UNIVERSITATEADEMEDICINIFARMACIEIULIUHAIEGANUCLUJNAPOCA

REZUMATUL TEZEI DE DOCTORAT

Artroplastia total de old: abord chirurgical

clasic vs. abord minim invaziv
Doctorand Nicolae Filip
Conductor de doctorat Alexandru Georgescu
Cluj-Napoca 2012

CUPRINS
INTRODUCERE.................................................................................................................................................. 13
STADIULACTUALALCUNOATERII .........................................................................................................15
1.Paradigmedeabordareastriidesntateiboal
ntiinelemedicale:perspectivabiomedicalvs.biopsihosocial............................................ 17
1.1.Modelulbiomedicalalstriidesntateiboal .......................................................................................................... 17
1.1.1.Aspectepozitivealemodeluluibiomedical ................................................................................................................. 18
1.1.2.Criticialemodeluluibiomedical .................................................................................................................................. 18
1.2.Modelulbiopsihosocialalstriidesntateiboal .................................................................................................... 19
1.2.1.Aspectepozitivealemodeluluibiopsihosocial ........................................................................................................... 20
1.2.2.Criticialemodeluluibiopsihosocial............................................................................................................................. 21
2.Elementedeanatomiecuimplicaiipracticeasupracelor
doutipurideabordchirurgicalntratamentulcoxartrozei........................................................ 22
2.1.Generalitaidesprecoxartroz ...................................................................................................................................... 22
2.2.Noiunianatomiceifuncionalerelevantelaniveluloldului .................................................................................... 23
2.2.1.Scheletulososaloldului ............................................................................................................................................. 23
2.2.1.1.Coxalul ........................................................................................................................................................................ 23
2.2.1.2.Femurul ...................................................................................................................................................................... 24
2.2.2.Articulaiacoxofemural .............................................................................................................................................. 25
2.2.3.Musculaturaoldului .................................................................................................................................................... 25
2.2.3.1.Muchiilomboiliaci .................................................................................................................................................. 25
2.2.3.2.Muchiibazinului ....................................................................................................................................................... 26
2.2.3.3.Muchiicoapsei .......................................................................................................................................................... 26
2.3.Tipurideabordchirurgicalnartroplastiatotaldeold ............................................................................................ 27
2.3.1.Aborduriclasice ........................................................................................................................................................... 27
2.3.1.1.AbordulanteriorHueter............................................................................................................................................ 27
2.3.1.2.AbordulanteriorSmithPetersen ............................................................................................................................. 28
2.3.1.3.AbordulanterolateralWatsonJones ........................................................................................................................ 28
2.3.1.4.Abordulposterior ...................................................................................................................................................... 29
2.3.1.5.AbordullateralHardinge........................................................................................................................................... 29
2.3.1.6.AbordullateraltransglutealBauer .......................................................................................................................... 29
2.3.2.Aborduriminiminvazive............................................................................................................................................. 30
2.3.2.1.Abordulanteriorminiminvaziv ............................................................................................................................... 30
2.3.2.2.Abordulposterolateralminiminvaziv ..................................................................................................................... 31
2.3.2.3.Abordulanterolateralminiminaziv ......................................................................................................................... 31
2.3.2.4.Abordulminiminvazivpedouincizii ..................................................................................................................... 32
3.Aplicaiialemodeluluibiopsihosocialnetiopatogeneza,
diagnosticulitratamentulcoxartrozei ................................................................................................32
3.1.Modelulbiopsihosocialalcoxartrozei ............................................................................................................................ 33
3.1.1.Conceptualizareacoxartrozeidinpunctdevederealfactorilorbiopsihosociali .................................................... 33

3.1.2.Tratamentulcoxartrozeidinperspectivaparadigmeibiopsihosociale .................................................................... 34
3.2.Abordareabiopsihosocialadureriicronicencoxartroz ......................................................................................... 35
3.2.1.Modelulcognitivcomportamentalaldureriicronice ............................................................................................... 35
3.2.2.Doveziempiricealemodeluluicognitivcomportamentalaldureriicronice .......................................................... 36
3.3.Mecanismulbiologicalvindecriiplgilor..................................................................................................................... 37
3.3.1.Interaciuneamecanismelorpsihologiceibiologicenvindecareaplgiloroperatorii ......................................... 38
3.3.2.Doveziempiricealevaliditiimodeluluibiopsihosocialalvindecriiplgiloroperatorii ..................................... 40
CONTRIBUIAPERSONAL .........................................................................................................................41
1.Obiectivgeneraliipotezedelucru ...................................................................................................43
2.Metodologiegeneral ...............................................................................................................................45

3.Studiul1Studiulcomparativalevoluieipacienilorcuartroplastie
totaldeoldpracticatpeabordminiminvazivvs.abordclasic .............................................. 47
3.1.Introducere ...................................................................................................................................................................... 47
3.2.Ipotezadelucru ............................................................................................................................................................... 51
3.3.Materialimetod ........................................................................................................................................................... 51
3.4.Rezultate........................................................................................................................................................................... 53
3.5.Discuii .............................................................................................................................................................................. 59
3.6.Concluzii ........................................................................................................................................................................... 62
4.Studiul2Predictorimedicali,demograficiipsihologiciaistatusului
funcionalidureriipostoperatoriilapacieniicuartroplastietotaldeold ....................... 63
4.1.Introducere ...................................................................................................................................................................... 63
4.2.Ipotezadelucru ............................................................................................................................................................... 68
4.3.Materialimetod ........................................................................................................................................................... 68
4.4.Rezultate........................................................................................................................................................................... 70
4.5.Discuii .............................................................................................................................................................................. 74
4.6.Concluzii ........................................................................................................................................................................... 76
5.Studiul3Schimbrialecalitiivieiipacienilorcareaubeneficiat
deartroplastietotaldeold,studiatenfazapreipostoperatorie ........................................77
5.1.Introducere ...................................................................................................................................................................... 77
5.2.Ipotezadelucru .............................................................................................................................................................. 85
5.3.Materialimetod ........................................................................................................................................................... 85
5.4.Rezultate........................................................................................................................................................................... 87
5.5.Discuii .............................................................................................................................................................................. 98
5.6.Concluzii ......................................................................................................................................................................... 100
6.Discuiigenerale ..................................................................................................................................... 101
7.Concluziigenerale.................................................................................................................................... 105
8.Originalitateaicontribuiileinovativealetezei ......................................................................... 107
REFERINE ...................................................................................................................................................... 109
ANEXE................................................................................................................................................................ 125
Anexa1.Repereanatomice .................................................................................................................................................. 125
Anexa2.AbordultransglutealBauer .................................................................................................................................. 128
Anexa3.Abordulminiminvazivanterolateral ................................................................................................................... 130

Cuvinte cheie: artroplastie de old, biopsihosocial, predictori, calitatea vieii, abord, chirurgie clasic,
minim invaziv.

INTRODUCERE
Coxartroza reprezint una dintre cele mai frecvente afeciuni cronice ntlnite n rndul
vrstnicilor. Impactul bolii asupra calitii vieii pacienilor este unul major, aceasta fiind nsoit de
durere i disfuncii severe ale articulaiei coxofemurale. Exist numeroase dovezi empirice care atest
eficiena,attpetermenscurt,ctipetermenlungaartroplastieitotaledeold(efectuatprindiferite
tipurideabordurichirurgicale)ntratamentulcoxartrozei.
nprezent,asistmlaocretereapopularitiiinterveniilorminiminvazivenartroplastiatotala
oldului.Printreavantajeleacesteiasenumrafectareamaipuinseveraesutuluimuscular,dimensiunea
maimicainciziei,pierdereauneicantitimaimicidesnge,diminuareadureriipostoperatorii,precumio
recuperare mai rapid n urma interveniei. Dei tehnica a fost adoptat nc din deceniul trecut, datele
empiricecarevalideazsuperioritateaaborduluiminiminvazivfadecelclasicprefigureazdeocamdato

imagine confuz. Considerm c exist dou motive principale care explic aceast heterogenitate a
rezultatelorcercetrii:i)multitudineaabordurilorminiminvazive,nuexistunabordminiminvaziv,studiile
efectuate comparnd diferite aborduri minim invazive cu diferite tipuri de abord clasic; ii) n general
calitatea slab a cercetrilor realizate (lipsa controlului statistic, a controlului metodologic, ignorarea
indicatorilordeputereatestuluistatisticetc.);iii)ignorareafactorilorpsihosocialicarepotmedia/modera
uneventualefectalintervenieichirurgicaleasuprasimptomatologieibolii.

CONTRIBUIAPERSONAL
1.Obiectivgeneraliipotezedelucru
Una din caracteristicile marcante ale literaturii de specialitate referitoare la etiopatogeneza i
tratamentul chirurgical al coxartrozei este c abordeaz aceast problem doar din perspectiva
biomedical.Aceastabordarereducionisttrateazstareade boaldoardinperspectivamecanismelor
biochimice implicate, fr a lua n calcul impactul pe care l au factorii psihosociali asupra debutului,
simptomatologieiievoluieibolii.
Cercetrile recente susin necesitatea abordrii strii de boal, a diagnosticului clinic i
tratamentului din perspectiva modelului biopsihosocial, o perspectiv care s pun accent pe
interaciunea factorilor biochimici i psihosociali n etiopatogeneza, simptomatologia i tratamentul
chirurgicalalcoxartrozei.Dinperspectivaparadigmeibiopsihosociale,tratamentulnuserezumdoarla
soluionarea simptomatologiei somatice, ci vizeaz abordarea pacientului ntrun cadru mai larg, cel al
funcionalitiiemoionaleiintegritiinplansocial.
n acest context, obiectivul principal al acestui studiu este de a compara eficiena a dou tehnici
chirurgicale, un abord clasic (transgluteal Bauer) i un abord minim invaziv (anterolateral) n contextul
interaciuniifactorilorbiomedicaliipsihosociali.Dincolodevariabileleclinicenregistratencercetrile
clinice(funcionalitateaarticulaieiolduluiidurerea),studiulactualpropuneextindereamsurtorilor
ilanregistrareafactorilorpsihologiciiaicalitiivieii.
Potrivitobiectivuluigeneralformulat,ipotezeletestatenstudiileinclusenaceastlucraresunt:
i.Abordulminiminvazivpracticatnartroplastiatotaldeaoldesteointerveniechirurgicalmai
eficient, din punct de vedere al remiterii simptomatologiei clinice (disfunciile articulaiei oldului i
durerea),fadeabordulclasic;
ii. Superioritatea abordului minim invaziv fa de cel clasic n remitarea simptomatologiei clinice
estemediatdeoseriedefactoripsihologici,precumatitudinileicredinelepacientului,optimismuli
mecanismeledecopingmobilizate;
iii.Interveniachirurgicalreprezintometodeficientncretereacalitiivieiipacienilorcare
suferdecoxartroziaccelerareareinserieisociale.

2.Metodologiegeneral
Participaniilastudiileinclusencercetareadefaaufostselectaidinrndulpacienilorinternai
nseciaOrtopediedinSpitalulClinicdeRecuperareClujNapoca,nperioadaNoiembrie2009Iulie2012.
Includerea n studiu a participanilor sa efectuat pe baza unui acord de participare i a respectrii
criteriilordeincludere/excludere.nstabilireavolumuluieantionuluisauluatncalculindicatoridemrimea
efectuluiideputereatestului,pentruareducelaminimprobabilitateaunoreroridetipIInanalizastatistic.
Dateleclinicealefuncionalitiioldului,dateledemograficeipsihologiceaufostnregistrateprin
utilizarea unor instrumente de msur validate tiinific i a cror fidelitate este susinut empiric.
Analizelestatisticeefectuatesempartndoucategorii:statisticidescriptiveistatisticiinfereniale.

3.Studiul1Studiulcomparativalevoluieipacienilorcuartroplastietotal
deoldpracticatpeabordminiminvazivvs.abordclasic
Ipotezadelucru
Studiul actual i propune s investigheze evoluia comparativ a pacienilor supui artroplastiei
totaledeold,practicatpedoutipurideabordchirurgical,unulclasic(abordullateralBauer) 54iunul
miniminvaziv(abordulanterolateral) 63ntratamentulchirurgicalalcoxartrozei.Eficienatratamentelor

este exprimat n primul rnd n termeni de funcionalitate a oldului i intensitate a durerii, respectiv
ScorulHarrisiscalaVASDurere.Ipotezelecercetriisunt:
i) Funcionalitatea postoperator (2, 6 sptmni i 6 luni) a pacienilor care sufer intervenie
chirurgical prin utilizarea abordului clasic de intervenie va fi mai redus, fa de cea a pacienilor cu
intervenieminiminvaziv.
ii)Intensitateadureriipostoperator(2,6sptmnii6luni)apacieniloroperaiprinabordclasicvafi
maicrescutdectceaapacienilorcareausuferitointervenieprinutilizareaaborduluiminiminvaziv.
Materialimetod
Participanii la studiu (N=55) au fost inclui pe baza urmtoarelor criterii: i) pacieni suferind de
coxartrozprimarsausecundardisplazieinfazchirurgical,ntre4075ani;ii)pacienicuunindicede
mascorporalsub30,indiferentdegen.Nuaufostacceptainstudiuurmtoarelecategoriidepacieni:i)
pacienisuferinddecoxartrozsecundarpoliartriteireumatoideispondiliteianchilozante;ii)pacienicu
coxartroz primar cu deformare avansat a articulaiei coxofemurale prin osteofitoz important sau
ncapsularecuprotruzieacetabular;iii)pacienicuindicedemascorporaldepeste30;iv)pacienicare
seprezintpentruartroplastiederevizie.
Pacienii au fost inclui n cele dou grupe experimentale pe baza unei scheme de randomizare:
grupulabordclasic(N=31)igrupulabordminiminvaziv(N=24).
Instrumenteledeevaluare:i)Scaladeevaluareadurerii(ScalaAnalogVizual,VAS);ii)ScorulHarris;
iii)Chestionaruldenregistrareaindicatorilorintervenieichirurgicale.
Concluzii
Rezultatelestudiuluisusinsuperioritateaaborduluiminiminvaziv(anterolateral)fadeabordulclasic
(transgluteal Bauer) n artroplastia total de old, n ceea ce privete recuperarea funcional a articulaiei
olduluiidurereapostoperatorie.Rezultatelenususinosuperioritateaaborduluiminiminvazivcuprivirela
durataintervenieichirurgicaleicantitateadesngepierdut.Subliniemcacesteconlcuziisuntvalabiledoar
lapopulaiadefinitprincriteriiledeincludereiexcludereastudiului.ncontextulacestorrezultate,studiul
recomand utilizarea abordului minim invaziv fa de abordul clasic. Pentru generalizarea rezultatelor
considermc este nevoiede efectuarea unorstudiiclinice randomizate efectuatepe eantioaneaparinnd
unorpopulaiidiferitedeceadinstudiulactual.

4. Studiul 2 Predictori medicali, demografici i psihologici ai statusului

funcionalidureriipostoperatoriilapacieniicuartroplastietotaldeold
Ipotezadelucru
Scopul studiului actual este de a elabora i verifica un model multicomponenial care s prezic
succesul/insuccesulnceeaceprivetegraduldefuncionalitateiintensitateadureriipostoperatorii,la
pacieni care au suferit o artroplastie de old. Subsumat acestor obiective, sau formulat urmtoarele
ipotezedecercetare:
i)Factoriimedicaliidemografici,caracteristicileindividuale alepacientuluinfazapreoperatorie
prezicgraduldefuncionalitateaarticulaieiolduluila6lunipostoperator;
ii)Factoriimedicaliidemografici,caracteristicileindividualealepacientuluinfazapreoperatorie
prezicintensitateaperceputadureriila6lunipostoperator;
iii)Efectulsuperioralaborduluiminiminvazivfadecelclasicasupragraduluidefuncionalitate
al oldului i intensitii durerii postoperatorii nu se poate explica doar prin mecanismele psihosociale
implicate.
Materialimetod
Participanii studiului (N=81) au fost selectai n perioada Aprilie 2010 Decembrie 2010, dintre
pacieniiinternainseciaOrtopedieaSpitaluluiClinicdeRecuperare,ClujNapoca.
nsetareavolumuluieantionuluisainutcontdecriteriilemetodologicecuprivirelaputereatestului
Instrumenteledeevaluare,scaleleutilizatepentruevaluareavariabilelorcriteriufuncionalitatefizic
i durere, au fost: i) Scorul Harris; ii) Scala de evaluare a durerii 160 Scala Analog Vizual (VAS). Scalele
variabilelor predictor au fost: i) Tipul interveniei operatorii, Vrsta, Genul, IMC i au fost preluate din

nregistrrileclinicealepacientului;ii)VersiuneaadaptataChestionaruluiABSII(Attitudeandbeliefscale
Scaladeatitudiniicredine)iii)ScalaBCOPE;iv)LOT(Lifeorientationtest);v)Activitateafizic.
Concluzii
Factorii de care pacientul i medicul chirurg trebuie s in cont n momentul n care se pune
problema unei artroplastii de old sunt: tipul de abord chirurgical, vrsta, activitatea fizic i stilul de
gndirecatastrofic,aceastevariabileavndimpactattasuprafuncionalitiifizicepostoperatorii,cti
asupradurerii.
De asemenea, efectul unor intervenii kinetoteraputice preoperatorii a cror scop este pregtirea
musculaturiipentruinterveniaoperatorie,sevalimitadoarlarecuperareafuncionalitii,nuneputem
ateptasseeliminedurereapostoperatorie,aceastapresupunndopregtirepsihologicapacientuluia
crui scop primordial ar trebui s fie restructurarea cognitiv i schimbarea schemelor cognitive
disfuncionale.

5. Studiul 3 Schimbri ale calitii vieii pacienilor care au beneficiat de

artroplastietotaldeold,studiatenfazapreipostoperatorie
Ipotezadelucru
Studiulactualipropunecaiobiectivprincipalsinvestighezeevoluiacalitiivieiiiacorelatelor
acesteia(durere,anxietateistres)nfazelepreipostoperatorii(la2,6sptmnii6luni),lapacieniicare
aufostsupuiartroplastieitotaledeold.Asociatacestuiobiectiv,studiulesteinteresatsverificeimsuran
careindicatoriidesntatenmomentulexternrii(la2sptmni)justificexternareapacientului,astfelnct
ssereducrisculcomplicaiilordatorateunuitratamentpostoperatorneadecvatladomiciliulpacientului.Al
doileaobiectivalstudiuluiesteanalizamoduluincareateptrilepacienilorcuprivireladurerea,stresuli
anxietatea postoperatorii influeneaz calitatea vieii. Subsumat acestor obiective sau formulat urmtoarele
ipotezedecercetare:
i)n faza postoperatorie pacienii care au suferit intervenie chirurgical resimt o durere, anxietate i
stres postoperator (2, 6 sptmni i 6 luni) mai reduse ca i intensitate dect cele resimite n faza
preoperatorie;
ii)Calitateavieiipostoperator(2,6sptmnii6luni)apacienilorcareaufostsupuiartroplastiei
totaledeoldestemairidicatdectcalitateavieiinfazapreoperatorie;
iii)Ateptrilepacienilornaintedeoperaiecuprivireladurerea,anxietateaidistresulpostoperator
prezicelementelecalitiivieii(sntateamentalifiziologic)nregistratepostoperatorla6luni.
Materialimetod
Participanii studiului (N=103) au fost selectai n perioada Ianuarie 2011 Ianuarie 2012, dintre
pacienii internai n secia Ortopedie a Spitalului Clinic de Recuperare, ClujNapoca. Dintre pacieni, 48 au
suferitinterveniechirurgicalminiminvaziv,iar55intervenieprinabordclasic.
Instrumente de evaluare: i) Scala analog vizual (VAS); ii) Scala de Evaluare a Calitii Vieii
chestionarului Health Status Questionnaire SF36; iii) Chestionarul de nregistrare a indicatorilor
intervenieichirurgicale.
Concluzii
Artroplastiatotaldeoldareefectevizibilepostoperator,uneledintreelefiindobservabileimediat(la
dou sptmni), altele putnd fi sesizate dup un timp mai ndelungat (la ase sptmni sau ase luni).
Rezultate asemntoare au fost obinute i de ali autori 241, 242, 244, care arat existena unor mbuntiri
semnificativelanivelulfuncionalitiifiziceilaniveluldiminuriiintensitiidureriiresimite.
Dacanxietateaidurereasediminueazdinpunctuldevederealintensitiiimediatdupintervenia
chirurgical,niveluldestresperceputnusemodificsemnificativntrefazeledeevaluarepostoperator,fiindo
variabil meninut de factori precum adaptarea la nou sau apariia complicaiilor n urma interveniei
chirurgicale.
Esenial din punct de vedere al mbuntirii calitii vieii este ateptarea pe care o are pacientul
preoperator.Oateptarecarenmultecazuripoatefiinfluenatnsenspozitivdecomportamentulcadrelor
medicale.

Concluziigenerale
1. Rezultatele studiilor susin superioritatea abordului minim invaziv fa de abordul clasic, n
artroplastiatotalaoldului,nceeacepriveterecuperareafuncionalaarticulaieiolduluiidurerea
postoperatorie.
2. Concluziile formulate sunt valabile doar la populaia definit prin criteriile de includere i
excludere a studiului. n acest context, studiul recomand utilizarea abordului minim invaziv fa de
abordul clasic. Pentru generalizarea rezultatelor considerm c este nevoie de efectuarea unor studii
clinicerandomizateefectuatepeeantioaneaparinndunorpopulaiidiferitedeceadinstudiulactual.
3. Tipul de abord nu este singurul factor care explic funcionalitatea i durerea perceput
postoperator.Factoriidecarepacientulimediculchirurgtrebuie sincont nmomentul n carese pune
problemauneiartroplastiideoldsunt:tipuldeabordchirurgical,vrsta,activitateafizicistiluldegndire
catastrofic, aceast variabil avnd impact att asupra funcionalitii fizice postoperatorii, ct i asupra
durerii.
4. Kinetoterapia preoperatorie, al crui scop este pregtirea musculaturii pentru intervenia
operatorie, va avea ca efect recuperarea funcionalitii oldului. Eliminarea durerii postoperatorii
presupune o pregtire psihologic a pacientului a crui scop primordial ar trebui s fie reducerea
impactuluipecarelauuneleschemecognitiveiraionaleicultivareaunorateptrirealiste,darpozitive,
dinparteapacientului.
5. Anxietateaidurereascadnintensitateimediatdupinterveniachirurgical.Niveluldestres
perceputnusemodificsemnificativntrefazeledeevaluarepostoperatorie,fiindovariabilmeninut
defactoriprecumadaptarealanousaurisculdeapariieacomplicaiilornurmaintervenieichirurgicale.
6. La ase luni postoperator indicatorii calitii vieii pacientului prezint o mbuntire
semnificativ statistic, limitrile de ordin fiziologic sau medical sunt reduse, crescnd vitalitatea i
participareapacientuluilaactivitisociale.

Originalitateaicontribuiileinovativealetezei
Acoperind att planul metodologiei de cercetare ct i al practicii, considerm c cercetarea
prezentatreprezintunexemplubundeevidencebasedpracticecontribuindlapromovareamodelului
decercettorpracticianndomeniulmedical.
nplanteoretic,cercetareaabordeazproblematicatratamentuluichirurgicalalcoxartroxeintrun
context care depete limitele cadrului tradiional biomedical i anume din perspectiva abordrii
biopsihosociale.Studiile2i3ipropunsinvestighezeimpactulunorfactoripsihosociali(atitudinilei
credinele, mecanismele de coping mobilizate, optimismul i ateptrile) n recuperarea funcional
postoperatorie a pacientului care a fost supus unei artroplastii totale de old. Studiul 3 investigheaz
modul n care variabilele evaluate n mod curent n cercetrile similare au impact asupra calitii vieii,
adicvizeaznmoddirectaspectecaredepescreducereasimptomatologieisomaticeiredobndirea
funcionalitiioldului.
n planul metodologiei de cercetare, considerm c lucrarea de fa reprezint un model de best
practice, care include studii clinice randomizate, cercetri care n cadrul designurilor de cercetare
mbiningenioscontrolulmetodologicicontrolulstatistic,astfelcrescndvaliditateainternastudiilor,
implicit a concluziilor formulate. De asemenea, cercetrile descrise (studiul 2 i 3) utilizeaz modele
statistice care permit estimareaaportului pe care l au diferiii factori asupra variabilelor criteriu, adic
asuprarezultatelorfinalealetratamentului(funcionalitateaarticulaieioldului,durereapostoperatorie)
i,ngeneral,asupracalitiivieii.
Unaltaspectimportantdinpunctdevederemetodologicalstudiuluiesteaccentulcaresepunepe
indicatorii de mrime a efectului i putere a testului n analizele statistice efectuate. Acesta vine n
ntmpinareanoilorsolicitridinparteaborduriloreditorialedeacontrolanudoareroriledetipI,cii
eroriledetipII,complementndtesteleclasiceinferenialecuindicatoridemrimeaefectuluicareofer
informaii cu privire semnificativitatea clinic i nu se limiteaz doar la testarea semnificativitii
statistice.

n planul practicii chirurgicale, considerm c aceast cercetare ofer un protocol clinic validat
tiinificdetratamentchirurgicalalcoxartrozei(studiul1).Deasemenea,oferoseriedeinstrumentede
evaluare psihologic, care permit diagnosticul, monitorizarea i intervenia psihologic, cu scopul de a
sporigradulderecuperarepostoperatorieapacientului.

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Press,2005,119,
4. DumitracuD,PohribneacC.Medicinpsihosomatic.ClujNapoca.Ed.Med.Univ.IuliuHaieganu;2007
5. ProcaE,ArseniC,DenischiAicolab.Tratatdepatologiechirurgical.Ed.Medical;1988,3:62643,
6. LucaciuDO.Ortopedieitraumatologie.Ed.MedicalUniversitarIuliuHaieganu;2000,
7. Parks ML,Macaulay W. Operative Approaches for total hip replacement. Ed.WB Saunders Co;
2000;10(2):10614,
8. TrousdaleRT.AnteriorSurgicalApproachesforHipArthroplasty.SeminArthro.2004;15:768,
9. SzeplakiA.Aborduriminiminvazivenartroplastiadeold.Ed.CentruldePresReformatCluj;2005,2752,
10. BaohuiY,HaopengL,ZijingH,GouyuW,SiyueX.MinimallyInvasiveSurgicalApproachesandTraditional
TotalHipArthroplasty:AMetaAnalysisofRadiologicalandComplicationsOutcomes.PlosOne.2012;7(5):e37947,
11. FilipN,BalazsiR,CiuleiR,PocolP,SalomieC,BogdanV,GeorgescuA.Studiucomparativalpacienilorcu
artroplastietotaldeoldabordminiminvazivvs.clasic.ClujulMedical.2012;85(3):47682,
12. Filip N, Ciulei R, Pocol P, Georgescu A. Predictori medicali, demografici i psihologici ai statusului
funcionalidureriipostoperatoriilapacieniicuartroplastiedeold.PalestricaMileniuluiIII,2012;13(3):234240
13. Filip N, Ciulei R, Pocol P, Georgescu A. Schimbri pre i postoperatorii ale calitii vieii pacienilor cu
artroplastietotaldeold.PalestricaMileniuluiIII2012;13(3):188193
14. Woolson, S.T., Mow, C.S., Syquia, J.F., Lannin, J.V., & Schurman, D.J. Comparison of primary total hip
replacementsperformedwithastandardincisionoraminiincision.TheJournalofBoneandJointSurgery,2004;86,
135358,
15. PospischillM,KranzlA,AttwengerB,KnahrK.JMinimallyinvasivecomparedwithtraditionaltransgluteal
approachfortotalhiparthroplasty:acomparativegaitanalysis.BoneJointSurgAm.2010Feb;92(2):32837,
16. Cohen, J. (1988).Statistical power analysis for the behavioral sciences(2nd ed.). Hillsdale, NJ:
Erlbaum.PospischillM,KranzlA,AttwengerB,KnahrK.JBoneJointSurgAm.2010Feb;92(2):32837,
17. LiebermanJR,DoreyF,ShekellePetal.Outcomeaftertotalhiparthroplasty,comparisonofatraditional
diseasespecificandaqualityoflifemeasurementoutcome.JArthroplasty1997;12:63943,
18. CohenJ,CohenP,WestSG,AikenLS.AppliedMultipleRegression/CorrelationAnalysisfortheBehavioral
Sciences.HillsdaleNJErlbaum;2003,
19. WallSL,SimonMC.AnalysisofPublishedEvidenceonMinimallyInvasiveTotalHipArthroplasty.The
JournalofArthroplasty.2009;Vol.23;7:558,
20. KhanRS,AhmedK,BlakewayE,etal.Catastrophizing:apredictivefactorforpostoperativepain.AmJSurg.
2011;201(1):12231,
21. Weller IMR, Kunz M. Physical activity and pain following total hip arthroplasty. Physiotherapy. 2007;
93(1):239,
22. Montgomery,GuyH.;Bovbjerg,DanaH.PresurgeryDistress andSpecificResponseExpectanciesPredict
PostsurgeryOutcomesinSurgeryPatientsConfrontingBreastCancer.HealthPsychology.2004;23(4):38187,
23. Mahomed NN, Liang MH, Cook EF, Daltroy LH, Fortin PR, Fossel AH, Katz JN. The importance of patient
expectationsinpredictingfunctionaloutcomesaftertotaljointarthroplasty.JRheumatol.2002;29:12739,
24. AkkerScheek IV, Stevens M, Groothoff JW, Bulstra SK, Zijlstra W. Preoperative or postoperative self
efficacy:Whichisabetterpredictorofoutcomeaftertotalhiporkneearthroplasty?PatientEducationandCounseling.
2007;66(1):929,
25. Stephens MAP, Zautra AJ, Druley JA.. Older adults recovery from surgery for osteoarthritis of the knee:
psychosocialresourcesandconstraintsaspredictorsofoutcomes.HealthPsychology2002;21(4):37783,
26. LaChapelle DL, Hadjistavropoulos T. AgeRelated Differences in Coping with Pain: Evaluation of a
DevelopmentalLifeContextModel.CanadianJournalofBehaviouralScience2005;37:12337,
27. VincentHK,AlfanoAP,LeeL,etal.Sexandageeffectsonoutcomesoftotalhiparthroplastyafterinpatient
rehabilitation.ArchPhysMedRehabil.2006;87:4617,
28. Dauty M, Genty M, Ribinik P. Physical training in rehabilitation programs before and after total hip and
kneearthroplasty.AnnalesdeReadaptationetdeMedecinePhysique.2007;50(6):46268,
29. Ostendorf M, Buskens E, van Stel H, Schrijvers A, Marting L, Dhert W, Verbout A:Waiting for Total Hip
Arthroplasty.AvoidableLossinQualityTimeandPreventableDeterioration.JArthroplasty2004,19:3029,
30. EthgenO,BruyereO,RichyF,etal.Health.Relatedqualityoflifeintotalhipandtotalkneearthroplasty.A
qualitativeandsystematicreviewoftheliterature.JBoneJointSurgAm.2004;86A:96374

IULIU HAIEGANU UNIVERSITY OF MEDICINE AND PHARMACY CLUJ-NAPOCA

DOCTORAL THESIS

Total hip arthroplasty: classic surgical approach vs.

minimally invasive approach
PhD student: Nicolae Filip
Mentor: Alexandru Georgescu
Cluj-Napoca 2012
CONTENTS

INTRODUCTION .............................................................................................................................................. 13
STATEOFKNOWLEDGE .............................................................................................................................. 15
1.Paradigmofhealthanddiseaseapproachinmedicalsciences:
biomedicalvs.biopsychosocialperspective ....................................................................................... 17
1.1.Biomedicalmodelofhealthanddisease .................................................................................................................................................. 17
1.1.1.Positiveaspectsofthemodel .................................................................................................................................................................... 18
1.1.2.Criticismsofthebiomedicalmodel......................................................................................................................................................... 18
1.2.Biopsychosocialmodelofhealthanddisease ........................................................................................................................................ 19
1.2.1.Positiveaspectsofthebiopsychosocialmodel .................................................................................................................................. 20
1.2.2.Criticismsofthemodel................................................................................................................................................................................. 21

2.Elementsofanatomywithpracticalimplicationsonthetwotypes
ofsurgicalapproachinthetreatmentofcoxarthrosis.................................................................... 22
2.1.Generaldataaboutcoxarthrosis.................................................................................................................................................................. 22
2.2.Hipanatomyandphysiology......................................................................................................................................................................... 23
2.2.1.Thebonesofthehip ...................................................................................................................................................................................... 23
2.2.1.1.Hip ..................................................................................................................................................................................................................... 23
2.2.1.2.Femur............................................................................................................................................................................................................... 24
2.2.2.Hipjoint .............................................................................................................................................................................................................. 25
2.2.3.Musclesofthehip ........................................................................................................................................................................................... 25
2.2.3.1.Lumbopelvicmuscles .............................................................................................................................................................................. 25
2.2.3.2.Pelvicmuscles .............................................................................................................................................................................................. 26
2.2.3.3.Thighmuscles............................................................................................................................................................................................... 26
2.3.Typesofsurgicalapproachesinhiptotalarthroplasty...................................................................................................................... 27
2.3.1.Clasicalsurgicalapproaches ...................................................................................................................................................................... 27
2.3.1.1.AnteriorHueterapproach....................................................................................................................................................................... 27
2.3.1.2.AnteriorSmithPetersenapproach ..................................................................................................................................................... 28
2.3.1.3.AnterolateralWatsonJonesapproach............................................................................................................................................... 28
2.3.1.4.Posteriorapproach..................................................................................................................................................................................... 29
2.3.1.5.LateralHardingeapproach ..................................................................................................................................................................... 29
2.3.1.6.LateraltransglutealBauerapproach .................................................................................................................................................. 29
2.3.2.Minimallyinvasivesurgicalapproaches ............................................................................................................................................... 30
2.3.2.1.Minimallyinvasiveanteriorapproach ............................................................................................................................................... 30
2.3.2.2.Minimallyinvasiveposterolateralapproach................................................................................................................................... 31
2.3.2.3.Minimallyinvasiveanterolateralapproach ..................................................................................................................................... 31
2.3.2.4.Minimallyinvasivetwoincisionsapproach .................................................................................................................................... 32

3.Applicationofthebiopsychosocialmodelincoxarthrosis
etiopathogenesis,diagnosisandtreatment ........................................................................................ 32

3.1.Coxarthrosisbiopsychosocialmodel ......................................................................................................................................................... 33
3.1.1.Coxarthrosisconceptualizationintermsofbiopsychosocialfactors ....................................................................................... 33
3.1.2.Coxarthrosistreatmentfromthebiopsychosocialperspective .................................................................................................. 34
3.2.Chronicpainbiopsychosocialapproachtoincoxarthrosis.............................................................................................................. 35
3.2.1.Cognitivebehavioralmodelofchronicpain ....................................................................................................................................... 35
3.2.2.Empiricalevidenceofcognitivebehavioralmodelofchronicpain .......................................................................................... 36
3.3.Biologicalmechanismofhealing.................................................................................................................................................................. 37
3.3.1.Interactionofpsychologicalandbiologicalmechanismsinsurgicalwoundhealing ........................................................ 38

3.3.2.Empiricalevidenceofthevalidityofthebiopsychosocialmodelofsurgicalwoundhealing ........................................ 40
PERSONALCONTRIBUTION .................................................................................................................................................................
1.Objectivesandhypotheses ......................................................................................................................................................... 43
2.Generalmethods........................................................................................................................................ 45

3.FirstStudyComparativestudyofpatientevolutionintotalhiparthroplastyby
minimallyinvasivevs.classicalapproach ........................................................................................... 47
3.1.Introduction.......................................................................................................................................................................................................... 47
3.2.Workinghypothesis .......................................................................................................................................................................................... 51
3.3.Materialsandmethods..................................................................................................................................................................................... 51
3.4.Results..................................................................................................................................................................................................................... 53
3.5.Discussions............................................................................................................................................................................................................ 59
3.6.Conclusions ........................................................................................................................................................................................................... 62

4.SecondstudyMedical,demographicandpsychologicalstatuspredictorsof
functionandpostoperativepaininpatientswithtotalhiparthroplasty................................ 63

4.1.Introduction.......................................................................................................................................................................................................... 63
4.2.Workinghypothesis .......................................................................................................................................................................................... 68
4.3.Materialsandmethods..................................................................................................................................................................................... 68
4.4.Results..................................................................................................................................................................................................................... 70
4.5.Discussions............................................................................................................................................................................................................ 74
4.6.Conclusions ........................................................................................................................................................................................................... 76

5.ThirdstudyLifequalitychangesinpatientswithtotalhiparthroplastyinpreoperative
andpostoperativephases .......................................................................................................................... 77
5.1.Introduction.......................................................................................................................................................................................................... 77
5.2.Workinghypothesis .......................................................................................................................................................................................... 85
5.3.Materialsandmethods..................................................................................................................................................................................... 85
5.4.Results..................................................................................................................................................................................................................... 87
5.5.Discussions............................................................................................................................................................................................................ 98
5.6.Conclusions ........................................................................................................................................................................................................ 100
6.Generaldiscussion .................................................................................................................................. 101
7.Generalconclusions ............................................................................................................................... 105
8.Originalityandinnovativecontributionsofthethesis............................................................. 107
REFERENCES .................................................................................................................................................. 109
Annexes ........................................................................................................................................................... 125
Annex1.Anatomichighlights .............................................................................................................................................................................. 125
Annex2.TransglutealBauerapproach ........................................................................................................................................................... 128
Annex3.Anterolateralminimallyinvasiveapproach ............................................................................................................................. 130

Keywords: hip arthroplasty, biopsychosocial, predictors, life quality, approach, classical surgery,
minimallyinvasive.

INTRODUCTION
Coxarthrosisisoneofthemostcommonchronicdiseasesfoundamongelderly.Diseaseimpacton
lifequalityisamajorone,anditisassociatedwithseverepainanddysfunctionofthehipjoint.Thereare
many empirical evidences showing both short and longterm effectiveness of total hip arthroplasty
(performed by different types of surgical approaches) in the treatment of coxarthrosis. Today, we are
witnessing an increase of minimally invasive interventions popularity in total hip arthroplasty. Its
advantagesincludelessseveredamagetomuscletissue,thesmallerincision,smallbloodloss,decreased
postoperative pain, and a faster recovery after surgery. Although the technique has been adopted since
the last decade, empirical evidence validating the superiority of minimally invasive approach to the
classicalapproachcreatesaconfusingimage.Webelievethattherearetwomainreasonsexplainingthis
heterogenic research results: i) existence of many minimally invasive surgical approaches, and studies
comparing different surgical classic approaches with different minimally invasive approaches ii) poor
quality of researches (lack of statistical, and methodology control, ignoring power of the statistical test
indicators, etc..), iii) ignoring psychosocial factors that can mediate/moderate possible surgery effects
upondiseasesymptoms.

PERSONALCONTRIBUTION
1.Objectivesandhypotheses
Oneofthestrikingfeaturesofthecoxarthrosisetiopathogenesisandsurgicaltreatmentliteratureis
thatitdiscussedthisproblemonlyfromthebiomedicalperspective.Thisreductionistapproachtreatsthe
illnessonlyintermsofinvolvedmechanisms,withouttakingintoconsiderationtheimpactofpsychosocial
factorsondiseaseonset,symptomsandprogression.
Recentresearchsupportingtheneedtoapproachthediseasestate,clinicaldiagnosisandtreatment
from the biopsychosocial model perspective, a perspective that places emphasis on biochemical and
psychosocial factors interaction in etiopathogenesis, symptoms and treatment of coxarthrosis surgery.
From the perspective of biopsychosocial paradigm, treatment is not only for somatic symptoms, but it
approaches the patient in a broader context, that of emotional functioning and social integrity. In this
respect, the main objective of this study was to compare the effectiveness of two surgical methods, a
classicapproach(transglutealBauer)andaminimallyinvasiveapproach(anterolateral),inthecontextof
biomedical and psychosocial factors interaction. Beyond clinical variables recorded in clinical research
(hipjointfunctionandpain),thecurrentstudyproposestoextendthemeasurementsandregistrationto
psychologicalfactorsandlifequalityparameters.
Accordingtothegeneralobjective,thehypothesisofthestudywas:
1. Minimallyinvasivetotalhiparthroplastyisamoreefficientthantheclassicalapproachinterms
ofremissionofclinicalsymptoms(hipjointdysfunctionandpain).
2. Minimally invasive total hip arthroplasty advantages are mediated by a number of
psychologicalfactors,suchaspatientattitudeandbeliefs,optimismandcopingmechanisms.
3. Surgery is an effective method to improve life quality of patients suffering from coxarthrosis
andtoacceleratesocialinclusion.

2.GeneralMethodology
Participants included in the present study were selected from the patients admitted in the
RehabilitationHospitalClujNapoca,DepartmentofOrthopaedics,betweenNovember2009andJuly2012.
Participants enrollment was conducted under a written consent of participation and compliance for
inclusionandexclusioncriteria.Indeterminingthesamplesizewereconsideredindicatorsofsizeeffect
andpowerofthetesttominimizethelikelihoodofTypeIIerrorsinstatisticalanalysis.Clinicaldataofhip
functionality, demographic and psychological data were recorded by using scientifically validated
measurement instruments whose fidelity is supported empirically. Statistical analysis fall into two
categories:descriptivestatisticsandinferentialstatistics.

3. FirstStudyComparisonofpatientoutcomesintotalhiparthroplasty by
minimallyinvasivevs.classicalapproach
Workinghypothesis
Thecurrentstudyaimstoinvestigatethecomparativeevolutionofcoxarthitispatientsundergoing
total hip arthroplasty by classic Bauer lateral approach (n = 54) and minimally invasive anterolateral
approach (n=63). Effectiveness of treatments was expressed primarily in terms of functionality and hip
painintensity,respectivelyVASpainscoreandHarrisscore.Researchhypotheseswere:
i) the postoperativefunctionality(2, 6 weeksand 6 months) in patients with classic laparoscopic
surgerywaslowercomparedtothatofpatientswithminimallyinvasiveintervention.
ii)thepostoperativepainintensity(2,6weeksand6months) inpatientsoperatedbytraditional
approaches was significantly increased than that of patients who underwent minimally invasive
intervention.
Materialsandmethods
Studyparticipants(N=55)wereincludedaccordingtothefollowingcriteria:i)patientssuffering
from primary or secondary coxarthrosis dysplasia in surgical phase, between 4075 years, ii) patients
withBMIunder30,regardlessofgender.

There were not accepted into the study following patients: i) secondary coxarthrosis patients
suffering from rheumatoid arthritis and ankylosing spondylitis, ii) patients with advanced primary
coxarthrosiswithsignificantosteophytosisorencapsulationwithacetabularprotrusioniii)patientswith
bodymassindexover30iv)patientspresentedforrevisionarthroplasty.
Patientswereenrolledinthetwoexperimentalgroupsbasedonarandomizationscheme:classical
approach group (n = 31) and minimally invasive group (n = 24). Assessment instruments were: i) pain
assessmentscale(VisualAnalogueScale,VAS),ii)Harrisscore;
iii)questionnaireforsurgeryindicatorsregistration.
Conclusions
Study results support the superiority of minimally invasive approach (anterolateral) approach to
classic approach (Transgluteal Bauer) in total hip arthroplasty in terms of recovering hip joint and
postoperative pain. The results do not support the superiority of minimally invasive related to the
durationofthesurgeryandtheamountofbloodlost.Weemphasizethattheseconclusionsarevalidjust
for the population defined by inclusion and exclusion criteria of the study. In light of these results, the
studyrecommendstheminimallyinvasiveapproachtotheclassicone.Inordertogeneralizetheresultsis
neededtoconductmorerandomizedtrialsperformedondifferentpopulations.

4. Second study Medical, demographic and psychosocial predictors of the

functionalstatusandpostoperativepaininpatientswithtotalhiparthroplasty
Workinghypothesis
Theaimofthecurrentstudyistodevelopandverifyamulticomponentialmodelthatwouldpredict
the success / failure in what concerns the functionality level and intensity of postoperative pain at
patientswhounderwenthiparthroplasty.Theobjectiveswere:
i) medical and demographic factors, individual characteristics of the patient in the preoperative
phasepredictthedegreeoffunctionalityofthehipjointat6monthspostoperative;
ii) medical and demographic factors, individual characteristics of the patient in the preoperative
phasepredictthepainintensityofat6monthspostoperative;
iii) the superior effect of the minimally invasive approach vs. the classic one upon the level of
functionalityofthehipandpostoperativepainintensitycannotbeexplainedbypsychosocialmechanisms.
Materialsandmethods
Study participants (N = 81) were selected during April 2010 December 2010, from the patients
hospitalizedinOrthopaedicRehabilitationHospital,ClujNapoca.
Insettingthesamplevolumewereconsideredthemethodologicalcriteriaontestpower.
Assessmentinstruments,scalesusedtoassessphysicalfunctionalityandpainwere:i)Harrisscore,ii)
PainRatingScale160VisualAnalogueScale(VAS).Scalesofpredictorvariableswere:i)Typeofsurgery,age,
gender,andBMItakenfrompatient'sclinicalrecords,ii)adaptedversionofthequestionnaireABSII(Attitude
andBeliefScaleiii)ScaleBCOPEiv)LOT(LifeOrientationTest),v)physicalactivity.
Conclusions
When a hip arthroplasty must be performed, patient and surgeon must consider: the type of
surgicalapproach,age,physicalactivityandstylecatastrophicthinking,thesevariablesimpactingonboth
thepostoperativephysicalfunctionalityandpain.
Theeffectofpreoperativekinetotherapeuticalinterventions,whosepurposeistopreparemuscles
forsurgery,willbelimitedtofunctionalityrecovery,wecan notexpecttoeliminatepostoperativepain.
The psychological preparation of the patient primary purpose should be cognitive restructuring and
dysfunctionalcognitiveschemaschange.

5. Third Study Life quality changes in patients with total hip arthroplasty,
studiedpreandpostoperative
Workinghypothesis
Thecurrentstudymainobjectivewastoinvestigateintotalhiparthroplastypatientstheevolution
of the life quality and its parameters (pain, anxiety and stress), in the pre and postoperative (at 2, 6

weeks and 6 months) stages. Associated with this objective, the study is interesting to examine if the
healthindicatorsatthetimeofdischarge(2weeks)ofthejustifyiedpatientdischarge,inordertoreduce
theriskofpostoperativecomplicationsduetotreatmentatthepatient'shome.Thesecondobjectiveofthe
studyistoanalyzehowthepatientsexpectationsaboutpain,stressandpostoperativeanxietyinfluences
lifequality.Accordingly,theresearchhypotheseswere:
i) patients who underwent surgical interventions in the postoperative phase feel reduced pain,
anxietyandpostoperativestress(2,6weeksand6months)comparedtothepreoperativephase;
ii)postoperatively(2,6weeksand6months)lifequalityofthepatientswithtotalhiparthroplasty
ishigherinthepreoperativephase;
iii)beforesurgery,patientsexpectationsrelatedtopain,anxietyandpostoperativedistresspredict
lifequality(mentalhealthandphysiological)recordedpostoperativelyat6months.
Materialsandmethods
Study participants (N = 103) were selected between January 2011 and January 2012, from the
patients hospitalized in Orthopaedic Rehabilitation Hospital, ClujNapoca: 48 underwent minimally
invasivesurgicalapproachand55underwentaclassicalapproach.
Assessment tools were: i) visual analog scale (VAS), ii) life quality Health Status Questionnaire
surveySF36,iii)Questionnaireforsurgicalindicatorsregistration.
Conclusions
Totalhiparthroplastyhasvisibleeffects,someofwhichareimmediatelyobservable(intwoweeks),
others can be spotted after a long time (at six weeks or six months). Similar results were obtained by
otherauthors, showinga significant improvementof the physical functionalityand decreaseof the pain
intensity.
If it decreases anxiety and pain in terms of intensity immediately after surgical intervention,
perceived stress level does not change significantly between postoperative assessment phases, being a
variable maintained by factors such as adaptation to new or complications of surgery. In terms of life
quality improvement are patient preoperative expectations, that in many cases can be positively
influencedbymedicalstaffbehavior.

Generalconclusions
1. Study results reveal the superiority of minimally invasive approach compared to the classic
approachintotalhiparthroplasty,inrespecttothefunctionalrecoveryandpostoperativepain.
2. Conclusions arevalidonly for thepopulation defined bythe inclusionand exclusion criteriaof
the study. In this context, the study recommends the use of minimally invasive approach instead of the
classicalapproach.Togeneralizetheresultsareneededclinicaltrialsstudiesperformedondifferentthe
samplesthanthepopulationfromthecurrentstudy.
3.Typeofapproachisnottheonlyfactorexplainingfunctionalityandpostoperativeperceivedpain.
Thefactorsthatthepatientandsurgeonmustconsiderhiparthroplastyisrecommendedare:thetypeof
surgical approach, age, physical activity and thinking catastrophic style with impact on both the
postoperativephysicalfunctionalityandpain.
4.Preoperativekynetotherapy,whosepurposeistopreparethemusclesforsurgery,willresultin
hip functionality recovery. Postoperative pain relief involves a psychological preparation of the patient
whoseprimarypurposewouldbetoreducetheimpactofirrationalcognitiveschemeandcultivationof
realisticpositiveexpectationsofthepatient.
5. Anxiety and pain intensity decrease immediately after surgical intervention. Stress levels
perceived do not change significantly between postoperative assessment phases, being a variable
maintainedbyfactorssuchasadaptationtonewortheriskofcomplicationsaftersurgery.
6. At six months postoperatively the patient had improved life quality indicators. Statistical
significance of physiological or medical limitations are reduced, increasing vitality and patient
participationinsocialactivities.

Originalityandinnovativecontributionsofthethesis
Covering both research methodology and practice methodology, we believe that the present
researchcurrentlyrepresentsagoodexampleof"evidencebasedpractice"helpingtopromotethemodel
ofThemedicalpractitionerresearcher.
In theory, the researchaddressesthe issue of surgical treatment incoxarthrosis in a contextthat
exceeds the limits you traditional biomedical framework, namely in terms of biopsychosocial approach.
Studies 2 and 3 wanted to investigate the impact of psychosocial factors (attitudes and coping
mechanismsdeployed,optimismandhold)inpostoperativerecoveryafteratotalhiparthroplasty.Study
3investigateshowvariablesroutinelyassessedinsimilarresearchimpactlifequality,targetingdirectly
concerningmattersthatexceedsomaticsymptomreductionandrecoveryofhipfunctionality.
Intermsofresearchmethodology,webelievethatthispaperrepresentsamodelof"bestpractice",
including randomized clinical trials, research of which designs combines methodological control and
statistical control, thereby increasing the internal validity of the studies and conclusions. The described
researches (study 2 and 3) are also using models allowing statistical estimation of the contribution of
different factors upon the final treatment results (hip joint functionality, postoperative pain) and, in
general,uponlifequality.
Another important aspect in the study methodologically emphasis is on indicators of size and
powerofthetestintheperformedstatisticalanalyzes.Itcomesinmeetnewdemandsfromtheeditorial
boardtocontrolnotonlythetypeIerrors,butalsotypeIIerrors,complementingconventionalinferetial
testswithindicatorsofsizeeffectthatprovideinformationaboutclinicalsignificanceanddoesnotlimited
totestingstatisticalsignificance.
In surgical practice plan, we believe that this research provides a clinically validated scientific
protocolofcoxarthrosistreatment(study1).Italsoprovidesanumberofpsychologicalassessmenttools,
enabling diagnosis, monitoring and psychological intervention, in order to enhance postoperative
recoveryofthepatient.

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funcionalidureriipostoperatoriilapacieniicuartroplastiedeold.PalestricaMileniuluiIII,2012;13(3):234240
13. Filip N, Ciulei R, Pocol P, Georgescu A. Schimbri pre i postoperatorii ale calitii vieii pacienilor cu
artroplastietotaldeold.PalestricaMileniuluiIII2012;13(3):188193
14. Woolson, S.T., Mow, C.S., Syquia, J.F., Lannin, J.V., & Schurman, D.J. Comparison of primary total hip
replacementsperformedwithastandardincisionoraminiincision.TheJournalofBoneandJointSurgery,2004;86,
135358,
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approachfortotalhiparthroplasty:acomparativegaitanalysis.BoneJointSurgAm.2010Feb;92(2):32837,
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2011;201(1):12231,
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93(1):239,
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PostsurgeryOutcomesinSurgeryPatientsConfrontingBreastCancer.HealthPsychology.2004;23(4):38187,
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