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Bilateral Total Knee Arthroplasty: A Major Morbid Condition!

Bilateral Total Knee Arthroplasty: Risk Factors for Major Morbidity and Mortality

Anesth Analg 2011

Background: Bilateral total knee arthroplasty (BTKA) performed during the same hospitalization carries increased risk for morbidity and mortality compared with the unilateral approach. However, no evidence-based stratifications to identify patients at risk for major morbidity and mortality are available. The objective of the study was to determine the incidence and patient-related risk factors for major morbidity and mortality among patients undergoing BTKA.

Methods: Nationwide Inpatient Survey data collected for the years 1998 to 2007 were analyzed and cases of elective BTKA procedures were included. Patient demographics, including comorbidities, were analyzed and frequencies of mortality and major complications were computed. Subsequently, a multivariate analysis was conducted to determine independent risk factors for major morbidity and mortality.

Results: Included were 42,003 database entries, representing an estimated 206,573 elective BTKAs. The incidence of major in-hospital complications and mortality was 9.5%. Risk factors for adverse outcome included advanced age (odds ratios [ORs] for age groups 65–74 and >75 years were 1.88 [confidence interval, CI: 1.72, 2.05] and 2.66 [CI: 2.42, 2.92], respectively, compared with the 45–65 years group), male gender (OR: 1.54 [CI: 1.44, 1.66]), and a number of comorbidities. The presence of congestive heart failure (OR: 5.55 [CI: 4.81, 6.39]) and pulmonary hypertension (OR: 4.10 [CI: 2.72, 6.10]) were the most significant risk factors associated with increased odds for adverse outcome.

Conclusions: Patient-related risk factors for major morbidity and mortality in patients undergoing BTKA are identified. Although it is beyond the scope of this article to provide final and specific guidelines, the authors would urge institutions to engage in discussions to establish criteria to restrict BTKA procedures to patients with decreased reserve of the cardiopulmonary, vascular, renal, and central nervous system and contemplate exclusion of patients of advanced age and those with evidence of significant end-organ disease. Until detailed evaluation guidelines can be agreed on, it seems prudent to exclude the elderly and patients with ASA physical status 3. Patients at risk for occult derangements of pulmonary hemodynamics and right heart dysfunction (i.e., the obese and those with sleep apnea, chronic obstructive pulmonary disease, and previous pulmonary embolism) should undergo cardiopulmonary evaluation with echocardiography to rule out significant preexisting increases in pulmonary artery pressures, which may predispose patients to increased morbidity and mortality. These data can be used to aid in the selection of patients for this procedure.

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