“SBTKA has higher complications and mortality and should be reserved for a select group of patients, ” says Javad Parvizi. “But, ” counters Tom Sculco, “patients prefer it, there is less recovery time, only one operative procedure, symmetrical recovery, and it’s less costly.”
This week’s Orthopaedic Crossfire® debate is “Simultaneous Bilateral TKA: Double Trouble.” For the proposition was Javad Parvizi, M.D., F.R.C.S. from the Rothman Institute in Philadelphia. Against the proposition was Thomas Sculco, M.D. from Hospital for Special Surgery (HSS) in New York; moderating was William J. Maloney, III, M.D. from Stanford Hospital and Clinics in California.
Dr. Parvizi: “If having white hair and looking semi-attractive and coming from the East Coast is a sign of intellect, then our next speaker will qualify. He will say that simultaneous bilateral total knee arthroplasty (SBTKA) is best because you can do it under single anesthesia, have one preoperative workup, one hospital admission, one rehab, it’s less costly and more convenient for the patient.”
“Not so fast! Let’s first define SBTKA: both knees under the same anesthesia at the same hospital admission. There isn’t much data in terms of Level 1 studies; there is a lower level of evidence based on meta-analyses. We performed a meta-analysis on nearly 28, 000 patients undergoing TKA from 1966-2005. Number one finding: cardiac complications are significantly higher in SBTKA.”
“Although the DVT risks were lower, pulmonary embolism (PE) was much higher; urinary and gastrointestinal complications were also higher. Most significantly, mortality was much higher in patients undergoing SBTKA. The neurologic complications were also higher in this patient group. And if you’re doing both knees under the same anesthesia within a short period of time this patient will have to deal with the physiological adverse effects of marrow and embolic load in the right side of the heart.”
“And if patients have patent foramen ovale then some of that embolic load can transmit to the brain. Data from Dr. Sculco’s institution, performed by one of the anesthesiologists…incredible work based on the Nationwide Inpatient Survey of over 206, 000 patients undergoing bilateral total knee replacement. Just about every single complication is higher in patients who undergo SBTKA—approximately eight fold higher compared to single.”
“He will try to convince you that the cost is lower in these patients, and that’s probably true if you’re looking at hospital charges. But some of this cost saving will be offset by the higher cost of dealing with the complications.”
“SBTKA takes longer, so you must modify your anesthesia technique; patients must lie awake under regional anesthesia for several hours, which pushes some of these institutions to administer general anesthesia…which has a higher risk for complications. These patients have a higher incidence of blood transfusion.”
“Infection is very difficult to manage in these patients. So should it be done? Sure…in select patients, by select surgeons, in select institutions.”
“Based on Dr. Sculco’s study, the groups at high risk are those over 65, male gender, patients with comorbidities. The recommendation of that paper was that these patients should be admitted to at least a Level 2 care unit with detailed observations rather than routine general orthopedic wards. So if you don’t have a full ICU then perhaps you shouldn’t do this operation.”
“In conclusion, SBTKA has higher complications and mortality and should be reserved for a select group of patients. If you listen to Dr. Sculco, he’s probably going to lead you into a ditch.”
Dr. Sculco: “I am speaking in favor of bilateral one stage TKR. I do these procedures because overwhelmingly patients prefer it, there is less recovery time, one operative procedure, symmetrical recovery, and it’s less costly. It’s particularly useful in patients with severe flexion contraction. If you fix one knee the other knee will accommodate the side with the flexion contraction, and you will not achieve full extension in both knees.”
“In a study we published in 2004 there were 500 patients with no deaths, strokes or myocardial infarctions. We found increased morbidity in the over 75 age group (that comes to patient selection), and in those that had increased preoperative comorbidities.”
“A recent study from Korea found that perioperative mortality was greater in the unilateral population, and with no significant difference in major or minor complications in either group. In our own series of over 21, 000 knee replacement patients there are 3, 000 patients who had one stage bilateral procedures (about 15% of patients at our institution have one stage bilaterals). Mortality is less in the bilateral versus the unilateral population. That’s probably because of patient selection. Interestingly, our infection rates were lower in the bilateral one stage versus the unilateral population.”
“Savings? In that same study, Dr. Parvizi is correct…there is more rehab in these patients and maybe that does end up costing more, but certainly in the perioperative management the reduction in that series was about $25, 000 per patient.”
“Patient selection is key…this is what reduces complications…better anesthetic techniques, improved perioperative monitoring, and expeditious surgery. A lot of what Dr. Parvizi cited in his paper is from 2004 and previously…it’s a whole different world taking care of these patients today.”
“Here is a randomized series of patients looking at the use of hydrocortisone to reduce fat embolism and lung injury. This involved use of hydrocortisone preoperatively at two aliquots eight hours apart postoperatively; the IL 6 levels indicate a hit to the lung and also active inflammation. There was significant reduction when compared to the control population in this double blind study.”
“Additionally, we looked at Desmosine. We found a reduction noted in those patients who had perioperative cortisone in terms of reduction in lung injury if you use this hydrocortisone preoperatively and immediately postoperatively to reduce lung injury and increases in IL 6. The hydrocortisone patients also had greater knee range of motion and a reduced need for pain medication; no infections in this series.”
“So I think this may be something for the future. The use of perioperative hydrocortisone appears to be protective of fat embolism syndrome in bilateral TKA patients and facilitates recovery.”
Dr. Parvizi: “The data speaks for itself. I can’t see that Dr. Sculco presented anything that convinces me otherwise.”
Dr. Sculco: “Javad, you don’t do bilateral one stage knee replacements?”
Dr. Parvizi: “I do what Seth has told me, so I came up here to argue against bilateral total knee replacement.”
Moderator Maloney: “Do you do bilateral total knee replacement?”
Dr. Parvizi: “Yes.”
Moderator Maloney: “What’s your selection process?”
Dr. Parvizi: “Very healthy patients…ASA 1 [American Society of Anesthesiologists].”
Moderator Maloney: “No ASA 2?”
Dr. Parvizi: “No. I wouldn’t do it in diabetics, nor in anybody over the age of 70 or in patients who have underlying conditions like hypertension.”
Moderator Maloney: “You just eliminated my entire practice.”
Dr. Parvizi: “Mine too. Honestly, I don’t know how many bilateral total knees I would do.”
Moderator Maloney: “At Jefferson what percent of the knees are bilaterals?”
Dr. Parvizi: “5-6%.”
Moderator Maloney: “Tom, tell us about your criteria.”
Dr. Sculco: “Patients see an internist, an anesthesiologist…and they must be cleared by both to go through the funnel to be selected for bilaterals. There are patients who are 70 who are fitter than my patients who are 60, so I use physiologic age.”
Moderator Maloney: “So what are the contraindications in your mind?”
Dr. Sculco: “Morbid obesity, significant cardiovascular disease.”
Moderator Maloney: “Congestive heart failure has been documented in many studies to have a higher morbidity…COPD [chronic obstructive pulmonary disease]?”
Dr. Sculco: “COPD, severe lung disease. In my practice about 15-17% I do are one stage bilaterals.”
Moderator Maloney: “Jay, what about deformity? Tom showed a case that’s got bilateral 20 degree fixed flexion contractures in varus deformities…you do one knee and three months later they come back for the other knee and the patient’s got a 20 degree flexion contracture when they come in for their six week. Are you going to push it to an ASA 2?”
Dr. Parvizi: “No, the selection criteria is clear. You don’t have to wait three moths. You can bring these patients back and based on studies that I’ve evaluated the major…”
Moderator Maloney: “What’s the safe time period?”
Dr. Parvizi: “The data doesn’t quite clarify it and hopefully that threshold will be determined soon. I think two weeks is fine. By then the heart and lungs would have cleared the embolic load and you can bring the patients back…their preoperative clearance is still valid during those two weeks. They’ve lived with a flexion contracture all their lives—they can live another two weeks.”
Moderator Maloney: “Tom, two weeks worries me a little.”
Dr. Sculco: “I think it’s the worst time to do it. Patients are hypercoagulable for four to six weeks, so I’d wait a minimum of six weeks out to three months to do the second surgery.”
Moderator Maloney: “I’ve been leaning toward six weeks too…that hypercoagulable state does worry me. What about pain, Tom? A patient comes in with routine osteoarthritis, mild varus deformity, range of motion is 5-105 degrees; one knee hurts a lot (8 out of 10 on the pain scale) and the other hurts maybe a 3 out of 10. Do you say, ‘We’ll do the bad knee and we’ll wait and see how the other one does.’”
Dr. Sculco: “That’s exactly what I would do. Just because they have involvement of the other knee is not a reason to do both knees. They have to be symptomatic on both sides.”
Moderator Maloney: “Jay?”
Dr. Parvizi: “I agree. It’s the only thing I agree with.”
Moderator Maloney: “Jay, when you guys do bilaterals do they get a medical workup ahead of time or are you making that call yourself?”
Dr. Parvizi: “Everything is done by a multidisciplinary team so I don’t see the patient and say, ‘Your radiograph shows arthritis…I’ll see you in six weeks in the OR.’ We’re involved with every process; we check their labs, look at their hemoglobin, etc. I think it’s critical and that’s probably the reason for the huge success at HSS because they really have that incredible involvement in every step.”
Moderator Maloney: “Tom, comment on that because we don’t want to give the audience the impression that if you’re at a community hospital you don’t have great medical backup.”
Dr. Sculco: “I think it’s key; it’s patient selection, perioperative management and anesthetic management. All these people were done under regional anesthesia; all patients spend a night in a recovery room which is an ICU setting. Things do happen and I think you must be prepared for it in the immediate postoperative period. But most of these people do extremely well.”
Dr. Parvizi: “The anesthesia team at HSS is one of the best in the world. That is critical. Tom talks about these Desmosine inhibitors…they were the one part of these lipoprotein inhibitions, the intraoperative administration of Heparin IV. Most of these things have emerged from HSS thanks to their fantastic anesthesia team. So of course they will do better at HSS.”
Moderator Maloney: “The hospital makes more, and it may save the system a little money, but the surgeon makes less if he does them both at once.”
Dr. Sculco: “That’s a deterrent to doing it because if you do bilateral one setting you get half the reimbursement for the second side.”
Moderator Maloney: “Jay, can’t you change the system and…”
Dr. Parvizi: “I don’t get paid for these cases anyway…$200 for a primary knee in Philadelphia. But it does make a difference in the long run if you are a high volume surgeon you should have the profit sharing with the hospital.”
Moderator Maloney: “Thank you gentlemen.”
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