Shelbourne Knee Center: Spring 2024 Newsletter

KNEE TREATMENT NEWS

RESEARCH-BASED INSIGHTS THAT MAXIMIZE PATIENT OUTCOMES

SIMULTANEOUS BILATERAL TKA: THE BEST CHOICE FOR SOME PATIENTS

Severe osteoarthritis in both knees was making it difficult for Ron Bigler to do the activities he enjoyed, and even painful for him to walk and climb stairs. When the 61-year-old decided that he

had had enough, he traveled from Henderson, Texas, to Shelbourne Knee Center in Indianapolis for treatment. “Ron came a long way to see us because he believed in our protocol,” says Rodney Benner, MD,

an orthopedic surgeon at Shelbourne Knee Center.

Shared Decision-Making

After examining Bigler’s knees with a thorough knee exam and X-rays, Dr. Benner confirmed that Bigler had severe osteoarthritis in both knees. Other than the osteoarthritis, Bigler was generally healthy. Since he met Dr. Benner’s medical criteria for simultaneous bilateral total knee arthroplasty (TKA), they discussed that option and staged unilateral TKA, including an overview of the pros and cons of each option.

Bigler chose to have one operation and one recovery period. “Ron is a little younger than our average TKA patient. He’s an active guy in great shape who’s otherwise very healthy. Functionally and emotionally, Ron was able to handle doing both at the same time,” says Dr. Benner.

On December 1, 2023, Dr. Benner performed simultaneous bilateral TKA on Bigler. Within a few months, Bigler began to show considerable improvement in his range of motion and functioning, and he had considerably less pain, as measured objectively and using the Osteoarthritis Outcome Score survey.

“Ron tolerated the pain well and followed the rehab protocol exactly,” says Dr. Benner. “He was an ideal patient.”

Safe and Effective for the Right Patients

While controversy exists over simultaneous versus staged bilateral TKA, for properly selected patients like Bigler, and in the hands of an

RODNEY BENNER, MD

SIMULTANEOUS BILATERAL TKA: THE BEST CHOICE FOR SOME PATIENTS

experienced surgeon like Dr. Benner, the simultaneous procedure is safe and effective. Each year, Dr. Benner performs up to 30 simultaneous bilateral TKAs.

Many orthopedic surgeons do not perform simultaneous bilateral TKA due to a perceived higher risk of major complications. Dr. Benner believes that the risks of the simultaneous procedure are only slightly higher than the risks of staged procedures.

Surgical advances, such as roboticassisted TKA and the perioperative use of tranexamic acid, have reduced major complications in all TKAs.

Key Criteria for Simultaneous Bilateral TKA

• Severe osteoarthritis in both knees, as confirmed on X-ray

• Severe symptoms in both knees

• General good health

• Patient preference for simultaneous bilateral TKA

• Contraindications:

- Cardiovascular risk factors

- Diabetes

- History of blood clots

About 10% of Shelbourne Knee Center patients who are candidates for bilateral knee replacement choose a simultaneous procedure.

Benefits of Simultaneous Bilateral TKA

• Shorter overall duration of treatment

• One surgery, one anesthetic and one recovery period

• Shorter hospital stay

• Less physical and emotional burden

• Earlier return to normal activities

Robotic-assisted TKA reduces pain and bleeding by eliminating the need for an alignment rod. Tranexamic acid minimizes blood loss and the need for transfusion, along with reducing the number of infections.

Shelbourne Knee Center’s pain management protocol for all TKAs helps patients recover faster and with less pain. Key elements of the protocol are:

• Prevention of postoperative swelling

• Seven days of bed rest

• Use of a continuous passive motion machine

• Use of a Cryo-Cuff.

In the hospital, TKA patients receive a low-dose continuous infusion of Toradol (ketorolac) to control inflammatory pain, which has reduced the use of opioids by 85%. That, in turn, has reduced opioid-associated adverse effects.¹ Patients also take Tylenol, and after completing Toradol they take the NSAID Mobic (meloxicam). As needed, they also can take Tramadol or Norco (a combination of acetaminophen and hydrocodone, an opioid). “Very seldom do our patients need IV opioid pain medications,” says Dr. Benner.

With less pain, patients can make more progress in Shelbourne Knee Center’s research-based post-op rehab program, which focuses on restoring range of motion followed by strengthening. Each patient works with the same physical therapist or athletic trainer throughout their treatment. They complete most of their physical therapy at home, with periodic visits to the center.

Considerations in Patient Selection

Severe osteoarthritis, symptoms in both knees and generally good health are the key medical considerations for Dr. Benner in recommending

“ OUR EXPERIENCE ENABLES US

TO IDENTIFY PATIENTS WHO ARE MOST LIKELY TO BE ABLE TO TOLERATE SIMULTANEOUS BILATERAL TKA AND PATIENTS FOR WHOM STAGED TKA IS A BETTER OPTION.”

Rodney Benner, MD

simultaneous versus staged bilateral TKA for a patient. While younger, healthier patients are more likely to be candidates for the simultaneous procedure, sometimes older patients who are healthy do better than younger patients who are less healthy.

For healthy patients with deformities such as genu valgum, genu varum or flexion contractures, Dr. Benner is more likely to recommend simultaneous bilateral TKA. “If you correct the deformity on one side but not the other, the legs aren’t even and the patient will have trouble getting around,” he says.

Patient preference is also a key consideration. Some patients are concerned about the pain and longer recovery period with simultaneous bilateral TKA. Others, like Bigler, prefer to face only one procedure and one recovery period.

“Recovery from simultaneous bilateral TKA is longer than recovery from unilateral TKA, but it’s not twice as long,” says Dr. Benner. “The early post-op period is worse but when patients recover, they don’t have to start all over again on the other knee.”

REFERENCES

1. Schwinghammer AJ, Isaacs AN, Benner RW, et al. Continuous Infusion Ketorolac for Postoperative Analgesia Following Unilateral Total Knee Arthroplasty. Ann Pharmacother. 2017 Jun;51(6):451-456. doi: 10.1177/1060028017694655. Epub 2017 Feb 1.

KEY MEASURABLE FACTORS IN FASTER RETURN TO SPORT AFTER ACL RECONSTRUCTION

PHYSICAL THERAPISTS can help anterior cruciate ligament (ACL) reconstruction patients return to sport faster and safely by focusing on achieving symmetric knee extension range of motion (ROM) and symmetric quadriceps strength. Researchers identified those two modifiable factors as most important in earlier return to sport in a retrospective study of 569 patients who had ACL reconstruction at Shelbourne Knee Center (SKC). They also found three non-modifiable factors that impact the timing of return to sport: age, BMI and whether the surgeon used a contralateral patellar tendon graft.

“By focusing earlier in physical therapy on the measurable factors we identified, PTs can help their athletes succeed,” says Scot Bauman, PT, DPT, PhD, a clinical researcher at SKC. Bauman conducted the study with Bill Claussen, MPT, K. Donald Shelbourne, MD, and Rodney Benner, MD. The results were presented at the 2024 American Physical Therapy Association Combined Sections Meeting and will be presented at the American Orthopedic Society for

Sports Medicine's meeting in July.

Key: Extension and Strength

Comparing the reconstructed knee to the noninvolved knee:

• 97.2% of patients had an extension deficit of ≤2°

• 29.0% had strength symmetry within 10%

• 94.7% had a manual maximum KT ≤3mm (KT = KT arthrometer used to measure stability)

• 43.1% had single hop symmetry within 10% ¹

Extension ROM and strength had the largest impact on the timing of return to sport:

• Impact of extension deficit on return to sport:

- 5.0 months for patients with extension deficit ≤2°

- 6.0 months for patients with ≥3°, p=0.035

• Impact of symmetric strength on return to sport:

- 4.7 months for patients with symmetric strength

- 5.1 months for patients with asymmetric strength, p=0.015.

• Impact of symmetric single leg hop on return to sport:

Study Methods

The retrospective study included 569 patients who underwent ACL reconstruction between 1982 and 2022. Researchers collected objective data between one and three months postoperative and patient-reported time to full participation in sport. Objective data measured extension, strength, single leg hop and stability.

Participants

• Mean age: 22.0 ± 7.8 years (range: 13.4-53.6)

• 52.5% were male

• 73.6% received a contralateral patellar tendon graft

Participants were split into two groups—normal and abnormal—based on objective measures compared to the noninvolved knee.

The study is part of the Shelbourne Knee Center Research Program, which has collected data on outcomes for more than 15,759 patients over 43+ years. The research process includes annual email surveys and objective evaluations (for surgical patients) during free follow-up visits.

RETURN TO SPORT TIME

- 4.6 months for patients with symmetric single leg hop

- 5.2 months for patients with asymmetric single leg hop, p<0.001.¹

Stability did not have a statistically significant impact on the timing of return to sport.

REFERENCE

1. Bauman S, Claussen B, Shelbourne KD, and Benner R. Early Objective Predictors of Return to Sport Time Following Anterior Cruciate Ligament Reconstruction. American Physical Therapy Association Combined Sections Meeting, Boston, MA, February 2024.

FixKnee.com: A Resource for Clinicians

AT SHELBOURNE KNEE CENTER, we’ve been conducting research for 40+ years. More than 13,000 of our patients have participated in follow-up surveys and exams. The result? A trove of clinical information related to treating knee injuries and disorders. We’ve made much of this material available to clinicians via our website, www.FixKnee.com. Visit to find a complete list of our published research (with links) organized by topic. Our website also features two blogs for clinicians, For Colleagues and For Professionals, which you’ll find under News + Resources. That section also hosts a Knee Treatment News page with links to digital flipbook versions of each issue of this newsletter.

Research-Backed Treatment for Rare Knee Injuries

Shelbourne Knee Center’s two orthopedic surgeons, K. Donald Shelbourne, MD, and Rodney Benner, MD, have had their research published in more than 160 medical journals and over 100 book chapters. To discuss a rare knee injury or other case with one of our surgeons, email skckneecare@ecommunity.com or call 888-FIX-KNEE (317-924-8636)

MEET OUR TEAM

ORTHOPEDIC SURGEONS

n K. Donald Shelbourne, MD

n Rodney Benner, MD

CLINICAL TEAM

n Jean Fouts, RN, BSN

n Lee Linenberg, CA

n Emily Guy, PA

PHYSICAL THERAPISTS AND ATHLETIC TRAINERS

n Bill Claussen, MPT

n Emma Sterrett, LAT, ATC

n Darla Baker, PT, DPT, ATC/L

n Jennifer Christy, PT

n Alana Gillenwater, PT, DPT

n Bryanna McKinstry, PT

n Noah Runyon, PT

n Jenna Hedlund, PT

RESEARCH TEAM

n Scot Bauman, PT, DPT, PhD

n Diane Davidson, BS, MBA, CCRC

n Adam Norris, ACRP-CP

n Heather Garrison