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Careful look at tradeoffs involved with double knee replacement

A patient before double knee replacement surgery.

A patient before double knee replacement surgery.

PHOTO: PETE HAUSLER/THE WALL STREET JOURNAL

With knee-replacement surgery on the rise, more patients with two bad knees are opting for a controversial procedure that replaces both at the same time.

Simultaneous bilateral knee replacement, as the surgery is known, is a subject of debate among orthopedic surgeons, with conflicting evidence about the risks and benefits. Proponents say it eliminates the need for a second hospital stay and grueling rehabilitation period, reduces time spent under anesthesia and costs less.

Some studies have found no difference in complication rates after bilateral surgery compared with unilateral surgery. A 2013 study in the Journal of Bone and Joint Surgery estimated the cost of bilateral surgery at $43,401 compared with $72,233 for two separate surgeries staged over time. The study concluded that bilateral surgery is more cost-effective with better outcomes for the average patient than staged procedures for two knees.

But more recent studies have found increased rates of complication such as blood clots that travel to the lung, an increased need for blood transfusions, and a higher risk of death with the bilateral procedure.

The rate of knee replacements in the U.S. almost doubled from 2000 through 2010, according to the Centers for Disease Control and Prevention, and now exceeds 700,000 procedures a year. The CDC doesn’t break out data, but studies indicate the percentage of patients who had both knees replaced at the same time has risen from less than 4% in 1999 to more than 6% at present.

 

Ken McLaughlin, 63, had bilateral knee replacement surgery in October 2014; he spent three nights in the hospital, about a week in a rehabilitation clinic and took a three-month leave from work. He experienced pain but no complications.

Ken McLaughlin, 63, had bilateral knee replacement surgery in October 2014; he spent three nights in the hospital, about a week in a rehabilitation clinic and took a three-month leave from work. He experienced pain but no complications.

Simultaneous bilateral procedures can be performed either by two surgeons operating in tandem or by a single surgeon who completes one knee and immediately turns to the other.

Although the average age has dropped for patients getting knee surgery, many also have health issues that can increase the risk of complications. In 2013, a consensus group of experts recommended that surgeons use more restrictive criteria to select patients for double knee replacements and exclude those with high cardiac risks. The majority said patients who aren’t candidates for simultaneous procedures should get a second one no sooner than three months after the first.

“We’ve learned a lot from years of data on who has complication issues,” says Steven Haas, an orthopedic surgeon at the Hospital for Special Surgery in New York. The hospital avoids bilateral knee surgery in patients who have any type of heart disease, as well as those with a body mass index of 40 or more. Obese patients often have conditions such as diabetes and high blood pressure than can complicate surgery. Typically, Dr. Haas says, he doesn’t perform bilateral surgery in patients over 80, and prefers not to do it in those over 75 unless they are in exceptional health.

For healthy patients in their 50s and 60s, “it’s an elective decision,” Dr. Haas says.

With knee-replacement surgery on the rise, more patients with two bad knees are opting for a controversial procedure that replaces both at the same time.

Simultaneous bilateral knee replacement, as the surgery is known, is a subject of debate among orthopedic surgeons, with conflicting evidence about the risks and benefits. Proponents say it eliminates the need for a second hospital stay and grueling rehabilitation period, reduces time spent under anesthesia and costs less.

Some studies have found no difference in complication rates after bilateral surgery compared with unilateral surgery. A 2013 study in the Journal of Bone and Joint Surgery estimated the cost of bilateral surgery at $43,401 compared with $72,233 for two separate surgeries staged over time. The study concluded that bilateral surgery is more cost-effective with better outcomes for the average patient than staged procedures for two knees.

But more recent studies have found increased rates of complication such as blood clots that travel to the lung, an increased need for blood transfusions, and a higher risk of death with the bilateral procedure.

The rate of knee replacements in the U.S. almost doubled from 2000 through 2010, according to the Centers for Disease Control and Prevention, and now exceeds 700,000 procedures a year. The CDC doesn’t break out data, but studies indicate the percentage of patients who had both knees replaced at the same time has risen from less than 4% in 1999 to more than 6% at present.
Ken McLaughlin, 63, had bilateral knee replacement surgery in October 2014; he spent three nights in the hospital, about a week in a rehabilitation clinic and took a three-month leave from work. He experienced pain but no complications. PHOTO: KEN MCLAUGHLIN
Simultaneous bilateral procedures can be performed either by two surgeons operating in tandem or by a single surgeon who completes one knee and immediately turns to the other.

Although the average age has dropped for patients getting knee surgery, many also have health issues that can increase the risk of complications. In 2013, a consensus group of experts recommended that surgeons use more restrictive criteria to select patients for double knee replacements and exclude those with high cardiac risks. The majority said patients who aren’t candidates for simultaneous procedures should get a second one no sooner than three months after the first.

“We’ve learned a lot from years of data on who has complication issues,” says Steven Haas, an orthopedic surgeon at the Hospital for Special Surgery in New York. The hospital avoids bilateral knee surgery in patients who have any type of heart disease, as well as those with a body mass index of 40 or more. Obese patients often have conditions such as diabetes and high blood pressure than can complicate surgery. Typically, Dr. Haas says, he doesn’t perform bilateral surgery in patients over 80, and prefers not to do it in those over 75 unless they are in exceptional health.

 

For healthy patients in their 50s and 60s, “it’s an elective decision,” Dr. Haas says.

 

Sandra Lynch, a 62-year-old wedding officiant in Frederick, Md., had trouble with her knees for more than a decade before getting bilateral knee replacement surgery in December 2014. She says she has no regrets.ENLARGE
Sandra Lynch, a 62-y

Sandra Lynch, a 62-year-old wedding officiant in Frederick, Md., had trouble with her knees for more than a decade before getting bilateral knee replacement surgery in December 2014. She says she has no regrets. PHOTO: SANDRA LYNCH
Nicholas Grosso, president of the Centers for Advanced Orthopaedics in Bethesda, Md., performs bilateral surgery in tandem with another surgeon. A typical hospital stay is three days, compared with two days for single-knee surgery. New anesthetic techniques help control pain after surgery, and as many as 40% of his bilateral patients go directly home. Others go to a rehabilitation facility for about a week, which isn’t usually necessary for unilateral patients. Dr. Grosso says overall recovery time is typically the same, with full recovery in about four months.

Ken McLaughlin, 63, had a bilateral knee replacement surgery in October 2014, with Dr. Grosso and a colleague, M. Brian Polsky. Mr. McLaughlin, who was an avid basketball player and volleyball coach, now teaches physical education to developmentally disabled children. Despite several surgeries over the years to repair damage, he had constant pain in both knees. Yet he wanted to put replacement off, he says, “until I couldn’t stand it anymore.”

After consulting with Dr. Grosso, he decided on bilateral surgery. First, he spent several months getting ready by building up strength in his legs and hamstrings.

Mr. McLaughlin, who lives in Laurel, Md., says it “really hurt” at first after surgery but he stopped taking pain medication after two days. After three nights in the hospital, he spent about a week in a rehabilitation clinic and took a leave from work until mid-January, working out twice a day for an hour and walking around his house. He had no complications and works out at the gym three times weekly. “I’m feeling stronger and getting ready to snow ski this winter,” he says.

A study in May in the Journal of Arthroplasty compared cases matched for risks in simultaneous bilateral and unilateral knee surgeries in a database of nearly 44,000 patients. It found no significant difference in the rate of complications including infection, hospital re-admission, or death. But bilateral procedures were associated with increased overall complications and risk of subsequent surgery within 30 days.

Study co-author David Manning, a joint replacement specialist at Northwestern Memorial Hospital in Chicago and associate professor at Northwestern University Feinberg School of Medicine, says he recommends staged procedures over time for patients who need both knees replaced. He doesn’t perform bilateral knee replacements.

“We decided it is not a safe practice, and it adds risk, so we don’t do it,” he says.

Last year, a large study comparing the two types of surgery indicated that bilateral patients were at increased risk of both minor and major in-hospital complications as well as death. The study, published in the Journal of Bone and Joint Surgery, included hospital claims data on 24,574 simultaneous bilateral surgeries and 382,496 unilateral procedures.

Surgeon Bryan Springer, a co-author of the study and fellowship director at OrthoCarolina Hip and Knee Center in Charlotte, N.C., says while complication rates are generally low for all knee surgeries, he is “extremely selective” about recommending bilateral surgery. “If you pick your patient appropriately you can do this operation very safely,” he says. Dr. Springer performs bilateral surgery with a team, starting the second knee while the first incision is being closed; if there are safety concerns after the first, he won’t proceed with the second.

Sandra Lynch, a 62-year-old wedding-officiant in Frederick, Md., had trouble with her knees for more than a decade. But with a busy schedule, she didn’t want recovery to take more than four months. Before the procedure, she took a year to exercise, walking daily and building a desk over a disassembled recumbent bike. She had the bilateral knee replacement with Dr. Grosso and Dr. Polsky in December last year.

Afterward, Ms. Lynch was hospitalized for four days. She needed a blood transfusion but was able to manage physical therapy before being transferred to a rehabilitation center for about a week. After bad reactions to narcotic pain medications and an anti-nausea patch, she switched to over-the-counter painkillers. Though she had to use a walker at first, after eight weeks she began to drive and walk without assistance. She is now back to work officiating at weddings and says she has no regrets.

Write to Laura Landro at laura.landro@wsj.com

Why Double Knee Replacement Might Be Best

Our Review Summary

double knee replacement

A patient profiled in this WSJ story awaits double knee replacement. Credit: Pete Hausler/The Wall Street Journal

This installment of the Wall Street Journal’s “Informed Patient” feature looks at the risks and benefits of bilateral knee replacement surgery (in which both knees are replaced during the same operation) as compared to staged knee replacement surgery (in which the knees are replaced during separate surgeries, usually months apart). While the story finds that it can be less expensive and time-consuming to have the bilateral knee replacement, it also reports that bilateral replacement surgery may pose increased health risks for patients.

The coverage overall is thorough and gives readers a good sense of the tradeoffs involved with each approach. The inclusion of more details about the “better outcomes” achieved in some studies of bilateral replacement would have been a valuable addition to the piece.

 

Why This Matters

A 2012 paper in the Journal of Bone & Joint Surgery reported that the number of knee replacements performed each year in the United States increased by 134 percent between 1999 and 2008, with 615,050 replacements done in 2008. And the number appears to still be on the rise, with the CDC reporting that 719,000 total knee replacements were performed in the U.S. in 2010. And no surgery is without risk. The Mayo Clinic notes that risks associated with knee replacement include infection, blood clots, heart attack, stroke and nerve damage. Some of these risks are life threatening and there’s a small, but real and unavoidable, fatality rate associated with knee replacements. In addition, the surgery can be costly. The website Healthline estimates the average cost of a total knee replacement to be $49,500 — or $57,000 if it requires a hospital stay. The fact that knee replacements are not uncommon, coupled with the presence of significant costs and health risks, makes it a subject worth reporting on. And if bilateral knee replacement is becoming more common (as reported in the story), and it affects both the costs and the risks, that’s worth discussing.

Criteria

Does the story adequately discuss the costs of the intervention?

Satisfactory

This is an essential part of the story, since cost is presented as one of the most significant benefits of performing bilateral knee replacement. The story cites a 2013 study that “estimated the cost of bilateral surgery at $43,401 compared with $72,233 for two separate surgeries staged over time.” One addition that would have made the story a bit stronger: since many patients requiring knee replacement surgery are older adults, it might have been useful for readers to know the extent to which Medicare might defray related costs. Still, the story tackles cost head on, and gets a solid Satisfactory here.

Does the story adequately quantify the benefits of the treatment/test/product/procedure?

Not Satisfactory

As mentioned above, one of the most significant benefits of the bilateral surgery is cost. However, there are others — such as the fact that a patient only has to be anesthetized once, and will likely spend less time (overall) in the hospital. The story says that the 2013 study where it got its cost numbers “concluded that bilateral surgery is more cost-effective with better outcomes for the average patient than staged procedures for two knees.” We italicized the “with better outcomes” part, because that’s the sticking point. What does it mean? In order for readers to make sense of a term like “better outcomes” it needs to be both clearly defined and quantified. On a side note, it would be great if the story linked to the relevant 2013 study.

Does the story adequately explain/quantify the harms of the intervention?

Satisfactory

The story is pretty clear on this, noting early on that “recent studies have found increased rates of complication such as blood clots that travel to the lung, an increased need for blood transfusions, and a higher risk of death with the bilateral procedure.” Later the story refers to two different studies. One, published earlier this year, found “increased overall complications and risk of subsequent surgery within 30 days” for patients who had the bilateral replacement. The other, published in 2014, found that “bilateral patients were at increased risk of both minor and major in-hospital complications as well as death.” Again, it would have been great to include links — or citations — for the relevant studies.

Does the story seem to grasp the quality of the evidence?

Satisfactory

We’ll give the benefit of the doubt here, as the story does a reasonably good job of summarizing the broad outlines of evidence from several recent studies. In that respect it’s more illuminating than stories that rely on a single study while ignoring the bigger picture. But the story could have been more thorough. In discussing a recent Journal of Arthroplasty study, for example, the story states that researchers found “no significant difference in the rate of complications including infection, hospital re-admission, or death. But bilateral procedures were associated with increased overall complications and risk of subsequent surgery within 30 days.” It’s unclear to us what this means. How can there be “no significant difference in the rate of complications” but also “increased overall complications”? The description of a 2014 study is also somewhat vague, really only telling readers how many patient claims were reviewed (this was the study that found an increased risk of both complications and death). And the story doesn’t really tell readers anything about the 2013 study (where it got its cost numbers and the “better outcomes” reference).

Does the story commit disease-mongering?

Satisfactory

No disease mongering here.

Does the story use independent sources and identify conflicts of interest?

Satisfactory

The story talked to multiple sources and clearly identified those who played a role in studies that were cited in the story.

Does the story compare the new approach with existing alternatives?

Satisfactory

The story is, in effect, all about comparing alternatives — bilateral versus staged knee replacement. One thing that’s not made clear anywhere in the story is whether the knee replacements in question for any or all of the studies were total knee replacements, partial knee replacements, or both. Are there differences in cost? Benefits? Risks? That would have been useful to include.

Does the story establish the availability of the treatment/test/product/procedure?

Satisfactory

It was made clear that both bilateral and staged knee replacement surgeries are fairly common and widely available. Similarly, it was made clear that some surgeons refuse to perform bilateral surgeries, or will only perform them for patients that meet fairly stringent criteria.

Does the story establish the true novelty of the approach?

Satisfactory

The story notes that, as of 2010, approximately 6 percent of patients who get both knees replaced have bilateral surgery — up from 4 percent in 1999. So, the technique is not new, but there has been some growth in the use of the surgery as younger and healthier patients become candidates for knee replacements — and the story establishes this. The story could have been clearer about the fact that this technique has been routinely used even longer than that. (Reviewer Jim Rickert can recall doing bilateral replacements not infrequently as far back as the 1980s.)

Does the story appear to rely solely or largely on a news release?

Satisfactory

The story does not appear to be tied to a news release. And, given the number of patients and doctors interviewed, the story goes well beyond what would be included in a news release anyway.

Total Score: 9 of 10 Satisfactory

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