【正文】 s (less than 60 years of age) internal fixation 2. Older patients70 years of age or olderarthroplasty depending on activity level, overall health, bone stock 3. 6170 years of agegray area, decision should be made based upon ability to obtain reduction, bone quality, general health, activity level and occupation.,第七頁，共六十三頁。,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,第五頁，共六十三頁。,Hip Arthroplasty: I. Introduction A. Demographics ◆More 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 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 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. C.Treatment 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、生物反應(yīng)、以及確認(rèn)臨床發(fā)展的方向。ngy242。ngy242。 ◆ 提出對疑難的髖關(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 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.,第一頁，共六十三頁。,◆ 使會議參加者對當(dāng)前髖關(guān)節(jié)、膝關(guān)節(jié)及肩關(guān)節(jié)的成形進行討論，包括設(shè)計概念、材料發(fā)展和臨床效果。 ◆ 評價當(dāng)前的固定方法在原發(fā)和翻修操作步驟的應(yīng)用(y236。ng)，包括骨水泥壓迫嵌入、壓迫移植應(yīng)用(y236。ng)。,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, 2002),第六頁，共六十三頁。,V. Arthroplasty Options For Treatment of Displaced Femoral Neck Fractures A. Treatment Options 1. Decisions regarding