Simultaneous bilateral total knee and ankle arthroplasty as a single surgical procedure
© Pagenstert and Hintermann; licensee BioMed Central Ltd. 2011
Received: 18 March 2011
Accepted: 13 October 2011
Published: 13 October 2011
Simultaneous osteoarthritis (OA) of the ankle joint complicates primary total knee arthroplasty (TKA). In such cases, rehabilitation of TKA is limited by debilitating ankle pain, but varus or valgus ankle arthritis may even compromise placement of knee prosthetic components.
We present a patient with simultaneous bilateral valgus and patellofemoral OA of the knees and bilateral varus OA of the ankle joints that equally contributed to overall disability. This 63 years old, motivated and otherwise healthy patient was treated by simultaneous bilateral total knee and ankle arthroplasty (quadruple total joint arthroplasty, TJA) during the same anesthesia. Two years outcome showed excellent alignment and function of all four replaced joints. Postoperative time for rehabilitation, back to work (6th week) and hospital stay (12 days) of this special patient was markedly reduced compared to the usual course of separate TJA.
Simultaneous quadruple TJA in equally disabling OA of bilateral deformed knees and ankles resulted in a better functional outcome and faster recovery compared to the average reported results after TKA and TAA in literature. However, careful preoperative planning, extensive patient education, and two complete surgical teams were considered essential for successful performance. To the best of our knowledge this is the first case report in literature about quadruple major total joint arthroplasty implanted during the same anesthesia in the same patient.
Total joint arthroplasty (TJA) of the knee (TKA) and ankle (TAA) are well established procedures demonstrated to provide good long-term results in terms of reduced pain and increased function [1, 2]. In the presence of bilateral osteoarthritis (OA) of the knees and ankles contributing equally to cumulative gait inability in the same patient, surgical treatment of all four joints may be indicated. Surgery can be accomplished in a staged fashion or as a simultaneous procedure under one anesthesia to shorten disability and rehabilitation time that would accumulate with sequential TJA.
To our knowledge, there have been no special reports on simultaneous bilateral TAA and outcome was usually incorporated in overall reports on TAA . In contrast, bilateral TKA have been extensively discussed in literature [3–8]. Simultaneous bilateral TKA has been shown to be associated with higher complication rates than staged bilateral or unilateral TKA . However, reduction in costs and rehabilitation time and improvement of surgical technique [5, 10] with critical patient selection [4, 8] has led to significant reduction of complications and further recommendation of the simultaneous procedure [4, 5, 8]. Current studies found even better functional outcome and patient survival in simultaneous bilateral TKA compared to unilateral TKA [11, 12].
We present the unusual case of a patient who had bilateral valgus and patellofemoral OA of the knees and bilateral varus OA of the ankle joints that equally contributed to overall disability. This highly motivated and otherwise healthy patient was treated by simultaneous bilateral total knee and ankle arthroplasty in the same anesthesia. Our patient was informed that data concerning the case would be submitted for publication, and he consented.
A sixty-three-year-old executive consultant manager presented to us with known osteoarthritis (OA) in both ankles and knees since years and incremental debilitating pain since months. Valgus-extension contracture in both knees and varus-equines contracture in both ankles have reduced his maximum walking distance to about 1 km in 20 min despite crutches, bilateral custom-made lower leg orthotics and daily pain medication. He was increasingly restricted to work at his home office; needed two crutches to rise from a chair, because of bilateral knee pain; descended stairs backwards, because of bilateral knee and ankle pain. His history revealed an otherwise healthy patient, no medications other than for pain, height 178 cm, weight 92 kg, with status post right knee arthroscopic joint lavage and medial meniscectomy about 12 years ago, and repetitive ankle sprains since youth which have been managed non-surgically. Physical therapy and multiple intraarticular injections with steroids and anesthetics have lost its long-term benefit at each of the four joints. To continue his own business he was seeking surgical help.
Lower leg casts have been exchanged to control wound healing and to remove sutures of both ankles by the family physician 2 weeks after surgery. Final cast removal has been done 2 months after surgery. All wounds healed uneventfully; all joints were stabile without effusion. Range of motion was documented for knees extension/flexion 0-0-120°, and ankles dorsi-/plantarflexion 10-0-30°. Plain standing radiographs showed correct alignment and no signs of loosening of any implant. Compressive stockings were prescribed, phenprocoumon continued to a total of 5 months postoperative, physical therapy extended to the ankles and reappointment was set at one year after surgery. The patient went back to full work capacity 3 months after surgery, has discontinued all pain medications, and was able (for the first time since years) to finish 18 holes golf course by feet (in 5 hours walking on uneven ground, using regular hiking boots) 6 months after surgery.
This special case illustrates that simultaneous bilateral TKA and TAA as a quadruple procedure reduced disability without major complications. To our knowledge, there have been no previous reports of a simultaneous quadruple major TJA in the literature.
In contrast, simultaneous TJA of two joints (simultaneous knees, simultaneous hips, simultaneous ipsilateral hip and knee during one anesthesia) versus staged bilateral TJA during different anesthesias have been studied extensively. Two TJA during one anesthesia was found to offer a multitude of advantages including patient convenience, shorter disability and recovery periods, and reduced costs for patients and institutions [3, 6, 8]. Our case report supports these findings. Currently knee flexion can be expected to be on average between 110 and 125° with excellent results in 70% of cases [1, 9]. Our patient was able to flex to 150° with at most times "forgotten" TKAs. For the ankles outcome is less predictable. According to current reports, average outcomes have been reported as: combined dorsi-plantarflexion ROM of about 22.7°, AOFAS-score of 78.2 points, decreased but persistent mild pain, and an excellent result in only about 38% of cases . Our patient had left ankle: no pain, ROM 55°, AOFAS-score 97; right ankle: mild intermittent pain, ROM 45°, AOFAS-score 81 points. This superior outcome after quadruple TJA may be caused in part by positive interaction of simultaneous replacements of all disabled joints as it has been described elsewhere [3, 16, 17]. However, in our special patient, we have to quote the strong commitment to gain independent walking ability and get back to work.
Simultaneous bilateral TKA has been found significant more often associated with severe perioperative complications as myocardial infarction, pulmonary emboli or even mortality when compared to staged bilateral TKA in patients with co-morbidities and age over 70 years [4, 8]. However, in healthy and younger candidates, like our patient, no elevated risk has been detected . The accumulated surgical trauma and blood loss of the simultaneous approach during one anesthesia was thought to exceed the capacity mounting compensatory physiological responses in morbid and old aged patients.
It has been shown that medical complications of simultaneous bilateral TKA can be reduced by meticulous planning together with the anesthesiologist . Adjusted tourniquet use  and operation-time less than 2.5 hours per TKA  was reported to significantly reduce blood loss, infection, and revision surgery [5, 18]. Total operating time of our patient was 2 h 29 min and 1270 ml blood loss of all four TJA during first 48 h postoperatively. This was comparable to an average operation-time of 2 h 16 min  and 1299 ml blood loss for two TKA per 48 h . However, pulmonary embolism remains the leading cause of perioperative mortality and morbidity in patients undergoing TKA . During TKA we used overdrilling of the femoral entry hole and irrigation of the femoral canal before insertion of the fluted intramedullary alignment rod. This technical details have been shown in literature to significantly reduce production of embolic loads . In addition, we used intraoperative catheter monitoring of arterial and pulmonary arterial pressures for early detection of relevant disturbances to abort transition to next TJA, if necessary . Finally, administration of oral warfarin for 3 months after TKA have been found to reduce effectively postoperative and delayed thrombembolic events . Our patient received phenprocoumon for 5 months postoperative to decrease risk of thromembolic complications during rehabilitation.
OA of more than two major weight bearing joints in the same patient, i.e. bilateral hip and knee OA, have been always managed sequentially in the past . However, the non-operated hip or knee joint was left deformed or restricted in mobility. It has been reported that such decreased joint function negatively influences joint posture, locomotion and overall rehabilitation of the replaced joints, frequently causing recurrence of flexion contracture at the replaced hip or knee joints [3, 10, 15]. Therefore quadruple TJA staged to ipsilateral simultaneous total hip and knee with a short interval of two weeks between both sides have been recommended . This relatively short period seemed to be a reasonable compromise between the two aims of multiple TJA: long enough time-interval between TJA to allow regeneration from surgical trauma to reduce medical morbidity and mortality down to rates of single TJA; but short enough to prevent limited rehabilitation capacity and consecutive adhesions caused by the neglected arthritic joints. Recently, Farquhar and Snyder-Mackler showed in a prospective comparative study that the functional condition of the non-operated knee was the primary predictor of the functional outcome after unilateral TKA . However, there is no literature to support that both TJA during one anesthesia has advantages over a short two weeks interval between both TJA [3, 10, 15]. Based on these findings it seems to be crucial to treat al disabled major joints of one patient within a short time interval to increase functional overall outcome but control fatal medical complications. When we would consider sequential TJA for combined knee and ankle OA in our patient, a correct TKA done without treatment of the ankle would have increased the varus deformity of the ankle and might have hindered full weight bearing of the limb. On the other hand a primary TAA would have experienced a change in alignment during secondary TKA. Therefore, primary TKA with consecutive TAA during one anesthesia seems to be most advantageous in such setting.
The recommended sequence during multiple TJA at the same limb was proposed to implant "from proximal to distal" to control alignment. For example, a deformed arthritic hip may confuse proper placement of femoral knee implant if TKA is done before THA. On the other hand, even a correct aligned primary TKA may experience a critical change in alignment during secondary THA . Although we could not find a report about TKA and TAA during one anesthesia in the literature, we believe that severely deformed ankle OA may have a similar influence on TKA as described for hip OA. However, in our case there were no huge deformities at the knee or tibial shaft, therefore one surgical team worked at the ankle and the other simultaneously at the knee to decrease disturbance between teams, decrease instruments on the operative tables, and increase speed of overall surgical time. Therefore at the right leg the TAA was done before TKA. In addition, postoperative limb alignment was equal to the left side because alignment was adjusted to the tibial shaft in TAA and TKA. Therefore the rule to replace major joints from proximal to distal may be less important in combined TKA and TAA.
Replacements of deformed and disabled arthritic knee and ankle joints within a short period of time have beneficial influences on each other and improve overall rehabilitation and patients' outcome. However, primary decision for simultaneous TJA should be based on the medical condition of the patient to tolerate multiple surgical trauma.
total knee arthroplasty
total joint arthroplasty
total ankle arthroplasty
visual analogue scale
range of motion
intensive care unite
international normalized ratio
score of the American Orthopaedic Foot and Ankle Society
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