Case 2, presented by Charles N. Cornell, MD and Sravisht Iyer, MD, describes a 54-year-old male who presented with a painful right total knee arthroplasty following multiple prior surgeries. Most recently, the patient had undergone a 2-staged revision for treatment of deep infection. He was 12 months following the re-implantation and presented complaining of constant pain, swelling and a sense of instability in the knee. After thorough work-up and evaluation, the patient was advised to undergo revision surgery, inserting a thicker tibial component to stabilize the knee. At the time of surgery the tibial component was revised to a 22mm CCK plastic tibial insert. Post-operatively the patient experienced immediate improvement in the sense of knee stability, uncomplicated early wound healing and recovery of both walking and functional range of motion. Three weeks following revision surgery the patient slipped and fell backwards when walking on an icy sidewalk. The knee was hyperflexed during the fall resulting in a dehiscence of the surgical wound and distal rupture of the patellar ligament (Figure 1). The patient was taken emergently to the OR for irrigation and debridement of the open wound with repair of the ruptured patellar ligament. Post-operatively, the knee was maintained in full extension in a brace for 6 weeks. Quadriceps isometric exercises were started at 4 weeks post-op with the brace in place. At 6 weeks the patient could maintain full extension with palpable continuity of the patellar ligament repair. Passive flexion extension exercises were then allowed advancing to 90 degrees of flexion over 4 weeks. Active exercises and quadriceps strengthening were then begun and slowly advanced. At four months post-op there was complete wound healing without evidence of infection. The patient had full active extension with 120 degrees of knee flexion and proper patellar alignment (Figures 2 and 3).
Read full case details in Volume 5, Issue 1 of Grand Rounds - Complex Cases.
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