, Volume 471, Issue 8, pp 2649-2657
Date: 06 Apr 2013

Consensus Statement from the Consensus Conference on Bilateral Total Knee Arthroplasty Group

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Abstract

Background

Controversy exists regarding many aspects of decision making pertaining to same-day versus staged bilateral TKA (BTKAs), including patient selection, perioperative management decisions, and other important choices.

Questions/purposes

In the absence of suitable randomized trials, we sought to determine areas of consensus among national experts on the following questions: (1) What are the comparative risks of same-day BTKAs compared with unilateral TKA (UTKA) and staged BTKAs? (2) Who should be considered an appropriate candidate for same-day BTKAs? (3) What constitutes appropriate workup and perioperative management for BTKAs? (4) What is the optimal time between procedures if same-day BTKAs are not deemed appropriate? (5) Are there orthopaedic or rehabilitation considerations for BTKAs that might outweigh medical contraindications?

Methods

In the setting of a consensus conference of national experts in orthopaedic surgery, anesthesiology, perioperative medicine, and epidemiology, the major questions surrounding same-day BTKAs were addressed by using an extensive literature review and the modified Delphi process. The process concluded with a meeting of participants and formulation of consensus statements.

Results

Eighty-one percent of participants agreed that BTKAs are more invasive and complex procedures associated with increased risk for perioperative adverse events compared with UTKA in an unselected group of patients. The consensus group agreed that physicians and hospitals should consider using more restrictive patient selection criteria and exclude those with a modified cardiac risk index greater than 3 to mitigate the potentially increased risk. The majority of the group agreed that perioperative assessment and management should reflect the higher level of acuity of same-day BTKAs. Eighty-one percent of participants agreed that if a patient is not deemed a candidate for same-day BTKAs, a second TKA should be scheduled no sooner than 3 months after the first. The entire group agreed that when there is a conflict between the orthopaedic need and the medical adequacy of same-day BTKAs, the medical concern for the patient’s safety should prevail over the orthopaedic need.

Conclusions

Experts perceived that same-day BTKAs increase medical risk, and thus a systematic approach to the management of patients should be taken to minimize complications.

Each author certifies that he or she, or a member of his or her immediate family, has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. The institution of one of the authors (JP) has received, during the study period, funding from the Journal of Arthroplasty (Philadelphia, PA); consultancy with Biomet (Warsaw, IN), Smith & Nephew (London, UK), Zimmer (Warsaw, IN), Convatec (Skillman, NJ), Covidien (Mansfield, MA), TissueGene (Rockville, MD), Ceramtec (Plochingen, Germany), Advanced Biologics (Ladera Ranch, CA), Pfizer (New York, NY); payment for development of educational presentations: Elsevier (Philadelphia, PA), Wolters Kluwer (Alphen aan den Rijn, the Netherlands), Slack (Thorofare, NJ); stock options: SmarTech (Fort Worth, TX); other: Philadelphia Orthopaedics (Philadelphia, PA); Eastern Orthopaedics (Yardley, PA); CD diagnostics (Wynnewood, PA); United Healthcare (Minnetonka, MN), Magnifi Group (San Diego, CA), 3 M Healthcare (St. Paul, MN). One author (TPS) discloses an industrial affiliation: a consultancy with Exactech (Gainesville, FL).
The consensus process and the meeting were funded by the Departments of Orthopedic Surgery and Anesthesiology at the Hospital for Special Surgery, by the Hospital for Special Surgery, and by John A. Moran.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.
This work was performed at the Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY, USA.