The Application Of Evidence-based Medicine In Hip And Knee Arthroplasty

In recent ten years, with the rapid development of biomaterials and biomedical;ngineering, the orthopaedic means of diagnosis and treatment also get great levelopment, and all kinds of new technology and new therapy have sprung up. So nangy new treatments in a wide range of well meets the clinical needs and service, out it is also a problem for clinicians to choose the suitable surgical approach.In total hip arthroplasty technology, minimally invasive surgery is more and more popular. Many orthopedic surgeons believed that minimally invasive total hip replacement had many advantages, such as minimally invasive incision, small trauma, lightweight soft tissue injury, so the patients can weight bearing on fields early, and resume the function of hip joint activities as soon as possible. In addition, all the above advantages can prevent the postoperative complications, such as hypostatic pneumonia, deep vein thrombosis, etc. However, there are still some orthopedic surgeons prefer traditional incision total hip arthroplasty, they think it can expose clearly, decrease operating time and shortened the time of anesthesia. Minimally invasive surgery or traditional incision total hip arthroplasty, which is better? It is still in debate.In terms of total knee arthroplasty, with the emergence of diversified joint prosthesis type, orthopedic surgeons are also faced with a difficult choice. Some orthopedic surgeons believed that posterior cruciate ligament should be retained for the following reasons:1. the range of motion of the knee joint is increasing,2. the muscle arm of the femoral quadriceps should be retained,3. strengthening the stability of the knee joint.4. the stress between the bone and the tibia prosthesis is reduced,5.the proprioception of the knee joint is improved. However, other orthopedic surgeon thought that posterior cruciate ligament could be sacrificed. The reasons are as follow:1. it is easier to correct the deformity of the knee jiont,2. the passive range of motion could be increased.3. it can reduce the stress between the bone and the tibia prosthesis.Evidence-based medicine (EBM) is to follow the modern medical research proof. It is the best scientific decision making of diagnosis and treatment and the best research evidence available. At the same time, EBM is combined with personal professional skills and clinical experience for a long time, considering a patient’s values and willingness to perfect combination together and developing a specific treatmen. The final purpose of EBM is to improve the quality of clinical medical treatment, the quality of medical talents and promote the development of clinical medicine, so as to serve patients more effective safeguard and health.This study, by comparing single incision minimally invasive total hip arthroplasty and traditional incision total hip arthroplasty. confinned that single incision minimally invasive surgery is not better than the traditional incision total hip arthroplasty as regardes early postoperative clinical outcomes. Then, by comparing posterior cruciate-retaining with posterior stabilized total knee arthroplasty. we got that posterior cruciate-retaining and posterior stabilized TKA have similar clinical outcomes with regard to knee function, postoperative knee pain and the other complications. Prosthesis survivorship for posterior cruciate-retaining and posterior stabilized TKA are both satisfactory and there are no differences between them at short and middle term follow-up.PART ONE Single-incision minimally invasive surgery total hip arthroplasty versus conventional incision techniques:a Meta-analysis of randomized controlled trialsObjective The aim of this Meta-analysis was to demonstrate whether single-incision minimally invasive surgery (MIS) total hip arthroplasty (THA) was superior to conventional incision techniques by comparing Harris hip scores (HHS), Western Ontario and McMaster Universities Arthritis Index (WOMAC) and postoperative complication rates.Methods We reviewed randomized controlled trials(RCTs) comparing single-incision MIS and conventional THA. Methodological quality of each included RCTs was assessed using the modified Jadad scale. The analyses were performed with Cochrane RevMan software version4.2. The GRADE approach was used to determine the quality of the evidence.Results16studies involving1415patients with1490hips were included in this Meta-analysis. A funnel plot of postoperative complication rates showed only a slight publication bias existed in this study. Meta-analysis provided different quality evidences that no significant statistical difference was observed for HHS in a period of no more than2postoperative years (WMD=0.60,95%CI:-3.98to5.18, P=0.80) and complication rates in a period of no more than3postoperative years (OR=1.07,95%CI:0.68to1.68, P=0.78) between single-incision MIS and conventional THA.Conclusion No difference was observed between MIS and conventional THA for HHS, WOMAC and complication rate. High-quality studies are still required to compare the clinical effect with different surgical approaches.PART TWO Posterior cruciate-retaining versus posterior stabilized total knee arthroplasty:a Meta-analysis of randomized controlled trialsObjective To compare the outcomes between posterior cruciate-retaining and posterior stabilized total knee arthroplasty (TKA) in order to evaluate which approach is superior.Methods Randomized controlled trials (RCTs) comparing posterior cruciate-retaining with posterior stabilized TKA were reviewed which were published up to August2011. Methodological quality of each included RCT was assessed using the Physiotherapy Evidence Database (PEDro) scale. The relevant data were analyzed using Review Manager5.1. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to determine the quality of the evidence.Results Eight RCTs involving888patients with963knee joints met predetermined inclusion criteria. The postoperative range of motion (ROM) and flexion angle were11.07°and2.88°higher for patients with a posterior stabilized TKA than those with a posterior cruciate-retaining TKA, respectively [weighted mean difference (WMD)-11.07;95%confidence interval (CI),-18.06to-4.08;p<O.01and WMD,-2.88;95%CI,-5.63to-0.12; p=0.04]. No statistical differences were observed between the two designs for knee society pain score, extension angle,2-year and5-year knee society score,2-year and5-year knee society function score and complications after primary TKA.Conclusion Posterior cruciate-retaining and posterior stabilized TKA have similar clinical outcomes with regard to knee function, postoperative knee pain and the other complications. Prosthesis survivorship for posterior cruciate-retaining and posterior stabilized TKA are both satisfactory and there are no differences between them at short and middle term follow-up.