Joint replacement surgery in the treatment of arthritic disease is now commonplace and on the whole very successful. Research into the design and development of prostheses has made major advances since the 1940s resulting in complex devices for almost all articulating joints of the body. In this thesis, a programme of work to design and test a surface replacement prosthesis for the metacarpophalangeal joint is presented. The anatomy and kinematics of the MCP joint are discussed for both normal and abnormal joint function and, based on these considerations, the design of a new surface replacement prosthesis is described. Various materials are explored with respect to their biocompatibility, durability and ease of fabrication with special attention being paid to one material - a new cross linked ultra-high molecular weight polyethylene - which is tested for wear and assessed for durability in long-term prototype tests. A finger function simulator is detailed which was designed and developed during this research programme, and results of tests on bone replicas, Swanson Silastic implants and prototypes of the new design are presented. The simulator can be easily modified to accept any MCP joint prosthesis for bench testing. Finally the stress response of the prototype design is studied using finite element analysis and modifications to the implant design and bone preparation are suggested.

As a therapist within the multi-disciplinary setting, one is confronted with a wide array of pathology and diagnoses. Care is taken to optimize treatment outcomes and overall return of function to every patient admitted to the various rehabilitation facilities. Treatment is often standardized to ensure quality care benchmarked against outcome parameters. The aforementioned is also true for medical practitioners, pharmacists and other auxiliary service providers. Research is aimed at improving quality of care, finding and establishing the best practises through all hospitals and care facilities. Medical care has undergone a transformation over the past few decades with a strong emphasis being placed on protocols and procedures. Through applying standardized care, protocols and procedures, the researcher have come to realize that certain denominators within patient care have no prediction or outcome control. After more than a decade of treating patients in various rehabilitation settings the researcher have come to realize that one complaint exists with each and every patient under my care – pain. This was even more evident within the group of joint replacement patients. No two patients presented with the exact same pain profile or pain reports despite various commonalities such as anthropometric data (age, gender, length, mass), surgical procedure, attending physician, care facility, pathway exposure, diagnosis, radiographic findings and pharmaceutical intervention. If all the obvious factors were identical – what accounted for the different pain reports? This question is at the heart of the study – why do pain reports differ in the presence of so many similarities between patients? It soon became apparent that pain is recognized in the organic form. Organic pain can be measured and is expected with injury, illness or surgical intervention. The entire multi-disciplinary team is aware of organic pain and ready to intervene with medication, surgery and a pathway of care. All vigorously record organic pain and adapt treatment according to the pain levels as organic pain is real pain: real pain existing through exposure to real surgical intervention. Still the question remained: if all the factors prior to surgery, during surgery and after surgery were the same, why are patients experiencing and reporting very different pain levels? This question was the catalyst for the research and lead to keen focus during patient interviews. Every patient receiving an educational session prior to surgery had very vivid ideas about the pain they will experience post-operatively. The majority of patients formed pre-conceived notions about pain prior to undergoing surgery. They presented with a clear pain rating of what they expected to feel post-operatively. The pre-conceived pain rating was constructed in almost all the cases after some form of information obtained during consultation with their surgeon or a member of the multidisciplinary team. This pain notion existed as a tangible and measurable rating in the client’s mind prior to undergoing the knee replacement surgery. In select cases perceived pain was constructed as a result of information obtained from family or friends that underwent the same procedure while other clients constructed perceived pain due to a lack of information on the proposed surgery. It became evident that education or lack thereof on surgical interventions played a primary role in the construct of perceived pain. Patients were entering theatres for procedures and already experienced a form of perceived pain. If pain could be constructed prior to experiencing surgical intervention – can perceived pain then translate into actual organic pain and account for the variable pain reports post surgery? Against this backdrop, research was directed at understanding perceived pain and the factors that aid the construction of perceived pain. As education was found to be at the heart of every pain construct, the doctor-patient consultation was evaluated as a core component to ascertain the impact this relationship has on perceived pain. Measurement of perceived pain was also performed to conclude on the impact of this pain form on organic pain. The study is aimed at addressing the variant pain reports that no pathway or procedure can predict and provide for. It is an attempt to validate pain as constructed by the patient that impacts on their post-surgical pain ratings and behaviour. This research might contribute towards existing knowledge and understanding of the influence of doctor-patient interaction as well as the significance of this interaction on pain. As only scant research on perception of pain has been undertaken this research can prove insightful for further studies or as supplement to existing views and opinions. It can also serve as a foundation in developing practices that will manage pain by enhancing doctor-patient interaction in the health setting. / MA, Medical Sociology, North-West University, Vaal Triangle Campus, 2012

As a therapist within the multi-disciplinary setting, one is confronted with a wide array of pathology and diagnoses. Care is taken to optimize treatment outcomes and overall return of function to every patient admitted to the various rehabilitation facilities. Treatment is often standardized to ensure quality care benchmarked against outcome parameters. The aforementioned is also true for medical practitioners, pharmacists and other auxiliary service providers. Research is aimed at improving quality of care, finding and establishing the best practises through all hospitals and care facilities. Medical care has undergone a transformation over the past few decades with a strong emphasis being placed on protocols and procedures. Through applying standardized care, protocols and procedures, the researcher have come to realize that certain denominators within patient care have no prediction or outcome control. After more than a decade of treating patients in various rehabilitation settings the researcher have come to realize that one complaint exists with each and every patient under my care – pain. This was even more evident within the group of joint replacement patients. No two patients presented with the exact same pain profile or pain reports despite various commonalities such as anthropometric data (age, gender, length, mass), surgical procedure, attending physician, care facility, pathway exposure, diagnosis, radiographic findings and pharmaceutical intervention. If all the obvious factors were identical – what accounted for the different pain reports? This question is at the heart of the study – why do pain reports differ in the presence of so many similarities between patients? It soon became apparent that pain is recognized in the organic form. Organic pain can be measured and is expected with injury, illness or surgical intervention. The entire multi-disciplinary team is aware of organic pain and ready to intervene with medication, surgery and a pathway of care. All vigorously record organic pain and adapt treatment according to the pain levels as organic pain is real pain: real pain existing through exposure to real surgical intervention. Still the question remained: if all the factors prior to surgery, during surgery and after surgery were the same, why are patients experiencing and reporting very different pain levels? This question was the catalyst for the research and lead to keen focus during patient interviews. Every patient receiving an educational session prior to surgery had very vivid ideas about the pain they will experience post-operatively. The majority of patients formed pre-conceived notions about pain prior to undergoing surgery. They presented with a clear pain rating of what they expected to feel post-operatively. The pre-conceived pain rating was constructed in almost all the cases after some form of information obtained during consultation with their surgeon or a member of the multidisciplinary team. This pain notion existed as a tangible and measurable rating in the client’s mind prior to undergoing the knee replacement surgery. In select cases perceived pain was constructed as a result of information obtained from family or friends that underwent the same procedure while other clients constructed perceived pain due to a lack of information on the proposed surgery. It became evident that education or lack thereof on surgical interventions played a primary role in the construct of perceived pain. Patients were entering theatres for procedures and already experienced a form of perceived pain. If pain could be constructed prior to experiencing surgical intervention – can perceived pain then translate into actual organic pain and account for the variable pain reports post surgery? Against this backdrop, research was directed at understanding perceived pain and the factors that aid the construction of perceived pain. As education was found to be at the heart of every pain construct, the doctor-patient consultation was evaluated as a core component to ascertain the impact this relationship has on perceived pain. Measurement of perceived pain was also performed to conclude on the impact of this pain form on organic pain. The study is aimed at addressing the variant pain reports that no pathway or procedure can predict and provide for. It is an attempt to validate pain as constructed by the patient that impacts on their post-surgical pain ratings and behaviour. This research might contribute towards existing knowledge and understanding of the influence of doctor-patient interaction as well as the significance of this interaction on pain. As only scant research on perception of pain has been undertaken this research can prove insightful for further studies or as supplement to existing views and opinions. It can also serve as a foundation in developing practices that will manage pain by enhancing doctor-patient interaction in the health setting. / MA, Medical Sociology, North-West University, Vaal Triangle Campus, 2012

BACKGROUND: One of the most recurrent complaints after total joint replacement is difficulty sleeping. Sleep disturbance after major surgery is common. The “stress response” to surgery, personal factors and environmental factors can affect quality and quantity of sleep in the hospital setting. Occupational therapy intervention for individuals that have problems with function as a result of sleep insufficiency is an emerging practice area. However, there are few occupational therapy practitioners who have addressed the important occupation of sleep in acute care settings. There is a need to develop science-driven research and establish evidence to support acute care occupational therapy interventions that address sleep hygiene, a set of behavioral and environmental practices designed to improve both quality and quantity of sleep. In response to this need, the author designed and carried out a non- randomized controlled study to evaluate the effectiveness of a non-pharmacological occupational therapy intervention to improve quality and quantity of clients’ sleep in a fast track joint replacement center. OBJECTIVE: In the author’s study, the aim was to compare sleep quality, sleep quantity, and activities of daily living (ADL) performance before and after fast track total joint replacement surgery for clients who received an occupational therapy intervention targeted at improving sleep hygiene, in addition to conventional acute care occupational therapy, compared to those that received only conventional acute care occupational therapy. The project focused on 1) identifying evidence-based literature to support the benefit of non-pharmacological interventions for joint replacement surgery clients, 2) designing a program that represented best practice while incorporating the holistic and occupation-based theoretical base of occupational therapy, 3) implementing the program, 4) conducting summative program evaluation, and 5) developing a dissemination plan and implementation budget. RESULTS: There were no initial significant differences between the control and experimental groups. The quality of sleep in the experimental group at discharge was significantly better than in the controls and this group reported significantly improved quality of sleep at discharge compared to 2 weeks before surgery. At discharge the experimental group reported significantly longer sleep duration compared to the control group and the increase in duration from 2 weeks before surgery to discharge was significant. CONCLUSION: The results of this study demonstrated that improvement in sleep quality and quantity can be achieved in clients undergoing fast track joint replacement surgery who receive an occupation-based intervention that incorporates implementation of sleep hygiene practices. Moreover the change appears to persist after the client returns home. More research examining the effectiveness of this intervention with other surgical populations and the persistence of learned sleep hygiene practices over time after hospital discharge are warranted. / 2018-11-07T00:00:00Z

Text in Afrikaans / In this quantitative study emphasis is placed on the role of the nurse as a member of the rehabilitation team. Furthermore, the role of the nurse in patient education as well as the importance of effective patient education during the rehabilitation process after hip replacement surgery is emphasised. Various factors that impacted on the rehabilitation process are highlighted. A structured interview schedule was used to interview a group of 20 respondents. All of the respondents participated voluntarily. Orem's Selfcare Theory was used as a theoretical basis for the study. The researcher determined which information respondents regarded as important to attain functional independence during the rehabilitation process. The data gathered would serve as recommendation for a planned information brochure that could in future be given to patients at their first visit to the surgeon before surgery. The brochure could then be used as a basis for patient education in the course of the rehabilitation process. / Advanced Nursing Sciences / M.A. (Verpleegkunde)

<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>

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.

Thesis (MScEng)--Stellenbosch University, 2013. / ENGLISH ABSTRACT: Osteoarthritis (OA), also known as degenerative joint disease is a progressive disorder of the joints caused by gradual loss of cartilage and resulting in the development of bony spurs and cysts at the margins of the joints. The degradation of the musculoskeletal system, which is mainly caused by joint injury, obesity (leading to musculoskeletal fatigue) and aging can also lead to osteoarthritis. The hands, feet, spine, and large weight-bearing joints, such as the hips and knees are commonly affected. The only medical solution to severe cases of osteoarthritis is the surgical reconstruction or replacement of a malformed or degenerated joint, better known as arthroplasty. Arthroplasty makes use of biomedical implants and replacements to restore functionality of the joints. Biomedical engineering in arthroplasty is an ever increasing field of interest as a result of its innovative improvements to surgical quality. Certain cases of partial osteoarthritis require less surgical action. Partial knee replacement surgery, also known as unicondylar (or unicompartmental) knee arthroplasty involves a covering which is placed over the affected area to resurface the affected bone and protect the patient from further degeneration. Advantages of partial replacement include faster recovery time and less post-operative pain. The biomedical implants used for these operations consist of a standardized implant that is fit onto the bone by modifying (cutting away) the outer structure of the bone. The result is known to cause post-operative discomfort among some patients. The problem with these standard designs includes the requirement of the removal of unaffected (healthy) bone matter, leading to induced trauma and pain for patients during the recovery phase of the operations. A preferred alternative to the standard design would be to create a custom implant for every patient, reducing the need to remove parts of unaffected bone matter. The implementation of this proposed method tends toward Minimally Invasive Surgery (MIS). MIS is normally preferred as it reduces the risk of various negative consequences of normal arthroplasty such as nerve or tendon damage during surgery. It could be argued that the proposed method may cause less damage to the fragile tendon, bloodflow, and nerve networks of the knee. Increasing material costs of metal products introduce great interest in more cost efficient forming processes to reduce the loss of redundant blank material. Incremental Sheet Forming (ISF), a relatively new class of forming process, has the potential to meet the need for this more efficient forming process. The ISF process is highly flexible, can be developed in normal milling machines, and can reduce production cost by up to 90% in comparison to processes such as stamping. The ISF process is a non-patented process, as the existing patents are referred to the designed machines and not the process. The availability of the ISF process contributes greatly to its attractiveness. ISF can be implemented in any facility that has access to a three- or more-axis CNC machine. The advantage of ISF implemented in CNC machines is that CNC technology has already reached a mature stage in development, contributing to the accuracy and methodology (such as feed rate or angular velocity of the tool) of the ISF process. The forming of valuable lightweight materials is well covered by ISF processes. A variety of studies contribute to research on the forming of titanium and titanium based alloys as part of ISF of lightweight materials. The ISF process utilizes the functionality of commercial CNC machines, improving the process availability of many manufacturing companies. The ISF process offers fast setup times and flexibility of the forming process. The purpose of this project is to define a process chain for creating a customized biomedical implant as well as determining the validity of the process chain by applying each step. The design and development procedure of a titanium based biomedical arthroplasty implant using innovative Incremental Sheet Forming (ISF) techniques will be documented, as well as an investigation of the financial cost and potential gain that this implant can offer. / AFRIKAANSE OPSOMMING: Osteoartritis is 'n gewrig siekte wat degeneratiewe newe-effekte behels in die gewrigte. Hierdie siekte lei to die geleidelike verlies van kraakbeen en lei tot die onreelmatige ontwikkeling van abnormale beengroei. Osteoartritis kan ook deur beserings in die gewrig veroorsaak word. Die hande, voete, ruggraat, en enige groter gewigdraende gewrigte, soos die heupe en knieë kan geaffekteer word. Die enigste mediese oplossing tot ernstige gevalle van die siekte is chirurgiese rekonstruksie of vervanging van die gewrig, meer bekend as artroplastie. Artroplastie maak gebruik van biomediese implantate om funksionaliteit van die gewrig te herstel. Biomediese ingenieurswese in artroplastie is 'n toenemende navorsingsveld as gevolg van die innoverende aspekte om chirurgiese kwaliteit te verhoog. Sekere gevalle van gedeeltelike osteoartritis vereis veel minder chirurgiese behandeling. Gedeeltelike knie vervanging chirurgie, meer bekend as unikompartementele knie artroplastie, behels 'n bedekking wat slegs die geaffekteerde been bedek, om die pasiënt van verdere degenerasie te beskerm. Voordele van gedeeltelike vervanging sluit vinniger herstel tyd en minder pyn in. Die biomediese implantate wat gebruik word vir hieride operasies bestaan uit standaard ontwerpe wat aan die been gepas word deur die wysiging (of wegsny) van die buitenste beenstruktuur. Die nagevolg van hierdie chirurgie is lang herstel periodes en kan ongemaklikheid in die knie veroorsaak. Die probleem met die bogenoemde standaard is dat die prosedure die verweidering van selfs ongeaffekteerde (of gesonde) been in sluit, wat lei tot verdere kniepyn en ongemak vir pasiënte lei tydens die herstelperiode. 'n Verkiesde alternatief tot die standaard ontwerpe is om 'n persoonlikke implantaat vir elke pasiënt te skep, en so kan die behoefte om dele van ongeaffekteerde been te behou moontlik wees. Die toepassing van die voorgestelde metode neig na Minimale Skade Chirurgie (MSC). MSC word gewoonlik verkies om die risiko van verskeie negatiewe nagevolge te verminder, en skade aan die tendon, bloed- en senunetwerke van die knie te beperk. Die toenemende materiaalkoste vand metal produkte lei tot 'n groot belangstelling in meer koste besparing vormings prosesse, om sodoende die verlies van oortollige materiaalverlies te verminder. Inkrementele Plaat Vervorming (IPV), 'n relatiewe nuwe klas van vervorming, is 'n waardige kanidaat om hierdie doel te bereik. Die IPV proses is baie toepaslik, en kan deur die gebruik van Rekenaar Numeriese Kontrole (RNK) masjienerie toegepas word. Verder sal dit vervaardigingskoste kan verlaag met soveel as 90% in vergelyking met ander prosese soos die stempel metode. Die beskikbaarheid van die IPV proses dra grootliks by tot die proses se aantreklikheid in die industrie. IPV kan geimplementeer word in enige fasiliteit wat toegang tot 'n drie-as RNK masjien het. Die voordeel van dit is die feit dat RNK masjienerie klaar ontwikkel en volwasse is, wat kan bydra tot goeie akkuraatheid in die vormingsproses. Die vervaardiging van laegewig materiale soos titaan of aluminium is gedokumenteer. 'n Verskeidenheid van studies dra waarde tot navorsing van die vormingsproses van titaan as deel hiervan. Die IPV proses bied vinnige opstel tye en goeie buigsaamheid met die vormingsproses, veral met behulp van 'n vyf-as masjien. Die doel van hierdie projek is om 'n proses ketting te ontwerp. Die proses ketting, wat uit vele stappe bestaan, sal die ontwerp en vervaardigingsproses van 'n persoonlike biomediese knie implantaat bevestig deur middel van die IPV vormings tegniek. Validasie van die proses ketting sal dus plaasvind deur die stappe van die voorgestelde proses ketting uit te voer. 'n Finale ondersoek sal die finansiele en regalutoriese aspekte van die projek aanspreek.

Text in Afrikaans / In this quantitative study emphasis is placed on the role of the nurse as a member of the rehabilitation team. Furthermore, the role of the nurse in patient education as well as the importance of effective patient education during the rehabilitation process after hip replacement surgery is emphasised. Various factors that impacted on the rehabilitation process are highlighted. A structured interview schedule was used to interview a group of 20 respondents. All of the respondents participated voluntarily. Orem's Selfcare Theory was used as a theoretical basis for the study. The researcher determined which information respondents regarded as important to attain functional independence during the rehabilitation process. The data gathered would serve as recommendation for a planned information brochure that could in future be given to patients at their first visit to the surgeon before surgery. The brochure could then be used as a basis for patient education in the course of the rehabilitation process. / Advanced Nursing Sciences / M.A. (Verpleegkunde)

It has been noticed that the need for total knee replacement surgery is increasing for Asian region. A total knee replacement is a permanent surgical solution for a patient having debilitating pain in knee joint suffering from arthritis. In this surgery, knee joint is replaced with components made up of bio-compatible materials after which the patient can resume the normal day to day activities. Western population has bigger build compared to Asian population. Most of the total knee replacement prosthesis are designed for western population. When these total knee prosthesis are used for Asian population, they cause a mismatch leading to various clinical complications such as reduced range of motion and pain. The studies have been limited to clinical complications caused by the mismatch. To address this limitation, current study is aimed to find the mechanical implications such as stress distribution, maximum stresses, maximum displacements etc., caused by mismatch of total knee replacement components with knee. A surgeon selects total knee components for a patient based on some critical dimensions of femur and tibia bone of knee. In addition, a method to accurately calculate these dimensions of the femur and tibia bone of a real knee was developed in the current study. This method calculated the points of curvature greater than a threshold (decided based on the radius of the curvature) found out using the formula of curvature. Further, the highest point was calculated based on maximum height from a line drawn between initial and final point within the captured points, also the extreme points were calculated based on the sign change in slope of points within the captured points, giving multiple points on the boundary of bones extracted in an MRI image of a patient. The distance between two selected farthest points, out of these points, in specific direction was the basis for selection of the TKR components. Total knee replacement components were modeled in Geomatics Studio 12 software, bones were modeled in Rhinoceros 5 software, assembly of bones and total knee replacements components was done in Solid works 2013 software, the finite element model of the assembly was developed in Hyper mesh 11 software and, the stress analysis and post processing was done in ABAQUS 6.13 software. A static, implicit non linear analysis was performed. Simulations were performed for two conditions: at standing (0o of flexion) and at hyper-flexed (120o of flexion). In order to figure out if there were any mechanical implications of mismatch, the full model of assembly consisting of femur, tibia and fibula bones assembled with total knee replacement components, and the reduced model consisting of only total knee replacement components were simulated separately, results of which have been discussed in the current thesis. In this work, the effect of change of length of ligaments at 120o of flexion in detail was also studied. This study brought out various outcomes of contact mechanics and kinematics between the components of total knee replacement prosthesis.