While many orthopedic surgeons no longer perform bilateral total knee arthroplasty (TKA), for some patients the procedure is appropriate and beneficial. “Some patients are too anxious or too busy to go through TKA twice. They want to get it over with and move on with their lives,” says Rodney Benner, MD, an orthopedic surgeon at Shelbourne Knee Center.
In carefully selected patients, bilateral TKA is safe and effective. “My role is to talk about the pluses and minuses of both options,” says Dr. Benner. “Once we figure out whether bilateral or staged TKA is the best option for that patient, we move forward.”
Good Outcomes With Few Complications
A perceived higher risk of major complications is one reason for not performing bilateral TKA. Dr. Benner believes that the risks of bilateral TKA and two unilateral TKAs are similar. “If you combine two unilateral TKAs, the complication rates are probably more comparable to the risk of bilateral TKA,” he says.
Surgical advances such as the perioperative use of tranexamic acid have reduced major complications. By minimizing blood loss and the need for transfusion, tranexamic acid also has reduced the number of infections.
While bilateral TKA patients do have more pain initially than staged TKA patients, they only have the pain once. Shelbourne Knee Center’s TKA pain-management protocol focuses on minimizing that pain.
Both bilateral and unilateral TKA patients usually are discharged from the hospital the day after the procedure and recover at the same rate. Few patients require inpatient rehabilitation. The center’s post-operative rehabilitation program, guided for each patient by one of the center’s physical therapists or athletic trainers, is the same whether patients have bilateral or unilateral TKA.
“Our bilateral TKA patients do really well,” says Dr. Benner. “Our experience enables us to select patients who are most likely to be able to tolerate bilateral TKA and patients for whom staged TKA is a better option.”
Who’s a Candidate?
Shelbourne Knee Center’s key criteria for bilateral TKA:
- Severe osteoarthritis in both knees
- Severe symptoms in both knees
- Contraindications:
- Cardiovascular risk factors
- Diabetes
- History of blood clots
Better Pain Management after TKA
Whether patients have unilateral or bilateral TKA, Shelbourne Knee Center’s TKA pain management protocol helps them recover faster and with less pain. Key elements of the protocol are:
- Prevention of post-operative swelling.
- Seven days of bed rest.
- Use of a continuous passive motion machine.
- Use of a Cryo-Cuff.
In the hospital, TKA patients receive a low-dose continuous infusion of Toradol (ketorolac) to control inflammatory pain. A study by Rodney Benner, MD, and colleagues found that post-op ketorolac improved pain control while reducing the use of opioids and adverse effects.(1) “We found an 85% reduction in the amount of narcotic pain medication patients needed while in the hospital and statistically significant pain reduction,” says Dr. Benner.
Patients also take Tylenol, and after completing Toradol they take the NSAID Mobic (meloxicam). As needed, they also can take Tramadol or Norco (a combination of acetaminophen and hydrocodone, an opioid). “Very seldom do our patients need IV opioid pain medications,” says Dr. Benner.
References
- Schwinghammer AJ, Isaacs AN, Benner RW, et al. Continuous Infusion Ketorolac for Postoperative Analgesia Following Unilateral Total Knee Arthroplasty. Ann Pharmacother. 2017 Jun;51(6):451-456. doi: 10.1177/1060028017694655. Epub 2017 Feb 1.