Arthrodesis of the shoulder joint is one of the most effective treatment options for destabilization of joint activity. If the time does not take advantage of the possibilities of this operation, then the person faces a complete loss of working ability, a pronounced pain syndrome and a constant feeling of discomfort.
Features of arthrodesis
The main objective of the intervention presented is the immobilization of the problem joint in order to fix it in one constantly state. After the surgery is completed, the treated area will be an ankylosis. Translated from professional terminology, this means articular ossification.
Such a radical move is in demand among patients who need to return their former support 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 opportunity to rely on the shoulder part.
Modern classification provides for several types of arthrodesis, which are divided according to the localization of the overlay installation. The intra-articular and extra-articular variants in 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. Separately, extensions and compression variations are considered.
The basic principle of the intra-articular approach covers the removal of cartilage, after which it is necessary to control the subsequent merging of the bone surfaces. But with extra-articular analogue, the cartilaginous surfaces are left in place. Instead, the bone structures are connected, and then fixed by means of a high-strength special bone graft.
To implement the combined measure, you first have to find the optimal bone graft, which will be strengthened after excision of excess cartilage tissue. The method also often includes the need to add metal clamps to increase the reliability of the design.
Until now, compressed arthrodesis, which is known even to many philistines, is listed as a highly sought-after offer. It is based on the bonding of bones when squeezing the articular surface. Various installations like devices help with this compression:
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 joint damage with a different location, which is characteristic of polytrauma. Most often, for purposes of extensive compression, when, in addition to direct treatment of the shoulder joint, an identical intervention is required on the entire upper limb, an Ilizarov apparatus is involved. It began to be used even fifty years ago and a more convenient assistant for establishing the correct compression was not found so far.
The device is ideal not only for compression of the bone enzyme, but also for subsequent long-term fixation for correct healing, and even for distortion, providing for therapeutic stretching. The lengthening type of operation is based on the need to make an artificial fracture. After that, the bone element is fixed anew in a more physiologically advantageous position. Mounted on top of a suitable apparatus, which is designed to help with traction.
What kind of surgery is better?
Only an experienced traumatologist will be able to choose the best option for shoulder arthrodesis. In order to make a decision, the expert will necessarily take into account the information from the medical record of the patient, his individual characteristics, the results of clinical studies. Finally helps to determine the choice of medical indication. So, for intra-articular intervention, the main indications are called:
- arthrosis in remission.
But with the defeat of the articular structure and surrounding bones by tuberculosis infection, such assistance will only be detrimental. 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 a victim has been diagnosed with particularly large articular defects, it is more effective to involve a combined system that can cope with even running clinical cases. She also showed herself well in situations where the working area of contact between the articular ends was too small.
Also, the compression technique helps if the lesion contains an infection, but it is no longer possible to postpone the surgery for any reason.
A special case is the osteoplastic type, 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 an absolute guarantee of mandatory engraftment of the transplanted cells.
Against this background, the compression method looks like a much better solution, since it has a number of positive qualities:
- reduced surgical intervention;
- the absence 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 spoke osteomyelitis. The patient always has to worry about the integrity of the structure, since the careless shift of the rods is quite a common phenomenon for compression equipment, even of a new type.
No less unpleasant will be the reverse process - dismantling the device, because it is usually accompanied by pain. To avoid negative possible side effects, 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 accept the fact that it will still not be possible to fully restore physical activity.
The operated joint will indeed be able to withstand the load and will cease to deliver pain.
But for such relief, the condition will have to be paid off by depriving 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 exposed to partial disability with subsequent disability.
Medical indications and contraindications
Since arthrodesis, even if successful, carries with it some negative consequences, they try to resort to it only after other options have been tried, but they have not provided the desired effect.
The surgeon will insist on the need to take extreme measures only after it is confirmed that it is impossible to use the technique of endoprosthetics. The latter, albeit more expensive, but at the same time allows to maintain the mobility of the shoulder at a quite acceptable level.
If you summarize all medical indications for different classes of the specified operation, the list will look as follows:
- arthritis, which is accompanied by a pronounced pain syndrome;
- arthrosis at a chronic stage of the course;
- incorrectly accrete old fractures;
- congenital articular defects;
- dislocations of the pathological format;
- arthritis of tuberculous nature, subject to intervention during remission.
The list also supplemented lesions of the shoulder, which arose due to the spread of infections. Most often, polio becomes a provocateur for this.
Even in spite of the fact that for many victims of articular destabilization, arthrodesis is practically the only solution to the problem, the procedure has several contraindications. These include:
- age restrictions (up to 12 years and after 60 years);
- the presence of non-healing fistulas that have a non-tuberculous etiology;
- outstanding inflammatory process with a high probability of formation of suppuration;
- general serious condition;
- systemic infectious diseases;
- malignant neoplasms of any localization.
The fact that the ward suffers from diseases of the musculoskeletal system that develops very quickly is taken into account by the surgeon. Osteomyelitis, osteoporosis, osteopenia, Paget's disease are usually referred to as such pathologies.
How is the surgery going?
Regardless of the class of intervention chosen, the preparatory stage will have to begin with a general survey. 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 identified. It is not complete without an allergic test for anesthetic compositions, if a person has never previously received anesthesia.
Approximately one week prior to the appointed 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 receiving approval from him can an approved therapeutic program be postponed to the benefit of helping the shoulder. Likewise, you need to do if a previous victim took non-steroidal anti-inflammatory drugs.
The day before the operation, you need to switch to the mode of receiving extremely light food. And on the day of manipulation you cannot 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 in only the right part of the body.
If the choice is made in favor of a non-articular approach, then for ankylosis, you should use an autograft from the scapular or humerus. After that, the limb is retracted at an angle in order to apply the plaster. He will hold on for about four months.
When the intra-articular method is chosen, it is necessary to open the joint in order to cut off the cartilage tissue together with the bone fragments. Only after this fixation is allowed. In order 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. Finally, suturing of the wound surface is performed, so that later a plaster bandage is applied over the top.
To alleviate the condition of the victim, the surgeon usually prescribes a number of analgesics for the first time. In the event of a dangerous situation or suspected inflammation, antibiotics are prescribed. Walking with gypsum will have from 3 to 6 months, depending on the dynamics of convalescence. For slow healing, it is necessary to walk with a bandage for about a year, changing it periodically and making a control radiograph.
For speedy convalescence, in addition a person is prescribed a massage, exercise therapy, physiotherapy. UHF, electrophoresis, magnetic therapy, laser therapy sessions will be useful. This will help reduce 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 is usually about six months. But even after the recovery is complete, the patient will have to undergo regular checkups to eliminate the risks of complications.
Major side effects immediately after manipulation usually include bleeding and infection, which leads to the rapid development of osteomyelitis. A little later, thrombosis of deep veins of the lower extremities or loss of sensation, which is characteristic of damage to nerve endings, can manifest itself.
Increases the likelihood of a negative scenario associated chronic diseases, weakened immunity, smoking, use of hormonal drugs. In rare cases, you have to repeat the manipulation, but usually everything goes well, if you follow the postoperative recommendations.