Looking at Mayo Clinic data—94 simultaneous patients matched to staged—they found that the simultaneous cases had shorter operative times, no different mortality or complications and reduced cost by nearly one-third. (Houdek, et al., JBJS AM, 2017)
In Denmark, very similar, lower rates of readmission, lower length of stay when you do these at the same time compared to staging them. (Lindberg Larsen, et al., Arch Orthop Trauma Surg, 2013)
If you’re going to do the second side, I think you need to wait a little while. The risk of myocardial infarction and complications are higher in the first interval after surgery, so if you’re going to stage them, I think you ought to wait at least 6 weeks.
The problem with all the data is the selection bias because only the youngest, healthiest patients are often offered the simultaneous. I use younger patients. Thinner patients. No active cardiopulmonary disease. And I discuss the risks with the patient and let them choose.
In summary, I think there are significant advantages. Single anesthetic exposure. Shorter length of stay. Less time off from work. And, overall cost savings.
Moderator Maloney: Matt, you have a 1 minute.
Dr. Abdel: I think Bill did a very nice and honest job of presenting it in his skilled hands. And I think there’s a subset of patients that no question would benefit from simultaneous procedures. The fact remains, and I think Bill it highlighted nicely…this is a hyper select group of patients. These are the healthiest, youngest patients. There’s obviously a bias when you look at the literature, but you just want to stratify based on your patients.
Dr. Hamilton: Yes, this surgery is not for everyone. I select them…not the larger patients, not the real difficult cases. And I have a discussion with them so there’s shared decision making here. I go over the fact that the transfusion rate is a little higher. And you explain all that and tell them it’s one exposure to anesthesia. It’s less time off from work. Patients have been very happy with this surgery in my hands.
Dr. Abdel: I suspect if we actually had a randomized clinical trial with less than 50-year-old patients with no more than 1 co-morbidity, and looked at that too, the data would probably not filter out. I bet you probably staging them they would have lower numbers on most of those things. But we just don’t have that data available to us right now.
Moderator Maloney: So Matt. Let’s start with the issue of bilateral simultaneous hip replacement regardless of approach. Do you do it? And if you do it, what are your indications for that?
Dr. Abdel: I do it. It’s quite rare in my practice. If I look at my hip practice, probably 5% of my patients, they’re usually young, active, healthy, non-obese and, as Bill nicely alluded to, they’re usually professionals that are getting back to their careers pretty quick.
Moderator Maloney: There are many patients who have bilateral hip osteoarthritis. But often one is significantly worse than the other. Trying to think back over the years how many say both hips hurt the same? You’re often doing 2 hips—1 of which is a little worse than the other?
Dr. Hamilton: Yes, most often one hip hurts worse than the other. But both hips must meet criteria for surgery. If they say, “My other hip doesn’t hurt at all,” then they get a single hip.
Moderator Maloney: Bill, talk to us a little bit about your post-op protocol. You said they have to be a little careful walking with 2 fresh hips. What do you do differently post-op?
Dr. Hamilton: I waited about a year after starting the anterior approach to do my first bilateral patient. I was quite nervous because of all the reasons…but I think you need to get pretty good at it before you start doing these two at once. I want to make sure the stem goes in very solid. I use a triple taper with a collar. And I typically will have these patients use an assistive device a little bit longer. For a single hip they can get off their device when they’re ready, but for these I typically want them to use something for at least the first 4-6 weeks. Really protecting against that fall or stumble.
Moderator Maloney: Experience definitely matters. Thank you very much gentlemen.
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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..