BACKGROUND: Evidence-based international expert consensus regarding anaesthetic practice in hip/knee arthroplasty surgery is needed for improved healthcare outcomes.
METHODS: The International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) systematic review, including randomised controlled and observational studies comparing neuraxial to general anaesthesia regarding major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, genitourinary, thromboembolic, neurological, infectious, and bleeding complications. Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, from 1946 to May 17, 2018 were queried. Meta-analysis and Grading of Recommendations Assessment, Development and Evaluation approach was utilised to assess evidence quality and to develop recommendations.
RESULTS: The analysis of 94 studies revealed that neuraxial anaesthesia was associated with lower odds or no difference in virtually all reported complications, except for urinary retention. Excerpt of complications for neuraxial vs general anaesthesia in hip/knee arthroplasty, respectively: mortality odds ratio (OR): 0.67, 95% confidence interval (CI): 0.57-0.80/OR: 0.83, 95% CI: 0.60-1.15; pulmonary OR: 0.65, 95% CI: 0.52-0.80/OR: 0.69, 95% CI: 0.58-0.81; acute renal failure OR: 0.69, 95% CI: 0.59-0.81/OR: 0.73, 95% CI: 0.65-0.82; deep venous thrombosis OR: 0.52, 95% CI: 0.42-0.65/OR: 0.77, 95% CI: 0.64-0.93; infections OR: 0.73, 95% CI: 0.67-0.79/OR: 0.80, 95% CI: 0.76-0.85; and blood transfusion OR: 0.85, 95% CI: 0.82-0.89/OR: 0.84, 95% CI: 0.82-0.87.
CONCLUSIONS: Recommendation: primary neuraxial anaesthesia is preferred for knee arthroplasty, given several positive postoperative outcome benefits; evidence level: low, weak recommendation.
CONCLUSIONS: neuraxial anaesthesia is recommended for hip arthroplasty given associated outcome benefits; evidence level: moderate-low, strong recommendation. Based on current evidence, the consensus group recommends neuraxial over general anaesthesia for hip/knee arthroplasty.
UNASSIGNED: PROSPERO CRD42018099935.

BACKGROUND: Total shoulder arthroplasty (TSA) is indicated for patients with glenohumeral arthritis. In this procedure, the humeral head and glenoid surface are replaced with prosthetic components. Reverse total shoulder arthroplasty (RTSA) is indicated for patients with glenohumeral arthritis and a poorly functioning rotator cuff. In this procedure, a glenosphere articulates with a humerosocket. While those surgeries are commonly performed, a thorough review of the literature is required to determine the areas of agreement and variations in postoperative rehabilitation.
OBJECTIVE: To describe the literature on rehabilitation protocols following anatomic TSA and RTSA.
METHODS: For this systematic review, a computerized search was conducted in medical databases from inception to May 21, 2018 for relevant descriptive studies on TSA and RTSA rehabilitation protocols. The methodological index for nonrandomized studies tool and the modified Downs and Black tool for randomized controlled trials were used for assessment of the individual studies.
RESULTS: Sixteen studies met the inclusion criteria, of which 1 provided level I evidence, 1 provided level III evidence, 2 provided level IV evidence, and 12 provided level V evidence. Ten of the studies described rehabilitation guidelines for TSA and 6 described those for RTSA. Following TSA, the use of a sling was recommended for a duration that varied from 3 to 8 weeks, and 4 of the 10 published protocols included resisted exercise during the initial stage of healing (the first 6 weeks after surgery). Seven of 10 published protocols recommended limiting shoulder external rotation to 30° and that passive range of motion be fully restored by 12 weeks post surgery. Suggested use of a sling post RTSA varied from \"for comfort only\" to 6 weeks, motion parameters varied from no passive range of motion to precautionary range limits, and all protocols agreed on performing deltoid isometric exercises early post surgery. There was a high level of heterogeneity for the rehabilitation guidelines and associated precautions for both TSA and RTSA.
CONCLUSIONS: The majority of published protocols were descriptive in nature. Published rehabilitation strategies following TSA and RTSA are based on biomechanical principles, healing time frames, and exercise loading principles, with little consistency among protocols. There is a need to determine optimal rehabilitation approaches post TSA and RTSA based on clinical outcomes.
METHODS: Therapy, level 5. J Orthop Sports Phys Ther 2019;49(5):337-346. doi:10.2519/jospt.2019.8616.

Despite the initial promise of metal-on-metal (MoM) implants as the ideal bearing surface for hip replacements and resurfacings, high short term failure rates due to an adverse reaction to metal debris (ARMD) have led to a dramatic reduction in the number of MoM implants used in the modern era. With over one million patients worldwide having undergone hip operations utilizing a MoM bearing surface, the long term outcomes for such patients remains unknown, and there is much debate as to the most effective management of these patients. Although several regulatory bodies have released guidelines on the management of patients with MoM hips, these recommendations remain open to interpretation, and the most effective management for these patients remains unclear. The aim of this review is to compare the current guidelines for managing patients with MoM hips and also to discuss established ARMD risk factors, evidence regarding the optimum management for patients with MoM hips, and the indications for revision surgery. Furthermore, although specialized laboratory tests and imaging can be used to facilitate clinical decision making, over-reliance on any single tool should be avoided in the decision making process, and surgeons should carefully consider all findings when determining the most appropriate course of action.

BACKGROUND: Identifying risk factors and strategies for the prevention of deep venous thromboembolism in major orthopedic surgery has allowed the development of Clinical Practice Guidelines (CPGs). Currently, there is a gap between clinical practice and the implementation of the recommendations of CPGs. The purpose of this paper is to report the impact of the implementation of improvement strategies on adherence to venous thromboembolism (VTE) prophylaxis guidelines.
METHODS: We defined 3 quality indicators to assess the adequate use of thromboprophylaxis according to CPGs. We obtained a baseline measurement and identified several barriers for adherence. Six improvement strategies to promote adherence to CPGs were designed and applied. A systematic monitoring of these indicators was performed in real time and a description of the data was completed for patients undergoing primary joint replacement of the hip, knee and shoulder, during February 2012 and August 2014.
RESULTS: Data from 773 patients were obtained. In the first trimester, the average of adherence was: 98.3% for medical order in the post-operative note, 60.3% for opportune administration and 67% for adherence to therapy at home. In the trimester, the rates of adherence were 100%, 95.7% and 100% respectively.
CONCLUSIONS: Combined strategies for improvement of adherence to VTE prophylaxis is associated with higher compliance with clinical practice guidelines.