The aim of this thesis was to establish the long-term outcomes of the Oxford medial Unicompartmental Knee Arthroplasty (OUKA), define patient selection criteria and to develop and externally validate an evidence based method of patient selection for this procedure. In the hands of the developer surgeons, outcomes following medial OUKA were found to be good with an implant survival of 94% (95%CI 92 to 96) at ten-years and 91% (95%CI 83 to 98) at fifteen-years. Across the published literature, however, variation in outcomes was observed with a meta-analysis of published series of OUKA finding estimates of ten-year survival ranging from 57% to 100%, mean 88% (95%CI 85 to 90). It was identified that both increased surgical caseload (volume) and increased surgical usage (proportion of primary knee arthroplasty that are OUKA), a surrogate marker of indications, were associated with improved outcomes. Surgical usage, however, was more important, with good results following OUKA seen with high surgical usage, representing broad indications, independent of the surgical volume. This finding, coupled with differences in patient demographics and failure mechanisms between usage groups, highlighted that differences in indications for OUKA may explain the variability in outcomes observed. One reason surgeons may have a low usage is if they apply previously recommended patient factor contraindications based on age (<60 years), weight (≥82kg) and activity level (high activity). When disease factors are standardised, however, it was found that patients with these previously reported contraindications often actually did better than those without, and outcomes of knees implanted where all these factors were present were as good as where none were present. Therefore, the decision to proceed with OUKA should be based on the pathoanatomy of disease. Optimal candidates for OUKA should have full-thickness cartilage loss, with bone on bone arthritis, in the medial compartment, as knees with partial thickness cartilage loss were found to have worse functional outcomes and almost three-times the reoperation rate, predominantly for unexplained pain. Provided there was full-thickness preserved cartilage laterally and functionally normal ligaments, the presence of lateral osteophytes and the macroscopic status of the anterior cruciate ligament was not found to influence outcomes, nor did the presence of patellofemoral joint disease (with the exception of lateral facet disease with bone loss and grooving) or anterior knee pain. The pathoanatomy of disease can be identified radiologically, however, standing knee radiograph were found to perform poorly. To identify medial compartment full-thickness cartilage loss either a varus stress radiograph or fixed flexion radiograph, both at 20° flexion and aligned to the joint surface, were identified as the optimum views. To confirm preserved lateral compartment full-thickness cartilage a valgus stress radiograph at 20° flexion, aligned to the joint surface, was identified as the most appropriate technique. As stress radiographs are time and resource consuming, a novel stress device was developed in line with the IDEAL-D framework and validated against the gold standard of manual, clinician performed stress radiographs, as well as independently tested in clinical practice. Finally, to simplify patient selection, an atlas based Decision Aid, combined with a structured radiographic assessment, was developed and externally validated with an accuracy of over 90% at identifying suitability for OUKA. The routine use of this approach would be expected to standardise patient selection and ultimately translate into improved long-term outcomes.

Orientador: Maria Jose D'Elboux / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-12T11:56:56Z (GMT). No. of bitstreams: 1 Rampazo-Lacativa_MarianaKatia_M.pdf: 2793177 bytes, checksum: 7f2d1a73d29dbd1e5e1e6ab93f84eecd (MD5) Previous issue date: 2008 / Resumo: Este estudo teve como objetivo avaliar a qualidade de vida relacionada à saúde (QVRS) de idosos com artroplastia total de quadril (ATQ) por meio de um instrumento genérico e outro específico e investigar a influência de variáveis sociodemográficas, clínicas e funcionais desses sujeitos. Fizeram parte deste estudo 88 idosos com 60 anos ou mais, de ambos os gêneros, submetidos à ATQ primária, unilateral, há no mínimo seis meses, em dois hospitais de referência do interior de São Paulo. Os dados foram obtidos por meio da aplicação de quatro instrumentos: 1. questionário para a caracterização sociodemográfica, clínica e relacionada a ATQ; 2. questionário de avaliação funcional do quadril - Harris Hip Score (HHS); 3. instrumento genérico de avaliação da QVRS The Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) e 4. instrumento específico Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Os dados foram submetidos à análise estatística descritiva, efeitos teto e chão, de confiabilidade por meio do alfa de Cronbach, de variância univariada (ANOVA) e multivariada (MANOVA) e de comparação por meio dos testes de Mann-Whitney e Kruskal-Wallis. A amostra estudada teve predomínio das mulheres e a média de idade foi de 68,8(±7,4) anos. Os escores dos instrumentos de avaliação da QVRS demonstraram que as questões de natureza física afetaram mais a qualidade de vida desses idosos. A confiabilidade foi satisfatória para ambos instrumentos, com Alpha de Cronbach > 0,70, exceto na dimensão rigidez do WOMAC. O efeito teto foi exibido em alguns domínios tanto do WOMAC quanto do SF-36. De acordo com a MANOVA, a variável função do quadril, avaliada pelo HHS, foi a variável que apresentou influência significativa na QVRS sob a perspectiva dos instrumentos genérico e específico. As variáveis: uso de acessórios para a locomoção, função do quadril e satisfação com a cirurgia foram as variáveis que apresentaram diferenças significativas relevantes nas dimensões do SF-36 e do WOMAC. Os resultados evidenciam que os instrumentos SF-36 e WOMAC são adequados para avaliar a QVRS nesse grupo de idosos, porém apresentam algumas limitações. Por fim, sugere-se que ações que otimizem o status funcional possam contribuir para melhorar a QVRS dos idosos com ATQ. / Abstract: This study it had as objective to evaluate the Health-Related Quality of Life (HRQL) of elderly with Total Hip Arthroplasty (THA) by means of a generic instrument and another specific one and to investigate the influence of variable sociodemografics, clinical and functional of these citizens. It had been part of this study 88 aged ones with 60 years or more, of both the sorts, submitted the THA primary, unilateral, at least has six months, in two hospitals of the interior of São Paulo. The data had been gotten by means of the application of four instruments: 1. questionnaire for the characterization socio-demographic, clinical and related the THA; 2. questionnaire of functional evaluation of the hip - Harris Hip Score (HHS); 3. generic instrument of evaluation of the HRQL The Medical Study 36-item Short-Form Health Survey (SF-36) and 4. the specific Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). The data had been submitted to the analysis descriptive statistics, ceiling and floor effects, of trustworthiness by means of the alpha of Cronbach < 0,70, variance univariada (ANOVA) and multivaried (MANOVA) and of comparison by means of the tests of Mann-Whitney and Kruskal-Wallis. The studied sample had predominance of the women and the age average was of 68,8 (±7,4) years. The scores of the instruments of the evaluation of HRQL had demonstrated that the questions of physical nature had affected more the quality of life (QoL) of these elderly. The reliability was satisfactory for both instruments, with Alpha de Cronbach > 0,70, except in the dimension stiffness of the WOMAC. The effect ceiling was shown in some domains in such a way of the WOMAC as well of the SF-36. According to MANOVA the variable function of the hip, evaluated for the HHS, was the variable that presented significant influence in the HRQL under the perspective of the instruments generic and specific. The variables: use of accessories for the locomotion, function of the hip and satisfaction with the surgery had been the variables that had presented excellent significant differences in the dimensions of the SF-36 and the WOMAC. The results evidence that instruments SF-36 and WOMAC are adjusted to evaluate the HRQL of elderly patients with THA, but present some limitations. Therefore, one suggests that actions that optimize the functional status can contribute to improve the HRQL of the aged ones with THA. / Mestrado / Mestre em Gerontologia

Class of 2013 Abstract / Specific Aims:  To determine the efficacy of apixaban when compared to LMWH (enoxaparin) when used as thromboprophylaxis for patients undergoing total hip arthroplasty (THA), total knee arthroplasty (TKA), and medically ill patients  To determine the safety of apixaban when compared to LMWH (enoxaparin) when used as thromboprophylaxis for patients undergoing total hip arthroplasty (THA), total knee arthroplasty (TKA), and medically ill patients Methods: A systematic search of the literature for randomized controlled trials of apixaban thromboprophylaxis therapy versus enoxaparin was conducted using three databases: PubMed, EMBASE, and the Cochrane library. Data from five studies with 12,938 total patients were analyzed using Bayesian random effects meta-analysis. To evaluate efficacy, a composite of venous thromboembolism and death during follow-up was measured. To evaluate safety, major and total bleeding events were considered. Main Results: The odds ratio (OR) for the composite outcome of thromboembolism/death was 0.66 (95% CI: 0.33 to 1.29) for apixaban compared to enoxaparin, while there was a similar risk of major bleeding (OR=1.03, 95%CI: 0.36 to 3.73) and total bleeding (OR=0.92, 95%CI: 0.64 to 1.20). Conclusion: These results suggest a lack of clear superiority of apixaban relative to enoxaparin. Apixaban is an oral alternative with similar efficacy and safety to existing anticoagulant therapies.

Study Objective Although data from the Regulation of Coagulation in Orthopedic Surgery to Prevent Deep Venous Thrombosis and Pulmonary Embolism (RECORD) 1-4 trials have shown a similar postoperative bleeding risk between rivaroxban and enoxaparin in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA), anecdotal observations from local institutions have suggested that postoperative bleeding rates seemed higher in patients who received rivaroxaban than those reported in the RECORD trials. Thus, the objective of this pilot study was to assess postoperative bleeding events observed in clinical practice in patients receiving rivaroxaban after undergoing THA and TKA and to compare their results with those published in the RECORD trials. Design Retrospective cohort study with a comparator group of patients from the RECORD 1-4 trials. Setting Two institutions within a regional health care system. Patients Four hundred forty adults who received at least one dose of rivaroxaban 10 mg daily after undergoing THA or TKA in the two institutions between August 2011 and October 2013 (cohort group), and 6183 patients who received rivaroxaban in the RECORD 1-4 trials (comparator group). Measurements and Main Results Postoperative bleeding was assessed in the cohort patients versus the patients in the RECORD trials. The primary outcome, occurrence of any postoperative bleeding, was a composite of major and clinically relevant nonmajor bleeding as defined in the RECORD trials. Any postoperative bleeding occurred in 6.8% of the cohort patients versus 3.2% of the RECORD trial patients (p<0.0001); 1.4% of the cohort patients versus 0.38% of the RECORD trial patients suffered a major bleed (p=0.013). Within defined major bleeding, bleeding leading to reoperation and clinically overt extrasurgical site bleeding resulting in either a hemoglobin level decrease of at least 2 g/dl or transfusion of 2 units or greater of packed red blood cells were reported in 0.68% versus 0.19% (p=0.073) and 0.68% versus 0.13% (p=0.032), respectively, of the cohort patients versus the RECORD trial patients. Conclusion Overall, any postoperative bleeding in the cohort patients occurred significantly more frequently than that observed in the RECORD trial patients. The major bleeding rate was also significantly higher in the cohort patients, influenced by higher rates of bleeding leading to reoperation and clinically overt extrasurgical site bleeding resulting in either a hemoglobin decrease of at least 2 g/dl or transfusion of two units or greater of packed red blood cells. These findings from our pilot study are thought provoking and, thus, invite further investigation.

No description available.

Total hip arthroplasty commonly involves a hard metallic/ceramic femoral ball component articulating against an acetabular ultra-high molecular weight polyethylene (UHMWPE) counter-bearing. A novel six-station, wear tribometer, featuring programmable load and motion, was designed to further the investigation into wear, sub-surface plasticity and debris generation of UHMWPE. This thesis describes the pin-on-plate device, its validation and subsequent use to assess unirradiated (-PE) and gamma-irradiated highly crosslinked (+PE) UHMWPE wear behaviour. With the emphasis on dynamic loading and a closer gait matched open wear path, the tribometer improves on the clinical relevance of pin-on-plate testing. There is a requirement for this type of machine in order to investigate the directional dependence of wear and debris generation of UHMWPE more accurately, where “simplified” tribometers (adequate for constant load/constant velocity and constant load/sinusoidal velocity work) are not capable or suitable. For the first time in orthopaedic pin-on-plate studies, tests were conducted using an advanced dynamic load synchronised to a more physiologically accurate elliptical motion path. To validate the machine, three orthopaedic polymers of clinical relevance; Polytetrafluroethylene, Polyacetal, and UHMWPE were subjected to linear-reciprocating (LR) and novel elliptical motion paths under a Paul-type load profile. All three polymers showed higher wear factors under elliptical motion, by up to 2 orders of magnitude, agreeing well with explanted values. The UHMWPE elliptical wear factor was comparable to that reported for clinical, where kelliptical = 1.56 x 10-6 mm3/Nm. In the crosslinked study, the mean steady state wear of -PE and +PE groups under linear reciprocating motion was not significantly different. However, under elliptical motion, crosslinking reduced UHMWPE wear by up to 92% when compared to the unirradiated group. In –PE pins worn under LR motion and in +PE pins subjected to both motion paths a sub-surface damage zone with reduced crystallinity and increased strain was measured using Raman spectroscopy. This was attributed to large strain accumulation in the slower wearing surfaces providing a mechanism for de-crystallisation. The discovery of such a near-surface layer is in good agreement with critical strain wear models. In disagreement, however, we found the sliding induced layer to extend to greater depths than previous reported.

published_or_final_version / Orthopaedics and Traumatology / Doctoral / Doctor of Philosophy

published_or_final_version / abstract / Orthopaedics and Traumatology / Doctoral / Doctor of Philosophy

Computer assisted mosaic arthroplasty (CAMA) is a surgical technique that transplants cylindrical osteochondral grafts to repair damaged cartilage. An earlier in vivo study on sheep showed that short-term clinical outcomes are improved with the use of computer assistance, as compared to the conventional technique. This thesis reports on a study comparing three mosaic arthroplasty techniques -- one conventional and two computer assisted -- on human anatomy. This in vitro study used solid foam femur models modified to incorporate simulated cartilage defects. There were five participating surgeons ranging from a third year resident to a senior orthopedic surgeon. Each of the five participating surgeons performed a total of nine trials. There were three distinct sets of identical solid foam femur models with simulated cartilage defects. Three surgical techniques (conventional, opto-electronic, and patient-specific template) were performed on each. Several measures were made to compare surgical techniques: operative time; surface congruency; defect coverage; graft surface area either too high or too low; air volume below the grafts; and distance and angle of the grafts from the surgical plan. The patient-specific template and opto-electronic techniques resulted in improved surface congruency, defect surface coverage, graft surface within 0.50mm recessed and 0.25mm proud of the original surface, and below-graft air gap volume in comparison to the conventional technique. However, the conventional technique had a shorter operative time. The patient-specific template technique had less variance in surface congruency and shorter operative time than did the opto-electronic technique. / Thesis (Master, Computing) -- Queen's University, 2013-11-28 17:06:06.961

Introduction: Studies show that Total Knee Arthroplasty (TKA) is successful for the majority of patients however some continue to experience some functional limitations and anecdotal evidence indicates that stiffness is a common complaint. Some studies have suggested an association between stiffness and functional limitations however there has been no previous work which has attempted to objectively quantify knee joint stiffness following TKA. The purpose of this study was to pilot and evaluate a method for the quantitative evaluation in joint stiffness in replaced knees, OA knees and healthy controls and to explore whether there is an association between stiffness and functional limitations post-TKA surgery. Methods: The first part of the study created a biomechanical model of knee stiffness and built a system from which stiffness could be calculated. A torque transducer was used to measure the resistance as the knee was flexed and extended passively and an electrogoniometer concurrently measured the angular displacement. Stiffness was calculated from the slope of the line relating the passive resistive torque and displacement. The torque and joint angle at which stiffness was seen to increase greatly was also noted. The system was bench tested and found to be reliable and valid. Further tests on 6 volunteers found stiffness calculations to have acceptable intra-day reliability. The second part was conducted on three groups: those with end-stage knee OA (n = 8); those who were 1 year post-TKA (n = 15) and age matched healthy controls (n = 12). Knee range of motion was recorded and participants then completed the WOMAC, the SF-12 and a Visual Analogue Score for stiffness as well as indicating words to describe their stiffness. Four performance based tests – the Timed Up and Go (TUG), the stair ascent/descent, the 13m walk and a quadriceps strength test were also undertaken. Finally, passive stiffness at the affected knee was measured. Results: 100% of OA, 80% of TKA and 58% of controls reported some stiffness at the knee. The OA group reported significantly higher stiffness than the OA or TKA groups. There was no difference in self-reported stiffness between the TKA and control groups. Of the total number of words used to describe stiffness, 52% related to difficulty with movement, 35% were pain related and 13% related to sensations. No significantly differences were found between groups in the objective stiffness measures. Significant differences were found however in threshold flexion stiffness angles between groups. When this angle was normalised, differences between groups were not significant. No significant differences were found between groups in the threshold stiffness torque. Greater self-reported stiffness was found to be associated with worse self-reported function. A higher flexion stiffness threshold angle was associated with slower timed tests of function but also with better quadriceps muscle strength. Conclusions: The results support anecdotal reports that perceived stiffness is a common complaint following TKA but there was no evidence to show that patients with TKA have greater stiffness than a control group. There was however evidence to show that patients’ were unable to distinguish between sensations of stiffness and other factors such as pain. Self-perceived increased stiffness was associated with worse functional performance. Greater stiffness however was not necessarily negative. Stiffness increases earlier in flexion range were associated with better functional performance. These results suggest that an ideal threshold range for stiffness may exist; above which negative perceptions of the knee result in worse function but below which, knee laxity and instability may also result in worse function.