Principal of arthrodesis

here we have given all details description about pricinipal of athrodesis and its type .

1. ARTHRODESIS PRINCIPLE AND IT’S TYPES Dr RAJESH KUMAR MS ORTHOPEDICS RESIDENT GSVM KANPUR 1

2. ARTHRODESIS The term arthrodesis refers to surgical immobilization of a joint by fusion of the bones. Also known as artificial ankylosis or syndesis is the artificial induction of joint ossification between two bones by surgery. The indications for this are pain and 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. 2

3. ARTHRODESIS A successful arthrodesis is a sure way of permanently relieving pain but it is bought at the price of stiffness 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. A bone graft can be created between the two bones using a bone from elsewhere in the patient’s body( autograft ) or using donor bone (allograft) from a bone bank. They are held there by internal fixation, an external fixator or external splintage (e.g. POP) or a combination of these methods, until the fusion is achieved 3

4. INDICATIONS Post traumatic arthritis in younger patients Degenerative arthritis Salvage for failed arthroplasty Neuropathic arthropathy ( charcot’s arthropathy ) Tumour resection Tuberculosis Severe deformity in paralytic condition Poliomyelitis RA 4

5. Contraindications ABSOLUTE - Active sepsis, vascular impairment through which approach is planned. RELATIVE - Poor bone stock iatrogenic (severe osteoporosis) Peripheral neuropathy ( non union) Severe degenerative changes in lumbosacral spine and , contralateral hip and ipsilateral knee Polyarticular disease e.g. RA 5

6. HIP ARTHRODESIS ARTHRODESIS-REPLACED BY THA INTRODUCED IN 1930-WATSON-JONES MULLER- DOUBLE PLATING COMPRESSION SCHNEIDER- COBRA PLATE IDEAL POSITION- 6 20 TO 30 degrees FLEXION 0 TO 5 degrees ADDUCTION 0 TO 15 degrees EXTERNAL ROTATION Limb length discrepancy < 2 cm

7. TECHNIQUES With cancellous screw fixation Arthrodesis with anterior plate fixation With double plate fixation With cobra plate fixation With hip compression screw fixation Arthrodesis in absence of the femoral head 7 Correction of deformity Arthrodesis of the hip in wide abduction Final positioning by subtrochanteric osteotomy

8. ANTERIOR PLATING Useful when loss of acetabular or proximal femoral bone stock 8 Modified Smith Peterson approach Dislocate the hip Denude the articular Cartilage of hip and Acetabulum Relocate the hip in desired Position Place a lag screw into iliac bone Place the plate over internal Ilium, pelvic brim and Proximal femoral shaft

9. DOUBLE PLATING Indications- unreduced hip dislocation, Avascularity of bone 9 Watson jones approach Steps- Trochanteric osteotomy done Dislocate the hip and remove articular cartilage Relocate hip and place in desired position Contour the lateral plate & place it anterior to the Sciatic notch. Contour the Anterior plate & place it Inferior to the anterior Superior iliac spine. Replace the greater trochanter to the osteotomy site & fix it With screw

10. ARTHRODESIS WITH COBRA PLATE Allows restoration of abductor mechanism if later converted to THA Medial displacement osteotomy of acetabulum and rigid internal fixation with cobra plate Disadvantage - Femur fracture Pseudoarthrosis Ambulation encouraged after 2-3 days of surgery by walker 10

11. COBRA PLATE FIXATION 11 Steps - Longitudinal midlateral Incision given Greater trochanteric osteotomy Superior hip capsulotomy done transverse innominate osteotomy at the superior acetabular dome. Medial displacement of the distal fragment of the osteotomy . Place the plate and fix it in desired position & reattach the greater trochanter

12. ARTHRODESIS WITH SLIDING HIP COMPRESSION SCREW By Watson-Jones approach ADVANTAGES - 1)Minimizes low back pain 2)Minimum post op immobilisation 3)Conversion to THA 4)Preservation of abductors 5)Avoids bulky internal fixator 12

13. ARTHRODESIS IN ABSENCE OF FEMORAL HEAD INDICATIONS -1 ) Nonunion Of Femoral head ,infection 2) osteonecrosis of femoral head 3) Failed Femoral Head Prosthesis STAGES - a) Correction of deformity b) Arthrodesis in wide abduction c) Final positioning by subtrochanteric osteotomy Arthrodesis of proximal femur to ischium Indicated when femoral head extremely diseased or absent 13

14. KNEE ARTHRODESIS FIRST TIME IN 1878- ALBERT OF VIENNA( POLIO) IN 1911- HIBBS( TB KNEE) IN 1932- KEY USED EXTERNAL FIXATOR CHARNLEY- FURTHER MODIFICATION OF EX. FIX. 1948- CHAPCHAL USED INTRAMEDULARY NAIL 1954- BRASHEAR AND HILL MINIMISED RISK 1982-KNUTSON & LIDGREN USED LONG INTRAMEDULARY NAIL 14

15. Indication for knee arthrodesis Post traumatic arthritis Salvage for failed total knee arthroplasty (most common) Chronic infection ,TB Painful ankylosis after infection or trauma Neuropathic arthropathic Los of extensor mechanism of knee(the joint become non functional ) 15

16. Contraindication for knee arthrodesis Active infection Bilateral knee arthrodesis Contralateral limb amputation Ipsilateral hip arthrodesis Ipsillateral hip or ankle degenerative joint disease 16

17. TECHNIQUES & POSITION COMPRESSION ARTHRODESIS WITH EXTERNAL FIXATION WITH INTRAMEDULLARY NAILING WITH PLATING WITH SCREW FIXATION POSITION FLEXION 0 TO 15 DEGREES EXTERNAL ROTATION 10 DEGREES VALGUS 5 TO 8 DEGREES IT IS IMPORTANT TO SLIGHTLY SHORTEN THE LIMB AND ACHIEVE SLIGHT FLEXION AT KNEE 17

18. Compression Arthrodesis by external fixator Steps- Longitudinal incision Remove patella, joint capsule, collateral ligaments, synovium , menisci Raw surface of distal femur & proximal tibia Flexion 0 to 15 degree Valgus 5 to 8 degree Ext rotn 10 degree Compression load of 45 kg 18

19. Post operative care Long leg cast or cylindrical cast is applied just postoperatively External fixator is removed after 6-8 weeks Gradual weight bearing started and cast is continued for 6-8 more weeks 19

20. ARTHRODESIS BY INTRAMEDULLARY NAILING Prerequisite - when extensive bone loss does not allow compression by external fixator Indication - Failed TKR Arthrodesis after tumor resection Advantages - early weight bearing easy rehabilitation high fusion rate 20

21. Arthrodesis by intramedullary nail 21 Steps- Incision 10 to 12 cm proximal and Distal to the joint line Debride the joint and place it in Proper position Excise the patella and keep it for bone Graft if necessary Make an entry point at the GT & Pass a guide wire and ream it upto The distal tibia Insert the nail antegradely , maintain Compression at the arthrodesis site &The nail should be bowed concave Laterally to reconstitute the normal valgus

22. Post operative care Hip flexion and abduction exercise Touch down mobilisation for 4-6 weeks If significant gap noted at knee after 6-12 weeks Dynamisation of nail is done 22

23. Arthrodesis using dual plating 23 LUCAS AND MURRAY TECHNIQUE Steps- Make a long medial para Patellar incision Excise the patella, menisci, Cruciate ligaments & joint Debris Debride the joint & articular cartilage Place two plates either anteriorly & medially or laterally & Medially Fix it in desired position

24. ANKLE ARTHRODESIS Albert (1879) described ankle arthrodesis in paralytic poliomyelitis Charnley (1951) given the concept of compression ankle arthrodesis Feasibility of ankle arthrodesis - minimum movement restriction, minimum biomechanical conseqences Alternatives of arthrodesis - arthroscopic debridement, periarticular osteotomy distraction arthroplasty , total ankle arthroplasty 24

25. Biomechanical aspect of ankle good bone stock for arthrodesis , minimum ROM- flexion 20 degrees , it is a hinge joint with continuously changing axis of rotation throughout its range of motion extension 10-12 degrees 25

26. POSITION OF FUSION Flexion/extension- neutral External rotation-5 degrees Valgus - 5 degrees Slight posterior translation of talus under tibia Things to avoid - NO EXTENSION NO VARUS NO ANTERIOR TRANSLATION 26

27. TECHNIQUES ARTHROSCOPIC ARTHRODESIS MINI INCISION ARTHRODESIS TRANSFIBULAR (TRANSMALLEOLAR) ARTHRODESIS WITH FIBULAR STRUT GRAFT aka MANN PROCEDURE BLAIR PROCEDURE RETROGRADE CALCANEOTALOTIBIAL NAILING ANTERIOR APPROACH WITH PLATE FIXATION ARTHRODESIS WITH EXTERNAL FIXATOR 27

28. ARTHROSCOPIC ARTHRODESIS Advantage - maintenance of malleolar congruency, less chance of malunion less vessel damage, less pain 28

29. MINI INCISION ARTHRODESIS Two incision given Three 6.5/8 mm cannulated cancellous screw used a) posterolateral screw or ‘home run’ screw b) proximomedial screw c) anterolateral screw Bone grafting if necessary 29

30. POSTOPERATIVE CARE NON WEIGHT BEARING AND CAST APPLICATION FOR 6 WEEKS POSTOPERATIVE X RAY OR CT SCAN IS DONE USE OF ROLLING WALKER KNEE HIGH WALKING BOOT GRADUAL CHANGE OVER FROM “BOOT TO SHOE” 30

31. TRANSFIBULAR(TRANSMALLEOLAR) ARTHRODESIS WITH FIBULAR STRUT GRAFT 31 Mann procedure- Incision given over the lateral Ankle and extended upto the Cuboid in a j shaped fashion Elevate the periosteum and joint Capsule over the tibial plafond Remove any anterior marginal Osteophyte if present & use a Saw to transect fibula proximal To the plafond(medial 2/3 rd of it) Use a lamina spreader to Debride the joint Position the ankle & fix it with Partially threaded cancellous Screw & fibular graft

32. BLAIR PROCEDURE Loss of body of talus A sliding bone graft is used from anterior tibia An additional calcaneotibial steinmann pin is inserted Postoperatively a long leg cast is applied in 30* of knee flexion 32

33. BLAIR PROCEDURE 33 Incision given 8 cm proximal to the ankle & Ended in the medial cuneiform Dissect interval between EDL & EHL and Remove the avascular talus A rectangular bone graft is cut from the Anterior aspect of distal tibia. Make a Transverse slot 2cm deep on the superior Aspect of talar neck Position the ankle and slide the tibial graft Into it & fix it with a screw Steps-

34. RETROGRADE CALCANEOTALOTIBIAL NAIL FIXATION STEPHENSON METHOD OF DETERMINING THE ENTRY SITE 34

35. RETROGRADE NAILING 35 After positioning the patient determine the entry Point according to the stephenson method Guidewire placement through the calcaneum talus And tibia followed by reaming TRIGEN Hindfoot fusion nail is used. Locking bolts Are placed sequentially from calcaneum to tibia Four screws are placed 1. TALAR screw 2. CUBOID screw 3. TRANSVERSE screw 4. PROXIMAL screw Bone grafting done in the sinus tarsi of calcaneum

36. ARTHRODESIS WITH ANTERIOR PLATE FIXATION 36 Double plating SINGLE PLATING

37. ARTHRODESIS WITH EXTERNAL FIXATOR 37 By An anterior or transmalleolar approach Proper debridement of joint is done followed by thin K wire fixation and ring placement of external fixator 4 rings are usually used 1. in the proximal tibia 2. In the supramalleolar region 3. a half talar ring With the wires placed 50 to 60 degree to each other 4. Another half ring in the calcaneum & metatarsal Apply compression between the distal tibial ring & The talar half ring and fix it in desired position

38. 38 S.no indication contraindication 1 Post traumatic arthritis vascular impairment 2 osteoarthritis Peripheral neuropathy 3 Autoimmune inflammatory arthritis e.g. RA 4 Charcoat neuroarthropathy 5 Osteonecrosis of talus

39. COMPLICATIONS NONUNION- 1.10% nonunion rate 2. tobacco users have 2.7 times risk LATERAL PLANTAR NERVE INJURY SUPERFICIAL PERONEAL NERVE INJURY HINDFOOT ARTHRITIS MALUNION(corrected by osteotomy ) INFECTION PERSISTENT PAIN DEGENERATIVE CHANGES 39

40. SHOULDER ARTHRODESIS The goal shoulder arthrodesis is to provide a stable base. Techniques - 1.external fixation 2.screw fixation 3.plate fixation Position - abduction 20degree forward flexion 30 degree internal rotation 30 degree 40

41. Position of arthrodesis 41

42. Arthrodesis with External fixator 42 Steps- Before the operation apply the trunk portion of the shoulder spica cast & Allow the cast to harden & Bivalve it. Make a saber cut incision centered over the Lateral border of acromian Take down the lateral & anterior deltoid. Excise the soft tissue from subacromial space & denude the articular cartilage of humeral Head & glenoid fossa Split off the greater tuberosity and articulate Superiorly with undersurface of acromion & superior glenoid fossa Place two pins in the ‘base of the coracoid ’ & ‘scapular neck’. Similar two pins are placed in The surgical neck of humerus posterolaterally

43. Plate arthrodesis 43 Steps- Incision given over the scapular spine upto the Proximal third of humerus . Denude the articular cartilages of hmeral head & glenoid fossa . Place the humeral head in desired position & Place a contoured plate over the scapular spine, acromian & proximal 1/3 rd humerus & fix it with Long cortical screws. If stability is insuficient then place a second Plate from the scapular spine to the humerus posteriorly

44. Recon Plate Fixation 44 Incision given from spine of scapula to the anterior aspect of the acromian & distally on the anterior aspect of the humeral shaft Detach the anterior deltoid & the Rotator cuff Maintain the desired position & bend the recon plate along the spine of scapula, over the acromian & down o the shaft of humerus & fix it with screws STEPS

45. ELBOW ARTHRODESIS Position of fusion- Unilateral ( 90 to 100* flexion) Bilateral (110 to 120* flexion ) (45 to 65* flexion) The fusion is done between the ulna and the distal humerus 45

46. Staples procedure 46 Steps- Posterior longitudinal incision & retract the ulnar nerve Osteotomize the olecranon for proper exposure denude the elbow joint cartilage & cut the distal humerus on its posterior Surface Pack iliac bone chips in the joint & apply an iliac graft to the posterior surface of humerus .. Place two screws to fix the graft proximally and the olecranon back to itsposition

47. Muller procedure 47 Posterior longitudinal incision Denude joint cartilage & fashion a Squared off shelf in the proximal Ulna & resect the distal humerus to Fit it Resect the radial head at the level of the biceps tuberosity Insert one steinmann pin transversely through the olecranon & one through the shaft of humerus Place a cancellous screw through the olecranon to the medullary cavity of The humerus and apply compression by fixing an external fixator .

48. Spier procedure 48 Steps- Posterior longitudinal incision Osteotomize the olecranon and Distal humerus as before to fit in. Contour an AO plate to achieve The degree of flexion and fix it Secure a tensioning device to the Ulna & distal end of the plate to Apply compression

49. Wrist arthrodesis Contraindications - 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 . 49

50. Indication for wrist arthrodesis 50 Segmental bone loss after tumour resection or Post traumatic arthritis trauma Rheumatoid arthritis Spastic hemiplagia Failed total j oint arthroplasty

51. 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

52. 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 .

53. Cancellous bone harvested from the excised bone Denude the radiocarpel and intercarpal joint surfaceof cartilage and fill the gap with cancellous Bone harvested from the excised bone and distal radius metaphysis Cast 10 to 12 weeks Technique 1(AO GROUP )

54. Remove 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 . bone graft is not necessary. cast or splint for 12 to 16 weeks TECHNIQUE 2(Louis et al.)

55. 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. If the wrist is unstable, insert a nonthreaded Kirschner wire thr 2nd MCP and radius TECHNIQUE 3( Hadded and Riordan ) CAST OR SPLINT FOR 12 TO 16 WEEKS

56. Painful hardware Tendon adhesions Early wound problem and post op swelling DRUJ pain/INSTABILITY Carpal tunnel syndrome Reflex Sympathetic Dystrophy Nonunion COMPLICATION OF WRIST ARTHRODESIS

57. 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

58. 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

59. Splint2-3days TECHNIQUE (Stern et al.; Segmüller , Modified ) Ball socket or cup and cone MCP JOINT FUSION

60. TENSION BAND ARTHRODESIS A, Phalangeal osteotomy. B. Hole for 25- or 26-gauge stainless steel wire made through middle phalangeal base dorsal to midaxial line . 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 .

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