Case Study: Right Total Knee Replacement with Custom Instruments

in a 60-year-old female with Avascular Necrosis of the Knee

A 60-year-old female complained of worsening right knee pain. She states that the symptoms have been acute non-traumatic and began two years ago. The symptoms occur constantly. The pain is described as a dull ache and discomforting. The patient previously had a right meniscal repair done by an outside physician 3 years ago.

The pain was moderate to severe in intensity and disturbed her sleep. She described a sensation of giving away of her right knee. The pain was located on the inner side of the knee and was non-radiating.

The patient was unable to perform her daily activities. She described exacerbation of pain with walking, bending, kneeling, sitting, standing and climbing stairs. She was unable to walk for more than 3 blocks and negotiated stairs one step at a time.

She was employed as a manager at a grocery store but was currently not working secondary to pain. She was emotionally stressed about the pain. She stated she avoided getting out of her bed due to apprehension of pain. She used a cane as an assistive device.

She tried physical therapy and home exercise program with minimal to no relief. She received three cortisone injections in the right knee. Initially, she described significant relief with the injection for a month. But subsequently, her last injection only lasted for less than a week. She also tried heat pads and gel injections without any significant relief.

She described a previous intake of steroids for lupus. She was currently not taking any steroids or immunosuppressants. She was a non-smoker and non-drinker. She was currently taking Tylenol for pain and Crestor for dyslipidemia.

On physical examination, she had marked pain in her arch of motion. Her gait was antalgic with a reduced stance phase on the right side. There was mild swelling of the right knee. The patellofemoral crepitus was present. There was tenderness on the medial joint line and patellar facet.

The Mcmurray test was positive for medial meniscus. There was no laxity or instability on valgus and varus stress testing at 0 degrees, 30 degrees and 60 degrees. There was no laxity in the sagittal and axial planes.

The examination of the left knee, bilateral hip and ankles were normal. There was no distal neurological deficit. The bilateral pulses were palpable and comparable. There was no bladder bowel dysfunction.

Imaging studies revealed severe osteoarthritis of the medial compartment of the right knee along with patellofemoral arthritis. MRI revealed progression of previous subchondral fracture at the medial femoral condyle now resulting in a region of avascular necrosis and prominent fluid-filled subchondral fracture line measuring up to 2.8 cm. There was a mild collapse of the articular margin and severe surrounding bone marrow edema.

There was a progression of the medial meniscal tear now with a high-grade tear at the posterior root attachment. Considering lifestyle limiting knee pain with avascular necrosis and arthritis of the right knee. The patient was advised right total knee replacement with custom instruments. She agreed with the plan.

T2 weighted image showing the coronal section of the knee with altered bone marrow signal and rim sign

T2 weighted image showing the coronal section of the knee with altered bone marrow signal and rim sign.

Preoperative X-ray of the right knee in anteroposterior and lateral views Preoperative X-ray of the right knee in anteroposterior and lateral views - img 2

Preoperative X-ray of the right knee in anteroposterior and lateral views.

PREOPERATIVE DIAGNOSIS(ES): Right knee arthritis with osteonecrosis.

OPERATION: Right posterior stabilized total knee replacement
IMPLANTS USED: Tibia stemmed size E with a stem extension with highly cross-linked polyethylene patella 35 mm with femur size 11 with 10-mm posterior stabilized polyethylene.

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

The patient was brought to the operating room and anesthesia was obtained by the anesthesiologist. The patient was definitely positioned and the right lower extremity was then draped and prepped in the usual sterile manner. The time-out was performed and after antibiotics were given, the limb was then exsanguinated.

A straight incision was used for the arthrotomy. Skin and subcutaneous tissue were incised, medial parapatellar arthrotomy was performed. The knee was then exposed. The tibial cutting guide was used for making the tibial resection. The tibial resection was then made and the bone was then removed.

The alignment guides were used for checking the alignment of the cut. Attention was then turned towards the femur. The distal femur was then drilled and distal cutting guide was then placed into position. The distal cut was then made followed by the chamfer cuts and the notch cut.

Lamina spreaders were used medially and laterally and the remainder of the meniscus and the cruciate were then debrided. The flexion and extension gaps were then checked and were found to be correct. Patellar resection was then made.

Drill holes were then made in the patella. The patellar prosthesis was then placed into position. After placing the femur and the tibia and the poly trials, the knee was then trialed through a full range of motion and the stability was found to be excellent. The trial components were then removed. 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 placed into position and the knee was then reduced and then held in extension with the bump under the ankle. The patella was then cemented into position.

Excess cement was then removed. The patellar clamp was then placed into position until the cement hardened and after the cement hardened, the most thorough lavage was given. An injection was used for local anesthetic and the wound was then closed in layers. Sterile dressing was then applied to the wound, and the patient was transferred to the postanesthesia care unit in stable condition.

Postoperative x-ray showing the anteroposterior and lateral views of the right knee Postoperative x-ray showing the anteroposterior and lateral views of the right knee - img 2

Postoperative x-ray showing the anteroposterior and lateral views of the right knee.

Post-op she had an excellent recovery. She was able to stand and walk the same day of the procedure. The pain was managed well with medications. She received outpatient physical therapy and was compliant with the home exercise program. Aspirin was given for deep vein thrombosis prophylaxis.

Three months post-op she demonstrated a full range of motion with no pain. She was walking without the support and reported her status back to her baseline. 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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Dr. Nakul Karkare is awesome! And patriotic! Thank you, Dr. Karkare for displaying the American Flag in your waiting room, honoring and mourning our military personnel, this Memorial Day, who died while serving in the United States Armed Forces.
00:52 30 May 23
Excellent and skilled orthopedic practice specializing in joint replacements. Dr Karkare was trained at the Hospital for Special Surgery and has excellent results, as do his associates!! Would gladly refer family members to the practice!!
00:24 30 May 23
I had such a wonderful experience with Complete Orthopedics in Stony Brook. Not only did Dr. Kuo fix my broken wrist with such kindness and care, but the office staff, including Billing, Reception and the X-Ray Technician, was always so helpful, going out of their way to ensure that each patient felt welcome, answering any questions with a smile, and ensuring any issues with insurance/billing were handled with the utmost professionalism. I highly recommend their practice!
Victoria DeMatteo
19:49 10 May 23
I'm very happy St. Catherine's sent me to this office for treatment after I broke my collar bone! Unfortunately the break was too severe to repair on its own and I had to have it rebuilt a week after the injury. Dr. Vaksha did a great job fixing it. I'm three months out, and I have full use of the arm and shoulder. The whole office staff is very professional, accommodating, and welcoming. I hope to not need orthopedic services again, but Dr. Vaksha will be my number one choice if I or anyone in family suffers such am injury.
Tina Rivera
20:42 08 May 23
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!!
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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 .
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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.
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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
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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.