Spinal cord stimulation (SCS) is an established therapy for refractory neuropathic pain following lumbar spine surgery and frequently allows for meaningful pain reductio, functional improvement, and minimizing reliance on pharmacotherapy and opioids. Despite its efficacy, hardware-related complications remain an important cause of treatment failure. We present a fictional teaching case of a 68-year old man with persistent bilateral radicular pain after lumbar decompression who experienced 80% relief following SCS implantation. Eight months later, after a motor vehicle collision, he developed abrupt loss of stimulation coverage and recurrence of severe neuropathic symptoms. This teaching case discusses appropriate next steps for evaluation and management in this particular clinical scenario.

Total Knee Arthroplasty (TKA) is a leading treatment for severe knee osteoarthritis, offering improved function and pain relief. While conventional TKA is well-established, robotic-assisted TKA provides enhanced precision in implant placement and soft tissue balance, potentially reducing surgery time and cost. However, its effectiveness and complication rates require further study to validate its benefits over conventional methods. This study aims to report the outcomes of CTKA and RTKA performed for the same patient as a bilateral staged TKA. It is a cross-sectional design conducted at a tertiary center. It includes collecting retrospective data on patients undergoing bilateral staged TKA performed by a single senior arthroplasty surgeon, analyzed using IBM SPSS 29.0.0. Our study analyzed 38 knee surgeries for 19 patients, split equally between robotic (RTKA) and conventional (CTKA) methods. Both groups showed similar demographics and surgical settings. RTKA had a longer mean operative time (105.3 minutes, SD=12.9) compared to CTKA (81.4 minutes, SD=10.8, p<0.001) and a shorter hospital stay (4.2 days vs.5.6 days, p=0.006). Complications were minimal, with no significant differences in blood loss, post-operative complications, or narcotic use after three weeks between the groups. Both groups showed significant functional gains with KOOS improved from 14.2-16.8 to 84.4-87.0 (p < 0.001), and WOMAC decreased from 83.9-85.3 to 18.5-26.2 (p < 0.001). Subdomain analysis revealed greater pain improvement in conventional TKA and superior daily activity and QoL gains in robotic TKA (p < 0.001). Our study reveals that robotic-assisted TKA results in longer operative periods, but shorter hospital stays compared to conventional TKA. Both methods show similar rates of blood loss, complications, and post-operative narcotic use. Robotic TKA offered better recovery in daily activities and quality of life while conventional TKA achieved greater pain reduction. Overall, both methods proved safe and effective for functional improvement after knee replacement.

Nerve injury is an uncommon but consequential complication following total hip arthroplasty (THA), with outcomes that range from full recovery to persistent long-term deficits. Despite decades of research, uncertainty remains regarding its true incidence, risk factors, and prognosis. This systematic review and meta-analysis synthesized data from 17 studies encompassing diverse designs, including large database analyses and focused case series. Clinical characteristics, surgical factors, nerve-injury patterns, management strategies, and recovery outcomes were extracted. Pooled proportions were calculated using a random-effects model, and predictors were assessed through meta-regression. Across 17 studies, the most frequently affected nerves were the sciatic, peroneal, and femoral branches, with the peroneal division consistently identified as most vulnerable. Immediate postoperative presentation was common, particularly in injuries related to traction, limb lengthening, or retractor compression, while delayed-onset injuries were often linked to hematoma, screw prominence, or pseudotumor formation. Pooled incidence of nerve injury after THA was 0.36% (95% CI 0.35-0.37%). Complete recovery occurred in 48.6% (95% CI 33.9-63.3%), whereas 50.5% (95% CI 36.0-65.0%) experienced residual deficits. Reoperation was required in 33.1% (95% CI 4.2-62.0%), and 39.8% (95% CI 25.1-54.4%) had permanent neurological impairment. Orthotic use was common due to persistent dorsiflexion weakness. Meta-regression identified comorbidity burden as the only significant predictor of nerve injury. Nerve injuries after THA remain clinically significant, with substantial variability in presentation, recovery, and long-term disability. Early detection, careful surgical technique, and risk stratification especially in patients with the multiple comorbidities are very important for prevention and improved outcomes.

Periprosthetic joint infection (PJI) remains one of the most devastating complications of total joint arthroplasty (TJA), with profound clinical, economic and psychosocial consequences. While modern operating theatres are designed to reduce microbial load, there remains ongoing debate about the role of laminar airflow (LAF), turbulent ventilation, high-efficiency particulate air (HEPA) systems, ultraviolet adjuncts and surgical helmet systems (SHS) in mitigating infection risk. This narrative review synthesizes current evidence on airborne contamination, environmental controls and adjunctive measures in orthopaedic theatres. It highlights key advances in monitoring (e.g., particle counts vs.microbiological sampling), the impact of human behaviour on contamination and integrates findings with patient risk factors, operative efficiency and seasonality. It further examines economic and regulatory perspectives, providing a holistic framework for future directions in infection prevention.

Obligatory dislocation of the patella is a type of patellar instability characterized by the consistent lateral dislocation of the patella during knee flexion. Adult cases are uncommon and frequently difficult to manage, with no consensus on the most effective reconstructive approach. We report a-31-year-old male with lifelong ambulatory difficulty and a painless, irreducible lateral patellar dislocation. Surgical management included lateral release, quadriceps lengthening, semitendinosus tenodesis, and anteromedial tibial tubercle transfer. Postoperative imaging confirmed proper patellar alignment (Insall-Salvati ratio 1.2; Caton-Deschamps ratio 0.8). At six- and twenty-months follow-up, the patient achieved improved range of motion, flexion of 115 degrees and extension of 0 degrees with satisfactory function Tegner Lysholm score of 85 and the IKDC score of 80.5. Obligatory dislocation of the patella often involves proximal abnormalities, proximal realignment is generally prioritized, though distal realignment via tibial tubercle anteromedial transfer also reduces patellofemoral contact stress. Given the limited literature on adult obligatory dislocation of the patella, combining proximal and distal realignment may offer superior outcomes. This case demonstrates that a combined proximal and distal realignment technique can successfully restore patellar tracking and function in adult obligatory dislocation of the patella. Considering the limited evidence available, this strategy could potentially be a significant option for addressing complex adult cases.

Femoroacetabular impingement syndrome (FAIS) is a major cause of chronic hip pain and early osteoarthritis. Surgical correction, traditionally via open surgical dislocation and increasingly via hip arthroscopy, aims to restore hip function by correcting bony morphology. While both techniques address cam and pincer lesions, the long-term implications of the surgical approach and specific impingement morphology on five-year structural outcomes, including hip instability, osteoarthritis (OA) progression, and conversion to total hip arthroplasty (THA), remain poorly defined. We conducted a retrospective cohort study using the TriNetX US Collaborative Network, analyzing de-identified electronic medical records from 2,725 patients (2,321 arthroscopic, 404 open) who underwent FAIS correction between 2003 and 2023 with a minimum five-year follow-up. Patients were grouped by surgical approach (Arthroscopic vs.Open) and morphology (Cam-only vs.Pincer-only vs.Mixed). Primary outcomes were five-year cumulative incidence and time-to-event incidence (Hazard Ratio, HR) of hip instability/dislocation, hip OA, and THA conversion. In patients with mixed FAIS morphology, the arthroscopic approach was associated with a significantly lower risk of instability/dislocation (3.7% vs.11.6%; HR 0.393, p<0.001) compared to the open approach. Conversely, the open approach demonstrated a lower incidence of hip OA (4.6% vs.7.8%; HR 2.320, p=0.001 favoring open). Although the overall five-year THA incidence was equal (2.4%), arthroscopy had a significantly higher hazard of conversion (HR 6.112, p=0.004). Subgroup analysis found no statistically significant difference in instability, OA, or THA rates between cam and pincer morphologies within either the arthroscopic or open cohort. Surgical approach significantly impacts five-year structural outcomes in FAIS correction. Arthroscopy offers superior early joint stability, but the open approach may be associated with a more protective effect against long-term OA progression. Impingement morphology (cam vs.pincer) did not independently influence these five-year outcomes. These findings support a trade-off between approaches and highlight the need for tailored surgical selection to optimize joint preservation.

Accurate assessment of skeletal maturity is essential in pediatric orthopedics, particularly in the management of adolescent idiopathic scoliosis (AIS), where remaining growth potential strongly influences treatment decisions. The Risser sign remains a widely used radiographic indicator of skeletal maturity. Accurate assessment of skeletal maturity is essential in pediatric orthopedics, particularly in the management of adolescent idiopathic scoliosis (AIS), where remaining growth potential strongly influences treatment decisions. The Risser sign remains a widely used radiographic indicator of skeletal maturity. A modified staging system incorporating triradiate cartilage status and refined iliac crest ossification stages has been proposed to improve characterization of early skeletal maturation. However, data describing the relationship between chronological age and these stages remain limited. However, data describing the relationship between chronological age and Risser+ stages remain limited. To evaluate the relationship between chronological age and Risser+ stages and to assess sex-related differences in skeletal maturation timing and progression. This retrospective observational study included pelvic radiographs obtained at a single tertiary center between October 2024 and March 2025. A total of 588 radiographs were initially identified; after exclusion of studies with inadequate image quality or incomplete data, 535 radiographs from patients aged 8-20 years were included in the final analysis. Skeletal maturity was assessed using the Risser+ classification. Age distributions across stages were analyzed using descriptive statistics and independent-sample t-tests. Stage-to-stage progression was evaluated in a subset of 123 patients with serial radiographs. Inter- and intra-observer reliability of Risser+ staging were assessed using Cohen's kappa coefficient. Chronological age increased progressively with advancing Risser+ stages, from a mean of 10.69 years at stage 0 (-) to 15.82 years at stage 5. Females reached stages 1-3 at significantly younger ages than males (p ≤ 0.05), with small to moderate effect sizes, whereas no significant sex differences were observed at stages 0+, 4, or 5. Among patients with serial radiographs, the mean stage-to-stage progression interval was 10.5 ± 9.1 months, with the longest transition occurring between stages 4 and 5 (13.96 months). No statistically significant differences in progression tempo were detected between sexes. Reliability analysis demonstrated excellent reproducibility of Risser+ staging (inter-observer κ = 0.907; intra-observer κ = 0.893). Chronological age shows a consistent relationship with Risser+ stages, supporting the clinical utility of this classification in skeletal maturity assessment. Sex-related differences are most evident during early maturation stages, with females reaching equivalent stages earlier than males. Distinguishing between Risser 0(-) and 0(+) further refines early maturity assessment and may improve interpretation of pelvic radiographs in the management of AIS.

Benzodiazepines are frequently administered in orthopedic anesthesia for anxiolysis, sedation, amnesia, and seizure prophylaxis. Their role continues to evolve with the growing use of regional anesthesia, outpatient joint procedures, and enhanced recovery after surgery (ERAS) pathways. This narrative review examines the pharmacology, mechanisms of action, clinical indications, contraindications, and key clinical studies of benzodiazepines commonly used in the operating room in the United States, with a specific focus on their application in orthopedic surgical practice.

Craniofacial hyperplasia is a disorder where the face and head do not fully develop. This leads to difficulties in airway management in those undergoing general anesthesia (GA), requiring consideration in anesthetic planning with GA and intubation versus approaches with regional/spinal anesthesia. A 54-year-old male (45 kg, 172.7 cm) presented for a penile implant insertion for severe erectile dysfunction following radical prostatectomy. He was classified as ASA physical status class III. Pertinent medical history included craniofacial hypoplasia from childhood surgical interventions and radiation for sinus cancer (rhabdomyosarcoma), moderate mitral regurgitation, mild tricuspid regurgitation, pulmonary hypertension, recurrent esophageal strictures, and anemia. Spinal anesthesia was selected over GA. Airway complications were avoided, and cardiopulmonary stability was preserved while maintaining adequate analgesic coverage. Craniofacial hypoplasia patients require individualized anesthesia planning that anticipates complications. Spinal anesthesia can be used in these patients to avoid airway and hemodynamic complications.

Bone metastases cause pain and disability in advanced prostate, breast, and lung cancers. Traditional treatments may not work for all patients. Minimally invasive procedures such as cryoablation (CA) and radiofrequency ablation (RFA) have emerged as good options. This review aims to evaluate and summarize the effectiveness and safety of CA and RFA separately in managing painful bone metastases. We performed a comprehensive search of Ovid Medline, Google Scholar, Web of Science, CENTRAL, and ClinicalTrials.gov covering studies published between January 2000 and January 2025. The search included English-language cohorts. or randomized trials of adults (≥18 years) with bone metastases treated using RFA or CA. Outcomes such as pain levels, tumor recurrence, and adverse events were collected from each study. To assess the quality and reliability of the studies, we used the Cochrane Risk of Bias 2 (RoB 2) tool for randomized trials and the ROBINS-I tool for nonrandomized studies. We performed separate single-arm meta-analyses for RFA and for CA and integrated findings from the small number of direct comparative studies using a narrative synthesis.We performed separate single-arm meta-analyses for RFA and for CA and integrated findings from the small number of direct comparative cohort studies using a narrative synthesis. A total of 30 studies involving 1121 patients were included in the qualitative synthesis, and 24 were included in the meta-analysis. Separate single-arm meta-analyses revealed that both radiofrequency ablation (RFA) and cryoablation (CA) significantly reduced pain at all follow-up timepoints. RFA had the greatest pain reduction at 6 months (SMD: -3.50; 95% CI: -4.42, -2.27), whereas CA had a greater effect at 24 hours (SMD: -2.43; 95% CI: -3.84, -1.02) but ,a smaller effect at 6 months (SMD: -2.14; 95% CI: -3.43, -0.85). Both were safe, with mostly mild adverse events. The reported tumor control outcomes have been inconsistent, limiting conclusions in this area. On separate analyses, CA appeared to produce larger short-term effect sizes (greater early pain reduction) while RFA had larger medium/long-term effect sizes in the available studies. Because direct comparative data are sparse and heterogeneous, these observations do not establish superiority of one modality over the other. Both techniques demonstrated favorable safety profiles across included studies. Ablation combined with external beam radiation therapy (EBRT) was superior to either modality alone. Standardized measures and more comparative studies are needed to guide treatment.