Arthrodesis

Arthrodesis The term arthrodesis refers to surgical

fusion of a joint.

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.

ArthrodesisIn 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.

Arthrodesis 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.

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.

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 than autograft;

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.

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FIXATION POSITIONSThe 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 ArthrodesisIndications:      - 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 periscapular pain;

ELBOW ARTHRODESIS

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ELBOW ARTHRODESISAn 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 deformation.

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

Elbow Arthrodesis

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Surgical Procedurefor Elbow FusionThere are many different types of operations to

fuse the elbow. 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.

When the fusion is healed, a strong, solid connection between the humerus and ulna will have replaced the painful arthritic joint.

Elbow Arthrodesis

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Elbow Arthrodesis

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WRIST ARTHRODESIS Many 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.

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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 bone.

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.

A wrist fusion is a trade-off. Patient will lose some motion, but will regain a strong and pain-free wrist.

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Specific indications for

wrist (radiocarpal) arthrodesis: Posttraumatic OA of the radiocarpal joint and

midcarpal joints

An unsuccessful total-joint or previous arthroplasty of the radiocarpal joint

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

Rheumatoid arthritis

Etiology: Causative factors for wrist arthropathy include, ►trauma, ►RA, ► 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 transfers, ► correction of wrist deformities in patients with spastic hemiplegia, and ► for salvage of unsuccessful wrist arthroplasty.

Specific wrist fusion complications : Specific wrist fusion complications : Nonunion

Plate tenderness

Extensor/flexor tendon adhesions requiring tenolysis

Carpal tunnel syndrome

Iliac crest donor complications

Distal radioulnar joint pain or dysfunction

Reflex sympathetic dystrophy

Wound-healing problems

Persistent unexplained pain

Wrist arthrodesisLateral view following wrist fusion demonstrating dorsiflexion provided by plate.

Wrist arthrodesis.

Posteroanterior radiograph of wrist following scaphoid excision and

4-corner (lunate-capitate-hamate-triquetrum) fusion.

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FINGER ARTHRODESIS

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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.

KNEE: Straight.

ANKLE: 90°;

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.

Hip Arthrodesis

    - indications:            - desire to return to near-normal physical activity                    

    - 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 and

need for postoperative hip spica casting;

- Complications:        - malposition (most common)    - nonunion        - 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;

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Arthrodesis

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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.

INDICATIONS INDICATIONS 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.

The primary indications for the procedure :

Valgus foot deformities that cannot be adequately braced

Collapsing pes planovalgus deformity Tibialis posterior tendon dysfunction Tarsal coalition Rheumatoid arthritis (RA) Degenerative arthritis (e.g., DJD) Posttraumatic arthritis Chronic pain Varus foot deformities that cannot be

adequately braced Cavus and cavo-varus Talipes equino-varus Joint instability Neuromuscular disease

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Contraindications:Contraindications: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.

COMPLICATIONSCOMPLICATIONSNonunion

Degenerative joint disease

Wound healing problems

Nerve injury

Avascular necrosis

Lateral instability

Stiff foot

Arthrodesis Lateral view

showing subtalar joint arthrodesis with 7.3 cannulated screw going from talus to calcaneus.

ARTHRODESIS OF 1ST MTP JOINT

ARTHRODESIS OF SPINEArthrodesis of spine is routinely performed for a

large number of conditions. The types of spinal fusion are as follows:

(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 spondylolisthesis.

(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 had Laminectomy.