Dissertations / Theses on the topic 'Hip joint - Surgery'

This thesis is a compilation of published manuscripts arising from research activities that I have undertaken over the last ten years in relation to the surgical management of adult hip joint disorders. The objectives of these research activities have been to improve the outcomes of the surgical procedures performed within my own clinical practice and to share my conclusions more broadly with the orthopaedic community by publication. Typically my publications are of a practical nature, often relating to the technical aspects of the conduct of surgery. They represent my attempts to answer questions that have arisen during my day-to-day clinical practice as an orthopaedic surgeon. The themes that constitute the majority of the material included within this thesis relate to the development of innovative surgical techniques, testing the validity of traditional methods of orthopaedic practice and the management of difficult clinical presentations. As my clinical practice and associated research activities span a number of topics within the broader discipline of adult hip joint surgery, I have divided this thesis into four chapters. Each chapter contains manuscripts that relate to a distinct area of my clinical practice - Perioperative Management, Trauma Management, Hip Arthroscopy and Elective Hip Arthroplasty. At the start of each chapter, a content introduction and concise background of the contained material is provided. A chronologic listing of each of the manuscripts contained within this thesis is provided in Appendix 1.<br>Thesis (PhD Doctorate)<br>Doctor of Philosophy by Publication (PhD)<br>School of Medical Science<br>Griffith Health<br>Full Text

Hip simulators are designed to reproduce the forces and motion patterns of normal walking. In vivo demands on total hip replacements, however, are varied and often more severe than normal walking conditions. It is these severe conditions that often lead to implant failure. This is clinically based research aimed at understanding some of the more severe conditions in hips and the effect that these have on the performance of the total hip replacement. The polyethylene liner can act as a pump in an acetabular component, forcing fluid and wear particles through the holes to the retroacetabular bone causing osteolysis. Ten patients were studied at revision surgery. Pressures were measured in retroacetabular osteolytic lesions while performing pumping manouvers with the hip. Two laboratory experiments were then designed to study pumping mechanisms in vitro. In patients with contained osteolytic lesions, fluid pressure fluctuations could be measured in the lesion in association with the pumping action. Patients with uncontained osteolytic lesions showed no such pressure fluctuations. In the laboratory we identified 3 distinct mechanisms whereby fluid can be pumped from the hip joint to the retroacetabular bone. These pumping effects could be mitigated by improved implant design. Loading of the femoral head against the edge of the acetabular component produces dramatically increased contact pressures particularly in hard-on-hard bearings. In an analysis of 16 retrieved ceramic-on-ceramic bearings we were able to characterise the mechanism of edge loading based on the pattern of edge loading wear on the bearing surface. Finally in a radiographic study of patients with squeaking ceramic-on-ceramic hips. Squeaking was found to be associated with acetabular component malposition. It seems that edge loading or impingement may be an associated factor in these cases.

Surgical interventions on the hip joint have greatly increased over the past decade, with the cumulative cost total hip arthroplasties (THA) alone exceeding $400B/year by 2020. Although positive patient-reported outcomes and satisfaction after THA and hip preservation for cam femoroacetabular impingement (FAI) are among the highest in orthopaedics, a limited number of research has investigated the biomechanics of dynamic activities following-up the surgery. This doctoral thesis examined the kinematics, muscle force component, and hip contact loading in pre- and postoperative patients during the deep squat motion. Specifically, this research: 1) examined muscle strength and pelvic kinematics in asymptomatic FAI, 2) examined lower-limb kinematics and muscle activity in postoperative patients who underwent either THA or FAI correction during a deep squat task, and 3) examined muscle force contributions and hip contact forces (HCF) during dynamic motion in postoperative FAI patients. First, clinical and medical imaging evaluations classified the participants into three groups: symptomatic FAI, asymptomatic FAI (FAD – participants had the cam deformity, but no pain), and healthy controls. The FAD participants had significantly greater hip extensor strength compared to the FAI and CTRL groups, which allowed them to achieve greater pelvic mobility and squat as deep as the CTRL group. Second, at the follow-up for the FAI surgery the patients showed increased pelvic ROM during the squat, and weakness associated with hip flexion and hip flexion-with-abduction were associated with postoperative alterations. For the THA follow-up analyses, the patients using a dual- mobility (DM) prosthesis reached an anterior pelvic tilt similarly to the CTRL during the dynamic parts of the squat; however, without returning its neutral tilt at the bottom of the squat, while the single- bearing (SB) prosthesis was associated with excessive hip abduction during the squat. Third, a generic full-body musculoskeletal model (MSKM) was optimized to allow for the analysis of tasks with a high range of motion (ROM; e.g. deep squat task), which controlled muscle moment arms during the high joint flexions to avoid the model’s motor tendon units (MTU) to penetrate the bony structures and respect the anatomical via points. Simulation performed during gait demonstrated that FAI patients enhance medial-lateral hip stability postoperatively, allowing reduced dynamic forces of the muscles associated with the sagittal aspect of the gait due to a less compensatory strategy to stabilize the hip joint. Furthermore, simulations performed during deep squat showed a higher anterior pelvic tilt in postoperative FAI patients as a ‘restore to native’ mechanism once the cam-deformity was no longer present. Increased semimembranosus force was linked to higher vertical HCF and total magnitude. The outcomes of this research include findings for gait and squat analyses that provide a better understanding of the pelvic mobility and hip muscle forces in hip diseases. In silico models can improve biomechanical assessment of postoperative patients in order to quantify surgical effectiveness and support clinicians in making subject-specific case decisions. The contributions also lay on the assertion of helping us to formulate future research directions in biomechanics applied to the orthopaedics field.

Metal-on-metal (MoM) hip joint replacements have been increasingly used for younger and more active patients in recent years due to their improved wear performance compared to conventional metal-on-polymer bearings. MoM bearings operate at body temperature within a corrosive joint environment and therefore are inevitably being subjected to wear and corrosion as well as the combined action of tribo-corrosion. Issues such as metal sensitivity/metallosis associated with high levels of metal ion release triggered by the wear and corrosion products remain critical concerns. During the past few decades, significant research has been conducted into understanding the wear/lubrication mechanisms within the MoM hip joints in order to improve their performance and thereby prolonging their life. However, not much attention has been given to the combined effect of wear and corrosion of such devices in the hip joint environment, in addition, the role of third body particles and the effects of proteins have not been well understood. In this work, a systemic approach is presented for the first time for the mapping of abrasion and tribo-corrosion performance of a cast CoCrMo (F75) in simulated hip joint environments. The effects of third body particles have been studied in the MoM context using 4 μm SiC, 1 μm and 300 nm Al2O3, as well as sub-micron BaSO4. Modified tribo-testers (micro-abrasion, nanoindenter/scratching) incorporating a novel electrochemical cell have been used to monitor the abrasion-corrosion behaviour of the alloy in situ. The effects of solution chemistry, abrasives size / concentration and presence of proteins on the wear / corrosion level, wear-corrosion mechanisms, and the depassivation/repassivation kinetics of the CoCrMo have been explored. A variety of surface and sub-surface characterization techniques have been employed to identify the microstructual wear mechanism interactions. Results show that the change of protein concentration (0, 25% and 50% bovine serum) and pH (pH 7.4 and pH 4.0) of the test solutions can significantly influence the protein adsorption behaviour, which subsequently influence the wear rates (synergy), wear mechanisms as well as the wear-induced corrosion currents of the CoCrMo. For abrasion-corrosion tests, reducing abrasive size from 4 μm to 300 nm and/or abrasive volume concentration from 0.238 vol% to 0.006 vol% results in different abrasion-corrosion wear mechanisms (rolling or grooving abrasion) and the average wear-induced corrosion currents show a linear correlation with wear rates for 4 μm and 1 μm abrasives. For low volume concentration (< 0.03 vol%) slurries containing bovine serum, organo-metallic conglomerates have been found within the wear scars. These conglomerates help separate the surfaces, impose less damage to the surface passive film and polish the wear scars through a chemical mechanical polishing mechanism. In addition, tribo-corrosion tests at micro-/nano- scales reveal the effects of single abrasive particle on the surface/sub-surface microstructual change. This investigation has revealed the nanoscale wear mechanisms that generate nanoscale wear debris, the mechanical mixing of the surface nanostructure with adsorbed denatured protein and also the slip/dislocation systems that are present near and on abraded surfaces that are likely to disrupt the surface passive films. The findings give a better understanding of the evolution of the sub-surface nanocrystalline structures and tribo-layers formation seen for the retrieved implants. This near surface nanostructure layer and phase transformation might offer better wear resistance through these inherent self-protecting mechanisms (i.e. increased hardness); conversely, it may become the precursors to debris ejection and enhanced ion-release into the CoCrMo joints. This work established an experimental technique that gives greater understanding of the tribocorrosion behaviour of cast CoCrMo in simulated hip joint environments. In particular, the roles of third body abrasive particles and proteins have been addressed, which are relevant to clinical applications. The material multi-scale wear mechanisms as well as the evolution of the surface / subsurface microstructures and tribo-layers have been elucidated, which provide new insights into the in vivo wear mechanisms of CoCrMo. The findings of this study may provide some important indications for improved MoM joint materials, design, manufacture and evaluation.

According to the World Health Organisation, hip fracture among elderly people is a global public health problem, with 1.7 million cases worldwide in 1991, a figure due to the aging population and believed likely to increase. Post-operative delirium is a common complication following hip-fracture surgery, and occurs in 25% to 65% of cases (Gustafson 1988). It not only affects the rehabilitation progress of the elderly, but also prolongs hospitalisation, which in turn increases the financial burden on the government. There are different ways of managing post-operative delirium among the elderly, including pharmacological and multifactorial interventions and education programmes. However, there is no standard nursing management of post-operative delirium in Hong Kong, and this affects both patient care and nursing standards. According to the National Institute for Health and Clinical Excellence (2011), multifactorial intervention is cost-effective and an effective method of reducing postoperative delirium, where nurses play an important role as gatekeepers, and thus allow such intervention to be introduced into the clinical setting. With this in mind, translational nursing research was performed by a review of four studies, to introduce the concept of multifactorial intervention to nurses, to formulate the implementation for the intervention, and finally to obtain feedback from colleagues.<br>published_or_final_version<br>Nursing Studies<br>Master<br>Master of Nursing

Made available in DSpace on 2014-06-11T19:23:44Z (GMT). No. of bitstreams: 0 Previous issue date: 2009-10-06Bitstream added on 2014-06-13T19:50:51Z : No. of bitstreams: 1 barros_lp_me_jabo.pdf: 894125 bytes, checksum: 291c2da790713462f8653ad7c1ce412f (MD5)<br>No presente trabalho comparou-se, experimentalmente, duas técnicas: a estabilização coxofemoral com pino em cavilha ou “toggle pin” e a colocefalectomia. Foram utilizados 16 cães, machos ou fêmeas, distribuidos em dois grupos: o de Pino (GP) e o Colocefalectomia (GC), os quais foram separados em 4 subgrupos: animais com peso superior e, inferior ou igual a 15 kg. Avaliou-se o tempo de cirurgia, o grau de atrofia muscular, a deambulação e a dor, além de presença ou não de alterações radiograficas da articulação. O tempo cirúrgico, devido a maior complexidade da técnica do pino, foi menor no GC. A técnica do GP foi melhor quanto à recuperação do membro, apresentando menor atrofia muscular<br>On the present assay was compared experimentally between two techniques: hip joint stabilization with toggle pin and hip joint stabilization with head of the femur. Were used 16 dogs, female or male, distributed in 2 groups: the pin group (GP) and head of the femur group (GC), the groups were distributed in 4 subgroups: by weight equal, more or less than 15kg. Evaluating the time of surgery, and the notch of muscle atrophy, wander around the pain and also with the presence or not of alterations on the joint radiograph. The time of surgery is longer in the technique of pin than on the group GC, because the technique of pin had more complexity. So the technical of the group GP was better on the recovery member, which presented less muscle atrophy

Orientador: Cintia Lúcia Maniscalco<br>Banca: Paola Castro Moraes<br>Banca: Gustavo Garkalns de Souza Oliveira<br>Resumo: No presente trabalho comparou-se, experimentalmente, duas técnicas: a estabilização coxofemoral com pino em cavilha ou "toggle pin" e a colocefalectomia. Foram utilizados 16 cães, machos ou fêmeas, distribuidos em dois grupos: o de Pino (GP) e o Colocefalectomia (GC), os quais foram separados em 4 subgrupos: animais com peso superior e, inferior ou igual a 15 kg. Avaliou-se o tempo de cirurgia, o grau de atrofia muscular, a deambulação e a dor, além de presença ou não de alterações radiograficas da articulação. O tempo cirúrgico, devido a maior complexidade da técnica do pino, foi menor no GC. A técnica do GP foi melhor quanto à recuperação do membro, apresentando menor atrofia muscular<br>Abstract: On the present assay was compared experimentally between two techniques: hip joint stabilization with toggle pin and hip joint stabilization with head of the femur. Were used 16 dogs, female or male, distributed in 2 groups: the pin group (GP) and head of the femur group (GC), the groups were distributed in 4 subgroups: by weight equal, more or less than 15kg. Evaluating the time of surgery, and the notch of muscle atrophy, wander around the pain and also with the presence or not of alterations on the joint radiograph. The time of surgery is longer in the technique of pin than on the group GC, because the technique of pin had more complexity. So the technical of the group GP was better on the recovery member, which presented less muscle atrophy<br>Mestre

L’estratègia quirúrgica d’una cirurgia en dos temps és un dels procediments més emprats en el tractament de la infecció crònica del maluc. S’han descrit diferents tipus d’espaiadors provisionals en la literatura (estàtics, mòbils, fets a mà, emmotllats, metall-polietilè i prefabricats). L’ús d’un espaiador de polimetilmetacrilat prefabricat impregnat amb antibiòtic és un dels tractaments més utilitzats amb unes taxes elevades de curació de la infecció. Aquesta tesi està dedicada a l’estudi d’aquest espaiador prefabricat de polimetilmetacrilat impregnat amb antibiòtic en l’estratègia quirúrgica del recanvi en dos temps (recanvi en 2-temps). El primer objectiu ha estat avaluar la taxa de curació de la infecció crònica del maluc utilitzant aquest tipus d’espaiador en l’estratègia quirúrgica dels 2-temps. Els resultats han demostrat que la taxa de curació de la infecció utilitzant aquest tipus d’espaiador és similar a les de la literatura existent. D’aquesta manera se suggereix que aquest tipus d’espaiador és útil en aquesta estratègia quirúrgica, donat que obté resultats similars en termes d’erradicació de la infecció als de la literatura existent. El segon objectiu ha estat analitzar la complicació mecànica més freqüent d’aquest tipus d’espaiador, la luxació. S’ha estudiat si existeix algun factor etiològic relacionat amb aquesta complicació i el pronòstic clínic dels pacients que la pateixen. De manera específica, s’ha estudiat si el valor postquirúrgic de l’offset femoral lateral (OFL) i l’offset femoral vertical modificat (OFVM) del maluc intervingut és significativament diferent al del costat contralateral, i si és així, si augmenta el risc de luxació. Els resultats han demostrat que la situació clínica final dels pacients que van presentar una luxació de l’espaiador és pitjor respecte als que no la van presentar de forma estadísticament significativa. En referència als factors etiològics analitzats, únicament l’existència d’una tija cimentada en la pròtesi prèvia va presentar significació estadística associada a la luxació. Per altra banda, l’OFL del maluc intervingut és, estadísticament, significativament inferior al del costat contralateral, mentre que no s’ha demostrat una diferència significativa en els valors de l’OFVM. No obstant això, els valors de l’OFL i l’OFVM no s’han associat com a factor de risc de luxació de l’espaiador. Una altra complicació descrita amb l’ús d’espaiadors prefabricats és la producció d’erosió òssia a nivell acetabular. Per tant, el tercer objectiu ha estat determinar si aquesta erosió es produeix i el temps que tarda a produir-se. Els resultats mostren que l’ús d’espaiadors de polimetilmetacrilat amb antibiòtic per tractar la infecció crònica de maluc durant menys d’un any no s’associa amb l’aparició d’erosió radiològica a nivell acetabular, sempre que els pacients mantinguin la deambulació amb càrrega parcial.<br>Two-stage replacement has become one of the most frequently used treatment methods for chronic hip infections. Different types of spacers have been reported in the literature. Preformed antibiotic-loaded polymethylmetacrylate spacer is one of the most common treatments with higher eradication rates of infection. This thesis is devoted to the study preformed antibiotic-impregnated polymethylmethacrylate spacer in two-stage replacement. Assess the eradication rate of chronic hip infection by two-stage revision using a hip spacer has been the first objective of the study. The results have showed that the cure rate by using this spacer is similar to the reported one, so it is suggested that this spacer could be used for two-stage replacements. The second objective has been to evaluate one of the most common mechanical complication with this spacer, dislocation. It has been reviewed whether any etiological factor could be related to this complication and the clinical prognosis of patient with a dislocation of the spacer. Moreover, it has assessed whether the postoperative value of the lateral and vertical femoral offset of the operated hip is significantly different to the contralateral side, and in that case, evaluate if the risk of dislocation of the spacer becomes higher. The results have concluded that patients who had suffered a dislocation of the spacer after the first-stage, presenting a lower cure rate during the interim period and a worse final clinical hip situation. On the other hand, lateral femoral offset of the operated limb is statistically significant lower than the contralateral side, whereas the vertical femoral offset has not evidenced differences on both sides. Otherwise, the lateral and vertical femoral offset values have not been associated as a risk factor for dislocation of the spacer. A potential disadvantage of monoblock prefabricated spacer is that it may cause acetabular bone loss, the third objective of this study has been to evaluate radiological acetabular erosion with preformed antibiotic-loaded spacers. The results have determined that using this type of spacers in chronic hip infection treatment for less than one year has not been associated with radiological acetabular erosion if the patient is maintained at partial weight bearing.

Submitted by Filipe dos Santos (fsantos@pucsp.br) on 2018-11-26T11:12:22Z No. of bitstreams: 1 Carolina Campos Machado Marques Horta.pdf: 13050055 bytes, checksum: d05c55aa48de89c384578ec4803c576e (MD5)<br>Made available in DSpace on 2018-11-26T11:12:22Z (GMT). No. of bitstreams: 1 Carolina Campos Machado Marques Horta.pdf: 13050055 bytes, checksum: d05c55aa48de89c384578ec4803c576e (MD5) Previous issue date: 2018-08-15<br>Treatment adherence has become a recurrent debate and research topic during the last 40 years. Poor adhesion is one of the main reasons for unsatisfactory results in the treatment of a disease. One of the main problems found by health professionals in the area of hip orthopedy is the poor adhesion to the preoperative and postoperative protocols for the total hip joint replacement arthroplasty, which reduce the patient's quality of life and waste health resources. This study aimed to develop and evaluate a behavioral intervention to increase the adhesion to the preoperative and postoperative protocols for the total hip joint replacement arthroplasty addressed to a patient which presented poor adhesion to the protocol in his first surgery. We used: (a) two surveys: one to evaluate the adhesion of the patient to the protocols, and the other to verify if the patient knew how to detect and describe relevant signals that should be reported to health professionals after the surgery; (b) two logs: one to evaluate the answers given by the patient in face-to-face meetings, and the other to evaluate the verbal report about his behavior in the last 24 hours in phone interviews; (c) an educational booklet with written instructions and images to guide the patient on the appropriate behavior before and after the surgery; and (d) three videos with examples of the exercises that should be executed before and after the surgery and appropriate movements of the body. In the initial meeting with the patient, we evaluated whether he fulfilled all the criteria to participate in the study. Before the intervention the researcher evaluated which behaviors were already a part of the patient's behavioral repertoire. During the intervention, the researcher used several strategies to increase the probability of adhesion to the surgical protocol, including shaping, modeling, instructions and positive reinforcement, in face-to-face meetings and in telephone interviews. After the intervention, the researcher repeated the same steps carried in before the intervention, besides phone interviews. During this phase the patient also filled a survey similar to the one used in the initial meeting. The results showed that the intervention produced a positive effect on patient's adherence to the surgical protocols. After the study, the patient presented a more complete adhesion to the items in the protocol to which adhesion was initially only partial<br>A adesão ao tratamento tornou-se objeto de intensas investigações e debates nos últimos 40 anos. Um dos grandes problemas encontrados pelos profissionais de saúde, na área da ortopedia do quadril, é a pobre adesão ao protocolo pré e pós-operatório da artroplastia de substituição total do quadril (ATQ), o que causa prejuízos à qualidade de vida e à saúde do paciente e desperdiça recursos de saúde. O presente estudo teve como objetivo desenvolver e avaliar uma intervenção comportamental para aumentar a adesão ao protocolo cirúrgico da revisão da artroplastia de substituição total da articulação do quadril (ARQ) por um paciente que apresentou pobre adesão ao protocolo na primeira cirurgia. Foram utilizados (a) dois questionários, um para avaliar a adesão do participante ao protocolo cirúrgico, e outro para avaliar a identificação e descrição de sinais relevantes que devem ser descritos à equipe de saúde após a cirurgia, utilizado nas fases Pré-Intervenção, Intervenção e Seguimento; (b) duas folhas de registro, uma para avaliar as respostas apresentadas pelo participante em encontros presenciais com a pesquisadora, outra para avaliar o relato sobre a ocorrência de adesão apresentada pelo participante nas últimas 24 horas em entrevistas por telefone; (c) um livreto educativo com instruções escritas e imagens relacionadas à cirurgia para orientar o participante sobre os comportamentos que devem ser apresentados no pré e no pós-operatório da ARQ e (d) três vídeos para oferecer modelos dos exercícios que devem ser executados no pré-operatório, dos movimentos apropriados após a cirurgia e dos exercícios que devem ser praticados no pós-operatório. No Encontro Inicial avaliou-se se o participante preenchia os critérios para participação no estudo. Na Pré-intervenção, a pesquisadora avaliou os comportamentos de adesão que já faziam parte do repertório comportamental do participante. Na fase Intervenção, a pesquisadora utilizou estratégias para aumentar a probabilidade de ocorrência de comportamentos de adesão ao protocolo cirúrgico, a saber, modelagem, modelação, instruções e reforçamento positivo, em encontros presenciais e em entrevistas por telefone. No seguimento a pesquisadora repetiu o mesmo procedimento da fase Pré-intervenção acrescido de entrevistas por telefone utilizadas na Intervenção e do Questionário de adesão ao protocolo cirúrgico utilizado no Encontro Inicial. Os resultados mostraram que a intervenção produziu um efeito positivo sobre a adesão do participante ao protocolo cirúrgico. Ao final do estudo o participante passou a apresentar uma adesão mais completa aos itens do tratamento para os quais a adesão era inicialmente apenas parcial

Knie- und Hüftgelenkersatz zählt weltweit zu den erfolgreichsten und häufigsten Operationen, wenngleich 3-24% der Patienten unzufrieden sind. Der OECD-Ländervergleich ergab 2014 für Deutschland die höchste Durchführungsrate an Hüft-TEP und die zweithöchste an Knie-TEP. Erhebungen der Patientenzufriedenheit und Rückkehrbereitschaft können zur Prozessoptimierung und Qualitätsverbesserung genutzt werden und zugleich eine Steigerung der Zufriedenheit und Kundenbindung fördern. Mit der erstmaligen Aufnahme eines P4P-Ansatzes im KHSG, sind zukünftig qualitätsbezogene Zuschlagszahlungen an ein Krankenhaus unter Berücksichtigung der Patientenzufriedenheit denkbar. Damit gewinnen Erwartungen der Patienten an ein Krankenhaus zunehmend an Bedeutung, da deren Erfüllung Einfluss auf die Erlösrechnung haben kann. Parallel kann eine Anpassung der Versorgungsstruktur dazu führen, dass verstärkt Behandlungszentren entstehen und operative Eingriffe bei geringer Fallzahl in abgeschiedenen, ländlichen Regionen nicht mehr erbracht werden. Diese Studie befasste sich mit medizinischen und servicebezogenen Parametern sowie Krankenhausdaten, die signifikant mit der Zufriedenheit bei Patienten nach Knie- und Hüft-TEP assoziiert waren und die Bereitschaft in dasselbe Krankenhaus zurückzukehren beeinflussen. Neben der Frage, ob unterschiedliche Parameter Einfluss auf die Gesamtzufriedenheit und Rückkehrbereitschaft haben, wurde untersucht, inwiefern potentielle Einflussgrößen zwischen Knie- und Hüft-TEP-Patienten variieren. Zudem wurde die Relevanz verschiedener Kriterien erhoben, die aus Patientensicht Einfluss auf die Wahl eines zukünftigen Krankenhausaufenthalts haben kann. Die Daten der Studie wurden über eine schriftliche Befragung von Knie- und Hüft-TEP-Patienten gewonnen, die zwischen 2010 und 2011 in sächsischen Krankenhäusern in den Direktionsbezirken Dresden und Chemnitz behandelt wurden. Zufriedenheit und Rückkehrbereitschaft waren jeweils abhängige Variablen in mehreren logistischen Regressionsanalysen. Gemeinsam mit den unabhängigen Variablen wurden diese über einen validierten, mehrdimensionalen Fragebogen anhand 6-stufiger Skalen abgefragt und zusammen mit Routinedaten der Krankenhäuser bivariat und multivariat ausgewertet. Die Krankenhausdaten wurden den strukturierten Qualitätsberichten der Krankenhäuser entnommen. In die Analyse wurden 856 Fragebögen von Knie-TEP-Patienten und 810 Fragebögen von Hüft-TEP-Patienten eingeschlossen, was einer Rücklaufquote von 12,04% bzw. 11,89% entsprach. Bei beiden Behandlungsgruppen war im Ergebnis der multivariaten Analyse das subjektive Behandlungsergebnis sowohl mit der Gesamtzufriedenheit als auch mit der Rückkehrbereitschaft assoziiert. Postoperative Komplikationen waren jeweils nur mit der Rückkehrbereitschaft verknüpft. Einfluss auf die Rückkehrbereitschaft hatte bei Knie-TEP-Patienten zudem die Freundlichkeit des Pflegepersonals, die Organisation und der Ablauf von Untersuchungen sowie die Zimmerausstattung. Letztere wies zusammen mit der Qualität des Essens einen Zusammenhang zur Gesamtzufriedenheit bei dieser Patientengruppe auf. Bei den Hüft-TEP-Patienten war die Einschätzung der Aufenthaltsdauer, die verständliche Beantwortung von Patientenfragen durch Ärzte, die Sauberkeit und die verständliche Aufklärung über die Operation sowie die Wahrung der Privatsphäre bei Untersuchungen auch mit der Rückkehrbereitschaft assoziiert. Ein weiterer Zusammenhang zur Gesamtzufriedenheit zeigte sich dagegen bei der Einschätzung der ärztlichen Betreuung und der Einschätzung der Aufenthaltsdauer für Hüft-TEP-Patienten. Den Krankenhausparametern Behandlungsfallzahl, postoperative Beweglichkeit und Reoperation lag kein Zusammenhang gegenüber den abhängigen Variablen zugrunde. Die Befragten beider Behandlungsgruppen gaben gleichermaßen an, dass die Qualität der Behandlung bei der zukünftigen Wahl eines Krankenhauses am wichtigsten ist. Demgegenüber waren die Entfernung der Klinik zum Wohnort sowie die Größe des Krankenhauses im unteren Bereich der Bewertung angesiedelt. Es konnten verschiedene Interventionsmaßnahmen aufgezeigt werden, die auf der Makro-, Meso- und Mikroebene einzuordnen waren und in ihren Auswirkungen den einzelnen Patienten ebenso wie Entscheidungsträger im Gesundheitswesen ansprechen. Die relevanten Einflussfaktoren aus Patientensicht zeigten, dass Zufriedenheit und Rückkehrbereitschaft differenziert bewertet werden und auch zwischen Knie- und Hüft-TEP-Patienten variieren. Die Ergebnisse liefern krankenhausübergreifend wertvolle Informationen und unterstützen das medizinische Fachpersonal, Erwartungen von Knie- und Hüft-TEP-Patienten gerecht zu werden, die sich unter anderem auf die Bereiche Personalentwicklung, Patientenaufklärung und Catering erstreckten. Patientenzufriedenheit kann sich auf die Compliance auswirken, womit ein verbessertes Behandlungsergebnis erreicht werden kann. Infolge einer gezielten Steigerung der Patientenzufriedenheit sind Einsparungen durch eine kürzere Krankenhausverweildauer oder seltenere Komplikationen denkbar. Somit konnte die Präsenz der Patientenzufriedenheit im Rahmen aktueller DRG-Abrechnungsverfahren und zukünftig unter Berücksichtigung des P4P-Ansatzes aufgezeigt werden, die neben einer Erlössteigerung für das einzelne Krankenhaus zugleich Einsparungen auf der Gesundheitssystemebene bewirken kann. In Betracht an den im Aufbau befindlichen P4P-Ansatz, können die Ergebnisse als Grundlage dienen, um die Wirksamkeit der Patientenzufriedenheit als einem von vier möglichen Leistungszielen statistisch auf deren Wirksamkeit zu überprüfen. Die Bewertung verschiedener Parameter bei der zukünftigen Wahl eines Krankenhauses deutet darauf hin, dass sich weitere Anfahrtswege infolge der im Wandel befindlichen Versorgungsstruktur aus Patientensicht nicht nachteilig auswirken werden<br>Knee and hip joint replacements are among the most successful and frequent operations conducted worldwide, with 3-24% of all patients being dissatisfied. In 2014, an OECD country comparison showed that Germany had the highest implementation rate for total hip replacement and the second highest for total knee replacement. Surveys of patient satisfaction and willingness to return can be used to optimize processes and improve quality while at the same time encouraging an increase in satisfaction and customer loyalty. With the first-time inclusion of a P4P approach in the German Hospital Structures Act (Krankenhausstrukturgesetz (KHSG)), quality-related supplementary payments to a hospital may be feasible in the future, taking patient satisfaction into account. In this way, patients' expectations of a hospital increasingly gain in importance, since their fulfilment can have an impact on the revenue calculation. At the same time, an adjustment of the care structure may lead to the increasing emergence of treatment centers and that surgical intervention will no longer be provided in isolated, rural regions with a sparse number of cases. This study looked at medical and services-related parameters as well as hospital data significantly associated with satisfaction in patients after total knee and hip endoprosthesis and affecting their willingness to return to the same hospital. In addition to the question whether different parameters have an influence on the overall satisfaction and willingness to return, the extent was examined to which potential influencing variables vary between the total knee and hip endoprosthesis patients. In addition, the relevance of different criteria was assessed, which from the view of a patient may have an influence on the choice of a future hospital stay. The data of the study were obtained through a written survey of total knee and hip endoprosthesis patients treated between 2010 and 2011 in Saxon hospitals of the directorate districts of Dresden and Chemnitz. In several logistic regression analyses, the dependent variables were satisfaction and returnability, respectively. These were obtained together with the independent variables on the basis of 6-step scales by way of a validated, multidimensional questionnaire and were evaluated in bivariate and multivariate manner together with the routine data of the hospitals. The hospital data were retrieved from the structured quality reports of the hospitals. The analysis included 856 questionnaires of total knee endoprosthesis patients and 810 questionnaires of total hip endoprosthesis patients, which corresponded to a return rate of 12.04% and 11.89%, respectively. In the result of the multivariate analysis, the subjective outcomes of the treatment for both treatment groups were associated with overall satisfaction as well as with the readiness to return. Postoperative complications were in each case only associated with the willingness to return. In the case of total knee endoprosthesis patients, the friendliness of the nurses, the organization, and the course of examinations as well as the room equipment had an influence on the willingness to return. The latter, together with the quality of the food, was related to the overall satisfaction in this patient group. In the total hip endoprosthesis patients, the readiness to return was also associated with assessing the duration of stay, the clarity of the doctors’ answers to patients, the cleanliness, and clear information provided of the operation as well as the maintenance of privacy during examinations. A further link to the overall satisfaction of total hip endoprosthesis patients was found, however, in the assessment of medical care and the assessment of the duration of stay. The hospital parameters of the number of patients treated, postoperative mobility, and reoperation were not related to the dependent variables. Respondents of both treatment groups also stated in equal measure that the quality of treatment is most important in their future choice of a hospital. On the other hand, the distance from the hospital to the place of residence, as well as the size of the hospital, was located in the lower segment of the evaluation. Various interventions could be identified, which could be categorized on the macro, meso, and micro level and of which their impacts are addressed to the individual patient as well as the decision makers in the healthcare system. The relevant influencing factors from the patient's view showed that satisfaction and the willingness to return are assessed differently and also vary between the knee and the hip endoprosthesis patients. The results provide valuable comprehensive information for hospitals and help medical professionals meet the expectations of knee and hip endoprosthesis patients, including personnel development, patient education, and catering. Patient satisfaction can affect compliance, resulting in an improved treatment outcome. As a result of a targeted increase in patient satisfaction, savings are possible due to a shorter hospital stay or more infrequent complications. Thus, the presence of patient satisfaction could be demonstrated within current DRG billing procedures and, in the future, taking into account the P4P approach, which in addition to an increase in revenue for the individual hospital at the same time can bring about savings on the health care system level. Considering the ongoing P4P approach, the results can serve as a basis to statistically assess the efficacy of patient satisfaction as one of four possible performance targets. The assessment of various parameters in the future choice of a hospital suggests that further access routes will not be disadvantageous from the patient's perspective due to the changing care structure

碩士<br>國立中央大學<br>機械工程研究所<br>100<br>The elderly orthopedic diseases are getting more and more popular recently as Taiwan has gone into aging society. Joint operation is a common surgery due to accident slip, degradation, etc., which occurs frequently in elderly people. At present, the preoperative planning and medical treatment explanation are mostly performed with verbal instructions. It is usually difficult for the patients and their families to fully understand the surgical process and the risk which might occur. Improving doctor-patient relationship is an important issue and is a government health care policy. With the advance in computer software and medical imaging technology, computer-assisted medical treatment system should be an important tool to help doctors in explanation. Although computed tomography has been widely used in most hospitals, its implementation in diagnosis and surgery for lower limb fractures is still limited. Most doctors use X-ray only in daily diagnosis and surgical planning for lower limb operation. This study aims to develop a preoperative assessment and planning system for hip fracture surgery and artificial joint replacement surgery. The proposed preoperative planning system is mainly composed of the following functions: (1) X-ray image contour detection, (2) hip DHS surgery assessment and explanation, (3) knee surgery preoperative planning, and (4) a touch screen operating mode for the entire system. It is expected that the proposed system can provide fast image information, quantitative tool for evaluation and hardware assistance to enhance the understanding of the disease site, surgical informing and the understanding of recovery status. Moreover, doctors can employ it for the preoperative planning of lower limb surgery.

Joint replacement surgery leaves many patients with postoperative pain and function limitations for extensive periods of time after surgery. This research will predict the likelihood of poor symptomatic recovery following surgery using preoperative patient data, including data on patient age, sex and comorbidities. The dataset to be analysed is total hip replacement data collected between 1989 and 2013 at the Royal Adelaide Hospital. Using the pain and function data collected repeatedly after surgery, longitudinal data analysis will be explored. The mortality information in the data will be used to explore the survival probability of patients based on different predictors using survival analysis. Repeated pain and function outcomes are modelled using mixed-effects modelling. The joint modelling of both survival and longitudinal models will be developed. Prediction methods surrounding these models will be compared to help assess the potential benefits of total hip replacement surgery for patients prior to surgery.<br>Thesis (MPhil) -- University of Adelaide, School of Mathematical Sciences, 2019

Bibliography: leaves 198-219.<br>xii, 219 leaves : ill. (chiefly col.) ; 30 cm.<br>Examines the effect of implant design on the femoral bone remodelling response in a sheep cemented hip arthroplasty model. The clinical section of the thesis also indicates the importance of biological factors in the femoral bone remodelling response.<br>Thesis (Ph.D.)--University of Adelaide, Dept. of Orthopaedics and Trauma, 1998

Bibliography: leaves 198-219.<br>xii, 219 leaves : ill. (chiefly col.) ; 30 cm.<br>Title page, contents and abstract only. The complete thesis in print form is available from the University Library.<br>Examines the effect of implant design on the femoral bone remodelling response in a sheep cemented hip arthroplasty model. The clinical section of the thesis also indicates the importance of biological factors in the femoral bone remodelling response.<br>Thesis (Ph.D.)--University of Adelaide, Dept. of Orthopaedics and Trauma, 1998

BACKGROUND: There has been an enormous rise in total joint arthroplasties (TJA) in the United States over the past several years. Researchers have documented the increase in healthcare costs associated with unplanned hospital readmissions among patients post-TJA, specifically total hip and total knee arthroplasties. Additionally, researchers have reported the burden that these costs place on the healthcare system, private payers and on patients and their caregivers. Social routines, quality of life and occupational functioning are often interrupted because of a patient’s unplanned hospital readmission after receiving a total hip or total knee arthroplasty. Investigators have identified the major causes of costly unexpected hospital readmissions among patients with a TJA; they include surgical site infections, blood clots, joint dislocations and periprosthetic fractures. The Occupational Therapy Practice Framework: Domain and Process describes the practice of occupational therapy as promoting health, well-being, and engagement in meaningful occupation. Nonetheless, there is limited literature in the occupational therapy field directed towards reducing hospital readmissions among patients with a total hip or knee arthroplasty, thus suggesting an area that is well-positioned for intervention development and testing. PURPOSE: This Occupational Therapy Doctoral Project entitled Teaching Intervention to Reduce Readmissions-Post Surgery (TIRR-PS) is a proposed program for an acute care hospital setting which: (a) described the problem of hospital readmissions among patients with a total hip or total knee arthroplasty, (b) investigated evidence and best practices for imparting knowledge and/or teaching skills to hospital administrators, healthcare professionals, occupational therapy staff, patients, and caregivers, (c) proposed an intervention based on empirically supported strategies and theoretical frameworks, (d) recommended activities to include as part of the program evaluation, the funding plan and the dissemination plan to promote this multi-level, multi-component pilot program. TIRR-PS will aim to reduce unplanned 30-day hospital readmissions and their associated healthcare costs. Unplanned readmissions are in part caused by inadequate education of hospital administrators, occupational therapy staff, patients, and caregivers. The TIRR-PS program will raise awareness about how to address common medical complication risks and promote the support of hospital administration for the education and skill building activities directed towards healthcare professionals with an emphasis on occupational therapy. CONCLUSION: TIRR-PS was designed for an acute care setting to reduce hospital readmission rates, to reduce healthcare costs, to improve patient quality of life, and to reduce the societal burden of unplanned hospital care. TIRR-PS is an innovative program designed to be comprehensive and to impart knowledge and skills to all relevant professionals in an acute care setting with a particular emphasis on the contribution of the OT profession. TIRR-PS, once evaluated, will provide a standardized, systematic approach to reducing unexpected hospitalizations post-TJA and shows promise for contributing to routine orthopaedic rehabilitative practice in acute care hospitals. This in turn will not only reduce healthcare costs, but will improve the post-surgery quality of life for patients with a recent total hip or total knee arthroplasty.

BACKGROUND: Tranexamic acid (TXA) has become highly utilized in total joint arthroplasties for its anti-fibrinolytic effect. Recently, intra-articular application of TXA has become popular for its avoidance of systemic distribution within the body. With a more direct application to the surgical site, there is interest to see if topical application will provide hemostasis without increasing rates of venous or arterial thrombotic events and infections. In particular, there is lack of published data describing the safety of TXA in patients who have a significant disposition towards thromboembolic events. METHODS: This study was a retrospective chart-review (RCR) to assess the safety and efficacy of intra-articular TXA (IA-TXA) in total knee and hip arthroplasty patients. IA-TXA 2g/50mL NS was administered to patients who were contraindicated for IV-TXA usage based on our hospital’s guidelines (history of VTE events, mitral or aortic valve replacement with additional risk factors for stroke, active cancer, genetic or acquired thrombophilia, significant cardiac disease, serum creatinine > 2.8 mg/dL). Primary efficacy outcomes were total blood loss on post-operative day 1 (POD1), overall perioperative blood loss, and changes in hemoglobin/hematocrit values over the hospital stay. Primary safety outcomes were the incidence of arterial or venous thrombosis and wound infections. The study compared patients who received IA-TXA (study group) to patients who did not receive TXA (control group). The study included TKA patients=156 (Control=72 Study=83), anterior THA patients=57 (Control=20 Study=37), and posterior THA patients=59 (Control=27 Study=32). RESULTS: TKA patients administered IA-TXA showed a significant decrease in POD1 blood loss compared to the control group [305.84 mL, p = 0.004]. Additionally, the control patients showed significantly lower levels of overall hematocrit than those who had received IA-TXA [0.9 units, p = 0.041]. However, IA-TXA did not cause a reduction in blood loss in either the anterior or posterior THA patients. No statistically significant differences existed between treatment and control groups for transfusion rates or post-operative complications (VTE events and infections). CONCLUSION: IA-TXA 2g/50mL is effective in reducing blood loss in TKA patients; however, further research is needed regarding IA-TXA use in THA patients. The lack of efficacy in THA may have been related to the dosage used, the volume instilled, the timing of administration, or technique of administration.

Les arthroplasties totales de la hanche (ATH) et du genou (ATG) sont souvent offertes aux patients atteints de dégénérescence articulaire sévère. Bien qu’efficace chez la majorité des patients, ces interventions mènent à des résultats sous-optimaux dans de nombreux cas. Il demeure difficile d’identifier les patients à risque de résultats sous-optimaux à l’heure actuelle. L’identification de ces patients avant la chirurgie pourrait permettre d’optimiser la gamme de soins et de services offerts et de possiblement améliorer les résultats de leur chirurgie. Ce mémoire a comme objectifs : 1) de réaliser une revue systématique des déterminants associés à la douleur et aux incapacités fonctionnelles rapportées par les patients à moyen-terme suivant ces deux types d’arthroplastie et 2) de développer des modèles de prédiction clinique permettant l’identification des patients à risque de mauvais résultats en terme de douleur et d’incapacités fonctionnelles suivant l’ATH et l’ATG. Une revue systématique de la littérature identifiant les déterminants de la douleur et de la fonction suivant l’ATH et l’ATG a été réalisée dans quatre bases de données jusqu’en avril 2015 et octobre 2014, respectivement. Afin de développer un algorithme de prédiction pouvant identifier les patients à risque de résultats sous-optimaux, nous avons aussi utilisé des données rétrospectives provenant de 265 patients ayant subi une ATH à l’Hôpital Maisonneuve-Rosemont (HMR) de 2004 à 2010. Finalement, des données prospectives sur 141 patients recrutés au moment de leur inclusion sur une liste d’attente pour une ATG dans trois hôpitaux universitaires à Québec, Canada et suivis jusqu’à six mois après la chirurgie ont permis l’élaboration d’une règle de prédiction clinique permettant l’identification des patients à risque de mauvais résultats en terme de douleur et d’incapacités fonctionnelles. Vingt-deux (22) études d’une qualité méthodologique moyenne à excellente ont été incluses dans la revue. Les principaux déterminants de douleur et d’incapacités fonctionnelles après l’ATH incluaient: le niveau préopératoire de douleur et de fonction, un indice de la masse corporelle plus élevé, des comorbidités médicales plus importantes, un état de santé générale diminué, une scolarité plus faible, une arthrose radiographique moins sévère et la présence d’arthrose à la hanche controlatérale. Trente-quatre (34) études évaluant les déterminants de douleur et d’incapacités fonctionnelles après l’ATG avec une qualité méthodologique moyenne à excellente ont été évaluées et les déterminants suivant ont été identifiés: le niveau préopératoire de douleur et de fonction, des comorbidités médicales plus importantes, un état de santé générale diminué, un plus grands niveau d’anxiété et/ou de symptômes dépressifs, la présence de douleur au dos, plus de pensées catastrophiques ou un faible niveau socioéconomique. Pour la création d’une règle de prédiction clinique, un algorithme préliminaire composé de l’âge, du sexe, de l’indice de masse corporelle ainsi que de trois questions du WOMAC préopératoire a permis l’identification des patients à risque de résultats chirurgicaux sous-optimaux (pire quartile du WOMAC postopératoire et percevant leur hanche opérée comme artificielle avec des limitations fonctionnelles mineures ou majeures) à une durée moyenne ±écart type de 446±171 jours après une ATH avec une sensibilité de 75.0% (95% IC: 59.8 – 85.8), une spécificité de 77.8% (95% IC: 71.9 – 82.7) et un rapport de vraisemblance positif de 3.38 (98% IC: 2.49 – 4.57). Une règle de prédiction clinique formée de cinq items du questionnaire WOMAC préopratoire a permis l’identification des patients en attente d’une ATG à risque de mauvais résultats (pire quintile du WOMAC postopératoire) six mois après l’ATG avec une sensibilité de 82.1 % (95% IC: 66.7 – 95.8), une spécificité de 71.7% (95% IC: 62.8 – 79.8) et un rapport de vraisemblance positif de 2.9 (95% IC: 1.8 – 4.7). Les résultats de ce mémoire ont permis d’identifier, à partir de la littérature, une liste de déterminants de douleur et d’incapacités fonctionnelles après l’ATH et l’ATG avec le plus haut niveau d’évidence à ce jour. De plus, deux modèles de prédiction avec de très bonnes capacités prédictives ont été développés afin d’identifier les patients à risque de mauvais résultats chirurgicaux après l’ATH et l’ATG. L’identification de ces patients avant la chirurgie pourrait permettre d’optimiser leur prise en charge et de possiblement améliorer les résultats de leur chirurgie.<br>Total joint arthroplasties (TJA) are commonly performed procedures for patients afflicted with hip and knee osteoarthritis (OA), and although successful, these surgeries can yield suboptimal results in a non-negligible proportion of patients. In order to improve surgical outcomes, patients at risk of poor results could be targeted with focused interventions. However, the evidence regarding the ability to identify which patients are at risk of poor outcomes is scarce. The objectives of this memoir were 1) to systematically review the literature of preoperative determinants of medium-term patient-reported pain and physical function after total hip arthroplasty (THA) and total knee arthroplasty (TKA) and 2) to develop clinical prediction models allowing the individual identification of patients at risk of poor outcomes following THA and TKA. Systematic literature searches targeting studies evaluating all studied determinants of pain and function following THA and TKA were performed in four important databases until April 2015 and October 2014 respectively. Moreover, retrospective data from 265 patients having undergone THA at the Hôpital Maisonneuve-Rosemont from 2004 to 2010 was used to develop a preliminary prediction algorithm (PA) to identify patients at risk of poor surgical results. Finally, prospective data from 141 patients recruited at their inclusion on a preoperative waitlist for TKA in three hospitals in Québec City, Canada and followed 6 months postoperatively was used to develop a clinical prediction rule (CPR) to identify patients at risk of poor outcomes Twenty-two (22) studies evaluating determinants of poor pain and function after THA with moderate-to-excellent methodological quality found that preoperative levels of pain and function, higher body mass index (BMI), greater medical comorbidities, worse general health, lower education level, lower OA radiographic severity and contralateral hip OA were consistently associated with poor THA outcomes. Thirty-four (34) studies evaluating determinants of poor pain and function after TKA with moderate-to-excellent methodological quality identified preoperative levels of pain and function, greater medical comorbidity, lower general health, greater levels of depression and/or anxiety, presence of back pain, greater pain catastrophizing and greater socioeconomic deprivation as consistently associated with worse outcomes. A preliminary PA consisting of age, gender, BMI and three items of the preoperative Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was able to identify patients at risk of suboptimal outcomes (worst quartile of the postoperative WOMAC score and perceiving their operated hip as artificial with minor or major limitations) on an average±standard deviation (SD) of 446±171 days after THA with a sensitivity of 75.0% (95% CI: 59.8 – 85.8), a specificity of 77.8% (95% CI: 71.9 – 82.7) and a positive likelihood ratio of 3.38 (98% CI: 2.49 – 4.57). A CPR consisting of five items of the preoperative WOMAC was able to predict the identity of patients awaiting TKA at the highest risk of poor outcomes (worst quintile of the postoperative WOMAC score) six months postoperatively with a sensitivity of 82.1 % (95% CI: 66.7 – 95.8), a specificity of 71.7% (95% CI: 62.8 – 79.8) and a positive likelihood ratio of 2.9 (95% CI: 1.8 – 4.7). This memoir led to the identification of a list of determinants of pain and disability following TKA and THA with the highest level of evidence to date. Moreover, two clinical prediction models with good predictive capabilities were developed in order to allow the identification of patients at risk of poor outcomes following TKA and THA. These findings could help target the patients most likely to benefit from interventions aimed at diminishing their risk profile and improving surgical outcomes of hip or knee arthroplasties. External validation of these rules is warranted before clinical implementation.

Purpose: To determine whether reduced serum levels of AHSG and elevated levels of BMP-2, 4, 7 are associated with post-arthroplasty HO. Patients: Thirty arthroplasty patients were included, 15 with evidence of peri-articular HO and 15 without (NHO). Methods: Blood samples were collected from all patients ≥ 8 weeks after arthroplasty. Analytes were measured using ELISAs. Mann-Whitney U tests were performed to compare serum analyte concentrations between HO and NHO groups, and between arthroplasty patients and healthy humans. Results: There is no difference in serum concentrations of AHSG, BMP-2, 4, 7 between HO and NHO patients. Arthroplasty patients showed significantly higher BMP-2 and BMP-4 and lower AHSG serum levels compared to healthy humans (p < 0.01). Conclusion: Baseline BMP-2, 4, 7 and AHSG serum levels are not markers of acquired HO. However, elevated baseline levels of BMP- 2, 4 and reduced levels of AHSG appear to be markers of severe inflammatory arthritis.