The Debate Over Simultaneous Bilateral Knee Replacement

    At ICJR’s annual Winter Hip & Knee Course, David Nazarian, MD, and R. Michael Meneghini, MD, squared off on the issue of simultaneous bilateral total knee arthroplasty (TKA).

    Here are some of the key points raised by both surgeons during the debate.

    Pro: David Nazarian, MD

    In his practice, Dr. Nazarian performs bilateral TKAs in the same surgery, doing the procedures sequentially. He and his team tried concurrent procedures, but he described that as “like working at the bottom of a Cuisinart.”

    Both knees are prepped and draped at the same time. The surgeon stands on the right side of the patient and leans the table either away from him for the right knee or toward him for the left knee.

    Dr. Nazarian contends that the literature shows bilateral TKA “can be done reasonably safely in a simultaneous fashion without a significant increase in complications.” He noted that one large study showed an increase in mortality in patients undergoing a simultaneous bilateral TKA, but other studies, he said, do not support that conclusion.

    Dr. Nazarian acknowledged that in a worst case scenario, some patients will be at increased risk for complications when undergoing a simultaneous bilateral TKA. To reduce the risk, all of his patients have a cardiac evaluation prior to surgery, and most also undergo a cardiac stress test.

    During surgery, Dr. Nazarian uses neuraxial anesthesia and a cell saver to salvage as much blood as possible, and he does the worse knee first. The risk of embolic issues is mitigated by either the use of suction catheters to diminish intermedullary pressures or use of an extra medullary guide on all four canals. The latter has been shown to diminish the amount of fat embolic material traveling through the right side of the heart at tourniquet release.

    Dr. Nazarian’s presentation can be found here.

    Con: R. Michael Meneghini, MD

    Dr. Meneghini, who admitted he recently performed his first bilateral TKA in 7 years on a non-ambulatory patient with severe contractures, does not believe the potential benefits of simultaneous bilateral TKA is worth the risks – namely, death, deep vein thrombosis/pulmonary embolism (DVT/PE), and cardiac and neurologic complications.

    He quoted a study from 1997 by Ritter et al that examined outcomes of more than 300,000 TKAs, nearly 63,000 of which were bilateral TKAs (simultaneous and staged). The investigators concluded that “staging the procedure 3 or 6 months seems to offer the fewest disadvantages, is only slightly more expensive, and has the lowest mortality rate.”

    A later study by Ritter et al confirmed a greater incidence of complications in simultaneous bilateral TKAs versus unilateral TKAs. The higher rate of ileus, gastrointestinal bleeding, and DTV/PE reached statistical significance.

    Dr. Meneghini reported on more recent literature as well. A 2011 study based on a California hospital database found a lower risk of infection and mechanic complications among patients who underwent a simultaneous bilateral TKA versus those who underwent a staged procedure, but a higher risk for myocardial infarction, PE, stroke, and death.

    A 2013 study based on a national inpatient survey included more than 250,000 bilateral TKA patients. The data indicated a trend in decreasing age for patients, but increasing comorbidities. The in-hospital mortality rate decreased, but when the data were adjusted for length of stay, there was an increase in pneumonia, PE, and cardiac issues in patients who underwent simultaneous bilateral TKA.

    Dr. Meneghini agreed with Dr. Nazarian that some patients can safely undergo simultaneous bilateral TKA. The problem he has is that there is still some difficulty in determining which patients are the best candidates. Some, but not all, risk factors have been clearly identified.

    His bottom line is that despite better selection of patients and improved perioperative care, the risk of medical complications continues to be greater for simultaneous bilateral TKA than for unilateral TKA. The literature shows, he said, that the risks with staged bilateral TKAs done 3 months apart are the same as for unilateral TKA.

    Dr. Meneghini’s presentation can be found here.