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Is Simultaneous Bilateral Total Knee Arthroplasty (BTKA) as Safe as Staged BTKA?
Take-Home Points
- Complication rates did not statistically significantly differ between simultaneous and staged TKA.
- Length of stay of 2 TKA admissions was greater than 1 BTKA admission.
- Transfusion requirements were greater in BTKA.
- Avoid bilateral procedures in ASA 3 patients.
- Develop institutional protocols for BTKA with multidisciplinary input.
In the United States, osteoarthritis is the most common cause of knee pain and one of the leading causes of disability.1 Total knee arthroplasty (TKA) is an effective treatment for end-stage osteoarthritis of the knee.2 Whether patients with severe, debilitating bilateral disease should undergo simultaneous bilateral TKA (BTKA) or staged BTKA (2 separate procedures during separate hospital admissions) continues to be debated. The relative risks and benefits of simultaneous BTKA relative to staged BTKA or unilateral TKA are controversial.3-6 Proponents of simultaneous BTKA have argued that this surgery results in shorter hospital length of stay (LOS) and higher patient satisfaction without increased risk of perioperative complications,7-9 and opponents have argued that it leads to increased perioperative mortality and complications and should not be performed routinely.10,11
The safety of simultaneous BTKA cannot necessarily be extrapolated from data on unilateral TKA. Authors have argued that the complication rate for simultaneous BTKA is not comparable to the rate for unilateral TKA but instead is double the rate.12 Although a doubled rate may more closely approximate the true risk of simultaneous BTKA, it still does not account for the increased surgical impact of 2 procedures (vs 1 procedure) on a patient. In this regard, comparing simultaneous and staged BTKA provides a more accurate assessment of risk, as long as the interval between surgeries is not excessive. The major stress experienced during TKA affects the cardiovascular, pulmonary, and musculoskeletal systems, and full recovery may take up to 6 months.13-15 Outcome studies have found significant improvement in validated measures of function and pain up to but not past 6 months.13,15 Furthermore, a large study comparing American Society of Anesthesiologists (ASA) scores with morbidity and mortality rates recorded in the New Zealand Total Joint Database established 6 months as a best approximation of postoperative mortality and morbidity risk.14 Given these data, we propose that the most accurate analysis of postoperative morbidity and mortality would be a comparison of simultaneous BTKA with BTKA staged <6 months apart. The staged procedures fall within the crucial postoperative period when increased morbidity and mortality would more likely be present. A between-surgeries interval >6 months would effectively separate the 2 procedures, rendering their risks not truly representative.
We retrospectively analyzed all simultaneous BTKA and staged BTKA (<6 months apart) surgeries performed at our orthopedic specialty hospital between 2005 and 2009. We hypothesized there would be no significant difference in perioperative morbidity or mortality between the groups.
Methods and Materials
Our institution’s Institutional Review Board approved this study. All patients who underwent either simultaneous BTKA or staged BTKA (<6 months apart) at a single orthopedic specialty hospital between 2005 and 2009 were retrospectively identified. Twenty-five surgeons performed the procedures. Which procedure to perform (simultaneous or staged) was decided by the attending surgeon in consultation with an anesthesiologist. Preoperative medical diagnostic testing was determined by the internist, who provided medical clearance, and was subject to review by the anesthesiologist. A patient was excluded from simultaneous BTKA only if the medical or anesthesiology consultant deemed the patient too high risk for bilateral procedures. Revision TKAs were excluded from the study.
Implant, approach, tourniquet use, and TKA technique were selected by the individual surgeons. Strategies for the simultaneous procedures were (1) single surgeon, single team, sequential, start second knee after closure of first, and (2) single surgeon, single team, sequential, start second knee after implantation of first but before closure. The decision to proceed with the second knee was confirmed in consultation with the anesthesiologist after implantation and deflation of the tourniquet on the first knee.
Individual electronic patient charts were reviewed for information on demographics, comorbidities, anesthesia type, antibiotics, and postoperative venous thromboembolism prophylaxis. Demographic variables included age, sex, height, weight, and body mass index (BMI). Comorbidities recorded were diabetes mellitus, coronary artery disease, prior myocardial infarction, stroke, and endocrinopathies. In addition, available ASA scores were recorded. The primary outcome was perioperative complications, defined as any complications that occurred within 6 months after surgery. These included death, pulmonary embolism (PE), and deep surgical-site infections (SSIs). Secondary outcome measures were LOS, discharge location (rehabilitation or home), and blood transfusion requirements.
The 2 groups (simultaneous BTKA, staged BTKA) were compared using Student t test for continuous variables and χ2 test for categorical variables. Subgroup analysis was performed to compare healthier patients (ASA score 1 or 2) with patients who had more severe comorbidities (ASA score 3). Statistical significance was set at P < .05.
Results
Between 2005 and 2009, 371 patients had simultaneous BTKA, and 67 had staged BTKA (134 procedures) <6 months apart (Table 1). 
Most surgeries (84.4% simultaneous, 90.3% staged) were performed with the patient under spinal anesthesia, and there was a trend (P = .167) toward more frequent use of general anesthesia in the simultaneous group relative to the staged group (Table 2). 
The 2 cohorts’ perioperative complication rates were not statistically significantly different (P = .97) (Table 3). 
There was no statistically significant difference (P = .398) in occurrence of postoperative complications between the 2 cohorts compared on ASA scores, and the difference between patients with ASA score 1 or 2 and those with ASA score 3 was not statistically significant (P = .200) (Table 4). 
Discussion
Although there was no significant difference in postoperative complication rates within 6 months after surgery between the simultaneous and staged BTKA groups, the incidence of complications in the simultaneous group was notable. The disproportionate size of the 2 comparison groups limited the power of our study to analyze individual perioperative complications. This study may be underpowered to detect differences in complications occurring relatively infrequently, which may explain why the difference in number of complications (13 in simultaneous group, 1 in staged group) did not achieve statistical significance (β = 0.89). Post hoc power analysis showed 956 patients would be needed in each group to adequately power for such small complication rates. However, our results are consistent with those of other studies.13-15 The 1.9% PE rate in our simultaneous BTKA group does not vary from the average PE rate for TKA in the literature and is actually lower than the PE rate in a previous study at our institution.16 Fat embolism traditionally is considered more of a concern in bilateral cases than in unilateral cases. Although fat embolism surely is inherent to the physiologic alterations caused by TKA, we did not find clinically significant fat embolism in either cohort.
Similarly, the 1.08% rate of deep SSIs is within the range for postoperative TKA infections at our institution and others.17 Our staged BTKA group’s complication rate, 0.75% (1 SSI), was slightly lower than expected. However, 0.75% is in keeping with institutional norms (typical rate, ~1%). We would have expected a nonzero rate for venous thromboembolism, and perhaps such a rate would have come with an inclusion period longer than 6 months. Last, the death in the simultaneous BTKA group was not an outlier, given the published rate of mortality after elective total joint surgery.18The characteristics of our simultaneous and staged BTKA groups were very similar (Table 1), though the larger number of staged-group patients with diabetes mellitus and coronary artery disease may represent selection bias. Nevertheless, the proportions of patients with each of 3 ASA scores were similar. It is also important to note that, in this context, a high percentage of patients in each group (33.6% simultaneous, 37.5% staged) received ASA score 3 from the anesthesiologist (P > .05). This may be an important factor in explaining the larger though not statistically significant number of complications in the simultaneous group (13) relative to the staged group (1). 
Other authors have studied the safety of simultaneous vs staged BTKA and drawn conflicting conclusions.11,19-21 Walmsley and colleagues21 found no differences in 90-day mortality between 3 groups: patients with simultaneous BTKA, patients with BTKA staged within 5 years, and patients with unilateral TKA. Stefánsdóttir and colleagues11 found that, compared with simultaneous BTKA, BTKA staged within 1 year had a lower 30-day mortality rate. Meehan and colleagues20 compared simultaneous BTKA with BTKA staged within 1 year and found a lower risk of infection and device malfunction and a higher risk of adverse cardiovascular outcomes in the simultaneous group. A recent meta-analysis found that, compared with staged BTKA, simultaneous BTKA had a higher risk of perioperative complications.19 A systematic review of retrospective studies found simultaneous BTKA had higher rates of mortality, PE, and transfusion and lower rates of deep SSI and revision.22 A survey of Medicare data found higher 90-day mortality and myocardial infarction rates for simultaneous BTKA but no difference in infection and revision rates.23 Clearly, there is no consensus as to whether simultaneous BTKA carries higher risks relative to staged BTKA.
The amount of blood transfused in our simultaneous BTKA group was more than double that in the 2 staged TKAs combined. It is intuitive that the blood loss in 2 concurrent TKAs is always more than in 1 TKA, but the clinical relevance of this fact is unknown. Transfusions have potential complications, and this risk needs to be addressed in the preoperative discussion.
LOS for simultaneous BTKA was on average 4 days shorter than the combined LOS (2 hospitalizations) for staged BTKA. This shorter LOS has been shown to provide the healthcare system with a cost savings.8 However, not considered in the equation is the difference in cost of rehabilitations, 2 vs 1. In the present study, 92.7% of simultaneous BTKA patients and only 50.7% of staged BTKA patients were discharged to an inpatient acute rehabilitation unit. Interestingly, the majority of the staged patients who went to inpatient rehabilitation did so after the second surgery. At our institution at the time of this study, simultaneous BTKA patients, and staged BTKA patients with the second surgery completed, were more likely than unilateral TKA patients to qualify for inpatient acute rehabilitation. Staged BTKA patients’ higher cost for 2 rehabilitations, rather than 1, adds to the cost savings realized with simultaneous BTKA. In the context of an episode-based payment system, the cost of posthospital rehabilitation enters the overall cost equation and may lead to an increase in the number of simultaneous BTKAs being performed.
Conclusion
In this study, the incidence of postoperative complications was higher for simultaneous BTKA than for staged BTKA performed <6 months apart, but the difference was not significantly different. There were significant differences in LOS and blood transfusion rates between the groups, as expected. At present, only patients with ASA score 1 or 2 are considered for simultaneous BTKA at our institution. Patients with ASA score 3 or higher are not eligible.
Am J Orthop. 2017;46(4):E224-E229. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.
1. Hootman JM, Helmick CG. Projections of US prevalence of arthritis and associated activity limitations. Arthritis Rheum. 2006;54(1):226-229.
2. Kolettis GT, Wixson RL, Peruzzi WT, Blake MJ, Wardell S, Stulberg SD. Safety of 1-stage bilateral total knee arthroplasty. Clin Orthop Relat Res. 1994;(309):102-109.
3. Kim YH, Choi YW, Kim JS. Simultaneous bilateral sequential total knee replacement is as safe as unilateral total knee replacement. J Bone Joint Surg Br. 2009;91(1):64-68.
4. Luscombe JC, Theivendran K, Abudu A, Carter SR. The relative safety of one-stage bilateral total knee arthroplasty. Int Orthop. 2009;33(1):101-104.
5. Memtsoudis SG, Ma Y, González Della Valle A, et al. Perioperative outcomes after unilateral and bilateral total knee arthroplasty. Anesthesiology. 2009;111(6):1206-1216.
6. Zeni JA Jr, Snyder-Mackler L. Clinical outcomes after simultaneous bilateral total knee arthroplasty: comparison to unilateral total knee arthroplasty and healthy controls. J Arthroplasty. 2010;25(4):541-546.
7. March LM, Cross M, Tribe KL, et al; Arthritis C.O.S.T. Study Project Group. Two knees or not two knees? Patient costs and outcomes following bilateral and unilateral total knee joint replacement surgery for OA. Osteoarthritis Cartilage. 2004;12(5):400-408.
8. Reuben JD, Meyers SJ, Cox DD, Elliott M, Watson M, Shim SD. Cost comparison between bilateral simultaneous, staged, and unilateral total joint arthroplasty. J Arthroplasty. 1998;13(2):172-179.
9. Ritter MA, Harty LD. Debate: simultaneous bilateral knee replacements: the outcomes justify its use. Clin Orthop Relat Res. 2004;(428):84-86.
10. Restrepo C, Parvizi J, Dietrich T, Einhorn TA. Safety of simultaneous bilateral total knee arthroplasty. A meta-analysis. J Bone Joint Surg Am. 2007;89(6):1220-1226.
11. Stefánsdóttir A, Lidgren L, Robertsson O. Higher early mortality with simultaneous rather than staged bilateral TKAs: results from the Swedish Knee Arthroplasty Register. Clin Orthop Relat Res. 2008;466(12):3066-3070.
12. Noble J, Goodall J, Noble D. Simultaneous bilateral total knee replacement: a persistent controversy. Knee. 2009;16(6):420-426.
13. Fortin PR, Penrod JR, Clarke AE, et al. Timing of total joint replacement affects clinical outcomes among patients with osteoarthritis of the hip or knee. Arthritis Rheum. 2002;46(12):3327-3330.
14. Hooper GJ, Rothwell AG, Hooper NM, Frampton C. The relationship between the American Society of Anesthesiologists physical rating and outcome following total hip and knee arthroplasty: an analysis of the New Zealand Joint Registry. J Bone Joint Surg Am. 2012;94(12):1065-1070.
15. MacWilliam CH, Yood MU, Verner JJ, McCarthy BD, Ward RE. Patient-related risk factors that predict poor outcome after total hip replacement. Health Serv Res. 1996;31(5):623-638.
16. Hadley SR, Lee M, Reid M, Dweck E, Steiger D. Predictors of pulmonary embolism in orthopaedic patient population. Abstract presented at: 43rd Annual Meeting of the Eastern Orthopaedic Association; June 20-23, 2012; Bolton Landing, NY.
17. Hadley S, Immerman I, Hutzler L, Slover J, Bosco J. Staphylococcus aureus decolonization protocol decreases surgical site infections for total joint replacement. Arthritis. 2010;2010:924518.
18. Singh JA, Lewallen DG. Ninety-day mortality in patients undergoing elective total hip or total knee arthroplasty. J Arthroplasty. 2012;27(8):1417-1422.e1.
19. Hu J, Liu Y, Lv Z, Li X, Qin X, Fan W. Mortality and morbidity associated with simultaneous bilateral or staged bilateral total knee arthroplasty: a meta-analysis. Arch Orthop Trauma Surg. 2011;131(9):1291-1298.
20. Meehan JP, Danielsen B, Tancredi DJ, Kim S, Jamali AA, White RH. A population-based comparison of the incidence of adverse outcomes after simultaneous-bilateral and staged-bilateral total knee arthroplasty. J Bone Joint Surg Am. 2011;93(23):2203-2213.
21. Walmsley P, Murray A, Brenkel IJ. The practice of bilateral, simultaneous total knee replacement in Scotland over the last decade. Data from the Scottish Arthroplasty Project. Knee. 2006;13(2):102-105.
22. Fu D, Li G, Chen K, Zeng H, Zhang X, Cai Z. Comparison of clinical outcome between simultaneous-bilateral and staged-bilateral total knee arthroplasty: a systematic review of retrospective studies. J Arthroplasty. 2013;28(7):1141-1147.
23. Bolognesi MP, Watters TS, Attarian DE, Wellman SS, Setoguchi S. Simultaneous vs staged bilateral total knee arthroplasty among Medicare beneficiaries, 2000–2009. J Arthroplasty. 2013;28(8 suppl):87-91.
Take-Home Points
- Complication rates did not statistically significantly differ between simultaneous and staged TKA.
- Length of stay of 2 TKA admissions was greater than 1 BTKA admission.
- Transfusion requirements were greater in BTKA.
- Avoid bilateral procedures in ASA 3 patients.
- Develop institutional protocols for BTKA with multidisciplinary input.
In the United States, osteoarthritis is the most common cause of knee pain and one of the leading causes of disability.1 Total knee arthroplasty (TKA) is an effective treatment for end-stage osteoarthritis of the knee.2 Whether patients with severe, debilitating bilateral disease should undergo simultaneous bilateral TKA (BTKA) or staged BTKA (2 separate procedures during separate hospital admissions) continues to be debated. The relative risks and benefits of simultaneous BTKA relative to staged BTKA or unilateral TKA are controversial.3-6 Proponents of simultaneous BTKA have argued that this surgery results in shorter hospital length of stay (LOS) and higher patient satisfaction without increased risk of perioperative complications,7-9 and opponents have argued that it leads to increased perioperative mortality and complications and should not be performed routinely.10,11
The safety of simultaneous BTKA cannot necessarily be extrapolated from data on unilateral TKA. Authors have argued that the complication rate for simultaneous BTKA is not comparable to the rate for unilateral TKA but instead is double the rate.12 Although a doubled rate may more closely approximate the true risk of simultaneous BTKA, it still does not account for the increased surgical impact of 2 procedures (vs 1 procedure) on a patient. In this regard, comparing simultaneous and staged BTKA provides a more accurate assessment of risk, as long as the interval between surgeries is not excessive. The major stress experienced during TKA affects the cardiovascular, pulmonary, and musculoskeletal systems, and full recovery may take up to 6 months.13-15 Outcome studies have found significant improvement in validated measures of function and pain up to but not past 6 months.13,15 Furthermore, a large study comparing American Society of Anesthesiologists (ASA) scores with morbidity and mortality rates recorded in the New Zealand Total Joint Database established 6 months as a best approximation of postoperative mortality and morbidity risk.14 Given these data, we propose that the most accurate analysis of postoperative morbidity and mortality would be a comparison of simultaneous BTKA with BTKA staged <6 months apart. The staged procedures fall within the crucial postoperative period when increased morbidity and mortality would more likely be present. A between-surgeries interval >6 months would effectively separate the 2 procedures, rendering their risks not truly representative.
We retrospectively analyzed all simultaneous BTKA and staged BTKA (<6 months apart) surgeries performed at our orthopedic specialty hospital between 2005 and 2009. We hypothesized there would be no significant difference in perioperative morbidity or mortality between the groups.
Methods and Materials
Our institution’s Institutional Review Board approved this study. All patients who underwent either simultaneous BTKA or staged BTKA (<6 months apart) at a single orthopedic specialty hospital between 2005 and 2009 were retrospectively identified. Twenty-five surgeons performed the procedures. Which procedure to perform (simultaneous or staged) was decided by the attending surgeon in consultation with an anesthesiologist. Preoperative medical diagnostic testing was determined by the internist, who provided medical clearance, and was subject to review by the anesthesiologist. A patient was excluded from simultaneous BTKA only if the medical or anesthesiology consultant deemed the patient too high risk for bilateral procedures. Revision TKAs were excluded from the study.
Implant, approach, tourniquet use, and TKA technique were selected by the individual surgeons. Strategies for the simultaneous procedures were (1) single surgeon, single team, sequential, start second knee after closure of first, and (2) single surgeon, single team, sequential, start second knee after implantation of first but before closure. The decision to proceed with the second knee was confirmed in consultation with the anesthesiologist after implantation and deflation of the tourniquet on the first knee.
Individual electronic patient charts were reviewed for information on demographics, comorbidities, anesthesia type, antibiotics, and postoperative venous thromboembolism prophylaxis. Demographic variables included age, sex, height, weight, and body mass index (BMI). Comorbidities recorded were diabetes mellitus, coronary artery disease, prior myocardial infarction, stroke, and endocrinopathies. In addition, available ASA scores were recorded. The primary outcome was perioperative complications, defined as any complications that occurred within 6 months after surgery. These included death, pulmonary embolism (PE), and deep surgical-site infections (SSIs). Secondary outcome measures were LOS, discharge location (rehabilitation or home), and blood transfusion requirements.
The 2 groups (simultaneous BTKA, staged BTKA) were compared using Student t test for continuous variables and χ2 test for categorical variables. Subgroup analysis was performed to compare healthier patients (ASA score 1 or 2) with patients who had more severe comorbidities (ASA score 3). Statistical significance was set at P < .05.
Results
Between 2005 and 2009, 371 patients had simultaneous BTKA, and 67 had staged BTKA (134 procedures) <6 months apart (Table 1).
Most surgeries (84.4% simultaneous, 90.3% staged) were performed with the patient under spinal anesthesia, and there was a trend (P = .167) toward more frequent use of general anesthesia in the simultaneous group relative to the staged group (Table 2).
The 2 cohorts’ perioperative complication rates were not statistically significantly different (P = .97) (Table 3).
There was no statistically significant difference (P = .398) in occurrence of postoperative complications between the 2 cohorts compared on ASA scores, and the difference between patients with ASA score 1 or 2 and those with ASA score 3 was not statistically significant (P = .200) (Table 4).
Discussion
Although there was no significant difference in postoperative complication rates within 6 months after surgery between the simultaneous and staged BTKA groups, the incidence of complications in the simultaneous group was notable. The disproportionate size of the 2 comparison groups limited the power of our study to analyze individual perioperative complications. This study may be underpowered to detect differences in complications occurring relatively infrequently, which may explain why the difference in number of complications (13 in simultaneous group, 1 in staged group) did not achieve statistical significance (β = 0.89). Post hoc power analysis showed 956 patients would be needed in each group to adequately power for such small complication rates. However, our results are consistent with those of other studies.13-15 The 1.9% PE rate in our simultaneous BTKA group does not vary from the average PE rate for TKA in the literature and is actually lower than the PE rate in a previous study at our institution.16 Fat embolism traditionally is considered more of a concern in bilateral cases than in unilateral cases. Although fat embolism surely is inherent to the physiologic alterations caused by TKA, we did not find clinically significant fat embolism in either cohort.
Similarly, the 1.08% rate of deep SSIs is within the range for postoperative TKA infections at our institution and others.17 Our staged BTKA group’s complication rate, 0.75% (1 SSI), was slightly lower than expected. However, 0.75% is in keeping with institutional norms (typical rate, ~1%). We would have expected a nonzero rate for venous thromboembolism, and perhaps such a rate would have come with an inclusion period longer than 6 months. Last, the death in the simultaneous BTKA group was not an outlier, given the published rate of mortality after elective total joint surgery.18The characteristics of our simultaneous and staged BTKA groups were very similar (Table 1), though the larger number of staged-group patients with diabetes mellitus and coronary artery disease may represent selection bias. Nevertheless, the proportions of patients with each of 3 ASA scores were similar. It is also important to note that, in this context, a high percentage of patients in each group (33.6% simultaneous, 37.5% staged) received ASA score 3 from the anesthesiologist (P > .05). This may be an important factor in explaining the larger though not statistically significant number of complications in the simultaneous group (13) relative to the staged group (1).
Other authors have studied the safety of simultaneous vs staged BTKA and drawn conflicting conclusions.11,19-21 Walmsley and colleagues21 found no differences in 90-day mortality between 3 groups: patients with simultaneous BTKA, patients with BTKA staged within 5 years, and patients with unilateral TKA. Stefánsdóttir and colleagues11 found that, compared with simultaneous BTKA, BTKA staged within 1 year had a lower 30-day mortality rate. Meehan and colleagues20 compared simultaneous BTKA with BTKA staged within 1 year and found a lower risk of infection and device malfunction and a higher risk of adverse cardiovascular outcomes in the simultaneous group. A recent meta-analysis found that, compared with staged BTKA, simultaneous BTKA had a higher risk of perioperative complications.19 A systematic review of retrospective studies found simultaneous BTKA had higher rates of mortality, PE, and transfusion and lower rates of deep SSI and revision.22 A survey of Medicare data found higher 90-day mortality and myocardial infarction rates for simultaneous BTKA but no difference in infection and revision rates.23 Clearly, there is no consensus as to whether simultaneous BTKA carries higher risks relative to staged BTKA.
The amount of blood transfused in our simultaneous BTKA group was more than double that in the 2 staged TKAs combined. It is intuitive that the blood loss in 2 concurrent TKAs is always more than in 1 TKA, but the clinical relevance of this fact is unknown. Transfusions have potential complications, and this risk needs to be addressed in the preoperative discussion.
LOS for simultaneous BTKA was on average 4 days shorter than the combined LOS (2 hospitalizations) for staged BTKA. This shorter LOS has been shown to provide the healthcare system with a cost savings.8 However, not considered in the equation is the difference in cost of rehabilitations, 2 vs 1. In the present study, 92.7% of simultaneous BTKA patients and only 50.7% of staged BTKA patients were discharged to an inpatient acute rehabilitation unit. Interestingly, the majority of the staged patients who went to inpatient rehabilitation did so after the second surgery. At our institution at the time of this study, simultaneous BTKA patients, and staged BTKA patients with the second surgery completed, were more likely than unilateral TKA patients to qualify for inpatient acute rehabilitation. Staged BTKA patients’ higher cost for 2 rehabilitations, rather than 1, adds to the cost savings realized with simultaneous BTKA. In the context of an episode-based payment system, the cost of posthospital rehabilitation enters the overall cost equation and may lead to an increase in the number of simultaneous BTKAs being performed.
Conclusion
In this study, the incidence of postoperative complications was higher for simultaneous BTKA than for staged BTKA performed <6 months apart, but the difference was not significantly different. There were significant differences in LOS and blood transfusion rates between the groups, as expected. At present, only patients with ASA score 1 or 2 are considered for simultaneous BTKA at our institution. Patients with ASA score 3 or higher are not eligible.
Am J Orthop. 2017;46(4):E224-E229. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.
Take-Home Points
- Complication rates did not statistically significantly differ between simultaneous and staged TKA.
- Length of stay of 2 TKA admissions was greater than 1 BTKA admission.
- Transfusion requirements were greater in BTKA.
- Avoid bilateral procedures in ASA 3 patients.
- Develop institutional protocols for BTKA with multidisciplinary input.
In the United States, osteoarthritis is the most common cause of knee pain and one of the leading causes of disability.1 Total knee arthroplasty (TKA) is an effective treatment for end-stage osteoarthritis of the knee.2 Whether patients with severe, debilitating bilateral disease should undergo simultaneous bilateral TKA (BTKA) or staged BTKA (2 separate procedures during separate hospital admissions) continues to be debated. The relative risks and benefits of simultaneous BTKA relative to staged BTKA or unilateral TKA are controversial.3-6 Proponents of simultaneous BTKA have argued that this surgery results in shorter hospital length of stay (LOS) and higher patient satisfaction without increased risk of perioperative complications,7-9 and opponents have argued that it leads to increased perioperative mortality and complications and should not be performed routinely.10,11
The safety of simultaneous BTKA cannot necessarily be extrapolated from data on unilateral TKA. Authors have argued that the complication rate for simultaneous BTKA is not comparable to the rate for unilateral TKA but instead is double the rate.12 Although a doubled rate may more closely approximate the true risk of simultaneous BTKA, it still does not account for the increased surgical impact of 2 procedures (vs 1 procedure) on a patient. In this regard, comparing simultaneous and staged BTKA provides a more accurate assessment of risk, as long as the interval between surgeries is not excessive. The major stress experienced during TKA affects the cardiovascular, pulmonary, and musculoskeletal systems, and full recovery may take up to 6 months.13-15 Outcome studies have found significant improvement in validated measures of function and pain up to but not past 6 months.13,15 Furthermore, a large study comparing American Society of Anesthesiologists (ASA) scores with morbidity and mortality rates recorded in the New Zealand Total Joint Database established 6 months as a best approximation of postoperative mortality and morbidity risk.14 Given these data, we propose that the most accurate analysis of postoperative morbidity and mortality would be a comparison of simultaneous BTKA with BTKA staged <6 months apart. The staged procedures fall within the crucial postoperative period when increased morbidity and mortality would more likely be present. A between-surgeries interval >6 months would effectively separate the 2 procedures, rendering their risks not truly representative.
We retrospectively analyzed all simultaneous BTKA and staged BTKA (<6 months apart) surgeries performed at our orthopedic specialty hospital between 2005 and 2009. We hypothesized there would be no significant difference in perioperative morbidity or mortality between the groups.
Methods and Materials
Our institution’s Institutional Review Board approved this study. All patients who underwent either simultaneous BTKA or staged BTKA (<6 months apart) at a single orthopedic specialty hospital between 2005 and 2009 were retrospectively identified. Twenty-five surgeons performed the procedures. Which procedure to perform (simultaneous or staged) was decided by the attending surgeon in consultation with an anesthesiologist. Preoperative medical diagnostic testing was determined by the internist, who provided medical clearance, and was subject to review by the anesthesiologist. A patient was excluded from simultaneous BTKA only if the medical or anesthesiology consultant deemed the patient too high risk for bilateral procedures. Revision TKAs were excluded from the study.
Implant, approach, tourniquet use, and TKA technique were selected by the individual surgeons. Strategies for the simultaneous procedures were (1) single surgeon, single team, sequential, start second knee after closure of first, and (2) single surgeon, single team, sequential, start second knee after implantation of first but before closure. The decision to proceed with the second knee was confirmed in consultation with the anesthesiologist after implantation and deflation of the tourniquet on the first knee.
Individual electronic patient charts were reviewed for information on demographics, comorbidities, anesthesia type, antibiotics, and postoperative venous thromboembolism prophylaxis. Demographic variables included age, sex, height, weight, and body mass index (BMI). Comorbidities recorded were diabetes mellitus, coronary artery disease, prior myocardial infarction, stroke, and endocrinopathies. In addition, available ASA scores were recorded. The primary outcome was perioperative complications, defined as any complications that occurred within 6 months after surgery. These included death, pulmonary embolism (PE), and deep surgical-site infections (SSIs). Secondary outcome measures were LOS, discharge location (rehabilitation or home), and blood transfusion requirements.
The 2 groups (simultaneous BTKA, staged BTKA) were compared using Student t test for continuous variables and χ2 test for categorical variables. Subgroup analysis was performed to compare healthier patients (ASA score 1 or 2) with patients who had more severe comorbidities (ASA score 3). Statistical significance was set at P < .05.
Results
Between 2005 and 2009, 371 patients had simultaneous BTKA, and 67 had staged BTKA (134 procedures) <6 months apart (Table 1).
Most surgeries (84.4% simultaneous, 90.3% staged) were performed with the patient under spinal anesthesia, and there was a trend (P = .167) toward more frequent use of general anesthesia in the simultaneous group relative to the staged group (Table 2).
The 2 cohorts’ perioperative complication rates were not statistically significantly different (P = .97) (Table 3).
There was no statistically significant difference (P = .398) in occurrence of postoperative complications between the 2 cohorts compared on ASA scores, and the difference between patients with ASA score 1 or 2 and those with ASA score 3 was not statistically significant (P = .200) (Table 4).
Discussion
Although there was no significant difference in postoperative complication rates within 6 months after surgery between the simultaneous and staged BTKA groups, the incidence of complications in the simultaneous group was notable. The disproportionate size of the 2 comparison groups limited the power of our study to analyze individual perioperative complications. This study may be underpowered to detect differences in complications occurring relatively infrequently, which may explain why the difference in number of complications (13 in simultaneous group, 1 in staged group) did not achieve statistical significance (β = 0.89). Post hoc power analysis showed 956 patients would be needed in each group to adequately power for such small complication rates. However, our results are consistent with those of other studies.13-15 The 1.9% PE rate in our simultaneous BTKA group does not vary from the average PE rate for TKA in the literature and is actually lower than the PE rate in a previous study at our institution.16 Fat embolism traditionally is considered more of a concern in bilateral cases than in unilateral cases. Although fat embolism surely is inherent to the physiologic alterations caused by TKA, we did not find clinically significant fat embolism in either cohort.
Similarly, the 1.08% rate of deep SSIs is within the range for postoperative TKA infections at our institution and others.17 Our staged BTKA group’s complication rate, 0.75% (1 SSI), was slightly lower than expected. However, 0.75% is in keeping with institutional norms (typical rate, ~1%). We would have expected a nonzero rate for venous thromboembolism, and perhaps such a rate would have come with an inclusion period longer than 6 months. Last, the death in the simultaneous BTKA group was not an outlier, given the published rate of mortality after elective total joint surgery.18The characteristics of our simultaneous and staged BTKA groups were very similar (Table 1), though the larger number of staged-group patients with diabetes mellitus and coronary artery disease may represent selection bias. Nevertheless, the proportions of patients with each of 3 ASA scores were similar. It is also important to note that, in this context, a high percentage of patients in each group (33.6% simultaneous, 37.5% staged) received ASA score 3 from the anesthesiologist (P > .05). This may be an important factor in explaining the larger though not statistically significant number of complications in the simultaneous group (13) relative to the staged group (1).
Other authors have studied the safety of simultaneous vs staged BTKA and drawn conflicting conclusions.11,19-21 Walmsley and colleagues21 found no differences in 90-day mortality between 3 groups: patients with simultaneous BTKA, patients with BTKA staged within 5 years, and patients with unilateral TKA. Stefánsdóttir and colleagues11 found that, compared with simultaneous BTKA, BTKA staged within 1 year had a lower 30-day mortality rate. Meehan and colleagues20 compared simultaneous BTKA with BTKA staged within 1 year and found a lower risk of infection and device malfunction and a higher risk of adverse cardiovascular outcomes in the simultaneous group. A recent meta-analysis found that, compared with staged BTKA, simultaneous BTKA had a higher risk of perioperative complications.19 A systematic review of retrospective studies found simultaneous BTKA had higher rates of mortality, PE, and transfusion and lower rates of deep SSI and revision.22 A survey of Medicare data found higher 90-day mortality and myocardial infarction rates for simultaneous BTKA but no difference in infection and revision rates.23 Clearly, there is no consensus as to whether simultaneous BTKA carries higher risks relative to staged BTKA.
The amount of blood transfused in our simultaneous BTKA group was more than double that in the 2 staged TKAs combined. It is intuitive that the blood loss in 2 concurrent TKAs is always more than in 1 TKA, but the clinical relevance of this fact is unknown. Transfusions have potential complications, and this risk needs to be addressed in the preoperative discussion.
LOS for simultaneous BTKA was on average 4 days shorter than the combined LOS (2 hospitalizations) for staged BTKA. This shorter LOS has been shown to provide the healthcare system with a cost savings.8 However, not considered in the equation is the difference in cost of rehabilitations, 2 vs 1. In the present study, 92.7% of simultaneous BTKA patients and only 50.7% of staged BTKA patients were discharged to an inpatient acute rehabilitation unit. Interestingly, the majority of the staged patients who went to inpatient rehabilitation did so after the second surgery. At our institution at the time of this study, simultaneous BTKA patients, and staged BTKA patients with the second surgery completed, were more likely than unilateral TKA patients to qualify for inpatient acute rehabilitation. Staged BTKA patients’ higher cost for 2 rehabilitations, rather than 1, adds to the cost savings realized with simultaneous BTKA. In the context of an episode-based payment system, the cost of posthospital rehabilitation enters the overall cost equation and may lead to an increase in the number of simultaneous BTKAs being performed.
Conclusion
In this study, the incidence of postoperative complications was higher for simultaneous BTKA than for staged BTKA performed <6 months apart, but the difference was not significantly different. There were significant differences in LOS and blood transfusion rates between the groups, as expected. At present, only patients with ASA score 1 or 2 are considered for simultaneous BTKA at our institution. Patients with ASA score 3 or higher are not eligible.
Am J Orthop. 2017;46(4):E224-E229. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.
1. Hootman JM, Helmick CG. Projections of US prevalence of arthritis and associated activity limitations. Arthritis Rheum. 2006;54(1):226-229.
2. Kolettis GT, Wixson RL, Peruzzi WT, Blake MJ, Wardell S, Stulberg SD. Safety of 1-stage bilateral total knee arthroplasty. Clin Orthop Relat Res. 1994;(309):102-109.
3. Kim YH, Choi YW, Kim JS. Simultaneous bilateral sequential total knee replacement is as safe as unilateral total knee replacement. J Bone Joint Surg Br. 2009;91(1):64-68.
4. Luscombe JC, Theivendran K, Abudu A, Carter SR. The relative safety of one-stage bilateral total knee arthroplasty. Int Orthop. 2009;33(1):101-104.
5. Memtsoudis SG, Ma Y, González Della Valle A, et al. Perioperative outcomes after unilateral and bilateral total knee arthroplasty. Anesthesiology. 2009;111(6):1206-1216.
6. Zeni JA Jr, Snyder-Mackler L. Clinical outcomes after simultaneous bilateral total knee arthroplasty: comparison to unilateral total knee arthroplasty and healthy controls. J Arthroplasty. 2010;25(4):541-546.
7. March LM, Cross M, Tribe KL, et al; Arthritis C.O.S.T. Study Project Group. Two knees or not two knees? Patient costs and outcomes following bilateral and unilateral total knee joint replacement surgery for OA. Osteoarthritis Cartilage. 2004;12(5):400-408.
8. Reuben JD, Meyers SJ, Cox DD, Elliott M, Watson M, Shim SD. Cost comparison between bilateral simultaneous, staged, and unilateral total joint arthroplasty. J Arthroplasty. 1998;13(2):172-179.
9. Ritter MA, Harty LD. Debate: simultaneous bilateral knee replacements: the outcomes justify its use. Clin Orthop Relat Res. 2004;(428):84-86.
10. Restrepo C, Parvizi J, Dietrich T, Einhorn TA. Safety of simultaneous bilateral total knee arthroplasty. A meta-analysis. J Bone Joint Surg Am. 2007;89(6):1220-1226.
11. Stefánsdóttir A, Lidgren L, Robertsson O. Higher early mortality with simultaneous rather than staged bilateral TKAs: results from the Swedish Knee Arthroplasty Register. Clin Orthop Relat Res. 2008;466(12):3066-3070.
12. Noble J, Goodall J, Noble D. Simultaneous bilateral total knee replacement: a persistent controversy. Knee. 2009;16(6):420-426.
13. Fortin PR, Penrod JR, Clarke AE, et al. Timing of total joint replacement affects clinical outcomes among patients with osteoarthritis of the hip or knee. Arthritis Rheum. 2002;46(12):3327-3330.
14. Hooper GJ, Rothwell AG, Hooper NM, Frampton C. The relationship between the American Society of Anesthesiologists physical rating and outcome following total hip and knee arthroplasty: an analysis of the New Zealand Joint Registry. J Bone Joint Surg Am. 2012;94(12):1065-1070.
15. MacWilliam CH, Yood MU, Verner JJ, McCarthy BD, Ward RE. Patient-related risk factors that predict poor outcome after total hip replacement. Health Serv Res. 1996;31(5):623-638.
16. Hadley SR, Lee M, Reid M, Dweck E, Steiger D. Predictors of pulmonary embolism in orthopaedic patient population. Abstract presented at: 43rd Annual Meeting of the Eastern Orthopaedic Association; June 20-23, 2012; Bolton Landing, NY.
17. Hadley S, Immerman I, Hutzler L, Slover J, Bosco J. Staphylococcus aureus decolonization protocol decreases surgical site infections for total joint replacement. Arthritis. 2010;2010:924518.
18. Singh JA, Lewallen DG. Ninety-day mortality in patients undergoing elective total hip or total knee arthroplasty. J Arthroplasty. 2012;27(8):1417-1422.e1.
19. Hu J, Liu Y, Lv Z, Li X, Qin X, Fan W. Mortality and morbidity associated with simultaneous bilateral or staged bilateral total knee arthroplasty: a meta-analysis. Arch Orthop Trauma Surg. 2011;131(9):1291-1298.
20. Meehan JP, Danielsen B, Tancredi DJ, Kim S, Jamali AA, White RH. A population-based comparison of the incidence of adverse outcomes after simultaneous-bilateral and staged-bilateral total knee arthroplasty. J Bone Joint Surg Am. 2011;93(23):2203-2213.
21. Walmsley P, Murray A, Brenkel IJ. The practice of bilateral, simultaneous total knee replacement in Scotland over the last decade. Data from the Scottish Arthroplasty Project. Knee. 2006;13(2):102-105.
22. Fu D, Li G, Chen K, Zeng H, Zhang X, Cai Z. Comparison of clinical outcome between simultaneous-bilateral and staged-bilateral total knee arthroplasty: a systematic review of retrospective studies. J Arthroplasty. 2013;28(7):1141-1147.
23. Bolognesi MP, Watters TS, Attarian DE, Wellman SS, Setoguchi S. Simultaneous vs staged bilateral total knee arthroplasty among Medicare beneficiaries, 2000–2009. J Arthroplasty. 2013;28(8 suppl):87-91.
1. Hootman JM, Helmick CG. Projections of US prevalence of arthritis and associated activity limitations. Arthritis Rheum. 2006;54(1):226-229.
2. Kolettis GT, Wixson RL, Peruzzi WT, Blake MJ, Wardell S, Stulberg SD. Safety of 1-stage bilateral total knee arthroplasty. Clin Orthop Relat Res. 1994;(309):102-109.
3. Kim YH, Choi YW, Kim JS. Simultaneous bilateral sequential total knee replacement is as safe as unilateral total knee replacement. J Bone Joint Surg Br. 2009;91(1):64-68.
4. Luscombe JC, Theivendran K, Abudu A, Carter SR. The relative safety of one-stage bilateral total knee arthroplasty. Int Orthop. 2009;33(1):101-104.
5. Memtsoudis SG, Ma Y, González Della Valle A, et al. Perioperative outcomes after unilateral and bilateral total knee arthroplasty. Anesthesiology. 2009;111(6):1206-1216.
6. Zeni JA Jr, Snyder-Mackler L. Clinical outcomes after simultaneous bilateral total knee arthroplasty: comparison to unilateral total knee arthroplasty and healthy controls. J Arthroplasty. 2010;25(4):541-546.
7. March LM, Cross M, Tribe KL, et al; Arthritis C.O.S.T. Study Project Group. Two knees or not two knees? Patient costs and outcomes following bilateral and unilateral total knee joint replacement surgery for OA. Osteoarthritis Cartilage. 2004;12(5):400-408.
8. Reuben JD, Meyers SJ, Cox DD, Elliott M, Watson M, Shim SD. Cost comparison between bilateral simultaneous, staged, and unilateral total joint arthroplasty. J Arthroplasty. 1998;13(2):172-179.
9. Ritter MA, Harty LD. Debate: simultaneous bilateral knee replacements: the outcomes justify its use. Clin Orthop Relat Res. 2004;(428):84-86.
10. Restrepo C, Parvizi J, Dietrich T, Einhorn TA. Safety of simultaneous bilateral total knee arthroplasty. A meta-analysis. J Bone Joint Surg Am. 2007;89(6):1220-1226.
11. Stefánsdóttir A, Lidgren L, Robertsson O. Higher early mortality with simultaneous rather than staged bilateral TKAs: results from the Swedish Knee Arthroplasty Register. Clin Orthop Relat Res. 2008;466(12):3066-3070.
12. Noble J, Goodall J, Noble D. Simultaneous bilateral total knee replacement: a persistent controversy. Knee. 2009;16(6):420-426.
13. Fortin PR, Penrod JR, Clarke AE, et al. Timing of total joint replacement affects clinical outcomes among patients with osteoarthritis of the hip or knee. Arthritis Rheum. 2002;46(12):3327-3330.
14. Hooper GJ, Rothwell AG, Hooper NM, Frampton C. The relationship between the American Society of Anesthesiologists physical rating and outcome following total hip and knee arthroplasty: an analysis of the New Zealand Joint Registry. J Bone Joint Surg Am. 2012;94(12):1065-1070.
15. MacWilliam CH, Yood MU, Verner JJ, McCarthy BD, Ward RE. Patient-related risk factors that predict poor outcome after total hip replacement. Health Serv Res. 1996;31(5):623-638.
16. Hadley SR, Lee M, Reid M, Dweck E, Steiger D. Predictors of pulmonary embolism in orthopaedic patient population. Abstract presented at: 43rd Annual Meeting of the Eastern Orthopaedic Association; June 20-23, 2012; Bolton Landing, NY.
17. Hadley S, Immerman I, Hutzler L, Slover J, Bosco J. Staphylococcus aureus decolonization protocol decreases surgical site infections for total joint replacement. Arthritis. 2010;2010:924518.
18. Singh JA, Lewallen DG. Ninety-day mortality in patients undergoing elective total hip or total knee arthroplasty. J Arthroplasty. 2012;27(8):1417-1422.e1.
19. Hu J, Liu Y, Lv Z, Li X, Qin X, Fan W. Mortality and morbidity associated with simultaneous bilateral or staged bilateral total knee arthroplasty: a meta-analysis. Arch Orthop Trauma Surg. 2011;131(9):1291-1298.
20. Meehan JP, Danielsen B, Tancredi DJ, Kim S, Jamali AA, White RH. A population-based comparison of the incidence of adverse outcomes after simultaneous-bilateral and staged-bilateral total knee arthroplasty. J Bone Joint Surg Am. 2011;93(23):2203-2213.
21. Walmsley P, Murray A, Brenkel IJ. The practice of bilateral, simultaneous total knee replacement in Scotland over the last decade. Data from the Scottish Arthroplasty Project. Knee. 2006;13(2):102-105.
22. Fu D, Li G, Chen K, Zeng H, Zhang X, Cai Z. Comparison of clinical outcome between simultaneous-bilateral and staged-bilateral total knee arthroplasty: a systematic review of retrospective studies. J Arthroplasty. 2013;28(7):1141-1147.
23. Bolognesi MP, Watters TS, Attarian DE, Wellman SS, Setoguchi S. Simultaneous vs staged bilateral total knee arthroplasty among Medicare beneficiaries, 2000–2009. J Arthroplasty. 2013;28(8 suppl):87-91.
