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The selection of a regimen for venous thromboembolic prophylaxis after total joint arthroplasty is a balance between efficacy and safety. Bleeding may have a negative impact on clinical outcomes. Recently, both the American Academy of Orthopaedic Surgeons (AAOS) and the American College of Chest Physicians (ACCP) developed new evidence-based guidelines for venous thromboembolic prophylaxis after total joint arthroplasty. On the basis of a review of the available literature, the AAOS guideline panel was unable to make a recommendation with respect to the selection of a specific prophylaxis regimen or duration of prophylaxis following routine total joint arthroplasty. The ACCP panel recommended one of the following modalities as prophylaxis (rather than no prophylaxis at all) for a minimum of fourteen days: warfarin, low-molecular-weight heparin, fondaparinux, aspirin, rivaroxaban, dabigatran, apixaban, or portable mechanical compression. Both the AAOS and the ACCP guidelines recommended against screening with postoperative duplex ultrasonography at the time of discharge after routine total joint arthroplasty. There is renewed interest in the use of mechanical compression as prophylaxis with the advent of portable compression devices, which allow continuation of this type of prophylaxis after hospital discharge. Although the early data are promising, appropriately powered randomized trials are needed to determine the efficacy of the devices compared with other prophylaxis regimens.

Recent studies have reported that massive rotator cuff tears do not heal as predictably as, and may have diminished clinical outcomes compared with, smaller rotator cuff tears. An improved understanding of the biologic degeneration and the biomechanical alterations of massive rotator cuff tears should provide better strategies to optimize outcomes. The approach to patients with massive rotator cuff tears requires careful assessment of the patient and the extent of rotator cuff degeneration to determine the appropriate treatment. For a rotator cuff tear that is repairable, the goal is to produce a tension-free, anatomical repair that restores the footprint using soft tissue releases and various suturing techniques, including double-row, transosseous-equivalent suture bridges or the rip-stop stitch. For irreparable cuff tears, the surgeon may elect to proceed with 1 of 2 approaches: (1) palliative surgical treatment-that is, rotator cuff debridement, synovectomy, biceps tenotomy, tuberoplasty and/or nonanatomical repair with partial repair; or (2) salvage treatment with various tendon transfers. Even though the biomechanical constructs for rotator cuff repairs have been improved, the integrity of the repair still depends on biologic healing at the tendon-to-bone junction. There has been much interest in the development of a scaffold to bridge massive rotator cuff tears and adjuvant biologic modalities including growth factors and tenocyte-seeded scaffolds to augment tendon-to-bone healing. The treatment of rotator cuff disease has improved considerably, but massive rotator cuff tears continue to pose a challenging problem for orthopaedic surgeons.

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