Content uploaded by Piti Rattanaprichavej
Author content
All content in this area was uploaded by Piti Rattanaprichavej on Feb 07, 2022
Content may be subject to copyright.
Available via license: CC BY-NC 4.0
Content may be subject to copyright.
World Journal of
Orthopedics
ISSN 2218-5836 (online)
World J Orthop 2022 January 18; 13(1): 1-121
Published by Baishideng Publishing Group Inc
WJO https://www.wjgnet.com IJanuary 18, 2022 Volume 13 Issue 1
World Journal of
Orthopedics
W J O
Contents Monthly Volume 13 Number 1 January 18, 2022
EDITORIAL
Three-dimensional printing in paediatric orthopaedic surgery
1
Goetstouwers S, Kempink D, The B, Eygendaal D, van Oirschot B, van Bergen CJ
REVIEW
Regional anesthesia for orthopedic procedures: What orthopedic surgeons need to know
11
Kamel I, Ahmed MF, Sethi A
Management of proximal biceps tendon pathology
36
Lalehzarian SP, Agarwalla A, Liu JN
ORIGINAL ARTICLE
Retrospective Cohort Study
Should we use similar perioperative protocols in patients undergoing unilateral and bilateral one-stage
total knee arthroplasty?
58
Laoruengthana A, Rattanaprichavej P, Samapath P, Chinwatanawongwan B, Chompoonutprapa P, Pongpirul K
Retrospective Study
Epidemiology and incidence of paediatric orthopaedic trauma workload during the COVID-19 pandemic:
A multicenter cohort study of 3171 patients
70
Rasmussen MK, Larsen P, Rölfing JD, Kirkegaard BL, Thorninger R, Elsoe R
Clinical Trials Study
Can bedside needle arthroscopy of the ankle be an accurate option for intra-articular delivery of injectable
agents?
78
Stornebrink T, Stufkens SAS, Mercer NP, Kennedy JG, Kerkhoffs GMMJ
Observational Study
High-resolution, three-dimensional magnetic resonance imaging axial load dynamic study improves
diagnostics of the lumbar spine in clinical practice
87
Lorenc T, Gołębiowski M, Michalski W, Glinkowski W
Prospective Study
Comparing shoulder maneuvers to magnetic resonance imaging and arthroscopic findings in patients with
supraspinatus tears
102
Anauate Nicolao F, Yazigi Junior JA, Matsunaga FT, Archetti Netto N, Belloti JC, Tamaoki MJS
WJO https://www.wjgnet.com II January 18, 2022 Volume 13 Issue 1
World Journal of Orthopedics
Contents Monthly Volume 13 Number 1 January 18, 2022
SYSTEMATIC REVIEWS
Long-term outcomes of the four-corner fusion of the wrist: A systematic review
112
Andronic O, Nagy L, Burkhard MD, Casari FA, Karczewski D, Kriechling P, Schweizer A, Jud L
WJO https://www.wjgnet.com III January 18, 2022 Volume 13 Issue 1
World Journal of Orthopedics
Contents Monthly Volume 13 Number 1 January 18, 2022
ABOUT COVER
Editorial Board Member of World Journal of Orthopedics, Stuart Adam Callary, BSc, PhD, Postdoctoral Fellow,
Research Scientist, Senior Lecturer, Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide
5000, Australia. stuart.callary@sa.gov.au
AIMS AND SCOPE
The primary aim of World Journal of Orthopedics (WJO, World J Orthop) is to provide scholars and readers from
various fields of orthopedics with a platform to publish high-quality basic and clinical research articles and
communicate their research findings online.
WJO mainly publishes articles reporting research results and findings obtained in the field of orthopedics and
covering a wide range of topics including arthroscopy, bone trauma, bone tumors, hand and foot surgery, joint
surgery, orthopedic trauma, osteoarthropathy, osteoporosis, pediatric orthopedics, spinal diseases, spine surgery,
and sports medicine.
INDEXING/ABSTRACTING
The WJO is now abstracted and indexed in PubMed, PubMed Central, Emerging Sources Citation Index (Web of
Science), Scopus, China National Knowledge Infrastructure (CNKI), China Science and Technology Journal
Database (CSTJ), and Superstar Journals Database. The 2021 edition of Journal Citation Reports® cites the 2020
Journal Citation Indicator (JCI) for WJO as 0.66. The WJO's CiteScore for 2020 is 3.2 and Scopus CiteScore rank 2020:
Orthopedics and Sports Medicine is 87/262.
RESPONSIBLE EDITORS FOR THIS ISSUE
Production Editor: Ying-Yi Yuan; Production Department Director: Xiang Li; Editorial Office Director: Jin-Lei Wang.
NAME OF JOURNAL INSTRUCTIONS TO AUTHORS
World Journal of Orthopedics https://www.wjgnet.com/bpg/gerinfo/204
ISSN GUIDELINES FOR ETHICS DOCUMENTS
ISSN 2218-5836 (online) https://www.wjgnet.com/bpg/GerInfo/287
LAUNCH DATE GUIDELINES FOR NON-NATIVE SPEAKERS OF ENGLISH
November 18, 2010 https://www.wjgnet.com/bpg/gerinfo/240
FREQUENCY PUBLICATION ETHICS
Monthly https://www.wjgnet.com/bpg/GerInfo/288
EDITORS-IN-CHIEF PUBLICATION MISCONDUCT
Massimiliano Leigheb https://www.wjgnet.com/bpg/gerinfo/208
EDITORIAL BOARD MEMBERS ARTICLE PROCESSING CHARGE
http://www.wjgnet.com/2218-5836/editorialboard.htm https://www.wjgnet.com/bpg/gerinfo/242
PUBLICATION DATE STEPS FOR SUBMITTING MANUSCRIPTS
January 18, 2022 https://www.wjgnet.com/bpg/GerInfo/239
COPYRIGHT ONLINE SUBMISSION
© 2022 Baishideng Publishing Group Inc https://www.f6publishing.com
© 2022 Baishideng Publishing Group Inc. All rights reserved. 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA
E-mail: bpgoffice@wjgnet.com https://www.wjgnet.com
WJO https://www.wjgnet.com 58 January 18, 2022 Volume 13 Issue 1
World Journal of
Orthopedics
W J O
Submit a Manuscript: https://www.f6publishing.com World J Orthop 2022 January 18; 13(1): 58-69
DOI: 10.5312/wjo.v13.i1.58 ISSN 2218-5836 (online)
ORIGINAL ARTICLE
Retrospective Cohort Study
Should we use similar perioperative protocols in patients
undergoing unilateral and bilateral one-stage total knee
arthroplasty?
Artit Laoruengthana, Piti Rattanaprichavej, Parin Samapath, Bhuwad Chinwatanawongwan, Pariphat
Chompoonutprapa, Krit Pongpirul
ORCID number: Artit Laoruengthana
0000-0001-5827-6411; Piti
Rattanaprichavej 0000-0002-2802-
0762; Parin Samapath 0000-0003-
1850-5755; Bhuwad
Chinwatanawongwan 0000-0003-
1594-2896; Pariphat
Chompoonutprapa 0000-0002-2446-
7751; Krit Pongpirul 0000-0003-3818-
9761.
Author contributions:
Laoruengthana A contributed to
the conception and design of the
study, and performed the
operation as the surgeon;
Rattanaprichavej P, Samapath P,
Chinwatanawongwan B, and
Chompoonutprapa P collected the
required data; Laoruengthana A
and Rattanaprichavej P wrote and
completed the manuscript;
Laoruengthana A,
Rattanaprichavej P, and Pongpirul
K were responsible for data
interpretation and performed the
statistical analysis; all authors have
read and approved the manuscript.
Institutional review board
statement: The study was
reviewed and approved by the
Naresuan University Institutional
Review Board (No. 756/2017).
Informed consent statement: All
Artit Laoruengthana, Piti Rattanaprichavej, Parin Samapath, Bhuwad Chinwatanawongwan,
Pariphat Chompoonutprapa, Department of Orthopaedics, Naresuan University, Mueang 65000,
Phitsanulok, Thailand
Krit Pongpirul, Department of Preventive and Social Medicine, Faculty of Medicine,
Chulalongkorn University, Bangkok 10330, Thailand
Corresponding author: Piti Rattanaprichavej, MD, Associate Professor, Director, Lecturer,
Surgeon, Department of Orthopaedics, Naresuan University, 99 Moo 9, Mueang 65000,
Phitsanulok, Thailand. pt-rp@hotmail.com
Abstract
BACKGROUND
Bilateral one-stage total knee arthroplasty (BTKA) is now in greater use as an
alternative option for patients with bilateral end-stage knee arthropathy.
However, postoperative pain and disablement during convalescence from BTKA,
and procedure-related complications have been concerning issues for patients and
surgeons. Although some studies reported that BTKA in selected patients is as
safe as the staged procedure, well-defined guidelines for patient screening, and
perioperative care and monitoring to avoid procedure-related complications are
still controversial.
AIM
To compare the perioperative outcomes including perioperative blood loss (PBL),
cardiac biomarkers, pain intensity, functional recovery, and complications
between unilateral total knee arthroplasty (UTKA) and BTKA performed with a
similar perioperative protocol.
METHODS
We conducted a retrospective study on consecutive patients undergoing UTKA
and BTKA that had been performed by a single surgeon with identical periop-
erative protocols. The exclusion criteria of this study included patients with an
American Society of Anesthesiologists score > 3, and known cardiopulmonary
comorbidity or high-sensitivity Troponin-T (hs-TnT) > 14 ng/L. Outcome
Laoruengthana A et al. Unilateral vs bilateral TKA
WJO https://www.wjgnet.com 59 January 18, 2022 Volume 13 Issue 1
study participants, or their legal
guardian, provided informed
written consent prior to study
enrollment.
Conflict-of-interest statement: The
authors declare that they have no
competing interests related to the
study design, data collection, and
interpretation of results presented
in this manuscript.
Data sharing statement: No
additional data are available.
STROBE statement: The authors
have read the STROBE
Statement—checklist of items, and
the manuscript was prepared and
revised according to the STROBE
Statement—checklist of items.
Country/Territory of origin:
Thailand
Specialty type: Orthopedics
Provenance and peer review:
Invited article; Externally peer
reviewed.
Peer-review model: Single blind
Peer-review report’s scientific
quality classification
Grade A (Excellent): 0
Grade B (Very good): B
Grade C (Good): 0
Grade D (Fair): 0
Grade E (Poor): 0
Open-Access: This article is an
open-access article that was
selected by an in-house editor and
fully peer-reviewed by external
reviewers. It is distributed in
accordance with the Creative
Commons Attribution
NonCommercial (CC BY-NC 4.0)
license, which permits others to
distribute, remix, adapt, build
upon this work non-commercially,
and license their derivative works
on different terms, provided the
original work is properly cited and
the use is non-commercial. See: htt
p://creativecommons.org/License
s/by-nc/4.0/
Received: April 28, 2021
Peer-review started: April 28, 2021
First decision: October 17, 2021
Revised: October 28, 2021
measures included visual analogue scale (VAS) score of postoperative pain,
morphine consumption, range of knee motion, straight leg raise (SLR), length of
stay (LOS), and serum hemoglobin (Hb) and hs-TnT monitored during hospital-
ization.
RESULTS
Of 210 UTKA and 137 BTKA patients, those in the BTKA group were younger and
more predominately female. The PBL of the UTKA vs BTKA group was 646.45 ±
272.26 mL vs 1012.40 ± 391.95 mL (P < 0.01), and blood transfusion rates were
10.48% and 40.88% (P < 0.01), respectively. Preoperative Hb and body mass index
were predictive factors for blood transfusion in BTKA, whereas preoperative Hb
was only a determinant in UTKA patients. The BTKA group had significantly
higher VAS scores than the UTKA group at 48, 72, and 96 h after surgery, and also
had a significantly lower degree of SLR at 72 h. The BTKA group also had a
significantly longer LOS than the UTKA group. Of the patients who had
undergone the procedure, 5.71% of the UTKA patients and 12.41% of the BTKA
patients (P = 0.04) had hs-TnT > 14 ng/L during the first 72 h postoperatively.
However, there was no difference in other outcome measures and complications.
CONCLUSION
Following similar perioperative management, the blood transfusion rate in BTKA
is 4-fold that required in UTKA. Also, BTKA is associated with higher pain
intensity at 48 h postoperatively and prolonged LOS when compared to the
UTKA. Hence, BTKA patients may require more extensive perioperative
management for blood loss and pain, even if having no higher risk of complic-
ations than UTKA.
Key Words: Bilateral one-stage total knee arthroplasty; Unilateral total knee arthroplasty;
Blood loss; Postoperative pain; High-sensitivity Troponin-T; Cardiovascular events
©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
Core Tip: The safety of bilateral one-stage total knee arthroplasty (BTKA) is still
debated because of greater blood loss, higher risk of cardiovascular events, increased
postoperative pain, and longer disablement period than unilateral total knee arthro-
plasty (UTKA). After comparing consecutive patients underwent BTKA and UTKA
with similar perioperative management, we found that the blood transfusion rate in the
BTKA is 4-fold than UTKA. Moreover, BTKA is associated with significantly higher
pain intensity at 48 h postoperatively and prolonged hospitalization. Although our
study demonstrated that BTKA is a safe procedure in selected patients, extensive
perioperative management for blood loss and pain is mandatory for BTKA patients.
Citation: Laoruengthana A, Rattanaprichavej P, Samapath P, Chinwatanawongwan B,
Chompoonutprapa P, Pongpirul K. Should we use similar perioperative protocols in patients
undergoing unilateral and bilateral one-stage total knee arthroplasty? World J Orthop 2022;
13(1): 58-69
URL: https://www.wjgnet.com/2218-5836/full/v13/i1/58.htm
DOI: https://dx.doi.org/10.5312/wjo.v13.i1.58
INTRODUCTION
Total knee arthroplasty (TKA) is widely accepted as one of the most effective and safe
surgical procedures for treating severe osteoarthritis (OA) of the knee. Currently,
advances in anesthesia, surgical techniques, and perioperative care, including
multimodal pain management and accelerated rehabilitation, have improved
functional recovery and shortened the length of the hospital stay for patients
undergoing unilateral total knee arthroplasty (UTKA)[1]. There have also been
contemporary blood-conserving methods published that substantially decrease the
Laoruengthana A et al. Unilateral vs bilateral TKA
WJO https://www.wjgnet.com 60 January 18, 2022 Volume 13 Issue 1
Accepted: December 25, 2021
Article in press: December 25, 2021
Published online: January 18, 2022
P-Reviewer: Xiao JL
S-Editor: Fan JR
L-Editor: Wang TQ
P-Editor: Fan JR
rate of postoperative blood transfusions when kept below 10%[2-4].
Approximately 25% of patients undergoing UTKA have bilateral OA knees[5] and
subsequently will undergo contralateral TKA within 1 year[6]. Thus, bilateral one-
stage total knee arthroplasty (BTKA) is now in greater use as an alternative option for
patients with bilateral OA knees because of the potential advantages that include
single anesthesia, reduction in total hospitalization and rehabilitation time, as well as
overall costs[7]. However, the safety of BTKA is still debated because of perioperative
morbidity that is associated with greater blood loss and a higher risk of cardiovascular
adverse events than UTKA[8,9]. Various blood-conserving strategies including
regional anesthesia, tourniquet use and deflation after wound closure, femoral canal
occlusion, and use of tranexamic acid (TXA) are commonly implemented in patients
having BTKA with documented efficacy[10]. However, recently published studies
revealed that blood loss after BTKA ranged between 874 and 1067 mL, and blood
transfusion rate ranged between 24% and 44% even if TXA was administered[11-13].
The substantial blood loss related to BTKA may subsequently cause occult hypoper-
fusion of vital organs such as the heart and kidneys. Conversely, requirements for
blood transfusions may also increase the risk of complications such as allergic reaction,
cardiovascular volume overload, and subsequent heart failure or pulmonary edema
[14,15]. The risk of myocardial infarction (MI) has been reported to significantly
increase among the TKA group during the immediate postoperative phase when
compared to the non-surgical group[16,17]. Taking data from the National Hospital
Discharge database, 1.1% of patients were diagnosed with cardiac complications in the
90 d after TKA, and BTKA had a higher rate than UTKA (2.0% vs 1.7%)[18]. Therefore,
these findings may emphasize the need for extensive perioperative care and
monitoring to avoid such complications in BTKA.
Furthermore, significant pain after UTKA has been noted and inadequate pain
control has been demonstrated to be associated with inferior functional outcomes at 2
years after TKA[19]. Thus, postoperative pain has been an issue frequently concerning
patients as to whether the intensity of pain and disablement during convalescence
from BTKA are worse than that following UTKA. Nevertheless, there has been limited
evidence comparing postoperative pain and functional recovery after BTKA and
UTKA, and the known results are still equivocal[20,21]. Therefore, the objective of the
present study was to compare the perioperative outcomes including perioperative
blood loss (PBL), cardiac biomarkers, pain intensity and functional recovery, and
complications between patients undergoing UTKA and BTKA with a similar periop-
erative protocol. The authors hypothesized that patients undergoing BTKA may
require additional perioperative care and monitoring to improve outcomes.
MATERIALS AND METHODS
The study received institutional review board approval for retrospective analysis of
data recorded prior to initiation and has been registered as TCTR20181220001. The
authors’ criteria for BTKA were painful bilateral end-stage OA knees, and therefore
the selection of BTKA or UTKA was based upon patient preference. Consecutive
patients who had undergone UTKA and BTKA for primary OA, performed by a single
surgeon between January 2016 and December 2019, were enrolled in the study. The
exclusion criteria of this study were patients with a history of prior knee surgery or
previous knee infection. Participants with an American Society of Anesthesiologists
(ASA) score > 3, known cardiopulmonary comorbidity or high-sensitivity Troponin-T
(hs-TnT) > 14 ng/L, CKD stage ≥ 3, or significant renal impairment (serum creatinine >
1.5 mg/dL) were also excluded.
All the UTKA and BTKA were performed by a single surgeon with identical pre-,
peri-, and postoperative protocols. Regional anesthesia, prophylactic intravenous
antibiotics (ATB), and tourniquet control at 250 mmHg were applied for all patients. A
medial parapatellar approach was performed through an approximately 10 cm
midline skin incision, the cruciate ligaments were excised, and conventional
instruments were then used to prepare the proximal tibial and distal femoral bone cuts
by using extramedullary and intramedullary reference guides, respectively. A bone
plug was applied to occlude the opening hole of the distal femur after finishing all the
bone cuts. Soft tissue balancing was performed to achieve appropriate flexion and
extension gaps. The patella was selectively resurfaced. Before prosthesis implantation,
local infiltration anesthesia (LIA) was induced by injecting Bupivacaine (0.5%
Marcaine; AstraZeneca, Sweden), 30 mg of ketorolac tromethamine (ketorolac
tromethamine 1 mL; SiuGuan, Taiwan), and sterile normal saline solution into the
Laoruengthana A et al. Unilateral vs bilateral TKA
WJO https://www.wjgnet.com 61 January 18, 2022 Volume 13 Issue 1
anterior and posterior compartment of the knee with the 2:1 ratio technique. All the
patients received a fixed bearing, posterior stabilized prosthesis which was implanted
with bone cement. A vacuum drain was then applied, and 15 mg/kg of topical
tranexamic acid was poured into the knee joint before closure of the arthrotomy. The
drain was clamped for 3 h and subsequently removed at 24 h after the surgery.
For postoperative management, intravenous patient-controlled analgesia morphine
(100 mL solution containing 50 mg of morphine sulphate) was injected as an on-
demand bolus of 1 mL with a 5 min lockout period, 30 mg of ketorolac was given
intravenously every 8 h, and 500 mg of oral acetaminophen was administered three
times a day. After 48 h, all the catheters were discarded, and 2 mg of morphine were
injected every 8 h with an additional 2 mg of morphine used for a breakthrough pain
throughout hospitalization. Also, oral medications including 250 mg of naproxen twice
a day and 500 mg of acetaminophen three times a day were given. All patients were
administered with low molecular weight heparin for the first 48 h and combined with
oral warfarin for 10 d. Rehabilitation including active ankle pump was started after the
surgery, and a continuous passive motion device was utilized on the day after surgery.
Every patient was encouraged to attempt early ambulation with gait aids as able to be
tolerated.
Data collected for analysis were patient demography, visual analogue scale (VAS)
scores of postoperative pain, morphine consumption, range of knee motion (ROM),
straight leg raise (SLR), length of stay (LOS), and laboratory evaluation comprising
serum hemoglobin (Hb), blood transfusion rate, creatine phosphokinase (CPK), and
hs-TnT preoperatively and at 24, 48, and 72 h after the surgery.
The patient's total blood volume (TBV) was calculated by the equation of Nadler et
al[22]. The difference between preoperative and lowest postoperative Hb was applied
with the Hb balance method to determine PBL[2].
Males: TBV (mL) = [0.0003669 × height3 (cm)] + [32.19 × body weight (kg)] + 604
Females: TBV (mL) = [0.0003561 × height3 (cm)] + [33.08 × body weight (kg)] + 183
PBL (mL) = TBV (mL) × (Hbi – Hbe)/Hbi + sum of blood products transfused (mL),
where Hbi (g/dL) is the preoperative Hb, and Hbe (g/dL) is the postoperative Hb.
Serum Hb level that drops below 9.0 g/dL is indicated for blood transfusion for
both the UTKA and BTKA at our institution. A hs-TnT level > 14 ng/L is considered as
possible for MI in our laboratory system. Any complications and readmission rates at
90 d after the index surgery were recorded.
Statistical analysis
All demographic data and measured outcomes are summarized with descriptive
statistics. Continuous data are presented as the mean and standard deviation, and
Student’s t-test was used to compare between the UTKA and BTKA groups.
Categorical data which are presented as counts and percentages were compared by
using Chi-square or Fisher’s exact test. Repeated-measures analysis of variance was
applied to compare the time-dependent variables including VAS, ROM, SLR, Hb, CPK,
and hs-TnT between groups. The post hoc comparisons of all pairwise points in time
were applied to account for multiple testing with Bonferroni adjustments. A multiple
logistic regression analysis was performed to determine which of these variables,
including age, gender, body mass index (BMI), ASA physical status classification, and
preoperative Hb, were the predictive factors for allogeneic blood transfusion. The
sample size of the UTKA and BTKA groups had 99.5% power to detect a difference of
200 mL in PBL, which could significantly impact on blood transfusion rate, with
standard deviation (SD) of 400 mL, and 95.4% power to ascertain a difference of 1.0 for
VAS with SD of 2.5, with type I error of 5%. Stata/MP 15.0 software (StataCorp LP,
College Station, TX, United States) was used for all statistical analyses. Statistical
significance was defined as P < 0.05.
RESULTS
There were 210 UTKA and 137 BTKA included for analysis. The demographic and
perioperative characteristics are briefly summarized in Table 1. Patients in the BTKA
group were younger and more predominately female, and had a longer total duration
of operation (TDO).
Blood loss
The postoperative Hb level of both groups gradually dropped and reached the lowest
point at 72 h after the surgery. BTKA was associated with a significantly lower level of
Laoruengthana A et al. Unilateral vs bilateral TKA
WJO https://www.wjgnet.com 62 January 18, 2022 Volume 13 Issue 1
Table 1 Demographic and perioperative characteristics
UTKA BTKA P value
Age (yr) 65.00 ± 7.48 63.10 ± 6.83 0.02a
Gender (female/male) 178/32 129/8 0.01a
BMI (kg/m2) 26.99 ± 3.49 26.54 ± 3.89 0.20
ASA (1/2/3) 4/134/72 5/101/31 0.05
Preop. VAS pain score 6.89 ± 2.33 6.77 ± 1.89 0.44
Preop. ROM 113.86 ± 13.55 111.16 ± 14.26 0.13
Preop. Hb (g/dL) 12.60 ± 1.19 12.44 ± 1.08 0.21
Preop. CPK (u/L) 125.05 ± 84.64 116.05 ± 65.12 0.41
Preop. TnT (ng/dL) 6.77 ± 3.04 6.46 ± 3.18 0.79
TDO (min) 62.21 ± 9.86 125.12 ± 16.30 < 0.01a
aP < 0.05 indicates statistical significance. All parameters are presented as the mean ± standard deviation, except for gender and American Society of
Anesthesiologists score.
BMI: Body mass index; ASA: American Society of Anesthesiologists; Preop.: Preoperative; VAS: Visual analog scale; TDO: Total duration of operation; Hb:
Hemoglobin; sCr: Serum creatinine; TnT: Troponin-T; CPK: Creatine Phosphokinase; UTKA: Unilateral total knee arthroplasty; BTKA: Bilateral one-stage
total knee arthroplasty.
Hb than UTKA at 24, 48, and 72 h postoperatively (Figure 1). The PBL of the UTKA vs
BTKA group was 646.45 ± 272.26 mL vs 1012.40 ± 391.95 mL (P < 0.01), respectively.
Blood transfusion rates in UTKA and BTKA were 10.48% (22/210) and 40.88%
(56/137), (P < 0.01), respectively. For UTKA, 18 of 69 (26.09%) patients with
preoperative anemia (defined as preoperative Hb < 12 g/dL in females and < 13 g/dL
in males) received blood transfusion compared to 6 of 141 (4.26%) patients without
anemia (P < 0.01). Twenty-eight of 43 (65.12%) patients with preoperative anemia in
the BTKA group required a transfusion, whereas patients without anemia had a
transfusion rate of approximately 1 in 4 (26/94, 27.67%; P < 0.01). The multivariate
analysis demonstrated that preoperative Hb [odd ratio (OR): 0.33, 95% confidence
interval (CI): 0.22-0.50, P < 0.01] and BMI (OR: 0.90, 95%CI: 0.81-0.99, P = 0.03) were
predictive factors for blood transfusion in the BTKA group, whereas preoperative Hb
(OR: 0.21, 95%CI: 0.12-0.37, P < 0.01) was only a determinant in the UTKA group when
using similar perioperative blood management and cut-off values for transfusion.
Postoperative pain and recovery
There was no difference between the UTKA and BTKA groups regarding VAS scores
at 6, 12, and 24 h, but the BTKA group had significantly higher VAS scores than the
UTKA group at 48, 72, and 96 h after surgery (Figure 2A). The BTKA group had a
significantly lower degree of SLR than the UTKA group at 72 h; however, the ROM
was comparable between groups throughout the study period (Figure 2B and C). Total
morphine consumption in the UTKA vs BTKA group was 11.93 ± 9.20 vs 13.81 ± 10.81 (
P = 0.16) at 24 h, and 16.78 ± 13.24 vs 19.51 ± 15.47 (P = 0.15) at 48 h postoperatively.
The incidence of postoperative nausea and vomiting (PONV) during the first 24 h in
the UTKA and BTKA groups was 38.79% (90/142) and 46.47% (112/129) (P = 0.09),
respectively. The UTKA had an LOS of 4.01 ± 0.97 d, which was significantly shorter
than that of the BTKA group (5.17 ± 1.32 d; P < 0.01).
Cardiac biomarkers
The BTKA group showed significantly higher CPK than the UTKA group at 24 h and
48 h after the surgery (Figure 3A). For the hs-TnT, it was gradually rising during 72 h
after the UTKA and it was rising to a peak at 48 h after the BTKA, but the hs-TnT level
was not significantly different between groups along the study period (Figure 3B).
Nonetheless, there were 12 patients (5.71%) who had hs-TnT > 14 ng/L during the first
72 h after the UTKA compared to 17 patients (12.41%) following the BTKA (P = 0.04),
but no patient presented cardiovascular symptoms and signs, or abnormal electrocar-
diogram indicating MI.
Laoruengthana A et al. Unilateral vs bilateral TKA
WJO https://www.wjgnet.com 63 January 18, 2022 Volume 13 Issue 1
Figure 1 Serum hemoglobin levels preoperatively and at 24 h, 48 h and 72 h after the surgery. UTKA: Unilateral total knee arthroplasty; SBTKA:
Safety of bilateral one-stage total knee arthroplasty.
Figure 2 Index changes in different time periods after operation. A: Visual analog scale scores for pain intensity determined at 6 h, 12 h, 24 h, 48 h, and
72 h after the surgery; B: Straight leg raise assessed at 24 h, 48 h, and 72 h postoperatively; C: Range of knee motion measured at 24 h, 48 h, and 72 h after the
surgery. VAS: Visual analogue scale; ROM: Range of knee motion; SLR: Straight leg raise; UTKA: Unilateral total knee arthroplasty; SBTKA: Safety of bilateral one-
stage total knee arthroplasty.
Complications and readmission at 90 d
During the 90 d after the index surgery, there was one superficial infection, one
cerebrovascular event, and two deep vein thromboses (DVT) in the UTKA group. For
the BTKA group, one patient experienced peptic ulcer bleeding, one had DVT in the
unilateral leg, and one had periprosthetic joint infection (PJI) which was successfully
treated by two-stage revision TKA. Additionally, each group had one patient who
required readmission due to severe pain at the surgical site.
DISCUSSION
Bilateral one-stage TKA potentially increases the rate of complications which are
related to more soft tissue trauma, blood loss, postoperative pain, and cardiovascular
Laoruengthana A et al. Unilateral vs bilateral TKA
WJO https://www.wjgnet.com 64 January 18, 2022 Volume 13 Issue 1
Figure 3 Changes in creatine phosphokinase and high-sensitivity Troponin-T before operation and at 24 h, 48 h, and 72 h after operation.
A: Creatine phosphokinase evaluated preoperatively and at 24 h, 48 h, and 72 h postoperatively; B: High-sensitivity Troponin-T preoperatively and at 24 h, 48 h, and
72 h postoperatively. CPK: Creatine phosphokinase; UTKA: Unilateral total knee arthroplasty; SBTKA: Safety of bilateral one-stage total knee arthroplasty.
adverse events, and therefore this is still a concerning issue for some patients and
surgeons[8,9]. However, recent studies reported that BTKA in selected patients is as
safe as the staged procedure, but proper patient screening, and perioperative care and
monitoring to avoid complications and mortality are still controversial[23,24]. In the
current study, BTKA was associated with significantly greater blood loss and higher
allogeneic blood transfusion rates, as well as higher CPK levels, when compared to the
UTKA group. The BTKA group tended to have higher hs-TnT levels at 48 h despite not
reaching statistical significance. After 48 h, the BTKA group had a significantly higher
VAS score than the UTKA group, and the SLR at 72 h after the BTKA was also worse
than that after the UTKA. The LOS of the BTKA group was also significantly longer
than that for the UTKA group. Nevertheless, the total morphine use, ROM, complic-
ations, and 90-d readmission rate were not different between the groups.
Generally, BTKA is known for its association with inevitably greater blood loss than
UTKA. Advances in surgical techniques, use of TXA, and change in transfusion
thresholds have substantially reduced postoperative transfusions following UTKA[3].
Recently, TXA is widely respected as an effective anti-fibrinolytic agent and has been
demonstrated as having advantages when used in BTKA[25]. Although TXA is
effective for reducing blood loss following BTKA, when it is applied either
intravenously (IV) or intra-articularly (IA), the ideal regimen of TXA is still not well
defined[13]. Arora et al[26] revealed no difference in average drop of Hb and blood
transfusion rate between patients undergoing BTKA with IV-TXA or IA-TXA. Also,
combined IA and IV TXA administration in BTKA did not show superior efficacy in
blood loss reduction[27]. Therefore, the intraoperative IA-TXA use alone, in our study,
should be sufficient to control blood loss, while avoiding potential complications
related to systemic administration of TXA. However, our transfusion rate in BTKA is
still quite high at 40.88%. Chalmers et al[28] retrospectively reviewed 475 patients who
underwent BTKA and received double doses of TXA and contemporary blood
management. They found that BTKA is still associated with a blood transfusion rate of
approximately 1 in 5, and 50% of patients with a preoperative Hb < 12.5 required
blood transfusion. Accordingly, we identified the preoperative Hb as a predictive
factor for allogeneic transfusion in BTKA. Particularly, approximately 1 out of 3
patients in our study had preoperative anemia, and this finding may underline the
opportunity for further improvement and for addressing this modifiable risk factor
before BTKA. Delasotta et al[29] demonstrated that giving three preoperative doses of
epoetin-α could significantly increase Hb levels and reduce blood transfusions in
BTKA. Intravenous iron supplementation has also been reported for its efficacy in
reducing the rate of transfusion in BTKA when combined with IA-TXA administration
[30]. Other determinants including female gender, preoperative Hb level, operative
time, and drain use have also been identified as risk factors for blood transfusion in
BTKA[11,28]. In addition, soft tissue surface and intramedullary canal violation have
been revealed as a possible significant source of bleeding[11,31-33]. Nevertheless, the
efficacy of fibrin sealant applied to the bleeding soft tissue is unclear for blood loss
reduction in BTKA[31], and also outcomes of emerging technologies such as
computer-assisted or accelerometer-based navigation are still equivocal[13,34].
Significant pain after UTKA has been noted and this has been an issue frequently
concerning patients as to whether the intensity of pain and disablement, during
Laoruengthana A et al. Unilateral vs bilateral TKA
WJO https://www.wjgnet.com 65 January 18, 2022 Volume 13 Issue 1
convalescence from BTKA, is worse than that of UTKA. Shetty et al[20] reported that
BTKA had significantly higher VAS pain scores than UTKA on the first postoperative
day. However, the VAS, ROM, and SLR were equal in both groups at the time of
discharge. Other researchers found a 1-point higher VAS in the BTKA group during
day 1, with 20% more narcotic use for the first 48 h, and patients in the BTKA group
lagged behind the UTKA group in ambulatory milestones by approximately 36 h[21].
In the present study, we found that the UTKA and BTKA group had comparable pain
intensity, morphine consumption, and knee function during the first 24 h after the
surgery by using the same multimodal pain management. The neuroaxial anesthesia,
LIA that was induced by injecting with bupivacaine and ketorolac tromethamine, and
opioid-sparing analgesia with a multidrug regimen may be an explanation of the
effective pain control during the first 24 h after UTKA and BTKA. Despite that,
patients in the BTKA gradually developed higher pain scores afterwards and had
worse SLR at 72 h. Higher postoperative CPK levels might reflect the certainty of more
muscle injury in the BTKA, and so may indicate the need for intensive pain control
extended beyond 48 h after the surgery. Intravenous administration of non-steroidal
anti-inflammatory drugs (NSAIDs) is commonly used because of their efficacy in
controlling post-TKA pain and may be administered up to 72 h after the surgery.
Recently, Parecoxib, which is a selective cyclooxygenase-2 (COX-2) inhibitor, has been
demonstrated to be effective in the reduction of post-TKA pain with the additional
advantage of having less platelet inhibition and is consequently associated with less
blood loss when compared to conventional NSAIDs[2]. Furthermore, intravenous
corticosteroid and acetaminophen were also revealed as useful adjuncts for mitigating
pain after TKA[35,36].
The safety of BTKA is still debated. Chen et al[24] recently demonstrated that
patients aged > 80 years with an ASA score ≥ 3 who received careful screening for
cardiopulmonary disorder and contemporary perioperative management for BTKA,
had significantly decreased incidences of major and minor complications. Gromov et al
[37] reported a 0% incidence of mortality in 284 selected patients without cardiopul-
monary compromise, and they also found that ASA score ≥ 3 was a risk factor for 90-d
readmission and prolonged LOS whereas higher BMI was a weak predictive factor for
readmission. Lindberg-Larsen et al[23] conducted a study to compare outcomes after
simultaneous and staged bilateral TKA in propensity-scores matched patients from
nine centers. Of 232 matched patients in each group, perioperative complications and
re-operation rates were significantly higher after simultaneous bilateral TKA.
However, there was no difference in the rate of readmission within 30 d as well as the
mortality between groups. In the present study, the hs-TnT level, which is a biomarker
for cardiac muscle injury, was not different between UTKA and BTKA when patients
had an ASA score ≤ 3 and preoperative hs-TnT within normal values. Although there
were 12 and 17 patients after the UTKA and BTKA who had hs-TnT > 14 ng/L, no
patients in either group presented symptoms and signs of cardiovascular complic-
ations. Hence, serial testing of cardiac biomarkers may be indicated only when
patients have suspected clinical presentation[38]. Additionally, Hb evaluation seems to
be unnecessary for non-anemic patients who undergo UTKA, due to the very low risk
for blood transfusion. However, we suspect that Hb testing at 48 h after BTKA may be
appropriate as a reflection of ongoing blood loss that is possibly linked to cardiac
stress because the hs-TnT was rising to a peak at 48 h after BTKA when the Hb level
was dropping. For other complications, the risk of PJI and DVT was not different
between BTKA and UTKA when similar prophylaxis ATB and anticoagulants were
applied. Nevertheless, further investigation may be needed to develop well-defined
guidelines for perioperative monitoring in patients undergoing BTKA to decrease
potential morbidity and mortality.
Nonetheless, we realized some limitations of the present study. First, this invest-
igation is retrospective with some limitations accorded by study design, even if the
selection of BTKA or UTKA as patient preference might be better accommodated with
our real-life practice. Second, both study groups comprised predominantly female
patients. However, previous studies found that gender has no effect on blood loss and
functional recovery following TKA[12,39]. Third, variation of thresholds or cut-off
values for blood transfusion among individual institutions may result in a different
transfused rate. Indeed, the incidence of patients with preoperative anemia in our
study seems to be higher than previously reported[3] and thereby may be a reason for
higher transfusion rates than those reported in other studies[4,28]. Lastly, our sample
size might not be sufficient to assess the exact risk of cardiovascular events and
thromboembolism after UTKA and BTKA.
Laoruengthana A et al. Unilateral vs bilateral TKA
WJO https://www.wjgnet.com 66 January 18, 2022 Volume 13 Issue 1
CONCLUSION
Following similar perioperative management, the blood transfusion rate in BTKA is 4-
fold that required in UTKA. Also, BTKA is associated with higher pain intensity at 48
h postoperatively and prolonged LOS when compared to UTKA. Hence, patients
undergoing BTKA may require more extensive perioperative management for blood
loss and pain, even if they have no higher risk of complications and 90-d readmission
than those receiving UTKA.
ARTICLE HIGHLIGHTS
Research background
Bilateral one-stage total knee arthroplasty (BTKA) is a notable option for patients with
bilateral end-stage knee arthropathy because of the potential advantages that include
reduction in total hospitalization and rehabilitation time, as well as overall cost.
Research motivation
Despite previously acknowledged benefits, there is an issue frequently concerning
patients as to whether the intensity of pain and disablement during convalescence
from BTKA is worse than that following unilateral total knee arthroplasty (UTKA).
Also, the risk of cardiovascular morbidity and other complications are subjects that
lead some surgeons to refrain from BTKA. Thus, our objective was to identify what
perioperative aspects of BTKA need to be improved and handled differently than for
UTKA.
Research objectives
To compare the perioperative outcomes including perioperative blood loss (PBL),
cardiac biomarkers, pain intensity, functional recovery, and complications between
UTKA and BTKA by using an identical perioperative protocol.
Research methods
All patients who had undergone UTKA and BTKA for primary osteoarthritis that had
been performed by a single surgeon with identical perioperative protocols between
January 2016 and December 2019 were retrospectively reviewed. The exclusion criteria
of this study included patients with an American Society of Anesthesiologists score >
3, known cardiopulmonary comorbidity or high-sensitivity Troponin-T (hs-TnT) > 14
ng/L, CKD stage ≥ 3 or significant renal impairment (serum creatinine > 1.5 mg/dL),
prior knee surgery, and previous knee infection.
Research results
Patients who received BTKA had significantly higher PBL with a 4-fold greater
transfusion rate. As well, the patients in the BTKA group had higher visual analogue
scale scores at 48, 72, and 96 h after the surgery and a higher postoperative creatine
phosphokinase level. Consequently, a longer length of hospital stays than those who
had UTKA was required. However, there was no difference regarding the
postoperative hs-TnT level and complications.
Research conclusions
Patients who undergo BTKA may require more extensive perioperative care for blood
loss and pain than those patients who undergo UTKA.
Research perspectives
Future prospective studies may be required to develop a particular perioperative
protocol in patients undergoing BTKA to decrease potential morbidity and mortality.
ACKNOWLEDGEMENTS
We thank Mr. Roy I Morien of the Naresuan University Graduate School for his
assistance in editing the English expression and grammar in this document. We also
thank Passakorn Teekaweerakit, MD, Watcharapong Eiamjumras, MD, Thanawat
Tantimethanon, MD, Panapol Varakornpipat, MD, and Kongpob Reosanguanwong,
Laoruengthana A et al. Unilateral vs bilateral TKA
WJO https://www.wjgnet.com 67 January 18, 2022 Volume 13 Issue 1
MD, for their technical assistance.
REFERENCES
Fransen BL, Hoozemans MJM, Argelo KDS, Keijser LCM, Burger BJ. Fast-track total knee
arthroplasty improved clinical and functional outcome in the first 7 days after surgery: a randomized
controlled pilot study with 5-year follow-up. Arch Orthop Trauma Surg 2018; 138: 1305-1316
[PMID: 30027483 DOI: 10.1007/s00402-018-3001-2]
1
Laoruengthana A, Rattanaprichavej P, Reosanguanwong K, Chinwatanawongwan B,
Chompoonutprapa P, Pongpirul K. A randomized controlled trial comparing the efficacies of
ketorolac and parecoxib for early pain management after total knee arthroplasty. Knee 2020; 27:
1708-1714 [PMID: 33197808 DOI: 10.1016/j.knee.2020.10.005]
2
Warren JA, McLaughlin JP, Molloy RM, Higuera CA, Schaffer JL, Piuzzi NS. Blood Management
in Total Knee Arthroplasty: A Nationwide Analysis from 2011 to 2018. J Knee Surg 2020 [PMID:
33241545 DOI: 10.1055/s-0040-1721414]
3
Kim TK, Chang CB, Kang YG, Seo ES, Lee JH, Yun JH, Lee SH. Clinical value of tranexamic acid
in unilateral and simultaneous bilateral TKAs under a contemporary blood-saving protocol: a
randomized controlled trial. Knee Surg Sports Traumatol Arthrosc 2014; 22: 1870-1878 [PMID:
23592025 DOI: 10.1007/s00167-013-2492-1]
4
Metcalfe AJ, Andersson ML, Goodfellow R, Thorstensson CA. Is knee osteoarthritis a symmetrical
disease? BMC Musculoskelet Disord 2012; 13: 153 [PMID: 22917179 DOI:
10.1186/1471-2474-13-153]
5
Walmsley P, Murray A, Brenkel IJ. The practice of bilateral, simultaneous total knee replacement in
Scotland over the last decade. Data from the Scottish Arthroplasty Project. Knee 2006; 13: 102-105
[PMID: 16481171 DOI: 10.1016/j.knee.2006.01.003]
6
Odum SM, Troyer JL, Kelly MP, Dedini RD, Bozic KJ. A cost-utility analysis comparing the cost-
effectiveness of simultaneous and staged bilateral total knee arthroplasty. J Bone Joint Surg Am 2013;
95: 1441-1449 [PMID: 23965693 DOI: 10.2106/JBJS.L.00373]
7
Memtsoudis SG, Besculides MC, Reid S, Gaber-Baylis LK, González Della Valle A. Trends in
bilateral total knee arthroplasties: 153,259 discharges between 1990 and 2004. Clin Orthop Relat Res
2009; 467: 1568-1576 [PMID: 19002540 DOI: 10.1007/s11999-008-0610-z]
8
Bohm ER, Molodianovitsh K, Dragan A, Zhu N, Webster G, Masri B, Schemitsch E, Dunbar M.
Outcomes of unilateral and bilateral total knee arthroplasty in 238,373 patients. Acta Orthop 2016; 87
Suppl 1: 24-30 [PMID: 27167849 DOI: 10.1080/17453674.2016.1181817]
9
Soranoglou V, Poultsides LA, Triantafyllopoulos GK, De Martino I, Memtsoudis SG, Sculco TP.
Optimizing Intraoperative Blood Management for One-Stage Bilateral Total Knee Arthroplasty. HSS
J 2018; 14: 202-210 [PMID: 29983664 DOI: 10.1007/s11420-017-9590-4]
10
Rattanaprichavej P, Laoruengthana A, Rasamimogkol S, Varakornpipat P, Reosanguanwong K,
Pongpirul K. The Effect of Prosthesis Design on Blood Loss in Simultaneous Bilateral Total Knee
Arthroplasty: Closed-Box vs Open-Box Prosthesis. Clin Orthop Surg 2019; 11: 409-415 [PMID:
31788163 DOI: 10.4055/cios.2019.11.4.409]
11
Cao G, Chen G, Huang Q, Huang Z, Alexander PG, Lin H, Xu H, Zhou Z, Pei F. The efficacy and
safety of tranexamic acid for reducing blood loss following simultaneous bilateral total knee
arthroplasty: a multicenter retrospective study. BMC Musculoskelet Disord 2019; 20: 325 [PMID:
31299945 DOI: 10.1186/s12891-019-2692-z]
12
Laoruengthana A, Rattanaprichavej P, Tantimethanon T, Eiamjumras W, Teekaweerakit P,
Pongpirul K. Usefulness of an accelerometer-based navigation system in bilateral one-stage total knee
arthroplasty. BMC Musculoskelet Disord 2021; 22: 164 [PMID: 33568132 DOI:
10.1186/s12891-021-04027-9]
13
Friedman R, Homering M, Holberg G, Berkowitz SD. Allogeneic blood transfusions and
postoperative infections after total hip or knee arthroplasty. J Bone Joint Surg Am 2014; 96: 272-278
[PMID: 24553882 DOI: 10.2106/JBJS.L.01268]
14
Silliman CC, Fung YL, Ball JB, Khan SY. Transfusion-related acute lung injury (TRALI): current
concepts and misconceptions. Blood Rev 2009; 23: 245-255 [PMID: 19699017 DOI:
10.1016/j.blre.2009.07.005]
15
Lu N, Misra D, Neogi T, Choi HK, Zhang Y. Total joint arthroplasty and the risk of myocardial
infarction: a general population, propensity score-matched cohort study. Arthritis Rheumatol 2015;
67: 2771-2779 [PMID: 26331443 DOI: 10.1002/art.39246]
16
Lalmohamed A, Vestergaard P, Klop C, Grove EL, de Boer A, Leufkens HG, van Staa TP, de Vries
F. Timing of acute myocardial infarction in patients undergoing total hip or knee replacement: a
nationwide cohort study. Arch Intern Med 2012; 172: 1229-1235 [PMID: 22826107 DOI:
10.1001/archinternmed.2012.2713]
17
Memtsoudis SG, González Della Valle A, Besculides MC, Gaber L, Sculco TP. In-hospital
complications and mortality of unilateral, bilateral, and revision TKA: based on an estimate of
4,159,661 discharges. Clin Orthop Relat Res 2008; 466: 2617-2627 [PMID: 18704616 DOI:
10.1007/s11999-008-0402-5]
18
Lakra A, Murtaugh T, Shah RP, Cooper HJ, Geller JA. Early Postoperative Pain Predicts 2-Year 19
Laoruengthana A et al. Unilateral vs bilateral TKA
WJO https://www.wjgnet.com 68 January 18, 2022 Volume 13 Issue 1
Functional Outcomes following Knee Arthroplasty. J Knee Surg 2020; 33: 1132-1139 [PMID:
31269524 DOI: 10.1055/s-0039-1692650]
Shetty GM, Mullaji A, Bhayde S, Chandra Vadapalli R, Desai D. Simultaneous bilateral vs unilateral
computer-assisted total knee arthroplasty: a prospective comparison of early postoperative pain and
functional recovery. Knee 2010; 17: 191-195 [PMID: 19786351 DOI: 10.1016/j.knee.2009.08.009]
20
Powell RS, Pulido P, Tuason MS, Colwell CW Jr, Ezzet KA. Bilateral vs unilateral total knee
arthroplasty: a patient-based comparison of pain levels and recovery of ambulatory skills. J
Arthroplasty 2006; 21: 642-649 [PMID: 16877148 DOI: 10.1016/j.arth.2005.08.009]
21
Nadler SB, Hidalgo JH, Bloch T. Prediction of blood volume in normal human adults. Surgery 1962;
51: 224-232 [PMID: 21936146]
22
Lindberg-Larsen M, Pitter FT, Husted H, Kehlet H, Jørgensen CC; Lundbeck Foundation Centre for
Fast-Track Hip and Knee Replacement Collaborative Group. Simultaneous vs staged bilateral total
knee arthroplasty: a propensity-matched case-control study from nine fast-track centres. Arch Orthop
Trauma Surg 2019; 139: 709-716 [PMID: 30840128 DOI: 10.1007/s00402-019-03157-z]
23
Chen SH, Chen JY, Wong TH, Buechel F Jr, Wu MH. Simultaneous Bilateral Total Knee
Arthroplasty Becomes Safer after Institution of Optimal Perioperative Management: A Longitudinal
Cohort Study. J Knee Surg 2021; 34: 941-951 [PMID: 31952092 DOI: 10.1055/s-0039-1700979]
24
Bagsby DT, Samujh CA, Vissing JL, Empson JA, Pomeroy DL, Malkani AL. Tranexamic Acid
Decreases Incidence of Blood Transfusion in Simultaneous Bilateral Total Knee Arthroplasty. J
Arthroplasty 2015; 30: 2106-2109 [PMID: 26235522 DOI: 10.1016/j.arth.2015.06.040]
25
Arora M, Singh S, Gupta V, Dongre A, Shetty V. Comparing the efficacy of intravenous or intra-
articular tranexamic acid in reducing blood loss in simultaneous bilateral knee replacement surgery
without the use of tourniquet. Eur J Orthop Surg Traumatol 2018; 28: 1417-1420 [PMID: 29594528
DOI: 10.1007/s00590-018-2194-y]
26
Meshram P, Palanisamy JV, Seo JY, Lee JG, Kim TK. Combined Intravenous and Intraarticular
Tranexamic Acid Does Not Offer Additional Benefit Compared with Intraarticular Use Alone in
Bilateral TKA: A Randomized Controlled Trial. Clin Orthop Relat Res 2020; 478: 45-54 [PMID:
31498264 DOI: 10.1097/CORR.0000000000000942]
27
Chalmers BP, Mishu M, Chiu YF, Cushner FD, Sculco PK, Boettner F, Westrich GH. Simultaneous
Bilateral Primary Total Knee Arthroplasty With TXA and Restrictive Transfusion Protocols: Still a 1
in 5 Risk of Allogeneic Transfusion. J Arthroplasty 2021; 36: 1318-1321 [PMID: 33190997 DOI:
10.1016/j.arth.2020.10.042]
28
Delasotta LA, Orozco F, Jafari SM, Blair JL, Ong A. Should We Use Preoperative Epoetin-α in the
Mildly Anemic Patient Undergoing Simultaneous Total Knee Arthroplasty? Open Orthop J 2013; 7:
47-50 [PMID: 23526659 DOI: 10.2174/1874325001307010047]
29
Suh DW, Han SB, Park JH, Cheong K, Kyung BS. Intravenous iron supplementation with intra-
articular administration of tranexamic acid reduces the rate of allogeneic transfusions after
simultaneous bilateral total knee arthroplasty. Blood Transfus 2017; 15: 506-511 [PMID: 27483483
DOI: 10.2450/2016.0051-16]
30
Skovgaard C, Holm B, Troelsen A, Lunn TH, Gaarn-Larsen L, Kehlet H, Husted H. No effect of
fibrin sealant on drain output or functional recovery following simultaneous bilateral total knee
arthroplasty: a randomized, double-blind, placebo-controlled study. Acta Orthop 2013; 84: 153-158
[PMID: 23350579 DOI: 10.3109/17453674.2013.769082]
31
Aggarwal AK, Shashikanth VS, Marwaha N. Platelet-rich plasma prevents blood loss and pain and
enhances early functional outcome after total knee arthroplasty: a prospective randomised controlled
study. Int Orthop 2014; 38: 387-395 [PMID: 24114251 DOI: 10.1007/s00264-013-2136-6]
32
Kuo SJ, Wang FS, Wang CJ, Ko JY, Chen SH, Siu KK. Effects of Computer Navigation vs
Conventional Total Knee Arthroplasty on Endothelial Damage Marker Levels: A Prospective
Comparative Study. PLoS One 2015; 10: e0126663 [PMID: 25955252 DOI:
10.1371/journal.pone.0126663]
33
Jhurani A, Agarwal P, Aswal M, Jain P, Malepati S, Sharma R. Computer navigation has no
beneficial effect on blood loss and transfusion in sequential bilateral total knee Arthroplasty. J Orthop
Surg (Hong Kong) 2019; 27: 2309499019832440 [PMID: 30803319 DOI:
10.1177/2309499019832440]
34
Liang L, Cai Y, Li A, Ma C. The efficiency of intravenous acetaminophen for pain control following
total knee and hip arthroplasty: A systematic review and meta-analysis. Medicine (Baltimore) 2017;
96: e8586 [PMID: 29145272 DOI: 10.1097/MD.0000000000008586]
35
Zhuo Y, Yu R, Wu C, Huang Y, Ye J, Zhang Y. The role of perioperative intravenous low-dose
dexamethasone in rapid recovery after total knee arthroplasty: a meta-analysis. J Int Med Res 2021;
49: 300060521998220 [PMID: 33685282 DOI: 10.1177/0300060521998220]
36
Gromov K, Troelsen A, Stahl Otte K, Ørsnes T, Husted H. Morbidity and mortality after bilateral
simultaneous total knee arthroplasty in a fast-track setting. Acta Orthop 2016; 87: 286-290 [PMID:
26823094 DOI: 10.3109/17453674.2016.1141631]
37
Reichlin T, Cullen L, Parsonage WA, Greenslade J, Twerenbold R, Moehring B, Wildi K, Mueller S,
Zellweger C, Mosimann T, Rubini Gimenez M, Rentsch K, Osswald S, Müller C. Two-hour
algorithm for triage toward rule-out and rule-in of acute myocardial infarction using high-sensitivity
cardiac troponin T. Am J Med 2015; 128: 369-79.e4 [PMID: 25446294 DOI:
10.1016/j.amjmed.2014.10.032]
38
Alattas SA, Smith T, Bhatti M, Wilson-Nunn D, Donell S. Greater pre-operative anxiety, pain and 39
