【正文】 than 220,000 fractures of the hip occur each year in North America. ◆ Costgreater than 9 billion dollar health care costs per year. ◆ eterogeneous patient populationsome patients are active munity ambulators but many are nursing home residents. ◆ Optimal treatment of displaced femoral neck fractures remains controversial. ◆ General agreement that patients regardless of age with nondisplaced 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. Options ◆ Internal fixation ◆ Arthroplasty 第三頁，共六十三頁。 發(fā)表當(dāng)前一些新概念，如材料的研制、生物反響、以及確認(rèn)臨床開展的方向。 ◆ 提出對(duì)疑難的髖關(guān)節(jié)，膝關(guān)節(jié)肩關(guān)節(jié)如何解決的問題，以及相關(guān)的外科技術(shù)。CURRENT CONCEPTS IN JOINT REPLACEMENT TM SPRING 2024 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. 第一頁，共六十三頁。 ◆ 使會(huì)議參加者對(duì)當(dāng)前髖關(guān)節(jié)、膝關(guān)節(jié)及肩關(guān)節(jié)的成形進(jìn)行討論，包括設(shè)計(jì)概念、材料開展和臨床效果。 ◆ 評(píng)價(jià)當(dāng)前的固定方法在原發(fā)和翻修操作步驟的應(yīng)用，包括骨水泥壓迫嵌入、壓迫移植應(yīng)用。 第二頁，共六十三頁。 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 information to support these decisions? 第四頁，共六十三頁。 B. Meta Analyses (Cochrane database, Bhandari et al) 1. Summary Results of MetaAnalyses ◆ Arthroplasty reduces the risk of revision surgery. ◆ Internal fixationdecreased 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 ◆ 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, 2024) 第六頁，共六十三頁。 V. Arthroplasty Options For Treatment of Displaced Femoral Neck Fractures A. 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 in nursing homes that are not munity ambulators are probablybest treated with a unipolar arthroplasty as long as the hip joint is fairly well preserved B. Unipolar Versus Bipolar 1. Assessed in a number of randomized trials and retrospective reviews. ◆ Studies do not find a difference in overall outes or plication rates between unipolar and bipolar arthroplasty ◆ The extra cost may not warrant the use of bipolar endoprosthesis in elderly patients. 第八頁，共六十三頁。 髖關(guān)節(jié)成形術(shù) I．髖關(guān)節(jié)成形術(shù) A．人口統(tǒng)計(jì)學(xué) 1． 220240多例髖關(guān)節(jié)骨折發(fā)生于北美〔每年〕 2．費(fèi)用，每年消耗 900億美元的保健費(fèi)。 B．焦點(diǎn) 1．樂觀治療股骨頸移位仍有爭論 2．一般的共識(shí)是不管病人的年齡，只要是非移位或外翻型骨折可采用內(nèi)固定治療 3．一般的共識(shí)為 60歲或不到 60歲的健康病人可作為內(nèi)固定的候選人。 C．治療方式 1．內(nèi)固定 2．關(guān)節(jié)置換術(shù) 第十頁，共六十三頁。 III．內(nèi)固定與假體置換比照 A．臨床資料 1．觀察研究 2．任意試驗(yàn) ◆ 由于任意性偏差下降 ◆ 但正因?yàn)槿我庠囼?yàn)才有不同方式的成形術(shù)，這些方式在現(xiàn)今的臨床上互不相關(guān)。 B．總結(jié)結(jié)果 ◆ 成形術(shù)減低修正手術(shù)的風(fēng)險(xiǎn) ◆ 內(nèi)固定 ——降低血喪失，手術(shù)時(shí)間，輸血和深部傷口的風(fēng)險(xiǎn) ◆ 可惜的是以上兩種手術(shù)之間沒有