Bilateral Knee Replacement Q&A

Two of our leading consultant orthopaedic specialists, Mr Henry Bourke and Mr Rakesh Kucheria, offer bilateral simultaneous knee replacement to patients at The Princess Margaret Hospital. They answer questions about the procedure, including how it works, who can have this type of surgery, and the secret to working so well together.

Can you tell us a bit more about your background and how you've decided to pair up and perform surgery together?

Mr Henry Bourke: We have been working together since 2013. I was appointed a consultant at Wexham Park and Heatherwood Hospitals and met Mr Kucheria as a result of that appointment. The way the operating lists worked when we started, we were always in next door theatres and as a result decided to team up to start doing some of these cases as we had got used to how each other had worked very quickly. Mr Kucheria had been doing some bilateral simultaneous procedures with another consultant and the formula of the anaesthetic, procedure and rehabilitation was already in place.

For the both of us operating at the same time on the same patient works extremely well as I am left-handed and Mr Kucheria is right-handed. When we stand together to operate on both knees, having that advantage means we get in each other's way less. There are a lot of instruments needed for a total knee replacement and having that left-hand, right-hand combination has been very successful. The operation is slicker as a result.

Mr Rakesh Kucheria: The first time I saw a bilateral knee replacement was at the Princess Alexandra Hospital in Harlow, where I first had my training. I then implemented this at Heatherwood Hospital with one of my associate specialists. Until then I didn’t have a colleague who believed in the philosophy of doing both knees together, therefore we only started doing simultaneous knee replacements in the private sector in the last 18 months. In the NHS I have been practicing simultaneous knee replacements for the last 15 years with extremely good results.

What is the bilateral simultaneous knee replacement and how does it work?

Mr Henry Bourke: Historically, knee replacements have been done one at a time. It is a reasonably big operation for the patient with a degree of blood loss sometimes requiring transfusion. Losing blood can stress the cardiovascular system somewhat and thus, up until recently, doing two procedures has not been safe for the patient. Better advances in anaesthesia and better surgical techniques have been able to minimise the risk to the patient and allow us to operate on both knees in the same sitting.

Many surgeons around the world will offer patients two knee replacements in the same sitting but this involves replacing one knee, sewing up the skin and then starting on the other knee. This leads to a fairly prolonged anaesthetic time of 2.5-3 hours. Bilateral simultaneous knee replacement means two surgeons are operating at the same time, one on each knee. This means that both knees can be replaced inside one hour. The advantage of this is much less anaesthetic time which is in theory much safer for the patient leading to a quicker recovery in addition.

Mr Rakesh Kucheria: Bilateral knee replacements can be done either sequentially or simultaneously. Simultaneously, is when two surgeons are operating at the same time, which means within an hour to an hour and a half both knees are replaced. This reduces the time under anaesthesia, as well as exposure to the atmosphere, offering significant benefits for the patient.

Who can get the procedure and who shouldn't?

Mr Henry Bourke: The ultimate decision on who is suitable for this procedure lies with the anaesthetist. We work with two anaesthetists regularly and patients will have an appointment with the anaesthetist prior to the operation assess their general health and to identify potential existing illnesses that may make the operation riskier. These comorbidities are usually bleeding disorders, prior cardiovascular problems such as previous heart attack and problems with the respiratory system (breathing difficulties).

From the surgeon's perspective we feel the patients need to have an overall fitness level to allow them to get up out of bed after the operation to mobilise with a frame or crutches. This requires a certain amount of upper body strength and muscle power in the legs to get going again quickly on two replaced knees. Having this procedure also requires a certain amount of family and/or social support as it can be quite tough in the first few weeks to get about on the two new knees, obviously if you are not able to rely on one that you have known for many years.

Mr Rakesh Kucheria: Anyone who has got bad knees and are in reasonable health can have this procedure. Patients who should not have both knees done simultaneously are those with cardiac issues or other high-risk factors towards having surgery.

How common is this procedure?

Mr Henry Bourke: Mr Kucheria and I have performed 30 of these procedures in a three-year period thus far. This equates to almost one per month. As far as we are aware, there are no other surgeons in the UK offering this procedure in the private sector. There are surgeons that will however offer to do both knees in the same sitting but as mentioned before, this is usually one then the other with a prolonged anaesthetic time.

Mr Rakesh Kucheria: Simultaneous knee replacement procedures are not as common as they could be in the UK, contrary to the third world where resources are limited and this procedure is quite common.

What are the alternatives to knee replacement surgery?

Mr Henry Bourke: 97% of knee replacements are done for osteoarthritis. Osteoarthritis is a disease that has a multi-factorial cause. This means there are many different contributing factors that cause it to affect your knees. Some of this is genetic, some of it environmental and some of it is due to previous trauma and the weight of the patient. Carrying extra weight above your normal body mass index (BMI) will lead to earlier onset of the disease. The symptoms of osteoarthritis are mostly pain but also stiffness and giving way. The simple conservative measures for improving these symptoms are gentle regular exercise, simple painkillers and weight reduction. These three simple measures can keep the disease at bay for some years.

Arthroscopy (keyhole surgery) has largely been phased out for osteoarthritis of the knee. Although it can improve the symptoms in the short-term, there may be some damage to the knee in the longer term by having the cartilage removed surgically.

The main surgical alternatives are realignment procedures (osteotomy) which we tend to favour in younger patients with physical jobs, and partial knee replacement. Partial knee replacement is an option if the arthritis is just affecting one side of the knee and the other side is well preserved. Mr Kucheria and I both offer this procedure and we have also done a number of bilateral simultaneous partial knee replacements. When these other options have been exhausted, total knee replacement is indicated.

Mr Rakesh Kucheria: The alternatives to knee replacements are conservative measures such as physiotherapy, analgesics and losing weight. For the younger population, partial knee replacement can be performed as well as osteotomies.

What is the recovery period like for such a procedure?

Mr Henry Bourke: We have not noticed that the recovery is that much different to having one knee replacement. We tell our patients to clear their diaries for six weeks after the procedure. The majority of this time is spent at home although in the latter few weeks you can get out of the house and do a little a bit of walking just gently. Unfortunately, you cannot drive a car in this period. We also do not let any of our patients fly in this period due to the increased risk of deep vein thrombosis. Most patients are mobile by six weeks, walking independently or just with a single stick. A return to gentle sporting activities such as golf usually is possible by three months.

Mr Rakesh Kucheria: The recovery period for bilateral knee replacement is between 8-12 weeks but most patients are in hospital for about 5-7 days.

What are the risks of this surgery? Are there any specific complications of undergoing simultaneous knee replacement?

Mr Henry Bourke: Unfortunately, all surgical procedures have some risks. The most important risks of knee replacement surgery are infection (1%), post-operative stiffness, on-going pain (10-15%) and blood clots (deep vein thrombosis). There are also some uncommon risks such as blood transfusion, nerve or vessel damage, fracture and in time the knee replacement may loosen. Having two replacements done at the same time does increase some of these risks very slightly. The most important of these is the risk of transfusion. As two knees have been operated on the risk of a transfusion does go up. In our series thus far the incidence of transfusion has been 12.5%. This is usually 1-2 units of blood given straight after the operation.

Mr Rakesh Kucheria: The risks of any operation are 1-2% of infection, Deep Vein Thrombosis, Pulmonary Embolism, anaesthetics, neurovascular damage and risks in this care are similar to having a single knee replaced. If the patient was to have both the knees replaced at different stages, the risk would be 1+1=2, whereas if they had both the knees replaced together simultaneously, then the risk is 1.2. There are no specific complications of undergoing simultaneous knee replacements. The only complication is that this is a major procedure and can occasionally result in more blood transfusions.

How should patients prepare ahead of the surgery?

Mr Henry Bourke: Knee replacement is performed for pain and stiffness in the knee. As a result, we do not expect patients to be able to do too much prior to the surgery. If at all at possible the muscles and joints should be gently exercised to keep the strength and flexibility. Research has shown that the more flexible knee prior to the operation, the better the flexibility after the operation. One or two visits to the physiotherapist prior to the surgery is useful, particularly to learn the exercises that will be used after the procedure has been performed.

Otherwise, good nutrition is important and general health optimisation as guided by the anaesthetist will mean a smoother transit through the operation. A routine appointment is arranged with the anaesthetist 2-4 weeks before the operation so that many of these health issues can be looked into and potentially optimised. If the haemoglobin is low, there are some measures that can be done to improve this as blood loss will occur as a result of having both knees replaced.

Mr Rakesh Kucheria: Before surgery the patient should prepare by asking their surgeons in detail what is involved. Sometimes we as surgeons also offer them the opportunity to speak to other patients who have undergone similar procedures, giving them the chance to talk to them and understand exactly what is involved from a patient’s perspective in having a simultaneous knee replacement procedure.

How do you find working together on the same patient at the same time?

Mr Henry Bourke: It is relatively straightforward performing knee replacement once you have the experience of doing a few hundred, however operating with somebody next door to you, requiring the same instruments as you at the same time can be a challenge. It helps that we understand each other’s surgical techniques and usually we can predict who needs which instrument when. As previously discussed, having a left-hand and right-hand combination of surgeons does help as we do get in each other’s way less. It has been interesting working together as I have certainly learnt many techniques from Mr Kucheria as it is not often as a consultant you operate with another consultant and this has been enormously beneficial. We also have the ability to help each other out as some cases can be challenging and we frequently will ask each other's opinions and help each other out during the operation to ensure the surgery is done to the best and highest standard.

Mr Rakesh Kucheria: Working together on the same patient at the same time can be difficult but fortunately, because I am right-handed and Mr Bourke is left-handed this means we do not clash whilst doing the operation.

Is there anything else you can tell us about the procedure, yourselves or the benefits that would be of interest to our readers?

Mr Henry Bourke: Both Mr Kucheria and I are still learning. We have only been doing this for a few years and after each case we gain more experience. We have been following up the cases that we have done so far and are particularly interested in the feedback from our patients. One of the drawbacks of having a staged procedure is going through the operation and the recovery and then having to do it all over again. The patients that have been through bilateral simultaneous procedures have been very relieved that once it is all over, they do not have to go back into hospital again as you only do have two knees luckily!

We have submitted our work to a number of specialist societies around the world and are hoping to present the data and our experiences to an international forum later on this year. Our philosophy is to try to improve patient experience as osteoarthritis of the knees is often a symmetrical disease, it seems logical to me to try to treat the disease in one go, which means operating on two knees and then in theory nothing further needs to be done after that.