人工全髋关节置换术系统护理及康复治疗的临床疗效

目的:探讨人工全髋关节置换术患者的康复护理方法.方法:选取2005年1月-2007年4月80例人工髋关节置换术患者80例入选实验组,2000年1月-2004年12月70例行人工髋关节置换术怠者入对照组,对对照组实行系统的人工全髋关节置换术固术期康复训练程序.结果:实验组患者髋关节功能按Charnley标准评分,优良率80%;对照组优良率为60%,两组具有统计学差异(P＜0.05).结论:系统化康复护理有利于人工全髋关节置换术患者关节功能恢复,减少并发症发生,提高患者生活质量.     

Assessment of quadriceps muscle weakness in patients after total knee arthroplasty and total hip arthroplasty: Methodological issues

The aim of this exploratory study was to verify whether the evaluation of quadriceps muscle weakness is influenced by the testing modality (isometric vs. isokinetic vs. isoinertial) and by the calculation method (within-subject vs. between-subject comparisons) in patients 4–8 months after total knee arthroplasty (TKA, n = 29) and total hip arthroplasty (THA, n = 30), and in healthy controls (n = 19). Maximal quadriceps strength was evaluated as (1) the maximal voluntary contraction (MVC) torque during an isometric contraction, (2) the peak torque during an isokinetic contraction, and (3) the one repetition maximum (1-RM) load during an isoinertial contraction. Muscle weakness was calculated as the difference between the involved and the uninvolved side (within-subject comparison) and as the difference between the involved side of patients and controls (between-subject comparison). Muscle weakness estimates were not significantly affected by the calculation method (within-subject vs. between-subject; P > 0.05), whereas a significant main effect of testing modality (P < 0.05) was observed. Isometric MVC torque provided smaller weakness estimates than isokinetic peak torque (P = 0.06) and isoinertial 1-RM load (P = 0.008), and the clinical occurrence of weakness (proportion of patients with large strength deficits) was also lower for MVC torque. These results have important implications for the evaluation of quadriceps muscle weakness in TKA and THA patients 4–8 months after surgery.     

Simulated hip abductor strengthening reduces peak joint contact forces in patients with total hip arthroplasty

Lower extremity muscle strength training is a focus of rehabilitation following total hip arthroplasty (THA). Strength of the hip abductor muscle group is a predictor of overall function following THA. The purpose of this study was to investigate the effects of hip abductor strengthening following rehabilitation on joint contact forces (JCFs) in the lower extremity and low back during a high demand step down task. Five THA patients performed lower extremity maximum isometric strength tests and a stair descent task. Patient-specific musculoskeletal models were created in OpenSim and maximum isometric strength parameters were scaled to reproduce measured pre-operative joint torques. A pre-operative forward dynamic simulation of each patient performing the stair descent was constructed using their corresponding patient-specific model to predict JCFs at the ankle, knee, hip, and low back. The hip abductor muscles were strengthened with clinically supported increases (0–30%) above pre-operative values in a probabilistic framework to predict the effects on peak JCFs (99% confidence bounds). Simulated hip abductor strengthening resulted in lower peak JCFs relative to pre-operative for all five patients at the hip (18.9–23.8 ± 16.5%) and knee (20.5–23.8 ± 11.2%). Four of the five patients had reductions at the ankle (7.1–8.5 ± 11.3%) and low back (3.5–7.0 ± 5.3%) with one patient demonstrating no change. The reduction in JCF at the hip joint and at joints other than the hip with hip abductor strengthening demonstrates the dynamic and mechanical interdependencies of the knee, hip and spine that can be targeted in early THA rehabilitation to improve overall patient function.     

Pelvic instability and trunk and hip muscle recruitment patterns in patients with total hip arthroplasty

Hip and lumbar spine disorders often coexist in patients with total hip arthroplasty (THA). The current study aimed to reveal pelvic motion pathology and altered trunk and hip muscle recruitment patterns relating to pelvic motion in patients with THA. Twenty-one women who underwent THA and 12 age-matched healthy women were recruited. Pelvic kinematics and muscle recruitment patterns (i.e., amplitude, activity balance, and onset timing) of the gluteus maximus, semitendinosus, multifidus, and erector spinae were collected during prone hip extension. Compared with healthy subjects, the patients showed increased pelvic motion, especially ventral rotation, decreased multifidus muscle activity relative to the hip extensors, and delayed onset of multifidus activity, despite reaction times and speeds of leg motion not being significantly different between the groups. Furthermore, while contributing factors associated with ventral pelvic rotation were not found, delayed onset of multifidus activity was detected as a factor related to the increased anterior tilt of the pelvis (r = 0.47, p < 0.05) in patients with THA. These results suggest that patients with THA have dysfunction of the stabilizer muscles of the lumbopelvic region along with increased pelvic motion.     

Measuring improvement following total hip and knee arthroplasty using the SF-36 Health Survey

The aim of this study was to evaluate the impact of total hip or knee arthroplasty upon quality of life in elderly patients. The study was carried out at the Clinic for Orthopaedic Surgery Lovran on 74 total hip arthroplasty and 70 total knee arthroplasty patients. All patients had completed the Medical Outcomes Study 36-Item Short Form in the week having preceded their surgery and then again postoperatively, 2 years after. The data obtained were statistically processed at the level of physical function, role limitations due to physical problems, role limitations due to emotional problems, social function, mental health, energy or vitality, pain and general health perception, and change in health. The primary total hip arthroplasty patients showed significant improvement at all levels measured. Similarly, the primary total knee arthroplasty patients expressed significant improvement according to all the parameters but the mental health assessment. Comparison of outcomes between the two assessment groups of patients resulted in slightly superior quality of life outcomes in total hip arthroplasty patients. It can be concluded that total hip or knee arthroplasty significantly enhances the health related quality of life in elderly patients.     

Subject-specific musculoskeletal modelling in patients before and after total hip arthroplasty*

The goal of this study was to define the effect on hip contact forces of including subject-specific moment generating capacity in the musculoskeletal model by scaling isometric muscle strength and by including geometrical information in control subjects, hip osteoarthritis and total hip arthroplasty patients. Scaling based on dynamometer measurements decreased the strength of all flexor and abductor muscles. This resulted in a model that lacked the capacity to generate joint moments required during functional activities. Scaling muscle forces based on functional activities and inclusion of MRI-based geometrical detail did not compromise the model strength and resulted in hip contact forces comparable to previously reported measured contact forces.     

Cementless Vektor-titan stem in total hip arthroplasty.

INTRODUCTION: Cementless THR is a well established, and a widely accepted optimal procedure for younger patients. The cementless Vektor-Titan stem is made of Ti6AI7Nb, has got the shape of a three-dimensional cone, and an optimal proximal anchoring property. MATERIALS AND METHODS: The aim of this prospective study was to scrutinise the outcome of 250 Vektor-Titan stems in cementless THRs with an average follow-up time of 3.0 years (Min: 1, Max: 6). The average age of the patients including 148 women and 102 men was calculated with 54.6 years (Min: 22.5, Max: 77.7). RESULTS: The score according to Merle d'Aubigné improved from preoperative 9.3 (Min: 7, Max: 13) to postoperative 17.0 (Min: 14, Max: 18). Distal cortical hypertrophy and proximal atrophy was detected in 4 cases. Single atrophy of the proximal femur was found in additional 3 cases. Progressive radiolucent lines in zone 1 and 7 according to Gruen were observed in one case. Postoperative local and general complications were seen as two subfascial hematomas, two single dislocations, two recurrent dislocations of the hip prosthesis, 6 lesions of the sciatic nerve (one persisting), two deep venous thrombosis, two pneumonias, and one lethal pulmonary embolism. A stable proximal fixation was achieved in 242 of 250 cases (96.8%). CONCLUSION: The results of this study using the Vektor-Titan stem in cementless total hip arthroplasty showed that the principle of proximal fixation was optimized. Long term follow-up studies are needed to confirm these good results.     

Reduced patient restrictions following total hip arthroplasty: study protocol for a randomized controlled trial

Stepped wedge cluster randomised trials introduce interventions to groups of clusters in a random order and have been used to evaluate interventions for health and wellbeing. Standardised guidance for reporting stepped wedge trials is currently absent, and a range of potential analytic approaches have been described. We systematically identified and reviewed recently published (2010 to 2014) analyses of stepped wedge trials. We extracted data and described the range of reporting and analysis approaches taken across all studies. We critically appraised the strategy described by three trials chosen to reflect a range of design characteristics. Ten reports of completed analyses were identified. Reporting varied: seven of the studies included a CONSORT diagram, and only five also included a diagram of the intervention rollout. Seven assessed the balance achieved by randomisation, and there was considerable heterogeneity among the approaches used. Only six reported the trend in the outcome over time. All used both ‘horizontal’ and ‘vertical’ information to estimate the intervention effect: eight adjusted for time with a fixed effect, one used time as a condition using a Cox proportional hazards model, and one did not account for time trends. The majority used simple random effects to account for clustering and repeat measures, assuming a common intervention effect across clusters. Outcome data from before and after the rollout period were often included in the primary analysis. Potential lags in the outcome response to the intervention were rarely investigated. We use three case studies to illustrate different approaches to analysis and reporting. There is considerable heterogeneity in the reporting of stepped wedge cluster randomised trials. Correct specification of the time-trend underlies the validity of the analytical approaches. The possibility that intervention effects vary by cluster or over time should be considered. Further work should be done to standardise the reporting of the design, attrition, balance, and time-trends in stepped wedge trials.     

In-vivo 3-Dimensional gait symmetry analysis in patients with bilateral total hip arthroplasty

Although three-dimensional (3D) asymmetry has been reported in unilateral THA patients during gait, it is not well understood whether asymmetric hip kinematics during gait persist in bilaterally operated THA patients. The purpose of this study was to compare the in vivo 3D kinematics and component placement between bilateral and unilateral THA patients during gait. Eight bilateral and thirty-three unilateral THA patients were evaluated for both hips during treadmill gait using a validated combination of 3D computer tomography-based modeling and dual fluoroscopic imaging system (DFIS). The in vivo 3D kinematics of the unilateral THA group was first assessed. The magnitudes of kinematics and component placement difference between implanted hips in the bilateral THA group and between the implanted and non-implanted hips in the unilateral THA group were compared. The study results showed asymmetric gait kinematics in the unilateral THA group. Although the magnitude of kinematics differences between sides for both the bilateral and unilateral THA groups did not change significantly for hip rotations (p > 0.05), the bilaterally operated THA group has significantly lower magnitude of hip gait translation difference. Significant reduction in the magnitude of the acetabular cup adduction, stem adduction, and combine hip anteversion and adduction difference was observed in the bilateral THA group (p < 0.05). Our findings demonstrated that despite significant improvements of component placement and reduced magnitude of hip gait translation difference between implanted hips in the bilateral THA group, asymmetric hip kinematic rotations persisted in patients with bilateral THA during gait.     

Osteodensitometry in uncemented total hip arthroplasty using computertomography.

The aim of this investigation was to evaluate a new method developed for the measurement of bone mineral density and bone remodelling phenomena after total hip arthroplasty using computer tomography. Computertomography is a radiological technique to examine bone structures in high resolution. Using an extended scale it is possible to investigate bone scans and implants with fewer metal artifacts. For osteodensitometry measurement a special software (IMPact HIP) for the analysis of the data was used. The measured parameters were the overall bone mineral density (mg Calcium-Hydroxyapatite/ml) and the cortical bone structure. A standard scan mode enable to compare the computertomography scans at follow-up. Nineteen total hip arthroplasty patients (20 hips) with a mean age of 58 years (31-70) were operated on using an uncemented titanium alloy stem with a tapered design. The periprosthetic bone was assessed using computertomography-assisted osteodensitometry two weeks and one year after surgery. We observed a decrease of the overall bone mineral density (15%) and of the cortical bone structure (20%) one year after insertion of the stem in the proximal part of the femur. The area corresponds to the Gruen zones 1 and 7. On the other hand, a decrease of mineral density of 5% for the overall bone and of 3% for the cortical bone was found at the level of the tip of the stem, which corresponds to the Gruen zones 3, 4 and 5. Computertomography-assisted osteodensitometry allows to investigate the bone remodelling after total hip arthroplasty by separating the analysis of the overall bone mineral density and of the cortical structure. The present method is a reliable tool for quality-control in total hip arthroplasty.     

Occlusion following laser resurfacing promotes reepithelialization and wound healing

One of the critical parameters that has not been examined carefully following laser skin resurfacing is the effect of eschar on the wound healing process. Because occlusive dressings minimize the occurrence of eschar, the present study was undertaken to evaluate the effect of occlusion following laser resurfacing. It is clear that CO2 lasers promote epidermal cell loss and variable amounts of dermal injury. To characterize the wound repair process after laser treatment, biopsy specimens were obtained 2 to 4 days after treatment. Specimens from 15 patients were examined; the preauricular biopsy specimens were paired such that one specimen was from skin that had been occluded and the other specimen (from the same patient) was from skin treated without occlusion. Skin specimens were examined by indirect immunofluorescence using antibodies to specific epidermal and dermal antigens. The results indicate that the keratinocytes that repopulate the epidermis migrate from the hair follicles and express keratin 17, an intermediate filament protein expressed in keratinocytes during the early stages of wound healing. The migration of keratin 17-expressing cells begins 48 hours following laser resurfacing in skin treated with occlusion, whereas cell migration from the follicles of skin treated without occlusion is delayed. In summary, occlusion promotes enhanced cell migration and diminished eschar formation, resulting in more rapid healing.     

Spontaneous skin damage and delayed wound healing in SOD1-deficient mice

Superoxide dismutase 1 (SOD1) is an important antioxidative enzyme that protects skin from oxidative stress. SOD1 ^?/? mice with a genetic background of b129Sv mice showed facial skin damage after 15 weeks of age. Eyelid swelling occurred as the initial symptom and caused impairment by triggering self-scratching. The period required for wound healing in the back was markedly delayed in 20-week SOD1 ^?/? mice. Oxidative stress markers, 4-hydroxynonenal and thiobarbituric acid-reactive substances, were unexpectedly lower in SOD1 ^?/? mice at day 1 after wounding. The decay rate of electron paramagnetic resonance signal intensity of intravenously injected nitroxide radical indicated that the half-life of the signal intensity was significantly prolonged in the wounded skin of SOD1 ^+/+ mice. However, while the half-life of the signal intensity in control skin was a little longer in SOD1 ^?/? mice, it did not change in wounded skin. Taken together, these data suggest that the skin of SOD1 ^?/? mice is in redox imbalance and prone to damage by wounding.     

Four-dimensional model of the lower extremity after total hip arthroplasty

We have developed a four-dimensional (4D) model of the lower extremities after total hip arthroplasty in patients. The model can aid in preventing complications such as dislocation and wearing of the sliding surface. The skeletal structure and implant alignment were obtained from CT data. We applied registration method using CAD data to estimate accurate implant alignment from scattered CT data. The reconstructed three-dimensional (3D) skeletal model was combined with motion capture data that were acquired by an optical tracking system. We displayed the patient's skeletal movement and analyzed several parameters that relate to complications. The patient's skeletal model was superimposed onto video footage that was taken by a synchronized and calibrated digital video camera. For validation of the measurement error in this system, we used open MRI to evaluate the relative movement between skin markers and bones. This system visually represents not only the 3D anatomical structure, but also 4D dynamic functions that include the time sequential transitions of components and their positions. The open MRI results indicated that the average error in hip angle was within 5° for each static posture. This system enables clinicians to analyze patient's motions on the basis of individual differences. We found that our system was an effective tool in providing precise guidance of daily postoperative motions that was individualized for each patient. This system will be applicable for surgical planning, assessment of postoperative activities, and the development of new surgical techniques, materials, and prosthetic designs.     

Comparison of patient and surgeon expectations of total hip arthroplasty

Objectives

Analysis of discrepancies between patient and surgeon expectations before total hip arthroplasty (THA) should enable a better understanding of motives of dissatisfaction about surgery, but this question has been seldom studied. Our objectives were to compare surgeons'' and patients'' expectations before THA, and to study factors which affected surgeon-patient agreement.

Methods

132 adults (mean age 62.8+/−13.7 years, 52% men) on waiting list for THA in three tertiary care centres and their 16 surgeons were interviewed to assess their expectations using the Hospital for Special Surgery Total Hip Replacement Expectations Survey (range 0–100). Patients'' and surgeons'' answers were compared, for the total score and for the score of each item. Univariate analyses tested the effect of patients'' characteristics on surgeons'' and patients'' expectations separately, and on surgeon-patient differences.

Results

Surgeon and patient expectations'' mean scores were high (respectively 90.9+/−11.1 and 90.0+/−11.6 over 100). Surgeons'' and patients'' expectations showed no systematic difference, but there was little agreement on Bland and Altman graph and correlation coefficient was low. Patients had higher expectations than surgeons for sports. Patients rated their expectations according to trust in physician and mental quality of life, surgeons considered disability. More disabled patients and patients from a low-income professional category were often “more optimistic” than their surgeons.

Conclusion

Surgeons and patients often do not agree on what to expect from THA. More disabled patients expect better outcomes than their surgeons.     

Assessment of hip extensor and flexor strength two months after unilateral total hip arthroplasty

This investigation assessed strength of the hip extensors and flexors when assistive devices and weight bearing are changing after total hip arthroplasty (THA). Eleven individuals (6 men, 5 women; mean age 74.45 +/- 4.88 years) with unilateral THA were evaluated isokinetically at 60 degrees x sec(-1) before surgery on the involved and uninvolved limbs. Each subject's involved limb was tested 60 days after surgery. Comparisons were made between involved and uninvolved limbs and between the involved limb before surgery and 60 days after surgery for both the hip extensors and flexors. Hip extensor and flexor strength before surgery on the involved side was 39% and 29% lower, respectively, compared with the uninvolved side. Sixty days after surgery, strength of the hip extensors and flexors improved 50% and 27%, respectively, compared with before surgery. Over the 60-day interval, the responsiveness of isokinetic testing was high for both muscle groups (range, 0.74-1.51). It would seem appropriate that intensive rehabilitation continue through at least the 60-day period and that isokinetic testing is an effective tool to monitor hip strength before and after surgery.     

Mice lacking Smad3 show accelerated wound healing and an impaired local inflammatory response

The generation of animals lacking SMAD proteins, which transduce signals from transforming growth factor-beta (TGF-beta), has made it possible to explore the contribution of the SMAD proteins to TGF-beta activity in vivo. Here we report that, in contrast to predictions made on the basis of the ability of exogenous TGF-beta to improve wound healing, Smad3-null (Smad3ex8/ex8) mice paradoxically show accelerated cutaneous wound healing compared with wild-type mice, characterized by an increased rate of re-epithelialization and significantly reduced local infiltration of monocytes. Smad3ex8/ex8 keratinocytes show altered patterns of growth and migration, and Smad3ex8/ex8 monocytes exhibit a selectively blunted chemotactic response to TGF-beta. These data are, to our knowledge, the first to implicate Smad3 in specific pathways of tissue repair and in the modulation of keratinocyte and monocyte function in vivo.     

Patient-specific computational simulations of wound healing following midline laparotomy closure

Biomechanics and Modeling in Mechanobiology - In the current study, we developed a new computational methodology to simulate wound healing in soft tissues. We assumed that the injured tissue...