1. www.sori.com.au Sydney Australia SORI Simultaneous Bilateral vs Unilateral TKR Complications & Analysis of the Patient’s Perspective Chloe Donovan RN David A Parker FRACS AOA Annual Scientific Meeting Adelaide, 2010

2. Sydneyortho.com.au/sori_page Conflict of Interest There is no conflict of interest in this research project There is no conflict of interest in this research project

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

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

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

6. Sydneyortho.com.au/sori_page Study Aims Comparison of: Comparison of: Unilateral Unilateral Staged Bilateral Staged Bilateral Simultaneous Bilateral Simultaneous Bilateral Analysis of: Analysis of: Complications Complications Outcomes Outcomes Patient Satisfaction & Perspective Patient Satisfaction & Perspective

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

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

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

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

11. Sydneyortho.com.au/sori_page Methods: Patient Questionnaire

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

13. Sydneyortho.com.au/sori_page Results: Complication Rate (%) UnilateralStagedSimultaneousP-value Retention3.36.95.70.59 Postop delirium11.710.75.70.23 VTE8.33.44.60.66 Blood Tx10.03.410.30.45 ICU3.30.06.90.47 Other3.33.42.30.74

14. Sydneyortho.com.au/sori_page Oxford

15. Sydneyortho.com.au/sori_page WOMAC

16. Sydneyortho.com.au/sori_page Range of Motion

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

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

19. Sydneyortho.com.au/sori_page Results: Patient Satisfaction * Significantly different to Unilateral and Staged (p<0.05) *

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

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

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

23. Sydneyortho.com.au/sori_page Thankyou