Simultaneous Bilateral THA Can Be Done Safely with the Direct Anterior Approach

    There’s a certain appeal to simultaneous bilateral total hip arthroplasty (THA) for patients who clearly need to have both hips replaced: It’s 1 procedure instead of 2, so there’s less time in surgery, less time in the hospital, and less recovery time. There may even be cost savings.

    But there are downsides, too: Longer operative time, greater blood loss, lower postoperative hemoglobin level, and more transfusions.

    So, it’s not surprising that some surgeons and patients are apprehensive about undertaking a simultaneous bilateral THA.

    A study by William G. Hamilton, MD, from Anderson Orthopaedic Research Institute, Alexandria, Virginia, may help to allay some of the concerns. His research, presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons, showed that with the right patient selection criteria and a protocol that helps to minimize potential issues, simultaneous bilateral THA can be safely performed.

    Dr. Hamilton and his colleagues matched a consecutive series of 109 simultaneous bilateral THA patients on a 1:2 basis with 218 patients who had undergone unilateral THA between 2010 and 2016. Patients were matched according to gender, age, body mass index (BMI), and date of surgery. All procedures were performed by Dr. Hamilton using the direct anterior approach.

    Study data included comparisons of:

    • In-hospital complications
    • 30-day complications
    • Operative time
    • Blood loss
    • Hemoglobin on POD1
    • Transfusion rate
    • Length of stay
    • Distance ambulated on POD1
    • Discharge disposition

    The researchers found that compared with the unilateral THA group, the simultaneous bilateral THA group had:

    • Longer operative time
    • Greater intraoperative blood loss
    • Lower postoperative hemoglobin
    • Shorter distance ambulated
    • Higher transfusion rate
    • Longer stay

    But no difference was observed between groups for complications – in-hospital and 30-day complications – or discharge disposition, demonstrating the safety of simultaneous bilateral THA.

    Dr. Hamilton wasn’t surprised that the bilateral patients in this study had low complication rates and did well clinically; it just confirmed what he’s observed in his practice.

    He performs 20 to 30 simultaneous bilateral procedures a year. With this volume, his team has now been able to develop a protocol for prepping and draping both sides and for quickly shifting the fluoroscope and instruments after the first side is complete. “We do the surgeries in an overlapping fashion, so while the first hip is being closed, the second surgery is started. This saves considerable time,” Dr. Hamilton said.

    “I also have the perception – although unproven – that I am better able to replicate the sizing and positioning of the implants by doing the procedures back to back,” he said. “Replicating the neck cut, cup reaming and positioning, and broaching seems to be more accurate by learning what you did on the first side minutes before instead of staging them months apart.”

    One of the keys to simultaneous bilateral THA, at least for Dr. Hamilton, is the direct anterior approach: He calls it “the gateway to performing simultaneous bilateral surgery.”

    “I became more interested in simultaneous bilateral surgery once I became competent in performing the anterior approach. The supine positioning with the anterior approach makes bilateral surgery so much more appealing, avoiding the need to reposition, reprep, and redrape,” Dr. Hamilton said.

    To select appropriate candidates for simultaneous bilateral THA, Dr. Hamilton uses these criteria:

    • Bilateral hip disease, with both hips meeting the criteria for surgery
    • Age under 70 to 75
    • BMI under 35
    • No active end-organ failure
    • No active cardiopulmonary disease

    Most of all, the patient has to choose to undergo the simultaneous bilateral procedure. “Patients are often skeptical at first, but once I explain the details, they often leap at the chance to avoid 2 surgeries,” Dr. Hamilton said. “There is some data to suggest bilateral surgery poses more medical risks. I discuss this with patients so they know this data exists.”

    The takeaway message for surgeons, Dr. Hamilton said, is that, “Simultaneous bilateral surgery, especially when done in the supine position, is an attractive alternative for patients and surgeons alike. Patients recover well, do not have a dramatically harder recovery, and are thankful in the end. Surgeons should recognize the increased risk of transfusion and take appropriate precautions,” such as the use of tranexamic acid.


    Tauchen A, Hushmendy S, Parks NL, Pfefferle KJ, Hamitlon WG. Modern Simultaneous Bilateral Anterior Total Hip Arthroplasty is a Safe and Efficient Surgery (Paper 700). Presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 12-16, Las Vegas, Nevada.