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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%
249/794
Yes - additional radiographic views (i.e full limb lengths, aXR)
22%
178/794
Yes - CT scan of the knee (CT)
23%
189/794
Yes - MRI of the knee (MRI)
3%
24/794
Yes - aXR + CT
11%
94/794
Yes - aXR + MRI
0%
7/794
Yes - aXR + CT + MRI
2%
23/794
Outside my area of expertise - best if I don't vote
3%
30/794
2. How would you manage the patient at this time?
Nonoperative - Primary + Revision Knee
5%
41/773
Operative - Primary Knee Alone
17%
135/773
Operative - Revision Knee Alone
31%
241/773
Operative - Primary + Revision Knee
43%
334/773
Outside my area of expertise - best if I don't vote
2%
22/773
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%
102/710
No - I do not feel it is important to match the implant design
59%
423/710
Yes - I would try to match the implant design on the Primary knee to the Revision knee
20%
143/710
Outside my area of expertise - best if I don't vote
5%
42/710
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%
34/697
Simultaneous
5%
40/697
Staged - Revision TKA First (wait 1-4 weeks btw surgeries)
8%
62/697
Staged - Revision TKA First (wait > 4 weeks btw surgeries)
52%
367/697
Staged - Primary Knee First (wait 1-4 weeks btw surgeries)
4%
30/697
Staged - Primary Knee First (wait > 4 weeks btw surgeries)
20%
142/697
Outside my area of expertise - best if I don't vote
3%
22/697
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%
18/687
Retain the PCL
34%
240/687
Partial release of the PCL
4%
33/687
Sacrifice the PCL
53%
367/687
Outside my area of expertise - best if I don't vote
4%
29/687
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%
15/654
No Technology - Traditional Guides only
62%
407/654
Navigation (NAV) Alone
7%
47/654
Robotic assisted Navigation (ROBOT) Alone
8%
56/654
Patient Specific Instrumentation (PSI)
5%
37/654
Sensors (Sensor)
0%
5/654
NAV + Sensors
2%
17/654
ROBOT + Sensors
3%
21/654
PSI + Sensors
0%
4/654
Other Combination
0%
1/654
Outside my area of expertise - best if I don't vote
6%
44/654
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%
8/633
Fixed - standard bearing with POST
58%
369/633
Fixed - standard bearing without Post
7%
50/633
Fixed - Medial Stabilized bearing (medial pivot, medial congruence)
17%
110/633
Mobile - with POST
7%
49/633
Mobile - without POST
1%
9/633
Outside my area of expertise - best if I don't vote
6%
38/633
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%
90/608
Cement - all components
69%
424/608
Press-fit - all components
4%
28/608
Hybrid (cemented femur + press-fit tibia)
1%
8/608
Hybrid (press-fit femur + cemented tibia)
5%
32/608
Outside my area of expertise - best if I don't vote
4%
26/608
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%
14/609
Liner Exchange Alone
36%
223/609
Revision of Femoral Component Alone (Femur)
10%
65/609
Revision of Tibial Component Alone (Tibia)
3%
22/609
Revision TKA of Tibia + Femur
43%
263/609
Outside my area of expertise - best if I don't vote
3%
22/609
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%
111/594
Add Fixed 2 mm to existing liner thickness
6%
36/594
Add Fixed 4 mm to existing liner thickness
3%
23/594
Based on Intraoperative Feel - same feel as primary
58%
345/594
Based on Intraoperative Feel - make tight and overstuff
8%
53/594
Outside my area of expertise - best if I don't vote
4%
26/594
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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