DOCTOR’s pre-op diagnosis was degenerative joint disease (DJD) left knee. X-rays showed bone on bone in left knee. P underwent a total left knee TKA on 8/30/2023 at HOSPITAL. DOCTOR implanted a Stryker “Triathlon Cruciate Retaining Femoral” component in the P’s distal femur above the knee. Surgery was uneventful with no complications. Two x-rays of the left knee taken on 8/30/2024 were viewed by RADIOLOGIST with HOSPITAL. RADIOLOGIST’s opinion was that x-rays revealed “well seated total knee arthroplasty.”
P also had a companion diagnosis with DOCTOR of low back pain, degenerative disc disease and radiculopathy.
P underwent PT in hospital and was discharged to an in-patient rehab facility on 9/06/2023. P then attempted rehab at the in-patient rehab facility where she failed PT due to pain and related mechanical issues with the knee implant. Following failed PT at in-patient rehab facility, DOCTOR continued to treat P with narcotics for pain and never stated in his medical records nor informed his P that he failed to resurface the patella or used an oversized femoral component during the TKA on 8/30/2023. P treated post-op with DOCTOR through her last office visit on 1/02/2024.
Due to her ongoing pain and failure to recover, on 12/19/2023, P got a second ortho opinion from DOCTOR 2 with ORTHOPEDIC OFFICE. DOCTOR 2 impression was non-resurfaced patella as well as a “potentially oversized femoral component.” DOCTOR 2 obtained x-rays and/or reviewed x-rays revealing no resurfaced patella and “prominence of the anterior femoral flange.” DOCTOR 2 recommended revision surgery.
On 1/08/2024, P got a third opinion from DOCTOR 3. His impression was “other mechanical complication of internal left knee prosthesis.”. DOCTOR 3 recommended a revision. He noted that a TKA can fail for a variety of reasons. Early on (less than 5 years), infection and implant failure are the most common causes of a failed TKA.
The P has had no infection in her left knee since the TKA with DOCTOR, leaving essentially implant failure as the likely or probable cause of the P’s pain and limited range of motion and subsequent need for revision surgery resurface the underside of the patella and to replace the femoral component.
On 2/07/2024, P obtained a fourth opinion from DOCTOR 4 (he is a DO not an MD). DOCTOR 4 stated that the x-rays show a stable TKA with a “generously sized femoral component.” DOCTOR 4’s impression or diagnosis included a generously sized femoral component and an un-resurfaced patella causing pain and mechanical symptoms in the knee. DOCTOR 4’s options included replacing the femoral component with a small femoral component and resurfacing the patella. P underwent revision surgery with DOCTOR 4 on 3/21/2024.
Patient contends that DOCTOR used a femoral component for the TKA on 8/30/2023 at HOSPITAL which was too big or oversized or generously sized and also failed to resurface the patella leading to failure of the TKA, including increased pain requiring narcotic management, failure of PT, mechanical complications, intense pain on climbing and descending stairs, antalgic gait when walking and standing on uneven ground, difficulty arising from a chair and generally negatively impacting the P’s activities of daily living.
Files:
Q: please send a copy of the x-rays, they would be helpful to better answer the question
A: —
Q: An exam with documented range of motion would also be helpful.
A: —
Do you believe there might have been medical error?
It is unclear from the records why the femoral component contributed to any symptoms. The nonresurfaced patella could be causing pain and if there was significant arthritis on the patella, not resurfacing it could have been a medical error. However, only 80% of people are happy with their knee replacements and the cause of this patient's pain is not yet clear.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If the patella should have been resurfaced (does not need to be in all cases), then this would cause pain for the patient.
What makes you a good expert for this case?
Significant knee replacement experience.
How often do you encounter cases similar to this one in your practice?
Rarely. I do perform many knee replacements, but few revisions.
Do you believe there might have been medical error?
Failure to resurface the patella is not necessarily itself malpractice, as there are some surgeons who often do not do so. However, in combination with a likely-oversized component, it is a recipe for prolonged pain and debility. Multiple other opinions from orthopedic surgeons interpreted the femoral component as being too large. The radiologist's opinion should frankly not carry much weight, as radiologists are not trained in evaluation of the sizing and appropriate placement of knee implants - this is specialized knowledge they generally do not possess. When a radiologist says that there is an arthroplasty without sign of complication, that only should be interpreted to mean no major complications. Subtle things like slight malpositioning, or inappropriate sizing, would generally not be recognized by a radiologist. However, I cannot say with certainty without seeing the images myself whether the component was truly oversized.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The other opinions seem to agree that the component is oversized. Oversizing with anterior overhang is a common cause of continued anterior knee pain and dysfunction following TKA.
What makes you a good expert for this case?
I am a board-certified orthopedic surgeon who has done hundreds of total knee replacements and have offered medicolegal opinions in similar cases.
How often do you encounter cases similar to this one in your practice?
Not very frequently, thankfully. But every now and then I do see inappropriately-sized components, with subsequent symptoms, as a second opinion.
Do you believe there might have been medical error?
Persistent patellofemoral pain following total knee arthroplasty is a known potential complication, particularly when the native kinematics of the anterior compartment are not maintained or sometimes when the anterior compartment is not resurfaced. Unfortunately in this case, if the femoral component was oversized and created excessive patellofemoral compartment pressure because of this, both a change in the native kinematics AND the lack of resurfacing the patella more likely than not let to this persistence of complaints and what I presume was limited motion most notably in flexion past ~70 degrees.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Persistent patellofemoral pain following total knee arthroplasty is a known potential complication, particularly when the native kinematics of the anterior compartment are not maintained or sometimes when the anterior compartment is not resurfaced. Unfortunately in this case, if the femoral component was oversized and created excessive patellofemoral compartment pressure because of this, both a change in the native kinematics AND the lack of resurfacing the patella more likely than not let to this persistence of complaints and what I presume was limited motion most notably in flexion past ~70 degrees.
What makes you a good expert for this case?
I am a dual fellowship trained sports medicine shoulder/knee and foot/ankle expert. I perform ~90 total knee arthroplasty cases a year.
How often do you encounter cases similar to this one in your practice?
I have seen this complication in a select few cases where the anterior compartment was not resurfaced.
Do you believe there might have been medical error?
Controversy: supporting patellar resurfacing in total knee arthroplasty – do it Abstract Patellar resurfacing during total knee arthroplasty remains a controversial topic. Some surgeons routinely resurface the patella to avoid the increased rates of postoperative anterior knee pain and reoperation for secondary resurfacing, whilst others selectively resurface based on the presence of preoperative anterior knee pain, damaged articular cartilage, inflammatory arthritis, isolated patellofemoral arthritis, and patellar subluxation and/or maltracking. A third group of surgeons never resurface the patella. The anatomy and biomechanics of the patellofemoral joint as well as the advances in surgical techniques and prosthetic design must be taken into account when making a decision about whether to resurface the patella. Accurate component implantation if the patella is resurfaced becomes crucial to avoid complications. In our institution before 2008 we were performing a selective resurfacing of the patella, but in the last decade we have decided to always resurface it, with good outcomes and low complication rate. A reproducible surgical technique may be helpful in reducing the risk of postoperative anterior knee pain and complications related to implants. In this article we analyse the current trend and controversial topics in dealing with the patella in total knee arthroplasty, and discuss the available literature in order to sustain our choice. Cite this article: EFORT Open Rev 2020;5:785-792. DOI: 10.1302/2058-5241.5.190075 Overhang of the Femoral Component in Total Knee Arthroplasty: Risk Factors and Clinical Consequences Mahoney, Ormonde M. MD1; Kinsey, Tracy MSPH1 Author Information The Journal of Bone & Joint Surgery 92(5):p 1115-1121, May 2010. Conclusions: In this series, overhang of the femoral component was highly prevalent, occurring more often and with greater severity in women, and the prevalence and magnitude of overhang increased with larger femoral component sizes among both sexes. Femoral component overhang of ≥3 mm approximately doubles the odds of clinically important knee pain two years after total knee arthroplasty.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The research shows that the patients post operative pain and (possible loss of motion) can be due to both not resurfacing the patella and/or too large a femoral component.
What makes you a good expert for this case?
I do not perform total knee replacements but I do see patients who have had knee replacements and do deal with their issues.
How often do you encounter cases similar to this one in your practice?
Rarely, since I do not perform knee replacements.
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