Management of Grade III Femoral Notching During Robotic-Assisted Total Knee Arthroplasty Using a Proximal Tibial...

Femoral notching is an iatrogenic violation of the anterior cortex of the distal femur that occurs during femoral component preparation in total knee arthroplasty (TKA). This cortical breach has been implicated as a risk factor for a future periprosthetic supracondylar fracture, particularly when the defect is deep and compromises structural integrity. Robotic systems may reduce the incidence but do not eliminate this error. We report a case of intraoperative management of a grade III femoral notching during robotic-assisted primary TKA in a 56-year-old female with Kellgren-Lawrence grade IV bilateral knee osteoarthritis and severe varus deformity, with a baseline Knee Society Score (KSS) knee score of 31 and functional score of 20. The defect was reconstructed using an autograft harvested from the proximal tibial cut, which was fashioned to fit the defect and secured with two 3.5 mm countersunk cortical screws. Following reconstruction, standard cruciate-retaining primary femoral and tibial components were implanted. The patient followed a strict non-weight-bearing regimen for four weeks, followed by protected weight-bearing for a further four weeks. At 12 months postoperatively, the patient had a range of motion of 0°-0°-120°(extension-neutral-flexion) with a KSS knee score of 99 and a functional score of 90. The radiographs showed cortical and trabecular continuity at the anterior cortex, indicating autograft incorporation and remodeling. Even though robotic and navigation systems promise precision, they are never without errors, and the need for human skill and expertise should never be overlooked. This report describes the feasibility of reconstruction of a grade III femoral notch using a structural autograft from the proximal tibial resection, avoiding conversion to a stemmed femoral component, use of allograft, or metal augments, with short-term clinical and radiographic follow-up.