The term arthrodesis refers to surgical fusion of a
The indications for this are pain & instability in a
joint and, in some situations, following the failure
of joint replacement .
With the increase & improvements in the field of
joint replacement arthrodesis is now carried out
much less frequently.
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.
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.
A successful arthrodesis is a sure way of permanently
relieving pain but it is bought at the price of stiffness.
ArthrodesisIdeally 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.
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
Where possible compression is applied to the bone ends to promote fusion.
Occasionally extra-articular arthrodesis is carried out.
This usually applies to hip and shoulder joints.
It can be done in several ways:
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.
Bone autograft is generally preferred by surgeons because, as well as
eliminating the risks associated with allografts, The main drawback of
bone autograft is the limited supply available for harvest.
Bone allograft has the advantage of being available in far larger quantities
A variety of synthetic bone substitutes are commercially available.
These are usually hydroxyapatite based granules formed into a
trabecular structure to mimic the structure of cancellous
Metal implants can be attached to the two bones to hold them
together in a position which favors bone growth.
A combination of the above methods is also commonly employed
to facilitate bony fusion.
The optimum positions for arthrodesis in different joints are as follows:
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.
ELBOW : 90° of flexion .
WRIST: A few degree of extension
THUMB: MCP joint in 20° of flexion. IP joint in slight flexion.
FINGERS: MCP joints in 20° -30° of flexion. (these joints are rarely fused).
Proximal IP joints in 40° -45° of flexion (less in middle & index fingers)
- shoulder paralysis:
- may include paralytic dislocation or combined
rotator cuff / deltoid paralysis
- as a requirement for shoulder fusion, the muscles
of forearm and hand need to be functional
as do the serratus anterior and trapezius;
- the later muscles need to be strong inorder to
control scapulothoracic motion after the fusion;
- degenerative or rheumatoid arthritis;
Post Operative Evaluation:
- motion of scapula then compensates for the
lack of motion in joint;
- single most important cause of
complications following shoulder arthrodesis
is malposition, either too much flexion or too
much abduction, which results in
An elbow fusion helps get rid of pain because the bones of the joint no
longer rub together
Fusing the bones together improves the alignment and prevents further
Patient will not be able to bend the elbow after fusion surgery. Patient will
lose the hinge motion in your elbow, but Patient will regain a strong, pain-
free elbow joint
for Elbow FusionThere are many different types of operations to fuse the
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
When the fusion is healed, a strong, solid connection
between the humerus and ulna will have replaced the
painful arthritic joint.
WRIST ARTHRODESISMany of the small joints in the wrist arthritic.When►
this happens, the wrist joint ► extremelypainful
In advanced arthritis, the alignment of the wrist can
change, leading to ► deformity.
Fusion may also be needed to align the wrist after a
severe wrist injury.
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.
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
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
A wrist fusion is a trade-off. Patient will lose some motion, but
will regain a strong and pain-free wrist.
Specific indications for
wrist (radiocarpal) arthrodesis:
Posttraumatic OA of the radiocarpal joint and midcarpal joints
An unsuccessful total-joint or previous arthroplasty of the
Paralysis of the wrist or hand with potential for reconstruction
involving the use of wrist or finger motions for tendon transfer
Reconstruction following segmental tumor resection, infection,
or traumatic segmental bone loss of the distal radius and carpus
Adolescent spastic hemiplegia with wrist flexion deformity
Etiology:Causative factors for wrist arthropathy include,
► crystalline arthropathy, carpal instability,►
► avascular necrosis,
► destruction due to tumors,
► septic arthritis, and
► mechanical overuse.
Wrist arthrodesis is also indicated for
► stabilization of the wrist when combined with tendon
► correction of wrist deformities in patients with spastic
► for salvage of unsuccessful wrist arthroplasty.
Finger fusionArthritis of the finger joints may be surgically treated with a
fusion procedure. Fusion keeps the problem joints from
moving so that pain is eliminated.
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.
Fusing the two joint surfaces together eases pain, makes the
joint stable, and prevents additional joint deformity.
ArthrodesisHIP: In 10° -15° of flexion (to permit comfortable sitting); 10 ° of
abduction; and 5° of external rotation.
SUBTALAR: Neutral (i.e. no varus or valgus).
GREAT TOE: MTP joint in a few degree extension and slight
valgus. IP joint straight.
LESSER TOES: Straight.
- desire to return to near-normal physical activity
- 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 and
need for postoperative hip spica casting;
- malposition (most common)
- instability of ipsilateral knee, back, and contralateral hip;
- low back pain is present in over 50% of patients with hip fusion;
- 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;
Triple ArthrodesisTriple ArthrodesisA triple arthrodesis consists of the surgical fusion of the
talocalcaneal (TC), talonavicular (TN), and calcaneocuboid
(CC) joints in the foot.
The primary goals of a triple arthrodesis are to relieve pain
from arthritic, deformed, or unstable joints.
Other important goals are the correction of deformity and
creation of a stable, balanced plantigrade foot.
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
The primary indications for the procedure :
Valgus foot deformities that cannot be adequately braced
Collapsing pes planovalgus deformity
Tibialis posterior tendon dysfunction
Rheumatoid arthritis (RA)
Degenerative arthritis (e.g., DJD)
Varus foot deformities that cannot be adequately braced
Cavus and cavo-varus
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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.
Chronic smoking is a relative contraindication due to the
associated high incidence of nonunion.
ARTHRODESIS OF SPINE
Arthrodesis of spine is routinely performed for a large
number of conditions. The types of spinal fusion are as
(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.
(b) Posterolateral Fusion: is performed in
(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.
(d) Ant spinal fusion: is done in Tuberculosis of the
spine, spondylolisthesis and in patients who have