Are You A Candidate For A Bilateral Operation?
October 27, 2023
Candidate for simultaneous
(Simultaneous Replacement Operation on both hips)
Patients with both hips equally painful and stiff often wonder whether both hips will need total hip replacement operation, and whether it will be possible to walk on two artificial hip joints.
The surgery that replaces both worn hips is called bilateral total hip operation.
You should know that bilateral hip surgery is done routinely and it presents one of the most spectacular successes of the total hip replacement surgery.
This is so because two impaired hips cause much more symptoms than twice the symptoms caused by one diseased hip. Patients with both hips affected have no healthy leg to rely on!
Staged Total Hip Replacement.
The surgeon may replace your destructed hip joints one at a time, at two separate operations, often several months apart one from the other. You will need two hospital stays, two anesthesia and two rehabilitation periods. The surgeons call these two surgeries for Staged Total Hip Replacement.
Simultaneous Bilateral Total Hip Replacement.
But if you have both hips equally painful and stiff, it is possible to have both hips replaced with total hip 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 Hip Replacement.
Should you take the chance?
Who should have a Bilateral Total Hip replacement?
Patients of almost all ages who have severe pain and stiffness in both hips; patients whose hip impairment makes their lives miserable, restricts considerably their activities of daily living , and progresses over time.
Especially patients with fixed deformity of both hips and concomitant impairment of the back (lumbar spine) are candidates for bilateral total hip replacement. Fixed deformity of both hip joint imposes strain on low back and these patients often have more symptoms from their back spines than from their hip joints.
Also patients with bilateral painful osteoarthritis of the hip joints and contemplated total knee replacement should have both hips operated first.
Should the X-ray changes of the other hip alone decide the bilateral operation?
If you have one bad hip and one good hip and both hips show X-ray signs of osteoarthritis, should you have both hips replaced at once?
- No. You should have total hip replacement only of that hip which gives you pain and stiffness.
- You should not have bilateral total hip replacement only because X-rays of both of your hips show osteoarthritic changes.
- There is, however, a 54 % chance that you will need a total hip replacement of the second symptomless hip (with apparent X-ray changes) during the next ten years.
(If your second hip shows no X-ray changes, there is still an 8 % chance that you will need total hip replacement of this healthy hip during the next ten years. -Ritter et al. 1996.)
Will the impairment of the other hip 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 hip in these cases:
- All patients with severe flexion deformity in both of their hips (hips that are stiff in forward bent position)
- All patients with failed total hip arthroplasty on one side and impairment of the other hip joint. These patients need a "good hip to stand on" while being treated for the failed total hip.
- Aged patients. In these patients a medical complication may develop and prevent the second operation. An elderly patient, who was suffering misery from bilateral hip 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.
My total hip replacement on one side has been infected, can I have total hip replacement of the opposite painful hip ?
Yes, of course. The combination of one already failed total hip arthroplasty with severely impaired other hip (opposite) is extremely incapacitating.
Total hip replacement of the impaired contralateral (opposite) hip is the only possible solution of the patient misery.
The risk of blood-borne infection from the infected contralateral hip is, of course, present, but with careful antibiotic treatment and prevention, this risk is low. (Eftekhar, 1994)
Who is the candidate for a Staged Total Hip replacement?
Because the staged operations put less stress on you heart and circulation system, this is a choice for patients with cardiac, circulatory and pulmonary diseases, or for older patients (arbitrarily > 75).
The disadvantages are, of course, two separate surgeries, two anesthesias and much longer total hospital stay.
Who is the candidate for Simultaneous Total Hip Replacement?
Because this simultaneous surgery include increased stress on the patient's cardiovascular system, the candidates must be carefully selected. Only patients in good health condition, without any cardiac, circulatory and pulmonary diseases, and younger than 75 years old are appropriate candidates.
The decision to undergo Simultaneous Total Hip Replacement must be taken after careful consultation between the medical consultant (cardiologist), the anesthesiologist, the surgeon, and the patient.
If you consider this surgery, you will also need a good general muscle condition, because the initial rehabilitation will demand more work from your arms than usually. During the first weeks after the Simultaneous THR, you will namely have "no good leg to stand on".
Not more complications
Several statistics shoved that Simultaneous Total Hip Replacement and Staged Total Hip Replacement are equally safe operations. (Ritter 1996)
The total blood loss and the total operation time are the same for one- and two-stage operations and also the complications from anesthesia are not more frequent after one-stage operations. The total costs are 25 % lower for one-stage operations.
The weight bearing may be a problem for patients with cementless bilateral total hip replacements. But several surgeons allow their patients "full weight" bearing immediately after the operation, if the cementless total hip prostheses were anchored stable during the operation. The immediate weight bearing in these patients did not cause any complications, on the contrary the speed of recovery was quickened.
What are the results of these operations?
Several statistics show that both types of procedures produce equivalent and equally good results. (Links: www.rothmaninstitute.com/joints )
BILATERAL SIMULTANEOUS TOTAL HIP REPLACEMENT – IS IT SAFE?
Yes say the British surgeons who studied the published statistics (Tsiridis 2008). The authors found reliable reports on 2800 such simultaneous operations.
Depending on the diagnosis, about 10 to 20% of all patients may have severe engagement of both hip joints that need replacement with total hip, For these patients there arise a problem: should they have replacement of both hip joints done simultaneously, that means during one narcosis session? Or should the surgeon replace first one hip joint and then wait with the operation of the second hip some weeks or months until I recover from the first surgery – so called staged operation?
Bilateral simultaneous total hip replacement was first reported by the well known English hip surgeon sir John Charnley in 1971. Since then the surgeons disputed whether the simultaneous procedure entails bigger risks for the patient than the staged procedure.
The English surgeons found that the simultaneous procedure is safe provided that the patient is healthy. Thus all potential candidates for bilateral simultaneous THR should undergo a detailed anaesthetic assessment preoperatively, and patients with ASA grades 1 and 2 are the safest for the simultaneous procedure. (ASA grades is an evaluation procedure for evaluating operation risks developed by American anaesthesiologists) .
It follows that elderly patients are not excluded from bilateral simultaneous THR if they are otherwise healthy, as age is not per se a contraindication.
The risk of DVT or pulmonary embolism, the risk of dislocation is not
increased in bilateral simultaneous THR, provided that appropriate prophylactic measures are taken.
The overall surgical time is not different between bilateral simultaneous THR and staged THR and the length of hospital stay is shorter after a bilateral simultaneous THR.
Functional outcomes are similar after bilateral simultaneous THR and staged THR.
Information for you: This article present a very well presented evidence that bilateral simultaneous total hip replacement is safe for healthy patients. Higher blood transfusion requirements are expected following bilateral simultaneous THR than staged THR or unilateral THR, because of total cumulative loss in one sitting.
The authors therefore strongly suggest that autologous blood transfusion, whether by pre-operative donation or by intraoperative blood salvage, be considered. The authors also recommend that bilateral simultaneous THR be ideally undertaken in tertiary referral hospitals experienced in major hip surgery.
Tsiridis E. et al.: The safety and efficacy of bilateral simultaneous total hip replacement. J Bone joint Surg-Br 2008; 90-B: 1005 -15
Tsiridis et al: The safety and effic<cy of bilateral simultaneous hip replacement. J Bone Joint Surg-Br 2008, 90-B: 1005 -15
Eftekhar N Principles of total hip arthroplasty, 1994
Ritter et al. J Arthroplasty; 1996, 11: 242-6
Rao R.R et al : Immediate weight bearing after uncemented total hip arthroplasty. Clin Orthop 1998, 349, 156-62