COMPRESSION

ARTHRODESIS
JOHN CHARNLEY,

OF

THE

ANKLE
ENGLAND

AND

SHOULDER

MANCHESTER,

the

Success with arthrodesis of the writer to describe his experiences The application of compression

knee by compression (Charnley 1948) has now prompted with compression arthrodesis in the ankle and shoulder. to arthrodesis of the ankle and shoulder is more difficult

than it is in the knee, be described perhaps orthopaedic procedures to complicate essentially explored osteogenesis operative simple. and, unless in the

and the writer does not wish to minimise the fact that the methods to demand a little more mechanical aptitude than is necessary in most ; on this account there may be some who will deplore any tendency procedures, in the the belief that all the great operations of surgery are But practically all some revolutionary surgeons power, elaboration classical discovery advance operations of surgery have is made which will put the is likely which to come from now been control of

no great

modifications grafting would

of their detail. For the same

reason

the

of techniques

depend

on bone

also seem to have a restricted future, with the exception of a few instances, notably that of the Brittain operation in the hip, where the function of the graft seems to be in harmony with some natural trend in the architecture of the skeleton. Experience with the tibial graft during a quarter of a century, following the pioneer work of Albee in the shaping and fixing of this graft, has shown that the fate of cortical bone is unpredictable ; these grafts sometimes fail to unite, sometimes fracture after union, sometimes fail to heal when fractured, and at
all

any lack

times are slow to become incorporated. In the phenomenal ability to bridge the moving zone of rigidity has been supplemented by metallic recently ; but

same way cancellous of a joint line either internal fixation. that an it obvious

bone has not shown by itself or when its bone-graft osteogenic only living of the bones was powers living

Until osteogenic

the idea has further experience almost non-existent direct

been has and union

prevalent now made that

autogenous that the is a property

of a bone graft are bone of the host. In compression

osteogenesis

arthrodesis

is achieved

between

the

forming

the joint surfaces without the intervention of an inert is to eliminate all shearing strains as well as preventing Under these conditions the healing of a compression the healing of an accurately coapted skin with the production of callus. Technical researches in compression procedures will become more complicated; early part of their career, and with the techniques will offer no danger that sufficient attention is paid procedures have been described coming when the principle no surgeon and in the
will

graft. One of the effects of compression a gap between the cut hone surfaces. arthrodesis is more aptly compared to to the union of a displaced fracture

wound

than

arthrodesis but with protection

make surgeons now

it inevitable that operative specially trained to this at an by antibiotics, elaborate

afforded

in the hands of the orthopaedic surgeon of the future, provided to the minutiae of the technique. For this reason the technical here in minute detail to emphasize the fact that the time embark on a new procedure of himself improvising the ARTHRODESIS OF surface which sight, THE with details. ANKLE talus and the lower surface only a general knowledge

is of

hope

In order

to gain

free

access into here

to the plane may,

upper

of the

of the

tibia, so as to shape them the approach advocated

180

surfaces at first

can be exactly coapted under seem unnecessarily destructive;

THE JOURNAL OF BONE AND

compression, but before

JOINT SURGERY

COMPRESSION

ARTHRODESIS

OF

THE

ANKLE

AND

SHOULDER

181
problem experiments approach. numerous were

it

was

finally were with the

decided made on following

that cadaveric

this exposures:

method as well as

provided on living anterior 1) The

the

best midline

answer In

to this

the way

trials made

subjects.

longitudinal

The

1..
Flie
td)

1 By
This

problem
restore

of the

arthrodesis alignment of

of

the the

ankle talus

in to

mal-position. the tibia.

this

technique the

it

was correction

possible of

necessitated

45

degrees

of inversion

of the

talus.

FIG. Position six months after

2 Early
evidence of bone union.

operation.

lateral lateral as to
\OL.

approach, approaches, compression

with with arthrodesis.

resection resection

of the
of

lower both

end malleoli,
found

of

tile

fibula. way of

3) The described these anterior

combined by incision. Anderson

medial

and

in the that none a transverse

(1945)
lent itself

concentric the

But as

it easily

was

approaches

technique
2,
MAY

as

did

Compression

33

B,

NO.

1951

182 can Potts be applied, fracture though

normal,

J. with
but

CHARNLEY

difficulty,
it is when

through
the talus

any
lies

of the that idea

and

standard

incisions
as after

when
an

the

ankle

is anatomically

in malalignment,

unreduced

or an epiphysial (Figs. can

tendons,

injury

disturbing

growth, against the

vessels

the advantages of a transverse

nerves and the

of the
inCision,

transverse
dividing branches

incision are appreciated Numerous arguments

as it does the extensor

1 and 2). be advanced

the anterior

tibial

terminal

of the musculo-cutaneous be argued: 1) that the be an exceedingly might be a serious disagreeable nature,

suture

nerve ; but in practice all have proved insignificant. of the divided tendons at the conclusion of the
2)

Thus operation

it can would

tedious and irksome procedure ; loss to the circulation ; 3) that may result : 4) that the

that division of the anterior tibial artery anaesthesia of the toes, of a particularly of the Steinman nail from the ends

emergence

of the skin incision is undesirable because it offers a communication between the skin wound and the arthrodesis line. In practice all these fears seem to be without foundation ; there is no permanent anaesthesia after the operation, and the circulation in the foot is unimpaired.

Technique
Skin incision-The

the the

other. line

incision It is important
distal compression

crosses to start
pin,

the and
when

front finish
the

of the exactly
wound

ankle over line make

from the tip the extreme

will not

of one malleolus to tips of tile malleoli;

emerge by easily the from

otherwise

the

is sutured,

of the between

incision. the two

Instead malleoli,

of passing

in a straight to the malleoli the tendon skin wound fall

across this

the incision

ankle curve

shortest

distance mid-point, tendons incision direct

Section

it is important

distally

at its of the the skin until anterior, the

because the direct line between and this precaution therefore avoids (Fig. line
of the

is to sutures

be the line of section lying directly under up as a flap : 1) tibialis

3).

The the

proximal

edge

of

the

is dissected into three groups

between

tendons-The

malleoli is reached. tendons to be and 3) all as one unit. are passed

divided

2) extensor hallucis longus peroneus tertius considered sutures of the Bunnel type the sutures approximation
is treated as

parts The before

of the extensor communis digitorum intended line of section is identified the tendons are cut (Fig. 4) The
.

and the and thread passage of

can
a

be done very quickly of the extensor tendons

single tendon and is

because there is no need for any at this level. The group of common
transfixed by one suture. It

very meticulous extensor tendons

to discard

is important

the

distal toes.

part

of peroneus

tertius

as this

will

obstruct

the

action

of the

combined

tendon

on the
Opening

the joint-The

ligation from
Defining

of the one
the

divided

incision anterior other.

is deepened in the direct tibial vessels the capsule flap of the joint capsule

line between of the joint is now

the malleoli and after is opened transversely from the front of

malleolus
malleoli-The

to the

proximal

elevated

the tibia laterally malleoli of the to the

Sawing

for and

about half an inch by sharp medially until both malleoli

dissection. are exposed

The and

subperiosteal exposure is carried until the posterior edges of both

margins

are within reach. This is the crucial malleoli are accessible the subsequent soft
the

step in the operation; unless the posterior steps will be obscured and there will the calf and amount the foot left unsupported which for a shoe joint just

be danger posteriorly,
it is hoped

parts now

when holds

talus--With

the saw is used. a sandbag under the final saw foot so that

the

assistant

it is in the

of plantar-flexion

to perpetuate in the ordinary amputation talus talus emerges are sawn

to

arthrodesis; this should be enough to allow is now started across the front of the ankle margin of the tibia (Fig. held exactly at right angles
the malleoli lest
THE

heel. where and tibia.

them

An the the It
be

from below the anterior through, with the saw

saw completely through

5). The malleoli to the axis of the

lying
BONE

is dangerous

the

tendons
OF

behind
AND JOINT

JOURNAL

SURGERY

((IMPRESSION

;RiHRODESIS

oF

THE

ANKLE

ANI)

Sll()ULI)ER

183

ligIlIt iuteude(l

-(out

ilII1OLIS of

hIlt in sccti(

in(licat(s in.

the Figure of the

line

tel)d

skIn 4 -Runuell ten(Ious.

1I1CIS100. sutures

I )ottcd
10 posItion

hue

lu(Ilcatus

the section

1)efur(

FIG. Figure position Figure 5-----LIne the saw

5 cut. the lo talus show j ust

FIG.

FIG.

of first saw cut touches

this the foot has l)een at its point of emergence

6-Showing
and

the

appearance

after
apl)lied.

removal
Note

of
the

the
hair-line

lower

compression

slightly jlantar-flexed but in the correct below the anterior margin of the tibia. end of the tibia. Figure 7-lins inserted fit of the opposed surfaces.

VOL.

33

B,

NO.

2,

MAY

l95J

184

j.

CHARNLEY

damaged, surfaces. care foot of the upper

Sawing

and the saw should Because the medial

therefore malleolus

be stopped within a quarter of an inch lies in a more anterior plane than the
will

of their lateral

posterior malleolus

must be taken is now forcibly unsawn aspect

the lower

not to deepen plantar-flexed of the talus.

of the tibia-In

the saw cut as much and the ankle joint A flat the and rectangular

on the inner side as on the outer. The open like a book by the fracturing cut position surface of the of an inch will foot, thick, now tile be seen lower on the end both of

portions of the
end

malleoli.

plantar-flexed about

the

tibia

is completely

exposed

a slice

a quarter

including

malleoli, must now be carefully sawn off. Care must be exercised of the tibia is being reached because of the important structures should be cracked off before the posterior cortex is cut and the should test the malleoli
posterior Insertion

when the posterior cortex lying behind it. The slice projecting bone left behind up to a right angle to of the tibialis passed skin.

be nibbled apposition should be

and of peroneal the

away

with

bone

forceps.

The

foot

is now

brought

of the cut preserved

tendons nail-The

bone surfaces (Fig. 6). If possible the distal fragments as they provide the natural pulleys round which the
pass.

distal

distal the open

Steinman wound

nail, without

through any attempt

the

talus, to pierce

should

be

first.

It

is passed

through

adjacent

It should be passed slightly anterior to the axis of the talus because the compression force will hold the anterior edges of the arthrodesis closed while the pull of the Achilles tendon will keep the posterior edges closed. It is important to see that the nail is clear of the subtalar joint, and that it is at right angles it can
Passing

to the axis be corrected

the proximal

of the tibia as seen in the front later by the range of adjustment

nail-The

view. (Any rotary error provided in the clamps.) are now attached lower end of the trocar point to tibia. will

is unimportant the It often distal nail is important split

as so

as to guide to use if driven nails

the which

second have

nail
drill

compression clamps in parallel through the points, because the

simple

a tibia

in with a mallet. Closure-The screw clamps are now tightened until the nails are slightly compression force and the firmness of the arthrodesis is tested by attempts to on the tibia (Fig. 7). If any error in rotation is detected at this stage it can releasing the compression, twisting the foot into correct relation with the retightening sutures and cover light plaster not necessary Post-operative the clamps. The tendons are now approximated the skin is closed in one layer. Dressings are applied, and a pressure for bandage comfort dressings is applied and before the of untouched case is advisable for fixation. management-The
permanence

bent under the move the talus be adjusted by tibia and then the appropriate layer of wool is released. though weeks; to A it is during

by

tying a thick dressings for four

everything,

tourniquet the

are

left

this time the patient is confined to a bed or couch, and is not allowed to hold the ankle in a dependent position. After four weeks the pins are removed and a walking plaster is applied for another four weeks. At the end of this time, that is, eight weeks after operation, plaster is discarded and the patient allowed to start rehabilitation, and he should be fit for light work three months from the time of the operation. Results
The writer has now performed this operation nineteen times in three years. The results

have first case and

been most ten cases. mid-tarsal mid-tarsal

In four cases

encouraging The end-results

even though the were excellent

technique was in all nineteen existed

The

subject cases the

to many changes except one, and operation

result

in the in this

arthritis was later found fusion had to be carried

bony fusion failed

to have out later.

place.

before
functional

and

a subtalar
four fibrous

to take

of these

unions

was,

however,

practically

equivalent

to bony
THE

fusion;
JOURNAL

the
OF

reason
BONE AND

for
JOINT

this

seems
SURGERY

COMPRESSION

ARTHRODESIS

OF

THE

ANKLE

AND

SHOULDER

185
loose where was to form tile inadequate. tibia a

to

be

that

the

closely Two

applied of the proximal four pin

flat

surfaces to get where,

of

this bone

fusion fusion the

cannot occurred compression

work in cases force

pseudarthrosis.

failures and

had

been

split

by

the

therefore,

---

Case

2-Radiographs

six

months

after
established.

operation.

Trabecular

continuity

is

In and
for

the
tile

remaining talus line

to of

two was the

technical

cases quite

of

fibrous

union

tile

talus the Thus

was

not

accurately being in both

to get

fitted cases bony

to

tile

tibia could

never

immobile
to gape in

against
front.

tibia-there

a tendency union

the
traced

arthrodesis
errors.

all

four

failures

be
VOL.

33

B,

NO.

2,

MAY

1951

1 86 From
this joint

J these
does

CHARNLEY

experiences
not possess

with
the

compression
same natural

arthrodesis
potential for

in the
bony

ankle
union

it would
as exists

appear
in the

that
soft

cancellous

bone

of the

knee.
it stands

The of the
in

narrow talus
marked

latitude often much shows

contrast

for
to

technical
the cut

error
surface

probably dense
of the

follows and
lower

from
end of

the fact that the cut bone ; in this respect the end tibia, of the In the and though
of the

surface even
ankle

it to be a remarkably than
suggests

bloodless upper cases

months

this shows
the cut

is very red
surface

harder and
talus

is the
that

cancellous structure.
it might

bone In
even

at the some six

has

tibia,

it always

marrow
of the

a cancellous after operation,

of

osteoarthritis

be ischaemic. taken

radiological

examination

of these

ankles

it takes

at least

for trabeculation place the line union union because, is already

to be seen crossing the line of the fusion. \Vhen fibrous union of bone apposition becomes sclerosed and this fact is useful in predicting so long present, as there is no sclerosis and that trabecular
ARTHRODESIS

osseous

at six continuity
OF THE

months, will

it can eventually

be inferred that osseous follow (Figs. 8 and 9).

SHOULDER

Principle-In glenoid fossa under it has

is

arthrodesis

of

the

shoulder

the

discrepancy

between

the

small

size

of

the two,

and

the

large

size

of the

humeral

head

makes

stable

apposition

of the

a compression been found

against

force, possible of the

it lies upper three

a precarious and to secure stability

uncertain feat. In under compression, and

: the three

the method if the head forwards,

bony stability. structures

to be described of the humerus it will take

form,

compressed

If the
position in front,

head
and the

the scapula humerus

snugly part of

in a subluxated position. is displaced slightly upwards

between the three glenoid bony below. points These

up
as

a
it

in which

acromion

above,

the

coracoid

were, contact of the

easily

a hollow of bare acromion

denuded

pyramid
find

into
points

which the

the head

head
contact

of the
and

humerus
considerable

can

be driven only
coracoid

and
In

where
practice,

it will
the be

automatically

of bone

bone and
of the

against the
soft the joint

of the of the
it. the

humerus glenoid,
Despite and parts this,

is possibly because
the
tile

at the
process

under-surface
cannot

upper
tissues two the areas

part
covering

coracoid

still

offers

an important

anterior
losing In

buttress
contact the with shoulder

and

prevents

the

head
on

of the
glenoid

humerus

from
acromion. does not

slipping
lend

forwards
itself to an

and
ideal

thereby
design

configuration

of the

for compression coapted

overcome-and compression

arthrodesis-that an extensive
with

is, one in which area, as exemplified

as results have

the surfaces in the knee

shown-by

of cancellous and ankle.

producing

hone This
bony

are accurately can

under

over

handicap
union

be

success,

of contact. places on mechanical

at two separate points, even though these points The essential feature seems to be that these two the humeral head and together they thus achieve,

each possess only a small area points are at widely separated in some measure, one of the base. The humerus thus becomes

effects

of contact

over

a large

area,

that

is, a wide

adherent to the scapula in a way which is able to resist the strains of adduction and of rotation, without a tendency for the arthrodesis to work loose and form a pseudarthrosis as happens when a single point of contact coincides with the centre of movement. In this operation the only axis of movement which both points of contact; this axis extension. It is worth emphasizing adduction directions in front By found method humeral is unstable is that which corresponds roughly with that in this arthrodesis passes simultaneously through the movement of flexion and the movements of abductionthese are the

and of rotation are both strongly resisted; this is important because in which the shoulder is under the greatest strain when the patient of the body with the elbow at right angles and the forearm horizontal. a recent and easily performed addition to the compression technique,

lifts
it

a weight
has been

possible to strengthen the end-result even further by combining it with the Putti of arthrodesis. In the Putti arthrodesis the greater tuberosity is split away from the head so as to allow the tip of the acromion to be inserted into the cleft. This ancillary
THE JOURNAL OF BONE AND JOINT SURGERY

COMPRESSION

ARTHROI)ESIS

OF

THE

ANKLE

ANI)

SHOULDER

187

prc(It1r( of l)ofle afl(1

for
;is

(lOts
contact,

Ilot

l)trticil)tte
it

ill

the
under

rapid the

fusion

\ViHCi)

is

shared

by
there

the tue

two

other
of

J)Oiflts contact

i)eCallse

is

not

conipression,

but

as

it illcreaSes

area

it

is S() easily
it in

comi)ifled rolltille

vith (Fig. 10).

CompreSsioll

technique,

seems

e\erv

reason

retailllllg

the

Technique
IOSit?OJl

Before of til( l)(rtti1 sittiflg the the -ihe

acronliOn.

operation can
J)OsitH)fl

a 1)it5t(r 1w (ISilV
ill a IleIltal

j acket
converted chair incision

is

;tp)lie(l
into

so ci al.

thtt

an
siic:t.

arni

J)iaster lilti patient i);tck

;tp)lie(1
is

;it

tilt

end
OIl ill

a shoulder

operated the outer

tiit

(.-\hbott
is

1949).
fronl front to

.c/ti,l

ZUC1S100 of

sai)re

cut

used

)assing

over ied\e

edge Ii().i()
i)Ofle

-Iiit (I(ltOid
of

is (letached of the as possil)le

froni down the

the

acronlion

1)1,

sharp

(IiSSe(tiOIl
of

50

tS

to

the

ra

outer

j)art

acromioll

eXpose(I. anterior

ihe and

capsule
J)osterior

the
;tsl)ects

siloulder
until

joint the

is iIlCiSe(i head of
tiit

and

eXt(Ild((I

as far

I-u;. SI
(WIng art t lie hirodesis Iliet

I (I
compression techniq ue. \iew of t lie

lo.

11
from above

1(1(1 (if ci mblnlng

with

I utti

the

the shoulder position of

t(

Indicate

the

coull)ression

Pins

liulilerus

Can

IX retracted
()/ 1/it 1)O1l\

downwards
Sl(lf((CtS-lile

alul

outvards fossa is

to

reveal (Ienucle(l

tue of

depths
cartilage

of

the
vitii

gienoici
a ide

fossa.
gouge

Prepaialion
after
OsteOtOlll(

gienoid dissectt
surface.
sui)acromial tile humerus

till

glenoid ()tt wide which lo do

surgeon
at

iai)rulll

has illtO

been
tile

d away. iiie bursa

is

File under-surface and

now

cancelious
of

bone the

is opened is

up

with

;tn i)\

1)i, cross-cuts the

gouge.

acromion
substance

(XpOSe(l

(hssecting with Ta tested. while It incorporating it will against for

is tile

remains The

()f tile head of

its

cancelious

is

exposed

a
Ill

denuded forearm
ilis IlIlger.

of articular to vhich in
strength it is to

cartilage
i)e fused

and
is

tue
now

it will gain this

apposition holds
points

against the
of

the arm

surfaces with

the assistant
explores tile

and

the

position
of

of arthrodesis final added riding acromion. on again

tile

contact

is be the

this the

point Putti that, edge surface

that fusion in the of the

tile

possihiiitv can be assessed.

of increasing If tile the tile tue prevents with outwards

now
tile

the summit Ilead

the for this

fusion detail,

i)V

case

is favourable of of the surface

an snugly osteotome under

found outer tile that

arthrodesing acromion firm must that is received

tuberositv.

position, and contact be split

tile head

tile of

great humerus tile and

tile

tuherositv

abuts upwards If and head this in of trying

its
tile

denuded
case

to make tuberositv be found

deep with

great it will the

and

tile

apposition

reaches

acromion

addition the
VOL.

acromion
tile
MAY

into

upper

end

of

the

cleft

between

humerus

detached 1951

33

B,

NO.

2,

188
Insertion

J. CHARNLEY of the compression nails-The

of the

operation nail

the

details

of this The

proximal nail is inserted manoeuvre must be studied nail is passed through the

first. closely. outer

Because
In

it

15

tile

crux

a thickset

patient

a ten-inch

is necessary.

inch

of the

clavicle

and

Showing

position

of

compression

clamps.

FIG. Case

14
injury. month after Figure operation 14-Plaster sustaining spica and abduction

FIG. compression without

15
clamps discomfort. in position.

3-Old

brachial Figure

plexus 15-One

directed

backwards,

outwards

and

downwards.

It

traverses

the

supraspinous

fossa

and

pierces

the

thick

part

of the

spinous

process

of the

scapula
for

just
this them
JOURNAL

where
nail the
BONE

it springs
to wound of body
AND

out
any the
JOINT

of
scapula.

the

blade of the scapula. important structures

It will be seen that it is impossible in the axilla as it is separated from

THE

of the

by
OF

SURGERY

COMPRESSION

ARTHRODESIS

OF

THE

ANKLE

AND

SHOULDER

189 three of
different

Tills planes,
when

rather is not
tile

complicated difficult is held

tilat

spatial to in the
of

direction arthrodesing

of

tile

nail, by (Figs. 3) with tile that parallel

involving

as

it

does position

estimate the

if it is checked position and found roughly

its relation

to the

the

arm

latter

recommended

arm
tile

should
coronal about humerus 45

be held:
plane; degrees and it will i)e

1) in 45
above

11 to 13). For this degrees of abduction;

the the
humerus externally

45
that at right

degrees
the angles

in
forearm

front

PtlII)05e it is 2) advanced rotated so

elbow be is held passed at

is inclined axis of the

horizontal proximal to tile

axis

when

the must the

a right angle.
to tile

In this position

nail
of

forearm.

Ihe
compression

second
champs

Ilail

is

now

passed

tilrough

tile

upper

end

of the

humerus.

To guide

do tile

tills

tile

are attached direction.

bone
a nail

to tile It shaft
only than

first

nail

so that this is The

very

it will automaticahl nail should be dense and only direction

to as far
tile

second

nail
point

in a parallel
because
to i)e

is important of the a trocar

nail

that humerus point.

is its

provided split must

The

with

a drill

tile
on

of

tile

has enter

used

with

it may which

if the mallet be carefully

nail should

watched surgical of its

tilougil

in
slightly neck wounding
at

tile

insertion higher in humerus

of the
front

second

inclination

Ilorizontal.

its

point at this

of exit level

behind. lies medially,

It

should in the

pass
tile

as near
remote

to tile
chance bundle,

of tile the

as possible

so as to diminish

as possible

radial

nerve,
from

which
the nail.

neurovascular

a safe
NO.

distance
MAY

\OL.

33

B,

2,

1951

19()
Tightening

J. the clamps-On
quite
all(l

CHARNLEY

tightening

tile of

champs

tile alld

arthrodesing rotation

position

should altered angle by which

i)e cilecked. releasing cannot in front

tiit

If not clamps

satisfactory,
fllO\iflg tile

the is that which

degree

abduction

can lhe the nail proximal

be only

humerus

in controls

tile

desired the amount This

direction. v1uch proximal from Ilead

has

be
of

reset at this stage the coronal wrong to not

tile screwed of
tile

elbow must in
so fixation from a

is advanced Ilail and

Plane;

this is governed

by the
in

the siting of tile is viewed

tile

if it is seriously

this nail will have

aXIS

to be reinserted.
when

al\Va\s lie transversely (Fig.

of

tile

hUmertls clamps consecutive

patient
which and tile flhigilt tins

above
tile

Ii);
ilsed,

if this the
tile

detail
sitillg

is of
are

observed In
nails up

the
four has

will
no

not
cases

compress

humeral
operation

right when

direction.
cialllps examillation

the

far i)een

offered has far of tile

dithcultv
\Vilat

rigidity
have

of
exj)ected

the

exceeded parts.

one

superficial

the

anatomy

FIG.

18 of Eight
operation.

110.
the shoulder weeks and for two

10

Compression brachial

arthrodcsis plexus P1Y days after

Radiograph
Osseous is firnilv

of anot her put ient st yen mont Ii s after operat i( II. union has not taken Place but clinically the sliouhleifused and patient is at work as a titter. Note the Putti motlitication described in text.

Application

of plaster-The
tile

forearm

and

arm

are

no thus

incorporated
making a shoulder

in a pltsttr spica. weeks,

of four

which

is

then

connected to Post-operative preferably

removed and but

applied management-The
previously

body
nails are

case,

plaster for

is retained At a further

for the four

four end weeks.

use
of

tile weeks

patient

being

kept
the

in bed
shoulder

vhile has

the spica

in position.

the

nails has

are
time

is retained

At
tile

the

end
in

of this plaster

all
be

external
wiser.

fixation
it is

been

abolished
tilat

and
future

unsupported
a considerably

shoulder

been would

permitted,

probable

in

longer

period

Results
The
Ilas

rapidity so striking

with that

which the

the
writer

patients
feels

have
justified

returned
in making

to normal
this

activity
report though

after

tilis

operation

been

it only

concerns that it

four cases; would take

but arthrodesis several years

of the shoulder before this series

is not a common operation and could be significantly increased.

THE JOURNAL OF BONE

it is likely

AND

JOINT

SURGERY

COMPRESSION

ARTHRODESIS

OF

THE

ANKLE

AND

SHOULDER

191
following first attempt. been successful brachial in which, in The

Tilree plexus the fourth injuries adult, case

of the and

patients because

were of the difficult a tuberculous disease

operated mobility to obtain shoulder para-articular

on

for

paralysis shoulder

of the joint arthrodesis it appears are to be this

shoulder at the to

of the

is a condition

it is notoriously concerned that in this

successful and though methods

have

it is probable

preferred.

In
hesitation weeks

all
after

four
four

cases
weeks

the
after from seems months

patients
the the

were
operation

able
when

to

elevate
tile

their

arms
pins

actively
were

and
removed.

without the Ten elbow plexus

work as a

compression

tile operation abducted

they that
after

were
side

able union
the

to sustain 18).
patient and has This failed

a weigilt In one
to occur returned has now

of five of the
but to been the

pounds cases
his back

with of brachial

straigilt and

(Figs. 14 to

injury
good

there
that

is a suspicion
this point three

bony

functional ordinary at work

result is so

immaterial.

draughtsman

operation

without

tile

interruption Ilumerus
bony

over six months. This illustrates is attached to the scapula and

fusion fail to occur.

the importance which thereby ten months on clinical

union is perhaps not

of the produces

wide base by a sort of bone

which block

should

The longest post-operative observe that though there

taken tardy because place, the the radiological development

period
can be no evidence

is now doubt
of bony unlike

and it is interesting examination that

not convincing in unexpected

in this case to bony fusion has

(Fig. the 19). This joint shoulder

is still

of trabecular and variable

continuity in direction.

forces which

it transmits,

the

weight-bearing

joints of the

lower

extremity,

are less in amount

REFERENCES ABBOTT, Joint

I..
Surgery,

C.,

SAUNDERS, 31-A, 235.

J. B.
of of

DE

C.

M.,
and and

HAGEY,
Joint Joint

H.,
Surgery,

and 27, 30-B,

JoNEs,

E.

W.

(1949):

Journal

of

Bone

and

ANDERSON,

R. (1945):

Journal
Journal

Bone Bone

37. 478.

CHARNLEY,

J.

(1948):

Surgery,

vor..

33B,

NO.

2,

MAY

1951