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Arthrodesis, position and brief technique in all joints

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  1. 1. ARTHRODESIS Moderator Dr. R.K ARORA
  2. 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. 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 -
  5. 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.
  6. 6. Contraindications Osteonecrosis. Charcot arthropathy(nonunion rate is high). Ipsilateral elbow fusion. Contralateral shoulder fusion.
  7. 7. The position of rotation is the most critical factor in obtaining optimal function.
  8. 8. 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. 10. 5 to 6 weeks cast 12 weeks
  12. 12. 45 Degrees TECHNIQUE 1 (Cofield) spica cast 12 to 16 weeks
  13. 13. 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.
  14. 14. the distal acromion as avascularize d graft TECHNIQUE (Mohammed) A shoulder spica 8-10 weeks
  15. 15. Apply bone grafts No cast TECHNIQUE 4 (AO Group)
  16. 16. 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.)
  18. 18. 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.
  19. 19. AGraft:1.5 x 9 cm Fitting cast 8 weeks TECHNIQUE 1 (Steindler)
  20. 20. Grafts:8 mm x 7.5-10 cm Fitting cast 8 weeks TECHNIQUE 2 (Brittain)
  21. 21. Fitting cast 8 weeks TECHNIQUE 3 (Staples)
  22. 22. 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
  23. 23. 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
  24. 24. 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
  25. 25. Complications Complications of elbow arthrodesis include: Delayed union. Nonunion. Malunion. Neurovascular injury . Painful prominent hardware . Skin breakdown.
  27. 27. 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.
  28. 28. 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).
  29. 29. 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.
  30. 30. 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
  31. 31. 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.)
  32. 32. 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)
  33. 33. Place an outer cortical piece of iliac bone graft Cast 6-8weeks TECHNIQUE 4 (Watson and Vendor)
  35. 35. 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.
  36. 36. 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.
  37. 37. Ball-socket Or Cupcone Splint2-3days TECHNIQUE (Stern et al.; Segmüller, Modified)
  38. 38. 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
  39. 39. 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
  40. 40. 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:
  41. 41. 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;
  42. 42. 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
  43. 43. 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
  44. 44. 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
  45. 45. 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;
  46. 46. 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.
  47. 47. 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
  48. 48. 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
  49. 49. 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
  50. 50. 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