This diploma thesis deals with hip endoprothesis, primarily with endoprothesis conservative Mayo. A part of this paper considers a study aimed at an anatomy, types and modern trends in endoprothetic. On the basis of this study, gained CT data and the help of systems Ansys Workbench, Rhino Ceros and Catia there was made a model of proximal part of femur and TEP Conservative Mayo. A computational model was build up afterwards, which was used for a stress-train analysis.

隨著全球人口結構高齡化和醫療技術的日新月異，使得全球醫療器材市場，正以前所未有的速度，快速地蓬勃發展，預估2006年全球醫療器材市場的總值約為1,643.57億美元，相對於2006年我國醫療器材產業的營業額新台幣690億元，我國目前大概只佔全球醫療器材市場總值的1.4%，相較於半導體、以及電子業稱霸國際，全球醫療器材市場，不啻是我國廠商的一片藍海! 2004年全球骨科市場的價值達190億美元，預期未來十年的年平均成長率將高達10~13%，聯合骨科在人工關節的設計與製造，具有亞洲第一的水準，非常具有競爭優勢，然而，由於歐美知名品牌的公司規模及在中國人工關節市場先驅者的地位，聯合骨科如何在激烈的競爭環境中脫穎而出，考驗著聯合骨科經理人的智慧；目前，聯合骨科在台灣及大陸，分別擁有約20% 以及10% 的市場佔有率，並在西安與新竹建立生產基地。 透過實際參與中國人工關節市場操作的台灣及大陸的聯合骨科經理人、競爭廠商經理人、以及學術界的專家的角度，利用策略行銷4C成本理論，分析聯合骨科在中國人工關節市場的發展現況的優缺點與可能的成因之後，本研究建議聯合骨科在運用有限資源的有效性及時效性的考量之下，可以考慮優先解決買者的外顯單位效益成本以及買者的專屬陷入成本，進而取得市場上的優勢，除此之外，如果他們能夠持續地提升技術層面的優勢之外，更進一步的創造行銷與服務方面的效能，必能在中國的人工關節市場上，取得優勢，創造出更亮麗的成績；深耕中國、佈局世界，以期與世界級的品牌大廠，能夠在全球的人工關節市場競爭上，有更卓越的表現！ / Along with global aging population and rapid advancement of medical technology, global medical devices market is increasing at the fastest speed ever and is reaching US$ 164B in 2006. 2006 Taiwan medical devices market is US$ 2.3B which is only 1.4% of overall global medical devices market. Comparing with dominant positions of Taiwan semiconducting and electronic industries, global medical devices market is a great “Blue Ocean” opportunity! Global orthopedic market will reach US$ 19B in 2004 and is expected to grow at 10-13% annually for the coming 10 years. United Orthopedic Corporation （UOC） is very competitive and is in a leading position in orthopedic joint design and manufacturing in Asia. Due to relative large company size and market pioneer position of well-known US & European brands in China, management team of UOC is facing a tremendous challenge to win this game；So far, UOC is holding 20% and 10% of market share in Taiwan and China, respectively. UOC has set-up manufacturing bases in both Xian and Hsin-Chu. After consolidating individual assessment of UOC management team, competitors’ management team as well as experts from academic society who are personally involving in orthopedic joint market in China and applying the strategic marketing analysis of 4C theory, we have concluded the strength/weakness and their possible causes of UOC current market status in China. Based on our findings, we suggest UOC could consider utilize its limited resources effectively and efficiently, as priorities, to build up its competitiveness on Cost/Utility ratio and Asset Specificity. If UOC can create effectiveness on both marketing and service furthermore, it can achieve competitive advantage and better performance in China orthopedic joint market；Establishing a strong foundation in China and structuring its market position in the world. UOC will be able to tackle face-to-face competition with world-class orthopedic companies in global market!

Depuis les dernières années, la prévalence de personnes souffrant de dégénérescence des cartilages articulaires, communément appelée ostéoarthrite (OA), ne cesse d’augmenter. Les douleurs articulaires et les raideurs musculaires associées à cette pathologie mènent à des limitations des capacités fonctionnelles, à une perte de mobilité et d’autonomie affectant grandement la qualité de vie de ces personnes. Afin de soulager les personnes souffrant de cette pathologie, l’arthroplastie de la hanche est une procédure chirurgicale fréquemment utilisée. À la suite de cette chirurgie, une amélioration de la qualité de vie et une reprise des capacités fonctionnelles sont souvent observées. Cependant, comparativement à des sujets sains, la vitesse de marche est diminuée, une faiblesse des muscles abducteurs de la hanche est constatée et des mouvements compensatoires au niveau du tronc sont persistants. L’objectif de cette thèse est d’évaluer le patron locomoteur chez des patients qui subiront une arthroplastie de la hanche. Plus spécifiquement, les adaptations locomotrices pré et post-opératoires seront quantifiées dans le but d’apporter des modifications aux programmes de réhabilitation pour ainsi favoriser un patron locomoteur sans déficit. Afin de répondre à cet objectif, trois études distinctes ont été effectuées. Dans le cadre de la première étude, l’impact de l’implantation d’une prothèse totale de la hanche avec une tête fémorale de large diamètre et une prothèse de resurfaçage a été évalué par rapport aux sujets sains lors de la locomotion. Au cours de cette étude, le contrôle du tronc a été analysé en utilisant la distance entre le centre de masse corporel et le centre articulaire de la hanche opérée. Suite aux résultats obtenus, aucune différence majeure n’existe entre les deux types de prothèses en ce qui a trait au contrôle du tronc et ce, à un an post-opératoire. Lors de la deuxième étude, la symétrie des paramètres biomécaniques des membres inférieurs lors de la locomotion chez des patients ayant bénéficié de l’implantation d’une prothèse de la hanche a été caractérisée suite à un programme d’exercices péri-opératoires (pré et post-opératoire). Lors de cette étude, le programme d’exercices péri-opératoires était complémentaire au protocole de réadaptation du centre hospitalier. D’après les résultats obtenus lors de cette étude exploratoire, ce programme d’exercices péri-opératoires semble permettre d’améliorer la symétrie de la puissance et du travail musculaire au niveau de la hanche, du genou et de la cheville favorisant ainsi un patron de marche avec de minimes compensations. Finalement, dans le cadre de la troisième étude, l’approche prédictive et l’approche fonctionnelle, utilisées pour localiser le centre articulaire de la hanche, ont été comparées aux mesures radiographiques, chez des patients à la suite d’un remplacement articulaire de la hanche. À la suite de cette étude, les résultats démontrent que l’utilisation de l’approche fonctionnelle est plus appropriée chez des patients ayant bénéficié d’une arthroplastie de la hanche. En effet, cette approche individualisée est plus précise ce qui, par conséquent, permettra d’obtenir des résultats de plus grande qualité lors d’analyses biomécaniques de la locomotion. / In recent years, the prevalence of people suffering from joint cartilage degeneration, called osteoarthritis (OA), still increases. The joint pain and muscle stiffness related to this pathology have an impact on patients’ quality of life by limiting their functional capacities, mobility and autonomy. In order to relieve these patients, hip arthroplasty is a frequently used surgical procedure. Even if there is an improvement in quality of life and a restoration of functional capacities in these patients, some impairment seem to persist during the post-operative period. The walking velocity is slower when compared to healthy subjects, a hip abductor muscle weakness is observed and trunk compensations lasted during the post-operative period. The aim of this thesis is to evaluate patients undergoing hip arthroplasty during locomotion. More specifically, gait pattern adaptations will be quantified pre and post-operatively to revise rehabilitation programs in order to promote a healthy gait pattern. Three separate studies were conducted to meet this objective. The first study compared the effect of a large femoral head hip prosthesis and a hip resurfacing prosthesis to healthy subjects. During this study, the trunk control was analyzed using the distance between the body center of mass and the hip prosthetic joint center. The results obtained show no major difference between the two types of prosthesis and the healthy control one year post-operatively. During the second study, biomechanics parameter symmetry of the lower limb of gait pattern in patients undergoing hip arthroplasty was characterized following a peri-operative (pre and post-operatively) exercise program. The exercise program was complementary to the medical center standard rehabilitation program. Based on the results of this exploratory study, the peri-operative exercise program seems to improve the symmetry of the muscular power and work of the hip, knee and ankle which promote a healthy gait pattern without compensations. Finally, for the third study, the predictive and the functional approaches, used to locate the hip joint center, were compared to radiographic measurements in patients undergoing hip arthroplasty. The results of this study demonstrated that the functional approach was more appropriate for these patients. This individualized approach is more accurate which leads to quality improvement during biomechanical analysis of gait pattern.

Submitted by Filipe dos Santos (fsantos@pucsp.br) on 2018-11-26T11:12:22Z No. of bitstreams: 1 Carolina Campos Machado Marques Horta.pdf: 13050055 bytes, checksum: d05c55aa48de89c384578ec4803c576e (MD5) / Made available in DSpace on 2018-11-26T11:12:22Z (GMT). No. of bitstreams: 1 Carolina Campos Machado Marques Horta.pdf: 13050055 bytes, checksum: d05c55aa48de89c384578ec4803c576e (MD5) Previous issue date: 2018-08-15 / Treatment adherence has become a recurrent debate and research topic during the last 40 years. Poor adhesion is one of the main reasons for unsatisfactory results in the treatment of a disease. One of the main problems found by health professionals in the area of hip orthopedy is the poor adhesion to the preoperative and postoperative protocols for the total hip joint replacement arthroplasty, which reduce the patient's quality of life and waste health resources. This study aimed to develop and evaluate a behavioral intervention to increase the adhesion to the preoperative and postoperative protocols for the total hip joint replacement arthroplasty addressed to a patient which presented poor adhesion to the protocol in his first surgery. We used: (a) two surveys: one to evaluate the adhesion of the patient to the protocols, and the other to verify if the patient knew how to detect and describe relevant signals that should be reported to health professionals after the surgery; (b) two logs: one to evaluate the answers given by the patient in face-to-face meetings, and the other to evaluate the verbal report about his behavior in the last 24 hours in phone interviews; (c) an educational booklet with written instructions and images to guide the patient on the appropriate behavior before and after the surgery; and (d) three videos with examples of the exercises that should be executed before and after the surgery and appropriate movements of the body. In the initial meeting with the patient, we evaluated whether he fulfilled all the criteria to participate in the study. Before the intervention the researcher evaluated which behaviors were already a part of the patient's behavioral repertoire. During the intervention, the researcher used several strategies to increase the probability of adhesion to the surgical protocol, including shaping, modeling, instructions and positive reinforcement, in face-to-face meetings and in telephone interviews. After the intervention, the researcher repeated the same steps carried in before the intervention, besides phone interviews. During this phase the patient also filled a survey similar to the one used in the initial meeting. The results showed that the intervention produced a positive effect on patient's adherence to the surgical protocols. After the study, the patient presented a more complete adhesion to the items in the protocol to which adhesion was initially only partial / A adesão ao tratamento tornou-se objeto de intensas investigações e debates nos últimos 40 anos. Um dos grandes problemas encontrados pelos profissionais de saúde, na área da ortopedia do quadril, é a pobre adesão ao protocolo pré e pós-operatório da artroplastia de substituição total do quadril (ATQ), o que causa prejuízos à qualidade de vida e à saúde do paciente e desperdiça recursos de saúde. O presente estudo teve como objetivo desenvolver e avaliar uma intervenção comportamental para aumentar a adesão ao protocolo cirúrgico da revisão da artroplastia de substituição total da articulação do quadril (ARQ) por um paciente que apresentou pobre adesão ao protocolo na primeira cirurgia. Foram utilizados (a) dois questionários, um para avaliar a adesão do participante ao protocolo cirúrgico, e outro para avaliar a identificação e descrição de sinais relevantes que devem ser descritos à equipe de saúde após a cirurgia, utilizado nas fases Pré-Intervenção, Intervenção e Seguimento; (b) duas folhas de registro, uma para avaliar as respostas apresentadas pelo participante em encontros presenciais com a pesquisadora, outra para avaliar o relato sobre a ocorrência de adesão apresentada pelo participante nas últimas 24 horas em entrevistas por telefone; (c) um livreto educativo com instruções escritas e imagens relacionadas à cirurgia para orientar o participante sobre os comportamentos que devem ser apresentados no pré e no pós-operatório da ARQ e (d) três vídeos para oferecer modelos dos exercícios que devem ser executados no pré-operatório, dos movimentos apropriados após a cirurgia e dos exercícios que devem ser praticados no pós-operatório. No Encontro Inicial avaliou-se se o participante preenchia os critérios para participação no estudo. Na Pré-intervenção, a pesquisadora avaliou os comportamentos de adesão que já faziam parte do repertório comportamental do participante. Na fase Intervenção, a pesquisadora utilizou estratégias para aumentar a probabilidade de ocorrência de comportamentos de adesão ao protocolo cirúrgico, a saber, modelagem, modelação, instruções e reforçamento positivo, em encontros presenciais e em entrevistas por telefone. No seguimento a pesquisadora repetiu o mesmo procedimento da fase Pré-intervenção acrescido de entrevistas por telefone utilizadas na Intervenção e do Questionário de adesão ao protocolo cirúrgico utilizado no Encontro Inicial. Os resultados mostraram que a intervenção produziu um efeito positivo sobre a adesão do participante ao protocolo cirúrgico. Ao final do estudo o participante passou a apresentar uma adesão mais completa aos itens do tratamento para os quais a adesão era inicialmente apenas parcial

Sze Pan Ching. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2006. / Includes bibliographical references (leaves 162-178). / Abstracts in English and Chinese. / ABSTRACT --- p.i / ABSTRACT (IN CHINESE) --- p.iv / ACKNOWLEGEMENT --- p.vi / TABLE OF CONTENTS --- p.viii / LIST OF FIGURES --- p.xv / LIST OF TABLES --- p.xviii / LIST OF APPENDIX --- p.xx / LIST OF ABBREVIATIONS --- p.xxi / LIST OF DEFINITIONS OF TERMS --- p.xxii / Chapter I. --- INTRODUCTION --- p.1 / Chapter 1.1 --- Epidemiology of hip fracture among elderly worldwide --- p.1 / Chapter 1.2 --- Impact of hip fractures --- p.3 / Chapter 1.2.1 --- Mortality --- p.3 / Chapter 1.2.2 --- Hospitalization and institutionalization --- p.4 / Chapter 1.2.3 --- Morbidity --- p.4 / Chapter 1.2.4 --- Psychological impact and quality of life --- p.5 / Chapter 1.2.5 --- Financial burden --- p.6 / Chapter 1.3 --- Causes of hip fracture --- p.6 / Chapter 1.3.1 --- Mechanisms of hip fracture --- p.7 / Chapter 1.3.2 --- Degenerated protective mechanism --- p.8 / Chapter 1.3.3 --- Poor hip strength indices --- p.9 / Chapter 1.4 --- Prevention of hip fractures --- p.10 / Chapter 1.4.1 --- Reduction of the chance of lateral fall --- p.10 / Chapter 1.4.2 --- Increase hip strength indices --- p.11 / Chapter 1.4.3 --- Limitations of current strategies --- p.12 / Chapter 1.5 --- Hip protectors for prevention of hip fractures --- p.12 / Chapter 1.6 --- Effectiveness of hip protector --- p.14 / Chapter 1.6.1 --- Laboratory studies on effectiveness in force attenuation --- p.14 / Chapter 1.6.2 --- Clinical studies on prevention of hip fractures --- p.16 / Chapter 1.6.3 --- Cost-effectiveness study --- p.17 / Chapter 1.7 --- Problems on the use of hip protectors --- p.19 / Chapter 1.7.1 --- Discomfort --- p.19 / Chapter 1.7.2 --- Extra effort in wearing --- p.20 / Chapter 1.7.3 --- Appearance after wearing --- p.21 / Chapter 1.7.4 --- Urinary incontinence --- p.22 / Chapter 1.7.5 --- Oth er problems --- p.23 / Chapter 1.8 --- Acceptance and Compliance of hip protectors --- p.23 / Chapter 1.8.1 --- Acceptance --- p.23 / Chapter 1.8.2 --- Compliance --- p.24 / Chapter 1.9 --- Strategies to improve compliance of hip protector --- p.25 / Chapter 1.9.1 --- Better design of hip protector --- p.25 / Chapter 1.9.2 --- Encouragement/support to the user --- p.26 / Chapter 1.9.3 --- Support from nursing staff/carer --- p.27 / Chapter 1.10 --- Rationale and objectives of present study --- p.28 / Chapter II. --- METHODOLOGY --- p.36 / Chapter 2.1 --- Development of hip protector --- p.36 / Chapter 2.1.1 --- Design of the pads --- p.36 / Chapter 2.1.2 --- Design of the pants --- p.38 / Chapter 2.1.2.1 --- Fabric materials --- p.38 / Chapter 2.1.2.2 --- Anthropometric measurement --- p.42 / Chapter 2.1.2.3 --- Pattern design --- p.43 / Chapter 2.1.3 --- Trial use of hip protector --- p.43 / Chapter 2.1.4 --- Calculation and statistical method --- p.43 / Chapter 2.2 --- Mechanical test on force attenuation properties --- p.44 / Chapter 2.2.1 --- Testing system --- p.44 / Chapter 2.2.2 --- Simulation of impact force and identification of dropping height --- p.45 / Chapter 2.2.3 --- Testing method --- p.46 / Chapter 2.2.4 --- Calculation and statistical method --- p.47 / Chapter 2.3 --- Compliance study --- p.47 / Chapter 2.3.1 --- Setting --- p.47 / Chapter 2.3.2 --- Subjects --- p.48 / Chapter 2.3.3 --- Study design --- p.49 / Chapter 2.3.4 --- Implementation procedure and intervening Program --- p.49 / Chapter 2.3.4.1 --- Liaison with the heads and responsible staff in the elderly hostels --- p.49 / Chapter 2.3.4.2 --- Education program for hostel staff --- p.50 / Chapter 2.3.4.3 --- Education program for elderly subjects --- p.50 / Chapter 2.3.4.4 --- Fall and fracture risk counseling --- p.51 / Chapter 2.3.4.5 --- Consent and Ethical approval --- p.51 / Chapter 2.3.4.5 --- Provision of hip protector and training program on wearing hip protector --- p.51 / Chapter 2.3.4.6 --- Follow up and encouragement on the use of hip protector --- p.52 / Chapter 2.3.5 --- Outcome measures --- p.52 / Chapter 2.3.5.1 --- Primary outcome --- p.52 / Chapter 2.3.5.2 --- Secondary outcomes --- p.53 / Chapter 2.3.6 --- Measurement method --- p.55 / Chapter 2.3.6.1 --- Compliance --- p.55 / Chapter 2.3.6.2 --- Falls and fractures incidence --- p.56 / Chapter 2.3.6.3 --- Adverse effect and feedback after wearing hip protector --- p.56 / Chapter 2.3.6.4 --- Fear of fall --- p.57 / Chapter 2.3.6.5 --- Fall and fracture history --- p.57 / Chapter 2.3.6.6 --- Medical co-morbidities --- p.58 / Chapter 2.3.6.7 --- Presence of urinary incontinence --- p.58 / Chapter 2.3.6.8 --- Functional level --- p.58 / Chapter 2.3.6.9 --- Hand function --- p.58 / Chapter 2.3.6.10 --- Mobility --- p.59 / Chapter 2.3.6.11 --- Cognitive function --- p.59 / Chapter 2.3.7 --- Sample size calculation --- p.59 / Chapter 2.3.8 --- Calculation and Statistical method --- p.60 / Chapter III. --- RESULTS --- p.73 / Chapter 3.1 --- Design of hip protector --- p.73 / Chapter 3.1.1 --- The design of pants --- p.73 / Chapter 3.1.1.1 --- The fabric materials --- p.73 / Chapter 3.1.1.2 --- The size of the pants --- p.74 / Chapter 3.1.2 --- The design of pads --- p.75 / Chapter 3.1.2.1 --- Thickness of silicon padding --- p.75 / Chapter 3.1.1.2 --- Dimension of the hard shield --- p.75 / Chapter 3.2 --- Mechanical test on force attenuation properties of the pads --- p.76 / Chapter 3.2.1 --- Impact force --- p.76 / Chapter 3.2.2 --- Impact duration --- p.78 / Chapter 3.2.3 --- Selection of th e prototype --- p.78 / Chapter 3.3 --- Compliance study --- p.79 / Chapter 3.3.1 --- Demograph ics --- p.79 / Chapter 3.3.2 --- Primary outcome --- p.79 / Chapter 3.3.2.1 --- Initial acceptance rate --- p.79 / Chapter 3.3.2.2 --- Compliance rate --- p.79 / Chapter 3.3.2.3 --- Percentage of people wearing hip protector across the study period --- p.81 / Chapter 3.3.2.4 --- Percentage of protected fall --- p.81 / Chapter 3.3.3 --- Secondary outcomes --- p.81 / Chapter 3.3.3.1 --- Fall and related injury among the subjects in the study period --- p.81 / Chapter 3.3.3.2 --- Reasons for non-acceptance --- p.82 / Chapter 3.3.3.3 --- Feedback in using hip protector --- p.84 / Chapter 3.3.3.4 --- Factors associated with compliance and non-compliance (feedback in wearing hip protector) --- p.84 / Chapter 3.3.3.5 --- Factors associated with compliance and non-compliance (subject characteristics) --- p.85 / Chapter 3.3.3.6 --- Effect on mobility after wearing hip protector --- p.85 / Chapter 3.3.3.7 --- Fear of fall after wearing hip protector --- p.85 / Chapter IV. --- DISCUSSION --- p.123 / Chapter 4.1 --- Development of a hip protector for Chinese elderly --- p.124 / Chapter 4.1.1 --- Successful modifications made to the pads --- p.124 / Chapter 4.1.1.1 --- More comfort to wear with silicon cushioning materials added --- p.124 / Chapter 4.1.1.2 --- Better mechanical properties with semi-flexible plastic and silicon pad --- p.125 / Chapter 4.1.1.3 --- Smaller in dimension of the present model might improve appearance after wearing --- p.127 / Chapter 4.1.2 --- No significant improvement on compliance with modification of the pants --- p.128 / Chapter 4.2 --- Sufficient mechanical properties of hip protector demonstrated --- p.129 / Chapter 4.2.1 --- Mechanical test set up --- p.130 / Chapter 4.2.2 --- Mechanism of force attenuation --- p.132 / Chapter 4.3 --- No significant improvement on compliance shown --- p.134 / Chapter 4.4 --- Compliance at night time better than other studies --- p.136 / Chapter 4.5 --- Determinants of compliance mostly related to subjects' feedback of using hip protector rather than on their characteristics --- p.137 / Chapter 4.6 --- Better compliance observed in hostel with higher staff-to-subject ration and with occupational therapist as contact person --- p.138 / Chapter 4.7 --- Better acceptance rate of hip protector shown in the present study --- p.139 / Chapter 4.8 --- Identification of factors influencing acceptance --- p.139 / Chapter 4.9 --- Percentage of protected fall was higher than mean compliance --- p.141 / Chapter 4.10 --- No hip fracture occurred while subjects wearing hip protector --- p.141 / Chapter 4.11 --- Decreased fear of falling after wearing hip protector --- p.142 / Chapter 4.12 --- Limitation --- p.142 / Chapter 4.13 --- Recommendation --- p.143 / Chapter V. --- CONCLUSION --- p.146 / Chapter VI. --- APPENDIX --- p.148 / Chapter VII. --- BIBLIOGRAPHY --- p.162 / Chapter VIII. --- PUBLICATIONS --- p.179

Depuis les dernières années, la prévalence de personnes souffrant de dégénérescence des cartilages articulaires, communément appelée ostéoarthrite (OA), ne cesse d’augmenter. Les douleurs articulaires et les raideurs musculaires associées à cette pathologie mènent à des limitations des capacités fonctionnelles, à une perte de mobilité et d’autonomie affectant grandement la qualité de vie de ces personnes. Afin de soulager les personnes souffrant de cette pathologie, l’arthroplastie de la hanche est une procédure chirurgicale fréquemment utilisée. À la suite de cette chirurgie, une amélioration de la qualité de vie et une reprise des capacités fonctionnelles sont souvent observées. Cependant, comparativement à des sujets sains, la vitesse de marche est diminuée, une faiblesse des muscles abducteurs de la hanche est constatée et des mouvements compensatoires au niveau du tronc sont persistants. L’objectif de cette thèse est d’évaluer le patron locomoteur chez des patients qui subiront une arthroplastie de la hanche. Plus spécifiquement, les adaptations locomotrices pré et post-opératoires seront quantifiées dans le but d’apporter des modifications aux programmes de réhabilitation pour ainsi favoriser un patron locomoteur sans déficit. Afin de répondre à cet objectif, trois études distinctes ont été effectuées. Dans le cadre de la première étude, l’impact de l’implantation d’une prothèse totale de la hanche avec une tête fémorale de large diamètre et une prothèse de resurfaçage a été évalué par rapport aux sujets sains lors de la locomotion. Au cours de cette étude, le contrôle du tronc a été analysé en utilisant la distance entre le centre de masse corporel et le centre articulaire de la hanche opérée. Suite aux résultats obtenus, aucune différence majeure n’existe entre les deux types de prothèses en ce qui a trait au contrôle du tronc et ce, à un an post-opératoire. Lors de la deuxième étude, la symétrie des paramètres biomécaniques des membres inférieurs lors de la locomotion chez des patients ayant bénéficié de l’implantation d’une prothèse de la hanche a été caractérisée suite à un programme d’exercices péri-opératoires (pré et post-opératoire). Lors de cette étude, le programme d’exercices péri-opératoires était complémentaire au protocole de réadaptation du centre hospitalier. D’après les résultats obtenus lors de cette étude exploratoire, ce programme d’exercices péri-opératoires semble permettre d’améliorer la symétrie de la puissance et du travail musculaire au niveau de la hanche, du genou et de la cheville favorisant ainsi un patron de marche avec de minimes compensations. Finalement, dans le cadre de la troisième étude, l’approche prédictive et l’approche fonctionnelle, utilisées pour localiser le centre articulaire de la hanche, ont été comparées aux mesures radiographiques, chez des patients à la suite d’un remplacement articulaire de la hanche. À la suite de cette étude, les résultats démontrent que l’utilisation de l’approche fonctionnelle est plus appropriée chez des patients ayant bénéficié d’une arthroplastie de la hanche. En effet, cette approche individualisée est plus précise ce qui, par conséquent, permettra d’obtenir des résultats de plus grande qualité lors d’analyses biomécaniques de la locomotion. / In recent years, the prevalence of people suffering from joint cartilage degeneration, called osteoarthritis (OA), still increases. The joint pain and muscle stiffness related to this pathology have an impact on patients’ quality of life by limiting their functional capacities, mobility and autonomy. In order to relieve these patients, hip arthroplasty is a frequently used surgical procedure. Even if there is an improvement in quality of life and a restoration of functional capacities in these patients, some impairment seem to persist during the post-operative period. The walking velocity is slower when compared to healthy subjects, a hip abductor muscle weakness is observed and trunk compensations lasted during the post-operative period. The aim of this thesis is to evaluate patients undergoing hip arthroplasty during locomotion. More specifically, gait pattern adaptations will be quantified pre and post-operatively to revise rehabilitation programs in order to promote a healthy gait pattern. Three separate studies were conducted to meet this objective. The first study compared the effect of a large femoral head hip prosthesis and a hip resurfacing prosthesis to healthy subjects. During this study, the trunk control was analyzed using the distance between the body center of mass and the hip prosthetic joint center. The results obtained show no major difference between the two types of prosthesis and the healthy control one year post-operatively. During the second study, biomechanics parameter symmetry of the lower limb of gait pattern in patients undergoing hip arthroplasty was characterized following a peri-operative (pre and post-operatively) exercise program. The exercise program was complementary to the medical center standard rehabilitation program. Based on the results of this exploratory study, the peri-operative exercise program seems to improve the symmetry of the muscular power and work of the hip, knee and ankle which promote a healthy gait pattern without compensations. Finally, for the third study, the predictive and the functional approaches, used to locate the hip joint center, were compared to radiographic measurements in patients undergoing hip arthroplasty. The results of this study demonstrated that the functional approach was more appropriate for these patients. This individualized approach is more accurate which leads to quality improvement during biomechanical analysis of gait pattern.

This project attempts to quantify the integrity of the fixation of total hip arthro- T plasties (THAs) by observing vibration signal features. The aim of this thesis is, therefore, to find the signal differences between firm and loose prosthesis. These difference will be expressed in different transformed domains with the expectation that a certain domain will provide superior results. Once the signal differences have been determined they will be examined for their ability to quantify the looseness. Initially, a new definition of progressive, femoral component loosening was created, based on the application of mechanical fit, involving four general conditions. In order of increasing looseness the conditions (with their equivalent engineering associations) are listed as, firm (adherence), firm (interference), micro-loose (transition) and macro-loose (clearance). These conditions were then used to aid in the development and evaluation of a simple mathematical model based on an ordinary differential equation. Several possible parameters well suited to quantification such as gap displacement, cement/interface stiffness and apparent mass were the identified from the model. In addition, the development of this model provided a solution to the problem of unifying early and late loosening mentioned in the literature by Li et al. in 1995 and 1996. This unification permitted early (micro loose) and late (macro loose) loosening to be quantified, if necessary, with the same parameter. The quantification problem was posed as a detection problem by utilising a varying amplitude input. A set of detection techniques were developed to detect the quantity of a critical value, in this case a force. The detection techniques include deviation measures of the instantaneous frequency of the impulse response of the system (accuracy of 100%), linearity of the systems response to Gaussian input (total accuracy of 97.9% over all realisations) and observed resonant frequency linearity with respect to displacement magnitude (accuracy of 100%). Note, that as these techniques were developed with the model in mind their simulated performance was, therefore, considerably high. This critical value found by the detector was then fed into the model and a quantified output was calculated. The quantification techniques using the critical value approach include, ramped amplitude input resonant analysis (experimental accuracy of 94%) and ramped amplitude input stochastic analysis (experimental accuracy of 90%). These techniques were based on analysing the response of the system in the time-frequency domain and with respect to its short-time statistical moments to a ramping amplitude input force, respectively. In addition, other mechanically sound forms of analysis, were then applied to the output of the nonlinear model with the aim of quantifying the looseness or the integrity of fixation of the THA. The cement/interface stiffness and apparent mass techniques, inspired by the work of Chung et.al. in 1979, attempt to assess the integrity of fixation of the THA by tracking the mechanical behaviour of the components of the THA, using the frequency and magnitude of the raw transducer data. This technique has been developed fron the theory of Chung etal but with a differing perspective and provides accuracies of 82% in experimentation and 71% in simulation for the apparent mass and interface stiffness techniques, respectively. Theses techniques do not quantify all forms of clinical loosening, as clinical loosening can exist in many different forms, but they do quantify mechanical loosening or the mechanical functionality of the femoral component through related parameters that observe reduction in mechanical mass, stiffness and the amount of rattle generated by a select ghap betweent he bone/cement or prosthesis/cement interface. This form of mechanical loosening in currently extremely difficult to detect using radiographs. It is envisaged that a vibration test be used in conjunction with radiographs to provide a more complete picture of the integrity of fixation of the THA.

Fundação Carlos Chagas Filho de Amparo a Pesquisa do Estado do Rio de Janeiro / A avaliação da qualidade de vida tem sido cada vez mais utilizada pelos profissionais da área de saúde para mensurar o impacto de doenças na vida dos pacientes, bem como para avaliar os resultados dos tratamentos realizados. O crescente interesse por protocolos de pesquisa clínica em doenças não degenerativas do quadril tem encontrado muitos obstáculos na avaliação objetiva de seus resultados, principalmente nos estudos de observação de novas intervenções terapêuticas, como a artroscopia. O Nonarthritic Hip Score (NAHS) é um instrumento de avaliação clínica, desenvolvido originalmente em inglês, cujo objetivo é avaliar a função da articulação do quadril em pacientes jovens e fisicamente ativos. O objetivo desse estudo foi traduzir esse instrumento para a língua portuguesa, adaptá-lo para a cultura brasileira e validá-lo para que possa ser utilizado na avaliação de qualidade de vida de pacientes brasileiros com dor no quadril, sem doença degenerativa. A metodologia utilizada é a sugerida por Guillemin et al. (1993) e revisado por Beaton et al. (2000), que propuseram um conjunto de instruções padronizadas para adaptação cultural de instrumentos de qualidade de vida, incluindo cinco etapas: tradução, tradução de volta, revisão pelo comitê, pré-teste e teste, com reavaliação dos pesos dos escores, se relevante. A versão de consenso foi aplicada em 30 indivíduos. As questões sobre atividades esportivas e tarefas domésticas foram modificadas, para melhor adaptação à cultura brasileira. A versão brasileira do Nonarthritic Hip Score (NAHS-Brasil) foi respondida por 64 pacientes com dor no quadril, a fim de avaliar as propriedades de medida do instrumento: reprodutibilidade, consistência interna e validade. A reprodutibilidade foi 0,9, mostrando uma forte correlação; a consistência interna mostrou correlação entre 0,8 e 0,9, considerada boa e excelente; a validade foi considerada respectivamente boa e excelente; a correlação entre NAHS-Brasil e WOMAC foi 0,9; e a correlação entre o NAHS-Brasil e Questionário Algofuncional de Lequesne foi 0,79. O Nonarthritic Hip Score foi traduzido para a língua portuguesa e adaptado à cultura brasileira, de acordo com o conjunto de instruções padronizadas para adaptação cultural de instrumentos de qualidade de vida. Sua reprodutibilidade, consistência interna e validade foram também demonstradas. / The assessment of quality of life has been increasingly used by health professionals to measure the consequences of disease on patients' lives and evaluate the results of treatments. The growing interest in clinical research protocols of non-arthritic hip diseases has found many difficulties in dealing with the objective assessment of its results, especially in observational studies of new therapeutic interventions such as arthroscopy. The Nonarthritic Hip Score (NAHS) is a clinical assessment tool, originally developed in English to evaluate the function of the hip joint in young and physically active patients. The aim of this study was to translate this instrument into Portuguese, adapt it to the Brazilian culture and validate it, in order to evaluate quality of life of Brazilian patients with hip pain without osteoarthritis. The methodology used is suggested by Guillemin et al., (1993) and reviewed by Beaton et al., (2000), who proposed a set of standardized instructions for cultural adaptation of instruments for quality of life, including five steps: translation, back translation, review by committee, pre-test and test with a reassessment of the weights of scores, if relevant. The consensus version was administered to 30 individuals. Questions about sports and household chores were modified to better adapt to the Brazilian culture. The Brazilian version of Nonarthritic Hip Score (NAHS-Brasil) was answered by 64 patients with hip pain to evaluate the measurement properties of the instrument: reproducibility, internal consistency and validity. Reproducibility was 0.9, showing a strong correlation; the internal consistency showed a correlation between 0,8 and 0,9, considered good and excellent; the validity was considered good and excellent respectively; the correlation between NAHS-Brasil and WOMAC was 0,9, and the correlation between NAHS-Brasil and Lequesne Algofunctional Index was 0.79. The Nonarthritic Hip Score was translated into Portuguese and adapted to Brazilian culture, according to the instruction set of standardized instruments for cultural adaptation of quality of life. Its reliability, internal consistency and validity have also been demonstrated.

Fundação Carlos Chagas Filho de Amparo a Pesquisa do Estado do Rio de Janeiro / A avaliação da qualidade de vida tem sido cada vez mais utilizada pelos profissionais da área de saúde para mensurar o impacto de doenças na vida dos pacientes, bem como para avaliar os resultados dos tratamentos realizados. O crescente interesse por protocolos de pesquisa clínica em doenças não degenerativas do quadril tem encontrado muitos obstáculos na avaliação objetiva de seus resultados, principalmente nos estudos de observação de novas intervenções terapêuticas, como a artroscopia. O Nonarthritic Hip Score (NAHS) é um instrumento de avaliação clínica, desenvolvido originalmente em inglês, cujo objetivo é avaliar a função da articulação do quadril em pacientes jovens e fisicamente ativos. O objetivo desse estudo foi traduzir esse instrumento para a língua portuguesa, adaptá-lo para a cultura brasileira e validá-lo para que possa ser utilizado na avaliação de qualidade de vida de pacientes brasileiros com dor no quadril, sem doença degenerativa. A metodologia utilizada é a sugerida por Guillemin et al. (1993) e revisado por Beaton et al. (2000), que propuseram um conjunto de instruções padronizadas para adaptação cultural de instrumentos de qualidade de vida, incluindo cinco etapas: tradução, tradução de volta, revisão pelo comitê, pré-teste e teste, com reavaliação dos pesos dos escores, se relevante. A versão de consenso foi aplicada em 30 indivíduos. As questões sobre atividades esportivas e tarefas domésticas foram modificadas, para melhor adaptação à cultura brasileira. A versão brasileira do Nonarthritic Hip Score (NAHS-Brasil) foi respondida por 64 pacientes com dor no quadril, a fim de avaliar as propriedades de medida do instrumento: reprodutibilidade, consistência interna e validade. A reprodutibilidade foi 0,9, mostrando uma forte correlação; a consistência interna mostrou correlação entre 0,8 e 0,9, considerada boa e excelente; a validade foi considerada respectivamente boa e excelente; a correlação entre NAHS-Brasil e WOMAC foi 0,9; e a correlação entre o NAHS-Brasil e Questionário Algofuncional de Lequesne foi 0,79. O Nonarthritic Hip Score foi traduzido para a língua portuguesa e adaptado à cultura brasileira, de acordo com o conjunto de instruções padronizadas para adaptação cultural de instrumentos de qualidade de vida. Sua reprodutibilidade, consistência interna e validade foram também demonstradas. / The assessment of quality of life has been increasingly used by health professionals to measure the consequences of disease on patients' lives and evaluate the results of treatments. The growing interest in clinical research protocols of non-arthritic hip diseases has found many difficulties in dealing with the objective assessment of its results, especially in observational studies of new therapeutic interventions such as arthroscopy. The Nonarthritic Hip Score (NAHS) is a clinical assessment tool, originally developed in English to evaluate the function of the hip joint in young and physically active patients. The aim of this study was to translate this instrument into Portuguese, adapt it to the Brazilian culture and validate it, in order to evaluate quality of life of Brazilian patients with hip pain without osteoarthritis. The methodology used is suggested by Guillemin et al., (1993) and reviewed by Beaton et al., (2000), who proposed a set of standardized instructions for cultural adaptation of instruments for quality of life, including five steps: translation, back translation, review by committee, pre-test and test with a reassessment of the weights of scores, if relevant. The consensus version was administered to 30 individuals. Questions about sports and household chores were modified to better adapt to the Brazilian culture. The Brazilian version of Nonarthritic Hip Score (NAHS-Brasil) was answered by 64 patients with hip pain to evaluate the measurement properties of the instrument: reproducibility, internal consistency and validity. Reproducibility was 0.9, showing a strong correlation; the internal consistency showed a correlation between 0,8 and 0,9, considered good and excellent; the validity was considered good and excellent respectively; the correlation between NAHS-Brasil and WOMAC was 0,9, and the correlation between NAHS-Brasil and Lequesne Algofunctional Index was 0.79. The Nonarthritic Hip Score was translated into Portuguese and adapted to Brazilian culture, according to the instruction set of standardized instruments for cultural adaptation of quality of life. Its reliability, internal consistency and validity have also been demonstrated.

La drépanocytose est la maladie moléculaire et héréditaire (transmission mendélienne récessive et autosomique) la plus répandue au monde. Elle est un problème de santé publique par sa gravité et ses implications socio-économiques dans de nombreux pays. Seuls les sujets homozygotes (SS) ou hétérozygotes composites (SC) sont malades, les hétérozygotes (AS) ne sont que des transmetteurs du gène S. Elle est la première cause d’OstéoNécrose de la Tête Fémorale (ONTF), douloureuse évoluant vers l’arthrose, en l’absence de traitement chez un patient jeune.<p>La Guadeloupe compte 450.000 habitants, dont 12% sont porteurs de l’hémoglobine S. Le nombre des drépanocytaires est estimé à 1.200 dont les 3/4 sont suivis au Centre Caribéen de la Drépanocytose (CCD), créé en 1990. Le centre assure la prise en charge médicale des enfants dès leur naissance et des adultes malades. Nos activités au CHU de Pointe-à-Pitre, au CCD et à l’Unité INSERM-UMR S458 depuis juillet 1992 nous ont permis d’étudier:<p>- le diagnostic de l’ONTF;<p>- l’évaluation de l’hyperpression osseuse dans l’ONTF et l’évaluation du traitement par forage simple;<p>- l’étude de l’impact de la prise en charge orthopédique précoce sur la survenue et l’évolution de l’ONTF.<p>Notre étude concerne les patients drépanocytaires adultes homozygotes (SS) et double hétérozygotes (SC):<p>- une série rétrospective de 1993-1994 [E-1994] portant sur 115 patients (58 SS, 57 SC) identifiés en 1984,<p>sans suivi médical ni orthopédique;<p>- une série prospective de 1995 à 2008 [E-2008] portant sur 215 patients (94 SS, 121 SC) avec prise en<p>charge médicale et orthopédique.<p>L’IRM est l’examen de référence pour le diagnostic de l’ONTF comme dans la nécrose idiopathique. En absence d’imagerie moderne, la radiographie traditionnelle réalisée de façon complète (profil et, surtout, faux profil), permet le diagnostic avant toute déformation. Seules les lésions cliniquement symptomatiques et évolutives (examen clinique itératif, contrôle radiologique, tomographie, TDM ou IRM) ont une indication opératoire.<p>L’hyperpression intra osseuse, dans l’ONTF drépanocytaire, est significativement liée à la douleur (que les patients soient homozygotes ou hétérozygotes). Sa diminution a un effet antalgique objectif, observée après forage. Elle permet de confirmer le diagnostic d’ostéonécrose au stade précoce, dans les régions où l’IRM est inexistante.<p>Un forage réalisé aux stades précoces de l’ONTF permet un arrêt rapide de l’évolution des lésions vers une arthrose, avec une efficacité certaine pour les stades I et II. Il garde une efficacité limitée pour le stade III. En plus de l’indolence apportée par la décompression, le bénéfice du forage se manifeste par l’allongement du délai avant arthroplastie (de 7,4 ± 2,7 ans). La technique est réalisable dans les régions sous équipées, où la drépanocytose est fréquente.<p>La description histologique aux différents stades radiologiques de l’ONTF montre toujours des lésions de nécrose médullaire et osseuse. A l’inverse des lésions idiopathiques, les lésions drépanocytaires sont caractérisées par la présence d’une inflammation, en dehors de tout processus infectieux.<p>Dans la littérature, la fréquente de l’ONTF drépanocytaire chez l’adulte est voisine de 40%, proche de celle observée dans [E-1994], notre population non suivie (36,5%). En comparant les études [E-1994] et [E-2008], la fréquence de l’ONTF passe de 36,5% à 14,4%. L’officialisation en 1992 d’une prise en charge médicale et d’un suivi orthopédique régulier au CCD et au CHU de Pointe-à-Pitre, a permis la réduction de la fréquence de l’ONTF et d’autres morbidités.<p>Le rappel sur la drépanocytose révèle la complexité de la maladie, la variabilité de son expression clinique et de ses complications. L’amélioration de vie des patients nécessite une prévention primaire, secondaire et tertiaire, en l’absence d’un traitement spécifique de la maladie.<p>La prise en charge médicale, complétée par une prévention et un traitement précoce (orthopédique ou chirurgical) telle que réalisés au CCD en Guadeloupe, a permis une réduction significative de la survenue de la nécrose de hanche et de ses complications. Pour une prévention tertiaire des complications ostéo-articulaires, nous suggérons:<p>- une prise en charge médicale régulière des enfants et des adultes afin de réduire les crises vaso-occlusives;<p>- une éducation des patients à la recherche de signes d’appel de l'ONTF et, aussi, d’autres articulations;<p>- un examen clinique ostéo-articulaire lors des bilans annuels et après toute crise vaso-occlusive;<p>- une attention particulière à l’adolescence (passage enfant-adulte), après une grossesse;<p>- une prise en charge précoce, orthopédique ou chirurgicale conservatrice (forage ou ostéotomie) face à une<p>nécrose, afin de réduire les complications invalidantes de l’ONTF.<p><p>Sickle-cell anemia is the most widespread hereditary (autosomal recessive Mendelian transmission) molecular pathology in the world. It is a public health issue in many countries, due to its severity and socio-economic impact. Only homozygous (SS) and double heterozygous (SC) subjects are affected, heterozygous (AS) subjects merely transmitting the gene S. Sickle-cell anemia is the most frequent cause of osteonecrosis of the femoral head (ONFH), a painful condition which evolves towards osteoarthritis if not treated at an early age.<p>Guadeloupe has a population of 450,000, 12% of whom are carriers of hemoglobin S. There are estimated to be 1,200 sickle-cell anemia sufferers, three-quarters of whom are followed in the Caribbean Sickle-Cell Center (Centre Caribéen de la Drépanocytose: CCD), which was set up in 1990. The Center provides medical care for adult patients and for children as of birth. Work has been ongoing since July 1992, in the Pointe-à-Pitre University Hospital, the CCD and the INSERM-UMR S458 research unit, focusing on:<p>- diagnosis of ONFH;<p>- bone hyperpressure measurement in ONFH and assessment of simple drilling treatment;<p>- the impact of early orthopedic treatment on the onset and evolution of ONFH.<p>The present study involved homozygous (SS) and double heterozygous (SC) adult sickle-cell anemia patients:<p>- a retrospective series, from 1993 to 1994 [S-1994], including 115 patients (58 SS, 57 SC) identified in 1984,<p>who had no medical or orthopedic care;<p>- a prospective series, from 1995 to 2008 [S-2008], including 215 patients (94 SS, 121 SC), with medical and orthopedic care.<p>MRI is the diagnostic gold-standard in ONFH, as in idiopathic necrosis. Where such modern imaging is not available, complete standard X-ray (lateral and especially false lateral) enables diagnosis to be made before deformity sets in. Surgery is indicated only for clinically symptomatic evolutive lesions on iterative clinical check-up, X-ray control, tomography, CT or MRI.<p>Intraosseous hyperpressure in sickle-cell ONFH shows a significant correlation with pain, in both homozygous and heterozygous patients. Pressure reduction is objectively pain-relieving, as seen after drilling, and can confirm diagnosis of ONFH at an early stage, in places where MRI is not available.<p>Drilling performed in the early stages of ONFH quickly arrests evolution towards osteoarthritis, with proven efficacy in grades I and II, and a certain degree of effectiveness in grade III. Over and above the pain-relief provided by decompression, drilling also enables hip replacement to be postponed, by 7.4±2.7 years. Moreover, the technique is feasible in those under-equipped regions in which sickle-cell disease is widespread.<p>Histologic description of radiologic ONFH stages consistently finds medullary and bone necrosis. In contrast to idiopathic lesions, sickle-cell related lesions show inflammation without any associated infection.<p>In the literature, the frequency of adult sickle-cell ONFH is reported to be nearly 40%, close to the 36.5% found in the S-1994 study of a non-treated population. In the S-2008 study of a population with medical and orthopedic care, ONFH frequency fell to 14.4%. The official provision of medical care and regular orthopedic follow-up in the CCD and Pointe-à-Pitre Hospital has reduced the frequency of ONFH and other morbidities.<p>A review of sickle-cell disease reveals its complexity: the variability of its clinical expression and associated complications. Improving patients’ quality of life requires primary, secondary and tertiary prevention, in the absence of specific treatment.<p>Medical care, supplemented by early prevention and treatment (orthopedic or surgical), as practiced in the Guadeloupe CCD, has significantly reduced the rates of ONFH and associated complications. We recommend the following CCD protocol for tertiary prevention of osteoarticular complications:<p>- regular medical care for children and adults, to reduce the incidence of vaso-occlusive crises;<p>- patient education in alarm signs of osteonecrosis of the femoral head and of other joints;<p>- systematic osteoarticular assessment at yearly check-up and after all vaso-occlusive crises;<p>- special focus on adolescence (child-to-adult transition) and following pregnancy;<p>- early care, both orthopedic and by conservative surgery (drilling or osteotomy), in case of necrosis, to reduce the rate of disabling complications of ONFH / Doctorat en Sciences médicales / info:eu-repo/semantics/nonPublished