Orthopedics

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Feature Article 

One- Versus Two-stage Bilateral Total Hip Arthroplasty

Shu Saito, MD; Yasuaki Tokuhashi, MD; Takao Ishii, MD; Sei Mori, MD; Kunihiro Hosaka, MD; Shin Taniguchi, MD

  • Orthopedics. 2010;33(8)
  • Posted August 1, 2010

Abstract

We compared the results of 1-stage uncemented bilateral total hip arthroplasty (THA) performed in 49 patients (98 hips) with those of 2-stage uncemented bilateral THA performed during the same hospital stay in 40 patients (80 hips). There was no significant difference in mean Harris Hip Score preoperatively and at final follow-up between the 2 groups. Radiographic evaluation of patients in the 1-stage group revealed the acetabular component was stable in 95 hips and possibly unstable in 3. The femoral component was bone-ingrown in 91 hips and stable fibrous in 7. In the 2-stage group, the acetabular component was stable in 77 hips and possibly unstable in 3. The femoral component was bone-ingrown in 71 hips and stable fibrous in 9. In both groups, no patients exhibited clear signs of loosening, migration or osteolysis.

In the 1-stage group, postoperative dislocation occurred in 2 hips and 1 patient had developed deep venous thrombosis and pulmonary embolism. In the 2-stage group, no complications were observed. The incidence of complications was not significantly different between the 2 groups.

There was no significant difference in the total blood loss and mean hemoglobin level preoperatively and at discharge between the 2 groups. However, in the 1-stage group, operative time, intraoperative blood loss, procedure cost, and hospital stay were significantly reduced compared with the 2-stage group. Therefore, 1-stage bilateral THA is a safe and effective option for patients with significant arthritic disease of both hips.

A majority of total hip arthroplasties (THAs) being performed are unilateral. However, osteoarthritis of the hip presents as bilateral disease in 42% of patients.1,2 One-stage bilateral THA began being performed in the 1970s.3-5 Some studies have reported a higher incidence of medical and surgical complications after the introduction of 1-stage bilateral THA.6,7 Ritter and Randolph5 reported that simultaneous bilateral THA showed an increased incidence of deep venous thrombosis (DVT), pulmonary embolism, and myositis ossification, while the duration of hospital stay averaged 1 week longer and operative time and blood loss doubled as compared with patients who underwent a single unilateral operation.

Improvements in anesthetic and surgical techniques and postoperative care have resulted in improved outcomes in 1-stage bilateral THA. One-stage bilateral THA offers benefits that include faster recovery, easier rehabilitation, shorter hospital stay, lower procedure cost, and 1-session anesthetic risk.8,9 Recently, several studies have indicated that 1-stage bilateral THA is an effective procedure for patients affected with bilateral hip arthritis without significantly increasing the risk for the patient.10-19

The purpose of this study was to determine the results of 1-stage bilateral THA and compare them with those of 2-stage bilateral THA performed during the same hospital stay.

Between February 1996 and December 2004, a total of 354 consecutive THAs in 312 patients were performed by 4 surgeons (S.S., T.I., S.M., K.H.) at our institution using the Metasul Hip System (Zimmer, Warsaw, Indiana). From January 2004 to December 2008, a total of 333 consecutive THAs in 285 patients were performed using the Total Nichidai Hip System (TNH; Nakashima Medical, Okayama, Japan). Acetabular and femoral components were made of titanium alloy, whereas articulating surfaces were made of cobalt-chromium-molybdenum.

Since September 1999, we used 1-stage bilateral THA or 2-stage bilateral THA in a 2-part hospital stay for patients with symptomatic bilateral arthritis of the hip. From January 2004, 2-stage bilateral THA was performed during the same hospital stay. We randomly selected patients who underwent 1- and 2-stage bilateral THA for our study.

Of 687 THAs, 98 hips in 49 patients underwent 1-stage bilateral THA by 2 surgeons (S.S., T.I.): 12 hips in 6 men and 86 hips in 43 women. None of the 49 patients…

Abstract

We compared the results of 1-stage uncemented bilateral total hip arthroplasty (THA) performed in 49 patients (98 hips) with those of 2-stage uncemented bilateral THA performed during the same hospital stay in 40 patients (80 hips). There was no significant difference in mean Harris Hip Score preoperatively and at final follow-up between the 2 groups. Radiographic evaluation of patients in the 1-stage group revealed the acetabular component was stable in 95 hips and possibly unstable in 3. The femoral component was bone-ingrown in 91 hips and stable fibrous in 7. In the 2-stage group, the acetabular component was stable in 77 hips and possibly unstable in 3. The femoral component was bone-ingrown in 71 hips and stable fibrous in 9. In both groups, no patients exhibited clear signs of loosening, migration or osteolysis.

In the 1-stage group, postoperative dislocation occurred in 2 hips and 1 patient had developed deep venous thrombosis and pulmonary embolism. In the 2-stage group, no complications were observed. The incidence of complications was not significantly different between the 2 groups.

There was no significant difference in the total blood loss and mean hemoglobin level preoperatively and at discharge between the 2 groups. However, in the 1-stage group, operative time, intraoperative blood loss, procedure cost, and hospital stay were significantly reduced compared with the 2-stage group. Therefore, 1-stage bilateral THA is a safe and effective option for patients with significant arthritic disease of both hips.

A majority of total hip arthroplasties (THAs) being performed are unilateral. However, osteoarthritis of the hip presents as bilateral disease in 42% of patients.1,2 One-stage bilateral THA began being performed in the 1970s.3-5 Some studies have reported a higher incidence of medical and surgical complications after the introduction of 1-stage bilateral THA.6,7 Ritter and Randolph5 reported that simultaneous bilateral THA showed an increased incidence of deep venous thrombosis (DVT), pulmonary embolism, and myositis ossification, while the duration of hospital stay averaged 1 week longer and operative time and blood loss doubled as compared with patients who underwent a single unilateral operation.

Improvements in anesthetic and surgical techniques and postoperative care have resulted in improved outcomes in 1-stage bilateral THA. One-stage bilateral THA offers benefits that include faster recovery, easier rehabilitation, shorter hospital stay, lower procedure cost, and 1-session anesthetic risk.8,9 Recently, several studies have indicated that 1-stage bilateral THA is an effective procedure for patients affected with bilateral hip arthritis without significantly increasing the risk for the patient.10-19

The purpose of this study was to determine the results of 1-stage bilateral THA and compare them with those of 2-stage bilateral THA performed during the same hospital stay.

Materials and Methods

Between February 1996 and December 2004, a total of 354 consecutive THAs in 312 patients were performed by 4 surgeons (S.S., T.I., S.M., K.H.) at our institution using the Metasul Hip System (Zimmer, Warsaw, Indiana). From January 2004 to December 2008, a total of 333 consecutive THAs in 285 patients were performed using the Total Nichidai Hip System (TNH; Nakashima Medical, Okayama, Japan). Acetabular and femoral components were made of titanium alloy, whereas articulating surfaces were made of cobalt-chromium-molybdenum.

Since September 1999, we used 1-stage bilateral THA or 2-stage bilateral THA in a 2-part hospital stay for patients with symptomatic bilateral arthritis of the hip. From January 2004, 2-stage bilateral THA was performed during the same hospital stay. We randomly selected patients who underwent 1- and 2-stage bilateral THA for our study.

Of 687 THAs, 98 hips in 49 patients underwent 1-stage bilateral THA by 2 surgeons (S.S., T.I.): 12 hips in 6 men and 86 hips in 43 women. None of the 49 patients were lost to follow-up. Mean patient age at the index procedure was 59.0 years (range, 36-75 years). Mean body mass index (BMI) was 23.5 kg/m2 (range, 19.5-25.9 kg/m2), and mean follow-up was 5.5 years (range, 1-10 years). The primary diagnosis for each hip was osteoarthritis in 43 patients, rheumatoid arthritis in 3, and aseptic necrosis in 3.

Eighty hips in 40 patients underwent 2-stage bilateral THA by 4 surgeons (S.S., T.I., S.M., K.H.) during the same hospital stay. The more symptomatic side was operated on first, and the contralateral side was operated on an average of 30.7 days (range, 16-63 days) later: 8 hips in 4 men and 72 hips in 36 women. None of the 40 patients were lost to follow-up. Mean patient age at the index procedure was 61.9 years (range, 46-74 years). Mean BMI was 23.8 kg/m2 (range, 19.9-26.8 kg/m2), and mean follow-up was 3.1 years (range, 1-5 years). The primary diagnosis for each hip was osteoarthritis in 38 patients and rheumatoid arthritis in 2 (Table).

Table: Patient Data

All patients were admitted 7 days preoperatively. All patients were evaluated using echocardiograms and pulmonary function tests. Two units of predonated autologous blood were conserved preoperatively.

In the surgical procedure for 1-stage bilateral THA, patients were positioned laterally and the more symptomatic side was operated on first. After completing the first hip, the hemodynamic status of the patient was evaluated. If the patient’s hemodynamic condition was deemed to be stable, the position was changed and the contralateral side was initiated. The changeover time ranged between 10 and 15 minutes.

Total hip arthroplasty was performed using the posterolateral approach without resecting the greater trochanter, and both the acetabular and femoral sides were fixed without cement. In cases of osteoarthritis with acetabular dysplasia where the bony coverage of the acetabular component was <70%, autogenous grafting from femoral head solid bone grafts was performed on the acetabular edge. In the 1-stage group, acetabular edge bone grafting was performed in 3 hips.

The Constavac Blood Conservation device (Stryker, Kalamazoo, Michigan) was used for all patients to reduce the need for allogenic blood transfusion. Salvaged blood was retransfused from the device 6 hours postoperatively. Predonated autologous blood (2 units) was transfused 2 days postoperatively.

Intravenous antibiotics were administered for 3 days postoperatively. No anticoagulation prophylaxis was administered. Sequential compression device and intermittent pneumatic compression was used for all patients. The patients were allowed to be transferred to a wheelchair 3 days postoperatively and start rehabilitation with full weight bearing.

All clinical information was obtained through office interviews and physical examinations. Patients were scheduled for follow-up visits at 1, 3, and 6 months postoperatively and yearly thereafter, with radiographs obtained at each visit. The hips were clinically rated preoperatively and at final follow-up using the Harris Hip Score,20 by which a score of >90 points is considered an excellent result, 80 to 89 points is considered good, 70 to 79 points is considered fair, and <70 points is considered poor.

Radiographically, the hips were evaluated for the fixation of components, osteolysis, and loosening. Acetabular component fixation was evaluated using the method described by Tompkins et al.21 Femoral component fixation was evaluated using the method described by Engh et al.22 A Kaplan-Meier survivorship analysis was performed with the endpoint defined as a revision operation for symptomatic loosening and radiological loosening.

Complications, operative time, intraoperative blood loss, total blood loss, change of hemoglobin, length of hospital stay, and total hospital cost were reviewed. The total cost of the procedures included surgical, anesthesia, hospitalization, and inpatient rehabilitation charges.

Statistical analysis between the 2 groups was performed using the Mann-Whitney U test, and the level of significance was set at P<.05.

Results

In the 1-stage bilateral THA group, mean HHS was 44.9 points (range, 21-53 points). At final follow-up an average of 5.5 years postoperatively, mean HHS was 87.8 points (range, 85-100 points). Overall, 95 hips were rated as excellent and 3 hips as good. In the 2-stage bilateral THA group, mean HHS was 41.1 points (range, 25-61 points). At final follow-up an average of 3.1 years postoperatively, mean HHS was 87.3 points (range, 85-95 points). Overall, 75 hips were rated as excellent and 5 hips as good. In both groups, no patient had an early or late postoperative deep infection. There was no significant difference in mean Harris Hip Score preoperatively and at final follow-up between the 2 groups.

Radiographic evaluation of patients in the 1-stage group revealed the acetabular component was stable in 95 hips and possibly unstable in 3. The femoral component was bone-ingrown in 91 hips and stable fibrous in 7 (Figure). In the 2-stage group, the acetabular component was stable in 77 hips and possibly unstable in 3. The femoral component was bone-ingrown in 71 hips and stable fibrous in 9. In both groups, no patients exhibited clear signs of loosening, migration, or osteolysis.

Figure A: Marked acetabular dysplasia Figure B: Autologous femoral head bone graft was performed

Figure: Preoperative AP radiograph of the bilateral hips. Marked acetabular dysplasia is observed (A). AP radiograph of the bilateral hips 8 years postoperatively. The acetabular component fixation is stable and the femoral component fixation is bone-ingrown. Autologous femoral head bone graft was performed on the left side of the acetabular edge (B).

In the 1-stage group, postoperative dislocation occurred in 2 hips and 1 patient developed DVT and pulmonary embolism. In the 2-stage group, no complication was observed. There was no appropriate statistical testing method applicable for comparison between the 2 groups.

The survival rate at 5.5 years postoperatively for patients in the 1-stage group and at 3.1 years postoperatively for those in the 2-stage group was 100%.

The mean total operative time was 159 minutes (range, 90-255 minutes) in the 1-stage group and 179 minutes (range, 120-228 minutes) in the 2-stage group. The mean total operative time in 1-stage group was significantly shorter than in the 2-stage group (P<.01).

The mean intraoperative blood loss was 295 mL (range, 60-845 mL) in the 1-stage group and 378 mL (range, 172-703 mL) in the 2-stage group. The mean intraoperative blood loss in the 1-stage group was significantly less than in the 2-stage group (P<.05). The mean total blood loss was 1018 mL (range, 130-2845 mL) in the 1-stage group and 1019 mL (range, 312-2003 mL) in the 2-stage group (P>.45). The mean blood retransfusion from the Constavac Blood Conservation device was 378 mL (range, 0-1040 mL) in the 1-stage group and 464 mL (range: 0-1020 mL) in the 2-stage group (P>.28).

The mean hemoglobin level preoperatively was 13.1 mg/dL (range, 12.7-15.1 mg/dL) in the 1-stage group and 12.3 mg/dL (range, 11.5-14.3 mg/dL) in the 2-stage group (P>.67). The mean hemoglobin level at discharge was 10.9 mg/dL (range, 9.3-12.1 mg/dL) in the 1-stage group and 10.8 mg/dL (range, 9.2-12.3 mg/dL) in the 2-stage group (P>.84). There was no significant difference in the mean hemoglobin level preoperatively and at discharge between the 2 groups. Two patients in the 1-stage group received 4 units of allogenic blood transfusion, while no patients in the 2-stage group did.

The mean length of hospital stay was 39.6 days (range, 25-76 days) in the 1-stage group and 60.6 days (range, 49-80 days) in the 2-stage group. The mean length of hospital stay in the 1-stage group was significantly shorter than in the 2-stage group (P<.01). The length of hospital stay was mainly accounted by inpatient rehabilitation.

The mean total hospital cost per patient was lower in the 1-stage group (¥384,833) compared with the 2-stage group (¥461,156) (P<.01). The differences in costs were associated with 2 anesthetics and separate rehabilitations.

Discussion

It remains controversial whether it is better to do bilateral THA in 1 or 2 stages. One-stage bilateral THA may be associated with a higher incidence of medical and surgical complications.5-7 These studies have detected a higher incidence in particular cardiopulmonary complications in patients with 1-stage bilateral THA. The possible higher morbidity and mortality rate of 1-stage bilateral THA may inhibit some surgeons from advocating this procedure.5 Berend et al6 reported simultaneous bilateral THA showed a two-fold increase in the incidence of pulmonary complications compared with patients receiving 2-stage bilateral THA.

However, 1-stage bilateral THA seems a reasonable option for the patients with symptomatic bilateral arthritis of the hip. Recently, several studies have indicated that 1-stage bilateral THA is an effective procedure without significantly increasing the risk for the patients.10-19 One-stage bilateral THA offers the benefits of a 1-session anesthetic risk, a shorter disability and recovery period, and a shorter cumulative hospitalization. Additionally, 1-stage bilateral THA costs less than 2-stage bilateral THA.8,9 These studies included patients younger than 63 years and recommended 1-stage bilateral THA only for patients who were younger and healthy. However, several studies demonstrate 1- or 2-stage bilateral THA to be safe and effective in elderly patients with typical comorbidities associated with advanced age.16,23,24 In addition, 1-stage bilateral THA confers a potential benefit of greater postoperative hip functions because contralateral hip disabilities do not adversely affect the replaced hip.25 Wykman and Olsson26 reported the gait analysis of 1-stage bilateral THA compared with unilateral THA. One-stage bilateral THA indicated an optimal recovery of walking ability. In our study, at final follow-up almost all patients were pain free and able to walk without walking aids.

Our data suggest the short-term outcome of bilateral THA is excellent in the majority of patients and indicate that there was no significant difference in the mean hemoglobin level preoperatively and at discharge between the 2 groups. Only 2 patients in the 1-stage group received 4 units of allogenic blood transfusion. Moreover, in the 1-stage group, the mean total operative time was significantly shorter and the mean intraoperative blood loss was significantly less than in the 2-stage group.

Regarding postoperative complications, dislocation occurred in 2 hips and 1 patient developed DVT and pulmonary embolism in the 1-stage group. However, the incidence of complications was not significantly different between the 2 groups. One reason for this may be that the 1-stage bilateral THA was performed by 2 surgeons who had high surgeon volume. In several studies, high surgeon volume (>500) was significantly associated with shorter operative time, less blood loss, and a lower rate of postoperative complications in the United States.27 In Japan, Yasunaga et al28 indicated that surgeon volume was a significant predictor of better outcomes after THA, and surgeons with the highest volumes were associated with significantly shorter operative time, less blood loss, and a lower rate of postoperative complications.

The hospital cost in the 2-stage bilateral THA was higher than in the 1-stage bilateral THA associated with 2 anesthetics, separate rehabilitations, and markedly longer cumulative hospital stays. The cost difference did not include expenses associated with the management of complications such as DVT, pulmonary embolism, reoperations, and revision surgery. Because of the increased incidence of complications, the cost is likely to be even higher for 2-stage bilateral THA.8,9,18 In this study, no patient required reoperation or revision surgery.

References

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Authors

Drs Saito, Tokuhashi, Ishii, Mori, Hosaka, and Taniguchi are from the Department of Orthopedic Surgery, Nihon University School of Medicine, Tokyo, Japan.

Drs Saito, Tokuhashi, Ishii, Mori, Hosaka, and Taniguchi have no relevant financial relationships to disclose.

Correspondence should be addressed to: Shu Saito, MD, Department of Orthopedic Surgery, Nihon University School of Medicine, 30-1 Oyaguchi, Kamimachi, Itabashi-Ku, Tokyo, 173-8610 Japan (ssaito@med.nihon-u.ac.jp).

doi: 10.3928/01477447-20100625-07

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