Successful Left Total Knee Replacement for Severe Osteoarthritis in an 88 Y.O. Male from Somalia

Chief Complaints

An 88-year-old male patient with a body mass index (BMI) of 20 presented to the Orthopaedic Department at PACE Hospitals, Hitech City, Hyderabad, with complaints of persistent left knee pain and difficulty in fully straightening the knee for approximately one year. The restricted knee movement significantly affected his walking and daily activities. He was admitted for further evaluation and management.

The patient had a history of trauma and subsequent infection involving the left lower limb approximately one year earlier, for which he underwent treatment at an outside hospital, including skin grafting. 

On examination, the patient was conscious, coherent, and oriented, with stable vital signs. Local examination of the left knee revealed a severe 90-degree flexion deformity with significant restriction of movement and associated pain. The knee was functionally compromised, affecting the patient's mobility and daily activities. There were no active clinical signs of infection in the affected limb. Systemic examination was found to be normal.

Following the clinical evaluation, the Orthopaedic team at PACE Hospitals conducted a detailed assessment of the patient's persistent left knee pain and severe restriction of knee movement for approximately one year.

On examination, the patient had a 90-degree fixed flexion deformity of the left knee, with significant restriction of movement and functional limitation. An X-ray of the left knee was performed, which showed advanced degenerative changes consistent with severe osteoarthritis. The clinical and imaging findings confirmed significant joint degeneration with a severe flexion deformity.

Based on these findings, the patient was advised to undergo Osteoarthritis Treatment in Hyderabad, India, under the expert care of the Orthopaedic Department.

After a detailed consultation with Dr. Raghuram (Consultant Orthopaedic Surgeon), a comprehensive evaluation was performed to determine the most appropriate treatment approach. Considering the patient's history of persistent left knee pain, severe restriction of knee movement, and difficulty performing daily activities, along with the 90-degree fixed flexion deformity, focused clinical and radiological assessments were undertaken.

Clinical examination demonstrated severe functional limitation of the left knee, while X-ray of the left knee showed advanced degenerative changes consistent with severe osteoarthritis. The significant deformity, joint degeneration, and functional impairment were considered in planning the definitive treatment.

Based on the clinical findings and imaging results, it was determined that Left Total Knee Replacement surgery was the most appropriate intervention to relieve pain, correct the severe flexion deformity, restore joint function and alignment, improve mobility, and enhance the patient's quality of life.

The patient and his family members were counselled regarding the diagnosis, proposed surgery, expected benefits, potential risks, postoperative rehabilitation, and recovery process. Informed consent was obtained before proceeding with surgery.

Following the diagnosis and treatment decision, the patient was scheduled to undergo Left Total Knee Replacement Surgery in Hyderabad at PACE Hospitals, under the expert care of the Orthopaedic Department.

The surgical procedure involved the following steps:

• Anaesthesia, Positioning, and Surgical Preparation: The patient was administered combined spinal and epidural anaesthesia and positioned appropriately on the operating table. The left lower limb was prepared and draped under strict aseptic precautions.

• Surgical Exposure and Joint Access: A medial parapatellar approach was used to expose the left knee joint. Intraoperative assessment revealed severely porotic bone. The anterior and posterior cruciate ligaments and meniscal structures were carefully dissected and addressed to facilitate joint preparation.

• Management of Femoral and Tibial Bone: During femoral bone preparation, a hairline crack was identified and stabilised using cannulated screw fixation. The tibia was subsequently prepared with careful handling due to the underlying bone porosity.

• Correction of Flexion Deformity: To address the patient's severe 90-degree flexion deformity, posterior capsular release and pie-crusting of the iliotibial band were performed. Additional distal femoral bone cuts were made to improve alignment and achieve better correction of the deformity.

• Trial Assessment and Implant Placement: Trial components were positioned to assess joint stability, alignment, and range of motion. Following satisfactory assessment, definitive Smith & Nephew Oxinium posterior-stabilised (PS) components were implanted, including a size 6 femoral component, size 4 tibial tray with a 16 × 150 mm stem, and a 13 mm spacer.

• Closure and Completion: The operative field was thoroughly irrigated, and haemostasis was achieved. The wound was closed in layers with a surgical drain placed in situ. A sterile dressing and long-leg knee immobiliser were applied, and the patient was shifted for postoperative monitoring.
  

Following the left total knee replacement, the patient was closely monitored for pain, wound condition, blood loss, vital signs, and overall recovery. Postoperative care included infection prevention, pain management, blood clot prevention, and supportive treatment. Dressing and wound care were performed regularly. Physiotherapy and gait training with a walker were initiated during the hospital stay to promote early mobilisation and improve knee function.

The patient developed low haemoglobin during the postoperative period, which was managed with three units of blood transfusion. He subsequently showed satisfactory clinical recovery and was discharged in a hemodynamically stable condition.

Upon discharge, the patient was prescribed medications for infection prevention, pain and inflammation control, gastric protection, blood clot prevention, bone health, and nutritional support, along with other supportive treatment as required.

The patient was advised to use the long-leg knee immobiliser as instructed and continue regular knee physiotherapy focusing on strengthening the quadriceps and hamstrings. Continuous passive motion (CPM) exercises with a range of 0–100 degrees were recommended to improve knee mobility. He was also advised to maintain adequate hydration, follow a balanced high-protein diet, include calcium-rich foods, and follow the rehabilitation plan provided by the Orthopaedic team.

The patient was advised to contact the emergency ward at PACE Hospitals immediately in case of fever, increasing knee pain or swelling, wound redness or discharge, bleeding, sudden difficulty in walking, calf pain or swelling, breathing difficulty, or any other emergency symptoms.

The patient was advised to return for follow-up with the Orthopaedic Doctor in Hyderabad at PACE Hospitals for wound assessment, dressing review, staple removal, evaluation of knee movement, and further rehabilitation guidance as scheduled.

This case highlights the successful management of severe osteoarthritis of the left knee with a 90-degree flexion deformity through left total knee replacement surgery. Despite severe deformity and porotic bone, the procedure was completed successfully with correction of the deformity and restoration of joint stability. The patient showed satisfactory postoperative recovery with physiotherapy and gait training and was discharged in a stable condition with rehabilitation and follow-up advice.