Skip to main content

Advertisement

SpringerLink
Log in

Simultaneous bilateral total knee arthroplasty has higher in-hospital complications than both staged surgeries: a nationwide propensity score matched analysis of 38,764 cases

  • Original Article
  • Published:
European Journal of Orthopaedic Surgery & Traumatology Aims and scope Submit manuscript

Abstract

Purpose

To investigate (1) healthcare utilization, (2) in-hospital metrics and (3) total in-hospital costs associated with simultaneous versus staged BTKA while evaluating staged BTKA as a single process consisting of two combined episodes.

Methods

The national readmissions database was reviewed for simultaneous and staged (two primary unilateral TKAs12 months apart) BTKA patients (2016–2017). A total of 19,382 simultaneous BTKAs were identified, and propensity score matched (1:1) to staged BTKA patients (19,382 patients; 38,764 surgeries) based on demographics, comorbidities, and socioeconomic determinants. Outcomes included healthcare utilization [length of stay (LOS) and discharge disposition], in-hospital periprosthetic fractures, non-mechanical complications, and costs. Staged BTKA was evaluated as one process consisting of two episodes. For each staged patient, continuous outcomes were evaluated via the sum of both episodes. Categorical outcomes were added, and percents were expressed relative to total number of surgeries (n = 38,764).

Results

Simultaneous BTKA had longer LOS (5.0 days ± 4.7 vs. 4.5 days ± 3.5; p < 0.001), higher non-home discharge [36.9% (n = 7150/19,382) vs. 13.6% (n = 5451/38,764)], in-hospital periprosthetic fractures [0.13% (26/19,382) vs. 0.08% (31/38,764); p = 0.049], any non-mechanical complication [33.76% (6543/19,382) vs.15.93% (6177/38,764); p < 0.0001], hematoma/seroma formation [0.11% (22/19,382) vs. 0.05% (20/38,764); p = 0.0088], wound disruption [0.08% (16/19,382) vs. 0.04% (16/38,764); p = 0.0454], and any infection [1.13% (219/19,382) vs. 0.50% (194/38,764); p < 0.0001]. Average in-hospital costs for the two staged BTKA episodes combined were $5006 higher than those of simultaneous BTKA ($28,196 ± $18,488 vs. $33,202 ± $15,240; p < 0.001).

Conclusion

Simultaneous BTKA had higher healthcare utilization and in-hospital complications than both episodes of staged BTKA combined, with a minimal in-hospital cost savings. Future studies are warranted to further explore patient selection who would benefit from BTKA.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Pallin DJ, Espinola JA, Camargo CAJ (2014) US population aging and demand for inpatient services. J Hosp Med 9:193–196. https://doi.org/10.1002/jhm.2145

    Article  PubMed  Google Scholar 

  2. Sloan M, Premkumar A, Sheth NP (2018) Projected volume of primary total joint arthroplasty in the U.S., 2014 to 2030. J Bone Jt Surg Am 100:1455–1460. https://doi.org/10.2106/JBJS.17.01617

    Article  Google Scholar 

  3. Konopka JF, Lee Y-Y, Su EP, McLawhorn AS (2018) Quality-adjusted life years after hip and knee arthroplasty: health-related quality of life After 12,782 joint replacements. JBJS open access 3:e0007–e0007. https://doi.org/10.2106/JBJS.OA.18.00007

    Article  PubMed  PubMed Central  Google Scholar 

  4. Liu L, Liu H, Zhang H et al (2019) Bilateral total knee arthroplasty: Simultaneous or staged? A systematic review and meta-analysis. Medicine (Baltimore) 98:e15931. https://doi.org/10.1097/MD.0000000000015931

    Article  PubMed  Google Scholar 

  5. Grace TR, Tsay EL, Roberts HJ et al (2020) Staged bilateral total knee arthroplasty: increased risk of recurring complications. J Bone Jt Surg Am 102:292–297. https://doi.org/10.2106/JBJS.19.00243

    Article  Google Scholar 

  6. Santana DC, Anis HK, Mont MA et al (2020) What is the likelihood of subsequent arthroplasties after primary TKA or THA? Data from the osteoarthritis initiative. Clin Orthop Relat Res 478:34–41. https://doi.org/10.1097/CORR.0000000000000925

    Article  PubMed  Google Scholar 

  7. McMahon M, Block JA (2003) The risk of contralateral total knee arthroplasty after knee replacement for osteoarthritis. J Rheumatol 30:1822–1824

    PubMed  Google Scholar 

  8. Latifi R, Thomsen MG, Kallemose T et al (2016) Knee awareness and functionality after simultaneous bilateral versus unilateral total knee arthroplasty. World J Orthop 7:195–201. https://doi.org/10.5312/wjo.v7.i3.195

    Article  PubMed  PubMed Central  Google Scholar 

  9. Patil N, Wakankar H (2008) Morbidity and mortality of simultaneous bilateral total knee arthroplasty. Orthopedics 31:780–781. https://doi.org/10.3928/01477447-20080801-23

    Article  PubMed  Google Scholar 

  10. Stubbs G, Pryke SER, Tewari S et al (2005) Safety and cost benefits of bilateral total knee replacement in an acute hospital. ANZ J Surg 75:739–746. https://doi.org/10.1111/j.1445-2197.2005.03516.x

    Article  PubMed  Google Scholar 

  11. Odum SM, Springer BD (2014) In-hospital complication rates and associated factors after simultaneous bilateral versus unilateral total knee arthroplasty. J Bone Jt Surg Am 96:1058–1065. https://doi.org/10.2106/JBJS.M.00065

    Article  Google Scholar 

  12. Ritter MA, Harty LD, Davis KE et al (2003) Simultaneous bilateral, staged bilateral, and unilateral total knee arthroplasty. A survival analysis. J Bone Jt Surg Am 85:1532–1537. https://doi.org/10.2106/00004623-200308000-00015

    Article  Google Scholar 

  13. Kim Y-H, Choi Y-W, Kim J-S (2009) Simultaneous bilateral sequential total knee replacement is as safe as unilateral total knee replacement. J Bone Jt Surg Br 91:64–68. https://doi.org/10.1302/0301-620X.91B1.21320

    Article  Google Scholar 

  14. Lindberg-Larsen M, Pitter FT et al (2019) Simultaneous versus staged bilateral total knee arthroplasty: a propensity-matched case–control study from nine fast-track centres. Arch Orthop Trauma Surg 139:709–716. https://doi.org/10.1007/s00402-019-03157-z

    Article  CAS  PubMed  Google Scholar 

  15. Restrepo C, Parvizi J, Dietrich T, Einhorn TA (2007) Safety of simultaneous bilateral total knee arthroplasty. A meta-analysis. J Bone Jt Surg Am 89:1220–1226. https://doi.org/10.2106/JBJS.F.01353

    Article  Google Scholar 

  16. Fu D, Li G, Chen K et al (2013) Comparison of clinical outcome between simultaneous-bilateral and staged-bilateral total knee arthroplasty: a systematic review of retrospective studies. J Arthroplast 28:1141–1147. https://doi.org/10.1016/j.arth.2012.09.023

    Article  Google Scholar 

  17. Warren JA, Siddiqi A, Krebs VE et al (2021) Bilateral simultaneous total knee arthroplasty may not be safe even in the healthiest patients. J Bone Jt Surg Am 103:303–311. https://doi.org/10.2106/JBJS.20.01046

    Article  Google Scholar 

  18. Klika AK, Myers T, Szubski CR et al (2015) Early postoperative outcomes of primary total knee arthroplasty after solid organ transplantation in the United States, 1998–2011. J Arthroplast 30:1716–1723. https://doi.org/10.1016/j.arth.2015.04.044

    Article  Google Scholar 

  19. Menendez ME, Neuhaus V, van Dijk CN, Ring D (2014) The elixhauser comorbidity method outperforms the charlson index in predicting inpatient death after orthopaedic surgery. Clin Orthop Relat Res 472:2878–2886. https://doi.org/10.1007/s11999-014-3686-7

    Article  PubMed  PubMed Central  Google Scholar 

  20. Richardson SS, Kahlenberg CA, Blevins JL et al (2019) Complications associated with staged versus simultaneous bilateral total knee arthroplasty: an analysis of 7747 patients. Knee 26:1096–1101. https://doi.org/10.1016/j.knee.2019.06.008

    Article  PubMed  Google Scholar 

  21. Taylor BC, Dimitris C, Mowbray JG et al (2010) Perioperative safety of two-team simultaneous bilateral total knee arthroplasty in the obese patient. J Orthop Surg Res 5:38. https://doi.org/10.1186/1749-799X-5-38

    Article  PubMed  PubMed Central  Google Scholar 

  22. Makaram NS, Roberts SB, Macpherson GJ (2021) Simultaneous bilateral total knee arthroplasty is associated with shorter length of stay but increased mortality compared with staged bilateral total knee arthroplasty: a systematic review and meta-analysis. J Arthroplast 36:2227–2238. https://doi.org/10.1016/j.arth.2021.01.045

    Article  Google Scholar 

  23. Hutchinson JRM, Parish EN, Cross MJ (2006) A comparison of bilateral uncemented total knee arthroplasty: simultaneous or staged? J Bone Jt Surg Br 88:40–43. https://doi.org/10.1302/0301-620X.88B1.16454

    Article  CAS  Google Scholar 

  24. Zeng F, Waldo D (2016) Total knee arthroplasty post acute care costs by discharge status. Value Heal 19:A13–A14. https://doi.org/10.1016/j.jval.2016.03.273

    Article  Google Scholar 

  25. Kahlenberg CA, Krell EC, Sculco TP et al (2021) Differences in time to return to work among patients undergoing simultaneous versus staged bilateral total knee arthroplasty. Bone Jt J 103-B:108–112. https://doi.org/10.1302/0301-620X.103B6.BJJ-2020-2102.R1

    Article  Google Scholar 

  26. Macario A, Schilling P, Rubio R, Goodman S (2003) Economics of one-stage versus two-stage bilateral total knee arthroplasties. Clin Orthop Relat Res. https://doi.org/10.1097/01.blo.0000079265.91782.ca

    Article  PubMed  Google Scholar 

  27. Houdek MT, Wyles CC, Watts CD et al (2017) Single-anesthetic versus staged bilateral total hip arthroplasty: a matched cohort study. J Bone Jt Surg Am 99:48–54. https://doi.org/10.2106/JBJS.15.01223

    Article  Google Scholar 

  28. Grove A, Johnson R, Clarke A, Currie G (2016) Evidence and the drivers of variation in orthopaedic surgical work: a mixed methods systematic review. Heal Syst Policy Res 3:6. https://doi.org/10.21767/2254-9137.100025

    Article  Google Scholar 

  29. Tripathi A, Abbott JD, Fonarow GC et al (2017) Thirty-day readmission rate and costs after percutaneous coronary intervention in the United States: a national readmission database analysis. Circ Cardiovasc Interv. https://doi.org/10.1161/CIRCINTERVENTIONS.117.005925

    Article  PubMed  Google Scholar 

Download references

Funding

No source of funding was required for the present study.

Author information

Authors and Affiliations

  1. Department of Orthopedic Surgery, Cleveland Clinic, Orthopaedic and Rheumatology Institute, 9500 Euclid Avenue, A41, Cleveland, OH, 44195, USA

    Michael Erossy, Ahmed K. Emara, Guangjin Zhou, Siran Kourkian, Alison K. Klika, Robert M. Molloy & Nicolas S. Piuzzi

Authors
  1. Michael Erossy
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ahmed K. Emara
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Guangjin Zhou
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Siran Kourkian
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Alison K. Klika
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Robert M. Molloy
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Nicolas S. Piuzzi
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Nicolas S. Piuzzi.

Ethics declarations

Conflict of interest

AKE, ME, AKK, GJ, and SK have nothing to disclose. NSP has the following disclosures, none of which are related to the topic of the present study: American Association of Hip and Knee Surgeons: Board or committee member. ISCT: Board or committee member. Journal of Hip Surgery: Editorial or governing board. Journal of Knee Surgery: Editorial or governing board. Orthopaedic Research Society: Board or committee member. Regeneron: Paid consultant. RegenLab: Research support. Stryker: Paid consultant. Zimmer: Research support. RMM has the following disclosures none of which are related to the topic of the present study: American Association of Hip and Knee Surgeons: Board or committee member. Stryker: Paid consultant; Paid presenter or speaker; Research support. Zimmer: Research support.

Ethical statement

The present study utilized a publicly available deidentified database; therefore, institutional review board approval was not required. All research activities conformed to the Helsinki Accord (1964) and all subsequent amendments.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 28 KB)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Erossy, M., Emara, A.K., Zhou, G. et al. Simultaneous bilateral total knee arthroplasty has higher in-hospital complications than both staged surgeries: a nationwide propensity score matched analysis of 38,764 cases. Eur J Orthop Surg Traumatol 33, 1057–1066 (2023). https://doi.org/10.1007/s00590-022-03248-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00590-022-03248-5

Keywords

Search

Navigation