Thesis (doctoral)--Lund University, 1997. / Added t.p. with thesis statement inserted. Includes bibliographical references.

The history of total knee arthroplasty stretches back over 70 years. Many studies have shown that TKA is, in general, a successful operation for the relief of joint pain, with patient satisfaction rates of 90-95% and implant survival rates at 10-15 years of greater than 90%. However, a number of studies have also shown the potential for failures or complications arising post-implantation leading to revision surgery. This thesis presents finite element (FE) models of the distal femur following primary and revision total knee arthroplasty. Pre-arthroplasty models are also developed for comparison. Particular attention is given to how femoral component design and method of fixation impacts the mechanical environment of the distal femur and stability of the prosthesis. FE analyses with fully bonded interfaces indicate that femoral components are subject to areas of low stress (stress shielding) immediately under the anterior flange and chamfer regardless of internal implant features. However, internal implant features were found to play a role in the pattern and magnitude of stress concentrations. Both stresses and motions were observed to increase with increasing flexion angle, indicating the importance of testing at multiple angles. The initial models of the distal femur were extended to incorporate the effects of ageing and endosteal thinning of the femoral cortex, through novel application of pre-existing FE modelling techniques, specifically the ability to assign variable material properties corresponding to the nodal temperatures output from a heat transfer analysis. The findings from this study indicate that older patients with osteoporosis may be at increased risk of periprosthetic fracture compared to younger healthy patients. The use of a revision femoral component with a cemented stem as a means to mitigate this fracture risk was also investigated. FE analyses using frictional interfaces were employed to determine the influence of femoral component design on micromotion at the interface. These models showed that all primary implants were subject to similar magnitudes of relative motion at the interface, however, the distinct internal implant features led to very different regional variations. Furthermore, certain internal implant features (i.e. femoral box) were found to be highly sensitive to errors in surgical bone cuts. This aspect of the thesis also concluded that the addition of a stem served to significantly reduce motions at the interface in comparison to primary stemless implants. Long stemmed prostheses were found to result in the smallest levels of interface motion. This study also detailed the design and creation of an in vitro test setup for the purposes of determining the influence of stem length and fixation on the stability of revision prostheses. Experimental results using this test rig showed that a cemented short stem provides as much initial stability as the uncemented long stem, and is easier to fit surgically. Corresponding FE models incorporating a virtual representation of the test rig and in vitro loading conditions revealed that the relative motion at the multi-planar bone-prosthesis interface cannot be adequately described using a single reference point. However, in vitro setups may be used to predict a general measure of implant stability and to provide a source of calibration for FE. The distal femur models were further modified to investigate how the presence of condylar defects as classified by AORI defect classification system (Engh 2006) and weak osseous support due to osteoporosis may adversely affect the survival of the prosthesis. These investigations revealed that fixation of the femoral component, the presence of a large condylar defect and the level of osseous support all had an impact on stress in the implant, it is concluded that a non-modular approach should be adopted in older patient groups with severe osteoporosis to mitigate the risk of component junction failure and distal femoral fracture.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第22831号 / 医博第4670号 / 新制||医||1047(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 安達 泰治, 教授 別所 和久, 教授 妻木 範行 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Increased workload on our healthcare system calls for more automation, this too in the pre-operative planning of total knee arthroplasty (TKA) surgery. This should keep in mind however that success in TKA is measured through having proper limb alignment. This thesis project implemented a virtual positioning assessment software that provides an initial position based on its bone and implant inputs with their specific landmarks. Positions can be furtherly adapted and evaluated based on flexion facets, obtaining decreased pre-operative workloads. The software was validated through an analysis comparison of the femur positioning of nine cases with the former used analysis tool of the university Hospital of Ghent. The newly implemented software was concluded to approximate the patients’ pre-operative alignment better for all translational and rotational parameters, except anteroposterior translation and internal/external rotation of the femur.

The purpose of this integrated review of the literature was to explore the postsurgical infection complications commonly occurring in individuals undergoing total knee replacement surgery, and the relationship of co-morbidities, lifestyle choices, and genetics on the risk for complication. A comprehensive search of the literature focusing on the patient surgical site infection and total knee replacement surgery using the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Medical Literature On-line (MEDLINE). Initial searches revealed 80 results. Upon closer scrutiny, duplicates were removed, as well as those not relevant to infection in total knee arthroplasty. This resulted in a review of 6 articles that fit the inclusion criteria. Inclusion criteria were articles written in the English language and published in scholarly, peer-reviewed, journals from 2009 to present. In addition to published articles, pertinent material from current nursing textbooks was evaluated and chosen to further substantiate the literature results. In cases of knee arthroplasty, diagnoses of obesity and diabetes were discovered to be risk factors for postsurgical infection. The findings of this thesis offer interpretation for nursing practice, research, education, and policy. Implications for nursing research, policy, education and practice are highlighted along with limitations of this integrative review.

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Decreased gait symmetry has been correlated with an increased fall risk, abnormal joint loading and decreased functional outcomes. Therefore, symmetry is focused on in the rehabilitation of many patient populations. Currently, load based symmetry is collected using expensive and immobile devices that are not clinically accessible, but there is a clinical need for an objective measure of loading symmetry during daily tasks like walking. Therefore, the purpose of this dissertation was to 1) assess the validity and reliability of the loadsol® to capture ground reaction force data, 2) use the loadsol® to determine the differences in symmetry between adults with a TKA and their healthy peers and 3) explore the potential of a commercially available biofeedback system to acutely improve gait symmetry in adults. The results of this work indicate that the loadsol® is a valid and reliable method of collecting loading measures during walking in both young and older adults. TKA patients who are 12-24 months post-TKA have lower symmetry in the weight acceptance peak force, propulsive peak force and impulse when compared to their healthy peers. Finally, a case study with four asymmetric adults demonstrated that a 10-minute biofeedback intervention with the loadsol® resulted in an acute improvement in symmetry. Future work is needed to determine the potential of this intervention to improve symmetry in patient populations and to determine whether the acute response is retained following the completion of the intervention. / Doctor of Philosophy / Symmetry during walking is a valuable attribute as asymmetry has been correlated with an increased fall risk and decreased mobility. Currently, load based symmetry is collected using expensive and immobile devices that are not clinically accessible. As a result, there is a critical need for a system that can objectively measure load and loading symmetry during rehabilitation and everyday tasks in a variety of settings. A new device has been developed (loadsol®) that could potentially fill this need. Before it can be used to assess and treat patients, the loadsol® needed to be assessed for accuracy and reliability in both older and younger adults and at various speeds. Then we needed to determine if the loadsol® can be used to look at the levels of symmetry in patients who have had a knee replacement compared to their healthy peers. Finally, we tested a visual biofeedback intervention with the loadsol® to see if this intervention was able to improve symmetry. We found that the loadsol® is accurate and reliable. Patients with a knee replacement were less symmetric than their age matched peers. Finally, in a small study, the visual biofeedback intervention improved symmetry during walking in a group of people with less than 90% symmetry. Future work is needed to explore the potential of this biofeedback intervention to improve symmetry in various patient populations and to determine the extent to which patients are able to retain these improvements.

Résumé : Problématique: Près de 40% des 57 718 Canadiens ayant subi une arthroplastie du genou entre 2013 et 2014 étaient des travailleurs; la majorité étant âgée entre 55 à 64 ans. Des indices démographiques et législatifs laissent entrevoir que ce nombre continuera d’augmenter dans les prochaines années. Environ 15 à 30% de ces patients éprouvent des difficultés à reprendre ou à demeurer au travail six mois après la chirurgie. Malgré l’ampleur du phénomène, la perspective des travailleurs quant à ces difficultés demeure inconnue. Objectifs : Ce projet vise à mieux comprendre, selon la perspective du travailleur, les mécanismes sous-jacents à reprendre, ou non, une vie saine et active au travail à la suite d’une arthroplastie du genou. Plus précisément, il s’agit de décrire les représentations de l’incapacité au travail de ces travailleurs. Méthode : Ce projet qualitatif est basé sur une approche narrative avec comme cadre conceptuel le modèle d’autorégulation de Leventhal. Un échantillon de convenance de huit travailleurs ayant eu une arthroplastie du genou et éprouvant des difficultés à reprendre ou à demeurer au travail a été recruté. Des entrevues individuelles semi-dirigées ont été conduites. La méthode de Landry a été suivie pour le codage. D’abord, le cadre conceptuel a permis l’élaboration du cahier de codification tout en laissant la place à des codes émergents. Une analyse thématique des verbatim a ensuite été réalisée à l’aide du logiciel AtlasTi par deux codeurs indépendants (PM et MFC) qui ont discuté des codes divergents. Une fois toutes les entrevues codées, des réunions en équipe multidisciplinaire (kinésiologue, psychologue et physiothérapeute) ont eu lieu pour discuter de chaque cas et profiter de l’expertise de chacun des membres de l’équipe pour une analyse en profondeur. Résultats : La moitié des travailleurs rencontrée était absente du travail au moment de l’entrevue. L’émergence de cinq thèmes principaux a permis d’identifier deux cas types, soient retournés au travail avec difficultés, mais présence de soutien, et non retournés. Les travailleurs de la première trajectoire rapportent une implication de l’entreprise dans les démarches de retour au travail et ont les conditions nécessaires pour prendre des moyens actifs afin d’améliorer leur condition. Pour les travailleurs de la deuxième trajectoire, différents obstacles nuisent à la reprise des activités dont des complications postopératoires, une perception d’exigences de travail élevées, un faible soutien de l’environnement de travail et peu de ressources pour les aider. Conclusion : L’identification d’une trajectoire qui est moins favorable au retour au travail permet d’identifier les travailleurs à risque d’être en situation d’incapacité au travail. Ces travailleurs pourraient bénéficier de services en réadaptation au travail pour favoriser la reprise d’une vie saine et active après l’arthroplastie du genou. / Abstract : Purpose: Nearly 40% of the 57,718 Canadians who underwent total knee arthroplasty (TKA) between 2013 and 2014 were workers; the majority of them were aged from 55 to 64 years. Demographic and legislative indications suggest that this number will increase in the coming years. Actually, 15 to 30% of these patients report limitations at work or are not able to return to work six months after the surgery. Despite this growing phenomenon, workers’ insight on what influence work disability remains unknown. Objectives: The purpose of this study is to understand the worker’s perspective on what contributes or impedes the return to an active working life after TKA. Specifically, we aimed to document workers’ representations of their disability following TKA. Method: This qualitative study was conducted based on a narrative approach using Leventhal’s Common Sense Model (CSM) as the conceptual framework. A convenience sample of eight workers experiencing limitations while at work or being fully disabled (on sick leave) after TKA was interviewed. We conducted semistructured interviews, and then we followed Landry’s method for coding. First, we used a mixed coding method whereby codes were established a priori using the CSM with the possibility for emergent codes. Second, two researchers (PM and MFC) independently coded all interviews, compared the codes, and discussed diverging results. Third, after coding all interviews and based on the coding, content analysis was performed in multidisciplinary team (psychologist, physiotherapist, kinesiologist). Each interview was discussed by the team to compare the analysis and to obtain consensus as we believe our disciplinary backgrounds might impact interpretation of the data by bringing new information to the case. Content analysis was performed with Atlas-Ti software. Results: Half of the workers were fully disabled because of TKA. We identified two typical cases: workers who returned to work with difficulties but perceived support from their environment and workers who did not returned to work. The workers that returned to work reported involvement of their work environment in the return-to-work process. They felt they had greater improvement after TKA, and this enables them to further improve their condition. Workers who did not return to work encountered various obstacles such as ostoperative complications, a more physically-demanding job, negligible support from their work environment, and few resources to help them. Conclusion: The identification of a case that is less favorable to return to work allowed us to identify workers at risk of work disability. These workers could benefit from work rehabilitation services in order to promote a better active working life after TKA.