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TKA Instability
Posted: Aug 26 2022 #(C102078)
A

Painful Right Knee and Symptomatic Left TKA in 72F

HPI

A 72-year-old female had a total knee arthroplasty (TKA) done at an outside institution 2 years prior to presentation. She now presents with continued knee pain and instability of the left knee since her primary TKA. She notes the inability to trust the knee with weight-bearing activities. She complains of clicking and clunking of the knee with movement which makes noises and feels unstable. A complete knee revision has been recommended by another surgeon. In addition, she has had progressive right knee pain that has failed nonoperative treatment. She is considering proceeding with a TKA but is weary due to her poor outcome on the left knee.

PMH

Notable for chronic back pain, chronic fatigue syndrome, seasonal allergies, sleep apnea, GERD

PE

LEFT KNEE (Revision Knee) A focused exam of LLE shows a well-healed anterior-medial skin incision with a mild knee effusion. Limb alignment is neutral. She has medial joint line TTP. ROM is slight hyperextension to 130 degrees of flexion. Moderate laxity to varus/valgus stress at 30 degrees. Audible and palpable endpoints during varus/valgus ligamentous testing. Posterior drawer intact, with an audible and palpable endpoint. Neurovascular status is intact distally. RIGHT KNEE (Primary Knee) Right knee with typical varus deformity and medial joint line and PF pain to palpation. An exam of the right knee shows expected ligamentous laxity for a varus knee. ROM 0-120 degrees.

Poll
1 of 10
1. In addition to AP/Lat plain film radiographs of the REVISION knee, would you obtain further imaging to guide management?
No - additional imaging would not change my management
31%
249/797
Yes - additional radiographic views (i.e full limb lengths, aXR)
22%
179/797
Yes - CT scan of the knee (CT)
23%
190/797
Yes - MRI of the knee (MRI)
3%
24/797
Yes - aXR + CT
11%
94/797
Yes - aXR + MRI
0%
7/797
Yes - aXR + CT + MRI
2%
23/797
Outside my area of expertise - best if I don't vote
3%
31/797
2. How would you manage the patient at this time?
Nonoperative - Primary + Revision Knee
5%
41/775
Operative - Primary Knee Alone
17%
135/775
Operative - Revision Knee Alone
31%
242/775
Operative - Primary + Revision Knee
43%
334/775
Outside my area of expertise - best if I don't vote
2%
23/775
3. If you choose TKA of the Primary Knee, and Nonoperative or Liner Exchange only on the Revision Knee, would you try to match the implant design on the Primary Knee to the Revision Knee?
I would NOT choose TKA of the Primary Knee, and Nonoperative or Liner Exchange only on the Revision Knee
14%
103/712
No - I do not feel it is important to match the implant design
59%
423/712
Yes - I would try to match the implant design on the Primary knee to the Revision knee
20%
143/712
Outside my area of expertise - best if I don't vote
6%
43/712
4. If you choose Operative Management of the Primary Knee and Revision Knee, how would you sequence the surgeries
I would Not Choose Operative Management of the - Primary Knee and Revision Knee
4%
34/699
Simultaneous
5%
40/699
Staged - Revision TKA First (wait 1-4 weeks btw surgeries)
8%
62/699
Staged - Revision TKA First (wait > 4 weeks btw surgeries)
52%
367/699
Staged - Primary Knee First (wait 1-4 weeks btw surgeries)
4%
30/699
Staged - Primary Knee First (wait > 4 weeks btw surgeries)
20%
143/699
Outside my area of expertise - best if I don't vote
3%
23/699
5. If you choose TKA of the Primary knee, what would you do with the PCL?
I would NOT choose TKA of the Primary knee
2%
18/689
Retain the PCL
34%
241/689
Partial release of the PCL
4%
33/689
Sacrifice the PCL
53%
367/689
Outside my area of expertise - best if I don't vote
4%
30/689
6. If you choose TKA of the Primary Knee AND Sacrificed the PCL, what technology would you use for implant positioning/balancing?
I would NOT choose TKA of the Primary Knee and used a Medial Stabilized Bearing
2%
15/656
No Technology - Traditional Guides only
62%
407/656
Navigation (NAV) Alone
7%
47/656
Robotic assisted Navigation (ROBOT) Alone
8%
57/656
Patient Specific Instrumentation (PSI)
5%
37/656
Sensors (Sensor)
0%
5/656
NAV + Sensors
2%
17/656
ROBOT + Sensors
3%
21/656
PSI + Sensors
0%
4/656
Other Combination
0%
1/656
Outside my area of expertise - best if I don't vote
6%
45/656
7. If you choose TKA of the Primary Knee AND Sacrificed the PCL, what type of bearing design would you use?
I would not choose TKA
1%
8/635
Fixed - standard bearing with POST
58%
370/635
Fixed - standard bearing without Post
7%
50/635
Fixed - Medial Stabilized bearing (medial pivot, medial congruence)
17%
110/635
Mobile - with POST
7%
49/635
Mobile - without POST
1%
9/635
Outside my area of expertise - best if I don't vote
6%
39/635
8. If you choose TKA of the Primary Knee AND Sacrificed the PCL AND used a Medial Stabilized bearing, what component fixation strategy would you utilize?
I would not choose TKA of the Primary Knee with a Medial Stabilized bearing
14%
90/610
Cement - all components
69%
425/610
Press-fit - all components
4%
28/610
Hybrid (cemented femur + press-fit tibia)
1%
8/610
Hybrid (press-fit femur + cemented tibia)
5%
32/610
Outside my area of expertise - best if I don't vote
4%
27/610
9. If you choose Operative management of the Revision Knee, what surgery would you perform?
I would not Operative management of the Revision Knee
2%
14/611
Liner Exchange Alone
36%
223/611
Revision of Femoral Component Alone (Femur)
10%
65/611
Revision of Tibial Component Alone (Tibia)
3%
22/611
Revision TKA of Tibia + Femur
43%
264/611
Outside my area of expertise - best if I don't vote
3%
23/611
10. If you choose Liner Exchange Alone of the Revision Knee, how would you determine you Liner Thickness
I would Not choose Liner Exchange Alone of the Revision Knee
18%
111/596
Add Fixed 2 mm to existing liner thickness
6%
36/596
Add Fixed 4 mm to existing liner thickness
3%
23/596
Based on Intraoperative Feel - same feel as primary
58%
346/596
Based on Intraoperative Feel - make tight and overstuff
8%
53/596
Outside my area of expertise - best if I don't vote
4%
27/596
PROCEDURE #1 DOP: 10/1/2021

Revision Left Knee with Liner Revision (Thicker and semi-constrained)

POLL#
Surgeon's Choices
1
In addition to AP/Lat plain film radiographs of the REVISION knee, would you obtain further imaging to guide management?
No - additional imaging would not change my management
2
How would you manage the patient at this time?
Operative - Primary + Revision Knee
3
If you choose TKA of the Primary Knee, and Nonoperative or Liner Exchange only on the Revision Knee, would you try to match the implant design on the Primary Knee to the Revision Knee?
No - I do not feel it is important to match the implant design
4
If you choose Operative Management of the Primary Knee and Revision Knee, how would you sequence the surgeries
Staged - Revision TKA First (wait > 4 weeks btw surgeries)
5
If you choose TKA of the Primary knee, what would you do with the PCL?
Sacrifice the PCL
6
If you choose TKA of the Primary Knee AND Sacrificed the PCL, what technology would you use for implant positioning/balancing?
No Technology - Traditional Guides only
7
If you choose TKA of the Primary Knee AND Sacrificed the PCL, what type of bearing design would you use?
Fixed - Medial Stabilized bearing (medial pivot, medial congruence)
8
If you choose TKA of the Primary Knee AND Sacrificed the PCL AND used a Medial Stabilized bearing, what component fixation strategy would you utilize?
Cement - all components
9
If you choose Operative management of the Revision Knee, what surgery would you perform?
Liner Exchange Alone
10
If you choose Liner Exchange Alone of the Revision Knee, how would you determine you Liner Thickness
Based on Intraoperative Feel - same feel as primary
PROCEDURE #2 DOP: 5/1/2022

Right TKA with a medial pivot design

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OUTCOMES
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