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Tomasz Poboży

Autor: Tomasz Poboży

  • Type II Collagen, Glucosamine and Diacerein for Knee Osteoarthritis — No Advantage Over Placebo

    A recent double-blind randomized trial found no significant advantage over placebo for undenatured type II collagen, pharmaceutical-grade crystalline glucosamine sulfate, or diacerein in patients with mild to moderate knee osteoarthritis. The study is clinically useful because all three commonly discussed oral treatments were assessed within the same four-arm, placebo-controlled protocol, with more than 96% of participants completing follow-up.

    Polish version: Kolagen typu II, glukozamina i diacereina w gonartrozie — bez przewagi nad placebo

    Why is this study worth attention?

    Oral agents often described as slow-acting treatments for osteoarthritis remain widely used despite inconsistent evidence of benefit. Glucosamine is particularly controversial, but similar questions apply to undenatured type II collagen and diacerein. The trial by Narkbunnam and colleagues, published online on 9 September 2026 in JB & JS Open Access, tested all three strategies under a single protocol against a common placebo group.

    Study question and methods

    The four-arm, double-blind randomized trial enrolled 216 adults in Thailand with symptomatic Kellgren-Lawrence grade 2 or 3 knee osteoarthritis. For 24 weeks, participants received one of the following:

    • undenatured type II collagen, 40 mg once daily,
    • pharmaceutical-grade crystalline glucosamine sulfate, 500 mg three times daily,
    • diacerein, 50 mg once or twice daily,
    • or placebo.

    The primary endpoint was total WOMAC score at 24 weeks, with follow-up extended to 36 weeks. The analysis followed the intention-to-treat principle, using imputation and repeated-measures models to account for missing data.

    Overall, 208 of 216 participants completed the study, a completion rate of 96.3%. Mean age was 61.7 years, 90.9% were women, and 73.6% had Kellgren-Lawrence grade 2 radiographic disease.

    Results

    At 24 weeks, none of the three active treatments was superior to placebo for the primary endpoint. The between-group differences in total WOMAC score versus placebo were:

    • type II collagen: −4.7 points (95% CI −18.6 to 9.1),
    • glucosamine: −8.1 points (95% CI −21.8 to 5.7),
    • diacerein: −12.3 points (95% CI −25.9 to 1.3).

    All confidence intervals crossed zero, and none of the comparisons demonstrated a clear difference exceeding the study’s threshold for minimal clinical importance. At 36 weeks, the pattern remained similar, with differences versus placebo of −1.8, −4.8 and −1.3 points, respectively.

    No significant between-group differences were found for pain measures, joint-space width or performance tests. Adverse events were mild and similar across groups, and no serious adverse events were reported.

    Clinical interpretation for an orthopaedic surgeon

    The important point is not simply that the p values were above 0.05, but the size and precision of the observed effects. Point estimates for all three interventions favoured improvement, yet the effects were neither sufficiently precise nor sufficiently large to establish a reliable advantage over placebo. There was also no consistent supportive signal across secondary outcomes.

    Clinically, these findings weaken the rationale for routinely using any of the three products as stand-alone treatment with the expectation of a substantial improvement in pain and function. The results may be especially useful when discussing realistic treatment benefit, cost and alternatives with better-established efficacy.

    Limitations

    The study was conducted in a Thai population, with a marked predominance of women and mostly Kellgren-Lawrence grade 2 disease. The findings therefore cannot automatically be assumed to apply identically to populations with different demographics or more advanced osteoarthritis.

    Follow-up to 36 weeks is adequate for short-term symptomatic assessment but too short to support conclusions about long-term structural effects. The trial was also not designed to detect rare adverse events.

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

    The trial provides a strong argument against treating undenatured type II collagen, crystalline glucosamine sulfate or diacerein as routine monotherapy expected to deliver a clinically important improvement in knee osteoarthritis. It does not prove that no individual patient can improve, nor can the result be extrapolated automatically to every commercial formulation, different doses, combination therapy or patients with a different disease stage.

    It also does not show that these interventions increase or reduce the long-term likelihood of joint replacement. Answering that question would require a substantially longer follow-up and a different study design.

    Reference

    1. Narkbunnam R, Awirotananon K, Chareancholvanich K, Achawakulthep C, Adulkasem N, Chatmaitri S, Hirunyachoke P, Pornrattanamaneewong C. A Comparison of Clinical Outcomes Among Undenatured Collagen Type II, Glucosamine Sulfate, and Diacerein on Osteoarthritic Knee Treatment: A Randomized Clinical Trial. JB & JS Open Access. 2026;11(3). DOI: 10.2106/JBJS.OA.26.00225. PMID: 42698930.

    ← Research updates, literature and EBM

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Sport After Hip or Knee Replacement — What Can You Do and When?

    Polish version

    After an uncomplicated hip or knee replacement, most patients can gradually return to low-impact activity such as walking, cycling and swimming once the wound has fully healed. There is no single date when every sport becomes safe. Running, jumping, contact sports and activities involving sudden changes of direction require much more cautious assessment because higher loads also increase the consequences of a fall or injury.

    The important question is not only how many weeks have passed since surgery. Healing, muscle strength, balance, range of motion, gait stability, the joint’s response to exercise, the type of replacement and the patient’s previous experience in the sport all matter.

    Do you have to give up sport after joint replacement?

    No. The purpose of joint replacement is to improve function and quality of life, and regular physical activity is an important part of maintaining overall fitness. Current evidence shows that a large proportion of patients return to recreational activity after surgery, particularly low-impact sports.

    In a meta-analysis of knee arthroplasty including 45 studies and 14,498 knees, approximately 85% of patients returned to physical activity or sport, with a median return time of 4.1 months. The authors emphasised, however, that certainty of evidence for the analysed outcomes was very low. These figures describe a population; they are not an individual clearance date for sport.

    A similar pattern is seen after total hip arthroplasty. In a review of 57 studies, the pooled return-to-sport rate was about 85%, with a mean time of approximately 16 weeks. Return to low-intensity activity was much more common than return to high-impact sport.

    Which activities are usually easiest to resume?

    Return is most predictable for activities with lower joint loading and a lower risk of falling. These commonly include:

    • walking and brisk walking;
    • stationary cycling, followed later by outdoor cycling in safe conditions;
    • swimming once the wound is fully healed;
    • water-based exercise;
    • golf;
    • controlled strength training appropriate to the stage of recovery.

    This does not mean that every activity can be restarted immediately. Entering a swimming pool before the wound has fully healed can create wound problems, while cycling in traffic requires substantially more balance and reaction speed than exercising on a stationary bike.

    What about running, tennis, skiing and contact sports?

    The greater the impact, jumping, cutting and risk of falling, the less useful a simple rule such as “you can return after this many weeks” becomes. High-intensity sports are resumed much less often after joint replacement than low-impact activities.

    This is particularly relevant to regular running, contact sports, games with frequent changes of direction, intensive tennis, combat sports and activities with a substantial risk of falling. The issues are not limited to implant wear: dislocation, periprosthetic fracture and an injury requiring another operation also need to be considered.

    This does not amount to an automatic ban on every demanding sport. A patient who has skied recreationally for years and regains full control of the limb after surgery is different from someone planning to start a high-fall-risk sport only after joint replacement. The decision should be individual.

    Is return to sport the same after hip and knee replacement?

    Not entirely. After hip replacement, early limitations may relate to tissue healing, muscle weakness, pelvic control and fall risk. After knee replacement, swelling, limited flexion, stiffness and quadriceps weakness often remain relevant for longer.

    After unicompartmental knee arthroplasty, some patients return to activity more readily than after total knee arthroplasty. In the recent meta-analysis, the probability of returning to physical activity or sport was higher after unicompartmental replacement, but the certainty of this finding was rated very low. It should not be treated as a guarantee of faster return for an individual patient.

    How does an orthopaedic surgeon assess readiness to increase the load?

    Before moving to more demanding activity, function is more useful than the calendar. Favourable conditions for increasing load generally include:

    • a fully healed wound;
    • no increasing pain at rest;
    • stable walking without a pronounced limp;
    • enough range of motion for the planned activity;
    • adequate strength in the operated limb;
    • good balance and movement control;
    • no marked increase in swelling after the current level of exercise.

    If a higher load produces a clear increase in pain or swelling that does not return to the previous level, progression may have been too rapid.

    How should return to sport be progressed in practice?

    A staged return is the safest approach. First rebuild basic function: walking, range of motion, strength and balance. Then increase exercise duration and intensity. More complex sport-specific movements should be introduced later.

    Avoid increasing duration, intensity and technical difficulty all at once. For sports requiring rapid reactions, it is useful to regain movement control first in a safer environment. Patients returning to more demanding disciplines may benefit from physiotherapy assessment and an agreed plan with the operating surgeon.

    When should activity be stopped and medically reviewed?

    New severe pain after a fall, sudden inability to bear weight, obvious deformity, a sensation that the joint has moved out of position or a sudden loss of function requires urgent assessment. Fever, increasing redness, warmth or wound drainage also warrants prompt review.

    New calf pain and swelling may require assessment for deep-vein thrombosis. Shortness of breath, chest pain, coughing up blood or fainting requires immediate medical attention.

    The key principle

    Returning to activity after joint replacement is desirable, but the type of sport should match the stage of healing, current function and the risk of injury. Average time points from studies are useful for planning recovery, but they do not replace assessment of the individual patient.

    In a publication by Tomasz Poboży and Maciej Kielar on selection of hip prostheses, everyday activity and the patient’s future plans were highlighted as relevant elements in treatment planning. That paper does not define the timing of return to sport, but it illustrates why activity level should already be considered when planning surgery and selecting an implant strategy.

    Back to: Before and After Orthopaedic Surgery

    References

    1. Poboży T, Kielar M. The use of various types of hip prostheses depending on the patient’s age and level of everyday activity. Medical Studies/Studia Medyczne. 2015;31(3):213–222. DOI: 10.5114/ms.2015.54763.
    2. Braz R, Gomes E, Valente C, et al. High rate of return to low-impact physical activity or sports after total and unicompartmental knee arthroplasty: A systematic review with meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2026;34(9):3415–3428. DOI: 10.1002/ksa.70267. PMID: 41527885.
    3. Pasqualini I, Emara AK, Rullan PJ, et al. Return to Sports and Return to Work After Total Hip Arthroplasty: A Systematic Review and Meta-analysis. JBJS Rev. 2023;11(8). DOI: 10.2106/JBJS.RVW.22.00249. PMID: 37549241.
    4. Pasqualini I, Emara AK, Rullan PJ, et al. Return to Sports and Return to Work After Total Knee Arthroplasty: A Systematic Review and Meta-Analysis. JBJS Rev. 2023;11(7). PMID: 37499045.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Immediate Sarmiento Bracing After a Humeral Shaft Fracture? Not Always

    Polish version

    For an acute humeral shaft fracture, applying a functional brace immediately after the injury may not be the most comfortable or safest option during the first few days. The multicentre randomised COBRAS trial, published in the Journal of Orthopaedic Trauma, found that immediate Sarmiento bracing was associated with more pain and more skin complications than initial coaptation splinting followed by conversion to a brace after the acute swelling had settled. The study addresses only the first 10 days of treatment and does not answer questions about fracture union or long-term function.

    Why is this study relevant to an orthopaedic surgeon?

    Non-operative treatment of selected humeral shaft fractures is based on functional bracing. A practical question remains, however: should the Sarmiento brace be applied immediately after injury, or is it better to use a splint during the period of greatest swelling and move to functional bracing later?

    This may look like a technical detail, but it affects pain, treatment tolerance and the condition of the skin. The value of the COBRAS trial is that it compared the two strategies in a randomised design rather than relying only on local preference.

    Study question and methods

    The multicentre, parallel-group randomised trial included adults with an acute closed AO/OTA 12A, 12B or 12C humeral shaft fracture selected for non-operative treatment. The analysis included 58 patients.

    Two strategies were compared:

    • initial coaptation splinting, followed by transition to a Sarmiento brace after the acute swelling had decreased;
    • immediate application of a Sarmiento brace.

    The investigators recorded daily pain on a 0–10 scale for the first 10 days, opioid use converted to morphine equivalents, PROMIS function, patient satisfaction and skin complications related to pressure from the splint or brace.

    Results

    Patients who received an immediate Sarmiento brace reported more pain during the first 10 days. The mean treatment effect was 0.97 points on the 0–10 pain scale against immediate bracing (95% CI 0.26–1.69; p=0.010).

    The skin-complication difference was more pronounced: complications occurred in 33.3% of patients treated with an immediate brace compared with 7.1% of those who started in a coaptation splint (p=0.022).

    There was no significant difference in cumulative opioid use over 10 days: the median was 20.0 mg morphine equivalents in the splint group and 32.5 mg in the immediate-brace group (p=0.308). There was also no significant difference in function measured on day 7 or in patient satisfaction.

    How should the findings be interpreted?

    The most practical conclusion is straightforward: there is no clear reason to rush the transition to a functional brace at the expense of poorer tolerance during the acute phase of injury. During the period of greatest swelling, a conventional coaptation splint may be better tolerated, with conversion to a functional brace once the soft tissues have settled.

    A pain difference of about one point is not large in isolation, but it occurred alongside more than a fourfold difference in skin complications. That makes the overall result more clinically persuasive than the pain score alone.

    Importantly, immediate bracing did not produce a detectable advantage in early function, opioid use or satisfaction. The trial therefore supports a staged approach during the first days after injury.

    Limitations

    • The analysis included only 58 patients, so the sample was small.
    • The main observation period covered only the first 10 days after injury.
    • The study focused on pain, tolerance and skin complications rather than fracture union.
    • It does not show whether either strategy changes the risk of nonunion, secondary displacement or later surgery.
    • The results apply to closed fractures selected for non-operative treatment and should not be extrapolated to fractures that require surgical fixation.

    What could this change in practice?

    The study does not introduce a new technology. Instead, it clarifies a simple element of everyday fracture care. For a patient with a closed humeral shaft fracture being treated non-operatively, it is reasonable to accept an initial period of splinting and move to functional bracing once swelling decreases rather than treating immediate Sarmiento bracing as a goal in itself.

    What does the study not prove?

    It does not prove that coaptation splinting leads to better union or better function after several months. It also does not determine which humeral shaft fractures should be treated operatively rather than non-operatively. This is a study of the initial phase of non-operative treatment, not of the entire management strategy.

    Back to: Trauma — Literature for Clinicians

    Source

    Kingery MT, Ganta A, Egol KA. Comparison of Early Bracing Versus Splinting for the Initial Treatment of Acute Humeral Shaft Fractures (The COBRAS Trial). Journal of Orthopaedic Trauma. 2026;40(8):408–415. DOI: 10.1097/BOT.0000000000003196. PubMed: PMID 42466769.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Clavicle Fracture — When Is Surgery Needed?

    Polish version

    A clavicle fracture does not automatically mean surgery. Many fractures can be treated successfully without an operation, usually with a sling. The choice depends on the location of the fracture, the degree of displacement and comminution, the condition of the skin, shoulder-girdle stability, neurovascular findings, and the patient’s age and functional needs. In selected displaced fractures, surgery reduces the risk of nonunion, but it does not give every patient a better long-term functional result.

    How does a clavicle fracture happen?

    The most common mechanism is a direct fall onto the shoulder, for example while cycling, skiing or taking part in contact sport. A clavicle fracture can also occur in a road-traffic injury or after a fall onto an outstretched arm.

    The location matters as much as the fact that the bone is broken. Midshaft fractures behave differently from lateral fractures near the acromioclavicular joint, while medial fractures near the sternum are less common and raise a different set of anatomical concerns.

    What symptoms are typical?

    • pain over the clavicle that increases with arm movement;
    • swelling and bruising;
    • a palpable step, irregularity or deformity;
    • difficulty lifting the arm;
    • sometimes a clearly prominent bone fragment beneath the skin.

    The appearance of the shoulder alone cannot determine whether surgery is required. Clinical examination and X-rays are central to the decision.

    How is a clavicle fracture diagnosed?

    Plain X-rays are the first-line imaging test. They usually show the fracture location, displacement and comminution well enough to guide initial management. CT can be useful in selected fractures with more complex anatomy, particularly when standard radiographs do not answer the relevant clinical questions.

    Ultrasound does not replace X-ray for routine diagnosis of a clavicle fracture. It may, however, help assess selected associated soft-tissue problems around the shoulder.

    When does a clavicle fracture need urgent assessment?

    Many isolated clavicle fractures can be reviewed in an urgent or planned orthopaedic pathway depending on the injury. Some findings should not wait.

    • An open wound over the fracture or visible bone may indicate an open fracture.
    • Marked skin tenting, blanching or skin damage over a sharp fragment can mean that the fragment is threatening to break through the skin.
    • Numbness, weakness of the hand, a cold or pale limb, or abnormal pulses require assessment for nerve or vascular injury.
    • Shortness of breath, chest pain or a high-energy mechanism requires assessment for chest injury and other associated trauma.
    • Major shoulder-girdle deformity or suspicion of an associated scapular fracture may indicate a more unstable injury pattern.

    When can treatment be non-operative?

    Non-operative treatment is often appropriate when displacement is limited or the overall alignment is acceptable, the skin is not threatened and there is no neurovascular injury.

    In the acute phase, a sling is usually used. The American Academy of Orthopaedic Surgeons guideline favours a sling over a figure-of-eight brace for most acute clavicle fractures. The main purpose is pain relief and protection during the early phase of healing.

    This does not mean complete immobility for many weeks. Movement of the elbow, wrist and fingers is usually maintained from the outset, while shoulder movement is gradually increased according to pain, fracture stability and the treating clinician’s instructions.

    When is surgery more likely to be considered?

    Absolute or very strong indications for urgent operative treatment include open fractures, threatened skin, significant neurovascular injury and selected unstable injuries of the shoulder girdle.

    Outside those situations, the decision is more individual. Surgery is considered more often in adults with markedly displaced, shortened or comminuted midshaft fractures and in selected unstable fractures of the lateral end. Occupation, sport, arm dominance, patient expectations and the estimated risk of nonunion also matter.

    No single X-ray measurement determines the need for surgery on its own. Shortening and displacement are part of the assessment, but they need to be interpreted in the full clinical context.

    Does surgery give a better result?

    The best available evidence is more nuanced than simply saying that surgery is better. Meta-analyses of randomised trials in displaced midshaft clavicle fractures show that operative treatment reduces the risk of nonunion. It may also provide faster functional improvement during the first weeks.

    That functional advantage becomes much smaller over time. A meta-analysis of 10 randomised trials including 1,333 patients found a DASH difference of about 9.4 points at 6 weeks in favour of surgery, but the differences at 3 and 6 months were smaller and no longer clinically meaningful.

    A 2026 systematic review of 18 randomised trials including 1,201 adults treated non-operatively for displaced midshaft clavicle fractures found that function generally improved substantially during the first months. Nonunion occurred in about 14%, while approximately 13% later underwent surgery.

    The practical conclusion is that surgery can reduce the risk of union-related problems in appropriately selected patients, but it is not necessary for every adult with a displaced fracture.

    What are the disadvantages of surgery?

    Plate fixation or another form of internal fixation carries the usual operative risks, including infection, wound problems, nerve injury, implant-related symptoms and the possibility of another procedure, for example to remove symptomatic hardware. The benefit of reducing nonunion risk therefore has to be weighed against the risks and burden of surgery itself.

    How long does a clavicle fracture take to heal?

    Healing takes weeks and varies between patients. Pain often improves before full bony union is achieved, so feeling better does not mean the clavicle is ready for heavy loading or contact sport.

    Return to heavy work, strength training or sport with a meaningful risk of falling should be based on several factors together: pain resolution, recovery of movement and strength, and adequate fracture healing. Lighter daily activity is often possible earlier, but progression should remain individual.

    When should you seek reassessment during non-operative treatment?

    • pain is clearly increasing rather than gradually improving;
    • a new deformity appears or the fragments seem to be moving;
    • the skin over a fragment becomes increasingly tense or red;
    • numbness, weakness, or a change in the colour or temperature of the hand develops;
    • marked tenderness and lack of healing progress persist after many weeks;
    • general symptoms or wound problems develop after operative treatment.

    Key points for an orthopaedic surgeon

    • Many clavicle fractures can be treated without surgery.
    • X-ray is the main imaging test.
    • When non-operative care is chosen, a sling is generally preferred to a figure-of-eight brace.
    • Surgery is considered more strongly for open fractures, threatened skin, neurovascular injury, instability and selected markedly displaced fractures.
    • In adults with displaced midshaft fractures, surgery reduces nonunion risk, but long-term functional results often converge with non-operative treatment.
    • The decision should not be based on one radiographic measurement alone.

    Back to: Injuries and Fractures

    References

    1. American Academy of Orthopaedic Surgeons. Treatment of Clavicle Fractures: Evidence-Based Clinical Practice Guideline. Published December 2, 2022. Full AAOS guideline.
    2. Vaajala M, Tarkiainen J, Liukkonen R, Launonen AP, Mattila VM. Non-surgical treatment for displaced midshaft clavicle fractures: a systematic review and meta-analysis. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-10208-1.
    3. Qvist AH, Jensen SL. Minimal early functional gains after operative treatment of midshaft clavicular fractures: a meta-analysis of 10 randomized controlled trials including 1333 patients. JSES International. 2024;8(3):400–406. DOI: 10.1016/j.jseint.2023.12.011.

    This material is educational and does not replace individual medical assessment of a fracture.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Lisfranc Injury — Preserve TMT1 or Perform Primary Arthrodesis?

    Polish version

    A randomised trial with a mean follow-up of 10.8 years found no advantage to preserving the first tarsometatarsal joint (TMT1) over primary arthrodesis in selected patients with unstable Lisfranc injury. This is important because it is easy to assume that preserving a mobile joint must lead to better long-term function. In this specific patient group, that advantage was not demonstrated.

    Why is this study clinically interesting?

    Lisfranc injuries have long generated debate about when joint preservation should be prioritised and when primary arthrodesis is the more reasonable strategy. Most published studies have relatively short follow-up. The report by Grün and colleagues, published online on 9 July 2026 in The Journal of Bone and Joint Surgery, is a long-term continuation of an earlier randomised trial and provides a rare comparison of the two approaches more than a decade later.

    Study question and methodology

    The original trial enrolled 48 adults with unstable Lisfranc injuries involving the three medial tarsometatarsal joints. An important detail is that patients with a fracture involving TMT1 were not included.

    • One group underwent primary arthrodesis of TMT1, TMT2 and TMT3.
    • In the other group, TMT1 was preserved and temporarily stabilised with a dorsal bridge plate, while TMT2 and TMT3 were also fused.

    After a mean of 10.8 years, 41 of the 48 originally randomised patients—85% of the cohort—were assessed. Outcomes included the AOFAS midfoot score, Manchester–Oxford Foot Questionnaire (MOxFQ), pain, SF-36, return to activity, use of orthoses or inserts, and degenerative changes on computed tomography.

    Results

    At approximately 10 years, there was no significant difference in AOFAS scores: 89.3 points after primary TMT1 arthrodesis versus 92.6 points after temporary bridge plating (p = 0.66). No significant differences were found in MOxFQ, pain, SF-36, return to activity or the need for orthotic support.

    The frequency of degenerative changes in adjacent joints was similar. After TMT1 preservation, degenerative changes within TMT1 itself were common, but only one patient subsequently required arthrodesis. The bridge-plating strategy, however, involved planned removal of the fixation hardware, meaning an additional procedure that was not required after primary arthrodesis.

    Clinical interpretation for an orthopaedic surgeon

    The practical conclusion is not that every patient should undergo arthrodesis. The study shows something narrower and more useful: in this selected group, preserving TMT1 did not translate into a detectable functional advantage after more than 10 years. At the same time, primary fusion of the first tarsometatarsal joint did not lead to poorer function or a higher frequency of degenerative change in adjacent joints.

    Imaging findings should also be separated from symptoms. Degenerative change in a preserved TMT1 was common on imaging, but this did not automatically lead to another operation; only one patient required secondary arthrodesis.

    Limitations

    • The study was randomised but small: 48 patients were enrolled initially and 41 were assessed at approximately 10 years.
    • A non-significant statistical difference is not formal proof that the procedures are equivalent; the sample may have been too small to detect subtle differences or uncommon complications.
    • TMT2 and TMT3 were fused in both groups. The findings therefore cannot be directly extrapolated to a comparison between completely joint-preserving fixation and arthrodesis of the entire medial Lisfranc complex.
    • Fractures involving TMT1 were excluded, so the conclusions apply to a defined injury pattern.
    • The AOFAS score is an older measure combining patient-reported elements with clinical examination. It is therefore useful that the investigators also included MOxFQ, pain and SF-36.

    What may change in practice—and what the study does not prove

    The study strengthens the argument that primary TMT1 arthrodesis in an appropriately selected patient with an unstable Lisfranc injury does not necessarily produce a worse long-term result simply because motion at that joint is sacrificed. Conversely, preserving TMT1 can also produce a good result despite frequent degenerative changes on imaging.

    The study does not prove that arthrodesis is universally superior, does not resolve every type of Lisfranc injury and does not allow every fixation technique to be treated as equivalent to temporary dorsal bridge plating. The decision must still account for the injury pattern, condition of the articular surfaces, ability to restore the Lisfranc complex anatomically, patient activity and the consequences of a possible additional procedure.

    Back to: Trauma — Literature for Clinicians

    References

    Grün W, Poulsen M, Riiser MØ, Hvaal K, Husebye EE, Stødle AH. A Randomized Controlled Trial of Primary Arthrodesis Versus Temporary Bridge Plating in Unstable Lisfranc Injuries: A Concise Follow-up, at 10 Years, of a Previous Report. J Bone Joint Surg Am. Published online July 9, 2026. DOI: 10.2106/JBJS.26.00020. PubMed: PMID 42424434.

    Original trial: Stødle AH, Hvaal KH, Brøgger HM, Madsen JE, Husebye EE. Temporary Bridge Plating vs Primary Arthrodesis of the First Tarsometatarsal Joint in Lisfranc Injuries: Randomized Controlled Trial. Foot Ankle Int. 2020;41(8). DOI: 10.1177/1071100720925815.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • When Can You Stop Using Crutches After Hip or Knee Replacement?

    Polish version

    After an uncomplicated hip or knee replacement, the decision to stop using crutches should not be based on the number of days since surgery alone. What matters most is whether you can walk safely, without a clear limp or giving way of the operated leg, with adequate balance and muscle control. Many patients begin weight-bearing very early, often as tolerated, but progression from two crutches to one and then to unaided walking should reflect the operation performed and the individual postoperative instructions.

    Can you put weight on the operated leg immediately after joint replacement?

    After a typical, stable primary hip or knee replacement, contemporary recovery programmes favour early mobilisation and getting out of bed as soon as practical. ERAS recommendations for hip and knee replacement support early mobilisation, while current physical therapy guidance after total knee arthroplasty emphasises early recovery of walking, balance and efficient movement patterns.

    For uncemented total hip arthroplasty, a meta-analysis of 17 studies found no evidence that immediate unrestricted weight-bearing increased excessive stem micromotion, failure of bone integration or revision risk compared with partial weight-bearing. This does not mean, however, that every patient after every operation may load the leg without restriction.

    When may the instructions be different?

    Temporary weight-bearing restrictions may be needed after revision surgery, an intraoperative or periprosthetic fracture, bone grafting, an osteotomy, repair of additional soft-tissue structures, or whenever the reconstruction needs protection while healing. For that reason, the operating surgeon’s discharge instructions take priority over any general rehabilitation timetable.

    How do patients usually progress from two crutches to one?

    A common sequence is a walking frame or two crutches, followed by one crutch or a walking stick, and finally unaided walking. There is no requirement for every patient to move through each stage at the same time.

    • Two crutches or a walking frame are useful while gait remains uncertain, the leg is weak, pain limits loading or there is a meaningful risk of losing balance.
    • One crutch or a walking stick may be the next step when the patient can safely transfer weight onto the operated leg without clearly increasing the limp.
    • Unaided walking is best introduced when removing support does not worsen gait quality.

    When one crutch or a walking stick is used after hip or knee surgery, it is usually held on the side opposite the operated leg. This reduces the demand on the muscles that stabilise the pelvis and can help maintain a better gait pattern.

    How can you tell when it is reasonable to try walking without crutches?

    Functional criteria are more useful than a fixed date. Reducing support is reasonable when:

    • you can walk on a level surface without a pronounced limp;
    • the operated leg does not feel as though it is giving way or suddenly buckling;
    • your balance allows you to turn, stop and rise from a chair safely;
    • pain and swelling remain controlled after increasing your step count;
    • after knee replacement, quadriceps control is sufficient to keep the knee stable during weight-bearing;
    • after hip replacement, pelvic control is sufficient and walking without a crutch does not produce marked trunk leaning;
    • the orthopaedic surgeon has not prescribed a temporary weight-bearing restriction.

    Is it better to keep one crutch for longer or stop using it as soon as possible?

    If walking without the crutch produces a clear limp, shorter steps, trunk leaning or reluctance to load the operated leg, it is usually more sensible to continue using support for a while and work on strength and gait quality. The goal is not to “get rid of the crutches” as quickly as possible, but to regain safe and reasonably symmetrical walking.

    Conversely, there is no benefit in continuing with two crutches purely out of habit when there are no loading restrictions, walking is stable and the patient can reduce support without deteriorating gait. Current guidance after knee replacement emphasises functional training, balance and gait retraining rather than the passage of time alone.

    What if pain or swelling increases after reducing support?

    A temporary increase in muscle fatigue after greater activity can occur. If changing the way you walk clearly increases pain, swelling or limping, reduce the load and briefly return to the previous level of support. Symptoms that worsen from day to day should prompt assessment of the cause rather than continued attempts to push through them.

    When should you seek urgent assessment rather than wait for a routine review?

    Urgent assessment is particularly important if there is:

    • sudden shortness of breath, chest pain or fainting;
    • markedly increasing one-sided calf swelling with pain or tenderness;
    • fever accompanied by increasing redness, warmth or wound drainage;
    • sudden severe pain after a fall or twisting injury;
    • a new deformity, obvious limb shortening or inability to bear weight after previously making progress;
    • a sudden substantial loss of function instead of gradual improvement.

    Stopping crutches is only one stage of recovery

    Independent walking does not mean rehabilitation is complete. Strength, balance and tolerance of longer periods of activity continue to improve. Readiness for driving, returning to work and returning to sport should be assessed separately rather than inferred simply from the ability to walk without a crutch.

    Back to: Before and After Orthopaedic Surgery

    References

    1. Bove AM, Carroll LA, Cone S, et al. Clinical practice guideline for physical therapist management of total knee arthroplasty: revision 2026. Physical Therapy. 2026;106(7). DOI: 10.1093/ptj/pzag058.
    2. Huang L, Han W, Qi W, et al. Early unrestricted vs. partial weight bearing after uncemented total hip arthroplasty: a systematic review and meta-analysis. Front Surg. 2023;10:1225649. DOI: 10.3389/fsurg.2023.1225649.
    3. Wainwright TW, Gill M, McDonald DA, et al. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations. Acta Orthop. 2020;91(1):3–19. DOI: 10.1080/17453674.2019.1683790.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Neutrophil Extracellular Traps and Fracture Nonunion — A New Therapeutic Target?

    Polish version

    Fracture nonunion is usually analysed in terms of mechanical stability, blood supply, infection, bone quality and systemic patient factors. A study published on 2 September 2026 in Science Translational Medicine adds a compelling immunological component: sustained neutrophil extracellular traps (NETs) may actively impair bone regeneration.

    Why is this study clinically interesting?

    NETs are structures released by neutrophils in response to tissue injury and infection. During acute trauma they are part of the normal inflammatory response. The study suggests, however, that the important issue is not simply whether NETs appear at a fracture site, but how long they persist. A short-lived response may form part of physiological healing, whereas prolonged activation may become detrimental.

    The study is particularly interesting because it goes beyond a simple association. It combines observations in humans with mechanistic experiments in animal models and identifies a specific biological pathway linking persistent inflammation with impaired vascularisation of the fracture callus.

    Study question and methodology

    The investigators asked whether excessive and sustained NET formation could be causally related to fracture nonunion and whether suppressing this process might improve bone regeneration.

    The study used mouse models with genetic alterations affecting NET formation or clearance, pharmacological inhibition of selected components of the pathway, and assessment of biomarkers in patients with normally healing fractures and in patients with nonunion. Particular attention was paid to type H vessels, which are involved in coupling angiogenesis with osteogenesis within the fracture callus.

    Key findings

    Bone injury produced a rapid increase in NET formation in both mice and humans. In normal healing, however, this response was transient.

    • Genetically impaired NET clearance caused by combined deficiency of DNase1 and DNase1-like-3 initially favoured callus mineralisation, but later led to persistent NETs, impaired regeneration and more frequent nonunion.
    • Additional deletion of PAD4, an enzyme important for NET formation, improved bone regeneration and reduced nonunion in the experimental model.
    • Persistent NETs increased activation of the cGAS-STING pathway and reduced formation of type H vessels within the callus.
    • Pharmacological inhibition of cGAS-STING restored type H vessel formation and improved healing in the relevant animal model.
    • In patients with normal healing, serum NET markers declined over time. In nonunion, they remained elevated and were accompanied by greater accumulation of NETs and STING within the callus.
    • In preclinical models, both the PAD4 inhibitor GSK484 and dornase alfa, a recombinant DNase I that enhances NET clearance, accelerated bone repair and reduced nonunion.

    Clinical interpretation for an orthopaedic surgeon

    One of the most important messages is that the inflammatory response after fracture is strongly time-dependent. The conclusion is not simply that “less inflammation means better healing”. Early neutrophil activity is part of normal fracture repair; the problem appears when mechanisms that should resolve that response fail.

    A second important finding is the proposed connection between persistent immune activation and impaired angiogenesis. Type H vessels are associated with areas of active osteogenesis, so their loss provides a biologically plausible explanation for how abnormally prolonged neutrophil activation could translate into poorer bone regeneration.

    For trauma surgeons, the work is also interesting because it may eventually support biological risk stratification. At present, nonunion risk is assessed mainly from the injury pattern, mechanical stability, soft-tissue condition, vascularity, infection and patient-related factors. Markers of sustained NET activity might one day complement these variables, but clinical use remains a distant prospect.

    Limitations

    The principal limitation is fundamental: the therapeutic interventions were evaluated preclinically. The human data show an association between sustained NET markers and nonunion, but they do not provide randomised evidence that inhibiting NETs in patients improves fracture healing.

    Genetic models with impaired NET clearance deliberately create an exaggerated biological phenotype and may not reflect the most common causes of nonunion in routine trauma practice. The optimal timing, dose and duration of any therapy directed against NETs are also unknown. This matters because suppressing a normal inflammatory response too early or too strongly could theoretically have the opposite effect.

    It is also unclear whether the mechanism will have similar importance across different fracture settings, including high-energy injuries, open fractures, infected fractures, osteoporotic bone or substantial mechanical instability.

    What may change in practice—and what the study does not prove

    At present, this study does not justify using dornase alfa, PAD4 inhibitors or cGAS-STING inhibitors to treat fracture nonunion. There are no clinical data defining efficacy, safety or a treatment regimen for orthopaedic patients.

    The work does, however, change the biological framework in which nonunion can be considered. It describes a coherent sequence: sustained NETs → cGAS-STING activation → impaired type H vessel formation → poorer bone regeneration. If this is confirmed prospectively in humans, it could lead both to a new risk biomarker and to a new class of adjunctive therapies aimed at fracture healing.

    A particularly valuable next step would be clinical research testing whether NET biomarker profiles can distinguish, early in the course of healing, fractures likely to unite normally from those at risk of nonunion. Controlled interventional trials would logically come later.

    Back to: Trauma — Literature for Clinicians

    Reference

    Xie W, Albertsen L-C, Eis-Janzyk G, et al. Sustained neutrophil extracellular traps cause fracture nonunion. Science Translational Medicine. 2026;18(865):eadx9869. DOI: 10.1126/scitranslmed.adx9869. PubMed PMID: 42685150.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Ulnar-Sided Wrist Pain — Could It Be the TFCC?

    Polish version

    Pain on the little-finger side of the wrist may come from the triangular fibrocartilage complex (TFCC), particularly when it begins after a fall onto the hand or a sudden twisting injury, or when it increases with forearm rotation and forceful gripping. TFCC injury is not the only possible cause. The extensor carpi ulnaris tendon, the distal radioulnar joint and other structures occupy the same region, so pain location alone is not enough to establish the diagnosis.

    What is the TFCC?

    The TFCC, or triangular fibrocartilage complex, is a group of fibrocartilaginous and ligamentous structures on the ulnar side of the wrist. It is an important stabiliser of the distal radioulnar joint, helps transmit load and acts as a cushion between the ulna and the carpal bones.

    TFCC damage may be traumatic or degenerative. Traumatic tears can follow a fall onto an outstretched hand, sudden wrist rotation, sport or work involving strong forearm rotation. Degenerative changes more often develop gradually, particularly when the ulnar side of the wrist is subjected to chronic overload.

    Which symptoms fit a TFCC injury?

    Typical pain is felt on the ulnar side of the wrist, between the ulnar head and the carpal bones. It may be provoked by opening a jar, using a screwdriver, turning a door handle, gripping firmly, pushing up from the hand or using the hands to rise from a chair.

    • pain with pronation and supination of the forearm,
    • tenderness in the ulnar fovea region,
    • clicking, catching or a sense that the wrist momentarily jams,
    • reduced grip strength,
    • a feeling of instability during forearm rotation.

    Not every click represents clinically important damage. TFCC abnormalities can also be visible on imaging in people without symptoms, so MRI findings must always be interpreted together with the clinical examination.

    What else can cause ulnar-sided wrist pain?

    This is one of the more demanding areas of wrist diagnosis. Similar symptoms may arise from irritation or instability of the extensor carpi ulnaris (ECU) tendon, distal radioulnar joint instability, ulnocarpal impaction, lunotriquetral ligament injury, fracture of the ulnar styloid or hook of the hamate, and sometimes a ganglion.

    How is TFCC injury diagnosed?

    Clinical examination

    The mechanism of injury and a careful examination are central. The clinician assesses the point of maximal tenderness, wrist motion, grip strength and distal radioulnar joint stability. Provocative tests that load the TFCC may also be used. No single manoeuvre is completely diagnostic, so findings must be considered together.

    X-ray

    After trauma, radiographs are often the first imaging test. They do not show the TFCC itself, but they can identify fractures, assess alignment and provide information such as ulnar variance, which can influence loading on the ulnar side of the wrist.

    Ultrasound

    Ultrasound can be valuable in the assessment of ulnar-sided wrist pain. It allows dynamic examination of the ECU tendon, parts of the TFCC and the distal radioulnar joint. It also has important limitations: a central TFCC disc tear cannot be reliably excluded with ultrasound. A normal scan therefore does not necessarily end the diagnostic process when symptoms continue to suggest an intra-articular lesion.

    MRI

    MRI provides detailed soft-tissue imaging and is commonly used when symptoms persist. It is not a perfect test. A diagnostic meta-analysis showed that conventional MRI can miss some TFCC tears and that accuracy varies with lesion location; peripheral tears can be particularly difficult to define unequivocally.

    MR arthrography or CT arthrography may be used in selected situations, but they are not required for every patient with ulnar-sided wrist pain.

    Arthroscopy

    Arthroscopy allows direct inspection of the TFCC and other structures inside the wrist. It is the most direct method of assessing the lesion itself, but because it is an operative procedure it is not a routine first-line diagnostic test. It is most relevant when symptoms are substantial, non-operative treatment has failed, or a lesion is suspected that can be treated during the same procedure.

    Does every TFCC tear require surgery?

    No. Stable traumatic TFCC tears without distal radioulnar joint instability can often be treated non-operatively first. A 2024 systematic review including 425 patients and 427 wrists found that appropriately selected non-operative management can produce good functional outcomes. Distal radioulnar joint instability or subluxation and complete foveal detachment were associated with a greater risk of failure of conservative treatment.

    The studies included in that review used different treatment protocols, so they do not support one universal immobilisation regimen. The type and duration of bracing should reflect the injury pattern and joint stability rather than the MRI report alone.

    What does non-operative treatment involve?

    Initially, activities that reproduce pain are usually reduced, particularly forceful gripping, rotation and weight bearing through the hand. Depending on the injury, temporary immobilisation or a brace may be used, followed by progressive restoration of movement and loading.

    Analgesic or anti-inflammatory medication can be used in selected patients when appropriate. Hand therapy may then help restore motion, strength and control without repeatedly overloading the injured region.

    An injection may occasionally be considered to reduce associated pain or inflammation, but an injection does not repair or “suture” a torn TFCC. When accurate needle placement matters, image guidance can be useful. See: Injection Treatments.

    When does an orthopaedic surgeon consider surgery?

    Surgery is considered more often when pain continues to limit function despite appropriate non-operative treatment or when clinically important distal radioulnar joint instability is present from the outset. The type and location of the lesion are important.

    Peripheral and foveal tears, particularly those associated with instability, may be suitable for repair. The central disc has a much poorer blood supply, so some symptomatic central tears are treated by arthroscopic debridement of unstable tissue rather than suturing. When ulnocarpal impaction is also present, treatment may need to address the underlying bony anatomy.

    Can the TFCC heal on its own?

    Healing potential depends partly on lesion location. The peripheral TFCC has a better blood supply than the central portion and therefore greater biological healing potential. Clinically, however, the more important question is whether the wrist regains stable, painless function rather than whether the structural tear disappears on imaging. Symptoms can improve without surgery even when structural changes remain visible.

    When should assessment not be delayed?

    Earlier assessment is required after a more substantial injury when there is deformity, rapidly increasing swelling, marked inability to rotate the forearm or move the wrist, major loss of strength or concern about a fracture. Urgent assessment is also needed if the hand becomes pale or cold, new sensory loss develops, there is an open wound, or signs of infection such as increasing redness, fever and marked warmth appear.

    For less acute symptoms, review is appropriate when ulnar-sided wrist pain persists despite reducing load, repeatedly returns during ordinary activities, or is accompanied by catching or a sense of instability.

    Key points

    Ulnar-sided wrist pain can result from a TFCC injury, but diagnosis requires the history, an assessment of wrist and distal radioulnar joint stability, and appropriately selected imaging. Ultrasound and MRI answer somewhat different questions, and neither replaces the clinical examination. Stable traumatic injuries can often be managed without surgery initially, whereas persistent pain combined with distal radioulnar joint instability requires more detailed assessment and more often leads to consideration of repair.

    Back to: Hand Surgery

    References

    1. Choi SI, Malik S, MacLean S. The Natural History of Non-operatively Treated Traumatic Triangular Fibrocartilage Complex Tears: A Systematic Review. J Wrist Surg. 2024;13(6):550-558. DOI: 10.1055/s-0044-1786164.
    2. Zhou JY, Tuyishime H, Yao J. Arthroscopic-Assisted Repair of the Triangular Fibrocartilage Complex. J Hand Surg Glob Online. 2024;6(4):445-457. DOI: 10.1016/j.jhsg.2024.03.011.
    3. Treiser MD, Crawford K, Iorio ML. TFCC Injuries: Meta-Analysis and Comparison of Diagnostic Imaging Modalities. J Wrist Surg. 2018;7(3):267-272. DOI: 10.1055/s-0038-1629911.
    4. Winnett M, et al. Sonographic Anatomy and Imaging of the Triangular Fibrocartilage Complex and the Distal Radio-Ulnar Joint. Australas J Ultrasound Med. 2025. DOI: 10.1002/ajum.70012.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Intraosseous Morphine After Total Knee Arthroplasty — No Additional Benefit

    Polish version

    Adding 10 mg of morphine to an intraosseous injection during primary total knee arthroplasty did not reduce pain or opioid consumption during the first 14 days after surgery. This is the practical finding of a double-blind randomised trial published in the 19 August 2026 issue of The Journal of Bone and Joint Surgery; the paper had been available online since 21 April 2026.

    Why is this study clinically interesting?

    Multimodal analgesic protocols are increasingly used in total knee arthroplasty to control pain while limiting opioid exposure. One approach is intraosseous drug delivery, intended to produce a high local concentration in the operative region. Intraosseous administration has established uses for selected antibiotics, but that does not mean every drug given by this route will provide a clinically meaningful additional effect.

    The study by Pekas and colleagues addressed a specific question: does adding morphine to an intraosseous injection improve pain control after TKA beyond a contemporary multimodal analgesic protocol?

    Study question and methodology

    The prospective randomised trial enrolled 100 patients undergoing elective primary total knee arthroplasty and used double blinding. The final analysis included 88 patients; mean age was 69.1 years.

    All patients received spinal anaesthesia with intravenous sedation and a surgeon-performed adductor canal block. Both groups received 500 mg of vancomycin in 110 mL of normal saline by the intraosseous route. In the intervention group, 10 mg of morphine was added to that solution; the control group received an otherwise identical injection without morphine.

    For 14 days after surgery, patients repeatedly reported pain intensity, opioid use converted to morphine equivalents, and nausea and vomiting. Immediate postoperative pain and opioid requirements, as well as patient-reported outcomes, were also assessed.

    Results

    There were no between-group differences in daily pain at any time point during the 14-day follow-up (p = 0.969). Daily opioid consumption also did not differ (p = 0.377), and total and weekly opioid consumption remained similar (p ≥ 0.878).

    In practical terms, within the protocol studied, 10 mg of intraosseous morphine provided no measurable additional analgesic benefit.

    Clinical interpretation for an orthopaedic surgeon

    The negative result is clinically relevant. Adding another component to a perioperative pathway is justified only if the benefit outweighs the additional cost, risk and complexity. In this trial, no such benefit was demonstrated for intraosseous morphine.

    The finding should nevertheless be interpreted in the context of effective baseline analgesia. Patients received spinal anaesthesia, intravenous sedation and an adductor canal block. With such a regimen, the scope for demonstrating a small incremental benefit may have been limited. That does not change the principal practical conclusion: this study provides no basis for routinely adding morphine to the intraosseous injection in TKA.

    Limitations

    • The final analysis included 88 of the 100 randomised patients.
    • Pain and opioid use were followed for only the first 14 postoperative days.
    • The trial evaluated one specific 10 mg morphine dose within one perioperative protocol; it does not answer questions about other doses or drug combinations.
    • The study population was relatively demographically homogeneous, which may limit generalisability.
    • Both groups received intraosseous vancomycin, so the study isolates the effect of added morphine rather than comparing the intraosseous route itself with other routes of drug administration.

    What may change in practice—and what the study does not prove

    The results argue against routinely including intraosseous morphine as an additional analgesic component in primary TKA when a similar multimodal protocol is already being used. This supports simplifying pathways in which an added drug does not provide a demonstrable benefit.

    The trial does not show that the intraosseous route is ineffective in general. It did not assess the efficacy of intraosseous antibiotics or other drugs, and it does not resolve the value of other local analgesic strategies. Nor can it be used to conclude that morphine has no role in pain management after TKA—the intervention tested was specifically intraoperative intraosseous administration at the stated dose.

    Back to: Joint Replacement — Literature for Clinicians

    Reference

    Pekas DR, Adrados M, Lee MM, et al. Effectiveness of Intraosseous Morphine for Pain Control in Total Knee Arthroplasty: A Double-Blinded, Randomized Trial. J Bone Joint Surg Am. 2026;108(16):1249-1255. DOI: 10.2106/JBJS.25.01037. PubMed: PMID 42013190.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Osteochondral Lesion of the Talus — Symptoms, Diagnosis and Treatment

    Polish version

    An osteochondral lesion of the talus is damage involving the articular cartilage and the bone immediately beneath it. It often becomes apparent after an ankle sprain as deep joint pain that does not settle within the expected time. Recurrent swelling, catching or locking may also occur. Standard X-rays can be normal, so persistent symptoms may require more detailed imaging—most often MRI and, in selected situations, CT.

    Not every osteochondral lesion requires surgery. Management depends on the size and depth of the defect, the condition of the subchondral bone, fragment stability, duration of symptoms, age and activity level, and whether ankle instability is also present.

    What does “osteochondral lesion” mean?

    The surface of the talus is covered by cartilage that forms a smooth part of the ankle joint. An injury can damage cartilage alone, cartilage together with the underlying bone, or create an osteochondral fragment. In some cases, a cyst develops in the bone beneath the lesion.

    These injuries are commonly abbreviated as OLT, for osteochondral lesion of the talus. Finding an OLT on imaging is not, by itself, enough to determine treatment. The key question is whether the lesion actually explains the patient’s symptoms.

    When should cartilage injury be suspected after an ankle sprain?

    A typical ankle sprain should gradually improve. If deep pain inside the joint persists despite appropriate treatment—particularly with weight bearing, running, descending stairs or twisting movements—it is worth considering causes other than ligament injury alone.

    Symptoms that may accompany an osteochondral lesion include:

    • persistent or recurrent ankle pain after injury,
    • pain felt deep within the joint rather than only around the lateral or medial malleolus,
    • swelling after greater activity,
    • catching, clicking or intermittent locking,
    • restricted motion,
    • difficulty returning to running or sport despite improvement in ligament stability.

    If the problem began with a recent sprain, the initial assessment still needs to address the ankle injury as a whole. See: Ankle Injuries.

    How is an osteochondral lesion of the talus diagnosed?

    Clinical examination

    The examination considers the location of pain, range of motion, swelling, ligament stability, foot and ankle alignment, and any mechanical symptoms. This matters because similar complaints can result from chronic instability after a sprain, syndesmotic injury, impingement, tendon disorders or degenerative joint disease.

    X-ray

    Radiographs are often the first imaging test, especially after injury. They may show a larger bony defect, a loose fragment, evidence of previous trauma or degenerative change. A normal X-ray does not exclude an osteochondral lesion, particularly when the defect is small or predominantly cartilaginous.

    MRI

    MRI provides useful information about cartilage, bone-marrow oedema, joint fluid, ligaments and other intra-articular structures. It is particularly helpful when pain persists despite normal radiographs or when associated injuries need to be assessed.

    CT

    CT depicts the bony architecture in detail, including the size of the osseous defect, cysts and fragment morphology. It may be useful before surgery or when the principal diagnostic question concerns the bony component of the lesion.

    Is ultrasound enough?

    Ultrasound is not the primary test for a complete assessment of cartilage over the talar dome because much of the articular surface lies deep within the joint and is obscured by bone. It can, however, help assess associated effusion, ligaments, tendons and other superficial structures. A normal ultrasound therefore does not exclude an OLT.

    Does every lesion need surgery?

    No. For a stable lesion without a loose fragment or another urgent indication, non-operative treatment is often a reasonable first step. This may include modifying activity and loading, temporary unloading or stabilisation in selected cases, and a progressive exercise programme to restore movement, strength and ankle control. Coexisting chronic instability should be addressed as part of the treatment plan.

    In a prospective study of 40 patients involving 42 ankles, clinically meaningful improvement in pain while walking was achieved by 38% of patients after one year of non-operative treatment. The mean improvement for the group as a whole remained below the threshold considered clinically important, but lesion size on imaging did not increase during the one-year follow-up. This illustrates two points: conservative management can be a sensible first option for appropriately selected patients, but it will not provide sufficient improvement for everyone.

    When does an orthopaedic surgeon consider surgery?

    Surgery is considered mainly when symptoms persist despite appropriately conducted non-operative treatment, when significant mechanical symptoms are present, when a fragment is unstable, or when the characteristics of the lesion favour repair from the outset.

    There is no single operation that suits every osteochondral lesion. Depending on the situation, options may include:

    • arthroscopic debridement with stimulation of subchondral healing for selected small lesions,
    • fixation of a preserved osteochondral fragment when its quality and morphology allow stable repair,
    • osteochondral grafting or other restorative techniques for larger, deeper or previously unsuccessfully treated lesions,
    • bone grafting when there is a substantial cyst or osseous defect.

    The latest international consensus on moderate-to-large lesions emphasises that the choice between reparative and restorative procedures still relies partly on expert judgement because high-quality head-to-head trials of many techniques are lacking. Lesion size matters, but it should not be the only criterion used to choose an operation.

    Can an osteochondral fragment be fixed rather than removed?

    In selected cases, yes. If there is a sufficiently large and viable osteochondral fragment, fixation may be considered to preserve the native joint surface. A systematic review of 10 studies involving 241 ankles reported high rates of union and clinical improvement after fixation, but most of the evidence came from non-comparative studies. These results therefore do not prove that fixation is superior to all other treatment options.

    What influences treatment selection?

    • lesion size and depth,
    • the presence of a subchondral cyst,
    • stability and quality of an osteochondral fragment,
    • lesion location,
    • time since injury and previous treatment,
    • age, activity level and patient expectations,
    • ankle instability, limb alignment and other associated pathology.

    For that reason, two patients with very similar MRI reports may require quite different management.

    When is urgent assessment needed?

    • the ankle is locked and cannot move freely after an injury,
    • the limb cannot be loaded after a recent injury or there is obvious deformity,
    • the foot becomes cold, pale or blue, or increasing numbness develops,
    • the joint becomes hot, markedly swollen and red, particularly with fever,
    • pain is rapidly worsening rather than gradually settling.

    Common questions

    Does an osteochondral lesion always occur after a sprain?

    No, although ankle trauma is common in the clinical history. The lesion may become apparent immediately, or only later when deep weight-bearing pain persists after an apparently healed sprain.

    Does a normal X-ray exclude cartilage damage?

    No. Small osteochondral lesions may not be visible on standard radiographs. If symptoms persist, MRI or CT may be requested depending on the specific diagnostic question.

    Is an MRI finding alone an indication for surgery?

    No. The decision should integrate symptoms, clinical examination and imaging characteristics. An asymptomatic or incidental lesion is not the same clinical problem as an unstable fragment causing pain and mechanical locking.

    Back to: Foot and Ankle Conditions

    References

    • Buck TMF, Steman JAH, Dahmen J, et al. Nonoperative Treatment for Osteochondral Lesions of the Talus Provides Clinical Improvement in the Minority of the Patients at Short-term Follow-up. Foot Ankle Int. 2025;46(7):699-706. DOI: 10.1177/10711007251330881.
    • van Bergen CJA, Baur OL, Murawski CD, et al. Diagnosis: History, Physical Examination, Imaging, and Arthroscopy: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle. Foot Ankle Int. 2018;39(1 Suppl):3S-8S. DOI: 10.1177/1071100718779393.
    • Rubin J, et al. Surgical Intervention for Moderate-To-Large Lesions (1-2.9 cm²): Proceedings of the International Consensus Meetings on Cartilage Repair of the Ankle. Foot Ankle Spec. 2026. DOI: 10.1177/19386400261456897.
    • Rikken QGH, Dahmen J, Stufkens SAS, Nakasa T, Kerkhoffs GMMJ. Fixation for osteochondral lesions of the talus leads to successful clinical outcomes in 9 out of 10 patients: A systematic review. J ISAKOS. 2025;11:100389. DOI: 10.1016/j.jisako.2025.100389.

    This material is educational. Investigation and treatment should be selected from the clinical examination and the individual characteristics of the lesion.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.