Surgical Review

Patient Information

Arthur Pendelton

68 years

Male

NHS: 482 910 3847

Presenting Complaint

Mr Pendelton attends the orthopaedic clinic today for a surgical review regarding worsening right knee pain and progressive mechanical stiffness.

History of Presenting Complaint

The patient reports a 3-year history of insidious-onset right knee pain, which has deteriorated significantly over the past 6 months. The pain is localised to the medial joint line, rated at 8/10 on weight-bearing, and frequently disturbs his sleep. His walking distance is now restricted to less than 200 m, and he requires a walking stick for outdoor mobilisation. He denies any history of acute trauma, locking, or true giving way, though he notes persistent morning stiffness lasting approximately 20 minutes. Conservative measures, including physiotherapy, weight loss, and an intra-articular corticosteroid injection 4 months ago, now provide minimal relief.

Past Medical History

He has a history of primary hypertension, hyperlipidaemia, and GORD. Previous surgical procedures include a laparoscopic cholecystectomy in 2014 and a left inguinal hernia repair in 2018, with no anaesthetic complications reported.

Medications

• Amlodipine 5 mg PO OD
• Atorvastatin 20 mg PO ON
• Omeprazole 20 mg PO OD
• Paracetamol 1,000 mg PO QDS PRN
• Ibuprofen 5% gel TOP TDS PRN

Allergies

• Penicillin (maculopapular rash)

Family History

His mother had severe osteoarthritis requiring bilateral total hip arthroplasties in her seventies. There is no family history of venous thromboembolism or inflammatory arthropathy.

Social History

Mr Pendelton is a retired postal worker who lives in a two-storey house with his wife; the bathroom is located upstairs. He is an ex-smoker, having quit 15 years ago with a 10 pack-year history, consumes 6 units of alcohol per week, and denies recreational drug use.

Review of Systems

Cardiovascular, respiratory, and neurological systems are unremarkable with no chest pain, SOB, or lower limb paraesthesia reported. He reports no recent dental infections, skin ulcerations, or urinary tract symptoms.

Physical Examination

Vital signs today show BP 134/82 mmHg, HR 72 bpm, Temp 36.6 °C, and BMI 29.4 kg/m². On inspection, he walks with an antalgic gait and demonstrates a mild, correctable varus alignment of the right knee with a small joint effusion and no prior surgical scars. Palpation reveals marked tenderness along the medial joint line and osteophytic lipping, with grade 2 crepitus noted throughout passive movement. Range of motion is 5 to 95 degrees of flexion, with stable collateral and cruciate ligaments. Distal neurovascular status is intact with palpable dorsalis pedis and posterior tibial pulses, and examination of the ipsilateral hip is pain-free with full range of motion.

Investigations

Weight-bearing AP, lateral, and skyline radiographs of the right knee dated 12/05/2024 demonstrate Kellgren-Lawrence grade 4 osteoarthritis of the medial compartment with complete loss of joint space, subchondral sclerosis, and marginal osteophytes, alongside relative preservation of the lateral and patellofemoral compartments. Pre-assessment bloods from 05/05/2024 show Hb 142 g/L, WCC 6.8 x 10^9/L, Plt 245 x 10^9/L, eGFR > 90 mL/min/1.73m², and HbA1c 38 mmol/mol.

Impression

Severe, symptomatic medial compartment osteoarthritis of the right knee, refractory to non-operative management. Differentials such as referred lumbar radiculopathy or ipsilateral hip pathology have been clinically excluded.

Plan

Mr Pendelton has been consented and listed for a right unicompartmental vs total knee arthroplasty, depending on intra-operative assessment of the anterior cruciate ligament and lateral compartment cartilage. The risks of surgery, including infection, bleeding, DVT/PE, neurovascular injury, stiffness, prosthetic loosening, and persistent pain, were discussed in detail. He has been referred to the pre-operative assessment clinic for routine MRSA screening and anaesthetic workup, and advised to continue quadriceps strengthening exercises in the interim. He will be reviewed on the morning of surgery, with routine post-operative follow-up at 6 weeks.