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Arthrodesis

Ankle arthrodesis is the surgical fusion of bones that form the ankle joint. The ankle joint is formed by the tibia, talus, and the fibula bones.

The goal of ankle arthrodesis is to relieve pain in the affected joint. This is achieved by surgically eliminating the joint.

Ankle arthrodesis is recommended for the treatment of severe end stage arthritis that has not responded to conservative treatment measures such as medications or injections. The other indications include ankle infections, neurological ankle instability, and tumours.

Ankle conditions should be evaluated for proper diagnosis and treatment. Accurate diagnosis comprises of a detailed medical history and physical examination. Imaging tests such as X-rays, Doppler Test, and MRI may be ordered.

Ankle arthrodesis can be performed as an arthroscopic or open traditional surgery. The approach for an open technique can be either from anterior (front) aspect or lateral (side) aspect of the ankle. The joints are then fused together with the help of screws, wires, plates, or rods. Bone grafting is recommended in cases of substantial bone loss. This is done using a graft taken from the patient (auto graft) or donor tissue (allograft). The recovery time following fusion will depend on the technique employed and the health status of the individual patient.

The post-operative guidelines to be followed immediately after ankle arthrodesis include:

  • Keep your cast or dressing dry and do not remove for the specified time period given by your surgeon
  • Avoid bearing weight on the operated ankle joint and use crutches or wheelchairs for a few weeks
  • Elevate the foot above heart level to minimize swelling.
  • Eating a healthy diet and quitting smoking will help with healing.

Ankle arthrodesis is usually a safe procedure and complications are uncommon. However, apart from general complications related to any surgery, complications after ankle arthrodesis can include infection, nerve damage, unresolved pain, non-union of bones, excessive swelling and stiffness, and irritation from foreign material such as pins or screws.

Fracture Care

The word “Fracture” implies to broken bone. A bone may get fractured completely or partially and it is caused commonly from trauma due to fall, motor vehicle accident or sports. Thinning of the bone due to osteoporosis in the elderly can cause the bone to break easily. Overuse injuries are common cause of stress fractures in athletes.

Fracture Healing

Our body reacts to a fracture by protecting the injured area with a blood clot and callus or fibrous tissue. Bone cells begin forming on the either side of the fracture line. These cells grow towards each other and thus close the fracture.

Medical Therapy

The objective of early fracture management is to control bleeding, prevent ischemic injury (bone death) and to remove sources of infection such as foreign bodies and dead tissues. The next step in fracture management is the reduction of the fracture and its maintenance. It is important to ensure that the involved part of the body returns to its function after fracture heals. To achieve this, maintenance of fracture reduction with immobilization technique is done by either non-operative or surgical method.

Non-operative (closed) therapy comprises of casting and traction (skin and skeletal traction).

Casting

Closed reduction is done for any fracture that is displaced, shortened, or angulated. Splints and casts made up of fibreglass or plaster of Paris material are used to immobilize the limb.

Traction

Traction method is used for the management of fractures and dislocations that cannot be treated by casting. There are two methods of traction namely, skin traction and skeletal traction.

Skin traction involves attachment of traction tapes to the skin of the limb segment below the fracture. In skeletal traction, a pin is inserted through the bone distal to the fracture. Weights will be applied to this pin, and the patient is placed in an apparatus that facilitates traction. This method is most commonly used for fractures of the thighbone.

Surgical Therapy

  • Open Reduction and Internal Fixation (ORIF): This is a surgical procedure in which the fracture site is adequately exposed and reduction of fracture is done. Internal fixation is done with devices such as Kirschner wires, plates and screws, and intramedullary nails.
  • External fixation: External fixation is a procedure in which the fracture stabilization is done at a distance from the site of fracture. It helps to maintain bone length and alignment without casting.

External fixation is performed in the following conditions:

  • Open fractures with soft-tissue involvement
  • Burns and soft tissue injuries
  • Comminuted and unstable fractures
  • Fractures having bony deficits
  • Fractures with infection or non-union

Rehabilitation

Fractures may take several weeks to months to heal completely. You should limit your activities even after the removal of cast so that the bone becomes solid enough to bear the stress. Rehabilitation program involves exercises and gradual increase in activity levels until the process of healing is complete

Limb Salvage

Bone cancer and soft tissue cancers are both very rare cancers but are mostly malignant and can spread to other parts of the body. They occur more frequently in children and young adults, or people above 60 years. The main symptom of the bone cancer is pain in the affected bone, whereas soft tissue cancers develop as a painless lump mostly on the arms or leg. The treatment of bone cancer involves chemotherapy, radiation therapy, and removal of the tumour through surgery. Earlier surgery involved amputation of the entire arm or leg to prevent the cancer from spreading, but now with the advancement in diagnostic procedures, chemotherapy and surgical procedures in limb reconstruction limb salvage surgery can be done.

Limb salvage surgery, also called limb sparing surgery is an alternative to limb amputation for treatment of bone and soft tissue cancer. It involves removing the tumour along with some adjoining normal tissue and then reconstructing the limb, both functionally and in appearance. The diseased bone is replaced by the bone graft either from a different body part of the same individual, or from another person, or metal implants. If required, even the joints are reconstructed using artificial implants.

Eligibility For The Surgery

Decision of the surgery depends on many factors such as age of the patient and general health, the type, the location and size of tumour, and the spread of the tumour.

Limb salvage surgery is not indicated if the child is too young, tumour is too close to an important nerve or artery, the tumour does not shrink in response to the chemotherapy given before the surgery, or the reconstruction of the limb is not possible after the removal of the tumour.

Procedure

  • Removal of the cancer: Before surgery chemotherapy or radiation is given for few months to kill the cancer cells and shrink the tumour. The tumour is then evaluated by imaging studies to check whether it has shrunk, and its biopsy sample is observed by the pathologist to check for the necrosis of the tumour tissue. Then, the remaining shrunk tumour with live cancer cells is then removed by surgery. Limb salvage surgery is done only if the tumour has shrunk and has adequate margin as the surgery is done only through the normal tissue to prevent recurrence of the cancer. The gap formed by the surgery is reconstructed.
  • If the gap involving bone is small, bone from the patient’s other part of the body such as iliac crest is taken or else allograft or prosthesis or a combination of both is used.
  • If implant is used to construct the bone, it is fixed in the bone using bone cement. The muscle tendons are attached to the implant and the surgical site is closed after covering the implant with the healthy soft tissue cover.
  • Allograft is taken from the dead person after freezing the bone in cryopreservant at -80 degree C. This kills the bone, preserving the cartilage. The allograft is shaped to the required size and is attached to the patient’s bone using an intramedullary rod or bone plate. Tendons are attached to the stumps of the allograft.
  • If joint reconstruction is required the allograft is used along with prosthesis for the articular surfaces of the joint as is done in total joint arthroplasty. The use of allograft with prosthesis is preferred over the use of only allograft.

The bone graft heals with the patient bone after the surgery.

Risk and Complications

The potential risks and Complications associated with the surgery include:

  • Superficial and deep infection of the operated site
  • Cancer recurrence Artificial implant loosening due to active use of the reconstructed limb Variation of limb growth, especially in growing children. Formation of non-union, due to improper healing of bone, development of contractures, permanent tightening of joints, especially in physically inactive individuals

After The Surgery

After the surgery, pain medications are given as epidural or patient controlled analgesia pump, or as an injection. Broad-spectrum antibiotics are also given to prevent the infection. The tube attached to the wound, to drain the surgery site blood and fluid in an attached bag, is taken out on the third or the fourth day after the surgery.

The wound heals mostly in few days, and then the stitches or staples are removed. The physiotherapy starts soon after the surgery and continues for a year to regain muscle strength and functional mobility of the limb.

Post-Operative Care

To maintain proper limb function and to determine other problems that may develop in the limb in future after the surgery, lifelong follow-up is essential. X-rays are done every six months till the patient is in growing age, and then onwards at least once every year. To prevent wear and tear of the salvaged leg, certain activities such as contact sports and running are not allowed. Any signs of infection such as pain, redness, swelling of the operated limb, or fever even long after the surgery should be reported to the doctor at the earliest. Before going for any surgical procedure, even a simple dental procedure, the person should consult the orthopaedic surgeon since the possible infection due to surgical procedure can spread to the bone graft or implant.

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