5. syr jänen rajoitukset - suomen artroplastiayhdistys · vii valtakunnallinen tekonivelkirurgian...

VARAUS JA LIIKERAJOITUKSET LONKANTEKONIVELLEIKKAUKSEN JÄLKEEN

JARI SYRJÄNEN, ORTOPEDIORTON OY, TEKONIVELOSASTO

VIIIvaltakunnallinentekonivelkirurgiankurssi19.-21.4.2017SoloSokosHotelTorni,Tampere

Sidonnaisuudet

• Smith&Nephew• Zimmer-Biomet• Stryker• DePuy


Historiaa

• Perinteenäonollutrajoittaa– Varausta6vkoa- 3kk– Fleksiorajoitus90° 6vkoa-2kk– Sisäkierto- taiulkokiertorajoitusviillostariippuen

– AktiivinenabduktiorajoitusHardingenviillonyhteydessä


Miksirajoitettu?

• Estetäänsementittömienkomponenttienmigraatiojasitenparannetaanniidenosseointegraatiota

• Vähennetäänvarhaistaluksaatioriskiä• Kudoksetparanevatparemminjasaavutetaanparempifunktio


Vaikuttaakovarausosseointegraatioon?

–Komponenttientarttumistavoiseuratamigraatiotamittaamalla- RSA

–Migraatioeilisäännyvaikkaaloitetaanvarhainentäysipainovaraus• Markmiller,M.,etal.(2011)

• Wolf,O.,etal.(2012)


Vaikuttaakovarausosseointegraatioon?


Eiolenäyttöävarauksenrajoittamisentarpeestavälittömästipostoperatiivisessavaiheessa.

Olennaistaonkomponenttienhyväprimääristabiliteetti.

Vapaaliike- luksoituuko?– Luksaatioistapuoletensimmäisen3kkaikana–30%revisioistatoistuvienluksaatioidenvuoksi• Perka,C.,etal.(2012)

–Vapaallamobilisaatiollaeivaikutustaluksaatioihin• Barnsley,L.,etal.(2015),Gromov,K.,etal.(2015),Klein,G.R.,etal.(2017),Mikkelsen,L.R.,etal.(2014),Restrepo,C.,etal.(2011),vanderWeegen,W.,etal.(2016),Peak,E.L.,etal.(2005).


Vapaaliike- luksoituuko?


– Luksaatioitavähentävillätekijöillävoidaanvarhaistamobilisaatiotatehdäturvallisemmaksi

– Isommallanupillavähemmänluksaatioita• Kostensalo,I.,etal.(2013)

– 28vs.32 RR0,40– 28vs.36 RR0,41– 28vs.>36 RR0,09

• Lombardi,A.V.,Jr.,etal.(2011),

– Takavillossakapselinjaulkokiertäjiensulku• Browne,J.A.andM.W.Pagnano(2012),Ho,K.W.,etal.(2012),Shen,P.,etal.(2012)

Vapaaliike- luksoituuko?


Varausjakudostenparaneminen?

–MRI-tutkimuksissakudostentodettuparanevanhyvintakaviillossa• McLawhorn,A.S.,etal.(2015)

– Kudostenhuolellinensulkuparantaafunktionaalistatulosta• Shen,P.,etal.(2012)

– Aktiviteettienpalautuminennopeampaakuneirajoitteita• vanderWeegen,W.,etal.(2016),Barnsley,L.,etal.(2015),Mikkelsen,L.R.,etal.(2014)


Suositus

• KOMPLISOITUMATTOMASSA primäärissälonkantekonivelleikkauksessapostoperatiivisetvaraus-jaliikerajoitteetovatturhia

• POTILASKOHTAISESTI pohdittavaonkokyseessäkomplisoitumatonleikkaus

• Varhaisellavapaallamobilisaatiollanopeutetaanpotilaantoipumista,etenkiniäkkäidenpotilaiden– Starks,I.,etal.(2014)

• Hyvähoitolonkanjapolventekonivelkirurgiassa2015


KIITOS


Kirjallisuutta

1. Barnsley,L.,L.Barnsley,andR.Page,AreHipPrecautionsNecessaryPostTotalHipArthroplasty?ASystematicReview. GeriatrOrthopSurgRehabil,2015.6(3):p.230-5.2. Browne,J.A.andM.W.Pagnano,Surgicaltechnique:asimplesoft-tissue-onlyrepairofthecapsuleandexternalrotatorsin

posterior-approachTHA.ClinOrthopRelatRes,2012.470(2):p.511-5.3. Finnila,S.,etal.,Increasedmigrationofuncementedacetabularcupsinfemaletotalhiparthroplastypatientswithlow systemicbonemineraldensity.A2-yearRSAand8-yearradiographicfollow-upstudyof34patients.ActaOrthop,2016. 87(1):p.48-54.4. Georgiou,C.,etal.,DoesChoiceofHeadSizeandNeckGeometryAffectStemMigrationinModularLarge-DiameterMetal- on-MetalTotalHipArthroplasty?APreliminaryAnalysis.OpenOrthopJ,2012.6:p.593-600.5. Gromov,K.,etal.,RemovalofrestrictionsfollowingprimaryTHAwithposterolateralapproachdoesnotincreasetheriskof earlydislocation.ActaOrthop,2015.86(4):p.463-8.6. Ho,K.W.,G.S.Whitwell,andS.K.Young,Reducingtherateofearlyprimaryhipdislocationbycombiningachangeinsurgical

techniqueandanincreaseinfemoralheaddiameterto36mm.ArchOrthopTraumaSurg,2012.132(7):p.1031-6.7. Ibrahim,M.S.,etal.,Enhancedrecoveryintotalhipreplacement:aclinicalreview.BoneJointJ,2013.95-B(12):p.1587-94.8. Kadar,T.,etal.,ArandomizedstudyonmigrationoftheSpectronEFandtheCharnleyflanged40cementedfemoral

componentsusingradiostereometricanalysisat2years.ActaOrthop,2011.82(5):p.538-44.9. Klein,G.R.,etal.,SameDayTotalHipArthroplastyPerformedatanAmbulatorySurgicalCenter:90-DayComplicationRate on549Patients.JArthroplasty,2017.32(4):p.1103-1106.10. Kostensalo,I.,etal.,Effectoffemoralheadsizeonriskofrevisionfordislocationaftertotalhiparthroplasty:apopulation- basedanalysisof42,379primaryproceduresfromtheFinnishArthroplastyRegister.ActaOrthop,2013.84(4):p.342-7.11. Lombardi,A.V.,Jr.,etal.,Dolargeheadsenhancestabilityandrestorenativeanatomyinprimarytotalhiparthroplasty?Clin

OrthopRelatRes,2011.469(6):p.1547-53.12. Markmiller,M.,etal.,Partialweightbearingisnotnecessaryaftercementlesstotalhiparthroplasty:atwo-yearprospective

randomizedstudyon100patients.IntOrthop,2011.35(8):p.1139-43.13. McLawhorn,A.S.,etal.,PosteriorSoftTissueRepairAfterPrimaryTHAisDurableatMid-termFollowup:AProspectiveMRI Study.ClinOrthopRelatRes,2015.473(10):p.3183-9.

VIIvaltakunnallinentekonivelkirurgiankurssi8.-10.4.2015HotelliRadissonBlu,Oulu

Kirjallisuutta

14. McLawhorn,A.S.,etal.,TargetingaNewSafeZone:AStepintheDevelopmentofPatient-SpecificComponentPositioningforTotalHipArthroplasty.AmJOrthop(BelleMeadNJ),2015.44(6):p.270-6.

15. Mikkelsen,L.R.,etal.,Doesreducedmovementrestrictionsanduseofassistivedevicesaffectrehabilitationoutcomeafter totalhipreplacement?Anon-randomized,controlledstudy.EurJPhysRehabilMed,2014.50(4):p.383-93.16. Minten,M.J.,P.J.Heesterbeek,andM.Spruit,Noeffectofadditionalscrewfixationofacementless,all-polyethylenepress-fit

socketonmigration,wear,andclinicaloutcome.ActaOrthop,2016.87(4):p.363-7.17. Moussallem,C.D.,F.A.Hoyek,andJ.C.Lahoud,Incidenceofpiriformistendonpreservationonthedislocationrateoftotalhip

replacementfollowingtheposteriorapproach:aseriesof226cases.JMedLiban,2012.60(1):p.19-23.18. Pakvis,D.,etal.,Acementless,elasticpress-fitsocketwithandwithoutscrews.ActaOrthop,2012.83(5):p.481-7.19. Pakvis,D.,etal.,Isthereevidenceforasuperiormethodofsocketfixationinhiparthroplasty?Asystematicreview.Int Orthop,2011.35(8):p.1109-18.20. Perka,C.,F.Haschke,andS.Tohtz,[Dislocationaftertotalhiparthroplasty].ZOrthopUnfall,2012.150(2):p.e89-103,quiz e104-5.21. Peters,A.,etal.,Reducedpatientrestrictionsfollowingtotalhiparthroplasty:studyprotocolforarandomizedcontrolledtrial.

Trials,2015.16:p.360.22. Peters,A.,A.Vochteloo,andR.H.Veld,RemovalofrestrictionsfollowingprimaryTHAwithposterolateralapproachdoesnot

increasetheriskofearlydislocation.ActaOrthop,2015.86(4):p.518-9.23. Pijls,B.G.,etal.,EarlyproximalmigrationofcupsisassociatedwithlaterevisioninTHA:asystematicreviewandmeta- analysisof26RSAstudiesand49survivalstudies.ActaOrthop,2012.83(6):p.583-91.24. Ranawat,C.S.,etal.,TheposteriorapproachinTHR:assuringcapsularstability.Orthopedics,2011.34(9):p.e452-5.25. Restrepo,C.,etal.,Hipdislocation:arehipprecautionsnecessaryinanteriorapproaches?ClinOrthopRelatRes,2011. 469(2):p.417-22.26. Sangiorgio,S.N.,etal.,Effectofproximalfemoralbonesupportonthefixationofapress-fitnoncementedtotalhipreplacementfemoralcomponent.JApplBiomaterFunctMater,2013.11(1):p.e26-34.


Kirjallisuutta

27. Schmidt-Braekling,T.,etal.,Minimalinvasiveposteriortotalhiparthroplasty:are6weeksofhipprecautionsreally necessary?ArchOrthop TraumaSurg,2015.135(2):p.271-4.28. Shen,P.,etal.,[Impact ofjoint capsule repair andexternal rotators suture onprognosis inprimary total hiparthroplasty by

posterolateral approach].Zhongguo Xiu FuChong Jian Wai KeZa Zhi,2012.26(11):p.1300-5.29. Starks,I.,etal.,Olderpatientshavethemosttogainfromorthopaedic enhancedrecoveryprogrammes.AgeAgeing,2014. 43(5):p.642-8.30. Timperley,A.J.,etal.,Dislocationaftertotalhipreplacement- thereisnosuchthingasasafezoneforsocketplacementwith

theposteriorapproach.HipInt,2016.26(2):p.121-7.31. vanderWeegen,W.,A.Kornuijt,andD.Das,Dolifestylerestrictionsandprecautionspreventdislocationaftertotalhip

arthroplasty?Asystematicreviewandmeta-analysisoftheliterature.Clin Rehabil,2016.30(4):p.329-39.32. Wolf,O.,etal.,Theeffectsofdifferentweight-bearingregimesonpress-fitcupstability:arandomised studywithfiveyearsof

follow-upusingradiostereometry.Int Orthop,2012.36(4):p.735-40.33. Zilkens,C.,etal.,Migrationpatternofcementless pressfitcupsinthepresenceofstabilizingscrewsintotalhiparthroplasty.

Eur JMedRes,2011.16(3):p.127-32.


Markmiller,M.,etal.(2011)."Partialweightbearingisnotnecessaryaftercementlesstotalhiparthroplasty:atwo-yearprospectiverandomizedstudyon100patients."IntOrthop35(8):1139-1143.

• Thepurposeofthisstudywastoevaluatetheeffectsofpartialandfullweightbearingaftercementlesstotalhiparthroplastyoveratwoyearfollow-upperiod.Fifty-ninewomenand41men(averageage61years)receivedanuncementedSpotornostemandwererandomisedintoafullandapartialweightbearinggroup.NosignificantdifferencewasfoundbetweenthegroupswithregardtotheMerled'Aubignehipscore,VASpainlevel,shaftmigrationorradiographicsignsofbonyingrowth.Allfemoralcomponentsseemedradiologicallywell-fixedandshowedboneingrowthat24months.Providedthatsolidinitialfixationisobtainedfullweightbearingimmediatelyaftercementlesstotalhiparthroplastyusingahydroxyapatite-coatedSpotorno-typefemoralshaftcomponentcanberecommended.


Wolf,O.,etal.(2012)."Theeffectsofdifferentweight-bearingregimesonpress-fitcupstability:arandomisedstudywithfiveyearsoffollow-upusingradiostereometry."IntOrthop36(4):735-740.

• PURPOSE:Thereislittleevidencetosupportimmediateweightbearingafteruncementedtotalhiparthroplasty(THA).METHODS:Thirty-sevenpatientswithunilateralosteoarthritisofthehipreceivedapress-fitcup.Cupstabilitywasassessedwithradiostereometry(RSA)overfiveyears.Patientswererandomisedtoimmediatefullweightbearing,orpartialweightbearingforthreemonths.RESULTS:Atfiveyears,wefoundnodifferenceinmicro-motionasassessedwithradiostereometry.Numerically,therewasmoreproximaltranslationandincreasedinclinationwithimmediateweightbearing,butthesevaluesbarelyexceededtheprecisionlimitforthemethod.Pooleddataforthetwogroupsrevealedtranslationsof0.1-0.3mmandrotationsof0.2-0.3degreesoverthefiveyearfollow-upperiod.CONCLUSIONS:WefoundnoadverseeffectsofimmediateweightbearingafterTHAinrelationtostabilityofthesepress-fitcups. Earlymobilisationmighthaveotheradvantages.


Barnsley,L.,etal.(2015)."AreHipPrecautionsNecessaryPostTotalHipArthroplasty?ASystematicReview."GeriatrOrthopSurgRehabil6(3):230-235.

• PURPOSE:Totalhiparthroplasty(THA)isacommonandeffectivetreatmentofhiposteoarthritis.ActivityrestrictionsknownashipprecautionsarewidelypracticedinrehabilitationpostTHA,aimingtofosterhealingandpreventhipdislocation.Thefocusedclinicalquestionwas:DoestheapplicationofhipprecautionsinpatientspostTHAversusunrestrictedactivitiessignificantlydecreasetheriskofprostheticdislocation?METHODS:Acomprehensiveliteraturesearchwasconductedforrandomizedcontrolledtrialsorcohortstudieswithacomparativegroupandminimum6monthsfollow-up,withdislocationasanendpoint.Retrievedtitleswereassessedindependentlyby2reviewersforinclusionandunderwentstandardizeddataextraction.RESULTS:Titlesearchproduced80potentiallyrelevantarticles.Fivearticleswereretrievedfordataextractionofwhich2metaprioreligibilitycriteria.Noeligiblestudieswerefoundthatconcernedposteriorapproachestohiparthroplasty,sotheresultsofthisreviewconcernonlyanterolateralapproaches.Neitherincludedstudyshowedanybenefitofhipprecautionsinpreventingdislocation.CONCLUSION:TherateofdislocationafteranterolateralTHAislowandisnotimprovedbyhipprecautions.Hipprecautionsareassociatedwithaslowerreturntoactivities,significantexpense,anddecreasedpatientsatisfaction. ExistingstudiesriskbeingcompromisedbyatypeIIerror,butadefinitivestudymaybeprohibitivelylargeandexpensive.


Gromov,K.,etal.(2015)."RemovalofrestrictionsfollowingprimaryTHAwithposterolateralapproachdoesnotincreasetheriskofearlydislocation."ActaOrthop86(4):463-468.

• BACKGROUNDANDPURPOSE:PatienteducationandmobilizationrestrictionsareoftenusedinanattempttoreducetheriskofdislocationfollowingprimaryTHA.Todate,therehavebeennostudiesinvestigatingthesafetyofremovalofmobilizationrestrictionsfollowingTHAperformedusingaposterolateralapproach.Inthisretrospectivenon-inferioritystudy,weinvestigatedtherateofearlydislocationfollowingprimaryTHAinanunselectedpatientcohortbeforeandafterremovalofpostoperativemobilizationrestrictions.PATIENTSANDMETHODS:FromtheDanishNationalHealthRegistry,weidentifiedpatientswithearlydislocationin2consecutiveandunselectedcohortsofpatientswhoreceivedprimaryTHAatourinstitutionfrom2004through2008(n=946)andfrom2010through2014(n=1,329).PatientsinthefirstcohortweremobilizedwithfunctionalrestrictionsfollowingprimaryTHAwhereaspatientsinthesecondcohortwereallowedunrestrictedmobilization.Riskofearlydislocation(within90days)wascomparedinthe2groupsandoddsratio(OR)-adjustedforpossibleconfounders-wascalculated.Reasonsforearlydislocationinthe2groupswereidentified.RESULTS:Whenweadjustedforpotentialconfounders,wefoundnoincreasedriskofearlydislocationwithin90daysinpatientswhoweremobilizedwithoutrestrictions.Riskofdislocationwithin90dayswaslower(3.4%vs2.8%),riskofdislocationwithin30dayswaslower(2.1%vs2.0%),andriskofmultipledislocations(1.8%vs1.1%)waslowerinpatientswhoweremobilizedwithoutrestrictions,butnotstatisticallysignificantlyso.Increasingagewasanindependentriskfactorfordislocation.INTERPRETATION:RemovalofmobilizationrestrictionsfromthemobilizationprotocolfollowingprimaryTHAperformedwithaposterolateralapproachdidnotleadtoanincreasedriskofdislocationwithin90days.


Klein,G.R.,etal.(2017). "SameDayTotalHipArthroplastyPerformedatanAmbulatorySurgicalCenter:90-DayComplicationRateon549Patients.“JArthroplasty32(4):1103-1106.

• BACKGROUND:Thereisanincreasinginterestinoutpatienttotalhiparthroplasty(THA),asthereareperceivedbenefitstothepatient,insurer,andoverallhealthcaresystem.However,thesafetyofoutpatienttotaljointarthroplastyhasnotbeenstudied.METHODS:Fivehundredforty-ninepatientswhounderwentmini-posteriorTHAatafreestandingindependentambulatorysurgicalcenter(ASC)werereviewed.Allpatientsweredischargedtohomeonthedayofsurgery.RESULTS:Theaverageageofthepatientswas54.4years(range27-73).TheaverageAmericanSocietyofAnesthesiologistsscorewas1.6(range1-3).Ofthe549patients,3(0.5%)admittedfromthesurgerycentertoourlocalhospital.Onepatientwasadmittedforpaincontrolafterfailingtodisclosehislong-termhigh-dosenarcoticdependence,onepatientwasadmittedforanacetabularcomponentmigrationidentifiedonpostoperativex-ray,andonepatientwasadmittedforhypotension,bradycardia,andanacutepolyarthralgiaexacerbation.Anadditionalpatientwasseen2daysaftersurgeryinalocalemergencydepartmentforoversedationsecondarytonarcoticsandlaterdischargedtohome.CONCLUSION:OutpatientTHAatanASCissafeandeffectivewhenperformedontheappropriatelyindicatedpatient.Therewere4visitstothehospitalwithin2daysofsurgery.Only1wasrelatedtomedicalevents,2werepaincontroland/ormedication-relatedandthefinalwastechnique-related.Knownorthopediccomplicationsincludinginfection,dislocation,anddeepveinthrombosisappearconsistentwiththeliteratureforaseriesofthissize.SamedaydischargeTHAinanASCissafeandreproducible.


Mikkelsen,L.R.,etal.(2014)."Doesreducedmovementrestrictionsanduseofassistivedevicesaffectrehabilitationoutcomeaftertotalhipreplacement?Anon-randomized,controlledstudy."EurJPhysRehabilMed50(4):383-393.

• BACKGROUND:Improvementsinsurgicaltechniquesandincreaseoffemoralheadsizemighthavechangedtherationaleformovementrestrictionsaftertotalhipreplacement(THR).AIM:ToevaluatetheinfluenceofmovementrestrictionsandassistivedevicesonrehabilitationafterfasttrackTHR.DESIGN:Non-randomized,controlledstudy.SETTING:Inpatient.POPULATION:365consecutivelyincludedTHRpatients.METHODS:Patientsincludedthe3initialmonthofthestudyunderwentrehabilitationwithrestrictionsinhipmovementandastandardpackageofassistivedevices(restrictedgroup).Thisgroupwascomparedtopatientsincludedthefollowing3monthswithlessrestrictedhipmovementanduseofassistivedevicesaccordingtoindividualneeds(unrestrictedgroup).Questionnairesonfunction,pain,qualityoflife(HOOS),anxiety(HADS),workingstatusandpatientsatisfactionwerecompletedbeforeTHR,3and6weeksafter.RESULTS:TheHOOSfunctionscoreatthe3measurementtimeswas(mean+/- SD);unrestrictedgroup:46+/- 17- 76+/- 9- 83+/- 14comparedtorestrictedgroup:43+/- 16- 81+/- 14- 83+/-13.Changesovertimewassignificantlyhigherintherestrictedgroup(P=0.004).Returntowork6weeksafterTHRfortheunrestrictedgroupcomparedtorestrictedgroupwas:53%versus32%(P=0.045).Nosignificantdifferencesbetweengroupsinpain,symptoms,qualityoflife,anxiety/depression,hipdislocationsandpatientsatisfaction.CONCLUSION:Thisstudyshowedslightlyslowerrecoveryinpatient-reportedfunctionafterreductioninmovementrestrictionsanduseofassistivedevices,butthedifferencewaseliminatedafter6weeks.Reducedmovementrestrictionsdidnotaffecttheotherpatient-reportedoutcomesandledtoearlierreturntowork.CLINICALREHABILITATIONIMPACT:Itispossibletoreducemovementrestrictionsanduseofassistivedevicesconsiderably.Moreresearchonsafetyissuesisneededtoelucidatetheeffectofunrestrictedrehabilitationonhipdislocation.


Restrepo,C.,etal.(2011)."Hipdislocation:arehipprecautionsnecessaryinanteriorapproaches?"ClinOrthopRelatRes 469(2):417-422.

• BACKGROUND:In2005,wereportedremovaloffunctionalrestrictionafterprimaryTHAperformedthroughtheanterolateralapproachdidnotincreasetheincidenceofdislocation.QUESTIONS/PURPOSES:Todevelopacurrentpracticeguideline,weevaluatedtheincidenceofearlydislocationafterprimaryTHAafterimplementationofano-restrictionprotocol.METHODS:BetweenJanuary2005andDecember2007,2532patients(2764hips;1541women,1223men;meanage,63.2years[28-98years])underwentprimaryTHAatourinstitution.BilateralTHAwasperformedin232patients(464hips).Thedirectanteriororanterolateralapproachwasusedinallpatients.Femoralheadsizewas28,32,or36mm.Patientsweregivennotraditionalfunctionalrestrictionspostoperatively,suchasuseofelevatedseats,abductionpillows,andrestrictionfromdriving.Allpatientsreceivedstandardcareatthejudgmentoftheattendingsurgeon.Onehundredforty-sixpatientsmissedfollowupappointmentsdespiteeffortstobecontactedbytelephone.Theremaining2386of2532patients(94%)hadaminimumfollowupof6months(mean,14.2months;range,6-34months).RESULTS:Fourknowndislocationsoccurredinthefollowedcohortof2386patientswith2612hips(0.15%)atameanof5days(3-12days)postoperatively,nonerelatedtohigh-impacttrauma.Onedislocationoccurredinapatientwithahistoryofdevelopmentaldysplasiaofthehip,twodislocationsoccurredwhileatthetoilet(onewithaprevioushipfracturetreatedwithamodularsystem),andonedislocationwasidiopathic.CONCLUSIONS:WeconfirmedalowincidenceofdislocationafterprimaryTHAintheabsenceofearlypostoperativerestrictions.Weconcludeano-restrictionprotocoldoesnotincreasetheincidenceofearlydislocationafterprimary THA.LEVELOFEVIDENCE:LevelII,therapeuticstudy.SeetheGuidelinesforAuthorsforacompletedescriptionoflevelsofevidence.


vanderWeegen,W.,etal.(2016)."Dolifestylerestrictionsandprecautionspreventdislocationaftertotalhiparthroplasty?Asystematicreviewandmeta-analysisoftheliterature."ClinRehabil30(4):329-339.

• OBJECTIVE:Asystematicliteraturereviewandmeta-analysisontheeffectivenessoflifestylerestrictionsandprecautionstopreventdislocationaftertotalhiparthroplasty.DATASOURCES:MEDLINEandtheCochraneLibraryweresearchedinFebruary2015,withadditionalhandsearchingofsystematicreviewsandreferencelists.REVIEWMETHODS:ThisreviewwasconductedinaccordancewiththePRISMAstatementforreportingsystematicreviewsandmeta-analysis.PubMedandtheCochraneLibraryweresearchedfromtheirstartdatethroughtoFebruary2015.RandomizedcontrolledtrialsandcomparativecaseseriesinEnglish,DutchorGermanlanguagewereincluded.Onlyprimarytotalhiparthroplastyproceduresmanagedwithdifferentpostoperativerestrictionsandprecautionsprotocolswereincluded.Primaryoutcomewasthetotalhiparthroplastydislocationrate,secondaryoutcomeswerepatientfunctioning,returntoactivitiesofdailylivingandpatientsatisfaction.RESULTS:Atotalof119eligiblearticleswereidentified,sixwereincluded:threerandomizedcontrolledtrials,oneretrospectivematchedcohortstudy,oneretrospectiveandoneprospectivecohortstudy,describing1122procedures(restrictionsgroup:n=528;norestrictionsgroup:n=594).Boththestandardposteriorandanterolateralsurgicalapproacheswereincluded.Therewereeightdislocations(1.5%)intherestrictedgroup,vs.sixdislocations(1.0%)intheunrestrictedgroup.Patientsintheunrestrictedgroupresumedactivitiessignificantlyfasterandweremoresatisfiedwiththeirpaceofrecovery.CONCLUSION:Amoreliberallifestylerestrictionsandprecautionsprotocolwillnotleadtoworsedislocationratesaftertotalhiparthroplasty,butwillleadtoearlierandbetterresumptionofactivitiesandhigherpatientsatisfaction.Theseresultsappeartoholdupforvarioussurgicalapproaches.


Kostensalo,I.,etal.(2013)."Effectoffemoralheadsizeonriskofrevisionfordislocationaftertotalhiparthroplasty:apopulation-basedanalysisof42,379primaryproceduresfromtheFinnishArthroplastyRegister."ActaOrthop84(4):342-347.

• BACKGROUNDANDPURPOSE:Previouspopulation-basedregistrystudieshaveshownthatlargerfemoralheadsizeisassociatedwithreducedriskofrevisionfordislocation.However,thepreviousdatahavenotincludedlargenumbersofhipresurfacingarthroplastiesorlargemetal-on-metal(>36-mm)femoralheadarthroplasties.WeevaluatedtheassociationbetweenfemoralcomponentheadsizeandtheriskofrevisionfordislocationafterTHAbyusingFinnishArthroplastyRegisterdata.PATIENTSANDMETHODS:42,379patientswhowereoperatedduring1996-2010fulfilledourcriteria.18differentcup/stemcombinationswereincluded.Thehead-sizegroupsstudied(numbersofcases)were28mm(23,800),32mm(4,815),36mm(3,320),and>36mm(10,444).Otherriskfactorsstudiedweresex,agegroup(18-49years,50-59years,60-69years,70-79years,and>80years),andtimeperiodofoperation(1996-2000,2001-2005,2006-2010).RESULTS:TheadjustedriskratiointheCoxmodelforarevisionoperationduetodislocationwas0.40(95%CI:0.26-0.62)for32-mmheadsize,0.41(0.24-0.70)for36-mmheadsize,and0.09(0.05-0.17)for>36-mmheadsizecomparedtoimplantswithaheadsizeof28mm.INTERPRETATION:Largerfemoralheadsclearlyreducetheriskofdislocation.Thedifferenceinusingheadsof>36mmasopposedto28-mmheadsfortheoverallrevisionrateat10yearsfollow-upisabout2%.Thus,althoughattractivefromamechanicalpointofview,basedonrecentlessfavorableclinicaloutcomedataontheselargeheads,consistingmainlyofmetal-on-metalprostheses,oneshouldbecautioususingtheseimplants.


Browne,J.A.andM.W.Pagnano(2012)."Surgicaltechnique:asimplesoft-tissue-onlyrepairofthecapsuleandexternalrotatorsinposterior-approachTHA."ClinOrthopRelatRes470(2):511-515.

• BACKGROUND:PosteriorsofttissuerepairafterposteriorTHAreportedlydecreasestheriskofdislocation.Previouslydescribedtechniquesoftenrequiredrillholesthroughthegreatertrochanter,donotincludeboththeshortexternalrotatorsandthecapsule,orrequireacomplexseriesofmultiplesutures.Wethereforedescribeatechniquetoaddresstheseissues.DESCRIPTIONOFTECHNIQUE:Theposteriorsofttissueswererepairedwithasinglenonabsorbablesuturepassedthroughtheexternalrotatorsandposteriorcapsuleandthenthroughthecapsuleandposteriorborderofminimusinafigure-of-eightpattern.Thisrepairremainspliableandobliteratesthedeadspace.METHODS:Weretrospectivelyreviewed165patientswhounderwent178primaryTHAsthroughamini-posteriorTHAandalsounderwentsofttissuerepairusingourtechnique.Wedeterminedtherateofdislocationandcomplicationsassociatedwiththistechnique.Theminimumclinicalfollowupwas1year(mean,23months;range,12-37months).RESULTS:Thisrepairwasassociatedwithalowriskofdislocationat1year(oneof178hips,0.56%) andnoapparentcomplicationsrelatedtothetechnique.CONCLUSIONS:Thissofttissuetosofttissuerepairtechniqueafterposterior-approachTHAistechnicallystraightforwardandreliablewithalowassociateddislocationrate.LEVELOFEVIDENCE:LevelIV,therapeuticstudy.SeetheGuidelinesforAuthorsforacompletedescriptionoflevelsofevidence.


Ho,K.W.,etal.(2012)."Reducingtherateofearlyprimaryhipdislocationbycombiningachangeinsurgicaltechniqueandanincreaseinfemoralheaddiameterto36mm."ArchOrthopTraumaSurg132(7):1031-1036.

• INTRODUCTION:Wereporthowchangestoourtotalhiparthroplasty(THA)surgicalpractiseleadtoadecreaseinearlyhipdislocationrates.METHODS:GroupBconsistedof421consecutiveprimaryTHAoperationsperformedviaaposteriorapproach.Theoperativetechniqueincludedameticulousrepairoftheposteriorcapsule,alignmentoftheacetabularcupwiththetransverseacetabularligament(TAL)anda36-mm-diameterfemoralhead.WecomparedthedislocationratesandcostimplicationsofthistechniquetoahistoricalcontrolGroupAconsistingof389patients.ThecontrolgrouphadtheirTHAperformedwithnorepairofthecapsule,noidentificationoftheTALandallreceiveda28-mm-diameterhead.Ourprimaryoutcomeistherateofearlyhipdislocationandwehypothesisedthatwecanreducetherateofearlyhipdislocationwiththisnewregime.RESULTS:InGroupBtherewerenoearlydislocations(within6months)andtwo(0.5%)dislocationswithin18months;minimumfollow-uptimewas18monthswitharangeof(18-96months).Thiscomparedtoa1.8%earlydislocationrateanda2.6%rateat18monthsinGroupA;minimumfollow-uptimewas60monthswitharangeof(60-112months).Theseresultswerestatisticallysignificant(p=0.006).CONCLUSION:Wesuggestthatwhenprimaryhiparthroplastyisperformedthroughaposteriorapproach,alowearlydislocationratecanbeachievedusingthedescribedmethods.


Shen,P.,etal.(2012)."[Impactofjointcapsulerepairandexternalrotatorssutureonprognosisinprimarytotalhiparthroplastybyposterolateralapproach]."ZhongguoXiuFuChongJianWaiKeZaZhi26(11):1300-1305.

• OBJECTIVE:Toinvestigatetheimpactofjointcapsulerepairandexternalrotatorssutureontheprognosisinprimarytotalhiparthroplasty(THA)byposterolateralapproach.METHODS:BetweenJanuary2006andJune2009,159patientswithfemoralneckfractureunderwentprimaryTHAbyposterolateralapproach,andweredividedinto4groupsaccordingtodifferenttreatments:jointcapsulerepairandexternalrotatorssutureweregiveningroupA(n=38),onlyjointcapsulerepairingroupB(n=39),onlyexternalrotatorssutureingroupC(n=41),andnojointcapsulerepairorexternalrotatorssutureingroupD(n=41).Therewasnosignificantdifferenceingender,age,causeofinjure,diseaseduration,typeoffracture,combinedmedicaldisease,orprosthesisselectionamong4groups(P>0.05).Thebleedingvolume,drainage,postoperativehipdislocationrate,hipHarrisscore,andthehiprangeofmotion(ROM)ininternalrotationandexternalrotationwerecompared.RESULTS:Therewasnosignificantdifferenceinoperativetime,bleedingvolume,ordrainageamong4groups(P>0.05).Postoperativehipdislocationoccurredin0,0,4(9.8%),and4(9.8%)casesofgroupsA,B,C,andD,respectively,showingsignificantdifferenceinincidenceofpostoperativehipdislocationamong4groups(chi2=7.910,P=0.048).ThehipHarrisscoresweresignificantlyimprovedafteroperationwhencomparedwithpreoperativescoresin4groups(P<0.05).SignificantdifferenceswerefoundinhipHarrisscoreat6weeksand6monthsafteroperationamong4groups(P<0.05);groupDwassignificantlylowerthangroupsA,B,andC,andgroupsBandCweresignificantlylowerthangroupA(P<0.05).TherewasnosignificantdifferenceinthehipROMininternalrotationamong4groupsat6weeksand6,12monthsafteroperation(P>0.05);butthehipROMinexternalrotationweresignificantlybiggeringroupsAandCthaningroupsBandDat6weeksand6monthsafteroperation(P<0.05).CONCLUSION:JointcapsulerepairandexternalrotatorssutureinprimaryTHAbyposterolateralapproachdonotincreasethebleedingvolumeanddrainage,butcanreducetheearlypostoperativehipdislocationrisk,increasetheHarrisscore,andrecovertheexternalrotationfunctionofinvolvedhip.SojointcapsuleandexternalrotatorsshouldberepairedinTHAbyposterolateralapproach.


McLawhorn,A.S.,etal.(2015)."PosteriorSoftTissueRepairAfterPrimaryTHAisDurableatMid-termFollowup:AProspectiveMRIStudy."ClinOrthopRelatRes473(10):3183-3189.

• BACKGROUND:TheenhancedposteriorsofttissuerepairhasreducedthefrequencyofdislocationafterprimaryTHAperformedthroughtheposterolateralapproach.However,thelong-termintegrityoftherepairisunknownandcouldinfluencesurgeonchoiceregardingsurgicaltechniqueandTHAapproach.QUESTIONS/PURPOSES:Weasked:(1)Whatisthedurabilityoftheenhancedposteriorsofttissuerepairataminimumof49monthsusingMRItoevaluatesofttissuetoboneintegrity?(2)Howdoestheappearanceoftheposteriorsofttissueschangeduringthistime?(3)Aretherepatientcharacteristicsassociatedwiththelong-termimagingappearanceoftheposteriorrepair?METHODS:AllpatientswithoutacontraindicationforMRIwhowereundergoingunilateralprimaryuncementedTHAthroughaposteriorapproachbetweenFebruaryandMay2005wereeligibleforinclusion.Ninetypercentconsentedtoparticipate(36of40patients),and30patientswerefollowedprospectivelywithMRIpostoperativelyandagainat3months;ofthose,22(73%;12men,10women)completedthestudybyhavinganotherMRIstudyataminimumof49months(mean,51months;range,49-59months).Eachpatientunderwentmetal-artifact-reductionsequenceMRItoevaluatetheintegrityoftheposteriorsofttissues,whichhadbeenrepairedanatomicallyduringprimaryTHAataminimumof4yearsearlier.TheresultswerecomparedwiththoseofpriorMRimagesobtainedimmediatelyaftersurgeryandat3monthspostoperatively.Allpatientsweregivenaself-reportedmodifiedHarrishipscoreatthetimeofthemostrecentMRIstudy(maximumscore=81).RESULTS:Atlatestfollowup,21of22(96%)patientshadaposteriorcapsuleincontactwithbone,and21of22(96%)hadanintactquadratusfemoris.Twenty-onepatients(96%)hadsofttissueorascarfromthepiriformisandconjoinedtendonsincontinuitywithbone.Inthesecases,theinterfacebetweenthepiriformisandconjoinedtendonsandthegreatertrochanterobservedimmediatelypostoperativelyandat3monthspostoperativelybecamefilledwithhypointensetissue,withsignalcharacteristicssimilartotendon.Timefromsurgerywasmostassociatedwithchangesinnativetendon-to-bonedistances(p<0.001)andMRIsignalintensityoftherepair(p<0.001).CONCLUSIONS:Atfollowupofjustmorethan4years,theposteriorcapsuleandquadratusfemorismostoftenwerehealedtobone.Inthemajorityofpatients,scartissuebetweenthepiriformisandconjoinedtendonsandbonematuredtoachieveorientationandsignalintensityresemblingnativetendon.Webelievetheenhancedposteriorsofttissuerepairfacilitatesthisprocess.Ourresultsprovideaplausibleexplanationforimprovedpostoperativestabilityobservedinpatientsreceivinganenhancedsofttissuerepaircomparedwiththoseinwhomarepairisnotperformed.LEVELOFEVIDENCE:LevelIV,therapeuticstudy.


Peak,E.L.,etal.(2005)."Theroleofpatientrestrictionsinreducingtheprevalenceofearlydislocationfollowingtotalhiparthroplasty.Arandomized,prospectivestudy."JBoneJointSurgAm87(2):247-253.

• BACKGROUND:Itiscurrentlyunknownwhetherfunctionalrestrictionsfollowingtotalhiparthroplastycanreducetheprevalenceofearlypostoperativedislocation.Ourhypothesiswasthatdislocationwasmorelikelytooccurinpatientswhowerenotplacedontheserestrictions.METHODS:Weperformedaprospective,randomizedstudytoevaluatetheroleofpostoperativefunctionalrestrictionsontheprevalenceofdislocationfollowinguncementedtotalhiparthroplastythroughananterolateralapproach.Ofthe630eligibleconsecutivepatients,265patients(303hips)consentedtoberandomizedintooneoftwogroups(the"restricted"grouporthe"unrestricted"group).Thepatientsinbothgroupswereaskedtolimittherangeofmotionofthehipto<90degreesofflexionand45degreesofexternalandinternalrotationandtoavoidadductionforthefirstsixweeksaftertheprocedure.Thepatientsintherestrictedgroupwereinstructedtocomplywithadditionalhipprecautionsduringthefirstsixweekspostoperatively.Specifically,thesepatientsweremanagedwiththeplacementofanabductionpillowintheoperatingroombeforebedtransferandusedpillowstomaintainabductionwhileinbed;usedelevatedtoiletseatsandelevatedchairsinthehospital,intherehabilitationfacility,andathome;andwerepreventedfromsleepingontheside,fromdriving,andfrombeingapassengerinanautomobile.Allpatientswerefollowedforaminimumofsixmonthspostoperatively.RESULTS:Therewasonedislocationintheentirecohort(prevalence,0.33%).Thisdislocationoccurredinapatientintherestrictedgroupduringtransferfromtheoperatingtabletoabedwithanabductionpillowinplace.Patientsintheunrestrictedgroupwerefoundtoreturntoside-sleepingsooner(p<0.001),torideinautomobilesmoreoften(p<0.026),todriveautomobilesmoreoften(p<0.001),toreturntoworksooner(p<0.001),andtohaveahigherlevelofsatisfactionwiththepaceoftheirrecovery(p<0.001)thanthoseintherestrictedgroup.Therewasanadditionalexpenditureofapproximately$655perpatientintherestrictedgroup.CONCLUSIONS:Totalhiparthroplastythroughananterolateralapproachislikelytobeassociatedwithalowdislocationrate.Removalofseveralrestrictionsdidnotincreasetheprevalenceofdislocationfollowingprimaryhiparthroplastyatourinstitution.However,itdidpromotesubstantiallylowercostsandwasassociatedwithahigherlevelofpatientsatisfactionaspatientsachievedafasterreturntodailyfunctionsintheearlypostoperativeperiod.


5. syr jänen rajoitukset - suomen artroplastiayhdistys · vii valtakunnallinen tekonivelkirurgian...

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