COMPLEX TOTAL KNEE ARTHROPLASTY IN OLD FRACTURE

1. COMPLEX PRIMARY TOTAL KNEE
ARTHROPLASTY
SUSHANT S. SONARKAR

2. • 50 YRS OLD MALE
• RFN (AR) VIKRAM SINGH 2201586-K
• 45 ASSAM RIFLES
• DOI- 14 APR 2008
• MODE- FALL FROM HEIGHT (HILL) WHILE ON LEAVE
• DIAGNOSIS- COMMINUTED BICONDYLAR # TIBIA WITH # FIBULAR HEAD
AND SEVERE SEC OSTEOARTHRITIS LEFT KNEE (OPTD)

3. MANAGEMENT
OPEN REDUCTION INTERNAL FIXATION WITH JESS FIXATOR FOR
PROXIMAL TIBIA AT MH DEHRADUN ON 27 APR 2008.
ORIF WITH PROXIMAL TIBIAL LOCKING PLATE
BICEPS FEMORIS TENODESIS AND LCL REPAIR IN 2012 AT 151BH
IMPLANT REMOVAL & PRIMARY COMPLEX TOTAL KNEE
ARTHROPLASTY LEFT AT 5AFH ON 13 MARCH 2020

4. PRE OPERATIVE GAIT OF PATIENT

5. WRITE UP
• 50 Yrs old serving JCO case of bicondylar fracture tibia & lateral condyle
femur with severe secondary OA (Lt) knee. Individual presented to this
hospital with C/o pain & instability of knee & difficulty in walking &
prolonged standing. Patient suffered injury to this (Lt) knee in Apr 2008 for
which he was initially managed with ORIF with JESS fixation application for
fracture tibia and cannulated cancellous screw fixation for fracture lateral
condyle.
• For valgus thrust gait of individual, he was managed with biceps femoris
tendon LCL repair in 2012 at 151 BH Guwahati.
• Patient was reviewed by Orthopaedic team headed by Wg Cdr Pankaj Rai
at 5AFH and planned for complex primary total knee arthroplasty bearing
metaphysis sleeve and stem extender.
• This was the challenging case as the patient had severe bone loss in the
metaphysis of tibia (AOR I type III) with MCL and LCL grade II laxity.
• He was planned for complex primary knee arthroplasty with metaphyseal
sleeve and stem extender. In review of constrains and owing the
difficulties in availability of implants.

6. INVESTIGATIONS
LAB IVESTIGATION
• COMPLETE BLOOD COUNTS, VIRAL MARKERS
• PTTK,PTINR,ESR ,CRP, RA FACTOR, ANA
RADIOLOGICAL INVESTIGATIONS
• XRAYS CHEST PA , BOTH KNEE’S AP & LATERAL
RADIOGRAPHS
• WEIGHT BEARING X-RAYS OF LEFT KNEE
• 3D CT RECONSTRUCTION OF LEFT KNEE
• MRI OF LEFT KNEE

7. PRE-OPERATIVE X-RAYS
OLD COMMINUTED BICONDYLAR FRACTURE
METAPHYSEAL BONE LOSS
HYPOPLASTIC LATERAL FEMORALCONDYLE
SEVERE SECONDARY OA CHANGES

8. CT SCAN PRE OPERATIVE IMAGES
GROSS COMMINUTION WITH
METAPHYSEAL FIBROUS NON- UNION

9. PRE OPERATIVE MRI IMAGES

10. BED SIDE KNEE EXAMINATION FOR INSTABILITY

11. CHALLENGES
• PREVIOUS SURGICAL SCARS
• SEVERE BONE LOSS
• IMPLANT AVAILABILITY CONSTRAINS
• CHOICE BETWEEN SLEEVE & AUGMENTS
• TRAINED MANPOWER
• NON AVAILABILITY OF SUPER-SPECIALITIES AT
HOSPITAL

12. PRE OPERATIVE SKIN MARKINGS

13. MEDIAL PARA-PATELLAR APPROACH

14. REMOVAL OF STUCK CANNULATED SCREW

15. HYPOPLASTIC FEMUR DISECTION AND
PREPATION OF FEMORAL CANAL

16. BONY DEFECTS AND PREPARATION OF
TIBIAL CANAL

17. PREPARATION OF DISTAL FEMUR

18. TRIAL IMPLANTS

19. MBT TRAY WITH METAPHYSEAL SLEEVE

20. FEMORAL COMPONENT

21. FINAL IMPLANTATION

22. POST OPERATIVE X-RAYS

23. POST OP GAIT OF PATIENT ON 6TH WEEK