This week’s Orthopaedic Crossfire® debate is “Simultaneous Bilateral TKA: Double Trouble.” For the proposition is Javad Parvizi, M.D., F.R.C.S. of The Rothman Institute. Against the proposition is Thomas Sculco, M.D. of the Hospital for Special Surgery (HSS). Moderating is Leo Whiteside, M.D. of the Missouri Bone and Joint Center.
Dr. Parvizi: “If white hair is a sign of wisdom, decadence, and intellect then my friend Dr. Sculco will qualify. So we’re talking about simultaneous, bilateral knee surgery performed under one anesthesia and one hospital admission. There are few Level 1 studies on this—everything we have is probably Level 3 and beyond.”
“We performed a meta analysis at our institution involving 151 papers and over 27 patients. When we looked at complications and mortality, we found that those undergoing simultaneous bilateral TKA [total knee arthroplasty] had a higher rate of cardiac complications than those who had either a staged or single TKA. In addition, deep vein thrombosis was lower in bilateral TKA, but pulmonary embolus was higher in patients undergoing bilateral simultaneous TKA. The same was true for other complications, including urinary and gastrointestinal issues. Interestingly, every paper published showed a higher mortality rate in patients undergoing simultaneous bilateral TKA compared to single. This is notable because most of these patients are supposed to be healthier.”
“In another meta analysis published about six years later we showed similar findings, with overall mortality being higher; 30 day mortality in particular was much higher. Neurological complications were also higher in patients undergoing simultaneous bilateral TKA. But if none of this convinces Dr. Sculco, a paper from his own institution should help.”
“A publication from his anesthesia department looked at the National Inpatient Sample Survey from 1998-2007. This included over 200 patients undergoing elective bilateral TKA. The incidence of complications overall was 9.5%…eight fold higher than with single TKA.”
“His other argument will be that simultaneous bilateral TKA is cheaper and perhaps more cost effective. But because of the increase in these complications, the savings that the hospitals may experience will be offset by treating these patients later (including hospitalization). Also, these patients have longer OR time, so regional anesthesia may not be appropriate; this may predispose them to a higher incidence of complications. Blood transfusion and blood loss in these patients is much higher, leading to a higher requirement for transfusion-related complications—including infection related to immunological problems. We know that development of a bilateral knee prosthetic joint infection is extremely challenging; these patients have between 20-30% mortality within the first five years.”
“So, should you be doing bilateral TKA simultaneously in anyone? Yes, but only in a select group of patients…and perhaps only at select institutions. The publication from HSS identified the following as risk factors for complications following simultaneous bilateral TKA: advanced age (65-74), male gender, comorbidities (for example, congestive heart failure increased the odds ratio by 5.5), and pulmonary hypertension. The same paper argued that patients should be admitted to at least a Level 2 care unit with more detailed observation than a routine orthopedic ward…and some of these may require Level 3 full ICU support in the postoperative period.”
“So in conclusion, higher complications and mortality have been observed in patients who undergo bilateral simultaneous TKA. Hence, if you’re going to do this then it should be reserved for a select group of patients.”
Dr. Sculco: “I’m speaking in favor of simultaneous bilateral TKA. Overwhelmingly, patients want to have both knees done at once because there is less recovery time, one operation, symmetrical recovery…and we believe it is less costly.”
“If you have a patient with a flexion contracture of any significance it is especially important that you try to do both at once. If you do the first knee and get it out straight, then it will go on to take on the deformity of the second knee, and you’ll lose the correction you got with the first procedure. There are some disadvantages, including increased risk. The short term recovery can be slower, and reimbursement—both to the hospital and physician—is less.”
“In a paper that included 501 of my patients who underwent simultaneous bilateral TKA there were no deaths, no strokes, and no myocardial infarctions. However, there was increased morbidity, particularly in patients over 75 and those that had increased preoperative comorbidity.”
“Let’s return to the paper Jay quoted—a large hospital discharge database that included four million TKA. In this population there were 153, 000 bilateral knee replacements—not necessarily done simultaneously, but done during the same hospital stay. The mortality was less in the unilateral group compared to the bilateral group. However, remember that these patients are coming back for a second procedure and there is going to be some mortality related to the second operation. So comparing unilaterals and bilaterals isn’t always good and may not be totally accurate.”
“Interestingly, as you look at these complications as we moved to a more current treatment mode (for example, more current anesthetic management), they all tended to come down. The reduction in the complications is due to many things: improved patient selection, better anesthetic techniques, better perioperative care, and faster surgery.”
“Over a 10 year period (1999-2009) at HSS there were 20, 000 knee replacements, 3, 000 of which were bilateral. The unilateral populations actually had a higher mortality rate than our bilateral populations…probably due to good patient selection. Even our infection rate was lower in this population. As for hospital charges, a bilateral procedure was $67, 000 as opposed to a unilateral times two ($46, 652 per), was less even if you factored in the need for rehabilitation.”
“We’ve tried to mitigate the perioperative response from fat emboli and potential acute respiratory distress syndrome. In a randomized trial we published in the Journal of Bone and Joint Surgery we used a perioperative steroid to mitigate perioperative complications—in particular, lung complications—after a bilateral procedure. We took 30 patients and gave them three doses of hydrocortisone (one preoperatively, another one eight hours after surgery, and another one eight hours after that). We monitored the inflammatory cytokine IL6 and desmosine, which is a lung enzyme.”
“We found that IL6 rises then drops down normally. In the population that received perioperative cortisone there was essentially no change in the elevation of that inflammatory cytokine. Desmosine is a marker that we can use for lung injury. When we looked at the same cohort of patients that received perioperative hydrocortisone, we found a significant reduction in desmosine levels as opposed to those patients in the control population.”
“Our clinical findings showed that in the group treated with hydrocortisone there was better range of motion, a reduced need for pain medication, and zero infections. So if you’re going to do bilateral knee replacement surgery you should consider using perioperative hydrocortisone to mitigate some of the potential lung injury that can occur from fat emboli (as we have seen in the trauma population).”
Moderator Whiteside: “Jay, when a patient asks to have both knees done at once, what do you say?”
Dr. Parvizi: “If they are sufficiently fit, i.e., no cardiac or pulmonary comorbidities, and if I feel that the risk is justified, then I will offer it to them. But the majority of patients I see don’t fall into that category.”
Moderator Whiteside: “If they are very eager to go ahead despite significant morbidity in their history, do you let them make that decision?”
Dr. Parvizi: “I think it’s my responsibility as their doctor to make that decision.”
Moderator Whiteside: “Tom, what do you do when someone you think is not a good candidate for bilateral simultaneous joint replacement wants it anyway?”
Dr. Sculco: “We have a clearance system. There are many patients who I think are right for a bilateral knee replacement, but they also see an internist and an anesthesiologist. Also, we put a multidisciplinary consensus panel together and we developed a series of guidelines that we adhere to. Adhering to these guidelines has meant that morbidity and mortality is significantly reduced.”
Moderator Whiteside: “So you feel that in your hands bilateral TKA has a lower morbidity and mortality rate than if you separated them by three months?”
Dr. Sculco: “If you look at our data—over 3, 000 cases—the mortality was less in that population. It was less because these patients are screened and healthier.”
Dr. Parvizi: “Leo, that statistic is flawed. You can’t just multiply the risk factor by two in these patients. If your chance of getting hit by a car is 10% each time you cross the street it doesn’t mean that if you cross the street 10 times that you’ll definitely get hit.”
Moderator Whiteside: “Thank you both very much.”
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