1. ARTHRODESIS1

2. 2

3. 3 INDICATIONS Indications for shoulder fusion have diminished over the years because of: the excellent results of shoulder arthroplasty. the near elimination of poliomyelitis and tuberculosis. the improved techniques for shoulder stabilization.

4. ARTHRODESIS4

5. 5 Contraindications Osteonecrosis. Charcot arthropathy(nonunion rate is high). Ipsilateral elbow fusion. Contralateral shoulder fusion.

6. ARTHRODESIS6 We agree that the position of rotation is the most critical factor in obtaining optimal function.

7. ARTHRODESIS7

8. 8 SURGICAL TECHNIQUES the limited contact between the glenoid fossa and humeral head can be improved by including the acromion in the fusion mass. Firm internal fixation usually eliminates the need for bone grafting and external fixation.

9. ARTHRODESIS9 COMPRESSION TECHNIQUES — EXTERNAL FIXATION TECHNIQUE 1 (Charnley and Houston) Used as graft

10. ARTHRODESIS10 5 to 6 weeks cast 12 weeks

11. ARTHRODESIS11 COMPRESSION TECHNIQUES—INTERNAL FIXATION TECHNIQUE 1 (Cofield)

12. ARTHRODESIS12 TECHNIQUE 1 (Cofield) 45 Degrees spica cast 12 to 16 weeks

13. ARTHRODESIS13 AFTERTREATMENT: A pelvic band extending from the nipples to the pubic symphysis is applied. With the elbow flexed 90 degrees, a cylinder cast is applied to the upper extremity. The extremity is suspended by two wooden struts, or a cock-up wrist splint is used. At 1 to 2 weeks after surgery, a plastic shoulder spica cast is applied and worn until union is achieved, 12 to 16 weeks after surgery.

14. ARTHRODESIS14 TECHNIQUE 2 (Uematsu) Position 20 degrees of abduction, 30 degrees of flexion, and 40 degrees of internal rotatio Used as graft A cast 3 months

15. ARTHRODESIS15 TECHNIQUE 3 (Mohammed) the distal acromion as avascularized graft A shoulder spica 8-10 weeks

16. ARTHRODESIS16 TECHNIQUE 4 (AO Group) Apply bone grafts No cast

17. ARTHRODESIS17 TECHNIQUE 5 (Richards et al.) 60 D Position 30 degrees of flexion, 30 degrees of abduction, and 30 degrees of internal rotation. Do not osteotomize the acromion A shoulder spica cast 6weeks

18. ARTHRODESIS18

19. ARTHRODESIS19

20. ARTHRODESIS20

21. ARTHRODESIS21 POSITION For unilateral arthrodesis of the elbow, a position of 90 degrees of flexion is desirable. Bilateral elbow arthrodesis rarely is indicated because of resultant functional limitations. If indicated, one elbow should be placed in 110 degrees of flexion to permit the patient to reach the mouth and the other should be placed in 65 degrees to aid in personal hygiene.

22. ARTHRODESIS22 TECHNIQUE 1 (Steindler) AGraft:1.5 x 9 cm Fitting cast 8 weeks

23. ARTHRODESIS23 TECHNIQUE 2 (Brittain) Grafts:8 mm x 7.5-10 cm Fitting cast 8 weeks

24. ARTHRODESIS24 TECHNIQUE 3 (Staples) Fitting cast 8 weeks

25. ARTHRODESIS25 Technique for fusion in tuberculous arthritis of elbow. TECHNIQUE 4(Arafiles) use the resected epicondylar and olecranon fragments as bone grafts a long arm cast for 3 months

26. ARTHRODESIS26 TECHNIQUE 5 (Müller et al.) The fixator and pins 6 to 8 weeks a long arm cast until the arthrodesis is solid

27. ARTHRODESIS27 TECHNIQUE 6 (Spier) The most common indication was a high-energy, open, infected injury with associated bone loss. Apply bone graft The plate and screws 1year only

28. ARTHRODESIS28 Complications Complications of elbow arthrodesis include: Delayed union. Nonunion. Malunion. Neurovascular injury. Painful prominent hardware. Skin breakdown.

29. ARTHRODESIS29

30. ARTHRODESIS30

31. ARTHRODESIS31 Contraindications include : An open physis of the distal radius( The distal radial physis close approximately 17 years of age). After partial destruction of the physis,the remaining part may be excised to prevent unequal growth. An elderly patient with a sedentary lifestyle, especially if the nondominant wrist is involved.

32. ARTHRODESIS32 POSITION Usually 10 to 20 degrees of extension (dorsiflexion) with the long axis of the third metacarpal shaft aligned with the long axis of the radial shaft (allow maximum grasping strength). In general, neutral to 5 degrees of ulnar deviation is preferred. If bilateral wrist fusions are indicated, the positions of the wrists should be determined by the needs of the patient( The neutral position).

33. ARTHRODESIS33 The straight plate is employed when a large intercalary graft is required for a traumatic or tumorous defect. The short carpal bend is used in small wrists and those in which the proximal row has been resected. The longer carpal bend is used in large wrists.

34. ARTHRODESIS34 TECHNIQUE 1 (AO Group) cancellous bone harvested from the excised bone A cast (10 to 12 weeks)

35. ARTHRODESIS35 80% TECHNIQUE 2 (Louis et al.) Supporting the fusion site with Kirschner wires or staples. bone graft is not necessary. cast or splint for 12 to 16 weeks

36. ARTHRODESIS36 TECHNIQUE 3 (Haddad and Riordan) 2.5x4cm If the wrist is unstable, insert a nonthreaded Kirschner wire cast or splint for 12 to 16 weeks

37. ARTHRODESIS37 TECHNIQUE 4 (Watson and Vendor) Place an outer cortical piece of iliac bone graft Cast 6-8weeks

38. ARTHRODESIS38

39. ARTHRODESIS39

40. ARTHRODESIS40 INDICATIONS Damaged by injury or disease. Pain. Deformity. Instability makes motion a liability rather than an asset. Arthrodesis is used most often for the proximal interphalangeal joint because motion in this joint is so important. When the metacarpophalangeal joint is destroyed, if good muscle strength is present, arthroplasty is indicated more often than arthrodesis.

41. ARTHRODESIS41 POSITION The metacarpophalangeal joint should be fixed in 20 to 30 degrees of flexion. The proximal interphalangeal joints should be fixed from 25 degrees of flexion in the index finger to almost 40 degrees in the small finger (less flexion in the radial fingers than in the ulnar fingers). The distal interphalangeal joints are fixed in 15 to 20 degrees of flexion.

42. ARTHRODESIS42 TECHNIQUE (Stern et al.; Segmüller, Modified) Ball-socket Or Cup-cone Splint2-3days

43. ARTHRODESIS43 A, Phalangeal osteotomy. B, Hole for 25- or 26- gauge stainless steel wire made through middle phalangeal base dorsal to midaxial line. C C, Retrograde insertion of 0.028-or 0.035-inch Kirschner wire into proximal phalanx. D, Kirschner wire driven into anterior cortex of middle phalanx. E, Figure-eight tension band created and tightened. Tension band arthrodesis

44. ARTHRODESIS44 A, Anteroposterior and lateral views of crossed Kirschner wires. B, Anteroposterior and lateral views of interfragmentary wire and longitudinal Kirschner wires. C, Anteroposterior and lateral views of Herbert screw

45. ARTHRODESIS45

46. MoKazem.com هذه المحاضرة هي من سلسلة محاضرات تم إعدادها و تقديمها من قبل الأطباء المقيمين في شعبة الجراحة العظمية في مشفى دمشق, تحت إشراف د. بشار ميرعلي. الموقع غير مسؤول عن الأخطاء الواردة في هذه المحاضرة. This lecture is one of a series of lectures were prepared and presented by residents in the department of orthopedics in Damascus hospital, under the supervision of Dr. Bashar Mirali. This site is not responsible of any mistake may exist in this lecture. د. مؤيد كاظمDr. Muayad Kadhim