Simultaneous bilateral total knee arthroplasty - is it the final answer?

Original Article Simultaneous bilateral total knee arthroplasty - is it the final answer? Sabari Girish R1, Gopalakrishnan KC2, Subin Sugath3, Anoop ...
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Original Article

Simultaneous bilateral total knee arthroplasty - is it the final answer? Sabari Girish R1, Gopalakrishnan KC2, Subin Sugath3, Anoop S4 Sri Uthradom Thirunal Hospital Trivandrum, Kerala India


Consultant in Orthopaedics


Professor of Orthopaedics

Correspondence should be sent to: [email protected]

Kerala Journal of Orthopaedics 2011;24:15-22 © Kerala Journal of Orthopaedics

Abstract Many patients have arthritis of both knees requiring operative intervention. The are studies favouring and criticising bilateral simultaneous total knee replacements. 30 patients who underwent bilateral simultaneous total knee replacements were compared to five published international studies. The authors conclude that they recommend bilateral simultaneous total knee replacements because it reduces cost, hospital stay and rehabilitation time, while there was no significant increase in any of the complications. Keywords: Bilateral simultaneous total knee arthroplasty Introduction Total knee arthroplasty can provide reliable pain relief and consistent correction of limb alignment in patients with moderate or severe arthritis. Many of these patients have bilateral gonarthrosis requiring operative intervention. The surgeon and patient are then faced with the decision of whether to proceed with staged bilateral total knee replacement done as two unilateral total knee arthroplasty procedures performed on different days or a simultaneous bilateral total knee replacement. Critics of simultaneous bilateral total knee replacement believe that the rate of perioperative complications is greater than that associated with staged bilateral arthroplasty. Several authors have reported an increased risk of cardiovascular and neurological complications in patients undergoing bilateral surgery. However, proponents of simultaneous bilateral total knee arthroplasty have reported greater patient satisfaction, lower overall rehabilitation time, similar functional gains and decreased costs for the patient and institution. Several authors have also found no difference between

unilateral and bilateral procedures in Simultaneous Bilateral TKAs, in carefully selected patients with bilateral arthritis of knee requiring intervention, since 2001. We hypothesised that there would be no difference in the prevalence of perioperative complications between unilateral total knee arthroplasty and simultaneous bilateral total knee arthroplasty. Aims and objectives 1. To study the safety of simultaneous bilateral TKA in terms of perioperative complications. 2. To compare perioperative complications of Simultaneous Bilateral TKA performed in our institute with that of staged bilateral TKA in international published studies. Materials and methods All patients with clinical and radiological evidence of bilateral arthritis of knee requiring surgical intervention, in the study period (2006 January to 2008 December), were offered simultaneous surgery after explaining risks and benefits. Patients who were willing for the simultaneous procedure underwent a preliminary cardiac and anaesthetic

Kerala Journal Of Orthopaedics Volume 24 | Issue 1 | July 2011


Original Article Sabari et al.: Simultaneous bilateral total knee arthroplasty - is it the final answer?

evaluation. Those with adequate cardiac and pulmonary reserve were selected for simultaneous TKA. 60 knees of 30 patients (F:M = 4:1) who underwent simultaneous bilateral primary TKA between 2006 January and 2008 December were selected for the study. All of them had a minimum follow up of 1 year. 65% of the cases were primary osteoarthritis, followed in frequency by Rhuematoid Arthritis and secondary osteoarthritis. 80% of the patients were ASA (American Society of Anaesthesiologists) grade 2 or 3, 15% were ASA grade 1 and 5% were ASA grade 4. 35% of patients

had Diabetes Mellitus, 25% had Hypertension and 40% had both as co morbidities. All procedures were carried out under single aanesthesia in a sequential manner. Tourniquet was used in majority of cases. Except in two, cruciate retaining prosthesis was used in all the cases. The same surgical technique and postoperative protocol was used in all cases. Data was collected using a structured proforma and was analysed using SPSS ver. 17 (Statistical Package for the Social Sciences). These were then compared with 5 published articles on staged TKA in indexed journals, selected randomly. [1,2,3,4,5]

Figure 1. Age distribution

Discussion Total knee arthroplasty continues to be one of the most effective orthopedic operative procedures and is considered to be extremely safe. Although the majority of patients with arthritis of the knee undergo unilateral total knee arthroplasty, not infrequently patients present with symptomatic arthritis of both knees. The orthopedic surgeon must then decide if bilateral simultaneous total knee arthroplasty is a safe operation to perform in this setting. There are many advantages to performing bilateral arthroplasty during one anaesthetic session. Patient convenience, reduced length of stay in the hospital and a potentially shortened period of rehabilitation and disability are some of the appeals of this approach. On the other hand, the fear of increased complications deters some


surgeons from performing bilateral arthroplasty during one anaesthetic session. An orthopedic surgeon attempting to extract information from the literature regarding the safety of simultaneous bilateral total knee arthroplasty may be faced with conflicting findings. There may be several reasons for the apparent conflict noted in the literature. Because of the relative rarity of complications such as pulmonary embolism, the majority of studies have a type-II statistical error resulting from a patient population of inadequate size. In addition, the effect of probable and important, selection bias cannot often be gleaned from these studies. Cardiac complications Cardiac complications can be potentially life threatening and have been consistently reported

Kerala Journal of Orthopaedics Volume 24 | Issue 1 | July 2011

Original Article Sabari et al.: Simultaneous bilateral total knee arthroplasty - is it the final answer?

to be higher following simultaneous bilateral TKA than following unilateral knee arthroplasties or staged bilateral procedures. Myocardial infarction, angina, cardiac arrhythmias and congestive cardiac failure are some of the reported cardiac complications with simultaneous bilateral TKA. Among these complications, cardiac arrhythmias and myocardial infarction are the two relatively frequently observed complications. Lynch et al, in a study comparing 98 patients older than 80 years who had had either unilateral or simultaneous bilateral TKA concluded that older patients might not have the reserve to manage the fluid shifts that occur after a bilateral procedure. In the study, cardiovascular complications were observed after 22% of bilateral procedures compared with 6% of unilateral procedures. This finding was reaffirmed in another study in which the relative risk of myocardial

infarction in the bilateral group compared with that in the unilateral group was 4.38 for patients between 70 and 79 years and 6.76 for those older than 80 years. Cardiac complications in our patients undergoing SBTKR did not show any significant difference from staged TKR published in the selected studies (Figure 2). Pulmonary complications Pulmonary embolism and fat embolism are two serious complications reported with relatively higher incidence with simultaneous bilateral knee arthroplasty, culminating in higher mortality in these patient groups. However, in a recent study on a large patient population group, Barrett et al concluded that the risk of developing symptomatic pulmonary embolism in patients with simultaneous

Figure 2. Cardiac complications

Figure 3. Pulmonary complications

Kerala Journal Of Orthopaedics Volume 24 | Issue 1 | July 2011


Original Article Sabari et al.: Simultaneous bilateral total knee arthroplasty - is it the final answer?

bilateral procedures is 80% higher than in those with staged bilateral or unilateral knee arthroplasty, with the absolute risk being low in either case, thus suggesting that the sum of the risks associated with the 2 operations of a staged procedure may equal or exceed the risk of simultaneous TKA. Additionally, pneumonia and pulmonary hypoxia have also been observed in association with bilateral procedures in a few studies. Pulmonary complications in our series did not show significant difference with those in staged TKR in the selected studies (Figure 3). Neurological complications Neurological complications have been reported more commonly with simultaneous bilateral TKA than unilateral or staged procedures with confusion being the most frequently reported complication. It is thought that the physiological stress imposed by surgery and anaesthesia leading

to dehydration, electrolyte imbalance and anaemia may contribute to confusion regardless of whether unilateral or simultaneous bilateral TKA was performed. Moreover, confusion is believed to occur with simultaneous bilateral TKA due to a higher propensity for dissemination of fat emboli in systemic circulation with this procedure. Postoperative confusion is considered to be one of the manifestations of fat embolism and the presence of confusion combined with altered arterial blood gases is a definitive indication of fat embolism. Cerebrovascular accidents have been documented with variable incidence in some cases, but these studies have not delineated the causes and severity of this complication with simultaneous bilateral TKA. In our series we had three patients suffering from post operative confusion (Figure 4) who recovered uneventfully. None of our patients suffered from CVA or fat embolism.

Figure 4. Neurologic Complications

30 day mortality Perioperative death is undoubtedly the most feared complication by the patient and the surgeon. Various authors have attempted to report the mortality rates with simultaneous bilateral knee procedures , with the rates being reported over a period of 30 days, 90 days, or 1 year postoperatively. In an interesting analysis, Bullock et al observed that the risk of 1-year mortality after bilateral arthroplasty (2.1%) approached the risk of mortality for a patient of average age in his cohort group (2.3%). Hence, they concluded that patients


undergoing bilateral TKA are, in general, at no more risk of dying than are individuals of a similar age dying of natural causes. However, it would be reasonable to consider that reporting of mortality rates beyond 30 days of surgical procedure may lead to inclusion of deaths that are not attributable to knee surgery and the 30 day mortality rates represent the true measure of the mortality associated with the procedure. The 30 day mortality rate has been observed to be higher with simultaneous bilateral procedures as compared to unilateral or staged procedures. Although some

Kerala Journal of Orthopaedics Volume 24 | Issue 1 | July 2011

Original Article Sabari et al.: Simultaneous bilateral total knee arthroplasty - is it the final answer?

studies have failed to report the medical events leading to the high mortality, it seems probable that the cardiac and respiratory complications often lead to this consequence. Older age, especially older than 80 years, and preexisting comorbid factors have been correlated with higher mortality in bilateral procedures. The 90-day and 1-year mortality rates of simultaneous bilateral procedures

have been estimated to reach close to those of staged or unilateral procedures and may even become less after a 10-year period, but consideration of these morality rates may lead to erroneous interpretations. 30 day mortality in our series was 0 which is less when compared to that of staged TKA in selected studies (Figure 5).

Figure 5. 30 day mortality rates

Blood transfusion rates






There appears to be substantial variation in

variations, the rates of blood transfusion in



simultaneous bilateral TKA have been found to be

simultaneous bilateral TKA. This is most likely due

greater than those in unilateral arthroplasty

to differences in criteria used for reporting the blood






transfusion rates and blood loss and the perioperative measures used to manage blood loss







such as preoperative donation of autologous blood,

transfusion. 1.7 units of blood were transfused per

reinfusion of drained blood and duration of the

patient. This certainly is higher when compared to staged TKA (Figures 6, 7).

Figure 6. Percentage of patients requiring blood transfusion

Kerala Journal Of Orthopaedics Volume 24 | Issue 1 | July 2011


Original Article Sabari et al.: Simultaneous bilateral total knee arthroplasty - is it the final answer?

Figure 7. No. of units of blood transfused per patient

Intensive Care Unit Admissions The rates of intensive care unit admission are

Our no of ICU days per patient was certainly higher when compared to staged TKA (Figure 8).

also reported to be higher with simultaneous bilateral procedures. This might be a reflection of

Infection rates

the greater need for monitoring of cardiopulmonary

Superficial infection in our series was

parameters with this procedure, especially in elderly

comparable to staged TKA. We did not have any

patients. In a study by Bullock et al, the rate of

patients with deep infection (Figure 9)

intensive care unit admission was observed to be 0.59% in the unilateral group and 3.9% in the


bilateral group, with a relative risk of 6.61. Similarly,

Rates of cardiac, pulmonary and neurologic complications showed no significant difference. 30 day mortality rate was comparable to staged procedures. Superficial infection rate showed no significant difference. Deep infection rate was nil.

Ritter et al reported that the number of intensive care unit care days of simultaneous bilateral knee arthroplasty were twice that in unilateral or staged groups. Figure 8. No. of ICU days


Kerala Journal of Orthopaedics Volume 24 | Issue 1 | July 2011

Original Article Sabari et al.: Simultaneous bilateral total knee arthroplasty - is it the final answer?

Figure 9. Deep infection

Figure 10. Delayed wound healing

Blood transfusion rates were higher.


Cost was reduced by 15-20 thousand rupees when compared to the cost of staged bilateral TKR in our institution. Hospital stay reduced by 5-7 days. Rehabilitation period was shortened. Post op knee function was better than staged procedures.


Rosenberg AG.

True indications for bilateral

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Lynch NM, Trousdale RT, Ilstrup DM. Complications after concomitant bilateral total knee arthroplasty in elderly patients. Mayo Clin

There is certainly a substantial reduction in cost, hospital stay and rehabilitation time.

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Ritter MA, Meding JB. Bilateral simultaneous total knee arthroplasty. J Arthroplasty.

We would certainly recommend simultaneou s bilateral TKR in patients with bilateral advanced arthritis of knee after adequate pre operative analysis.

1987;2:185-9. 4.

Ritter MA. Bilateral simultaneous TKR: doing what’s best for the patient. Orthopedics. 2000;23:538.

Kerala Journal Of Orthopaedics Volume 24 | Issue 1 | July 2011


Original Article Sabari et al.: Simultaneous bilateral total knee arthroplasty - is it the final answer?



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Source of funding: Nil; Conflict of interest: Nil

Cite this article as: Sabari Girish R, Gopalakrishnan KC, Subin Sugath, Anoop S. Simultaneous bilateral total knee arthroplasty- is it the final answer?. Kerala Journal of Orthopaedics. 2011;24:15-22


Kerala Journal of Orthopaedics Volume 24 | Issue 1 | July 2011

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