FUSIONS Flashcards
1st MTP
Dorsal approach
Joint preparation
Bone graft
Position
* Neutral rotation
* 10 deg valgus
* 30 degrees DF compared to 1st MT ray
* 15-20 degrees DF compared to floor
Fixation
* Inter-frag lag screws 3.5 cortical – crossed
* 2.7 mm T plate
Ankle Fusion
Goal: pain free stable union of the tibiotalar joint in a functional position using an anterior open-fibular sparing technique, denuding the articular cartilage and compressing across the joint with partial threaded screws
1 Supine position with tourniquet
2 Direct anterior approach between tib ant and EHL protecting neurovascular bundle
3 Expose the entire joint denuding articular cartilage with a burr/osteotomes, preserving the fibula as a guide for length and block to lateral subluxation
4 Position the ankle in 5 degrees valgus, neutral dorsiflexion, 5-10 degrees of ER
5 Perc medial tibial incision and guidepin inserted medial tibia to the talar dome in position of fusion and confirm with fluoro prior to inserting cannulated partially threaded screw, 2nd screw is inserted in parallel from the medial tibia
6 Tension free closure in layers with protected post-operative weight bearing until there is radiographic evidence of union
subtalar fusion
Patient supine (or lateral)
sinus tarsi approach - inline with tip of fibula and base of 4th MT
avoid sural nerve and peroneal tendons
elevate EDB and retract distal, remove all fat and tissue from sinus tarsi
laminar spreader is inserted into sinus tarsi
articular surface is prepared by removing all cartilage (curettes, osteotomes) and scaled with an osteotome
typically bone graft is not needed - local bone graft is available from calcaneus if needed
subtalar joint is position in 5 degrees of valgus, neutral DF/PF
provisional fixation is held with k-wire and alignment confirmed with fluoro
fixation with two 7.0 partially threaded screws
either 2 from nonWB portion of the calcaneal tuberosity to the talar neck crossing the posterior facet
Calcaneo-tibial fusion
Lateral approach with fibular osteotomy used for bone graft
Articular preparation of ankle and ST joints to bleeding cancellous bone
Bone graft of fusion site
Position
* Neutral DF / PF
* 5 deg valgus
Fixation with hindfoot nail
Knee fusion
Midline approach, medial parapatellar, patellectomy w/ tendon splitting
Joint surface preparation
Bone graft
Position
Valgus 5 deg
ER 5 deg
Flex – 10 deg
Fixation
ORIF
- two staggered dynamic compression plates-one placed medially and one placed laterally–are contoured to the knee;
- twelve-hole plate is recommended;
- above-the-knee cast is used, with weight-bearing as tolerated, until radiographs show that the arthrodesis site has united
IM Nail
- Entered via piriformis
Hip fusion
Can use anterior or posterior approach to hip,
Cobra Plate, direct lateral with GT osteotomy and superior retraction with Steinman pins
Clean off inner table from sciatic notch to AIIS
Do innominate osteotomy and medialize pelvis
Cut femoral head 1cm off for fusion surface
Lay Cobra plate and fix to shaft, head and ilium
Fix GT to plate with 4.5 mm screw
For peds case I’ll use anterior approach in virgins
Use previous incision if prior surgery
Hip dislocation and joint surface preparation
Bone graft
“Intra-articular arthrodesis with an abductor sparing procedure”
Position
Flex 20 degrees
Adduction 0-5
ER 5 degrees/or neutral
Fixation
COBRA PLATE
- 3 cannulated screws with washers from gr troch across hip joint into acetabulum – same orientation as cannulated screws for hip fracture
- 4th cannulated screw with washer from proximal part of greater troch placed more horizontal across hip joint into inferior acetabulum
1st CMC fusion
FCR interval extended distally
Joint surface preparation
Bone graft
Position
Palmar abduction 30
Radial abduction 15 degrees
Fixation
Crossed mini-frag lag screws
Cast post-op
Wrist fusion
Dorsal approach b/w 3 & 4 extensor compartments
Joint surface preparation
Remove lister’s, proximal row carpectomy for autograft
+/- DRUJ procedure (darrach) if arthritis
Position
slight ulnar deviation and 15 degrees of extension
Fixation
precontoured locking plate to 3rd MC shaft and distal radius in compression
Note: wrist spanning plate in trauma setting
2 dorsal incision (minimally invasive over wrist)
Plate to 2nd MC and distal radius
Elbow fusion
Elbow fusion
Posterior approach with olecranon excision
Joint preparation
Bone graft
Ulnar nerve transposition
Position
Neutral pro-sup
90 degrees flexion
Cast pre-op to determine best position
Fixation
Interfragmentary lag screw across joint supported with posterior neutralization plate 4.5 mm extended from distal humerus (4 holes) to ulna (4 holes)
Shoulder fusion
Delto-pectoral extended over acromion and scapular spine, or strap incision
GH joint and acromion decorticated and joint surface preparation
Bone graft
Position
Abduction 30
Flexion 30
IR 30
Fixation
Posterior approach
Lag screws from acromion into humerus, and humerus to glenoid
Neutralization plate extending from prox humerus (4 screws) to scapular spine (4 screws)
