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Shoulder arthrodesis is one of the most effective treatment options for articular destabilization. If you do not take advantage of the possibilities of this operation in time, then the person is threatened with a complete loss of ability to work, a pronounced pain syndrome and a constant feeling of discomfort.
Features of arthrodesis
The main objective of the presented intervention is the immobilization of the problem joint in order to fix it in a permanently one state. After the surgical intervention is completed, the treated area will be an artificial ankylosis. Translated from professional terminology, this means articular ossification.
Such a radical move is in demand among patients who need to regain their former supporting ability in a relatively short time. This means that after the completion of the postoperative course of rehabilitation, the person can again expect the return of the ability to lean on the shoulder part.
The modern classification provides for several types of arthrodesis, which are divided according to the localization of the installation. Intra-articular and extra-articular options by their name already show the big picture.
The combined format is designed to combine the best elements of both solutions to help with extensive lesions or complex clinical cases. Lengthening and compression variations are considered separately.
The basic principle of the intra-articular approach involves the removal of cartilage, after which it is required to control the subsequent fusion of the bone surfaces. But with an extra-articular analogue, the cartilaginous surfaces are left in place. Instead, the bone structures are connected and then fixed with a high-strength special bone graft.
To implement a combined measure, you first have to choose the optimal bone graft, which will be fixed after excision of excess cartilage tissue. Also, the method often includes the need to add metal retainers to increase the reliability of the structure.
Until now, compression arthrodesis, which is known even to many ordinary people, is still a fairly popular offer. It is based on the bonding of bones when squeezing the articular surface. This compression is helped by various settings such as devices:
- Ilizarov;
- Grishina;
- Kalnberza;
- Volkov-Oganesyan.
The type of instrument is selected based on the results of a general examination, as well as taking into account the presence of some other articular damage with a different localization, which is typical of polytrauma. Most often, for the purposes of extensive compression, when, in addition to direct treatment of the shoulder joint, an identical intervention is required on the entire upper limb, the Ilizarov apparatus is involved. It began to be used fifty years ago and a more convenient assistant for establishing the correct compression has not yet been found.
The device is ideal not only for compression of the bone enzyme, but also for the subsequent long-term fixation for correct healing, and even for distraction, which involves therapeutic stretching. The lengthening type of operation is based on the need to make an artificial fracture. After that, the bone element is fixed again in a more physiologically favorable position. A suitable apparatus is mounted on top, which is designed to help with traction.
What kind of operation is best?
Only an experienced traumatologist can choose the best option for shoulder arthrodesis. To make a decision, the expert will necessarily take into account the information from the patient’s medical record, his individual characteristics, and the results of clinical trials. Finally, a medical indication helps to make a choice. So, for intra-articular intervention, the main indications are called:
- arthritis;
- arthrosis in remission.
But if the articular structure and surrounding bones are affected by a tuberculosis infection, such help will only go to the detriment. Here it is better to give preference to the extra-articular category. She will be able to block the aggravation of the process, its transition to the active stage.
When the victim was diagnosed with particularly extensive articular defects, it is more efficient to involve a combined system that can cope even with advanced clinical cases. She also proved to be excellent in situations where the working area of uXNUMXbuXNUMXbcontact of the articular ends turned out to be too small.
Also, the compression technique helps out if the lesion contains an infection, but the surgical operation can no longer be postponed for some reason.
The osteoplastic type stands apart, which is used very rarely due to a number of risks. It covers the use of donor tissues or autografts. But here the percentage probability of infection is too high. Also, no professional will ever give a XNUMX% guarantee of mandatory engraftment of transplanted cells.
Against this background, the compression method looks like a much more successful solution, as it has a number of positive qualities:
- reduced volume of surgical intervention;
- lack of subsequent mandatory plaster immobilization;
- accelerated fusion with properly set compression.
But even such an effective procedure has several negative aspects, the most important of which is the possible occurrence of pin osteomyelitis. The patient all the time has to worry about the integrity of the structure, since careless shifting of the rods is quite a common occurrence for compression equipment, even of a new type.
The reverse process will be no less unpleasant – dismantling the device, because it is usually accompanied by pain. To avoid possible negative side effects, the victims have to be under the supervision of medical personnel all the time. Regardless of the chosen class of arthrodesis, a person will have to come to terms with the fact that it will still not be possible to fully restore physical activity.
The operated joint will really be able to withstand the load and cease to cause pain.
But for such relief of the condition, you will have to pay with the deprivation of the articular articulation of most of the mobility. It is not for nothing that some people, at the end of the rehabilitation stage after the operation, are given a partial disability with subsequent disability.
Medical indications and contraindications
Since arthrodesis, even if successful, carries some negative consequences, they try to resort to it only after other options have been tried, but did not provide the desired effect.
The surgeon will insist on the need to go to extreme measures only after the impossibility of using the endoprosthetic technique is confirmed. Although the latter will cost more, it will allow you to maintain shoulder mobility at a completely acceptable level.
If we summarize all medical indications for different classes of the specified operation, then the list will look like this:
- arthritis, which is accompanied by a pronounced pain syndrome;
- arthrosis at the chronic stage of the course;
- osteoarthritis;
- improperly fused old fractures;
- congenital articular defects;
- dislocations of a pathological format;
- arthritis of a tuberculous nature, subject to intervention during remission.
Also, the list was supplemented by shoulder lesions that arose as a result of the spread of infections. The most common trigger for this is poliomyelitis.
Even though for many victims of articular destabilization, arthrodesis is practically the only solution to the problem, the procedure has a number of contraindications. These include:
- age restrictions (up to 12 years and after 60 years);
- the presence of non-healing fistulas that are of non-tuberculous etiology;
- outstanding inflammatory process with a high probability of formation of suppuration;
- general serious condition;
- infectious diseases of a systemic type;
- malignant neoplasms of any localization.
The surgeon also takes into account the fact that the ward suffers from diseases of the musculoskeletal system, which develop very quickly. Such pathologies usually include osteomyelitis, osteoporosis, osteopenia, and Paget’s disease.
How is the operation going?
Regardless of the chosen class of intervention, you will have to start the preparatory stage with a general examination. It provides for the delivery of a standard package of analyzes, the conclusion of narrow specialists, if the situation requires it. Possible latent contraindications, chronic diseases are also revealed. It does not do without an allergic test for anesthetic compounds, if a person has never been anesthetized before.
Approximately one week before the scheduled date, the victim should stop taking blood thinning medications. But here it is extremely important to first consult with the specialist who appointed them. Only after getting approval from him, you can postpone the approved therapeutic program for the benefit of helping the shoulder. The same should be done if the victim has previously taken non-steroidal anti-inflammatory drugs.
The day before the operation, you need to switch to the mode of taking only light food. And on the day of manipulation, you can’t eat at all. In total, the intervention will last from two to five hours. The exact time depends on the chosen treatment format and the degree of joint damage.
Anesthesia is chosen between general and spinal. The latter provides for the relief of pain exclusively in the desired part of the body.
If the choice is made in favor of an extra-articular approach, then an autograft from the scapula or humerus should be used for ankylosis. After that, the limb is retracted at an angle to apply a cast. It will keep for about four months.
When an intra-articular method is chosen, it is necessary to open the joint in order to cut off the cartilage tissue along with bone fragments. Only after that is fixation allowed. To increase the productivity of splicing, doctors take grafts, high-strength metal screws and special medical needles as a basis. All of the above is adapted for increased loads in the form of external pressure on the affected area. In conclusion, the wound surface is sutured, in order to then apply a plaster bandage on top.
Rehabilitation period
To alleviate the condition of the victim, the surgeon usually prescribes a number of analgesics at first. In the event of dangerous situations or suspicions of inflammation, antibiotics are additionally prescribed. You will have to walk with a cast for 3 to 6 months, depending on the dynamics of recovery. With slow healing, you need to walk with a bandage for about a year, periodically changing it and making a control radiograph.
For a speedy recovery, a person is additionally prescribed massage, exercise therapy, physiotherapy. Useful will be sessions of UHF, electrophoresis, magnetotherapy, laser therapy. This will help relieve inflammation, eliminate soreness and swelling. They will also work as a stabilizer of normal blood supply, activation of the mechanism of tissue regeneration in the operated area.
General rehabilitation usually takes about six months. But even after the recovery is completed, the patient will have to undergo regular check-ups to eliminate the risk of complications.
The main side effects immediately after the manipulation usually include bleeding and infection, which leads to the rapid development of osteomyelitis. A little later, deep vein thrombosis of the lower extremities or loss of sensitivity can manifest itself, which is typical with damage to the nerve endings.
Increases the likelihood of a negative scenario associated with chronic ailments, weakened immunity, smoking, the use of hormonal drugs. In rare cases, you have to repeat the manipulation, but usually everything goes well if you follow the postoperative recommendations.