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See also: Clinical Features and Management of Congenital Fibrinogen Deficiencies Semin Thromb Hemost 2016; 42(04): 366-374 DOI: 10.1055/s-0036-1571339 Casini A, de Moerloose P, Neerman-Arbez M. Clinical features and management of congenital fibrinogen deficiencies. Semin Thromb Hemost 2016;42(4):366–374 We read with great interest the article by Casini et al[ 1 ] describing clinical features and management of congenital fibrinogen deficiencies, which was published along with other interesting articles related to such disorders in a recent issue of Seminars in Thrombosis & Hemostasis .[ 2 ] We therefore wish to report the only case of congenital afibrinogenemia in Slovakia with a successful perioperative management of hemostasis during revision total hip arthroplasty. Congenital afibrinogenemia is an autosomal recessive bleeding disorder that refers to the total absence of fibrinogen, as measured by an antigenic assay.[ 1 ] This disorder is caused by variations in the FGA , FGB , and FGG genes, which encode the fibrinogen Aα, Bβ, and γ chains, respectively. Afibrinogenemia is associated with homozygous or compound heterozygous mutations, and hypofibrinogenemia is usually linked with heterozygous mutations.[ 3 ] [ 4 ] The estimated prevalence of afibrinogenemia is around 1 in 1,000,000,[ 4 ] although in Slovakia we estimate it to be 1 in 5,000,000.[ 5 ] The commonest manifestation of the disease is bleeding from mucosal surfaces; however, musculoskeletal bleeding, gynecologic and obstetric complications, spontaneous bleeding, bleeding after minor trauma and during interventional procedures, or thromboembolic episodes have also been reported.[ 6 ] Absence of immunoreactive fibrinogen is essential for the diagnosis of congenital afibrinogenemia. All coagulation tests that depend on the formation of fibrin as the end point, that is, prothrombin time (PT), activated partial thromboplastin time (aPTT), or thrombin time (TT), are infinitely prolonged.[ 1 ] [ 4 ] Fibrinogen replacement therapy, particularly the most widely used plasma-derived fibrinogen concentrate, is considered as the treatment of choice in spontaneous bleeding episodes and as prophylaxis before surgical procedures or against spontaneous bleeding in patients with congenital and acquired fibrinogen deficiency.[ 1 ] [ 7 ] We herein report the successful perioperative management of hemostasis during revision total hip arthroplasty in a 26-year-old man we have previously reported with congenital afibrinogenemia and a homozygous point mutation in exon 4 (Gln180Stop) of FGB gene.[ 8 ] Early after birth, the patient experienced umbilical cord bleeding and development of epidural hematoma and hygroma in the occipital region with the need of neurosurgical evacuation. In the patient's history, there were many further bleeding episodes, including repeated hemorrhage into joints, muscles, mucocutaneous bleeding, and bleeding into soft tissues. This patient was managed with prophylactic intravenous administration of fibrinogen concentrate at the dose of 2 g once a month from the age of 15 years.[ 5 ] Since then, he had significant reduction in the intensity and frequency of spontaneous bleeding. The patient developed coxitis, or inflammation of the hip, in August 2002 due to microbleeds into the joint capsule. Coxitis was one of the most devastating complications of the patient's disease, and the implantation of a total hip endoprosthesis appeared the only possible treatment option. This was performed in the patient at age 15 years. One day before surgery, laboratory screening indicated grossly prolonged results for PT, aPTT, and TT (all of them > 300 s). Platelet count (230 × 10 9 /L) and hemoglobin (151 g/L) were in the normal range; however, fibrinogen according to the Clauss procedure was undetectable. Owing to the rarity of afibrinogenemia, little is known about the optimal perioperative management of patients with this disease, including the pharmacokinetics of fibrinogen concentrate.[ 9 ] In a survey conducted by Bornikova et al, the authors noted that for patients in surgical cases with satisfactory hemostasis, a plasma fibrinogen level ranging from 100 to 200 mg/dL was achieved at the time of surgery.[ 7 ] Preoperatively, the patient received fibrinogen concentrate (Haemocomplettan P, CSL Behring, Marburg, Germany) in the dose of 75 mg/kg (6 g of fibrinogen concentrate, weight of the patient 80 kg). This dose increased the patient's level of fibrinogen after 2 hours to a rate corresponding to 170 mg/dL. Intravenous administration of fibrinogen concentrate also led to a rapid change of previously unmeasurable PT, TT, and aPTT values to detectable values. These data were similar to those reported by Négrier et al.[ 10 ] Thus, as demonstrated here and previously, patients can successfully be treated with a wide range of target fibrinogen levels and duration of treatment. This decision may be influenced by the severity of the deficiency and the invasiveness of the surgical procedure. The surgery itself lasted 3 hours under general anesthesia. During surgery, the patient received fibrinogen concentrate in the dose of 25 mg/kg. The estimated blood loss was 800 mL. The patient was given an intraoperative transfusion 499 mL (2U) of packed red blood cells and 380 mL of auto transfusion. Immediately after surgery, the level of fibrinogen achieved was 110 mg/dL. X-ray showed acceptable positioning and alignment of the implants ([ Fig. 1 ]). Postoperatively, the patient's fibrinogen levels were checked twice a day. Fig. 1 Postoperative X-ray after the revision total hip. Twenty-four hours after surgery, fibrinogen concentrate was given to the patient at the dose of 37.5 mg/kg every 8 hours. The level of plasma fibrinogen was maintained above 130 mg/dL. One day after surgery, fibrinogen concentrate was administered at the dose of 37.5 mg/kg every 12 hours with a targeted level of fibrinogen in the range of 130 to 150 mg/dL. Two days after surgery, the fibrinogen concentrate administration was reduced to a dose of 25 mg/kg every 12 hours. This dose was given during the next 5 days. In this period, the fibrinogen activity was retained in the range of 170 to 210 mg/dL. On the sixth and seventh day after surgery, the reduced dose of fibrinogen concentrate was continued at 12.5 mg/kg every 24hours. During these days, the level of fibrinogen ranged as high as 120 to 140 mg/dL. Between 8th and 12th day after surgery, we administered the fibrinogen concentrate at the dose of 12.5 mg/kg once every 48 hours. As the surgery required thorough hematological management, there was a need to ensure fine adjustment of the balance between the administration of fibrinogen concentrate and thromboprophylaxis. Accordingly, after surgery, the administration of fibrinogen concentrate was combined with low-molecular-weight heparin (nadroparin) at the dose of 0.3 mL (2,850 IU) daily. Immediately after surgery, there were no signs or symptoms of excessive bleeding. The patient was discharged safely at the 12th day after surgery with a level of plasma fibrinogen above 50 mg/dL ([ Fig. 2 ]). Fig. 2 The levels of fibrinogen measured preoperatively, intraoperatively, and postoperatively together with fibrinogen replacement therapy. Regular orthopedic checks once a year were recommended. Unfortunately, 10 years later, from March 2014, the patient started to limp with a frequent and gradually disabling pain localized in the left hip. Control X-ray examination showed protrusion of the femoral head with the thinning of the inlay 4 to 5 mm and incipient osteolytic lesions below the acetabulum with the necessity of surgical revision ([ Fig. 3 ]). Fig. 3 Decentration of the femoral head and incipient osteolytic lesions below the acetabulum. The management of thrombotic complications in patients with afibrinogenemia is problematic because of their bleeding tendency. Some authors recommend use of compression stockings and low-molecular-weight heparin in patients with a history of thrombosis who are undergoing surgery.[ 11 ] In patients who develop thrombotic complications following replacement therapy, some authors continue the latter if indicated and co-administer low-molecular-weight or unfractionated heparin. Our patient and members of the family have not experienced any thrombotic episodes. Furthermore, screening tests for thrombophilic mutations in the family have been negative. Therefore, thromboprophylaxis was applied at the dose of 0.3 mL daily only during hospitalization. Our patient has otherwise been managed with prophylactic administration of fibrinogen concentrate at the dose of 25 mg/kg once a month from the age of 15 years before surgery.[ 5 ] We managed the patient during intensive rehabilitation with prophylactic dose fibrinogen concentrate once a week within 2 months after surgery. At present, the patient is given a prophylactic dose of 25 mg/kg of fibrinogen concentrate once every 2 weeks and he is without any bleeding or thrombotic complications. In conclusion, our results in this patient with congenital afibrinogenemia who underwent the successful repeated total left hip arthroplasty reaffirm the recommendation to tailor treatment to ensure a hemostasis balance between the replacement of clotting factor (fibrinogen concentrate) and thromboprophylaxis.

The Journal of Bone and Joint Surgery. British volumeVol. 36-B, No. 3 Clinical Reviews and StudiesFree AccessAPPROACH TO THE HIPA Suggested Improvement on Kocher's MethodBryan McFarland, Geoffrey OsborneBryan McFarlandSearch for more papers by this author, Geoffrey OsborneSearch for more papers by this authorPublished Online:1 Aug 1954https://doi.org/10.1302/0301-620X.36B3.364AboutSectionsPDF/EPUB ToolsAdd to FavouritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetailsCited byAnterolateral minimally invasive hip approach offered faster rehabilitation with lower complication rates compared to the minimally invasive posterior hip approach—a University clinic case control study of 120 cases2 January 2021 | Archives of Orthopaedic and Trauma Surgery, Vol. 142, No. 5The Idea of “Minimally Invasive Solution” Total Hip Arthroplasty: History and Perspective Behind the Modernization of Surgery Through the Watson-Jones Muscle Interval27 July 2022Lateraler transglutealer Zugang – Goldstandard oder aus der Mode gekommen?3 February 2021 | Orthopädie und Unfallchirurgie up2date, Vol. 16, No. 01Hip Arthroplasty18 December 2020Approaches for Total Hip Arthroplasty21 November 2021Supercapsular Percutaneously Assisted total hip arthroplasty versus lateral approach in Total Hip Replacement. A prospective comparative studyJournal of Orthopaedics, Vol. 21Surgical Approaches for Primary Total Hip Arthroplasty from Charnley to Now1 January 2020 | JBJS Reviews, Vol. 8, No. 1Muscle Damage in Different Approaches in Total Hip Arthroplasty According to Serum MarkersThe Open Orthopaedics Journal, Vol. 13, No. 1Anatomy and Physiology of the Pediatric Hip29 June 2019Surgical approaches for primary total hip replacementOrthopaedics and Trauma, Vol. 32, No. 1Nonunion of greater trochanter following total hip arthroplasty: Treated by an articulated hook plate and bone graftingIndian Journal of Orthopaedics, Vol. 51, No. 3Surgical approaches for total hip arthroplastyIndian Journal of Orthopaedics, Vol. 51, No. 4Abductor Muscle Function and Trochanteric Tenderness After Hemiarthroplasty for Femoral Neck FractureJournal of Orthopaedic Trauma, Vol. 30, No. 6Exposure of the Hip Joint12 March 2016Surgical approaches to the hip jointOrthopaedics and Trauma, Vol. 29, No. 6Revision total hip arthroplasty exposure considerations: Which way in?Seminars in Arthroplasty, Vol. 26, No. 3A Modified Anterolateral, Less Invasive Approach to the Hip: Surgical Technique and Preliminary Results of First 103 Cases29 November 2013Hip Dislocation and Femoral Head Fractures22 April 2014Exposure of the Hip - Trochanteric Osteotomy, Re-Attachment and Results22 April 2014Hip: Type of Prosthesis and Implantation TechniqueA modified direct lateral approach for neck-preserving total hip arthroplasty: tips and technical notes8 March 2013 | Journal of Orthopaedics and Traumatology, Vol. 14, No. 2Surgical Techniques and ApproachesPrimary total hip arthroplasty23 July 2013The Rottinger approach for total hip arthroplasty: technique and review of the literature9 August 2011 | Current Reviews in Musculoskeletal Medicine, Vol. 4, No. 3Repair of Gluteus Medius Muscle Avulsion following Transgluteal Hip Replacement6 June 2011 | HIP International, Vol. 21, No. 3Surgical approaches for total hip arthroplastyOrthopaedics and Trauma, Vol. 24, No. 6Late Repair of Abductor Avulsion After the Transgluteal Approach for Hip ArthroplastyThe Journal of Arthroplasty, Vol. 25, No. 3Hip Abductor Strengths After Total Hip Arthroplasty Via the Lateral and Posterolateral ApproachesThe Journal of Arthroplasty, Vol. 25, No. 1Two-stage revision arthroplasty of the hip for infection using an interim articulated Prostalac hip spacerA 10- TO 15-YEAR FOLLOW-UP STUDYG. S. Biring, T. Kostamo, D. S. Garbuz, B. A. Masri, C. P. Duncan1 November 2009 | The Journal of Bone and Joint Surgery. British volume, Vol. 91-B, No. 11Results of Surgical Repair of Abductor Avulsion After Primary Total Hip ArthroplastyThe Journal of Arthroplasty, Vol. 23, No. 5The safe distance for the superior gluteal nerve in direct lateral approach to the hip and its relation with the femoral length: a cadaver study9 October 2007 | Archives of Orthopaedic and Trauma Surgery, Vol. 128, No. 7Effects of the Lateral Approach on Blood Flow of the Gluteus Medius and Abductor Function in Total Hip ArthroplastyOrthopedics, Vol. 31, No. 6Objective functional assessment of total hip arthroplasty following two common surgical approaches: The posterior and direct lateral approaches10 September 2008 | Proceedings of the Institution of Mechanical Engineers, Part H: Journal of Engineering in Medicine, Vol. 222, No. 6Surgical Techniques and ApproachesDirect Lateral ExposureLong-term survival of a cemented titanium-aluminium-vanadium alloy straight-stem femoral componentS. Kovac, R. Trebse, I. Milosev, V. Pavlovcic, V. Pisot1 December 2006 | The Journal of Bone and Joint Surgery. British volume, Vol. 88-B, No. 12Anterior or Posterior: Does the Surgical Approach to the Hip Influence the Quality of the Femoral Cement Mantle?24 January 2018 | HIP International, Vol. 16, No. 2Poor results from the isoelastic total hip replacement8 July 2009 | Acta Orthopaedica, Vol. 76, No. 2Mini-incision Anterior Approach Does Not Increase Dislocation RateClinical Orthopaedics and Related Research, Vol. 426An Extensile Posterior Exposure for Primary and Revision Hip ArthroplastyVariations in the anterolateral approach to the hip24 January 2018 | HIP International, Vol. 13, No. 4Surgical Approach, Abductor Function, and Total Hip Arthroplasty DislocationClinical Orthopaedics and Related Research, Vol. 405Early dislocation after total hip arthroplastyThe Journal of Arthroplasty, Vol. 17, No. 8A Proximal Referencing System for the Charnley Low Friction Arthroplasty26 January 2018 | HIP International, Vol. 12, No. 3A Modified Direct Lateral Approach in Total Hip Arthroplasty4 December 2016 | Journal of Orthopaedic Surgery, Vol. 10, No. 1Instability in Primary Total Hip Arthroplasty With the Direct Lateral ApproachClinical Orthopaedics and Related Research, Vol. 393Intraoperative electromyography of the superior gluteal nerve during lateral approach to the hip for arthroplastyThe Journal of Arthroplasty, Vol. 15, No. 7The Direct Lateral and Vastus Slide ApproachThe Anterolateral Surgical ApproachConversion of Girdlestone Arthroplasty to Total Hip ReplacementA modified direct lateral approach in total hip arthroplasty A comprehensive reviewThe Journal of Arthroplasty, Vol. 13, No. 7Surgical Approaches in Revision Hip ReplacementJournal of the American Academy of Orthopaedic Surgeons, Vol. 6, No. 2Update on Nerve Palsy Associated With Total Hip ReplacementClinical Orthopaedics and Related Research, Vol. 344Anatomic basis of the transgluteal approach to the hip-joint by anterior hemimyotomy of the gluteus mediusSurgical and Radiologic Anatomy, Vol. 19, No. 2An anterolateral approach to the hip joint8 July 2009 | Acta Orthopaedica Scandinavica, Vol. 68, No. 5Nerve injury after hip arthroplasty: 5/600 cases after uncemented hip replacement, anterolateral approach versus direct lateral approach8 July 2009 | Acta Orthopaedica Scandinavica, Vol. 68, No. 6A new classification for heterotopic ossifications in total hip arthroplasty considering the surgical approachArchives of Orthopaedic and Trauma Surgery, Vol. 115, No. 6Muscular Activity and the Biomechanics of the Hip10 May 2019 | HIP International, Vol. 6, No. 3A modified direct lateral approach for primary and revision total hip arthroplastyThe Journal of Arthroplasty, Vol. 11, No. 3Significance of the Trendelenburg test in total hip arthroplastyThe Journal of Arthroplasty, Vol. 11, No. 2A clinical and radiographic study of the “safe area” using the direct lateral approach for total hip arthroplastyThe Journal of Arthroplasty, Vol. 9, No. 5The surgical anatomy of the superior gluteal nerve and anatomical radiologic bases of the direct lateral approach to the hipSurgical and Radiologic Anatomy, Vol. 16, No. 3Heterotopic ossification in total hip arthroplastyThe Journal of Arthroplasty, Vol. 9, No. 2Muscle strength following total hip arthroplastyThe Journal of Arthroplasty, Vol. 8, No. 6The transgluteal approaches to the hipArchives of Orthopaedic and Trauma Surgery, Vol. 111, No. 4Exposure of the hip using a modified anterolateral approachThe Journal of Arthroplasty, Vol. 6, No. 2Integrity of the gluteus medius after the transgluteal approach in total hip arthroplastyThe Journal of Arthroplasty, Vol. 5, No. 1Clinical experience with a triradiate exposure of the hip for difficult total hip arthroplastyThe Journal of Arthroplasty, Vol. 3, No. 3Comparison of functional outcome of total hip arthroplasties involving four surgical approachesThe Journal of Arthroplasty, Vol. 3, No. 3Anatomic basis of the transgluteal approach to the hipSurgical and Radiologic Anatomy, Vol. 9, No. 1The Direct Lateral Approach to the Hip for Arthroplasty: Advantages and ComplicationsOrthopedics, Vol. 10, No. 2The history of surgical access for hip replacementCurrent Orthopaedics, Vol. 1, No. 1Trans-gluteal approach for hemiarthroplasty of the hipArchives of Orthopaedic and Traumatic Surgery, Vol. 104, No. 2Surgical Approaches to the HipLong-Term Results of Rotator Cuff RepairThe Transgluteal Approach to the Hip JointArchives of Orthopaedic and Traumatic Surgery, Vol. 95, No. 1-2The transacromial approach to the shoulder for ruptures of the rotator cuffInternational Orthopaedics, Vol. 1, No. 2Para-Articular Ossification Following Hip Replacement: 70 Arthroplasties AD Modum Moore Using McFarland's Approach8 July 2009 | Acta Orthopaedica Scandinavica, Vol. 48, No. 4The Surgical Approach for Total Hip ReplacementSurgical Clinics of North America, Vol. 53, No. 2Surgical ApproachesAn Exposition of Uncertain Reasoning Based AnalysisLate Complications of the Use of Endoprosthetic Devices in Surgery of the Hip JointSurgical Clinics of North America, Vol. 41, No. 6INVETERATE DISLOCATION OF THE HIPThe Lancet, Vol. 277, No. 7177Erfahrungen mit Kunstharz- und Cupplastiken am H�ftgelenkArchiv f�r Orthop�dische und Unfall-Chirurgie, Vol. 50, No. 5 Vol. 36-B, No. 3 Metrics History Published online 1 August 1954 Published in print 1 August 1954 InformationCopyright © 1954, The British Editorial Society of Bone and Joint Surgery: All rights reservedPDF download

BACKGROUND: Total hip replacement performed through a small incision theoretically results in less trauma to the underlying structures, reduced blood loss, less pain, and a shorter hospital stay, but it may result in increased complications, particularly early in a surgeon's experience with a new technique. In the present study, we reviewed the early results of two techniques involving the use of smaller incisions; specifically, we evaluated one series of primary total hip replacements that had been performed through two small incisions and another series of total hip replacements that had been performed through a single small incision. METHODS: Eighty-nine consecutive primary total hip replacements were performed with use of the two-incision technique as described by Mears and Berger; all procedures were performed without cement and with use of fluoroscopic guidance. Outcomes data were reviewed at a minimum of six months following the procedure. The results of these procedures were retrospectively compared with those of a historical control series of ninety-six total hip replacements that had been performed by the same surgeon with use of a single mini-incision technique. No special attempt was made to discharge any patient early from the hospital. In preparation for the use of the two-incision technique, the surgeon attended a two-day seminar that included cadaveric training and mentoring by surgeons who had experience with this technique. RESULTS: In the two-incision group, nine patients (nine hips; 10%) required repeat surgery because of a femoral fracture that had been identified postoperatively (two hips), dislocation (one hip), a wound complication (two hips), or subsidence and loosening of the femoral implant (four hips). Twenty-two patients (twenty-two hips; 25%) sustained an injury of the lateral femoral cutaneous nerve, and one patient (one hip) had a neuropraxia of the femoral nerve. In the comparative series of ninety-six total hip arthroplasties that had been performed with use of a single mini-incision and a direct lateral exposure of the hip joint, the overall complication rate was 6% (six of ninety-six) and the reoperation rate was 3% (three of ninety-six). The rate of complications associated with the two-incision technique decreased significantly as the surgeon gained experience with the procedure (p = 0.0202). CONCLUSIONS: Although total hip arthroplasty with use of the two-incision technique was performed by a surgeon who was experienced in the performance of total hip replacement surgery with use of a single small incision, the rates of complications and repeat surgery associated with the two-incision technique initially were very high. While the rate diminished with increasing experience, total hip replacement with use of two incisions and fluoroscopic guidance is a technically demanding procedure that may be associated, especially initially, with higher rates of complications and repeat surgery.

Background Since its approval, reverse total shoulder arthroplasty (rTSA) has continued to increase in usage, with expanding indications beyond rotator cuff arthropathy. Existing literature has captured further increased utilization over the last decade through 2017. However, this data has not been updated to include a contemporary cohort of patients. This study sought to determine the trends of anatomic total shoulder arthroplasty (aTSA), rTSA, and hemiarthroplasty (HA) usage based on primary diagnosis and total number of surgeons performing each procedure annually from 2016-2020. Methods Patients who underwent primary rTSA, aTSA, and HA from 2016-2020 were identified in the Premier Healthcare Database. Primary indication diagnoses for procedures were identified using International Classification of Diseases 10th edition codes. Temporal trends in patient and hospital demographics, primary indication, and procedure utilization were captured on an annualized basis. The number of surgeons performing each procedure annually was noted. Descriptive statistics were employed with significance set at P < .05. Results From 2016 to 2020, 154,499 patients undergoing primary shoulder arthroplasty were identified: 48,890 aTSA, 95,808 rTSA, and 9801 HA. In 2016, rTSA comprised a slight majority (55%) of all arthroplasty cases but increased to nearly 70% of all arthroplasty cases in 2020. The absolute numbers of aTSA and HA cases decreased over time, while rTSA volume increased from 14,781 in 2016 to a high of 23,644 cases in 2019. There was a corresponding 12% increase in the number of surgeons performing rTSA across the same time period, contrasted with a 42.1% decrease in surgeons performing HA and a 14.3% decrease for aTSA. Glenohumeral osteoarthritis remains the most common indication for rTSA and aTSA, while HA is used primarily for proximal humerus fractures or hardware complications. Conclusion The volume of primary rTSA in the United States has continued to increase from 2016 to 2020 with concurrent decreases in the number of primary aTSA and HA cases performed. Primary rTSA accounts for nearly 70% of all primary shoulder arthroplasty cases. The number of surgeons performing rTSA continues to increase, while there has been a decrease in the number of surgeons performing aTSA and HA.

Accurate component placement in shoulder arthroplasty is crucial for avoiding complications, achieving superior biomechanical performance and optimizing functional outcomes. Shoulder and elbow surgeons have explored various methods to improve surgical understanding and precise execution including preoperative planning with 3D computed tomography (CT), patient-specific instrumentation (PSI), intraoperative navigation, and mixed reality (MR). 3D preoperative planning facilitated by CT scans and advanced software, enhances surgical precision, influences decision-making for implant types and approaches, reduces errors in guide pin placement, and contributes to cost-effectiveness. Navigation demonstrates benefits in reducing malpositioning, optimizing baseplate stability, improving humeral cut, and potentially conserving bone stock, although challenges such as varied operating times and costs warrant further investigation. The personalized patient care and enhanced operational efficiency associated with PSI are not only attractive for achieving desired component positions but also hold promise for improved outcomes in complex cases involving glenoid bone loss. Augmented reality (AR) and virtual reality (VR) technologies play a pivotal role in reshaping shoulder arthroplasty. They offer benefits in preoperative planning, intraoperative guidance, and interactive surgery. Studies demonstrate their effectiveness in AR-guided guidewire placement, providing real-time surgical advice during reverse total shoulder arthroplasty (RTSA). Additionally, these technologies show promise in orthopedic training, delivering superior realism and accelerating learning compared to conventional methods.

BACKGROUND: One in five patients experience chronic pain 12 months following total knee arthroplasty (TKA). This longitudinal study used a person-centred approach to identify subgroups of patients with distinct chronic pain profiles following TKA and identified preoperative characteristics associated with these profiles. METHODS: On the day before surgery, 202 patients completed questionnaires that assessed pain, interference with functioning, fatigue, anxiety, depression and illness perceptions. Average and worst pain were assessed prior to surgery, on postoperative day 4, at 6 week and at 3 and 12 months following surgery. Using growth mixture modelling, two subgroups with distinct average and worst pain profiles were identified. RESULTS: Patients in the "lower average" and "lower worst" pain classes had moderate preoperative pain scores that decreased over the remaining 9 months following TKA. Patients in the "higher average" and "higher worst" pain classes had relatively higher preoperative pain scores that increased during the first three months and then decreased slightly over the remaining 9 months. Patients in the higher pain classes had higher interference with function scores; used opioids prior to surgery more often, were more likely to receive a continuous nerve block and ketamine; had higher preoperative fatigue severity and interference scores; and had worse perceptions of illness than patients in the lower pain classes. CONCLUSIONS: These risk factors may be used to identify subgroups of patients at higher risk for more severe pain after TKA. Future studies should test whether modifying these risk factors can improve patients' outcomes after TKA. SIGNIFICANCE STATEMENT: The present study provides a novel and original analysis of pain profiles following total knee arthroplasty that may contribute to our understanding of the transition from acute to chronic pain. Our results may be used to identify patients at higher risk for poorer outcomes based on preoperative risk factors.

Total knee arthroplasty (TKA) and total hip arthroplasty (THA) improve symptoms in end-stage osteoarthritis, yet long-term objective characterization of perioperative physical activity trajectories remains limited. We conducted a longitudinal observational study within the All of Us Research Program dataset, linking electronic health records with continuous Fitbit-derived step count data over a four-year perioperative window (two years before and two years after arthroplasty). Piecewise linear mixed-effects models characterized preoperative declines and postoperative recovery trajectories, and time-to-recovery was evaluated using Kaplan-Meier curves and Cox proportional hazards models under remote and immediate preoperative physical activity baseline definitions. Among 238 participants (147 TKA; 91 THA), both procedures exhibited progressive preoperative decline with distinct procedure-specific patterns and staged postoperative recovery: rapid improvement during weeks 1-6, decelerating gains through weeks 7-19/20, and subsequent stabilization through week 104. Recovery to remote and immediate baselines differed in timing (median 22 vs 13 weeks) and associated predictors. Higher imm

In recent times, discussions on social media platforms have increasingly come under scrutiny due to the proliferation of science denial and fake news. Traditional solutions, such as regulatory actions, have been implemented to mitigate the spread of misinformation; however, these measures alone are not sufficient. To complement these efforts, educational approaches are becoming essential in empowering users to critically engage with misinformation. Conversation training, through serious games or personalized methods, has emerged as a promising strategy to help users handle science denial and toxic conversation tactics. This paper suggests an interdisciplinary seminar to explore the suitability of Large Language Models (LLMs) acting as a persona of a science denier to support people in identifying misinformation and improving resilience against toxic interactions. In the seminar, groups of four to five students will develop an AI-based chatbot that enables realistic interactions with science-denial argumentation structures. The task involves planning the setting, integrating a Large Language Model to facilitate natural dialogues, implementing the chatbot using the RASA framework, an

The rise of agentic AI is reshaping software engineering in two intertwined directions: agents are increasingly applied to support software engineering tasks, and Agentic AI systems themselves are complex systems that require re-thinking currently established software engineering practices. To chart a coherent research agenda covering the two directions, we organized the A2SE seminar in Rio de Janeiro, bringing together 18 experts from academia and industry. Through structured presentations, collaborative topic clustering, and focused group discussions, participants identified six thematic areas: Governance, Software Engineering for Agents, Agents for Software Architecture, Quality and Evaluation, Sustainability, and Code, and they prioritized short-term and long-term research directions for each. This paper presents the resulting community-driven, opinionated research agenda, offering the SE community a structured foundation for coordinating efforts at this critical juncture.

BACKGROUND: Sensorimotor function is degraded in patients after lower limb arthroplasty. Sensorimotor training is thought to improve sensorimotor skills, however, the optimal training stimulus with regard to volume, frequency, duration, and intensity is still unknown. The aim of this study, therefore, was to firstly quantify the progression of sensorimotor function after total hip (THA) or knee (TKA) arthroplasty and, as second step, to evaluate effects of different sensorimotor training volumes. METHODS: 58 in-patients during their rehabilitation after THA or TKA participated in this prospective cohort study. Sensorimotor function was assessed using a test battery including measures of stabilization capacity, static balance, proprioception, and gait, along with a self-reported pain and function. All participants were randomly assigned to one of three intervention groups performing sensorimotor training two, four, or six times per week. Outcome measures were taken at three instances, at baseline (pre), after 1.5 weeks (mid) and at the conclusion of the 3 week program (post). RESULTS: All measurements showed significant improvements over time, with the exception of proprioception and static balance during quiet bipedal stance which showed no significant main effects for time or intervention. There was no significant effect of sensorimotor training volume on any of the outcome measures. CONCLUSION: We were able to quantify improvements in measures of dynamic, but not static, sensorimotor function during the initial three weeks of rehabilitation following TKA/THA. Although sensorimotor improvements were independent of the training volume applied in the current study, long-term effects of sensorimotor training volume need to be investigated to optimize training stimulus recommendations. TRIAL REGISTRATION: Clinical trial registration number: DRKS00007894.

PURPOSE: The fixation of revision total knee arthroplasties (rTKA) tends to be difficult, leading to a reduction in implant survival. One option for achieving a more stable anchorage is to use metaphyseal cones and sleeves. The objective of the present paper is to provide a current comparative meta-analysis on survival and clinical results of cones vs. sleeves, with a differentiation between the short- and long-term outcome. METHODS: A search of the literature was conducted systematically to include original papers from 2010 to June 2021. The following parameters were taken into account: revision for aseptic loosening, revision for any reason, periprosthetic joint infections (PJI), KSS as well as KSFS. Studies with a mean follow-up of at least 60 months were defined to be long-term follow-up studies (LT). All other studies were included in the short-term (ST) study analysis. A pooled incidence was used as a summary statistic using a random intercept logistic regression model. RESULTS: The present meta-analysis included 43 publications with 3008 rTKA. Of these, 23 publications with 1911 cases were allocated to the sleeve group (SG) and 20 papers with 1097 cases to the cone group (CG). CG showed overall numerically higher complication rates in short- and long-term follow-up, compared with SG. Aseptic loosening occurred at a rate of 0.4% in SG (LT) and 4.1% in CG (LT) (p = 0.09). Periprosthetic joint infection (PJI) was more frequent in the cone group (7% in ST and 11.7% in LT) than in the sleeve group (3.4% in ST and 4.9% in LT, p = 0.02 both). The total revision rate was 5.5% in SG (LT) and 14.4% in CG (LT) (p = 0.12). The clinical scores were also comparable between the two groups. Hinged prothesis were used more frequent in the cone group (ST p < 0.001; LT p = 0.10), whereas CC type protheses were used more frequently in the sleeve group (ST p < 0.001; LT p < 0.11). CONCLUSIONS: This meta-analysis takes into account the longest follow-up periods covered to date. Both cones and sleeves represent a reliable fixation method in the case of severe bone loss in rTKA, although the higher rate of PJI after cone fixation remains a source of concern. A metaphyseal fixation of hinged implants should be taken into account. LEVEL OF EVIDENCE: II (meta-analysis).

Despite rapid commercialization of surgical robots, their autonomy and real-time decision-making remain limited in practice. To address this gap, we propose ArthroCut, an autonomous policy learning framework that upgrades knee arthroplasty robots from assistive execution to context-aware action generation. ArthroCut fine-tunes a Qwen--VL backbone on a self-built, time-synchronized multimodal dataset from 21 complete cases (23,205 RGB--D pairs), integrating preoperative CT/MR, intraoperative NDI tracking of bones and end effector, RGB--D surgical video, robot state, and textual intent. The method operates on two complementary token families -- Preoperative Imaging Tokens (PIT) to encode patient-specific anatomy and planned resection planes, and Time-Aligned Surgical Tokens (TAST) to fuse real-time visual, geometric, and kinematic evidence -- and emits an interpretable action grammar under grammar/safety-constrained decoding. In bench-top experiments on a knee prosthesis across seven trials, ArthroCut achieves an average success rate of 86% over the six standard resections, significantly outperforming strong baselines trained under the same protocol. Ablations show that TAST is the p

Background. Osteoarthritis affects about 528 million people worldwide, causing pain and stiffness in the joints. Arthroplasty is commonly performed to treat joint osteoarthritis, reducing pain and improving mobility. Nevertheless, a significant share of patients remain unsatisfied with their surgery. Personalised arthroplasty was introduced to improve surgical outcomes however current solutions require delays, making it difficult to integrate in clinical routine. We propose a fully automated workflow to design patient-specific implants for total knee arthroplasty. Methods. The proposed pipeline first uses artificial neural networks to segment the femur and tibia proximal and distal extremities. Then the full bones are reconstructed using augmented statistical shape models, combining shape and landmarks information. Finally, 77 morphological parameters are computed to design patient-specific implants. The developed workflow has been trained on 91 CT scans and evaluated on 41 CT scans, in terms of accuracy and execution time. Results. The workflow accuracy was $0.4\pm0.2mm$ for segmentation, $1.0\pm0.3mm$ for full bone reconstruction, and $2.2\pm1.5mm$ for anatomical landmarks determ

Background Postoperative pain after total knee arthroplasty (TKA) is a continuing problem despite optimised multimodal analgesia. Previous studies have shown preoperative glucocorticoids to reduce postoperative pain, but knowledge about specific doses and effects in specific patient groups is lacking. Methods A two-centre, double-blind, two-arm study comparing preoperative dexamethasone (1 mg kg −1 vs 0.3 mg kg −1 i.v.) on postoperative pain in 160 planned TKA subjects with low preoperative pain catastrophising and no opioid use. Subjects received multimodal analgesia with paracetamol, cyclooxygenase-2 inhibitors, local anaesthetic infiltration analgesia, and rescue opioids. The primary outcome was percentage of subjects experiencing moderate to severe pain (visual analogue scale >30 mm) upon ambulation at 24 h. Secondary outcomes included pain scores, postoperative inflammation (C-reactive protein), opioid and antiemetics use, and ‘Quality of Recovery-15' and ‘Opioid-Related Symptom Distress Scale', length of stay, readmissions, and complications up to Day 90. Results A total of 157 subjects (80 vs 77) were included. No difference was found between groups in the incidence of subjects experiencing visual analogue scale >30 on ambulation 24 h after surgery (56% vs 53%, relative risk =1.07, confidence interval: 0.8–1.4, P =0.65). No differences in other pain outcomes or use of rescue opioids and antiemetics, in Quality of Recovery-15 and Opioid-Related Symptom Distress Scale, length of stay, readmissions, or complications. C-reactive protein values were comparable at 24 h (13 [6–25] mg L −1 vs 16 [9–38] mg L −1 , P = 0.07), but lower at 48 h (26 [9–52] mg L −1 vs 50 [30–72] mg L −1 , P <0.01) in the high-dose group. Conclusion Use of 1 mg kg −1 vs 0.3 mg kg −1 i.v. dexamethasone in low pain responders after TKA did not improve early postoperative pain or other outcomes in contrast to benefits in a high pain responder population. Clinical trial registration NCT03758170 (first registration 29-11-2018).

Audio event classification has recently emerged as a promising approach in medical applications. In total hip arthroplasty (THA), intra-operative hammering acoustics provide critical cues for assessing the initial stability of the femoral stem, yet variability due to femoral morphology, implant size, and surgical technique constrains conventional assessment methods. We propose the first deep learning framework for this task, employing a TimeMIL model trained on Log-Mel Spectrogram features and enhanced with pseudo-labeling. On intra-operative recordings, the method achieved 91.17 % +/- 2.79 % accuracy, demonstrating reliable estimation of stem stability. Comparative experiments further show that reducing the diversity of femoral stem brands improves model performance, although limited dataset size remains a bottleneck. These results establish deep learning-based audio event classification as a feasible approach for intra-operative stability assessment in THA.

OBJECTIVE: Aseptic loosening (AL) is the most frequent long-term reason for revision of total knee arthroplasty (TKA) affecting about 15-20% patients within 20 years after the surgery. Although there is a solid body of evidence about the crucial role of inflammation in the AL pathogenesis, scared information on inflammation signature and its time-axis in tissues around TKA exists. DESIGN: The inflammation protein signatures in pseudosynovial tissues collected at revision surgery from patients with AL (AL, n = 12) and those with no clinical/radiographic signs of AL (non-AL, n = 9) were investigated by Proximity Extension Assay (PEA)-Immunoassay and immunohistochemistry. RESULTS: AL tissues had elevated levels of TNF-family members sTNFR2, TNFSF14, sFasL, sBAFF, cytokines/chemokines IL8, CCL2, IL1RA/IL36, sIL6R, and growth factors sAREG, CSF1, comparing to non-AL. High interindividual variability in protein levels was evident particularly in non-AL. Levels of sTNFR2, sBAFF, IL8, sIL6R, and MPO discriminated between AL and non-AL and were associated with the time from index surgery, suggesting the cumulative character of inflammatory osteolytic response to prosthetic byproducts. The source of elevated inflammatory molecules was macrophages and multinucleated osteoclast-like cells in AL and histiocytes and osteoclast-like cells in non-AL tissues, respectively. All proteins were present in higher levels in osteoclast-like cells than in macrophages. CONCLUSIONS: Our study revealed a differential inflammation signature between AL and non-AL stages of TKA. It also highlighted the unique patient's response to TKA in non-AL stages. Further confirmation of our preliminary results on a larger cohort is needed. Analysis of the time-axis of processes ongoing around TKA implantation may help to understand the mechanisms driving periprosthetic bone resorption needed for diagnostic/preventative strategies.

These notes describe our experience with running a student seminar on average-case complexity in statistical inference using the jigsaw learning format at ETH Zurich in Fall of 2024. The jigsaw learning technique is an active learning technique where students work in groups on independent parts of the task and then reassemble the groups to combine all the parts together. We implemented this technique for the proofs of various recent research developments, combined with a presentation by one of the students in the beginning of the session. We describe our experience and thoughts on such a format applied in a student research seminar: including, but not limited to, higher engagement, more accessible talks by the students, and increased student participation in discussions. In the Appendix, we include all the exercises sheets for the topic, which may be of independent interest for courses on statistical-to-computational gaps and average-case complexity.

Background and purpose - Length of stay (LOS) following total hip and knee arthroplasty (THA and TKA) has been reduced over the years due to fast-track. Short stays of 2 days in fast-track departments in Denmark have resulted in low total costs of around US$2,550. Outpatient THA and TKA is gaining popularity, albeit in a limited and selected group of patients; however, the financial benefit of outpatient arthroplasty remains unknown. We present baseline detailed economic calculations of outpatient THA and TKA in 2 different settings: one from the hospital and another from the ambulatory surgery department. Patients and methods - Data from 6 patients (1 TKA, 1 uncemented THA, 1 cemented THA in each department) were collected prospectively using the Time Driven Activity Based Costing method (TDABC). Time consumed by different staff members involved in patient treatment in the perioperative period of outpatient THA and TKA was calculated in 2 different settings: one in the orthopedic department and one in the ambulatory surgery department. Results - LOS was around 11 h in the orthopedic department and around 7 h in the ambulatory surgery department, respectively. TDABC revealed minor differences in the operative settings between departments and similar expenses occurred during the short stay of US$777 and US$746, respectively. Adding the preoperative preparation and postoperative follow-up resulted in total cost of US$951 and US$942 for the ward and the ambulatory surgery department, respectively. Interpretation - Outpatient THA and TKA in hospital and ambulatory surgery departments results in similar cost using the TDABC method. Compared with the cost associated with 2-day stays, outpatient procedures are around two-thirds cheaper provided no increase occurs in complications or readmissions.

Large reasoning models (LRMs) achieve strong performance on complex reasoning tasks but often generate harmful responses to malicious user queries. This paper investigates the underlying cause of these safety risks and shows that the issue lies in the reasoning structure itself. Based on this insight, we claim that effective safety alignment can be achieved by altering the reasoning structure. We propose AltTrain, a simple yet effective post training method that explicitly alters the reasoning structure of LRMs. AltTrain is both practical and generalizable, requiring no complex reinforcement learning (RL) training or reward design, only supervised finetuning (SFT) with a lightweight 1K training examples. Experiments across LRM backbones and model sizes demonstrate strong safety alignment, along with robust generalization across reasoning, QA, summarization, and multilingual setting.