A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / Background: The hip joint tends to be highly affected in patients with Cerebral Palsy (CP). Subluxation, problems with ambulation, posture, perineal hygiene, and pain can result. Severe cases often require corrective surgery of the affected dysplastic hip(s). This often is accomplished with varus derotational osteotomy (VDRO), femoral osteotomy, pelvic osteotomy, tendon releases/lengthening, or a combination of any of these procedures. These reconstructive hip surgeries can result in marked blood loss. Due to the highly vascularized nature of bone, surgery can result in marked blood loss. This increases the transfusion burden on the patient and increases exposure to blood products and the associated risks therein. By identifying the risk factors that contribute to intraoperative and postoperative blood loss, targeted strategies may be developed to reduce this risk to the patient. Aims: The purpose of this study is to provide descriptive analysis of the pediatric CP population undergoing corrective hip surgery. We will attempt to identify various risk factors that may predispose patients to significant blood loss during reconstructive hip surgery. This study will be the largest study analyzing blood management therapy with the VDRO procedure. Methods: This is a retrospective chart review of consecutive CP patients who have undergone reconstructive hip surgery at a single institution from 2000 to 2012. Demographic data to be analyzed includes patient age, gender, race/ethnicity, height, weight, BMI, and medical comorbidities. Also, type of procedure performed, bilateral vs unilateral reconstruction, specific diagnosis, preoperative hemoglobin and hematocrit (H and H), pre‐transfusion H and H, estimated blood loss (EBL), total operative time, cell saver volume, units transfused, complications, quantity of postoperative transfusion, and post‐transfusion H and H was recorded. Data was compared using the Chi‐squared method, or non‐parametric analog, to assess the likelihood of the need for postop transfusions as an initial univariate analyses. Results: 87 patients were included in the study. There was no significant relationship between the use of autologous blood and age, gender, weight, height, or BMI. Patients who received autologous blood also had a higher EBL (p=0.029) and were more likely to need allogenic transfusion (p=0.023). Concomitant DEGA procedure carried a 2.25 times relative risk of needing blood transfusion (p<0.001, 95% CI 1.402‐3.611). Bilateral VDRO was 1.64 times more likely to need a transfusion, however this was not quite statistically significant (p=0.052, 95% CI 0.972‐2.756) Conclusion: Varus derotational osteotomy for the correction of neuromuscular hip dysplasia can be associated with excessive blood loss, especially in the CP patient population. The use of autologous vs allogenic blood products carries various risks and benefits. This paper has identified that the need of concomitant DEGA osteotomy is correlated with increased blood loss. Also, the use of autologous blood product is correlated with increased blood loss.

Osteoarthritis develops secondary to the action of hostile biomechanics upon susceptible cartilage. Cam morphology describes a loss of concavity at the femoral head-neck junction resulting in femoral impaction against the acetabular rim within a functional range of movement. This impaction is termed femoroacetabular impingement and can result in pain and cause damage to adjacent articular cartilage that progresses to osteoarthritis. Cam morphology is a target for joint preservation strategies. The first study in this thesis compares hip development in academy football players with controls from local schools. The results provide strong evidence that cam morphology can develop in response to intense sporting activity during adolescence. At present, it is not possible to recommend activity modification as the cardiovascular benefits of exercise are likely to outweigh potentially detrimental effects on hip morphology. Nevertheless, individuals participating in high-level sports during youth may represent a high risk cohort for osteoarthritis warranting surveillance. Diagnostic tools currently available only allow identification of late joint degeneration when disease is irreversible. Advances in the field of disease biomarkers may overcome this challenge. The second study of this thesis explored the prognostic value of compositional MRI. Baseline delayed gadolinium-enhanced MRI of cartilage was able to predict the development of radiographic hip osteoarthritis in asymptomatic individuals within five years. As well as identifying individuals who are likely to benefit from intervention, compositional MRI may allow the evaluation of treatment efficacy within short timeframes. A number of interventions aimed at joint preservation are under investigation for treating cam morphology femoroacetabular impingement. Arthroscopic surgery is increasingly performed to restore the concavity at the femoral head-neck junction and prevent impaction against the acetabular rim. A feasibility study was performed for a proposed randomised controlled study comparing operative and non-operative treatment. The study protocol was developed for the 'Femoroacetabular Impingement Trial' (FAIT).

Title: The evaluation of surgical treatment of the hip in the diagnosis of femor- acetabular impingement syndrome. Objectives: The main objective of this work is to evaluate the effect of the surgery of the hip in diagnosis of femor-acetabular hip impingement. Methods: In our work we have cooperated with 103 patients who have been operated on hip with the diagnosis of femor-acetabular hip impingement (FAI). We used standardized questionnaires of WOMAC and NAHS, which assesses functional self- care, limitations in motion and painfulness. Patients completed questionnaires twice. For the first time before surgery and second time at least one year after the surgery. The specimens of questionnaire are attached in the Annex. Results: We found out that postoperative condition is significantly different from the preoperative state in terms of improved self-care, increased range of motion and reduction of painfulness. Keywords: Femor-acetabular impingement, hip surgery, WOMAC, NAHS

Bakgrund: Höftartroplastik är rankad som nummer 11 på listan över de mest smärtsamma kirurgiska ingreppen. Att utveckla kronisk smärta postoperativt rapporteras vara så hög som 10%. Syfte: Studera vuxna patienters upplevelser av postoperativ smärta efter planerad höftoperation samt patienternas erfarenhet av smärtbehandlingen. Metod: En litteraturöversikt baserad på 10 vetenskapliga artiklar publicerade mellan år 2000 och 2019. Fem artiklar har kvantitativ ansats och fem av artiklarna har kvalitativ ansats. Resultat: Patienters upplevelser av postoperativ smärta efter en elektiv höftoperation är individuell och beskrivs både kvantitativt med hjälp av smärtskattningsskalor och kvalitativt med egna ord. Majoriteten av studierna visar att patienterna upplever sig tillräckligt smärtlindrade av de läkemedel de får i syfte att minska den postoperativa smärtan och i andra fall där religiösa åskådningar spelar in, så förlitar sig patienterna på sin tro och med hjälp av sin familj. Slutsats: Postoperativ smärta efter elektiv höftoperation är ett faktum. Patienterna upplever sig smärtlindrade eller i andra fall står ut med smärtan av kulturella och religiösa skäl. Patienternas delaktighet under sin vårdtid, bättre uppföljning av vården efter utskrivning och ytterligare forskning kring effektivare postoperativ smärtbehandling, krävs i framtiden. / Introduction: Hip arthroplasty is ranked number 11 on the list of the most painful surgical procedures. Developing chronic pain postoperatively is reported to be as high as 10%. Aim: Study adult patients' experiences of postoperative pain after planned hip surgery and the patients' experience of pain management. Methods: A review of literature based on 10 scientific articles published between 2000 and 2019. Five articles have quantitative approach and five of the articles has qualitative approach.   Results: Patients' experiences of postoperative pain after an elective hip operation are individual and described both quantitatively by means of pain estimation scales and qualitatively in their own words. The majority of the studies show that the patients feel sufficiently pain-relieved by the drugs they receive in order to reduce the postoperative pain and in other cases where religious views are recorded, the patients rely on their faith and with the help of their family. Conclusion: Postoperative pain after elective hip surgery is a fact. The patients feel pain-relieved or in other cases stand out with the pain for cultural and religious reasons. Patients' involvement during their care period, better follow-up of care after discharge and further research in more effective postoperative pain treatment, are required in the future.

No description available.

The thesis deals with comparing the postoperative analgesia with a focus on pacients after hip replacement surgery at the intensive care units. The quantitative study realized at the Fakultní nemocnice v Motole and Nemocnice Třebíč during November 2012 and February 2013. The main task of the theoretical part is to analyze the current trends in the field of post- operativeanalgesia by the patients undergoing hip joint surgery as well as the explanation the basicconcepts of this issue and overviewing the international postoperative pain treatments. The practical part is an objective comparison the postoperative analgesia byselected patients at the Fakultní nemocnice v Motole and Nemocnice Třebíč determined by questionnaire. The results of the questionnaire are processed into graphical representation and subsequently evaluated. The work serves to clarify the overall issue of post-operative analgesia. The focus is mainly on ensuring the quality of postoperative analgesia, the financial requirements administered analgesics and the possible complications associated with the use of analgesic therapy. Key words: Analgesia, pain, hip surgery, visual analogue scale, analgesics

Bakgrund: Åldersrelaterade sjukdomar och skador som höftledsartros och höftfrakturer ökar i takt med att befolkningen blir allt äldre. Vårdkostnader för smärta relaterat till höftkirurgi förväntas därmed öka. För att äldre ska få fullgod smärtlindring som kan öka chansen för en effektiv rehabilitering krävs kunskap om upplevelser hos patienter äldre än 50 år. Syfte: Att beskriva upplevelser av smärta och smärtlindring hos patienter som genomgått höftkirurgi. Metod: Litteraturstudien omfattade 11 vetenskapliga artiklar. Samtliga artiklar var publicerade mellan år 2003 och 2019 och använde sig av kvalitativa metoder. Patientgruppen omfattade personer mellan 50 år och äldre. Huvudresultat: Smärtan efter höftkirurgi var som mest påtaglig de första dagarna och särskilt vid mobilisering. Långvarig smärta påverkade förmågan att klara av vardagsaktiviteter och bidrog till en mer isolerad tillvaro. Den långvariga smärtan skapade även känslor av frustration och hopplöshet. Samtidigt förekom ett accepterande förhållningssätt där smärtan sågs som naturlig och som en del av läkningsprocessen. Smärtlindringen var central för rehabiliteringen och återanpassningen till det vardagliga livet. Det fanns dock en rädsla för läkemedelsbiverkningar hos många äldre. Slutsats: Det fanns stora variationer i hur smärtan upplevdes, hanterades och kommunicerades. Äldre patienter riskerar dessutom att inte få fullgod smärtlindring. Smärta behöver kommuniceras på fler sätt än genom enbart skattning av intensitet. Sjuksköterskan har därför en central roll i att hjälpa patienten att hitta mening med lidande och smärta, vilket är en viktigt del i personcentrerad vård. Smärtan kan annars leda till försämrad rehabilitering samt ökade vårdkostnader som följd. / Introduction: Age-related illnesses and injuries such as hip arthrosis and hip fractures are increasing as the population grows older. Costs for pain related to hip surgery are thus expected to increase. Knowledge of experiences in patients older than 50 years is required for the elderly to receive adequate pain relief that can increase the chance of effective rehabilitation. Aim: To describe experiences of pain and pain relief in patients who have undergone hip surgery. Methods: The literature study included 11 scientific articles. All articles used qualitative methods and were published between 2003 and 2019. The patient group included persons between 50 years and older. Results: The pain was experienced by the whole individual and in a unique way for each person. The pain after hip surgery was most evident during the first few days, and especially during mobilization. Prolonged pain affected the ability to cope with everyday activities and contributed to isolation. The lingering pain also created feelings of frustration and hopelessness. At the same time, there was an accepting approach where the pain was seen as natural and as part of the healing process. The pain relief of the elderly was central to the rehabilitation and re-adjustment to everyday life. However, there was a fear of drug side effects among many elderly people. Conclusion: There were large variations in how the pain was experienced, managed and communicated. There was also a risk that elderly patients did not receive adequate pain relief. Pain needs to be communicated in more ways than by estimating intensity alone. The nurse therefore has a central role in helping the patient find meaning with suffering and pain, which is an important part of person-centered care. The pain can otherwise lead to impaired rehabilitation as well as increased health care costs as a result.

Bakgrund: God omvårdnad och snabb mobilisering till den drabbade personen är ett krav för att kunna återgå till en fungerande vardag efter en höftoperation. Tidig postoperativ mobilisering har visat sig minska risken för komplikationer. Aktuell forskning belyser kunskapsbrister hos hälso- och sjukvårdpersonal angående patienters upplevelser av tidig mobilisering samt bristande forskning kring sjuksköterskors etablerande av förtroendefulla relationer och kommunikation med patienter, vilket medför utmaningar i vården. Syfte: Syftet var att belysa patienters upplevelser av postoperativ mobilisering efter höftoperation. Metod: En allmän litteraturstudie utfördes och 11 resultatartiklar inkluderades. Resultat: Analysen av resultatartiklarna identifierade följande fyra kategorier: upplevelser av bristande kommunikation och information, upplevelser av rädsla, sårbarhet och isolering, upplevelser av motivation, stöd och självuppfattning och upplevelser av att återgå till en ny vardag som belyser upplevelser av att anpassa sig till en ny normalitet, smärta och sömn. Konklusion/implikation: Bristande kommunikation från hälso- och sjukvårdspersonal, rädsla för felbelastning och känslor av sårbarhet och isolering framstod som de vanligast förekommande upplevelserna. Hälso- och sjukvårdspersonal behöver öka sin förståelse för hur patienter upplever postoperativ mobilisering. En implikation av resultatet är att ytterligare utbildning och forskning behövs för att förstå och möta patienters behov och upplevelser för att kunna erbjuda god och effektiv omvårdnad. / Background: Adequate care and mobilization for the individual is essential to facilitate a return to daily life following hip surgery. Early postoperative mobilization has been shown to reduce the risk of complications. Current research highlights knowledge gaps among healthcare professionals regarding patients' experiences of early mobilization, as well as insufficient research concerning nurses' establishment of trusting relationships and communication with patients, posing challenges in healthcare. Aim: The aim was to illustrate patients' experiences of postoperative mobilization following hip surgery. Method: A general literature review was conducted, and 11 research articles were included. Results: Analysis of the research articles identified the following four categories: experiences of inadequate communication and information, experiences of fear, vulnerability, and isolation, experiences of motivation, support, and self-perception, and experiences of returning to a new daily life, which contain experiences of adjusting to a new normalcy, pain, and sleep. Conclusion/Implication: Inadequate communication from healthcare professionals, fear of misloading, and feelings of vulnerability and isolation were the most reported experiences. Healthcare professionals need to enhance their understanding of how patients perceive postoperative mobilization. An implication of the findings is that further education and research are necessary to understand and address patients' needs to provide quality and efficient care.

INTRODUÇÃO: A displasia do desenvolvimento do quadril (DDQ) é uma das patologias mais relevantes e polêmicas que acometem as crianças desde o nascimento. A anatomia tridimensional, a complexidade da articulação do quadril, o pouco conhecimento sobre o potencial de remodelação acetabular após luxação ou sub-luxação e as sequelas na marcha e na movimentação suscitam várias discussões sobre esse tema. A revisão bibliográfica a respeito dos diferentes tipos de capsulorrafia é muito pouco discutida entre os pesquisadores. Técnicas menos agressivas e que possibilitem maior resistência à recidiva da luxação após a redução cruenta devem ser pesquisadas. OBJETIVO: a presente pesquisa busca, por meio de ensaios biomecânicos, comparar as capsulorrafias com sutura simples e com âncoras, em quadris de coelhos. MATERIAL E MÉTODO: Foram utilizados 13 coelhos, 26 quadris, todos machos da raça Nova Zelândia albinos (Oryctolagus cuniculus). Inicialmente, realizamos um projeto piloto em três coelhos (06 quadris). Este experimento constou de 10 coelhos, divididos em 02 grupos: o grupo 1 submetido à capsulorrafia (quadris direito e esquerdo) com sutura simples utilizando fio absorvível de ácido poliglicólico e o grupo 2 submetido a capsulorrafia (quadris direito e esquerdo) com âncora de titânio. Após o período de quatro semanas de operados, todos animais foram submetidos à eutanásia e seus quadris congelados. Após um descongelamento prévio das peças no mesmo dia das análises biomecânicas, foram avaliados os parâmetros da rigidez (Rig), força máxima (Fmax), deformidade máxima (Dmax) e energia (E). RESULTADO: não houve diferença estatisticamente significante em relação à força no limite de proporcionalidade, rigidez e força máxima entre os grupos com sutura simples e com âncora. CONCLUSÃO: Por meio dos ensaios biomecânicos, tendo como parâmetro a rigidez (Rig), força máxima (Fmax), deformidade máxima (Dmax) e energia (E), ficou demonstrado que as capsulorrafias em quadris de coelhos com sutura simples e com âncora são semelhantes entre si. / INTRODUCTION:HDD (Hip Development Dysplasia) is one of the most important and controversial pathologies which affect children. The threedimensional anatomy and complexity of the hip joint, as well as the little understanding of the potential of acetabular reconstruction after luxation or sub-luxation and the later effects on the child\'s gait and movement, raise various points of discussion. Little literature exists about the different types of capsulorrhaphy. Techniques which are less aggressive or decrease risk of luxation after surgical reduction must be researched. OBJECTIVE: Using biomechanical studies, this research aims to compare hip capsulorrhaphy in rabbits, carried out with two different techniques: capsulorrhaphy with simple sutures and with anchors. MATERIAL AND METHOD: Thirteen New Zealand Albino (Oryctolagus cuniculus) male rabbits, twenty-six hip joints, were used. First, a pilot project was performed with three rabbits (six hip joints). The experimental group consisted of ten rabbits and was divided in two sub-groups: group 1 underwent capsulorrhaphy on both right and left hips with simple suture using polyglocolic acid absorbable thread, and group 2 underwent capsulorrhaphy with titanium anchors. After a four-week postoperation period, the animals were euthanized and the hip joints were frozen. On the same day the hip joints were unfrozen, a biomechanical study was carried out, evaluating the following parameters: rigidity, maximum force, maximum deformity and energy. RESULTS: There was no relevant statistical difference in rigidity, maximum force, maximum deformity and energy between the simple suture and anchor groups. CONCLUSION: Through biomechanical analyses, using parameters of rigidity, maximum force, maximum deformity and energy, it has been shown that a capsulorrhaphy with simple suture and with an anchor has similar results in rabbit hip joints.

<p>Delirium is common among old patients admitted to hospital, but is often a neglected problem in patient care. The principal aim of this thesis was to evaluate aspects of delirium in relation to incidence, risk factors, behavioural changes, cognitive function and health-related quality of life (HRQOL). A further aim was to describe patients’ experiences of being delirious. The study was prospective, descriptive and comparative, with repeated measures (six-month follow up). The sample consisted of 225 consecutive patients, aged 65 years or older, who were to be operated on due to hip fracture or hip replacement. Exclusion criteria were serious cognitive disorder or delirium on admission. Data were collected via frequent daily observations, cognitive functioning tests (MMSE), HRQOL questionnaires (SF-36) and interviews. Delirium was assessed according to the DSM-IV criteria. A total of 45/225 became delirious, with an incidence of 24.3% among patients undergoing hip fracture surgery and 11.7% among those with hip replacement surgery. A predictive model for delirium included four factors: impaired hearing, passivity, low cognitive functioning, and waiting more than 18h for hip fracture surgery. Disorientation and urgent calls for attention were the most frequent behavioural changes in the prodromal phase prior to delirium. Delirium in connection with hip fracture revealed deteriorated HRQOL and cognitive functioning when measured at a six-month follow-up. The experience of being delirious was described by the patients as a sudden change of reality. Such an experience gave rise to strong emotional feelings, as did recovery from delirium. Nurses’ observations of behavioural changes in old patients with impaired cognitive function may be the first step in managing and reducing delirium. The predictive model of delirium ought to be tested further before use in clinical practice.</p>