Natasha Varghese Isaac

Persistent pain following technically successful total knee arthroplasty (TKA) affects 10–20% of patients despite satisfactory implant alignment and stability. Conventional diagnostic algorithms predominantly emphasize structural pathology while often under-recognizing extra-articular and centralized pain mechanisms, contributing to delayed diagnosis and unnecessary revision surgery. This narrative review was conducted in accordance with the Scale for the Assessment of Narrative Review Articles (SANRA). PubMed, Embase and the Cochrane Library were searched from database inception to June 2026 for studies addressing persistent pain after primary TKA. Evidence was synthesized across four domains: intra-articular pathology, extra-articular/referred causes, centralized and psychosocial pain mechanisms, and existing diagnostic algorithms. Based on the available literature, a timeline-stratified diagnostic framework was developed. Persistent pain after well-aligned TKA arises from three principal mechanistic categories: intra-articular, extra-articular/referred, and centralized pain. The differential diagnosis evolves with postoperative timing, with structural complications predominating early, instability and patellofemoral disorders emerging during intermediate follow-up, and aseptic loosening alongside centralized pain becoming increasingly relevant later. The proposed algorithm prioritizes systematic exclusion of infection, targeted assessment of mechanical pathology, evaluation of hip, spine and hindfoot disorders, and mandatory screening for central sensitization and neuropathic pain before considering revision surgery. Persistent pain following well-aligned TKA is multifactorial and requires a structured, timeline-based diagnostic strategy that integrates structural, extra-articular and centralized pain mechanisms. This comprehensive approach may facilitate earlier diagnosis, reduce unnecessary investigations and revision procedures, and support more individualized management while providing a practical framework for future prospective validation.

High-energy tibial shaft fractures in geriatric patients present significant challenges due to osteoporotic bone, compromised soft tissues and multiple medical comorbidities. Conventional fixation methods may be limited in the presence of fracture blisters or poor physiological reserve, making minimally invasive strategies increasingly relevant. An 88-year-old previously independent male with hypertension and prior cerebrovascular accident sustained a high-velocity road traffic injury resulting in an AO/OTA 42C3 comminuted tibial shaft fracture and 4F2B fibula fracture with ipsilateral rib fractures. Early circumferential fracture blebs precluded plating and staged external fixation was avoided due to advanced age and comorbidities. A single-stage four-ring Ilizarov circular fixator was applied using tensioned wires and selective Schanz pins, prioritizing biological fixation and soft-tissue preservation. Postoperatively, the patient followed a staged rehabilitation protocol with adjunctive teriparatide therapy. Radiographs demonstrated progressive callus formation and fracture union at one year with acceptable varus and recurvatum alignment. The postoperative course was uneventful and implant removal was performed after consolidation. Functional outcomes beyond one year could not be assessed due to loss to follow-up. Single-stage Ilizarov circular fixation can be an effective definitive option for complex high-energy tibial fractures in medically complex elderly patients when conventional fixation is contraindicated. Careful consideration of soft-tissue status, comorbidities and biological fixation principles is essential to optimize outcomes.

Floating knee injuries are high-energy injuries with considerable functional morbidity. In Fraser type I injuries, dual intramedullary nailing permits early stabilization and mobilization. While suprapatellar nailing offers technical advantages for proximal-third tibial fractures, its role within floating knee injuries remains inadequately described. This study evaluated functional recovery following portal-matched tibial nailing in Fraser type I floating knee injuries. A retrospective case series of seven adults with Fraser type I floating knee injuries treated with dual intramedullary nailing between February 2022 and February 2026 was conducted at a tertiary care centre. Five patients with diaphyseal tibial fractures underwent infrapatellar nailing, while two with proximal-third fractures underwent suprapatellar nailing. Functional outcome was assessed using the International Knee Documentation Committee (IKDC) subjective score at 6 weeks, 6 months and 2 years. Pain, radiological union and complications were also recorded. Outcomes were analysed descriptively given the small and imbalanced subgroups. The COHORT comprised five males and two females, with a mean age of 33.6±7.2 years. Mean IKDC scores improved progressively from 61.54±2.15 to 82.42±2.46 and 86.70±1.30 at 6 weeks, 6 months and 2 years, respectively, in the infrapatellar group. Corresponding scores in the suprapatellar group were 60.30±0.85, 82.85±1.34 and 86.80±0.57. No clinically meaningful difference in functional recovery was observed. No non-union, malunion or implant failure occurred. Portal-matched tibial nailing demonstrated favourable and comparable functional recovery across diaphyseal and proximal-third fractures in Fraser type I floating knee injuries. Larger prospective studies are required to validate these findings.

Background: Hospital-acquired COVID-19 presents a distinct challenge in orthopaedic care within low- and middle-income country (LMIC) settings, where prolonged isolation, delayed mobilization and system constraints increase immobilization-related morbidity. Unlike high-income settings that emphasize respiratory outcomes, LMIC orthopaedic inpatients appear to face a disproportionate burden of thromboembolic complications, particularly deep vein thrombosis (DVT). Methods: A retrospective cohort study was conducted at a South Indian teaching hospital between January 2020 and December 2025. Orthopaedic inpatients with RT-PCR–confirmed COVID-19 were categorized as having nosocomial or community-acquired infection based on timing of diagnosis. Demographic data, injury and treatment characteristics, immobilization duration, comorbidity burden, thromboprophylaxis use and vitamin D status were analysed. DVT was diagnosed using duplex ultrasonography and multivariable logistic regression identified independent predictors. Results: Of 217 patients (median age 48 years; 68.2% male), 68 developed nosocomial COVID-19. Hospital-acquired infection was associated with significantly longer hospital stay and immobilization. Overall DVT incidence was 11.1%, with a higher prevalence in nosocomial compared with community-acquired cases (19.1% vs. 7.4%). Nosocomial infection, immobilization exceeding seven days and vitamin D deficiency independently predicted DVT. In-hospital mortality did not differ between groups. Conclusion: Hospital-acquired COVID-19 significantly increases DVT risk among orthopaedic inpatients in LMIC settings, driven primarily by prolonged immobilization. Preventive strategies should prioritize early mobilization, optimized isolation workflows and correction of modifiable risk factors to reduce avoidable thromboembolic morbidity.

Total hip and knee arthroplasty volumes are increasing worldwide and neuraxial anaesthesia is often preferred over general anaesthesia because of perceived perioperative benefits. However, much of the available evidence is derived from observational studies and may be influenced by selection bias and confounding by indication. This narrative review synthesised contemporary literature from PubMed and Google scholar up to December 2025, focusing on large cohort, registry and administrative database studies comparing the two techniques in primary THA and TKA. Across multiple datasets, neuraxial anaesthesia was associated with lower mortality, fewer complications, reduced transfusion requirements and shorter hospital stay. However, patients receiving general anaesthesia consistently had higher baseline risk profiles, including older age, higher ASA status and greater comorbidity burden, along with more frequent contraindications to neuraxial techniques. Although multivariable adjustment and propensity score matching reduced the magnitude of these differences, the overall trends favouring neuraxial anaesthesia persisted. Importantly, residual confounding from unmeasured factors such as frailty, spinal pathology and institutional practices remains a key limitation. Overall, while neuraxial anaesthesia appears to offer favourable perioperative outcomes, the evidence is largely observational and should be interpreted with caution. Anaesthetic choice should be individualised and context-specific, especially in resource-limited settings and future research should focus on randomised trials and risk-stratified decision-making approaches.

Background: Periprosthetic joint infection (PJI) after revision total hip arthroplasty (THA) poses significant wound-management challenges. Outcomes following vacuum-assisted closure (VAC) therapy vary and may be influenced by regional microbiology and host soft-tissue characteristics. Methods: This retrospective comparative cohort study (2019-2025) included adults undergoing revision THA for chronic PJI at a tertiary center. Patients were grouped by geographic origin: India (n=20) and Democratic Republic of Congo (DRC; n=18). Demographics, microbiology, postoperative wound gaping, debridement and VAC sessions, soft-tissue reconstruction, and time to complete wound healing were analysed using non-parametric statistics. Results: The Indian cohort was younger (60.3 vs 67.8 years; p=0.010) but required more debridement’s (3.1 vs 2.3; p=0.031), VAC sessions (2.7 vs 1.6; p=0.003), and flap reconstructions (70% vs 22%). Initial wound gaping occurred at a similar postoperative interval in both cohorts; however, healing time was significantly longer in Indian patients (36.8 vs 18.2 days; p=0.002). Klebsiella predominated in the Indian cohort, whereas Pseudomonas was more common in DRC patients. Conclusions: Geographic differences in wound behaviour following revision THA for PJI suggest that regional microbiology and host soft-tissue factors influence VAC effectiveness and healing outcomes, supporting population-specific wound management strategies.

Enchondromas of the proximal humerus are benign cartilaginous lesions frequently identified incidentally during magnetic resonance imaging (MRI) performed for shoulder pain. Their coexistence with rotator cuff tears, particularly supraspinatus tears, creates diagnostic uncertainty regarding the primary pain generator and may influence management strategies. Evidence guiding treatment in such dual-pathology scenarios remains limited. This case series evaluates five consecutive patients (mean age 47.4 years) presenting with symptomatic full-thickness supraspinatus tears and incidental proximal humeral enchondromas. All patients underwent arthroscopic double-row rotator cuff repair without intervention for the osseous lesion, followed by a standardized rehabilitation protocol. Clinical outcomes were assessed using Visual analog scale (VAS) and Oxford shoulder score (OSS) over a 2-year follow-up period. All patients demonstrated excellent clinical outcomes, with VAS scores improving from 8 to 9 preoperatively to 0 to 1 at final follow-up and mean OSS improving from 24.2 to 46.0. No rotator cuff re-tears or lesion-related complications were observed. Serial imaging confirmed radiological stability of the enchondromas, supporting their benign and incidental nature. These findings suggest that in patients with concomitant rotator cuff tears and proximal humeral enchondromas, symptoms are primarily attributable to rotator cuff pathology. Arthroscopic repair alone yields favourable outcomes, while stable enchondromas can be safely managed with observation. Accurate clinic-radiological correlation is essential to avoid unnecessary surgical intervention for incidental benign lesions.

This case series evaluated the outcomes of arthroscopic repair in five patients aged over 40 years with chronic medial bucket-handle meniscal tears, with a mean symptom duration of nine months. All patients demonstrated intraoperative adhesions (60% classified as major) along with grade 1 to 2 chondral changes. Despite attempted repair, a 100% failure rate was observed within 2 to 5 months, necessitating subsequent meniscectomy in all cases. Functional outcomes, as measured by the IKDC score, showed only modest improvement following repair (38.2%-54.0%), but improved substantially after meniscectomy (77.5% at one year; mean gain of 39.5%). Similarly, pain scores (VAS) demonstrated significant reduction only after meniscectomy (6.6-2.4). These findings suggest that in middle-aged patients with delayed presentation of chronic bucket-handle tears, the likelihood of repair failure is high, and primary or early meniscectomy may represent a more pragmatic treatment strategy.

Computed tomography (CT) -guided percutaneous bone biopsy is a cornerstone technique in the diagnostic evaluation of musculoskeletal lesions, offering high diagnostic accuracy with lower morbidity and cost compared with open surgical biopsy. Despite its widespread use, diagnostic yield varies considerably across studies, influenced by lesion biology, anatomical location and modifiable technical factors. Non-diagnostic sampling remains a clinically relevant problem, particularly in sclerotic, occult and necrotic or cystic intraosseous lesions, often leading to repeat procedures and delayed definitive management. This narrative review synthesizes current evidence on the diagnostic performance of CT-guided musculoskeletal bone biopsy and organizes predictors of biopsy success into lesion-related, site-related and technique-related domains. Particular emphasis is placed on technical strategies aimed at optimizing diagnostic yield and specimen adequacy, including meticulous pre-procedural planning, appropriate needle selection, multi-core sampling, use of on-site cytologic or histologic assessment and advanced imaging guidance for challenging lesions. Emerging low-cost innovations such as the “sandwich technique” are discussed as potential solutions for traditionally low-yield scenarios, especially in resource-constrained settings. The review also highlights important gaps in the existing literature, which is dominated by retrospective single-centre studies from high-income environments and underscores the need for prospective, protocol-driven, multicentre research using standardized outcome definitions and inclusive of low- and middle-income settings. Continued refinement and validation of pragmatic biopsy strategies are essential to reduce non-diagnostic rates, minimize repeat procedures and improve the efficiency and equity of musculoskeletal biopsy care worldwide.