Surgeons discuss the advantages, risks of bilateral total knee arthroplasty

Orthopedists debated the complications, mortality rates and costs of a simultaneous procedure.

Proponents of simultaneous bilateral total knee arthroplasty cite patient preference for the dual procedure and shorter recovery, while detractors note the greater risks for complications and mortality.

At the Current Concepts in Joint Replacement 2011 Winter Meeting in Orlando, Fla., Javad Parvizi, MD, FRCS, and Thomas P. Sculco, MD, participated in a crossfire debate about the procedure.

Risks

Parvizi said that simultaneous bilateral total knee arthroplasty (TKA) increases the risks of pulmonary emboli and mortality. In a meta-analysis of 150 papers published between 1996 and 2005, he and colleagues found that pulmonary, intestinal and gastric emboli risks, as well as cardiac complications, were higher in bilateral patients. Another meta-analysis from 2011 showed overall mortality reaching 3.2% and topping 5.5% at 30 days. Parvizi also cited a study from Hospital for Special Surgery that revealed a 9.5% rate of major in-hospital complications and mortality among 206 patients who had simultaneous TKA.

“Interestingly, a lot of these patients get worked up postoperatively, and that is most likely due to the embolic load these patients have to endure having two knees with intramedullary instrumentation leading to a higher fat and marrow embolism, leading to cerebral as well as the cardiac complications,” Parvizi said.

Javad Parvizi

Performing two TKAs at once does not result in a lower cost, Parvizi said, because the “the majority of these patients do exhibit complications and, unfortunately, most of them require work up.” Patients may require modified anesthesia, he said, because they lie awake for several hours. They may also have a greater need for blood transfusion, causing further complications. Although infections occur infrequently, Parvizi noted they are difficult to treat.

“If you are going to be doing simultaneous bilateral TKA, you should have special care units available because as these patients develop complications, they need special care,” Parvizi, who is an Orthopedics Today Editorial Board member, said.

Lower cost, mortality

Sculco argued that morbidity and mortality are not higher in patients undergoing simultaneous bilateral TKAs when compared to patients have two unilateral procedures. In a study of 500 consecutive patients, Sculco and colleagues found no deaths, strokes or myocardial infarctions. However, they found increased morbidity perioperatively and in patients older than 75 years. Sculco pointed out that in the same paper Parvizi quoted, overall mortality in bilateral patients was 0.47% and mortality was greater in those who underwent unilateral TKA and those who underwent TKA on the contralateral knee at a later time.

Advances in perioperative management have reduced the mortality and complication rate, Sculco said. From 1990 to 2004, mortality decreased as perioperative treatments improved. In 3,000 consecutive bilateral TKAs performed at Sculco’s institution, 30-day mortality was less in the bilateral group than the unilateral group when patients were carefully selected for bilateral surgery.

In the same study, Sculco found that costs for bilateral TKA totaled $67,000 compared to $90,000 for two unilateral procedures.

Thomas P. Sculco

Ways to reduce complications

Sculco said that complications can be reduced with “good patient selection, good anesthetic techniques are key, good perioperative monitoring and expeditious surgery. If it takes you 2.5 hours to do a knee replacement, you should not do one-stage bilateral procedures.”

Sculco also recommends using perioperative hydrocortisone to decrease lung complications. He said three doses can be given at 8-hour intervals. In prospective randomized trials, Sculco and his team discovered hydrocortisone reduced IL-6 and desmosine, a breakdown product of elastin that signals lung injury. Hydrocortisone also reduced the need for pain medications. Patients’ range of motion improved, and the team found no infections in patients who received hydrocortisone.

Patient selection

Parvizi and Sculco agreed that orthopedists must be selective when choosing patients to undergo bilateral TKA. Sculco says the operation is “ideal” for patients with severe bilateral flexion deformity.

“If you do one knee and not do the other knee, [it is] guaranteed that the operative knee will take on the flexed position of the unoperated knee,” Sculco said.

Based on studies from the Hospital for Special Surgery, Parvizi said, most patients at risk of complications are older, between 65 years and 74 years, “which constitute 80% of patients undergoing total knees.”

“Patient selection is key for this operation,” Sculco said. – by Renee Blisard

References:

• Parvizi J, Sculco TP. Simultaneous-bilateral TKA: Double trouble. Papers #99 and #100. Presented at the Current Concepts in Joint Replacement 2011 Winter Meeting. Dec. 7-10. Orlando, Fla.

• Javad Parvizi, MD, FRCS, can be reached at the Rothman Institute, 925 Chestnut St., 5th Flr., Philadelphia, PA 19107; 267-339-3617; email: parvj@aol.com.
• Thomas P. Sculco, MD, can be reached at the Hospital for Special Surgery, 5535 E. 70th St., New York, NY 10021; 212-774-2478; email: sculcot@hss.edu.
• Disclosures: Parvizi is a consultant for Biomet, Covidien, Smith & Nephew Orthopaedics, Stryker Orthopaedics and Zimmer Inc. Sculco has no relevant financial disclosures.