Pros and Cons of Simultaneous Bilateral Total Knee Arthroplasty Including Morbidity and Mortality Rates

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By Nilesh Patil, MS(Orth); Hemant Wakankar, MS, FRCS, Mch(Orth), FRCS(Orth)
ORTHOPEDICS 2008; 31:780

August 2008

Total knee arthroplasty (TKA) is an effective treatment for end-stage arthritis of the knee. Published studies in the literature have consistently reported TKA as an efficacious and cost-effective means of alleviating pain and restoring function.1,2 A significant number of patients with severe end-stage degenerative joint disease have symptomatic bilateral knee joint affliction, necessitating joint replacement in both knees.3-5 The surgical options available for these patients include a staged procedure with a certain time interval between 2 procedures, simultaneous arthroplasty of both knees using 2 surgical teams, or bilateral arthroplasty using 1 team with the patient under 1 anesthetic. However, the decision to perform bilateral knee arthroplasty staged or simultaneous is debated.

Advantages of bilateral TKA performed under 1 anesthetic compared with bilateral arthroplasty conducted as a 2-staged procedure are well known and include limiting an invasive surgical procedure and anesthesia to a single event and promoting symmetrical rehabilitation of both knees, potentially reducing the length of the hospital stay and thereby the hospital costs associated with TKA.3,5-8

The authors in support of simultaneous bilateral TKA are of the opinion that with appropriate patient selection, the potential benefits of conducting this procedure in a simultaneous fashion outweigh the possible risks of the procedure. In a study evaluating the safety of simultaneous bilateral TKA, Lombardi et al9 reported that performing bilateral TKA in a simultaneous manner is advantageous, and 95% of patients would prefer to undergo the procedure in a similar manner if presented with the same opportunity again.

However, some studies have questioned the safety and relative risk of simultaneous bilateral TKA and demanded further critical evaluation.10-14 Lynch et al10 suggested that simultaneous bilateral knee arthroplasty should be avoided in patients older than 80 years due to a higher rate of complications observed in these patient groups. Similarly, Lane et al11 reported higher cardiopulmonary complications and blood transfusion requirements with simultaneous procedures, questioning its true safety.

The issue of perioperative complications with simultaneous bilateral TKA is crucial from the viewpoint of the decision-making process of the arthroplasty surgeon in patients with symptomatic bilateral knee arthritis. Likewise, with improvement in anesthesia techniques and postoperative management measures, it is important to note that the population of patients considered as candidates for elective arthroplasty has changed over time, and more patients who are older, sicker, and at greater risk are offered TKA now more than in the past.

This review article provides a brief overview of perioperative complications, blood transfusion requirements, mortality rates of simultaneous bilateral TKA, and underlying factors related to occurrence of these events.

The rates of cardiac, pulmonary, and neurological complications have been reported to be relatively greater in most of the studies for simultaneous bilateral TKA. The consideration of likelihood of these complications undoubtedly should take precedence over the potential benefits of the procedure before offering simultaneous arthroplasties to patients with bilateral knee arthritis.

There is a great deal of variation in the type and incidence of perioperative complications reported in published studies, and it is not possible to single out a predominant complication associated with simultaneous bilateral TKA. In addition, comparison of the rates of clinically relevant adverse events from study to study and over time is complicated by the differing endpoints and lack of uniformity in the criteria used for diagnosis of adverse events.

Complications

Cardiac Complications

Cardiac complications can be potentially life threatening and have been consistently reported to be higher following simultaneous bilateral TKA than following unilateral knee arthroplasties or staged bilateral procedures (Table 1). 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.9,16-18 Lynch et al,10 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 this study, cardiovascular complications were observed after 22% of bilateral procedures compared with 6% of unilateral procedures.10 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. In the same study, it is worth noting that the only primary outcome that was significantly different between bilateral and unilateral groups was myocardial infarction with an absolute difference of 1.61%, and no myocardial infarctions occurred in patients younger than 70 years, thus implying that it occurred only in patients older than 70 years who underwent simultaneous bilateral TKA.17

The exact cause for higher cardiac complications in patients with simultaneous bilateral TKA remains uncertain; however, the rates of cardiac complication have been reported to be higher in patients with preexisting comorbid medical conditions and in elderly patients (>80 years). It can be deduced that the stress imposed by the simultaneous procedure on this group of high-risk patients with suboptimal cardiorespiratory reserves could be the cause of increased complications.19 The higher stress imposed by conducting bilateral knee arthroplasties in a simultaneous manner may be attributed to longer length of hypotension secondary to spinal anesthesia, larger fluid shifts, and potentially greater intraoperative hypoxia or anemia during hospitalization.

Intensive Care Unit Admissions

The rates of intensive care unit admission are also reported to be higher with simultaneous bilateral procedures. This might be a reflection of the greater need for monitoring of cardiopulmonary parameters with this procedure, especially in elderly patients. In a study by Bullock et al,17 the rate of 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, Ritter et al12 reported that the number of intensive care unit care days of simultaneous bilateral knee arthroplasty were twice that in unilateral or staged groups.

Leonard et al20 proposed that shortening the total duration of anesthesia and surgical procedure by performing a simultaneous bilateral procedure concomitantly using 2 surgical teams may help to keep the complication rate low by reducing the overall burden on the cardiorespiratory system. There are no studies comparing the safety of simultaneous arthroplasties performed by a single team to those performed by 2 surgical teams under 1 anesthetic to support this notion. Additionally, when bilateral TKA is performed under 1 anesthetic simultaneously by 2 surgical teams, inflation of both tourniquets at the same time may considerably increase the afterload for the left ventricle and expose the patient to a significant upsurge in procoagulants once the tourniquets are released.21 This potential complication can be avoided by doing the bilateral procedures without the application of a tourniquet.22 However, cement interdigitation into bony surfaces may be compromised when a tourniquet is not used. Hence, some authors advocate deflating the tourniquet on the first knee before replacing the second knee during bilateral knee arthroplasty.19 Moreover, in patients undergoing sequential bilateral TKA under 1 anesthetic, the surgeon can abort the procedure after the first knee arthroplasty in anticipation of an untoward event as determined by the anesthetist.

Table 1: Cardiac Complications Reported with Simultaneous /Unilateral/Staged TKA 

 

Pulmonary Complications

Pulmonary embolism and fat embolism are 2 serious complications reported with relatively higher incidence with simultaneous bilateral knee arthroplasty, culminating in higher mortality in these patient groups (Table 2).5,8,11,13,24-26 However, in a recent study on a large patient population group, Barrett et al27 concluded that the risk of developing symptomatic pulmonary embolism in patients with simultaneous 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.9,19,20 However, they have been reported inconsistently in the studies documenting the results of simultaneous procedures.

Table 2: Pulmonary Complications Reported With Simultaneous/ Unilateral/Staged TKA

Fat embolism manifests in the form of encephalopathy, altered arterial blood gas parameters, dyspnea, and cutaneous petechiae. There is clear evidence in the literature that occurrence of fat embolism is not related to preoperative comorbid factors.8,28 The higher incidence of fat embolism with simultaneous bilateral TKA can be considered to be a direct consequence of a significant rise in intramedullary pressure during bony preparation of the femur or tibia. This may be further compounded by the presence of small intramedullary canals in the patient. Pulmonary arterial pressure and pulmonary vascular resistance have been shown in scientific studies to rise with femoral and tibial rodding, tourniquet deflation, and cementing of the components.29-32 This is thought to be secondary, in part, to occlusion of the pulmonary microcirculation by embolized particles. This presents in the form of decreased oxygen saturation and oxygen tension in the blood. Hence, some authors advocate intraoperative assessment of cardiopulmonary hemodynamics with a pulmonary artery catheter. In support of this observation, Dorr et al28 concluded that the second TKA should be abandoned if the pulmonary vascular resistance is more than double the baseline or above 200 dyne/second/cm5 at the completion of the first TKA. It was further reported that patient predictive factors or use of pulse oximetry readings are not as useful as the intraoperative pulmonary catheter monitoring, and that monitoring the ratio of pulmonary vascular resistance to systemic vascular resistance may serve as an additional measure to assist the surgeon in making the appropriate decision after the first procedure. An experienced anesthesiologist has been observed to be a prerequisite for safe insertion of the pulmonary artery catheter that can otherwise lead to deleterious complication.28 The use of an extramedullary tibial rod for alignment, over-reaming, and suctioning of the femoral entry hole, and the use of a short fluted intramedullary femoral rod are measures proposed by some authors to prevent fat embolism.20,29,31,33

Pulmonary embolism presents as pleuritic chest pain, dyspnea, and altered blood gases, and can be confirmed with pulmonary arteriography or a ventilation/perfusion scan. The increased operative time associated with a simultaneous bilateral procedure, the cementing of femoral and tibial components, the surgical intervention in both lower extremities (site of origin for the emboli), and a probable prolonged duration of relative immobility constitute possible explanations for the higher risk of pulmonary embolism involved with the simultaneous bilateral procedure compared with the single TKA. As a safer alternative, Barrett et al27 proposed that staging the TKA may result in a lower initial probability of pulmonary embolism and then provide the option to the patient of undergoing the second TKA depending on the result of the first surgery. Additionally, the higher association of pulmonary hypoxia in older patients having simultaneous bilateral TKA may be a result of greater sensitivity of these patients to atelectasis and increased hydration resulting in pulmonary vascular congestion and further leading to pulmonary shunting and decreased oxygenation of blood.9 Thus, the importance of postoperative oxygen administration and incentive spirometry in these patients cannot be overlooked.

Neurological Complications

Neurological complications have been reported more commonly with simultaneous bilateral TKA than unilateral or staged procedures in some cases (Table 3), with confusion being the most frequently reported complication. It is thought that the physiological stress imposed by surgery and anesthesia leading to dehydration, electrolyte imbalance, and anemia 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.11,26,28 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. Confusion after simultaneous bilateral procedures has also been observed more commonly in older patients.11 The higher incidence of confusion in elderly patients undergoing this procedure could be the result of the inability of these patients to respond to large fluid shifts and the resulting fluid and electrolyte imbalance. 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.10,34,35

Table 3: Neurologic Complications Reported With Simultaneous/Unilateral/Staged TKA

 

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 (Table 4), with the rates being reported over a period of 30 days, 90 days, or 1 year postoperatively. In an interesting analysis, Bullock et al17 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.17 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.36 The 30-day mortality rate has been observed to be higher with simultaneous bilateral procedures as compared to unilateral or staged procedures.12,37 Although some 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.9,11,18 Older age, especially older than 80 years, and preexisting comorbid factors have been correlated with higher mortality in bilateral procedures.9,10,17,19,20,34,35 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,17,38,39 but consideration of these morality rates may lead to erroneous interpretations.

Table 4: Mortality Rates Reported with Simultaneous/Unilateral/Staged TKA

Blood Transfusion Requirements

The use of banked blood is of potential concern to the surgeon and sometimes is unacceptable to the patient. The orthopedic community has made an effort to avoid the use of banked blood and minimize blood loss during and after surgery. There appears to be substantial variation in the reported blood transfusion rates for simultaneous bilateral TKA. This is most likely due 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, reinfusion of drained blood, and duration of the operative procedure. Regardless of these variations, the rates of blood transfusion in simultaneous bilateral TKA have been found to be greater than those in unilateral arthroplasty groups (Table 5).11

Table 5: Blood Transfusion Rates Reported with Simultaneous/Unilateral/Staged TKA

The average number of units of blood transfused has also been found to be higher in bilateral study groups.16,17 The increased need for banked blood products puts these patients at higher risk for transmission of various blood transfusion-related viral infections. Bould et al40 revealed statistically significant blood loss in the second sequential TKA, whereas comparable blood loss was observed between the first sequential TKA and the control unilateral TKA group, indicating more blood loss after the second knee surgery. The increased operative and tourniquet time leading to decrease in clotting factors, trauma to the tissue, and hypothermia are some of the plausible explanations for greater blood loss with simultaneous bilateral TKA. In addition, the increased blood loss and blood transfusion requirements in elderly patient vs younger patient populations undergoing simultaneous bilateral arthroplasties may be a result of a greater sensitivity to hypothermia observed in elderly patients. Furthermore, Lane et al11 observed that longer surgical duration in patients with simultaneous TKA is associated with higher crystalloid replacement, leading to a dilutional component of anemia.

Keating et al41 concluded that preoperative anemia is a strong indicator of blood transfusion in unilateral and bilateral TKAs. The preoperative levels of hemoglobin and hematocrit may alert the operating surgeon as to the necessary measures to be taken to manage blood loss during and after surgery. Pavone et al19 observed that more than two-thirds of the overall blood loss in the patients undergoing simultaneous bilateral TKA occurred postoperatively through drainage systems. Blood loss has not been found to decrease with elimination of drains; however, an increase has been observed in wound drainage, ecchymosis, and wound problems with this measure. Hence, the routine use of drains has been recommended following TKA.42,43

Preoperative autologous blood donation is recommended to address increased banked blood requirements.44 Alternatively, Bould et al40 and Goulet et al45 suggested the use of a reinfusion drainage system in addition to preoperative autologous blood collection to deal with the increased demand for blood in simultaneous bilateral TKA, thereby reducing the possible risks of bloodborne diseases associated with allogeneic blood use.40,45 Preoperative use of erythropoietin may also help to reduce the increased blood transfusion requirement in simultaneous bilateral TKA,41 but further studies are needed to qualify its cost effectiveness in this scenario.

Other Complications

There is conflicting data as to the prevalence of deep vein thrombosis in patients undergoing simultaneous bilateral TKA. Earlier studies have observed higher rates of deep vein thrombosis,3,13 whereas some recent studies have found it to be lower after simultaneous arthroplasty.9,17,46-48 It is interesting to note that deep vein thrombosis and pulmonary embolism were observed in a few studies, although the criteria used for reporting deep vein thrombosis appears to be ill defined in these studies.47,48 Low rates of deep vein thrombosis in simultaneous bilateral TKA groups are supported by the hypothesis of a postoperative hypocoagulable state due to consumption of coagulation factors following greater surgical insult and larger blood loss in these groups of patients.48

Minor complications such as gastrointestinal ileus and electrolyte imbalances have been documented in few cases of simultaneous bilateral TKA.9,11,12 The higher propensity for gastrointestinal ileus could be attributed to a possible higher required dose of narcotics and relatively longer duration of immobility in these patients.

Benefits of Simultaneous Bilateral TKA

The surgical procedure-related outcome measures with simultaneous bilateral surgery, like functional and radiographic knee scores and prosthesis survivorship, have been consistently reported to be comparable with those of unilateral or staged knee replacements.5,6,9,28,34,46,49,50 The results of simultaneous bilateral procedures in obese patients and in patients with rheumatoid arthritis have also been encouraging.50-52 The patient satisfaction rates and pain scores have been observed to be comparable to those of unilateral TKA.46,49-51,53

The length of hospital stay has been observed to reduce with the simultaneous procedure. Lane et al11 indicated that this potential benefit may be offset by additional need for postoperative rehabilitation required to achieve independent ambulation and acceptable range of motion. However, patients can undergo rehabilitation of both knees in a single hospital stay, thus effectively making the hospital stay less than the cumulative hospital stay of 2 separate procedures.6,7,51 Additionally, in patients with severe bilateral knee deformities undergoing simultaneous bilateral TKA, it is more convenient and beneficial for the patient to undergo symmetrical rehabilitation of both knees rather than having a cumbersome rehabilitation regime with corrected deformity on one side and not the other should the patient undergo a staged procedure.

The majority of studies have supported the cost benefits offered by simultaneous bilateral TKA. In a cost analysis of simultaneous bilateral TKA versus staged bilateral TKA procedures, Reuben et al54 reported that simultaneous bilateral TKA resulted in a 36% cost reduction for each total knee patient.54 Similarly, Ritter et al12 concluded that the cost of bilateral TKA increased by approximately 20% when performed as a staged procedure.

Discussion

Many authors believe that the decision to perform simultaneous bilateral TKA should be based on the patient?s expectations and needs and the recommendation of the surgeon based on the known risks of the surgical procedure and any associated medical disorders of the patient. Additional factors such as availability of extra support staff in the form of nurses or surgeons required to perform simultaneous operations, paucity of additional equipments, and lack of experience may influence the feasibility of conducting a simultaneous bilateral procedure. Soudry et al46 and Worland et al49 reported that simultaneous TKA may be performed in an efficient manner, given an experienced surgeon and competent operating room staff.55

In the study by Barrett et al27 on a large group of patients with simultaneous bilateral knee procedures, bivariate analysis revealed that high-volume hospitals and surgeons were much more likely to perform simultaneous TKA than their low-volume counterparts. Additionally, given the higher rates of intensive care unit admissions, it may be appropriate to perform simultaneous bilateral TKA in units well equipped with intensive care unit facilities.

The potential benefits of performing simultaneous bilateral TKA appear manifold, but the cardiopulmonary complications, blood transfusion requirements, mortality rates, and neurological complications appear to be higher in elderly patients and patients with comorbid medical conditions, making it an unfavorable option in these patients.

No evidence exists in the literature criticizing the role of simultaneous bilateral TKA in younger patients without preexisting comorbid factors. Hence, with most studies reporting higher complications in elderly patients and in patients with comorbid factors, it is a safer option in younger patients without comorbid factors; however, the exact age for these younger patients remains undefined. This also highlights the need to formulate an evaluation or scoring system based on type, severity of comorbid factors, and patient age (similar to or on the basis of the American Society of Anesthesiology classification [ASA]) to define anticipated risk in patients willing to undergo simultaneous TKA. This can serve as a valuable aid to the operating surgeon in appropriate patient selection and in avoiding depriving eligible patients of the potential benefits of a simultaneous procedure. In addition to appropriate patient selection for simultaneous procedures, the importance of intraoperative monitoring of cardiorespiratory parameters, maintenance of intraoperative normothermia and fluid and electrolytes balance, practicing the proposed intraoperative measures to prevent embolic events, judicious management of blood loss, and postoperative care cannot be overemphasized.

The relatively higher complications reported in some cases should be considered in view of potential shortcomings of these studies. Some studies have failed to report cardiopulmonary complications in accordance with type (eg, hypertension, ischemic heart disease) and severity of the preoperative comorbid factors (eg, mild/moderate hypertension, ischemic heart disease/myocardial infarction) based on comprehensive patient data.9,11,17,27,34 This could be due to inherent shortcomings of the data system (eg, Medicare) to provide accurate information on the preoperative health status of individual patients used to retrieve data on patients in these studies. Second, unilateral TKA may not represent true controls for simultaneous bilateral TKA in comparative analysis of perioperative complication rates.

It can be argued that the risk with the unilateral procedure is understandably low and ideally complication rates need to be doubled to consider the cumulative risk of 2 surgical procedures to make comparative analysis more equitable, or otherwise use the results of staged procedures for such an analysis. Additionally, there appears to be no conclusive data as to the exact time interval between the 2 surgeries that could possibly eliminate the risks associated with simultaneous bilateral TKA. Third, a few retrospective studies reporting the results of simultaneous bilateral TKA have failed to describe the precise manner of performing the simultaneous procedure that is either sequentially by a single surgical team under 1 anesthetic or simultaneously by 2 surgical teams.11,12,18,27

Lastly, studies reporting results of the simultaneous procedure in fewer numbers of patients may not be provide a true estimate of the complication rates of this procedure, leading to improper conclusions.16,33,37,48 In order to address all of these issues, it is essential to conduct clinical trials on large patient population groups comparing staged and simultaneous procedures using standard techniques with well-defined criteria for reporting the complication rates. Rigorous analysis and correlation of the probable complications need to performed with comprehensive preoperative data of the patients and their respective comorbidities.

The cardiopulmonary complication, morbidity, and mortality rates of simultaneous bilateral procedures appear to be higher in elderly patients, and it may be considered unsafe in this group of patients. It may be a safer option in younger patients without preoperative comorbid factors. Safety of the procedure needs to be individualized, and the importance of expertise and adequate intensive care unit facilities cannot be overlooked for successful expedition of the procedure.

Although current evidence suggests that it may not be a safer option in patients with comorbid medical conditions, it will be useful to conduct further studies to determine the exact risk of the procedure in these patients, especially younger patients, depending on the types of various preexisting comorbid factors.

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Authors

Dr Patil is from Stanford Medical Center, Palo Alto, California; and Dr Wakankar is from the Department of Joint Replacement, Deenanath Mangeshkar Hospital, Pune, India.

Drs Patil and Wakankar have no relevant financial relationships to disclose. Dr Morgan, CME Editor, has disclosed the following relevant financial relationships: Stryker, speakers bureau; Smith & Nephew, speakers bureau, research grant recipient; AO International, speakers bureau, research grant recipient; Synthes, institutional support. Dr D?Ambrosia, Editor-in-Chief, has no relevant financial relationships to disclose. The staff of Orthopedics have no relevant financial relationships to disclose.


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