Staged Bilateral Total Knee Arthroplasty: Increased Risk of Recurring Complications

Abstract

Background: As the demand for knee arthroplasty increases, risk assessment and counseling are critical for optimal patient outcomes perioperatively. The purpose of this study was to determine if specific complications occurring after unilateral knee replacement predict the risk of recurrence after a staged replacement of the contralateral knee for patients with bilateral symptomatic disease. Methods: Linked, nationwide data from the U.S. Hospital Cost and Utilization Project from 2005 to 2014 were used to measure the occurrence of complications after the first and second procedures in staged bilateral total knee arthroplasties (TKAs). Odds ratios (ORs) and conditional probabilities were determined to assess whether having a specific complication after the first TKA increased the chance that the same complication occurred after the second procedure. Results: A total of 36,278 patients who underwent staged bilateral TKAs were analyzed. All complications occurring after the first arthroplasty were associated with both a significantly increased probability and odds of recurrence following the second arthroplasty. These included myocardial infarction (OR, 56.63 [95% confidence interval (CI), 18.04 to 155.44]; p < 0.001), ischemic stroke (OR, 41.38 [95% CI, 1.98 to 275.82]; p = 0.03), other cardiac complications (OR, 7.73 [95% CI, 4.24 to 14.11]; p < 0.001), respiratory complications (OR, 8.58 [95% CI, 2.85 to 23.17]; p = 0.002), urinary complications (OR, 11.19 [95% CI, 5.44 to 22.25]; p = 0.001), hematoma (OR, 15.05 [95% CI, 7.90 to 27.27]; p < 0.001), deep vein thrombosis (OR, 7.40 [95% CI, 5.37 to 10.08]; p < 0.001), and pulmonary embolism (OR, 11.00 [95% CI, 5.01 to 23.92]; p < 0.001). Conclusions: Medical complications that occur postoperatively after TKA are associated with a significantly increased risk of recurrence of these complications after staged replacement of the contralateral knee. Although overall complication rates remain low, patients who develop these medical complications after the first replacement should be counseled on their increased risk profile prior to the contralateral surgical procedure. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Simultaneous bilateral total knee arthroplasty

“…5 However, more recently, there is emerging evidence to indicate that significantly higher rates of cardiac, respiratory, urinary, PE, and deep vein thrombosis (DVT) complications occur after the second staged TKA has been performed when compared to after the first single TKA. 6 This supports a move back to simultaneous bilateral TKA. In a study by Tsay et al, 7 the absolute clinical difference in complication rates between staged and simultaneous bilateral TKA was shown to be minimal (< 1%) when analyzing over 70,000 knees that were operated on bilaterally (either staged or simultaneous).…”

Clinical outcomes of simultaneous bilateral total knee arthroplasty.

“…5 Another study found an increased risk of recurrent complications in patients undergoing staged approaches. 14 The implant survival was significantly longer in patients who had simBTKR. 15 The contradictory results of these studies indicated the need for a randomized trial comparing both approaches.…”

Trends of Obese and Morbidly Obese Patients in Same-Day Bilateral Total Knee Arthroplasty from 2009 to 2016

“…In addition to the potential financial incentive of sd-BTKA, this operation may be a safer option for those at increased risk for complications. In a study by Grace et al, 37 patients experiencing a complication following their first stage of BTKA were at significantly higher risk for complications following the second stage of BTKA. This finding has implications on more than just the patient level, as physicians and hospitals participating in bundled payment models are now being penalized if patients sustain a complication.…”