Klinisch-funktionelle Nachuntersuchung verschiedener handchirurgischer Versteifungsmethoden

Background

Total and partial arthrodesis of the wrist are currently sophisticated treatment options for many advanced pathological changes of the wrist. This retrospective study analyzed the subjective and objective outcome of different wrist arthrodesis techniques, e.g. total wrist arthrodesis, scaphotrapeziotrapezoid (STT) bone fusion and midcarpal arthrodesis.

Materials and methods

Subjective physical and mental quality of life of 98 patients (total wrist arthrodesis n?=?43, STT fusion n?=?30 and midcarpal arthrodesis n?=?25) was measured using the DASH questionnaire. The range of motion and grip strength were analyzed in 48 patients (total wrist arthrodesis n?=?21, STT fusion n?=?17 and midcarpal arthrodesis n?=?10).

Results

Patients with partial wrist arthrodesis achieved a significantly better DASH score than patients with total wrist arthrodesis. Grip strength did not show any statistically significant differences between the two groups. Patients with STT fusion showed the best range of motion of the wrist.

Conclusion

Partial arthrodesis seems to be superior to total wrist arthrodesis. Patients profit from a higher physical and mental quality of life.     

Arthrodesis of the hip joint as a treatment of degenerative changes--anachronism or an alternative for endoprosthetic arthroplasty?]

On the basis of the observation of 22 patients with arthrodesis of the hip (the average age -- 34 years), the value of the method in the treatment of osteoarthritis that joint has been discussed. The comparison of intraarticular arthrodesis with stable compression with pelvis osteotomy and stabilization by the "cobra" plate has proved that the second method is better because of elimination of immobilization by a plaster cast and low percentage of complications of union. The clinical analysis of the majority of the patients has not revealed negative influence of arthrodesis on the other hip, the lumbar spine and the knee. Arthrodesis of the hip has improved walking efficiency and ability to work in 17 from 22 patients. Very good and good results have been obtained in 16 patients, fair in 3, and poor in 3.     

Segmental spinal instrumentation of the lumbar spine

Obtaining an arthrodesis of the lumbar spine has always been a problem, especially in the presence of severe disease. The understanding of the segmental character of the lesions and the application of sound orthopedic principles toward low-back spine pathology has led the way to improving arthrodesis with rigid internal fixation. For about eight years, segmental spinal instrumentation has been used in 352 cases to "stabilize" the spine. Many modifications have taken place and knowledge of the biomechanics of abnormal spine has increased through designs of new methods for different disorders. Fixation of low back, when indicated, should be rigid. The rectangular or rhomboid-shaped rod, bent to conform to the lamina cephalad and caudad, and fixed segmentally, proves to be the most rigid. It is contoured to maintain lordosis, sometimes in distraction, sometimes in compression. Fixation is not a substitute for correction of bony deformity or a good surgical arthrodesis. The objective is to maintain correction and promote prompt bony fusion.     

Opera-glass hand in rheumatoid arthritis.

Characteristic deformities occur in the fingers, thumb, and wrist in the opera-glass hand in rheumatoid arthritis. Shortening and instability are the result of bone resorption and dislocation and can be severely disabling. Early spontaneous fusion of the proximal interphalangeal joint preserves digital length. Functional improvement can be obtained in the fingers by interphalangeal joint arthrodesis and metacarpophalangeal prosthetic arthroplasty and in the thumb with metacarpophalangeal and/or interphalangeal arthrodesis. With interphalangeal arthrodesis, interposition grafts often are required in order to restore length and secure fusion. "Prophylactic" arthrodesis of interphalangeal joints should be considered when resorption seems imminent.     

Subtalar distraction arthrodesis using a ramp cage

Subtalar distraction bone block arthrodesis has been described to treat late complications of displaced calcaneal fractures. A "ramp cage" can be used to restore the talocalcaneal relationship by providing stable correction in the coronal and sagittal dimensions.     

Arthrodese der Mittel- und Endgelenke der Kleinzehen

Objective

Elimination of the fixed lesser toe deformity by arthrodesis of the proximal or distal interphalangeal joints (PIP and DIP, respectively).

Indications

Painful fixed deformity. PIP joint: fixed hammer toe or clawtoe. DIP joint: fixed mallet toe. Relative indication: flexible hammer toe, clawtoe or mallet toe.

Contraindications

General operative contraindications. Relative contraindications also include severe deformities affecting the metatarsophalangeal (MTP) joint, for which the arthrodesis should combine an operative procedure of the MTP joint.

Surgical techniques

PIP arthrodesis: Dorsal incision centered over the PIP joint, exposure of the PIP joint by transsecting the extensor tendon and joint capsule, release of the collateral ligaments, while carefully protecting the neurovascular bundles, resection of the head of the proximal phalanx and the articular surface of the middle phalanx. The arthrodesis should be stabilised in mild plantar flexion. The tip of the toe should have contact with the surface when the push up test is done. The arthrodesis technique depends on the implant used. The extensor tendon is sutured and the wound is closed. DIP arthrodesis: dorsal incision centered over the DIP joint, exposure of the DIP joint by transsecting the extensor tendon and joint capsule, release of the collateral ligaments, while carefully protecting the neurovascular bundles. Resection of the head of the middle phalanx and the articular surface of the distal phalanx. The arthrodesis should be stabilised in straight position. The arthrodesis technique depends on the implant used. The extensor tendon is sutured and the wound is closed.

Postoperative management

Postoperative full weight bearing for 3–6 weeks, depending on the arthrodesis technique used.

Results

Stabilisation of the toe with adequate alignment is achieved by arthrodesis of the affected joint. In general, digital fusion of the fixed lesser toe pathology shows a high subjective satisfaction rate among the patients, although the rate of pseudarthrosis in attempted PIP or DIP arthrodesis is quite high. Major reasons for postoperative dissatisfaction were swelling, wound necrosis, pin infection, floating toe, shortening and angulation of the toe.     

Possible use of arthrodesis for intractable sacroiliitis in spondylarthropathy: report of two cases

STUDY DESIGN: Two cases of successful sacroiliac joint arthrodesis for medically intractable aseptic sacroiliitis are reported. SUMMARY OF BACKGROUND DATA: Although successful arthrodesis of the sacroiliac joint had been reported previously for septic sacroiliitis, no report had shown the procedure to be effective for spondylarthropathy. METHODS: Two women with spondylarthropathy involving very painful sacroiliac arthritis for 18 and 24 months had been relieved only transiently by several injections of steroids into the sacroiliac joint under fluoroscopy and by Bermuda casts. Both patients underwent sacroiliac joint arthrodesis. RESULTS: Both patients showed dramatic improvement after sacroiliac joint arthrodesis. Moreover, no relapses had occurred, respectively, after 2 and 3 years of follow-up evaluation despite continuing spondylarthropathy in other joints. CONCLUSIONS: After a careful selection of patients, including positive blocks in the sacroiliac joint, arthrodesis of sacroiliac joint might be considered for so-called "intractable" aseptic sacroiliitis.     

Arthroscopic subtalar arthrodesis through the sinus tarsi portal approach: A series of 77 cases

Background

Subtalar arthrodesis through an open approach carries significant risk of complications. An arthroscopic approach aims to minimise damage to the soft tissue envelope to improve recovery, union and complication rates. A two portal approach through the sinus tarsi was used.

What Are the Frequency,Associated Factors,and Mortality of Amputation and Arthrodesis After a Failed Infected TKA?

Background

For patients with failed surgical treatment of an infected TKA, salvage operations such as arthrodesis or above-knee amputation (AKA) may be considered. Clinical and institutional factors associated with AKA and arthrodesis after a failed TKA have not been investigated in a large-scale population, and the utilization rate and trend of these measures are not well known.

Questions/purposes

(1) How has the frequency of arthrodesis and AKA after infected TKA changed over the last 10 years? (2) What clinical or institutional factors are associated with patients undergoing arthrodesis or AKA? (3) What is the risk of mortality after arthrodesis or AKA?

Methods

The Medicare 100% National Inpatient Claims Database was used to identify 44,466 patients 65 years of age or older who were diagnosed with an infected TKA and who underwent revision between 2005 and 2014 based on International Classification of Diseases, 9^th Revision, Clinical Modification codes. Overall, 1182 knee arthrodeses and 1864 AKAs were identified among the study population. One year of data before the index infection-related knee revision were used to examine patient demographic, institutional, and clinical factors, including comorbidities, hospital volumes, and surgeon volumes. We developed Cox regression models to investigate the risk of arthrodesis, AKA, and death as outcomes. In addition, the year of the index revision was included as a covariate to determine if the risk of subsequent surgical interventions was changing over time. The risk of mortality was also assessed as the event of interest using a similar multivariate Cox model for each patient group (arthrodesis, AKA) in addition to those who underwent additional revisions but who did not undergo either of the salvage procedures.

Results

The number of arthrodesis (hazard ratio [HR], 0.90, p < 0.001) and amputation (HR, 0.95, p < 0.001) procedures showed a declining trend. Clinical factors associated with arthrodesis included acute renal failure (HR, 1.22 [1.06–1.41], p = 0.006), obesity (HR, 1.58 [1.35–1.84], p < 0.001), and having additional infection-related revisions (HR for 2+ additional revisions, 1.36 [1.13–1.64], p = 0.001). Higher Charlson comorbidity score (HR for a score of 5+ versus 0, 2.56 [2.12–3.14], p < 0.001), obesity (HR, 1.14 [1.00–1.30], p = 0.044), deep vein thrombosis (HR, 1.34 [1.12–1.60], p = 0.001), and additional revisions (HR for 2+ additional revisions, 2.19 [1.91–2.49], p < 0.001) were factors associated with AKA, which in turn was an independent risk factor for mortality. The risk of death increased with amputation after adjusting for age, comorbidities, and other factors (HR, 1.28 [1.20–1.37], p < 0.001), but patients who received arthrodesis did not show a change in mortality compared with the patients who did not receive arthrodesis or amputation (HR, 1.00 [0.91–1.10], p = 0.971).

Conclusions

The findings of this study suggest that clinicians may be more aggressively attempting to preserve the knee even in the face of chronic prosthetic joint infection but also show that a greater number of revisions is associated with a greater risk of subsequent AKA or arthrodesis. The results also suggest that recommending centers with a high volume of joint arthroplasties may be a way to reduce the risk of the salvage procedures.

Level of Evidence

Level III, therapeutic study.

     

Adolescent idiopathic scoliosis correction by instrumented vertebral arthrodesis with autologous bone graft from local harvesting without bone substitute use: results with mean 3 year follow-up

Purpose

Bone substitutes’ advantage is enhancing arthrodesis biologic support without further autologous bone graft harvested from other skeleton sites, as from posterior iliac crests; however, in our experience, bone substitutes’ integration is often incomplete.

Methods

From 2012 to 2017, we operated 108 patients by posterior instrumented vertebral arthrodesis in adolescent idiopathic scoliosis (AIS) correction, mean main curve 80° Cobb, and mean age 12 years and 6 months, with all pedicle screws instrumentation in main curve/curves area and hooks at upper tip of implant; bone graft has been harvested only at vertebral level, without bone substitutes or autologous graft from other patient sites or allogenic bone graft. We matched this group with 98 patients previously operated in which we used calcium triphosphate.

Results

At 3 year mean follow-up, all patients in group treated with autologous bone graft only have complete and stable arthrodesis without loss of correction (mean curve 27° Cobb) or instrumentation failure. At 6 year mean follow-up in the group treated with autologous bone graft augmented by calcium triphosphate, 96 patients have stable arthrodesis without loss of correction (mean curve 24°), 1 case has implant break, and 1 case has 8° Cobb loss of correction.

Conclusion

Bone substitutes are a further cost in arthrodesis surgery and suboptimal integration leaves foreign bodies on vertebras. Our experience shows that all pedicle screw instrumentation and bracing after surgery obtain stable correction showing in time a solid arthrodesis with autologous bone only, harvested at local site, without bone substitutes or further bone graft.

Graphical abstract

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Arthrodesis of the metatarsophalangeal joint of the great toe

Since 1975 the usual treatment of hallux valgus and hallux rigidus at the Medical High School, Lübeck, has been arthrodesis of the metatarophalangeal joint of the great toe. We report 48 operations performed between 1975 and 1977 on 35 patients with a follow-up of 3-32 months. The operative technique, using the "dynamic compression plate" is described in detail. The patient's assessment and the clinical and radiological situations were recorded. There were only three poor results. Thus, arthrodesis of the metatarsophalangeal joint is considered to be a reliable therapeutic method in hallux valgus, with minimal post-operative complications. It compares well with other operations, including Keller's arthroplasty.     

Conservative surgery in Kienbock's disease with perilunate arthrosis: articular resurfacing using resected carpal bones

We present 2 cases of Kienb?ck's disease in which peri-lunate chondral lesions contra-indicated classical procedures such as proximal row carpectomy or 4 corner arthrodesis. A partial carpectomy provided us with an osteochondral graft, used to resurface the areas of chondral damage over the capitate or on the radius. The clinical and radiological result was stable at a follow-up of 3 and 6 years. In the first case, degenerative changes over the head of the capitate contra-indicated proximal row carpectomy. The lunate was removed and the proximal 2/3 of the scaphoid were shifted medially and fused in a "four-corner"-like arthrodesis. In the second case, the lunate fossa on the radius was damaged. The proximal row was excised and an osteochondral graft was harvested from the triquetrum. This was used to replace the lunate fossa on the radius. This new concept of a "carpal bank" has enabled us to extend the classical indications for proximal row carpectomy and four-corner arthrodesis. It makes it possible to withdraw the limits of conservative wrist surgery in Kienb?ck's disease and we believe this concept could also be extended to similar situations of localized chondral damage in small joints.     

Teilarthrodesen und Fusionen am rheumatischen Handgelenk

The hand (wrist and fingers) is one of the regions most frequently affected by rheumatic arthritis (RA). Obviously, the functional handicap affects activities of daily living and imposes an additional psychological burden, because the nature of the alterations means that the clinical picture can be interpreted as RA from external appearances. Thus, treatment of the rheumatoid wrist is a prodigious challenge for hand surgeons. Radiolunate arthrodesis (RLA), as pioneered by Chamay and Della-Santa, has become an established surgical technique for stabilizing and relieving pain in wrists destroyed by RA. RLA has been described by Stanley as the "golden standard" for the treatment of rheumatoid wrists. For patients with a severe wrist deformity and pain, a complete wrist arthrodesis may be the only viable surgical option.     

STT arthrodesis versus proximal row carpectomy for Lichtman stage IIIB Kienb?ck’s disease: first results of an ongoing observational study

Introduction

Scapho-trapezial-trapezoidal (STT) arthrodesis and proximal row carpectomy (PRC) are used for the treatment of Lichtman stage IIIB Kienb?ck’s disease. This study prospectively compares 1-year results of STT arthrodesis and PRC in Lichtman stage IIIB Kienb?ck’s disease.

Materials and methods

Nineteen patients were operated: eight with STT arthrodesis and 11 with PRC. Preoperatively and 1-year postoperatively, mobility and grip strength were examined. Both DASH and Mayo Wrist Scores were obtained from the patients.

Results

In the STT arthrodesis group, mean extension/flexion worsened from 54 to 39?% of the opposite hand. Grip strength improved from 52.9 to 62.1?%. The DASH Score improved from 32.6 to 21.4, and the Mayo Wrist Score from 50.6 to 57.9. In the PRC group, extension/flexion decreased from 62.5 to 57.0?% of the opposite hand. Grip strength improved from 38.6 to 69.0?%, the DASH Score from 36.7 to 18.9, and the Mayo Wrist Score from 54.6 to 66.0.

Conclusion

One year after operation, slightly better results were observed in patients with PRC compared to STT arthrodesis.     

Medial Double Arthrodesis: Technique Guide and Tips

The triple arthrodesis procedure remains the historical standard to treat complex hindfoot pathology. However, in recent data, the medial double arthrodesis has been documented to provide similar benefit with decreased complication rates compared with the triple arthrodesis. Therefore, increased interest in this procedure for the treatment of complex hindfoot pathologies has ensued. We describe the technical components of the medial double arthrodesis.     

The use of dynamic radiographs in trapeziometacarpal joint arthrodesis for accurate range of motion evaluation

Background

Increased motion at the scaphotrapeziotrapezoidal (STT) joint and compensatory hypermobility of metacarpophalangeal (MP) joint contribute to the total abduction and adduction motion of the thumb after trapeziometacarpal (TM) joint arthrodesis. However, there were no detailed studies to evaluate the contribution of motion of each joint towards total thumb mobility.

Beware the hallucal interphalangeal joint sesamoid in first metatarsophalangeal joint arthrodesis

Background

We describe a previously unreported presentation of the hallucal interphalangeal joint sesamoid (HIPJS) following arthrodesis of the first metatarsophalangeal joint (MTP1).

Implantable Electrical Bone Stimulation for Arthrodeses of the Foot and Ankle in High-Risk Patients: A Multicenter Study

This study assessed arthrodesis procedures performed in the foot and ankle of high-risk patients following implantation of an internal electrical bone stimulator. Criteria defining patients as "high risk" included diabetes, obesity, habitual tobacco and/or alcohol use, immunosuppressive therapy, and previous history of nonunion. Standard arthrodesis protocol of bone graft and internal fixation was supplemented with the implantable electrical bone stimulator. A retrospective, multicenter review was conducted of 26 patients (28 cases) who underwent 28 forefoot and hindfoot arthrodeses from 1998 to 2002. Complete fusion was defined as bony trabeculation across the joint, lack of motion across the joint, maintenance of hardware/fixation, and absence of radiographic signs of nonunion or pseudoarthrosis. Radiographic consolidation was achieved in 24 of the 28 cases at an average 10.3+/-4.0 weeks. Followup averaged 27.2 months. Complications included 2 patients who sustained breakage of the cables to the bone stimulator. Five patients underwent additional surgery. Four of the 5 patients had additional surgery in order to achieve arthrodesis. All 4 went on to subsequent arthrodesis. This study demonstrates how arthrodesis of the foot and ankle may be enhanced by the use of implantable electrical bone stimulation.     

Decompression and fusion with or without instrumentation

Fusion methods for degenerative spondylolisthesis and stenosis have been continuously evolving over the past few decades. Non-instrumented arthrodesis has been replaced with posterolateral instrumented arthrodesis and the potential addition of an interbody arthrodesis. In this chapter we discuss the advantages and disadvantages seen in the literature with posterolateral instrumented f arthrodesis (IF) versus non-instrumented arthrodesis as well as with posterolateral instrumented arthrodesis and additional interbody arthrodesis (IBF) in the setting of degenerative spondylolisthesis.