Arthrodesis of the knee following failed arthroplasty

Abstract

There is no definite answer as to which method is superior in performing an arthrodesis of the knee. Intramedullary nailing achieved the best fusion rates, but was used most in cases without--or cured--infection. Our data and the contemporary literature suggest that external fixation can be abandoned as standard fusion method, but can be of use following persisting infection. The Ilizarov circular external fixator, however, seems to render high fusion rates. Good patient selection and appropriate individual treatment are the key to a successful arthrodesis. Based upon these findings, a practical algorithm was developed.

Modern Techniques in Knee Arthrodesis

“…In regards to patients who present with severe bony defects, IM nailing serves as a reliable treatment option. As evidenced in a recent study by Van Rensch et al assessing the effects that the severity of bony defects has on arthrodesis outcomes, IM nailing showed comparable fusion rates (compared to previously published series) despite the majority of patients presenting with type III bony defects (according to the Anderson classification) [8] . Different variations of treatment have been proposed to overcome extensive bone loss including the possibility of lengthening the bone using a circular frame, the use of bone grafts with IM nails, or newer modular IM nail techniques that do not require bone-to-bone contact [1,9,10] .…”

“…Parcel observed that in patients with type III AORI classified bony deficiency in both the femoral and tibial aspects, lower fusion rates occurred when treated with modular nails [16] . Similarly, Van Rensch reported a decrease in fusion rates among multiple techniques of arthrodesis when there was only ¾ -¼ femorotibial surface contact immediately following arthrodesis versus surface contact of greater than ¾ [8] .…”

“…Deciding which specific arthrodesis technique to use, whether IM nail, external fixation, or compression plates, can be based on three main variables: infection state, condition of the soft tissue envelope, and preoperative bone loss [8,9] . No definitive indications for treatment have been established, and much of the decision-making process as to which technique to treat a patient lies in the judgment of the surgeon.…”

“…Lee et al found that in patients who underwent arthrodesis procedures using both short and long Huckstep (Downs Surgical, Sheffield, UK) modular IM nails, there was no correlation between the time to union and certain preoperative and intraoperative variables including: initial diagnosis, number of co-morbid medical diseases, number of surgical procedures prior to arthrodesis, total duration from the time the infection was diagnosed to arthrodesis, interval from last prior surgery to arthrodesis, type of prosthesis, and the shortest length of bone defect [14] . Finally, evidence suggests that increased bony defects are correlated with lower fusion rates [8,15] . Parcel observed that in patients with type III AORI classified bony deficiency in both the femoral and tibial aspects, lower fusion rates occurred when treated with modular nails [16] .…”

“…Knee arthrodesis is known to have its advantages, namely in regards to improved pain relief, decreased need for future surgery, preferred cosmetic appearance, and improved ambulation and energy efficiency, compared to above the knee amputation [7,8] . When comparing between the various arthrodesis techniques available, each presents with its own set of advantages and disadvantages, as well as technique-specifics that cater to the unique condition of each patient.…”