There have been many advances in surgical residency education and similar interest exists in fellowship education. This study evaluated perceptions among spine surgeons about the specific competencies required for successful spine surgical fellowship training, and then compared these perceptions to clinical practice. Firstly, a questionnaire was administered to spine fellow trainees and academic spine surgeons across Canada in order to identify the cognitive and technical skills required for successful spine fellowship training. Fellowship trainees and supervisors had similar perceptions on the relative importance of specific cognitive and technical competencies. Differences in perceptions were found when comparing surgeons based on background residency specialty training (orthopaedic surgical or neurosurgical). Secondly, using administrative data, a retrospective study assessed volumes, surgeon characteristics, and outcomes for surgery of the degenerative lumbar spine in Ontario between 1995 and 2001. Neurosurgeons were found to perform more decompressions, and more total procedures, than orthopaedic surgeons with similar outcomes.

Healing large bone defects remains a clinical challenge. While autografts are the gold standard treatment for large bone defects, they are limited by availability and donor site pain. Growth factor treatments such as BMP therapy provide a promising alternative but are expensive and present clinical safety concerns, primarily due to delivery of BMPs at supraphysiological doses. Integrins are ECM receptors which mediate crucial cell functions such as adhesion and differentiation. Therefore, understanding the role of integrins in bone formation and directing desired interactions may enable modulation of host cell functions for therapeutic applications. In this work, beta 1 integrins were deleted in osteolineage cells of transgenic mice at three different stages of differentiation to elucidate their role in bone development. We also engineered bioartificial PEG-based matrices which target the pro-osteogenic alpha 2 beta 1 integrin to promote bone healing. Conditional deletion of beta 1 integrins in osteochondroprogenitor cells under the Twist 2 promoter resulted in severe pre-natal skeletal mineralization defects and embryonic lethality. Targeted deletion of beta 1 integrins in osterix-expressing osteoprogenitors resulted in growth abnormalities, reduced calvarial mineralization, impaired femur development, and tooth defects. However, mice lacking beta 1 integrins in osteocalcin-expressing osteoblasts and osteocytes displayed only a mild skeletal phenotype, indicating that beta 1 integrins play an important role in early skeletal development, but are not required for mature osteoblast function. PEG hydrogels functionalized with the integrin-specific GFOGER ligand enhanced bone regeneration, induced defect bridging in combination with low doses of rhBMP-2 and stimulated improved bone healing compared collagen sponges, which are the clinical standard delivery vector for BMP-2 therapy. These results suggest that treatment with bioartificial integrin-specific PEG hydrogels may be a promising clinical strategy for bone regeneration in large bone defects.

Η μηχανοργάνωση των φορέων υγείας αποτελεί προαπαιτούμενο για τη βελτίωση των παρεχόμενων υπηρεσιών τους ως προς τους πολίτες. Αν και η διεργασία έχει καθυστερήσει σημαντικά, φαίνεται πως οι εμπλεκόμενοι έχουν αντιληφθεί τη σπουδαιότητα της και πλέον ήδη βρίσκονται σε εξέλιξη προγράμματα προς αυτή την κατεύθυνση. Η ορθοπαιδική κλινική του ΠΓΝΠ, αποτελεί υπόδειγμα στο συγκεκριμένο τομέα καθώς ήδη από δεκαετίας έχει ηλεκτρονικό αρχείο με βασικά στοιχεία των ασθενών που νοσηλεύτηκαν, ενώ το 2005 πήγε ένα βήμα παραπέρα και επέκτεινε τη μηχανοργάνωση της με ηλεκτρονικό φάκελο υγείας ασθενή, εντάσοντας και τις απεικονιστικές εξετάσεις. Στο παρόν κείμενο στην εισαγωγή γίνεται μια ανάλυση της υπάρχουσας κατάστασης και μια λεπτομερής περιγραφή των προγραμμάτων που βρίσκονται σε εξέλιξη σχετικά με το θέμα. Δίνεται μια εξήγηση για την υστέρηση που έχει παρουσιαστεί και τα προβλήματα που αντιμετωπίζουν ανάλογα εγχειρήματα. Στην ενότητα 4 περιγράφεται σε γενικές γραμμές η εφαρμογή (λογισμικό) που εγκαταστάθηκε στην ορθοπαιδική κλινική και πως αυτή μηχανογραφεί της λειτουργικές διαδικασίες που ακολουθούνται στην καθημερινότητα του τμήματος. Στην επόμενη ενότητα η αναφορά εστιάζει περισσότερο στο “μικρόκοσμο” της κλινικής. Μιλάει με στατιστικά στοιχεία για το προσφερόμενο έργο της και ουσιαστικά αναλύει τον τρόπο με τον οποίο έγνε η εφαρμογή της μηχανοργάνωσης. Πώς ξεπεράστηκαν προβλήματα, τι χειρισμοί έγιναν με το προσωπικό, τι διαρθωτικές αλλαγές έγιναν ώστε να δημιουργηθεί ένα νέο τμήμα που ανέλαβε να κάνει το data entry. Η συνέχεια είναι με τις προοπτικές εξέλιξες οι οποίες χάρη σε μια θετική συγκυρία φαντάζουν εξαιρετικά ευοίωνες και στο τέλος παραθέτονται κάποια τεχνικά παραρτήματα που αφορούν περισσότερο το προσωπικό της κλινικής κι έχουν στόχο τη μετάδοση γνώσεων που θα βοηθήσουν στην εύρυθμη λειτουργία. / Computerization of health organizations consists precondition for the improvement of provided health services to citizens. Despite the process has an important delay, it seems the concerned parts are aware of the importance and projects aiming on this direction running already. The clinic of Orthopaedics at University Hospital of Patras, insists a positive sample in this sector. Since 90’s keeps a basic electronic database of patients’ data and in 2005 stepped forward adding health records and imaging platings (PAKS). Present thesis makes an analysis of present status and a description of relative projects in progress. An explanation for the hysteresis is given and solutions for past resolved problems. In chapter 4 presented the installed software in the clinic of Orthopaedics and how it is engaged with the procedures taking place in day life. In the next chapter the present thesis focuses on the clinic. It speaks in the language of statistics for the offered work towards the society and analysis the steps followed for the project of computerization. Finishing with the potential for evolution which seems to be very high thanks to a trend.

The composition of orthopaedic wear testing lubricants used to mimic synovial fluid (SF) is known to significantly affect in vitro polyethylene (PE) wear; however, some wear testing standards may be promoting the use of lubricants that are not clinically relevant. The present thesis evaluated the biochemical composition of human osteoarthritic and periprosthetic SF in order to propose changes to lubricant specifications in current wear testing standards. Using this data, pin-on-disc wear tests were conducted to explore the effects of more clinically relevant lubricants on PE wear. Results showed that wear decreased using a more clinically relevant lubricant. Samples of these lubricants were biochemically evaluated and compared to the SF results previously obtained, which showed that current standards for wear testing lubricants are biochemically different from SF. The findings from the present thesis encourage the modification of standardized lubricant specifications to improve wear testing protocols and guarantee clinically relevant wear testing.

The aim of this study was to investigate noise levels in the New Zealand health industry. The goal was to investigate the room acoustics and the characteristics of the noise sources along with noise exposure of health care workers, in New Zealand, in dental clinics and orthopaedic cast clinics and assess whether they are at risk of noise-induced hearing loss (NIHL). A literature review was conducted to determine the definition, cause, and ways to prevent NIHL in relation to the dental clinics and orthopaedic cast clinics. Also determined from a review of the literature were ways to assess and monitor the acoustics of these spaces. Initially room acoustic measurements of background noise levels as well as reverberation times were made and frequency information on the major noise sources was obtained. This was followed by measurement of the daily noise dose exposure of staff working in the participating dental clinics and orthopaedic cast clinics. It was found that noise dose levels did not exceed the damage risk criterion set by The New Zealand Occupational Safety and Health Service of Leq8h of 85 dBA and therefore staff were considered to not be at risk of NIHL. However, the background noise levels measured may be putting healthcare workers at risk of non-auditory related effects of noise exposure, affecting work performance, cognitive abilities and vital communication between staff and patients. Healthcare workers may also be at risk of non-auditory health effects due to increased noise annoyance leading to raised stress levels, which may ultimately lead to pathophysiological changes in the myocardium. Future research in the area of noise levels in the New Zealand health industry should be performed to obtain noise data on a larger sample and look further at the non-auditory health effects of exposure to noise in the health industry.

The composition of orthopaedic wear testing lubricants used to mimic synovial fluid (SF) is known to significantly affect in vitro polyethylene (PE) wear; however, some wear testing standards may be promoting the use of lubricants that are not clinically relevant. The present thesis evaluated the biochemical composition of human osteoarthritic and periprosthetic SF in order to propose changes to lubricant specifications in current wear testing standards. Using this data, pin-on-disc wear tests were conducted to explore the effects of more clinically relevant lubricants on PE wear. Results showed that wear decreased using a more clinically relevant lubricant. Samples of these lubricants were biochemically evaluated and compared to the SF results previously obtained, which showed that current standards for wear testing lubricants are biochemically different from SF. The findings from the present thesis encourage the modification of standardized lubricant specifications to improve wear testing protocols and guarantee clinically relevant wear testing.

Abstract can be viewed in PDF document. / Thesis (Ph.D)-University of KwaZulu-Natal, Durban, 2008.

<p>Bakgrund: Teorier i omvårdnad har beskrivits av många omvårdnadsforskare. Sjuksköterskeprofessionen är tvärvetenskaplig. Huvudämnet i sjuksköterskeutbildningen är omvårdnad och stödämnen i professionen kan vara biomedicin och folkhälsa. Det akademiska ämnet omvårdnad är professionsneutralt. En vanlig uppfattning bland sjuksköterskor är att jämställa professionen med ämnet. Detta mångvetenskapliga perspektiv har lett till att det inte finns någon klar definition om vad som är kärnan i ämnet omvårdnad. Syfte: Syftet med examensarbetet var att studera hur sjuksköterskor på en ortopedavdelning beskriver god omvårdnad. Metod: Studien gjordes på en ortopedavdelning i Sverige under 2008. Åtta sjuksköterskor deltog i studien. En kvalitativ intervju genomfördes på en ortopedavdelning. Data transkriberades och analyserades med hjälp av kvalitativ innehållsanalys. Resultat: Sjuksköterskornas beskrivning av god omvårdnad sammanfattades i sju teman; smärtlindring, sjuksköterskans ansvarsområde, kommunikation, glädje, tid, teamwork och etiskt förhållningssätt. Konklusion: När sjuksköterskorna beskrev god omvårdnad utgick de ifrån deras arbetsuppgifter i sjuksköterskeprofessionen. De särskiljde inte omvårdnadskunskap från kunskaper inom stödämnen. Teorier i omvårdnad och centrala begrepp i omvårdnad var inte självklara för sjuksköterskorna. Däremot har de beskrivit delar av kärnan i omvårdnadsämnet utan att relatera till teorier i omvårdnad.</p> / <p>Background: Theories in nursing care has been described by several researchers. The profession is multidisciplinary. The major subject in the education for nurses is nursing care and other subjects in the profession can be biomedicine and public health. The academic subject nursing care is not bounded to the nurses’ profession. A common idea among the nurses is to see the profession as equal to the academic subject nursing care. Because of many perspectives, there is no clear definition that describes the essence of nursing care. Aim: The aim of this dissertation was to study how nurses´ describe good nursing care at an orthopaedic unit. Methods: The study was carried out in one orthopaedic unit in Sweden in 2008. Eight nurses’ took part in the study. A qualitative interview with was performed at the orthopaedic unit. Data were transcribed and analysed using qualitative content analysis. Findings: The nurses’ description of good nursing care was summarized in seven themes; pain management, a nurse responsibility, communication, joy, time, teamwork and ethical attitude. Conclusions: When the nurses´ described god nursing care they assumed from their tasks in the profession. They did not distinguished nursing care from the knowledge of subjects included in a nurse profession. Theories in nursing care and central concepts were not obvious for the nurses´. Although the parts of the core in nursing care has been described without relating to theories.</p>

Pour la plupart des entreprises, l’innovation est devenue un élément indispensable, garant de la pérennité de l’entreprise.Cependant, durant les phases de développement des produits, le concepteur est confronté lors des principaux jalons du processus à faire des choix de conception. Ces prises de décisions ont par la suite un fort impact sur l’acceptabilité ou non des produits par le marché. Le monde de la conception des implants orthopédiques n’y échappe pas.Le but de ce travail de thèse est de montrer qu’il est possible d’intégrer dans les phases amonts du processus de développement d’implants orthopédiques, un outil d’aide à la décision pour le choix de concepts intégrant des critères techniques, médicaux, chirurgicaux et économiques permettant de réduire les risques pour le patient mais aussi les risques d’un possible échec commercial.La première partie de ce document s’intéresse à l’analyse du contexte de cette étude et en particulier aux dispositifs médicaux. Ensuite, l’état de l’art étudie les différents processus d’innovation et plus spécifiquement les processus de conception dans le secteur médical des implants orthopédiques. Ces travaux nous ont amené à nous questionner et à analyser les méthodes d’évaluation du potentiel d’innovation disponibles au sein de la littérature scientifique, et de leur intégration au sein du secteur des implants.De cette analyse a émergé une question se situant au cœur de nos travaux de recherche : comment concevoir des implants innovants avec un niveau de risques faibles (risque clinique, risque de défaillance, risque d’utilisation) ?La réponse à cette question s’est traduite par la proposition d’un nouvel outil d’aide à la décision (hypothèse1) intégré aux phases amont d’un processus de conception adapté (hypothèse2) au développement d’implants. Celles-ci ont ensuite été vérifiées et validées lors de 3 expérimentations qui ont aboutis à la réalisation d’implants orthopédiques posés sur des patients. / For a majority of companies, innovation has become an essential element of corporate sustainability.However, during the product development phase the designer is forced to make decisions on design. These decisions subsequently have a strong impact on the acceptability of the products by the market. Orthopaedics implants design is no exception.The aim of this thesis is to show that it is possible to integrate, in the early phases of the orthopaedic implant development process, a tool for decision-making; in choosing concepts that incorporate technical, medical, surgical and economic criteria. The goal is to reduce the risk for the patient but also reduce the risk of commercial failure.The first part of this document focuses on analysing the context of this study, particularly for medical devices. Following this, the state of the art studies the various innovation processes and more specifically, the design process of medical orthopaedic implants. This work forced us to question and analyse evaluation methods for potential innovations available in the scientific literature, and integrate them into the implant sector.From this analysis, a question emerged lying at the heart of our research: how to design innovative implants with a low level of risk (clinical risk, default risk, risk of use)?The answer to this question has resulted in the proposal of a new tool for decision-making (Hypothesis 1) integrated within upstream phases of a suitable decision process (Hypothesis 2) for developing implants. These were then checked and validated in three experiments that resulted in the development of orthopaedic implants that were successfully inserted into patients.

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 (&LT;60 years), weight (&GE;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.