Arthrodesis of the Hip and Knee

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Arthrodesis of the Hip and Knee

• Presented by
• Spencer F. Schuenman D.O.

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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.

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Indications

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

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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.

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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

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Complications

• Nonunion, ranging from 8-40
• Malposition (most common)

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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.)

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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.

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Extraarticular Arthrodesis

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

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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

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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.

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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

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Combined Intraarticular and Extraarticular
Arthrodesis
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Types of Internal Fixation

• Compression Screw
• Compression Bolts
• Cobra Head Plate

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Goals of Arthrodesis of the Hip

• 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

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Arthrodesis of the Knee-Introduction

• Historically, the first knee arthrodesis was
  performed by Albert in 1878 in Vienna, and then
  in the U.S. by Hibbs in 1911.

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Indications

• 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

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Complications

• 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

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Optimal Position of Fusion

• 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.

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Surgical Procedures-type of fixation depends on
the indication for the procedure

• External Fixation- this is the preferred method
  following infected TKAs
• Hak et al reported a 61 fusion rate with use of
  ext fixation

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• 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.

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Goals of Arthrodesis of the Knee

• Pain relief
• Return to functional activities