Higher Early Mortality with Simultaneous Rather than Staged Bilateral TKAs: Results From the Swedish Knee Arthroplasty Register

Abstract

Patients with knee osteoarthritis (OA) often present with symptoms that warrant bilateral TKAs. There are potential benefits to operating on both knees on the same day, but the safety of simultaneous bilateral TKAs has been questioned. To evaluate whether there were any differences in 30-day mortality between patients having simultaneous bilateral TKAs and those having staged bilateral TKAs, we analyzed data from the Swedish Knee Arthroplasty Register and the Swedish Cause of Death Register. We included 48,931 patients with OA having 60,062 primary TKAs during 1985 to 2004; 1139 had surgery on both knees on the same day (simultaneous bilateral) and 3432 had surgery on both knees on two different occasions with less than 1 year between operations (staged bilateral). The 30-day mortality after simultaneous bilateral TKAs was 7.53 (confidence interval, 2.62-21.69) times higher than after the second of staged TKA and 3.77 (confidence interval, 2.04-6.98) times higher than after a primary unilateral TKA. Assuming the total risk for a staged procedure is twice that of a unilateral procedure, the risk of mortality within 30 days is 1.94 (confidence interval, 1.05-3.59) times higher with simultaneous than staged TKA. It is safer to operate on one knee at a time.

Perioperative Morbidity and Mortality of Same-day Bilateral TKAs: Incidence and Risk Factors

“…The risk for major morbidity or mortality was comparable among the cohorts after adjustment for significant patient-related factors, which is similar to other studies using large databases finding no significant differences between same-day and staged bilateral TKAs regarding in-hospital [18] and 90-day mortality [28]. However, two meta-analyses [7,22] and the Swedish Knee Arthroplasty Register [26] showed a higher rate of mortality in same-day compared to staged bilateral TKAs. Another study [21] identified same-day bilateral TKA as a significant risk factor for perioperative mortality and concluded that same-day bilateral TKAs should be avoided in sick or elderly patients and that the medical condition of patients who have a history of cardiac or pulmonary problems should be optimized preoperatively [21].…”

“…However, despite potential advantages of the same-day approach, including exposure to the risks of anesthetic only once, one postoperative course of pain, reduced rehabilitation, and an earlier return to baseline function [10,11,23], the safety of same-day procedures has been questioned because of higher morbidity and mortality when compared with unilateral TKAs [15,22]. Several studies have attempted to compare the incidence of complications after same-day bilateral TKAs, staged bilateral TKAs, and unilateral TKAs using single institution databases, large administrative datasets, or meta-analyses [1,6,7,9,14,15,18,22,[26][27][28]. However, there are no randomized trials comparing the safety of these surgical strategies.…”

“…However, there are no randomized trials comparing the safety of these surgical strategies. Because of the diversity of study settings and designs, it is difficult to draw definitive conclusions [1,6,7,9,14,15,18,22,[26][27][28].…”

Perioperative Complications of Simultaneous versus Staged Unicompartmental Knee Arthroplasty

“…Advocates of simultaneous TKA have cited benefits of a single anesthetic, shorter cumulative hospital stays, patient convenience and satisfaction, and increased cost effectiveness for the healthcare system without increasing perioperative morbidity and mortality and without compromising the clinical outcomes of the operation [8, 9, 11, 12, 17, 18, 24, 27-30, 32, 35]. Opponents of the simultaneous approach cite increased perioperative complications, including pulmonary embolism, major cardiac events, ileus, higher transfusion rates, confusion, and death [1,4,12,15,21,23,27,33,35]. Concern also exists regarding the financial disincentive to the surgeon for performing bilateral simultaneous arthroplasty procedures [2,6,28].…”

Editor’s Spotlight/Take 5: Have Bilateral Total Knee Arthroplasties Become Safer? A Population-Based Trend Analysis (DOI: 10.1007/s11999-012-2608-9)

“…But these benefits may come at a serious cost to patient safety, as welldesigned studies have identified greater likelihoods of serious complications occurring in patients having same-day, bilateral surgeries compared to those having staged, bilateral surgeries [4,5].…”