Bilateral Simultaneous Total Knee Arthroplasty (SBTKA) in patients above 70 years old Dr (Prof) Raju Vaishya (MBBS, MS, MCh, FRCS) Sr Consultant Orthopaedics & Joint Replacement Surgery Indraprastha Apollo Hospitals, New Delhi, INDIA

TKA in octo & nonagenarians Worldwide, the population of the elderly continues to grow. This increase naturally will be associated with a parallel increase in the number of TKAs done in this age group. The results of TKA in octogenarians have been reported. But the reports & results of TKA in patients >90 years old (nonagenarians) are not well documented The results of bilateral simultaneous TKA (SBTKA) in a single sitting have not been reported. 

Problems in Octo & Nonagenarians Age related physical & medical issues (Hilton et al 2004) More severe & complex deformities (Zicat et al, 1993) Associated osteoporosis Lesser response to rehabilitation More post of assistance required Total cost of treatment higher (Brander et al, 1997) Willful neglect of even eligible patients by the family & doctors (Hamel et al 2008)

Criteria for selection of cases Remaining life expectancy (>5yrs) Enthusiasm of the patient & family members Willingness to cooperate in rehab, post operatively No major medical co morbidities Availability of back up medical care facilities

Advantages of TKA in elderly Significant freedom for ADL Decreased dependence and improved quality of life (Laskin RS, CORR 1999) Reduction in subsequent risk of serious cardiovascular events (Ravi et al, BMJ 2014)

Our experience 177 SBTKA between 2003 and 2012. Retrospective cohort study of 46 patients (92 knees) of age >70 years. Combined spinal epidural anesthesia (93.5%) or general anesthesia (6.5%). More painful side operated first and 2nd side done during same anesthesia

Demographics Mean/number Standard deviation/percentage Age Sex Male Female BMI ASA Grade I Grade II Grade III Grade IV Grade V Preoperative Hb Postoperative Hb Tourniquet time ( in minutes) Postoperative blood loss in drain (ml) 80.13 25 21 29.4 12 8 1 12.6 9.94 44.43 45.56 968.19 5.25 54.4% 45.6% 5.36 26.08% 54.34% 17.4% 2.2% 0% 1.62 1.1 14.01 16.63 495.7 Demographics

Co-morbidities

Results 24% patients - no significant co-morbidity. 80% ASA grade 1 or 2. Significant improvement in post op KSS. No in-hospital mortality.

Complications Most common post op complication – delirium. Renal dysfunction (2), Angina (2), UTI (2), MI (1). No hospital mortality or till one year after index surgery. Average time of death after surgery 5.6 years.

How old is old?? These elderly people are ‘special class’ & have only minimal medical problems These people had lived a very healthy life & are keen to live good quality of life even in late age (living life king size!)

How old is old for a simultaneous bilateral total knee arthroplasty? With predictable benefits of surgery, SBTKA seems a safe, effective, viable procedure for carefully selected elderly adults, provided that doctors, the individuals, and family members accept the risks. These individuals should not be deprived of potential benefits of this surgery. Biological age is more important than the chronological age of these elderly adults when considering them for SBTKA.

Our oldest couple to undergo Bilateral TKA in a single sitting (makes a record!)

Conclusions SBTKA seems a safe, effective, and viable procedure for carefully selected elderly patients. Biological age is more important than the chronological age SBTKA cannot add years to the lives of these individuals, but it can add quality to the remaining years of their lives.

Conclusions Biological age is more important than the chronological age SBTKA cannot add years to the lives of these individuals, but it can add quality to the remaining years of their lives.

THANKS & Welcome to Delhi

J Arthroplasty. 2014 Aug;29(8):1635-8. Review of literature Retrospective study of 216 patients. No increased risk of pulmonary embolism. Nonagenarians did not have an increased risk of infection. Postoperative mortality was within expected rates. The patients do have higher re-admission rates and hence close follow up is needed in the post operative period. Miric A et al. Can total knee arthroplasty be safely performed among nonagenarians? An evaluation of morbidity and mortality within a total joint replacement registry. J Arthroplasty. 2014 Aug;29(8):1635-8.

Review of Literature Octogenarians can be expected to have their implants survive them. SBTKA can be a safe and effective option for octogenarians. Complications and mortality are not higher for SBTKA compared to UTKA. Cahill CW. Simultaneous bilateral knee arthroplasty in octogenarians: can it be safe and effective? J Arthroplasty. 2014 May;29(5):998-1000

Our observations to Cahill et al Patients suffering from cardio-pulmonary disorders - most likely to benefit from SBTKA. For better risk stratification of the elderly, the patients suffering from cardio-pulmonary disorders should not be excluded from the study by Cahill et al. Vijay V, Vaishya R. J Arthroplasty. 2014 Sep;29(9):1877-8 Letter to the editor on "Simultaneous bilateral knee arthroplasty in octogenarians: can it be safe and effective?".

The older group was more satisfied with their THR The outcome of primary total hip and knee arthroplasty in patients aged 80 years or more. Clement ND, MacDonald D, Howie CR, Biant LC. J Bone Joint Surg Br. 2011 Sep;93(9):1265-70. Primary arthroplasty may be denied to very elderly patients based upon the perceived outcome and risks associated with surgery The older group was more satisfied with their THR The older group had a longer hospital stay for both THR and TKR The rates of post-operative complications and mortality were increased in the older group.

Total knee arthroplasty in patients over 80 years of age Stroh DA, Delanois R, Naziri O, Johnson A, Mont M (J Knee Surg. 2011;24(4):279-83) Although the incidence of medical complications in the peri operative period may be higher, TKA is a safe and effective treatment for refractory joint pain in patients over 80 years of age.

Total knee replacement in patients older than 85 years Total knee replacement in patients older than 85 years. Laskin RS (Clin Orthop Relat Res. 1999 (367):43-9. There was a 70% preoperative cardiac disease comorbidity. Overall, confusion after surgery was greater in this older group than in the patients younger than 85 years of age, however, confusion was lower in the group of patients who had epidural anesthesia as compared with those patients who had surgery under general anesthesia. Seventy-six percent of the patients were living independently or in senior retirement housing after surgery. Only two of the patients required living accommodations in a nursing home. One third of the patients still could drive their own car after surgery. Quality of life improvement was markedly increased in this elderly group of patients. The results of this study indicate that total knee replacement still is a valuable procedure even for this elderly group, and most of these patients returned to a more functional lifestyle.

Simultaneous Bilateral, Staged Bilateral, and Unilateral TKA (Ritter et al.JBJS;85-A, 2003) The rates of perioperative morbidity and mortality are areas of concern associated with simultaneous bilateral TKA. The unilateral group had significantly lower Knee Society scores than the simultaneous bilateral group The percentage of patients who had thrombophlebitis was significantly higher in the simultaneous bilateral group (0.9%) than in the unilateral group (0.3%) (p = 0.0326). No significant differences were found with regard to prosthetic failure, cardiac complications, and the rates of death in the three groups. Ten years postoperatively, the simultaneous bilateral group had a significantly higher rate of patient survival than did the unilateral group (78.6% compared with 72.0%) (p = 0.0062).

Simultaneous Bilateral, Staged Bilateral, and Unilateral TKA (Ritter et al.JBJS;85-A, 2003) Survival analysis of 6200 total knee replacements, performed in 3998 patients between 1983 and 2000, consisted of 2050 simultaneous bilateral, 1796 unilateral, and 152 staged bilateral total knee replacements. There are adequate indications for bilateral total knee replacement, simultaneous bilateral arthroplasty is beneficial to patients, with a minimal increase in the risk of death or other complications compared with that associated with unilateral and staged procedures.

Is anyone too old for TKR? Mortality in the elderly group who had knee replacements was almost (1/2) that of the general population (standardized mortality ratio, 0.53). (Biau et al 2006) The survival of patients in their nineties who undergo total joint arthroplasty is at least equal to the survival of an age-matched population for 2.5 years following surgery. With careful patient selection and patient care to minimize medical complications, total joint arthroplasty can be an excellent option for patients who are age 89 and older. (Berend et al 2003)

Our experience of TKA in elderly In some selected patients with good medical condition, it is possible to do SBTKA in nonagenarians & octogenarians, with good results. Chronological age should not be a limitation for SBTKA in elderly patients, although they need special care while in the hospital For octo & nonagenarians, TKA provides excellent clinical improvement (measured by pain relief and knee score) with moderate function improvement, allowing improved ability to handle activities of daily living and improving quality of life

Welcome to Apollo Hospitals, New Delhi Invitation for Apollo Joint fellowship For 3months duration Contact: raju.vaishya@gmail.com