Better outcomes using suture button compared to screw fixation in talofibular syndesmotic injuries of the ankle: a level I evidence-based meta-analysis.

INTRODUCTION: The present meta-analysis evaluated current level I clinical trials which compared the use of a suture button (SB) versus syndesmotic screw (SS) fixation techniques for syndesmosis injuries of the ankle. The outcomes of interest were to compare patient-reported outcome measures (PROMs) and complications. It was hypothesised that SB might achieve better PROMs along with a lower rate of complications. METHODS: This study was conducted according to the 2020 PRISMA statement. In August 2023, PubMed, Web of Science, Google Scholar, and Embase were accessed. All the randomised controlled trials (RCTs) which compared SB versus SS fixation for syndesmosis injuries of the ankle were accessed. Data concerning the American Orthopaedic Foot & Ankle Society (AOFAS), and Olerud-Molander score (OMS) were collected at baseline and at last follow-up. Data on implant failure, implant removal, and joint malreduction were also retrieved. RESULTS: Data from seven RCTs (490 patients) were collected. 33% (161 of 490) were women. The mean length of the follow-up was 30.8 ± 27.4 months. The mean age of the patients was 41.1 ± 4.1 years. Between the two groups (SB and SS), comparability was found in the mean age, and men:women ratio. The SS group evidenced lower OMS (P = 0.0006) and lower AOFAS (P = 0.03). The SS group evidenced a greater rate of implant failure (P = 0.0003), implant removal (P = 0.0005), and malreduction (P = 0.04). CONCLUSION: Suture button fixation might perform better than the syndesmotic screw fixation in syndesmotic injuries of the ankle.

Physiotherapeutic and non-conventional approaches in patients with chronic low-back pain: a level I Bayesian network meta-analysis.

Chronic low back pain (cLBP) is a major cause of disability and healthcare expenditure worldwide. Its prevalence is increasing globally from somatic and psychosocial factors. While non-pharmacological management, and in particular physiotherapy, has been recommended as a first-line treatment for cLBP, it is not clear what type of physiotherapeutic approach is the most effective in terms of pain reduction and function improvement. This analysis is rendered more difficult by the vast number of available therapies and a lack of a widely accepted classification that can effectively highlight the differences in the outcomes of different management options. This study was conducted according to the PRISMA guidelines. In January 2024, the following databases were accessed: PubMed, Web of Science, Google Scholar, and Embase. All the randomised controlled trials (RCTs) which compared the efficacy of physiotherapy programs in patients with cLBP were accessed. Studies reporting on non-specific or mechanical cLPB were included. Data concerning the Visual Analogic Scale (VAS) or numeric rating scale (NRS), Roland Morris Disability Questionnaire (RMQ) and Oswestry Disability Index (ODI). Data from 12,773 patients were collected. The mean symptom duration was 61.2 ± 51.0 months and the mean follow-up was 4.3 ± 5.9 months. The mean age was 44.5 ± 9.4 years. The mean BMI was 25.8 ± 2.9 kg/m2. The Adapted Physical Exercise group evidenced the lowest pain score, followed by Multidisciplinary and Adapted Training Exercise/Complementary Medicine. The Adapted Physical Exercise group evidenced the lowest RMQ score followed by Therapeutic Exercises and Multidisciplinary. The Multidisciplinary group evidenced the lowest ODI score, followed by Adapted Physical Exercise and Physical Agent modalities. Within the considered physiotherapeutic and non-conventional approaches to manage nonspecific and/or mechanic cLBP, adapted physical exercise, physical agent modalities, and a multidisciplinary approach might represent the most effective strategy to reduce pain and disability.

Return to Sport at Preinjury Level is Common After Surgical Treatment of SLAP Lesions: A Systematic Review and a Meta-analysis.

BACKGROUND: Patients undergoing surgery for Superior-Labrum-anterior-to-posterior (SLAP) lesions are often worried about their return to sport performance. This systematic review determined the rate of return to sport and return to sport at the previous level (RTSP) after surgery for SLAP lesion. MATERIALS AND METHODS: The PRISMA guidelines were followed. Meta-analysis of data through forest plot projections was conducted. Studies were divided and analyzed according to the type of interventions (isolated slap repair or SLAP repair with rotator cuff debridement and biceps tenodesis). RESULTS: The mean overall rate of return to sport after the procedures was 90.6% and the mean overall rate of return to sport at the previous level after the procedures was 71.7%. RTSP rates of the whole population were 71% (95% CI: 60%-80%), 66% (95% CI: 49%-79%), and 78% (95% CI: 67%-87%) for isolated SLAP repair, SLAP repair with the rotator cuff debridement and biceps tenodesis, respectively. A lack of subgroup analysis for the specific performance demand or type of lesion related to the surgical technique used might induce a high risk of bias. DISCUSSION: Return to sports at the previous level after surgically treated superior labrum anterior to posterior lesion is possible and highly frequent, with the highest rates of RTSP in patients treated with biceps tenodesis. More studies and better-designed trials are needed to enrich the evidence on indications of SLAP surgical treatment in relation to specific sports-level demand. LEVEL OF EVIDENCE: Level-IV.

TENDINopathy Severity assessment-Achilles (TENDINS-A): evaluation of reliability and validity in accordance with COSMIN recommendations.

OBJECTIVE: To evaluate the construct validity (structural validity and hypothesis testing), reliability (test-retest reliability, measurement error and internal consistency) and minimal important change (MIC) of the 13-item TENDINopathy Severity assessment-Achilles (TENDINS-A). METHODS: Participants with Achilles pain completed an online survey including: demographics, TENDINS-A, Foot and Ankle Outcome Score (FAOS) and Victorian Institute of Sport Assessment-Achilles (VISA-A). Exploratory factor analysis (EFA) assessed dimensionality. Confirmatory factor analysis (CFA) assessed structural validity (root mean square error of approximation (RMSEA); Comparative Fit Index (CFI); Tucker-Lewis Index (TLI); standardised root measure square (SRMS)). Correlations between TENDINS-A and the FAOS or VISA-A assessed hypothesis testing. Intraclass correlation (ICC) assessed test-retest reliability. Cronbach's alpha assessed internal consistency. SE of the measurement (SEM) assessed measurement error. A distribution-based approach assessed MIC. RESULTS: 79 participants (51% female) with a mean (SD) age=42.6 (13.0) years, height=175.0 (11.7) cm and body mass=82.0 (19.1) kg were included. EFA identified three meaningful factors, proposed as pain, symptoms and function. The best model identified using CFA for TENDINS-A had structural validity (RMSEA=0.101, CFI=0.959, TLI=0.947, SRMS=0.068), which included three factors (pain, symptoms and function), but excluded three items from the original TENDINS-A. TENDINS-A exhibited moderate positive correlation with FAOS (r=0.598, p<0.001) and a moderate negative correlation with VISA-A (r=-0.639, p<0.001). Reliability of the TENDINS-A was excellent (ICC=0.930; Cronbach's α=0.808; SEM=6.54 units), with an MIC of 12 units. CONCLUSIONS: Our evaluation of the revised 10-item TENDINS-A determined it has construct validity and excellent reliability, compared with the VISA-A and FAOS which lack content and construct validity. The TENDINS-A is recommended as the preferred patient-reported outcome measure to assess disability in people with Achilles tendinopathy.

Long head of biceps tendon augmentation for massive rotator cuff tears improves clinical results regardless of the number of tendons involved.

PURPOSE: Management of massive rotator cuff tears (MRCTs) remains debated, and various arthroscopic and open techniques have been described for their management. Nevertheless, the optimal strategy remains unclear. The present study evaluated the clinical results in patients managed arthroscopically for MRCTs augmented with the long head biceps tendon (LHBT) at a minimum 1-year follow-up, considering different type of tears, demographic data and number of torn tendons. METHODS: Patients treated in a secondary referral centre from January 2021 to April 2022 were enroled prospectively. Inclusion criteria were pain, inability to fully elevate the affected shoulder, irreparable tears and active and motivated patients. All patients were managed within 2 months from diagnosis in a single centre by the same surgeons. Preoperative shoulder radiographs and magnetic resonance imaging (MRI) were collected, and clinical assessment was also performed using the Numerical analogue scale (NAS), Constant score (CS) American Shoulder and Elbow Surgeons Shoulder Score (ASES). Tissue retraction and tendon fatty infiltration were evaluated using Patte and Fuchs scale, respectively. Clinical assessment was performed using the same scales at 3-6 months and 1-year follow-up. RESULTS: A total of 55 patients (31 female and 24 male) with a mean age of 60 ± 7.1 years were enroled for a mean follow-up of 18.2 ± 4.3 months. The mean preoperative NAS was 7.8 ± 0.6, CS was 20.5 ± 7.6 and ASES was 22.6 ± 9.2, increasing, respectively, to 0.3 ± 0.6, 91.5 ± 6.9 and 94.2 ± 6.7. No adverse side effects (infection, rejection, allergy) were reported during the study period. All patients were evaluated after surgery at 3 and 6 months and 1 year with statistically significant improvement for each score at the first and last follow-up (p < 0.05). CONCLUSIONS: The use of LHBT augmentation in patients with MRCTs in appropriately selected patients is safe and effective and can lead to pain relief and acceptable clinical outcomes. Furthermore, its use carries low donor site morbidity and is cost effective. Comparative studies, including randomised controlled trials, with other proposed techniques are needed to confirm these findings. LEVEL OF EVIDENCE: Level IV.

Predictors of success of pharmacological management in patients with chronic lower back pain: systematic review.

BACKGROUND: Conservative management is recommended as the first therapeutic step in chronic low back pain (LBP), but there is no available evidence regarding the possible effect of patients' baseline characteristics on the therapeutic outcomes. A systematic review of the literature was performed to investigate this point. METHODS: In February 2024, all the level I studies investigating the role of pharmacological management for chronic LBP were accessed. Data concerning the patient demographic at baseline were collected: number of patients and related mean BMI and age, duration of the symptoms, duration of the follow-up, percentage of females, Numeric Rating Scale (NRS), the Roland Morris Disability Questionnaire (RMQ), Oswestry Disability Index (ODI). The outcomes at the last follow-up were evaluated through NRS, RMQ, and ODI. A multiple linear model regression diagnostic through the Pearson Product-Moment Correlation Coefficient (r) was used. RESULTS: Data from 47 articles (9007 patients) were obtained. The analysis yielded the following significant associations: age at baseline and NRS at follow-up (r = - 0.22; P = 0.04), NRS at baseline with NRS (r = 0.26; P = 0.03) and RMQ (r = - 0.58; P = 0.02) at follow-up, RMQ at baseline and the same at follow-up (r = 0.69; P = 0.0001). CONCLUSION: Older age, higher BMI, presence of comorbidities, higher ODI and a long history of symptoms or surgical treatments do not reduce the efficacy of pharmacological management of chronic LBP. However, pharmacological therapy is not an effective option for patients with high baseline RMQ. LEVEL OF EVIDENCE: I systematic review of RCTs.

EFAS Score - Validation of Danish Version by the Score Committee of the European Foot and Ankle Society (EFAS).

BACKGROUND: The Score Committee of the European Foot and Ankle Society (EFAS) developed, validated, and published the EFAS Score in 13 languages. Currently, the Danish version completed data acquisition and underwent further validation. METHODS: The data were collected pre-operatively and post-operatively at a minimum follow-up of 3 months and mean follow-up of 6 months. Item reduction, scale exploration, confirmatory analyses and responsiveness were executed using classical test theory and item response theory. RESULTS: The internal consistency was confirmed in the Danish version (Cronbach's Alpha 0.88). The Standard Error of Measurement (SEM) was 0.31 and is similar to other language versions. Between baseline and follow-up, 77.2% of patients showed an improvement on their EFAS score, with adequate responsiveness (effect size 1.05). CONCLUSIONS: The Danish EFAS Score version was successfully validated in patients with a wide variety of foot and ankle pathologies. All score versions are freely available at www.efas.net.

Management of rotator cuff injuries using allogenic platelet-rich plasma.

Rotator cuff injuries are a major cause of shoulder pain, affecting the quality of life and producing a significant burden on healthcare systems. Conservative management modalities are prioritized, resorting to surgery only when required. The field of regenerative medicine involving the use of biologics, such as platelet-rich plasma (PRP), has evolved and shown potential for managing rotator cuff injuries. Nonetheless, limitations including subpar outcomes have led clinicians to question the efficacy of autologous PRP. To circumvent this, the possibility of utilizing a standardized and well-characterized allogenic PRP for RCI has been explored. In this manuscript, we qualitatively present the evidence from in vitro, pre-clinical, clinical and ongoing studies investigating the applications of allogenic PRP in the context of rotator cuff disorders. Administration of allogenic PRP is safe and potentially efficacious to manage rotator cuff injuries, though more adequately powered randomized controlled trials with longer follow-ups are warranted to further establish the efficacy of allogenic PRP and justify its routine clinical use.

Functional alignment in robotic-assisted total knee arthroplasty: a systematic review.

PURPOSE: The present study systematically reviewed current evidence on functional alignment (FA) in robotic total knee arthroplasty (TKA), discussing advantages and limitations, possible pitfalls, and prospects. METHODS: This study was conducted according to the 2020 PRISMA statement. In August 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar, and Embase with no additional filters or time constraints. All the clinical studies investigating functional alignment in robotic TKA were accessed. Only studies published in peer-reviewed journals were considered. The risk of bias was evaluated following the guidelines in the Cochrane Handbook for Systematic Reviews of Interventions. Non-randomized controlled trials (non-RCTs) were evaluated using the Risk of Bias in Nonrandomised Studies of Interventions (NRSI) (ROBINS-I) tool. RESULTS: Data from 1198 patients (seven studies) were retrieved. The mean length of the follow-up was 17.1 ± 6.4 months. The mean age was 67.2 ± 5.4 years, and the mean BMI was 30.9 ± 2.7 kg/m2. CONCLUSION: FA might improve resection accuracy, implant alignment, and gap balancing in TKA, and additional high-quality clinical trials are necessary to properly establish the superiority of FA to other alignment techniques in TKA. Long-term clinical trials are needed to investigate the impact of FA on implant survivorship. LEVEL OF EVIDENCE: Level IV, systematic review and meta-analysis.

The pandemic is gone but its consequences are here to stay: avascular necrosis following corticosteroids administration for severe COVID-19.

BACKGROUND: In patients with COVID-19 infection and respiratory insufficiency, corticosteroid (CCS) administration is recommended. Among the wide range of complications and interactions, time-limited high-dose CCS administration might promote avascular necrosis (AVN) in a cumulative dose. This systematic review updated the current evidence and characterises the trend of AVN following time-limited high-dose CCS administration in patients who had severe COVID-19, discussing management strategies and outcomes. METHODS: This systematic review was conducted according to the 2020 PRISMA statement. In October 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar, and Scopus restricting the search to the years 2019 to 2023. All the clinical studies which investigated the association between time-limited high-dose CCS administration in patients with severe COVID-19 infection and AVN were accessed. RESULTS: A total of 245 patients (9 studies) who experienced AVN following COVID-19 were included in the present investigation. 26% (63 of 245 included patients) were women. The mean age of the patients was 42.9 ± 17.7 years. Four studies focused on AVN of the hip and two on the knee, and the other studies included patients with AVN from mixed areas of the body (spine, pelvis, and shoulder). The mean time elapsed from COVID-19 infection to the development of symptomatic AVN was 79.4 ± 59.2 days (range, 14 to 166 days). CONCLUSION: It is possible that even time-limited high-dose CCS administration in patients with severe COVID-19 infection increased the incidence of AVN. The mean time elapsed from COVID-19 infection to the development of symptomatic AVN was approximately 80 days. Given the high risk of bias in all the included studies, the quality of recommendations of the present investigation is low, and no reliable conclusion can be inferred.

Diagnosis and management of Achilles tendon ailments: the Scottish mist.

The diagnosis and management of Achilles tendon ailments continue to be widely discussed by the scientific community. Also, the nomenclature used to describe the tendinopathic lesion in patients changed over the last decades together with the evolution in the knowledge of the physiopathology of Achilles tendinopathy, and unfortunately, through ignorance and possibly laziness, confusion still abounds. To emerge from these foggy paths, some clarifications are still necessary. The present Editorial tries to clarify some of these issues.

Surgical management of chronic Achilles tendon rupture: evidence-based guidelines.

BACKGROUND: Chronic Achilles tendon ruptures (CATR) often require surgical intervention to restore function. Despite numerous treatment modalities available, the optimal management strategy remains controversial given the limited high-quality evidence available. This article aims to provide evidence-based guidelines for the surgical management of CATR through a comprehensive systematic review of the available data. The consensus reached by synthesizing the findings will assist clinicians in making informed decisions and improving patient outcomes. METHODS: A group of 9 foot surgeons in three continents was consulted to gather their expertise on guidelines regarding the surgical management of CATR. Following the proposal of 9 clinical topics, a thorough and comprehensive search of relevant literature published since 1980 was conducted for each topic using electronic databases, including PubMed, MEDLINE, and Cochrane Library, to identify relevant studies published until 1 October 2023. All authors collaborated in drafting, discussing, and finalizing the recommendations and statements. The recommendations were then categorized into two grades: grade a (strong) and grade b (weak), following the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) concept. Additionally, feedback from 21 external specialists, who were independent from the authors, was taken into account to further refine and finalize the clinical guidelines. RESULTS: Nine statements and guidelines were completed regarding surgical indications, surgical strategies, and postoperative rehabilitation protocol. CONCLUSION: Based on the findings of the systematic review, this guideline provides recommendations for the surgical management of CATR. We are confident that this guideline will serve as a valuable resource for physicians when making decisions regarding the surgical treatment of patients with CATR.

Endoscopic peroneus brevis tendon transfer for chronic ruptures of the Achilles tendon: surgical technique.

Chronic Achilles tendon rupture is usually defined as a rupture diagnosed 4-6 weeks after injury. The management of chronic Achilles tendon rupture (CATR) is a topic of hot debate, and no consensus has been achieved. Surgical management of CATR is recommended. Several approaches, techniques, and grafts have been described. Open techniques carry a high risk of wound breakdown, infection, and necessitate long rehabilitation times. Surgical techniques with smaller incisions to reduce the risk of scar fibrosis, pain, and infection are becoming common. The ipsilateral tendon of the hallux flexor longus and the peroneus brevis is commonly used. Endoscopic transfer of the peroneus brevis tendon is an innovative alternative to other procedures, with comparable results of other autografts even in elite athletes. The tendon of the peroneus brevis is harvested by tendoscopy before performing a calcaneal tendon endoscopy and fixing the graft in a calcaneal tunnel using an interference screw. After surgery, an anterior splint is placed for 3 weeks with immediate forefoot weight bearing. The rehabilitation starts on the 15th postoperative day.

Rotator cuff tears.

Rotator cuff tears are the most common upper extremity condition seen by primary care and orthopaedic surgeons, with a spectrum ranging from tendinopathy to full-thickness tears with arthritic change. Some tears are traumatic, but most rotator cuff problems are degenerative. Not all tears are symptomatic and not all progress, and many patients in whom tears become more extensive do not experience symptom worsening. Hence, a standard algorithm for managing patients is challenging. The pathophysiology of rotator cuff tears is complex and encompasses an interplay between the tendon, bone and muscle. Rotator cuff tears begin as degenerative changes within the tendon, with matrix disorganization and inflammatory changes. Subsequently, tears progress to partial-thickness and then full-thickness tears. Muscle quality, as evidenced by the overall size of the muscle and intramuscular fatty infiltration, also influences symptoms, tear progression and the outcomes of surgery. Treatment depends primarily on symptoms, with non-operative management sufficient for most patients with rotator cuff problems. Modern arthroscopic repair techniques have improved recovery, but outcomes are still limited by a lack of understanding of how to improve tendon to bone healing in many patients.

All-epiphyseal anterior cruciate ligament reconstruction yields superior sports performances than the trans-epiphyseal technique in skeletally immature patients: a systematic review.

BACKGROUND: Anterior cruciate ligament (ACL) tears in skeletally immature patients are increasingly common. Evidence comparing the outcomes of all-epiphyseal versus trans-epiphyseal ACL reconstruction in skeletally immature patients is limited, and the current literature could benefit from a comprehensive systematic review. The present study compared all-epiphyseal versus trans-epiphyseal ACL reconstruction in skeletally immature patients. The outcomes of interest were to compare joint laxity, patient-reported outcome measures (PROMs), return to sport, and complications. METHODS: This study was conducted according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. In November 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar, and Embase. No additional filters were used in the database search. All the clinical studies investigating ACL reconstruction in skeletally immature patients were accessed. Only articles that clearly stated the surgical technique (all- or trans-epiphyseal) were eligible. Only articles with a minimum of 6 months of follow-up were included. Only articles that clearly stated that surgeries were conducted in children with open physis were eligible. RESULTS: Data from 1489 patients (1493 procedures) were collected, of which 32% (490 of 1489 patients) were female. The mean length of follow-up was 46.6 months. The mean age of the patients was 12.7 years. No difference was found in joint laxity (Table 3): positive pivot shift (P = 0.4), positive Lachman test (P = 0.3), and mean arthrometer laxity (P = 0.1). No difference was found in PROMs (Table 4): International Knee Documentation Committee (IKDC) (P = 0.3), Lysholm (P = 0.4), and Tegner (P = 0.7). The trans-epiphyseal technique was associated with a greater rate of patients unable to return to sports (1% versus 7%, P = 0.0001) and with a longer time to return to sports (7.7 versus 8.6 months, P = 0.01). Though the trans-epiphyseal technique was associated with a lower rate of return to sport, this difference was not statistically significant (P = 0.8). No difference was evidenced in the rate of patients who had reduced their league or level of sports activity (P = 0.6) or in the rate of patients who had returned to their previous league or level of sports activity (P = 0.7). No difference was found in the rate of complication: re-tear (P = 0.8), reoperation (P = 0.7), increased laxity (P = 0.9), and persistent instability sensation (P = 0.3). CONCLUSION: Trans-epiphyseal ACL reconstruction was associated with a greater rate of patients unable to return to sport and with a longer time to return to sport compared with the all-epiphyseal technique in skeletally immature patients. Level of evidence Level III, systematic review.

Anterior cruciate ligament reconstruction in skeletally immature patients is effective: A systematic review.

PURPOSE: The present study evaluated the outcomes of anterior cruciate ligament (ACL) reconstruction in children with open physes. The outcomes of interest were to compare the increase in joint laxity and PROMs from baseline to the last follow-up, the rate and features of the return to sport and the rate of complications. METHODS: This study was conducted according to the 2020 PRISMA guidelines. In October 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar and Embase. All the clinical studies investigating ACL reconstruction in skeletally immature patients were accessed. Only articles which clearly stated that surgeries were conducted in children with open physis were eligible. RESULTS: Data from 53 studies (1691 procedures) were collected. 35% (597 out of 1691 patients) were women. The mean length of the follow-up was 44.7 ± 31.3 months. The mean age of the patients was 12.7 ± 1.1 years old. All PROMs significantly improved from the baseline values to those at the last follow-up. The mean time to return to sport was 8.3 ± 1.9 months. 89% (690 out of 771 patients) returned to sports, 15% (109 out of 721 patients) reduced their level of sports activity or league, and 84% (651 out of 771 patients) returned to their previous level of sport. 9% (112 out of 1213) of patients experienced re-tear of the reconstructed ACL, and 11% (75 out of 660) of patients underwent a further ACL reoperation. No patients (0 out of 83) demonstrated increased laxity at the last follow-up, and persistent sensation of instability was reported by 5% (11 out of 235) of patients. CONCLUSION: ACL reconstruction in skeletally immature patients is effective and safe, and is associated with fast recovery and a high rate of return to sport. LEVEL OF EVIDENCE: Level IV.

Antithrombotic prophylaxis following total hip arthroplasty: a level I Bayesian network meta-analysis.

BACKGROUND: Several clinical investigations have compared different pharmacologic agents for the prophylaxis of venous thromboembolism (VTE). However, no consensus has been reached. The present investigation compared enoxaparin, fondaparinux, aspirin and non-vitamin K antagonist oral anticoagulants (NOACs) commonly used as prophylaxis following total hip arthroplasty (THA). A Bayesian network meta-analysis was performed, setting as outcomes of interest the rate of deep venous thrombosis (DVT), pulmonary embolism (PE) and major and minor haemorrhages. METHODS: This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension statement for reporting systematic reviews incorporating network meta-analyses of healthcare interventions. All randomised controlled trials (RCTs) comparing two or more drugs used for the prophylaxis of VTE following THA were accessed. PubMed, Web of Science and Google Scholar databases were accessed in March 2023 with no time constraint. RESULTS: Data from 31,705 patients were extracted. Of these, 62% (19,824) were women, with age, sex ratio, and body mass index (BMI) being comparable at baseline. Apixaban 5 mg, fondaparinux, and rivaroxaban 60 mg were the most effective in reducing the rate of DVT. Dabigatran 220 mg, apixaban 5 mg, and aspirin 100 mg were the most effective in reducing the rate of PE. Apixaban 5 mg, ximelagatran 2 mg and aspirin 100 mg were associated with the lowest rate of major haemorrhages, while rivaroxaban 2.5 mg, apixaban 5 mg and enoxaparin 40 mg were associated with the lowest rate of minor haemorrhages. CONCLUSION: Administration of apixaban 5 mg demonstrated the best balance between VTE prevention and haemorrhage control following THA. Level of evidence Level I, network meta-analysis of RCTs.