Arthrodesis, position and brief technique in all joints

1. ARTHRODESIS
Moderator
Dr. R.K ARORA

2. Arthrodesis is an operation designed to produce bony fusion of a diseased
joint. It often is a satisfactory solution for infection, tumors, trauma, and
paralytic conditions and in certain cases of osteoarthritis and rheumatoid
arthritis to relieve pain, joint instability . Arthrodesis often results in disturbed
mechanics of adjacent joints, and in the lower extremity energy
requirements for ambulation usually are increased. The ability to achieve
nearly normal activity levels, especially in young, vigorous patients, often
outweighs these disadvantages, however. Also, it is now possible to
convert hip, and possibly knee, arthrodeses to satisfactory arthroplasties if
necessary later in life.
Arthrodesis can be intraarticular, extraarticular, or combined intraarticular and
extraarticular. Extraarticular techniques are especially useful in treating
children, because much of children's joint surfaces are cartilage, and in
treating patients who have large amounts of necrotic bone or active
infection, as in tuberculosis. Intraarticular techniques permit greater
correction of deformity and are satisfactory if adequate areas of healthy
bone surfaces can be apposed. If adequate bone is unavailable
locally, bone grafts—preferably autogenous, cancellous bone—should be
added.

3. Principles
Exposure
Good exposure
whilst care not to over devascularise bone
Preparation
Denude joints
feather subchondral bone
add bone graft in larger joints
Coaptation
Surfaces are apposed in optimal position
Fixation surfaces held rigidly
protect until union
no localized problems dermatitis, open wounds, or sepsis.
handle all surrounding soft tissues and especially tendons with great care. It is important that tendons spanning the
joint continue to function normally. Because the joints above and below the arthrodesis will compensate to a
degree, If bone ends are sclerotic as a result of a disease process, they must be removed
-

4. SHOULDER
ARTHRODESiS

5. INDICATIONS
Indications for shoulder fusion have diminished over the years
because of:
the excellent results of shoulder arthroplasty.
the near elimination of poliomyelitis and
tuberculosis.
the improved techniques for shoulder
stabilization.

7. Contraindications
Osteonecrosis.
Charcot
arthropathy(nonunion rate
is high).
Ipsilateral elbow fusion.
Contralateral shoulder
fusion.

8. The position of rotation is the most critical factor in
obtaining optimal function.

9. SURGICAL TECHNIQUES
the limited contact between the glenoid fossa and humeral
head can be improved by including the acromion in the
fusion mass.
Firm internal fixation usually eliminates the need for bone
grafting and external fixation.

10. Used as graft
COMPRESSION TECHNIQUES—EXTERNAL FIXATION
TECHNIQUE 1 (Charnley and Houston)

11. 5 to 6
weeks
cast 12
weeks

12. COMPRESSION TECHNIQUES—INTERNAL FIXATION
TECHNIQUE 1 (Cofield)

13. 45 Degrees
TECHNIQUE 1 (Cofield)
spica cast
12 to 16
weeks

14. AFTERTREATMENT:
A pelvic band extending from the
nipples to the pubic symphysis is
applied.
With the elbow flexed 90 degrees, a
cylinder cast is applied to the upper
extremity.
The extremity is suspended by two
wooden struts, or a cock-up wrist splint
is used.
At 1 to 2 weeks after surgery, a plastic
shoulder spica cast is applied and worn
until union is achieved, 12 to 16 weeks
after surgery.

15. the distal
acromion as
avascularize
d graft
TECHNIQUE (Mohammed)
A shoulder
spica 8-10
weeks

16. Apply
bone grafts
No cast
TECHNIQUE 4 (AO Group)

17. 60 D
Do not
osteotomize
the acromion
Position 30
degrees of
flexion, 30
degrees of
abduction, and
30 degrees of
internal
rotation.
A shoulder spica
cast 6weeks
TECHNIQUE 5 (Richards et al.)

19. ELBOW
ARTHRODESIS

21. POSITION
For unilateral arthrodesis of the elbow, a position
of 90degrees of flexion is desirable.
Bilateral elbow arthrodesis rarely is indicated
because of resultant functional limitations. If
indicated, one elbow should be placed in 110
degrees of flexion to permit the patient to reach
the mouth and the other should be
placed in 65 degrees to aid in personal hygiene.

22. AGraft:1.5 x 9 cm
Fitting cast
8 weeks
TECHNIQUE 1 (Steindler)

23. Grafts:8 mm x 7.5-10 cm
Fitting cast 8
weeks
TECHNIQUE 2 (Brittain)

24. Fitting cast
8 weeks
TECHNIQUE 3 (Staples)

25. Technique for fusion
in tuberculous
arthritis of elbow.
Rad head cut with
shaPING
HUMERUS+ULNA
TECHNIQUE
4(Arafiles)
use the resected
epicondylar and
olecranon fragments
as bone grafts
a long arm
cast for 3
months

26. The fixator and
pins 6 to 8 weeks
Ulna &humeral
osteotomy
done long arm
cast until the
arthrodesis is
solid
TECHNIQUE 5 (Müller et al.)ao IF+EXFIX

27. The plate and
screws 1year only
Apply bone
graft
TECHNIQUE 6 (Spier)
The most common indication was a high-energy, open, infected injury
with associated bone loss. Ulna &humeral osteotomy done

28. Complications
Complications of elbow
arthrodesis
include:
Delayed union.
Nonunion.
Malunion.
Neurovascular injury .
Painful prominent
hardware .
Skin breakdown.

29. WRIST
ARTHRODESIS

31. Contraindications
include :
An open physis of the distal radius( The distal radial physis close
approximately 17 years of age).
After partial destruction of the physis ,the remaining part may be
excised to prevent unequal growth.
An elderly patient with a sedentary lifestyle, especially if the
nondominant wrist is involved.

32. POSITION
Usually 10 to 20 degrees of extension (dorsiflexion) with the
long axis of the third metacarpal shaft aligned with the long axis
of the radial shaft (allow maximum grasping strength).
In general, neutral to 5 degrees of ulnar deviation is preferred.
If bilateral wrist fusions are indicated, the positions of the wrists
should be determined by the needs of the patient( The neutral
position).

33. The straight plate is employed when a large intercalary graft is required for a
traumatic or tumorous defect.
The short carpal bend is used in small wrists and those in which the proximal
row has been resected.
The longer carpal bend is used in large wrists.

34. TECHNIQUE 1
(AO Group)
cancellous bone
harvested from
the excised bone
A cast (10 to 12
weeks)
Denude the radiocarpal and intercarpal joint surfaces of
cartilage, and fill the gaps with cancellous bone harvested
from the excised bone and distal radial metaphysis

35. Remove approximately
80% of the proximal
scaphoid, a portion of
the hamate, and the
entire triquetrum and
lunate Retain a portion
of the scaphoid and
hamate to prevent
distal carpal row
migration. Supporting
the fusion site with
Kirschner wires or
staples.
80%
bone graft is not
cast or
splint for 12
to 16 weeks
necessary.
TECHNIQUE 2 (Louis et al.)

36. radial or lateral approach
The distal radioulnar
joint is not entered, the
extensor tendons to the
digits are not disturbed
With the wrist in 15
degrees of
dorsiflexion, cut a
slot, still using an
electric saw, in the distal
end of the radius, the
carpal bones, and the
bases of the second and
third metacarpals.
cast or splint
for 12 to 16
weeks
2.5x4cm
If the wrist is unstable,
insert a nonthreaded
Kirschner wire thr 2nd MCP
and radius
TECHNIQUE 3 (Haddad and Riordan)

37. Place an outer cortical
piece of iliac bone graft
Cast 6-8weeks
TECHNIQUE 4 (Watson and Vendor)

39. ARTHRODESIS OF
FINGER JOINTS

40. INDICATIONS
Damaged by injury or disease.
Pain.
Deformity.
Instability makes motion a liability rather than an
asset.
Arthrodesis is used most often for the proximal
interphalangeal joint because motion in this joint is
so important.
When the metacarpophalangeal joint is
destroyed, if good muscle strength is present,
arthroplasty is indicated more often than arthrodesis.

41. POSITION
The metacarpophalangeal joint should be fixed in 20 to 30 degrees of flexion.
The proximal interphalangeal joints should be fixed from 25 degrees of
flexion in the index finger to almost 40 degrees in the small finger (less flexion
in the radial fingers than in the ulnar fingers).
The distal interphalangeal joints are fixed in 15 to 20 degrees of flexion.

42. Ball-socket Or Cupcone
Splint2-3days
TECHNIQUE (Stern et al.; Segmüller, Modified)

43. A, Phalangeal osteotomy.
B, Hole for 25- or 26-gauge stainless
steel wire made through middle
phalangeal base dorsal to midaxial line.
C C, Retrograde insertion of 0.028-or
0.035-inch Kirschner wire into proximal
phalanx.
D, Kirschner wire driven into anterior
cortex of middle phalanx.
E, Figure-eight tension band created
and tightened.
Tension band
arthrodesis

44. A, Anteroposterior and lateral views of
crossed Kirschner wires.
B, Anteroposterior and lateral views of
interfragmentary wire and
longitudinal Kirschner wires.
C, Anteroposterior and lateral views of
Herbert screw

45. HIP ARTHRODESIS
hip fusions acn occur spontaneously following childhood sepsis or after ORIF of
acetabular fractures (secondary to heterotopic bone).
- they also occur spontaneously due to ankylosing spondylitis;
- surgical fusions are performed for young adults with advanced arthritis;
- indications:
- desire to return to near-normal physical activity with manual labor;
- 20 yrs years after surgery, 80% of pts w/ hip arthrodesis performed at
relatively young age were working & satisfied w/ their results;
- relief of pain;
- young male;
- requirements:
- normal contralateral hip, ipsilateral knee, and a low back are
prerequisites in preoperative planning;
- pain and instability of the ipsilateral knee may also occur in pts w/ a
fused hip;
- pts w/ long-standing hip fusion may develop progressive
nonradicular pain in the low back that worsens with activity;
- no cardiovascular pathology:

46. Surgical Considerations:
- position of hip fusion:
- neutral abduction, exteran rotation of 0-30 deg &, 20-25 deg of flexion;
- avoid abduction and internal rotation;
- this position is design to minimize excessive lumbar spine motion and
opposite knee motion which helps minimize pain in these regions;
- fixation:
- AO Cobra Plate: stable but disrupts abductors:
- trans-articular sliding hip screw:
- lag screw is inserted across the joint and just superior to the dome
of the acetabulum;
- disadvantage of this technique includes poor fixation (due to large
lever arm and the resulting torque on the lever arm) and need
for postoperative hip spica casting;
- osteotomy:
- some authors advocate supra-acetabular osteotomy or
subtrochanteric osteotomy for improved positioning;

47. Arthrodesis with Cancellous Screw Fixation
Benaroch et al. described a simple method of hip arthrodesis for adolescent
patients. Through an anterolateral approach, an anterior capsulotomy is
performed, the femoral head is dislocated, and both sides of the joint are
denuded of articular cartilage and necrotic bone
Arthrodesis with a Muscle-Pedicle Bone Graft
Davis described a technique in 1954 that included transfer of a portion of the
anterior ilium with the origins of the tensor fascia lata and the anterior fibers
of the gluteus medius and gluteus minimus as a muscle-pedicle bone graft.
12 weeks of postoperative spica cast immobilization

48. Schneider's development of the
cobra-head plate for hip
arthrodesis, the technique has
been modified to allow
restoration of abductor function
if the fusion is later converted to
a total hip arthroplasty withGT
reattachment. The technique
includes a medial displacement
osteotomy of the acetabulum
and rigid internal fixation with
the cobra plate. transverse
innominate osteotomy between
the iliopectineal eminence and
the sciatic notch at the superior
pole of the acetabulum.
Pseudoarthrodesis in overweight
patients

49. Arthrodesis in the Absence of the Femoral Head
In 1931, Abbott and Fischer designed a method for arthrodesis of the hip after
infection with complete destruction of the femoral head and neck. The
procedure also has been used after nonunion of the femoral neck, in patients
with osteonecrosis of the femoral head, after failed femoral head
prostheses, and in patients with infected trochanteric mold arthroplasties. The
operation is carried out in two or three stages: (1) correction of the deformity
(rarely necessary as a separate stage), (2) arthrodesis of the hip in wide
abduction, and (3) final positioning by subtrochanteric osteotomy
Total Hip Arthroplasty after Hip Arthrodesis
Conversion of a hip arthrodesis to total hip arthroplasty most often is indicated for
pain or generalized loss of function from immobility or malposition. This is a
technically demanding procedure, complications and failures are frequent, and
improvement of function is uncertain.
In addition to cobra-plate fixation, anterior AO plate is used. Reikerås et al. found
that their best results were obtained in patients who were young when they
underwent fusion of the hip and who had had the hip fusion for a relatively
short time

50. Knee arthrodesis
optimal position of arthrodesis:
- slight valgus, 10 deg of external rotation, and 0-20 deg of flexion
(knees that have been shortened due to previous arthroplasty should be
fused in full extension);
- valgus alignment with slight flexion easier to obtain with an
external fixator than w/ IM nail;
- IM nails tend to cause 2-5 deg of varus;
Plate used in difficult cases needing segmental alllografts
- note that if future total knee replacement is a consideration (fusion
takedown and arthroplasty) then it is important that the patella not be
included in the fusion;
Perform knee debridement
there must be vascular cancellous bone apposition.
- resection of 1-2 mm of bone from distal aspect of femur & proximal
aspect of tibia exposes vascular bone;
- contra-indications:
- bilateral knee disease;
- ipsilateral ankle or hip disease;
- severe segmental bone loss;
- contralateral leg amputation;

51. Knee arthrodesis with Ex fix
Compression arthrodesis generally is indicated for knees
with minimal bone loss and broad cancellous surfaces
with adequate cortical bone to allow good bony
apposition and compression. Advantages of compression
arthrodesis include the application of good, stable
compression across the fusion site and the placement of
fixation proximal and distal to an infected or neuropathic
joint. Disadvantages include external pin track problems,
poor patient compliance, and the frequent need for early
removal and cast immobilization.

52. Arthrodesis with nail
Intramedullary nailing techniques probably are
most appropriate when extensive bone loss does
not allow compression to be exerted across broad
areas of cancellous bone, such as after tumor
resection or failed total knee arthroplasty. The
advantages of intramedullary nailing are
immediate weight bearing, easier
rehabilitation, absence of pin track
complications, and high fusion rate
A two-stage procedure adviced for all patients
with an infected total knee arthroplasty and ab
beads implanted
Resection arthrodesis with intercalary allografts
fixed with intramedullary nails was used by
Weiner et al. for treatment of malignant or
aggressive benign bone
The nail should extend from the tip of the greater
trochanter to within 2 to 6 cm from the plafond of
the ankle
Kuntscher nail were used for it but nowadays IL
nails preferred

53. ANKLE ARTHRODESIS
Arthrodesis of the ankle is performed more frequently than arthrodesis of the hip or knee.
The most common indication is posttraumatic arthritis . Other indications include
rheumatoid arthritis, infection, neuromuscular conditions, and salvage of failed total
ankle arthroplasty. Resection arthrodesis may be indicated for treatment of bone tumors
around the ankle. Ankle arthrodesis currently is being performed more frequently in
patients with neuropathic arthropathy with severe deformity, but
complications, especially infection and nonunion, are more common in these
patients.The optimal position for ankle fusion is 0 degrees of flexion, 0 to 5 degrees of
valgus, and 5 to 10 degrees of external rotation with slight posterior displacement of the
talus. This position is best attained by draping the lower extremity so that the area from
the toes to above the knee is accessible.
An attempt should be made to create broad, flat, cancellous surfaces that are placed into
apposition to allow fusion to occur.
The arthrodesis site should be stabilized with rigid internal fixation, if possible, or with
external fixation. This may be difficult in patients with osteoporotic bone.
The hindfoot should be aligned to the leg and the forefoot to the hindfoot to create a
plantigrade foot
prior to ankle arthrodesis, the patient should be given the option of wearing either a below
knee cast or CAM walker

54. aRThrodesis a=can be achieved with Ex-fix,trans-articular cross screw fixation,
posterior blade-plate fixation for ankles with segmental bone loss, infected
nonunion, or collapsed talar body.
Nail used as salvage procedure
significant posttraumatic
arthrosis and bone loss after
tibial plafond
fracture, concomitant
subtalar arthrosis, severe
osteopenia (e.g., in patients
with rheumatoid
arthritis), and neuropathic
arthropathy

55. Types of bone grafts used in ankle
arthrodesis. A, Tricortical block of iliac
crest wedged between tibia and talus.
B and C, Sliding graft impacted into
tunnel in talar neck or talar bed (C).
D, Central bone graft inserted in hole
bored across ankle
Arthroscopic arthrodesis is trending
upwards nowadays