knee arthrodesis

1. Arthrodesis of Knee Joint
Presenter :Dr. Sushil Pokhrel

2. Objectives:
• History
• Introduction
• Indications and contra-indications
• Principle of management
• Complications
• Rehabilitation

3. History
• Albert of Vienna in 1878 - first arthrodesis -
instability of poliomyelitis
• Hibbs in 1911 -tuberculous knee
• Key (1932) - use external fixation to obtain
fusion
• Nelson and Evarts (1971)- first described knee
arthrodesis as a treatment option for failed
knee arthroplasty

4. Introduction
Arthrodesis:
Fusion of joint
Knee Arthrodesis: fusion of knee joint
Despite the loss of a functioning , knee fusion
can provide a functional symptom-free
extremity

5. INDICATIONS
1.Salvage of failed total knee arthroplasty
a.Secondary to infection:
1. presence of resistant organisms
2. immune compromised patient
3. gross instability
4. inadequate skin and soft tissue coverage
5. Deficient extensor mechanism
b. Patient is unwilling: revision arthroplasty

6. INDICATIONS
2.Relative indication:
1.painful ankylosis after infection
2.loss of the extensor mechanism
3.tuberculosis
4.trauma: severe destruction in young who
desire to continue vigorus activity
5.severe deformity in paralytic conditions:
-neuropathic arthropathy: DM
- malignant or potentially malignant

7. CONTRA-INDICATIONS
• Contra -lateral knee amputation
• Advanced degenerative changes in ipsilateral
hip or ankle
• Arthrodesis of the contralateral hip or knee

8. This study demonstrates the presence pathologic advancement of
degenerative osteoarthritis in the contralateral knee following arthrodesis
in a select patient cohort. Arthrodesis of the knee creates adverse
compensatory stresses on the contralateral knee which lead to symptoms
in 58% of patients and the need for surgery in 42%.

9. Biomechanics
Conway et al.
-Increased pelvic inclination
-Increased ipsilateral coxal abduction
-Increased ipsilateral dorsi-flection of the ankle
-Increased energy required for walking (plus 25 to
30%) while amputation knee 25% extra then
arthrodesis of knee
*Conway JD et al. Arthrodesis of the knee.J Bone Joint Surg Am. 2004 Apr; 86(4):835-48

10. Arthrodesis in TB Knee
Indications:
• Advanced tubercular arthritis-
- gross limitation of movements
- marked diminution of the joint space
-destruction of the apposing joint surfaces
• Tubercular arthritis with triple deformity
-gross instability
-painful ankylosis
*SM Tuli Tuberculosis of the Skeletal System(Bones, Joints, Spine and Bursal Sheaths)4 e
Triple deformity

11. Arthrodesis in TB Knee
• Charnley (1953) -
recommended compression
arthrodesis in tuberculous
knee joint in children
• compression pins are
removed around 4 weeks
• Plaster till groin should be
used in the best possible
functional position for 8
to16 weeks till osseous
fusion is demonstrable in
the x-rays
SM Tuli Tuberculosis of the Skeletal System(Bones, Joints, Spine and Bursal Sheaths)4 e

12. Arthrodesis in TB Knee
• Patient is encouraged to
walk 3 to 4 weeks after
operation.
• Weight bearing in the
plaster cast is
commenced 5 to 6
weeks after the
operation
• walking plaster is
retained for 3 to 6
months

13. Arthrodesis in charcot arthropathy
• Indications:
1.severe instability
2. soft-tissue laxity
3. bony destruction
• surgical intervention :
destructive phase – ceased radiologically
bone reconstruction - started
Sina Babazadeh et al. arthroplasty of knee joint ,Orthopedic Reviews 2010; 2:e17

14. Arthrodesis in charcot arthropathy
• Successful arthrodesis depends on :
-carefull removal of all cartilage and debris
-removal of sclerotic bone down to bleeding
-careful fashinoning of congurent surface for bone
apposition
- Firm fixatation of bone by intra medullary nail or
other methods
- Carefull debridement of all synovial tissue and
scarred capsule
*Drennan DB et .al,Important factors in achieving arthrodesis of the Charcot knee., J Bone Joint
Surg Am. 1971 Sep; 53(6):1180-93.

15. Patients concerns after knee fusion
-attention attract in public
-difficulty riding public transportation
-difficulty sitting in theaters and stadiums
- difficulty getting up after a fall
• acceptability test: simulating the functional
restrictions imposed by arthrodesis of the knee
joint with use of cast of brace

16. Pre-Operative Considerations
1. Adress:
- systemic primary disease such as DM, CVD,
endocrinological diseases ,RA
2. tumour resection:
- chemotherapy and radiotherapy-completed
to avoid the associated bone- and wound-healing
- early rehabilitation
3. examination of the limb:
-neurological and vascular status

17. Pre-Operative Considerations
4.soft-tissue situation:
- consider interdisciplinary treatment with the aid of
plastic surgery
5.radiological examinations:
-available bone & any bone defects
-whole-leg radiographs- the leg axis
-LLD
6. considerable bone loss:
- autologous as well as allografts.
-iliac crest cancellous bone,
-pedicled vascularised fibula grafts

18. Principles in arthrodesis of knee
1.Use of compression : for rigid fixation
- external fixatation
-internal fixatation
- both
2. Load bearing when possible : which increases the stability
and area of bone contact :
3. 1. contact arthrodesis (“tibio-femoral kissing”):
-direct contact between femur and tibia – bone fusion occur
3.2. non-contact arthrodesis:
-loss of bone stock is significant- need graft
4. Preserve vascularity : soft tissue

19. General principles
Aim:
overall limb alignment with the knee:
valgus :5-7 degree
flexion:10-15 degree
external rotation :10 degree
position
-extension- minimises the loss of leg length
-slight flexion- improves comfort when
seated and improves the gait pattern

20. General principles

21. General principles –infected TKR cont.
• first stage consists –
 surgical debridement
 removal of components
 insertion of an antibiotic impregnated cement spacer
 followed by 6– 8 weeks of antibiotic treatment based
c/s from the tissues
 serial estimation of inflammatory markers
 Antibiotics are discontinued - two weeks and
inflammatory markers are rechecked
• Final step -Arthodesis

22. Klinger et al classified bone loss
1. Mild—full bony contact possible
2. Moderate—incomplete bony contact
3. Severe—minimal or no bony contact
• severe bone loss-additional bone grafting
procedures including vascularised fibular graft
or allograft techniques

23. Various techniques
1. Long nail
Modular nail
Non-modular nail
2. External fixation
Monoplanar fixators
Biplanar fixators
Circular frames
3.Hybrid systems
intramedular and external techniques
4.Compression plating

24. Decision tree for specific knee arthrodesis technique with different clinicl indications
Indications for specific knee arthrodesis technique
infection
Noninfection
Severe Soft
tissue
compromise
With or without
bony defect
Severe bony
defect with or
without
soft tissue
compromise
No severe
soft tissue
compromise &
No severe bone
defect
Severe Soft
tissue
Compromise
with or without
bony defect
Severe bony
defect with or
without soft tissue
compromise
No severe soft
tissue compromise
No severe bone
defect
External
fixatation
Consider IMN
only with
concomitant
flap coverage
(Consider
antibiotic
cement coated
IMN )
Long or
shot IMN
Consider
IMN coated
with
antibiotic
cement;
Circular
external
fixator
External
fixatation :
Long or short
IMN :
(Consider
antibiotic
coated IMN)
External
fixatation
Consider IMN
only with
concomitant flap
coverage
External
fixatation :
Long or short
IMN
Compression
plate
External fixatation :
Long or short IMN
Compression plate
Source: Kim K, Snir N, Schwarzkopf R. Modern Techniques in Knee Arthrodesis. International
Journal of Orthopaedics 2016; 3(1): 487-496

25. • End point of arthrodesis:
successful when bony trabeculae traverse from
tibia to femur in at least two radiographic
projections
proper alignment :as per pre-operative
assessment

26. TECHNIQUES
Selection of arthrodesis technique - based on
the individual patient and the surgeon’s
experience

27. COMPRESSION ARTHRODESIS WITH
EXTERNAL FIXATION
Popularized by charnley –initial compression followed by
plaster cast
Indication:
infected knee
minimal bone loss with broad cancellous surfaces with
adequate cortical bone to allow good bony apposition
and compression

28. COMPRESSION ARTHRODESIS WITH
EXTERNAL FIXATION cont.
Disadvantage :
reduced fusion rates compared with intramedullary nailing
Advantages:
- application of good, stable compression across fusion site
- placement of fixation at site remote from the infected or
neuropathic joint

29. COMPRESSION ARTHRODESIS WITH
EXTERNAL FIXATION cont.
Procedure :
-with long parapatellar incision reflect patella laterally ,
expose joint and through debridement
-cut distal femur and proximal tibia using TKR guide system
-Apply biplanner external fixator to compress two surface
Denude patellofemoral surface and fix to anterior femoral
surface

31. COMPRESSION ARTHRODESIS WITH
EXTERNAL FIXATION cont.
• Post operative care :
walk immediately after surgery with assistive devices bearing
weight of leg
Pin site care
once wound healed – follow up 6 weekly
till fusion Radiological and clinical union -apply long leg
orthosis /cylinder cast and full weight bearing for 4 weeks

32. Conclusion: Knee arthrodesis using a monolateral external fixator for
failed septic TKR achieved high fusion and infection eradication rates,
despite the extended time needed. When fusion is achieved, patients
had good pain relief and satisfaction.

33. ARTHRODESIS WITH
INTRAMEDULLARY ROD FIXATION
Extensive bone loss does not allow compression
- after tumor resection
- failed total knee arthroplasty
• Advantages:
Immediate weight bearing
Easier Rehabilitation
Absence of pin track complications
High fusion rate

34. • Disadvantages:
-fat embolism
-intramedullary dissemination of infection
-potential impediment to obtaining correct alignment
- prolong duration of operation time

35. • Procedure :
periprosthetic TKA infection : 2-stage procedure is
recommended
Refreshing the distal femur and proximal tibia surfaces
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
Severe bony defects :
allograft and autograft bone grafts or a metal or polyethylene
spacer

37. • Post operative care:
Mobilized as soon as possible post operatively with assistive
device
Follow up 6 weekly
Radiological and clinical union : ambulatory aid dis continued

38. ARTHRODESIS WITH PLATE FIXATION
indications :
difficult salvage cases with severe bone loss with segmental
vascularised allogarft
advantages :
- pin track infection and pin loosening are avoided
- earlier weight bearing possible
- easier for patient in post operative period

39. • Disadvantage:
not recommended for even to low garde infection
Procedure :
Use 12-16 hole plate
Secure the plates to femur and tibia with at least five bicortical
screw through each plate in each fragment using
compression technique

41. • Post operative care :
apply cylindrical cast
Allow touch down weight bearing with crutches till 12 weeks
Full weight bearing after radiological and clinical healing

42. IM nailing appears to have a higher rate of successful union but a higher risk of
recurrent infection when compared with external fixation knee arthrodesis.

43. Management of complications following
knee arthrodesis
1. Nonunion after knee arthrodesis:-
until 6-9 mo after arthrodesis procedure
range from 17% to 80%
multiple factors :
patient comorbidities
presence of active knee infection
choice of implant
Treatment options:
-bone grafting the nonunion site plus either exchange intramedullary
nailing (EIN) or supplemental plate fixation (SPF)

44. • 2. LIMB LENGTH DISCREPANCY AFTER KNEE ARTHRODESIS
goal : 2 cm LLD
fused side being shorter : allow easier foot clearance when
walking, assist in dressing ,relives tenson hamstring tendon
and sciatic nerve
treatment:
Nonoperative :shoe lift
balance issues occur more when a lift height of 5 cm or more
is required
surgical intervention:
lengthening over a nail
exchange nailing with an internal lengthening device

45. 3. THE WELL FUSED BUT INFECTED KNEE ARTHRODESIS:
-nail must be removed
- long, antibiotic cement-coated IM nail can be placed if
a large amount of bone is debrided or if the fusion is
disrupted

46. TEMPORARY KNEE FUSION FOR TREATMENT OF
INFECTED TOTAL KNEE ARTHROPLASTY
goals:
- eradication of infection
- stabilization of the knee.
articulating antibiotic cement-coated spacer
-may not provide adequate stability
- postoperative knee dislocation
- inability to bear weight
Wood JH et al. Advanced concepts in knee arthrodesis.World J Orthop 2015

47. • temporary knee fusion is accomplished by inserting
both an antibiotic cement-coated IM knee fusion nail
and a static antibiotic cement-coated spacer
• Indications:
morbidly obese
lack an extensor mechanism,
have significant soft tissue defects
have extensive distal femoral or proximal tibial bone
loss
*Wood JH et al. Advanced concepts in knee arthrodesis.World J Orthop 2015

49. Temporary knee arthrodesis

50. Physiotherapy after knee fusion
surgery
• Early stages (1-12 weeks):
• Modalities to control pain and swelling
• Crutch training
• Non weight bearing exercises
• Strengthening exercises for muscles in unaffected leg
(quadriceps, hamstrings, calf muscles)
• Ankle exercises in affected leg
• Functional, non weight bearing activities using crutches
(climbing stairs, sit to stand, moving certain distances
etc)

51. 3-6 months:
• Partial to full weight bearing exercises as
tolerated
• Strengthening of muscles in hip, knee and ankle
in affected and non affected leg
• Stretching of quadriceps, hamstrings, hip flexor,
and calf muscles in both legs
• Range of movement exercises in hip and ankle of
affected leg
• Range of movement exercises in unaffected leg
and back
• Gait re-education
• Proprioception ( balance) training

52. 6 months onwards:
• Continuation of strengthening exercises for
both lower limbs, upper limbs, core muscles
and back
• Continuation of range of movement exercises
for both lower limbs, upper limbs, core
muscles and back
• Gait re-education
• Proprioception (balance) training

53. Quadriceps Knee Strengthening Exercises
Calf Strengthening Exercises

54. Summary
Major indication of arthdrodesis-salvage of infected TKR while other
are tb,neuropathic joint , malignant or potentially malignant
Patients concerns after knee fusion should be preoperatively
counselled
Pre-operative considerations are most for successful arthrodesis eg co-
morbidities ,soft tissue coverage ,bone loss status , malignant
condition , garft asessment
Position of limb in valgus :5-7 degree, flexion:10-15 degree,external
rotation :10 degree and LLD should be adressed
For infected TKR two stage procedure recommended
IMN has better union but have higher chances of infection
Illozarov’s has advantage of mechanical bone induction along with
stabilaization and correction of LLD
Post operative physiotherapy ranges from Strengthening Exercises to
weight bearing and gait re education should be well educated

55. Refrences
• Cambell operative orthopedics 13 e
• Chapmans orthopaedic surgery 3e
• Tuberculosis of skeletal system 4
• Internet