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Presented by

Dr. SUMAN PAULD.Ortho- Resident

Department of Orthopaedic Surgery

Rajshahi Medical College Hospital

KNEE ARTHRODESIS

Prepared by

James H. MacDonald, MD, Sanjeev Agarwal, FRCS (Orth)

Matthew P. Lorei, MD Norman A. Johanson, MD Andrew A. Freiberg, MD

THE JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPEDIC SURGEONS

VOLUME 14 NUMBER 3 MARCH 2006

IntroductionKnee arthrodesis stands for surgical fusion of the knee joint. Arthrodesis is one of the last options available to obtain a stable, painless knee in a diseased or damaged knee joint which cannot be reconstructed or replaced. Today, there is reduction in number of arthrodesis surgeries are performed because of success of replacement arthroplasty.

Indications for Knee Arthrodesis Salvage for failed total knee arthroplasty [Most common indication in modern times]Post-traumatic arthritisChronic infectionPainful ankylosis after infection or traumaNeuropathic arthropathyLoss of extensor mechanism of Knee [The joint becomes non functional]

Contraindications for Knee Arthrodesis

Active infectionBilateral knee arthrodesisContralateral limb amputationIpsilateral hip arthrodesisIpsilateral hip or ankle degenerative joint disease

Optimal Joint Position of Knee Arthrodesis

It is  important to slightly shorten the limb and achieve slight flexion at the knee.5-8° valgus0-10° of external rotation depending on the rotation of other leg0-15° of flexionSome amount of limb shortening is done which eases self care and ground clearance while walking.

Patient Selection and Preoperative simulationThe patient should know that this would kill the movement at knee joint. Not only this, patient should also understand about the finality and irreversibility of the outcome. To make enable the patient to make better choice that suits him, a preoperative idea can be given to patient about the loss of movements and restrictions imposed by arthrodesis by application of above knee cast.The plaster is applied for 3-6 weeks and in this period patient can very well chose if he wants to make the choice for knee arthrodesis.

Surgery for Knee ArthrodesisThere are many surgical procedures employed for knee arthrodesis. A variety of techniques has been described for surgical fusion and a range of implants is available.Basic aim of the surgery is to remove cartilage and other tissues of the knee joint to expose the underlying bone on both sides [tibia and femur]. These exposed bones would fuse together in due course of time.The techniques areExternal fixationInternal fixation by compression plates across the kneeIntramedullary fixation with nail across the kneeIn all procedures, bone grafting may be necessary to restore lost bone stock or to augment fusion.

Charnley compression clamp

Intramedullary NailsAfter eradication of the infection arthrodesis should be performed. Refreshing the distal femur and proximal tibia surfaces is recommended. Typically, the femoral and tibial surfaces are recut to create a more parallel plane of contact.The IM nail is inserted in an anterograde fashion through the piriformis fossa, while the distal aspect of the nail should sit close to the tibial plafond.When bony defects are severe, allograft and autograft bone grafts are different options available.

External FixationMonoplanar fixation This procedure uses compression at the site of arthrodesis through an external frame along a singular plane and is secured by multiple pins along the frame. The frame is placed based on the position of the skin incision, which is done either anterolaterally or anteromedially. Although compression and bending stiffness is adequate along these planes, there have been reports of reduced stability along the mediolateral aspect.

Biplanar fixatorsBiplanar fixators add the mediolateral support that is not present in monoplanar frames. This is achieved by providing additional support through the use of fixation in two planes, which are secured by transfixation pins in the tibia and femur along with Schanz pins that secure the arthrodesis anteriorly.

Circular frames The Ilizarov external fixator uses rings and arches to stabilize the femur and tibia. The rings and arches are anchored to the bone using multiple pins and Ilizarov wires and rods are used between the rings and arches.

The advantage of the circular frames include cost effectiveness, versatility, the ability to restore severe leg length discrepancy, lower deep infection rates, and the ability to make spatial adjustments without any additional surgical procedures, such as changing the axis of compression.

Compression platesCompression plates involve using single or dual plating devices as an internal fixation method with multiple screws securing the plate along the axis of the femur and tibia. The plates are placed at either the anterior, lateral, and/or medial aspect of the fusion site.

Complications of Knee ArthrodesisComplications of knee arthrodesis can be due to infection, failure to unite or effects of altered gait biomechanics.•Nonunion•Infection•Low back pain•Ipsilateral hip degenerative changes•Contralateral knee degenerative changes•Stress fracture due to increased stress in the regions

Supracondylar femurProximal tibial metaphysis fractures

Thank you…..