Arthrodesis (Joint Fusion): What Arthritis Patients Should Know

Answers to Common Questions About Having a Joint Fusion

A group of surgeons.
What do you need to know about joint fusion surgery (arthrodesis)?. Morsa Images/DigitalVision/Getty Images

If your orthopedic surgeon has recommended a joint fusion (arthrodesis) what do you need to know? When is the best time to have this surgery done? What will it mean with regard to both your pain and mobility?

What Exactly Is Arthrodesis (Joint Fusion)?

Surgery is regarded as a "last resort treatment option" for joints severely damaged by arthritis. While joint replacement surgery has become an increasingly common procedure, especially for certain joints, not all affected joints are candidates for replacement.

Arthrodesis, also known as joint fusion, may be more suitable for ankles, wrists, thumbs, toes, fingers, and the top vertebrae in the neck.

The ends of two bones are fused together in arthrodesis with screw fixation and possible bone grafting, depending on the condition of the bone.

Indications: What Are the Reasons for Having a Joint Fusion?

There are several different reasons a joint fusion may be recommended. These include:

  • Joint instability
  • Severe joint damage caused by injury or disease
  • Pain with movement of the joint

The goal of arthrodesis is pain relief and regained stability and strength. The bones are aligned in the most functional position but do lose their natural motion. Let's look at some of the more common questions people have regarding joint fusion surgery.

At What Stage in the Progression of Arthritis Should a Fusion Be Done?

A fusion is usually done as a last resort after medications and other pain treatment regimens produce unsatisfactory results.

In other words, an arthrodesis is usually considered only after conservative treatments for arthritis have failed. The extreme pain which justifies fusion surgery is felt when bone rubs on bone after cartilage has significantly worn away. At this point in the disease, there is usually clear evidence of joint destruction visible on an x-ray.

Does a Fusion Relieve All of the Pain?

For the most part, a fusion will relieve the majority of pain a person has experienced due to severe arthritis in a joint. There are, however, a few caveats to this answer. The best result is obtained if there are no complications and if the surgeon is proficient with a high success rate, ideally having done the procedure many times. Failure to place the ankle in the "optimal position" could lead to a poor clinical result.

How Much Joint Motion Is Sacrificed for Pain Relief with a Fusion?

Essentially all joint motion is usually sacrificed when a joint fusion is performed, as the joint is placed in a fixed position. With an ankle fusion, if the ankle is fused in the optimal position, some compensatory increase in motion can be expected at the midtarsal joints. Rocker bottom shoes are usually recommended to compensate for the loss of motion if it is bothersome.

How Long Must You Be Non-Weightbearing After an Ankle Fusion?

Following an ankle fusion, you will need to be non-weightbearing for a period of 6 to 12 weeks, and this can vary depending on several factors. Following your ankle joint fusion your doctor will follow up with x-rays, and unprotected weightbearing can begin only after some bone striation is visible on x-ray at the site of fusion.

How Long Will You Need a Cast After a Fusion?

The average immobilization time until all casts are removed is between 4 and 7 months. The pins are not removed if the internal fixation operative technique is used. There also are external fixation techniques, as well as arthroscopic arthrodesis.

What is Walking Like After an Ankle Fusion?

For people with a well-aligned ankle fusion, the walking gait in an appropriate shoe (obviously high-heels are out!) is nearly normal. Your gait may appear to be stiffer, but this is usually subtle, and it feels normal. Running or walking on uneven ground is made more difficult.

Finger and Toe Fusions

You have probably seen or heard more about ankle fusions, but fusions of other joints can also be very effective in relieving pain due to arthritis or injury. Fusion of fingers or toes is not considered a difficult operation, but the period of recuperation is long and arduous. As with the ankle or any joint being fused, motion is sacrificed for pain relief and stability. Some function can possibly be restored with the increased stability.

Wrist Fusions

If you are considering a wrist fusion, and have heard about ankle fusions, you might be wondering how much movement will be possible. Will you still be able to write and type? The answer will depend largely on the particular individual and the condition of their fingers prior to surgery, as the motion needed for writing and typing comes mostly from the fingers, not the wrist.

Complications of Joint Fusion

As with any surgery, infection is a possible complication, as well as wound dehiscence (splitting open at the incision line). A failed fusion is also a possibility, whereby the bone ends do not completely fuse despite fixation. A condition known as osteopenia may compromise fixation.

Other possible complications include persistent pain at the fusion site, injuries to nerves during the surgery, and broken hardware that must be replaced. Complications of ankle fusion surgery are higher in people who smoke, and smoking cessation should be strongly considered prior to having this surgery.

Ankle Fusion vs Ankle Replacement

Since both an ankle fusion and ankle replacement can bring relief from pain and regained stability, and more motion is retained with an ankle replacement, why might ankle fusion be a better procedure? A major concern with ankle replacement surgery is the failure rate of ankle replacement prostheses. In contrast, there appears to be an 85 percent success rate with ankle fusion in people with rheumatoid arthritis. Reoperation rates are also lower with an ankle fusion when compared with ankle replacement surgery.

Bottom Line if You Are Considering an Arthrodesis (Joint Fusion)

A joint fusion can bring relief from the constant pain of arthritis and strengthen a joint, but this pain relief is exchanged for the loss of mobility. That said, an arthrodesis is not usually considered until very significant damage to a joint has taken place and medications and other pain relief measures are no longer effective. An alternative to ankle fusion is an ankle replacement, but with severe arthritis, the chance of success of surgery is often higher with a joint fusion.

It's important to carefully discuss all of your options and the risks and benefits of each with your orthopedic surgeon and rheumatologist. Every person is different, and what worked the best for another person may not be the best choice for you. Ask a lot of questions. You may wish to ask your orthopedic surgeon if you can talk to someone who has previously gone through the procedure. Due to confidentiality laws, your doctor would need to get consent from another patient to arrange this, but many people who have battled the same challenges you are today are anxious to pass on what has helped them in their journey with arthritis.

Sources:

Kim, J., and S. Patel. Is It Worth Discriminating Against Patients Who Smoke? A Systematic Literature Review on the Effects of Tobacco Use in Foot and Ankle Surgery. Journal of Foot and Ankle Surgery. 2017. 56(3):594-599.

Morash, J., Walton, D., and M. Glazebrook. Ankle Arthrodesis Versus Total Ankle Arthroplasty. Foot and Ankle Clinics. 2017. 22(2):251-266.

Wheeless’ Textbook of Orthopaedics. Ankle Arthrodesis. Updated 08/25/16. http://www.wheelessonline.com/ortho/ankle_arthrodesis

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