Osteoarthritis (OA) of the knees and non specific lower back pain are one of the most common disorders of population of Asia Pacific region. Knee OA has significant effect on the quality of life of patients, as they are not able to perform their daily activities with ease and gradually develop dependence on other family members. This leads to eventual disconnection from the social life and development of depression in patients. Incidence of knee OA is well documented in Asian countries with figures reaching up to 28% in the urban population of Pakistan. Incidence is found to be greater in patients of female gender and those with greater body mass index (BMI). Population of Pakistan has tendency to develop OA earlier than the European population mostly having isolated involvement of the knee joints only. Total Knee Arthroplasty (TKA) is a life changing procedure for such patients. Great improvements in quality of life and outcome measure scores have been observed in patients undergone TKA. Our patients are challenging further as compared to western population because they present late for consultation when the disease and deformity is advanced. Their expectations are high, as they wish to resume their ground base activities such as kneeling for prayers. Furthermore with financial constraints present with most of the patients, one has to be careful in choosing the type of implant and keep in consideration other alternative available options. This case series encompasses our experience of TKA on patients with variety of challenging deformities, their short term outcome and a review of the literature.