Thesis (doctor of medicine)--Universitetet i Lund.

Thesis (doctor of medicine)--Universitetet i Lund.

The number of patients electing to undergo total hip arthroplasty (THA) in the United States has been projected to double by the year 2030, with a growing number of these patients below the age of 65 years. This cohort of patients not only desires to return to pain free daily activity, but wishes to participate in recreation and sporting activities. However, many of these patients report pain, impairments, and functional limitations following THA. The number one deficit observed for patients who fail conventional post-operative rehabilitation is persistent weakness of the hip abductor muscles. In order to safely progress these patients back to their desired activity level, appropriate postoperative rehabilitation programs need to be developed. The primary objective of this dissertation was to examine the effectiveness of a hip abductor strengthening program on subjective and objective outcomes following THA. The secondary aims of this study were to document hip muscle activation and lower extremity movement patterns during functional exercises; and to compare shortterm subjective and objective clinical outcomes for subjects following THA compared to controls. Several observations were made from our results. First, the lunge, single leg squat, and step-up and over exercises may be appropriate to include in post-operative rehabilitation programs to transition THA subjects from static strengthening exercises to dynamic activities. Second, subjects at 6- and 12-weeks following THA continue to exhibit strength and functional deficits, which contributes to decreases in activity level. Third, the addition of an exercise program targeting the hip abductor muscles following THA may help to improve subjective and objective outcomes compared to conventional post-operative rehabilitation. Finally, findings from our results are summarized and we propose a model to develop patient-specific rehabilitation programs.

INTRODUÇÃO: a doença de Legg-Calvé-Perthes (DLCP) é a causa da osteoartrose de quadril em menos de 5% dos casos com indicação de artroplastia total do quadril (ATQ). Por isso, poucos estudos descrevem os resultados clínicos e radiológicos da ATQ nessa situação, em que deformidades no fêmur proximal e no acetábulo tornam a cirurgia um desafio técnico. MÉTODO: neste estudo tipo caso-controle, foram revisados os prontuários de pacientes admitidos num hospital público universitário de referência para serem submetidos à ATQ por osteoartrose primária ou secundária à DLCP entre 2008 e 2015, utilizando um determinado modelo de prótese não cimentada de um mesmo fabricante. Os pacientes foram convocados para análise clínica e radiográfica. Indivíduos com ATQ por osteoartrose secundária à DLCP foram comparados a um grupo controle de pacientes com osteoartrose primária quanto a dor e função por meio do questionário de Lequesne. Foram também avaliadas as seguintes variáveis radiográficas: inclinação lateral do componente acetabular em relação à pelve, offset femoral e posicionamento do componente femoral em relação ao canal femoral. As avaliações radiográficas no pós-operatório imediato e na última consulta de seguimento foram comparadas. O tempo cirúrgico, o tamanho dos componentes protéticos utilizados e as complicações decorrentes do ato cirúrgico foram comparados nos dois grupos. RESULTADOS: no período do estudo, foram analisados 22 pacientes no grupo estudo (25 quadris) e 22 pacientes (25 quadris) do grupo controle, que foram comparados. Os dois grupos eram homogêneos quanto a lateralidade, sexo, tempo de cirurgia, tempo de seguimento e tamanho dos componentes utilizados. Os pacientes do grupo controle, com osteoartrose primária, tinham idade superior aos do grupo estudo. Ocorreram quatro fraturas periprotéticas femorais intraoperatórias no grupo com sequela da DLCP e nenhuma no grupo com osteoartrose primária (p = 0,050). A avaliação clínica e funcional mostrou maior comprometimento no grupo de pacientes com sequela da DLCP (p = 0,002). As medidas angulares de inclinação lateral acetabular foram semelhantes entre os dois grupos. Tanto no pós-operatório imediato quanto no final do seguimento, os componentes femorais estavam posicionados significativamente mais em valgo para o grupo com sequela da DLCP quando comparados ao grupo controle (com p = 0,008 no pós-operatório imediato e p = 0,002 no seguimento final). A medida do offset femoral lateral não teve diferenças significativas entre os grupos. Em nenhum dos casos dos grupos estudados houve infecção, luxação ou lesão neurológica decorrentes do ato cirúrgico. Não foi indicada ou realizada nenhuma cirurgia de revisão em ambos os grupos. CONCLUSÕES: há risco aumentado de fratura femoral periprotética intraoperatória e resultados clínico-funcionais piores em pacientes com osteoartrose secundária à sequela da DLCP submetidos a ATQ sem cimento convencional do que em pacientes com osteoartrose primária do quadril. Os componentes femorais da ATQ sem cimento convencional tendem a ser implantados mais em valgo no canal femoral nos casos motivados por osteoartrose secundária à sequela da DLCP comparados aos casos motivados por osteoartrose primária do quadril / INTRODUCTION: Legg-Calvé-Perthes disease (LCPD) is the cause of hip osteoarthrosis in less than 5% of cases with an indication of total hip arthroplasty (THA). For that reason, few studies describe the clinical and radiological results of THA in this situation, in which proximal femur and acetabulum deformities make surgery a technical challenge. METHODS: In this case-control study, the medical records of patients admitted to a public university reference hospital to undergo THA due to primary osteoarthrosis or to LCPD sequelae between 2008 and 2015, using a cementless prosthesis from the same manufacturer, were reviewed. Patients were recruited for clinical and radiographic analysis. Individuals with osteoarthrosis secondary to LCPD were compared to a control group of patients with primary osteoarthrosis regarding pain and function using the Lequesne questionnaire. The following radiographic variables were also evaluated: acetabular component inclination in relation to the pelvis, femoral offset, and femoral component position in relation to the femoral canal. Evaluations in the immediate postoperative period and at the last follow-up visit were compared. The surgical time, the size of the prosthetic components used and the complications resulting from the surgical procedure were studied and compared between groups. RESULTS: During the study period, 22 patients in the study group (25 hips) were compared to 22 patients (25 hips) in the control group. The two groups were homogeneous regarding the laterality, sex, surgery time, follow-up time and size of the prosthetic components used. Patients in the control group, with primary osteoarthrosis, were older than those in the study group. There were four intraoperative femoral periprosthetic fractures in the group with LCPD sequelae and none in the primary osteoarthrosis group (p = 0.050). The clinical and functional evaluation showed greater impairment in the group of patients with LCPD sequelae (p = 0.002). Angular measures of acetabular inclination were similar between the two groups. Both in the immediate postoperative period and at the end of the follow-up, the femoral components were positioned significantly more in valgus for the LCPD sequelae group when compared to the control group (p = 0.008 in the immediate postoperative period and 0.002 in the final follow-up). The measurement of the lateral femoral offset was similar between the groups. In none of the cases of the studied groups, there was infection, dislocation or neurological injury resulting from the surgical act. No revision surgery was indicated or performed in both groups. CONCLUSIONS: There is an increased risk of intraoperative periprosthetic femoral fracture and worse clinical-functional results in patients with osteoarthrosis secondary to LCPD sequelae undergoing conventional cementless THA than in patients with primary hip osteoarthrosis. The femoral components of the cementless THA tend to be implanted more in valgus in the femoral canal in the cases of osteoarthrosis secondary to the sequelae of the LCPD compared to cases of primary hip osteoarthrosis

INTRODUÇÃO: a doença de Legg-Calvé-Perthes (DLCP) é a causa da osteoartrose de quadril em menos de 5% dos casos com indicação de artroplastia total do quadril (ATQ). Por isso, poucos estudos descrevem os resultados clínicos e radiológicos da ATQ nessa situação, em que deformidades no fêmur proximal e no acetábulo tornam a cirurgia um desafio técnico. MÉTODO: neste estudo tipo caso-controle, foram revisados os prontuários de pacientes admitidos num hospital público universitário de referência para serem submetidos à ATQ por osteoartrose primária ou secundária à DLCP entre 2008 e 2015, utilizando um determinado modelo de prótese não cimentada de um mesmo fabricante. Os pacientes foram convocados para análise clínica e radiográfica. Indivíduos com ATQ por osteoartrose secundária à DLCP foram comparados a um grupo controle de pacientes com osteoartrose primária quanto a dor e função por meio do questionário de Lequesne. Foram também avaliadas as seguintes variáveis radiográficas: inclinação lateral do componente acetabular em relação à pelve, offset femoral e posicionamento do componente femoral em relação ao canal femoral. As avaliações radiográficas no pós-operatório imediato e na última consulta de seguimento foram comparadas. O tempo cirúrgico, o tamanho dos componentes protéticos utilizados e as complicações decorrentes do ato cirúrgico foram comparados nos dois grupos. RESULTADOS: no período do estudo, foram analisados 22 pacientes no grupo estudo (25 quadris) e 22 pacientes (25 quadris) do grupo controle, que foram comparados. Os dois grupos eram homogêneos quanto a lateralidade, sexo, tempo de cirurgia, tempo de seguimento e tamanho dos componentes utilizados. Os pacientes do grupo controle, com osteoartrose primária, tinham idade superior aos do grupo estudo. Ocorreram quatro fraturas periprotéticas femorais intraoperatórias no grupo com sequela da DLCP e nenhuma no grupo com osteoartrose primária (p = 0,050). A avaliação clínica e funcional mostrou maior comprometimento no grupo de pacientes com sequela da DLCP (p = 0,002). As medidas angulares de inclinação lateral acetabular foram semelhantes entre os dois grupos. Tanto no pós-operatório imediato quanto no final do seguimento, os componentes femorais estavam posicionados significativamente mais em valgo para o grupo com sequela da DLCP quando comparados ao grupo controle (com p = 0,008 no pós-operatório imediato e p = 0,002 no seguimento final). A medida do offset femoral lateral não teve diferenças significativas entre os grupos. Em nenhum dos casos dos grupos estudados houve infecção, luxação ou lesão neurológica decorrentes do ato cirúrgico. Não foi indicada ou realizada nenhuma cirurgia de revisão em ambos os grupos. CONCLUSÕES: há risco aumentado de fratura femoral periprotética intraoperatória e resultados clínico-funcionais piores em pacientes com osteoartrose secundária à sequela da DLCP submetidos a ATQ sem cimento convencional do que em pacientes com osteoartrose primária do quadril. Os componentes femorais da ATQ sem cimento convencional tendem a ser implantados mais em valgo no canal femoral nos casos motivados por osteoartrose secundária à sequela da DLCP comparados aos casos motivados por osteoartrose primária do quadril / INTRODUCTION: Legg-Calvé-Perthes disease (LCPD) is the cause of hip osteoarthrosis in less than 5% of cases with an indication of total hip arthroplasty (THA). For that reason, few studies describe the clinical and radiological results of THA in this situation, in which proximal femur and acetabulum deformities make surgery a technical challenge. METHODS: In this case-control study, the medical records of patients admitted to a public university reference hospital to undergo THA due to primary osteoarthrosis or to LCPD sequelae between 2008 and 2015, using a cementless prosthesis from the same manufacturer, were reviewed. Patients were recruited for clinical and radiographic analysis. Individuals with osteoarthrosis secondary to LCPD were compared to a control group of patients with primary osteoarthrosis regarding pain and function using the Lequesne questionnaire. The following radiographic variables were also evaluated: acetabular component inclination in relation to the pelvis, femoral offset, and femoral component position in relation to the femoral canal. Evaluations in the immediate postoperative period and at the last follow-up visit were compared. The surgical time, the size of the prosthetic components used and the complications resulting from the surgical procedure were studied and compared between groups. RESULTS: During the study period, 22 patients in the study group (25 hips) were compared to 22 patients (25 hips) in the control group. The two groups were homogeneous regarding the laterality, sex, surgery time, follow-up time and size of the prosthetic components used. Patients in the control group, with primary osteoarthrosis, were older than those in the study group. There were four intraoperative femoral periprosthetic fractures in the group with LCPD sequelae and none in the primary osteoarthrosis group (p = 0.050). The clinical and functional evaluation showed greater impairment in the group of patients with LCPD sequelae (p = 0.002). Angular measures of acetabular inclination were similar between the two groups. Both in the immediate postoperative period and at the end of the follow-up, the femoral components were positioned significantly more in valgus for the LCPD sequelae group when compared to the control group (p = 0.008 in the immediate postoperative period and 0.002 in the final follow-up). The measurement of the lateral femoral offset was similar between the groups. In none of the cases of the studied groups, there was infection, dislocation or neurological injury resulting from the surgical act. No revision surgery was indicated or performed in both groups. CONCLUSIONS: There is an increased risk of intraoperative periprosthetic femoral fracture and worse clinical-functional results in patients with osteoarthrosis secondary to LCPD sequelae undergoing conventional cementless THA than in patients with primary hip osteoarthrosis. The femoral components of the cementless THA tend to be implanted more in valgus in the femoral canal in the cases of osteoarthrosis secondary to the sequelae of the LCPD compared to cases of primary hip osteoarthrosis

Die Zielsetzung dieser Arbeit besteht darin zu prüfen, ob die Luxationsrate bei Hochrisikopatienten durch den Einsatz von 40-mm- und 44-mm-Köpfen im Vergleich zu Patienten mit maximal 36-mm-Köpfen reduziert werden kann. Hierzu wurden die im Zeitraum von September 2009 bis Mai 2014 hüftendoprothetisch versorgten Patienten mit einem erhöhten Luxationsrisiko erfasst und die Verläufe auf Luxationen überprüft. Zur Risikobewertung diente eine eigens entwickelte Klassifikation. Des Weiteren erfolgte die Analyse der postoperativen Verläufe, der Röntgenbilder und eines Telefoninterviews in den Fällen, in denen Köpfe ≥ 40 mm zum Einsatz kamen. Im Untersuchungszeitraum wurden 288 Hüftendoprotheseneingriffe mit erhöhtem Luxationsrisiko durchgeführt. Bei 278 HTEP-Implantationen erfolgte der Einsatz von Gelenkköpfen ≤ 36 mm. In dieser Gruppe betrug die Luxationsrate 15,1% (n=42). Bei 10 Patienten wurden 40-mm- oder 44-mm-Gelenkköpfe eingesetzt. In diesen Fällen wurde das Luxationsrisiko entsprechend der vorgeschlagenen Klassifikation mit 3A (hoch) bis 4B (sehr hoch) bewertet. Bei einem mittleren Follow up von 22,8 Monaten wurde bei diesen Patienten keine Luxation festgestellt. Die mit 40-mm- sowie 44-mm-Köpfen erzielten Ergebnisse und die aktuelle Literatur sprechen für eine wesentlich höhere Gelenkstabilität und eine deutlich verminderte Luxationsneigung größerer Köpfe. Deren Einsatz ist daher gegenwärtig bei Risiko-patienten gerechtfertigt, sofern dieser in Abhängigkeit vom Pfannenaußendurch-messer konstruktiv möglich ist. In der weiteren Entwicklung der Hüftendoprothetik sollte die Verwendung größerer Köpfe angestrebt werden.:Inhaltsverzeichnis Bibliographische Beschreibung Abkürzungsverzeichnis 1. Einleitung 1.1 Bedeutung der Hüftendoprothetik 1.2 Hüftendoprothesenluxation 1.2.1 Definition und Häufigkeit 1.2.2 Ursachen 1.2.3 Einteilung und Klassifikation 1.2.4 Risikofaktoren 1.2.5 Beurteilung des Luxationsrisikos bei hüftendoprothetischen Eingriffen 1.2.6 Ursachen des luxations-mindernden Effektes großer Köpfe 1.2.7 Vorgehen nach Luxation 1.2.7.1 Diagnostik 1.2.7.2 Therapie 1.3 Zielsetzung der Arbeit 2. Publikation 3. Zusammenfassung 4. Literaturverzeichnis 5. Tabellenverzeichnis 6. Abbildungsverzeichnis 7. Erklärung über die eigenständige Abfassung der Arbeit 8. Lebenslauf und wissenschaftlicher Werdegang 9. Danksagung 10. Anlagen Anlage 1 - Dokumentationsbogen Patienten mit Großköpfen Anlage 2 - Telefoninterviewbogen zu 40/44mm Köpfen