Is this the equivalent of a ball and socket knee joint

 This is an Xray of a 53 year old lady with history of septic arthritis when 15 years of age send for opinion by a good friend of mine.

This is the closet to a ball and socket knee joint. The only similar case I did was a 83 year old lady from Delhi wherein we did a Link  RHK( Pic below).  The preop pics was with valgus correction for templatingThere was no endpoint in Varus valgus under anaesthesia and the femur appeared to drop off the tibia. In view of her age we did RHK. Its 3 years now and so far successful

Here the h/o septic arthritis which is hopefully quiscent now. In view of her one could try to use a femoral  metephyseal sleeve TM may be and a Varus valgus contrained knee. AN RHK should be on table in case one tries a VV constained knee.  The baja patella is the next problem if resurfaced put a smaller button superiorly. Any other comments are welcome

3 complex knee cases

 Below are 3 cases  send my fellow orthopods for comments. I have given my opinion and would appreciate  and welcome other contributions for this interesting cases

Case 1- 47 year old lady with pain. Apparently patient refused an arthrodesis

My views on case 1.
As  she is 47  an arthrodesis is the first option in view of the complexity, one may not get the best bearings and position. if insistent,  I would use possible a trabecular metal metaphyseal cone or sleeve with wedges to rebuild the lateral condyle. Tibia is standard wedge and stem.  Patella would be major realignment problem. The BAJA could be corrected  by using a smaller patellar button  superiorly. We do not have the skyline view to comment


The answer to bonegrafting question would be if at all it should be an entire distal femoral allograft shaped with a conical proximal( Red Triangle) end jammed into the  host metaphysis and protected with a by pass long stem( green line) as simple lateral condyle reconstruction alone is prone to resorption in the  short to medium term. Even the method I described from elsewhere is prone to fractures and resorption in the medium term. You could argue that one wants to rebulit the bone.

I have one case where in I used the sculpted femoral head( no cartilage) from amrita bone bank to rebuild the lateral condyle in a trauma(bone loss) situation. after  6 months non wt bearing  i did an arthroscopic arthrolysis and got 90 degree ROM. Tthinking about future TKR as the condyle appears vascurised on xray.  No TKR as of yet as least to my knowledge.


Below is vijays postop xray and comments ,
I used femoral metaphyseal cones and L wedges to build up the defect. Th Quadriceps was atrophic and patella was on the lateral gutter. Could mobilize by lateral release . Post op flexion is 80 now. Active extension is very weak.






Kindly opine

 Of course we need better xrays to comment on alignment. He had a RHK back up incase. The metaphyseal cone gave him a stable paltform for the femur to build on.o

Case 2 .A case of 71 yr old female having bilateral FFD of 40 degrees

 On the Lt knee in case 2  One  needs  to be careful of the MCL which,  if incompetent would need a Rotating hinge back up. I  feels if MCL is intact  I would do  try a primary knee or CCK with wedge and stem back up. Stems even if no wedges in view of the porosis and start PTH. 
At 71 RHK is techinically less demanding.

 I think the Rt side  should be standard with  just wedges and stem for tibia and a lateral femoral wedge at best. Watch out for intraop fractures and ligamentous avulsions

.Please send me the post op pics too  if possible for  all of us
 Dr mahajan comments
On Right side - I will use medial tibial wedge & for lateral femoral condyle I will use distal & posterior wedge.I will need tibial as well as femoral stems.

 The postop pics  look fine. The  rt femur is extended . It might be a stress riser if he falls. I would have stemmed  the femur too. Consider PTH injections to build bone too








I

infected MOM bearing THR

6 years post MOM bearing presented with infected THR(psuedomonas).   The cup became vertical a year ago. Patient continued visiting various hospital and was put ion oral antibiotic. Stage 1  excision arthroplasty with HAP granules soaked in antibiotic(vancomycin) and 6 weeks of IV antiobiotics were administered

Stage 2 revision with trabecular metal augment and trabecular metal cup and wagner  stem with ceramic on poly bearing

Osteoarthritis knee- post trauma tibia vara

 62 year old lady 5 year post open fracture tibia presently with pain and instabilty. ESR and CRP are normal. An oblique scar(red Line) below the knee healed by primary intention.

 Problems .
Medial tibial condyle has collapsed.
Mcl end point felt.
The oblique open wound distal to the tubercle is healed by primary intention and will not interfere with the  TKR incision unless osteotomy below
Sclerotic irregular eccentric canal

Options and comments please 

 Our templated plan is below including an oblique  lateral  entry to be central distally . The end result is further down. comments please.

Supracondylar fracture with RA and secondary OA in 65 year old lady

osteoporotic Patient with RA and supracondylar fracture

 Options

1. Fix and  TKA

2. Fix and TKA later

3. TKA now