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Patients at higher risk for pulmonary embolism after bilateral THA, TKA
Patients undergoing bilateral total hip or knee arthroplasty remain at a higher risk for pulmonary embolism even after being screened before surgery, according to study results.
Researchers retrospectively reviewed in-patient pulmonary embolism (PE) rates for patients who underwent unilateral or bilateral total knee arthroplasty (TKA) or total hip arthroplasty (THA) between 2002 and 2011.
Of the 7,347 THA and TKA surgeries completed, the researchers found 36 patients experienced postoperative PE while in the hospital. Among the 3,576 primary unilateral THA surgeries performed, six patients experienced postoperative PE, whereas one of 194 patients experienced PE after bilateral THA.
Of the 3,239 primary unilateral total knee arthroplasty surgeries performed, the researchers found 20 cases of PE; eight cases of PE occurred among the 428 bilateral TKA surgeries.
According to the study results, three times as many patients experienced PE after bilateral THA/TKA compared with those who underwent unilateral surgery.
“Patients who are considering simultaneous bilateral total joint arthroplasty surgery should be counseled appropriately as to the increased risk of PE,” the researchers wrote. “The potential risk of PE and other complications needs to be weighed against the benefits of having a single surgery for each individual patient.”
Disclosure: Westrich is on the speaker’s bureau and employed by Exactech, Stryker and DJO; received research support from Exactech and Stryker; and is a board member for the Knee Society and the Eastern Orthopaedic Association.
Perspective
Back to TopIn the study by Yeager and colleagues, a significantly higher incidence of pulmonary embolism was observed in patients undergoing bilateral knee replacement, compared with unilateral procedures. There was a higher rate of pulmonary embolism in bilateral hip replacements compared to unilateral procedures, but was not statistically significant. The retrospective analysis of patients from a single center was based on data from 2011, and is, therefore, an investigation utilizing contemporary practices. Venous thromboembolic prophylaxis included neuraxial anesthesia and mechanical and pharmacologic measures (warfarin or aspirin). Identification of pulmonary embolism events was limited to in-hospital spiral CT scan results, which were only ordered for symptomatic patients. Despite screening for patients presumably healthy and young enough for bilateral procedures, a higher risk of pulmonary embolism was observed.
With only 194 bilateral total hip replacement procedures and 428 bilateral total knee replacement procedures, the study is likely underpowered to definitively investigate the association of bilateral procedures and a rare event as pulmonary embolism.
It would be of interest to see if similar findings would be found from multiple centers, with larger numbers, utilizing varying forms of venous thromboembolic prophylaxis. It would also be of interest to see whether a multivariate analysis including other recognized risk factors (race, gender, body mass index, cerebrovascular, renal disease, etc.) confirms bilateral procedures to be a risk factor for pulmonary embolism. Nevertheless, this study contributes to a growing body of evidence showing an increased risk of some complications with bilateral total joint procedures, and these risks should be considered and discussed withpatients.