Knee Arthrodesis

                                       Dr. KS Dhillon

Background

There are a wide range of clinical indications for knee arthrodesis. These include advanced primary osteoarthritis, posttraumatic osteoarthritis, rheumatoid arthritis, tuberculosis, poliomyelitis, and syphilis [1,2]. With the advent and success of total knee replacement (TKR) surgery, along with

advances in medicine eliminating the later stages of some diseases, the indications for arthrodesis have narrowed [1,2,3].

The current indications for arthrodesis include bone or tissue damage, weakness or loss of the knee extensor mechanism, inadequate ligamentous constraint, arthrofibrosis, infection, substantial bone loss or defects, osteosarcoma, posttraumatic arthritis [1,4], and the failure of total knee replacements [2,5,6,7]. The functional outcome and quality of life after knee arthrodesis is generally low [8]. There are some studies which show that knee arthrodesis offers no significant protection against persistent infection or any substantial loss in pain [9]. Although the procedure has been around for a long time, there has been little biomedical innovation in this area to enable a wider acceptance of this procedure. This has made knee arthrodesis an undesirable, last resort option. It is used only in cases where other treatment options are inadequate or of unacceptable risk.

Clinical interest in knee arthrodesis procedures and outcomes remains constant. There are a large number of published case reports and review articles on the subject [10]. Some of these articles have focused on the conflicting methods of achieving fusion, including external fixation [11,12,13] and internal fixation by means of intramedullary nails [14,15,16] or dynamic compression plates [13,17]. Internal fixation tends to be a simpler procedure. External fixation is indicated in cases of substantial bone or tissue loss [15].

There are challenging conditions that often undermine the success of knee arthrodesis procedures. Advanced surgical techniques have been developed to counteract some of these challenges [18]. New methods of achieving fusion have been developed [19], including implantable prosthetics dedicated to knee arthrodesis (fig 1) [6,20,21,22].

These implants can serve as a rigid spacer in the absence of sufficient

bone stock and they can improve the surgical success rate. However,

they offer patients no functional advantages over traditional knee arthrodesis techniques.

Fig 1.

The outcomes of knee arthrodesis are varied. By salvaging the limb, knee arthrodesis can allow patients to ambulate without assistive devices. This allows the patients to maintain independence.

There are disadvantages of knee arthrodesis. Walking with an arthrodesis

is physically more demanding. An immobilized knee can make activities of daily living such as sitting and tying one's shoelaces difficult. These disadvantages have made some patients elect for desarthrodesis, or reversal of a previous fusion, despite its high complication rate [23,24,25,26,27]. 

In some cases where radical revision surgery to save knee function is not

advisable or unethical, patients may even prefer to have the affected limb amputated [28]. 

Indications for knee arthrodesis

Knee arthrodesis is indicated for the following conditions:

• Salvage for failed TKA (most common)

• Painful knee ankylosis after infection or trauma

• Neuropathic knee arthropathy

• Tumor resection

• Loss of knee extensor mechanism

Contraindications for knee arthrodesis

Active infection is an absolute contradiction for knee arthrodesis. The 

relative contraindications include:

• Bilateral knee arthrodesis

• Contralateral leg amputation

• Significant bone loss

• Ipsilateral hip or ankle degenerative joint disease

Technique of knee arthrodesis

The optimal position for arthrodesis would be:

• 5-8° valgus

• 0-10° of external rotation (similar to the other leg)

• 0-15° of flexion

Some limb shortening resulting from arthrodesis is advantageous for patient self-care.

Intramedullary rod fixation can be done with a long antegrade device or a two-part device connected at the knee. The patella can be left alone or incorporated into arthrodesis.

External fixation can be done with a unilateral external fixation device, Ilizarov fixator, or Taylor Spatial Frame. The external fixation must allow compression of the arthrodesis site.

Plate fixation can be done alone or in combination with intramedullary nailing.

Indications for each technique

Deciding on the specific arthrodesis technique to use, whether it is IM nail, external fixation, or compression plates, can be based on three main variables: infection state, condition of the soft tissue envelope, and bone loss [2,29]. 

Majority of recent studies have looked into the use of external fixation devices and IM nails when recurrent infection was the main indication for the procedure. Results have generally shown favorable outcomes for these two main techniques. The lesser studied of the three techniques, compression plates, have shown to have comparable, if not better, fusion rates compared to external fixators.

Data surrounding the efficacy of compression plates is sparse relative to external fixation devices and IM nails in the presence of infection. External fixation and IM nails may be more reliable options in cases with infection [1].

In patients who present with severe bony defects, IM nailing serves as a reliable treatment option. Extensive bone loss can be treated by bone lengthening 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 [29,30]. 

Complications of knee arthrodesis

Complications of knee arthrodesis include:

• Nonunion

• Infection

• Low back pain

• Ipsilateral hip degenerative changes

• Contralateral knee degenerative changes

• Fracture- supracondylar femur fracture or proximal tibial metaphysis fracture occurs due to increased stress in these regions after the arthrodesis

Prognostic factors

A successful knee arthrodesis is evaluated based on a number of factors including a high rate of union, a straightforward surgical technique, a low complication rate, short inpatient stay, ability to ambulate and weight-bear, minimal post-operative follow-up treatment, and need for reoperation [1,31-33]. 

Schwarzkopf et al [34] evaluated 43 consecutive arthrodesis procedures and they found that the key factors predicting a successful surgical outcome included reduced wound healing complications, reduced number of days to discharge after arthrodesis, and lower final inflammatory marker values (for patients with a history of periprosthetic infection) before the arthrodesis. In the study, success was defined as a lack of further surgery, successful bony fusion, and successful eradication of infection. A failed procedure was defined as one that required further surgery, prolonged use of antibiotics, or unsuccessful bony fusion. 

Lee et al [15] found that in patients who underwent arthrodesis procedures using both short and long Huckstep 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, the interval from last prior surgery to arthrodesis, type of prosthesis, and the shortest length of the bone defect. Evidence suggests that increased bony defects lead to lower fusion rates [2,35].

Parcel et al [36] observed that in patients with type III Anderson orthopaedic research institute (AORI) classified bony deficiency in both the femoral and tibial aspects, lower fusion rates occurred when treated with modular nails. Van Rensch et al [2] also 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.

Conclusion

Knee arthrodesis has proven to be an acceptable alternative to knee amputation. There are a number of different techniques that exist which have their own specific indications, advantages, and disadvantages. It is important that the surgeon is familiar with these procedures and their different attributes. Recent knee arthrodesis studies confirm many of the findings from older studies. There are higher rates of fusion with the use of long IM nails compared to all other techniques. The overall complication rates are lower with the use of IM nails as compared to external fixation.  The recurrent/ persistent infection rates are lower with external fixation as compared to IM nails. The time to fusion is faster with IM nails as compared to external fixation.

A successful knee arthrodesis is evaluated based on a number of factors including a high union rate, a straightforward surgical technique, a low complication rate, short hospital stay, ability to ambulate and weight-bear, minimal follow-up treatment, and need for reoperation.

References

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