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

1. Dr RAJESH KUMAR
MS ORTHOPEDICS RESIDENT GSVM
KANPUR
1

2.  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.  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.  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. 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.  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.  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
1. Correction of deformity
2. Arthrodesis of the hip in wide abduction
3. Final positioning by subtrochanteric osteotomy

8. 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.  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.  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. 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. 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.  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.  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.  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.  Active infection
 Bilateral knee arthrodesis
 Contralateral limb amputation
 Ipsilateral hip arthrodesis
 Ipsillateral hip or ankle degenerative
joint disease
16

17.  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.  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.  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. 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.  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. 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.  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.  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.  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.  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.  Advantage- maintenance of malleolar
congruency,
less chance of malunion
less vessel damage, less pain
28

29. 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.  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. 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 2/3rd of it)
Use a lamina spreader to
Debride the joint
Position the ankle & fix it with
Partially threaded cancellous
Screw & fibular graft

32.  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. 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.  STEPHENSON
METHOD OF
DETERMINING THE
ENTRY SITE
34

35. 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. 36
Double
platingSINGLE PLATING

37. 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.  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. 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. 41

42. 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

43. 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 1/3rd 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. 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.  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. 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. 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. 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. 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. 50
Segmental bone loss after tumour
resection or Post traumatic arthritis
trauma
Rheumatoid arthritis
Spastic hemiplagia
Failed total joint 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
cancellousBone harvested from the excised bone and distal radius metaphysis
Cast 10 to 12 weeks
Technique 1(AO
GROUP)

54. cast or
splint for 12
to 16 weeksTECHNIQUE 2(Louis et al.)

55. TECHNIQUE 3(Hadded and Riordan)
CAST OR SPLINT
FOR 12 TO 16
WEEKS

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

58.  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

59.  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

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

61. TENSION
BAND
ARTHRODESI
S
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.

62. 62
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