These increasingly hectic times are characterized by demands for limitless mobility. To keep pace, technical progress has also been made in the surgical theater in clinics. Continually improved implants and constant changes in artificial joints make it difficult for doctors to obtain long-term experience with one certain procedure. One must not, however, forget that a surgeon’s or orthopedic surgeon’s individual learning curve means the patient’s suffering curve. Changing the implant used too often is counterproductive and increases the complication rate considerably.

Nonetheless, we surgeons nourish the patient’s belief that just about everything can be corrected. Every trauma and every degenerating process in the joints which has been going on for decades is expected to be rectified by the physician’s skill together with an optimal implant. Interestingly enough, both doctors and patients have contributed to the gradual development of this process in the clinical routine. For example, it is expected that a lower extremity which has suffered the severest traumatic injury can be salvaged and will even function after all reconstructive procedures have been applied. The surgeon is, of course, pleased and the patient happy when the leg need not be amputated. But, after getting used to the situation, instead of being satisfied both parties astoundingly became dissatisfied. Residual complaints are overrated, and new surgical procedures are considered. No one wants to remember the initial situation. This step, albeit well meant, often leads to complications. In individual cases the physician is well advised to say “no.” But this must be learned.

In this difficult situation, arthrodesis—stiffening of the joint—is considered a relic of the distant past. It is expected to destroy the patient’s mobility and create a permanent problem. If this procedure is recommended to a patient, the initial reaction is sudden doubt concerning the physician’s professional competence. “You can just as well amputate my leg right now,” is often the spontaneous reply. The patient has already suffered considerably. It is not taken into consideration that arthrodesis is often not the initial intervention, but is at the end of a long chain of operations and presents the possibility of painless or at least less painful use of the limb. If the individual case is critically analyzed from the physician’s point of view, this step should actually have been taken earlier in the chain of interventions. A correctly performed arthrodesis offers undeniable advantages for the patient:

This can, however, only be achieved if sufficient bone substance remains in the knee or ankle when the arthrodesis is performed.

It makes little functional sense for the patient if one extremity is much shorter due to bone defects because then he or she will permanently have to rely on walking aids. A difference in length of up to 3 cm can easily be compensated in or on a shoe. The patient can even walk short distances barefoot without uncertainty. Greater limb-length discrepancies limit mobility and quality of life and can even be dangerous, especially among the elderly.

Depending on the localization of the arthrodesis and the patient’s age and compliance, bone construction should be undertaken to equalize the difference in length. Whether bone grafting will be sufficient, callus distraction will be necessary, or an arthrodesis rod must be implanted (especially if there is a bone defect in the knee after numerous total knee replacements) to solve the problem, must be decided together with the patient and depends largely on the condition of the extremity. The goal must be to compensate the handicap of a stiff joint with optimal surrounding conditions.

An increasing number of total knee and ankle replacements are now being implanted worldwide. As the number of implants increases, so does the absolute number of complications. Under these circumstances, arthrodesis will revive. It offers patients the possibility to walk without pain in the majority of cases. If arthrodesis had been considered in the individual’s chain of treatment at a time when there was still enough bone substance, far better functional outcomes would be possible.

Under these considerations, arthrodesis could even be a primary option for young patients with completely destroyed knee or angle joints as a result of extreme traumas. Implanting an artificial joint, which is a justified therapeutic option for older individuals in such situations, should not be considered for young patients. They experience the severe resulting problems while they are still relatively young. Remember the inventor of the total hip replacement, Sir John Charnley (1911–1982), who wisely said, “The surgeon implants a disease with every total joint replacement.” This disadvantage does not exist with arthrodesis.

Knee Joint

Indications

Fig. 8.1 Stage 4 infection of the knee joint with extensive destruction of the bone and complete loss of cartilage.

Contraindications

General Comments

The complex problems in destructive infectious joint disease of the knee are so multifaceted that different therapeutic options—arthrodesis versus total joint replacement—must always be discussed. The patient’s wishes have priority. Even if these wishes in some cases make no sense medically, the physician is bound to respect them.

The surgeon’s primary function is to offer advice; making demands or even applying pressure is simply not an option, regardless of contrary specialist opinion. The physician must never forget that any stiffening of the knee joint places considerable limitations on every patient. You can only try to convince the patient that a stiff knee joint is a safe option offering full weight bearing in the future, despite all functional restrictions.

If a patient is unsatisfied after successful arthrodesis, one should always consider whether the primary information and advice given to the patient was not sufficiently detailed.

Surgical Concepts

Principal Signs and Symptoms

Surgical Preparations

Special Instruments and Materials

Therapeutic Concept: Eradication of the Infection by Means of Primary Arthrodesis with an External Fixator

Soft Tissues