Intraoperative range of motion (ROM) radiographs are routinely taken during scaphoidectomy and four corner fusion surgery (S4CF) at our institution. It is not known if intraoperative ROM predicts postoperative ROM. We hypothesize that patients with a greater intra-operativeROM would have an improved postoperative ROM at one year, but that this arc would be less than that achieved intra- operatively. We retrospectively reviewed 56 patients that had undergone S4CF at our institution in the past 10 years. Patients less than 18, those who underwent the procedure for reasons other than arthritis, those less than one year from surgery, and those that had since undergone wrist arthrodesis were excluded. Intraoperative ROM was measured from fluoroscopic images taken in flexion and extension at the time of surgery. Patients that met criteria were then invited to take part in a virtual assessment and their ROM was measured using a goniometer. T-tests were used to measure differences between intraoperative and postoperative ROM, Pearson Correlation was used to measure associations, and linear regression was conducted to assess whether intraoperative ROM predicts postoperative ROM. Nineteen patients, two of whom had bilateral surgery, agreed to participate. Mean age was 54 and 14 were male and 5 were male. In the majority, surgical indication was scapholunate advanced collapse; however, two of the participants had scaphoid nonunion advanced collapse. No difference was observed between intraoperative and postoperative flexion. On average there was an increase of seven degrees of extension and 12° arc of motion postoperatively with p values reaching significance Correlation between intr-operative and postoperative ROM did not reach statistical significance for flexion, extension, or arc of motion. There were no statistically significant correlations between intraoperative and postoperative ROM. Intraoperative ROM radiographs are not useful at predicting postoperative ROM. Postoperative extension and arc of motion did increase from that measured intraoperatively

Introduction. The Patient's Dream is not to stay in hospital even overnight, including in limb lengthening. We developed the ‘Hyper Fast Track Protocol’ (HFTP) in 2015 to fasten recovery and shorten hospital stay. Materials and Methods. The protocol included surgical stab incisions, use of weight bearing lengthening nails (G-Nail), intramedullary saw, a specific anaesthesia care (blood hypo-pressure, tranexamic acid, low hydration), absence of early anticoagulants, systematic vascular US controls, but early motion (hip and knee Ext/Fle, leg raise, horizontal ‘scissors’), walking, stairs, bike, clicking (maneuvers to lengthen), early discharge, along with other patient's parameters. Timing and exercises reps were registered. Protocols improved over time. Means ± SD are computed. Results. Forms were analysed in 112 patients (unilateral 7, dwarfism 2, cosmetic 103). Besides patients operated in the afternoon (18), physio sessions initiated (h:mm) in average 0:46 ± 0:19 after awakening in operative room, for a duration of 2:15 ± 0:46. No DVT was noted on US nor clinically. In 2016, hospitalisation averaged 2.88 nights, decreasing to 2.07 in 2017, then to 1.07 from 2020. In late 2020 and in 2021, we had several patients in Daycare only, even in bilateral lengthening. In late 2021, we could discharge a patient after walking, full motion and exercises 3.5 hours after awakening from bilateral surgery. Conclusions. With continuous result monitoring and constant improvement of Care, walking, stairs, clicks and biking are fully feasible within 3h of surgery awakening, with discharge on the same day, using specific protocols

Since its creation, labral repair has become the preferred method among surgeons for the arthroscopic treatment of acetabular labral tears resulting in pain and dysfunction for patients. Labral reconstruction is performed mainly in revision hip arthroscopy but can be used in the primary setting when the labrum cannot be repaired or is calcified. The purpose of this study was to compare the survival between primary labral repair and labral reconstruction with survival defined as no further surgery (revision or total hip replacement). Patients who underwent labral repair or reconstruction between January 2005 and December 2018 in the primary setting were included in the study. Patients were included if they had primary hip arthroscopy with the senior author for femoroacetabular impingement (FAI), involving either labral reconstruction or labral repair, and were within the ages of 18 and 65 at the time of surgery. Exclusion criteria included confounding injuries (Leggs Calves Perthes, avascular necrosis, femoral head fracture, etc.), history of unilateral or bilateral hip surgeries, or Tönnis grades of 2 or 3 at the time of surgery. Labral repairs were performed when adequate tissue was available for repair and labral reconstruction was performed when tissue was absent, ossified or torn beyond repair. A total of 501 labral repairs and 114 labral reconstructions performed in the primary setting were included in the study. Labral reconstruction patients were older (37±10) compared to labral repair (34±11).(p=0.021). Second surgeries were required in 19/114 (17%) of labral reconstruction and 40/501(8%) [odds ratio: 2.3; 95% CI 1.3 to 4.2] (p=0.008). Revision hip arthroscopy were required in 6/114(5%) labral reconstructions and 33/501(6.5%) labral repair (p=0.496). Total hip replacement was required in 13/114 labral reconstructions and 7/501 labral repairs [odds ratio:9.1 95%CI 3.5 to 23] (p=< 0.01). The mean survival for the labral repair group was 10.2 years (95%CI:10 to 10.5) and 11.9 years (98%CI:10.9 to 12.8) in the labral reconstruction group. Conversion to total hip was required more often following primary labral reconstruction. Revision hip arthroscopy rates were similar between groups as was the mean survival, with both over 10 years. Similar survival was seen in labral repair and reconstruction when strict patient selection criteria are followed

Patients undergoing revision surgery of a primary total hip arthroplasty often exhibit bone loss and poor bone quality, which make achieving stable fixation and osseointegration challenging. Implant components coated in porous metals are used clinically to improve mechanical stability and encourage bone in-growth. We compared ultra-porous titanium coatings, known commercially as Gription and Porocoat, in an intra-articular model by press-fitting coated cylindrical implants into ovine femoral condyles and evaluating bone in-growth and fixation strength 4, 8 and 16 weeks post-operatively. Bilateral surgery using a mini-arthrotomy approach was performed on twenty-four Dorset-Rideau Arcott rams (3.4 ± 0.8 years old, 84.8 ± 9.3 kg) with Institutional Animal Care Committee approval in accordance with the Canadian Council on Animal Care. Cylindrical implants, 6.2 mm in diameter by 10 mm in length with surface radius of curvature of 35 mm, were composed of a titanium substrate coated in either Porocoat or Gription and press-fit into 6 mm diameter recipient holes in the weight-bearing regions of the medial (MFC) and lateral (LFC) femoral condyles. Each sheep received 4 implants; two Gription in one stifle (knee) and two Porocoat in the contralateral joint. Biomechanical push-out tests (Instron ElectroPuls E10000) were performed on LFCs, where implants were pushed out relative to the condyle at a rate of 2 mm/min. Force and displacement data were used to calculate force and displacement at failure, stiffness, energy, stress, strain, elastic modulus, and toughness. MFCs were fixed in 70% ethanol, processed undecalcified, and polished sections, approximately 70 µm thick (Exakt Micro Grinding system) were carbon-coated. Backscattered electron images were collected on a scanning electron microscope (Hitachi SU3500) at 5 kV and working distance of 5 mm. Bone in-growth within the porous coating was quantified using software (ImageJ). Statistical comparisons were made using a two-way ANOVA and Fisher's LSD post-hoc test (Statistica v.8). Biomechanical evaluation of the bone-implant interface revealed that by 16 weeks, Gription-coated implants exhibited higher force (2455±1362 N vs. 1002±1466 N, p=0.046) and stress (12.60±6.99 MPa vs. 5.14±7.53 MPa, p=0.046) at failure, and trended towards higher stiffness (11510±7645 N/mm vs. 5010±8374 N/mm, p=.061) and modulus of elasticity (591±392 MPa vs. 256±431 MPa, p=0.61). Similarly, by 16 weeks, bone in-growth in Gription-coated implants was approximately double that measured in Porocoat (6.73±3.86 % vs. 3.22±1.52 %, p=0.045). No statistically significant differences were detected at either 4 nor 8 weeks, however, qualitative observations of the exposed bone-implant interface, made following push-out testing, showed more bony material consistently adhered to Gription compared to Porocoat at all three time points. High variability is attributed to implant placement, resulting from the small visual window afforded during surgery, unique curvatures of the condyles, and presence of the extensor digitorum longus tendon which limited access to the LFC. Ultra-porous titanium coatings, know commercially as Gription and Porocoat, were compared for the first time in a challenging intra-articular ovine model. Gription provided superior fixation strength and bone in-growth, suggesting it may be beneficial in hip replacement surgeries where bone stock quality and quantity may be compromised

Background. Total hip arthroplasty (THA) is a highly successful procedure, yet access to arthroplasty is limited in many developing nations. In response, organizations around the world have conducted service trips to provide international arthroplasty care to underserved populations. Little outcomes data are currently available related to these trips. We present a 1-year follow up. Methods. We completed an arthroplasty service trip to Brazil in 2017 where we performed 46 THAs on 38 patients. Patient demographic data, comorbidity profile, complication data, and pre- and postoperative Modified Harris Hip Score (mHHS), PROMIS Short Form Pain (SF-Pain), PROMIS Short Form Physical Function (SF-Function), and HOOS Jr scores were collected. Outcomes were collected postoperatively at 2, 6, and 12 weeks and 1 year. A multivariate regression analysis was performed to identify associations between patient factors and 12-week outcomes. Results. The mean patient age was 48.8 years. 47% were female. 30 patients had a unilateral THA and 8 had bilateral simultaneous THA (table 1). 61% of patients had a preoperative diagnosis of osteoarthritis (OA), 13% avascular necrosis, 13% post-traumatic OA, 8% developmental hip dysplasia, and 5% rheumatoid arthritis. Mean pain duration was 1–5 years for 45% of patients and >5 years for 55% of patients. The mean mHHS, HOOS, PROMIS SF-Pain and PROMIS SF-Function all improved significantly compared to baseline at 2, 6, 12 weeks and 1 year post-operatively (table 2, figure 1 & 2). At 1 year, only 11 of 38 patients (29%) were reachable by phone for follow up. The mobile phones were out of service for 27 of 38 patients (71%). Multivariate regression analysis did not reveal any associations at 12 weeks between patient reported outcomes and age, gender, pain duration, preoperative diagnosis or unilateral versus bilateral surgery (table 3). Conclusion. We found that patients in a developing country benefitted significantly from THA when performed by a visiting surgical team. Outcomes were similar to those seen in the United States. Of those that could be contacted, outcomes were stable at 1 year. This study highlights the difficulty of following patients in developing countries once they leave the hospital. Methods need to be developed to assure that the outcomes of these potentially valuable procedures can be determined. We are currently establishing the capability of using email and smart phone applications linked through email addresses to improve follow up on future missions

Total hip and knee arthroplasty is known to have a significant blood loss averaging 3–4 g/dL. Historically, transfusion rates have been as high as 70%. Despite years of work to optimise blood management, some published data suggests that transfusion rates (especially with allogeneic blood) are rising. There is wide variability between surgeons as well, suggesting that varying protocols can influence transfusion rates. Multiple studies now associate blood transfusions with negative outcomes including increased surgical site infection, costs, and length of stay. Preoperative measures can be employed. Identify patients that are at increased risk of blood transfusion. Smaller stature female patients, have pre-operative anemia (Hgb less than 13.0 gm/dl), or are undergoing revision or bilateral surgery are at high risk. We identify these patients and check a hemoglobin preoperatively, using a non-invasive finger monitor for screening. For anemic patients, iron administration (oral or IV) can be given, along with Procrit/Epogen in select cases. Insurance coverage for that medication has been challenging. Intraoperative measures that have been linked to reduced postoperative transfusions include regional anesthesia and intraoperative hypotension (mean arterial pressure <60mm/hg). Lowering the surgical time by practicing efficient, organised, and quality surgery, along with leaving a dry field at the completion of surgery can reduce blood loss. Tranexemic acid (TXA) is an antifibrinolytic agent that has been shown to be effective, reducing average blood loss by 300 cc per case. There are multiple different administration protocols: IV using either a weight-based dosing 10–20 mg/kg or standardised dosing for all patients. Our current regimen is 1 gm IV preoperatively, 1 gm IV in PACU. Topical TXA can be used, usually 2–3 gm mixed in 50–100 cc of saline, sprayed in wound and allow to soak for 3–5 minutes. Oral administration is attractive for ease of use and reduced cost, standard oral dosing is 1950 mg PO 2 hours prior to surgery. The American Association of Hip and Knee Surgeons, in collaboration with the American Association of Orthopedic Surgeons, American Society of Regional Anesthesiologists, and the Hip & Knee Society have developed a Clinical Practice Guideline with 8 recommendations for TXA as follows: All individual formulations are effective at reducing blood loss – strong; No method of administration is clearly superior at reducing blood loss and the risk of transfusion; The dose of IV or topical TXA does not significantly affect the drug's ability to reduce blood loss and risk of transfusion; Multiple doses of IV or oral TXA compared to a single dose does not significantly alter the risk of blood transfusion; Pre-incision IV TXA administration potentially reduces blood loss and risk of transfusion compared to post-incision administration; Administration of all TXA formulations in patients without history of VTE does not increase the risk of VTE; Administration of all TXA formulations in patients with a history of VTE, MI, CVA, TIA, or vascular stent does not appear to increase the risk of VTE; Administration of all TXA formulations does not appear to increase the risk of arterial thrombotic events; Postoperative measures to reduce transfusion rates include changing transfusion triggers. Instead of treating a “number”, use lower thresholds and employ safe algorithms established. In conclusion, a comprehensive blood management program can reduce transfusion rates to less than 3% for THA and 1% for TKA and facilitate outpatient total joint arthroplasty

Background. Total hip replacement is a highly successful procedure, yet access to arthroplasty is limited in many developing nations. In response, organizations in the United States have conducted service trips to provide international arthroplasty care to underserved populations. Little outcomes data are currently available related to these trips. We aimed to assess patient outcomes following total hip arthroplasty performed on a surgical mission trip. Methods. We completed an arthroplasty service trip to Brazil during which we performed 46 total hip arthroplasties (THA) on 38 patients. Patient demographic data, comorbidity profile, complication data, and pre- and postoperative Modified Harris Hip Score (mHHS), PROMIS Short Form Pain (SF-Pain), PROMIS Short Form Physical Function (SF-Function), and HOOS Jr scores were collected. Baseline and final follow-up scores were compared. In addition, we utilized a novel questionnaire that was designed to determine outcomes most relevant to patients receiving joint replacements in developing countries. A multivariate regression analysis was performed to identify associations between patient factors and outcomes. Results and Discussion. The mean patient age was 48.8 years, and 47% were female. 30 patients had a unilateral THA and 8 had bilateral simultaneous THA. 61% of patients had a preoperative diagnosis of osteoarthritis (OA), 13% avascular necrosis, 13% post-traumatic OA, 8% developmental hip dysplasia, and 5% rheumatoid arthritis. Mean pain duration was 1–5 years for 45% of patients and >5 years for 55% of patients. The mean mHHS, HOOS, PROMIS SF-Pain and PROMIS SF-Function all improved significantly compared to baseline at 2 and 6 weeks post-operatively. Multivariate regression analysis did not reveal any associations between patient reported outcomes and age, gender, pain duration, preoperative diagnosis or unilateral versus bilateral surgery. Subjective questionnaires at 12 weeks postoperatively revealed that surgery met expectations for 94% of patients; 97% of patients had as much pain relief as they expected; 45% of patients had no physical limitations; 82% of patients were not taking any medications for their hip (18% used occasional NSAIDs); 82% of patients gained new independence at home; and 97% felt their overall quality of life improved significantly. Two patients had postoperative periprosthetic femur fractures requiring an ORIF. One patient had a DVT requiring 6 months of anticoagulation. Conclusion. We found that patients in a developing country benefitted significantly from total hip arthroplasty when performed by a visiting surgical team, with acceptable complication profiles. Validated legacy outcome measures show improvements in pain and function after THA similar to those observed in patients in the United States. Additionally, the results of our questionnaire help to identify outcomes of specific interest to developing countries with relatively limited resources, particularly regaining functional independence after THA

Approximately 20% of patients undergoing primary unilateral total knee arthroplasty complain of severe pain in the contralateral knee, and 10% of patients who have had a primary total knee (TKA) undergo contralateral surgery within 1 year. The number of patients suitable for primary TKA is rising, and so is the need for simultaneous bilateral TKA (BTKA) procedures. The advantages of single-stage BTKA include its low complication rates, high patient satisfaction, and cost-effectiveness. Others believe that there is increased morbidity and mortality. The goal of reducing the exposure to repeated anaesthesia, total hospitalization and recovery time, and cost, while maintaining patient safety, is a laudable one. Our data suggest that bilateral TKA patients have a lower total operating time, use less pain medication, have a shorter hospital stay and lower overall treatment costs. The cohort of patients selected for bilateral surgery in our unit is younger and has fewer comorbidities than unilateral controls. They have a high satisfaction rate and no increase in complication or readmission rates. We have seen a higher blood transfusion rate but no increase in cardiac, thromboembolic or septic complications. The key to BTKA is patient selection and the implementation of efficient care and surgical pathways that includes a thorough pre-assessment, careful education and well-resourced aggressive post-operative physiotherapy. When appropriately applied, the benefits include a shorter overall recovery time and an accelerated return to everyday life and work

Venous thromboembolism (VTE) prophylaxis following total joint arthroplasty (TJA) should be individualised in order to maximise the efficacy of prophylactic measures while avoiding the adverse events associated with the use of anticoagulants. At our institution, we have developed a scoring model using the Nationwide Inpatient Sample (NIS) database, which is validated against our institutional data, to stratify patients into low- and high-risk groups for VTE. Low-risk patients are placed on aspirin 81 mg twice daily for four weeks post-operatively, and high-risk patients are placed on either a Vitamin K antagonist (warfarin), low molecular weight heparin, or other oral anticoagulants for four weeks post-operatively. All patients receive sequential pneumatic compression devices post-operatively, and patients are mobilised with physical therapy on the day of surgery. Patients who have a history of peptic ulcer disease or allergy to aspirin are also considered for other types of anticoagulation following surgery. Risk Stratification Criteria. Major comorbid risk factors utilised in our risk stratification model include history of hypercoagulability or previous VTE, active cancer or history of non-cutaneous malignancy, history of stroke, and pulmonary hypertension. We consider patients with any of these risk factors at elevated risk of VTE and therefore candidates for formal anticoagulation. Other minor risk factors include older age, bilateral surgery compared with unilateral, inflammatory bowel disease, varicose veins, obstructive sleep apnea, and history of myocardial infarction, myeloproliferative disorders, and congestive heart failure. Each minor criterion is associated with a score. The cumulative score is compared with a defined threshold and the score that surpasses the threshold indicates that the patient should receive post-operative anticoagulation. To facilitate the use of this scoring system, an iOS mobile application (VTEstimator) has been developed and can be downloaded from the app store

Introduction. Rapid recovery protocols (RRP) for joint replacements have been shown to improve efficiency, reduce costs, and minimize adverse outcomes in academic health systems. The purpose of this study is to evaluate if RRP can be safely implemented in a community health system for total knee arthroplasty. Methods. This study used a retrospective cohort of 3,608 patients who underwent primary unilateral total knee arthroplasty from January 1, 2013 to December 31, 2014. 60 Patients were excluded because data or surgery could not be verified: BMI less than 18.5 or greater than 60 kg/m∘2 or if the surgical time was less than 45 seconds or greater than 180 minutes, and bilateral surgery. Data was obtained from querying the health system's inpatient database containing information for all joint replacements within the system. Patients were compared in two groups: those who received a RRP after surgery versus those who received traditional post-op care. The main outcome measure was all-cause 30-day readmissions. Multivariate logistic regression was used to calculate the odds for all-cause 30-day readmission for patients who received RRP versus traditional care when controlling for age, gender, race, insurance status (Medicare versus no Medicare), obesity, diabetes, renal disease, tobacco use, and ASA score (less than 3 versus 3 or greater). Results. Patients receiving RRP were readmitted less than those who received traditional care (1.6% versus 3.6%, p<0.001) and had a lower mean length of stay (1.5 versus 3.3 days, p<0.001). When controlling for confounding factors, the odds of 30-day readmission for patients receiving RRP versus traditional care was 0.42 (95% CI 0.26–0.66, p<0.001). Conclusions. Rapid recovery protocols are an effective means of reducing 30-day readmissions and length of stay in patients undergoing primary unilateral total knee arthroplasty in a community setting

To consider bilateral simultaneous knee replacement, both knees must have significant structural damage. It is best if the patient can't decide which knee is more bothersome. In borderline cases, ask the patient to pretend that the worse knee is normal and if so, would they be seeing you for consideration of knee replacement on the less involved side. If the answer to this question is “yes,” consider the patient a potential candidate for bilateral knee replacement. If the answer is “no,” recommend operating only on the worse knee, and expect that the operation on the second knee can probably be delayed for a considerable period of time. Strong indications for bilateral simultaneous TKA are bilateral severe angular deformity, bilateral severe flexion contracture, and anesthesia difficulties, i.e., patients who are anatomically or medically difficult to anesthetise, such as some adult or juvenile rheumatoid arthritis patients or patients with severe ankylosing spondylitis. Relative indications for bilateral simultaneous TKA include the need for multiple additional surgical procedures to achieve satisfactory function and financial or social considerations for the patient. Contraindications to bilateral TKA include medical infirmity (especially cardiac), a reluctant patient, and a patient with a very low pain threshold. When performing bilateral simultaneous TKA, both limbs are prepped and draped at the same time. An initial dose of an intravenous antibiotic is given (usually 1g of a cephalosporin) before inflation of the tourniquet. Surgery begins on the more symptomatic side or on either side if neither knee is significantly worse than the other. The reason for starting on the more symptomatic side is in case surgery has to be discontinued after only one procedure owing to anesthetic considerations. After the components have been implanted on the first side, the tourniquet is deflated and a second dose of intravenous antibiotic is administered (usually 500mg of a cephalosporin). After the joint capsule is closed and flexion against gravity is measured, one team completes the subcutaneous and skin closure on the first side while the other team inflates the second tourniquet and begins the exposure of the second side. When the second tourniquet is deflated, a third dose of antibiotic is given (usually 500mg of a cephalosporin for a total dose of 2g for both knees). Because of concern about the potential for cross-contamination of the knee wounds when instruments used during the final stages of skin closure on the first knee are maintained on the field and used on the second knee, they should probably be handed off the field and outer surgical gloves changed. Most patients will report after their complete recovery that they are glad they did both knees at the same time. A patient who has any uncertainty about proceeding with bilateral surgery should have only one knee done at a time. In many cases, the second side receives a “reprieve,” becoming more tolerable after the first side has been operated on

The purpose of this study was to investigate whether patients who had had excision of the Ligamentum Teres as part of a surgical hip dislocation for femoro-acetabular impingement exhibited symptoms of acute Ligamentum Teres rupture post-operatively. Recent reports in the literature suggest that injury to the Ligamentum Teres can cause instability, severe pain and inability to walk. We present the results of a postal questionnaire to 217 patients who had undergone open surgical hip dislocation for femoro-acetabular impingement where the LT was excised. This included seven patients who had undergone bilateral surgery. The questionnaire was designed to enquire about specific symptoms attributed to LT injuries in the literature; gross instability, incomplete reduction, inability to bear weight and mechanical symptoms. 161 patients responded (75%), with a total of 168 (75%) questionnaires regarding 224 hips completed. There were 104 females and 64 males. Median age was 34 and median follow-up was 52 months. All patients were found to have cam deformities, 72% (n=121) had associated labral tears. All patients were able to fully weight bear after surgery. 77% experienced no groin pain and 61% experienced no pain on exercise. 35% of patients experienced popping and locking in their operated hip and 24% had subjective feeling of their hip giving way. Oxford Hip scores and Nonarthritic Hip scores improved by 12 and 28 points respectively (n=47). Our results show that the symptoms of pain and instability described with LT pathology can be present but are by no means universal. This leads us to conclude that their symptoms may be attributed to labral pathology which is frequently noted to coexist

To consider bilateral simultaneous knee replacement, both knees must have significant structural damage. It is best if the patient can't decide which knee is more bothersome. In borderline cases, ask the patient to pretend that the worse knee is normal and if so, would they be seeing you for consideration of knee replacement on the less involved side. If the answer to this question is “yes,” consider the patient a potential candidate for bilateral knee replacement. If the answer is “no,” recommend operating only on the worse knee, and expect that the operation on the second knee can probably be delayed for a considerable period of time. Strong indications for bilateral simultaneous TKA are bilateral severe angular deformity, bilateral severe flexion contracture, and anesthesia difficulties, i.e., patients who are anatomically or medically difficult to anesthetise, such as some adult or juvenile rheumatoid arthritis patients or patients with severe ankylosing spondylitis. Relative indications for bilateral simultaneous TKA include the need for multiple additional surgical procedures to achieve satisfactory function and financial or social considerations for the patient. Contraindications to bilateral TKA include medical infirmity (especially cardiac), a reluctant patient, and a patient with a very low pain threshold. When performing bilateral simultaneous TKA, both limbs are prepped and draped at the same time. An initial dose of an intravenous antibiotic is given (usually 1 gram of a cephalosporin) before inflation of the tourniquet. Surgery begins on the more symptomatic side or on either side if neither knee is significantly worse than the other. The reason for starting on the more symptomatic side is in case surgery has to be discontinued after only one procedure owing to anesthetic considerations. After the components have been implanted on the first side, the tourniquet is deflated and a second dose of intravenous antibiotic is administered (usually 500 mg of a cephalosporin). After the joint capsule is closed and flexion against gravity is measured, one team completes the subcutaneous and skin closure on the first side while the other team inflates the second tourniquet and begins the exposure of the second side. When the second tourniquet is deflated, a third dose of antibiotic is given (usually 500 mg of a cephalosporin for a total dose of 2 g for both knees). Because of concern about the potential for cross-contamination of the knee wounds when instruments used during the final stages of skin closure on the first knee are maintained on the field and used on the second knee, they should probably be handed off the field and outer surgical gloves changed. Most patients will report after their complete recovery that they are glad they did both knees at the same time. A patient who has any uncertainty about proceeding with bilateral surgery should have only one knee done at a time. In many cases, the second side receives a “reprieve,” becoming more tolerable after the first side has been operated on

Bilateral simultaneous total knee replacement surgery remains controversial with arguments for and against its use. Doing sequentially staged TKR's is a safer procedure and may have additional benefits as set out below. If both knees need to be replaced we have often seen that the symptoms of the contralateral knee improve after the one knee is replaced and that patients wait some time before having the opposite knee replaced. Materials:. 333 of 2084 patients having primary total knee replacements needing bilateral replacements were reviewed retrospectively. Results. 245 patients were seen initially with bilateral arthritis of the knee and needed bilateral TKR, while 88 patients developed arthritis in the contralateral knee following TKR. No patients had simultaneous bilateral TKR's; operations were done sequentially and the average time between the TKRs was 20.77 months with a range between 1.5–111 months. Most patients had the contralateral knee replaced within two years of the first knee replacement but 81 patients actually waited between 2 and 10 years before coming in for the second TKR. Conclusion:. It is possible to wait some time before it becomes necessary to replace the contralateral knee in patients who need bilateral TKRs and avoid the increased risk of bilateral simultaneous surgery. The delay not only reduces the cost for the first operation but also gives the second knee a longer time to failure. This is especially important in the typical patients who qualify for bilateral simultaneous TKR's i.e. the younger fitter patients