Case Study: Bilateral Custom Total Knee Replacement

in a 61-year-old male with Knee Arthritis & Genu Valgum Deformity

The patient was a 61-year-old man presenting with complaints of bilateral knee pain. He first noticed the pain while walking on the beach two years ago. The pain was located along the inner sides of both knees. The patient denied any precipitating injury or fall leading to knee pain.

The pain was described as sharp pain and moderate to severe in intensity. The pain was exacerbated on activities such as walking, sitting and getting up from a chair, navigating stairs, bending, and kneeling. The patient denied any laxity or instability in the knee. There was no radiation of the pain.

The patient previously consulted another physician who gave him gel injections in both knees. He reported relief for only two weeks. He subsequently received cortisone injections in both knees without significant relief. He had tried physical therapy and heat therapy without much help.

He was a nonsmoker and nondrinker and had a family history of hip and knee arthritis. He was currently taking Lipitor for dyslipidemia and Flomax for benign hypertrophy of the prostate. He stated he was prediabetic but was unable to exercise or walk secondary to knee pain.

He was a librarian and currently not working due to pain. His work involved lifting, moving and walking around the aisles of the library. He stated feeling bad not being able to go to the library and interact with people, a career he had pursued passionately for the past 45 years.

On physical examination, there was genu valgum deformity in both knees. The gait of the patient was steady and coordinated. The skin overlying both the knees was normal with no evidence of any scar marks or sinus tracts. There was the presence of mild swelling in both knees demonstrated on milking the suprapatellar pouch.

There was tenderness on bilateral medial and lateral joint lines and patellar facets. The range of motion was restricted secondary to pain in both knees (right- 5 degrees to 90 degrees, left- 10 degrees to 80 degrees). There was no evidence of any laxity or instability in coronal, sagittal and axial planes.

The examination of bilateral hips revealed bilateral hip bursitis. The examination of the bilateral ankle was normal. There was no distal neurological deficit and the bilateral pulses were palpable and comparable. There was no bowel or bladder dysfunction. The bilateral lower extremity deep tendon reflexes were present and comparable.

Imaging studies done revealed severe tricompartmental osteoarthritis in both knees. Considering his lifestyle limiting knee pain and exhaustion of conservative management options, he was advised bilateral knee replacement. He was deemed a candidate for custom total knee replacement. He agreed with the plan.

As a part of the preoperative assessment, a CT of both the knees with hips and ankles was obtained a couple of weeks prior to the procedure. Anatomical and biomechanics assessment was done for constructing custom implants. Further, disposable bone cutting jigs were made customized for the patient’s knees. A preoperative plan was made outlining the steps and bone cuts.

Preoperative X-ray showing the AP view of the left and the right knee respectivelyPreoperative X-ray showing the AP view of the left and the right knee respectively - img 2

Preoperative X-ray showing the AP view of the left and the right knee respectively.

Preoperative X-ray showing the lateral views of the right and the left knee respectivelyPreoperative X-ray showing the lateral views of the right and the left knee respectively - img 2

Preoperative X-ray showing the lateral views of the right and the left knee respectively.

Complete Orthopedics patient specific surgical plan for a Bilateral Custom Total Knee Replacement in a 61-year-old male with Knee Arthritis & Genu Valgum DeformityComplete Orthopedics patient specific surgical plan for a Bilateral Custom Total Knee Replacement in a 61-year-old male with Knee Arthritis & Genu Valgum Deformity - scan 2Complete Orthopedics patient specific surgical plan for a Bilateral Custom Total Knee Replacement in a 61-year-old male with Knee Arthritis & Genu Valgum Deformity - scan 3Complete Orthopedics patient specific surgical plan for a Bilateral Custom Total Knee Replacement in a 61-year-old male with Knee Arthritis & Genu Valgum Deformity - scan 4

OPERATION: Bilateral total knee arthroplasty.

IMPLANTS USED: Custom tibial tray with a Custom femoral implant with a custom patella implant 29 mm with 8-mm polyethylene insert on the left side, and with a 6 mm polyethylene insert with poly 32 mm x 6 mm patellar implant with a custom femoral implant with a custom tibial tray.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room. After obtaining informed consent, signed the correct surgical site, the risks, benefits, and alternatives were extensively discussed with the patient and with the family prior to the procedure.

They understood the increased risk of bilateral total knee replacement.Doctors performing the actual surgery

It was decided to do the left knee first because the left knee was more symptomatic than the right. Both knees were then draped and prepped in the usual sterile manner.

An Esmarch was used to exsanguinate the limb and the tourniquet was elevated. A straight incision was used for arthrotomy. Skin and subcutaneous tissues were incised.

Medial parapatellar arthrotomy was then performed. The tibia was then subluxated and the tibial preparation was then performed. A tibial cut was used making the custom tibial guide. The bone was then removed. The tibia was then prepared.

Attention was then turned towards the femur. The femoral custom guides were used for making the distal chamfer as well as the notch cut. The laminar spreaders were used medially and laterally and the osteophytes were then removed. Gap balancing was performed, and the gap was well balanced.

The patella was then resected. Drill holes were then made in the patella. The trial femur was then placed into position followed by the trial tibia and the poly. The knee was then trialed through a full physiological range of motion. There was a full-extension, full flexion possible. The patellar tracking vas excellent.

Trial components were then removed. The injection was given in the knee. A thorough lavage was given. The femur was cemented into position. Excess cement was removed. The tibia was then cemented into position. Excess cement was removed. The poly was then placed on the tibia and the knee was then reduced.

The knee was held in full extension with a bump under the ankle and the patella was then cemented into position. Patella was held in position with a patellar clamp. Excess cement was removed. Thorough lavage was given.

Medial parapatellar arthrotomy was closed with 0 Vicryl in Stratafix, cutaneous tissues were closed with 0 Vicryl, subcuticular tissues were closed with 2-0 Vicryl, the skin was closed using staples. The tourniquet was let down. Sterile dressing was then placed over the left knee.

Attention was then turned towards the right knee. Esmarch was used to exsanguinate the limb. The tourniquet was then elevated. A straight incision was used for the arthrotomy. Skin and subcutaneous tissues were then incised. Medial parapatellar arthrotomy was then performed.

The tibia was then subluxed and the tibia was then prepared. The tibial resection was made using the custom guide. Attention was then turned towards the femur. The femur was then prepared and the custom guides were used for the distal chamfer as well as the notch cuts.

The medial and lateral laminar spreader was used for debriding the meniscus and the posterior osteophytes were then removed. Gap balancing was performed, and the gap was well balanced.

The patellar resection was then performed. Drill holes were then made in the patella. The trial patella was then placed into position, followed by the trial femur and the trial tibia. Trial poly was then placed into position.

The knee was then trialed through a full physiological range of motion. Full-extension was achieved, full flexion was achieved, patellar tracking was excellent. Trial components were then removed. Thorough lavage was given. An injection was given. Femur was cemented into position followed by the tibia.

The final poly was then placed into position. The knee was then reduced and held in full extension with a bump under the ankle. Thorough lavage was given. The patella was then cemented into position and was held with a patellar clamp. Excess cement was removed. Thorough lavage was given.

After the cement hardened, medial parapatellar arthrotomy was closed with Vicryl and with Stratafix. Cutaneous tissues were closed with O Vicryl, subcuticular tissues were closed with 2-0 Vicryl, the skin was closed using staples.

Sterile dressing was then applied to the wound. The tourniquet was let down. The patient was then transferred to the postoperative care unit in stable condition.

Postoperative X-ray showing the AP view of both knees

Postoperative X-ray showing the AP view of both knees.

Postoperative X-ray showing the lateral view of the right and the left knee respectivelyPostoperative X-ray showing the lateral view of the right and the left knee respectively - img 2

Postoperative X-ray showing the lateral view of the right and the left knee respectively.

The patient was able to walk the same day of the procedure. He felt confident and comfortable walking. His post-op pain was managed well with medications. He was prescribed medications (aspirin) for deep vein thrombosis prophylaxis. Physical therapy was started to increase range of motion and strengthen the muscles.

The sutures on both knees were inspected to be clean, dry and intact. Three months post-op the patient was happily walking without support. He reported zero pain and demonstrated a full range of motion. He was happily back to do his daily activities and enjoyed his job as a librarian. He follows up as needed.

Disclaimer – Patient’s name, age, sex, dates, events have been changed or modified to protect patient privacy.

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Dr Vaksha, is a great doctor very professional knows what he talking about. Treat patient with upmost respect. Thank You
Troy Spencer
16:46 19 Jan 23
Dr. Karkare is an amazing doctor, very caring and attentive, the girl at the front desk is very kind and helpful. .elizabeth .thank you so much .
blanca ventura
21:32 26 Oct 22
Been going to this place before my accident and after I had my knee surgery. So happy how I been treated and how well I am getting. Thank you all and specially Dr. VAKSHA for everything and getting back on track.
Ita Opico
19:01 25 Oct 22
Love this place From the minute I called I was treated kindly. When I arrived The Dr saw me right away he was compassionate and ordered the appropriate tests for me. I came back in for my follow up and had the same great experience.
Christine Rostock
21:28 23 May 22
Dr Vaksha and Dr karkare are 2 of the best orthopedic doctors around my wife Susan had a very serious broken ankle in March of 2019 she didn't think she was going to walk again Dr vaksha did an excellent surgery on her ankle he said it was his toughest he ever did he put a lot of hardware in her ankle and told her she would be alright she made remarkable recovery thanks to his surgery as of now she regained 100 percent use of her ankle she would highly recommend him to anyone. My own experience with Dr karkare has been wonderful he takes his time with you listens to what you have to say and prescribes various treatments and is very caring I would highly recommend him to anyone I would give both doctors a 10 plus rating we are very happy with them the best.
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23:31 19 May 22
Complete orthopedics is a wonderful place to go when you hurt or injured a great staff and wonderful doctors very knowledgeable and helpful I would recommend this place to all of my family and friends that is in me of orthopedic care I give them 10 thumbs up
Wayne Pemberton
17:39 18 May 22
The staff is very professional and helpful. Dr. Vaksha is excellent. He takes time to listen and offer suggestions to help you get better. I’m very thankful and happy to be a patient here at Complete Orthopedics.
Phoenix Rising
19:54 16 May 22
Dr.Karkare is the best. He listens to everything and explains everything I recommend him to everyone. I am so happy he is my doctor.
Myrna James
00:48 13 May 22
Dr.Kuo is amazing very attentive,caring,and passionate and staff is awsome too.Thank you for everything Dr.kuo.
Erick Murillo
23:17 12 May 22
I was in a car accident November 1 I was referred to Dr. Vaksha For shoulder surgery . I he was amazing he made me feel very comfortable and explained everything that was going to happen from surgery all the way through my physical therapy highly recommend Dr. Vaksha
Yolanda Ojeda
19:37 09 May 22
My appointment with Dr. Vaksha was amazing. Dr. Vaksha was very thorough and kind. I would refer this office to anyone who needs a great orthopedic doctor.
John Senechal
19:54 05 May 22
Scheduling my appointment was quick and easy. The staff was super friendly and down to earth. I was seen on time. The appropriate test, “x-rays” were taken before the conversation with doctor, something I really liked, test for analysis and conversation was done upfront. Dr. V had a great personality and was no BS, straight forward diagnosis and a play on next steps. I am happy I found them and would refer them to friends and family.
Sam
00:46 03 May 22
I have seen Dr. Kuo two times already and he's awesome along with his staff. Very friendly office and I'm glad to be a patient here.
Camaris A
20:01 28 Apr 22
Amazing team!! Very caring, profesional, and friendly!! Dr. Kevin Kuo, you are the best, very passionate, caring, and helping thank you for getting me better and being so kind to me! Elizabeth you the best thank you for you help always and you big smile and positive actitud❤️🙏🏼
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19:01 22 Apr 22
The staff is truly exceptional, they make you feel comfortable and welcomed. The doctors are amazing,always professional, compassionate and great listeners.
Elizabeth Collado
03:25 09 Apr 22
What a great place! The place is clean and organized.The staff is wonderful. Setting up physical therapy is right there as well.I'm so glad I found this place.
Donna Anne
22:45 05 Apr 22
This was my 1st time breaking something in my 27 years on this planet. I was recommended here by a friend Dr. Vashka helped me from day 1 and still continues to check in on me and my healing ankle. Would highly recommend
tyron davis
16:06 01 Apr 22
Brand new office, same great doctors! Rooms are clean, plenty of parking, physical therapy attached, Dr. Karkare and his staff are awesome. Thank you!
Emily B
02:49 24 Mar 22
Dr.VAksha is the best, I love the way he treats me as his patient, he is caring,understanding and very attentive to my needs
Mirna Caballero
14:53 03 Mar 22
Great staff. Dr. Vaksha is awesome and takes the time to listen to his patients. He is very compassionate. I would highly recommend this office.
Bebe Doyle
01:24 23 Feb 22
After suffering from a severe ankle injury Dr. V was able to help me heal and return back to work completely to a job where I stand for 12 hours a day. The office is very clean and I appreciated the reminders of my appointments via phone call and through text. The patient portal made it easy for me to access all my documents including work notes. The office staff is wonderful and Rebecca was able to schedule me with a busy schedule and awesome at answering all of my questions including referring me to a great physical therapy office. I highly recommend this office to anyone who’s looking for knowledgeable and kind orthopedic office.
Elizabeth Birchwell
21:31 28 Jan 21
The staff here are great, I was seen at the time of my appointment and was well taken care of!
Shaun Berry
18:14 07 Jan 21
They are an excellent practice. The front and back office people are amazing and so helpful. Rebecca is such a kind and understanding person. I had an issue with paperwork and she cleared it right up. Dr. Karkare is very knowledgeable, helpful, and caring.
Matt S.
19:31 18 Nov 20
Rebecca K. - What a true burst of sunshine. Very friendly and definitely an asset to the practice!
Laura Aston
18:17 17 Nov 20
Great experience, the Doctor is nice but the staff is incredible. I worked with Linda, who was profession and assisted me beyond what any person has done at other practices. Complete Ortho should be complimented for having such a person on their staff.I highly recommend this place!!!
Joe Allen
17:26 17 Nov 20
Linda and Becca they are so good ever time I come they are very nice I would tell everyone I no to come to this office..
Barbara Victor
16:45 17 Nov 20
I was rear ended in an auto accident , Dr Vashka was recommended by a friend of mine .I was experiencing Back , neck , and shoulder pain . After a thorough examination and given exercises to do at home , I am feeling much better , and I ended up avoiding surgery . The staff at Complete Ortho is extremely attentive and show great care when making an appointment and are very friendly and i never waited more than 5 minutes for my appointment . So I would strongly recommend Complete Orthopedics for any aches and pains that one might be experiencing.....
Bill Becht
04:44 17 Nov 20
It was the afternoon of Friday Sept. 24. We were in Pt. Jefferson and my wife, Mary Ann, broke her hip. We went to Mather Hospital and it was determined that she would have to have an operation to have it repaired. This would be her third time under the knife in the past year. It just so happened that we were very fortunate enough to have Dr. Karkare, who was on standby, perform the surgery. He put in a rod and two screws in her hip. She spent a few days in the hospital and then went to Gurwin rehabilitee for another few weeks.It has now been almost six weeks and we both worked the election the other day. If it wasn’t for Dr. Karkare’s expertise she never would have been able to work. She is able to walk with a walker and is doing physical therapy three times a week.We can not thank the doctor enough for the compassion and dedication that he puts into his work. It allows Mary Ann do the things that she likes to do, even on a limited basis for a while. I know that with her will, perseverance and the great work that the surgeon performed she will be back on her feet in no time.Sincerely:John V. PlumpEast Northport, NY 11731
Jack Harris
14:36 06 Nov 20
In the year of 2018 I was referred to Dr. Karkare because I was experiencing severe knee joint pain. After exhausting physical therapy and trying to labor through the pain, I had to make a quality of life decision. Total knee replacement was the only viable option. Dr. Karkare made my decision easy as he walked me through the whole process from surgery to recovery.On 12/13/19 ( Friday the 13th) I enter Lenox Hill Hospital in great hands. From the time I entered Dr. Karkare’s office for the first time until now, his staff has been amazing. Andrea the medical coordinator walked me through all the paper work and necessary preparations for the surgery. Courtesy and kind would be an understatement. Dr. Karkare went over and beyond from the wellness checks and phone calls all to assure me that I was important to him. This was the right decision no pain and no limp. Complete Orthopedics should be your choice!
Kenneth Randolph
22:18 25 Sep 20
Dr. Vadshka has a great bedside manner. He really takes his time and explains treatment options.
T Lee
12:33 09 Sep 20
I suffered with pain in both knees for years. My orthopedic doctor kept recommending knee replacement . I fought it for years, as I was just afraid. When I had no choice and could barely walk , it was recommended I see Dr. Karkare. We set up a consultation and my wife and I left his office feeling totally confident and comfortable with moving ahead with the surgery. He explained everything to us, and the office staff set everything up for us and made the process easy. So about one month after our initial meeting I had the first knee done. I was up walking mere hours after the surgery, and on the workout machines the next morning. I went home two days after the surgery, and yes walked my daughter down the aisle at her wedding only one week after the surgery without even a cane! Three months later I had the other knee done and went home the very next day. Dr. Karkare put my fears to rest . I would highly recommend him. His expertise gave me my life back. Thank you Dr. Karkare.SincerelyVito Congro
Ethel Congo
23:58 12 Aug 20
Dr Rhodin really cares for his patients. When I see him he makes sure to review my progress in detail.
Micki Cahill
15:03 08 Feb 20
My mom had a total hip replacement by dr karkare. He is the BEST orthopedic doctor.Her incision is almost invisable.She is going back for her other hip next week. The office staff is the best, love Andrea.You wont find a better doctor.
Ryan Brigandi
21:06 13 Jul 18
There is no better Orthopedic doctor you will find. Broke my ankle three places on a Saturday. Called Dr. Karkare. He had is team ready at the hospital and operated on me within 6 hours after my injury. Now After 3 months of great care by him and his staff, I am walking to normalcy.
Spacecom Tel
04:13 23 Mar 18
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My name is Dr. Suhirad Khokhar, and am an orthopaedic surgeon. I completed my MBBS (Bachelor of Medicine & Bachelor of Surgery) at Govt. Medical College, Patiala, India.

I specialize in musculoskeletal disorders and their management, and have personally approved of and written this content.

My profile page has all of my educational information, work experience, and all the pages on this site that I've contributed to.