Painful Right Knee and Symptomatic Left TKA in 72F

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PRESENTATION
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POLLS
6,404
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OUTCOMES
5
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VIDEOS
7
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EVIDENCE
35
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Comments
30
CASE DESCRIPTION
AGE 72 / Female
CC 1. Left Knee Instability and Pain s/p TKA. 2. Right Knee Arthritis and Pain.
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.
Pre-procedure IMAGES:
https://upload.orthobullets.com/cases/102078/145bd87f-b5a9-4a25-b63d-075af6b346a0_left_knee_preop_(1).jpg https://upload.orthobullets.com/cases/102078/8ce0cb0f-a279-40b4-8def-9fb57a57bc28_lateral_left_knee_preop.jpg https://upload.orthobullets.com/cases/102078/a7572e19-3100-4755-9d17-ad8682ad1a91_preop_lateral_right_copy.jpg
POLLS
OB Community
1) In addition to AP/Lat plain film radiographs of the REVISION knee, would you obtain further imaging to guide management?
Other
2) How would you manage the patient at this time?
Other
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?
Other
4) If you choose Operative Management of the Primary Knee and Revision Knee, how would you sequence the surgeries
Other
5) If you choose TKA of the Primary knee, what would you do with the PCL?
Other
6) If you choose TKA of the Primary Knee AND Sacrificed the PCL, what technology would you use for implant positioning/balancing?
Other
7) If you choose TKA of the Primary Knee AND Sacrificed the PCL, what type of bearing design would you use?
Other
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?
Other
9) If you choose Operative management of the Revision Knee, what surgery would you perform?
Other
10) If you choose Liner Exchange Alone of the Revision Knee, how would you determine you Liner Thickness
Other
CASE OUTCOMES
PROCEDURE 1: Revision Left Knee with Liner Revision (Thicker and semi-constrained)
POLL#
SURGEON CHOICE
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
DOP: 10/1/2021
Post-procedure P1
1 day Post-procedure P1
https://upload.orthobullets.com/cases/102078/95f7ffe8-0a46-48a8-8cea-620c3c4dbcd2_postop_left_knee_(1).jpg https://upload.orthobullets.com/cases/102078/a74af858-f333-4c7f-b252-426c1076b411_pacu_left.jpg https://upload.orthobullets.com/cases/102078/bb08a3d0-322f-40a9-a3ac-cbb69ae16898_left_post_op.jpg
PROCEDURE 2: Right TKA with a medial pivot design
DOP: 5/1/2022
Post-procedure P2
1 day Post-procedure P2
https://upload.orthobullets.com/cases/102078/14e81606-13db-470b-8670-8734d6070b3e_postop_right_knee_ap.jpg https://upload.orthobullets.com/cases/102078/postop_right_knee_lateral_(1) r.jpg
VIDEOS & PODCASTS (7)
EVIDENCE (35)
EXPERT COMMENTS