Bilateral Joint Replacement: Should You Just Get it Over With?

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Some patients have end-stage osteoarthritis in both hips or both knees at the same time. When this occurs, the specialist and patient must collectively decide whether to proceed with replacing both joints during the same surgery (1-stage procedure) or through two different surgeries over a defined time interval (2-stage procedures). Despite a growing body of evidence studying the two different interventions, debate remains in the medical community on whether there is a higher risk of medical complications and mortality by having both joints replaced at once. Only experiencing one surgery and one recovery phase with the chance to get quality of life back sooner is enticing to patients. And for the health system, the 1-stage procedure normally results in cost savings compared to the 2-stage procedures.

According to a study conducted by University of Calgary researchers and ABJHI, healthy patients who have 1-stage or 2-stage bilateral total hip or knee replacements have comparable medical complication rates, 30-day readmission rates and mortality rates after surgery. While medical complications are rare after having a hip or knee replacement, some patients may experience adverse conditions such as heart attack, pulmonary embolism, blood clots, cardiovascular events or pneumonia. 30-day readmission rates monitor how often patients are urgently readmitted to hospital within 30 days of being discharged following surgery. Analysts tend to focus on this window because beyond 30 days it becomes difficult to say for certain that the admission is an outcome of the surgical intervention (other health conditions could be the cause). The study considered 2-stage bilaterals where both joints were replaced within 13 months.

Published in the Canadian Journal of Surgery this spring, the retrospective study included data from ABJHI’s Alberta Bone and Joint Health Data Repository on Alberta patients who underwent procedures between April 1, 2009, and January 31, 2016. Operating room times were found to be significantly lower for 1-stage surgeries compared to 2-stage (when considering the sum of the two surgeries). The study determined that patients who underwent the 1-stage procedure had shorter total stays in hospitals but were more likely to be discharged to a subacute or rehabilitation facility before going home. The cost associated with a hospital stay is generally higher than at less care-intensive subacute or rehabilitation facilities. But transferring a patient to these less intensive care facilities doesn’t always equate to lower total costs, depending on how long patients spend at the facilities.

Consistent with other studies, there was an increased likelihood of receiving a blood transfusion when undergoing a 1-stage procedure compared to the 2-stage procedures. Blood transfusions can increase the risk of infection and have been linked to poorer clinical and functional outcomes. There are also religious and personal considerations for why a patient may wish to avoid a blood transfusion. Blood transfusion policies in Alberta have changed within the last 10 years to reduce the amount of unnecessary blood products given to patients and to introduce routine use of tranexamic acid (a drug that reduces blood loss). Given the timeframe of data that was reviewed in the study, this finding may not reflect current practices.

“This study demonstrates that 1-stage bilateral surgery can be safely considered for otherwise healthy individuals with few risk factors. Functional, safety and cost-related outcomes appear to be similar to patients undergoing 2-stage bilaterals, although total operating room time and time spent in acute care is lower for 1-stage procedures,” says Christopher Smith, ABJHI’s Director of Operations (Technical) and contributor to the publication.

The researchers considered the 11 presurgical risk factors selected by Alberta’s Hip and Knee Clinical Committee (a group of provincial orthopedic surgeons), which includes: cardiac illness, chronic pulmonary condition, cancer, stroke, history of deep vein thrombosis or pulmonary embolism, chronic hepatic condition, chronic renal condition, diabetes with complications, obesity, dementia, and moderate or severe mental illness. Having one or more of these medical conditions prior to hip or knee replacement surgery increases the chance of complications. The study indicated that a high percentage of patients who underwent the 1-stage procedure did not have any of the identified risk factors, which means the findings from the study may not be as conclusive when considering patients that have one or more of the 11 pre-surgical risk factors.

The publication notes that the Canadian Arthroplasty Society is conducting a randomized controlled trial on bilateral knee patients at centres in Winnipeg (MB), Hamilton (ON), London (ON), and Montréal (QC) which has an estimated study completion in 2022.

Reference:

Raghav S, Powell J, Sharma R, Puloski S, Mahdavi S, Smith C, Johnston KD. One-stage versus 2-stage bilateral total joint arthroplasty: a matched cohort study. Can J Surg 2020;63(2):E167-E173.