Have Bilateral Total Knee Arthroplasties Become Safer?: A Population-Based Trend Analysis

Abstract

Background Studies suggest a trend in the selection of younger and healthier individuals to undergo bilateral TKAs in an attempt to diminish the incidence of complications. It remains unclear whether this development has reduced overall perioperative morbidity and mortality.Questions/purposes We investigated whether changes in demographics and comorbidity patterns of patients undergoing bilateral TKAs are detectable and coincide with changes in length and cost of hospitalization, incidence of perioperative complications, morbidity, and mortality.The institution of one of the authors (MM) has received funding, during the study period, from the Clinical Translational Science Center, National Center for Advancing Translational Sciences (NCATS) (Grant UL1-RR024996), and the Center for Education, Research, and Therapeutics, Agency for Healthcare Research and Quality (AHRQ) (Grant U18 HSO16-75). The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding sources NCATS and AHRQ, Rockville, MD, USA. One of the authors (SGM) certifies that he, or a member of his immediate family, has received or may receive funding supporting research related expenses, during the study period, from the 123Clin Orthop Relat Res (2013) 471:17-25 DOI 10.1007/s11999-012-2608 Clinical Orthopaedics and Related Research ® A Publication of The Association of Bone and Joint Surgeons®Methods We accessed Nationwide Inpatient Survey data files between 1999 and 2008. One-year periods were created and changes in demographics, length of in-hospital stay, and perioperative morbidity and mortality were analyzed. Results An estimated 258,524 bilateral TKAs were performed between 1999 and 2008 in the United States. The number of annual procedures increased from 19,288 to 33,679 (75%). Length of hospital stay decreased from 4.98 to 4.01 days. Absolute in-hospital mortality rates decreased at an average rate of 10% per year. The unadjusted percent and adjusted incidence per 1000 inpatient days decreased from 0.42% and 0.85 to 0.16% and 0.39. Although the unadjusted incidence of pneumonia, pulmonary embolism, and nonmyocardial infarction cardiac complications did not change, an increase with time was detectible after adjustment for length of stay. No changes in adjusted incidence were seen for other complications. Conclusions Although a decreased incidence was seen for some major complications, others either remained unchanged or had an increased incidence when adjusted for length of stay. Future interventions should focus on reducing perioperative risk to improve patient safety.

The Patient’s Age and American Society of Anesthesiologists Status Are Reasonable Criteria for Deciding Whether to Perform Same-Day Bilateral TKA

“…However, the type of TKA, such as SD BTKA or St BTKA, was not identified as a risk factor in this study cohort of patients for whom the type of TKA was chosen based on age and ASA classification. Our findings agree with those of several previous studies reporting that an increased risk for postoperative complications was associated with ASA score of 3 or 4, preoperative cardiovascular disease, and older age [8,15,18,24,[29][30][31][32][33][34][35][36][37]. Our data, together with the data of these previous studies, suggest that if patients are properly selected, the type of BTKA procedure, such as SD BTKA and St BTKA, may not increase the risk of postoperative complications and has a risk comparable to the risk of UTKA.…”

Risks and Benefits of Simultaneous Bilateral Total Knee Arthroplasty

“…Risk factors for poor inhospital outcomes included older age and comorbidities such as congestive heart failure, pulmonary hypertension, renal failure, cardiac valve disease, and coagulopathies. In a separate report involving the Nationwide Inpatient Sample database, Memtsoudis et al specifically examined the yearly incidence of in-hospital mortality and morbidity among patients who underwent simultaneous bilateral total knee arthroplasty between 1999 and 2008 27 20.011]). They concluded that the significant decrease in in-hospital mortality may have been related to improvements in perioperative care, such as an expanded role for telemetry.…”

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

“…The number of TKAs performed in the United States has been steadily increasing. Most recently, approximately 6% of all TKAs performed were bilateral TKAs (BTKAs) [32]. Considerable controversy exists surrounding various aspects of the practice of same-day BTKAs [28,39].…”