Sahas Nithyanand

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.

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.

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.