Successful Total Knee Replacement for Grade 4 Knee Osteoarthritis

Chief Complaints

A 69-year-old female patient with a body mass index (BMI) of 21 presented to the Orthopaedic Department at PACE Hospitals, Hitech City, Hyderabad, with complaints of right knee pain for approximately one year. The pain was associated with difficulty in performing daily activities such as walking and standing, along with significant difficulty in climbing and descending stairs. There was no history of trauma or known drug allergies. The patient was admitted for further evaluation and management.

The patient had a history of left total knee replacement performed at an outside facility. The patient was a known case of diabetes mellitus.

On examination, the patient was conscious, coherent, and oriented, and was afebrile with stable vital parameters. General physical examination was normal. Local examination of the right knee revealed a valgus deformity with associated swelling. There was a fixed flexion deformity, with palpable crepitus and tenderness over the medial joint line and suprapatellar region. Medial collateral ligament laxity was noted. The range of motion was grossly restricted and painful. No distal neurovascular deficits were observed.

Systemic examination revealed adequate bilateral air entry in the respiratory system, normal heart sounds without murmurs on cardiovascular examination, a soft and non-tender abdomen with normal bowel sounds, and no focal neurological deficits on central nervous system evaluation.

Following the clinical evaluation, the Orthopaedics team at PACE Hospitals conducted a detailed assessment focusing on the patient’s complaints of right knee pain associated with difficulty in walking, standing, and performing routine daily activities for the past one year, along with difficulty in climbing and descending stairs.

A comprehensive clinical and systemic examination was carried out to determine the severity of the condition. Examination of the right knee revealed valgus deformity with associated swelling, fixed flexion deformity, and palpable crepitus. There was tenderness over the medial joint line and suprapatellar region, along with medial collateral ligament laxity. The range of motion was significantly restricted and painful. No distal neurovascular deficit was noted. Systemic examination was within normal limits. Radiological evaluation (X-ray of the right knee) was consistent with advanced degenerative changes.

Based on these findings, the patient was advised to undergo Grade 4 Osteoarthritis Treatment in Hyderabad, India, under the care of the Orthopaedic Department to relieve pain, correct deformity, restore joint function, improve mobility, and enhance overall quality of life.

After a detailed consultation with Dr. Anand Agroya, Senior Orthopaedic Consultant, a comprehensive evaluation was performed to determine the most appropriate diagnostic and therapeutic approach. Considering the patient’s history of right knee pain, difficulty in walking, standing, and performing daily routine activities, along with difficulty in climbing and descending stairs, and associated restriction in functional movements, a focused local examination and radiological assessment were undertaken to formulate an optimal treatment strategy. Clinical findings revealed valgus deformity, swelling, fixed flexion deformity, crepitus, medial joint line tenderness, ligament laxity, and restricted, painful range of motion. Radiological evaluation confirmed Grade 4 osteoarthritis of the right knee.

Based on the clinical findings and imaging, which confirmed Grade 4 osteoarthritis of the right knee, it was determined that Right Total Knee Replacement surgery was identified as the most suitable intervention to relieve pain, correct deformity, restore joint alignment, improve mobility, and enhance overall functional outcome, as conservative treatment had failed to provide adequate relief.

The patient and her family members were thoroughly counselled regarding the diagnosis, need for surgery, procedure details, associated risks, and recovery process. Informed consent was obtained, ensuring their understanding and involvement in the treatment plan.

Following the diagnosis, the patient was scheduled to undergo Right Total Knee Replacement surgery in Hyderabad at PACE Hospitals, under the supervision of the expert Orthopaedic Department.

The surgical procedure involved the following steps:

• Anaesthesia, Positioning, and Surgical Preparation: The patient was administered combined spinal epidural anaesthesia and positioned supine on the operating table. The affected right lower limb was flexed to 90 degrees, prepared, and draped in a sterile manner. A tourniquet was applied to maintain a bloodless surgical field. Prophylactic intravenous antibiotics were administered prior to incision.

• Surgical Exposure and Joint Access: A midline skin incision was made over the right knee, followed by careful dissection of subcutaneous tissues. A medial para-patellar arthrotomy was performed to access the joint. The patella was everted, and the joint was exposed. Intraoperative findings revealed Grade 4 osteoarthritic changes. Medial and lateral soft tissue releases were carried out. The anterior cruciate ligament (ACL) was excised, and medial and lateral meniscectomy was performed. Osteophytes from the distal femur and proximal tibia were removed.

• Bone Preparation and Alignment: The knee joint was dislocated using appropriate instrumentation. Proximal tibial resection was performed using a tibial jig, ensuring proper alignment. Distal femoral entry was made, and femoral cuts were carried out using a distal femoral jig with appropriate valgus angulation. Sequential anterior, posterior, and chamfer cuts were completed. Flexion and extension gaps were assessed and balanced. Trial components were inserted to evaluate alignment, stability, and patellar tracking.

• Implant Placement and Fixation: After confirming satisfactory trial reduction, definitive preparation of the tibial and femoral surfaces was done. Thorough irrigation was performed using pulsavac lavage. Bone cement was applied, and the prosthetic components (Femur size D – PS, Tibia size 4, Polyethylene insert 9 mm) were implanted. Stability, alignment, and range of motion were reassessed and confirmed. Synovectomy was performed, and patellar osteophytes were excised.

• Wound Closure: Hemostasis was achieved, and the surgical wound was closed in layers. Skin closure was performed using staples, completing the procedure without intraoperative complications.

Postoperatively, the patient was started on medications for infection prevention, pain control, blood thinning, and prevention of blood clots. Dressing was done on postoperative day 1, and mild soakage was noted, followed by appropriate wound care and physiotherapy. The patient was mobilized with a walker on postoperative day 2 and experienced transient giddiness, after which close monitoring of vital signs was continued. Foley’s catheter and epidural catheter were removed on postoperative day 3 after clinical stabilization. By postoperative day 4, the patient showed satisfactory recovery and was discharged in a hemodynamically stable condition with medications and advice.

Upon discharge, the patient was prescribed medications for postoperative infection prevention, pain and inflammation control, gastric acid protection, severe pain relief on an as-needed basis, and blood thinning to prevent clot formation. These medications were advised for short-term postoperative recovery along with continued antiplatelet therapy for an extended duration.

At the time of discharge, the patient was advised to keep the surgical dressing dry and not to wet it. She was instructed to avoid sitting cross-legged or using traditional Indian-style toilets. She was also advised to continue regular physiotherapy exercises involving the knee, calf, ankle, toes, and chest as per the total knee replacement rehabilitation protocol to aid recovery and improve joint mobility.

The patient was advised to contact the emergency ward at PACE Hospitals immediately in case of any emergency or if symptoms such as fever, knee pain, and vomiting.

The patient was advised to return for follow-up at the Orthopaedic Doctor in Hyderabad at PACE Hospitals, after 5 days for wound dressing review in case of any soakage, and subsequently after 14 days from the date of surgery for staple removal and further clinical assessment.

This case highlights advanced Grade 4 osteoarthritis of the knee managed successfully with total knee replacement surgery. The procedure was completed without intraoperative complications, achieving good implant positioning and restoration of joint alignment. Postoperative recovery was smooth with early mobilization, stable clinical parameters, and satisfactory pain control. The patient was discharged in a stable condition with advice for rehabilitation and follow-up.