Kategoria: Updates for Doctors (EN)

Polish version: Podwójna mobilność w THA po złamaniu szyjki kości udowej — mniej zwichnięć

Dual-mobility cups can substantially reduce dislocation after total hip arthroplasty (THA) for displaced femoral neck fracture. In the pragmatic DUALITY trial published in The Lancet, dislocation requiring reduction or surgery within 1 year occurred in 1.3% with dual mobility and 4.2% with standard cups.

Why this study matters

Dislocation is a major early complication of THA for femoral neck fracture in older adults, potentially requiring readmission, anaesthesia for reduction or further surgery. Dual mobility aims to improve stability. Earlier support largely came from observational evidence and small studies; DUALITY was the first large randomized trial designed to address the question in routine practice.

Study design

Patients aged at least 65 with displaced femoral neck fracture, already selected for THA, were recruited at 44 hospitals: 20 in Sweden and 24 in the UK. A total of 1,600 patients were randomized 1:1 to dual-mobility or standard cups. Patients and clinical teams knew the implant allocation, while investigators and statisticians remained masked until analysis was complete.

The primary endpoint was operated-hip dislocation within 1 year requiring closed reduction or surgery. The modified intention-to-treat analysis included 1,566 patients.

Main results

• Dislocation occurred in 10/779 patients (1.3%) with dual mobility and 33/787 (4.2%) with standard cups.
• The adjusted hazard ratio was 0.27 (95% CI 0.13–0.56; P < 0.0001).
• The absolute risk difference was 2.9 percentage points.
• The authors also found a lower overall risk of surgical complications with dual mobility.

The reduction concerned a complication with substantial functional consequences for older adults after fracture, making it clinically as well as statistically relevant.

Clinical interpretation for an orthopaedic surgeon

The strongest conclusion applies to patients aged ≥65 with displaced femoral neck fracture for whom THA has already been chosen. Dual mobility reduced first-year dislocation in that setting. Apart from cup allocation, treatment followed local practice across 44 hospitals. This increases variation in techniques and implants but also makes the trial more representative of routine care than a single specialist-centre study.

Limitations

• Findings should not automatically be extrapolated to elective THA for osteoarthritis.
• The study compared cups after selection for THA; it does not determine when THA is preferable to hemiarthroplasty.
• Patients and treating teams were unblinded.
• First-year outcomes do not resolve long-term wear, implant durability or rare late complications specific to dual mobility.
• The overall result does not identify one brand or cup design as best.

Implications for practice

DUALITY provides strong support for considering dual mobility to reduce dislocation in older patients undergoing THA after displaced femoral neck fracture. It does not justify universal use in every primary THA, eliminate dislocation risk or establish superior long-term implant survival. Bone quality, patient function, approach, anatomy and team experience remain relevant to individual decisions.

References

1. Poboży T, Janowski K, Michalak K, Rulewska N, Grabowski F, Konarski W. Total Hip Arthroplasty After Femoral Neck Fracture in an Ipsilateral High Transfemoral Amputee With Less Than 50% Femoral Length. Cureus. 2025;17(10):e95722. DOI: 10.7759/cureus.95722. This report concerns THA after femoral neck fracture in a particularly challenging technical setting; it does not compare cup designs.
2. Hailer NP, Griffin XL, Mukka S, et al.; DUALITY Investigators. Dual mobility versus standard cups in total hip replacement for displaced femoral neck fractures (Duality): an international, multicentre, randomised, controlled, superiority trial. Lancet. 2026;408(10552):348–356. DOI: 10.1016/S0140-6736(26)00759-2. PMID 42392114.

Related resources

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

Content prepared by: Tomasz Poboży - orthopaedic surgeon.

Polish version: Endoproteza jednoprzedziałowa kolana — czy indywidualne prowadnice poprawiają wynik?

Patient-specific guides are intended to help reproduce planned component positioning in unicompartmental knee replacement, but a meta-analysis found no corresponding advantage in patient-reported function. Greater technical sophistication does not automatically mean better clinical outcomes.

Why this study matters

Accurate component placement matters in unicompartmental arthroplasty. Patient-specific instrumentation (PSI), produced from preoperative imaging, aims to improve reproducibility. The review compared PSI with conventional instrumentation to assess pain, function and outcomes important to patients rather than assuming that technical accuracy guarantees benefit.

Review methods

The PRISMA-based review searched MEDLINE, Embase and the Cochrane Library. Fourteen studies included 1,680 knees in 1,670 patients: five RCTs and nine retrospective comparative studies. All RCTs had low overall risk of bias, while some observational studies were weaker.

Main outcomes were Oxford Knee Score (OKS) at 1 year and change from baseline. Knee Society Score, KOOS, WOMAC and revision data were also assessed.

Main results

OKS at 12 months did not differ significantly: mean difference 0.90 points (95% CI −2.65 to 4.45; I² = 0%). Knee Society Score and KOOS showed no significant PSI advantage at 3 months or assessments at least 1 year after surgery. WOMAC data were insufficient for reliable pooling.

Revision data were too heterogeneous for a meaningful combined analysis. The effect on later reoperation or implant survival therefore remains uncertain.

Clinical interpretation for an orthopaedic surgeon

Current evidence does not confirm better functional outcomes with PSI than with conventional instrumentation. PSI may assist planning or technical steps, but should not be presented as a guarantee of less pain, better function or greater satisfaction. New technology warrants assessment through patient-reported outcomes, safety, durability and total pathway costs alongside technical and radiographic measures.

Limitations

• Only five of the 14 studies were randomized; most evidence was retrospective.
• Some observational studies had moderate or high risk of bias.
• PSI systems, techniques and patient populations varied.
• The strongest functional evidence concerns approximately 1 year, not long-term durability.
• Revision evidence could not be pooled reliably.

Implications for practice

Where PSI is used, the rationale should rest on specific technical or organisational benefits rather than a promised improvement in patient-reported function. The review does not exclude usefulness in particular anatomical situations, establish equivalence between every PSI system or show that component accuracy is unaffected. It answers the narrower question that available evidence shows no functional advantage over well-performed surgery with standard instruments.

References

Ruhle V, Rudran B, Leung B, Merle C, Murray D, Price A, Alvand A. Functional outcomes of patient-specific instrumentation versus conventional instrumentation for unicompartmental knee replacement: A systematic review and meta-analysis. The Knee. Published online 25 August 2026;63:104608. DOI: 10.1016/j.knee.2026.104608. PMID 42641204.

The numerical findings above are limited to information publicly available in the abstract and publication metadata. In the conflict-of-interest declaration, one author reported an institutional grant, consulting payments and royalties from Zimmer Biomet.

Related resources

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

Content prepared by: Tomasz Poboży - orthopaedic surgeon.

Polish version: Paluch sztywny — artrodeza zmniejszała ból bardziej niż obserwacja

For symptomatic hallux rigidus, first metatarsophalangeal joint arthrodesis reduced walking pain substantially more than watchful waiting. In the first randomized comparison of fusion with the natural course of the condition, the 12-month difference exceeded both statistical significance and the prespecified threshold for clinical importance.

Why this study matters

Osteoarthritis of the first metatarsophalangeal joint may cause pain and restricted dorsiflexion that interfere with walking, footwear and activity. Arthrodesis is an established option for painful, more advanced disease, but randomized evidence against watchful waiting had been lacking. Miettinen and colleagues’ trial, published in Annals of Internal Medicine on 11 August 2026, examined the benefit of choosing fusion rather than comparing two operative techniques.

Study design

The single-centre randomized trial followed patients for 12 months. Eligibility required age ≥40 years, radiographic Coughlin–Shurnas grade I–III disease, symptoms for more than 1 year and walking pain ≥4 on a 0–10 scale. Exclusions included type 1 diabetes, rheumatoid arthritis and hallux valgus exceeding 15°.

Ninety patients were randomized 1:1 to arthrodesis or watchful waiting without surgery; 89 attended the 12-month assessment. The primary endpoint was walking pain on a 0–10 scale, with a prespecified clinically important difference of 1.7 points.

Main result

Mean walking pain at 12 months was 1.3 after arthrodesis and 5.7 with watchful waiting. The adjusted difference was −5.0 points (95% CI −6.1 to −3.9), favouring surgery. This substantially exceeded the 1.7-point threshold and represented a large clinical effect.

Clinical interpretation for an orthopaedic surgeon

The trial supports fusion for carefully selected patients with longstanding, clearly symptomatic hallux rigidus and substantial walking pain. The comparator was watchful waiting, however, rather than a standardised active nonoperative programme. It also did not compare fusion with cheilectomy, implants, interposition arthroplasty or other motion-preserving procedures, so it cannot determine the best operation for every stage.

Limitations

• A single-centre study limits generalisability across populations and services.
• Twelve-month follow-up does not establish long-term results, adjacent-joint loading or late reoperation.
• Patients were selected by age, symptom duration, pain severity and radiographic stage.
• The control was observation, not a structured active nonoperative programme.
• Other surgical treatments were not compared.

Implications for practice

Discussion of expected pain relief from fusion can now draw on direct randomized evidence against watchful waiting, in addition to case series and technique comparisons. The trial does not imply that every patient needs surgery, that arthrodesis is best at every stage or that nonoperative care should be omitted. Comparative effectiveness against other procedures and long-term consequences of losing first-joint motion remain unresolved.

References

• Miettinen M, Sirola T, Lähdeoja T, Sandelin H, Nummela M, Repo JP, Ponkilainen V, Rämö L. Surgery Versus Watchful Waiting for First Metatarsophalangeal Joint Osteoarthritis: A Randomized Controlled Trial. Ann Intern Med. Published August 11, 2026. DOI: 10.7326/ANNALS-26-00710. PubMed: PMID 42574728.

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

Related resources

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

Content prepared by: Tomasz Poboży - orthopaedic surgeon.

Polish version: Obrąbek biodra w FAI — naprawa czy częściowe usunięcie?

Hip preservation surgery generally favours retaining a functional labrum when tissue quality allows reliable repair. A meta-analysis published on 11 August 2026 in The American Journal of Sports Medicine supports this approach. In arthroscopic treatment of femoroacetabular impingement (FAI), repair was associated with fewer subsequent total hip arthroplasties (THAs) and better long-term pain outcomes than debridement with partial removal.

Why this study matters

The labrum contributes to the joint seal, stability and synovial fluid distribution. However, much earlier evidence was observational: patients selected for repair may differ from those selected for debridement in tissue quality, degeneration and baseline prognosis. This review analysed randomized and cohort evidence separately.

Review methods

The systematic review and meta-analysis followed a prospectively registered PROSPERO protocol and searched PubMed, Embase and Cochrane CENTRAL. Studies compared arthroscopic labral repair with debridement in FAI. Open procedures and labral reconstruction were excluded to reduce clinical heterogeneity.

Ten studies included 2,730 hips: 1,580 repairs and 1,150 debridements. Outcomes were patient-reported function, pain and conversion to THA, with analyses by study design and follow-up duration.

Main results

Pooled modified Harris Hip Score did not differ significantly: mean difference 1.92 points (95% CI −2.33 to 6.16). Observational studies showed no HOS-ADL or HOS-SSS difference, whereas the randomized trial favoured repair by 10.3 points for HOS-ADL and 12.4 for HOS-SSS.

Short-term pain was similar. At follow-up of at least 5 years, VAS pain favoured repair by a mean of −1.37 points. Conversion to THA occurred in 3.5% of repaired hips versus 7.4% after debridement: pooled RR 0.56 (95% CI 0.37–0.84; P = 0.006). The difference was mainly driven by longer-term results.

Clinical interpretation for an orthopaedic surgeon

The results support preserving a functional, repairable labrum, with long-term pain and THA conversion providing the most compelling signals. They do not support repair irrespective of tissue quality. Repairable and irreparable tissue differ, as may patient age, cartilage condition, joint-space width and degeneration. Some apparent benefit may reflect better baseline prognosis in patients selected for repair.

Limitations

• The review combined randomized and observational evidence and was rated Level 3 overall.
• Most evidence came from cohorts susceptible to treatment-selection bias.
• Arthroscopic techniques, FAI correction and repairability criteria varied.
• Lower THA conversion does not prove that repair itself prevents osteoarthritis.
• Findings should not be extrapolated to irreparable labra, reconstruction or advanced hip degeneration.

Implications for practice

Reliable repair of a functional labrum remains a preferred strategy when feasible. The long-term direction of results is more persuasive than small differences in general functional scores. The study does not imply that every debridement is an error or that repair is beneficial regardless of cartilage and tissue quality. It also does not determine when reconstruction is preferable to either treatment.

References

• Konarski W, Poboży T. Removal of a Periarticular Cyst of the Hip Joint Using an Ultrasoundbased Minimally Invasive Technique – A Case Report. Current Medical Imaging. 2022;18(11):1226–1230. DOI: 10.2174/1573405618666220415125416. This report concerned peri-articular hip pathology associated with an acetabular labral lesion and arthroscopic treatment.
• Bohn DS, Bigarella LG, Gusmão PDF, Fritsch CG, Lima DJL. Arthroscopic Labral Repair Versus Debridement for Femoroacetabular Impingement: A Systematic Review and Meta-analysis of 2730 Hips. Am J Sports Med. Published online 11 August 2026. DOI: 10.1177/03635465261465092. PubMed PMID 42578456.

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

Related resources

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

Content prepared by: Tomasz Poboży - orthopaedic surgeon.

Polish version: Masywne uszkodzenie stożka rotatorów — ścięgno bicepsa czy przeszczep skórny?

A meta-analysis of reconstruction for massive rotator cuff tears does not establish a clearly superior graft material. Both long head of biceps tendon autograft and acellular dermal allograft were associated with improved pain, function and motion. All included studies were observational, however, and surgical techniques varied substantially.

Why this study matters

Massive tears can be difficult to repair durably when there is marked retraction, poor tissue quality or muscle atrophy. Biological augmentation and reconstruction may help address inadequate coverage or structural integrity. Biceps autograft avoids donor material and may preserve biological continuity with the patient’s tissues, while dermal allograft offers material with predictable dimensions and mechanical properties. Robust comparisons have been limited.

Review methods

Alhussain and colleagues followed PRISMA and searched PubMed, Embase, Scopus and the Cochrane Library. Seventeen observational studies included 613 patients: 322 treated with biceps tendon autograft and 291 with acellular dermal allograft.

Outcomes included ASES, VAS pain, range of motion, acromiohumeral distance and structural failure. The groups encompassed superior capsular reconstruction, repair augmentation and bridging grafts, rather than one identical operation performed across centres.

Main results

Both strategies produced substantial postoperative improvement. Standardised mean differences for ASES were 2.35 with biceps autograft and 1.65 with dermal allograft; the between-subgroup difference was not statistically significant (P = 0.07).

VAS pain improved considerably in both groups, without a significant difference between techniques (P = 0.32). Elevation, external rotation and acromiohumeral distance also improved, without convincing evidence favouring one strategy.

No significant difference in structural failure was demonstrated. Failure rates varied widely between studies, however, and definitions and imaging surveillance were inconsistent.

Clinical interpretation for an orthopaedic surgeon

Both approaches can yield good results in selected patients, but current evidence does not support routinely preferring one material. Selection still depends on tear pattern, tendon quality, availability and condition of the biceps tendon, muscle atrophy and fatty infiltration, prior surgery, patient expectations and surgeon experience.

These studies did not simply compare otherwise identical reconstructions using different grafts. Differences may reflect operative design, indications and patient selection as well as material properties.

Limitations

• All 17 studies were observational; there were no randomized comparisons.
• Definitions of a massive tear varied by defect size or number of involved tendons.
• Superior capsular reconstruction, augmentation and bridging are biomechanically different procedures.
• Fatty infiltration, retraction, subscapularis integrity, graft thickness, associated procedures and rehabilitation were inconsistently reported.
• Failure was usually assessed with MRI, but some studies used ultrasound or clinical criteria.

Implications for practice

The review supports individual selection rather than assuming that one graft is inherently better. Biceps autograft was not clearly inferior in the available clinical data, but absence of a significant difference does not establish equivalence. Optimal treatment for particular tear patterns and comparative long-term outcomes remain uncertain. Prospective, preferably randomized studies with standardised techniques and eligibility criteria are needed.

References

• Poboży T, Kielar M, Miąskiewicz J. Ultrasound-guided biodegradable subacromial spacer implantation in a patient with massive irreparable rotator cuff tears. Wideochir Inne Tech Maloinwazyjne. 2019;14(1):145-148. DOI: 10.5114/wiitm.2018.77555. This report concerns a different treatment for the same clinical problem: a massive irreparable rotator cuff tear.
• Alhussain AH, Alzahrani MT, Aljaafri ZA, et al. Rotator Cuff Reconstruction Using Biceps Tendon Autograft Versus Acellular Dermal Allograft: A Systematic Review and Meta-analysis of Clinical Outcomes. Orthop J Sports Med. 2026;14(8):23259671261470960. DOI: 10.1177/23259671261470960. PubMed.

The meta-analysis was published on 24 August 2026. The full text is legally available in PubMed Central.

Related resources

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

Content prepared by: Tomasz Poboży - orthopaedic surgeon.

Polish version: Odbarczenie cieśni nadgarstka pod kontrolą USG — wyniki po 2 latach

Percutaneous ultrasound-guided carpal tunnel release produced improvement lasting at least 2 years, with its clearest advantage over mini-open release occurring early after treatment. Patients reported less incision-related pain, while both groups achieved clinically meaningful improvement in symptoms, pain and hand function.

Why this study matters

Carpal tunnel surgery aims to minimise tissue injury without compromising median nerve decompression. Continuous ultrasound allows real-time visualisation of the nerve, vessels, transverse carpal ligament and instrument, and the procedure can be performed in an office setting under local anaesthesia. The randomized trial by Smith and colleagues, published on 29 June 2026, addresses whether clinical improvement persists beyond the early period.

Study design

This prospective single-centre trial enrolled 41 beneficiaries of the US military healthcare system: 21 underwent office-based percutaneous ultrasound-guided release and 20 mini-open release. Mean age was 49.5 years; 58.5% were women and 41.5% were on active duty. Two-year data were available for every randomized and treated patient.

The primary endpoint was QuickDASH at 1 month. Pain, Boston Carpal Tunnel Questionnaire (BCTQ) symptom severity, incision-related palmar pain and adverse events were followed for 2 years.

Main results

At 1 month, mean QuickDASH changes were −8.2 points after ultrasound-guided release and −8.4 after mini-open surgery. BCTQ symptom severity changed by −0.9 and −1.2, respectively; numerical pain scores changed by −1.1 in both groups.

Ultrasound-guided release caused less incision-related pain during the first 4 weeks and less function-limiting pain during the first 3 weeks. Both groups maintained clinically meaningful symptom, pain and functional improvements through 2 years. One infection occurred in the ultrasound-guided group.

Clinical interpretation for an orthopaedic surgeon

The study does not demonstrate superior hand function at 2 years with ultrasound guidance. It suggests that a smaller access site may reduce early wound-related symptoms while maintaining durable clinical improvement. Office-based treatment may simplify the care pathway, but the trial did not assess whole-system costs or establish organisational advantages in every centre.

Limitations

• Only 41 patients were enrolled, precluding reliable comparison of rare complications.
• A single centre and a military healthcare population limit generalisability.
• Assessment mainly used patient-reported outcomes; this was not a comprehensive study of costs, return to work or reoperation.
• Results concern a specific percutaneous ultrasound-guided technique and do not apply automatically to every minimally invasive method.

Implications for practice

The findings support ultrasound-guided release as a technique with sustained clinical benefit, beyond a short-lived cosmetic advantage, and less early access-related pain. They do not establish greater overall efficacy than mini-open release or justify replacing conventional surgery for every patient. They also do not establish superiority in unusual anatomy, substantial structural abnormalities or cases requiring broader exploration.

References

1. Domańska J, Poboży K, Domański P, Konarski W, Poboży T. Case Report: Diagnosis and Management of Carpal Tunnel Syndrome in a Patient With Oligodactyly. Issue Rehabil Orthop Neurophysiol Sport Promot. 2024;46(1):69–76. DOI: 10.19271/IRONS-000206-2024-46.
2. Smith MS, Yuan X, Deal JB Jr, Nanos GP 3rd, Tintle SM, Hager NA, Reece DE, Miller ME. Carpal Tunnel Release Using Ultrasound Guidance: Two-Year Outcomes of a Randomized Controlled Trial Within the Military. J Hand Surg Glob Online. 2026;8(5):101078. DOI: 10.1016/j.jhsg.2026.101078. PMID 42404100.
3. American Academy of Orthopaedic Surgeons. Management of Carpal Tunnel Syndrome: Evidence-Based Clinical Practice Guideline. 2024. AAOS Clinical Practice Guideline.

Related resources

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

Content prepared by: Tomasz Poboży - orthopaedic surgeon.

Polish version: Czy liczba endoprotez biodra wykonywanych przez chirurga wpływa na wyniki?

Experience matters in hip arthroplasty, but cannot be reduced to a single annual case threshold. A systematic review and meta-analysis published on 20 August 2026 in Archives of Orthopaedic and Trauma Surgery found that some outcomes favoured surgeons performing more total hip arthroplasties (THAs). Definitions of low and high volume varied too much to establish one reliable cutoff.

Why this study matters

Regularly performing a procedure may improve technical consistency, shorten operating time and help surgeons manage unusual situations. However, previous studies defined high volume very differently, from a few or a dozen procedures to more than 100 per year. The review examined annual primary THA volume in relation to revision, complications, readmission, mortality and clinical outcomes.

Review methods

The review followed PRISMA, was registered in PROSPERO and searched Medline and Embase. Eighteen studies involving 796,061 patients were included. All were retrospective, although their methodological quality was rated highly using the selected assessment tool.

Definitions of high volume ranged from a few to more than 100 THAs per year. Nine of the 18 studies used at least 50 procedures annually as one threshold, but this was not a consistent standard across the literature.

Main results

The clearest differences concerned early outcomes. Lower-volume groups had higher odds of readmission within the first month (OR 1.6) and mortality at 3 months (OR 1.8).

There were no statistically significant differences in revision at 3 months, 12 months or beyond 1 year, in readmission at 3 months, or in venous thromboembolism. Many estimates still favoured higher-volume surgeons, but confidence intervals were wide. Only one of the 18 studies reported patient-reported outcomes by surgeon volume, providing little evidence about pain, function or quality of life.

Clinical interpretation for an orthopaedic surgeon

Regular experience with primary THA is probably one contributor to better outcomes, operating within a broader system of care. Higher-volume surgeons often work in specialised hospitals with standardised perioperative pathways, experienced anaesthetic and rehabilitation teams and ready access to complication management. Retrospective data cannot fully separate these influences from patient selection.

Procedure counts are easy to measure, but cannot replace outcomes such as revision, infection, dislocation, function and appropriate selection for surgery.

Limitations

• All studies were retrospective and cannot establish a simple causal relationship.
• Volume definitions differed substantially.
• Surgeon and hospital volume effects were difficult to separate.
• Follow-up periods and complication definitions varied.
• Functional and quality-of-life data were sparse.

Implications for practice

Quality assessment should consider procedural experience alongside implants and surgical approach. The findings may also support concentrating complex cases in teams that regularly perform arthroplasty. They do not define an annual number below which THA is necessarily performed poorly or imply that high volume guarantees a good result. The relative contributions of technique, organisation and patient selection remain uncertain.

References

• Meissner N, Ortwig K, Ramos-Pascual S, Agu C, Stoeve J, Schrednitzki D, Rolvien T, Halder AM. The effect of surgeon volume on outcomes after total hip arthroplasty: a systematic review and meta-analysis. Arch Orthop Trauma Surg. 2026;146:308. DOI: 10.1007/s00402-026-06434-w. PubMed PMID 42622668.

The full publication is available open access.

Related resources

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

Content prepared by: Tomasz Poboży - orthopaedic surgeon.

Polish version: Pierwsze zwichnięcie barku — co zmieniają nowe wytyczne?

Management after a first traumatic shoulder dislocation varies widely, from prolonged immobilisation to rapid mobilisation. A multidisciplinary guideline published in Acta Orthopaedica on 10 August 2026 sets out a structured pathway: confirm the diagnosis and reduction with imaging, avoid routinely prolonged immobilisation, restore function early and assess recurrence risk from the outset.

Why this guideline matters

A 20-year-old contact-sport athlete and a 65-year-old woman after a fall have different risks of recurrence, fracture, rotator cuff injury and reduction-related complications. The guideline combines orthopaedics, trauma surgery, emergency medicine, radiology, physiotherapy and patient representation. It addresses seven areas: diagnosis, reduction technique, analgesia for reduction, immobilisation, physiotherapy, recurrence risk and primary surgical stabilisation.

Imaging before and after reduction

Radiographs in at least two orthogonal views are recommended both before and after reduction. They confirm dislocation, identify associated fractures, document restored alignment and help exclude iatrogenic injury. CT is indicated when imaging remains unclear or complex bony injury is suspected. Ultrasound should not replace radiographs in this acute setting.

Reduction technique

No single technique was identified as universally best. The operator should use a familiar technique and preferably start with a gentle biomechanical method based on scapular and humeral positioning rather than substantial traction. After a failed attempt, reassess the clinical situation and possible mechanical obstacles before trying again. Rarely, reduction in the operating theatre is required.

Analgesia and sedation

Routine sedation is not required for every first reduction attempt. Analgesia should reflect the patient’s condition, team experience and emergency department resources. If an attempt without deeper sedation fails, procedural sedation with analgesia becomes the recommended first-choice approach. This recommendation largely reflects expert opinion and safety considerations because no studies met the review criteria for this question.

Immobilisation and early function

The guideline recommends approximately 1 week of relative immobilisation, using a sling mainly for comfort and pain relief. After the acute phase, early functional recovery should address rotator cuff activity, coordination and proprioception. Routinely extending immobilisation solely to reduce recurrence is not supported.

Recurrence risk and early stabilisation

Younger age and male sex are important recurrence factors, but assessment must also consider activity, contact or overhead sports, and glenoid and humeral bone defects. Discussion of primary surgical stabilisation is particularly relevant for patients under 40, contact-sport athletes and those with substantial bone loss. These factors are not automatic indications for surgery.

In the studies considered by the guideline, early arthroscopic Bankart stabilisation was associated with recurrence in approximately 8.9% versus 49% after nonoperative treatment. Return to sport was approximately 90% versus 62%. These striking figures come from selected populations and are not universal forecasts; certainty for some recommendations was low or very low.

Implications for an orthopaedic surgeon’s practice

Management should reflect the individual risk profile. Older patients require particular attention to fractures and rotator cuff injury. Young contact-sport athletes need an early discussion of recurrence and potential benefits of stabilisation. Across the pathway, key principles are radiographs before and after reduction, brief sling use and early restoration of function.

Limitations

• Many recommendations rest on low- or very-low-certainty evidence.
• No studies met the review criteria for reduction analgesia or physiotherapy, so these recommendations rely largely on expert opinion.
• Selection for primary surgery requires individual assessment rather than one age cutoff.
• The guideline addresses first-time traumatic anterior dislocation, not every form of shoulder instability.

What remains individualised

The guideline does not imply that every young patient needs surgery after a first dislocation or that 1 week of sling use suits every associated injury, such as a greater tuberosity fracture. It provides a pathway for identifying patients who need a different approach from standard nonoperative care.

References

Van Gastel ML, Hekman KMC, Boon F, Nelen SD, Schep NWL, Van der Meijden OAJ, Baden DN, Jonkergouw MAT, Huygen LE, Balemans ACJ, Griekspoor M, Derksen RJ, Van den Bekerom MPJ. Clinical practice on treatment of primary traumatic anterior shoulder dislocation: a multidisciplinary guideline. Acta Orthopaedica. 2026;97:531–537. DOI: 10.2340/17453674.2026.46434. PubMed: PMID 42573533. Full text: PubMed Central.

The article is open access under CC BY 4.0.

Related resources

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

Content prepared by: Tomasz Poboży - orthopaedic surgeon.

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

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

Why this study matters

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

Study design

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

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

Main results

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

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

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

Clinical interpretation for an orthopaedic surgeon

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

Limitations

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

Implications for practice

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

References

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

The publication is open access under CC BY 4.0.

Related resources

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

Content prepared by: Tomasz Poboży - orthopaedic surgeon.

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

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

Why this study matters

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

Review methods

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

Main results

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

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

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

Clinical interpretation for an orthopaedic surgeon

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

Limitations

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

Implications for practice

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

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

References

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

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

Related resources

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

Content prepared by: Tomasz Poboży - orthopaedic surgeon.