A 48-year-old woman with psoriatic arthritis develops rapidly destructive arthritis of the knee with radiological appearance of near-complete articular cartilage loss, subchondral collapse, and large osteophytes in a pattern sometimes described as 'pencil-in-cup' deformity. She requires TKR. What is the MOST important intraoperative challenge anticipated compared to a standard osteoarthritis TKR?
- A Difficulty in achieving balanced flexion-extension gaps due to severe soft-tissue contracture and bony destruction ✓
- B Increased risk of intraoperative fracture due to osteoporotic bone
- C Higher incidence of patellar tendon avulsion during eversion
- D Inability to use tourniquet due to peripheral vascular disease
Correct answer: A. Difficulty in achieving balanced flexion-extension gaps due to severe soft-tissue contracture and bony destruction
Explanation
Psoriatic arthritis produces severe joint destruction with marked soft-tissue fibrosis, synovial pannus, and unpredictable bony erosion that can make gap balancing extremely challenging during TKR. The severe combined deformities (flexion contracture, ligamentous laxity from erosions, and bony deficiency) often necessitate more constrained implants, augments, and stems. Intraoperative fracture due to osteoporosis is primarily a concern in RA. Patellar tendon avulsion is a risk in long-standing flexion contractures of any etiology requiring extensile approaches.
Reference: Maheshwari Essential Orthopaedics, 6th ed.
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