A total of 64 patients with clinical and radiographic signs of bilateral knee arthritis were evaluated based on multiple associated variables including complications, community ambulatory levels, and timing of staged knee replacement. A pain/dysfunction categorization based on initial presentation was established so that temporal progression of symptoms could be documented. Two surgical groups were represented: simultaneous bilateral total knee replacement and staged bilateral knee replacement. The findings in this study indicate that a patient with equally painful knees should undergo simultaneous bilateral total knee arthroplasty. If a patient has bilateral disease but only one knee is symptomatic, surgery should be performed on only the painful knee. If both knees are symptomatic, but one knee is much more painful than the other, the choice of treatment must be individualized based on the patient's medical health, symptoms, type of fixation used, and Charnley activity classification.