Bilateral TKR

Gabrielle Morris

50 yo man with complex co-morbidities for bilateral TKR’s

Background

  • HTN – BP 170/125 in clinic. Pt states this is high – usually in normal range
  • Asthma
  • Smoker 4g THC/ day
  • Ex IVDU methamphetamines and opioids (stopped meth for 2/12)

Issues

  • Dilated lateral ventricles with cerebral aqueduct stenosis following historical meningitis infection
    • Lost to neurological follow up and repeat MRI not performed
    • Non-specific symptoms – Long term memory issues. Headaches. 
    • Hypertension noted
  • Discussed with Neurosurgical team – Recommended MRI brain and cerebral flow studies to exclude obstructive hydrocephalus
    • Patient attended MRI – unfortunately radiology could not cannulate patient so test not performed 

Update: Bilateral TKR’s in an ASA 3 patient

  • Usually reserved for ASA 1 and 2 patients
  • Social reasons – This may be the only opportunity for this patient to access the surgery
  • Facilitate single hospital admission and rehabilitation given both knees are significantly affected 
  • Surgery booked for next week, after Easter holiday

Discussion

  • Literature shows some improved postoperative outcomes; cumulative decreased LOS, pain, costs, and improved rehabilitation. 
  • However – increased mortality and morbidity with bilateral cf unilateral, this increases further with increased BMI and ASA status
  • Many studies performed on ASA 1&2 patients!
  • Consensus statement from AOA recommends shared decision-making https://www.kneesociety.org.au/resources/AOA-AKS-Position-Statement-on-bilateral-tkr-2021.pdf
  • Not appropriate to proceed to surgery without MRI given potential contribution of cerebral pathology to balance and mobility issues

Plan

  • Re-attempt MRI with anaesthetic assistance for cannulation
  • May require postponement of surgery – difficult to have MRI done and reviewed before OT date with Easter long weekend