Posted: Aug 26 2022 #(C102078) 2022 Global Medial Pivot Symposium

Painful Right Knee and Symptomatic Left TKA in 72F

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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

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

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

30%

(238/769)

Yes - additional radiographic views (i.e full limb lengths, aXR)

22%

(170/769)

Yes - CT scan of the knee (CT)

23%

(184/769)

Yes - MRI of the knee (MRI)

(24/769)

Yes - aXR + CT

12%

(93/769)

Yes - aXR + MRI

(7/769)

Yes - aXR + CT + MRI

(23/769)

Outside my area of expertise - best if I don't vote

(30/769)

How would you manage the patient at this time?

Nonoperative - Primary + Revision Knee

(40/749)

Operative - Primary Knee Alone

17%

(133/749)

Operative - Revision Knee Alone

30%

(229/749)

Operative - Primary + Revision Knee

43%

(325/749)

Outside my area of expertise - best if I don't vote

(22/749)

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%

(98/695)

No - I do not feel it is important to match the implant design

59%

(413/695)

Yes - I would try to match the implant design on the Primary knee to the Revision knee

20%

(142/695)

Outside my area of expertise - best if I don't vote

(42/695)

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

(34/683)

Simultaneous

(39/683)

Staged - Revision TKA First (wait 1-4 weeks btw surgeries)

(62/683)

Staged - Revision TKA First (wait > 4 weeks btw surgeries)

51%

(355/683)

Staged - Primary Knee First (wait 1-4 weeks btw surgeries)

(29/683)

Staged - Primary Knee First (wait > 4 weeks btw surgeries)

20%

(142/683)

Outside my area of expertise - best if I don't vote

(22/683)

If you choose TKA of the Primary knee, what would you do with the PCL?

I would NOT choose TKA of the Primary knee

(18/670)

Retain the PCL

35%

(236/670)

Partial release of the PCL

(33/670)

Sacrifice the PCL

52%

(354/670)

Outside my area of expertise - best if I don't vote

(29/670)

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

(15/640)

No Technology - Traditional Guides only

62%

(397/640)

Navigation (NAV) Alone

(47/640)

Robotic assisted Navigation (ROBOT) Alone

(54/640)

Patient Specific Instrumentation (PSI)

(37/640)

Sensors (Sensor)

(5/640)

NAV + Sensors

(16/640)

ROBOT + Sensors

(20/640)

PSI + Sensors

(4/640)

Other Combination

(1/640)

Outside my area of expertise - best if I don't vote

(44/640)

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

(8/618)

Fixed - standard bearing with POST

57%

(357/618)

Fixed - standard bearing without Post

(49/618)

Fixed - Medial Stabilized bearing (medial pivot, medial congruence)

17%

(109/618)

Mobile - with POST

(48/618)

Mobile - without POST

(9/618)

Outside my area of expertise - best if I don't vote

(38/618)

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%

(87/593)

Cement - all components

69%

(413/593)

Press-fit - all components

(28/593)

Hybrid (cemented femur + press-fit tibia)

(8/593)

Hybrid (press-fit femur + cemented tibia)

(31/593)

Outside my area of expertise - best if I don't vote

(26/593)

If you choose Operative management of the Revision Knee, what surgery would you perform?

I would not Operative management of the Revision Knee

(14/595)

Liner Exchange Alone

36%

(219/595)

Revision of Femoral Component Alone (Femur)

10%

(64/595)

Revision of Tibial Component Alone (Tibia)

(21/595)

Revision TKA of Tibia + Femur

42%

(255/595)

Outside my area of expertise - best if I don't vote

(22/595)

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%

(109/578)

Add Fixed 2 mm to existing liner thickness

(36/578)

Add Fixed 4 mm to existing liner thickness

(22/578)

Based on Intraoperative Feel - same feel as primary

57%

(333/578)

Based on Intraoperative Feel - make tight and overstuff

(52/578)

Outside my area of expertise - best if I don't vote

(26/578)

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

How would you manage the patient at this time?

Operative - Primary + Revision Knee

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

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)

If you choose TKA of the Primary knee, what would you do with the PCL?

Sacrifice the PCL

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

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)

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

If you choose Operative management of the Revision Knee, what surgery would you perform?

Liner Exchange Alone

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

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