Posted: May 4 2022 #(C102051) ICJR 9th Annual Revision Hip & Knee Course

TKA Extensor Mechanism Disruption in 61F

HPI

A 61-year-old female presents for evaluation of left knee pain. She had a primary left TKA done in December 2010 and presented 10 years later with acute onset knee pain after a fall in March 2020. She was initially seen at an outside hospital which recommended conservative management, but the patient reports she is debilitated and can not walk.

PMH

PMH: hyperlipidemia, hypertension, obesity (BMI 39), restless leg syndrome, stress incontinence, and GERD. Social: Retired CNA, She does not use tobacco products.

Focused physical examination of the left knee shows 1+ knee effusion with diffuse tenderness to palpation. Range of motion is 0-120º with a 45º extensor lag. She is unable to perform a straight leg raise and has global instability in the coronal and sagittal planes. Her gait is antalgic and favors the contralateral side. She is neurovascularly intact Labs: -ESR: 5, CRP: 7.6 (elevated) -Aspiration: 163 WBC, 41% PMNs, Cx negative

Poll

1 of 10

1. In addition to the plain film radiographs, would you obtain any further imaging to guide your treatment?

No - current radiographs are sufficient

46%

351/756

Yes - additional x-rays (i.e full limb length alignment XRs)

24/756

Yes - CT of the knee (CT)

16%

127/756

Yes - Metal-subtraction MRI of the knee (MRI)

15%

114/756

Yes - bone scan

10/756

Yes - XR + CT

15/756

Yes - XR + MRI

20/756

Yes - XR + Bone scan

6/756

Yes - CT + MRI

33/756

Yes - CT + Bone scan

13/756

Yes - MRI + Bone scan

13/756

Yes - 3 or more of the above

9/756

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

21/756

2. How would you manage the patient?

Nonoperative

24/732

Operative

94%

695/732

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

13/732

3. If you choose Nonoperative management, what would you do?

I would not choose Nonoperative management

84%

560/666

Observation

2/666

Physical therapy

23/666

Knee immobilizer

25/666

Drop-lock brace

42/666

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

14/666

4. If you choose Operative management, what procedure would you do?

I would not choose Operative management

3/737

Knee arthrodesis

3/737

Extensor mechanism reconstruction only

43%

317/737

Modular polyethylene exchange with extensor mechanism reconstruction

32%

240/737

Revision TKA with extensor mechanism reconstruction

20%

153/737

Above-knee amputation

0/737

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

21/737

5. If you choose Extensor mechanism reconstruction, what technique would you use?

I would not choose Extensor mechanism reconstruction

6/698

Direct repair

31%

223/698

Mesh implant reconstruction

21%

148/698

Allograft reconstruction

34%

241/698

Extended gastrocnemius flap

18/698

Other

12/698

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

50/698

6. If you choose Revision TKA with extensor mechanism reconstruction, what components would you revise?

I would not choose Revision TKA with extensor mechanism reconstruction

49%

324/652

Patella only

15%

104/652

Femur only

14/652

Tibia only

15/652

Femur + tibia

44/652

All components

17%

116/652

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

35/652

7. If you choose Revision TKA with extensor mechanism reconstruction, what prosthesis design would you choose?

I would not choose Revision TKA with extensor mechanism reconstruction

54%

336/616

Posterior stabilized (PS) construct

14%

92/616

Varus/valgus constraint construct

11%

69/616

Rotating hinge construct

13%

83/616

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

36/616

8. If you choose Revision TKA with extensor mechanism reconstruction and obtained the construct shown below, what would be your initial postoperative immobilization protocol?

I would not choose Operative management

44/553

No immobilization

26/553

Brace for 1-2 weeks

15/553

Brace for 3-4 weeks

12%

68/553

Brace for 5-6 weeks

33%

184/553

Brace for > 6 weeks

20%

116/553

Cast for 3 weeks

3/553

Cast for 4-6 weeks

31/553

Cast for 7-9 weeks

8/553

Cast for 10-12 weeks

23/553

Cast for > 12 weeks

7/553

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

28/553

9. If you choose Revision TKA with extensor mechanism reconstruction and obtained the construct below, when would you initiate knee flexion?

I would not choose Operative management

9/524

Immediately

47/524

1-2 weeks

49/524

3-6 weeks

45%

236/524

7-10 weeks

22%

120/524

11-12 weeks

18/524

> 12 weeks

21/524

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

24/524

10. If you choose Revision TKA with extensor mechanism reconstruction and obtained the construct below, how would you manage initial weight-bearing?

I would not choose Operative management

5/511

Non-weight bearing (NWB)

25/511

Touch-down weight bearing (TDWB)

20%

107/511

Partial weight bearing (PWB, < 25-50%)

18%

97/511

Weight bearing as tolerated (WBAT)

50%

256/511

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

21/511

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