Evidence Experience Mixed On Simultaneous Bilateral Knee Replacement
His would-be surgeon tried mightily to talk him out of a bilateral knee replacement. At 340 pounds, the patient’s BMI — above 43 — was a significant contraindication.
But the patient — Nick Yphantides, MD, chief medical officer for California’s San Diego County — told MedPage Today he “aggressively” insisted, threatening to find another surgeon if he had to.
Osteoarthritis in both knees had so hobbled Yphantides that at one point, he couldn’t walk to his car. What with the stress of grappling with county health issues, including its complex homeless problem and well-publicized hepatitis A outbreak that killed 20 and hospitalized hundreds and prompted a grand jury investigation in 2017, his pledge to diet and exercise took a back seat.
Last July, Yphantides joined the growing number of people with debilitating OA pain who’ve opted to get both diseased knees replaced at the same time, during the same surgery, rather than spread out the ordeal over months. There’s just one recovery period to suffer through, less time off work, and less time being incapacitated and requiring supportive care. Plus, in most cases it costs less, for the patient and the provider.
That’s in part because under most payers’ rules, doctors get half their regular fee for replacing the second knee in bilateral surgery .
Criteria for who gets surgery “is completely practice- and surgeon-dependent,” said orthopedic surgeon Derek Ward, MD, of the University of California, San Francisco.
Do I Have A Helper For My Recovery Period
If you opt for simultaneous replacement, you wont be able to use either of your legs normally for most of your recovery period. After a hospital stay of up to 10 days, you need assistance at home for up to six weeks. If a family member cant help out, you may need to hire a home health worker.
If you have your knees replaced in stages, your second operation isnt scheduled until about three months after your first operation. Your hospital stay is shorter per surgery and each recovery period is quicker, too. While you may need a helper for the first week, once youre released from the hospital with an assistance device such as a walker, crutches, or a cane you should be able to get around the house on your own without too much help during your 3-6 weeks of recovery
I Am Agonizing Over The Decision Whether To Have Both My Knees Replaced At The Same Time Or Do Them One At A Time How Do Other People Make This Decision
Like you, many patients with painful arthritic knees wrestle with the decision to have them replaced one at a time or both at the same time. The proposed advantages of the simultaneous bilateral knee replacements are decreased costs and shorter recovery time.
Some people make the decision simply based on economics . A recent study showed that the difference in overall costs is significant: $43,401 for simultaneous procedures compared to $72,233 for staged procedures . This can add up to quite a bit of difference in out-of-pocket expenses.
You may find the results of a recent study of interest. Researchers at the University of North Carolina and the OrthoCarolina Research Institute took on the task of doing a cost-utility and cost-effectiveness study. They used the Nationwide Inpatient Sample data to compare the results of 24,574 cases of simultaneous knee replacements with 382,496 patients who had unilateral procedures.
Measures used to compare the outcomes included perioperative complications , hospital costs, rehabilitation costs, anesthesia costs, and health utilities . The results were just as good between the staged approach and the simultaneous method.
In fact, for minor, major and in-hospital mortality , simultaneous procedures had lover complication rates. For example, the major complication rate for the staged group was 2.36 per cent compared with 1.49 per cent among the simultaneous group. The minor complication rate was 8.98 per cent versus 6.84 per cent .
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If youre faced with replacing both of your knees, is it better to have them done at the same time? Or should you wait until the first replacement has healed before having the second knee replaced?
Orthopedic surgeons Richard Davis II, MD, and Matthew Lawless, MD, have extensive experience withknee replacement surgeries. Although not every patient is a candidate for bilateral knee replacement , they say there are advantages.
Trends In Bilateral Replacements
I recently took a look at a study on bilateral knee replacement surgery published by Hospital for Special Surgery, where much of the pioneering behind knee replacement was done. I was surprised at what I found. The number of bilateral total knee replacements performed between 1999 and 2008 increased by 75%. In 1999 bilateral procedures accounted for 3.7% of all knee replacement operations. By 2008 they accounted for 6% of operations. The average age for bilateral surgeries during that same time frame decreased by 2.5 years.
Not All Good News
However the rate of comorbidities increased measurably during this time frame. More complications and difficulties were seen for those with two knee replacements. Here is an article that discusses the fact that there can be twice the complications for bilateral patient vs. single knee patients: HSS Article
Obesity as a Factor
Clouding matters further was the fact that obesity increased by 131% during this time frame. It is all related as the number one cause for knee replacement surgery is obesity. Dr. Stavros Memtsoudis, the highly respected orthopedic surgeon who oversaw the study, said patients should critically look at themselves and talk to their physicians about how their health status plays into the choice of surgery.
Ed and Pre-hab before Double TKA
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Betsy, Two Knees, One Knee Per Surgeon
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15 Mar 2019 | General, Knee Surgery
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Should You Have Both Knees Replaced At The Same Time
When your knees are stiff, painful, and cant perform their job anymore due to arthritis, a complex fracture, or an injury that wont heal, you may need knee replacement surgery. If both knees are shot, you face a dilemma: Should you replace them at the same time and get the whole thing over with, or deal with one surgery at a time?
At Texas Orthopaedic Associates LLP with locations in the Dallas-Fort Worth and Plano, Texas, areas our expert orthopedists only recommend knee surgery when other, less-invasive options have failed. Knee replacement surgery removes damaged tissue, resurfaces the joint bones, and then separates the bones with a spacer so your knee can move freely and without pain again.
If you need to replace both knees, you can choose for either a simultaneous bilateral knee replacement or a staged bilateral knee replacement . To choose between simultaneous or staged surgeries, ask yourself the following questions:
Risk Of A Simultaneous Knee Replacement
When considering a bilateral knee replacement surgery, your doctor will assess your ability to tolerate and recover from surgery. Bilateral knee replacement is a longer surgery than a single knee replacement, making it more demanding on the body. If you have cardiovascular problems, pulmonary disease, or are over the age of 80, you might be advised against a simultaneous procedure.
In fact, studies have shown that simultaneous knee replacement surgery increases the risk of cardiac events and death compared to staged operations.
A 2013 review from McMaster University in Ontario, Canada analyzed 18 different studies and reported that individuals undergoing a simultaneous replacement had a threefold increase in the risk of death 30 days following the surgery compared to those who had staged replacements. Moreover, the risk remained elevated even after three months and 12 months . There was no difference in the risk of death while in the hospital or during the operation itself.
Another disadvantage of a simultaneous procedure is that rehabilitation can be far more difficult for older people who don’t have a non-surgical leg to stand on or the upper body strength to support themselves during physical therapy.
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Reasons That You May Need A Knee Replacement
When your knees hurt on a daily basis and its starting to affect your life, it may be time for you to look into treatment. You may have tried many conservative treatments without much relief. But what could be causing you to have so much pain that youre considering a knee replacement?
The main culprit behind chronic knee issues is osteoarthritis. This condition causes the cartilage that cushions your joint to deteriorate, leading to inflammation and pain. This condition can become severe, causing daily problems with certain activities including:
- Climbing up a flight of stairs
- Difficulty walking even short distances
- Trouble getting up from a sitting position
- Pain even at rest
Osteoarthritis is a chronic condition, so there is no permanent cure. There are treatments that help with the symptoms, but the only way to repair your knee completely is with an artificial knee replacement.
If both of your knees have damage from arthritis, you’re probably curious if you can get them both fixed at the same time. The truth is that you can, but there are advantages and disadvantages to this procedure.
Risks You Should Consider
As with any procedure, there are risks involved with knee replacement surgery. These risks increase when having both of your knees operated on. You should never enter into surgery lightly, and a knee replacement is no different.
With a bilateral knee replacement, the most obvious risk is the increased amount of time that you’re under anesthesia. Other risks of knee replacement surgery include:
- Infection
- Nerve damage
- Blood transfusion
There is also the risk that the surgery won’t work completely, and you’ll still have pain even after the procedure. If you arent completely motivated to stay on track with your rehabilitation, failure of the prosthetic is more of a risk.
Your risks are significantly increased if you’re a man over the age of 65. With both knees being replaced, you also have a higher risk of being readmitted to the hospital due to complications.
Dr. Osmani discusses all of the risks and advantages to surgery ahead of time, and if you and he both decide this is the best choice, we proceed with getting you on the road to recovery with two new knee joints.
As the only orthopedic center in the area, our staff is committed to getting your symptoms under control. Whether you need one knee replaced, or both, call our office today at 575-623-9101 or book an appointment with one of our providers online.
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Start Using The Knee Early
Recovery and rehabilitation must start shortly after you awake from surgery. On the first day, you need to start standing up and walking with an assistive device, like a walker or crutches, with the aid of a physical therapist. Use your artificial knee as soon as you can. Your therapist will guide you through exercises that will increase the strength of your muscles, as well as help you get in and out of bed.
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Who Is A Good Candidate For Bilateral Replacement
The best candidates are those who are active and have strength in the muscles, ligaments and tendons around their knees.
Youll also fare better if your general health is good. Its best if you have few other medical problems, such as any heart or lung disease.
Even then, Dr. Greene says, you should approach simultaneous surgery cautiously.
If youre young, healthy and a risk-taker, you can contemplate doing both knees, he says. I tell people the day of surgery, though, to tell me which knee is worse. That way, if the anesthesiologist tells me we need to stop after one knee which actually hasnt happened the more symptomatic knee is fixed.
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Benefits Of A Simultaneous Knee Replacement
One benefit of a simultaneous knee replacement is that two problems are solved at once. The overall rehabilitation time is shorter, and there is only one hospitalization and one round of anesthesia. This can be a better situation for people who would rather not be away from work for extended periods of time.
The co-payments and out-of-pocket expenses from insurance might be lower with one surgery and a single round of rehabilitation.
Know What To Expect Before Having A Knee Replacement
Whether having two separate procedures or both knees replaced simultaneously, the orthopedic surgeon should have a detailed discussion with the patient about what to expect. Because of the special considerations involved in bilateral knee replacement, its especially important to choose a highly experienced orthopedic surgeon who specializes in joint replacement.
Patients should also choose a hospital that performs a high volume of joint replacements, such as HSS. The entire staff will be accustomed to dealing with the needs of patients before, during and after the surgery.
Knee replacement is a big step, but knowing the facts can help patients make an informed decision. After the surgery, most patients will tell you that in terms of arthritis pain relief and improved mobility, they wished they had done it sooner.
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Having Both Knees Replaced At The Same Time: Pros And Cons
With todays improved technology in and out of the operating room, patients have the option of bilateral total knee replacement at the same time. This can be done by one surgical team doing both knees in the same operation. Or there can be two surgical teams working on both knees at the same time.
Patients who qualify for bilateral simultaneous TKRs have changed over the years. Surgeons still agree that patients older than 80 years of age should not have both knees done at the same time. The risk of serious complications is just too high in this group. The biggest change in patient selection is that older, sicker adults are approved for this procedure.
In this article, surgeons review the major complications, pros, and cons of having both knees replaced at the same time. They start out by saying there isnt one most common adverse event reported in the literature.
Cardiac, pulmonary, and neurologic complications are compared. The most serious complication is not any more likely after this procedure than in people of the same age dying of natural causes. Other problems that can occur include blood clots, the need for blood transfusion, and electrolyte imbalances. Gastrointestinal problems have also been reported.
Cardiac complications range from angina to heart attack, unstable heart rhythm, and heart failure. Heart attacks and heart arrhythmias top the list of most commonly reported cardiac problems.
What To Expect From Surgery
Having two knees replaced typically takes three or more hours, although every case is individual. During this time the doctor carefully removes damaged bone and cartilage and replaces it with a combination of metal and plastic that enables your new knee to function as closely as possible to how a healthy knee functions.
Dr. Hood may use robot-assisted technologies or any number of other methods to make the surgery less invasive and lend itself to quicker healing time. Dr. Hood and his team will discuss surgery plans with you beforehand and give a more specific and individual idea of what to expect.
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Should I Have Both Hips Or Knees Replaced At The Same Time Or Separately What If I Dont Feel Like Coming Back For The Second Procedure
I see many patients who have arthritic symptoms from both their hips or knees, although one side is usually more painful or disabling than the other. This is because there is often an underlying genetic basis or predisposition that led to the arthritic destruction of the joint in the first place, such as dysplasia with hips or bowleg deformity with knees. Another consideration which helps explain why both sides are arthritic is that both lower extremities tend to be subjected to similar traumas, such as from sports.
Patients often ask me if they should have both their hips or knees replaced during one anesthetic session or would it be better to do the procedures in stages, first replacing the hip or knee that is most symptomatic and then replacing the other side after the original side has rehabilitated. Many patients then ask me if they stager their procedures will they feel like coming back for the other side.
The x-rays below are from a 77- year-old, farmer from Illinois. He traveled to Fort Lauderdale for bilateral knee surgeries which were staged three weeks apart. This patient was disabled from severe degenerative arthritis of both knees and had bow leg deformities. He rehabilitated beautifully and flew home just several weeks after his second surgery, telling me he was so pleased that both of his legs looked straight!
So to again answer the question, if I have one knee or hip, replaced, will I come back for the other side, the resounding answer is absolutely yes.
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Potential Complications With A Bilateral Knee Replacement
In the United States, about 600,000 people get knee replacement surgery each year. Severe side effects, such as infection, are uncommon. They only happen around 2% of the time. However, as with any surgery, complications can happen when you least expect them. Below, we list the most common complications associated with knee replacements.
- Anesthesia complications
- Allergic reactions to metal pieces
- Bleeding and wound complications