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Tomasz Poboży

Autor: Tomasz Poboży

  • Fifth Metatarsal Base Fracture — Avulsion or Jones Fracture?

    Not every fracture at the base of the fifth metatarsal is a Jones fracture. An avulsion fracture lies closer to the tip of the bone and usually heals more readily. A Jones fracture is slightly more distal, in an area with less favourable blood supply, so it more often requires prolonged protection from loading, closer follow-up and, in selected patients, surgery.

    Polish version · For Patients

    Where is the fifth metatarsal?

    The fifth metatarsal runs along the outer side of the foot and connects with the little toe. Its proximal end forms the bony prominence that can be felt along the lateral border of the foot. Several different injuries can occur in this small region, with different prognoses, so the phrase “fracture of the fifth metatarsal base” is not always specific enough to plan treatment.

    Avulsion, Jones and stress fractures — what is the difference?

    Zone 1: avulsion fracture

    A fragment is pulled away from the tuberosity at the base of the bone. This injury often accompanies an inversion-type ankle or foot injury and may initially resemble a simple ankle sprain. Most small, stable fractures in this zone are treated without surgery.

    Zone 2: Jones fracture

    The fracture line lies at the metaphyseal-diaphyseal junction, typically near the articulation between the fourth and fifth metatarsals. Blood supply is less favourable here, increasing the risk of delayed union or nonunion. The term “Jones fracture” should not be used for every fracture along the lateral border of the foot.

    Zone 3: stress fracture

    This occurs farther distally toward the shaft, often after repetitive loading. Pain may build gradually without a single clear injury. It has to be distinguished from other metatarsal stress fractures.

    Which symptoms are important?

    • pain along the outer border of the foot, worse with walking;
    • focal tenderness over the base or proximal fifth metatarsal;
    • swelling and bruising along the lateral foot;
    • difficulty bearing weight;
    • pain that increases with running or jumping even without a single acute injury.

    Similar symptoms can come from an ankle sprain, injury around the cubometatarsal joint or peroneal tendon pathology. The point of maximal tenderness and the injury mechanism are therefore more useful than the general label “sprained foot”.

    How does an orthopaedic surgeon establish the diagnosis?

    After an acute injury, standard foot radiographs in appropriate views are the first-line investigation. They help define the fracture zone, displacement and any articular involvement. In a stress-type presentation, early X-rays can still be normal; further imaging should then be selected according to the clinical examination.

    CT can be useful when union is difficult to assess, the fracture pattern is complex or surgery is being planned. MRI is particularly useful for a suspected early stress fracture when radiographs remain normal. Ultrasound may show some cortical abnormalities or associated soft-tissue injuries, but it does not replace standard imaging of the entire fracture.

    Is surgery always required?

    No. Stable avulsion fractures are most often treated functionally in a walking boot or stiff-soled shoe, with weight bearing adjusted to pain and the treatment plan. Follow-up is used to confirm satisfactory healing.

    For an acute Jones fracture, non-operative treatment usually requires more careful protection and a period of restricted weight bearing. Surgery is considered more often when there is displacement, failure of healing to progress, a stress fracture, refracture, or in athletes for whom a predictable return to high loads is particularly important. Activity level alone does not replace assessment of the fracture pattern and a discussion of surgical risk.

    Why does follow-up of union matter?

    Pain can improve before the bone has regained full strength. Returning too early to running, jumping or cutting sports increases the risk of refracture. Progression of loading should be based on symptoms, examination, fracture type and evidence of healing rather than simply the number of weeks since injury.

    When is urgent assessment needed?

    • the foot is visibly deformed or a wound exposes bone;
    • the toes become cold, pale or blue;
    • numbness is increasing or the toes cannot be moved normally;
    • pain and swelling increase rapidly despite elevation;
    • it is impossible to take a few steps after the injury;
    • persistent lateral foot pain remains after an earlier diagnosis of a “sprain”.

    Sources

    1. Chloros GD, Kakos CD, Tastsidis IK, Giannoudis VP, Panteli M, Giannoudis PV. Fifth metatarsal fractures: an update on management, complications, and outcomes. EFORT Open Reviews. 2022;7(1):13–25. DOI: 10.1530/EOR-21-0025.
    2. Attia AK, Taha T, Kong G, Alhammoud A, Mahmoud K, Myerson M. Return to Play and Fracture Union After the Surgical Management of Jones Fractures in Athletes: A Systematic Review and Meta-analysis. American Journal of Sports Medicine. 2021;49(12):3422–3436. DOI: 10.1177/0363546521990020.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

    Related postoperative rehabilitation protocol

    Fifth metatarsal fracture — postoperative rehabilitation. The rehabilitation pathway depends on the procedure performed.

  • Bioresorbable Screws for First MTP Fusion — Promising, but Evidence Is Limited

    Bioresorbable screws may be a feasible alternative to titanium screws for first metatarsophalangeal joint arthrodesis, but the new trial is too small to establish equivalence or superiority. This distinction matters: failure to detect a statistically significant difference in a pilot sample does not mean that the two methods produce identical outcomes.

    Polish version · For Doctors and Physiotherapists

    Why is this study interesting?

    First MTP joint fusion is used for advanced hallux rigidus, severe deformity and selected revision procedures. Fixation has to maintain alignment until union occurs. A bioresorbable implant could theoretically avoid permanent metal hardware, but it still has to provide adequate stability and degrade without clinically important tissue reactions.

    Question and methodology

    Partio and colleagues conducted a prospective pilot randomised trial in two Finnish hospitals. Thirty patients were allocated 1:1 to fixation with cannulated bioresorbable screws or titanium screws. Joint surfaces were prepared using a cup-and-cone technique, and full weight bearing in a postoperative shoe was allowed after six weeks.

    Union, complications and functional outcomes were assessed at 3, 6, 12 and 24 months. The trial was registered as NCT03133039.

    Results

    • Both groups showed substantial functional improvement, with no demonstrated between-group difference.
    • At 24 months, mean AOFAS scores were 89.1 in the titanium group and 90.0 in the bioresorbable group (p = 0.23).
    • The overall union rate was 90%.
    • Nonunion occurred in one patient with titanium screws and two patients with bioresorbable screws; all three required revision surgery.
    • No clinical or radiographic adverse events were attributed to degradation of the bioresorbable screws.
    • No patient in either group underwent hardware removal.

    Clinical interpretation for an orthopaedic surgeon

    The main value of this study is as an early signal of feasibility and safety. At two years there were no reported reactions related to implant degradation, and functional outcomes were good in both groups. That is sufficient to justify a larger study, particularly if bioresorbable fixation is expected to reduce problems associated with retained metalwork.

    It does not, however, demonstrate a practical advantage. Hardware was not removed in the titanium group either, so the proposed benefit of avoiding a later removal procedure was not shown here. Three nonunions among 30 participants are also far too few events for a reliable comparison of uncommon complications.

    Key limitations

    • This was a pilot study with only 30 patients.
    • It was not designed as an equivalence trial with a prespecified equivalence margin.
    • The small sample provides very limited power for nonunion, implant reactions and reoperations.
    • The AOFAS score has methodological limitations, and the bioresorbable group was reported with a mean of 90.0 and a standard deviation of 0.0 at 24 months, making the score distribution difficult to interpret.
    • Two years of follow-up does not answer every question about late material degradation.

    What might this change in practice — and what does it not prove?

    For now, these results support further adequately powered trials of bioresorbable screws. They do not justify treating the technique as standard, safer, or equivalent to titanium fixation. Choice of fixation should still account for construct biomechanics, bone quality, deformity, likelihood of union and the surgeon’s experience.

    Source

    Partio N, Mattila V, Waris V, Mäenpää H. Bioabsorbable vs. titanium screws in first metatarsophalangeal joint arthrodesis: a pilot randomized controlled trial with 2-year follow-up. Archives of Orthopaedic and Trauma Surgery. Published 9 September 2026;146(1):329. DOI: 10.1007/s00402-026-06501-2. PMID: 42714616.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Why Are Sensation and Pulses Checked After an Injury?

    After a limb injury, assessment should not stop at the painful bone or joint: circulation and nerve function below the injury also need to be checked. A fracture, dislocation, large haematoma or overly tight immobilisation can compress a blood vessel or nerve. Detecting that problem early may be more urgent than assigning a precise fracture label.

    Polish version · For Patients

    What does an orthopaedic surgeon check during the examination?

    A neurovascular examination combines several observations. The clinician compares colour and temperature between limbs, checks capillary refill after pressure on a nail bed, feels for pulses at appropriate sites, tests sensation in the territories of individual nerves and asks the patient to perform selected movements of the fingers, toes, hand or foot.

    Each part answers a different question. A palpable pulse is reassuring, but it does not exclude every clinically important circulatory problem. Likewise, normal skin colour does not rule out injury to a specific nerve. The overall pattern and comparison with the opposite side matter.

    Why is the examination repeated?

    The condition of a limb can change after reduction of a fracture or dislocation, application of a cast, increasing swelling or secondary displacement. Neurovascular findings should therefore be documented before an intervention and checked again afterwards. This helps establish whether an abnormality was present from the outset or developed later.

    This is also why patients are told to watch their fingers or toes after immobilisation. Swelling often increases during the first few days and a cast or splint that was initially comfortable may become too tight.

    What can an abnormal finding mean?

    • a cold, pale or blue limb may indicate impaired blood flow;
    • delayed capillary refill has to be interpreted together with temperature and pulses;
    • new numbness may reflect nerve compression or injury;
    • inability to perform a movement can result from pain, tendon or muscle injury, or nerve dysfunction;
    • pain that seems disproportionate to the injury and worsens with passive movement of the digits can be one warning sign of acute compartment syndrome.

    Why is an X-ray not enough?

    X-rays show bone position well, but they do not directly assess nerve function or blood flow. Good fracture alignment therefore does not automatically mean that all soft tissues are safe. Conversely, numbness does not necessarily mean that a nerve has been divided; swelling or pressure can cause temporary symptoms. Distribution, progression and the complete examination determine how concerning a finding is.

    Which symptoms after injury or casting need urgent reassessment?

    • increasing numbness or reduced ability to move the fingers or toes;
    • digits that become clearly colder, pale or blue;
    • severe and increasing pain despite elevation and prescribed analgesia;
    • a rapidly increasing sense of pressure or tightness under a cast;
    • marked swelling that makes finger or toe movement difficult.

    In that situation, do not cut or alter the immobilisation yourself. Prompt reassessment is needed. Trying to check a pulse at home is not an adequate substitute: it may be difficult to locate reliably, and the presence of a pulse does not rule out every complication.

    Sources

    1. National Institute for Health and Care Excellence. Fractures (complex): assessment and management. NICE guideline NG37.
    2. National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. NICE guideline NG38.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Virtual Knee Rehabilitation — Promising, but the Evidence Remains Uncertain

    Interactive digital rehabilitation may improve short-term function in some people with knee osteoarthritis and after total knee arthroplasty, but the available evidence is too heterogeneous to treat it as a proven replacement for standard rehabilitation. A recent systematic review provides an encouraging signal while also showing how very different interventions can be grouped under the broad label of “virtual reality”.

    Why is this study interesting?

    Digital tools are increasingly used in rehabilitation, ranging from screen-based exercises with real-time feedback to immersive virtual-reality headsets. They may make home exercise easier to deliver, increase engagement and provide therapists with information about how tasks are performed. The clinically relevant question, however, is not simply whether patients enjoy the technology, but whether it improves pain and function more than conventional exercise or education.

    The review by Kalinowski and colleagues, published on 8 September 2026 in the Journal of Medical Internet Research, evaluated extended-reality (XR) interventions in knee osteoarthritis and recovery after total knee arthroplasty. The authors used a broad XR definition that included both immersive virtual reality and interactive screen-based digital rehabilitation. That distinction is central to interpreting the findings.

    Question and methodology

    The authors performed a systematic review and meta-analyses using a prospectively registered PROSPERO protocol. Five databases were searched, with the search updated through December 2025. Twenty-one studies were included: 12 addressing non-operative management of knee osteoarthritis and 9 evaluating rehabilitation after total knee arthroplasty. Individual study sample sizes ranged from 36 to 306 participants.

    The interventions varied substantially. Some used games or movement-tracking exercises displayed on a screen, others used more elaborate feedback systems, and only 6 of the 21 studies actually evaluated immersive virtual reality. No study directly compared immersive headsets with non-immersive digital rehabilitation.

    Main findings

    In knee osteoarthritis, interactive digital rehabilitation was associated with better function than control interventions. The pooled standardised effect was −0.59, but the 95% prediction interval included both possible benefit and no effect. Certainty of evidence was rated low. For pain at 6–8 weeks, the effect was small and near the threshold of statistical significance; the prediction interval again included no benefit.

    After total knee arthroplasty, individual studies suggested possible functional improvement, but at 3–4 months there was no clear advantage for pain. The pooled effect was −0.12, with a wide confidence interval from −0.75 to 0.52. Most studies followed patients for only a short period, generally no longer than three months.

    Clinical interpretation for an orthopaedic surgeon

    The most reasonable interpretation is that digital rehabilitation can be a useful way to deliver and support exercise, particularly when it improves access, motivation or adherence. The review does not show that XR technology itself is responsible for the benefit. Better outcomes may instead reflect more repetitions, immediate feedback, gamification, greater contact with the rehabilitation team or simply more consistent participation.

    The review also does not justify the claim that immersive virtual-reality headsets are more effective than a simpler app or screen-based exercise programme. Intervention categories were inconsistent, and no direct comparison between those approaches was available.

    Important limitations

    • Most trials were small, and 16 of 21 studies had follow-up shorter than 6 months.
    • The XR label covered technologically and therapeutically different programmes.
    • Some studies had risk of bias related to missing data and deviations from the planned intervention.
    • Only 5 studies reported adverse events, so safety cannot be assessed with confidence.
    • The review included English-language publications only, and individual meta-analyses contained relatively few studies.

    What could this change in practice?

    The review supports using well-designed digital tools as a possible adjunct to rehabilitation when they solve a specific problem—for example, limited access to therapy, difficulty monitoring exercises or poor adherence. Selection should be based on the functional goal, the patient’s abilities, supervision and safety rather than on the novelty of the technology.

    The study does not show that XR improves long-term outcomes, reduces revision risk after arthroplasty or can replace individual physiotherapy assessment. It also does not establish superiority of immersive virtual reality over simpler forms of digital rehabilitation. Larger studies with clearly described interventions, longer follow-up and systematic adverse-event reporting are needed.

    Source

    Kalinowski C, et al. Extended Reality Interventions for Osteoarthritis of the Knee and Recovery After Total Knee Arthroplasty: Systematic Review and Meta-Analyses. J Med Internet Res. 2026;28:e84753. DOI: 10.2196/84753. PubMed · Full text.

    Polish version · Research Updates, Literature and Evidence-Based Medicine

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Retained Foreign Body in the Hand or Foot — When Is Ultrasound Useful?

    After a puncture, cut or stepping on a sharp object, ultrasound can help locate retained glass, wood, metal or plastic in the hand or foot—especially when the fragment is not visible on an X-ray. A normal ultrasound does not exclude every retained foreign body, and the decision to remove a fragment depends on its material, depth, symptoms and proximity to nerves, vessels, tendons or a joint.

    When should a retained foreign body be suspected?

    Common examples include a splinter, thorn, piece of glass, metal or plastic after an injury to the hand or foot. Suspicion is higher when the patient remembers the object entering the skin, the wound was deep, or part of the object broke during an attempt to remove it.

    Possible clues include focal tenderness, a sharp sensation during movement or weight bearing, a palpable lump, recurrent redness, drainage from the wound or difficulty fully bending a finger. Symptoms may develop only after several days or weeks. Pain alone, however, does not prove that a foreign body remains: a haematoma, tendon or nerve injury, fracture and infection can produce similar symptoms.

    X-ray or ultrasound—which is more useful?

    X-rays show some materials well

    Plain radiographs are usually the first test when glass, metal or another radiopaque material is possible. They can also reveal a fracture. Wood, thorns and some plastics are much less visible. A very small fragment, or one projected over bone, may also be difficult to identify.

    Ultrasound shows soft tissues and anatomical relationships

    Ultrasound can show the foreign body itself and the tissue reaction around it. It can help determine the fragment’s depth and its relationship to a tendon, tendon sheath, nerve, blood vessel or joint. For superficial foreign bodies, the skin can be marked before a procedure and, in selected cases, removal can be guided in real time.

    Ultrasound also has limitations. Detection depends on the fragment’s size, material and location, the time since injury and the examiner’s experience. Air in a fresh wound, proximity to bone and deep location can make assessment more difficult. In a meta-analysis of 17 studies, pooled ultrasound sensitivity was 72% and specificity 92%. A positive result can therefore be very helpful, but a normal result does not completely exclude a retained foreign body when clinical suspicion remains high.

    When are CT or MRI needed?

    CT may be useful for deeply located foreign bodies, complex anatomy or an equivocal radiograph. MRI is used selectively, particularly when soft-tissue complications need to be assessed. If a metallic fragment is possible, MRI should not be ordered blindly; the type and location of the material should first be established.

    Does every foreign body need to be removed?

    No. Removal is more often indicated when the fragment causes pain, infection, restricted movement or compression of a nerve, vessel or tendon. Organic material such as wood or a thorn is more likely to provoke inflammation and infection. Foreign bodies close to a joint, tendon sheath or neurovascular structures deserve prompt assessment.

    A small, deeply located, inert and asymptomatic fragment can sometimes be left in place when retrieval would cause more tissue damage than benefit. The decision should balance the expected benefit of removal against the procedural risk. Tetanus protection should also be reviewed according to the wound and vaccination history.

    What does ultrasound-guided removal involve?

    The fragment is first located and the safest access route is planned. In an appropriate superficial location, a small incision can be made and the instrument followed under real-time ultrasound, potentially reducing unnecessary tissue dissection. Not every case is suitable for this approach.

    Operating-room conditions may be required when the object is deep, brittle, large, fragmented, close to a nerve or vessel, has penetrated a tendon, or lies within a joint. Blind attempts to dig out an unseen fragment with a needle or tweezers can push it deeper, break it into smaller pieces and increase the risk of infection.

    What should you do after a fresh injury?

    • Do not probe a deep wound with household instruments.
    • If an object remains deeply embedded, do not force it out.
    • Cover the wound with a clean dressing and reduce loading of the painful hand or foot.
    • Note what material caused the injury and when it occurred.
    • For a deep, contaminated or puncture wound, seek advice about cleaning, antibiotics when indicated and tetanus prophylaxis.

    Warning signs

    Urgent assessment is needed for increasing pain and swelling, rapidly spreading redness, pus, fever, red streaking along the limb, numbness or weakness of finger or toe movement, a pale or cold hand or foot, severe pain when moving a finger, or a wound that may have penetrated a joint. A high-pressure injection injury requires immediate medical attention even when the skin opening looks minor.

    Key points for an orthopaedic surgeon

    Ultrasound is especially valuable when a retained fragment is not visible on X-ray or when its relationship to soft tissues needs to be mapped. It is not a perfect test. When the history and symptoms still strongly suggest a retained foreign body, one normal imaging result should not automatically end the diagnostic process.

    Sources

    1. Davis J, et al. Diagnostic Accuracy of Ultrasonography in Retained Soft Tissue Foreign Bodies: A Systematic Review and Meta-analysis. Acad Emerg Med. 2015;22(7):777–787. DOI: 10.1111/acem.12714. PubMed.
    2. Rupert J, Honeycutt JD, Odom MR. Foreign Bodies in the Skin: Evaluation and Management. Am Fam Physician. 2020;101(12):740–747. Full text.

    Polish version · Diagnostic Tests · For Patients

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Why Does an Injury Sometimes Need to Be Re-Examined?

    A repeat examination a few days after an injury does not necessarily mean that the first assessment was wrong. Early pain, swelling and protective muscle guarding can obscure important findings, while some injuries become easier to identify only as symptoms evolve or swelling settles.

    The first examination answers different questions

    Immediately after an injury, the priority is to identify problems that require urgent treatment: an open fracture, dislocation, impaired circulation, nerve injury, compartment syndrome or an infected wound. The assessment focuses on the mechanism of injury, deformity, tenderness, ability to bear weight, sensation, movement and the peripheral pulse.

    Why can the early examination be difficult?

    Severe pain may make almost every movement seem impossible. Swelling can blur normal anatomical landmarks. Reflex muscle guarding can make joint-stability testing unreliable, and diffuse bruising may hide the focal tenderness that points toward a particular bone or ligament.

    This can occur after wrist, ankle, knee and shoulder injuries. Some fractures are also occult on the first radiographs. A classic example is a suspected scaphoid fracture: initial X-rays may be normal despite a genuine fracture, so immobilisation, repeat clinical assessment and appropriately selected MRI or CT may be needed.

    What can an orthopaedic surgeon learn from a follow-up examination?

    • It can localise the most tender area more precisely.
    • It allows a more reliable assessment of movement and stability after pain settles.
    • It shows whether swelling, bruising and function are changing as expected.
    • It may reveal tendon or nerve dysfunction that was initially unclear.
    • It helps decide whether different imaging or a change in treatment is needed.

    When does repeating an X-ray make sense?

    That depends on the suspected injury. In some cases, a later radiograph can show fracture signs that were not visible initially. In others, early MRI or CT is more useful than simply waiting for another X-ray. For example, when a scaphoid fracture is clinically suspected despite negative initial radiographs, expert guidance supports MRI, or CT when appropriate, within the following few days.

    Imaging should not be repeated merely because a certain amount of time has passed. There should be a specific question: are we looking for an occult fracture, checking fracture alignment, assessing healing, or investigating persistent symptoms?

    When should you not wait for a routine follow-up?

    Urgent reassessment is appropriate for rapidly increasing pain or swelling, new numbness, worsening weakness, a pale or cold limb, increasing pressure or severe pain under a cast, fever, pus, spreading redness, a new deformity or inability to bear weight after an injury. In those situations, waiting several days for a scheduled review is not the right plan.

    The key principle

    Trauma diagnosis is a process, not a single image or test. The first visit is designed to identify urgent threats and establish safe initial management. Follow-up checks whether the clinical course supports the initial diagnosis and whether new findings justify more targeted imaging or a different treatment strategy.

    Sources

    1. Clementson M, Björkman A, Thomsen NOB. Acute scaphoid fractures: guidelines for diagnosis and treatment. EFORT Open Rev. 2020;5(2):96–103. DOI: 10.1302/2058-5241.5.190025. PubMed.
    2. National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. NICE guideline NG38. NICE.

    Polish version · For Patients

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Dental Treatment After Joint Replacement — Is Antibiotic Prophylaxis Needed?

    Having a hip or knee replacement does not usually mean that antibiotics are required before every dental procedure. Current guidance does not support routine prophylaxis for all patients. The type of dental treatment, timing in relation to arthroplasty, active oral infection and individual risk factors all matter.

    Why was dental treatment considered a risk after joint replacement?

    Some dental procedures can cause transient bacteraemia. This led to concern that bacteria might seed the surface of a joint implant and cause periprosthetic joint infection. Such infection is a serious complication, but biological plausibility alone does not prove that a preventive antibiotic dose before dental care effectively reduces that risk.

    Bacteraemia also occurs during everyday activities such as brushing, flossing and chewing, particularly when gum health is poor. Over the long term, regular dental care and good oral hygiene are therefore more important than an occasional antibiotic dose before every procedure.

    Is an antibiotic needed before dental treatment?

    According to the AAOS and AAHKS guideline published on 18 November 2024, routine systemic antibiotic prophylaxis before dental procedures in patients with a hip or knee replacement may not reduce the risk of subsequent periprosthetic joint infection. The evidence quality was rated low, so this is a limited-strength option rather than an absolute rule for every patient.

    The American Dental Association likewise states that prophylactic antibiotics are generally not recommended for every patient with a prosthetic joint. Uncommon exceptions should be considered individually, particularly in people with previous complications related to the joint replacement and when the planned procedure involves gingival manipulation or incision of oral mucosa.

    Leftover antibiotics should not be taken without a specific recommendation. Unnecessary treatment can cause allergic reactions, diarrhoea, Clostridioides difficile infection and contributes to antimicrobial resistance.

    A joint replacement is not the same as a prosthetic heart valve

    Antibiotic prophylaxis for infective endocarditis is a separate issue. Some people with specific cardiac conditions may require antibiotics before procedures involving gingival manipulation or oral mucosa. In those situations, the indication may be cardiac rather than orthopaedic. Patients should tell their dentist about all implants and relevant medical conditions, but the two indications should not be conflated.

    When should dental infection be treated before arthroplasty?

    Before elective joint replacement, active sources of oral infection should be treated. Tooth pain, an abscess, facial swelling, fever or active periodontal infection require dental care, and elective arthroplasty is generally postponed until treatment is completed and healing is confirmed.

    The AAOS/AAHKS guidance suggests that planned dental extractions and oral surgical procedures should be completed at least three weeks before arthroplasty to allow mucosal healing. A routine dental examination without probing, dental radiographs or denture adjustment does not require the same interval.

    When can dental treatment be performed after surgery?

    An urgent dental infection should not be left untreated simply because a joint replacement was recent. It requires prompt dental care, with the dentist informed about the recent operation and management coordinated with the orthopaedic team when appropriate.

    For planned procedures that manipulate the gingiva or require oral surgery, the guideline suggests considering a delay of up to three months after joint replacement. This is a consensus recommendation based on indirect evidence; it does not mean that every earlier dental procedure causes an implant infection. Non-invasive assessment and dental imaging may be performed sooner when clinically needed.

    How should a patient prepare for a dental visit?

    • Tell the dentist which joint was replaced and when.
    • Report any previous joint replacement infection or other implant-related complication.
    • List diseases and medications that affect immunity, clotting or healing.
    • Ask whether the planned procedure involves the gingiva, bone or oral mucosa.
    • Do not stop anticoagulants or start antibiotics without a specific instruction.

    When is urgent assessment needed?

    Increasing tooth pain, an abscess, swelling of the face or neck, difficulty swallowing, trismus and fever require prompt dental assessment. In a person with a joint replacement, new severe pain in the operated joint, swelling, marked warmth, fever or drainage from the surgical scar also requires rapid orthopaedic evaluation.

    Key points for an orthopaedic surgeon

    A joint replacement is not an automatic indication for antibiotics before every dental visit. Good oral health, timely treatment of active infection and sensible scheduling of dental procedures around arthroplasty are more important. If prophylaxis is considered in an unusual high-risk situation, it should be based on an individual decision involving the dentist, orthopaedic team and patient.

    Sources

    1. American Academy of Orthopaedic Surgeons; American Association of Hip and Knee Surgeons. Prevention of Total Hip and Knee Arthroplasty Periprosthetic Joint Infection in Patients Undergoing Dental Procedures. Guideline published 18 November 2024. Full guideline.
    2. American Dental Association. Antibiotic Prophylaxis Prior to Dental Procedures. ADA guidance.

    Polish version · Before and After Orthopaedic Surgery

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Conservative Treatment Is Not the Same as Waiting

    Conservative treatment should not mean passively waiting for a problem to disappear. It is a structured process with a working diagnosis, specific interventions, a measurable goal and a planned review point. Without those elements, it is difficult to know whether treatment was actually carried out or why it failed.

    What makes a good plan?

    The first step is to identify the likely source of symptoms and rule out conditions that need urgent treatment. Management of tendon overload is different from care after an unstable injury, and both differ from management of advanced osteoarthritis. The same exercise, brace or medication is not a universal answer to every musculoskeletal pain problem.

    The plan should also define the outcome that matters to the patient: sleeping through the night, climbing stairs, returning to work, restoring a particular range of motion or returning gradually to sport. A change on an imaging report is rarely the main goal by itself.

    What can conservative treatment include?

    Depending on the diagnosis, treatment may include load modification, exercise, physiotherapy, analgesic treatment, temporary use of a brace or crutches, changes in work tasks, weight reduction or an injection. The aim is not to collect as many treatments as possible, but to select those that fit the specific problem.

    Activity modification does not mean complete rest

    Temporarily reducing a movement that reliably provokes pain may be appropriate, but prolonged avoidance of all activity often leads to weakness, loss of fitness and greater fear of movement. In many situations it is better to identify a tolerable level of loading and increase it gradually rather than wait for perfect symptom-free status.

    Exercise has a dose

    Just as medication has a dose and frequency, an exercise programme should specify the movement, number of repetitions, resistance, frequency and progression. “Do some exercises” is not a complete plan. There should also be criteria for reducing load when the tissue response is excessive.

    How long should treatment be tried?

    There is no single mandatory duration of conservative treatment for every condition. Some acute problems change over days, tendon and muscle adaptation usually takes weeks or months, and osteoarthritis management is long term. The review interval should reflect biology and risk rather than an administrative rule.

    A review does not always mean waiting until the full programme is finished. Earlier adjustment is appropriate when symptoms worsen, new weakness appears, the recommended load is not tolerated or the working diagnosis no longer matches the clinical course.

    How do we know whether treatment is working?

    • Pain is less intense or settles more quickly after activity.
    • The patient can do more daily activities.
    • Strength, range of motion, stability or exercise tolerance improves.
    • There is less need for medication or mobility aids.
    • A previously agreed goal that matters to the patient is being reached.

    Complete absence of pain is not always necessary. A clinically meaningful and durable gain in function may matter more.

    When has a trial genuinely failed?

    Lack of improvement becomes informative only when the diagnosis was reasonable, the intervention was appropriate, the dose was sufficient and the patient could realistically carry out the plan. If exercises were random, inconsistent or repeatedly exceeded tissue tolerance, it may be unclear whether the method failed or the programme was not delivered effectively.

    After a properly conducted trial, the next decision may be to modify treatment, revisit the diagnosis, obtain targeted imaging or discuss a procedure. Surgery is not a “punishment” for unsuccessful rehabilitation, and conservative treatment is not a ritual that must precede every operation. The decision depends on expected benefit, risk and the patient’s goals.

    When should we not wait for months?

    More urgent management may be needed for an open or displaced fracture, dislocation, threatened skin, compromised circulation, progressive nerve injury, infection, a locked joint or rapidly increasing weakness. In these situations, a routine “rehabilitation first for several months” approach may be inappropriate.

    Key point for an orthopaedic surgeon

    Good conservative treatment has a structure: diagnosis, goal, selected intervention, appropriate dose, monitoring and a decision point. That structure makes it possible to adjust treatment intelligently and, when necessary, decide about surgery on the basis of the actual treatment course rather than the passage of time alone.

    Sources

    1. American Academy of Orthopaedic Surgeons. Management of Osteoarthritis of the Knee (Non-Arthroplasty). Evidence-Based Clinical Practice Guideline. 2021. Full guideline.
    2. National Institute for Health and Care Excellence. Osteoarthritis in over 16s: diagnosis and management. NICE guideline NG226. 2022. Guideline.

    Polish version · Treatments and Procedures

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Colchicine for Knee Osteoarthritis — Biomarkers Improved, Pain Did Not

    Colchicine changed several inflammatory biomarkers, but after three months it did not reduce pain, improve function or reduce knee effusion more than placebo. This is an important negative clinical result: a favourable laboratory signal does not necessarily translate into a benefit that patients can feel.

    Why is this study interesting?

    Synovitis and innate immune activation are involved in the pathophysiology of knee osteoarthritis, making colchicine a plausible drug-repurposing candidate. It affects several inflammatory pathways and is well established in gout and pericarditis, yet previous osteoarthritis studies have been inconsistent.

    The CLOAK trial, published online on 23 August 2026 in Seminars in Arthritis and Rheumatism, assessed not only pain and function but also ultrasound-detected effusion and a panel of biological markers. This allowed the investigators to compare clinical outcomes with biochemical effects.

    Question and methods

    The trial included 120 people with symptomatic Kellgren–Lawrence grade 2 or 3 knee osteoarthritis. Participants were randomly assigned to daily colchicine or placebo for three months. The study used double blinding, and concomitant non-steroidal anti-inflammatory drugs were not permitted.

    The primary endpoint was the between-group difference in change in visual analogue scale pain in the index knee. Secondary outcomes included KOOS, ultrasound-measured effusion depth, paracetamol use and changes in markers associated with inflammation and osteoarthritis.

    Results

    At three months, colchicine was not superior to placebo for pain reduction. There was also no advantage in KOOS or ultrasound-detected effusion. No clinically meaningful difference emerged in subgroup analyses of participants with greater pain, more advanced radiographic disease, higher hsCRP or higher uric acid.

    At the same time, the colchicine group showed favourable changes in some biomarkers. Statistically significant between-group differences included hsCRP and beta-NGF. For several additional markers the authors reported only trends; these signals should not be treated as proof of clinical benefit.

    Clinical interpretation for an orthopaedic surgeon

    The most important finding is the absence of improvement in outcomes that matter directly to patients. A biomarker shift may indicate biological activity, but it is not enough to justify treatment when pain, function and effusion do not improve.

    The study does not support starting colchicine solely to treat symptomatic knee osteoarthritis. For a patient taking colchicine for another recognised indication, these results of course do not imply that the drug should be stopped; the trial addresses its effectiveness as a treatment for knee osteoarthritis.

    Limitations

    • A three-month follow-up cannot assess long-term effects or structural progression.
    • A sample of 120 may miss small treatment effects and uncommon adverse events.
    • Exclusion of concomitant NSAID use limits direct generalisation to some routine clinical settings.
    • Multiple biomarker analyses increase the chance of false-positive findings.
    • Biochemical change remains a surrogate outcome, not evidence of patient benefit.

    What might this change in practice — and what does it not prove?

    The findings strengthen the case against routine colchicine use for symptomatic knee osteoarthritis outside another accepted indication or a clinical trial. They also reinforce an important hierarchy of evidence: pain, function and safety should carry more weight in treatment decisions than improvement in an isolated biomarker.

    The trial does not prove that colchicine has no anti-inflammatory biological effect or that longer treatment could never produce benefit. It does show that there is currently no clinical basis for waiting for such an effect at the expense of better-supported care. Appropriate exercise and loading, education, weight management, analgesic strategies that respect contraindications, and surgery for properly selected patients remain central to practice.

    Source

    Samuels J, Tse K, Wei D, et al. CoLchicine for Treatment of OsteoArthritis of the Knee (CLOAK): Clinical and biochemical outcomes from a three-month double-blind, placebo-controlled study. Semin Arthritis Rheum. 2026;153066. DOI: 10.1016/j.semarthrit.2026.153066. PubMed.

    Polish version · Research Updates, Literature and Evidence-Based Medicine

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Return to Sport After an Ankle Sprain — When Is It Safe?

    Return to sport after an ankle sprain is safest when the joint tolerates loading, has sufficient range of motion, strength and balance, and the athlete can perform sport-specific movements without substantial pain, giving way or a clear increase in symptoms the following day. The number of days since injury—or the disappearance of swelling alone—is not enough.

    Progression should be gradual: from normal walking and simple exercises to running, changes of direction and finally full training. A more severe injury, suspected syndesmotic injury, fracture or osteochondral lesion requires a different plan.

    First establish what was injured

    A typical lateral ankle sprain involves the ligaments on the outer side of the ankle. Similar symptoms, however, can occur with a fracture, syndesmotic injury, peroneal tendon injury or an osteochondral lesion. If the diagnosis is uncertain, an early return to sport can delay appropriate treatment.

    Imaging should be selected to answer a clinical question rather than ordered automatically. See the English overview of diagnostic tests for the roles of X-ray, ultrasound, MRI and CT.

    There is no single safe number of days

    Two injuries both described as an “ankle sprain” can differ greatly in severity, stability and sporting demands. A runner returning after a minor sprain faces different requirements from a footballer, basketball player or tennis player who needs to brake, land and change direction rapidly.

    The calendar is therefore only one part of the decision. More important is how the ankle responds to progressively harder loading and how it feels over the following 24 hours.

    Five areas an orthopaedic surgeon and physiotherapist assess

    The international PAASS consensus organises return-to-sport assessment into five domains. It is not a single test or an automatic clearance certificate, but a practical framework that helps ensure important elements are not overlooked.

    1. Pain

    Pain should be assessed during sport and over the previous 24 hours. Mild discomfort does not always mean activity must stop, but pain that increases during training, changes movement technique or is clearly worse the next day suggests that the load was too high.

    2. Range of motion, strength and power

    The ankle should regain the range of motion required for the sport. Strength of the peroneal muscles and calf matters, but so do endurance and the ability to produce force quickly. Calf raises, single-leg squats and side-to-side comparison tasks can be useful in practice.

    3. Confidence and perceived stability

    The athlete should trust the ankle during landing, cutting and contact. Fear of movement can alter loading even when simple tests look satisfactory. A persistent feeling that the ankle “gives way” deserves reassessment.

    4. Balance and neuromuscular control

    The ankle must respond to loss of balance and uneven ground. Single-leg stance and dynamic tasks help assess limb control. It is useful to observe not only time or distance but also landing quality, knee and trunk position, and the number of errors.

    5. Sport-specific tasks and full training

    Jumping, landing, acceleration, deceleration, cutting and ball drills should reflect the demands of the individual sport. One of the most useful tests is the ability to complete a full training session without loss of control and without a meaningful increase in symptoms afterwards.

    How should return be progressed?

    1. Daily loading: walking without a marked limp, stairs and basic exercises.
    2. Straight-line movement: brisk walking, jogging and easy running.
    3. Dynamic loading: hops, landings and acceleration.
    4. Change of direction: cutting, braking and tasks on less predictable surfaces.
    5. Sport training: controlled drills first, followed by full training.
    6. Competition: only after the athlete tolerates the full demands of training.

    Each stage should be performed with good movement quality. If pain, swelling or a sense of instability clearly increases during activity or the next day, the load should be reduced and the situation reassessed.

    What should rehabilitation include?

    Current guidance supports progressive restoration of weight-bearing, range of motion, strength and neuromuscular control. Rehabilitation commonly includes mobility work, strengthening, balance training, single-leg tasks and gradual progression toward sport-specific movement.

    Prolonged complete immobilisation is not standard for every ankle sprain. A short period of immobilisation can be appropriate after a severe injury, but subsequent care should usually include early, safe mobilisation. The details depend on ankle stability and associated injuries.

    Can a brace or taping reduce the risk of another sprain?

    For athletes returning after a sprain, bracing or taping can be one component of recurrence-risk reduction, particularly in sports involving jumps and rapid changes of direction. They do not replace rehabilitation. External support by itself does not restore strength, balance or confidence in movement.

    When do symptoms not fit a simple ankle sprain?

    Reassessment is appropriate when pain is higher above the ankle, deep within the joint, accompanied by locking, tendon snapping, repeated giving way or a lack of expected improvement. Pain behind the lateral malleolus may also arise from the peroneal tendons rather than from the ankle ligaments themselves.

    Warning signs

    • visible deformity or suspected dislocation;
    • inability to bear weight with marked focal bony tenderness;
    • a cold, pale or blue foot, increasing numbness or weakness;
    • very severe or rapidly increasing pain;
    • an open wound;
    • increasing calf swelling, shortness of breath or chest pain;
    • lack of expected improvement or deterioration after initial improvement.

    The key point

    Safe return to sport after an ankle sprain is a function-based decision. Pain, movement, strength, balance, confidence in the joint and sport-specific performance all matter. Completing full training without a subsequent symptom flare is a much more useful test than the date of injury alone.

    Polish version · Sports Medicine and Reconstructive Surgery

    References

    • Smith MD et al. Return to sport decisions after an acute lateral ankle sprain injury: introducing the PAASS framework—an international multidisciplinary consensus. Br J Sports Med. 2021;55:1270–1276. DOI: 10.1136/bjsports-2021-104087.
    • Martin RL et al. Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021. J Orthop Sports Phys Ther. 2021;51(4):CPG1–CPG80. DOI: 10.2519/jospt.2021.0302.

    This material is educational. Rehabilitation pace and return-to-sport decisions should be tailored to the injury, clinical examination and demands of the sport.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.