Bilateral Simultaneous Total Knee Arthroplasty

The Decision

For me to have considered bilateral simultaneous knee replacement, both knees must have significant structural damage. It is best if the patient cannot decide which knee is more bothersome. In borderline cases, I asked the patient to pretend that the worse knee is normal. Then I asked if the patient would be seeing me for consideration of knee replacement on the other, less involved side. If the answer to this question was “yes,” I considered the patient a potential candidate for bilateral knee replacement. If the answer was “no,” I recommended operating only on the worst knee, and I expected that the operation on the second knee could be delayed for a considerable period.

Strong indications for bilateral simultaneous TKA are bilateral severe angular deformity ( Fig. 11.1 ), bilateral severe flexion contracture, and anesthesia difficulties, that is, patients who are anatomically or medically difficult to anesthetize, such as some adult or juvenile patients with rheumatoid arthritis or patients with severe ankylosing spondylitis.

Relative indications for bilateral simultaneous TKA include the need for multiple additional surgical procedures to achieve satisfactory function and financial or social considerations for the patient.

Contraindications to bilateral TKA include medical infirmity (especially cardiac), a reluctant patient, and a patient with a very low pain threshold. Advanced age (octogenarian or above) is only a relative contraindication.

Anesthetic Considerations

In performing bilateral TKA, regional anesthesia has been preferred. Traditionally, it was in the form of epidural anesthesia with an indwelling catheter. The catheter is maintained in place for 24 to 48 hours, at which time it is capped or removed and oral medications are substituted. Alternatively, spinal or general anesthesia with possible bilateral nerve blocks can be used. With the advent of pericapsular injection techniques, anesthetic considerations will continue to evolve.

Anticoagulation

Anticoagulation for the prevention of deep vein thrombosis (DVT) is important, because the potential for DVT is intuitively greater with bilateral surgery. Pharmacologic methods will continue to evolve.

Other ancillary measures that might decrease the possibility of DVT include the use of an epidural for anesthesia, pulsatile compression stockings applied immediately postoperatively, and early (same day) patient mobilization with standing and short-distance ambulation.