储存式自体输血在脊柱外科手术中应用的疗效及安全性研究

目的 探讨储存式自体血回输对脊柱外科非肿瘤手术中应用的疗效和安全性.方法 回顾分析广州市第一人民医院脊柱外科诊断为非肿瘤脊柱疾病的手术患者134例,分为自体输血组77例,异体输血组57例,记录并比较组间的住院时间、术后血红蛋白的差异、输血相关不良反应率,并分析住院时长以及自体血的节血效果.结果 自体输血组术前采血及自体...     

Revision hip arthroplasty in aseptic loosening of total hip replacement

Background. Problems encountered during revision hip arthroplasty are presented, based on 30 years of experience at the Orthopedic Clinic of the Medical University of Lodz.
Material and methods. During this period of time 96 cases (5,13%) with aseptic hip loosening were diagnosed. All patients were evaluated clinically based o the Merle d'Aubigne-Postel criteria, and radiologically by means of De Lee and Gruen migration zones.
Results. In our material hip loosening was most frequently observed in cases where a McKee-Farrar hip prosthesis had been used, and in cases with a PM uncemented acetabulum or uncemented Mittelmeier pin.
Conclusions. The study showed that surgical technique plays the most significant role in aseptic loosening of hip replacement. The aseptic loosening of hip prostheses should be diagnosed early, and revision hip arthroplasty should be performed as soon as possible. This surgery must be preformed in specialized centers with adequate equipment and a team of experienced surgeons.     

Balance and gait in total hip replacement: a pilot study

OBJECTIVE: Evaluation of balance, gait changes, sexual functions, and activities of daily living in patients with total hip replacement in comparison with healthy subjects. DESIGN: A total of 30 patients were included in the study after total hip replacement. Balance was examined using dynamic posturography, and gait evaluation was done clinically. Sexual functions and activities of daily living were also assessed. A total of 30 healthy subjects of comparable age and sex served as a control group. RESULTS: Dynamic balance and gait differed significantly in both the groups. Despite capsulectomy, no significant difference was observed on testing proprioception. In the sensory organization tests with difficult tasks, patients needed more sensory input from vision and vestibular sense, despite normal proprioceptive sense. Significant difference was observed for limits of stability, rhythmic weight shifts, and for gait variables other than walking base. Some of the patients had major difficulties with sexual functions and activities of daily living. CONCLUSIONS: Compared with the healthy age- and sex-matched controls, patients with total hip replacement did not have any proprioceptive deficit. Patients required extrasensory input, and there was a delayed motor response. Gait and dynamic balance results also indicated the motor deficit and required a compensatory strategy. Restoration of the postural control in these patients is thus essential. Necessary training is required for balance, gait, and activities of daily living, and proper sexual counseling is necessary in postoperative care.     

Preoperative prediction of inpatient recovery of function after total hip arthroplasty using performance-based tests: a prospective cohort study

Purpose: The aim of this study was to evaluate the value of conventional factors, the Risk Assessment and Predictor Tool (RAPT) and performance-based functional tests as predictors of delayed recovery after total hip arthroplasty (THA). Method: A prospective cohort study in a regional hospital in the Netherlands with 315 patients was attending for THA in 2012. The dependent variable recovery of function was assessed with the Modified Iowa Levels of Assistance scale. Delayed recovery was defined as taking more than 3 days to walk independently. Independent variables were age, sex, BMI, Charnley score, RAPT score and scores for four performance-based tests [2-minute walk test, timed up and go test (TUG), 10-meter walking test (10?mW) and hand grip strength]. Results: Regression analysis with all variables identified older age (>70 years), Charnley score C, slow walking speed (10?mW >10.0 s) and poor functional mobility (TUG >10.5 s) as the best predictors of delayed recovery of function. This model (AUC 0.85, 95% CI 0.79–0.91) performed better than a model with conventional factors and RAPT scores, and significantly better (p = 0.04) than a model with only conventional factors (AUC 0.81, 95% CI 0.74–0.87). Conclusions: The combination of performance-based tests and conventional factors predicted inpatient functional recovery after THA.

• Implications for Rehabilitation

• Two simple functional performance-based tests have a significant added value to a more conventional screening with age and comorbidities to predict recovery of functioning immediately after total hip surgery.

• Patients over 70 years old, with comorbidities, with a TUG score >10.5 s and a walking speed >1.0 m/s are at risk for delayed recovery of functioning.

• Those high risk patients need an accurate discharge plan and could benefit from targeted pre- and postoperative therapeutic exercise programs.

     

Postural balance during quiet standing in patients with total hip arthroplasty and surface replacement arthroplasty

BACKGROUND: Primary total hip arthroplasty leads to better functional capacities but a general weakness of abductor muscles often persists. A larger head component may improve the postural balance in the medial-lateral direction. The aims of this study are (1) to compare postural stability in patients after total hip and surface replacement arthroplasties and (2) to evaluate the effect of the biomechanical reconstruction on postural stability. METHODS: Six months post-surgery, three groups of ten subjects (total hip and surface replacement arthroplasties and control) performed quiet standing tasks in both dual and one leg stance and a hip abductor muscles strength test. The root-mean-square amplitude of centre of pressure and centre of mass displacement in the anterior-posterior and medial-lateral directions were calculated for dual stance task. FINDINGS: Statistical analyses showed greater centre of pressure and centre of mass displacement amplitude in the medial-lateral direction during the dual stance for the total hip arthroplasty compared to the surface replacement and control subjects (P<0.05). All control subjects completed the one leg stance compared to nine in the surface replacement and five in the total hip arthroplasty group. No statistical difference was found between the groups in the hip abductor muscles strength. INTERPRETATION: The better anatomical preservation, absence of femoral stem and the larger bearing component could account for the return to better postural stability in surface replacement patients in comparison to total hip patients. Further studies are needed to determine the impact of each of these factors on the postural balance.     

Conversion of a failed hip resurfacing arthroplasty to total hip arthroplasty: pearls and pitfalls

Surface replacement arthroplasty (SRA) remains a viable alternative to total hip arthroplasty (THA) in appropriately selected, active adults with degenerative hip disease. However, orthopedic surgeons are facing a number of scenarios where revision of one or both components of an SRA is indicated. Indications for revision vary and impact the potential outcomes of conversion of a SRA to THA. While clinical outcomes are generally favorable, a growing body of data illustrates patients who undergo conversion of a SRA to THA to be at increased risk of requiring a repeat revision surgery and experiencing functional outcomes inferior to that of a primary THA. The results of patients undergoing conversion of a SRA to THA highlight the need for careful patient selection, thorough preoperative counseling, and technical precision when performing a SRA. Furthermore, a systematic approach to the failed SRA is necessary to ensure optimal clinical results.     

人工全髋关节置换术后感染的诊治体会

目的探讨人工全髋关节置换术后感染的诊断与治疗方法。方法 2007年2月至2011年7月收治36例人工全髋关节置换术术后感染的患者,其中男22例,女14例,平均年龄(69.3±5.8)岁。其中8例采用单纯抗生素治疗;3例行清创一期翻修术;18例行清创二期翻修手术;7例感染严重患者行关节融合术。对患者进行3～7个月的中长期随访,观察治疗效果和关节功能恢复情况。结果 8例采用单纯抗生素治疗患者获得治愈,关节功能Harris评分平均(86.5±3.25)分,优良率87.9%。所有清创一期和二期翻修术患者均获得治愈,关节功能Harris平均评分分别为(80.5±2.83)分和(90.0±5.0)分,优良率分别为66.7%和76.4%。7例行关节融合术中6例治愈,1例复发后应用抗生素联合利福平治疗治愈,但是所有行关节融合术患者关节功能丧失。结论临床上应该根据不同的病情与适应证选择合适的方式科学治疗髋关节置换术后感染,假体翻修手术能够有效地控制保守治疗无效的感染,挽救关节的功能。     

全髋关节置换术后的康复治疗研究

目的研究髋关节置换术后的康复治疗的效果。方法将髋关节置换术后康复治疗的36例病人及未康复治疗的32例病人于术前、术后2周、术后3个月、术后6个月进行调查、比较分析其Harris评分、关节脱位及深静脉血栓发生情况。结果康复治疗组在术后3个月及6个月时Harris评分明显高于对照组(P<0.05),对照组在术后两周时关节脱位及深静脉血栓发生率高于康复组。结论康复治疗是一项提高髋关节置换术效果的有效措施。     

Preoperative quadriceps strength as a predictor for short-term functional outcome after total hip replacement

Holstege MS, Lindeboom R, Lucas C. Preoperative quadriceps strength as a predictor for short-term functional outcome after total hip replacement.

Objective

To determine the preoperative strength of the muscle group of the lower extremity that is most important in predicting functional recovery after primary unilateral total hip replacement (THR).

Design

Prospective observational study with inception cohort.

Settings

Joint care program (hospital care/clinical division of a nursing home/outpatient physical therapy).

Participants

Patients (N=55) undergoing primary unilateral THR.

Interventions

Not applicable.

Main Outcome Measures

Baseline measures within 2 weeks preoperative and follow-up at 6 and 12 weeks postoperative included isometric strength measurement of the hip (flexors, extensors, abductors, adductors) and knee (flexors, extensors) musculature using a handheld dynamometer. Functional outcome was tested using performance-based (Timed Up and Go Test, 6-Minute Walk Test) and self-report measures (Western Ontario and McMaster Universities Osteoarthritis Index, subscale Physical Function [WOMAC PF], 36-Item Short Form Health Survey subscale Mental Health, visual analog scale for pain).

Results

Of the patients (N=55; mean age, 72.7±6.8y; 41 women) included; 18 dropped out, leaving 37 patients for analyses. After correction for WOMAC PF score at baseline, body mass index, sex, and age, the preoperative knee extensors strength measure of the operated site was the only muscle group showing a significant effect on functional outcome measured by using the WOMAC PF at 12 weeks postoperatively (R²=.355; β=−.105; P for β=.004).

Conclusion

Preoperative greater knee extensor strength of the operated site is associated with better physical function, measured by using the WOMAC PF at 12 weeks postoperative.     

应用低分子肝素对初次全髋及全膝关节置换后失血的影响

背景：下肢深静脉栓塞为人工髋、膝关节后常见并发症,置换后应用低分子肝素抗凝已成为常规指导原则。目的：探讨应用低分子肝素对初次全髋关节及全膝关节置换后失血的影响。方法：回顾分析2006年1月至2011年6月初次行人工关节置换病例529例,对有否应用低分子肝素抗凝者分为应用组和对照组。置换后8-12h开始,应用组每天皮下注射低分子肝素4000-6000U,连续使用10-15d;对照组未使用任何抗凝药物。统计比较病例失血总量、显性失血量及隐性失血量。结果与结论：应用组中关节置换患者出血总量与对照组比较,差异有显著性意义（t=-23.42,P〈0.01）。膝关节置换患者以显性失血为主,髋关节置换患者则隐性失血量较大,二者比较,差异有显著性意义（t=-23.3,P〈0.01）。说明人工关节置换后使用低分子肝素抗凝治疗,可增加置换后失血量,这其中髋关节置换及膝关节置换显性、隐性失血比例各有不同。单纯通过计量置换中出血及置换后引流来评估有效血容量的丢失较为片面。抗凝治疗的同时应密切关注血红蛋白变化,结合手术特点充分考虑隐性失血,及时补充血容量。     

Preoperative platelet-rich plasmapheresis and hemodilution with an autotransfusion device in total hip replacement surgery

The effectiveness of both preoperative autologous donation (PAD) and intraoperative autotransfusion (IAT) with an autotransfusion device has recently been questioned. Preoperative apheresis, with separation of concentrated platelet rich-plasma (c-PRP) and erythrocyte concentrate (ERC), represents an aggressive use of the autotransfusion device. Can such a procedure replace PAD in total hip replacement surgery (THR)? Eighty patients undergoing THR were investigated in a prospective and randomized study. Forty patients underwent PAD, and 2 units of ERC + plasma were retrieved within 4 weeks preoperatively. Another 40 patients underwent an immediately preoperative apheresis with a concomitant hemodilution with 4% albumin, retrieving c-PRP (30% of the platelet pool) and 2 units of ERC. Both groups used IAT up to 2 hours postoperatively, with 3% dextran-60 as a plasma substitute according to our standard of care. There were no differences in blood loss, B-hemoglobin or allogeneic transfusions between the groups: 85% of the patients did not receive allogeneic blood. Both apheresis and reinfusion of c-PRP had minor impact on the coagulation parameters. Platelet count increased slightly but significantly (P<0.05) from 154 to 179 x 10(9)/L after the c-PRP at wound closure. Preoperative apheresis with an autotransfusion device, separating platelet-rich plasma and erythrocyte concentrate, is a useful alternative for patients who are unable to utilize the PAD technique for either religious or practical reasons.     

Redefinition of life experience following total hip replacement: a qualitative study

Purpose: We drew on a qualitative research design to examine patients’ experiences of coping following total hip replacement (THR) by obtaining their perspectives through participants’ personal language. Method: Post-operative patients who were able to explore their experiences and express them verbally were purposively sampled from an out-patient orthopaedic department of a UK hospital. Narrative interviews were conducted with the participants at two points in time. Interviews were transcribed verbatim and analysed using Coffey and Atkinson’s model (1996). Results: They employed different psychological coping mechanisms to adjust themselves to the new stressful situations that led to reinterpretation of the meaning of life. They used problem-focused, emotion-focused, comparative, spiritual and self-oriented coping strategies and shifted their focus from disease-related problems to other aspects of their lives. Conclusion: The participants in this study used a range of coping strategies to accommodate to the challenges of their hip condition and the consequences of the THR. They placed greater emphasis on positive gains from their experiences and alleviated the harmful effects of pain and physical limitations by reinterpreting the meaning of life. It is suggested that the findings of the study could have clinical implications when applying patient-reported outcome measures over time.

Implications for Rehabilitation

• Qualitative studies of this type show how people change their values over the course of an illness and reinterpret the meaning of life.

• An understanding of the complexity of experiences following THR surgery is important when evaluating the outcomes of treatment using patient-reported outcome measures.

• Recognizing the importance of psychological strategies to coping is important in rehabilitation and may account for differences in outcome.