ArticleJournal of orthopaedic case reports2026
Intraoperative Discovery of Incorrect Femoral Component Packaging during Bilateral Total Knee Arthroplasty: A Near-Miss Case Report.
Article in Journal of orthopaedic case reports, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Introduction: Incorrect implant delivery during total knee arthroplasty (TKA) is rare but represents a potential patient safety risk. Implant discrepancies may remain undetected until intraoperative opening despite correct external labeling. Case Report: A 76-year-old woman with bilateral varus knee osteoarthritis underwent simultaneous bilateral TKA using a medial pivot system planned with computed tomography-based patient-specific instrumentation. Cementless fixation was intended for both knees. The left knee was implanted uneventfully. During right TKA, a femoral component with correct external labeling was opened; however, the implant inside was a cemented component, one size larger than planned, and intended for the contralateral side. An appropriately sized backup component was available, allowing completion of surgery without interruption. At 1 year, range of motion improved from -5°-110° to 0°-120° on the left and from -10°-114° to 0°-125° on the right. Pain on the visual analog scale improved from 67 to 0, and the Western Ontario and McMaster Universities Osteoarthritis Index score improved from 56.1 to 90.6. Conclusion: This intraoperative implant packaging discrepancy represents a near-miss event. Even with correct external labeling and meticulous pre-operative planning, implant mismatch may occur. Intraoperative verification and immediate availability of appropriate backup implants are essential to prevent patient harm.
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