Six (6.4%) of the patients in the single-anesthetic group and 18 (19%) of the patients in the staged THA group died during the follow-up period. There was no difference in this overall mortality (HR = 0.47, p = 0.10, Table II) or in the 30 and 90-day mortality (p = 1.0 for both; Table IV) between single-anesthetic and staged bilateral THA (Fig. 1-D).
Over 2 million THAs were performed in the United States between 2002 and 2010, with <1% of these procedures being single-anesthetic bilateral procedures10. Although as many as one-third of patients undergoing unilateral THA have symptoms sufficient to warrant bilateral procedures5,6, there remains hesitation in using single-anesthetic bilateral THA for severe bilateral coxarthrosis. Historically, the use of single-anesthetic THA was associated with an increased risk of systemic complications12,19-21. With advances in perioperative medical management, more recent studies have shown no difference in systemic complications between single-anesthetic and staged bilateral procedures10,22-25. A major flaw with existing studies is the lack of patient matching. The goals of this study were to evaluate the outcomes of single-anesthetic and staged bilateral THA, in terms of in-hospital data, hospital discharge data, revision and reoperation, and postoperative complications (including mortality), in matched patients.
Similar to previous reports, this study showed that length of stay was longer for patients undergoing single-anesthetic bilateral THA compared with patients undergoing unilateral THA, but the total length of stay was less compared with patients undergoing staged bilateral THA, contributing to a decreased cost of care associated with a single-anesthetic procedure7,10,14-16,26. At our institution, the use of single-anesthetic bilateral THA was associated with significant reductions in the total costs of the operating room (by 28%) and hospitalization (by 27%) compared with staged bilateral procedures.
Similar cost-containment issues are associated with in-hospital and early postoperative complications, which place a substantial strain on the health-care system27-29. Retrospective, unmatched cohorts have shown an increased risk of DVT/PE following single-anesthetic bilateral THA12,19,21. This finding was not supported in the present matched cohort study, in which there was no difference in the rate of DVT/PE. The present study also showed no difference in other complications such as dislocation, periprosthetic fracture, and infection. This is similar to a recent review of the U.S. Nationwide Inpatient Sample (NIS) database by Rasouli et al.10, which showed no increase in the rate of complications in patients undergoing single-anesthetic bilateral THA.
Patient disposition following THA is related to the patient’s ability to participate in physical therapy and mobilize following the procedure. In the present study, there was no difference in the proportion of patients discharged to home versus a rehabilitation facility following single-anesthetic or staged bilateral THA, with a majority of patients discharged to home. This is in contrast to the findings by Parvizi et al.30, who noted a 96% rate of transfer to a rehabilitation center following single-anesthetic bilateral THA. In a study by Lindberg-Larsen et al.24, all patients undergoing bilateral THA (both staged and single-anesthetic) were discharged to home after a mean of 6 days (staged) or 4 days (single-anesthetic) on a fast-track rehabilitation program. We attribute our low rate of transfer to a rehabilitation facility to our institution’s advanced pain management program, rapid integration of physical therapy, and preoperative patient education protocols.
Because of the reported high risk of complications, the use of single-anesthetic bilateral THA had been reserved for patients with relatively “good” overall health20,23. The ASA score quantifies a patient’s general overall health and has been used to separate patients into those with “low” (ASA 1 and 2) and “high” (ASA 3 and 4) risk34. In a matched study comparing single-anesthetic bilateral THA with unilateral THA, Swanson et al.17 showed that the ASA score was predictive of perioperative complications. In the present study, preoperative ASA classification was not associated with an increased risk of postoperative complications. However, there were no patients in either group with an ASA classification of 4.
Allogenic blood transfusion has been shown to lead to immunosuppression and coagulopathy, and to have negative systemic effects in general, with multiple studies showing an increased transfusion rate in bilateral compared with unilateral THA procedures7,20,35-38. Although the change in hemoglobin level was not measured in the present study, we used the need for transfusion as a marker of blood loss. In our series, we noted a higher percentage of patients in the single-anesthetic group receiving autologous blood, while there was no difference in the amount of allogenic blood transfused. This is similar to a study by Alfaro-Adrián et al.7 in which the authors noted no difference in the rate of transfusion between patients undergoing single-anesthetic or staged bilateral THA.
We acknowledge several study limitations. It should be stressed that <1.5% of the THAs performed at our institution were single-anesthetic bilateral procedures, leading to selection bias. Although the data in this study were collected prospectively by our registry, which may help to reduce recall and selection bias, they were examined retrospectively and we are unable to comment on variables not collected by the registry or patient records. Lastly, although patients had similar perioperative management in terms of anesthesia, pain control, and physical therapy, there was no standardized protocol for determining eligibility for single-anesthetic or staged bilateral THA, with multiple adult reconstruction subspecialty surgeons performing the surgical procedure. Therefore, the potential of selection bias is present.
In summary, single-anesthetic bilateral THA can be safely performed for patients with bilateral coxarthrosis. There was no difference in terms of patient outcomes with respect to revision, reoperation, complications, and perioperative mortality between matched patients undergoing single-anesthetic or staged bilateral THA. Single-anesthetic bilateral THA resulted in lower overall operating room utilization and hospital length of stay. We currently consider single-anesthetic bilateral THA for patients who have clinical and radiographic changes that would warrant a THA in each hip, are <70 years of age, are relatively healthy, and/or have bilateral hip flexion contractures that would make rehabilitation difficult.
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