Arthrodesis 22 5-2007

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Arthrodesis 22 5-2007

  1. 1. ARTHRODESIS Dr. Dibyendunarayan Bid
  2. 2. Arthrodesis <ul><li>The term arthrodesis refers to surgical fusion of a joint. </li></ul><ul><li>The indications for this are pain & instability in a joint and, in some situations, following the failure of joint replacement . </li></ul><ul><li>With the increase & improvements in the field of joint replacement arthrodesis is now carried out much less frequently. </li></ul>01/16/11 dibyendu
  3. 3. Arthrodesis <ul><li>In the lower limb, because of the larger stresses brought about by wt-bearing, arthrodesis as a primary procedure should only be used if adjacent joints and the joints of other leg are sound. </li></ul><ul><li>This applies to a much lesser degree in the upper limb where, for e.g. arthrodesis of a painful, unstable wrist in RA may in fact considerably improve the function of involved fingers & thumb. </li></ul><ul><li>A successful arthrodesis is a sure way of permanently relieving pain but it is bought at the price of stiffness . However it may be a small price to pay in some situations. </li></ul>01/16/11 dibyendu
  4. 4. Arthrodesis <ul><li>Ideally arthrodesis is carried out as an intra-articular procedure. All articular cartilage is removed from both surfaces of the joint and the bone ends shaped to fit in the required position. </li></ul><ul><li>They are held there by internal fixation , an external fixator device or external splintage (e.g. POP) or a combination of these methods, until the fusion is sound. </li></ul><ul><li>Where possible compression is applied to the bone ends to promote fusion. Occasionally extra-articular arthrodesis is carried out. </li></ul><ul><li>This usually applies to hip and shoulder joints. </li></ul><ul><li>Here the joint surfaces are not disturbed and fusion is achieved by bridging the joint by a bone graft adjacent to it, e.g. from the femur to the ischium. </li></ul>01/16/11 dibyendu
  5. 5. Arthrodesis W IKIPEDIA DEFINITION <ul><li>Arthrodesis , also known as artificial ankylosis or syndesis , is the artificial induction of joint ossification between two bones via surgery . </li></ul><ul><li>This is done to relieve intractable pain in a joint which cannot be managed by pain medication , splints , or other normally-indicated treatments. </li></ul><ul><li>The typical causes of such pain are fractures which disrupt the joint, and arthritis . </li></ul><ul><li>It is most commonly performed on joints in the spine , hand , ankle , and foot . </li></ul>01/16/11 dibyendu
  6. 6. <ul><li>It can be done in several ways: </li></ul><ul><li>A bone graft can be created between the two bones using a bone from elsewhere in the person's body (autograft) or using donor bone ( allograft ) from a bone bank . </li></ul><ul><ul><li>Bone autograft is generally preferred by surgeons because, as well as eliminating the risks associated with allografts, bone autograft contains native bone-forming cells ( osteoblasts ), so the graft actually forms new bone itself (osteoinductive), as well as acting as a matrix or scaffold to new bone growing from the bones being bridged (osteoconductive). The main drawback of bone autograft is the limited supply available for harvest. </li></ul></ul><ul><ul><li>Bone allograft has the advantage of being available in far larger quantities than autograft; however, the treatment process the bone goes through following harvest, which usually involves irradiation and deep-freezing, kills the bone forming cells. This significantly reduces the immunogenicity (risk of graft rejection) such that no anti rejection drugs are needed. The process also makes the allograft function only as an osteoconductive matrix. </li></ul></ul>01/16/11 dibyendu
  7. 7. <ul><li>A variety of synthetic bone substitutes are commercially available. These are usually hydroxyapatite based granules formed into a coralline or trabecular structure to mimic the structure of cancellous bone . They act solely as an osteoconductive matrix. Some manufacturers have recently begun supplying these products with soluble bone-forming factors such as bone morphogenetic protein to attempt to create a synthetic product with osteoinductive properties . </li></ul><ul><li>Metal implants can be attached to the two bones to hold them together in a position which favors bone growth. </li></ul><ul><li>A combination of the above methods is also commonly employed to facilitate bony fusion. </li></ul><ul><li>At the completion of surgery and healing, which takes place over a period of several months to over a year, the two adjoining bones are fused and no motion takes place between them. This can have the effect of actually strengthening the bones, as in anterior cervical fusion. </li></ul>01/16/11 dibyendu
  8. 8. FIXATION POSITIONS The optimum positions for arthrodesis in different joints are as follows: <ul><li>SHOULDER: In such a position that the hand can comfortably reach the mouth. Arthrodesis of shoulder joint is usually reserved for a flail joint as may follow a brachial plexus injury. Stabilization of this joint may lead to improvement in the remaining distal function of the arm. </li></ul><ul><li>ELBOW : 90 ° of flexion in clerical workers. Slightly straighter in laborers. </li></ul><ul><li>WRIST: A few degree of extension unless both wrists are arthrodesed, in which case one should be fused in some flexion to permit the carrying out of certain toilet functions. </li></ul><ul><li>THUMB: MCP joint in 20 ° of flexion. IP joint in slight flexion. </li></ul><ul><li>FINGERS: MCP joints in 20 ° -30 ° of flexion. (these joints are rarely fused). </li></ul><ul><li>Proximal IP joints in 40 ° -45 ° of flexion (less in middle & index fingers) </li></ul>01/16/11 dibyendu
  9. 9. Episode: 2 01/16/11 dibyendu
  10. 10. Shoulder Arthrodesis <ul><li>Indications:       - shoulder paralysis:       - may include paralytic dislocation or combined </li></ul><ul><li>rotator cuff / deltoid paralysis (in which case </li></ul><ul><li>shoulder arthroplasty would be contra-indicated);       - as a requirement for shoulder fusion, the muscles </li></ul><ul><li>of forearm and hand need to be functional         as do the serratus anterior and trapezius ;       - the later muscles need to be strong inorder to </li></ul><ul><li>control scapulothoracic motion after the fusion;       - degenerative or rheumatoid arthritis; </li></ul>01/16/11 dibyendu
  11. 11. <ul><li>Functional Position:     - fusion should allow the patient to reach the face as well as the back </li></ul><ul><li>pocket;     - when trapezius and serratus anterior function is acceptable, position </li></ul><ul><li>in:           - abduction:                 - recommendations have ranged from 15 deg to 45 deg;                 - historically recommended positions for shoulder fusion have </li></ul><ul><li>ranged from 30-45 deg;                 - abduction beyond 45 deg may be associated with pain and </li></ul><ul><li>winging of the scapula;                 - when serratus anterior is paralyzed, the shoulder should be </li></ul><ul><li>fused in no more than 30 deg of abduction;                 - otherwise, the weight of the arm may depress the lateral part </li></ul><ul><li>of the scapula and overstretch and   weaken the trapezius;           </li></ul><ul><li>- flexion: less than 10-30 deg; </li></ul><ul><li>          - internal rotation: 20-45 deg;                 - allows patient to reach contra-lateral should, belt, and mouth;                 - deg of rotation can be the most important factor determining </li></ul><ul><li>extremity function;       </li></ul>01/16/11 dibyendu
  12. 12. <ul><li>Post Operative Evaluation: </li></ul><ul><li>  - motion of scapula then compensates for the </li></ul><ul><li>lack of motion in joint; </li></ul><ul><li>  - single most important cause of </li></ul><ul><li>complications following shoulder arthrodesis </li></ul><ul><li>is malposition, either too much flexion or too </li></ul><ul><li>much abduction, which results in </li></ul><ul><li>periscapular pain; </li></ul>01/16/11 dibyendu
  13. 13. <ul><li>Arthrodesis in Children: </li></ul><ul><li>    - indications:           - children w/ paralysis of shoulder girdle muscles w/ subluxation or dislocation (as might occur in Polio) inorder to stabilize the flail shoulder;     </li></ul><ul><li> - prerequisites for procedure:           - functional results are related to neurologic status of distal arm & </li></ul><ul><li>hand, & therefore normal function of forearm & hand is a </li></ul><ul><li>prerequisite;           - strong trapezius & serratus anterior muscles are required in order to </li></ul><ul><li> allow for increased scapulothoracic movement;     </li></ul><ul><li> - optimal age is controversial;             - since it is difficult to predict the final position, some delay shoulder arthrodesis until skeletal maturity;     </li></ul><ul><li>- pseudoarthrosis: may occur in 20%;             - solid fusion is technically difficult to achieve in children because of the amount of cartilage in pediatric humeral head;             - care must be taken to preserve the proximal humeral growth plate in skeletally immature patient;     </li></ul>01/16/11 dibyendu
  14. 14. <ul><li>- optimal position of arthrodesis: </li></ul><ul><li>            - abduction: 15 deg (but 45 deg as been </li></ul><ul><li>recommended historically);                   - excessive abduction should be avoided, because excessive scapular winging can result; </li></ul><ul><li>                  - there may be loss of 10-20 degrees of abduction during first 12 months in young children;             - flexion: 25 deg;             - internal rotation: 25 deg; </li></ul>01/16/11 dibyendu
  15. 15. Episode: 3 01/16/11 dibyendu
  16. 16. ELBOW ARTHRODESIS 01/16/11 dibyendu
  17. 17. ELBOW ARTHRODESIS <ul><li>An elbow fusion helps get rid of pain because the bones of the joint no longer rub together. </li></ul><ul><li>Advanced arthritis ►change the alignment of the elbow► leading to deformity. </li></ul><ul><li>Likewise, elbow injuries ► alter normal alignment and eventually produce arthritis. </li></ul><ul><li>Fusing the bones together improves the alignment and prevents further deformation. </li></ul><ul><li>Patient will not be able to bend the elbow after fusion surgery. An elbow fusion is a tradeoff. Patient will lose the hinge motion in your elbow, but Patient will regain a strong, pain-free elbow joint. Regaining strength is especially important to laborers who work with their arms and hands. </li></ul><ul><li>The radius bone of the forearm is usually not part of the elbow fusion. The end of the radius forms a joint with the ulna. When this joint is a source of pain, the surgeon may remove the round end of the radius near the elbow. This still allows the forearm to rotate. </li></ul>01/16/11 dibyendu
  18. 18. Elbow Arthrodesis 01/16/11 dibyendu
  19. 19. Surgical Procedure for Elbow Fusion <ul><li>There are many different types of operations to fuse the elbow. </li></ul><ul><li>Most of the procedures are designed to remove the articular cartilage from the joint surfaces of the hinge joint and then bind the two surfaces together until they heal. </li></ul><ul><li>When the fusion is healed, a strong, solid connection between the humerus and ulna will have replaced the painful arthritic joint. </li></ul>01/16/11 dibyendu
  20. 20. Surgical Procedure for Elbow Fusion <ul><li>The first step in an elbow fusion is an incision down the back of the elbow. The incision is made on the back side because most of the blood vessels and nerves are on the inside of the elbow. Entering through the back of the elbow makes them less likely to be damaged. </li></ul><ul><li>The surgeon then moves the tendons and ligaments to the side to expose the joint surfaces. Care must be taken to protect the nerves that run beside the elbow joint on their way to the hand. The surgeon then removes the articular cartilage surface of each side of the joint. </li></ul><ul><li>The surgeon must then fix the humerus and ulna in place until they can heal together. The elbow is bent to 90 degrees and the bones are carefully aligned. The bones must be properly aligned and immobilized for fusion to occur. </li></ul>01/16/11 dibyendu
  21. 21. Elbow Arthrodesis 01/16/11 dibyendu
  22. 22. Plate Fixation <ul><li>There are different ways of holding the bones together. Many surgeons place a metal plate with screw holes onto the back of the elbow, from the humerus to the ulna. The metal plate is attached to the bone with metal screws. </li></ul><ul><li>The metal plate stays in the arm permanently. </li></ul><ul><li>It is only removed if it causes problems. </li></ul>01/16/11 dibyendu
  23. 23. External Fixation <ul><li>Another way to hold the bones together is to use an external fixator . Surgeons sometimes choose ►an external fixator if there have been an infection. </li></ul><ul><li>An external fixator involves placing metal pins through the bones above and below the elbow joint. </li></ul><ul><li>Surgeon may also place a metal screw inside the ulna and humerus to pull the bones together. The external fixator device is then placed on the elbow outside the skin, after the incision is sewn up. The external fixator attaches to the metal pins, which come through the skin, with metal rods and bolts. </li></ul><ul><li>At the end of the fusion operation, the incisions are sutured together. </li></ul><ul><li>If patient does not have an external fixator, the arm is placed in a large splint or cast. It usually takes about 12 weeks for the fusion to become solid. At this point the metal pins and rods of the external fixator are removed. </li></ul>01/16/11 dibyendu
  24. 24. Elbow Arthrodesis 01/16/11 dibyendu
  25. 25. ELBOW ARTHRODESIS 01/16/11 dibyendu
  26. 26. After Surgery <ul><li>After surgery, patient will either wear an external fixator for up to 12 weeks or a long-arm cast for about six weeks. </li></ul><ul><li>Both devices hold the elbow still while the ends of the bones fuse together. Surgeon will check operated elbow within five to seven days. Stitches will be removed after 10 to 14 days, although most of them will have been absorbed by the body. </li></ul><ul><li>Patient may have some discomfort after surgery ► give pain medicine to control the discomfort. </li></ul><ul><li>Patient should keep arm elevated above the level of heart for several days to avoid swelling and throbbing. </li></ul><ul><li>Keep it propped up on a stack of pillows when sleeping or sitting. </li></ul>01/16/11 dibyendu
  27. 27. Rehabilitation <ul><li>Patients who have an external fixator should expect to wear it for up to 12 weeks. When a cast is used, some doctors will replace it with a removable splint after six to eight weeks. </li></ul><ul><li>If patient wears a cast, the joints in wrist and fingers may feel stiff or sore. </li></ul><ul><li>Surgeon will X-ray the elbow several times after surgery to make sure that the bones are healing properly. </li></ul><ul><li>Once surgeon is sure that fusion has occurred, patient can safely begin a strengthening program. It will take some time to regain the strength in the arm. </li></ul><ul><li>As with any surgery, one needs to avoid doing too much, too quickly. </li></ul>01/16/11 dibyendu
  28. 28. <ul><li>If patient gets pain or stiffness in the shoulder, wrist, or finger joints, may need a physical therapist to direct recovery program. The first few therapy treatments will focus on controlling the pain and swelling. Therapist may use gentle massage and other types of hands-on treatments to ease muscle spasm and pain. </li></ul><ul><li>Then patient will begin gentle range-of-motion exercises for the arm. </li></ul><ul><li>Strengthening exercises give patient added stability around the elbow joint. Some of the exercises patient do are designed to get the arm working in ways that are similar to work tasks and daily activities. </li></ul>Rehabilitation 01/16/11 dibyendu
  29. 29. <ul><li>Therapist will teach ways to use the arm so that patient can do the tasks safely and with the least amount of stress on the elbow. </li></ul><ul><li>Before your therapy sessions end, therapist will teach patient a number of ways to avoid future problems. </li></ul><ul><li>Therapist's goal is to help patient keep pain under control, improve strength, and learn how to adjust activities to avoid putting too much strain on arm and elbow. </li></ul>Rehabilitation 01/16/11 dibyendu
  30. 30. Episode : 4 01/16/11 dibyendu
  31. 31. <ul><li>WRIST ARTHRODESIS </li></ul>01/16/11 dibyendu
  32. 32. <ul><li>Arthritis of the wrist has many causes, and there are many ways of treating the pain. These treatments can be very successful, at least for awhile. But eventually the entire wrist can become so painful that nonsurgical treatments don't work anymore. </li></ul><ul><li>At this point, surgeon may recommend a wrist fusion . Wrist fusion may also be necessary after severe trauma to the wrist. </li></ul>01/16/11 dibyendu
  33. 33. 01/16/11 dibyendu
  34. 34. Rationale of wrist arthrodesis <ul><li>Many of the small joints in the wrist ►arthritic. When this happens, the wrist joint ► extremely painful . Moving wrist may become difficult because of the pain and stiffness. Grip can also get weak from the pain . Whenever the hand grips or uses strength in any way, the wrist feels the force. This happens because the muscles running from the forearm to the hand contract, tightening the wrist bones together. This causes ► pain. </li></ul><ul><li>In advanced arthritis, the alignment of the wrist can change, leading to ► deformity. </li></ul><ul><li>Fusing the bones together is a way to improve the alignment and prevent further deformation. Fusion may also be needed to align the wrist after a severe wrist injury. </li></ul>01/16/11 dibyendu
  35. 35. <ul><li>A fusion of any joint eliminates pain by making all the bones grow together into one solid bone. </li></ul><ul><li>Fusion surgeries were very common before the invention of artificial joints. </li></ul><ul><li>A wrist fusion is somewhat different from fusion in other joints. Most joints are made up of only two bones. Wrist fusion involves getting 12 or 13 bones to grow together. </li></ul>01/16/11 dibyendu
  36. 36. <ul><li>The goal of a wrist fusion is to get the radius in the forearm, the carpal bones of the wrist, and the metacarpals of the hand to fuse into one long bone. </li></ul><ul><li>The ulna of the forearm is not included in the fusion. By not fusing the ulna, one should still be able to rotate the hand. However, one will not be able to bend the wrist after the operation. </li></ul><ul><li>A wrist fusion is a trade-off. Patient will lose some motion, but will regain a strong and pain-free wrist. </li></ul><ul><li>Regaining strength is especially important to younger people who need to work with their hands. These patients need strength more than flexibility. Wrist fusion gives them a strong wrist that is good for gripping. </li></ul><ul><li>Patients who need more movement than strength should consider another type of operation, such as an artificial wrist joint replacement. </li></ul>01/16/11 dibyendu
  37. 37. Surgical Procedure <ul><li>Surgeons fuse wrists in many different ways. In the past, most of the procedures used a bone graft from the pelvis. Surgeons now try to take a small amount of bone from the end of the radius bone instead. </li></ul><ul><li>A bone graft involves taking bone tissue from one area and transplanting it into another area. This encourages the ends of the bone to grow together. </li></ul>01/16/11 dibyendu
  38. 38. <ul><li>Surgery can last up to 90 minutes. Surgery may be done using a general anesthetic . In some cases, surgery is done using a local anesthetic , which numbs just the wrist and hand. </li></ul><ul><li>Once patient has anesthesia, surgeon will make sure the skin of the wrist and hand are free of infection. The surgeon then makes an incision down the back of the wrist. Since most of the blood vessels and nerves are on the other side of the wrist, going through the back helps prevent nerve and vessel damage. </li></ul>01/16/11 dibyendu
  39. 39. <ul><li>Next, the tendons and ligaments are moved to the side. This allows the surgeon to see all the bones and joints of the wrist. The articular cartilage is then removed from each joint that will be fused. At this point, the wrist joint consists of many small bones with space between them where the cartilage is missing. If patient is getting a bone graft, the graft is placed between each of the spaces in the wrist bones. </li></ul><ul><li>The surgeon places a metal plate with screw holes on the back of the wrist. The plate goes from the radius to the metacarpal bone of the middle finger. The plate is attached to the bone with metal screws. The plate keeps the bones from moving so that they stay in proper alignment while they grow together. The plate usually stays inside the hand permanently. It is not removed unless it causes problems. </li></ul>01/16/11 dibyendu
  40. 40. 01/16/11 dibyendu
  41. 41. <ul><li>At the end of the operation, the incisions are stitched together. </li></ul><ul><li>Patient’s arm is placed in a large, rigid splint or cast, and is woken up and taken to the recovery room. </li></ul>01/16/11 dibyendu
  42. 42. After Surgery <ul><li>After surgery, patient will wear an elbow-length cast for about six weeks. This holds the wrist still while the ends of the bones fuse together. </li></ul><ul><li>Surgeon will check the hand within five to seven days. Stitches will be removed after 10 to 14 days, although most of them will have been absorbed by the body. Patient may have some discomfort after surgery. Surgeon can give pain medicine to control the discomfort. </li></ul><ul><li>Patient should keep the hand and wrist elevated above the level of heart for several days to avoid swelling and throbbing. Keep it propped up on a stack of pillows when sleeping or sitting up. </li></ul>01/16/11 dibyendu
  43. 43. Rehabilitation <ul><li>A removable splint replaces the cast after 6-8 weeks. One can then take the splint off to do exercises during the day. The joints in the fingers may feel stiff or sore from the immobility caused by the cast. </li></ul><ul><li>If patient still have pain, or if the stiffness in the joints above or below the wrist doesn't improve, patient may need a physical therapist to direct recovery program. The first few therapy treatments will focus on controlling the pain and swelling from surgery. </li></ul><ul><li>Therapist may use gentle massage and other types of hands-on treatments to ease muscle spasm and pain. Then patient will begin gentle ROM exercises for the joints above and below the wrist. </li></ul>01/16/11 dibyendu
  44. 44. <ul><li>Surgeon will X-ray the wrist several times after surgery to make sure that the bones are healing properly. </li></ul><ul><li>Once surgeon is sure that fusion has occurred, patient will begin a strengthening program. It will take some time to regain the strength in the hand and arm. </li></ul><ul><li>As with any surgery, one needs to avoid doing too much, too quickly. </li></ul>01/16/11 dibyendu
  45. 45. <ul><li>Strengthening exercises gives added stability around the wrist joint. </li></ul><ul><li>Some of the exercises patient will do are designed to get the hand and wrist working in ways that are similar to the work tasks and daily activities. </li></ul>01/16/11 dibyendu
  46. 46. <ul><li>Therapist's goal is to help patient keep: </li></ul><ul><li>► pain under control, </li></ul><ul><li>► improve strength, and </li></ul><ul><li>► to regain fine motor abilities with wrist </li></ul><ul><li>and hand. </li></ul>01/16/11 dibyendu
  47. 47. Wrist Arthrodesis <ul><li>Lateral wrist radiograph depicting marked wear in radiocarpal articulation. </li></ul>01/16/11 dibyendu
  48. 48. Specific indications for wrist (radiocarpal) arthrodesis: <ul><li>Posttraumatic OA of the radiocarpal joint and midcarpal joints as commonly observed following chronic scapholunate dissociation complex fractures </li></ul><ul><li>A previous unsuccessful more limited arthrodesis. </li></ul><ul><li>An unsuccessful total-joint or previous arthroplasty of the radiocarpal joint </li></ul><ul><li>Paralysis of the wrist or hand with potential for reconstruction involving the use of wrist or finger motions for tendon transfer </li></ul><ul><li>Reconstruction following segmental tumor resection, infection, or traumatic segmental bone loss of the distal radius and carpus </li></ul><ul><li>Adolescent spastic hemiplegia with wrist flexion deformity </li></ul><ul><li>Rheumatoid arthritis </li></ul>01/16/11 dibyendu
  49. 49. Etiology: <ul><li>Causative factors for wrist arthropathy include, but are not limited to: </li></ul><ul><li>► trauma, ►RA, </li></ul><ul><li>► crystalline arthropathy, ► carpal instability, </li></ul><ul><li>► avascular necrosis, </li></ul><ul><li>► destruction due to tumors, </li></ul><ul><li>► septic arthritis, and </li></ul><ul><li>► mechanical overuse. </li></ul><ul><li>Wrist arthrodesis is also indicated for </li></ul><ul><li>► stabilization of the wrist when combined with tendon </li></ul><ul><li>transfers, </li></ul><ul><li>► correction of wrist deformities in patients with spastic </li></ul><ul><li>hemiplegia, and </li></ul><ul><li>► for salvage of unsuccessful wrist arthroplasty. </li></ul>01/16/11 dibyendu
  50. 50. Clinical findings: <ul><li>The patient reports pain in one or both wrists. The individual may recall a history of trauma to the affected wrist or have a related diagnosis such as rheumatoid arthritis or gout. The patient's pain is usually progressive and, has already been treated conservatively. The pain is usually exacerbated with use and relieved with rest and NSAIDS. The patient may have swelling and stiffness associated with the wrist pain. </li></ul><ul><li>Preoperatively, patients should be assessed for the presence of carpal tunnel syndrome, distal radioulnar joint arthritis, or ulnocarpal impaction syndrome, which may become or remain symptomatic after arthrodesis. </li></ul><ul><li>On physical examination, painful ROM of the wrist is present. Soft tissue swelling may be noted around the wrist or an effusion. Provocative testing of the carpus may reveal instability or laxity of the intercarpal ligaments. The patient usually has decreased ROM of the wrist due partly to a mechanical block and partly to pain. </li></ul><ul><li>Radiographs of the wrist reveal changes consistent with arthropathy and arthritis. </li></ul>01/16/11 dibyendu
  51. 51. Specific wrist fusion complications : <ul><li>Nonunion </li></ul><ul><li>Plate tenderness </li></ul><ul><li>Extensor/flexor tendon adhesions requiring tenolysis </li></ul><ul><li>Carpal tunnel syndrome </li></ul><ul><li>Iliac crest donor complications </li></ul><ul><li>Distal radioulnar joint pain or dysfunction </li></ul><ul><li>Reflex sympathetic dystrophy </li></ul><ul><li>Wound-healing problems </li></ul><ul><li>Persistent unexplained pain </li></ul>01/16/11 dibyendu
  52. 52. Wrist arthrodesis. <ul><li>Posteroanterior wrist radiograph demonstrating marked radiolunate degenerative joint disease. </li></ul><ul><li>Either a radioscapholunate fusion or total wrist fusion is an appropriate treatment option. </li></ul>01/16/11 dibyendu
  53. 53. Wrist arthrodesis <ul><li>Radiograph of a patient following wrist fusion. </li></ul><ul><li>No distal ulna resection was necessary in this case. </li></ul>01/16/11 dibyendu
  54. 54. Wrist arthrodesis <ul><li>Lateral view following wrist fusion demonstrating dorsiflexion provided by plate. </li></ul>01/16/11 dibyendu
  55. 55. Wrist arthrodesis . <ul><li>Posteroanterior radiograph of wrist following scaphoid excision and </li></ul><ul><li>4-corner (lunate-capitate-hamate-triquetrum) fusion. </li></ul>01/16/11 dibyendu
  56. 56. Episode: 5 01/16/11 dibyendu
  57. 57. THUMB ARTHRODESIS 01/16/11 dibyendu
  58. 58. THUMB FUSION <ul><li>When the articular cartilage wears out, the CMC joint becomes arthritic. The joint becomes painful when the thumb is used for gripping and pinching. </li></ul><ul><li>Joint fusion is a procedure that joins the surfaces of the thumb metacarpal and the trapezium so they don't move or cause pain. </li></ul><ul><li>This surgery is usually done on younger patients who have to have a lot of thumb strength on the job, such as carpenters who need to use a hammer all day. Once the CMC joint is fused, their pain goes away. They lose joint movement, but they still have a good ability to grip and pinch. </li></ul>01/16/11 dibyendu
  59. 59. 01/16/11 dibyendu
  60. 60. After Surgery <ul><li>After surgery, patient will be fitted in an elbow-length cast. This gives the ends of the bones the opportunity to fuse together. </li></ul><ul><li>Surgeon will check the hand within five to seven days. Stitches will be removed in 10 to 14 days, though most of stitches will be absorbed into the body. </li></ul><ul><li>Patient may have some discomfort after surgery & will be given pain medicine to control the discomfort. </li></ul><ul><li>Patient should keep the hand elevated above the level of the heart for several days to avoid swelling and throbbing. Keep it propped up on a stack of pillows when sleeping or sitting up. </li></ul>01/16/11 dibyendu
  61. 61. Rehabilitation of thumb fusion <ul><li>Patient will wear the cast for about six weeks to give the fusion time to heal. When the cast is removed, patient may have stiffness in the joints on both sides of the fusion. </li></ul><ul><li>If patient has pain or stiffness that doesn't improve, ► may need a physical therapist to direct recovery program. The first few therapy treatments will focus on controlling the pain and swelling from surgery. Therapist may use gentle massage and other hands-on treatments to ease muscle spasm and pain. </li></ul><ul><li>Then patient will begin gentle ROM exercise for the joints above and below the fusion. Strengthening exercises are used to give added stability around the thumb joint. </li></ul><ul><li>Patient will learn ways to grip and support items in order to do the tasks safely and with the least amount of stress on the thumb joint. </li></ul>01/16/11 dibyendu
  62. 62. Continued…. <ul><li>Therapist's goal is to help patient keep </li></ul><ul><li>► pain under control, </li></ul><ul><li>► improve your strength and range of motion, and </li></ul><ul><li>► regain fine motor abilities with the hand and thumb. </li></ul>01/16/11 dibyendu
  63. 63. Episode: 6 01/16/11 dibyendu
  64. 64. FINGER ARTHRODESIS 01/16/11 dibyendu
  65. 65. Finger fusion <ul><li>Arthritis of the finger joints may be surgically treated with a fusion procedure. Fusion keeps the problem joints from moving so that pain is eliminated. </li></ul><ul><li>Arthritic finger joints cause pain and make it difficult to perform normal movements, such as grasping and pinching. Advanced arthritis can also loosen the joint and may begin to cause finger joint deformity. </li></ul><ul><li>Joint fusion is a procedure that binds the two joint surfaces of the finger together, keeping them from rubbing on one another. </li></ul><ul><li>Fusing the two joint surfaces together eases pain, makes the joint stable, and prevents additional joint deformity. </li></ul>01/16/11 dibyendu
  66. 66. Surgical Procedure <ul><li>Surgery can last up to 90 minutes. Surgery may be done using a general anesthetic , or a local anesthetic . </li></ul><ul><li>An incision is made on the back part of the finger over the surface of the joint that is to be fused. Special care is taken not to damage the nearby nerves going to the finger. </li></ul>01/16/11 dibyendu
  67. 67. <ul><li>The joint capsule surrounding the finger joint is then opened so that the surgeon can see the joint surfaces. The articular cartilage is removed from both joint surfaces to leave two surfaces of raw bone. The bottom of the phalange is hollowed with a special tool to form a socket. The other surface is shaped into a rounded cone that fits inside the socket. </li></ul><ul><li>The surgeon places a metal pin through the center of both bones and then connects the cone and socket snugly together. The metal pin allows the surgeon to hold the two bones in the correct alignment and prevents the bones from moving too much as they grow together, or fuse. </li></ul><ul><li>The soft tissues over the joint are sewn back together. The forearm and hand are then placed in a cast until the bones completely fuse together. This takes about 6 weeks. </li></ul>01/16/11 dibyendu
  68. 68. After Surgery <ul><li>After surgery, patient will wear an elbow-length cast for about 6 weeks. </li></ul><ul><li>Surgeon will check patient’s hand in 5-7 days. Stitches will be removed after 10 to 14 days, though most of the stitches will be absorbed into the body. </li></ul><ul><li>Patient may have some discomfort after surgery. Patient will be given pain medicine to control the discomfort. </li></ul><ul><li>Patient should keep the hand elevated above the level of heart for several days to avoid swelling and throbbing. Keep it propped up on a stack of pillows when sleeping or sitting up. </li></ul>01/16/11 dibyendu
  69. 69. Rehabilitation <ul><li>Patient will wear a cast on the arm and hand for about 6 weeks to give the fusion time to heal. When the cast is removed, patient may have stiffness in the joints closest to the fused joint. If patient has pain or stiffness that doesn't improve, patient may need a physical therapist to direct recovery program. </li></ul><ul><li>The first few therapy treatments will focus on controlling the pain and swelling from surgery. Therapist may use gentle massage and other hands-on treatments to ease muscle spasm and pain. </li></ul><ul><li>Patient will begin gentle ROM exercise for the joints nearest the fusion. Strengthening exercises are used to give added stability around the finger joint. </li></ul>01/16/11 dibyendu
  70. 70. <ul><li>Therapist's goal is to help patient to keep : </li></ul><ul><li>► pain under control, </li></ul><ul><li>► improve strength and </li></ul><ul><li>► range of motion, and regain fine motor abilities with the </li></ul><ul><li>hand and fingers. </li></ul>01/16/11 dibyendu
  71. 71. Episode: 7 01/16/11 dibyendu
  72. 72. Arthrodesis <ul><li>HIP: In 10 ° -15 ° of flexion (to permit comfortable sitting); 10 ° of abduction; and 5 ° of external rotation. </li></ul><ul><li>KNEE: Straight. </li></ul><ul><li>ANKLE: 90 ° ; (a little equinus in women who wear high heels). </li></ul><ul><li>SUBTALAR: Neutral (i.e. no varus or valgus). </li></ul><ul><li>GREAT TOE: MTP joint in a few degree extension and slight valgus. (A little more extension for women who wear high heels). IP joint straight. </li></ul><ul><li>LESSER TOES: Straight. </li></ul>01/16/11 dibyendu
  73. 73. Hip Arthrodesis <ul><li>Discussion:     - 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; </li></ul><ul><li>    - 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 </li></ul><ul><li>relatively young age were working & satisfied w/ their results;             - relief of pain;             - young male; </li></ul><ul><li>    - requirements:             - normal contralateral hip, ipsilateral knee, and a low back are prerequisites in </li></ul><ul><li>preoperative planning;             - pain and instability of the ipsilateral knee may also occur in pts w/ a fused </li></ul><ul><li>hip;             - pts w/ long-standing hip fusion may develop progressive nonradicular pain </li></ul><ul><li>in the low back that worsens with activity;             - no cardiovascular pathology:                   - rate of oxygen consumption is   32% greater than normal;                   - average walking speed was 84% of normal gait velocity; </li></ul>01/16/11 dibyendu
  74. 74. <ul><li>- Surgical Considerations: </li></ul><ul><li>    - position of hip fusion:             - neutral abduction, exteran rotation of 0-30 deg &, 20-25 deg of </li></ul><ul><li>flexion;             - avoid abduction and internal rotation;             - this position is design to minimize excessive lumbar spine motion </li></ul><ul><li>and opposite knee motion which helps minimize pain in these </li></ul><ul><li>regions; </li></ul><ul><li>    - exposure:             - may use either an anterior or posterior approach inorder to </li></ul><ul><li>dislocate the hip and to remove the joint surfaces; </li></ul><ul><li>    - 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 </li></ul><ul><li>dome of the acetabulum;                     - disadvantage of this technique includes poor fixation (due to </li></ul><ul><li>large lever arm and the resulting torque on the lever arm) and </li></ul><ul><li>need for postoperative hip spica casting;     </li></ul>01/16/11 dibyendu
  75. 75. <ul><li>- osteotomy:             - some authors advocate supra-acetabular osteotomy or subtrochanteric osteotomy for improved positioning;             - references:                     - Combined hip fusion and subtrochanteric osteotomy allowing early ambulation. FR Thompson.   JBJS. Vol 38-A. 1956. p 13-22.                     - Osteotomy as an aid to arthrodesis of teh hip.   AG Apley and RA Denham.   JBJS. 1955. Vol 37-B. p 185-190. </li></ul><ul><li>    - contra-lateral epiphysiodesis:             - limb-length discrepancy resulting from disruption of the proximal femoral epiphysis has a negative effect on gait mechanics;             - consider epiphysiodesis of the distal femoral epiphysis (at the appropriate age) inorder to equalize leg length descrepancy; </li></ul>01/16/11 dibyendu
  76. 76. <ul><li>- Complications:     - expect that most patients will have complications which are either major or minor;     - malposition (most common)     - nonunion     - leg length descrepancy (common and can be severe enough to require lift);     - DJD or instability of ipsilateral knee, back, and contralateral hip;             - low back pain is present in over 50% of patients with hip fusion;     - in the study, by LA Karol MD et al (J Bone Joint Surg Am 82-A: 561-9, 2000), the authors performed gait analysis on hip fusion patients;             - gait analysis showed excessive motion in the lumbar spine and the ipsilateral knee in all nine patients;             - abnormal motion led to pain as the duration of follow-up increased, and all patients who had been followed for four                     or more years after the arthrodesis complained of back pain;             - excessive hip flexion may cause excessive compensatory lumbar lordosis (leads to back pain);             - more than 10 deg of hip adduction or abduction may lead to varus/valgus knee instability; </li></ul>01/16/11 dibyendu
  77. 77. 01/16/11 dibyendu
  78. 78. Knee Arthrodesis <ul><li>Radiograph of a patient after arthrodesis with a Sampson rod after failed knee arthroplasty. </li></ul>01/16/11 dibyendu
  79. 79. 01/16/11 dibyendu
  80. 80. Arthrodesis 01/16/11 dibyendu
  81. 81. 01/16/11 dibyendu
  82. 82. 01/16/11 dibyendu
  83. 83. Triple Arthrodesis <ul><li>A triple arthrodesis consists of the surgical fusion of the talocalcaneal (TC), talonavicular (TN), and calcaneocuboid (CC) joints in the foot. </li></ul><ul><li>The primary goals of a triple arthrodesis are to relieve pain from arthritic, deformed, or unstable joints. </li></ul><ul><li>Other important goals are the correction of deformity and creation of a stable, balanced plantigrade foot. </li></ul>01/16/11 dibyendu
  84. 84. INDICATIONS <ul><li>Triple arthrodesis should be considered as a salvage procedure and only used after other treatment modalities have been exhausted. In conditions in which a lesser fusion or soft-tissue procedure will suffice, triple arthrodeses should not be used because of the potential long-term complications associated with it. </li></ul>01/16/11 dibyendu
  85. 85. <ul><li>The primary indications for the procedure : </li></ul><ul><li>Valgus foot deformities that cannot be adequately braced </li></ul><ul><li>Collapsing pes planovalgus deformity </li></ul><ul><li>Tibialis posterior tendon dysfunction </li></ul><ul><li>Tarsal coalition </li></ul><ul><li>Rheumatoid arthritis (RA) </li></ul><ul><li>Degenerative arthritis (e.g., DJD) </li></ul><ul><li>Posttraumatic arthritis </li></ul><ul><li>Chronic pain </li></ul><ul><li>Varus foot deformities that cannot be adequately braced </li></ul><ul><li>Cavus and cavo-varus </li></ul><ul><li>Talipes equino-varus </li></ul><ul><li>Joint instability </li></ul><ul><li>Neuromuscular disease </li></ul>01/16/11 dibyendu
  86. 86. Contraindications: <ul><li>Contraindications to triple arthrodesis include conditions that can be adequately corrected and maintained via external bracing, soft-tissue procedures and tendon balancing, or lesser fusions. </li></ul><ul><li>Chronic smoking is a relative contraindication due to the associated high incidence of nonunion. </li></ul>01/16/11 dibyendu
  87. 87. <ul><li>Postoperative details: Patients are usually kept overnight in the hospital for observation, pain control, and IV antibiotics. </li></ul><ul><li>After discharge, patients are instructed to spend at least the first three days with their foot elevated above their heart in order to control edema and pain. </li></ul><ul><li>Sutures are removed after two weeks and the patient is placed into a non–weight-bearing (NWB) removable boot. </li></ul><ul><li>If excellent fixation was achieved during the procedure, ROM exercises may begin. </li></ul><ul><li>If in doubt, a NWB short leg cast is applied. The authors have also used external electric stimulation from the first day postoperatively with good success. </li></ul>01/16/11 dibyendu
  88. 88. Follow-up care: <ul><li>The patient remains NWB for 6-8 weeks and is then reevaluated. At that time, the patient is allowed to bear weight in a removable walker boot if no complications have arisen and trabeculation is noted on radiographs. </li></ul><ul><li>A second set of films is obtained at approximately 12 weeks and evaluated for consolidation. If stable fusion is observed, the patient is taken out of the cast boot and allowed to progress to normal shoes. The patient should undergo physical therapy for continued ROM and strength training. </li></ul><ul><li>Delayed union, especially at the TN joint, is not uncommon and may require further immobilization and NWB. </li></ul>01/16/11 dibyendu
  89. 89. COMPLICATIONS <ul><li>Nonunion </li></ul><ul><li>Degenerative joint disease </li></ul><ul><li>Wound healing problems </li></ul><ul><li>Nerve injury </li></ul><ul><li>Avascular necrosis </li></ul><ul><li>Lateral instability </li></ul><ul><li>Stiff foot </li></ul>01/16/11 dibyendu
  90. 90. Arthrodesis <ul><li>Picture 29. Lateral view showing subtalar joint arthrodesis with 7.3 cannulated screw going from talus to calcaneus. </li></ul>01/16/11 dibyendu
  91. 91. 01/16/11 dibyendu
  92. 92. ARTHRODESIS OF 1 ST MTP JOINT 01/16/11 dibyendu
  93. 93. 01/16/11 dibyendu
  94. 94. ARTHRODESIS OF SPINE <ul><li>Arthrodesis of spine is routinely performed for a large number of conditions. The types of spinal fusion are as follows: </li></ul><ul><li>(a) Posterior Spinal Fusion is commonly performed in scoliosis, old healed tuberculosis, in association with disc excision surgery, in fracture dislocations of the cervical spine, etc. </li></ul><ul><li>(b) Posterolateral Fusion : is performed in spondylolisthesis. </li></ul>01/16/11 dibyendu
  95. 95. <ul><li>(c) Trans-alar Fusion : is fusion between transverse processes of the lower lumbar vertebrae and the ala of the sacrum. It commonly performed in spondylolisthesis at L4-5 or L5-S1 levels. </li></ul><ul><li>(d) Ant spinal fusion : is done in Tuberculosis of the spine, spondylolisthesis and in patients who have had Laminectomy. </li></ul>01/16/11 dibyendu
  96. 96. <ul><li>The post op regime after all these types of spinal fusion is almost similar. Initially the patient is nursed in bed for period of 2-3 weeks. </li></ul><ul><li>After this period the patient is given a spinal support which may be a corset, plaster jacket or a brace (depending upon the disease & the level of fusion) till the fusion consolidates, which may take 3-6 months. </li></ul>01/16/11 dibyendu
  97. 97. Physiotherapy Management <ul><li>The basic objective is to train the patient to functionally use the arthrodesed joint and the limb. </li></ul><ul><li>During Immobilization: </li></ul><ul><li>(a) To prevent &/or manage the possible post op complications. </li></ul><ul><li>(b) Maintenance of proper position of the operated joint. The limb should be protected against postures putting strain on the joint. </li></ul>01/16/11 dibyendu
  98. 98. <ul><li>(c) Strengthening & ROM exercises for the joints free from immobilization. </li></ul><ul><li>(d) Initiating early non-wt-bearing ambulation in case of hip, knee & ankle arthrodeses. The functional use is encouraged and initiated early in upper extremity arthrodesis. Early functional mobilization need to be emphasized as immobilization following arthrodesis is often prolonged. </li></ul>01/16/11 dibyendu
  99. 99. <ul><li>During Mobilization: </li></ul><ul><li>Whole limb to be exercised in the functional patterns of movements. Ideally it should be incorporated with some objective & competitive tasks. Several repetitions of such sessions are necessary to improve the function in the upper extremity. </li></ul><ul><li>In the lower extremity gradual & correct wt-bearing, wt-transfers and balancing should be initiated with adequate aid. </li></ul>01/16/11 dibyendu
  100. 100. <ul><li>Functionally important muscle groups and compensatory techniques are to be strengthened. </li></ul><ul><li>Guidance and assistance with several sessions a day are needed to achieve functional proficiency. </li></ul><ul><li>Optimal function should be regained by 4 weeks following mobilization. </li></ul>01/16/11 dibyendu
  101. 101. PT following Spinal Arthrodesis 01/16/11 dibyendu
  102. 102. 01/16/11 dibyendu
  103. 103. Anterior cervical discectomy and fusion (ACDF) <ul><li>(ACDF) is a procedure used to treat neck problems such as cervical radiculopathy, disc herniations, fractures, and spinal instability. </li></ul><ul><li>In this procedure, the surgeon approaches the neck from the front and removes a spinal disc. </li></ul><ul><li>The vertebrae above and below the disc are then held in place with bone graft and sometimes metal hardware. </li></ul><ul><li>The goal is to help the bones to grow together into one solid bone. This is known as fusion or arthrodesis. </li></ul>01/16/11 dibyendu
  104. 104. 01/16/11 dibyendu
  105. 105. <ul><li>Once the disc is removed, surgeons distract the bones of the spine apart slightly to make room for the bone graft . This is bone is taken from the pelvis bone ( autograft ) or from a natural substitute ( allograft ). </li></ul><ul><li>The bone graft separates and holds the vertebrae apart. Enlarging the space between the vertebrae widens the opening of the neural foramina, taking pressure off the spinal nerves that pass through them. </li></ul><ul><li>Also, the ligaments inside the spinal canal are pulled taut so they don't buckle into the spinal canal. </li></ul>01/16/11 dibyendu
  106. 106. <ul><li>No movement occurs between the bones that are fused together. By holding the sore part of the neck steady, the fusion helps relieve pain. And it prevents additional wear and tear on the structures inside the section that was fused. </li></ul><ul><li>This stops bone spurs formation, and it has been shown that fusion causes existing bone spurs to shrink. </li></ul><ul><li>By fusing the bones together, surgeons hope that patients won't have future pain and problems from cervical disc disease. </li></ul>01/16/11 dibyendu
  107. 107. After Surgery <ul><li>After ACDF, patients usually wear a special neck brace for several months. These neck braces are often bulky and restrictive. However, the bone graft needs time to heal in order for the fusion to succeed. This requires the neck to be immobilized. </li></ul><ul><li>Recently, surgeons have begun using metal hardware, called instrumentation , to lock the bones in place. This hardware includes metal plates and screws that are fastened to the cervical bones. </li></ul><ul><li>They hold the cervical bones still so the graft can heal, replacing the need for a rigid neck brace. </li></ul>01/16/11 dibyendu
  108. 108. <ul><li>Patients may stay in the hospital for one to two days after surgery. </li></ul><ul><li>When the surgery is done on an outpatient basis, patients may even go home the same day of surgery. </li></ul><ul><li>Patients can get out of bed as soon as they feel up to it. </li></ul><ul><li>They are watched carefully when they begin eating to make sure they don't have problems swallowing. </li></ul><ul><li>They usually drink liquids at first, and if they are not having problems, they can start eating solid food. </li></ul>01/16/11 dibyendu
  109. 109. Rehabilitation <ul><li>Patients are able to return home when their medical condition is stable. However, they are usually required to keep their activities to a minimum in order to give the graft time to heal. </li></ul><ul><li>Rehabilitation after ACDF can be a slow process. Patient will probably need to attend therapy sessions for two to three months, and one should expect full recovery to take up to eight months. </li></ul>01/16/11 dibyendu
  110. 110. <ul><li>Many surgeons prescribe outpatient physical therapy beginning a minimum of four weeks after surgery . </li></ul><ul><li>At first, treatments are used to help control pain and inflammation. Ice and electrical stimulation treatments are commonly used. </li></ul><ul><li>Physiotherapist may also use massage and other hands-on treatments to ease muscle spasm and pain. </li></ul><ul><li>Active treatments are slowly added. These include exercises for improving heart and lung function. Walking and stationary cycling are ideal cardiovascular exercises. </li></ul><ul><li>Therapists also teach specific exercises to help tone and control the muscles that stabilize the neck and upper back. </li></ul>01/16/11 dibyendu
  111. 111. <ul><li>Physiotherapist also works with patient on how to move and do activities. This form of treatment, called body mechanics , is used to help patient develop new movement habits. </li></ul><ul><li>This training helps patient keep the neck in safe positions as they go about their work and daily activities. </li></ul><ul><li>At first, this may be as simple as helping patient learn how to move safely and easily in and out of bed, how to get dressed and undressed, and how to do some of their routine activities. </li></ul><ul><li>Then patient will learn how to keep his neck safe while they lift and carry items and as they begin to do other heavier activities. </li></ul>01/16/11 dibyendu
  112. 112. <ul><li>As condition improves, physiotherapist will begin tailoring rehab program to help prepare patient to go back to work. Some patients are not able to go back to a previous job that requires heavy and strenuous tasks. </li></ul><ul><li>Physiotherapist may suggest changes in job tasks that enable patient to go back to their previous job or to do alternate forms of work. Patient will learn to do these tasks in ways that keep the neck safe and free of extra strain. </li></ul><ul><li>Before the therapy sessions ends, physiotherapist will teach the patient ways to avoid future problems. </li></ul>01/16/11 dibyendu
  113. 113. 01/16/11 dibyendu
  114. 114. 01/16/11 dibyendu
  115. 115. Posterior cervical fusion <ul><li>Posterior cervical fusion is done through the back of the neck. The surgery joins two or more cervical vertebrae into one solid section of bone. Posterior cervical fusion is most commonly used to treat neck fractures and dislocations and to fix deformities in the curve of the cervical. </li></ul><ul><li>Surgeons sometimes attach metal hardware to the neck bones during posterior fusion surgery, called instrumentation. </li></ul>01/16/11 dibyendu
  116. 116. <ul><li>Posterior cervical fusion is used to stop movement between the bones of the neck. A serious fracture or dislocation of the cervical vertebrae poses a risk to the spinal cord. The spinal cord is sometimes damaged by the fractured or dislocated bones. Surgeons hope to protect the spinal cord from additional injury by fusing these bones together. </li></ul><ul><li>Surgeons also use posterior cervical fusion to help patients who have mechanical neck pain . Extra movement within the parts of the cervical spine can be a source of this type of neck pain. Fusing these bones together prevents the extra movement, ► easing pain. </li></ul>01/16/11 dibyendu
  117. 117. <ul><li>Posterior fusion is also used to line up and hold the cervical bones when there's a deformity in the curve of the neck called kyphosis. </li></ul><ul><li>Kyphosis can also occur when a severe injury compresses the vertebral body into the shape of a wedge. </li></ul><ul><li>Neck surgeries that weaken the bony ring around the spinal canal can also lead to kyphosis. When kyphosis is a problem, a posterior fusion procedure may be used to correct the curve. </li></ul>01/16/11 dibyendu
  118. 118. Surgical Procedure <ul><li>Patients are given a general anesthesia during most spine surgeries. During anesthesia patient’s breathing may be assisted with a ventilator. </li></ul><ul><li>This surgery is usually done with the patient lying face down on the operating table. The surgeon makes an incision down the middle of the back of the neck. Retractors are used to gently separate and hold the neck muscles and soft tissues apart so the surgeon can work on the back of the spine. </li></ul>01/16/11 dibyendu
  119. 119. <ul><li>A layer of bone is shaved off the surface of the outer ring (the lamina ) of each vertebra to be fused. This causes the surface to bleed and to stimulate the bone to heal. (This is similar to the way the two sides of a fractured bone begin to heal.) </li></ul><ul><li>Small strips of bone are grafted from the top part of the pelvis and laid over the back of the spinal column. This bone graft also helps stimulate the bones to heal together, or fuse . </li></ul>01/16/11 dibyendu
  120. 120. 01/16/11 dibyendu
  121. 121. After Surgery <ul><li>Most patients are placed in a rigid neck brace after surgery for several months. </li></ul><ul><li>These restrictive measures may not be needed if the surgeon attached metal hardware to the spine during the surgery. </li></ul><ul><li>Patients usually stay in the hospital after surgery for up to one week. But they can start to get up as soon as they feel up to it. </li></ul><ul><li>Patients are watched carefully when they begin eating. They usually drink liquids at first. If they are not having problems, they can go on to solid food. </li></ul>01/16/11 dibyendu
  122. 122. <ul><li>A physical therapist will schedule daily sessions to help patients learn safe ways to move, dress, and do activities without putting extra strain on the neck. </li></ul><ul><li>Patients are able to return home when their medical condition is stable. However, they are usually required to keep their activities to a minimum in order to give the graft time to heal. </li></ul><ul><li>Outpatient physical therapy is usually started four to six weeks after the date of surgery. </li></ul>01/16/11 dibyendu
  123. 123. Rehabilitation <ul><li>Rehabilitation after posterior cervical fusion can be a slow process. </li></ul><ul><li>If the spinal cord was injured from a neck fracture or dislocation, patients may need intensive and ongoing rehabilitation for the neurological condition. </li></ul><ul><li>When the spinal cord has not been damaged, patients may need to attend therapy sessions for two to three months and should expect full recovery to take up to eight months. </li></ul>01/16/11 dibyendu
  124. 124. <ul><li>Many surgeons prescribe outpatient physical therapy beginning a minimum of four weeks after surgery. </li></ul><ul><li>At first, treatments are used to help control pain and inflammation. Ice and electrical stimulation treatments are commonly used to help with these goals. </li></ul><ul><li>Physiotherapist may also use massage and other hands-on treatments to ease muscle spasm and pain. </li></ul>01/16/11 dibyendu
  125. 125. <ul><li>Active treatments are slowly added. These include exercises for improving heart and lung function. </li></ul><ul><li>Walking and stationary cycling are ideal cardiovascular exercises. </li></ul><ul><li>Therapists also teach specific exercises to help tone and control the muscles that stabilize the neck and upper back. </li></ul>01/16/11 dibyendu
  126. 126. <ul><li>Physiotherapist also works with patient on how to move and do activities. This form of treatment, called body mechanics , is used to help patient develop new movement habits. </li></ul><ul><li>This training helps patient keep the neck in safe positions as the patient goes about his work and daily activities. </li></ul><ul><li>At first, this may be as simple as helping patient learn how to move safely and easily in and out of bed, how to get dressed and undressed, and how to do some of the routine activities. </li></ul>01/16/11 dibyendu
  127. 127. <ul><li>Then patient will learn how to keep the neck safe while they lift and carry items and as patient begins to do other heavier activities. </li></ul><ul><li>As patient’s condition improves, therapist will begin tailoring rehab program to help prepare the patient to go back to work. </li></ul><ul><li>Some patients are not able to go back to a previous job that requires heavy and strenuous tasks. </li></ul>01/16/11 dibyendu
  128. 128. <ul><li>Therapists often help as a resource to suggest changes in job tasks that may enable patient to go back to their previous job or to do alternate forms of work. </li></ul><ul><li>Patient will learn new ways to do these tasks in ways that keep his neck safe and free of extra strain. </li></ul><ul><li>Before your therapy sessions ends, physiotherapist will teach you a number of ways to avoid future problems. </li></ul>01/16/11 dibyendu
  129. 129. LUMBAR ARTHRODESIS <ul><li>Anterior Lumbar Interbody Fusion </li></ul>01/16/11 dibyendu
  130. 130. 01/16/11 dibyendu
  131. 131. Anterior lumbar interbody fusion (ALIF) <ul><li>ALIF is a procedure used to treat problems such as disc degeneration, spine instability, and deformities in the curve of the spine. </li></ul><ul><li>In this procedure, the surgeon works on the spine from the front and removes a spinal disc in the lumbar spine. The surgeon inserts a bone graft into the space between the two vertebrae where the disc was removed. </li></ul><ul><li>Fusion creates a rigid and immovable column of bone in the problem section of the spine. </li></ul><ul><li>This type of procedure is used to reduce back pain and other symptoms. </li></ul>01/16/11 dibyendu
  132. 132. <ul><li>Also, the outer rings of the disc, the annulus , weaken and develop small cracks. Tears in the outer annulus are painful because these tissues are rich with pain sensors. The nucleus may press on the weakened annulus and actually squeeze out of the annulus. </li></ul><ul><li>Inflammation from the nucleus as it escapes the annulus also causes pain. </li></ul><ul><li>The nucleus normally does not come in contact with the body's blood supply. </li></ul><ul><li>However, a tear in the annulus puts the nucleus at risk for contacting this blood supply. </li></ul><ul><li>When the nucleus herniates into the torn annulus, the nucleus and blood supply meet, causing a reaction of the chemicals inside the nucleus. This produces inflammation and pain. </li></ul>01/16/11 dibyendu
  133. 133. <ul><li>If the nucleus presses against the spinal nerves, symptoms of pain, numbness, and weakness may occur where the nerve travels. Pressure on the spinal nerves inside the spinal canal can also produce problems with the bowels and bladder, requiring emergency surgery. </li></ul><ul><li>Discectomy is the removal of the disc (and any fragments) between the vertebrae that are to be fused. </li></ul><ul><li>Taking out the painful disc is intended to alleviate symptoms. It also provides room for placing the bone graft that will allow the two vertebrae to fuse together. </li></ul>01/16/11 dibyendu
  134. 134. <ul><li>Once the disc is removed, the surgeon spreads the bones of the spine apart slightly to make more room for the bone graft. </li></ul><ul><li>The bone graft separates and holds the vertebrae apart. Enlarging the space between the vertebrae widens the opening of the neural foramina, taking pressure off the spinal nerves that pass through these openings. </li></ul><ul><li>Also, the long ligaments that run up and down inside the spinal canal are pulled taut so they don't buckle into the spinal canal. </li></ul>01/16/11 dibyendu
  135. 135. <ul><li>If the fusion is successful, it helps relieve the mechanical pain , which occurs in the moving parts of the back. Fusion also prevents additional wear and tear on the spinal segment that was fused. </li></ul><ul><li>By fusing the bones together, surgeons hope to reduce future problems at the spinal segment. </li></ul>01/16/11 dibyendu
  136. 136. Rationale <ul><li>This procedure is often used to stop symptoms from lumbar disc disease. Discs degenerate, or wear out, as a natural part of aging and also from stress and strain on the back. Over time, the disc begins to collapse, and the space decreases between the vertebrae. </li></ul><ul><li>When this happens, the openings around the spinal nerves (the neural foramina) narrow and may put pressure on the nerves. </li></ul><ul><li>The long ligaments in the spine slacken due to the collapse in vertebral height. These ligaments may buckle and put pressure on the spinal nerves. </li></ul>01/16/11 dibyendu
  137. 137. 01/16/11 dibyendu
  138. 138. After Surgery <ul><li>Patients are sometimes placed in a rigid body brace after surgery. This may not be necessary if the surgeon attached metal hardware to the spine during the surgery. </li></ul><ul><li>Patients usually stay in the hospital after surgery for up to one week . During this time, patients work daily with a physical therapist. The therapist demonstrates safe ways to move, dress, and do activities without putting extra strain on the back. The therapist may recommend that the patient use a walker for the first day or two. Before going home, patients are shown ways to help control pain and avoid problems. </li></ul><ul><li>Patients are able to return home when their medical condition is stable. However, they are usually required to keep their activities to a minimum in order to give the graft time to heal. Patients should avoid activities that cause the spine to bend back for at least six weeks. Patients are also cautioned against bending, lifting, twisting, driving, and prolonged sitting for up to six weeks. Outpatient physical therapy is usually started a minimum of six weeks after the date of surgery. </li></ul>01/16/11 dibyendu
  139. 139. Rehabilitation <ul><li>Rehabilitation after ALIF can be a slow process. Many surgeons prescribe outpatient physical therapy beginning a minimum of six weeks after surgery. This delay is needed to make sure the graft has time to fuse. </li></ul><ul><li>You will probably need to attend therapy sessions for two to three months. You should expect full recovery to take up to eight months. However, therapy can usually progress faster in patients who had fusion with instrumentation. </li></ul><ul><li>At first, treatments are used to help control pain and inflammation. Ice and electrical stimulation are commonly used to help with these goals. Your therapist may also use massage and other hands-on treatments to ease muscle spasm and pain. </li></ul><ul><li>Active treatments are slowly added. These include exercises for improving heart and lung function. Short, slow walks are generally safe to start with. Swimming and use of a stair-climbing machine are helpful in the later phases of treatment. Therapists also teach specific exercises to help tone and control the muscles that stabilize the low back. </li></ul>01/16/11 dibyendu
  140. 140. <ul><li>Your therapist also works with you on how to move and do activities. This form of treatment, called body mechanics, is used to help you develop new movement habits. This training helps you keep your back in safe positions as you go about your work and daily activities. Training includes positions you use when sitting, lying, standing, and walking. You'll also work on safe body mechanics with lifting, carrying, pushing, and pulling. </li></ul><ul><li>As your condition improves, the therapist tailors your program to prepare you to go back to work. Some patients are not able to go back to a previous job that requires strenuous tasks. Your therapist may suggest changes in job tasks that enable you to go back to your previous job or to do alternate forms of work. You'll learn to do these tasks in new ways that keep your back safe and free of strain. </li></ul><ul><li>Before your therapy sessions end, your therapist will teach you ways to avoid future problems. </li></ul>01/16/11 dibyendu
  141. 141. <ul><li>Posterior Lumbar Fusion </li></ul>01/16/11 dibyendu
  142. 142. 01/16/11 dibyendu
  143. 143. <ul><li>A posterior lumbar fusion is the most common type of fusion surgery for the low back. The procedure is called a posterior fusion because the surgeon works on the back, of the spine. </li></ul><ul><li>Posterior fusion procedures in the lumbar spine are used to treat spine instability, severe degenerative disc disease, and fractures in the lumbar spine. </li></ul><ul><li>Other procedures are usually done along with the spinal fusion to take the pressure off nearby nerves. They may include removing bone spurs and injured portions of one or more discs in the low back. </li></ul><ul><li>Most surgeons also apply instrumentation , to hold the bones securely while they fuse. </li></ul>01/16/11 dibyendu
  144. 144. <ul><li>Surgeons perform this procedure through an incision in the low back. The incision reaches to the spinous processes , the bony projections off the back of the vertebrae. </li></ul><ul><li>The surgeon must move aside the muscles along the spine, called the paraspinal muscles. The fusion itself involves the lamina bone, the protective roof over the back surface of the spinal cord. </li></ul><ul><li>In some cases, the surgeon may enlarge the neural foramina . </li></ul>01/16/11 dibyendu
  145. 145. Rationale <ul><li>The main goal of the spinal fusion is to stop movement of one or more vertebrae. Keeping the fused section from moving helps stop mechanical pain . </li></ul><ul><li>Mechanical pain occurs when damaged discs and joints that connect the vertebrae become inflamed from excessive motion between the vertebrae. This type of pain is commonly felt in the low back and may radiate into the buttocks and upper thighs. </li></ul>01/16/11 dibyendu
  146. 146. 01/16/11 dibyendu
  147. 147. <ul><li>The spinal nerves are also affected by too much vertebral motion. They begin to rub where they pass through the neural foramina and become swollen and irritated. </li></ul><ul><li>Also, the neural foramina narrow when a vertebra slides too far forward or backward over the vertebra below. This immediately pinches the nerves where they pass through the neural foramina. Nerve swelling, irritation, and pinching produce neurogenic pain . </li></ul><ul><li>This type of pain often radiates down one or both legs below the knee. Fusion stops this harm to the nerves. </li></ul><ul><li>By fusing the vertebrae together, surgeons hope to slow down the process of degeneration at the fused segments and prevent future problems. </li></ul>01/16/11 dibyendu
  148. 148. 01/16/11 dibyendu
  149. 149. After Surgery <ul><li>Patients may be placed in a rigid body brace after surgery. This brace may not be needed if the surgeon attached metal hardware to the spine during the surgery. The drain tube is removed from the wound within 24 to 48 hours. </li></ul><ul><li>Patients usually stay in the hospital after surgery for up to one week. During this time, a physical therapist helps patients learn safe ways to move, dress, and do activities without putting extra strain on the back. Patients may be instructed to use a walker for the first day or two. Before going home, patients are shown how to help control pain and avoid problems. </li></ul><ul><li>Patients are able to return home when their medical condition is stable. However, they are usually required to keep their activities to a minimum in order to give the graft time to heal. Patients should avoid bending, lifting, twisting, driving, and prolonged sitting for up to six weeks. Outpatient physical therapy usually starts a minimum of six weeks after surgery. </li></ul><ul><li>Patients gradually do more activities and exercise with the goal of getting back to a normal and productive life. </li></ul>01/16/11 dibyendu
  150. 150. Rehabilitation <ul><li>Rehabilitation after posterior lumbar fusion can be a slow process. Many surgeons prescribe outpatient physical therapy beginning a minimum of six weeks after surgery. This delay is needed to make sure the fusion is taking. You will probably need to attend therapy sessions for two to three months. You should expect full recovery to take up to eight months. Therapy can usually progress faster in patients who had an instrumented fusion. </li></ul><ul><li>At first, treatments help control pain and inflammation. Ice and electrical stimulation treatments are commonly used to help with these goals. Your therapist may also use massage and other hands-on techniques to ease muscle spasm and pain. </li></ul><ul><li>Active treatments are slowly added. These include exercises for improving heart and lung function. Short, slow walks are generally safe to start with after posterior lumbar fusion. Swimming and use of a stair-climbing machine are helpful in the later phases of treatment. Therapists also teach patients specific exercises to help tone and control the muscles that stabilize the low back. </li></ul>01/16/11 dibyendu
  151. 151. <ul><li>Your therapist also works with you on how to move and do activities. This form of treatment, called body mechanics, is used to help you develop new movement habits. This training helps you keep your back in safe positions as you go about your work and daily activities. Training includes positions you use when sitting, lying, standing, and walking. You'll also work on safe body mechanics for lifting, carrying, pushing, and pulling. </li></ul><ul><li>As your condition improves, the therapist tailors your program to help prepare you to go back to work. Some patients are not able to go back to a previous job that requires strenuous tasks. Your therapist may suggest changes in job tasks that enable you to go back to your previous job or to do alternate forms of work. You'll learn to do these tasks in new ways that keep your back safe and free of strain. </li></ul><ul><li>Before your therapy sessions end, your therapist will teach you how to avoid future problems. </li></ul>01/16/11 dibyendu
  152. 152. <ul><li>Posterior Lumbar Interbody Fusion </li></ul>01/16/11 dibyendu
  153. 153. <ul><li>Posterior lumbar interbody fusion (PLIF) is a procedure used to treat problems such as disc degeneration, disc herniation, and spine instability. </li></ul><ul><li>In this procedure, the surgeon works on the spine from the back and removes a spinal disc in the lumbar spine. The surgeon inserts bone graft material into the space between the two vertebrae. </li></ul><ul><li>The graft may be held in place with a special fusion cage. </li></ul>01/16/11 dibyendu
  154. 154. 01/16/11 dibyendu
  155. 155. Anatomy <ul><li>This surgery is done through an incision in the low back. The incision reaches to the spinous processes . </li></ul>01/16/11 dibyendu
  156. 156. 01/16/11 dibyendu
  157. 157. Rationale <ul><li>This procedure is often used to stop symptoms from lumbar disc disease. Discs degenerate, or wear out, as a natural part of aging and also from stress and strain on the back. Over time, the disc begins to collapse, and the space decreases between the vertebrae. </li></ul><ul><li>When this happens, the openings around the spinal nerves (the neural foramina) narrow and may put pressure on the nerves. The long ligaments in the spine slacken due to the collapse in vertebral height. These ligaments may even buckle and put pressure on the spinal nerves. </li></ul>01/16/11 dibyendu
  158. 158. <ul><li>Pain from disc degeneration can come from a tear in the outer portion of the disc, from chemical inflammation inside the disc, or from a herniated disc that pushes on a nearby spinal nerve. Mechanical pain can also occur from excess movement within the problem part of the spine. </li></ul><ul><li>Discectomy is the removal of the disc and any fragments between the vertebrae that are to be fused. Taking out the painful disc is intended to relieve symptoms. It also provides room for placing a graft that will allow the two vertebrae to fuse together. </li></ul><ul><li>Once the disc is removed, the surgeon spreads the bones of the spine apart slightly to make room to implant bone graft material. Bone graft is commonly taken from the rim of the pelvis and packed in a special case, called a fusion cage . Bone taken from your own body is called autograft . Bone substitutes are also being used and avoid the need for taking bone from your pelvis. </li></ul>01/16/11 dibyendu
  159. 159. <ul><li>Another option is to use a wedge of hard, cortical bone taken from preserved human bone. This source of bone graft is called allograft . During the PLIF procedure, the cage or bone wedge is implanted into the interbody space. </li></ul><ul><li>The graft creates a solid spacer to separate and hold the vertebrae apart. Enlarging the space between the vertebrae widens the opening of the neural foramina, taking pressure off the spinal nerves that pass through these openings. Also, the long ligaments that run up and down inside the spinal canal are pulled taut so they don't buckle into the spinal canal. </li></ul>01/16/11 dibyendu
  160. 160. <ul><li>The surgeon also fixes the bones in place using pedicle screws. This instrumentation holds the vertebrae together and prevents them from moving. The less motion there is between two bones trying to heal, the higher the chance they will successfully fuse. </li></ul><ul><li>The use of instrumentation has increased the success rate of spinal fusions considerably. </li></ul><ul><li>During the PLIF procedure, surgeons also commonly add bone graft material along the back sides of the spine. This step is called posterolateral bone grafting . </li></ul><ul><li>When combined with instrumentation, this approach helps fuse a large surface area on the back ( posterior column ) of the spine. </li></ul><ul><li>In a successful fusion, the vertebrae that are fused together no longer move against one another. The fusion creates one solid bone. </li></ul><ul><li>This helps stop the mechanical pain that was coming from the moving parts of the back. </li></ul><ul><li>Fusion also prevents additional wear and tear on the spinal segment that was fused. </li></ul>01/16/11 dibyendu
  161. 161. After surgery? <ul><li>Patients are sometimes placed in a rigid body brace after surgery. The surgical drain is removed within one to two days. </li></ul><ul><li>Patients usually stay in the hospital after surgery for three to five days. During this time, patients work daily with a physical therapist. The therapist demonstrates safe ways to move, dress, and do activities without putting extra strain on the back. The therapist may recommend that the patient use a walker for the first day or two. Before going home, patients are shown ways to help control pain and avoid problems. </li></ul><ul><li>Patients are able to return home when their medical condition is stable. However, they are usually required to keep their activities to a minimum in order to give the fusion time to begin healing. Patients are cautioned against bending, lifting, twisting, driving, and prolonged sitting for up to six weeks. Outpatient physical therapy is usually started a minimum of six weeks after the date of surgery. </li></ul>01/16/11 dibyendu
  162. 162. Rehabilitation <ul><li>Rehabilitation after PLIF can be a slow process. Many surgeons prescribe outpatient physical therapy beginning a minimum of six weeks after surgery. This delay is needed to make sure the graft has time to begin to fuse. You will probably need to attend therapy sessions for two to three months. You should expect full recovery to take up to eight months. </li></ul><ul><li>At first, treatments are used to help control pain and inflammation. Ice and electrical stimulation are commonly used to help with these goals. Your therapist may also use massage and other hands-on treatments to ease muscle spasm and pain. </li></ul><ul><li>Active treatments are slowly added. These include exercises for improving heart and lung function. Short, slow walks are generally safe to start with. Swimming and use of a stair climbing machine are helpful in the later phases of treatment. Therapists also teach specific exercises to help tone and control the muscles that stabilize the low back. </li></ul>01/16/11 dibyendu
  163. 163. <ul><li>Your therapist also works with you on how to move and do activities. This form of treatment, called body mechanics , is used to help you develop new movement habits. This training helps you keep your back in safe positions as you go about your work and daily activities. Training includes positions you use when sitting, lying, standing, and walking. You'll also work on safe body mechanics with lifting, carrying, pushing, and pulling. </li></ul><ul><li>As your condition improves, the therapist tailors your program to prepare you to go back to work. Some patients are not able to go back to a job that requires strenuous tasks. Your therapist may suggest changes in job tasks that enable you to go back to your previous job or to do alternate forms of work. You'll learn to do these tasks in new ways that keep your back safe and free of strain. </li></ul><ul><li>Before your therapy sessions end, your therapist will teach you ways to avoid future problems. </li></ul>01/16/11 dibyendu
  164. 164. <ul><li>SACRO-ILIAC FUSION </li></ul>01/16/11 dibyendu
  165. 165. <ul><li>Surgery may be considered if other treatments don't work. Surgery consists of fusing the painful SI joint. </li></ul><ul><li>The two bones are held together with plates and screws until the two bones grow together, or fuse, into one bone. </li></ul><ul><li>This stops the motion between the two bones and theoretically eliminates the pain from the joint. </li></ul><ul><li>This is a big operation and is not always successful at relieving the pain. The operation is not commonly performed unless the pain is debilitating. SI joint pain is seldom this severe. </li></ul>01/16/11 dibyendu
  166. 166. 01/16/11 dibyendu
  167. 167. <ul><li>You will normally need to wait at least six weeks before beginning a rehabilitation program after having SI joint fusion surgery. You should plan on attending therapy sessions for six to eight weeks. Expect full recovery to take up to six months. </li></ul><ul><li>During therapy after SI joint surgery, your therapist may use treatments such as heat or ice, electrical stimulation, massage, and ultrasound to help calm your pain and muscle spasm. </li></ul><ul><li>Then you'll begin learning how to move safely with the least strain on the healing area. </li></ul>01/16/11 dibyendu
  168. 168. <ul><li>Anterior Lumbar Fusion with Cages </li></ul>01/16/11 dibyendu
  169. 169. 01/16/11 dibyendu
  170. 170. <ul><li>Anterior lumbar fusion is an operation done on the front (the anterior region) of the lower spine. </li></ul><ul><li>Fusion surgery helps two or more bones grow together into one solid bone. Fusion cages are new devices, essentially hollow screws filled with bone graft, that help the bones of the spine heal together firmly. </li></ul><ul><li>Surgeons use this procedure when patients have symptoms from disc degeneration, disc herniations, or spinal instability. </li></ul>01/16/11 dibyendu
  171. 171. 01/16/11 dibyendu
  172. 172. After Surgery <ul><li>As your rehabilitation program evolves, you'll begin doing more challenging exercises. The goal is to safely advance your strength and function. </li></ul><ul><li>As your therapy sessions come to an end, your therapist helps you get back to the activities you enjoy. Ideally, you'll be able to resume your normal activities. You may need guidance on which activities are safe or how to change the way you go about your activities. </li></ul><ul><li>Your therapist will continue to be a resource. But you'll be in charge of doing your exercises as part of an ongoing home program. </li></ul>01/16/11 dibyendu
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  174. 174. THE END 01/16/11 dibyendu

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