text:
Q: FluentValidation failure not returning BadRequest I have wired up FluentValidation as per instructions, and when debuging test I can see that model is invalid based on the test setup, but exception is not thrown, but rather method on the controller is being executed. This is on 3.1 with EndPoint routing enabled. Is there anything else one needs to do to get this to work and throw. What happens is that validation obviously runs; it shows as ModelState invalid and correct InstallmentId is invalid, but it keeps processing in Controller instead of throwing exception.
services.AddMvc(
                    options =>
                    {
                         options.EnableEndpointRouting = true;
                         //// options.Filters.Add<ExceptionFilter>();
                         //// options.Filters.Add<CustomerRequestFilter>();
                     })
                    .AddFluentValidation(
                         config =>
                         {
                            config.RegisterValidatorsFromAssemblyContaining<Startup>();
                         })

Command and Validator
     public class ProcessManualPayment
        {
            public class Command
                : CustomerRequest<Result?>
            {
                public Guid PaymentPlanId { get; set; }

                public Guid InstallmentId { get; set; }

                public Guid PaymentCardId { get; set; }
            }

            public class Validator : AbstractValidator<Command>
            {
                public Validator()
                {
                    this.RuleFor(x => x.CustomerId)
                        .IsValidGuid();

                    this.RuleFor(x => x.PaymentPlanId)
                        .IsValidGuid();

                    this.RuleFor(x => x.InstallmentId)
                        .IsValidGuid();

                    this.RuleFor(x => x.PaymentCardId)
                        .IsValidGuid();
                }
            }

Controller
    [Authorize]
    [HttpPost]
    [Route("payments")]
    [ProducesResponseType(StatusCodes.Status200OK)]
    [ProducesResponseType(StatusCodes.Status400BadRequest)]
    public async Task<IActionResult> ProcessManualPayment(
           [FromBody]
            ProcessManualPayment.Command command)
    {

Test
            [Fact]
            public async Task When_Command_Has_Invalid_Payload_Should_Fail()
            {
                var client = this.factory.CreateClient();

                // Arrange
                var validCmd = new ProcessManualPayment.Command()
                {
                    CustomerId = Guid.NewGuid(),
                    PaymentPlanId = Guid.NewGuid(),
                    InstallmentId = Guid.NewGuid(),
                    PaymentCardId = Guid.NewGuid(),
                };

                var validCmdJson = JsonConvert.SerializeObject(validCmd, Formatting.None);

                var jObject = JObject.Parse(validCmdJson);

                jObject["installmentId"] = "asdf";

                var payload = jObject.ToString(Formatting.None);

                // Act
                var content = new StringContent(payload, Encoding.UTF8, MediaTypeNames.Application.Json);

                var response = await client.PostAsync(MakePaymentUrl, content);

                var returned = await response.Content.ReadAsStringAsync();

                response.StatusCode.ShouldBe(HttpStatusCode.BadRequest);
            }

            [Fact]
            public async Task When_Payload_Is_Null_Should_Fail()
            {
                // Arrange
                var client = this.factory.CreateClient();

                // Act
                var response = await client.PostAsJsonAsync(MakePaymentUrl, null);

                // Assert
                response.StatusCode.ShouldBe(HttpStatusCode.BadRequest);
            }

GuidValidator
    public class GuidValidator : PropertyValidator
    {
        public GuidValidator()
            : base("'{PropertyName}' value {AttemptedValue} is not a valid Guid.")
        {
        }

        protected override bool IsValid(PropertyValidatorContext context)
        {
            context.MessageFormatter.AppendArgument("AttemptedValue", context.PropertyValue ?? "'null'");

            if (context.PropertyValue == null)
            {
                return false;
            }

            Guid.TryParse(context.PropertyValue.ToString(), out var value);

            return IsValid(value);
        }

        private static bool IsValid(Guid? value) =>
            value.HasValue
            && !value.Equals(Guid.Empty);
    }

A: Mystery solved, I was missing [ApiController] attribute on the controller.


Gdansk airport is named after Lech Walesa and if visitors don't know much about this man before they arrive then they will know a lot by the time they leave, especially if they visit the European Solidarity Centre, which is about 500 metres from Gdansk Glowny by the entrance to the shipyards.This museum is an absolute joy and educational beyond belief. I left wondering why on earth I hadn't known some of the information on display in the centre. The museum made me realise my own ignorance of events in the continent of Europe just before my birth and that's a good thing. It does show we are always living through history and the key is to be finding out the truth at all times.


text:
On March 24, 2016 By sgriffiths8In Victorian
Christina Rossetti's Goblin Market is overflowing with vehement sexual imagery, despite the fact that she insisted that is was appropriate for children. Lines 390 through 420 depict the shift that occurs when the goblins discover that Lizzie wants to take the fruits to Laura in hopes of curing her. In lines 334 through 349, the goblins were portrayed as being very happy and affectionate (too affectionate, if you ask me) ("chuckling, clapping, crowing", "hugged her and kissed her, squeezed and caressed her"). However, this changes quickly as they "grunt" and "snarl" and appear now to be evil and violent.
In both instances, the goblins are compared to animals however the comparisons are vastly different. When Lizzie and Laura first meet them, they are "wagging" and "purring" like harmless creatures, but when Lizzie encounters them later on they lash their tails and bark and hiss. The goblins absolutely represent a binary, as they embody both innocence and corruption.
When Lizzie is attacked by the goblins, the word choice suggests that their intentions are perhaps more sinister than previously thought. The goblins "held her hands and squeezed their fruits against her mouth to make her eat". The fact that they held her down and "squeezed their fruits against her mouth" suggests that this act was performed against her will. Also, the goblins "tore her gown and soiled her stocking" which too suggests that she was violated in some way by the goblins.
Color is also symbolic in this passage, as Lizzie is described in line 408 as being "white and golden". White symbolizes purity, which has been soiled by the goblins in the previous stanza, however she stands strong despite the horrors she has faced. Lizzie is also compared to "a royal virgin town, topped with gilded dome and spire, close beleaguered by a fleet mad to tug her standard down". This image of a beautiful, untouched town being ravaged by pillagers also alludes to the sexual violence that has befallen Lizzie. Surely, Rosetti includes this scene to make a statement about the evils of temptation and how reputation greatly affects women in the Victorian era.
Christina Rossetti. "Goblin Market." The Norton Anthology of English Literature. Vol. E. New York: W.W. Norton &, 2012. 1496-1508. Print.
One thought on "Close Reading of Christina Rossetti's Goblin Market"
You cover a LOT here in the post! 🙂 You say early on that the goblins represent a binary between innocence and evil. How are they innocent? Does their purring necessarily make them innocent? Also, don't forget to cite your quotations as you move in analysis later in the post!

redpajama_set_name: RedPajamaCommonCrawl


text:
Operators, Telehealth Providers See Skilled Nursing Promise in New CMS Proposal
By Alex Spanko | July 24, 2018
While they don't represent broad-based coverage for skilled nursing facilities, new proposed telehealth guidelines from the Centers for Medicare & Medicaid Services (CMS) have drawn praise from providers and groups that see the news as a sign of even wider coverage on the horizon.
Under the proposed rule issued earlier this month, CMS would expand physician coverage to include remote check-ins on patients — with the goal of determining whether an in-person doctor visit is really necessary — while also covering a wider swath of preventative telehealth interventions.
"Getting to the doctor can be a challenge for some beneficiaries, whether they live in rural or urban areas," CMS said in a statement announcing the proposed rule, which would take effect on New Year's Day 2019. "Innovative technology that enables remote services can expand access to care and create more opportunities for patients to access personalized care management as well as connect with their physicians quickly."
The federal government currently only covers telemedicine services in rural skilled nursing facilities — which, according to Tapestry Telehealth COO Mordy Eisenberg, only equates to about a third of the more than 15,000 SNFs that operate in the United States. But Eisenberg indicated that further expansion of those services is likely over the coming years.
"I really think that as CMS starts to see the results of the telemedicine outcomes, and that it's really practically the same as being there in person, I think they're going to expand it to non-rural markets," he told Skilled Nursing News.
The current proposal would have some direct benefits for nursing home residents, according to Majd Alwan, executive director of the Center for Aging Services Technologies (CAST) at LeadingAge, an association that represents non-profit long-term care providers.
"This is certainly a step in the right direction," Alwan told SNN via e-mail.
The proposed rule would cover "virtual check-ins" — which would include phone conversations, e-mail, or texts sent through a patient portal — with nursing home medical directors, primary care physicians, and other doctors or nurse practitioners, Alwan said.
"These types of providers, physicians, can now take or return calls initiated by nursing home, AL [assisted living], or CCRC staff on behalf of patients to talk to them about their medical concerns, including management of opioid medications," he said.
Telemedicine promise
Founded by David Chess, the doctor who also founded telemedicine provider TripleCare, Tapestry first started seeing patients in January and currently operates in 23 rural nursing homes. The company's offerings take the form of virtual rounds, with nurse practitioners preforming routine checks on skilled nursing residents remotely.
Under its arrangements with individual nursing operators, the company doesn't charge an ongoing rate for its services, instead billing Medicare directly for the nurse practitioner visits. Providers are on the hook for a nominal monthly administrative fee, but Eisenberg noted that the facilities can also receive Medicare reimbursements of about $25 per telemedicine encounter — with one building in particular ending up about $2,000 per month in the black.
Using telemedicine also has benefits outside of potentially making money by providing digital rounds: With the SNF Value-Based Purchasing Program taking effect this fall, preventing rehospitalizations could determine whether or not a particular building earns back its automatic 2% reduction in Medicare, and Eisenberg emphasized the importance of using virtual visits to avoid a costly hospital trip.
When providers do a post-hospitalization analysis, Eisenberg said, many times doctors and nurses conclude that the acute care stay was inevitable — but it didn't have to be if someone had noticed the warning signs a few days earlier.
"At that point, they probably did have to go back to the hospital. If you look back three, four days before that, there were so many things that were missed along the way … If there's a change in their ADL status, something different about the way they're eating, they'll try to flag that so they can see those patients earlier and hopefully mitigate any problems," he said.
I-SNP benefits
Right now, the stakes are even higher for rural facilities, which may not have access to private ambulette services — forcing them to use more expensive municipal ambulance rides to transport residents the long distances to area hospitals. In addition to the Medicare hit, sending patients to faraway acute-care facilities also represents a census issue for rural skilled nursing facilities, according to Eisenberg: If a given town doesn't have a hospital, the patient may have to travel 100 miles or more to receive acute care. Once it's time for him or her to be discharged back into a SNF, it's likely the hospital or surgical center will pick a facility in its immediate vicinity.
"They'll never come back home," Eisenberg said. "What we're finding as we partner with these facilities, they're able to say: We can actually handle this stuff now. We have an NP on staff."
Going forward, expanded telemedicine coverage could help attract the attention of Institutional Special Needs Plans (I-SNPs), special Medicare Advantage plans for nursing home residents.
Eisenberg gave the example of a 30-building chain that used telemedicine services in its eight rural locations, but not the urban and suburban buildings where Medicare doesn't cover it. If the operator elected to deploy telemedicine across the entire spectrum, it could help create the kind of consistent medical model that would lend itself to an I-SNP — either a third-party plan or one created internally, as some skilled nursing operators have already done.
"The real goal is, once you have your 30 buildings being managed effectively, now you can take risk surrounding those buildings. Now you can start thinking about I-SNPs or even bundled payments," Eisenberg said.
Centers for Medicare and Medicaid Services, LeadingAge, Tapestry Telehealth


text:
2009-10 game previews
Up next: Alex Ovechkin, Mike Knuble and the Washington Capitals
By FrankD Updated Apr 6, 2010, 7:00am EDT
Share All sharing options for: Up next: Alex Ovechkin, Mike Knuble and the Washington Capitals
[SBN Capitals blog - Japers' Rink]
Record: 52-15-12 (1st in East)
Scorers: Alex Ovechkin (46g, 58a), Nicklas Backstrom (31g, 64a), Alex Semin (38g, 40a)
I can't decide which goaltender I despise more this week: Jose Theodore or Tuukka Rask. Why Rask, you ask? Well you see, it all has to do with fantasy hockey.
It was a great regular season for Malkin's Stoli Stash, my team in Pensburgh League A. Undefeated during the regular season, a first round bye - things were looking great. Till Tuukka Rask (my opponent's goaltender) chose to play like Patrick Roy and Martin Brodeur combined. Theodore, on the other hand, not so much.
But I'm over it. Truly, I am. Third place is a decent finish. If I can even do that. For what it's worth, Theo and Rask played each other last night (in the real world of hockey) to a 3-2 Washington win in OT, so it's likely Jose gets the bench tonight in favor of Semyon Varlamov anyway.
There are a bunch of undertones to tonight's game, yet at the same time not. For starters, Washington officially claimed the Presidents' Trophy Sunday night. For those of you playing at home, this means the Caps have officially finished the season better than every other team in the league, even with three games remaining. Pensburgh user JohnCarter1966 passed along the following info that he gathered from the Presidents' Trophy wiki page:
There have been 23 President's Trophy winners since '85. Only 6 were from the Eastern Conference and 17 from the West. 7 President's Trophy Winners have won the Cup. 6 of the 7 were from the Western Conference!
That's something I can live with. And hey, for extra credit (without looking) try and think of which team in the East won the trophy and the Cup in the same year. Shouldn't be hard, but you know how these stat things are sometimes...
After that whole trophy thing, we have the goals/points leaderboard. Both Ovechkin and Crosby are neck and neck for the Rocket Richard Trophy, while Ovechkin also remains in a tight race with Vancouver's Henrik Sedin for the Art Ross. Both Crosby and Ovechkin have had nothing short of great years and each has already reached the 50+ assist plateau. Whether they can round it out with 50+ goals each will come down to the wire.
Then there's the regular season record between these two teams. In a best of four series the Penguins are currently 0-1-2 against the Caps. This of course means the Caps are 3-0 against the Pens, and you can bet your Rico Fata autographed jersey that they (and the fans) want that to be 4-0 by the end of tonight.
The little pieces, like those just mentioned, are what drives both teams to get onto the ice tonight. In the big picture though, when you push aside all the personal motives and regular season records, you have to imagine both teams are gearing up for the playoffs. Yet if there's one thing that's evident in any Caps/Pens match-up, it's that you get a playoff caliber game no matter the time of year. So take this as a preface to what will no doubt be an exciting postseason. But before we even get there, let's at least see the Pens manage a regulation win today. The thought of being swept by Washington and New Jersey in the same season is something I can't bear to accept at the moment.
Puck and thread at 7:30.


text:
NC Medical Dental Clinic offers care to Afghan refugees awaiting official status
Afghannews December 13, 2021 2 min read
RALEIGH, NC (WNCN) – Medical Assistance. Dental care. Both are essential for everyone's health, but are sometimes overlooked due to life situations.
This is especially true of the hundreds of Afghan refugees who have entered the Triangle area.
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A special health clinic was held on Saturday to help people who fled Afghanistan but are still waiting for their official state-issued refugee status.
"Once they become an official refugee, they are eligible for Medicaid," said Cory Whittaker, area director of the Christian Medical and Dental Associations in the Triangle. "But until then, they do not have health care available to them or dental care."
This means that at least 150 Afghan refugees typically would not have a place to go to get needed medicine, get a physical examination or even check for gaps.
"We hope to catch something that is a chronic problem, like high blood pressure," Whittaker said of why the event took place last Saturday. "It's our way of welcoming them into the community."
On Saturday, families piled into the basement of Forest Hills Baptist Church in Raleigh to make sure they are healthy after months of travel and escape from the Taliban regime.
"We left Afghanistan and were then taken to Qatar, and then to Italy, (and then) from Italy to New Mexico … we stayed there for 15 plus days, and from there we were brought here," said refugees Khadija Wazeen.
Qatar agrees to represent US interests in Afghanistan
Wazeen and her husband left their homeland in August. Since then, she has not had the opportunity to check her physical health.
"They recommended an x-ray of my teeth," she said.
Wazeen knows the importance of following your doctor's appointments and getting ahead of any potential health issues.
"I was a doctor and we had free medical plans for the needy people or for people who were displaced," she said.
She also told CBS 17 that she is very grateful to be on this end of things, and she even tried to help the staff at the clinic by translating for other refugees.
"It's a great thing to help and be helped," Wazeen said.
Campbell University, Duke University and the University of North Carolina at Chapel Hill medical and dental students assisted at the clinic.
"There are plenty of opportunities to serve underserved communities," Whittaker said.
The clinic was a by-product of a community partnership with the Christian Medical and Dental Association of the Triangle and Lutheran Services.
Download the WAVY News app to stay up to date with the latest news, weather and sports from WAVY-TV 10. Available in both Apple and Google Play stores.
Previous: 'Worse than it was before': Afghan exiles mourn the fate of their homeland
Next: The $ 88 billion bet on the Afghan army going up in smoke


text:
Q: Dataset output in Shinyapp in R using DT package does not show the full data I would like to display my full data on the shinyapp output. My dataset is 31 columns wide but using DT::renderDataTable i only get at max 17 columns. I need to be able to see or at least be able to scroll to the right and left to view the entire data table on my shiny app. Here is the UI and SERVER code below.
My question: Is this possible to do? Or is there a limit to the number of columns that DT package can display in the shiny app?
ui.interface <- fluidPage(title = "Pokemon Analysis",
            tabsetPanel(
              ########### Data table below ##############
              tabPanel(title = "Pokemon Go",
                       # plotOutput("go"),
                       titlePanel("Pokemon Go"),
                       # Create a new Row in the UI for selectInputs
                       fluidRow(
                         column(4,
                                selectInput("evostage",
                                            "Evolution Stage:",
                                            c("All",
                                              unique(as.character(dt.pokemon$EvoStage))))
                         ),
                         column(4,
                                selectInput("evo",
                                            "Evolution:",
                                            c("All",
                                              unique(as.character(dt.pokemon$EvolutionPips))))
                         ),
                         column(4,
                                selectInput("battack",
                                            "Attack:",
                                            c("All",
                                              unique(as.character(dt.pokemon$BaseAttack))))
                         )
                       ),
                       # Create a new row for the table.
                       fluidRow(
                         DT::dataTableOutput("table")
                       ))
              ########### Data table above ##############
            )
)

Below is my server code...
server.interface <- function(input, output) {

########### Data table below ##############
output$table <- DT::renderDataTable(DT::datatable({
   data <- pokemon
   if (input$evostage != "All") {
     data <- data[data$EvoStage == input$evostage,]
   }
   if (input$evo != "All") {
     data <- data[data$EvolutionPips == input$evo,]
   }
   if (input$battack != "All") {
    data <- data[data$BaseAttack == input$battack,]
   }
   data
   }))
 ########### Data table above ##############
}
shinyApp(server = server.interface, ui = ui.interface)

A: It seems your question is similar to this one.
As described in the link above, it is possible to add a horizontal scrollbar by adding options = list(scrollX = TRUE) parameter to the renderDataTable function (after ( and before {).

redpajama_set_name: RedPajamaStackExchange


text:
All-American Comics foi a principal revista em quadrinhos da editora All-American Publications, uma das precursoras da DC Comics. Ela contou com um total de 102 edições de 1939 a 1948. Os personagens criados para o título, como o Lanterna Verde, o Átomo, o Tornado Vermelho, Doutor Meia-Noite e Sargon, o Feiticeiro, seriam mais tarde, os pilares da linha de quadrinhos da DC.

Histórico da publicação
All-American Comics publicou 102 edições de Abril de 1939 até Outubro de 1948. A série foi uma antologia que incluía uma mistura de material novo e reimpressões de tiras de jornais. O roteirista Sheldon Mayer foi apresentado na primeira edição, assim como, Hop Harrigan. O  Lanterna Verde da Era de Ouro foi mostrado pela primeira vez pelo escritor Bill Finger e pelo artista Martin Nodell na edição #16 (Julho de 1940). O Átomo da Era de Ouro estreou na #19 (Outubro de 1940) e Mayer criou o Tornado Vermelho original na #20 (Novembro de 1940). O Doutor Meia-Noite teve sua primeira aparição na #25 (Abril de 1941). Alfred Bester e Paulo Reinman criaram o monstruoso super-vilão Solomon Grundy na #61 (Outubro de 1944). Outros histórias incluíram "Toonerville Folks", "Mutt e Jeff" e "Ripley's Believe It or Not!".

A All-American Publications e todos os seus títulos foram adquiridos pela National Periodicals (DC Comics) em 1946. Em resposta à demanda de pedidos por quadrinhos de faroeste, a All-American Comics mudou seu título e formato na #103 (Novembro de 1948) para All-American Western. A série renomeada tinha agora Johnny Trovoada como a história principal. Ela mudou seu título e formato novamente para All-American Men of Warna #127 (Agosto–Setembro de 1952).

Em 1999, um one-shot especial foi criado para ser parte da história "Justice Society Returns."

Links externos

All-American Comics na Mike's Amazing World of Comics

Publicações da DC Comics

redpajama_set_name: RedPajamaWikipedia


text:
Louisville Bound Ohio Surge Moving Forward
on July 1, 2015 by ASGR Basketball
The Ohio Surge program started four years ago, and each summer the club has stepped up its efforts to face the best possible competition. In 2015, that journey led the Surge to the Deep South Classic in June, and they will be competing in the Summer Derby Classic in July.
The Summer Derby Classic will be played in Louisville, KY on July 23-24. The tournament, which will include many of the top travel programs in the country, will be played at the Mid America Sports Center.
"We started the program when these girls were in the sixth grade, and every year we try to evaluate where the team is, and what type of events we should be playing," said Coach Todd Pennington. "We had to fight through some injury issues in the spring, but we got some good experience, and everyone is healthy now. I think we're ready to make a strong run in July."
That run will be powered by a trio of talented athletes from the Class of 2018. That group includes Grace Pennington (5-9, PG, who is the coach's daughter), Victoria Flehman (5-11, W) and Ise Bolender (5-9, G).
"Grace is a natural two guard, but she plays the point for us. It helps our team to have her at the point, and it has really helped Grace become a better overall player," the coach/father said. "She can score but she also does a good job of getting our team into our offense and getting everyone in the right place.
"Victoria is a versatile player who is a tough matchup for our opponents. She can shoot the three and drive to the basket, but if she is going against a smaller guard, so can use her size and strength to post people up.
"Ise has probably been our leading scorer through the first part of the season. She is very good at slashing to the basket, and she is also a very good shooter. She had a game in our last tournament where she hit six three-pointers."
That perimeter unit will be complemented by a promising young post player, Mikala Morris (2019, 6-3).
"Mikala just joined us in the middle of the spring, and then she had an ankle problem, but she is a player with a very bright future," Pennington said. "Right now she is a true post player, but she is working to develop her outside game. She is great already out to 15 feet, and she is working hard on all her perimeter skills. She has good size and she moves very well, and I just think she is a player that everyone will want to look at."


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Jameya is a 13-year-old who was diagnosed with sickle cell anemia in January 2015 and is being treated by Dr. Cunningham at Comer Children's Hospital in Chicago (Comer). Jameya lives with her family in Dolton, Illinois, a south suburb of Chicago. Her mom, Elizabeth, told us she just received her nursing degree and takes Jameya to her appointments to Comer.
Jameya learned of Alyssa Alvin Foundation for Hope through Jonathan Tutko, Music Therapist at Comer. Jameya enjoys singing, playing the piano and listening to music. Jonathan shared with Jameya that she could request her own electronic keyboard if she wanted it and she did. Jameya's mom, Elizabeth, submitted Jameya's gift request on July 26, 2017 and soon after it was ready to be delivered to her.
On Saturday July 28th, Daniel, Alyssa's cousin, arrived at Comer to deliver an electronic keyboard, headset and stand to Jameya. She was very happy to receive the keyboard and is looking forward to playing it at home. Jameya was scheduled to be discharged from Comer and we wish her all the best.


text:
Images from 24th July 1999
Images from Barrow Hill
Around the turntable inside Barrow Hill roundhouse on 24th July 1999 were MR Johnson Class 1F 0-6-0T No. 41708 in steam, and visiting from the Bluebell Railway North London Railway 75 Class 0-6-0T No. 58850. Both locomotive were initially constructed in 1880, and worked locally to Barrow Hill; No. 41708 at Staveley Ironworks and No. 58850 on the Cromford & High Peak Railway. In 2020, now both 140 years old, the locomotives are static exhibits at their respective heritage railway sites.
John NeaveView All Images
If your referring to the image in your forum or blog post, please do remember to credit the original photographer, in this case John Neave


: tractor fuse box. ... by John Deere. ... John Deere M133730 Fuse Box Latch 110TBL 3120 3720 4120 4200 4400 4410 4600 4700.
: john deere 4120. Skip to main content. ... John Deere M133730 Fuse Box Latch 110TBL 3120 3720 4120 4200 4400 4410 4600 4700. $19.99 $ 19. 99. FREE Shipping.
The fuse box on a John Deere 4430 diesel tractor can be foundbeneath the drivers seat. The drivers seat should tilt forwardrevealing the fuse box.


In addition to conventional surgical approaches, total hip arthroplasty (THA) may be done via minimally invasive surgery (MIS). Minimally invasive THA (MIS-THA) is often portrayed in the lay community and press as involving a small skin incision; actually, it is limited soft-tissue and bony dissection. Existing MIS-THA techniques are based on variations of conventional surgical approaches that have been used by surgeons for decades.
To date, no single technique has been proved superior to the others. The benefits of a shorter incision (see the image below) must outweigh the added technical difficulty caused by reduced visualization. The choice of operative approach depends on surgeon preference and experience.
Minimally invasive total hip arthroplasty. Shown are skin incisions for direct anterior (black), miniposterior/lateral/anterolateral (dark blue), conventional posterior (dark blue plus red extensions), direct superior (green), and SuperPATH (purple) approaches to hip. Conventional posterior incision is usually 10-25 cm long. Single incisions for minimally invasive approaches are usually less than 10 cm long. In two-incision approach, both incisions are usually less than 5 cm long.
In addition to conventional surgical approaches, total hip arthroplasty (THA) may be done via minimally invasive surgery (MIS).  Minimally invasive THA (MIS-THA) is often portrayed in the lay community and press as involving a small skin incision; actually, it is limited soft-tissue and bony dissection. Existing MIS-THA techniques are based on variations of traditional direct anterior, anterolateral, direct lateral, and posterior surgical approaches that have been used by surgeons for decades. To date, no single technique has been proved definitively superior to the others.
For surgeons, the benefits of a shorter incision must outweigh the added technical difficulty from reduced visualization. A thorough knowledge of the relevant anatomy is important for any elective procedure but takes on added significance for MIS-THA. The hip consists of a ball (femoral head) that fits into a socket (acetabulum); the joint capsule and the surrounding ligaments and muscles provide stability to the joint. Ideally, for MIS-THA to be considered, there should be little or no anatomic deformity of the femoral head and acetabulum. Surgeons may try to progressively shorten their incisions while on the upward portion of the learning curve.
Degenerative arthritis of the hip can often be managed medically by means of reasonable exercise, therapy, analgesics, assistive devices to unload the diseased hip, and alternative pain management techniques that work for a particular patient. If medical therapy fails, then surgical therapy can be considered.
Specific indications for MIS-THA vary by author and by type of surgical approach. Most authorities cite the presence of a straightforward anatomy and the absence of obesity (ie, body mass index [BMI] lower than 30 kg/m2) as desirable factors in choosing patients for MIS, especially early in the surgeon's learning curve.
Although MIS-THA is increasingly being used as an alternative to conventional THA, there is still some debate as to whether MIS-THA is an acceptable replacement for or even an improvement on conventional THA. At present, although there is support for MIS-THA in the literature, no definitive answer to this question is available.
Before undertaking MIS-THA, surgeons need to gain specialized hands-on training by operating on cadavers and by visiting experienced surgeons. A double-blinded, randomized, controlled trial determined that the risks associated with MIS-THA were doubled in a surgeon's first 60 cases but that this increased risk was not present in the surgeon's next 60 cases.  These data give some idea of the learning curve associated with MIS-THA and suggest that surgeons should not undertake this procedure without appropriate training and mentorship.
Computer or robotic guidance is currently advocated by some and may allow virtual visualization of the minimally exposed surgical anatomy. The advantage of such guidance is that the proper medialization for correct coverage of the cup can be both qualitatively and quantitatively achieved.
The growth of interest in MIS-THA is related to market- and patient-driven demand for the procedure. In one study, 53% of hip surgeons admitted feeling pressured to use a specific surgical technique or implant as a result of a patient request, in some cases in a way that they believed could be harmful to their patients. Surgeons should consider whether they are prepared to subject themselves to the increased stress and learning curve associated with MIS-THA, especially if the desire for MIS-THA does not exist among their patients. The learning curve connected with MIS-THA is steep, and mastering the skill is frequently an ongoing process.
Comorbid conditions (eg, obesity, diabetes mellitus, alcoholism, and hypertension) influence rehabilitation more than incision length. Any functional advantages of MIS-THA disappear by 6 weeks to 6 months after surgery. It is yet to be determined whether good pain scores and functional recovery are due to MIS or to newer anesthesia and pain-management techniques. Studies suggest that young patient age and high preoperative hemoglobin levels are the only factors associated with shorter hospital stays; incision size is not.
Poehling-Monaghan et al, in a study of 222 patients receiving either direct anterior or miniposterior THAs, found no differences in mean length of stay, operative or in-hospital complications, maximum feet walked in hospital, or percent discharged to home.  Direct anterior patients had longer mean operating times than miniposterior patients (114 vs 60 minutes). In addition, they had greater need for gait aids at 2 weeks (92% vs 68%) but higher Harris Hip Scores at 8 weeks (95 vs 89). Direct anterior patients had lower rates of return to work and driving but did not differ in regard to use of gait aids, narcotics, activities of daily living, or walking 0.5 miles. Fewer wound problems occurred in the direct anterior group.
Maratt et al compared dislocation rates between direct anterior and posterior THA in 2147 patients.  There was no reported difference in dislocation rates (0.84% for direct anterior vs 0.79% for posterior). They also agreed with the previous literature in noting a slightly shorter length of stay with the direct anterior approach but a higher risk of fracture, increased blood loss, and increased hematoma risk.
Tripuraneni et al, in a matched cohort of 132 hip procedures, compared 66 direct anterior THAs with 66 posterior THAs.  Average acetabular abduction angle was 41.9° (range, 32-60°) in the posterior group and 43.8° (range, 30-62°) in the direct anterior group. The percentage of outliers (outside the Lewinnek safe zone, 30-50°) was 9.1% in the posterior group and 13.6% in the direct anterior group. There were two anterior dislocations in the direct anterior group and one anterior dislocation in the posterior group. Overall, it was concluded that there was no observable difference in hip stability or acetabular abduction between the direct anterior and posterior approaches.
Berend et al investigated the incidence of early periprosthetic fractures associated with primary THA in the direct anterior approach.  After identifying 2689 primary THAs, they reported 26 (0.9%) early periprosthetic femoral fractures, with 23 requiring revision. Analyzing risk factors, including age, gender, body mass index, and stem length, they noted that only increased age was associated with an increased risk of femoral fracture. Finally, logistic regression analysis revealed a significant age-fracture association for female gender only, which remained when controlled for BMI, stem length, or both.
Xu et al, in a case-control study of 149 patients, compared the anterolateral approach with the posterolateral approach in terms of hip abductor strength and function.  At 3 months after surgery, the anterolateral group had significantly better hip abduction angles. At 6 months after surgery, the anterolateral group had significantly better hip abductor strength. No differences were observed in Harris Hip Scores at any time point up to 1 year after surgery. The observed differences were attributed to the fewer muscles interrupted in the anterolateral approach.
Tsai et al reported on outcomes in 1077 primary THAs performed in 1003 patients.  Median wound length was 6 cm (range, 4.8-9.2), median operation time was 68 minutes (range, 45-112). Mean perioperative blood loss was 422 mL (range, 56-990). The median cup inclination angle was 44º (range, 33-54º), median acetabular version angle was 17° (range, 12-24º), and median hospital stay was 4 days (range, 3-8).
A total of 22 (2.0%) complications were noted, including five cases of stem subsidence, four of cup loosening, five greater trochanter fractures, four infections, two intraoperative proximal femur fractures, and two iliopsoas impingements.  In all, 13 (1.2%) received additional surgery. No neurovascular injury or dislocation was noted. The Harris Hip Score improved from 53 (range, 33-67) preoperatively to 94 postoperatively (range, 87-100).
Nakai et al compared 103 anterolateral-approach THAs with 98 posterolateral-approach THAs. In the anterolateral group, intraoperative fracture was observed in six hips, three in the greater trochanter and three in the calcar femorale.  One hip was subjected to irrigation because postoperative infection was suspected. In the posterolateral group, intraoperative fracture was demonstrated in four hips in the calcar femorale. No postoperative dislocation and no pulmonary embolism or nerve paralysis were observed in either group. The authors noted that by their measurements, the anterolateral approach was not superior to the posterolateral approach.
De Beer et al, in a comparison of matched-pair cohorts comprising 30 patients who underwent primary MIS-THA and 30 who underwent conventional THA via the direct lateral approach, reported no significant differences in operating time, opioid consumption, postoperative blood loss, complications, length of hospital stay, and Harris and Oxford hip scores 6 weeks after the procedure.  .
De Anta-Diaz et al compared muscle damage and functional outcomes between 50 lateral-approach patients and 49 direct anterior patients in a randomized controlled study.  Postoperatively, there were significantly higher mean levels of interleukin (IL)-6, IL-8, and tumor necrosis factor alpha (TNF-α) in the lateral group up to postoperative day 4. By magnetic resonance imaging (MRI) at postoperative month 6, the lateral group showed greater fatty atrophy in the gluteus muscles but similar degrees in the other muscles. The mean thickness of the tensor fasciae latae (TFL) was significantly higher in the lateral group. Functional outcome was similar between groups at 3 and 12 months postoperatively.
Eto et al, in a retrospective review of revision THAs, found that the direct anterior approach was associated with early revision surgery when compared with the posterior and anterolateral (nondirect anterior) approaches.  Aseptic loosening occurred in 30% of the direct anterior cases, whereas the rate was 8% for the nondirect anterior approaches.
Mardones et al, in a cadaveric study, compared the extent and location of damage to the abductor and external rotator muscles and tendons after two-incision and miniposterior THA.  Damage to the muscle of the gluteus medius and gluteus minimus was substantially less with the miniposterior technique than with the two-incision technique. Every miniposterior hip replacement caused the external rotators to detach during the exposure and caused additional measurable damage to the abductor muscles and tendon. None of the two-incision hip replacements were done without cutting, reaming, or damaging the gluteus medius or gluteus minimus muscle or external rotators.
A cadaveric study by Meneghini et al compared direct anterior and posterior approaches in 12 hips.  The mean amount of damage to the gluteus medius was 2.62% of its muscular area (range, 0-7.94%) in the direct anterior group and 2.85% (range, 0-8.9%) in the posterior group. Muscle damage to the TFL occurred in all six specimens in the direct anterior group and was a mean of 31.32% (range, 18.31–58.48%) of its muscular area. The direct head of the rectus femoris was damaged a mean of 12.24% (range, 0-24%) of its muscular area in the direct anterior group, with preservation of its origin on the anterior superior iliac spine (ASIS) in each specimen. Neither site of damage was noted in the posterior group.
Pagnano et al, in a comparison of two-incision THA with posterior MIS-THA in 26 patients who underwent staged bilateral MIS-THA (with two-incision MIS-THA on one hip and posterior MIS-THA on the other), found that the majority of patients preferred the latter.  The added surgical technical difficulty of the two-incision MIS-THA was not rewarded with an earlier return to functional activities. There were no differences in the times to discontinue ambulatory aids, to return to driving, to climb stairs, to return to work, or to walk half a mile. Many patients were annoyed by the mere presence of the anterior incision during simple daily activities (eg, bathing or changing clothes) because the incision was clearly visible.
When 100 of the patients in this study were selected randomly for gait analysis, no differences related to incision length were demonstrated in average stride length, cadence, or walking speed.  The main determinant for discharge home was adequate family support; age and preoperative hematocrit correlated with length of hospital stay.
Woolson et al, in a retrospective comparison of 50 posterior MIS-THAs and 85 conventional THAs, found no differences in transfusion rate, estimated blood loss, operating time, or length of hospital stay.  They did note an increased number of malpositioned components in the MIS-THA cohort. Acetabular inclination was less than 30° or more than 50° in 30% of the MIS-THAs, compared with 15% of the conventional THAs. The femoral stem was in varus in 12% of the MIS-THAs, compared with 4% of the conventional THAs.
When hemodialysis patients were excluded, there was a significant increase in wound complications in the MIS-THA cohort as compared with the conventional THA cohort.  Of the MIS-THAs, 33% were graded as having poor fit and fill, compared with 14% of conventional THAs. The MIS-THA cohort reported a significantly higher incidence of wound edges curling into the scar.
Winther at al conducted a prospective cohort study comparing the direct anterior, posterior, and lateral approaches.  At 6 weeks after surgery, the posterior approach allowed greater hip abduction strength than the direct anterior approach and allowed greater muscle strength than the lateral approach. At 3 months post surgery, however, no significant differences in muscle strength were found between the three groups.
Khan et al initially described the piriformis-sparing approach in a study comparing 100 patients undergoing this procedure with 100 patients undergoing a standard posterior approach.  With a minimum follow-up of 2 years, they reported lower mean blood loss in the piriformis group, shorter inpatient stay, and greater improvement in WOMAC scores for up to 1 year.
Khan et al later compared the piriformis-sparing and standard posterior approaches in a randomized controlled study of 100 patients.  In the piriformis-sparing group, there was a trend towards a better 6-minute walk test at 2 weeks and greater patient satisfaction at 6 weeks, and the acetabular components were less anteverted and had a lower mean inclination angle. In both groups, mean component positions were within Lewinnek's safe zone. Surgeons perceived the piriformis-sparing approach as significantly more difficult, particularly in obese patients, leading them to conclude that as compared with the standard posterior approach, it is more difficult while providing only short-term benefits.
A cadaveric study comparing the direct anterior and direct superior approaches found no statistically significant difference in the rate of gluteus medius and quadratus femoris muscle injury in terms of percentage of surface area.  The direct superior approach was associated with less damage to the gluteus minimus, the TFL, and the rectus femoris. Finally, there was no statistically significant difference in the percentage of surface area of damage to the gluteus medius tendon between these approaches; however, it was noted that the direct superior approach had a statistically reduced transected length of the gluteus minimus tendon as compared with the direct anterior approach.
Roger et al retrospectively analyzed outcomes of 135 patients undergoing the direct superior approach.  There were no dislocations, no sciatic nerve palsies, no wound complications, and low transfusion rates (8%). The postoperative Harris Hip Score averaged 96.5 (range, 87-100). Overall acetabular cup abduction angle averaged 41 (range, 21-49), and anteversion averaged 21 (range, 15-27). Four percent and 2% of femoral components were inserted into more than 2º varus and 2º valgus alignment, respectively.
Of these patients, 25% sustained an LFCN injury, and one patient had neurapraxia of the femoral nerve.  Surgical experience proved highly significant: The rate of complications associated with the two-incision approach decreased substantially after the initial learning curve had been completed, resulting in a reliably safe and predictable operation.
Nivbrant et al, in a clinical and cadaveric study documenting anatomic variations of LFCN injury during minimally invasive two-incision MIS-THA, reported a 38% incidence of paresthesia in the nerve's distribution postoperatively, with almost 50% resolution at 6-month follow-up. Upon cadaveric dissection (97 specimens), the investigators identified a significant variation in the lateral branch of the LFCN in 31% of cases, which correlated with proximal and lateral thigh sensory loss.
Archibeck et al, reviewing results of the first 10 cases performed by surgeons who had completed the two-incision MIS-THA training course, noted a challenging learning curve.  Investigators observed no complications in 47% of cases, one complication in 37%, and more than one complication in 22%. Femur fractures occurred in 6.5% of cases. Nerve injury occurred in 3.2%, consisting mostly of lateral femoral cutaneous nerve injury and an isolated case of sciatic nerve injury. Early revisions were seen in 0.9% of patients (seven for infection and eight for dislocation). Patients with BMIs greater than 30 kg/m2 had a higher complication rate (16.3%) than those with BMIs less than 30 kg/m2 (8.3%).
The most striking finding of this study was that the number of complications did not significantly decrease from the first to the tenth case in a single surgeon's experience, which suggests the learning curve may extend beyond the first 10 cases.  Accordingly, this procedure may be best performed by specially trained surgeons who perform a high volume of these cases.
In a randomized controlled trial comparing the miniposterior and two-incision approaches, Sershon et al found no significant differences in Harris Hip Scores or 12-item Short Form Survey physical and mental composite scores.  However, a longer operating time, increased operative complexity, and need for fluoroscopy in the two-incision approach were found to be significant disadvantages.
Penenberg et al, in a study of 250 consecutive hip implants with the SuperPATH approach, found no increased risk of component malposition, dislocation, or other adverse effects at the time of short-term evaluation or follow-up for 24 months.  The authors cite improvements made with regard to instrumentation, which allow this technique to be user-friendly and likely to be associated with a shorter learning curve than the two-incision approach.
Torre et al, in a case series, had an independent third party analyze postoperative radiographs in 66 of the first 100 patients who underwent the SuperPATH approach for component positioning and seating, femoral offset, and leg length.  Analysis deemed all components in the case series to be well seated and positioned. Leg lengths were measured to within 5 mm of the contralateral side, and mean acetabular abduction angle was 40.13°. It was concluded that implant position was optimal within the learning curve of the first 100 cases for described THA safe zones.
Rasuli et al, comparing the first consecutive 49 PATH cases with the first 50 SuperPATH cases, reported the mean operating times for the two procedures (114.5 ± 17.5 minutes and 101.7 ± 18.3 minutes, respectively).  They noted that PATH operating time reached a plateau by case 40, whereas SuperPATH operating time continued to decrease by case 50. In addition, mean length of stay was shorter for SuperPATH (2.2 vs 3.0 days).
Finally, Rasuli et al noted that acetabular cups were significantly more anteverted and less abducted in the SuperPATH cohort (anteversion, 23.5° ± 8.2°; abduction, 39.0° ± 8.4°) than in the PATH cohort (anteversion, 13.1° ± 7.1°; abduction, 42.9° ± 7.6°).  Despite the learning curve, these results indicate that PATH and SuperPATH approaches can be adopted with minimal complications and outcomes consistent with innovator outcomes.
Gofton et al, in a retrospective study of healthcare databases at three institutions, found that patients implanted using the SuperPATH technique experienced reduced 30-day all-cause readmission rates (2.3% vs 4.2%) and were more routinely discharged home (91.5% vs 27.3%) than was previously reported for patients in the United States.  They concluded that use of this tissue-sparing technique has the potential to significantly reduce postdischarge costs.
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Minimally invasive total hip arthroplasty: two-incision approach. Photograph of right hip in supine position showing outlines of anterior superior iliac spine and greater trochanter. Dotted line marks anterior incision.
Minimally invasive total hip arthroplasty: direct anterior approach. Insertion of acetabular component after acetabular component reaming in supine position.
Minimally invasive total hip arthroplasty: direct anterior approach. Circumferential view of acetabular component is shown with visual confirmation of orientation. Insertion guides and radiographs also may be used to assess positioning.
Minimally invasive total hip arthroplasty: direct anterior approach. View of proximal femur and right hip in supine position, showing lesser trochanter femoral neck resection marked with pen.
Minimally invasive total hip arthroplasty: direct anterior approach. Photograph of right anterior thigh after draping on fracture table. Note metal spar with square holes; this device attaches to fracture table and allows elevation of femur during femoral preparation.
Minimally invasive total hip arthroplasty: direct anterior approach. Left femoral head is dislocated anteriorly before osteotomy of femoral neck.
Minimally invasive total hip arthroplasty: direct anterior approach. Proximal femoral exposure and rasp is introduced into femoral canal facilitated by fracture table via metal spar elevating femur anteriorly.
Minimally invasive total hip arthroplasty: two-incision approach. Surgeon can guide femoral broaches through small posterior incision while palpating through anterior incision.
Minimally invasive total hip arthroplasty: two-incision approach. After wound closure, length of anterior incision is approximately 7.5 cm (3 in.).
Minimally invasive total hip arthroplasty: direct superior approach. Gluteus maximus fascia is incised sharply to expose gluteus maximus muscle.
Minimally invasive total hip arthroplasty: direct superior approach. Gluteus maximus muscle fibers are divided longitudinally, and deep gluteus maximus fascia is divided to expose pericapsular fat; prirformis tendon is detached close to its insertion.
Minimally invasive total hip arthroplasty: direct superior approach. Capsule is incised in inferior aspect of wound; capsulotomy is extended posterior and superior to superior acetabulum.
Minimally invasive total hip arthroplasty: direct superior approach. Hip is dislocated, femoral neck osteotomized, and femoral head removed.
Minimally invasive total hip arthroplasty: direct superior approach. Sharp curved Hohmann retractor is placed over anterior acetabular rim; second bent 90-degree Hohman at inferior margin; 90-degree handheld retractor in superior aspect of wound; and 90-degree sharp Hohmann deep to superior capsule. Optional retractor may be placed on posterior aspect of acetabulum.
Minimally invasive total hip arthroplasty: direct superior approach. Acetabular labrum is excised; acetabulum is reamed. Retractor is placed in inferior aspect of wound to retract quadratus femoris away from proximal femur.
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Stanford University<br/>Received research grant from: OREF; OTCF; Stryker; Zimmer-Biomet; Roam Robotics<br/>Have a 5% or greater equity interest in: Arthrology Designs (DBA: PlantarTech), Arthrology Consulting, Ankaa Safe Assets<br/>Received income in an amount equal to or greater than $250 from: Stryker; Exactech; Ethicon<br/>Patents: Dynamic Tension Plantar Fasciitis Splint; Cool Cut Cast Saw, Modular Total Knee, Augmented Reality Arthroplasty; Surgical Instrument Visualization System for: Honoraria: WebMD.