CURRENT CONCEPTS IN JOINT REPLACEMENT TM SPRING 2004

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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.
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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
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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?
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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
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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 ? 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)
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IV. Treatment Recommendations A. Internal
Fixation Versus 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
quality, general health, activity level and
occupation.
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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 community 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 outcomes or
complication rates between unipolar and bipolar
arthroplasty ? The extra cost may not warrant
the use of bipolar endoprosthesis in elderly
patients.
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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.
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DVT Prophylaxis Better Living Through Chemistry
Opposes Paul A. Lotke, M. D. During the past
decade, the prevalence of symptomatic pulmonary
emboli after total joint surgery, has been
reduced to less than 1, and the rate of fatal
pulmonary emboli is only 0.1 to 0.2. This
prevalence is surprisingly similar with most
prophylactic regimens. This reduction is believed
due to early mobilization, better anesthesia and
shorter surgical times. Despite the relatively
low-incidence of fatal pulmonary emboli, the
debate continues as to the best methods to
prevent thromboembolic disease.
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Most of the current recommendations for
prophylaxis are based on the venographic evidence
of deep venous thrombosis, yet there does not
seem to be a direct correlation between the
presence of DVT and PE. A proportionate reduction
in DVT does not result in a similar reduction in
the prevalence of pulmonary emboli or fatal PE.
Therefore, DVT may not be an appropriate
surrogate marker for the patients at risk for
pulmonary emboli, and lead us to question the
recommendations based solely on DVT. While
pulmonary embolism is recognized to be a risk to
patients after total joint arthroplasty, it is
currently significantly lower than previously
thought and must be balanced against the risks of
potential bleeds from chemotherapeutic
prophylactic agents. The bleeding complications
can be increased anywhere from 2 to 5.
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Aspirin is known to inhibit platelet function
immediately and completely for the entire life
span of the platelet and has been effective in
reducing thrombi for a variety of clinical
problems. It appears to protect patients from PE
with minimal added risks. Our evaluation of 2.850
consecutive primary total knees has shown a fatal
pulmonary embolism rate of 0.1 in patients using
aspirin, 325mg twice a day for 6 weeks. This
compares favorably to other regimens. Balancing
our results with aspirin, along with early
mobilization, more rapid surgery, better
anesthesia and reduced bleeding risks, we
continue to recommend aspirin as our
chemoprophylactic agent of choice.
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