Small Joint Arthrodesis

1
(No Transcript)
2
The HandSmall Joint Arthrodesis

• Reza Sh. Kamrani
• Orthopaedic surgeon
• Hand surgeon
• AO Congress
• 25 Apr 2004

3
Hand Function
GRASP
Mobility to mold the object
4
Small joint arthrodesis of hand

• Indication
• Pain
• Instability
• Deformity
• Loss of neuromuscular control
• Function Cosmetic impairment
• Trauma
• Contraction ( Burn, RA, Infection, )
• Nerve palsy

5
Trauma
6
Congenital
Neglected synductyly
7
(No Transcript)
8
Rheumatoid hand
9
Soft tissue injury
10
Tendon substance loss
11
Residual deformity
Cosmetic
12
Electrical burn
13
Industrial injury
14
Long standing deformity
15
Ulnar nerve palsy
16
Fingers joints

• - DIP There is no indication for arthroplasty
• - PIP
• - MP The most important joint for finger mobility

17
DIP

• There is no indication for arthroplasty
• Specific indications
• Isolated FDP rupture
• Chronic mallet finger

18
Terminal tendon reduction
19
DIP arthrodesis
20
DIP

• There is no indication for arthroplasty
• Specific indications
• Isolated FDP rupture
• Chronic mallet finger
• Position
• 0 deg Extension

21
(No Transcript)
22
DIP

• There is no indication for arthroplasty
• Specific indications
• Isolated FDP rupture
• Chronic mallet finger
• Position
• 0 deg Extension
• Alternative options
• Tenodesis

23
PIP

• Specific indication
• Rigid boutonniere deformity
• Central slip substance loss

24
Dorsal hand injury
25
Central slip loss
PIP
26
PIP

• Specific indication
• Rigid boutonniere deformity
• Central slip substance loss
• Position
• Contraversy
• Cascade from 40 to 55 deg.
• All in 40 deg.
• 5-10 deg supination in index and middle fingers

27
PIP

• Specific indication
• Rigid boutonniere deformity
• Central slip substance loss
• Position
• Contraversy
• Cascade from 40 to 55 deg.
• All in 40 deg.
• 5-10 deg supination in index and middle fingers
• Alternative options
• Arthroplasty

28
Recurent intra-osseus hemangioma
29
Osteo-cartilagr auto graft
Destroyed joint
30
Free PIP joint transfer
31
MP

• The most important joint in finger motion
• Specific indication
• Failed arthroplasty
• Position
• Cascade from 25 to 40 deg.
• Without rotation or deviation
• Alternative option
• Artroplasty is more reliable and satisfactory

32
Post traumatic tendon adhesion
33
Extensor tenolysis
34
Rheumatoid hand
35
MP arthroplasty
36
Technique

• Arthrodesis
• The prime requisites of a good digital
  arthrodesis
• - a painless and stable union
• - in a proper position
• - in a reasonable space of time
• Moberg

37
Technique

• Approaches
• DIP dorsal H , Y , transverse cut the terminal
  tendon
• PIP dorsal split tendon app.
• MP dorsal radial side of tendon
• CMC dorsal transverse
• 1st CMC radiovolar curvilinear

38
Different approaches of DIP
39
(No Transcript)
40
Dorsal app.
41
Extensor split app.
42
Technique

• Preparation of bone surface
• Fixation method
• Bone graft

43
Surface preparation

• Cancellous to cancellous contact

44
Cancellous to cancellous bone contact
45
Surface preparation

• Cancellous to cancellous contact
• Good position
• Flat angled
• Chevron
• Cup and Cone

46
Flat cut
Cup and Cone
47
Flat cut in exact correct angle
48
Surface preparation

• Cancellous to cancellous contact
• Good position
• Flat angled
• Chevron
• Cup and Cone
• Full flexion to deliver the ends

49
Hyper flexion of the joint
50
Hyperflexion of the joint to remove articular
surface
51
Method of fixation

• Cross articular K wire
• Interosseus wiring
• 90-90 wiring
• Compresion techniques
• TBW
• Compresion screw
• AO Plating
• Bioabsorbable Rod and Pins

52

• K wire
• At least two wires
• Cross out of joint line
• Osteoporosis
• 6-8 weeks support
• Remove of the wires after fusion

53
K wire for DIP arthrodesis
54
K wire
55
Thumb reconstruction with foucher flap
56
MP arthrodesis in thumb recostruction
57

• Interosseus wiring
• 3mm. From joint line
• 0035 K wire 26g wiring
• Less cumbersome than plate and screw
• Less dissection
• Contraind. Osteoporosis

58
Crushed hand with open metacarpal Fx.
59
90-90 wiring
Stable with minimal dissection
60
Phalageal Fx. With soft tissue cntusion
61
Gray angiocath.
Passing wire
62
90-90 wiring
63
Good result in a contused PP Fx.
64

• TBW
• PIP , MP
• Early ROM

65
(No Transcript)
66
(No Transcript)
67
Intra medulary K wires
68
Thumb reconstruction with Foucher flap
69
MP artrodesis with TBW
70
(No Transcript)
71

• Compression screw
• DIP , PIP , MP , CMC
• AO 2.7 screw
• Herbert screw

72
(No Transcript)
73

• Plating
• PIP , MP
• Bone loss
• 2-2.7 mm plate
• 3-4 holes
• More demanding
• More dissection

74
Thumb instability in Rheumatoid hand
75
AO 2.7mm T plate
76

• External fixator
• PIP , MP
• Infection
• Soft tissue injuries
• Less invasive
• Cumbersome

77
Ilizarov
Open comminuted Fx.
78
ilizarov
lengthening
79
Ilizarov
arthrodesis
80
Congenital Ring syndrome
81
Finger lengthening
Synductyly release
Toe transfer
82
Two times arthrodesis failure
83
Critical vascularity
Minimal invasion
84
Bone graft

• Usually not required
• Bone loss
• Bone peg ( Moberg technique )
• Donor site

85
Intercalary Bone graft
86
Complications

• These operations
• are not simple
• are not safe

87
Complication

• Acute vascular insufficiency
• Non-union
• Mal-union
• Cold intolerance
• Infection

88

• Acute vascular insufficiency
• Following correction of flex. contraction
• Tourniquet release
• Correction with shortening or flexion

89
Partial amputation with saw
Compromised vascularity
90
Revascularization with vein graft
91
Thumb in malposition
With questionable vascularity
92

• Non-union
• Technique of fixation
• In DIP is not important
• In PIP the technique is important for rate of
  union
• Bone stock
• The most important factor in union rate in DIP
• Premature removal of K wire
• The primary cause of non-union

93

• Swan neck deformity
• In DIP arthrodesis,
• terminal tendon must be repaired

94

• Infection
• Arthrodesis and implantation is contraindicate in
  acute infection

95
Crush finger
Wound dehiscence In spite of flap
sequesterum
96
Techniques Special problems

• Insensitive hand
• Soft tissue loss
• Soft tissue coverage
• Cumbersome stiff finger
• Nail deformity

97
Special problems

• Insensitive Hand

98
Special problems

• Soft tissue loss

99
Radial forearm flap
Finger joints can not be saved
100
Tendon substance loss
Rotational flap
101
Bad quality of skin over MP
Posterior interosseus flap
102
DIP crushed with skin loss
Neurovascular island flap
103
Special problems

• Soft tissue coverage after correction

104
Electrical burn in childhood
105
Simple skin graft
106
Residual deformity of bifid thumb
Clawer leaf flao
107
(No Transcript)
108
Sever long standing deformity
109
1st post intermetacarpal flap
110
Uncovered plate
111
Island flap
112
Special problems

• Cumbersome stiff finger
• A stiff finger is less cumbersome if it is
  slightly shorter

113
(No Transcript)
114
Special problems

• Nail deformity

115
Germinal layer 2mm proximal to nail bed
Transient deformity due to manipulation
116
Deformity from childhood
Nail deformity remains
117
Hand small joints arthrodesis in summary

• A satisfactory technique functionally
  cosmetically
• A delicate technique
• A successful technique gt90 union rate
• Not a simple operation
• There are many complications vascular,
  mal-union,
• Need a preoperative planning

118
Thank You