Safe Sex After Total Hip Arthroplasty: Using Computed Tomography-Based Robotics to Evaluate "At-Risk" Sexual Positions.

BACKGROUND: Total hip arthroplasty (THA) can improve sexual satisfaction, but fear of dislocation can lead to sexual difficulties following this procedure. Previous kinematic research identified 4 sexual positions in women and 2 in men that were considered at risk for impingement. This study aimed to validate these findings using current robotic THA simulations. METHODS: The 3-dimensional renderings from 12 patients who received computed tomography (CT)-based robotic THA were used to assess for prosthetic and/or bony impingement among 12 popular sexual positions. There were 9 cup orientations tested for each position (a combination of anteversion [0 °, 15 °, and 30 °] and inclination [40 °, 45 °, and 60 °]). The at-risk positions were tested again using the unique hip positions and cup orientations where previous geometric modeling data found impingement to occur. RESULTS: Using mean hip positions, impingement occurred in at least 1 patient in 1 of the 12 positions for women (position 5) and 5 of the 12 positions for men (positions 1, 5, 8, 10, and 11). Among the at-risk positions, impingement occurred in none of the 2 at-risk women positions (0 of 17 cup orientations) and in both at-risk men positions (9 of 9 cup orientations for position 8 and 1 of 1 for position 11). CONCLUSION: Recreating popular and at-risk sexual positions following THA with a CT-based robotics system yielded results that were inconsistent with previous geometric modeling data. Resolving these discrepancies is crucial for surgeons to provide accurate postoperative patient education. The CT-based robotic systems may provide necessary input to feasibly individualize such recommendations, but current limitations in CT-based robotics require continued attention and innovation.

Learning curve for imageless robotic-assisted total knee arthroplasty in non-fellowship trained joint replacement surgeons.

Introduction: Robotic-assisted total knee arthroplasty (RA-TKA) has become increasingly popular, although an associated learning curve can be a deterrent for some surgeons. Prior studies have addressed this learning curve in fellowship-trained arthroplasty surgeons, however the learning curve among non-fellowship-trained surgeons remains unclear. The objective of this study was to investigate the learning curve for imageless RA-TKA related to operative time and rates of complications among two non-arthroplasty-trained orthopedic surgeons. Methods: This retrospective case series included 200 RA-TKA consecutive cases performed by two non-arthroplasty-trained orthopedic surgeons (100 each). Cases were divided into 2 cohorts for each surgeon: the first 50 consecutive cases and the second 50 cases. These cohorts were then compared to assess for trends in each surgeon as well as in both surgeons combined. Mean operative times were compared, as were hospital length of stay, complications, readmission, and reoperations. Results: For both surgeons, the mean operative time significantly decreased from the first 50 cases to the next 50 cases (116.5 vs 108.4 min for surgeon 1, P = 0.031; 125.7 vs 109.1 min for surgeon 2, P = 0.001). No significant differences were found among length of stay, complications, readmissions, or reoperations between cohorts. Conclusion: General orthopedic surgeons can expect to optimize operative time within 50 cases, while not carrying associated risks of related complications during the early learning period.

Comparing dislocation rates by approach following elective primary dual mobility total hip arthroplasty: a systematic review.

BACKGROUND: Dual mobility components can be implanted during total hip arthroplasty (THA) for primary osteoarthritis via a direct anterior approach (DAA), anterolateral approach (ALA), direct lateral approach (DLA), or posterior/posterolateral approach (PLA). This review compares dual mobility hip dislocation rates using these approaches for elective primary THA. METHODS: PubMed, Embase, and Cochrane databases were systematically searched for articles published after January 1, 2006 that reported dislocation rates for adult patients after primary THA with dual mobility implants. Articles were excluded if they reported revision procedures, nonelective THA for femoral neck fractures, acetabular defects requiring supplemental implants, prior surgery, or ≤ 5 patients. The primary outcome was hip dislocation rate. Secondary outcomes included infection, Harris Hip Score (HHS), and Postel-Merle d'Aubigné (PMA) score. RESULTS: After screening 542 articles, 63 met inclusion criteria. Due to study heterogeneity, we did not perform a meta-analysis. Eight studies reported DAA, 5 reported ALA, 6 reported the DLA, and 56 reported PLA. Study size ranged from 41 to 2,601 patients. Mean follow-up time ranged from 6 months to 25 years. Rates of infection and dislocation were low; 80% of ALA, 87.5% of DAA, 100% of DLA, and 82.1% of PLA studies reported zero postoperative dislocations. Studies reporting postoperative HHS and PMA scores showed considerable improvement for all approaches. CONCLUSIONS: Patients undergoing primary THA with dual mobility implants rarely experience postoperative dislocation, regardless of surgical approach. Additional studies directly comparing DAA, ALA, DLA, and PLA are needed to confirm these findings.

Single-Person Reduction of Ipsilateral Elbow, Lunate, and Scaphoid Dislocation: A Review of the Literature.

Here, we present a novel emergency department reduction for a rare case of dissociative scaphoid and lunate dislocation with an ipsilateral elbow dislocation. Dissociative scaphoid and lunate dislocations have rarely been described in the literature. Most often, the reduction is performed on an urgent basis in the operating room because of the difficulty of closed reduction and associated complications, such as acute carpal tunnel syndrome. We illustrate and describe the setup and stepwise reduction techniques of ipsilateral elbow, scaphoid, and lunate dislocations, without the use of an assistant. A review of the current literature, a description of the patient's operative management, and 2-year follow-up data are provided.

Survivability of the Femoral Neck System for the treatment of femoral neck fractures in adults.

INTRODUCTION: Hip fractures are common injuries in the elderly, with an incidence that continues to rise. The femoral neck system (FNS) recently emerged as a novel treatment option for femoral neck fractures, but long-term survivability of the implant remains uncertain. The purpose of this study is to evaluate survivability of the FNS and assess risk factors for implant failure. METHODS: One hundred five adult patients who received the FNS (DePuy Synthes, Raynham, MA) for femoral neck fractures (AO/OTA 31B) were included. Surgeries were performed within a regional hospital system comprising 18 facilities. All patients had a minimum follow-up of 1 year. The primary outcome measures were cumulative incidence of implant failure and 1-year mortality, including risk factor analysis. RESULTS: Twelve implants failed at a follow-up ranging from 17 days to 8 months, and 7 failed within 90 days. Cumulative incidence of implant failure was 2% at 30 days, 7% at 90 days, 12% at 6 months, and 13% at 1 year. Causes of implant failure included cut-out (n = 5), non-union (n = 4), peri-implant fracture (n = 2), and avascular necrosis (n = 1). Univariate Cox regression identified Pauwels type III fractures and an increasing AP Parker ratio as significant risk factors for failure. Pauwels type III fractures showed a 5.48 times higher risk compared to Pauwels types I & II. Every 10% increase in AP Parker ratio increased risk of failure by 2.39 times. The 1-year mortality rate was 21%, and univariate logistic regression identified age as the only risk factor (odds ratio = 3.71). CONCLUSIONS: The incidence of implant failure and 1-year mortality rate in this study suggests that the FNS can provide reliable fixation compared to rates in the literature, but complications are not uncommon. Avoiding Pauwels type III fractures and optimizing implant placement appear crucial to preventing implant failure. LEVEL OF EVIDENCE: Therapeutic Level IV.

Can Component Size in Total Knee Arthroplasty Be Predicted Preoperatively?-An Analysis of Patient Characteristics.

Accurately predicting component sizing in total knee arthroplasty (TKA) can ensure appropriate implants are readily available, avoiding complications from malsizing while also reducing cost by improving workflow efficiency through a reduction in instrumentation. This study investigated the utility of demographic variables to reliably predict TKA component sizes. A retrospective chart review of 337 patients undergoing primary TKA was performed. Patient characteristics (age, sex, race, height, weight) were recorded along with implant and shoe size. Correlation between shoe size and TKA component size was assessed using Pearson's correlation coefficient and linear regression analysis using three models: (A) standard demographic variables, (B) shoe size, and (C) combination of both models. Shoe size demonstrated the strongest correlation with femoral anteroposterior (FAP) (p < 0.001) followed by height (p < 0.001). Conversely, height exhibited the strongest correlation with tibial mediolateral (TML) (p < 0.001) followed by shoe size (p < 0.001). Model C was able to correctly predict both the femur and tibia within one and two sizes in 83.09 and 98.14% of cases, respectively. Individually, model C predicted the FAP within one and two sizes in 83.09 and 96.14% of cases, and the TML in 98.81 and 100% of cases, respectively. A patient's shoe size demonstrates a strong correlation to the TKA implant size, and when combined with standard demographic variables the predictive reliability is further increased. Here, we present a predictive model for implant sizing based solely on easily attainable demographic variables, that will be useful for preoperative planning to improve surgical efficiency. LEVEL OF EVIDENCE: II, Diagnostic.

Bikini Incision vs Longitudinal Incision for Anterior Total Hip Arthroplasty: A Systematic Review.

Background: Direct anterior approach total hip arthroplasty (DAA THA) traditionally involves a longitudinal incision, but a bikini incision may improve postoperative scar cosmesis and patient satisfaction while reducing wound complications. This systematic review compares the clinical outcomes and surgical complications in patients undergoing DAA THA via a bikini vs longitudinal incision. Methods: A Preferred Reporting Items for Systematic Review and Meta-Analyses-compliant search of PubMed, Cochrane, and EMBASE was performed to identify original articles comparing patients undergoing DAA THA via a bikini vs longitudinal incision published from 2010 to 2021. Patient demographic data and postoperative outcomes (scar appearance, patient satisfaction, functional hip scores, and complications) were collected and qualitatively evaluated. Results: A total of 8 double-armed studies were included, allowing comparison of clinical outcomes of a bikini incision (n = 952) vs a longitudinal incision (n = 1361). Three out of 4 (75.0%) studies comparing postoperative scar appearance and patient satisfaction reported improvements following bikini incision, while 1 study reported comparable results between incision types. Postoperative hip function was similar between incision types in 3 of 4 (75.0%) studies comparing this outcome. Lateral femoral cutaneous nerve injury was the most frequently reported complication following anterior THA, but rates were low overall, and most injuries resolved. Conclusions: Bikini incision appears to be a safe alternative to the traditional longitudinal incision, with similar functional hip outcomes and potentially improved cosmesis and patient satisfaction while reducing wound complications. Current evidence suggests an elevated risk of lateral femoral cutaneous nerve injury with bikini incision, but this needs to be confirmed in further prospective randomized studies.

Does shoulder stability differ with or without subscapularis repair after primary reverse total shoulder arthroplasty? A systematic review.

The use of reverse total shoulder arthroplasty (RTSA) has expanded from its original indication as a rotator cuff arthropathy treatment to include a large variety of pathologies. A frequently reported complication with this surgery is postoperative shoulder instability with reported incidence varying widely from 2.3 to 38%. The etiology for this instability is broad and includes prosthesis design, mechanical impingement, surgical technique, and axillary/deltoid function. A PROSPERO-registered systematic review was performed utilizing PRISMA guidelines using Cochrane, PUBMED, Embase, and Eline. Of the 1442 studies initially identified, 7 studies met all inclusion criteria, all of which were level III or IV evidence. All 7 studies evaluated postoperative instability, but no study reported a statistically significant difference in instability rates between the groups. Dislocations occurred in 5 patients (5/679, 0.7%) with subscapularis repair and 8 patients (8/527, 1.5%) without repair. A nonsignificant difference in the risk of instability for surgeries with repair compared to surgeries without repair was found (overall risk difference: 0.01, random effects 95% confidence interval: -0.00 to 0.02, P = .11). This review suggests no difference in postoperative shoulder instability rates between patients that underwent primary RTSA with or without subsequent repair of the subscapularis tendon. Interestingly, one study comparing implants with a medialized or nonlateralized implant showed a significantly increased rate of dislocation with the medialized group compared to the lateralized group. When these groups were then stratified based on subscapularis repair status, there was no increased risk with a nonrepaired tendon. This study suggests that implant design may have more influence on the stability of RTSA than subscapularis status. However, overall, there does appear to be a trend suggesting improved postoperative clinical outcomes and active range of motion for patients with a subscapularis repair vs. without a repair. Further research is needed to better elucidate the ideal combination of surgical technique and implant design to minimize postoperative glenohumeral joint instability while optimizing postoperative clinical outcomes and range of motion after primary RTSA.

Dispersal ability predicts spatial genetic structure in native mammals persisting across an urbanization gradient.

As the rate of urbanization continues to increase globally, a growing body of research is emerging that investigates how urbanization shapes the movement-and consequent gene flow-of species in cities. Of particular interest are native species that persist in cities, either as small relict populations or as larger populations of synanthropic species that thrive alongside humans in new urban environments. In this study, we used genomic sequence data (SNPs) and spatially explicit individual-based analyses to directly compare the genetic structure and patterns of gene flow in two small mammals with different dispersal abilities that occupy the same urbanized landscape to evaluate how mobility impacts genetic connectivity. We collected 215 white-footed mice (Peromyscus leucopus) and 380 big brown bats (Eptesicus fuscus) across an urban-to-rural gradient within the Providence, Rhode Island (U.S.A.) metropolitan area (population =1,600,000 people). We found that mice and bats exhibit clear differences in their spatial genetic structure that are consistent with their dispersal abilities, with urbanization having a stronger effect on Peromyscus mice. There were sharp breaks in the genetic structure of mice within the Providence urban core, as well as reduced rates of migration and an increase in inbreeding with more urbanization. In contrast, bats showed very weak genetic structuring across the entire study area, suggesting a near-panmictic gene pool likely due to the ability to disperse by flight. Genetic diversity remained stable for both species across the study region. Mice also exhibited a stronger reduction in gene flow between island and mainland populations than bats. This study represents one of the first to directly compare multiple species within the same urban-to-rural landscape gradient, an important gap to fill for urban ecology and evolution. Moreover, here we document the impacts of dispersal capacity on connectivity for native species that have persisted as the urban landscape matrix expands.

Stimulant Medication Prescribing Practices Within a VA Health Care System.

Setting clear expectations for patients and prescribers before and during prescription use and the development of a clinical practice protocol may improve patient misuse of stimulant medications.