Recommendations for Double Knee Surgery
Double knee surgery (bilateral total knee arthroplasty) should be considered only for select patients with severe bilateral knee osteoarthritis who have failed conservative management, with careful patient selection based on age, comorbidities, and ASA status to minimize complications. 1
Patient Selection Criteria
Recommended Candidates
- Patients younger than 70 years of age 1
- ASA (American Society of Anesthesiologists) status 1-2 1
- Patients with radiographic evidence of moderate-to-severe bilateral knee OA 1
- Patients with refractory pain and disability despite conservative management 1
- Patients without significant comorbidities 2
Contraindications/Higher Risk Patients
- Patients over 75 years old (higher complication rates) 1
- Patients with diabetes (higher risk for complications) 1
- Patients with chronic pain conditions (less improvement in outcomes) 1
- Patients with depression/anxiety (less improvement in patient-reported outcomes) 1
- Patients with obesity (less improvement in outcomes) 1
- Patients with cardiovascular disease 3
- Patients with pulmonary disease 3
Types of Bilateral Knee Surgery
Simultaneous Bilateral TKA
- Two-surgeon simultaneous approach may have lower complication rates compared to single-surgeon sequential approach 4
- Associated with higher risk of:
Staged Bilateral TKA
- Complication rates similar to unilateral TKA 3
- Recommended for higher-risk patients 3
- Optimal time interval between surgeries not definitively established 3
Perioperative Management
Preoperative Optimization
- Weight management for patients with BMI ≥25 kg/m² (minimum weight loss target of 5.0-7.5%) 1
- Improved glycemic control for diabetic patients 1
- Smoking cessation 1
- Supervised exercise program to improve preoperative function 1
Intraoperative Considerations
- Regional anesthesia and analgesia preferred 5
- Invasive monitoring recommended for simultaneous bilateral TKA 5
- Cemented tibial components show strong evidence of effectiveness 1
- No difference in outcomes between all-polyethylene or modular tibial components 1
- No recommendation for or against patellar resurfacing based on pain or function outcomes 1
Postoperative Care
- Rehabilitation started on day of surgery reduces length of hospital stay 1
- Postoperative observation in intensive care unit setting for simultaneous bilateral TKA 5
- Aggressive management of hemodynamic aberrations 5
- Supervised exercise program during first 2 months after TKA improves physical function 1
- Cryotherapy devices after knee arthroplasty do not improve outcomes 1
- Continuous passive motion after knee arthroplasty does not improve outcomes 1
Complications to Monitor
- Pulmonary embolism (higher risk in simultaneous bilateral TKA) 2, 3
- Cardiac complications 3
- Stroke 2
- Blood loss requiring transfusion 2, 4
- Fat embolism syndrome 5
- Cardiac arrhythmias 5
Patient Expectations Management
Patients should be counseled about realistic expectations regarding:
- Pain relief 6
- Improvement in walking ability 6
- Psychological well-being 6
- Recovery timeline 6
- Potential complications specific to bilateral procedures 2, 3
Key Pitfalls to Avoid
- Performing simultaneous bilateral TKA in high-risk patients (elderly, multiple comorbidities, ASA >2) 1, 2, 3
- Underestimating blood loss and transfusion requirements in simultaneous procedures 2, 4
- Inadequate perioperative monitoring for cardiopulmonary complications 5
- Delaying mobilization (rehabilitation should start on day of surgery) 1
- Using patient-specific instrumentation (no difference in pain or functional outcomes) 1
- Using intraoperative navigation (no difference in outcomes or complications) 1
By following these evidence-based recommendations and carefully selecting appropriate candidates, double knee surgery can be performed safely with good outcomes for patients with bilateral knee osteoarthritis who have failed conservative management.