Comment on “Comparison of the major intraoperative and postoperative complications between unilateral and sequential bilateral total knee arthroplasty in a high-volume community hospital”

It was with great interest that we read the recent article by Spicer, Thomas and Rumble,1 which provides an insight into the safety of unilateral total knee arthroplasty (UTKA) versus sequential or simultaneous bilateral total knee arthroplasty (BTKA) in a high-volume community hospital. The authors excluded from their study patients who underwent staged TKA, defined as “2 distinct surgeries on both knees within a 1-year period.” Instead, candidates with bilateral knee symptoms who were deemed eligible for surgery were given the option of BTKA or 2 UTKAs.1

In our experience with patients who present with bilateral fixed flexion knee deformities, even if a UKTA is initially successful, it may develop stiffness and adopt the fixed flexion of the contralateral knee if the latter is not likewise replaced within a few months. Residual flexion contractures after knee replacement have been associated with poor outcomes.2

The limitation of movement and impact on quality of life caused by a residual flexion contracture3 should be considered a complication in itself. This complication might be avoided by performing a BTKA or careful pre- and postoperative management to safely complete staged TKA procedures in considerably less than 1 year. Although it seems reasonable that “individuals who decline the second operation may have been better served by a 1-step BTKA,”1 the alternative is perhaps more relevant to orthopedic departments where there is less experience and expertise in performing BTKAs.

The merits of BTKA versus staged TKA have been extensively discussed in the literature. Reduced costs, single anesthetic and decreased total recovery time have been highlighted as advantages of BTKA,4 but an increased risk of serious postoperative complications have also been reported.5 We hope that future studies will continue to objectively evaluate the risks and benefits of each, and identify which patients might be more suited to a particular method.