Bilateral THR in Single Setting: Where we Stand

Courtesy: Dr Rajesh Malhotra, Dr Ashok Shyam, Ortho TV

Overview

• Simultaneous bilateral total hip replacement refers to replacing both hip joints during the same surgical session.
• This approach is increasingly practiced in carefully selected patients with disease affecting both hips.
• Improvements in anesthesia, surgical techniques, and perioperative care have contributed to the growing acceptance of this procedure.

Current Practice Trends

• National joint registry data from England and Wales indicate an increase in simultaneous bilateral hip replacement procedures over recent years.
• Bilateral procedures remain less common in knee replacement compared with hip replacement.
• Growing surgical experience and improved perioperative safety have encouraged surgeons to consider performing both hip replacements during one operative session.

Historical Perspective

• The concept of performing both hip replacements during a single anesthesia session has existed for several decades.
• Early clinical series demonstrated that simultaneous procedures could be performed safely in selected patients.
• Initial observations suggested a slightly higher complication risk compared with unilateral surgery, but several advantages were identified:
  • A single exposure to anesthesia
  • Reduced total hospital stay
  • Faster overall rehabilitation period

Factors That Improved Safety

Advances in modern medical practice have improved the safety of simultaneous bilateral hip replacement.

Key improvements include:

• Refinement of anesthesia techniques, including controlled hypotensive anesthesia.
• Effective prevention of blood clot formation through appropriate prophylactic measures.
• Improved implant design and surgical instruments.
• Enhanced monitoring during surgery and better postoperative care.

These advancements have significantly reduced complications associated with longer surgical procedures.

Findings from Clinical Studies

Comparative studies evaluating simultaneous bilateral hip replacement and staged procedures have reported several important findings:

• Mortality rates are comparable to those observed in unilateral hip replacement.
• Overall complication rates are similar between simultaneous and staged procedures in appropriately selected patients.
• Blood transfusion requirements may be slightly higher compared with single hip replacement.
• When compared with two separate operations, the overall duration of hospitalization is reduced.
• Performing both procedures during one admission can lower the total cost of treatment.

Economic and Rehabilitation Advantages

Simultaneous bilateral hip replacement offers several practical benefits:

• Reduced overall length of hospitalization.
• Lower cumulative hospital expenses.
• Shorter period of disability.
• Faster return to daily activities and functional independence.
• Reduced cumulative exposure to anesthesia and surgical stress.

These factors can make the procedure more convenient and cost effective for both patients and healthcare systems.

Patient Selection Considerations

Appropriate patient selection is critical to achieving safe outcomes.

Patients most suitable for simultaneous bilateral hip replacement typically include:

• Individuals with low to moderate medical risk.
• Patients with stable general health and absence of severe systemic illness.
• Individuals without major cardiovascular or pulmonary compromise.

Patients with very high anesthesia risk are generally not considered suitable candidates for simultaneous bilateral procedures.

Surgical Technique Considerations

When bilateral hip replacement is performed through a posterior surgical approach:

• One hip is replaced first.
• The patient is then repositioned to allow access to the opposite hip.
• Imaging may be obtained between procedures to confirm implant alignment and leg length restoration.

Careful intraoperative planning is required to maintain accuracy and prevent complications.

Clinical Indications

Certain conditions strongly favor performing bilateral hip replacement during the same surgical session.

Common indications include:

• Severe flexion deformity affecting both hip joints.
• Bilateral bony fusion of the hip joints.
• Significant leg length discrepancy associated with bilateral hip disease.
• Young patients with advanced disease in both hips.
• Patients with minimal medical comorbidities.

In cases where both hip joints are fused, replacing only one hip may not provide adequate functional improvement.

Management of Complex Deformities

Patients with severe musculoskeletal deformities may require additional corrective procedures during the same surgical session.

Possible procedures include:

• Release of contracted hip adductor muscles.
• Surgical correction of knee flexion contractures.
• Release of ankle contractures.
• Soft tissue balancing procedures around affected joints.

In rare cases, multiple joint corrections involving both hips and knees may be performed during one surgical session in specialized centers.

Functional Improvements

Simultaneous bilateral hip replacement can significantly improve patient function.

Observed improvements include:

• Increased range of motion in both hips.
• Improved ability to perform daily activities such as sitting and standing.
• Better alignment between the spine and pelvis.
• Improved walking pattern and overall mobility.

Restoration of hip flexion is particularly important because it enables patients to sit comfortably and perform routine activities.

Balance and Walking Pattern

Studies evaluating balance and gait have reported important findings:

• Patients with bilateral hip disease treated with only one hip replacement may experience impaired balance for several years.
• The risk of falls may remain higher when only one hip is replaced in the presence of disease affecting both sides.
• Simultaneous bilateral hip replacement allows more symmetrical weight distribution and improved balance during standing and walking.

Implant Fixation Methods

Both cemented and uncemented implants are commonly used in bilateral hip replacement.

Key observations include:

• Long term outcomes appear similar with both fixation methods.
• Cemented implants may theoretically increase embolic load during surgery, but clinical evidence has not demonstrated a significant difference in complications.
• Both short stem and conventional femoral stem designs can be used effectively.

Surgical Approach Options

Several surgical approaches can be used for bilateral hip replacement:

• Direct anterior approach
• Posterior approach
• Lateral approach
• Anterolateral approach

The choice of approach depends on surgeon preference, patient anatomy, and institutional experience.

Advantages of the Direct Anterior Approach

The direct anterior approach offers several potential advantages when performing simultaneous bilateral hip replacement:

• The patient remains in the same position throughout the entire procedure.
• There is no need to reposition the patient between surgeries.
• Surgical workflow becomes more efficient.
• Implant positioning can be assessed more accurately.
• Some patients experience reduced postoperative pain.
• Recovery of walking pattern may occur more quickly.

Because of these advantages, this approach is often considered well suited for simultaneous bilateral procedures.

Use of Dual Surgical Teams

In highly specialized centers, two surgical teams may operate simultaneously on both hips.

Potential benefits include:

• Reduction in total operative time.
• Shorter duration of anesthesia exposure.
• Increased operating room efficiency.

However, this technique requires experienced surgical teams, appropriate infrastructure, and careful coordination.

Summary

• Simultaneous bilateral total hip replacement is an effective option for patients with severe disease affecting both hip joints.
• The procedure can reduce total treatment cost, shorten hospital stay, and accelerate rehabilitation.
• Careful patient selection and experienced surgical teams are essential to ensure safe outcomes.
• Choice of surgical approach and operative planning play important roles in optimizing results.