J Knee Surg
DOI: 10.1055/s-0043-1775872
Original Article

Postoperative Opioid Consumption is Greater after Simultaneous versus Staged Bilateral Total Knee Arthroplasty

Sara J. Sustich
1   Department of Orthopedic Surgery, University of Oklahoma, Oklahoma City, Oklahoma
2   Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
Ryan Hui
2   Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
Eric R. Siegel
3   Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
C. Lowry Barnes
2   Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
Simon C. Mears
2   Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
› Author Affiliations


Increased exposure to opioids around total knee arthroplasty (TKA) can lead to a risk of long-term dependence. We hypothesized that performing simultaneous bilateral total knee arthroplasty (simBTKA) over staged surgery (staged bilateral total knee arthroplasty [stgBTKA]) may decrease the total amount of opiates used. We retrospectively reviewed 29 patients who underwent simBTKAs performed between February 2015 and November 2020 and identified 23 that did not use opioids ≤90 days prior to surgery. These were frequency matched for gender and body mass index to 50 stgBTKAs completed within 6 months who also were opioid-free ≤90 days prior to their first surgery. Using our state's prescription database, we reviewed postsurgery opioid refills and morphine milligram equivalents (MMEs) for the two groups and compared their initial MME prescription at discharge and their total MME consumption 6 months postoperatively. Total MME consumption for the stgBTKA group included all prescriptions following the first and 6 months after the second surgery, whereas for the simBTKA group, total consumption included the 6 months after their two same-day surgeries. The simBTKA group had more MMEs prescribed initially (median = 375) than did the stgBTKA group after second surgery (median = 300; p < 0.007), larger postoperative-refill MMEs in the first 30 days (median = 300) than stgBTKA (median = 0; p = 0.221) and increased total MME consumption 6 months after surgery (median = 675) compared with stgBTKA after second surgery (median = 450; p = 0.077). However, both groups had similar monthly consumptions rates, with medians I MMEs/month of 112 for simBTKA versus 96 for stgBTKA (p = 0.585). Our results suggest there is no significant difference in opioid consumption between simBTKA and stgBTKA. In fact, we found that simBTKA patients received larger opioid amounts in the immediate postoperative period as well as slightly larger amounts at 30 days.

Publication History

Received: 06 September 2023

Accepted: 11 September 2023

Article published online:
18 October 2023

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  • References

  • 1 Kelly MA. Addressing the opioid epidemic with multimodal pain management. Am J Orthop 2016; 45 (07) S6-S8
  • 2 Hernandez NM, Parry JA, Taunton MJ. Patients at risk: large opioid prescriptions after total knee arthroplasty. J Arthroplasty 2017; 32 (08) 2395-2398
  • 3 Seymour RB, Ring D, Higgins T, Hsu JR. Leading the way to solutions to the opioid epidemic: AOA critical issues. J Bone Joint Surg Am 2017; 99 (21) e113
  • 4 Gerbershagen HJ, Pogatzki-Zahn E, Aduckathil S. et al. Procedure-specific risk factor analysis for the development of severe postoperative pain. Anesthesiology 2014; 120 (05) 1237-1245
  • 5 Sun EC, Darnall BD, Baker LC, Mackey S. Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period. JAMA Intern Med 2016; 176 (09) 1286-1293
  • 6 Politzer CS, Kildow BJ, Goltz DE, Green CL, Bolognesi MP, Seyler TM. Trends in opioid utilization before and after total knee arthroplasty. J Arthroplasty 2018; 33 (7S): S147 , 153.e1
  • 7 Zhang Y, Jordan JM. Epidemiology of osteoarthritis. Clin Geriatr Med 2010; 26 (03) 355-369
  • 8 Memtsoudis SG, Mantilla CB, Parvizi J, Stundner O, Mazumdar M. Have bilateral total knee arthroplasties become safer? A population-based trend analysis. Clin Orthop Relat Res 2013; 471 (01) 17-25
  • 9 Hart A, Antoniou J, Brin YS, Huk OL, Zukor DJ, Bergeron SG. Simultaneous bilateral versus unilateral total knee arthroplasty: a comparison of 30-day readmission rates and major complications. J Arthroplasty 2016; 31 (01) 31-35
  • 10 Lindberg-Larsen M, Pitter FT, Husted H, Kehlet H, Jørgensen CC. Lundbeck Foundation Centre for Fast-Track Hip and Knee Replacement Collaborative Group. Simultaneous vs staged bilateral total knee arthroplasty: a propensity-matched case-control study from nine fast-track centres. Arch Orthop Trauma Surg 2019; 139 (05) 709-716
  • 11 Fu D, Li G, Chen K, Zeng H, Zhang X, Cai Z. Comparison of clinical outcome between simultaneous-bilateral and staged-bilateral total knee arthroplasty: a systematic review of retrospective studies. J Arthroplasty 2013; 28 (07) 1141-1147
  • 12 Adili A, Bhandari M, Petruccelli D, De Beer J. Sequential bilateral total knee arthroplasty under 1 anesthetic in patients > or = 75 years old: complications and functional outcomes. J Arthroplasty 2001; 16 (03) 271-278
  • 13 Jankiewicz JJ, Sculco TP, Ranawat CS, Behr C, Tarrentino S. One-stage versus 2-stage bilateral total knee arthroplasty. Clin Orthop Relat Res 1994; (309) 94-101
  • 14 Lynch NM, Trousdale RT, Ilstrup DM. Complications after concomitant bilateral total knee arthroplasty in elderly patients. Mayo Clin Proc 1997; 72 (09) 799-805
  • 15 Alghadir AH, Iqbal ZA, Anwer S, Anwar D. Comparison of simultaneous bilateral versus unilateral total knee replacement on pain levels and functional recovery. BMC Musculoskelet Disord 2020; 21 (01) 246
  • 16 March LM, Cross M, Tribe KL. et al; Arthritis C.O.S.T. Study Project Group. Two knees or not two knees? Patient costs and outcomes following bilateral and unilateral total knee joint replacement surgery for OA. Osteoarthritis Cartilage 2004; 12 (05) 400-408
  • 17 Zeni Jr JA, Snyder-Mackler L. Clinical outcomes after simultaneous bilateral total knee arthroplasty: comparison to unilateral total knee arthroplasty and healthy controls. J Arthroplasty 2010; 25 (04) 541-546
  • 18 Mears SC, Shnaekel A, Wilkinson J, Chen C, Barnes CL. A departmental policy can reduce opioid prescribing after orthopedic surgery. J Opioid Manag 2019; 16 (01) 41-47
  • 19 King SA. CDC guideline for prescribing opioids for chronic pain. Psychiatr Times 2016;33(06):
  • 20 Jones CM, Mack KA, Paulozzi LJ. Pharmaceutical overdose deaths, United States, 2010. JAMA 2013; 309 (07) 657-659
  • 21 Kim SC, Choudhry N, Franklin JM. et al. Patterns and predictors of persistent opioid use following hip or knee arthroplasty. Osteoarthritis Cartilage 2017; 25 (09) 1399-1406
  • 22 Abdelaal MS, Calem D, Sherman MB, Sharkey PF. Short interval staged bilateral total knee arthroplasty: safety compared to simultaneous and later staged bilateral total knee arthroplasty. J Arthroplasty 2021; 36 (12) 3901-3908
  • 23 Tsay EL, Grace TR, Vail T, Ward D. Bilateral simultaneous vs staged total knee arthroplasty: minimal difference in perioperative risks. J Arthroplasty 2019; 34 (12) 2944-2949.e1
  • 24 Leonard L, Williamson DM, Ivory JP, Jennison C. An evaluation of the safety and efficacy of simultaneous bilateral total knee arthroplasty. J Arthroplasty 2003; 18 (08) 972-978
  • 25 Yakkanti RR, Ovadia JE, Reddy GB, Browne JA, D'Apuzzo MR. Inhospital complications and costs of simultaneous bilateral total knee arthroplasty: the case for selection and potential cost savings. J Arthroplasty 2022; 37 (07) 1273-1277
  • 26 Makaram NS, Roberts SB, Macpherson GJ. Simultaneous bilateral total knee arthroplasty is associated with shorter length of stay but increased mortality compared with staged bilateral total knee arthroplasty: a systematic review and meta-analysis. J Arthroplasty 2021; 36 (06) 2227-2238
  • 27 Phillips JLH, Rondon AJ, Gorica Z, Fillingham YA, Austin MS, Courtney PM. No difference in total episode-of-care cost between staged and simultaneous bilateral total joint arthroplasty. J Arthroplasty 2018; 33 (12) 3607-3611
  • 28 Rajamäki TJ, Puolakka PA, Hietaharju A, Moilanen T, Jämsen E. Predictors of the use of analgesic drugs 1 year after joint replacement: a single-center analysis of 13,000 hip and knee replacements. Arthritis Res Ther 2020; 22 (01) 89
  • 29 Triantafyllopoulos GK, Fiasconaro M, Wilson LA. et al. Bilateral total knee arthroplasty and in-hospital opioid dispension: a population-based study. J Arthroplasty 2020; 35 (12) 3581-3586
  • 30 Ritter MA, Harty LD. Debate: simultaneous bilateral knee replacements: the outcomes justify its use. Clin Orthop Relat Res 2004; (428) 84-86
  • 31 Luscombe JC, Theivendran K, Abudu A, Carter SR. The relative safety of one-stage bilateral total knee arthroplasty. Int Orthop 2009; 33 (01) 101-104
  • 32 Stambough JB, Hui R, Siegel ER, Edwards PK, Barnes CL, Mears SC. Narcotic refills and patient satisfaction with pain control after total joint arthroplasty. J Arthroplasty 2021; 36 (02) 454-461