CONSENSUS RECOMMENDATION This recommendation has been downgraded due to the potential harms to the patient. In the limited evidence available, no difference in overall complication rates for patients who underwent bilateral simultaneous TKA versus stage TKA is found. Several studies demonstrate lower hemoglobin (Feng 2019) in simultaneous TKA group, but there are mixed findings regarding increased blood transfusion (Feng 2019, Wan 2021, Bohn 2016). Some studies found increased risk of PE with bilateral simultaneous TKA (Hadley 2017, Bohm 2016) though others found no difference in the compared groups (Goyal 2020, Arslan 2018, Zhao 2015). When specifically comparing bilateral simultaneous versus staged (excluding unilateral TKA), no mortality difference has been reported (Yoon 2010).
In the limited evidence available, findings are consistent that there are no functional outcome differences between simultaneous and staged bilateral TKA (Goyal 2020, Feng 2019).
Advantages to simultaneous bilateral TKA include cost savings (Wan 2021), decreased overall length of stay (Feng, 2020, Wan 2021, Kahlenberg 2021, Siedlecki 2018).
Benefits/ Harms of Implementation
Bilateral simultaneous TKA may be preferred for some patients with bilateral advanced knee osteoarthritis. While bilateral simultaneous TKA has shown to have increased risks when compared to unilateral TKA in recent literature (Warren 2021), multiple low-quality studies (Poultisides 2015, Seol 2016, Bohm 2016) have found adverse effects, including total adverse effects, in favor bilateral simultaneous TKA in comparison to bilateral staged TKA.
Cost Effectiveness / Resource Utilization
Limited evidence suggests bilateral simultaneous total knee arthroplasty is cost saving.
Future Research
This recommendation is based on limited evidence from retrospective studies and limited power prospective series, and analyses thereof. Well-designed large prospective or randomized trials will further the understanding of specific criteria for patients choosing between either staged or simultaneous bilateral total knee arthroplasty
- Bohm, E. R., Molodianovitsh, K., Dragan, A., Zhu, N., Webster, G., Masri, B., Schemitsch, E., Dunbar, M. Outcomes of unilateral and bilateral total knee arthroplasty in 238,373 patients. Acta Orthopaedica 2016; 0: 24-30
- Feng, S., Yang, Z., Sun, J. N., Zhu, L., Wang, S., Guo, K. J., Chen, X. Y., Zha, G. C. Comparison of the therapeutic effect between the simultaneous and staged unicompartmental knee arthroplasty (UKA) for bilateral knee medial compartment arthritis. BMC Musculoskeletal Disorders 2019; 1: 340
- Goyal, T., Azam, M. Q., Syed, A., Paul, S. Simultaneous single-stage versus two-staged bilateral total knee arthroplasty: a prospective comparative study. International Orthopaedics 2020; 7: 1305-1310
- Hadley, S., Day, M., Schwarzkopf, R., Smith, A., Slover, J., Zuckerman, J. Is Simultaneous Bilateral Total Knee Arthroplasty (BTKA) as Safe as Staged BTKA?. 2017; 4: E224-E229
- Wan, R. C. W., Fan, J. C. H., Hung, Y. W., Kwok, K. B., Lo, C. K. M., Chung, K. Y. Cost, safety, and rehabilitation of same-stage, bilateral total knee replacements compared to two-stage total knee replacements. Knee Surgery & Related Research 2021; 1: 17
- Arslan, A., Utkan, A., Ozkurt, B. Are unilateral or staged bilateral total knee arthroplasty really safer than simultaneously bilateral TKA, or is it a myth?. Acta Orthopaedica Belgica 2018; 2: 192-202
- Zhao, Y. T., Chu, H. J., Heng, D. F., Lei, J. Comparison of the effectiveness and safety of one-stage versus two-stage bilateral total knee arthroplasty. Acta Orthopaedica Belgica 2015; 4: 784-9
- Yoon, H. S., Han, C. D., Yang, I. H. Comparison of simultaneous bilateral and staged bilateral total knee arthroplasty in terms of perioperative complications. Journal of Arthroplasty 2010; 2: 179-85
- Kahlenberg, C. A., Krell, E. C., Sculco, T. P., Katz, J. N., Nguyen, J. T., Figgie, M. P., Sculco, P. K. Differences in time to return to work among patients undergoing simultaneous versus staged bilateral total knee arthroplasty. Bone & Joint Journal 2021; 6: 108-112
- Siedlecki, C., Beaufils, P., Lemaire, B., Pujol, N. Complications and cost of single-stage vs. two-stage bilateral unicompartmental knee arthroplasty: A case-control study. Orthopaedics & traumatology, surgery & research 2018; 7: 949-953
- Warren, J. A., Siddiqi, A., Krebs, V. E., Molloy, R., Higuera, C. A., & Piuzzi, N. S. (2021). Bilateral simultaneous total knee arthroplasty may not be safe even in the healthiest patients. JBJS, 103(4), 303-311.
- Poultsides, L. A., Memtsoudis, S. G., Do, H. T., Sculco, T. P., Figgie, M. P. Perioperative morbidity and mortality of same-admission staged bilateral TKA. Clinical Orthopaedics & Related Research 2015; 1: 190-7
- Bohm, E. R., Molodianovitsh, K., Dragan, A., Zhu, N., Webster, G., Masri, B., Schemitsch, E., Dunbar, M. Outcomes of unilateral and bilateral total knee arthroplasty in 238,373 patients. Acta Orthopaedica 2016; 0: 24-30
- Seol, J. H., Seon, J. K., Song, E. K. Comparison of postoperative complications and clinical outcomes between simultaneous and staged bilateral total knee arthroplasty. Journal of Orthopaedic Science 2016; 6: 766-769