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Lower rates of prosthetic joint infection and fewer mechanical failures seen after simultaneous bilateral TKA
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Simultaneous bilateral total knee arthroplasty results in significantly fewer prosthetic joint infections compared with staged arthroplasties, according to results recently presented at the 2011 Annual Meeting of the American Academy of Orthopaedic Surgeons.
However, the study revealed that simultaneous bilateral total knee arthroplasty (B-TKA) carried a moderately higher risk of having an adverse cardiovascular outcome within 30 days of the procedure.
Lead investigator John P. Meehan, MD, explained the findings could potentially lead to the reduction of complications, failures, operating room sessions and overall length of hospital stay. The higher risk of cardiovascular events, however, indicates that physicians must be careful in their selection of patients as potential candidates for the simultaneous bilateral total knee replacement procedure.
A retrospective comparison
Meehan and colleagues used the California Patient Discharge Database to perform a retrospective comparison of adverse outcomes in 11,445 patients who underwent simultaneous B-TKA and 23,715 patients who had the first of two sequential, or staged, TKAs performed between 1997 and 2006.
The investigators used sophisticated methods to adjust for factors that make a comparison of the incidence of complications after a single bilateral operation vs two sequential operations complex.
The investigators discovered that patients who underwent simultaneous B-TKA had a 48% lower rate of major joint infection and a 26% lower rate of mechanical malfunction compared with the staged-TKA group. However, the simultaneous group also displayed a similar risk of death and had a 50% to 60% higher risk-adjusted odds of having a myocardial infarction or pulmonary embolism than the staged cohort.
The risk of developing a serious knee joint infection requiring additional knee revision surgery, the group reported, was nearly two times higher in patients who had staged knee replacements than it was in patients who had both knees replaced simultaneously — 2.2% compared with 1.2% respectively.
Changes in practice
Although further research is needed to better define which patients should or should not be considered for bilateral simultaneous knee replacement, Meehan told Orthopedics Today the evidence has been enough to shift some of his own practices.
“On a personal note, this study has caused me to offer simultaneous bilateral knee replacement to more people with symptomatic osteoarthritis in both knees,” he said. “I believe our study addresses the significant bias which is inherent in most previous studies, and gives a more accurate estimate of the risks and benefits of the procedures.”
Meehan added he informs patients their “absolute risk of having a perioperative cardiac event” is 3 in 1,000, compared with an absolute risk of 10 in 1,000 for needing a reoperation because of a joint infection or mechanical failure.– by Robert Press
Reference:
- Meehan JP, et al. Safety of simultaneous bilateral total knee arthroplasty (B-TKA) versus staged bilateral TKA (S-TKA). Paper 593. Presented at the 2011 Annual Meeting of the American Academy of Orthopaedic Surgeons. Feb. 14-19, 2011. San Diego.
- John P. Meehan, MD, is an orthopedic surgeon and can be reached at 2315 Stockton Blvd., Sacramento, CA 95817; e-mail: meehan3@hotmail.com.
- Disclosure: Meehan has no relevant financial disclosures.
This article uses a large database from the California public hospital system to identify medical and mechanical complications following simultaneous- vs. a staged-bilateral-knee arthroplasty.
The authors identified a low incidence of prosthetic joint infection and mechanical failure in the simultaneous-bilateral group vs. the staged-bilateral total knee arthroplasty (TKA) group. They also identified a higher risk of cardiovascular events in the simultaneous TKA group. The authors use 10% as a loss incidence for patients who decide not to proceed with the second TKA. I am not sure if that is valid, and were there any patients lost to the private hospital system? It is unclear if a different provider performed the second TKA and if that played a role in the increased mechanical failure rate. There has been a concern in the literature regarding increased incidence of infection following simultaneous-bilateral-knee arthroplasty. This article, with a fairly large cohort of patients, offers a different perspective. Given these findings, orthopedic surgeons may be more inclined to perform simultaneous-bilateral arthroplasty in their healthier patients, those without significant comorbidities. Simultaneous-bilateral TKA would benefit patients by avoiding a second operation and may also help decrease health care costs.
— Arthur L. Malkani, MD
University of
Louisville
Louisville, KY