Perioperative Outcomes after Unilateral and Bilateral Total Knee Arthroplasty

Abstract

Background The safety of bilateral total knee arthroplasties (BTKA) during the same hospitalization remains controversial. We sought to study differences in perioperative outcomes between unilateral and BTKA, and further compare BTKAs performed during the same versus different operations during the same hospitalization. Methods Nationwide Inpatient Sample data from 1998 to 2006 were analyzed. Entries for unilateral and BTKA procedures performed on the same day (simultaneous) and separate days (staged) during the same hospitalization were identified. Patient and health-care system related demographics were determined. The incidence of in-hospital mortality and procedure related complications was estimated and compared between groups. Multivariate regression was used to identify independent risk factors for morbidity and mortality. Results Despite younger average age and lower comorbidity burden, procedure related complications and in-hospital mortality were more frequent after BTKA than after unilateral procedures (9.45% vs. 7.07% and 0.30% vs. 0.14%, P<0.0001 each). An increased rate of complications was associated with a staged versus simultaneous approach with no difference in mortality (10.30% vs. 9.15% (P<0.0001) and 0.29% vs. 0.26% (P=0.2875)). Independent predictors for in-hospital mortality included: BTKA (simultaneous: OR 2.23, CI=[1.69; 2.95], P<0.0001; staged: OR 2.01, CI=[1.28; 3.41], P=0.0031), male gender (OR 2.02, CI=[1.75, 2.34], P<0.0001), age above 75 years (OR 3.96 CI=[2.77, 5.66], P<0.0001), and the presence of a number of comorbidities and complications. Conclusion BTKAs carry increased risk of perioperative morbidity and mortality compared to unilateral procedures. Staging BTKA procedures during the same hospitalization offers no mortality benefit, and may even expose patients to increased morbidity.

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.…”

“…In our cohort, the overall rates of procedure-related complications were similar among the bilateral TKA groups, while same-day TKA was associated with lower inhospital infection rate. Prior research has shown that the overall incidence of procedure-related complications was lower after same-day compared to staged bilateral TKAs during a single hospitalization [18]. Likewise, a recent analysis [14] suggested, after risk adjustment, the odds of developing hematoma and infection were lower in patients undergoing same-day bilateral TKAs than in patients undergoing staged bilateral TKAs.…”

“…In this context, a history of CHF suggests reduced end organ reserve and thus decreased ability to compensate for the stresses of surgery [20]. Therefore, physicians should be cautioned against worsening of cardiopulmonary function, especially in the setting of same-day bilateral TKAs, because these procedures are associated with significant metabolic injury, fluid shifts, and other insults exposing various organ systems to significant stresses [15,16,18,25].…”

“…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].…”

“…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.…”