Case Study: Left Custom Total Knee Replacement

in a 74-year-old female

A 74-year-old female presented to our office complaining of worsening pain in the left knee. She stated she had been dealing with the pain in both her knees (left greater than right). She reported that around last winter the pain got worse in her left knee. She underwent cortisone injections, but the relief didn’t last beyond a few days.

She also tried other conservative options such as physical therapy and heat pads but with minimum relief. The patient is a retired security guard. She is currently living with her daughter. The pain has reportedly decreased her daily activities. She expressed anguish being not able to play with her grandkids.

The pain was described as a dull ache located more on the inner side of the left knee. The intensity varied from moderate to severe occurring with activities. She found difficulty in doing daily activities such as standing, walking, sitting, using stairs, kneeling, bending, turning and twisting.

She was a former smoker having quit ten years ago. Her medical history was positive for hypertension and dyslipidemia, both well controlled with medications. She reported seasonal allergies. She previously had a hysterectomy done 20 years ago.

Her physical examination was revealed an antalgic gait with a decreased stance phase on the left side. There was no evidence of genu varum or valgus deformity. There was a presence of mild bilateral knee swelling. There were no scars, sinus or redness on the skin overlying the left knee.

The range of motion was painful terminally ( 5-120 degrees on the left and 5-125 degrees on the right). There was joint crepitus with positive patellofemoral tenderness. Medial and lateral joint line tenderness was positive. Tests for instability in the coronal, sagittal and axial plane were negative.

Right hip demonstrated tenderness at the right greater trochanter suggesting bursitis. Left hip, bilateral ankle examination was normal. Examination of the sensory dermatomes of both lower extremities to light touch was intact. Motor examination of the great toe and ankle plantar flexors and dorsiflexors were normal. The distal pulses were palpable and good volume.

Imaging studies revealed severe osteoarthritis of the left knee. The patient was informed of treatment options in the form of surgical and nonsurgical methods. In view of lifestyle limiting left knee arthritis, she agreed to go for left knee total arthroplasty.

Risks, benefits, and alternatives were discussed at length. She was deemed as a candidate for custom knee replacement. The patient agreed with the plan. A few weeks prior CT of the patient’s lower extremities was obtained. Accurate planning of the bone cuts and offsets was made possible with data from the CT scan.

Patient-specific implants were made unique for the patient’s anatomy. Customized disposable jigs were constructed using 3D printers. A preoperative plan was formulated outlining the surgical steps.

Preoperative CT scan topography images Preoperative CT scan topography images - img 2

Preoperative CT scan topography images.

OPERATION: Left total knee arthroplasty using custom knee implants. Implants used were femoral implant with a custom tibial tray with 16 mm polyethylene insert with
29-mm x 6-mm patellar implant.

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

The patient was brought to the operating room, and anesthesia was obtained by the anesthesiologist.

Complete Orthopedics patient specific surgical plan for a Left Custom Total Knee Replacement in a 74-year-old femaleComplete Orthopedics patient specific surgical plan for a Left Custom Total Knee Replacement in a 74-year-old female - scan 2

The patient was then definitively positioned, and a cuff was placed over the left thigh. The left lower extremity was draped and prepped in the usual sterile manner. An Esmarch was used to exsanguinate the extremity, and the tourniquet was elevated.Needed equipment for the surgery

A straight incision was used for the arthrotomy. Skin and subcutaneous tissues were incised. A medial parapatellar arthrotomy was performed. The tibia was exposed, and the tibial resection was performed using the cutting guides.

Attention was then turned towards the femur. The distal femur was cut using cut customized guide followed by the anterior, posterior, and the chamfer cuts. The notch cut was then performed.

Gap balancing was performed and was found to be correct. Attention was then turned towards the patella. Patellar resection was performed. Drill holes were made in the patella. The trial patella was then placed into position. Attention was then turned towards the femur. A trial femur was placed into position.

Attention was then turned towards the tibia. The tibial preparation was made. The trial tibia was placed into position, and the poly was then placed into position. The knee was then reduced.

The knee was trialed to a full range of motion. The patellar tracking was excellent. 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 was held in full extension with a bump under the ankle. The patella was then cemented into position. Excess cement was removed. The patella was then held into position with a clamp.

After the cement hardened, the clamp was removed. A thorough lavage was given. Medial parapatellar arthrotomy was closed with O Viqryl and with StrataflX. Cutaneous tissues were closed with 0 Vicryl.

Subcuticulartissues was closed with 2-0 Vicryl. The skin was closed using staples. The tourniquet was let down. Sterile dressing was then applied, and the patient was then transferred to the postoperative care unit in stable condition.

Postoperative X-ray of the left knee showing lateral and AP viewsPostoperative X-ray of the left knee showing lateral and AP views - img 2

Postoperative X-ray of the left knee showing lateral and AP views.

The pain was managed with medications and the patient was able to walk on the day of the surgery. She was started on aspirin for DVT prophylaxis. Range of motion and muscle strengthening exercises were utilized. Sutures were removed uneventfully.

The patient demonstrated excellent recovery and achieved a full range of motion in 4 weeks. She continued physical therapy. The aspirin was discontinued after 3 months. She was now back to her physical state before knee pain. She was extremely happy with the outcome of the surgery.

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

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Based on 93 reviews
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.
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❤️🙏🏼
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
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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.