It’s really a whole second surgery. The time from getting an implant in to the time of the second incision is maybe as much as 45 minutes. It’s costly. Most of us receive 50% reimbursement for the second side. To do an entire second hip, this really doesn’t have as much to do with the patient as much as it has to do with the surgeon. It’s simply not conducive to the flow of our day.
When you put your patient in the supine position it really facilitates bilateral surgery. You can prep and drape both hips simultaneously. You can overlap the surgeries to reduce the total surgery time.
Here’s a demonstration of a patient of mine. He’s a 46-year-old male and he had bilateral hip arthritis. Nearly equal symptoms in both hips. He’s relatively healthy, only a history of medically controlled hypertension. BMI [body mass index} is 28. Pre-op hemoglobin 14.5. He’s very concerned about his total time out of work.
Here’s how we do it. I drape both hips at the same time. We do our standard draping routine. I begin the first hip and, in this case, after 40 minutes, I had the implants in and I started my shuffle to the other side of the patient. It does take a little time. You’ve got to move the fluoroscopy around. You’ve got to move the OR table around. By 46 minutes, I began the second side. It took us about 6 minutes to shift everything around. By this time the closure has begun on the other side. My fellow and the PA [physician’s assistant} are starting to close the other side and we’ll start the second side.
By 64 minutes, the first side was completely closed, so the PA there can start helping me on the second side. And then at 84 minutes the implants were in on the second side and another 14 minutes for closure. In this particular case it was 98 minutes skin-to-skin for both surgeries.
It is very important that you get these implants very stable because when you’re walking on 2 newly replaced hips, I do worry about the risk of fracture.
This patient returned to his office by 3 weeks.
I looked at my own data. I had 105 patients; 210 hips and I matched those to 217 unilateral hips just for comparison sake to equal demographics. For my unilateral hips average skin-to-skin time over this interval was 72 minutes and the bilaterals was 123 minutes. The skin-to-skin bilaterals are 20 minutes less than if you did 2 unilaterals because you can overlap and you don’t need to reposition or redrape.
This is something you wouldn’t be able to do with a posterior approach, and I understand why Matt is so against this.
If you look at complications, they really are quite similar. In fact, hip related complications were lower in the bilateral group. The transfusion rate, although not statistically significant, was higher for the bilaterals. All of my patients went home except for 1 patient in the bilateral group who went to a skilled nursing facility. The average length of stay in the bilateral group was just under 2 days. Many of these patients will leave after 1 night in the hospital.
I was 60 y/o and had bilateral simultaneous posterior approach thr’s in June 2010 using SROM with ceramic on both sides of joint. Done by Mattingly in Boston. Doing well. Hgb dropped to 6.9, then got 2 bags autologous. ASA prophylaxis. Playing 18 holes today..