Posted: Aug 26 2022 #(C102078)

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 1

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

30%

250/807

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

22%

181/807

Yes - CT scan of the knee (CT)

24%

194/807

Yes - MRI of the knee (MRI)

25/807

Yes - aXR + CT

11%

95/807

Yes - aXR + MRI

7/807

Yes - aXR + CT + MRI

24/807

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

31/807

1 day after

Post-procedure P1

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

1 day after

Post-procedure P2

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