# Effect of Operation Room Nursing Intervention and Ceramic Prosthesis on Total Hip Arthroplasty

Authors: Ting Xu; Jie Zhang
Journal: Scanning
 (2022)

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## Abstract

In order to solve the problems of large trauma, many postoperative complications, and complex operation of artificial hip arthroplasty, a method to analyze the application effect of operating room nursing intervention in artificial hip arthroplasty was proposed. Firstly, 120 patients who underwent hip arthroplasty in our hospital from January to December 2017 were selected; Secondly, they were randomly divided into routine group (60 cases) and intervention group (60 cases); finally, on this basis, the intervention group strengthened the nursing in the operating room and used nanoceramic prosthesis. The Harris score of hip joint, the incidence of postoperative complications, and the satisfaction with nursing services were compared between the two groups. The results showed that the Harris score of hip joint and the satisfaction score of nursing service in the intervention group were significantly higher than those in the routine group (P<0.05); the incidence of postoperative complications in the intervention group was significantly lower than that in the routine group (P<0.05). It is proved that actively carrying out nursing intervention in the operating room and using nanoceramic prosthesis can not only improve the clinical efficacy and nursing service satisfaction of patients undergoing total hip arthroplasty but also reduce the incidence of complications.


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## Body

## 1. Introduction

With the aggravation of aging and the continuous increase of the elderly population, hip disease is one of the main reasons affecting the healthy life of the elderly. However, with the rapid development of medicine, hip arthroplasty has gradually matured and relieved more pain for patients. At present, the operation has been quite mature. Total hip arthroplasty (THA) uses artificial hip prosthesis to replace the femoral head and acetabulum of the diseased hip joint. Its purpose is to relieve pain, restore joint function, and improve the quality of life of patients. Relevant data show that there are nearly 2 million joint replacement operations in the United States every year, and there is a growing trend year by year. Some researchers have predicted the growth trend of hip arthroplasty. It is speculated that hip arthroplasty will increase to 174% by 2030. Therefore, the professional and technical requirements of the operation for medical staff are also increasing, and the patients’ postoperative effect and life recovery are increasing accordingly. Both doctors and patients hope to experience the least pain and obtain the best postoperative recovery through efficient surgery. The main nursing staff for the rehabilitation of patients after hip arthroplasty will play an important role, as shown in Figure1.Figure 1
HIP arthroplasty.


## 2. Literature Review

Despite the rapid development of hip arthroplasty technology, patients will still leave some unique complications, such as postoperative joint instability and dislocation, bleeding and hematoma, infection, and thrombosis. Among them, the most common is deep venous thrombosis (DVT), which mostly occurs in the lower limb, and the left side is the most common. If the patient does not receive timely and effective treatment and care, the thrombus will affect the whole limb through retrograde expansion, and there will be serious complications—pulmonary embolism (PE), which threatens the life of the patient.Scholars Wang and others predict that the demand for hip arthroplasty among the elderly in China will be greater, and the growth of hip arthroplasty will be faster [1]. Liu and others reported that the probability of DVT after hip arthroplasty is as high as 75% [2]. Synderm and others synthesized relevant guidelines and literature and found that if corresponding preventive measures were not taken after hip arthroplasty, DVT confirmed by venography occurred in 30% [3]. Li and Zhang also showed that the incidence of DVT after hip arthroplasty was 20% without preventive measures [4]. According to Triantafyllou et al., the probability of DVT after joint replacement is 45% [5]. Garcia-Rey and other studies show that caregivers’ mastery of disease-related knowledge will have a positive impact on patients’ knowledge and even behavior [6]. Clarkeic and others carried out health education for relatives and caregivers of stroke patients. The results showed that the psychological state and health and safety problems of elderly stroke patients were significantly improved [7]. Liu and others implemented health education for caregivers of patients with pancreatitis at the same time. The results further confirmed that health education participated by caregivers can enhance patients’ mastery of relevant disease knowledge and effectively improve patients’ psychological status [8]. Lucchini et al. believe that standardized operating room nursing intervention is helpful to improve the clinical treatment effect of total hip arthroplasty [9]. Xiong and Ge believe that surgeons are responsible for the organization and operation of the surgical process, cooperate with assistants, anesthesiologists, and nursing staff, maintain positive communication and exchange with each other, and jointly discuss the treatment methods of various emergency problems [10].On the basis that patients with hip arthroplasty will still leave some unique complications, this paper puts forward that surgical nursing intervention combined with nanoceramic prosthesis can not only reduce the probability of postoperative complications but also reduce the cost of follow-up treatment and maintenance. Finally, the analysis data under the control test are given to prove the feasibility of this technology. It is proved that actively carrying out nursing intervention in the operating room and using nanoceramic prosthesis can not only improve the clinical efficacy and nursing service satisfaction of patients undergoing total hip arthroplasty but also reduce the incidence of complications.


## 3. Effect of Nursing Intervention in Operating Room Combined with Nanoceramic Prosthesis on Total Hip Arthroplasty

### 3.1. Application of Nanoceramic Prosthesis in Hip Arthroplasty

#### 3.1.1. Application Method

Inclusion criteria: (1) primary total hip arthroplasty patients with surgical indications; (2) agreed to participate in this study. Exclusion criteria: (1) coinfection; (2) with mental illness; (3) those with insufficient bone mass and unfit for biological fixation; (4) there are other surgical contraindications. The fourth-generation nanoceramic interface hip prosthesis was used in 28 patients. The basic information of the research object is shown in Table1.Table 1
Basic data of research object.
ProjectDataDiagnostic typeDataGender (male/female)15/13Osteoarthritis8Age (years)52.2Dislocation of hip joint4BMI24.7Femoral head necrosis9Left/right hip14/15Ankylosing spondylitis1


#### 3.1.2. Prosthesis Materials

The materials of hip prosthesis are the fourth-generation nanoceramics (Ceramtechag, Plochingen, Germany); the lining and ball joint compatibility interface all adopt biological fixed mortar cup and femoral handle (Corail DePuy, Warsaw, IN).


#### 3.1.3. Operation Method

All patients were treated with intravenous inhalation combined with general anesthesia. In the healthy lateral position, take the posterolateral incision of the hip, cut the gluteus maximus muscle membrane, and separate the gluteus maximus muscle. Cut off some external rotation muscles and joint capsule. Osteotomy was performed 1.5 cm on the lesser trochanter, and the femoral head was taken out. Remove the labial margin of acetabulum and femoral round ligament, expand the acetabulum, and test the model in turn. Choose a suitable Pinnacle metal acetabular cup, keep it abducted about 40 degrees and tilted forward about 20 degrees, and fix it with two acetabular screws. Implant corresponding nanoceramic lining. Remove the proliferative osteophyte around the acetabulum. The femoral medullary cavity was found out, and the medullary cavity file was expanded in turn. Appropriate femoral head test model was placed and reset. Measure the limb length, and test the hip flexion, adduction, internal rotation, extension, external rotation, and abduction without dislocation. Select suitable Corail femoral stem and nanoceramic femoral head [11]. Reset check is the same as before. Wash repeatedly, stop bleeding thoroughly, and place a drainage tube for drainage. Repair the joint capsule and external rotator brevis muscle, and suture the wound in layers. 1.4 postoperative treatment after operation, cefuroxime was routinely used for 2-3 days to prevent infection, low molecular weight heparin was used for 14 days to prevent venous thrombosis (rivaroxaban was taken if the patient was discharged from the hospital), and celecoxib was used for 3-5 days to relieve pain. The drainage tube was pulled out 24 hours after operation. Two days after operation, they got out of bed with the aid of walking aid for walking function training [12]. After 6 weeks, gradually abandon the turn and walk independently.


#### 3.1.4. Evaluation Index

Harris hip score was performed before operation. The patients were followed up at 3 months, 6 months, 12 months, and every other year. Harris score, X-ray implant analysis, and complications were investigated [13]. The last follow-up score was taken as the final result. Harris hip function score grading standard: excellent is 90-100 points, good is 80-89 points, medium is 70-79 points, and poor is 70 points.


#### 3.1.5. Statistical Analysis

Spss21.0 software was used to conduct pairedt-test on the Harris score data before and after operation. The measurement data were expressed in x±s, with P<0.05 as the difference, which was statistically significant, as shown in Table 2.Table 2
Harris score before and after operation.
ProjectPreoperativeAfter operationtPScore41.7±10.892.2±7.037.60.000


### 3.2. Characteristics of Nanoceramic Materials

#### 3.2.1. Advantages of Nanoceramic Materials

The excellent tribological properties of nanoceramic materials are its main advantages. Alumina nanoceramics are widely used in clinic. Theoretically, the hardness of alumina nanoceramics is 10 times that of cobalt chromium alloy. Alumina with almost 2000VH hardness is the second hard material on earth after diamond. This hardness gives it scratch resistance [14]. The good lubrication brought by the wettability of nanoceramics is another advantage, especially when a microliquid film is formed on the surface. In addition, the close combination between oxygen and aluminum atoms provides excellent corrosion resistance of nanoceramics, so the biocompatibility is also superior [15]. At the same time, its chemical properties are inert, so there is no need to worry about allergy or rejection. However, the high hardness of alumina nanoceramics is accompanied by low toughness and low bendability [16]. Therefore, it is relatively fragile and cannot be completely deformed.


#### 3.2.2. Innovation of Nanoceramic Materials

In order to meet the strict requirements of increasing patient activity and long service life expectation, the material industry has developed a new fourth-generation nanoceramics, namely, alumina-based composite nanoceramics (AMC). This material synthesizes and strengthens the tribological properties of nanoceramics and creates better mechanical resistance. In the friction test, AMC shows excellent wear resistance, especially under the condition of challenging thermal aging, a variety of new technologies have been introduced into the production of AMC, such as the integration of zirconia in alumina matrix, resulting in bioloxdelta nanoceramics [17]. Nanoyttria-reinforced tetragonal zirconia particles prevent the generation and expansion of nanoceramic cracks, improve mechanical properties, and further reduce wear. The flake crystal structure provided by the oxide additive disperses the force leading to the crack. Chromium oxide (0.5%) was added to increase hardness; strontium oxide crystal (0.5%) enhanced toughness and dispersed crack energy. The final AMC consists of 82% alumina, 17% zirconia, and less than 1% chromium oxide and strontium oxide. In vitro experiments, the wear rate of AMC to AMC with 28 mm ball head was reduced from 1.84 mm3 to 0.16 mm per million cycles compared with the traditional alumina to alumina interface, and the AMC particles were reduced to less than 0.8 μm compared with the size of the third-generation alumina nanoceramic particles (1-5 μm). This is more favorable for the formation of liquid film layer [18], as shown in Figure 2.Figure 2
Formation curve of AMC particles and liquid film layer.


#### 3.2.3. Excellent Wear Resistance

Due to the high strength and hardness of nanoceramics, nanoceramics can resist the wear of bone tissue, bone cement, and metal debris. In this way, the wear of the weight-bearing surface between prostheses is reduced. Nanoceramics is the compatibility mode with the lowest wear rate in hip arthroplasty. Lusty and others reported that 283 hips (301 hips) underwent the third-generation COC hip arthroplasty, the 7-year in place rate was 99%, the wear rate of nanoceramic head was 0.2 mm3, and only one femoral stem had aseptic loosening 2 months after operation.


#### 3.2.4. Extremely High Hardness

Nanoceramic materials are very hard, and their hardness is second only to diamond, which is much higher than metal materials such as cobalt chromium alloy and titanium alloy. Therefore, parts made of nanoceramics are not easy to be scratched. It is a kind of brittle material, but its tensile strength is still significantly lower than that of nanoceramic material. The reported incidence of prosthesis fragmentation is 0.015%, and most reports suggest that the incidence of nanoceramic lining is much higher than that of nanoceramic femoral head fragmentation [19]. Zirconia nanoceramics have higher hardness and better toughness than alumina, which can reduce the incidence of fragmentation of nanoceramic parts.


#### 3.2.5. Good Biocompatibility

The concentration of metal ions in serum of patients with metal prosthesis increases after replacement. The metal particles produced by metal metal prosthesis are not only toxic to macrophages but also affect the growth of osteoblasts. Metal prosthesis can also lead to the hypersensitivity of human tissue to metal ions. Friedman et al. pointed out that the principle to solve osteolysis around the prosthesis is to reduce the wear particles around the prosthesis. Alumina nanoceramics reduce the biological reaction caused by wear and prolong the service life of prosthesis. Nanoceramics can work normally under humid conditions, which overcomes the problem that metal prosthesis is easy to release metal ions in the humid environment in the body. Alumina nanoceramics are biologically inert materials with stable chemical bonds, low histological reaction, and no corrosion. Nanoceramic particles also have less stimulation to the tissue than metal particles. The particles produced during wear are small, and the tissue reaction is small, so the nanoceramic joint can effectively reduce osteolysis [20]. It was found that the wear particles of alumina nanoceramics induced the production of interleukin- (IL-) 6, tumor necrosis factor (TNF), and granulocyte macrophage colony stimulating factor (GM-GSF) lower than polyethylene wear particles. The average diameter of alumina nanoceramics wear particles used in the experiment was 94 μm. Human peripheral blood monocytes were used to establish the artificial joint model in vitro to make it closer to the actual situation in vivo. The results show that alumina nanoceramic wear particles have lower bioactivity. These improvements have improved the rupture strength of the material, and each part has been subjected to failure test, which is a standard that cannot be reached by early nanoceramic materials.


## 3.1. Application of Nanoceramic Prosthesis in Hip Arthroplasty

### 3.1.1. Application Method

Inclusion criteria: (1) primary total hip arthroplasty patients with surgical indications; (2) agreed to participate in this study. Exclusion criteria: (1) coinfection; (2) with mental illness; (3) those with insufficient bone mass and unfit for biological fixation; (4) there are other surgical contraindications. The fourth-generation nanoceramic interface hip prosthesis was used in 28 patients. The basic information of the research object is shown in Table1.Table 1
Basic data of research object.
ProjectDataDiagnostic typeDataGender (male/female)15/13Osteoarthritis8Age (years)52.2Dislocation of hip joint4BMI24.7Femoral head necrosis9Left/right hip14/15Ankylosing spondylitis1


### 3.1.2. Prosthesis Materials

The materials of hip prosthesis are the fourth-generation nanoceramics (Ceramtechag, Plochingen, Germany); the lining and ball joint compatibility interface all adopt biological fixed mortar cup and femoral handle (Corail DePuy, Warsaw, IN).


### 3.1.3. Operation Method

All patients were treated with intravenous inhalation combined with general anesthesia. In the healthy lateral position, take the posterolateral incision of the hip, cut the gluteus maximus muscle membrane, and separate the gluteus maximus muscle. Cut off some external rotation muscles and joint capsule. Osteotomy was performed 1.5 cm on the lesser trochanter, and the femoral head was taken out. Remove the labial margin of acetabulum and femoral round ligament, expand the acetabulum, and test the model in turn. Choose a suitable Pinnacle metal acetabular cup, keep it abducted about 40 degrees and tilted forward about 20 degrees, and fix it with two acetabular screws. Implant corresponding nanoceramic lining. Remove the proliferative osteophyte around the acetabulum. The femoral medullary cavity was found out, and the medullary cavity file was expanded in turn. Appropriate femoral head test model was placed and reset. Measure the limb length, and test the hip flexion, adduction, internal rotation, extension, external rotation, and abduction without dislocation. Select suitable Corail femoral stem and nanoceramic femoral head [11]. Reset check is the same as before. Wash repeatedly, stop bleeding thoroughly, and place a drainage tube for drainage. Repair the joint capsule and external rotator brevis muscle, and suture the wound in layers. 1.4 postoperative treatment after operation, cefuroxime was routinely used for 2-3 days to prevent infection, low molecular weight heparin was used for 14 days to prevent venous thrombosis (rivaroxaban was taken if the patient was discharged from the hospital), and celecoxib was used for 3-5 days to relieve pain. The drainage tube was pulled out 24 hours after operation. Two days after operation, they got out of bed with the aid of walking aid for walking function training [12]. After 6 weeks, gradually abandon the turn and walk independently.


### 3.1.4. Evaluation Index

Harris hip score was performed before operation. The patients were followed up at 3 months, 6 months, 12 months, and every other year. Harris score, X-ray implant analysis, and complications were investigated [13]. The last follow-up score was taken as the final result. Harris hip function score grading standard: excellent is 90-100 points, good is 80-89 points, medium is 70-79 points, and poor is 70 points.


### 3.1.5. Statistical Analysis

Spss21.0 software was used to conduct pairedt-test on the Harris score data before and after operation. The measurement data were expressed in x±s, with P<0.05 as the difference, which was statistically significant, as shown in Table 2.Table 2
Harris score before and after operation.
ProjectPreoperativeAfter operationtPScore41.7±10.892.2±7.037.60.000


## 3.1.1. Application Method

Inclusion criteria: (1) primary total hip arthroplasty patients with surgical indications; (2) agreed to participate in this study. Exclusion criteria: (1) coinfection; (2) with mental illness; (3) those with insufficient bone mass and unfit for biological fixation; (4) there are other surgical contraindications. The fourth-generation nanoceramic interface hip prosthesis was used in 28 patients. The basic information of the research object is shown in Table1.Table 1
Basic data of research object.
ProjectDataDiagnostic typeDataGender (male/female)15/13Osteoarthritis8Age (years)52.2Dislocation of hip joint4BMI24.7Femoral head necrosis9Left/right hip14/15Ankylosing spondylitis1


## 3.1.2. Prosthesis Materials

The materials of hip prosthesis are the fourth-generation nanoceramics (Ceramtechag, Plochingen, Germany); the lining and ball joint compatibility interface all adopt biological fixed mortar cup and femoral handle (Corail DePuy, Warsaw, IN).


## 3.1.3. Operation Method

All patients were treated with intravenous inhalation combined with general anesthesia. In the healthy lateral position, take the posterolateral incision of the hip, cut the gluteus maximus muscle membrane, and separate the gluteus maximus muscle. Cut off some external rotation muscles and joint capsule. Osteotomy was performed 1.5 cm on the lesser trochanter, and the femoral head was taken out. Remove the labial margin of acetabulum and femoral round ligament, expand the acetabulum, and test the model in turn. Choose a suitable Pinnacle metal acetabular cup, keep it abducted about 40 degrees and tilted forward about 20 degrees, and fix it with two acetabular screws. Implant corresponding nanoceramic lining. Remove the proliferative osteophyte around the acetabulum. The femoral medullary cavity was found out, and the medullary cavity file was expanded in turn. Appropriate femoral head test model was placed and reset. Measure the limb length, and test the hip flexion, adduction, internal rotation, extension, external rotation, and abduction without dislocation. Select suitable Corail femoral stem and nanoceramic femoral head [11]. Reset check is the same as before. Wash repeatedly, stop bleeding thoroughly, and place a drainage tube for drainage. Repair the joint capsule and external rotator brevis muscle, and suture the wound in layers. 1.4 postoperative treatment after operation, cefuroxime was routinely used for 2-3 days to prevent infection, low molecular weight heparin was used for 14 days to prevent venous thrombosis (rivaroxaban was taken if the patient was discharged from the hospital), and celecoxib was used for 3-5 days to relieve pain. The drainage tube was pulled out 24 hours after operation. Two days after operation, they got out of bed with the aid of walking aid for walking function training [12]. After 6 weeks, gradually abandon the turn and walk independently.


## 3.1.4. Evaluation Index

Harris hip score was performed before operation. The patients were followed up at 3 months, 6 months, 12 months, and every other year. Harris score, X-ray implant analysis, and complications were investigated [13]. The last follow-up score was taken as the final result. Harris hip function score grading standard: excellent is 90-100 points, good is 80-89 points, medium is 70-79 points, and poor is 70 points.


## 3.1.5. Statistical Analysis

Spss21.0 software was used to conduct pairedt-test on the Harris score data before and after operation. The measurement data were expressed in x±s, with P<0.05 as the difference, which was statistically significant, as shown in Table 2.Table 2
Harris score before and after operation.
ProjectPreoperativeAfter operationtPScore41.7±10.892.2±7.037.60.000


## 3.2. Characteristics of Nanoceramic Materials

### 3.2.1. Advantages of Nanoceramic Materials

The excellent tribological properties of nanoceramic materials are its main advantages. Alumina nanoceramics are widely used in clinic. Theoretically, the hardness of alumina nanoceramics is 10 times that of cobalt chromium alloy. Alumina with almost 2000VH hardness is the second hard material on earth after diamond. This hardness gives it scratch resistance [14]. The good lubrication brought by the wettability of nanoceramics is another advantage, especially when a microliquid film is formed on the surface. In addition, the close combination between oxygen and aluminum atoms provides excellent corrosion resistance of nanoceramics, so the biocompatibility is also superior [15]. At the same time, its chemical properties are inert, so there is no need to worry about allergy or rejection. However, the high hardness of alumina nanoceramics is accompanied by low toughness and low bendability [16]. Therefore, it is relatively fragile and cannot be completely deformed.


### 3.2.2. Innovation of Nanoceramic Materials

In order to meet the strict requirements of increasing patient activity and long service life expectation, the material industry has developed a new fourth-generation nanoceramics, namely, alumina-based composite nanoceramics (AMC). This material synthesizes and strengthens the tribological properties of nanoceramics and creates better mechanical resistance. In the friction test, AMC shows excellent wear resistance, especially under the condition of challenging thermal aging, a variety of new technologies have been introduced into the production of AMC, such as the integration of zirconia in alumina matrix, resulting in bioloxdelta nanoceramics [17]. Nanoyttria-reinforced tetragonal zirconia particles prevent the generation and expansion of nanoceramic cracks, improve mechanical properties, and further reduce wear. The flake crystal structure provided by the oxide additive disperses the force leading to the crack. Chromium oxide (0.5%) was added to increase hardness; strontium oxide crystal (0.5%) enhanced toughness and dispersed crack energy. The final AMC consists of 82% alumina, 17% zirconia, and less than 1% chromium oxide and strontium oxide. In vitro experiments, the wear rate of AMC to AMC with 28 mm ball head was reduced from 1.84 mm3 to 0.16 mm per million cycles compared with the traditional alumina to alumina interface, and the AMC particles were reduced to less than 0.8 μm compared with the size of the third-generation alumina nanoceramic particles (1-5 μm). This is more favorable for the formation of liquid film layer [18], as shown in Figure 2.Figure 2
Formation curve of AMC particles and liquid film layer.


### 3.2.3. Excellent Wear Resistance

Due to the high strength and hardness of nanoceramics, nanoceramics can resist the wear of bone tissue, bone cement, and metal debris. In this way, the wear of the weight-bearing surface between prostheses is reduced. Nanoceramics is the compatibility mode with the lowest wear rate in hip arthroplasty. Lusty and others reported that 283 hips (301 hips) underwent the third-generation COC hip arthroplasty, the 7-year in place rate was 99%, the wear rate of nanoceramic head was 0.2 mm3, and only one femoral stem had aseptic loosening 2 months after operation.


### 3.2.4. Extremely High Hardness

Nanoceramic materials are very hard, and their hardness is second only to diamond, which is much higher than metal materials such as cobalt chromium alloy and titanium alloy. Therefore, parts made of nanoceramics are not easy to be scratched. It is a kind of brittle material, but its tensile strength is still significantly lower than that of nanoceramic material. The reported incidence of prosthesis fragmentation is 0.015%, and most reports suggest that the incidence of nanoceramic lining is much higher than that of nanoceramic femoral head fragmentation [19]. Zirconia nanoceramics have higher hardness and better toughness than alumina, which can reduce the incidence of fragmentation of nanoceramic parts.


### 3.2.5. Good Biocompatibility

The concentration of metal ions in serum of patients with metal prosthesis increases after replacement. The metal particles produced by metal metal prosthesis are not only toxic to macrophages but also affect the growth of osteoblasts. Metal prosthesis can also lead to the hypersensitivity of human tissue to metal ions. Friedman et al. pointed out that the principle to solve osteolysis around the prosthesis is to reduce the wear particles around the prosthesis. Alumina nanoceramics reduce the biological reaction caused by wear and prolong the service life of prosthesis. Nanoceramics can work normally under humid conditions, which overcomes the problem that metal prosthesis is easy to release metal ions in the humid environment in the body. Alumina nanoceramics are biologically inert materials with stable chemical bonds, low histological reaction, and no corrosion. Nanoceramic particles also have less stimulation to the tissue than metal particles. The particles produced during wear are small, and the tissue reaction is small, so the nanoceramic joint can effectively reduce osteolysis [20]. It was found that the wear particles of alumina nanoceramics induced the production of interleukin- (IL-) 6, tumor necrosis factor (TNF), and granulocyte macrophage colony stimulating factor (GM-GSF) lower than polyethylene wear particles. The average diameter of alumina nanoceramics wear particles used in the experiment was 94 μm. Human peripheral blood monocytes were used to establish the artificial joint model in vitro to make it closer to the actual situation in vivo. The results show that alumina nanoceramic wear particles have lower bioactivity. These improvements have improved the rupture strength of the material, and each part has been subjected to failure test, which is a standard that cannot be reached by early nanoceramic materials.


## 3.2.1. Advantages of Nanoceramic Materials

The excellent tribological properties of nanoceramic materials are its main advantages. Alumina nanoceramics are widely used in clinic. Theoretically, the hardness of alumina nanoceramics is 10 times that of cobalt chromium alloy. Alumina with almost 2000VH hardness is the second hard material on earth after diamond. This hardness gives it scratch resistance [14]. The good lubrication brought by the wettability of nanoceramics is another advantage, especially when a microliquid film is formed on the surface. In addition, the close combination between oxygen and aluminum atoms provides excellent corrosion resistance of nanoceramics, so the biocompatibility is also superior [15]. At the same time, its chemical properties are inert, so there is no need to worry about allergy or rejection. However, the high hardness of alumina nanoceramics is accompanied by low toughness and low bendability [16]. Therefore, it is relatively fragile and cannot be completely deformed.


## 3.2.2. Innovation of Nanoceramic Materials

In order to meet the strict requirements of increasing patient activity and long service life expectation, the material industry has developed a new fourth-generation nanoceramics, namely, alumina-based composite nanoceramics (AMC). This material synthesizes and strengthens the tribological properties of nanoceramics and creates better mechanical resistance. In the friction test, AMC shows excellent wear resistance, especially under the condition of challenging thermal aging, a variety of new technologies have been introduced into the production of AMC, such as the integration of zirconia in alumina matrix, resulting in bioloxdelta nanoceramics [17]. Nanoyttria-reinforced tetragonal zirconia particles prevent the generation and expansion of nanoceramic cracks, improve mechanical properties, and further reduce wear. The flake crystal structure provided by the oxide additive disperses the force leading to the crack. Chromium oxide (0.5%) was added to increase hardness; strontium oxide crystal (0.5%) enhanced toughness and dispersed crack energy. The final AMC consists of 82% alumina, 17% zirconia, and less than 1% chromium oxide and strontium oxide. In vitro experiments, the wear rate of AMC to AMC with 28 mm ball head was reduced from 1.84 mm3 to 0.16 mm per million cycles compared with the traditional alumina to alumina interface, and the AMC particles were reduced to less than 0.8 μm compared with the size of the third-generation alumina nanoceramic particles (1-5 μm). This is more favorable for the formation of liquid film layer [18], as shown in Figure 2.Figure 2
Formation curve of AMC particles and liquid film layer.


## 3.2.3. Excellent Wear Resistance

Due to the high strength and hardness of nanoceramics, nanoceramics can resist the wear of bone tissue, bone cement, and metal debris. In this way, the wear of the weight-bearing surface between prostheses is reduced. Nanoceramics is the compatibility mode with the lowest wear rate in hip arthroplasty. Lusty and others reported that 283 hips (301 hips) underwent the third-generation COC hip arthroplasty, the 7-year in place rate was 99%, the wear rate of nanoceramic head was 0.2 mm3, and only one femoral stem had aseptic loosening 2 months after operation.


## 3.2.4. Extremely High Hardness

Nanoceramic materials are very hard, and their hardness is second only to diamond, which is much higher than metal materials such as cobalt chromium alloy and titanium alloy. Therefore, parts made of nanoceramics are not easy to be scratched. It is a kind of brittle material, but its tensile strength is still significantly lower than that of nanoceramic material. The reported incidence of prosthesis fragmentation is 0.015%, and most reports suggest that the incidence of nanoceramic lining is much higher than that of nanoceramic femoral head fragmentation [19]. Zirconia nanoceramics have higher hardness and better toughness than alumina, which can reduce the incidence of fragmentation of nanoceramic parts.


## 3.2.5. Good Biocompatibility

The concentration of metal ions in serum of patients with metal prosthesis increases after replacement. The metal particles produced by metal metal prosthesis are not only toxic to macrophages but also affect the growth of osteoblasts. Metal prosthesis can also lead to the hypersensitivity of human tissue to metal ions. Friedman et al. pointed out that the principle to solve osteolysis around the prosthesis is to reduce the wear particles around the prosthesis. Alumina nanoceramics reduce the biological reaction caused by wear and prolong the service life of prosthesis. Nanoceramics can work normally under humid conditions, which overcomes the problem that metal prosthesis is easy to release metal ions in the humid environment in the body. Alumina nanoceramics are biologically inert materials with stable chemical bonds, low histological reaction, and no corrosion. Nanoceramic particles also have less stimulation to the tissue than metal particles. The particles produced during wear are small, and the tissue reaction is small, so the nanoceramic joint can effectively reduce osteolysis [20]. It was found that the wear particles of alumina nanoceramics induced the production of interleukin- (IL-) 6, tumor necrosis factor (TNF), and granulocyte macrophage colony stimulating factor (GM-GSF) lower than polyethylene wear particles. The average diameter of alumina nanoceramics wear particles used in the experiment was 94 μm. Human peripheral blood monocytes were used to establish the artificial joint model in vitro to make it closer to the actual situation in vivo. The results show that alumina nanoceramic wear particles have lower bioactivity. These improvements have improved the rupture strength of the material, and each part has been subjected to failure test, which is a standard that cannot be reached by early nanoceramic materials.


## 4. Experimental Results and Discussion

### 4.1. Effect of Operating Room Nursing Intervention Combined with Nanoceramic Prosthesis on the Rehabilitation of Total Hip Replacement

#### 4.1.1. Technical Route

Multidisciplinary team usually refers to the clinical treatment mode that experts from multiple disciplines form a relatively fixed expert group to put forward diagnosis and treatment opinions through regular and localized meetings for an organ or system disease. It is widely used in many clinical fields. In this study, it refers to the establishment of a team with researchers as the coordinator, including surgeons, surgical nurses, anesthesiologists, rehabilitators, psychological counselors, nutritionists, and nurses. Under the coordination of caregivers (caregivers are educators of patients’ disease related knowledge, transmitters of patients’ information, supervisors of patients’ compliance with medical orders, and supporters of patients’ exercise and medication to prevent DVT), intervention is implemented for elderly patients after hip arthroplasty to effectively prevent DVT [21], as shown in the technical roadmap in Figure 3.Figure 3
Technical roadmap.


#### 4.1.2. Inclusion Criteria

(1)
Age≥60 years old(2)
There are fixed caregivers during the whole hospitalization, and the education level of caregivers is junior middle school or above(3)
After hip arthroplasty, they can accept intervention measures with the help of caregivers(4)
No serious diseases such as cardiac and renal dysfunction(5)
Clear consciousness without obvious impairment of language and cognitive function(6)
Voluntary participation, informed consent, and researchers


#### 4.1.3. Exclusion Criteria

(1)
Preoperative B-ultrasound examination of patients with lower extremity deep venous thrombosis, thrombophlebitis, or pulmonary embolism(2)
Abnormal local conditions of lower limbs (such as dermatitis, gangrene, and recent skin transplantation)(3)
Severe arteriosclerosis or other ischemic vascular diseases and severe deformities of lower limbs(4)
Congestive cardiac failure and pulmonary edema


#### 4.1.4. Exit Criteria

(1)
The participants were unable to continue the study due to the aggravation of their condition(2)
Patients asked to withdraw for various reasons during the study


#### 4.1.5. Sample Size Calculation

According to the comparison formula of the mean of two samples (1),
(1)x+an=∑k=0nknxkan−k.According to the research results of literature, the difference of health belief score is 4.10, and the standard deviation is 3.6. Finally, it is calculated that 49 patients in each group need hip arthroplasty. Considering the 15% loss of follow-up rate, about 55 samples are needed in each group, and the final total sample size is 110 [22].


### 4.2. Effectiveness Analysis of Operating Room Nursing Combined with Nanoceramic Prosthesis in Total Hip Arthroplasty

#### 4.2.1. General Information

The subjects of this study were 94 patients who underwent total hip arthroplasty in our hospital from March 2017 to February 2019. According to the application of nursing cooperation in the operating room, 48 patients in the observation group (after application: March 2018 to February 2019) and 46 patients in the control group (before application: March 2017 to February 2018) were analyzed. There were 28 males and 20 females in the observation group. The age range was 49-75 years, with an average age of61.18±4.42 years. There were 29 males and 17 females in the control group. The age range was 48-76 years, with an average of 62.31±4.29 years. The basic data were comparable P>0.05 [23].


#### 4.2.2. Method

Patients in the control group received routine nursing during total hip arthroplasty. During the total hip arthroplasty, the patients in the observation group received nursing cooperation in the operating room. The specific measures are as follows:(1)
Preoperative preparation: prepare the operating room, and adjust the temperature and humidity to the appropriate range after strict cleaning and disinfection. Check the surgical instruments and various medical items, and check the operation performance of relevant instruments. In the operation guidance, nurses should care about the feelings of patients and ask patients about their thoughts and attitudes towards total hip arthroplasty. According to the patients’ cognition of their own diseases and operations, appropriate publicity, and education methods should be applied. Understand the causes of patients’ anxiety and tension, and conduct psychological counseling. In order to reduce patients’ concern about surgical risk, it is necessary to carry out surgical guidance in combination with successful treatment medical records, improve patients’ self-confidence, relax, and accept surgical treatment with a peaceful attitude [24](2)
Intraoperative nursing: combined with previous experience, emergency treatment measures should be prepared for common risk events during surgical treatment. When the patient has elevated blood pressure and accelerated heart rate, they need to be vigilant, and the medical staff can respond quickly and deal with it in time. During the operation, the principle of sterility must be strictly followed. Disinfect the skin of the operation field and prepare sterile bandage and operation film. Nurses need to fully master the operation process and actively assist and cooperate with doctors. Deliver surgical instruments timely, accurately, and stably according to the operation process. According to the patient’s hip injury, select the appropriate specification of prosthesis materials. Before installing the prosthesis, it is necessary to prepare the femoral medullary cavity, expand the medullary cavity, correct the osteotomy surface, and reset the femoral head, and then, install the prosthesis correctly after washing and drying with normal saline. At the same time, keep the surgical incision clean and drain and rinse [25](3)
Postoperative care: during the postoperative care period, sort out the surgical instruments and related medical articles, and place them in the designated position after checking them, to recycle the medical waste. Strengthen the monitoring of signs, check whether there is loosening and dislocation of artificial acetabulum, and ask the patient’s feelings. To properly adjust the patient’s posture, we need to consider the patient’s comfort and pay attention to protecting the patient’s surgical incision. In the hip bone carina, axillary nerve, and other parts, protection should be done to avoid skin damage. Under the guidance and assistance of nursing staff, functional rehabilitation training is carried out, such as hip lifting and turning over


#### 4.2.3. Results

The physical signs of the two groups before and after nursing are shown in Table3.Table 3
Physical signs of patients in the two groups before and after nursing.
GroupTimeSBP (mmHg)DBP (mmHg)HR (times/min)Observation group (n=48)Before nursing123.6±7.979.1±6.373.1±4.6After nursing127.3±9.483.5±5.274.9±3.7Control group (n=46)Before nursing124.2±8.379.5±5.973.5±4.4After nursing35.4±9.6∗89.7±7.3∗#84.6±5.5∗#The nursing effects of the two groups are shown in Table4.Table 4
Nursing effect of two groups of patients.
GroupSatisfactionPostoperative complicationsObservation group (n=48)46 (95.83)1 (2.08)Control group (n=46)35 (76.09)8 (17.39)χ27.6864.713P<0.05


## 4.1. Effect of Operating Room Nursing Intervention Combined with Nanoceramic Prosthesis on the Rehabilitation of Total Hip Replacement

### 4.1.1. Technical Route

Multidisciplinary team usually refers to the clinical treatment mode that experts from multiple disciplines form a relatively fixed expert group to put forward diagnosis and treatment opinions through regular and localized meetings for an organ or system disease. It is widely used in many clinical fields. In this study, it refers to the establishment of a team with researchers as the coordinator, including surgeons, surgical nurses, anesthesiologists, rehabilitators, psychological counselors, nutritionists, and nurses. Under the coordination of caregivers (caregivers are educators of patients’ disease related knowledge, transmitters of patients’ information, supervisors of patients’ compliance with medical orders, and supporters of patients’ exercise and medication to prevent DVT), intervention is implemented for elderly patients after hip arthroplasty to effectively prevent DVT [21], as shown in the technical roadmap in Figure 3.Figure 3
Technical roadmap.


### 4.1.2. Inclusion Criteria

(1)
Age≥60 years old(2)
There are fixed caregivers during the whole hospitalization, and the education level of caregivers is junior middle school or above(3)
After hip arthroplasty, they can accept intervention measures with the help of caregivers(4)
No serious diseases such as cardiac and renal dysfunction(5)
Clear consciousness without obvious impairment of language and cognitive function(6)
Voluntary participation, informed consent, and researchers


### 4.1.3. Exclusion Criteria

(1)
Preoperative B-ultrasound examination of patients with lower extremity deep venous thrombosis, thrombophlebitis, or pulmonary embolism(2)
Abnormal local conditions of lower limbs (such as dermatitis, gangrene, and recent skin transplantation)(3)
Severe arteriosclerosis or other ischemic vascular diseases and severe deformities of lower limbs(4)
Congestive cardiac failure and pulmonary edema


### 4.1.4. Exit Criteria

(1)
The participants were unable to continue the study due to the aggravation of their condition(2)
Patients asked to withdraw for various reasons during the study


### 4.1.5. Sample Size Calculation

According to the comparison formula of the mean of two samples (1),
(1)x+an=∑k=0nknxkan−k.According to the research results of literature, the difference of health belief score is 4.10, and the standard deviation is 3.6. Finally, it is calculated that 49 patients in each group need hip arthroplasty. Considering the 15% loss of follow-up rate, about 55 samples are needed in each group, and the final total sample size is 110 [22].


## 4.1.1. Technical Route

Multidisciplinary team usually refers to the clinical treatment mode that experts from multiple disciplines form a relatively fixed expert group to put forward diagnosis and treatment opinions through regular and localized meetings for an organ or system disease. It is widely used in many clinical fields. In this study, it refers to the establishment of a team with researchers as the coordinator, including surgeons, surgical nurses, anesthesiologists, rehabilitators, psychological counselors, nutritionists, and nurses. Under the coordination of caregivers (caregivers are educators of patients’ disease related knowledge, transmitters of patients’ information, supervisors of patients’ compliance with medical orders, and supporters of patients’ exercise and medication to prevent DVT), intervention is implemented for elderly patients after hip arthroplasty to effectively prevent DVT [21], as shown in the technical roadmap in Figure 3.Figure 3
Technical roadmap.


## 4.1.2. Inclusion Criteria

(1)
Age≥60 years old(2)
There are fixed caregivers during the whole hospitalization, and the education level of caregivers is junior middle school or above(3)
After hip arthroplasty, they can accept intervention measures with the help of caregivers(4)
No serious diseases such as cardiac and renal dysfunction(5)
Clear consciousness without obvious impairment of language and cognitive function(6)
Voluntary participation, informed consent, and researchers


## 4.1.3. Exclusion Criteria

(1)
Preoperative B-ultrasound examination of patients with lower extremity deep venous thrombosis, thrombophlebitis, or pulmonary embolism(2)
Abnormal local conditions of lower limbs (such as dermatitis, gangrene, and recent skin transplantation)(3)
Severe arteriosclerosis or other ischemic vascular diseases and severe deformities of lower limbs(4)
Congestive cardiac failure and pulmonary edema


## 4.1.4. Exit Criteria

(1)
The participants were unable to continue the study due to the aggravation of their condition(2)
Patients asked to withdraw for various reasons during the study


## 4.1.5. Sample Size Calculation

According to the comparison formula of the mean of two samples (1),
(1)x+an=∑k=0nknxkan−k.According to the research results of literature, the difference of health belief score is 4.10, and the standard deviation is 3.6. Finally, it is calculated that 49 patients in each group need hip arthroplasty. Considering the 15% loss of follow-up rate, about 55 samples are needed in each group, and the final total sample size is 110 [22].


## 4.2. Effectiveness Analysis of Operating Room Nursing Combined with Nanoceramic Prosthesis in Total Hip Arthroplasty

### 4.2.1. General Information

The subjects of this study were 94 patients who underwent total hip arthroplasty in our hospital from March 2017 to February 2019. According to the application of nursing cooperation in the operating room, 48 patients in the observation group (after application: March 2018 to February 2019) and 46 patients in the control group (before application: March 2017 to February 2018) were analyzed. There were 28 males and 20 females in the observation group. The age range was 49-75 years, with an average age of61.18±4.42 years. There were 29 males and 17 females in the control group. The age range was 48-76 years, with an average of 62.31±4.29 years. The basic data were comparable P>0.05 [23].


### 4.2.2. Method

Patients in the control group received routine nursing during total hip arthroplasty. During the total hip arthroplasty, the patients in the observation group received nursing cooperation in the operating room. The specific measures are as follows:(1)
Preoperative preparation: prepare the operating room, and adjust the temperature and humidity to the appropriate range after strict cleaning and disinfection. Check the surgical instruments and various medical items, and check the operation performance of relevant instruments. In the operation guidance, nurses should care about the feelings of patients and ask patients about their thoughts and attitudes towards total hip arthroplasty. According to the patients’ cognition of their own diseases and operations, appropriate publicity, and education methods should be applied. Understand the causes of patients’ anxiety and tension, and conduct psychological counseling. In order to reduce patients’ concern about surgical risk, it is necessary to carry out surgical guidance in combination with successful treatment medical records, improve patients’ self-confidence, relax, and accept surgical treatment with a peaceful attitude [24](2)
Intraoperative nursing: combined with previous experience, emergency treatment measures should be prepared for common risk events during surgical treatment. When the patient has elevated blood pressure and accelerated heart rate, they need to be vigilant, and the medical staff can respond quickly and deal with it in time. During the operation, the principle of sterility must be strictly followed. Disinfect the skin of the operation field and prepare sterile bandage and operation film. Nurses need to fully master the operation process and actively assist and cooperate with doctors. Deliver surgical instruments timely, accurately, and stably according to the operation process. According to the patient’s hip injury, select the appropriate specification of prosthesis materials. Before installing the prosthesis, it is necessary to prepare the femoral medullary cavity, expand the medullary cavity, correct the osteotomy surface, and reset the femoral head, and then, install the prosthesis correctly after washing and drying with normal saline. At the same time, keep the surgical incision clean and drain and rinse [25](3)
Postoperative care: during the postoperative care period, sort out the surgical instruments and related medical articles, and place them in the designated position after checking them, to recycle the medical waste. Strengthen the monitoring of signs, check whether there is loosening and dislocation of artificial acetabulum, and ask the patient’s feelings. To properly adjust the patient’s posture, we need to consider the patient’s comfort and pay attention to protecting the patient’s surgical incision. In the hip bone carina, axillary nerve, and other parts, protection should be done to avoid skin damage. Under the guidance and assistance of nursing staff, functional rehabilitation training is carried out, such as hip lifting and turning over


### 4.2.3. Results

The physical signs of the two groups before and after nursing are shown in Table3.Table 3
Physical signs of patients in the two groups before and after nursing.
GroupTimeSBP (mmHg)DBP (mmHg)HR (times/min)Observation group (n=48)Before nursing123.6±7.979.1±6.373.1±4.6After nursing127.3±9.483.5±5.274.9±3.7Control group (n=46)Before nursing124.2±8.379.5±5.973.5±4.4After nursing35.4±9.6∗89.7±7.3∗#84.6±5.5∗#The nursing effects of the two groups are shown in Table4.Table 4
Nursing effect of two groups of patients.
GroupSatisfactionPostoperative complicationsObservation group (n=48)46 (95.83)1 (2.08)Control group (n=46)35 (76.09)8 (17.39)χ27.6864.713P<0.05


## 4.2.1. General Information

The subjects of this study were 94 patients who underwent total hip arthroplasty in our hospital from March 2017 to February 2019. According to the application of nursing cooperation in the operating room, 48 patients in the observation group (after application: March 2018 to February 2019) and 46 patients in the control group (before application: March 2017 to February 2018) were analyzed. There were 28 males and 20 females in the observation group. The age range was 49-75 years, with an average age of61.18±4.42 years. There were 29 males and 17 females in the control group. The age range was 48-76 years, with an average of 62.31±4.29 years. The basic data were comparable P>0.05 [23].


## 4.2.2. Method

Patients in the control group received routine nursing during total hip arthroplasty. During the total hip arthroplasty, the patients in the observation group received nursing cooperation in the operating room. The specific measures are as follows:(1)
Preoperative preparation: prepare the operating room, and adjust the temperature and humidity to the appropriate range after strict cleaning and disinfection. Check the surgical instruments and various medical items, and check the operation performance of relevant instruments. In the operation guidance, nurses should care about the feelings of patients and ask patients about their thoughts and attitudes towards total hip arthroplasty. According to the patients’ cognition of their own diseases and operations, appropriate publicity, and education methods should be applied. Understand the causes of patients’ anxiety and tension, and conduct psychological counseling. In order to reduce patients’ concern about surgical risk, it is necessary to carry out surgical guidance in combination with successful treatment medical records, improve patients’ self-confidence, relax, and accept surgical treatment with a peaceful attitude [24](2)
Intraoperative nursing: combined with previous experience, emergency treatment measures should be prepared for common risk events during surgical treatment. When the patient has elevated blood pressure and accelerated heart rate, they need to be vigilant, and the medical staff can respond quickly and deal with it in time. During the operation, the principle of sterility must be strictly followed. Disinfect the skin of the operation field and prepare sterile bandage and operation film. Nurses need to fully master the operation process and actively assist and cooperate with doctors. Deliver surgical instruments timely, accurately, and stably according to the operation process. According to the patient’s hip injury, select the appropriate specification of prosthesis materials. Before installing the prosthesis, it is necessary to prepare the femoral medullary cavity, expand the medullary cavity, correct the osteotomy surface, and reset the femoral head, and then, install the prosthesis correctly after washing and drying with normal saline. At the same time, keep the surgical incision clean and drain and rinse [25](3)
Postoperative care: during the postoperative care period, sort out the surgical instruments and related medical articles, and place them in the designated position after checking them, to recycle the medical waste. Strengthen the monitoring of signs, check whether there is loosening and dislocation of artificial acetabulum, and ask the patient’s feelings. To properly adjust the patient’s posture, we need to consider the patient’s comfort and pay attention to protecting the patient’s surgical incision. In the hip bone carina, axillary nerve, and other parts, protection should be done to avoid skin damage. Under the guidance and assistance of nursing staff, functional rehabilitation training is carried out, such as hip lifting and turning over


## 4.2.3. Results

The physical signs of the two groups before and after nursing are shown in Table3.Table 3
Physical signs of patients in the two groups before and after nursing.
GroupTimeSBP (mmHg)DBP (mmHg)HR (times/min)Observation group (n=48)Before nursing123.6±7.979.1±6.373.1±4.6After nursing127.3±9.483.5±5.274.9±3.7Control group (n=46)Before nursing124.2±8.379.5±5.973.5±4.4After nursing35.4±9.6∗89.7±7.3∗#84.6±5.5∗#The nursing effects of the two groups are shown in Table4.Table 4
Nursing effect of two groups of patients.
GroupSatisfactionPostoperative complicationsObservation group (n=48)46 (95.83)1 (2.08)Control group (n=46)35 (76.09)8 (17.39)χ27.6864.713P<0.05


## 5. Conclusion

During the treatment of total hip arthroplasty, affected by a variety of risk factors, the safety and effectiveness of the operation are reduced, resulting in an unsatisfactory prognosis. The effective development of nursing work in the operating room can provide a good safety guarantee for surgical treatment and postoperative rehabilitation. Strengthening the nursing cooperation in the operating room can effectively manage and control the whole process of surgical treatment, more standardized, and refined implementation of surgical operation, and reduce the occurrence of errors and errors. In the preoperative nursing stage, medical devices, instruments, and various items should be fully prepared and in place. Respect the opinions and ideas of patients, take into account the actual feelings of patients, pay attention to their emotional state, and implement psychological nursing intervention. Through psychological nursing intervention, eliminate patients’ negative emotions, and guide patients to face treatment with a positive and optimistic attitude. In intraoperative nursing, medical staff need to divide their work reasonably and clarify their own responsibilities. The results also showed that the Harris score of hip joint and the satisfaction score of nursing service in the dry group were significantly higher than those in the routine group (P<0.05); the incidence of postoperative complications in the intervention group was significantly lower than that in the routine group (P<0.05). For common risk events, emergency treatment preparations can be made in advance, which can fully ensure the safety of surgery and reduce the harm of risk events. At the same time, good posture management, pain nursing, and complication prevention can actively promote the postoperative rehabilitation of patients. In conclusion, the operating room nursing in total hip arthroplasty combined with nanoceramic prosthesis has a positive impact on improving the safety of surgical treatment and promoting the postoperative rehabilitation of patients.



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*Source: 2421723-2022-06-21.xml*