早期康复在高龄患者髋关节置换术中的效果评价

目的:探讨早期康复训练在高龄髋关节置换术患者中的应用效果。方法:根据就诊日期单双号将65岁以上全髋置换术患者共64例,随机分为实验组和对照组,单日手术者为实验组,双日为对照组,实验组除常规护理外加用早期康复训练。结果:实验组术后髋关节功能恢复良好,术后6个月髋关节功能基本恢复正常。结论:早期康复训练具有使患者康复快,关节功能恢复良好,并发症少的优点。     

Appropriateness of total hip joint replacement.

OBJECTIVE: To evaluate the appropriateness of the use of total hip joint replacements. DESIGN: Observational study of consecutive patients with a diagnosis of hip osteoarthritis and who had undergone total hip arthroplasty over a 1-year period from seven hospitals. MAIN MEASURES: The appropriateness of the use of hip replacement was judged by explicit criteria developed by a panel of experts using RAND methodology. The length of hospital stay during the admission and complications were recorded 6 months post-operatively. Patients were also surveyed 6 months after discharge to determine whether they believed they had recovered or their satisfaction with the intervention. Appropriateness results of this study were compared with a previous study performed with the same criteria 4 years previously. RESULTS: In total, 784 patients participated in the study. Indications for surgery were considered necessary in 52.2% of cases, appropriate in 21.3%, uncertain in 21.4%, and inappropriate in 5.1%. Differences were found in the rates of appropriateness exclusively from one hospital. At 6 months after discharge, differences between centres were found for the proportion of patients that reported they had recovered from surgery (range 57.7-24.8%) and in the length of hospital stay during admission (range 10-16 days). Improvement in the appropriateness rates were found for all participant hospitals during both periods. CONCLUSIONS: We identified a low percentage of inappropriate indications and differences in some outcomes between centres. Compared with previously, there has been improvement in the use of this technique, although both periods are not methodologically comparable.     

Use of telephone interviews to follow up patients after total hip replacement

We studied the feasibility of telephone interviews to assess hip function in patients who had had a total hip replacement. One hundred patients attending the orthopaedic clinic for follow-up after undergoing total hip replacement were studied. A modified Harris hip score was used. Since range of motion and deformity cannot be assessed by telephone, only pain and function were assessed. The maximum possible score was 100. Patients attending follow-up clinics were contacted by telephone one to two weeks prior to their appointment and a telephone assessment was completed. This was then compared with a face-to-face assessment in the subsequent clinic. The mean hip score obtained with the telephone interview was 85.2 and the mean hip score at face-to-face assessment was 86.1. The mean of the differences between the individual scores was -0.9 (SD 5.5). This difference was not significant ( P=0.11). Only three patients had a clinically significant difference (>20 points) between the two methods. Telephone questionnaires may be a useful adjunct to face-to-face assessment for patient follow-up after total hip replacement.     

Evaluation of explicit criteria for total hip joint replacement

We tested an appropriateness of indications tool for total hip joint replacement in patients with osteoarthritis. Criteria were developed using a modified Delphi panel judgment process. Ratings were analyzed regarding level of agreement among panelists. Another panel rated the same indications; results were compared with the main panel. Test-retest of the main panel was performed. Regression models were used to assess the contribution of each algorithm variable. Appropriateness indication judgment was applied to 84 patients and compared to health-related quality-of-life improvement before and 3 months following intervention. Main panel ratings compared to those of a second panel resulted in a kappa statistic of 0.77. Test-retest kappa for the main panel was 0.81. Patients considered appropriate candidates for surgery, based on their composite indication scores, showed more improvement in health-related quality of life after 3 months than those considered inappropriately by composite indication scores. The previous parameters tested showed acceptable results for an evaluation tool. These results support the use of this indications algorithm as a screening tool for assessing the appropriateness of hip replacement surgery in osteoarthritis.     

Extended follow-up of patients suspected of having joint sepsis after total joint replacement

During an average follow-up time of about 2 1/2 years after total hip or knee-joint replacement in 8052 patients, suspected joint infection was recorded in 85 patients whose joints had not been re-operated during that period. The hospital records of 72 of these patients were examined after a further period, averaging about 5 years. Thirty-five of these had suffered continuing major problems with the joint, 18 of which had been revised, and a further 9 joints needed such treatment. Infection was confirmed in 17 of the 35. These numbers are proportionately about three times greater than those observed among a set of matched controls followed-up for a similar period. The evidence from the extended follow-up suggests that the failure rate, unassociated with infection, reached about 5% by 7 years after operation and that late infections, manifested between about 2 1/2 and 7 years after operation, were about as frequent as those confirmed during the first 2 1/2 years.     

手术室预防高龄人工全髋置换患者术后感染的管理

目的探讨手术室为预防高龄人工全髋置换患者术后发生感染所采取的各项细节管理方法。方法回顾总结94例70~93岁人工全髋置换患者为预防术后感染,手术室所采取的细节管理措施。结果 94例高龄患者均安全度过手术期,术后恢复良好,无一例发生感染,感染率为0。结论根据高龄患者的身心特点以及该手术的特殊性,做好术前的准备工作,加强术中管理,术后进行正确地搬运等细节管理,可有效预防高龄人工全髋置换患者术后发生感染。     

Extended follow-up of patients suspected of having joint sepsis after total joint replacement.

During an average follow-up time of about 2 1/2 years after total hip or knee-joint replacement in 8052 patients, suspected joint infection was recorded in 85 patients whose joints had not been re-operated during that period. The hospital records of 72 of these patients were examined after a further period, averaging about 5 years. Thirty-five of these had suffered continuing major problems with the joint, 18 of which had been revised, and a further 9 joints needed such treatment. Infection was confirmed in 17 of the 35. These numbers are proportionately about three times greater than those observed among a set of matched controls followed-up for a similar period. The evidence from the extended follow-up suggests that the failure rate, unassociated with infection, reached about 5% by 7 years after operation and that late infections, manifested between about 2 1/2 and 7 years after operation, were about as frequent as those confirmed during the first 2 1/2 years.     

人工全髋关节置换早期康复训练效果观察

目的：尽早康复训练,以帮助患者改善肌肉力量,耐力以及功能,提高生活自理能力,改善生活质量。方法：随机分为对照组和实验组,对实验组进行康复训练,有计划分阶段进行,健康教育、术后麻醉清醒后可进行康复训练,出院指导是以口头、书面、电话等联系方式落实三个阶段的康复训练。结果：实验组的疼痛程度明显低于对照组,实验组的关节活动度明显大于对照组,两组间比较有显著性差异,p〈0．05,实验组护理干预方法明显优于对照组。结论：采用康复训练程序为患者进行患肢功能锻炼,明显的改善患者下肢功能,有较减轻患者疼痛。     

Thromboprophylaxis in patients undergoing total hip replacement

Venous thromboembolism is a common complication following a hip replacement. It was the authors' impression that prophylaxis of deep vein thrombosis has changed in recent years. The authors felt that it was important to repeat a survey, done in 1997, on the use of thromboembolism prophylaxis among British orthopaedic surgeons.     

A holistic programmatic approach to natural hormone replacement

With an unprecedented number of women reaching midlife, the impact of menopause has become a significant public health issue. Recent findings have left women and practitioners questioning traditional hormone replacement therapy (HRT) and searching for reasonable alternatives. Growing numbers of women in this country are choosing to use natural progesterone and estrogen to treat symptoms of menopause. This article describes a program that focuses on education, client participation, and alternative methodology to support individualized HRT therapy using natural compounded bio-identical hormones.     

全髋关节置换治疗强直性脊椎炎髋关节晚期病变

目的探讨强直性脊椎炎髋关节晚期病变行全髋关节置换术的效果及其处理和对策。方法通过29例(48侧髋)强直性脊椎炎髋关节晚期病变患者施行全髋关节置换术,对手术前后髋关节疼痛、功能以及生活和工作能力的改善情况进行对比研究。结果术后除1侧髋关节疼痛较明显、4侧髋关节轻度疼痛外,余关节无疼痛。髋关节屈伸活动度由术前平均18°(0°~70°),改善为术后平均80°(50°~120°);屈伸、收展、内外旋总活动度由术前平均42°(0°~90°)改善为术后平均165°(110°~250°)。术后全部患者生活可自理,2例需扶拐,23例可做轻体力劳动,4例可做中等体力劳动。术后并发症少:早期人工股骨头脱位1例,后期髋臼假体松动和脱位各1例,股骨假体下沉5例。结论强直性脊椎炎髋关节晚期病变适宜行全髋关节置换术。选择气管插管全麻和髋关节外侧切口,术中强直髋关节处理措施得当,人工假体选择合适,术后康复手段完善和规范,能达到减轻髋关节疼痛、改善功能和提高患者生活和工作质量的目的。     

Use of explicit criteria for total hip joint replacement fixation techniques

We developed a tool to judge the appropriateness of indications and fixation mechanisms for total hip joint replacement (THJR) and applied it to a sample of patients. Criteria were developed using a modified Delphi panel judgment process, following the RAND methodology (RAM). We recruited, during 1 year, patients with a diagnosis of osteoarthritis undergoing THJR in five public hospitals. The appropriateness of the THJR intervention and the fixation mechanism was judged by the explicit criteria developed by a panel of experts. Of the 216 scenarios scored by the panel for the use of each of three fixation mechanisms, the cemented fixation was considered inappropriate in 69.5%, versus just 33.3% for the non cemented. Of those scenarios considered appropriate, the most appropriate mechanism of fixation was considered to be non cemented (74.4%), while cemented (17.8%) and hybrid (7.8%) scenarios were scored as appropriate less often. The previous explicit criteria were applied to 583 real patients. After evaluation of the interventions, 30% of the fixation mechanisms used were considered appropriate, while 21.8% inappropriate. Appropriate use of fixation mechanisms varied among hospitals. RAM can provide explicit criteria to help in clinical decision making and evaluating indications for a THJR intervention. Nevertheless, in the case of the appropriateness of fixation mechanisms, due to the lack of evidence, the panel criteria were biased towards the non cemented technique, which had important implications for the evaluation of some hospitals.     

Using patient reports to assess health-related quality of life after total hip replacement

Data on disease severity, co-morbidity, and process of care were obtained from the medical records of 356 patients without rheumatoid arthritis undergoing a first unilateral total hip replacement at four teaching hospitals in California and Massachusetts. Sociodemographic characteristics, functional status prior and subsequent to hospitalization, and improvement in health status were measured with a patient questionnaire 12 months after discharge. Completed questionnaires were received from 284 patients, a reponse rate of 79.8%. The questionnaire was acceptable to patients, reliable, and had good construct validity. The data indicate substantial benefits from hip arthroplasty. As expected, pre-surgical functioning was a strong predictor of outcomes 1 year after surgery. Controlling for pre-surgical functioning, age was not related to outcomes.     

Uncemented total hip replacement.

During the last 20 years almost 3000 uncemented total hip replacements have been used in the treatment of osteoarthritis and rheumatoid arthritis. The development of an axially located prosthesis is outlined, and the causes of failure indicated. Uncemented prostheses have the advantage of a relatively low mortality and morbidity and the rate of infection in particular is low. Interface pain, with or without frank prosthetic loosening, is the commonest cause of failure, but revisional surgery is relatively easy, and usually successful. Loss of function without significant pain may occur after many years from distal migration of the femoral component. The development of an uncemented metal-on-plastic joint has produced better short-term results than the metal-on-metal articulation, probably because of its lower frictional coefficient and the use of a wider range of pelvic and femoral components.     

Complications in total hip replacement

AIM: THE PURPOSE of the present study was to present the most common treatment failures and complications associated with total hip replacement. MATERIAL AND METHODS: Between 1986 and 2002, 486 total hip replacements (THR) in 403 patients were performed at the Clinics of Orthopedic and Trauma Surgery (St. George University Hospital, Plovdiv). 315 (61.8%) of the patients underwent THR for coxarthrosis, 171 (35.1%)--for traumatic or pathologic subcapital femoral neck fractures. 312 (64.2%) of the patients were women and 174 (35.8%) were men. Right and left arthroplasties were carried out. Patients' age was in the range of 28 to 53 years (median age 59.6). Complications were diagnosed in 97 (19.9%). Late postoperative complications (53.6%) as aseptic loosening of the prosthetic components, superficial and deep hematogenous infections, prosthetic dislocations and heterotopic ossifications were predominant. RESULTS: Complications were categorized as intraoperative, postoperative and late--a finding, consistent with the data in the literature. Among the intraoperative complications most common were malposition of the capsule (7 patients) and of the stem (4 patients) and longer stem (in 1 patient), but they caused no complaints. The postoperative complications consisted of hematomas and seromas wich were treated with early revision surgery. The main causes for late complications were postoperative ossification in 28 patients. Aseptic loosening of the prosthesis was seen in 11 patients. 8 of them complained of acetabular and 3 of thigh pain. Capsule dislocation was registered in 3 patients. CONCLUSIONS: Complications in THR are not infrequent. Their avoidance is largely dependent on the skill and qualification of the team and the quality of hospital care. Adequate risk assessment and prophylaxis are essential in disease outcome.     

Hospital care versus home care for rehabilitation after hip replacement.

A pilot study was done to assess the feasibility of reducing the hospital stays of patients with total hip replacement (THR). The length of hospital stay for these patients depends largely on how rehabilitation, mostly physical therapy, is organized. This study shows that not more than a half hour per postoperative day was devoted to care services and rehabilitation activities. It is feasible and less expensive to reduce substantially hospital stay by planned physical therapy in the patient's home. These results have prompted a randomized controlled clinical trial to assess hospital versus home rehabilitation.     

循证护理在全髋置换术护理中的应用

目的：探讨如何预防全髋置换术后并发症。方法：根据循证护理对30例全髋置换术后并发症制订护理计划，实施相应护理方法。结果：全髋置换术后并发症的发生率明显降低。结论：循证护理既解决了全髋置换术后并发症的预防问题，又有利于提高专科学术水平和护理质量。     

Criteria for determining optimal time of discharge after total hip replacement

Total hip replacement is a common and expensive procedure and any attempt to shorten the length of hospital stay safely is desirable. This paper proposes a scoring system specifically designed for this patient population, to determine the optimal timing of safe discharge and post-acute care placement. The authors discuss the implications for the quality of patient care.