Knee arthrodesis and its procedure with updated management.

1. Welcome to
Journal Club

2. Presented by
Dr. SUMAN PAUL
D.Ortho- Resident
Department of Orthopaedic Surgery
Rajshahi Medical College Hospital

4. James H. MacDonald, MD,
Sanjeev Agarwal, FRCS (Orth)
Matthew P. Lorei, MD
Norman A. Johanson, MD
Andrew A. Freiberg, MD
THE JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPEDIC SURGEONS
VOLUME 14 NUMBER 3 MARCH 2006

5. Knee arthrodesis stands for surgical
fusion of the knee joint. Arthrodesis is
one of the last options available to
obtain a stable, painless knee in a
diseased or damaged knee joint which
cannot be reconstructed or replaced.
Today, there is reduction in number of
arthrodesis surgeries are performed
because of success of replacement
arthroplasty.

6.  Salvage for failed total knee arthroplasty
[Most common indication in modern times]
Post-traumatic arthritis
Chronic infection
Painful ankylosis after infection or trauma
Neuropathic arthropathy
Loss of extensor mechanism of Knee [The
joint becomes non functional]

7. Active infection
Bilateral knee arthrodesis
Contralateral limb amputation
Ipsilateral hip arthrodesis
Ipsilateral hip or ankle degenerative
joint disease

8. It is important to slightly shorten the limb and
achieve slight flexion at the knee.
5-8° valgus
0-10° of external rotation depending on the
rotation of other leg
0-15° of flexion
Some amount of limb shortening is done which
eases self care and ground clearance while walking.

9. The patient should know that this would kill the
movement at knee joint. Not only this, patient should also
understand about the finality and irreversibility of the
outcome.
To make enable the patient to make better choice that
suits him, a preoperative idea can be given to patient about
the loss of movements and restrictions imposed by
arthrodesis by application of above knee cast.
The plaster is applied for 3-6 weeks and in this period
patient can very well chose if he wants to make the choice
for knee arthrodesis.

10. There are many surgical procedures employed for knee
arthrodesis. A variety of techniques has been described for
surgical fusion and a range of implants is available.
Basic aim of the surgery is to remove cartilage and other
tissues of the knee joint to expose the underlying bone on both
sides [tibia and femur]. These exposed bones would fuse
together in due course of time.
The techniques are
External fixation
Internal fixation by compression plates across the knee
Intramedullary fixation with nail across the knee
In all procedures, bone grafting may be necessary to restore lost
bone stock or to augment fusion.

13. After eradication of the infection arthrodesis
should be performed. Refreshing the distal femur
and proximal tibia surfaces is recommended.
Typically, the femoral and tibial surfaces are recut
to create a more parallel plane of contact.
The IM nail is inserted in an anterograde
fashion through the piriformis fossa, while the
distal aspect of the nail should sit close to the
tibial plafond.
When bony defects are severe, allograft and
autograft bone grafts are different options
available.

15. Monoplanar fixation
This procedure uses compression at the site of
arthrodesis through an external frame along a
singular plane and is secured by multiple pins
along the frame. The frame is placed based on the
position of the skin incision, which is done either
anterolaterally or anteromedially. Although
compression and bending stiffness is adequate
along these planes, there have been reports of
reduced stability along the mediolateral aspect.

17. Biplanar fixators
Biplanar fixators add the mediolateral support
that is not present in monoplanar frames. This is
achieved by providing additional support through
the use of fixation in two planes, which are
secured by transfixation pins in the tibia and
femur along with Schanz pins that secure the
arthrodesis anteriorly.

19. The Ilizarov external fixator uses rings and arches to
stabilize the femur and tibia. The rings and arches are
anchored to the bone using multiple pins and Ilizarov
wires and rods are used between the rings and arches.
The advantage of the circular frames include cost
effectiveness, versatility, the ability to restore severe leg
length discrepancy, lower deep infection rates, and the
ability to make spatial adjustments without any additional
surgical procedures, such as changing the axis of
compression.

21. Compression plates involve using
single or dual plating devices as an
internal fixation method with multiple
screws securing the plate along the
axis of the femur and tibia. The plates
are placed at either the anterior,
lateral, and/or medial aspect of the
fusion site.

24. Complications of knee arthrodesis can be due to infection,
failure to unite or effects of altered gait biomechanics.
•Nonunion
•Infection
•Low back pain
•Ipsilateral hip degenerative changes
•Contralateral knee degenerative changes
•Stress fracture due to increased stress in the regions
Supracondylar femur
Proximal tibial metaphysis fractures