Abstract
Soft tissue balancing is critical to successful knee arthroplasty. Pre-operative planning ensures that the surgeon is prepared for any eventuality. We report a large femoral exostosis resulting in gross instability, requiring revision to a constrained implant.
An 81 year old female presented with osteoarthritis of the left knee. Xray showed a medial bony mass. CT noted a large bony exostosis arising from the posteromedial femoral condyle. Review showed the exostosis was not related to the medial collateral ligament (MCL). At surgery, the exostosis was noted to be tenting the MCL – excision resulted in complete flaccidity. A trial of the Biomet AGC prosthesis revealed gross medial instability. The decision was taken to convert to a DePuy Sigma TC3 system. Whilst removing TC3 trial components, a lateral condyle fracture occurred. This was fixed with a 1/3 tubular plate and interfragmentary screw. The TC3 system and an AGC patellar button were found to be congruent. A small lateral release was performed, the deep MCL was replaced with tagging sutures through the MCL and the pes anserinus. At 9 weeks post operatively, the patient was pain free and mobilising independently. The knee was stable, with range of movement from 0 to 110 degrees.
To our knowledge, this is the first report of such a complication in the literature. It highlights that despite optimal preoperative planning, the surgeon must be prepared to adapt to the situation at hand. It also highlights the importance of having ‘bail out’ options available on shelf when performing routine surgery.
