Elizabeth Hofheinz, M.P.H., M.Ed.
Noting the existing data indicating disparities in unilateral total knee arthroplasty (UTKA) surgery, a team from Hospital for Special Surgery (HSS) in Manhattan set out to see if racial variations also exist for same-day bilateral total knee arthroplasty (BTKA). The study, “Bilateral vs Unilateral Total Knee Arthroplasty: Racial Variation in Utilization and In-Hospital Major Complication Rates,” appears in the November 2, 2020 edition of the Journal of Arthroplasty.
“In our retrospective analysis, we found the utilization rate of bilateral knee replacement was much lower in African American patients compared to white patients,” said Bella Mehta, MBBS, a rheumatologist at HSS. “On the other hand, although African Americans having unilateral knee replacement have been shown to have higher in-hospital complication rates compared to white patients, this pattern was not consistent for bilateral knee replacement during the time period we studied.” 
Using data from the National Inpatient Sample – Healthcare Cost and Utilization Project database from 2007 to 2016, the HSS researchers examined trends in utilization and major in-hospital complication rates of unilateral versus bilateral knee replacement nationwide in patients age 50+.
The authors noted that an estimated 276,194 bilateral TKA and 5,528,429 unilateral TKA were performed in the U.S., with the proportion of bilateral TKA amongst all TKAs declining. They found that African-Americans were significantly less likely to undergo bilateral TKA compared to Whites throughout the period analyzed. “In-hospital complication rates for UTKA were higher in AAs compared to Whites throughout the study period. However, for bilateral TKA, the in-hospital complication rates varied between Whites and AAs throughout the study period.”
Dr. Mehta hypothesized that there could be a more rigorous patient selection process when considering candidates for same-day bilateral knee replacement. “Regarding the lower number of African Americans having the bilateral procedure, she said physicians may be offering it less often to African American patients or they may be choosing not to have the procedure.”
“Since the complication rate for bilateral knee replacement is not higher for African American patients, health providers should work to provide access to all appropriate patients,” Dr. Mehta said. She noted that future studies could take a closer look at the patient selection process or assess the role of an individual’s health insurance plan in utilization of the bilateral procedure.”
“As we seek to achieve health equity for our patients, we must understand the challenges they face in accessing care, as well as variance in their outcomes,” said Michael Parks, M.D., an orthopedic surgeon at HSS and study author. “Our ultimate goal is to provide the same quality of care to everyone.”
Bella Mehta told OSN, “I think the most interesting finding is that the utilization of bilateral knee replacements is lower in African-Americans in spite of accounting for comorbidities and hospital factors. Also, that complication rates for bilateral knee replacement are not necessarily higher in African-Americans.”
Asked why surgeons might be offering bilateral TKA less often to African American patients OR why might they be choosing not to have the procedure, Dr. Mehta stated to OSN, “I think that is a very good question, we do not know what is driving this decision. Is it that the surgeons will think that the patient is at high risk and do not want to offer this procedure, or is it that the patients do not accept this procedure for bilateral? We need to take a deeper dive at this and figure out what these factors are and how to attain equity.”