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Simultaneous bilateral THA, TKA not a problem with proper patient selection
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Recently, there has been a significant increase in the number of patients who have bilateral joint degeneration that involves either both hips and both knees and requires surgery. As a result, discussions are underway in Europe and the United States to establish guidelines for performing simultaneous bilateral total hip arthroplasty or total knee arthroplasty.
Such guidelines are needed, as the literature on the topic seems inconclusive as to whether simultaneous surgery is of benefit to patients and whether there are increased risks for bilateral surgery compared to staged surgery.
In my practice, I regularly see patients who request simultaneous total hip arthroplasty (THA). We have offered this procedure since the 1990s, and with the proper selection of surgical candidates we have seen no difference in complication rates and neither has my colleague who performs simultaneous bilateral total knee arthroplasty (TKA). However, strict guidelines need to be followed.
Proper patient selection
In our clinic, for patients to eligible for this complex surgery they must be younger than 75 years, be American Society of Anesthesiologists grade 1 or 2 and be without major cardiac and pulmonary comorbidities. However, the final decision about whether to proceed with bilateral total joint arthroplasty (TJA) is always a joint decision between the surgeon, anesthetist and patient.
We never promise a patient we will replace both joints because we may make the decision after the first THA or TKA that it may be too risky to replace the second joint. This surgery must be done by experienced, high-volume and efficient surgeons who can minimize the time in surgery and thus reduce the cardiovascular load to the patients.
Patients who are selected for bilateral procedures require detailed information preoperatively, which should include a statement that says despite two joints being replaced, it is still only one surgery and their recovery and pain will not be twice that of a unilateral arthroplasty. This information is helpful and can remove a patient’s psychological barrier to surgery that may result in an “I cannot do it” attitude toward the postoperative protocol. The anesthetists, nurses and physiotherapists also require experience with patients with simultaneous, bilateral surgery, to be able to support and guide patients.
When the fast-track concept of mobilization on the day of surgery is added to the above scenario, patients are discharged at about the same time as the unilateral cases.
Guidelines may guide decisions
The main issue is whether patients can request a simultaneous bilateral TJA. I think patients should be able to make such a request, but they should only decide about proceeding after the surgeon and anesthetist make a professional decision based on clinical facts and guidelines.
I welcome more studies that demonstrate the benefits and potential drawbacks of simultaneous bilateral THA or TKA, as well as open discussions on this topic at international congresses to improve our knowledge in this growing area of arthroplasty.
- For more information:
- Per Kjaersgaard-Andersen, MD, is Chief Medical Editor of Orthopaedics Today Europe. He can be reached at Orthopaedics Today Europe, 6900 Grove Rd., Thorofare, NJ 08086, USA; email: orthopaedics@healio.com.
Disclosure: Kjaersgaard-Andersen reports no relevant financial disclosures.