ARTHRODESIS

• Arthrodesis is an elective surgical procedure to eliminate

motion in a joint by providing a bony fusion. The procedure is
used for several specific purposes: to relieve pain; to provide
stability; to overcome postural deformity resulting from
neurologic deficit; and to halt advancing disease.

• Pain in joints may be the result of end-stage joint disease, that

is, instability or incongruity of joint surfaces as a result of
trauma. It may also result from exuberant callus following
fracture. A painful joint will result in animal discomfort and
limb dysfunction for as long as motion remains; the range of
motion need be only 1 or 2 but if the motion causes pain, the
dysfunction will continue.
• Instability of a joint due to disease or traumatic
loss of ligaments necessitates arthrodesis.
When ligaments can be successfully repaired
surgically, joint function will return to normal
or near normal.
• When ligaments are lost as a result of diseased
tissue or are destroyed traumatically
arthrodesis may be the only successful
treatment. Spinal instability, resulting in spinal
cord compression or nerve root irritation, may
be prevented by bony fusion of the involved
vertebral bodies.
• Radial nerve injury in the forelimb generally results in flexion
deformities of the carpus following loss of normal extensor
muscle function. Assuming the animal's shoulder and elbow
joints function normally and are not neurologically
compromised, the carpus may be successful arthrodesed in a
normal position, allowing the animal improved function and
lessening the likelihood of dorsal decubital ulcers on the paw.

• Tibial nerve dysfunction resulting in hock flexion or peroneal

nerve dysfunction resulting in hock extension may likewise be
corrected by arthrodesis if the hip and knee joints remain
above the level of nerve dysfunction.

• Joint diseases such as septic arthritis, degenerative joint

disease, and rheumatoid arthritis may result in joint instability,
pain, or both. Often when medical or conservative surgical
means prove unsuccessful, arthrodesis.
• Isolated joints with such disease processes
may be treated very successfully; however,
polyarthritic problems do not lend themselves
to this technique, since multiple joint
arthrodeses are not compatible with normal
function.
 PRINCIPLES
• In order to accomplish successful arthrodesis, it is necessary
to optimize the patient's condition prior to this elective
procedure. The animal should be healthy, possess no
generalized disease that might make it a poor surgical risk,
and have no localized problems such as bacterial dermatitis
over the surgical site, open wounds, or sepsis of the involved
joint.
• Planning of an arthrodesis is as important as planning an
osteotomy. Equally important is observation of the patient
standing and walking to determine the best angle for
arthrodesis of that joint. Observation of the patient under
anesthesia is useless and may result in a joint arthrodesed in
too much extension.
• When surgically approaching a joint on which arthrodesis is to be
performed, the surgeon must handle all surrounding soft tissues and
especially tendons with great care. It is important that tendons
spanning the joint continue to function normally, since joints below
the arthrodesis will have to function as well as possible to compensate
for the loss of motion at the arthrodesed site. Because the joints
above and below the arthrodesis will compensate to a degree, it is
imperative that surgery does not damage tendons or muscles needed
to allow these joints to function.

• To best accomplish arthrodesis of a joint, all articular cartilage must be

removed to a level of bleeding cancellous subchondral bone. If bone
ends are sclerotic as a result of a disease process, they must be
removed.(1-3)
• Where possible, flat surfaces should be cut on opposing joint ends to ensure
optimal bony contact for the bony union. Joints with deep joint contours may
be debrided of cartilage and allowed to remain with naturally stable
geometry.

• The angle of arthrodesis must approximate the normal anatomical position;

however, this may differ from animal to animal as a result of other underlying
disease of the limb or of the contralateral "normal" limb. It is best to carefully
observe the animal preoperatively, in normal gait and standing, to determine
the best angle for the particular patient. It is preferable to err by making the
arthrodesed angle too flexed, rather than too extended, which may result in
paw dragging. It must be remembered that if significant portions of bone
ends are removed, the expected angle of arthrodesis must be extended to
compensate for bony loss, or the limb may be too short to function well.
• Following proper joint positioning, the internal fixation should be applied to
ensure joint stability during the period of bony union. If normal joint
contours have been used, autogenous cancellous bone should be interposed
between the bony surfaces and also placed along the hidden surface of the
joint prior to placement of the internal fixation. Following fixation, more
cancellous bone should be placed around and over the arthrodesis surface. It
is far better to place more than enough bone graft than too little.

• Following completion of surgery, the limb must be placed in additional rigid

external fixation until radiographic evidence of bony union. Failure to do so is
likely to result in metal loosening or arthrodesis failure. Since the joint is
being arthrodesed at a normal angle, the biomechanical forces of
unprotected weight bearing will tend to bend the joint, cycle the metal, and
result in failure.
• A limb with an arthrodesed joint is more prone to
subsequent injury than a normal limb. The
remaining joints must compensate, probably by
increased range of motion, and are under more wear
and tear; thus they are more prone to subsequent
degenerative arthritis. Bones are more prone to
fracture because the shock-absorbing ability of one
joint is gone. One is therefore more likely to see
fractures resulting from axial loading (long spiral
fractures or shear fractures at bone ends).
• Two types of arthrodeses are routinely done in
veterinary medicine intra-articular and extra-articular.
Intra-articular arthrodesis is done when fusing
peripheral joints after debriding the joint cartilage,
grafting, and stabilizing, Extra-articular arthrodesis is
performed on the spine when short or long segments
of spine are bridged with bone to provide stability to
entire segments of the spine. Generally this is
performed without destroying each spinal facet or
the intervertebral joints prior to bridging.
• Occasionally, both intra-articular and extra-
articular arthrodeses are performed on the spine
when intervertebral disks are removed, grafted,
and the entire site bridged with an onlay graft.
Similarly, peripheral joints can have both intra-
articular and extra-articular arthrodesis. This may
be accomplished by using dowels of bone that are
placed through a joint or by using
(corticocancellous) grafts that are cut into a
trough that crosses a joint.
• A final form of arthrodesis is the phantom arthrodesis. This
procedure is performed by running fixation through a joint
without removing the articular cartilage or adding bone graft.
This procedure will not result in actual arthrodesis; at best, the
joint will remain ankylosed; usually, however, such fixation will
break down in time, resulting in the return of painful motion.

• The technique used for articular cartilage removal depends on

the available instruments and the surgeon's desires. The most
efficient and fastest method is to use a power bur, usually a Hall
drill, or similar cutting tool. This rapidly cuts through cartilage;
however, the surgeon must cool the bur with saline to prevent
burning, and extreme care must be used to avoid wrapping soft
tissue around the bur. Equally effective, although slower, is the
use of a sharp bone curette, rasps, or gouges.
• Since cancellous bone is an integral part of arthrodesis, the surgeon
must plan what sites to use and estimate how much bone is necessary.
When arthrodesing a joint of the forelimb, enough bone can be
harvested from the proximal humerus of the same limb. If in doubt as
to the volume of cancellous bone available, the surgeon should always
prepare the ipsilateral ilial wing. When arthrodesing in the pelvic limb,
the entire limb, including the ilial wing, should always be prepared to
ensure sufficient graft material.

• If a cortical bone onlay or inlay graft is to be used for internal fixation,

the donor site must be prepared as well. If the graft is to be a sliding
graft from the area of the arthrodesis, no other special preparation is
needed. If a rib or piece of ilial wing may be required, if must be
prepared surgically.
 FIXATION
• All types of conventional internal and external fixation can
be and have been used for arthrodesis fixation. The desired
end result is rigid fixation, regardless of type of fixation
used.
• Plates and screws have proven very successful in arthrodesis
and have been so used since their introduction into the the
same rules apply as for internal fixation of fractures: place
the device on the tension band surface to get best results. In
an arthrodesis, that means over the convex surface. If
placed on the compression surface (concave surface), the
plate will be placed under incredible bending forces and
probably will fail if not adequately supported.
• Intramedullary pins, either cross pinning a joint or traversing
the length of a bone in its medullary cavity then entering and
transfixing the joint, work well. Single pins tend to be
rotationally unstable; multiple pins or crossed pins are
superior.

• Single or multiple interfragmentary screws may be adequate

fixation for arthrodesis when external fixation covers the limb
postoperatively. However, as in fracture fixation, the result
will be far better and more stable if a plate, namely, a
neutralization plate, is also present to reduce the incredible
load placed on the interfragmentary screws.
• External half-pin devices work very well as
fixation for an arthrodesis.
 COMPLICATIONS
• Factors favoring the mechanical instability of an arthrodesis usually
account for most postoperative complications. Therefore, the
surgeon must provide well-apposed surfaces, use implants of
adequate strength and number, and apply the implants in an
optimal biomechanical position.
• Premature removal of external fixation may result in arthrodesis
failure.

• Infection of the surgical site may result in bone destruction, implant

loosening, and arthrodesis failure. Infection may be prevented by
planning the surgery well so as to minimize the length of surgery
and by careful handling of all bone and soft tissues.