Arthrodesis of the Hip and Knee

1. Arthrodesis of the Hip and Knee Presented by Spencer F. Schuenman D.O.

2. Arthrodesis of the Hip-Introduction • Historically this was first performed in France by Lagrane in 1886, then in the U.S. by Albee in 1908. • This served as the procedure of choice up until the advent of cup arthroplasty and total hip arthroplasty. • This is now rarely performed secondary to poor patient tolerance and the technology with hip arthroplasty.

3. Indications • Unilateral hip disease (usually posttraumatic) • Posttraumatic degenerative arthritis • Septic arthritis • Tuberculosis • Legg-Calve-Perthes Disease • Failed osteotomies and arthroplasties in the young patient

4. Patient Selection and Criteria • Patients must have a normal ipsilateral knee and an asymptomatic lumbar spine (spondylolisthesis and spondylolysis must be ruled out) • Young (under 40 y.o.), active, and a heavy laborer • Preoperative immobilization (hip spica) is commonly used to aquaint the patient with postoperative expectations.

5. Contraindications to hip arthrodesis • Rheumatoid arthritis • Lupus • Morbid obesity • Jobs that require prolonged sitting • Contralateral hip disease-however, it can be done with a contralateral total hip arthroplasty

6. Complications • Nonunion, ranging from 8-40% • Malposition (most common)

7. Clinical Studies • Studies have shown that 60% of patients have pain in the ipsilateral knee and lumbar spine, and 25% have contralateral hip pain. (Callaghan et al.) • Compensation occurs with increased pelvic rotation, increased motion of the ipsilateral knee and contralateral hip. (Gore et al.) • Long term follow-up studies reveal a 78% patient satisfaction and all of the patients were able to return to work with a 57% and 45% incidence of low back and ipsilateral knee pain respectively. (Sponseller et al.)

8. Hip arthrodesis-Technique • Fusion may be obtained by extraarticular, intraarticular, or a combination of the two. Most use the combined method supplemented with some form of internal fixation. • The optimal position for hip fusion is 30 degrees of flexion, 0-5 degrees adduction, and 10-15 degrees of external rotation.

9. Extraarticular Arthrodesis • This is rarely indicated today. It was generally used in cases of tuberculosis of the hip when the bone quality was diminished.

10. Technique • A guide pin is inserted at a 45 degree angle to the femoral shaft thru the femur and 2.5cm into the ischium. • Osteotomize the femur along the guide pin • Obtain cortical bone graft from the tibia which approximates the osteotomized femur • Insert tibial graft • Displace distal femur medially so it contacts the ischium • Close wound and then apply hip spica cast

11. Intraarticular Arthrodesis-Technique • Anterior iliofemoral approach to the hip • Dislocate the hip anteriorly and remove cartilage from the femoral head and acetabulum to cancellous bone. • Pack the opposing surfaces with cancellous autologous bone graft • Internal fixation may or may not be used. If internal fixation is not used a hip spica is then applied. • Immobilization is continued until radiographs indicate fusion.

12. Combined Intraarticular and Extraarticular Arthrodesis • An anterior approach is used • The surface of the femoral neck is denuded • A graft or flap is removed from the pelvis and is applied from above the acetabulum to the trochanter and is placed in contact with the denuded femur. • The arthrodesis is then supplemented with internal fixation • Immobilization is continued until radiographic evidence of fusion

13. Combined Intraarticular and Extraarticular Arthrodesis

14. Types of Internal Fixation • Compression Screw • Compression Bolts • Cobra Head Plate

15. To achieve ideal positioning To avoid damage to the abductors, trochanter and quadriceps To avoid deformities of the pelvis and proximal femur To provide the patient with a pain-free and functional hip Goals of Arthrodesis of the Hip

16. Historically, the first knee arthrodesis was performed by Albert in 1878 in Vienna, and then in the U.S. by Hibbs in 1911. Arthrodesis of the Knee-Introduction

17. Uncontrollable septic arthritis and complete joint destruction In young patients with severe ligamentous and articular damage In neuropathic joint disease Patients with failed total knee replacements Tumors Indications

18. Nonunion and pseudoarthrosis Persistent knee pain Low back pain secondary to altered gait patterns. Siller et al reported nearly 50% incidence of low back pain after knee arthrodesis, but Rud et al reported only 3 of 30 patients with low back pain. Bone loss and leg length discrepancy Complications

19. Anatomic position relative to the opposite extremity - 5-7 degrees of valgus Flexion/Extension depends on leg length-if the leg lengths are equal it is recommended that arthrodesis be in 10-15 degrees of flexion to facilitate clearance of the foot during the swing phase of walking If there is bone loss and limb shortening, arthrodesis in full extension is recommended. Optimal Position of Fusion

20. External Fixation- this is the preferred method following infected TKAs Hak et al reported a 61% fusion rate with use of ext fixation Surgical Procedures-type of fixation depends on the indication for the procedure

21. Intramedullary Rods-Fixation is from the greater trochanter to the distal tibia The advantage is that there is progressive compression at the knee joint and fusion rates have been reported as high as 92%. Plate fixation-useful when bone graft is required to protect the graft during healing, this also provides compression across the joint.

22. Pain relief Return to functional activities Goals of Arthrodesis of the Knee