**3.2 Simultaneous bilateral total hip arthroplasty**

The first simultaneous bilateral total hip arthroplasty was published in 1967 [12]. Jaffe and Charnley published an article in 1971, analysing results of this procedure in 50 patients [13]. Authors found minimally increased risk of complications in a simultaneous group compared to a staged group and noticed advantages of the simultaneous procedure: a single anaesthesia, a single rehabilitation period and shorter hospital days (unlike two hospital slots in a staged procedure). In the succeeding years, multiple authors will have published their results with performing a single-stage bilateral total hip arthroplasty, with lack of consensus regarding safety of procedure, patient selection and frequency of complications. At the same time, authors agreed about benefits of this simultaneous procedure: a significantly

**133**

*Simultaneous Bilateral Joint Arthroplasties in Treatment of Osteoarthritis*

hence we may assume that that real savings are even higher.

due to lower income for the surgeon and hospital [23, 24].

general health and who are younger and healthier [17, 25–27].

better functional recovery and rehabilitation. Some authors have even claimed that a full functional recovery of patient is possible only after implantation of endoprosthesis in both hips and that functional scores on operated hips are lower if only one hip is operated than in patients with both hips operated in the same procedure [14]. Patients operated in a single procedure achieved better range of movement and better functional satisfaction without significant difference in pain [15]. There are also discrepancies when it comes to the period of time recommended between two surgeries in a staged procedure. Most authors prefer a period ranging from 3 to 6 months between two hip replacements. There was also a strategy of staged surgery during same hospitalization within 7–10 days between two operations. This one has however been abandoned due to significantly increased number of complications

Authors unanimously agree that simultaneous procedure decreases hospital expenses, numbers of hospital days as well as length of rehabilitation [16–22]. It is estimated that hospital costs are reduced by 24–35%. Some authors quote shorter sick leave from work as an additional advantage. There are no studies that have analysed additional expenses (home care services, public services for patient care);

While discussing financial side effects of the procedure itself, it is interesting to mention that some authors fail to recommend performing a single-stage procedure

Authors' opinions differ regarding selection of patients as well as the type and frequency of complications. Comorbidity is the most important factor when deciding about a safe performance of a bilateral single-stage procedure. Some authors use general determinants such as patients without significant comorbidity, with good

While analysing articles that tried to objectivize selection of patients, it is noticeable that American Society of Anesthesiologists (ASA) scoring system is

• **ASA 3**: A patient with a severe systemic disease that is not life-threatening.

• **ASA 5**: A moribund patient who is not expected to survive without the

• **ASA 6**: A declared brain-dead patient whose organs are being removed for

Authors' opinions about groups of ASA scoring systems eligible for safe performance of bilateral single-stage surgery differ as well. Some recommend performing a simultaneous procedure with ASA 1 and 2 [28–30], others suggest this surgery on patients from ASA 1–4 groups [31], some of them say those are patients in ASA 1 and 2 and probably ASA 3 and 4, while certain authors find no differences in

One of the major issues with bilateral simultaneous procedure was a theoretical possibility of a higher incidence of thromboembolic complications caused by a prolonged surgical procedure as one of the best-known triggers for this kind of

• **ASA 4**: A patient with a severe systemic disease that is a constant threat to life.

*DOI: http://dx.doi.org/10.5772/intechopen.93147*

reported in majority of studies.

almost exclusively used (see below).

operation.

donor purposes.

• **ASA 1**: A normal healthy patient.

• **ASA 2**: A patient with a mild systemic disease.

complications with patients belonging to ASA 1–3 [32].

#### *Simultaneous Bilateral Joint Arthroplasties in Treatment of Osteoarthritis DOI: http://dx.doi.org/10.5772/intechopen.93147*

*Recent Advances in Bone Tumours and Osteoarthritis*

**3.2 Simultaneous bilateral total hip arthroplasty**

*Simultaneous bilateral knee arthroplasty.*

The first simultaneous bilateral total hip arthroplasty was published in 1967 [12]. Jaffe and Charnley published an article in 1971, analysing results of this procedure in 50 patients [13]. Authors found minimally increased risk of complications in a simultaneous group compared to a staged group and noticed advantages of the simultaneous procedure: a single anaesthesia, a single rehabilitation period and shorter hospital days (unlike two hospital slots in a staged procedure). In the succeeding years, multiple authors will have published their results with performing a single-stage bilateral total hip arthroplasty, with lack of consensus regarding safety of procedure, patient selection and frequency of complications. At the same time, authors agreed about benefits of this simultaneous procedure: a significantly

**132**

**Figure 4.**

**Figure 3.**

*Bilateral gonarthrosis.*

better functional recovery and rehabilitation. Some authors have even claimed that a full functional recovery of patient is possible only after implantation of endoprosthesis in both hips and that functional scores on operated hips are lower if only one hip is operated than in patients with both hips operated in the same procedure [14]. Patients operated in a single procedure achieved better range of movement and better functional satisfaction without significant difference in pain [15]. There are also discrepancies when it comes to the period of time recommended between two surgeries in a staged procedure. Most authors prefer a period ranging from 3 to 6 months between two hip replacements. There was also a strategy of staged surgery during same hospitalization within 7–10 days between two operations. This one has however been abandoned due to significantly increased number of complications reported in majority of studies.

Authors unanimously agree that simultaneous procedure decreases hospital expenses, numbers of hospital days as well as length of rehabilitation [16–22]. It is estimated that hospital costs are reduced by 24–35%. Some authors quote shorter sick leave from work as an additional advantage. There are no studies that have analysed additional expenses (home care services, public services for patient care); hence we may assume that that real savings are even higher.

While discussing financial side effects of the procedure itself, it is interesting to mention that some authors fail to recommend performing a single-stage procedure due to lower income for the surgeon and hospital [23, 24].

Authors' opinions differ regarding selection of patients as well as the type and frequency of complications. Comorbidity is the most important factor when deciding about a safe performance of a bilateral single-stage procedure. Some authors use general determinants such as patients without significant comorbidity, with good general health and who are younger and healthier [17, 25–27].

While analysing articles that tried to objectivize selection of patients, it is noticeable that American Society of Anesthesiologists (ASA) scoring system is almost exclusively used (see below).


Authors' opinions about groups of ASA scoring systems eligible for safe performance of bilateral single-stage surgery differ as well. Some recommend performing a simultaneous procedure with ASA 1 and 2 [28–30], others suggest this surgery on patients from ASA 1–4 groups [31], some of them say those are patients in ASA 1 and 2 and probably ASA 3 and 4, while certain authors find no differences in complications with patients belonging to ASA 1–3 [32].

One of the major issues with bilateral simultaneous procedure was a theoretical possibility of a higher incidence of thromboembolic complications caused by a prolonged surgical procedure as one of the best-known triggers for this kind of complication [27, 33]. Earlier publications dealing with simultaneous bilateral hip arthroplasty reported a higher rate of pulmonary embolism and a slightly higher mortality rate while performing this procedure [33–35]. Improvements in surgical technique, anaesthesiology (introduction of hypotensive anaesthesia), anticoagulant therapy and early mobilisation showed decrease in numbers of reported complications of this type. Berend and Glait [36, 37] found increased incidence rate of pulmonary thromboembolism, while majority of other authors did not mention similar findings [20, 38–41]. Some of the authors who failed to find any thromboembolic complications in their series of simultaneous procedures explain this as a better adaptation of a patient to mobilisation protocols when both hips are operated.

Majority of authors reported higher need for transfusion in a simultaneous group [20, 24, 29, 32, 38, 42, 43]. Bhan found lower estimated blood loss in simultaneous group but higher number of transfusions [19]. He explained that in a staged group, blood loss is a sum of losses in two surgeries that are separated long enough for organism to compensate loss from first surgery. Some authors did not discover any increased blood loss in a simultaneous group [17, 25, 37, 44]. Glait pointed out that an increased need for transfusion can be expected if a simultaneous procedure is performed by a less experienced surgeon [37].

#### **3.3 Simultaneous bilateral total knee replacement**

While history of bilateral total hip replacement is very well documented, there are almost no papers of a single-stage total knee replacement background. There is a trend of growing number of performed TKA. In the period from 1990 to 2004, number of bilateral total knee replacements doubled and even tripled in female population [45].

Similar to bilateral simultaneous hip arthroplasties, there are certain differences among authors regarding safety of the procedure, potential complications and consensus over its benefits. Overall savings from simultaneous procedure are estimated to be 20–58% with the following contributing factors: fewer hospital days, single medical consultations, single anaesthesia and single rehabilitation period [18, 46]. It is also found by majority of authors that patients in a single-stage group experience equal or better functional result and satisfaction [47, 48]. In one study, 95% of patients would rather choose a single-stage procedure all over again, demonstrating high level of satisfaction [46]. Differences among authors apply to potential increased risk of systemic and local complications, as well as to mortality rate following the procedure itself. Some register studies (the USA and Sweden) found increased morbidity and mortality rate [49, 50], while data from New Zealand arthroplasty registry show no differences between two procedures in same terms [51]. Many authors have discovered with their series of patients an increased risk in systemic complications in a single-stage group [52–55], while a few found no difference in the incidence of complications [47, 56–58]. As per selection of patients, there are only several articles recommending application of the scoring system (ASA, see above). Hadley et al. recommend performing the procedure only in ASA 1 and 2 groups [58], while several authors say this procedure is safe with ASA 1–3 groups as well [59–61]. All authors agree there is an increased blood loss in a simultaneous group [52, 58, 62].
