arthrodesis

Management

Non-Operative

 

Education regarding shoe wear

- extra wide / large toe box

 

Insoles

- longitudinal arch support

- pre MT dome for metatarsalgia

- podiatry to attend to callosities

 

Toe spacers

 

Analgesia

 

Operative

 

Indications

 

1.  Continued pain and discomfort

2.  Difficulties with shoe wear

Subtalar and Triple Arthodesis

Biomechanics

 

Able to achieve relatively high level of function after STJ fusion

- previously believed that isolated STJ fusion should not be performed

- believed that triple arthrodesis was operation of choice for hindfoot

- STJ fusion has superior result with less stress on AJ

 

Average loss of DF 30% / PF 10%

 

Position of hindfoot determines flexibility of transverse tarsal (CCJ & TNJ) joints

- imperative that fusion be positioned in ~ 5o valgus 

Rheumatoid Thumb

Nalebuff Classification

 

Type I - Boutonniere 

- commonest

- MP flexion /  IP hyperextension

- usually EPB rupture with EPL subluxation

 

Rheumatoid Boutonniere Thumb

 

Type II

- Boutonniere & Swan Neck

- doesn't exist according to Nalebuff

 

Rheumatoid Fingers

ConditionsBoutonniere Fingers

 

1.  PIPJ Synovitis

- synovectomy via dorsomedial approach

2.  Flexor tenosynovitis

- may cause trigger finger

- trial HCLA

- remove synovits but don't release A1 pulley

- will worsen ulna drift

3.  DIPJ

- rarely affects

Arthrodesis

Indications

 

Indications have narrowed

- due to success of shoulder arthroplasty

 

1. Chronic infections of GHJ

2. Stabilization in paralytic disorders

3. Post-traumatic brachial plexus palsy

4. Salvage of failed GHJ Arthroplasty

- may need bone graft procedures

5. Arthritic diseases unsuitable for arthroplasty / young patient

Arthrodesis

Indications

 

Very few

- young labourer with severe disabling elbow pain

- trial in POP at 90o for 6 weeks

 

Poor function

- adjacent joints cannot compensate for loss of function

 

Contraindications

 

RA

- high failure rate especially flail elbow with poor bone stock

 

Arthrodesis Conversion

Indications

 

Severe LBP 

- most common indication

 

Ipsilateral knee pain

- less beneficial

 

Malposition

- especially abduction

 

Contraindications

 

Absent abductor mechanism

Flail

Active infection

Insufficient bone stock

 

Examination

 

LLD