Abstract
Bilateral one stage total knee replacement (TKR) has a number of advantages. There is one operative procedure and anesthetic and overall recovery time is significantly reduced. It is a more cost-effective procedure in that acute hospital stay is less and although rehabilitation time is greater in the short term, overall it is less. Additionally, if there is a bilateral flexion contracture present there is an inevitable loss of extension if a single knee is operated upon as this knee will assume the position of the unoperated knee. Patients greatly prefer having both knees corrected at one operative setting rather than having to have the inconvenience and pain associated with a second operative procedure at three to six months after the first one.
There are potential disadvantages to a one stage procedure. One concern has been that there is more peri-operative morbidity associated with one stage bilateral total knee replacement. In a review of 501 patients undergoing bilateral one stage total knee replacement at the Hospital for Special Surgery (HSS) there were no peri-operative deaths, myocardial infarctions or cerebrovascular accidents. There were arrhythmias present in 5% of patients. Fat emboli were present in 3% and 2 patients (0.4%) had pulmonary emboli. The average transfusion requirement was 2.6 units and allogeneic blood was required in 42%. There were 2 deep infections, 3 hematomas and 5 patients with delayed wound healing There was an increased incidence of major complications in patients with ASA classification 3 and with increasing age over 70 years.
New data indicates peri-operative administration of hydrocortisone may mitigate lung injury as demonstrated by reduction in cytokine and desmosine levels in a randomised trial. There was also a trend toward less need for narcotic medication and better range of motion in the steroid treated group
Patient selection is important and all patients are screened pre-operatively by an internist and anesthesiologist. In over 3000 bilateral TKRs at HSS infection rate and mortality were lower than in the unilateral total knee replacement patients. Much of this is due to patient selection criteria. All patients underwent the procedure with epidural anesthesia with post-operative epidural PCA for 48 hours. All patients are discharged on warfarin and spend the operative night in the recovery room. The procedure has acceptable morbidity and great advantage in properly selected patients.
