Case Study: Bilateral Customized Total Knee

Replacement in a 72-year-old patient with Arthritis

A retired bank manager presented to our office with complaints of bilateral knee pain. She first noticed the pain a few years back but was unable to localize the exact time of onset. She stated the pain was insidious in onset and progressed gradually with some good days and some bad days.

The pain was located diffusely within both the knees and was a dull aching in character. The pain was especially worse on prolonged walking, standing and activities which involved sitting, squatting, turning, twisting and climbing stairs. She was unable to do daily activities such as cooking, doing laundry or going up the stairs.

She previously had a meniscal surgery on her right knee with only relief for a couple of months. She also received hyaluronic gel injections in both knees but with minimal relief. She tried physical therapy and hot-cold treatment, with no relief.

She was currently living with her family and was distressed with the worsening knee pain. She was unable to socialize with her family and relatives. She was a nonsmoker and a nondrinker. Her past medical history was positive for diabetes mellitus, hypertension, and asthma. All her medical conditions were well controlled with medications.

On physical examination, there was genu varum deformity in both knees. Her gait was steady and well-coordinated using cane as an assistive device. The skin overlying both the knees was normal. There was no evidence of any swelling in both knees.

On palpation, tenderness was present on bilateral joint lines and patellar facets. The range of motion of both knees was painful with restricted end movements. There was crepitus in both the knees joints on motion. The range of motion of the right knee was from 5 degrees to 110 degrees and that of the left was 0 degrees to 110 degrees.

The examination of the bilateral hip and ankle was normal. There was no evidence of distal neurological deficit. Bilateral lower extremity pulses were palpable and comparable. The lower extremity deep tendon reflexes were illustrated and comparable bilaterally.

Her imaging studies of both the knee revealed severe tricompartmental osteoarthritis. Considering her lifestyle limiting knee pain, she was advised bilateral custom total knee replacement. Risks, benefits, and alternatives were discussed with the patient at length. She agreed to go ahead with a bilateral custom knee replacement.

A few weeks prior to the procedure, a CT scan of both knees, ankles, and hips was obtained. The data was utilized to form 3D images of the patient’s knees. Unique customized patient-specific implants were constructed along with disposable bone cutting jigs. A unique preoperative plan was formed suggesting bone cuts and femoral offsets.

Preoperative X-ray showing the AP view of both knees

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

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 Customized Total Knee Replacement in a 72-year-old patient with ArthritisComplete Orthopedics patient specific surgical plan for a Bilateral Customized Total Knee Replacement in a 72-year-old patient with Arthritis - scan 2Complete Orthopedics patient specific surgical plan for a Bilateral Customized Total Knee Replacement in a 72-year-old patient with Arthritis - scan 3Complete Orthopedics patient specific surgical plan for a Bilateral Customized Total Knee Replacement in a 72-year-old patient with Arthritis - scan 4

PROCEDURE: Bilateral total knee arthroplasty.

IMPLANTS USED: Custom femoral implant with a tibial tray with 6-mm polyethylene inserts on the right side with 29-mm patellar component. Custom femoral implant with a custom tibial tray with 6-mm polyethylene inserts on the left side with the 32-mm patellar implant.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room after obtaining informed consent, signing the correct surgical site. Risks, benefits. and alternatives were extensively discussed with the patient as well as the family prior to the procedure.

They understand the increased risk of bilateral total knee arthroplasty. Then, it was decided to do the right knee first.Doctors performing surgery

After obtaining anesthesia. both knees were then draped and prepped in the usual sterile manner. The knee was exsanguinated. A straight incision was performed. Medial parapatellar arthrotomy was performed on the right side.

The tibia was exposed. The tibial cutting guide was used. and the tibial resection was performed. The tibia was reamed and broached.

Attention was then turned towards the femur. Distal chamfer cutting guides were used, and the notch cutting guide was used for making the cuts. Medially and laterally laminar spreaders were used to remove the remainder of the meniscus and the cruciates.

Posterior osteophytes were then removed. The knee was then balanced, and the balance was found to be correct. The trial tibia was placed into position followed by the trial femur and the poly.

The patellar resection was then performed. Ori ti holes were made in the patella. The trial patella was 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. The trial components were then removed. A thorough lavage was given. The femur was cemented into position. Excess cement was removed.

The tibia was cemented into position. Excess cement was removed. Poly was then placed into position, and the knee was then held in full extension with a bump under the ankle. The patella was then cemented into position. Excess cement was removed and was held with a clamp until the cement hardened.

After the cement hardened, the patellar clamp was removed. The tourniquet was let down. Thorough hemostasis was achieved. The injection was given for pain control. Medial parapatellar arthrotomy was closed, followed by O Vicryl, 2-0 Vicryl, and then, the skin was closed with sutures.

Attention was then turned towards the left side. A straight incision was performed. After exsanguinating the extremity, medial parapatellar arthrotomy was performed. The tibia was then exposed, and the tibial cut was made with the tibial cutting guide. Tibia was then broached and reamed. Attention was then turned towards the femur.

The femur was then resected using distal chamfer cutting guides as well as the notch cutting guide. Medial and lateral laminar spreaders were used for resection of the meniscus and the cruciates. Posterior osteophytes were then removed. The gap balancing was performed and found to be correct.

The trial femur was placed followed by the trial tibia. Poly was placed into position. The extension was full, and full flexion was obtained. Patellar resection was then performed. Drill holes were made in the patella. Patellar tracking was found to be perfect.

Trial components were then removed. Thorough lavage was given. The injection was given. The femur was cemented into position. Excess cement was removed. The tibia was cemented into position. Excess cement was removed. Poly was then placed into position. The knee was then reduced and held in full extension with a bump under the ankle.

Tourniquet was let down. Thorough hemostasis was achieved. Medial parapatellar arthrotomy was closed followed by subcutaneous tissue, subcuticular tissue. The skin was closed using Prineo. A sterile dressing was then applied over both wounds. The patient was then transferred to the postoperative care unit in stable condition.

Postoperative X-ray showing the lateral views of both kneesPostoperative X-ray showing the lateral views of both knees - img 2

Postoperative X-ray showing the lateral views of both knees.

Postoperative X-ray showing the AP view of both knees

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

Post-op she had an excellent recovery, she was walking the day of surgery with support. Her pain was managed with medications and she was able to go home the next day of the procedure. The patient was started on aspirin and TED stockings to prevent deep vein thrombosis. Physical therapy was started to increased flexibility.

Sutures were removed uneventfully. On her eight weeks follow up, she reported zero pain with a full range of motion in both knees. She was happily back to her baseline. She was able to drive a car, navigate stairs and do her daily activities without any discomfort. She was extremely happy with the outcome.

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

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Based on 96 reviews
No one likes going to the doctor. But these people make it painless. I go for knees, hips and shoulders. At almost 70 Complete Orthopedics keeps my active life style running smoothly. Whether chasing my Grandson and even surfing again, I highly recommend them!!
Thomas Slavin
15:02 02 Mar 23
Dr. Kuo knowledgeable and competent surgeon- very good experience and more importantly great result.
Joseph McCoy
21:23 25 Feb 23
Dr Vaksha was so kind and helpful. He took extra time with us and explained things so thoroughly. Highly recommend. Office very clean.
Susan Bosinius
20:20 19 Feb 23
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.
Harry Jones
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.
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❤️🙏🏼
breidy valerio
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

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.