Autor: Tomasz Poboży

Polish version: Robotyczna TKA bez przewagi po roku — wyniki badania RACER-Knee

Greater technical precision does not necessarily produce better clinical outcomes. RACER-Knee, a pragmatic multicentre randomized trial published in The Lancet on 20 August 2026, compared Mako-assisted total knee arthroplasty (TKA) with conventional surgery. Robotic assistance did not produce a clinically important improvement in the primary endpoint at 12 months.

Why this study matters

Component positioning and soft-tissue balance are important technical measures, but patients primarily experience pain, function, safety and durability. RACER-Knee tested whether robotic assistance translated into a perceptible clinical benefit. The trial involved 33 surgeons at 10 UK hospitals. Patients and assessors were masked, with measures including additional dressings and sham incisions to conceal allocation.

Study design

Patients with advanced knee osteoarthritis undergoing primary TKA received conventional instrumentation or Mako-assisted surgery. Exclusions included inflammatory arthropathy, previous fractures in the operated limb and cases requiring more complex implants.

Of 807 people assessed, 339 were randomized 1:1: 168 to robotic and 171 to conventional TKA. The primary outcome was Forgotten Joint Score (FJS) at 12 months, analysed by intention to treat. The prespecified minimum clinically important difference was 12 points.

Main results

At 12 months, mean FJS was 49.2 in the robotic group (SD 28.4; n = 154) and 50.2 in the conventional group (SD 29.9; n = 158). The adjusted mean difference was −1.5 points (95% CI −7.5 to 4.5; P = 0.62).

The confidence interval remained well short of the prespecified 12-point clinically important difference. Thus, the finding was more informative than a simple nonsignificant P value: it provided no signal of a noticeable patient benefit at 1 year.

Sixteen patients in each group experienced at least one serious adverse event. Robotic surgery was more expensive, although the public abstract did not report the exact cost difference.

Clinical interpretation for an orthopaedic surgeon

In this population, with this system used pragmatically, greater technical precision did not translate into better patient-reported outcomes at 12 months. Evaluation of robotics should therefore consider clinical outcomes, safety, costs and service delivery alongside component alignment and balancing accuracy.

Limitations

• The trial evaluated Mako, so findings cannot automatically be generalised to all robotic systems or future technology.
• The primary assessment was at 12 months; longer follow-up is ongoing.
• More complex cases, previous fractures and inflammatory arthropathies were excluded.
• The trial was not designed to establish long-term implant survival or revision risk.
• It does not determine whether selected subgroups benefit more from robotics.

Implications for practice

RACER-Knee weakens the claim that using a robot alone ensures a better TKA outcome. It does not show that robotics has no value, exclude benefits in selected indications, establish identical long-term results or resolve differences between all alignment strategies. At 1 year, Mako-assisted TKA did not offer a clinically important advantage over well-performed conventional surgery.

References

Parsons H, Metcalfe A, Griffin J, Khatri C, Bradley H, Blyth M, et al.; RACER-Knee trial team. Robotic-arm-assisted versus conventional total knee replacement (RACER-Knee): a pragmatic, multicentre, participant-masked and assessor-masked, superiority, randomised controlled trial. The Lancet. Published online 20 Aug 2026; issue publication Sep 2026. DOI: 10.1016/S0140-6736(26)00986-4. PubMed PMID 42624811.

The publication is open access under CC BY 4.0.

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For Doctors and Physiotherapists · Research Updates, Literature and Evidence-Based Medicine

Content prepared by: Tomasz Poboży - orthopaedic surgeon.

Polish version: PRP w chorobie zwyrodnieniowej kolana — co pokazuje metaanaliza badań z placebo?

A meta-analysis and meta-regression published on 17 August 2026 in Knee Surgery, Sports Traumatology, Arthroscopy examined not only whether platelet-rich plasma (PRP) benefits knee osteoarthritis, but which patient and preparation characteristics might influence outcomes. Only placebo-controlled randomized trials were included.

Why this study matters

PRP is not a single standardised product. Preparations differ in platelet concentration, leukocyte content, activation, volume and number of injections. These differences limit extrapolation from one preparation system to another. The authors investigated whether age and PRP characteristics could explain some of the heterogeneity.

Review methods

Three databases were searched through 25 May 2025 for placebo-controlled RCTs of intra-articular PRP in knee osteoarthritis. Pain and function were assessed at 6 and 12 months. Twenty studies included 26 PRP groups with 1,774 patients and 20 placebo groups with 1,518 patients. Random-effects meta-analysis was followed by meta-regression using patient-related and preparation-related variables.

Main results

PRP was associated with significantly better pain and function than placebo at both 6 and 12 months. The authors described the effect as large, while rating the certainty of evidence as very low.

At 6 months, younger age, a higher platelet enrichment factor and calcium chloride activation were associated with better outcomes. Leukocyte-rich PRP was associated with better knee function. At 12 months, none of the assessed moderators explained the PRP advantage.

Preparation characteristics were not independent: PRP type and platelet concentration were correlated, limiting attribution of effects to any single parameter.

Clinical interpretation for an orthopaedic surgeon

The label “PRP” is insufficiently precise when products differ biologically. Variation in composition may contribute to variation in clinical outcomes. The age association is plausible but does not define an eligibility threshold: younger patients may also have less advanced disease, different activity levels or a different biological profile. Study-level meta-regression cannot separate these relationships as reliably as direct randomized comparisons of tightly standardised products.

Limitations

• Certainty in the benefit over placebo was very low.
• Meta-regression identifies associations between study characteristics and outcomes, not causation.
• Correlated preparation parameters prevent identification of a single optimal ingredient.
• PRP characteristics were inconsistently and incompletely reported.
• Moderators explained some differences at 6 months but not at 12 months.

Implications for practice

The findings support more detailed reporting of PRP composition in research and clinical records, with interpretation in the context of age and patient phenotype. They do not yet justify routinely preferring leukocyte-rich PRP or calcium chloride activation.

The study does not establish LR-PRP as superior to LP-PRP for an individual patient, identify an optimal platelet concentration or support automatic eligibility based on younger age. These are hypotheses requiring direct, well-standardised comparisons.

References

Delgado D, Andrade R, Gomes E, Lopes T, Azofra J, Espregueira-Mendes J, Sánchez M. Younger age and platelet-rich plasma characteristics influence short-term outcomes in knee osteoarthritis, but independent effects remain uncertain: A systematic review with meta-analysis and meta-regression of placebo-controlled randomised trials. Knee Surg Sports Traumatol Arthrosc. 2026 Aug 17. DOI: 10.1002/ksa.70567. PubMed.

This summary is based on the publicly available abstract and publication metadata.

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Content prepared by: Tomasz Poboży - orthopaedic surgeon.

Polish version: LET przy rekonstrukcji ACL — mniej uszkodzeń przeszczepu, bez przewagi w powrocie do sportu

Lateral extra-articular tenodesis (LET) is an adjunct to ACL reconstruction (ACLR) for selected patients at higher risk of persistent rotational instability or graft failure. A meta-analysis of randomized trials in the Orthopaedic Journal of Sports Medicine supports benefits for graft survival and pivot-shift control, without showing improvement in every outcome that matters to patients.

Why this study matters

Patient selection must balance insufficient rotational control after isolated ACLR against possible overconstraint and altered lateral compartment loading after an additional procedure. Alkhunein and colleagues restricted their review to randomized trials of primary ACLR. The article was published on 21 August 2026 and is available in full text.

Review methods

The review compared primary autograft ACLR with and without LET for stability, graft failure, function and return to sport. It followed PRISMA 2020 and was registered in PROSPERO (CRD420251070504). Multiple databases were searched through 1 October 2025. Eleven RCTs involving 1,419 patients entered the systematic review; one was excluded from the final meta-analysis because of serious statistical calculation errors, leaving 10 RCTs for quantitative synthesis. Weighted mean age was approximately 23–24 years.

RoB 2 assessments rated four trials at low risk of bias, five as raising some concerns and two at high risk. Randomization alone therefore did not ensure uniformly high-quality evidence.

Main results

Seven trials reported graft failure. Adding LET was associated with an OR of 0.30 compared with isolated ACLR (P = 0.00001; I² = 0%). This is a large relative effect, but an odds ratio is not an absolute risk reduction. The analysis does not supply a universal number of failures prevented per 100 operations.

Positive pivot-shift findings also favoured ACLR plus LET: pooled OR 0.44 (P < 0.00001; I² = 0%). No significant advantage was found for KT-1000 or Lachman testing, suggesting a particular contribution to rotational control rather than improvement in every measure of laxity.

The mean Lysholm difference was 1.98 points. The reported subjective IKDC difference was 1.65 points, but the abstract and full text contained inconsistent P-value reporting for that outcome. It should not be treated as decisive evidence. The authors also considered the clinical importance of these small patient-reported differences uncertain.

LET did not significantly improve return to sport or return to the preinjury level. KOOS subscales and Tegner scores also showed no advantage.

Clinical interpretation for an orthopaedic surgeon

The findings strengthen the rationale for selective LET when reducing graft failure and controlling pivot-shift are priorities, particularly in young, highly active patients at increased risk of rotational instability. They do not justify automatically adding LET to every primary ACLR.

No subgroup analyses established effects by age, graft type, LET technique or risk profile, such as high-grade pivot-shift or participation in pivoting sports. Absolute benefits within these groups would be needed before defining a simple indication algorithm.

Limitations

Trials differed in technique, patient characteristics and follow-up. Several had less than 2 years of follow-up, potentially undercounting later failures and complications. Two of the 11 trials had high risk of bias, and one required exclusion from quantitative analysis because of statistical errors. Long-term concerns about overconstraint and lateral compartment loading remain incompletely resolved.

Implications for practice

The evidence increasingly supports additional lateral stabilisation for appropriately selected young patients returning to pivoting sports, especially with meaningful rotational instability or other failure risk factors. It does not demonstrate superior return-to-sport rates, define a mandatory age or pivot-shift threshold, or justify routine LET in every primary reconstruction. The long-term risk of degenerative change related to altered lateral compartment mechanics also remains uncertain.

References

Alkhunein F, Alrasheed K, Alrasheed R, et al. Anterior Cruciate Ligament Reconstruction With or Without Lateral Extra-articular Tenodesis: A Systematic Review and Meta-analysis of Comparative Outcomes From Randomized Controlled Trials. Orthopaedic Journal of Sports Medicine. 2026;14(8):23259671261470939. DOI: 10.1177/23259671261470939. PubMed.

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Content prepared by: Tomasz Poboży - orthopaedic surgeon.

Polish version: Blok PENG po endoprotezoplastyce biodra — możliwa ochrona siły bez stałej przewagi przeciwbólowej

A systematic review of 10 randomized trials presents a nuanced view of the pericapsular nerve group (PENG) block after total hip arthroplasty (THA). It may preserve quadriceps function better than some blocks, but does not consistently outperform other modern analgesic strategies. Its additional benefit alongside effective peri-articular infiltration may be small.

Why this study matters

PENG targets articular branches of the femoral and accessory obturator nerves while aiming to spare the main femoral nerve trunk and quadriceps strength. That goal matters in early mobilisation after THA. However, the literature is heterogeneous. Bravo and colleagues restricted their review to prospectively registered randomized trials without discrepancies between the registered protocol and publication, excluding many nominally randomized studies for methodological reasons.

Review methods

The review concerned adults undergoing THA. MEDLINE, EMBASE, CINAHL and Google Scholar were searched from inception to May 2026. Of 468 initially identified publications, 44 randomized trials underwent full-text assessment; 34 were excluded mainly because of inadequate prospective registration or discrepancies between registered and reported outcomes. Ten RCTs were included.

Comparators included intrathecal morphine, infra- and suprainguinal fascia iliaca blocks, quadratus lumborum block, L4 erector spinae plane block and peri-articular local anaesthetic infiltration. Outcomes included static and dynamic pain, opioid consumption, quadriceps weakness and function.

Main results

• PENG provided analgesia noninferior to 100 µg intrathecal morphine and better than infrainguinal fascia iliaca block.
• Analgesia and opioid requirements were similar to suprainguinal fascia iliaca, anterior quadratus lumborum and L4 erector spinae blocks, with possible advantages in early muscle strength.
• In one comparison with suprainguinal fascia iliaca block (SIFIB), quadriceps motor block occurred in 45% after PENG versus 90% after SIFIB at 3 hours, and 25% versus 85% at 6 hours.
• Effective peri-articular infiltration produced less movement pain during the first 6 hours and less resting pain during the first 48 hours than PENG.
• Adding PENG to a comprehensive peri-articular infiltration regimen provided little additional benefit.

Clinical interpretation for an orthopaedic surgeon

PENG is an option whose value depends on the overall analgesic pathway and mobilisation goals. Preserving quadriceps function may be particularly useful for very early mobilisation, but a well-designed multimodal regimen can provide similar or better analgesia without routinely adding another block.

The term “motor-sparing” does not mean that motor weakness is eliminated. Local anaesthetic may spread to the femoral nerve, and injectate volume matters. These considerations are relevant when physiotherapy begins soon after surgery.

Limitations

• Only 10 RCTs were included, with varying drugs, volumes, block techniques and background analgesia.
• Diverse comparators prevent a single effect estimate applicable to every ERAS protocol.
• Excluding 34 trials for methodological problems strengthened the selected evidence but reduced its volume.
• The review itself was registered in INPLASY only after completion, which the authors acknowledged as a limitation.
• Preserving muscle strength is most consequential where very early mobilisation is actually planned.

Implications for practice

The useful question is what PENG adds to a particular analgesic regimen. With effective peri-articular infiltration and multimodal treatment already in place, its incremental value may be limited. It remains a reasonable option when quadriceps preservation is a priority.

The review does not justify abandoning PENG or establish one universally optimal strategy after THA. Results cannot automatically be transferred between centres using different surgical approaches, infiltration regimens or mobilisation schedules.

References

Bravo D, Arancibia H, Manzanilla M, Jara Á, Pirotesak S, Aliste J, Tran DQ. Pericapsular nerve group block for total hip arthroplasty: A systematic review. J Int Med Res. 2026;54(8):3000605261476867. Published online 25 August 2026. DOI: 10.1177/03000605261476867. PubMed · Full text in PubMed Central.

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Content prepared by: Tomasz Poboży - orthopaedic surgeon.

Polish version: Krótki trzpień szyjkowo-fiksowany a zachowanie kości po endoprotezoplastyce biodra

Short stems do not all preserve bone in the same way. A Danish randomized trial found that the neck-fixated, non-diaphyseal Primoris stem was associated with higher bone mineral density (BMD) in selected Gruen zones at 2 years than the conventional Echo stem in younger patients with primary hip osteoarthritis. Patient-reported function did not show a measurable advantage.

Why this study matters

Stress shielding and periprosthetic bone loss remain concerns after uncemented total hip arthroplasty (THA), particularly when considering bone stock for future revision. Short stems aim to reduce distal load transfer and load the proximal femur more physiologically, but the category includes distinct biomechanical concepts. Tjønneland and colleagues compared two specific designs: neck-fixated Primoris and conventional Echo, which achieves metaphyseal fixation with diaphyseal engagement.

Study design

At Aalborg University Hospital in Denmark, 61 patients with primary hip osteoarthritis were randomized: 31 to Primoris and 30 to Echo. One Primoris patient was excluded after a periprosthetic fracture was identified at the 6-week review, leaving 60 in the final analysis.

The population was deliberately young and selected: women were no older than 55 and men no older than 65. Exclusions included osteoporosis, diabetes, rheumatoid arthritis, smoking and medication affecting bone metabolism. The primary outcome was periprosthetic BMD measured by DXA before surgery and at 6 weeks, 12 months and 24 months. EQ-5D, Oxford Hip Score and Forgotten Joint Score-12 were also assessed.

Main results

At 24 months, BMD was significantly higher with Primoris in three Gruen zones:

• Zone 3: difference 0.40 g/cm² (95% CI 0.26–0.53; P < 0.001).
• Zone 5: difference 0.20 g/cm² (95% CI 0.07–0.33; P = 0.003).
• Zone 7: difference 0.27 g/cm² (95% CI 0.14–0.41; P < 0.001).

The authors expressed these differences as approximately 19.1%, 9.1% and 14.3%, respectively, relative to Echo. The increase in zone 7 BMD from 6 weeks to 24 months was also greater with Primoris. Patient-reported outcomes improved similarly, with no significant between-group differences in EQ-5D, Oxford Hip Score or FJS-12.

Clinical interpretation for an orthopaedic surgeon

This trial separates a biological effect from a benefit perceived by patients. Greater proximal bone preservation could matter over many years and potentially assist future revision, but the 2-year trial did not demonstrate better function or quality of life. The results support proximal load transfer with this neck-fixated design, not superiority of every short stem over every conventional stem.

Limitations

• The study was small and conducted at one centre.
• Participants were younger and healthier than typical THA recipients; osteoporosis, diabetes and smoking were excluded.
• Only two stem models were compared.
• BMD is a surrogate endpoint. The trial was not designed to assess revision, aseptic loosening or late periprosthetic fractures.
• One Primoris patient was excluded after a periprosthetic fracture detected at 6 weeks.

Implications for practice

For selected younger patients, a neck-fixated design may preserve bone in parts of the proximal femur, which is of interest when long implant service and future bone stock matter. The study does not establish fewer revisions, fractures or loosening, demonstrate functional superiority, or determine safety in older patients with osteoporosis or poor bone quality. Larger studies and substantially longer follow-up are required.

References

Tjønneland A, Christiansen JD, Jakobsen T, Nielsen PT. Preservation of periprosthetic bone with a collum-fixated short stem versus conventional metaphyseal-fixated stems in total hip arthroplasty: a randomized controlled trial with 2-year follow-up in 61 patients. Acta Orthop. 2026;97:510–516. DOI: 10.2340/17453674.2026.46481. PubMed · Full text in PubMed Central.

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For Doctors and Physiotherapists · Research Updates, Literature and Evidence-Based Medicine

Content prepared by: Tomasz Poboży - orthopaedic surgeon.

Polish version: HbA1c przed endoprotezoplastyką kolana a ryzyko wczesnej sztywności po operacji

A study published online in The Journal of Arthroplasty on 24 August 2026 examined whether preoperative glycaemic control is associated with early arthrofibrosis after primary total knee arthroplasty (TKA). Higher HbA1c was associated with greater odds of manipulation under anaesthesia (MUA) or arthroscopic lysis of adhesions (aLOA) within the first 3 months.

Why this study matters

The association between diabetes and stiffness after TKA has been uncertain. A 2019 meta-analysis of 7 studies and 246,053 cases found no strong evidence of increased stiffness risk in patients with diabetes. The new analysis goes beyond a diabetes yes/no diagnosis by examining HbA1c strata and an endpoint reflecting clinically significant stiffness requiring intervention.

Study design

This retrospective database study included primary TKA procedures from 2006–2026. Patients were stratified by preoperative HbA1c: <5.7%, 5.7–6.9%, 7.0–7.9% and ≥8.0%. Propensity score matching was used before comparing MUA/aLOA during three periods: within 3 months, 3–12 months and after 12 months. The public abstract does not report cohort sizes.

Main results

• HbA1c 5.7–6.9%: OR 1.21 for MUA/aLOA within 3 months (95% CI 1.07–1.37).
• HbA1c 7.0–7.9%: OR 1.65 (95% CI 1.37–1.97).
• HbA1c ≥8.0%: OR 1.91 (95% CI 1.35–2.71).

No significant later differences were found for the 5.7–6.9% and 7.0–7.9% groups. In the ≥8.0% group, no significant difference was found at 3–12 months; analysis beyond 12 months was limited by too few reported events.

Clinical interpretation for an orthopaedic surgeon

The stepwise association with HbA1c is biologically plausible and suggests that poorer metabolic control may mark susceptibility to early postoperative stiffness. The endpoint, however, was an intervention rather than a direct range-of-motion measurement. It captures clinically important cases but also depends on local thresholds and institutional practice for MUA or aLOA.

Limitations

Propensity score matching reduces measured differences but cannot remove unmeasured confounding. The abstract does not explain in sufficient detail how preoperative motion, rehabilitation, surgical technique, implant choice, analgesia, patient motivation or intervention thresholds were captured.

The apparent difference from the 2019 meta-analysis may partly reflect varying definitions of stiffness in older studies and their lack of an HbA1c dose-response analysis.

Implications for practice

HbA1c may be useful in preoperative risk discussions and in identifying patients who merit closer monitoring of motion recovery. The findings also support considering metabolic optimisation beyond infection and wound-healing risk.

The study does not prove that lowering HbA1c before surgery reduces arthrofibrosis. It establishes no HbA1c threshold for postponing TKA and does not show that diabetes independently causes stiffness. Prospective evidence, ideally assessing an actual change in glycaemic control, is needed.

References

Hall RP, Braithwaite CL, Van Schuyver PR et al. Diabetes is Associated with an Increased Risk of Arthrofibrosis Following Total Knee Arthroplasty. The Journal of Arthroplasty. Published online August 24, 2026. DOI: 10.1016/j.arth.2026.08.041. PubMed · Journal website.

This summary is based solely on the publicly available abstract and metadata.

Context: Jump C, Malik RA, Anand A, Charalambous CP. Diabetes mellitus does not increase the risk of knee stiffness after total knee arthroplasty: a meta-analysis of 7 studies including 246 053 cases. Knee Surg Relat Res. 2019;31:6. DOI.

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Content prepared by: Tomasz Poboży - orthopaedic surgeon.

Polish version: Złamanie rzepki — płytka blokowana czy klasyczny popręg napięciowy?

Choosing between conventional tension-band wiring (TBW) and plating remains a practical issue in surgically treated patellar fractures. A multicentre randomized trial of 122 adults, published in The Bone & Joint Journal on 1 September 2026, provides substantial clinical support for locking plates. Its predefined superiority criterion required both statistical significance and a minimum clinically important difference (MCID).

Why this study matters

TBW is familiar, but symptomatic implants, implant removal and fixation failure remain concerns. Dedicated patellar plates offer biomechanical advantages, while much of the previous clinical evidence was observational. This trial provides a prospective randomized comparison.

Study design

The trial enrolled 122 adults with displaced patellar fractures requiring surgery and allocated them 1:1 to locking plate fixation or TBW. Patients and assessors were blinded, and analysis followed the intention-to-treat principle.

• Locking plate fixation: 63 patients.
• TBW: 59 patients.
• Follow-up at 12 months was completed by 57/63 (90.5%) and 52/59 (88.1%), respectively.
• The primary outcome comprised the five KOOS subscales at 12 months.

Superiority was predefined as statistically significant differences in at least three KOOS subscales, together with differences exceeding their prespecified MCIDs.

Main results

Locking plate fixation met the superiority criterion in three of five KOOS domains: symptoms, sport/recreation and quality of life. The abstract reported these mean differences:

• KOOS Symptoms: −10.4 points (95% CI −16.4 to −4.4).
• KOOS Sport/Recreation: −14.1 points (95% CI −24.7 to −3.4).
• KOOS Quality of Life: −10.9 points (95% CI −19.0 to −2.7).

The negative signs reflect the direction in which the comparison was defined; the authors interpret all three results as favouring plates. Implant removal, fixation failure and reoperation were more frequent after TBW. Exact event rates were not provided in the public abstract and should not be estimated from it.

Clinical interpretation for an orthopaedic surgeon

The advantage concerned patient-reported outcomes and exceeded predefined thresholds for clinical importance in three domains, rather than being limited to radiographic or biomechanical measures. The adverse-event pattern also fits the familiar problems of symptomatic TBW hardware and further surgery. Confirmation through longer follow-up and other centres could strengthen the role of locking plates where suitable implants and expertise are available.

Limitations

• The primary endpoint was assessed at 12 months; persistence of the advantage is unknown from the abstract.
• The findings apply to displaced fractures requiring surgery, not every patellar fracture or those managed nonoperatively.
• Exact rates of implant removal, fixation failure and reoperation are unavailable in the public abstract.
• Results for this plate system and operative protocol do not establish superiority of every plate over every TBW variant.
• This was not a cost-effectiveness study; the abstract cannot establish whether fewer reoperations offset higher implant costs.

Implications for practice

The trial may lower the threshold for choosing a plate in an operatively treated displaced patellar fracture, on the basis of clinical rather than purely biomechanical evidence. It does not imply that every patellar fracture needs surgery, that all locking plates are equivalent, or that every patient will benefit. Fracture pattern, bone quality, soft tissues and technical feasibility still require individual assessment, and the 12-month advantage cannot be assumed to persist for years.

References

Larsen P. et al. Locking plate fixation compared with tension-band wiring for patellar fractures: a multicentre randomized controlled trial. The Bone & Joint Journal. 2026;108-B(9):1182–1189. Published: 1 September 2026.

• DOI: 10.1302/0301-620X.108B9.BJJ-2026-0517.R1
• PubMed: PMID 42674573
• Trial registration: NCT04891549

The NCT04891549 registry lists six participating centres in Denmark: Aalborg, Aarhus, Hjørring, Kolding, Randers and Viborg. This summary relies solely on publicly available metadata, the abstract and the trial registry.

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Content prepared by: Tomasz Poboży - orthopaedic surgeon.

Polish version: Rekonstrukcja ACL z zachowaniem przyczepu piszczelowego — szybsze dojrzewanie przeszczepu w MRI

Can preserving the native tibial attachment of the hamstring tendons improve graft maturation after ACL reconstruction? A randomized trial in the August issue of The American Journal of Sports Medicine found clearly earlier maturation on MRI with attachment preservation. This is an interesting biological finding, but should not yet be treated as proof of clinical superiority.

Why this study matters

Hamstring grafts are usually detached from their native insertion and fixed within bone tunnels. An attachment-sparing technique retains the distal tibial insertion, potentially preserving some blood supply and the biological connection to bone. Earlier revascularisation and ligamentisation might shorten the period of biological vulnerability.

Earlier MRI maturation does not necessarily mean better function, fewer reruptures or a safe basis for accelerated rehabilitation. A randomized comparison is therefore particularly useful.

Study design

This Level I randomized trial compared attachment-sparing (AS) hamstring autografts with conventional free grafts (FG). Initially, 56 patients were randomized. The methods describe 25 undergoing AS reconstruction and 25 receiving FG reconstruction.

MRI at 3, 6 and 9 months assessed Figueroa maturation scores, graft characteristics, orientation and tunnel widening. Independent clinical assessments at 3, 6, 9 and 12 months included Lysholm, IKDC and Tegner scores and KT-2000 anterior tibial translation. Final follow-up was completed by 78% of participants: 19 in the AS group and 20 in the FG group. The final imaging comparisons therefore involved a small sample.

Main results

• Figueroa MRI scores were significantly better with attachment preservation at successive assessments.
• The earliest signs of maturity appeared at 3 months in the AS group, when 26.3% of grafts reached Figueroa grade 4. A comparable stage first appeared at 6 months in the FG group.
• At final assessment, all AS patients remaining in the analysis reached Figueroa grade 5, compared with 10% in the FG group.
• Graft diameter was more stable with AS, while FG grafts showed greater swelling on serial MRI.
• Tibial tunnel widening progressed in both groups and was greater with attachment preservation.
• Lysholm, IKDC and anterior tibial translation improved significantly in both groups.

Clinical interpretation for an orthopaedic surgeon

The clearest finding concerns MRI evidence of graft maturation. Preserving the tibial attachment appears to influence early graft biology, consistent with the technique’s proposed mechanism and relevant to further research on remodelling.

Functional implications require more caution. The abstract reports improvements in both groups, but provides insufficient detail to establish a clinically important advantage for AS. Although the paper’s title refers to better short-term clinical outcomes, the abstract does not quantify that difference sufficiently.

Limitations

• The sample was small, with only 39 patients completing final follow-up.
• The reported 78% completion rate raises the possibility of attrition bias.
• The strongest signal concerned a surrogate endpoint, MRI appearance, rather than rerupture, return to sport or long-term function.
• Clinical follow-up extended to 12 months, too short to establish durability or late failure rates.
• Greater tibial tunnel widening with AS shows that not every assessed parameter favoured attachment preservation.
• The full text has restricted access. This summary is limited to the public abstract and publisher/PubMed metadata.

Implications for practice

The study strengthens the biological rationale for preserving the tibial hamstring attachment and supports larger, longer comparative trials. For surgeons using this technique, it suggests a real effect on early graft remodelling.

It does not establish fewer ACL reruptures, earlier safe return to sport or grounds for shortening a standard rehabilitation protocol. A more mature MRI appearance also does not by itself demonstrate greater mechanical strength in humans. Those conclusions require larger studies, longer follow-up and clinical endpoints.

References

Sinha S, Arumugham KC, Singh DK, Kumar N, Bera AP, Uppal H, Vakharia KS. ACL Reconstruction With Attachment-Sparing Hamstring Autograft Results in Earlier Graft Maturation and Better Short-Term Clinical Outcome in Comparison to Free Graft: A Randomized Controlled Trial. The American Journal of Sports Medicine. 2026;54(10):2399–2406. First published online: 17 June 2026; journal issue: August 2026. DOI: 10.1177/03635465261455046. PubMed: PMID 42310826.

The publisher labels the article as restricted access; this summary therefore relies solely on the public abstract and metadata.

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Content prepared by: Tomasz Poboży - orthopaedic surgeon.

Polish version: Zaburzenia metaboliczne a ryzyko braku zrostu po złamaniu trzonu piszczeli

Does nonunion risk after surgical treatment of a tibial shaft fracture increase with the number of coexisting metabolic disorders? A TriNetX analysis of 36,474 patients found a stepwise association with diabetes, hypertension, obesity and dyslipidaemia. This is a clinically relevant prognostic finding, but it does not prove that treating those four diagnoses will prevent nonunion.

Why this study matters

Assessment of tibial nonunion risk usually considers fracture pattern, soft-tissue injury, infection, smoking, fixation stability and healing biology. This study asked whether common metabolic conditions also matter as a cumulative burden. Hypertension and dyslipidaemia are not usually regarded as direct determinants of union, but their coexistence may identify patients who warrant closer risk assessment, follow-up and general medical optimisation.

Study design

This retrospective cohort study used the TriNetX Research Network to identify surgically treated AO/OTA 42 tibial shaft fractures during 2013–2023. At least 1 year of follow-up was required. Patients with a previous tibial nonunion diagnosis or known metabolic bone disease were excluded.

The primary outcome was postoperative tibial shaft nonunion. Diabetes, hypertension, obesity and dyslipidaemia were analysed individually and according to the number of concurrent conditions. The 36,474 patients had a mean age of 41.5 years; 62.7% were men. The cohort thus covered a broad age range rather than a solely geriatric population.

Main results

• Diabetes had the largest association with nonunion: HR 2.82 (P < 0.001).
• HRs were 1.87 for hypertension, 1.45 for obesity and 1.25 for dyslipidaemia; all associations were statistically significant.
• In the strata reported in the public abstract, nonunion occurred in 5.0% of patients with none of these conditions, 8.5% with one, 10.4% with two and 11.8% with at least three.
• Time-to-event analysis showed a stepwise increase: HR 1.59 with one condition, 2.62 with two, 3.16 with three and 3.37 with all four.

No clear risk gradient was demonstrated across obesity classes. The public abstract contains an inconsistency between one HR and its confidence interval for BMI 30–35; that specific estimate should not be reproduced or interpreted uncritically.

Clinical interpretation for an orthopaedic surgeon

The cumulative pattern is more informative than any isolated HR. A patient with several metabolic disorders may have a different biological risk profile from someone with a similar fracture and no such comorbidities. Risk assessment should therefore extend beyond a simple diabetes yes/no classification.

These findings support documenting metabolic burden when discussing prognosis and planning follow-up. They are also consistent with careful optimisation of glycaemic control and general metabolic health, but no optimisation intervention was tested in this study.

Limitations

• This retrospective observational study demonstrates associations, not causation.
• Results depend on the accuracy of diagnostic and outcome coding in a large clinical data network.
• The public abstract provides limited detail on fracture morphology, soft tissues, fixation and longitudinal disease control.
• Hypertension and dyslipidaemia may partly mark a broader metabolic phenotype rather than directly cause nonunion.
• The findings concern surgically treated tibial shaft fractures and cannot automatically be transferred to other bones or fracture types.

Implications for practice

Metabolic burden, particularly the number of concurrent disorders, merits consideration in formal nonunion risk assessment. The analysis does not show that reducing blood pressure, body weight or lipids after a fracture reduces nonunion risk in proportion to the reported HRs. It establishes no threshold for changing fixation, weight-bearing progression or routinely adding biological treatments.

This is prognostic evidence rather than an interventional trial. Union still reflects the interaction of biology, mechanics, injury characteristics and treatment; metabolic phenotype is one part of that assessment.

References

Kotzur T, Peterson B, McCoy L, Pereira DE, Hosseinzadeh P, Martin C. Metabolic Derangements Are Independent Additive Risk Factors for Tibial Diaphyseal Nonunion. Journal of Orthopaedic Trauma. 2026;40(9):473–481. DOI: 10.1097/BOT.0000000000003202. PubMed: PMID 42048121.

This summary is based on the public abstract and PubMed metadata.

Related resources

For Doctors and Physiotherapists · Research Updates, Literature and Evidence-Based Medicine

Content prepared by: Tomasz Poboży - orthopaedic surgeon.

Polish version: Abaloparatyd po złamaniu miednicy — brak potwierdzenia szybszego zrostu

Could an anabolic osteoporosis treatment also accelerate healing of an acute pelvic fracture? This is an attractive hypothesis for older adults with fragility fractures. A double-blind phase 2 randomized trial, however, found no benefit from abaloparatide for radiographic healing, pain or physical performance at 3 months.

Why this study matters

Pelvic fractures in older adults can cause prolonged pain, impaired mobility and loss of independence. Because PTH receptor agonists stimulate bone formation, there is interest in whether they can promote healing as well as prevent future fractures. This trial used a prospective, randomized, placebo-controlled, double-blind design and CT assessment of the primary endpoint, making its negative findings more informative than uncontrolled observations.

Study design

Postmenopausal women and men aged at least 50 were enrolled within 4 weeks of pelvic fracture. Forty-eight participants were randomized to abaloparatide 80 µg subcutaneously once daily or matching placebo for 12 weeks. Mean age was 82 years; 93% were women, 98% had multiple pubic ramus fractures, 67% had an associated sacral fracture, and 36% had at least one displaced fracture.

The primary outcome was healing at 3 months, assessed by two radiologists using cortical bridging on CT. Pain and physical performance were also measured, including the Short Physical Performance Battery (SPPB) and Timed Up and Go (TUG).

The planned sample was 78, but recruitment stopped at 48 when funding ended. Three participants allocated to abaloparatide did not begin treatment and were excluded from analyses. CT at 3 months was available for 40 patients.

Main results

• The distribution of CT cortical bridging scores did not differ significantly at 3 months (P = 0.15).
• In the patient-level healed/not-healed analysis, 39% of the abaloparatide group and 64% of the placebo group met the healing criterion: RR 0.61 (95% CI 0.33–1.12).
• Among 81 individual fractures, healing rates were 47% and 53%, respectively: RR 0.88 (95% CI 0.55–1.40).
• Changes in pain did not differ between groups.
• SPPB and TUG improved over time in both groups, without an advantage for abaloparatide.

Bone turnover markers increased with abaloparatide, demonstrating a biochemical response. The absence of clinical benefit therefore did not reflect a complete lack of pharmacodynamic activity.

Clinical interpretation for an orthopaedic surgeon

The trial does not support prescribing abaloparatide solely to accelerate healing of a recent pelvic fracture. In this population and regimen, no radiographic, functional or analgesic benefit emerged during the first 3 months. This question is separate from treating osteoporosis and preventing subsequent fractures; the trial does not challenge abaloparatide’s established role in osteoporosis treatment for appropriately selected patients.

Limitations and disclosures

• The trial randomized 48 rather than the planned 78 patients; the authors reported a reduction in statistical power to approximately 75%.
• The population was highly specific: mean age 82 years, 93% women and all participants White, limiting generalisability.
• Healing was principally assessed at one time point, 3 months.
• Treatment began approximately 3 weeks after fracture on average, so the study does not address very early initiation.
• Three participants assigned to abaloparatide did not start treatment and were excluded from analyses.

Radius Pharmaceuticals supplied the drug and placebo. According to the publication, the company did not participate in trial conduct, interpretation or manuscript preparation. Funding came primarily from the NIH. Some authors disclosed financial relationships with pharmaceutical manufacturers, including Radius.

Implications for practice

These results temper expectations for routinely using PTH receptor agonists to accelerate pelvic fracture healing. They provide no reason to start abaloparatide solely because a recent fracture might heal faster. Conversely, the numerically lower patient-level healing rate does not prove that abaloparatide impairs union: confidence intervals were wide, recruitment was insufficient, and the authors regarded the findings as exploratory. Other fracture sites and age groups were not addressed.

References

Nieves JW, Cosman F, McMahon D et al. Abaloparatide and pelvic fracture healing: a phase 2 randomized placebo-controlled trial. Osteoporosis International. Published online 20 August 2026. DOI: 10.1007/s00198-026-08176-2. PubMed: PMID 42618812.

The full text is legally available through the publisher, Springer Nature.

Related resources

For Doctors and Physiotherapists · Research Updates, Literature and Evidence-Based Medicine

Content prepared by: Tomasz Poboży - orthopaedic surgeon.