Case Study: Right Total Knee Replacement with

Custom Instruments in a 66-year-old male

A retired commercial pilot presented for consultation regarding his worsening right knee pain. The pain started when he had a slip and fall about 3 years ago. He went to a hospital where he was told he had a hairline fracture. He subsequently had an MRI which revealed no fracture or ligament tear.

The patients carried on his activities but noticed pain again after a month. He substantially undertook outpatient physical therapy. He also received gel injections in his knee. Both physical therapy and gel injections provided minimal relief to the patient.

He reported the subsequent use of an assistive device in the form of a cane. He received cortisone knee injections twice, with relief lasting roughly for a month. He currently took over the counter pain medications for his knee pain.

The pain was described as a dull ache with no radiation. The pain was constant and also disturbed his sleep. He was unable to walk more than two blocks without discomfort. The pain was especially worse on activities such as climbing stairs, getting up from a chair, turning, twisting, bending and kneeling. The pain was better in rest.

He was a lifelong teetotaler and a nonsmoker. He reported no known drug allergies. He was currently taking medications for high blood pressure, hypothyroidism, asthma, and benign prostate hypertrophy. All his conditions were well managed with medications.

His physical examination revealed an antalgic gait with reduced stance phase on the right side. There was mild swelling with a positive patellar tap. Tenderness was present on the medial and lateral joint line. The patellofemoral grind test was positive for tenderness.

There was crepitus throughout the arch of motion of the right knee. The range of motion was from 10 degrees to 100 degrees. The quadriceps and patellar tendons were intact with no tenderness. The examination of the left knee, bilateral hips and ankles were normal.

There was no distal neurological deficit. The bilateral distal pulses were palpable and comparable. The bulk and tone of the bilateral lower extremities were normal. There was no bladder or bowel dysfunction.

The patients lived with his son and were quite dismayed at his lack of physical activity due to pain. He was unable to enjoy his time with his friends or drive for an extended period of time.

The imaging results revealed severe tricompartmental osteoarthritis of the knee. Considering his lifestyle limiting knee pain, he was advised right total knee replacement with custom instruments. The risks, benefits, and alternatives were discussed with the patient at length. He agreed with the plan.

A preoperative MRI was done a few weeks prior to the procedure to get data for custom implants. Custom implants ensured less tissue trauma and accurate bone cuts for the procedure.

Preoperative X-ray showing the anteroposterior and lateral view of the right knee.Preoperative X-ray showing the anteroposterior and lateral view of the right kneePreoperative X-ray showing the anteroposterior and lateral view of the right knee.Preoperative X-ray showing the anteroposterior and lateral view of the right knee - img 2

Preoperative X-ray showing the anteroposterior and lateral view of the right knee.

Preoperative x-ray showing the merchant view of both the knees

Preoperative x-ray showing the merchant view of both the knees.

OPERATION: Right total knee replacement.

IMPLANTS USED: Femur posterior stabilized size 3 with a Persona tibia 5-degree stemmed size C with polyethylene 10-mm posterior stabilized insert with 14-mm diameter stem extension with 29-m cemented patella.

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 as well as her husband prior to the procedure. The anesthesia was obtained by the anesthesiologist.

The patient was then definitely positioned, and the right lower extremity was then draped and prepped in the usual sterile manner with the cuff of tourniquet over the right thigh. Before the surgery, the time-out was performed and the limb was exsanguinated.

A straight incision was used for the arthrotomy. Skin and subcutaneous tissues were then incised. Medial parapatellar arthrotomy was then performed. The femoral PSI guide was then placed into position and the distal femoral cut was then performed. The anterior and posterior chamfer cuts were then performed.

The tibial cut was then performed using the PSI guide and gap balancing was performed. The notch cut of the femur was then made, and then the laminar spreaders were used medially and laterally, and posterior soft tissue osteophytes were then excised. Gap was balanced.

Patellar resection was made. Drill holes were made in the patella. The trial patella was placed into position. The trial femur was placed into position, followed by the tibia. The poly was placed into position, and the knee was trialed through a full range of motion. There was no flexion contracture that existed earlier, and the patellar tracking was excellent.

The trial components were then removed. A periarticular injection was then performed. The bone was then dried. The femur was cemented into position; excess cement was then removed. The tibia was cemented into position; excess cement was removed.

The poly was then placed into position. The knee was then reduced and with a bump under the ankle. Patella was then cemented into position; excess cement was removed.

After the cement hardened, the patellar clamp was removed. Medial parapatellar arthrotomy was closed. Cutaneous tissues were closed, subcuticular tissues were closed, and the skin was closed using layers. Sterile dressing was then applied over the wound, and the patient was then transferred to the postoperative care unit in a stable condition.

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

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

The recovery was excellent with same-day weight-bearing. He was able to walk 100 feet without discomfort. He was given aspirin for deep vein thrombosis prophylaxis. The pain was managed well with medications. Physical therapy was started on an outpatient basis.

The patient was compliant with his home exercise program. Two months later, he reported with a full range of motion and zero pain. He was able to walk, climb stairs, and drive his car without any limitation. He was extremely happy with the outcome of the procedure.

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.