Abdel v Hamilton: Simultaneous Bilateral Anterior Hips: Double Trouble

This week’s Orthopaedic Crossfire® debate was part of the 19th Annual Current Concepts in Joint Replacement® (CCJR®), Spring meeting, which took place in Las Vegas. This week’s topic is “Simultaneous Bilateral Anterior Hips: Double Trouble” For is Matthew P. Abdel, M.D. – Mayo Clinic, Rochester, Minnesota. Opposing is William G. Hamilton, M.D. – Anderson Orthopaedic Research Institute, Alexandria, Virginia. Moderating is William J. Maloney III, M.D. – Stanford Hospital & Clinics, Stanford, California.

Dr. Abdel: Total hip arthroplasty is largely considered one of the most successful procedures in all of medicine. However, many recent advances have actually been regressions in the world of hip arthroplasty. These include metal-on-metal total hip arthroplasty, dual modular necks, and trunnion-related issues.

I contend that simultaneous bilateral anterior total hip arthroplasty will fall into a similar category.

Why do I say that?

There are unique and numerous complications with bilateral procedures. There are also unique and numerous complications with direct anterior total hip arthroplasty. Combining those two, in my hands, creates a risk profile that is too high for me to tolerate.

Let’s look at the risks with simultaneous bilateral total hip arthroplasty. Here are my top 4 reasons for saying “No.”

1. Foremost, there is an increased risk of blood transfusion.
2. Longer operative times. Longer operative times increase the risk of perioperative morbidity and periprosthetic joint infection. It’s also longer operative times for the surgeon, surgical team and through-put for that particular day.
3. What about length of stay? Most of these patients are the youngest, healthiest, most active patients and many of them can have an outpatient procedure. If you could have 2 outpatient procedures, you’d have a length of stay of zero, in contrast to length of stay of 2-3 days for these patients that are often hospitalized after bilateral simultaneous procedures.
4. Finally, mortality. There are multiple series that have looked at simultaneous procedures and mortality. What we do know is that in those patients who are 75-years or greater in age, male gender and ASA 3 or 4, [American Society of Anesthesiologists] there is an increased mortality rate in simultaneous bilateral procedures. (Garland et al., BMC 2015)

I would contend to you that if we exclude 75-year-old males or those patients with ASA 3 or 4, we lose a large proportion of our arthroplasty patients.