Advanced concepts in knee arthrodesis

The aim is to describe advanced strategies that can be used to diagnose and treat complications after knee arthrodesis and to describe temporary knee arthrodesis to treat infected knee arthroplasty. Potential difficult complications include nonunited knee arthrodesis, limb length discrepancy after knee arthrodesis, and united but infected knee arthrodesis. If a nonunited knee arthrodesis shows evidence of implant loosening or failure, then bone grafting the nonunion site as well as exchange intramedullary nailing and/or supplemental plate fixation are recommended. If symptomatic limb length discrepancy cannot be satisfactorily treated with a shoe lift, then the patient should undergo tibial lengthening over nail with a monolateral fixator or exchange nailing with a femoral internal lengthening device. If a united knee arthrodesis is infected, the nail must be removed. Then the surgeon has the option of replacing it with a long, antibiotic cement-coated nail. The authors also describe temporary knee arthrodesis for infected knee arthroplasty in patients who have the potential to undergo insertion of a new implant. The procedure has two goals: eradication of infection and stabilization of the knee. A temporary knee fusion can be accomplished by inserting both an antibiotic cement-coated knee fusion nail and a static antibiotic cement-coated spacer. These advanced techniques can be helpful when treating difficult complications after knee arthrodesis and treating cases of infected knee arthroplasty.     

Kniearthrodesen

When arthrodesis of the knee is indicated, the operative procedure selected for fixation depends on the condition of the soft tissues, the bone stock, whether infection is present, and the age of the patient and his or her capacity for partial weight-bearing. In young patients with no infection or soft tissue problems, when adequate bone stock is present compression plating or the use of an intramedullary nail is possible and allows stable fixation. Soft tissue problems with defect(s) or infection are a good indication for the use of an external fixator. The most common indication for knee arthrodesis is a failed total knee prosthesis that has become infected. Deficient bone stock with osteopenic bone or a defect after failed total knee arthroplasty are problems that can be solved by the use of modular fusion nail systems, especially in older patients. These systems are more comfortable for the patient than external fixation devices and allow early full weight-bearing.     

Knee arthrodesis with circular external fixation

Knee arthrodesis can enable limb salvage in patients with disability secondary to trauma, infected total knee arthroplasty, pyarthrosis, and other complications. Historically, intramedullary nailing has resulted in the highest overall knee fusion rates. However, intramedullary nailing is relatively contraindicated in the presence of active infection. Nineteen patients who underwent knee arthrodesis with circular external fixation were studied retrospectively. Postoperative radiographs were evaluated for evidence of bony fusion, which was defined as trabecular bridging between the femur and tibia. Patients were interviewed and graded using the functional assessment portion of the Knee Society clinical rating system. Fusion was successful in 13 of 19 (68%) patients. Overall, patients spent an average of 4 months 8 days wearing the circular external fixator. Average time to radiographic and clinical evidence of arthrodesis (defined as lack of motion across the fusion site) was 4 months 18 days. No patient with successful fusion considered himself or herself housebound. All but one of these patients require some form of assistive device for ambulation. Complications occurred in 16 of 19 (84%) patients overall. Superficial pin tract infection (55%) and nonunion (32%) were the most common. Circular external fixation is an effective method for obtaining knee arthrodesis in patients who are not good candidates for intramedullary nailing.     

Use of an intramedullary rod in knee arthrodesis following failed total knee arthroplasty

A retrospective review was conducted of 20 consecutive patients (10 men and 10 women) with failed total knee arthroplasty (TKA) who underwent arthrodesis using an intramedullary rod. Average patient age was 70.5 years. One patient was lost to follow-up, and the remaining 19 patients were evaluated an average of 4.5 years postoperatively (range: 1-24 years). Three patients without infections achieved a solid arthrodesis without complications. In 16 patients, the indication for fusion was an infection, and 12 of these patients had an uncomplicated postoperative course and achieved a solid arthrodesis. Of the remaining 4 patients, 1 required revision for a nonunion, 1 a skin graft, and 2 had recurrence of their infections in the postoperative period. Both patients had positive cultures at attempted arthrodesis. One patient underwent debridement at 3 months, and a solid fusion was obtained. The other patient required rod removal and currently has a nonunion, uses a brace, and is on suppressive antibiotic treatment. An intramedullary rod is the ideal fixation choice for knee arthrodesis in patients with a failed, noninfected TKA; however, in patients with an infection, the infection must be eradicated prior to rod use.     

Arthrodesis following knee arthroplasty

In 44 failed total arthroplasties of the knee joint, arthrodesis was attempted (1970-1986). The interval between implantation of the total knee arthroplasty and diagnosis of infection was more than 2 years on average. Removal of the arthroplasty and arthrodesis was performed about 1 year later. In 80% of the knees, compression arthrodesis using an AO plate was used 34 times, with solid fusion occurring after 6 months. External fixation was used in 10 patients; rate of solid fusion was only 60%. The reasons for delayed union or failure had to do with reduced bone stock in the metaphysis with poor bone quality, inadequate fixation, and uncontrolled infections.     

The Ilizarov external fixation frame in compression arthrodesis of large, weight bearing joints

Solid bony fusion of large joints affected with active chronic infections, is still the most effective surgical solution to establish a useful function of the affected limb. Even with extensive peri-articular bone loss and severe deformities, arthrodesis in a functional position can provide effective stability. The reported fusion rates in such patients are not encouraging however, and secondary amputations have been reported. Compression arthrodesis using an Ilizarov external fixation frame was performed for 17 destroyed feet (14 tibiotalar and 3 subtalar joints) and 6 badly disrupted knees in a series of 20 patients. Evaluation of the results was based on the clinical and radiological joint alignment, achievement of fusion, presence or absence of infection, and functional outcome. One patient after knee joint arthrodesis was lost to follow-up, and two knees had developed a clinically stable fibrous union. Solid fusion was obtained in all other joints. All joints were in anatomical alignment and the patients were fully functional at the time of review. Our experience of using the Ilizarov fixation frame for achieving joint fusion is very rewarding. The results reported hereby justify the further use of this hybrid frame as an effective mechanical method to achieve bony joint fusion without bone grafts, and to ensure a low failure rate.     

Circular external fixation in knee arthrodesis following septic trauma sequelae: preliminary report

Deep infection is one of the most devastating complications after knee fractures. It may be related to the initial fracture status or, more commonly, the surgical intervention. From 1991 to 2003, 12 patients underwent knee fusion to treat resistant infection after complex knee fractures or arthrodesis fractures using the Ilizarov method and frame. There were 9 men and 3 women (mean age, 39.7 years). Two-thirds of the patients had long-standing infection and 5 patients had undergone earlier attempts at knee arthrodesis. Correction of concurrent malalignment was achieved in 2 patients. Bone transport using the same arthrodesis frame was necessary in 2 patients to overcome large bony defects. Solid fusion was achieved in all patients by the end of treatment. The average duration of external fixation was 22 weeks (range: 11-44 weeks). No patients required secondary bone grafting to achieve union. Complications occurred in 6 (50%) patients. The most common problem seen was pin tract infection, but only 2 patients required surgical intervention for its treatment. The study emphasizes the clinical success of the Ilizarov method in knee arthrodesis after infected fractures.     

Arthrodesis after failed knee arthroplasty. A nationwide multicenter investigation of 91 cases

Ninety-one patients with attempted arthrodesis after failed knee arthroplasty were identified in a prospective nationwide study of knee arthroplasties performed from October 1975 through January 1982 in Sweden. The study included 43 hinged or stabilized, 34 bi- or tricompartment, and 14 unicompartment endoprostheses. Three-fourths of the failures were caused by infections. At follow-up evaluation, two patients had expired from infection and four patients had amputations. Fusion was achieved in only 50% of 108 attempts in 91 knees. Patients with unstable joints had limited function. The fusion rate was relatively high after unicompartment endoprostheses, in cases with sustained rigid fixation, or in cases where infection was brought under control at arthrodesis. Rigid fixation was best achieved with an external double frame or an intramedullary nail. Repeated attempts were worthwhile. Removal of all foreign material, eradication of the infectious lesion, and an arthrodesis performed in a one- or two-stage procedure with insertion of gentamicin beads seemed to be the best way to combat infection. The treatment of prosthetic failures should be referred to centers with special interest in knee arthroplasty.     

Arthrodesis for failed knee arthroplasty. A report of 20 cases

Twenty consecutive patients treated by arthrodesis for failed knee arthroplasty are reviewed. Eight hinged, five stabilised and seven compartmental prostheses were removed, for infection (15 cases), loosening (4) and instability (1). One patient refused a second-stage operation but the remainder gained sound fusion. Infected knees had a two-stage procedure with temporary insertion of gentamicin-loaded beads after removal of the prosthesis; all infections healed. Six arthrodeses using a Hoffmann-Vidal external fixator resulted in two temporary failures. One Ace-Fischer external fixation was successful. Of 10 primary attempts at arthrodesis with an intramedullary Küntscher nail, nine were successful; the tenth fused after two more attempts by the same method. The two failures of external fixation and two failures after Charnley single-frame compression done elsewhere were successfully fused with intramedullary nails. Delayed union in three cases fused after prolonged fixation and repeated bone grafts. The indications for and methods of arthrodesis after failed knee arthroplasty are discussed.     

Knee arthrodesis following total knee arthroplasty in rheumatoid arthritis

Twenty-seven knees in 23 patients, all with seropositive rheumatoid arthritis and failed total knee arthroplasty, were treated by arthrodesis. Twenty of the 27 knees were solidly fused. A fusion aligned in 7 degrees +/- 5 degrees of valgus and knee flexion from zero to 30 degrees was associated with the highest rate of arthrodesis, the lowest rate of progression of disease in other joints, and the highest functional scores. Stable fixation using either internal or external fixation gave the most predictable rate of arthrodesis. Persistent sepsis and bone stock losses were associated with failure of arthrodesis, even under the best circumstances. All of the 20 successfully arthrodesed knees were completely functional.     

Knee arthrodesis with the Sheffield external ring fixator: fusion in 6 of 10 consecutive patients

Background Knee arthrodesis with external fixation (XF) is a possible salvage procedure for infected total knee arthroplasties (TKA). We report the outcome in 10 patients who underwent arthrodesis with the Sheffield Ring Fixator.

Patients and methods The patients had primary arthrosis in 8 cases; 2 cases were due to rheumatoid arthritis and sclerodermia. The mean time between the primary TKA and arthrodesis was 6 (0.5-14) years. The average age at arthrodesis was 69 years. The average follow-up period was 10 months.

Results Stable fusion was obtained in 6 patients after a mean XF time of 3.6 (2-4) months. 1 patient was referred to another hospital because of nonunion. This patient showed fusion with intramedullary nailing after 7 months. 3 nonunion patients required permanent bracing. 7 patients had pin tract infections. Infections healed in all patients.

Interpretation The Sheffield Ring Fixator gives an acceptable fusion rate for arthrodesis in the infected TKA, with limited complications.     

Salvage of infected total knee fusion: the last option

Currently the most common indication for an arthrodesis of the knee is a failed infected total knee prosthesis. Other causes of a failed total knee replacement that might necessitate a knee fusion include aseptic loosening, deficient extensor mechanism, poor soft tissues, and Charcot joint. Techniques available for achieving a knee fusion are external fixation and internal fixation methods. The external fixation compression devices have been the most widely used for knee fusion and have been successful until the indications for fusion changed to mostly failed prosthetic knee replacement. With failed total knee replacement, the problem of severe bone loss became an issue, and the external fixation compression devices, even including the biplane external fixators, have been the least successful method reported for gaining fusion. The Ilizarov technique has been shown to achieve rigid fixation despite this bone loss, and a review of reports are showing high fusion rates using this method. Internal fixation methods including plate fixation and intramedullary nails have had the best success in gaining fusion in the face of this bone loss and have replaced external fixation methods as the technique of choice for knee fusion when severe bone loss is present. A review of the literature and a discussion of different fusion techniques are presented including a discussion of the influence that infection has on the success of fusion.     

Knee fusion--a new technique using an old Belgian surgical approach and a new intramedullary nail

Knee arthrodesis is a useful procedure in difficult cases such as failed total knee arthroplasty, severe articular trauma, bone tumors, and infected knee joints. The most common techniques for knee fusion include external fixation and intramedullary nailing. Küntscher's nail is driven antegrade from the intertrochanteric region into the knee. We describe a new technique for knee arthrodesis using a new intramedullary nail and an old Belgian surgical approach to the knee joint published by Lambotte in 1913. This approach provides excellent exposure for the implantation of the nail by osteotomizing the patella vertically. The nail is implanted using HeyGroves method, whereby the nail is inserted retrograde into the femur and pulled distally anterograde into the tibia. We now use this technique as our standard procedure for knee fusion.     

Knee arthrodesis with the Sheffield external ring fixator: Fusion in 6 of 10 consecutive patients

Background?Knee arthrodesis with external fixation (XF) is a possible salvage procedure for infected total knee arthroplasties (TKA). We report the outcome in 10 patients who underwent arthrodesis with the Sheffield Ring Fixator.

Patients and methods?The patients had primary arthrosis in 8 cases; 2 cases were due to rheumatoid arthritis and sclerodermia. The mean time between the primary TKA and arthrodesis was 6 (0.5–14) years. The average age at arthrodesis was 69 years. The average follow-up period was 10 months.

Results?Stable fusion was obtained in 6 patients after a mean XF time of 3.6 (2–4) months. 1 patient was referred to another hospital because of nonunion. This patient showed fusion with intramedullary nailing after 7 months. 3 nonunion patients required permanent bracing. 7 patients had pin tract infections. Infections healed in all patients.

Interpretation?The Sheffield Ring Fixator gives an acceptable fusion rate for arthrodesis in the infected TKA, with limited complications.     

Capitolunate arthrodesis with compression screws

Scapholunate dissociation or scaphoid pseudarthrosis may lead to wrist osteoarthritis. When osteoarthritis concerns the midcarpal joint, proximal row carpectomy is not possible. Only 4-corner or capitolunate arthrodesis may be indicated. In this procedure, pseudarthrosis was frequently described in literature. However, in these series, fixation was performed with pins or staples. Type and position of the device are important to obtain carpal bones fusion. The efficiency of compression screws has been validated in scaphoid fracture or pseudarthrosis. Moreover, the axial position of the screws, parallel to the physiological wrist loads, may participate to improve bone fusion. Therefore, we present our technique of capitolunate arthrodesis with compression screws fixation through a dorsal approach.     

The Stanmore knee arthrodesis prosthesis

Knee arthrodesis is most commonly performed for failed total knee arthroplasty. Conventional arthrodesis techniques are associated with a high incidence of complications and are unsuitable in cases with extensive bone loss. We report our medium-term results using a custom-made cemented knee arthrodesis prosthesis in 10 patients with a mean follow-up of 56.4 months (range, 15-199 months). The prosthesis was implanted as a 1- or 2-stage procedure for infected revision knee arthroplasty or tumor endoprosthesis in 9 patients and as a primary procedure in 1 patient with angiosarcoma involving the knee extensor mechanism. The average combined femoral and tibial bone deficit was 170 mm (range, 56-220 mm). Implant survivorship was 90%. All patients with retained prosthesis had no evidence of residual infection or loosening and were able to mobilize independently. One prosthesis was revised though retained following a prosthetic fracture, and 1 patient underwent above-knee amputation for uncontrolled infection. We conclude that the Stanmore knee arthrodesis prosthesis provides reliable fusion in an otherwise difficult-to-treat group of patients.     

Infected total knee arthroplasty treated with arthrodesis using a modular nail.

Failed treatment of infected total knee replacement presents few attractive surgical options. Knee arthrodesis is challenging surgically and can be complicated by nonunion, malunion, or recurrent infection. Recently, a modular titanium intramedullary nail has been used in an attempt to reduce the incidence of nonunion and the rate of complications. In the present study, a review of the results of knee arthrodesis after infected total knee arthroplasty in 21 patients at three large academic institutions was performed. All patients were followed up for a mean of 2.4 years (range, 2-7.5 years). The mean age of the patients was 64 years. The mean number of previous operations was four (range, 2-9 operations). A solid arthrodesis was achieved without additional surgical treatment in 20 of 21 patients (95%). The mean time to fusion was 6.3 months. The one patient who suffered a nonunion achieved fusion after a subsequent bone grafting procedure. Based on the present study, intramedullary arthrodesis with a coupled titanium nail, is a reliable, effective method of achieving fusion after infection of a total knee arthroplasty. This procedure resulted in a high rate of fusion and a lower rate of complications when compared with traditional methods of arthrodesis.     

Knie- und Sprunggelenk

Despite the advances made in joint replacement surgery, there are still situations in which arthrodesis of the ankle or knee is indicated. In fact, owing to the rising numbers of endoprostheses implanted and the resulting growth in the frequency of complications, arthrodesis is actually enjoying a revival. The essential principles of arthrodesis are the opposition of vital bone surfaces, stable fixation, and compression. External fixation procedures have some disadvantages compared with internal fixation techniques. As examples, we should mention the higher rate of nonunion, the frequent pin infections, and the greater discomfort to the patient. Intramedullary internal fixation techniques have long been used for arthrodesis operations. As a central load-bearing device intramedullary nails provide superior biomechanical stability compared to most other forms of internal fixation. In addition, since the nail can be inserted away from the arthrodesis site the soft-tissues will not be further compromised. The compression option of the intramedullary nail is of central importance. If intramedullary nailing is performed for a joint arthrodesis without compression a significant decline in stiffness must be expected.     

Arthrodesis of the ankle in patients who have rheumatoid arthritis.

We reviewed thirty-two arthrodeses of the ankle in twenty-six patients who had rheumatoid arthritis. In seventeen patients (eighteen ankles), a compression arthrodesis was done and external fixation was used. In eight patients (twelve ankles), we used internal fixation with 6.5-millimeter cancellous-bone screws. In the remaining patient, an arthrodesis with external fixation was done in one ankle and internal fixation was used in the other ankle; data for the appropriate ankle are included in each group. The patients were followed for an average of thirty-three months. The two groups were comparable with respect to age, sex, preoperative medications, and severity of disease. The average time to fusion was nineteen weeks in the compression arthrodesis group and seventeen weeks in the internal fixation group. Of the nineteen ankles that had a compression arthrodesis, four failed to fuse; all of the failures were associated with infection. Infection developed in two additional patients, there was malposition of the fusion in three patients, and neurapraxia developed in three patients. Of the thirteen ankles that had internal fixation, three ankles failed to fuse; one of the failures was associated with infection. Infection developed in one additional ankle. In two patients, the ankle fused in excessive valgus. Comparison of the two groups revealed comparable rates of fusion: fusion occurred in fifteen of the nineteen ankles in the group that had compression arthrodesis and in ten of the thirteen ankles in the group that had internal fixation. The method of arthrodesis did not affect the time to fusion or the rate of complications.(ABSTRACT TRUNCATED AT 250 WORDS)     

Autologous bone from hip or knee replacement in simultaneous foot or ankle arthrodeses

Simultaneous operations on the lower extremities may potentially benefit some patients. However, the only literature discussing simultaneous operations has been limited to bilateral simultaneous total hip or knee replacements. The cases of 10 patients who had combined joint arthroplasty (8 knee, 2 hip) and foot and ankle arthrodesis (6 subtalar, 4 ankle) were reviewed retrospectively. Combining the procedures allowed the patient to have autologous bone brought from the joint replacement site to the foot or ankle to assist in filling defects in the arthrodesis. The fusion rate of 100% and the good results of hip or knee replacement demonstrate that successful treatment is possible when both conditions are treated simultaneously.