Arthroscopy: The Journal of Arrhroscopic and Related Surgery 7(2):237-240 Published by Raven Press, Ltd. 0 1991 Arthroscopy Association of North America
Case Report
Arthroscopic-Assisted
Arthrodesis of the Knee
John D. Papilion, M.D., Robert S. Heidt, Jr., M.D., Edward H. Miller, M.D., and Michael C. Welch, M.D.
Summary: Arthrodesis of the knee is an accepted procedure to alleviate pain and deformity in posttraumatic degenerative arthritis, in patients who are not candidates for total joint arthroplasty. Most all of the accepted surgical methods involve an arthrotomy to remove bone and prepare the surfaces for fusion. We present an unusual case of posttraumatic arthritis of the knee in a young
woman with a history of osteomyelitis. An arthrodesis was planned, but an arthrotomy was precluded. Arthroscopically assisted preparation of the fusion bed was performed for compression arthrodesis of the knee with an external fixator. A successful arthrodesis was obtained in 14 weeks. Key Words:
Arthrodesis-Knee.
ture with severe soft tissue damage about the knee. She subsequently underwent stabilization and a total of 14 surgical procedures, secondary to osteomyelitis, which ultimately required an almost circumferential muscle pedicle flap to the anterior knee. This was based on a single vessel arterial runoff to the lower leg. All fractures and soft tissue subsequently healed, and the infection resolved. Over the past 4 years, she developed severe posttraumatic arthritis with varus deformity (Fig. 1). She was otherwise healthy. Because of her age, history of infection, and desired activity level, she was not felt to be a candidate for total knee arthroplasty. In preparation for an arthrodesis of the knee, an arteriogram was performed, which confirmed single vessel vascularity with little collateral flow about the knee. Plastic surgery consultation indicated that any incisional approach to the knee joint could compromise the viability of the pedicle flap. Consequently, an attempt was made to use arthroscopic control to assist in preparation of the articular surfaces for compression arthrodesis.
Arthrodesis is an honored surgical procedure that can be used both initially and as a salvage operation. The indications for knee arthrodesis have included infection, tumor, instability, posttraumatic and degenerative arthritis, and failed arthroplasty (1). Many methods for knee arthrodesis have been used, including external fixation (l-6), internal fixation with plates and screws (7,8), and intramedullary rods (9). All of these described methods involve an arthrotomy to resect bone and prepare the cancellous surfaces for fusion. We present an unusual situation in which arthroscopic control was used in preparation of the fusion bed for compression arthrodesis . CASE REPORT N.F. is a 39-year-old woman who, 15 years prior, was involved in a motorcycle accident. She sustained a closed left femur fracture, and a Grade IIIC (Gustillo) open proximal left tibia and fibula fracFrom the Departments of Arthroscopy and Sports Medicine, Bone and Joint Institute, The Christ Hospital (J.D.P.), and Wellington Orthopedics and Sports Medicine, and The Christ Hospital, Cincinnati, Ohio, U.S.A. Address correspondence and reprint requests to Dr. R. S. Heidt, Jr., at Wellington Orthopedics and Sports Medicine, 111 Wellington PI., Cincinnati, OH 45219, U.S.A.
SURGICAL TECHNIQUE General anesthesia was utilized. The patient was given 1 g of Cefazolin IV prophylactically. Standard 237
J. D. PAPILION
238
ET AL.
FIG. 1. Posttraumatic degenerative arthritis of the knee joint.
inferolateral and inferomedial arthroscopy portals were used. An arthroscopy pump (3M, St. Paul, MN, U.S.A.) and pneumatic tourniquet were also utilized. The menisci were completely resected with
FJIG. 2. Postoperative arthroscopic sisted compression arthrodesis.
Arthroscopy,
Vol. 7, No. 2, 1991
as-
basket forceps and an aggressive arthroscopy shaver. A 5-mm high-speed power burr was used to denude all articular cartilage from the weightbearing surface of both the tibia1 plateau and femo-
ARTHRODESIS
ral condyles, to bleeding cancellous bone. The surfaces were somewhat contoured so that the femoral condyles fit into the tibia1 surface. Multiple drill holes were placed into both surfaces to incite vascular ingrowth. Tourniquet time was 80 min. No attempt was made to include the patellofemoral joint in the arthrodesis. An Ace-Fischer external fixation frame was then placed with three 5-mm bicortical half-pins anterolateral in the femur and three medially in the tibia. The knee was placed in anatomic alignment and 5” of flexion, and joint compression was applied (Fig. 2). A suction drain was used. FOLLOW-UP The patient was started on immediate straight-leg raising and crutch ambulation, toe-touch weight bearing. At 3 weeks, she was progressed to weight bearing as tolerated. The flap was completely viable, and the pin-sites remained benign. By 8 weeks, radiographs revealed evidence of
FIG. 3. One year postoperative:
fusion complete.
OF THE KNEE
239
bridging bone and the external fixator was removed. Under anesthesia, there was no gross motion at the knee. The patient was placed in a fiberglass cylinder cast and allowed full weight bearing. Six weeks later, the cast was removed and radiographs showed complete healing. Recent follow-up at 1 year postoperative, showed the patient to be ambulating independently, pain-free, with clinical and radiographic evidence of fusion (Fig. 3). DISCUSSION Compression arthrodesis of the knee, described by Charnley (2) in 1948, has been an excellent tool in the treatment of posttraumatic and degenerative arthritis. The advent of total joint arthroplasty has decreased the need for arthrodesis. Many surgical methods have been described to obtain a successful fusion (l-9). Common to all of these methods is a midline or parapatellar arthrotomy with extensive soft tissue dissection to expose the knee joint for preparation of the articular surfaces (l-9). An arthrotomy was precluded in our patient because of the danger of compromising flap viability. If needed, flap revision was also perilous because of the one vessel vascularity of the leg. The patient was young, had a history of infection, and desired to remain active. Therefore, she was not a candidate for total joint arthroplasty, which would have also required an arthrotomy. These extenuating circumstances led to the use of arthroscopic control to assist in preparation of the articular surfaces for compression arthrodesis. An extensive search of the literature failed to reveal any documentation of arthroscopically assisted arthrodesis of the knee, and to our knowledge, this is the first report. Several authors have reported successful results of arthroscopically assisted compression arthrodesis of the ankle (IO,1 1; S. J. Snyder et al., personal communication, 1990). Most arthrodesis methods currently used involve external skeletal fixation (l-5). Sufficient bone stock and bone contact, a high degree of rigidity of fixation, compression of the surfaces, and a prolonged period of such fixation have all been advocated as the most important features for enhancing the chance of successful fusion (3). This method was also indicated in our case, as it could be applied with minimal incisions and morbidity. We are not advocating this method as the panacea for knee arthrodesis. However, under the right circumstances, arthroscopically assisted compresArthroscopy,
Vol. 7, No. 2, 1991
J. D. PAPILION sion arthrodesis is a viable alternative to traditional open methods. Removal of all intervening soft tissue and articular cartilage, broad bleeding contoured cancellous surfaces, and rigid external tixation with compression in anatomic alignment are all principles that must be adhered to for a successful arthrodesis. REFERENCES 1. Rand JM. Knee arthrodesis. In: Anderson LD, ed. Instructional course lectures. St. Louis: Mosby Co., 1986:325-35. 2. Charnley JC. Arthrodesis of the knee joint. J Bone Joint Surg [Br] 1948;30B:375. 3. Cunningham JL, Richardson JB, Soriano RM, Kenwright J. A mechanical assessment of applied compression and healing in knee arthrodesis. Cfin Orthop 1989;242:256-64.
Arthroscopy, Vol. 7, NO. 2, 1991
ET AL. 4. Rothacker GW, Cabanella ME. External fixation for arthrodesis of the knee and anMe. Clin Orthop 1983;180:101-8. 5. Velazco A, Fleming L. Compression arthrodesis of the knee and ankle with the Hoffman external fixator. South Med J 1983;76:1393-6. 6. Fahmy NR, Barnes KL, Noble J. A technique for difficult arthrodesis of the knee. J Bone Joint Surg [Br] 1984;66B: 367. 7. Lucas DB, Murray WR. Arthrodesis of the knee by double plating. J Bone Joint Surg [Am] 1961;43A:795-808. 8. Pritchett JW, Mallin BA, Mathew AC. Knee arthrodesis with a tension band plate. J Bone Joint Surg [Am] 1988;70A: 285-8. 9. Harris CM, Froelich 3. Knee fusion with intramedullary rods for failed total knee arthroplasty. Clin Urthop 1985;197:20916. 10. Stulberg DS, Reilly J. Arthroscopic ankle arthrodesis. Orth Trans 1988:12:763. 11. Glick JM, Sampson TG, Meyerson ME, Morgan CD. Arthroscopic ankle arthrodesis [Abstract]. Arthroscopy 1990; 6: 155-6.
Case Report
Arthroscopic-Assisted
Arthrodesis of the Knee
John D. Papilion, M.D., Robert S. Heidt, Jr., M.D., Edward H. Miller, M.D., and Michael C. Welch, M.D.
Summary: Arthrodesis of the knee is an accepted procedure to alleviate pain and deformity in posttraumatic degenerative arthritis, in patients who are not candidates for total joint arthroplasty. Most all of the accepted surgical methods involve an arthrotomy to remove bone and prepare the surfaces for fusion. We present an unusual case of posttraumatic arthritis of the knee in a young
woman with a history of osteomyelitis. An arthrodesis was planned, but an arthrotomy was precluded. Arthroscopically assisted preparation of the fusion bed was performed for compression arthrodesis of the knee with an external fixator. A successful arthrodesis was obtained in 14 weeks. Key Words:
Arthrodesis-Knee.
ture with severe soft tissue damage about the knee. She subsequently underwent stabilization and a total of 14 surgical procedures, secondary to osteomyelitis, which ultimately required an almost circumferential muscle pedicle flap to the anterior knee. This was based on a single vessel arterial runoff to the lower leg. All fractures and soft tissue subsequently healed, and the infection resolved. Over the past 4 years, she developed severe posttraumatic arthritis with varus deformity (Fig. 1). She was otherwise healthy. Because of her age, history of infection, and desired activity level, she was not felt to be a candidate for total knee arthroplasty. In preparation for an arthrodesis of the knee, an arteriogram was performed, which confirmed single vessel vascularity with little collateral flow about the knee. Plastic surgery consultation indicated that any incisional approach to the knee joint could compromise the viability of the pedicle flap. Consequently, an attempt was made to use arthroscopic control to assist in preparation of the articular surfaces for compression arthrodesis.
Arthrodesis is an honored surgical procedure that can be used both initially and as a salvage operation. The indications for knee arthrodesis have included infection, tumor, instability, posttraumatic and degenerative arthritis, and failed arthroplasty (1). Many methods for knee arthrodesis have been used, including external fixation (l-6), internal fixation with plates and screws (7,8), and intramedullary rods (9). All of these described methods involve an arthrotomy to resect bone and prepare the cancellous surfaces for fusion. We present an unusual situation in which arthroscopic control was used in preparation of the fusion bed for compression arthrodesis . CASE REPORT N.F. is a 39-year-old woman who, 15 years prior, was involved in a motorcycle accident. She sustained a closed left femur fracture, and a Grade IIIC (Gustillo) open proximal left tibia and fibula fracFrom the Departments of Arthroscopy and Sports Medicine, Bone and Joint Institute, The Christ Hospital (J.D.P.), and Wellington Orthopedics and Sports Medicine, and The Christ Hospital, Cincinnati, Ohio, U.S.A. Address correspondence and reprint requests to Dr. R. S. Heidt, Jr., at Wellington Orthopedics and Sports Medicine, 111 Wellington PI., Cincinnati, OH 45219, U.S.A.
SURGICAL TECHNIQUE General anesthesia was utilized. The patient was given 1 g of Cefazolin IV prophylactically. Standard 237
J. D. PAPILION
238
ET AL.
FIG. 1. Posttraumatic degenerative arthritis of the knee joint.
inferolateral and inferomedial arthroscopy portals were used. An arthroscopy pump (3M, St. Paul, MN, U.S.A.) and pneumatic tourniquet were also utilized. The menisci were completely resected with
FJIG. 2. Postoperative arthroscopic sisted compression arthrodesis.
Arthroscopy,
Vol. 7, No. 2, 1991
as-
basket forceps and an aggressive arthroscopy shaver. A 5-mm high-speed power burr was used to denude all articular cartilage from the weightbearing surface of both the tibia1 plateau and femo-
ARTHRODESIS
ral condyles, to bleeding cancellous bone. The surfaces were somewhat contoured so that the femoral condyles fit into the tibia1 surface. Multiple drill holes were placed into both surfaces to incite vascular ingrowth. Tourniquet time was 80 min. No attempt was made to include the patellofemoral joint in the arthrodesis. An Ace-Fischer external fixation frame was then placed with three 5-mm bicortical half-pins anterolateral in the femur and three medially in the tibia. The knee was placed in anatomic alignment and 5” of flexion, and joint compression was applied (Fig. 2). A suction drain was used. FOLLOW-UP The patient was started on immediate straight-leg raising and crutch ambulation, toe-touch weight bearing. At 3 weeks, she was progressed to weight bearing as tolerated. The flap was completely viable, and the pin-sites remained benign. By 8 weeks, radiographs revealed evidence of
FIG. 3. One year postoperative:
fusion complete.
OF THE KNEE
239
bridging bone and the external fixator was removed. Under anesthesia, there was no gross motion at the knee. The patient was placed in a fiberglass cylinder cast and allowed full weight bearing. Six weeks later, the cast was removed and radiographs showed complete healing. Recent follow-up at 1 year postoperative, showed the patient to be ambulating independently, pain-free, with clinical and radiographic evidence of fusion (Fig. 3). DISCUSSION Compression arthrodesis of the knee, described by Charnley (2) in 1948, has been an excellent tool in the treatment of posttraumatic and degenerative arthritis. The advent of total joint arthroplasty has decreased the need for arthrodesis. Many surgical methods have been described to obtain a successful fusion (l-9). Common to all of these methods is a midline or parapatellar arthrotomy with extensive soft tissue dissection to expose the knee joint for preparation of the articular surfaces (l-9). An arthrotomy was precluded in our patient because of the danger of compromising flap viability. If needed, flap revision was also perilous because of the one vessel vascularity of the leg. The patient was young, had a history of infection, and desired to remain active. Therefore, she was not a candidate for total joint arthroplasty, which would have also required an arthrotomy. These extenuating circumstances led to the use of arthroscopic control to assist in preparation of the articular surfaces for compression arthrodesis. An extensive search of the literature failed to reveal any documentation of arthroscopically assisted arthrodesis of the knee, and to our knowledge, this is the first report. Several authors have reported successful results of arthroscopically assisted compression arthrodesis of the ankle (IO,1 1; S. J. Snyder et al., personal communication, 1990). Most arthrodesis methods currently used involve external skeletal fixation (l-5). Sufficient bone stock and bone contact, a high degree of rigidity of fixation, compression of the surfaces, and a prolonged period of such fixation have all been advocated as the most important features for enhancing the chance of successful fusion (3). This method was also indicated in our case, as it could be applied with minimal incisions and morbidity. We are not advocating this method as the panacea for knee arthrodesis. However, under the right circumstances, arthroscopically assisted compresArthroscopy,
Vol. 7, No. 2, 1991
J. D. PAPILION sion arthrodesis is a viable alternative to traditional open methods. Removal of all intervening soft tissue and articular cartilage, broad bleeding contoured cancellous surfaces, and rigid external tixation with compression in anatomic alignment are all principles that must be adhered to for a successful arthrodesis. REFERENCES 1. Rand JM. Knee arthrodesis. In: Anderson LD, ed. Instructional course lectures. St. Louis: Mosby Co., 1986:325-35. 2. Charnley JC. Arthrodesis of the knee joint. J Bone Joint Surg [Br] 1948;30B:375. 3. Cunningham JL, Richardson JB, Soriano RM, Kenwright J. A mechanical assessment of applied compression and healing in knee arthrodesis. Cfin Orthop 1989;242:256-64.
Arthroscopy, Vol. 7, NO. 2, 1991
ET AL. 4. Rothacker GW, Cabanella ME. External fixation for arthrodesis of the knee and anMe. Clin Orthop 1983;180:101-8. 5. Velazco A, Fleming L. Compression arthrodesis of the knee and ankle with the Hoffman external fixator. South Med J 1983;76:1393-6. 6. Fahmy NR, Barnes KL, Noble J. A technique for difficult arthrodesis of the knee. J Bone Joint Surg [Br] 1984;66B: 367. 7. Lucas DB, Murray WR. Arthrodesis of the knee by double plating. J Bone Joint Surg [Am] 1961;43A:795-808. 8. Pritchett JW, Mallin BA, Mathew AC. Knee arthrodesis with a tension band plate. J Bone Joint Surg [Am] 1988;70A: 285-8. 9. Harris CM, Froelich 3. Knee fusion with intramedullary rods for failed total knee arthroplasty. Clin Urthop 1985;197:20916. 10. Stulberg DS, Reilly J. Arthroscopic ankle arthrodesis. Orth Trans 1988:12:763. 11. Glick JM, Sampson TG, Meyerson ME, Morgan CD. Arthroscopic ankle arthrodesis [Abstract]. Arthroscopy 1990; 6: 155-6.
