1. Dr (Prof) Raju Vaishya (MBBS, MS, MCh, FRCS) Sr Consultant Orthopaedics & Joint Replacement Surgery Indraprastha Apollo Hospitals, New Delhi, INDIA

2. Apollo Chennai 1983 Apollo Hyderabad 1988 Apollo Speciality Chennai 1993 Indraprastha Apollo Delhi 1996 Apollo Madurai 1997 Apollo Arragonda 2000 Apollo Ahmedabad 2003 Apollo Agra 2006 Apollo Dhaka 2005 Apollo Colombo 2002 Apollo Ludhiana 2005 Apollo Bangalore 2007 Apollo Calcutta 2002 Apollo Bilaspur 2001 Apollo Mauritius 2009 Apollo Lavasa 2009 Apollo Children Hospital 2009 Apollo Karur 2009 Apollo Secunderabad 2010 Apollo Cancer, Hyderabad 2010 Apollo Cancer, Kolkata 2010 Apollo Bhubaneshwar 2010 Apollo Karaikudi 2010 Apollo Hyderaguda 2011 Apollo Alwarpet 2011 Apollo Trichy 2012 Apollo Koramangla Cradle 2012 Apollo Vanagram 2013 Apollo Nashik 2013 Apollo Rajshree Hospital, Indore 2014 Apollo today 65 locations Over 9000 beds More than 75,000 family members Apollo Karimnagar 2008

3.  Has consistently risen around the world.  Average life expectancy has gone up 5 years in the last decade in India – 66.21 years.  It is estimated that in the United States alone, the population of elderly adults (≥85) will increase 400% by 2050.1 U.S. Census Bureau. Projections of the population by age and sex for the United States: 2010 to 2050; 2009 [on-line] MOHFW, Govt. of India official data.

4.  Worldwide, the population of the elderly continues to grow. This increase naturally will be associated with a parallel increase in the number of TKAs done in this age group.  The results of TKA in octogenarians have been reported. But the reports & results of TKA in patients >90 years old (nonagenarians) are not well documented & bilateral simultaneous TKA (SBTKA)in a single sitting have not been reported.

5.  Patients who live significantly longer than their counterparts are relatively healthy and hence could reach to this age.  Such people constitute the “Healthy cohort”.  Are expected to survive longer than their counter-parts. Vaishya R, Vijay V. “Can total knee arthroplasty be safely performed among nonagenarians? An evaluation of morbidity and mortality within a total joint replacement registry". J Arthroplasty. 2015 Jan;30(1):156-7.

6.  Continuous increase in number of elderly population in developed countries with fastest growing age > 85 years old.  Population aged >90 years in USA will double from 2 to 4 million from 2010 to 2035.  Likely to be associated with a parallel increase in number of TKA done.  Elderly people unwilling to undergo TKA as compared to younger counterparts.

7. Elderly not willing to undergo TKA due to  Ignorance  Consideration of their old age  Uncertainty about their life expectancy  Associated comorbidities  Fear of potential postoperative complications Kreder HJ, Berry GK, McMurtry IA et al. Arthroplasty in the octogenarian:Quantifying the risks. J Arthroplasty 2005;20:289–293

8.  Age related physical & medical problems (Hilton et al 2004)  More severe & complex deformities (Zicat et al, 1993)  Associated osteoporosis  Lesser response to rehabilitation  More post of assistance required  Total cost of treatment higher (Brander et al, 1997)  Willful neglect of even eligible patients by the family & doctors (Hamel et al 2008)

9.  Remaining life expectancy  Enthusiasm of the patient & family members  Willingness to cooperate post op in rehab  No major medical co morbidities  Availability of back up medical care facilities  Biological age is more important than chronological age

10.  Ravi et al - concluded total joint replacement in moderate to severe osteoarthritis was associated with significant (40%) reduction in subsequent risk of serious cardiovascular events. Reasons  Improvement in physical activity  Reduction of pain and thus psychosocial stress  Decreased need for NSAIDs Bheeshma R, Ruth C, Peter AC, Lipscombe L, Bierman AS, Harvet PJ, et al (2013). The relation between total joint arthroplasty and risk for serious cardiovascular events in patients with moderate-severe osteoarthritis: propensity score matched landmark analysis.BMJ 347:f6187.

11.  After TKA, 76% 85 and older could live independently and approximately one- third could drive a car.  Significant freedom for ADL.  Decreased dependence and improved quality of life. (Laskin RS. Total knee replacement in patients older than 85 years. Clin Orthop Relat Res 1999;367:43–49).

12. Advantages of SBTKA as compared to two stage:  Shorter time of exposure to anesthesia,  Less time spent in hospital,  Shorter rehabilitation and physical therapy,  Fewer wound complications,  Decreased surgical stress,  Convenient to family members  More cost-effective treatment Jankiewicz JJ, Sculco TP, Ranawat CS et al. One stage versus 2-stage bilateral total knee arthroplasty. Clin Orthop 1994;309:94–101

13.  177 SBTKA between 2003 and 2012.  Retrospective cohort study of 46 patients (92 knees) of age >70 years.  Combined spinal epidural anesthesia (93.5%) or general anesthesia (6.5%).  More painful side operated first and 2 nd side done during same anesthesia, if no significant events during surgery.

14.  <70 years  Undergone staged B/L, U/L or uni compartmental knee arthroplasty  Less than Ahlback’s grade IV OA  Revision TKA

15.  All patients had Dobutamine Stress Echo  Associated co-morbidities noted.  Patient’s age, sex, weight, height, BMI, American Society of Anesthesiologist (ASA) grade, Knee Society Score (KSS), tourniquet time, preoperative and postoperative hemoglobin, peri and post operative complications, length of hospital stay, amount of blood in the drain (in first 24 and 48 hours) after surgery, blood transfusions.

16.  Post operative complications like – UTI, myocardial ischemia, confusion, respiratory tract infection, DVT with positive scan, shifting to high dependency unit or ICU, implant infection, and repeat surgery noted.  Surgery under torniquet  PS cemented knee (Scorpio, Stryker)  Drain used in all cases  Multi-modal DVT prophylaxis used – mechanical & pharmacological  Mobilization as per patient comfort

17.  Data assimilated by Fellow  Average of all continuous data expressed in mean±SD.  Pre-operative and post –operative KSS assessed by applying Wilcoxon Signed Ranks test.

18. Mean/numberStandard deviation/percentage Age Sex Male Female BMI ASA Grade I Grade II Grade III Grade IV Grade V Preoperative Hb Postoperative Hb Tourniquet time ( in minutes) Postoperative blood loss in drain (ml) 80.13 25 21 29.4 12 25 8 1 0 12.6 9.94 44.43 45.56 968.19 5.25 54.4% 45.6% 5.36 26.08% 54.34% 17.4% 2.2% 0% 1.62 1.1 14.01 16.63 495.7 D e m o g ra p hi cs

20.  24% patients - no significant co- morbidity.  80% ASA grade 1 or 2.  Significant improvement in post op KSS.  No in-hospital mortality.

22.  Most common post op complication – delirium.  Renal dysfunction (2), Angina (2), UTI (2), MI (1).  No hospital mortality or till one year after index surgery.  Average time of death after surgery 5.6 years.

23.  Retrospective study of 216 patients.  No increased risk of pulmonary embolism.  Nonagenarians did not have an increased risk of infection.  Postoperative mortality was within expected rates.  The patients do have higher re-admission rates and hence close follow up is needed in the post operative period. Miric A et al. Can total knee arthroplasty be safely performed among nonagenarians? An evaluation of morbidity and mortality within a total joint replacement registry. J Arthroplasty. 2014 Aug;29(8):1635-8.

24.  Octogenarians can be expected to have their implants survive them.  SBTKA can be a safe and effective option for octogenarians.  Complications and mortality are not higher for SBTKA compared to UTKA. Cahill CW. Simultaneous bilateral knee arthroplasty in octogenarians: can it be safe and effective? J Arthroplasty. 2014 May;29(5):998-1000

25.  Patients suffering from cardio-pulmonary disorders - most likely to benefit from SBTKA.  For better risk stratification of the elderly, the patients suffering from cardio- pulmonary disorders should not be excluded from the study by Cahill et al. Vijay V, Vaishya R. J Arthroplasty. 2014 Sep;29(9):1877-8 Letter to the editor on "Simultaneous bilateral knee arthroplasty in octogenarians: can it be safe and effective?".

26.  Primary arthroplasty may be denied to very elderly patients based upon the perceived outcome and risks associated with surgery  The older group was more satisfied with their THR  The older group had a longer hospital stay for both THR and TKR  The rates of post-operative complications and mortality were increased in the older group.

27.  Although the incidence of medical complications in the peri operative period may be higher, TKA is a safe and effective treatment for refractory joint pain in patients over 80 years of age.

28.  There was a 70% preoperative cardiac disease comorbidity.  Overall, confusion after surgery was greater in this older group than in the patients younger than 85 years of age, however, confusion was lower in the group of patients who had epidural anesthesia as compared with those patients who had surgery under general anesthesia.  Seventy-six percent of the patients were living independently or in senior retirement housing after surgery. Only two of the patients required living accommodations in a nursing home. One third of the patients still could drive their own car after surgery.  Quality of life improvement was markedly increased in this elderly group of patients. The results of this study indicate that total knee replacement still is a valuable procedure even for this elderly group, and most of these patients returned to a more functional lifestyle.

29.  The rates of perioperative morbidity and mortality are areas of concern associated with simultaneous bilateral TKA.  The unilateral group had significantly lower Knee Society scores than the simultaneous bilateral group  The percentage of patients who had thrombophlebitis was significantly higher in the simultaneous bilateral group (0.9%) than in the unilateral group (0.3%) (p = 0.0326).  No significant differences were found with regard to prosthetic failure, cardiac complications, and the rates of death in the three groups.  Ten years postoperatively, the simultaneous bilateral group had a significantly higher rate of patient survival than did the unilateral group (78.6% compared with 72.0%) (p = 0.0062).

30.  Survival analysis of 6200 total knee replacements, performed in 3998 patients between 1983 and 2000, consisted of 2050 simultaneous bilateral, 1796 unilateral, and 152 staged bilateral total knee replacements.  There are adequate indications for bilateral total knee replacement, simultaneous bilateral arthroplasty is beneficial to patients, with a minimal increase in the risk of death or other complications compared with that associated with unilateral and staged procedures.

31.  Mortality in the elderly group who had knee replacements was almost (1/2) that of the general population (standardized mortality ratio, 0.53). (Biau et al 2006)  The survival of patients in their nineties who undergo total joint arthroplasty is at least equal to the survival of an age-matched population for 2.5 years following surgery.  With careful patient selection and patient care to minimize medical complications, total joint arthroplasty can be an excellent option for patients who are age 89 and older. (Berend et al 2003)

32.  Biological age is more important than the chronological age  These elderly people are ‘special class’ & have only minimal medical problems  These class of people had lived a very healthy life & are keen to live good quality of life even in late age (living life like king size!)

33.  A case report of 93 yr old man who had undergone SBTKA  With predictable benefits of surgery, SBTKA seems a safe, effective, viable procedure for carefully selected elderly adults, provided that doctors, the individuals, and family members accept the risks.  These individuals should not be deprived of potential benefits of this surgery.  Biological age is more important than the chronological age of these elderly adults when considering them for SBTKA.

35.  In some selected patients with good medical condition, it is possible to do SBTKA in nonagenarians & octogenarians, with good results.  Chronological age should not be a limitation for SBTKA in elderly patients, although they need special care while in the hospital  For octo & nonagenarians, TKA provides excellent clinical improvement (measured by pain relief and knee score) with moderate function improvement, allowing improved ability to handle activities of daily living and improving quality of life

36.  SBTKA is not associated with any additional or significant increased risk of morbidity or mortality.  SBTKA seems a safe, effective, and viable procedure for carefully selected elderly patients.

37.  Biological age is more important than the chronological age  SBTKA cannot add years to the lives of these individuals, but it can add quality to the remaining years of their lives. (Vaishya R, Vijay V. J Arthroplasty. 2015 Jan;30(1):156-7) (Vaishya R, Vijay V. J Am Geriatr Soc. 2014 Oct;62(10):2011-2)

38. Invitation for Apollo Joint fellowship For 3months duration Contact: raju.vaishya@gmail.com

39. Thank you