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 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 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. IntroductionA. DemographicsMore 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.IssuesOptimal 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 OptionsInternal fixationArthroplasty,II. Questions1. 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 health2. 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?,III. Internal Fixation versus Prosthetic Replacement A. Clinical Data1.Observational StudiesValue limited by retrospective design, potential selection bias2.Randomized trialsBias decreased by randomizationHowever, randomized trials assessed a variety of different arthroplasty options which may not be clinically relevant todaySmall 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 treatments2. Primary Arthroplasty Versus Early Salvage After Failed Internal Fixation Conclusions: Patients undergoing internal fixation 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),IV. Treatment RecommendationsA. Internal Fixation Versus Arthroplasty1. Young and healthy patients (less than 60 years of age) internal fixation2. Older patients-70 years of age or older-arthroplasty depending on activity level, overall health, bone stock3. 61-70 years of age-gray area, decision should be made based upon ability to obtain reduction, bone quality, general health, activity level and occupation.,V. Arthroplasty Options For Treatment of Displaced Femoral Neck Fractures A. Treatment Options1. Decisions regarding treatment should be based on age, activity level quality of bone stock and overall health of the patient.2. Patients residing in nursing homes that are not community ambulators are probablybest treated with a unipolar arthroplasty as long as the hip joint is fairly well preserved B. Unipolar Versus Bipolar1. Assessed in a number of randomized trials and retrospective reviews. Studies do not find a difference in overall outcomes or complication rates between unipolar and bipolar arthroplasty The extra cost may not warrant the use of bipolar endoprosthesis in elderly patients.,C. Cemented Versus Uncemented Arthroplasties 1. Assessed in a number of randomized studies but these studies were small and they are of variable 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-Indications 1. 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.,髋关节成形术 I髋关节成形术 A人口统计学 1220000多例髋关节骨折发生于北美（每年） 2费用，每年消耗900亿美元的保健费。 3异源病人人口，有的病人是社区积极的活动者，有不少则是养老院的居住人员。 B焦点 1乐观治疗股骨颈移位仍有争论 2一般的共识是不论病人的年龄，只要是非移位或外翻型骨折可采用内固定治疗 3一般的共识为60岁或不到60岁的健康病人可作为内固定的候选人。 4于60岁以上的病人能否治疗尚有争论。 C治疗方式 1内固定 2关节置换术,