Successful Surgical Management of Severe Osteoarthritis with Flexion Deformity Through Total Knee Replacement

An 88-year-old Somali male presented with a one-year-long history of left knee pain and flexion deformity. He was diagnosed with severe osteoarthritis and successfully underwent left total knee replacement surgery. 

Chief complaints

The patient, an 88-year-old male from Somalia, presented to PACE Hospitals, Hyderabad, with a one-year history of persistent pain in the left knee, accompanied by an inability to achieve complete extension of the left knee joint. The restricted movement significantly impaired his daily activities and overall quality of life.

History of present illness

The pain and flexion deformity began insidiously one year ago. The patient reported difficulty performing daily activities due to restricted movement in the left knee.

Past medical history

The patient had a history of trauma and subsequent infection in the left lower limb one year ago, which required treatment at an external hospital. As part of the management, he underwent a skin grafting procedure. At the time of presentation to PACE Hospitals, there were no active signs of infection or complications related to the previous injury or surgical intervention.

Diagnosis

The patient was diagnosed with osteoarthritis affecting both knees, with the left knee being more severely impacted. The condition was characterized by a 90-degree flexion deformity in the left knee, causing significant functional impairment and chronic pain.

Medical decision-making (MDM)

The patient underwent thorough preoperative investigations, including clearance from anesthesia and pre-anesthetic checks (PAC). Due to the severity of the flexion deformity and bone porosity, the orthopedic consultant, trauma, shoulder and knee arthroscopic surgeon, hip and knee Joint replacement specialist, Dr. Raghuram, affirmed that a total knee replacement (TKR) was deemed necessary to restore functionality and relieve pain.

Preoperative preparations

The patient was prepared for surgery with spinal and epidural anesthesia to ensure effective pain management during the procedure. Additionally, urinary catheterization was performed by urologist by Dr. Abhik Debnath, to maintain bladder function and prevent complications during the surgery.

Surgical procedure

The surgery began with exposure of the joint through a medial parapatellar approach, where the bone was noted to be highly porotic. The anterior and posterior cruciate ligaments (ACL, PCL) and meniscus were carefully dissected to avoid damage. During femoral cuts, a hairline crack was identified and managed with cannulated screw fixation to ensure structural stability. Tibial preparation involved the removal of the meniscal remnants and meticulous dissection due to bone porosity.

To address the 90-degree flexion deformity, posterior capsular release and pie-crusting of the iliotibial band were performed, achieving a one-third correction. Additional Distal femoral cuts were made to enhance alignment.

Implantation involved the use of Smith and Nephew Oxinium PS components, including a Size 6 femoral component, Size 4 tibial tray with a 16 x 150 mm stem, and a 13 mm spacer. The stability of the joint was confirmed intraoperatively.

The procedure concluded with thorough lavage, closure of the wound in layers with a drain in situ, application of a sterile dressing, and placement of a long leg knee immobilizer.

Postoperative course

The patient’s immediate postoperative recovery was uneventful, with no significant complications observed. However, he developed low hemoglobin levels, which were successfully managed with the transfusion of three units of blood. Physiotherapy, including gait training, was initiated during his hospital stay to promote mobility and support rehabilitation.

Discharge medications

The patient was prescribed anti-inflammatory drugs, proton pump inhibitors (PPIs), analgesics, antibiotics, calcium supplements, and nutritional supplements including protein powders and anabolic agents, as well as anticoagulants to support recovery and prevent complications.

Postoperative instructions

The patient was advised to use a long leg knee immobilizer and continue knee physiotherapy with a focus on strengthening the quadriceps and hamstrings. Continuous passive motion (CPM) exercises targeting a range of 0–100 degrees were recommended to improve joint mobility.

Dietary recommendations

The patient was advised to follow a balanced nutritional diet with an emphasis on high-protein intake through supplements and natural food sources to aid in recovery. Adequate hydration was recommended, along with the inclusion of calcium-rich foods, such as dairy products, to support bone health and overall healing.