ARTHRODESIS

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
 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

-
 SHOULDER
ARTHRODESiS
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.
Contraindications
Osteonecrosis.
Charcot
arthropathy(nonunion
rate is high).
Ipsilateral elbow
fusion.
Contralateral shoulder
fusion.
 The position of rotation is the most critical factor in obtaining optimal
function.
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.
 Used as graft

COMPRESSION TECHNIQUESEXTERNAL FIXATION

TECHNIQUE 1 (Charnley and Houston)

5 to 6
weeks

cast 12
weeks
COMPRESSION TECHNIQUESINTERNAL FIXATION

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

TECHNIQUE 1 (Cofield)
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.
 the distal
acromion as
avascularize A shoulder
d graft spica 8-10
weeks

TECHNIQUE (Mohammed)
 Apply
bone grafts

No cast

TECHNIQUE 4 (AO Group)

 60 D
Position 30
degrees of
flexion, 30
degrees of
Do not abduction, and
30 degrees of
osteotomize
internal
the acromion rotation.

A shoulder spica
cast 6weeks

TECHNIQUE 5 (Richards et al.)

 ELBOW
ARTHRODESIS
POSITION

For unilateral arthrodesis of the elbow, a position

of 90 degrees 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.
 AGraft:1.5 x 9 cm

Fitting cast
8 weeks

TECHNIQUE 1 (Steindler)
 Grafts:8 mm x 7.5-10 cm

Fitting cast 8
weeks

TECHNIQUE 2 (Brittain)
 Fitting cast
8 weeks

TECHNIQUE 3 (Staples)
 Technique for fusion
in tuberculous
arthritis of elbow.
Rad head cut with
shaPING
HUMERUS+ULNA

TECHNIQUE use the resected

4(Arafiles) epicondylar and
olecranon fragments
as bone grafts

a long arm
cast for 3
months
 The fixator and
pins 6 to 8 weeks

Ulna &humeral
osteotomy
done long arm
cast until the
arthrodesis is
solid

TECHNIQUE 5 (Mller et al.)ao IF+EXFIX

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

 TECHNIQUE 1
(AO Group)

cancellous bone
harvested from A cast (10 to 12
the excised bone 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
Remove approximately
80% of the proximal
scaphoid, a portion of
the hamate, and the
entire triquetrum and
lunate Retain a portion 80%
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.)

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

TECHNIQUE 3 (Haddad and Riordan)

 Place an outer cortical
piece of iliac bone graft
Cast 6-8weeks

TECHNIQUE 4 (Watson and Vendor)

ARTHRODESIS OF
FINGER JOINTS
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.
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.
 Ball-socket Or Cup-
cone

Splint2-3days

TECHNIQUE (Stern et al.; Segmller, Modified)

 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
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
HIP ARTHRODESIS
hip fusions can 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
Surgical Considerations
- position of hip fusion
- neutral abduction, external rotation of 0-30 &, 20-25
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
needfor postoperative hip spica casting;
- osteotomy:
- some authors advocate supra-acetabular osteotomy or
subtrochanteric osteotomy for improved positioning;
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
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 with GT
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
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.
Reikers et al. found that their best results were obtained
in patients who were young when they underwent fusion of
Knee arthrodesis
optimal position of arthrodesis:
- slight valgus, 10of external rotation, and 0-20
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 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;
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.
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
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
arthrodesis 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
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