Total Knee Replacement in Severe Osteoarthritis: Surgical Approach and Outcomes

Abstract

Severe osteoarthritis of the knee is a leading cause of chronic pain, functional limitation, and reduced quality of life in the elderly population. When conservative management fails to provide adequate symptom relief, total knee replacement (TKR) remains the definitive treatment option. We report the case of a 68-year-old female with advanced tricompartmental knee osteoarthritis who underwent total knee replacement, highlighting preoperative evaluation, surgical technique, postoperative management, and functional outcomes. This case emphasizes the role of timely surgical intervention, meticulous operative planning, and structured rehabilitation in achieving optimal patient outcomes.

Introduction

Osteoarthritis (OA) of the knee is a progressive degenerative joint disease characterized by cartilage loss, osteophyte formation, subchondral sclerosis, and synovial inflammation [1]. It is one of the most common causes of disability among older adults worldwide and poses a substantial socioeconomic burden [2]. Patients with advanced disease often experience persistent pain, deformity, and severe limitation of daily activities despite optimal conservative treatment.

Total knee replacement has become a well-established and highly effective surgical intervention for end-stage knee osteoarthritis, offering significant pain relief and functional improvement [3]. This case study illustrates the clinical presentation, diagnostic workup, surgical approach, and postoperative outcomes of TKR in a patient with severe osteoarthritis, reinforcing best practices in contemporary orthopedic care.

Patient Information

• Age / Gender: 68-year-old female
• Medical History: Hypertension, obesity (BMI 31 kg/m²)
• Medication History: Antihypertensive therapy, NSAIDs for knee pain
• Duration of Symptoms: 8 years, progressively worsening
• Chief Complaint: Severe bilateral knee pain (right > left), difficulty walking, inability to climb stairs, and reduced mobility

Clinical Findings

The patient presented with chronic, progressively worsening knee pain associated with morning stiffness lasting less than 30 minutes and significant functional impairment. She reported difficulty standing from a seated position and reliance on walking aids for ambulation.

On physical examination, the right knee showed varus deformity, diffuse tenderness along the medial joint line, crepitus on movement, and restricted range of motion (flexion limited to 90 degrees with a 10-degree flexion contracture). There was no evidence of joint instability or active inflammation. Neurovascular examination of the limb was normal.

Timeline

• Year 0–6: Gradual onset and progression of knee pain managed conservatively
• Year 7: Worsening pain and functional decline despite medications and physiotherapy
• Month 0: Orthopedic consultation and decision for surgical intervention
• Day 0: Total knee replacement performed
• Day 2: Initiation of postoperative physiotherapy
• Week 6: Significant pain reduction and improved mobility
• Month 6: Excellent functional recovery and independent ambulation

Diagnostic Assessment

Plain radiographs of the right knee, including anteroposterior, lateral, and skyline views, demonstrated advanced tricompartmental osteoarthritis with classical radiographic features. These included severe and diffuse joint space narrowing across all compartments, prominent subchondral sclerosis, extensive marginal osteophyte formation, and significant varus malalignment of the knee joint. The overall radiological appearance was consistent with Kellgren–Lawrence grade IV osteoarthritis, indicating end-stage degenerative disease with irreversible structural damage [4]. These findings correlated well with the patient’s clinical symptoms of persistent pain, stiffness, and functional limitation.

Routine laboratory investigations, including complete blood count, renal and liver function tests, and inflammatory markers, were within normal limits, effectively excluding active infection or inflammatory arthropathy. A comprehensive pre-anesthetic evaluation, including cardiovascular and respiratory assessment, deemed the patient medically fit for elective surgical intervention. In view of the severity of symptoms, failure of conservative management, and definitive radiological evidence of end-stage disease, a diagnosis of advanced osteoarthritis of the right knee was confirmed. After detailed discussion regarding treatment options, risks, benefits, and expected outcomes, total knee replacement was recommended as the most appropriate definitive management strategy to restore function and alleviate pain.

Diagnosis

End-stage tricompartmental osteoarthritis of the right knee with severe functional impairment.

Therapeutic Intervention

The patient underwent elective right total knee replacement under spinal anesthesia. A standard medial parapatellar approach was used. Intraoperatively, extensive cartilage loss and osteophyte formation were noted across all compartments. Bone cuts were performed using intramedullary femoral and extramedullary tibial alignment guides to restore mechanical alignment.

A cemented posterior-stabilized knee prosthesis was implanted, ensuring proper soft tissue balancing and restoration of joint stability. The patella was resurfaced due to significant degenerative changes. Meticulous hemostasis was achieved, and the wound was closed in layers with a drain placed temporarily.

Postoperatively, the patient received multimodal analgesia, thromboprophylaxis, and early mobilization. Physiotherapy was initiated on postoperative day two, focusing on range-of-motion exercises and progressive weight-bearing.

Follow-Up and Outcomes

The postoperative course was uneventful. The patient demonstrated steady improvement in pain control and knee mobility. At six weeks, she achieved 0–110 degrees of knee flexion and was able to walk independently without assistive devices. At six-month follow-up, she reported significant improvement in quality of life, with complete resolution of rest pain and the ability to perform daily activities comfortably.

Functional assessment using the Knee Society Score showed marked improvement compared to preoperative status, confirming the success of the intervention.

Discussion

Total knee replacement is a highly effective and well-established surgical intervention for patients with severe osteoarthritis who do not achieve adequate symptom relief with conservative management strategies such as pharmacotherapy, physiotherapy, and intra-articular injections [3,5]. Careful patient selection remains a cornerstone of success, as factors such as disease severity, functional limitation, and patient expectations directly influence postoperative outcomes. In addition, accurate restoration of limb alignment, precise implant positioning, and balanced soft tissue handling during surgery are critical technical determinants that contribute to joint stability, optimal range of motion, and long-term prosthesis survival. In this case, timely surgical intervention played a decisive role in preventing progressive pain, deformity, and functional decline, ultimately resulting in excellent postoperative recovery and meaningful improvement in the patient’s quality of life.

Comorbid conditions such as obesity, hypertension, and metabolic disorders are frequently encountered in patients with advanced osteoarthritis and can significantly increase perioperative risk if not adequately addressed [2]. Thorough preoperative optimization, including medical stabilization, weight management counseling, and cardiovascular risk assessment, is essential to minimize surgical and anesthetic complications. Furthermore, structured postoperative rehabilitation and strict patient adherence to physiotherapy protocols are indispensable for restoring strength, mobility, and joint function. Consistent engagement in supervised exercises, combined with long-term lifestyle modifications, plays a pivotal role in achieving sustained functional gains and ensuring durable, favorable outcomes following total knee replacement.

Conclusion

Total knee replacement offers substantial and sustained pain relief, significant functional improvement, and a marked enhancement in overall quality of life for patients suffering from end-stage knee osteoarthritis who have failed conservative management. By restoring joint alignment, stability, and range of motion, the procedure enables patients to regain independence in daily activities and improves long-term mobility and physical performance.

This case highlights the critical importance of a comprehensive preoperative assessment, including careful evaluation of comorbidities, functional status, and patient expectations, along with meticulous surgical planning and adherence to standardized operative techniques. Equally important is the role of early and structured postoperative rehabilitation, which facilitates faster recovery, optimizes joint function, and reduces the risk of complications. With appropriate patient selection, coordinated multidisciplinary care, and adherence to evidence-based protocols, total knee replacement continues to be a reliable, durable, and highly effective solution for the management of severe knee osteoarthritis.

References

1. Hunter DJ, Bierma-Zeinstra S. Osteoarthritis. Lancet. 2019;393(10182):1745–1759.
2. Cross M, Smith E, Hoy D, et al. The global burden of hip and knee osteoarthritis. Ann Rheum Dis. 2014;73(7):1323–1330.
3. Carr AJ, Robertsson O, Graves S, et al. Knee replacement. Lancet. 2012;379(9823):1331–1340.
4. Kellgren JH, Lawrence JS. Radiological assessment of osteo-arthrosis. Ann Rheum Dis. 1957;16(4):494–502.
5. Skou ST, Roos EM, Laursen MB, et al. Total knee replacement and conservative treatment. N Engl J Med. 2015;373(17):1597–1606.

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