Case Report  Rapport de cas

Arthrodesis tarsocrural or tarsometatarsal in 2 dogs using circular

external skeletal fixator
Sheila C. Rahal, Reinaldo S. Volpi, Khadije Hette, Francisco J. Teixeira Neto, Luiz C. Vulcano

Abstract — An external fixation technique, using a circular fixator, to obtain arthrodesis was evaluated
in 2 dogs with infected open lesions and soft tissue damage. In both cases, articular cartilage was curetted,
and devitalized bone and necrotic soft tissue were removed. No bone graft was used. The wounds
were maintained open and the dogs received postoperative antibiotic therapy. The arthrodesis site was
compressed progressively as needed. Infection was eradicated and bony union was obtained in both dogs.
It was concluded that the use of a circular fixator is an effective method to achieve arthrodesis.

Résumé — Arthrodèse tarsocrurale ou tarsométatarsienne par fixation externe circulaire chez

2 chiens. Une technique de fixation externe par fixation circulaire, visant à obtenir une arthrodèse, a
été évaluée chez 2 chiens présentant des lésions ouverte infectées et des atteintes aux tissus mous. Dans
les 2 cas; après curetage du cartilage articulaire, l’os dévitalisé et les tissus mous nécrotiques ont été
enlevés. Il n’y a pas eu de greffe osseuse. Les plaies ont été maintenues ouvertes et les chiens ont reçu une
antibiothérapie postopératoire. Le site de l’arthrodèse a été comprimé progressivement selon les besoins.
L’infection a été éliminée et la consolidation osseuse a été obtenue chez les 2 chiens. Il a été conclu que
l’utilisation d’un fixateur circulaire est une méthode efficace d’arthrodèse.
(Traduit par Docteur André Blouin)
Can Vet J 2006;47:894–898

Case description tered for 8 wk and ketoprofen (Ketofen 1%; Merial,

A 1-year-old, 30-kg, intact-female crossbred dog was
referred to the Veterinary Hospital with an extensive
shearing injury involving the right hindlimb as a result of
a collision with an automobile 10 d previously. The dog
had been treated by another veterinarian with enrofloxacin,
5 mg/kg body weight (BW), PO, q12h, and nitrofurazone
ointment. Clinical examination revealed loss of ligaments
and soft tissues, and exposed bone along the laterodorsal
aspect from the distal extremity of the tibia to the phalan-
ges (Figure 1). Instability and crepitation was elicited on
palpation of the tibiotarsal joint. Radiographs of the right
hindlimb revealed subluxation of the tibiotarsal joint and
luxation of the 4th and 5th metatarsophalangeal joints
(Figure 2a). Because of gross contamination and marked
soft tissue swelling, surgery was delayed. The wound was
treated by irrigation with copious amounts of 0.9% saline
solution, q24h, the application of granulated sugar, and
covering it with dry dressing. A temporary splint was
applied to the hindlimb. Cephalexin (Keflex; Eli Lilly,
São Paulo, Brazil), 30 mg/kg BW, PO, q8h, was adminis-
Departments of Veterinary Surgery and Anesthesiology (Rahal,
Teixeira Neto, Hette); Animal Reproduction and Radiology
(Vulcano), Faculty of Veterinary Medicine and Animal Science;
Department of Surgery and Orthopedics (Volpi), Faculty of
Medicine, University of São Paulo State (UNESP) Botucatu, PO
Box 560, Rubião Júnior s/n, Botucatu (SP), Brazil 18618-000.
Address all correspondence and reprint requests to Dr. Rahal;
e-mail: sheilacr@fmvz.unesp.br
Campinas, Brazil), 2 mg/kg BW, SC, q24h, was adminis-
tered for 4 d. Buprenorphine hydrochloride (Temgesic;
Schering Plough, Rio de Janeiro, Brazil), 15 mg/kg BW,
SC, was administered when required. After 10 d of treat-
ment, healthy granulation tissue began to cover the wound,
and arthrodesis of the tarsocrural joint was performed.
After premedication with methotrimeprazine (Levozine;
Cristália, Itapira, Brazil), 0.5 mg/kg BW, IM, an epidural
anesthetic, lidocaine 2% (Xylestesin; Cristália, Itapira,
Brazil), 2.5 mL; bupivacaine 0.25% (Neocaína; Cristália,
Itapira, Brazil), 2.5 mL; and morphine (Dimorf; Cristália,
Itapira, Brazil), 0.1 mg/kg BW, was administered. General
anesthesia was maintained with halothane (Halothano;
Cristália, Itapira, Brazil). The articular cartilage of the
tarsocrural joint was removed by using a burr and follow-
ing the normal contour of the articular surface. A 4-ring
circular fixation frame (Cruz Alta Company, Fernandópolis,
São Paulo, Brazil) was constructed with 1 half-ring posi-
tioned on the midshaft of the tibia, 1 full ring on the distal
third of the tibia, 1 ring at the level of the tarsal bones, and
1 5/8 ring at the level of the metatarsal bones (Figure 2b).
Two transosseous wires, 1.5 mm in diameter, were placed
in each ring with wire intersection angles between 60° and
90°. The wires were tensioned by using a dynamometric
wire tensioner (Dynamometer; Ortosintese Company,
São Paulo City, São Paulo, Brazil) in the full rings to a
force of 90 kg and in the half ring to a force of 60 kg.
Three threaded rods were used to connect the proximal and
distal rings around the tibia (block 1), and 3 other rods
connected the rings around the tarsal and metatarsal bones

894 CVJ / VOL 47 / SEPTEMBER 2006


Figure 1.  Right hindlimb of dog 1 before the treatment. Notice
the loss of ligaments and soft tissues, and the exposed bone along
the laterodorsal aspect from the distal extremity of the tibia to
the phalanges.
(block 2). Two angular hinges were positioned between the
distal ring around the tibia and the ring around the tarsal
bones. A threaded rod was placed through posts between
ring blocks. All fixator components, including the rings,
were made of stainless steel. Compression of the arthrod-
esis site was applied at surgery and increased by 0.5 mm
every 15 d for 60 d. The wound was almost fully epitheli-
alized 3 wk after surgery. Partial weight-bearing on the
affected limb was observed when the dog walked slowly.
After this period, the owner returned 4.5 mo after the sur-
gery. The affected hind limb showed muscle atrophy and
the dog was not weight-bearing. The fixator was removed
immediately due to its instability and the drainage from
wire-tract sites. Radiographic examination showed com-
plete fusion of the joint, but osteolysis and bone prolifera-
tion around the wires were apparent (Figure 2c). After
removal of the frame, the wire tracks healed quickly and
the animal started to bear weight on the affected limb. At
last evaluation, 4 mo after frame removal, there was no
evidence of infection by clinical and radiographic examina-
tions and the dog was placing full weight on the limb when
standing but, intermittently, did not bear weight on it after
intensive exercise. This may be associated with luxation
of the 4th and 5th metatarsophalangeal joints that was not
treated because the owner did not authorize it.
A 2.8-year-old, 45-kg, intact female Fila Brasileiro dog
was admitted for evaluation of a nonweight-bearing right
hind limb lameness, which had persisted for 5 d. Swelling
of the right tarsal joint was observed on clinical examina-
tion; as well, there were 2 wounds, each measuring approx-
CVJ / VOL 47 / SEPTEMBER 2006
imately 2 cm, with serosanguineous drainage, located at
the lateral and dorsal aspects of the tarsometatarsal region.
Pain and crepitus were elicited on palpation of the tarsal
bones. Radiographs of the right hind limb demonstrated
multifragment fractures of the tarsal bones with ballistic
projectiles, and longitudinal fractures of the proximal 3rd,
4th, and 5th metatarsal bones (Figure 3a). The tarsocrural
CA S E R E P O R T
joint was apparently intact, but stress radiographs were
not taken because on palpation this joint was normal.
After premedication with buprenorphine hydrochloride
(Temgesic; Schering Plough), 15 mg/kg BW, IV, and chlor-
promazine (Amplictil; Aventis Farma, São Paulo, Brazil),
0.5 mg/kg BW, IV, anesthesia was induced with thiopental
(Thiopentax; Cristália, Itapira, Brazil), 10 mg/kg BW,
IV, and maintained with halothane (Halothano; Cristália,
Itapira, Brazil). Following a medial approach to the bones
of the tarsus and tarsometatarsal joint, the ballistic projec-
tiles and devitalized infected tarsal bones (central; 1st, 2nd,
and 3rd), and proximal third of 5th metatarsal bone were
removed. The remaining articular cartilage of the affected
joints was removed by using a burr. The fracture site was
lavaged copiously with isotonic saline solution, and a
fine-needle aspirate was taken and submitted for aerobic
and anaerobic culture; a beta-hemolytic streptococcus
was isolated. A 3-ring circular fixation frame (Cruz Alta
Company) was constructed preoperatively with 1 full ring
positioned on the distal third of the tibia, 1 full ring at the
level of the talus and calcaneus, and 1 half ring at the level
of the metatarsal bones (Figure 3b). Two tensioned transos-
seous wires, 1.5 mm in diameter, were placed in each ring,
in a similar fashion to case 1. Three threaded rods were
used to connect the rings around the tarsal and metatarsal
bones. Also, 2 angular hinges and a threaded rod, placed
through the posts, were positioned between the ring around
the distal third of the tibia and the ring around the tarsal
bones. The wounds in tarsometatarsal region were left
open, but covered with nitrofurazone ointment and a dry
dressing. Isotonic saline solution with povidone iodine was
used to irrigate the wound. Cephalexin (Keflex; Eli Lilly),
30 mg/kg BW, PO, q8h for 6 wk; carprofen (Rimadyl;
Pfizer, Guarulhos, Brazil), 2.2 mg/kg BW, PO, q 12h, for
7 d; and buprenorphine hydrochloride (Temgesic; Schering
Plough), 15 mg/kg BW, IM, as needed, were administered
postoperatively. Compression through the talus, calca-
neus, 4th tarsal bone, and metatarsal bones was applied at
surgery and increased by 0.5 mm every 15 d for 60 d by
moving the half ring positioned on the metatarsal bones in
the direction of the full ring positioned at the level of the
talus and calcaneus. Seven days after surgery, hemorrhage
related to 1 of fixation wires positioned on the ring around
the tibia was detected and controlled by a compression
bandage and tranexamic acid (Transamin; Nikkho, Rio de
Janeiro, Brazil), 25 mg/kg BW, IM. Approximately 45 d
after surgery, new bleeding was observed and was treated
by using the same protocol as described previously. Two
and a half months postoperatively, the circular fixator
frame was removed, and radiographs showed fusion of the
talus, calcaneus, 4th tarsal bone, and metatarsal bones, and
fracture healing of the metatarsal bones. At last evalua-
tion, 2.5 y after frame removal, there was no evidence of
infection by clinical and radiographic examinations and
the dog showed full functional use of the limb. However,
895
R A P P O R T D E CA S

A B C
Figure 2.  Lateral radiographic views of the right hindlimb of the dog 1. (A) Notice the subluxation of the tibiotarsal
joint and the luxation of the 4th and 5th metatarsophalangeal joints, before the surgery. (B) Notice the stabilization of
the tarsocrural joint immediately after the use of the circular external fixator. (C) Notice the complete fusion of the
joint immediately after the fixator removal, 6.5 mo postoperatively. Osteolysis and bone proliferation around the wires
were apparent, due to the long time that the fixator was used.

the range of motion of the tarsocrural joint was decreased
in flexion, and on radiographic examination, a diminution
of the joint space and the presence of an osteophyte was
observed (Figure 3c).
Discussion
Arthrodesis in a functional position is the final solution to
joints destroyed by trauma or degraded by inflammatory
processes and bacteria, since the development of osteo-
arthritis is inevitable (1,2). It is categorized as a salvage
procedure (1,3). Several techniques for accomplishing
solid fusion have been described (1–3), but some basic
principles, such as removal of all articular cartilage from
the joint surfaces; rigid fixation, ideally with compression
at a functional angle; and the use of a cancellous bone graft
are indicated to ensure a successful outcome (2,3).
Internal fixation with plate and screws provides rigid
stabilization of the bone segments, but it needs extensive
surgical exposure, which causes further damage to the
blood supply (2). Also, the implants may break, loosen,
or migrate out of the bone, especially in infected areas
(3), and, in some cases, the implant has to be removed to
allow full recovery (2). External fixation offers advantages,
including stabilization without additional insult to compro-
mised soft tissue and a lower risk of infection dissemina-
tion (2). In addition, the transfixing pins are placed away
from the fusion site and can be used when there is inad-
equate soft-tissue coverage. The frame is easily removed,
preventing the need for a 2nd operation (2,4).
The circular fixator has been used to induce arthrodesis
in humans (5,6) and animals (7–10). Besides providing
stable fixation of the athrodesis site, this frame allows
dynamic compression of the fusion site during the post­
operative period, adjustment throughout the treatment
period to correct any deformity, and a supplementary bone
graft is usually not required (5).
In the presence of severe contamination and soft-tissue
loss, an arthrodesis is generally recommended as a 2nd step
after the of local environment has been improved (2,7,8),
as in case 1. Wound treatment with granulated sugar is
commonly used in our hospital, especially because of
its low cost and effective antibacterial action. Sugar is
believed to inhibit bacterial growth by promoting low
water activity (11).
Other authors have treated carpal and tarsal shearing
injuries for an average of 6.5 d after trauma by using man-
agement of the soft tissues simultaneously with immediate
arthrodesis (12). This strategy was used in dog 2, because
the degree of contamination, time from injury to treatment,
and soft tissue compromise were less severe than in case 1.
Patient discomfort was diminished by immediate skeletal
stability, as reported by other authors (12).
Osseous union is facilitated and stimulated when articu-
lar cartilage in contact areas is removed to expose subchon-
dral or cancellous bone and an autogenous cancellous bone
graft is packed into and around the joint cavity (1,2). When
this type of bone graft is used, union of arthrodesis occurs
in 4 to 8 wk, whereas without this type of bone graft,
arthrodesis union may take up to 12 wk (1). However, it
is necessary to consider that bone healing in open injuries
is delayed (2).
Tarsocrural joint fusion, using the circular fixator and a
cancellous bone graft, was observed at 6 wk postsurgery in
a 4-year-old dog with a contaminated intra-articular frac-
ture (7), and within 60 d in a 12-month-old dog presented
with a degloving injury (8). Also, in 3 dogs submitted to
tarsometatarsal arthrodesis due to tarsometatarsal closed
injuries (fracture/luxations), the time of radiographic union
was 11 wk (n = 2) and 28 wk (n = 1) (10). Progressive

896 CVJ / VOL 47 / SEPTEMBER 2006

 CA S E R E P O R T
A B C
Figure 3.  Radiographic views of the right hindlimb of the dog 2. (A) Notice the multifragmental fractures of the tarsal
bones with ballistic projectiles, and the longitudinal fractures of the proximal 3rd, 4th, and 5th metatarsal bones, before
the surgery. (B) Immediately after removal of the ballistic projectiles and the devitalized infected tarsal bones, and the
application of the circular external fixator to induce arthrodesis among the remained bones (talus, calcaneus, 4th tarsal
bone and metatarsal bones). (C) Notice the fusion of the joint, fracture healing of the metatarsal bones, and absence of
signs of infection, 2.5 y after removal of the fixator.

compression of the arthrodesis without a bone graft has
been reported with success in human patients (5,6,13). This
technique was performed in the present cases. In case 1,
the exact time of fusion was not determined, because the
owner only returned 4.5 mo after the surgery. In case 2,
time of fusion occurred 2.5 mo postoperatively, which was
similar to the case cited above in which a cancellous bone
autograft was used (10). However, in both cases, the elimi-
nation of the infection was fundamental to a successful
arthrodesis. The ideal rhythm and rate to compression of
arthrodesis site have not been described clearly. The aim is
to stimulate bone fusion and to maintain a level of dynamic
compression across the arthrodesis site (5,6,13).
Another advantage of the circular external fixator is
the possibility of progressive adjustment of the angle of
fusion and correction of any malalignment, during the post­
operative period (6,8). The interconnecting rods and the
hinges between the fixation blocks allow rapid changes. If
internal fixation is used, the angle in the arthrodesis needs
to be precise by taking preoperative measurements from
the opposite limb (2). Arthrodesis heals, in general, with
minimum external callus formation, because periosteum
is normally absent at the joints associated with a stable
fixation (1). Minimum external callus was observed in the
present cases with the circular fixator.
Because the tarsocrural joint was intact in case 2, 1 full
ring was positioned on the distal third of the tibia, not
because a panarthrodesis was planned, but to increase the
stability of the fixator. The bones of this joint were main-
tained in their normal anatomic position, but no compres-
sion was applied. However, the restriction on the range
of movement in the joint and the signs of osteoarthritis
observed 2.5 y after removal of the frame could have been
associated with the 2.5 mo that the fixator was in position,
since prolonged immobilization of a joint is deleterious
to articular cartilage (14). One way to avoid this problem
is to use intermittent active motion or continuous passive
motion of the joint (14), or to use a U-shaped stretch ring
positioned around and parallel to the long axis of the
calcaneus (10).
The postoperative complications observed in dog 1,
namely muscle atrophy, osteolysis, and bone proliferation
around the wires, were associated with partial weight-
bearing on the operated on limb, and because the frame
was maintained for an excessively long time. The owner’s
collaboration is essential when an external fixator is used.
Wire track inflammation or pin tract inflammation were
the most frequent complications observed in dogs sub-
mitted to talocrural (n = 1), pantarsal (n = 1), pancarpal
(n = 2), and tarsometatarsal (n = 3) arthrodeses, using a
circular external fixator (8,10). Also, osteomyelitis, which
resolved following antibiotic therapy, was observed in 2
of the 3 dogs receiving the tarsometatarsal arthrodesis
(10). The hemorrhage associated with 1 of the fixation

CVJ / VOL 47 / SEPTEMBER 2006 897

 wires, as occurred in dog 2, also was reported in a case of
pancarpal arthrodesis performed with a circular fixator,
which was solved after wire removal (8). Vascular injury
is generally associated with improper pin placement (15),
and in this case, it was likely that an intramedullary vessel
was injured.
R A P P O R T D E CA S
From the results of the present case series, it can be
concluded that the use of a circular fixator is an effective
method to obtain arthrodesis without violation of the injury
site. CVJ
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