Clinical Orthopaedics and Related Research

, Volume 466, Issue 11, pp 2617–2627

In-hospital Complications and Mortality of Unilateral, Bilateral, and Revision TKA: Based on an estimate of 4,159,661 Discharges

  • Stavros G. Memtsoudis
  • Alejandro González Della Valle
  • Melanie C. Besculides
  • Licia Gaber
  • Thomas P. Sculco
Symposium: Papers Presented at the Annual Meetings of the Knee Society


Patients undergoing bilateral total knee arthroplasty (BTKA) may have higher complication rates and mortality than those undergoing a unilateral procedure (UTKA). To evaluate this hypothesis, we analyzed nationally representative data collected for the National Hospital Discharge Survey on discharges after BTKA, UTKA, and revision TKA (RTKA) between 1990 and 2004. The demographics, comorbidities, in-hospital stay, complications, and mortality of each procedure were compared. An estimate of 4,159,661 discharges (153,259 BTKAs; 3,672,247 UTKAs; 334,155 RTKAs) were included. Patients undergoing BTKA were younger (1.5 years) and had a lower prevalence of comorbidities for hypertension (versus UTKA), diabetes, pulmonary disease, and coronary artery disease (versus UTKA and RTKA). The length of hospitalization was 5.8 days for BTKA, 5.3 for UTKA, and 5.4 for RTKA. Despite similar length of hospitalization, the prevalence of procedure-related complications was higher for BTKA (12.2%) compared with UTKA (8.2%) and RTKA (8.7%). In-hospital mortality was highest for patients undergoing BTKA (BTKA, 0.5%; UTKA, 0.3%; RTKA, 0.3%). Patients undergoing BTKA had a 1.6 times higher rate of procedure-related complications and mortality compared with those undergoing UTKA. Outcomes for patients undergoing RTKA for most variables were similar to those for UTKA. BTKA, advanced age, and male gender were independent risk factors for complications and mortality after TKA.

Level of Evidence: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.


  1. 1.
    Adili A, Bhandari M, Petruccelli D, De Beer J. Sequential bilateral total knee arthroplasty under 1 anesthetic in patients > or = 75 years old: complications and functional outcomes. J Arthroplasty. 2001;16:271–278.PubMedCrossRefGoogle Scholar
  2. 2.
    Alemparte J, Johnson GV, Worland RL, Jessup DE, Keenan J. Results of simultaneous bilateral total knee replacement: a study of 1208 knees in 604 patients. J South Orthop Assoc. 2002;11:153–156.PubMedGoogle Scholar
  3. 3.
    Amin AK, Clayton RA, Patton JT, Gaston M, Cook RE, Brenkel IJ. Total knee replacement in morbidly obese patients. Results of a prospective, matched study. J Bone Joint Surg Br. 2006;88:1321–1326.PubMedCrossRefGoogle Scholar
  4. 4.
    Barrett J, Baron JA, Losina E, Wright J, Mahomed NN, Katz JN. Bilateral total knee replacement: staging and pulmonary embolism. J Bone Joint Surg Am. 2006;88:2146–2151.PubMedCrossRefGoogle Scholar
  5. 5.
    Besser MI. Bilateral Attenborough total knee replacement as a single procedure. Arch Orthop Trauma Surg. 1983;101:271–272.PubMedCrossRefGoogle Scholar
  6. 6.
    Bhattacharyya T, Iorio R, Healy WL. Rate of and risk factors for acute inpatient mortality after orthopaedic surgery. J Bone Joint Surg Am. 2002;84:562–572.PubMedGoogle Scholar
  7. 7.
    Bottner F, Pavone V, Johnson T, Heitkemper S, Sculco TP. Blood management after bilateral total knee arthroplasty. Clin Orthop Relat Res. 2003;410:254–261.PubMedCrossRefGoogle Scholar
  8. 8.
    Bozic KJ, Durbhakula S, Berry DJ, Naessens JM, Rappaport K, Cisternas M, Saleh KJ, Rubash HE. Differences in patient and procedure characteristics and hospital resource use in primary and revision total joint arthroplasty: a multicenter study. J Arthroplasty. 2005;20:17–25.PubMedCrossRefGoogle Scholar
  9. 9.
    Brotherton SL, Roberson JR, de Andrade JR, Fleming LL. Staged versus simultaneous bilateral total knee replacement. J Arthroplasty. 1986;1:221–228.PubMedCrossRefGoogle Scholar
  10. 10.
    Bullock DP, Sporer SM, Shirreffs TG Jr. Comparison of simultaneous bilateral with unilateral total knee arthroplasty in terms of perioperative complications. J Bone Joint Surg Am. 2003;85:1981–1986.PubMedGoogle Scholar
  11. 11.
    Dennis DA. Debate: bilateral simultaneous total knee arthroplasty. Clin Orthop Relat Res. 2004;428:82–83.PubMedCrossRefGoogle Scholar
  12. 12.
    Dennison C, Pokras R. Design, operation of the National Hospital Discharge Survey: 1988 redesign. In: Vital and Health Statistics. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics; 2000;39:1–42.Google Scholar
  13. 13.
    Diduch DR, Insall JN, Scott WN, Scuderi GR, Font-Rodriguez D. Total knee replacement in young, active patients. Long-term follow-up and functional outcome. J Bone Joint Surg Am. 1997;79:575–582.PubMedGoogle Scholar
  14. 14.
    Font-Rodriguez DE, Scuderi GR, Insall JN. Survivorship of cemented total knee arthroplasty. Clin Orthop Relat Res. 1997;345:79–86.PubMedCrossRefGoogle Scholar
  15. 15.
    Foran JR, Mont MA, Etienne G, Jones LC, Hungerford DS. The outcome of total knee arthroplasty in obese patients. J Bone Joint Surg Am. 2004;86:1609–1615.PubMedGoogle Scholar
  16. 16.
    Foran JR, Mont MA, Rajadhyaksha AD, Jones LC, Etienne G, Hungerford DS. Total knee arthroplasty in obese patients: a comparison with a matched control group. J Arthroplasty. 2004;19:817–824.PubMedCrossRefGoogle Scholar
  17. 17.
    Forster MC, Bauze AJ, Bailie AG, Falworth MS, Oakeshott RD. A retrospective comparative study of bilateral total knee replacement staged at a one-week interval. J Bone Joint Surg Br. 2006;88:1006–1010.PubMedGoogle Scholar
  18. 18.
    Gandhi R, Petruccelli D, Devereaux PJ, Adili A, Hubmann M, de Beer J. Incidence and timing of myocardial infarction after total joint arthroplasty. J Arthroplasty. 2006;21:874–877.PubMedCrossRefGoogle Scholar
  19. 19.
    Gill GS, Mills D, Joshi AB. Mortality following primary total knee arthroplasty. J Bone Joint Surg Am. 2003;85:432–435.PubMedGoogle Scholar
  20. 20.
    Gillespie GN, Porteous AJ. Obesity and knee arthroplasty. Knee. 2007;14:81–86.PubMedCrossRefGoogle Scholar
  21. 21.
    Griffin FM, Scuderi GR, Insall JN, Colizza W. Total knee arthroplasty in patients who were obese with 10 years followup. Clin Orthop Relat Res. 1998;356:28–33.PubMedCrossRefGoogle Scholar
  22. 22.
    Hanssen AD, Pagnano MW. Revision of failed patellar components. Instr Course Lect. 2004;53:201–206.PubMedGoogle Scholar
  23. 23.
    Hawker GA, Wright JG, Coyte PC, Williams JI, Harvey B, Glazier R, Badley EM. Differences between men and women in the rate of use of hip and knee arthroplasty. N Engl J Med. 2000;342:1016–1022.PubMedCrossRefGoogle Scholar
  24. 24.
    Healy WL, Iorio R, Ko J, Appleby D, Lemos DW. Impact of cost reduction programs on short-term patient outcome and hospital cost of total knee arthroplasty. J Bone Joint Surg Am. 2002;84:348–353.PubMedGoogle Scholar
  25. 25.
    Healy WL, Iorio R, Lemos MJ. Athletic activity after joint replacement. Am J Sports Med. 2001;29:377–388.PubMedGoogle Scholar
  26. 26.
    Hersekli MA, Akpinar S, Ozalay M, Ozkoc G, Uysal M, Cesur N, Tandogan RN. A comparison between single- and two-staged bilateral total knee arthroplasty operations in terms of the amount of blood loss and transfusion, perioperative complications, hospital stay, and cost-effectiveness. Acta Orthop Traumatol Turc. 2004;38:241–246.PubMedGoogle Scholar
  27. 27.
    Horne G, Devane P, Adams K. Complications and outcomes of single-stage bilateral total knee arthroplasty. ANZ J Surg. 2005;75:734–738.PubMedCrossRefGoogle Scholar
  28. 28.
    Huotari K, Lyytikainen O, Seitsalo S. Patient outcomes after simultaneous bilateral total hip and knee joint replacements. J Hosp Infect. 2007;65:219–225.PubMedCrossRefGoogle Scholar
  29. 29.
    Hutchinson JR, Parish EN, Cross MJ. A comparison of bilateral uncemented total knee arthroplasty: simultaneous or staged? J Bone Joint Surg Br. 2006;88:40–43.PubMedCrossRefGoogle Scholar
  30. 30.
    Iezzoni LI, Foley SM, Daley J, Hughes J, Fisher ES, Heeren T. Comorbidities, complications, and coding bias. Does the number of diagnosis codes matter in predicting in-hospital mortality? JAMA. 1992;267:2197–2203.PubMedCrossRefGoogle Scholar
  31. 31.
    Jain NB, Higgins LD, Ozumba D, Guller U, Cronin M, Pietrobon R, Katz JN. Trends in epidemiology of knee arthroplasty in the United States, 1990–2000. Arthritis Rheum. 2005;52:3928–3933.PubMedCrossRefGoogle Scholar
  32. 32.
    Katz JN, Barrett J, Mahomed NN, Baron JA, Wright RJ, Losina E. Association between hospital and surgeon procedure volume and the outcomes of total knee replacement. J Bone Joint Surg Am. 2004;86:1909–1916.PubMedCrossRefGoogle Scholar
  33. 33.
    Kim YH. Incidence of fat embolism syndrome after cemented or cementless bilateral simultaneous and unilateral total knee arthroplasty. J Arthroplasty. 2001;16:730–739.PubMedCrossRefGoogle Scholar
  34. 34.
    Kim YH, Oh SW, Kim JS. Prevalence of fat embolism following bilateral simultaneous and unilateral total hip arthroplasty performed with or without cement: a prospective, randomized clinical study. J Bone Joint Surg Am. 2002;84:1372–1379.PubMedGoogle Scholar
  35. 35.
    Kolettis GT, Wixson RL, Peruzzi WT, Blake MJ, Wardell S, Stulberg SD. Safety of 1-stage bilateral total knee arthroplasty. Clin Orthop Relat Res. 1994;309:102–109.PubMedGoogle Scholar
  36. 36.
    Kovacik MW, Singri P, Khanna S, Gradisar IA. Medical and financial aspects of same-day bilateral total knee arthroplasties. Biomed Sci Instrum. 1997;33:429–434.PubMedGoogle Scholar
  37. 37.
    Kurtz S, Mowat F, Ong K, Chan N, Lau E, Halpern M. Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002. J Bone Joint Surg Am. 2005;87:1487–1497.PubMedCrossRefGoogle Scholar
  38. 38.
    Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89:780–785.PubMedCrossRefGoogle Scholar
  39. 39.
    Lachiewicz PF, Ranawat CS. Fat embolism syndrome following bilateral total knee replacement with total condylar prosthesis: report of two cases. Clin Orthop Relat Res. 1981;160:106–108.PubMedGoogle Scholar
  40. 40.
    Lane GJ, Hozack WJ, Shah S, Rothman RH, Booth RE Jr, Eng K, Smith P. Simultaneous bilateral versus unilateral total knee arthroplasty. Outcomes analysis. Clin Orthop Relat Res. 1997;345:106–112.PubMedCrossRefGoogle Scholar
  41. 41.
    Leitch KK, Dalgorf D, Borkhoff CM, Kreder HJ. Bilateral total knee arthroplasty–staged or simultaneous? Ontario’s orthopedic surgeons reply. Can J Surg. 2005;48:273–276.PubMedGoogle Scholar
  42. 42.
    Leonard L, Williamson DM, Ivory JP, Jennison C. An evaluation of the safety and efficacy of simultaneous bilateral total knee arthroplasty. J Arthroplasty. 2003;18:972–978.PubMedCrossRefGoogle Scholar
  43. 43.
    Liu TK, Chen SH. Simultaneous bilateral total knee arthroplasty in a single procedure. Int Orthop. 1998;22:390–393.PubMedCrossRefGoogle Scholar
  44. 44.
    Lombardi AV, Mallory TH, Fada RA, Hartman JF, Capps SG, Kefauver CA, Dodds K, Adams JB. Simultaneous bilateral total knee arthroplasties: who decides? Clin Orthop Relat Res. 2001;392:319–329.PubMedCrossRefGoogle Scholar
  45. 45.
    Macario A, Schilling P, Rubio R, Goodman S. Economics of one-stage versus two-stage bilateral total knee arthroplasties. Clin Orthop Relat Res. 2003;414:149–156.PubMedCrossRefGoogle Scholar
  46. 46.
    Mahomed NN, Barrett J, Katz JN, Baron JA, Wright J, Losina E. Epidemiology of total knee replacement in the United States Medicare population. J Bone Joint Surg Am. 2005;87:1222–1228.PubMedCrossRefGoogle Scholar
  47. 47.
    Mangaleshkar SR, Prasad PS, Chugh S, Thomas AP. Staged bilateral total knee replacement–a safer approach in older patients. Knee. 2001;8:207–211.PubMedCrossRefGoogle Scholar
  48. 48.
    Mantilla CB, Horlocker TT, Schroeder DR, Berry DJ, Brown DL. Frequency of myocardial infarction, pulmonary embolism, deep venous thrombosis, and death following primary hip or knee arthroplasty. Anesthesiology. 2002;96:1140–1146.PubMedCrossRefGoogle Scholar
  49. 49.
    March LM, Cross M, Tribe KL, Lapsley HM, Courtenay BG, Cross MJ, Brooks PM, Cass C, Coolican M, Neil M, Pinczewski L, Quain S, Robertson F, Ruff S, Walter W, Zicat B. Two knees or not two knees? Patient costs and outcomes following bilateral and unilateral total knee joint replacement surgery for OA. Osteoarthritis Cartilage. 2004;12:400–408.PubMedCrossRefGoogle Scholar
  50. 50.
    Meding JB, Reddleman K, Keating ME, Klay A, Ritter MA, Faris PM, Berend ME. Total knee replacement in patients with diabetes mellitus. Clin Orthop Relat Res. 2003;416:208–216.PubMedCrossRefGoogle Scholar
  51. 51.
    Morrey BF, Adams RA, Ilstrup DM, Bryan RS. Complications and mortality associated with bilateral or unilateral total knee arthroplasty. J Bone Joint Surg Am. 1987;69:484–488.PubMedGoogle Scholar
  52. 52.
    Nunley RM, Lachiewicz PF. Mortality after total hip and knee arthroplasty in a medium-volume university practice. J Arthroplasty. 2003;18:278–285.PubMedCrossRefGoogle Scholar
  53. 53.
    Oakes DA, Hanssen AD. Bilateral total knee replacement using the same anesthetic is not justified by assessment of the risks. Clin Orthop Relat Res. 2004;428:87–91.PubMedCrossRefGoogle Scholar
  54. 54.
    Parvizi J, Mui A, Purtill JJ, Sharkey PF, Hozack WJ, Rothman RH. Total joint arthroplasty: when do fatal or near-fatal complications occur? J Bone Joint Surg Am. 2007;89:27–32.PubMedCrossRefGoogle Scholar
  55. 55.
    Parvizi J, Sullivan TA, Trousdale RT, Lewallen DG. Thirty-day mortality after total knee arthroplasty. J Bone Joint Surg Am. 2001;83:1157–1161.PubMedGoogle Scholar
  56. 56.
    Pavone V, Johnson T, Saulog PS, Sculco TP, Bottner F. Perioperative morbidity in bilateral one-stage total knee replacements. Clin Orthop Relat Res. 2004;421:155–161.PubMedCrossRefGoogle Scholar
  57. 57.
    Powell RS, Pulido P, Tuason MS, Colwell CW Jr, Ezzet KA. Bilateral vs unilateral total knee arthroplasty: a patient-based comparison of pain levels and recovery of ambulatory skills. J Arthroplasty. 2006;21:642–649.PubMedCrossRefGoogle Scholar
  58. 58.
    Primary total hip and total knee arthroplasty projections to 2030. Bulletin of the American Academy of Orthopaedic Surgeons. Rosemont, IL: American Academy of Orthopaedic Surgeons; 1998.Google Scholar
  59. 59.
    Radmer S, Andresen R, Sparmann M. Simultaneous bilateral total knee arthroplasty in patients with rheumatoid arthritis. Z Orthop Ihre Grenzgeb. 2006;144:472–476.PubMedCrossRefGoogle Scholar
  60. 60.
    Restrepo C, Parvizi J, Dietrich T, Einhorn TA. Safety of simultaneous bilateral total knee arthroplasty. A meta-analysis. J Bone Joint Surg Am. 2007;89:1220–1226.PubMedCrossRefGoogle Scholar
  61. 61.
    Reuben JD, Meyers SJ, Cox DD, Elliott M, Watson M, Shim SD. Cost comparison between bilateral simultaneous, staged, and unilateral total joint arthroplasty. J Arthroplasty. 1998;13:172–179.PubMedCrossRefGoogle Scholar
  62. 62.
    Ritter M, Mamlin LA, Melfi CA, Katz BP, Freund DA, Arthur DS. Outcome implications for the timing of bilateral total knee arthroplasties. Clin Orthop Relat Res. 1997;345:99–105.PubMedCrossRefGoogle Scholar
  63. 63.
    Ritter MA, Harty LD. Debate: simultaneous bilateral knee replacements: the outcomes justify its use. Clin Orthop Relat Res. 2004;428:84–86.PubMedCrossRefGoogle Scholar
  64. 64.
    Ritter MA, Harty LD, Davis KE, Meding JB, Berend M. Simultaneous bilateral, staged bilateral, and unilateral total knee arthroplasty. A survival analysis. J Bone Joint Surg Am. 2003;85:1532–1537.PubMedGoogle Scholar
  65. 65.
    Schafer M, Elke R, Young JR, Gancs P, Kindler CH. Safety of one-stage bilateral hip and knee arthroplasties under regional anaesthesia and routine anaesthetic monitoring. J Bone Joint Surg Br. 2005;87:1134–1139.PubMedCrossRefGoogle Scholar
  66. 66.
    Selected articles using National Hospital Discharge Survey or National Survey of Ambulatory Surgery data. Centers for Disease Control and Prevention. 2007. Available at: Accessed October 19, 2007.
  67. 67.
    Shah K, Smith J, Jones B, Hullin M. Bilateral total knee replacement under a single anaesthetic, using a cementless implant is not unsafe. Knee Surg Sports Traumatol Arthrosc. 2007;15:269–275.PubMedCrossRefGoogle Scholar
  68. 68.
    Sierra RJ, Cooney WP 4th, Pagnano MW, Trousdale RT, Rand JA. Reoperations after 3200 revision TKAs: rates, etiology, and lessons learned. Clin Orthop Relat Res. 2004;425:200–206.PubMedCrossRefGoogle Scholar
  69. 69.
    Sliva CD, Callaghan JJ, Goetz DD, Taylor SG. Staggered bilateral total knee arthroplasty performed four to seven days apart during a single hospitalization. J Bone Joint Surg Am. 2005;87:508–513.PubMedCrossRefGoogle Scholar
  70. 70.
    SooHoo NF, Lieberman JR, Ko CY, Zingmond DS. Factors predicting complication rates following total knee replacement. J Bone Joint Surg Am. 2006;88:480–485.PubMedCrossRefGoogle Scholar
  71. 71.
    SooHoo NF, Zingmond DS, Lieberman JR, Ko CY. Primary total knee arthroplasty in California 1991 to 2001: does hospital volume affect outcomes? J Arthroplasty. 2006;21:199–205.PubMedCrossRefGoogle Scholar
  72. 72.
    Soudry M, Binazzi R, Insall JN, Nordstrom TJ, Pellicci PM, Goulet JA. Successive bilateral total knee replacement. J Bone Joint Surg Am. 1985;67:573–576.PubMedGoogle Scholar
  73. 73.
    Stanley D, Stockley I, Getty CJ. Simultaneous or staged bilateral total knee replacements in rheumatoid arthritis. A prospective study. J Bone Joint Surg Br. 1990;72:772–774.PubMedGoogle Scholar
  74. 74.
    Stubbs G, Pryke SE, Tewari S, Rogers J, Crowe B, Bridgfoot L, Smith N. Safety and cost benefits of bilateral total knee replacement in an acute hospital. ANZ J Surg. 2005;75:739–746.PubMedCrossRefGoogle Scholar
  75. 75.
    Sturmer T, Gunther KP, Brenner H. Obesity, overweight and patterns of osteoarthritis: the Ulm Osteoarthritis Study. J Clin Epidemiol. 2000;53:307–313.PubMedCrossRefGoogle Scholar
  76. 76.
    Vessely M, Harmsen WS, Schleck C, Melton LJ, Kurland R, Berry D. James A. Rand Award Paper: a population based study of trends in use of total hip and knee arthroplasty. J Arthroplasty. 2007;22:303.CrossRefGoogle Scholar
  77. 77.
    Vessely MB, Whaley AL, Harmsen WS, Schleck CD, Berry DJ. The Chitranjan Ranawat Award: long-term survivorship and failure modes of 1000 cemented condylar total knee arthroplasties. Clin Orthop Relat Res. 2006;452:28–34.PubMedCrossRefGoogle Scholar
  78. 78.
    Walmsley P, Murray A, Brenkel IJ. The practice of bilateral, simultaneous total knee replacement in Scotland over the last decade. Data from the Scottish Arthroplasty Project. Knee. 2006;13:102–105.PubMedCrossRefGoogle Scholar
  79. 79.
    Worland RL, Jessup DE, Clelland C. Simultaneous bilateral total knee replacement versus unilateral replacement. Am J Orthop. 1996;25:292–295.PubMedGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons 2008

Authors and Affiliations

  • Stavros G. Memtsoudis
    • 1
  • Alejandro González Della Valle
    • 2
  • Melanie C. Besculides
    • 3
  • Licia Gaber
    • 4
  • Thomas P. Sculco
    • 2
  1. 1.Department of Anesthesiology, Hospital for Special SurgeryWeill Medical College of Cornell UniversityNew YorkUSA
  2. 2.Department of Orthopaedic Surgery, Hospital for Special SurgeryWeill Medical College of Cornell UniversityNew YorkUSA
  3. 3.Mathematica Policy Research, Inc.PrincetonUSA
  4. 4.LKG ConsultingPlainsboroUSA

Personalised recommendations