Clinical Orthopaedics and Related Research®

, Volume 467, Issue 6, pp 1568–1576 | Cite as

Trends in Bilateral Total Knee Arthroplasties: 153,259 Discharges between 1990 and 2004

  • Stavros G. Memtsoudis
  • Melanie C. Besculides
  • Shane Reid
  • Licia K. Gaber-Baylis
  • Alejandro González Della Valle
Original Article


Information regarding national trends in bilateral TKAs is needed for a rational allocation of resources, policy making, and research. Therefore, we analyzed data from the National Hospital Discharge Survey to elucidate temporal changes in the demographics, comorbidity profiles, hospital stay, and in-hospital complications of patients undergoing bilateral TKAs in the United States. We created three 5-year periods: 1990–1994, 1995–1999, 2000–2004. Procedure, healthcare system, and patient-related variables were analyzed for an estimated 153,259 discharges. Use of bilateral TKAs more than doubled for the entire civilian population and almost tripled among the female population, with the steepest increase seen during the last two study periods. A decline of nearly 50% in the use of bilateral TKAs in patients 85 years and older was seen between the second and third study periods. The prevalence of coronary artery disease and pulmonary disease increased from the first to the second study periods but decreased from the second to the third. The changes in the variables studied may reflect a recently acquired reluctance to perform bilateral TKAs in elderly patients with cardiopulmonary comorbidities. Additional studies are necessary to identify other causal relationships and define the impact of these changes on various aspects of the healthcare system.

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


  1. 1.
    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
  2. 2.
    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
  3. 3.
    Design and Operation of the National Hospital Discharge Survey: 1988 Redesign. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics; 1988.Google Scholar
  4. 4.
    Forrest GP, Roque JM, Dawodu ST. Decreasing length of stay after total joint arthroplasty: effect on referrals to rehabilitation units. Arch Phys Med Rehabil. 1999;80:192–194.PubMedCrossRefGoogle Scholar
  5. 5.
    Graves EJ. 1993 summary: National Hospital Discharge Survey. Adv Data. 1995;264:1–11.PubMedGoogle Scholar
  6. 6.
    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
  7. 7.
    Health, United States, 2006. Hyattsville, MD: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics; 2006.Google Scholar
  8. 8.
    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
  9. 9.
    International Classification of Diseases, 9th Revision, Clinical Modification [ICD-9-CM], 6th ed, 2008. Available at: Accessed September 19, 2008.
  10. 10.
    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
  11. 11.
    Kadam UT, Jordan K, Croft PR. Clinical comorbidity in patients with osteoarthritis: a case-control study of general practice consulters in England and Wales. Ann Rheum Dis. 2004;63:408–414.PubMedCrossRefGoogle Scholar
  12. 12.
    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
  13. 13.
    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
  14. 14.
    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
  15. 15.
    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
  16. 16.
    Lin JJ, Kaplan RJ. Multivariate analysis of the factors affecting duration of acute inpatient rehabilitation after hip and knee arthroplasty. Am J Phys Med Rehabil. 2004;83:344–352.PubMedCrossRefGoogle Scholar
  17. 17.
    Livingston EH. Procedure incidence and in-hospital complication rates of bariatric surgery in the United States. Am J Surg. 2004;188:105–110.PubMedCrossRefGoogle Scholar
  18. 18.
    Mehrotra C, Remington PL, Naimi TS, Washington W, Miller R. Trends in total knee replacement surgeries and implications for public health, 1990–2000. Public Health Rep. 2005;120:278–282.PubMedGoogle Scholar
  19. 19.
    Memtsoudis SG, Gonzalez Della Valle A, Besculides MC, Garber LK, Laskin RS. Trends in demographics, comorbidity profiles, in-hospital complications and mortality associated with primary knee arthroplasty: 3,830,420 hospital discharges in the United States between 1990 and 2004. J Arthroplasty. 2008 April 14. [Epub ahead of print]Google Scholar
  20. 20.
    Memtsoudis SG, Gonzalez Della Valle A, Besculides MC, Garber LK, Sculco TP. In-hospital complications and mortality of patients undergoing primary unilateral, bilateral and revision TKA: based on an estimate of4,169,489 discharges. Clin Orthop Relat Res. 2008;466:2617–2627.PubMedCrossRefGoogle Scholar
  21. 21.
    National Intercensal Estimates (1990–2000). US Census Bureau, 2007. Available at: Accessed August 15, 2008.
  22. 22.
    Nowygrod R, Egorova N, Greco G, Anderson P, Gelijns A, Moskowitz A, McKinsey J, Morrissey N, Kent KC. Trends, complications, and mortality in peripheral vascular surgery. J Vasc Surg. 2006;43:205–216.PubMedCrossRefGoogle Scholar
  23. 23.
    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
  24. 24.
    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
  25. 25.
    Primary total hip and total knee arthroplasty projections to 2030. Communication of the American Academy of Orthopaedic Surgeons. Rosemont, IL: American Academy of Orthopaedic Surgeons; 1998:7.Google Scholar
  26. 26.
    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
  27. 27.
    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
  28. 28.
    Ritter MA, Harty LD. Debate: simultaneous bilateral knee replacements: the outcomes justify its use. Clin Orthop Relat Res. 2004;428:84–86.PubMedCrossRefGoogle Scholar
  29. 29.
    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
  30. 30.
    Robertsson O, Dunbar MJ, Knutson K, Lidgren L. Past incidence and future demand for knee arthroplasty in Sweden: a report from the Swedish Knee Arthroplasty Register regarding the effect of past and future population changes on the number of arthroplasties performed. Acta Orthop Scand. 2000;71:376–380.PubMedCrossRefGoogle Scholar
  31. 31.
    Selected articles using National Hospital Discharge Survey or National Survey of Ambulatory Surgery data. Centers for Disease Control and Prevention., 2007. Available at: Accessed August 15, 2008.
  32. 32.
    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

Copyright information

© The Association of Bone and Joint Surgeons 2008

Authors and Affiliations

  • Stavros G. Memtsoudis
    • 1
  • Melanie C. Besculides
    • 2
  • Shane Reid
    • 1
  • Licia K. Gaber-Baylis
    • 3
  • Alejandro González Della Valle
    • 4
  1. 1.Department of Anesthesiology, Hospital for Special SurgeryWeill Medical College of Cornell UniversityNew YorkUSA
  2. 2.Mathematica Policy Research, IncPrincetonUSA
  3. 3.LKG ConsultingPlainsboroUSA
  4. 4.Department of Orthopaedic Surgery, Hospital for Special SurgeryWeill Medical College of Cornell UniversityNew YorkUSA

Personalised recommendations