Clin Orthop Surg.  2019 Dec;11(4):409-415. 10.4055/cios.2019.11.4.409.

The Effect of Prosthesis Design on Blood Loss in Simultaneous Bilateral Total Knee Arthroplasty: Closed-Box versus Open-Box Prosthesis

  • 1Department of Orthopedics, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand.
  • 2Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.


Various pre- and perioperative risk factors have been reported in association with blood loss in knee arthroplasty. However, the effect of the uncovered cancellous surface on blood loss in simultaneous bilateral total knee arthroplasty (SBTKA) by different prosthetic designs is not well elucidated. Therefore, this study aimed to compare the blood loss and transfusion rate between different knee prostheses in SBTKA and to identify risk factors that influence blood loss and transfusion after SBTKA.
Demographic and perioperative data of patients who underwent SBTKA using either a closed-box or an open-box femoral component of posterior-stabilized fixed-bearing (PS FB) knee system were retrospectively reviewed. The calculated blood loss (CBL) and blood transfusion rate were compared by using Student t-test and confirmed with multivariate regression analysis.
There was no significant difference in preoperative parameters between 54 closed-box and 56 open-box PS FB TKAs. The CBL of the closed-box TKA group was 135.23 mL less (95% confidence interval [CI], −215.30 to −55.16; p = 0.001) than that of the open-box TKA group. However, the blood transfusion rates of the closed- and open-box TKA groups were not significantly different (24.1% and 38.5%, p = 0.11). For each additional minute of total operative time, 3.75 mL (95% CI, 1.75 to 5.76; p < 0.001) of blood loss was anticipated. For each additional mg/dL of preoperative hemoglobin, 71% (p < 0.001) reduction of blood transfusion probability was predicted.
The use of closed- and open-box knee prostheses resulted in a significant difference in blood loss in SBTKA. Prolonged operative time also significantly increased CBL. Therefore, strategies to control the bleeding surface and shorten operative duration may be considered if blood loss is of special concern. The preoperative hemoglobin was the only factor that affects the probability of blood transfusion in SBTKA.


Knee; Arthroplasty; Prosthesis; Bilateral; Blood loss; Transfusion

MeSH Terms

Arthroplasty, Replacement, Knee*
Blood Transfusion
Knee Prosthesis
Operative Time
Prostheses and Implants*
Prosthesis Design*
Retrospective Studies
Risk Factors
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