additional years respectively (the average age of our cohort) [19]. Total knee arthroplasty done unilaterally is effective for this growing population with improvements in pain, function and quality of life [1–4,20]. Our study confirms the efficacy of the operation even when done simultaneously, with statistically significant improvements in both objective knee scores and patient reported outcomes. Concerns over postoperative complications have limited the use of SBTKA in the elderly. Specifically, higher risks of early mortality in unilateral TKA have been reported by Kreder at 1.09% [6] and Hosick noted two early perioperative deaths in a series of 107 patients [2]. Clement also reported a 2.5% one-year mortality rate for patients ≥ 80 years old [1]. Our study did not have any deaths related to perioperative events and no deaths within 30 days after the Table 1 Postoperative Complications in Octogenarians Undergoing Simultaneous Bilateral Total Knee Arthroplasty. Complications
Major
PE Wound Drainage
2 1a
Complications
Minor
DVT UTI Decubitus Ulcer Confusion Ileus Neuropathy Total
1 2 2 2 1 1 12
a
Required operative intervention.
Please cite this article as: Cahill CW, et al, Simultaneous Bilateral Knee Arthroplasty in Octogenarians: Can It Be Safe and Effective?, J Arthroplasty (2013), http://dx.doi.org/10.1016/j.arth.2013.10.026
C.W. Cahill et al. / The Journal of Arthroplasty xxx (2013) xxx–xxx
procedure. Additionally, our patient cohort life expectancy after surgery was comparable to the general population and similar to the 8.3 years reported by Joshi et al [3]. However, in our cohort, patients with preexisting cardiopulmonary disease were excluded from SBTKA based on literature defining it as a risk factor for morbidity and mortality [8,21,22]. With appropriate preoperative screening, mortality rates for octogenarians undergoing SBTKA may not be higher than for the general population or those undergoing UTKA. Pulmonary embolism has been previously cited as a concern for all patients undergoing SBTKA [2,10,20] and is one of the leading causes of postoperative mortality in those series. Two nonfatal PEs occurred in our series, so concern for this complication in both UTKA and SBTKA in octogenarians should remain high with particular attention paid to postoperative anticoagulation. Minor complications are still a concern, but our rate of 27% compares favorably with published data for UTKA for octogenarians. Overall complications in the literature for octogenarians undergoing TKA range from 4.5% to 87% [2–4,22]. Previous authors have noted postoperative confusion to be common for the elderly [2,6,22]. At a rate of 7%, confusion proved to be one of the most common complications in our patient cohort as well. Another worrisome complication for the elderly, decubitus ulcer, significantly affected postoperative recovery for one of our patients and has been reported in up to 11% of octogenarians undergoing UTKA [2]. Ultimately, in our group SBTKA had comparable surgical outcomes to reported UTKA in an octogenarian population. Although complications do occur, frequency does not seem to be higher than for unilateral TKA. Patients significantly improved their pain and function in regards to the knee and were spared the time and recovery of staged TKA procedures. The majority of patients and their families that undergo simultaneous procedure are pleased that they chose this route. With appropriate preoperative screening and cardiac exclusionary criteria, SBTKA can be a safe option for elderly patients. As with any procedure the risks and benefits must be weighed and discussed with the patient and family, but SBTKA in the appropriate octogenarian can be a viable option. References 1. Clement ND, MacDonald D, Howie CR, et al. The outcome of primary total hip and knee arthroplasty in patients aged 80 years or more. J Bone Joint Surg Br 2011;93(9):1265.
3
2. Hosick WB, Lotke PA, Baldwin A. Total knee arthroplasty in patients 80 years of age and older. Clin Orthop Relat Res 1994;299:77. 3. Joshi AB, Markovic L, Gill G. Knee arthroplasty in octogenarians: results at 10 years. J Arthroplasty 2003;18(3):295. 4. Kennedy JW, Johnston L, Cochrane L, et al. Total Knee Arthroplasty in the Elderly: Does Age Affect Pain, Function or Complications? Clin Orthop Relat Res 2013;471(6):1964. 5. Sah AP, Springer BD, Scott RD. Unicompartmental knee arthroplasty in octogenarians: survival longer than the patient. Clin Orthop Relat Res 2006;451:107. 6. Kreder HJ, Berry GK, McMurtry IA, et al. Arthroplasty in the octogenarian: quantifying the risks. J Arthroplasty 2005;20(3):289. 7. Easterlin MC, Chang DG, Talamini M, et al. Older Age Increases Short-term Surgical Complications After Primary Knee Arthroplasty. Clin Orthop Relat Res 2013;471(8):2611. 8. Memtsoudis SG, Ma Y, Chiu YL, et al. Bilateral total knee arthroplasty: risk factors for major morbidity and mortality. Anesth Analg 2011;113(4):784. 9. Bullock DP, Sporer SM, Shirreffs Jr TG. Comparison of simultaneous bilateral with unilateral total knee arthroplasty in terms of perioperative complications. J Bone Joint Surg Am 2003;85-A(10):1981. 10. Fu D, Li G, Chen K, et al. Comparison of Clinical Outcome Between SimultaneousBilateral and Staged-Bilateral Total Knee Arthroplasty: A Systematic review of Retrospective Studies. J Arthroplasty 2013;28(7):1141. 11. Oakes DA, Hanssen AD. Bilateral total knee replacement using the same anesthetic is not justified by assessment of the risks. Clin Orthop Relat Res 2004;428:87. 12. Restrepo C, Parvizi J, Dietrich T, et al. Safety of simultaneous bilateral total knee arthroplasty. A meta-analysis. J Bone Joint Surg Am 2007;89(6):1220. 13. Stefansdottir A, Lidgren L, Robertsson O. Higher early mortality with simultaneous rather than staged bilateral TKAs: results from the Swedish Knee Arthroplasty Register. Clin Orthop Relat Res 2008;466(12):3066. 14. Memtsoudis SG, Hargett M, Russell LA, et al. Consensus statement from the consensus conference on bilateral total knee arthroplasty group. Clin Orthop Relat Res 2013;471(8):2649. 15. Kim YH, Choi YW, Kim JS. Simultaneous bilateral sequential total knee replacement is as safe as unilateral total knee replacement. J Bone Joint Surg Br 2009;91(1):64. 16. McLaughlin TP, Fisher RL. Bilateral total knee arthroplasties. Comparison of simultaneous (two-team), sequential, and staged knee replacements. Clin Orthop Relat Res 1985;199:220. 17. Soudry M, Binazzi R, Insall JN, et al. Successive bilateral total knee replacement. J Bone Joint Surg Am 1985;67(4):573. 18. Ritter MA, Harty LD, Davis KE, et al. Simultaneous bilateral, staged bilateral, and unilateral total knee arthroplasty. A survival analysis. J Bone Joint Surg Am 2003;85-A(8):1532. 19. Social Security Administration: Period Life Table. Available from: http://www.ssa. gov. 20. Jones CA, Voaklander DC, Johnston DW, et al. The effect of age on pain, function, and quality of life after total hip and knee arthroplasty. Arch Intern Med 2001;161(3): 454. 21. Detsky AS, Abrams HB, McLaughlin JR, et al. Predicting cardiac complications in patients undergoing non-cardiac surgery. J Gen Intern Med 1986;1(4):211. 22. Adili A, Bhandari M, Petruccelli D, et al. Sequential bilateral total knee arthroplasty under 1 anesthetic in patients N or = 75 years old: complications and functional outcomes. J Arthroplasty 2001;16(3):271.
Please cite this article as: Cahill CW, et al, Simultaneous Bilateral Knee Arthroplasty in Octogenarians: Can It Be Safe and Effective?, J Arthroplasty (2013), http://dx.doi.org/10.1016/j.arth.2013.10.026
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
Simultaneous Bilateral Knee Arthroplasty in Octogenarians: Can It Be Safe and Effective? Catherine W. Cahill, MD a, Ran Schwarzkopf, MD b, Sumi Sinha, MS c, Richard D. Scott, MD d a
Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas University of California, Irvine, California Harvard Medical School, Boston, Massachusetts d Department of Orthopedic Surgery, New England Baptist Hospital, Harvard Medical School, Roxbury Crossing, Massachusetts b c
a r t i c l e
i n f o
Article history: Received 15 August 2013 Accepted 29 October 2013 Available online xxxx Keywords: simultaneous bilateral total knee arthroplasty octogenarians complications
a b s t r a c t Simultaneous bilateral knee arthroplasty (SBTKA) in octogenarians is controversial. Our purpose was to review the outcomes of octogenarians undergoing SBTKA. All patients greater than 80 years of age who underwent SBTKA by a single surgeon were retrospectively evaluated. Fifty-six patients with an average age of 82.5 years were identified. Twelve postoperative complications occurred. Three were serious; two nonfatal PEs and one wound debridement. Minor complications included UTI, decubitus ulcer, DVT, confusion, transfusion reaction and ileus. Average postoperative survival was 7.4 years. No deaths occurred within 30 days postoperatively. Simultaneous bilateral total knee arthroplasty can be a safe and effective option for octogenarians. Complications and mortality are not higher for SBTKA compared to UTKA in this population. © 2013 Elsevier Inc. All rights reserved.
With the aging population, an increasing number of octogenarians will present as potential candidates for total knee arthroplasty (TKA). The efficacy of TKA in this population has been well established [1–4]. Octogenarians report reliable improvements in pain and function, have equal if not improved satisfaction compared to a younger cohort and can be expected to have their implants survive them [1–3,5]. In regards to safety, however, several authors have pointed out the increased number of postoperative complications in this group [2,6–8]. Many of these octogenarians will have bilateral disease and require bilateral arthroplasties. Most surgeons will recommend sequential surgery spaced months apart because of the higher risk profile for this age group as well as for bilateral procedures in any age group [9–13]. Complications for the elderly include higher mortality, postoperative confusion, cardiopulmonary events and genitourinary dysfunction [2,6,7]. Complications associated with simultaneous bilateral TKA (SBTKA) include higher mortality in some series, cardio-pulmonary complications and greater blood loss and transfusion requirements [11–13]. In addition, a recent consensus article commented that age N 75 should be an exclusionary criteria for SBTKA [14]. Several series, however, report outcomes of SBTKA that are equivalent to staged arthroplasties with no increase in serious complications [15–18].
The Conflict of Interest statement associated with this article can be found at http:// dx.doi.org/10.1016/j.arth.2013.10.026. Reprint requests: Catherine Cahill, MD, Department of Orthopedic Surgery, Baylor College of Medicine, 1 Baylor Plaza, Suite 1325, Houston, TX 77030.
The purpose of our study was to retrospectively review the results of a selected group of octogenarians who underwent SBTKA to determine if this procedure could be both safe and effective in this age group. We hypothesize that a properly selected octogenarian patient cohort undergoing SBTKA will not have a higher complication rate than patients undergoing TKA. Materials and Methods All patients who underwent SBTKA between 1990 and 2010 and were over the age of 80 years on the day of surgery were identified retrospectively. All patients underwent SBTKA at a single orthopedic specialty hospital by a single surgeon. All patients had bilateral knee pain or deformity with evidence of end stage osteoarthritis amenable to total knee arthroplasty and who requested simultaneous bilateral procedures. Exclusion criteria included preoperative cardiopulmonary disease, specifically, congestive heart failure, moderate or severe COPD, arrhythmias or valvular dysfunction. Individual patient charts were reviewed to obtain demographics, comorbidities, knee society scores, complications and survival. IRB approval was obtained according to our institutional requirements. Demographic data were collected including: age, sex, height, and weight. History of diabetes, CAD, CHF, arrhythmias, prior myocardial infarction, valvular heart disease, stroke, dementia, COPD, genitourinary dysfunction and endocrinopathies were sought from records to determine preoperative comorbidities. All complications were recorded. Thirty-day mortality, deep wound infections, return to the operating room for any reason, pulmonary embolus, cerebrovascular accidents and postoperative MI were considered major complications.
0883-5403/0000-0000$36.00/0 – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.arth.2013.10.026
Please cite this article as: Cahill CW, et al, Simultaneous Bilateral Knee Arthroplasty in Octogenarians: Can It Be Safe and Effective?, J Arthroplasty (2013), http://dx.doi.org/10.1016/j.arth.2013.10.026
2
C.W. Cahill et al. / The Journal of Arthroplasty xxx (2013) xxx–xxx
Minor complications included any other perioperative adverse event related to the surgery. Mortality was specifically sought and a combination of chart review, phone calls and social security databases was used to confirm date of death. Patients lost to follow up without a confirmed death date or to be living were excluded past their most recent office follow up for survival data analysis. Knee society scores were calculated preoperatively and at most recent patient follow up based on data collected from the primary surgeon at office visits. Prescreening was undertaken, as is standard practice and included medical clearance. Patients with significant cardiac history did not undergo SBTKA and were treated with staged UTKA even if approved for elective TKA. Arthroplasty was performed sequentially under the same anesthetic by one team led by the primary surgeon. After the first knee, the patient’s cardiopulmonary status was assessed by anesthesiology to determine whether or not to begin the second side. If the patient showed no signs of cardiopulmonary decompensation, evidenced by significant shifts in heart rate, oxygen saturation or blood pressure, then the second procedure was undertaken. No patients originally scheduled for bilateral procedures had the second side aborted after assessment. Surgical technique included intramedullary femoral and extramedullary tibial guides. Prophylaxis for DVT consisted of warfarin therapy initiated the night before surgery and continued for 4 weeks postoperatively with the goal INR between 1.8 and 2.2. Results Fifty-six patients were identified for inclusion in the study. Of the 56 patients, 11 were excluded from outcome data due to inadequate clinical information or follow up less than 6 months. All but one of the patients excluded from outcome data had confirmed dates of death so were included in survival analysis. The remaining patient was international and underwent follow up in their home country and was excluded from all analysis. Of the remaining 45 patients, 17 were male and 28 were female. Average age was 82.5 years with the eldest being 90 at the time of surgery. Average BMI for the group was 27 and the maximum was 36. Follow up for our group of 45 patients ranged from 10 months to 10 years and averaged 4.5 years. Preoperative knee and functional scores averaged 70 and 62 respectively and improved to 97 and 89 after surgery assessed at postoperative office visits. Improvement was statistically significant, (P b 0.0001). Survival data were sought for all 56 patients and could be obtained for 55. Through 1 year, it was 98%, with one death occurring at 11 months postoperatively due to complications of ALS diagnosed 6 months after the total knee arthroplasty. The average life expectancy after surgery for patients with confirmed dates of death in our cohort with an average age of 82 was 7.4 years, SD ± 3.6. For females and males the averages were 6.9 and 8.0 years respectively, and if patients still surviving were included that rose to 7.6 and 8.7 years. No deaths were related to the total knee arthroplasty or postoperative complications. A survival curve for patients with confirmed dates of death was plotted (Fig. 1). There was 100% survival of the prosthetic components, with revision for any reason as an end point, in this cohort. Complications occurred in 12 patients (27%) (Table 1). Major complications occurred in 3 patients (7%) and included 2 non-fatal pulmonary emboli and 1 return to the operating room to resolve superficial wound infection. Other complications included urinary tract infection, confusion, neuropathy, new onset atrial fibrillation, ileus and sacral decubitus ulcer. Each minor complication occurred once except UTI and decubitus ulcers which occurred in 2 patients, and confusion which was significant, occurred in 2 patients as well (4%). None of the postoperative confusion resulted in permanent mental status change. Complications were not associated statistically with any of the preoperative comorbidities which were recorded.
Fig. 1. SBTKA in octogenarians survival curve.
We asked surviving patients and/or family to retrospectively reevaluate the decision they made to undergo SBTKA. Of the 26 patients surveyed, 21 responded. Of those, 19 rated their satisfaction with surgical outcome as excellent, and 2 rated it as good. All but two patients said they would choose SBTKA again. One patient thought the rehab kept them away from home longer and would have preferred to have had them staged, and one patient felt that staged TKA would have been less painful.
Discussion Octogenarians are a growing segment of the population and as such are presenting much more frequently for orthopedic consultation regarding knee arthritis. According to the United States Social Security Administration the life expectancy of a male and female aged of 82 years old is 7.1 and 8.5 additional years respectively (the average age of our cohort) [19]. Total knee arthroplasty done unilaterally is effective for this growing population with improvements in pain, function and quality of life [1–4,20]. Our study confirms the efficacy of the operation even when done simultaneously, with statistically significant improvements in both objective knee scores and patient reported outcomes. Concerns over postoperative complications have limited the use of SBTKA in the elderly. Specifically, higher risks of early mortality in unilateral TKA have been reported by Kreder at 1.09% [6] and Hosick noted two early perioperative deaths in a series of 107 patients [2]. Clement also reported a 2.5% one-year mortality rate for patients ≥ 80 years old [1]. Our study did not have any deaths related to perioperative events and no deaths within 30 days after the Table 1 Postoperative Complications in Octogenarians Undergoing Simultaneous Bilateral Total Knee Arthroplasty. Complications
Major
PE Wound Drainage
2 1a
Complications
Minor
DVT UTI Decubitus Ulcer Confusion Ileus Neuropathy Total
1 2 2 2 1 1 12
a
Required operative intervention.
Please cite this article as: Cahill CW, et al, Simultaneous Bilateral Knee Arthroplasty in Octogenarians: Can It Be Safe and Effective?, J Arthroplasty (2013), http://dx.doi.org/10.1016/j.arth.2013.10.026
C.W. Cahill et al. / The Journal of Arthroplasty xxx (2013) xxx–xxx
procedure. Additionally, our patient cohort life expectancy after surgery was comparable to the general population and similar to the 8.3 years reported by Joshi et al [3]. However, in our cohort, patients with preexisting cardiopulmonary disease were excluded from SBTKA based on literature defining it as a risk factor for morbidity and mortality [8,21,22]. With appropriate preoperative screening, mortality rates for octogenarians undergoing SBTKA may not be higher than for the general population or those undergoing UTKA. Pulmonary embolism has been previously cited as a concern for all patients undergoing SBTKA [2,10,20] and is one of the leading causes of postoperative mortality in those series. Two nonfatal PEs occurred in our series, so concern for this complication in both UTKA and SBTKA in octogenarians should remain high with particular attention paid to postoperative anticoagulation. Minor complications are still a concern, but our rate of 27% compares favorably with published data for UTKA for octogenarians. Overall complications in the literature for octogenarians undergoing TKA range from 4.5% to 87% [2–4,22]. Previous authors have noted postoperative confusion to be common for the elderly [2,6,22]. At a rate of 7%, confusion proved to be one of the most common complications in our patient cohort as well. Another worrisome complication for the elderly, decubitus ulcer, significantly affected postoperative recovery for one of our patients and has been reported in up to 11% of octogenarians undergoing UTKA [2]. Ultimately, in our group SBTKA had comparable surgical outcomes to reported UTKA in an octogenarian population. Although complications do occur, frequency does not seem to be higher than for unilateral TKA. Patients significantly improved their pain and function in regards to the knee and were spared the time and recovery of staged TKA procedures. The majority of patients and their families that undergo simultaneous procedure are pleased that they chose this route. With appropriate preoperative screening and cardiac exclusionary criteria, SBTKA can be a safe option for elderly patients. As with any procedure the risks and benefits must be weighed and discussed with the patient and family, but SBTKA in the appropriate octogenarian can be a viable option. References 1. Clement ND, MacDonald D, Howie CR, et al. The outcome of primary total hip and knee arthroplasty in patients aged 80 years or more. J Bone Joint Surg Br 2011;93(9):1265.
3
2. Hosick WB, Lotke PA, Baldwin A. Total knee arthroplasty in patients 80 years of age and older. Clin Orthop Relat Res 1994;299:77. 3. Joshi AB, Markovic L, Gill G. Knee arthroplasty in octogenarians: results at 10 years. J Arthroplasty 2003;18(3):295. 4. Kennedy JW, Johnston L, Cochrane L, et al. Total Knee Arthroplasty in the Elderly: Does Age Affect Pain, Function or Complications? Clin Orthop Relat Res 2013;471(6):1964. 5. Sah AP, Springer BD, Scott RD. Unicompartmental knee arthroplasty in octogenarians: survival longer than the patient. Clin Orthop Relat Res 2006;451:107. 6. Kreder HJ, Berry GK, McMurtry IA, et al. Arthroplasty in the octogenarian: quantifying the risks. J Arthroplasty 2005;20(3):289. 7. Easterlin MC, Chang DG, Talamini M, et al. Older Age Increases Short-term Surgical Complications After Primary Knee Arthroplasty. Clin Orthop Relat Res 2013;471(8):2611. 8. Memtsoudis SG, Ma Y, Chiu YL, et al. Bilateral total knee arthroplasty: risk factors for major morbidity and mortality. Anesth Analg 2011;113(4):784. 9. Bullock DP, Sporer SM, Shirreffs Jr TG. Comparison of simultaneous bilateral with unilateral total knee arthroplasty in terms of perioperative complications. J Bone Joint Surg Am 2003;85-A(10):1981. 10. Fu D, Li G, Chen K, et al. Comparison of Clinical Outcome Between SimultaneousBilateral and Staged-Bilateral Total Knee Arthroplasty: A Systematic review of Retrospective Studies. J Arthroplasty 2013;28(7):1141. 11. Oakes DA, Hanssen AD. Bilateral total knee replacement using the same anesthetic is not justified by assessment of the risks. Clin Orthop Relat Res 2004;428:87. 12. Restrepo C, Parvizi J, Dietrich T, et al. Safety of simultaneous bilateral total knee arthroplasty. A meta-analysis. J Bone Joint Surg Am 2007;89(6):1220. 13. Stefansdottir A, Lidgren L, Robertsson O. Higher early mortality with simultaneous rather than staged bilateral TKAs: results from the Swedish Knee Arthroplasty Register. Clin Orthop Relat Res 2008;466(12):3066. 14. Memtsoudis SG, Hargett M, Russell LA, et al. Consensus statement from the consensus conference on bilateral total knee arthroplasty group. Clin Orthop Relat Res 2013;471(8):2649. 15. Kim YH, Choi YW, Kim JS. Simultaneous bilateral sequential total knee replacement is as safe as unilateral total knee replacement. J Bone Joint Surg Br 2009;91(1):64. 16. McLaughlin TP, Fisher RL. Bilateral total knee arthroplasties. Comparison of simultaneous (two-team), sequential, and staged knee replacements. Clin Orthop Relat Res 1985;199:220. 17. Soudry M, Binazzi R, Insall JN, et al. Successive bilateral total knee replacement. J Bone Joint Surg Am 1985;67(4):573. 18. Ritter MA, Harty LD, Davis KE, et al. Simultaneous bilateral, staged bilateral, and unilateral total knee arthroplasty. A survival analysis. J Bone Joint Surg Am 2003;85-A(8):1532. 19. Social Security Administration: Period Life Table. Available from: http://www.ssa. gov. 20. Jones CA, Voaklander DC, Johnston DW, et al. The effect of age on pain, function, and quality of life after total hip and knee arthroplasty. Arch Intern Med 2001;161(3): 454. 21. Detsky AS, Abrams HB, McLaughlin JR, et al. Predicting cardiac complications in patients undergoing non-cardiac surgery. J Gen Intern Med 1986;1(4):211. 22. Adili A, Bhandari M, Petruccelli D, et al. Sequential bilateral total knee arthroplasty under 1 anesthetic in patients N or = 75 years old: complications and functional outcomes. J Arthroplasty 2001;16(3):271.
Please cite this article as: Cahill CW, et al, Simultaneous Bilateral Knee Arthroplasty in Octogenarians: Can It Be Safe and Effective?, J Arthroplasty (2013), http://dx.doi.org/10.1016/j.arth.2013.10.026
