Bilateral Operation - Knees

Candidate for

BILATERAL  OPERATION?

  (Operation on both knees)

Knee joint is a paired organ and one or both knees may be affected by the disease.

If both knee joints show changes on X-rays and

only one knee joint is painful, stiff, and disturbs your life, then only this knee joint should be operated on 

if both knees are equally difficult, then both should be operated on.

The surgery that replaces both damaged knee joints is called bilateral total knee operation.

You should know that bilateral knee surgery is done routinely and it presents one of the most spectacular successes of the total knee replacement surgery.

This is so because  two impaired knee joints cause much more symptoms than twice the symptoms caused by one diseased knee joint. Patients with both knee joints affected have no healthy leg to rely on!

Staged Total Knee Replacement.

The surgeon replaces your destructed knee joints one at a time, at two separate operations, often  several months apart. You will need two hospital stays, two anesthesia and two rehabilitation periods. This is called  Staged Total Knee Replacement.

Simultaneous Bilateral Total Knee Replacement.

If you have both knees equally painful and stiff, it is possible to have both knees replaced with total knee prostheses during one operation seance, under one anesthesia. The operations are followed by a single rehabilitation period  within one hospital stay. Such two  simultaneous surgeries are called Simultaneous Bilateral Total Knee Replacement.

Are the results of Simultaneous Total knee replacement equally good as the results of Staged Total knee replacement?

Both procedures produce equally good relief of pain and equally good return of function in the operated knees

Should you take the chance?

What are the advantages of a Simultaneous Total knee replacement?

You will have only one surgical "event", single anesthesia, shorter hospital stay.

What are the risks of  a Simultaneous Total Knee replacement?

In comparison with staged procedure  the risks with Simultaneous TKR are:

trice increased risk of death during the 30 days period for people > 70 years (Parvizi  2001, Restrepo 2007) 

twice increased risk of complications, especially vascular complications such as deep vein thrombosis (Ritter 1997, Restrepo 2007)

much higher need  (17 times) for banked blood with all possible complications (Lane  1997)

three times increased risk of cardiopulmonary complications (Restrepo 2007)

twice increased  length of the stay at the intensive unit department

twice increased need for prolonged rehabilitation

higher rate of bone marrow emboli into the brain (Sulek 1999)

What are the advantages of a Staged Total knee replacement

lower stress on cardiovascular system, less complications, less risk for requiring allogenic (banked) blood

What are the disadvantages of a Staged Total knee replacement

It requires two hospital stays and two anesthesia and it delays return to full activity.

Who should have a   Simultaneous Bilateral Total Knee replacement?

The ideal candidate is a patient under 70 years of age (some surgeons accept even older patients, up to 80 years), in good physical condition, without cardiac, pulmonary or vascular diseases. Such patient should also have severe pain in both knees that interferes with the activities of daily living. There should be signs of knee joint damage on X-ray pictures of both knees.

Because there are significant risks associated with Simultaneous Total knee replacement, a very careful evaluation of candidates is necessary. The patients should also be informed about the risks associated with this procedure.

If you contemplate to have a Simultaneous Total knee replacement you should discuss this procedure carefully with your surgeon

Should the  X-ray changes of the other knee alone decide the bilateral  operation? 

If  you have one bad knee and one good knee and both knees show X-ray signs of osteoarthritis, should you have both knees replaced at once?

• No. You should have total knee replacement only of that knee joint which gives you pain and stiffness.
• You should not have bilateral total knee replacement only because X-rays of both  of your knees show osteoarthritic changes.
• There is, however,  a  75 % chance that your second symptomless  knee  (with apparent X-ray changes) will become painful during the next five years.

Will the impairment of the other knee recede after operation on one side?

It is possible, but it is not predictable. It is no idea to wait too long with the operation of the other painful knee

• if both knee joints have severe flexion deformity (knees   that are stiff in  bent position) 

• in aged patients. In these patients a medical complication may develop and prevent the operation of the other knee. An elderly patient, who was suffering misery from bilateral knee impairment is able to function "normally" in 2 to 3 weeks after bilateral replacement. The psychical state (depression) of these patients often improves after their source of pain has been removed.

l(Links: www.rothmaninstitute.com/joints )

WHO CANNOT HAVE A TOTAL KNEE SURGERY

(of one or both knees)

• Patients with recent ( arbitrary < 9 months) heart infarct and stroke
• Patients with uncontrolled diabetes, lung, kidney, or other systemic disease
• Patients with ongoing or recent infection in the knee joint area
• Patients with severe paralysis of muscles around the knee
• Patients with severe circulation problems (painful claudicatio) in the extremity.
• Patients with severe skin damage in the front of the knee joint
• Patients with open wounds in the lower leg.

Other reasons why surgeons may abstain from operation

Many surgeons will hesitate to carry out total knee replacement in

• badly motivated patients
• patients seeking financial or other gain from total knee surgery
• overweight patients ( > 100 kg)
• persons with alcohol abuse
• people with dementia

  (Mancuso   1996)

OTHER  IMPORTANT  FACTORS

There are other very important factors that decide whether you should have total knee replacement at all and whether you will be satisfied with the operation.

These factors include  your age - you are never too old but you may be too young (in the eyes of your surgeon) for a TKR surgery

For more information about this factor, please visit the sections below:

Are  you  too young to have a TKR?

References:

Lane et al.: Clin Orthop 1997;345:106-12

Parvizi et al.:  J Bone Joint Surg-Am, 2001; 83-A: 1157 -60) 

Ritter et al.: Clin Orthop 1997;345:99-105)

Restrepo et al.: Safety of Bilateral Total knee arthroplasty. J Bone Joint Surg - Am, 2007; 89-A: 1220- 8

Sulek et al.:  Anesthesiology 1999;3:672-6)