1、CURRENT CONCEPTS IN JOINT REPLACEMENT TM SPRING 2004The course objectives are:To facilitate faculty/participant discussion on contemporary hip,knee and shoulder arthroplasty use inclusive of design concepts,material advances and clinical results.To present solutions to difficult hip,knee and shoulde
2、r management problems as well as surgical techniques which assist their solution.To evaluate the use of current fixation methods in primary and revision procedures including cement,hydroxyapatite,porous coated,press fit and impaction grafting applications.To address current concerns regarding implan
3、t material limitations and biologic response as well as identify clinical intervention strategies.,第一页，共六十三页。,使会议参加者对当前髋关节、膝关节及肩关节的成形进行讨论，包括设计概念、材料发展和临床效果。提出对疑难的髋关节，膝关节肩关节如何解决的问题，以及相关的外科技术。评价当前的固定方法在原发和翻修操作步骤的应用，包括骨水泥压迫嵌入、压迫移植应用。发表当前一些新概念，如材料的研制、生物反应(fnyng)、以及确认临床发展的方向。,第二页，共六十三页。,Hip Arthroplasty:I
4、.Introduction A.Demographics More than 220,000 fractures of the hip occur each year in North America.Cost-greater than 9 billion dollar health care costs per year.eterogeneous patient population-some patients are active community ambulators but many are nursing home residents.B.Issues Optimal treatm
5、ent of displaced femoral neck fractures remains controversial.General agreement that patients regardless of age with non-displaced or valgus impacted fractures(stable)will be treated with internal fixation.General agreement that healthy patients 60 years or younger are good candidates for internal f
6、ixation.However,treatment of patients older than 60 years of age is controversial.C.Treatment Options Internal fixation Arthroplasty,第三页，共六十三页。,II.Questions 1.Which patients with displaced femoral neck fractures should be treated with internal fixation?Factors that should be considered include age,f
7、racture type,activity level and overall health 2.Should patients being treated with an arthroplasty procedure receive a unipolar,bipolar or total hip arthroplasty?3.Is there evidence based information to support these decisions?,第四页，共六十三页。,III.Internal Fixation versus Prosthetic ReplacementA.Clinica
8、l Data 1.Observational Studies Value limited by retrospective design,potential selection bias 2.Randomized trials Bias decreased by randomization However,randomized trials assessed a variety of different arthroplasty options which may not be clinically relevant today Small sample size:limit the abil
9、ity of these trials to provide definitive guidance for the orthopaedic surgeon,第五页，共六十三页。,B.Meta Analyses(Cochrane database,Bhandari et al)1.Summary Results of Meta-Analyses Arthroplasty reduces the risk of revision surgery.Internal fixation-decreased blood loss,operative time,blood transfusion and
10、risk of deep wound infection.Unfortunately,no definitive differences were noted with respect to mortality,degree of residual pain,or functional levels between the two treatments 2.Primary Arthroplasty Versus Early Salvage After Failed Internal Fixation Conclusions:Patients undergoing internal fixati
11、on for a displaced femoral neck fracture need to be informed that if this treatment fails and that if a cemented hip is subsequently performed,the results may not be as good as a primary hip arthroplasty.(McKinley and Robinson,JBJS,2002),第六页，共六十三页。,IV.Treatment RecommendationsA.Internal Fixation Ver
12、sus Arthroplasty 1.Young and healthy patients(less than 60 years of age)internal fixation 2.Older patients-70 years of age or older-arthroplasty depending on activity level,overall health,bone stock 3.61-70 years of age-gray area,decision should be made based upon ability to obtain reduction,bone qu
13、ality,general health,activity level and occupation.,第七页，共六十三页。,V.Arthroplasty Options For Treatment of Displaced Femoral Neck FracturesA.Treatment Options 1.Decisions regarding treatment should be based on age,activity level quality of bone stock and overall health of the patient.2.Patients residing
14、 in nursing homes that are not community ambulators are probablybest treated with a unipolar arthroplasty as long as the hip joint is fairly well preservedB.Unipolar Versus Bipolar 1.Assessed in a number of randomized trials and retrospective reviews.Studies do not find a difference in overall outco
15、mes or complication rates between unipolar and bipolar arthroplasty The extra cost may not warrant the use of bipolar endoprosthesis in elderly patients.,第八页，共六十三页。,C.Cemented Versus Uncemented Arthroplasties1.Assessed in a number of randomized studies but these studies were small and they are of va
16、riable quality.2.In general,cemented prostheses tend to provide better pain relief but it is not clear if this offsets the potential disadvantage with respect to cardiopulmonary issues when using cement in elderly patients.D.Total Hip Arthroplasty-Indications1.Patients with moderate to severe degenerative changes of the hip.2.Based on the available data,it is difficult to determine if older patients with a femoral neck fracture will benefit from a THA.,第九页，共六十三页。,髋关节成形术I髋关节成形术A人口统计学1220000多例髋关节骨
