Letter to the Editor on “Bilateral Total Hip Arthroplasty: 1-Stage or 2-Stage? A Meta-Analysis”

Guillermo A. Bonilla, Meilyn A. Muskus, Camilo Gutierrez, Adolfo M. Llinas

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To the Editor:
Recently, the journal featured a study by Shao Hongyi et al [1], addressing the controversy that stands regarding the benefits and risks of performing a simultaneous bilateral vs a staged total hip arthroplasty (THA). This is a relevant question and remains under debate because it is a critical part of the decision-making process for patient treatment and management. As the authors point out, there is evidence that a significant proportion of patients presenting with hip arthritis could have bilateral involvement [1]. Therefore, as surgeons, we must ask ourselves whether a simultaneous surgery is just as safe and beneficial as staged THA. We acknowledge the authors' work, as it is a valuable contribution for this discussion; however, we would like to point out certain concerns regarding the methodology of this study.

This study encompasses 2 major potential sources of error. Firstly, only one of the articles included for analysis was randomized [2]; therefore, the vast majority of the patients in these studies were allocated to treatment according to the surgeons' judgment, which includes a potential selection bias as the natural medical trend is to choose simultaneous surgery in younger, healthier patients. In fact, several of the cited studies showed that patients who underwent simultaneous bilateral surgery were younger than those undergoing staged procedures 3, 4, 5, 6. For instance, the article by Parvizi et al [4] shows a difference of 12 years between groups. This situation could have misled authors to conclude that there is no relevant difference between staged vs simultaneous surgery.

Secondly, as the authors acknowledge in their discussion, they were not able to stratify staged surgery depending on the time lapse between procedures. However, they did not give this limitation the relevance it deserves. Available evidence has shown that staged surgery during the same hospitalization is associated with more complications than simultaneous bilateral surgery [7]. Therefore, it is not correct to group all patients who underwent staged surgery without taking into account the interval between surgeries. Again, this limitation could be responsible for the results and conclusion of this study.

In summary, the results of this study show no relevant difference between treatments, which might be a product of its methodological limitations. Moreover, because the time lapse between staged surgeries could significantly determine the rate of complications, the classical approach to this question, which compares simultaneous vs staged procedures should be replaced by a more appropriate question that focuses on the ideal time between procedures in a staged approach. Such an analysis would allow the medical community to perform an accurate comparison between simultaneous and staged bilateral THA.
Original languageEnglish (US)
Pages (from-to)1404-1405
Number of pages2
JournalJournal of Arthroplasty
Issue number4
StatePublished - Apr 1 2017

All Science Journal Classification (ASJC) codes

  • Orthopedics and Sports Medicine


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