Bilateral Total Knee Replacement Research Articles

Focal Increased Tc-99m MDP Uptake in the Nutrient Foramen of the Femoral Diaphysis on Bone SPECT/CT.

We present images of an 83-year-old female with a history of osteoporosis and bilateral total knee replacement arthroplasty, referred for bone scintigraphy and single-photon emission computed tomography (SPECT)/computed tomography (CT), owing to left knee pain. No trauma to, or intense exercise of, the knee was reported. The bone scan and SPECT/CT revealed a focally increased Tc-99m methylene diphosphonate (MDP) uptake in the medial cortex of the left femoral diaphysis with matched linear radiolucency on CT images. This was misinterpreted as atypical femoral stress fracture; however, focal stress reaction injury to the nutrient foramen was confirmed on contrast-enhanced magnetic resonance imaging.

Predictive factors for length of hospital stay following primary total knee replacement in a total joint replacement centre in Hong Kong.

The demand for total knee replacement in Hong Kong places tremendous economic burden on our health care system. Shortening hospital stay reduces the associated cost. The aim of this study was to identify perioperative predictors of length of hospital stay following primary total knee replacement performed at a high-volume centre in Hong Kong. We retrospectively reviewed all primary total knee replacements performed at Yan Chai Hospital Total Joint Replacement Centre from October 2011 to October 2015. Perioperative factors that might influence length of stay were recorded. A total of 1622 patients were identified. The mean length of hospital stay was 6.8 days. Predictors of prolonged hospital stay following primary total knee replacement were advanced age; American Society of Anesthesiologists physical status class 3; bilateral total knee replacement; in-patient complications; and the need for blood transfusion, postoperative intensive care unit admission, and urinary catheterisation. Evaluating factors that can predict length of hospital stay is the starting point to improve our current practice in joint replacement surgery. Prediction of high-risk patients who will require a longer hospitalisation enables proactive discharge planning.

Spontaneous Heparin-Induced Thrombocytopenia Following Orthopaedic Surgery: Case Report and Review of the Literature

Background: Spontaneous heparin induced thrombocytopenia (HIT) is a medical phenomenon whereby patients develop clinical and laboratory features of HIT without prior exposure to heparin. Aim: We present a patient who underwent bilateral total knee replacement complicated by spontaneous HIT causing bilateral adrenal hemorrhage and deep vein thrombosis. Our patient had no prior history of heparin exposure. We reconcile our patient’s presentation with other case reports of spontaneous HIT in patients who had orthopaedic surgery. Conclusion: Spontaneous HIT is a rare but potentially devastating complication associated with total knee arthroplasty.

Successful Bilateral Total Knee Replacements with ongoing Allergic Contact Dermatitis to Benzoyl Peroxide

Successful Bilateral Total Knee Replacements with ongoing Allergic Contact Dermatitis to Benzoyl Peroxide

Treatment of Spinal Infection Following Bilateral Total Knee Replacement Postoperative Infection

Treatment of Spinal Infection Following Bilateral Total Knee Replacement Postoperative Infection

Bedside Pulmonary Function Testing and Incentive Spirometry in Bilateral Total Knee Replacement Surgery Patients-A Pilot Study

Bedside Pulmonary Function Testing and Incentive Spirometry in Bilateral Total Knee Replacement Surgery Patients-A Pilot Study

Adductor canal block for post-operative analgesia after simultaneous bilateral total knee replacement: A randomised controlled trial to study the effect of addition of dexmedetomidine to ropivacaine.

Background and Aims:Knee replacement surgery causes tremendous post-operative pain and adductor canal block (ACB) is used for post-operative analgesia. This is a randomised, controlled, three-arm parallel group study using different doses of dexmedetomidine added to ropiavcaine for ACB.Methods:A total of 150 patients aged 18–75 years, scheduled for simultaneous bilateral total knee replacement, received ultrasound-guided ACB. They were randomised into three groups -Group A received ACB with plain ropivacaine; Groups B and C received ACB with ropivacaine and addition of dexmedetomidine 0.25 μg/kg and 0.50 μg/kg, respectively, on each side of ACB. The primary outcome was the duration of analgesia. Total opioid consumption, success of early ambulation, and level of patient satisfaction were also assessed.Results:The patient characteristics and block success rates were comparable in all groups. Group C patients had longer duration of analgesia (Group C 18.4 h ± 7.4; Group B 14.6 ± 7.1; Group A 10.8 ± 7; P < 0.001); lesser tramadol consumption (Group C 43.8 mg ± 53.2; Group B 76.4 ± 49.6; Group A 93.9 mg ± 58.3; P < 0.001) and lesser pain on movement (P < 0.001). The patients in Group B and C walked more steps than in Group A (P < 0.002). The level of patient satisfaction was highest in Group C (P < 0.001).Conclusions:The addition of dexmedetomidine to ropivacaine resulted in longer duration of analgesia after adductor canal block for simultaneous bilateral total knee replacement surgery.

Computer-Assisted TKR Vs Conventional TKR: Post-Operative Ankle Radiographic Finding and Ankle Clinical Assessment

Background: Few previous studies showed that the conventional total knee replacement (TKR) has affection to the same side of talar tilt (TT). We expected to prevent this problem by the computer-assisted (CAS) TKR. Objective: The purpose of this study was to compare between pre and post-operative talar tilt and ankle clinical assessment on the CAS TKR and the Conventional TKR in 28 patients (56 knees) whom underwent bilateral TKR. Material and Method: 28 patients, 56 knees, whom underwent both CAS total knee replacement (TKR) and conventional total knee replacement (TKR), in both knees, with the combination of Gap Balance and Measurement Resection techniques performed by one surgeon (P. Sriphirom) at Rajavithi Hospital, Bangkok. The post-operative has a 12 months follow-up for ankle radiographic finding by tibiotalar angle (TTA), tibial articular surface angle (TAS), and talar tilt (TT) = (TAS-TTA) and for ankle clinical assessment by foot functional index (FFI) from pre-operation and post-operation from both groups. The study also compares the CAS TKR with the Conventional TKR for pre-operation and post-operation. Results: 56 knees, 28 patients, mean age = 67.79 years whom underwent bilateral TKR by the Conventional group and the CAS group had pre-operative TT (TT = TAS - TTA). The Conventional group = 1.5 (-5, 8), the CAS group = .5 (-5, 8), P value = .65. On post-operative TT the Conventional group = .0 (-5, 3), the CAS group = 1.0 (-3, 8), the P value = .4. The comparison of pre-operative TT and post-operative TT in the Conventional group, the P value = .01. On pre-operative TT and post-operative TT in the CAS group, the P value = .65. TT was significantly different in the Conventional group but was not significantly different in the CAS group. The ankle clinical assessment by foot functional index (FFI), which is (1) Pain, (2) Difficulty living, and (3) Daily life activity limitation. The pre-operative FFI in the Conventional group = 1.85 (.81, 6.88) and pre-operative FFI in the CAS group = 1.91 (.24, 66.5), the P value = .57. The post-operative FFI in the Conventional group = 1.68 (0.24, 7.0) and post-operative FFI in the CAS group = 1.65 (.24, 6.76), the P value = .04, which showed a significantly different between the post-operative FFI from both groups. In the Conventional group the post-operative FFI was not significantly different from pre-operative FFI, the P value = .2 but for the CAS group the post-operative FFI was not significantly different from pre-operative FFI, the P value = .04. Conclusion: This study has shown that the conventional TKR effected to post-operative talar tilt but the CAS TKR has less effect and was not significantly different to ankle joint. Finally, the study needs to be conducted on more patients and to be observed on a longer term follow-up.

Comparison of ropivacaine with and without fentanyl vs bupivacaine with fentanyl for postoperative epidural analgesia in bilateral total knee replacement surgery

Study ObjectivesPain after total knee replacement (TKR) interferes with early rehabilitation. Although the use of epidural bupivacaine in post-TKR patients is associated with effective analgesia, the associated motor blockade effect delays functional recovery. We compared analgesic efficacy and side effects of postoperative patient-controlled epidural analgesia (PCEA) with plain ropivacaine 0.1% with/without fentanyl 2.5 μg/mL vs plain bupivacaine 0.0625% with fentanyl 2.5 μg/mL in patients undergoing bilateral TKR. DesignProspective, double-blind, randomized study. SettingsOperation room, postoperative recovery room, and intensive joint replacement unit. PatientsNinety American Society of Anesthesiologists I to II post-TKR patients who were randomly allocated to receive postoperative PCEA with plain ropivacaine 0.1% (group 1), ropivacaine 0.1% with fentanyl 2.5 μg/mL (group 2), and plain bupivacaine 0.0625% with fentanyl 2.5 μg/mL (group 3). InterventionPostoperatively, the PCEA settings were standardized for a basal flow of 4 mL/h, demand dose of 6 mL, and lock-out interval of 20 minutes. “Rescue” analgesia included epidural boluses (6 mL) of respective study drug over and above PCEA administration. MeasurementsPostoperative pain profile, total PCEA drug used, heart rate, and noninvasive blood pressure, side effects, and patient satisfaction were recorded. Main resultsDemographic parameters, duration of surgery, and hemodynamic variables (heart rate and noninvasive blood pressure) were comparable for the 3 study groups. Pain scores and rescue drug requirements were greater in “ropivacaine-only” group. Motor blockade was greatest in “bupivacaine-fentanyl” group. Postoperatively, despite the presence of minor side effects (nausea, itching) in the “ropivacaine-fentanyl” and bupivacaine-fentanyl groups, the patients belonging to these groups were more satisfied. ConclusionAfter bilateral TKR, ropivacaine-fentanyl combination administered through a PCEA system resulted in “superior” analgesic efficacy, that is, pain relief without motor blockade, than “ropivacaine alone” (lesser pain relief) and bupivacaine-fentanyl (pain relief but with attendant motor blockade). Overall, the addition of fentanyl to epidural local anesthetic returned favorable postoperative analgesia profile and patient satisfaction with minor incidence of opioid-related side effects.

Bilateral total knee replacement in severe knee osteoarthritis with large bone defect using autologous bone graft augmentation

40 years old malay gentleman with underlying gout presenting with severe pain in both knees for 10 years, analgesic dependant and wheelchair ambulation. Examination of right knee shows fixed flexion at 10 degrees, range of movement 10-100 degree flexion, lateral collateral laxity and varus deformity. Left knee had fixed flexion at 10 degrees, range of movement 5-100 degree and varus deformity. Blood investigation showed uric acid. X-ray of bilateral knee showed severe tricompartmental arthritis with large medial tibial defect. The patient has undergone bilateral knee replacement in 5 months interval started with left knee. Surgical technique is the same for both knees, intraoperative shows a large posteromedial bone defect. We used 5mm metal augmentation on the right knee, but due to limited financial resources, we have to use the bone graft from the osteotomized bone for the augmentation on the left side. The bone augmentation was fixed with cancellous screw. The patient was referred to physiotherapy for range of motion exercises. 1 year post operatively patient able to ambulate without aid. Pain score improved. The patient does not require analgesia. Functional and knee score is excellent. Range of movement, bilateral knee are 0-100 degree. Radiological finding shows no evidence of construct failure in both metal block and bone graft construct. Severe arthritis with bone defect is common due to late presentation. Using autologous bone graft can provide good result as using expensive meta block for reconstruction.

Tumor-like lesions of the heart valve

Valvular tumor and tumor-like lesions are rare. Fibroelastoma is the most common valvular tumor, followed by myxoma. Atypical valvular lesions, such as organized thrombus, valvular calcification and valvular abscess may develop symptoms and present morphological features similar to those of the valvular tumors. The Author here reports a case of a tumour or tumour- like lesion over the mitral valve detected in a asymptomatic patient on preoperative evaluation prior to bilateral total knee replacement surgery for osteoarthritis.. Key-words: Valvular tumour, Tumour -like lesions, Key Messages: Patients should be counselled about the high risk of stroke when tumour or tumour-like lesions are visualised on echocardiogram and encouraged to have a definitive diagnosis established by surgery and biopsy.

Evaluation of lower limb axial alignment using digital radiography stitched films in pre-operative planning for total knee replacement

BackgroundFor patients with knee osteoarthritis, even slight anatomical variations in the femur or the tibia could affect total limb alignment during total knee replacement (TKR). Our hypothesis implies that the femoral valgus correction angle (VCA) in patients indicated for TKR, is variable and higher than the reported norm of 6° utilized in most intramedullary instrumentation systems, and that tibial bowing may result to a disparity of the tibial mechanical axis to the anatomical axis. MethodsOur study is a retrospective review of 216 pre-operative arthritic knees, which investigated the lower limb axial alignment using digitally-stitched films. Patients excluded from the study are those with history of previous tibial or femoral osteotomy, secondary gonarthrosis, rheumatoid arthritis, previous femoral or tibial fracture, patients for bilateral TKR, or history of hip surgery. ResultsThe mean age was 68-years old (range 39–86 years). The mean VCA was 7° (4.7–9.3) for men and 6.6° (4.9–9) for women. However, 71 patients (33%) had more than 7° VCA. Subsequently, 46 patients (21%) had tibial bowing producing an angle >1.5° between its mechanical and anatomic axis. ConclusionsThe 6° standard when used as a guide may result in suboptimal prosthesis positioning during conventional TKR surgery. Therefore our findings suggest that the femoral valgus correction angle has a broad range, and using standard femoral intramedullary guides should not be overlooked.

Mortality following primary total knee replacement in public hospitals in Hong Kong

More than 2000 total knee replacements are performed each year in Hong Kong and more than 10 000 patients are on the waiting list. How safe is total knee replacement, however? The aims of the study were to review the mortality of primary total knee replacement in public hospitals in Hong Kong and to identify risk factors for mortality in a high-volume hospital. All primary total knee replacements performed in Hospital Authority hospitals and Yan Chai Hospital from October 2011 to September 2014 were reviewed. Case-control analysis was performed for risk factors of total all-cause mortality in total knee replacement at Yan Chai Hospital. There were 6588 patients in Hospital Authority hospitals and 1184 in Yan Chai Hospital (1095 unilateral and 89 bilateral total knee replacement). The mean follow-up time of patients in Yan Chai Hospital was 12.8 months. The mortality at 30 days, 90 days and 1 year was 0%, 0.08%, 0.34% for Yan Chai Hospital; and 0.1%, 0.2%, 0.7% for Hospital Authority hospitals, respectively. For Yan Chai Hospital, the mean operation-to-death interval was 21 months (range, 1-35 months). The mean age at death was 78 years and main causes were malignancy (50%) and pneumonia (21%). Predictors of mortality included age at surgery, American Society of Anesthesiologists class 3, and preoperative range of motion. Hospital surgery volume, preoperative co-morbidities, and postoperative deep vein thrombosis were not significant factors. Mortality after primary total knee replacement was low in public hospitals in Hong Kong. Patients of older age or poorer general well-being in terms of poor range of motion or American Society of Anesthesiologists class 3 should be in optimal health before surgery and counselled about the higher mortality rate. A citywide joint replacement registry may help monitor and analyse postoperative total knee replacement mortality specific to our locality.

Aerobic Capacity after Bilateral Total Knee Replacement Surgery

PURPOSE: The purpose of this case study was to analyze aerobic capacity during a walking treadmill test and a staircase walk before and after bilateral total knee replacement (TKR) surgery. METHODS: The patient was a 61-year-old male who underwent a simultaneous bilateral TKR procedure for advanced osteoarthritis and began physical therapy four days post-surgery. His physician classified his condition as “bone-on-bone” prior to the surgery. The patient performed outpatient rehabilitation three times per week for a total of thirteen sessions and then returned to normal activities of daily living. Aerobic capacity, including heart rate, minute ventilation, and oxygen consumption during submaximal exercise were assessed one day before surgery and 2, 4, 6, and 12 months post-surgery using COSMED K4b2 mobile metabolic analyzer. RESULTS: Heart rate and oxygen consumption were higher throughout the walking treadmill test before TKR surgery when compared to all four post-surgery time points. Maximum exercise heart rate during the treadmill test was 23.9% lower 2 months, 37% lower 4 months, 37.8% lower 6 months, and 43.7% lower 12 months post-surgery. Maximum exercise oxygen consumption was 24.2% lower 2 months, 31.2% lower 4 months, 39% lower 6 months, and 27.2% lower 12 months post-surgery. Interestingly, minute ventilation was similar before and after surgery. The time it took the patient to perform four passes on a three story staircase greatly improved over time post-surgery from 8 minutes 2 months post-surgery to 5 minutes 12 months post-surgery. CONCLUSION: The case study patient demonstrated major improvements in aerobic capacity following the cessation of physical therapy both on the treadmill and during a staircase walk following bilateral TKR surgery.

Compare Between the Complication of Simultaneous and Staged Bilateral Knee Replacement at King Abdulaziz Medical City (KAMC) - Riyadh

Introduction: Total Knee replacement is a procedure commonly performed for degenerative joint disorder, e.g. osteoarthritis and rheumatoid arthritis. It is considered to be the most common and successful joint replacement. There will be an increase demand for the bilateral total knee replacement in the future due to increase of aging population and the indication to perform the surgery. There are controversies in the post surgical complication following simultaneous and staged bilateral total knee replacement; many studies have shown an increase in the mortality rate with simultaneous bilateral knee replacement. Other studies are showing evidence that suggest that there is no difference in the complication between simultaneous and staged bilateral total knee replacement. Methods: The study included 84 simultaneous BTKR, 110 staged BTKR (with time interval between the two 3 to 6 months) and 51 UTKR whom performed the surgery between January 2000 and August 2014. The collected data included demographic data, surgical data, complications and length of stay. We also have collected some variables of interest; Demographic (Gender, Age and Weight), Type of surgery (study groups), Hospital stay, Duration of procedure, Amount of bleeding, hemoglobin level before and after the operation and type of anesthesia. Results: We have a total of 245 patients. 110 (44.9%) underwent staged bilateral total knee replacement (BTKR), 84 underwent simultaneous bilateral total knee replacement (BTKR), and 51 of did the surgery on only one. The results showed that out of the 245, 194(79.18%) have not developed any complications, 62(73.81%) were simultaneous BTKR, 89(80.91%) of the staged BTKR and only 43(84.31%) were bilateral TKR. 43(17.55%) have developed minor complications which includes, Infection, UTI, Infected knee post operation or pulmonary complication other than pulmonary embolism. 18(21.43%) underwent simultaneous BTKR, 17(15.45%) for the staged BTKR and 8(15.69%) for the unilateral TKR. Only 8 patients have developed major complication (3.27%) of the general population. 4(4.76%) of the simultaneous BTKE and 4(3.64%) of the staged BTKR. None of the unilateral has developed major complication. We found a mean ± SE of the total days of hospital stay for all the groups was 12.58±. 52, for the simultaneous BTKR patients, the mean ± SE of hospital stay was 11.05±0.39 days, and for the staged was 16.19±1.31 days and 9.96±0.58 days, with a p value <.0001. Conclusion: We can say that simultaneous TKR is a save procedure to be performed especially in hospital where there is long waiting list as well difficulty of having elective bed as in our hospital. And we found out that patients whom underwent staged BTKR stayed at the hospital more than patients whom underwent simultaneous BTKR.

The effects of standing balance in anteroposterior and mediolateral directions on knee strengthening in post-total knee replacement.

[Purpose] The purpose of this study was to examine the association between muscle-strengthening exercises applied to the knee extensor muscles and the maintenance of standing balance in both, the anteroposterior and mediolateral directions in patients who had undergone total knee replacement. [Subjects and Methods] Thirty patients who underwent total knee replacement with bilateral artificial joints participated in this study. During the eight-week study period, the load on the knee extensors was gradually increased, and the standing balance ability was measured by differentiating the anteroposterior and mediolateral directions both, before and after the experimental period. [Results] In both, the anteroposterior and the mediolateral directions, there were statistically significant increases after the eight-week experiment, with a 29% increase in standing balance maintenance in the anteroposterior direction and a 22% increase in the mediolateral direction. [Conclusion] In patients who underwent bilateral total knee replacement, strengthening exercises applied to the knee extensor muscles with gradually increasing load positively affected standing balance in both anteroposterior and mediolateral directions.

Efficacy and Safety of Tranexamic Acid in Bilateral Total Knee Replacement: A Meta-Analysis and Systematic Review.

BackgroundTranexamic acid (TXA) has been well documented to reduce blood loss and transfusion requirements in patients undergoing unilateral total knee arthroplasty (TKA). However, the efficacy and safety of TXA in simultaneous bilateral TKA have not been clearly defined. The aim of our study was to systematically review the existing evidence regarding the role of TXA in patients undergoing simultaneous bilateral TKA.Material/MethodsA systematic search of all studies published through June 2014 was performed using Medline, EMBASE, OVID, and other databases. All studies that compared the efficacy and safety of TXA administration in simultaneous bilateral TKA patients were identified. The data from the included trials were extracted and analyzed regarding blood loss and transfusion rates. The evidence quality levels of the selected articles were evaluated using a grading system.ResultsSix studies were included, in which a total of 245 patients received TXA and 271 patients were controls. Overall, the results demonstrated that the use of TXA significantly reduced total blood loss by a mean of 371.1 ml (95% confidence interval (CI)=−412.12 to −330.09; p<0.001) and reduced the number of patients requiring blood transfusion (risk ratio (RR)=0.16; 95% CI=0.10 to 0.28; p<0.001). No significant differences in adverse effects such as deep vein thrombosis (DVT) or pulmonary embolism (PE) were noted in any group.ConclusionsThe intravenous use of TXA in patients undergoing simultaneous bilateral TKA is effective and safe and results in significantly reduced estimated blood loss and transfusion rates. No significant difference was observed in the incidence of side effects. Due to the limitations in the evidence quality of current meta-analyses, well-conducted, larger, high-quality randomized controlled trials (RCTs) are required.

Efficacy and safety of intravenous tranexamic acid drips at different time points in bilateral primary total knee replacement

Objective To investigate the effects of intravenous tranexamic acid (TA) drips at different time points on perioperative hemorrhage and postoperative venous thromboembolism (VTE) following bilateral primary total knee arthroplasty (TKA). Methods We reviewed 52 patients who had undergone primary bilateral TKA from February 2012 to February 2014. They were 25 men and 27 women, 50 to 75 years of age. They were divided into 4 even groups (n=13) according to timing of medication. Group A received a dose of 15 mg/kg TA intravenously 30 minutes preoperation and 30 minutes before wound closure; group B received a dose of 15 mg/kg TA intravenously 15 minutes preoperation; group C received 15 mg/kg TA intravenously 30 minutes before wound closure; group D received an equal volume of normal saline before surgery. The following indexes were recorded: 24 h postoperative drainage volume; total drainage volume; blood transfusion rate; postoperative haemoglobin (Hb) levels at 24 h, 72 h and 7 d; postoperative prothrombin time (PT); activated partial thromboplastin time (APTT); fibrinogen (FIB); visual analogue scale (VAS) at 24 h & 36 h postoperation; level of bilateral knee passive movement 3 days after surgery and VTE incidence. Patients' lower limbs were examined with Doppler ultrasound 2 weeks postoperatively. Results The 24h postoperative drainage volume and total drainage volume in groups A, B & C were significantly lower than in group D with group A being significantly less than groups B & C (P 0.05). No VTE occurred in any of the 4 groups. Conclusions In bilateral primary total knee arthroplasty, intravenous TA drips can reduce postoperative hemorrhage and blood transfusion rate but may not increase the risk of VTE or hinder passive movement rehabilitation of the knee early after the surgery. The intravenous infusion of 15 mg/kg of TA 30 minutes preoperation and 30 minutes before wound closure may lead to optimal efficacy. Key words: Tranexamic acid; Arthroplasty, replacement, knee; Postoperative hemorrhage; Embolism and thrombosis

PCL-retaining versus PCL-substituting TKR - Outcome assessment based on the "forgotten joint score".

Posterior cruciate ligament (PCL) retention or sacrifice figures prominently among the current controversies in total knee arthroplasty (TKA). Even though biomechanical advantages and disadvantages have been claimed for each type of TKA, clinical studies have not shown significant differences in the outcomes. In this retrospective study, the recently introduced "forgotten joint score" (FJS) was used to assess whether any differences exist between the two types of total knee replacement (TKR). FJ scores of 169 patients with PCL-retaining TKA and 178 patients with PCL sacrificing were obtained. The mean follow-up period was 3.5 years and the minimum follow-up period was 2.5 years. Both groups showed high FJ scores indicating that majority of the patients were oblivious to the presence of the artificial joint during daily activities. There was no statistically significant difference between the mean FJ scores of the two groups. Scores of subsets based on gender, age and unilateral and bilateral TKR also did not show significant differences. Since there are no clinically important differences between the two types of TKR, the choice of the TKA should be based on surgeon preferences and training and local conditions of the knee. Patient-reported outcomes appear to be similar regardless of the choice of TKA. Further prospective studies and validation of FJS outcomes with those of other questionnaires are essential to confirm the absence of differences between PCL retention and sacrifice.

Total knee replacement in triple deformity with posterior subluxation of the knee joint

Dislocation or subluxation following total knee arthroplasty has been extensively reported, but vice versa that is total knee replacement for subluxed or dislocated knee has not been published. Triple deformity of knee that is flexion, external rotation, valgus at knee associated with posterior subluxation of tibia occurs in rheumatoid arthritis, advanced tubercular arthritis and neglected posttraumatic residual dislocated knee. A 50 year old female with seropositive rheumatoid arthritis had the above disabling deformity in left lower limb and varus with medial tibial thrust in the other. Bilateral total knee arthroplasty was planned. Conservative method of reduction of left knee posterior subluxation preoperatively by 90-90 skeletal traction failed; hence patient was subjected to a staged bilateral total knee replacement using an innovative technique. The most difficult and determining initial surgical step of knee replacement in such dislocated/subluxed knee is reduction of posterior subluxation and gaining flexion at knee, as only after gaining flexion and reducing dislocated tibia, will we be able to do knee arthroplasty in triple deformity of knee. These knees are grossly unstable as most of the capsule-ligamentous structures are attritioned/non-existent. So, a fine balance of bone cuts and soft-tissue release needs to be done in a sequential manner to fine tune valgus and posterior subluxation correction without jeoparadising neurovascular structures. After 3 years of knee arthroplasty the patient has painless, stable knee with good range of motion and is able to do all her activities, of living in a hilly terrain.