Making minimally invasive THR safe: conclusions from biomechanical simulation and analysis.

The use of smaller surgical incisions has become popularized for total hip arthroplasty (THR) because of the potential benefits of shorter recovery and improved cosmetic appearance. However, an increased incidence of serious complications has been reported. To minimize the risks of minimally invasive approaches to THR, we have developed an experimental approach which enables us to evaluate risk factors in these procedures through cadaveric simulations performed within the laboratory. During cadaveric hip replacement procedures performed via posterior and antero-lateral mini-incisions, pressures developed between the wound edges and the retractors were approximately double those recorded during conventional hip replacement using Charnley retractors (p < 0.01). In MIS procedures performed via the dual-incision approach, lack of direct visualisation of the proximal femur led to misalignment of broaches and implants with increased risk of cortical fracture during canal preparation and implant insertion. Cadaveric simulation of surgical procedures allows surgeons to measure variables affecting the technical success of surgery and to master new procedures without placing patients at risk.

Age, trauma and the critical shoulder angle accurately predict supraspinatus tendon tears.

BACKGROUND The pathogenesis of full-thickness tears of the rotator cuff remains unclear. Apart from age and trauma, distinct scapular morphologies have been found to be associated with rotator cuff disease. The purpose of the present study was to evaluate whether a score formed using these established risk factors was able to predict the presence of a rotator cuff tear reliably. METHODS We retrospectively assessed a consecutive series of patients with a minimal age of 40 years old, who had true antero-posterior (AP) radiographs of their shoulders, as well as a magnetic resonance (MR) gadolinium-arthrography, between January and December 2011. In all of these patients, the critical shoulder angle (CSA) was determined, and MR images were assessed for the presence of rotator cuff tears. Additionally, the patients' charts were reviewed to obtain details of symptom onset. Based on these factors, the so-called rotator cuff tear (RCT) score was calculated. RESULTS Patients with full-thickness RCTs were significantly older and had significantly larger CSAs than patients with intact rotator cuffs. Multiple logistic regression, using trauma, age and CSA as independent variables, revealed areas under the curve (AUCs) for trauma of 0.55, for age of 0.65 and for CSA of 0.86. The combination of all three factors was the most powerful predictor, with an AUC of 0.92. CONCLUSION Age, trauma and the CSA can accurately predict the presence of a posterosuperior RCT. LEVEL OF EVIDENCE Level IV. Case series with no comparison groups.

Reconstruction of femoro-acetabular offsets using a short-stem

PURPOSE Despite the fact that new and modern short-stems allow bone sparing and saving of soft-tissue and muscles, we still face the challenge of anatomically reconstructing the femoro-acetabular offset and leg length. Therefore a radiological and clinical analysis of a short-stem reconstruction of the femoro-acetabular offset and leg length was performed. METHODS Using an antero-lateral approach, the optimys short-stem (Mathys Ltd, Bettlach, Switzerland) was implanted in 114 consecutive patients in combination with a cementless cup (Fitmore, Zimmer, Indiana, USA; vitamys RM Pressfit, Mathys Ltd, Bettlach, Switzerland). Pre- and postoperative X-rays were done in a standardized technique. In order to better analyse and compare X-ray data a special double coordinate system was developed for measuring femoral- and acetabular offset. Harris hip score was assessed before and six weeks after surgery. Visual analogue scale (VAS) satisfaction, leg length difference and the existence of gluteal muscle insufficiency were also examined. RESULTS Postoperative femoral offset was significantly increased by a mean of 5.8 mm. At the same time cup implantation significantly decreased the acetabular offset by a mean of 3.7 mm, which resulted in an increased combined femoro-acetabular offset of 2.1 mm. Postoperatively, 81.7 % of patients presented with equal leg length. The maximum discrepancy was 10 mm. Clinically, there were no signs of gluteal insufficiency. No luxation occurred during hospitalization. The Harris hip score improved from 47.3 before to 90.1 points already at six weeks after surgery while the mean VAS satisfaction was 9.1. CONCLUSION The analysis showed that loss of femoro-acetabular offset can be reduced with an appropriate stem design. Consequently, a good reconstruction of anatomy and leg length can be achieved. In the early postoperative stage the clinical results are excellent.

A complete-pelvis segmentation framework for image-free total hip arthroplasty (THA): methodology and clinical study

Background Complete-pelvis segmentation in antero-posterior pelvic radiographs is required to create a patient-specific three-dimensional pelvis model for surgical planning and postoperative assessment in image-free navigation of total hip arthroplasty. Methods A fast and robust framework for accurately segmenting the complete pelvis is presented, consisting of two consecutive modules. In the first module, a three-stage method was developed to delineate the left hemipelvis based on statistical appearance and shape models. To handle complex pelvic structures, anatomy-specific information processing techniques were employed. As the input to the second module, the delineated left hemi-pelvis was then reflected about an estimated symmetry line of the radiograph to initialize the right hemi-pelvis segmentation. The right hemi-pelvis was segmented by the same three-stage method, Results Two experiments conducted on respectively 143 and 40 AP radiographs demonstrated a mean segmentation accuracy of 1.61±0.68 mm. A clinical study to investigate the postoperative assessment of acetabular cup orientations based on the proposed framework revealed an average accuracy of 1.2°±0.9° and 1.6°±1.4° for anteversion and inclination, respectively. Delineation of each radiograph costs less than one minute. Conclusions Despite further validation needed, the preliminary results implied the underlying clinical applicability of the proposed framework for image-free THA.

Computer Assisted Diagnosis and Treatment Planning of Femoroacetabular Impingement (FAI)

Femoroacetabular impingement (FAI) is a dynamic conflict of the hip defined by a pathological, early abutment of the proximal femur onto the acetabulum or pelvis. In the past two decades, FAI has received increasing focus in both research and clinical practice as a cause of hip pain and prearthrotic deformity. Anatomical abnormalities such as an aspherical femoral head (cam-type FAI), a focal or general overgrowth of the acetabulum (pincer-type FAI), a high riding greater or lesser trochanter (extra-articular FAI), or abnormal torsion of the femur have been identified as underlying pathomorphologies. Open and arthroscopic treatment options are available to correct the deformity and to allow impingement-free range of motion. In routine practice, diagnosis and treatment planning of FAI is based on clinical examination and conventional imaging modalities such as standard radiography, magnetic resonance arthrography (MRA), and computed tomography (CT). Modern software tools allow three-dimensional analysis of the hip joint by extracting pelvic landmarks from two-dimensional antero-posterior pelvic radiographs. An object-oriented cross-platform program (Hip2Norm) has been developed and validated to standardize pelvic rotation and tilt on conventional AP pelvis radiographs. It has been shown that Hip2Norm is an accurate, consistent, reliable and reproducible tool for the correction of selected hip parameters on conventional radiographs. In contrast to conventional imaging modalities, which provide only static visualization, novel computer assisted tools have been developed to allow the dynamic analysis of FAI pathomechanics. In this context, a validated, CT-based software package (HipMotion) has been introduced. HipMotion is based on polygonal three-dimensional models of the patient’s pelvis and femur. The software includes simulation methods for range of motion, collision detection and accurate mapping of impingement areas. A preoperative treatment plan can be created by performing a virtual resection of any mapped impingement zones both on the femoral head-neck junction, as well as the acetabular rim using the same three-dimensional models. The following book chapter provides a summarized description of current computer-assisted tools for the diagnosis and treatment planning of FAI highlighting the possibility for both static and dynamic evaluation, reliability and reproducibility, and its applicability to routine clinical use.

Initial biomass and biomass change of tundra and forest plants in three herbivore treatments in Norway and Sweden

Recent Pan-Arctic shrub expansion has been interpreted as a response to a warmer climate. However, herbivores can also influence the abundance of shrubs in arctic ecosystems. We addressed these alternative explanations by following the changes in plant community composition during the last 10 years in permanent plots inside and outside exclosures with different mesh sizes that exclude either only reindeer or all mammalian herbivores including voles and lemmings. The exclosures were replicated at three forest and tundra sites at four different locations along a climatic gradient (oceanic to continental) in northern Fennoscandia. Since the last 10 years have been exceptionally warm, we could study how warming has influenced the vegetation in different grazing treatments. Our results show that the abundance of the dominant shrub, Betula nana, has increased during the last decade, but that the increase was more pronounced when herbivores were excluded. Reindeer have the largest effect on shrubs in tundra, while voles and lemmings have a larger effect in the forest. The positive relationship between annual mean temperature and shrub growth in the absence of herbivores and the lack of relationships in grazed controls is another indication that shrub abundance is controlled by an interaction between herbivores and climate. In addition to their effects on taller shrubs (> 0.3 m), reindeer reduced the abundance of lichens, whereas microtine rodents reduced the abundance of dwarf shrubs (< 0.3 m) and mosses. In contrast to short-term responses, competitive interactions between dwarf shrubs and lichens were evident in the long term. These results show that herbivores have to be considered in order to understand how a changing climate will influence tundra ecosystems.

(Table 2) Seroprevalence against Trichinella spp. in Ursus maritimus from Svalbard and Barents Sea pack ice

Blood samples of live-caught polar bears (Ursus maritimus) from Svalbard collected 1991-2000 (Period 1) and 2006-2008 (Period 2) and from the pack ice of the Barents Sea collected in Period 1, were assayed for antibodies against Trichinella spp. by ELISA. Of 54 cubs-of-the-year included in the Period 1 sample, 53 were seronegative, indicating that exposure to Trichinella infected meat is uncommon during the first months of life for polar bears in the Svalbard region. Of 30 mother-offspring pairs, 18 mothers were seropositive with seronegative offspring (n = 27), suggesting (1) that maternal antibodies had dropped to levels below detection limit by the time of capture in April (offspring approximately 4 months old), and (2) supporting experimental studies in other animal models showing that vertical transmission of Trichinella spp. is uncommon. Bear 1 year and older had higher prevalence in Svalbard (78%) than in the Barents Sea (51%). There was no temporal change in prevalence for bears from Svalbard during the time between the two periods. The prevalence increased with age in both sexes. A positive correlation was found between anti-Toxoplasma gondii and anti-Trichinella spp. antibodies.

Comparison of different stomatal conductance algorithms for ozone flux modelling

A multiplicative and a semi-mechanistic, BWB-type [Ball, J.T., Woodrow, I.E., Berry, J.A., 1987. A model predicting stomatalconductance and its contribution to the control of photosynthesis under different environmental conditions. In: Biggens, J. (Ed.), Progress in Photosynthesis Research, vol. IV. Martinus Nijhoff, Dordrecht, pp. 221–224.] algorithm for calculating stomatalconductance (gs) at the leaf level have been parameterised for two crop and two tree species to test their use in regional scale ozone deposition modelling. The algorithms were tested against measured, site-specific data for durum wheat, grapevine, beech and birch of different European provenances. A direct comparison of both algorithms showed a similar performance in predicting hourly means and daily time-courses of gs, whereas the multiplicative algorithm outperformed the BWB-type algorithm in modelling seasonal time-courses due to the inclusion of a phenology function. The re-parameterisation of the algorithms for local conditions in order to validate ozone deposition modelling on a European scale reveals the higher input requirements of the BWB-type algorithm as compared to the multiplicative algorithm because of the need of the former to model net photosynthesis (An)

Análisis biomecánico del segmento de la carrera a pie de la competición en triatlón

El principal objetivo de la presente investigación fue el conocer el perfil de rendimiento técnico de los triatletas, desde un punto de vista biomecánica, en el segmento carrera a pie durante la competición en triatlón. Asimismo, como el genero y el nivel deportivo del triatleta podrían influir en su respuesta motriz durante la competicion. Para ello, se necesitaba desarrollar y validar una técnica experimental que fuera lo suficientemente precisa (validez interna), con una alta fiabilidad y con una gran validez externa (ecologica) debido al entorno de la competicion. La muestra la formaron un total de 64 deportistas: 32 triatletas participantes en la Copa del Mundo de Triatlon de Madrid-2008 (16 hombres y 16 mujeres) y 32 triatletas participantes en el Clasificatorio del Campeonato de Espana Elite (16 hombres y 16 mujeres). El análisis de la técnica de carrera de los deportistas se realizo mediante un sistema fotogramétrico en 2d que permitió calcular las coordenadas (x,y) de los centros articulares con un error de 1.66% en el eje x y de un 2.10% en el eje y. Las imágenes fueron obtenidas por una cámara que filmaba el movimiento en un plano antero-posterior del triatleta. Algoritmos basados en la DLT (Abdel-Aziz & Karara, 1971) permitieron conocer las coordenadas reales a partir de las coordenadas digitalizadas en el plano y posteriormente las distintas variables analizadas. El análisis biomecánica de la carrera se realizo en 4 ocasiones diferentes durante la competición, correspondiendo con cada una de las vueltas de 2,5 km, que el triatleta tenía que realizar. La velocidad de carrera resulto estar íntimamente ligada al nivel deportivo del triatleta. Del mismo modo, 3 de los 4 grupos analizados presentaron valores inferiores a 3 minutos 30 segundos por kilometro recorrido, poniendo de manifiesto el altísimo nivel de los sujetos analizados. Del mismo modo parece que las chicos consiguen una mayor velocidad gracias a una mayor longitud de ciclo en relación a las chicas, ya que estas muestran valores mayores en cuanto a frecuencia de zancada. La frecuencia de zancada presento los valores más altos en la primera vuelta en todos los deportistas analizados. Asimismo, los triatletas de nivel internacional y las chicas fueron los que mostraron los mayores valores. La longitud de zancada presento distintas tendencias en función del nivel y el género del deportista. Así pues, en los deportistas internacionales y en los chicos los mayores valores se encontraron en la primera vuelta mientras que la tendencia fue al descenso, siendo probablemente la fatiga acumulada la causante de dicha tendencia. En cambio, aquellos deportistas de nivel nacional y las chicas mostraron valores mayores en la segunda vuelta que en la primera, evidenciando que además de la fatiga, el ciclismo previo tiene una incidencia directa sobre su rendimiento. Los tiempos de vuelo permanecieron constantes durante toda la carrera, encontrando cierta evolución en los tiempos de apoyo, la cual provoca una modificación en los porcentajes relativos en los tiempos de vuelo. Los tiempos de apoyo más bajos se encontraron en la primera vuelta. Del mismo modo, los deportistas de nivel internacional y los chicos mostraron valores inferiores. También, estos grupos fueron más constantes en sus valores a lo largo de las vueltas. Por el contrario, se encontraron tendencias al aumento en los triatletas de nivel nacional y en las chicas, los cuales no fueron capaces de mantener el mismo rendimiento debido seguramente a su menor nivel deportivo. La oscilación vertical de la cadera se mostro constante en los triatletas de mayor nivel, encontrándose tendencias al aumento en los de menor nivel. Del mismo modo, los valores más altos correspondieron a las chicas y a los deportistas de nivel nacional. La distancia de la cadera al apoyo permaneció constante a lo largo de las vueltas en todos los grupos, obteniéndose valores mayores en los triatletas de nivel internacional y en los chicos. El ángulo de la rodilla apoyada en el momento del despegue no mostro una tendencia clara. Los deportistas de nivel internacional y los chicos presentaron los valores más bajos. El ángulo de la rodilla libre en el momento del despegue mostro una correlación muy alta con la velocidad de carrera. Del mismo modo, los ángulos más pequeños se encontraron en los triatletas internacionales y en los chicos, debido seguramente a los mayores valores de velocidad registrados por ambos grupos. Los ángulos de los tobillos no mostraron ninguna tendencia clara durante la competición analizada. Los cuatro grupos de población presentaron valores similares, por lo que parece que no representan una variable que pueda incidir sobre el rendimiento biomecánica del triatleta. Los resultados obtenidos en el presente estudio de investigación avalan la utilización de la fotogrametría-video en 2d para el análisis de la técnica de carrera durante la competición en triatlón. Su aplicación en una competición de máximo nivel internacional ha posibilitado conocer el perfil técnico que presentan los triatletas a lo largo del segmento de carrera a pie. Del mismo modo, se ha podido demostrar como los estudios realizados en laboratorio no reflejan la realidad competitiva de un triatlón de máximo nivel. The aim of this research was to determine the running technique profile during a triathlon competition from a biomechanical perspective. Also, to analyze the triathlete gender’s and level of performance’s influence on this profile in competition. An accurate (internal validity) and reliable methodology with a high external validity (ecological) had to be developed to get those aims in competition. Sixty-four triathletes were analyzed. 32 (16 males, 16 females) took part in the Madrid 2008 Triathlon World Cup and 32 (16 males and 16 females) took part in the Spanish Triathlon National Championships. The biomechanical analyses were carried out by a photogrammetric system that allow to calculate the landmarks coordinates (x,y) with a 1.66% error in x axis, and a 2.10% error in y axis. The frames were obtained with a camera situated perpendicular to the triathletes’ trajectory, filming the saggittal plane. DLT based algorithms (Abdel-Aziz & Karara, 1971) were used to calculate the real coordinates from the digitalized ones and the final variables afterwards. The biomechanical analisys itself was performed in four different moments during the competition, according to each 2.5 km lap the triathletes had to do. Running speed was highly related to performance level. Also, 3 of the 4 analyzed groups showed speed values under the 3 minutes and 30 seconds per kilometer. It demonstrated the very high performance level of the analized triathletes. Furthermore, it seems that men get higher speeds because their longer stride length, while women shows higher stride frequency values. The highest stride frequency values were found in the first lap. Women and the international level triathletes showed the highest values. Stride length showed different tendencies according to the gender and level of performance. Men and international level triathletes showed the highest level in the first lap and a decreasing tendency after that. The accumulated fatigue was probably the reason of this tendency. On the other hand, higher values than in first lap were found in the second one in women and national level triathletes. It demonstrated the previous cycling can affect to those groups in terms of biomechanics. Flight times remained constant during the running part, while the contact times showed an increasing tendency that caused a variation in flight times percents. The lowest contact times were found in the first lap and in men and international triathletes’ values. Also, these two groups were more consistent during the whole running. On the other hand, increasing tendencies were found in women and national level triathletes, who were not able to maintain the same values probably due to their lower level of performance. Higher level triathletes showed more consistent hip vertical oscillation values than lower level triathletes, who presented increasing tendencies. The highest values were found in women and national level triathletes. The horizontal distance hip-toe cap remained constant among the laps in all the groups. Men and international level triathletes showed the highest values. The support knee angle at toe-off did not show a clear tendency. The lowest values were found in men and international level triathletes. A high correlation was found between the non-support knee angle and the running speed. Furthermore, men and international level triathletes showed the smallest values, due to the higher velocities reached by these two groups. Ankles angles did not show any tendency during the running part. Similar values were found in the four analyzed groups, so this variable does not seem to represent an important one within the triathlete’s performance. The results obtained in the present research support the use of the bidimensional photogrammetric video-system to analyze the running technique during a triathlon competition. Its application in international triathlon meetings has allowed determining the triathletes’ technique profile during the running part. Also, it has been demonstrated the laboratory-based studies does not reproduce a top-level competition.

AVALIAÇÃO DE DESEMPENHO DOS SETORES PRODUTIVOS DE UM HOSPITAL ESCOLA VETERINÁRIO: USO DE UM MODELO HIERARQUICO MULTICRITERIAL.

O curso de Medicina Veterinária compõe-se essencialmente de aulas práticas e teóricas desenvolvidas pelas mais diversas disciplinas presentes em sua matriz curricular. Para que as aulas práticas, principalmente aquelas relacionadas às disciplinas profissionalizantes, possam ser ministradas, o curso deve apresentar um Hospital Escola. Este local tem como missões: o ensino (aulas práticas), a pesquisa (desenvolvimento de novas tecnologias e conhecimentos) e a extensão ou assistência (atendimento aos anseios e necessidades das comunidades onde está inserido). Apesar de estar inserido no contexto do curso, o hospital deve apresentar um controle, não só sob o ponto de vista financeiro, mas de acordo com suas premissas a fim de garantir tanto a satisfação das pessoas que ali trabalham e a continuidade de suas atividades, bem como permitir que seus clientes internos (os alunos) e externos (a comunidade) possam ser atendidos em suas necessidades. O termo controle predispõe um pensamento de comando, que tem como objetivo principal permitir que a organização cumpra com os seus objetivos. O processo de controle gerencial é o processo que os líderes encontram para assegurar que os outros membros da organização respeitem as estratégias determinadas. Instituições de saúde e ensino desenvolvem suas atividades através de seus centros de responsabilidades, que existem para cumprir suas finalidades. Como a organização é o conjunto de centro de responsabilidades, e se cada centro de responsabilidade cumpre com suas estratégias a própria organização atinge suas metas. Cabe ao gestor hospitalar decidir qual a estratégia a seguir congruindo com as premissas ou objetivos da organização. Esta decisão deve ser fundamentada em parâmetros e resultados que podem ser conseguidos através de ferramentas de decisão. Muitas organizações utilizam a avaliação do desempenho financeiro de seus centros de responsabilidade para tomar suas decisões. O presente trabalho é uma pesquisa ação, que propõe a apresentação de um modelo teórico, aqui representado por uma ferramenta de decisão que disponibilizará como indicadores de avaliação de desempenho as premissas de ensino, pesquisa e extensão, bem como as de cunho financeiro que permitirão ao gestor hospitalar decidir qual o foco ou caminho a seguir, auxiliando-o em situações de decisões administrativas. Foi realizada a comparação da classificação ou ranqueamento de cada um dos setores produtivos de acordo com o desempenho financeiro, neste caso, a margem de contribuição própria e seu ranqueamento após os cálculos apresentados pelo modelo proposto a fim de demonstrar que ocorreu mudança no ranqueamento dos setores. Este modelo baseou-se em uma ferramenta de hierarquização multicriterial. O fato mais importante foi de perceber que todos os setores produtivos tiveram seu ranqueamento modificado após os cálculos com a ferramenta apresentada. Assim, esta ferramenta torna-se uma forma de decisão mais abrangente, pois contempla outros critérios, ou neste caso, premissas importantes para a decisão, sendo muito útil também para identificar entre as premissas apresentadas quais foram as de pior desempenho em cada setor. Desta forma, o gestor pode determinar ações de melhorias, buscando metas que possam ser alcançadas e determinando aporte financeiro, sendo este o caso, para alcançá-las.(AU)