Skip to main content

Advertisement

SpringerLink
Log in

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

  • Survey
  • Published:
Clinical Orthopaedics and Related Research®

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.

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. 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.

    Article  PubMed  Google Scholar 

  2. Basilico FC, Sweeney G, Losina E, Gaydos J, Skoniecki D, Wright EA, Katz JN. Risk factors for cardiovascular complications following total joint replacement surgery. Arthritis Rheum. 2008;58:1915–1920.

    Article  PubMed  Google Scholar 

  3. Benjamin J, Tucker T, Ballesteros P. Is obesity a contraindication to bilateral total knee arthroplasties under one anesthetic? Clin Orthop Relat Res. 2001;392:190–195.

    Article  PubMed  Google Scholar 

  4. Berend KR, Morris MJ, Skeels MD, Lombardi AV Jr, Adams JB. Perioperative complications of simultaneous versus staged unicompartmental knee arthroplasty. Clin Orthop Relat Res. 2011;469:168–173.

    Article  PubMed  Google Scholar 

  5. 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.

    Article  PubMed  Google Scholar 

  6. 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.

    PubMed  Google Scholar 

  7. Carson JL, Grossman BJ, Kleinman S, Tinmouth AT, Marques MB, Fung MK, Holcomb JB, Illoh O, Kaplan LJ, Katz LM, Rao SV, Roback JD, Shander A, Tobian AAR, Weinstein R, Swinton McLaughlin LG, Djulbegovic B; Clinical Transfusion Medicine Committee of the AABB. Red blood bell transfusion: a clinical practice guideline from the AABB. Ann Intern Med. 2012;157:49–58.

    Article  PubMed  Google Scholar 

  8. Ersozlu S, Akkaya T, Ozgur AF, Sahin O, Senturk I, Tandogan R. Bilateral staged total knee arthroplasty in obese patients. Arch Orthop Trauma Surg. 2008;128:143–148.

    Article  PubMed  Google Scholar 

  9. Fabi DW, Mohan V, Goldstein WM, Dunn JH, Murphy BP. Unilateral vs bilateral total knee arthroplasty risk factors increasing morbidity. J Arthroplasty. 2011;26:668–673.

    Article  PubMed  Google Scholar 

  10. Ferraris VA, Davenport DL, Saha SP, Austin PC, Zwischenberger JB. Surgical outcomes and transfusion of minimal amounts of blood in the operating room. Arch Surg. 2012;147:49–55.

    Article  PubMed  Google Scholar 

  11. Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Antman EM, Buller CE, Creager MA, Ettinger SM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Ornato JP, Page RL, Tarkington LG, Yancy CW; American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery); American Society of Echocardiography; American Society of Nuclear Cardiology; Heart Rhythm Society; Society of Cardiovascular Anesthesiologists; Society for Cardiovascular Angiography and Interventions; Society for Vascular Medicine and Biology; Society for Vascular Surgery. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. Circulation. 2007;116:e418–499.

    Google Scholar 

  12. 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.

    Article  PubMed  CAS  Google Scholar 

  13. Hashmi FR, Barlas K, Mann CF, Howell FR. Staged bilateral hip or knee arthroplasties. J Orthop Surg (Hong Kong). 2007;15:159–162.

    PubMed  CAS  Google Scholar 

  14. Hu J, Liu Y, Lv Z, Li X, Qin X, Fan W. Mortality and morbidity associated with simultaneous bilateral or staged bilateral total knee arthroplasty: a meta-analysis. Arch Orthop Trauma Surg. 2011;131:1291–1298.

    Article  PubMed  Google Scholar 

  15. 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.

    PubMed  CAS  Google Scholar 

  16. Jankiewicz JJ, Sculco TP, Ranawat CS, Behr C, Tarrentino S. One-stage versus 2-stage bilateral total knee arthroplasty. Clin Orthop Relat Res. 1994;309:94–101.

    PubMed  Google Scholar 

  17. Jules-Elysee KM, Wilfred SE, Memstoudis SG, Kim DH, YaDeau JT, Urban MK, Lichardi ML, McLawhorn AS, Sculco TP. Steroid modulation of cytokine release and desmosine levels in bilateral total knee replacement: a prospective randomized controlled trial. J Bone Joint Surg Am. 2012;94:2120–2127.

    Article  PubMed  Google Scholar 

  18. Jules-Elysee KM, YaDeau JT, Urban MK. Pulmonary artery versus central venous catheter monitoring in the outcome of patients undergoing bilateral total knee replacement. HSS J. 2009;5:27–30.

    Article  PubMed  Google Scholar 

  19. Kim S, Losina E, Solomon DH, Wright J, Katz JN. Effectiveness of clinical pathways for total knee and total hip arthroplasty: literature review. J Arthroplasty. 2003;18:69–74.

    Article  PubMed  Google Scholar 

  20. Kim YH, Choi YW, Kim JS. Simultaneous bilateral sequential total knee replacement is as safe as unilateral total knee replacement. J Bone Joint Surg Br. 2009;91:64–68.

    Article  PubMed  Google Scholar 

  21. Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, Sugarbaker DJ, Donaldson MC, Poss R, Ho KK, Ludwig LE, Pedan A, Goldman L. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100:1043–1049.

    Article  PubMed  CAS  Google Scholar 

  22. 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.

    PubMed  Google Scholar 

  23. Linstone HA, Turoff M, eds. The Delphi Method: Technique and Application. Boston, MA: Addison-Wesley; 1975.

    Google Scholar 

  24. Macfarlane AJ, Prasad GA, Chan VW, Brull R. Does regional anesthesia improve outcome after total knee arthroplasty? Clin Orthop Relat Res. 2009;467:2379–2402.

    Article  PubMed  Google Scholar 

  25. MacGillivray RG, Tarabichi SB, Hawari MF, Raoof NT. Tranexamic acid to reduce blood loss after bilateral total knee arthroplasty: a prospective, randomized double blind study. J Arthroplasty. 2011;26:24–28.

    Article  PubMed  Google Scholar 

  26. 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.

    Article  PubMed  Google Scholar 

  27. Meehan JP, Danielsen B, Tancredi DJ, Kim S, Jamali AA, White RH. A population-based comparison of the incidence of adverse outcomes after simultaneous-bilateral and staged-bilateral total knee arthroplasty. J Bone Joint Surg Am. 2011;93:2203–2213.

    Article  PubMed  Google Scholar 

  28. Memtsoudis SG, Besculides MC, Reid S, Gaber-Baylis LK, Gonzalez Della Valle A. Trends in bilateral total knee arthroplasties: 153,259 discharges between 1990 and 2004. Clin Orthop Relat Res. 2009;467:1568–1576.

    Google Scholar 

  29. Memtsoudis SG, Gonzalez Della Valle A, Besculides MC, Gaber L, Sculco TP. In-hospital complications and mortality of unilateral, bilateral, and revision TKA: based on an estimate of 4,159,661 discharges. Clin Orthop Relat Res. 2008;466:2617–2627.

    Article  PubMed  Google Scholar 

  30. Memtsoudis SG, Ma Y, Chiu YL, Poultsides L, Gonzalez Della Valle A, Mazumdar M. Bilateral total knee arthroplasty: risk factors for major morbidity and mortality. Anesth Analg. 2011;113:784–790.

    PubMed  Google Scholar 

  31. Memtsoudis SG, Ma Y, Gonzalez Della Valle A, Mazumdar M, Gaber-Baylis LK, MacKenzie CR, Sculco TP. Perioperative outcomes after unilateral and bilateral total knee arthroplasty. Anesthesiology. 2009;111:1206–1216.

    Article  PubMed  Google Scholar 

  32. Memtsoudis SG, Mantilla CB, Parvizi J, Stundner O, Mazumdar M. Have bilateral total knee arthroplasties become safer? A population-based trend analysis. Clin Orthop Relat Res. 2013;471:17–25.

    Article  PubMed  Google Scholar 

  33. Noble J, Goodall JR, Noble DJ. Simultaneous bilateral total knee replacement: a persistent controversy. Knee. 2009;16:420–426.

    Article  PubMed  CAS  Google Scholar 

  34. 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.

    Article  PubMed  Google Scholar 

  35. Parvizi J, Chaudhry S, Rasouli MR, Pulido L, Joshi A, Herman JH, Rothman RH. Who needs autologous blood donation in joint replacement? J Knee Surg. 2011;24:25–31.

    Article  PubMed  Google Scholar 

  36. 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.

    Article  PubMed  Google Scholar 

  37. Peskun C, Mayne I, Malempati H, Kosashvili Y, Gross A, Backstein D. Cardiovascular disease predicts complications following bilateral total knee arthroplasty under a single anesthetic. Knee. 2012;19:580–584.

    Article  PubMed  Google Scholar 

  38. Reidy CM, Beach ML, Gallagher JD, Sites BD. Postoperative hemodynamic instability after simultaneous bilateral total knee arthroplasty. J Patient Saf. 2010;6:233–237.

    Article  PubMed  Google Scholar 

  39. 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.

    Article  PubMed  Google Scholar 

  40. 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.

    Article  PubMed  Google Scholar 

  41. 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.

    PubMed  Google Scholar 

  42. Rojas-Serrano J, González-Velásquez E, Mejía M, Sánchez-Rodríguez A, Carrillo G. Interstitial lung disease related to rheumatoid arthritis: evolution after treatment. Reumatol Clin. 2012;8:68–71.

    Article  PubMed  Google Scholar 

  43. Severson EP, Mariani EM, Bourne MH. Bilateral total knee arthroplasty in patients 70 years and older. Orthopedics. 2009;32:316.

    Article  PubMed  Google Scholar 

  44. Shin YH, Kim MH, Ko JS, Park JA. The safety of simultaneous bilateral versus unilateral total knee arthroplasty: the experience in a Korean hospital. Singapore Med J. 2010;51:44–49.

    PubMed  CAS  Google Scholar 

  45. 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.

    Article  PubMed  Google Scholar 

  46. Stefánsdóttir A, Lidgren L, Robertsson O. Higher early mortality with simultaneous rather than staged bilateral TKAs: results from the Swedish Knee Arthroplasty Register. Clin Orthop Relat Res. 2008;466:3066–3070.

    Article  PubMed  Google Scholar 

  47. Stundner O, Chiu YL, Sun X, Mazumdar M, Fleischut P, Poultsides L, Gerner P, Fritsch G, Memtsoudis SG. Comparative perioperative outcomes associated with neuraxial versus general anesthesia for simultaneous bilateral total knee arthroplasty. Reg Anesth Pain Med. 2012;37:638–644.

    Article  PubMed  Google Scholar 

  48. Taylor BC, Dimitris C, Mowbray JG, Gaines ST, Steensen RN. Perioperative safety of two-team simultaneous bilateral total knee arthroplasty in the obese patient. J Orthop Surg Res. 2010;5:38.

    Article  PubMed  Google Scholar 

  49. Thorey F, Stukenborg-Colsman C, Windhagen H, Wirth CJ. The effect of tourniquet release timing on perioperative blood loss in simultaneous bilateral cemented total knee arthroplasty: a prospective randomized study. Technol Health Care. 2008;16:85–92.

    PubMed  Google Scholar 

  50. Urban MK, Chisholm M, Wukovits B. Are postoperative complications more common with single-stage bilateral (SBTKR) than with unilateral knee arthroplasty: guidelines for patients scheduled for SBTKR. HSS J. 2006;2:78–82.

    Article  PubMed  CAS  Google Scholar 

  51. 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.

    Article  PubMed  CAS  Google Scholar 

  52. Wu CC, Lin CP, Yeh YC, Cheng YJ, Sun WZ, Hou SM. Does different time interval between staggered bilateral total knee arthroplasty affect perioperative outcome? A retrospective study. J Arthroplasty. 2008;23:539–542.

    Article  PubMed  Google Scholar 

  53. Yoon HS, Han CD, Yang IH. Comparison of simultaneous bilateral and staged bilateral total knee arthroplasty in terms of perioperative complications. J Arthroplasty. 2010;25:179–185.

    Article  PubMed  Google Scholar 

  54. Zeni JA Jr, Snyder-Mackler L. Clinical outcomes after simultaneous bilateral total knee arthroplasty: comparison to unilateral total knee arthroplasty and healthy controls. J Arthroplasty. 2010;25:541–546.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

We thank Carey Ford, George Go, Allison Goldberg, Carol Ibsen, Eileen Moynihan, Roberta Stack, Barbara Wukovits, and Daniel Yoo for the administrative support they provided for this initiative, and Timothy Roberts for assistance with the literature search.

Members of the Bilateral Total Knee Arthroplasty Group are: Angela Bader MD, MPH; Joshua Beckman MD, MS; Darin Correll, MD; Philip Faris MD; Alejandro Gonzalez Della Valle MD; Steven B. Haas MD; Paul Heerdt MD, PhD; Stephen Incavo MD; Raymond Kim MD; Daniel Krauser MD; Jay Lieberman MD; Lawrence Levin MD; Carlos Mantilla, MD, PhD; Madhu Mazumdar PhD, MA, MS; Thomas McCoy MD; Stavros Memtsoudis MD, PhD; Michael Nurok MBChB, PhD; Susan M. Odum PhD; Michael Parks MD; Javad Parvizi MD; Lazaros Poultsides MD, MS, PhD; Mohammad R. Rasouli MD; Linda Russell MD; Thomas P. Sculco MD; Rafael Sierra MD; Gerald Smetana MD; Bryan Springer MD; Ottokar Stundner MD; Michael K. Urban MD, PhD; Aaron Waxman MD, PhD; Christopher L. Wu MD.

Author information

Authors and Affiliations

  1. Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell University, 535 East 70th Street, New York, NY, 10021, USA

    Stavros G. Memtsoudis MD, PhD, Mary Hargett BS & Ottokar Stundner MD

  2. Department of Perioperative Medicine, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY, USA

    Linda A. Russell MD

  3. Department of Orthopaedic Surgery, Jefferson University, The Rothman Institute, Philadelphia, PA, USA

    Javad Parvizi MD

  4. School of Business Administration, The University of Vermont, Burlington, VT, USA

    William L. Cats-Baril PhD

  5. Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY, USA

    Thomas P. Sculco MD

Authors
  1. Stavros G. Memtsoudis MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Mary Hargett BS
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Linda A. Russell MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Javad Parvizi MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. William L. Cats-Baril PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Ottokar Stundner MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Thomas P. Sculco MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Consortia

For the Consensus Conference on Bilateral Total Knee Arthroplasty Group

Corresponding author

Correspondence to Stavros G. Memtsoudis MD, PhD.

Additional information

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.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOC 34 kb)

About this article

Cite this article

Memtsoudis, S.G., Hargett, M., Russell, L.A. et al. Consensus Statement from the Consensus Conference on Bilateral Total Knee Arthroplasty Group. Clin Orthop Relat Res 471, 2649–2657 (2013). https://doi.org/10.1007/s11999-013-2976-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11999-013-2976-9

Keywords

Search

Navigation