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File:R10.01 Brücke Möckern, ET www.interreg4c.eu

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Background Hip replacement ranks among the more successful operations on the musculoskeletal system, but it can have serious complications. A common one is dislocation of the total hip endoprosthesis, an event that arises in about 2% of patients within 1 year of the operation. Physicians should be aware of how this problem can be prevented and, if necessary, treated, so that the degree of trauma due to hip dislocation after hip replacement surgery can be kept to a minimum. Results The rate of dislocation of primary hip replacements ranges from 0. Patient-specific risk factors for displacement of a hip endoprosthesis include advanced age, accompanying neurologic disease, and impaired compliance. Patients should scrupulously avoid hip movements such as bending far forward from a standing position, or internal rotation of the flexed hip. Operation-specific risk factors include suboptimal implant position, insufficient soft-tissue tension, and inadequate experience of the surgeon. Conservative treatment is justified the first time dislocation occurs without any identifiable cause. If a mechanical cause of instability is found, then operative revision should be performed as recommended in a standardized treatment algorithm, because, otherwise, dislocation is likely to recur. Conclusions The dislocation of a total hip endoprosthesis is an emotionally traumatizing event that should be prevented if possible. Preoperative risk assessment should be performed and the operation should be performed with optimal technique, including the best possible physical configuration of implant components, soft-tissue balance, and an adequately experienced orthopedic surgeon. To patients with osteoarthritis of the hip, it offers significant pain relief, improved quality of life and increase mobility, in both the medium and long term. Yet complications after total hip replacement can be very challenging for both the patient and the surgeon. Along with this trend, the absolute number of revision surgeries and associated complications will also surge ,. Dislocation rates of up to 28% are reported after revision and implant exchange surgeries ,. For a series of 10 500 primary total hip replacements, Woo and Morrey reported that 59% 196 hips of the dislocations occurred within the first three months after surgery and overall 77% 257 hips within the first year. The cumulative risk of dislocation within the first postoperative month is 1% und within the first year approximately 2% ,. Thereafter, the cumulative risk continuously increases by approximately 1% per 5-year period and amounts to approximately 7% after 25 years. It represents the failure of those individual hip joint mechanics which are to be established by implanting the prosthesis. Here, the aim is to achieve optimum load transfer between pelvis and femur along with normal multiaxial mobility of the joint and optimum muscular function. These biomechanical requirements can technically be met by stable prosthesis positioning, reconstruction of cup inclination and anteversion, stem antetorsion, reconstruction of the rotational center of the hip, offset, and leg length , as well as by using a muscle-sparing surgical technique. If these biomechanical requirements are not met, mechanical dysfunction may result and lead to instability of the hip arthroplasty. Pelvic radiograph after total hip arthroplasty. The latter is suggestive of inadequate tissue tension or component malpositioning. Information about when the implantation was performed helps to distinguish between early dislocation, i. Cause Consequence Malpositioning or loosening of stem or acetabular component No sufficiently stable contact between the articulating partners Contact between neck of the prosthesis and articular component subject to joint position Primary impingement; the femoral head is levered out of the cup Contact between bony femur and bony pelvis Secondary impingement; the femoral head is levered out of the cup. Possibility of an abnormally increased translational mobility of the femur. In this case, prosthesis infection led to loosening of the acetabular component and secondary dislocation Depending on the mechanical cause, 3 dislocation directions can be observed, even though dislocation direction and component positioning are not necessarily related : Directions of dislocation after total hip arthroplasty. The latter allows for causal risk evaluation where risks can be attributed to the patient, the surgeon or the implant. At the same time, preventive and therapeutic approaches are based on the knowledge and consideration of specific risk factors. Patient-related factors One of the key factors contributing to joint stability is the muscular and capsular guidance for the replaced hip joint. For the population of patients older than 80 years of age, an increased risk of dislocation has been described and attributed to sarcopenia, loss of proprioception and the increased risk for falls. Likewise, non-compliance is more prevalent in these patient populations, as dislocation-promoting hip movements, such as deep flexion or internal rotation of the flexed hip joint, are not strictly avoided. Consequently, dislocation may result even in the absence of procedure-specific mistakes. In contrast, high-impact factors contributing to the dislocation risk include anatomical variations of the hip, often occurring along with congenital hip dysplasia or metabolic bone disorders, rapidly progressive and inflammatory arthropathies, as well as necrosis of the femoral head. Prior fractures or surgical procedures involving the hip significantly increase the risk of dislocation. Dislocation rates of up to 50% after prior femoral neck fractures have been reported in the literature. Revision total hip replacements after previous dislocation, periprosthetic fractures, and septic or aseptic loosening are associated with dislocation rates of up to 28% due to at times significant soft-tissue trauma, extensive scarring, heterotopic ossification, and acetabular or femoral bone loss. During the preoperative risk assessment, the surgeon should pay particular attention to patient-specific risk factors and highlight these during the informed consent discussion. Numerous studies have shown that the posterior approach to the hip, involving detachment of the external rotators and the posterior joint capsule, is associated with a higher dislocation risk compared with the lateral, anterolateral or anterior approaches. A meta-analysis including more than 13 000 primary total hip arthroplasties with a follow-up period of at least 12 months calculated a dislocation rate of 3. However, the dislocation rates for the posterior approach can be significantly reduced to rates as low as 0. In contrast, the lateral transgluteal approach to the hip joint is associated with an increased risk of functional weakening of the abductor muscles resulting from partial detachment of the gluteus medius muscle or fracture of the greater trochanter. The alignment of the implants during hip replacement surgery is of special importance for the stability of the artificial joint. Even though both acetabular and femoral cup positioning is guided by individual anatomic requirements, the dislocation-stable cup position with an inclination of 40±10° and an anteversion of 10 to 20°as published by Lewinnek is internationally considered desirable. It was found that when surgeons estimated intraoperatively an acetabular component anteversion between 10° and 30°, only 45% of components actually were within this target range. Implant-related factors A wide range of acetabular and femoral components as well as sliding pairings are available for primary and revision arthroplasties. The service life of these components and the abrasion of various sliding pairings are the main factors influencing late dislocation by material wear. In addition, implant design may contribute to instability, especially when the use of over-hemispheric acetabular and inlay components or extended prosthetic heads—intended to increase the stability of the prosthesis—cause primary impingement, i. Extended prosthetic heads are used to improve the soft-tissue tension of a total hip arthroplasty and thereby its stability. They feature a shoulder arrow in the area of head-neck junction which can — subject to the position of the acetabular component cup and the extent of motion — cause the shoulder to collide with the rim of the cup, thereby promoting the levering of the prosthetic head out of the cup eFigure: Directions of dislocation after total hip arthroplasty. The head-to-neck ratio is of special importance for the stability of the prosthesis and the impingement-free range of motion. Thus, a larger head diameter offers better protection against dislocation ,. These advantages are contrasted by the following disadvantages: inlay thickness has to decrease with increasing head diameters; increased abrasion along the head-neck plug connection; the stabilizing effect is lost in case of abductor insufficiency ; and the increased range of motion promotes secondary impingement with resulting contact between proximal femur and pelvic bone. For these reasons, femoral heads with diameters of more than 36 mm are not normally used. Management of unstable hip arthroplasties The treatment algorithm for hip prosthesis instability has not yet been comprehensively standardized and randomized controlled studies comparing the outcomes of non-surgical and surgical management are not available in the literature. Thus, immediate admission to a hospital, preferable where arthroplasties are performed, is crucial. On physical examination, the affected leg is shortened and shows malrotation. When taking and documenting the history, the patient should be asked about any adequate trauma or the sequence of motions that led to the dislocation. In addition, it should be explored whether the event represents a first or recurrent dislocation and how long ago the primary arthroplasty was performed. Ideally, the patient has a so-called prosthesis pass which identifies the components of the prosthesis. Initial radiography should include an anterior-posterior view of the pelvis and, where possible, a second plane to rule out implant loosening or periprosthetic fracture. In case of concomitant compression of blood vessels and nerves, immediate reduction is essential. Subsequently, the sufficiency of the pelvis-trochanter soft tissues and the dislocation mechanism are evaluated under dynamic fluoroscopy. A femoral head with distractibility of more than 1 cm is indicative of pelvis-trochanter insufficiency. Where movement stability is achieved after reduction, conservative treatment with occupational therapy and physiotherapy can be initiated, initially on an in-patient basis. The efficacy of commercially available orthoses, primarily limiting flexion and adduction, has not yet been supported by scientific evidence. Nevertheless, these devices offer both the patient and the doctor a certain degree of security; therefore their use can be openly discussed with the patient. Patients in whom dynamic fluoroscopy reveals instability should undergo revision surgery. Whether definite revision surgery is attempted in the acute dislocation situation or a two-stage approach is favored will depend on the structure of the hospital. In patients with soft tissue insufficiency, soft tissue tension can be increased without extending the leg by increasing the offset, the distance between the femoral stem and the hip joint rotation center. In addition, techniques, such as capsule suture, fascial tightening and the use of attachment tubes, as well as a combination of these techniques are available. The head-neck ratio should always be optimized. In patients with recurrent dislocations, the option of surgical revision should generally be considered. In case of component malpositioning, it is necessary to perform a component exchange. In patients with muscular or coordination deficits, tripolar head systems may be used which allow movement of a mobile polyethylene cup both in the bone-anchored socket and along the head of the prosthesis. This design enables recentering of the joint with shifting of the inlay in the acetabular component when the neck of the prosthesis gets in contact with the polyethylene inlay ,. The French literature reports about the successful use of tripolar cup systems as primary treatment in patients with increased dislocation risk; however, because of the lack of adequate data from abrasion behavior studies and the possibility of intraprosthetic dislocation disconnection of head and inlay , this method has not been generally adopted. In hip revision surgery, this implant has the disadvantage that it offers limited modularity and does not allow screw augmentation for cup anchoring. Due to their high failure rates, constrained inlays or snap-in cups with circular, over-hemispheric enclosure of the head are rarely used. Conclusion Dislocation following total hip replacement can be extremely traumatizing for patients. Thus, dislocation prophylaxis is essential. Apart from preoperative risk assessment, this includes proper surgical technique with optimized alignment of the components, soft-tissue balancing and head-neck ratio, as well as adequate surgical experience. Treatment of instability after total hip replacement should follow a standardized algorithm.

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Background Various types of electrical stimulation have been examined for soft tissue injuries and wound healing. Diapulse has been used in the management of chronic wounds, soft tissues injuries, and other indications including migraine, tinnitus, acute head injuries, and pelvic inflammatory disease. Although there are case studies Duma-Drzewinska and Buczynski, 1978; Itoh et al, 1991; Comorosan et al, 1993; Tung et al, 1995 as well as small randomized controlled trials Goldin et a. Another electromagnetic device for the treatment of refractory wounds and soft tissue injuries is SofPulse. However, there is a lack of published data on its effectiveness for these indications. Goldin et al 1981 focused on donor site skin graft healing reported positive results, but it is unclear how the positive outcome 90 % healing was selected, and whether the results were statistically different at other degrees of healing. The statistical analysis involved adding the scores together from 3 different scales. The validity of this type of analysis is very questionable. Furthermore, healing of donor skin graft sites is perhaps physiologically different than the more common situation of pressure ulcer healing, and it is not clear if the results can be extrapolated from one clinical situation to another. Subjects were given non-thermal pulsed high-frequency electromagnetic energy treatment for 30 mins twice-daily for 12 weeks or until healed. The percentage of pressure ulcers healed was measured at 1 week. After controlling for the baseline status of the pressure ulcer, active treatment was independently associated with a significantly shorter median time to complete healing of the ulcer. Diapulse has also been used for the treatment of acute post-operative pain and edema. This application is more difficult to evaluate due to the lack of objective outcome measures. However, randomized controlled trials are still considered critical. Both Wilson 1974 and Barclay 1983 reported positive results in randomized trials looking at ankle and hand injuries, respectively, but the statistical analysis was seriously flawed compromising any evaluation of the results. Pennington et al 1993 reported the use of Diapulse to reduce swelling in association with ankle sprains in an effort to reduce lost training days in the military. Although this randomized trial showed a 4. For example, it is not known if the use of Diapulse actually reduced the morbidity of ankle sprains in terms of lost training days. In addition, the specific statistical test used to evaluate the results is not given. Bentall and Eckstein 1975 studied the use of Diapulse to reduce post-operative ecchymoses and edema in patients undergoing orchidopexy. This randomized double blind study showed a significant improvement in scrotal wound color changes at 6 and 8 days post surgery. The clinical significance of these findings is unknown. Finally, there have been 2 studies on the use of Diapulse after oral surgery Aronofsky, 1971; Rhodes, 1981. However, both represented case series studies, so the true contribution of Diapulse cannot be determined. However the possibility of a beneficial or harmful effect cannot be ruled out due to the fact there were only two trials with methodological limitations and small numbers of patients. Chronic ulcers are defined as those that have not healed despite 30 days of treatment with standard wound therapy. However, this improvement appears to be small and may not be clinically useful. Furthermore, in a systematic review on wound care management, Cullum et al. Flemming and Cullum 2001 also concluded that there is currently no reliable evidence of benefit of electromagnetic therapy in the healing of venous leg ulcers. In a systematic review on treatment of pressure ulcers, Reddy and colleagues 2008 concluded that there is little evidence to support routine nutritional supplementation or adjunctive therapies including electromagnetic therapy compared with standard care. A total of 12 patients male:female, 9:3 having neurological disorders, with age between 12 to 50 years and 24 pressure ulcers were enrolled in this study. Whole body exposure was given in both the groups. In a Cochrane review, Hulme et al 2002 examined the effectiveness of pulsed electric stimulation in treating patients with osteoarthritis pulsed electric stimulation has been demonstrated to stimulate cartilage growth on the cellular level. These investigators concluded that current evidence suggests that electrical stimulation therapy may provide significant improvements for knee osteoarthritis, but further studies are needed to confirm whether the statistically significant findings shown in these studies result in important health benefits. An example of pulsed electromagnetic field therapy is the OrthoCor Active Knee System. This treatment must be performed by a healthcare professional in an office or clinic setting. During the treatment, the patients lay on the mat for 30 mins per session, twice a day for 3 weeks. The authors stated that they can not make any definite statements on the efficacy and clinical usefulness of electrotherapy modalities for neck pain. McCarthy and colleagues 2006 noted that the rehabilitation of knee osteoarthritis often includes electrotherapeutic modalities as well as advice and exercise. Its equivocal benefit over placebo treatment has been previously suggested. However, recently a number of randomized controlled studies have been published that have allowed a systematic review to be conducted. A total of 55 patients were included. At the end of treatment, there was statistically significant improvement in pain scores in both groups p 0. These investigators observed statistically significant improvement in some of the subgroups of Lequesne index e. The cases were randomly separated into two groups. All cases received a treatment program for 3 weeks consisting of Codman's pendulum exercises and subsequent cold pack gel application on shoulders with pain 5 times a day, restriction of daily activities that require the hands to be used over the head, and meloxicam tablet 15 mg daily. Daily living activities were evaluated by shoulder disability questionnaire. Results were assessed before and after treatment. When compared with the baseline values, significant improvements in all these variables were observed at the end of the treatment in both groups p 0. Allograft bone and an anterior cervical plate were used in all cases. Two orthopedic surgeons not otherwise affiliated with the study and blinded to treatment group evaluated the radiographs, as did a blinded radiologist. Adverse events were reported by all patients throughout the study to determine device safety. Post-operative care was otherwise identical. Follow-up was carried out at 1, 2, 3, 6, and 12 months post-operatively. Both groups were also comparable in terms of baseline diagnosis herniated disc, spondylosis, or both and number of levels operated 1, 2, 3, or 4. At 12 months after surgery, the stimulated group had a fusion rate of 92. No significant differences were found in the incidence of adverse events in the groups. All identified papers were read by title, abstract and full-length article when relevant. Hand search of the articles' sources identified additional papers. For included studies, the level of evidence was determined. No studies conclusively showed an effective intervention. Five studies on weight-bearing early post-injury are conflicting, but standing or walking may help retain bone mineral. In the chronic phase, there was no effect of weight-bearing 12 studies. Improvements correspond to trabecular bone in the distal femur or proximal tibia. Impact vibration and pulsed electromagnetic fields may have some positive effects, whereas pulsed ultrasound does not. Six studies on the influence of spasticity show inconsistent results. If bone mineral is to remain, the stimulation has to be possibly continued for long-term. Nerve conduction testing was performed serially. Pieber et al 2010 reviewed different types of electrotherapy for the treatment of painful diabetic peripheral neuropathy. Articles in English and German were selected. The efficacy of different types of electrotherapy for painful diabetic peripheral neuropathy has been evaluated in 15 studies; the effects of transcutaneous electrical nerve stimulation are consistent. The beneficial effects of prolonged use have been reported in 3 large studies and 1 small study. The effects of frequency-modulated electromagnetic neural stimulation were assessed in 1 large study, and a significant reduction in pain was reported. Treatment with pulsed and static electromagnetic fields has been investigated in 2 small and 3 large studies, and analgesic benefits have been reported. Only small studies were found concerning other types of electrotherapy, such as pulsed-dose electrical stimulation, high-frequency external muscle stimulation or high-tone external muscle stimulation. The conclusions drawn in these articles were diverse. Shortcomings and problems, including a poor study design, were observed in some. The authors concluded that further randomized, double-blind, placebo-controlled studies comprising larger sample sizes, a longer duration of treatment, and longer follow-up assessments are needed. Participants were instructed to wear the device for 10 hours daily for 12 weeks. The primary outcome was the proportion of participants requiring a secondary surgical intervention because of delayed union or nonunion within 12 months after the injury. Secondary outcomes included surgical intervention for any reason, radiographic union at 6 months, and the Short Form-36 Physical Component Summary and Lower Extremity Functional Scales at 12 months. Main analyses were by intention-to-treat. A total of 218 participants 84 % completed the 12-month follow-up; 106 patients were allocated to the active device group, and 112 were allocated to the placebo group. Compliance was moderate, with 6. Overall, 16 patients in the active group and 15 in the inactive group experienced a primary outcome event risk ratio, 1. According to per-protocol analysis, there were 6 primary events 12. No between-group differences were found with regard to surgical intervention for any reason, radiographic union, or functional measures. A total of 12 patients with mandibular fractures were selected for the present study. The effectiveness of the 2 treatment modalities was evaluated clinically and radiographically using computerized densitometry. The data were statistically analyzed. An insignificant difference was found between the mean bone density values of the 2 groups at all study intervals. In contrast, the percentage of changes in bone density of the 2 groups revealed that group A had insignificant decreases at the 15th post-operative day and a significant increase 30 days post-operatively compared with group B. In a Cochrane review, Griffin et al 2011 evaluated the effects of electromagnetic stimulation for treating delayed union or non-union of long bone fractures in adults. Randomized controlled trials evaluating electromagnetic field stimulation for the treatment of delayed union or non-union of long bones in adults were selected. Two authors independently selected studies and performed data extraction and risk of bias assessment. Treatment effects were assessed using risk ratios and, where appropriate, data were pooled using a random-effects model. Participants with delayed union and non-union of the long bones were included, but most data related to non-union of the tibia. Although all studies were blinded randomized placebo-controlled trials, each study had limitations. The primary measure of the clinical effectiveness of electromagnetic field stimulation was the proportion of participants whose fractures had united at a fixed time point. The overall pooled effect size was small and not statistically significant risk ratio 1. A sensitivity analysis conducted to determine the effect of multiple follow-up time-points on the heterogeneity among the studies showed that the effect size remained non-significant at 24 weeks risk ratio 1. There was no reduction in pain found in 2 trials. No study reported functional outcome measures. One trial reported 2 minor complications resulting from treatment. The authors concluded that although the available evidence suggests that electromagnetic field stimulation may offer some benefit in the treatment of delayed union and non-union of long bone fractures, it is inconclusive and insufficient to inform current practice. Schmidt-Rohlfing et al 2011 performed a systematic review and meta-analysis on the potential effects of electromagnetic fields and high-frequency electric fields on bony healing. Randomized clinical trials were identified and analyzed. Out of the 14 studies, 9 were suitable for the meta-analysis that revealed a cumulative odds ratio of 3. When performing a subgroup analysis a statistically significant result could not be confirmed by the studies with a higher methodological quality. In view of the heterogeneous physical parameters with different frequencies, time course, flux densities and in view of the methodological deficits, a general conclusion seems difficult. The clinical and radiological outcomes were assessed at 4, 6, 9, 12, 24 and 52 weeks. A log-rank analysis showed that neither time to clinical and radiological union nor the functional outcome differed significantly between the groups. A total of 28 patients 19 males and 9 females, aged 49. Treatment failure was defined as patients undergoing knee arthroplasty. Pain significantly reduced at 6 months from 73. Knee society score significantly increased in first 6 months from 34. There were a total of 4 failures 14. These preliminary findings need to be validated by well-designed studies. The relevant studies were identified by searching 8 electronic databases and hand-searches of the past systematic reviews on the same topic till April 5, 2012. Two reviewers independently selected studies, extracted relevant data and assessed quality. The strength of the body of evidence was low for physical function and very low for pain. They also manually reviewed sources to identify additional relevant studies. A total of 14 trials were analyzed, comprising 482 patients in the treatment group and 448 patients in the placebo group. Female fibromyalgia patients aged 22 to 50 years were randomly assigned to either a stimulation group or a sham group. Pressure pain thresholds before and after stimulation were determined using an algometer during the 8 consecutive weekly sessions of the trial. In addition, blood serotonin levels were measured and patients completed questionnaires to monitor symptom evolution. While improvement in pain thresholds was apparent after the 1st stimulation session, improvement in the other 3 measures occurred after the 6th week. No significant between-group differences were observed in scores of depression, fatigue, severity of headaches or serotonin levels. No adverse side effects were reported in any of the patients. The authors concluded that very low-intensity magnetic stimulation may represent a safe and effective treatment for chronic pain and other symptoms associated with fibromyalgia. This was a small study treatment group had only 28 subjects0 with a short follow-up 6 weeks ; its findings need to be validated by well-designed studies. Manual searching in the relevant journals and screening of the reference lists of identified studies and reviews were carried out. Abstracts published in proceedings of conferences were also scrutinized. A meta-analysis was not possible due to methodological, clinical and statistical heterogeneity of included studies. Two reviewers independently extracted data and assessed the methodological quality. A best-evidence synthesis was used to summarize the results. Moderate evidence was found for the effectiveness of ultrasound versus placebo on mid-term follow-up. Ultrasound plus friction massage showed moderate evidence of effectiveness versus laser therapy on short-term follow-up. On the contrary, moderate evidence was found in favor of laser therapy over plyometric exercises on short-term follow-up. However, few studies have reported the effects of this technique on the osseo-integration of endosseous implants, especially with regard to different implant topographies. Pulsed electromagnetic field stimulation oriented the osteoblasts perpendicular to the electromagnetic field lines and increased the number of microfilaments and pseudopodia formed by the osteoblasts. Electromagnetic therapy has been extensively used in the clinical setting in the form of transcranial magnetic stimulation, repetitive transcranial magnetic stimulation, high-frequency transcranial magnetic stimulation and pulsed electromagnetic field therapy that can also be used in the domestic setting. Mechanical stimulation may play a role in regulation of inflammation. Treatment of Cancer Vadala and colleagues 2016 noted that cancer is one of the most common causes of death worldwide. Available treatments are associated with numerous side effects and only a low percentage of patients achieve complete remission. Thus, there is a strong need for new therapeutic strategies. Treatment of Osteoporosis Krpan and Kullich 2017 noted that despite various pharmacotherapies, the problem of osteoporosis is not yet solved nor decreased. This study presented case reports based on the follow-up of the.

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At the time it was built, this was one of the world's largest privately funded rail construction schemes. The system is based primarily on Japan's. Most intermediate stations on the line lie outside the cities served; however, a variety of transfer options, such as free shuttle buses, conventional rail, and metros have been constructed to facilitate transport connections. Ridership initially fell short of forecasts, but grew from fewer than 40,000 passengers per day in the first few months of operation to over 129,000 passengers per day in June 2013. Daily passenger traffic reached 130,000 in 2014, well below the forecast of 240,000 daily passengers for 2008. The system carried its first 100 million passengers by August 2010 and over 200 million passengers had taken the system by December 2012, followed by 400 million by December 2016. The government also extended the rail concession from 35 years to 70 years and terminated the company's build-operate-transfer business model. The idea of a new high-speed rail line arose in the 1970s, and informal planning began in 1980. In 1987 the executive branch of Taiwan's government, the , instructed the to launch a feasibility study for a high-speed rail line in the western Taiwan corridor, which was completed in 1990. The study found that in a comparison of potential solutions to traffic problems in the corridor, a high-speed rail line would offer the highest transit volume, lowest land use, highest energy savings, and least pollution. However, controversy arose during rolling-stock selection. Four additional stations were added in 2014 and 2015. On 10 September 2019, the announced that the railway would be expanded to. Although lowest in cost, the option was met with criticism regarding its economic benefits. On 25 October 2019, the Railway Bureau published an assessment report to extend the line from Taipei to , cutting travel time to 13 minutes. This marked the first time Shinkansen technology was exported to a foreign country. Customization was focused on adapting to Taiwan's climate and geography, and the nose shape was optimized for tunnels wider than those in Japan. The 12 cars of a 700T train are grouped in three traction units with three power cars and one trailer each, providing 10. The train is 304 m 997 ft long and has a mass of 503 554 when empty. The trains have a passenger capacity of 989 seats in two classes: 66 seats in 2+2 configuration in the single Business Car and 923 seats in 2+3 configuration in the eleven Standard Cars. The per capita energy consumption of a fully loaded 700T train is 16% of that of private cars and half that of buses; emissions are 11% of private cars and a quarter that of buses. All driver candidates must spend 8 months completing 1,326 hours of professional training and pass the National Certification before they can drive the train. In addition, after becoming a certified high-speed train driver, they undergo further on-the-job training at least three times each year in order to guarantee they can drive the train safely. This system consists of a network of sensors installed along the rail route to detect unexpected situations such as earthquakes, strong winds, heavy rainfall, floods, landslides, and intrusions. One operating train was slightly derailed in , and six trains were stopped on the track. In spite of the temporary suspension of operations, there was no damage or casualties. All 2,500 affected passengers were evacuated in two hours without injury. Such a record was well noted, and provided valuable experience in operational safety to the global railway industry. In April 2010, it was reported that had been observed during construction on a 6 km 3. The subsidence continued, reaching up to 55 cm 22 in over seven years. By 2010 subsidence had slowed, which was ascribed to the closure of some deep wells operating in the region. On 25 July 2011, the government announced plans to close almost 1,000 wells in and counties, reducing the amount of water pumped from deep wells by 210,000,000 tonnes 2. Most southbound trains originate from and most northbound trains originate from ; however, a few trains operate just between Nangang and or between Taichung and Zuoying. Southbound trains are designated by odd train numbers, and northbound trains by even train numbers. Each train consists of 1 business car car 6 and 11 standard cars including reserved seats and non-reserved seats. Since July 2010, non-reserved seats are available in cars 10 through 12 some trains available in cars 9 through 12. Car 7 of each train is fitted with 4 wheelchair accessible chairs and a disabled-friendly restroom. Business and standard car reserved ticket reservations are available 28 days prior to the date of departure including the departure day. A group discount is offered for groups of 11 or more. A group discount cannot be used in combination with other discount offers and does not include non-reserved seats. Passengers eligible for multiple discounts can only choose one discount offer. Since 1 July 2010, a system has provided frequent travelers with multi-ride eight trips or periodic tickets. Only adult tickets are available in this format, and cannot be used for rides between Banqiao and Taipei. After purchasing or adding value to a multi-ride card, the card balance is valid for 45 days counted from the day of first use. The ticket is good for 8 rides. The multi-ride card provides a discount of about 21% off the full fare of a reserved Standard Seat. Since November 2012, an Early Bird discount of 35% has been offered for a limited number of tickets sold no later than 8 days before the departure date. If the 35% off tickets sell out before the deadline, tickets with a discount of 20% off are offered. If these tickets sell out before the deadline, tickets with a discount of 10% off are offered. If all early bird tickets are sold out, then full fare tickets are offered. In view of a 50% drop in airline passengers in the wake of the , forecasts were revised downwards. The final initial ridership estimate was 140,000 passengers per day. Actual initial ridership did not match these projections. In the second year, passenger numbers almost doubled. In the third year, average daily ridership continued to grow to 88,000 passengers per day, jumping to over 120,000 passengers per day in 2012. The 10-millionth passenger was carried after 265 days of operation on 26 September 2007, while the 100-millionth passenger was carried after 1,307 days on 3 August 2010, and 200-millionth by December 2012. The next single-day record was reached on 25 January 2012, also the third day of Chinese New Year's celebration, at 191,989 passengers. The most recent record is 212,000 passengers transported on 1 January 2013. Total domestic air traffic was expected to be halved from 2006 to 2008, and actually fell from 8. In June 2012, officials announced the discontinuation of the last remaining commercial flight between Taipei and Kaohsiung. The share for conventional rail between Taipei and Kaohsiung fell from 9. Construction of the system took more than 2,000 professional engineers from 20 countries and over 20,000 foreign and domestic workers six years to complete. Construction work was broken into several specialized lots that were contracted separately. One group of contracts was for civil works, covering the construction of the superstructure of open line sections. Stations and depots were the subject of separate groups of construction lots. A fourth group of lots was for track work. Track laying began in July 2003. The signalling and train control system was laid out for bi-directional operation according to European specifications. Each track section has a checkpoint, and an automatic control system ensures that trains are spaced at least 1 km 0. After four months of delays, trial runs using the first trains began on 27 January 2005, on the Tainan—Kaohsiung section. The section between Taipei and Kaohsiung opened to the public on 5 January 2007. About 251 km 156 mi or 73% of the line runs on , mostly spans, the first of which was put in place in October 2001. It was the second in the world as of 2017. Viaducts were designed to be to allow for trains to stop safely during a seismic event and for repairable damage following a maximum design earthquake. Bridges built over known were designed to survive fault movements without catastrophic damage. About 61 km 38 mi or 18% of the line is in tunnels, including 14 km 8. Forty-two of the tunnels included a total of 39,050 m 24. The finished interior cross-sectional area of 90 m 2 970 sq ft , set according to wider European standards, provides space for two tracks with safety walkways. The pheasant-tailed Jacana population in Tainan, Taiwan, which at one point numbered less than 50, has increased to over 300. The temple established beside the old tree is the belief center of the people there. Advertising spots on trains and station platforms have also been sold. Revenues grew along with ridership over the first three years, but ridership remained below expectations. Revenues first exceeded this level, thus generating a positive , in the fourth month of operation April 2007. As a result, the balance of operating revenues and costs showed a high loss in the first year of operation, which was only reduced as revenues grew in the second year. In 2011, the Company continued to pursue sustainable growth aligned with the interests of shareholders and society, achieving record profits even amid a challenging economic environment. The interest cost is another major item of this company's financing. In the first few years of operation, interest rates were well above market rates. Interest rates fell in the first half of 2009, reducing interest expenses and contributing to a reduced. In comparison with the terms and conditions of previous loans, the newly signed refinancing debts carried lower interest rates and longer tenors up to 22 years. The Company's financial burden is therefore largely reduced. The company was put under new management in September 2009 with the aim of turning around the company's finances with government help in arranging refinancing of the loans. The government took majority control of the company after the election of its new board on 10 November 2009. The government also approved the company's new variable depreciation charge. The train was stopped at and all of the passengers were evacuated. Later, it was determined the luggage contained an unidentified liquid in cans, alarm clock and white particulate matter. The items were dismantled by the bomb squad and taken for further investigation. Two legislators, and , were on board. The traffic control center decided to evacuate passengers after the train stopped at Taoyuan station at 9:45 am. More than 600 people were asked to disembark and continue their journey on another train. Two bomber suspects were arrested in a hotel in Zhongshan City, Guangdong Province, China on 15 April and repatriated to Taiwan on 17 April 2013. Part of the tracks near were badly damaged during the on 6 February 2016. All high-speed rail services south of were suspended until 7 February 2016. On 10 May 2017, a non-passenger carrying train headed the opposite direction of the track from Zuoying to Tainan for 1 km due to human negligence. The switch to reserved seats only aims to reduce crowding. On public display was an enormous 2 meter tall by 3 meter wide calligraphy sculpture created by Ms. Dong using naturally weathered wood from Taiwan. This is the first calligraphy sculpture in Taiwan that allows the spirit of calligraphy and the connotation of words to transcend the constraints of the writing brush, and its cultural and artistic significance enriched Taichung Station as well as the journeys of passengers transiting through the station. The performances were well received by passengers, with fans even forming groups to catch a glimpse of the musicians at various stations. It also continues to actively conduct experience sharing with its fellow railway transportation operators to enhance the quality of public transportation and create better planning, design and service. In of the internationally aired reality television game show , which was watched by 11. International Journal of Business and Management. Canadian Center of Science and Education. The Taiwan-Japan Workshop on the Earthquake Early Warning System abstract. Taiwan High Speed Rail Corporation. Ministry of Transportation and Communications stat. Proceedings of the 13th World Conference on Earthquake Engineering.

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