Proper patient selection key to simultaneous bilateral total joint arthroplasty
Although simultaneous bilateral total hip or knee arthroplasty can provide patients with a “one-and-done” anesthesia and recovery, noted surgeons who spoke with Orthopedics Today highlighted the importance of patient selection in avoiding complications and achieving outcomes comparable to staged-unilateral procedures.
“You can get excellent outcomes doing [simultaneous total joint procedures] bilaterally. It is just that we have a concern, particularly in patients who carry any significant comorbidities, that they obviously are at higher risk for perioperative complications,” Michael P. Bolognesi, MD, of Duke University Medical Center, told Orthopedics Today. “We like and prefer to do it on patients who are healthier, and we always try to have a frank discussion with the patient about how challenging the bilateral recovery might be and try not to under-inform the patient about what to expect, because I am sure it is not an easy thing to go through.”
When it comes to performing either a staged unilateral or simultaneous bilateral total knee or hip arthroplasty, sources interviewed by Orthopedics Today noted that both procedures can have similar outcomes provided patients do not encounter postoperative complications. However, Ran Schwarzkopf, MD, assistant professor of orthopedic surgery at UC Irvine Health, told Orthopedics Today there is a higher postoperative complication rate among patients who undergo bilateral surgery.
Image: Les Todd/Duke Photography
“Overall outcome is the same [in bilateral vs. unilateral] as long as there are no postoperative complications,” Schwarzkopf said. “It is well established that there is a little higher postoperative complication rate in bilateral total knee or total hip compared to unilateral, and that is what has led to a lot of information that we have today that guides us on proper patient selection. When proper patient selection is done for bilateral total joint replacement, then the outcomes and the complication risks are not increased compared to unilateral.”
Although there can be higher complication rates with simultaneous bilateral surgery, according to Geoffrey Westrich, MD, professor of clinical orthopedic surgery at Hospital for Special Surgery, many patients prefer to undergo a simultaneous bilateral procedure so they do not have to undergo the procedure again in a few months.
“The advantages, as far as doing bilateral surgery, are [patients] get to do one surgery with one anesthetic, one recovery and one physical therapy,” Westrich said. “The advantages also are that patients, if they are working age, can possibly return to work earlier than if they did one [surgery], and then came back 3 months later and did the second [surgery]. So there is less time off in the given year.”
When performing a simultaneous bilateral procedure, surgeons need to be aware of total operative time. Due to the risk of fat emboli traveling to patients’ hearts and lungs and a greater risk of blood loss, Robert T. Trousdale, MD, orthopedic surgeon at the Mayo Clinic, noted simultaneous bilateral procedures should be performed expeditiously.
“For some surgeons, it takes 4 hours to do a total knee replacement [TKR],” Trousdale said. “I imagine a bilateral total procedure is not a good idea for that surgeon. But if the surgeon can do the operation in 45 minutes to an hour, then it is probably a little more worthwhile doing.”
Not only do the surgeons need to be aware of any conditions the patient may have that could cause complications during and after a simultaneous bilateral procedure, but, according to Javad Parvizi, MD, FRCS, director of clinical research at the Rothman Institute, the rest of the surgical team should be aware as well and the patient should be well prepared for the surgery.
“The anesthesiologist needs to be aware of any complexities in the bilateral cases compared to the unilateral. Patients need to be well hydrated and inotropic agents need to be available in case these patients experience hemodynamic instability during the procedure,” Parvizi said. “It is critical that these patients are watched carefully during the postoperative period for any episodes of hyperoxygenation and treated accordingly. It is also important to perform these procedures in centers where there is access to intensive care units, should a complication arise that necessitates strict observation.”
Patients who have too high of a complication risk to undergo simultaneous bilateral total knee or hip replacement may still be eligible to undergo a staged bilateral surgery. According to Westrich, a staged surgery, which has at least a 3 months waiting time between procedures, is a safer solution to simultaneous bilateral surgery.
“The safer way, with respect to getting a better outcome is doing one [knee], waiting 3 months and then doing the second [knee],” Westrich said.
However, he noted one controversial situation for performing simultaneous bilateral TKR includes patients who have significant bilateral deformity, such as bilateral very severe varus, valgus or flexion contracture.
“A lot of times the [knee] you fix will bend again to try to match the other knee, especially with flexion contracture,” Westrich said. “In the interim, if I am not going to do both [knees] at the same time, I will usually put a lift in the patient’s shoe on the other side that has the contracture so they do not bend the side that I just did. So there are ways to get around it, but that is the argument that some people will make is we should do them both because they have such bad deformities.”
Bolognesi said surgeons should determine whether patients should undergo simultaneous bilateral or staged unilateral total arthroplasty on a case-by-case basis.
“I understand the [patients] that are interested in bilateral,” he said. “They want to get it done in one setting, and I am empathetic to that. I understand they want to go through it just one time, but I think you have to risk stratify patients, and the patients that are truly high at risk based on however sick they show up, those patients need to be counseled that it is probably not advisable.”
Researchers from Hospital for Special Surgery looked at the risk of postoperative complications among patients undergoing either single-stage bilateral TKR or unilateral TKR. The researchers created guidelines for the selection of patients best suited for bilateral surgery based upon their finding that patients who underwent bilateral TKR had a significantly higher incidence of fat embolism syndrome and cardiac arrhythmias, and that patients 75 years and older experienced more postoperative complications than younger patients.
According to these guidelines, patients should be excluded from bilateral surgery if they are 75 years or older and categorized as ASA class III, and if they have active ischemic heart disease, poor ventricular function or oxygen-dependent pulmonary disease. Patients should be considered at an increased risk for perioperative complications if they have other significant medical comorbidities, such as insulin-dependent diabetes, renal insufficiency, pulmonary hypertension, steroid-dependent asthma, morbid obesity, chronic liver disease and cerebral vascular disease.
“You want to limit the operation to patients who are healthy enough to handle a bilateral operation,” Trousdale said. “Most surgeons only do [bilateral surgery] on patients who are physiologically healthy, their heart and lungs are in good shape, they get proper perioperative management and the surgery is done efficiently by a surgeon team.”
Along with patients who have a high comorbidity risk, patients who are on narcotic medications for chronic pain would also not be good candidates for bilateral procedures, according to Westrich.
“Say [a patient has] a chronic back problem and they are on narcotics, they are not going to be a great candidate for bilateral surgery because we are going to have to give them more narcotics and sometimes it is a high dose of narcotics,” Westrich said. “If they have already been on narcotics that they take every day for some other issue, then they are going to require too much narcotic postoperatively if we [perform bilateral surgery].”
Question of age and obesity
Although patients 75 years and older may experience more postoperative complications, age has not been labeled as a cut off for bilateral surgery. However, most surgeons believe bilateral surgery should not be performed on elderly patients who have a history of comorbidities and most hospitals will not allow bilateral surgery to be performed on patients older than 75 years of age.
“We should consider age, although age by itself is not the main deterrent. You have to look at patients comorbidities, such as diabetes, cardiac history, pulmonary history, history of previous infection and also obesity,” Schwarzkopf said. “The ideal candidates for bilateral [surgery] should be patients who are younger, who do not have many comorbidities, not overweight and are active. [Those patients] may have the best benefit of having a bilateral knee or hip replacement, thus eliminating the need for twice as long period of disability or inability to go to work and they can have a faster recovery and go back to their professional and personal lives.”
He said patients who are obese would not be included as ideal candidates for simultaneous bilateral TKR, as several studies have indicated a link between obesity and increased risk with these procedures. He also noted that research has shown that morbidly obese patients who underwent simultaneous bilateral TKR experienced an increased risk of transfusion, increased length of stay and increased discharge to a skilled nursing facility compared with obese patients who had staged unilateral TKR.
According to Westrich, patients who are obese are also at a higher risk of cardiopulmonary complications, pulmonary embolism and thromboembolism during simultaneous bilateral total joint arthroplasty, and have a greater risk of wound healing problems.
“Bilateral [total knee arthroplasty] TKA should be done on our ideal patient population and obese patients do not fall under that,” Schwarzkopf said. “They will have increased risks of complications and decreased short-term outcomes. We do not have enough data to report long-term outcome differences.”
Trousdale added that patients who have complex deformities are not good candidates for simultaneous bilateral surgery.
“[Patients] should not be extremely complex, [such as] complex total hips or complex total knees, some major deformity or previous surgery or fracture,” Trousdale said. “If it is a difficult primary total hip, those are probably best done staged; but if it is a routine hip or knee replacement, then it is easier to do them at the same time.”
“Patient selection is key if you are going to do [simultaneous bilateral],” Westrich said. “The non-obese, healthy patient without medical comorbidities who is relatively physically fit and has a high pain tolerance, those are the best patients. Patients who are older, who are heavy, who have medical comorbidities and who have a low pain tolerance, those are the worst patients. The problem is it is a multimodal type of thing. It is not a simple yes or no.”
Rehabilitation protocols for both unilateral and bilateral total hip arthroplasty and TKA stress the importance of early mobilization.
“For any patient undergoing joint replacement, accelerated rehabilitation is believed to reduce the incidence of complication, improve outcomes and also reduce the time to return to full function,” Parvizi said. “[Simultaneous bilateral] patients need to be subjected to the same aggressive regimen of rehabilitation, which involves early mobilization of the patient, extensive rehabilitation in terms of stretching and strength and gait training, and also instruction for patients to engage in as much activity as possible to reduce these complications. Their rehabilitation is not different than the regular unilateral arthroplasty, but, obviously because of the added risk of complications, patients need to be rehabilitated even more efficiently.”
Immediate ambulation of the patient is important in rehabilitation, noted Schwarzkopf, and at-home physical therapy may help patients ambulate faster, start outpatient physical therapy sooner and get back to their daily routines faster.
“You want to have quick ambulation, try to ambulate the patient as early as the day of surgery, have them work on range of motion and ambulation with assisted devices as needed,” Schwarzkopf said. “We are more tended to use ambulation and patient self-exercises, as well as physical therapy. It could be considered for these patients to even have a physical therapist come to the home to help them in the first weeks until the family or they can by themselves go to outpatient physical therapy, especially in knee replacements.”
However, patients undergoing a simultaneous bilateral procedure may have a tougher time with physical therapy because they are unable to bend their knees as easily, Westrich noted, leading to slower ambulation and recovery time.
“There are some patients who want to do both, but after they do both they really have a tougher time with the physical therapy,” Westrich said. “Let us say for knee replacement, they may have a tougher time bending the knees [with bilateral] then if they had done one at a time. [The] safer way with respect to getting a better outcome is doing one [knee], waiting 3 months and then doing the second [knee].”
According to Bolognesi, getting patients into rehabilitation as soon as possible may also be complicated from an insurance standpoint. Where patients used to be able to get into rehabilitation for 5 days to 7 days, some private payers will not cover that stay anymore.
“If [the insurance company] reviews the medical record and they think the patient is well enough to go home and does not require inpatient rehabilitation, they are not going to approve it,” Bolognesi said. “Nowadays, it is harder to get insurance approval for patients even with bilateral cases. [Simultaneous bilateral patients] are patients who you definitely want to get into outpatient therapy as quickly as possible, because you certainly want them to be doing aggressive therapy under the direction of a physical therapist to guarantee they get ideal results for both sides.” – by Casey Tingle
Urban MK. HSSJ. 2006;doi:10.1007/s11420-005-0125-z.
For more information:
Michael P. Bolognesi, MD, can be reached at Duke University Medical Center, 200 Trent Dr. #5216, Durham, NC 27710; email: email@example.com.
Javad Parvizi, MD, FRCS, can be reached at the Rothman Institute, 925 Chestnut St., Philadelphia, PA 19107; email: firstname.lastname@example.org.
Ran Schwarzkopf, MD, can be reached at UC Irvine Health Orthopaedic & Sports Medicine Center, 1640 Newport Blvd., Suite 230, Costa Mesa, CA 92627; email: email@example.com.
Robert T. Trousdale, MD, can be reached at the Mayo Clinic, 200 First St. SW, Rochester, MN 55905; email: firstname.lastname@example.org.
Geoffrey Westrich, MD, can be reached at Hospital for Special Surgery, East 70th St., New York, NY 10021; email: email@example.com.
Disclosures: Bolognesi, Parvizi, Schwarzkopf, Trousdale and Westrich report no relevant financial disclosures.
Why do you think bilateral total joint replacement should or should not be routinely performed?
Simultaneous bilateral is cost-effective
Patients with significant arthritis of both knees with substantial symptoms limiting their quality of life often ask if they should have both knees replaced simultaneously. The idea of a single hospitalization, anesthesia event and recovery period, and limitation of overall office visits, is attractive to both patients and surgeons. However, many patients are concerned about having to do a more difficult rehabilitation on two knees at once and have concerns about increasing the risk of complications, including venous thromboembolism, infection, blood loss and other medical complications; and the need to use two tourniquets also exist. In addition, patients with significant deformity wonder how correction of only one leg will impact the other. All of these factors, and the evidence that supports or does not support them in the context of each individual patient’s medical condition and personal preferences, need to be discussed when deciding whether to perform simultaneous bilateral knee replacements. Furthermore, in the current climate where cost containment has become the responsibility of all health care providers, cost of these two strategies should also be considered.
A recent study of more than 6,672 staged vs. simultaneous total knee arthroplasties showed no significant difference in infection, revision or mortality rates, and the authors concluded that overall risks obtained from the cumulative data from stage procedures shows complication rates very similar to the rates for simultaneous procedures. Other studies have reported lower infection rates in patients undergoing simultaneous bilateral total knee replacement (TKR), though the study was retrospective and patients having these procedures may have been healthier than those undergoing unilateral or staged bilateral procedures. However, there are studies which have demonstrated increased complications, including myocardial infarction, pulmonary embolus, stroke and death, with simultaneous bilateral procedures. One study demonstrated increased pulmonary embolus, cardiac complications and death, while deep vein thrombosis rates were equivalent. Another study examined this issue and found that patients with pulmonary hypertension and congestive heart failure preoperatively had the highest risk of major complications with simultaneous total knee replacement, and that cardiac complications were the most common postoperative complication seen. Studies have also demonstrated that patients older than age 70 years are at risk for myocardial infarction with simultaneous bilateral knee replacements, while those younger than this age were not. Therefore, screening for predisposing pulmonary and cardiac conditions such as sleep apnea, chronic obstructive pulmonary disease, history of pulmonary embolus and congestive heart failure is warranted before proceeding with simultaneous knee replacements, and limiting these simultaneous procedures to younger patients will increase chances of optimizing patient outcomes and minimizing complications.
Lastly, from an economic perspective, studies have shown that simultaneous bilateral knee replacement is cost-effective with lower overall cost when the cumulative costs of two separate hospitalizations and recovery periods is considered for a staged approach.
In conclusion, simultaneous bilateral TKR is a cost-effective procedure that offers patients with severe bilateral disease the opportunity to address both limbs with a single hospitalization and recovery period. However, the rehabilitation period may be more difficult than a single unilateral procedure and this may not be preferred by some patients. Individual patient preferences will dictate which strategy they prefer. Given the choice, some patients will opt for simultaneous procedures, while others will opt for a staged approach, and surgeons should discuss both in appropriate patients. For the patient, this is similar to running a full marathon or two half marathons. Both are difficult, but the challenges are somewhat different. Furthermore, patients with certain comorbidities, including cardiac and pulmonary conditions, and more elderly patients may be better served by a staged approach due to the increased risk a simultaneous approach imparts to these patient groups.
James Slover, MD, MS, is an associate professor in the Adult Reconstruction Division in the Department of Orthopaedic Surgery at the NYU Hospital for Joint Diseases.
Disclosure: Slover reports no relevant financial disclosures.
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Higher risk of perioperative complications
The utilization of simultaneous bilateral total knee arthroplasties (TKAs) has been controversial in the field of adult knee reconstruction during the last several years. With the increasing demand for TKA procedures, the likelihood that patients will require knee arthroplasties performed on both knees is increasing.
The literature supports that there is a slightly higher risk of perioperative complications with simultaneous bilateral TKA which include increased operative time, increased blood loss and increased risk for requiring a higher level of care (i.e., intensive care unit), as well as increased mortality. These data have predominantly been published in the arena of simultaneous bilateral TKA performed in elderly patients. It is clear that octogenarians should not be considered candidates for bilateral simultaneous TKA due to the associated higher complication rate.
A secondary component associated with simultaneous bilateral TKA is a more difficult postoperative rehabilitation course. Patients exhibit an easier time with postoperative rehabilitation after unilateral TKA. In addition, most patients after a unilateral procedure are now being sent home as opposed to historically being routinely sent to a rehab facility. Most patients with bilateral TKA often still require a short stay in rehab as opposed to being discharged home.
The only true indication for bilateral simultaneous TKA is a patient who has significant flexion contractures of both knees. Since the knee seeks symmetry, performing a unilateral TKA with the contralateral knee still affected may not allow patients to maximize their postoperative rehab potential and gain full range of motion, specifically full extension.
Neil Sheth, MD, is an assistant professor of orthopedic surgery at the Hospital of the University of Pennsylvania.
Disclosure: Sheth reports no relevant financial disclosures.