Journal of Orthopaedics 24 (2021) 58–64

Contents lists available at ScienceDirect

Journal of Orthopaedics
journal homepage: www.elsevier.com/locate/jor

Safety and outcome of simultaneous bilateral unicompartmental knee

arthroplasty: A systematic review
Michael-Alexander Malahias a, Philip P. Manolopoulos a, b, Fabio Mancino a, c, d, *, Seong J. Jang e,
Alex Gu a, f, Dimitrios Giotis g, Matteo Denti h, Vasileios S. Nikolaou i, Peter K. Sculco a
a
The Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, 535 E 70th St, New York, NY, 10021, USA
b
School of Medicine, European University of Cyprus, Diogenis Str 6 Nicosia CY, 2404, Cyprus
c
Division of Orthopaedics and Traumatology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
d
Università Cattolica del Sacro Cuore, Rome, Italy
e
Weill Cornell Medical College, 1300 York Ave, New York, NY, 10065, USA
f
Department of Orthopedic Surgery, George Washington School of Medicine and Health Sciences, 2300 M St NW, Washington, DC, 20037, USA
g
Department of Orthopaedic Surgery, General Hospital of Grevena, Grevena, Greece
h
IRCCS Istituto Ortopedico Galeazzi, Milano, Italy
i
2nd Orthopaedic Department, National & Kapodistrian University of Athens, School of Medicine, Athens, Greece

A R T I C L E I N F O A B S T R A C T

Keywords: Purpose: Simultaneous bilateral unicompartmental knee arthroplasty (BUKA) is considered safe and effective. We
Unicompartmental knee arthroplasty performed a systematic review to assess the postoperative outcomes.
Simultaneous Methods: The US National Library of Medicine (PubMed/MEDLINE), Google Scholar, and the Cochrane Database
Bilateral
of Systematic Reviews were queried for publications.
Knee
Staged arthroplasty
Results: Ten articles were included with 765 simultaneous BUKA. Overall complication rate was 7.0%, survi-
Knee arthroplasty vorship was 97.6% at mean 17 months follow-up. No differences were reported between simultaneous and staged
BUKA.
Conclusion: Simultaneous BUKA is as safe as staged BUKA, it is associated with decreased length of stay and
operative time, although it has an increased rate of blood transfusion.

1. Introduction
Unicompartmental knee arthroplasty (UKA) is a good surgical
alternative to total knee arthroplasty (TKA) for patients suffering from
single-compartment osteoarthritis (OA).1–3 In the proper setting, UKAs
can potentially spare more bone, and are associated with less bleeding,
shorter anesthetic time, and shorter length of stay compared to TKA.4–6
Furthermore, UKAs can result in improved knee kinematics and quicker
postoperative recovery compared to TKAs in treating
single-compartment OA.7,8
In bilateral knee OA patients who are suffering from single-
compartment disease, an alternative option to staged bilateral uni-
compartmental knee arthroplasty (BUKA), which requires multiple
hospitalizations, is simultaneous BUKA. While a number of papers have
been published reporting on the safety and efficacy of simultaneous
BUKA, no systematic review of the literature has been published to date.
We therefore performed a systematic review of the contemporary liter-
ature to assess the effect of simultaneous BUKA on postoperative out-
comes. Specifically, we aimed to answer the following questions: 1)
What are the complication and revision rates of simultaneous BUKA? 2)
What is the mortality rate of simultaneous BUKA? 3) Is simultaneous
BUKA a significant risk factor for postoperative complications?
Secondarily, we aimed to examine if simultaneous BUKA is associated
with increased blood transfusion rate compared to staged BUKA and if it
results in decreased length of stay compared to the cumulative length of
stay of the staged procedure.

* Corresponding author. Division of Orthopaedics and Traumatology, Department of Aging, Neurological, Orthopaedic and Head- Neck Studies, Fondazione
Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.
E-mail address: fabio_mancino@yahoo.com (F. Mancino).

https://doi.org/10.1016/j.jor.2021.02.019
Received 11 January 2021; Accepted 14 February 2021
Available online 19 February 2021
0972-978X/© 2021 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.
M.-A. Malahias et al.
2. Methods
2.1. Search criteria
The US National Library of Medicine (PubMed/MEDLINE), Google
Scholar, and the Cochrane Database of Systematic Reviews were queried
for publications utilizing the following keywords: “simultaneous” OR
“one stage” OR “one-stage” AND “bilateral” AND “unicompartmental”
AND “knee” AND “arthroplasty” OR “replacement”. Only abstracts that
evaluated the outcome of simultaneous bilateral unicompartmental
knee arthroplasty were included in this review.
2.2. Inclusion and exclusion criteria
The inclusion criteria were: 1) studies describing human subjects of
any age and gender, 2) studies that include a population of at least ten
patients who underwent simultaneous (both procedures performed
under a single anesthesia) BUKA. The exclusion criteria were: 1) general
reviews or systematic reviews, 2) case studies, 3) editorial comments, 4)
studies stratifying patients based on perioperative management (anes-
thesia protocol, limitation of blood loss, surgical technique, prosthesis
type, etc.), 5) non-english language publications, 6) studies that only
observed perioperative and not postoperative outcomes (regardless of
the follow-up) following BUKA, 7) studies without clinical, functional,
or radiological outcomes, 8) studies with results including mixed types
of operations without stratification for sub-cohorts receiving simulta-
neous BUKA, 9) non full text articles, 10) preclinical studies, 11) studies
published after July 30th, 2019. For articles that met these criteria, the
reference lists were reviewed for additional studies not captured using
the initial search terms.
Fig. 1. Flow chart of study selection according to PRISMA guidelines for reporting systematic reviews and meta-analyses.
59
Journal of Orthopaedics 24 (2021) 58–64
2.3. Data collection
Two authors (PM, MM) independently conducted the search. All
authors compiled a list of articles after application of the inclusion and
exclusion criteria. Discrepancies between the authors were discussed
and resolved. In case of any disagreement amongst reviewers, the final
decision was made by the senior author. During initial review of the
data, the following information was collected for each study: title,
author, study design, number of patients, number of knees, gender,
American Society of Anesthesiologists (ASA) score, functional scores,
length of stay (LOS), blood transfusion rate, mortality rate, revision rate,
infection rate, rates of cardiac events, thromboembolic events and
postoperative complications.
The quality of the evidence was then classified using the US Pre-
ventive Services Task Force system for ranking level of evidence.9 The
methodological quality of each study and the different types of detected
bias were assessed independently by each reviewer with the use of
modified Coleman methodology score.10
3. Results
3.1. Search results
The literature search identified 430 abstracts related to the use of
simultaneous BUKA (Fig. 1). Among those, 29 duplicate articles were
identified and removed from the search. Following the removal of
duplicate articles, the 401 articles were subject to application of the
predetermined inclusion and exclusion criteria. Following the applica-
tion of these criteria, 15 articles were subject to a full text screening
process. Ultimately, 10 articles met the inclusion criteria.11–20 There
were seven retrospectives,11–14,16–18 and three prospective case control
study15,19,20 included in this review. The total mean modified Coleman
score was 60, ranging from 5519 to 76,15 indicating a moderate-to-good
M.-A. Malahias et al. Journal of Orthopaedics 24 (2021) 58–64

quality of evidence (Table 1).
Patient cohorts undergoing simultaneous bilateral UKA (simBUKA)
were included in all ten studies of the review.11–20 Seven studies utilized
simBUKA only in the medial compartment,11–13,15,17,19,20 one study re-
ported simBUKA performed either in the medial or the lateral
compartment,16 and two studies did not provide any information about
side.14 (Table 1).
Seven studies included a second patient cohort treated with staged
UKA (stagedBUKA).12,14–19 Two studies compared simBUKA and uni-
lateral UKA,11,20 one study compared simBUKA and unilateral TKA.13 In
addition, one study compared simBUKA with staged BUKA and simul-
taneous bilateral TKA (BTKA).14 (Table 1).
Nine of the studies included in this review mentioned the type of
unicompartmental implants used.12–20 Three studies utilized
fixed-bearing unicompartmental implants,13,15,16 while five studies
implemented mobile-bearing implants,12,17–20 and one study used both
fixed- and mobile-bearing implants.14 (Table 1).
Six out of the ten studies reported that they used a tourniquet during
surgery13,15,17–20 and two studies reported that they did not use any
tourniquet.11,16
had lower BMI compared to those who underwent stagedBUKA.12
Furthermore, six studies included the American Society of Anesthe-
siologists score (ASA score) for their preoperative evaluation.15–20 The
majority of the patients were ASA I and II in both the simBUKA and
stagedBUKA groups. When comparing simBUKA to stagedBUKA, five
studies showed comparable ASA scores.15,17–20 One study reported a
significantly higher ASA score in the simBUKA group compared to the
stagedBUKA group (p = 0.023).16
3.4. Complications and mortality
The overall complication rate for patients treated with simBUKA was
7.0% (54 out of 765 patients. The overall complication rate for patients
treated with stagedBUKA was 11.5% (53 out of 462 patients). The three
most common complications encountered in either group were cardio-
pulmonary events, wound drainage and DVT (Table 3). The overall
mortality rate for the simBUKA was 0.1% (n = 1) at short-term follow-
up. One study reported a death in the simBUKA group, which was
attributed to pulmonary embolism.18 Remaining studies reported no
deaths.12,15–17

3.2. Demographics 3.4.1. Simultaneous vs. staged BUKA

In total 1676 patients were included in this review. Amongst them,
765 patients underwent simBUKA, 462 patients underwent stage-
dBUKA, 399 patients underwent unilateral UKA, 52 patients underwent
unilateral TKA and 56 patients underwent simultaneous BTKA.11–20
There were 649 males and 806 females included in this review.11,13–18
The mean age ranged from 58 years12 to 70 years16 in the simBUKA
group. The mean follow-up for simBUKA patients was 17 months,
ranging from 115,16,18 to 50 months,19 indicating a short-term follow-up
(Table 2).
3.3. Comparison of the baseline demographic and clinical characteristics
between simBUKA and stagedBUKA
Nine studies that compared the outcomes of simBUKA with either
staged BUKA, UKA or TKA, reported comparable baseline demographic
characteristics as stated by the authors in the methods of the stud-
ies.11,13–20 One study reported a statistical difference among the two
cohorts with patients who underwent simBUKA that were younger and
Six studies compared mean complication rates of simBUKA-treated
patients and stagedBUKA-treated patients.12,15–19 Five out of these six
studies reported no significant differences amongst groups on compli-
cation rates.12,15–17,19,20 One study reported significantly increased
complication rate (p = 0.005) in the simBUKA group compared to the
stagedBUKA group.18
3.5. Cardiopulmonary complications and thromboembolic events (DVT)
Nine studies reported on cardiopulmonary complications and DVT
events.12–20 The overall rate of DVT events for simBUKA patients was
2% (15 out of 574 patients). When considering patients treated with
stagedBUKA it was 1.4% (7 out of 467 patients). The overall rate of PE
events for simBUKA patients was 1.6% (9 out of 574 patients) and for
patients treated with stagedBUKA it was 0% (Table 3).
3.5.1. Simultaneous vs. staged BUKA
Six studies compared DVT rates and PE events between simBUKA
and the stagedBUKA-treated patients.12,15–19 Five studies did not report

Table 1
Authors, Type of study, Modified Coleman Methodology Score, Operation, Joint Compartment, and Type of Implant.
Authors (year) Type of study (LoE) MCMS Operation Joint Type of Implant
Compartment

Feng et al. Retrospective Case 58 Bilateral UKA versus Staged UKA Medial Mobile-bearing unicompartmental implants
(2019) Control (III)
Biazzo et al. Retrospective Case 58 Bilateral UKA versus Staged UKA Medial or Fixed-bearing unicompartmental implants
(2018) Control (IV) Lateral
Clavé et al. Prospective Case 61 Bilateral UKA versus Unilateral UKA Medial Mobile-bearing unicompartmental implants
(2018) Control (III)
Ahn et al. Retrospective Case 58 Bilateral UKA versus Unilateral TKA Medial Fixed-bearing unicompartmental implants
(2017) Control (III)
Ma et al. (2015) Prospective Case 55 Bilateral UKA versus Staged UKA Medial Mobile-bearing unicompartmental implants
Control (III)
Romagnoli et al. Retrospective Case 59 Bilateral UKA versus Unilateral UKA Medial NR
(2015) Control (III)
Winder et al. Retrospective Case 50 Bilateral UKA, Staged UKA 2nd surgery before 3 NR Mobile-bearing unicompartmental implants or
(2014) Control (III) months, Staged UKA 2nd after 3 months, Bilateral Fixed-bearing unicompartmental implants
TKA
Chen et al. Prospective Case 76 Bilateral UKA versus Staged UKA Medial Fixed-bearing unicompartmental implants
(2013) Control (III)
Berend et al. Retrospective Case 66 Bilateral UKA versus Staged UKA Medial Mobile-bearing unicompartmental implants
(2011) Control (III)
Chan et al. Retrospective Case 60 Bilateral UKA versus Staged UKA NR Mobile-bearing unicompartmental implants
(2009) Control (IV)

LoE Level of Evidence, UKA Unicompartmental Knee Arthroplasty, TKA Total Knee Arthroplasty, NR Not Reported, MCMS Modified Coleman Methodology Score.

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Table 2
Demographics data of the studies.
Authors No. of No. of patients No. of patients No. of Patients Sex (M/F) Mean age (range) BMI (range) Mean follow-up,
Patients Bilateral UKA Unilateral UKA Staged UKA months (range)

Feng et al. 93 39 – 54 Bilateral Male 3, Bilateral 65 ± 8 Bilateral 24 ± 2.5 42 (32–133)

(2019) Female 33 Staged 64 ± 6 Staged 24 ± 2.5
Staged Male 5,
Female 49
Biazzo et al. 102 51 – 51 Bilateral Male 13, Bilateral 70 Bilateral 29 1
(2018) Female 38 (68–73) (28–31)
Staged Male 19, Staged 69 Staged 29 (27–30)
Female 32 (65–72)
Clavé et al. 150 50 100 – Bilateral Male 35, Bilateral 64.4 Bilateral 28.8 Bilateral 44
(2018) Female 15 (50–86.7) (22.1–38.9) (24–84)
Unilateral Male 66, Unilateral 68.1 Unilateral 29.8 Unilateral 61
Female 34 (56–87) (21.9–47.6) (24–96)
Ahn et al. 104 52 52 unilateral – Bilateral Male 48, Bilateral 65.1 Bilateral 28.1 6
(2017) (TKA) Female 4 (49–87) (22–35)
Unilateral (TKA) Unilateral (TKA) Unilateral (TKA)
Male 48, Female 4 65.6 (51–83) 28.3 (21.8–37.9)
Ma et al. 81 36 – 45 Bilateral Male 15, Bilateral 65.6 ± Bilateral 25.0 ± 1.9 50 (12–84)
(2015) Female 21 6.1 Staged 25.5 ± 2.0
Staged Male 18, Staged 65.3 ± 5.6 (p = 0.25)
Female 27 (p = (p = 0.8)
0.88)
Romagnoli 490 191 299 – Bilateral Male 72, Bilateral 67.5 Bilateral 30 6
et al. (2015) Female 119 (66–69) (29–31)
Unilateral Male 120 Unilateral 68.2 Unilateral 29
Female 179 (67–69) (28–29)
Winder et al. 72 28 – 44 Bilateral Males 16, Bilateral 64 ± 10 NR 3
(2014) Females 12
Chen et al. 171 124 – 47 Bilateral Male 33, Bilateral 62.9 Bilateral 27.3 1
(2013) Female 91 (45–86.1) (19.1–42.3)
Staged Male 11, Staged 61.6 Unilateral 26.8
Female 36 (51.0–82.3) (19.5–33.7)
Berend et al. 176 35 – 141 NR Bilateral 58 Bilateral 31 Bilateral 19.4
(2011) (55–62) (29–32) Staged 13.9
Staged 63 Staged 33 (32–35)
(61–64)
Chan et al. 239 159 – 80 Bilateral Male 92, Bilateral 66 NR 1
(2009) Female 67 (42–85)
Staged Male 35, Staged 66
Female 45 (48–86)

TKA Total Knee Arthroplasty, NR Not Reported, BMI Body Mass Index, BUKA Bilateral Unicompartmental Knee Arthroplasty, BTKA Bilateral Total Knee Arthroplasty.

Table 3
Complications reported per study.
Authors Complications Cardiopulmonary Complications Wound drainage DVT PE

Feng et al. (2019) Bilateral 4 Bilateral 1 Bilateral 3 Bilateral 0 Bilateral 0

Staged 5 (n.s.) Staged 2 Staged 2 Staged 0 Staged 0
Biazzo et al. (2018) Bilateral 4 Bilateral 1 Bilateral 0 Bilateral 0 Bilateral 0
Staged 2 Staged 0 Staged 0 Staged 0 Staged 0
Clavé et al. (2018) Bilateral 5 Bilateral 0 Bilateral 0 Bilateral 2 Bilateral 1
Ahn et al. (2017) Bilateral 1 Bilateral 0 Bilateral 1 Bilateral 0 Bilateral 0
Unilateral (TKA) 7 (p = 0.028) Unilateral (TKA) 0 Unilateral (TKA) 3 Unilateral (TKA) 2 Unilateral (TKA) 3
Ma et al. (2015) Bilateral 3 Bilateral 0 Bilateral 1 Bilateral 1 Bilateral 0
Staged 5 Staged 0 Staged 1 Staged 2 Staged 0
Romagnoli et al. (2015) Bilateral 9 NR NR NR NR
Unilateral 19 (n.s.)
Winder et al. (2014) Bilateral 2 Bilateral 0 Bilateral 1 Bilateral 1 0
Chen et al. (2013) Bilateral 5 Bilateral 2 Bilateral 0 Bilateral 1 Bilateral 2
Staged 5 (n.s) Staged 0 (n.s.) Staged 3 (p = 0.02) Staged 2 (n.s.) Staged 0 (n.s.)
Berend et al. (2011) Bilateral 4 Bilateral 2 Bilateral 2 Bilateral 0 Bilateral 0
Staged 31 Staged 10 Staged 7 Staged 0 Staged 0
Chan et al. (2009) Bilateral 17 Bilateral 3 Bilateral 4 Bilateral 10 Bilateral 6
Staged 5 Staged 0 (p < 0.005) Staged 2 Staged 3 Staged 0

DVT Deep Venous thrombosis, PE Pulmonary Embolism, NR Not Reported, TKA Total Knee Arthroplasty, n.s. Not Significant.

any significant differences amongst groups,12,15–17,19 whereas one study
reported a significantly higher DVT rate (p = 0.036) in the stagedBUKA
group compared to the simBUKA group.18
3.6. Surgical site infections
Nine studies included in this review reported on superficial wound
infection rate as well as periprosthetic joint infection (PJI) rate.12–20 The
overall rate of superficial wound infections for simBUKA patients was

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2.1% (12 out of 574 patients). When considering the patients treated
with staged BUKA the overall rate of superficial wound infections was
3.2% (15 out 467 patients). One study reported significant difference
between simultaneous BUKA (0 cases out of 124) and staged BUKA (3
cases out of 47) at 30-days follow-up (p = 0.02)15 The PJI rate for
simBUKA patients was 0.2%, while for the stagedBUKA patients it was
0% (Table 3).
3.7. Revision rate
Nine studies included in this analysis reported on revision
rates.11–17,19,20 The overall revision rate for the simBUKA group was
2.4% (16 out of 679). The overall revision rate for the stagedBUKA
group was 2.9% (11 out of 382). (Table 4).
3.7.1. Simultaneous vs. staged BUKA
Six studies compared the revision rates between simBUKA and the
stagedBUKA.12,14–17,19 However, none of the studies reported statisti-
cally different results among the two groups.
3.8. Clinical and functional outcome variables
Six studies included postoperative functional
variables.12,13,15,17,19,20 Four studies used the Knee Society Score
(KSS),12,13,15,17 and all of them reported a significant improvement
compared to preoperative values. When comparing the KSS score in
patients who underwent simBUKA with patients who underwent staged
BUKA, none of the studies reported a significant difference among the
two protocols. One study12 reported significant difference at mean
follow-up of 19 months regarding the “functional” section of the KSS
with a score of 87.9 in the simBUKA group and 72.9 in the staged BUKA
group (p < 0.001). When the KSS was compared between simBUKA and
UKA it was noticed a significant difference at final follow-up (89.2 vs
83.4; p < 0.001).13 The Oxford Knee Score (OKS) was used in three
studies15,19,20 and all of them compared simBUKA with staged BUKA.
Improved OKS score was reported at final follow-up compared to the
preoperative value, however, none of the studies achieved statistically
significance when comparing the two surgical protocols. The Range of
Motion (ROM) was used in two studies.13,15 One study [13] compared
the outcomes of simBUKA with UKA and reported significant improve-
ment of 136.9◦ and 121.3◦ , respectively (p < 0.001). One study15
compared the ROM after simBUKA and staged BUKA reporting
improvement respect to the preoperative values, but no significant dif-
ference was noticed between the two surgical protocols. Finally, one
study used the Lower Extremity Score (LEAS) and reported a signifi-
cantly higher postoperative value in the simBUKA group compared to
outcome the stagedBUKA group (11.3 vs 10.2; p < 0.001).12 (Table 5).

Table 4
3.9. Perioperative blood transfusion
Revision rates, Length of Stay, Operation Time, and Blood Transfusion per
Study.
Six studies of this analysis reported on perioperative blood trans-
Authors Revision Length of Total Blood
Hospital Stay Operation Transfusion
fusion rates in patients treated with simBUKA.11,13,15–17,20 The overall
(days) Time (min) (rate) transfusion rate (number of patients transfused) in the simBUKA was
8.1% (41 out of 507). (Table 4).
Feng et al. 0 Bilateral 4.2 ± Bilateral Bilateral 1
(2019) 0.7 120.2 ± 9.7 (2.6%)
Staged 7.5 ± Staged 141.6 Staged 0 (n.s.)
3.10. Simultaneous vs. staged BUKA
1.5 (p < 0.01) ± 8.7 (p <
0.01)
Biazzo et al. 0 NR Bilateral 93 Bilateral 4 (8%) Three studies compared the transfusion rates of the simBUKA group
(2018) (88–98) Staged 0 (p =
Staged 102 0.041)
(p = 0.023)
Table 5
Clavé et al. 2 – – Bilateral 3 (6%) Clinical reported outcomes.
(2018) Unilateral 5 Authors Bilateral Staged Unilateral
(5%) (p = 0.6)
Ahn et al. 0 Bilateral 8.4 NR Bilateral 9 Feng et al. (2019) KSS 88 KSS87 (n.s.) –
(2017) (4–21) (17.3%) KSSf 82 KSSf 80 (n.s.)
Unilateral-TKA Unilateral-TKA Biazzo et al. (2018) NR NR –
12.7 (9–44) [p 44 (84.6%) [p Clavé et al. (2018) OKS 44.5 OKS 42.2 (p = –
< 0.001] < 0.001] 0.61)
Ma et al. Bilateral 1 – Bilateral 113 – Ahn et al. (2017) KSS 89.2 – KSS 83.4 (p < 0.001)
(2015) Staged 2 ± 8.7 KSSf 84.2 KSSf 76.0 (p <
Staged 133 ± ROM 136.9 0.001)
9.9 (p < ROM 121.3 (p <
0.005) 0.001)
Romagnoli Bilateral 13 Bilateral 4 Bilateral 61.3 Bilateral 24 Ma et al. (2015) OKS 18.3 OKS 18.0 (p = –
et al. Unilateral (3.8–4.2) Unilateral (10.9%) 0.52)
(2015) 9 (n.s.) Unilateral 4.2 29.7 Unilateral 13 Romagnoli et al. NR – NR
(4.0–4.3) (3.8%) [p < (2015)
0.001] Winder et al. (2014) NR NR NR
Winder et al. 0 Bilateral 3.9 ± Bilateral 150 NR Chen et al. (2013) KSS 89 KSS 88 –
(2014) 1.2 (114–206) KSSf 80 KSSf 80 (n.s.)
Chen et al. 0 Bilateral 5 Bilateral 130 Bilateral 1 ROM ROM 0–126◦ (n.s.)
(2013) (3–20) Staged Staged 153 (0.8%) 0–128◦ OKS 18 (n.s.)
8 (4–23) [p < [p < 0.001] Staged 0 (n.s) OKS 18
0.001] Berend et al. (2011) KSSc 91.4 KSSc 90.1 (n.s) –
Berend et al. Bilateral 0 Bilateral 1.7 Bilateral 109 NR KSSp 44.6 KSSp 46.8 (n.s)
(2011) Staged 0 Staged 1.3 (p Staged 6 [p KSSf 87.9 KSSf 72.9 (p <
< 0.001) < 0.001] LEAS 11.3 0.001)
Chan et al. NR Bilateral 5 Bilateral 113’ – LEAS 10.2 (p <
(2009) (2–19) (45–180) 0.001)
Staged 6 Staged 129’ Chan et al. (2009) NR NR NR
(2–15) (80–190) [p
KSS Knee Society Score, KSSf Knee Society Function Score, KSSc Knee Society
< 0.001]
Clinical Score, KSSp Knee Society Pain Score, LEAS Lower Extremity Activity
NR Not Reported, TKA Total Knee Arthroplasty. Score, OKS Oxford Knee Score, ROM Range of Motion, NR Not Reported.

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and the stagedBUKA group.15–17 One study reported significant
increased transfusion rate in the simBUKA group (8%) compared to the
stagedBUKA group (0%) (p = 0.041),16 while the remaining two studies
did not report any significant difference amongst groups.15,17
3.11. Length of stay
3.11.1. Simultaneous vs. staged BUKA
Seven studies reported on inpatient length of stay (LOS).11–15,17,18
Four studies compared the LOS of the simBUKA group and the stage-
dBUKA group, and all them reported a significant difference among the
groups.12,15,17,18 When comparing the cumulative LOS of the patients in
the simBUKA group and the stagedBUKA group, three studies found that
mean LOS was significantly longer in the stagedBUKA group (sim-
BUKA:1.7 days vs. stagedBUKA:2.5 days; p < 0.001,12 simBUKA:5 days
vs. stagedBUKA:8 days; p < 0.001,15 and simBUKA:4.2 days vs. stage-
dBUKA:7.5 days; p < 0.01).17 (Table 4).
3.12. Operative time
Eight studies reported on mean operative (OR) time of simBUKA and
compared them to either stagedBUKA,12,14–19 UKA,11 and simultaneous
BTKA.14 Cumulatively, the mean OR time of the simBUKA patient cohort
varied per study between 93 and 150 min, while the mean OR time of
the stagedBUKA cohort ranged per study from 101.6 min to 152.5 min.
Six studies reported that the cumulative mean OR time of stagedBUKA
was significantly higher12,15–19 than that of simBUKA (Table 4).
4. Discussion
The key finding of our analysis was that simultaneous BUKA resulted
in satisfactory clinical outcomes, with minimal postoperative mortality
(0.1%), acceptable medical complication rates (7.0%) and good early to
short-term implant survivorship (97.6%). Moreover, all clinical/func-
tional subjective scores which were reported in the studies included in
this review were significantly improved compared to the preoperative
values and compared to unilateral UKA. However, no significant dif-
ference was reported among the studies included when compared to
staged BUKA. In addition, simBUKA was significantly associated with
reduced LOS and mean OR time, potentially affecting the postoperative
complication rate and the hospital costs. Despite that, further high-
quality studies with longer follow-up comparing the mid-to-longterm
outcomes of simBUKA and stagedBUKA are necessary to confirm these
preliminary outcomes. However, based on these findings, it seems that
simBUKA can be considered a safe and effective option in selected pa-
tients with bilateral single-compartment OA.
It has been routinely recommended by physicians that patients with
serious comorbidities should be advised against a simultaneous bilateral
knee arthroplasty procedure. Surprisingly, in most studies comparing
simBUKA with stagedBUKA patients with statistically comparable
baseline clinical and demographic characteristics, it was demonstrated
that there were no differences amongst groups in the overall complica-
tion rates as well as mortality rate, cardiopulmonary complication rates,
and rate of thromboembolic events.12,15–20 A recent systematic analysis
comparing simultaneous bilateral TKA and staged bilateral TKA re-
ported also comparable overall complication, DVT, cardiac complica-
tion, and mortality rates amongst groups.21–24 Recent advances in all
aspects of perioperative care and patient optimization might explain
these comparable peri- and post-operative morbidity rates between
simultaneous and staged knee arthroplasty procedures.
This does not mean that all patients are ideal candidates for simul-
taneous BUKA. In our analysis, the simBUKA-treated cohort mainly
comprised of patients suffering from mild (ASA grade 2) diseases. We
still feel that patients who are at increased risk for cardiac events or they
are suffering from a severe systemic disease should be recommended to
have a staged BUKA.
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Journal of Orthopaedics 24 (2021) 58–64
Interestingly, while there was no statistical difference reported in the
individual studies comparing PE rates between simultaneous and staged
BUKA cohorts, there was a trend towards higher risk for PE in the
simultaneous BUKA cohort (1.6% versus 0% in the staged group) when
comparing overall PE rates. Taking into consideration the increased
invasiveness of simultaneous BUKA compared to unilateral BUKA, we
feel that patients undergoing simultaneous BUKA should be post-
operatively protected with stronger anticoagulation than those treated
with a unilateral BUKA.
In regard to surgical site infection rate and all cause revision rate,
neither were increased in the simBUKA group.12,15–18 Similarly, a recent
analysis21,25 showed that almost all studies comparing simultaneous
bilateral TKA and staged bilateral TKA reported no significant differ-
ences in infection rates amongst groups. Overall, we suggest that
simultaneous BUKA does not appear to increase the rate of revision or
devastating complications such as surgical site infections.
For postoperative functional scores, no study showed inferior out-
comes with simBUKA compared to stagedBUKA.11–20 Therefore, it might
be supported that simultaneous BUKA is correlated with at least
equivalent functional outcomes compared to staged BUKA, but further
studies are required to clarify whether the former leads to better func-
tional outcomes compared to the latter procedure.
As expected, the rate of postoperative blood transfusion was
increased in the simultaneous group (8.1%) compared to the staged
group (0%) throughout the studies of this review. Similarly, a recent
systematic analysis comparing simultaneous bilateral TKA and staged
bilateral TKA reported increased blood transfusion rates in the simul-
taneous cohort.21 As such, we suggest that candidates for BUKA who
have been diagnosed with preoperative anemia either avoid simBUKA or
are counseled that they are at increased risk of perioperative blood
transfusion if they choose to undergo the simultaneous BUKA procedure.
Finally, it was shown that patients treated with simultaneous BUKA
had significantly decreased cumulative LOS compared to the cumulative
LOS of stagedBUKA-treated patients12,15,17 which might correlate with
decreased costs. In addition, all studies reporting cumulative OR time
found it significantly decreased in the simBUKA group compared to the
stagedBUKA group.12,15–18 Likewise, a systematic review comparing
simultaneous bilateral TKA and staged bilateral TKA reported signifi-
cantly decreased cumulative LOS in the simultaneous cohort.21
The overall quality of the studies included in this review was not
high; however, most studies were rated as either moderate or good ac-
cording to the mean modified Coleman methodology score. The vast
majority of the studies were retrospective, and there was no randomized
controlled trial level I studies amongst them. Therefore, all studies were
susceptible for various types of potential biases. Further studies of
higher quality are required to lead to more definitive conclusions in
relation to the safety of simultaneous BUKA in comparison with staged
BUKA.
The studies included in this analysis were not without limitations.
The number of BUKA-treated patients was rather low, while time in-
terval between the first and the second surgery in patients treated with
staged BUKA varied widely amongst studies. Follow-up was another
variable that varied amongst studies, and no studies reported mid-to
long-term follow-up. Nonetheless, the rationale for these studies was
to compare simultaneous and staged BUKA, and simultaneous and UKA
as for the early postoperative morbidity and mortality rates.
5. Conclusion
There was moderate-to-good quality evidence to show that simul-
taneous BUKA might be as safe as the staged procedure in selected pa-
tients who are not suffering from severe comorbidities. Furthermore,
simultaneous BUKA is associated with decreased cumulative LOS and
OR time compared to staged BUKA. In contrast, simultaneous BUKA
correlates with increased perioperative blood transfusion rate when
compared to staged BUKA and to UKA. Since perioperative tranexamic
M.-A. Malahias et al.
acid has been proven effective in decreasing perioperative blood loss, we
feel that it should be routinely used in simultaneous BUKA-treated pa-
tients. Furthermore, simultaneous BUKA trends towards increased PE
rates compared to staged BUKA and to UKA. Taking this finding into
consideration, we suggest that stronger anticoagulation might be needed
in simultaneous BUKA-treated patients. Finally, while simultaneous
BUKA is associated with satisfactory short-term clinical outcomes,
further research of higher quality is required to generate more evidence-
based conclusions regarding the mid- and long-term outcome of simul-
taneous BUKA compared to the standard staged procedure.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Availability of data and material
Not applicable.
Code availability
Not applicable.
Contributions
MAM, PPM, FM, MD, PKS: designing the work. MAM, PPM, FM, SJJ,
AG: acquisition and analysis of the data and drafting the work. DG, MD,
VSN, PKS: revised it critically for important intellectual content. PKS:
final approval of the version to be published.
Declaration of competing interest
All authors declare that they have no conflict of interest. No benefits
in any form have been received or will be received from a commercial
party related directly or indirectly to the subject of this article. Dr.
Sculco reports grants from Intellijoint, personal fees from Lima Corpo-
rate, grants from DePuy, personal fees from EOS Imaging, outside the
submitted work.
Acknowledgements
This study was conducted and performed in the Stavros Niarchos
Foundation Complex Joint Reconstruction Center, Hospital for Special
Surgery, 535 E 70th St, New York NY 10021.
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