arthrodesis for failed knee arthroplasty - Bone & Joint

ARTHRODESIS

FOR

FAILED

A KAJ

REPORT

KNUTSON,

Twenty

hinged,

and

(4) and instability (1). One patient Infected knees had a two-stage

LARS

Hospital

in Lund

arthrodesis prostheses

by

all infections

the

same

healed.

method.

Six

The

two

Charnley single-frame compression done elsewhere Delayed union in three cases fused after prolonged The indications for and methods of arthrodesis

and

(1982)

Waugh

arthroplasties cumulative Reports

1980), theses

UCI (Hamilton (Marmor 1982)

support

on

finding.

has

only

in Sound said

best

were

series were

not

suitable

for

Cameron

and

usually 1984b),

results in considerable it is important to

improve

Since

the the

fusion

main

arthrodeses

failure

so

inability

bone

describes

K. Knutson, A. Lindstrand,

MD MD,

and

20 cases

Associate

L. Lidgren, MD, Associate Department of Orthopaedics, Lund, Sweden. Requests

for

reprints

revision

arthrodeses

©1985 British 0301-620X/85/

Editorial

VOL.

1, JANUARY

67-B,

No.

is are and

1979;

Lionberger

be addressed

Society

of Bone

1008 $2.00

1985

and

Of

and

of

of the

hospitals.

reported

arthritis

the

Seventeen

ofone

to Dr and

Joint

K.

Knutson. Surgery

_________

of

ofthe

17 patients

had

these

authors

were

(LL)

at

Hospital consultation.

in

been referred and seven

from other men with an

(range

47 to 82 years).

arthroplasty

had

The indicarheumatoid

I 3 women

were

years

primary

of after

in I 1 patients,

osteoarthritis

been

in five and

fracture

knee with secondary arthritis in four. Eight of the primary arthroplasties had previously been revised, by exchange ofthe prosthesis in seven and by the addition of of the

in one

arthrodesis Georg,

single-compartment

prosthesis was I

which of

Marmor complication

removed

type

the

types

1 Richards

stabilised

modular, for

and

in the

at the time of (5 Guepar, 2 St

in eight

I Spherocentric)

three-compartment

condylar,

arthroplasty.

was

of the hinge

Shiers);

Attenborough,

85

patients

of Orthopaedics, University were done elsewhere after

age of66 for

for 20 consecutive

in

five

(4

of the one,

type

two

or

remaining

seven

maximal contact, I St Georg-Sledge)

which

arthrodesis

deep infection in 1 5 cases, mechanical and severe instability in one. Thirteen one or more knee operations as well 5-221

after nails.

METHODS

arthroplasty.

There

The

arthrodesis.

in Lund,

failures

1977 to 1982 arthrodesis

the supervision

the Department Lund, and three Eleven

from

attempted

knee

components

in I 8 secondary infection, loss of stabilisation. This

Hospital

fixator

10 primary fused after

tenth two

AND

period

was

average

Professor

should

knee

of an arthrodesis

of attempted

Professor University

the

a six-year

tions

et al. (1983)

for failure to control inadequate

Over failure

far

few reports

fixation

sound fusion. beads after external

was successful. successful; the

of external

done under

disability (Knutson et a!. develop methods that can

Bigliani

reasons

were

metaphysial

rate.

Woods,

of fusion

failures

a Hoffmann-Vidal

fixation nine were

MATERIAL

the five

by arthrodesis.

1982;

Hunter

1983).

arthrodeses

knee

Aglietti

result

fusion in these secondary to be difficult to achieve, and

Tullos

report

and

(Deburge et al. 1976; Hagemann, Woods 1978; Brodersen et al. 1979; Vahvanen

available Tullos

that

of found within

Marmor endoprosof over five years

five-year

treated

are reviewed. Eight (15 cases), loosening

were successfully fused with intramedullary fixation and repeated bone grafts. after failed knee arthroplasty are discussed.

revised failures from 100 total et al. 1983). Some of the

(Insall

and

results

(Insall

1982) and with follow-up

seven

these

the

rate, and one quarter

unicondylar

The

replacements

arthroplasty usually

the

this

reported failures

estimated

in terms of survival risk of failure to reach

years.

knee

using

in two temporary failures. One Ace-Fischer external at arthrodesis with an intramedullary K#{252}ntscher nail, attempts

arthroplasty for infection

refused a second-stage operation but the remainder gained procedure with temporary insertion of gentamicin-loaded

of the

more

LIDGREN

for failed knee were removed,

removal

attempts

Tew

CASES

resulted two

prosthesis;

20

ARTHROPLASTY

LINDSTRAND,

the University

patients treated by seven compartmental

consecutive

five stabilised

OF

ANDERS

From

KNEE

(I

total

I Geomedic, 3 (Table I). The was

required

was

loosening in four patients had had as their final knee

arthroplasty

before arthrodesis. In this study infection was considered when one or more of the following four present: a fistula from more positive cultures

thejoint

from

or adjacent

to be proven criteria were bone;

five tissue biopsies

three

taken

or at 47

Table

I. Details

of 20 patients

undergoing

operations

for failed

knee

arthroplasty Follow-up Shorten-

Age Case 1

Diag-

(years)

Sex

nosis*

Previous operations Type ofprosthesis

80

F

OA

Tibial

osteotomy

Cause failure

Deep

of

Operations

Period

ing

(months)

(cm)

Result

53

9

Fused,

29

3

Fused, painfree Died of unrelated disease

19

8

Fused Late supracondylar fracture healed Painfree

1. Beads and H-V fixation 2. Sinus excision 3. IM nail

18

5

Fused,

painfree

1. Beads 2. IM nail

12

3

Fused,

painfree

28

5

Fused, slight pain Uses one stick

12

4

Fused, healed Painfree

fracture

6

3

Fused,

painfree

6

8

Fused, painfree Uses crutches

6

1

Fused,

4

4

Fused Died from disease

arthrodesist

infection

1. Beads

Guepar 2

3

66

80

RA

M

F

OA

H-V

Lateral

Marmor

Loosening

Medial

Marmor

grade

infection

Tibial osteotomy St Georg (fractured) St Georg

Deep

infection

Deep

4

54

F

RA

Guepar

5

76

F

OA

Total

6

55

M

Sec OA

Attenborough (infected) Attenborough

7

53

M

Sec

Guepar

OA

Multiple

condylar

and

low-

1. IM

and

nail

and

1. H-V fixation 2. IM nail 3. Reinsertion

infection

and

infection

Deepinfection

1. Beads 2. IM nail and for fracture 1. Beads and H-V fixation 2. Bone graft

8

60

M

Sec OA

Spherocentric

Wound breakdown Deep infection

9

55

M

RA

Guepar Revision Shiers Revision

Progressive resorption loosening

bone and

10

47

M

RA

Instability loosening

and

I I

72

F

Synovectomy Marmor (loose) A ttenborough Tibial osteotomy Geomedic St Georg-Sledge Fixation of supracondylar fracture

Deep infection and pseudarthrosis

1. IM

Guepar Guepar

Deep infection and loosening

1. Beads 2. Revision and 3. A-F fixation bone graft 4. Bone graft

Instability, loosening, overweight

1. IM

Sec

OA 12

13

14

15

16

17

71

73

69

73

56

61

F

RA

F

RA

F

OA

F

(loose)

Marmor Richards contact

RA

F

Loosening

Marmor

RA

F

(loose)

RA

Deep infection and septicaemia

Attenborough

Deep

I. Charnley 2. Revision 3. Revision 4. IM nail graft 1. Beads 2. IM nail graft

infection

1. Beads 2. Revision 3. IM nail graft

F

RA

Marmor

Instability

1. H-V

70

M

OA

St Georg Osteosynthesis femoral fracture

Deep infection and bone resorption

1. Beads 2. IM nail graft

Deep

I.

#{149}Diagnosis: OA,

RA

osteoarthritis;

tBeads, insertion of intramedullary nailing

beads

Guepar

RA, containing

rheumatoid gentamicin;

arthritis;

Sec H-V,

2

I1

4

beads and

nail

57

F

12

Fused,

painfree

unrelated

painfree

Walking

19

82

clamps

nail

18

20

cerclage

frame

Fused, proximal fracture healed brace Painfree Uses crutches

6

2

Fused,

painfree

7

5

Fused,

painfree

9

4

Fused Supracondylar fracture healed Painfree

11

2

Fused,

in

grossly

Synovectomy Attenborough(loose) A ttenborough

of

bone

1. Beads 2. IM nail and bone graft 3. Change IM nail; bone graft 4. Change IM nail; bone graft I. H-V fixation

I. Charnley 2. IM nail

Skin necrosis and deep infection

maximal

bone

of nail

1. Beads 2. IM nail and graft 3. Bone graft

revisions

painfree

fixation

graft

Deep infection septicaemia Deep

for

infection

OA,

osteoarthritis

Hoffmann-Vidal

clamp and beads and beads and bone

and

bone

and beads and bone

fixation and

secondary

painfree sticks

6

1

Fused,

painfree

8

4

Stable

fibrous

4

4

Cardiac infarction after removal of prosthesis Refused arthrodesis

union

bone

Beads (Brace)

external

Uses

to fracture fixation;

A-F,

Ace-Fischer

external

fixation;

IM,

ARTHRODESIS

operation (Kamme with isolation of the knee

aspirate;

more

of the

aspirations. principles

infection

used.

Lindberg bacteria

or growth

knee Certain

proven

and same

and infected in the femur

bacteria

of treatment

stage

At thefirst

1981); septicaemia in the blood and the same

a two-stage

FOR FAILED

were

in two

followed.

procedure

was

For

debris were removed, cutting and tibia when necessary. The

cement

(Septopal). using local

Any fistulae were plastic procedures

If external Vidal

fixation

fixator)

first stage. supported could, awaiting

excised and if necessary.

(most

often

to be used,

with

it was

the

bone ends gentamicin

the skin

within a few days, the second operation. treatment

was

be

often

started

during

the

crutches while cases systemic

before

revision.

the

first

stage

The second performed

was

wound

were

dealt

with

was

of treatment

stage when

well

the

before

the

was

If

in

removed

combined fused for

pro-

and

with bone mechanical

either grafting failure,

One patient with a loose I I) was referred to us for a

arthrodesed

because

and in secondary of these patients

of the

type usually therefore treated tissue cultures

was

and

report

(see

case

Table

II. Revision

with patient

after failure of a Charnley-type The other two uninfected knees

10) were

primary One

the

a one-stage

14 and 18) had Marmor arthroplasties one of these was also loose and the

9 and

in both plasties.

arthroplasty by

on page

of loosening

replacement had osteolytic

arthrobone

seen in low-grade infecin two stages; repeated were, however, negative

50).

procedures

used in 20 patients

with

failure

of knee

arthroplasty

of failure

Deepinfection

One-stage

Two-stage

procedure

procedure

3

11+1*

15

3

1

4

Total

healed,

usually

knee.

The

condyles

obtain

a better was also used retained during

four

K#{252}ntscher nail

brace

settled

to six

and

sometimes

For internal fixation was inserted from

weeks

was

used

after

stability.

crutches

operation The

a few days

after

to

chiselled

and

provide

was

off

to

up

full weight-bearing

on

started

infection

was

Case I 2, where the supracondylar first-stage

diagnosed

No.

infection

operation

to

I, JANUARY

l985

provide

were

II).

In Case

arthrodesis,

and

there was an infected pseudarthrosis region, the knee was stabilised

infection. 67-B.

before

better

1

-

second-stage

2 in in

during

control

of

adjusted.

considered

operation

was

at least until for I 3 months were regularly

refused

Radiographs

the knee was (range 4 to 53 checked and

were

taken

and at four months, at which usually tested; radiographic

and

(range

3 to 41 months).

months

the

a secondary

fixation

was

soon

time clinical follow-up

Iffusion bone

continued.

.

If

at this time, the external fixator for one to two months to protect

union and encourage had been fixed by

further bone intramedullary

rotatory stability had been achieved.

and

the

brace

was was

graft

was clinically sound replaced by a brace

fusion was the

healing. Knees which nails were tested for was

removed

when

this

for

each

RESULTS of fixation.

patient

are

Vidal

mann

The

(Table quadrilateral pins was

nine

treatment in Table

summarised

in

fixation

not

planned

averaged I l months not sound at four

arthrodesis

six weeks.

Twelve of the 1 5 patients with deep treated by a two-stage procedure (Table

the

after operation stability was

Method

additional

allowed

I

patient

compression

a long intramedullary the greater trochanter

patient

instability one

after

femur to below the narrowest part of the canal of the tibia after reaming both bones 1983; Knutson and Lidgren 1982). A dorsal

rotatory

*In

cases the

stage the gentamicinthe proximal tibia and and a large amount of from the iliac crest to

were

Severe

loosening

Follow-up continued soundly fused, on average months). External fixators

shape and bone contact; bone so obtained as graft. The external fixation device was the second stage unless internal fixation

was planned. of the medullary (Fischer

had

Mechanical

actual

for the infected

infection

the first stage. At the second containing beads were removed, distal femur were decorticated cancellous bone was transferred

VOL.

the prosthesis

second attempt at fusion compression arthrodesis. (Cases

knee

treated

external or internal fixation was used. Of the five knees

Type

fusion operation.

the

at which

of

were

had

after

after

failures

infection

bacteriological

not been done, treatment was started after five cultures had been taken during operation. In cases of proven infection, antibiotic treatment was continued until the knee was fused. Any skin problems remaining

the

of

cedure

tion

the Hoffmann-

applied

up on In infected

Mechanical absence

destruction

closed,

If internal fixation was planned, the knee was with a dorsal plaster slab so that the patient

antibiotic this

was

between containing

49

was extremely overweight. Geomedic prosthesis (Case

anterior slots least possible

amount of the bone ends was resected to improve the contact area of the arthrodesis. The posterior capsular attachment and the head of the fibula were resected if more bone contact was required. The cavities in the femur and the tibia and the space were then filled with cement beads

ARTHROPLASTY

two (Cases instability;

normally

and all bone

the prosthesis

or

KNEE

of

the

and I. The

patients

III).

In six of these

used

fixator (Connes

results first

attempt

was

with

nine

a Hoffmann-

at

external

with six transverse Stein1977). Three of these six

I 3 and 4) were undergoing revision of long-stemmed hinge prostheses; two ofthe three failed to fuse but later had successful operations with intrapatients

medullary stemmed

(Cases

,

nail fixation. Two stabilised prostheses

were (Cases

revisions of short8 and 10) and both

50

K. KNUTSON,

Table

III.

Attempted

method

of arthrodesis

related

A. LINDSTRAND,

to type

of knee

arthroplasty

Complications. small fissure but

of arthroplasty

Type

L. LIDGREN

these

Two Two three

compart-

compart-

Hinge

ised

ment

ment

Hoffmann-Vidal external fixator

3 (2 failed)

2

-

Ace-Fischer external fixator

I

-

-

method

Intramedullary primary attempt

nail,

Intramedullary after failure of primary method

nail,

a

Initially

treated

fused

with

bone

grafts.

mental

3 (I failed)

3

4 (1 failed)

elsewhere

external

fixation,

One

prosthesis

patient removed

3

Partridge

nylon

fractures

healed.

One

though (Case and

fixation

one

needed

further

I 8) had a unicompartfused uneventfully.

cerclage

patient

nail

the knee; this In two cases migrated report,

fracture (Cases

proximally Figs 4 to

fusion. major

fractures, fracture fixation.

but healed A lateral during (Case

7) sustained a subtrochanneeded fixation by two (Partridge

I 3) sustained pin had

or more

femur occurred nail in one patient

bands

(Case

healing

sustained

femoral and the

(Case which

the proximal fixator which

external

on

16)

intramedullary

19) and another patient teric fissure fracture,

-

single-frame

effects

3 and

and condylar the arthrodesis after

through

by Charnley

adverse

flake fracture of the proximal insertion of the intramedullary

*2

-

no (Cases

uneventfully

1

1

had

patients

supracondylar in each case

Single

Stabil-

Attempted arthrodesis

of

and

The removal of the prosthesis resulted in fractures of the condyles in some patients,

a femoral

holes helped

healed 3 and

1976).

Both

fracture

after removal of to produce fusion

an of

in a brace (Figs I 2 and 3). 9) the intramedullary nail ,

and needed reinsertion (see case Fistulae required revision in five

7).

patients (Cases I 4, 1 3, 1 5 and 1 7) before arthrodesis; Case 1 5 closure was by a myocutaneous flap from medial gastrocnemius. There were no septic reactions

in the to

,

I I and I 5) with two and three compartment prostheses had been initially treated elsewhere by Charnley single-frame fixation and had failed Two

patients

(Cases

to fuse. Arthrodesis nail fixation. One defects sound

and a fusion

was successful patient (Case

long-stemmed after further

tion in an Ace-Fischer support of ventral pins

with intramedullary 13) with large bony

hinge grafts

fixator (Knutson,

prosthesis gained and immobilisa-

with the additional Bodelind and Lidgren

I 984a). Table

IV.

Shortening

of

the

leg after

arthrodesis

for

failed

knee

the operations

operation

for arthrodesis;

was

ununited

o f arthroplasty

Shortening (cm)

Two and three

Single

Hinge

Stabilised

compartment

compartment

0-2

-

2

-

3

3-4

4

2

2

1

5-6

1

1

1

7-8

2

-

-

-

>8

1

-

-

-

Case

9. A 49-year-old replacement.

but

this

but

bone

‘

healed

in which fused,

intramedullary though one

treatment

with

intramedullary

an

nail was patients attempt

(Table

shortening

IV).

of

the

nail fixation patient after nail

legs

after

prosthesis

--

at the latest supported with

bone

The

knee

was

replaced was

knee

a

Multiple

r-1--1

a Guepar

postoperatively, well

prosthesis with

used.

had

months

functioned of the

cement

the

arthritis

for three

subsidence

review

after infarcrefused

by a brace.

rheumatoid

persisted

revision. and

up of infection

for then

Shiers

three

years,

developed. prosthesis;

cultures

of tissue

i

needed

used at the an intraat fusion. was used primary two

more

operations for nail fixation and bone grafting (Case 9, case report). All healed fusions but one (Case 19) showed bridging callus; in the one exception the knee was clinically stable with fibrous union, but the patient had slight pain in the hip on weight-bearing. The average clinical

man A fistula

resorption

Guepar

was

flaring

(Case 20) had a cardiac the prosthesis and later

-

In 10 patients an intramedullary primary fusion operation; in four medullary nail was used at the second All knees eventually

and

knee

gentamicin-loaded Type

no further

One patient removal of

The

arthroplasty

and

arthrodesis. tion after

after

fusion

was

4 cm

.

.&

-

.?

2

Fi3

Case 1 3. Figure 1-Lateral radiograph of the fused knee after removal of an Ace-Fischer external fixator. Note the anterior bone defects after a revision arthroplasty. Figure 2-Oblique radiograph showing a stress fracture ofthe femur which occurred two days later through a pin hole. Figure 3-Lateral radiograph of the healed fracture.

THE

JOURNAL

OF BONE

AND

JOINT

SURGERY

FOR FAILED

ARTHRODESIS

biopsies

were

was

successfully

then

resorption

amount

negative,

and

excised. and

of

a fistula

Knee

subsidence

granulation

defects

but

no

was

One

month

K#{252}ntscher nail, from

the iliac

after

operation,

migration.

4) and

bone

was

was but

was

reinserted,

screw

with

amount

the with

larger

nail

grafted.

Six

months

bridging

callus

also

months

later

the

visible

on

at

16 mm,

later

further 6).

knee

was

used

knee

necessitated was

cancellous

stable

and

(Fig.

bone painfree,

a

was while

recent

review

of

the

or

literature

by

Stulberg

for

and

healing

primary

arthrodesis

unicompartmental good and the Charnley

and

1948;

In cases

No.

often seen in failed hinge and Matthews 1981). In

in arthrodesis

with

for the failure

the bone stock even with the

compression et al.

Skolnick good

use the Hoffmann-Vidal 1977). This does not

67-B.

most Louie

replacement, fusion rate is high,

single-frame

(Charnley

VOL.

are

I. JANUARY

bone

and

fixation

1976).

stock

quadrilateral require further

1985

plaster

of a

is usually use of the

the authors fixator stabilisation

prefer

to

(Connes with

the

problems

pins

or the

198 1 ; Fidler

of intramedullary

surgical

If the

fracture.

to ream

commended

have

who

femur

and

tibia

of a secondary weeks

before

to

have

of

initial

stability

external

intramedullary

nail

and the nail itself needs replacement

nail

both

refuse

of a long

procedure

Ten

bone (Hankin,

sagittal

Hansen

arthrodesis

patients

process.

the metaphysial arthroplasties

and knee

insertion

is helpful. The

to control infection (Bigliani et a!. 1983), poor bone stock (Brodersen et a!. 1979) and unstable fixation (Hagemann et al. 1978; Vahvanen 1979). Large defects in

with

and

been

arthrodeses after unconstrained reasons for failure ofsecondary

The main are: inability

frames

1982). stock, of legs

major

arthroplasties. arthrodesis

anteroin a bio-

previously

The

enough

the

the

reported a fusion rate of between 25% and 100% when external fixation was used in arthrodesis for failed knee arthroplasty. The higher fusion rates were seen in

or

wound

this fixator

authors (Knutson and Lidgren for nailing include: poor bone overweight patients, relative weakness

arms,

fixation.

(1982)

the

1983).

by indications

fractures,

to

is poor

et a!. (l984a). In the were attempted with the hinge arthroplasty and We therefore advise the

(Brooker

technique

discussed

access

stock

especially in demonstrated

ventral

fixator

fixation

nail The

7).

DISCUSSION A

better

the bone

stability,

of additional

The

with

gives

Where

improved

1983; Fischer

5) and

fixed

therefore

Ace-Fischer

cancellous

movement which

use

level

(Fig.

More

radiographs

64 cm

proximal

original More

needs

bone

was

and

to the skin.

posterior plane. This has been mechanical study by Knutson present series three arthrodeses Hoffmann-Vidal fixator after two of them failed (Table III).

bone

brace

nail.

and

filled

proximally

1978)

(Fig.

a

allowed

the

migrated

(Klemm

trochanter

was

broke

large

ofcancellous

nail

but

a large

was

using

A dorsal

the

a wider, nail

a locking-nail the

negative.

A large

four

through

were

were

the cavity. around

and

cavity

There

cultures

in diameter.

replaced but

the

grafted

into

years

51

ARTHROPLASTY

plaster

operation

four

prosthesis

and

performed

resorption

The

for

was

18 months

grafted.

The

(Septopal).

multiple

arthrodesis

14 mm crest

replacement

again

later

After

(Fig. was

and

after

good

removed

beads

pus

appeared

was

reappeared.

tissue

gentamicin-containing

with

which

function

KNEE

from

the trochanter

arthrodesis fixation

is

tested

is a

may migrate a drill long

is a slow

is

usually

(Stulberg

re1982;

Thornhill, Dalziel and Sledge 1982) but healing time has been reported to be four to five months even in uncomplicated cases (Hagemann et a!. 1978; Brodersen et al. 1979; Woods et a!. 1983). We chose a four-month initial

period

of fixation.

If there

is delay

in fusion

should be no hesitation in grafting cancellous a pseudarthrosis is developing in repeating desis.

Provided

used,

the

the

second

chance attempt

(14 out of 17).

that

an

adequate

of success (4 out

in our

method series

of 5) as at the

there

bone,

or if

the arthroof fixation

was first

as good operation

is at

52

K. KNUTSON,

The

treatment

procedure,

of infected

using

has been shown

beads,

failures

temporary

that the initiation based on reliable

A. LINDSTRAND,

by a two-stage

to be safe. It has also been clear

of systemic cultures,

treatment with before starting

has been beneficial. Stable to help control infection and

institute fusion (Hagemann et al. 1978; 1979). When starting a two-stage procedure achieve good bone contact at the first operation be

possible

to

achieve

Vahvanen we try to so that it

fixation or by a support be contra-indicated. The

choice

arthrodesis

the

between

state

previous

a revision

the

type

the virulence

organisms

and

the

of and

the needs

major

failure

of

sensitivity

of the patient

and quality of bone desis was best when

stock. failure

an the

of adjacent the

knee,

the

primary

of any

infective

in the

et al. 1982). important factors

living (Thornhill One of the most

and

around

activities

is the

Revision

cases

of

to or

progressive to infection

arthroplasty failure,

was

insufficiency of a hinge considered

which

The

prostheses. arthrodesis

of pros-

primarily

especially if this infected compartmental

for

and

with long-stemmed All 19 cases in

fused.

factors:

condition

quality,

or muscles,

was

due to arthro-

plasties. A revision arthroplasty or an arthrodesis be performed early in the course of progressive in order to save bone stock. This is especially

should failure true of

was

attempted

main reasons revisions for infection, lems, cancellous bone

for this success were repeated careful attention to skin probgrafting and the repetition of

arthrodesis

types

operation

many

tissues

thesis.

external

arthroplasty

by

soft

the

by

a second

influenced patient,

of

surgery,

arthroplasty, daily

should

must be health of the

general

joints,

arthrodesis

bone

for mechanical technical error,

antibiotics, arthrodesis

to

poor

ligaments

gentamicin-containing

and bone transplantation fixation is important both

may

to

L. LIDGREN

using

stable

of fixation.

and especially those with rheumatoid the arms, suffer great disability from

Most

patients,

arthritis an unstable

pseudarthrosis of the knee (Knutson et a!. treatment of these patients is very demanding probably be concentrated at clinics which knee surgery and its complications.

involving painful

l984b). The and should specialise in

amount

We considered that arthroof the arthroplasty was due

This work was supported Foundation, and the number B83- 1 7x-4776-9).

by grants from Swedish Medical

the Greta Research

and Johan Kock Council (project

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