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ATLAS OF ORTHOPEDIC SURGICAL ISBN 0-7216-9381-4


PROCEDURES OF THE DOG AND CAT
Copyright 2005, Elsevier Inc.

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NOTICE

Veterinary Medicine is an ever-changing field. Standard safety precautions must be followed, but
as new research and clinical experience broaden our knowledge, changes in treatment and drug
therapy may become necessary or appropriate. Readers are advised to check the most current
product information provided by the manufacturer of each drug to be administered to verify the
recommended dose, the method and duration of administration, and contraindications. It is the
responsibility of the treating veterinarian, relying on experience and knowledge of the patient, to
determine dosages and the best treatment for each individual patient. Neither the publisher nor
the authors assume any liability for any injury and/or damage to persons or property arising from
this publication.

International Standard Book Number 0-7216-9381-4

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Printed in the United States of America


Last digit is the print number: 9 8 7 6 5 4 3 2 1
This book is dedicated to my family,
mentors, colleagues, residents, and students,
all of whom have provided input in my
development as a surgeon and consequently in
the development of this book.
Ann Johnson

I thank Ann Johnson for her generosity and


friendship. This book is dedicated to my
amazing children, George Henry and Sydney,
who generate an abundance of love, happiness,
and true joy in my life.
Dianne Dunning
Preface

Our goal in writing this atlas of orthopedic surgical procedures tial for those who do not have the opportunity to master each
was to create a uniquely portable, easy-to-use reference technique by performing the procedures on a daily basis.
resource for surgeons in the operating rooman atlas that The techniques selected and described are based on our
demonstrates a wide range of procedures commonly performed years of experience in training surgical residents, interns, and
in veterinary surgery. We thank Laura Duprey for helping us students and in offering continuing education to practicing vet-
reach this goal by providing superb illustrations of the proce- erinarians. Also included are tips that we have found helpful as
dures. we have performed these procedures in our own practice.
In our surgical practice at the University of Illinois, we It was a joy to compile this atlas; we hope that it is as illumi-
strongly encourage our residents and students to use textbooks nating to read as it was instructive to write.
in the surgery suite to guide them in each surgical technique
and to maximize their proficiency. With the constant explosion Ann Johnson
of surgical techniques and procedures, this guidance is essen- Dianne Dunning

vii
2 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

SHOULDER

CHAPTER 1Osteochondrosis of the Shoulder


via Caudolateral or Caudal Approach
INDICATIONS of the deltoideus and the long and lateral heads of the triceps
Candidates include dogs with persistent lameness of the muscle (Plate 1B). Bluntly dissect under the deltoideus muscle
shoulder caused by osteochondrosis that is not responsive to to visualize the axillary nerve and caudal circumflex humeral
conservative management. artery and vein. Use Gelpi retractors to craniodorsally retract
the teres minor muscle located deep to the spinous head of the
OBJECTIVES deltoideus muscle. Elevate and gently retract the axillary nerve
To improve limb function by removal of the entire osteo- off of the joint capsule. Incise the joint capsule parallel to the
chondrosis flap, curettage of the adjacent diseased cartilage, rim of the glenoid cavity, and replace the Gelpi retractors within
and forage to provide blood supply to the exposed subchon- the joint space to facilitate visualization. Internally rotate and
dral bone adduct the humerus to maximize exposure to the caudal aspect
of the femoral head (Plate 1D).
ANATOMIC CONSIDERATIONS Curettage: Remove the cartilage flap with thumb or
The shoulder joint is easily located by palpating the acromial Halstead forceps. Probe the remaining cartilage surrounding
process of the scapula and the greater tubercle of the humerus. the defect with a curette, and remove any abnormal cartilage
The acromial head of the deltoideus is bordered cranially by not adherent to the subchondral bone (Plate 1E).
the omobrachial vein and caudally by the axillobrachial vein. Forage: Using a small Kirschner wire or small Steinmann
Muscular branches of the axillary nerve and caudal circumflex pin, penetrate the sclerotic subchondral bone in multiple sites
vessels are located deep in the caudal aspect of the acromial until it bleeds (Plate 1F). Explore the caudal cul-de-sac of the
head of the deltoideus muscle, superficial to the triceps muscle. joint for loose or free fragments of cartilage. Lavage the joint,
and close the joint capsule and wound in a routine fashion.
EQUIPMENT
Standard surgical pack, two medium or large Gelpi retractors CAUTIONS
(depending on the size of the dog), blunt Hohmann retractor, Osteochondrosis is often bilateral (42% to 65%)3; both shoulders
bone curettes, pin chuck or high-speed wire driver, Kirschner should be evaluated, even if the animal exhibits a unilateral lame-
wires or small Steinmann pin for forage ness. Accurate hemostasis should be used when approaching the
shoulder, as hemorrhage will greatly impede joint visualization.
PREPARATION AND POSITIONING
Prepare the leg circumferentially from dorsal midline to the POSTOPERATIVE EVALUATION
carpus. Use a hanging leg preparation with the dog in lateral No specific postoperative evaluation is required.
recumbency to allow for maximal manipulation of the shoulder
joint during surgery. POSTOPERATIVE CARE
Exercise should be restricted for 3 to 4 weeks to allow soft
PROCEDURE tissue healing and cartilage resurfacing, and then normal
Craniolateral Approach:1 Incise the skin and subcuta- activity should be reintroduced slowly.
neous tissues in a curvilinear fashion from mid-scapula to mid-
humerus. Incise the deep fascia between the acromial and EXPECTED OUTCOME
spinous portions of the deltoideus muscle (Plate 1A). Further Outcome is good to excellent in most cases.4 Note that degen-
delineate this separation by blunt dissection with Mayo scissors, erative joint disease may develop despite the surgical removal
allowing for cranial retraction of the acromial head and caudal of an osteochondrosis flap.
retraction of the spinous portion of the deltoideus muscle. The
muscle branch of the axillary nerve is visualized at this point References
and preserved. Place the Gelpi retractors at 90 degrees to each 1. Piermattei DL, Johnson KA: Approach to the caudolateral region of
other to facilitate visualization. Incise the joint capsule parallel the shoulder joint. In An Atlas of Surgical Approaches to the Bones
to the rim of the glenoid cavity and replace the Gelpi retractors and Joints of the Dog and Cat, 4th ed. Philadelphia, WB Saunders,
within the joint space to facilitate visualization. Internally rotate 2004.
and adduct the humerus to maximize exposure to the caudal 2. Piermattei DL, Johnson KA: Approach to the caudal region of the
shoulder joint. In An Atlas of Surgical Approaches to the Bones and
aspect of the femoral head. Place a blunt Hohmann retractor
Joints of the Dog and Cat, 4th ed. Philadelphia, WB Saunders, 2004.
caudomedial to the femoral head to exteriorize the femoral 3. Whitehair J, Rudd R: Osteochondritis dissecans of the humeral head
head and further facilitate lesion visualization (Plate 1C). in dogs. Compend Cont Ed 12:195203, 1990.
Caudal Approach:2 Incise the skin and subcutaneous 4. Rudd R, Whitehair J, Marogolis J: Results of management of osteo-
tissues in a curvilinear fashion from mid-scapula to mid- chondritis dissecans of the humeral head in dogs: 44 cases
humerus. Incise between the caudal border of the spinous head (19821987). J Am Anim Hosp Assoc 26:173178, 1990.
CHAPTER 1 OSTEOCHONDROSIS OF THE SHOULDER 3

P L AT E 1

A B

Caudolateral
approach

Deltoideus muscle:
Scapular part
Acromial part

Triceps brachii muscle:


Long head
Lateral head

Caudal
approach

C
Teres minor Glenoid
muscle
(retracted D
craniodorsally)

Deltoideus muscle:
Scapular part
Acromial part
Joint
capsule Deltoideus muscle

E F
4 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

SHOULDER

CHAPTER 2 Infraspinatus Contracture


INDICATIONS spinous tendon should be visible as it inserts on the greater
Candidates are animals with infraspinatus contracture that is tubercle of the proximal humerus. Affected tendons will appear
not responsive to rest and management with nonsteroidal anti- grossly thickened and fibrotic and will become visibly taut and
inflammatory drugs. These dogs display a characteristic gait inhibit the range of motion of the shoulder when it is placed in
abnormality of external rotation of the shoulder, elbow abduc- extension or flexion. Isolate the tendon by sharp and blunt dis-
tion, and outward rotation of the pes. section with a scalpel blade and periosteal elevator. Transect
the tendon and any associated fibrotic bands until the shoulder
OBJECTIVES moves freely. Resect a portion of the tendon (approximately
To restore normal shoulder joint range of motion and fore- 1 cm) to prevent recurrence and submit for histopathology
limb function by releasing the fibrotic infraspinatus muscle (Plate 2B). Closure is routine.

ANATOMIC CONSIDERATIONS CAUTIONS


The infraspinatus muscle is one of the cuff muscles of the There are no specific cautions.
shoulder joint,1 lying just caudal to the scapular spine. Its
tendon lies beneath the acromial head of the deltoideus muscle POSTOPERATIVE EVALUATION
and crosses the joint craniolaterally, inserting on the lateral Once released, the shoulder should resume full range of motion.
aspect of the greater tubercle of the humerus. The teres minor A portion of the affected tendon should be biopsied and sub-
tendon inserts just distally to the infraspinatus along the lateral mitted for histopathology for disease verification.
aspect of the greater tubercle of the humerus.
POSTOPERATIVE CARE
EQUIPMENT Excessive activity should be restricted for 10 to 14 days to pre-
Standard surgical pack, two medium or large Gelpi retractors vent seroma formation.
(depending on the size of the dog), periosteal elevator, and
formalin jar for histopathology EXPECTED OUTCOME
Outcome is usually excellent, with a full return to function
PREPARATION AND POSITIONING expected.3
Prepare the leg circumferentially from dorsal midline to the
carpus. Use a hanging leg preparation, with the dog in lateral
recumbency to allow for maximal manipulation of the shoulder
References
joint during surgery.
1. Vasseur P, Moore D, Brown S: Stability of the canine shoulder joint:
2 An in vitro analysis. Am J Vet Res 43:352355, 1982.
PROCEDURE
2. Piermattei DL, Johnson KA: Approach to the craniolateral region of
Incise the skin and subcutaneous tissue in a curvilinear fashion the shoulder joint by tenotomy of the infraspinatus muscle. In An
from the mid-scapular spine to the proximal portion of the Atlas of Surgical Approaches to the Bones and Joints of the Dog and
humerus. Incise the deep fascia along the cranial border of the Cat, 4th ed. Philadelphia, WB Saunders, 2004.
acromial head of the deltoideus muscle. Elevate and caudally 3. Bennet R: Contracture of the infraspinatus muscle in dogs: A review
retract the muscle with Gelpi retractors (Plate 2A). The infra- of 12 cases. J Am Anim Hosp Assoc 22:481487, 1986.
CHAPTER 2 I N F R A S P I N AT U S C O N T R A C T U R E 5

P L AT E 2

Supraspinatus
muscle Deltoideus muscle:
acromial part
Infraspinatus
muscle

Teres minor muscle

Triceps brachii muscle:


lateral head

Infraspinatus
muscle
6 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

SHOULDER

CHAPTER 3Stabilization of Medial


Shoulder Luxation
INDICATIONS anchor system, a screw and washer combination may be used.
This procedure is indicated in animals with medial shoulder Additional instrumentation needed for this technique includes a
luxation and instability. Open reduction and stabilization is indi- high-speed drill, bone screw and washer, drill bit, tap, depth
cated if a traumatic luxation is unstable enough after closed gauge, and screwdriver.
reduction that reluxation occurs, or if the luxation is chronic.
Surgery is warranted in animals with congenital luxation or PREPARATION AND POSITIONING
instability that causes severe or persistent lameness. Prepare the leg circumferentially, from the dorsal midline to the
carpus. Use a hanging leg preparation with the dog in dorsal
OBJECTIVES recumbency to allow for maximal manipulation of the shoulder
To restore normal stability, congruency, mobility, and function joint during surgery.
to the shoulder joint without altering regional anatomy1
PROCEDURE
ANATOMIC CONSIDERATIONS Approach:2 Use an approach to the craniomedial shoulder
Anatomic landmarks for the scapulohumeral joint are the joint to expose the luxated joint. If possible, reduce the luxation
acromion process of the scapular spine, the greater tubercle, before the approach to reestablish normal anatomic relation-
and the acromial head of the deltoid muscle. Anatomic land- ships. Incise the skin and subcutaneous tissue from the medial
marks for positioning the skin incision include the acromion of aspect of the acromion over the greater tubercle to the medial
the scapula, the greater tubercle of the humerus, and the pec- aspect of the midhumeral diaphysis. Ligate the omobrachial
toral muscles. The suprascapular nerve is present over the vein if it interferes with the intended approach. Incise the fas-
cranial lateral surface of the scapula. The caudal circumflex cial border of the brachiocephalicus muscle and retract the
humeral artery and axillary nerve are present on the caudolat- muscle medially. Incise the insertions of the superficial and
eral aspect of the shoulder, and these should be avoided. deep pectoral muscles from the humerus and retract them
medially. Retract the supraspinatus muscle laterally. Transect
EQUIPMENT the tendon of the coracobrachialis muscle near its origin to
Standard surgical pack, two medium or large Gelpi retractors expose the subscapularis muscular tendon. Incise and elevate
(depending on the size of the dog), periosteal elevator, two the subscapularis muscle tendon at its origin, exposing 0.5 to
small Hohmann retractors, wire driver, intramedullary pins or 1.0 cm of the distal scapula. Place one small Hohmann retractor
Kirschner wires, mallet, 20-pound nylon* or the appropriate- cranial and underneath the supraspinatus muscle and another
size nonabsorbable suture material, and a suture anchor caudally against the caudal scapula for good visualization of the
system medial glenohumeral joint (Plate 3A). Inspect the joint, and
Alternatively, if a suture anchor system is not available or if assess the condition of the humeral head and medial labrum of
the animal is not large enough to accommodate the suture the glenoid.
Continued

*Mason Nylon Leader Line, Mason Tackle Company, Otisville, Michigan.

Bone Biter Suture Anchor System, Warsaw, Indiana.


CHAPTER 3 S TA B I L I Z AT I O N O F M E D I A L S H O U L D E R L U X AT I O N 7

P L AT E 3

Subscapularis
muscle

Supraspinatus
muscle

Biceps brachii
muscle

Coracobrachialis
muscle

Deep pectoral
muscle
Superficial
pectoral
muscle
8 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

Stabilization with the Suture Anchor System:1,3 CAUTIONS


Reduce the joint and identify the insertion and origins of the Because the suprascapular nerve lies in close proximity to the
medial glenohumeral ligament in the distal scapula and prox- fascial attachment between the deep pectoral and supraspinatus
imal humerus. Drill three holes, one each at the cranial and muscles, care must be taken during the approach in order to
caudal components of the ligament origin on the distal scapula avoid trauma.
and another at the ligament insertion on the proximal humerus
(Plate 3B). Insert suture anchors threaded with fish leader line POSTOPERATIVE EVALUATION
or nonabsorbable suture into each of these holes. There should Joint stability and range of motion should be evaluated at 2 and
be two independent suture loops for the cranial and caudal 4 weeks to assess continued need for external coaptation.
components of the medial glenohumeral ligament. Tie the
sutures with the limb held at a normal standing angle (approxi- POSTOPERATIVE CARE
mately 135 degrees of extension) such that the sutures are taut, A Velpeau sling is indicated to protect the repair for 2 to
but not overly tight, avoiding plication of the joint capsule 4 weeks.
(Plate 3C). Imbricate the capsule and subscapularis tendon
with nonabsorbable mattress sutures. Place the scapulo- EXPECTED OUTCOME
humeral joint through a range of motion and evaluate joint sta- Outcome is good to excellent in most cases. A published case
bility and mobility. Closure is routine. series noted minimal gait abnormalities following surgery and
Stabilization with a Screw and Washer rehabilitation, even in the face of degenerative joint disease
Combination:1 Reduce the joint and identify the origins and and joint malformation stemming from congenital shoulder
insertion of the medial glenohumeral ligament in the distal luxation.1
scapula and proximal humerus. Drill, measure, and tap three
holes, one each at the cranial and caudal components of the lig- References
ament origin on the distal scapula and another at the ligament 1. Fitch R, Breshears L, Staatz A, et al: Clinical evaluation of prosthetic
insertion on the proximal humerus. Use a screw and washer medial glenohumeral ligament repair in the dog (10 cases). Vet
combination to prevent subsidence into the soft metaphyseal Comp Orthop Traumatol 14:222228, 2001.
bone and slippage of the ligature. There should be two inde- 2. Piermattei DL, Johnson KA: Approach to the craniomedial region of
pendent suture loops for the cranial and caudal components of the shoulder joint. In An Atlas of Surgical Approaches to the Bones
the medial glenohumeral ligament. Tie the sutures with the limb and Joints of the Dog and Cat, 4th ed. Philadelphia, WB Saunders,
2004.
held at a normal standing angle (approximately 135 degrees of
3. Ringwood P, Kerwin S, Hosgood G, et al: Medial glenohumeral liga-
extension) such that the sutures are taut, but not overly tight, ment reconstruction for ex-vivo medial glenohumeral luxation in the
avoiding plication of the joint capsule (Plate 3D). Imbricate the dog. Vet Comp Orthop Traumatol 14:196200, 2001.
capsule and subscapularis tendon with nonabsorbable mattress
sutures. Place the scapulohumeral joint through a range of
motion and evaluate joint stability and mobility. Closure is
routine.
CHAPTER 3 S TA B I L I Z AT I O N O F M E D I A L S H O U L D E R L U X AT I O N 9

P L AT E 3

Suture anchor threaded


D with two sutures
inserted in humerus

Anchor locked beneath


cortices
10 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

SHOULDER

CHAPTER 4Stabilization of Lateral


Shoulder Luxation
INDICATIONS PROCEDURE
Lateral shoulder luxations are usually traumatic in origin and Approach:1,2 Use an approach to the craniolateral region of
occur after glenohumeral ligament and infraspinatus tendon the shoulder joint to expose the luxated joint. It may be helpful
rupture. Open reduction and stabilization is indicated if the lux- to reestablish normal anatomic relationships by reducing the
ation is unstable enough after closed reduction that reluxation joint before the approach is made. Incise the skin and subcuta-
occurs, or if the luxation is chronic. neous tissue in a curvilinear fashion from the mid-scapular
spine to the proximal portion of the humerus. Incise the deep
OBJECTIVES fascia along the cranial border of the acromial head of the del-
To restore normal stability, congruency, mobility, and func- toideus muscle. Elevate and caudally retract the muscle with
tion to the shoulder joint without altering regional anatomy Gelpi retractors. If the infraspinatus tendon is not torn, either
incise it 5 mm from its origin or perform an osteotomy of the
ANATOMIC CONSIDERATIONS acromial process to facilitate reattachment. Incise the joint cap-
Anatomic landmarks for the scapulohumeral joint are the sule, inspect the joint, and assess the condition of the humeral
acromion process of the scapular spine, the greater tubercle, head and lateral labrum of the glenoid (Plate 4A). If the labrum
and the acromial head of the deltoideus muscle. Anatomic land- is worn, the prognosis for successful stabilization of the
marks for positioning the skin incision include the acromion of shoulder is poor and arthrodesis should be considered (see
the scapula, the greater tubercle of the humerus, and the acro- Chapter 5). Reduce the joint and identify the origin and inser-
mial head of the deltoideus muscle. tion of the lateral glenohumeral ligament. Primary apposition of
the torn ligament, if possible, is the method of choice for repair.
EQUIPMENT If greater stability is desired, reinforcement of the repaired
Standard surgical pack, two medium or large Gelpi retractors ligament with prosthetics may be necessary.
(depending on the size of the dog), periosteal elevator, wire Stabilization with the Suture Anchor System:3
driver, intramedullary pins or Kirschner wires, mallet, 20- to Drill one hole in the distal scapula at the lateral glenohumeral
60-pound nylon,* and a suture anchor system* ligament origin and a second hole at the ligament insertion on
Alternatively a bone tunnel, screw, and washer combination the proximal humerus. Insert suture anchors threaded with
may be used, if a suture anchor system is not available or if the fishing leader line into each of these holes (Plate 4B). Tie the
animal is not large enough to accommodate the suture anchor sutures with the limb held at a normal standing angle (approxi-
system. Additional instrumentation needed for this technique mately 135 degrees of extension) such that the sutures are taut,
includes a high-speed drill, bone screw and washer, drill bit, tap, but not overly tight, avoiding plication of the joint capsule.
depth gauge, and screwdriver. Imbricate the capsule with nonabsorbable mattress sutures.
Reattach the infraspinatus tendon with a three-loop pulley or
PREPARATION AND POSITIONING locking loop suture pattern. Place the scapulohumeral joint
Prepare the leg circumferentially from the dorsal midline to the through a range of motion and evaluate joint stability and
carpus. Use a hanging leg preparation, with the dog in lateral mobility. Closure is routine.
recumbency, to allow for maximal manipulation of the shoulder Continued
joint during surgery. The animal is positioned in lateral recum-
bency with the affected leg draped.

*Bone Biter Suture Anchor System, Warsaw, Indiana.


CHAPTER 4 S TA B I L I Z AT I O N O F L AT E R A L S H O U L D E R L U X AT I O N 11

P L AT E 4

A B

Joint capsule
incised

Supraspinatus Infraspinatus
muscle muscle
Deltoideus muscle:
Infraspinatus acromial part
muscle

Suture anchor threaded


with two sutures
inserted in humerus
Teres minor
muscle

Anchor locked beneath


cortices
12 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

Stabilization with a Bone Tunnel and Screw and be evaluated at 2 and 4 weeks to assess continued need for
Washer Combination:4 Reduce the joint, and identify the external coaptation.
origin and insertion of the lateral glenohumeral ligament. Drill
an oblique bone tunnel through the distal scapula at the origin POSTOPERATIVE CARE
of ligament (Plate 4C). Thread the fishing leader line through The limb should be supported in a spica splint for 10 to 14 days.
the bone tunnel. Drill, measure, and tap a bicortical screw hole Passive range of motion exercises should be implemented after
in the ligament insertion on the proximal humerus. Use a screw splint removal for the next 2 weeks, with concurrent exercise
and washer to prevent subsidence into the soft metaphyseal restriction. Over the following 2 weeks, the animal should slowly
bone and ligature slippage. Tie the sutures in a figure-eight pat- be returned to normal activity.
tern, with the limb held at a normal standing angle (approxi-
mately 135 degrees of extension) such that the sutures are taut, EXPECTED OUTCOME
but not overly tight, avoiding plication of the joint capsule Outcome is usually fair to excellent, depending on the degree of
(Plate 4D). Imbricate the capsule with nonabsorbable mattress trauma to the joint.
sutures. Reattach the infraspinatus tendon with a three-loop
pulley or locking loop suture pattern (Plate 4E). Place the References
scapulohumeral joint through a range of motion and evaluate 1. Piermattei DL, Johnson KA: Approach to the craniolateral region of the
joint stability and mobility. Closure is routine. shoulder joint. In An Atlas of Surgical Approaches to the Bones and
Joints of the Dog and Cat, 4th ed. Philadelphia, WB Saunders, 2004.
CAUTIONS 2. Piermattei DL, Johnson KA: Approach to the lateral aspect of the
There is a high potential for concurrent chest trauma with these humeral condyle and epicondyle. In An Atlas of Surgical Approaches
injuries. Patients should be thoroughly evaluated (e.g., with to the Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
Saunders, 2004.
electrocardiogram, thoracic radiographs, and blood work) and
3. Slocum B, Slocum TD: Suture stabilization for luxations of the
stabilized before initiating surgical repair. shoulder. In Bojrab MJ (ed): Current Techniques in Small Animal
Surgery, 4th ed. Baltimore, Williams & Wilkins, 1998.
POSTOPERATIVE EVALUATION 4. Engen MH: Surgical treatment of shoulder luxations. In Bojrab MJ
The joint should be radiographed to assess implant positioning (ed): Current Techniques in Small Animal Surgery, 4th ed. Baltimore,
and joint congruency. Joint stability and range of motion should Williams & Wilkins, 1998.
CHAPTER 4 S TA B I L I Z AT I O N O F L AT E R A L S H O U L D E R L U X AT I O N 13

P L AT E 4

Tendon of
infraspinatus
muscle

E
14 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

SHOULDER

CHAPTER 5 Shoulder Arthrodesis


INDICATIONS scapular and the proximal humeral ostectomy surfaces, and
This procedure is used for animals with unreconstructable joint temporarily fix them with Kirschner wires (Plate 5C). Use an alu-
fractures, chronic shoulder luxation, or severe osteoarthritis minum template to determine the cranial contour of the junction
that is refractory to medical treatment.1 of the spine and body of the scapula and the cranial aspect of the
proximal humerus. Use the bending pliers and the torque irons to
OBJECTIVES contour an appropriately sized bone plate (allowing at least three
To fuse the bones of the scapulohumeral joint in a functional screws proximally and distally to the shoulder) to match the alu-
position minum template. Apply the plate by first placing screws through
the proximal and distal plate holes. Place a lag screw through the
ANATOMIC CONSIDERATIONS plate and across the ostectomy surfaces (see Plate 5C). Fill the
The greater tubercle of the humerus and the acromion of the remaining plate holes, directing the proximal screws into the thick
scapula are palpable landmarks. Osteotomy of the acromion bone at the junction of the spine and body of the scapula (Plate
allows reflection of a portion of the deltoideus muscle and visu- 5D). Remove the Kirschner wires. Collect cancellous bone from
alization of the joint. Osteotomy of the greater tubercle also the ostectomized humeral head with rongeurs and place it around
aids joint exposure and provides a flat surface for the plate. The the ostectomy surfaces. Reattach the biceps brachii tendon
suprascapular nerve and artery course over the scapular notch to the fascia of the supraspinatus muscle. Attach the greater
and under the acromion. The axillary artery and nerve are tubercle to the humerus lateral to the plate with a lag screw (see
located immediately caudal to the joint, but these are not usu- Plate 5D). Wire the acromion.1,2 Close the wound routinely.
ally visualized with this approach.
CAUTIONS
EQUIPMENT The suprascapular nerve and artery must be protected during
Surgical pack, Senn retractors, Hohmann retractors, Gelpi the procedure, and care must be taken not to trap the nerve
retractors, periosteal elevator, oscillating saw, self-centering under the plate. Medial and lateral angulation of the saw blade
plate-holding forceps, high-speed drill and wire driver, should be avoided when performing the scapular and humeral
Kirschner wires, wire cutter, orthopedic wire, wire twister, articular ostectomies. Angular and rotational alignment of the
plating equipment, and rongeurs limb should be checked carefully before the plate is secured.

PREPARATION AND POSITIONING POSTOPERATIVE EVALUATION


Prepare the forelimb circumferentially from dorsal midline to The axial alignment of the limb and the angle of the arthrodesis
mid-radius. Position the animal in lateral recumbency with the should be observed critically. Radiographs for limb alignment
affected limb up. Drape the limb out from a hanging position to and implant placement should be evaluated.
allow maximal manipulation during surgery. A cancellous bone
graft can be harvested from the ostectomized humeral head. POSTOPERATIVE CARE
A soft padded bandage should be placed around the forelimb
PROCEDURE and over the scapula to control bleeding and swelling. The
Approach: Incise the skin and subcutaneous tissue over the arthrodesis site should be protected with a spica splint for 6
cranial lateral aspect of the shoulder from the distal one third of weeks or until early radiographic evidence of bone bridging is
the scapula to the proximal one third of the humerus. observed. Radiographs should be repeated at 6-week intervals
Osteotomize the acromion and retract the deltoideus muscle until bone healing occurs. The animal should be confined, with
distally and caudally. Osteotomize the greater tubercle and ele- activity limited to leash walks until bone healing is complete.
vate the supraspinatus muscle proximally. Incise the infra- Barring complications, the plate should not be removed.
spinatus, teres minor, and biceps brachii tendons and the joint
capsule to expose the articular surfaces (Plate 5A).2 EXPECTED OUTCOME
Alignment: Predetermine the cranial caudal angle for the The bone should heal in 12 to 18 weeks. Satisfactory function of
shoulder arthrodesis by observing the normal standing angle of the treated limb can be expected as long as the elbow and
the shoulder in the individual patient. This angle is commonly carpus are free of disease.
110 degrees (Plate 5B).1,2
Stabilization: Remove the articular surface of the scapula References
with an oscillating saw directed perpendicular to the spine of the 1. Johnson KA: Arthrodesis. In Olmstead ML (ed): Small Animal
scapula. Flex the shoulder to the predetermined angle and perform Orthopedics. St. Louis, Mosby, 1995.
an ostectomy of the humeral head. The humeral ostectomy should 2. Piermattei DL, Flo GL: The shoulder joint. In Brinker, Piermattei,
parallel the ostectomy surface of scapula when the shoulder is and Flos Handbook of Small Animal Orthopedics and Fracture
flexed to the appropriate angle (see Plate 5B). Appose the distal Repair, 3rd ed. Philadelphia, WB Saunders, 1997.
CHAPTER 5 S H O U L D E R A RT H R O D E S I S 15

P L AT E 5

Supraspinatus muscle

Tendon of biceps
brachii muscle cut
Spinous head of B
deltoideus muscle

Joint capsule
incised

Osteotomy site
Infraspinatus muscle
Teres minor muscle

110

Acromial head of
deltoideus muscle

C D
16 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

ELBOW

CHAPTER 6Fragmented Medial Coronoid


Process and Osteochondrosis of the Elbow
INDICATIONS 1 This eliminates excessive forces on the medial coronoid
The ideal candidates for this surgery are dogs with persistent process that are present when incongruities in radial and ulnar
lameness that exhibit minimal degenerative changes to the joint length exist.3,4
on radiographs. Dogs with severe degenerative joint disease Osteochondrosis Curettage: Remove the cartilage flap
and persistent lameness that are not responsive to conservative with thumb or Ochsner forceps. Probe the remaining cartilage
management and nonsteroidal anti-inflammatory drugs may surrounding the defect with a curette, and remove any abnormal
also benefit from joint exploration, loose fragment excision, cartilage not adherent to the subchondral bone (Plate 6C).
and osteophyte curettage. Forage: Using a small Kirschner wire or small Steinmann
pin, penetrate the sclerotic subchondral bone in multiple sites
OBJECTIVES until it bleeds. Lavage the joint copiously, and close the joint
To improve function and limit pain stemming from capsule and wound in a routine fashion.
osteoarthritis and elbow incongruity
CAUTIONS
ANATOMIC CONSIDERATIONS 2 A muscular branch of the recurrent ulnar artery and vein is
The elbow joint is exposed through a medial approach. The present in the intermuscular septum between the flexor carpi
medial epicondyle and the pronator teres and flexor carpi radi- radialis and deep digital flexor muscles. Strict hemostasis of
alis muscles are key anatomic landmarks for this approach. The these intermuscular vessels is imperative for adequate visuali-
median nerve, brachial artery, and ulnar nerve are located just zation within the joint.
proximal to the epicondyle. The median nerve and brachial
artery and vein course cranially to the medial epicondyle. The POSTOPERATIVE EVALUATION
ulnar nerve courses caudally to the medial epicondyle, over the No specific postoperative evaluation is required.
anconeus muscle.
POSTOPERATIVE CARE
EQUIPMENT The limb should be bandaged after surgery for 2 to 3 days to pre-
Standard surgical pack, a small Frazier suction tip (size 8 or vent swelling and to provide soft-tissue support. Exercise should
10), two baby Gelpi retractors, bone curettes, osteotome and be restricted for 4 weeks (e.g., kennel confinement when not under
mallet, periosteal elevator, Lempert rongeur, pin chuck or direct observation; walks outside on leash only to urinate/defecate;
high-speed wire driver, Kirschner wires or small Steinmann no running, jumping, or playing). Over the following 4 weeks, the
pin for forage, and an Ochsner forceps animal should slowly return to normal activity.

PREPARATION AND POSITIONING EXPECTED OUTCOME 1,5


Prepare the limb from shoulder to carpus. Position the dog in The outcome is usually guarded to good. Multiple clinical
dorsal recumbency, with the affected limb suspended for studies have found that surgical treatment does not halt the pro-
draping. Then release the limb to allow access to the medial sur- gression of degenerative joint disease. Continued nonsteroidal
face of the elbow. anti-inflammatory therapy may be required in some patients,
especially those with advanced degenerative joint disease.
PROCEDURE
Approach:2 Incise the skin from just proximal to the medial
epicondyle to the proximal radius. Incise the subcutaneous fat References
and fascia along the same lines. Identify the separation between 1. Read R, Armstrong S, Black A, et al: Relationship between physical
the flexor carpi radialis and the superficial digital flexor tendon signs of elbow dysplasia and radiographic score in growing rot-
by counting the muscle bellies from cranial to caudal, starting tweilers. J Am Vet Med Assoc 209:14271430, 1996.
with the pronator teres. Separate the muscles via blunt dissec- 2. Piermattei DL, Johnson KA: Approach to the medial aspect of the
tion, paying close attention to the muscular branch of the ulnar humeral condyle and the medial coronoid process of the ulna by an
artery and vein. Expose the joint capsule and incise it parallel intermuscular incision. In An Atlas of Surgical Approaches to the
to the muscle-splitting incision to expose the coronoid process. Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
Insert the baby Gelpi retractors into the joint to facilitate visu- Saunders, 2004.
3. Wind AP: Elbow incongruity and developmental elbow diseases in
alization (Plate 6A).
the dog: Part I. J Am Anim Hosp Assoc 22:711724, 1986.
Joint Exploration: Identify the fragmented coronoid
4. Wind AP, Packard ME: Elbow incongruity and developmental elbow
process and any osteochondrotic or kissing lesions on the diseases in the dog: Part II. J Am Anim Hosp Assoc 22:725731, 1986.
medial humeral condyle. Remove the coronoid fragment with 5. Huibregtse BA, Johnson AL, Muhlbauer MC, et al: The effect of treat-
rongeurs or osteotome and mallet so that the base of the medial ment of fragmented coronoid process on the development of
coronoid process is level with that of the radial head (Plate 6B). osteoarthritis of the elbow. J Am Anim Hosp Assoc 30:190195, 1994.
CHAPTER 6 OSTEOCHONDROSIS OF THE ELBOW 17

P L AT E 6

Flexor carpi
radialis muscle

Joint capsule
incised

Superficial digital
flexor muscle

Medial coronoid
process of ulna
(fragmented)

C Sharp adduction and internal


rotation of humerus
18 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

ELBOW

Stabilization of Lateral
CHAPTER 7

Elbow Luxation
INDICATIONS 1 recumbency to allow for maximal manipulation of the shoulder
The indications for open reduction of luxated elbows include joint during surgery. The animal is positioned in lateral recum-
Monteggia fractures; acute luxations that cannot be reduced by bency with the affected leg draped.
closed manipulation because of instability, bony fragments, or
hematomas; failed closed reductions; and chronic luxations PROCEDURE
with muscle contracture and capsule fibrosis. Approach:2,3 Incise the skin and subcutaneous tissue over
the lateral condyle, from the distal humerus to the proximal
OBJECTIVES radius. Incise the deep brachial and antebrachial fascia to
To reestablish normal joint orientation and stability while expose the lateral head of the triceps. Continue the incision
preserving functional pain-free range of motion of the elbow though the deep fascia on the cranial border of the triceps and
joint extend it distally over the extensor muscles of the ante-
brachium. Retract the muscles to expose the lateral condyle.
ANATOMIC CONSIDERATIONS 2 Incise the periosteal origin of the anconeal muscle to expose
More than 90% of traumatic elbow luxations are lateral because the caudolateral compartment of the elbow. If additional expo-
of the large medial epicondylar ridge of the humerus and the sure to the joint is necessary to visualize the radial head, a cran-
distal slope of the medial epicondyle. A limited lateral approach iolateral compartment can be made. Incise the periosteal origin
to the elbow is used. Anatomic landmarks for open reduction of the extensor carpi radialis, and extend this incision distally
are the lateral humeral condyle, the olecranon and anconeal along the intermuscular septum between the extensor carpi
processes, and the radial head. A deep branch of the radial radialis and the common digital extensor muscle. Elevate the
nerve courses proximally to the cranial border of the extensor extensor carpi radialis muscle from the bone and enter the joint
carpi radialis muscle. A superficial branch of the radial nerve is (Plate 7A).
located between the lateral head of the triceps and the Reduction:4,5 Reduce the elbow by hooking the anconeal
brachialis muscle, and this must be protected in the proximal process into the lateral condyle and restoring radiohumeral
portion of the incision. joint orientation (Plate 7B). First, flex the elbow about 100
degrees and inwardly rotate the antebrachium. Next, hook the
EQUIPMENT anconeal process over the lateral condyle and slightly extend
Standard surgical pack, two medium or large Gelpi retractors the elbow. While placing lateral to medial pressure over the
(depending on the size of the dog), periosteal elevator, two head of the radius, reduce the radial head under the humeral
small Hohmann retractors, wire driver, intramedullary pins or capitulum. Abduct and inwardly rotate the antebrachium and
Kirschner wires, mallet, and a suture anchor system* into the fully reduced position (Plate 7C). Try to protect the car-
If a suture anchor system is not available or if the animal is tilage during reduction. If the muscle contraction and subse-
not large enough to accommodate the suture anchor system, a quent overriding are severe, a blunt periosteal elevator can be
screw and washer combination may be used. Additional instru- used to gently lever the radial head into position. If reduction is
mentation needed for this technique includes high-speed not achieved, perform an olecranon osteotomy to eliminate the
drill, bone screw and washer, drill bit, tap, depth gauge, and pull of the triceps muscle. After reduction, flush the joint and
screwdriver. assess stability.
Continued
PREPARATION AND POSITIONING
Prepare the leg circumferentially from dorsal midline to the
carpus. Use a hanging leg preparation with the dog in lateral

*Bone Biter Suture Anchor System, Warsaw, Indiana.


CHAPTER 7 S TA B I L I Z AT I O N O F L AT E R A L E L B O W L U X AT I O N 19

P L AT E 7

Deep fascia

Anconeal muscle

Extensor
carpi Lateral
radialis condyle
muscle exposed

Common digital
extensor muscle

Anconeal process
hooked over
B lateral epicondyle C

Medial
pressure
on olecranon
100
20 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

Collateral Ligament Repair: Identify the torn lateral splint removal for the next two weeks with concurrent exercise
collateral ligament. If possible, primary repair of the torn liga- restriction. Over the following 2 weeks, the animal should
ment should be attempted. Appose the torn ends of the ligament slowly return to normal activity.
with a locking loop or three-loop pulley suture pattern.
Reattach avulsed ligaments with a bone screw and spiked EXPECTED OUTCOME 1
Teflon washer (Plate 7D). If needed, ligamentous repair may be The usual outcome is fair to excellent. Most dogs have good
supplemented with suture anchors with either heavy (No. 1 or limb function after surgical reduction. Smaller, less active dogs
No. 2) nonabsorbable suture or two screws and a figure-eight have a better prognosis than do larger, more active dogs.
wire (Plate 7E). Check the joint for stability and range of Common complications following surgery included degenera-
motion. If additional stability is necessary, consider medial col- tive joint disease and decreased range of joint motion.
lateral ligament repair.
References
CAUTIONS
1. Schaeffer IGF, Wolvekamp P, Meij BP, et al: Traumatic luxation of
There is a high potential for concurrent chest trauma with these the elbow in 31 dogs. Vet Comp Orthop Traumatol 12:3339, 1999.
injuries. Patients should be thoroughly evaluated (e.g., with 2. Piermattei DL, Johnson KA: Approach to the lateral aspect of the
electrocardiogram, thoracic radiographs, and blood work) and humeral condyle and epicondyle. In An Atlas of Surgical Approaches
stabilized before initiating surgical repair. As soon as the patient to the Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
is stabilized, reduction, repair, or both should be attempted. Saunders, 2004.
3. Piermattei DL, Johnson KA: Approach to the lateral humeroulnar
POSTOPERATIVE EVALUATION part of the elbow joint. In An Atlas of Surgical Approaches to the
The joint should be radiographed to assess implant positioning Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
and joint congruency. Joint stability and range of motion should Saunders, 2004.
4. Piermattei DL, Johnson KA: Approach to the humeroulnar part of
be evaluated at 2 and 4 weeks to assess continued need for
the elbow joint by osteotomy of the tuber olecrani. In An Atlas of
external coaptation. Surgical Approaches to the Bones and Joints of the Dog and Cat,
4th ed. Philadelphia, WB Saunders, 2004.
POSTOPERATIVE CARE 5. Piermattei DL, Flo GL: Brinker, Piermattei, and Flos Handbook of
The limb should be supported in a spica splint for 10 to 14 days. Small Animal Orthopedics and Fracture Repair, 3rd ed. Philadelphia,
Passive range of motion exercises should be implemented after WB Saunders, 1997.
CHAPTER 7 S TA B I L I Z AT I O N O F L AT E R A L E L B O W L U X AT I O N 21

P L AT E 7

D Avulsed E
fragment
22 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

ELBOW

CHAPTER 8Treatment of Ununited Anconeal


Process via Removal, Lag-Screw Fixation,
and Dynamic Proximal Ulnar Osteotomy
INDICATIONS 14 vator, high-speed wire driver/drill/oscillating saw, aiming
Surgery is the treatment of choice for dogs older than 5 months device, Kirschner wires or small Steinmann pins, plating
with failure to form an osseous union between the anconeal equipment, bone curettes, osteotome and mallet, Lempert
process and the ulna. Medical therapy alone has been associ- rongeur, and two Hohmann retractors
ated with a rapid progression of severe degenerative joint dis-
ease (DJD) and lameness. Three surgical treatment options PREPARATION AND POSITIONING
have been reported: surgical excision, lag-screw fixation, and Prepare the limb from shoulder to carpus. Position the dog in
dynamic proximal ulnar osteotomy (DPUO). Considerable con- dorsal recumbency with the affected limb suspended for
troversy exists regarding the best course of therapy. DPUO is draping. Then release the limb to allow access to the lateral and
recommended in dogs with minimal DJD and ununited caudal surfaces of the elbow.
anconeal process (UAP) that is tightly adhered to the ulna. Lag-
screw fixation of the UAP, followed by concurrent DPUO, is rec- PROCEDURE
ommended in dogs with minimal DJD and a loose anconeal Caudolateral Approach:6 Incise the skin and subcuta-
process and an incongruent joint as found by evaluation of the neous tissue over the lateral condyle, from the distal humerus
joint via arthrotomy or arthroscopy. Surgical excision is gener- to the proximal radius. Incise the deep brachial and ante-
ally reserved as a salvage procedure for dogs with severe DJD brachial fascia to expose the lateral head of the triceps.
and UAP. Continue the incision though the deep fascia on the cranial
border of the triceps and extend it distally over the extensor
OBJECTIVES 1,2 muscles of the antebrachium. Retract the muscles to expose the
To improve joint congruity, encourage fusion of the anconeal lateral condyle. Incise the periosteal origin of the anconeal
process, and prevent DJD by DPUO and lag-screw fixation. muscle to expose the caudolateral compartment of the elbow
Surgical excision is considered a salvage procedure aimed at and enter the joint through a capsular incision.
eliminating the irritation caused by the UAP Caudal Approach to the Proximal Ulna:5 Incise the
skin and subcutaneous tissue along the shaft of the ulna from
ANATOMIC CONSIDERATIONS 5,6 the tuber olecrani to the proximal midshaft region. Incise the
Exposure of the anconeal process for either lag-screw fixation periosteum of the flexor carpi ulnaris and the anconeus, con-
or excision is made via a caudolateral approach. Anatomic land- tinuing distally along the ulnaris lateralis muscle. Place the
marks for the elbow are the lateral humeral condyle, the ole- Hohmann retractors between the radius and ulna just distal to
cranon and anconeal processes, and the radial head. A deep the medial and lateral coronoids to retract the tissues and visu-
branch of the radial nerve courses proximally to the cranial alize the ulna.
border of the extensor carpi radialis muscle. A superficial Ununited Anconeal Process Excision:4 Flex the
branch of the radial nerve is located between the lateral head of elbow joint fully to expose the anconeal process. Grasp the
the triceps and the brachialis muscle, and this must be pro- floating process with pointed reduction or tissue forceps and
tected in the proximal portion of the incision. For a DPUO, a remove (Plate 8A). If the process is adherent to the ulna, sever
caudal approach to the proximal ulnar diaphysis is used. The the fibrous attachments with a periosteal elevator or osteotome
landmark for ulnar osteotomy is the caudal border of the prox- and mallet.
imal ulna. Continued

EQUIPMENT
Standard surgical pack, a Frazier suction tip, two medium
Gelpi retractors, pointed reduction forceps, periosteal ele-
CHAPTER 8 T R E AT M E N T O F U N U N I T E D A N C O N E A L P R O C E S S 23

P L AT E 8

Triceps muscle retracted


A

Anconeus
muscle
retracted
24 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

Ununited Anconeal Process Lag-Screw Stabiliza- restricted until healing of the UAP is confirmed by radiograph.
tion:2,3,7 Reduce and maintain the UAP with the ulna using Exercise should be restricted for 2 to 4 weeks in dogs with sur-
pointed reduction forceps (Plate 8B). Insert a Kirschner wire gical excision of the UAP.
into the proximal quadrant of the anconeal process, passing
perpendicular to the cleavage line and exiting 1 mm to 2 mm EXPECTED OUTCOME 2,3,8
beyond the articular margin. Use this pin as a reference point to Surgical excision of the UAP is associated with a variable prog-
guide lag-screw positioning; it will be removed once the nosis, with 70% of the patients improving in the immediate post-
anconeal process is secured. Drill the screw hole from the operative period. However, only 50% of the dogs were free of
caudal cortex of the ulna, parallel to the K-wire, and exiting at lameness on long-term follow-up examination, and moderate to
the point of the anconeal process (Plate 8C). Alternatively, an severe DJD can be expected because of the inherent instability
aiming device can be used to ensure accurate screw placement of the elbow following removal of the anconeal process and
(Plate 8D). Secure the anconeal process with either a 2.7-mm or because of the preexisting joint pathology. The expected out-
3.5-mm cortical screw placed in lag fashion or a partially come is better in dogs with DPUO and/or lag-screw fixation.
threaded 4.0 cancellous screw. Insert an additional Kirschner The reported clinical outcome is good to excellent for these ani-
wire parallel to the screw to ensure rotational stability. Remove mals, with fusion of the anconeal process and minimal to no
the first Kirschner wire that is penetrating the joint. Closure is progression of DJD expected.
routine.
Dynamic Proximal Ulnar Osteotomy:13,8 Using an
oscillating saw or Gigli wire, cut the bone distal to proximal at
a 20- to 30-degree angle to the long axis of the ulna shaft. When
the osteotomy is complete, the ulna should separate 2 mm to References
4 mm spontaneously. Stabilize the ulna with a small intra- 1. Turner BM, Abercromby RH, Innes J, et al: Dynamic proximal ulnar
medullary pin (Plate 8E). If not separated, lever the bone ends osteotomy for the treatment of ununited anconeal process in 17
with a periosteal elevator to release the interosseus ligament. dogs. Vet Comp Orthop Traumatol 11:7679, 1998.
Closure is routine. 2. Meyer-Lindenberg A, Fehr M, Nolte I: Short- and long-term results
after surgical treatment of an ununited anconeal process in the dog.
Vet Comp Orthop Traumatol 4:101110, 2001.
CAUTIONS
3. Krotscheck U, Hulse DA, Bahr A, et al: Ununited anconeal process:
Lag-screw fixation for UAP is technically difficult. Correct posi- Lag-screw fixation with proximal ulnar osteotomy. Vet Comp Orthop
tioning of the lag screw is imperative. Incorrect drillings can Traumatol 13:212216, 2000.
result in failure because of penetration of the joint as a result of 4. Cross AR, Chambers JN: Ununited anconeal process of the canine
the small size of the anconeal process. elbow. Compend Cont Ed 19:349362, 1997.
5. Piermattei DL, Johnson KA: Approach to the proximal shaft and
POSTOPERATIVE EVALUATION trochlear notch of the ulna. In An Atlas of Surgical Approaches to
The joint should be placed through a thorough range of motion the Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
before closure. Postoperative radiographs are indicated to Saunders, 2004.
verify complete UAP excision, joint congruency, and/or implant 6. Piermattei DL, Johnson KA: Approach to the lateral humeroulnar
part of the elbow joint. In An Atlas of Surgical Approaches to the
and osteotomy position. Radiographs should be repeated every
Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
4 to 6 weeks until the UAP is healed. Saunders, 2004.
7. Fox SM, Burbidge HM, Bray JC, et al: Ununited anconeal process:
POSTOPERATIVE CARE Lag-screw fixation. J Am Anim Hosp Assoc 32(1):5256, 1996.
All patients should be placed in a soft padded bandage for 2 8. Sjostrom L: Ununited anconeal process in the dog. Vet Clin North
to 3 days to prevent seroma formation. Exercise should be Am Small Anim Pract 28(1):7586, 1998.
CHAPTER 8 T R E AT M E N T O F U N U N I T E D A N C O N E A L P R O C E S S 25

P L AT E 8

E
26 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

ELBOW

CHAPTER 9Distal Ulnar Ostectomy


with Fat Graft
INDICATIONS 13 CAUTIONS 2,5
Distal ulnar ostectomy is indicated as an early corrective sur- The periosteum must be completely removed with the ostec-
gery for premature closure of the distal ulnar physis, before the tomized bone, because it will form a premature bony union if left
appearance of severe angular limb deformities. This procedure in situ. Hemostasis is imperative to ensure that large blood clots
is most effective in young dogs (median age, 5 months) with do not fill the defect and promote connective tissue replacement.
less than 25 degrees of carpal valgus or in older animals (medial The fat graft should be harvested atraumatically in one piece, and
age, 6.5 months) with less than 13 degrees of valgus. should be of a size that is adequate to fill the ostectomy site. This
will minimize the amount of graft necrosis and shrinkage.
OBJECTIVES
To prevent or correct angular limb deformity, limb short- POSTOPERATIVE EVALUATION
ening, abnormal load transmission, and joint subluxation Postoperative radiographs are indicated to verify ostectomy
position and the complete removal of periosteum. To monitor
ANATOMIC CONSIDERATIONS ostectomy healing, joint congruity, and angular limb deformity,
A caudal approach to the distal ulnar diaphysis is used. radiographs should be repeated every 4 to 6 weeks until radial
Landmarks for the ostectomy are the caudolateral border of bone growth is complete. Once bone growth is complete, cor-
the distal third ulna, the tendons of the lateral digital extensor, rective osteotomies can be performed if necessary.
the ulnaris lateralis, the deep digital flexor muscles, and the
abductor pollicis longus muscle. POSTOPERATIVE CARE 2
All patients should be placed in a soft padded bandage for 2 to
EQUIPMENT 3 days to prevent seroma formation. Exercise should be
Standard surgical pack, a Frazier suction tip, one Gelpi restricted for at least 6 to 8 weeks, until the full effect of the
retractor or two Senn retractors, two Hohmann retractors, distal ulnar ostectomy is achieved. Excessive movement of the
periosteal elevator, high-speed oscillating saw or Gigli wire, ostectomy site inhibits graft vascularization and may result in
and Lempert rongeur displacement and subsequent premature union of the ulna.

PREPARATION AND POSITIONING EXPECTED OUTCOME 6


Prepare the limb from shoulder to just distal to the carpus. The outcome is usually good to excellent. Younger dogs with less
Position the dog in dorsal or lateral recumbency, with the severe angular limb deformities have better functional results
affected limb suspended for draping. Then release the limb to after distal ulnar ostectomy than do older dogs with severe angu-
allow access to the caudolateral aspect of the antebrachium. lation and joint subluxation. The mean age at surgery of dogs with
Prepare the caudal abdominal/inguinal region for fat graft good to excellent results is 6.5 months, contrasted to the mean
harvest. age at surgery of 9.75 months in dogs with fair to poor results.

PROCEDURE
References
Approach:4 Incise the skin and subcutaneous tissue along
1. Shields Henney LH, Gambardella PC: Premature closure of the ulnar
the shaft of the ulna, from the midshaft of the diaphysis to the
physis in the dog: A retrospective clinical study. J Am Anim Hosp
styloid process. Incise the antebrachial fascia between the Assoc 25:573581, 1989.
ulnaris lateralis and the lateral digital extensor tendons, 2. Vandewater A, Olmstead ML, Stevenson S: Partial ulnar ostectomy
exposing the periosteal surface of the ulna. Use a periosteal ele- with free autogenous fat grafting for treatment of radius curvus in
vator to elevate the surround musculature, and place the the dog. Vet Surg 11:9299, 1982.
Hohmann retractors between the radius and ulna at the pro- 3. Shields Henney LH: Partial ulnar ostectomy for treatment of prema-
posed osteotomy site. ture closure of the proximal and distal radial physes in the dog. J Am
Distal Ulnar Ostectomy:1,3 Using an oscillating saw or Anim Hosp Assoc 26:183188, 1990.
Gigli wire, cut the bone perpendicular to the longitudinal axis of 4. Piermattei DL, Johnson KA: Approach to the distal shaft and styloid
the ulna (Plate 9A). Remove a 1-cm to 2-cm section of the ulna, process of the ulna. In An Atlas of Surgical Approaches to the Bones
and Joints of the Dog and Cat, 4th ed. Philadelphia, WB Saunders,
and add a fat graft. Close the subcutaneous tissue and skin over
2004.
the ostectomy site (Plates 9B and 9C). 5. Craig E: Autogenous fat grafts to prevent recurrence following sur-
Fat Graft Harvest:2,5 Incise the skin and subcutaneous gical correction of growth deformities of the radius and ulna in the
tissue in the cranial inguinal/caudal abdominal region. Harvest dog. Vet Surg 10:6976, 1981.
a fat graft of sufficient size to fill the defect, and place in the gap 6. Morgan PW, Miller CW: Osteotomy for correction of premature growth
created by the ostectomy (Plate 9D). Closure is routine. plate closure in 24 dogs. Vet Comp Orthop Traumatol 7:129165, 1994.
CHAPTER 9 D I S TA L U L N A R O S T E C T O M Y W I T H FAT G R A F T 27

P L AT E 9

Lateral digital B
extensor muscle

Ulnaris lateralis
muscle

C D

Fat graft
28 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

ELBOW

CHAPTER 10 Elbow Arthrodesis


INDICATIONS ends. Perform an ostectomy of the proximal ulna to create a
This procedure is indicated in animals with unreconstructable smooth surface for the plate (see Plate 10B). Temporarily fix the
joint fractures, chronic elbow luxation or subluxation, or severe distal humeral condyle to the trochlear notch with a Kirschner
degenerative joint disease that is not responsive to medical wire (Plate 10C). Use an aluminum template to determine the
treatment. contour of the caudal surfaces of the distal humerus and prox-
imal ulna. Use the bending pliers and the torque irons to con-
OBJECTIVES tour an appropriate-size bone plate (allowing at least four
To fuse the bones of the humeroradial and humeroulnar screws proximally and distally to the elbow) to match the alu-
joints in a functional position minum template. Apply the plate by first placing screws through
the proximal and distal plate holes. Place a lag screw through
ANATOMIC CONSIDERATIONS the plate and across the lateral portion of the humeral condyle
The triceps muscle courses in a cranial proximal direction from its into the radial head. Place a second lag screw through the
insertion on the olecranon, and crosses the humerus rather than plate across the ulna and into the medial portion of the
running parallel to it. The radial nerve lies beneath the lateral head humeral condyle (see Plate 10C). Fill the remaining plate holes.
of the triceps near the distal third of the humerus. The ulnar nerve Screws placed through the ulna should penetrate the radius, if
courses over the medial aspect of the elbow, caudal to the medial possible. Remove the temporary Kirschner wire. Reattach the
epicondyle, and an olecranon osteotomy aids joint exposure. A osteotomized portion of the olecranon to the medial epicondyle
proximal ulnar ostectomy provides a flat surface for the plate. with a lag screw (Plate 10D).1,2 Collect cancellous bone from
the proximal humerus and place it around the ostectomy
EQUIPMENT surfaces. Close the wound routinely.
Surgical pack, Senn retractors, Hohmann retractors, Gelpi
retractors, periosteal elevator, oscillating saw, bone curette, CAUTIONS
self-centering plate-holding forceps, high-speed drill, burrs and The radial and ulnar nerves must be protected. All articular car-
wire driver, Kirschner wires, wire cutters, plating equipment tilage must be removed. Angular and rotational alignment of the
limb must be checked carefully before the plate is secured.
PREPARATION AND POSITIONING
Prepare the forelimb circumferentially from dorsal midline to POSTOPERATIVE EVALUATION
carpus. Position the animal in lateral recumbency, with the The axial alignment of the limb and the angle of the arthrodesis
affected limb elevated. Drape the limb out from a hanging position should be observed critically. Radiographs should be evaluated
to allow maximal manipulation during surgery. A cancellous bone for limb alignment and implant placement.
graft can be harvested from the ipsilateral proximal humerus.
POSTOPERATIVE CARE
PROCEDURE A soft padded bandage should be placed to control bleeding and
Approach: Incise the skin and subcutaneous tissue on the swelling. A lateral splint should be used for 6 weeks or until
caudal lateral aspect of the elbow from the distal one third of early radiographic evidence of bone bridging is observed.
the humerus to the proximal one third of the ulna. Elevate the Radiographs should be repeated at 6-week intervals until bone
anconeus muscle from the olecranon. Osteotomize the ole- healing occurs. The animal should be confined and activity
cranon process, and retract the triceps muscle proximally to should be limited to leash walks until bone healing is complete.
expose the caudal surface of the distal humerus. Elevate the The plate may be removed 6 to 9 months after bone healing if it
flexor carpi ulnaris and deep digital flexor muscles medially causes soft tissue irritation.
and the ulnaris lateralis muscle laterally to expose the proximal
ulna. Reflect the origin of the flexor carpi ulnaris muscle to EXPECTED OUTCOME
expose the trochlear notch. Incise the ulnaris lateralis, lateral The bone usually heals in 12 to 18 weeks. Function of the treated
collateral ligament, and joint capsule to expose the articular limb can be awkward, and the animal may have trouble with stairs
surfaces (Plate 10A). or with rough terrain.1 Amputation may offer better function.2
Alignment: Predetermine the cranial caudal angle for the
elbow arthrodesis by observing the normal standing angle of References
the elbow in the individual patient (commonly 110 degrees) 1. Johnson KA: Arthrodesis. In Olmstead ML (ed): Small Animal
(Plate 10B).1,2 Orthopedics. St. Louis, Mosby, 1995.
Stabilization: Remove the articular cartilage of the 2. Piermattei DL, Flo GL: The elbow joint. In Brinker, Piermattei, and
humeral condyle, radial head, and trochlear notch with a bone Flos Handbook of Small Animal Orthopedics and Fracture Repair,
curette or high-speed burr, following the contours of the bone 3rd ed. Philadelphia, WB Saunders, 1997.
CHAPTER 10 E L B O W A RT H R O D E S I S 29

P L AT E 1 0

A B

Osteotomy of
the olecranon
process 110

Anconeus
muscle
Joint capsule
incised

Flexor carpi
ulnaris muscle
Lateral collateral
ligament

Ulnaris lateralis muscle


Ulnar
ostectomy

C D
30 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

CARPUS

CHAPTER 11 Radial and Ulnar Styloid Fractures


INDICATIONS avulsions, two pins may be inserted into the far cortex of the
Candidates include dogs with avulsion fractures of one or both radius (Plate 11C). Drill a transverse hole 1 to 2 cm proximal to
styloid processes. the fracture site and pass a figure-eight wire through the hole
and around the Kirschner wires. Tighten the wire, bend the pins
OBJECTIVES over, and cut. Closure is routine.
To restore normal joint orientation and stability to the ante- Lag-Screw Technique: For the radial styloid process,
brachial carpal joint drill a gliding hole (equal to the diameter of the threads on
the screw) in the styloid fragment. Place an insert drill sleeve
ANATOMIC CONSIDERATIONS 14 into the gliding hole and drill a smaller hole (equal to the core
The antebrachial carpal joint is formed by the radius and the diameter of the screw) across the radius. Measure, tap, and
styloid process of the ulna, articulating with the radial and ulnar select and place the appropriate-length screw (Plate 11D).
carpal bones. This joint contributes to nearly 90% of the move- Compression of the fracture should occur. When stabilizing the
ment in the carpus and is important to carpal function. The ulnar styloid process, treat the styloid process as the fragment
radial and ulnar styloid processes serve as the origin of the by drilling the gliding hole through the ulna and the tapped hole
collateral ligaments and also extend down into the joint, in the radius (Plate 11E). Closure is routine.
serving as a physical buttress against medial lateral instability.
Internal fixation is required to restore stability to the ante- CAUTIONS 1
brachial carpal joint. It may not be possible to place two pins into the distal ulna in
small dogs; therefore, the ulnar styloid fracture may not be
EQUIPMENT completely rotationally stable. External coaptation is strongly
Surgical pack, pointed reduction forceps, Kirschner wires or recommended.
small Steinmann pins (for large dogs), pin chuck or high-
speed wire driver; plating equipment is required for lag-screw POSTOPERATIVE EVALUATION
fixation Radiographs should be evaluated for articular surface reduction
and implant placement. Radiographs should be repeated every
PREPARATION AND POSITIONING 6 to 8 weeks until the fracture has healed.
Prepare the limb circumferentially from the shoulder to the
digits. Position the animal in dorsal recumbency for greater POSTOPERATIVE CARE 2,4
flexibility, with the affected limb suspended for draping. Then A Mason Meta splint or fiberglass half-cast is necessary to
release the limb to allow access to the distal antebrachium. protect the repair for the first 6 to 8 weeks. Exercise should be
restricted until the fracture heals. Implant removal is indicated
PROCEDURE if the implants become loose or if they irritate the soft tissues
Approach: Expose the styloid processes by incising directly after the fracture heals.
over the processes through the skin and subcutaneous tissue.
Continue the incision into the retinacular and antebrachial EXPECTED OUTCOME 3,4
fascia. Elevate the surrounding tissue as necessary to visualize Outcome is fair to excellent in most cases. Carpal stability and
the fracture and collateral ligament (Plate 11A [lateral view]). alignment depend on adequate reduction and stability of the
Reduction:3 Reduce the fractured process by tenting the styloid process. Mild to moderate degenerative joint disease
bone ends, and lever the bone back into position. Maintain may be expected because of the articular nature of this fracture.
reduction with pointed reduction forceps.
Stabilization:1,2,4 Accomplish fixation of the styloid References
process with the pin and tension band wire or lag-screw tech- 1. Bruce WJ: Radius and ulna. In Coughlan AR, Miller A (eds): BSAVA
nique. If the fragments are too small to permit pin insertion, the Manual of Small Animal Fracture Repair and Management.
collateral ligament may be reattached to the bone with a screw Cheltenham, British Small Animal Veterinary Association, 1998.
and spiked plastic washer. 2. Egger EL: Fractures of the radius and ulna. In Vasseur P, Slatter D
(eds): Textbook of Small Animal Surgery, vol. 2, 2nd ed. Philadelphia,
Pin and Tension Band Wire Technique:14 Depending
WB Saunders, 1993.
on the avulsed fragment size, drive one or two wires into the 3. Miller AS: What is your diagnosis? (Radial carpal dislocation in a
styloid process, directing the wires obliquely across the dog). J Small Anim Pract 34:11, 576, 582583; 3 ref. 1993.
fracture into the far cortex of the radius or ulna. For ulnar 4. Probst CW: Stabilization of fractures of the radius and ulna. In
avulsions, insert a single K-wire into either the ulna or into the Bojrab MJ (ed): Current Techniques in Small Animal Surgery, 4th ed.
far cortex of the distal radius (Plate 11B). For radial styloid Baltimore, Williams & Wilkins, 1998.
CHAPTER 11 RADIAL AND ULNAR STYLOID FRACTURES 31

P L AT E 1 1

Radius
Flexor
carpi ulnaris
Ulna

C D E
32 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

CARPUS

CHAPTER 12 Pancarpal Arthrodesis


INDICATIONS larger screws over the radius and smaller screws over the
Candidates include dogs with hyperextension of the ante- metacarpal bones.3) Position the plate so that one screw will
brachial carpal joint; dogs with severe injury (e.g., fracture, penetrate the radial carpal bone. Ensure adequate plate holes
luxation, or shearing injury) of the antebrachial carpal joint for a minimum of three screws in the radius and three screws in
that precludes maintaining a long-term, pain-free articulation; the metacarpal bone. Mark the level of the distal metacarpal
or dogs with painful degenerative joint disease that is not plate screw. Remove the plate and center the drill on the
responsive to conservative measures.1,2 metacarpal bone. Secure the plate with three screws in the
metacarpal bone, and then reduce the plate to the radius with
OBJECTIVES self-centering forceps. Check plate and joint alignment and
To fuse the bones of the antebrachial, middle carpal, and car- attach the plate to the radius, using the loaded drill guide in one
pometacarpal joints in a functional position or two holes to compress the antebrachial carpal joint (see
Plate 12C). Fill the remaining plate holes (Plate 12D). One plate
ANATOMIC CONSIDERATIONS screw should secure the radial carpal bone (Plate 12E).1
The carpus consists of the radius, ulna, proximal (radial, ulnar,
and accessory) carpal bones, distal row (II, III, and IV) carpal CAUTIONS
bones, and the metacarpal bones, forming the antebrachio- All of the articular cartilage should be removed. Angular and
carpal, middle carpal, and carpometacarpal joints. rotational alignment of the limb should be checked carefully
before securing the plate to the radius. Tourniquet use should
EQUIPMENT be limited to 60 minutes.
Surgical pack, Senn retractors, Gelpi retractors, Hohmann
retractors, periosteal elevator, self-centering plate-holding for- POSTOPERATIVE EVALUATION
ceps, bone curette, high-speed drill and burrs, plating equipment The axial alignment of the limb and the angle of the arthrodesis
should be observed critically. Radiographs for limb alignment
PREPARATION AND POSITIONING and implant placement should be evaluated.
Prepare the forelimb circumferentially from shoulder to digits.
Position the animal in lateral recumbency with the affected POSTOPERATIVE CARE
limb up. Drape the limb out from a hanging position to allow A soft, padded bandage should be placed to control bleeding and
maximal manipulation during surgery. Prepare the ipsilateral swelling. Casting should be delayed for 48 to 72 hours if a tourni-
proximal shoulder or ilial wing for cancellous bone graft quet has been used. A bivalve cast should be used for 6 weeks or
harvest. Consider using a tourniquet to control bleeding. until early radiographic evidence of bone bridging is observed.
Radiographs should be repeated at 6-week intervals until bone
PROCEDURE healing occurs. The animal should be confined, with activity
Approach: Incise the skin and subcutaneous tissue over the limited to leash walks until bone healing is complete. Implants
dorsal surface of the joint from the distal third of the radius to are generally removed after 6 to 12 months to avoid soft tissue
the distal third of the metacarpal bones. Elevate and resect the irritation.3
attachment of the carpal extensor tendons from the metacarpal
bones. Elevate and retract the digital extensor tendons laterally EXPECTED OUTCOME
to expose the distal radius, the carpus, and the proximal two Bone healing is expected in 12 to 18 weeks, and good function
thirds of the third metatarsal bone. Incise the joint capsule in the treated limb is anticipated. Fatigue fractures of the distal
to enter each joint space and expose the articular surfaces metacarpal bone may occur; covering more than 50% of the
(Plate 12A). metacarpal bone with the plate may reduce this problem.4
Alignment: The cranial caudal angle for the pancarpal
arthrodesis is commonly 10 to 12 degrees1,2 (see Plate 12E).
Stabilization: Flex the carpus and remove the articular References
cartilage from the antebrachial carpal joint surfaces, the middle 1. McLaughlin RM: Arthrodesis. In Brinker WO, Olmstead ML, Sumner-
joint surfaces, and the carpometacarpal joint surfaces with a Smith G, et al (eds): Manual of Internal Fixation in Small Animals.
bone curette or high-speed burr, following the contours of the New York, Springer-Verlag, 1998.
2. Johnson KA: Arthrodesis. In Olmstead ML (ed): Small Animal
bone ends (Plate 12B). Harvest cancellous bone and place the
Orthopedics. St. Louis, Mosby, 1995.
graft within the prepared joints (Plate 12C). Place an appro- 3. Li A, Gibson N, Carmichael S, et al: Thirteen pancarpal arthrodeses
priate-size bone plate (limited by the size of the metacarpal using 2.7/3.5 mm hybrid dynamic compression plates. Vet Comp
bone), precontoured to 10 to 12 degrees of carpal extension, on Orthop Traumatol 12:102, 1999.
the dorsal surface of the distal radius and third metacarpal 4. Whitelock RG, Dyce J, Houlton JEF: Metacarpal fractures associated
bone. (Alternatively, use a hybrid plate that accommodates with pancarpal arthrodesis in dogs. Vet Surg 28:25, 1999.
CHAPTER 12 PA N C A R PA L A RT H R O D E S I S 33

P L AT E 1 2

Abductor pollicis B
longus muscle
Radial Radius
carpal bone

Tendon of
Tendon of
common digital
extensor carpi
extensor tendon
radialis muscle

C D E

10 - 12
carpal extension
34 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

CARPUS

CHAPTER 13 Partial Carpal Arthrodesis


with a Plate
INDICATIONS Harvest cancellous bone and place the graft within the prepared
Candidates include dogs with hyperextension of the middle joints (Plate 13C). Position a veterinary T plate distally on the
carpal and carpometacarpal joints.1 dorsal surface of the radial carpal bone and third metacarpal
bone. It is imperative that the plate be distal to the articular car-
OBJECTIVES tilage on the radial carpal bone to avoid interference with the
To fuse the bones of the middle carpal and carpometacarpal radius. Secure the plate to the radial carpal bone. Select screws
joints in a functional position that are slightly shorter than the measured length to avoid inter-
ference with palmar soft tissues. Reduce the plate to the third
ANATOMIC CONSIDERATIONS metacarpal bone (see Plate 13C). Starting with the most distal
The carpus consists of the radius, ulna, proximal (radial, ulnar plate hole, fill the remaining plate holes, securing the plate to
and accessory) carpal bones, distal row (II, III, and IV) carpal the third metacarpal bone (Plate 13D).1
bones, and the metacarpal bones, forming the antebrachio-
carpal, middle carpal, intercarpal, and carpometacarpal joints. CAUTIONS
All articular cartilage must be removed. The plate must not
EQUIPMENT interfere with the articular surface of the radial carpal bone or
Surgical pack, Senn retractors, small Hohmann retractors, with the radius when the limb is extended. Tourniquet use
Gelpi retractors, periosteal elevator, plate-holding forceps, should be limited to 60 minutes.
bone curette, high-speed drill and burrs, plating equipment
POSTOPERATIVE EVALUATION
PREPARATION AND POSITIONING Radiographs should be evaluated for limb alignment and
Prepare the forelimb circumferentially from shoulder to digits. implant placement.
Position the animal in lateral recumbency with the affected
limb up. Drape the limb out from a hanging position to allow POSTOPERATIVE CARE
maximal manipulation during surgery. Prepare the ipsilateral A soft, padded bandage should be placed to control bleeding
proximal shoulder or ilial wing for cancellous bone graft and swelling. Casting should be delayed for 48 to 72 hours if a
harvest. Consider using a tourniquet to control bleeding. tourniquet has been used. A bivalve cast should be used for
6 weeks or until early radiographic evidence of bone bridging is
PROCEDURE observed. Radiographs should be repeated at 6-week intervals
Approach: Incise the skin and subcutaneous tissue over the until bone healing occurs. The animal should be confined, with
dorsal surface of the joint from the distal metaphysis of the activity limited to leash walks until bone healing is complete.
radius to the distal third of the metacarpal bones. Elevate and Implants may need to be removed after 6 to 12 months to avoid
retract the carpal extensor tendons medially and the digital soft tissue irritation.
extensor tendons laterally to expose the distal radius, the
carpus, and the proximal two thirds of the third metatarsal EXPECTED OUTCOME
bone. Incise the joint capsule to enter each middle and distal Bone healing is expected in 12 to 18 weeks. A decrease in range
joint space and expose the articular surfaces (Plate 13A). of motion in the antebrachial carpal joint is usually seen. Near-
Alignment: Align the dorsal surfaces of the radial carpal normal function of the treated limb can be expected unless
bone and third metacarpal bone with the plate to produce the undiagnosed antebrachial carpal joint injuries are present.
correct alignment for the arthrodesis.
Stabilization: Flex the carpus and remove the articular
cartilage from the middle carpal, intercarpal, and car- Reference
pometacarpal joint surfaces with a bone curette or high-speed 1. Johnson KA: Arthrodesis. In Olmstead ML (ed): Small Animal
burr, following the contours of the bone ends (Plate 13B). Orthopedics. St. Louis, Mosby, 1995.
CHAPTER 13 PA RT I A L C A R PA L A RT H R O D E S I S W I T H A P L AT E 35

P L AT E 1 3

A B

Radial
carpal bone Radius

Tendon of
Tendon of
common digital
extensor carpi
extensor tendon
radialis muscle

C D
36 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

CARPUS

CHAPTER 14Partial Carpal Arthrodesis


with Intramedullary Pins
INDICATIONS joints. Create burr slots in the dorsal surface of the distal third
Candidates have hyperextension of the middle carpal and car- of the third and fourth metacarpal bones. Drive small inter-
pometacarpal joints.1,2 medullary pins or Kirschner wires through the slots proximally
into the base of the bones. Reduce the subluxation and align the
OBJECTIVES carpus as described previously. Drive the pins into the radial
To fuse the bones of the middle carpal and carpometacarpal carpal bone (Plate 14C). Back the pins out a few millimeters,
joints in a functional position and then cut and bend the ends into hooks. Reseat the pins and
rotate the hooks flat against the bones (Plate 14D).1,2
ANATOMIC CONSIDERATIONS
The carpus consists of the radius, ulna, proximal (radial, ulnar, CAUTIONS
and accessory) carpal bones, distal row (II, III, and IV) carpal All articular cartilage must be removed. The slots will have to
bones, and the metacarpal bones, forming the antebrachio- be long enough to allow the pins to bend as they are driven
carpal, middle carpal, intercarpal, and carpometacarpal joints. proximally. The carpus must be flexed 90 degrees and pressure
placed on the metacarpal bones to align the carpal bones with
EQUIPMENT the metacarpal bones while the pins are placed. The pins should
Surgical pack, Senn retractors, Hohmann retractors, Gelpi not penetrate the radial carpal bone articular surface.
retractors, periosteal elevator, bone curette, high-speed drill Tourniquet use should be limited to 60 minutes.
and burrs, intramedullary pins or Kirschner wires, Jacob pin
chuck, pin or wire cutters POSTOPERATIVE EVALUATION
Radiographs should be evaluated for limb alignment and
PREPARATION AND POSITIONING implant placement.
Prepare the forelimb circumferentially from shoulder to digits.
Position the animal in lateral recumbency with the affected POSTOPERATIVE CARE
limb up. Drape the limb out from a hanging position to allow A soft, padded bandage should be placed to control bleeding
maximal manipulation during surgery. Prepare the ipsilateral and swelling. Casting should be delayed for 48 to 72 hours if a
proximal shoulder or ilial wing for cancellous bone graft har- tourniquet has been used. A bivalve cast should be used for 6
vest. Consider using a tourniquet to control bleeding. weeks or until early radiographic evidence of bone bridging is
observed. Radiographs should be repeated at 6-week intervals
PROCEDURE until bone healing occurs. The animal should be confined, with
Approach: Incise the skin and subcutaneous tissue over the activity limited to leash walks until bone healing is complete.
dorsal surface of the joint from the distal third of the radius to Implants are generally removed after healing to avoid soft
the distal third of the metacarpal bones. Elevate and retract the tissue irritation.
carpal extensor tendons medially and the digital extensor ten-
dons laterally to expose the distal radius, the carpus, and the EXPECTED OUTCOME
proximal two thirds of the third metatarsal bone. Incise the Bone healing is expected in 12 to 18 weeks. A decrease in range
joint capsule to enter each middle and distal joint space and of motion in the antebrachial carpal joint is usually seen.
expose the articular surfaces (Plate 14A). Lameness is eliminated or improved in two thirds of the dogs.2
Alignment: Flex the antebrachial carpal joint 90 degrees Hyperextension may persist in some dogs, especially if ante-
and apply proximal and palmar pressure to the metacarpal brachialcarpal injuries have been overlooked.
bones while placing the intramedullary pins to align the dorsal
surfaces of the radial carpal bone and metacarpal bones cor-
rectly for the arthrodesis1 (see Plate 14C). References
Stabilization: Flex the carpus and remove the articular
1. Johnson KA: Arthrodesis. In Olmstead ML (ed): Small Animal
cartilage from the middle carpal, intercarpal, and car- Orthopedics. St. Louis, Mosby, 1995.
pometacarpal joint surfaces with a bone curette or high-speed 2. Willer RL, Johnson KA, Turner TM, et al: Partial carpal arthrodesis
burr, following the contours of the bone ends (Plate 14B). for third-degree carpal sprains: A review of 45 carpi. Vet Surg
Harvest cancellous bone and place the graft within the prepared 92:334, 1990.
CHAPTER 14 PA RT I A L C A R PA L A RT H R O D E S I S W I T H I N T R A M E D U L L A RY P I N S 37

P L AT E 1 4

A B

Radial
carpal bone Radius

Tendon of
Tendon of
common digital
extensor carpi
extensor tendon
radialis muscle

C D
38 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

HIP

CHAPTER 15Extracapsular Stabilization


of Hip Luxation (Suture Anchors or Screw
and Washer)
INDICATIONS 1 Craniolateral Approach:1 Use a craniolateral approach
Open reduction and stabilization is indicated in animals with to the coxofemoral joint. Incise the skin and subcutaneous
chronic luxations, failed closed reductions, excessive postre- tissue 5 cm proximal to the greater trochanter, curving distally
duction instability, intra-articular fractures, concurrent pelvic adjacent to the cranial ridge of the trochanter and extending
fractures, or other fractures of the affected limb that prevent distally from 5 cm over the proximal femur. Incise between the
closed reduction. tensor fasciae latae muscle and deep border of the biceps
femoris muscle and superficial gluteal muscle. Retract the
OBJECTIVES tensor fasciae latae cranially, the biceps caudally, and the
To restore normal stability, congruency, mobility, and func- middle gluteal muscle proximally. Incise the deep gluteal
tion to the coxofemoral joint muscle close to its attachment on the trochanter for one third
to one half of its width. Incise the joint capsule (or enlarge the
ANATOMIC CONSIDERATIONS 2 traumatic tear) parallel to the long axis of the femoral neck,
Osseous anatomic landmarks for the coxofemoral joint are the near its proximal ridge. Continue the joint capsule incision lat-
greater trochanter of the femur and the ischial tuberosity and erally through the point of origin of the vastus lateralis muscle
ilial wing of the pelvis. The curvilinear incision should center on on the cranial face of the proximal femur. Reflect the vastus lat-
the cranial edge of the greater tubercle. Distally, it extends cra- eralis distally to expose the hip joint (Plate 15A).
nial and parallel to the proximal third of the shaft of the femur. Dorsal Approach with Trochanteric Osteotomy:2
Muscular landmarks include the biceps femoris, the gluteals, Use a dorsal approach to the coxofemoral joint with an
and the vastus lateralis. Reduce the hip prior to starting the sur- osteotomy of the greater trochanter. Incise the skin over the
gical approach to establish normal tissue relationships. cranial border of the greater trochanter, from 3 cm to 4 cm
proximal to the dorsal ridge of the greater trochanter and
EQUIPMENT curved 3 cm to 4 cm, following the cranial border of the femur.
Standard surgical pack, two medium or large Gelpi retractors Incise the superficial leaf of the fascia lata, and carry the inci-
(depending on the size of the dog), periosteal elevator, wire sion proximally through the insertion of the tensor fasciae latae
driver, intramedullary pins or Kirschner wires, mallet, 20- to muscle at the greater trochanter and along the cranial border of
60-pound nylon* and a suture anchor system the superficial gluteal muscle. Incise through the insertion of
Alternatively, a bone tunnel and screw and washer combina- the superficial gluteal muscle at the third trochanter. Reflect the
tion may be used if a suture anchor system is not available or superficial gluteal muscle proximally and the biceps femoris
if the animal is not large enough to accommodate the suture caudally to find and visualize the course of the sciatic nerve.
anchor system. Additional instrumentation needed for this tech- Perform an osteotomy of the greater trochanter with an
nique includes a high-speed drill, bone screw and washer, drill osteotome and mallet or with Gigli wire. Reflect the gluteal
bit, tap, depth gauge, and screwdriver. muscles and greater trochanter from the joint capsule with a
periosteal elevator, and incise both structures together at the
PREPARATION AND POSITIONING trochanter fossa. Elevate the gemellus muscle from the cau-
Prepare the rear limb circumferentially from dorsal midline to dolateral surface of the acetabulum with a periosteal elevator.
mid-tibia. Position the animal in lateral recumbency with the Use a suture to retract the muscle proximally and caudally.
affected limb up. Drape the limb out from a hanging position to Incise the joint capsule (see Plate 15A).
allow maximal manipulation during surgery. Explore the hip joint prior to stabilizing the joint to assess
cartilage viability and surrounding soft-tissue injury. If the joint
PROCEDURE integrity is intact, a number of hip-stabilizing techniques are
Approach: A trochanteric osteotomy is not always necessary available.
to reduce and stabilize the hip; however, chronic cases may Continued
benefit from the additional exposure of an osteotomy.

*Mason Nylon Leader Line, Mason Tackle Company, Otisville, Michigan.

Bone Biter Suture Anchor System, Warsaw, Indiana.


CHAPTER 15 E X T R A C A P S U L A R S TA B I L I Z AT I O N O F H I P L U X AT I O N 39

P L AT E 1 5

Deep gluteal
muscle

Incision in
joint capsule Middle gluteal
muscle retracted
proximally

Vastus lateralis
muscle

Tensor fasciae Biceps femoris muscle


latae muscle retracted caudally
retracted cranially

Osteotomy of the
greater trochanter

Tensor fasciae Superficial gluteal muscle


latae muscle (retracted proximally)
(retracted cranially)

Gemelli muscles incised


Sciatic nerve

Osteotomy of the
greater trochanter
Vastus lateralis muscle
40 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

Stabilization: To achieve successful reduction and stabi- POSTOPERATIVE EVALUATION


lization of the coxofemoral joint, the use of one or more of the The joint should be radiographed to assess implant positioning
following techniques may be necessary: Suture anchors, screws and joint congruency. Joint stability and range of motion should
and washers, and wire sutures may be employed for added be evaluated at 2 to 3 days to assess hip position.
stability when the capsule cannot be securely closed and
imbricated. POSTOPERATIVE CARE
Stabilization with Capsular Repair and Imbrication: An Ehmer bandage can be used to assist hip reduction in the
Luxate the femoral head to visually inspect the cartilage surface early postoperative period. The bandage should be removed 4
for damage. Dbride any remaining fibrous tissue, hematoma, to 7 days after reduction. Cage confinement may be adequate
and fracture fragments from the acetabular socket. Reduce the for dogs with stable hips. Leash activity is required for an addi-
femoral head and imbricate the joint capsule with nonab- tional 3 weeks, and the animal should gradually be returned to
sorbable monofilament material using an interrupted or cru- full activity over a 2-week period. Reexamination is advisable
ciate pattern (Plate 15B). Place the joint through a range of 3 days after removal of the Ehmer bandage and before resump-
motion. If the joint is stable, joint capsule repair and imbrica- tion of unsupervised activity.
tion alone can constitute the reconstructive procedure.
Stabilization with Screw and Washer:3 Drill two EXPECTED OUTCOME 4
holes into the craniodorsal aspect of the acetabular rim at the The success rate for maintaining reduction and regaining good
10-oclock and 1-oclock positions. Measure, tap, and select two to excellent limb function with closed reduction is about 50%.
appropriate-length screws, adding 2 mm to the screw length to The rate is lower in patients with poor conformation of the hip
accommodate the washer. Drill, measure, tap, and insert a third joint secondary to hip dysplasia or previous trauma. Clinical
screw and washer in the trochanteric fossa, or drill a bone studies indicate that the success for surgical intervention fol-
tunnel through the femoral neck in the trochanteric fossa to lowing failure of closed reduction does not differ from the suc-
accept the suture. Pass heavy, nonabsorbable suture or cerclage cess rate for surgical reduction as a primary treatment.
wire between the acetabular screws and trochanteric fossa Therefore, it is reasonable to attempt closed reduction in
(Plate 15C). Place the joint through a range of motion to ensure patients with a hip luxation. Regarding maintenance of reduc-
stability and function. tion with good to excellent limb function following open reduc-
Stabilization with the Suture Anchor System: tion, the success rate is approximately 85% to 90%. The results
Drill two holes into the craniodorsal aspect of the acetabular do not appear to favor any one reconstruction technique. Mild
rim at the 10-oclock and 1-oclock positions. Insert suture to moderate degenerative joint disease may be expected in
anchors threaded with heavy, nonabsorbable suture into each cases with questionable cartilage viability or obvious cartilage
of these holes. Drill and insert a third suture anchor thread with trauma. If cartilage viability or reduction is questionable, sal-
the suture from the acetabular anchors into the trochanteric vaging limb function with a femoral head and neck ostectomy
fossa (Plate 15D). Tie the sutures with the hip at a normal angle or a total hip replacement should be considered. The long-term
of flexion and slight abduction and internal rotation. Place the prognosis with open reduction is good to excellent if the joint
joint through a range of motion to ensure stability and function. integrity is intact.
Closure: Reattach the external rotator muscles as neces-
sary. If a trochanteric osteotomy has been performed, reattach
the trochanter in a caudodistal position on the femur to pro-
mote joint stability and femoral adduction and internal rotation References
(Plate 15E1). Stabilize the greater trochanter with two 1. Martini FM, Simonazzi B, Bue MD, et al: Extra-articular absorbable
Kirschner wires and a tension band (Plate 15E2). Suture the fas- suture stabilization of coxofemoral luxation in dogs. Vet Surg
cial layers, subcutaneous tissue, and skin. 30(5):468475, 2001.
2. Piermattei DL, Johnson KA: Approach to the craniodorsal aspect of
the hip joint through a craniolateral incision. In An Atlas of Surgical
CAUTIONS 4
Approaches to the Bones and Joints of the Dog and Cat, 4th ed.
The most common cause of coxofemoral luxation in the dog is
Philadelphia, WB Saunders, 2004.
motor vehicular trauma; concurrent injuries should therefore 3. Braden T, Johnson M: Technique and indications of a prosthetic cap-
be ruled out. Open reduction may need to be delayed until the sule for repair of recurrent and chronic coxofemoral luxations. Vet
animal has been adequately stabilized. A femoral head and neck Comp Orthop Traumatol 1:2629, 1988.
excision or total hip replacement should be considered if coxo- 4. Bone DL, Walker M, Cantwell HD: Traumatic coxofemoral luxation
femoral integrity is questionable. in dogs: Results of repair. Vet Surg 13(4):263270, 1984.
CHAPTER 15 E X T R A C A P S U L A R S TA B I L I Z AT I O N O F H I P L U X AT I O N 41

P L AT E 1 5

Bone anchor
C D

Anchor locked beneath


cortices

E1
E2

Reattachment
site
42 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

HIP

CHAPTER 16Intracapsular Stabilization of Hip


Luxation with Modified Toggle Pin
INDICATIONS Craniolateral Approach:1 Perform a craniolateral
Open reduction and stabilization is indicated in animals with approach to the coxofemoral joint. Incise the skin and subcuta-
chronic luxations, failed closed reductions, excessive postre- neous tissue 5 cm proximal to the greater trochanter, curving
duction instability, intra-articular fractures, concurrent pelvic distally adjacent to the cranial ridge of the trochanter and
fractures, or other fractures of the affected limb that prevent extending distally from 5 cm over the proximal femur. Incise
closed reduction. between the tensor fasciae latae muscle and deep border of the
biceps femoris muscle and superficial gluteal muscle. Retract
OBJECTIVES the tensor fasciae latae cranially, the biceps caudally, and the
To restore normal stability, congruency, mobility, and func- middle gluteal muscle proximally. Incise the deep gluteal
tion to the coxofemoral joint muscle close to its attachment on the trochanter for one third
to one half of its width. Incise the joint capsule (or enlarge the
ANATOMIC CONSIDERATIONS traumatic tear) parallel to the long axis of the femoral neck near
Osseous anatomic landmarks for the coxofemoral joint are the its proximal ridge. Continue the joint capsule incision laterally
greater trochanter of the femur and ischial tuberosity and the ilial through the point of origin of the vastus lateralis muscle on the
wing of the pelvis. The curvilinear incision should center on cra- cranial face of the proximal femur. Reflect the vastus lateralis
nial edge of the greater tubercle. Distally it extends cranial and distally to expose the hip joint (Plate 16A).
parallel to the proximal third of the shaft of the femur. Muscular Dorsal Approach with Trochanteric Osteotomy:2
landmarks include the biceps femoris, the gluteals, and the vastus Use a dorsal approach to the coxofemoral joint with an
lateralis. Soft tissue bruising and swelling often distort the nor- osteotomy of the greater trochanter. Incise the skin over the
mal anatomy. To establish normal tissue relationships, the hip cranial border of the greater trochanter, from 3 to 4 cm
should be reduced before the surgical approach is begun. proximal to the dorsal ridge of the greater trochanter and
curved 3 to 4 cm, following the cranial border of the femur.
EQUIPMENT Incise the superficial leaf of the fascia lata and carry the
Standard surgical pack, two medium or large Gelpi retractors incision proximally through the insertion of the tensor fasciae
(depending on the size of the dog), periosteal elevator, high- latae muscle at the greater trochanter and along the cranial
speed drill, C-arm aiming device, toggle pin or rod and toggle border of the superficial gluteal muscle. Incise through the
rod insertion device.* insertion of the superficial gluteal muscle at the third
trochanter. Reflect the superficial gluteal muscle proximally
PREPARATION AND POSITIONING and the biceps femoris caudally to find and visualize the course
Prepare the rear limb circumferentially from dorsal midline to of the sciatic nerve. Perform an osteotomy of the greater
mid-tibia. Position the animal in lateral recumbency with the trochanter with an osteotome and mallet or with Gigli wire (see
affected limb up. Drape the limb out from a hanging position to Plate 16A). Reflect the gluteal muscles and greater trochanter
allow maximal manipulation during surgery. from the joint capsule with a periosteal elevator. Elevate the
gemellus muscle from the caudolateral surface of the acetab-
PROCEDURE ulum with a periosteal elevator. Use a suture to retract the
Approach: A trochanteric osteotomy is not always necessary muscle proximally and caudally (see Plate 16A). Incise the joint
to reduce and stabilize the hip; however, chronic cases may capsule, and explore the hip joint prior to stabilizing the joint to
benefit from the additional exposure of an osteotomy. assess cartilage viability and surrounding soft-tissue injury.
Continued

*Securos Coxofemoral Luxation Management System, Charlton, Massachusetts.


CHAPTER 16 I N T R A C A P S U L A R S TA B I L I Z AT I O N O F H I P L U X AT I O N 43

P L AT E 1 6

Deep gluteal
muscle

Incision in
joint capsule Middle gluteal
muscle retracted
proximally

Vastus lateralis
muscle

Tensor fasciae Biceps femoris muscle


latae muscle retracted caudally
retracted cranially

Osteotomy of the
greater trochanter

Tensor fasciae Superficial gluteal muscle


latae muscle (retracted proximally)
(retracted cranially)

Gemelli muscles incised


Sciatic nerve

Osteotomy of the
greater trochanter
Vastus lateralis muscle
44 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

Toggle Pin Stabilization:3 Luxate the femoral head to POSTOPERATIVE EVALUATION


visually inspect the cartilage surface for damage. Dbride any The joint should be radiographed to assess implant positioning
remaining fibrous tissue, hematoma, and fracture fragments and joint congruency. Joint stability and range of motion should
from the acetabular socket. Drill the acetabular tunnel into the be evaluated at 2 to 3 days to assess continued need for assisted
origin of the round ligament with a 3.5-mm drill bit (Plate 16B). weight bearing.
Drill the femoral tunnel from the lateral subtrochanteric area to
the fovea capitis using a C-arm aiming device and a 2.5-mm drill POSTOPERATIVE CARE
bit (Plate 16C). Thread four strands of 0 or 1 monofilament A belly band sling should be used outside for the first 2 to 3 days
nonabsorbable suture material through the toggle pin or rod. to prevent uncontrolled use of the limb. Exercise should be
Position the toggle device into the acetabular hole and lock it restricted and the animal should be confined to a kennel for
into position on the medial cortex of the acetabulum (Plate the first 4 to 6 weeks. Then normal activity can be slowly
16D). Thread the sutures through the femoral head and neck reintroduced.
(Plate 16E). Reduce the femoral head and drill a second trans-
verse bone tunnel cranial to caudal in the subtrochanteric EXPECTED OUTCOME 3
region of the femur, slightly proximal to the exit hole of the Outcome is usually good to excellent. Mild to moderate degen-
suture (Plate 16F1). Pull one pair of the sutures through the erative joint disease and gait abnormalities may be expected in
second femoral tunnel and snugly tie them to the opposite cases with questionable cartilage viability or obvious cartilage
sutures (Plate 16F2). trauma. If cartilage viability or reduction is questionable, a
Capsular Repair and Imbrication: Imbricate the joint femoral head and neck ostectomy or total hip replacement
capsule with nonabsorbable monofilament material using an should be considered to salvage limb function.
interrupted or cruciate pattern. Place the joint through a range
of motion. References
Closure: Reattach the external rotator muscles as neces- 1. Piermattei DL, Johnson KA: Approach to the craniodorsal aspect of
sary. Reduce and stabilize the greater trochanter with two the hip joint through a craniolateral incision. In An Atlas of Surgical
Kirchner wires and a tension band. Suture the fascial layers, Approaches to the Bones and Joints of the Dog and Cat, 4th ed.
subcutaneous tissue, and skin. Philadelphia, WB Saunders, 2004.
2. Piermattei DL, Johnson KA: Approach to the craniodorsal and cau-
CAUTIONS 4 dodorsal aspects of the hip joint by osteotomy of the greater
trochanter. In An Atlas of Surgical Approaches to the Bones and
The sciatic nerve courses dorsomedial to the acetabulum; to
Joints of the Dog and Cat, 4th ed. Philadelphia, WB Saunders, 2004.
avoid damaging this nerve, caution must be exercised when 3. Beckman HP: Use of a modified toggle pin for repair of coxofemoral
performing the trochanteric osteotomy. When implanting luxation in dogs with multiple orthopedic injuries (19861994). J Am
toggle pins, passage of suture back through one arm of the Vet Med Assoc 208:8184, 1996.
toggle pin in the 3-oclock and 9-oclock positions prevents rota- 4. Flynn MF, Edmiston DN, Roe SC, et al: Biomechanical evaluation of
tion and eliminates uncertainty with regard to final orientation a toggle pin technique for management of coxofemoral luxation. Vet
after insertion. Surg 23(5):311321, 1994.
CHAPTER 16 I N T R A C A P S U L A R S TA B I L I Z AT I O N O F H I P L U X AT I O N 45

P L AT E 1 6

D
Aiming device

E
F1 F2

Suture passer
46 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

HIP

Femoral Head and Neck


CHAPTER 17

Ostectomy with Joint Capsule Interpolation


INDICATIONS 1 femur is parallel to the operating table (Plate 17B). Visualize the
Candidates include dogs with recurrent or chronic coxofemoral osteotomy line from the medial aspect of the great trochanter to
luxation, intra-articular coxofemoral fractures that are not the most proximal aspect of the lesser or second trochanter (Plate
amenable to reduction and stabilization, degenerative joint dis- 17C). Direct the saw blade or osteotome caudally to ensure com-
ease secondary to hip dysplasia, and avascular necrosis of the plete excision of the femoral neck and head (Plate 17D). Perform
femoral head and neck. the osteotomy and grasp the head and neck with pointed reduc-
tion forceps. Remove the femoral head and neck by severing the
OBJECTIVES 1 remaining medial joint capsule attachments. Palpate the
To relieve pain and salvage limb function in cases of osteotomy for irregularities, and remove any sharp prominences
irreparable damage to the coxofemoral joint with rongeurs or a bone file. Return the leg to normal standing
position, and place it through a range of motion, putting medial
ANATOMIC CONSIDERATION pressure on the greater trochanter. If there is excessive crepitus or
Osseous anatomic landmarks for the coxofemoral joint are the bone-on-bone contact between the femur and acetabulum, remove
greater trochanter of the femur and ischial tuberosity and the more of the femoral neck with rongeur, file, or oscillating saw.
ilial wing of the pelvis. The curvilinear incision should center on Flush the joint and suture the joint capsule over the acetabular
the cranial edge of the greater tubercle. Distally it extends cra- fossa. The deep gluteal may also be sutured over the acetabulum
nial and parallel to the proximal third of the shaft of the femur. if joint capsule coverage is deemed insufficient. Closure is routine.
Muscular landmarks include the biceps femoris, the gluteals,
and the vastus lateralis. To establish normal tissue relationships, CAUTIONS
the hip should be reduced before the surgical approach is begun. Proper orientation of the osteotomy is essential to ensure com-
plete removal of the femoral head and neck. Soft tissue inter-
EQUIPMENT polation will not compensate for a poor cut.
Standard surgical pack, two medium or large Gelpi retractors
(depending on the size of the dog), periosteal elevator, oscillat- POSTOPERATIVE EVALUATION
ing saw, osteotome and mallet or Gigli wire, rongeur, bone file Postoperative radiographs are indicated to evaluate the
osteotomy. Limb function and range of motion should be evalu-
PREPARATION AND POSITIONING ated at suture removal and at 6 to 8 weeks.
Prepare the rear limb circumferentially from dorsal midline to
mid-tibia. Position the animal in lateral recumbency with the POSTOPERATIVE CARE
affected limb up. Drape the limb out from a hanging position to Exercise and physical therapy after surgery should be encour-
allow maximal manipulation during surgery. aged. Frequent leash walks and passive range-of-motion exer-
cise will improve limb function and use.
PROCEDURE
Approach:2 Use a craniolateral approach to the coxofemoral EXPECTED OUTCOME 1
joint. Incise the skin and subcutaneous tissue 5 cm proximal to Results of this surgery vary among animals. Factors reported to
the greater trochanter, curving distally adjacent to the cranial influence limb function include patient temperament, concurrent
ridge of the trochanter and extending distally from 5 cm over orthopedic disorders, body weight, chronicity of lameness before
the proximal femur. Incise between the tensor fasciae latae surgery, preexisting muscle atrophy, extent of surgically induced
muscle and deep border of the biceps femoris muscle and trauma, completeness of excision, and postoperative activity and
superficial gluteal muscle. Retract the tensor fasciae latae cra- physical therapy. Of these factors, body weight has been impli-
nially, the biceps caudally, and the middle gluteal muscle proxi- cated as critical. Dogs that weigh less than 17 kg are reported to
mally. Incise the deep gluteal muscle close to its attachment on have good to excellent clinical results. Decreased efficacy has
the trochanter for one third to one half of its width. Incise the been attributed to greater body mass and increased bony con-
joint capsule parallel to the long axis of the femoral neck near tact between the femur and acetabulum during weight bearing.
its proximal ridge. Continue the joint capsule incision laterally
through the point of origin of the vastus lateralis muscle on the
References
cranial face of the proximal femur. Reflect the vastus lateralis
1. Lewis DD: Femoral head and neck excision and the controversy
distally to expose the head and neck of the femur (Plate 17A).
concerning adjunctive soft tissue interposition. Compend Contin
Femoral Head and Neck Excision: Subluxate the
Educ Pract Vet 14:14631473, 1992.
femoral head by placing lateral traction with pointed reduction 2. Piermattei DL, Johnson KA: Approach to the craniodorsal aspect of
forceps on the greater trochanter. Sever the round ligament, if it the hip joint through a craniolateral incision. In An Atlas of Surgical
is intact, with Mayo scissors, and fully luxate the hip. Rotate the Approaches to the Bones and Joints of the Dog and Cat, 4th ed.
limb externally so that the patella is directed at the ceiling and the Philadelphia, WB Saunders, 2004.
CHAPTER 17 F E M O R A L H E A D A N D N E C K O S T E C TO M Y 47

P L AT E 1 7

A
Middle gluteal muscle
retracted proximally

Deep gluteal muscle

Tensor fasciae latae


muscle retracted cranially Vastus lateralis muscle
retracted distally
Incision in joint capsule

Biceps femoris muscle


retracted caudally

C
Maxi driver
blade directed caudally

Externally
rotated limb

Patella is
directed at ceiling
48 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

HIP

CHAPTER 18 Triple Pelvic Osteotomy


INDICATIONS 1 PREPARATION AND POSITIONING
Candidates include immature dogs with coxofemoral laxity and Prepare the entire hindquarter circumferentially to allow access
subluxation with minimal radiographic signs of degenerative to the pubis, tuber ischii, and ilium from dorsal and ventral
joint disease. midline to mid-tibia. Place a pursestring suture to prevent fecal
contamination. Position the animal in dorsal recumbency with
OBJECTIVES 2 the affected limb up. Drape the limb out from a hanging position
To improve joint stability and function by providing greater to allow maximal manipulation during surgery.
dorsal coverage of the femoral head by rotating the dorsal
rim of the acetabulum laterally PROCEDURE
Pubic Ostectomy:3 With the dog in dorsal recumbency,
ANATOMIC CONSIDERATIONS incise the skin and subcutaneous tissues over the pubis, cen-
Three separate surgical approaches and osteotomies of the tering on the pectineal muscle as it inserts on the iliopectineal
pelvis are necessary to free the acetabular segment for axial eminence. Elevate the gracilis and adductor muscles from the
rotation and improved dorsal femoral head coverage. The pubic pubis, and severe the prepubic tendon and pectineus from its
osteotomy is performed first and includes removal of the cranial aspect. Place two Hohmann retractors ventral to the
pubic ramus. Osseus anatomic landmarks include the pelvic proposed osteotomy sites to protect the underlying soft tissues
symphysis, the iliopubic eminence, and the ventral aspect of the and the obturator nerve (Plate 18A). Using an oscillating saw,
coxofemoral joint. Pertinent soft tissue landmarks include the Gigli wire, or osteotome and mallet, perform the first osteotomy
origin of the pectineus muscle on the iliopectineal eminence, medial to the iliopubic eminence, and the second osteotomy
the prepubic tendon, and the adductor and gracilis muscles. near the medial limit of the obturator foramen. Remove and pre-
Care should be taken to protect the obturator nerve as it serve the segment of bone in a blood-soaked gauze as a corti-
courses through the cranial portion of the obturator foramen. cocancellous graft for the ilial osteotomy. Suture the gracilis
Osseus anatomic landmarks for the ischial osteotomy include muscle to the prepubic tendon to prevent inguinal herniation.
the tuber ischii laterally and the obturator foramen. Muscular Closure is routine.
landmarks include the internal obturator and the semitendinous Ischial Osteotomy:3 With the dog in lateral recumbency,
and semimembranosus muscles. incise the skin and subcutaneous tissue sagittally over the
ischial shelf, midway between midline and the tuber ischii.
EQUIPMENT Elevate the internal obturator, semimembranous, and semi-
Standard surgical pack, two medium or large Gelpi retractors tendinosus muscles off of the ischial shelf. Perform an
(depending on the size of the dog), periosteal elevator, oscil- osteotomy of the ischium beginning from the most lateral
lating saw, osteotome and mallet, Gigli wire or reciprocating aspect of the obturator foramen with a reciprocating saw or
saw, rongeur, two Hohmann retractors, Kern bone-holding Gigli wire (Plate 18B). The osteotomy is not stabilized. Closure
forceps, plating equipment, drill, and Canine Pelvic is routine.
Osteotomy plate* Continued

*Canine Pelvic Osteotomy Plate, Slocum Enterprises, Eugene, Oregon.


CHAPTER 18 T R I P L E P E LV I C O S T E O T O M Y 49

P L AT E 1 8

Prepubic
tendon
A

Section of
pubic ramus
to be Pectineus
removed muscle

Adductor
muscle

Gracilis
muscle

Ischial Ischial
osteotomy site osteotomy
50 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

Ilial Osteotomy and Stabilization:3,4 Incise the skin second cranial screw and filling the ischial cerclage hole with a
and subcutaneous tissue from the center of the iliac crest to the screw or cerclage.
greater trochanter. Following muscle planes, incise the deep
gluteal fascia between the tensor fascia latae and the middle POSTOPERATIVE EVALUATION
gluteal muscle from the ventral iliac spin to the cranial border Postoperative radiographs are indicated to evaluate osteotomy
of the biceps femoris muscle. Preserving the cranial gluteal and implant position and acetabular coverage. Radiographs
artery, vein, and nerve, sharply elevate the origin of the middle should be repeated at 6- to 8-week intervals to evaluate implant
and deep gluteal muscles cranially and dorsally to expose the position and acetabular coverage until the ilial union is complete.
ilial shaft. Cauterize the iliolumbar vessels as necessary.
Continue elevating the soft tissues off of the ilial wing medially, POSTOPERATIVE CARE
being careful not to injure the sciatic nerve. Palpate the caudal The animal should be confined to a small area or kennel until
extent of the sacrum and position two large, blunt Hohmann the ilial union is evident. Activity should be limited to outside
retractors medial to the ilium to protect the sciatic nerve (Plate leash walks for urination and defecation. Care should be taken
18C). Perform the osteotomy of the ilial wing with an oscillating to avoid stairs and slippery surfaces.
saw. Be sure the osteotomy is caudal to the sacroiliac joint and
perpendicular to a reference pin positioned parallel to the ven- EXPECTED OUTCOME 5,6
tral third of the ilial wing to the tuber ischii (Plate 18D). Move Outcome is usually good to excellent. Force plate analysis
the acetabular segment cranially and laterally with Kern bone- confirms that weight-bearing forces improve in operated versus
holding forceps, and remove the sharp spike of the ilium of the nonoperated hips. Ninety-two percent of the clinical signs asso-
caudal segment with an oscillating saw or rongeurs. Preserve ciated with lameness and gait abnormalities resolve with min-
the bone segment as a corticocancellous graft for the ilial imal progression of degenerative joint disease in dogs
osteotomy. Attach the Canine Pelvic Osteotomy Plate to the undergoing this procedure. In a separate clinical study, loco-
caudal segment 3 mm dorsal to the ventral margin with motor, physical, and owners evaluation demonstrate the supe-
3.5-mm cortical screws (Plate 18E). Drill, measure, and tap the riority of the triple pelvic osteotomy over medical treatment
plate holes in the following order: 1, 2, and 3. Rotate the acetab- and excision arthroplasty.
ular segment caudolaterally, and fix the plate to the cranial ilial
segment. Drill, measure, and tap the plate holes in the following References
order: 4, 5, and 6. The small hemi cerclage hole in the caudal 1. Simmons S, Johnson AL, Schaeffer DJ: Risk factors for screw
half of the plate may be left open or filled with a 2.7-mm screw. migration after triple pelvic osteotomy. J Am Anim Hosp Assoc
37(3):269273, 2001.
The hip should now be stable and the Ortolani sign eliminated.
2. Graehler RA, Weigel JP, Pardo AD: The effects of plate type, angle of
If not, the plate can be removed and replaced with another plate ilial osteotomy, and degree of axial rotation on the structural
of increased angle. Most coxofemoral joints in dogs are anatomy of the pelvis. Vet Surg 23:1320, 1994.
sufficiently stable with 20 to 30 degrees of rotation. Joints that 3. Slocum B, Slocum TD: Pelvic osteotomy. In Bojrab MJ (ed): Current
require more rotation may not have sufficient acetabular depth Techniques in Small Animal Surgery, 4th ed. Baltimore, Williams &
to warrant the triple pelvic osteotomy procedure. Lavage, place Wilkins, 1998.
the corticocancellous graft along the osteotomy, and suture 4. Piermattei DL, Johnson KA: Approach to the ilium through a lateral
the deep gluteal to the sartorius fascia. The remainder of the incision. In An Atlas of Surgical Approaches to the Bones and Joints
closure is routine. of the Dog and Cat, 4th ed. Philadelphia, WB Saunders, 2004.
5. Plante J, Dupuis J, Beauregard G, et al: Long-term results of conser-
vative treatment, excision arthroplasty and triple pelvic osteotomy
CAUTIONS 1
for the treatment of hip dysplasia in the immature dog: Part 1:
Caution should be taken to protect the cranial gluteal, obtu- Radiographic and physical results. Vet Comp Ortho Traum
rator, and sciatic nerves. Premature screw loosening and migra- 10:101110, 1997.
tion are commonly associated with the cranial portion of the 6. McLaughin RM, Miller CW, Taves CL, et al: Force plate analysis of
plate. Factors associated with decreased screw migration triple pelvic osteotomy for the treatment of canine hip dysplasia. Vet
include increasing the depth of sacral purchase in the first and Surg 20:291297, 1991.
CHAPTER 18 T R I P L E P E LV I C O S T E O T O M Y 51

P L AT E 1 8

Middle gluteal
C muscle D Osteotomy
line

Cranial gluteal Ilial


artery and vein osteotomy
Deep Reference line for
gluteal muscle ilial osteotomy

Tensor Shaft of
fasciae ilium
latae muscle

6 5 1
4 3
2
Canine pelvic Rotated segment
osteotomy plate of pelvis
52 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

STIFLE

CHAPTER 19Medial Patella Luxation Stabilized


with Wedge Recession Trochleoplasty,
Desmotomy, Tibial Tuberosity Transposition,
and Retinacular Imbrication
INDICATIONS recumbency at the end of the surgery table to allow for maximal
Candidates include clinically lame animals with Putmanns manipulation and visualization of the stifle joint during surgery.
grade II and above patella luxations.
PROCEDURE 2,3
OBJECTIVES Lateral Arthrotomy and Medial Desmotomy: Incise
To improve limb function and prevent degenerative joint dis- the skin and subcutaneous tissue in a curvilinear fashion on the
ease by anatomic realignment and stabilization of the patella craniolateral aspect of the stifle (Plate 19A). The middle third of
within the trochlear groove the incision should center on the patellar tendon. Reflect the
skin and subcutaneous tissue laterally with blunt dissection.
ANATOMIC CONSIDERATIONS 1,2 Return the patella to its normal orientation within the trochlear
The patella is the largest sesamoid bone in the body; it is groove, and incise the lateral retinaculum and joint capsule
located within the tendon of insertion of the quadriceps muscle from the cupola to the tibial plateau to release the patella and
group. The quadriceps muscle group, formed by the rectus expose the joint. If the cranial sartorius and vastus medialis
femoris, vastus lateralis, vastus medialis, and vastus inter- muscles inhibit patellar alignment, release the insertions of
medius muscles, converges on the patella and continues as the these muscles at the proximal patella. Examine the cruciate
patellar ligament to insert on the tibial tuberosity. The vastus ligaments and menisci to check for tears caused by stifle insta-
lateralis and medialis have additional attachments to the patella bility, and excise as necessary. Delay closure of the joint until
by medial and lateral parapatellar fibrocartilages, which aid in patella alignment and stability are assessed.
stifle stability through contact with the ridges of the femoral Wedge Recession Trochleoplasty: With the stifle in
trochlear. Originating from the fabella and merging with the flexion and the patella luxated, cut the abaxial and axial mar-
medial and lateral parapatellar fibrocartilages are the collagen gins of the wedge osteotomy using the fine-toothed saw (Plate
fibers of the medial and lateral retinacula. The patella articu- 19B1). Keep the margins of the cut wide enough to accommo-
lates within the trochlear groove, which is formed by the date the width of the patella. Remove the wedge and deepen the
trochlear ridges of the medial and lateral condyle. The medial recession in the trochlea by removing additional bone from
trochlear ridge is thicker than the lateral in normal dogs. Proper either side of the trochlear ridge with a file or an additional
anatomic alignment of the extensor mechanism is a straight line osteotomy, sliced parallel to the original cut. Resect the basilar
of force; this is necessary for stability of the patella. The patella surface of the osteochondral wedge with rongeurs to allow the
functions in the extensor mechanism of the stifle to provide cartilage to seat deeply into the new femoral groove patella
cranial and rotary stability to the joint and serves as a lever (Plate 19B2). Additional trochlear depth can be achieved by
arm, preserving even tension of the extensor mechanism during rotating the wedge 180 degrees. Replace the patella, and
extension of the stifle. examine limb alignment and patellar stability. With the stifle
and tarsus flexed at 90 degrees, the patella, tibial tuberosity, and
EQUIPMENT tarsus should follow the same linear orientation. After evalu-
Standard surgical pack, small Hohmann retractor, fine- ating limb alignment, flex and extend the stifle while internally
toothed saw,* bone cutters or osteotome and mallet, Freer and externally rotating the pes. If the patella luxates or appears
periosteal elevator, Kirschner wires, wire driver malaligned, a desmotomy and tibial tubercle transposition are
indicated.
PREPARATION AND POSITIONING Continued
Prepare the leg circumferentially from dorsal midline to below
the tarsus. Use a hanging leg preparation with the dog in dorsal

*X-ACTO Inc., Long Island City, New York.


CHAPTER 19 M E D I A L PAT E L L A L U X AT I O N 53

P L AT E 1 9

Incision in lateral
retinaculum Wedge resected
Biceps B1
femoris
Additional wedge resected
muscle
on either side

B2 Osteochondral
wedge replaced

Patella
Cranialis
tibialis
muscle

M L

Cranialis tibialis
muscle reflected
54 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

Tibial Tubercle Transposition: Incise the lateral retina- transposition is imperative to a successful outcome of the sur-
culum and joint capsule, extending the parapatellar incision dis- gery. Retinacular imbrication and joint capsule closure should
tally to the tibial tubercle. Elevate the cranial tibial muscle from be evaluated after each imbricating suture to ensure a balanced
the tibia to the level of the long digital extensor tendon. Perform and stable closure.
a partial osteotomy of the tibial tubercle, preserving the distal
periosteal attachment of the tibial tubercle to serve as a biolog- POSTOPERATIVE EVALUATION
ical tension band using bone cutters or an osteotome and mallet Radiographs should be evaluated for patellar alignment and
(Plate 19C1). Rongeur an osseus bed for the tibial tubercle to implant placement. Radiographs should be repeated every 6 to
reside in, and with the stifle and tarsus flexed at 90 degrees, 8 weeks until the osteotomy site is healed.
lever the tibial tubercle laterally with a periosteal elevator so
that it is in alignment with the patella and tarsus. Stabilize the POSTOPERATIVE CARE
tubercle with two divergent Kirschner wires directed caudally The limb should be placed in a soft, padded bandage for 1 to
and slightly proximally, engaging but not extending beyond the 2 days. Activity should be restricted to walks on a leash until the
caudal cortex of the tibia (Plate 19C2). Reevaluate patellar osteotomy site is healed. Passive range-of-motion exercises
alignment and stability, and relocate the tuberosity if needed. may help maintain muscle mass and stifle range of motion.
Cut and bend the Kirschner wires to prevent soft tissue irrita-
tion and facilitate removal if migration occurs. EXPECTED OUTCOME 3
Joint Capsule Closure and Retinacular Imbrication: Outcome is usually good to excellent. The prognosis depends
Excise excessive lateral joint capsule and perform a balanced on the age of the patient at the time of surgery, the body weight
closure of the joint capsule and retinaculum. Check patellar sta- and condition score, and the amount of degenerative joint dis-
bility after each imbricating suture. Imbricate the lateral joint ease present prior to surgery. Degenerative joint disease pro-
capsule and lateral patellar tendon. Recheck patellar stability. gresses despite surgical correction and is positively correlated
Close the lateral and medial retinaculum with a vest-over-pants with the animals age at surgery.
pattern (modified Mayo mattress pattern) (Plate 19D). After
each suture is placed, evaluate patellar stability. Closure of the
medial joint capsule may not be indicated in higher grades of References
patellar luxation. Allow the medal arthrotomy to separate, and 1. Roush JK: Canine patellar luxation. Vet Clin North Amer 23:855875,
do not suture the cut edges if medial luxation is severe. Close 1992.
the subcutaneous tissue and skin over the arthrotomy and 2. LEplattenier H, Montavon P: Patellar luxation in dogs and cats:
Pathogenesis and diagnosis. Compend Contin Educ Pract Vet
retinacular incisions.
24:234239, 2002.
3. LEplattenier H, Montavon P: Patellar luxation in dogs and cats:
CAUTIONS 4 Management and prevention. Compend Contin Educ Pract Vet
The most common complication associated with surgical repair 24:292300, 2002.
of patella luxation is recurrence of the luxation. Correction of 4. Willauer CC, Vasseur PB: Clinical results of surgical correction of
the malalignment of the extensor mechanism via tibial tubercle medial luxation of the patella in dogs. Vet Surg 16:3136, 1987.
CHAPTER 19 M E D I A L PAT E L L A L U X AT I O N 55

P L AT E 1 9

C1

C2

D
Biceps
femoris
muscle

Modified Mayo mattress suture

Cranialis tibialis
muscle reflected
56 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

STIFLE

CHAPTER 20 Deranged Stifle Luxation


Stabilized with Suture Anchors, Screws,
and Suture
INDICATIONS 14 and baby Ochsner forceps for joint inspection and cruciate lig-
Surgical stabilization and internal fixation is indicated in ani- ament dbridement.
mals with gross instability of the stifle resulting from multiple
ligament injury. The most common structures injured in the PREPARATION AND POSITIONING
luxated stifle are the cranial and caudal cruciate, and either Prepare the leg circumferentially from dorsal midline to below
the lateral or medial collateral ligament. Reconstruction of the the tarsus. Use a hanging leg preparation with the dog in dorsal
collateral and cranial cruciate ligaments and careful repair or recumbency at the end of the surgery table to allow for maximal
removal of damaged menisci and joint capsule is an effective manipulation and visualization of the stifle joint during surgery.
treatment method for medium and large dogs. Reconstruction
of the caudal cruciate ligament and postoperative limb support PROCEDURE
is not found to be essential. Approach:57 Incise the skin and subcutaneous tissue in a
curvilinear fashion on the craniolateral aspect of the stifle. The
OBJECTIVES middle third of the incision should center on the patellar
To restore normal stability, congruency, mobility, and func- tendon. Reflect the skin and subcutaneous tissue medially and
tion to the stifle joint laterally with blunt dissection. Perform a medial arthrotomy,
and incise the joint capsule from the cupula to the tibial plateau
ANATOMIC CONSIDERATIONS 2,4 to expose the joint. Luxate the patella, and flex the limb.
The stifle joint is primarily stabilized by the cranial and caudal Examine the cruciate ligaments and menisci to check for tears,
cruciate ligaments, the medial and lateral collateral ligaments, and excise/dbride as necessary. Lavage and close the joint. To
the joint capsule, and menisci. Additional stability may be expose the medial collateral ligament, sharply incise the fascia
provided by the patellar tendon, quadriceps, and popliteal of the caudal belly of the sartorius and elevate its insertion
musculature. caudally to the level of the ligament (Plate 20A). To expose the
lateral collateral ligament, incise the aponeurosis of the biceps
EQUIPMENT femoris muscle just cranial to the muscle fibers and elevate the
Standard surgical pack, two medium or large Gelpi retractors biceps femoris and attached fascia lata caudally to the level of
(depending on the size of the dog), periosteal elevator, Jacob the ligament. Before cranial cruciate repair is begun, stabilize
chuck and key, intramedullary pins, mallet, 20- to 80-pound the collateral ligament(s) to restore normal joint alignment and
fishing leader line,* suture anchor system, and crimp clamp congruity.
system Collateral Ligament Repair: Inspect the ligament for
Alternatively, a bone tunnel and screw and washer combina- tears or avulsions. Repair avulsed intact ligaments with a screw
tion may be used if a suture anchor system is not available or if and spiked plastic washer (Plate 20B1). As a general rule,
the animal is not large enough to accommodate the suture repair mid-substance tears with a locking loop suture (Plate
anchor system. Additional instrumentation needed for this tech- 20B2). Then protect the repaired ligament with screws,
nique includes a high-speed drill, bone screw and washer, drill washers, and heavy suture; wire placed in a figure-eight suture
bit, tap, depth gauge, screwdriver, and baby Hohmann retractor pattern; or suture anchors (Plate 20B3).
Continued

*The 20-, 40-, 60-, 80-, 100-pound test is available through Mason Tackle Company,
Otisville, Michigan.

Innovative Animal Products, Rochester, Minnesota.



Securos Veterinary Orthopedics, Charlton, Massachusetts. Synthes, Monument, Colorado.
CHAPTER 20 D E R A N G E D S T I F L E L U X AT I O N 57

P L AT E 2 0

A B1

Caudal head of
sartorius
muscle reflected

Ruptured medial
collateral ligament
and joint capsule

B2 B3

Suture anchor threaded


with two sutures
inserted in femur

Anchor locked beneath


cortices
Locking loop
repair
58 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

Cranial Cruciate Ligament Repair: To expose the in many cases surgical inspection of the stifle is often necessary
lateral collateral ligament, incise the aponeurosis of the biceps for definitive diagnosis.
femoris muscle just cranial to the muscle fibers, and bluntly ele-
vate the biceps femoris and attached fascia lata caudally to the POSTOPERATIVE EVALUATION
level of the ligament. Palpate the fabella and fibular head for The range of motion should be evaluated, and the stifle should
proper anatomic orientation of the lateral fabellar suture. Pass be checked for cranial drawer before the patient awakens. The
the appropriate-size monofilament fishing leader line through stifle should be radiographed to assess implant positioning and
the eye of a Martin uterine needle, and pass the needle around joint congruency.
the cranial half of the fabella from proximal to distal. As a gen-
eral rule, use 1 pound of test per pound of body weight. Drill a POSTOPERATIVE CARE
hole with intramedullary pin and Jacob chuck of sufficient size Exercise should be restricted to outside leash walks for urina-
to pass the eye of the needle through the tibial crest from lateral tion and defecation, and the animal should be confined to a
to medial. The hole should be proximal to the most prominent kennel for the first 4 to 6 weeks. Then the animals activity
point of the tibial tuberosity, in order to estimate the insertion should slowly be returned to normal.
of the cranial cruciate ligament. Pass the suture under the soft
tissues of the cranial tibia to avoid muscle entrapment and pre- EXPECTED OUTCOME 3
mature loosening of the lateral fabellar suture from tissue Because of the traumatic nature of this disease, concomitant
necrosis. Pass the leader line from lateral to medial through the injuries are common and must be addressed prior to surgery;
hole in the tibial crest and then under the patellar ligament however, they do not justify a worse prognosis in dogs with
immediately proximal to the tibial tuberosity. Cut the leader line stifle luxation. Delaying surgery to stabilize the patient is often
in half to remove the needle, obtaining two sutures to tie. Flex necessary and also does not contribute to any difference in out-
the stifle to a normal standing angle, hold the tibia caudally and come. The long-term prognosis with stifle stabilization is fair to
rotated externally to remove drawer motion, and tie each suture good, despite decreases in range of motion and reductions of
individually. Using the Securos crimp clamp system, slide one muscle mass of the affected limb. Mild to moderate degenera-
suture end at a time through the surgical crimp clamps and pull tive joint disease and gait abnormalities may be expected in
the ends so that the loop becomes taut (Plate 20C). Slide the cases with questionable cartilage viability or obvious cartilage
additional crimp clamps on each end of the suture, positioning trauma.
them 2 mm to 3 mm from the center crimp clamp. Use the crimp
tool to firmly crimp the clamp on the individual strands. Slide References
the slotted tips of the tensioning device over the suture, and 1. Aron DN: Traumatic dislocation of the stifle joint: Treatment of 12
squeeze the arms of the tensioning device one click at a time, dogs and one cat. J Am Anim Hosp Assoc 22:333340, 1988.
2. Welches CD, Scavelli TD: Transarticular pinning to repair luxation of
palpating for drawer and range of motion (Plate 20D). Once the
the stifle joint in dogs and cats: A retrospective study of 10 cases. J
appropriate amount of tension is obtained, crimp the middle Am Anim Hosp Assoc 26:207214, 1990.
clamp holding the two sutures three times, once in the middle 3. Hulse DA, Shires P: Multiple ligament injury of the stifle joint in the
and once on either end (Plates 20E1 and 20E2). Alternatively, dog. J Am Anim Hosp Assoc 22:105110, 1986.
use a sliding half hitch or a clamped square knot to stabilize 4. Bruce WJ: Multiple ligamentous injuries of the canine stifle joint: A
the stifle. Check the stifle for range of motion and cranial study of 12 cases. J Small Anim Pract 39:333340, 1998.
drawer after each suture is tied. Imbricate the lateral fascia 5. Piermattei DL, Johnson KA: Approach to the stifle joint through a
covering of the biceps femoris with a vest-over-pants closure. medial incision. In An Atlas of Surgical Approaches to the Bones and
Joints of the Dog and Cat, 4th ed. Philadelphia, WB Saunders, 2004.
CAUTIONS 3 6. Piermattei DL, Johnson KA: Approach to the medial collateral liga-
ment and caudomedial part of the stifle joint. In An Atlas of Surgical
Preoperative palpation should be performed and stress radio-
Approaches to the Bones and Joints of the Dog and Cat, 4th ed.
graphs of the stifle joint should be taken under sedation or gen- Philadelphia, WB Saunders, 2004.
eral anesthesia for proper assessment of the suspected injuries. 7. Piermattei DL, Johnson KA: Approach to the lateral collateral liga-
Stifle joint stability should be assessed in all planes with the ment and caudolateral part of the stifle joint. In An Atlas of Surgical
joint held in extension, normal standing angle, and 90 degrees Approaches to the Bones and Joints of the Dog and Cat, 4th ed.
flexion while maintaining the tibia in neutral position; however, Philadelphia, WB Saunders, 2004.
CHAPTER 20 D E R A N G E D S T I F L E L U X AT I O N 59

P L AT E 2 0

C
D

Lateral
fabella
Lateral
collateral
ligament

Drill hole
in tibial
crest

Tensioning
device

E1 E2

Correct Crimp Pattern

Crimps too close


to the edge
Incorrect Crimp Pattern
60 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

STIFLE

CHAPTER 21Cranial Cruciate Repair


with a Lateral Fabellar Suture
INDICATIONS Jacob chuck and key, intramedullary pin, 20- to 80-pound
Candidates include animals with stifle instability caused by par- fishing leader line,* Martin uterine needles, and crimp clamp
tial or complete cranial cruciate ligament injury as diagnosed system
via palpation or arthrotomy. Additional instrumentation needed for this technique
includes a baby Hohmann retractor, baby Ochsner forceps, and
OBJECTIVES a no. 11 blade for joint inspection and cruciate ligament
To improve limb function by stabilization of the stifle and dbridement.
to prevent cranial displacement of the tibial plateau via an
external suture strut to temporarily support the limb in neu- PREPARATION AND POSITIONING
tral drawer position Prepare the leg circumferentially from dorsal midline to below
the tarsus. Use a hanging leg preparation with the dog in dorsal
ANATOMIC CONSIDERATIONS 1 recumbency at the end of the surgery table to allow for maxi-
The cranial cruciate ligament is composed of two elements: mal manipulation and visualization of the stifle joint during
(1) the craniomedial and (2) the caudal lateral band. It has three surgery.
important functions in defining stifle motion and stability.
Together the bands work to limit joint hyperextension and PROCEDURE
internal rotation and cranial displacement of the tibial plateau. Approach: Incise the skin and subcutaneous tissue in a curvi-
The smaller craniomedial band remains taut (and thus restricts linear fashion on the craniolateral aspect of the stifle. The
motion) in both extension and flexion of the stifle joint. The middle third of the incision should center on the patellar
more substantial caudolateral band is taut in only extension. tendon. Reflect the skin and subcutaneous tissue medially and
This seemingly minute piece of anatomic trivia is important in laterally with blunt dissection.
understanding the clinical signs associated with partial and Arthrotomy: Perform a medial arthrotomy, and incise the
complete cranial cruciate injury. If the craniomedial band is joint capsule from the cupula to the tibial plateau to expose the
disrupted, which is more commonly seen in the dog, cranial joint. Luxate the patella and flex the limb. Examine the cruciate
drawer will be only elicited in flexion, because the caudolateral ligaments and menisci to check for tears, and excise/dbride
band is lax with the stifle held in this position. If the caudo- as necessary. To dbride the injured cruciate ligament, use a
lateral band is disrupted, there may be no drawer palpable, no. 11 blade and incise the origins of the ligament within the
because the craniomedial band is still present and taut in both intercondylar notch of the caudomedial portion of the lateral
flexion and extension. If both bands are torn, drawer will be condyle (Plate 21A). Take care not to injure the caudal cruciate
palpable in both flexion and extension. ligaments where they cross each other near attachments in
the intercondylar fossa of the femur. This may be achieved
EQUIPMENT with three incisions. Lavage and close the joint in one or two
Standard surgical pack, one medium or large Gelpi retrac- layers, making sure to appose the synovial layer with either
tor (depending on the size of the dog), periosteal elevator, method.
Continued

*The 20-, 40-, 60-, 80-, 100-pound test is available through Mason Tackle Company,
Otisville, Michigan.

Innovative Animal Products, Rochester, Minnesota.
CHAPTER 21 C R A N I A L C R U C I AT E R E PA I R W I T H A L AT E R A L FA B E L L A R S U T U R E 61

P L AT E 2 1

Cranial
cruciate Cut 2
ligament Cut 1

Cut 3

Medial
meniscus
62 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

Lateral Fabellar Suture:2,3 To expose the lateral collat- CAUTIONS 2,4


eral ligament, incise the aponeurosis of the biceps femoris Activity should be restricted to short walks on a leash to pre-
muscle just cranial to the muscle fibers, and bluntly elevate the vent premature breakdown of the stifle stabilization. Risk of early
biceps femoris and attached fascia lata caudally to the level of failure may be higher with poor fabella anchorage; therefore,
the ligament (Plate 21B). Palpate the fabella and fibular head for particular attention should be paid to needle position relative to
proper anatomic orientation of the lateral fabellar suture. Pass fabella anatomy. Meniscal damage is reported in 45% of cranial
the appropriate-size monofilament fishing leader line through the cruciate rupture, with the medial meniscus being most commonly
eye of a Martin uterine needle, and pass the needle around affected. Careful assessment of both menisci is important because
the cranial half of the fabella from proximal to distal. As a gen- damaged menisci should be partially dbrided or excised.
eral rule, use 1 pound of test per pound of body weight. Drill a
hole with intramedullary pin and Jacob chuck of sufficient size POSTOPERATIVE EVALUATION 4
to pass the eye of the needle through the tibial crest from lateral The range of motion should be evaluated and the stifle for cra-
to medial. Make the hole proximal to the most prominent point nial drawer should be checked before the patient awakens. It is
of the tibial tuberosity in order to estimate the insertion of the not necessary to radiograph the stifle to assess implant posi-
cranial cruciate ligament. Pass the suture under the soft tissues tioning and joint congruency in this repair.
of the cranial tibia to avoid muscle entrapment and premature
loosening of the lateral fabellar suture from tissue necrosis. POSTOPERATIVE CARE
Pass the leader line from lateral to medial through the hole in The leg should be placed in a soft, padded bandage for 24 hours
the tibial crest and then under the patellar ligament immedi- to cover the wound and provide support. Exercise should be
ately proximal to the tibial tuberosity. Cut the leader line in half restricted and the animal should be confined to a kennel for
to remove the needle, obtaining two sutures to tie. Flex the the first 4 to 6 weeks. Then normal activity should slowly be
stifle to a normal standing angle, hold the tibia caudally and reintroduced.
rotated externally to remove drawer motion, and tie each suture
individually. Using the Securos crimp clamp system, slide one EXPECTED OUTCOME
suture end at a time through the surgical crimp clamps and pull Osteoarthritis is a common sequela to cranial cruciate rupture,
the ends so that the loop becomes taut. Slide the additional particularly when meniscal damage is present. However, the
crimp clamps on each individual end of the suture, positioning prognosis is good to excellent with proper postoperative care
them 2 mm to 3 mm from the center crimp clamp (Plate 21C). and confinement.
Use the crimp tool to firmly crimp the clamp on the individual
strands. Slide the slotted tips of the tensioning device over the References
suture, and squeeze the arms of the tensioning device one click 1. Hart RC, Hulse DA, Slater MR: Contribution of periarticular tissue to
at a time, palpating for drawer and range of motion (Plate 21D). stabilization of the canine stifle joint after cranial cruciate ligament
Once the appropriate amount of tension is obtained, crimp the reconstruction. Vet Comp Orthop Traumatol 16:2125, 2003.
middle clamp holding the two sutures three times, once in the 2. Lampman TJ, Lund EM, Lipowitz AJ: Cranial cruciate disease:
Current status of diagnosis, surgery, and risk for disease. Vet Comp
middle and once on either end (Plate 21E1). Alternatively, use a
Orthop Traumatol 16:122126, 2003.
sliding half hitch or a clamped square knot to stabilize the stifle.
3. Peycke LE, Kerwin SC, Hosgood G, Metcalf JB: Mechanical compar-
Check the stifle for range of motion and cranial drawer after ison of six loop fixation methods with monofilament nylon leader
each suture is tied. Imbricate the lateral fascia covering of the line. Vet Comp Orthop Traumatol 15:210214, 2002.
biceps femoris with a vest-over-pants closure (Plate 21E2) from 4. Stork CK, Gibson NR, Owen MR, et al: Radiographic features of a
the patella to the tibial crest to cover the sutures and help pre- lateral extracapsular wire suture in the canine cranial cruciate
vent seroma formation (Plate 21E3). deficient stifle. J Small Anim Pract 42:487490, 2001.

Securos Veterinary Orthopedics, Charlton, Massachusetts.


CHAPTER 21 C R A N I A L C R U C I AT E R E PA I R W I T H A L AT E R A L FA B E L L A R S U T U R E 63

P L AT E 2 1

B C D

Lateral
fabella
Lateral
collateral
ligament

Secondary
crimp clamp
Drill hole
in tibial Primary
crest crimp clamp
Secondary
crimp clamp
Tensioning
device

E1 E2

Modified Mayo mattress suture

E3

Correct Crimp Pattern

Crimps too close


to the edge
Incorrect Crimp Pattern
64 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

STIFLE

CHAPTER 22 Cranial Cruciate Repair


with Intra-articular Repair
INDICATIONS Additional instrumentation needed for this technique
Candidates include animals with stifle instability caused by par- includes baby Hohmann retractor, baby Ochsner forceps, and
tial or complete cranial cruciate ligament injury as diagnosed a no. 11 blade for joint inspection and cruciate ligament
via palpation or arthrotomy. dbridement.

OBJECTIVES PREPARATION AND POSITIONING


To improve limb function and prevent degenerative joint dis- Prepare the leg circumferentially from dorsal midline to below
ease by stabilization of the stifle, and to prevent cranial dis- the tarsus. Use a hanging leg preparation with the dog in dorsal
placement of the tibial plateau by replacing the cranial crucial recumbency at the end of the surgery table to allow for maximal
ligament with an autogenous internal graft manipulation and visualization of the stifle joint during surgery.

ANATOMIC CONSIDERATIONS 1 PROCEDURE


The cranial cruciate ligament is composed of two elements: Approach: Incise the skin and subcutaneous tissue in a curvi-
(1) the craniomedial and (2) the caudal lateral band. It has three linear fashion on the craniolateral aspect of the stifle. Center
important functions in defining stifle motion and stability. the middle third of the incision on the patellar tendon. Reflect
Together the bands work to limit joint hyperextension and the skin and subcutaneous tissue medially and laterally with
internal rotation and cranial displacement of the tibial plateau. blunt dissection.
The smaller craniomedial band remains taut (and thus restricts Arthrotomy and Notchplasty:2,3 Perform a lateral
motion) in both extension and flexion of the stifle joint. The arthrotomy, and incise the joint capsule from the cupula to the
more substantial caudolateral band is taut in only extension. tibial plateau to expose the joint, taking care not to damage the
This seemingly minute piece of anatomic trivia is important in long digital extensor tendon (Plate 22A). Luxate the patella and
understanding the clinical signs associated with partial and flex the limb. Examine the cruciate ligaments and menisci to
complete cranial cruciate injury. If the craniomedial band is check for tears and excise/dbride as necessary. To dbride the
disrupted, which is more commonly seen in the dog with partial injured cruciate ligament, use a no. 11 blade, and incise
cranial cruciate injury, cranial drawer will be elicited only in the origins of the ligament within the intercondylar notch of
flexion, because the caudolateral band is lax with the stifle held the caudomedial portion of the lateral condyle. Take care not to
in this position. If the caudolateral band is disrupted, there may injure the caudal cruciate ligaments where they cross each
be no palpable drawer at all, because the craniomedial band is other near attachments in the intercondylar fossa of the femur.
still present and taut in both flexion and extension. If both Perform a notchplasty with a bone rasp, curette, or rongeur,
bands are torn, drawer will be palpable in both flexion and removing any osteophytes and widening the lateral wall of the
extension. intercondylar notch to allow adequate space to pass the graft
and to protect the graft from impingement of the craniolateral
EQUIPMENT wall of the intercondylar fossa (Plate 22B). Lavage the joint and
Standard surgical pack, one medium or large Gelpi retractor return the patella to its original position.
(depending on the size of the dog), periosteal elevator, drill, Continued
drill bit, screws, plastic washers, rongeurs, bone rasp, curette,
straight needle and/or cerclage wire
66 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

Intracapsular Graft:1,2,3 Harvest a 10-cm graft from the POSTOPERATIVE EVALUATION 5


craniolateral aspect of the distal fascia lata and lateral third of The range of motion should be evaluated, and the stifle should
the patellar tendon, using the arthrotomy incision as the caudal be checked for cranial drawer before the patient awakens. It is
border of the graft. Free the graft and its bony insertion onto the not necessary to radiograph the stifle to assess implant posi-
tibial plateau with an osteotome while maintaining its distal fas- tioning and joint congruency in this repair.
cial attachments (see Plate 22A). Create a tibial tunnel with a
drill bit large enough to accept the graft from the cranial surface POSTOPERATIVE CARE
of the tibia (see Plate 22B). Alternatively, use a guide wire fol- The leg should be placed in a soft, padded bandage for 24 hours
lowed by a cannulated drill bit to ensure accuracy of the graft to cover the wound and provide support. Exercise should be
placement. The entry point location of the tunnel is just lateral restricted and the animal should be confined to a kennel for
and distal to the tibial tuberosity, exiting into the joint at the the first 4 to 6 weeks. Then normal activity should be slowly
point of insertion of the cranial cruciate ligament (Plate 22C). reintroduced.
Place one or two stay sutures in the end of the graft using large
diameter monofilament suture (0 or 1) or cerclage wire. Thread EXPECTED OUTCOME
the stay suture with a straight needle or loop of cerclage wire Osteoarthritis is a common sequela to cranial cruciate rupture,
through the bone tunnel in the tibia from distal to proximal. particularly when meniscal damage is present; however, the
Place the graft through the intercondylar notch by passing prognosis is good to excellent with proper postoperative care
curved Kelly or Carmalt forceps over the top of the lateral and confinement.
condyle or by creating a separate femoral tunnel extending
from the point of origin of the cranial cruciate to the caudolat-
eral aspect of the femoral condyle and passing the straight
needle or looped cerclage wire through the tunnel (Plate 22D). References
Secure the graft to the distal femur by suturing it to the femo- 1. Hart RC, Hulse DA, Slater MR: Contribution of periarticular tissue to
rofabellar ligament with large (0 to 2) monofilament, with non- stabilization of the canine stifle joint after cranial cruciate ligament
absorbable suture, or with a spiked screw and washer with the reconstruciton. Vet Comp Orthop Traumatol 16:2125, 2003.
stifle in standing flexion (Plate 22E). Check the stifle for range 2. Fitch RB, Montgomery RD, Kincaid SA, et al: The effect of inter-
of motion and cranial drawer after the graft is secured. condylar notchplasty on the normal canine stifle. Vet Surg
24:156164, 1996.
CAUTIONS 4,5 3. Moore KW, Read RA: Rupture of the cranial cruciate ligament in
dogs. Part II. Diagnosis and management. Compend Contin Educ
Placing excessive tension on the graft should be avoided,
Pract Vet 18(4):381391, 1996.
because it will lead to premature failure of the repair. Normally,
4. Lampman TJ, Lund EM, Lipowitz AJ: Cranial cruciate disease:
2 mm to 3 mm of drawer motion should be detected on palpa- Current status of diagnosis, surgery, and risk for disease. Vet Comp
tion. Excessive drawer may then be removed by joint capsule Orthop Traumatol 16:122126, 2003.
and fascial imbrication; however, many surgeons at this point 5. Stork CK, Gibson NR, Owen MR, et al: Radiographic features of a lat-
often reenforce the intracapsular repair with a lateral fabellar eral extracapsular wire suture in the canine cranial cruciate
suture (see Chapter 21 for details regarding this procedure). deficient stifle. J Small Anim Pract 42:487490, 2001.
CHAPTER 22 C R A N I A L C R U C I AT E R E PA I R W I T H I N T R A - A RT I C U L A R R E PA I R 67

P L AT E 2 2

D E

Site of Lateral Spiked


drill hole fibula washer

M L
68 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

STIFLE

CHAPTER 23 Meniscectomy
INDICATIONS (particularly to the caudal pole), and increases the likelihood of
Candidates include animals with meniscal damage caused by degenerative joint disease and stifle dysfunction. The medial
stifle instability from chronic partial or complete cranial cru- meniscus has been reported to be damaged in 47% to 80% of
ciate ligament injury or traumatic luxation. cranial cruciate deficient stifles and around 14% of previously
Dogs with meniscal damage usually experience more pain repaired cranial cruciate deficient stifles.4,5
and display more lameness in association with stifle instability
than in association with a pure cruciate tear. EQUIPMENT
Standard surgical pack, one medium or large Gelpi retractor
OBJECTIVES (depending on the size of the dog), baby Hohmann retractor,
To improve limb function and decrease pain associated with baby Ochsner forceps, and a no. 11 or 15 blade for joint
meniscal injury caused by entrapment of the femoral condyle inspection and cruciate ligament and meniscal dbridement
because of stifle instability or excision

ANATOMIC CONSIDERATIONS 1 PREPARATION AND POSITIONING


Dogs and cats have a medial and a lateral menisci that reside Prepare the leg circumferentially from dorsal midline to below
within the stifle joint. The functions of the menisci are complex, the tarsus. Use a hanging leg preparation with the dog in dorsal
but these structures are very important to normal stifle biome- recumbency at the end of the surgery table to allow for maximal
chanics. They are white, C-shaped, discoid, fibrocartilagenous manipulation and visualization of the stifle joint during surgery.
structures that are wedge-shaped when viewed on cross sec-
tion. Each meniscus consists of a body and a cranial and caudal PROCEDURE
pole. The medial meniscus is stabilized by cranial and caudal Approach: Incise the skin and subcutaneous tissue in a curvi-
tibial ligaments, an intermeniscal ligament, and a strong attach- linear fashion on the craniolateral aspect of the stifle. Center
ment to the medial collateral ligament. The lateral meniscus is the middle third of the incision on the patellar tendon. Reflect
less firmly attached via cranial and caudal tibial ligaments, an the skin and subcutaneous tissue medially and laterally with
intermeniscal ligament, and a caudal femoral ligament. The blunt dissection.
menisci move slightly while the stifle joint moves through its Arthrotomy: Perform a medial arthrotomy, and incise the
ranges of motion, but because of the presence of more synovial joint capsule from the cupula to the tibial plateau to expose the
attachment, the caudal tibial ligament, and the lack of a femoral joint. Luxate the patella and flex the limb. Examine the cruciate
attachment, the medial meniscus moves less than the lateral ligaments and menisci to check for tears and excise/dbride as
and therefore may be more predisposed to injury in a cranial necessary. To dbride the injured cruciate ligament, use a no. 11
cruciate deficient stifle.2 Once the cranial cruciate ligament is blade and incise the origins of the ligament within the inter-
disrupted, cranial displacement of the tibia acts to wedge the condylar notch of the caudomedial portion of the lateral
posterior horn of the medial meniscus between the tibial plateau condyle (Plate 23A). Take care not to injure the caudal cruciate
and the femoral condyle.3 Repetitive entrapment between the ligaments where they cross each other near attachments in the
femoral condyle and tibial plateau results in meniscal injury intercondylar fossa of the femur.
Continued
CHAPTER 23 M E N I S C E C TO M Y 69

P L AT E 2 3

Cranial
cruciate
ligament Cut 1 Cut 2

Cut 3

Medial
meniscus
CHAPTER 22 C R A N I A L C R U C I AT E R E PA I R W I T H I N T R A - A RT I C U L A R R E PA I R 65

P L AT E 2 2

A B

Biceps
femoris Notchplasty
muscle
Cranial cruciate
ligament dbrided
Fascia
lata strip Tibial
tunnel

Cranialis tibialis
muscle reflected
70 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

Meniscectomy: Using a baby Hohmann retractor, lever POSTOPERATIVE CARE


the tibial plateau forward by placing the tip of the instrument The leg should be placed in a soft, padded bandage for 24 hours
behind the tibial plateau while holding the stifle at a normal to cover the wound and provide support. Therapeutic exercise
standing angle (Plate 23B). Avoid excessive flexion of the joint, and rehabilitation should be strongly considered for the first 4
because it will close the joint space and limit visualization of to 6 weeks. Then normal activity should be slowly reintroduced.
the menisci. Inspect both the medial and lateral menisci for
tears or crushing injury (see Plate 23B). If only the caudal pole EXPECTED OUTCOME 7,8
is affected, perform a partial meniscectomy. Grasp the damage A guarded prognosis for full return to function is the general
portion of the meniscus firmly with Ochsner forceps and place rule when meniscal damage is present, because degenerative
cranial traction on the damaged pole. Incise the caudal menis- joint disease is a common sequela. Aggressive postoperative
cotibial ligament to release the caudal pole with a number 11 or rehabilitation has been shown to improve the function in the
15 blade (Plate 23C1). Next release the synovium and collateral case of dogs with meniscal damage.
attachments (if performing a medial meniscectomy) of the body
until healthy fibrocartilage is reached and cut perpendicularly
across the body of the meniscus to remove the caudal pole References
(Plate 23C2). If the entire meniscus is damaged, perform a com- 1. Flo GL: Meniscal injuries. Vet Clin North Am Small Anim Pract
plete meniscotomy. Incise the intermeniscal and cranial tibial 23(4):831843, 1993.
attachments of the cranial pole (Plate 23D1). Release the 2. Arnoczky SP: Pathomechanics of cruciate and meniscal injuries. In
synovium and collateral attachments (if present) while placing Bojrab MJ: Disease Mechanisms in Small Animal Surgery.
lateral traction on the cranial pole of the meniscus with an Philadelphia, Lea & Febiger, 1993.
Ochsner forceps. Finally, incise the caudal meniscotibial liga- 3. Aglietti P, Zaccherotti G, De Biase P, et al: A comparison between
ment to release the caudal pole and remove the meniscus medial meniscus repair, partial meniscectomy, and normal meniscus
in anterior cruciate ligament reconstructed knees. Clin Orthop
(Plate 23D2).
(307):165173, 1994.
Lavage and close the joint in one or two layers, making sure
4. Metelman LA, Schwarz PD, Salman M, Alvis MR: An evaluation of
to appose the synovial layer with either method. Stabilize the three different cranial cruciate ligament surgical stabilization
joint with either an extracapsular or intercapsular method to procedures as they relate to postoperative meniscal injuries: A
prevent further injury. retrospective study of 665 stifles. Vet Comp Orthop Traumatol
8(2):118123, 1995.
CAUTIONS 5. Timmermann C, Meyer-Lindenberg A, Nolte I: Meniscus injuries in
Meniscectomy should not be performed unless there is dogs with rupture of the cruciate ligament. Dtsch Tierarztl
meniscal pathology present, because either partial or complete Wochenschr 105(10):374377, 1998.
meniscectomy results in the progression of degenerative joint 6. Stork CK, Gibson NR, Owen MR, et al: Radiographic features of a
lateral extracapsular wire suture in the canine cranial cruciate
disease.
deficient stifle. J Small Anim Pract 42:487490, 2001.
7. Innes JF, Bacon D, Lynch C, et al: Long-term outcome of surgery for
POSTOPERATIVE EVALUATION 6 dogs with cranial cruciate ligament deficiency. Vet Rec
The range of motion should be evaluated and the stifle should 147(12):325328, 2000.
be checked for cranial drawer before the patient awakens. It is 8. Marsolais GS, Dvorak G, Conzemius MG: Effects of postoperative
not necessary to radiograph the stifle to assess implant posi- rehabilitation on limb function after cranial cruciate ligament repair
tioning and joint congruency. in dogs. J Am Vet Med Assoc 220(9):13251330, 2002.
CHAPTER 23 M E N I S C E C TO M Y 71

P L AT E 2 3

C1 C2

D1 D2
72 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

STIFLE

CHAPTER 24 Stifle Arthrodesis


INDICATIONS of the selected joint angle (see Plate 24B). Resect the articular
Candidates include animals with unreconstructable joint frac- portion of the tibia parallel to wire 1 and perpendicular to the
tures, stifle luxation, or severe osteoarthritis. Other candidates long axis of the tibia. Resect the articular surface of the femur
have grade 4 patellar luxations that have not responded to parallel to wire 3 and perpendicular to the long axis of the
conventional treatment.1,2 femur (see Plate 24B). Appose the femoral and tibial ostectomy
surfaces and temporarily fix them with Kirschner wires (Plate
OBJECTIVES 24C). Ensure that the guiding Kirschner wires are in the same
To fuse the bones of the femoral tibial joint in a functional plane to preserve rotational alignment. Remove the guiding
position Kirschner wires. Resect the trochlear ridges to improve plate
contact (see Plate 24B). Apply a plate of appropriate size and
ANATOMIC CONSIDERATIONS contour, allowing at least four screws in the femur and four
The landmarks for the incision are the distal femoral diaphysis, screws in the tibia. Secure the plate by first placing screws
the patella, the tibial tuberosity, and the proximal tibial through the most distal and most proximal plate holes (see
diaphysis. The tibial tuberosity is osteotomized to gain joint Plate 24C). If possible, place one or two screws as lag screws
exposure and to provide a flat surface for the plate. across the joint. Fill the remaining plate holes. Remove the sta-
bilizing Kirschner wires. Attach the tibial tuberosity to the
EQUIPMENT medial surface of the tibia with a lag screw (Plate 24D).1
Surgical pack, Senn retractors, Hohmann retractors, Gelpi
retractors, periosteal elevator, oscillating saw, self-centering CAUTIONS
plate-holding forceps, high-speed drill, wire driver and burrs, Avoid angling the saw blade medially or laterally when per-
Kirschner wires, wire cutters, plating equipment forming the tibial and femoral articular ostectomies. Check
angular and rotational alignment of the limb carefully before
PREPARATION AND POSITIONING securing the plate.
Prepare the rear limb circumferentially from dorsal midline to
the hock. Position the animal in dorsal recumbency. Drape the POSTOPERATIVE EVALUATION
limb out from a hanging position to allow maximal manipulation The axial alignment of the limb and the angle of the arthrodesis
during surgery. A cancellous bone graft is not needed because of should be critically observed. Radiographs for limb alignment
the large cancellous bone contact surfaces at the arthrodesis site. and implant placement should be evaluated.

PROCEDURE POSTOPERATIVE CARE


Approach: Incise the skin and subcutaneous tissue over the A soft, padded bandage should be placed to control bleeding
craniolateral aspect of the stifle, extending from the mid-diaphysis and swelling. A lateral splint should be used for 6 weeks or until
of the femur to the mid-diaphysis of the tibia. Incise the lateral early radiographic evidence of bone bridging is observed.
retinaculum, and retract the quadriceps muscle and patella medi- Radiographs should be repeated at 6-week intervals until bone
ally to expose the distal femur. Elevate the cranial tibial muscle healing occurs. The animal should be confined, with activity
to expose the proximal tibia. Osteotomize the tibial tuberosity to limited to leash walks, until bone healing is complete. The plate
aid exposure of the joint and to prepare a surface for the plate. may be removed 6 to 9 months after bone healing to avoid stress
Excise the menisci and cruciate ligaments. Preserve the col- concentration at the distal plate end.
lateral ligaments to aid in maintaining alignment (Plate 24A).1
Alignment: Predetermine the cranial caudal angle for the EXPECTED OUTCOME
stifle arthrodesis by observing the normal standing angle of the The bone usually heals in 12 to 18 weeks. For most pet animals,
stifle in the individual patient. Consider adding 10 degrees to satisfactory function of the treated limb is seen; however,
the normal angle in large dogs and 5 degrees to the normal angle circumduction of the limb and toe knuckling may occur at
in small dogs and cats to compensate for the bone loss during faster gaits. Results are best when the correct angle for fusion is
the procedure. Commonly, the angle is 135 to 140 degrees for achieved. Fracture may occur in the tibia at the end of the plate.
dogs and 120 to 124 degrees for cats (Plate 24B).1
Stabilization: To determine the ostectomy angles, place References
three Kirschner wires as follows: Place the first Kirschner wire
1. McLaughlin RM: Arthrodesis. In Brinker WO, Olmstead ML, Sumner-
perpendicular to the tibial diaphysis and in the midsaggital Smith G, et al (eds): Manual of Internal Fixation in Small Animals.
plane. Place the second wire perpendicular to the femoral dia- New York, Springer-Verlag, 1998.
physis and in the midsaggital plane. Place a third wire into the 2. Johnson KA: Arthrodesis. In Olmstead ML (ed): Small Animal
femur distal to the second wire and at the complementary angle Orthopedics. St. Louis, Mosby, 1995.
CHAPTER 24 S T I F L E A RT H R O D E S I S 73

P L AT E 2 4

A B

2
Patella
40
Lateral collateral
ligament 3

140

Long digital
extensor tendon
Osteotomy 1
site Cranial tibial muscle
retracted

C D
74 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

TA R S U S

CHAPTER 25 Achilles Tendon Repair


INDICATIONS In type 3 injuries, the AT is intact but inflamed. AT injuries may
Candidates include animals with partial or complete rupture of be acute or chronic in duration. Type 2 injuries are more
the Achilles or calcanean tendon. common than full AT tears (i.e., type 1). Chronic injuries are
technically more difficult to repair because tendon contracture
OBJECTIVES and fibrosis hamper identification and apposition.
To restore normal weight bearing and limb function and
eliminate the plantigrade stance associated with the injury EQUIPMENT
Surgical pack, Gelpi retractors or Senn retractors, pointed
ANATOMIC CONSIDERATIONS 14 reduction forceps, Kirschner wires or small Steinmann pins
The Achilles tendon (AT) is the largest tendon complex in the for large dogs, pin chuck or high-speed wire driver, cerclage
dog. It consists of the combined tendinous insertion of five sep- wire, snub-nosed wire twisters, wire cutter, heavy-gauge
arate muscles: (1) the gastrocnemius, (2) the superficial digital monofilament nonabsorbable suture for tendon repair,
flexor, and (35) the combined tendon of the biceps femoris, external skeletal fixation set, equipment for casting and
the semitendinosus, and the gracilis. Tendon injuries may be bandage material
classified into three general types. Type 1 involves a complete
disruption of the tendon apparatus. On physical examination, PREPARATION AND POSITIONING
the hock may be fully flexed, with no tension placed on the Prepare the leg circumferentially from dorsal midline to the
Achilles mechanism. Dogs with this injury have a characteristic phalanges. Use a hanging leg preparation, with the dog in dorsal
plantigrade stance, with the metatarsals and digits lying flat on recumbency at the end of the surgery table to allow for maximal
the floor. Type 2 involves a lengthened AT system. Three sub- manipulation and visualization of the stifle joint during surgery.
classifications of this category are recognized: (1) type 2a is a
musculotendinous rupture; (2) type 2b is an AT rupture with an PROCEDURE
intact paratenon or tendon sheath; and (3) type 2c is partial AT Approach:5 With the tarsus extended, incise the skin 3 cm to
rupture, with an intact superficial digital flexor tendon. Dogs 4 cm proximal to the injury on the caudolateral aspect of the
that have a type 2c AT injury display a characteristic crab-like common calcanean tendon to the level of the fourth tarsal bone
stance, with a hyperflexed tarsus with contracture of the toes. (Plate 25A). Reflect the skin and subcutaneous tissue to expose
The superficial digital flexor tendon is placed under consider- the deep fascia. Incise the deep fascia and lateral retinaculum
able tension with partial disruption of the AT, which pulls on its along the lateral border of the superficial digital tendon,
insertions on the palmar surface of the proximal end of the exposing the injured AT apparatus. Extend the incision proxi-
middle phalanges of digits II, III, IV, and V, contracting the toes. mally as needed to expose the injured tendon.
Continued
CHAPTER 25 A C H I L L E S T E N D O N R E PA I R 75

P L AT E 2 5

A Tendon of
flexor hallucis
longus muscle

Tendon of
gastrocnemius
muscle
Calcaneus

Tendon of superficial
flexor muscle

Tendon of
abductor digiti
quinti muscle
76 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

Acute Midsubstance Tendon Repair: Identify the POSTOPERATIVE EVALUATION 3


three separate tendons and attempt apposition. Using a Radiographs are not necessary unless a tension band or transar-
monofilament nonabsorbable suture (0 to 1 for large dogs; 2-0 ticular fixator is placed. Ultrasound can be used to monitor
to 3-0 for cats and small dogs), suture each tendon separately tendon healing. Full healing and reorganization of the AT is a
using a three-loop pulley pattern with the tarsus in extension slow process that may go on for years.
(Plate 25B). Make the first two passes with the needle from
near to far, and orient the third and fourth passes 120 degrees POSTOPERATIVE CARE 7
from the previous two sutures and in the middle. Redirect External coaptation or transarticular fixation is necessary to
the final fifth and sixth passes 120 degrees, and place them far protect the repair for the first 6 to 8 weeks. Exercise should be
to near. restricted until the tendon heals. Then the animal should slowly
Chronic Midsubstance Tendon Repair: Ideally, the be returned to normal activity.
fibrotic scar should be sharply resected until normal tendon is
identified. Most often, however, this is not possible because of EXPECTED OUTCOME 7
tendon retraction and contracture. Resect as much scar tissue The expectation for return to full athletic ability is guarded;
as possible to permit apposition of the tendon ends. Because however, most animals will be able to function very well as
the individual tendons will probably be undistinguishable in the pets. Tarsal arthrodesis may be employed if, despite repair, pain
fibrotic scar, the AT apparatus is repaired using a single locking- and dysfunction persist.
loop pattern.
Avulsed Achilles Tendon Repair:6 Sharply dbride the
AT using a scalpel blade or Mayo scissors. Using a Jacob chuck References
or mini-driver, create a bone tunnel from lateral to medial of 1. Moreshead D, Leeds EB: Kirschner-Ehmer apparatus immobilization
following Achilles tendon repair in six dogs. Vet Surg 13(1):1114,
sufficient size to pass the suture through. Place the suture
1984.
through the bone tunnel using a straight needle or bent pin
2. Meutstege FG: The classification of canine Achilles tendon lesions.
(Plate 25C). Secure the tendon to the calcaneus using a locking- Vet Comp Orthop Traumatol 6:5355, 1993.
loop suture pattern. 3. Kramer M, Gerwing M, Michele U, et al: Ultrasonographic examina-
Fracture of the Calcaneal Bone: Fracture of the cal- tion of injuries to the Achilles tendon in dogs and cats. J Small Anim
caneus is treated with a tension band wire (Plate 25D). See Pract 42:531535, 2001.
Chapter 81 for details. 4. Rivers BJ, Walters PA, Kramek B, Wallace L: Sonographic findings
in canine common calcaneal tendon injury. Vet Comp Orthop
CAUTIONS 1,7 Traumatol 10:4553, 1997.
Dbridement of the AT should be performed in a stepwise 5. Piermattei DL, Johnson KA: Approach to the calcaneus. In An Atlas
of Surgical Approaches to the Bones and Joints of the Dog and Cat,
fashion. Excessive resection will prevent apposition of the
4th ed. Philadelphia, WB Saunders, 2004.
tendon ends and complicate recovery. Tarsal immobilization
6. Guerin S, Burbidge H, Firth E, Fox S: Achilles tenorrhaphy in five
and support is critical to wound healing and to preventing dogs: A modified surgical technique and evaluation of a cranial half
catastrophic failure of the AT repair. External coaptation (i.e., cast. Vet Comp Orthop Traumatol 11:205211, 1998.
lateral splints or bivalved casts) or transarticular fixation 7. de Haan JJ, Goring RL, Renburg C, Bertrand S: Modified transartic-
should be placed with the tarsus in a slightly extended but ular external skeletal fixation for support of Achilles tenorrhaphy in
weight-bearing position. four dogs. Vet Comp Orthop Traumatol 8:3235, 1995.
CHAPTER 25 A C H I L L E S T E N D O N R E PA I R 77

P L AT E 2 5

B C D
Midsubstance Avulsion Fracture of calcaneal bone

Three-loop pulley repair Locking-loop repair Pin and tension band repair
78 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

TA R S U S

CHAPTER 26Shearing Injury


with Tarsal Luxation
INDICATIONS tarsus is more common than injury to the lateral aspect; how-
Candidates include animals with shearing wounds to the tarsus ever, both have been reported in the literature.
sustained from motor vehicle trauma.
EQUIPMENT
OBJECTIVES Surgical pack, Gelpi retractors or Senn retractors, pointed
To restore stability to the tarsal joint and salvage joint func- reduction forceps, periosteal elevator, snub-nosed wire
tion while allowing soft tissue healing to occur twisters, heavy-gauge monofilament nonabsorbable fishing
leader line for collateral ligament repair, high-speed drill,
ANATOMIC CONSIDERATIONS 1,2 bone screw and washer, drill bit, tap, depth gauge, screw-
The tarsus is composed of six separate anatomic joints: (1) the driver, pin chuck and key, low-speed drill, external skeletal
talocrural or tarsocrural joint, (2) the talocalcaneal joint, fixation set, equipment for casting and bandage material
(3) the talocalcaneocentral joint, (4) the calcaneoquartal
joint, (5) the centrodistal joint intertarsal joint, and (6) the PREPARATION AND POSITIONING
tarsometatarsal joint. Functionally, however, the joint can be Prepare the leg circumferentially from dorsal midline to the
separated into four compartments: (1) the talocrural, (2) the phalanges. Use a hanging leg preparation with the dog in dorsal
proximal intertarsal joint (consisting of the calcaneoquartal and recumbency at the end of the surgery table to allow for maxi-
the talcalcaneocentral joint), (3) the distal intertarsal joint (cen- mal manipulation and visualization of the stifle joint during
trodistal joint), and (4) the tarsometatarsal joint. The majority surgery.
of movement of the tarsus is at the talocrural joint, between the
tibia and talus. Joint stability is provided by the medial and lat- PROCEDURE
eral collateral ligaments, which are composed of long and short Approach:3 Center a curvilinear incision over the talocrural
components originating on the malleoli of the tibia and fibula, joint along the medial aspect of limb, exposing the distal tibial
respectively. The long component of the medial collateral liga- to the level of the tarsometatarsal joint. Retract the subcuta-
ment inserts on the proximal portion of the second metatarsus, neous and crural fascia and expose the medial ridge of the talus
whereas the short component attaches to the talus. The long by incising the joint capsule cranial to the collateral ligament. If
component of the lateral collateral inserts on the proximal the shearing injury is extensive, removing much of the covering
aspect of the fifth metatarsal, and the short component attaches soft tissues, much of this approach may be unnecessary
to the body of the calcaneus. Injury to the medial aspect of the (Plate 26A).
Continued
CHAPTER 26 S H E A R I N G I N J U RY W I T H TA R S A L L U X AT I O N 79

P L AT E 2 6

Tendon of
cranial tibial
muscle
80 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

Prosthetic Ligament Repair:2 Drill, measure, and tap POSTOPERATIVE EVALUATION 4


a bicortical screw hole into the distal aspect of the tibia at the The wound should be evaluated at least daily for the first 7 to
level of the medial malleolus, being careful to avoid the joint 10 days, until healthy granulation tissue is present or as tissue
surface. Place a screw and washer to prevent subsidence into viability dictates. A nonadherent bandage can then be placed
the metaphyseal bone and to prevent ligature slippage. Place over the wound and the dressing changed less frequently.
two additional screws and washers in similar fashion into the Radiographs should be repeated every 6 to 8 weeks until the
body of the talus (aiming distally to avoid the trochlear sulcus) soft tissues heal to evaluate limb alignment, apposition of the
and into the head of the talus, which is located midway between fracture-luxation, and apparatus integrity.
the medial trochlear ridge and the intertarsal articular surface.
Depending on the size of the animal, utilize 20- to 60-pound test POSTOPERATIVE CARE 2,4,5
of monofilament fishing leader line to place two independent External coaptation or transarticular fixation is necessary in
suture loops for the long and short components of the medial order to protect the repair for the first 6 to 8 weeks. Exercise
collateral ligament. Tie the sutures independently: tie the short should be restricted until the fixator is removed and the soft tis-
component with the tarsus held in flexion and the long compo- sues heal. Then the animal should slowly be returned to normal
nent with the tarsus held in extension. The sutures should be activity.
taut, but not overly tight, to avoid compromising joint range of
motion (Plate 26B). EXPECTED OUTCOME 6
Prosthetic ligament repair for a lateral shearing injury is very There is a 75% chance of good to excellent function, despite
similar to the medial repair just described (Plate 26C). The progressive degenerative joint disease and restricted range of
proximal screw and washer is placed in the distal fibula/tibia, motion of the tarsal joint. Pantarsal arthrodesis may be
taking care to avoid the joint. The distal two screws and employed if pain and dysfunction persist despite repair.
washers are positioned in the base of the coracoid process,
midway between the base of the coracoid process and the prox-
imal intertarsal joint (Plate 26D). References
Transarticular External Skeletal Fixation:2,4 Place a
1. Benson JA, Boudrieu RA: Severe carpal and tarsal shearing injuries
type I or II transarticular external fixator with two pins through treated with immediate arthrodesis in seven dogs. J Am Anim Hosp
the tibia (one proximal and one distal), one pin in the calca- Assoc 38:370380, 2002.
neus, and one pin into the metatarsal bones 2 and 3. Position the 2. Harasen GLG: Tarsal shearing injury in the dog. Can Vet J 41:
tarsus in a normal standing angle and immobilize it for 6 to 940943, 2000.
8 weeks, depending on the severity of soft tissue trauma. 3. Piermattei DL, Johnson KA: Approach to the medial malleolus and
talocrural joint. In An Atlas of Surgical Approaches to the Bones and
CAUTIONS Joints of the Dog and Cat, 4th ed. Philadelphia, WB Saunders, 2004.
Lavage and wound dbridement of the tarsus should be per- 4. Kraus KH, Toombs JP, Ness MG: Transarticular case studies. In
External Fixation in Small Animal Practice. Blackwell Sciences,
formed once the patient is stabilized. Excessive dbridement
Oxford, England, 2003.
should be avoided early on, becausegiven the right conditions
5. de Haan JJ, Goring RL, Renberg C, Bertrand S: Modified transartic-
and wound carethe soft tissue coverage, which is a premium, ular external skeletal fixation for support of Achilles tenorrhaphy in
will survive despite extensive damage. The use of sterile wet-to- four dogs. Vet Comp Orthop Traumatol 8:3235, 1995.
dry bandages until healthy granulation tissue is present is an 6. Diamond DW, Besso J, Boudrieu RA: Evaluation of joint stabilization
excellent way to improve wound quality without surgical for treatment of shearing injuries of the tarsus in 20 dogs. J Am Anim
dbridement. Hosp Assoc 35:147153, 1999.
CHAPTER 26 S H E A R I N G I N J U RY W I T H TA R S A L L U X AT I O N 81

P L AT E 2 6

C D
82 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

TA R S U S

CHAPTER 27Osteochondrosis of the Lateral


Trochlear Ridge of the Talus
INDICATIONS bone curettes, pin chuck or high-speed wire driver, Kirschner
Candidates include dogs with persistent lameness and pain of wires or small Steinmann pin for forage
the tarsus caused by osteochondrosis (OCD) that is not respon-
sive to conservative management. PREPARATION AND POSITIONING
Prepare the leg circumferentially from dorsal midline to the
OBJECTIVES phalanges. Use a hanging leg preparation, with the dog in dorsal
To improve limb function by removal of the entire OCD flap, recumbency at the end of the surgery table to allow for maximal
curettage of the adjacent diseased cartilage, and forage to manipulation and visualization of the tarsus during surgery.
provide blood supply to the exposed subchondral bone via
forage PROCEDURE
Dorsolateral Approach:2,46 Flex and extend the tarsus to
ANATOMIC CONSIDERATIONS 15 accurately identify dorsal aspect of the lateral trochlear ridge
The tarsus is the third most common joint to be affected by via palpation. Center a curvilinear 4-cm to 5-cm incision over
OCD, with a reported incidence of 9%. Forty-four percent of the trochlear ridge from the distal tibia and fibula to the distal
the tarsal lesions are bilateral, although the typical presenting intertarsal joint. Retract the skin and subcutaneous tissues with
complaint of a dog with tarsal OCD is a unilateral lameness. a Gelpi or Senn retractor to improve visualization of the ten-
Seventy-five percent of the OCD lesions of the tarsus occur on dons of the long digital extensor muscle, the cranial tibial
the plantar half of the medial trochlear ridge of the talus, and muscle, the extensor hallucis longus muscle, the dorsal branch
25% occur on the lateral ridge. Because of the diversity of the of the lateral saphenous vein, and the superficial peroneal nerve
lesion location, the surgical approach used to expose the lesion (Plate 27A). Retract these structures laterally. Retract the
is as important as the surgical dbridement and curettage. Both tendons of the peroneus longus, the lateral digital extensor,
medial and lateral approaches have been described. A com- and the peroneus brevis in a plantar direction. Incise the deep
bined dorsomedial and plantaromedial approach exposes all fascia and adherent joint capsule longitudinally along the mid-
but 4% of the medial trochlear ridge of the talus. Similarly, a line of the palpable portion of the lateral trochlear ridge, pre-
combined dorsolateral and plantarolateral approach exposes serving the lateral collateral ligament of the tarsus. If necessary,
the entire lateral trochlear ridge, with the central 20% of the lat- extend the joint capsular incision into the periosteum at the
eral ridge being accessible from either individual approach. junction of the distal tibia and fibula to increase the exposure of
the trochlea (Plate 27B).
EQUIPMENT Continued
Standard surgical pack, two medium or large Gelpi retractors
(depending on the size of the dog), blunt Hohmann retractor,
CHAPTER 27 O S T E O C H O N D R O S I S O F T H E L AT E R A L T R O C H L E A R R I D G E O F T H E TA L U S 83

P L AT E 2 7

Proximal extensor
retinaculum
B

Tendon of long Tendon of


digital extensor musle peroneus brevis muscle
Tendon of lateral
Tendon of cranial digital extensor muscle
tibial muscle

Digital extensor
Tendon of retinaculum
extensor hallucis
longus muscle
84 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

Plantarolateral Approach:2,46 Flex and extend the 6 weeks until the articular cartilage heals. Passive range-of-
tarsus to accurately identify the plantar aspect of the lateral motion exercises should be performed two or three times daily
trochlear ridge of the talus via palpation. Center a curvilinear for 5 to 10 minutes per session to maintain range of motion and
4-cm to 5-cm incision over the plantar aspect of the trochlear to improve cartilage healing. After 4 to 6 weeks, the animal
ridge. Retract the skin and subcutaneous tissue with a Gelpi or should slowly be returned to normal activity.
Senn retractor to improve visualization of the tendons of the
peroneus brevis, the lateral digital extensor, and the peroneus EXPECTED OUTCOME 5,6,8
longus muscles (Plate 27C). Retract these structures dorsally. Expected outcome is usually guarded to fair, depending on
Retract the plantar branch of the lateral saphenous vein, and a numerous factors (e.g., unilateral versus bilateral disease,
branch of the caudal cutaneous sural nerve, in a plantar direc- lesion size, surgical approach, and presence of degenerative
tion, preserving the lateral collateral ligament. Incise the joint joint disease). Degenerative joint disease develops regardless of
capsule longitudinally along the center of the palpable portion surgical removal of the flap, but it does not correlate with the
of the lateral trochlear ridge. If necessary, extend the joint cap- degree of lameness. Nonetheless, owners should be advised
sular incision into the periosteum at the junction of the distal that nonsteroidal anti-inflammatory drugs may be indicated to
tibia and fibula to increase the exposure of the trochlear ridge control the clinical signs of lameness and pain associated with
(Plate 27D). degenerative joint disease.
Curettage:26 Remove the cartilage flap with thumb or
Halstead forceps. Probe the remaining cartilage surrounding References
the defect with a curette, and remove any abnormal cartilage 1. Montgomery RD, Hathcock JJ, Milton JL, Fitch RB: Osteochondrosis
not adherent to the subchondral bone (see Plates 27B and 27D). dissecans of the canine tarsal joint. Compend Contin Educ Pract Vet
Forage: Using a small Kirschner wire or small Steinmann 16(7):835845, 1994.
pin, penetrate the sclerotic subchondral bone in multiple sites 2. Beale BS, Goring RL, Herrington J, et al: A prospective evaluation
until it bleeds. of four surgical approaches to the talus of the dog used in the
treatment of osteochondritis dissecans. J Am Anim Hosp Assoc
CAUTIONS 7 27(2):221229, 1991.
Unlike the more common OCD of the medial trochlear ridge, 3. Beale BS, Goring RL: Exposure of the medial and lateral trochlear
ridges of the talus in the dog. Part I: Dorsomedial and plantarome-
where the lesion is generally located in the proximal region of
dial surgical approaches to the medial trochlear ridge. J Am Anim
the trochlear, lateral trochlear ridge lesions have been reported Hosp Assoc 26(1):1318, 1990.
to arise from both proximal and dorsal aspects of the ridge, thus 4. Goring RL, Beale BS: Exposure of the medial and lateral trochlear
necessitating a more aggressive surgical exposure. In addition, ridges of the talus in the dog. Part II: Dorsolateral and plantaro-
clinical reports of lateral trochlear ridge OCD lesions describe lateral surgical approaches to the lateral trochlear ridge. J Am Anim
large, shelf-like lesions that may result in significant malar- Hosp Assoc 26(1):1924, 1990.
ticulation, joint instability, and degenerative joint disease. 5. Fitch R, Beale BS: Osteochondrosis of the canine tibiotarsal joint.
Vet Clin North Am Small Anim Pract 28(1):95113, 1998.
POSTOPERATIVE EVALUATION 6. Smith M, Vasseur P, Morgan J: Clinical evaluation of dogs after
No specific postoperative evaluation is required. Note that joint surgical and nonsurgical management of osteochondritis dissecans
of the talus. J Am Vet Med Assoc 187(1):3135, 1985.
goniometry should be performed preoperatively to provide a
7. Wisner ER, Berry CR, Morgan JP, et al: Osteochondrosis of the
baseline assessment of tarsal range of motion and function. lateral trochlear ridge of the talus in seven Rottweiler dogs. Vet Surg
19(6):435439, 1990.
POSTOPERATIVE CARE 8. Diamond DW, Besso J, Boudrieu RA: Evaluation of joint stabilization
The limb should be bandaged for 2 to 3 days, depending on for treatment of shearing injuries of the tarsus in 20 dogs. J Am Anim
the degree of swelling. Exercise should be restricted for 4 to Hosp Assoc 35:147153, 1999.
CHAPTER 27 O S T E O C H O N D R O S I S O F T H E L AT E R A L T R O C H L E A R R I D G E O F T H E TA L U S 85

P L AT E 2 7

Tendon of flexor
hallucis longus muscle
C D
Tendon of
peroneus brevis muscle

Calcaneus

Tendon of
peroneus
longus muscle Tendon of lateral
digital extensor muscle

Tendon of abductor
digiti quinti muscle
86 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

TA R S U S

CHAPTER 28Osteochondrosis of the Medial


Trochlear Ridge of the Talus
INDICATIONS 1 PREPARATION AND POSITIONING
Candidates include dogs with persistent lameness and pain of Prepare the leg circumferentially from dorsal midline to the
the tarsus caused by osteochondrosis (OCD) of the medial phalanges. Use a hanging leg preparation with the dog in dorsal
trochlear ridge that is not responsive to conservative manage- recumbency at the end of the surgery table to allow for maximal
ment. The most common location of OCD of the medial manipulation and visualization of the tarsus during surgery.
trochlear ridge is the plantar aspect, which accounts for more
than 80% of all medial trochlear lesions. PROCEDURE
Dorsomedial Approach:16 Flex and extend the tarsus to
OBJECTIVES accurately identify the dorsal aspect of the medial trochlear
To improve limb function by removal of the entire OCD flap, ridge via palpation. Center a curvilinear 4-cm to 5-cm incision
curettage of the adjacent diseased cartilage, and forage to over the trochlear ridge, from the distal tibia and fibula to the
provide blood supply to the exposed subchondral bone distal intertarsal joint. Retract the skin and subcutaneous tis-
sues with a Gelpi or Senn retractor (Plate 28A). Preserve the
ANATOMIC CONSIDERATIONS 15 distal extensor retinaculum, and laterally retract the tendon of
Surgical exposure of the tarsus can be achieved through a the cranial tibial muscle, the saphenous nerve, the cranial tibial
variety of surgical approaches. The plantaromedial approach is artery and vein, and the dorsal branches of the saphenous
the most commonly used surgical approach, because it exposes artery and vein. Preserve the medial collateral ligament, and
40% of the plantar aspect of the medial trochlear ridge, which is longitudinally incise the deep fascia and adherent joint capsule
the most common site of OCD in the tarsus. along the palpable midportion of the medial trochlear ridge. If
necessary, extend the joint capsular incision into the perios-
EQUIPMENT teum at the junction of the distal tibia and fibula to increase the
Standard surgical pack, two medium or large Gelpi retractors exposure of the trochlea (Plate 28B).
(depending on the size of the dog), blunt Hohmann retractor, Continued
bone curettes, pin chuck or high-speed wire driver, Kirschner
wires or small Steinmann pin for forage
CHAPTER 28 O S T E O C H O N D R O S I S O F T H E M E D I A L T R O C H L E A R R I D G E O F T H E TA L U S 87

P L AT E 2 8

Proximal extensor
retinaculum
B

Tendon of long Tendon of


digital extensor muscle peroneus brevis muscle
Tendon of lateral
Tendon of cranial digital extensor muscle
tibial muscle

Digital extensor
Tendon of retinaculum
extensor hallucis
longus muscle
88 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

Plantaromedial Approach:1,3,5,6 Flex and extend the provide a baseline assessment of tarsal range of motion and
tarsus to accurately identify the plantar aspect of the medial function.
trochlear ridge of the talus via palpation. Center a curvilinear
4-cm to 5-cm incision over the plantar aspect of the trochlear POSTOPERATIVE CARE
ridge. Retract the skin and subcutaneous tissue with a Gelpi or The limb should be bandaged for 2 to 3 days, depending on the
Senn retractor to improve visualization of the tendons of the degree of swelling. Exercise should be restricted for 4 to
medial head of the deep digital flexor muscle, the distal attach- 6 weeks, until the articular cartilage heals. Passive range-of-
ment of the caudal tibial muscle, the flexor hallucis longus motion exercises should be performed two or three times daily
muscle, and the medial collateral ligament (Plate 28C). Retract for 5 to 10 minutes per session to maintain range of motion and
the medial head of the deep digital flexor muscle and the caudal to improve cartilage healing. After 4 to 6 weeks, the animal
tibial tendon dorsally; and laterally retract the flexor hallucis should slowly be returned to normal activity.
longus, the tibial nerve with its superficial branch, the plantar
branches of the medial saphenous vein and saphenous artery, EXPECTED OUTCOME 1,6,9
and superficial plantar metatarsal vein. Taking care to preserve Expected outcome is guarded to fair. Most dogs seem to benefit
the medial collateral ligament, incise the joint capsule longitu- from early surgical removal of the OCD flap. A decreased suc-
dinally along the center of the palpable portion of the medial cess rate has been reported for dogs older than 12 months
trochlear ridge. If necessary, extend the joint capsular incision because of the progression of degenerative joint disease.
into the periosteum at the junction of the distal tibia and fibula Dbridement and curettage should be kept to a minimum to
to increase the exposure of the trochlear ridge (Plate 28D). avoid tarsal instability and joint incongruency.
Curettage:1,36 Remove the cartilage flap with thumb or
Halstead forceps. Probe the remaining cartilage surrounding References
the defect with a curette, and remove any abnormal cartilage 1. Fitch R, Beale BS: Osteochondrosis of the canine tibiotarsal joint.
not adherent to the subchondral bone (see Plates 28B and 28D). Vet Clin North Am Small Anim Pract 28(1):95113, 1998.
Forage: Using a small Kirschner wire or small Steinmann 2. Montgomery RD, Hathcock JT, Milton JL, Fitch RB: Osteo-
pin, penetrate the sclerotic subchondral bone in multiple sites chondrosis dissecans of the canine tarsal joint. Compend Contin
until it bleeds. Educ Pract Vet 16(7):835845, 1994.
3. Beale BS, Goring RL, Herrington J, et al: A prospective evaluation of
four surgical approaches to the talus of the dog used in the treat-
CAUTIONS 1,7,8
ment of osteochondritis dissecans. J Am Anim Hosp Assoc 27(2):
Excellent radiographic technique and positioning is necessary 221229, 1991.
to diagnose OCD lesions within the tarsus. Standard antero- 4. Beale BS, Goring RL: Exposure of the medial and lateral trochlear
posterior and lateral views of the tarsus provide good visualiza- ridges of the talus in the dog. Part I: Dorsomedial and plantarome-
tion of the plantar aspect of the medial trochlear ridge, but dial surgical approaches to the medial trochlear ridge. J Am Anim
additional views may be necessary to fully evaluate the joint. Hosp Assoc 26(1):1318, 1990.
The dorsolateral-plantaromedial oblique projection provides 5. Goring RL, Beale BS: Exposure of the medial and lateral trochlear
good visualization of the medial trochlear ridge; the dorso- ridges of the talus in the dog. Part II: Dorsolateral and plantarolat-
medial-plantarolateral oblique projection highlights the lateral eral surgical approaches to the lateral trochlear ridge. J Am Anim
Hosp Assoc 26(1):1924, 1990.
trochlear ridge; and the flexed dorsoplantar projection profiles
6. Smith M, Vasseur P, Morgan J: Clinical evaluation of dogs after sur-
the central region of both trochlear ridges. Computed tomog-
gical and nonsurgical management of osteochondritis dissecans of
raphy and magnetic resonance imaging also provide additional the talus. J Am Vet Med Assoc 187(1):3135, 1985.
information; however, expense and limited access prohibit their 7. Wisner ER, Berry CR, Morgan JP, et al: Osteochondrosis of the lat-
widespread use. Owners should be advised that the nature of eral trochlear ridge of the talus in seven rottweiler dogs. Vet Surg
the surgical procedure is exploratory and that a negative 19(6):435439, 1990.
exploratory is possible and is necessary to rule out OCD. 8. Miyabayashi T, Biller DS, Manley PA, et al: Use of a flexed dorso-
Arthroscopy has greatly improved tarsal joint access and visu- plantar radiographic view of the talocrural joint to evaluate lame-
alization, but it does not completely eliminate the necessity of ness in two dogs. J Am Vet Med Assoc 199(5):598600, 1991.
arthrotomy because of the difficulty of lesion location and 9. Diamond DW, Besso J, Boudrieu RA: Evaluation of joint stabilization
for treatment of shearing injuries of the tarsus in 20 dogs. J Am Anim
treatment.
Hosp Assoc 35:147153, 1999.

POSTOPERATIVE EVALUATION
No specific postoperative evaluation is required. Note that joint
goniometry should be performed preoperatively in order to
CHAPTER 28 O S T E O C H O N D R O S I S O F T H E M E D I A L T R O C H L E A R R I D G E O F T H E TA L U S 89

P L AT E 2 8

Tendon of long
digital flexor muscle C
(deep digital flexor, D
medial head)
Tendon of flexor Tendon of caudal
hallucis longus muscle tibial muscle
(deep digital flexor,
lateral head)
Medial collateral ligament:
Short part
Long part
90 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

TA R S U S

CHAPTER 29 Pantarsal Arthrodesis


INDICATIONS Stabilization: Extend the hock and remove the articular
Candidates include animals with severe injury (e.g., fracture, cartilage from the talocrural, intertarsal, and tarsometatarsal
luxation, or shearing injury) of the tibial cochlea and condyles joint surfaces with a bone curette or high-speed burr, following
of the talus that precludes maintaining a long-term, pain-free the contours of the bone ends (see Plate 29A). Harvest cancel-
articulation; animals with painful degenerative joint disease lous bone, and place the graft within the prepared joints (Plate
that is not responsive to conservative measures; and animals 29B). Place an appropriate-size bone plate, precontoured to
with irreparable Achilles tendon injury and sciatic nerve palsy provide the selected joint angle, on the cranial surface of the
treated with tendon transfer.1 tibia, the talus, the central tarsal bone, and the third metatarsal
bone (see Plates 29B and 29C). Position the acute bend in the
OBJECTIVES plate over the neck of the talus. Ensure adequate plate holes for
To fuse the bones of the tarsocrural, intertarsal, and tar- a minimum of three screws in the tibia and three screws in the
sometatarsal joints in a functional position metatarsal bone. Mark the level of the distal metatarsal plate
screw. Remove the plate, and center the drill on the metatarsal
ANATOMIC CONSIDERATIONS bone. Secure the plate with three screws in the metatarsal bone,
The tarsus consists of the tibia, fibula, proximal tarsal, distal check the plate and joint alignment, and secure the plate to the
tarsal, and metatarsal bones, forming the tarsocrural, intertarsal, tibia (see Plate 29B). Fill the remaining plate holes. Ensure that
and tarsometatarsal joints. The tarsocrural joint is formed by at least two plate screws penetrate the calcaneus to secure the
the fibula and cochlea of the tibia proximally, and by the talus joint1 (see Plate 29C).
and calcaneus distally. The intertarsal joints are formed by
articulations between the tarsal bones, and the tarsometatarsal CAUTIONS
joints are formed by the articulations between the distal tarsal All articular cartilage must be removed. Angular and rotational
and metatarsal bones. alignment of the limb should be checked carefully before the
plate is secured to the tibia.
EQUIPMENT
Surgical pack, Senn retractors, Hohmann retractors, Gelpi POSTOPERATIVE EVALUATION
retractors, periosteal elevator, self-centering plate-holding The axial alignment of the limb and the angle of the arthrodesis
forceps, bone curette, high-speed drill and burrs, plating should be critically observed. Radiographs should be evaluated
equipment for limb alignment and implant placement.

PREPARATION AND POSITIONING POSTOPERATIVE CARE


Prepare the rear limb circumferentially from hip to digits. A soft, padded bandage should be placed to control bleeding
Position the animal in dorsal recumbency for greater flexi- and swelling. A bivalve cast should be used for 6 weeks or until
bility. Drape the limb out from a hanging position to allow early radiographic evidence of bone bridging is observed.
maximal manipulation during surgery. Prepare the ipsilateral Radiographs should be repeated at 6-week intervals until bone
proximal tibia or proximal humerus for cancellous bone graft healing occurs. The animal should be confined, with activity
harvest. limited to leash walks until bone healing is complete. Implants
are generally removed after 6 to 12 months to avoid soft tissue
PROCEDURE irritation and the common sequella of implant loosening.2
Approach: Incise skin and soft tissue over the cranial medial
surface of the joint, from the distal third of the tibia to the EXPECTED OUTCOME
middle of the metatarsal bones. Elevate and retract the cranial Bone healing is expected in 12 to 18 weeks. The animal should
tibial and long digital extensor tendons to expose the distal have acceptable function of the treated limb, as long as stifle
tibia, the tarsus, and the proximal third of the metatarsal bone. and hip remain free of disease.
If necessary, transect the cranial tibial tendon and the medial
collateral ligament to gain access to the joint. Enter the tarsal References
joints to expose the articular surfaces (Plate 29A).1 1. Johnson KA: Arthrodesis. In Olmstead ML (ed): Small Animal
Alignment: Predetermine the cranial caudal angle for the Orthopedics. St. Louis, Mosby, 1995.
pantarsal arthrodesis by observing the normal standing angle of 2. DeCamp CE, Martinez SA, Johnston SA: Pantarsal arthrodesis in
the tarsus in the individual patient. The angle is commonly dogs and a cat: 11 cases (19831991). J Am Vet Med Assoc 203:
between 135 and 145 degrees1 (see Plate 29C). 1705, 1993.
CHAPTER 29 PA N TA R S A L A RT H R O D E S I S 91

P L AT E 2 9

A
Cranial
tibial muscle

Tibia

Talus

B
Central
tarsal
bone

Long digital
extensor tendon

140
92 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

TA R S U S

Proximal Intertarsal
CHAPTER 30

or Tarsometatarsal Arthrodesis with a Plate


INDICATIONS of the fifth metatarsal bone, and a portion of the fourth tarsal
Candidates include animals with severe injury (e.g., fracture, bone, with the oscillating saw to provide a smooth surface
luxation, or shearing injury) of the proximal intertarsal or for the plate (Plate 30B). Place an appropriate-size and
tarsometatarsal joint.1 appropriate-contour plate on the lateral surfaces of the calca-
neus, the fourth tarsal bone, and the fifth metatarsal bone.
OBJECTIVES Position the plate with three screw holes over the calcaneus
To fuse the bones of the proximal intertarsal, the tar- and three screw holes over the metatarsal bones. Place a screw
sometatarsal joints, or both in a functional position through the proximal plate hole into the calcaneus. Check the
plate position, and place a screw through the distal plate hole
ANATOMIC CONSIDERATIONS into metatarsal bones 4 and 5. Fill the remaining plate holes.
The intertarsal joints are formed by articulations between the Ensure that the distal screw into the calcaneus also secures the
tarsal bones. The proximal intertarsal joint is a combination of talus (Plate 30C).1
the talocalcaneocentral joint, formed by the articulation of the
talus and central tarsal bone with a continuous joint capsule CAUTIONS
with the calcaneus, and the calcaneoquartal joint, located All articular cartilage must be removed. Rotational alignment of
between the calcaneus and the fourth tarsal bone. The tar- the limb should be checked carefully before the plate is secured
sometatarsal joints are formed by the articulations between the to the metatarsal bones.
distal tarsal and metatarsal bones.
POSTOPERATIVE EVALUATION
EQUIPMENT The axial alignment of the limb should be critically observed.
Surgical pack, Senn retractors, Hohmann retractors, Gelpi Radiographs should be evaluated for limb alignment and
retractors, periosteal elevator, self-centering plate-holding implant placement.
forceps, bone curette, high-speed drill and burrs, plating
equipment POSTOPERATIVE CARE
A soft, padded bandage should be placed to control bleeding
PREPARATION AND POSITIONING and swelling. A bivalve cast should be used for 6 weeks or until
Prepare the rear limb circumferentially from hip to digits. early radiographic evidence of bone bridging is observed.1
Position the animal in dorsal recumbency for greater flexibility. Radiographs should be repeated at 6-week intervals until bone
Drape the limb out from a hanging position to allow maximal healing occurs. The animal should be confined, with activity
manipulation during surgery. Prepare the ipsilateral proximal limited to leash walks until bone healing is complete. Implants,
tibia or proximal humerus for cancellous bone graft harvest. which may loosen as a result of movement of the metatarsal
bones, should be removed after joint fusion, usually within 6 to
PROCEDURE 12 months after surgery.
Approach: Incise the skin, subcutaneous tissue, and deep
crural fascia over the lateral surface of the tarsometatarsal EXPECTED OUTCOME
joint. Retract the superficial and deep digital flexor tendons Bone healing is usually expected in 12 to 18 weeks, with animals
medially, and elevate the abductor digiti quinti muscle to obtaining near-normal function of the treated limb. Some dogs
expose the calcaneus, fourth tarsal bone, and the base of the exhibit lameness, which resolves after implant removal.2
fifth metatarsal bone. Enter the affected joint(s) to expose the
articular surfaces (Plate 30A).
References
Alignment: There is no angle to the partial tarsal
1. Piermattei DL, Flo GL: Fractures and other orthopedic injuries of
arthrodesis. Use a straight plate to align the bones.
the tarsus, metatarsus and phalanges. In Brinker, Piermattei, and
Stabilization: Stress the paw medially, and remove the
Flos Handbook of Small Animal Orthopedics and Fracture Repair,
articular cartilage from the calcaneoquartal and/or tar- 3rd ed. Philadelphia, WB Saunders, 1997.
sometatarsal joints with a bone curette or high-speed burr, 2. Dyce J, Whitelock RG, Robinson KV, et al: Arthrodesis of the tar-
following the contours of the bone ends. Harvest and place the sometatarsal joint using a laterally applied plate in 10 dogs. J Small
cancellous bone within the prepared joints. Smooth the base Anim Pract 39:19, 1998.
CHAPTER 30 P R OX I M A L I N T E RTA R S A L O R TA R S O M E TA R S A L A RT H R O D E S I S W I T H A P L AT E 93

P L AT E 3 0

A Tendon of
flexor hallucis
longus muscle

Tendon of
gastrocnemius B
muscle
Calcaneus

Peroneus
longus

Peroneus Tendon of superficial


brevis flexor muscle

Tendon of
abductor digiti
quinti muscle

Plantar view
94 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

TA R S U S

CHAPTER 31 Proximal Intertarsal


or Tarsometatarsal Arthrodesis
with an Intramedullary Pin and Wire
INDICATIONS (depending on the joints involved) with a bone curette or high-
Candidates include animals with subluxation of the proximal speed burr, following the contours of the bone ends (see Plate
intertarsal or tarsometatarsal joints caused by injury of the 31A). Drill transverse holes in the base of the calcaneus and the
plantar tarsal fibrocartilage.1 fourth tarsal bone (for calcaneoquartal arthrodesis), and place
orthopedic wire through the holes, deep to the superficial dig-
OBJECTIVES ital flexor tendon and crossing at the arthrodesis site (Plate
To fuse the bones of the calcaneoquartal or tarsometatarsal 31B). Predrill the calcaneus and place a small IM pin starting at
joints in a functional position the tuber calcanei, through the calcaneus and the fourth tarsal
bone (see Plate 31B). Harvest and place cancellous bone within
ANATOMIC CONSIDERATIONS the prepared joints before tightening the wire. Retract the IM
The tarsus consists of the tibia, fibula, and proximal tarsal, pin 1 cm, cut the pin, and countersink it into the tuber calcanei.
distal tarsal, and metatarsal bones forming the tarsocrural, Tighten the figure-eight wire (Plate 31C).
intertarsal, and tarsometatarsal joints. The tarsocrural joint is Alternatively, to fuse the tarsometatarsal joint, predrill the
formed by the fibula and cochlea of the tibia proximally and the holes for the figure-eight wire through the calcaneus and the
talus and calcaneus distally. The intertarsal joints are formed by metatarsal bones. Usually only three of the four metatarsal
articulations between the tarsal bones. The proximal intertarsal bones will be drilled. Drive the Steinmann pin distally into the
joint is a combination of the talocalcaneocentral joint, formed base of the fourth metatarsal bone (Plate 31D).1
by the articulation of the talus and central tarsal bone with a
continuous joint capsule with the calcaneus; and the calcaneo- CAUTIONS
quartal joint, located between the calcaneus and the fourth All articular cartilage should be removed. Avoid irritating flexor
tarsal bone. The tarsometatarsal joints are formed by the artic- tendons with the IM pin or wire.
ulations between the distal tarsal and metatarsal bones.
POSTOPERATIVE EVALUATION
EQUIPMENT The axial alignment of the limb should be critically observed.
Surgical pack, Senn retractors, Hohmann retractors, Gelpi Radiographs for limb alignment and implant placement should
retractors, periosteal elevator, bone curette, high-speed drill be evaluated.
and burrs, Jacob pin chuck, intramedullary (IM) pins, ortho-
pedic wire, wire twister, wire cutter, pin cutter POSTOPERATIVE CARE
A soft, padded bandage should be placed to control bleeding
PREPARATION AND POSITIONING and swelling. A splint should be used for 6 weeks or until
Prepare the rear limb circumferentially from hip to digits. early radiographic evidence of bone bridging is observed.
Position the animal in lateral recumbency. Drape the limb out Radiographs should be repeated at 6-week intervals until bone
from a hanging position to allow maximal manipulation during healing occurs. The animal should be confined, with activity
surgery. Prepare the ipsilateral proximal tibia or proximal limited to leash walks until bone healing is complete. Pin migra-
humerus for cancellous bone graft harvest. tion may occur. Implants should be removed if the soft tissue
is irritated.1
PROCEDURE
Approach: Incise the skin, subcutaneous tissue, and deep EXPECTED OUTCOME
crural fascia over the lateral surface of the tarsometatarsal Bone healing is usually expected in 12 to 18 weeks. Animals
joint. Retract the superficial and deep digital flexor tendons should have near-normal function of the treated limb.
medially, and elevate the abductor digiti quinti muscle to
expose the calcaneus, fourth tarsal bone, and the base of the
fifth metatarsal bone. Enter the affected joint(s) to expose the
articular surfaces (Plate 31A). Reference
Alignment: Fuse the proximal intertarsal or tarsometa- 1. Piermattei DL, Flo GL: Fractures and other orthopedic injuries of
tarsal joints in a straight line. Use an IM pin to align the bones. the tarsus, metatarsus and phalanges. In Brinker, Piermattei, and
Stabilization: Remove the articular cartilage from the Flos Handbook of Small Animal Orthopedics and Fracture Repair,
calcaneoquartal joint, the tarsometatarsal joint, or both 3rd ed. Philadelphia, WB Saunders, 1997.
CHAPTER 31 P R OX I M A L A RT H R O D E S I S W I T H A N I N T R A M E D U L L A RY P I N A N D W I R E 95

P L AT E 3 1

A Tendon of
flexor hallucis
longus muscle

Tendon of
gastrocnemius
muscle
Calcaneus
B

Peroneus
longus

Peroneus Tendon of superficial


brevis flexor muscle

Tendon of
abductor digiti
quinti muscle

C D
96 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

A M P U TAT I O N S

CHAPTER 32 Mandibulectomy
INDICATIONS 14 EQUIPMENT
Mandibulectomy is indicated in the management of tumors Standard surgical pack; electrocautery; hemoclips; bone wax
involving the jaw, and in the treatment of open or infected or suture material for vascular ligation; periosteal elevator;
mandibular fractures in which surgical repair is not an option Senn or Gelpi retractors; and a saw, Gigli wire, or osteotome
because of economic restrictions, osteomyelitis, or severe bone for osteotomy of the mandible
and soft tissue loss. Specifically, a rostral mandibulectomy is
indicated for bilateral disease conditions affecting the rostral PREPARATION AND POSITIONING
mandible to the level of the second or third premolars. Rostral Prepare mandible from the proximal neck to the chin and lat-
hemimandibulectomy is indicated for tumors in the region of eral aspect of the face and cheeks. Correct surgical positioning
the lower canine tooth, incisors, or first premolar that have is imperative to provide optimum visualization of the oral
not crossed the symphysis based on clinical and radiographic cavity. For the rostral mandibulectomy, position the animal in
evaluation. dorsal recumbency, with the maxilla taped to the operating
table to allow maximal exposure to the oral cavity during sur-
OBJECTIVES 5 gery. For a rostral hemimandibulectomy, position the animal in
To remove the rostral mandible or rostral hemimandible and lateral recumbency, with the affected side up.
provide the animal with a disease-free, functional, and cos-
metic oral cavity PROCEDURE
Rostral Mandibulectomy:13,6 Sharply incise the buccal
ANATOMIC CONSIDERATIONS 2,3,5,6 mucosa along the rostral aspect of the mandible (Plate 32A1).
The oral cavity is a complex structure composed of lips, gin- Elevate the subcutaneous tissue and connective tissue from the
giva, tongue teeth, palate, and salivary glands and ducts. The bone, exposing the ventral and lateral aspects of the mandible
vascular supply to the mouth is provided by the lingual, major (Plate 32A2). Reflect and retract the tissues caudally and later-
palatine, mandibular alveolar, and facial arteries, which are ally to the level of the osteotomy. Perform an osteotomy with an
branches of the external and internal carotid arteries. Anatomic oscillating saw, osteotome, or Gigli wire caudal to the canine
landmarks for the procedure include the incisors, the canine teeth or first or second molars (Plate 32B). Locate the mandibular
teeth and the second and third premolars, and the mandibular arteries within the intramedullary canal, and ligate. If the arteries
symphysis. Brisk hemorrhage from the mandibular artery retract within the intramedullary canal and cannot be located,
may occur at the osteotomy site; this should be identified use bone wax and electrocautery to staunch the hemorrhage.
and either ligated or controlled with bone wax and electro- Incise any remaining connective tissue, remove the rostral
cautery. mandible, and submit for histopathology and margin evaluation.
Continued
CHAPTER 32 M A N D I B U L E C TO M Y 97

P L AT E 3 2

A2 B
A1

Oscillating bone saw


Periosteal elevator
98 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

Rostral Hemimandibulectomy:13,6 Sharply incise the POSTOPERATIVE CARE


buccal mucosa from the mandibular symphysis to the first or Preemptive multimodal analgesia should be instituted in all
second premolar. Elevate the subcutaneous tissue and connec- patients for the first 48 to 72 hours. Postoperative antibiotics
tive tissue from the bone, exposing the ventral and lateral are recommended for the first 5 to 7 days. The patient should be
aspects of the mandible. Reflect and retract the tissues caudally fed moist food formed in individual meatballs to protect the sur-
and laterally to the level of the osteotomy (Plate 32C). Separate gical incision. Access to chew toys and rawhide bones should
the mandibular symphysis with an osteotome, and perform an be restricted until the incision is healed.
osteotomy with an oscillating saw, osteotome, or Gigli wire
caudal to the canine tooth or first or second molar (Plate 32D). EXPECTED OUTCOME 1,6,8,9
Locate the mandibular artery within the intramedullary canal, In a study evaluating owner satisfaction with partial mandi-
and ligate. If the arteries retract within the intramedullary bulectomy or maxillectomy for the treatment of oral tumors,
canal and cannot be located, use bone wax and electrocautery 85% of owners were satisfied with the results from the surgery.
to staunch the hemorrhage. Incise any remaining connective Forty-four percent noted a change in prehension and difficulty
tissue, remove the rostral hemimandible, and submit for in eating, but pain was perceived to be reduced in most animals,
histopathology and margin evaluation. and cosmesis was acceptable in all 27 cases. Prognosis in dogs
Closure: Replace the lip over the exposed hemimandible(s) with oral neoplasia varies, depending on the histopathologic
and appose the gingiva and sublingual mucosa with simple con- type of the tumor, tumor size, the amount of bony involvement,
tinuous or interrupted absorbable suture, taking care to avoid presence of regional and distant metastases, the clinical stage
entrapment of the salivary ducts (Plate 32E). It may be neces- of the disease, and the location of the tumor within the oral
sary to remove redundant labial tissue to provide a more cavity. The prognosis is excellent for dogs that undergo partial
cosmetic closure and to prevent excessive drooling (Plates 32F mandibulectomy for the treatment of mandibular fractures,
and 32G). with owner acceptance of the cosmetic appearance and
mandibular function reported as good to excellent.
CAUTIONS 1,3,5,6
It may be necessary to modify the surgical incision to obtain
adequate surgical margins. Preoperative planning is crucial to References
ensure complete tumor excision. Patients should be thoroughly 1. White R: Mandibulectomy and maxillectomy in the dog: Long-term
staged and assessed (e.g., with presurgical incisional biopsy; survival in 100 cases. J Small Anim Pract 32(2):6972, 1991.
skull, intraoral, and thoracic radiographs; fine needle aspiration 2. Manfra-Marretta S, Schrader S, Matthiesen D: Problems associated
of the local lymph nodes; blood work; coagulation profile; and with the management and treatment of jaw fractures. Problems in
electrocardiogram) prior to surgery. To decrease the inci- Vet Med 2(1):220247, 1990.
dence of postoperative infection, perioperative antibiotics are 3. Salisbury S: Problems and complications associated with maxillec-
recommended. tomy, mandibulectomy, and oronasal fistula repair. Problems in Vet
Med 3(2):153169, 1991.
4. Hoelzler M, Holmberg D: Partial mandibulectomy as the treatment
POSTOPERATIVE EVALUATION 1,3,57
of a comminuted mandibular fracture in a dog. Can Vet J 42(2):
The mandible and associated musculature should be submitted 143144, 2001.
for histopathology and margin evaluation. Suture removal is not 5. Matthiesen D, Manfra-Marretta S: Results and complications asso-
necessary; however, the oral cavity should be thoroughly exam- ciated with partial mandibulectomy and mexillectomy techniques.
ined at 10 to 14 days for postoperative complications. Possible Problems in Vet Med 2(1):248275, 1990.
complications include incisional dehiscence, infection, ranulas 6. White R: The oral cavity. In Hedlund C, Taboada J (eds): Clinical
and sialoceles from iatrogenic salivary duct trauma, subcuta- Atlas of Ear, Nose and Throat Diseases in Small Animals: The Case-
neous emphysema, mandibular drift and instability, abnormal Based. Schlutersche, Hannover, Germany, 2002.
salivation with secondary cheilitis and dermatitis, oral pain, 7. Kosovsky JK, Matthiesen DT, Marretta SM, et al: Results of partial
local tumor recurrence, and distant metastatic disease. Owners mandibulectomy for the treatment of oral tumors in 142 dogs. Vet
Surg 20(6):397401, 1991.
should also be asked about any problems with prehension or
8. Fox LE, Geoghegan SL, Davis LH, et al: Owner satisfaction with par-
cosmetic concerns. Patients should be evaluated every 3 months tial mandibulectomy or maxillectomy for treatment of oral tumors
with a complete physical and oral examination. Thoracic in 27 dogs. J Am Anim Hosp Assoc 33(1):2531, 1997.
radiographs are recommended every 3 months in animals 9. Lantz G, Salisbury S: Partial mandibulectomy for treatment of
with malignant tumors to evaluate for distant metastasis for the mandibular fractures in dogs: Eight cases (19811984). J Am Vet
first year. Med Assoc 191(2):243245, 1987.
CHAPTER 32 M A N D I B U L E C TO M Y 99

P L AT E 3 2

E
F

Redundant labial Labial


tissue to be removed tissue excised

Redundant labial
tissue to be removed
100 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

A M P U TAT I O N S

CHAPTER 33Forelimb Amputation


with Scapulectomy
INDICATIONS 1 33F). Ligate and sever the axillary vein. Disarticulate the limb
Forelimb amputation is a salvage procedure indicated for by transecting the pectoral muscles and ligating and dividing
the treatment of neoplasia, osteomyelitis, nonunion fractures, the lateral thoracic vessels.
severe trauma with vascular compromise and limb necrosis, Closure: Inverting the muscle bellies, place interrupted
paralysis caused by brachial plexus avulsion, and congenital Lembert sutures, with 0 to 2-0 absorbable suture material, in the
limb deformities. lateral fascial sheaths of the latissimus dorsi, omotransver-
sarius, and trapezius muscles to the pectoral muscle (Plate
OBJECTIVES 33G). Eliminate the dead space with 2-0 to 3-0 absorbable
To remove the limb and preserve the animals quality of life sutures in an interrupted cruciate or simple interrupted pattern
in the subcutaneous tissue. Appose the skin edges with inter-
ANATOMIC CONSIDERATIONS 2 dermal or skin sutures (Plate 33H).
Forelimb amputation is most commonly performed by removing
the limb at the scapula. More distal procedures have been CAUTIONS
described, but they are thought to produce less aesthetically Patients should be thoroughly assessed before surgery is
pleasing results in short-haired animals because of the scapular initiated (e.g., with electrocardiogram, thoracic radiographs,
spine and acromial prominence. Anatomic landmarks for the and blood work). Hemodynamically unstable patients should be
procedure include the scapula and associated musculature. treated prior to surgery to ensure an uneventful recovery.
Whole blood and plasma products should be on hand in the
EQUIPMENT event that major hemorrhage occurs.
Standard surgical pack; electrocautery; hemoclips or ample
suture material for vascular ligation; sterile syringe; 25-gauge POSTOPERATIVE EVALUATION
needle; 1 to 2 mL of 0.5% bupivacaine, not exceeding 1.5 to If indicated, the entire limb should be submitted for histo-
2.0 mg/kg of body weight in the dog and 1 mg/kg of body pathology. Sutures should be removed in 10 to 14 days.
weight in the cat, for brachial plexus injection3
POSTOPERATIVE CARE
PREPARATION AND POSITIONING Postoperative bandaging of the wound for 2 to 3 days may be
Prepare the forelimb circumferentially from dorsal midline to desirable to prevent seroma formation. Preemptive multimodal
carpus. Position the animal in lateral recumbency, with the analgesia should be instituted in all patients for the first 48 to
affected limb up. Drape the limb out from a hanging position to 72 hours. Common parameters to evaluate in the postoperative
allow maximal manipulation during surgery. amputee are heart rate, pulse quality, respiratory rate, capillary
refill time, body temperature, electrocardiogram, pulse
PROCEDURE oximetry, central venous pressure, serial packed cell volume,
Amputation:1,4 Incise the skin and subcutaneous tissue in a total protein, serum glucose, and activated clotting times.
reverse Y incision from the vertebral border of the scapula to
the acromial process, following the scapular spine, and around EXPECTED OUTCOME 1,2,4
the forelimb medially (Plate 33A). Reflect the skin, and ligate the The outcome for return to function and quality of life is good to
axillobrachial and omobrachial veins proximal to the greater excellent. Most animals adapt very well to forelimb amputation
tubercle of the humerus (Plate 33B). Ligate the cephalic vein but will have a noticeable gait deficit on ambulation.
distal to the cleidobrachialis muscle. Using electrocautery for
all the muscle incisions, transect the brachiocephalicus muscle
through the clavicular tendon. Sever the omotransversarius and
trapezius muscles along the cranial and dorsal edge of the spine References
of the scapula. Sever the latissimus dorsi muscle close to its 1. Daly WR: Amputation of the forelimb. In Bojrab MJ (ed): Current
insertion on the humerus (Plate 33C). Rotate the cranial edge of Techniques in Small Animal Surgery, 4th ed. Baltimore, Williams &
Wilkins, 1998.
the scapula laterally, and sever the insertion of the scalenus,
2. Bone DL, Aberman HM: Forelimb amputation in the dog using
rhomboideus, and serratus ventralis muscles (Plate 33D). Block humeral osteotomy. J Am Anim Hosp Assoc 24:5, 525529, 1988.
and sever the supraspinatus and brachial plexus nerves. Inject 3. Muir WW, Hubbell JAE: Handbook of Veterinary Anesthesia. St. Louis,
each nerve prior to transection with 0.2 to 0.4 mL bupivacaine Mosby, 1989.
until a bleb forms under the epineurium proximal to the cut 4. Harvey CE: Forequarter amputation in the dog and cat. J Am Anim
(Plate 33E). Transfix, ligate, and sever the axillary artery (Plate Hosp Assoc 10(1):2528, 1974.
CHAPTER 33 F O R E L I M B A M P U TAT I O N W I T H S C A P U L E C T O M Y 101

P L AT E 3 3

A
B C Trapezius muscle
Spine of scapula Latissimus
dorsi muscle

Omotransversarius
muscle

Omobrachial
vein
Axillobrachial
vein
Brachiocephalicus Long head of
Cephalic muscle triceps muscle
vein
Deltoideus
muscle Lateral head of
triceps muscle

D Rhomboideus E
muscle Scalenus
muscle
Serratus
ventralis
muscle
C6 C7
C8 T1

Scalenus
muscle

Axillary Axillary First Deep Lateral


F artery vein rib pectoral thoracic
G muscle artery,
Trapezius vein, and
muscle nerve

Latissimus H
dorsi muscle
Transfixion
suture Pectoral
muscle
Omotransversarius
muscle
102 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

A M P U TAT I O N S

Forelimb Salvage via Partial


CHAPTER 34

and Complete Scapulectomy


INDICATIONS 1,2 affected limb up. Drape the limb out from a hanging position to
Partial and total scapulectomy are limb-sparing procedures allow maximal manipulation during surgery.
most commonly used in the treatment of neoplasia of the prox-
imal scapula or in select cases of degenerative joint disease and PROCEDURE
pain in the shoulder that are not responsive to conservative Complete Scapulectomy:1 Incise the skin and subcuta-
management and in which arthrodesis is not an option. neous tissue from the dorsal border of the scapula to the prox-
imal third of the humerus, following the dorsal border of the
OBJECTIVES scapula. Incise along the caudal aspect of the scapula, con-
To preserve limb function and, in the cases of cancer, to allow necting the two incisions at the apices (Plate 34A). Hemorrhage
for local tumor control may be controlled with ligatures, hemoclips, and electro-
cautery. Without disturbing the pseudocapsule of the tumor,
ANATOMIC CONSIDERATIONS 1 reflect the skin and subcutaneous tissue to expose the
Partial scapulectomy is most commonly performed by superficial muscles of the trapezius, omotransversarius, rhom-
removing the proximal scapula while preserving the scapulo- boideus, and deltoideus (Plate 34B1). Using electrocautery,
humeral joint. Complete scapulectomy is indicated for tumors incise these muscles close to their origins on the scapula,
involving the distal part of the scapula, or when more than 90% without disturbing the tumor. Retract the scapula laterally, and
of the scapula is involved. Anatomic landmarks for the pro- elevate the serratus ventralis muscle from the medial aspect of
cedure include the scapular spine, neck, acromial process, the scapula, taking care to preserve the brachial plexus and
glenoid cavity, supraglenoid process, and associated muscu- axillary artery and vein (Plate 34B2). Identify the supra- and
lature. subscapular nerves coming from the brachioplexus bundle, and
inject each nerve prior to transection with 0.2 to 0.4 mL bupiva-
EQUIPMENT caine until a bleb forms under the epineurium proximal to the
Standard surgical pack; electrocautery; hemoclips or ample cut. Transect the tendons of the coracobrachialis, teres minor,
suture material for vascular ligation; Senn, Army-Navy, and/or infraspinatus, supraspinatus, and subscapularis muscles close
Gelpi retractors; a saw or osteotome for osteotomy of the to their insertions on the humerus (Plate 34C). Sharply incise
scapula; sterile syringe; 25-gauge needle; 1 to 2 mL of 0.5% the joint capsule of the shoulder, and transect the teres major
bupivacaine, not exceeding 1.5 to 2.0 mg/kg of body weight in muscle and the long head of the triceps from their insertions
the dog and 1 mg/kg of body weight in the cat, for brachial from the caudal aspect of the scapula using electrocautery
plexus injection3 (Plate 34D1). Perform an osteotomy of the supraglenoid tubercle,
preserving the attachment of the biceps tendon (see Plate 34D1).
PREPARATION AND POSITIONING The scapula and associated musculature (i.e., infraspinatus,
Prepare the forelimb circumferentially from dorsal midline to supraspinatus, and subscapularis) may now be removed and
carpus. Position the animal in lateral recumbency with the submitted for histopathology and margin evaluation.
Continued
CHAPTER 34 F O R E L I M B S A LVA G E V I A PA RT I A L A N D C O M P L E T E S C A P U L E C T O M Y 103

P L AT E 3 4

Omotransversarius muscle Trapezius muscle Trapezius muscle

Omotransversarius muscle

Latissimus
dorsi muscle B1
Tumor
Skin Long head of
incision triceps muscle
Deltoideus muscle

Lateral head of
triceps muscle

Deltoideus muscle

B2
Serratus Biceps Infraspinatus
ventralis muscle tendon muscle (cut)
(elevated)
Infraspinatus muscle Teres minor muscle
(cut)
Teres minor muscle
Long head
Supraspinatus
of triceps muscle
muscle
(cut)

D1

Teres major muscle

Long head of
triceps muscle

Lateral head of
triceps muscle
104 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

Closure: Secure the biceps tendon and supraglenoid presurgical fine needle aspiration or biopsy, blood work, coagu-
tubercle to the caudal aspect of the joint capsule using nonab- lation profile, and electrocardiogram).
sorbable monofilament suture in a horizontal mattress pattern.
Reattach the triceps muscle to the deltoideus, omotransver- POSTOPERATIVE EVALUATION
sarius, and trapezius muscles with an interrupted Lembert or The scapula and associated musculature should be submitted
horizontal mattress suture pattern and nonabsorbable suture. for histopathology and margin evaluation. The sutures should
Secure the remaining trapezius to the underlying serratus ven- be removed in 10 to 14 days. For the first year the patient should
tralis muscle to further eliminate dead space. The subcutaneous be checked every 3 months with a physical examination and
tissue and skin closure is routine. thoracic radiographs to evaluate for local recurrence of disease.
Partial Scapulectomy:1 A partial scapulectomy is per-
formed in a manner similar to a complete scapulectomy, with POSTOPERATIVE CARE
the exception that the scapulohumeral joint is left intact, and Postoperative bandaging of the wound for 3 to 5 days may be
the osteotomy is at the level of or proximal to the scapular desirable to prevent seroma formation. Preemptive multimodal
neck. The osteotomy site will vary, depending on the level and analgesia should be instituted in all patients for the first 48 to
size of the tumor, and only the proximal portion of the scapula 72 hours. Rehabilitation and range-of-motion exercises should
is removed (Plate 34D2). Attach the transected muscles of the be instituted early to prevent joint contraction and loss of
trapezius, omotransversarius, serratus ventralis, and rhom- function.
boideus to the distal scapula via holes drilled into the body
using nonabsorbable suture in a simple interrupted or hori- EXPECTED OUTCOME 1
zontal mattress pattern. Alternatively, close the remaining mus- Postoperative use of the limb is usually fair to excellent. Dogs
culature without bone tunnels by suturing transected muscles that undergo partial scapulectomy are reported to have better
of the supraspinatus, infraspinatus, deltoideus, and the long function than dogs with total scapulectomy.
head of the triceps to the serratus ventralis, omotransversarius,
and trapezius muscles. The subcutaneous tissue and skin
closure are routine.
References
1. Kirpensteijn J, Straw RC, Pardo AD, et al: Partial and total scapulec-
CAUTIONS
tomy in the dog. J Am Anim Hosp Assoc 30(4):313319, 1994.
It may be necessary to modify the surgical incision to obtain 2. Trout N, Pavletic M, Kraus K: Partial scapulectomy for management
adequate surgical margins. Preoperative planning is crucial to of sarcomas in three dogs and two cats. J Am Vet Med Assoc
ensure complete tumor excision. Patients should be thoroughly 207(5):585587, 1995.
staged and assessed before this limb salvage procedure surgery 3. Muir WW, Hubbell JAE: Handbook of Veterinary Anesthesia. St.
is initiated (e.g., with thoracic and abdominal radiographs, Louis, Mosby, 1989.
CHAPTER 34 F O R E L I M B S A LVA G E V I A PA RT I A L A N D C O M P L E T E S C A P U L E C T O M Y 105

P L AT E 3 4

D2
106 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

A M P U TAT I O N S

CHAPTER 35Rear Limb Amputation


via Coxofemoral Disarticulation
INDICATIONS ilium. On the medial aspect of the leg, isolate, ligate, and divide the
Rear limb amputation is a salvage procedure indicated for the treatment femoral artery and vein in the femoral triangle via placement of a cir-
of neoplasia, osteomyelitis, nonunion fractures, severe trauma with cumferential and transfixation suture proximally and a hemostat or cir-
vascular compromise and limb necrosis, paralysis caused by sciatic or cumferential suture distad (Plate 35D). Identify, block, and sever the
femoral nerve damage, and congenital limb deformities. femoral nerve. Transect the pectineus, the cranial belly of the sartorius,
the gracilis, and the adductor muscles at the level of the midshaft femur
OBJECTIVES (Plate 35E). Transect the iliopsoas muscle at its insertion on the lesser
To remove the limb and preserve the animals quality of life trochanter, and retract it cranially to fully expose the coxofemoral joint
capsule. Incise the joint capsule and sever the round ligament to
ANATOMIC CONSIDERATIONS remove the limb (Plate 35F).
Rear limb amputation may be performed via two methods: (1) by Closure: Inverting the muscle bellies, suture the lateral fascial
removing the limb at the midshaft femur; or (2) by removal at the sheaths of the muscle bellies in an interrupted Lembert pattern with
coxofemoral joint. More distal procedures have been described, but 0 to 2-0 monofilament absorbable suture (Plate 35G). Eliminate the
these produce a nonfunctional limb that may actually inhibit ambula- dead space with 2-0 to 3-0 absorbable sutures in an interrupted cruciate
tion and that is aesthetically less pleasing. Coxofemoral disarticulation or simple interrupted pattern in the subcutaneous tissue. Appose the
should be performed in dogs with neoplastic conditions affecting the skin edges with interdermal or skin sutures (see Plate 35G).
femur to ensure adequate surgical margins, and the entire limb should
be submitted for histopathology to confirm tumor-free margins and CAUTIONS
tumor identification. Anatomic landmarks for the procedure include the Preoperative planning will ensure adequate soft tissue coverage and
femur, the coxofemoral joint, and associated musculature. tension-free closure of the surgical wound. Elizabethan collars should
be employed in animals that lick or chew at the incision.
EQUIPMENT 1
Standard surgical pack; electrocautery, hemoclips, or ample suture POSTOPERATIVE EVALUATION
material for vascular ligation; Senn, Army-Navy, and/or Gelpi retrac- If indicated, the entire limb should be submitted for histopathology.
tors; sterile syringe; 25-gauge needle; 1 to 2 mL of 0.5% bupivacaine, Sutures can be removed in 10 to 14 days.
not exceeding 1.5 to 2.0 mg/kg of body weight in the dog and 1 mg/kg
of body weight in the cat, for brachial plexus injection POSTOPERATIVE CARE
Preemptive multimodal analgesia should be instituted in all patients for
PREPARATION AND POSITIONING the first 48 to 72 hours. Common parameters to evaluate in the post-
Prepare the rear limb circumferentially from dorsal midline to tarsus. operative amputee are heart rate, pulse quality, respiratory rate, capil-
Position the animal in lateral recumbency, with the affected limb up. lary refill time, body temperature, electrocardiogram, pulse oximetry,
Drape the limb out from a hanging position to allow maximal manipu- central venous pressure, serial packed cell volume, total protein, serum
lation during surgery. glucose, and activated clotting times. Activity should be restricted for
2 weeks until sutures are removed. It may be necessary to assist ambu-
PROCEDURE lation with slings or carts in some cases, until the animal adjusts to its
Coxofemoral Disarticulation: Incise the skin and subcuta- new center of balance.
neous tissue, using a curved incision on the lateral aspect of the leg that
begins at the flank fold and extends caudodistally to the distal third of EXPECTED OUTCOME 2,3
the femur, and then caudodorsally to the tuber ischii (Plate 35A). Make Expectations for a return to function and quality of life are good to
a similar incision on the medial aspect of the leg, connecting at either excellent. Most animals adapt well to hind limb amputation, but they
end. Retract the skin and subcutaneous tissue to expose the muscle bel- will have a noticeable gait deficit on ambulation, and about one dog in
lies of the biceps femoris and the tensor fascia latae. Using electro- three has a noticeable change in behavior.
cautery in the coagulation mode, transect these muscle belly groups at
the level of midshaft femur (Plate 35B). Reflect the muscle bellies prox-
imally to expose the sciatic nerve. Block and sever the sciatic nerve,
injecting it prior to transection with 0.2 to 0.4 mL bupivacaine until a References
bleb forms under the epineurium proximal to the cut. Using electro- 1. Muir WW, Hubbell JAE: Handbook of Veterinary Anesthesia. St.
cautery, transect the gluteal muscles at their insertions at the greater Louis, Mosby, 1989.
and third trochanters (Plate 35C). Transect the semitendinosus and 2. Kirpensteijn J, Van Den Bos R, Endenburg N: Adaptation of dogs to
semimembranosus at the level of the proximal femur, and reflect prox- the amputation of a limb and their owners satisfaction with the pro-
imally (see Plate 35C). Transect the external rotator and quadratus cedure. Vet Rec 144(5):115118, 1999.
femoris muscles at their insertions in the trochanteric fossa. Working 3. Endicott M: Principles of treatment for osteosarcoma. Clin Tech
cranially, transect the rectus femoris muscle close to its origin on the Small Anim Pract 18(2):110114, 2003.
CHAPTER 35 R E A R L I M B A M P U TAT I O N V I A C OX O F E M O R A L D I S A RT I C U L AT I O N 107

P L AT E 3 5

Lateral View
Deep Middle Superficial
gluteal muscle gluteal muscle gluteal muscle
A
Biceps
B femoris muscle

C
Skin
incision
Adductor muscle
Sciatic Gracilis muscle
Tensor nerve Semimembranosus muscle
fascia latae muscle Semitendinosus muscle

Vastus
lateralis muscle
Vastus
lateralis muscle

Medial View

D Pectineus muscle
E
Femoral Pectineus muscle
artery and vein Iliopsoas muscle

Adductor muscle

Gracilis muscle

Transfixion Gracilis
suture muscle

Sartorius muscle Adductor muscle


Sartorius muscle

G
F Medial View
Adductor muscle Quadriceps
Iliopsoas muscle
Ligament of Gracilis muscle
the long head Semimembranosus muscle
of the femur
Rectus femoris
Joint capsule muscle Semitendinosus muscle

Sartorius muscle
Biceps femoris muscle

Lateral View

Incision in
joint capsule
108 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

A M P U TAT I O N S

CHAPTER 36 Midshaft Femur Amputation


INDICATIONS suture proximally, and a hemostat or circumferential suture distad
Rear limb amputation is a salvage procedure indicated for the treatment (Plate 36E). Identify, block, and sever the femoral nerve. Transect the
of neoplasia, osteomyelitis, nonunion fractures, severe trauma with remaining pectineus muscle and the cranial belly of the sartorius
vascular compromise and limb necrosis, paralysis caused by sciatic or muscle to fully isolate the femoral diaphysis. Elevate any remaining
femoral nerve damage, and congenital limb deformities. tissue or muscle from the proximal femur at the osteotomy site, and cut
the femur using a saw or Gigli wire to remove the limb (Plate 36F).
OBJECTIVES The level of the osteotomy is located within the proximal third of the
To remove the limb and preserve the animals quality of life femoral shaft to ensure appropriate soft tissue coverage.
Closure: Inverting the muscle bellies, suture the lateral fascial
ANATOMIC CONSIDERATIONS sheaths of the muscle bellies in an interrupted Lembert pattern with
Rear limb amputation may be performed via two methods: (1) removing 0 to 2-0 monofilament absorbable suture. Cover the femoral shaft by
the limb at the midshaft femur; or (2) removing it at the coxofemoral suturing the transected muscle bellies of the quadriceps to the
joint. More distal procedures have been described, but these produce a adductor. Suture the transected biceps femoris to the gracilis, the semi-
nonfunctional limb that may actually inhibit ambulation and that is tendinosus, and the semimembranosus muscles. Eliminate the dead
aesthetically less pleasing. Midshaft femoral amputation is easier to space with 2-0 to 3-0 absorbable sutures in an interrupted cruciate or
perform than is a coxofemoral disarticulation, and therefore it is the simple interrupted pattern in the subcutaneous tissue. Appose the skin
method preferred by most veterinarians. Anatomic landmarks for edges with interdermal or skin sutures.
the procedure include the femur, the coxofemoral joint, and associated
musculature. CAUTIONS
Preoperative planning is imperative to ensure adequate soft tissue cov-
EQUIPMENT 1 erage and tension-free closure of the surgical wound. Elizabethan col-
Standard surgical pack; electrocautery, hemoclips, or ample suture lars should be employed in animals that lick or chew at the incision.
material for vascular ligation; Senn, Army-Navy, and/or Gelpi retrac-
tors; a Gigli wire or saw for midshaft femoral amputation; sterile POSTOPERATIVE EVALUATION
syringe; 25-gauge needle; 1 to 2 mL of 0.5% bupivacaine, not If indicated, the entire limb should be submitted for histopathology.
exceeding 1.5 to 2.0 mg/kg of body weight in the dog and 1 mg/kg of Sutures should be removed in 10 to 14 days.
body weight in the cat, for local nerve blockade
POSTOPERATIVE CARE
PREPARATION AND POSITIONING Preemptive multimodal analgesia should be instituted in all patients for
Prepare the rear limb circumferentially from dorsal midline to tarsus. the first 48 to 72 hours. Common parameters to evaluate in the post-
Position the animal in lateral recumbency, with the affected limb up. operative amputee are heart rate, pulse quality, respiratory rate, capil-
Drape the limb out from a hanging position to allow maximal manipu- lary refill time, body temperature, electrocardiogram, pulse oximetry,
lation during surgery. central venous pressure, serial packed cell volume, total protein, serum
glucose, and activated clotting times. Activity should be restricted for
PROCEDURE 2 weeks until suture removal. It may be necessary to assist ambulation
Midshaft Femoral Amputation:1 Incise the skin and subcu- with slings or carts, until the animal adjusts to its new center of balance.
taneous tissue, using a curved incision on the lateral aspect of the leg
that begins at the flank fold and extends caudodistally to the distal third EXPECTED OUTCOME 2,3
of the femur and then caudodorsally to the tuber ischii (Plate 36A). The outcome for return to function and quality of life should be good to
Make a similar incision on the medial aspect of the leg, connecting at excellent. Most animals adapt well to hind limb amputation, although
either end. Retract the skin and subcutaneous tissue to expose the they will have a noticeable gait deficit on ambulation. About one dog in
muscle bellies of the biceps femoris, the tensor fascia latae, and the three has a noticeable change in behavior.
quadriceps (Plate 36B1). Using electrocautery in the coagulation mode,
transect these muscle belly groups at the level of the distal third of the
femur (Plate 36B2). Identify, block, and sever the sciatic nerve, injecting References
it prior to transection with 0.2 to 0.4 mL bupivacaine until a bleb forms 1. Muir WW, Hubbell JAE: Handbook of Veterinary Anesthesia. St.
under the epineurium proximal to the cut. At the same level, use elec- Louis, Mosby, 1989.
trocautery to transect the semitendinosus, semimembranosus, and 2. Kirpensteijn J, Van Den Bos R, Endenburg N: Adaptation of dogs to
adductor muscles (Plate 36C). On the medial aspect of the leg, transect the amputation of a limb and their owners satisfaction with the
the gracilis and the caudal belly of the sartorius muscles at the level of procedure. Vet Rec 144(5):115118, 1999.
the midshaft femur (Plate 36D). Isolate, ligate, and divide the femoral 3. Endicott M: Principles of treatment for osteosarcoma. Clin Tech
artery and vein via placement of a circumferential and transfixation Small Anim Pract 18(2):110114, 2003.
CHAPTER 36 M I D S H A F T F E M U R A M P U TAT I O N 109

P L AT E 3 6

Lateral View

B1
A

Quadriceps Semitendinosus muscle


group

Biceps femoris muscle


Skin incision

B2 C

Semitendinosus muscle
Semimembranosus muscle
Adductor
muscle Adductor muscle Gracilis muscle

Semimembranosus
muscle

Quadriceps
group Semitendinosus muscle

Biceps femoris muscle

Medial View
Sartorius muscle Osteotomy site
Adductor muscle (caudal part)
D
Femoral vessels
Pectineus muscle

E
F

Gracilis
muscle

Sartorius muscle
Transfixion
(cranial part)
suture Sartorius muscle
(cranial part)
110 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

A M P U TAT I O N S

CHAPTER 37 Digital Amputation


INDICATIONS 13 of the appendages attachment to the paw (Plate 37C1). Using a scalpel
Digital amputation is indicated for the treatment of neoplasia, blade, scissors, or digital pressure, remove the digit and suture the
osteomyelitis, nonunion fractures, severe trauma, and severe toe defor- wound closed with a simple interrupted or cruciate suture and monofil-
mities that result in lameness or pain. Dewclaw removal is indicated for ament absorbable suture (optional) (Plate 37C2). Usually, neither band-
cosmesis, and as a preventative measure to avoid future injury. aging nor suture removal is necessary.
Dewclaws should not be removed in working breeds such as the Briard
or Great Pyrenees, in which double dewclaws on each hindfoot are a CAUTIONS 4
breed standard and requirement. Dewclaws in puppies less than 1 week The surgical incision may need to be modified in order to obtain
of age may be amputated with minimal instrumentation. Once the digits adequate surgical margins in the cases of neoplasia. Preoperative plan-
develop, amputation of the dewclaw is more complicated and requires ning is crucial to ensure complete tumor excision. Patients should be
general anesthesia. thoroughly staged and assessed before this limb salvage procedure
surgery is initiated (e.g., with thoracic radiographs, presurgical fine
OBJECTIVES needle aspiration or biopsy, blood work, coagulation profile, and elec-
To remove a digit and preserve the foot function and normal weight- trocardiogram). Evidence of bone lysis is present in 83% of cases of
bearing capacity malignant tumors and in 17% of the benign or pyogranulomatous
masses.
ANATOMIC CONSIDERATIONS
The primary weight-bearing digits of the paw are the third and fourth POSTOPERATIVE EVALUATION
digits. Each digit is composed of three phalangeal bones. Anatomic If indicated, the digit should be submitted for histopathology and
landmarks for the procedure include the phalanges of digits 1 through 5 culture and sensitivity. Sutures should be removed in 10 to 14 days.
and associated tendons and musculature.
POSTOPERATIVE CARE 5
EQUIPMENT The foot should be protected with a soft, padded bandage. Elizabethan
Standard surgical pack, electrocautery, bone cutters for proximal collars should be employed until the wound is healed in animals that
phalangeal amputation, tourniquet to control hemorrhage (optional) lick or chew at the bandage or incision. Activity should be restricted for
2 weeks, until suture removal.
PREPARATION AND POSITIONING
Clip and prepare the affected paw from the carpus or tarsus distally. EXPECTED OUTCOME 4,6
Position the animal in lateral recumbency with the affected limb up. The level of amputation depends on the disease; however, pad preser-
Place a tourniquet on the limb below the elbow or above the tarsus vation is important in ensuring pain-free ambulation. Up to two
(optional). Drape the limb out from a hanging position to allow maximal nonweight-bearing digits may be completely amputated without
manipulation during surgery. affecting limb function. Amputation of both digits 3 and 4 may result in
lameness, and therefore should be avoided if possible. The prognosis in
PROCEDURE dogs with digital neoplasia varies depending on the histopathologic
Digital Amputation of Digits 3 and 4: Incise the skin and type of the tumor, the presence of regional and distant metastasis, and
subcutaneous tissue in a reverse Y incision beginning at the mid- the clinical stage of the disease.
metacarpus of the affected digit, excising the digital pad (Plate 37A1).
Disarticulate the phalanges at the metacarpophalangeal joint, or create
an osteotomy of the proximal phalanx with bone-cutting forceps. Bevel References
the angle of the osteotomy to ensure adequate soft tissue coverage of 1. Basher A: Foot injuries in dogs and cats. Compend Contin Educ
the protruding bone (Plate 37A2). Using the electrocautery and suture, Pract Vet 16(9):11591176, 1994.
identify and ligate any persistent bleeding vessels. Appose the subcuta- 2. American Kennel Club Staff: Briard. In The Complete Dog Book.
neous tissue and fascia in a simple interrupted pattern with monofila- New York, Howell House Book, 1998.
ment absorbable suture. The remaining closure is routine (Plate 37A3). 3. American Kennel Club Staff: Great Pyrenees. In The Complete Dog
Amputation of Digit 1: Incise the skin and subcutaneous Book. New York, Howell House Book, 1998.
tissue from the midshaft metatarsus around the medial or lateral digit 4. Marino DJ, Matthiesen DT, Stefanacci JD, Moroff SD: Evaluation of
(Plate 37B1). Disarticulate the phalanges at the metacarpophalangeal dogs with digit masses: 117 cases (19811991). J Am Vet Med Assoc
joint, and identify and ligate or cauterize any persistent bleeding vessels 207(6):726728.
(Plate 37B2). Appose the subcutaneous tissue and fascia in a simple 5. Swaim S: Management and bandaging of soft tissue injuries of dog
interrupted pattern with monofilament absorbable suture. The remain- and cat feet. J Am Anim Hosp Assoc 21(3):329340, 1985.
ing closure is routine (Plate 37B3). 6. OBrien M, Berg J, Engler S: Treatment by digital amputation of sub-
Dewclaw Amputation in a Neonate: Crush the tissue ungual squamous cell carcinoma in dogs. J Am Vet Med Assoc
of the dewclaw using straight or curved hemostatic forceps at the level 201(5):759761, 1992.
CHAPTER 37 D I G I TA L A M P U TAT I O N 111

P L AT E 3 7

Adult Middle Digit Amputation

A1 A2 A3

Skin
incision

2 3 4 5

Bone incision
Proximal phalanx
Middle phalanx

Distal phalanx

Juvenile/Puppy Dewclaw Amputation

C1 C2

Adult Digit 1 Amputation

B1 B2 B3

Metacarpo-
phalangeal
joint

Proximal
(first)
phalanx
Distal 2 3 4 5
phalanx
112 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

A D D I T I O N A L C O R R E C T I V E O S T E OTO M I E S

CHAPTER 38Oblique Osteotomy Stabilized


with a Type II External Fixator
INDICATIONS surfaces are parallel (Plate 38C). Cranial caudal joint surface relation-
Candidates include animals with either angular or rotational deformity ships should mimic the contralateral intact bone. Rotational alignment
of the radius and ulna1 or tibia and fibula,2 with minimal length discrep- is correct if the paw aligns with the radius or tibia when the elbow and
ancy when compared with the contralateral limb. carpus or stifle and hock are flexed.
Stabilization: Stabilize the bone by adding medial and lateral
OBJECTIVES connecting bars and additional fixation pins to create a type II external
To realign joint surfaces, reestablish rotational alignment, and pre- fixation frame3 (see Plate 38C).
serve length of the affected bone
CAUTIONS
ANATOMIC CONSIDERATIONS It is important to avoid major nerves and vessels and joint surfaces
A physical examination is needed to estimate the degree of rotation. By when placing the fixation pins. Angular and rotational alignment
flexing the carpus and the elbow or the hock and stifle of the affected should be monitored during the reduction. Intraoperative radiographs
limb, the degree of angulation of the metacarpal or metatarsal bones are useful to verify proximal and distal pin placement and joint align-
in relation to the radius and ulna or in relation to the tibia can be ment during reduction and stabilization.
measured. The degree of angulation approximates the degree of rota-
tion. The osteotomy should be planned at the site of greatest curvature POSTOPERATIVE EVALUATION
visible on the radiographic view that shows the most deformity (usually Radiographs should be evaluated for bone alignment and implant place-
the cranial caudal view) and parallel to the joint surface closest to the ment. The joint surfaces should be parallel, and a cranial caudal view of
deformed area (usually the distal joint surface) (Plate 38A). Landmarks the proximal joint should be visible in the same radiograph as a cranial
for the pin placement and the vital structures to avoid vary with the caudal view of the distal joint. If angular deformity persists, the external
affected bone. fixator should be manipulated by loosening the clamps distal to the
osteotomy and realigning the fixation pins on the connecting bar to
EQUIPMENT correct the deformity (Plate 38D).
Surgical pack, Senn retractors, small Hohmann retractors, periosteal
elevator, oscillating saw, Jacob pin chuck, low-speed power POSTOPERATIVE CARE
drill, external fixation equipment, pin cutter, bone curette for har- Gauze sponges should be packed around the pins; the sponges should
vesting graft be secured with a bandage, which also incorporates the paw, to limit
postoperative swelling. The animal should be confined, with activity
PREPARATION AND POSITIONING limited to leash walking. External fixator management includes daily
For the radius, prepare the forelimb circumferentially from above the pin care and pin packing as needed. Radiographs should be repeated at
shoulder to the phalanges. Position the animal in dorsal recumbency, 6-week intervals to evaluate healing. The fixator may be destabilized by
and suspend the affected limb from the ceiling. Drape the limb out in removing selected fixation pins, or one connecting bar of the type II
the hanging position. For the tibia, prepare the affected rear limb cir- fixator, when early bone bridging is observed. The external fixator
cumferentially from midline to foot. Position the animal in dorsal should be removed when the osteotomy has healed.
recumbency, and suspend the affected limb from the ceiling. Drape the
limb out in the hanging position. Prepare the ipsilateral proximal EXPECTED OUTCOME
humerus as a cancellous bone graft donor site for either osteotomy. In most dogs, bone healing is seen in 6 to 12 weeks. Function may be
compromised while the external fixator is in place. Good correction of
PROCEDURE medial lateral angular deformities can be achieved with this technique;
Approach: Position a transfixation pin parallel to the proximal joint however, minimal correction is anticipated for cranial caudal bowing or
surface in the dorsal plane of the proximal portion of the bone. For the restoration of large length discrepancies.1
radius, start the pin on the lateral surface of the proximal radius or
radial head. Position a transfixation pin parallel to the distal joint sur-
face in the dorsal plane of the distal portion of the bone. For the radius,
start the pin on the lateral surface of the distal radius, just cranial to the References
ulna. Make a transverse osteotomy of the ulna or fibula at the same level 1. Quinn M, Ehrhart N, Johnson AL: Realignment of the radius in
as the radial or tibial osteotomy. Make an oblique osteotomy of canine antebrachial growth deformities treated with corrective
the radius or tibia at the area of greatest curvature (Plate 38B). The osteotomy and bilateral (Type II) external fixation. Vet Surg 29:558,
osteotomy should parallel the distal joint surface in both the dorsal and 2000.
transverse planes.3 2. Johnson SG, Hulse DA, Vangundy TE, et al: Corrective osteotomy
Reduction: Lower the table to allow the animals weight to align for pes varus in the dachshund. Vet Surg 18:373, 1989.
the bone. Use the distal transfixation pin to manipulate the distal bone 3. Johnson AL, Hulse DA: Management of specific fractures: Radial and
segment to align the joint surfaces and derotate the bone. Medial and ulnar growth deformities. In Fossum TW (ed): Small Animal Surgery,
lateral angular alignment is correct when the proximal and distal joint 2nd ed. St. Louis, Mosby, 2002.
CHAPTER 38 O B L I Q U E O S T E O T O M Y S TA B I L I Z E D W I T H A T Y P E I I E X T E R N A L F I X AT O R 113

P L AT E 3 8

A B

Craniocaudal view Lateral view

C D
114 PA RT O N E SURGICAL PROCEDURES FOR JOINT DISEASES

A D D I T I O N A L C O R R E C T I V E O S T E OTO M I E S

Transverse Derotational
CHAPTER 39

Osteotomy Stabilized with a Plate


INDICATIONS Kirschner wire perpendicular to the bone in the transverse
Candidates include animals with isolated rotational deformity plane of the distal joint (Plate 39A). The approach depends on
of a long bone caused by fracture malunion. Concurrent angular the affected bone. Make the transverse osteotomy at the major
deformity may be corrected by performing an oblique osteotomy region of rotation (Plate 39B).
at the area of greatest curvature and then realigning the joint Reduction: Rotate the distal segment until the Kirschner
surfaces.1 wires are in the same plane (see Plate 39B).
Stabilization: Apply an appropriately contoured plate to
OBJECTIVES the bone (Plate 39C). The plate should function as a com-
To reestablish rotational alignment pression plate. Harvest a cancellous bone autograft, and place
it at the osteotomy site.
ANATOMIC CONSIDERATIONS
Rotation should be estimated from radiographic landmarks for CAUTIONS
the humerus and femur. The rotation for the radius or tibia from Rotational alignment and reduction should be maintained
a physical examination by flexing the carpus and the elbow or during implant application. It is important to be sure that the
the hock and stifle of the affected limb. The degree of angula- plate is centered on the bone. Irrigation is needed during
tion of the metacarpal or metatarsal bones should be measured drilling to reduce bone necrosis. All screws should be tightened
in relation to the radius and ulna or in relation to the tibia. The after each screw is placed and at the end of the procedure.
degree of angulation approximates the degree of rotation.
Generally, the osteotomy can be made at the mid-diaphysis. POSTOPERATIVE EVALUATION
Landmarks for the approach, and vital structures to avoid, vary Radiographs should be evaluated for bone alignment and
with the affected bone. implant placement. For radius and tibia, it is important to check
the alignment of the metacarpal or metatarsal bones to the
EQUIPMENT radius or tibia to verify rotational correction.
Surgical pack, periosteal elevator, Gelpi retractors, Myerding
or Hohmann retractors, Kern bone-holding forceps, self- POSTOPERATIVE CARE
centering plate-holding forceps, high-speed drill, Kirschner The animal should be confined, with activity limited to leash
wires, plating equipment, bone curette for harvesting graft walking. Radiographs should be repeated at 6-week intervals to
evaluate healing. Activity should be increased when bone
PREPARATION AND POSITIONING bridging is observed.
Prepare the affected limb circumferentially from midline to
foot. If a cancellous bone graft harvest is anticipated, prepare a EXPECTED OUTCOME
donor site as well. Positioning depends on the affected bone. In most dogs, bone healing is seen in 12 to 18 weeks. Implant
Drape the limb out from a hanging position to allow maximal removal may be necessary if soft tissues are irritated.
manipulation during surgery.

PROCEDURE Reference
Approach: Position a Kirschner wire perpendicular to the 1. Johnson AL: Osteotomies. In Olmstead ML (ed): Small Animal
bone in the transverse plane of the proximal joint. Position a Orthopedics. St. Louis, Mosby, 1995.
CHAPTER 39 T R A N S V E R S E D E R O TAT I O N A L O S T E O T O M Y S TA B I L I Z E D W I T H A P L AT E 115

P L AT E 3 9

Cranial caudal view Cranial caudal view


of proximal femur of distal femur

B C
118 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

GENERAL PRINCIPLES FOR DIAPHYSEAL FRACTURES

CHAPTER 40Stabilizing a Transverse


or Short Oblique Diaphyseal Fracture
with a Compression Plate
INDICATIONS to cause the plate to stand away from the fracture surface by
Candidates include animals with transverse or short oblique about 2 mm (see Plate 40A). Make sure the plate is long enough
diaphyseal fractures requiring fixation with implants that to allow at least 6 cortices secured by screws on both sides of
will securely hold bone for a long time (12 weeks or more). The the fracture. Compress the fracture line, using the loaded drill
procedure is also indicated in large active older dogs, dogs guide to insert one or two screws (Plate 40B). Place the
with multiple limb injuries, toy breed dogs with distal radial remaining screws in a neutral position (Plate 40C). Short,
fractures, and animals for which postoperative comfort is oblique fractures may additionally be compressed with a lag
imperative.1 screw positioned through the plate or outside of the plate (Plate
40D).2,3 If indicated, harvest a cancellous bone autograft and
OBJECTIVES place it at the fracture site. Close the incision routinely.
To anatomically reduce and compress the fracture line using
the bone plate as a compression plate CAUTIONS
The plate provides rigid fixation and resists axial loading, Reduction should be maintained during implant application.
bending, and rotational forces at the fracture. It is important to make sure that the plate is centered on the
bone. Irrigatation during drilling is needed to reduce bone
ANATOMIC CONSIDERATIONS necrosis. It is necessary to drill, measure, tap, and insert each
Landmarks for the approach, and vital structures to avoid, vary screw before moving on to prepare the next screw hole. All
with the affected bone. screws should be tightened after each screw is placed and at
the end of the procedure.
EQUIPMENT
Surgical pack, Senn retractors, Gelpi retractors, Hohmann POSTOPERATIVE EVALUATION
retractors, periosteal elevator, Kern bone-holding forceps, Radiographs are necessary to evaluate for fracture reduction
self-centering plate-holding forceps, high-speed drill, plating and implant placement.
equipment, bone curette for harvesting cancellous bone
autograft POSTOPERATIVE CARE
The animal should be confined, with activity limited to leash
PREPARATION AND POSITIONING walking. Radiographs should be repeated at 6-week intervals
Prepare the affected limb circumferentially from midline to to monitor healing. Activity should be increased when bone
foot. If cancellous bone graft harvest is anticipated, prep a bridging is observed.
donor site as well. Positioning depends on the affected bone.
Drape the limb out from a hanging position to allow maximal EXPECTED OUTCOME
manipulation during surgery. Bone healing is usually seen in 12 to 18 weeks. A good return to
function can be expected. Implant removal may be necessary if
PROCEDURE soft tissues are irritated.
Approach: The required approach varies with the affected
bone.
Reduction: Reduce the fracture by lifting the bone ends References
from the incision and bringing them into contact. With the bone 1. Johnson AL, Hulse DA: Fundamentals of orthopedic surgery and
ends in contact, slowly push the bone segments back into the fracture management: Decision making in fracture management. In
normal position. Alternatively, use a lever to reduce the frac- Fossum TW (ed): Small Animal Surgery, 2nd ed. St. Louis, Mosby, 2002.
2. Schatzker J, Muestage F, Prieur WD: Implants and their application.
ture. With transverse fractures, manual maintenance of reduc-
In Brinker WO, Olmstead ML, Sumner-Smith G, et al (eds): Manual
tion is necessary. Alternatively, after the plate is contoured, of Internal Fixation in Small Animals. New York, Springer-Verlag,
secure the fracture in reduction with self-centering plate- 1998.
holding forceps applied to the plate and the bone (Plate 40A). 3. Wittner G, Holz U: Plates. In Ruedi TP, Murphy WM (eds): AO
Stabilization: Contour the plate to match the bone Principles of Fracture Management. New York, AO Publishing and
surface. Prestress the plate by bending it an additional amount Thieme, 2000.
CHAPTER 40 S TA B I L I Z I N G A D I A P H Y S E A L F R A C T U R E W I T H A C O M P R E S S I O N P L AT E 119

P L AT E 4 0

D
120 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

GENERAL PRINCIPLES FOR DIAPHYSEAL FRACTURES

CHAPTER 41Stabilizing a Transverse or Short


Oblique Diaphyseal Fracture with an
Intramedullary Pin and External Fixator
INDICATIONS the pins (Plate 41B). If additional stability is needed, add a fixation pin,
The procedure is indicated for transverse or short oblique diaphyseal placed close to the fracture, to both bone segments (Plate 41C). Cut the
fractures in animals with anticipated short healing times (6 to 12 IM pin below the level of the skin (see Plate 41B), or leave it long and
weeks). It is indicated in smaller dogs and cats that are young, that are tie it into the fixator (see Plate 41C).3 Tighten all of the fixation clamps.
healthy, and that have single limb injuries.1 Owners must be willing and If indicated, harvest a cancellous bone autograft and place it at the
able to assume fixator management. fracture. The incision closure is routine.

OBJECTIVES CAUTIONS
To anatomically reduce the fracture line and stabilize the bone It is important to pay attention to the direction of the IM pin and
The intramedullary (IM) pin resists bending forces at the fracture, external fixation pins in the soft tissues to avoid nerves and
whereas the external fixator resists axial loading and rotational forces vessels. It is also necessary to ensure that the IM pin does not interfere
at the fracture. IM pins are not indicated in the radius. with a joint surface.

ANATOMIC CONSIDERATIONS POSTOPERATIVE EVALUATION


Landmarks for the approach, and the vital structures to avoid, vary with Radiographs should be evaluated for fracture reduction and implant
the affected bone. placement.

EQUIPMENT POSTOPERATIVE CARE


Surgical pack, Senn retractors, Gelpi retractors, Hohmann retractors, Gauze sponges should be packed around the pins, and the sponges
periosteal elevator, Kern bone-holding forceps, Jacob pin chuck, low- should be secured with a bandage to limit postoperative swelling and
speed power drill, IM pins, external fixation equipment, pin cutter, to protect the pin tracts. The animal should be confined, with activity
bone curette for harvesting cancellous bone autograft limited to leash walking. External fixator management includes daily
pin care and pin packing as needed. Radiographs should be repeated at
PREPARATION AND POSITIONING 6-week intervals to monitor healing. The external fixator should be
Prepare the affected limb circumferentially from midline to foot. If can- removed when bone bridging is observed. If the tie-in is used, the
cellous bone graft harvest is anticipated, prep a donor site as well. proximal fixation pin should be left secured to the IM pin (Plate 41D).
Positioning depends on the affected bone. Drape the limb out from a The IM pin (and proximal fixation pin) should be removed after the
hanging position to allow maximal manipulation during surgery. fracture has healed.

PROCEDURE EXPECTED OUTCOME


Approach: The approach varies with the affected bone. Incise the Bone healing is usually seen in 6 to 12 weeks. Animals usually
skin, and create soft tissue tunnels for fixation pin placement. experience a good return to function.
Reduction: Place an IM pin (of a size selected to equal 50% of
the medullary canal at the isthmus) in the proximal segment using
a retrograde (humerus or femur) (Plate 41A1) or antegrade (tibia, References
humerus, or femur) (Plate 41A2) technique.2 Retract the pin within the 1. Johnson AL, Hulse DA: Fundamentals of orthopedic surgery and
medullary canal of the proximal segment. Reduce the fracture by lifting fracture management, decision making in fracture management. In
the bone ends from the incision and bringing them into contact. With Fossum TW (ed): Small Animal Surgery, 2nd ed. St. Louis, Mosby,
the bone ends in contact, slowly push the bone segments back into the 2002.
normal position. Alternatively, use a lever to reduce the fracture. Drive 2. Johnson AL, Hulse DA: Management of specific fractures, femoral
the IM pin distally to maintain reduction (Plate 41A3). diaphyseal fractures. In Fossum TW (ed): Small Animal Surgery, 2nd
Stabilization: Seat the IM pin in the distal segment of the bone. ed. St. Louis, Mosby, 2002.
Establish rotational alignment, and place external fixation pins through 3. Aron DN, Dewey C: Experimental and clinical experience with an
the proximal and distal metaphyses of the bone. Predrill the bone IM pin external skeletal fixator tie-in configuration. Vet Comp
before placing the threaded fixation pins. Secure the connecting bar to Orthop Traumatol 4:86, 1991.
CHAPTER 41 S TA B I L I Z I N G A F R A C T U R E W I T H A N I M P I N A N D E X T E R N A L F I X AT O R 121

P L AT E 4 1

A1 A2 A3

Retrograde Antegrade
B

Bridging
callus

C D
122 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

GENERAL PRINCIPLES FOR DIAPHYSEAL FRACTURES

CHAPTER 42Stabilizing a Transverse or Short


Oblique Diaphyseal Fracture with a Type Ib
External Fixator
INDICATIONS tion through the proximal and distal metaphyses of the bone.
The procedure is indicated for transverse or short oblique radial Predrill the bone before placing threaded fixation pins. Secure
and tibial diaphyseal fractures in animals with anticipated short the connecting bar to the pins. Add fixation pins, placed 1 cm
or moderate healing times (6 to 18 weeks).1 A modified type Ib from the fracture, to both bone segments (Plate 42B). Place
external fixator may also be used for humeral fractures. Smooth additional pins to fill out the frame (Plate 42C). Repeat the steps
fixation pins or a combination of threaded and smooth fixation to place a similar frame in a cranial-lateral plane at 90 degrees
pins can be used for smaller dogs and cats that are young, that to the first frame (see Plate 42C). Connect the frames with artic-
are healthy, and that have single limb injuries and an anticipated ulations proximally and distally (Plate 42D).3 Tighten all of the
rapid healing time (6 weeks).1 Threaded pins should be used in fixation clamps. If indicated, harvest a cancellous bone auto-
large, active, older dogs and in dogs with multiple limb injuries graft and place it at the fracture. The incision closure is routine.
where postoperative load is increased and anticipated healing
times are longer.1 Owners must be willing and able to assume CAUTIONS
fixator management. It is important to pay attention to the direction of the fixation
pins in the soft tissues to avoid nerves and vessels. It is also
OBJECTIVES necessary to avoid the joint surfaces when placing the fixation
To anatomically reduce the fracture line and stabilize the bone pins. Articulations must not interfere with elbow flexion.
The external fixator resists bending, axial loading, and rota-
tional forces at the fracture. POSTOPERATIVE EVALUATION
Radiographs should be evaluated for bone alignment and
ANATOMIC CONSIDERATIONS implant placement.
Landmarks for the approach, and the vital structures to avoid,
vary with the affected bone. POSTOPERATIVE CARE
Gauze sponges should be packed around the pins, and the
EQUIPMENT sponges should be secured with a bandage that incorporates
Surgical pack, Senn retractors, Gelpi retractors, Hohmann the paw to limit postoperative swelling. The animal should be
retractors, periosteal elevator, Kern bone-holding forceps, confined, with activity limited to leash walking. External fixator
Jacob pin chuck, low-speed power drill, external fixation management includes daily pin care and pin packing as needed.
equipment, pin cutter, bone curette for harvesting cancellous Radiographs should be repeated at 6-week intervals to monitor
bone autograft healing. The fixator should be destabilized by removing the
cranial frame (converting to a type Ia cranial medial frame)
PREPARATION AND POSITIONING when early bone bridging is observed. The rest of the external
Prepare the affected limb circumferentially from midline to fixator should be removed when the fracture is healed.
foot. For both the radius and the tibia, position the animal in
dorsal recumbency and suspend the affected limb from the EXPECTED OUTCOME
ceiling. Drape the limb out in the suspended position. If cancel- Bone healing is usually seen in 12 to 18 weeks. The animal will
lous bone graft harvest is anticipated, prep a donor site (usually, have limited function while the external fixator is in place, but
the ipsilateral proximal humerus) as well. a good return to function is expected.

PROCEDURE
Approach: Perform a limited open reduction to align the References
bone segments. Pin location and limited open approaches vary 1. Johnson AL, Hulse DA: Fundamentals of orthopedic surgery and
with the affected bone. Incise the skin, and create soft tissue fracture management, decision making in fracture management. In
tunnels for fixation pin placement. Fossum TW (ed): Small Animal Surgery, 2nd ed. St. Louis, Mosby,
2002.
Reduction: For the radius and tibia, lower the table
2. Aron DN, Palmer RH, Johnson AL: Biologic strategies and a bal-
to suspend the animal from the ceiling.2 Allow the animals anced concept for repair of highly comminuted long bone fractures.
weight to fatigue the muscles. Use a lever to reduce the fracture Compend Cont Educ Pract Vet 17:35, 1995.
(Plate 42A). 3. Lauer SK, Aron DN, Evans MD: Finite element method evaluation:
Stabilization: Establish rotational alignment, and place Articulations and diagonals in an 8-pin type 1b external skeletal
external fixation pins in a cranial-medial to caudal-lateral direc- fixator. Vet Surg 29:28, 2000.
CHAPTER 44 S TA B I L I Z I N G A F R A C T U R E W I T H A N I M P I N A N D C E R C L A G E W I R E S 127

P L AT E 4 4

A B

Loop cerclage Twist

1 2
Alternate
twist

4
3 4
D 3
C

E
CHAPTER 42 S TA B I L I Z I N G A F R A C T U R E W I T H A T Y P E I B E X T E R N A L F I X AT O R 123

P L AT E 4 2

Cranial
view

Left
forelimb

A
B

Cranial
view
D

C
124 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

GENERAL PRINCIPLES FOR DIAPHYSEAL FRACTURES

Stabilizing a Long Oblique


CHAPTER 43

Diaphyseal Fracture with Lag Screws


and a Neutralization Plate
INDICATIONS Slightly countersink the near cortex (Plate 43B3), measure
The procedure is indicated for long oblique diaphyseal fractures (Plate 43B4), tap (Plate 43B5), and place the screw (Plate
in animals requiring fixation with implants that will securely 43B6).2 Contour a plate to match the bone surface. The plate
hold bone for a longer period (e.g., 12 weeks or longer). It is should be long enough to span the bone and allow a minimum
also indicated in large, active, older dogs; in dogs with multiple of six cortices secured by screws on both sides of the fracture
limb injuries; and in animals for which postoperative comfort is (Plate 43C). Secure the plate with screws placed in a neutral
imperative.1 position.2 Alternatively, when the fracture line is parallel to
the plate surface of the bone, secure the reduced segments
OBJECTIVES with cerclage wire. Place the plate and insert the screws which
To anatomically reduce and compress the fracture line with are crossing the fracture as lag screws (Plate 43D). Remove the
lag screws cerclage wire before tightening the screws. If indicated, harvest
Application of a bone plate neutralizes the load on the frac- a cancellous bone autograft and place it at the fracture. The
ture. The plate and screw combination provides rigid fixation incision closure is routine.
and resists axial loading, bending, and rotational forces at the
fracture. CAUTIONS
Reduction should be maintained with reduction forceps during
ANATOMIC CONSIDERATIONS lag screw application. It is important to ensure that the plate is
Landmarks for the approach, and the vital structures to avoid, centered on the bone so the plate holes at the ends of the plate
vary with the affected bone. are over bone. Irrigation during drilling is needed to reduce
bone necrosis. It is necessary to drill, measure, tap, and insert
EQUIPMENT each screw before moving on to prepare the next screw hole.
Surgical pack, Senn retractors, Gelpi retractors, Hohmann All screws should be tightened after each screw is placed and
retractors, periosteal elevator, Kern bone-holding forceps, again at the end of the procedure.
pointed reduction forceps, self-centering plate-holding for-
ceps, high-speed drill, plating equipment, bone curette for POSTOPERATIVE EVALUATION
harvesting cancellous bone autograft Radiographs should be evaluated for fracture reduction and
implant placement.
PREPARATION AND POSITIONING
Prepare the affected limb circumferentially from midline to POSTOPERATIVE CARE
foot. If cancellous bone graft harvest is anticipated, prep a The animal should be confined, with activity limited to leash
donor site as well. Positioning depends on the affected bone. walking. Radiographs should be repeated at 6-week intervals to
Drape the limb out from a hanging position to allow maximal monitor healing. Activity should be increased when bone
manipulation during surgery. bridging is observed.

PROCEDURE EXPECTED OUTCOME


Approach: The approach varies, depending on the affected Bone healing is usually seen in 12 to 18 weeks. Animals usually
bone. experience a good return to function. Implant removal may be
Reduction: Reduce the fracture by distracting the bone necessary if soft tissues are irritated.
segments, and approximate the fracture surfaces. Use pointed
reduction forceps to manipulate the bone segments into reduc-
References
tion. Maintain reduction with the pointed reduction forceps
(Plate 43A). 1. Johnson AL, Hulse DA: Fundamentals of orthopedic surgery and
fracture management, decision making in fracture management.
Stabilization: When the fracture line is perpendicular
In Fossum TW (ed): Small Animal Surgery, 2nd ed. St. Louis,
to the plate surface of the bone, place two or three lag Mosby, 2002.
screws across the fracture line. Drill the near cortex with a 2. Schatzker J, Muestage F, Prieur WD: Implants and their application.
drill bit equal to the diameter of the screw threads (Plate In Brinker WO, Olmstead ML, Sumner-Smith G, et al (eds):
43B1). Place a drill insert sleeve, and drill the far cortex Manual of Internal Fixation in Small Animals. New York, Springer-
with the appropriate drill bit for the screw (Plate 43B2). Verlag, 1998.
CHAPTER 43 S TA B I L I Z I N G A F R A C T U R E W I T H L A G S C R E W S A N D N E U T R A L I Z AT I O N P L AT E 125

P L AT E 4 3

B1 B2 B3

B6

B4 B5

C D
126 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

GENERAL PRINCIPLES FOR DIAPHYSEAL FRACTURES

CHAPTER 44Stabilizing a Long Oblique


Diaphyseal Fracture with an Intramedullary
Pin and Multiple Cerclage Wires
INDICATIONS the reduced fracture at intervals of 0.5 cm to 1 cm. Pass a wire
The procedure is indicated for long oblique diaphyseal fractures passer around the bone. Feed the plain end of the wire through
in animals with anticipated short healing times (6 to 12 weeks). the wire passer, and pull the wire around the bone (Plate 44B).
It is also indicated in smaller dogs and cats that are young, that For loop cerclage, tighten the wire by passing the plain end of
are healthy, and that have single limb injuries.1 It is especially the wire through the eye of the wire (Plate 44C1). Insert the
useful for immature dogs and cats. Intramedullary (IM) pins are wire into the wire tightener, and crank the wire tight (Plate
not indicated in the radius. 44C2). Bend the wire over the eye. Retract the wire tightener,
and finish bending the wire (Plate 44C3). Cut the wire (Plate
OBJECTIVES 44C4).3 For plain orthopedic wire, begin twisting the wire ends
To anatomically reduce the fracture line and stabilize the bone by hand (Plate 44D1). Place the wire twisting pliers or needle-
The IM pin resists bending forces at the fracture, whereas holders onto the twist, and tighten the wire by pulling and
the cerclage wire compresses the fracture to resist axial loading twisting (Plate 44D2). When the wire is tight, cut the wire 3 mm
and rotational forces at the fracture. from the start of the twist (Plate 44D3). Alternatively, cut the
wire 5 mm to 7 mm from the twist, and bend it over in the direc-
ANATOMIC CONSIDERATIONS tion of the twist (Plate 44D4).3 Cut the IM pin below the level of
Landmarks for the approach, and the vital structures to avoid, the skin (Plate 44E). If indicated, harvest a cancellous bone
vary with the affected bone. autograft and place it at the fracture. The incision closure is
routine.
EQUIPMENT
Surgical pack, Senn retractors, Gelpi retractors, Hohmann CAUTIONS
retractors, periosteal elevator, Kern bone-holding forceps, All wires must be tight. It is important to pay attention to the
pointed reduction forceps, Jacob pin chuck, IM pins, ortho- direction of the IM pin in the soft tissues to avoid nerves and
pedic wire (spool or eye cerclage), wire passer, wire tightener vessels. The IM pin must not interfere with a joint surface.
(pliers, needle-holder, or loop cerclage wire tightener), wire
cutter, pin cutter, bone curette for harvesting cancellous bone POSTOPERATIVE EVALUATION
autograft Radiographs should be taken to evaluate for fracture reduction
and implant placement.
PREPARATION AND POSITIONING
Prepare the affected limb circumferentially from midline to POSTOPERATIVE CARE
foot. If cancellous bone graft harvest is anticipated, prep a The animal should be confined, with activity limited to leash
donor site as well. Positioning depends on affected bone. Drape walking. Radiographs should be repeated at 6-week intervals to
the limb out from a hanging position to allow maximal manipu- monitor healing. The IM pin should be removed after the frac-
lation during surgery. ture has healed.

PROCEDURE EXPECTED OUTCOME


Approach: The approach varies, depending on the affected Bone healing is usually seen in 6 to 12 weeks. Animals usually
bone. experience a good return to function.
Reduction: Place an IM pin (sized to equal 60% to 70% of
the medullary canal at the isthmus) in the proximal segment
using an antegrade (tibia, humerus, or femur) or retrograde References
(humerus or femur) technique.2 Retract the pin within the 1. Johnson AL, Hulse DA: Fundamentals of orthopedic surgery and
medullary canal of the proximal segment. Reduce the fracture fracture management, decision making in fracture management. In
by distracting the bone segments and approximating the frac- Fossum TW (ed): Small Animal Surgery, 2nd ed. St. Louis, Mosby, 2002.
2. Johnson AL, Hulse DA: Management of specific fractures, femoral
ture surfaces. Use pointed reduction forceps to manipulate the
diaphyseal fractures. In Fossum TW (ed): Small Animal Surgery, 2nd
bone segments into reduction. Maintain reduction with the ed. St. Louis, Mosby, 2002.
pointed reduction forceps (Plate 44A). 3. Schatzker J, Muestage F, Prieur WD: Implants and their application.
Stabilization: Seat the IM pin in the distal segment of the In Brinker WO, Olmstead ML, Sumner-Smith G, et al (eds): Manual
bone (see Plate 44A). Plan to place two or three (or more, of Internal Fixation in Small Animals. New York, Springer-Verlag,
depending on the length of the fracture) cerclage wires around 1998.
CHAPTER 46 S TA B I L I Z I N G A F R A C T U R E W I T H A T Y P E I I E X T E R N A L F I X AT O R 131

P L AT E 4 6

C D
128 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

GENERAL PRINCIPLES FOR DIAPHYSEAL FRACTURES

CHAPTER 45Stabilizing a Comminuted


Diaphyseal Fracture with an Intramedullary
Pin and a Bridging Plate
INDICATIONS distal ends of the fractured bone. Restore rotational alignment,
The procedure is indicated for comminuted nonreducible (more and secure the plate to the appropriate bone surface with self-
than one or two large fragments) humeral, femoral, and tibial centering plate-holding forceps (Plate 45C). The plate should
diaphyseal fractures in large, active, older dogs; and in dogs span the length of the bone, and the screws should secure a
with multiple limb injuries in which postoperative load is minimum of six cortices on either side of the fracture. Place
increased and anticipated healing times are longer.1 A plate and bicortical screws in the metaphyses and unicortical screws in
intramedullary (IM) pin can be used to stabilize comminuted the diaphysis where the IM pin interferes with screw placement.
radial fractures, with the plate stabilizing the radius and the pin Cut the pin below the skin.3,4 Harvest cancellous bone graft and
supporting the ulna. place it at the fracture site (Plate 45D).

OBJECTIVES CAUTIONS
To restore normal bone length and alignment The plate should be centered on the bone so that the plate holes
The IM pin restores axial alignment and protects the plate at the ends of the plate are over bone. Irrigation is needed
from bending forces at the fracture, whereas the plate resists during drilling to reduce bone necrosis. All screws should be
axial loading, bending, and rotational forces at the fracture. tightened after each screw is placed and at the end of the
procedure. The IM pin must not interfere with nerves, vessels,
ANATOMIC CONSIDERATIONS or any joint surface.
Landmarks for the approach, and the vital structures to avoid,
vary with the affected bone. POSTOPERATIVE EVALUATION
Radiographs should be taken to evaluate for fracture reduction
EQUIPMENT and implant placement.
Surgical pack, Senn retractors, Gelpi retractors, Hohmann
retractors, periosteal elevator, Kern bone-holding forceps, POSTOPERATIVE CARE
self-centering plate-holding forceps, Jacob pin chuck, IM The animal should be confined, with activity limited to leash
pins, plating equipment, high-speed drill, bone curette for walking. Radiographs should be repeated at 6-week intervals to
harvesting cancellous bone autograft monitor healing. Activity should be increased when bone
bridging is observed. The IM pin should be removed when early
PREPARATION AND POSITIONING fracture bridging is evident.
Prepare the affected limb circumferentially from midline to
foot. If cancellous bone graft harvest is anticipated, prep a EXPECTED OUTCOME
donor site as well. Positioning depends on the affected bone. The IM pin may cause morbidity and lameness. Bone healing is
Drape the limb out from a hanging position to allow maximal usually seen in 12 to 18 weeks. Animals usually experience a
manipulation during surgery. good return to function. Plate removal may be necessary if soft
tissues are irritated.
PROCEDURE
Approach: The approach varies, depending on the affected References
bone. Use an open but do not disturb the fragments technique 1. Johnson AL, Hulse DA: Fundamentals of orthopedic surgery and
to expose the proximal and distal bone segments with minimal fracture management, decision making in fracture management. In
disturbance of the fracture hematoma and bone fragments.2 Fossum TW (ed): Small Animal Surgery, 2nd ed. St. Louis, Mosby,
Reduction and Stabilization: Place an IM pin (sized to 2002.
equal 40% to 50% of the medullary canal width at the isthmus) in 2. Aron DN, Palmer RH, Johnson AL: Biologic strategies and a bal-
the proximal segment using an antegrade (tibia, humerus, or anced concept for repair of highly comminuted long bone fractures.
femur) or retrograde (humerus or femur) technique. Drive the Compend Cont Educ Pract Vet 17:35, 1995.
3. Johnson AL, Hulse DA: Fundamentals of orthopedic surgery and
pin to the fracture site, and blunt the pin tip. Lift and align the
fracture management, bone plates and screws. In Fossum TW (ed):
distal segment, and insert the IM pin. Distract the bone to length Small Animal Surgery, 2nd ed. St. Louis, Mosby, 2002.
by advancing the pin while holding the proximal segment with 4. Johnson AL, Smith CW, Schaeffer DJ: Fragment reconstruction and
bone-holding forceps (Plate 45A). Contour a plate so that the bone plate fixation compared with bridging plate fixation for
bend matches a radiographic image of the contralateral intact treating highly comminuted femoral fractures in dogs: 35 cases
bone (Plate 45B). Torque the plate to match the proximal and (19871997). J Am Vet Med Assoc 213:1157, 1998.
CHAPTER 45 S TA B I L I Z I N G A F R A C T U R E W I T H A N I M P I N A N D B R I D G I N G P L AT E 129

P L AT E 4 5

Vastus
lateralis
muscle
retracted
Biceps femoris
muscle retracted
Shaft
of femur

Adductor magnus
Vastus muscle B
intermedius
muscle

Cancellous
bone
autograft

C D
130 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

GENERAL PRINCIPLES FOR DIAPHYSEAL FRACTURES

CHAPTER 46Stabilizing a Comminuted


Diaphyseal Fracture with a Type II
External Fixator
INDICATIONS CAUTIONS
The procedure is indicated for animals with comminuted nonreducible It is important to avoid the joint surfaces and the fracture lines with the
(more than one or two large fragments) radial and tibial diaphyseal fixation pins. Intraoperative radiographs are helpful in evaluating bone
fractures. Smooth fixation pins, or a combination of threaded fixation alignment and pin location.
plus and smooth fixation pins, can be used for animals with rapid
healing times (i.e., 6 to 12 weeks). Threaded pins should be used in POSTOPERATIVE EVALUATION
large, active, older dogs and in dogs with multiple limb injuries in which Radiographs should be evaluated for bone alignment and implant loca-
postoperative load is increased and anticipated healing times are tion. If the fractured bone is reduced in a varus or valgus position
longer.1 (i.e., the proximal and distal joint surfaces are not parallel), then the
distal clamps should be loosened and the distal segment should be
OBJECTIVES repositioned to eliminate the angular deformity. If rotational malalign-
To restore normal bone length and alignment ment is present, some correction may be obtained by repositioning the
A type II external fixator is applied to bridge the fracture. The distal clamps onto the opposite side of the bar.
fixator resists axial loading, bending, and rotational forces at the
fracture. POSTOPERATIVE CARE
Gauze sponges should be packed around the pins, and the sponges
ANATOMIC CONSIDERATIONS should be secured with a bandage that incorporates the paw, to limit
Landmarks for the pin placement, and the vital structures to avoid, vary postoperative swelling. The animal should be confined, with activity
with the affected bone. limited to leash walking. External fixator management includes daily
pin care and pin packing as needed. Radiographs should be repeated at
EQUIPMENT 6-week intervals to monitor healing. The fixator should be destabilized
Surgical pack, Senn retractors, small Hohmann retractors, low-speed by removing selected fixation pins (or the lateral connecting bar) when
power drill, Jacob pin chuck, external fixator equipment early bone bridging is observed. If the lateral bar is removed, the
associated transfixation pins should be left long enough to exit the skin
PREPARATION AND POSITIONING on the lateral surface of the limb. The pins should be covered to prevent
Prepare the affected limb circumferentially from midline to foot. For injury to the owner. The external fixator should be removed when the
both the radius and the tibia, position the animal in dorsal recumbency, fracture is healed.
and suspend the affected limb from the ceiling. Drape the limb out in
the hanging position. EXPECTED OUTCOME
Bone healing is usually seen in 12 to 18 weeks. The animal may experi-
PROCEDURE ence limited function while the external fixator is in place but will even-
Approach: Perform a closed reduction to preserve the integrity of tually have a good return to function.
the fracture hematoma and the surrounding soft tissues.2 If necessary,
use a limited open reduction to line up major bone segments.3 References
Pin location and limited open approaches vary depending on the 1. Johnson AL, Hulse DA: Fundamentals of orthopedic surgery and frac-
affected bone. Incise the skin and create soft tissue tunnels for pin ture management, decision making in fracture management. In Fossum
placement. TW (ed): Small Animal Surgery, 2nd ed. St. Louis, Mosby, 2002.
Reduction: Lower the table to allow the animals weight to align 2. Aron DN, Palmer RH, Johnson AL: Biologic strategies and a
the fractured bone (Plate 46A). balanced concept for repair of highly comminuted long bone
Stabilization: Place a centrally threaded fixation pin through fractures. Compend Cont Educ Pract Vet 17:35, 1995.
the distal metaphyses. Make sure the pin parallels the distal joint sur- 3. Lavarty PH, Johnson AL, Toombs JP, et al: Simple and multiple frac-
face and is in the medial to lateral plane. Predrill the hole with a drill bit tures of the radius treated with an external fixtor. Vet Comp Orthop
0.1 mm smaller than the selected pin.4 Insert the pin with a hand chuck Traumatol 15:97, 2002.
or low RPM power. Repeat the procedure for the proximal metaphysis 4. Clary EM, Roe SC: In vitro biomechanical and histological assess-
(Plate 46B). Align the segments, checking for angular and rotational ment of pilot hole diameter for positive-profile external skeletal
alignment, and secure the pins to medial and lateral connecting bars. fixation pins in canine tibiae. Vet Surg 25:543, 1996.
Fill out the frame with either transfixation pins or unilateral fixation 5. Johnson AL, Seitz SE, Smith CW, et al: Closed reduction and type II
pins, depending on the anatomy of the bone and surrounding soft external fixation of severely comminuted fractures of the radius and
tissues (Plate 46C). Use a guiding device or additional connecting bar tibia in dogs: 23 cases (19901994). J Am Vet Med Assoc 209:1445, 1996.
and guide clamp to ensure accurate placement of transfixation pins 6. Kraus KH, Wotton HM, Boudrieau RJ, et al: Type II external fixation
(see Plate 46C).5,6 Be sure that there are at least two pins, or preferably using new clamps and positive profile threaded pins for treatment of
three pins, above and below the fracture (Plate 46D). Tighten all of the fractures of the radius and tibia in dogs. J Am Vet Med Assoc
clamps. 212:1267, 1998.
132 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

GENERAL PRINCIPLES FOR DIAPHYSEAL FRACTURES

Stabilizing a Comminuted
CHAPTER 47

Diaphyseal Fracture with an Interlocking Nail


INDICATIONS the proximal bone segment with a bone-holding forceps, and
The procedure is indicated in comminuted nonreducible (more continue to drive the nail distally to distract the distal bone
than one or two large fragments) humeral, femoral, and tibial segment to length (Plate 47B). Ensure that the proximal portion
diaphyseal fractures. It is indicated in dogs that have antici- of the nail is seated within the proximal segment. Remove the
pated healing times that are short or intermediate, and when nail driver, and attach the jig. Drill, measure, and tap the distal
postoperative comfort is important.1 Interlocking nails are con- screw hole, using the jig and associated guides to maintain
traindicated for the radius. screw alignment with the hole in the nail. Insert the screw
(Plate 47C). Check rotational alignment, and insert the
OBJECTIVES remaining screws. Remove the extension piece.3 Harvest can-
To restore normal bone length and alignment cellous bone graft and place it at the fracture site (Plate 47D).
The interlocking nail restores axial alignment and resists Close the incision routinely.
axial loading, bending, and rotational forces at the fracture.
CAUTIONS
ANATOMIC CONSIDERATIONS It is important to ensure that the nail does not penetrate the
Landmarks for the approach, and the vital structures to avoid, distal joint. The first screw should be placed in the distal hole of
vary with the affected bone. Pin insertion sites vary with the the nail to help secure nail and jig alignment. The rotational
affected bone. alignment must be correct before proximal screws are inserted.
Irrigation must be done during drilling to reduce bone necrosis.
EQUIPMENT
Surgical pack, Senn retractors, Gelpi retractors, Hohmann POSTOPERATIVE EVALUATION
retractors, periosteal elevator, Kern bone-holding forceps, Radiographs should be taken to evaluate for fracture reduction
interlocking nail equipment, bone screws, high-speed drill, and implant placement.
bone curette for harvesting cancellous bone autograft
POSTOPERATIVE CARE
PREPARATION AND POSITIONING The animal should be confined, with activity limited to leash
Prepare the affected limb circumferentially from midline to walking. Radiographs should be repeated at 6-week intervals
foot. If a cancellous bone graft harvest is anticipated, prep a to monitor healing. Activity should be increased when bone
donor site as well. Positioning depends on the affected bone. bridging is observed.
Drape the limb out from a hanging position to allow maximal
manipulation during surgery. EXPECTED OUTCOME
Bone healing is usually seen in 12 to 18 weeks. Animals should
PROCEDURE experience a good return to function. Removal of the inter-
Approach: The approach varies, depending on the affected locking nail may be necessary if soft tissues are irritated.
bone. Use an open but do not disturb the fragments technique
to expose the proximal and distal bone segments with minimal
disturbance of the fracture hematoma and bone fragments.2 References
Reduction and Stabilization: Establish the insertion 1. Johnson AL, Hulse DA: Fundamentals of orthopedic surgery and
hole in the proximal bone segment, using a reamer of the appro- fracture management, decision making in fracture management. In
Fossum TW (ed): Small Animal Surgery, 2nd ed. St. Louis, Mosby, 2002.
priate size to prepare for the nail. The nail diameter and length
2. Aron DN, Palmer RH, Johnson AL: Biologic strategies and a balanced
are estimated from preoperative radiographs of the contra- concept for repair of highly comminuted long bone fractures.
lateral bone (Plate 47A). Attach the nail to the extension piece Compend Cont Educ Pract Vet 17:35, 1995.
and nail driver, and insert it into the proximal bone segment 3. Dueland RT, Johnson KA, Roe SC, et al: Interlocking nail treatment
so that it exits at the fracture surface. Align the distal segment, of diaphyseal long-bone fractures in dogs. J Am Vet Med Assoc
and drive the nail distally within the medullary canal. Stabilize 214:59, 1999.
CHAPTER 47 S TA B I L I Z I N G A F R A C T U R E W I T H A N I N T E R L O C K I N G N A I L 133

P L AT E 4 7

Reamer Extension
piece
and nail
driver

Vastus
lateralis
muscle
retracted Biceps femoris
Shaft muscle retracted
of femur
Adductor magnus
Vastus muscle
intermedius
muscle

Jig

Cancellous
bone autograft

C D
134 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

GENERAL PRINCIPLES FOR DIAPHYSEAL FRACTURES

CHAPTER 48 Cancellous Bone Autograft


INDICATIONS Proximal Tibia: Incise the skin and subcutaneous tissue
Autogenous cancellous bone grafts are used to promote rapid over the medial surface of the proximal tibia. Harvest can-
bone formation. Candidates include animals with cortical cellous bone as previously described (Plate 48C). Closure is
defects after fracture repair and adult and elderly animals routine.
with fractures, delayed unions, nonunions, osteotomies, joint Iliac Wing: Incise the skin over the craniodorsal iliac spine.
arthrodesis, or cystic defects. Autogenous cancellous bone also Incise subcutaneous tissues, and expose the dorsal surface of
promotes bone formation in infected fractures.1 the iliac wing. Elevate the musculature from the lateral
surface and medial surfaces of the craniodorsal portion of
OBJECTIVES the iliac wing. Obtain a corticocancellous graft by using an
To promote bone formation and bone cell survival by har- osteotome to remove a cortical wedge from the iliac wing.
vesting cancellous bone at the end of the procedure and Harvest cancellous bone from between the inner and outer cor-
transferring directly to the recipient site tical bone of the iliac body with a bone curette (Plate 48D).
Macerate the wedge with rongeurs, and place it into the recip-
ANATOMIC CONSIDERATIONS ient site. Closure is routine.
Optimal sites for cancellous bone harvest are the proximal
humeral metaphysis, the wing of the ilium, and the proximal CAUTIONS
tibial metaphysis. All three sites have minimal soft tissue Avoid open physes in immature animals. Avoid penetrating the
coverage and are easily accessible. The proximal humerus and articular surface or other cortical surfaces with the curette.
iliac wing yield the largest amounts of cancellous bone. Create round holes in the long bone cortex to minimize stress
concentration and possible fracture. If the recipient site is
EQUIPMENT infected, or is the site of a tumor, harvest the graft first to avoid
Surgical pack, Gelpi retractors, Senn retractors, Army-Navy contamination of the donor site. Alternatively, use a separate
retractors, drill bit or intramedullary pin, osteotome and surgical team and instrumentation to harvest the graft.
mallet, rongeur, bone curette, stainless steel cup, syringe
POSTOPERATIVE EVALUATION
PREPARATION AND POSITIONING Wound healing at the donor site should be evaluated when the
Select, prepare, and drape the graft donor site so that it is easily recipient site procedure is evaluated.
accessible when the recipient site is draped.
POSTOPERATIVE CARE
PROCEDURE Routine procedures for caring for a surgical wound should be
Proximal Humerus: Incise the skin and subcutaneous followed.
tissues over the craniolateral aspect of the proximal humerus.
Retract the acromial head of the deltoid muscle caudally, and EXPECTED OUTCOME
expose the flat aspect of the craniolateral metaphysis just distal Bone formation should be seen at the recipient site by 12 weeks
to the greater tubercle. Make a round hole in the bone cortex after surgery. Complications at the donor site include seroma
using an intramedullary pin or drill bit. Insert a bone curette, formation; infection; and, rarely, fracture. Complications at the
and harvest cancellous bone (Plate 48A). Place the cancellous recipient site (e.g., failure of grafts to stimulate bone formation)
bone in a stainless steel cup. Use a syringe to collect blood from are difficult to recognize.
the donor site to add to the graft (Plate 48B). The blood will
clot and form a moldable composite with the graft, facilitating Reference
handling. Flush and loosely pack the recipient site with graft 1. Johnson AL, Hulse DA: Fundamentals of orthopedic surgery and
material. Close subcutaneous tissues around the graft to hold it fracture management, bone grafts. In Fossum TW (ed): Small
in position. Animal Surgery, 2nd ed. St. Louis, Mosby, 2002.
CHAPTER 48 C A N C E L L O U S B O N E A U TO G R A F T 135

P L AT E 4 8

A Deltoid B Syringe
muscle with blood

Osteotome
blade

Curette
C D
136 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

MANDIBLE

CHAPTER 49 Mandibular Symphyseal Fractures


INDICATIONS across and behind the canine teeth, and reinsert it through the
Candidates include animals with mandibular symphyseal frac- hypodermic needle to exit from the skin incision at the original
tures. insertion point (Plate 49C). Remove the needle. While holding
the fracture in reduction, tighten the wire (Plate 49D). Leave
OBJECTIVES the ends of the wire exposed through the skin incision, and
To reduce and stabilize the symphyseal fracture and restore bend them to decrease the possibility of injury to the owner
dental alignment and occlusion (Plate 49E).1

ANATOMIC CONSIDERATIONS CAUTIONS


Realignment of dental occlusion is important for return to The incisor alignment should be observed when tightening the
function. wire, and dental occlusion should be checked after the wire is
tightened.
EQUIPMENT
Scalpel blade, 18- to 20-gauge (for dogs) or 20- to 22-gauge POSTOPERATIVE EVALUATION
(for cats) orthopedic wire, hypodermic needles sized to Radiographs should be taken to evaluate symphyseal reduction
accommodate the orthopedic wire, wire tightener, wire cutter and implant placement.

PREPARATION AND POSITIONING POSTOPERATIVE CARE


Prepare the ventral aspect of the mandible for aseptic surgery. It is important to clean the wire daily where it is exposed ven-
Rinse the mouth with an antiseptic. Position the animal in trally. Hard food, chew toys, and tug of war games should be
dorsal recumbency. It is not necessary to drape the mandible eliminated until the fracture has healed.
for an isolated symphyseal fracture.
EXPECTED OUTCOME
PROCEDURE Symphyseal union is usually seen in 6 to 12 weeks.
Approach: Make a small incision in the skin overlying the Radiographic evidence of bone bridging or callus formation is
ventral aspect of the symphysis. usually not evident. Once the fracture has stabilized, the wire
Reduction: Reduce and hold the symphysis with digital can be removed by cutting it with wire scissors where it is
pressure applied to the mandibular canine teeth (Plate 49A). exposed behind the canine teeth and extracting it by the twist.
Stabilization: Insert the hypodermic needle through the
skin incision and along one lateral mandibular surface (under
the subcutaneous tissues). Exit the needle in the oral cavity Reference
caudal to the canine tooth, and thread an 18- or 20-gauge wire 1. Johnson AL, Hulse DA: Management of specific fractures: Maxillary
through the needle (Plate 49B). Remove the needle and reposi- and mandibular fractures. In Fossum TW (ed): Small Animal
tion it on the opposite side of the mandible. Curve the wire Surgery, 2nd ed. St. Louis, Mosby, 2002.
CHAPTER 49 MANDIBULAR SYMPHYSEAL FRACTURES 137

P L AT E 4 9

E
138 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

MANDIBLE

Transverse and Oblique


CHAPTER 50

Mandibular Body Fractures


INDICATIONS slightly closer to the fracture line (see Plate 50A1). Drill a similar hole
Candidates include animals with single fracture lines of the mandibular on the caudal segment at the same level in the bone so the wire will be
body that can be anatomically reconstructed. placed perpendicular to the fracture. Feed a 12- to 18-inch strand of
orthopedic wire through each pair of holes, starting and finishing on the
OBJECTIVES lateral aspect of the mandible. Hold the fracture in reduction, and twist
To restore dental occlusion by anatomic reconstruction of the fracture the wire (Plate 50A2). To ensure the wire contacts the medial cortex,
Stable internal fixation allows a rapid return to function and place a forceps between the twist and the lateral mandible, and lever
minimizes aftercare. the wire away from the bone. Finish tightening the wire, cut the excess,
and bend the remaining twist into the bone (Plate 50A3). The interfrag-
ANATOMIC CONSIDERATIONS mentary wires applied perpendicular to the fracture line will result in
The mandibular body is easily palpated and surgically approached compression at the fracture. Transverse fractures are best stabilized
through the skin and subcutaneous tissue. The mandibular alveolar with two wires (Plate 50B1); occasionally, however, one wire in the
nerve, which is sensory to the teeth of the mandible, passes through the rostral mandible is sufficient (Plate 50B2). Interdental wiring may com-
mandibular canal along with the mandibular alveolar artery. These plement the interfragmentary wire (Plate 50B3). For oblique fractures,
structures are often damaged during mandibular fractures, although follow the previous steps, taking care to orient the wire perpendicular
clinical signs are seldom evident. Tooth roots must be avoided when to the fracture. Stabilize caudal-to-rostral oblique fracture with two
placing implants. wires placed at right angles to each other (Plate 50C). Stabilize medial-
to-lateral oblique fracture with two wires placed perpendicular to each
EQUIPMENT other in two planes (Plate 50D).2 In both cases, the second wire
Surgical pack, Gelpi retractors, Senn retractors, small Hohmann prevents overriding of the fracture as the wires are tightened.
retractors, periosteal elevator, baby Kern bone-holding forceps, small Evaluate the oral cavity for open wounds. If large wounds are
pointed reduction forceps, high-speed Kirschner wire driver or Jacob present, close the mucosa partially to decrease their size. Do not com-
pin chuck, Kirschner wires, orthopedic wire, wire-tighteners, wire pletely close contaminated wounds; to do so would prevent postopera-
cutters tive drainage. Place a Penrose drain if infection is present or likely to be
present. Suture the subcutaneous tissue over the mandibles. Suture the
PREPARATION AND POSITIONING skin incision.
Prepare the ventral aspect of the mandible for surgery. Rinse the mouth
with an antiseptic. Position the animal in dorsal recumbency, and CAUTIONS
secure the maxilla to the table by placing adhesive tape from one table Tooth roots should be avoided when drilling through the bone. It is
edge across the maxilla to the opposite table edge. Drape the mandible important to check that interfragmentary wires lie flat against the bone
out to allow maximal manipulation during surgery by placing one of the surface.
drapes into the mouth to cover the maxilla. A cancellous bone graft is
usually not necessary. POSTOPERATIVE EVALUATION
Dental occlusion should be evaluated. Radiographs should be taken to
PROCEDURE evaluate bone alignment and implant placement.
Approach: Incise the skin on the ventral midline between the
mandibles. Extend the incision from the symphysis to 1 cm to 2 cm POSTOPERATIVE CARE
caudal to the angular process of the mandibles. Move this incision in Oral exercise should be limited, soft foods should be provided, and no
either direction to expose both mandibles. If only one mandible is chew toys should be allowed. Radiographs should be repeated at
involved, incise directly over that mandible. Incise the subcutaneous 6-week intervals until bone bridging occurs.
tissue to expose the ventral portions of the mandibles. Elevate soft
tissues from both sides of the mandibles to expose the fracture(s). EXPECTED OUTCOME
Preserve the digastricus muscle attachments (Plate 50A1).1 Bone healing is usually seen in 6 to 12 weeks. Animals generally expe-
Reduction: Reduce the fracture by securing each bone segment rience an excellent return to function if dental occlusion is normal.
with Kern bone-holding forceps and then manipulating them into Intraoral wires are removed after fracture healing, but interfragmentary
anatomic alignment. Maintain reduction manually (with transverse wires remain in place unless they cause a problem. Damaged teeth may
fractures) or with pointed reduction forceps (for oblique fractures). require endodontic care or extraction.
Because there is little musculature around the mandibular body, reduc-
tion is usually easily accomplished. Anatomic reduction of the References
mandibular cortex will realign the teeth. 1. Piermattei DL, Johnson KA: An Atlas of Surgical Approaches to the
Stabilization: For transverse fractures, drill a hole with the Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
Kirschner wire. Start on the lateral aspect of the cranial mandibular Saunders, 2004.
segment, 0.5 cm to 1 cm from the fracture line and close to the oral edge 2. Rudy RL, Boudrieau RJ: Maxillofacial and mandibular fractures.
of the mandible. Aim the wire to exit on the medial side of the mandible, Sem Vet Med Surg Small Anim 7:3, 1992.
CHAPTER 50 T R A N S V E R S E A N D O B L I Q U E M A N D I B U L A R B O DY F R A C T U R E S 139

P L AT E 5 0

A1
Hemimandible A2 A3

Myelohyoideus
muscle
Branch of facial
artery and vein

Digastricus
muscle

B1

B2

B3
140 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

MANDIBLE

Comminuted Mandibular
CHAPTER 51

Body Fractures
INDICATIONS Reduction: After the fixation pins are placed, use them as a
Candidates include animals with comminuted fractures of the handle to realign the major bone segments so the dental occlusion is
mandibular body that cannot be anatomically reconstructed. restored. Maintain the reduction manually or by securing two fixation
pins on each side of the mandible with clamps and connecting bars
OBJECTIVES (biphasic splint) (Plate 51B). Remove the clamps and bars after the
To align major mandibular segments and restore dental occlusion acrylic is placed.
Stabilization: Insert at least two and, if possible, three fixation
ANATOMIC CONSIDERATIONS pins into each major bone segment by predrilling a pilot hole and
The mandibular body is easily palpated through the skin and subcuta- placing the pins with a pin chuck. Bend or notch the free ends of the
neous tissue. The mandibular alveolar nerve, which is sensory to the pins to enhance acrylic purchase. Mix methyl methacrylate acrylic until
teeth of the mandible, passes through the mandibular canal along it becomes doughy (3 to 4 minutes). Mold the acrylic to form a con-
with the mandibular alveolar artery. These structures are commonly necting column incorporating all of the pins at a distance of 1 cm to
damaged with mandibular fractures, although clinical signs are seldom 2 cm from the skin. Place saline moistened sponges around the fixation
evident. Tooth roots must be avoided when placing fixation pins. pins to dissipate the heat generated by the methyl methacrylate. Check
Normal occlusion is assessed by observing the unobstructed interdigi- the fracture reduction and hold it in position until the acrylic hardens
tation of the mandibular canine teeth between the maxillary incisors (8 to 10 minutes) (Plate 51C).1
and canine teeth and the mandibular fourth premolar positioned Evaluate the oral cavity for open wounds. If large wounds are
between the maxillary third and fourth premolars. present, close the mucosa partially to decrease their size. In order
to allow postoperative drainage, do not close contaminated wounds
EQUIPMENT completely.
Surgical pack, low-speed power drill, Jacob pin chuck, positive
profile threaded external fixation pins, external fixator equipment, CAUTIONS
methyl methacrylate acrylic Tooth roots should be avoided when drilling through the bone.

PREPARATION AND POSITIONING POSTOPERATIVE EVALUATION


To gain an unobstructed view of dental occlusion, place an endotra- Dental occlusion should be evaluated. Radiographs should be evaluated
cheal tube via a pharyngotomy incision. Insert an index finger into the for bone alignment and implant placement.
oral cavity, and locate the pharyngeal area immediately cranial to the
hyoid bones. Incise skin, subcutaneous tissues, and mucous membrane POSTOPERATIVE CARE
to create a passage for the endotracheal tube. Place a forceps through The skin and the apparatus should be cleaned daily to avoid food accu-
the surgically created passage to grasp the endotracheal tube (with mulation and skin excoriation. Oral exercise and soft foods should be
connector removed), and reroute it (Plate 51A).1 Prepare the ventral limited, and no chew toys should be allowed. Radiographs should be
aspect of the mandible for aseptic surgery. Rinse the mouth with an repeated at 6-week intervals until bone bridging occurs. After the frac-
antiseptic. Position the animal in dorsal recumbency, and secure the ture has healed, the external fixator should be removed by cutting each
maxilla to the table by placing adhesive tape from one table edge across pin to remove the acrylic frame and then removing individual pins.
the maxilla to the opposite table edge. Drape the mandible out to allow
maximal manipulation during surgery by placing one of the drapes into EXPECTED OUTCOME
the mouth to cover the maxilla and the rest of the drapes secured Bone healing is usually seen in 12 to 18 weeks. Large gaps may benefit
around the mandible. A cancellous bone graft is not generally used with from cancellous bone autograft if healing appears delayed. Excellent
closed reduction. return to function is expected if dental occlusion is restored.

PROCEDURE
Approach: There is no surgical approach to the fracture site for Reference
closed reduction of comminuted fractures, only the approaches for the 1. Egger EL: Skull and mandibular fractures. In Slatter D (ed):
fixation pin insertion. Incise the skin at each pin insertion site. Dissect Textbook of Small Animal Surgery, 2nd ed. Philadelphia, WB
the overlaying soft tissues to gain access to the bone surface. Saunders, 1993.
CHAPTER 51 C O M M I N U T E D M A N D I B U L A R B O DY F R A C T U R E S 141

P L AT E 5 1

Thyroid cartilage
Trachea

Point of
incision

Endotracheal tube
rerouted through
pharyngotomy incision

B C
142 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

SCAPULA

Transverse Scapular
CHAPTER 52

Body Fractures
INDICATIONS distal segment with pointed reduction forceps, and lift the bone
Candidates include animals with folding or displaced scapular segments out of the soft tissues until the fracture ends are
body fractures. apposed. While maintaining contact, slowly replace the frag-
ments into the reduced position. Maintain reduction manually
OBJECTIVES (see Plate 52A).
To restore normal anatomic contour to the shoulder area and Stabilization: Lay an appropriately contoured veterinary
internally splint the fracture cuttable plate(s) across the fracture on the cranial portion of
the body of the scapula, and secure with screws placed through
ANATOMIC CONSIDERATIONS the distal and proximal plate holes (Plate 52B). Direct the
Palpable landmarks are the spine and the acromial process of screws into the thick bone at the junction of the spine and body
the scapula; and the cranial, dorsal, and caudal borders of of the scapula (Plate 52C). Place additional screws in plate
the scapula. The body and spine of the scapula are easily holes close to the fracture. Fill additional plate holes with
approached with dissection and elevation of muscle. The screws. Alternate plate holes may be filled (see Plate 52B).
suprascapular nerve runs over the scapular notch and under the When additional support is needed, the veterinary cuttable
acromion process.1 plates can be stacked, an additional plate can be positioned on
the caudal border of the scapula (Plate 52D), or both.
EQUIPMENT
Surgical pack, Senn retractors, Hohmann retractors, Gelpi CAUTIONS
retractors, periosteal elevator, pointed reduction forceps, It is important to avoid placing screws in the thin bone of the
plating equipment, high-speed drill body of the scapula.

PREPARATION AND POSITIONING POSTOPERATIVE EVALUATION


Prepare the scapular region from dorsal midline to carpus. Radiographs should be evaluated for reduction and implant
Position the animal in lateral recumbency with the affected position.
limb up. Drape the limb out from a hanging position to allow
maximal manipulation during surgery. A cancellous bone graft POSTOPERATIVE CARE
is usually not necessary. The animal should be confined, with activity limited to leash
walking, until the fracture has healed. Radiographs should be
PROCEDURE repeated at 6-week intervals until the fracture is healed.
Approach: Incise the skin and subcutaneous tissue the
length of the spine distally to the shoulder joint. Transect the EXPECTED OUTCOME
omotransversarius muscle from the spine, and reflect it Bone healing is usually seen in 12 to 18 weeks. Excellent return
cranially. Incise trapezius and scapular parts of the deltoideus to function is expected.
muscles from the spine, and reflect them caudally. Incise
the supraspinatus and infraspinatus muscular attachments to References
the spine, and elevate these muscles from the scapular body 1. Jerram RM, Herron MR: Scapular fractures in dogs. Comp Cont
(Plate 52A).2 Educ Small Animal 20:1254, 1998.
Reduction: Use a periosteal elevator or small Hohmann 2. Piermattei DL, Johnson KA: An Atlas of Surgical Approaches to the
retractor as a lever to reduce the transverse fracture. Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
Alternatively, secure the spine on the proximal segment and the Saunders, 2004.
CHAPTER 52 T R A N S V E R S E S C A P U L A R B O DY F R A C T U R E S 143

P L AT E 5 2

Supraspinatus
muscle
A

Infraspinatus
muscle

Acromion
process

Long head of
triceps muscle
B

D
144 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

SCAPULA

CHAPTER 53 Supraglenoid Tuberosity Fractures


INDICATIONS be used if the bone is soft. To place a tension band wire, start
Candidates include animals with avulsion fractures of the two Kirschner wires in the fragment, and drive them across the
supraglenoid tuberosity. fracture line to lodge in the main bone segment. Place a trans-
verse drill hole in the main bone segment, pass a figure-eight
OBJECTIVES wire through the hole and around the Kirschner wires, and
To restore the articular surface and compress the fracture tighten the figure-eight wire. Bend the Kirschner wires and
with a lag screw or tension band wire rotate the ends over the biceps tendon (Plate 53C).2,3 For
chronic cases, where fracture reduction is impossible, attach
ANATOMIC CONSIDERATIONS the biceps tendon to the proximal humerus with a bone screw
The biceps brachii muscle originates from the supraglenoid and spiked Teflon washer.3 Reattach the greater tubercle with
tuberosity. The supraglenoid tuberosity is part of the articular lag screws (Plate 53D). Repair the acromion osteotomy with a
surface of the scapula. The suprascapular nerve runs over the tension band wire (Plate 53E).
scapular notch and under the acromion process.
CAUTIONS
EQUIPMENT Articular reduction should be maintained during implant appli-
Surgical pack, Senn retractors, Hohmann retractors, Gelpi cation. It is important to avoid injuring or entrapping the
retractors, periosteal elevator, osteotome and mallet or oscil- suprascapular nerve.
lating saw, pointed reduction forceps, Kirschner wires, ortho-
pedic wire, high-speed drill and wire driver, bone screws and POSTOPERATIVE EVALUATION
instruments for inserting bone screws, metal washer or Radiographs should be evaluated for articular surface reduction
spiked Teflon washer, wire twister, wire cutter and implant placement.

PREPARATION AND POSITIONING POSTOPERATIVE CARE


Prepare the forelimb circumferentially from dorsal midline to The forelimb should be in a sling for 2 weeks to prevent
carpus. Position the animal in lateral recumbency. Drape the weight bearing and to protect the fracture repair.3 The animal
limb out from a hanging position to allow maximal manipula- should be confined, with activity limited to leash walking, until
tion during surgery. A cancellous bone graft is not necessary. the fracture has healed. Radiographs should be repeated at
6-week intervals until the fracture(s) is healed. The animal
PROCEDURE should be slowly returned to normal activity after the fracture
Approach: Incise the skin and subcutaneous tissue from the is healed.
middle portion of the scapular spine distally to the shoulder
joint. Incise the attachments of the omotransversarius, EXPECTED OUTCOME
trapezius, and scapular head of the deltoideus muscles to the Bone healing is usually seen in 6 to 12 weeks. A good return to
scapula to expose the acromion process. Osteotomize the function is expected, although some degree of lameness may
acromion process, and reflect it distally with the acromial head persist.2 Degenerative joint disease may result from articular
of the deltoideus muscle. Reflect the supraspinatus muscle trauma, with the severity depending on accuracy and mainte-
away from the scapular spine and neck. Identify and protect the nance of reduction. Implant removal may be necessary if soft
suprascapular nerve. Incise the joint capsule to observe the tissues are irritated.
articular surface during reduction. For additional exposure,
osteotomize the greater tubercle and reflect the supraspinatus
References
muscle proximally (Plate 53A).1
Reduction: Extend the shoulder and reduce the fragment. 1. Piermattei DL, Johnson KA: An Atlas of Surgical Approaches to the
Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
Maintain reduction with pointed reduction forceps (Plate 53B).
Saunders, 2004.
Stabilization: To place a lag screw, drill an appropriate-
2. Johnston SA: Articular fractures of the scapula in the dog: A clinical
sized glide hole in the fragment. Place a corresponding drill retrospective study of 26 cases. J Am Anim Hosp Assoc 29:157, 1993.
sleeve in the glide hole and drill, measure, and then tap the 3. Piermattei DL, Flo GL: Fractures of the scapula. In Brinker,
thread hole to accept the appropriate screw (see Plate 53B). Piermattei, and Flos Handbook of Small Animal Orthopedics and
A cancellous screw is preferred if size permits. A washer may Fracture Repair, 3rd ed. Philadelphia, WB Saunders, 1997.
CHAPTER 53 SUPRAGLENOID TUBEROSITY FRACTURES 145

P L AT E 5 3

A
Suprascapular
nerve
Infraspinatus
muscle
B
Teres minor
muscle

Osteotomy
line
Humeral
head
Glenoid

E
146 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

SCAPULA

Intra-articular and Scapular


CHAPTER 54

Neck Fractures
INDICATIONS Stabilization: Reflect the cranial fragment, and drill a
Candidates include animals with T fractures of the scapular glide hole from the center of the fracture surface to exit proxi-
neck, or with scapular neck fractures without an intra-articular mally to the supraglenoid tuberosity prior to reducing the frac-
component. ture. Reduce the fracture, and secure the reduction with
pointed reduction forceps. Place an appropriate-sized drill
OBJECTIVES sleeve in the glide hole and drill, measure, and then tap the
To achieve anatomic articular surface reduction and rigid thread hole to accept the appropriate screw (see Plate 54B).
immobilization of the fracture Reduce the neck fracture, and stabilize it with a small L plate
(Plate 54C) or a veterinary cuttable plate or plates (Plate 54D).
ANATOMIC CONSIDERATIONS Close the joint capsule, and re-appose the infraspinatus tendon
Osteotomy of the acromion process allows reflection of a por- with a tendon suture. Repair the acromion osteotomy with a
tion of the deltoideus muscle and visualization of the joint. The tension band wire (Plate 54E).2,3
suprascapular nerve and artery course over the scapular notch
and under the acromial process, and should be avoided. The CAUTIONS
axillary artery and nerve are located immediately caudal to the Articular reduction should be maintained during implant appli-
joint, but these are not usually visualized with routine cation. It is important to avoid injuring or entrapping the
approaches.1 suprascapular nerve.

EQUIPMENT POSTOPERATIVE EVALUATION


Surgical pack, Senn retractors, Hohmann retractors, Gelpi Radiographs should be evaluated for reduction and implant
retractors, periosteal elevator, pointed reduction forceps, position.
osteotome and mallet or oscillating saw, plating equipment,
high-speed drill and wire driver, Kirschner wires, orthopedic POSTOPERATIVE CARE
wire, wire twisters, wire cutters The forelimb should be in a sling for 2 weeks to prevent weight
bearing and to protect the fracture repair.3 Physical therapy
PREPARATION AND POSITIONING should be performed, flexing and extending the shoulder daily
Prepare the forelimb from dorsal midline to carpus. Position the after the sling is removed, until adequate range of motion
animal in lateral recumbency, with the affected limb up. Drape returns. The animal should be confined, with activity limited to
the limb out from a hanging position to allow maximal manipu- leash walking, until the fracture has healed. Radiographs should
lation during surgery. A cancellous bone graft is generally not be repeated at 6-week intervals until the fracture is healed. The
needed. animal should slowly be returned to normal activity after the
fracture is healed.
PROCEDURE
Approach: Incise the skin and subcutaneous tissue from the EXPECTED OUTCOME
middle portion of the scapular spine distally to the shoulder Bone healing is usually seen in 12 to 18 weeks. Animals should
joint. Incise the attachments of the omotransversarius, trapezius, experience a fair return to function, although some degree of
and scapular head of the deltoideus muscles to the scapula to lameness may persist.2 Decreased shoulder range of motion
expose the acromion process. Osteotomize the acromion process, occurs but has a minimal effect on function. Atrophy of the
and reflect it distally with the acromial head of the deltoideus shoulder muscles occurs if the suprascapular nerve is damaged.
muscle. Reflect the supraspinatus and infraspinatus muscles Degenerative joint disease may result from articular trauma,
away from the scapular spine and neck. Identify and protect the with the severity depending on accuracy and maintenance of
suprascapular nerve. If needed for complete joint exposure, reduction. Implant removal may be necessary if soft tissues are
tenotomize the infraspinatus muscle. Incise the joint capsule to irritated.
observe the articular surface during reduction (Plate 54A). For
References
additional exposure, osteotomize the greater tubercle of the
humerus and reflect the supraspinatus muscle.1 (See surgical 1. Piermattei DL, Johnson KA: An Atlas of Surgical Approaches to the
Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
procedure for supraglenoid tuberosity fracture, Chapter 53.)
Saunders, 2004.
Reduction: Reduce the intra-articular fracture anatomi-
2. Johnston SA: Articular fractures of the scapula in the dog: A clinical
cally, and maintain reduction with pointed reduction forceps retrospective study of 26 cases. J Am Anim Hosp Assoc 29:157, 1993.
(Plate 54B). After lag screw fixation of the intra-articular 3. Piermattei DL, Flo GL: Fractures of the scapula. In Brinker,
fracture, reduce the neck fracture by carefully levering it into Piermattei, and Flos Handbook of Small Animal Orthopedics and
position. Maintain reduction manually. Fracture Repair, 3rd ed. Philadelphia, WB Saunders, 1997.
CHAPTER 54 I N T R A - A RT I C U L A R A N D S C A P U L A R N E C K F R A C T U R E S 147

P L AT E 5 4

A
Suprascapular
nerve

Infraspinatus
muscle

Teres minor
muscle

Humeral Deltoideus
head muscle
Glenoid

C D

E
148 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

HUMERUS

CHAPTER 55Proximal Humeral


Physeal Fractures
INDICATIONS Reduction: Secure the greater tubercle with a pointed
Candidates include animals with Salter I and Salter III fractures reduction forceps, and secure the proximal humeral diaphysis
of the proximal humeral physes. with a Kern bone-holding forceps. Reduce the epiphyseal
segment or segments by manipulating the forceps while gently
OBJECTIVES levering the bone into position. Maintain reduction with pointed
To achieve fracture stabilization and anatomic reduction of reduction forceps (Plate 55B).
the proximal humeral epiphysis and articular surface Stabilization: Starting proximally at the greater tubercle,
drive two Kirschner wires or Steinmann pins distally and
ANATOMIC CONSIDERATIONS caudally to cross the fracture line and seat in the caudal
Proximally, the greater tubercle and acromion process of the metaphysis (see Plate 55B). Stabilize Salter III fractures of
scapula are palpable. The cephalic vein courses within the sub- the proximal physis by first securing the humeral head to the
cutaneous tissue along the craniolateral surface of the limb. The proximal humerus with two Kirschner wires (Plate 55C) and
configuration of the physis and the cancellous bone surface then reducing the greater tubercle and securing it to the
provide some rotational stability to the fracture. humerus with two Kirschner wires or Steinmann pins (Plate
55D). Reattach the incised tendons, and close the incision
EQUIPMENT routinely.
Surgical pack, Senn retractors, Hohmann retractors, Gelpi
retractors, periosteal elevator, pointed reduction forceps, CAUTIONS
Kern bone-holding forceps, Kirschner wires or small It is important to avoid damaging the physeal cartilage during
Steinmann pins for large dogs, pin chuck or high-speed wire reduction and to avoid penetrating the articular cartilage with
driver, wire or pin cutter the Kirschner wires. The articular surface should be evaluated
to ensure anatomic alignment.
PREPARATION AND POSITIONING
Prepare the forelimb circumferentially from dorsal midline to POSTOPERATIVE EVALUATION
carpus. Position the animal in lateral recumbency, with the Radiographs should be evaluated for reduction and implant
affected limb up. Drape the limb out from a hanging position to placement.
allow maximal manipulation during surgery. A cancellous bone
graft is not necessary. POSTOPERATIVE CARE
The animal should be confined, with activity limited to leash
PROCEDURE walking. Radiographs should be evaluated in 4 weeks. Implant
Approach: Incise the skin and subcutaneous tissue over removal may be indicated if soft tissue irritation occurs.
the craniolateral region of the proximal humerus 2 to 3 cm
proximal to the greater tubercle and extending to a point near EXPECTED OUTCOME
the midshaft of the humerus. Elevate and reflect the brachio- Rapid bone healing is usually seen, but premature closure of the
cephalicus muscle from the cranial surface of the bone. Elevate physis may occur.
the deltoideus muscle, and retract it caudally to expose the
insertions of the teres minor and infraspinatus muscles.1 Incise Reference
through the insertions of these two muscles, and retract them 1. Piermattei DL, Johnson KA: An Atlas of Surgical Approaches to the
caudally to expose the lateral surface of the proximal humerus Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
(Plate 55A). Saunders, 2004.
CHAPTER 55 P R OX I M A L H U M E R A L P H Y S E A L F R A C T U R E S 149

P L AT E 5 5

Supraspinatus
muscle

Infraspinatus muscle

Teres minor muscle

Head of
humerus

Triceps brachii
muscle
(lateral head)

A
Deltoideus muscle
(acromial part),
retracted caudally

C
D
150 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

HUMERUS

CHAPTER 56Fractures of the Lateral Portion


of the Humeral Condyle
INDICATIONS Maintain reduction with pointed reduction forceps across the
Candidates include animals with Salter IV fracture of the lateral condyles and across the metaphyseal portion of the fracture.
portion of the humeral condyle, or mature animals with Stabilization: Reflect the lateral condyle fragment later-
condylar fractures. ally, and drill a glide hole from the center of the fracture surface
to exit cranially and distally to the lateral epicondyle prior to
OBJECTIVES reducing the fracture (Plate 56B). Reduce the fracture, and
To achieve anatomic alignment of the articular surface and secure the reduction with pointed reduction forceps. Place a
rigid fixation of the fracture to allow for rapid return to elbow Kirschner wire perpendicular to the fracture surface and par-
function, and to minimize development of degenerative joint allel to the glide hole. Place an appropriate-sized drill sleeve in
disease the glide hole and drill, measure, and then tap the thread hole to
accept the appropriate screw (Plate 56C). Use a washer with
ANATOMIC CONSIDERATIONS the screw to prevent subsidence of the screw head in soft bone.
The lateral portion of the humeral condyle projects laterally Place a Kirschner wire across the lateral epicondyloid crest to
from the humerus and articulates with the radial head. Fractures provide additional stability for short oblique or tranverse frac-
occur when the animal jumps or falls, and forces are transmitted tures (Plate 56D).2 Stabilize long oblique metaphyseal fractures
up the radius to the lateral condyle. The triceps muscle courses with an additional lag screw (Plate 56E).
in a cranial proximal direction from its insertion on the ole-
cranon and crosses the humerus rather than paralleling it. The CAUTIONS
radial nerve lies beneath the lateral head of the triceps near the The radial nerve should be protected. A washer should be used
distal third of the humerus and must be identified and protected. in immature dogs. The joint should be inspected to ensure
anatomic alignment of the articular surface.
EQUIPMENT
Surgical pack, Senn retractors, Hohmann retractors, Gelpi POSTOPERATIVE EVALUATION
retractors, periosteal elevator, pointed reduction forceps, Radiographs should be evaluated for fracture reduction and
Kirschner wires, bone screws and instruments for insertion implant position.
of bone screws, washers, high-speed drill and wire driver,
wire cutter POSTOPERATIVE CARE
The animal should be confined, with activity limited to leash
PREPARATION AND POSITIONING walking, until the fracture is healed. Physical therapy should be
Prepare the forelimb circumferentially from dorsal midline to performed daily, flexing and extending the elbow, until adequate
carpus. Position the animal in lateral recumbency, with the range of motion returns. Radiographs should be evaluated in 4 to
affected limb up. Drape the limb out from a hanging position to 6 weeks and then at 6-week intervals until the fracture is healed.
allow maximal manipulation during surgery. A cancellous bone
graft is not necessary. EXPECTED OUTCOME
Rapid healing is usually seen in immature dogs, but premature
PROCEDURE closure of the physis may occur; generally this does not cause a
Approach: Incise the skin and subcutaneous tissue beginning clinical problem. Slow healing may be seen in mature dogs,
over the distal third of the humerus, curving cranial to the lat- especially spaniels. Animals may experience a decreased elbow
eral epicondyle and extending 4 cm to 5 cm distal to the joint. range of motion. Degenerative joint disease may occur, with the
Incise the deep fascia along the cranial border of the lateral severity depending on accuracy and maintenance of reduction.
triceps muscle, and continue this incision across the joint Implant removal may be necessary if soft tissues are irritated.
over the extensors. Incise the intermuscular septum between Refracture may occur in some mature dogs after implant
the extensor carpi radialis and the common digital extensor removal.
muscle, and continue the incision proximally through the
periosteal origin of the extensor carpi radialis muscle. Retract References
the muscle cranially to expose the joint capsule and underlying 1. Piermattei DL, Johnson KA: An Atlas of Surgical Approaches to the
lateral condyle. Incise the joint capsule with an L-shaped inci- Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
sion to visualize the lateral portion of the humeral condyle Saunders, 2004.
(Plate 56A).1 2. Johnson AL, Hulse DA: Management of specific fractures, humeral
Reduction: Reduce the fracture by pushing proximally on fractures. In Fossum TW (ed): Small Animal Surgery, 2nd ed. St.
the medial condyle and distracting the lateral fragment distally. Louis, Mosby, 2002.
CHAPTER 56 F R A C T U R E S O F T H E L AT E R A L P O RT I O N O F T H E H U M E R A L C O N DY L E 151

P L AT E 5 6

Deep fascia

Triceps
brachii muscle

Incision in
joint capsule
Extensor
carpi
radialis
muscle

Lateral
condyle
exposed

A
B
Common digital
extensor muscle

E
152 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

HUMERUS

CHAPTER 57 T or Y Fractures
of the Distal Humerus
INDICATIONS Stabilization: Stabilize the articular fracture with a lag screw.
Candidates include animals with T or Y fractures of the distal humerus. Drill a glide hole in the lateral condylar fragment. Place an appropriate-
sized drill sleeve in the glide hole and drill, measure, and then tap the
OBJECTIVES thread hole to accept the appropriate screw (see Plate 57B). Secure the
To achieve anatomic alignment of the articular surface and rigid condyle to the humeral shaft with a plate/rod combination. Start an IM
fixation of the fracture to allow for rapid return to elbow function, pin into the medial condyle just below the medial epicondyle.
and to minimize development of degenerative joint disease Alternatively, retrograde the IM pin from the fracture site to exit below
the medial epicondyle. Drive the pin proximally across the fracture and
ANATOMIC CONSIDERATIONS up the humeral diaphysis to lodge at the greater tubercle. Place a plate
The radial nerve lies beneath the lateral head of the triceps near the across the lateral fracture line (see Plate 57C). Cut the pin short at the
distal third of the humerus. The median, ulnar, and musculocutaneous distal humerus. Alternatively, stabilize the medial and lateral fractures
nerves course along the cranial edge of the medial head of the triceps by applying one plate to the medial surface of the humerus and a second
muscle. The brachial artery and vein accompany the nerves on the plate to the caudolateral epicondyloid crest (Plate 57D). The plates
medial aspect of the humerus. The medial side of the humerus is flat should function as compression plates if the fractures are transverse.2
and straight, making it amenable to plate placement. Fitting a plate to
the lateral side of the humerus requires bending and twisting of the CAUTIONS
plate to fit the surface. The medial condyle is an extension of the The radial nerve should be protected on the lateral approach and the
humeral shaft, allowing an intramedullary (IM) pin to travel from neurovascular structures on the medial approach. The joint should be
the medial condyle to the greater tubercle. inspected to ensure anatomic alignment of the articular surface. The
elbow should be taken through range of motion to check for screws
EQUIPMENT penetrating the olecranon fossa.
Surgical pack, Senn retractors, Hohmann retractors, Gelpi retractors,
periosteal elevator, pointed reduction forceps, Kern bone-holding POSTOPERATIVE EVALUATION
forceps, high-speed power drill, IM pins and Jacob pin chuck, plating Radiographs should be evaluated for reduction and implant position.
equipment, pin cutter
POSTOPERATIVE CARE
PREPARATION AND POSITIONING The animal should be confined, with activity limited to leash walking,
Prepare the forelimb circumferentially from dorsal midline to carpus. until the fracture is healed. Physical therapy should be performed daily,
Position the animal in dorsal recumbency, with the affected limb up. flexing and extending the elbow, until adequate range of motion returns.
Drape the limb out from a hanging position to allow maximal manipu- Radiographs should be repeated at 6-week intervals until the fracture is
lation during surgery. The proximal humerus serves as a cancellous healed.
bone graft donor site.
EXPECTED OUTCOME
PROCEDURE Bone healing is usually seen in 12 to 18 weeks. Slow healing may be
Approach: Incise the skin and subcutaneous tissue beginning over seen in mature dogs, especially spaniels. Animals may experience
the distal third of the humerus, curving cranial to the lateral epicondyle decreased elbow range of motion. Degenerative joint disease may
and extending 4 cm to 5 cm distal to the joint. Incise the deep fascia occur, with severity depending on accuracy and maintenance of reduc-
along the cranial border of the lateral triceps muscle, and continue this tion.3,4 The IM pin may interfere with elbow function; it should be
incision across the joint over the extensors. Incise the intermuscular removed after the fracture has bridged with bone. Plate and screw
septum between the extensor carpi radialis and the common digital removal may be necessary if soft tissues are irritated. Refracture may
extensor muscle, and continue the incision proximally through the occur in some mature dogs after implant removal.
periosteal origin of the extensor carpi radialis muscle. Retract the
muscle cranially to expose the joint capsule and underlying lateral
condyle. Incise the joint capsule with an L-shaped incision to visualize References
the lateral humeral condyle and the articular surface (Plate 57A1). To 1. Piermattei DL, Johnson KA: An Atlas of Surgical Approaches to the
expose the medial aspect of the fracture, incise the skin and subcuta- Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
neous tissue over the medial surface of the distal humerus. Bluntly Saunders, 2004.
dissect the subfascial fat, and retract the nerves and vessels to expose 2. Johnson AL, Hulse DA: Management of specific fractures: Humeral
the humerus (Plate 57A2).1 fractures. In Fossum TW (ed): Small Animal Surgery, 2nd ed. St.
Reduction: Reduce the articular fracture, and maintain reduc- Louis, Mosby, 2002.
tion with pointed reduction forceps across the condyles. Inspect the 3. Vannini R, Smeak DD, Olmstead ML: Evaluation of surgical repair of
joint surface to ensure anatomic alignment (Plate 57B). After the lag 135 distal humeral fractures in dogs and cats. J Am Anim Hosp
screw is placed, reduce the humeral metaphyseal fracture. Place an IM Assoc 24:537, 1988.
pin up the medial portion of the condyle and across the fracture line to 4. Anderson TJ, Carmicheal S, Miller A: Intercondylar humeral fracture
help maintain reduction (Plate 57C). in the dog: A review of 20 cases. J Small Anim Pract 31:437, 1990.
CHAPTER 57 T O R Y F R A C T U R E S O F T H E D I S TA L H U M E R U S 153

P L AT E 5 7

A1 Deep A2
fascia
Triceps
brachii
Biceps brachii
muscle
muscle
Extensor Incision in Neurovascular
carpi joint capsule bundle
radialis
muscle

Lateral
condyle
exposed
Brachiocephalicus
muscle

Pronator teres
Common digital muscle
extensor muscle
Triceps brachii
muscle
(medial head)

C D

Cranial Lateral Caudal


view view view
154 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

HUMERUS

CHAPTER 58 Application of an Intramedullary


Pin or Interlocking Nail to the Humerus
INDICATIONS clage wire, wire tightener, wire cutter, low-speed drill,
Candidates include animals with single or comminuted humeral external fixator equipment, pin cutter, ILN equipment
diaphyseal fractures. including high-speed drill, bone curette for harvesting can-
cellous graft
OBJECTIVES
To achieve anatomic reduction of single fracture lines or PREPARATION AND POSITIONING
restoration of normal bone alignment for nonreducible com- Prepare the forelimb circumferentially from dorsal midline to
minuted fractures carpus. Position the animal in lateral recumbency, with the
The intramedullary (IM) pin is used in animals with high affected limb up. Drape the limb out from a hanging position to
fracture-assessment scores. The IM pin neutralizes bending allow maximal manipulation during surgery. Prepare the ipsi-
forces at the fracture and is combined with cerclage wire for lateral proximal humerus or ilial wing for surgery if harvesting
long oblique fractures and with external fixation for transverse cancellous bone.
or short oblique fractures to neutralize rotational and axial
compressive forces. The interlocking nail (ILN) neutralizes
bending, rotational, and axial compressive forces at the frac- PROCEDURE
ture; it can be used for animals with medium and low fracture- Approach: Incise the skin and subcutaneous tissues laterally
assessment scores. from the cranial border of the greater tubercle to the lateral epi-
condyle. Incise the brachial fascia along the border of the bra-
ANATOMIC CONSIDERATIONS chiocephalicus muscle and the lateral head of the triceps.
The radial nerve lies superficial to the brachialis muscle and Visualize and isolate the radial nerve. Incise through the
deep to the lateral head of the triceps; it must be identified and periosteal insertion of the superficial pectoral and brachio-
protected during the surgical approach, fracture reduction, cephalicus muscles at their insertion on the humeral shaft.
and stabilization. The humerus has a cranial curvature that Reflect these two muscles cranially, and the brachialis muscle
positions the long axis of the marrow cavity cranial to the caudally, to expose the proximal and central humeral shaft.1 To
shoulder joint, allowing normograde or retrograde placement of gain further exposure of the distal humeral shaft, encircle the
an IM pin and normograde placement of the ILN. The narrowest brachialis muscle and the radial nerve with a Penrose drain;
part of the medullary canal, the isthmus, is located within the retract them caudally to expose the proximal and mid-diaphysis
distal third of bone, just proximal to the supratrochlear and cranially to expose the distal diaphysis. Insert the IM pin
foramen. The medial portion of the humeral condyle is the into the proximal humerus in either a normograde or retrograde
extension of the medullary canal. In cats, the median nerve and manner (Plate 58A).2 Insert the ILN in a normograde manner,
brachial artery run through the supracondylar foramen. starting at the greater tubercle.3 Use an open but do not disturb
the fragments technique to expose the proximal and distal
EQUIPMENT bone segments with minimal disturbance of the fracture
Surgical pack, Senn retractors, Gelpi retractors, Hohmann hematoma and bone fragments for nonreducible fractures.4
retractors, periosteal elevator, pointed reduction forceps, Incise the skin, and create soft tissue tunnels to the bone for
Kern bone-holding forceps, Jacob pin chuck, IM pins, cer- fixator pin placement.
Continued
CHAPTER 58 A P P L I C AT I O N O F A N I M P I N O R I N T E R L O C K I N G N A I L T O T H E H U M E R U S 155

P L AT E 5 8

Greater
tubercle

Deltoideus muscle
(acromial part)
Radial nerve

Penrose
drain
Superficial
pectoral muscle

Brachiocephalicus Brachialis
muscle muscle
156 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

Reduction: Place an IM pin (sized to equal 70% to 80% of POSTOPERATIVE EVALUATION


the medullary canal at the isthmus) in the proximal segment. Radiographs should be evaluated for bone alignment and
Direct the pin toward the caudomedial cortex so it will seat in implant placement.
the medial portion of the condyle when the fracture is reduced
and the pin is driven distally.2 Retract the pin within the POSTOPERATIVE CARE
medullary canal of the proximal segment (see Plate 58A). The animal should be confined, with activity limited to leash
Reduce transverse and short oblique fractures by tenting the walking, until the fracture has healed. External fixator manage-
bone ends and levering the bone back into position. Reduce ment includes daily pin care and pin packing as needed.
long oblique fractures by distracting the bone segments and Radiographs should be evaluated in 6 weeks. Fixation pins
approximating the fracture surfaces. Use pointed reduction for- should be removed after radiographic signs of bone bridging are
ceps to manipulate the bone segments into reduction. Maintain observed. If a tie-in is used, the top fixation pin and its connec-
the reduction manually (for transverse fractures) or with pointed tion to the IM pin should be retained. Radiographs should be
reduction forceps (for oblique fractures). Reduce comminuted repeated at 6-week intervals until the fracture is healed. The IM
nonreducible fractures by distracting the distal end with the pin should be removed when the fracture is healed.
IM pin or ILN and aligning the major segments of the bone.
Be sure to restore length and normal rotational alignment to EXPECTED OUTCOME
the bone. Bone healing is usually seen in 12 to 18 weeks (depending on
Stabilization: Apply an IM pin and type Ia external fixator fracture and signalment of the animal).
to the lateral surface of the humerus (Plate 58B). In each seg-
ment, place a fixation pin in the metaphysis and a fixation pin References
close to the fracture. The external fixator can be connected 1. Piermattei DL, Johnson KA: An Atlas of Surgical Approaches to the
or tied-in to the IM pin in order to strengthen the fixa- Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
tion.5 Apply an IM pin and cerclage wire to a long oblique Saunders, 2004.
fracture (Plate 58C). Apply an ILN and four screws to the 2. Johnson AL, Hulse DA: Management of specific fractures, humeral
humerus for treatment of comminuted nonreducible fractures fractures. In Fossum TW (ed): Small Animal Surgery, 2nd ed. St.
(Plate 58D). Louis, Mosby, 2002.
3. Dueland RT, Johnson KA, Roe SC, et al: Interlocking nail treatment
of diaphyseal long bone fractures in dogs. J AM Vet Med Assoc
CAUTIONS
214:59, 1999.
The radial nerve should be identified and protected during the
4. Aron DN, Palmer RH, Johnson AL: Biologic strategies and a bal-
procedure. It is important to avoid the distal joint surface with anced concept for repair of highly comminuted long bone fractures.
the IM pin or ILN. The range of motion of the elbow should be Compend Cont Educ Pract Vet 17:35, 1995.
palpated to detect pin interference in the joint. Rotational align- 5. Aron DN, Dewey C: Experimental and clinical experience with an
ment should be monitored during the realignment of com- IM pin external skeletal fixator tie-in configuration. Vet Comp
minuted fractures. Orthop Traumatol 4:86, 1991.
CHAPTER 58 A P P L I C AT I O N O F A N I M P I N O R I N T E R L O C K I N G N A I L T O T H E H U M E R U S 157

P L AT E 5 8

C D
158 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

HUMERUS

CHAPTER 59Application of a Plate


to the Humerus
INDICATIONS speed drill, plating equipment, bone curette for harvesting
Candidates include animals with single or comminuted humeral graft
diaphyseal fractures.
PREPARATION AND POSITIONING
OBJECTIVES Prepare the forelimb circumferentially from dorsal midline to
To achieve anatomic reduction and compression of single carpus. Position the animal in lateral recumbency, with the
fracture lines, or restoration of normal bone alignment, in affected limb up for the craniolateral approach. Position
nonreducible comminuted fractures the animal in dorsal recumbency for the medial approach to the
The plate is used as a compression plate for transverse or humerus. Drape the limb out from a hanging position to allow
short oblique fractures; it is combined with lag screws to com- maximal manipulation during surgery. Prepare the ipsilateral
press long oblique fractures, neutralizing bending, rotational, proximal humerus or ilial wing for surgery to harvest cancel-
and axial compressive forces. The plate is used as a bridging lous bone.
plate for nonreducible comminuted fractures and may be com-
bined with an intramedullary (IM) pin to reduce strain on the PROCEDURE
plate and to extend fatigue life of the fixation.1 Approach: Incise the skin and subcutaneous tissues laterally
from the cranial border of the greater tubercle to the lateral epi-
ANATOMIC CONSIDERATIONS condyle. Incise the brachial fascia along the border of the bra-
The plate may be placed on the cranial, lateral, or medial sur- chiocephalicus muscle and the lateral head of the triceps.
face of the humerus. The cranial and medial surfaces of the Visualize and protect the radial nerve. Incise through the
humerus are relatively flat and amenable to plate placement. periosteal insertion of the superficial pectoral and brachio-
Fitting a plate to the lateral side of the humerus requires cephalicus muscles at their insertions on the humeral shaft.
bending and twisting of the plate to fit the surface. The radial Reflect these two muscles cranially, and the brachialis muscle
nerve lies superficial to the brachialis muscle and deep to the caudally, to expose the proximal and central, cranial, or lateral
lateral head of the triceps; it must be identified and protected humeral shaft (Plate 59A).2 To gain further exposure of the
during the surgical approach, fracture reduction, and stabiliza- distal lateral humeral shaft, encircle the brachialis muscle and
tion. In cats, the median nerve and brachial artery run through the radial nerve with a Penrose drain and retract them caudally
the supracondylar foramen. During the medial approach to the (to expose the proximal and mid-diaphysis) and cranially (to
humerus, care must be taken to isolate and protect the median, expose the distal diaphysis).
musculocutaneous, and ulnar nerves; and the brachial artery To expose the medial aspect of the fracture, incise the skin
and vein.2 The humerus has a cranial curvature that positions and subcutaneous tissue over the medial surface of the
the long axis of the marrow cavity cranial to the shoulder joint, humerus from the greater tubercle to below the medial epi-
allowing normograde or retrograde placement of an IM pin. The condyle. Incise the deep brachial fascia along the caudal border
medial portion of the condyle is an extension of the humeral of the brachiocephalicus muscle and the distal portion of the
shaft, allowing an IM pin to travel from the medial condyle to insertion of the superficial pectoral muscle. Retract the biceps
the greater tubercle. brachii muscle and the nerves and vessels caudally (to expose
the proximal portion of the humerus) and cranially (to expose
EQUIPMENT the middle and distal portion of the humerus) (Plate 59B).2 Use
Surgical pack, Senn retractors periosteal elevator, Gelpi an open but do not disturb the fragments technique to expose
retractors or Hohmann retractors, Penrose drain, pointed the proximal and distal bone segments with minimal distur-
reduction forceps, Kern bone-holding forceps, self-center- bance of the fracture hematoma and bone fragments for nonre-
ing plate-holding forceps, Jacob pin chuck, IM pins, high- ducible fractures.3
Continued
CHAPTER 59 A P P L I C AT I O N O F A P L AT E T O T H E H U M E R U S 159

P L AT E 5 9

A B

Musculocutaneous
nerve
(proximal branch)
Greater
Brachiocephalicus
tubercle Superficial muscle
pectoral
muscle

Biceps brachii
Deltoideus muscle muscle
(acromial part) (retracted
Radial nerve Triceps cranially)
brachii
muscle Musculocutaneous
nerve
Penrose (distal branch)
drain
Superficial
pectoral muscle

Brachiocephalicus Brachialis
muscle muscle
160 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

Reduction: Reduce transverse and short oblique fractures POSTOPERATIVE EVALUATION


by tenting the bone ends and levering the bone back into posi- Radiographs should be evaluated for bone alignment and
tion. Reduce long oblique fractures by distracting the bone seg- implant placement.
ments and approximating the fracture surfaces. Use pointed
reduction forceps to manipulate the bone segments into reduc- POSTOPERATIVE CARE
tion. Maintain the reduction manually (for transverse fractures) The animal should be confined, with activity limited to leash
or with pointed reduction forceps (for oblique fractures). walking. Physical therapy may be necessary to restore elbow
Reduce comminuted, nonreducible fractures by distracting the range of motion. Radiographs should be evaluated in 6 weeks.
distal or proximal segments with an IM pin (sized to equal 40% The IM pin should be removed after radiographic signs of bone
to 50% of the medullary canal at the isthmus) and aligning the bridging are observed. Radiographs should be repeated at 6-
major segments of the bone (see Plate 59A). Insert the IM pin week intervals until the fracture is healed. Plate removal may be
into the proximal humerus in either a normograde or retrograde necessary after the fracture heals to relieve soft tissue irritation.
manner. For distal fractures, start an IM pin into the medial
condyle just below the medial epicondyle. Alternatively, retro- EXPECTED OUTCOME
grade the IM pin from the fracture site to exit below the medial Bone healing is usually seen in 12 to 18 weeks (depending on
epicondyle. Drive the pin proximally across the fracture and up fracture and signalment of the animal).
the humeral diaphysis to lodge at the greater tubercle. Be sure
to restore length and normal rotational alignment to the bone.4
Stabilization: Apply an appropriately contoured plate to References
the cranial, lateral, or medial surface of the humerus. The plate 1. Hulse D, Hyman W, Nori M, et al: Reduction in plate strain by addi-
can function as a compression plate (Plate 59C) when used to tion of an intramedullary pin. Vet Surg 26:451, 1997.
compress transverse or short oblique fractures; a neutralization 2. Piermattei DL, Johnson KA: An Atlas of Surgical Approaches to the
plate to support a reconstructed fracture (Plate 59D); or as a Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
bridging plate, spanning a nonreducible comminuted fracture Saunders, 2004.
(Plate 59E).5 3. Aron DN, Palmer RH, Johnson AL: Biologic strategies and a bal-
anced concept for repair of highly comminuted long bone fractures.
Compend Cont Educ Pract Vet 17:35, 1995.
CAUTIONS
4. Johnson AL, Hulse DA: Management of specific fractures, humeral
All neurovascular structures should be identified and protected
fractures. In Fossum TW (ed): Small Animal Surgery, 2nd ed. St.
during the procedure. It is important to avoid the distal joint Louis, Mosby, 2002.
surface and olecranon fossa with the IM pin and bone screws. 5. Kasa F, Kasa G, Koestlin R, et al: Fractures of the humerus.
The range of motion of the elbow should be palpated to detect In Brinker WO, Piermattei D, Flo GL (eds): Handbook of Small
implant interference in the joint. Rotational alignment should Animal Orthopedics and Fracture Repair, 3rd ed. Philadelphia, WB
be monitored during the realignment of comminuted fractures. Saunders, 1997.
CHAPTER 59 A P P L I C AT I O N O F A P L AT E T O T H E H U M E R U S 161

P L AT E 5 9

C D E
162 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

HUMERUS

CHAPTER 60Application of an External Fixator


to the Humerus
INDICATIONS to allow maximal manipulation during surgery. Prepare the
Candidates include animals with single or comminuted humeral ipsilateral proximal humerus or ilial wing for harvesting
diaphyseal fractures. cancellous bone.

OBJECTIVES PROCEDURE
To achieve anatomic reduction of single fracture lines or Approach: Incise the skin and subcutaneous tissues laterally
restoration of normal bone alignment in comminuted from the cranial border of the greater tubercle to the lateral
fractures epicondyle. Incise the brachial fascia along the border of the
The stiffness of the fixator can be increased in animals with brachiocephalicus muscle and the lateral head of the triceps.
low fracture-assessment scores by adding fixation pins, using Visualize and isolate the radial nerve. Incise through the
biplanar frames, and incorporating an intramedullary (IM) pin.1 periosteal insertion of the superficial pectoral and brachio-
The fracture and fixator combination, the IM pin and fixator cephalicus muscles at their insertions on the humeral shaft.
combination, or the biplanar fixator alone resists axial loading, Reflect these two muscles cranially, and the brachialis muscle
bending, and rotational forces at the fracture. caudally, to expose the proximal and central humeral shaft.2 To
gain further exposure of the distal humeral shaft, reflect the
ANATOMIC CONSIDERATIONS brachialis muscle cranially and the lateral triceps muscle cau-
The radial nerve lies superficial to the brachialis muscle and dally. Insert the IM pin into the proximal humerus in either a
deep to the lateral head of the triceps; it must be identified and normograde or retrograde manner (Plate 60A). Use an open
protected during the surgical approach, fracture reduction, but do not disturb the fragments technique to expose the prox-
and fixation pin placement. The humerus has a cranial curva- imal and distal bone segments with minimal disturbance of the
ture that positions the long axis of the marrow cavity cranial to fracture hematoma and bone fragments, or a closed reduction
the shoulder joint, allowing normograde or retrograde place- technique for nonreducible fractures.3 Incise the skin and
ment of an IM pin. The narrowest part of the medullary canal, create soft tissue tunnels to the bone for fixator pin placement.
the isthmus, is located within the distal third of bone, just prox- Reduction: Place an IM pin (sized to equal 70% to 80% of
imal to the supratrochlear foramen. The medial portion of the the medullary canal at the isthmus) in the proximal segment.
humeral condyle is the extension of the medullary canal. In Direct the pin toward the caudal medial cortex so it will seat in
cats, the median nerve and brachial artery run through the the medial portion of the condyle when the fracture is reduced
supracondylar foramen. The proximity of the thorax prohibits and the pin is driven distally. Retract the pin within the
use of bilateral frames in the proximal humerus. medullary canal of the proximal segment (see Plate 60A).4
Reduce transverse and short oblique fractures by tenting the
EQUIPMENT bone ends and levering the bone back into position. Reduce
Surgical pack, Senn retractors, small Hohmann retractors, long oblique fractures by distracting the bone segments and
Gelpi retractors, periosteal elevator, Kern bone-holding for- approximating the fracture surfaces. Use pointed reduction for-
ceps, pointed reduction forceps, Jacob pin chuck, IM pins, ceps to manipulate the bone segments into reduction. Maintain
low-speed power drill, external fixation equipment, pin the reduction manually (for transverse fractures) or with
cutter, bone curette for harvesting graft pointed reduction forceps (for oblique fractures). Reduce com-
minuted, nonreducible fractures by distracting the distal end
PREPARATION AND POSITIONING with the IM pin and aligning the major segments of the bone; or
Prepare the forelimb circumferentially from dorsal midline to use the distal fixation pin to distract and align the bone during
carpus. Position the animal in lateral recumbency, with the closed reduction. Be sure to restore length and normal rota-
affected limb up. Drape the limb out from a hanging position tional alignment to the bone.
Continued
CHAPTER 60 A P P L I C AT I O N O F A N E X T E R N A L F I X AT O R T O T H E H U M E R U S 163

P L AT E 6 0

Greater
tubercle

Deltoideus muscle
(acromial part)
Radial nerve

Penrose
drain
Superficial
pectoral muscle

Brachiocephalicus
muscle Brachialis
muscle
164 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

Stabilization: Apply an IM pin and a type Ia external by removing the unilateral frame (type Ia and IM pin) or the cra-
fixator to the lateral surface of the humerus (Plate 60B). In each nial frame (modified type Ib fixator) when bone bridging is
segment, place a fixation pin in the metaphysis and a fixation observed. If a tie-in is used, the top fixation pin and its connec-
pin close to the fracture. The external fixator can be connected tion to the IM pin should be retained. The IM pin, the remaining
or tied in to the IM pin to strengthen the fixation.5 Long oblique external fixator, or both should be removed when the fracture
fractures benefit from cerclage wire in addition to the IM pin, is healed.
the external fixator, or both (Plate 60C). Apply a modified type
Ib external fixator to a comminuted nonreducible fracture EXPECTED OUTCOME
(Plate 60D). Add an IM pin and tie it into the fixator for addi- Bone healing is usually seen in 12 to 18 weeks (depending on
tional stability for comminuted fractures.6 fracture and signalment of the animal). The animal may experi-
ence limited function while the external fixator is in place, but
CAUTIONS a good return to function can be expected.
Identify and protect the radial nerve during the procedure.
Avoid major nerves and vessels and joint surfaces with the
fixation pins. Avoid penetrating the distal joint surface or ole-
cranon fossa with the IM pin. Palpate the range of motion of the References
elbow to detect pin interference in the joint. Monitor rotational 1. Johnson AL, Hulse DA: Fundamentals of orthopedic surgery and
and angular alignment during the reduction and fixation of com- fracture management, decision making in fracture management. In
Fossum TW (ed): Small Animal Surgery, 2nd ed. St. Louis, Mosby,
minuted fractures.
2002.
2. Piermattei DL, Johnson KA: An Atlas of Surgical Approaches to the
POSTOPERATIVE EVALUATION Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
Radiographs should be evaluated for bone alignment and Saunders, 2004.
implant placement. Angular malalignments should be corrected 3. Aron DN, Palmer RH, Johnson AL: Biologic strategies and a bal-
by loosening the clamps and realigning the fixation pins on the anced concept for repair of highly comminuted long bone fractures.
connecting bar. Compend Cont Educ Pract Vet 17:35, 1995.
4. Johnson AL, Hulse DA: Management of specific fractures, humeral
POSTOPERATIVE CARE fractures. In Fossum TW (ed): Small Animal Surgery, 2nd ed. St.
Gauze sponges should be packed around the pins, and the Louis, Mosby, 2002.
5. Aron DN, Dewey C: Experimental and clinical experience with an
sponges should be secured with a bandage. The animal should
IM pin external fixator tie-in configuration. Vet Comp Orthop
be confined, with activity limited to leash walking. External Traumatol 4:86, 1991.
fixator management includes daily pin care and pin packing as 6. Aron DN: External skeletal fixation system application to the
needed. Physical therapy should be instituted to restore elbow humerus and femur. In Proceedings of the 10th Annual Complete
range of motion. Radiographs should be repeated at 6-week Course in External Skeletal Fixation, University of Georgia,
intervals to monitor healing. The fixator should be destabilized 127141, 2002.
CHAPTER 60 A P P L I C AT I O N O F A N E X T E R N A L F I X AT O R T O T H E H U M E R U S 165

P L AT E 6 0

C D
166 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

RADIUS

CHAPTER 61Application of a Plate


to the Radius
INDICATIONS Stabilization: Apply an appropriately contoured plate to the
Candidates include animals with single or comminuted radial diaphy- cranial surface of the radius (Plate 61B1). The plate can function as a
seal fractures or toy breed dogs with distal diaphyseal fractures. compression plate when used to compress transverse or short oblique
fractures. Alternatively, a veterinary T plate or cuttable plate may be
OBJECTIVES used for distal radial transverse or short oblique fractures (Plate 61B2).
To achieve anatomic reduction and compression of single fracture Round hole plates act as tension band plates and do not allow com-
lines, or restoration of normal bone alignment, in nonreducible com- pression with the plate.3 A plate may also be applied to the medial sur-
minuted fractures face of the distal radius (Plate 61B3).4 Plates are used as a neutralization
The plate is used as a compression plate for transverse or short plate to support a reconstructed fracture (Plate 61C) or as a bridging
oblique fractures; it is combined with lag screws to compress long plate spanning a nonreducible comminuted fracture (Plate 61D). If addi-
oblique fractures, neutralizing bending, rotational, and axial compres- tional support is needed, an intramedullary pin may be placed in the
sive forces. The plate is used as a bridging plate for nonreducible com- ulna to support the bridging plate fixation.3
minuted fractures.
CAUTIONS
ANATOMIC CONSIDERATIONS In immature dogs, crossing the distal radial physis with the plate or
The flat cranial surface of the radius is ideal for plate placement; how- screws should be avoided. The articular surface should also be avoided.
ever, interference with tendons is possible. The medial surface may be It is important to pay careful attention to bony anatomic landmarks to
used for plate placement for distal radial fractures. The cephalic vein avoid rotation of the distal segment.
crosses the medial portion of the distal radius. Limited soft tissue cov-
erage and marginal vascular supply contribute to a high percentage of POSTOPERATIVE EVALUATION
delayed unions or nonunions in toy breed dogs.1 Radiographs should be evaluated for fracture reduction or bone align-
ment and implant placement.
EQUIPMENT
Surgical pack, Senn retractors, Hohmann retractors, periosteal POSTOPERATIVE CARE
elevator, self-centering plate reduction forceps, pointed reduction The animal should be confined, with activity limited to leash walking.
forceps, high-speed drill, plating equipment, bone curette for har- Radiographs should be evaluated in 6 weeks. The intramedullary pin
vesting graft should be removed from the ulna after radiographic signs of bone
bridging are observed. Radiographs should be repeated at 6-week
PREPARATION AND POSITIONING intervals until the fracture is healed. Plate removal may be necessary
Prepare the forelimb circumferentially from above the shoulder to the after the fracture heals to relieve soft tissue irritation or thermal
phalanges. Position the animal in dorsal recumbency. Drape the limb conduction.
out from a hanging position. Roll the animal slightly to allow access to
the medial surface of the limb. The ipsilateral proximal humerus serves EXPECTED OUTCOME
as a cancellous bone graft donor site. Generally, bone healing is seen in 6 to 12 weeks; then good function is
expected.5 Delayed union may occur in toy breed dogs.1 Bone resorp-
PROCEDURE tion or osteopenia may occur under the plate in toy breed dogs whose
Approach: Palpate the radius directly under the skin and subcuta- fractures are stabilized with relatively large, stiff plates.5
neous tissue on the craniomedial surface of the limb. Incise the skin and
subcutaneous tissue to expose the radial diaphysis. Extend the incision References
distally, and elevate the extensor tendons to expose the cranial surface 1. Welch JA, Boudrieau RJ, DeJardin LM, et al: The intraosseous blood
of the radius. Extend the incision proximally by incising between the supply of the canine radius: Implications for healing of distal frac-
extensor carpi radialis muscle and the pronator teres muscle. If needed, tures in small dogs. Vet Surg 26:57, 1997.
the insertions of the pronator and supinator muscles are incised on the 2. Piermattei DL, Johnson KA: An Atlas of Surgical Approaches to the
radius (Plate 61A).2 Limit the exposure to the distal portion of the radius Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
for distal radial diaphyseal fractures. Saunders, 2004.
Reduction: Reduce transverse fractures by tenting the bone 3. Binnington AG, Miller CW: Fractures of the radius and ulna. In
ends dorsally and levering the bone back into position. Short oblique Brinker WO, Piermattei D, Flo GL (eds): Handbook of Small Animal
fractures may be better reduced by tenting the bone ends medially and Orthopedics and Fracture Repair, 3rd ed. Philadelphia, WB
levering the bone back into position. Distal radial fractures may also be Saunders, 1997.
reduced by securing a precontoured plate to the distal segment and 4. Sardinas JC, Montavon PM: Use of a medial bone plate for repair of
reducing the proximal segment to the plate. Maintain reduction by radius and ulna fractures in dogs and cats: A report of 22 cases. Vet
securing the plate with plate-holding forceps. Reduce and secure long Surg 26:108, 1997.
oblique fractures with pointed reduction forceps. Reduce comminuted 5. Larsen LJ, Roush JK, McLaughlin RM: Bone plate fixation of distal
nonreducible fractures by distracting and aligning the major segments radius and ulnar fractures in small- and miniature-breed dogs. J Am
of the bone while being careful not to disturb the fragments. Anim Hosp Assoc 35:243, 1999.
CHAPTER 61 A P P L I C AT I O N O F A P L AT E T O T H E R A D I U S 167

P L AT E 6 1

Supinator
muscle

Pronator
teres muscle
Flexor carpi
radialis muscle
Radius
Superficial
digital flexor
Radial muscle
artery

Median
artery

B1 B2 B3

C D
168 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

RADIUS

CHAPTER 62Application of an External Fixator


to the Radius
INDICATIONS two (or preferably three) fixation pins in each bone segment. Use posi-
Candidates include animals with single or comminuted radial diaphy- tive profile, end-threaded pins to increase pin bone interface stability.
seal fractures. Apply a type Ib frame by placing a unilateral frame on the cranial medial
surface of the radius and an additional unilateral frame on the cranial
OBJECTIVES lateral surface of the radius (Plate 62D1). Connect the biplanar frames
To achieve anatomic reduction of single fracture lines or restoration with articulating bars (Plate 62D2). Apply a type II frame by inserting
of normal bone alignment for comminuted fractures transfixation pins through the metaphyses and additional fixation pins 1
The stiffness of the fixator can be increased for animals with low cm to 2 cm from the fracture line. Place additional pins when there is
fracture-assessment scores by adding fixation pins and using biplanar adequate bone. If the cranial curve of the radius precludes the place-
or bilateral frames.1 The fracture and fixator combination, or the fixator ment of transfixation pins, unilateral fixation pins can be applied to the
alone, resists axial loading, bending, and rotational forces at the fracture. diaphysis of the radius (Plate 62E).2,3

ANATOMIC CONSIDERATIONS CAUTIONS


The radius has a flat, wide, cranial surface; narrow medial and lateral It is important to avoid major nerves and vessels and joint surfaces with
surfaces; and variable cranial bowing of the diaphysis. The proximal the fixation pins. To accommodate the width of the radius and avoid
radial joint surface parallels the distal radial joint surface when viewed fracturing the bone, it is advisable to consider using smaller fixation
on a cranial caudal radiograph. The proximal third of the bone is com- pins when they are inserted medially and laterally. Angular and
pletely covered with muscle, whereas the medial aspect of the distal rotational alignment should be monitored during the reduction.
two thirds of the radius is covered only by skin and subcutaneous Intraoperative radiographs are useful to verify joint alignment during
tissue. The cephalic vein crosses the medial portion of the distal radius. closed reductions.
In general, fixation pins can be applied on the cranial medial, medial,
cranial lateral, and lateral surfaces of the bone. POSTOPERATIVE EVALUATION
Radiographs should be evaluated for fracture reduction or bone align-
EQUIPMENT ment and implant placement. Angular malalignments should be
Surgical pack, Senn retractors, small Hohmann retractors, periosteal corrected by loosening the clamps and realigning the fixation pins on
elevator, pointed reduction forceps, Jacob pin chuck, low-speed the connecting bar.
power drill, external fixation equipment, pin cutter, bone curette for
harvesting cancellous graft POSTOPERATIVE CARE
Gauze sponges should be packed around the pins, and the sponges
PREPARATION AND POSITIONING should be secured with a bandage that incorporates the paw to limit
Prepare the affected forelimb circumferentially from midline to foot. postoperative swelling. The animal should be confined, with activity
Position the animal in dorsal recumbency, and suspend the affected limited to leash walking. External fixator management includes daily
limb from the ceiling. Drape the limb out in the hanging position. pin care and pin packing as needed. Radiographs should be repeated at
Prepare the ipsilateral proximal humerus for cancellous bone autograft 6-week intervals to evaluate healing. The fixator should be destabilized
donor site if open reduction is used. by removing one unilateral frame (type Ib fixator), selected fixation pins
(type Ia or type II fixator), or one connecting bar (of the type II fixator)
PROCEDURE when bone bridging is observed. The external fixator should be
Approach: Perform a limited medial approach to the fracture site removed when the fracture is healed.
for reducible fractures (Plate 62A). Use closed reduction techniques for
nonreducible fractures (Plate 62B). Incise the skin and create soft EXPECTED OUTCOME
tissue tunnels to the bone for pin placement. Bone healing is usually seen in 12 to 18 weeks, depending on fracture
Reduction: Lower the table to allow the animals weight to and signalment of the animal. Animals experience limited function
fatigue the muscles. For transverse fracture lines, lever the fragments while the external fixator is in place but should have a good return to
into position through the limited surgical approach (see Plate 62A). function.3
Maintain the reduction manually. Reduce and maintain long oblique
fractures with pointed reduction forceps while lag screws or cerclage
wires are applied. For closed reduction of comminuted fractures, use References
the proximal and distal transfixation pins to manipulate the bone and 1. Johnson AL, Hulse DA: Fundamentals of orthopedic surgery and
align the joint surfaces. Maintain reduction by securing the connecting fracture management, decision making in fracture management. In
bars. Medial and lateral angular alignment is correct when the proximal Fossum TW (ed): Small Animal Surgery, 2nd ed. St. Louis, Mosby, 2002.
and distal joint surfaces are parallel (see Plate 62B). Cranial caudal joint 2. Johnson AL, Hulse DA: Fundamentals of orthopedic surgery and
surface relationships should mimic the contralateral intact bone. Check fracture management, external skeletal fixators. In Fossum TW (ed):
rotational alignment by flexing the elbow and the carpus after raising Small Animal Surgery, 2nd ed. St. Louis, Mosby, 2002.
the table: the paw should align with the radius. 3. Johnson AL, Seitz SE, Smith CW, et al: Closed reduction and type II
Stabilization: Apply a type Ia external fixator to the cranial external fixation of severely comminuted fractures of the radius and
medial surface of the radius (Plate 62C). Place fixation pins in the tibia in dogs: 23 cases (19901994). J Am Vet Med Assoc 209:1445,
metaphysis of each segment and close to the fracture line. Place at least 1996.
CHAPTER 62 A P P L I C AT I O N O F A N E X T E R N A L F I X AT O R T O T H E R A D I U S 169

P L AT E 6 2

Cranial
view
A
Left
forelimb

D2 Cranial view

C D1 E
170 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

RADIUS

CHAPTER 63 Distal Radial Physeal Fractures


INDICATIONS retract the extensor tendons laterally as needed for fracture
Candidates include animals with Salter I and Salter II fractures visualization (Plate 63A).
of the distal radial physis. Reduction: Carefully reduce the physeal fracture to avoid
crushing or injuring the physeal cartilage. Maintain reduction
OBJECTIVES with pointed reduction forceps or manual pressure (Plate 63B).
To stabilize the fracture and achieve anatomic reduction of Stabilization with Crossed Kirschner Wires: Drive
the distal radial physis a Kirschner wire from the medial styloid process, across the
physis into the radial metaphyses, and through the lateral
ANATOMIC CONSIDERATIONS cortex. Drive a second wire from the lateral aspect of the distal
The cranial medial surface of the distal radius can be easily radial epiphysis, across the fracture into the metaphysis, and
palpated to serve as a landmark for location of the incision. The through the medial cortex avoiding the articular surface
cephalic vein crosses the medial portion of the distal radius. (Plate 63C). If possible, bend the pins and cut off the excess.1
The common and lateral digital extensor tendons lie cranial to
the antebrachial carpal joint and may need to be retracted to CAUTIONS
expose the antebrachial carpal joint surface. The extensor carpi It is important to avoid damaging the physeal cartilage or
radialis tendon lies over the medial aspect of the joint. The ante- articular cartilage.
brachial carpal joint is supported by the short radial collateral
ligaments, which arise from the medial styloid process of the POSTOPERATIVE EVALUATION
radius; by the dorsal radiocarpal ligament, which arises from Radiographs should be evaluated for reduction and implant
the dorsal surface of the distal radius; and by the short ulnar placement.
collateral and radioulnar ligaments, which arise from the ulnar
styloid process. POSTOPERATIVE CARE
The animal should be confined, with activity limited to leash
EQUIPMENT walking. Radiographs should be evaluated in 4 weeks. Implant
Surgical pack, Senn retractors, Hohmann retractors, periosteal removal may be required if irritation occurs.
elevator, pointed reduction forceps, Kirschner wires or small
Steinmann pins (for large dogs), pin chuck or high-speed wire EXPECTED OUTCOME
driver, wire cutter or pin cutter Rapid bone healing is usually seen, but premature closure of the
physis may occur; this will cause radial shortening if the animal
PREPARATION AND POSITIONING is still growing.
Prepare the forelimb circumferentially from shoulder to the
digits. Position the animal in lateral recumbency, with the Reference
affected limb up or in dorsal recumbency for greater flexibility. 1. Johnson AL, Hulse DA: Management of specific fractures, radial and
Drape the limb out from a hanging position to allow maximal ulnar physeal fractures. In Fossum TW (ed): Small Animal Surgery,
manipulation during surgery. A cancellous bone graft is not 2nd ed. St. Louis, Mosby, 2002.
necessary.

PROCEDURE
Approach: Incise skin and subcutaneous tissue dorsally from
distal radial diaphysis to the proximal metacarpus. Elevate and
CHAPTER 63 D I S TA L R A D I A L P H Y S E A L F R A C T U R E S 171

P L AT E 6 3

Radial
diaphysis

Radial Ulna
metaphysis

Radial
carpal bone

C
172 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

ULNA

CHAPTER 64 Proximal Ulnar Fractures


INDICATIONS fractures by distracting the fracture and aligning the major segments of
Transverse proximal ulnar fractures, including articular fractures, are the bone. Be sure to restore length and normal rotational alignment to
treated with either a tension band wire or a plate, depending on the size, the bone.
activity, and healing potential of the animal. Comminuted reducible Stabilization: To stabilize a transverse or short oblique frac-
proximal ulnar fractures, including articular fractures and comminuted ture, use a tension band wire. Start two Kirschner wires in the proximal
nonreducible ulnar fractures, are treated with reconstruction of the fragment, and drive them across the fracture line to lodge in the distal
articular surface and either a neutralization plate or bridging plate. The bone segment. Alternatively, retrograde the Kirschner wires before
tension band wire converts tensile forces to compressive forces at the reducing the fracture. Place a transverse drill hole in the distal bone
fracture. The plate provides rigid fixation and resists axial loading, segment, pass a figure-eight wire through the hole and around the
bending, and rotation. Kirschner wires, and tighten the figure-eight wire. Bend the Kirschner
wires and rotate the ends over the triceps tendon (Plate 64B).
OBJECTIVES Alternatively, apply an appropriately contoured plate to the lateral sur-
To convert the tensile forces resulting from the pull of the triceps face of the ulna. Compress the fracture line, using the loaded drill guide
muscles to compressive forces at the fracture; to achieve anatomic to insert one or two screws (Plate 64C). To stabilize a comminuted
reduction of the articular surface; and to neutralize the forces acting reducible fracture, reduce the articular fragments anatomically, and
on the fracture or bridge the fracture with a plate compress the fracture lines with lag screws. Apply an appropriately
If an associated luxation of the radial head is present (Monteggia contoured plate to the lateral surface of the ulna (Plate 64D).
fracture), reduction and stabilization of the radial head are imperative. Comminuted, nonreducible fractures that do not affect the joint
surface may be bridged with a plate (Plate 64E). Plates may be applied
ANATOMIC CONSIDERATIONS to the caudal surface of the ulna, if size permits.3
Landmarks for the approach to the proximal ulna are the olecranon and
the palpable caudal border of the ulna. The articular surface of the CAUTIONS
trochlear notch can be exposed surgically by muscle elevation. The Articular reduction should be maintained during implant application. It
ulnar nerve courses over the medial aspect of the elbow, caudal to the is important to avoid penetrating the articular surface with implants.
medial epicondyle. The hard bone of the ulna makes drilling wires difficult. It is necessary
to irrigate during drilling to reduce bone necrosis. Pin placement must
EQUIPMENT follow the contour of the proximal ulna.
Surgical pack, Senn retractors, Gelpi retractors, Hohmann retractors,
periosteal elevator, pointed reduction forceps, high-speed drill POSTOPERATIVE EVALUATION
and Kirschner wire driver, Kirschner wires, orthopedic wire, wire Radiographs should be evaluated for articular surface reduction and
tighteners, plating equipment, bone curette for harvesting cancel- implant placement.
lous graft
POSTOPERATIVE CARE
PREPARATION AND POSITIONING The animal should be confined, with activity limited to leash walking.
Prepare the forelimb circumferentially from shoulder to carpus. Physical therapy should be performed daily, flexing and extending the
Position the animal in lateral recumbency, with the affected limb up. elbow until adequate range of motion returns. Radiographs should be
Drape the limb out from a hanging position to allow maximal manipu- repeated at 6-week intervals until the fracture is healed.
lation during surgery. The ipsilateral proximal humerus can serve as a
cancellous graft harvest site. EXPECTED OUTCOME
Bone healing is usually seen in 6 to 18 weeks, depending on the fracture
PROCEDURE and signalment of the animal. Animals usually experience a good return
Approach: Incise the skin and subcutaneous tissue medial to the to function. Degenerative joint disease may result from articular
caudal border of the ulna, starting at the olecranon and extending dis- trauma, with severity depending on accuracy and maintenance of
tally over the ulnar diaphysis. Elevate the flexor carpi ulnaris and deep reduction. Pin migration may occur with tension band wires.3 Implant
digital flexor muscles medially, and the ulnaris lateralis muscle laterally, removal may be necessary if soft tissues are irritated.
to expose the bone surface. Reflect the origin of the flexor carpi ulnaris
muscle to expose the trochlear notch and articular surface (Plate 64A).1
Use an open but do not disturb the fragments technique to expose the
proximal and distal bone segments with minimal disturbance of the References
fracture hematoma and bone fragments for nonreducible nonarticular 1. Piermattei DL, Johnson KA: An Atlas of Surgical Approaches to the
fractures.2 Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
Reduction: Extend the elbow to aid reduction. For single frac- Saunders, 2004.
tures, secure the proximal fragment with a pointed reduction forceps 2. Aron DN, Palmer RH, Johnson AL: Biologic strategies and a
and place it into alignment. Oblique fracture reduction may be main- balanced concept for repair of highly comminuted long bone frac-
tained with pointed reduction forceps, but in transverse fractures, tures. Compend Cont Educ Pract Vet 17:35, 1995.
manual maintenance of reduction is necessary. Be sure the articular 3. Muir P, Johnson KA: Fractures of the proximal ulna in dogs. Vet
surface is anatomically aligned. Reduce comminuted, nonreducible Comp Orthop Traumatol 9:88, 1996.
CHAPTER 64 P R OX I M A L U L N A R F R A C T U R E S 173

P L AT E 6 4

Flexor Ulnaris
carpi lateralis
ulnaris muscle
muscle
(ulnar head)

Anconeus
muscle

C D E
174 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

P E LV I S

CHAPTER 65 Sacroiliac Luxation


INDICATIONS iliac wing or by locating the glide hole in the caudal dorsal quad-
Candidates include animals with unstable sacroiliac luxations, rant of the area of the ilium under the straight portion of the
especially those that cause pelvic canal narrowing. dorsal iliac crest (Plate 65C). Drill the glide hole at the prede-
termined position with the appropriate-sized drill bit. Advance
OBJECTIVES a cancellous screw of the proper length through the glide hole
To restore pelvic canal width and stabilize the sacroiliac joint until the tip appears on the medial surface of the ilium. Use the
Kern bone-holding forceps to manipulate the ilium caudally into
ANATOMIC CONSIDERATIONS alignment with the articular surface of the sacroiliac joint.
The sacroiliac joint has two distinct components: (1) a semilunar, Visually guide the screw tip into the prepared thread hole in the
crescent-shaped, synovial joint and (2) a fibrocartilaginous syn- sacrum, and then tighten the screw (see Plate 65C). A second
chondrosis. The landmarks of the notch on the lateral surface of screw may be added if room permits.5 Large or overweight dogs
the sacrum and the crescent-shaped auricular cartilage are used may benefit from inserting a transilial bolt (generally a small
to position the screw into the body of the sacrum.1 The sacral end, threaded, Steinmann pin) through the iliac wings, over the
nerve roots and the sciatic nerve course behind the ilial body. dorsal surface of L7. Bend the smooth end, and place a nut on
the threaded end to prevent pin migration (Plate 65D).5
EQUIPMENT
Surgical pack, Senn retractors, periosteal elevator, Gelpi CAUTIONS
retractors, blunt Hohmann retractor, Kern bone-holding The screw must be optimally placed into the sacral body to gain
forceps, bone screws and instruments for inserting screws, secure bone purchase and avoid implant failure. It is important
high-speed drill to avoid damaging nerve roots and to avoid screw insertion into
the spinal canal.
PREPARATION AND POSITIONING
Prepare the rear limb circumferentially from dorsal midline to POSTOPERATIVE EVALUATION
mid-tibia and from 10 cm cranial to the iliac crest to the tail head Radiographs should be evaluated for bone alignment and
caudally. Position the animal in lateral recumbency, with the implant placement.
affected limb up and with the dorsal midline raised 45 degrees
from the table. A cancellous bone graft is usually unnecessary. POSTOPERATIVE CARE
The animal should be confined, with activity limited to leash
PROCEDURE walking, until the fracture/luxation has stabilized. Radiographs
Approach: Incise the skin and subcutaneous tissue, begin- should be evaluated at 6 and 12 weeks after surgery.
ning over the dorsal iliac crest and extending caudally parallel Radiographic evidence of bone bridging or callus formation at
to the spine to a point even with the hip joint, to expose the iliac the sacroiliac joint may or may not be evident.
crest. Incise through the periosteal origin of the middle gluteal
muscle on the lateral ridge of the iliac crest and the deep gluteal EXPECTED OUTCOME
fascia and periosteal origin of the sacrospinalis muscle on the Bone healing is usually seen in 6 to 12 weeks. Animals should
medial ridge of the iliac crest. The incisions merge caudally, experience an excellent return to function. Implant loosening
where it may be necessary to incise through fibers of the and migration, with loss of pelvic canal diameter, can occur.6
superficial gluteal muscle. Reflect the ilium laterally to expose
the sacroiliac joint. Elevate the middle gluteal muscle from the References
lateral surface of the ilium to further expose the ilium for screw 1. DeCamp CE, Braden TD: The anatomy of the canine sacrum for lag
placement.2 Position a blunt Hohmann retractor between the screw fixation of the sacroiliac joint. Vet Surg 14:131, 1985.
ilium and ventral bony shelf of the sacrum, and reflect the ilium 2. Piermattei DL, Johnson KA: An Atlas of Surgical Approaches to the
ventrally to expose the sacral joint surface (Plate 65A).3 Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
Reduction: Place a Kern bone-holding forceps on the wing Saunders, 2004.
of the ilium to manipulate the hemipelvis (see Plate 65C). 3. Johnson AL, Hulse DA: Management of specific fractures: Sacroiliac
Reduction is achieved and maintained with the bone screw. luxations/fractures. In Fossum TW (ed): Small Animal Surgery, 2nd
ed. St. Louis, Mosby, 2002.
Stabilization: Use the appropriate-sized drill bit to drill a
4. DeCamp CE: Principles of pelvic fracture management. Sem Vet
thread hole 2 mm cranial and 2 mm proximal to the center of Med Surg Sm Anim 7:63, 1992.
the crescent-shaped articular cartilage (Plate 65B). The depth 5. Piermattei DL, Flo GL: Fractures of the pelvis. In Brinker, Piermattei
of the thread hole in the sacral body should be such that and Flos Handbook of Small Animal Orthopedics and Fracture
the screw tip will extend to the midline of the sacral body.4 Repair, 3rd ed. Philadelphia, WB Saunders, 1997.
Determine the proper location of the glide hole in the ilium by 6. DeCamp CE, Braden TD: Sacroiliac fracture-separation in the dog:
palpating the articular prominence on the medial surface of the A study of 92 cases. Vet Surg 14:127, 1985.
CHAPTER 65 S A C R O I L I A C L U X AT I O N 175

P L AT E 6 5

Gluteal surface Intermediate


of wing of ilium sacral crest

Hohmann retractor

Middle gluteal muscle

C D
176 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

P E LV I S

CHAPTER 66 Ilial Body Fractures


INDICATIONS Reduction: Place Kern bone-holding forceps over the
Candidates include animals with transverse or oblique dis- caudal ilial segment, and reposition it lateral to the cranial seg-
placed ilial body fractures. ment. Contour a plate to fit the normal curvature of the lateral
surface of the bone, using a ventrodorsal radiograph of the
OBJECTIVES contralateral ilium as a guide.2 Attach the plate to the caudal
To achieve anatomic fracture reduction, rigid fracture stabi- segment first with bone screws. Use a periosteal elevator as a
lization, and restoration of pelvic canal width lever to help reduce transverse fractures. Use the Kern forceps
to retract the caudal segment caudally, and use pointed reduc-
ANATOMIC CONSIDERATIONS tion forceps to secure long oblique fractures in reduction.
The iliac wing curves medially to hold the middle and deep Clamp the cranial portion of the plate to the cranial segment of
gluteal muscles. The bone in the tip of the iliac wing is thin the ilium to obtain lateralization of the caudal ilial segment and
and may not hold implants well. The sacroiliac joint is located to maintain reduction (Plate 66B).
medially to the iliac wing. The ilial body is located between the Stabilization: Secure the plate by placing screws in the
wing of the ilium cranially and the acetabulum caudally. The cranial segment. Screws may penetrate the sacrum for addi-
cranial gluteal artery vein and nerve lie over the ilial body and tional bone purchase. Place at least three plate screws in the
are often damaged by the injury. The sciatic nerve is located cranial segment and two or three (space permitting) in the
medial to the ilial body. Reestablishment of ilial integrity is caudal segment (Plate 66C).2,3
required for weight transfer from the limb to axial skeleton.
With ilial fractures, the caudal fragment is often displaced CAUTIONS
medially and cranially to the wing of the ilium. It is important to avoid trapping the sciatic nerve during frac-
ture reduction and to avoid penetrating deeply into the pelvic
EQUIPMENT canal with drill bits and taps. The plate should be contoured
Surgical pack, Senn retractors, periosteal elevator, Gelpi sufficiently to open the pelvic canal.
retractors, Myerding retractors, blunt Hohmann retractor,
Kern bone-holding forceps, pointed reduction forceps, plate- POSTOPERATIVE EVALUATION
reduction forceps, plating equipment, high-speed drill Radiographs should be evaluated for bone alignment and
implant placement.
PREPARATION AND POSITIONING
Prepare the rear limb circumferentially from dorsal midline to POSTOPERATIVE CARE
mid-tibia and from 10 cm cranial to the iliac crest to the tail The animal should be confined, with activity limited to leash
head caudally. Position the animal in lateral recumbency, with walking, until the fracture has healed. Radiographs should be
the affected limb up. Drape the limb out from a hanging position repeated at 6-week intervals until fracture healing is observed.
to allow maximal manipulation during surgery. A cancellous
bone graft is usually unnecessary. EXPECTED OUTCOME
Bone healing is usually seen in 6 to 12 weeks. Animals should
PROCEDURE experience an excellent return to function. Generally, plates are
Approach: Incise skin and subcutaneous tissue over the not removed after bone healing unless there are problems with
ventral third of the iliac wing from the cranial extent of the iliac the implant.
crest to 1 cm to 2 cm beyond the greater trochanter caudally.
Incise the fascia to separate the tensor fasciae latae muscle and
middle gluteal muscle cranially, and the tensor fasciae latae and
superficial gluteal muscle caudally. Sharply dissect cranially References
to separate the middle gluteal muscle and long head of the 1. Piermattei DL, Johnson KA: An Atlas of Surgical Approaches to the
tensor fascia latae muscle. Elevate the deep and middle gluteal Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
Saunders, 2004.
muscles from the lateral surface of the ilium. Sharply dissect
2. Johnson AL, Hulse DA: Management of specific fractures: Ilial frac-
the origin of the middle gluteal from the cranial wing of the tures. In Fossum TW (ed): Small Animal Surgery, 2nd ed. St. Louis,
ilium for additional exposure and easier reduction.1 Maintain Mosby, 2002.
exposure using Gelpi retractors and by placing a blunt 3. Olmstead ML, Matis U: Fractures of the pelvis. In Brinker WO,
Hohmann retractor under the dorsal surface of the proximal Piermattei D, Flo GL (eds): Handbook of Small Animal Orthopedics
bone segment (Plate 66A). and Fracture Repair, 3rd ed. Philadelphia, WB Saunders, 1997.
CHAPTER 66 I L I A L B O DY F R A C T U R E S 177

P L AT E 6 6

Middle gluteal muscle

Deep gluteal muscle

Shaft of
ilium

B C
178 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

P E LV I S

CHAPTER 67Transverse or Short Oblique


Acetabular Fractures
INDICATIONS ture.2 In some cases, it is possible to maintain reduction with a pointed
Candidates include animals with transverse or short oblique fractures reduction forceps or a small Kirschner wire driven across the fracture
through the dorsal rim of the acetabulum. (Plate 67B). Otherwise, maintain reduction manually. Visualize the
alignment of the articular surface by distracting the femoral head from
OBJECTIVES the acetabulum.
To achieve anatomic articular surface reduction and rigid fixation to Stabilization: Position a contoured acetabular plate or recon-
encourage full return to function and minimize development of struction plate on the dorsal rim of the acetabulum so at least two plate
degenerative joint disease screws secure the caudal fragment and three plate screws secure the
cranial fragment3,4 (see Plate 67B). Move the plate to allow three screws
ANATOMIC CONSIDERATIONS purchase in the caudal segment if the fracture involves the cranial
The hip joint is a ball-and-socket joint composed of the femoral head acetabulum. Close the wound by suturing the gemelli and internal obtu-
and acetabulum. The normal conformation; surrounding musculature rator tendons to their point of insertion. Reduce and stabilize the
(i.e., gluteals, internal and external rotators, and the iliopsoas muscles); greater trochanter with two Kirschner wires and a tension band wire
suction-like effect of the synovial fluid; and ligament of the femoral (Plates 67C and 67D). Suture the fascial layers, subcutaneous tissue,
head act to stabilize the joint. The articular surface is on the dorsolat- and skin.
eral face of the acetabulum, with the round ligament on the medial face.
The fibrous joint capsule originates from the lateral acetabular rim and CAUTIONS
inserts onto the femoral neck. The sciatic nerve courses dorsomedial to The sciatic nerve must be protected. It is important to avoid penetrating
the acetabulum. deep into the pelvic canal or into the articular surface with drill bits,
taps, or screws. Accurate plate contouring is essential for maintaining
EQUIPMENT articular surface alignment.
Surgical pack, Senn retractors, periosteal elevator, Gelpi retractors,
Myerding retractors, blunt Hohmann retractor, Kern bone-holding POSTOPERATIVE EVALUATION
forceps, pointed reduction forceps, plating equipment, high-speed Radiographs should be evaluated for joint alignment and implant
drill and K-wire driver, Kirschner wires, orthopedic wire, wire twister, placement.
wire cutter
POSTOPERATIVE CARE
PREPARATION AND POSITIONING The animal should be confined, with activity limited to leash walking,
Prepare the rear limb circumferentially from dorsal midline to mid-tibia, until the fracture has healed. Radiographs should be repeated at 6-week
and from 10 cm cranial to the iliac crest to the tail head caudally. intervals until the fracture is healed. Slow leash walking and range-of-
Position the animal in lateral recumbency, with the affected limb up. motion exercises for the hip should be encouraged.
Drape the limb out from a hanging position to allow maximal manipu-
lation during surgery. A cancellous bone graft is usually unnecessary. EXPECTED OUTCOME
Bone healing is usually seen in 12 to 18 weeks. Animals should experi-
PROCEDURE ence a good return to function if anatomic reconstruction is achieved
Approach: Incise the skin and subcutaneous tissue starting 3 cm to and maintained. Progressive degenerative joint disease may occur if
4 cm proximal to the dorsal ridge of the greater trochanter and curving reduction is not anatomic.5 Plate removal is generally not necessary.
3 cm to 4 cm, following the cranial border of the femur. Incise the Kirschner wires and orthopedic wire may be removed after bone
superficial leaf of the fascia lata at the cranial border of the biceps healing if the implants irritate the soft tissues.
femoris muscle, and retract the muscle caudally. Incise the deep leaf of
the fascia lata, and carry the incision proximally through the insertion
of the tensor fasciae latae muscle at the greater trochanter and along
the cranial border of the superficial gluteal muscle. Incise through the References
insertion of the superficial gluteal muscle at the third trochanter. 1. Piermattei DL, Johnson KA: An Atlas of Surgical Approaches to the
Reflect the superficial gluteal muscle proximally, and the biceps femoris Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
caudally, to find and visualize the course of the sciatic nerve. Perform Saunders, 2004.
an osteotomy of the greater trochanter with an osteotome and mallet or 2. Johnson AL, Hulse DA: Management of specific fractures:
with Gigli wire. Reflect the gluteal muscles and greater trochanter from Acetabular fractures. In Fossum TW (ed): Small Animal Surgery, 2nd
the joint capsule with a periosteal elevator. Pre-place a suture through ed. St. Louis, Mosby, 2002.
the insertions of the gemelli muscles and tendon of the internal obtu- 3. Braden TD, Prieur WD: New plate for acetabular fractures:
rator, and incise both structures together at the trochanteric fossa. Technique of application and long-term follow-up evaluation. J Am
Elevate the gemelli muscles from the caudolateral surface of the Vet Med Assoc 188:1183, 1986.
acetabulum with a periosteal elevator. Use the suture to retract the 4. Dyce J, Houlton JEF: Use of reconstruction plates for repair of
muscles proximally and caudally (Plate 67A). Incise the joint capsule to acetabular fractures in 16 dogs. J Small Anim Pract 34:547, 1993.
expose the articular fracture.1 5. Anson LW, DeYoung DJ, Richardson DC, et al: Clinical evaluation of
Reduction: Expose the tuber ischium, and place a Kern bone- canine acetabular fractures stabilized with an acetabular plate. Vet
holding forceps on it. Use caudal segment control to reduce the frac- Surg 17:220, 1988.
CHAPTER 67 T R A N S V E R S E O R S H O RT O B L I Q U E A C E TA B U L A R F R A C T U R E S 179

P L AT E 6 7

Osteotomy of the
greater trochanter

Tensor fasciae Superficial gluteal muscle


latae muscle (retracted proximally)
(retracted cranially)

A
Gemelli muscles incised

Sciatic nerve

Osteotomy of the
greater trochanter

Vastus lateralis muscle

D
180 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

FEMUR

CHAPTER 68Proximal Femoral


Physeal Fractures
INDICATIONS Stabilization with Three Kirschner Wires: Insert the
Candidates include animals with Salter I and Salter II fractures wires from the lateral aspect of the femur, paralleling the
of the physis. Occasionally this injury is accompanied by a femoral neck anteversion angle. Place the wires parallel to one
trochanteric physeal fracture. another and position them in the femoral neck so that they lie
in a triangle. Drive the wires until the points are just visible at
OBJECTIVES the fracture surface (see Plate 68B). Reduce the fracture, and
To achieve anatomic reduction and fracture stabilization drive the pins into the femoral epiphysis. Estimate the distance
into the epiphysis, and mark an adjacent pin to provide a guide
ANATOMIC CONSIDERATIONS (see 68C; the distance between the pin chuck and the forceps
The proximal femoral physis lies between the femoral epiphysis on the adjacent pin, b, is equal to the distance the pin will be
and femoral neck, and provides neck length until maturity. The driven into the epiphysis, a). Drive the remaining wires into the
blood supply to the femoral epiphysis is a series of cervical femoral epiphysis using a similar guiding process. Move the
ascending vessels lying outside the femoral neck that cross the joint through a normal range of motion after each wire to
periphery of the physis and penetrate the epiphysis. Implants ensure that it has not penetrated the articular surface. Bend the
must provide stability against rotational and shearing forces.1 pins at the lateral surface, and cut off the excess (Plate 68D).
Closure is routine.
EQUIPMENT Stabilization of a Trochanteric Physeal Fracture
Surgical pack, Senn retractors, Gelpi retractors, Myerding with a Tension Band Wire: Reduce the trochanter, and
retractors, Hohmann retractors, pointed reduction forceps, secure it with a pointed reduction forceps. Start two Kirschner
periosteal elevator, Kirschner wires, high-speed quick-release wires in the fragment, and drive them perpendicular to and
wire driver, wire cutter across the physis to lodge in the medial cortex of the proximal
femur. Drill a transverse hole in the major bone segment, and
PREPARATION AND POSITIONING pass a figure-eight wire through the hole and around the
Prepare the rear limb circumferentially from dorsal midline to Kirschner wire. Tighten the wire (see Plate 68D).
mid-tibia. Position the animal in lateral recumbency, with the
affected limb up. Drape the limb out from a hanging position to CAUTIONS
allow maximal manipulation during surgery. A cancellous bone It is important to avoid penetrating the articular surface with
graft is not necessary. the Kirschner wires.

PROCEDURE POSTOPERATIVE EVALUATION


Approach: Incise the skin and subcutaneous tissue 5 cm Radiographs should be evaluated for reduction and implant
proximal to the greater trochanter, curving distally adjacent to position. Frog leg and extended hip views may help pin position
the cranial ridge of the trochanter, and extending distally for visualization.
5 cm over the proximal femur. Incise between the tensor fasciae
latae muscle and deep border of the biceps femoris muscle POSTOPERATIVE CARE
and superficial gluteal muscle. Retract the tensor fasciae latae The animal should be confined, with activity limited to leash
cranially, the biceps caudally, and the middle gluteal muscle walking for 3 to 4 weeks. Radiographs should be evaluated in 4
proximally. Incise the deep gluteal tendon close to its attach- to 6 weeks.
ment on the trochanter for one third to one half of its width.
Reflect the vastus lateralis distally to expose the hip joint. EXPECTED OUTCOME
Incise the joint capsule (or enlarge the traumatic tear) parallel Rapid bone healing is usually seen within 3 to 4 weeks.
to the long axis of the femoral neck near its proximal ridge. Premature closure of the physis may result in a misshapen
Continue the joint capsule incision laterally through the point of femoral head. Partial resorption of the femoral neck (apple
origin of the vastus lateralis muscle on the cranial face of the coring effect) usually occurs, but this rarely causes a problem.
proximal femur (Plate 68A).2
Reduction: Grasp the proximal femur with a pointed
References
reduction forceps, and retract the femoral neck distally so that
1. Tillson DM, McLaughlin RM, Roush JK: Fractures of proximal
it lies cranial and level with the acetabulum (Plate 68B). femoral physis in dogs. Compend Cont Educ Pract Vet 18(11):1164,
Derotate the femur, and slide the fracture surface of the femoral 1996.
neck caudally into the matching surface of the femoral epiph- 2. Piermattei DL, Johnson KA: An Atlas of Surgical Approaches to the
ysis. Hold the reduction by pressing against the proximal piece Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
in the acetabulum (Plate 68C). Saunders, 2004.
CHAPTER 68 P R OX I M A L F E M O R A L P H Y S E A L F R A C T U R E S 181

P L AT E 6 8

Tensor fasciae
latae muscle
retracted cranially

Middle gluteal muscle


retracted proximally

Deep gluteal muscle

Incision in joint capsule

Vastus lateralis muscle

A
Biceps femoris muscle
retracted caudally

a
Distance a = b

C b

D
182 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

FEMUR

CHAPTER 69 Femoral Neck Fractures


INDICATIONS visualization is not adequate for anatomic reduction and place-
Candidates include animals with transverse and short oblique ment of implants.2
femoral neck fractures. Reduction: Place two Kirschner wires so they lie at the
most proximal and distal level of the fracture surface. Drive the
OBJECTIVES pins either from medial to lateral beginning at the fracture sur-
To achieve anatomic reduction and rigid fixation of the face or from the lateral surface medially, to exit and lie flush at
fracture to allow early return to function the fracture surface (Plate 69B). Reduce the fracture, and drive
the Kirschner wires into the femoral epiphysis to maintain
ANATOMIC CONSIDERATIONS reduction (Plate 69C).
The femoral neck/femoral shaft junction in the frontal plane is Stabilization: Drill a thread hole through the femoral
known as the angle of inclination. This angle is normally 135 epiphysis with the appropriate-sized drill bit parallel to and
degrees and should be approximated when surgical reduction is centered between the Kirschner wires (see Plate 69C). Measure
performed. The normal angle of anteversion is 15 to 20 degrees the length of screw needed, and tap the thread hole. Insert a
and must be considered when inserting screws or pins into the partially threaded cancellous screw, 2 mm shorter than the
femoral neck.1 length measured, so that all the threads cross the fracture plane
and are seated into the femoral head. Leave one or both wires
EQUIPMENT in place to serve as antirotational devices (Plate 69D). Close the
Surgical pack, Senn retractors, Gelpi retractors, Hohmann incision routinely.
retractors, Myerding retractors, periosteal elevator, Kirschner
wires, bone screws and instruments for inserting bone screws, CAUTIONS
high-speed drill and wire driver, wire cutter It is important to follow the anteversion angle of the femoral
neck with the implants and to avoid penetrating the articular
PREPARATION AND POSITIONING surface with Kirschner wires and the bone screw.
Prepare the rear limb circumferentially from dorsal midline to
mid-tibia. Position the animal in lateral recumbency, with the POSTOPERATIVE EVALUATION
affected limb up. Drape the limb out from a hanging position to Radiographs should be evaluated for reduction and implant
allow maximal manipulation during surgery. Prepare the ipsilat- position. Frog leg and extended hip views may help implant
eral wing of the ilium for cancellous bone graft harvest. position visualization.

PROCEDURE POSTOPERATIVE CARE


Approach: Incise the skin and subcutaneous tissue 5 cm The animal should be confined, with activity limited to leash
proximal to the greater trochanter, curving distally adjacent to walking. Radiographs should be repeated at 6-week intervals
the cranial ridge of the trochanter, and extending distally for until the fracture has healed.
5 cm over the proximal femur. Incise between the tensor fasciae
latae muscle and deep border of the biceps femoris muscle and EXPECTED OUTCOME
superficial gluteal muscle. Retract the tensor fasciae latae Bone healing is usually seen within 6 to 12 weeks. Instability at
cranially, the biceps caudally, and the middle gluteal muscle the fracture site can result in delayed union and implant failure.
proximally. Incise the deep gluteal tendon close to its attach-
ment on the trochanter for one third to one half of its width.
Incise the joint capsule parallel to the long axis of the femoral References
neck near its proximal ridge. Continue the joint capsule incision 1. Johnson AL, Hulse DA: Femoral metaphyseal fractures. In Fossum
laterally through the point of origin of the vastus lateralis TW (ed): Small Animal Surgery, 2nd ed. St. Louis, Mosby, 2002.
muscle on the cranial face of the proximal femur. Reflect the 2. Piermattei DL, Johnson KA: An Atlas of Surgical Approaches to the
vastus lateralis ventrally to visualize the fracture surface (Plate Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
69A).2 A greater trochanteric osteotomy may be required if Saunders, 2004.
CHAPTER 69 FEMORAL NECK FRACTURES 183

P L AT E 6 9

Tensor fasciae
latae muscle
retracted cranially
Deep gluteal
muscle

Middle gluteal muscle


retracted proximally

Vastus lateralis
muscle

Biceps femoris muscle


retracted caudally

D
184 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

FEMUR

CHAPTER 70 Distal Femoral Physeal Fractures


INDICATIONS are just visible at the fracture surface. Reduce the fracture, and
Candidates include animals with Salter I and Salter II fractures drive the pins into the femoral metaphysis and through the
of the distal femoral physis. opposite cortices (Plate 70C).2
Stabilization with an Intramedullary Pin: Insert a
OBJECTIVES pin through the articular cartilage, cranial to the origin of the
To achieve fracture stabilization, and anatomic or slight over- caudal cruciate ligament, to the level of the fracture surface.
reduction of the femoral epiphysis Reduce the fracture, and direct the pin in a normograde fashion
proximally into the femur to exit at the trochanteric fossa. The
ANATOMIC CONSIDERATIONS pin should contact the caudal surface of the medullary canal
The distal femoral growth plate is shaped like a W and lies at proximal to the fracture. Cut the distal part of the pin, and coun-
the joint capsule reflection. A lateral arthrotomy is necessary tersink it below the level of the articular cartilage. Cut the
for exposure. The configuration of the growth plate and cancel- excess pin off below the skin above the trochanteric fossa.3 Add
lous bone surface provide some rotational stability. a cross pin at the fracture to establish rotational stability if nec-
essary (Plate 70D). Close the incision routinely.
EQUIPMENT
Surgical pack, Senn retractors, Gelpi retractors, blunt CAUTIONS
Hohmann retractor, periosteal elevator, Kern bone-holding The epiphyseal bone is soft: it is important to avoid excessive
forceps, pointed reduction forceps, Steinmann pins and bone forceps pressure. To avoid the sciatic nerve, the hip
Kirschner wires, Jacob pin chuck, wire cutter should be extended and the limb adducted when the intra-
medullary pin is driven through the trochanteric fossa.
PREPARATION AND POSITIONING
Prepare the rear limb circumferentially from dorsal midline to POSTOPERATIVE EVALUATION
tarsus. Position the animal in lateral recumbency, with the Radiographs should be evaluated for bone alignment and
affected limb up. Drape the limb out from a hanging position to implant placement.
allow maximal manipulation during surgery. A cancellous bone
graft is not necessary. POSTOPERATIVE CARE
The animal should be confined, with activity limited to leash
PROCEDURE walking. Physical therapy and early return to function are
Approach: Incise skin and subcutaneous tissue on the cra- necessary to avoid extensor tie down. Radiographs should be
nial lateral surface, with the incision centered over the palpable evaluated in 4 to 6 weeks.
end of the femoral metaphysis. Make a parapatellar arthrotomy
through the distal fascia lata and joint capsule, continuing the EXPECTED OUTCOME
incision proximally along the caudal border of the vastus later- Rapid bone healing is usually seen in 3 to 4 weeks. Premature
alis muscle through the intermuscular septum of the fascia lata. closure of the physis may result in a noticeable shortened leg in
Reflect the quadriceps muscles, patella, and patella tendon very young animals.
medially to expose the articular surface of the femoral condyles
(Plate 70A).1
Reduction: Reduce the fracture by levering the condyles
cranially and distally with a blunt Hohmann retractor placed References
between the fracture fragments. Maintain reduction during pin 1. Piermattei DL, Johnson KA: An Atlas of Surgical Approaches to the
placement by placing a Kern bone-holding forceps on the lateral Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
Saunders, 2004.
aspect of the distal femoral metaphysis. Place a pointed reduc-
2. Sukhiani HR, Holmburg DL: Ex vivo biomechanical comparison of
tion forceps from the trochlear surface to the jaws of the Kern pin fixation techniques for canine distal femoral physeal fractures.
(Plate 70B). Vet Surg 26:398, 1997.
Stabilization with Crossed Pins: Position two pins to 3. Stigen O: Supracondylar femoral fractures in 159 dogs and cats
enter the epiphysis at a point cranial to the medial and lateral treated using a nomograde intramedullary pinning technique. J small
epicondyles, and drive them proximally to a point where they Anim Pract 40:519, 1999.
CHAPTER 70 D I S TA L F E M O R A L P H Y S E A L F R A C T U R E S 185

P L AT E 7 0

Quadriceps muscles, patella, and


patella tendon reflected medially

Fascia latae and biceps


femoris muscles retracted

Joint capsule incised

Lateral head of the


gastrocnemius muscle

Lateral
collateral
ligament

D
186 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

FEMUR

CHAPTER 71 Application of an Intramedullary


Pin or Interlocking Nail to the Femur
INDICATIONS bone-holding forceps, Jacob pin chuck, IM pins, cerclage
Candidates include animals with single or comminuted femoral wire, wire tightener, wire cutter, external fixator clamps and
diaphyseal fractures. connecting bars (or ILN equipment, including high-speed
drill), bone curette for harvesting graft
OBJECTIVES
To achieve anatomic reduction of single fracture lines or PREPARATION AND POSITIONING
restoration of normal bone alignment for nonreducible com- Prepare the rear limb circumferentially from dorsal midline to
minuted fractures tarsus. Position the animal in lateral recumbency, with the
The intramedullary (IM) pin is used in animals with high affected limb up. Drape the limb out from a hanging position to
fracture-assessment scores. The IM pin neutralizes bending allow maximal manipulation during surgery. Prepare the ips-
forces at the fracture; it is combined with cerclage wire for long ilateral proximal humerus or ipsilateral ilial wing for surgery for
oblique fractures and with external fixation for transverse or harvesting cancellous bone graft.
short oblique fractures to neutralize rotational and axial com-
pressive forces. The interlocking nail (ILN) neutralizes bending, PROCEDURE
rotational, and axial compressive forces at the fracture; it can Approach: Incise the skin and subcutaneous tissue on the
be used for animals with medium and low fracture-assessment lateral surface of the thigh, from the greater trochanter to the
scores.1 femoral condyles. Incise the tensor fascia lata along the cranial
border of the biceps femoris to expose the vastus lateralis and
ANATOMIC CONSIDERATIONS biceps femoris muscles. Retract the muscles to expose the
The narrowest part of the medullary canal, the isthmus, is femur.2 Insert the IM pin into the proximal femur in either a nor-
located within the proximal third of bone, just distal to the third mograde or retrograde manner. Extend the hip and adduct the
trochanter. The distal femur has a pronounced cranial bow in limb when retrograding the IM pin, to avoid injuring the sciatic
most dogs, but it is straight in the cat. Both anatomic features nerve (Plate 71A).3 Insert the ILN in a normograde manner,
constrain the size of the IM pin or ILN selected. The starting at the trochanteric fossa. Use an open but do not
trochanteric fossa is directly in line with the medullary canal, disturb the fragments technique to expose the proximal and
allowing normograde or retrograde placement of an IM pin and distal bone segments with minimal disturbance of the fracture
normograde placement of the ILN. The adductor magnus hematoma and bone fragments for nonreducible fractures.4
muscle attaches to the caudal surface of the femur and serves Incise the skin, and create soft tissue tunnels to the bone for
as a guide for rotational alignment. Additionally, the greater fixator pin placement.
trochanter is 90 degrees to the patella when the rotational align- Continued
ment of the femur is correct.

EQUIPMENT
Surgical pack, periosteal elevator, Gelpi retractors, Myerding
or Hohmann retractors, pointed reduction forceps, Kern
CHAPTER 71 A P P L I C AT I O N O F A N I M P I N O R I N T E R L O C K I N G N A I L T O T H E F E M U R 187

P L AT E 7 1

Biceps femoris
muscle retracted

Shaft of the femur


Vastus
lateralis Adductor magnus
muscle muscle
retracted

Vastus
intermedius
muscle

A
188 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

Reduction: Place an IM pin (sized to equal 70% to 80% of POSTOPERATIVE EVALUATION


the medullary canal at the isthmus) in the proximal segment. Radiographs should be evaluated for bone alignment and
Retract the pin within the medullary canal of the proximal seg- implant placement.
ment. Reduce transverse and short oblique fractures by tenting
the bone ends and levering the bone back into position. Reduce POSTOPERATIVE CARE
long oblique fractures by distracting the bone segments and The animal should be confined, with activity limited to leash
approximating the fracture surfaces. Use pointed reduction for- walking, until the fracture is healed. External fixator manage-
ceps to manipulate the bone segments into reduction. Drive the ment includes daily pin care and pin packing as needed.
IM pin distally to seat in the femoral condyle. Maintain the Physical therapy is needed to restore stifle range of motion.
reduction manually for transverse fractures and with pointed Radiographs should be evaluated in 6 weeks. Fixator pins
reduction forceps for oblique fractures. Reduce comminuted should be removed after radiographic signs of bone bridging are
nonreducible fractures by distracting the distal end with the IM observed. If a tie-in is used, the top fixation pin and its connec-
pin or ILN and aligning the major segments of the bone. tion to the IM pin should be retained. Radiographs should be
Stabilization: Apply an IM pin and a type Ia external repeated at 6-week intervals until the fracture is healed. The IM
fixator to the lateral surface of the femur to stabilize a trans- pin should be removed when the fracture has healed.
verse or short oblique fracture. Place fixation pins in the meta-
physis of each segment and close to the fracture line. The EXPECTED OUTCOME
external fixator can be connected or tied in to the IM pin to Bone healing is usually seen in 12 to 18 weeks, depending on
strengthen the fixation (Plate 71B). Apply an IM pin and mul- fracture and signalment of the animal.
tiple cerclage wires to a long oblique fracture (Plate 71C). An
external fixator can be added for additional strength. Apply an
ILN and four screws to the femur to treat comminuted nonre- References
ducible fractures (Plate 71D). 1. Johnson AL, Hulse DA: Decision making in fracture management.
In Fossum TW (ed): Small Animal Surgery, 2nd ed. St. Louis, Mosby,
CAUTIONS 2002.
To avoid penetrating the sciatic nerve when retrograding the IM 2. Piermattei DL, Johnson KA: An Atlas of Surgical Approaches to the
Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
pin, the limb should be held in a hip extended and adducted
Saunders, 2004.
position while the pin exits the trochanteric fossa. It is impor-
3. Palmer RH, Aron DN, Purinton PT: Relationship of femoral
tant to avoid the femoral head and distal joint surface with the intramedullary pins to the sciatic nerve and gluteal muscles after
IM pin or ILN. The range of motion of the stifle should be pal- retrograde and normograde insertion. Vet Surg 17:65, 1988.
pated to detect pin interference in the joint. Angular and rota- 4. Aron DN, Palmer RH, Johnson AL: Biologic strategies and a
tional alignment should be monitored during the realignment of balanced concept for repair of highly comminuted long bone frac-
comminuted fractures. tures. Compend Cont Educ Pract Vet 17:35, 1995.
CHAPTER 71 A P P L I C AT I O N O F A N I M P I N O R I N T E R L O C K I N G N A I L T O T H E F E M U R 189

P L AT E 7 1

C D
190 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

FEMUR

CHAPTER 72Application of a Plate


to the Femur
INDICATIONS fractures. Reduce comminuted nonreducible fractures by distracting
Candidates include animals with single or comminuted femoral diaphy- the distal segment with an IM pin (sized to equal 40% to 50% of
seal fractures. the medullary canal at the isthmus) and aligning the major segments of
the bone (see Plate 72A). Be sure to restore length and normal rota-
OBJECTIVES tional alignment to the bone.4 Precontour the plate to the cranial caudal
To achieve anatomic reduction and compression of single fracture radiographic view of the contralateral femur to prevent angular defor-
lines or restoration of normal bone alignment for nonreducible com- mities.4
minuted fractures Stabilization: Apply an appropriately contoured plate to the
The plate is used as a compression plate for transverse or short lateral surface of the femur. The plate can function as a compression
oblique fractures, and it is combined with lag screws to compress long plate (Plate 72B) when used to compress transverse or short oblique
oblique fractures. The plate is used as a bridging plate for nonreducible fratures; as a neutralization plate to support a reconstructed fracture
comminuted fractures and may be combined with an intramedullary (Plate 72C); or as a bridging plate, spanning a nonreducible commin-
(IM) pin to reduce strain on the plate and to extend fatigue life of the uted fracture (Plate 72D).
fixation. The plate neutralizes bending, rotational, and axial compres-
sive forces. CAUTIONS
To avoid penetrating the sciatic nerve when retrograding the IM pin, the
ANATOMIC CONSIDERATIONS limb should be held in a hip extended and adducted position while the
The plate is placed on the lateral surface of the femur. The trochanteric pin exits the trochanteric fossa. It is important to avoid the femoral
fossa is directly in line with the medullary canal, allowing normograde head and distal joint surface with the IM pin or bone screws. The range
or retrograde placement of an IM pin. The adductor magnus muscle of motion of the stifle should be palpated to detect implant interference
attaches to the caudal surface of the femur and serves as a guide for in the joint. Angular and rotational alignment should be monitored
rotational alignment. Additionally, the greater trochanter is 90 degrees during the realignment of comminuted fractures.
to the patella when the rotational alignment of the femur is correct.
POSTOPERATIVE EVALUATION
EQUIPMENT Radiographs should be evaluated for bone alignment and implant
Surgical pack, periosteal elevator, Gelpi retractors, Myerding or placement.
Hohmann retractors, pointed reduction forceps, Kern bone-holding
forceps, self-centering plate-holding forceps, Jacob pin chuck, IM POSTOPERATIVE CARE
pins, high-speed drill, plating equipment, bone curette for harvesting The animal should be confined, with activity limited to leash walking.
graft Physical therapy is needed to restore stifle range of motion.
Radiographs should be evaluated in 6 weeks. If left long, the IM pin
PREPARATION AND POSITIONING should be removed after signs of bone bridging are observed.
Prepare the rear limb circumferentially from dorsal midline to tarsus. Radiographs should be repeated at 6-week intervals until the fracture is
Position the animal in lateral recumbency, with the affected limb up. healed. Plate removal may be necessary after the fracture heals.
Drape the limb out from a hanging position to allow maximal manipu-
lation during surgery. Prepare the ipsilateral proximal humerus or ipsi- EXPECTED OUTCOME
lateral ilial wing for surgery for harvesting cancellous bone graft. Bone healing is usually seen in 12 to 18 weeks, depending on fracture
and signalment of the animal.
PROCEDURE
Approach: Incise the skin and subcutaneous tissue on the
lateral surface of the thigh, from the greater trochanter to the femoral References
condyles. Incise the tensor fascia lata along the cranial border of the 1. Piermattei DL, Johnson KA: An Atlas of Surgical Approaches to the
biceps femoris to expose the vastus lateralis and biceps femoris mus- Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
cles. Retract the muscles to expose the femur.1 Insert the IM pin into the Saunders, 2004.
proximal femur in either a normograde or retrograde manner.2 Use an 2. Palmer RH, Aron DN, Purinton PT: Relationship of femoral
open but do not disturb the fragments technique to expose the prox- intramedullary pins to the sciatic nerve and gluteal muscles after ret-
imal and distal bone segments with minimal disturbance of the fracture rograde and normograde insertion. Vet Surg 17:65, 1988.
hematoma and bone fragments for nonreducible fractures (Plate 72A).3 3. Aron DN, Palmer RH, Johnson AL: Biologic strategies and a bal-
Reduction: Reduce transverse and short oblique fractures by anced concept for repair of highly comminuted long bone fractures.
tenting the bone ends and levering the bone back into position. Reduce Compend Cont Educ Pract Vet 17:35, 1995.
long oblique fractures by distracting the bone segments and approxi- 4. Johnson AL, Smith CW, Schaeffer DJ: Fragment reconstruction and
mating the fracture surfaces. Use pointed reduction forceps to manipu- bone plate fixation compared with bridging plate fixation for
late the bone segments into reduction. Maintain the reduction manually treating highly comminuted femoral fractures in dogs: 35 cases
for transverse fractures and with pointed reduction forceps for oblique (19871997). J Am Vet Med Assoc 213:1157, 1998.
CHAPTER 72 A P P L I C AT I O N O F A P L AT E T O T H E F E M U R 191

P L AT E 7 2

Vastus
lateralis
muscle
retracted
Biceps femoris
muscle retracted
Shaft
of femur

Adductor magnus
Vastus muscle
intermedius
muscle
B

C D
192 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

FEMUR

CHAPTER 73Application of an External Fixator


to the Femur
INDICATIONS affected limb up. Drape the limb out from a hanging position to
Candidates include animals with single or comminuted femoral allow maximal manipulation during surgery. Prepare the ipsilat-
diaphyseal fractures. eral proximal humerus or ilial wing for harvesting a cancellous
bone graft.
OBJECTIVES
To achieve anatomic reduction of single fracture lines or PROCEDURE
restoration of normal bone alignment for comminuted Approach: Incise the skin and subcutaneous tissue on the
fractures lateral surface of the thigh, from the greater trochanter to the
The stiffness of the fixator can be increased for animals with femoral condyles. Incise the tensor fascia lata along the cranial
low fracture-assessment scores by adding fixation pins, incor- border of the biceps femoris to expose the vastus lateralis and
porating an intramedullary (IM) pin or using biplanar frames.1 biceps femoris muscles.2 Retract the muscles to expose the
The IM pin and fixator combination resists axial loading, femur (Plate 73A). Insert the IM pin into the proximal femur in
bending, and rotational forces at the fracture. either a normograde or retrograde manner. Use an open but do
not disturb the fragments technique to expose the proximal
ANATOMIC CONSIDERATIONS and distal bone segments with minimal disturbance of the frac-
The narrowest part of the medullary canal, the isthmus, is ture hematoma and bone fragments for nonreducible fractures.3
located within the proximal third of bone, just distal to the third Incise the skin, and create soft tissue tunnels to the bone for
trochanter. The distal femur has a pronounced cranial bow in fixator pin placement.
most dogs, but it is straight in the cat. Both anatomic features Reduction: Place an IM pin (sized to equal 60% to 70% of
constrain the size of IM pin selected. The trochanteric fossa is the medullary canal at the isthmus) in the proximal segment.
directly in line with the medullary canal, allowing normograde Retract the pin within the medullary canal of the proximal seg-
or retrograde placement of an IM pin. The adductor magnus ment. Reduce transverse and short oblique fractures by tenting
muscle attaches to the caudal surface of the femur and serves the bone ends and levering the bone back into position. Reduce
as a guide for rotational alignment. Additionally, the greater long oblique fractures by distracting the bone segments and
trochanter is 90 degrees to the patella when the femur is in approximating the fracture surfaces. Use pointed reduction for-
correct rotational alignment. The proximity of the abdomen ceps to manipulate the bone segments into reduction. Drive the
prohibits use of bilateral frames in the proximal femur. pin distally to seat in the femoral condyle. Maintain the reduc-
tion manually for transverse fractures and with pointed reduc-
EQUIPMENT tion forceps for oblique fractures. Reduce comminuted
Surgical pack, Senn retractors, small Hohmann retractors, nonreducible fractures by distracting the distal femur with the
Gelpi retractors, Myerding retractors, periosteal elevator, IM pin and aligning the major segments of the bone (see Plate
Kern bone-holding forceps, pointed reduction forceps, Jacob 73A). Be sure to restore length and normal rotational alignment
pin chuck, IM pins, low-speed power drill, external fixation to the bone.
equipment, pin cutter, bone curette for harvesting graft Continued

PREPARATION AND POSITIONING


Prepare the rear limb circumferentially from dorsal midline to
tarsus. Position the animal in lateral recumbency, with the
CHAPTER 73 A P P L I C AT I O N O F A N E X T E R N A L F I X AT O R T O T H E F E M U R 193

P L AT E 7 3

Vastus
lateralis
muscle
retracted
Biceps femoris
muscle retracted
Shaft
of femur

Adductor magnus
Vastus muscle
intermedius
muscle
A
194 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

Stabilization: Apply an IM pin and a type Ia external monitor healing. The fixator should be destabilized by removing
fixator to the lateral surface of the femur. Place fixation pins in the unilateral frame (from a type Ia and IM pin combination) or
the metaphysis of each segment and close to the fracture line. the cranial frame (from a modified type Ib fixator) when bone
The external fixator can be connected or tied in to the IM pin to bridging is observed. If a tie-in is used, the top fixation pin and
strengthen the fixation (Plate 73B).4 Apply a modified type Ib its connection to the IM pin should be retained. The IM pin, the
external fixator and an IM pin to a comminuted nonreducible remaining external fixator, or both should be removed when the
fracture.5 Place a cancellous bone autograft at the fracture site fracture has healed.
(Plate 73C). Long oblique fractures benefit from cerclage wire
or lag screw fixation in addition to the IM pin and external EXPECTED OUTCOME
fixator (Plate 73D). Bone healing is usually seen in 12 to 18 weeks, depending on
fracture and signalment of the animal. The animal will experi-
CAUTIONS ence limited function while the external fixator is in place but
It is important to avoid major nerves, vessels, and joint surfaces should eventually have a good return to function.
with the fixation pins and to avoid the distal joint surface with
the IM pin. The range of motion of the stifle should be palpated
to detect pin interference in the joint. Rotational alignment References
should be monitored during the realignment of comminuted
1. Johnson AL, Hulse DA: Fundamentals of orthopedic surgery and
fractures. fracture management: Decision making in fracture management. In
Fossum TW (ed): Small Animal Surgery, 2nd ed. St. Louis, Mosby,
POSTOPERATIVE EVALUATION 2002.
Radiographs should be evaluated for bone alignment and 2. Piermattei DL, Johnson KA: An Atlas of Surgical Approaches to the
implant placement. Rotational malalignments should be cor- Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
rected by loosening the clamps and realigning the fixation pins Saunders, 2004.
on the connecting bar. 3. Aron DN, Palmer RH, Johnson AL: Biologic strategies and a bal-
anced concept for repair of highly comminuted long bone fractures.
POSTOPERATIVE CARE Compend Cont Educ Pract Vet 17:35, 1995.
4. Aron DN, Dewey C: Experimental and clinical experience with an
Gauze sponges should be packed around the pins, and the
IM pin external skeletal fixator tie-in configuration. Vet Comp
sponges should be secured with a bandage. The animal should Orthop Traumatol 4:86, 1991.
be confined, with activity limited to leash walking. External 5. Aron DN: External skeletal fixation system application to the
fixator management includes daily pin care and pin packing as humerus and femur. In Proceedings of the 10th Annual Complete
needed. Physical therapy is needed to restore stifle range of Course in External Skeletal Fixation, University of Georgia,
motion. Radiographs should be repeated at 6-week intervals to 127141, 2002.
CHAPTER 73 A P P L I C AT I O N O F A N E X T E R N A L F I X AT O R T O T H E F E M U R 195

P L AT E 7 3

Cancellous
bone
autograft

C D
196 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

TIBIAL FRACTURES

CHAPTER 74 Proximal Tibial Physeal Fractures


and Tibial Tuberosity Fractures
INDICATIONS epiphysis across the physis, into the tibial metaphysis, and
Candidates include animals with Salter I and Salter II fractures through the medial cortex. Drive a second wire from the medial
of the proximal tibial physes. tibial epiphysis across the physis, into the metaphysis, and
through the lateral cortex. Bend the wires to prevent migration
OBJECTIVES and aid removal (Plate 74C).2
To achieve anatomic reduction of the proximal tibial physis Stabilization of an Avulsion of the Tibial Tuberosity:
and fracture stabilization Drive two Kirschner wires into the tuberosity and across the
physis to lodge in the proximal tibia. Check the repair to see if
ANATOMIC CONSIDERATIONS stabilization is sufficient to prevent avulsion of the fracture. If
The medial aspect of the proximal tibia is covered only with not, place a tension band wire by drilling a transverse hole in
skin, subcutaneous tissue, and crural fascia and can easily be the tibial crest and passing a figure-eight wire through the hole
palpated and approached. The saphenous artery vein and nerve and around the Kirschner wires. Tighten the wire (Plate 74D).
lies caudal to the medial surface of the proximal tibia. Most repairs require a tension band wire.1

EQUIPMENT CAUTIONS
Surgical pack, Senn retractors, Hohmann retractors, Gelpi It is important to avoid damaging the physeal cartilage during
retractors, periosteal elevator, pointed reduction forceps, reduction and to avoid penetrating the articular cartilage with
Kirschner wires or small Steinmann pins for large dogs, the Kirschner wires.
orthopedic wire, wire tightener, pin chuck or high-speed wire
driver, wire cutter or pin cutter POSTOPERATIVE EVALUATION
Radiographs should be evaluated for reduction and implant
PREPARATION AND POSITIONING placement.
Prepare the rear limb circumferentially from the hip to below
the hock. Position the animal in dorsal recumbency for greater POSTOPERATIVE CARE
flexibility. Drape the limb out from a hanging position to allow The animal should be confined, with activity limited to leash
maximal manipulation during surgery. A cancellous bone graft walking. Radiographs should be evaluated in 3 to 4 weeks. The
is unnecessary. tension band wire should be removed at 3 weeks to allow
physeal function. Additional implant removal may be required
PROCEDURE if soft tissue irritation occurs.
Approach: Incise the skin, subcutaneous tissue, and crural
fascia craniomedially from the distal femur to the proximal EXPECTED OUTCOME
diaphysis of the tibia to expose the fracture. Retract the skin Rapid bone healing is usually seen, but premature closure of
laterally to expose the lateral tibial epiphysis. Elevate the fascia the physis will probably occur. Premature closure of the
and muscle to expose both medial and lateral surfaces of the tibial tuberosity physis in a very young animal may affect stifle
fracture (Plate 74A).1 conformation.
Reduction: Reduce the proximal physeal fracture by
extending the stifle and gently levering the epiphysis into References
position. Maintain reduction using a pointed reduction forceps
1. Piermattei D, Flo GL: Brinker, Piermattei, and Flos Handbook of
(Plate 74B). Reduce the avulsed tibial tuberosity by extending Small Animal Orthopedics and Fracture Repair, 3rd ed. Philadelphia,
the limb and putting pressure on the tuberosity. Maintain WB Saunders, 1997.
reduction with a pointed reduction forceps (see Plate 74B). 2. Johnson AL, Hulse DA: Management of specific fractures: Tibia and
Stabilization of a Proximal Tibial Physeal Fracture: fibular physeal fractures. In Fossum TW (ed): Small Animal Surgery,
Drive a Kirschner wire from the lateral surface of the tibial 2nd ed. St. Louis, Mosby, 2002.
CHAPTER 74 P R OX I M A L T I B I A L P H Y S E A L A N D T I B I A L T U B E R O S I T Y F R A C T U R E S 197

P L AT E 7 4

Patellar
ligament

A
Cranial tibial
muscle or

D
198 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

TIBIAL FRACTURES

CHAPTER 75 Distal Tibial Physeal Fractures


INDICATIONS reduction with pointed reduction forceps or with manual
Candidates include animals with Salter I and Salter II fractures pressure.
of the distal tibial physis. Stabilization with Crossed Kirschner Wires: Drive
a Kirschner wire from the medial malleolus, across the physis,
OBJECTIVES into the tibial metaphysis, and through the lateral cortex (Plate
To achieve anatomic reduction of the distal tibial physis and 75B). Drive a second wire from the medial aspect of the distal
fracture stabilization tibial metaphysis, across the fracture into the epiphysis, while
avoiding the articular surface (Plate 75C). Alternatively, drive
ANATOMIC CONSIDERATIONS the second wire from the lateral aspect of the tibial epiphysis or
The medial malleolus of the distal tibia and the lateral malleolus the fibular malleolus into the tibia.3 In larger dogs, the second
of the fibula extend distal to the articulating surfaces of the wire may driven from the fibular malleolus across the fibular
distal tibia and talus. The long and short parts of the medial fracture and into the proximal segment of the fibula (Plate 75D).
collateral ligaments arise from the medial malleolus of the tibia.
The long and short parts of the lateral collateral ligaments arise CAUTIONS
from the lateral malleolus of the fibula. These ligaments are It is important to avoid damaging either the physeal cartilage or
essential for hock stability. Tendons of the cranial tibial and articular cartilage.
long digital extensor muscles cross the cranial surface of
the distal tibia. The medial saphenous vein crosses the medial POSTOPERATIVE EVALUATION
surface of the distal tibia. Radiographs should be evaluated for reduction and implant
placement.
EQUIPMENT
Surgical pack, Senn retractors, Hohmann retractors, Gelpi POSTOPERATIVE CARE
retractors, periosteal elevator, pointed reduction forceps, A lateral splint should be used to support the fixation.2 The
Kirschner wires (or small Steinmann pins for large dogs), pin animal should be confined, with activity limited to leash
chuck or high-speed wire driver, wire cutter or pin cutter walking. Radiographs should be evaluated in 4 weeks. Implant
removal may be required if soft tissue irritation occurs.
PREPARATION AND POSITIONING
Prepare the rear limb circumferentially from hip to below the EXPECTED OUTCOME
hock. Position the animal in lateral recumbency, with the affected Rapid bone healing is usually seen, but premature closure of the
limb up or in dorsal recumbency for greater flexibility. Drape physis will probably occur.
the limb out from a hanging position to allow maximal manipu-
lation during surgery. A cancellous bone graft is unnecessary.
References
PROCEDURE 1. Piermattei DL, Johnson KA: An Atlas of Surgical Approaches to the
Approach: Incise the skin and subcutaneous tissue on the Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
Saunders, 2004.
cranial medial surface from the distal diaphysis to the tarsus to
2. Piermattei D, Flo GL: Brinker, Piermattei, and Flos Handbook of
expose the medial surface of the fracture (Plate 75A).1 Alterna- Small Animal Orthopedics and Fracture Repair, 3rd ed. Philadelphia,
tively, make a cranial skin incision and retract the extensor ten- WB Saunders, 1997.
dons. This approach allows visualization of the fibula.2 3. Johnson AL, Hulse DA: Management of specific fractures: Tibia and
Reduction: Carefully reduce the physeal fracture in order fibular physeal fractures. In Fossum TW (ed): Small Animal Surgery,
to avoid crushing or injuring the physeal cartilage. Maintain 2nd ed. St. Louis, Mosby, 2002.
CHAPTER 75 D I S TA L T I B I A L P H Y S E A L F R A C T U R E S 199

P L AT E 7 5

A
Tendon of
cranial tibial
muscle
Tendon of
caudal tibial Medial
muscle collateral
ligament

or

C D
200 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

TIBIAL FRACTURES

CHAPTER 76 Malleolar Fractures


INDICATIONS wires, and tighten it. Drill a transverse hole in the fibula prox-
Candidates include animals with transverse or oblique medial imal to the fracture, and pass a figure-eight wire through the
or lateral malleolar fractures. hole. Drive a Kirschner wire into the lateral malleolar fragment,
across the fracture line, and proximally into the fibula. Pass the
OBJECTIVES figure-eight wire around the Kirschner wire and tighten it (Plate
To achieve anatomic reduction of the malleoli and distal tibial 76C). Alternatively, if the fibula is too small to pass a Kirschner
articular surface, convert the tensile forces resulting from the wire proximally, drive the Kirschner wire through the lateral
pull of the collateral ligaments to compressive forces at the malleolar fragment and into the tibia.
fracture, and stabilize the tarsus To apply the lag screw, drill a gliding hole (equal to the
diameter of the threads on the screw) in the medial malleolar
ANATOMIC CONSIDERATIONS fragment. Place a drill sleeve into the gliding hole, reduce the
Tendons of the cranial tibial and long digital extensor muscles fracture, and drill a smaller hole (equal to the core diameter of
cross the cranial surface of the distal tibia. The medial saphe- the screw) across the tibia. Measure, tap, select, and place a
nous vein crosses the medial surface of the distal tibia. The long screw of the appropriate length. Compression of the fracture
and short parts of the medial collateral ligaments arise from the should occur (Plate 76D). To stabilize the fibular malleolus with
medial malleolus of the tibia. The long and short parts of the a screw, treat the fibular malleolus as the fragment by drilling
lateral collateral ligaments arise from the lateral malleolus of the gliding hole through the fibula and the tapped hole in the
the fibula. These ligaments are essential for hock stability. The tibia (Plate 76E).2
medial malleolus of the distal tibia and the lateral malleolus of
the fibula extend distal to the articulating surfaces of the distal CAUTIONS
tibia and talus. Articular reduction should be maintained during implant
application. It is important to take care when manipulating
EQUIPMENT and drilling the small malleolar fragments to avoid further
Surgical pack, Senn retractors, Hohmann retractors, Gelpi fragmentation.
retractors, periosteal elevator, pointed reduction forceps,
Kirschner wires, orthopedic wire, wire tightener, wire cutter, POSTOPERATIVE EVALUATION
bone screws and the instruments for screw insertion, high- Radiographs should be evaluated for articular surface reduction
speed wire driver or drill and implant placement.

PREPARATION AND POSITIONING POSTOPERATIVE CARE


Prepare the rear limb circumferentially from hip to below the The animal should be confined, with activity limited to leash
hock. Position the animal in dorsal recumbency. Drape the limb walking. A bivalve cast should be used to externally support the
out from a hanging position to allow maximal manipulation tarsus for 4 to 6 weeks.3 The cast should be destabilized as
during surgery. A cancellous bone graft is unnecessary. healing progresses by eliminating the cranial part of the case.
Radiographs should be repeated at 6-week intervals.
PROCEDURE
Approach: Incise the skin and subcutaneous tissue on the EXPECTED OUTCOME
cranial medial surface from the distal diaphysis to the tarsus to Bone healing is usually seen in 6 to 12 weeks with animals expe-
expose the medial malleolus (Plate 76A).1 Approach the lateral riencing a good return to function. Degenerative joint disease
malleolus via a lateral skin incision over the malleolus, and use may result from articular trauma, with the severity depending
blunt and sharp dissection of surrounding tissues to expose the on accuracy and maintenance of reduction. Implant removal
fracture (Plate 76B).1 may be necessary if soft tissues are irritated.
Reduction: Reduce the fracture (i.e., medial malleolus of
the tibia or lateral malleolus of the fibula) by securing the References
fragment with small or mini pointed reduction forceps and 1. Piermattei DL, Johnson KA: An Atlas of Surgical Approaches to the
placing it into alignment. In some cases, the fragment may be Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
Saunders, 2004.
secured with pointed reduction forceps; in other cases, manual
2. Johnson AL, Hulse DA: Management of specific fractures: Tibia and
maintenance of reduction is necessary. fibular metaphyseal and epiphyseal fractures. In Fossum TW (ed):
Stabilization: Start two Kirschner wires in the medial Small Animal Surgery, 2nd ed. St. Louis, Mosby, 2002.
malleolar fragment. Drive the wires across the fracture line to 3. Piermattei D, Flo GL: Brinker, Piermattei, and Flos Handbook of
lodge in the tibia. Place a transverse drill hole in the tibia, pass Small Animal Orthopedics and Fracture Repair, 3rd ed. Philadelphia,
a figure-eight wire through the hole and around the Kirschner WB Saunders, 1997.
CHAPTER 76 MALLEOLAR FRACTURES 201

P L AT E 7 6

Tendon of
lateral extensor
A B digital muscle
Tendon of
peroneus
brevis muscle
Tendon of
flexor hallucis
longus muscle

Saphenous
vein
Tendon of
cranial tibial Fibula
muscle
Caudal
Tendon of
Medial branch of
caudal tibial Lateral
collateral lateral
muscle extensor
ligament saphenous
retinaculum artery and vein
Tendon of
peroneus
longus muscle
Tendon of
lateral extensor
digital muscle

C D E
202 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

TIBIAL FRACTURES

CHAPTER 77 Application of an Intramedullary


Pin or Interlocking Nail to the Tibia
INDICATIONS tracting the bone segments and approximating the fracture surfaces.
Candidates include animals with single or comminuted tibial diaphyseal Use pointed reduction forceps to manipulate the bone segments into
fractures. reduction. Maintain the reduction manually for transverse fractures and
with pointed reduction forceps for oblique fractures. Reduce commin-
OBJECTIVES uted nonreducible fractures by distracting the distal bone end with the
To achieve anatomic reduction of single fracture lines or restoration IM pin or ILN and aligning the major segments of the bone.
of normal bone alignment for nonreducible comminuted fractures Stabilization: Apply an IM pin and type Ia external fixator to
The intramedullary (IM) pin is used in animals with high fracture- the cranial medial surface of the tibia to stabilize a transverse fracture
assessment scores.1 The IM pin neutralizes bending forces at the frac- (see Plate 77B). The IM pin should be smaller (5060% of the medullary
ture, and is combined with cerclage wire for long oblique fractures and canal) to accommodate the fixation pins within the medullary canal.
with external fixation for transverse or short oblique fractures to neu- Place fixation pins in the metaphysis of each segment and about 1 cm
tralize rotational and axial compressive forces. The interlocking nail on either side of the fracture line. Apply an IM pin and cerclage wire to
(ILN) neutralizes bending, rotational, and axial compressive forces at a long oblique fracture (Plate 77C). Apply an ILN and four screws to the
the fracture; it can be used for animals with medium and low fracture- tibia for treatment of comminuted nonreducible fractures (Plate 77D).4
assessment scores.1
CAUTIONS
ANATOMIC CONSIDERATIONS It is important to avoid the joint surfaces with the IM pin or ILN. The
The tibia has a pronounced S-shaped curve in most dogs. The proximal range of motion of the hock should be palpated to detect pin interfer-
and distal tibial articular surfaces cover the ends of the long bone, ence in the joint. Rotational alignment should be monitored during the
leaving little nonarticular surface to introduce an IM pin or ILN. The realignment of comminuted fractures.
cranial branch of the medial saphenous artery and vein and the saphe-
nous nerve cross the medial aspect of the tibia. The medial and lateral POSTOPERATIVE EVALUATION
malleoli extend distally to the distal tibial articular surface. Radiographs should be evaluated for fracture reduction or bone align-
ment and implant placement.
EQUIPMENT
Surgical pack, Senn retractors, Gelpi retractors, Hohmann retractors, POSTOPERATIVE CARE
periosteal elevator, pointed reduction forceps, Kern bone-holding The animal should be confined, with activity limited to leash walking.
forceps, Jacob pin chuck, IM pins, cerclage wire, wire tightener, wire External fixator management includes daily pin care and pin packing as
cutter, external fixator clamps and connecting bars (or ILN equip- needed. Radiographs should be repeated at 6-week intervals. Fixator
ment, including high-speed drill), bone curette for harvesting cancel- pins should be removed after radiographic signs of bone bridging are
lous graft observed. Radiographs should continue at 6-week intervals until the
fracture has healed. The IM pin should be removed when the fracture
PREPARATION AND POSITIONING has healed.
Prepare the rear limb circumferentially from mid-femur to the pha-
langes. Position the animal in dorsal recumbency. Drape the limb out EXPECTED OUTCOME
from a hanging position. Roll the animal slightly to access the medial Bone healing is usually seen in 12 to 18 weeks, depending on fracture
aspect of the limb. The ipsi-lateral proximal humerus serves as a can- and signalment of the animal.
cellous bone graft donor site.

PROCEDURE
Approach: Insert the IM pin or the ILN from a point on the proximal References
medial tibial plateau midway between the tibial tuberosity and the 1. Johnson AL, Hulse DA: Fundamentals of orthopedic surgery
medial tibial condyle (Plate 77A).2 Perform a limited medial approach and fracture management, decision making in fracture management.
through the skin and subcutaneous tissue to the fracture site for In Fossum TW (ed): Small Animal Surgery, 2nd ed. St. Louis,
reducible fractures (see Plate 77A).3 Use an open but do not disturb the Mosby, 2002.
fragments technique to expose the proximal and distal bone segments 2. Johnson AL, Hulse DA: Management of specific fractures: Tibial and
with minimal disturbance of the fracture hematoma and bone frag- fibular diaphyseal fractures. In Fossum TW (ed): Small Animal
ments for nonreducible fractures. Incise the skin, and create soft tissue Surgery, 2nd ed. St. Louis, Mosby, 2002.
tunnels to the bone for fixator pin placement (Plate 77B). 3. Piermattei DL, Johnson KA: An Atlas of Surgical Approaches to the
Reduction: Place an IM pin (sized to equal 60% to 70% of the Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
medullary canal at the isthmus) in the proximal segment.2 Retract the Saunders, 2004.
pin within the medullary canal of the proximal segment. Reduce trans- 4. Dueland RT, Johnson KA, Roe SC, et al: Interlocking nail treatment
verse and short oblique fractures by tenting the bone ends and levering of diaphyseal long bone fractures in dogs. J Am Vet Med Assoc
the bone back into position. Reduce long oblique fractures by dis- 214:59, 1999.
CHAPTER 77 A P P L I C AT I O N O F A N I M P I N O R I N T E R L O C K I N G N A I L T O T H E T I B I A 203

P L AT E 7 7

M L

Shaft of the tibia

Cranial branch
of medial saphenous B
artery and vein

Saphenous nerve

C D
204 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

TIBIAL FRACTURES

CHAPTER 78 Application of a Plate to the Tibia


INDICATIONS with pointed reduction forceps for oblique fractures. Reduce com-
Candidates include animals with single or comminuted tibial minuted nonreducible fractures by distracting and aligning the
diaphyseal fractures. major segments of the bone. An intramedullary pin can be used to
obtain axial alignment and distraction of the distal segment. Be
OBJECTIVES sure to restore length and normal rotational alignment to the
To achieve anatomic reduction and compression of single bone. Precontour the plate to the cranial caudal radiographic view
fracture lines or restoration of normal bone alignment for of the contralateral tibia to prevent angular deformities.
nonreducible comminuted fractures Stabilization: Apply an appropriately contoured plate to
The plate is used as a compression plate for transverse or the medial surface of the tibia. The plate can function as a
short oblique fractures, and it is combined with lag screws to compression plate (Plate 78B) when used to compress trans-
compress long oblique fractures. The plate is used as a bridging verse or short oblique fractures; as a neutralization plate to sup-
plate for nonreducible comminuted fractures and may be com- port a reconstructed fracture (Plate 78C); or as a bridging plate,
bined with an intramedullary pin to reduce strain on the plate with or without an intramedullary pin, spanning a nonreducible
and to extend fatique life of the fixation. The plate neutralizes comminuted fracture (Plate 78D).4
bending, rotational, and axial compressive forces.
CAUTIONS
ANATOMIC CONSIDERATIONS In immature dogs, it is important to avoid crossing the distal
Plates are generally placed on the medial surface of the tibia. tibial physis with the plate or screws. It is also important to
The tibia has an S-shaped curve that must be reproduced when avoid the distal articular surface. Careful attention must be paid
contouring the plate. The cranial branch of the medial saphe- to bony anatomic landmarks to avoid rotation of the distal
nous artery and vein and the saphenous nerve cross the medial segment. Failure to contour the plate to the normal S shape
aspect of the tibia. The medial malleolus extends distally to the of the tibia will result in a valgus angulation of the limb.
distal tibial articular surface. Monocortical screws may be necessary to avoid interference
with the intramedullary pin.
EQUIPMENT
Surgical pack, Senn retractors, Gelpi retractors, Hohmann POSTOPERATIVE EVALUATION
retractors, periosteal elevator, pointed reduction forceps, Radiographs should be evaluated for fracture reduction or bone
self-centering plate-holding forceps, high-speed drill, plating alignment and implant placement.
equipment, bone curette for cancellous bone harvest
POSTOPERATIVE CARE
PREPARATION AND POSITIONING The animal should be confined, with activity limited to leash
Prepare the rear limb circumferentially from mid-femur to the walking. Radiographs should be repeated at 6-week intervals
phalanges. Position the animal in dorsal recumbency. Drape the until the fracture has healed.
limb out from a hanging position. Roll the animal slightly
to allow access to the medial side of the bone. The ipsilateral EXPECTED OUTCOME
proximal humerus serves as a cancellous bone graft donor site. Bone healing is usually seen in 12 to 18 weeks, depending on
fracture and signalment of the animal. Plate removal may be
PROCEDURE necessary after the fracture heals if soft tissue irritation or cold
Approach: Incise the skin and subcutaneous tissue on the sensitivity occurs.
craniomedial surface of the tibia. Incise the crural fascia, and
retract the cranial tibial muscle cranially and the flexor muscles References
caudally to expose the medial surface of the tibia (Plate 78A).2 1. Johnson AL, Hulse DA: Fundamentals of orthopedic surgery and
Use an open but do not disturb the fragments technique to fracture management, plates and screws. In Fossum TW (ed): Small
expose the proximal and distal bone segments with minimal Animal Surgery, 2nd ed. St. Louis, Mosby, 2002.
disturbance of the fracture hematoma and bone fragments for 2. Piermattei DL, Johnson KA: An Atlas of Surgical Approaches to the
nonreducible fractures.3 Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
Saunders, 2004.
Reduction: Reduce transverse and short oblique fractures
3. Aron DN, Palmer RH, Johnson AL: Biologic strategies and a bal-
by tenting the bone ends medially and levering the bone back into anced concept for repair of highly comminuted long bone fractures.
position. Reduce long oblique fractures by distracting the bone Compend Cont Educ Pract Vet 17:35, 1995.
segments and approximating the fracture surfaces. Use pointed 4. Houlton JEF: Fractures of the tibia. In Brinker WO, Olmstead ML,
reduction forceps to manipulate the bone segments into reduc- Sumner-Smith G, et al (eds): Manual of Internal Fixation in Small
tion. Maintain the reduction manually for transverse fractures and Animals. New York, Springer-Verlag, 1998.
CHAPTER 78 A P P L I C AT I O N O F A P L AT E T O T H E T I B I A 205

P L AT E 7 8

Shaft of the tibia

Cranial branch
of medial saphenous
artery and vein

Saphenous nerve

C D
206 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

TIBIAL FRACTURES

CHAPTER 79 Application of an External Fixator


to the Tibia
INDICATIONS power drill, external fixation equipment, pin cutter, bone
Candidates include animals with single or comminuted tibial curette for harvesting cancellous graft
diaphyseal fractures.
PREPARATION AND POSITIONING
OBJECTIVES Prepare the affected rear limb circumferentially from midline to
To achieve anatomic reduction of single fracture lines or foot. Position the animal in dorsal recumbency, and suspend the
restoration of normal bone alignment for comminuted affected limb from the ceiling.2 Drape the limb out in the
fractures hanging position. Prepare the ipsilateral proximal humerus for
The stiffness of the fixator can be increased in animals with cancellous bone autograft harvest if open reduction is used.
low fracture-assessment scores by adding fixation pins and by
using biplanar or bilateral frames.1 The fracture and fixator PROCEDURE
combination, or the fixator alone, resists axial loading, bending, Approach: Perform a limited medial approach to the fracture
and rotational forces at the fracture. site for reducible fractures (Plate 79A).3 Use closed reduction
techniques for nonreducible fractures (Plate 79B).4 Incise the
ANATOMIC CONSIDERATIONS skin, and create soft tissue tunnels to the bone for pin placement.
The tibia has a triangular cross section in the proximal third, Reduction: Lower the table to allow the animals weight to
with a round cross section over the rest of the bone. The prox- fatigue the muscles. For single fracture lines, lever the frag-
imal tibial joint surface parallels the distal tibial joint surface. ments into position through the limited surgical approach (see
The medial aspect of the tibia is covered only by skin and sub- Plate 79A). Maintain the reduction manually for transverse frac-
cutaneous tissue. The saphenous artery vein and nerve spiral tures and with reduction forceps for oblique fractures. For
across the medial surface of the mid-diaphysis. In general, closed reduction of comminuted fractures, manipulate the
fixation pins can be applied on the medial, cranial medial, cra- proximal and distal fixation pins to align the joint surfaces.
nial lateral, and lateral surfaces of the bone. Medial and lateral angular alignment is correct when the
proximal and distal joint surfaces are parallel (see Plate 79B).
EQUIPMENT Make sure that cranial caudal joint surfaces are also parallel.
Surgical pack, Senn retractors, small Hohmann retractors, Check rotational alignment by flexing the stifle and hock after
Gelpi retractors, periosteal elevator, Kern bone-holding for- raising the table: the paw should align with the tibia. Maintain
ceps, pointed reduction forceps, Jacob pin chuck, low-speed reduction by securing the connecting bars (see Plate 79B).
Continued
CHAPTER 79 A P P L I C AT I O N O F A N E X T E R N A L F I X AT O R T O T H E T I B I A 207

P L AT E 7 9

B
208 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

Stabilization: Apply a type Ia external fixator to the with a bandage that also incorporates the paw. The animal
cranial medial surface of the tibia (Plate 79C). Place fixation should be confined, with activity limited to leash walking.
pins in the metaphysis of each segment and about 1 cm from External fixator management includes daily pin care and pin
either side of the fracture line. At least two (and preferably packing, as needed. Radiographs should be repeated at 6-week
three) fixation pins are placed in each bone segment. Use posi- intervals to evaluate healing. When bone bridging is observed,
tive profile end-threaded pins to increase pin bone interface sta- the fixator should be destabilized by removing one unilateral
bility. Apply a type Ib frame by placing a unilateral frame on the frame (type Ib fixator), selected fixation pins (type Ia or type II
cranial medial surface of the tibia and an additional fixator), or the lateral connecting bar of the type II fixator. The
unilateral frame on the cranial lateral surface of the tibia (Plate external fixator should be removed when the fracture is healed.
79D) Connect the biplanar frames with articulating bars. Apply
a type II frame by inserting transfixation pins through the meta- EXPECTED OUTCOME
physes and additional fixation pins about 1 cm from either side Bone healing is usually seen in 12 to 18 weeks, depending on
of the fracture. Place additional pins when there is adequate fracture and signalment of the animal. Animals may experience
bone (Plate 79E). Long oblique fractures benefit from cerclage limited function while the external fixator is in place, but good
wire or lag screw fixation in addition to the external fixator (see return to function generally occurs after the fixator is removed.
Plate 79D).5

CAUTIONS References
It is important to avoid major nerves, vessels, and joint surfaces
1. Johnson AL, Hulse DA: Fundamentals of orthopedic surgery and
with the fixation pins and to avoid the tibial crest when fracture management: Decision making in fracture management. In
inserting fixation pins. Angular and rotational alignment should Fossum TW (ed): Small Animal Surgery, 2nd ed. St. Louis, Mosby,
be monitored during the reduction. Intraoperative radiographs 2002.
are useful to verify joint alignment during closed reductions. 2. Aron DN, Palmer RH, Johnson AL: Biologic strategies and a bal-
anced concept for repair of highly comminuted long bone fractures.
POSTOPERATIVE EVALUATION Compend Cont Educ Pract Vet 17:35, 1995.
Radiographs should be evaluated for fracture reduction or bone 3. Piermattei DL, Johnson KA: An Atlas of Surgical Approaches to the
alignment and implant placement. Angular malalignments Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
should be corrected by loosening the clamps on the pins Saunders, 2004.
4. Johnson AL, Seitz SE, Smith CW, et al: Closed reduction and type II
through the distal segment and repositioning the clamps
external fixation of severely comminuted fractures of the radius and
attaching the fixation pins to the connecting bar. tibia in dogs: 23 cases (19901994). J Am Vet Med Assoc 209:1445,
1996.
POSTOPERATIVE CARE 5. Johnson AL, Hulse DA: Fundamentals of orthopedic surgery and
To limit postoperative swelling, gauze sponges should be fracture management, external skeletal fixators. In Fossum TW (ed):
packed around the pins, and the sponges should be secured Small Animal Surgery, 2nd ed. St. Louis, Mosby, 2002.
CHAPTER 79 A P P L I C AT I O N O F A N E X T E R N A L F I X AT O R T O T H E T I B I A 209

P L AT E 7 9

C D E
210 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

C A R P U S / TA R S U S

CHAPTER 80 Radial Carpal Bone Fractures


INDICATIONS fractures. Reduce large fragments, and maintain reduction with
Candidates include animals with transverse or short oblique pointed reduction forceps or Velsellum forceps.
fractures of the radial carpal bone. Dogs with radial carpal bone Stabilization: Stabilize dorsal slab fractures with one or
fractures may present with chronic lameness; these conditions two small lag screws (Plate 80B).3 Countersink the proximal
are more appropriately treated with carpal arthrodesis.1 fragment so that the screw heads lie beneath the articular
surface. Stabilize oblique fractures through the body of the
OBJECTIVES radial carpal bone with a lag screw (Plate 80C). Place the head
To achieve anatomic reduction of the articular surface of the screw through the insertion of the radial collateral liga-
and rigid fixation of the fracture to promote function and ment to avoid interfering with the joint motion.3
minimize degenerative changes
CAUTIONS
ANATOMIC CONSIDERATIONS It is important to avoid articular surfaces with implants.
The carpus is composed of the proximal (radial, ulnar, and
accessory) and distal rows (II, III, and IV) of carpal bones. The POSTOPERATIVE EVALUATION
radial carpal bone articulates primarily with the radius and Radiographs should be evaluated for bone alignment and
serves as the major weight-bearing area in the joint. It is the implant placement.
most common carpal bone fractured in companion animals.
POSTOPERATIVE CARE
EQUIPMENT A soft, padded bandage should be placed to control bleeding
Surgical pack, Senn retractors, Gelpi retractors, Hohmann and swelling. A splint should be used for 3 weeks. The animal
retractors, periosteal elevator, pointed reduction forceps, should be confined, with activity limited to leash walks until
Velsellum forceps, high-speed drill, bone screws and equip- bone healing is complete. Radiographs should be repeated at
ment for inserting bone screws 6-week intervals until fracture healing is observed.

PREPARATION AND POSITIONING EXPECTED OUTCOME


Prepare the forelimb circumferentially from elbow to digits. Bone healing is usually seen in 12 to 18 weeks, depending
Position the animal in dorsal recumbency for greater flexibility. on fracture and signalment of the animal. Degenerative
Drape the limb out from a hanging position to allow maximal joint disease and limited range of motion of the carpus may
manipulation during surgery. A cancellous bone graft is not occur.1,4
generally used.

PROCEDURE
Approach: An Esmarch bandage or tourniquet may be used References
to control bleeding. Incise the skin and subcutaneous tissue 1. Tomlin JL, Pead MJ, Langley-Hobbs SJ, et al: Radial carpal bone
mid-dorsally, beginning 3 cm to 4 cm proximal to the radio- fractures in dogs. J Am Anim Hosp Assoc 37:173, 2001.
carpal joint and extending distally to the mid-metacarpus. 2. Piermattei DL, Johnson KA: An Atlas of Surgical Approaches to the
Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
Continue deep dissection between the extensor carpi radialis
Saunders, 2004.
tendon and the common digital extensor tendon to expose the 3. Piermattei DL, Flo GL: Fractures of the pelvis. In Brinker,
joint capsule. Retract the tendons, and incise the joint capsule Piermattei, and Flos Handbook of Small Animal Orthopedics and
to expose the radial carpal bone (Plate 80A).2 Fracture Repair, 3rd ed. Philadelphia, WB Saunders, 1997.
Reduction: Remove fragments that are too small to 4. Li A, Bennet D, Gibbs C, et al: Radial carpal bone fractures in 15
handle and fragments that are associated with chronic dogs. J Small Anim Pract 41:74, 2000.
CHAPTER 80 R A D I A L C A R PA L B O N E F R A C T U R E S 211

P L AT E 8 0

Abductor pollicis
longus muscle
Radial Radius
carpal bone

Tendon of common
Tendon of extensor
digital extensor tendon
carpi radialis muscle

Palmar Dorsal

Short radial
collateral
ligament
212 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

C A R P U S / TA R S U S

CHAPTER 81 Tarsal Fractures


INDICATIONS pointed reduction forceps, holding the talar body to the cal-
Candidates include animals with transverse or short oblique caneus.
fractures of the calcaneus or the neck of the talus. Stabilization: For calcaneal fractures, drill a transverse
hole in the proximal segment and in the distal segment. Place a
OBJECTIVES wire through the proximal hole. Place two Kirschner wires
To achieve anatomic reduction and rigid fixation of the through the proximal bone segment, exiting at the fracture. It
fracture to promote function and minimize degenerative may be necessary to pre-drill the bone for the Kirschner wires.
changes and to convert tension forces to compressive forces Reduce the fracture, and drive the Kirschner wires distally.
in calcaneal fractures Retract the wires, cut, and countersink them into the calcaneus.
Secure the tension band wire (Plate 81C).2 For a talar neck frac-
ANATOMIC CONSIDERATIONS ture, angle a lag screw from the caudal medial surface of the
The calcaneus articulates with the talus to form a stable joint. head of the talus into the trochlea of the talus (Plate 81D). Drill
Proximally, the Achilles tendon inserts on the tuber calcanei. the glide hole from inside out before reducing the fracture
The medial and lateral trochleas of the talus articulate proxi- to center the hole and ensure purchase in the trochlea.
mally with the tibia and fibula, and the body articulates distally Alternatively, place a screw from the craniomedial surface of
with the central tarsal bone. the base of the talus into the calcaneus. If the reduction can be
maintained with forceps, the screw may be placed as a position
EQUIPMENT screw; otherwise, it may be placed as a lag screw (Plate 81E).2
Surgical pack, Senn retractors, Hohmann retractors, Gelpi
retractors, periosteal elevator, pointed reduction forceps, CAUTIONS
Kirschner wires, orthopedic wire, wire tighteners, wire It is important to avoid placing implants where they will
cutter, high-speed drill and wire driver, bone screws and interfere with articular surfaces.
instruments for inserting bone screws
POSTOPERATIVE EVALUATION
PREPARATION AND POSITIONING Radiographs should be evaluated for bone alignment and
Prepare the rear limb circumferentially from hip to digits. implant placement.
Position the animal in lateral recumbency for calcaneal frac-
tures and in dorsal recumbency for greater flexibility with talar POSTOPERATIVE CARE
fractures. Drape the limb out from a hanging position to allow A soft padded bandage should be placed to control bleeding and
maximal manipulation during surgery. A cancellous bone graft swelling. A splint should be used for 3 weeks. The animal
is unnecessary. should be confined, with activity limited to leash walks, until
bone healing is complete. Radiographs should be repeated at
PROCEDURE 6-week intervals until fracture healing is observed. If soft tissue
Approach: For calcaneal fractures, incise the skin, subcuta- irritation occurs, the orthopedic wire used in the tension band
neous tissue, and deep crural fascia along the lateral surface should be removed after bone healing.
of the calcaneus from just proximal to the tuber calcanei dis-
tally to the tarsometatarsal joint. Incise parallel to the lateral EXPECTED OUTCOME
aspect of the superficial digital flexor tendon, and retract the Bone healing is usually seen in 12 to 18 weeks, depending on
tendon medially to expose the caudal surface of the calcaneus the fracture and signalment of the animal. Degenerative joint
(Plate 81A).1 For talar fractures, incise the skin, subcutaneous disease and limited range of motion of the hock may occur.
tissue, and deep fascia from the medial malleolus to the
tarsometatarsal joint. Elevate the fascia to expose the bones
References
(Plate 81B).1
1. Piermattei DL, Johnson KA: An Atlas of Surgical Approaches to the
Reduction: For the calcaneal fracture, reduce the prox-
Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
imal segment by extending the hock and manipulating the frag- Saunders, 2004.
ment with pointed reduction forceps. Maintain the reduction by 2. Piermattei DL, Flo GL: Fractures and other orthopedic injuries of
driving the Kirschner wires. For the talar neck fracture, reduce the tarsus, metatarsus and phalanges. In Brinker, Piermattei, and
the distal fragment by manipulating the fragment with the Flos Handbook of Small Animal Orthopedics and Fracture Repair,
pointed reduction forceps. Maintain reduction manually or with 3rd ed. Philadelphia, WB Saunders, 1997.
CHAPTER 81 TA R S A L F R A C T U R E S 213

P L AT E 8 1

A B
Lateral Medial
Tendon of
flexor hallucis
longus muscle

Tendon of
gastrocnemius
muscle
Calcaneus

Tendon of superficial
flexor muscle Talus

Tendon of
abductor digiti
quinti muscle

C D

E
214 PA RT T W O SURGICAL PROCEDURES FOR FRACTURES

M E TA C A R PA L B O N E S , M E TATA R S A L B O N E S , A N D D I G I T S

Fractures of the Metacarpal


CHAPTER 82

and Metatarsal Bones


INDICATIONS mally across the fracture line to seat in the proximal bone seg-
Candidates include animals with multiple unstable fractures of ment. Bend the distal end of the pin to prevent migration and to
the metacarpal and metatarsal bones. simplify removal. Repeat the procedure for at least the third and
fourth metacarpal or metatarsal bones (Plate 82C).2
OBJECTIVES For older and larger dogs, or animals with expected athletic
To realign the bones and stabilize the fractures function, use plates or screws (or both) to achieve fracture
stability.3 Stabilize oblique or avulsion fractures with lag screws
ANATOMIC CONSIDERATIONS (Plate 82D, 1). A plate may be used with the lag screws to sup-
The primary weight-bearing bones are the third and fourth port the repair. Stabilize distal metaphyseal transverse fractures
digits. The superficial dorsal metacarpal or metatarsal artery with a veterinary T plate (see Plate 82D, 2). Bridge comminuted
courses over the dorsal aspect of the paw. The extensor ten- fractures with a dynamic compression plate or veterinary
dons course down the dorsal aspect of each digit. The flexor cuttable plate (see Plate 82D, 3). Stabilize mid-diaphyseal
tendons and superficial and deep metacarpal or metatarsal transverse fractures with a dynamic compression plate (see
artery and vein lie on the palmar or plantar aspect of the digits. Plate 82D, 4).
There is minimal soft tissue coverage, and the bones and joints
can be easily palpated. CAUTIONS
It is important to avoid placing intramedullary pins where they
EQUIPMENT will interfere with the joints. The extensor tendons should be
Surgical pack, Senn retractors, small Hohmann retractors, protected.
mini pointed reduction forceps, Kirschner wires or small
Steinmann pins, high-speed drill and burr, pin chuck, pin POSTOPERATIVE EVALUATION
cutters, plating equipment, bone curette for harvesting can- Radiographs should be evaluated for fracture reduction and
cellous bone implant placement.

PREPARATION AND POSITIONING POSTOPERATIVE CARE


Prepare the distal limb circumferentially from elbow or stifle to The fixation should be protected with a splint or cast for 4 to
the digits. Position the animal in dorsal recumbency for greater 6 weeks. The animal should be confined, with activity limit-
flexibility. Drape the limb out from a hanging position to allow ed to leash walking, until the fracture has healed. Radiographs
maximal manipulation during surgery. Prepare the proximal should be repeated at 6-week intervals until the fracture has
humerus or proximal tibia as a donor site for cancellous bone healed.
harvest.
EXPECTED OUTCOME
PROCEDURE Bone healing is usually seen in 12 to 18 weeks. The animal
Approach: Incise the skin and subcutaneous tissue on the should experience a good return to function if anatomic recon-
dorsal surface of the paw, either on the midline (for fractures of struction is achieved and maintained.4
the third and fourth bones) or directly over the fractured bone.
Retract the extensor tendons and ligaments of the dorsal
surface of the paw to expose the fractures (Plate 82A).1 References
Reduction: Lever transverse fractures into position. 1. Piermattei DL, Johnson KA: An Atlas of Surgical Approaches to the
Maintain reduction with the implants. Use pointed reduction Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB
forceps to reduce and maintain the position of oblique Saunders, 2004.
fractures. 2. Johnson AL, Hulse DA: Management of specific fractures:
Metacarpal, metatarsal, phalangeal and sesamoid fractures and lux-
Stabilization: Stabilize simple transverse (or very short
ations. In Fossum TW (ed): Small Animal Surgery, 2nd ed. St. Louis,
oblique) fractures in young or small dogs and cats with Mosby, 2002.
intramedullary pins. Use a high-speed burr to develop a slot 3. Bellenger CR, Johnson KA, Davis PE, et al: Fixation of metacarpal
in the distal dorsal surface of the fractured bone (Plate 82B). and metatarsal fractures in greyhounds. Aust Vet J 57:205, 1981.
Blunt the tip of the pin to prevent it from penetrating the intact 4. Muir P, Norris JL: Metacarpal and metatarsal fractures in dogs. J
opposite cortex, and drive the pin through the slot and proxi- Small Anim Pract 38:344, 1997.
CHAPTER 82 F R A C T U R E S O F T H E M E TA C A R PA L A N D M E TATA R S A L B O N E S 215

P L AT E 8 2

Tendon of common
digital extensor muscle

B C

Palmar Dorsal

1 4

2 3
218 PA RT T H R E E SURGICAL PROCEDURES FOR THE SPINE

CHAPTER 83 Ventral Fenestration


of Cervical Discs
INDICATIONS 1 chondystrophic breeds of dogs. It is characterized by the dys-
Ventral fenestration of the cervical spine is often performed in trophic calcification of the NP and extrusion of the disc material
combination with ventral decompression and surgical stabiliza- into the vertebral canal.
tion. It may be performed as a prophylactic or therapeutic
measure for degenerative intervertebral disc (IVD) disease of EQUIPMENT
the cervical region. Standard surgical pack, two medium or large Gelpi retractors
(depending on the size of the dog), bipolar and unipolar
OBJECTIVES cautery, suction hose and small Frazier suction tip, no. 11
To prevent herniation of the degenerative IVD into the verte- Bard Parker scalpel blade, Adson periosteal elevator, two
bral canal and to resolve clinical signs associated with inver- Senn retractors, Army-Navy retractors, DeBakey thumb for-
tebral disc disease (e.g., pain) ceps, ear loop, tartar scraper, small bone curette

ANATOMIC CONSIDERATIONS 1,2 PREPARATION AND POSITIONING


The IVD is a complex composite of ligamentous and fibrous Prepare the patient from the mid-mandible to just past the
tissue; it is located at all interveterbral spaces except C1-2 and manubrium. Position the animal in dorsal recumbency, crossing
the fused sacral segments. It is classified as an amphiarthrodial its forelimbs and securing them caudally. Pay careful attention
joint and collectively constitutes the largest avascular structure to patient positioning, and make every effort to ensure that the
in the body. Nutrition to the discs is via diffusion from the animal is straight and in true dorsal recumbency. Stabilize the
cartilaginous end-plates and is facilitated by normal vertebral head and neck with towels, sandbags, or a vacuum-activated
movement. The IVD is composed of two anatomically distinct surgical positioning system.* Secure the head by taping the
regions: (1) the annulus fibrosus and (2) the nucleus pulposus mandible to the table.
(NP). The annulus fibrosus is composed of fibrocartilaginous
material arranged in woven concentric layers that allow limited PROCEDURE
vertebral motion in three directions: (1) lateral, (2) dorsoven- Approach: Incise the skin and subcutaneous tissue on ven-
tral, and (3) rotation. The ventral and lateral portions of the tral midline from the caudal aspect of the thyroid cartilage to
annulus are 1.5 to 3 times thicker than the dorsal annulus, which the manubrium. Reflect the skin and subcutaneous tissue medi-
means that the NP is always dorsally eccentric; this explains the ally and laterally with blunt dissection. Bluntly separate the
propensity of the nucleus to herniate dorsally. The NP is a gelat- sternohyoideus and sternomastoideus muscles along the mid-
inous mass that arises from the embryonic notochord. It con- line. Identify and retract the esophagus and trachea to the left
tains an intercellular mass of mesenchymal cells in a dense with moistened laparotomy sponges and either self-retaining or
network of poorly arranged fibers. In the young animal, the NP Army-Navy retractors (Plate 83A). Identify the paired carotid
has a high water content, which provides the hydroelastic qual- sheaths, and gently maneuver them out of the surgical field.
ities needed to maintain function. The IVD forms a cushion Palpate the ventral spinous processes of the vertebral column
between the adjacent bony vertebrae to allow movement, to to locate the appropriate disc space(s). The large transverse
minimize and absorb shock, and to unite the segments of the processes of C6 and the wings of C1 are important anatomic
vertebral column. Age-related metaplastic degeneration results landmarks that assist in anatomic orientation. Once the IVD
in significant changes in the biochemistry and biomechanics of space(s) to be fenestrated have been located, cauterize the mus-
the disc. There are two different types of metaplastic changes culotendinous attachments of the longus colli muscle to the
that have been described: (1) fibroid and (2) chondroid meta- ventral spinous processes. The use of cautery will reduce the
plasia. Fibroid metaplasia occurs in nondystrophic breeds. It is amount of muscular bleeding and improve visualization. Once it
characterized by a slow degeneration or fibrocytic change of is free of its attachments, elevate the longus colli muscle to
the annulus fibrosus, resulting in the thinning of the annulus expose the ventral annulus fibrosus at the affected disc space
dorsally and a protrusion of the disc upon compression of the (Plate 83B).
spinal cord. Chondroid metaplasia occurs primarily in the Continued

*Hug-U-Vac, South Salem, Oregon.


CHAPTER 83 V E N T R A L F E N E S T R AT I O N O F C E R V I C A L D I S C S 219

P L AT E 8 3

A B
Sternohyoideus Longus colli
muscle muscles

Trachea

Sternocephalicus
muscle
220 PA RT T H R E E SURGICAL PROCEDURES FOR THE SPINE

Cervical Disc Fenestration: Using a no. 11 blade, that there was spondylosis and narrowing of the IVD space
excise a rectangular window in the ventral annulus that is large associated with the ventral fenestration procedure.
enough to allow removal of the calcified NP (Plate 83C).
Remember that the IVD space angles cranially, and angle the POSTOPERATIVE CARE
instrumentation accordingly to facilitate complete disc General supportive care and pain management are indicated in
removal. Remove all disc material with an ear loop, tartar all neurosurgery patients. Clean, dry, soft, padded bedding is
scraper, or small bone curette (Plates 83D and 83E). important for patients that are nonambulatory or weakly ambu-
Lavage and close longus colli in one layer with a simple con- latory. Maintenance fluid therapy is routine for the first 24 to
tinuous suture pattern. Remove the retractors, and return the 48 hours or until the animal is able to eat and drink without
trachea and esophagus to their normal positions. Lavage the assistance. Urine output and quantitation should be closely
soft tissues, and close the sternohyoideus and sternomas- monitored for the first 24 to 48 hours, and bladder expression or
toideus with a simple continuous suture pattern. Close the sub- catheterization (or both) should be provided in those patients
cutaneous tissues and skin in a routine fashion. not urinating on a voluntary basis. Rehabilitation may be imple-
mented as soon as the acute postoperative pain has subsided
CAUTIONS 1,3 (usually after 24 hours). Depending on the level of neurologic
Ventral fenestration is a technically easier procedure to perform dysfunction, therapy may consist of massage, assisted standing,
in comparison to ventral decompression; however, complete proprioceptive exercises, and controlled therapeutic exercise.
removal of disc material from the vertebral canal is not pos- Neck and buckle collars should be exchanged for a harness.
sible, and therefore complete resolution of the clinical signs
associated with disc herniation may not be achievable with this EXPECTED OUTCOME 35
procedure alone. Animals that display more advanced dysfunc- The prognosis will vary depending on the level of neurologic
tion associated with spinal cord compression (e.g., paresis or dysfunction. Most animals will improve following surgical inter-
paralysis) are candidates for ventral decompression. In addi- vention, given a sufficiently long convalescent period.
tion, in vitro studies of cadaveric spines have shown that ven-
tral fenestration produces sagittal instability of the caudal
References
cervical spine, which may contribute to the development of sec-
1. Macy NB, Les CM, Stover SM, et al: Effect of disc fenestration on
ondary instability and subsequent disc herniation (domino
sagittal kinematics of the canine C5-C6 intervertebral space. Vet
lesions) at adjacent disc sites. Surg 28(3):171179, 1999.
2. Bray JP, Burbidge HM: The canine intervertebral disc. Part two:
POSTOPERATIVE EVALUATION 1,36 Degenerative changesnonchondrodystrophoid versus chondrody-
The neurologic status of the patient should be serially evaluated strophoid discs. J Am Anim Hosp Assoc 34(2):135144, 1998.
upon recovery from anesthesia and surgery. Neurologic deterio- 3. Wheeler SJ, Sharp NJH: Cervical disc disease. In Wheeler SJ, Sharp
ration associated with ventral fenestration has been reported in NJH (eds): Small Animal Spinal Disorders: Diagnosis and Surgery.
the literature; it is thought to be caused by residual disc mate- London, Mosby, 1994.
rial herniating into the canal. Most animals experience a 4. Nakama S, Taura Y, Tabaru H, et al: A retrospective study of ventral
decrease in cervical pain associated with IVD disease; however, fenestration for disc diseases in dogs. J Vet Med Sci 55(5):781784,
1993.
recovery times may vary, depending on the severity of neuro-
5. Tomlinson J: Tetraparesis following cervical disc fenestration in two
logic dysfunction. Postoperative radiographs or ancillary dogs. J Am Vet Med Assoc 187(1):7677, 1985.
imaging (computed tomography or magnetic resonance 6. Dallman MJ, Moon ML, Giovannitti-Jensen A: Comparison of the
imaging) of the cervical vertebrae is usually not indicated. A width of the intervertebral disc space and radiographic changes
clinical study evaluating the width of the IVD space and the before and after intervertebral disc fenestration in dogs. Am J Vet
radiographic changes before and after IVD fenestration found Res 52(1):140145, 1991.
CHAPTER 83 V E N T R A L F E N E S T R AT I O N O F C E R V I C A L D I S C S 221

P L AT E 8 3

C D

E
222 PA RT T H R E E SURGICAL PROCEDURES FOR THE SPINE

CHAPTER 84 Ventral Cervical Slot


INDICATIONS 1 scalpel blade, Adson periosteal elevator, Senn retractors
Ventral decompression of the cervical spine is performed for and/or Army-Navy retractors, DeBakey thumb forceps,
intervertebral disc (IVD) disease of the cervical spine. It is often Lempert rongeur, Kerrison rongeur, pneumatic drill system
performed in combination with ventral fenestration. Surgical with burr guard and a variety of sizes of round and oval burrs,
candidates for a ventral slot are those animals that have exhib- bone wax,* gelfoam, or Avitene Sheets (Microfibrillar
ited multiple bouts of cervical pain, that are unresponsive to Hemostat).
previous conservative treatment, or that are nonambulatory Additional instrumentation that is useful for removing
tetraparetic or quadriplegic and that have been diagnosed with extruded disc material from the vertebral canal includes a Buck
extradural compression of the spinal cord via myelography, ear curette, Ball burnisher, tartar scraper, double-ended curette,
computed tomography, or magnetic resonance imaging. Iris spatula, and small bone curette.

OBJECTIVES PREPARATION AND POSITIONING


To relieve compression of the cervical spine from extruded or Prepare the patient from the mid-mandible to just past the
protruded disc material manubrium. Position the animal in dorsal recumbency, crossing
its forelimbs and securing them caudally. Pay careful attention
ANATOMIC CONSIDERATIONS 24 to patient positioning, and make every effort to ensure that the
Cervical spinal cord compression accounts for 15% of the animal is straight and in true dorsal recumbency. The head and
reported cases of IVD in the dog, with 80% occurring in the chon- neck can be stabilized with towels, sandbags, or a vacuum-
drodystrophic breeds. The most common site of disc protrusion activated surgical positioning system. Secure the head by
is C2-C3, followed by C3-4 and C7-T1. Clinical signs associated taping the mandible to the table.
with disc disease can vary from a nerve root signature and neck
pain to quadriplegia, depending on the degree and location of PROCEDURE
spinal cord compression. Myelography or ancillary imaging of Approach: Incise the skin and subcutaneous tissue on the
computed tomography and magnetic resonance imaging are ventral midline from the caudal aspect of the thyroid cartilage to
important for both diagnostic confirmation and neuroanatom- the manubrium. Reflect the skin and subcutaneous tissue medi-
ical localization of the lesion; they also determine lateralization ally and laterally with blunt dissection. Bluntly separate the
of the disc extrusion and rule out the presence of multiple sternohyoideus and sternomastoideous muscles along the mid-
lesions. line. Identify and retract the esophagus and trachea to the left
The midline location of the ventral slot must be precise to with moistened laparotomy sponges and either self-retaining or
avoid the internal vertebral venous plexus. The internal verte- Army-Navy retractors (Plate 84B). Identify the paired carotid
bral venous plexus or sinuses comprise two valveless veins, sheaths, and gently maneuver them out of the surgical field.
which reside on the floor of the vertebral canal. These two thin- Palpate the ventral spinous processes of the vertebral column
walled veins converge and diverge at the vertebral midbody and to locate the appropriate disc space(s). The large transverse
IVD space, respectively. To avoid damage of these vertebral processes of C6 and the wings of C1 are important landmarks
sinuses and instability of the vertebral spine, the dimensions of that assist in anatomical orientation. Once the IVD space(s) has
the slot must be no greater than one third the width and length been located, cauterize the musculotendinous attachments of
of the body of the vertebra, centering the slot slightly cranial to the longus colli muscle to the ventral spinous processes. The
the IVD space (Plate 84A). use of cautery will reduce the amount of muscular bleeding and
improve visualization. Once it is free of its attachments, elevate
EQUIPMENT and retract the longus colli muscle to expose the ventral
Standard surgical pack, two medium or large Gelpi retractors annulus fibrosus at the affected disc space and the adjacent ver-
(depending on the size of dog), bipolar and unipolar cautery, tebral bodies (Plate 84C), and remove the ventral spinous
suction hose and small Frazier suction tip, no. 11 Bard Parker process with a rongeur (Plate 84D).
Continued

*Bone wax, Ethicon, Johnson & Johnson, Somerville, New Jersey.



Gelfoam, Pharmacia and Upjohn, Kalamazoo, Michigan.

Avitene, Davol, Cranston, Rhode Island.

Hug-U-Vac, South Salem, Oregon.
CHAPTER 84 VENTRAL CERVICAL SLOT 223

P L AT E 8 4

Slot is 1/3 the width


of the vertebral body

A B Sternohyoideus
muscle

Trachea

Slot is centered
slightly cranial
to interspace

Carotid sheath Sternocephalicus


muscle

C D
Longus colli
muscles
224 PA RT T H R E E SURGICAL PROCEDURES FOR THE SPINE

Ventral Cervical Slot: Drill the proposed ventral slot site tomography or magnetic resonance imaging) of the cervical ver-
with a pneumatic air drill using a burr of appropriate size (Plate tebrae is usually not indicated.
84E). Generally, select a burr that is equal to the width of the
slot to promote even bone removal. Slowly trickle warm saline POSTOPERATIVE CARE
over the burr while drilling to prevent heat transfer from the General supportive care and pain management are indicated in
burr to the hemilaminectomy site, and intermittently lavage the all neurosurgery patients. Clean, dry, soft padded bedding is
entire laminectomy site to remove bone debris and to keep the important for patients that are nonambulatory or weakly ambu-
tissues moist. Once most of the bone has been removed, a latory. Maintenance fluid therapy is routine for the first 24 to
smaller bit can be used to remove the edges of inner cortical 48 hours, until the animal is able to eat and drink without assis-
bone plate. Any bone bleeding may be controlled with bone tance. Urine output and quantitation should be closely moni-
wax. Once the inner cortex has been removed, use a nerve root tored for the first 24 to 48 hours, and bladder expression or
probe, ear loop, or tartar scraper to palpate the inner bone and catheterization should be provided for those patients that are
periosteal shelf. When it is thin and pliable, use a probe to pen- not urinating on a voluntary basis. Rehabilitation may be imple-
etrate the site gently and create a long window to allow a mented as soon as the acute postoperative pain has subsided
Kerrison rongeur to remove any remaining bone in the oblong (usually after 24 hours). Depending on the level of neurologic
window. If necessary, excise the dorsal longitudinal ligament dysfunction, therapy may consist of massage, assisted standing,
with a no. 11 blade to visualize and decompress the cord. proprioceptive exercises, and controlled therapeutic exercise.
Remove any remaining extruded disc with a Buck ear curette, Neck and buckle collars should be exchanged for a harness.
ball burnisher, or iris scapula (Plate 84F). Avoid damaging the
venous sinuses that circumferentially surround the slot ventral EXPECTED OUTCOME 5,7
to the cord. If a venous sinus is damaged, control the bleeding Most patients with cervical IVD have a fair to good prognosis;
with the gelfoam or Avitene Sheets. Wait 5 minutes for the ces- however, expected outcomes vary depending on the level of
sation of bleeding before removing the hemostatic devices and neurologic dysfunction. Most animals improve following sur-
reinitiating the exploratory surgery. Once the spinal cord has gical intervention, given a convalescence period of reasonable
been fully decompressed, all sinus bleeding should cease. length (6 to 8 weeks). Recurrence of signs associated with IVD
Closure: Lavage and close the longus colli in one layer with has been reported within the literature and should be discussed
a simple continuous suture pattern. Remove the retractors, and with the owner prior to surgery.
return the trachea and esophagus to their normal position.
Lavage the soft tissues, and close the sternohyoideus and ster-
nomastoideus with a simple continuous suture pattern. Close References
the subcutaneous tissues and skin in a routine fashion. 1. Macy NB, Stover SM, Kass PH: Effect of disk fenestration on sagittal
kinematics of the canine C5-C6 intervertebral space. Vet Surg
CAUTIONS 1,5 28:171179, 1999.
Proper anatomic orientation is key to the identification of the 2. Tombs JP: Cervical intervertebral disk disease in dogs. Compend
Contin Educ Pract Vet 14:14771488, 1992.
correct surgical site. Postoperative or intraoperative radio-
3. Lemarie RJ, Partington BP, Hosgood G: Vertebral subluxation fol-
graphs should be taken if there is any doubt about lesion loca- lowing ventral cervical decompression in the dog. J Am Anim Hosp
tion. Severe hemorrhage can occur as a result of ventral sinus Assoc 36(4):348358, 2000.
laceration. It is important to cross-match any animal that is a 4. Bagley RS, Tucker R, Harrington ML: Lateral and foraminal disk
candidate for a coagulopathy before surgery. extrusion in dogs. Compend Contin Educ Pract Vet 18:795804,
1996.
POSTOPERATIVE EVALUATION 1,58 5. Wheeler SJ, Sharp NJH: Cervical disc disease. In Small Animal
The neurologic status of the patient should be serially evaluated Spinal Disorders. London, Mosby-Wolfe, 1994.
upon recovery from anesthesia and surgery. Neurologic deteri- 6. Dallman MJ, Giovannitti-Jensen A: Comparison of the width of the
oration associated with ventral fenestration has been reported intervertebral disk space and radiographic changes before and after
intervertebral disk fenestration in dogs. Am J Vet Res 52(1):140145,
in the literature and is thought to be due to the herniation of
1991.
residual disc material into the canal. Most animals experience a 7. Nakama S, Tabaru H, Yasuda M: A retrospective study of ventral fen-
decrease in cervical pain associated with IVD disease; however, estration for disk diseases in dogs. J Vet Med Sci 55(5):781784,
recovery times may vary depending on the severity of the neu- 1993.
rologic dysfunction and the intraoperative complications. 8. Tomlinson J: Tetraparesis following cervical disk fenestration in two
Postoperative radiographs or ancillary imaging (computed dogs. J Am Vet Med Assoc 187(1):7677, 1985.
CHAPTER 84 VENTRAL CERVICAL SLOT 225

P L AT E 8 4

E Slot is centered
slightly cranial
to interspace

F
226 PA RT T H R E E SURGICAL PROCEDURES FOR THE SPINE

CHAPTER 85 Hemilaminectomy
INDICATIONS 13 no. 15 Bard Parker scalpel blades, Freer periosteal elevator,
Surgical candidates for a hemilaminectomy are those animals Senn retractors, Lempert rongeur, Kerrison rongeur, pneu-
that have exhibited multiple bouts of thoracolumbar pain, that matic drill system with burr guard and a variety of sizes of
are unresponsive to previous conservative treatment, that round and oval burrs, DeBakey thumb forceps, bone wax,*
exhibit loss of voluntary motor function, or that have been gelfoam, or Avitene Sheets (Microfibrillar Hemostat).
diagnosed with compression of the spinal cord via myelography, Additional instrumentation that is useful for removing
computed tomography, or magnetic resonance imaging. extruded disc material from the vertebral canal includes a Buck
ear curette, Ball burnisher, tartar scraper, double-ended curette,
OBJECTIVES 1,4 Iris spatula, and small bone curette.
To decompress the spinal cord of the thoracolumbar spine
Hemilaminectomy is often performed in combination with PREPARATION AND POSITIONING 1,4,6,7
lateral fenestration. Position the animal in sternal recumbency, and prepare the
back from the mid-thoracic region to the lower lumbar area.
ANATOMIC CONSIDERATIONS 5 Support the animal with sandbags on each side of the abdomen,
The vertebrae are key components of the axial skeleton; they lie or use a vacuum-activated surgical positioning system. If
along the midline of the body. Vertebral body anatomy varies needed, further secure the animal in position with white tape to
depending on the location in the axial skeleton, but each has a prevent malposition during surgery. Perfect positioning and
basic structural configuration despite minor differences in mor- alignment assist in the approach and ensure proper orientation;
phology. Each vertebral bone has a body that lies directly however, some surgeons prefer that the patient be rotated
beneath the spinal cord. Interposed between and connecting slightly, with the operated side being most dorsal.
each vertebral body is an intervertebral disc (see Chapter 83 for
an in-depth discussion of disc anatomy). The spinal cord is sur- PROCEDURE
rounded and protected by the lamina and pedicle, which Approach:1,4,6,7 Incise the skin and subcutaneous tissue on
collectively make up the vertebral arch. Dorsal spinous dorsal midline centered from the mid-thoracic vertebra to the
processes project from the lamina. In the cranial thoracic ver- mid-lumbar region, and suture in two quarter drapes to decrease
tebra, these processes are tall and slant caudally; however, they skin contamination. The incision location and length will vary
change direction and decrease in size at the anticlinal vertebra, somewhat depending on the lesion location(s) and the number
usually located at T10. In the lumbar region, the processes of sites that need to be decompressed. Incise the thoracodorsal
become more substantial, shorter, and wider. Each vertebra fascia and supraspinous ligaments with a no. 15 scalpel blade,
also has two sets of articular facets located on the dorsal lateral extending the incision at least two dorsal spinous processes
aspect of the vertebral arch, which demarcate the position of proximal and distal to the site(s) to be decompressed. In order
the intervertebral foramina, where the nerve root exits the to minimize muscular hemorrhage, deviate the incision toward
spinal canal. In addition to articulating with each other, the tho- the side of the hemilaminectomy at each dorsal spinous process
racic vertebrae also articulate with a pair of ribs just ventral and and then return the incision back to midline. Elevate the epaxial
caudal to the intervertebral foramina. Each rib projects in a per- musculature (multifidus thoracis and lumborum muscles) away
pendicular fashion from the vertebral body. Location of the from the dorsal spinous process, pedicle, and lamina to the
proximal rib head with the vertebra is an important anatomic level of the articular facet using an Adson or Freer periosteal
landmark for identification of the proper intervertebral disc elevator. Retract the elevated muscles using two Gelpi self-
space. The articulation of the rib head with the vertebral body retaining retractors (Plate 85A). Using the bipolar cautery, cau-
is easily palpated and distinguished from the transverse process terize the musculotendinous attachments of the longissimus
of the lumbar vertebra, which slopes craniolaterally from the muscles originating on the articular facets, avoiding the nerve
vertebral body. A Freer or other small periosteal elevator may root coursing deep and caudoventrally under the facet. Elevate
be used to palpate these landmarks to avoid excessive soft any remaining tissue attached to the exposed facet, lamina, and
tissue dissection. pedicle, and repeat the procedure, one site cranial and one site
caudal to the hemilaminectomy, to provide adequate exposure.
EQUIPMENT Reposition the Gelpi retractors to improve visualization, and
Standard surgical pack, two medium or large Gelpi retractors remove the articular facets with a Lempert rongeur (Plate 85B).
(depending on the size of the dog), bipolar and unipolar
cautery, suction hose and small Frazier suction tip, no. 11 and Continued

*Bone wax, Ethicon, Johnson & Johnson, Somerville, New Jersey.



Gelfoam, Pharmacia and Upjohn, Kalamazoo, Michigan.

Avitene, Davol, Cranston, Rhode Island.

Hug-U-Vac, South Salem, Oregon.
CHAPTER 85 H E M I L A M I N E C TO M Y 227

P L AT E 8 5

T13

L1
228 PA RT T H R E E SURGICAL PROCEDURES FOR THE SPINE

Hemilaminectomy:1,4,6 Drill the proposed hemilaminec- subsided (usually after 24 hours). Depending on the level of
tomy site with a pneumatic air drill using a burr of appropriate neurologic dysfunction, therapy may consist of massage,
size. Generally, select a burr that is equal to the width of the assisted standing, proprioceptive exercises, and controlled
hemilaminectomy site to promote even bone removal (Plate therapeutic exercise. Most overweight animals also benefit
85C). Slowly trickle warm saline over the burr while drilling to from a weight loss program, because excessive weight can
prevent heat transfer from the burr to the hemilaminectomy impair neurologic recovery.
site, and intermittently lavage the entire laminectomy site to
remove bone debris and to keep the tissues moist. Once most of EXPECTED OUTCOME 13,12
the bone has been removed, a smaller bit can be used to remove Most patients with thoracolumbar intervertebral disc disease
the edges of inner cortical bone plate. Any bone bleeding may have good to excellent prognosis; however, expected outcomes
be controlled with bone wax. Once the inner cortex has been will vary, depending on the level of neurologic dysfunction.
removed, use a nerve root probe, ear loop, or tartar scraper to Animals with intact pain sensation generally have a greater than
palpate the inner bone and periosteal shelf. When it is thin and 90% chance of full recovery. Prognostic indicators for time to
pliable, use a probe to gently penetrate the site and create a ambulation after hemilaminectomy include the presence of
long window to allow admission of a Kerrison or small Lempert postoperative voluntary motor function. Most animals improve
rongeur to remove any remaining bone in the oblong window following surgical intervention given a convalescent period of
(see Plate 85C). Remove the extruded disc with a Buck ear reasonable length (6 to 8 weeks). Recurrence of signs associ-
curette, ball burnisher, or iris scapula (Plate 85D). Gently pass ated with intervertebral disc disease has been reported within
a neural probe under and dorsal to the spinal cord to ensure the literature and should be discussed with the owner prior to
complete decompression. Avoid damaging the venous sinuses surgery.
ventral to the cord. If a venous sinus is damaged, control the
bleeding with the gelfoam or Avitene Sheets. Wait 5 minutes for
the cessation of bleeding before removing the hemostatic
devices and reinitiating the exploratory. Once the spinal cord References
has been decompressed, gently lavage the hemilaminectomy 1. Harari J, Marks S: Surgical treatments for intervertebral disc
site, and harvest a fat graft from the subcutaneous region of the disease. Vet Clin North Am Small Anim Pract 22(4):899915, 1992.
back. Place the fat graft over the hemilaminectomy site to pre- 2. Kornegay J, Simpson S, Bailey CS, Joseph R: How do I treat?
vent fibrous scarring and adhesion. Suture the epaxial muscular Degenerative thoracolumbar intervertebral disc disease in small
fascia in a simple continuous pattern with absorbable suture. breed dogs. Prog Vet Neuro 4(3):8183, 1993.
Close the subcutaneous tissues and skin in a routine fashion. 3. Coates J: Intervertebral disk disease. Vet Clin North Am Small Anim
Pract 30(1):77110, 2000.
4. Seim HI: Dorsal decompressive laminectomy for T-L disk disease.
CAUTIONS 811 Canine Practice 20(6):610, 1995.
No more than four adjacent continuous hemilaminectomy sites 5. Wheeler SJ, Sharp NJH: Functional anatomy. In Wheeler SJ, Sharp
(or, bilaterally, up to two adjacent sites) should be performed to NJH (eds): Small Animal Spinal Disorders: Diagnosis and Surgery.
prevent destabilizing the spinal column. Accurate anatomic London, Mosby, 1994.
identification of the hemilaminectomy site is important for the 6. Wheeler SJ, Sharp NJH: Thoracolumbar disc disease. In Wheeler SJ,
success of the surgery. Prior to the surgery, a radiograph of a Sharp NJH (eds): Small Animal Spinal Disorders: Diagnosis and
sterile needle placed in a dorsal spinous process can be used to Surgery. London, Mosby, 1994.
assist in vertebral body identification. 7. Piermattei DL, Johnson KA: Approach to the thoracolumbar verte-
brae through a dorsal incision. In An Atlas of Surgical Approaches
to the Bones and Joints of the Dog and Cat, 4th ed. Philadelphia,
POSTOPERATIVE EVALUATION
WB Saunders, 2004.
The neurologic status of the patient should be serially evaluated 8. Schulz KS, Waldron DR, Grant JW, et al: Biomechanics of the tho-
upon recovery from anesthesia and surgery. Urinary continence racolumbar vertebral column of dogs during lateral bending. Am J
generally returns with the advent of voluntary ambulation. Vet Res 57:12281232, 1996.
9. Corse M, Renberg W, Friis E: In vitro evaluation of biomechanical
POSTOPERATIVE CARE effects of multiple hemilaminectomies on the canine lumbar verte-
General supportive care and pain management are indicated in bral column. Am J Vet Res 64(9):11391145, 2003.
all neurosurgery patients. Clean, dry, soft, padded bedding is 10. Hill T, Lubbe A, Guthrie A: Lumbar spine stability following hemil-
important for patients that are nonambulatory or weakly ambu- aminectomy, pediculectomy, and fenestration. Vet Comp Orthop
latory. Maintenance fluid therapy is routine for the first 24 to Traumatol 13:165171, 2000.
11. Hosgood G: Wound complications following thoracolumbar
48 hours or until the animal is able to eat and drink without
laminectomy in the dog: A retrospective study of 264 procedures.
assistance. Urine output and quantitation should be closely J Am Anim Hosp Assoc 28(1):4752, 1992.
monitored for the first 24 to 48 hours, and bladder expression or 12. Davis GJ, Brown DC: Prognostic indicators for time to ambulation
catheterization (or both) should be provided in those patients after surgical decompression in nonambulatory dogs with acute
that are not urinating on a voluntary basis. Rehabilitation may thoracolumbar disk extrusions: 112 cases. Vet Surg 31(6):513518,
be implemented as soon as the acute postoperative pain has 2002.
CHAPTER 85 H E M I L A M I N E C TO M Y 229

P L AT E 8 5

D
230 PA RT T H R E E SURGICAL PROCEDURES FOR THE SPINE

Fenestration of
CHAPTER 86

Thoracolumbar Discs
INDICATIONS 13 retractors, Lempert rongeur, Kerrison rongeur, DeBakey
Dorsolateral fenestration of the thoracolumbar spine may be thumb forceps, bone wax,* gelfoam, or Avitene Sheets
performed as a prophylactic or therapeutic measure for degen- (Microfibrillar Hemostat).
erative intervertebral disc disease; however, considerable Additional instrumentation that is useful for removing in situ
debate exists regarding the indications and therapeutic benefit calcified disc material from the vertebral canal includes a Buck
of fenestration. To date, clinical studies have yet to prove its ear curette, Ball burnisher, tartar scraper, double-ended curette,
therapeutic benefit over the hemilaminectomy procedure. In Iris spatula, and small bone curette.
addition, thoracolumbar fenestration has not been proven to
prevent future herniation of discs. In general, most surgeons PREPARATION AND POSITIONING
electing to perform this procedure do so in combination with a Position the animal in sternal recumbency, and prepare the
hemilaminectomy at adjacent intervertebral discs that are back from the mid-thoracic region to the lower lumbar area.
calcified in situ. Support the animal with sandbags on each side of the abdomen,
or use a vacuum-activated surgical positioning system. If
OBJECTIVES needed, further secure the animal in position with white tape to
To prevent herniation of a degenerative intervertebral disc prevent malposition during surgery. Perfect positioning and
into the vertebral canal and to resolve clinical signs associ- alignment assist in the approach and ensure proper orientation;
ated with intervertebral disc disease (e.g., pain) however, some surgeons prefer that the patient be rotated
slightly, with the operated side being most dorsal.
ANATOMIC CONSIDERATIONS 4,5
A dorsolateral approach (as described here) may be used to PROCEDURE
gain access to intervertebral disc sites from T10 to L5. Discs Thoracolumbar Fenestration: After performing the
above and below these sites are not routinely fenestrated via hemilaminectomy via a dorsal approach (Plate 86A) (see
this approach because of technical difficulties in the approach Chapter 85), locate the intervertebral disc site(s) to be fenes-
caused by anatomic differences and to avoid inadvertent trated. Craniolaterally retract the spinal nerve and artery,
damage to the femoral nerve segments. The intervertebral disc demarcating the intervertebral disc site to reveal the lateral
site of the thoracic vertebra lies just cranial and ventromedial to aspect of the annulus fibrosis (Plate 86B). With a no. 11 scalpel
the tubercle of the rib and adjacent to the head of the rib. The blade, resect a rectangular section of the lateral annular wall
intervertebral disc site of the lumbar vertebra lies just cranial to that is large enough to allow access to and removal of the
the area where the transverse process joins the vertebral body. calcified nucleus pulposus (see Plate 86B). With a tartar
Retraction of the multifidus thoracis or lumborum and longis- scraper, buck ear curette, or a neurologic instrument of choice,
simus dorsi muscles with the blunt end of a Senn retractor remove as much of the calcified disc material as possible (Plate
reveals the spinal nerve and artery, which lie over the lateral 86C). To avoid damage to the peridisc neurovascular structures,
wall of the annulus fibrosus. maintain the neurologic instrument at a perpendicular angle to
the longitudinal and transverse axis of the spine. Lavage and
EQUIPMENT remove the retractors from the epaxial musculature. Suture the
Standard surgical pack, two medium or large Gelpi retractors epaxial muscular fascia in a simple continuous pattern with
(depending on the size of the dog), bipolar and unipolar absorbable suture. Close the subcutaneous tissues and skin in a
cautery, suction hose and small Frazier suction tip, no. 11 routine fashion.
Bard Parker scalpel blade, Freer periosteal elevator, Senn Continued

*Bone wax, Ethicon, Johnson & Johnson, Somerville, New Jersey.



Gelfoam, Pharmacia and Upjohn, Kalamazoo, Michigan.

Avitene, Davol, Cranston, Rhode Island.

Hug-U-Vac, South Salem, Oregon.
CHAPTER 86 F E N E S T R AT I O N O F T H O R A C O L U M BA R D I S C S 231

P L AT E 8 6

T13

L1

C
232 PA RT T H R E E SURGICAL PROCEDURES FOR THE SPINE

CAUTIONS 5,6 assisted standing, proprioceptive exercises, and controlled


Fenestration of the disc space alone is not an appropriate treat- therapeutic exercise.
ment in animals with neurologic deficits (e.g., significant ataxia
or loss motor function) because it does not ameliorate spinal EXPECTED OUTCOME 1,6
cord compression stemming from disc extrusion. Animals that The prognosis varies depending on the level of neurologic dys-
display more advanced dysfunction associated with spinal cord function. Most animals improve following surgical intervention,
compression (e.g., paresis or paralysis) are candidates for given an adequate convalescent period.
decompression via hemilaminectomy.

POSTOPERATIVE EVALUATION 3,58 References


The neurologic status of the patient should be serially evaluated 1. McKee WM: A comparison of hemilaminectomy (with concomitant
upon recovery from anesthesia and surgery. Neurologic deterio- disc fenestration) and dorsal laminectomy for the treatment of tho-
ration associated with thoracolumbar fenestration has been racolumbar disc protrusion in dogs. Vet Rec 130(14):296300, 1992.
reported in the literature and is thought to be caused by 2. Hill T, Lubbe A, Guthrie A: Lumbar spine stability following hemil-
residual disc material herniating into the canal. Postoperative aminectomy, pediculectomy, and fenestration. Vet Comp Orthop
radiographs or ancillary imaging (computed tomography or Traumatol 13:165171, 2000.
3. Dallman MJ, Moon ML, Giovannitti-Jensen A: Comparison of the
magnetic resonance imaging) of the thoracolumbar vertebrae is
width of the intervertebral disc space and radiographic changes
usually not indicated. before and after intervertebral disc fenestration in dogs. Am J Vet
Res 52(1):140145, 1991.
POSTOPERATIVE CARE 4. Bray JP, Burbidge HM: The canine intervertebral disc. Part two:
General supportive care and pain management are indicated in Degenerative changesnonchondrodystrophoid versus chondrody-
all neurosurgery patients. Clean, dry, soft, padded bedding is strophoid discs. J Am Anim Hosp Assoc 34(2):135144, 1998.
important for patients that are nonambulatory or weakly ambu- 5. Macy NB, Les CM, Stover SM, et al: Effect of disc fenestration on
latory. Maintenance fluid therapy is routine for the first 24 to sagittal kinematics of the canine C5-C6 intervertebral space. Vet
48 hours or until the animal is able to eat and drink without Surg 28(3):171179, 1999.
assistance. Urine output and quantitation should be closely 6. Wheeler SJ, Sharp NJH: Cervical disc disease. In Wheeler SJ, Sharp
NJH (eds): Small Animal Spinal Disorders: Diagnosis and Surgery.
monitored for the first 24 to 48 hours, and bladder expression
London, Mosby, 1994.
and catheterization (or both) should be provided in those 7. Nakama S, Taura Y, Tabaru H, et al: A retrospective study of ventral
patients not urinating on a voluntary basis. Rehabilitation may fenestration for disc diseases in dogs. J Vet Med Sci 55(5):781784,
be implemented as soon as the acute postoperative pain has 1993.
subsided (usually after 24 hours). Depending on the level of 8. Tomlinson J: Tetraparesis following cervical disc fenestration in two
neurologic dysfunction, therapy may consist of massage, dogs. J Am Vet Med Assoc 187(1):7677, 1985.
234 PA RT T H R E E SURGICAL PROCEDURES FOR THE SPINE

CHAPTER 87 Dorsal Laminectomy of L7-S1


INDICATIONS 14 disease process. Regardless of the point of etiology, the disease is
Surgical candidates for a lumbosacral dorsal laminectomy are those caused by nerve root entrapment by either hard or soft tissue.
animals that have exhibited multiple bouts of lumbosacral pain and
that are nonresponsive to conservative treatment of rest and non- EQUIPMENT
steroidal anti-inflammatory drugs or those animals that exhibit loss Standard surgical pack, two medium or large Gelpi retractors
of voluntary motor function and urinary or fecal incontinence and that, (depending on the size of the dog), bipolar and unipolar cautery, suc-
ideally, have been diagnosed with compression of the cauda equina tion hose and small Frazier suction tip, no. 11 and no. 15 Bard Parker
via epidurography, computed tomography, or magnetic resonance scalpel blades, Freer periosteal elevator, Senn retractors, Lempert
imaging. rongeur, Kerrison rongeur, pneumatic drill system with burr guard and
a variety of sizes of round and oval burrs, DeBakey thumb forceps,
OBJECTIVES 16 bone wax,* gelfoam, or Avitene Sheets (Microfibrillar Hemostat)
Lumbosacral dorsal laminectomy is performed for exposure to and is Additional instrumentation that is useful for removing extruded disc
indicated for decompression of the cauda equina material from the vertebral canal includes a Buck ear curette, Ball bur-
Lumbosacral dorsal laminectomy is often performed in combination nisher, tartar scraper, double-ended curette, Iris spatula, small bone
with foraminotomy to relieve individual nerve root impingement. curette, and nerve root retractor.

ANATOMIC CONSIDERATIONS 2 PREPARATION AND POSITIONING 710


Because of the differential rate of growth between the bony vertebral Position the animal in sternal recumbency, and prepare the lower back
column and the spinal cord, the spinal cord terminates between L4 and and sacrum from the mid-lumbar region to the tail head. Elevate the
L6 in the dog. At the end of the spinal cord or conus medullaris, the hind end with sandbags, and position the rear limbs forward, with the
nerve root segments exit, forming the cauda equina, and then course hips and stifles flexed. Support the animal with sandbags on each side
obliquely and caudally to their respective intervertebral foramina. of the abdomen, or use a vacuum-activated surgical positioning system.
Specifically, the cauda equina is composed of nerve roots from the sev- If needed, further secure the animal in position with white tape to pre-
enth lumbar, three sacral, and a varying number of caudal spinal seg- vent malpositioning during surgery. Perfect positioning and alignment
ments. Nerve roots affected by degenerative lumbosacral stenosis or assist in the approach and ensure proper orientation.
cauda equina syndrome include the sciatic nerve (which arises from the
L6 to S1S2 spinal cord segments), the pudendal and pelvic nerves PROCEDURE
(which arise from the S1-S3 spinal cord segments), the cranial gluteal Approach:1113 Incise the skin and subcutaneous tissue on dorsal
nerves (L6-S1), and the caudal gluteal nerve (L7-S1). The femoral nerve, midline from the L5 dorsal spinous process to the first or second caudal
arising from the L4-L6 spinal cord segments, is usually spared from lum- vertebrae. Suture two quarter drapes to the subcutaneous tissue to
bosacral entrapment because of its early exit from the spinal canal at decrease skin contamination. Incise the lumbosacral and gluteal fascia
the L6-L7 intervertebral disc space. Degenerative lumbosacral stenosis with a no. 11 scalpel blade, from the L6 dorsal spinous process to the
or cauda equina is a multifactorial disease process, with clinical signs caudal median sacral crest. Bilaterally elevate the sacrocaudalis dorsal
ranging from lumbosacral pain, hind end lameness, and paraparesis and medialis muscles away from the dorsal spinous process, pedicle, and
ataxia of the hind end or tail to fecal and urinary incontinence. lamina to the articular facets of L7-S1 and the intermediate sacral crest,
Degenerative intervertebral disc disease; congenital lumbosacral using an Adson or Freer periosteal elevator. Retract the elevated
stenosis, malformation, or malarticulation; and degenerative changes muscles using two Gelpi self-retaining retractors (Plate 87A). Excise the
and hypertrophy of the ligamentum flavum, dorsal longitudinal liga- interarcuate ligament between the laminae of L7-S1 with a no. 15 blade
ment, and articular facet joint capsule have all been associated with this to expose the epidural space and the cauda equina.
Continued

*Bone wax, Ethicon, Johnson & Johnson, Somerville, New Jersey.



Gelfoam, Pharmacia and Upjohn, Kalamazoo, Michigan.

Avitene, Davol, Cranston, Rhode Island.

Hug-U-Vac, South Salem, Oregon.
CHAPTER 87 D O R S A L L A M I N E C TO M Y O F L 7 - S 1 235

P L AT E 8 7

Spinous
process L7

Spinous
process S1
236 PA RT T H R E E SURGICAL PROCEDURES FOR THE SPINE

Dorsal Laminectomy of L7-S1:4,12 Remove the dorsal presentation, as determined by magnetic resonance imaging, has been
spinous processes of L7 and S1 with a rongeur (Plate 87B). Drill the pro- found to be independent of disease severity and thus should not be used
posed laminectomy site with a pneumatic air drill, using a burr of appro- in prognostication. Young animals with mild signs of lumbosacral pain,
priate size (Plate 87C). Slowly trickle warm saline over the burr while ataxia, and weakness have a fair to good prognosis for full recovery.
drilling to prevent heat transfer from the burr to the laminectomy site. Urinary or fecal incontinence and extreme age have been associated
Intermittently lavage the entire laminectomy site to remove bone debris with poor or guarded recovery. Most animals improve after surgical
and to keep the tissues moist. The laminectomy site should extend from intervention, given a reasonable convalescent period (4 to 6 weeks).
the cranial aspect of the dorsal spinous process of L7 to the caudal Recurrence of signs has been reported at a varying rate of 15% to 67%
aspect of S1, preserving the articular facets (Plate 87D). Once most of and should be discussed with the owner before surgery.
the bone has been removed, a smaller bit can be used to remove the
edges of inner cortical bone plate. Control any bone bleeding with bone References
wax. Once the inner cortex has been removed, use a nerve root probe, 1. De Risio L, Sharp NJ, Olby NJ, et al: Predictors of outcome after
ear loop, or tartar scraper to palpate the inner bone and periosteal shelf. dorsal decompressive laminectomy for degenerative lumbosacral
When it is thin and pliable, use a probe to gently penetrate the site and stenosis in dogs: 69 cases (19871997). J Am Vet Med Assoc
create a long window to allow admission of a Kerrison or small Lempert 219(5):624628, 2001.
rongeur to remove any remaining bone in the oblong window (Plate 2. De Risio L, Thomas WB, Sharp NJ: Degenerative lumbosacral
87E). Inspect each nerve root for entrapment or compression from a stenosis. Vet Clin North Am Small Anim Pract 30(1):111132, 2000.
bulging or extruded intervertebral disc, hypertrophied dorsal longitu- 3. Linn LL, Bartels KE, Rochat MC, et al: Lumbosacral stenosis in 29
dinal ligament, or stenotic intervertebral foramina or canal. Trace each military working dogs: Epidemiologic findings and outcome after
nerve root with a nerve root retractor along its path toward its respec- surgical intervention (19901999). Vet Surg 32(1):2129, 2003.
tive intervertebral foramina. Depending on the lesion location, further 4. Danielsson F, Sjostrom L: Surgical treatment of degenerative lum-
decompression of a nerve root may be necessary by performing a bosacral stenosis in dogs. Vet Surg 28(2):9198, 1999.
discectomy (Plate 87F), dorsal longitudinal ligament resection, facetec- 5. Mayhew PD, Kapatkin AS, Wortman JA, et al: Association of cauda
tomy, or foraminotomy. Once the nerve root(s) has been decompressed, equina compression on magnetic resonance images and clinical
gently lavage the laminectomy site, and harvest a fat graft from the signs in dogs with degenerative lumbosacral stenosis. J Am Anim
subcutaneous region of the back. Place the fat graft over the hemilam- Hosp Assoc 38(6):555562, 2002.
inectomy site to prevent fibrous scarring and adhesion. Suture the 6. Jones J, Banfield C, Ward D: Association between postoperative
epaxial muscular fascia in a simple continuous pattern using absorbable outcome and results of magnetic resonance imaging and computed
suture. Close the subcutaneous tissues and skin in a routine fashion. tomography in working dogs with degenerative lumbosacral
stenosis. J Am Vet Med Assoc 216(11):17691774, 2000.
CAUTIONS 1417 7. Wheeler SJ, Sharp NJH: Thoracolumbar disc disease. In Wheeler SJ,
Every effort should be made to preserve the articular facets of the lum- Sharp NJH (eds): Small Animal Spinal Disorders. London, Mosby 1994.
bosacral junction to promote lumbosacral stability. An accurate and 8. Piermattei DL, Johnson KA: Approach to the thoracolumbar verte-
thorough identification of each nerve root will improve the postopera- brae through a dorsal incision. In An Atlas of Surgical Approaches
tive outcome. However, it is often difficult to identify a compressive to the Bones and Joints of the Dog and Cat, 4th ed. Philadelphia,
lesion because of the anatomic complexity of the area. Owner educa- WB Saunders, 2004.
tion is very important to the success of the surgery, because small but 9. Seim HI: Dorsal decompressive laminectomy for T-L disk disease.
significant lesions may be missed by ancillary imaging such as magnetic Canine Practice 20(6):610, 1995.
resonance imaging and computed tomography. Therefore, all lumbosacral 10. Harari J, Marks S: Surgical treatments for intervertebral disc
laminectomies must be approached as exploratory operations, empha- disease. Vet Clin North Am Small Anim Pract 22(4):899915, 1992.
sizing the diagnostic and therapeutic significance of the surgery. 11. Piermattei DL, Johnson KA: Approach to the lumbar vertebra 7 and
the sacrum through a dorsal incision. In An Atlas of Surgical
POSTOPERATIVE EVALUATION Approaches to the Bones and Joints of the Dog and Cat, 4th ed.
The neurologic status of the patient should be serially evaluated upon Philadelphia, WB Saunders, 2004.
recovery from anesthesia and surgery. Gentle retraction and manipula- 12. Wheeler SJ, Sharp NJH: Lumbosacral disease. In Wheeler SJ, Sharp
tion of the nerve roots is often necessary to access the compressive NJH (eds): Small Animal Spinal Disorders. London, Mosby, 1994.
lesion; however, peripheral nerve injury stemming from retraction is 13. Lenehan T, Tarvin G: Surgical treatment of cauda equina compression
usually transient and responsive to appropriate supportive care. syndrome by laminectomy. In Bojrab MJ (ed): Current Techniques
in Small Animal Surgery, 4th ed. Baltimore, Williams & Wilkins, 1998.
POSTOPERATIVE CARE 14. Schulz KS, Waldron DR, Grant JW, et al: Biomechanics of the
Neurosurgery patients require general supportive care and pain man- thoracolumbar vertebral column of dogs during lateral bending. Am
agement. Clean, dry, soft, padded bedding is needed for nonambulatory J Vet Res 57:12281232, 1996.
or weakly ambulatory patients. Maintenance fluid therapy is routine for 15. Corse M, Renberg W, Friis E: In vitro evaluation of biomechanical
the first 24 to 48 hours or until the animal can eat and drink unaided. effects of multiple hemilaminectomies on the canine lumbar verte-
Urine output and quantitation are closely monitored for the first 24 to bral column. Am J Vet Res 64(9):11391145, 2003.
48 hours, and bladder expression or catheterization (or both) are pro- 16. Hill T, Lubbe A, Guthrie A: Lumbar spine stability following hemil-
vided in patients not urinating voluntarily. Rehabilitation may be imple- aminectomy, pediculectomy, and fenestration. Vet Comp Orthop
mented as soon as the acute postoperative pain has subsided (usually Traumatol 13:165171, 2000.
after 24 hours). Depending on the level of neurologic dysfunction, 17. Hosgood G: Wound complications following thoracolumbar
therapy may consist of massage, assisted standing, proprioceptive exer- laminectomy in the dog: A retrospective study of 264 procedures.
cises, and controlled therapeutic exercise. Activity should be restricted J Am Anim Hosp Assoc 28(1):4752, 1992.
for 4 to 6 weeks. Barring extreme paresis or ataxia, normal activity is then 18. Davis GJ, Brown DC: Prognostic indicators for time to ambulation
slowly reintroduced. For animals with excessive weight, which can after surgical decompression in nonambulatory dogs with acute thora-
impair neurological recovery, a weight loss program may be beneficial. columbar disk extrusions: 112 cases. Vet Surg 31(6):513518, 2002.
19. Coates J: Intervertebral disk disease. Vet Clin North Am Small Anim
EXPECTED OUTCOME 16,10,12,1820 Pract 30(1):77110, 2000.
Most animals with degenerative lumbosacral stenosis have good to 20. Kornegay J, Simpson S, Bailey CS, Joseph R: How do I treat?
excellent prognosis, but expected outcomes vary, depending on the Degenerative thoracolumbar intervertebral disc disease in small
level of neurologic dysfunction. Degree of compression at the time of breed dogs. Prog Vet Neuro 4(3):8183, 1993.
CHAPTER 87 D O R S A L L A M I N E C TO M Y O F L 7 - S 1 237

P L AT E 8 7

B C

Spinous
process L7
removed

D E F

Ligamentum
flavum

Completed
laminectomy
Inner
cortical
layer
Index

Page numbers followed by p refer to plates. Anconeal muscle (Continued) Biceps femoris muscle (Continued)
in luxation of elbow, lateral, 18, 19p in femoral head and neck ostectomy with
A in ununited anconeal process, 22, 23p joint capsule interpolation, 46, 47p
Abductor digiti quinti muscle Anconeal process in femoral neck fractures, 182, 183p
in Achilles tendon repair, 75p in lateral elbow luxation, 18, 19p in femoral physeal fractures
in intertarsal or tarsometatarsal arthrodesis ununited, 2224, 23p, 25p distal, 185p
with intramedullary pin and wire, 94, 95p Antebrachial carpal joint proximal, 180, 181p
with plate, 92, 93p in pancarpal arthrodesis, 32 in hip luxation
in talus osteochondrosis of lateral in partial carpal arthrodesis with and extracapsular stabilization, 38, 39p
trochlear ridge, 85p intramedullary pins, 36 and intracapsular stabilization, 42
in tarsal fractures, 213p in radial and ulnar styloid fractures, 30, 31p in rear limb amputation
Abductor pollicis longus muscle Arthrodesis at coxofemoral joint, 106, 107p
in pancarpal arthrodesis, 33p of carpus, 32, 33p at midshaft of femur, 108, 109p
in radial carpal bone fractures, 211p with intramedullary pins, 36, 37p in stifle luxation, 56, 58
Acetabulum with plate, 34, 35p and intra-articular repair of cranial
contact with femur in ostectomy of of elbow, 28, 29p cruciate ligament, 65p
femoral head and neck with joint of shoulder, 14, 15p medial patellar, 53p, 55p
capsule interpolation, 46 of stifle, 72, 73p Bone graft
fractures of, transverse or short oblique, of tarsus, 90, 91p in carpal arthrodesis, 32
178, 179p with intramedullary pin and wire, 94, 95p with intramedullary pins, 36
in hip luxation, 38, 40, 44 with plate, 92, 93p with plate, 34
in triple pelvic osteotomy, 48, 50 Arthrotomy of stifle in diaphyseal fractures, 134, 135p
Achilles tendon repair, 7476, 75p, 77p in intra-articular repair of cranial cruciate comminuted, 128, 129p, 132, 133p
pin and tension band method, 76, 77p ligament, 64, 65p femoral, 186, 192, 194, 195p
single locking-loop method, 76, 77p in lateral fabellar suture repair of cranial long oblique, 124, 126
three-loop pulley method, 76, 77p cruciate ligament, 60, 61p short oblique or transverse, 118, 120, 122
Acromion process in medial patella luxation, 52, 53p tibial, 202, 204, 205p, 206
in arthrodesis of shoulder, 14 in meniscectomy, 68, 69p in elbow arthrodesis, 28
in neck of scapula fractures, 146 Avulsion fracture of supraglenoid tuberosity, in shoulder arthrodesis, 14
in supraglenoid tuberosity fractures, 144 144, 145p in tarsal arthrodesis, 90
in transverse scapular body fractures, 142, Axillary artery and vein with intramedullary pin and wire, 94
143p in forelimb amputation with scapulectomy, with plate, 92
Acrylic external fixation in mandibular body 100, 101p in transverse derotational osteotomy
fractures, 140, 141p in forelimb salvage with scapulectomy, 102 stabilized with plate, 114
Adductor muscles of thigh Axillary nerve in osteochondrosis of in triple pelvic osteotomy, 48, 50
in femoral diaphyseal fractures, 129p, 133p shoulder, 2 Brachialis muscle in humeral diaphyseal
and external fixator, 192, 193p Axillobrachial vein in forelimb amputation fractures
and intramedullary pin or interlocking with scapulectomy, 100, 101p and external fixator, 162, 163p
nail, 186, 187p and intramedullary pin or interlocking nail,
and plate application, 191p B 154, 155p
in rear limb amputation Biceps brachii muscle and plate application, 158, 159p
at coxofemoral joint, 106, 107p in forelimb salvage with scapulectomy, Brachiocephalicus muscle
at midshaft of femur, 108, 109p 103p, 104 in forelimb amputation with scapulectomy,
in triple pelvic osteotomy, 48, 49p in humeral diaphyseal fractures and plate 100, 101p
Amputations application, 158, 159p in humeral diaphyseal fractures
avoidance of, via scapulectomy, 102104, in humeral distal fractures, T or Y type, and external fixator, 162, 163p
103p 153p and intramedullary pin or interlocking
of digit, 110, 111p in shoulder arthrodesis, 14, 15p nail, 154, 155p
of forelimb, 100, 101p in shoulder luxation, medial, 7p and plate application, 158, 159p
of mandible, 9698, 97p, 99p Biceps femoris muscle in humeral distal fractures, T or Y type,
of rear limb in Achilles tendon repair, 74 153p
at coxofemoral joint, 106, 107p, 108 in femoral diaphyseal fractures, 129p, 133p Bridging plate in diaphyseal fractures
at midshaft of femur, 106, 108, 109p and external fixator, 192, 193p of femur, 128, 129p, 190, 191p
Anconeal muscle and intramedullary pin or interlocking of humerus, 158, 160, 161p
in arthrodesis of elbow, 28, 29p nail, 186, 187p of radius, 166, 167p
in fracture of proximal ulna, 173p and plate application, 190, 191p of tibia, 128, 204, 205p

239
240 INDEX

C Compression plate, 118, 119p Diaphyseal fractures (Continued)


Calcaneoquartal joint in femoral diaphyseal fractures, 190, 191p radial, 166168, 167p, 169p
in partial tarsal arthrodesis in humeral diaphyseal fractures, 158, 160, short oblique or transverse
with intramedullary pin and wire, 94 161p compression plate in, 118, 119p
with plate, 92 in metacarpal and metatarsal fractures, intramedullary pin and external fixator
in shearing injury with tarsal luxation, 78 214, 215p in, 120, 121p
Calcaneus in radial diaphyseal fractures, 166, 167p type Ib external fixator in, 122, 123p
in Achilles tendon repair, 75p in tibial diaphyseal fractures, 204, 205p tibial, 202208, 203p, 205p, 207p, 209p
in talus osteochondrosis of lateral Condylar fractures of humerus, 150, 151p Digastricus muscle in mandibular body
trochlear ridge, 85p Contracture of infraspinatus muscle, 4, 5p fractures, 138, 139p
in tarsal arthrodesis, 90 Coracobrachial muscles in medial shoulder Digit amputation, 110, 111p
with intramedullary pin and wire, 94, 95p luxation, 6, 7p Disarticulation, coxofemoral, in rear limb
with plate, 92, 93p Coronoid process of ulna, fragmented, 16, amputation, 106, 107p, 108
in tarsal fractures, 212, 213p 17p Disc disorders, intervertebral. See
in tarsal shearing injury and luxation, 80 Coxofemoral joint Intervertebral disc disorders
Carotid sheath in ventral cervical disarticulation in rear limb amputation, Dynamic proximal ulnar osteotomy in
decompression, 222, 223p 106, 107p, 108 ununited anconeal process, 22, 24, 25p
Carpometacarpal joint in extracapsular stabilization of hip
in pancarpal arthrodesis, 32 luxation, 3840, 39p, 41p E
in partial carpal arthrodesis in intracapsular stabilization of hip Elbow disorders
with intramedullary pins, 36 luxation, 4244, 43p, 45p arthrodesis in, 28, 29p
with plate, 34 in ostectomy of femoral head and neck distal ulnar ostectomy, 26, 27p
Carpus disorders with joint capsule interpolation, 46, humeral fractures, 150, 151p, 152, 153p
arthrodesis in, 32, 33p 47p lateral luxation, 1820, 19p, 21p
with intramedullary pins, 36, 37p in triple pelvic osteotomy, 4850, 49p, 51p osteochondrosis and fragmented medial
with plate, 34, 35p Cruciate ligaments in stifle luxation, 56, 58, coronoid process, 16, 17p
metacarpal fractures, 214, 215p 59p ununited anconeal process, 2224, 23p,
radial carpal bone fractures, 210, 211p intra-articular repair of, 6466, 65p, 67p 25p
radius or ulna styloid process fractures, 30, lateral fabellar suture in repair of, 6062, Extensor carpi radialis muscle
31p 61p, 63p in carpal arthrodesis, 33p
Cephalic vein in forelimb amputation with with meniscus damage, 68, 69p with intramedullary pins, 37p
scapulectomy, 100, 101p with plate, 35p
Cerclage wires, 126, 127p D in elbow luxation, lateral, 18, 19p
in femoral diaphyseal fractures, 126, 186, Deltoideus muscle in humeral fractures, distal
188, 189p in forelimb amputation with scapulectomy, lateral condylar, 150, 151p
in humeral diaphyseal fractures, 126 101p T or Y type, 152, 153p
external fixator used with, 164, 165p in forelimb salvage with scapulectomy, in radial carpal bone fractures, 210, 211p
intramedullary pin used with, 126, 156, 102, 103p, 104 Extensor digital muscles
157p, 164 in humeral diaphyseal fractures, 155p, in carpal arthrodesis, 32, 33p
in mandibular symphyseal fractures, 136, 159p, 163p with intramedullary pins, 36
137p in humeral physeal fractures, proximal, with plate, 34, 35p
in tibial diaphyseal fractures 148, 149p in elbow luxation, lateral, 18, 19p
external fixator used with, 208, 209p in infraspinatus muscle contracture, 4, 5p in humeral fractures, distal
intramedullary pin used with, 126, 202, in scapular neck fractures, 146, 147p lateral condylar, 150, 151p
203p in shoulder arthrodesis, 14, 15p T or Y type, 152, 153p
Cervical disc disorders in shoulder luxation, lateral, 10, 11p in metacarpal and metatarsal fractures,
ventral decompression in, 218, 220, in shoulder osteochondrosis, 2, 3p 214, 215p
222224, 223p, 225p Derotational osteotomy, transverse, in radial carpal bone fractures, 210, 211p
ventral fenestration in, 218220, 219p, stabilized with plate, 114, 115p in stifle arthrodesis, 73p
221p, 222 Desmotomy in medial patella luxation, in talus osteochondrosis
Collateral ligaments 52, 53p of lateral trochlear ridge, 82, 83p, 84, 85p
lateral Dewclaw amputation, 110, 111p of medial trochlear ridge, 87p
in cranial cruciate ligament repair with Diaphyseal fractures. See also specific bones in tibial malleolar fractures, 201p
lateral fabellar suture, 62, 63p bone grafts in, 134, 135p. See also Bone in ulnar ostectomy with fat graft, distal,
in elbow arthrodesis, 28, 29p graft, in diaphyseal fractures 26, 27p
in elbow luxation, lateral, 20, 21p comminuted Extensor hallucis longus muscle in talus
in stifle arthrodesis, 73p interlocking nail in, 132, 133p osteochondrosis, 82, 83p, 87p
in stifle luxation, 56, 58, 59p intramedullary pin and bridging plate in, External fixation
in tarsal shearing injury and luxation, 78 128, 129p in comminuted diaphyseal fractures, 130,
medial type II external fixator in, 130, 131p 131p
in stifle luxation, 56, 57p femoral, 186194, 187p, 189p, 191p, 193p, in femoral diaphyseal fractures, 192194,
in talus osteochondrosis of medial 195p 193p, 195p
trochlear ridge, 88, 89p humeral, 154164, 155p, 157p, 159p, 161p, intramedullary pin used with, 120, 186,
in tarsal shearing injury and luxation, 78, 163p, 165p 188, 189p, 192194, 193p, 195p
80 long oblique in humeral diaphyseal fractures, 120,
in tibial distal physeal fractures, 198, 199p intramedullary pin and cerclage wires in, 162164, 163p, 165p
in tibial malleolar fractures, 200, 201p 126, 127p cerclage wires used with, 164, 165p
radial, in radial carpal bone fractures, 210, lag screws and neutralization plate in, intramedullary pin used with, 120,
211p 124, 125p 162164, 165p
INDEX 241

External fixation (Continued) Femur (Continued) Fractures


type Ia external fixator in, 156, 157p, in femoral head and neck ostectomy with of carpus, 210, 211p
164, 165p joint capsule interpolation, 46, 47p of diaphysis. See Diaphyseal fractures
type Ib external fixator in, 164, 165p in femoral neck fractures, 182, 183p of femur, 180194, 181p, 183p, 185p, 187p,
in mandibular body fractures, in femoral physeal fractures, 180, 181p 189p, 191p, 193p, 195p
comminuted, 140, 141p in intracapsular stabilization of hip of humerus, 148164, 149p, 151p, 153p,
in radial diaphyseal fractures, 122, 168, 169p luxation, 4244, 43p, 45p 155p, 157p, 159p, 161p, 163p, 165p
in radial oblique osteotomy, 112, 113p transverse derotational osteotomy of mandible, 9698, 97p, 136140, 137p,
in short oblique or transverse diaphyseal stabilized with plate, 114, 115p 139p, 141p
fractures Fenestration of metacarpal and metatarsal bones, 214,
intramedullary pin used with, 120, 121p of cervical discs, ventral, 218220, 219p, 215p
type Ib external fixator in, 122, 123p 221p, 222 of pelvis, 174178, 175p, 177p, 179p
in tarsal shearing injury with luxation, of thoracolumbar discs, 226, 230232, of radius, 30, 31p, 166170, 167p, 169p,
80, 81p 231p 171p
in tibial diaphyseal fractures, 122, 206208, Fibula, distal of scapula, 142146, 143p, 145p, 147p
207p, 209p in malleolar fractures, 200, 201p of tarsus, 212, 213p
intramedullary pin used with, 120, 202, in talus osteochondrosis of tibia, 196208, 197p, 199p, 201p, 203p,
203p of lateral trochlear ridge, 82, 84 205p, 207p, 209p
in tibial oblique osteotomy, 112, 113p of medial trochlear ridge, 86, 88 of ulna, 30, 31p, 172, 173p
in tarsal arthrodesis, 90
F with intramedullary pin and wire, 94 G
Fabella in stifle luxation and instability, 52, 58 in tarsal shearing injury and luxation, 80 Gastrocnemius muscle
and lateral suture repair of cranial cruciate in tibial physeal fractures, 198, 199p in Achilles tendon repair, 74, 75p
ligament, 6062, 61p, 63p Flexor carpi radialis muscle in femoral physeal fractures, distal, 185p
Facial artery and vein in mandibular body in elbow osteochondrosis and fragmented in tarsal arthrodesis
fractures, 139p medial coronoid process, 16, 17p with intramedullary pin and wire, 95p
Fascia lata in radial fractures with plate, 93p
graft in cranial cruciate ligament repair, diaphyseal, and plate application, 167p in tarsal fractures, 213p
65p, 66 of styloid process, 31p Gemellus muscle
in physeal femoral fractures, distal, 185p in ulnar styloid fractures, 31p in acetabular fractures, 178, 179p
tensor muscle of. See Tensor fascia latae Flexor carpi ulnaris muscle in extracapsular stabilization of hip
muscle in elbow arthrodesis, 28, 29p luxation, 38
Fat graft, distal ulnar ostectomy with, 26, 27p in ulnar fractures, proximal, 172, 173p in intracapsular stabilization of hip
Femoral artery and vein in rear limb Flexor digital muscles luxation, 42, 43p
amputation in Achilles tendon repair, 74, 75p Glenohumeral ligament
at coxofemoral joint, 106, 107p in elbow osteochondrosis and fragmented in lateral shoulder luxation, 1012, 11p, 13p
at midshaft of femur, 108, 109p medial coronoid process, 16, 17p in medial shoulder luxation, 68, 7p, 9p
Femur in radial diaphyseal fracture and plate Gluteal artery and vein in triple pelvic
coxofemoral disarticulation in rear limb application, 167p osteotomy, 50, 51p
amputation, 106, 107p in talus osteochondrosis of medial Gluteal muscles
diaphyseal fractures of trochlear ridge, 88, 89p in acetabular fractures, 178, 179p
external fixator in, 120, 186, 188, 189p, in tarsal arthrodesis in femoral head and neck ostectomy with
192194, 193p, 195p with intramedullary pin and wire, 94, joint capsule interpolation, 46, 47p
interlocking nail in, 132, 133p, 186188, 95p in femoral neck fractures, 182, 183p
187p, 189p with plate, 92, 93p in femoral physeal fractures, proximal,
intramedullary pin in. See Intramedullary in tarsal fractures, 212, 213p 180, 181p
pins, in femoral diaphyseal Flexor hallucis longus muscle in hip luxation
fractures in Achilles tendon repair, 75p and extracapsular stabilization, 38, 39p
plate application in, 128, 129p, 190, 191p in talus osteochondrosis and intracapsular stabilization, 42, 43p
distal of lateral trochlear ridge, 85p in ilial body fractures, 176, 177p
in arthrodesis of stifle, 72, 73p of medial trochlear ridge, 88, 89p in rear limb amputation with coxofemoral
in deranged stifle luxation, 56, 57p in tarsal arthrodesis disarticulation, 107p
in femoral physeal fractures, 184, 185p with intramedullary pin and wire, 95p in sacroiliac luxation, 174, 175p
in intra-articular cranial cruciate with plate, 93p in triple pelvic osteotomy, 50, 51p
ligament repair, 64, 65p, 66, 67p in tarsal fractures, 213p Gluteal nerve in triple pelvic osteotomy, 50
in meniscectomy, 68, 70 in tibial malleolar fractures, 201p Gracilis muscle
in notchplasty for cranial cruciate Forage procedure in rear limb amputation
ligament repair, 64, 65p in elbow osteochondrosis, 16 at coxofemoral joint, 106, 107p
in tibial physeal fractures, 196, 197p in shoulder osteochondrosis, 2 at midshaft of femur, 108, 109p
in wedge recession trochleoplasty for Forelimb in triple pelvic osteotomy, 48, 49p
medial patella luxation, 52, 53p amputation with scapulectomy, 100, 101p Grafts
fractures of, 180194, 181p, 183p, 185p, carpus disorders, 3036, 31p, 33p, 35p, of bone. See Bone graft
187p, 189p, 191p, 193p, 195p 37p of fascia lata and patellar tendon in cranial
midshaft level rear limb amputation, 106, digit amputation, 110, 111p cruciate ligament repair, 65p, 66
108, 109p elbow joint disorders, 1628, 17p, 19p, 21p, of fat, distal ulnar ostectomy with, 26, 27p
proximal 23p, 25p, 27p, 29p
in acetabular fractures, 178, 179p salvage with scapulectomy, 102104, 103p H
in extracapsular stabilization of hip shoulder joint disorders, 214, 3p, 5p, 7p, Hemilaminectomy, thoracolumbar, 226228,
luxation, 3840, 41p 9p, 11p, 13p, 15p 227p, 229p, 230
242 INDEX

Hemimandible Ilium (Continued) Intramedullary pins (Continued)


in rostral hemimandibulectomy, 96, 98, 99p in intracapsular stabilization of hip in metacarpal and metatarsal fractures,
in transverse and oblique mandibular body luxation, 42 214, 215p
fractures, 139p in sacroiliac luxation, 174, 175p in radial diaphyseal fractures and plate
Hip disorders in triple pelvic osteotomy, 50, 51p application, 166
acetabular fractures, 178, 179p Imbrication in short oblique or transverse diaphyseal
femoral fractures, 180, 181p, 182, 183p in hip luxation fractures, 120, 121p
femoral head and neck ostectomy with and extracapsular stabilization, 40 in tarsal arthrodesis, partial, 94, 95p
joint capsule interpolation in, 46, 47p and intracapsular stabilization, 44 in tibial diaphyseal fractures, 202, 203p
luxation and instability in patella luxation, 54 cerclage wires used with, 126, 202, 203p
extracapsular stabilization in, 3840, Infraspinatus muscle external fixator used with, 120, 202,
39p, 41p contracture of, 4, 5p 203p
intracapsular stabilization in, 4244, 43p, in forelimb salvage with scapulectomy, plate used with, 128, 204, 205p
45p 102, 103p Ischium
triple pelvic osteotomy in, 4850, 49p, 51p in humeral physeal fractures, proximal, in extracapsular stabilization of hip
Humerus 148, 149p luxation, 38
diaphyseal fractures of in scapular body fractures, transverse, 142, in femoral head and neck ostectomy with
cerclage wires in, 126, 156, 157p, 164, 143p joint capsule interpolation, 46
165p in scapular neck fractures, 146, 147p in intracapsular stabilization of hip
external fixation in. See External in shoulder arthrodesis, 14, 15p luxation, 42
fixation, in humeral diaphyseal in shoulder luxation, lateral, 10, 11p, 12, in triple pelvic osteotomy, 48, 49p
fractures 13p
interlocking nail in, 132, 154156, 155p, in supraglenoid tuberosity fractures, 145p J
157p Instability. See Luxation and instability Joint disorders
intramedullary pin in. See Intramedullary Interlocking nail in diaphyseal fractures amputations in, 96110, 97p, 99p, 101p,
pins, in humeral diaphyseal of femur, 132, 133p, 186188, 187p, 189p 103p, 107p, 109p, 111p
fractures of humerus, 132, 154156, 155p, 157p of carpus, 3036, 31p, 33p, 35p, 37p
plate application in, 128, 158160, 159p, of tibia, 132, 202, 203p of elbow, 1628, 17p, 19p, 21p, 23p, 25p,
161p Intertarsal joint 27p, 29p
distal in pantarsal arthrodesis, 90 of hip, 3850, 39p, 41p, 43p, 45p, 47p, 49p,
in arthrodesis of elbow, 28, 29p in partial tarsal arthrodesis 51p
in fragmented medial coronoid process with intramedullary pin and wire, 94, 95p of shoulder, 214, 3p, 5p, 7p, 9p, 11p, 13p,
and osteochondrosis, 16, 17p with plate, 92, 93p 15p
in intercondylar T or Y type fractures, in shearing injury with tarsal luxation, 78, 80 of stifle, 5272, 53p, 55p, 57p, 59p, 61p,
152, 153p Intervertebral disc disorders 63p, 65p, 67p, 69p, 71p, 73p
in lateral condylar fractures, 150, 151p cervical of tarsus, 7494, 75p, 77p, 79p, 81p, 83p,
in luxation of elbow, lateral, 1820, 19p, ventral decompression in, 218, 220, 85p, 87p, 89p, 91p, 93p, 95p
21p 222224, 223p, 225p
in ununited anconeal process, 22, 25p ventral fenestration in, 218220, 219p, K
fractures of, 148164, 149p, 151p, 153p, 221p, 222 Kirschner wires
155p, 157p, 159p, 161p, 163p, 165p lumbosacral laminectomy in, 234236, in acetabular fractures, 178, 179p
proximal 235p, 237p in femoral neck fractures, 182, 183p
in arthrodesis of shoulder, 14, 15p thoracolumbar in femoral physeal fractures, proximal,
in bone grafts, as donor site, 134, 135p fenestration in, 230232, 231p 180, 181p
in forelimb amputation with hemilaminectomy in, 226228, 227p, in hip luxation and extracapsular
scapulectomy, 100 229p, 230 stabilization, 40, 41p
in forelimb salvage with scapulectomy, Intramedullary pins in humeral condylar fractures, 150, 151p
102 in carpal arthrodesis, partial, 36, 37p in humeral physeal fractures, proximal,
in humeral physeal fractures, 148, 149p in comminuted diaphyseal fractures, 128, 148, 149p
in lateral shoulder subluxation, 1012, 129p in radial physeal fractures, distal, 170, 171p
11p, 13p in femoral diaphyseal fractures, 186188, in radial styloid fractures, 30, 31p
in medial shoulder luxation, 68, 7p, 9p 187p, 189p in tarsal fractures, 212, 213p
in osteochondrosis, 2, 3p cerclage wires used with, 126, 186, 188, in tibial malleolar fractures, 200, 201p
in scapular neck fractures, 146, 147p 189p in tibial physeal fractures
in supraglenoid tuberosity fractures, 144, external fixator used with, 120, 186, 188, distal, 198, 199p
145p 189p, 192194, 193p, 195p proximal, 196, 197p
plate used with, 128, 129p, 190, 191p in ulnar styloid fractures, 30, 31p
I in femoral physeal fractures, distal, 184,
Iliopsoas muscle in rear limb amputation 185p L
with coxofemoral disarticulation, 106, in humeral diaphyseal fractures, 154156, Lag screw fixation, 124, 125p
107p 155p, 157p in elbow arthrodesis, 28, 29p
Ilium cerclage wires used with, 126, 156, 157p, in femoral diaphyseal fractures, plate
in bone grafts, as donor site, 134, 135p 164 application with, 190, 191p
in extracapsular stabilization of hip external fixator used with, 120, 162164, in humeral fractures, distal
luxation, 38 163p, 165p lateral condylar, 150, 151p
in femoral head and neck ostectomy with plate used with, 128, 158160, 159p, 161p T or Y type, 152, 153p
joint capsule interpolation, 46 in long oblique diaphyseal fractures, 126, in metacarpal and metatarsal fractures,
in fractures of ilial body, 176, 177p 127p 214, 215p
INDEX 243

Lag screw fixation (Continued) Mandible (Continued) Omobrachial vein in forelimb amputation
in radial carpal bone fractures, 210, 211p symphyseal, cerclage wire in, 136, 137p with scapulectomy, 100, 101p
in radial fractures transverse and oblique, orthopedic wire Omotransversarius muscle
diaphyseal, plate application with, 166, in, 138, 139p in forelimb amputation with scapulectomy,
167p tumors of, mandibulectomy in, 9698, 97p, 100, 101p
in styloid process, 30, 31p 99p in forelimb salvage with scapulectomy,
in sacroiliac luxation, 174, 175p Mandibular artery 102, 103p, 104
in scapular neck fractures, 146, 147p in fractures of mandibular body, 138, 140 Osteochondrosis
in shoulder arthrodesis, 14, 15p in mandibulectomy, 96, 98 of elbow, 16, 17p
in supraglenoid tuberosity fractures, 144, Mandibular nerve in mandibular body of shoulder, 2, 3p
145p fractures, 138, 140 of talus
in tarsal fractures, 212, 213p Mandibulectomy, 9698, 97p, 99p in lateral trochlear ridge, 8284, 83p, 85p
in tibial fractures Maxillectomy, 98 in medial trochlear ridge, 8688, 87p, 89p
diaphyseal, plate application with, 204, Mayo mattress suture, modified, in medial
205p patella luxation, 54, 55p P
malleolar, 200, 201p Median artery in radial diaphyseal fractures Pancarpal arthrodesis, 32, 33p
in ulnar fractures and plate application, 167p Pantarsal arthrodesis, 90, 91p
distal, in styloid process, 30, 31p Meniscectomy, 6870, 69p, 71p Patella
proximal, plate application with, 172, Meniscus in stifle luxation and instability, 56, in arthrodesis of stifle, 72, 73p
173p 6870, 69p, 71p in femoral physeal fractures, 184, 185p
in ununited anconeal process, 22, 24, 25p and intra-articular repair of cranial medial luxation of, 5254, 53p, 55p
Laminectomy cruciate ligament, 64, 66 Patellar ligament in proximal tibial physeal
lumbosacral dorsal, 234236, 235p, 237p and lateral fabellar suture repair of cranial fractures, 197p
thoracolumbar hemilaminectomy, 226228, cruciate ligament, 60, 61p, 62 Patellar tendon
227p, 229p, 230 Metacarpal bones in cranial cruciate ligament repair, 66
Latissimus dorsi muscle in forelimb fractures of, 214, 215p in femoral physeal fractures, 184, 185p
amputation with scapulectomy, 100, 101p in pancarpal arthrodesis, 32 in medial patella luxation, 52, 54
Longus colli muscles in partial carpal arthrodesis Pectineus muscle
in ventral cervical decompression, 222, with intramedullary pins, 36 in rear limb amputation
223p, 224 with plate, 34 at coxofemoral joint, 106, 107p
in ventral cervical fenestration, 218, 219p, Metacarpophalangeal joint in digital at midshaft of femur, 108, 109p
220 amputation, 110, 111p in triple pelvic osteotomy, 48, 49p
Lumbosacral laminectomy, dorsal, 234236, Metatarsal bones Pectoral muscles
235p, 237p fractures of, 214, 215p in forelimb amputation with scapulectomy,
Luxation and instability in pantarsal arthrodesis, 90 100, 101p
of elbow, lateral, 1820, 19p, 21p in partial tarsal arthrodesis in humeral diaphyseal fractures
of hip with intramedullary pin and wire, 94 and external fixator, 162, 163p
extracapsular stabilization in, 3840, with plate, 92 and intramedullary pin or interlocking
39p, 41p in shearing injury with tarsal luxation, 80 nail, 154, 155p
intracapsular stabilization in, 4244, 43p, Monteggia fracture, 172 and plate application, 158, 159p
45p Musculocutaneous nerve in humeral in shoulder luxation, medial, 6, 7p, 8
of sacroiliac joint, 174, 175p diaphyseal fractures and plate Pelvis
of shoulder application, 158, 159p in acetabular fractures, 178, 179p
lateral, 1012, 11p, 13p Mylohyoideus muscle in mandibular body in extracapsular stabilization of hip
medial, 68, 7p, 9p fractures, 139p luxation, 3840, 39p, 41p
of stifle in femoral head and neck ostectomy with
intra-articular repair of cranial cruciate N joint capsule interpolation, 46, 47p
ligament in, 6466, 65p, 67p Nail, interlocking. See Interlocking nail in in ilial body fractures, 176, 177p
lateral fabellar suture repair of cranial diaphyseal fractures in intracapsular stabilization of hip
cruciate ligament in, 6062, 61p, 63p Neutralization plate in diaphyseal fractures, luxation, 4244, 43p, 45p
meniscectomy in, 6870, 69p, 71p 124, 125p in sacroiliac luxation, 174, 175p
suture anchors, screws, and sutures in, of femur, 190, 191p in triple osteotomy, 4850, 49p, 51p
5658, 57p, 59p of humerus, 158, 160, 161p Peroneus muscles
wedge recession trochleoplasty, of radius, 166, 167p in talus osteochondrosis
desmotomy, tibial tuberosity of tibia, 204, 205p of lateral trochlear ridge, 82, 83p, 84, 85p
transposition, and retinacular Notchplasty, femoral, in intra-articular repair of medial trochlear ridge, 87p
imbrication in, 5254, 53p, 55p of cranial cruciate ligament, 64, 65p in tarsal arthrodesis
of tarsus, in shearing injury, 7880, 79p, with intramedullary pin and wire, 95p
81p O with plate, 93p
Oblique osteotomy stabilized with type II in tibial malleolar fractures, 201p
M external fixator, 112, 113p Phalangeal bones in digital amputation, 110,
Malleolar fractures of tibia or fibula, 200, Obturator nerve in triple pelvic osteotomy, 111p
201p 48, 50 Physeal fractures
Mandible Olecranon of ulna of femur
fractures of in arthrodesis of elbow, 28, 29p distal, 184, 185p
comminuted, acrylic external fixation in, in lateral elbow luxation, 18, 19p proximal, 180, 181p
140, 141p in ununited anconeal process, 2224, 23p, of humerus, proximal, 148, 149p
mandibulectomy in, 9698, 97p, 99p 25p of radius, distal, 170, 171p
244 INDEX

Physeal fractures (Continued) Q Retinaculum


of tibia Quadriceps muscles extensor
distal, 198, 199p in femoral physeal fractures, distal, 184, in lateral trochlear ridge of talus
proximal, 196, 197p 185p osteochondrosis, 83p
Pin fixation. See also Intramedullary pins in rear limb amputation in medial trochlear ridge of talus
in Achilles tendon repair with tension band at coxofemoral joint, 106, 107p osteochondrosis, 86, 87p
wire, 76, 77p at midshaft of femur, 108, 109p in tibial malleolar fractures, 201p
in femoral physeal fractures, distal, in stifle luxation, 52, 56 lateral, in medial patella luxation, 52, 53p, 54
crossed pins in, 184, 185p Rhomboideus muscle
in hip luxation, modified toggle pin in, R in forelimb amputation with scapulectomy,
4244, 43p, 45p Radial artery in diaphyseal fractures of 100, 101p
in humeral physeal fractures, proximal, radius and plate application, 167p in forelimb salvage with scapulectomy,
148, 149p Radial carpal bone 102, 104
in mandibular body fractures stabilized fractures of, 210, 211p Rotational deformity, transverse derotational
with acrylic external fixation, 140, in pancarpal arthrodesis, 32, 33p osteotomy stabilized with plate in, 114,
141p in partial carpal arthrodesis 115p
in radial diaphyseal fractures and external with intramedullary pins, 36, 37p
fixator, 168, 169p with plate, 34, 35p S
in radial styloid fractures and tension band in physeal fractures of radius, 171p Sacroiliac luxation, 174, 175p
wire, 30, 31p Radial nerve Saphenous artery
in ulnar styloid fractures and tension band in diaphyseal humeral fractures in tibial diaphyseal fractures, 202, 203p
wire, 30, 31p and external fixator, 162, 163p, 164 and plate application, 204, 205p
Plate application and intramedullary pin or interlocking in tibial malleolar fractures, 201p
in acetabular fractures, 178, 179p nail, 154, 155p, 156 Saphenous nerve in tibial diaphyseal
in carpal arthrodesis and plate application, 158, 159p fractures, 202, 203p
pancarpal, 32, 33p in distal humeral fractures, 150, 152 and plate application, 204, 205p
partial, 34, 35p Radius Saphenous vein
in comminuted diaphyseal fractures, 128, diaphyseal fractures of in talus osteochondrosis of lateral
129p external fixator in, 122, 168, 169p trochlear ridge, 82, 84
in elbow arthrodesis, 28, 29p plate application in, 166, 167p in tibial diaphyseal fractures, 202, 203p
in femoral diaphyseal fractures, 128, 129p, distal and plate application, 204, 205p
190, 191p in pancarpal arthrodesis, 32, 33p in tibial malleolar fractures, 200, 201p
in humeral fractures in partial carpal arthrodesis with Sartorius muscle
diaphyseal, 128, 158160, 159p, 161p intramedullary pins, 36, 37p in rear limb amputation
distal, T or Y type, 152, 153p in partial carpal arthrodesis with plate, at coxofemoral joint, 106, 107p
in ilial body fractures, 176, 177p 34, 35p at midshaft of femur, 108, 109p
in long oblique diaphyseal fractures, 124, in physeal fractures, 170, 171p in stifle luxation, 56, 57p
125p in radial carpal bone fractures, 210, 211p Scalenus muscle in forelimb amputation with
in metacarpal and metatarsal fractures, in styloid process fractures, 30, 31p scapulectomy, 100, 101p
214, 215p fractures of Scapula
in radial diaphyseal fractures, 166, 167p diaphyseal, 122, 166168, 167p, 169p in arthrodesis of shoulder, 14, 15p
in scapular fractures physeal distal, 170, 171p in forelimb amputation with scapulectomy,
in body of scapula, transverse, 142, styloid process, 30, 31p 100, 101p
143p oblique osteotomy stabilized with type II in forelimb salvage with scapulectomy,
in neck of scapula, 146, 147p external fixator, 112, 113p 102104, 103p
in short oblique or transverse diaphyseal proximal in luxation of shoulder
fractures, 118, 119p in arthrodesis of elbow, 28, 29p lateral, 1012, 11p, 13p
in shoulder arthrodesis, 14, 15p in lateral elbow luxation, 1820, 19p, 21p medial, 68, 7p, 9p
in stifle arthrodesis, 72, 73p in osteochondrosis of elbow and neck of scapula fractures, 146, 147p
in tarsal arthrodesis fragmented medial coronoid supraglenoid tuberosity fractures, 144,
pantarsal, 90, 91p process, 16, 17p 145p
partial, 92, 93p in ununited anconeal process, 22, 25p transverse scapular body fractures, 142,
in tibial diaphyseal fractures, 128, 204, Rear limb 143p
205p coxofemoral disarticulation in amputation, Scapulectomy
in transverse derotational osteotomy, 114, 106, 107p, 108 in forelimb amputation, 100, 101p
115p digital amputation, 110, 111p in forelimb salvage, 102104, 103p
in triple pelvic osteotomy, 50, 51p hip joint disorders, 3850, 39p, 41p, 43p, Scapulohumeral joint
in ulnar fractures, proximal, 172, 173p 45p, 47p, 49p, 51p arthrodesis of, 14
Prepubic tendon in triple pelvic osteotomy, midshaft femoral amputation, 106, 108, in forelimb salvage with partial
48, 49p 109p scapulectomy, 102, 104
Pronator teres muscle stifle disorders, 5272, 53p, 55p, 57p, 59p, in lateral shoulder luxation, 1012, 11p,
in elbow osteochondrosis and fragmented 61p, 63p, 65p, 67p, 69p, 71p, 73p 13p
medial coronoid process, 16 tarsus disorders, 7493, 75p, 77p, 79p, 81p, in medial shoulder luxation, 68, 7p, 9p
in humeral distal fractures, T or Y type, 83p, 85p, 87p, 89p, 91p, 93p, 95p Sciatic nerve
153p Rectus femoris muscle in acetabular fractures, 178, 179p
in radial diaphyseal fractures and plate in medial patella luxation, 52 in femoral diaphyseal fractures, 186, 188
application, 166, 167p in rear limb amputation with coxofemoral and plate application, 190
Pubis in triple pelvic osteotomy, 48, 49p disarticulation, 106, 107p in ilial body fractures, 176
INDEX 245

Sciatic nerve (Continued) Stifle disorders (Continued) Tarsocrural joint


in intracapsular stabilization of hip intra-articular repair of cranial cruciate in pantarsal arthrodesis, 90
luxation, 42, 43p, 44 ligament in, 6466, 65p, 67p in partial tarsal arthrodesis with
in rear limb amputation with coxofemoral lateral fabellar suture repair of cranial intramedullary pin and wire, 94
disarticulation, 107p cruciate ligament in, 6062, 61p, 63p in shearing injury with tarsal luxation, 78
in triple pelvic osteotomy, 50 medial patella luxation, 5254, 53p, 55p Tarsometatarsal joint
Screw, lag. See Lag screw fixation meniscectomy in, 6870, 69p, 71p in pantarsal arthrodesis, 90
Screw and washer combination suture anchors, screws, and sutures for in partial tarsal arthrodesis
in elbow luxation, lateral, 18, 20, 21p stabilization in, 5658, 57p, 59p with intramedullary pin and wire, 94,
in hip luxation, 40, 41p tibial physeal fractures, 196, 197p 95p
in humeral condylar fractures, 150 Styloid process fractures of radius and ulna, with plate, 92
in shoulder luxation 30, 31p in shearing injury with tarsal luxation, 78
lateral, 10, 12, 13p Subscapularis muscle Tarsus disorders
medial, 6, 8, 9p in forelimb salvage with scapulectomy, Achilles tendon rupture, 7476, 75p, 77p
in stifle luxation, 5658, 57p 102 arthrodesis in, 90, 91p
and intra-articular repair of cranial in medial shoulder luxation, 6, 7p, 8 with intramedullary pin and wire, 94,
cruciate ligament, 66, 67p Supinator muscle in radial diaphyseal 95p
in supraglenoid tuberosity fractures, 144, fractures and plate application, 166, with plate, 92, 93p
145p 167p fractures, 212, 213p
in tarsal luxation, 7880, 79p Supraglenoid tuberosity fractures, 144, 145p metatarsal, 214, 215p
Semimembranosus muscle in rear limb Suprascapular artery tibial malleolar, 200, 201p
amputation in scapular neck fractures, 146 tibial physeal, 198, 199p
at coxofemoral joint, 106, 107p in shoulder arthrodesis, 14 osteochondrosis
at midshaft of femur, 108, 109p Suprascapular nerve of lateral trochlear ridge of talus, 8284,
Semitendinosus muscle in rear limb in scapular neck fractures, 146, 147p 83p, 85p
amputation in shoulder arthrodesis, 14 of medial trochlear ridge of talus, 8688,
at coxofemoral joint, 106, 107p in shoulder luxation, medial, 6, 8 87p, 89p
at midshaft of femur, 108, 109p in supraglenoid tuberosity fractures, 144, shearing injury with luxation, 7880, 79p,
Serratus ventralis muscle 145p 81p
in forelimb amputation with scapulectomy, Supraspinatus muscle Teeth
100, 101p in forelimb salvage with scapulectomy, occlusion of
in forelimb salvage with scapulectomy, 102, 103p in comminuted mandibular body
102, 103p, 104 in humeral physeal fractures, proximal, fractures, 140, 141p
Shearing injury with tarsal luxation, 7880, 149p in symphyseal mandibular fractures, 136,
79p, 81p in infraspinatus muscle contracture, 5p 137p
Shoulder disorders in scapular body fractures, transverse, 142, in transverse and oblique mandibular
arthrodesis in, 14, 15p 143p body fractures, 138, 139p
contracture of infraspinatus muscle, 4, 5p in shoulder arthrodesis, 14, 15p removal in mandibulectomy, 96, 97p
humeral physeal fractures, 148, 149p in shoulder luxation Tension band wire
lateral luxation, 1012, 11p, 13p lateral, 11p in acetabular fractures, 178, 179p
medial luxation, 68, 7p, 9p medial, 6, 7p, 8 in Achilles tendon injuries, 76, 77p
osteochondrosis, 2, 3p Suture anchor system in femoral physeal fractures, proximal,
scapular fractures, 142146, 143p, 145p, in elbow luxation, lateral, 18, 20 180, 181p
147p in hip luxation, 40, 41p in hip luxation and extracapsular
Spine in shoulder luxation stabilization, 40, 41p
cervical disc disorders lateral, 10, 11p in radial styloid fractures, 30, 31p
ventral decompression in, 218, 220, medial, 6, 8, 9p in scapular neck fractures, 146, 147p
222224, 223p, 225p in stifle luxation, 5658, 57p, 59p in supraglenoid tuberosity fractures, 144,
ventral fenestration in, 218220, 219p, Symphyseal fracture of mandible, cerclage 145p
221p, 222, 224 wire in, 136, 137p in tarsal fractures, 212, 213p
lumbosacral laminectomy, 234236, 235p, in ulnar fractures
237p T distal, in styloid process, 30, 31p
thoracolumbar disc disorders Talocalcaneocentral joint proximal, 172, 173p
fenestration in, 226, 230232, 231p in partial tarsal arthrodesis Tensor fascia latae muscle
hemilaminectomy in, 226228, 227p, with intramedullary pin and wire, 94 in acetabular fractures, 178, 179p
229p, 230 with plate, 92 in femoral head and neck ostectomy with
Sternohyoideus muscle in shearing injury with tarsal luxation, 78 joint capsule interpolation, 46, 47p
in ventral cervical decompression, 222, Talocrural joint in shearing injury with tarsal in femoral neck fractures, 182, 183p
223p, 224 luxation, 78 in femoral physeal fractures, proximal,
in ventral cervical fenestration, 218, 219p, Talus 180, 181p
220 in pantarsal arthrodesis, 90, 91p in hip luxation
Sternomastoideus muscle in partial tarsal arthrodesis with and extracapsular stabilization, 38, 39p
in ventral cervical decompression, 222, intramedullary pin and wire, 94 and intracapsular stabilization, 42, 43p
224 in shearing injury with tarsal luxation, 78, 80 in rear limb amputation with coxofemoral
in ventral cervical fenestration, 218, 220 in tarsal fractures, 212, 213p disarticulation, 106, 107p
Stifle disorders trochlear ridge osteochondrosis of in triple pelvic osteotomy, 50, 51p
arthrodesis in, 72, 73p lateral, 8284, 83p, 85p Teres major muscle in forelimb salvage with
femoral physeal fractures, 184, 185p medial, 8688, 87p, 89p scapulectomy, 102, 103p
246 INDEX

Teres minor muscle Tibial muscles (Continued) Ulna (Continued)


in forelimb salvage with scapulectomy, in lateral trochlear ridge of talus fractures of
102, 103p osteochondrosis, 82, 83p distal, in styloid process, 30, 31p
in humeral physeal fractures, proximal, in medial patella luxation, 53p, 54, 55p proximal, 172, 173p
148, 149p in medial trochlear ridge of talus in physeal fracture of radius, 171p
in infraspinatus muscle contracture, 4, 5p osteochondrosis, 86, 87p proximal
in scapular neck fractures, 147p in stifle arthrodesis, 72, 73p fractures of, 172, 173p
in shoulder arthrodesis, 14, 15p in tarsal arthrodesis, 90, 91p in fragmented medial coronoid process,
in shoulder luxation, lateral, 11p in tarsal shearing injury and luxation, 16, 17p
in shoulder osteochondrosis, 2, 3p 79p in luxation of elbow, lateral, 1820, 19p,
in supraglenoid tuberosity fractures, 145p in tibial malleolar fractures, 200, 201p 21p
Thoracic artery and vein in forelimb in tibial physeal fractures, 197p, 198, in ostectomy for elbow arthrodesis, 28,
amputation with scapulectomy, 101p 199p 29p
Thoracic nerve in forelimb amputation with Toggle pin, modified, in intracapsular in ununited anconeal process, 2224,
scapulectomy, 101p stabilization of hip luxation, 4244, 43p, 23p, 25p
Thoracolumbar disc disorders 45p Ulnar artery and vein, in elbow
fenestration in, 226, 230232, 231p Trachea osteochondrosis and fragmented medial
hemilaminectomy in, 226228, 227p, 229p, in cervical disc decompression, 222, 223p coronoid process, 16
230 in cervical disc fenestration, 219p Ulnaris lateralis muscle
Tibia Transverse derotational osteotomy stabilized in arthrodesis of elbow, 28, 29p
diaphyseal fractures of with plate, 114, 115p in distal ulnar ostectomy with fat graft, 26,
cerclage wires in, 126, 202, 203p, 208, Trapezius muscle 27p
209p in forelimb amputation with scapulectomy, in proximal ulnar fractures, 172, 173p
external fixator in, 120, 122, 202, 203p, 100, 101p
206208, 207p, 209p in forelimb salvage with scapulectomy, V
interlocking nail in, 132, 202, 203p 102, 103p, 104 Vastus intermedius muscle
intramedullary pin in. See Intramedullary Triceps brachii muscle in femoral diaphyseal fractures, 129p,
pins, in tibial diaphyseal fractures in forelimb amputation with scapulectomy, 133p, 187p
plate application in, 128, 204, 205p 101p and external fixator, 193p
distal in forelimb salvage with scapulectomy, and plate application, 191p
in lateral trochlear ridge of talus 102, 103p, 104 in patella luxation, medial, 52
osteochondrosis, 82, 84 in humeral fractures Vastus lateralis muscle
in malleolar fractures, 200, 201p diaphyseal, and plate application, 158, in femoral diaphyseal fractures, 129p,
in medial trochlear ridge of talus 159p 133p, 186, 187p
osteochondrosis, 86, 88 distal, T or Y type, 152, 153p and external fixator, 192, 193p
in pantarsal arthrodesis, 90, 91p lateral condylar, 150, 151p and plate application, 190, 191p
in partial tarsal arthrodesis with proximal physeal, 149p in femoral head and neck ostectomy with
intramedullary pin and wire, 94 in infraspinatus muscle contracture, 5p joint capsule interpolation, 46, 47p
in physeal fractures, 198, 199p in scapular body fractures, transverse, in femoral neck fractures, 182, 183p
in shearing injury with tarsal luxation, 143p in hip luxation
78, 80 in shoulder osteochondrosis, 2, 3p and extracapsular stabilization, 38, 39p
oblique osteotomy stabilized with type II in ununited anconeal process, 22, 23p and intracapsular stabilization, 42, 43p
external fixator, 112, 113p Trochanteric fracture of femur, 180, 181p in patella luxation, medial, 52
physeal fractures of Trochanteric osteotomy of femur in rear limb amputation with coxofemoral
distal, 198, 199p in acetabular fractures, 178, 179p disarticulation, 107p
proximal, 196, 197p in extracapsular stabilization of hip Vastus medialis muscle in medial patella
proximal luxation, 38 luxation, 52
in arthrodesis of stifle, 72, 73p in intracapsular stabilization of hip
in bone grafts, as donor site, 134, 135p luxation, 42 W
in deranged stifle luxation, 56, 57p, 58 Trochlear ridge of talus osteochondrosis Wedge recession trochleoplasty in medial
in intra-articular repair of cranial lateral, 8284, 83p, 85p patella luxation, 52, 53p
cruciate ligament, 64, 65p, 66, 67p medial, 8688, 87p, 89p Wire techniques. See also Kirschner wires
in lateral fabellar suture repair of cranial Trochleoplasty of femur in medial patella in acetabular fractures, 178, 179p
cruciate ligament, 60, 62, 63p luxation, 52, 53p in Achilles tendon injuries, 76, 77p
in meniscectomy, 68, 70 Tuberosity of tibia in femoral diaphyseal fractures, 126, 186,
physeal fractures of, 196, 197p fracture of, 196, 197p 188, 189p
tuberosity fracture, 196, 197p transposition in medial patella luxation, 52, in femoral physeal fractures, proximal,
tuberosity transposition in medial 54, 55p 180, 181p
patella luxation, 52, 54, 55p in hip luxation and extracapsular
Tibial muscles U stabilization, 40, 41p
caudal Ulna in humeral diaphyseal fractures, 126
in medial trochlear ridge of talus distal external fixator used with, 164, 165p
osteochondrosis, 88, 89p fracture of styloid process, 30, 31p intramedullary pin used with, 126, 156,
in tibial malleolar fractures, 201p in ostectomy with fat graft, 26, 27p 157p, 164
in tibial physeal fractures, distal, 199p in pancarpal arthrodesis, 32 in long oblique diaphyseal fractures, 126,
cranial in partial carpal arthrodesis with 127p
in intra-articular cranial cruciate intramedullary pins, 36 in mandibular body fractures, transverse
ligament repair, 65p in partial carpal arthrodesis with plate, 34 and oblique, 138, 139p
INDEX 247

Wire techniques (Continued) Wire techniques (Continued) Wire techniques (Continued)


in mandibular symphyseal fractures, 136, in tarsal arthrodesis, partial, 94, 95p in tibial malleolar fractures, 200, 201p
137p in tarsal fractures, 212, 213p in tibial physeal fractures, proximal, 196,
in radial styloid fractures, 30, 31p in tibial diaphyseal fractures 197p
in scapular neck fractures, 146, 147p external fixator used with, 208, 209p in ulnar fractures
in supraglenoid tuberosity fractures, 144, intramedullary pin used with, 126, 202, distal, in styloid process, 30, 31p
145p 203p proximal, 172, 173p

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