关节置换的新概念

CURRENT CONCEPTS IN JOINT REPLACEMENT TM SPRING 2004 The 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 shoulder management problems as well as surgical techniques which assist their solution. ◆ To uate the use of current fixation s in primary and revision procedures including cement, hydroxyapatite, porous coated, press fit and impaction grafting applications. ◆ To address current concerns regarding implant material limitations and biologic response as well as identify clinical intervention strategies. ◆ 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、以及确认临床发展的方向。 Hip Arthroplasty: I. 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 treatment 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 fixation. ◆However, treatment of patients older than 60 years of age is controversial. C.Treatment Options ◆Internal fixation ◆Arthroplasty II. Questions 1. Which patients with displaced femoral neck fractures should be treated with internal fixation? ◆Factors that should be considered include age, fracture 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 ination to support these decisions? III. Internal Fixation versus Prosthetic Replacement A. Clinical 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 ability of these trials to provide definitive guidance for the orthopaedic surgeon 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 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 ◆ Conclusio