The BTK Safety Score: A Novel Scoring System for Risk Stratifying Patients Undergoing Simultaneous Bilateral Total Knee Arthroplasty

Selection of appropriate candidates for simultaneous bilateral total knee arthroplasty (si-BTKA) is crucial for minimizing postoperative complications. The aim of this study was to develop a scoring system for identifying patients who may be appropriate for si-BTKA. Patients who underwent si-BTKA were identified in the National Surgical Quality Improvement Program database. Patients who experienced a major 30-day complication were identified as high-risk patients for si-BTKA who potentially would have benefitted from staged bilateral total knee arthroplasty. Major complications included deep wound infection, pneumonia, renal insufficiency or failure, cerebrovascular accident, cardiac arrest, myocardial infarction, pulmonary embolism, sepsis, or death. The predictive model was trained using randomly split 70% of the dataset and validated on the remaining 30%. The scoring system was compared against the American Society of Anesthesiologists (ASA) score, the Charlson Comorbidity Index (CCI), and legacy risk-stratification measures, using area under the curve (AUC) statistic. Total 4,630 patients undergoing si-BTKA were included in our cohort. In our model, patients are assigned points based on the following risk factors: +1 for age ≥ 75, +2 for age ≥ 82, +1 for body mass index (BMI) ≥ 34, +2 for BMI ≥ 42, +1 for hypertension requiring medication, +1 for pulmonary disease (chronic obstructive pulmonary disease or dyspnea), and +3 for end-stage renal disease. The scoring system exhibited an AUC of 0.816, which was significantly higher than the AUC of ASA (0.545; p < 0.001) and CCI (0.599; p < 0.001). The BTK Safety Score developed and validated in our study can be used by surgeons and perioperative teams to risk stratify patients undergoing si-BTKA. Future work is needed to assess this scoring system's ability to predict long-term functional outcomes.

Simultaneous bilateral total knee arthroplasty

Aims Simultaneous bilateral total knee arthroplasty (TKA) has been used due to its financial advantages, overall resource usage, and convenience for the patient. The training model where a trainee performs the first TKA, followed by the trainer surgeon performing the second TKA, is a unique model to our institution. This study aims to analyze the functional and clinical outcomes of bilateral simultaneous TKA when performed by a trainee or a supervising surgeon, and also to assess these outcomes based on which side was done by the trainee or by the surgeon. Methods This was a retrospective cohort study of all simultaneous bilateral TKAs performed by a single surgeon in an academic institution between May 2003 and November 2017. Exclusion criteria were the use of partial knee arthroplasty procedures, staged bilateral procedures, and procedures not performed by the senior author on one side and the trainee on another. Primary clinical outcomes of interest included revision and re-revision. Primary functional outcomes included the Oxford Knee Score (OKS) and patient satisfaction scores. Results In total, 315 patients (630 knees) were included for analysis. Of these, functional scores were available for 189 patients (378 knees). There was a 1.9% (n = 12) all-cause revision rate for all knees. Overall, 12 knees in ten patients were revised, and both right and left knees were revised in two patients. The OKS and patient satisfaction scores were comparable for trainees and supervising surgeons. A majority of patients (88%, n = 166) were either highly likely (67%, n = 127) or likely (21%, n = 39) to recommend bilateral TKAs to a friend. Conclusion Simultaneous bilateral TKA can be used as an effective teaching model for trainees without any significant impact on patient clinical or functional outcomes. Excellent functional and clinical outcomes in both knees, regardless of whether the performing surgeon is a trainee or supervising surgeon, can be achieved with simultaneous bilateral TKA. Cite this article: Bone Jt Open 2022;3(1):29–34.

Tranexamic acid use in simultaneous bilateral total knee arthroplasty : a comparison of intravenous and intra-articular applications, which is more effective?

Patients applied with simultaneous bilateral total knee arthroplasty (SBTKA) with the administration of intravenous or intra-articular tranexamic acid (TXA) were compared in respect of blood loss and the need for allogenic blood transfusion. Of a total 53 patients applied with SBTKA, 32(60%) were administered intravenous TXA and 21(40%) intra-articular TXA. The patients were evaluated in respect of age, gender, height, weight, body mass index (BMI), body blood volume, preoperative and 1,2,3 and 4 days postoperative levels of hemoglobin (Hb) and hematocrit (Htc) and the change in Hb levels, estimated blood loss, mean actual blood loss, the need for allogenic blood transfusion (ABT) and the use or not of a drain. No difference was determined between the intravenous and intra-articular groups in respect of mean age, gender, height, weight, and body blood volume. No difference was determined between the groups in preoperative and postoperative mean Hb and Hct values, the reduction in mean Hb postoperatively, estimated blood loss, or the need for ABT. No deep vein thrombosis or pulmonary embolism was determined in any patient. In the application of SBTKA, TXA can be safely administered by the intravenous or intra-articular route to reduce the need for ABT. The results of this study determined no difference in efficacy between the routes of application. For patients with a risk of intravenous use, intra-articular application can be preferred.