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Bilateral Total Knee Replacement: Staging and Pulmonary Embolism
Jane Barrett, MSc1; John A. Baron, MD, MSc1; Elena Losina, PhD2; John Wright, MD3; Nizar N. Mahomed, MD, ScD4; Jeffrey N. Katz, MD, MS3
1 Departments of Medicine (J.A.B.) and Community and Family Medicine (J.B. and J.A.B.), and Section of Biostatistics and Epidemiology (J.B. and J.A.B.), Dartmouth Medical School, 46 Centerra Parkway, Evergreen Building, Suite 300, Lebanon, NH 03766. E-mail address for J. Barrett: jane.a.barrett@dartmouth.edu
2 Department of Biostatistics, Boston University School of Public Health, 715 Albany Street, TE421, Boston, MA 02118
3 Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy (J.N.K.), and Department of Orthopaedic Surgery (J.W. and J.N.K.) Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115
4 Musculoskeletal Health and Arthritis Program, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, Toronto, ON M5T 2S8, Canada
View Disclosures and Other Information
In support of their research for or preparation of this manuscript, one or more of the authors received grants or outside funding from the National Institute of Arthritis and Musculoskeletal and Skin Diseases and the National Institutes of Health. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at Dartmouth Medical School, Lebanon, New Hampshire and Brigham and Women's Hospital, Boston, Massachusetts

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2006 Oct 01;88(10):2146-2151. doi: 10.2106/JBJS.E.01323
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Background: When a bilateral total knee replacement is indicated, it is not clear whether it is preferable to operate on both knees during the same hospitalization (simultaneously) or to stage the procedures in two separate hospital stays. A greater risk of pulmonary embolism after simultaneous total knee replacement has been reported by some authors, but little national data are available.

Methods: We reviewed the records of 122,385 United States Medicare enrollees who had had a total knee replacement in 2000. We noted whether they had had a unilateral procedure or two procedures and, if they had had two procedures, whether both had been done during the same hospitalization or whether the operations had been performed during two separate hospital stays. Age, sex, race, residence, Medicaid eligibility (a proxy for low income), and the Charlson comorbidity score were documented for each patient as were the total numbers of total knee replacements performed in the year 2000 by the hospital and the surgeon. The probability of a symptomatic pulmonary embolism developing in the first three months after surgery was calculated for the simultaneous, staged, and unilateral procedures.

Results: Simultaneous procedures were much more likely to be performed in high-volume hospitals and by high-volume surgeons than were staged procedures. Men had proportionately more simultaneous procedures than did women. Hospitals in the northeastern United States were the most likely to perform simultaneous procedures. A pulmonary embolism developed in the first three months in 0.81% of the patients who had had a single procedure compared with 1.44% of the patients who had undergone a simultaneous procedure (adjusted hazard ratio 1.81; 95% confidence interval, 1.49, 2.20).

Conclusions: The systematic differences in patient gender, hospital and surgeon volume, and geographic region between those who undergo simultaneous total knee replacements and those who undergo staged procedures should be borne in mind when outcomes are being compared. The adjusted risk of pulmonary embolism is about 80% higher in the three months after a simultaneous procedure than in the three months after a single procedure, which suggests that the sum of the risks associated with the two operations of a staged procedure may equal or exceed the risk of simultaneous total knee replacement.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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