Umów wizytę

Tomasz Poboży

Autor: Tomasz Poboży

  • Frozen Shoulder — Manipulation Without General Anaesthesia?

    Polish version

    Does manipulation for frozen shoulder have to be performed under general anaesthesia? A new randomised trial suggests that, in carefully selected adults with primary frozen shoulder persisting despite at least 6 months of non-operative treatment, an outpatient procedure under local anaesthesia may be feasible. The study did not demonstrate superiority in its primary endpoint, so the findings are better viewed as evidence of feasibility than as proof of a new standard of treatment.

    Why is this study interesting?

    Manipulation under anaesthesia is one option for refractory frozen shoulder, but the conventional approach uses an operating theatre and general anaesthesia. The investigators asked whether a similar short-term result could be achieved in an outpatient setting using an ultrasound-guided WALANT protocol—wide-awake local anaesthesia without general anaesthesia.

    Question and methodology

    This single-centre prospective randomised trial enrolled 72 adults with primary frozen shoulder that persisted despite at least 6 months of conservative treatment. Participants were allocated 1:1 to outpatient manipulation using an ultrasound-guided WALANT protocol or to manipulation under general anaesthesia in the operating theatre.

    The primary endpoint was forward shoulder flexion at 4 weeks. The investigators also assessed other ranges of motion, pain, UCLA Shoulder, DASH and Constant–Murley scores, pre-procedure anxiety and early complications. Six participants in the general-anaesthesia group did not complete follow-up; complete-case analysis therefore included 36 patients in the WALANT group and 30 in the general-anaesthesia group.

    Results

    At 4 weeks, mean forward flexion was 170.6° in the WALANT group and 159.6° after manipulation under general anaesthesia. The between-group difference was 11.0°, but the 95% confidence interval crossed no difference (−0.8° to 22.7°; p=0.068). The prespecified primary endpoint therefore did not show a statistically significant advantage for either strategy.

    In secondary analyses, pain, selected motion measures and the Constant–Murley score transiently favoured WALANT during the earlier weeks, but these differences were no longer present at week 4. UCLA Shoulder and DASH scores did not differ between groups. Pre-procedure anxiety was lower in the outpatient group. During the short follow-up, the investigators reported no procedure-related complications, infections, early recurrences or repeat interventions.

    Clinical interpretation for an orthopaedic surgeon

    The clinically useful message is not that “WALANT is better”. Rather, the trial suggests that, in a specialised setting, ultrasound-guided outpatient manipulation can be technically feasible and can produce short-term outcomes broadly similar to manipulation under general anaesthesia. A potential organisational advantage would be reduced reliance on operating-theatre and anaesthetic resources, but the study did not formally evaluate costs or health-system efficiency.

    Patient selection remains central in frozen shoulder. Manipulation is not a first-line treatment for every patient with shoulder stiffness. The decision must take into account symptom duration, response to previous treatment, the clinical diagnosis and the risk of injury during manipulation.

    Limitations

    • The study was single-centre and included a relatively small number of patients.
    • The main follow-up lasted only 4 weeks, so durability of benefit, recurrence and late complications cannot be assessed.
    • Six patients were lost to follow-up, all from the general-anaesthesia group, and the reported analysis was based on complete cases.
    • The trial was registered retrospectively, an important methodological limitation.
    • The prespecified primary endpoint was not statistically significant; favourable differences at earlier time points were secondary findings.

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

    The study supports further evaluation of outpatient frozen-shoulder manipulation without general anaesthesia and may be particularly relevant to centres combining shoulder treatment with interventional ultrasound. It does not establish statistical equivalence between the two methods, does not show a WALANT advantage at 4 weeks and is far too small to assess rare complications reliably.

    Back to: Research Updates, Literature and Evidence-Based Medicine

    See also: Outpatient and Ultrasound-Guided Procedures

    References

    1. Konarski W, Poboży T, Hordowicz M, Poboży K, Domańska J. Current concepts of natural course and in management of frozen shoulder: A clinical overview. Orthopedic Reviews. 2020;12(4):8832. DOI: 10.4081/or.2020.8832.
    2. Kurtulus T, Bacaksiz T, Maden M, et al. WALANT technique versus general anesthesia in frozen shoulder manipulation: a prospective randomized controlled trial. Journal of Orthopaedic Surgery and Research. Published 6 September 2026. DOI: 10.1186/s13018-026-07169-5.

    Educational material for healthcare professionals. It does not constitute an individual therapeutic recommendation.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Ultrasound After a Muscle Injury — When Is It Worth Doing?

    Polish version

    Ultrasound is most useful after a muscle injury when the result may change management: for example when pain is severe, there is a substantial haematoma or weakness, a larger tear is suspected, or the clinician needs to determine whether the injury extends into the aponeurosis or tendon. Imaging is often unnecessary after a mild, typical strain. Ultrasound is particularly good for superficial muscles and dynamic assessment, whereas MRI may be more informative for deep injuries, tendon-origin injuries or marked loss of function.

    What can ultrasound show after a muscle injury?

    Normal muscle has an organised fibre pattern and visible connective-tissue septa on ultrasound. Injury can disrupt this architecture and produce focal fibre discontinuity, swelling, a haematoma or a change in muscle contour. In larger tears, ultrasound may also help define the extent of the defect and the relationship between the injured tissue ends.

    The exact location of the injury matters. Prognosis and treatment can differ between damage confined to muscle fibres and injury involving the myotendinous junction, aponeurosis or tendon. Modern sports-medicine classifications therefore pay attention to connective-tissue involvement rather than describing an injury only as a “small” or “large” tear.

    Does ultrasound need to be performed immediately?

    There is no single ideal hour or day for every muscle injury. A very early scan may underestimate a small lesion because haematoma and other tissue changes evolve over time. Conversely, prompt assessment can be important after a major injury, pronounced weakness or suspected tendon rupture because the result may affect the next step in treatment.

    In practice, ultrasound is often performed during the first few days when there is a specific clinical question. If symptoms and the initial scan do not agree, or the clinical picture changes, the examination can be repeated. This is one of ultrasound’s practical advantages: the same structure can be reassessed during healing without radiation exposure.

    When is ultrasound particularly useful?

    • after sudden pain during sprinting, jumping, kicking or forceful muscle lengthening;
    • when bruising, a palpable lump or a palpable defect develops after injury;
    • when there is clear weakness compared with the opposite side;
    • when muscle injury needs to be distinguished from tendon injury or another superficial soft-tissue problem;
    • when symptoms persist despite appropriately conducted treatment;
    • for follow-up of a larger haematoma, healing process or selected post-traumatic complications.

    How does an orthopaedic surgeon choose between ultrasound and MRI?

    These tests are not simply competitors; they often answer different questions. Ultrasound provides high-resolution imaging of superficial tissues, allows side-to-side comparison, can assess a muscle during movement and compression, and is convenient for serial follow-up. Its performance is more operator-dependent, however, and deep structures can be difficult to evaluate.

    MRI covers a larger anatomical field and depicts deep tissues more comprehensively. It is particularly useful when a substantial injury is suspected, when the proximal tendon origin may be involved, when there may be tendon avulsion from bone, when the clinical picture is unclear, or when detailed anatomy is required for operative planning. In severe hamstring injuries, MRI is especially valuable when proximal tendon-origin injury is suspected.

    Can ultrasound tell exactly when it is safe to return to sport?

    No. Imaging is only one part of the decision. Even when ultrasound shows healing, return to running, strength training or multidirectional sport should also reflect pain, range of motion, strength, tolerance of progressively increasing load and the demands of the specific activity.

    Research links some imaging features with time away from sport, but an image alone cannot reliably identify one exact day on which return becomes safe. A follow-up scan should therefore not replace functional assessment.

    How are muscle tears usually treated?

    Most partial muscle injuries are treated without surgery. Early management aims to control pain and excessive tissue bleeding, followed by a progressive return of movement, strength and load tolerance. Prolonged complete immobilisation is usually not beneficial; the loading programme should match the location and severity of the injury.

    Surgery is considered mainly for selected complete ruptures, tendon injuries with clinically important displacement, or other situations in which the injury anatomy makes a satisfactory result with non-operative treatment less likely.

    When does a muscle injury need urgent assessment?

    Urgent assessment is warranted when pain is very severe or rapidly worsening, swelling is large and increasing quickly, there is pronounced loss of strength, visible deformity, numbness, pallor or coolness of the limb. A large haematoma deserves particular caution in someone taking anticoagulant medication. Increasing pain that is disproportionate to the injury together with tense swelling can indicate compartment syndrome and requires immediate evaluation.

    The key point: imaging must fit the symptoms

    Musculoskeletal ultrasound is most useful when it follows from the history and clinical examination rather than being ordered “just in case”. It can answer many focused questions about muscle injury quickly, but not every episode of pain after exercise represents a tear and not every injury requires imaging.

    Back to: Muscle and Tendon Injuries

    See also: Diagnostic Tests

    References

    1. Palermi S, Scavone A, Anzà M, et al. Diagnostic ultrasound of muscle injuries: what the sports medicine clinician should know. British Journal of Sports Medicine. 2025;59(24):1759–1770. DOI: 10.1136/bjsports-2025-110255.
    2. Marrero AM, Mazza LA, Cedola N, et al. MRI and US in Hamstring Sports Injury Assessment: Anatomy, Imaging Findings, and Mechanisms of Injury. RadioGraphics. 2025;45(5). DOI: 10.1148/rg.240061.
    3. Martin RL, Cibulka MT, Bolgla LA, et al. Hamstring Strain Injury in Athletes. J Orthop Sports Phys Ther. 2022;52(3):CPG1–CPG44. DOI: 10.2519/jospt.2022.0301.

    This information is educational and does not replace an individual medical consultation.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Distal Radius Fracture Reduction — Ultrasound-Guided Radial Nerve Block or Hematoma Block?

    Polish version

    An ultrasound-guided radial nerve block may be a useful alternative to a hematoma block during closed reduction of a distal radius fracture. In a small randomised trial, more patients achieved a clinically meaningful reduction in pain from admission to the reduction manoeuvre, but the result is not strong enough to establish a new standard of care.

    Why might an orthopaedic surgeon find this study interesting?

    Closed reduction of a displaced distal radius fracture can be very painful. Emergency departments use several analgesic strategies, including hematoma block, sedation, regional anaesthesia or combinations of these approaches. A hematoma block is simple and does not require advanced equipment, but injecting local anaesthetic around the fracture does not always provide sufficient comfort. An ultrasound-guided nerve block, by contrast, allows local anaesthetic to be placed away from the fracture itself while the needle and surrounding anatomy are directly visualised.

    The study, conducted at Hospital Universitario San Ignacio and Pontificia Universidad Javeriana in Bogotá and published online on 7 August 2026 in Journal of Hand Surgery Global Online, compared an ultrasound-guided supracondylar radial nerve block with a conventional hematoma block in patients requiring fracture reduction in the emergency department.

    Question and methodology

    Adults with an acute distal radius fracture diagnosed within the first week after injury were enrolled in the randomised trial. Patients and clinicians performing the procedure could not be blinded, whereas outcome analysis was blinded.

    Fifty patients were included in the final analysis: 28 received the ultrasound-guided radial nerve block and 22 received a hematoma block. Median age was 62 years, and most participants were women. Pain was measured on a numerical rating scale at admission, 10 minutes after anaesthesia and during the reduction manoeuvre. The investigators also assessed radiographic reduction quality and recorded complications during the emergency-department stay and at a telephone follow-up after 2 weeks.

    Results

    There was no clinically meaningful between-group difference in the proportion of patients achieving at least a 2-point pain improvement either from admission to 10 minutes after the block or from the block to the reduction manoeuvre.

    A difference emerged when pain at admission was compared with pain during reduction. A clinically meaningful improvement was more frequent after the ultrasound-guided radial nerve block: the relative probability of improvement was 2.10 (95% CI 1.06–5.04), with an absolute risk difference of 29.9 percentage points. The authors calculated an NNT of 4. This result should be interpreted cautiously because the confidence interval was wide and the p value was 0.047, close to the conventional threshold for statistical significance.

    Radiographic measures of reduction quality did not differ significantly between groups. In other words, the signal for better pain control did not translate into measurably better fracture alignment in this trial.

    How should the findings be interpreted clinically?

    The most defensible conclusion is not that an ultrasound-guided nerve block is superior to a hematoma block. The evidence is too limited for that. Rather, the study suggests that a targeted regional block can be performed in the acute emergency setting and may increase the likelihood of a meaningful reduction in pain during fracture reduction.

    This may be particularly relevant in departments with experience in ultrasound-guided regional anaesthesia and an interest in reducing the need for deeper sedation. Ultrasound availability alone, however, does not replace knowledge of anatomy, regional anaesthesia principles or appropriate patient monitoring. Choice of analgesia should still reflect fracture characteristics, the patient’s clinical condition, staff expertise and the local protocol.

    Limitations

    • The study was small, with only 50 patients in the final analysis.
    • Patients and clinicians performing the block could not be fully blinded.
    • The key positive result had a wide confidence interval and a p value close to 0.05.
    • Safety follow-up lasted only 2 weeks.
    • This was a single-centre study, so results may depend on operator experience with ultrasound and regional blocks.
    • Radiographic quality of reduction was not improved.

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

    The trial provides a reasonable signal that an ultrasound-guided supracondylar radial nerve block can be considered among the analgesic options for closed reduction of distal radius fractures. Before it replaces hematoma block in routine care, larger multicentre studies are needed, ideally with a clearly specified primary endpoint and assessment of rescue analgesia, procedure time, complications and patient satisfaction.

    The study does not prove that the ultrasound-guided block produces a better reduction, is safer than a hematoma block or eliminates the need for sedation in every patient. It also did not show superiority at every pain-assessment time point. At present, the findings support further evaluation and selective use rather than a wholesale change in standard practice.

    Back to: Research Updates, Literature and Evidence-Based Medicine

    Source

    Olmos Muskus N, Botero Bermúdez M, Caro Hurtado D, Mejía Grueso A, Cadena De-Poortere V, García González LA. Ultrasound-Guided Supracondylar Radial Nerve Block Versus Hematoma Block for Closed Reductions of Distal Radius Fracture in the Emergency Department: A Randomized Controlled Clinical Trial. Journal of Hand Surgery Global Online. 2026;8(6):101095. DOI: 10.1016/j.jhsg.2026.101095. PubMed PMID: 42604104.

    Educational material for healthcare professionals. It does not constitute an individual therapeutic recommendation.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Can You Kneel After Total Knee Replacement?

    Polish version

    Yes. Once a total knee replacement has healed properly, kneeling is generally not considered harmful to the implant. For many patients it is still uncomfortable or difficult because of scar tenderness, numb skin, pressure sensitivity, stiffness or fear of putting weight through the operated knee. Kneeling should not be attempted on a fresh or incompletely healed wound, and the timing of return should reflect wound healing and the individual postoperative plan.

    Can kneeling damage a knee replacement?

    A common concern is whether direct pressure through the knee can loosen or damage the prosthesis. Available evidence does not indicate that kneeling, once healing is complete, is harmful to a normally functioning total knee replacement. The American Academy of Orthopaedic Surgeons likewise notes that kneeling may be uncomfortable after total knee arthroplasty but is not considered damaging to the implant.

    That does not mean every patient will kneel easily. A review of function after total knee replacement found that 60–80% of patients reported some difficulty with kneeling or avoided it. Importantly, the perception that “I cannot kneel” does not always match the person’s actual ability to perform the task when it is assessed directly.

    Why can kneeling remain difficult after surgery?

    • Scar tenderness — direct pressure on the front of the knee may remain uncomfortable for a long time.
    • Skin numbness — small cutaneous sensory branches can be divided during the surgical approach, leaving an area of reduced sensation, often lateral to the scar. This commonly becomes less troublesome with time but may not disappear completely.
    • Pressure pain — even a well-functioning knee can remain sensitive on a hard surface.
    • Limited range of motion — deeper kneeling requires sufficient flexion, although range of motion does not explain all of the difference between people who kneel and those who avoid it.
    • Fear of damaging the implant — some patients never try because they believe kneeling is prohibited.
    • Other musculoskeletal limitations — the opposite knee, hip, spine, muscle weakness or difficulty getting back up from the floor may be more limiting than the replaced knee itself.

    When can you start trying?

    There is no single date that is appropriate for everyone. The key prerequisite is complete wound healing. Do not put direct pressure on a fresh scar, a wound that is still draining, an area with a scab, increasing redness or marked tenderness. Some centres advise waiting several months, while others allow gentle attempts earlier once the wound is fully healed. Differences reflect surgical technique, the course of healing and the rehabilitation plan.

    Function and safety are more useful than the calendar alone. Before kneeling, the patient should have stable walking, adequate strength and the ability to lower themselves toward the floor and get up again safely.

    How can kneeling be reintroduced safely?

    First attempts are best made in a controlled setting with a stable support for the hands. A soft mat, thick pad or cushion can reduce focal pressure on the front of the knee. There is no need to move immediately into a deep kneeling position or stay on the knees for a prolonged period.

    A sensible progression is to begin with brief contact on a soft surface, then gradually increase time and load as long as pain and swelling are not increasing. When the main difficulty is getting down to the floor and standing up again rather than kneeling itself, practising those transitions with a physiotherapist can be useful. Studies suggest that instruction and task-specific practice can improve actual kneeling ability.

    Is a large amount of knee flexion required?

    Greater flexion makes some kneeling positions easier, but it is not the only requirement. Some patients with good range of motion still avoid kneeling because of tenderness or fear, while others can achieve a functional kneel despite only moderate flexion. The flexion angle alone therefore does not predict whether kneeling will be comfortable.

    Does the type of implant or surgery matter?

    The influence of incision type, implant design and patellar resurfacing has been studied, but the findings do not provide a simple way to predict kneeling ability. A meta-analysis of 36 studies found some associations between surgical technique and kneeling, while also emphasising the need for better randomised evidence. There is no good basis for selecting an implant solely to optimise this one activity.

    If regular kneeling is essential for work, gardening, a hobby or religious practice, it is worth discussing this before surgery. It should form part of the conversation about realistic functional goals after knee replacement.

    What about kneeling after partial knee replacement?

    Kneeling can also be difficult after unicompartmental knee replacement, although available evidence suggests that appropriate instruction may improve the ability to perform the task. Those findings should not be transferred automatically to every total knee replacement because the extent of surgery and biomechanics differ.

    When should kneeling be avoided and the knee assessed?

    Kneeling should be postponed when the wound has not fully healed or when symptoms suggest a postoperative complication. Earlier assessment is particularly important for:

    • drainage from or separation of the wound,
    • increasing redness and marked warmth around the operated knee,
    • fever together with worsening knee symptoms,
    • sudden or rapidly increasing pain and swelling,
    • new instability or a clear deterioration in function,
    • calf pain and swelling, especially if accompanied by shortness of breath or chest pain, which requires urgent medical assessment.

    Kneeling is only one part of returning to function

    Patients after knee replacement also ask about driving, work and sport. Each activity requires a different combination of strength, control and tolerance. Someone who can walk several kilometres comfortably may still dislike pressure on the scar while kneeling. Conversely, difficulty kneeling does not by itself mean that the knee replacement is functioning poorly.

    Key points for an orthopaedic surgeon

    After a well-healed total knee replacement, kneeling itself is not generally considered harmful to the implant. The more common barriers are scar tenderness, numbness, pressure pain, stiffness and fear of damaging the prosthesis. Return should be gradual, initially on a soft surface, and only once the wound has healed. Increasing pain, swelling, wound problems or other warning signs should be assessed before kneeling is resumed.

    Back to: Before and After Orthopaedic Surgery

    References

    • Wylde V, Artz N, Howells N, Blom AW. Kneeling ability after total knee replacement. EFORT Open Rev. 2019;4(7):460–467. DOI: 10.1302/2058-5241.4.180085.
    • Nadeem S, Mundi R, Chaudhry H. Surgery-related predictors of kneeling ability following total knee arthroplasty: a systematic review and meta-analysis. Knee Surg Relat Res. 2021;33:36. DOI: 10.1186/s43019-021-00117-z.
    • Wallace SJS, Berger RA. Most Patients Can Kneel After Total Knee Arthroplasty. J Arthroplasty. 2019;34(5):898–900. DOI: 10.1016/j.arth.2019.01.047.
    • American Academy of Orthopaedic Surgeons. Total Knee Replacement. OrthoInfo. Accessed 10 September 2026.

    This information is educational and does not replace an individual medical consultation.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • GLP-1 Receptor Agonists Before Joint Replacement — Fewer Complications?

    Polish version

    A meta-analysis including more than 96,000 patients suggests that people treated with GLP-1 receptor agonists before total hip or knee arthroplasty had fewer selected complications and readmissions. This should be interpreted primarily as an observational signal: all included studies were cohort studies, and certainty of evidence was rated very low for almost every outcome. The analysis therefore does not show that starting a GLP-1 receptor agonist itself reduces perioperative risk.

    Why might an orthopaedic surgeon find this study interesting?

    GLP-1 receptor agonists are increasingly used in people with type 2 diabetes and obesity—two groups that are common among patients undergoing joint replacement. From an orthopaedic perspective, the question is not only whether these drugs reduce body weight and improve glycaemic control, but whether their use is associated with a different risk profile after surgery.

    The study by Rudran and colleagues, published on 1 August 2026 in The Bone & Joint Journal, is notable because it combines data from almost 100,000 arthroplasties. At the same time, it illustrates the difference between a large sample and strong causal evidence: the numbers are impressive, but the underlying studies remain observational.

    Question and methodology

    The authors performed a PRISMA-based systematic review and meta-analysis. Ten matched cohort studies were included, covering a total of 96,356 patients: 30,350 after total hip arthroplasty and 66,606 after total knee arthroplasty. Mean age was 61.9 years, and 60.1% of participants were women.

    GLP-1 receptor agonists had been prescribed for type 2 diabetes or obesity. The primary outcome was 90-day surgical complications, including periprosthetic joint infection, wound dehiscence, periprosthetic fracture, haematoma, nerve injury and surgical-site infection. The authors also assessed medical complications, readmissions, revisions, length of stay and treatment costs.

    Results

    Across the overall cohort, GLP-1 receptor agonist use was associated with a lower rate of 90-day surgical complications, with a pooled risk ratio of 0.73. Medical complications were also lower (RR 0.78), as were hospital readmissions (RR 0.79).

    The signal was stronger in the total hip arthroplasty subgroup. GLP-1 therapy was associated with lower surgical complications (RR 0.63), medical complications (RR 0.55) and readmissions (RR 0.82). After total knee arthroplasty, the only statistically significant association that remained was a lower risk of readmission (RR 0.77).

    Two-year revision rates ranged from 1.7–3.3% in GLP-1 users and 1.7–4.5% in control groups. These ranges should not be interpreted as proof that GLP-1 therapy improves implant survival.

    How should the findings be interpreted clinically?

    The most defensible conclusion is that preoperative GLP-1 receptor agonist use was not associated with worse outcomes in the available studies, and some analyses suggested lower early complication rates. That is relevant in populations with obesity and diabetes, where metabolic optimisation is part of preparation for arthroplasty.

    However, the study cannot determine how much of the observed difference comes from the pharmacological effect of the drugs, weight loss, improved glycaemic control or characteristics of the patients who receive this treatment. GLP-1 users may differ from controls in healthcare access, adherence, intensity of treatment for comorbidities and other factors that matching cannot fully remove.

    Limitations

    • All 10 included studies were observational; there was no randomised trial comparing initiation of GLP-1 treatment with non-use before arthroplasty.
    • Two studies were judged to have a serious risk of bias and eight a moderate risk.
    • GRADE certainty was very low for all analysed outcomes except costs, for which certainty was moderate.
    • Indications for treatment, patient characteristics and probably the duration and type of therapy differed between studies.
    • Some endpoints were composite outcomes, so a single risk ratio does not reveal which individual complication accounted for the observed difference.
    • The difference between hip and knee findings may reflect a true effect, but could also reflect study heterogeneity and residual confounding.

    What might this change in practice?

    The study supports the view that GLP-1 receptor agonist use should not itself be treated as an automatic adverse prognostic factor before joint replacement. In a patient with obesity or diabetes, the medication may be one part of broader metabolic optimisation before surgery.

    Decisions about continuing or temporarily withholding a GLP-1 receptor agonist around the time of surgery should nevertheless follow the current anaesthetic and diabetes-care protocol for the individual patient. This meta-analysis was not designed to establish perioperative medication-withholding rules.

    What does the study not prove?

    The analysis does not prove that GLP-1 treatment should be started solely to reduce arthroplasty complications. It also cannot establish an optimal drug, dose or treatment duration before surgery, or determine whether any potential benefit is mediated by the medication itself, weight reduction, improved glycaemia or other mechanisms. Prospective studies, ideally randomised, would be needed to answer those questions.

    Back to: For Doctors and Physiotherapists

    Source

    Rudran B, Little CDJ, Palmer AJR, Judge A, Carli A, Price AJ, Alvand A. Glucagon-like peptide-1 receptor agonists are associated with improved 90-day outcomes after total hip and knee arthroplasty: a systematic review and meta-analysis. Bone Joint J. 2026;108-B(8):986–994. DOI: 10.1302/0301-620X.108B8.BJJ-2025-1486.R2. PMID: 42538001.

    Educational material for healthcare professionals. It does not constitute an individual therapeutic recommendation.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Tarsal Tunnel Syndrome — What Causes Numbness in the Sole?

    Polish version

    Burning, tingling or numbness in the sole can result from compression of the tibial nerve or its branches within the tarsal tunnel, the space on the inner side of the ankle. These symptoms do not automatically mean tarsal tunnel syndrome, however. Similar complaints can arise from the lumbar spine, other peripheral nerves or structures within the foot. Diagnosis therefore depends on the history, clinical examination and appropriately selected tests rather than on any single investigation.

    The tarsal tunnel lies behind and below the medial malleolus. Tendons, blood vessels and the tibial nerve pass through it; the nerve then divides into branches supplying much of the sole. Symptoms can develop when the available space becomes restricted or when the nerve is compressed locally by another structure.

    Which symptoms fit tarsal tunnel syndrome?

    The most typical complaints are felt around the medial ankle and on the sole. Patients may describe burning, tingling, numbness, electric-shock sensations or shooting pain. Symptoms can radiate into the heel, arch or toes.

    • numbness or tingling mainly affects the sole rather than the top of the foot,
    • symptoms may worsen with prolonged standing, walking or running,
    • pressure or percussion behind the medial malleolus may reproduce tingling into the foot,
    • pain may feel burning or electrical rather than purely mechanical,
    • more advanced cases can produce sensory loss and, much less often, weakness of the small muscles of the foot.

    The symptom pattern alone is not enough for diagnosis. Tarsal tunnel syndrome can be confused with plantar fasciopathy, S1 radiculopathy and other neuropathies of the foot. Pain that is most prominent with the first steps in the morning and is centred at the medial heel may point instead toward plantar fascia overload.

    What can compress the tibial nerve?

    The cause is not always obvious. Reduced space within the tunnel may follow injury and scarring, bony changes, tendon-sheath inflammation, a ganglion or another space-occupying lesion. Varicose veins and other vascular abnormalities, accessory muscles and foot deformity that alters local mechanics have also been described.

    For that reason, the aim of assessment is not simply to label the problem as “nerve compression”, but—when possible—to identify what is causing the compression. This can directly influence treatment: a ganglion, post-traumatic scarring and a syndrome without a clear structural lesion are not managed in exactly the same way.

    How is the diagnosis made?

    The first step is to define the exact sensory distribution and how the symptoms are provoked. Examination includes sensation, strength, sites of tenderness, foot alignment and whether pressure or percussion over the tibial nerve behind the medial malleolus reproduces typical paraesthesia. At the same time, the clinician should look for evidence of another explanation such as lumbosacral radiculopathy or a generalised polyneuropathy.

    A review in EFORT Open Reviews emphasised that there is no single test that can diagnose tarsal tunnel syndrome with complete certainty. Clinical findings should be integrated with imaging and, where appropriate, nerve-conduction studies or electromyography.

    What can nerve ultrasound show?

    Ultrasound can trace the tibial nerve around the ankle and through the tarsal tunnel, assess its calibre and internal appearance, and look for a local cause of compression. It can also reveal neighbouring abnormalities such as a ganglion, tendon-sheath inflammation, selected vascular abnormalities, accessory muscles or post-traumatic change. A further advantage is dynamic assessment while the ankle moves or symptoms are provoked locally.

    Ultrasound is not a rule-out test. In a 2026 study of 26 feet with tarsal tunnel syndrome confirmed clinically and electrophysiologically, nerve ultrasound detected abnormalities with a sensitivity of about 65% when the commonly used nerve cross-sectional-area threshold of 11.8 mm² was applied. In other words, a normal ultrasound does not exclude tarsal tunnel syndrome.

    The same study noted that, when ultrasound was abnormal, nerve swelling was often seen within the tunnel itself rather than only just proximal to the presumed compression. This supports scanning the nerve over a sufficiently long segment and comparing its appearance within the tunnel with more proximal portions.

    Is EMG necessary?

    Nerve-conduction studies and electromyography can provide objective information about the function of the tibial nerve and its branches, and can help distinguish local compression from radiculopathy or polyneuropathy. Their sensitivity is also limited, however. A normal result should not automatically end the diagnostic process when the history and examination continue to strongly suggest an entrapment neuropathy.

    When are MRI or CT useful?

    MRI is particularly helpful when deeper tissues need more detailed assessment, a space-occupying lesion is suspected, or the clinical examination and ultrasound do not provide a clear answer. In a small surgical series, MRI identified the site of compression in 23 of 28 feet, but it did not always identify the specific cause, including some varices or small vascular branches compressing the nerve.

    CT has less value for assessing the nerve itself, but it can be useful when a bony cause is suspected—for example deformity, an osteophyte, a consequence of fracture or another osseous abnormality whose anatomy matters for treatment planning.

    What else should be considered?

    Burning or numbness in the foot does not always originate in the tarsal tunnel. Depending on the distribution and character of symptoms, the differential diagnosis includes S1 radiculopathy, polyneuropathy, plantar fasciopathy, stress fracture and more distal focal neuropathies of the foot. Forefoot pain and tingling that radiate into adjacent toes, especially in tight footwear, may suggest Morton’s neuroma instead.

    How is tarsal tunnel syndrome treated?

    Treatment depends mainly on the cause and on the degree of nerve dysfunction. When there is no progressive neurological deficit and no clear lesion that requires removal, management usually starts non-operatively: reducing the loading that reproduces symptoms, modifying footwear or using an orthotic when appropriate, treating pain, and addressing relevant mechanical factors of the foot.

    An injection around the tarsal tunnel may be considered in selected patients, particularly when a local inflammatory component or swelling is suspected. Because the nerve and vessels lie close together, ultrasound guidance allows direct control of needle position. This is not, however, a universal treatment for every tibial neuropathy.

    When does an orthopaedic surgeon consider surgery?

    Surgical decompression is considered mainly when clinically important symptoms persist despite appropriate non-operative treatment and there is credible evidence that the nerve is actually being compressed within the tarsal tunnel. The indication is stronger when a specific cause can be identified, such as a ganglion, post-traumatic scar or another space-occupying lesion.

    Reported rates of good surgical outcomes vary widely. The result cannot be promised on the basis of one positive provocative test or one ultrasound image. Better outcomes have been reported when symptoms have been present for a shorter time, the cause of compression is clear and the clinical findings are concordant. Long-standing neuropathy with established nerve damage may not fully recover even after the compression has been removed.

    Which symptoms need faster assessment?

    • progressive weakness of the toes or foot muscles, especially with a new gait disturbance,
    • rapidly worsening or extensive sensory loss after a recent ankle injury,
    • marked swelling after injury accompanied by increasing pain and numbness,
    • a cold, pale or blue foot or other signs of impaired blood flow,
    • fever, redness, warmth and increasing swelling suggesting infection,
    • numbness affecting both feet or multiple limb regions, which may indicate a generalised problem rather than compression of one local nerve.

    What is the practical takeaway?

    Tarsal tunnel syndrome is worth considering when burning, tingling and numbness mainly affect the sole and relate to the region behind the medial malleolus. The key is to establish whether the symptoms truly fit tibial nerve compression and, where possible, identify the cause. Ultrasound can be very useful, but a normal scan does not exclude neuropathy. Likewise, an isolated abnormal EMG or MRI finding should not be interpreted without clinical correlation.

    Back to: Foot and Ankle Conditions

    See also: Peripheral Nerves

    References

    • Holtz B-O, Ceanga M, Behnert A, Marquardt R, Geis C, Axer H. Nerve Ultrasound for the Diagnosis of Tarsal Tunnel Syndrome: Findings in 26 Clinically and Electrophysiologically Confirmed Feet. J Clin Med. 2026;15(5):1699. DOI: 10.3390/jcm15051699.
    • Rodríguez-Merchán EC, Moracia-Ochagavía I. Tarsal tunnel syndrome: current rationale, indications and results. EFORT Open Rev. 2021;6(12):1140–1147. DOI: 10.1302/2058-5241.6.210031.
    • de Souza Reis Soares O, Duarte ML, Brasseur J-L. Tarsal Tunnel Syndrome: An Ultrasound Pictorial Review. J Ultrasound Med. 2022;41(5):1247–1272. DOI: 10.1002/jum.15793.
    • Kim K, Kokubo R, Isu T, Nariai M, Morimoto D, Kawauchi M, Morita A. Magnetic Resonance Imaging Findings in Patients with Tarsal Tunnel Syndrome. Neurol Med Chir (Tokyo). 2022;62(12):552–558. DOI: 10.2176/jns-nmc.2022-0118.

    This information is educational and does not replace an individual medical consultation.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Why Surgery Is Not Based on an MRI Result Alone

    Polish version

    An MRI report is one piece of the diagnostic puzzle, not an indication for surgery by itself. Treatment decisions concern a particular patient: their pain, functional limitation, clinical examination, course of symptoms and treatment goals. The same MRI finding can have very different significance in two different people.

    An imaging finding is not always the source of pain

    MRI is highly sensitive and often shows age-related or degenerative changes that may not cause symptoms. Degenerative meniscal changes, spinal-disc abnormalities and rotator cuff tendon changes can all be present in people without pain. Finding an abnormality is therefore not the end of the diagnostic process. The finding still has to match the location, character and mechanism of the patient’s symptoms.

    Five questions an orthopaedic surgeon considers before a treatment decision

    1. Does the imaging finding match the symptoms?

    A lesion described on MRI should fit the location of pain, loss of movement, weakness or instability. If the report concerns a different part of the joint from the area that is painful and reproduces symptoms on examination, the association may be incidental.

    2. Does the clinical examination support that explanation?

    Range of motion, strength, stability, swelling and provocative tests help determine whether an MRI abnormality has functional significance. MRI also cannot show everything that happens during movement or weight bearing.

    3. Have the actual images been reviewed, not only the report?

    The radiology report is important, but treatment planning also benefits from reviewing the images themselves. Location, extent, tissue quality, associated abnormalities and whether the finding genuinely explains the clinical problem can all matter.

    4. Was MRI the right test for the question?

    MRI does not replace X-rays when limb alignment, the weight-bearing joint space or the severity of some degenerative changes needs to be assessed. Nor does it replace dynamic ultrasound when the question concerns a snapping tendon, movement of a structure or a targeted image-guided procedure. The investigation should be chosen to answer the clinical question, not the other way around.

    5. Is surgery likely to improve the problem that actually matters to the patient?

    Even a genuine structural lesion does not always require an operation. Its natural history, the response to appropriate non-operative treatment, procedural risk and the patient’s functional goal all need to be considered. Surgery makes sense when there is a plausible mechanism for the symptoms and a reasonable likelihood that the procedure can change it.

    When can MRI before consultation be particularly useful?

    MRI can be very valuable after selected injuries, when an intra-articular lesion is suspected, in possible osteonecrosis, an occult fracture not seen on X-ray, infection or a tumour, and when earlier assessment and treatment have not explained persistent symptoms. That does not mean MRI should be the first test for every painful knee, shoulder or hip.

    How should imaging be brought to a consultation?

    • bring the actual images — on disc, another storage medium or through a working online viewer — rather than only a printed report,
    • bring previous X-rays, ultrasound or MRI when comparison over time may be useful,
    • note exactly where the pain occurs, which movements provoke it and what it prevents you from doing,
    • summarise previous treatment and what effect it actually had.

    The central principle

    We do not operate on an image. We treat a clinical problem, and MRI is one tool for understanding that problem and planning management. The best decision comes from combining the history, physical examination and appropriately interpreted imaging.

    Back to: Diagnostic Tests

    References

    • Poboży T, Konarski W, Janowski K, Michalak K, Poboży K, Domańska-Poboża J. Ultrasonographic Assessment of Meniscus Damage in the Context of Clinical Manifestations. Medicina. 2025;61(8):1339. DOI: 10.3390/medicina61081339.
    • Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811–816. DOI: 10.3174/ajnr.A4173.
    • Culvenor AG, Øiestad BE, Hart HF, Stefanik JJ, Guermazi A, Crossley KM. Prevalence of knee osteoarthritis features on magnetic resonance imaging in asymptomatic uninjured adults: a systematic review and meta-analysis. Br J Sports Med. 2019;53(20):1268–1278. DOI: 10.1136/bjsports-2018-099257.
    • Teunis T, Lubberts B, Reilly BT, Ring D. A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age. J Shoulder Elbow Surg. 2014;23(12):1913–1921. DOI: 10.1016/j.jse.2014.08.001.

    This material is educational and does not replace an individual medical consultation.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Lateral Ankle Pain — Could It Be the Peroneal Tendons?

    Polish version

    Pain on the outer side of the ankle, particularly behind or just below the lateral malleolus, may come from the peroneal tendons. It often becomes more noticeable when walking on uneven ground, running, rising onto the toes or after an ankle sprain. Similar symptoms can also arise from ligaments, joint cartilage, bone or the sural nerve, so pain location alone is not a diagnosis.

    What are the peroneal tendons?

    The peroneus longus and peroneus brevis tendons run together behind the lateral malleolus. They help stabilise the foot and ankle, especially during weight bearing on uneven surfaces, and are held within their groove by the retinaculum. Problems can include tendinopathy, longitudinal splitting or tearing, tenosynovitis, or instability in which the tendons snap or move out of their normal position.

    Which symptoms are typical?

    • pain and tenderness behind the lateral malleolus or along the outer border of the foot,
    • pain that increases on uneven ground, during running or with resisted eversion of the foot,
    • swelling along the course of the tendons,
    • a snapping sensation or audible click behind the ankle,
    • recurrent feelings of instability after previous ankle sprains.

    A sudden snap after injury can indicate retinacular damage with tendon subluxation. By contrast, persistent lateral ankle pain without one clear injury is more often associated with overload, foot alignment, recurrent sprains or chronic tendon damage.

    What else can cause pain in the same area?

    The differential diagnosis includes lateral ligament injury after a sprain, fracture of the ankle or the base of the fifth metatarsal, an osteochondral lesion of the talus, ankle impingement, sural nerve irritation and pain arising from more distal joints of the foot. After an acute injury, this is why an X-ray is often the first imaging test rather than ultrasound.

    See also: Ankle Injuries.

    How is the problem assessed?

    Clinical examination

    The exact site of tenderness, muscle strength, ankle stability, foot alignment and reproduction of pain with resisted movement all matter. When tendon snapping is suspected, the tendons should also be assessed while the ankle is moving.

    X-ray

    After a recent injury, radiographs help exclude a fracture. They may also show bony anatomy that contributes to impingement or chronic overload, but they do not usually assess the tendons themselves adequately.

    Ultrasound

    Ultrasound can show tendon continuity and structure, fluid within the tendon sheath and tendon behaviour during movement. Dynamic assessment is especially useful when snapping or subluxation behind the lateral malleolus is suspected. A normal ultrasound, however, does not exclude every subtle abnormality.

    MRI

    MRI can help define the extent of tendon injury while also assessing cartilage, ligaments, bone marrow and other deeper structures. The choice between ultrasound and MRI depends on the clinical question; the two tests can be complementary.

    How are peroneal tendon problems treated?

    Overuse-related symptoms and stable partial injuries are usually treated non-operatively first. Management may include temporarily reducing activities that provoke pain, progressive strengthening and ankle-control exercises, footwear modification and, in selected cases, an orthotic or a short period of immobilisation. Return to running should depend on strength, stability and the tendon’s response to loading rather than simply on the number of days that have passed.

    Analgesic or anti-inflammatory medication may be appropriate for selected patients, but it does not repair a damaged tendon. Tendon-sheath injections are considered selectively; image guidance is advisable, and steroid should not be injected into the tendon itself. Evidence for injections in this region remains limited.

    More about image-guided procedures: Injection Treatments.

    When does an orthopaedic surgeon consider surgery?

    Surgery is considered mainly for complete or extensive tendon tears, recurrent subluxation, persistent weakness or pain that continues despite appropriate non-operative treatment. The procedure depends on whether the main problem lies in the tendon itself, the retinaculum, the groove behind the lateral malleolus or associated ankle instability.

    Warning signs

    Earlier assessment is needed after an injury if the foot cannot be loaded, there is an obvious deformity, swelling is increasing rapidly, sensation or circulation is impaired, there is an open wound, fever develops with marked local redness, or a sudden snap is followed by clear weakness of the foot. The ability to take a few steps does not by itself rule out a significant injury.

    Back to: Foot and Ankle Conditions

    More about: Tendons and Enthesopathies

    References

    • van Dijk PAD, Miller D, Calder J, et al. The ESSKA-AFAS international consensus statement on peroneal tendon pathologies. Knee Surg Sports Traumatol Arthrosc. 2018;26(10):3096–3107. DOI: 10.1007/s00167-018-4971-x.
    • Ghandour S, Mercer RW, Strahan JA, et al. Diagnostic accuracy of MRI and US for peroneal tendon tears: a systematic review and meta-analysis. Eur Radiol. 2025. DOI: 10.1007/s00330-025-11472-w. PubMed.
    • Dombek MF, Lamm BM, Saltrick K, Mendicino RW, Catanzariti AR. Peroneal tendon tears: a retrospective review. J Foot Ankle Surg. 2003;42(5):250–258.

    This material is educational and does not replace an individual medical consultation.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Exercise and Bone Density — What Does a New Network Meta-Analysis Show?

    Polish version

    Key message: regular exercise can help limit age-related loss of bone mineral density, but different forms of activity are not equally effective and the evidence does not support one universal programme for everyone. A new network meta-analysis suggests the strongest signals for brisk walking or jogging and for programmes combining aerobic and resistance exercise.

    Why is this study interesting?

    Advice to “be more active” is broadly correct but not very specific. In a paper published in BMJ on 9 September 2026, the authors asked two practical questions: which forms of exercise best preserve bone mineral density after the age of 40, and what weekly exercise dose may be needed to produce a measurable effect?

    Question and methodology

    The investigators performed a hierarchical Bayesian network meta-analysis together with a dose-response analysis. The review included 124 randomised trials involving 18,429 participants aged at least 40 years. Structured exercise programmes were compared with no exercise or with other forms of activity.

    The main outcomes were changes in bone mineral density at the lumbar spine, femoral neck and total hip. Fractures were assessed as an additional outcome. The authors also modelled the relationship between weekly exercise dose, expressed as MET-minutes, and bone-density effects.

    Main results

    • At the lumbar spine, brisk walking or jogging and programmes combining aerobic with resistance exercise were associated with an average improvement in bone mineral density of about 0.013 g/cm² compared with control.
    • At the femoral neck, favourable signals were seen for brisk walking or jogging and for exercise combining movement, balance and concentration, such as tai chi.
    • For total hip bone mineral density, brisk walking or jogging ranked highest, but certainty in that estimate was low.
    • The dose-response relationship was not linear. The threshold for a potentially clinically meaningful benefit was estimated at about 400 MET-minutes per week for the lumbar spine and about 600 MET-minutes for the femoral neck and total hip.
    • The fracture analysis included 26 trials and 11,132 participants. Mixed aerobic exercise and mind-body exercise were associated with lower fracture risk, but certainty in these data was low.

    Clinical interpretation for an orthopaedic surgeon

    The most useful conclusion is not that everyone should start running. The findings support programmes that include skeletal loading, aerobic activity and strength training, adapted to age, physical capacity, fall risk and fracture risk. Around 600 MET-minutes per week corresponds roughly to 2–3 hours of brisk walking or jogging, but this is an average signal derived from a statistical model, not a ready-made prescription for an individual patient.

    Jogging may be inappropriate for someone with advanced osteoporosis, a recent fracture, impaired balance or substantial joint disease. In such situations, safe resistance training, balance work and graded loading may matter more than mechanically trying to achieve one numerical exercise target.

    Limitations

    • The included trials differed in population, duration, exercise intensity and monitoring of adherence.
    • A substantial proportion of comparisons between exercise methods were indirect, as is typical in network meta-analysis.
    • Certainty for many estimates was low or moderate, and rankings of interventions may be less stable than individual numbers suggest.
    • Bone mineral density is an important surrogate outcome but is not equivalent to a demonstrated reduction in fractures.
    • Fracture data were less abundant than densitometry data and therefore provide less certain evidence about actual fracture prevention.

    What could this change in practice?

    The study strengthens the case for making exercise advice for prevention of bone loss more specific. Recommendations should address the type of exercise, its weekly dose and safety. A sensible programme will often combine weight-bearing lower-limb activity with resistance training and balance work.

    What does the study not prove?

    The meta-analysis does not prove that walking or jogging alone prevents fractures in every patient. It also does not show that exercise replaces osteoporosis assessment or pharmacological treatment in people at high fracture risk. Nor does it justify naming a single form of activity as best regardless of age, comorbidity and functional capacity.

    Back to: For Doctors and Physiotherapists

    Source

    Lu C, Li L, Zhang L, et al. Effect of exercise on bone health in middle aged and older adults: hierarchical network meta-analysis of randomised trials. BMJ. 2026;394:e100561. DOI: 10.1136/bmj-2026-100561. PubMed.

    Educational material for healthcare professionals. It does not constitute an individual therapeutic recommendation.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Eight Sensory Nerve Blocks After Total Knee Arthroplasty — Less Opioid Use?

    Polska wersja

    Key finding: an extensive ultrasound-guided combination of eight sensory nerve blocks did not reduce pain after total knee arthroplasty compared with local infiltration analgesia. Lower opioid consumption and a shorter hospital stay were secondary findings, so they should be treated as signals for further research rather than proof that the entire protocol is superior.

    Why is this study interesting?

    Early mobilisation after total knee arthroplasty requires analgesia that controls pain while preserving muscle function as much as possible. This is why motor-sparing approaches such as adductor canal block, IPACK block and genicular nerve blocks have been developed. In a paper published electronically on 8 September 2026, the investigators asked whether a broader block of the knee’s sensory innervation could outperform local infiltration analgesia.

    Question and methodology

    The randomized trial included 217 patients undergoing total knee arthroplasty. The intervention group received an ultrasound-guided combination of eight sensory nerve blocks using 40 mL ropivacaine 5 mg/mL with 75 µg clonidine. In addition to the adductor canal, IPACK and genicular nerve blocks, the protocol also targeted nerves supplying the vastus medialis and vastus intermedius muscles and the anterior femoral cutaneous nerve.

    The control group received local infiltration analgesia with 150 mL ropivacaine 2 mg/mL plus 0.5 mg epinephrine. The primary endpoint was resting pain intensity, assessed repeatedly from admission to the post-anaesthesia care unit until 2:00 p.m. on the first postoperative day. Secondary outcomes included opioid consumption expressed as oral morphine equivalents over 48 hours and length of hospital stay.

    Results

    There was no statistically significant difference in pain intensity between the groups at any of the prespecified time points. The trial therefore did not demonstrate superiority of the extensive block combination for its primary endpoint.

    • Median 48-hour opioid consumption was 70 mg oral morphine equivalents after the nerve blocks and 96 mg after local infiltration analgesia; p = 0.008.
    • Median length of stay was 1 day and 2 days, respectively; p < 0.001.
    • Both findings were secondary and exploratory.

    Clinical interpretation for an orthopaedic surgeon

    No difference in pain combined with lower opioid use may appear encouraging: similar symptom control was achieved with less opioid exposure. However, the hierarchy of endpoints matters. The protocol was not superior for the primary outcome, and the differences in opioid consumption and length of stay require confirmation in a trial specifically designed around those outcomes.

    The study also cannot identify which component of the combination produced the observed signal. Two complete and substantially different perioperative protocols were compared, rather than a single additional block. Total ropivacaine dose, the use of clonidine or epinephrine, mobilisation pathways and discharge criteria may all influence the results.

    Limitations

    • The primary endpoint was negative, while the favourable differences concerned secondary outcomes.
    • The extensive procedure involves multiple needle placements and requires experience with ultrasound-guided nerve blocks.
    • The study cannot isolate the effect of individual blocks or the contribution of clonidine.
    • Length of stay depends not only on analgesia but also on local care pathways and discharge criteria.
    • The abstract does not show whether the difference in opioid consumption translated into fewer episodes of nausea, delirium, falls or other clinical benefits.

    What could this change in practice?

    The study supports further work on analgesic strategies that reduce opioid exposure without worsening pain control or muscle function. At this stage, it argues more strongly for comparing and simplifying individual components of the protocol than for routinely implementing all eight blocks.

    What does the study not prove?

    It does not show that blocking eight sensory nerves provides better analgesia than local infiltration analgesia. It also does not show that the same effect would occur in a different perioperative pathway or that the shorter hospital stay was caused directly by the nerve-block protocol itself.

    Back to: For Doctors and Physiotherapists

    Source

    Fellert F, Sjövall F, Flivik G, Ekman A. A Novel Multiple Sensory Nerve Block Combination Using Ultrasound Guidance in Knee Arthroplasty: A Randomized Clinical Trial. A&A Practice. 2026;20(9):e02274. DOI: 10.1213/XAA.0000000000002274. PubMed.

    Educational material for healthcare professionals. It does not constitute an individual therapeutic recommendation.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.