Paweł Pietraszek

Background: Postoperative pain control after pediatric hand surgery remains challenging despite the increasing use of regional anesthesia. This randomized triple-blind trial evaluated whether adjunctive intravenous dexamethasone prolongs postoperative opioid-free analgesia after pediatric supraclavicular brachial plexus block. Methods: Ninety children undergoing elective hand or wrist surgery were randomized to receive intravenous placebo, dexamethasone 0.1 mg/kg, or dexamethasone 0.2 mg/kg before ultrasound-guided supraclavicular brachial plexus block (30 patients/group). The primary outcome was time to first postoperative opioid administration within 48 hours. Secondary outcomes included opioid consumption, postoperative pain scores, time to first documented spontaneous finger movement, and adverse events. Results: Intravenous dexamethasone significantly prolonged postoperative opioid-free analgesia compared with placebo. Median time to first rescue opioid administration was 8.9 hours in the placebo group, 14.3 hours in the dexamethasone 0.1 mg/kg group, and 17.3 hours in the dexamethasone 0.2 mg/kg group ( P <0.0001). Patients receiving dexamethasone also demonstrated lower postoperative opioid consumption and lower pain scores during the 48-hour follow-up period. The time to first documented spontaneous finger movement was delayed in dexamethasone-treated patients. No serious adverse events were observed. Conclusions: Adjunctive intravenous dexamethasone prolonged opioid-free analgesia and reduced postoperative opioid requirements after pediatric hand surgery. Although analgesic outcomes improved in a dose-dependent manner, higher dexamethasone doses were associated with longer time to first documented spontaneous finger movement. Level of Evidence: Level I—therapeutic study.

Background: Total hip arthroplasty (THA) induces a pronounced postoperative inflammatory response that contributes to pain, increased opioid requirements, and delayed recovery, particularly in older adults. Although the pericapsular nerve group (PENG) block provides effective analgesia, its impact on systemic inflammation remains insufficiently defined. Methods: In this prospective, randomized, quadruple-blinded controlled trial, patients aged ≥ 60 years undergoing elective unilateral THA performed under spinal anesthesia were randomized (1:1) to receive an ultrasound-guided PENG block with ropivacaine or a sham block. The primary outcome was the neutrophil-to-lymphocyte ratio (NLR) at 12 h postoperatively. Secondary outcomes included platelet-to-lymphocyte ratio (PLR) at 12, 24, and 48 h, postoperative pain scores, time to first opioid administration, and cumulative opioid consumption within 48 h. Results: Sixty patients completed the study (30 per group). Baseline inflammatory markers were comparable between groups. At 12 h, NLR was significantly lower in the PENG group than in the control group (5.98 ± 1.42 vs. 9.60 ± 1.83; adjusted p < 0.0001), with sustained reductions at 24 h (2.47 ± 0.77 vs. 5.71 ± 1.74; adjusted p < 0.0001) and 48 h (1.84 ± 0.71 vs. 3.53 ± 1.08; adjusted p < 0.0001). PLR was also significantly lower in the PENG group at all postoperative time points (all adjusted p < 0.0001), with a significantly different postoperative trajectory between groups over time. The PENG block significantly prolonged time to first opioid administration (15.0 ± 1.5 vs. 9.3 ± 1.7 h; p < 0.001) and reduced cumulative 48-h opioid consumption (13.2 ± 2.7 vs. 20.8 ± 3.2 mg; p < 0.001). Pain scores at rest and during mobilization were consistently lower in the PENG group throughout the first 24 h. Conclusions: In older adults undergoing THA, the PENG block was associated with lower postoperative inflammatory indices, improved pain control, and reduced opioid requirements. Because NLR and PLR are indirect inflammatory markers, these findings should be interpreted cautiously and viewed as associative rather than mechanistic. Further studies are required to determine whether these physiological differences translate into improved clinical recovery outcomes. Trial registration: ClinicalTrials.gov (NCT07023107), registered on 8 June 2025.

Total knee arthroplasty (TKA) is increasingly performed in older adults, a population with a growing prevalence of frailty and sarcopenia. Analgesic strategies focused mainly on pain reduction may overlook mobility, functional independence, fall prevention, and delirium risk, making motor preservation a central goal of perioperative care. This narrative review examines the anatomical basis, clinical evidence, and practical application of motor-sparing regional analgesia for older adults undergoing TKA, with emphasis on frailty, sarcopenia, and mobility-centred recovery, synthesising current evidence on established, emerging, and experimental techniques. Evidence was classified as geriatric-specific, older-enriched mixed-age, or mixed-age adult. Most technique-specific evidence derives from cohorts that included younger adults; only two small randomised trials reported cohorts composed exclusively of patients aged ≥65 years, and no regional-analgesia trial stratified outcomes by frailty or sarcopenia. A pragmatic clinical decision framework was developed to support individualised strategy selection in frail and sarcopenic patients. Current evidence supports adductor canal block combined with local infiltration analgesia as the foundation of motor-sparing analgesia after TKA; supplementary techniques such as iPACK, popliteal plexus block, genicular nerve block, and anterior femoral cutaneous nerve block may further optimise sensory coverage while preserving quadricep strength, whereas femoral nerve block produces predictable motor impairment and appears less suitable for this population. The existing literature remains largely focused on pain scores and opioid consumption, while mobility-related outcomes are infrequently reported. Direct evidence for falls, near-falls, delirium, discharge destination, functional independence, and long-term mobility remains sparse or absent. Successful analgesia after TKA should be defined not only by pain relief but by preservation of mobility and functional recovery, and future research should prioritise frailty-specific, mobility-centred outcomes.

Orthopedic procedures trigger a complex inflammatory response that plays a central role in tissue repair and postoperative recovery. However, excessive or dysregulated inflammation may contribute to complications such as periprosthetic joint infection, thromboembolic events, delayed healing, or systemic organ dysfunction. Therefore, accurate perioperative monitoring of inflammatory activity has become increasingly important in orthopedic surgery. Evidence discussed in this review was identified through a literature search of PubMed, Scopus, and Web of Science databases covering publications from 2000 to 2026. This narrative review summarizes the current evidence regarding both traditional inflammatory biomarkers, including C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), procalcitonin (PCT), and D-dimers, as well as emerging biomarkers derived from complete blood count (CBC), such as the neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), systemic immune-inflammation index (SII), systemic inflammatory response index (SIRI), and aggregate index of systemic inflammation (AISI). Particular attention is devoted to the clinical utility of these biomarkers in orthopedic trauma, fracture healing, total joint arthroplasty, and the early detection of postoperative complications. Increasing evidence suggests that composite CBC-derived indices may provide a practical and cost-effective approach for perioperative risk stratification and prognosis assessment. Nevertheless, their interpretation remains challenging due to the lack of standardized cutoff values and the influence of multiple patient-related factors. Current evidence indicates that assessing biomarker kinetics and interpreting multiple inflammatory indices together may be more clinically valuable than isolated measurements. Future research should focus on standardization, validation in prospective studies, and integration of inflammatory biomarkers into personalized perioperative care pathways in orthopedic surgery.

Background: Total knee arthroplasty is associated with significant postoperative pain. The erector spinae plane block (ESPB) is increasingly used as part of multimodal analgesia, but its duration may be limited. Adjuvants such as dexamethasone and dexmedetomidine may enhance analgesic efficacy; however, direct comparisons between these agents in ESPB remain limited. Methods: In this prospective, randomized, double-blind trial, 90 patients undergoing total knee arthroplasty were allocated to receive ESPB with ropivacaine alone (control), with ropivacaine plus dexamethasone (DEX), or with ropivacaine plus dexmedetomidine (DEM) (n = 30 per group). The primary outcome was time-to-first opioid requirement within 48 h. Secondary outcomes included total opioid consumption, postoperative pain intensity (NRS), and adverse events. Time-to-event analysis was performed using Kaplan–Meier and Cox regression. Results: Time-to-first opioid requirement was significantly prolonged in both DEX and DEM groups compared with control (log-rank p < 0.0001). Median time was 7.85 h (95% CI 7.40–8.50) in control, 13.70 h (12.80–14.50) in DEX, and 12.40 h (11.20–14.30) in DEM. Both DEX (HR 0.036, 95% CI 0.017–0.079) and DEM (HR 0.058, 95% CI 0.028–0.121) significantly reduced the hazard of opioid requirement (p < 0.0001). Total opioid consumption was significantly lower in the DEX group compared with both control and DEM (p < 0.0001), while no difference was observed between DEM and control. Pain scores were lower in the DEX group in the early postoperative period. No statistically significant differences in adverse events were observed between groups. Conclusions: Both dexamethasone and dexmedetomidine prolong ESPB analgesia in total knee arthroplasty. However, dexamethasone provides superior analgesic efficacy without increasing adverse events.

Background: Supraclavicular brachial plexus block is a widely used technique for upper limb surgery in children. Although perineural dexamethasone has demonstrated efficacy in prolonging analgesia in adults, data on its optimal dosing and systemic safety in pediatric patients are limited. This study aimed to evaluate whether low-dose perineural dexamethasone can prolong postoperative analgesia without increasing systemic stress markers in young children undergoing hand or wrist surgery. Methods: In this triple-blinded, randomized controlled trial (ClinicalTrials.gov Identifier: NCT06086392), 90 children aged 3 months to 6 years undergoing elective upper extremity surgery were assigned to receive supraclavicular brachial plexus block with 0.2% ropivacaine combined with either normal saline (control), dexamethasone 0.05 mg/kg, or dexamethasone 0.1 mg/kg. The primary outcome was time from arrival in the postanesthesia care unit to first administration of rescue opioid analgesia. Secondary outcomes included total opioid consumption, postoperative pain intensity using the FLACC scale, blood glucose levels, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and time to motor recovery. Results: Both dexamethasone groups demonstrated significantly prolonged time to first opioid use compared with the control group (mean±SD: 19.4±2.2 h in the 0.1 mg/kg group, 16.0±1.9 h in the 0.05 mg/kg group, and 8.5±1.3 h in controls; P <0.0001). Total opioid consumption was significantly reduced in the dexamethasone groups. Postoperative pain scores were lower in both intervention groups, especially during the first 12 hours. No significant differences were found among groups in blood glucose, inflammatory markers, or incidence of nerve deficits. Motor recovery was delayed in the dexamethasone groups but did not interfere with early mobilization. Conclusions: Low-dose perineural dexamethasone (0.05 to 0.1 mg/kg) safely and effectively prolongs postoperative analgesia and reduces opioid needs in children undergoing upper limb surgery, without causing systemic metabolic or inflammatory disturbances. The 0.05 mg/kg dose may offer a more favorable balance between analgesic efficacy and motor recovery time. Level of Evidence: Level I—randomized controlled trial.

Background/Objectives: The pericapsular nerve group (PENG) block is increasingly used as part of multimodal analgesia for total hip arthroplasty (THA). However, standard high-volume local anesthetic regimens may impair motor function. The addition of perineural dexamethasone could allow for volume reduction while maintaining analgesic efficacy and minimizing quadriceps weakness. This study evaluated whether adding dexamethasone to a low-volume PENG block prolongs analgesia, reduces opioid consumption, maintains pain control, and preserves motor function compared to a standard-volume PENG block. Materials and Methods: In this randomized controlled trial (NCT06470334), 60 adult patients undergoing THA via the direct superior approach received either a standard-volume PENG block with 20 mL of 0.2% ropivacaine (PENG group) or a low-volume block with 10 mL of 0.2% ropivacaine plus 4 mg of perineural dexamethasone (PENG + DEX group). The primary outcome was time to first rescue opioid. Secondary outcomes included total 48-h opioid consumption (oral morphine equivalents), pain scores (numeric rating scale, NRS) at rest and during movement, and quadriceps muscle strength at predefined postoperative intervals. Results: The PENG + DEX group demonstrated a significantly longer time to first opioid administration (15.0 ± 1.5 h vs. 9.1 ± 1.7 h; p < 0.0001) and reduced total opioid consumption within 48 h (2.3 ± 3.1 mEQ vs. 5.0 ± 4.4 mEQ; p = 0.0120). Pain scores were similar at 4 h but significantly lower in the PENG + DEX group at 8, 12, and 24 h postoperatively (all p < 0.01). Quadriceps strength was fully preserved in both groups at all assessed timepoints (p > 0.9999). Conclusions: The addition of perineural dexamethasone to a low-volume PENG block provides longer-lasting analgesia and reduces opioid requirements without compromising pain control or quadriceps function. This approach may improve the safety and efficacy of regional anesthesia in THA.