Spectrum of Orthopaedic Disorders

Orthopaedic disorders span arthritis of the knee and hip, childhood hip conditions, avascular necrosis, ligament tears, fractures that fail to heal, bone infection and limb loss after blast injury. Evaluation of a painful joint draws on blood tests and inflammatory markers, a standing X-ray, and MRI when the X-ray cannot explain the pain. Treatment then escalates from physiotherapy and injections to joint-preserving surgery, replacement and staged reconstruction.

Dr. Rohit Lamba is an orthopaedic and joint replacement surgeon; at the time of this April 2025 session he was Consultant, Orthopaedics & Joint Replacement at Artemis Hospitals, Gurugram, India. He built the session around his own operating list rather than a textbook classification, and many of the patients he presented had travelled from Africa for treatment. The result is a practical map of the spectrum of orthopaedic disorders a referring doctor is likely to meet, and of what each one needs once it reaches a surgeon.

This guide sets out that map. Two companion articles go deeper: one on the causes of knee arthritis, its diagnosis and complex knee replacement, and one on when hip replacement is needed for avascular necrosis, DDH, Perthes disease and sickle cell disease. Trauma and limb reconstruction, which has no separate article, is covered in full below.

How orthopaedic disorders are evaluated

Evaluation starts with the cause, not the pain. Two patients with the same stiff, painful knee may have entirely different diseases, and the treatment that suits one can fail the other.

Across the cases Dr. Lamba presented, evaluation follows three steps:

1. Blood tests. Routine tests first, then inflammatory markers: the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), which rise with inflammation, and anti-CCP (anti-cyclic citrullinated peptide antibodies), a marker of rheumatoid arthritis.
2. A standing X-ray. The knee is X-rayed with the patient standing, because body weight closes the joint space and shows, in his words, the condition of the cartilage "in the best way possible".
3. MRI when the X-ray is normal. Avascular necrosis of the hip, the death of bone when its blood supply fails, is the clearest example: the patient has pain, the X-ray looks normal, and only an MRI scan shows the disease. The same scan is the investigation of choice for a loose knee, because it shows the ligaments and the meniscus, the shock absorber inside the joint.

How orthopaedic disorders are treated: the treatment ladder

Once the cause is known, treatment climbs a ladder, and the patient stays on the lowest rung that works.

• Exercise and physiotherapy for early disease.
• Injections into the joint in selected cases: viscosupplementation, a lubricating gel injected into the joint, or platelet-rich plasma (PRP), a concentrate prepared from the patient's own blood. The evidence for both is mixed, and major guidelines do not recommend either routinely for knee osteoarthritis.
• Medication for inflammatory arthritis. Rheumatoid arthritis caught before the cartilage is damaged can be managed very well with medicines, as described below.
• Joint-preserving surgery. In early avascular necrosis of the hip (stages 1 and 2), medication or a small operation called core decompression (drilling into the dead bone to relieve pressure inside it) with stem cell grafting can sometimes save the joint.
• Joint replacement once the cartilage or the shape of the joint is damaged beyond repair.
• Staged reconstruction for non-union, infection and bone loss, where the aim is to rebuild bone before function can return.

Rheumatoid arthritis treatment: medicine first, surgery when cartilage is gone

Asked whether arthritis has a definitive treatment, Dr. Lamba answered for rheumatoid arthritis, an inflammatory disease in which the patient's own immune system damages the joint. In the early stage, before cartilage damage develops, it can be managed very well with disease-modifying antirheumatic drugs (DMARDs). Cases that do not respond can be treated with biological disease-modifying drugs, which he said work very well. Both should start only after a complete evaluation by an orthopaedic surgeon or a rheumatologist.

Once the cartilage is already damaged, the definitive treatment is hip replacement. With the hip implants he uses, Dr. Lamba said a patient can be pain-free, active and doing almost all of their activities for many years. Registry data show that almost 90% of hip replacements last 15 years and nearly 60% last 25 years; implant survival in any individual depends on age, activity and bone quality.

Knee arthritis and robotic joint replacement

Knee arthritis has four main causes: osteoarthritis from age, rheumatoid arthritis, arthritis after a fracture or injury, and gout. Most of the knee cases Dr. Lamba presented were difficult ones: a knee with an old, badly healed fracture above the joint, a knee left completely stiff after a gunshot injury, and a knee in which almost 30% of the bone had been lost to arthritis.

For those knees he uses computer navigation, which tracks alignment, bone cuts and implant position during the operation, and a robotic system, which plans the bone cuts from a CT scan before the first incision and then performs the major part of the cutting with a robotic arm. In one case the robot allowed a severely deformed knee to be reconstructed with basic implants alone. The full detail is in the companion article on knee arthritis causes, diagnosis and complex replacement, linked above.

When hip disorders need hip replacement

Hip replacement is needed in four groups of patients, by Dr. Lamba's classification: congenital deformity such as developmental dysplasia of the hip (DDH), in which the hip socket is shallow from birth and the hip may sit partly or completely out of it; childhood infection of the hip, Perthes disease (damage to the blood supply of the hip bone in childhood) or a displaced growth plate that leaves the hip abnormally shaped; avascular necrosis in early adulthood that has progressed to arthritis; and a fracture around the hip that has not united or has united in the wrong position.

Sickle cell disease adds a further layer of risk. It causes avascular necrosis by blocking the blood vessels of the hip, and the patient cannot be operated on safely until the proportion of sickle haemoglobin in the blood has been reduced by exchange blood transfusion. Each of these conditions is covered in depth in the companion article on when hip replacement is needed, linked above.

Trauma and limb reconstruction

Trauma and limb reconstruction rebuilds bone, joints and soft tissue after ligament tears, fractures that fail to heal, bone infection and blast injury, often in stages. Trauma produced some of the most demanding cases in the session. Dr. Lamba told the audience that the patients in this part of the session were all from Africa, and that they may also see such injuries from war, blasts and accidents.

Knee ligament injury and reconstruction

A torn knee ligament leaves the joint loose: on examination, the shin moves forwards and backwards on the thigh bone. An MRI scan shows the state of the ligament and of the meniscus. The new ligament is made from a tendon graft taken from the patient's own body and placed inside the knee. When two or three ligaments need reconstruction at once and there are not enough tendons to harvest, an artificial graft material can be used instead. Costs for the standard single-ligament operation are on the arthroscopic ACL reconstruction cost page.

Fracture non-union treatment

A fracture that is not fixed well can fail to unite, a condition called non-union, and the implant holding it can then fail too. In the case Dr. Lamba showed, he removed the old implant, placed a long rod inside the bone and added bone graft to stimulate healing.

Bone infection after a fracture

Infection in a fractured bone kills part of it, and dead bone keeps the infection going. In his words, until the dead bone is taken out, it will keep causing infection. His approach is radical: remove all the dead bone, even when that leaves a large gap, then apply an external fixator, a frame outside the limb held to the bone by pins, and use it to grow new bone across the gap.

Blast injury of the elbow

One patient arrived after a blast injury with his hand already amputated and his elbow shattered. The reconstruction ran in stages: an external fixator first, then a flap (living tissue moved to cover exposed bone and close the wounds), and finally fusion of the elbow. With an artificial prosthesis he can now hold a pen and write.

Large bone loss and distraction osteogenesis

After war injuries, blasts or accidents, a large segment of bone can be lost altogether. Dr. Lamba rebuilds it by distraction osteogenesis: the bone is cut, and a fixator pulls the two ends apart very slowly, so that new bone forms in the widening gap. In the case he showed, the fixator regenerated the whole missing segment, and the patient was able to stand, walk and return to all of his work. The limb lengthening and Ilizarov frame cost page covers this family of procedures.

Rickets and knee deformity in children

Vitamin D deficiency in childhood causes rickets, in which growing bone is too soft to hold its shape, and the knees can bend into an angular deformity. Treated at the right time, the deformity can be prevented; left untreated, it ends in surgery. Dr. Lamba closed the session with such a child, whose X-rays before and after the operation showed both knees straightened. Corrective surgery for this kind of deformity ranges from guided growth in younger children, which steers the growth plates, to a corrective osteotomy, in which the bone is cut and realigned; the corrective osteotomy cost page covers the latter.

Key principles in treating orthopaedic disorders

Three principles run through every case in the session. First, the cause decides the treatment: a knee left stiff by a gunshot wound and a knee weakened by steroids in rheumatoid arthritis each need their own implant choice and planning. Second, early diagnosis keeps patients on the lower rungs of the ladder: rheumatoid arthritis treated before cartilage loss, avascular necrosis caught on MRI at stage 1 or 2, and rickets treated before the knees bend can all avoid major surgery. Third, when surgery is needed, technology and staging make the difficult cases possible: robots and navigation for deformed joints, transfusion before surgery in sickle cell disease, and fixators that grow new bone where the old bone was lost.

Questions the audience put to Dr. Lamba are on the Live Discussion page. For related series by other surgeons, see Dr. Ramkinkar Jha's guide to hip and knee replacement surgery and Dr. Rakesh Mahajan's guide to complex total hip arthroplasty. The full range of conditions is on the orthopaedics specialty page.