Simultaneous Bilateral TKA Less Risky Than Staged?

Stiffness that requires manipulation under anesthesia postoperatively is a problem for patients with bilateral knee arthritis. Turns out, says new research, that it’s more of an issue for those who undergo staged bilateral total knee arthroplasty (B-TKA) or unilateral TKA than for those who have simultaneous bilateral TKA.

The study, “Postoperative Stiffness Requiring Manipulation Under Anesthesia Is Significantly Reduced After Simultaneous Versus Staged Bilateral Total Knee Arthroplasty,” was published in the December 20, 2017 edition of The Journal of Bone and Joint Surgery.

Study co-author and member of the Department of Orthopaedic Surgery at the University of California, Davis in Sacramento, California, John P. Meehan, M.D. told OTW, “In a 2011 article published in Journal of Bone and Joint Surgery (JBJS), we developed a sophisticated methodological model to minimize the bias associated with studies that compared outcomes of patients who underwent simultaneous bilateral total knee arthroplasty (simultaneous-BTKA) versus patients who underwent staged bilateral TKA (staged B-TKA).”

“The most important part of the model was that we accounted for patients who planned to undergo two knee replacements in a staged manner (planned staged B-TKA) but did not undergo the second knee procedure due to medical, surgical complications or simply decided after the first knee replacement that they did not wish to undergo the procedure a second time. Our results indicated that surgical complications, especially periprosthetic joint infection and aseptic loosening, were significantly reduced in people who underwent simultaneous-BTKA versus staged B-TKA.”

“In our recent study published in JBJS, we utilized the same methodological model to assess for a difference in postoperative stiffness requiring manipulation under anesthesia (MUA). Using the California Patient Discharge Database (PDD) linked with the California Emergency Department (ED), Ambulatory Surgery (AS), and master death file databases, we were able to acquire records on 95-97% of all discharges in the state. From this, we performed hierarchical, risk adjusted, multivariate models of the outcome of undergoing MUA within 90 and 180 days after TKA.”

“We specifically wanted to determine if a person with symptomatic bilateral knee osteoarthritis would have less postoperative stiffness and by inference improved recovery if they underwent a single operative event, simultaneous B-TKA, or two separate operative events, staged B-TKA.”

“While numerous textbooks describe bilateral knee osteoarthritis with contractures as an indication to perform simultaneous B-TKA, to the best of our knowledge this recommendation has not been scientifically validated.”

“Our results supported the hypothesis that performing a simultaneous B-TKA in patients with symptomatic bilateral knee osteoarthritis would allow for an improved functional recovery with a statistically significant reduction in hospital readmissions for postoperative stiffness requiring MUA when compared to staged B-TKA.”

“With stiffness being associated with an increased need for revision surgery and decreased patient satisfaction, combined with the financial burden of hospital readmissions for MUA, the benefits of performing simultaneous B-TKA in appropriately selected patients with symptomatic bilateral knee osteoarthritis are even more justified by our findings.”