Failure of Polyethelene Insert Locking Mechanism after a Posterior Stabilised Total Knee Arthroplasty- A Case Report

INTRODUCTION: Disengagement of polyethylene insert used in total knee arthroplasty is a rare but serious complication. Still rarer is disengagement because of failure of tibial insert locking mechanism. We report a previously unpublished complication of polyethylene insert locking mechanism failure in a 10-months-old posterior stabilized total knee arthroplasty in a 70-year-old woman with osteoarthritis for whom Attune (Depuy) knee implant was used. CASE PRESENTATION: A 70-year-old female underwent (Attune, Depuy) primary bilateral posterior stabilised total knee arthroplasty in a private hospital. The patient did not have any complaints and had had been functioning well post her arthroplasty. After five months of surgery she had a fall and sustained injury over right hip which was treated with Cemented Bipolar Hemiarthroplasty. Ten months after index surgery, she sustained trivial fall and presented to the same hospital with knee pain and swelling, where the right knee prosthesis was found to be dislocated. An attempted closed reduction under anaesthesia failed, after which she was referred to our centre with an unstable, painful, swollen right knee in a long knee brace. The physical examination at the time of admission showed posterior sag of the tibia, fullness in the postero-lateral corner, quadriceps muscle atrophy without any neurovascular deficit oflower leg. Postero-lateral dislocation was confirmed with radiographs. Surgical error as a possible causative factor was excluded because patient had been functioning well after surgery. Her comorbidities included hypertension and hyponatremia. ESR and CRP were within normal limits. An open reduction surgery was planned. On exposure, polyethylene was found in the postero-lateral corner of the knee. We were not sure that revising the polyethylene alone would suffice as the poly and locking mechanism was of a relatively new design and hence it was decided to proceed with revision of the components. Revision was done with stemmed components, distal femoral augments and a constrained prosthesis (Total Condylar 3, Depuy). Intraoperative cultures were negative. The patient had an uncomplicated post-operative course. CONCLUSION: Disengagement of polyethylene should be considered as a differential diagnosis in patients who present with acute swelling and instability of the knee. Though it’s a rare complication, there is a possibility that design of the implant or its locking mechanism could contribute to dislocations in future.