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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.
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 room—an 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
P L AT E 1
A B
Caudolateral
approach
Deltoideus muscle:
Scapular part
Acromial part
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
P L AT E 2
Supraspinatus
muscle Deltoideus muscle:
acromial part
Infraspinatus
muscle
Infraspinatus
muscle
6 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES
SHOULDER
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
P L AT E 3
SHOULDER
P L AT E 4
A B
Joint capsule
incised
Supraspinatus Infraspinatus
muscle muscle
Deltoideus muscle:
Infraspinatus acromial part
muscle
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
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
110º
Acromial head of
deltoideus muscle
C D
16 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES
ELBOW
P L AT E 6
Flexor carpi
radialis muscle
Joint capsule
incised
Superficial digital
flexor muscle
Medial coronoid
process of ulna
(fragmented)
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
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 12:33–39, 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 Flo’s 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
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
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:1–3,8 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 11:76–79, 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 4:101–110, 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 13:212–216, 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 19:349–362, 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):52–56, 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):75–86, 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
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 25:573–581, 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 11:92–99, 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 26:183–188, 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 10:69–76, 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 7:129–165, 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
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
C D
30 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES
CARPUS
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
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
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
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
P L AT E 1 5
Deep gluteal
muscle
Incision in
joint capsule Middle gluteal
muscle retracted
proximally
Vastus lateralis
muscle
Osteotomy of the
greater trochanter
Osteotomy of the
greater trochanter
Vastus lateralis muscle
40 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES
P L AT E 1 5
Bone anchor
C D
E1
E2
Reattachment
site
42 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES
HIP
P L AT E 1 6
Deep gluteal
muscle
Incision in
joint capsule Middle gluteal
muscle retracted
proximally
Vastus lateralis
muscle
Osteotomy of the
greater trochanter
Osteotomy of the
greater trochanter
Vastus lateralis muscle
44 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES
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
P L AT E 1 7
A
Middle gluteal muscle
retracted proximally
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
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 owner’s 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):269–273, 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 23:13–20, 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- 10:101–110, 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 20:291–297, 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
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
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 animal’s 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 23:855–875,
do not suture the cut edges if medial luxation is severe. Close 1992.
the subcutaneous tissue and skin over the arthrotomy and 2. L’Eplattenier H, Montavon P: Patellar luxation in dogs and cats:
Pathogenesis and diagnosis. Compend Contin Educ Pract Vet
retinacular incisions.
24:234–239, 2002.
3. L’Eplattenier 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 24:292–300, 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 16:31–36, 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
Cranialis tibialis
muscle reflected
56 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES
STIFLE
*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
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 animal’s 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 22:333–340, 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 26:207–214, 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 22:105–110, 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 39:333–340, 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
STIFLE
*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
‡
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
E3
STIFLE
P L AT E 2 2
A B
Biceps
femoris Notchplasty
muscle
Cranial cruciate
ligament débrided
Fascia
lata strip Tibial
tunnel
Cranialis tibialis
muscle reflected
66 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES
P L AT E 2 2
D E
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 débridement
because of stifle instability or excision
P L AT E 2 3
Cranial
cruciate
ligament Cut 1 Cut 2
Cut 3
Medial
meniscus
70 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES
P L AT E 2 3
C1 C2
D1 D2
72 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES
STIFLE
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
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
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
P L AT E 2 6
Tendon of
cranial tibial
muscle
80 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES
P L AT E 2 6
C D
82 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES
TA R S U S
P L AT E 2 7
Proximal extensor
retinaculum
B
Digital extensor
Tendon of retinaculum
extensor hallucis
longus muscle
84 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES
Plantarolateral Approach:2,4–6 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:2–6 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):835–845, 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):221–229, 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):13–18, 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):19–24, 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):95–113, 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):31–35, 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):435–439, 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 35:147–153, 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
P L AT E 2 8
Proximal extensor
retinaculum
B
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 Débridement 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:1,3–6 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):95–113, 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):835–845, 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 221–229, 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):13–18, 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):19–24, 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):31–35, 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):435–439, 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):598–600, 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 35:147–153, 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
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
P L AT E 3 0
A Tendon of
flexor hallucis
longus muscle
Tendon of
gastrocnemius B
muscle
Calcaneus
Peroneus
longus
Tendon of
abductor digiti
quinti muscle
Plantar view
94 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES
TA R S U S
P L AT E 3 1
A Tendon of
flexor hallucis
longus muscle
Tendon of
gastrocnemius
muscle
Calcaneus
B
Peroneus
longus
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 1–4 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:1–3,6 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
P L AT E 3 2
E
F
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
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
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
P L AT E 3 4
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
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):313–319, 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):585–587, 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
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
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
P L AT E 3 6
Lateral View
B1
A
B2 C
Semitendinosus muscle
Semimembranosus muscle
Adductor
muscle Adductor muscle Gracilis muscle
Semimembranosus
muscle
Quadriceps
group Semitendinosus 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
P L AT E 3 7
A1 A2 A3
Skin
incision
2 3 4 5
Bone incision
Proximal phalanx
Middle phalanx
Distal phalanx
C1 C2
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
P L AT E 3 8
A B
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
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
B C
118 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES
P L AT E 4 0
D
120 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES
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.
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
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 animal’s 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 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
P L AT E 4 3
B1 B2 B3
B6
B4 B5
C D
126 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES
P L AT E 4 4
A B
1 2
Alternate
twist
4
3 4
D 3
C
E
128 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES
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 (1987–1997). 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
P L AT E 4 6
C D
132 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES
Stabilizing a Comminuted
CHAPTER 47
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
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
P L AT E 4 9
E
138 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES
MANDIBLE
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.
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.
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
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
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.
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
P L AT E 5 5
Supraspinatus
muscle
Infraspinatus 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
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
HUMERUS
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
P L AT E 5 8
C D
158 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES
HUMERUS
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
P L AT E 5 9
C D E
162 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES
HUMERUS
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 127–141, 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
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
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
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
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
P L AT E 6 5
Hohmann retractor
C D
176 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES
P E LV I S
P L AT E 6 6
Shaft of
ilium
B C
178 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES
P E LV I S
P L AT E 6 7
Osteotomy of the
greater trochanter
A
Gemelli muscles incised
Sciatic nerve
Osteotomy of the
greater trochanter
D
180 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES
FEMUR
P L AT E 6 8
Tensor fasciae
latae muscle
retracted cranially
A
Biceps femoris muscle
retracted caudally
a
Distance a = b
C b
D
182 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES
FEMUR
P L AT E 6 9
Tensor fasciae
latae muscle
retracted cranially
Deep gluteal
muscle
Vastus lateralis
muscle
D
184 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES
FEMUR
P L AT E 7 0
Lateral
collateral
ligament
D
186 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES
FEMUR
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
Vastus
intermedius
muscle
A
188 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES
P L AT E 7 1
C D
190 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES
FEMUR
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
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 127–141, 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
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 Flo’s 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
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
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
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
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
P L AT E 7 8
Cranial branch
of medial saphenous
artery and vein
Saphenous nerve
C D
206 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES
TIBIAL FRACTURES
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 (1990–1994). 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
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 Flo’s 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
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
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
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 3–5
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):171–179, 1999.
2. Bray JP, Burbidge HM: The canine intervertebral disc. Part two:
POSTOPERATIVE EVALUATION 1,3–6 Degenerative changes—nonchondrodystrophoid versus chondrody-
The neurologic status of the patient should be serially evaluated strophoid discs. J Am Anim Hosp Assoc 34(2):135–144, 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):781–784,
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):76–77, 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):140–145, 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
P L AT E 8 4
A B Sternohyoideus
muscle
Trachea
Slot is centered
slightly cranial
to interspace
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 28:171–179, 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 14:1477–1488, 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):348–358, 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 18:795–804,
1996.
POSTOPERATIVE EVALUATION 1,5–8 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):140–145,
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):781–784,
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):76–77, 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 1–3 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
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 1–3,12
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):899–915, 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):81–83, 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):77–110, 2000.
4. Seim HI: Dorsal decompressive laminectomy for T-L disk disease.
CAUTIONS 8–11 Canine Practice 20(6):6–10, 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 57:1228–1232, 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):1139–1145, 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 13:165–171, 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):47–52, 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):513–518,
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 1–3 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
P L AT E 8 6
T13
L1
C
232 PA RT T H R E E • SURGICAL PROCEDURES FOR THE SPINE
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 (1987–1997). J Am Vet Med Assoc
create a long window to allow admission of a Kerrison or small Lempert 219(5):624–628, 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):111–132, 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 (1990–1999). Vet Surg 32(1):21–29, 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):91–98, 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):555–562, 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):1769–1774, 2000.
CAUTIONS 14–17 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):6–10, 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):899–915, 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 57:1228–1232, 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):1139–1145, 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 13:165–171, 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):47–52, 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):513–518, 2002.
19. Coates J: Intervertebral disk disease. Vet Clin North Am Small Anim
EXPECTED OUTCOME 1–6,10,12,18–20 Pract 30(1):77–110, 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):81–83, 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, 22–24, 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, 74–76, 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, 102–104, 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, 96–98, 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
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, 96–98, 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, 96–98, 97p, 99p in lateral trochlear ridge, 82–84, 83p, 85p
in tibial fractures Maxillectomy, 98 in medial trochlear ridge, 86–88, 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, 68–70, 69p, 71p Patella
proximal, plate application with, 172, Meniscus in stifle luxation and instability, 56, in arthrodesis of stifle, 72, 73p
173p 68–70, 69p, 71p in femoral physeal fractures, 184, 185p
in ununited anconeal process, 22, 24, 25p and intra-articular repair of cranial medial luxation of, 52–54, 53p, 55p
Laminectomy cruciate ligament, 64, 66 Patellar ligament in proximal tibial physeal
lumbosacral dorsal, 234–236, 235p, 237p and lateral fabellar suture repair of cranial fractures, 197p
thoracolumbar hemilaminectomy, 226–228, 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, 234–236, 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, 18–20, 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, 38–40, with plate, 92 and intramedullary pin or interlocking
39p, 41p in shearing injury with tarsal luxation, 80 nail, 154, 155p
intracapsular stabilization in, 42–44, 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, 10–12, 11p, 13p Mylohyoideus muscle in mandibular body in extracapsular stabilization of hip
medial, 6–8, 7p, 9p fractures, 139p luxation, 38–40, 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, 64–66, 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, 60–62, 61p, 63p Neutralization plate in diaphyseal fractures, luxation, 42–44, 43p, 45p
meniscectomy in, 68–70, 69p, 71p 124, 125p in sacroiliac luxation, 174, 175p
suture anchors, screws, and sutures in, of femur, 190, 191p in triple osteotomy, 48–50, 49p, 51p
56–58, 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, 52–54, 53p, 55p of cranial cruciate ligament, 64, 65p in tarsal arthrodesis
of tarsus, in shearing injury, 78–80, 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, 22–24, 23p, of humerus, proximal, 148, 149p
mandibulectomy in, 96–98, 97p, 99p 25p of radius, distal, 170, 171p
244 INDEX