Arthrodesis

Introduction

Most reliable operation for pain or instability where stiffness does not seriously affect function, eg spine, tarsus, ankle, wrist, and inter-phalangeal joints.
Arthrodesis may be
Intra-articular
Intra-articular and extra-articular
Extra-articular
The choice will depend on the patients age, pathologic process and the presence or absence of gross deformity.

Principles

  1. Denude joints
  2. Surfaces are apposed in optimal position and stabilise
  3. Bone grafts are added in larger joints
  4. Splintage until union is evident
  5. Main complication is pseudarthrosis

Hip

Pseudarthrosis rate 0-10%
Femoral #'s develop in 5-15%
Back pain in ~ 60% (long term usually ~ 25 yrs post op)
Pain in the knee 50-55% (usually after ~ 24 yrs)
Fusion in adduction ® less back and knee pain than those fused in abduction.
Hip fused in adduction also ® lower incidence of degenerative changes in ipsilateral knee and better gait pattern.

Position

5o Adduction
35-40o Flexion
Neutral rotation
Later conversion to THR ® limp due to abductor weakness and positive Trendelenburg test.
Conversion to THR will however improve sitting comfort, may improve level of function, reduce back pain and knee pain.

Operative Technique

  1. Anterior Ilio-femoral approach, expose and dislocate the hip
  2. Remove cartilage from the femoral head and acetabulum
  3. All avascular bone must be removed
  4. Reduce joint and position 30o flexion, neutral Ab / Ad-duction to 5o adduction and neurtral external rotation. (using a fracture table have leg horizontal as 30o lumbar lordosis produced in patients with a mobile lumbar spine).
  5. Add extra articular graft if required
  6. Internal fixation using either CHS, Cobra plate, DC Plate, Cannulate screws etc
  7. Hip spica 2-4/12 and encourage WB

Knee

Compression arthrodesis ® best results and shortest time to union. Accurate fitting of concellous surfaces in correct position is of extreme importance. Use TKR cutting blocks.
Charnley (1948) used compression clamps with pins placed 4cm from the cut surfaces. Use of two pins at either end ® better control of angular movement about the osteotomy.
Optimal Angle: 15-20o flexion
Charnley used near full extension in children as grow into flexion
Indications: Historically TB ,Other joint sepsis, Failed TKR, Traumatic OA

Operative Technique

  1. Anterior midline incision
  2. Split quads and patella tendon ® excise patella
  3. Free patella tendon and capsule form tibial attachments
  4. Flex Knee and perform complete synovectomy, excise menisci and cruciate ligaments
  5. Excise tibial articular surface (use TKR jigs)
  6. Excise femoral condyles with the knee in the appropriate position
  7. Position stienman pins and apply compression clamp ® about 100lbs or 45kg compression
  8. Close wounds in layers (NB clamp skin closed at time of pin insertion)
  9. Immobilise in splint or POP

After treatment: Clamps off at 4 weeks ® POP cylinder

(Charnley) After another 4 weeks ® X-Ray out of POP
Others recommend clamps for 8/52 or POP 8/52
Charnley & Lowe 1958 ® 170 knees with 98.8% success
88.2% fusion at 4/52
Average time in clamps 9 weeks

Ankle

Indications

  1. Traumatic arthritis
  2. Avascular necrosis of the body of the talus (post traumatic)
  3. Infectious arthritis
  4. Epuinus deformity not treatable by bracing
  5. Osteoathritis or Rheumatoid arthritis of the ankle
  6. Salvage of failed TAR
Results are usually satisfactory with relief of pain achieved in 60 - 75% of cases

Operative Technique: (Compression arthrodesis modified from Charnley)

  1. Use an anterior midline incision begining ~ 10cm proximal to the ankle joint, ~ 2.5cm medial to the fibula to the third cuneiform
  2. Expose the distal 1/3 of the tibia and the ankle joint
  3. Remove the articular surface of the ankle joint using a micro-sagital saw (make allowance for correction of any equinus deformity in resecting the talar surface)
  4. May need to divide the tibio-talar ligaments in order to expose the dome of the talus adequately
  5. If necessary perfrom a posterior release and ETA through a separate incision
  6. Position Steinmann pins with the talar pin anterior to the line of the shaft of the tibia to correct for the pull of the achillies tendon
  7. Suppliment fixation with a sliding inlay graft from the distal tibia into the dome or neck of the talus
  8. Secure sliding graft with a screw
  9. Mobilise WB as tollerated after wounds satisfactory and swelling settled
  10. Maintain in clamps for 8 weeks then remove clamps and mobilise in walking cast for a further 4 weeks

Blair Fusion

Described a sliding anterior tibial graft for fixation of the head and neck of the talus in situations of AVN of the body following fracture
Performed via an anterior approach similar to the above with removal of the avascular body of the talus

Triple

Classic triple arthrodesis described by Ryerson (1923) -also by Dunn (1921)
Lambrinudi described his operation in 1927
Wedge resection of the talus to correct fixed equinus deformity
Angus & Cowel (1986) reported 310 triples
~ 60% had residual deformity
~ 23% Pseudarthrosis
~25% Significant pain
~38% Degenerative changes in the ankle
May need elongation of tendo Achilles and soft tissue release before able to obtain correction. This may decrease the resection required and the incidence of AVN of the talus.

Operative Technique

  1. Make a straight incision over the sinus tarsi from peroneus brevis tendon to the lateral border of the extensor tendons (shoe top)
  2. Elevate the periosteum of the calcaneus and reflect EDB distally as a flap of tissue
  3. Incise the capsule of the calcaneo-cuboid, Talo-navicular and subtalar joints
  4. Establish correct position of bones prior to resection and establish if wedges are required to correct deformity
  5. Remove articular surfaces of calcaneo-cuboid and talo-navicular joints first (may need second dorso-medial incison to get adequate exposure of talo-navicular joint)
  6. Finally excise the articular surface of the subtalar joint
  7. Reduce the bone surfaces and stabilise with percutaneous 'K' wires
  8. Place chips of cortio-cancellous graft in the region of the junction of the bone cuts and in any spaces
  9. Replace EDB and close the wound
  10. Apply a BK walking POP and mobilise when swelling settled commencing with PWB for 2/52 then WB as tolerated
  11. Remove pins at 6 weeks and reapply walking cast for another 2 - 4 weeks

Sub-talar

Indicated for mobile plano-valgus feet
Fullford (1976); 48 feet at average of 3 years ® 93% fusion rate
90% had satisfactory correction
Immobilisation for an average of 7.5 weeks

Operative Technique;

  1. Shoe top incision
  2. Pad of EDB and subcutaneous fat reflected to expose sinus tarsi
  3. Fat in sinus removed in one piece by sharp dissection
  4. Decortication of roof and floor of sinus but not in the area where the screw will pass
  5. Awl passed across neck of talus, through sinus into calcaneum directed laterally
  6. Screw inserted across sinus
  7. Bone then packed into sinus from iliac crest
  8. EDB replaced and skin closed
  9. BK walking POP 6-8 weeks

MTP Great Toe

The IP joint should be mobile if considering arthrodesis of the MTP joint of the great toe
The position of arthrodesis should be about 10 - 15o dorsiflexion relative to the sole of the foot or 20 - 25o in relation to the axis of the first metatarsal (depending on the heel height of normal shoes) and 15o of valgus
Stabilise with 'K' wires which can be removed in OPD at 4 - 6 weeks

Shoulder

Indications

  1. Active infection with destruction of the joint surfaces
  2. Gunshot wounds
  3. Brachial plexus / nerve injuries (most common cause)
  4. Failed prosthesis
  5. Massive cuff tears
Paralysis
Lesions of the upper plexus ® stabilisation of the shoulder to position the hand for ADL
Complete plexus injuries ® AEA and arthrodesis of the shoulder to enable use of a prosthesis
If trapezius, levator scapulae and perhaps serratus anterior may be functioning ® improved movement of the scapulo thoracic joint
Richards, Waddel & Hudson (Clin Orth 1985) found 78% relief of pain in plexus palsies after arthrodesis and a ROM of 60o abduction and 50o flexion
Contraindications
Charcots Joint (usually 2o to syringomyelia)
OA & RA ® Hemi or TSR
AVN ® Hemi or TSR
Position
Hand to mouth & ipsilateral trouser pocket
30o Abduction
30o Flexion
30o Internal rotation

Operative Technique

  1. Patient on side, arm hand & shoulder prepared and free draped
  2. Incision just inferior to spine of scapula over acromion and across humeral head to the insertion of the deltoid
  3. Expose spine of scapula by releasing trapezius and deltoid
  4. Split deltoid down to its insertion
  5. Excise rotator cuff and capsule
  6. Remove remaining articular surface of humeral head and glenoid
  7. Remove subchondral glenoid bone and undersurface of acromion, osteotomise upper surface of humeral head and greater tuberosity parallel to acromion with arm in desired position
  8. Position hand close to patients mouth ® correct position for fusion
  9. Fix humeral head to glenoid using AO screws
  10. Mould DC Plate over spine of scapula, acromion and onto shaft of humerus and secure
  11. Position second plate posteriorly to control rotation from post aspect of spine to humeral head
  12. Outer 2.5cm of clavicle is excised if evidence of AC joint OA
  13. Wounds closed over a drain and a pillow positioned in the axilla to support the arm
  14. Sling after a few days ® begin scapulo thoracic movement at about one week

Complications: Prominence of plate and screws

Infection
Non Union
# of humerus below plate
Malposition of the shoulder
Persistent pain in some patients

Elbow

Few indications
Sepsis
Post traumatic OA in a young patient
Position
Unilateral ® 90o flexion, (excise radial head to enable pronation and supination)
Bilateral ® one 110o ® mouth the other 65o ® body hygiene
Always use bone graft
One posterior into olecranon gutter
Two crossed through bone tunnels
Denude bone ® plate & screw fixation

Wrist

Provides a painless and stable wrist once fusion has taken place and is indicated for marked flexion deformity of the wrist and fingers, carpal dislocation or painful wrist associated with multiple ruptures of the extensor tendons
If both wrists are diseased may ® arthrodesis of one wrist and arthroplasty of the other
If not arthroplasty should fix one wrist in flexion and the other in extension to enable perineal care (ADL)

Operative Technique

  1. Make a dorsal longitudinal incision over the 4th extensor compartment
  2. Retract the extensor tendons and open the radio-carpal joint and intercarpal articulations
  3. Denude the articular surfaces of the joints to be arthrodeses
  4. Fashion a DC plate to fit over the distal radius onto the carpus and base of the 3rd metacarpal
  5. Dig a trough from distal radius in a straight line towards the proximal end of the 3rd metacarpal and obtain a suitable graft from the iliac crest for instertion into the trough
  6. Stabilise the plate and suture the extensor retinaculum over the plate and under the extensor tendons
  7. Close the wound and apply a BE POP which should remain in place for 6 weeks
Millender and Nalebuff used a longitudinal steinmann pin drilled from the carpus out between the second and thrid metacarpal and then back down the radius

MCP Thumb

Position of arthrodesis should be in ~ 20o of flexion and 20o pronation for pinch grip
Can use a Chevron type of arthrodesis resulting in some inherent stability or make straight bony cuts and stabilise the 'K' wires

IP Joints

In the hand require increased flexion as moving from radial to ulna digits (15 - 20o in the index up to 40o in the little finger)
Excise an elipse of skin over the dorsum of the joint if associated with FFD
Stabilsie the joint with 'K' wires for 4 - 6 weeks post operatively

Charcot Joints

Pain can be expected in between 35 and 90% of neurogenic joints depending on the stage of the disease but the pain is less severe than would be expected from the clinical appearance
Neuropathic joints generally are resistant to arthrodesis, success rates in the knee with compression arthrodesis are about 50% (Charnley).
Best results achieved with intramedullary fixation in the lower limb but generally avoid surgery and manage with external splintage

Operative Technique: (Knee; Drennan 1971, 90% success)

  1. Midline para patella incision
  2. Excision of synovium and patella
  3. Articular surfaces osteotomised
  4. Window made in distal 1/3 femur anterior surface, guide wire passed across joint and K nail inserted over wire
  5. Denuded joint surfaces approximated in 10-20o flexion
  6. Wounds closed
  7. POP cylinder applied
  8. NWB until clinical and radiological evidence of union
Success dependant on
Removal of all cartilage & synovium
Excision of joint surfaces down to bleeding bone
Careful fashioning of cut surfaces
Firm fixation of osteotomised segments
Debridement of all synovium and scared capsule