11830 Westline Industrial Drive St. Louis, Missouri 63146 ATLAS OF ORTHOPEDIC SURGICAL PROCEDURES OF THE DOG AND CAT Copyright © 2005, Elsevier Inc. ISBN 0-7216-9381-4 All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Health Sciences Rights Department in Philadelphia, PA, USA: phone: (+1) 215 238 7869, fax: (+1) 215 238 2239, e-mail:
[email protected]. You may also complete your request on-line via the Elsevier homepage (http://www.elsevier.com), by selecting “Customer Support” and then “Obtaining Permissions.” NOTICE Veterinary Medicine is an ever-changing field. Standard safety precautions must be followed, but as new research and clinical experience broaden our knowledge, changes in treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current product information provided by the manufacturer of each drug to be administered to verify the recommended dose, the method and duration of administration, and contraindications. It is the responsibility of the treating veterinarian, relying on experience and knowledge of the patient, to determine dosages and the best treatment for each individual patient. Neither the publisher nor the authors assume any liability for any injury and/or damage to persons or property arising from this publication. International Standard Book Number 0-7216-9381-4 Publishing Director: Linda Duncan Senior Editor: Liz Fathman Developmental Editor: John Dedeke Publishing Services Manager: Melissa Lastarria Senior Project Manager: Joy Moore Design Manager: Bill Drone Printed in the United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 1 This book is dedicated to my family, mentors, colleagues, residents, and students, all of whom have provided input in my development as a surgeon and consequently in the development of this book. Ann Johnson I thank Ann Johnson for her generosity and friendship. This book is dedicated to my amazing children, George Henry and Sydney, who generate an abundance of love, happiness, and true joy in my life. Dianne Dunning Preface Our goal in writing this atlas of orthopedic surgical procedures was to create a uniquely portable, easy-to-use reference resource for surgeons in the operating room—an atlas that demonstrates a wide range of procedures commonly performed in veterinary surgery. We thank Laura Duprey for helping us reach this goal by providing superb illustrations of the procedures. In our surgical practice at the University of Illinois, we strongly encourage our residents and students to use textbooks in the surgery suite to guide them in each surgical technique and to maximize their proficiency. With the constant explosion of surgical techniques and procedures, this guidance is essential for those who do not have the opportunity to master each technique by performing the procedures on a daily basis. The techniques selected and described are based on our years of experience in training surgical residents, interns, and students and in offering continuing education to practicing veterinarians. Also included are tips that we have found helpful as we have performed these procedures in our own practice. It was a joy to compile this atlas; we hope that it is as illuminating to read as it was instructive to write. Ann Johnson Dianne Dunning vii Use Gelpi retractors to craniodorsally retract the teres minor muscle located deep to the spinous head of the deltoideus muscle. and replace the Gelpi retractors within the joint space to facilitate visualization. blunt Hohmann retractor. Philadelphia. Incise between the caudal border of the spinous head . 2. Bluntly dissect under the deltoideus muscle to visualize the axillary nerve and caudal circumflex humeral artery and vein. Internally rotate and adduct the humerus to maximize exposure to the caudal aspect of the femoral head. Explore the caudal cul-de-sac of the joint for loose or free fragments of cartilage. both shoulders should be evaluated. Lavage the joint. The muscle branch of the axillary nerve is visualized at this point and preserved. and forage to provide blood supply to the exposed subchondral bone ANATOMIC CONSIDERATIONS The shoulder joint is easily located by palpating the acromial process of the scapula and the greater tubercle of the humerus. two medium or large Gelpi retractors (depending on the size of the dog). Philadelphia. POSTOPERATIVE CARE Exercise should be restricted for 3 to 4 weeks to allow soft tissue healing and cartilage resurfacing. Johnson KA: Approach to the caudolateral region of the shoulder joint. EXPECTED OUTCOME Outcome is good to excellent in most cases. PROCEDURE Craniolateral Approach:1 Incise the skin and subcuta- of the deltoideus and the long and lateral heads of the triceps muscle (Plate 1B). 3. Rudd R. and then normal activity should be reintroduced slowly. and remove any abnormal cartilage not adherent to the subchondral bone (Plate 1E). Use a hanging leg preparation with the dog in lateral recumbency to allow for maximal manipulation of the shoulder joint during surgery. Whitehair J. Johnson KA: Approach to the caudal region of the shoulder joint. 1990. as hemorrhage will greatly impede joint visualization. even if the animal exhibits a unilateral lameness. In An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. neous tissues in a curvilinear fashion from mid-scapula to midhumerus. pin chuck or high-speed wire driver. and close the joint capsule and wound in a routine fashion. Further delineate this separation by blunt dissection with Mayo scissors. 4th ed. Curettage: Remove the cartilage flap with thumb or Halstead forceps. 2004. OBJECTIVES • To improve limb function by removal of the entire osteochondrosis flap. Forage: Using a small Kirschner wire or small Steinmann pin. Accurate hemostasis should be used when approaching the shoulder. bone curettes. CAUTIONS Osteochondrosis is often bilateral (42% to 65%)3. Place a blunt Hohmann retractor caudomedial to the femoral head to exteriorize the femoral head and further facilitate lesion visualization (Plate 1C). In An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. 4. Kirschner wires or small Steinmann pin for forage PREPARATION AND POSITIONING Prepare the leg circumferentially from dorsal midline to the carpus. Piermattei DL. Whitehair J. 1990. References 1.2 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES SHOULDER Osteochondrosis of the Shoulder via Caudolateral or Caudal Approach CHAPTER 1 INDICATIONS Candidates include dogs with persistent lameness of the shoulder caused by osteochondrosis that is not responsive to conservative management. penetrate the sclerotic subchondral bone in multiple sites until it bleeds (Plate 1F). Caudal Approach:2 Incise the skin and subcutaneous tissues in a curvilinear fashion from mid-scapula to midhumerus. Internally rotate and adduct the humerus to maximize exposure to the caudal aspect of the femoral head (Plate 1D). Piermattei DL. Place the Gelpi retractors at 90 degrees to each other to facilitate visualization. J Am Anim Hosp Assoc 26:173–178. 4th ed.4 Note that degenerative joint disease may develop despite the surgical removal of an osteochondrosis flap. WB Saunders. superficial to the triceps muscle. The acromial head of the deltoideus is bordered cranially by the omobrachial vein and caudally by the axillobrachial vein. 2004. POSTOPERATIVE EVALUATION No specific postoperative evaluation is required. EQUIPMENT • Standard surgical pack. curettage of the adjacent diseased cartilage. Probe the remaining cartilage surrounding the defect with a curette. Muscular branches of the axillary nerve and caudal circumflex vessels are located deep in the caudal aspect of the acromial head of the deltoideus muscle. WB Saunders. Incise the joint capsule parallel to the rim of the glenoid cavity and replace the Gelpi retractors within the joint space to facilitate visualization. Marogolis J: Results of management of osteochondritis dissecans of the humeral head in dogs: 44 cases (1982–1987). Incise the joint capsule parallel to the rim of the glenoid cavity. Compend Cont Ed 12:195–203. allowing for cranial retraction of the acromial head and caudal retraction of the spinous portion of the deltoideus muscle. Elevate and gently retract the axillary nerve off of the joint capsule. Rudd R: Osteochondritis dissecans of the humeral head in dogs. Incise the deep fascia between the acromial and spinous portions of the deltoideus muscle (Plate 1A). CHAPTER 1 OSTEOCHONDROSIS OF THE SHOULDER 3 P L AT E 1 A Caudolateral approach Deltoideus muscle: Scapular part Acromial part B Triceps brachii muscle: Long head Lateral head Caudal approach C Teres minor muscle (retracted craniodorsally) Glenoid D Joint capsule Deltoideus muscle: Scapular part Acromial part Deltoideus muscle E F . with the dog in lateral recumbency to allow for maximal manipulation of the shoulder joint during surgery. EQUIPMENT • Standard surgical pack. A portion of the affected tendon should be biopsied and submitted for histopathology for disease verification. Resect a portion of the tendon (approximately 1 cm) to prevent recurrence and submit for histopathology (Plate 2B). POSTOPERATIVE CARE Excessive activity should be restricted for 10 to 14 days to prevent seroma formation. EXPECTED OUTCOME Outcome is usually excellent. inserting on the lateral aspect of the greater tubercle of the humerus. 4th ed. Transect the tendon and any associated fibrotic bands until the shoulder moves freely. Incise the deep fascia along the cranial border of the acromial head of the deltoideus muscle. Elevate and caudally retract the muscle with Gelpi retractors (Plate 2A). 1982. OBJECTIVES • To restore normal shoulder joint range of motion and forelimb function by releasing the fibrotic infraspinatus muscle ANATOMIC CONSIDERATIONS The infraspinatus muscle is one of the cuff muscles of the shoulder joint. with a full return to function expected. WB Saunders. periosteal elevator. Moore D.1 lying just caudal to the scapular spine. 2. Brown S: Stability of the canine shoulder joint: An in vitro analysis. Am J Vet Res 43:352–355. Use a hanging leg preparation. the shoulder should resume full range of motion. elbow abduction. The teres minor tendon inserts just distally to the infraspinatus along the lateral aspect of the greater tubercle of the humerus. Affected tendons will appear grossly thickened and fibrotic and will become visibly taut and inhibit the range of motion of the shoulder when it is placed in extension or flexion. Philadelphia. The infra2 References 1. These dogs display a characteristic gait abnormality of external rotation of the shoulder. two medium or large Gelpi retractors (depending on the size of the dog). Bennet R: Contracture of the infraspinatus muscle in dogs: A review of 12 cases. . Isolate the tendon by sharp and blunt dissection with a scalpel blade and periosteal elevator. PROCEDURE Incise the skin and subcutaneous tissue in a curvilinear fashion from the mid-scapular spine to the proximal portion of the humerus.3 INDICATIONS Candidates are animals with infraspinatus contracture that is not responsive to rest and management with nonsteroidal antiinflammatory drugs.4 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES SHOULDER CHAPTER 2 Infraspinatus Contracture spinous tendon should be visible as it inserts on the greater tubercle of the proximal humerus. Johnson KA: Approach to the craniolateral region of the shoulder joint by tenotomy of the infraspinatus muscle. 2004. Closure is routine. 1986. Its tendon lies beneath the acromial head of the deltoideus muscle and crosses the joint craniolaterally. J Am Anim Hosp Assoc 22:481–487. and formalin jar for histopathology PREPARATION AND POSITIONING Prepare the leg circumferentially from dorsal midline to the carpus. Vasseur P. Piermattei DL. 3. POSTOPERATIVE EVALUATION Once released. In An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. and outward rotation of the pes. CAUTIONS There are no specific cautions. CHAPTER 2 I N F R A S P I N AT U S C O N T R A C T U R E 5 P L AT E 2 A Supraspinatus muscle Infraspinatus muscle Deltoideus muscle: acromial part Teres minor muscle Triceps brachii muscle: lateral head B Infraspinatus muscle . Open reduction and stabilization is indicated if a traumatic luxation is unstable enough after closed reduction that reluxation occurs. reduce the luxation before the approach to reestablish normal anatomic relationships. Retract the supraspinatus muscle laterally. a screw and washer combination may be used. If possible. Warsaw. wire driver. from the dorsal midline to the carpus. Continued *Mason Nylon Leader Line. Incise the insertions of the superficial and deep pectoral muscles from the humerus and retract them medially. Mason Tackle Company. periosteal elevator. Otisville. The suprascapular nerve is present over the cranial lateral surface of the scapula.6 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES SHOULDER Stabilization of Medial Shoulder Luxation CHAPTER 3 INDICATIONS This procedure is indicated in animals with medial shoulder luxation and instability. Use a hanging leg preparation with the dog in dorsal recumbency to allow for maximal manipulation of the shoulder joint during surgery. the greater tubercle of the humerus. Surgery is warranted in animals with congenital luxation or instability that causes severe or persistent lameness. and assess the condition of the humeral head and medial labrum of the glenoid. Transect the tendon of the coracobrachialis muscle near its origin to expose the subscapularis muscular tendon. Incise and elevate the subscapularis muscle tendon at its origin. and the acromial head of the deltoid muscle. PREPARATION AND POSITIONING Prepare the leg circumferentially. mobility. and screwdriver. Incise the fascial border of the brachiocephalicus muscle and retract the muscle medially. drill bit. congruency. the greater tubercle. Incise the skin and subcutaneous tissue from the medial aspect of the acromion over the greater tubercle to the medial aspect of the midhumeral diaphysis. Place one small Hohmann retractor cranial and underneath the supraspinatus muscle and another caudally against the caudal scapula for good visualization of the medial glenohumeral joint (Plate 3A). Indiana. bone screw and washer.5 to 1. . depth gauge. † Bone Biter Suture Anchor System. Inspect the joint. two medium or large Gelpi retractors (depending on the size of the dog). two small Hohmann retractors. exposing 0. The caudal circumflex humeral artery and axillary nerve are present on the caudolateral aspect of the shoulder. and function to the shoulder joint without altering regional anatomy1 ANATOMIC CONSIDERATIONS Anatomic landmarks for the scapulohumeral joint are the acromion process of the scapular spine. EQUIPMENT • Standard surgical pack. if a suture anchor system is not available or if the animal is not large enough to accommodate the suture anchor system. intramedullary pins or Kirschner wires. Ligate the omobrachial vein if it interferes with the intended approach. PROCEDURE Approach:2 Use an approach to the craniomedial shoulder joint to expose the luxated joint. or if the luxation is chronic. and the pectoral muscles. and these should be avoided. and a suture anchor system† Alternatively. Michigan. Anatomic landmarks for positioning the skin incision include the acromion of the scapula. tap. OBJECTIVES • To restore normal stability. mallet. Additional instrumentation needed for this technique includes a high-speed drill. 20-pound nylon* or the appropriatesize nonabsorbable suture material.0 cm of the distal scapula. CHAPTER 3 S TA B I L I Z AT I O N O F M E D I A L S H O U L D E R L U X AT I O N 7 P L AT E 3 A Subscapularis muscle Supraspinatus muscle Biceps brachii muscle Coracobrachialis muscle Deep pectoral muscle Superficial pectoral muscle . Imbricate the capsule and subscapularis tendon with nonabsorbable mattress sutures. 2001. et al: Medial glenohumeral ligament reconstruction for ex-vivo medial glenohumeral luxation in the dog. EXPECTED OUTCOME Outcome is good to excellent in most cases. There should be two independent suture loops for the cranial and caudal components of the medial glenohumeral ligament.3 Reduce the joint and identify the insertion and origins of the medial glenohumeral ligament in the distal scapula and proximal humerus.8 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES Stabilization with the Suture Anchor System:1. In An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. Closure is routine. A published case series noted minimal gait abnormalities following surgery and rehabilitation. one each at the cranial and caudal components of the ligament origin on the distal scapula and another at the ligament insertion on the proximal humerus (Plate 3B). Hosgood G. and tap three holes. care must be taken during the approach in order to avoid trauma. Johnson KA: Approach to the craniomedial region of the shoulder joint. Closure is routine. Ringwood P. Breshears L. Use a screw and washer combination to prevent subsidence into the soft metaphyseal bone and slippage of the ligature. There should be two independent suture loops for the cranial and caudal components of the medial glenohumeral ligament. Fitch R. Staatz A. Drill three holes. Tie the sutures with the limb held at a normal standing angle (approximately 135 degrees of extension) such that the sutures are taut. insertion of the medial glenohumeral ligament in the distal scapula and proximal humerus. Insert suture anchors threaded with fish leader line or nonabsorbable suture into each of these holes. et al: Clinical evaluation of prosthetic medial glenohumeral ligament repair in the dog (10 cases). WB Saunders. even in the face of degenerative joint disease and joint malformation stemming from congenital shoulder luxation. Place the scapulohumeral joint through a range of motion and evaluate joint stability and mobility. Drill. measure. 2. POSTOPERATIVE EVALUATION Joint stability and range of motion should be evaluated at 2 and 4 weeks to assess continued need for external coaptation. Stabilization with a Screw and Washer Combination:1 Reduce the joint and identify the origins and CAUTIONS Because the suprascapular nerve lies in close proximity to the fascial attachment between the deep pectoral and supraspinatus muscles. but not overly tight. Tie the sutures with the limb held at a normal standing angle (approximately 135 degrees of extension) such that the sutures are taut. . but not overly tight. 2004. 2001. avoiding plication of the joint capsule (Plate 3D). Kerwin S. Vet Comp Orthop Traumatol 14:222–228. Philadelphia. 4th ed. 3. Vet Comp Orthop Traumatol 14:196–200. one each at the cranial and caudal components of the ligament origin on the distal scapula and another at the ligament insertion on the proximal humerus. Imbricate the capsule and subscapularis tendon with nonabsorbable mattress sutures. POSTOPERATIVE CARE A Velpeau sling is indicated to protect the repair for 2 to 4 weeks. Piermattei DL. Place the scapulohumeral joint through a range of motion and evaluate joint stability and mobility. avoiding plication of the joint capsule (Plate 3C).1 References 1. CHAPTER 3 S TA B I L I Z AT I O N O F M E D I A L S H O U L D E R L U X AT I O N 9 P L AT E 3 B C D Suture anchor threaded with two sutures inserted in humerus Anchor locked beneath cortices . if possible. two medium or large Gelpi retractors (depending on the size of the dog). screw. Place the scapulohumeral joint through a range of motion and evaluate joint stability and mobility. intramedullary pins or Kirschner wires. the prognosis for successful stabilization of the shoulder is poor and arthrodesis should be considered (see Chapter 5). If greater stability is desired. if a suture anchor system is not available or if the animal is not large enough to accommodate the suture anchor system. PREPARATION AND POSITIONING Prepare the leg circumferentially from the dorsal midline to the carpus. mobility. PROCEDURE Approach:1. Primary apposition of the torn ligament. . the greater tubercle. The animal is positioned in lateral recumbency with the affected leg draped. congruency. Anatomic landmarks for positioning the skin incision include the acromion of the scapula. Incise the deep fascia along the cranial border of the acromial head of the deltoideus muscle. but not overly tight. to allow for maximal manipulation of the shoulder joint during surgery. If the labrum is worn. and screwdriver. Use a hanging leg preparation. 20. Elevate and caudally retract the muscle with Gelpi retractors. Open reduction and stabilization is indicated if the luxation is unstable enough after closed reduction that reluxation occurs. Reattach the infraspinatus tendon with a three-loop pulley or locking loop suture pattern. and the acromial head of the deltoideus muscle. Continued *Bone Biter Suture Anchor System. inspect the joint. Stabilization with the Suture Anchor System:3 Drill one hole in the distal scapula at the lateral glenohumeral ligament origin and a second hole at the ligament insertion on the proximal humerus. and assess the condition of the humeral head and lateral labrum of the glenoid (Plate 4A). periosteal elevator. is the method of choice for repair. Closure is routine. wire driver. tap. Tie the sutures with the limb held at a normal standing angle (approximately 135 degrees of extension) such that the sutures are taut.2 Use an approach to the craniolateral region of the shoulder joint to expose the luxated joint.10 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES SHOULDER Stabilization of Lateral Shoulder Luxation CHAPTER 4 INDICATIONS Lateral shoulder luxations are usually traumatic in origin and occur after glenohumeral ligament and infraspinatus tendon rupture. and function to the shoulder joint without altering regional anatomy ANATOMIC CONSIDERATIONS Anatomic landmarks for the scapulohumeral joint are the acromion process of the scapular spine. or if the luxation is chronic. with the dog in lateral recumbency. mallet. reinforcement of the repaired ligament with prosthetics may be necessary. If the infraspinatus tendon is not torn. and the acromial head of the deltoideus muscle. and washer combination may be used.* and a suture anchor system* Alternatively a bone tunnel. Incise the skin and subcutaneous tissue in a curvilinear fashion from the mid-scapular spine to the proximal portion of the humerus. depth gauge. Reduce the joint and identify the origin and insertion of the lateral glenohumeral ligament. avoiding plication of the joint capsule. the greater tubercle of the humerus. OBJECTIVES • To restore normal stability. Incise the joint capsule. It may be helpful to reestablish normal anatomic relationships by reducing the joint before the approach is made. either incise it 5 mm from its origin or perform an osteotomy of the acromial process to facilitate reattachment. Additional instrumentation needed for this technique includes a high-speed drill. drill bit. Imbricate the capsule with nonabsorbable mattress sutures. Insert suture anchors threaded with fishing leader line into each of these holes (Plate 4B).to 60-pound nylon. Warsaw. Indiana. bone screw and washer. EQUIPMENT • Standard surgical pack. CHAPTER 4 S TA B I L I Z AT I O N O F L AT E R A L S H O U L D E R L U X AT I O N 11 P L AT E 4 A B Joint capsule incised Supraspinatus muscle Infraspinatus muscle Infraspinatus muscle Deltoideus muscle: acromial part Suture anchor threaded with two sutures inserted in humerus Teres minor muscle Anchor locked beneath cortices . with electrocardiogram. 2004. with concurrent exercise restriction. avoiding plication of the joint capsule (Plate 4D). and blood work) and stabilized before initiating surgical repair. Philadelphia. In An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. Piermattei DL. and tap a bicortical screw hole in the ligament insertion on the proximal humerus. WB Saunders. Use a screw and washer to prevent subsidence into the soft metaphyseal bone and ligature slippage. Philadelphia. Passive range of motion exercises should be implemented after splint removal for the next 2 weeks. Baltimore.g. but not overly tight. 1998. 1998. Place the scapulohumeral joint through a range of motion and evaluate joint stability and mobility. with the limb held at a normal standing angle (approximately 135 degrees of extension) such that the sutures are taut. In Bojrab MJ (ed): Current Techniques in Small Animal Surgery. Reattach the infraspinatus tendon with a three-loop pulley or locking loop suture pattern (Plate 4E). Williams & Wilkins. and identify the be evaluated at 2 and 4 weeks to assess continued need for external coaptation. WB Saunders. Johnson KA: Approach to the lateral aspect of the humeral condyle and epicondyle. 3. Williams & Wilkins. CAUTIONS There is a high potential for concurrent chest trauma with these injuries. In An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. Imbricate the capsule with nonabsorbable mattress sutures. POSTOPERATIVE CARE The limb should be supported in a spica splint for 10 to 14 days. 2004. Closure is routine. 4th ed. 2. Piermattei DL.12 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES Stabilization with a Bone Tunnel and Screw and Washer Combination:4 Reduce the joint. Slocum TD: Suture stabilization for luxations of the shoulder. origin and insertion of the lateral glenohumeral ligament. depending on the degree of trauma to the joint. Joint stability and range of motion should . In Bojrab MJ (ed): Current Techniques in Small Animal Surgery. References 1. Thread the fishing leader line through the bone tunnel. 4th ed. EXPECTED OUTCOME Outcome is usually fair to excellent. Johnson KA: Approach to the craniolateral region of the shoulder joint. Slocum B. 4.. thoracic radiographs. 4th ed. 4th ed. measure. the animal should slowly be returned to normal activity. POSTOPERATIVE EVALUATION The joint should be radiographed to assess implant positioning and joint congruency. Over the following 2 weeks. Tie the sutures in a figure-eight pattern. Patients should be thoroughly evaluated (e. Baltimore. Drill. Drill an oblique bone tunnel through the distal scapula at the origin of ligament (Plate 4C). Engen MH: Surgical treatment of shoulder luxations. 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 C D Tendon of infraspinatus muscle E . Incise the infraspinatus. The axillary artery and nerve are located immediately caudal to the joint. Johnson KA: Arthrodesis. Piermattei.1. Radiographs for limb alignment and implant placement should be evaluated. Wire the acromion. and rongeurs PREPARATION AND POSITIONING Prepare the forelimb circumferentially from dorsal midline to mid-radius. high-speed drill and wire driver. and care must be taken not to trap the nerve under the plate. Osteotomize the acromion and retract the deltoideus muscle distally and caudally. Satisfactory function of the treated limb can be expected as long as the elbow and carpus are free of disease. self-centering plate-holding forceps.2 Close the wound routinely. 2. Use an aluminum template to determine the cranial contour of the junction of the spine and body of the scapula and the cranial aspect of the proximal humerus. In Olmstead ML (ed): Small Animal Orthopedics. Flex the shoulder to the predetermined angle and perform an ostectomy of the humeral head. teres minor. A cancellous bone graft can be harvested from the ostectomized humeral head. periosteal elevator. Fill the remaining plate holes. Use the bending pliers and the torque irons to contour an appropriately sized bone plate (allowing at least three screws proximally and distally to the shoulder) to match the aluminum template. Osteotomy of the greater tubercle also aids joint exposure and provides a flat surface for the plate. Reattach the biceps brachii tendon to the fascia of the supraspinatus muscle. St. 1997. or severe osteoarthritis that is refractory to medical treatment.2 Alignment: Predetermine the cranial caudal angle for the shoulder arthrodesis by observing the normal standing angle of the shoulder in the individual patient. Attach the greater tubercle to the humerus lateral to the plate with a lag screw (see Plate 5D). The animal should be confined. INDICATIONS This procedure is used for animals with unreconstructable joint fractures. 3rd ed. and biceps brachii tendons and the joint capsule to expose the articular surfaces (Plate 5A). and temporarily fix them with Kirschner wires (Plate 5C). Piermattei DL. chronic shoulder luxation. wire twister. EXPECTED OUTCOME The bone should heal in 12 to 18 weeks. The arthrodesis site should be protected with a spica splint for 6 weeks or until early radiographic evidence of bone bridging is observed. Position the animal in lateral recumbency with the affected limb up. Kirschner wires. directing the proximal screws into the thick bone at the junction of the spine and body of the scapula (Plate 5D). Remove the Kirschner wires. 1995. Senn retractors. The suprascapular nerve and artery course over the scapular notch and under the acromion. POSTOPERATIVE EVALUATION The axial alignment of the limb and the angle of the arthrodesis should be observed critically.14 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES SHOULDER CHAPTER 5 Shoulder Arthrodesis scapular and the proximal humeral ostectomy surfaces. with activity limited to leash walks until bone healing is complete. Angular and rotational alignment of the limb should be checked carefully before the plate is secured. orthopedic wire. Drape the limb out from a hanging position to allow maximal manipulation during surgery. Louis.1. This angle is commonly 110 degrees (Plate 5B). plating equipment. the plate should not be removed. PROCEDURE Approach: Incise the skin and subcutaneous tissue over the cranial lateral aspect of the shoulder from the distal one third of the scapula to the proximal one third of the humerus. Mosby. Osteotomize the greater tubercle and elevate the supraspinatus muscle proximally. Place a lag screw through the plate and across the ostectomy surfaces (see Plate 5C). In Brinker. Medial and lateral angulation of the saw blade should be avoided when performing the scapular and humeral articular ostectomies. Barring complications. but these are not usually visualized with this approach. The humeral ostectomy should parallel the ostectomy surface of scapula when the shoulder is flexed to the appropriate angle (see Plate 5B). Radiographs should be repeated at 6-week intervals until bone healing occurs. CAUTIONS The suprascapular nerve and artery must be protected during the procedure.2 Stabilization: Remove the articular surface of the scapula with an oscillating saw directed perpendicular to the spine of the scapula. POSTOPERATIVE CARE A soft padded bandage should be placed around the forelimb and over the scapula to control bleeding and swelling. Philadelphia. Appose the distal . WB Saunders. Gelpi retractors.1 OBJECTIVES • To fuse the bones of the scapulohumeral joint in a functional position ANATOMIC CONSIDERATIONS The greater tubercle of the humerus and the acromion of the scapula are palpable landmarks. References 1. oscillating saw. Apply the plate by first placing screws through the proximal and distal plate holes. Osteotomy of the acromion allows reflection of a portion of the deltoideus muscle and visualization of the joint. Hohmann retractors. and Flo’s Handbook of Small Animal Orthopedics and Fracture Repair. Flo GL: The shoulder joint. EQUIPMENT • Surgical pack. Collect cancellous bone from the ostectomized humeral head with rongeurs and place it around the ostectomy surfaces. wire cutter. CHAPTER 5 S H O U L D E R A RT H R O D E S I S 15 P L AT E 5 Supraspinatus muscle A Tendon of biceps brachii muscle cut Spinous head of deltoideus muscle Joint capsule incised Osteotomy site Infraspinatus muscle Teres minor muscle B 110º Acromial head of deltoideus muscle C D . Strict hemostasis of these intermuscular vessels is imperative for adequate visualization within the joint. The median nerve. walks outside on leash only to urinate/defecate. Armstrong S. Probe the remaining cartilage surrounding the defect with a curette. 2004. Forage: Using a small Kirschner wire or small Steinmann pin. a small Frazier suction tip (size 8 or 10). Piermattei DL. J Am Vet Med Assoc 209:1427–1430. EQUIPMENT • Standard surgical pack. . 1994. 1986. EXPECTED OUTCOME 1. Wind AP: Elbow incongruity and developmental elbow diseases in the dog: Part I. Johnson AL. penetrate the sclerotic subchondral bone in multiple sites until it bleeds. loose fragment excision. 1996. Identify the separation between the flexor carpi radialis and the superficial digital flexor tendon by counting the muscle bellies from cranial to caudal. Lavage the joint copiously. 4th ed.. Expose the joint capsule and incise it parallel to the muscle-splitting incision to expose the coronoid process. Dogs with severe degenerative joint disease and persistent lameness that are not responsive to conservative management and nonsteroidal anti-inflammatory drugs may also benefit from joint exploration. OBJECTIVES • To improve function and limit pain stemming from osteoarthritis and elbow incongruity ANATOMIC CONSIDERATIONS 2 The elbow joint is exposed through a medial approach. POSTOPERATIVE CARE The limb should be bandaged after surgery for 2 to 3 days to prevent swelling and to provide soft-tissue support. especially those with advanced degenerative joint disease. Multiple clinical studies have found that surgical treatment does not halt the progression of degenerative joint disease. and close the joint capsule and wound in a routine fashion. Philadelphia.3. 1986. starting with the pronator teres. no running. and remove any abnormal cartilage not adherent to the subchondral bone (Plate 6C). Incise the subcutaneous fat and fascia along the same lines. over the anconeus muscle. PROCEDURE Approach:2 Incise the skin from just proximal to the medial epicondyle to the proximal radius. Over the following 4 weeks. paying close attention to the muscular branch of the ulnar artery and vein. Wind AP. jumping. Remove the coronoid fragment with rongeurs or osteotome and mallet so that the base of the medial coronoid process is level with that of the radial head (Plate 6B). 4. 2. brachial artery. 3. This eliminates excessive forces on the medial coronoid process that are present when incongruities in radial and ulnar length exist. Read R. two baby Gelpi retractors. POSTOPERATIVE EVALUATION No specific postoperative evaluation is required. Separate the muscles via blunt dissection. CAUTIONS A muscular branch of the recurrent ulnar artery and vein is present in the intermuscular septum between the flexor carpi radialis and deep digital flexor muscles. Exercise should be restricted for 4 weeks (e. Johnson KA: Approach to the medial aspect of the humeral condyle and the medial coronoid process of the ulna by an intermuscular incision. J Am Anim Hosp Assoc 22:725–731. Muhlbauer MC. Packard ME: Elbow incongruity and developmental elbow diseases in the dog: Part II. The ulnar nerve courses caudally to the medial epicondyle.5 The outcome is usually guarded to good. WB Saunders. kennel confinement when not under direct observation. the animal should slowly return to normal activity. periosteal elevator.16 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES ELBOW Fragmented Medial Coronoid Process and Osteochondrosis of the Elbow CHAPTER 6 INDICATIONS 1 The ideal candidates for this surgery are dogs with persistent lameness that exhibit minimal degenerative changes to the joint on radiographs. with the affected limb suspended for draping. The median nerve and brachial artery and vein course cranially to the medial epicondyle. Joint Exploration: Identify the fragmented coronoid process and any osteochondrotic or kissing lesions on the medial humeral condyle. bone curettes. pin chuck or high-speed wire driver. osteotome and mallet. et al: The effect of treatment of fragmented coronoid process on the development of osteoarthritis of the elbow. Kirschner wires or small Steinmann pin for forage. J Am Anim Hosp Assoc 30:190–195. Insert the baby Gelpi retractors into the joint to facilitate visualization (Plate 6A). and ulnar nerve are located just proximal to the epicondyle. and osteophyte curettage. and an Ochsner forceps PREPARATION AND POSITIONING Prepare the limb from shoulder to carpus.g.4 Osteochondrosis Curettage: Remove the cartilage flap with thumb or Ochsner forceps. In An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. J Am Anim Hosp Assoc 22:711–724. 5. Lempert rongeur. Then release the limb to allow access to the medial surface of the elbow. or playing). Black A. Continued nonsteroidal anti-inflammatory therapy may be required in some patients. References 1. Huibregtse BA. The medial epicondyle and the pronator teres and flexor carpi radialis muscles are key anatomic landmarks for this approach. Position the dog in dorsal recumbency. et al: Relationship between physical signs of elbow dysplasia and radiographic score in growing rottweilers. CHAPTER 6 OSTEOCHONDROSIS OF THE ELBOW 17 P L AT E 6 A Flexor carpi radialis muscle B Joint capsule incised Superficial digital flexor muscle Medial coronoid process of ulna (fragmented) C Sharp adduction and internal rotation of humerus . 5 Reduce the elbow by hooking the anconeal process into the lateral condyle and restoring radiohumeral joint orientation (Plate 7B). Elevate the extensor carpi radialis muscle from the bone and enter the joint (Plate 7A). mallet. perform an olecranon osteotomy to eliminate the pull of the triceps muscle. a craniolateral compartment can be made. Next. flush the joint and assess stability. wire driver. The animal is positioned in lateral recumbency with the affected leg draped. Warsaw. Anatomic landmarks for open reduction are the lateral humeral condyle. from the distal humerus to the proximal radius.3 Incise the skin and subcutaneous tissue over the lateral condyle. Retract the muscles to expose the lateral condyle. After reduction. a blunt periosteal elevator can be used to gently lever the radial head into position. tap. OBJECTIVES • To reestablish normal joint orientation and stability while preserving functional pain-free range of motion of the elbow joint ANATOMIC CONSIDERATIONS 2 More than 90% of traumatic elbow luxations are lateral because of the large medial epicondylar ridge of the humerus and the distal slope of the medial epicondyle. periosteal elevator. a screw and washer combination may be used. Continued *Bone Biter Suture Anchor System. and chronic luxations with muscle contracture and capsule fibrosis. Additional instrumentation needed for this technique includes high-speed drill.18 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES ELBOW Stabilization of Lateral Elbow Luxation CHAPTER 7 INDICATIONS 1 The indications for open reduction of luxated elbows include Monteggia fractures. If additional exposure to the joint is necessary to visualize the radial head. EQUIPMENT • Standard surgical pack. Incise the periosteal origin of the extensor carpi radialis. or hematomas. two medium or large Gelpi retractors (depending on the size of the dog). and a suture anchor system* If a suture anchor system is not available or if the animal is not large enough to accommodate the suture anchor system. and extend this incision distally along the intermuscular septum between the extensor carpi radialis and the common digital extensor muscle. Abduct and inwardly rotate the antebrachium and into the fully reduced position (Plate 7C). Continue the incision though the deep fascia on the cranial border of the triceps and extend it distally over the extensor muscles of the antebrachium. depth gauge. two small Hohmann retractors. A limited lateral approach to the elbow is used. intramedullary pins or Kirschner wires. Reduction:4. bony fragments. Indiana. drill bit. Incise the periosteal origin of the anconeal muscle to expose the caudolateral compartment of the elbow. A superficial branch of the radial nerve is located between the lateral head of the triceps and the brachialis muscle. the olecranon and anconeal processes. and screwdriver. First. Try to protect the cartilage during reduction. failed closed reductions. A deep branch of the radial nerve courses proximally to the cranial border of the extensor carpi radialis muscle. Use a hanging leg preparation with the dog in lateral recumbency to allow for maximal manipulation of the shoulder joint during surgery. bone screw and washer. . PREPARATION AND POSITIONING Prepare the leg circumferentially from dorsal midline to the carpus. flex the elbow about 100 degrees and inwardly rotate the antebrachium. hook the anconeal process over the lateral condyle and slightly extend the elbow. and this must be protected in the proximal portion of the incision. and the radial head. While placing lateral to medial pressure over the head of the radius. PROCEDURE Approach:2. If the muscle contraction and subsequent overriding are severe. reduce the radial head under the humeral capitulum. If reduction is not achieved. Incise the deep brachial and antebrachial fascia to expose the lateral head of the triceps. acute luxations that cannot be reduced by closed manipulation because of instability. CHAPTER 7 S TA B I L I Z AT I O N O F L AT E R A L E L B O W L U X AT I O N 19 P L AT E 7 A Deep fascia Anconeal muscle Extensor carpi radialis muscle Lateral condyle exposed Common digital extensor muscle B Anconeal process hooked over lateral epicondyle C Medial pressure on olecranon 100° . Meij BP.g. 5. If additional stability is necessary. with electrocardiogram. References 1. 2) nonabsorbable suture or two screws and a figure-eight wire (Plate 7E). or both should be attempted. Joint stability and range of motion should be evaluated at 2 and 4 weeks to assess continued need for external coaptation. 1997. POSTOPERATIVE EVALUATION The joint should be radiographed to assess implant positioning and joint congruency.. 2004. POSTOPERATIVE CARE The limb should be supported in a spica splint for 10 to 14 days. 4. and Flo’s Handbook of Small Animal Orthopedics and Fracture Repair. splint removal for the next two weeks with concurrent exercise restriction. Common complications following surgery included degenerative joint disease and decreased range of joint motion. Over the following 2 weeks. Vet Comp Orthop Traumatol 12:33–39. ligamentous repair may be supplemented with suture anchors with either heavy (No. the animal should slowly return to normal activity. 3. WB Saunders. less active dogs have a better prognosis than do larger. Piermattei DL. Piermattei DL. and blood work) and stabilized before initiating surgical repair. Smaller. 4th ed. 4th ed. Schaeffer IGF. If possible. repair. 2004. Appose the torn ends of the ligament with a locking loop or three-loop pulley suture pattern. In An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. In An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. Johnson KA: Approach to the humeroulnar part of the elbow joint by osteotomy of the tuber olecrani. consider medial collateral ligament repair.20 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES Collateral Ligament Repair: Identify the torn lateral collateral ligament. et al: Traumatic luxation of the elbow in 31 dogs. WB Saunders. Patients should be thoroughly evaluated (e. Check the joint for stability and range of motion. 2004. Johnson KA: Approach to the lateral humeroulnar part of the elbow joint. Philadelphia. In An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. Johnson KA: Approach to the lateral aspect of the humeral condyle and epicondyle. Philadelphia. Piermattei. Wolvekamp P. As soon as the patient is stabilized. Philadelphia. Passive range of motion exercises should be implemented after . 3rd ed. primary repair of the torn ligament should be attempted. Most dogs have good limb function after surgical reduction. If needed. 1 or No. Philadelphia. 1999. Piermattei DL. more active dogs. WB Saunders. thoracic radiographs. EXPECTED OUTCOME 1 The usual outcome is fair to excellent. Reattach avulsed ligaments with a bone screw and spiked Teflon washer (Plate 7D). reduction. 2. Piermattei DL. WB Saunders. 4th ed. Flo GL: Brinker. CAUTIONS There is a high potential for concurrent chest trauma with these injuries. 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 fragment E . Incise the deep brachial and antebrachial fascia to expose the lateral head of the triceps. periosteal elevator. is recommended in dogs with minimal DJD and a loose anconeal process and an incongruent joint as found by evaluation of the joint via arthrotomy or arthroscopy. Ununited Anconeal Process Excision:4 Flex the elbow joint fully to expose the anconeal process. Continued .6 Exposure of the anconeal process for either lag-screw fixation or excision is made via a caudolateral approach.2 • To improve joint congruity. If the process is adherent to the ulna. and Dynamic Proximal Ulnar Osteotomy CHAPTER 8 INDICATIONS 1–4 Surgery is the treatment of choice for dogs older than 5 months with failure to form an osseous union between the anconeal process and the ulna. Incise the periosteal origin of the anconeal muscle to expose the caudolateral compartment of the elbow and enter the joint through a capsular incision. PROCEDURE Caudolateral Approach:6 Incise the skin and subcuta- neous tissue over the lateral condyle. Continue the incision though the deep fascia on the cranial border of the triceps and extend it distally over the extensor muscles of the antebrachium. bone curettes. Caudal Approach to the Proximal Ulna:5 Incise the skin and subcutaneous tissue along the shaft of the ulna from the tuber olecrani to the proximal midshaft region. from the distal humerus to the proximal radius. high-speed wire driver/drill/oscillating saw. continuing distally along the ulnaris lateralis muscle. Surgical excision is generally reserved as a salvage procedure for dogs with severe DJD and UAP. and two Hohmann retractors PREPARATION AND POSITIONING Prepare the limb from shoulder to carpus. Place the Hohmann retractors between the radius and ulna just distal to the medial and lateral coronoids to retract the tissues and visualize the ulna. Position the dog in dorsal recumbency with the affected limb suspended for draping. lag-screw fixation. followed by concurrent DPUO. Considerable controversy exists regarding the best course of therapy. two medium Gelpi retractors.22 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES ELBOW Treatment of Ununited Anconeal Process via Removal. A superficial branch of the radial nerve is located between the lateral head of the triceps and the brachialis muscle. and the radial head. The landmark for ulnar osteotomy is the caudal border of the proximal ulna. pointed reduction forceps. Surgical excision is considered a salvage procedure aimed at eliminating the irritation caused by the UAP ANATOMIC CONSIDERATIONS 5. EQUIPMENT • Standard surgical pack. and prevent DJD by DPUO and lag-screw fixation. A deep branch of the radial nerve courses proximally to the cranial border of the extensor carpi radialis muscle. Medical therapy alone has been associated with a rapid progression of severe degenerative joint disease (DJD) and lameness. Kirschner wires or small Steinmann pins. Retract the muscles to expose the lateral condyle. sever the fibrous attachments with a periosteal elevator or osteotome and mallet. and dynamic proximal ulnar osteotomy (DPUO). plating equipment. Three surgical treatment options have been reported: surgical excision. Lempert rongeur. Lag-Screw Fixation. OBJECTIVES 1. encourage fusion of the anconeal process. aiming device. Incise the periosteum of the flexor carpi ulnaris and the anconeus. Anatomic landmarks for the elbow are the lateral humeral condyle. and this must be protected in the proximal portion of the incision. Then release the limb to allow access to the lateral and caudal surfaces of the elbow. DPUO is recommended in dogs with minimal DJD and ununited anconeal process (UAP) that is tightly adhered to the ulna. the olecranon and anconeal processes. osteotome and mallet. a Frazier suction tip. For a DPUO. Grasp the floating process with pointed reduction or tissue forceps and remove (Plate 8A). Lagscrew fixation of the UAP. a caudal approach to the proximal ulnar diaphysis is used. 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 A Triceps muscle retracted Anconeus muscle retracted . WB Saunders. However.and long-term results after surgical treatment of an ununited anconeal process in the dog. Drill the screw hole from the caudal cortex of the ulna. et al: Ununited anconeal process: Lag-screw fixation. Vet Comp Orthop Traumatol 4:101–110. Johnson KA: Approach to the proximal shaft and trochlear notch of the ulna. Abercromby RH. Cross AR. parallel to the K-wire. joint congruency. In An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. lever the bone ends with a periosteal elevator to release the interosseus ligament. If not separated. Exercise should be restricted until healing of the UAP is confirmed by radiograph. Insert an additional Kirschner wire parallel to the screw to ensure rotational stability. CAUTIONS Lag-screw fixation for UAP is technically difficult. The reported clinical outcome is good to excellent for these animals. Chambers JN: Ununited anconeal process of the canine elbow. 2001.5-mm cortical screw placed in lag fashion or a partially threaded 4. only 50% of the dogs were free of lameness on long-term follow-up examination.7-mm or 3. Piermattei DL. 8. Burbidge HM. Closure is routine. 2. et al: Ununited anconeal process: Lag-screw fixation with proximal ulnar osteotomy. 1996. Fehr M. and/or implant and osteotomy position.24 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES Ununited Anconeal Process Lag-Screw Stabilization:2. cut the bone distal to proximal at a 20. Fox SM. 4th ed. et al: Dynamic proximal ulnar osteotomy for the treatment of ununited anconeal process in 17 dogs. Johnson KA: Approach to the lateral humeroulnar part of the elbow joint. The expected outcome is better in dogs with DPUO and/or lag-screw fixation. 6. passing perpendicular to the cleavage line and exiting 1 mm to 2 mm beyond the articular margin. Stabilize the ulna with a small intramedullary pin (Plate 8E). Radiographs should be repeated every 4 to 6 weeks until the UAP is healed. 2004. 1998.8 Using an oscillating saw or Gigli wire. In An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat.to 30-degree angle to the long axis of the ulna shaft. Bray JC.3. EXPECTED OUTCOME 2.8 Surgical excision of the UAP is associated with a variable prognosis. with fusion of the anconeal process and minimal to no progression of DJD expected. and exiting at the point of the anconeal process (Plate 8C). 4th ed. Turner BM. Sjostrom L: Ununited anconeal process in the dog. Correct positioning of the lag screw is imperative. 3. Philadelphia. 1997. Bahr A. Postoperative radiographs are indicated to verify complete UAP excision. Nolte I: Short. 2004. WB Saunders. Exercise should be restricted for 2 to 4 weeks in dogs with surgical excision of the UAP. an aiming device can be used to ensure accurate screw placement (Plate 8D). 1998. it will be removed once the anconeal process is secured. Vet Clin North Am Small Anim Pract 28(1):75–86. .0 cancellous screw.3. POSTOPERATIVE EVALUATION The joint should be placed through a thorough range of motion before closure. 2000.7 Reduce and maintain the UAP with the ulna using pointed reduction forceps (Plate 8B). with 70% of the patients improving in the immediate postoperative period. POSTOPERATIVE CARE All patients should be placed in a soft padded bandage for 2 to 3 days to prevent seroma formation. Use this pin as a reference point to guide lag-screw positioning. Krotscheck U. 7. When the osteotomy is complete. 5. Remove the first Kirschner wire that is penetrating the joint. References 1. Piermattei DL. Insert a Kirschner wire into the proximal quadrant of the anconeal process. Vet Comp Orthop Traumatol 13:212–216. Philadelphia. Meyer-Lindenberg A. Closure is routine. Secure the anconeal process with either a 2. Compend Cont Ed 19:349–362. the ulna should separate 2 mm to 4 mm spontaneously. Dynamic Proximal Ulnar Osteotomy:1–3. and moderate to severe DJD can be expected because of the inherent instability of the elbow following removal of the anconeal process and because of the preexisting joint pathology. J Am Anim Hosp Assoc 32(1):52–56. Innes J. Incorrect drillings can result in failure because of penetration of the joint as a result of the small size of the anconeal process. 4. Alternatively. Vet Comp Orthop Traumatol 11:76–79. Hulse DA. 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 B C D E . The mean age at surgery of dogs with good to excellent results is 6.3 Using an oscillating saw or Gigli wire. cut the bone perpendicular to the longitudinal axis of the ulna (Plate 9A). and place in the gap created by the ostectomy (Plate 9D). and Lempert rongeur PREPARATION AND POSITIONING Prepare the limb from shoulder to just distal to the carpus.5 Incise the skin and subcutaneous tissue in the cranial inguinal/caudal abdominal region.75 months in dogs with fair to poor results. 3. Craig E: Autogenous fat grafts to prevent recurrence following surgical correction of growth deformities of the radius and ulna in the dog. This will minimize the amount of graft necrosis and shrinkage. and joint subluxation ANATOMIC CONSIDERATIONS A caudal approach to the distal ulnar diaphysis is used. 5 months) with less than 25 degrees of carpal valgus or in older animals (medial age. one Gelpi retractor or two Senn retractors. References 1. Exercise should be restricted for at least 6 to 8 weeks. from the midshaft of the diaphysis to the styloid process.5 months) with less than 13 degrees of valgus. PROCEDURE Approach:4 Incise the skin and subcutaneous tissue along the shaft of the ulna. joint congruity. Gambardella PC: Premature closure of the ulnar physis in the dog: A retrospective clinical study. Incise the antebrachial fascia between the ulnaris lateralis and the lateral digital extensor tendons. 1981. This procedure is most effective in young dogs (median age. 6. WB Saunders. with the affected limb suspended for draping. before the appearance of severe angular limb deformities. corrective osteotomies can be performed if necessary. Use a periosteal elevator to elevate the surround musculature. To monitor ostectomy healing. a Frazier suction tip. until the full effect of the distal ulnar ostectomy is achieved. 1989.5 months. Miller CW: Osteotomy for correction of premature growth plate closure in 24 dogs. 5. Vet Surg 11:92–99. Then release the limb to allow access to the caudolateral aspect of the antebrachium. 1982. In An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. because it will form a premature bony union if left in situ. Hemostasis is imperative to ensure that large blood clots do not fill the defect and promote connective tissue replacement. Vet Surg 10:69–76. POSTOPERATIVE EVALUATION Postoperative radiographs are indicated to verify ostectomy position and the complete removal of periosteum.26 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES ELBOW Distal Ulnar Ostectomy with Fat Graft CHAPTER 9 INDICATIONS 1–3 Distal ulnar ostectomy is indicated as an early corrective surgery for premature closure of the distal ulnar physis. 1990. Distal Ulnar Ostectomy:1. Shields Henney LH: Partial ulnar ostectomy for treatment of premature closure of the proximal and distal radial physes in the dog. Fat Graft Harvest:2. and add a fat graft. Harvest a fat graft of sufficient size to fill the defect. Vandewater A. EQUIPMENT • Standard surgical pack. exposing the periosteal surface of the ulna. J Am Anim Hosp Assoc 25:573–581. Younger dogs with less severe angular limb deformities have better functional results after distal ulnar ostectomy than do older dogs with severe angulation and joint subluxation. CAUTIONS 2. 1994. radiographs should be repeated every 4 to 6 weeks until radial bone growth is complete. and should be of a size that is adequate to fill the ostectomy site. Excessive movement of the ostectomy site inhibits graft vascularization and may result in displacement and subsequent premature union of the ulna. periosteal elevator. OBJECTIVES • To prevent or correct angular limb deformity. abnormal load transmission. the ulnaris lateralis. 2004. 6. two Hohmann retractors.5 The periosteum must be completely removed with the ostectomized bone. POSTOPERATIVE CARE 2 All patients should be placed in a soft padded bandage for 2 to 3 days to prevent seroma formation. and angular limb deformity. . 4. Landmarks for the ostectomy are the caudolateral border of the distal third ulna. Stevenson S: Partial ulnar ostectomy with free autogenous fat grafting for treatment of radius curvus in the dog. J Am Anim Hosp Assoc 26:183–188. high-speed oscillating saw or Gigli wire. Morgan PW. Closure is routine. contrasted to the mean age at surgery of 9. Close the subcutaneous tissue and skin over the ostectomy site (Plates 9B and 9C). limb shortening. The fat graft should be harvested atraumatically in one piece. Olmstead ML. Shields Henney LH. Position the dog in dorsal or lateral recumbency. Philadelphia. EXPECTED OUTCOME 6 The outcome is usually good to excellent. Once bone growth is complete. and place the Hohmann retractors between the radius and ulna at the proposed osteotomy site. the deep digital flexor muscles. Prepare the caudal abdominal/inguinal region for fat graft harvest. Remove a 1-cm to 2-cm section of the ulna. and the abductor pollicis longus muscle. the tendons of the lateral digital extensor. 2. Piermattei DL. 4th ed. Vet Comp Orthop Traumatol 7:129–165. Johnson KA: Approach to the distal shaft and styloid process of the ulna. 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 A Lateral digital extensor muscle B Ulnaris lateralis muscle C D Fat graft . 28 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES ELBOW CHAPTER 10 Elbow Arthrodesis ends. Perform an ostectomy of the proximal ulna to create a smooth surface for the plate (see Plate 10B). Temporarily fix the distal humeral condyle to the trochlear notch with a Kirschner wire (Plate 10C). Use an aluminum template to determine the contour of the caudal surfaces of the distal humerus and proximal ulna. Use the bending pliers and the torque irons to contour an appropriate-size bone plate (allowing at least four screws proximally and distally to the elbow) to match the aluminum template. Apply the plate by first placing screws through the proximal and distal plate holes. Place a lag screw through the plate and across the lateral portion of the humeral condyle into the radial head. Place a second lag screw through the plate across the ulna and into the medial portion of the humeral condyle (see Plate 10C). Fill the remaining plate holes. Screws placed through the ulna should penetrate the radius, if possible. Remove the temporary Kirschner wire. Reattach the osteotomized portion of the olecranon to the medial epicondyle with a lag screw (Plate 10D).1,2 Collect cancellous bone from the proximal humerus and place it around the ostectomy surfaces. Close the wound routinely. CAUTIONS The radial and ulnar nerves must be protected. All articular cartilage must be removed. Angular and rotational alignment of the limb must be checked carefully before the plate is secured. POSTOPERATIVE EVALUATION The axial alignment of the limb and the angle of the arthrodesis should be observed critically. Radiographs should be evaluated for limb alignment and implant placement. POSTOPERATIVE CARE A soft padded bandage should be placed to control bleeding and swelling. A lateral splint should be used for 6 weeks or until early radiographic evidence of bone bridging is observed. Radiographs should be repeated at 6-week intervals until bone healing occurs. The animal should be confined and activity should be limited to leash walks until bone healing is complete. The plate may be removed 6 to 9 months after bone healing if it causes soft tissue irritation. EXPECTED OUTCOME The bone usually heals in 12 to 18 weeks. Function of the treated limb can be awkward, and the animal may have trouble with stairs or with rough terrain.1 Amputation may offer better function.2 References 1. Johnson KA: Arthrodesis. In Olmstead ML (ed): Small Animal Orthopedics. St. Louis, Mosby, 1995. 2. Piermattei DL, Flo GL: The elbow joint. In Brinker, Piermattei, and Flo’s Handbook of Small Animal Orthopedics and Fracture Repair, 3rd ed. Philadelphia, WB Saunders, 1997. INDICATIONS This procedure is indicated in animals with unreconstructable joint fractures, chronic elbow luxation or subluxation, or severe degenerative joint disease that is not responsive to medical treatment. OBJECTIVES • To fuse the bones of the humeroradial and humeroulnar joints in a functional position ANATOMIC CONSIDERATIONS The triceps muscle courses in a cranial proximal direction from its insertion on the olecranon, and crosses the humerus rather than running parallel to it. The radial nerve lies beneath the lateral head of the triceps near the distal third of the humerus. The ulnar nerve courses over the medial aspect of the elbow, caudal to the medial epicondyle, and an olecranon osteotomy aids joint exposure. A proximal ulnar ostectomy provides a flat surface for the plate. EQUIPMENT • Surgical pack, Senn retractors, Hohmann retractors, Gelpi retractors, periosteal elevator, oscillating saw, bone curette, self-centering plate-holding forceps, high-speed drill, burrs and wire driver, Kirschner wires, wire cutters, plating equipment PREPARATION AND POSITIONING Prepare the forelimb circumferentially from dorsal midline to carpus. Position the animal in lateral recumbency, with the affected limb elevated. Drape the limb out from a hanging position to allow maximal manipulation during surgery. A cancellous bone graft can be harvested from the ipsilateral proximal humerus. PROCEDURE Approach: Incise the skin and subcutaneous tissue on the caudal lateral aspect of the elbow from the distal one third of the humerus to the proximal one third of the ulna. Elevate the anconeus muscle from the olecranon. Osteotomize the olecranon process, and retract the triceps muscle proximally to expose the caudal surface of the distal humerus. Elevate the flexor carpi ulnaris and deep digital flexor muscles medially and the ulnaris lateralis muscle laterally to expose the proximal ulna. Reflect the origin of the flexor carpi ulnaris muscle to expose the trochlear notch. Incise the ulnaris lateralis, lateral collateral ligament, and joint capsule to expose the articular surfaces (Plate 10A). Alignment: Predetermine the cranial caudal angle for the elbow arthrodesis by observing the normal standing angle of the elbow in the individual patient (commonly 110 degrees) (Plate 10B).1,2 Stabilization: Remove the articular cartilage of the humeral condyle, radial head, and trochlear notch with a bone curette or high-speed burr, following the contours of the bone CHAPTER 10 E L B O W A RT H R O D E S I S 29 P L AT E 1 0 A B Osteotomy of the olecranon process 110… Anconeus muscle Joint capsule incised Flexor carpi ulnaris muscle Lateral collateral ligament Ulnaris lateralis muscle Ulnar ostectomy C D 30 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES CARPUS CHAPTER 11 Radial and Ulnar Styloid Fractures avulsions, two pins may be inserted into the far cortex of the radius (Plate 11C). Drill a transverse hole 1 to 2 cm proximal to the fracture site and pass a figure-eight wire through the hole and around the Kirschner wires. Tighten the wire, bend the pins over, and cut. Closure is routine. Lag-Screw Technique: For the radial styloid process, drill a gliding hole (equal to the diameter of the threads on the screw) in the styloid fragment. Place an insert drill sleeve into the gliding hole and drill a smaller hole (equal to the core diameter of the screw) across the radius. Measure, tap, and select and place the appropriate-length screw (Plate 11D). Compression of the fracture should occur. When stabilizing the ulnar styloid process, treat the styloid process as the fragment by drilling the gliding hole through the ulna and the tapped hole in the radius (Plate 11E). Closure is routine. CAUTIONS 1 It may not be possible to place two pins into the distal ulna in small dogs; therefore, the ulnar styloid fracture may not be completely rotationally stable. External coaptation is strongly recommended. POSTOPERATIVE EVALUATION Radiographs should be evaluated for articular surface reduction and implant placement. Radiographs should be repeated every 6 to 8 weeks until the fracture has healed. POSTOPERATIVE CARE 2,4 A Mason Meta splint or fiberglass half-cast is necessary to protect the repair for the first 6 to 8 weeks. Exercise should be restricted until the fracture heals. Implant removal is indicated if the implants become loose or if they irritate the soft tissues after the fracture heals. EXPECTED OUTCOME 3,4 Outcome is fair to excellent in most cases. Carpal stability and alignment depend on adequate reduction and stability of the styloid process. Mild to moderate degenerative joint disease may be expected because of the articular nature of this fracture. References 1. Bruce WJ: Radius and ulna. In Coughlan AR, Miller A (eds): BSAVA Manual of Small Animal Fracture Repair and Management. Cheltenham, British Small Animal Veterinary Association, 1998. 2. Egger EL: Fractures of the radius and ulna. In Vasseur P, Slatter D (eds): Textbook of Small Animal Surgery, vol. 2, 2nd ed. Philadelphia, WB Saunders, 1993. 3. Miller AS: What is your diagnosis? (Radial carpal dislocation in a dog). J Small Anim Pract 34:11, 576, 582–583; 3 ref. 1993. 4. Probst CW: Stabilization of fractures of the radius and ulna. In Bojrab MJ (ed): Current Techniques in Small Animal Surgery, 4th ed. Baltimore, Williams & Wilkins, 1998. INDICATIONS Candidates include dogs with avulsion fractures of one or both styloid processes. OBJECTIVES • To restore normal joint orientation and stability to the antebrachial carpal joint ANATOMIC CONSIDERATIONS 1–4 The antebrachial carpal joint is formed by the radius and the styloid process of the ulna, articulating with the radial and ulnar carpal bones. This joint contributes to nearly 90% of the movement in the carpus and is important to carpal function. The radial and ulnar styloid processes serve as the origin of the collateral ligaments and also extend down into the joint, serving as a physical buttress against medial lateral instability. Internal fixation is required to restore stability to the antebrachial carpal joint. EQUIPMENT • Surgical pack, pointed reduction forceps, Kirschner wires or small Steinmann pins (for large dogs), pin chuck or highspeed wire driver; plating equipment is required for lag-screw fixation PREPARATION AND POSITIONING Prepare the limb circumferentially from the shoulder to the digits. Position the animal in dorsal recumbency for greater flexibility, with the affected limb suspended for draping. Then release the limb to allow access to the distal antebrachium. PROCEDURE Approach: Expose the styloid processes by incising directly over the processes through the skin and subcutaneous tissue. Continue the incision into the retinacular and antebrachial fascia. Elevate the surrounding tissue as necessary to visualize the fracture and collateral ligament (Plate 11A [lateral view]). Reduction:3 Reduce the fractured process by tenting the bone ends, and lever the bone back into position. Maintain reduction with pointed reduction forceps. Stabilization:1,2,4 Accomplish fixation of the styloid process with the pin and tension band wire or lag-screw technique. If the fragments are too small to permit pin insertion, the collateral ligament may be reattached to the bone with a screw and spiked plastic washer. Pin and Tension Band Wire Technique:1–4 Depending on the avulsed fragment size, drive one or two wires into the styloid process, directing the wires obliquely across the fracture into the far cortex of the radius or ulna. For ulnar avulsions, insert a single K-wire into either the ulna or into the far cortex of the distal radius (Plate 11B). For radial styloid CHAPTER 11 RADIAL AND ULNAR STYLOID FRACTURES 31 P L AT E 1 1 A Radius Flexor carpi ulnaris Ulna V B C D E and IV) carpal bones. SumnerSmith G. 4. bone curette. 1999. Elevate and retract the digital extensor tendons laterally to expose the distal radius. luxation. Secure the plate with three screws in the metacarpal bone. 1995. Vet Surg 28:25. Position the animal in lateral recumbency with the affected limb up. A bivalve cast should be used for 6 weeks or until early radiographic evidence of bone bridging is observed. ulna. Elevate and resect the attachment of the carpal extensor tendons from the metacarpal bones. and the carpometacarpal joint surfaces with a bone curette or high-speed burr. Hohmann retractors.2 (see Plate 12E).32 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES CARPUS CHAPTER 12 Pancarpal Arthrodesis larger screws over the radius and smaller screws over the metacarpal bones. Mark the level of the distal metacarpal plate screw. Gelpi retractors. Remove the plate and center the drill on the metacarpal bone. et al: Thirteen pancarpal arthrodeses using 2. and the metacarpal bones. distal row (II. PROCEDURE Approach: Incise the skin and subcutaneous tissue over the dorsal surface of the joint from the distal third of the radius to the distal third of the metacarpal bones. periosteal elevator. (Alternatively. pain-free articulation. use a hybrid plate that accommodates . Olmstead ML. POSTOPERATIVE CARE A soft. The animal should be confined. and carpometacarpal joints in a functional position ANATOMIC CONSIDERATIONS The carpus consists of the radius. Incise the joint capsule to enter each joint space and expose the articular surfaces (Plate 12A). and accessory) carpal bones. Alignment: The cranial caudal angle for the pancarpal arthrodesis is commonly 10 to 12 degrees1. self-centering plate-holding forceps. INDICATIONS Candidates include dogs with hyperextension of the antebrachial carpal joint. Drape the limb out from a hanging position to allow maximal manipulation during surgery. Johnson KA: Arthrodesis. Mosby. or shearing injury) of the antebrachial carpal joint that precludes maintaining a long-term.5 mm hybrid dynamic compression plates. the carpus. and the proximal two thirds of the third metatarsal bone.7/3. Carmichael S.g. and good function in the treated limb is anticipated. with activity limited to leash walks until bone healing is complete.3) Position the plate so that one screw will penetrate the radial carpal bone. Consider using a tourniquet to control bleeding. high-speed drill and burrs. Implants are generally removed after 6 to 12 months to avoid soft tissue irritation. POSTOPERATIVE EVALUATION The axial alignment of the limb and the angle of the arthrodesis should be observed critically. Angular and rotational alignment of the limb should be checked carefully before securing the plate to the radius. 1998. proximal (radial.1 CAUTIONS All of the articular cartilage should be removed. Dyce J. Casting should be delayed for 48 to 72 hours if a tourniquet has been used. Whitelock RG. Tourniquet use should be limited to 60 minutes. 2. on the dorsal surface of the distal radius and third metacarpal bone. Stabilization: Flex the carpus and remove the articular cartilage from the antebrachial carpal joint surfaces. Louis. and carpometacarpal joints. covering more than 50% of the metacarpal bone with the plate may reduce this problem. Place an appropriate-size bone plate (limited by the size of the metacarpal bone). EQUIPMENT • Surgical pack. or dogs with painful degenerative joint disease that is not responsive to conservative measures. forming the antebrachiocarpal. Fatigue fractures of the distal metacarpal bone may occur. Houlton JEF: Metacarpal fractures associated with pancarpal arthrodesis in dogs. middle carpal. plating equipment PREPARATION AND POSITIONING Prepare the forelimb circumferentially from shoulder to digits. Prepare the ipsilateral proximal shoulder or ilial wing for cancellous bone graft harvest. and then reduce the plate to the radius with self-centering forceps. Harvest cancellous bone and place the graft within the prepared joints (Plate 12C). fracture.. In Brinker WO. Radiographs should be repeated at 6-week intervals until bone healing occurs. 3. 1999. dogs with severe injury (e. Springer-Verlag.2 OBJECTIVES • To fuse the bones of the antebrachial. Senn retractors. III. following the contours of the bone ends (Plate 12B).4 References 1.3 EXPECTED OUTCOME Bone healing is expected in 12 to 18 weeks. et al (eds): Manual of Internal Fixation in Small Animals. Check plate and joint alignment and attach the plate to the radius. Vet Comp Orthop Traumatol 12:102. In Olmstead ML (ed): Small Animal Orthopedics. Fill the remaining plate holes (Plate 12D). One plate screw should secure the radial carpal bone (Plate 12E). padded bandage should be placed to control bleeding and swelling. the middle joint surfaces. middle carpal. ulnar. Gibson N. New York. precontoured to 10 to 12 degrees of carpal extension. Radiographs for limb alignment and implant placement should be evaluated. using the loaded drill guide in one or two holes to compress the antebrachial carpal joint (see Plate 12C).1. Li A. St. Ensure adequate plate holes for a minimum of three screws in the radius and three screws in the metacarpal bone. McLaughlin RM: Arthrodesis. CHAPTER 12 PA N C A R PA L A RT H R O D E S I S 33 P L AT E 1 2 A Abductor pollicis longus muscle Radial carpal bone Radius B Tendon of extensor carpi radialis muscle Tendon of common digital extensor tendon C D E 10° .12° carpal extension . St. A decrease in range of motion in the antebrachial carpal joint is usually seen. securing the plate to the third metacarpal bone (Plate 13D). Starting with the most distal plate hole. Gelpi retractors. distal row (II. Consider using a tourniquet to control bleeding. Prepare the ipsilateral proximal shoulder or ilial wing for cancellous bone graft harvest. bone curette. plating equipment PREPARATION AND POSITIONING Prepare the forelimb circumferentially from shoulder to digits. ulnar and accessory) carpal bones. Secure the plate to the radial carpal bone.34 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES CARPUS CHAPTER 13 Partial Carpal Arthrodesis with a Plate Harvest cancellous bone and place the graft within the prepared joints (Plate 13C). and carpometacarpal joint surfaces with a bone curette or high-speed burr. Select screws that are slightly shorter than the measured length to avoid interference with palmar soft tissues. periosteal elevator. Incise the joint capsule to enter each middle and distal joint space and expose the articular surfaces (Plate 13A). Tourniquet use should be limited to 60 minutes. and the proximal two thirds of the third metatarsal bone. PROCEDURE Approach: Incise the skin and subcutaneous tissue over the dorsal surface of the joint from the distal metaphysis of the radius to the distal third of the metacarpal bones. small Hohmann retractors. intercarpal. high-speed drill and burrs. and IV) carpal bones. POSTOPERATIVE CARE A soft. In Olmstead ML (ed): Small Animal Orthopedics. Drape the limb out from a hanging position to allow maximal manipulation during surgery. Elevate and retract the carpal extensor tendons medially and the digital extensor tendons laterally to expose the distal radius. Louis. intercarpal. Senn retractors. fill the remaining plate holes. Nearnormal function of the treated limb can be expected unless undiagnosed antebrachial carpal joint injuries are present. Alignment: Align the dorsal surfaces of the radial carpal bone and third metacarpal bone with the plate to produce the correct alignment for the arthrodesis. III.1 OBJECTIVES • To fuse the bones of the middle carpal and carpometacarpal joints in a functional position ANATOMIC CONSIDERATIONS The carpus consists of the radius. 1995. Stabilization: Flex the carpus and remove the articular cartilage from the middle carpal. Position a veterinary T plate distally on the dorsal surface of the radial carpal bone and third metacarpal bone. forming the antebrachiocarpal. The animal should be confined. Implants may need to be removed after 6 to 12 months to avoid soft tissue irritation. EQUIPMENT • Surgical pack. Mosby. Reduce the plate to the third metacarpal bone (see Plate 13C). proximal (radial.1 CAUTIONS All articular cartilage must be removed. INDICATIONS Candidates include dogs with hyperextension of the middle carpal and carpometacarpal joints. with activity limited to leash walks until bone healing is complete. POSTOPERATIVE EVALUATION Radiographs should be evaluated for limb alignment and implant placement. EXPECTED OUTCOME Bone healing is expected in 12 to 18 weeks. and carpometacarpal joints. and the metacarpal bones. following the contours of the bone ends (Plate 13B). the carpus. A bivalve cast should be used for 6 weeks or until early radiographic evidence of bone bridging is observed. Casting should be delayed for 48 to 72 hours if a tourniquet has been used. It is imperative that the plate be distal to the articular cartilage on the radial carpal bone to avoid interference with the radius. Reference 1. Johnson KA: Arthrodesis. The plate must not interfere with the articular surface of the radial carpal bone or with the radius when the limb is extended. Radiographs should be repeated at 6-week intervals until bone healing occurs. middle carpal. Position the animal in lateral recumbency with the affected limb up. plate-holding forceps. padded bandage should be placed to control bleeding and swelling. ulna. . CHAPTER 13 PA RT I A L C A R PA L A RT H R O D E S I S W I T H A P L AT E 35 P L AT E 1 3 A B Radial carpal bone Radius Tendon of extensor carpi radialis muscle Tendon of common digital extensor tendon C D . padded bandage should be placed to control bleeding and swelling. PROCEDURE Approach: Incise the skin and subcutaneous tissue over the dorsal surface of the joint from the distal third of the radius to the distal third of the metacarpal bones. Senn retractors. 1995. distal row (II. POSTOPERATIVE CARE A soft. III. Johnson KA. Hohmann retractors. The carpus must be flexed 90 degrees and pressure placed on the metacarpal bones to align the carpal bones with the metacarpal bones while the pins are placed. 1990. and carpometacarpal joints. middle carpal. EXPECTED OUTCOME Bone healing is expected in 12 to 18 weeks. forming the antebrachiocarpal. Johnson KA: Arthrodesis. Back the pins out a few millimeters. high-speed drill and burrs. Willer RL. In Olmstead ML (ed): Small Animal Orthopedics. Incise the joint capsule to enter each middle and distal joint space and expose the articular surfaces (Plate 14A). Casting should be delayed for 48 to 72 hours if a tourniquet has been used. Alignment: Flex the antebrachial carpal joint 90 degrees and apply proximal and palmar pressure to the metacarpal bones while placing the intramedullary pins to align the dorsal surfaces of the radial carpal bone and metacarpal bones correctly for the arthrodesis1 (see Plate 14C). Create burr slots in the dorsal surface of the distal third of the third and fourth metacarpal bones. bone curette. periosteal elevator. EQUIPMENT • Surgical pack. ulnar. proximal (radial. Lameness is eliminated or improved in two thirds of the dogs. Tourniquet use should be limited to 60 minutes. Vet Surg 92:334. . Drive small intermedullary pins or Kirschner wires through the slots proximally into the base of the bones. intercarpal. with activity limited to leash walks until bone healing is complete. Reduce the subluxation and align the carpus as described previously. Radiographs should be repeated at 6-week intervals until bone healing occurs. and carpometacarpal joint surfaces with a bone curette or high-speed burr. INDICATIONS Candidates have hyperextension of the middle carpal and carpometacarpal joints. 2.2 CAUTIONS All articular cartilage must be removed.2 OBJECTIVES • To fuse the bones of the middle carpal and carpometacarpal joints in a functional position ANATOMIC CONSIDERATIONS The carpus consists of the radius. Prepare the ipsilateral proximal shoulder or ilial wing for cancellous bone graft harvest. Harvest cancellous bone and place the graft within the prepared References 1. POSTOPERATIVE EVALUATION Radiographs should be evaluated for limb alignment and implant placement. Mosby. The animal should be confined. Elevate and retract the carpal extensor tendons medially and the digital extensor tendons laterally to expose the distal radius.36 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES CARPUS CHAPTER 14 Partial Carpal Arthrodesis with Intramedullary Pins joints. Jacob pin chuck. Reseat the pins and rotate the hooks flat against the bones (Plate 14D). The slots will have to be long enough to allow the pins to bend as they are driven proximally. Turner TM. St. et al: Partial carpal arthrodesis for third-degree carpal sprains: A review of 45 carpi. Louis. intercarpal. especially if antebrachialcarpal injuries have been overlooked. following the contours of the bone ends (Plate 14B). Gelpi retractors.2 Hyperextension may persist in some dogs.1. ulna. and the metacarpal bones. the carpus. and then cut and bend the ends into hooks. and accessory) carpal bones. Drive the pins into the radial carpal bone (Plate 14C). and the proximal two thirds of the third metatarsal bone. Drape the limb out from a hanging position to allow maximal manipulation during surgery. Implants are generally removed after healing to avoid soft tissue irritation.1. A bivalve cast should be used for 6 weeks or until early radiographic evidence of bone bridging is observed. The pins should not penetrate the radial carpal bone articular surface. Position the animal in lateral recumbency with the affected limb up. pin or wire cutters PREPARATION AND POSITIONING Prepare the forelimb circumferentially from shoulder to digits. and IV) carpal bones. Consider using a tourniquet to control bleeding. intramedullary pins or Kirschner wires. A decrease in range of motion in the antebrachial carpal joint is usually seen. Stabilization: Flex the carpus and remove the articular cartilage from the middle carpal. CHAPTER 14 PA RT I A L C A R PA L A RT H R O D E S I S W I T H I N T R A M E D U L L A RY P I N S 37 P L AT E 1 4 A B Radial carpal bone Radius Tendon of extensor carpi radialis muscle Tendon of common digital extensor tendon C D . and the middle gluteal muscle proximally. bone screw and washer. Use a suture to retract the muscle proximally and caudally. tap.38 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES HIP CHAPTER 15 Extracapsular Stabilization of Hip Luxation (Suture Anchors or Screw and Washer) Craniolateral Approach:1 Use a craniolateral approach to the coxofemoral joint. Michigan. Muscular landmarks include the biceps femoris. near its proximal ridge. or other fractures of the affected limb that prevent closed reduction. chronic cases may benefit from the additional exposure of an osteotomy. PROCEDURE Approach: A trochanteric osteotomy is not always necessary Use a dorsal approach to the coxofemoral joint with an osteotomy of the greater trochanter. Continue the joint capsule incision laterally through the point of origin of the vastus lateralis muscle on the cranial face of the proximal femur. two medium or large Gelpi retractors (depending on the size of the dog). *Mason Nylon Leader Line. failed closed reductions. Incise the superficial leaf of the fascia lata. and the vastus lateralis. Position the animal in lateral recumbency with the affected limb up. curving distally adjacent to the cranial ridge of the trochanter and extending distally from 5 cm over the proximal femur. intramedullary pins or Kirschner wires. a bone tunnel and screw and washer combination may be used if a suture anchor system is not available or if the animal is not large enough to accommodate the suture anchor system. OBJECTIVES • To restore normal stability. Indiana. Dorsal Approach with Trochanteric Osteotomy:2 INDICATIONS 1 Open reduction and stabilization is indicated in animals with chronic luxations. Incise the skin and subcutaneous tissue 5 cm proximal to the greater trochanter. and screwdriver. depth gauge. mallet. Reflect the gluteal muscles and greater trochanter from the joint capsule with a periosteal elevator. following the cranial border of the femur. however. Incise the skin over the cranial border of the greater trochanter. Reduce the hip prior to starting the surgical approach to establish normal tissue relationships. the biceps caudally. periosteal elevator. Retract the tensor fasciae latae cranially. wire driver. Reflect the vastus lateralis distally to expose the hip joint (Plate 15A). Drape the limb out from a hanging position to allow maximal manipulation during surgery. Reflect the superficial gluteal muscle proximally and the biceps femoris caudally to find and visualize the course of the sciatic nerve. and incise both structures together at the trochanter fossa. a number of hip-stabilizing techniques are available. mobility. Incise the joint capsule (see Plate 15A). excessive postreduction instability. 20. Otisville. Continued to reduce and stabilize the hip. Incise through the insertion of the superficial gluteal muscle at the third trochanter. If the joint integrity is intact. The curvilinear incision should center on the cranial edge of the greater tubercle. Incise the deep gluteal muscle close to its attachment on the trochanter for one third to one half of its width. the gluteals. . † Bone Biter Suture Anchor System. Incise between the tensor fasciae latae muscle and deep border of the biceps femoris muscle and superficial gluteal muscle. Additional instrumentation needed for this technique includes a high-speed drill. EQUIPMENT • Standard surgical pack. and carry the incision proximally through the insertion of the tensor fasciae latae muscle at the greater trochanter and along the cranial border of the superficial gluteal muscle. Mason Tackle Company. intra-articular fractures. from 3 cm to 4 cm proximal to the dorsal ridge of the greater trochanter and curved 3 cm to 4 cm. Perform an osteotomy of the greater trochanter with an osteotome and mallet or with Gigli wire. concurrent pelvic fractures. Warsaw. Distally.to 60-pound nylon* and a suture anchor system† Alternatively. Explore the hip joint prior to stabilizing the joint to assess cartilage viability and surrounding soft-tissue injury. and function to the coxofemoral joint ANATOMIC CONSIDERATIONS 2 Osseous anatomic landmarks for the coxofemoral joint are the greater trochanter of the femur and the ischial tuberosity and ilial wing of the pelvis. Incise the joint capsule (or enlarge the traumatic tear) parallel to the long axis of the femoral neck. it extends cranial and parallel to the proximal third of the shaft of the femur. Elevate the gemellus muscle from the caudolateral surface of the acetabulum with a periosteal elevator. congruency. drill bit. PREPARATION AND POSITIONING Prepare the rear limb circumferentially from dorsal midline to mid-tibia. CHAPTER 15 E X T R A C A P S U L A R S TA B I L I Z AT I O N O F H I P L U X AT I O N 39 P L AT E 1 5 A Deep gluteal muscle Incision in joint capsule Middle gluteal muscle retracted proximally Vastus lateralis muscle Tensor fasciae latae muscle retracted cranially Biceps femoris muscle retracted caudally Osteotomy of the greater trochanter Tensor fasciae latae muscle (retracted cranially) Superficial gluteal muscle (retracted proximally) Gemelli muscles incised Sciatic nerve Osteotomy of the greater trochanter Vastus lateralis muscle . Johnson KA: Approach to the craniodorsal aspect of the hip joint through a craniolateral incision. concurrent injuries should therefore be ruled out. The long-term prognosis with open reduction is good to excellent if the joint integrity is intact. Bone DL. Place the joint through a range of motion to ensure stability and function. or drill a bone tunnel through the femoral neck in the trochanteric fossa to accept the suture. If the joint is stable. Stabilization with Screw and Washer:3 Drill two holes into the craniodorsal aspect of the acetabular rim at the 10-o’clock and 1-o’clock positions. Luxate the femoral head to visually inspect the cartilage surface for damage. 1988. Stabilization with Capsular Repair and Imbrication: POSTOPERATIVE EVALUATION The joint should be radiographed to assess implant positioning and joint congruency. Stabilization with the Suture Anchor System: Drill two holes into the craniodorsal aspect of the acetabular rim at the 10-o’clock and 1-o’clock positions. Braden T. . subcutaneous tissue. Cage confinement may be adequate for dogs with stable hips. Johnson M: Technique and indications of a prosthetic capsule for repair of recurrent and chronic coxofemoral luxations. it is reasonable to attempt closed reduction in patients with a hip luxation. and insert a third screw and washer in the trochanteric fossa. Philadelphia. and skin. Suture the fascial layers. Clinical studies indicate that the success for surgical intervention following failure of closed reduction does not differ from the success rate for surgical reduction as a primary treatment. Walker M. The bandage should be removed 4 to 7 days after reduction. measure. 4th ed. and fracture fragments from the acetabular socket. screws and washers. Reduce the femoral head and imbricate the joint capsule with nonabsorbable monofilament material using an interrupted or cruciate pattern (Plate 15B). Place the joint through a range of motion to ensure stability and function. Vet Surg 30(5):468–475. 3. Measure. et al: Extra-articular absorbable suture stabilization of coxofemoral luxation in dogs. and the animal should gradually be returned to full activity over a 2-week period. Vet Surg 13(4):263–270. tap. adding 2 mm to the screw length to accommodate the washer. 1984. 2001. Débride any remaining fibrous tissue. nonabsorbable suture or cerclage wire between the acetabular screws and trochanteric fossa (Plate 15C). Simonazzi B. Therefore. salvaging limb function with a femoral head and neck ostectomy or a total hip replacement should be considered. The rate is lower in patients with poor conformation of the hip joint secondary to hip dysplasia or previous trauma. The results do not appear to favor any one reconstruction technique. 4. Bue MD. reattach the trochanter in a caudodistal position on the femur to promote joint stability and femoral adduction and internal rotation (Plate 15E1). Stabilize the greater trochanter with two Kirschner wires and a tension band (Plate 15E2). Drill and insert a third suture anchor thread with the suture from the acetabular anchors into the trochanteric fossa (Plate 15D). nonabsorbable suture into each of these holes. Open reduction may need to be delayed until the animal has been adequately stabilized. If cartilage viability or reduction is questionable. In An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. Joint stability and range of motion should be evaluated at 2 to 3 days to assess hip position. the use of one or more of the following techniques may be necessary: Suture anchors.40 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES Stabilization: To achieve successful reduction and stabilization of the coxofemoral joint. Closure: Reattach the external rotator muscles as necessary. Piermattei DL. POSTOPERATIVE CARE An Ehmer bandage can be used to assist hip reduction in the early postoperative period. Leash activity is required for an additional 3 weeks. the success rate is approximately 85% to 90%. CAUTIONS 4 The most common cause of coxofemoral luxation in the dog is motor vehicular trauma. Martini FM. Cantwell HD: Traumatic coxofemoral luxation in dogs: Results of repair. joint capsule repair and imbrication alone can constitute the reconstructive procedure. 2. Drill. Insert suture anchors threaded with heavy. Mild to moderate degenerative joint disease may be expected in cases with questionable cartilage viability or obvious cartilage trauma. If a trochanteric osteotomy has been performed. References 1. Pass heavy. EXPECTED OUTCOME 4 The success rate for maintaining reduction and regaining good to excellent limb function with closed reduction is about 50%. and select two appropriate-length screws. Regarding maintenance of reduction with good to excellent limb function following open reduction. Vet Comp Orthop Traumatol 1:26–29. and wire sutures may be employed for added stability when the capsule cannot be securely closed and imbricated. hematoma. tap. Reexamination is advisable 3 days after removal of the Ehmer bandage and before resumption of unsupervised activity. WB Saunders. A femoral head and neck excision or total hip replacement should be considered if coxofemoral integrity is questionable. 2004. Tie the sutures with the hip at a normal angle of flexion and slight abduction and internal rotation. Place the joint through a range of motion. CHAPTER 15 E X T R A C A P S U L A R S TA B I L I Z AT I O N O F H I P L U X AT I O N 41 P L AT E 1 5 B Bone anchor C D Anchor locked beneath cortices E1 E2 Reattachment site . OBJECTIVES • To restore normal stability. following the cranial border of the femur. Incise the deep gluteal muscle close to its attachment on the trochanter for one third to one half of its width. from 3 to 4 cm proximal to the dorsal ridge of the greater trochanter and curved 3 to 4 cm. Massachusetts. Use a suture to retract the muscle proximally and caudally (see Plate 16A). or other fractures of the affected limb that prevent closed reduction. mobility. The curvilinear incision should center on cranial edge of the greater tubercle. highspeed drill. Continued *Securos Coxofemoral Luxation Management System.42 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES HIP CHAPTER 16 Intracapsular Stabilization of Hip Luxation with Modified Toggle Pin Craniolateral Approach: 1 Perform a craniolateral approach to the coxofemoral joint. the hip should be reduced before the surgical approach is begun. Soft tissue bruising and swelling often distort the normal anatomy. Reflect the gluteal muscles and greater trochanter from the joint capsule with a periosteal elevator. Dorsal Approach with Trochanteric Osteotomy:2 INDICATIONS Open reduction and stabilization is indicated in animals with chronic luxations. and explore the hip joint prior to stabilizing the joint to assess cartilage viability and surrounding soft-tissue injury. two medium or large Gelpi retractors (depending on the size of the dog). and the middle gluteal muscle proximally. however. Drape the limb out from a hanging position to allow maximal manipulation during surgery. Incise the skin over the cranial border of the greater trochanter. Muscular landmarks include the biceps femoris. Incise through the insertion of the superficial gluteal muscle at the third trochanter. EQUIPMENT • Standard surgical pack. and function to the coxofemoral joint ANATOMIC CONSIDERATIONS Osseous anatomic landmarks for the coxofemoral joint are the greater trochanter of the femur and ischial tuberosity and the ilial wing of the pelvis. and the vastus lateralis. Incise the superficial leaf of the fascia lata and carry the incision proximally through the insertion of the tensor fasciae latae muscle at the greater trochanter and along the cranial border of the superficial gluteal muscle. Reflect the superficial gluteal muscle proximally and the biceps femoris caudally to find and visualize the course of the sciatic nerve. Charlton. Distally it extends cranial and parallel to the proximal third of the shaft of the femur. PROCEDURE Approach: A trochanteric osteotomy is not always necessary to reduce and stabilize the hip. Elevate the gemellus muscle from the caudolateral surface of the acetabulum with a periosteal elevator. congruency. Incise the joint capsule. Reflect the vastus lateralis distally to expose the hip joint (Plate 16A). Position the animal in lateral recumbency with the affected limb up. C-arm aiming device. curving distally adjacent to the cranial ridge of the trochanter and extending distally from 5 cm over the proximal femur. periosteal elevator. the gluteals. concurrent pelvic fractures. failed closed reductions. Incise the joint capsule (or enlarge the traumatic tear) parallel to the long axis of the femoral neck near its proximal ridge. excessive postreduction instability. the biceps caudally. Use a dorsal approach to the coxofemoral joint with an osteotomy of the greater trochanter. Continue the joint capsule incision laterally through the point of origin of the vastus lateralis muscle on the cranial face of the proximal femur. Retract the tensor fasciae latae cranially. chronic cases may benefit from the additional exposure of an osteotomy.* PREPARATION AND POSITIONING Prepare the rear limb circumferentially from dorsal midline to mid-tibia. . Incise the skin and subcutaneous tissue 5 cm proximal to the greater trochanter. To establish normal tissue relationships. Incise between the tensor fasciae latae muscle and deep border of the biceps femoris muscle and superficial gluteal muscle. Perform an osteotomy of the greater trochanter with an osteotome and mallet or with Gigli wire (see Plate 16A). toggle pin or rod and toggle rod insertion device. intra-articular fractures. CHAPTER 16 I N T R A C A P S U L A R S TA B I L I Z AT I O N O F H I P L U X AT I O N 43 P L AT E 1 6 A Deep gluteal muscle Incision in joint capsule Middle gluteal muscle retracted proximally Vastus lateralis muscle Tensor fasciae latae muscle retracted cranially Biceps femoris muscle retracted caudally Osteotomy of the greater trochanter Tensor fasciae latae muscle (retracted cranially) Superficial gluteal muscle (retracted proximally) Gemelli muscles incised Sciatic nerve Osteotomy of the greater trochanter Vastus lateralis muscle . 2004. Thread four strands of 0 or 1 monofilament nonabsorbable suture material through the toggle pin or rod. and fracture fragments from the acetabular socket. Piermattei DL. 1994. Reduce the femoral head and drill a second transverse bone tunnel cranial to caudal in the subtrochanteric region of the femur. . Edmiston DN.5-mm drill bit (Plate 16B). Joint stability and range of motion should be evaluated at 2 to 3 days to assess continued need for assisted weight bearing. Vet Surg 23(5):311–321. Then normal activity can be slowly reintroduced. Position the toggle device into the acetabular hole and lock it into position on the medial cortex of the acetabulum (Plate 16D). and skin. Reduce and stabilize the greater trochanter with two Kirchner wires and a tension band. 2004. Thread the sutures through the femoral head and neck (Plate 16E). slightly proximal to the exit hole of the suture (Plate 16F1).5-mm drill bit (Plate 16C). hematoma. passage of suture back through one arm of the toggle pin in the 3-o’clock and 9-o’clock positions prevents rotation and eliminates uncertainty with regard to final orientation after insertion. 2. In An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. Johnson KA: Approach to the craniodorsal and caudodorsal aspects of the hip joint by osteotomy of the greater trochanter. 3. Drill the femoral tunnel from the lateral subtrochanteric area to the fovea capitis using a C-arm aiming device and a 2. Philadelphia. POSTOPERATIVE EVALUATION The joint should be radiographed to assess implant positioning and joint congruency. EXPECTED OUTCOME 3 Outcome is usually good to excellent. 4. Exercise should be restricted and the animal should be confined to a kennel for the first 4 to 6 weeks. Piermattei DL. 4th ed. Roe SC. Beckman HP: Use of a modified toggle pin for repair of coxofemoral luxation in dogs with multiple orthopedic injuries (1986–1994). Drill the acetabular tunnel into the origin of the round ligament with a 3. Closure: Reattach the external rotator muscles as necessary. Mild to moderate degenerative joint disease and gait abnormalities may be expected in cases with questionable cartilage viability or obvious cartilage trauma. When implanting toggle pins. to avoid damaging this nerve. Débride any remaining fibrous tissue. WB Saunders. POSTOPERATIVE CARE A belly band sling should be used outside for the first 2 to 3 days to prevent uncontrolled use of the limb. subcutaneous tissue. Johnson KA: Approach to the craniodorsal aspect of the hip joint through a craniolateral incision. et al: Biomechanical evaluation of a toggle pin technique for management of coxofemoral luxation. WB Saunders. J Am Vet Med Assoc 208:81–84. If cartilage viability or reduction is questionable. In An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. 1996. caution must be exercised when performing the trochanteric osteotomy. Capsular Repair and Imbrication: Imbricate the joint capsule with nonabsorbable monofilament material using an interrupted or cruciate pattern. a femoral head and neck ostectomy or total hip replacement should be considered to salvage limb function. Pull one pair of the sutures through the second femoral tunnel and snugly tie them to the opposite sutures (Plate 16F2). References 1. CAUTIONS 4 The sciatic nerve courses dorsomedial to the acetabulum. Place the joint through a range of motion.44 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES Toggle Pin Stabilization:3 Luxate the femoral head to visually inspect the cartilage surface for damage. Suture the fascial layers. Philadelphia. Flynn MF. 4th ed. CHAPTER 16 I N T R A C A P S U L A R S TA B I L I Z AT I O N O F H I P L U X AT I O N 45 P L AT E 1 6 B D Aiming device C E F1 F2 Suture passer . 2004. Johnson KA: Approach to the craniodorsal aspect of the hip joint through a craniolateral incision. Factors reported to influence limb function include patient temperament. Incise the joint capsule parallel to the long axis of the femoral neck near its proximal ridge. Palpate the osteotomy for irregularities. if it is intact. Remove the femoral head and neck by severing the remaining medial joint capsule attachments. and remove any sharp prominences with rongeurs or a bone file. and fully luxate the hip. References 1. Soft tissue interpolation will not compensate for a poor cut. Limb function and range of motion should be evaluated at suture removal and at 6 to 8 weeks. oscillating saw. Compend Contin Educ Pract Vet 14:1463–1473. Frequent leash walks and passive range-of-motion exercise will improve limb function and use. Perform the osteotomy and grasp the head and neck with pointed reduction forceps. POSTOPERATIVE EVALUATION Postoperative radiographs are indicated to evaluate the osteotomy. Continue the joint capsule incision laterally through the point of origin of the vastus lateralis muscle on the cranial face of the proximal femur. Drape the limb out from a hanging position to allow maximal manipulation during surgery. Closure is routine. Incise the deep gluteal muscle close to its attachment on the trochanter for one third to one half of its width. file. 4th ed. and avascular necrosis of the femoral head and neck. putting medial pressure on the greater trochanter. Femoral Head and Neck Excision: Subluxate the femoral head by placing lateral traction with pointed reduction forceps on the greater trochanter. Sever the round ligament. The curvilinear incision should center on the cranial edge of the greater tubercle. Lewis DD: Femoral head and neck excision and the controversy concerning adjunctive soft tissue interposition. rongeur. Rotate the limb externally so that the patella is directed at the ceiling and the . body weight has been implicated as critical.46 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES HIP CHAPTER 17 Femoral Head and Neck Ostectomy with Joint Capsule Interpolation femur is parallel to the operating table (Plate 17B). The deep gluteal may also be sutured over the acetabulum if joint capsule coverage is deemed insufficient. Retract the tensor fasciae latae cranially. Position the animal in lateral recumbency with the affected limb up. and the vastus lateralis. EXPECTED OUTCOME 1 Results of this surgery vary among animals. osteotome and mallet or Gigli wire. EQUIPMENT • Standard surgical pack. PROCEDURE Approach:2 Use a craniolateral approach to the coxofemoral joint. 2. with Mayo scissors. Of these factors. or oscillating saw. To establish normal tissue relationships. 1992. Incise between the tensor fasciae latae muscle and deep border of the biceps femoris muscle and superficial gluteal muscle. the gluteals. and the middle gluteal muscle proximally. body weight. chronicity of lameness before surgery. curving distally adjacent to the cranial ridge of the trochanter and extending distally from 5 cm over the proximal femur. In An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. Dogs that weigh less than 17 kg are reported to have good to excellent clinical results. Visualize the osteotomy line from the medial aspect of the great trochanter to the most proximal aspect of the lesser or second trochanter (Plate 17C). bone file PREPARATION AND POSITIONING Prepare the rear limb circumferentially from dorsal midline to mid-tibia. preexisting muscle atrophy. and place it through a range of motion. remove more of the femoral neck with rongeur. Incise the skin and subcutaneous tissue 5 cm proximal to the greater trochanter. extent of surgically induced trauma. degenerative joint disease secondary to hip dysplasia. INDICATIONS 1 Candidates include dogs with recurrent or chronic coxofemoral luxation. WB Saunders. Return the leg to normal standing position. OBJECTIVES 1 • To relieve pain and salvage limb function in cases of irreparable damage to the coxofemoral joint ANATOMIC CONSIDERATION Osseous anatomic landmarks for the coxofemoral joint are the greater trochanter of the femur and ischial tuberosity and the ilial wing of the pelvis. periosteal elevator. Philadelphia. the biceps caudally. POSTOPERATIVE CARE Exercise and physical therapy after surgery should be encouraged. Muscular landmarks include the biceps femoris. Direct the saw blade or osteotome caudally to ensure complete excision of the femoral neck and head (Plate 17D). CAUTIONS Proper orientation of the osteotomy is essential to ensure complete removal of the femoral head and neck. completeness of excision. Reflect the vastus lateralis distally to expose the head and neck of the femur (Plate 17A). two medium or large Gelpi retractors (depending on the size of the dog). concurrent orthopedic disorders. Decreased efficacy has been attributed to greater body mass and increased bony contact between the femur and acetabulum during weight bearing. and postoperative activity and physical therapy. Piermattei DL. the hip should be reduced before the surgical approach is begun. Distally it extends cranial and parallel to the proximal third of the shaft of the femur. If there is excessive crepitus or bone-on-bone contact between the femur and acetabulum. Flush the joint and suture the joint capsule over the acetabular fossa. intra-articular coxofemoral fractures that are not amenable to reduction and stabilization. CHAPTER 17 F E M O R A L H E A D A N D N E C K O S T E C TO M Y 47 P L AT E 1 7 A Middle gluteal muscle retracted proximally Deep gluteal muscle Tensor fasciae latae muscle retracted cranially Incision in joint capsule Vastus lateralis muscle retracted distally B Biceps femoris muscle retracted caudally C Maxi driver blade directed caudally Externally rotated limb D Patella is directed at ceiling . Suture the gracilis muscle to the prepubic tendon to prevent inguinal herniation. Oregon.48 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES HIP CHAPTER 18 Triple Pelvic Osteotomy PREPARATION AND POSITIONING Prepare the entire hindquarter circumferentially to allow access to the pubis. and the second osteotomy near the medial limit of the obturator foramen. The osteotomy is not stabilized. Gigli wire. Elevate the gracilis and adductor muscles from the pubis. The pubic osteotomy is performed first and includes removal of the pubic ramus. Elevate the internal obturator. tuber ischii. or osteotome and mallet. Place a pursestring suture to prevent fecal contamination. Drape the limb out from a hanging position to allow maximal manipulation during surgery. the prepubic tendon. Position the animal in dorsal recumbency with the affected limb up. Ischial Osteotomy:3 With the dog in lateral recumbency. perform the first osteotomy medial to the iliopubic eminence. osteotome and mallet. drill. Closure is routine. oscillating saw. plating equipment. midway between midline and the tuber ischii. periosteal elevator. and the ventral aspect of the coxofemoral joint. and severe the prepubic tendon and pectineus from its cranial aspect. rongeur. Closure is routine. and the adductor and gracilis muscles. and Canine Pelvic Osteotomy plate* incise the skin and subcutaneous tissues over the pubis. the iliopubic eminence. . PROCEDURE Pubic Ostectomy:3 With the dog in dorsal recumbency. two medium or large Gelpi retractors (depending on the size of the dog). Gigli wire or reciprocating saw. EQUIPMENT • Standard surgical pack. Using an oscillating saw. and ilium from dorsal and ventral midline to mid-tibia. Osseus anatomic landmarks for the ischial osteotomy include the tuber ischii laterally and the obturator foramen. INDICATIONS 1 Candidates include immature dogs with coxofemoral laxity and subluxation with minimal radiographic signs of degenerative joint disease. incise the skin and subcutaneous tissue sagittally over the ischial shelf. centering on the pectineal muscle as it inserts on the iliopectineal eminence. two Hohmann retractors. Continued *Canine Pelvic Osteotomy Plate. Muscular landmarks include the internal obturator and the semitendinous and semimembranosus muscles. Remove and preserve the segment of bone in a blood-soaked gauze as a corticocancellous graft for the ilial osteotomy. and semitendinosus muscles off of the ischial shelf. Pertinent soft tissue landmarks include the origin of the pectineus muscle on the iliopectineal eminence. Kern bone-holding forceps. Place two Hohmann retractors ventral to the proposed osteotomy sites to protect the underlying soft tissues and the obturator nerve (Plate 18A). semimembranous. Eugene. Perform an osteotomy of the ischium beginning from the most lateral aspect of the obturator foramen with a reciprocating saw or Gigli wire (Plate 18B). OBJECTIVES 2 • To improve joint stability and function by providing greater dorsal coverage of the femoral head by rotating the dorsal rim of the acetabulum laterally ANATOMIC CONSIDERATIONS Three separate surgical approaches and osteotomies of the pelvis are necessary to free the acetabular segment for axial rotation and improved dorsal femoral head coverage. Care should be taken to protect the obturator nerve as it courses through the cranial portion of the obturator foramen. Slocum Enterprises. Osseus anatomic landmarks include the pelvic symphysis. CHAPTER 18 T R I P L E P E LV I C O S T E O T O M Y 49 P L AT E 1 8 Prepubic tendon A Section of pubic ramus to be removed Pectineus muscle Adductor muscle Gracilis muscle B Ischial osteotomy site Ischial osteotomy . Plante J. 3. and remove the sharp spike of the ilium of the caudal segment with an oscillating saw or rongeurs. 1991. The remainder of the closure is routine. Simmons S. place the corticocancellous graft along the osteotomy. Vet Surg 23:13–20. Care should be taken to avoid stairs and slippery surfaces. Dupuis J. Lavage. 4. WB Saunders. obturator. Johnson AL.50 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES Ilial Osteotomy and Stabilization:3. Attach the Canine Pelvic Osteotomy Plate to the caudal segment 3 mm dorsal to the ventral margin with 3. Vet Surg 20:291–297. Be sure the osteotomy is caudal to the sacroiliac joint and perpendicular to a reference pin positioned parallel to the ventral third of the ilial wing to the tuber ischii (Plate 18D). vein. Palpate the caudal extent of the sacrum and position two large. J Am Anim Hosp Assoc 37(3):269–273. The small hemi cerclage hole in the caudal half of the plate may be left open or filled with a 2. The hip should now be stable and the Ortolani sign eliminated. incise the deep gluteal fascia between the tensor fascia latae and the middle gluteal muscle from the ventral iliac spin to the cranial border of the biceps femoris muscle. POSTOPERATIVE EVALUATION Postoperative radiographs are indicated to evaluate osteotomy and implant position and acetabular coverage. Taves CL. and nerve. and 6. 2. CAUTIONS 1 Caution should be taken to protect the cranial gluteal. . Pardo AD: The effects of plate type. POSTOPERATIVE CARE The animal should be confined to a small area or kennel until the ilial union is evident. Graehler RA. Perform the osteotomy of the ilial wing with an oscillating saw. sharply elevate the origin of the middle and deep gluteal muscles cranially and dorsally to expose the ilial shaft. 1997. Radiographs should be repeated at 6. Philadelphia. 2004. and tap the plate holes in the following order: 1. et al: Long-term results of conservative treatment. Rotate the acetabular segment caudolaterally. Johnson KA: Approach to the ilium through a lateral incision. 2001. Most coxofemoral joints in dogs are sufficiently stable with 20 to 30 degrees of rotation. excision arthroplasty and triple pelvic osteotomy for the treatment of hip dysplasia in the immature dog: Part 1: Radiographic and physical results. Slocum TD: Pelvic osteotomy. Beauregard G.to 8-week intervals to evaluate implant position and acetabular coverage until the ilial union is complete. Activity should be limited to outside leash walks for urination and defecation. Miller CW. measure.4 Incise the skin and subcutaneous tissue from the center of the iliac crest to the greater trochanter. Schaeffer DJ: Risk factors for screw migration after triple pelvic osteotomy. If not. In Bojrab MJ (ed): Current Techniques in Small Animal Surgery. and sciatic nerves. blunt Hohmann retractors medial to the ilium to protect the sciatic nerve (Plate 18C). the plate can be removed and replaced with another plate of increased angle. In a separate clinical study. Following muscle planes.6 Outcome is usually good to excellent. 5. Weigel JP. McLaughin RM. 4th ed. 1994. and owner’s evaluation demonstrate the superiority of the triple pelvic osteotomy over medical treatment and excision arthroplasty. being careful not to injure the sciatic nerve. locomotor. Move the acetabular segment cranially and laterally with Kern boneholding forceps. et al: Force plate analysis of triple pelvic osteotomy for the treatment of canine hip dysplasia. and 3. Vet Comp Ortho Traum 10:101–110. Force plate analysis confirms that weight-bearing forces improve in operated versus nonoperated hips. Drill. Cauterize the iliolumbar vessels as necessary. Drill. 5. and degree of axial rotation on the structural anatomy of the pelvis. and tap the plate holes in the following order: 4. physical. EXPECTED OUTCOME 5. 4th ed. 1998. Preserving the cranial gluteal artery. In An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. 2. Continue elevating the soft tissues off of the ilial wing medially. Premature screw loosening and migration are commonly associated with the cranial portion of the plate. Joints that require more rotation may not have sufficient acetabular depth to warrant the triple pelvic osteotomy procedure. 6.5-mm cortical screws (Plate 18E). Ninety-two percent of the clinical signs associated with lameness and gait abnormalities resolve with minimal progression of degenerative joint disease in dogs undergoing this procedure. Preserve the bone segment as a corticocancellous graft for the ilial osteotomy. Williams & Wilkins.7-mm screw. measure. Piermattei DL. angle of ilial osteotomy. and fix the plate to the cranial ilial segment. Factors associated with decreased screw migration include increasing the depth of sacral purchase in the first and second cranial screw and filling the ischial cerclage hole with a screw or cerclage. and suture the deep gluteal to the sartorius fascia. References 1. Baltimore. Slocum B. 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 C Middle gluteal muscle D Osteotomy line Cranial gluteal artery and vein Deep Reference line for gluteal muscle ilial osteotomy Ilial osteotomy Tensor Shaft of fasciae ilium latae muscle E 6 5 4 1 2 3 Canine pelvic osteotomy plate Rotated segment of pelvis . The middle third of the incision should center on the patellar tendon. release the insertions of these muscles at the proximal patella. tibial tuberosity. Continued *X-ACTO Inc. flex and extend the stifle while internally and externally rotating the pes. Freer periosteal elevator. Long Island City. The patella articulates within the trochlear groove. and examine limb alignment and patellar stability. If the patella luxates or appears malaligned. Desmotomy.2 The patella is the largest sesamoid bone in the body. EQUIPMENT • Standard surgical pack. vastus medialis. . which aid in stifle stability through contact with the ridges of the femoral trochlear. Use a hanging leg preparation with the dog in dorsal the skin and subcutaneous tissue in a curvilinear fashion on the craniolateral aspect of the stifle (Plate 19A). The quadriceps muscle group. New York.3 Lateral Arthrotomy and Medial Desmotomy: Incise INDICATIONS Candidates include clinically lame animals with Putmann’s grade II and above patella luxations. formed by the rectus femoris.52 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES STIFLE CHAPTER 19 Medial Patella Luxation Stabilized with Wedge Recession Trochleoplasty.* bone cutters or osteotome and mallet. The patella functions in the extensor mechanism of the stifle to provide cranial and rotary stability to the joint and serves as a lever arm. small Hohmann retractor. After evaluating limb alignment. If the cranial sartorius and vastus medialis muscles inhibit patellar alignment. cut the abaxial and axial margins of the wedge osteotomy using the fine-toothed saw (Plate 19B1). a desmotomy and tibial tubercle transposition are indicated. converges on the patella and continues as the patellar ligament to insert on the tibial tuberosity. PROCEDURE 2. sliced parallel to the original cut. and vastus intermedius muscles. Wedge Recession Trochleoplasty: With the stifle in flexion and the patella luxated. Additional trochlear depth can be achieved by rotating the wedge 180 degrees. Proper anatomic alignment of the extensor mechanism is a straight line of force. Keep the margins of the cut wide enough to accommodate the width of the patella. the patella. this is necessary for stability of the patella. and tarsus should follow the same linear orientation. preserving even tension of the extensor mechanism during extension of the stifle. Reflect the skin and subcutaneous tissue laterally with blunt dissection. The vastus lateralis and medialis have additional attachments to the patella by medial and lateral parapatellar fibrocartilages. finetoothed saw. With the stifle and tarsus flexed at 90 degrees. Tibial Tuberosity Transposition. Originating from the fabella and merging with the medial and lateral parapatellar fibrocartilages are the collagen fibers of the medial and lateral retinacula. and incise the lateral retinaculum and joint capsule from the cupola to the tibial plateau to release the patella and expose the joint. which is formed by the trochlear ridges of the medial and lateral condyle. Kirschner wires. Replace the patella. Resect the basilar surface of the osteochondral wedge with rongeurs to allow the cartilage to seat deeply into the new femoral groove patella (Plate 19B2). Return the patella to its normal orientation within the trochlear groove. Delay closure of the joint until patella alignment and stability are assessed. vastus lateralis. and excise as necessary. wire driver PREPARATION AND POSITIONING Prepare the leg circumferentially from dorsal midline to below the tarsus. Examine the cruciate ligaments and menisci to check for tears caused by stifle instability. it is located within the tendon of insertion of the quadriceps muscle group. and Retinacular Imbrication recumbency at the end of the surgery table to allow for maximal manipulation and visualization of the stifle joint during surgery. OBJECTIVES • To improve limb function and prevent degenerative joint disease by anatomic realignment and stabilization of the patella within the trochlear groove ANATOMIC CONSIDERATIONS 1.. The medial trochlear ridge is thicker than the lateral in normal dogs. Remove the wedge and deepen the recession in the trochlea by removing additional bone from either side of the trochlear ridge with a file or an additional osteotomy. CHAPTER 19 M E D I A L PAT E L L A L U X AT I O N 53 P L AT E 1 9 A Incision in lateral retinaculum Biceps femoris muscle Wedge resected B1 Additional wedge resected on either side B2 Osteochondral wedge replaced Cranialis tibialis muscle Patella M L Cranialis tibialis muscle reflected . The prognosis depends on the age of the patient at the time of surgery. 1992. Excise excessive lateral joint capsule and perform a balanced closure of the joint capsule and retinaculum. preserving the distal periosteal attachment of the tibial tubercle to serve as a biological tension band using bone cutters or an osteotome and mallet (Plate 19C1). Vet Clin North Amer 23:855–875. Degenerative joint disease progresses despite surgical correction and is positively correlated with the animal’s age at surgery. Elevate the cranial tibial muscle from the tibia to the level of the long digital extensor tendon. After each suture is placed. Imbricate the lateral joint capsule and lateral patellar tendon. Willauer CC. Rongeur an osseus bed for the tibial tubercle to reside in. and relocate the tuberosity if needed. and the amount of degenerative joint disease present prior to surgery. POSTOPERATIVE CARE The limb should be placed in a soft. References 1. Perform a partial osteotomy of the tibial tubercle. Montavon P: Patellar luxation in dogs and cats: Management and prevention. Retinacular imbrication and joint capsule closure should be evaluated after each imbricating suture to ensure a balanced and stable closure. 2002. Correction of the malalignment of the extensor mechanism via tibial tubercle . Cut and bend the Kirschner wires to prevent soft tissue irritation and facilitate removal if migration occurs. L’Eplattenier H. Joint Capsule Closure and Retinacular Imbrication: transposition is imperative to a successful outcome of the surgery. L’Eplattenier H. CAUTIONS 4 The most common complication associated with surgical repair of patella luxation is recurrence of the luxation. Check patellar stability after each imbricating suture. Stabilize the tubercle with two divergent Kirschner wires directed caudally and slightly proximally. Reevaluate patellar alignment and stability. and with the stifle and tarsus flexed at 90 degrees. and do not suture the cut edges if medial luxation is severe. Closure of the medial joint capsule may not be indicated in higher grades of patellar luxation. Close the subcutaneous tissue and skin over the arthrotomy and retinacular incisions. Activity should be restricted to walks on a leash until the osteotomy site is healed. Compend Contin Educ Pract Vet 24:292–300. lever the tibial tubercle laterally with a periosteal elevator so that it is in alignment with the patella and tarsus. POSTOPERATIVE EVALUATION Radiographs should be evaluated for patellar alignment and implant placement. extending the parapatellar incision distally to the tibial tubercle. evaluate patellar stability. Radiographs should be repeated every 6 to 8 weeks until the osteotomy site is healed. Close the lateral and medial retinaculum with a vest-over-pants pattern (modified Mayo mattress pattern) (Plate 19D). Compend Contin Educ Pract Vet 24:234–239. 2002. the body weight and condition score. Recheck patellar stability. Roush JK: Canine patellar luxation. Passive range-of-motion exercises may help maintain muscle mass and stifle range of motion. Vasseur PB: Clinical results of surgical correction of medial luxation of the patella in dogs. 1987. 2. Allow the medal arthrotomy to separate. 4. EXPECTED OUTCOME 3 Outcome is usually good to excellent. Montavon P: Patellar luxation in dogs and cats: Pathogenesis and diagnosis. 3. engaging but not extending beyond the caudal cortex of the tibia (Plate 19C2). padded bandage for 1 to 2 days. Vet Surg 16:31–36.54 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES Tibial Tubercle Transposition: Incise the lateral retinaculum and joint capsule. CHAPTER 19 M E D I A L PAT E L L A L U X AT I O N 55 P L AT E 1 9 C1 C2 D Biceps femoris muscle Modified Mayo mattress suture Cranialis tibialis muscle reflected . Collateral Ligament Repair: Inspect the ligament for tears or avulsions. mobility. Screws. ‡ Securos Veterinary Orthopedics. periosteal elevator. 100-pound test is available through Mason Tackle Company. mallet. the medial and lateral collateral ligaments. Otisville. two medium or large Gelpi retractors (depending on the size of the dog). To expose the medial collateral ligament. depth gauge. and menisci. Before cranial cruciate repair is begun. § Synthes. Examine the cruciate ligaments and menisci to check for tears. Additional stability may be provided by the patellar tendon. The most common structures injured in the luxated stifle are the cranial and caudal cruciate. repair mid-substance tears with a locking loop suture (Plate 20B2). 40-. To expose the lateral collateral ligament. screwdriver. sharply incise the fascia of the caudal belly of the sartorius and elevate its insertion caudally to the level of the ligament (Plate 20A). OBJECTIVES • To restore normal stability. Reconstruction of the caudal cruciate ligament and postoperative limb support is not found to be essential. bone screw and washer. Use a hanging leg preparation with the dog in dorsal recumbency at the end of the surgery table to allow for maximal manipulation and visualization of the stifle joint during surgery. † Innovative Animal Products. Jacob chuck and key.56 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES STIFLE CHAPTER 20 Deranged Stifle Luxation Stabilized with Suture Anchors. EQUIPMENT • Standard surgical pack. Additional instrumentation needed for this technique includes a high-speed drill. PREPARATION AND POSITIONING Prepare the leg circumferentially from dorsal midline to below the tarsus. and Suture and baby Ochsner forceps for joint inspection and cruciate ligament débridement. and either the lateral or medial collateral ligament. quadriceps. and function to the stifle joint ANATOMIC CONSIDERATIONS 2. Massachusetts.to 80-pound fishing leader line. congruency. and popliteal musculature. Minnesota. Charlton. Perform a medial arthrotomy. the joint capsule.† and crimp clamp system‡ Alternatively. Reconstruction of the collateral and cranial cruciate ligaments and careful repair or removal of damaged menisci and joint capsule is an effective treatment method for medium and large dogs. wire placed in a figure-eight suture pattern. and baby Hohmann retractor curvilinear fashion on the craniolateral aspect of the stifle. stabilize the collateral ligament(s) to restore normal joint alignment and congruity. Michigan. and excise/débride as necessary. or suture anchors (Plate 20B3). tap. and incise the joint capsule from the cupula to the tibial plateau to expose the joint. Colorado. incise the aponeurosis of the biceps femoris muscle just cranial to the muscle fibers and elevate the biceps femoris and attached fascia lata caudally to the level of the ligament. a bone tunnel and screw and washer combination may be used if a suture anchor system is not available or if the animal is not large enough to accommodate the suture anchor system. 20.* suture anchor system. Luxate the patella. 60-. PROCEDURE Approach:5–7 Incise the skin and subcutaneous tissue in a INDICATIONS 1–4 Surgical stabilization and internal fixation is indicated in animals with gross instability of the stifle resulting from multiple ligament injury. Lavage and close the joint. Reflect the skin and subcutaneous tissue medially and laterally with blunt dissection. Then protect the repaired ligament with screws. 80-. washers. As a general rule.4 The stifle joint is primarily stabilized by the cranial and caudal cruciate ligaments. Continued *The 20-. and flex the limb. intramedullary pins. and heavy suture. . Repair avulsed intact ligaments with a screw and spiked plastic washer§ (Plate 20B1). Rochester. Monument. The middle third of the incision should center on the patellar tendon. drill bit. 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 Caudal head of sartorius muscle reflected B1 Ruptured medial collateral ligament and joint capsule B2 B3 Suture anchor threaded with two sutures inserted in femur Locking loop repair Anchor locked beneath cortices . Pass the suture under the soft tissues of the cranial tibia to avoid muscle entrapment and premature loosening of the lateral fabellar suture from tissue necrosis. however. J Small Anim Pract 39:333–340. Stifle joint stability should be assessed in all planes with the joint held in extension. As a general rule. WB Saunders. use 1 pound of test per pound of body weight. Johnson KA: Approach to the lateral collateral ligament and caudolateral part of the stifle joint. 1990. and 90 degrees flexion while maintaining the tibia in neutral position. 1988. Piermattei DL. hold the tibia caudally and rotated externally to remove drawer motion. J Am Anim Hosp Assoc 22:333–340. . The stifle should be radiographed to assess implant positioning and joint congruency. and tie each suture individually. use a sliding half hitch or a clamped square knot to stabilize the stifle. 4th ed. Pass the appropriate-size monofilament fishing leader line through the eye of a Martin uterine needle. Use the crimp tool to firmly crimp the clamp on the individual strands. The long-term prognosis with stifle stabilization is fair to good. Bruce WJ: Multiple ligamentous injuries of the canine stifle joint: A study of 12 cases. References 1. In An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. 6. Cut the leader line in half to remove the needle. positioning them 2 mm to 3 mm from the center crimp clamp. however. POSTOPERATIVE EVALUATION The range of motion should be evaluated. Slide the additional crimp clamps on each end of the suture. obtaining two sutures to tie. WB Saunders. despite decreases in range of motion and reductions of muscle mass of the affected limb. once in the middle and once on either end (Plates 20E1 and 20E2). slide one suture end at a time through the surgical crimp clamps and pull the ends so that the loop becomes taut (Plate 20C). 1998. Piermattei DL. concomitant injuries are common and must be addressed prior to surgery. in order to estimate the insertion of the cranial cruciate ligament. Shires P: Multiple ligament injury of the stifle joint in the dog. Then the animal’s activity should slowly be returned to normal. incise the aponeurosis of the biceps femoris muscle just cranial to the muscle fibers. Delaying surgery to stabilize the patient is often necessary and also does not contribute to any difference in outcome. The hole should be proximal to the most prominent point of the tibial tuberosity. Palpate the fabella and fibular head for proper anatomic orientation of the lateral fabellar suture.58 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES Cranial Cruciate Ligament Repair: To expose the lateral collateral ligament. they do not justify a worse prognosis in dogs with stifle luxation. normal standing angle. Slide the slotted tips of the tensioning device over the suture. 4th ed. 2. WB Saunders. Philadelphia. Pass the leader line from lateral to medial through the hole in the tibial crest and then under the patellar ligament immediately proximal to the tibial tuberosity. Once the appropriate amount of tension is obtained. Check the stifle for range of motion and cranial drawer after each suture is tied. POSTOPERATIVE CARE Exercise should be restricted to outside leash walks for urination and defecation. Johnson KA: Approach to the stifle joint through a medial incision. Flex the stifle to a normal standing angle. J Am Anim Hosp Assoc 26:207–214. 2004. Piermattei DL. crimp the middle clamp holding the two sutures three times. Welches CD. Imbricate the lateral fascia covering of the biceps femoris with a vest-over-pants closure. Johnson KA: Approach to the medial collateral ligament and caudomedial part of the stifle joint. and the stifle should be checked for cranial drawer before the patient awakens. 3. Philadelphia. and pass the needle around the cranial half of the fabella from proximal to distal. in many cases surgical inspection of the stifle is often necessary for definitive diagnosis. and squeeze the arms of the tensioning device one click at a time. Hulse DA. 4. In An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. and the animal should be confined to a kennel for the first 4 to 6 weeks. Drill a hole with intramedullary pin and Jacob chuck of sufficient size to pass the eye of the needle through the tibial crest from lateral to medial. 2004. Scavelli TD: Transarticular pinning to repair luxation of the stifle joint in dogs and cats: A retrospective study of 10 cases. 1986. 5. EXPECTED OUTCOME 3 Because of the traumatic nature of this disease. Using the Securos crimp clamp system. and bluntly elevate the biceps femoris and attached fascia lata caudally to the level of the ligament. 2004. CAUTIONS 3 Preoperative palpation should be performed and stress radiographs of the stifle joint should be taken under sedation or general anesthesia for proper assessment of the suspected injuries. 4th ed. 7. Philadelphia. In An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. palpating for drawer and range of motion (Plate 20D). Aron DN: Traumatic dislocation of the stifle joint: Treatment of 12 dogs and one cat. Alternatively. J Am Anim Hosp Assoc 22:105–110. Mild to moderate degenerative joint disease and gait abnormalities may be expected in cases with questionable cartilage viability or obvious cartilage trauma. CHAPTER 20 D E R A N G E D S T I F L E L U X AT I O N 59 P L AT E 2 0 C D Lateral fabella Lateral collateral ligament Drill hole in tibial crest Tensioning device E1 E2 Correct Crimp Pattern Crimps too close to the edge Incorrect Crimp Pattern . If the craniomedial band is disrupted. The middle third of the incision should center on the patellar tendon. EQUIPMENT • Standard surgical pack. cranial drawer will be only elicited in flexion. . Lavage and close the joint in one or two layers. 80-. because the caudolateral band is lax with the stifle held in this position. which is more commonly seen in the dog. PREPARATION AND POSITIONING Prepare the leg circumferentially from dorsal midline to below the tarsus. The smaller craniomedial band remains taut (and thus restricts motion) in both extension and flexion of the stifle joint.* Martin uterine needles. Luxate the patella and flex the limb. 11 blade and incise the origins of the ligament within the intercondylar notch of the caudomedial portion of the lateral condyle (Plate 21A). Together the bands work to limit joint hyperextension and internal rotation and cranial displacement of the tibial plateau. because the craniomedial band is still present and taut in both flexion and extension. there may be no drawer palpable. periosteal elevator. Use a hanging leg preparation with the dog in dorsal recumbency at the end of the surgery table to allow for maximal manipulation and visualization of the stifle joint during surgery. and excise/débride as necessary. If the caudolateral band is disrupted. 20. one medium or large Gelpi retractor (depending on the size of the dog). use a no. To débride the injured cruciate ligament. Reflect the skin and subcutaneous tissue medially and laterally with blunt dissection. Take care not to injure the caudal cruciate ligaments where they cross each other near attachments in the intercondylar fossa of the femur. drawer will be palpable in both flexion and extension. and crimp clamp system† Additional instrumentation needed for this technique includes a baby Hohmann retractor. If both bands are torn. Continued *The 20-. baby Ochsner forceps. † Innovative Animal Products. intramedullary pin. The more substantial caudolateral band is taut in only extension.60 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES STIFLE CHAPTER 21 Cranial Cruciate Repair with a Lateral Fabellar Suture Jacob chuck and key.to 80-pound fishing leader line. Michigan. It has three important functions in defining stifle motion and stability. 40-. This seemingly minute piece of anatomic trivia is important in understanding the clinical signs associated with partial and complete cranial cruciate injury. Rochester. making sure to appose the synovial layer with either method. Arthrotomy: Perform a medial arthrotomy. OBJECTIVES • To improve limb function by stabilization of the stifle and to prevent cranial displacement of the tibial plateau via an external suture strut to temporarily support the limb in neutral drawer position ANATOMIC CONSIDERATIONS 1 The cranial cruciate ligament is composed of two elements: (1) the craniomedial and (2) the caudal lateral band. 11 blade for joint inspection and cruciate ligament débridement. and a no. Examine the cruciate ligaments and menisci to check for tears. Minnesota. PROCEDURE Approach: Incise the skin and subcutaneous tissue in a curvi- INDICATIONS Candidates include animals with stifle instability caused by partial or complete cranial cruciate ligament injury as diagnosed via palpation or arthrotomy. and incise the joint capsule from the cupula to the tibial plateau to expose the joint. 100-pound test is available through Mason Tackle Company. This may be achieved with three incisions. 60-. linear fashion on the craniolateral aspect of the stifle. Otisville. 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 A Cranial cruciate ligament Cut 1 Cut 2 Cut 3 Medial meniscus . slide one suture end at a time through the surgical crimp clamps and pull the ends so that the loop becomes taut. Massachusetts. Lampman TJ. Pass the suture under the soft tissues of the cranial tibia to avoid muscle entrapment and premature loosening of the lateral fabellar suture from tissue necrosis. 3. use 1 pound of test per pound of body weight. . Vet Comp Orthop Traumatol 15:210–214. the prognosis is good to excellent with proper postoperative care and confinement. Kerwin SC. EXPECTED OUTCOME Osteoarthritis is a common sequela to cranial cruciate rupture. Exercise should be restricted and the animal should be confined to a kennel for the first 4 to 6 weeks. once in the middle and once on either end (Plate 21E1). incise the aponeurosis of the biceps femoris muscle just cranial to the muscle fibers. Owen MR. Gibson NR. Charlton. Use the crimp tool to firmly crimp the clamp on the individual strands. Metcalf JB: Mechanical comparison of six loop fixation methods with monofilament nylon leader line. and risk for disease. and squeeze the arms of the tensioning device one click at a time. Cut the leader line in half to remove the needle. Hart RC. CAUTIONS 2. Lipowitz AJ: Cranial cruciate disease: Current status of diagnosis. Slide the slotted tips of the tensioning device over the suture. As a general rule. Once the appropriate amount of tension is obtained. Vet Comp Orthop Traumatol 16:122–126. J Small Anim Pract 42:487–490.3 To expose the lateral collat- eral ligament. Vet Comp Orthop Traumatol 16:21–25. Then normal activity should slowly be reintroduced. However. Alternatively. Drill a hole with intramedullary pin and Jacob chuck of sufficient size to pass the eye of the needle through the tibial crest from lateral to medial. obtaining two sutures to tie. Palpate the fabella and fibular head for proper anatomic orientation of the lateral fabellar suture.4 Activity should be restricted to short walks on a leash to prevent premature breakdown of the stifle stabilization. Using the Securos‡ crimp clamp system. Lund EM. Slide the additional crimp clamps on each individual end of the suture. POSTOPERATIVE CARE The leg should be placed in a soft. Hulse DA. POSTOPERATIVE EVALUATION 4 The range of motion should be evaluated and the stifle for cranial drawer should be checked before the patient awakens. 4. Peycke LE. positioning them 2 mm to 3 mm from the center crimp clamp (Plate 21C). therefore. It is not necessary to radiograph the stifle to assess implant positioning and joint congruency in this repair. 2003. and tie each suture individually. ‡ Securos Veterinary Orthopedics. 2002. with the medial meniscus being most commonly affected. Risk of early failure may be higher with poor fabella anchorage. Pass the appropriate-size monofilament fishing leader line through the eye of a Martin uterine needle. and bluntly elevate the biceps femoris and attached fascia lata caudally to the level of the ligament (Plate 21B). 2003. Hosgood G. Careful assessment of both menisci is important because damaged menisci should be partially débrided or excised. Make the hole proximal to the most prominent point of the tibial tuberosity in order to estimate the insertion of the cranial cruciate ligament. palpating for drawer and range of motion (Plate 21D). 2001. crimp the middle clamp holding the two sutures three times. et al: Radiographic features of a lateral extracapsular wire suture in the canine cranial cruciate deficient stifle. particular attention should be paid to needle position relative to fabella anatomy. hold the tibia caudally and rotated externally to remove drawer motion. Flex the stifle to a normal standing angle. use a sliding half hitch or a clamped square knot to stabilize the stifle. surgery. Imbricate the lateral fascia covering of the biceps femoris with a vest-over-pants closure (Plate 21E2) from the patella to the tibial crest to cover the sutures and help prevent seroma formation (Plate 21E3). Check the stifle for range of motion and cranial drawer after each suture is tied. Slater MR: Contribution of periarticular tissue to stabilization of the canine stifle joint after cranial cruciate ligament reconstruction. References 1. 2. Stork CK. particularly when meniscal damage is present. Pass the leader line from lateral to medial through the hole in the tibial crest and then under the patellar ligament immediately proximal to the tibial tuberosity. padded bandage for 24 hours to cover the wound and provide support.62 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES Lateral Fabellar Suture:2. Meniscal damage is reported in 45% of cranial cruciate rupture. and pass the needle around the cranial half of the fabella from proximal to distal. 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 Lateral fabella Lateral collateral ligament C D Drill hole in tibial crest Secondary crimp clamp Primary crimp clamp Secondary crimp clamp Tensioning device E1 E2 Modified Mayo mattress suture E3 Correct Crimp Pattern Crimps too close to the edge Incorrect Crimp Pattern . plastic washers. bone rasp. drill bit. Examine the cruciate ligaments and menisci to check for tears and excise/débride as necessary. To débride the injured cruciate ligament. OBJECTIVES • To improve limb function and prevent degenerative joint disease by stabilization of the stifle. If the caudolateral band is disrupted. drill. or rongeur. use a no. which is more commonly seen in the dog with partial cranial cruciate injury. and incise the joint capsule from the cupula to the tibial plateau to expose the joint. because the caudolateral band is lax with the stifle held in this position. This seemingly minute piece of anatomic trivia is important in understanding the clinical signs associated with partial and complete cranial cruciate injury. taking care not to damage the long digital extensor tendon (Plate 22A). curette. and to prevent cranial displacement of the tibial plateau by replacing the cranial crucial ligament with an autogenous internal graft ANATOMIC CONSIDERATIONS 1 The cranial cruciate ligament is composed of two elements: (1) the craniomedial and (2) the caudal lateral band. one medium or large Gelpi retractor (depending on the size of the dog). baby Ochsner forceps. Together the bands work to limit joint hyperextension and internal rotation and cranial displacement of the tibial plateau. periosteal elevator. removing any osteophytes and widening the lateral wall of the intercondylar notch to allow adequate space to pass the graft and to protect the graft from impingement of the craniolateral wall of the intercondylar fossa (Plate 22B). The smaller craniomedial band remains taut (and thus restricts motion) in both extension and flexion of the stifle joint. cranial drawer will be elicited only in flexion. Lavage the joint and return the patella to its original position. Arthrotomy and Notchplasty:2. Reflect the skin and subcutaneous tissue medially and laterally with blunt dissection. PREPARATION AND POSITIONING Prepare the leg circumferentially from dorsal midline to below the tarsus. Center the middle third of the incision on the patellar tendon. Take care not to injure the caudal cruciate ligaments where they cross each other near attachments in the intercondylar fossa of the femur. screws. and a no.3 Perform a lateral arthrotomy. It has three important functions in defining stifle motion and stability. EQUIPMENT • Standard surgical pack. drawer will be palpable in both flexion and extension. If both bands are torn. PROCEDURE Approach: Incise the skin and subcutaneous tissue in a curvi- INDICATIONS Candidates include animals with stifle instability caused by partial or complete cranial cruciate ligament injury as diagnosed via palpation or arthrotomy. Luxate the patella and flex the limb. because the craniomedial band is still present and taut in both flexion and extension. straight needle and/or cerclage wire linear fashion on the craniolateral aspect of the stifle. 11 blade. Continued . If the craniomedial band is disrupted. The more substantial caudolateral band is taut in only extension. rongeurs. and incise the origins of the ligament within the intercondylar notch of the caudomedial portion of the lateral condyle. Use a hanging leg preparation with the dog in dorsal recumbency at the end of the surgery table to allow for maximal manipulation and visualization of the stifle joint during surgery. Perform a notchplasty with a bone rasp. curette. 11 blade for joint inspection and cruciate ligament débridement. there may be no palpable drawer at all.64 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES STIFLE CHAPTER 22 Cranial Cruciate Repair with Intra-articular Repair Additional instrumentation needed for this technique includes baby Hohmann retractor. CHAPTER 22 C R A N I A L C R U C I AT E R E PA I R W I T H I N T R A .A RT I C U L A R R E PA I R 65 P L AT E 2 2 A B Biceps femoris muscle Notchplasty Cranial cruciate ligament débrided Fascia lata strip Tibial tunnel Cranialis tibialis muscle reflected . . Moore KW. Secure the graft to the distal femur by suturing it to the femorofabellar ligament with large (0 to 2) monofilament. 4. Create a tibial tunnel with a drill bit large enough to accept the graft from the cranial surface of the tibia (see Plate 22B). Hart RC. The entry point location of the tunnel is just lateral and distal to the tibial tuberosity. the prognosis is good to excellent with proper postoperative care and confinement. 1996. Part II. Exercise should be restricted and the animal should be confined to a kennel for the first 4 to 6 weeks. or with a spiked screw and washer with the stifle in standing flexion (Plate 22E).3 Harvest a 10-cm graft from the craniolateral aspect of the distal fascia lata and lateral third of the patellar tendon. Slater MR: Contribution of periarticular tissue to stabilization of the canine stifle joint after cranial cruciate ligament reconstruciton. J Small Anim Pract 42:487–490. POSTOPERATIVE CARE The leg should be placed in a soft. 2003. because it will lead to premature failure of the repair. et al: The effect of intercondylar notchplasty on the normal canine stifle. Normally. Then normal activity should be slowly reintroduced. 1996. 2 mm to 3 mm of drawer motion should be detected on palpation. 3. 2003.5 Placing excessive tension on the graft should be avoided.2. Check the stifle for range of motion and cranial drawer after the graft is secured. Lampman TJ. however. Stork CK. Hulse DA. EXPECTED OUTCOME Osteoarthritis is a common sequela to cranial cruciate rupture. Diagnosis and management. It is not necessary to radiograph the stifle to assess implant positioning and joint congruency in this repair. CAUTIONS 4. use a guide wire followed by a cannulated drill bit to ensure accuracy of the graft placement. Place the graft through the intercondylar notch by passing curved Kelly or Carmalt forceps over the top of the lateral condyle or by creating a separate femoral tunnel extending from the point of origin of the cranial cruciate to the caudolateral aspect of the femoral condyle and passing the straight needle or looped cerclage wire through the tunnel (Plate 22D). and the stifle should be checked for cranial drawer before the patient awakens. Kincaid SA. 2001. References 1. et al: Radiographic features of a lateral extracapsular wire suture in the canine cranial cruciate deficient stifle. Vet Comp Orthop Traumatol 16:21–25.66 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES Intracapsular Graft:1. Read RA: Rupture of the cranial cruciate ligament in dogs. Excessive drawer may then be removed by joint capsule and fascial imbrication. 2. POSTOPERATIVE EVALUATION 5 The range of motion should be evaluated. Alternatively. padded bandage for 24 hours to cover the wound and provide support. Owen MR. Free the graft and its bony insertion onto the tibial plateau with an osteotome while maintaining its distal fascial attachments (see Plate 22A). Lund EM. with nonabsorbable suture. particularly when meniscal damage is present. Fitch RB. and risk for disease. Place one or two stay sutures in the end of the graft using large diameter monofilament suture (0 or 1) or cerclage wire. Gibson NR. surgery. however. exiting into the joint at the point of insertion of the cranial cruciate ligament (Plate 22C). 5. Lipowitz AJ: Cranial cruciate disease: Current status of diagnosis. many surgeons at this point often reenforce the intracapsular repair with a lateral fabellar suture (see Chapter 21 for details regarding this procedure). Vet Comp Orthop Traumatol 16:122–126. Compend Contin Educ Pract Vet 18(4):381–391. Thread the stay suture with a straight needle or loop of cerclage wire through the bone tunnel in the tibia from distal to proximal. using the arthrotomy incision as the caudal border of the graft. Vet Surg 24:156–164. Montgomery RD. CHAPTER 22 C R A N I A L C R U C I AT E R E PA I R W I T H I N T R A .A RT I C U L A R R E PA I R 67 P L AT E 2 2 D E C Lateral fibula Spiked washer Site of drill hole M L . and a no. The medial meniscus is stabilized by cranial and caudal tibial ligaments. baby Ochsner forceps. and increases the likelihood of degenerative joint disease and stifle dysfunction. Center the middle third of the incision on the patellar tendon. The functions of the menisci are complex. and a strong attachment to the medial collateral ligament. cranial displacement of the tibia acts to wedge the posterior horn of the medial meniscus between the tibial plateau and the femoral condyle. but because of the presence of more synovial attachment. and a caudal femoral ligament. Continued INDICATIONS Candidates include animals with meniscal damage caused by stifle instability from chronic partial or complete cranial cruciate ligament injury or traumatic luxation. 11 blade and incise the origins of the ligament within the intercondylar notch of the caudomedial portion of the lateral condyle (Plate 23A). the caudal tibial ligament. The lateral meniscus is less firmly attached via cranial and caudal tibial ligaments. an intermeniscal ligament. an intermeniscal ligament. use a no. They are white. fibrocartilagenous structures that are wedge-shaped when viewed on cross section. The menisci move slightly while the stifle joint moves through its ranges of motion. discoid. but these structures are very important to normal stifle biomechanics. baby Hohmann retractor.3 Repetitive entrapment between the femoral condyle and tibial plateau results in meniscal injury . C-shaped. Use a hanging leg preparation with the dog in dorsal recumbency at the end of the surgery table to allow for maximal manipulation and visualization of the stifle joint during surgery. Luxate the patella and flex the limb. Arthrotomy: Perform a medial arthrotomy. and incise the joint capsule from the cupula to the tibial plateau to expose the joint. PROCEDURE Approach: Incise the skin and subcutaneous tissue in a curvilinear fashion on the craniolateral aspect of the stifle. Examine the cruciate ligaments and menisci to check for tears and excise/débride as necessary. Each meniscus consists of a body and a cranial and caudal pole.2 Once the cranial cruciate ligament is disrupted. Take care not to injure the caudal cruciate ligaments where they cross each other near attachments in the intercondylar fossa of the femur. the medial meniscus moves less than the lateral and therefore may be more predisposed to injury in a cranial cruciate deficient stifle. and the lack of a femoral attachment.5 EQUIPMENT • Standard surgical pack. OBJECTIVES • To improve limb function and decrease pain associated with meniscal injury caused by entrapment of the femoral condyle because of stifle instability ANATOMIC CONSIDERATIONS 1 Dogs and cats have a medial and a lateral menisci that reside within the stifle joint. one medium or large Gelpi retractor (depending on the size of the dog). To débride the injured cruciate ligament. Reflect the skin and subcutaneous tissue medially and laterally with blunt dissection.68 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES STIFLE CHAPTER 23 Meniscectomy (particularly to the caudal pole). The medial meniscus has been reported to be damaged in 47% to 80% of cranial cruciate deficient stifles and around 14% of previously repaired cranial cruciate deficient stifles.4. Dogs with meniscal damage usually experience more pain and display more lameness in association with stifle instability than in association with a pure cruciate tear. 11 or 15 blade for joint inspection and cruciate ligament and meniscal débridement or excision PREPARATION AND POSITIONING Prepare the leg circumferentially from dorsal midline to below the tarsus. CHAPTER 23 M E N I S C E C TO M Y 69 P L AT E 2 3 A Cranial cruciate ligament Cut 1 Cut 2 Cut 3 Medial meniscus . 8. POSTOPERATIVE CARE The leg should be placed in a soft. Innes JF. lever the tibial plateau forward by placing the tip of the instrument behind the tibial plateau while holding the stifle at a normal standing angle (Plate 23B). et al: A comparison between medial meniscus repair. 4. Vet Comp Orthop Traumatol 8(2):118–123. Incise the intermeniscal and cranial tibial attachments of the cranial pole (Plate 23D1). incise the caudal meniscotibial ligament to release the caudal pole and remove the meniscus (Plate 23D2). Aglietti P.70 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES Meniscectomy: Using a baby Hohmann retractor. It is not necessary to radiograph the stifle to assess implant positioning and joint congruency. 1993. Then normal activity should be slowly reintroduced. Finally. Grasp the damage portion of the meniscus firmly with Ochsner forceps and place cranial traction on the damaged pole. perform a partial meniscectomy. Marsolais GS. Philadelphia. Stabilize the joint with either an extracapsular or intercapsular method to prevent further injury. 2. Dvorak G. CAUTIONS Meniscectomy should not be performed unless there is meniscal pathology present. Timmermann C. 6. Lynch C. Arnoczky SP: Pathomechanics of cruciate and meniscal injuries. Incise the caudal meniscotibial ligament to release the caudal pole with a number 11 or 15 blade (Plate 23C1). Lavage and close the joint in one or two layers. Schwarz PD. partial meniscectomy. EXPECTED OUTCOME 7. and normal meniscus in anterior cruciate ligament reconstructed knees. Next release the synovium and collateral attachments (if performing a medial meniscectomy) of the body until healthy fibrocartilage is reached and cut perpendicularly across the body of the meniscus to remove the caudal pole (Plate 23C2). Meyer-Lindenberg A. Gibson NR. because it will close the joint space and limit visualization of the menisci. Release the synovium and collateral attachments (if present) while placing lateral traction on the cranial pole of the meniscus with an Ochsner forceps. Zaccherotti G. 1995. because either partial or complete meniscectomy results in the progression of degenerative joint disease. 1993. Vet Clin North Am Small Anim Pract 23(4):831–843. 2001.8 A guarded prognosis for full return to function is the general rule when meniscal damage is present. 1994. Inspect both the medial and lateral menisci for tears or crushing injury (see Plate 23B). Nolte I: Meniscus injuries in dogs with rupture of the cruciate ligament. Flo GL: Meniscal injuries. Bacon D. De Biase P. Metelman LA. . References 1. 5. Vet Rec 147(12):325–328. padded bandage for 24 hours to cover the wound and provide support. et al: Long-term outcome of surgery for dogs with cranial cruciate ligament deficiency. 2002. Dtsch Tierarztl Wochenschr 105(10):374–377. perform a complete meniscotomy. POSTOPERATIVE EVALUATION 6 The range of motion should be evaluated and the stifle should be checked for cranial drawer before the patient awakens. Alvis MR: An evaluation of three different cranial cruciate ligament surgical stabilization procedures as they relate to postoperative meniscal injuries: A retrospective study of 665 stifles. making sure to appose the synovial layer with either method. 7. 3. Stork CK. 1998. Conzemius MG: Effects of postoperative rehabilitation on limb function after cranial cruciate ligament repair in dogs. Owen MR. et al: Radiographic features of a lateral extracapsular wire suture in the canine cranial cruciate deficient stifle. Therapeutic exercise and rehabilitation should be strongly considered for the first 4 to 6 weeks. Clin Orthop (307):165–173. because degenerative joint disease is a common sequela. If the entire meniscus is damaged. 2000. Avoid excessive flexion of the joint. In Bojrab MJ: Disease Mechanisms in Small Animal Surgery. Aggressive postoperative rehabilitation has been shown to improve the function in the case of dogs with meniscal damage. Salman M. Lea & Febiger. J Am Vet Med Assoc 220(9):1325–1330. If only the caudal pole is affected. J Small Anim Pract 42:487–490. CHAPTER 23 M E N I S C E C TO M Y 71 P L AT E 2 3 B C1 C2 D1 D2 . 1 CAUTIONS Avoid angling the saw blade medially or laterally when performing the tibial and femoral articular ostectomies.72 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES STIFLE CHAPTER 24 Stifle Arthrodesis of the selected joint angle (see Plate 24B). et al (eds): Manual of Internal Fixation in Small Animals. Remove the stabilizing Kirschner wires. The animal should be confined. A lateral splint should be used for 6 weeks or until early radiographic evidence of bone bridging is observed. Remove the guiding Kirschner wires. 1995. The plate may be removed 6 to 9 months after bone healing to avoid stress concentration at the distal plate end. Radiographs for limb alignment and implant placement should be evaluated. extending from the mid-diaphysis of the femur to the mid-diaphysis of the tibia. Fill the remaining plate holes. Osteotomize the tibial tuberosity to aid exposure of the joint and to prepare a surface for the plate. In Olmstead ML (ed): Small Animal Orthopedics. For most pet animals. Check angular and rotational alignment of the limb carefully before securing the plate. self-centering plate-holding forceps. POSTOPERATIVE EVALUATION The axial alignment of the limb and the angle of the arthrodesis should be critically observed. EXPECTED OUTCOME The bone usually heals in 12 to 18 weeks. POSTOPERATIVE CARE A soft. the tibial tuberosity. Position the animal in dorsal recumbency. Springer-Verlag. Secure the plate by first placing screws through the most distal and most proximal plate holes (see Plate 24C). Commonly. Elevate the cranial tibial muscle to expose the proximal tibia. Incise the lateral retinaculum. Excise the menisci and cruciate ligaments. Resect the articular portion of the tibia parallel to wire 1 and perpendicular to the long axis of the tibia. and retract the quadriceps muscle and patella medially to expose the distal femur. 2. Mosby. Consider adding 10 degrees to the normal angle in large dogs and 5 degrees to the normal angle in small dogs and cats to compensate for the bone loss during the procedure. periosteal elevator. Place a third wire into the femur distal to the second wire and at the complementary angle .2 OBJECTIVES • To fuse the bones of the femoral tibial joint in a functional position ANATOMIC CONSIDERATIONS The landmarks for the incision are the distal femoral diaphysis. Apply a plate of appropriate size and contour. New York. PROCEDURE Approach: Incise the skin and subcutaneous tissue over the craniolateral aspect of the stifle. SumnerSmith G. high-speed drill. allowing at least four screws in the femur and four screws in the tibia. References 1. the angle is 135 to 140 degrees for dogs and 120 to 124 degrees for cats (Plate 24B). Preserve the collateral ligaments to aid in maintaining alignment (Plate 24A). EQUIPMENT • Surgical pack. Gelpi retractors. Resect the trochlear ridges to improve plate contact (see Plate 24B). place three Kirschner wires as follows: Place the first Kirschner wire perpendicular to the tibial diaphysis and in the midsaggital plane. Radiographs should be repeated at 6-week intervals until bone healing occurs. wire driver and burrs. Other candidates have grade 4 patellar luxations that have not responded to conventional treatment. with activity limited to leash walks. The tibial tuberosity is osteotomized to gain joint exposure and to provide a flat surface for the plate. Olmstead ML. In Brinker WO. Kirschner wires. however. or severe osteoarthritis. Appose the femoral and tibial ostectomy surfaces and temporarily fix them with Kirschner wires (Plate 24C). Ensure that the guiding Kirschner wires are in the same plane to preserve rotational alignment. St. McLaughlin RM: Arthrodesis. Results are best when the correct angle for fusion is achieved.1 Stabilization: To determine the ostectomy angles. plating equipment PREPARATION AND POSITIONING Prepare the rear limb circumferentially from dorsal midline to the hock. wire cutters.1. If possible. Attach the tibial tuberosity to the medial surface of the tibia with a lag screw (Plate 24D). Drape the limb out from a hanging position to allow maximal manipulation during surgery. Johnson KA: Arthrodesis. circumduction of the limb and toe knuckling may occur at faster gaits. Senn retractors. Fracture may occur in the tibia at the end of the plate. padded bandage should be placed to control bleeding and swelling. until bone healing is complete. INDICATIONS Candidates include animals with unreconstructable joint fractures.1 Alignment: Predetermine the cranial caudal angle for the stifle arthrodesis by observing the normal standing angle of the stifle in the individual patient. Place the second wire perpendicular to the femoral diaphysis and in the midsaggital plane. 1998. oscillating saw. A cancellous bone graft is not needed because of the large cancellous bone contact surfaces at the arthrodesis site. satisfactory function of the treated limb is seen. and the proximal tibial diaphysis. the patella. Louis. place one or two screws as lag screws across the joint. Hohmann retractors. stifle luxation. Resect the articular surface of the femur parallel to wire 3 and perpendicular to the long axis of the femur (see Plate 24B). CHAPTER 24 S T I F L E A RT H R O D E S I S 73 P L AT E 2 4 A B 2 Patella 40° Lateral collateral ligament 3 140° Long digital extensor tendon Osteotomy site 1 Cranial tibial muscle retracted C D . Tendon injuries may be classified into three general types.. Use a hanging leg preparation. the semitendinosus. On physical examination. the AT is intact but inflamed. Chronic injuries are technically more difficult to repair because tendon contracture and fibrosis hamper identification and apposition. external skeletal fixation set. with the dog in dorsal recumbency at the end of the surgery table to allow for maximal manipulation and visualization of the stifle joint during surgery. equipment for casting and bandage material PREPARATION AND POSITIONING Prepare the leg circumferentially from dorsal midline to the phalanges. Kirschner wires or small Steinmann pins for large dogs. III. and the gracilis. The superficial digital flexor tendon is placed under considerable tension with partial disruption of the AT. OBJECTIVES • To restore normal weight bearing and limb function and eliminate the plantigrade stance associated with the injury ANATOMIC CONSIDERATIONS 1–4 The Achilles tendon (AT) is the largest tendon complex in the dog.e. and (3–5) the combined tendon of the biceps femoris. Reflect the skin and subcutaneous tissue to expose the deep fascia. exposing the injured AT apparatus. heavy-gauge monofilament nonabsorbable suture for tendon repair. (2) the superficial digital flexor. Gelpi retractors or Senn retractors. Extend the incision proximally as needed to expose the injured tendon. It consists of the combined tendinous insertion of five separate muscles: (1) the gastrocnemius. Three subclassifications of this category are recognized: (1) type 2a is a musculotendinous rupture. 4 cm proximal to the injury on the caudolateral aspect of the common calcanean tendon to the level of the fourth tarsal bone (Plate 25A). (2) type 2b is an AT rupture with an intact paratenon or tendon sheath. Dogs that have a type 2c AT injury display a characteristic “crab-like” stance. PROCEDURE Approach:5 With the tarsus extended. type 1). the hock may be fully flexed. snub-nosed wire twisters. and V. Type 1 involves a complete disruption of the tendon apparatus. and (3) type 2c is partial AT rupture.74 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES TA R S U S CHAPTER 25 Achilles Tendon Repair In type 3 injuries. contracting the toes. with a hyperflexed tarsus with contracture of the toes. AT injuries may be acute or chronic in duration. cerclage wire. Continued . with no tension placed on the Achilles mechanism. Dogs with this injury have a characteristic plantigrade stance. EQUIPMENT • Surgical pack. Type 2 injuries are more common than full AT tears (i. pointed reduction forceps. wire cutter. incise the skin 3 cm to INDICATIONS Candidates include animals with partial or complete rupture of the Achilles or calcanean tendon. with an intact superficial digital flexor tendon. Type 2 involves a lengthened AT system. IV. with the metatarsals and digits lying flat on the floor. Incise the deep fascia and lateral retinaculum along the lateral border of the superficial digital tendon. pin chuck or high-speed wire driver. which pulls on its insertions on the palmar surface of the proximal end of the middle phalanges of digits II. CHAPTER 25 A C H I L L E S T E N D O N R E PA I R 75 P L AT E 2 5 A Tendon of flexor hallucis longus muscle Tendon of gastrocnemius muscle Calcaneus Tendon of superficial flexor muscle Tendon of abductor digiti quinti muscle . Using a Jacob chuck or mini-driver.76 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES Acute Midsubstance Tendon Repair: Identify the three separate tendons and attempt apposition. Guerin S. Johnson KA: Approach to the calcaneus. External coaptation (i. 3. however. 4. Because the individual tendons will probably be undistinguishable in the fibrotic scar. 2-0 – to 3-0 for cats and small dogs). Vet Comp Orthop Traumatol 10:45–53. and place them far to near. Vet Comp Orthop Traumatol 11:205–211. Fracture of the Calcaneal Bone: Fracture of the calcaneus is treated with a tension band wire (Plate 25D). In An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. Exercise should be restricted until the tendon heals. Kramek B. Walters PA. 2004. lateral splints or bivalved casts) or transarticular fixation should be placed with the tarsus in a slightly extended but weight-bearing position. Using a monofilament nonabsorbable suture (0 to 1 for large dogs. this is not possible because of tendon retraction and contracture. Place the suture through the bone tunnel using a straight needle or bent pin (Plate 25C). Ultrasound can be used to monitor tendon healing. Avulsed Achilles Tendon Repair:6 Sharply débride the AT using a scalpel blade or Mayo scissors. Gerwing M. Wallace L: Sonographic findings in canine common calcaneal tendon injury. WB Saunders. Tarsal arthrodesis may be employed if. 7. Chronic Midsubstance Tendon Repair: Ideally. Moreshead D. POSTOPERATIVE CARE 7 External coaptation or transarticular fixation is necessary to protect the repair for the first 6 to 8 weeks. 1995. the AT apparatus is repaired using a single lockingloop pattern.7 Débridement of the AT should be performed in a stepwise fashion. suture each tendon separately using a three-loop pulley pattern with the tarsus in extension (Plate 25B). Resect as much scar tissue as possible to permit apposition of the tendon ends. Full healing and reorganization of the AT is a slow process that may go on for years. most animals will be able to function very well as pets. Redirect the final fifth and sixth passes 120 degrees. Leeds EB: Kirschner-Ehmer apparatus immobilization following Achilles tendon repair in six dogs. EXPECTED OUTCOME 7 The expectation for return to full athletic ability is guarded. 1993. Make the first two passes with the needle from near to far. Michele U. create a bone tunnel from lateral to medial of sufficient size to pass the suture through. Vet Surg 13(1):11–14. Fox S: Achilles tenorrhaphy in five dogs: A modified surgical technique and evaluation of a cranial half cast. 1997. Philadelphia. Vet Comp Orthop Traumatol 8:32–35. Vet Comp Orthop Traumatol 6:53–55. Meutstege FG: The classification of canine Achilles tendon lesions. and orient the third and fourth passes 120 degrees from the previous two sutures and in the middle. 6. et al: Ultrasonographic examination of injuries to the Achilles tendon in dogs and cats. pain and dysfunction persist.e. Burbidge H.. Then the animal should slowly be returned to normal activity. 1984. CAUTIONS 1. Excessive resection will prevent apposition of the tendon ends and complicate recovery. Rivers BJ. Piermattei DL. 4th ed. Goring RL. however. de Haan JJ. Kramer M. Renburg C. . despite repair. Firth E. J Small Anim Pract 42:531–535. Secure the tendon to the calcaneus using a lockingloop suture pattern. See Chapter 81 for details. the fibrotic scar should be sharply resected until normal tendon is identified. Most often. Tarsal immobilization and support is critical to wound healing and to preventing catastrophic failure of the AT repair. 2001. 5. 2. Bertrand S: Modified transarticular external skeletal fixation for support of Achilles tenorrhaphy in four dogs. 1998. POSTOPERATIVE EVALUATION 3 Radiographs are not necessary unless a tension band or transarticular fixator is placed. References 1. CHAPTER 25 A C H I L L E S T E N D O N R E PA I R 77 P L AT E 2 5 B Midsubstance C Avulsion D Fracture of calcaneal bone Three-loop pulley repair Locking-loop repair Pin and tension band repair . bone screw and washer. depth gauge. EQUIPMENT • Surgical pack. and (6) the tarsometatarsal joint. (2) the talocalcaneal joint. The long component of the lateral collateral inserts on the proximal aspect of the fifth metatarsal. If the shearing injury is extensive. however. external skeletal fixation set. Continued . however. PROCEDURE Approach:3 Center a curvilinear incision over the talocrural INDICATIONS Candidates include animals with shearing wounds to the tarsus sustained from motor vehicle trauma. snub-nosed wire twisters. heavy-gauge monofilament nonabsorbable fishing leader line for collateral ligament repair. Use a hanging leg preparation with the dog in dorsal recumbency at the end of the surgery table to allow for maximal manipulation and visualization of the stifle joint during surgery. pointed reduction forceps. removing much of the covering soft tissues. drill bit. between the tibia and talus. (4) the calcaneoquartal joint. much of this approach may be unnecessary (Plate 26A). equipment for casting and bandage material PREPARATION AND POSITIONING Prepare the leg circumferentially from dorsal midline to the phalanges.2 The tarsus is composed of six separate anatomic joints: (1) the talocrural or tarsocrural joint.78 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES TA R S U S CHAPTER 26 Shearing Injury with Tarsal Luxation tarsus is more common than injury to the lateral aspect. Joint stability is provided by the medial and lateral collateral ligaments. pin chuck and key. both have been reported in the literature. low-speed drill. (5) the centrodistal joint intertarsal joint. respectively. tap. (2) the proximal intertarsal joint (consisting of the calcaneoquartal and the talcalcaneocentral joint). The long component of the medial collateral ligament inserts on the proximal portion of the second metatarsus. Functionally. which are composed of long and short components originating on the malleoli of the tibia and fibula. OBJECTIVES • To restore stability to the tarsal joint and salvage joint function while allowing soft tissue healing to occur ANATOMIC CONSIDERATIONS 1. (3) the distal intertarsal joint (centrodistal joint). and the short component attaches to the body of the calcaneus. Retract the subcutaneous and crural fascia and expose the medial ridge of the talus by incising the joint capsule cranial to the collateral ligament. periosteal elevator. (3) the talocalcaneocentral joint. The majority of movement of the tarsus is at the talocrural joint. exposing the distal tibial to the level of the tarsometatarsal joint. screwdriver. Gelpi retractors or Senn retractors. and (4) the tarsometatarsal joint. whereas the short component attaches to the talus. high-speed drill. the joint can be separated into four compartments: (1) the talocrural. Injury to the medial aspect of the joint along the medial aspect of limb. CHAPTER 26 S H E A R I N G I N J U RY W I T H TA R S A L L U X AT I O N 79 P L AT E 2 6 A Tendon of cranial tibial muscle . 2003.80 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES Prosthetic Ligament Repair:2 Drill. which is located midway between the medial trochlear ridge and the intertarsal articular surface. Boudrieu RA: Evaluation of joint stabilization for treatment of shearing injuries of the tarsus in 20 dogs. which is a premium. and tap a bicortical screw hole into the distal aspect of the tibia at the level of the medial malleolus. England. Blackwell Sciences. 3. Tie the sutures independently: tie the short component with the tarsus held in flexion and the long component with the tarsus held in extension. 5. 2002.4. midway between the base of the coracoid process and the proximal intertarsal joint (Plate 26D). . because—given the right conditions and wound care—the soft tissue coverage. In External Fixation in Small Animal Practice. depending on the severity of soft tissue trauma. The proximal screw and washer is placed in the distal fibula/tibia. but not overly tight. 4th ed. and one pin into the metatarsal bones 2 and 3. Johnson KA: Approach to the medial malleolus and talocrural joint. Piermattei DL. Diamond DW. Toombs JP. 2000. Kraus KH. Benson JA. 1995. EXPECTED OUTCOME 6 There is a 75% chance of good to excellent function. Can Vet J 41: 940–943. Philadelphia. Then the animal should slowly be returned to normal activity. Excessive débridement should be avoided early on. Renberg C. Ness MG: Transarticular case studies. Pantarsal arthrodesis may be employed if pain and dysfunction persist despite repair. taking care to avoid the joint. Harasen GLG: Tarsal shearing injury in the dog. Exercise should be restricted until the fixator is removed and the soft tissues heal. Prosthetic ligament repair for a lateral shearing injury is very similar to the medial repair just described (Plate 26C). Place a screw and washer to prevent subsidence into the metaphyseal bone and to prevent ligature slippage. References 1. measure. POSTOPERATIVE CARE 2.4 Place a type I or II transarticular external fixator with two pins through the tibia (one proximal and one distal). The sutures should be taut. Place two additional screws and washers in similar fashion into the body of the talus (aiming distally to avoid the trochlear sulcus) and into the head of the talus. CAUTIONS Lavage and wound débridement of the tarsus should be performed once the patient is stabilized. 1999. 6. one pin in the calcaneus. J Am Anim Hosp Assoc 35:147–153. 2004. J Am Anim Hosp Assoc 38:370–380. will survive despite extensive damage. Transarticular External Skeletal Fixation:2. Goring RL. until healthy granulation tissue is present or as tissue viability dictates. Vet Comp Orthop Traumatol 8:32–35. Oxford. POSTOPERATIVE EVALUATION 4 The wound should be evaluated at least daily for the first 7 to 10 days. A nonadherent bandage can then be placed over the wound and the dressing changed less frequently. 4. despite progressive degenerative joint disease and restricted range of motion of the tarsal joint. to avoid compromising joint range of motion (Plate 26B). apposition of the fracture-luxation. The distal two screws and washers are positioned in the base of the coracoid process. Position the tarsus in a normal standing angle and immobilize it for 6 to 8 weeks. Boudrieu RA: Severe carpal and tarsal shearing injuries treated with immediate arthrodesis in seven dogs. In An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. de Haan JJ. Depending on the size of the animal.to 60-pound test of monofilament fishing leader line to place two independent suture loops for the long and short components of the medial collateral ligament. The use of sterile wet-todry bandages until healthy granulation tissue is present is an excellent way to improve wound quality without surgical débridement. being careful to avoid the joint surface. 2. utilize 20.5 External coaptation or transarticular fixation is necessary in order to protect the repair for the first 6 to 8 weeks. Bertrand S: Modified transarticular external skeletal fixation for support of Achilles tenorrhaphy in four dogs. Radiographs should be repeated every 6 to 8 weeks until the soft tissues heal to evaluate limb alignment. Besso J. WB Saunders. and apparatus integrity. CHAPTER 26 S H E A R I N G I N J U RY W I T H TA R S A L L U X AT I O N 81 P L AT E 2 6 B C D . Kirschner wires or small Steinmann pin for forage PREPARATION AND POSITIONING Prepare the leg circumferentially from dorsal midline to the phalanges. the surgical approach used to expose the lesion is as important as the surgical débridement and curettage. EQUIPMENT • Standard surgical pack. a combined dorsolateral and plantarolateral approach exposes the entire lateral trochlear ridge. If necessary. extend the joint capsular incision into the periosteum at the junction of the distal tibia and fibula to increase the exposure of the trochlea (Plate 27B). with the central 20% of the lateral ridge being accessible from either individual approach. although the typical presenting complaint of a dog with tarsal OCD is a unilateral lameness. Continued . Retract these structures laterally. and 25% occur on the lateral ridge. the cranial tibial muscle. and the peroneus brevis in a plantar direction. blunt Hohmann retractor.4–6 Flex and extend the tarsus to INDICATIONS Candidates include dogs with persistent lameness and pain of the tarsus caused by osteochondrosis (OCD) that is not responsive to conservative management. Because of the diversity of the lesion location. A combined dorsomedial and plantaromedial approach exposes all but 4% of the medial trochlear ridge of the talus. Retract the tendons of the peroneus longus. Both medial and lateral approaches have been described. Incise the deep fascia and adherent joint capsule longitudinally along the midline of the palpable portion of the lateral trochlear ridge. pin chuck or high-speed wire driver. and the superficial peroneal nerve (Plate 27A). accurately identify dorsal aspect of the lateral trochlear ridge via palpation. Seventy-five percent of the OCD lesions of the tarsus occur on the plantar half of the medial trochlear ridge of the talus. two medium or large Gelpi retractors (depending on the size of the dog). and forage to provide blood supply to the exposed subchondral bone via forage ANATOMIC CONSIDERATIONS 1–5 The tarsus is the third most common joint to be affected by OCD. OBJECTIVES • To improve limb function by removal of the entire OCD flap. the dorsal branch of the lateral saphenous vein. preserving the lateral collateral ligament of the tarsus. with the dog in dorsal recumbency at the end of the surgery table to allow for maximal manipulation and visualization of the tarsus during surgery. PROCEDURE Dorsolateral Approach:2. curettage of the adjacent diseased cartilage. the lateral digital extensor.82 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES TA R S U S CHAPTER 27 Osteochondrosis of the Lateral Trochlear Ridge of the Talus bone curettes. with a reported incidence of 9%. Retract the skin and subcutaneous tissues with a Gelpi or Senn retractor to improve visualization of the tendons of the long digital extensor muscle. Forty-four percent of the tarsal lesions are bilateral. Center a curvilinear 4-cm to 5-cm incision over the trochlear ridge from the distal tibia and fibula to the distal intertarsal joint. Use a hanging leg preparation. the extensor hallucis longus muscle. Similarly. CHAPTER 27 O S T E O C H O N D R O S I S O F T H E L AT E R A L T R O C H L E A R R I D G E O F T H E TA L U S 83 P L AT E 2 7 A Proximal extensor retinaculum B Tendon of long digital extensor musle Tendon of cranial tibial muscle Tendon of peroneus brevis muscle Tendon of lateral digital extensor muscle Tendon of extensor hallucis longus muscle Digital extensor retinaculum . Berry CR.8 Expected outcome is usually guarded to fair. Morgan J: Clinical evaluation of dogs after surgical and nonsurgical management of osteochondritis dissecans of the talus. the lateral digital extensor. 1985. and degenerative joint disease. J Am Anim Hosp Assoc 26(1):19–24. J Am Vet Med Assoc 187(1):31–35. 1994. Smith M. Retract the plantar branch of the lateral saphenous vein. Beale BS: Exposure of the medial and lateral trochlear ridges of the talus in the dog. CAUTIONS 7 Unlike the more common OCD of the medial trochlear ridge. Herrington J. 6. 1990. Retract the skin and subcutaneous tissue with a Gelpi or Senn retractor to improve visualization of the tendons of the peroneus brevis. penetrate the sclerotic subchondral bone in multiple sites until it bleeds. surgical approach. et al: Osteochondrosis of the lateral trochlear ridge of the talus in seven Rottweiler dogs. 1990. 5. 1990. J Am Anim Hosp Assoc 26(1):13–18. 1991. Part I: Dorsomedial and plantaromedial surgical approaches to the medial trochlear ridge. in a plantar direction. Montgomery RD. owners should be advised that nonsteroidal anti-inflammatory drugs may be indicated to control the clinical signs of lameness and pain associated with degenerative joint disease. lateral trochlear ridge lesions have been reported to arise from both proximal and dorsal aspects of the ridge. Vet Clin North Am Small Anim Pract 28(1):95–113. EXPECTED OUTCOME 5. et al: A prospective evaluation of four surgical approaches to the talus of the dog used in the treatment of osteochondritis dissecans. In addition. joint instability. 8. Center a curvilinear 4-cm to 5-cm incision over the plantar aspect of the trochlear ridge. After 4 to 6 weeks. 1999. 4. Nonetheless. Besso J. depending on the degree of swelling. 2.84 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES Plantarolateral Approach:2. Probe the remaining cartilage surrounding the defect with a curette. clinical reports of lateral trochlear ridge OCD lesions describe large. Hathcock JJ. depending on numerous factors (e. Beale BS. 7. and the peroneus longus muscles (Plate 27C). Fitch RB: Osteochondrosis dissecans of the canine tarsal joint. Goring RL: Exposure of the medial and lateral trochlear ridges of the talus in the dog. Wisner ER. J Am Anim Hosp Assoc 27(2):221–229. Morgan JP. Fitch R. Note that joint goniometry should be performed preoperatively to provide a baseline assessment of tarsal range of motion and function. Passive range-ofmotion exercises should be performed two or three times daily for 5 to 10 minutes per session to maintain range of motion and to improve cartilage healing. Milton JL.g. If necessary. Part II: Dorsolateral and plantarolateral surgical approaches to the lateral trochlear ridge. . and remove any abnormal cartilage not adherent to the subchondral bone (see Plates 27B and 27D). “shelf-like” lesions that may result in significant malarticulation. Forage: Using a small Kirschner wire or small Steinmann pin. Vasseur P. POSTOPERATIVE CARE The limb should be bandaged for 2 to 3 days.. Boudrieu RA: Evaluation of joint stabilization for treatment of shearing injuries of the tarsus in 20 dogs. Exercise should be restricted for 4 to 6 weeks until the articular cartilage heals. Diamond DW. lesion size. but it does not correlate with the degree of lameness. the animal should slowly be returned to normal activity.6. thus necessitating a more aggressive surgical exposure. Vet Surg 19(6):435–439. Degenerative joint disease develops regardless of surgical removal of the flap. Retract these structures dorsally. POSTOPERATIVE EVALUATION No specific postoperative evaluation is required. Curettage:2–6 Remove the cartilage flap with thumb or Halstead forceps. 1998. Goring RL. References 1. Goring RL. unilateral versus bilateral disease. Beale BS. and presence of degenerative joint disease). 3. and a branch of the caudal cutaneous sural nerve. where the lesion is generally located in the proximal region of the trochlear. J Am Anim Hosp Assoc 35:147–153. preserving the lateral collateral ligament.4–6 Flex and extend the tarsus to accurately identify the plantar aspect of the lateral trochlear ridge of the talus via palpation. extend the joint capsular incision into the periosteum at the junction of the distal tibia and fibula to increase the exposure of the trochlear ridge (Plate 27D). Incise the joint capsule longitudinally along the center of the palpable portion of the lateral trochlear ridge. Beale BS: Osteochondrosis of the canine tibiotarsal joint. Compend Contin Educ Pract Vet 16(7):835–845. 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 Tendon of peroneus brevis muscle Calcaneus D Tendon of peroneus longus muscle Tendon of lateral digital extensor muscle Tendon of abductor digiti quinti muscle . and laterally retract the tendon of the cranial tibial muscle. Use a hanging leg preparation with the dog in dorsal recumbency at the end of the surgery table to allow for maximal manipulation and visualization of the tarsus during surgery.86 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES TA R S U S CHAPTER 28 Osteochondrosis of the Medial Trochlear Ridge of the Talus PREPARATION AND POSITIONING Prepare the leg circumferentially from dorsal midline to the phalanges. EQUIPMENT • Standard surgical pack. Preserve the distal extensor retinaculum. The plantaromedial approach is the most commonly used surgical approach. the cranial tibial artery and vein. and forage to provide blood supply to the exposed subchondral bone ANATOMIC CONSIDERATIONS 1–5 Surgical exposure of the tarsus can be achieved through a variety of surgical approaches. two medium or large Gelpi retractors (depending on the size of the dog). curettage of the adjacent diseased cartilage. pin chuck or high-speed wire driver. Kirschner wires or small Steinmann pin for forage accurately identify the dorsal aspect of the medial trochlear ridge via palpation. Continued . because it exposes 40% of the plantar aspect of the medial trochlear ridge. and the dorsal branches of the saphenous artery and vein. which is the most common site of OCD in the tarsus. Preserve the medial collateral ligament. Center a curvilinear 4-cm to 5-cm incision over the trochlear ridge. If necessary. Retract the skin and subcutaneous tissues with a Gelpi or Senn retractor (Plate 28A). PROCEDURE Dorsomedial Approach:1–6 Flex and extend the tarsus to INDICATIONS 1 Candidates include dogs with persistent lameness and pain of the tarsus caused by osteochondrosis (OCD) of the medial trochlear ridge that is not responsive to conservative management. from the distal tibia and fibula to the distal intertarsal joint. the saphenous nerve. blunt Hohmann retractor. OBJECTIVES • To improve limb function by removal of the entire OCD flap. which accounts for more than 80% of all medial trochlear lesions. bone curettes. and longitudinally incise the deep fascia and adherent joint capsule along the palpable midportion of the medial trochlear ridge. extend the joint capsular incision into the periosteum at the junction of the distal tibia and fibula to increase the exposure of the trochlea (Plate 28B). The most common location of OCD of the medial trochlear ridge is the plantar aspect. CHAPTER 28 O S T E O C H O N D R O S I S O F T H E M E D I A L T R O C H L E A R R I D G E O F T H E TA L U S 87 P L AT E 2 8 A Proximal extensor retinaculum B Tendon of long digital extensor muscle Tendon of cranial tibial muscle Tendon of peroneus brevis muscle Tendon of lateral digital extensor muscle Tendon of extensor hallucis longus muscle Digital extensor retinaculum . Miyabayashi T.5. J Am Vet Med Assoc 187(1):31–35. J Am Vet Med Assoc 199(5):598–600. et al: A prospective evaluation of four surgical approaches to the talus of the dog used in the treatment of osteochondritis dissecans. Part II: Dorsolateral and plantarolateral surgical approaches to the lateral trochlear ridge. expense and limited access prohibit their widespread use. 1994. penetrate the sclerotic subchondral bone in multiple sites until it bleeds.3. Part I: Dorsomedial and plantaromedial surgical approaches to the medial trochlear ridge. 1990. Fitch R. POSTOPERATIVE CARE The limb should be bandaged for 2 to 3 days. Taking care to preserve the medial collateral ligament. Smith M. Goring RL: Exposure of the medial and lateral trochlear ridges of the talus in the dog. 1998.7. Débridement and curettage should be kept to a minimum to avoid tarsal instability and joint incongruency. and remove any abnormal cartilage not adherent to the subchondral bone (see Plates 28B and 28D). Hathcock JT. 2. 1999. POSTOPERATIVE EVALUATION No specific postoperative evaluation is required.3–6 Remove the cartilage flap with thumb or Halstead forceps. Passive range-ofmotion exercises should be performed two or three times daily for 5 to 10 minutes per session to maintain range of motion and to improve cartilage healing. Manley PA.6 Flex and extend the tarsus to accurately identify the plantar aspect of the medial trochlear ridge of the talus via palpation. Morgan JP. the distal attachment of the caudal tibial muscle. 8. Standard anteroposterior and lateral views of the tarsus provide good visualization of the plantar aspect of the medial trochlear ridge. Vasseur P. the dorsomedial-plantarolateral oblique projection highlights the lateral trochlear ridge. A decreased success rate has been reported for dogs older than 12 months because of the progression of degenerative joint disease. Beale BS: Osteochondrosis of the canine tibiotarsal joint. Retract the skin and subcutaneous tissue with a Gelpi or Senn retractor to improve visualization of the tendons of the medial head of the deep digital flexor muscle. Biller DS. Exercise should be restricted for 4 to 6 weeks. 4. 3. Forage: Using a small Kirschner wire or small Steinmann pin. 1991. 1991. . depending on the degree of swelling. Beale BS: Exposure of the medial and lateral trochlear ridges of the talus in the dog. Vet Surg 19(6):435–439. Arthroscopy has greatly improved tarsal joint access and visualization. the flexor hallucis longus muscle. Curettage:1. extend the joint capsular incision into the periosteum at the junction of the distal tibia and fibula to increase the exposure of the trochlear ridge (Plate 28D). Morgan J: Clinical evaluation of dogs after surgical and nonsurgical management of osteochondritis dissecans of the talus. Goring RL. Owners should be advised that the nature of the surgical procedure is exploratory and that a negative exploratory is possible and is necessary to rule out OCD. Goring RL. but it does not completely eliminate the necessity of arthrotomy because of the difficulty of lesion location and treatment. 7. Center a curvilinear 4-cm to 5-cm incision over the plantar aspect of the trochlear ridge. After 4 to 6 weeks. Berry CR. Milton JL. Beale BS. EXPECTED OUTCOME 1. 5. J Am Anim Hosp Assoc 35:147–153.88 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES Plantaromedial Approach:1. Fitch RB: Osteochondrosis dissecans of the canine tarsal joint. Boudrieu RA: Evaluation of joint stabilization for treatment of shearing injuries of the tarsus in 20 dogs. Vet Clin North Am Small Anim Pract 28(1):95–113. 1990. Wisner ER. CAUTIONS 1. 6. Diamond DW.6.9 Expected outcome is guarded to fair. the plantar branches of the medial saphenous vein and saphenous artery.8 Excellent radiographic technique and positioning is necessary to diagnose OCD lesions within the tarsus. Montgomery RD. Computed tomography and magnetic resonance imaging also provide additional information. but additional views may be necessary to fully evaluate the joint. References 1. Beale BS. and the flexed dorsoplantar projection profiles the central region of both trochlear ridges. Note that joint goniometry should be performed preoperatively in order to provide a baseline assessment of tarsal range of motion and function. 1985. The dorsolateral-plantaromedial oblique projection provides good visualization of the medial trochlear ridge. et al: Use of a flexed dorsoplantar radiographic view of the talocrural joint to evaluate lameness in two dogs. J Am Anim Hosp Assoc 26(1):19–24. the animal should slowly be returned to normal activity. incise the joint capsule longitudinally along the center of the palpable portion of the medial trochlear ridge. however. and laterally retract the flexor hallucis longus. J Am Anim Hosp Assoc 27(2): 221–229. Compend Contin Educ Pract Vet 16(7):835–845. 1990. and superficial plantar metatarsal vein. and the medial collateral ligament (Plate 28C). J Am Anim Hosp Assoc 26(1):13–18. Herrington J. until the articular cartilage heals. Besso J. the tibial nerve with its superficial branch. Most dogs seem to benefit from early surgical removal of the OCD flap. 9. Retract the medial head of the deep digital flexor muscle and the caudal tibial tendon dorsally. Probe the remaining cartilage surrounding the defect with a curette. If necessary. et al: Osteochondrosis of the lateral trochlear ridge of the talus in seven rottweiler dogs. medial head) Tendon of flexor hallucis longus muscle (deep digital flexor.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 (deep digital flexor. lateral head) C D Tendon of caudal tibial muscle Medial collateral ligament: Short part Long part . the central tarsal bone. Secure the plate with three screws in the metatarsal bone. and animals with irreparable Achilles tendon injury and sciatic nerve palsy treated with tendon transfer. fracture. and tarsometatarsal joints. 1993. If necessary. from the distal third of the tibia to the middle of the metatarsal bones. Ensure adequate plate holes for a minimum of three screws in the tibia and three screws in the metatarsal bone. the tarsus. precontoured to provide the selected joint angle. The angle is commonly between 135 and 145 degrees1 (see Plate 29C). and secure the plate to the tibia (see Plate 29B). distal tarsal. Remove the plate. Implants are generally removed after 6 to 12 months to avoid soft tissue irritation and the common sequella of implant loosening. The animal should have acceptable function of the treated limb. with activity limited to leash walks until bone healing is complete. CAUTIONS All articular cartilage must be removed. POSTOPERATIVE EVALUATION The axial alignment of the limb and the angle of the arthrodesis should be critically observed. Place an appropriate-size bone plate.90 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES TA R S U S CHAPTER 29 Pantarsal Arthrodesis Stabilization: Extend the hock and remove the articular cartilage from the talocrural. Position the animal in dorsal recumbency for greater flexibility.g. 1995. or shearing injury) of the tibial cochlea and condyles of the talus that precludes maintaining a long-term. and by the talus and calcaneus distally. the talus.2 EXPECTED OUTCOME Bone healing is expected in 12 to 18 weeks. Louis. check the plate and joint alignment. and tarsometatarsal joint surfaces with a bone curette or high-speed burr. Harvest cancellous bone. Enter the tarsal joints to expose the articular surfaces (Plate 29A). and place the graft within the prepared joints (Plate 29B). following the contours of the bone ends (see Plate 29A). J Am Vet Med Assoc 203: 1705. Mosby. Fill the remaining plate holes. as long as stifle and hip remain free of disease. fibula.1 Alignment: Predetermine the cranial caudal angle for the pantarsal arthrodesis by observing the normal standing angle of the tarsus in the individual patient. on the cranial surface of the tibia. Drape the limb out from a hanging position to allow maximal manipulation during surgery. Johnson KA: Arthrodesis. intertarsal. bone curette. The animal should be confined. self-centering plate-holding forceps. intertarsal. PROCEDURE Approach: Incise skin and soft tissue over the cranial medial surface of the joint. Johnston SA: Pantarsal arthrodesis in dogs and a cat: 11 cases (1983–1991). Position the acute bend in the plate over the neck of the talus. POSTOPERATIVE CARE A soft. 2. INDICATIONS Candidates include animals with severe injury (e. and the proximal third of the metatarsal bone. padded bandage should be placed to control bleeding and swelling. Ensure that at least two plate screws penetrate the calcaneus to secure the joint1 (see Plate 29C). and the third metatarsal bone (see Plates 29B and 29C). plating equipment PREPARATION AND POSITIONING Prepare the rear limb circumferentially from hip to digits. intertarsal. pain-free articulation.. Radiographs should be repeated at 6-week intervals until bone healing occurs. and metatarsal bones. high-speed drill and burrs. Angular and rotational alignment of the limb should be checked carefully before the plate is secured to the tibia. DeCamp CE. transect the cranial tibial tendon and the medial collateral ligament to gain access to the joint. Elevate and retract the cranial tibial and long digital extensor tendons to expose the distal tibia. luxation. periosteal elevator. Martinez SA. . Radiographs should be evaluated for limb alignment and implant placement.1 OBJECTIVES • To fuse the bones of the tarsocrural. Prepare the ipsilateral proximal tibia or proximal humerus for cancellous bone graft harvest. Senn retractors. proximal tarsal. St. and center the drill on the metatarsal bone. Hohmann retractors. forming the tarsocrural. References 1. EQUIPMENT • Surgical pack. Mark the level of the distal metatarsal plate screw. A bivalve cast should be used for 6 weeks or until early radiographic evidence of bone bridging is observed. and the tarsometatarsal joints are formed by the articulations between the distal tarsal and metatarsal bones. The tarsocrural joint is formed by the fibula and cochlea of the tibia proximally. animals with painful degenerative joint disease that is not responsive to conservative measures. Gelpi retractors. and tarsometatarsal joints in a functional position ANATOMIC CONSIDERATIONS The tarsus consists of the tibia. In Olmstead ML (ed): Small Animal Orthopedics. The intertarsal joints are formed by articulations between the tarsal bones. CHAPTER 29 PA N TA R S A L A RT H R O D E S I S 91 P L AT E 2 9 A Cranial tibial muscle Tibia Talus B Central tarsal bone Long digital extensor tendon C 140° . Hohmann retractors. EXPECTED OUTCOME Bone healing is usually expected in 12 to 18 weeks. A bivalve cast should be used for 6 weeks or until early radiographic evidence of bone bridging is observed. bone curette. or shearing injury) of the proximal intertarsal or tarsometatarsal joint. WB Saunders. the fourth tarsal bone. Dyce J.1 CAUTIONS All articular cartilage must be removed. Senn retractors. padded bandage should be placed to control bleeding and swelling.1 OBJECTIVES • To fuse the bones of the proximal intertarsal.2 References 1. high-speed drill and burrs. Ensure that the distal screw into the calcaneus also secures the talus (Plate 30C). Position the animal in dorsal recumbency for greater flexibility. and a portion of the fourth tarsal bone. Flo GL: Fractures and other orthopedic injuries of the tarsus. Radiographs should be evaluated for limb alignment and implant placement. Rotational alignment of the limb should be checked carefully before the plate is secured to the metatarsal bones. luxation. 1997. and elevate the abductor digiti quinti muscle to expose the calcaneus.92 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES TA R S U S CHAPTER 30 Proximal Intertarsal or Tarsometatarsal Arthrodesis with a Plate of the fifth metatarsal bone. J Small Anim Pract 39:19. fourth tarsal bone.g. subcutaneous tissue. 3rd ed. The tarsometatarsal joints are formed by the articulations between the distal tarsal and metatarsal bones. and place a screw through the distal plate hole into metatarsal bones 4 and 5. plating equipment PREPARATION AND POSITIONING Prepare the rear limb circumferentially from hip to digits. Place a screw through the proximal plate hole into the calcaneus. the tarsometatarsal joints. fracture. 2. POSTOPERATIVE CARE A soft. PROCEDURE Approach: Incise the skin. Fill the remaining plate holes. Gelpi retractors. Harvest and place the cancellous bone within the prepared joints. Place an appropriate-size and appropriate-contour plate on the lateral surfaces of the calcaneus. which resolves after implant removal. and the base of the fifth metatarsal bone. formed by the articulation of the talus and central tarsal bone with a continuous joint capsule with the calcaneus. located between the calcaneus and the fourth tarsal bone. Position the plate with three screw holes over the calcaneus and three screw holes over the metatarsal bones. EQUIPMENT • Surgical pack. should be removed after joint fusion.. Prepare the ipsilateral proximal tibia or proximal humerus for cancellous bone graft harvest. and the fifth metatarsal bone. Retract the superficial and deep digital flexor tendons medially. Check the plate position. or both in a functional position ANATOMIC CONSIDERATIONS The intertarsal joints are formed by articulations between the tarsal bones. Stabilization: Stress the paw medially. Enter the affected joint(s) to expose the articular surfaces (Plate 30A). metatarsus and phalanges. and Flo’s Handbook of Small Animal Orthopedics and Fracture Repair. and deep crural fascia over the lateral surface of the tarsometatarsal joint. INDICATIONS Candidates include animals with severe injury (e. with the oscillating saw to provide a smooth surface for the plate (Plate 30B). Alignment: There is no angle to the partial tarsal arthrodesis. Drape the limb out from a hanging position to allow maximal manipulation during surgery. which may loosen as a result of movement of the metatarsal bones. POSTOPERATIVE EVALUATION The axial alignment of the limb should be critically observed. The proximal intertarsal joint is a combination of the talocalcaneocentral joint. and remove the articular cartilage from the calcaneoquartal and/or tarsometatarsal joints with a bone curette or high-speed burr. Some dogs exhibit lameness. with activity limited to leash walks until bone healing is complete. Robinson KV. Use a straight plate to align the bones. following the contours of the bone ends. Piermattei. self-centering plate-holding forceps. periosteal elevator. Piermattei DL. Philadelphia. with animals obtaining near-normal function of the treated limb. Whitelock RG.1 Radiographs should be repeated at 6-week intervals until bone healing occurs. The animal should be confined. In Brinker. Smooth the base . Implants. usually within 6 to 12 months after surgery. and the calcaneoquartal joint. et al: Arthrodesis of the tarsometatarsal joint using a laterally applied plate in 10 dogs. 1998. CHAPTER 30 P R OX I M A L I N T E RTA R S A L O R TA R S O M E TA R S A L A RT H R O D E S I S W I T H A P L AT E 93 P L AT E 3 0 A Tendon of flexor hallucis longus muscle Tendon of gastrocnemius muscle Calcaneus B Peroneus longus Peroneus brevis Tendon of superficial flexor muscle Tendon of abductor digiti quinti muscle C Plantar view . Prepare the ipsilateral proximal tibia or proximal humerus for cancellous bone graft harvest. Avoid irritating flexor tendons with the IM pin or wire. to fuse the tarsometatarsal joint. Use an IM pin to align the bones. Piermattei. Radiographs should be repeated at 6-week intervals until bone healing occurs. The tarsometatarsal joints are formed by the articulations between the distal tarsal and metatarsal bones. Enter the affected joint(s) to expose the articular surfaces (Plate 31A). and place orthopedic wire through the holes. fibula. fourth tarsal bone. cut the pin. Usually only three of the four metatarsal bones will be drilled. Hohmann retractors. predrill the holes for the figure-eight wire through the calcaneus and the metatarsal bones. wire twister. periosteal elevator. Drill transverse holes in the base of the calcaneus and the fourth tarsal bone (for calcaneoquartal arthrodesis). high-speed drill and burrs. INDICATIONS Candidates include animals with subluxation of the proximal intertarsal or tarsometatarsal joints caused by injury of the plantar tarsal fibrocartilage. Senn retractors. bone curette. wire cutter. formed by the articulation of the talus and central tarsal bone with a continuous joint capsule with the calcaneus.1 EXPECTED OUTCOME Bone healing is usually expected in 12 to 18 weeks. following the contours of the bone ends (see Plate 31A). 1997. Predrill the calcaneus and place a small IM pin starting at the tuber calcanei. orthopedic wire.1 CAUTIONS All articular cartilage should be removed. The proximal intertarsal joint is a combination of the talocalcaneocentral joint. or both Reference 1. with activity limited to leash walks until bone healing is complete. Pin migration may occur. . 3rd ed. PROCEDURE Approach: Incise the skin. located between the calcaneus and the fourth tarsal bone. intertarsal. padded bandage should be placed to control bleeding and swelling. and tarsometatarsal joints. Implants should be removed if the soft tissue is irritated. metatarsus and phalanges. and the base of the fifth metatarsal bone. Piermattei DL. The intertarsal joints are formed by articulations between the tarsal bones. deep to the superficial digital flexor tendon and crossing at the arthrodesis site (Plate 31B). EQUIPMENT • Surgical pack. and metatarsal bones forming the tarsocrural. A splint should be used for 6 weeks or until early radiographic evidence of bone bridging is observed. and the calcaneoquartal joint. and elevate the abductor digiti quinti muscle to expose the calcaneus. POSTOPERATIVE EVALUATION The axial alignment of the limb should be critically observed. Retract the IM pin 1 cm. Drape the limb out from a hanging position to allow maximal manipulation during surgery. Flo GL: Fractures and other orthopedic injuries of the tarsus. and Flo’s Handbook of Small Animal Orthopedics and Fracture Repair. Animals should have near-normal function of the treated limb. Harvest and place cancellous bone within the prepared joints before tightening the wire. Stabilization: Remove the articular cartilage from the calcaneoquartal joint. distal tarsal. Alignment: Fuse the proximal intertarsal or tarsometatarsal joints in a straight line. The tarsocrural joint is formed by the fibula and cochlea of the tibia proximally and the talus and calcaneus distally. through the calcaneus and the fourth tarsal bone (see Plate 31B).1 OBJECTIVES • To fuse the bones of the calcaneoquartal or tarsometatarsal joints in a functional position ANATOMIC CONSIDERATIONS The tarsus consists of the tibia. Alternatively. The animal should be confined. subcutaneous tissue.94 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES TA R S U S CHAPTER 31 Proximal Intertarsal or Tarsometatarsal Arthrodesis with an Intramedullary Pin and Wire (depending on the joints involved) with a bone curette or highspeed burr. Philadelphia. Drive the Steinmann pin distally into the base of the fourth metatarsal bone (Plate 31D). Jacob pin chuck. Tighten the figure-eight wire (Plate 31C). and countersink it into the tuber calcanei. and proximal tarsal. WB Saunders. Radiographs for limb alignment and implant placement should be evaluated. intramedullary (IM) pins. Gelpi retractors. Retract the superficial and deep digital flexor tendons medially. POSTOPERATIVE CARE A soft. In Brinker. and deep crural fascia over the lateral surface of the tarsometatarsal joint. pin cutter PREPARATION AND POSITIONING Prepare the rear limb circumferentially from hip to digits. Position the animal in lateral recumbency. the tarsometatarsal joint. CHAPTER 31 P R OX I M A L A RT H R O D E S I S W I T H A N I N T R A M E D U L L A RY P I N A N D W I R E 95 P L AT E 3 1 A Tendon of flexor hallucis longus muscle Tendon of gastrocnemius muscle Calcaneus B Peroneus longus Peroneus brevis Tendon of superficial flexor muscle Tendon of abductor digiti quinti muscle C D . 96 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES A M P U TAT I O N S CHAPTER 32 Mandibulectomy EQUIPMENT • Standard surgical pack. this should be identified and either ligated or controlled with bone wax and electrocautery. and in the treatment of open or infected mandibular fractures in which surgical repair is not an option because of economic restrictions. Anatomic landmarks for the procedure include the incisors. exposing the ventral and lateral aspects of the mandible (Plate 32A2). position the animal in lateral recumbency. position the animal in dorsal recumbency. Senn or Gelpi retractors. and cosmetic oral cavity ANATOMIC CONSIDERATIONS 2. osteotome. functional. osteomyelitis. remove the rostral mandible. palate. or severe bone and soft tissue loss. the canine teeth and the second and third premolars.5. electrocautery. For a rostral hemimandibulectomy. which are branches of the external and internal carotid arteries. gingiva.6 Sharply incise the buccal INDICATIONS 1–4 Mandibulectomy is indicated in the management of tumors involving the jaw. tongue teeth. Continued . or osteotome for osteotomy of the mandible PREPARATION AND POSITIONING Prepare mandible from the proximal neck to the chin and lateral aspect of the face and cheeks. Rostral hemimandibulectomy is indicated for tumors in the region of the lower canine tooth. Incise any remaining connective tissue. hemoclips.3. and a saw. or Gigli wire caudal to the canine teeth or first or second molars (Plate 32B). Locate the mandibular arteries within the intramedullary canal. For the rostral mandibulectomy. incisors. and the mandibular symphysis. a rostral mandibulectomy is indicated for bilateral disease conditions affecting the rostral mandible to the level of the second or third premolars. OBJECTIVES 5 • To remove the rostral mandible or rostral hemimandible and provide the animal with a disease-free. with the affected side up. major palatine.6 The oral cavity is a complex structure composed of lips. mucosa along the rostral aspect of the mandible (Plate 32A1). and ligate. and submit for histopathology and margin evaluation. periosteal elevator. bone wax or suture material for vascular ligation. use bone wax and electrocautery to staunch the hemorrhage. with the maxilla taped to the operating table to allow maximal exposure to the oral cavity during surgery. Specifically. The vascular supply to the mouth is provided by the lingual. or first premolar that have not crossed the symphysis based on clinical and radiographic evaluation. Elevate the subcutaneous tissue and connective tissue from the bone. If the arteries retract within the intramedullary canal and cannot be located. Reflect and retract the tissues caudally and laterally to the level of the osteotomy. and facial arteries. and salivary glands and ducts. Gigli wire. mandibular alveolar. PROCEDURE Rostral Mandibulectomy:1–3. Brisk hemorrhage from the mandibular artery may occur at the osteotomy site. Perform an osteotomy with an oscillating saw. Correct surgical positioning is imperative to provide optimum visualization of the oral cavity. CHAPTER 32 M A N D I B U L E C TO M Y 97 P L AT E 3 2 A1 A2 B Periosteal elevator Oscillating bone saw . oral pain. and submit for histopathology and margin evaluation. with owner acceptance of the cosmetic appearance and mandibular function reported as good to excellent.6 It may be necessary to modify the surgical incision to obtain adequate surgical margins. infection. Access to chew toys and rawhide bones should be restricted until the incision is healed. Postoperative antibiotics are recommended for the first 5 to 7 days.6 Sharply incise the buccal mucosa from the mandibular symphysis to the first or second premolar. local tumor recurrence. depending on the histopathologic type of the tumor. fine needle aspiration of the local lymph nodes. Locate the mandibular artery within the intramedullary canal. The patient should be fed moist food formed in individual meatballs to protect the surgical incision. 5. Schlutersche. Lantz G. Matthiesen D.98 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES Rostral Hemimandibulectomy:1–3.8. however. with presurgical incisional biopsy. the amount of bony involvement. References 1. 85% of owners were satisfied with the results from the surgery. skull. 1990. et al: Owner satisfaction with partial mandibulectomy or maxillectomy for treatment of oral tumors in 27 dogs. 2001. Matthiesen DT. Reflect and retract the tissues caudally and laterally to the level of the osteotomy (Plate 32C). 3. 1990. use bone wax and electrocautery to staunch the hemorrhage. tumor size. Elevate the subcutaneous tissue and connective tissue from the bone. intraoral.3. If the arteries retract within the intramedullary canal and cannot be located. abnormal salivation with secondary cheilitis and dermatitis. but pain was perceived to be reduced in most animals. J Am Anim Hosp Assoc 33(1):25–31. 1991. and distant metastatic disease.5. Salisbury S: Partial mandibulectomy for treatment of mandibular fractures in dogs: Eight cases (1981–1984). Manfra-Marretta S. Separate the mandibular symphysis with an osteotome. 9. Problems in Vet Med 2(1):248–275. Preoperative planning is crucial to ensure complete tumor excision. POSTOPERATIVE CARE Preemptive multimodal analgesia should be instituted in all patients for the first 48 to 72 hours. 8. the clinical stage of the disease. 4. exposing the ventral and lateral aspects of the mandible. J Am Vet Med Assoc 191(2):243–245. To decrease the incidence of postoperative infection. Geoghegan SL. Can Vet J 42(2): 143–144. remove the rostral hemimandible. 1987. Prognosis in dogs with oral neoplasia varies. ranulas and sialoceles from iatrogenic salivary duct trauma. CAUTIONS 1. Suture removal is not necessary. blood work. Hannover. White R: Mandibulectomy and maxillectomy in the dog: Long-term survival in 100 cases. Davis LH. presence of regional and distant metastases.5–7 The mandible and associated musculature should be submitted for histopathology and margin evaluation. The prognosis is excellent for dogs that undergo partial mandibulectomy for the treatment of mandibular fractures. Possible complications include incisional dehiscence. EXPECTED OUTCOME 1. J Small Anim Pract 32(2):69–72. Patients should be thoroughly staged and assessed (e. Owners should also be asked about any problems with prehension or cosmetic concerns. subcutaneous emphysema. . Taboada J (eds): Clinical Atlas of Ear. Nose and Throat Diseases in Small Animals: The CaseBased. or Gigli wire caudal to the canine tooth or first or second molar (Plate 32D). and perform an osteotomy with an oscillating saw. and thoracic radiographs.6. It may be necessary to remove redundant labial tissue to provide a more cosmetic closure and to prevent excessive drooling (Plates 32F and 32G). and ligate. 7. Marretta SM. et al: Results of partial mandibulectomy for the treatment of oral tumors in 142 dogs. Incise any remaining connective tissue. 1991. and electrocardiogram) prior to surgery. coagulation profile. 2002. Hoelzler M. mandibulectomy. Germany. osteotome. Schrader S. perioperative antibiotics are recommended. Patients should be evaluated every 3 months with a complete physical and oral examination. the oral cavity should be thoroughly examined at 10 to 14 days for postoperative complications. Problems in Vet Med 2(1):220–247. In Hedlund C. Matthiesen D: Problems associated with the management and treatment of jaw fractures. mandibular drift and instability. 1997. Holmberg D: Partial mandibulectomy as the treatment of a comminuted mandibular fracture in a dog. Manfra-Marretta S: Results and complications associated with partial mandibulectomy and mexillectomy techniques. Vet Surg 20(6):397–401.g. 6. taking care to avoid entrapment of the salivary ducts (Plate 32E). Forty-four percent noted a change in prehension and difficulty in eating. Fox LE. and the location of the tumor within the oral cavity. White R: The oral cavity. POSTOPERATIVE EVALUATION 1. 1991. and cosmesis was acceptable in all 27 cases. Thoracic radiographs are recommended every 3 months in animals with malignant tumors to evaluate for distant metastasis for the first year. Problems in Vet Med 3(2):153–169. 2.3.9 In a study evaluating owner satisfaction with partial mandibulectomy or maxillectomy for the treatment of oral tumors. Salisbury S: Problems and complications associated with maxillectomy.. Closure: Replace the lip over the exposed hemimandible(s) and appose the gingiva and sublingual mucosa with simple continuous or interrupted absorbable suture. Kosovsky JK. and oronasal fistula repair. CHAPTER 32 M A N D I B U L E C TO M Y 99 P L AT E 3 2 C D E F Redundant labial tissue to be removed Labial tissue excised G Redundant labial tissue to be removed . 2. respiratory rate. J Am Anim Hosp Assoc 24:5. hemoclips or ample suture material for vascular ligation. paralysis caused by brachial plexus avulsion. osteomyelitis. Sever the latissimus dorsi muscle close to its insertion on the humerus (Plate 33C). Sever the omotransversarius and trapezius muscles along the cranial and dorsal edge of the spine of the scapula. POSTOPERATIVE EVALUATION If indicated. following the scapular spine. Hemodynamically unstable patients should be treated prior to surgery to ensure an uneventful recovery. Inject each nerve prior to transection with 0. EXPECTED OUTCOME 1. severe trauma with vascular compromise and limb necrosis. Closure: Inverting the muscle bellies. and blood work). Aberman HM: Forelimb amputation in the dog using humeral osteotomy. Transfix. and sever the insertion of the scalenus. 1974. Hubbell JAE: Handbook of Veterinary Anesthesia.4 mL bupivacaine until a bleb forms under the epineurium proximal to the cut (Plate 33E). PROCEDURE Amputation:1. electrocautery. Mosby. Common parameters to evaluate in the postoperative amputee are heart rate. omotransversarius. 4.100 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES A M P U TAT I O N S CHAPTER 33 Forelimb Amputation with Scapulectomy 33F). Baltimore. serial packed cell volume. CAUTIONS Patients should be thoroughly assessed before surgery is initiated (e. 1998. and trapezius muscles to the pectoral muscle (Plate 33G). 3. Ligate and sever the axillary vein. central venous pressure. In Bojrab MJ (ed): Current Techniques in Small Animal Surgery. place interrupted Lembert sutures. but they are thought to produce less aesthetically pleasing results in short-haired animals because of the scapular spine and acromial prominence.5 to 2. INDICATIONS 1 Forelimb amputation is a salvage procedure indicated for the treatment of neoplasia. with 0 to 2-0 absorbable suture material. 4th ed. Disarticulate the limb by transecting the pectoral muscles and ligating and dividing the lateral thoracic vessels. Sutures should be removed in 10 to 14 days. with the affected limb up. OBJECTIVES • To remove the limb and preserve the animal’s quality of life ANATOMIC CONSIDERATIONS 2 Forelimb amputation is most commonly performed by removing the limb at the scapula. body temperature. ligate. Harvey CE: Forequarter amputation in the dog and cat. and congenital limb deformities. Block and sever the supraspinatus and brachial plexus nerves. and ligate the axillobrachial and omobrachial veins proximal to the greater tubercle of the humerus (Plate 33B). Appose the skin edges with interdermal or skin sutures (Plate 33H). 1 to 2 mL of 0. Most animals adapt very well to forelimb amputation but will have a noticeable gait deficit on ambulation. Ligate the cephalic vein distal to the cleidobrachialis muscle. nonunion fractures. Eliminate the dead space with 2-0 to 3-0 absorbable sutures in an interrupted cruciate or simple interrupted pattern in the subcutaneous tissue.4 Incise the skin and subcutaneous tissue in a reverse Y incision from the vertebral border of the scapula to the acromial process.g. More distal procedures have been described. 25-gauge needle. electrocardiogram.. in the lateral fascial sheaths of the latissimus dorsi. St. Muir WW. 1989. Reflect the skin. not exceeding 1. and activated clotting times. Whole blood and plasma products should be on hand in the event that major hemorrhage occurs. Louis. 525–529. serum glucose. . and around the forelimb medially (Plate 33A). Anatomic landmarks for the procedure include the scapula and associated musculature. J Am Anim Hosp Assoc 10(1):25–28. sterile syringe. for brachial plexus injection3 PREPARATION AND POSITIONING Prepare the forelimb circumferentially from dorsal midline to carpus. capillary refill time.0 mg/kg of body weight in the dog and 1 mg/kg of body weight in the cat.2 to 0. rhomboideus. 1988. 2. Bone DL. Preemptive multimodal analgesia should be instituted in all patients for the first 48 to 72 hours.4 The outcome for return to function and quality of life is good to excellent. pulse oximetry.5% bupivacaine. EQUIPMENT • Standard surgical pack. Using electrocautery for all the muscle incisions. thoracic radiographs. Daly WR: Amputation of the forelimb. and serratus ventralis muscles (Plate 33D). the entire limb should be submitted for histopathology. Rotate the cranial edge of the scapula laterally. Drape the limb out from a hanging position to allow maximal manipulation during surgery. transect the brachiocephalicus muscle through the clavicular tendon. Williams & Wilkins. pulse quality. with electrocardiogram. total protein. and sever the axillary artery (Plate References 1. POSTOPERATIVE CARE Postoperative bandaging of the wound for 2 to 3 days may be desirable to prevent seroma formation. Position the animal in lateral recumbency. CHAPTER 33 F O R E L I M B A M P U TAT I O N W I T H S C A P U L E C T O M Y 101 P L AT E 3 3 A B Spine of scapula C Trapezius muscle Latissimus dorsi muscle Omotransversarius muscle Omobrachial vein Axillobrachial vein Cephalic vein Brachiocephalicus muscle Deltoideus muscle Long head of triceps muscle Lateral head of triceps muscle D Rhomboideus muscle Serratus ventralis muscle E Scalenus muscle C6 C7 C8 T1 Scalenus muscle F G Trapezius muscle Axillary artery Axillary vein First rib Deep pectoral muscle Lateral thoracic artery. vein. and nerve Latissimus dorsi muscle Transfixion suture Omotransversarius muscle Pectoral muscle H . 2 Partial and total scapulectomy are limb-sparing procedures most commonly used in the treatment of neoplasia of the proximal scapula or in select cases of degenerative joint disease and pain in the shoulder that are not responsive to conservative management and in which arthrodesis is not an option. and subscapularis muscles close to their insertions on the humerus (Plate 34C).e. or when more than 90% of the scapula is involved. PROCEDURE Complete Scapulectomy:1 Incise the skin and subcuta- INDICATIONS 1. neck. supraglenoid process. Position the animal in lateral recumbency with the neous tissue from the dorsal border of the scapula to the proximal third of the humerus. omotransversarius.and subscapular nerves coming from the brachioplexus bundle. hemoclips or ample suture material for vascular ligation. Hemorrhage may be controlled with ligatures. connecting the two incisions at the apices (Plate 34A). rhomboideus.5% bupivacaine..4 mL bupivacaine until a bleb forms under the epineurium proximal to the cut. and inject each nerve prior to transection with 0. 25-gauge needle. infraspinatus. Complete scapulectomy is indicated for tumors involving the distal part of the scapula. reflect the skin and subcutaneous tissue to expose the superficial muscles of the trapezius. preserving the attachment of the biceps tendon (see Plate 34D1). Perform an osteotomy of the supraglenoid tubercle. taking care to preserve the brachial plexus and axillary artery and vein (Plate 34B2). Retract the scapula laterally. and subscapularis) may now be removed and submitted for histopathology and margin evaluation. and/or Gelpi retractors. electrocautery. Senn.5 to 2. following the dorsal border of the scapula. in the cases of cancer. Sharply incise the joint capsule of the shoulder. Identify the supra. incise these muscles close to their origins on the scapula. EQUIPMENT • Standard surgical pack. Anatomic landmarks for the procedure include the scapular spine. Without disturbing the pseudocapsule of the tumor. supraspinatus. not exceeding 1. and transect the teres major muscle and the long head of the triceps from their insertions from the caudal aspect of the scapula using electrocautery (Plate 34D1). and elevate the serratus ventralis muscle from the medial aspect of the scapula. for brachial plexus injection3 PREPARATION AND POSITIONING Prepare the forelimb circumferentially from dorsal midline to carpus. OBJECTIVES • To preserve limb function and. a saw or osteotome for osteotomy of the scapula. and associated musculature. Continued . sterile syringe. Army-Navy. acromial process. The scapula and associated musculature (i.102 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES A M P U TAT I O N S CHAPTER 34 Forelimb Salvage via Partial and Complete Scapulectomy affected limb up. Using electrocautery. and deltoideus (Plate 34B1). Drape the limb out from a hanging position to allow maximal manipulation during surgery.0 mg/kg of body weight in the dog and 1 mg/kg of body weight in the cat. and electrocautery. 1 to 2 mL of 0. hemoclips.2 to 0. Transect the tendons of the coracobrachialis. infraspinatus. to allow for local tumor control ANATOMIC CONSIDERATIONS 1 Partial scapulectomy is most commonly performed by removing the proximal scapula while preserving the scapulohumeral joint. without disturbing the tumor. glenoid cavity. supraspinatus. Incise along the caudal aspect of the scapula. teres minor. CHAPTER 34 F O R E L I M B S A LVA G E V I A PA RT I A L A N D C O M P L E T E S C A P U L E C T O M Y 103 P L AT E 3 4 Omotransversarius muscle Trapezius muscle Omotransversarius muscle Trapezius muscle A Latissimus dorsi muscle Skin incision Long head of triceps muscle Lateral head of triceps muscle Deltoideus muscle B1 Tumor Deltoideus muscle C B2 Serratus ventralis muscle (elevated) Biceps tendon Infraspinatus muscle (cut) Teres minor muscle (cut) Long head of triceps muscle (cut) Infraspinatus muscle Teres minor muscle Supraspinatus muscle D1 Teres major muscle Long head of triceps muscle Lateral head of triceps muscle . J Am Vet Med Assoc 207(5):585–587. The subcutaneous tissue and skin closure is routine..104 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES Closure: Secure the biceps tendon and supraglenoid tubercle to the caudal aspect of the joint capsule using nonabsorbable monofilament suture in a horizontal mattress pattern. The sutures should be removed in 10 to 14 days. deltoideus. The subcutaneous tissue and skin closure are routine. POSTOPERATIVE EVALUATION The scapula and associated musculature should be submitted for histopathology and margin evaluation. POSTOPERATIVE CARE Postoperative bandaging of the wound for 3 to 5 days may be desirable to prevent seroma formation. Preoperative planning is crucial to ensure complete tumor excision. Trout N. . and rhomboideus to the distal scapula via holes drilled into the body using nonabsorbable suture in a simple interrupted or horizontal mattress pattern. Pavletic M. 1994. Kirpensteijn J. 3. Reattach the triceps muscle to the deltoideus.g. Straw RC. J Am Anim Hosp Assoc 30(4):313–319. blood work. Partial Scapulectomy:1 A partial scapulectomy is performed in a manner similar to a complete scapulectomy. Dogs that undergo partial scapulectomy are reported to have better function than dogs with total scapulectomy. Rehabilitation and range-of-motion exercises should be instituted early to prevent joint contraction and loss of function. serratus ventralis. depending on the level and size of the tumor. Alternatively. 1995. infraspinatus. and only the proximal portion of the scapula is removed (Plate 34D2). Muir WW. with the exception that the scapulohumeral joint is left intact. coagulation profile. Hubbell JAE: Handbook of Veterinary Anesthesia. close the remaining musculature without bone tunnels by suturing transected muscles of the supraspinatus. and the long head of the triceps to the serratus ventralis. et al: Partial and total scapulectomy in the dog. Attach the transected muscles of the trapezius. Kraus K: Partial scapulectomy for management of sarcomas in three dogs and two cats. References 1. Preemptive multimodal analgesia should be instituted in all patients for the first 48 to 72 hours. and the osteotomy is at the level of or proximal to the scapular neck. presurgical fine needle aspiration or biopsy. omotransversarius. EXPECTED OUTCOME 1 Postoperative use of the limb is usually fair to excellent. Patients should be thoroughly staged and assessed before this limb salvage procedure surgery is initiated (e. with thoracic and abdominal radiographs. Secure the remaining trapezius to the underlying serratus ventralis muscle to further eliminate dead space. For the first year the patient should be checked every 3 months with a physical examination and thoracic radiographs to evaluate for local recurrence of disease. St. and trapezius muscles with an interrupted Lembert or horizontal mattress suture pattern and nonabsorbable suture. CAUTIONS It may be necessary to modify the surgical incision to obtain adequate surgical margins. omotransversarius. Pardo AD. omotransversarius. 1989. 2. and electrocardiogram). Mosby. The osteotomy site will vary. and trapezius muscles. Louis. 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 . using a curved incision on the lateral aspect of the leg that begins at the flank fold and extends caudodistally to the distal third of the femur.3 Expectations for a return to function and quality of life are good to excellent. transect the rectus femoris muscle close to its origin on the EXPECTED OUTCOME 2. Position the animal in lateral recumbency. transect the gluteal muscles at their insertions at the greater and third trochanters (Plate 35C). Muir WW. and retract it cranially to fully expose the coxofemoral joint capsule. Retract the skin and subcutaneous tissue to expose the muscle bellies of the biceps femoris and the tensor fascia latae. POSTOPERATIVE CARE Preemptive multimodal analgesia should be instituted in all patients for the first 48 to 72 hours. capillary refill time. electrocautery. Van Den Bos R. Transect the external rotator and quadratus femoris muscles at their insertions in the trochanteric fossa. OBJECTIVES • To remove the limb and preserve the animal’s quality of life ANATOMIC CONSIDERATIONS Rear limb amputation may be performed via two methods: (1) by removing the limb at the midshaft femur. the entire limb should be submitted for histopathology. 3.5 to 2. Using electrocautery in the coagulation mode. serial packed cell volume. ligate.2 to 0. 2003. or (2) by removal at the coxofemoral joint. central venous pressure. 1999. Kirpensteijn J. Hubbell JAE: Handbook of Veterinary Anesthesia. the coxofemoral joint. Reflect the muscle bellies proximally to expose the sciatic nerve. PREPARATION AND POSITIONING Prepare the rear limb circumferentially from dorsal midline to tarsus. and associated musculature. 1 to 2 mL of 0. but they will have a noticeable gait deficit on ambulation. Coxofemoral disarticulation should be performed in dogs with neoplastic conditions affecting the femur to ensure adequate surgical margins. osteomyelitis. 1989. the cranial belly of the sartorius. Drape the limb out from a hanging position to allow maximal manipulation during surgery. 2. Working cranially. not exceeding 1. Sutures can be removed in 10 to 14 days. Eliminate the dead space with 2-0 to 3-0 absorbable sutures in an interrupted cruciate or simple interrupted pattern in the subcutaneous tissue. and reflect proximally (see Plate 35C). On the medial aspect of the leg. Endicott M: Principles of treatment for osteosarcoma. nonunion fractures. pulse quality. Block and sever the sciatic nerve. Appose the skin edges with interdermal or skin sutures (see Plate 35G). . Transect the iliopsoas muscle at its insertion on the lesser trochanter. hemoclips. Endenburg N: Adaptation of dogs to the amputation of a limb and their owners’ satisfaction with the procedure. and the entire limb should be submitted for histopathology to confirm tumor-free margins and tumor identification. electrocardiogram. and congenital limb deformities. Using electrocautery. total protein. Elizabethan collars should be employed in animals that lick or chew at the incision. respiratory rate. Activity should be restricted for 2 weeks until sutures are removed.106 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES A M P U TAT I O N S CHAPTER 35 Rear Limb Amputation via Coxofemoral Disarticulation ilium. for brachial plexus injection POSTOPERATIVE EVALUATION If indicated. and about one dog in three has a noticeable change in behavior. INDICATIONS Rear limb amputation is a salvage procedure indicated for the treatment of neoplasia. and activated clotting times. until the animal adjusts to its new center of balance. connecting at either end. Vet Rec 144(5):115–118. Common parameters to evaluate in the postoperative amputee are heart rate. but these produce a nonfunctional limb that may actually inhibit ambulation and that is aesthetically less pleasing. and sever the femoral nerve. isolate. body temperature. pulse oximetry. Clin Tech Small Anim Pract 18(2):110–114. 25-gauge needle. Mosby. Senn. with the affected limb up. sterile syringe. suture the lateral fascial sheaths of the muscle bellies in an interrupted Lembert pattern with 0 to 2-0 monofilament absorbable suture (Plate 35G). Make a similar incision on the medial aspect of the leg.4 mL bupivacaine until a bleb forms under the epineurium proximal to the cut. Transect the semitendinosus and semimembranosus at the level of the proximal femur. paralysis caused by sciatic or femoral nerve damage. More distal procedures have been described. Louis. Closure: Inverting the muscle bellies. Army-Navy. and divide the femoral artery and vein in the femoral triangle via placement of a circumferential and transfixation suture proximally and a hemostat or circumferential suture distad (Plate 35D). the gracilis. block. St. Most animals adapt well to hind limb amputation. EQUIPMENT 1 • Standard surgical pack. Anatomic landmarks for the procedure include the femur. Identify. Transect the pectineus. References 1. Incise the joint capsule and sever the round ligament to remove the limb (Plate 35F). serum glucose. and the adductor muscles at the level of the midshaft femur (Plate 35E). PROCEDURE Coxofemoral Disarticulation: Incise the skin and subcutaneous tissue. severe trauma with vascular compromise and limb necrosis. or ample suture material for vascular ligation.5% bupivacaine. transect these muscle belly groups at the level of midshaft femur (Plate 35B). and/or Gelpi retractors. and then caudodorsally to the tuber ischii (Plate 35A). injecting it prior to transection with 0. CAUTIONS Preoperative planning will ensure adequate soft tissue coverage and tension-free closure of the surgical wound.0 mg/kg of body weight in the dog and 1 mg/kg of body weight in the cat. It may be necessary to assist ambulation with slings or carts in some cases. CHAPTER 35 R E A R L I M B A M P U TAT I O N V I A C OX O F E M O R A L D I S A RT I C U L AT I O N 107 P L AT E 3 5 Lateral View A B Deep Middle Superficial gluteal muscle gluteal muscle gluteal muscle Biceps femoris muscle C Skin incision Adductor muscle Gracilis muscle Semimembranosus muscle Semitendinosus muscle Tensor fascia latae muscle Vastus lateralis muscle Sciatic nerve Vastus lateralis muscle Medial View D Pectineus muscle Femoral artery and vein E Pectineus muscle Iliopsoas muscle Adductor muscle Gracilis muscle Transfixion suture Sartorius muscle Gracilis muscle Adductor muscle Sartorius muscle F Medial View Ligament of the long head of the femur Joint capsule Iliopsoas muscle G Adductor muscle Quadriceps Gracilis muscle Semimembranosus muscle Rectus femoris muscle Semitendinosus muscle Sartorius muscle Biceps femoris muscle Lateral View Incision in joint capsule . but these produce a nonfunctional limb that may actually inhibit ambulation and that is aesthetically less pleasing. 1989. hemoclips. PROCEDURE Midshaft Femoral Amputation:1 Incise the skin and subcutaneous tissue.0 mg/kg of body weight in the dog and 1 mg/kg of body weight in the cat. Mosby. The level of the osteotomy is located within the proximal third of the femoral shaft to ensure appropriate soft tissue coverage. the coxofemoral joint. Louis. 2. severe trauma with vascular compromise and limb necrosis. total protein. References 1. sterile syringe. not exceeding 1. and associated musculature. until the animal adjusts to its new center of balance. and a hemostat or circumferential suture distad (Plate 36E). About one dog in three has a noticeable change in behavior. Hubbell JAE: Handbook of Veterinary Anesthesia. Preemptive multimodal analgesia should be instituted in all patients for the first 48 to 72 hours. Identify. Identify. Kirpensteijn J.108 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES A M P U TAT I O N S CHAPTER 36 INDICATIONS Midshaft Femur Amputation suture proximally. . or (2) removing it at the coxofemoral joint. for local nerve blockade POSTOPERATIVE EVALUATION If indicated. and divide the femoral artery and vein via placement of a circumferential and transfixation EXPECTED OUTCOME 2. semimembranosus. Elevate any remaining tissue or muscle from the proximal femur at the osteotomy site. the semitendinosus. Common parameters to evaluate in the postoperative amputee are heart rate. central venous pressure. block. Position the animal in lateral recumbency. OBJECTIVES • To remove the limb and preserve the animal’s quality of life ANATOMIC CONSIDERATIONS Rear limb amputation may be performed via two methods: (1) removing the limb at the midshaft femur. Van Den Bos R. EQUIPMENT 1 • Standard surgical pack. using a curved incision on the lateral aspect of the leg that begins at the flank fold and extends caudodistally to the distal third of the femur and then caudodorsally to the tuber ischii (Plate 36A). or ample suture material for vascular ligation. Clin Tech Small Anim Pract 18(2):110–114. the entire limb should be submitted for histopathology. ligate. 25-gauge needle. 1999. capillary refill time. electrocardiogram. Suture the transected biceps femoris to the gracilis. and the semimembranosus muscles. injecting it prior to transection with 0. Senn. Most animals adapt well to hind limb amputation. 1 to 2 mL of 0. use electrocautery to transect the semitendinosus. CAUTIONS Preoperative planning is imperative to ensure adequate soft tissue coverage and tension-free closure of the surgical wound. suture the lateral fascial sheaths of the muscle bellies in an interrupted Lembert pattern with 0 to 2-0 monofilament absorbable suture. respiratory rate. osteomyelitis. Eliminate the dead space with 2-0 to 3-0 absorbable sutures in an interrupted cruciate or simple interrupted pattern in the subcutaneous tissue. 3. and/or Gelpi retractors. and activated clotting times. and sever the sciatic nerve. Endicott M: Principles of treatment for osteosarcoma. connecting at either end.5 to 2. pulse quality. pulse oximetry. Activity should be restricted for 2 weeks until suture removal. serum glucose. transect the gracilis and the caudal belly of the sartorius muscles at the level of the midshaft femur (Plate 36D). Midshaft femoral amputation is easier to perform than is a coxofemoral disarticulation. Isolate. Transect the remaining pectineus muscle and the cranial belly of the sartorius muscle to fully isolate the femoral diaphysis. and the quadriceps (Plate 36B1). Closure: Inverting the muscle bellies. Vet Rec 144(5):115–118. Sutures should be removed in 10 to 14 days. and adductor muscles (Plate 36C). Using electrocautery in the coagulation mode. the tensor fascia latae. paralysis caused by sciatic or femoral nerve damage. 2003. body temperature. nonunion fractures. Elizabethan collars should be employed in animals that lick or chew at the incision. Drape the limb out from a hanging position to allow maximal manipulation during surgery. Muir WW. Retract the skin and subcutaneous tissue to expose the muscle bellies of the biceps femoris. On the medial aspect of the leg. Army-Navy. electrocautery. It may be necessary to assist ambulation with slings or carts. transect these muscle belly groups at the level of the distal third of the femur (Plate 36B2).5% bupivacaine. and cut the femur using a saw or Gigli wire to remove the limb (Plate 36F). serial packed cell volume. POSTOPERATIVE CARE PREPARATION AND POSITIONING Prepare the rear limb circumferentially from dorsal midline to tarsus. Anatomic landmarks for the procedure include the femur. a Gigli wire or saw for midshaft femoral amputation. Appose the skin edges with interdermal or skin sutures. Cover the femoral shaft by suturing the transected muscle bellies of the quadriceps to the adductor. Rear limb amputation is a salvage procedure indicated for the treatment of neoplasia. and therefore it is the method preferred by most veterinarians. Make a similar incision on the medial aspect of the leg. block. St. At the same level. Endenburg N: Adaptation of dogs to the amputation of a limb and their owners’ satisfaction with the procedure. with the affected limb up. More distal procedures have been described. although they will have a noticeable gait deficit on ambulation. and sever the femoral nerve.2 to 0.4 mL bupivacaine until a bleb forms under the epineurium proximal to the cut. and congenital limb deformities.3 The outcome for return to function and quality of life should be good to excellent. CHAPTER 36 M I D S H A F T F E M U R A M P U TAT I O N 109 P L AT E 3 6 Lateral View B1 A Quadriceps group Skin incision Semitendinosus muscle Biceps femoris muscle B2 C Semitendinosus muscle Adductor muscle Semimembranosus muscle Adductor muscle Semimembranosus muscle Quadriceps group Gracilis muscle Semitendinosus muscle Biceps femoris muscle Medial View Adductor muscle Sartorius muscle (caudal part) Femoral vessels Pectineus muscle Osteotomy site D E F Gracilis muscle Sartorius muscle (cranial part) Transfixion suture Sartorius muscle (cranial part) . amputation of the dewclaw is more complicated and requires general anesthesia. 1998. 5. Bevel the angle of the osteotomy to ensure adequate soft tissue coverage of the protruding bone (Plate 37A2). Disarticulate the phalanges at the metacarpophalangeal joint. Amputation of Digit 1: Incise the skin and subcutaneous tissue from the midshaft metatarsus around the medial or lateral digit (Plate 37B1). New York. EXPECTED OUTCOME 4. and electrocardiogram). Disarticulate the phalanges at the metacarpophalangeal joint.. and as a preventative measure to avoid future injury. The prognosis in dogs with digital neoplasia varies depending on the histopathologic type of the tumor. 1994. Amputation of both digits 3 and 4 may result in lameness. Preoperative planning is crucial to ensure complete tumor excision. 6. Berg J. 4. Moroff SD: Evaluation of dogs with digit masses: 117 cases (1981–1991). Engler S: Treatment by digital amputation of subungual squamous cell carcinoma in dogs. remove the digit and suture the wound closed with a simple interrupted or cruciate suture and monofilament absorbable suture (optional) (Plate 37C2). Swaim S: Management and bandaging of soft tissue injuries of dog and cat feet. CAUTIONS 4 The surgical incision may need to be modified in order to obtain adequate surgical margins in the cases of neoplasia. J Am Vet Med Assoc 207(6):726–728. Stefanacci JD.6 The level of amputation depends on the disease. Howell House Book. 1998. the digit should be submitted for histopathology and culture and sensitivity. coagulation profile. Activity should be restricted for 2 weeks. The remaining closure is routine (Plate 37B3). In The Complete Dog Book. Each digit is composed of three phalangeal bones. PREPARATION AND POSITIONING Clip and prepare the affected paw from the carpus or tarsus distally. pad preservation is important in ensuring pain-free ambulation. Anatomic landmarks for the procedure include the phalanges of digits 1 through 5 and associated tendons and musculature. and the clinical stage of the disease. Sutures should be removed in 10 to 14 days. 3.110 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES A M P U TAT I O N S CHAPTER 37 INDICATIONS 1–3 Digital Amputation of the appendage’s attachment to the paw (Plate 37C1). Elizabethan collars should be employed until the wound is healed in animals that lick or chew at the bandage or incision. Dewclaws should not be removed in working breeds such as the Briard or Great Pyrenees. Digital amputation is indicated for the treatment of neoplasia. Drape the limb out from a hanging position to allow maximal manipulation during surgery. and severe toe deformities that result in lameness or pain. Dewclaws in puppies less than 1 week of age may be amputated with minimal instrumentation. Once the digits develop. and identify and ligate or cauterize any persistent bleeding vessels (Plate 37B2). and therefore should be avoided if possible. Compend Contin Educ Pract Vet 16(9):1159–1176. padded bandage. Marino DJ. blood work. neither bandaging nor suture removal is necessary. . Appose the subcutaneous tissue and fascia in a simple interrupted pattern with monofilament absorbable suture. however. J Am Vet Med Assoc 201(5):759–761. Using the electrocautery and suture. 1985. osteomyelitis. In The Complete Dog Book. Matthiesen DT. nonunion fractures. Usually. American Kennel Club Staff: Great Pyrenees. tourniquet to control hemorrhage (optional) The foot should be protected with a soft. 1992. Appose the subcutaneous tissue and fascia in a simple interrupted pattern with monofilament absorbable suture. presurgical fine needle aspiration or biopsy. Basher A: Foot injuries in dogs and cats. identify and ligate any persistent bleeding vessels.g. until suture removal. or create an osteotomy of the proximal phalanx with bone-cutting forceps. the presence of regional and distant metastasis. Dewclaw Amputation in a Neonate: Crush the tissue of the dewclaw using straight or curved hemostatic forceps at the level References 1. electrocautery. American Kennel Club Staff: Briard. Dewclaw removal is indicated for cosmesis. Using a scalpel blade. OBJECTIVES • To remove a digit and preserve the foot function and normal weightbearing capacity ANATOMIC CONSIDERATIONS The primary weight-bearing digits of the paw are the third and fourth digits. Place a tourniquet on the limb below the elbow or above the tarsus (optional). in which double dewclaws on each hindfoot are a breed standard and requirement. J Am Anim Hosp Assoc 21(3):329–340. with thoracic radiographs. Up to two non–weight-bearing digits may be completely amputated without affecting limb function. bone cutters for proximal phalangeal amputation. New York. Patients should be thoroughly staged and assessed before this limb salvage procedure surgery is initiated (e. or digital pressure. 2. Evidence of bone lysis is present in 83% of cases of malignant tumors and in 17% of the benign or pyogranulomatous masses. The remaining closure is routine (Plate 37A3). PROCEDURE Digital Amputation of Digits 3 and 4: Incise the skin and subcutaneous tissue in a reverse Y incision beginning at the midmetacarpus of the affected digit. O’Brien M. severe trauma. scissors. POSTOPERATIVE EVALUATION If indicated. Howell House Book. Position the animal in lateral recumbency with the affected limb up. POSTOPERATIVE CARE 5 EQUIPMENT • Standard surgical pack. excising the digital pad (Plate 37A1). CHAPTER 37 D I G I TA L A M P U TAT I O N 111 P L AT E 3 7 Adult Middle Digit Amputation A1 A2 A3 Skin incision 2 3 4 5 Bone incision Proximal phalanx Middle phalanx Distal phalanx Juvenile/Puppy Dewclaw Amputation C1 C2 Adult Digit 1 Amputation B1 B2 B3 Metacarpophalangeal joint Proximal (first) phalanx Distal phalanx 2 3 4 5 . 2. POSTOPERATIVE EVALUATION Radiographs should be evaluated for bone alignment and implant placement. Rotational alignment is correct if the paw aligns with the radius or tibia when the elbow and carpus or stifle and hock are flexed. INDICATIONS Candidates include animals with either angular or rotational deformity of the radius and ulna1 or tibia and fibula. 2nd ed. low-speed power drill.112 PA RT O N E • SURGICAL PROCEDURES FOR JOINT DISEASES A D D I T I O N A L C O R R E C T I V E O S T E OTO M I E S CHAPTER 38 Oblique Osteotomy Stabilized with a Type II External Fixator surfaces are parallel (Plate 38C). to limit postoperative swelling. Hulse DA: Management of specific fractures: Radial and ulnar growth deformities. The degree of angulation approximates the degree of rotation. prepare the affected rear limb circumferentially from midline to foot. Senn retractors. just cranial to the ulna. 3. Function may be compromised while the external fixator is in place.3 Reduction: Lower the table to allow the animal’s weight to align the bone. . Cranial caudal joint surface relationships should mimic the contralateral intact bone. The osteotomy should be planned at the site of greatest curvature visible on the radiographic view that shows the most deformity (usually the cranial caudal view) and parallel to the joint surface closest to the deformed area (usually the distal joint surface) (Plate 38A). EQUIPMENT • Surgical pack. The joint surfaces should be parallel. Use the distal transfixation pin to manipulate the distal bone segment to align the joint surfaces and derotate the bone. bone curette for harvesting graft POSTOPERATIVE CARE Gauze sponges should be packed around the pins. Prepare the ipsilateral proximal humerus as a cancellous bone graft donor site for either osteotomy. which also incorporates the paw. Good correction of medial lateral angular deformities can be achieved with this technique. start the pin on the lateral surface of the proximal radius or radial head. The animal should be confined. the sponges should be secured with a bandage. For the tibia. Vet Surg 18:373. Angular and rotational alignment should be monitored during the reduction. Ehrhart N. or one connecting bar of the type II fixator. It is important to avoid major nerves and vessels and joint surfaces when placing the fixation pins. Position the animal in dorsal recumbency. For the radius. however. pin cutter. Drape the limb out in the hanging position. the external fixator should be manipulated by loosening the clamps distal to the osteotomy and realigning the fixation pins on the connecting bar to correct the deformity (Plate 38D). Louis. Hulse DA. If angular deformity persists.1 PROCEDURE Approach: Position a transfixation pin parallel to the proximal joint surface in the dorsal plane of the proximal portion of the bone. and a cranial caudal view of the proximal joint should be visible in the same radiograph as a cranial caudal view of the distal joint. Jacob pin chuck. Radiographs should be repeated at 6-week intervals to evaluate healing. PREPARATION AND POSITIONING For the radius. Position a transfixation pin parallel to the distal joint surface in the dorsal plane of the distal portion of the bone. prepare the forelimb circumferentially from above the shoulder to the phalanges. and suspend the affected limb from the ceiling. Drape the limb out in the hanging position. St. Johnson AL: Realignment of the radius in canine antebrachial growth deformities treated with corrective osteotomy and bilateral (Type II) external fixation. Medial and lateral angular alignment is correct when the proximal and distal joint References 1. 2000. OBJECTIVES • To realign joint surfaces. Intraoperative radiographs are useful to verify proximal and distal pin placement and joint alignment during reduction and stabilization. Johnson AL. and suspend the affected limb from the ceiling. The external fixator should be removed when the osteotomy has healed. the degree of angulation of the metacarpal or metatarsal bones in relation to the radius and ulna or in relation to the tibia can be measured. Quinn M. and preserve length of the affected bone CAUTIONS ANATOMIC CONSIDERATIONS A physical examination is needed to estimate the degree of rotation. External fixator management includes daily pin care and pin packing as needed. Stabilization: Stabilize the bone by adding medial and lateral connecting bars and additional fixation pins to create a type II external fixation frame3 (see Plate 38C). 1989. oscillating saw. EXPECTED OUTCOME In most dogs. 2002. Mosby. Make an oblique osteotomy of the radius or tibia at the area of greatest curvature (Plate 38B). external fixation equipment. Johnson SG. when early bone bridging is observed. bone healing is seen in 6 to 12 weeks. et al: Corrective osteotomy for pes varus in the dachshund. In Fossum TW (ed): Small Animal Surgery. reestablish rotational alignment. Position the animal in dorsal recumbency. The fixator may be destabilized by removing selected fixation pins. By flexing the carpus and the elbow or the hock and stifle of the affected limb. Make a transverse osteotomy of the ulna or fibula at the same level as the radial or tibial osteotomy. minimal correction is anticipated for cranial caudal bowing or restoration of large length discrepancies. Vangundy TE. The osteotomy should parallel the distal joint surface in both the dorsal and transverse planes. For the radius. small Hohmann retractors.2 with minimal length discrepancy when compared with the contralateral limb. with activity limited to leash walking. Landmarks for the pin placement and the vital structures to avoid vary with the affected bone. periosteal elevator. start the pin on the lateral surface of the distal radius. Vet Surg 29:558. CHAPTER 38 O B L I Q U E O S T E O T O M Y S TA B I L I Z E D W I T H A T Y P E I I E X T E R N A L F I X AT O R 113 P L AT E 3 8 A B Craniocaudal view Lateral view C D . Radiographs should be repeated at 6-week intervals to evaluate healing. Kirschner wires. EXPECTED OUTCOME In most dogs. The rotation for the radius or tibia from a physical examination by flexing the carpus and the elbow or the hock and stifle of the affected limb. The degree of angulation of the metacarpal or metatarsal bones should be measured in relation to the radius and ulna or in relation to the tibia. and vital structures to avoid.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 CHAPTER 39 Transverse Derotational Osteotomy Stabilized with a Plate Kirschner wire perpendicular to the bone in the transverse plane of the distal joint (Plate 39A). Position a Reference 1. bone curette for harvesting graft PREPARATION AND POSITIONING Prepare the affected limb circumferentially from midline to foot. high-speed drill. Johnson AL: Osteotomies. Make the transverse osteotomy at the major region of rotation (Plate 39B). selfcentering plate-holding forceps. . The plate should function as a compression plate. with activity limited to leash walking. Myerding or Hohmann retractors. EQUIPMENT • Surgical pack. If a cancellous bone graft harvest is anticipated. bone healing is seen in 12 to 18 weeks. St. 1995. CAUTIONS Rotational alignment and reduction should be maintained during implant application. PROCEDURE Approach: Position a Kirschner wire perpendicular to the bone in the transverse plane of the proximal joint. Generally. Harvest a cancellous bone autograft. For radius and tibia. Reduction: Rotate the distal segment until the Kirschner wires are in the same plane (see Plate 39B). Concurrent angular deformity may be corrected by performing an oblique osteotomy at the area of greatest curvature and then realigning the joint surfaces. plating equipment. and place it at the osteotomy site. Gelpi retractors. The degree of angulation approximates the degree of rotation. the osteotomy can be made at the mid-diaphysis. Landmarks for the approach. POSTOPERATIVE CARE The animal should be confined. Implant removal may be necessary if soft tissues are irritated. POSTOPERATIVE EVALUATION Radiographs should be evaluated for bone alignment and implant placement. Kern bone-holding forceps. INDICATIONS Candidates include animals with isolated rotational deformity of a long bone caused by fracture malunion. Positioning depends on the affected bone. The approach depends on the affected bone. Activity should be increased when bone bridging is observed. Louis. In Olmstead ML (ed): Small Animal Orthopedics. All screws should be tightened after each screw is placed and at the end of the procedure.1 OBJECTIVES • To reestablish rotational alignment ANATOMIC CONSIDERATIONS Rotation should be estimated from radiographic landmarks for the humerus and femur. It is important to be sure that the plate is centered on the bone. prepare a donor site as well. Drape the limb out from a hanging position to allow maximal manipulation during surgery. Irrigation is needed during drilling to reduce bone necrosis. it is important to check the alignment of the metacarpal or metatarsal bones to the radius or tibia to verify rotational correction. vary with the affected bone. Mosby. periosteal elevator. Stabilization: Apply an appropriately contoured plate to the bone (Plate 39C). 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 A Cranial caudal view of proximal femur Cranial caudal view of distal femur B C . In Brinker WO. Stabilization: Contour the plate to match the bone surface. Murphy WM (eds): AO Principles of Fracture Management. manual maintenance of reduction is necessary. 2nd ed. 3. Sumner-Smith G. Compress the fracture line. Drape the limb out from a hanging position to allow maximal manipulation during surgery. ANATOMIC CONSIDERATIONS Landmarks for the approach. Place the remaining screws in a neutral position (Plate 40C). POSTOPERATIVE EVALUATION Radiographs are necessary to evaluate for fracture reduction and implant placement. 1998. Positioning depends on the affected bone. Alternatively. after the plate is contoured. self-centering plate-holding forceps. harvest a cancellous bone autograft and place it at the fracture site. use a lever to reduce the fracture. All screws should be tightened after each screw is placed and at the end of the procedure. Irrigatation during drilling is needed to reduce bone necrosis. Schatzker J.118 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES GENERAL PRINCIPLES FOR DIAPHYSEAL FRACTURES CHAPTER 40 Stabilizing a Transverse or Short Oblique Diaphyseal Fracture with a Compression Plate to cause the plate to stand away from the fracture surface by about 2 mm (see Plate 40A). Prestress the plate by bending it an additional amount . POSTOPERATIVE CARE The animal should be confined. PROCEDURE Approach: The required approach varies with the affected bone. 2002. Hohmann retractors. and rotational forces at the fracture. It is important to make sure that the plate is centered on the bone. dogs with multiple limb injuries. high-speed drill. St. A good return to function can be expected.1 OBJECTIVES • To anatomically reduce and compress the fracture line using the bone plate as a compression plate The plate provides rigid fixation and resists axial loading. Kern bone-holding forceps. prep a donor site as well. Reduction: Reduce the fracture by lifting the bone ends from the incision and bringing them into contact. With transverse fractures. In Ruedi TP. 2000. Radiographs should be repeated at 6-week intervals to monitor healing. Springer-Verlag. Gelpi retractors. EQUIPMENT • Surgical pack. Mosby. Wittner G. Olmstead ML. and insert each screw before moving on to prepare the next screw hole. Make sure the plate is long enough to allow at least 6 cortices secured by screws on both sides of the fracture. Implant removal may be necessary if soft tissues are irritated. In Fossum TW (ed): Small Animal Surgery. Prieur WD: Implants and their application. With the bone ends in contact. New York. toy breed dogs with distal radial fractures. The procedure is also indicated in large active older dogs. It is necessary to drill. secure the fracture in reduction with self-centering plateholding forceps applied to the plate and the bone (Plate 40A). Close the incision routinely. vary with the affected bone. and vital structures to avoid. Louis. oblique fractures may additionally be compressed with a lag screw positioned through the plate or outside of the plate (Plate 40D). and animals for which postoperative comfort is imperative. Short. with activity limited to leash walking. INDICATIONS Candidates include animals with transverse or short oblique diaphyseal fractures requiring fixation with implants that will securely hold bone for a long time (12 weeks or more). slowly push the bone segments back into the normal position. bone curette for harvesting cancellous bone autograft PREPARATION AND POSITIONING Prepare the affected limb circumferentially from midline to foot. Holz U: Plates.3 If indicated. Johnson AL. tap. CAUTIONS Reduction should be maintained during implant application. using the loaded drill guide to insert one or two screws (Plate 40B). EXPECTED OUTCOME Bone healing is usually seen in 12 to 18 weeks. Muestage F. Activity should be increased when bone bridging is observed. Alternatively. AO Publishing and Thieme. plating equipment. If cancellous bone graft harvest is anticipated. References 1. Hulse DA: Fundamentals of orthopedic surgery and fracture management: Decision making in fracture management. 2. bending. et al (eds): Manual of Internal Fixation in Small Animals. periosteal elevator.2. New York. measure. Senn retractors. CHAPTER 40 S TA B I L I Z I N G A D I A P H Y S E A L F R A C T U R E W I T H A C O M P R E S S I O N P L AT E 119 P L AT E 4 0 A B C D . Secure the connecting bar to EXPECTED OUTCOME Bone healing is usually seen in 6 to 12 weeks. prep a donor site as well. and place external fixation pins through the proximal and distal metaphyses of the bone. and the vital structures to avoid. PROCEDURE Approach: The approach varies with the affected bone. 3.2 Retract the pin within the medullary canal of the proximal segment. and that have single limb injuries. Incise the skin. . bone curette for harvesting cancellous bone autograft POSTOPERATIVE CARE Gauze sponges should be packed around the pins. use a lever to reduce the fracture. St. and the sponges should be secured with a bandage to limit postoperative swelling and to protect the pin tracts. Drive the IM pin distally to maintain reduction (Plate 41A3).120 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES GENERAL PRINCIPLES FOR DIAPHYSEAL FRACTURES CHAPTER 41 Stabilizing a Transverse or Short Oblique Diaphyseal Fracture with an Intramedullary Pin and External Fixator the pins (Plate 41B). Senn retractors. Aron DN. Radiographs should be repeated at 6-week intervals to monitor healing. Mosby. femoral diaphyseal fractures. Louis. Mosby. or leave it long and tie it into the fixator (see Plate 41C). Hohmann retractors. lowspeed power drill. Vet Comp Orthop Traumatol 4:86. 2nd ed. pin cutter. The external fixator should be removed when bone bridging is observed. harvest a cancellous bone autograft and place it at the fracture. Alternatively. ANATOMIC CONSIDERATIONS Landmarks for the approach. Positioning depends on the affected bone.1 Owners must be willing and able to assume fixator management. Animals usually experience a good return to function. If additional stability is needed. 2002. In Fossum TW (ed): Small Animal Surgery. The animal should be confined.3 Tighten all of the fixation clamps. decision making in fracture management. INDICATIONS The procedure is indicated for transverse or short oblique diaphyseal fractures in animals with anticipated short healing times (6 to 12 weeks). Jacob pin chuck. St. If indicated. Hulse DA: Management of specific fractures. The IM pin (and proximal fixation pin) should be removed after the fracture has healed. slowly push the bone segments back into the normal position. external fixation equipment. Cut the IM pin below the level of the skin (see Plate 41B). whereas the external fixator resists axial loading and rotational forces at the fracture. and create soft tissue tunnels for fixation pin placement. IM pins are not indicated in the radius. placed close to the fracture. EQUIPMENT • Surgical pack. The incision closure is routine. Johnson AL. It is indicated in smaller dogs and cats that are young. periosteal elevator. Drape the limb out from a hanging position to allow maximal manipulation during surgery. Gelpi retractors. humerus. 1991. Reduce the fracture by lifting the bone ends from the incision and bringing them into contact. Hulse DA: Fundamentals of orthopedic surgery and fracture management. Dewey C: Experimental and clinical experience with an IM pin external skeletal fixator tie-in configuration. POSTOPERATIVE EVALUATION Radiographs should be evaluated for fracture reduction and implant placement. With the bone ends in contact. If cancellous bone graft harvest is anticipated. add a fixation pin. Kern bone-holding forceps. 2nd ed. vary with the affected bone. In Fossum TW (ed): Small Animal Surgery. IM pins. or femur) (Plate 41A2) technique. Reduction: Place an IM pin (of a size selected to equal 50% of the medullary canal at the isthmus) in the proximal segment using a retrograde (humerus or femur) (Plate 41A1) or antegrade (tibia. CAUTIONS It is important to pay attention to the direction of the IM pin and external fixation pins in the soft tissues to avoid nerves and vessels. PREPARATION AND POSITIONING Prepare the affected limb circumferentially from midline to foot. It is also necessary to ensure that the IM pin does not interfere with a joint surface. that are healthy. External fixator management includes daily pin care and pin packing as needed. to both bone segments (Plate 41C). Johnson AL. with activity limited to leash walking. OBJECTIVES • To anatomically reduce the fracture line and stabilize the bone The intramedullary (IM) pin resists bending forces at the fracture. Louis. Stabilization: Seat the IM pin in the distal segment of the bone. References 1. Predrill the bone before placing the threaded fixation pins. 2. If the tie-in is used. the proximal fixation pin should be left secured to the IM pin (Plate 41D). 2002. Establish rotational alignment. CHAPTER 41 S TA B I L I Z I N G A F R A C T U R E W I T H A N I M P I N A N D E X T E R N A L F I X AT O R 121 P L AT E 4 1 A1 Retrograde A2 Antegrade A3 B Bridging callus C D . and the sponges should be secured with a bandage that incorporates the paw to limit postoperative swelling. For both the radius and the tibia. Senn retractors. placed 1 cm from the fracture. prep a donor site (usually. ANATOMIC CONSIDERATIONS Landmarks for the approach.2 Allow the animal’s weight to fatigue the muscles. Secure the connecting bar to the pins. Gelpi retractors. Vet Surg 29:28. The animal will have limited function while the external fixator is in place. pin cutter.3 Tighten all of the fixation clamps. References 1. but a good return to function is expected. and that have single limb injuries and an anticipated rapid healing time (6 weeks). Stabilization: Establish rotational alignment. OBJECTIVES • To anatomically reduce the fracture line and stabilize the bone The external fixator resists bending. In Fossum TW (ed): Small Animal Surgery. Kern bone-holding forceps. periosteal elevator.1 Threaded pins should be used in large. PROCEDURE Approach: Perform a limited open reduction to align the bone segments. 3. position the animal in dorsal recumbency and suspend the affected limb from the ceiling. Aron DN. The fixator should be destabilized by removing the cranial frame (converting to a type Ia cranial medial frame) when early bone bridging is observed. Radiographs should be repeated at 6-week intervals to monitor healing. to both bone segments (Plate 42B). and rotational forces at the fracture. Hulse DA: Fundamentals of orthopedic surgery and fracture management. The rest of the external fixator should be removed when the fracture is healed. INDICATIONS The procedure is indicated for transverse or short oblique radial and tibial diaphyseal fractures in animals with anticipated short or moderate healing times (6 to 18 weeks). EQUIPMENT • Surgical pack. EXPECTED OUTCOME Bone healing is usually seen in 12 to 18 weeks. the ipsilateral proximal humerus) as well. with activity limited to leash walking. Add fixation pins. that are healthy. The incision closure is routine. Place additional pins to fill out the frame (Plate 42C). Incise the skin. CAUTIONS It is important to pay attention to the direction of the fixation pins in the soft tissues to avoid nerves and vessels. 2002. Repeat the steps to place a similar frame in a cranial-lateral plane at 90 degrees to the first frame (see Plate 42C). and place external fixation pins in a cranial-medial to caudal-lateral direc- . Mosby. External fixator management includes daily pin care and pin packing as needed. decision making in fracture management. Johnson AL: Biologic strategies and a balanced concept for repair of highly comminuted long bone fractures. Aron DN. Connect the frames with articulations proximally and distally (Plate 42D). and the vital structures to avoid. lower the table to suspend the animal from the ceiling. If cancellous bone graft harvest is anticipated. It is also necessary to avoid the joint surfaces when placing the fixation pins. Hohmann retractors. Reduction: For the radius and tibia. harvest a cancellous bone autograft and place it at the fracture. Jacob pin chuck. Johnson AL. 2. low-speed power drill. Lauer SK. 2nd ed.122 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES GENERAL PRINCIPLES FOR DIAPHYSEAL FRACTURES CHAPTER 42 Stabilizing a Transverse or Short Oblique Diaphyseal Fracture with a Type Ib External Fixator tion through the proximal and distal metaphyses of the bone. axial loading. Smooth fixation pins or a combination of threaded and smooth fixation pins can be used for smaller dogs and cats that are young. Predrill the bone before placing threaded fixation pins. POSTOPERATIVE CARE Gauze sponges should be packed around the pins. The animal should be confined.1 Owners must be willing and able to assume fixator management. and create soft tissue tunnels for fixation pin placement. If indicated. Drape the limb out in the suspended position. vary with the affected bone. Articulations must not interfere with elbow flexion. Use a lever to reduce the fracture (Plate 42A). POSTOPERATIVE EVALUATION Radiographs should be evaluated for bone alignment and implant placement. Compend Cont Educ Pract Vet 17:35. Louis. Evans MD: Finite element method evaluation: Articulations and diagonals in an 8-pin type 1b external skeletal fixator. older dogs and in dogs with multiple limb injuries where postoperative load is increased and anticipated healing times are longer. active. Palmer RH. Pin location and limited open approaches vary with the affected bone. external fixation equipment.1 A modified type Ib external fixator may also be used for humeral fractures. bone curette for harvesting cancellous bone autograft PREPARATION AND POSITIONING Prepare the affected limb circumferentially from midline to foot. St. 2000. 1995. 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 . EQUIPMENT • Surgical pack. Sumner-Smith G. measure (Plate 43B4). with activity limited to leash walking. 12 weeks or longer). Louis. Use pointed reduction forceps to manipulate the bone segments into reduction. bone curette for harvesting cancellous bone autograft PREPARATION AND POSITIONING Prepare the affected limb circumferentially from midline to foot. 2. and place the screw (Plate 43B6). CAUTIONS Reduction should be maintained with reduction forceps during lag screw application. All screws should be tightened after each screw is placed and again at the end of the procedure. Radiographs should be repeated at 6-week intervals to monitor healing. secure the reduced segments with cerclage wire. Johnson AL. New York. and approximate the fracture surfaces. The incision closure is routine. Place the plate and insert the screws which are crossing the fracture as lag screws (Plate 43D). Mosby. in dogs with multiple limb injuries. and insert each screw before moving on to prepare the next screw hole. and drill the far cortex with the appropriate drill bit for the screw (Plate 43B2). Hulse DA: Fundamentals of orthopedic surgery and fracture management. active. Senn retractors.2 Alternatively. pointed reduction forceps. 1998. Implant removal may be necessary if soft tissues are irritated. POSTOPERATIVE EVALUATION Radiographs should be evaluated for fracture reduction and implant placement. INDICATIONS The procedure is indicated for long oblique diaphyseal fractures in animals requiring fixation with implants that will securely hold bone for a longer period (e. POSTOPERATIVE CARE The animal should be confined. In Brinker WO. Place a drill insert sleeve. It is also indicated in large. Schatzker J. The plate and screw combination provides rigid fixation and resists axial loading. Secure the plate with screws placed in a neutral position. Drape the limb out from a hanging position to allow maximal manipulation during surgery. It is necessary to drill. It is important to ensure that the plate is centered on the bone so the plate holes at the ends of the plate are over bone. Muestage F. older dogs.1 OBJECTIVES • To anatomically reduce and compress the fracture line with lag screws Application of a bone plate neutralizes the load on the fracture. tap. Hohmann retractors. 2002. Irrigation during drilling is needed to reduce bone necrosis. self-centering plate-holding forceps. If indicated. and rotational forces at the fracture. prep a donor site as well. when the fracture line is parallel to the plate surface of the bone. Stabilization: When the fracture line is perpendicular to the plate surface of the bone. Remove the cerclage wire before tightening the screws. . Drill the near cortex with a drill bit equal to the diameter of the screw threads (Plate 43B1). PROCEDURE Approach: The approach varies. tap (Plate 43B5). and in animals for which postoperative comfort is imperative.124 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES GENERAL PRINCIPLES FOR DIAPHYSEAL FRACTURES CHAPTER 43 Stabilizing a Long Oblique Diaphyseal Fracture with Lag Screws and a Neutralization Plate Slightly countersink the near cortex (Plate 43B3). In Fossum TW (ed): Small Animal Surgery. high-speed drill. bending.g. and the vital structures to avoid. Gelpi retractors. References 1. harvest a cancellous bone autograft and place it at the fracture. decision making in fracture management. vary with the affected bone. If cancellous bone graft harvest is anticipated. Animals usually experience a good return to function.2 Contour a plate to match the bone surface. Olmstead ML. ANATOMIC CONSIDERATIONS Landmarks for the approach. periosteal elevator.. EXPECTED OUTCOME Bone healing is usually seen in 12 to 18 weeks. Positioning depends on the affected bone. measure. place two or three lag screws across the fracture line. St. Prieur WD: Implants and their application. Maintain reduction with the pointed reduction forceps (Plate 43A). The plate should be long enough to span the bone and allow a minimum of six cortices secured by screws on both sides of the fracture (Plate 43C). Kern bone-holding forceps. depending on the affected bone. Activity should be increased when bone bridging is observed. 2nd ed. plating equipment. SpringerVerlag. Reduction: Reduce the fracture by distracting the bone segments. et al (eds): Manual of Internal Fixation in Small Animals. CHAPTER 43 S TA B I L I Z I N G A F R A C T U R E W I T H L A G S C R E W S A N D N E U T R A L I Z AT I O N P L AT E 125 P L AT E 4 3 B1 B2 B3 A B6 B4 B5 C D . When the wire is tight. PROCEDURE Approach: The approach varies. Prieur WD: Implants and their application. St. Feed the plain end of the wire through the wire passer. POSTOPERATIVE CARE The animal should be confined. POSTOPERATIVE EVALUATION Radiographs should be taken to evaluate for fracture reduction and implant placement. needle-holder. In Fossum TW (ed): Small Animal Surgery. EQUIPMENT • Surgical pack. Mosby. Schatzker J. Maintain reduction with the pointed reduction forceps (Plate 44A). Jacob pin chuck. Olmstead ML. wire cutter. 2002. INDICATIONS The procedure is indicated for long oblique diaphyseal fractures in animals with anticipated short healing times (6 to 12 weeks). Hohmann retractors. Reduction: Place an IM pin (sized to equal 60% to 70% of the medullary canal at the isthmus) in the proximal segment using an antegrade (tibia. ANATOMIC CONSIDERATIONS Landmarks for the approach. that are healthy. CAUTIONS All wires must be tight. Johnson AL. periosteal elevator. Muestage F. Use pointed reduction forceps to manipulate the bone segments into reduction. Hulse DA: Management of specific fractures. femoral diaphyseal fractures. Hulse DA: Fundamentals of orthopedic surgery and fracture management. Radiographs should be repeated at 6-week intervals to monitor healing.2 Retract the pin within the medullary canal of the proximal segment. The IM pin should be removed after the fracture has healed. whereas the cerclage wire compresses the fracture to resist axial loading and rotational forces at the fracture. Louis. References 1. 2. Springer-Verlag. OBJECTIVES • To anatomically reduce the fracture line and stabilize the bone The IM pin resists bending forces at the fracture. EXPECTED OUTCOME Bone healing is usually seen in 6 to 12 weeks. Senn retractors. cut the wire 3 mm from the start of the twist (Plate 44D3). Intramedullary (IM) pins are not indicated in the radius. depending on the affected bone. Animals usually experience a good return to function. 2002. Retract the wire tightener. New York. Mosby. and finish bending the wire (Plate 44C3). 2nd ed. and the vital structures to avoid. decision making in fracture management. orthopedic wire (spool or eye cerclage). Insert the wire into the wire tightener.3 Cut the IM pin below the level of the skin (Plate 44E). wire passer. IM pins. Kern bone-holding forceps. Alternatively.1 It is especially useful for immature dogs and cats. cut the wire 5 mm to 7 mm from the twist. Place the wire twisting pliers or needleholders onto the twist.126 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES GENERAL PRINCIPLES FOR DIAPHYSEAL FRACTURES CHAPTER 44 Stabilizing a Long Oblique Diaphyseal Fracture with an Intramedullary Pin and Multiple Cerclage Wires the reduced fracture at intervals of 0. wire tightener (pliers. 1998. It is also indicated in smaller dogs and cats that are young. If indicated. et al (eds): Manual of Internal Fixation in Small Animals. begin twisting the wire ends by hand (Plate 44D1). prep a donor site as well. and tighten the wire by pulling and twisting (Plate 44D2). or loop cerclage wire tightener). Stabilization: Seat the IM pin in the distal segment of the bone (see Plate 44A). Positioning depends on affected bone.5 cm to 1 cm. humerus. Louis. 2nd ed. pointed reduction forceps. In Fossum TW (ed): Small Animal Surgery. Gelpi retractors. Sumner-Smith G. If cancellous bone graft harvest is anticipated. tighten the wire by passing the plain end of the wire through the eye of the wire (Plate 44C1). Bend the wire over the eye. and that have single limb injuries. vary with the affected bone. harvest a cancellous bone autograft and place it at the fracture. bone curette for harvesting cancellous bone autograft PREPARATION AND POSITIONING Prepare the affected limb circumferentially from midline to foot. or femur) or retrograde (humerus or femur) technique. 3.3 For plain orthopedic wire. Cut the wire (Plate 44C4). For loop cerclage. In Brinker WO. Plan to place two or three (or more. St. Pass a wire passer around the bone. and pull the wire around the bone (Plate 44B). with activity limited to leash walking. It is important to pay attention to the direction of the IM pin in the soft tissues to avoid nerves and vessels. The IM pin must not interfere with a joint surface. and bend it over in the direction of the twist (Plate 44D4). depending on the length of the fracture) cerclage wires around . The incision closure is routine. and crank the wire tight (Plate 44C2). Reduce the fracture by distracting the bone segments and approximating the fracture surfaces. Drape the limb out from a hanging position to allow maximal manipulation during surgery. pin cutter. Johnson AL. CHAPTER 44 S TA B I L I Z I N G A F R A C T U R E W I T H A N I M P I N A N D C E R C L A G E W I R E S 127 P L AT E 4 4 A B Loop cerclage Twist 1 1 2 Alternate twist 2 3 4 4 C D 3 E . with activity limited to leash walking. Johnson AL. St. The IM pin must not interfere with nerves. 4. humerus. and in dogs with multiple limb injuries in which postoperative load is increased and anticipated healing times are longer. depending on the affected bone. bending. and secure the plate to the appropriate bone surface with selfcentering plate-holding forceps (Plate 45C). Kern bone-holding forceps. and the screws should secure a minimum of six cortices on either side of the fracture.128 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES GENERAL PRINCIPLES FOR DIAPHYSEAL FRACTURES CHAPTER 45 Stabilizing a Comminuted Diaphyseal Fracture with an Intramedullary Pin and a Bridging Plate distal ends of the fractured bone. Mosby. with the plate stabilizing the radius and the pin supporting the ulna. and insert the IM pin. Plate removal may be necessary if soft tissues are irritated. OBJECTIVES • To restore normal bone length and alignment The IM pin restores axial alignment and protects the plate from bending forces at the fracture. Irrigation is needed during drilling to reduce bone necrosis.3. Aron DN. All screws should be tightened after each screw is placed and at the end of the procedure. Place bicortical screws in the metaphyses and unicortical screws in the diaphysis where the IM pin interferes with screw placement. Louis. Palmer RH. 2nd ed. POSTOPERATIVE CARE The animal should be confined. 2002. Restore rotational alignment. Contour a plate so that the bend matches a radiographic image of the contralateral intact bone (Plate 45B). Use an “open but do not disturb the fragments” technique to expose the proximal and distal bone segments with minimal disturbance of the fracture hematoma and bone fragments. Radiographs should be repeated at 6-week intervals to monitor healing. Cut the pin below the skin. decision making in fracture management. Gelpi retractors. Johnson AL. Positioning depends on the affected bone. Bone healing is usually seen in 12 to 18 weeks.1 A plate and intramedullary (IM) pin can be used to stabilize comminuted radial fractures. vessels. Schaeffer DJ: Fragment reconstruction and bone plate fixation compared with bridging plate fixation for treating highly comminuted femoral fractures in dogs: 35 cases (1987–1997). Animals usually experience a good return to function. 2nd ed.2 Reduction and Stabilization: Place an IM pin (sized to equal 40% to 50% of the medullary canal width at the isthmus) in the proximal segment using an antegrade (tibia. Torque the plate to match the proximal and . 1998. vary with the affected bone. Mosby. Drive the pin to the fracture site. CAUTIONS The plate should be centered on the bone so that the plate holes at the ends of the plate are over bone. older dogs. femoral. POSTOPERATIVE EVALUATION Radiographs should be taken to evaluate for fracture reduction and implant placement. Drape the limb out from a hanging position to allow maximal manipulation during surgery. or femur) or retrograde (humerus or femur) technique. or any joint surface. PROCEDURE Approach: The approach varies. 1995. plating equipment. prep a donor site as well. Activity should be increased when bone bridging is observed. In Fossum TW (ed): Small Animal Surgery. high-speed drill. Hohmann retractors. J Am Vet Med Assoc 213:1157. INDICATIONS The procedure is indicated for comminuted nonreducible (more than one or two large fragments) humeral. The IM pin should be removed when early fracture bridging is evident. Jacob pin chuck. Senn retractors. active. 3.4 Harvest cancellous bone graft and place it at the fracture site (Plate 45D). and tibial diaphyseal fractures in large. Johnson AL: Biologic strategies and a balanced concept for repair of highly comminuted long bone fractures. Hulse DA: Fundamentals of orthopedic surgery and fracture management. self-centering plate-holding forceps. bone plates and screws. References 1. 2002. bone curette for harvesting cancellous bone autograft PREPARATION AND POSITIONING Prepare the affected limb circumferentially from midline to foot. IM pins. periosteal elevator. and the vital structures to avoid. Lift and align the distal segment. 2. Distract the bone to length by advancing the pin while holding the proximal segment with bone-holding forceps (Plate 45A). Compend Cont Educ Pract Vet 17:35. EXPECTED OUTCOME The IM pin may cause morbidity and lameness. The plate should span the length of the bone. Johnson AL. Smith CW. and blunt the pin tip. ANATOMIC CONSIDERATIONS Landmarks for the approach. Hulse DA: Fundamentals of orthopedic surgery and fracture management. In Fossum TW (ed): Small Animal Surgery. Louis. St. and rotational forces at the fracture. EQUIPMENT • Surgical pack. whereas the plate resists axial loading. If cancellous bone graft harvest is anticipated. 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 Shaft of femur Biceps femoris muscle retracted Vastus intermedius muscle Adductor magnus muscle B A Cancellous bone autograft C D . or preferably three pins. Louis. INDICATIONS The procedure is indicated for animals with comminuted nonreducible (more than one or two large fragments) radial and tibial diaphyseal fractures.1 mm smaller than the selected pin.3 Pin location and limited open approaches vary depending on the affected bone. low-speed power drill. some correction may be obtained by repositioning the distal clamps onto the opposite side of the bar.1 POSTOPERATIVE EVALUATION Radiographs should be evaluated for bone alignment and implant location. Vet Surg 25:543. 2002. vary with the affected bone. to limit postoperative swelling. Repeat the procedure for the proximal metaphysis (Plate 46B). References 1. Smooth fixation pins. External fixator management includes daily pin care and pin packing as needed. et al: Type II external fixation using new clamps and positive profile threaded pins for treatment of fractures of the radius and tibia in dogs. and the sponges should be secured with a bandage that incorporates the paw. and suspend the affected limb from the ceiling. the proximal and distal joint surfaces are not parallel).. Drape the limb out in the hanging position. Johnson AL.6 Be sure that there are at least two pins. J Am Vet Med Assoc 212:1267.5. Use a guiding device or additional connecting bar and guide clamp to ensure accurate placement of transfixation pins (see Plate 46C). Roe SC: In vitro biomechanical and histological assessment of pilot hole diameter for positive-profile external skeletal fixation pins in canine tibiae. Palmer RH. Make sure the pin parallels the distal joint surface and is in the medial to lateral plane. Tighten all of the clamps. 2. active. checking for angular and rotational alignment. If rotational malalignment is present. with activity limited to leash walking. Boudrieau RJ. and secure the pins to medial and lateral connecting bars. 6. J Am Vet Med Assoc 209:1445. Lavarty PH. The pins should be covered to prevent injury to the owner. Johnson AL: Biologic strategies and a balanced concept for repair of highly comminuted long bone fractures.4 Insert the pin with a hand chuck or low RPM power. Incise the skin and create soft tissue tunnels for pin placement. and the vital structures to avoid. older dogs and in dogs with multiple limb injuries in which postoperative load is increased and anticipated healing times are longer.e. Clary EM. Vet Comp Orthop Traumatol 15:97. OBJECTIVES • To restore normal bone length and alignment A type II external fixator is applied to bridge the fracture. Jacob pin chuck. then the distal clamps should be loosened and the distal segment should be repositioned to eliminate the angular deformity. Hulse DA: Fundamentals of orthopedic surgery and fracture management. 1995. If the lateral bar is removed. small Hohmann retractors. Radiographs should be repeated at 6-week intervals to monitor healing. EQUIPMENT • Surgical pack.. The fixator resists axial loading. Predrill the hole with a drill bit 0. 2002. Toombs JP. 3. The fixator should be destabilized by removing selected fixation pins (or the lateral connecting bar) when early bone bridging is observed. 1996. and rotational forces at the fracture. Senn retractors. bending. POSTOPERATIVE CARE Gauze sponges should be packed around the pins. Align the segments. EXPECTED OUTCOME Bone healing is usually seen in 12 to 18 weeks. 1996. St. the associated transfixation pins should be left long enough to exit the skin on the lateral surface of the limb. Mosby. Threaded pins should be used in large. .2 If necessary. The external fixator should be removed when the fracture is healed. use a limited open reduction to line up major bone segments. Aron DN. position the animal in dorsal recumbency. Stabilization: Place a centrally threaded fixation pin through the distal metaphyses. PROCEDURE Approach: Perform a closed reduction to preserve the integrity of the fracture hematoma and the surrounding soft tissues. Kraus KH. 6 to 12 weeks). Reduction: Lower the table to allow the animal’s weight to align the fractured bone (Plate 46A). above and below the fracture (Plate 46D). 1998. or a combination of threaded fixation plus and smooth fixation pins. 5.130 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES GENERAL PRINCIPLES FOR DIAPHYSEAL FRACTURES CHAPTER 46 Stabilizing a Comminuted Diaphyseal Fracture with a Type II External Fixator CAUTIONS It is important to avoid the joint surfaces and the fracture lines with the fixation pins. et al: Closed reduction and type II external fixation of severely comminuted fractures of the radius and tibia in dogs: 23 cases (1990–1994). decision making in fracture management. et al: Simple and multiple fractures of the radius treated with an external fixtor. If the fractured bone is reduced in a varus or valgus position (i. external fixator equipment PREPARATION AND POSITIONING Prepare the affected limb circumferentially from midline to foot. For both the radius and the tibia. Johnson AL. The animal may experience limited function while the external fixator is in place but will eventually have a good return to function. 2nd ed. Compend Cont Educ Pract Vet 17:35. Fill out the frame with either transfixation pins or unilateral fixation pins. Johnson AL. In Fossum TW (ed): Small Animal Surgery. depending on the anatomy of the bone and surrounding soft tissues (Plate 46C). 4. ANATOMIC CONSIDERATIONS Landmarks for the pin placement. Wotton HM. Seitz SE. The animal should be confined. Intraoperative radiographs are helpful in evaluating bone alignment and pin location.e. can be used for animals with rapid healing times (i. Smith CW. CHAPTER 46 S TA B I L I Z I N G A F R A C T U R E W I T H A T Y P E I I E X T E R N A L F I X AT O R 131 P L AT E 4 6 A B C D . Drill. EXPECTED OUTCOME Bone healing is usually seen in 12 to 18 weeks.2 Reduction and Stabilization: Establish the insertion hole in the proximal bone segment. and tap the distal screw hole. ANATOMIC CONSIDERATIONS Landmarks for the approach. St. 1995. It is indicated in dogs that have anticipated healing times that are short or intermediate. Close the incision routinely. vary with the affected bone. Radiographs should be repeated at 6-week intervals to monitor healing. If a cancellous bone graft harvest is anticipated.3 Harvest cancellous bone graft and place it at the fracture site (Plate 47D). Hohmann retractors. Compend Cont Educ Pract Vet 17:35. and rotational forces at the fracture. Johnson AL: Biologic strategies and a balanced concept for repair of highly comminuted long bone fractures. POSTOPERATIVE EVALUATION Radiographs should be taken to evaluate for fracture reduction and implant placement. Stabilize . Hulse DA: Fundamentals of orthopedic surgery and fracture management. Mosby. and insert it into the proximal bone segment so that it exits at the fracture surface. femoral. Johnson KA. The first screw should be placed in the distal hole of the nail to help secure nail and jig alignment. OBJECTIVES • To restore normal bone length and alignment The interlocking nail restores axial alignment and resists axial loading. Ensure that the proximal portion of the nail is seated within the proximal segment. bending. INDICATIONS The procedure is indicated in comminuted nonreducible (more than one or two large fragments) humeral. EQUIPMENT • Surgical pack. using a reamer of the appropriate size to prepare for the nail. Roe SC. et al: Interlocking nail treatment of diaphyseal long-bone fractures in dogs. Align the distal segment. high-speed drill. periosteal elevator. Johnson AL. Removal of the interlocking nail may be necessary if soft tissues are irritated. In Fossum TW (ed): Small Animal Surgery. and attach the jig. References 1. Positioning depends on the affected bone. PROCEDURE Approach: The approach varies. POSTOPERATIVE CARE The animal should be confined. measure. and drive the nail distally within the medullary canal. bone curette for harvesting cancellous bone autograft PREPARATION AND POSITIONING Prepare the affected limb circumferentially from midline to foot. using the jig and associated guides to maintain screw alignment with the hole in the nail. Louis. 3. prep a donor site as well. Attach the nail to the extension piece and nail driver. Palmer RH. and continue to drive the nail distally to distract the distal bone segment to length (Plate 47B). Animals should experience a good return to function. Activity should be increased when bone bridging is observed. Insert the screw (Plate 47C). and insert the remaining screws. Senn retractors. The rotational alignment must be correct before proximal screws are inserted. with activity limited to leash walking. and the vital structures to avoid. 2002. 2. CAUTIONS It is important to ensure that the nail does not penetrate the distal joint. interlocking nail equipment. Pin insertion sites vary with the affected bone.132 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES GENERAL PRINCIPLES FOR DIAPHYSEAL FRACTURES CHAPTER 47 Stabilizing a Comminuted Diaphyseal Fracture with an Interlocking Nail the proximal bone segment with a bone-holding forceps. and when postoperative comfort is important. 2nd ed. Check rotational alignment. Remove the nail driver. decision making in fracture management. bone screws. Dueland RT. Irrigation must be done during drilling to reduce bone necrosis. Kern bone-holding forceps. The nail diameter and length are estimated from preoperative radiographs of the contralateral bone (Plate 47A). Aron DN. and tibial diaphyseal fractures.1 Interlocking nails are contraindicated for the radius. depending on the affected bone. Gelpi retractors. Use an “open but do not disturb the fragments” technique to expose the proximal and distal bone segments with minimal disturbance of the fracture hematoma and bone fragments. Remove the extension piece. 1999. Drape the limb out from a hanging position to allow maximal manipulation during surgery. J Am Vet Med Assoc 214:59. CHAPTER 47 S TA B I L I Z I N G A F R A C T U R E W I T H A N I N T E R L O C K I N G N A I L 133 P L AT E 4 7 Reamer Extension piece and nail driver Vastus lateralis muscle retracted Shaft of femur Vastus intermedius muscle Biceps femoris muscle retracted Adductor magnus muscle A B Jig Cancellous bone autograft C D . In Fossum TW (ed): Small Animal Surgery. bone grafts. use a separate surgical team and instrumentation to harvest the graft. Hulse DA: Fundamentals of orthopedic surgery and fracture management. and the proximal tibial metaphysis. . Insert a bone curette. Gelpi retractors. Close subcutaneous tissues around the graft to hold it in position. harvest the graft first to avoid contamination of the donor site. bone curette. If the recipient site is infected. Complications at the recipient site (e. rarely. Create round holes in the long bone cortex to minimize stress concentration and possible fracture. EQUIPMENT • Surgical pack. Mosby. INDICATIONS Autogenous cancellous bone grafts are used to promote rapid bone formation. The proximal humerus and iliac wing yield the largest amounts of cancellous bone. Harvest cancellous bone as previously described (Plate 48C). and drape the graft donor site so that it is easily accessible when the recipient site is draped. infection. Retract the acromial head of the deltoid muscle caudally. Alternatively. osteotome and mallet. Elevate the musculature from the lateral surface and medial surfaces of the craniodorsal portion of the iliac wing. POSTOPERATIVE EVALUATION Wound healing at the donor site should be evaluated when the recipient site procedure is evaluated. Closure is routine. stainless steel cup. 2002. osteotomies. Place the cancellous bone in a stainless steel cup. failure of grafts to stimulate bone formation) are difficult to recognize. prepare. Make a round hole in the bone cortex using an intramedullary pin or drill bit. Complications at the donor site include seroma formation. nonunions. drill bit or intramedullary pin. The blood will clot and form a moldable composite with the graft. Johnson AL. St. Use a syringe to collect blood from the donor site to add to the graft (Plate 48B). Obtain a corticocancellous graft by using an osteotome to remove a cortical wedge from the iliac wing. or is the site of a tumor. PROCEDURE Proximal Humerus: Incise the skin and subcutaneous CAUTIONS Avoid open physes in immature animals. Senn retractors. syringe PREPARATION AND POSITIONING Select. Reference 1.1 OBJECTIVES • To promote bone formation and bone cell survival by harvesting cancellous bone at the end of the procedure and transferring directly to the recipient site ANATOMIC CONSIDERATIONS Optimal sites for cancellous bone harvest are the proximal humeral metaphysis. Louis. Avoid penetrating the articular surface or other cortical surfaces with the curette. delayed unions. Closure is routine. and. rongeur. Macerate the wedge with rongeurs. 2nd ed. EXPECTED OUTCOME Bone formation should be seen at the recipient site by 12 weeks after surgery. Army-Navy retractors.. All three sites have minimal soft tissue coverage and are easily accessible.g. Autogenous cancellous bone also promotes bone formation in infected fractures. Candidates include animals with cortical defects after fracture repair and adult and elderly animals with fractures. Incise subcutaneous tissues. and expose the flat aspect of the craniolateral metaphysis just distal to the greater tubercle. and place it into the recipient site. and harvest cancellous bone (Plate 48A). tissues over the craniolateral aspect of the proximal humerus. Flush and loosely pack the recipient site with graft material. fracture. facilitating handling. Harvest cancellous bone from between the inner and outer cortical bone of the iliac body with a bone curette (Plate 48D). POSTOPERATIVE CARE Routine procedures for caring for a surgical wound should be followed. or cystic defects.134 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES GENERAL PRINCIPLES FOR DIAPHYSEAL FRACTURES CHAPTER 48 Cancellous Bone Autograft Proximal Tibia: Incise the skin and subcutaneous tissue over the medial surface of the proximal tibia. Iliac Wing: Incise the skin over the craniodorsal iliac spine. joint arthrodesis. and expose the dorsal surface of the iliac wing. the wing of the ilium. CHAPTER 48 C A N C E L L O U S B O N E A U TO G R A F T 135 P L AT E 4 8 A Deltoid muscle B Syringe with blood Osteotome blade C D Curette . Position the animal in dorsal recumbency.136 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES MANDIBLE CHAPTER 49 Mandibular Symphyseal Fractures across and behind the canine teeth. Exit the needle in the oral cavity caudal to the canine tooth. 2002. Reduction: Reduce and hold the symphysis with digital pressure applied to the mandibular canine teeth (Plate 49A). POSTOPERATIVE EVALUATION Radiographs should be taken to evaluate symphyseal reduction and implant placement.or 20-gauge wire through the needle (Plate 49B). and bend them to decrease the possibility of injury to the owner (Plate 49E). OBJECTIVES • To reduce and stabilize the symphyseal fracture and restore dental alignment and occlusion ANATOMIC CONSIDERATIONS Realignment of dental occlusion is important for return to function. and thread an 18. 18. Radiographic evidence of bone bridging or callus formation is usually not evident.1 CAUTIONS The incisor alignment should be observed when tightening the wire. POSTOPERATIVE CARE It is important to clean the wire daily where it is exposed ventrally. and tug of war games should be eliminated until the fracture has healed. Stabilization: Insert the hypodermic needle through the skin incision and along one lateral mandibular surface (under the subcutaneous tissues).to 22-gauge (for cats) orthopedic wire. Curve the wire Reference 1. .to 20-gauge (for dogs) or 20. EQUIPMENT • Scalpel blade. and reinsert it through the hypodermic needle to exit from the skin incision at the original insertion point (Plate 49C). PROCEDURE Approach: Make a small incision in the skin overlying the ventral aspect of the symphysis. Rinse the mouth with an antiseptic. Hard food. Johnson AL. wire tightener. Leave the ends of the wire exposed through the skin incision. the wire can be removed by cutting it with wire scissors where it is exposed behind the canine teeth and extracting it by the twist. St. and dental occlusion should be checked after the wire is tightened. Remove the needle and reposition it on the opposite side of the mandible. While holding the fracture in reduction. In Fossum TW (ed): Small Animal Surgery. EXPECTED OUTCOME Symphyseal union is usually seen in 6 to 12 weeks. Mosby. hypodermic needles sized to accommodate the orthopedic wire. Louis. INDICATIONS Candidates include animals with mandibular symphyseal fractures. tighten the wire (Plate 49D). Remove the needle. chew toys. Once the fracture has stabilized. Hulse DA: Management of specific fractures: Maxillary and mandibular fractures. wire cutter PREPARATION AND POSITIONING Prepare the ventral aspect of the mandible for aseptic surgery. 2nd ed. It is not necessary to drape the mandible for an isolated symphyseal fracture. CHAPTER 49 MANDIBULAR SYMPHYSEAL FRACTURES 137 P L AT E 4 9 A B C D E . Stabilization: For transverse fractures. 2004. POSTOPERATIVE CARE Oral exercise should be limited. drill a hole with the Kirschner wire. Stabilize medialto-lateral oblique fracture with two wires placed perpendicular to each other in two planes (Plate 50D). 2. Finish tightening the wire. to do so would prevent postoperative drainage.2 In both cases. To ensure the wire contacts the medial cortex. taking care to orient the wire perpendicular to the fracture. Evaluate the oral cavity for open wounds. Transverse fractures are best stabilized with two wires (Plate 50B1). EXPECTED OUTCOME Bone healing is usually seen in 6 to 12 weeks. soft foods should be provided. Sem Vet Med Surg Small Anim 7:3. Suture the subcutaneous tissue over the mandibles. Hold the fracture in reduction. high-speed Kirschner wire driver or Jacob pin chuck. Aim the wire to exit on the medial side of the mandible. CAUTIONS Tooth roots should be avoided when drilling through the bone. It is important to check that interfragmentary wires lie flat against the bone surface. EQUIPMENT • Surgical pack. Intraoral wires are removed after fracture healing. If only one mandible is involved.138 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES MANDIBLE CHAPTER 50 Transverse and Oblique Mandibular Body Fractures slightly closer to the fracture line (see Plate 50A1). Move this incision in either direction to expose both mandibles. Damaged teeth may require endodontic care or extraction. incise directly over that mandible. WB Saunders. Extend the incision from the symphysis to 1 cm to 2 cm caudal to the angular process of the mandibles. and twist the wire (Plate 50A2). 0.to 18-inch strand of orthopedic wire through each pair of holes. Preserve the digastricus muscle attachments (Plate 50A1). passes through the mandibular canal along with the mandibular alveolar artery. Radiographs should be repeated at 6-week intervals until bone bridging occurs. References 1. Rinse the mouth with an antiseptic. wire-tighteners. The interfragmentary wires applied perpendicular to the fracture line will result in compression at the fracture. Senn retractors. A cancellous bone graft is usually not necessary. and bend the remaining twist into the bone (Plate 50A3). These structures are often damaged during mandibular fractures. If large wounds are present. Drill a similar hole on the caudal segment at the same level in the bone so the wire will be placed perpendicular to the fracture. reduction is usually easily accomplished. Piermattei DL. however. Gelpi retractors. 1992. follow the previous steps. Do not completely close contaminated wounds. .5 cm to 1 cm from the fracture line and close to the oral edge of the mandible. For oblique fractures. Drape the mandible out to allow maximal manipulation during surgery by placing one of the drapes into the mouth to cover the maxilla. periosteal elevator. and lever the wire away from the bone. place a forceps between the twist and the lateral mandible. Boudrieau RJ: Maxillofacial and mandibular fractures. which is sensory to the teeth of the mandible. starting and finishing on the lateral aspect of the mandible. Incise the subcutaneous tissue to expose the ventral portions of the mandibles. Philadelphia. small pointed reduction forceps. small Hohmann retractors. Stabilize caudal-to-rostral oblique fracture with two wires placed at right angles to each other (Plate 50C).1 Reduction: Reduce the fracture by securing each bone segment with Kern bone-holding forceps and then manipulating them into anatomic alignment. OBJECTIVES • To restore dental occlusion by anatomic reconstruction of the fracture Stable internal fixation allows a rapid return to function and minimizes aftercare. cut the excess. INDICATIONS Candidates include animals with single fracture lines of the mandibular body that can be anatomically reconstructed. orthopedic wire. but interfragmentary wires remain in place unless they cause a problem. ANATOMIC CONSIDERATIONS The mandibular body is easily palpated and surgically approached through the skin and subcutaneous tissue. The mandibular alveolar nerve. Anatomic reduction of the mandibular cortex will realign the teeth. although clinical signs are seldom evident. Johnson KA: An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. Interdental wiring may complement the interfragmentary wire (Plate 50B3). Radiographs should be taken to evaluate bone alignment and implant placement. Suture the skin incision. Position the animal in dorsal recumbency. baby Kern bone-holding forceps. and no chew toys should be allowed. Animals generally experience an excellent return to function if dental occlusion is normal. Rudy RL. Because there is little musculature around the mandibular body. and secure the maxilla to the table by placing adhesive tape from one table edge across the maxilla to the opposite table edge. Start on the lateral aspect of the cranial mandibular segment. 4th ed. occasionally. Feed a 12. Kirschner wires. Maintain reduction manually (with transverse fractures) or with pointed reduction forceps (for oblique fractures). one wire in the rostral mandible is sufficient (Plate 50B2). wire cutters PREPARATION AND POSITIONING Prepare the ventral aspect of the mandible for surgery. close the mucosa partially to decrease their size. Tooth roots must be avoided when placing implants. Elevate soft tissues from both sides of the mandibles to expose the fracture(s). the second wire prevents overriding of the fracture as the wires are tightened. Place a Penrose drain if infection is present or likely to be present. PROCEDURE Approach: Incise the skin on the ventral midline between the mandibles. POSTOPERATIVE EVALUATION Dental occlusion should be evaluated. CHAPTER 50 T R A N S V E R S E A N D O B L I Q U E M A N D I B U L A R B O DY F R A C T U R E S 139 P L AT E 5 0 A1 Hemimandible A2 A3 Myelohyoideus muscle Branch of facial artery and vein Digastricus muscle B1 C B2 D B3 . 140 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES MANDIBLE CHAPTER 51 Comminuted Mandibular Body Fractures Reduction: After the fixation pins are placed, use them as a handle to realign the major bone segments so the dental occlusion is restored. Maintain the reduction manually or by securing two fixation pins on each side of the mandible with clamps and connecting bars (biphasic splint) (Plate 51B). Remove the clamps and bars after the acrylic is placed. Stabilization: Insert at least two and, if possible, three fixation pins into each major bone segment by predrilling a pilot hole and placing the pins with a pin chuck. Bend or notch the free ends of the pins to enhance acrylic purchase. Mix methyl methacrylate acrylic until it becomes doughy (3 to 4 minutes). Mold the acrylic to form a connecting column incorporating all of the pins at a distance of 1 cm to 2 cm from the skin. Place saline moistened sponges around the fixation pins to dissipate the heat generated by the methyl methacrylate. Check the fracture reduction and hold it in position until the acrylic hardens (8 to 10 minutes) (Plate 51C).1 Evaluate the oral cavity for open wounds. If large wounds are present, close the mucosa partially to decrease their size. In order to allow postoperative drainage, do not close contaminated wounds completely. INDICATIONS Candidates include animals with comminuted fractures of the mandibular body that cannot be anatomically reconstructed. OBJECTIVES • To align major mandibular segments and restore dental occlusion ANATOMIC CONSIDERATIONS The mandibular body is easily palpated through the skin and subcutaneous tissue. The mandibular alveolar nerve, which is sensory to the teeth of the mandible, passes through the mandibular canal along with the mandibular alveolar artery. These structures are commonly damaged with mandibular fractures, although clinical signs are seldom evident. Tooth roots must be avoided when placing fixation pins. Normal occlusion is assessed by observing the unobstructed interdigitation of the mandibular canine teeth between the maxillary incisors and canine teeth and the mandibular fourth premolar positioned between the maxillary third and fourth premolars. EQUIPMENT • Surgical pack, low-speed power drill, Jacob pin chuck, positive profile threaded external fixation pins, external fixator equipment, methyl methacrylate acrylic CAUTIONS Tooth roots should be avoided when drilling through the bone. PREPARATION AND POSITIONING To gain an unobstructed view of dental occlusion, place an endotracheal tube via a pharyngotomy incision. Insert an index finger into the oral cavity, and locate the pharyngeal area immediately cranial to the hyoid bones. Incise skin, subcutaneous tissues, and mucous membrane to create a passage for the endotracheal tube. Place a forceps through the surgically created passage to grasp the endotracheal tube (with connector removed), and reroute it (Plate 51A).1 Prepare the ventral aspect of the mandible for aseptic surgery. Rinse the mouth with an antiseptic. Position the animal in dorsal recumbency, and secure the maxilla to the table by placing adhesive tape from one table edge across the maxilla to the opposite table edge. Drape the mandible out to allow maximal manipulation during surgery by placing one of the drapes into the mouth to cover the maxilla and the rest of the drapes secured around the mandible. A cancellous bone graft is not generally used with closed reduction. POSTOPERATIVE EVALUATION Dental occlusion should be evaluated. Radiographs should be evaluated for bone alignment and implant placement. POSTOPERATIVE CARE The skin and the apparatus should be cleaned daily to avoid food accumulation and skin excoriation. Oral exercise and soft foods should be limited, and no chew toys should be allowed. Radiographs should be repeated at 6-week intervals until bone bridging occurs. After the fracture has healed, the external fixator should be removed by cutting each pin to remove the acrylic frame and then removing individual pins. EXPECTED OUTCOME Bone healing is usually seen in 12 to 18 weeks. Large gaps may benefit from cancellous bone autograft if healing appears delayed. Excellent return to function is expected if dental occlusion is restored. PROCEDURE Approach: There is no surgical approach to the fracture site for closed reduction of comminuted fractures, only the approaches for the fixation pin insertion. Incise the skin at each pin insertion site. Dissect the overlaying soft tissues to gain access to the bone surface. Reference 1. Egger EL: Skull and mandibular fractures. In Slatter D (ed): Textbook of Small Animal Surgery, 2nd ed. Philadelphia, WB 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 A 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 CHAPTER 52 Transverse Scapular Body Fractures distal segment with pointed reduction forceps, and lift the bone segments out of the soft tissues until the fracture ends are apposed. While maintaining contact, slowly replace the fragments into the reduced position. Maintain reduction manually (see Plate 52A). Stabilization: Lay an appropriately contoured veterinary cuttable plate(s) across the fracture on the cranial portion of the body of the scapula, and secure with screws placed through the distal and proximal plate holes (Plate 52B). Direct the screws into the thick bone at the junction of the spine and body of the scapula (Plate 52C). Place additional screws in plate holes close to the fracture. Fill additional plate holes with screws. Alternate plate holes may be filled (see Plate 52B). When additional support is needed, the veterinary cuttable plates can be stacked, an additional plate can be positioned on the caudal border of the scapula (Plate 52D), or both. CAUTIONS It is important to avoid placing screws in the thin bone of the body of the scapula. POSTOPERATIVE EVALUATION Radiographs should be evaluated for reduction and implant position. POSTOPERATIVE CARE The animal should be confined, with activity limited to leash walking, until the fracture has healed. Radiographs should be repeated at 6-week intervals until the fracture is healed. EXPECTED OUTCOME Bone healing is usually seen in 12 to 18 weeks. Excellent return to function is expected. References 1. Jerram RM, Herron MR: Scapular fractures in dogs. Comp Cont Educ Small Animal 20:1254, 1998. 2. Piermattei DL, Johnson KA: An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB Saunders, 2004. INDICATIONS Candidates include animals with folding or displaced scapular body fractures. OBJECTIVES • To restore normal anatomic contour to the shoulder area and internally splint the fracture ANATOMIC CONSIDERATIONS Palpable landmarks are the spine and the acromial process of the scapula; and the cranial, dorsal, and caudal borders of the scapula. The body and spine of the scapula are easily approached with dissection and elevation of muscle. The suprascapular nerve runs over the scapular notch and under the acromion process.1 EQUIPMENT • Surgical pack, Senn retractors, Hohmann retractors, Gelpi retractors, periosteal elevator, pointed reduction forceps, plating equipment, high-speed drill PREPARATION AND POSITIONING Prepare the scapular region from dorsal midline to carpus. Position the animal in lateral recumbency with the affected limb up. Drape the limb out from a hanging position to allow maximal manipulation during surgery. A cancellous bone graft is usually not necessary. PROCEDURE Approach: Incise the skin and subcutaneous tissue the length of the spine distally to the shoulder joint. Transect the omotransversarius muscle from the spine, and reflect it cranially. Incise trapezius and scapular parts of the deltoideus muscles from the spine, and reflect them caudally. Incise the supraspinatus and infraspinatus muscular attachments to the spine, and elevate these muscles from the scapular body (Plate 52A).2 Reduction: Use a periosteal elevator or small Hohmann retractor as a lever to reduce the transverse fracture. Alternatively, secure the spine on the proximal segment and the CHAPTER 52 T R A N S V E R S E S C A P U L A R B O DY F R A C T U R E S 143 P L AT E 5 2 Supraspinatus muscle A Infraspinatus muscle Acromion process Long head of triceps muscle B C D 3 For chronic cases. pointed reduction forceps.3 The animal should be confined. Piermattei DL. and tighten the figure-eight wire. A cancellous bone graft is not necessary. trapezius. and drive them across the fracture line to lodge in the main bone segment. Maintain reduction with pointed reduction forceps (Plate 53B). Repair the acromion osteotomy with a tension band wire (Plate 53E). The animal should be slowly returned to normal activity after the fracture is healed. 1993. INDICATIONS Candidates include animals with avulsion fractures of the supraglenoid tuberosity. Implant removal may be necessary if soft tissues are irritated. PROCEDURE Approach: Incise the skin and subcutaneous tissue from the middle portion of the scapular spine distally to the shoulder joint. with activity limited to leash walking. 3. orthopedic wire. Hohmann retractors. Kirschner wires. pass a figure-eight wire through the hole and around the Kirschner wires. Piermattei DL. J Am Anim Hosp Assoc 29:157. Piermattei. Position the animal in lateral recumbency. For additional exposure. and then tap the thread hole to accept the appropriate screw (see Plate 53B). 2004. POSTOPERATIVE CARE The forelimb should be in a sling for 2 weeks to prevent weight bearing and to protect the fracture repair. Philadelphia.3 Reattach the greater tubercle with lag screws (Plate 53D). EXPECTED OUTCOME Bone healing is usually seen in 6 to 12 weeks. drill an appropriatesized glide hole in the fragment. osteotomize the greater tubercle and reflect the supraspinatus muscle proximally (Plate 53A). until the fracture has healed. Osteotomize the acromion process. with the severity depending on accuracy and maintenance of reduction. Radiographs should be repeated at 6-week intervals until the fracture(s) is healed. The supraglenoid tuberosity is part of the articular surface of the scapula. To place a tension band wire. bone screws and instruments for inserting bone screws. A good return to function is expected. Johnson KA: An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. 3rd ed. and scapular head of the deltoideus muscles to the scapula to expose the acromion process. attach the biceps tendon to the proximal humerus with a bone screw and spiked Teflon washer.144 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES SCAPULA CHAPTER 53 Supraglenoid Tuberosity Fractures be used if the bone is soft. 1997. Philadelphia. EQUIPMENT • Surgical pack. WB Saunders. 4th ed. periosteal elevator.2 Degenerative joint disease may result from articular trauma. It is important to avoid injuring or entrapping the suprascapular nerve. Identify and protect the suprascapular nerve. high-speed drill and wire driver. Incise the joint capsule to observe the articular surface during reduction. The suprascapular nerve runs over the scapular notch and under the acromion process.2. Stabilization: To place a lag screw. although some degree of lameness may persist. Drape the limb out from a hanging position to allow maximal manipulation during surgery. Johnston SA: Articular fractures of the scapula in the dog: A clinical retrospective study of 26 cases. wire twister. Senn retractors. Gelpi retractors. Reflect the supraspinatus muscle away from the scapular spine and neck. A cancellous screw is preferred if size permits. References 1. In Brinker. A washer may . Place a transverse drill hole in the main bone segment. Incise the attachments of the omotransversarius. Flo GL: Fractures of the scapula. Place a corresponding drill sleeve in the glide hole and drill. osteotome and mallet or oscillating saw. start two Kirschner wires in the fragment. where fracture reduction is impossible. POSTOPERATIVE EVALUATION Radiographs should be evaluated for articular surface reduction and implant placement. and Flo’s Handbook of Small Animal Orthopedics and Fracture Repair. Bend the Kirschner wires and rotate the ends over the biceps tendon (Plate 53C). 2. WB Saunders. OBJECTIVES • To restore the articular surface and compress the fracture with a lag screw or tension band wire ANATOMIC CONSIDERATIONS The biceps brachii muscle originates from the supraglenoid tuberosity. wire cutter PREPARATION AND POSITIONING Prepare the forelimb circumferentially from dorsal midline to carpus.1 Reduction: Extend the shoulder and reduce the fragment. metal washer or spiked Teflon washer. and reflect it distally with the acromial head of the deltoideus muscle. CAUTIONS Articular reduction should be maintained during implant application. measure. CHAPTER 53 SUPRAGLENOID TUBEROSITY FRACTURES 145 P L AT E 5 3 A Suprascapular nerve Infraspinatus muscle B Teres minor muscle Osteotomy line Humeral head Glenoid C D E . and drill a glide hole from the center of the fracture surface to exit proximally to the supraglenoid tuberosity prior to reducing the fracture. flexing and extending the shoulder daily after the sling is removed. measure. Senn retractors. Incise the attachments of the omotransversarius. 4th ed. osteotomize the greater tubercle of the humerus and reflect the supraspinatus muscle. until adequate range of motion returns. Reduce the neck fracture.3 INDICATIONS Candidates include animals with T fractures of the scapular neck. Philadelphia. and should be avoided. pointed reduction forceps. or with scapular neck fractures without an intra-articular component. plating equipment. 3. tenotomize the infraspinatus muscle. Close the joint capsule. orthopedic wire. The axillary artery and nerve are located immediately caudal to the joint. Johnson KA: An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. wire twisters. Piermattei DL. although some degree of lameness may persist.) Reduction: Reduce the intra-articular fracture anatomically. until the fracture has healed. J Am Anim Hosp Assoc 29:157.2.1 (See surgical procedure for supraglenoid tuberosity fracture. The suprascapular nerve and artery course over the scapular notch and under the acromial process. and Flo’s Handbook of Small Animal Orthopedics and Fracture Repair. and maintain reduction with pointed reduction forceps (Plate 54B). 2004. and scapular head of the deltoideus muscles to the scapula to expose the acromion process. For additional exposure. Maintain reduction manually. WB Saunders. Kirschner wires. The animal should be confined. Incise the joint capsule to observe the articular surface during reduction (Plate 54A). and then tap the thread hole to accept the appropriate screw (see Plate 54B). WB Saunders. OBJECTIVES • To achieve anatomic articular surface reduction and rigid immobilization of the fracture ANATOMIC CONSIDERATIONS Osteotomy of the acromion process allows reflection of a portion of the deltoideus muscle and visualization of the joint. Place an appropriate-sized drill sleeve in the glide hole and drill. wire cutters PREPARATION AND POSITIONING Prepare the forelimb from dorsal midline to carpus. Johnston SA: Articular fractures of the scapula in the dog: A clinical retrospective study of 26 cases. with activity limited to leash walking. 2. 3rd ed. If needed for complete joint exposure. 1997. Hohmann retractors. Animals should experience a fair return to function. CAUTIONS Articular reduction should be maintained during implant application. Piermattei DL. In Brinker. Philadelphia.3 Physical therapy should be performed. EXPECTED OUTCOME Bone healing is usually seen in 12 to 18 weeks. Implant removal may be necessary if soft tissues are irritated. high-speed drill and wire driver. Gelpi retractors. trapezius. It is important to avoid injuring or entrapping the suprascapular nerve. Repair the acromion osteotomy with a tension band wire (Plate 54E). with the severity depending on accuracy and maintenance of reduction. Piermattei. with the affected limb up. but these are not usually visualized with routine approaches. Chapter 53. POSTOPERATIVE EVALUATION Radiographs should be evaluated for reduction and implant position.146 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES SCAPULA CHAPTER 54 Intra-articular and Scapular Neck Fractures Stabilization: Reflect the cranial fragment. Flo GL: Fractures of the scapula. After lag screw fixation of the intra-articular fracture.2 Decreased shoulder range of motion occurs but has a minimal effect on function. and secure the reduction with pointed reduction forceps. and re-appose the infraspinatus tendon with a tendon suture. . 1993. Drape the limb out from a hanging position to allow maximal manipulation during surgery. reduce the neck fracture by carefully levering it into position. and reflect it distally with the acromial head of the deltoideus muscle. Degenerative joint disease may result from articular trauma. Reflect the supraspinatus and infraspinatus muscles away from the scapular spine and neck. and stabilize it with a small L plate (Plate 54C) or a veterinary cuttable plate or plates (Plate 54D). References 1. The animal should slowly be returned to normal activity after the fracture is healed. Position the animal in lateral recumbency. POSTOPERATIVE CARE The forelimb should be in a sling for 2 weeks to prevent weight bearing and to protect the fracture repair. A cancellous bone graft is generally not needed. Radiographs should be repeated at 6-week intervals until the fracture is healed. PROCEDURE Approach: Incise the skin and subcutaneous tissue from the middle portion of the scapular spine distally to the shoulder joint. Osteotomize the acromion process. Identify and protect the suprascapular nerve. Reduce the fracture. osteotome and mallet or oscillating saw. periosteal elevator. Atrophy of the shoulder muscles occurs if the suprascapular nerve is damaged.1 EQUIPMENT • Surgical pack. CHAPTER 54 I N T R A .A RT I C U L A R A N D S C A P U L A R N E C K F R A C T U R E S 147 P L AT E 5 4 B A Suprascapular nerve Infraspinatus muscle Teres minor muscle Humeral head Glenoid Deltoideus muscle C D E . INDICATIONS Candidates include animals with Salter I and Salter III fractures of the proximal humeral physes.148 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES HUMERUS CHAPTER 55 Proximal Humeral Physeal Fractures Reduction: Secure the greater tubercle with a pointed reduction forceps. the greater tubercle and acromion process of the scapula are palpable. Philadelphia. pin chuck or high-speed wire driver. periosteal elevator. Position the animal in lateral recumbency. PROCEDURE Approach: Incise the skin and subcutaneous tissue over the craniolateral region of the proximal humerus 2 to 3 cm proximal to the greater tubercle and extending to a point near the midshaft of the humerus.1 Incise through the insertions of these two muscles. WB Saunders. and retract them caudally to expose the lateral surface of the proximal humerus (Plate 55A). Stabilization: Starting proximally at the greater tubercle. A cancellous bone graft is not necessary. 4th ed. Reduce the epiphyseal segment or segments by manipulating the forceps while gently levering the bone into position. Elevate and reflect the brachiocephalicus muscle from the cranial surface of the bone. OBJECTIVES • To achieve fracture stabilization and anatomic reduction of the proximal humeral epiphysis and articular surface ANATOMIC CONSIDERATIONS Proximally. Maintain reduction with pointed reduction forceps (Plate 55B). and close the incision routinely. Johnson KA: An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. Kern bone-holding forceps. EQUIPMENT • Surgical pack. Senn retractors. Stabilize Salter III fractures of the proximal physis by first securing the humeral head to the proximal humerus with two Kirschner wires (Plate 55C) and then reducing the greater tubercle and securing it to the humerus with two Kirschner wires or Steinmann pins (Plate 55D). with activity limited to leash walking. Kirschner wires or small Steinmann pins for large dogs. Piermattei DL. with the affected limb up. Drape the limb out from a hanging position to allow maximal manipulation during surgery. The articular surface should be evaluated to ensure anatomic alignment. POSTOPERATIVE EVALUATION Radiographs should be evaluated for reduction and implant placement. Reference 1. Hohmann retractors. Elevate the deltoideus muscle. wire or pin cutter PREPARATION AND POSITIONING Prepare the forelimb circumferentially from dorsal midline to carpus. . but premature closure of the physis may occur. POSTOPERATIVE CARE The animal should be confined. Implant removal may be indicated if soft tissue irritation occurs. Gelpi retractors. The configuration of the physis and the cancellous bone surface provide some rotational stability to the fracture. CAUTIONS It is important to avoid damaging the physeal cartilage during reduction and to avoid penetrating the articular cartilage with the Kirschner wires. Radiographs should be evaluated in 4 weeks. drive two Kirschner wires or Steinmann pins distally and caudally to cross the fracture line and seat in the caudal metaphysis (see Plate 55B). and secure the proximal humeral diaphysis with a Kern bone-holding forceps. and retract it caudally to expose the insertions of the teres minor and infraspinatus muscles. EXPECTED OUTCOME Rapid bone healing is usually seen. The cephalic vein courses within the subcutaneous tissue along the craniolateral surface of the limb. 2004. Reattach the incised tendons. pointed reduction forceps. CHAPTER 55 P R OX I M A L H U M E R A L P H Y S E A L F R A C T U R E S 149 P L AT E 5 5 Supraspinatus muscle Infraspinatus muscle Teres minor muscle Head of humerus Triceps brachii muscle (lateral head) A Deltoideus muscle (acromial part). retracted caudally B C D . with activity limited to leash walking. 4th ed. OBJECTIVES • To achieve anatomic alignment of the articular surface and rigid fixation of the fracture to allow for rapid return to elbow function. measure. Reduce the fracture. Philadelphia. with the severity depending on accuracy and maintenance of reduction. periosteal elevator. Use a washer with the screw to prevent subsidence of the screw head in soft bone. bone screws and instruments for insertion of bone screws. WB Saunders. Radiographs should be evaluated in 4 to 6 weeks and then at 6-week intervals until the fracture is healed. . A washer should be used in immature dogs. The triceps muscle courses in a cranial proximal direction from its insertion on the olecranon and crosses the humerus rather than paralleling it. The joint should be inspected to ensure anatomic alignment of the articular surface. Drape the limb out from a hanging position to allow maximal manipulation during surgery. Hulse DA: Management of specific fractures. Retract the muscle cranially to expose the joint capsule and underlying lateral condyle. wire cutter PREPARATION AND POSITIONING Prepare the forelimb circumferentially from dorsal midline to carpus. POSTOPERATIVE EVALUATION Radiographs should be evaluated for fracture reduction and implant position. and to minimize development of degenerative joint disease ANATOMIC CONSIDERATIONS The lateral portion of the humeral condyle projects laterally from the humerus and articulates with the radial head. Place a Kirschner wire across the lateral epicondyloid crest to provide additional stability for short oblique or tranverse fractures (Plate 56D). Kirschner wires.150 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES HUMERUS CHAPTER 56 Fractures of the Lateral Portion of the Humeral Condyle Maintain reduction with pointed reduction forceps across the condyles and across the metaphyseal portion of the fracture. until the fracture is healed. Place an appropriate-sized drill sleeve in the glide hole and drill. Refracture may occur in some mature dogs after implant removal. POSTOPERATIVE CARE The animal should be confined. EXPECTED OUTCOME Rapid healing is usually seen in immature dogs. Slow healing may be seen in mature dogs. CAUTIONS The radial nerve should be protected. Senn retractors. Stabilization: Reflect the lateral condyle fragment laterally. Piermattei DL. In Fossum TW (ed): Small Animal Surgery. high-speed drill and wire driver. Mosby. Implant removal may be necessary if soft tissues are irritated. flexing and extending the elbow. 2002. Position the animal in lateral recumbency. and drill a glide hole from the center of the fracture surface to exit cranially and distally to the lateral epicondyle prior to reducing the fracture (Plate 56B). but premature closure of the physis may occur. Gelpi retractors. until adequate range of motion returns. Physical therapy should be performed daily. St. and forces are transmitted up the radius to the lateral condyle. Incise the joint capsule with an L-shaped incision to visualize the lateral portion of the humeral condyle (Plate 56A). and then tap the thread hole to accept the appropriate screw (Plate 56C). Animals may experience a decreased elbow range of motion. Incise the intermuscular septum between the extensor carpi radialis and the common digital extensor muscle. 2nd ed. and secure the reduction with pointed reduction forceps. Louis. generally this does not cause a clinical problem. humeral fractures. or mature animals with condylar fractures. pointed reduction forceps. Fractures occur when the animal jumps or falls.1 Reduction: Reduce the fracture by pushing proximally on the medial condyle and distracting the lateral fragment distally. curving cranial to the lateral epicondyle and extending 4 cm to 5 cm distal to the joint. Incise the deep fascia along the cranial border of the lateral triceps muscle. with the affected limb up. especially spaniels.2 Stabilize long oblique metaphyseal fractures with an additional lag screw (Plate 56E). washers. The radial nerve lies beneath the lateral head of the triceps near the distal third of the humerus and must be identified and protected. and continue this incision across the joint over the extensors. Place a Kirschner wire perpendicular to the fracture surface and parallel to the glide hole. Johnson AL. References 1. Degenerative joint disease may occur. and continue the incision proximally through the periosteal origin of the extensor carpi radialis muscle. 2. 2004. EQUIPMENT • Surgical pack. INDICATIONS Candidates include animals with Salter IV fracture of the lateral portion of the humeral condyle. PROCEDURE Approach: Incise the skin and subcutaneous tissue beginning over the distal third of the humerus. A cancellous bone graft is not necessary. Hohmann retractors. Johnson KA: An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. CHAPTER 56 F R A C T U R E S O F T H E L AT E R A L P O RT I O N O F T H E H U M E R A L C O N DY L E 151 P L AT E 5 6 Deep fascia Triceps brachii muscle Incision in joint capsule Extensor carpi radialis muscle Lateral condyle exposed A B Common digital extensor muscle C D E . Incise the joint capsule with an L-shaped incision to visualize the lateral humeral condyle and the articular surface (Plate 57A1). Retract the muscle cranially to expose the joint capsule and underlying lateral condyle. Position the animal in dorsal recumbency.3. until the fracture is healed. The median. pin cutter POSTOPERATIVE EVALUATION Radiographs should be evaluated for reduction and implant position. Stabilization: Stabilize the articular fracture with a lag screw. 1990. Drape the limb out from a hanging position to allow maximal manipulation during surgery.2 CAUTIONS The radial nerve should be protected on the lateral approach and the neurovascular structures on the medial approach. 2nd ed. pointed reduction forceps. The animal should be confined. Secure the condyle to the humeral shaft with a plate/rod combination. Philadelphia. Incise the intermuscular septum between the extensor carpi radialis and the common digital extensor muscle. Gelpi retractors. 1988. plating equipment. 2002. allowing an intramedullary (IM) pin to travel from the medial condyle to the greater tubercle. high-speed power drill. reduce the humeral metaphyseal fracture. Alternatively. The elbow should be taken through range of motion to check for screws penetrating the olecranon fossa. 4th ed. retrograde the IM pin from the fracture site to exit below the medial epicondyle.152 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES HUMERUS T or Y Fractures of the Distal Humerus CHAPTER 57 INDICATIONS Candidates include animals with T or Y fractures of the distal humerus. Plate and screw removal may be necessary if soft tissues are irritated. Hulse DA: Management of specific fractures: Humeral fractures. Radiographs should be repeated at 6-week intervals until the fracture is healed. Drive the pin proximally across the fracture and up the humeral diaphysis to lodge at the greater tubercle. Place an IM pin up the medial portion of the condyle and across the fracture line to help maintain reduction (Plate 57C). The plates should function as compression plates if the fractures are transverse. Carmicheal S. Louis. EQUIPMENT • Surgical pack. Inspect the joint surface to ensure anatomic alignment (Plate 57B). Hohmann retractors. 3. Kern bone-holding forceps. with severity depending on accuracy and maintenance of reduction. Fitting a plate to the lateral side of the humerus requires bending and twisting of the plate to fit the surface. Place a plate across the lateral fracture line (see Plate 57C). Degenerative joint disease may occur. Physical therapy should be performed daily. Incise the deep fascia along the cranial border of the lateral triceps muscle. Refracture may occur in some mature dogs after implant removal. and maintain reduction with pointed reduction forceps across the condyles. The medial condyle is an extension of the humeral shaft. Olmstead ML: Evaluation of surgical repair of 135 distal humeral fractures in dogs and cats. stabilize the medial and lateral fractures by applying one plate to the medial surface of the humerus and a second plate to the caudolateral epicondyloid crest (Plate 57D). and then tap the thread hole to accept the appropriate screw (see Plate 57B). References 1. especially spaniels. and continue the incision proximally through the periosteal origin of the extensor carpi radialis muscle. and continue this incision across the joint over the extensors.1 Reduction: Reduce the articular fracture. OBJECTIVES • To achieve anatomic alignment of the articular surface and rigid fixation of the fracture to allow for rapid return to elbow function. WB Saunders. In Fossum TW (ed): Small Animal Surgery. until adequate range of motion returns. Start an IM pin into the medial condyle just below the medial epicondyle. Anderson TJ. The medial side of the humerus is flat and straight. 4. and retract the nerves and vessels to expose the humerus (Plate 57A2). Animals may experience decreased elbow range of motion. and to minimize development of degenerative joint disease ANATOMIC CONSIDERATIONS The radial nerve lies beneath the lateral head of the triceps near the distal third of the humerus. and musculocutaneous nerves course along the cranial edge of the medial head of the triceps muscle. Bone healing is usually seen in 12 to 18 weeks. ulnar. Piermattei DL. curving cranial to the lateral epicondyle and extending 4 cm to 5 cm distal to the joint. St. The joint should be inspected to ensure anatomic alignment of the articular surface. Alternatively. measure. Smeak DD. To expose the medial aspect of the fracture. J Am Anim Hosp Assoc 24:537. with the affected limb up. Mosby. Place an appropriatesized drill sleeve in the glide hole and drill. making it amenable to plate placement. Drill a glide hole in the lateral condylar fragment. flexing and extending the elbow. with activity limited to leash walking. Johnson AL. The proximal humerus serves as a cancellous bone graft donor site. Miller A: Intercondylar humeral fracture in the dog: A review of 20 cases. . Vannini R. Bluntly dissect the subfascial fat.4 The IM pin may interfere with elbow function. incise the skin and subcutaneous tissue over the medial surface of the distal humerus. 2004. Cut the pin short at the distal humerus. IM pins and Jacob pin chuck. periosteal elevator. After the lag screw is placed. EXPECTED OUTCOME PROCEDURE Approach: Incise the skin and subcutaneous tissue beginning over the distal third of the humerus. J Small Anim Pract 31:437. Slow healing may be seen in mature dogs. it should be removed after the fracture has bridged with bone. 2. Johnson KA: An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. Senn retractors. The brachial artery and vein accompany the nerves on the medial aspect of the humerus. POSTOPERATIVE CARE PREPARATION AND POSITIONING Prepare the forelimb circumferentially from dorsal midline to carpus. 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 fascia Triceps brachii muscle A2 Biceps brachii muscle Neurovascular bundle Extensor carpi radialis muscle Incision in joint capsule Lateral condyle exposed Brachiocephalicus muscle Pronator teres muscle Triceps brachii muscle (medial head) Common digital extensor muscle B C D Cranial view Lateral view Caudal view . pin cutter. just proximal to the supratrochlear foramen. wire cutter. Drape the limb out from a hanging position to allow maximal manipulation during surgery. IM pins. ANATOMIC CONSIDERATIONS The radial nerve lies superficial to the brachialis muscle and deep to the lateral head of the triceps. the isthmus. fracture reduction. The IM pin neutralizes bending forces at the fracture and is combined with cerclage wire for long oblique fractures and with external fixation for transverse or short oblique fractures to neutralize rotational and axial compressive forces. The medial portion of the humeral condyle is the extension of the medullary canal. is located within the distal third of bone. Hohmann retractors. Reflect these two muscles cranially. INDICATIONS Candidates include animals with single or comminuted humeral diaphyseal fractures. to expose the proximal and central humeral shaft. it can be used for animals with medium and low fractureassessment scores. Insert the IM pin into the proximal humerus in either a normograde or retrograde manner (Plate 58A). rotational. Visualize and isolate the radial nerve. the median nerve and brachial artery run through the supracondylar foramen. OBJECTIVES • To achieve anatomic reduction of single fracture lines or restoration of normal bone alignment for nonreducible comminuted fractures The intramedullary (IM) pin is used in animals with high fracture-assessment scores. Kern bone-holding forceps.1 To gain further exposure of the distal humeral shaft.154 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES HUMERUS CHAPTER 58 Application of an Intramedullary Pin or Interlocking Nail to the Humerus clage wire. encircle the brachialis muscle and the radial nerve with a Penrose drain. and axial compressive forces at the fracture.4 Incise the skin. Position the animal in lateral recumbency. Senn retractors. The interlocking nail (ILN) neutralizes bending. low-speed drill. In cats. allowing normograde or retrograde placement of an IM pin and normograde placement of the ILN. with the affected limb up. starting at the greater tubercle. pointed reduction forceps. Jacob pin chuck. Incise through the periosteal insertion of the superficial pectoral and brachiocephalicus muscles at their insertion on the humeral shaft. external fixator equipment. and the brachialis muscle caudally. and create soft tissue tunnels to the bone for fixator pin placement. Prepare the ipsilateral proximal humerus or ilial wing for surgery if harvesting cancellous bone. ILN equipment including high-speed drill. The humerus has a cranial curvature that positions the long axis of the marrow cavity cranial to the shoulder joint. wire tightener. bone curette for harvesting cancellous graft PREPARATION AND POSITIONING Prepare the forelimb circumferentially from dorsal midline to carpus. it must be identified and protected during the surgical approach.2 Insert the ILN in a normograde manner. cer- PROCEDURE Approach: Incise the skin and subcutaneous tissues laterally from the cranial border of the greater tubercle to the lateral epicondyle.3 Use an “open but do not disturb the fragments” technique to expose the proximal and distal bone segments with minimal disturbance of the fracture hematoma and bone fragments for nonreducible fractures. Gelpi retractors. EQUIPMENT • Surgical pack. retract them caudally to expose the proximal and mid-diaphysis and cranially to expose the distal diaphysis. Continued . Incise the brachial fascia along the border of the brachiocephalicus muscle and the lateral head of the triceps. and stabilization. The narrowest part of the medullary canal. periosteal elevator. CHAPTER 58 A P P L I C AT I O N O F A N I M P I N O R I N T E R L O C K I N G N A I L T O T H E H U M E R U S 155 P L AT E 5 8 A Greater tubercle Deltoideus muscle (acromial part) Radial nerve Penrose drain Superficial pectoral muscle Brachiocephalicus muscle Brachialis muscle . Louis.5 Apply an IM pin and cerclage wire to a long oblique fracture (Plate 58C). It is important to avoid the distal joint surface with the IM pin or ILN. External fixator management includes daily pin care and pin packing as needed. Dewey C: Experimental and clinical experience with an IM pin external skeletal fixator tie-in configuration. 4th ed. The IM pin should be removed when the fracture is healed. Philadelphia. Reduce comminuted nonreducible fractures by distracting the distal end with the IM pin or ILN and aligning the major segments of the bone. place a fixation pin in the metaphysis and a fixation pin close to the fracture. POSTOPERATIVE CARE The animal should be confined. Roe SC. Apply an ILN and four screws to the humerus for treatment of comminuted nonreducible fractures (Plate 58D). 1991. Piermattei DL. Reduce transverse and short oblique fractures by tenting the bone ends and levering the bone back into position. Vet Comp Orthop Traumatol 4:86. 5. J AM Vet Med Assoc 214:59. humeral fractures. Compend Cont Educ Pract Vet 17:35. POSTOPERATIVE EVALUATION Radiographs should be evaluated for bone alignment and implant placement. Hulse DA: Management of specific fractures. Johnson AL. Aron DN. 1995. Radiographs should be evaluated in 6 weeks. 2004. with activity limited to leash walking. EXPECTED OUTCOME Bone healing is usually seen in 12 to 18 weeks (depending on fracture and signalment of the animal). et al: Interlocking nail treatment of diaphyseal long bone fractures in dogs. Johnson KA: An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. 3. Maintain the reduction manually (for transverse fractures) or with pointed reduction forceps (for oblique fractures). Johnson AL: Biologic strategies and a balanced concept for repair of highly comminuted long bone fractures. Reduce long oblique fractures by distracting the bone segments and approximating the fracture surfaces. Aron DN. the top fixation pin and its connection to the IM pin should be retained. . 2nd ed. In each segment. Palmer RH. In Fossum TW (ed): Small Animal Surgery. Stabilization: Apply an IM pin and type Ia external fixator to the lateral surface of the humerus (Plate 58B).2 Retract the pin within the medullary canal of the proximal segment (see Plate 58A). If a tie-in is used.156 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES Reduction: Place an IM pin (sized to equal 70% to 80% of the medullary canal at the isthmus) in the proximal segment. Mosby. Use pointed reduction forceps to manipulate the bone segments into reduction. References 1. Radiographs should be repeated at 6-week intervals until the fracture is healed. Fixation pins should be removed after radiographic signs of bone bridging are observed. Johnson KA. 1999. 2. Rotational alignment should be monitored during the realignment of comminuted fractures. WB Saunders. 2002. until the fracture has healed. Be sure to restore length and normal rotational alignment to the bone. The external fixator can be connected or “tied-in” to the IM pin in order to strengthen the fixation. CAUTIONS The radial nerve should be identified and protected during the procedure. Direct the pin toward the caudomedial cortex so it will seat in the medial portion of the condyle when the fracture is reduced and the pin is driven distally. Dueland RT. The range of motion of the elbow should be palpated to detect pin interference in the joint. 4. St. CHAPTER 58 A P P L I C AT I O N O F A N I M P I N O R I N T E R L O C K I N G N A I L T O T H E H U M E R U S 157 P L AT E 5 8 B C D . The medial portion of the condyle is an extension of the humeral shaft. and the brachialis muscle caudally. to expose the proximal and central. OBJECTIVES • To achieve anatomic reduction and compression of single fracture lines.158 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES HUMERUS CHAPTER 59 Application of a Plate to the Humerus speed drill. Position the animal in lateral recumbency. self-centering plate-holding forceps. cranial. bone curette for harvesting graft PREPARATION AND POSITIONING Prepare the forelimb circumferentially from dorsal midline to carpus. and the brachial artery and vein. and stabilization. Incise through the periosteal insertion of the superficial pectoral and brachiocephalicus muscles at their insertions on the humeral shaft. Gelpi retractors or Hohmann retractors. care must be taken to isolate and protect the median. Prepare the ipsilateral proximal humerus or ilial wing for surgery to harvest cancellous bone. The cranial and medial surfaces of the humerus are relatively flat and amenable to plate placement. Retract the biceps brachii muscle and the nerves and vessels caudally (to expose the proximal portion of the humerus) and cranially (to expose the middle and distal portion of the humerus) (Plate 59B).2 The humerus has a cranial curvature that positions the long axis of the marrow cavity cranial to the shoulder joint. Penrose drain. rotational. The radial nerve lies superficial to the brachialis muscle and deep to the lateral head of the triceps. and ulnar nerves. Visualize and protect the radial nerve. lateral. Jacob pin chuck. high- from the cranial border of the greater tubercle to the lateral epicondyle. encircle the brachialis muscle and the radial nerve with a Penrose drain and retract them caudally (to expose the proximal and mid-diaphysis) and cranially (to expose the distal diaphysis). or restoration of normal bone alignment. Incise the brachial fascia along the border of the brachiocephalicus muscle and the lateral head of the triceps. PROCEDURE Approach: Incise the skin and subcutaneous tissues laterally INDICATIONS Candidates include animals with single or comminuted humeral diaphyseal fractures.3 Continued . musculocutaneous. or lateral humeral shaft (Plate 59A). allowing normograde or retrograde placement of an IM pin. or medial surface of the humerus. plating equipment. it is combined with lag screws to compress long oblique fractures. Position the animal in dorsal recumbency for the medial approach to the humerus. Drape the limb out from a hanging position to allow maximal manipulation during surgery. in nonreducible comminuted fractures The plate is used as a compression plate for transverse or short oblique fractures. with the affected limb up for the craniolateral approach. pointed reduction forceps. neutralizing bending. EQUIPMENT • Surgical pack. and axial compressive forces.1 ANATOMIC CONSIDERATIONS The plate may be placed on the cranial. Kern bone-holding forceps. IM pins. incise the skin and subcutaneous tissue over the medial surface of the humerus from the greater tubercle to below the medial epicondyle. Reflect these two muscles cranially. During the medial approach to the humerus.2 Use an “open but do not disturb the fragments” technique to expose the proximal and distal bone segments with minimal disturbance of the fracture hematoma and bone fragments for nonreducible fractures. allowing an IM pin to travel from the medial condyle to the greater tubercle.2 To gain further exposure of the distal lateral humeral shaft. To expose the medial aspect of the fracture. Senn retractors periosteal elevator. In cats. Incise the deep brachial fascia along the caudal border of the brachiocephalicus muscle and the distal portion of the insertion of the superficial pectoral muscle. it must be identified and protected during the surgical approach. The plate is used as a bridging plate for nonreducible comminuted fractures and may be combined with an intramedullary (IM) pin to reduce strain on the plate and to extend fatigue life of the fixation. Fitting a plate to the lateral side of the humerus requires bending and twisting of the plate to fit the surface. fracture reduction. the median nerve and brachial artery run through the supracondylar foramen. CHAPTER 59 A P P L I C AT I O N O F A P L AT E T O T H E H U M E R U S 159 P L AT E 5 9 A B Musculocutaneous nerve (proximal branch) Greater tubercle Superficial pectoral muscle Brachiocephalicus muscle Deltoideus muscle (acromial part) Radial nerve Triceps brachii muscle Penrose drain Superficial pectoral muscle Biceps brachii muscle (retracted cranially) Musculocutaneous nerve (distal branch) Brachiocephalicus muscle Brachialis muscle . Drive the pin proximally across the fracture and up the humeral diaphysis to lodge at the greater tubercle.160 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES Reduction: Reduce transverse and short oblique fractures by tenting the bone ends and levering the bone back into position. Johnson AL: Biologic strategies and a balanced concept for repair of highly comminuted long bone fractures. a neutralization plate to support a reconstructed fracture (Plate 59D). 2. 3. 1995. Compend Cont Educ Pract Vet 17:35. nonreducible fractures by distracting the distal or proximal segments with an IM pin (sized to equal 40% to 50% of the medullary canal at the isthmus) and aligning the major segments of the bone (see Plate 59A). POSTOPERATIVE CARE The animal should be confined. In Brinker WO. Hyman W. Piermattei DL. In Fossum TW (ed): Small Animal Surgery. lateral. Koestlin R. 2004. EXPECTED OUTCOME Bone healing is usually seen in 12 to 18 weeks (depending on fracture and signalment of the animal). Hulse DA: Management of specific fractures. Johnson AL. retrograde the IM pin from the fracture site to exit below the medial epicondyle. The plate can function as a compression plate (Plate 59C) when used to compress transverse or short oblique fractures. Palmer RH. Alternatively.4 Stabilization: Apply an appropriately contoured plate to the cranial. Radiographs should be evaluated in 6 weeks. et al: Fractures of the humerus. . Vet Surg 26:451. Insert the IM pin into the proximal humerus in either a normograde or retrograde manner. Philadelphia. Reduce comminuted. Physical therapy may be necessary to restore elbow range of motion. start an IM pin into the medial condyle just below the medial epicondyle. with activity limited to leash walking. Reduce long oblique fractures by distracting the bone segments and approximating the fracture surfaces. 1997. 5. References 1. It is important to avoid the distal joint surface and olecranon fossa with the IM pin and bone screws. humeral fractures. 2nd ed. 3rd ed. 4. Be sure to restore length and normal rotational alignment to the bone. The IM pin should be removed after radiographic signs of bone bridging are observed. Radiographs should be repeated at 6week intervals until the fracture is healed. For distal fractures. Johnson KA: An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. Nori M. 4th ed. Rotational alignment should be monitored during the realignment of comminuted fractures. The range of motion of the elbow should be palpated to detect implant interference in the joint. Plate removal may be necessary after the fracture heals to relieve soft tissue irritation. Maintain the reduction manually (for transverse fractures) or with pointed reduction forceps (for oblique fractures). Kasa G. 2002. or as a bridging plate. Philadelphia. Louis. Mosby.5 POSTOPERATIVE EVALUATION Radiographs should be evaluated for bone alignment and implant placement. or medial surface of the humerus. Kasa F. Use pointed reduction forceps to manipulate the bone segments into reduction. Aron DN. 1997. spanning a nonreducible comminuted fracture (Plate 59E). WB Saunders. WB Saunders. Flo GL (eds): Handbook of Small Animal Orthopedics and Fracture Repair. Hulse D. et al: Reduction in plate strain by addition of an intramedullary pin. St. CAUTIONS All neurovascular structures should be identified and protected during the procedure. Piermattei D. CHAPTER 59 A P P L I C AT I O N O F A P L AT E T O T H E H U M E R U S 161 P L AT E 5 9 C D E . and fixation pin placement. using biplanar frames. The proximity of the thorax prohibits use of bilateral frames in the proximal humerus. bending. and rotational forces at the fracture. In cats. Senn retractors. Be sure to restore length and normal rotational alignment to the bone. the median nerve and brachial artery run through the supracondylar foramen. is located within the distal third of bone. external fixation equipment. The medial portion of the humeral condyle is the extension of the medullary canal. allowing normograde or retrograde placement of an IM pin. bone curette for harvesting graft PREPARATION AND POSITIONING Prepare the forelimb circumferentially from dorsal midline to carpus. The humerus has a cranial curvature that positions the long axis of the marrow cavity cranial to the shoulder joint. just proximal to the supratrochlear foramen. Retract the pin within the medullary canal of the proximal segment (see Plate 60A). Kern bone-holding forceps. Position the animal in lateral recumbency. it must be identified and protected during the surgical approach. Direct the pin toward the caudal medial cortex so it will seat in the medial portion of the condyle when the fracture is reduced and the pin is driven distally. Reflect these two muscles cranially. Insert the IM pin into the proximal humerus in either a normograde or retrograde manner (Plate 60A). Continued . or the biplanar fixator alone resists axial loading. IM pins.1 The fracture and fixator combination. Gelpi retractors. Incise the brachial fascia along the border of the brachiocephalicus muscle and the lateral head of the triceps. reflect the brachialis muscle cranially and the lateral triceps muscle caudally. or a closed reduction technique for nonreducible fractures. low-speed power drill. Jacob pin chuck. ANATOMIC CONSIDERATIONS The radial nerve lies superficial to the brachialis muscle and deep to the lateral head of the triceps. Use an “open but do not disturb the fragments” technique to expose the proximal and distal bone segments with minimal disturbance of the fracture hematoma and bone fragments. small Hohmann retractors. Reduce comminuted. Reduce long oblique fractures by distracting the bone segments and approximating the fracture surfaces. PROCEDURE Approach: Incise the skin and subcutaneous tissues laterally INDICATIONS Candidates include animals with single or comminuted humeral diaphyseal fractures. to expose the proximal and central humeral shaft. Prepare the ipsilateral proximal humerus or ilial wing for harvesting cancellous bone. EQUIPMENT • Surgical pack. Reduction: Place an IM pin (sized to equal 70% to 80% of the medullary canal at the isthmus) in the proximal segment.3 Incise the skin and create soft tissue tunnels to the bone for fixator pin placement. or use the distal fixation pin to distract and align the bone during closed reduction. Drape the limb out from a hanging position from the cranial border of the greater tubercle to the lateral epicondyle. and incorporating an intramedullary (IM) pin. periosteal elevator. The narrowest part of the medullary canal.2 To gain further exposure of the distal humeral shaft. OBJECTIVES • To achieve anatomic reduction of single fracture lines or restoration of normal bone alignment in comminuted fractures The stiffness of the fixator can be increased in animals with low fracture-assessment scores by adding fixation pins.162 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES HUMERUS CHAPTER 60 Application of an External Fixator to the Humerus to allow maximal manipulation during surgery. Maintain the reduction manually (for transverse fractures) or with pointed reduction forceps (for oblique fractures). the IM pin and fixator combination. Visualize and isolate the radial nerve.4 Reduce transverse and short oblique fractures by tenting the bone ends and levering the bone back into position. pointed reduction forceps. fracture reduction. Incise through the periosteal insertion of the superficial pectoral and brachiocephalicus muscles at their insertions on the humeral shaft. with the affected limb up. Use pointed reduction forceps to manipulate the bone segments into reduction. pin cutter. and the brachialis muscle caudally. nonreducible fractures by distracting the distal end with the IM pin and aligning the major segments of the bone. the isthmus. 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 A Greater tubercle Deltoideus muscle (acromial part) Radial nerve Penrose drain Superficial pectoral muscle Brachiocephalicus muscle Brachialis muscle . In each segment. Aron DN. 4th ed. 1995. Add an IM pin and tie it into the fixator for additional stability for comminuted fractures. 1991. Monitor rotational and angular alignment during the reduction and fixation of comminuted fractures. Johnson AL. 5. EXPECTED OUTCOME Bone healing is usually seen in 12 to 18 weeks (depending on fracture and signalment of the animal).6 by removing the unilateral frame (type Ia and IM pin) or the cranial frame (modified type Ib fixator) when bone bridging is observed. The IM pin. In Proceedings of the 10th Annual Complete Course in External Skeletal Fixation. 4. The animal may experience limited function while the external fixator is in place.164 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES Stabilization: Apply an IM pin and a type Ia external fixator to the lateral surface of the humerus (Plate 60B). 2004. Avoid penetrating the distal joint surface or olecranon fossa with the IM pin. POSTOPERATIVE CARE Gauze sponges should be packed around the pins. Vet Comp Orthop Traumatol 4:86. Mosby.5 Long oblique fractures benefit from cerclage wire in addition to the IM pin. Angular malalignments should be corrected by loosening the clamps and realigning the fixation pins on the connecting bar. St. The external fixator can be connected or tied in to the IM pin to strengthen the fixation. 6. Avoid major nerves and vessels and joint surfaces with the fixation pins. 2002. . decision making in fracture management. 2002. In Fossum TW (ed): Small Animal Surgery. If a tie-in is used. Johnson KA: An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. 2002. 127–141. The animal should be confined. 2. Aron DN: External skeletal fixation system application to the humerus and femur. the external fixator. Palpate the range of motion of the elbow to detect pin interference in the joint. Hulse DA: Fundamentals of orthopedic surgery and fracture management. and the sponges should be secured with a bandage. The fixator should be destabilized References 1. University of Georgia. Compend Cont Educ Pract Vet 17:35. Johnson AL. but a good return to function can be expected. WB Saunders. St. with activity limited to leash walking. Apply a modified type Ib external fixator to a comminuted nonreducible fracture (Plate 60D). Louis. Hulse DA: Management of specific fractures. Aron DN. 2nd ed. Philadelphia. Dewey C: Experimental and clinical experience with an IM pin external fixator tie-in configuration. or both (Plate 60C). the top fixation pin and its connection to the IM pin should be retained. place a fixation pin in the metaphysis and a fixation pin close to the fracture. Physical therapy should be instituted to restore elbow range of motion. 2nd ed. or both should be removed when the fracture is healed. Radiographs should be repeated at 6-week intervals to monitor healing. humeral fractures. Palmer RH. External fixator management includes daily pin care and pin packing as needed. the remaining external fixator. POSTOPERATIVE EVALUATION Radiographs should be evaluated for bone alignment and implant placement. Louis. CAUTIONS Identify and protect the radial nerve during the procedure. In Fossum TW (ed): Small Animal Surgery. 3. Piermattei DL. Mosby. Johnson AL: Biologic strategies and a balanced concept for repair of highly comminuted long bone fractures. 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 B C D . In Brinker WO. and axial compressive forces. pointed reduction forceps. 3. bone curette for harvesting graft POSTOPERATIVE CARE The animal should be confined.4 Plates are used as a neutralization plate to support a reconstructed fracture (Plate 61C) or as a bridging plate spanning a nonreducible comminuted fracture (Plate 61D). 2004. EQUIPMENT • Surgical pack. 1997.166 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES RADIUS CHAPTER 61 Application of a Plate to the Radius Stabilization: Apply an appropriately contoured plate to the cranial surface of the radius (Plate 61B1). Reduce comminuted nonreducible fractures by distracting and aligning the major segments of the bone while being careful not to disturb the fragments. Roush JK. Larsen LJ. et al: The intraosseous blood supply of the canine radius: Implications for healing of distal fractures in small dogs. 4th ed. DeJardin LM. Welch JA. 5. J Am Anim Hosp Assoc 35:243. interference with tendons is possible. Philadelphia. Position the animal in dorsal recumbency. CAUTIONS ANATOMIC CONSIDERATIONS The flat cranial surface of the radius is ideal for plate placement. WB Saunders. rotational. Extend the incision proximally by incising between the extensor carpi radialis muscle and the pronator teres muscle. it is combined with lag screws to compress long oblique fractures. Senn retractors. Miller CW: Fractures of the radius and ulna. Reduce and secure long oblique fractures with pointed reduction forceps. The plate can function as a compression plate when used to compress transverse or short oblique fractures. 1997. . Alternatively. then good function is expected. Radiographs should be evaluated in 6 weeks. or restoration of normal bone alignment. neutralizing bending.and miniature-breed dogs. Sardinas JC. 1999. 3rd ed. The articular surface should also be avoided. Reduction: Reduce transverse fractures by tenting the bone ends dorsally and levering the bone back into position. Boudrieau RJ. periosteal elevator. McLaughlin RM: Bone plate fixation of distal radius and ulnar fractures in small. Extend the incision distally. WB Saunders. bone healing is seen in 6 to 12 weeks. The ipsilateral proximal humerus serves as a cancellous bone graft donor site. and elevate the extensor tendons to expose the cranial surface of the radius. Philadelphia. Incise the skin and subcutaneous tissue to expose the radial diaphysis. EXPECTED OUTCOME Generally. plating equipment. 2. The medial surface may be used for plate placement for distal radial fractures. Johnson KA: An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. crossing the distal radial physis with the plate or screws should be avoided. self-centering plate reduction forceps. The intramedullary pin should be removed from the ulna after radiographic signs of bone bridging are observed.3 A plate may also be applied to the medial surface of the distal radius (Plate 61B3). Montavon PM: Use of a medial bone plate for repair of radius and ulna fractures in dogs and cats: A report of 22 cases. stiff plates. Hohmann retractors. The plate is used as a bridging plate for nonreducible comminuted fractures. with activity limited to leash walking. however. If additional support is needed. OBJECTIVES • To achieve anatomic reduction and compression of single fracture lines.5 Delayed union may occur in toy breed dogs.2 Limit the exposure to the distal portion of the radius for distal radial diaphyseal fractures. 4. Binnington AG. Piermattei D. Vet Surg 26:57. PREPARATION AND POSITIONING Prepare the forelimb circumferentially from above the shoulder to the phalanges. POSTOPERATIVE EVALUATION Radiographs should be evaluated for fracture reduction or bone alignment and implant placement. It is important to pay careful attention to bony anatomic landmarks to avoid rotation of the distal segment.1 Bone resorption or osteopenia may occur under the plate in toy breed dogs whose fractures are stabilized with relatively large. an intramedullary pin may be placed in the ulna to support the bridging plate fixation. Roll the animal slightly to allow access to the medial surface of the limb.5 PROCEDURE Approach: Palpate the radius directly under the skin and subcutaneous tissue on the craniomedial surface of the limb. Flo GL (eds): Handbook of Small Animal Orthopedics and Fracture Repair. Drape the limb out from a hanging position. the insertions of the pronator and supinator muscles are incised on the radius (Plate 61A). Vet Surg 26:108. a veterinary T plate or cuttable plate may be used for distal radial transverse or short oblique fractures (Plate 61B2).1 In immature dogs. The cephalic vein crosses the medial portion of the distal radius. Maintain reduction by securing the plate with plate-holding forceps. Piermattei DL. If needed. Short oblique fractures may be better reduced by tenting the bone ends medially and levering the bone back into position. Plate removal may be necessary after the fracture heals to relieve soft tissue irritation or thermal conduction. in nonreducible comminuted fractures The plate is used as a compression plate for transverse or short oblique fractures. Distal radial fractures may also be reduced by securing a precontoured plate to the distal segment and reducing the proximal segment to the plate. high-speed drill. Round hole plates act as tension band plates and do not allow compression with the plate. 1997. Limited soft tissue coverage and marginal vascular supply contribute to a high percentage of delayed unions or nonunions in toy breed dogs.3 INDICATIONS Candidates include animals with single or comminuted radial diaphyseal fractures or toy breed dogs with distal diaphyseal fractures. References 1. Radiographs should be repeated at 6-week intervals until the fracture is healed. CHAPTER 61 A P P L I C AT I O N O F A P L AT E T O T H E R A D I U S 167 P L AT E 6 1 A Supinator muscle Pronator teres muscle Flexor carpi radialis muscle Radius Radial artery Superficial digital flexor muscle Median artery B1 B2 B3 C D . Place fixation pins in the metaphysis of each segment and close to the fracture line. bone curette for harvesting cancellous graft POSTOPERATIVE CARE Gauze sponges should be packed around the pins. Drape the limb out in the hanging position. Cranial caudal joint surface relationships should mimic the contralateral intact bone. 1996. The cephalic vein crosses the medial portion of the distal radius. Place at least EXPECTED OUTCOME Bone healing is usually seen in 12 to 18 weeks. end-threaded pins to increase pin bone interface stability. Maintain the reduction manually. Reduction: Lower the table to allow the animal’s weight to fatigue the muscles. Intraoperative radiographs are useful to verify joint alignment during closed reductions. periosteal elevator. low-speed power drill. 2nd ed. and lateral surfaces of the bone. whereas the medial aspect of the distal two thirds of the radius is covered only by skin and subcutaneous tissue. and variable cranial bowing of the diaphysis. Medial and lateral angular alignment is correct when the proximal and distal joint surfaces are parallel (see Plate 62B). 3. use the proximal and distal transfixation pins to manipulate the bone and align the joint surfaces. Position the animal in dorsal recumbency. or one connecting bar (of the type II fixator) when bone bridging is observed. pin cutter.168 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES RADIUS CHAPTER 62 Application of an External Fixator to the Radius two (or preferably three) fixation pins in each bone segment. CAUTIONS It is important to avoid major nerves and vessels and joint surfaces with the fixation pins. 2nd ed. External fixator management includes daily pin care and pin packing as needed. Apply a type Ib frame by placing a unilateral frame on the cranial medial surface of the radius and an additional unilateral frame on the cranial lateral surface of the radius (Plate 62D1). and the sponges should be secured with a bandage that incorporates the paw to limit postoperative swelling. In general. lever the fragments into position through the limited surgical approach (see Plate 62A). Seitz SE. 2002. cranial surface. St. Mosby. Jacob pin chuck. Mosby. Louis. Use positive profile. The external fixator should be removed when the fracture is healed. Senn retractors. ANATOMIC CONSIDERATIONS The radius has a flat. and suspend the affected limb from the ceiling. cranial lateral. Radiographs should be repeated at 6-week intervals to evaluate healing. pointed reduction forceps. Hulse DA: Fundamentals of orthopedic surgery and fracture management. external skeletal fixators. Smith CW. resists axial loading. For closed reduction of comminuted fractures. unilateral fixation pins can be applied to the diaphysis of the radius (Plate 62E). If the cranial curve of the radius precludes the placement of transfixation pins. The proximal radial joint surface parallels the distal radial joint surface when viewed on a cranial caudal radiograph. St. The animal should be confined. and rotational forces at the fracture. bending. To accommodate the width of the radius and avoid fracturing the bone. Angular malalignments should be corrected by loosening the clamps and realigning the fixation pins on the connecting bar. narrow medial and lateral surfaces.2. small Hohmann retractors. Johnson AL. Use closed reduction techniques for nonreducible fractures (Plate 62B). In Fossum TW (ed): Small Animal Surgery. medial. Johnson AL. et al: Closed reduction and type II external fixation of severely comminuted fractures of the radius and tibia in dogs: 23 cases (1990–1994). Animals experience limited function while the external fixator is in place but should have a good return to function. Hulse DA: Fundamentals of orthopedic surgery and fracture management. selected fixation pins (type Ia or type II fixator). or the fixator alone. Reduce and maintain long oblique fractures with pointed reduction forceps while lag screws or cerclage wires are applied. OBJECTIVES • To achieve anatomic reduction of single fracture lines or restoration of normal bone alignment for comminuted fractures The stiffness of the fixator can be increased for animals with low fracture-assessment scores by adding fixation pins and using biplanar or bilateral frames. Stabilization: Apply a type Ia external fixator to the cranial medial surface of the radius (Plate 62C). Maintain reduction by securing the connecting bars. . Incise the skin and create soft tissue tunnels to the bone for pin placement. POSTOPERATIVE EVALUATION Radiographs should be evaluated for fracture reduction or bone alignment and implant placement. Place additional pins when there is adequate bone. 2002. PROCEDURE Approach: Perform a limited medial approach to the fracture site for reducible fractures (Plate 62A). external fixation equipment. Johnson AL.3 References 1. Check rotational alignment by flexing the elbow and the carpus after raising the table: the paw should align with the radius. it is advisable to consider using smaller fixation pins when they are inserted medially and laterally. EQUIPMENT • Surgical pack. Apply a type II frame by inserting transfixation pins through the metaphyses and additional fixation pins 1 cm to 2 cm from the fracture line. Louis. decision making in fracture management. Connect the biplanar frames with articulating bars (Plate 62D2). 2. with activity limited to leash walking. Prepare the ipsilateral proximal humerus for cancellous bone autograft donor site if open reduction is used. For transverse fracture lines. The proximal third of the bone is completely covered with muscle. Angular and rotational alignment should be monitored during the reduction. J Am Vet Med Assoc 209:1445. fixation pins can be applied on the cranial medial. In Fossum TW (ed): Small Animal Surgery. The fixator should be destabilized by removing one unilateral frame (type Ib fixator).1 The fracture and fixator combination. depending on fracture and signalment of the animal.3 INDICATIONS Candidates include animals with single or comminuted radial diaphyseal fractures. PREPARATION AND POSITIONING Prepare the affected forelimb circumferentially from midline to foot. wide. CHAPTER 62 A P P L I C AT I O N O F A N E X T E R N A L F I X AT O R T O T H E R A D I U S 169 P L AT E 6 2 Cranial view A Left forelimb B D2 Cranial view C D1 E . Drape the limb out from a hanging position to allow maximal manipulation during surgery. POSTOPERATIVE EVALUATION Radiographs should be evaluated for reduction and implant placement. 2002. but premature closure of the physis may occur. Reduction: Carefully reduce the physeal fracture to avoid crushing or injuring the physeal cartilage. Hohmann retractors. POSTOPERATIVE CARE The animal should be confined. The common and lateral digital extensor tendons lie cranial to the antebrachial carpal joint and may need to be retracted to expose the antebrachial carpal joint surface. The cephalic vein crosses the medial portion of the distal radius. Johnson AL. wire cutter or pin cutter PREPARATION AND POSITIONING Prepare the forelimb circumferentially from shoulder to the digits. PROCEDURE Approach: Incise skin and subcutaneous tissue dorsally from distal radial diaphysis to the proximal metacarpus. radial and ulnar physeal fractures. Elevate and . across the physis into the radial metaphyses. Position the animal in lateral recumbency. Implant removal may be required if irritation occurs. Drive a second wire from the lateral aspect of the distal radial epiphysis. Kirschner wires or small Steinmann pins (for large dogs). and through the lateral cortex. across the fracture into the metaphysis. If possible. which arise from the ulnar styloid process. The antebrachial carpal joint is supported by the short radial collateral ligaments. Reference 1. St. bend the pins and cut off the excess. and by the short ulnar collateral and radioulnar ligaments. Louis. OBJECTIVES • To stabilize the fracture and achieve anatomic reduction of the distal radial physis ANATOMIC CONSIDERATIONS The cranial medial surface of the distal radius can be easily palpated to serve as a landmark for location of the incision. The extensor carpi radialis tendon lies over the medial aspect of the joint.1 CAUTIONS It is important to avoid damaging the physeal cartilage or articular cartilage. Senn retractors. by the dorsal radiocarpal ligament. with activity limited to leash walking. pointed reduction forceps. and through the medial cortex avoiding the articular surface (Plate 63C).170 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES RADIUS CHAPTER 63 Distal Radial Physeal Fractures retract the extensor tendons laterally as needed for fracture visualization (Plate 63A). A cancellous bone graft is not necessary. Hulse DA: Management of specific fractures. Mosby. EQUIPMENT • Surgical pack. INDICATIONS Candidates include animals with Salter I and Salter II fractures of the distal radial physis. 2nd ed. Radiographs should be evaluated in 4 weeks. which arise from the medial styloid process of the radius. EXPECTED OUTCOME Rapid bone healing is usually seen. with the affected limb up or in dorsal recumbency for greater flexibility. this will cause radial shortening if the animal is still growing. pin chuck or high-speed wire driver. which arises from the dorsal surface of the distal radius. Maintain reduction with pointed reduction forceps or manual pressure (Plate 63B). In Fossum TW (ed): Small Animal Surgery. periosteal elevator. Stabilization with Crossed Kirschner Wires: Drive a Kirschner wire from the medial styloid process. 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 A Radial diaphysis Radial metaphysis Radial carpal bone Ulna B C . retrograde the Kirschner wires before reducing the fracture. OBJECTIVES • To convert the tensile forces resulting from the pull of the triceps muscles to compressive forces at the fracture. but in transverse fractures. The hard bone of the ulna makes drilling wires difficult. Pin migration may occur with tension band wires. WB Saunders. It is necessary to irrigate during drilling to reduce bone necrosis. Be sure to restore length and normal rotational alignment to the bone. Alternatively. Hohmann retractors. 1995. and drive them across the fracture line to lodge in the distal bone segment. reduce the articular fragments anatomically. Elevate the flexor carpi ulnaris and deep digital flexor muscles medially. Be sure the articular surface is anatomically aligned. pointed reduction forceps.3 Transverse proximal ulnar fractures. including articular fractures. Comminuted reducible proximal ulnar fractures. Johnson KA: Fractures of the proximal ulna in dogs. Palmer RH. The tension band wire converts tensile forces to compressive forces at the fracture. wire tighteners. Piermattei DL. using the loaded drill guide to insert one or two screws (Plate 64C). Compend Cont Educ Pract Vet 17:35. 1996. Johnson KA: An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. pass a figure-eight wire through the hole and around the Kirschner wires. Drape the limb out from a hanging position to allow maximal manipulation during surgery. secure the proximal fragment with a pointed reduction forceps and place it into alignment. and compress the fracture lines with lag screws. depending on the size.1 Use an “open but do not disturb the fragments” technique to expose the proximal and distal bone segments with minimal disturbance of the fracture hematoma and bone fragments for nonreducible nonarticular fractures. with the affected limb up. To stabilize a comminuted reducible fracture. Vet Comp Orthop Traumatol 9:88. 2004. reduction and stabilization of the radial head are imperative. The plate provides rigid fixation and resists axial loading. Aron DN. The animal should be confined. The articular surface of the trochlear notch can be exposed surgically by muscle elevation. POSTOPERATIVE CARE PREPARATION AND POSITIONING Prepare the forelimb circumferentially from shoulder to carpus. For single fractures. and the ulnaris lateralis muscle laterally. Reduce comminuted. are treated with either a tension band wire or a plate. use a tension band wire. Oblique fracture reduction may be maintained with pointed reduction forceps. CAUTIONS Articular reduction should be maintained during implant application. Degenerative joint disease may result from articular trauma. ANATOMIC CONSIDERATIONS Landmarks for the approach to the proximal ulna are the olecranon and the palpable caudal border of the ulna. Pin placement must follow the contour of the proximal ulna. flexing and extending the elbow until adequate range of motion returns. Philadelphia.3 Implant removal may be necessary if soft tissues are irritated. Place a transverse drill hole in the distal bone segment. high-speed drill and Kirschner wire driver. bending. with severity depending on accuracy and maintenance of reduction. orthopedic wire. caudal to the medial epicondyle. EXPECTED OUTCOME Bone healing is usually seen in 6 to 18 weeks. Muir P. Start two Kirschner wires in the proximal fragment. Senn retractors. nonreducible fractures that do not affect the joint surface may be bridged with a plate (Plate 64E). Animals usually experience a good return to function. and tighten the figure-eight wire. The ulnar nerve courses over the medial aspect of the elbow. The ipsilateral proximal humerus can serve as a cancellous graft harvest site.2 Reduction: Extend the elbow to aid reduction. and rotation. Apply an appropriately contoured plate to the lateral surface of the ulna (Plate 64D). starting at the olecranon and extending distally over the ulnar diaphysis. activity. Position the animal in lateral recumbency. Physical therapy should be performed daily. apply an appropriately contoured plate to the lateral surface of the ulna. plating equipment. 4th ed. Reflect the origin of the flexor carpi ulnaris muscle to expose the trochlear notch and articular surface (Plate 64A). 3. Bend the Kirschner wires and rotate the ends over the triceps tendon (Plate 64B). periosteal elevator. bone curette for harvesting cancellous graft POSTOPERATIVE EVALUATION Radiographs should be evaluated for articular surface reduction and implant placement. and to neutralize the forces acting on the fracture or bridge the fracture with a plate If an associated luxation of the radial head is present (Monteggia fracture). Radiographs should be repeated at 6-week intervals until the fracture is healed. with activity limited to leash walking.172 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES ULNA CHAPTER 64 INDICATIONS Proximal Ulnar Fractures fractures by distracting the fracture and aligning the major segments of the bone. Kirschner wires. and healing potential of the animal. Gelpi retractors. Compress the fracture line. Johnson AL: Biologic strategies and a balanced concept for repair of highly comminuted long bone fractures. . Plates may be applied to the caudal surface of the ulna. 2. EQUIPMENT • Surgical pack. depending on the fracture and signalment of the animal. are treated with reconstruction of the articular surface and either a neutralization plate or bridging plate. Stabilization: To stabilize a transverse or short oblique fracture. if size permits. including articular fractures and comminuted nonreducible ulnar fractures. manual maintenance of reduction is necessary. nonreducible References 1. It is important to avoid penetrating the articular surface with implants. Alternatively. PROCEDURE Approach: Incise the skin and subcutaneous tissue medial to the caudal border of the ulna. to expose the bone surface. Comminuted. to achieve anatomic reduction of the articular surface. CHAPTER 64 P R OX I M A L U L N A R F R A C T U R E S 173 P L AT E 6 4 A Flexor carpi ulnaris muscle (ulnar head) Ulnaris lateralis muscle Anconeus muscle B C D E . Reduction is achieved and maintained with the bone screw. high-speed drill PREPARATION AND POSITIONING Prepare the rear limb circumferentially from dorsal midline to mid-tibia and from 10 cm cranial to the iliac crest to the tail head caudally.4 Determine the proper location of the glide hole in the ilium by palpating the articular prominence on the medial surface of the . Sem Vet Med Surg Sm Anim 7:63. where it may be necessary to incise through fibers of the superficial gluteal muscle. Steinmann pin) through the iliac wings. EQUIPMENT • Surgical pack. Bend the smooth end. Incise through the periosteal origin of the middle gluteal muscle on the lateral ridge of the iliac crest and the deep gluteal fascia and periosteal origin of the sacrospinalis muscle on the medial ridge of the iliac crest. crescent-shaped. WB Saunders. 1985. Gelpi retractors. POSTOPERATIVE CARE The animal should be confined. DeCamp CE.174 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES P E LV I S CHAPTER 65 Sacroiliac Luxation iliac wing or by locating the glide hole in the caudal dorsal quadrant of the area of the ilium under the straight portion of the dorsal iliac crest (Plate 65C). Drill the glide hole at the predetermined position with the appropriate-sized drill bit. The incisions merge caudally. Philadelphia. Senn retractors. over the dorsal surface of L7. DeCamp CE. Piermattei and Flo’s Handbook of Small Animal Orthopedics and Fracture Repair. INDICATIONS Candidates include animals with unstable sacroiliac luxations. 4. 4th ed.6 References 1. A cancellous bone graft is usually unnecessary. blunt Hohmann retractor. Kern bone-holding forceps. Use the Kern bone-holding forceps to manipulate the ilium caudally into alignment with the articular surface of the sacroiliac joint. Philadelphia. Radiographic evidence of bone bridging or callus formation at the sacroiliac joint may or may not be evident. 2002. Vet Surg 14:131. Visually guide the screw tip into the prepared thread hole in the sacrum. 2. The depth of the thread hole in the sacral body should be such that the screw tip will extend to the midline of the sacral body. Johnson AL. Reflect the ilium laterally to expose the sacroiliac joint. synovial joint and (2) a fibrocartilaginous synchondrosis.5 CAUTIONS The screw must be optimally placed into the sacral body to gain secure bone purchase and avoid implant failure. Radiographs should be evaluated at 6 and 12 weeks after surgery. Flo GL: Fractures of the pelvis.2 Position a blunt Hohmann retractor between the ilium and ventral bony shelf of the sacrum. and place a nut on the threaded end to prevent pin migration (Plate 65D). with activity limited to leash walking. Piermattei DL. OBJECTIVES • To restore pelvic canal width and stabilize the sacroiliac joint ANATOMIC CONSIDERATIONS The sacroiliac joint has two distinct components: (1) a semilunar. Position the animal in lateral recumbency. begin- ning over the dorsal iliac crest and extending caudally parallel to the spine to a point even with the hip joint. 5. 2nd ed. and then tighten the screw (see Plate 65C). especially those that cause pelvic canal narrowing.1 The sacral nerve roots and the sciatic nerve course behind the ilial body. 1985. WB Saunders. In Brinker. with loss of pelvic canal diameter. periosteal elevator. Louis. 1992. and reflect the ilium ventrally to expose the sacral joint surface (Plate 65A). Stabilization: Use the appropriate-sized drill bit to drill a thread hole 2 mm cranial and 2 mm proximal to the center of the crescent-shaped articular cartilage (Plate 65B). St. Braden TD: Sacroiliac fracture-separation in the dog: A study of 92 cases. A second screw may be added if room permits. Elevate the middle gluteal muscle from the lateral surface of the ilium to further expose the ilium for screw placement. Advance a cancellous screw of the proper length through the glide hole until the tip appears on the medial surface of the ilium. Braden TD: The anatomy of the canine sacrum for lag screw fixation of the sacroiliac joint. 3. POSTOPERATIVE EVALUATION Radiographs should be evaluated for bone alignment and implant placement. to expose the iliac crest. PROCEDURE Approach: Incise the skin and subcutaneous tissue. Hulse DA: Management of specific fractures: Sacroiliac luxations/fractures. Implant loosening and migration. with the affected limb up and with the dorsal midline raised 45 degrees from the table. 3rd ed. 2004.3 Reduction: Place a Kern bone-holding forceps on the wing of the ilium to manipulate the hemipelvis (see Plate 65C). The landmarks of the notch on the lateral surface of the sacrum and the crescent-shaped auricular cartilage are used to position the screw into the body of the sacrum. Johnson KA: An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. DeCamp CE: Principles of pelvic fracture management. Mosby. bone screws and instruments for inserting screws. 6. Animals should experience an excellent return to function. can occur. until the fracture/luxation has stabilized. threaded. In Fossum TW (ed): Small Animal Surgery. 1997.5 Large or overweight dogs may benefit from inserting a transilial bolt (generally a small end. Piermattei DL. EXPECTED OUTCOME Bone healing is usually seen in 6 to 12 weeks. Vet Surg 14:127. It is important to avoid damaging nerve roots and to avoid screw insertion into the spinal canal. CHAPTER 65 S A C R O I L I A C L U X AT I O N 175 P L AT E 6 5 Gluteal surface of wing of ilium Intermediate sacral crest A Hohmann retractor B Middle gluteal muscle C D . 2004. The sacroiliac joint is located medially to the iliac wing. Sharply dissect cranially to separate the middle gluteal muscle and long head of the tensor fascia latae muscle.2 Attach the plate to the caudal segment first with bone screws. Hulse DA: Management of specific fractures: Ilial fractures. Place at least three plate screws in the cranial segment and two or three (space permitting) in the caudal segment (Plate 66C). Contour a plate to fit the normal curvature of the lateral surface of the bone. with activity limited to leash walking. plating equipment. Flo GL (eds): Handbook of Small Animal Orthopedics and Fracture Repair. Sharply dissect the origin of the middle gluteal from the cranial wing of the ilium for additional exposure and easier reduction. EXPECTED OUTCOME Bone healing is usually seen in 6 to 12 weeks. and the tensor fasciae latae and superficial gluteal muscle caudally.176 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES P E LV I S CHAPTER 66 Ilial Body Fractures Reduction: Place Kern bone-holding forceps over the caudal ilial segment. pointed reduction forceps. . platereduction forceps. the caudal fragment is often displaced medially and cranially to the wing of the ilium. Position the animal in lateral recumbency. PROCEDURE Approach: Incise skin and subcutaneous tissue over the ventral third of the iliac wing from the cranial extent of the iliac crest to 1 cm to 2 cm beyond the greater trochanter caudally. and use pointed reduction forceps to secure long oblique fractures in reduction. In Fossum TW (ed): Small Animal Surgery. Matis U: Fractures of the pelvis. WB Saunders. and reposition it lateral to the cranial segment. Piermattei DL. Use a periosteal elevator as a lever to help reduce transverse fractures. With ilial fractures. Gelpi retractors. Reestablishment of ilial integrity is required for weight transfer from the limb to axial skeleton. OBJECTIVES • To achieve anatomic fracture reduction. Animals should experience an excellent return to function. with the affected limb up. Olmstead ML. A cancellous bone graft is usually unnecessary. 3rd ed. WB Saunders. The sciatic nerve is located medial to the ilial body. Johnson AL. EQUIPMENT • Surgical pack. In Brinker WO. high-speed drill PREPARATION AND POSITIONING Prepare the rear limb circumferentially from dorsal midline to mid-tibia and from 10 cm cranial to the iliac crest to the tail head caudally. periosteal elevator. Drape the limb out from a hanging position to allow maximal manipulation during surgery. References 1. POSTOPERATIVE EVALUATION Radiographs should be evaluated for bone alignment and implant placement. The ilial body is located between the wing of the ilium cranially and the acetabulum caudally. Kern bone-holding forceps. Clamp the cranial portion of the plate to the cranial segment of the ilium to obtain lateralization of the caudal ilial segment and to maintain reduction (Plate 66B). Incise the fascia to separate the tensor fasciae latae muscle and middle gluteal muscle cranially.1 Maintain exposure using Gelpi retractors and by placing a blunt Hohmann retractor under the dorsal surface of the proximal bone segment (Plate 66A). Elevate the deep and middle gluteal muscles from the lateral surface of the ilium. Louis. plates are not removed after bone healing unless there are problems with the implant. Generally. blunt Hohmann retractor. 2002. and restoration of pelvic canal width ANATOMIC CONSIDERATIONS The iliac wing curves medially to hold the middle and deep gluteal muscles. Stabilization: Secure the plate by placing screws in the cranial segment. The bone in the tip of the iliac wing is thin and may not hold implants well. 1997. Use the Kern forceps to retract the caudal segment caudally.2. Senn retractors. rigid fracture stabilization. Philadelphia. 4th ed. St. using a ventrodorsal radiograph of the contralateral ilium as a guide. POSTOPERATIVE CARE The animal should be confined. Radiographs should be repeated at 6-week intervals until fracture healing is observed.3 INDICATIONS Candidates include animals with transverse or oblique displaced ilial body fractures. Myerding retractors. Johnson KA: An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. CAUTIONS It is important to avoid trapping the sciatic nerve during fracture reduction and to avoid penetrating deeply into the pelvic canal with drill bits and taps. Piermattei D. Mosby. Philadelphia. Screws may penetrate the sacrum for additional bone purchase. until the fracture has healed. 3. 2nd ed. The plate should be contoured sufficiently to open the pelvic canal. 2. The cranial gluteal artery vein and nerve lie over the ilial body and are often damaged by the injury. CHAPTER 66 I L I A L B O DY F R A C T U R E S 177 P L AT E 6 6 A Middle gluteal muscle Deep gluteal muscle Shaft of ilium B C . Reflect the gluteal muscles and greater trochanter from the joint capsule with a periosteal elevator. Radiographs should be repeated at 6-week intervals until the fracture is healed. POSTOPERATIVE CARE PREPARATION AND POSITIONING Prepare the rear limb circumferentially from dorsal midline to mid-tibia. Use caudal segment control to reduce the frac- References 1. and place a Kern boneholding forceps on it. WB Saunders. Stabilization: Position a contoured acetabular plate or reconstruction plate on the dorsal rim of the acetabulum so at least two plate screws secure the caudal fragment and three plate screws secure the cranial fragment3. with the round ligament on the medial face. and the biceps femoris caudally. maintain reduction manually. Visualize the alignment of the articular surface by distracting the femoral head from the acetabulum. and incise both structures together at the trochanteric fossa. and skin. CAUTIONS The sciatic nerve must be protected. J Small Anim Pract 34:547. until the fracture has healed.4 (see Plate 67B). The fibrous joint capsule originates from the lateral acetabular rim and inserts onto the femoral neck. EQUIPMENT • Surgical pack. Suture the fascial layers. Incise the deep leaf of the fascia lata. Gelpi retractors. 3. DeYoung DJ. The sciatic nerve courses dorsomedial to the acetabulum. taps. The normal conformation. gluteals. Progressive degenerative joint disease may occur if reduction is not anatomic. Pre-place a suture through the insertions of the gemelli muscles and tendon of the internal obturator. 1986. and carry the incision proximally through the insertion of the tensor fasciae latae muscle at the greater trochanter and along the cranial border of the superficial gluteal muscle. wire cutter POSTOPERATIVE EVALUATION Radiographs should be evaluated for joint alignment and implant placement. Houlton JEF: Use of reconstruction plates for repair of acetabular fractures in 16 dogs. wire twister. Slow leash walking and range-ofmotion exercises for the hip should be encouraged. and the iliopsoas muscles). 4th ed. high-speed drill and K-wire driver.e. 5. and retract the muscle caudally. 2. Reduce and stabilize the greater trochanter with two Kirschner wires and a tension band wire (Plates 67C and 67D). following the cranial border of the femur. Incise through the insertion of the superficial gluteal muscle at the third trochanter. et al: Clinical evaluation of canine acetabular fractures stabilized with an acetabular plate. Richardson DC. internal and external rotators. with activity limited to leash walking. 1993. and from 10 cm cranial to the iliac crest to the tail head caudally. Prieur WD: New plate for acetabular fractures: Technique of application and long-term follow-up evaluation. Dyce J.. The articular surface is on the dorsolateral face of the acetabulum. Perform an osteotomy of the greater trochanter with an osteotome and mallet or with Gigli wire. periosteal elevator. Accurate plate contouring is essential for maintaining articular surface alignment.178 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES P E LV I S CHAPTER 67 Transverse or Short Oblique Acetabular Fractures ture. Vet Surg 17:220.1 Reduction: Expose the tuber ischium. pointed reduction forceps. Anson LW. Elevate the gemelli muscles from the caudolateral surface of the acetabulum with a periosteal elevator. to find and visualize the course of the sciatic nerve. Kirschner wires. 2nd ed. 2004. Reflect the superficial gluteal muscle proximally. Use the suture to retract the muscles proximally and caudally (Plate 67A). Incise the joint capsule to expose the articular fracture. and ligament of the femoral head act to stabilize the joint. Otherwise. EXPECTED OUTCOME Bone healing is usually seen in 12 to 18 weeks. Johnson AL. In Fossum TW (ed): Small Animal Surgery. 1988. Kirschner wires and orthopedic wire may be removed after bone healing if the implants irritate the soft tissues. with the affected limb up. blunt Hohmann retractor. orthopedic wire. Close the wound by suturing the gemelli and internal obturator tendons to their point of insertion. Myerding retractors. 4. The animal should be confined. Drape the limb out from a hanging position to allow maximal manipulation during surgery. St. Philadelphia. Position the animal in lateral recumbency. subcutaneous tissue. 2002. Piermattei DL. it is possible to maintain reduction with a pointed reduction forceps or a small Kirschner wire driven across the fracture (Plate 67B). It is important to avoid penetrating deep into the pelvic canal or into the articular surface with drill bits. Mosby. PROCEDURE Approach: Incise the skin and subcutaneous tissue starting 3 cm to 4 cm proximal to the dorsal ridge of the greater trochanter and curving 3 cm to 4 cm. Louis. Senn retractors. suction-like effect of the synovial fluid. Hulse DA: Management of specific fractures: Acetabular fractures. Johnson KA: An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. plating equipment. . J Am Vet Med Assoc 188:1183.2 In some cases. Kern bone-holding forceps. Animals should experience a good return to function if anatomic reconstruction is achieved and maintained. Move the plate to allow three screws purchase in the caudal segment if the fracture involves the cranial acetabulum. or screws. INDICATIONS Candidates include animals with transverse or short oblique fractures through the dorsal rim of the acetabulum.5 Plate removal is generally not necessary. OBJECTIVES • To achieve anatomic articular surface reduction and rigid fixation to encourage full return to function and minimize development of degenerative joint disease ANATOMIC CONSIDERATIONS The hip joint is a ball-and-socket joint composed of the femoral head and acetabulum. Braden TD. surrounding musculature (i. Incise the superficial leaf of the fascia lata at the cranial border of the biceps femoris muscle. A cancellous bone graft is usually unnecessary. CHAPTER 67 T R A N S V E R S E O R S H O RT O B L I Q U E A C E TA B U L A R F R A C T U R E S 179 P L AT E 6 7 Osteotomy of the greater trochanter Tensor fasciae latae muscle (retracted cranially) Superficial gluteal muscle (retracted proximally) A Gemelli muscles incised Sciatic nerve Osteotomy of the greater trochanter Vastus lateralis muscle B C D . the biceps caudally. . is equal to the distance the pin will be driven into the epiphysis. Move the joint through a normal range of motion after each wire to ensure that it has not penetrated the articular surface. and drive the pins into the femoral epiphysis. References 1. Start two Kirschner wires in the fragment. Drive the remaining wires into the femoral epiphysis using a similar guiding process. Incise the deep gluteal tendon close to its attachment on the trochanter for one third to one half of its width. Place the wires parallel to one another and position them in the femoral neck so that they lie in a triangle. and slide the fracture surface of the femoral neck caudally into the matching surface of the femoral epiphysis. The blood supply to the femoral epiphysis is a series of cervical ascending vessels lying outside the femoral neck that cross the periphery of the physis and penetrate the epiphysis. Philadelphia. Drape the limb out from a hanging position to allow maximal manipulation during surgery. OBJECTIVES • To achieve anatomic reduction and fracture stabilization ANATOMIC CONSIDERATIONS The proximal femoral physis lies between the femoral epiphysis and femoral neck. PROCEDURE Approach: Incise the skin and subcutaneous tissue 5 cm proximal to the greater trochanter. Radiographs should be evaluated in 4 to 6 weeks. A cancellous bone graft is not necessary. Continue the joint capsule incision laterally through the point of origin of the vastus lateralis muscle on the cranial face of the proximal femur (Plate 68A). the distance between the pin chuck and the forceps on the adjacent pin. Position the animal in lateral recumbency. curving distally adjacent to the cranial ridge of the trochanter. and retract the femoral neck distally so that it lies cranial and level with the acetabulum (Plate 68B). Drill a transverse hole in the major bone segment. Stabilization of a Trochanteric Physeal Fracture with a Tension Band Wire: Reduce the trochanter. high-speed quick-release wire driver. Tighten the wire (see Plate 68D). and pass a figure-eight wire through the hole and around the Kirschner wire. Piermattei DL. wire cutter PREPARATION AND POSITIONING Prepare the rear limb circumferentially from dorsal midline to mid-tibia. 2004. with the affected limb up.180 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES FEMUR CHAPTER 68 Proximal Femoral Physeal Fractures Stabilization with Three Kirschner Wires: Insert the wires from the lateral aspect of the femur. 1996. periosteal elevator. Tillson DM. and extending distally for 5 cm over the proximal femur. Estimate the distance into the epiphysis. pointed reduction forceps. Premature closure of the physis may result in a misshapen femoral head. Partial resorption of the femoral neck (apple coring effect) usually occurs. secure it with a pointed reduction forceps. Drive the wires until the points are just visible at the fracture surface (see Plate 68B). WB Saunders. a). Roush JK: Fractures of proximal femoral physis in dogs. Incise between the tensor fasciae latae muscle and deep border of the biceps femoris muscle and superficial gluteal muscle. Compend Cont Educ Pract Vet 18(11):1164. Bend the pins at the lateral surface. Implants must provide stability against rotational and shearing forces. Hold the reduction by pressing against the proximal piece in the acetabulum (Plate 68C). Johnson KA: An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. b. Frog leg and extended hip views may help pin position visualization. and cut off the excess (Plate 68D). and mark an adjacent pin to provide a guide (see 68C.1 EQUIPMENT • Surgical pack. 4th ed. paralleling the femoral neck anteversion angle. EXPECTED OUTCOME Rapid bone healing is usually seen within 3 to 4 weeks. Myerding retractors. Closure is routine. Reflect the vastus lateralis distally to expose the hip joint. and provides neck length until maturity. and INDICATIONS Candidates include animals with Salter I and Salter II fractures of the physis. and drive them perpendicular to and across the physis to lodge in the medial cortex of the proximal femur. Incise the joint capsule (or enlarge the traumatic tear) parallel to the long axis of the femoral neck near its proximal ridge. Occasionally this injury is accompanied by a trochanteric physeal fracture. 2. Retract the tensor fasciae latae cranially. Kirschner wires. but this rarely causes a problem. with activity limited to leash walking for 3 to 4 weeks. POSTOPERATIVE EVALUATION Radiographs should be evaluated for reduction and implant position. and the middle gluteal muscle proximally. Senn retractors. McLaughlin RM. CAUTIONS It is important to avoid penetrating the articular surface with the Kirschner wires.2 Reduction: Grasp the proximal femur with a pointed reduction forceps. Derotate the femur. POSTOPERATIVE CARE The animal should be confined. Gelpi retractors. Hohmann retractors. Reduce the fracture. CHAPTER 68 P R OX I M A L F E M O R A L P H Y S E A L F R A C T U R E S 181 P L AT E 6 8 Tensor fasciae latae muscle retracted cranially Middle gluteal muscle retracted proximally Deep gluteal muscle Incision in joint capsule Vastus lateralis muscle A Biceps femoris muscle retracted caudally B a Distance a = b C b D . Philadelphia. 2 mm shorter than the length measured. Frog leg and extended hip views may help implant position visualization. curving distally adjacent to the cranial ridge of the trochanter. 2002. 2004. Piermattei DL. St. with activity limited to leash walking. bone screws and instruments for inserting bone screws. the biceps caudally. 4th ed. Position the animal in lateral recumbency. periosteal elevator. Prepare the ipsilateral wing of the ilium for cancellous bone graft harvest. high-speed drill and wire driver.182 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES FEMUR CHAPTER 69 Femoral Neck Fractures visualization is not adequate for anatomic reduction and placement of implants. Hohmann retractors. CAUTIONS It is important to follow the anteversion angle of the femoral neck with the implants and to avoid penetrating the articular surface with Kirschner wires and the bone screw. Louis. Insert a partially threaded cancellous screw.2 A greater trochanteric osteotomy may be required if References 1. Drape the limb out from a hanging position to allow maximal manipulation during surgery. OBJECTIVES • To achieve anatomic reduction and rigid fixation of the fracture to allow early return to function ANATOMIC CONSIDERATIONS The femoral neck/femoral shaft junction in the frontal plane is known as the angle of inclination. In Fossum TW (ed): Small Animal Surgery. so that all the threads cross the fracture plane and are seated into the femoral head. and tap the thread hole. POSTOPERATIVE EVALUATION Radiographs should be evaluated for reduction and implant position. Myerding retractors. and extending distally for 5 cm over the proximal femur. Johnson AL. Johnson KA: An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. Retract the tensor fasciae latae cranially. Instability at the fracture site can result in delayed union and implant failure. Gelpi retractors. The normal angle of anteversion is 15 to 20 degrees and must be considered when inserting screws or pins into the femoral neck. This angle is normally 135 degrees and should be approximated when surgical reduction is performed.2 Reduction: Place two Kirschner wires so they lie at the most proximal and distal level of the fracture surface. and drive the Kirschner wires into the femoral epiphysis to maintain reduction (Plate 69C). Reduce the fracture. with the affected limb up.1 EQUIPMENT • Surgical pack. and the middle gluteal muscle proximally. . Incise the joint capsule parallel to the long axis of the femoral neck near its proximal ridge. Senn retractors. WB Saunders. POSTOPERATIVE CARE The animal should be confined. Measure the length of screw needed. Reflect the vastus lateralis ventrally to visualize the fracture surface (Plate 69A). Stabilization: Drill a thread hole through the femoral epiphysis with the appropriate-sized drill bit parallel to and centered between the Kirschner wires (see Plate 69C). Kirschner wires. Radiographs should be repeated at 6-week intervals until the fracture has healed. to exit and lie flush at the fracture surface (Plate 69B). 2nd ed. wire cutter PREPARATION AND POSITIONING Prepare the rear limb circumferentially from dorsal midline to mid-tibia. Incise the deep gluteal tendon close to its attachment on the trochanter for one third to one half of its width. PROCEDURE Approach: Incise the skin and subcutaneous tissue 5 cm proximal to the greater trochanter. Continue the joint capsule incision laterally through the point of origin of the vastus lateralis muscle on the cranial face of the proximal femur. Close the incision routinely. INDICATIONS Candidates include animals with transverse and short oblique femoral neck fractures. Hulse DA: Femoral metaphyseal fractures. Mosby. 2. Leave one or both wires in place to serve as antirotational devices (Plate 69D). Drive the pins either from medial to lateral beginning at the fracture surface or from the lateral surface medially. EXPECTED OUTCOME Bone healing is usually seen within 6 to 12 weeks. Incise between the tensor fasciae latae muscle and deep border of the biceps femoris muscle and superficial gluteal muscle. CHAPTER 69 FEMORAL NECK FRACTURES 183 P L AT E 6 9 Tensor fasciae latae muscle retracted cranially Deep gluteal muscle Middle gluteal muscle retracted proximally Vastus lateralis muscle Biceps femoris muscle retracted caudally A B C D . Close the incision routinely. OBJECTIVES • To achieve fracture stabilization. 3. A cancellous bone graft is not necessary. 2004. Reduce the fracture. EXPECTED OUTCOME Rapid bone healing is usually seen in 3 to 4 weeks. Cut the excess pin off below the skin above the trochanteric fossa. blunt Hohmann retractor. and drive the pins into the femoral metaphysis and through the opposite cortices (Plate 70C). pointed reduction forceps. EQUIPMENT • Surgical pack. To avoid the sciatic nerve. Holmburg DL: Ex vivo biomechanical comparison of pin fixation techniques for canine distal femoral physeal fractures. The configuration of the growth plate and cancellous bone surface provide some rotational stability.3 Add a cross pin at the fracture to establish rotational stability if necessary (Plate 70D). Cut the distal part of the pin. Philadelphia. 1997. wire cutter PREPARATION AND POSITIONING Prepare the rear limb circumferentially from dorsal midline to tarsus. with activity limited to leash walking. Radiographs should be evaluated in 4 to 6 weeks. and countersink it below the level of the articular cartilage. J small Anim Pract 40:519. to the level of the fracture surface. cranial to the origin of the caudal cruciate ligament. Place a pointed reduction forceps from the trochlear surface to the jaws of the Kern (Plate 70B). and anatomic or slight overreduction of the femoral epiphysis ANATOMIC CONSIDERATIONS The distal femoral growth plate is shaped like a W and lies at the joint capsule reflection. Drape the limb out from a hanging position to allow maximal manipulation during surgery. Reduce the fracture. Stabilization with Crossed Pins: Position two pins to enter the epiphysis at a point cranial to the medial and lateral epicondyles. Piermattei DL. periosteal elevator. Reflect the quadriceps muscles. Position the animal in lateral recumbency. Gelpi retractors. patella. with the affected limb up. Steinmann pins and Kirschner wires. and drive them proximally to a point where they References 1. Make a parapatellar arthrotomy through the distal fascia lata and joint capsule. Sukhiani HR. Johnson KA: An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. INDICATIONS Candidates include animals with Salter I and Salter II fractures of the distal femoral physis. Jacob pin chuck. and direct the pin in a normograde fashion proximally into the femur to exit at the trochanteric fossa. 1999. Vet Surg 26:398. 4th ed. CAUTIONS The epiphyseal bone is soft: it is important to avoid excessive bone forceps pressure. Premature closure of the physis may result in a noticeable shortened leg in very young animals. 2. POSTOPERATIVE CARE The animal should be confined. PROCEDURE Approach: Incise skin and subcutaneous tissue on the cra- nial lateral surface. continuing the incision proximally along the caudal border of the vastus lateralis muscle through the intermuscular septum of the fascia lata. Physical therapy and early return to function are necessary to avoid extensor tie down. and patella tendon medially to expose the articular surface of the femoral condyles (Plate 70A). POSTOPERATIVE EVALUATION Radiographs should be evaluated for bone alignment and implant placement. The pin should contact the caudal surface of the medullary canal proximal to the fracture. Kern bone-holding forceps. . A lateral arthrotomy is necessary for exposure. Maintain reduction during pin placement by placing a Kern bone-holding forceps on the lateral aspect of the distal femoral metaphysis. Stigen O: Supracondylar femoral fractures in 159 dogs and cats treated using a nomograde intramedullary pinning technique.2 Stabilization with an Intramedullary Pin: Insert a pin through the articular cartilage. with the incision centered over the palpable end of the femoral metaphysis. WB Saunders.184 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES FEMUR CHAPTER 70 Distal Femoral Physeal Fractures are just visible at the fracture surface.1 Reduction: Reduce the fracture by levering the condyles cranially and distally with a blunt Hohmann retractor placed between the fracture fragments. the hip should be extended and the limb adducted when the intramedullary pin is driven through the trochanteric fossa. Senn retractors. CHAPTER 70 D I S TA L F E M O R A L P H Y S E A L F R A C T U R E S 185 P L AT E 7 0 Quadriceps muscles. and patella tendon reflected medially Fascia latae and biceps femoris muscles retracted Joint capsule incised Lateral head of the gastrocnemius muscle Lateral collateral ligament A B C D . patella. Extend the hip and adduct the limb when retrograding the IM pin. periosteal elevator. Both anatomic features constrain the size of the IM pin or ILN selected. OBJECTIVES • To achieve anatomic reduction of single fracture lines or restoration of normal bone alignment for nonreducible comminuted fractures The intramedullary (IM) pin is used in animals with high fracture-assessment scores. Retract the muscles to expose the femur. allowing normograde or retrograde placement of an IM pin and normograde placement of the ILN. external fixator clamps and connecting bars (or ILN equipment.4 Incise the skin. including high-speed drill). just distal to the third trochanter. it is combined with cerclage wire for long oblique fractures and with external fixation for transverse or short oblique fractures to neutralize rotational and axial compressive forces. Position the animal in lateral recumbency. The IM pin neutralizes bending forces at the fracture. The trochanteric fossa is directly in line with the medullary canal. to avoid injuring the sciatic nerve (Plate 71A). bone curette for harvesting graft PREPARATION AND POSITIONING Prepare the rear limb circumferentially from dorsal midline to tarsus. Kern lateral surface of the thigh. the isthmus. the greater trochanter is 90 degrees to the patella when the rotational alignment of the femur is correct. is located within the proximal third of bone. and axial compressive forces at the fracture. EQUIPMENT • Surgical pack. The distal femur has a pronounced cranial bow in most dogs.186 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES FEMUR CHAPTER 71 Application of an Intramedullary Pin or Interlocking Nail to the Femur bone-holding forceps. IM pins. Incise the tensor fascia lata along the cranial border of the biceps femoris to expose the vastus lateralis and biceps femoris muscles. with the affected limb up. and create soft tissue tunnels to the bone for fixator pin placement. Prepare the ipsilateral proximal humerus or ipsilateral ilial wing for surgery for harvesting cancellous bone graft. Gelpi retractors. Continued . wire tightener. Jacob pin chuck. wire cutter. Use an “open but do not disturb the fragments” technique to expose the proximal and distal bone segments with minimal disturbance of the fracture hematoma and bone fragments for nonreducible fractures. starting at the trochanteric fossa. it can be used for animals with medium and low fracture-assessment scores.1 ANATOMIC CONSIDERATIONS The narrowest part of the medullary canal. from the greater trochanter to the femoral condyles. cerclage wire. The adductor magnus muscle attaches to the caudal surface of the femur and serves as a guide for rotational alignment. Myerding or Hohmann retractors. Additionally. PROCEDURE Approach: Incise the skin and subcutaneous tissue on the INDICATIONS Candidates include animals with single or comminuted femoral diaphyseal fractures.2 Insert the IM pin into the proximal femur in either a normograde or retrograde manner. rotational. The interlocking nail (ILN) neutralizes bending. but it is straight in the cat. Drape the limb out from a hanging position to allow maximal manipulation during surgery.3 Insert the ILN in a normograde manner. pointed reduction forceps. CHAPTER 71 A P P L I C AT I O N O F A N I M P I N O R I N T E R L O C K I N G N A I L T O T H E F E M U R 187 P L AT E 7 1 Biceps femoris muscle retracted Shaft of the femur Vastus lateralis muscle retracted Adductor magnus muscle Vastus intermedius muscle A . References 1. Compend Cont Educ Pract Vet 17:35. Johnson KA: An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. 3. Reduce long oblique fractures by distracting the bone segments and approximating the fracture surfaces. External fixator management includes daily pin care and pin packing as needed. Apply an ILN and four screws to the femur to treat comminuted nonreducible fractures (Plate 71D). Radiographs should be repeated at 6-week intervals until the fracture is healed. Reduce comminuted nonreducible fractures by distracting the distal end with the IM pin or ILN and aligning the major segments of the bone. Palmer RH. 1988. The range of motion of the stifle should be palpated to detect pin interference in the joint. Philadelphia. Fixator pins should be removed after radiographic signs of bone bridging are observed. An external fixator can be added for additional strength. CAUTIONS To avoid penetrating the sciatic nerve when retrograding the IM pin. Place fixation pins in the metaphysis of each segment and close to the fracture line. Reduce transverse and short oblique fractures by tenting the bone ends and levering the bone back into position. 2. POSTOPERATIVE EVALUATION Radiographs should be evaluated for bone alignment and implant placement. Palmer RH. 2004. Apply an IM pin and multiple cerclage wires to a long oblique fracture (Plate 71C). Johnson AL: Biologic strategies and a balanced concept for repair of highly comminuted long bone fractures. Aron DN. Louis. 2nd ed. Hulse DA: Decision making in fracture management. Drive the IM pin distally to seat in the femoral condyle. the limb should be held in a hip extended and adducted position while the pin exits the trochanteric fossa. 2002. The external fixator can be connected or tied in to the IM pin to strengthen the fixation (Plate 71B). It is important to avoid the femoral head and distal joint surface with the IM pin or ILN. Johnson AL. the top fixation pin and its connection to the IM pin should be retained. with activity limited to leash walking. Angular and rotational alignment should be monitored during the realignment of comminuted fractures. St.188 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES Reduction: Place an IM pin (sized to equal 70% to 80% of the medullary canal at the isthmus) in the proximal segment. Mosby. until the fracture is healed. . Radiographs should be evaluated in 6 weeks. In Fossum TW (ed): Small Animal Surgery. Physical therapy is needed to restore stifle range of motion. 4. Use pointed reduction forceps to manipulate the bone segments into reduction. depending on fracture and signalment of the animal. If a tie-in is used. Purinton PT: Relationship of femoral intramedullary pins to the sciatic nerve and gluteal muscles after retrograde and normograde insertion. Retract the pin within the medullary canal of the proximal segment. EXPECTED OUTCOME Bone healing is usually seen in 12 to 18 weeks. The IM pin should be removed when the fracture has healed. 1995. Aron DN. 4th ed. Vet Surg 17:65. Maintain the reduction manually for transverse fractures and with pointed reduction forceps for oblique fractures. WB Saunders. Piermattei DL. POSTOPERATIVE CARE The animal should be confined. Stabilization: Apply an IM pin and a type Ia external fixator to the lateral surface of the femur to stabilize a transverse or short oblique fracture. CHAPTER 71 A P P L I C AT I O N O F A N I M P I N O R I N T E R L O C K I N G N A I L T O T H E F E M U R 189 P L AT E 7 1 B C D . If left long. 1988. and it is combined with lag screws to compress long oblique fractures. The trochanteric fossa is directly in line with the medullary canal.190 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES FEMUR CHAPTER 72 Application of a Plate to the Femur fractures. the IM pin should be removed after signs of bone bridging are observed. Additionally.4 Stabilization: Apply an appropriately contoured plate to the lateral surface of the femur. 4th ed. Reduce comminuted nonreducible fractures by distracting the distal segment with an IM pin (sized to equal 40% to 50% of the medullary canal at the isthmus) and aligning the major segments of the bone (see Plate 72A). Angular and rotational alignment should be monitored during the realignment of comminuted fractures. POSTOPERATIVE EVALUATION EQUIPMENT • Surgical pack. OBJECTIVES • To achieve anatomic reduction and compression of single fracture lines or restoration of normal bone alignment for nonreducible comminuted fractures The plate is used as a compression plate for transverse or short oblique fractures. . Incise the tensor fascia lata along the cranial border of the biceps femoris to expose the vastus lateralis and biceps femoris muscles. with the affected limb up. CAUTIONS To avoid penetrating the sciatic nerve when retrograding the IM pin.2 Use an “open but do not disturb the fragments” technique to expose the proximal and distal bone segments with minimal disturbance of the fracture hematoma and bone fragments for nonreducible fractures (Plate 72A). PREPARATION AND POSITIONING Prepare the rear limb circumferentially from dorsal midline to tarsus. It is important to avoid the femoral head and distal joint surface with the IM pin or bone screws. Johnson AL: Biologic strategies and a balanced concept for repair of highly comminuted long bone fractures.3 Reduction: Reduce transverse and short oblique fractures by tenting the bone ends and levering the bone back into position. PROCEDURE Approach: Incise the skin and subcutaneous tissue on the lateral surface of the thigh. pointed reduction forceps. Aron DN. Johnson KA: An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. Be sure to restore length and normal rotational alignment to the bone. Jacob pin chuck. Philadelphia. Vet Surg 17:65. Use pointed reduction forceps to manipulate the bone segments into reduction. and axial compressive forces. Physical therapy is needed to restore stifle range of motion. 2.1 Insert the IM pin into the proximal femur in either a normograde or retrograde manner. with activity limited to leash walking. Radiographs should be evaluated in 6 weeks. Piermattei DL. WB Saunders. from the greater trochanter to the femoral condyles. Maintain the reduction manually for transverse fractures and with pointed reduction forceps for oblique References 1. as a neutralization plate to support a reconstructed fracture (Plate 72C). Johnson AL. Retract the muscles to expose the femur. self-centering plate-holding forceps. Purinton PT: Relationship of femoral intramedullary pins to the sciatic nerve and gluteal muscles after retrograde and normograde insertion. Aron DN. Prepare the ipsilateral proximal humerus or ipsilateral ilial wing for surgery for harvesting cancellous bone graft. plating equipment. allowing normograde or retrograde placement of an IM pin. EXPECTED OUTCOME Bone healing is usually seen in 12 to 18 weeks. Plate removal may be necessary after the fracture heals.4 Precontour the plate to the cranial caudal radiographic view of the contralateral femur to prevent angular deformities. rotational. POSTOPERATIVE CARE The animal should be confined. 3. The plate neutralizes bending. Gelpi retractors. 1995. J Am Vet Med Assoc 213:1157. Kern bone-holding forceps. spanning a nonreducible comminuted fracture (Plate 72D). depending on fracture and signalment of the animal. Palmer RH. ANATOMIC CONSIDERATIONS The plate is placed on the lateral surface of the femur. IM pins. Schaeffer DJ: Fragment reconstruction and bone plate fixation compared with bridging plate fixation for treating highly comminuted femoral fractures in dogs: 35 cases (1987–1997). the greater trochanter is 90 degrees to the patella when the rotational alignment of the femur is correct. 1998. 2004. the limb should be held in a hip extended and adducted position while the pin exits the trochanteric fossa. Palmer RH. The plate can function as a compression plate (Plate 72B) when used to compress transverse or short oblique fratures. bone curette for harvesting graft Radiographs should be evaluated for bone alignment and implant placement. The plate is used as a bridging plate for nonreducible comminuted fractures and may be combined with an intramedullary (IM) pin to reduce strain on the plate and to extend fatigue life of the fixation. Radiographs should be repeated at 6-week intervals until the fracture is healed. Drape the limb out from a hanging position to allow maximal manipulation during surgery. The range of motion of the stifle should be palpated to detect implant interference in the joint. 4. Position the animal in lateral recumbency. The adductor magnus muscle attaches to the caudal surface of the femur and serves as a guide for rotational alignment. high-speed drill. periosteal elevator. Reduce long oblique fractures by distracting the bone segments and approximating the fracture surfaces. Smith CW. Compend Cont Educ Pract Vet 17:35. Myerding or Hohmann retractors. or as a bridging plate. INDICATIONS Candidates include animals with single or comminuted femoral diaphyseal fractures. CHAPTER 72 A P P L I C AT I O N O F A P L AT E T O T H E F E M U R 191 P L AT E 7 2 Vastus lateralis muscle retracted Shaft of femur Biceps femoris muscle retracted Vastus intermedius muscle Adductor magnus muscle B A C D . Senn retractors.3 Incise the skin. allowing normograde or retrograde placement of an IM pin. Kern bone-holding forceps. with the lateral surface of the thigh. Incise the tensor fascia lata along the cranial border of the biceps femoris to expose the vastus lateralis and biceps femoris muscles. Be sure to restore length and normal rotational alignment to the bone. Reduce transverse and short oblique fractures by tenting the bone ends and levering the bone back into position. is located within the proximal third of bone. The proximity of the abdomen prohibits use of bilateral frames in the proximal femur. Use an “open but do not disturb the fragments” technique to expose the proximal and distal bone segments with minimal disturbance of the fracture hematoma and bone fragments for nonreducible fractures. from the greater trochanter to the femoral condyles. low-speed power drill. small Hohmann retractors. Myerding retractors. Reduction: Place an IM pin (sized to equal 60% to 70% of the medullary canal at the isthmus) in the proximal segment. Drive the pin distally to seat in the femoral condyle. EQUIPMENT • Surgical pack. Reduce comminuted nonreducible fractures by distracting the distal femur with the IM pin and aligning the major segments of the bone (see Plate 73A). bone curette for harvesting graft PREPARATION AND POSITIONING Prepare the rear limb circumferentially from dorsal midline to tarsus. Continued . Reduce long oblique fractures by distracting the bone segments and approximating the fracture surfaces. Maintain the reduction manually for transverse fractures and with pointed reduction forceps for oblique fractures. incorporating an intramedullary (IM) pin or using biplanar frames. and create soft tissue tunnels to the bone for fixator pin placement. and rotational forces at the fracture. Prepare the ipsilateral proximal humerus or ilial wing for harvesting a cancellous bone graft. the isthmus. PROCEDURE Approach: Incise the skin and subcutaneous tissue on the INDICATIONS Candidates include animals with single or comminuted femoral diaphyseal fractures.2 Retract the muscles to expose the femur (Plate 73A). Insert the IM pin into the proximal femur in either a normograde or retrograde manner. Drape the limb out from a hanging position to allow maximal manipulation during surgery. Position the animal in lateral recumbency. pointed reduction forceps. The distal femur has a pronounced cranial bow in most dogs. Use pointed reduction forceps to manipulate the bone segments into reduction. the greater trochanter is 90 degrees to the patella when the femur is in correct rotational alignment. Jacob pin chuck. Retract the pin within the medullary canal of the proximal segment. ANATOMIC CONSIDERATIONS The narrowest part of the medullary canal. bending. IM pins. just distal to the third trochanter. Gelpi retractors. OBJECTIVES • To achieve anatomic reduction of single fracture lines or restoration of normal bone alignment for comminuted fractures The stiffness of the fixator can be increased for animals with low fracture-assessment scores by adding fixation pins.192 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES FEMUR CHAPTER 73 Application of an External Fixator to the Femur affected limb up. external fixation equipment. but it is straight in the cat. Additionally. periosteal elevator.1 The IM pin and fixator combination resists axial loading. The adductor magnus muscle attaches to the caudal surface of the femur and serves as a guide for rotational alignment. Both anatomic features constrain the size of IM pin selected. The trochanteric fossa is directly in line with the medullary canal. pin cutter. CHAPTER 73 A P P L I C AT I O N O F A N E X T E R N A L F I X AT O R T O T H E F E M U R 193 P L AT E 7 3 Vastus lateralis muscle retracted Shaft of femur Biceps femoris muscle retracted Vastus intermedius muscle Adductor magnus muscle A . POSTOPERATIVE CARE Gauze sponges should be packed around the pins. Philadelphia. 2004. Vet Comp Orthop Traumatol 4:86. The external fixator can be connected or tied in to the IM pin to strengthen the fixation (Plate 73B). The animal will experience limited function while the external fixator is in place but should eventually have a good return to function. . the remaining external fixator.5 Place a cancellous bone autograft at the fracture site (Plate 73C). Hulse DA: Fundamentals of orthopedic surgery and fracture management: Decision making in fracture management. In Proceedings of the 10th Annual Complete Course in External Skeletal Fixation. Rotational alignment should be monitored during the realignment of comminuted fractures. Mosby. University of Georgia. vessels. 2002. POSTOPERATIVE EVALUATION Radiographs should be evaluated for bone alignment and implant placement. Place fixation pins in the metaphysis of each segment and close to the fracture line. CAUTIONS It is important to avoid major nerves. EXPECTED OUTCOME Bone healing is usually seen in 12 to 18 weeks. 3. WB Saunders. The animal should be confined. and the sponges should be secured with a bandage.4 Apply a modified type Ib external fixator and an IM pin to a comminuted nonreducible fracture. Aron DN. Louis. Compend Cont Educ Pract Vet 17:35. Johnson KA: An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat.194 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES Stabilization: Apply an IM pin and a type Ia external fixator to the lateral surface of the femur. In Fossum TW (ed): Small Animal Surgery. Physical therapy is needed to restore stifle range of motion. 1991. 127–141. St. the top fixation pin and its connection to the IM pin should be retained. 1995. with activity limited to leash walking. 2002. 5. Piermattei DL. The IM pin. Johnson AL. Rotational malalignments should be corrected by loosening the clamps and realigning the fixation pins on the connecting bar. 2. or both should be removed when the fracture has healed. If a tie-in is used. Radiographs should be repeated at 6-week intervals to References 1. 2nd ed. The fixator should be destabilized by removing the unilateral frame (from a type Ia and IM pin combination) or the cranial frame (from a modified type Ib fixator) when bone bridging is observed. depending on fracture and signalment of the animal. Palmer RH. and joint surfaces with the fixation pins and to avoid the distal joint surface with the IM pin. monitor healing. 4. Johnson AL: Biologic strategies and a balanced concept for repair of highly comminuted long bone fractures. Aron DN: External skeletal fixation system application to the humerus and femur. Long oblique fractures benefit from cerclage wire or lag screw fixation in addition to the IM pin and external fixator (Plate 73D). The range of motion of the stifle should be palpated to detect pin interference in the joint. 4th ed. External fixator management includes daily pin care and pin packing as needed. Dewey C: Experimental and clinical experience with an IM pin external skeletal fixator tie-in configuration. Aron DN. 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 B Cancellous bone autograft C D . 3rd ed. subcutaneous tissue. Louis. EQUIPMENT • Surgical pack. The saphenous artery vein and nerve lies caudal to the medial surface of the proximal tibia. Additional implant removal may be required if soft tissue irritation occurs. WB Saunders. St.2 Stabilization of an Avulsion of the Tibial Tuberosity: INDICATIONS Candidates include animals with Salter I and Salter II fractures of the proximal tibial physes. Hulse DA: Management of specific fractures: Tibia and fibular physeal fractures. Check the repair to see if stabilization is sufficient to prevent avulsion of the fracture. Drive a second wire from the medial tibial epiphysis across the physis. References 1. wire cutter or pin cutter PREPARATION AND POSITIONING Prepare the rear limb circumferentially from the hip to below the hock. and crural fascia and can easily be palpated and approached. POSTOPERATIVE EVALUATION Radiographs should be evaluated for reduction and implant placement. Mosby. Maintain reduction with a pointed reduction forceps (see Plate 74B). pin chuck or high-speed wire driver. and crural fascia craniomedially from the distal femur to the proximal diaphysis of the tibia to expose the fracture. Kirschner wires or small Steinmann pins for large dogs. with activity limited to leash walking. wire tightener. POSTOPERATIVE CARE The animal should be confined. Piermattei D. Gelpi retractors. Radiographs should be evaluated in 3 to 4 weeks. A cancellous bone graft is unnecessary. Drive a Kirschner wire from the lateral surface of the tibial . Stabilization of a Proximal Tibial Physeal Fracture: Drive two Kirschner wires into the tuberosity and across the physis to lodge in the proximal tibia. In Fossum TW (ed): Small Animal Surgery. and through the medial cortex. Tighten the wire (Plate 74D). Johnson AL. OBJECTIVES • To achieve anatomic reduction of the proximal tibial physis and fracture stabilization ANATOMIC CONSIDERATIONS The medial aspect of the proximal tibia is covered only with skin. 2. orthopedic wire. Flo GL: Brinker. Senn retractors. 2002. 2nd ed. Reduce the avulsed tibial tuberosity by extending the limb and putting pressure on the tuberosity. Most repairs require a tension band wire. and Flo’s Handbook of Small Animal Orthopedics and Fracture Repair. Drape the limb out from a hanging position to allow maximal manipulation during surgery. subcutaneous tissue. into the tibial metaphysis. periosteal elevator. place a tension band wire by drilling a transverse hole in the tibial crest and passing a figure-eight wire through the hole and around the Kirschner wires. Elevate the fascia and muscle to expose both medial and lateral surfaces of the fracture (Plate 74A). If not. EXPECTED OUTCOME Rapid bone healing is usually seen. Retract the skin laterally to expose the lateral tibial epiphysis. Position the animal in dorsal recumbency for greater flexibility. The tension band wire should be removed at 3 weeks to allow physeal function. but premature closure of the physis will probably occur.196 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES TIBIAL FRACTURES CHAPTER 74 Proximal Tibial Physeal Fractures and Tibial Tuberosity Fractures epiphysis across the physis. Premature closure of the tibial tuberosity physis in a very young animal may affect stifle conformation. Hohmann retractors. PROCEDURE Approach: Incise the skin.1 CAUTIONS It is important to avoid damaging the physeal cartilage during reduction and to avoid penetrating the articular cartilage with the Kirschner wires. and through the lateral cortex. Piermattei. into the metaphysis. Maintain reduction using a pointed reduction forceps (Plate 74B). 1997. Philadelphia. pointed reduction forceps.1 Reduction: Reduce the proximal physeal fracture by extending the stifle and gently levering the epiphysis into position. Bend the wires to prevent migration and aid removal (Plate 74C). 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 B C D . 198 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES TIBIAL FRACTURES CHAPTER 75 Distal Tibial Physeal Fractures reduction with pointed reduction forceps or with manual pressure. Gelpi retractors. Flo GL: Brinker. Drape the limb out from a hanging position to allow maximal manipulation during surgery. pointed reduction forceps. Mosby. 2002. Senn retractors.2 Reduction: Carefully reduce the physeal fracture in order to avoid crushing or injuring the physeal cartilage. 1997. INDICATIONS Candidates include animals with Salter I and Salter II fractures of the distal tibial physis. WB Saunders. Louis. Philadelphia. 2nd ed. POSTOPERATIVE EVALUATION Radiographs should be evaluated for reduction and implant placement. Drive a second wire from the medial aspect of the distal tibial metaphysis. Piermattei D. Stabilization with Crossed Kirschner Wires: Drive a Kirschner wire from the medial malleolus. In Fossum TW (ed): Small Animal Surgery. but premature closure of the physis will probably occur. EXPECTED OUTCOME Rapid bone healing is usually seen. These ligaments are essential for hock stability. WB Saunders. into the tibial metaphysis. Piermattei. Position the animal in lateral recumbency. across the physis. Hulse DA: Management of specific fractures: Tibia and fibular physeal fractures. 3. Philadelphia. Maintain . The long and short parts of the medial collateral ligaments arise from the medial malleolus of the tibia. Alternatively. Implant removal may be required if soft tissue irritation occurs. St. and Flo’s Handbook of Small Animal Orthopedics and Fracture Repair. while avoiding the articular surface (Plate 75C). pin chuck or high-speed wire driver. 4th ed. Tendons of the cranial tibial and long digital extensor muscles cross the cranial surface of the distal tibia. OBJECTIVES • To achieve anatomic reduction of the distal tibial physis and fracture stabilization ANATOMIC CONSIDERATIONS The medial malleolus of the distal tibia and the lateral malleolus of the fibula extend distal to the articulating surfaces of the distal tibia and talus. with the affected limb up or in dorsal recumbency for greater flexibility. A cancellous bone graft is unnecessary. References 1.3 In larger dogs. Kirschner wires (or small Steinmann pins for large dogs). make a cranial skin incision and retract the extensor tendons. wire cutter or pin cutter PREPARATION AND POSITIONING Prepare the rear limb circumferentially from hip to below the hock. periosteal elevator. the second wire may driven from the fibular malleolus across the fibular fracture and into the proximal segment of the fibula (Plate 75D). POSTOPERATIVE CARE A lateral splint should be used to support the fixation. Johnson KA: An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. Johnson AL. across the fracture into the epiphysis. EQUIPMENT • Surgical pack. drive the second wire from the lateral aspect of the tibial epiphysis or the fibular malleolus into the tibia. CAUTIONS It is important to avoid damaging either the physeal cartilage or articular cartilage. and through the lateral cortex (Plate 75B). PROCEDURE Approach: Incise the skin and subcutaneous tissue on the cranial medial surface from the distal diaphysis to the tarsus to expose the medial surface of the fracture (Plate 75A). Hohmann retractors. with activity limited to leash walking. Radiographs should be evaluated in 4 weeks.1 Alternatively. 2.2 The animal should be confined. Piermattei DL. The medial saphenous vein crosses the medial surface of the distal tibia. The long and short parts of the lateral collateral ligaments arise from the lateral malleolus of the fibula. 2004. 3rd ed. This approach allows visualization of the fibula. CHAPTER 75 D I S TA L T I B I A L P H Y S E A L F R A C T U R E S 199 P L AT E 7 5 A Tendon of cranial tibial muscle Medial collateral ligament Tendon of caudal tibial muscle B or C D . and drill a smaller hole (equal to the core diameter of the screw) across the tibia. Gelpi retractors. and Flo’s Handbook of Small Animal Orthopedics and Fracture Repair. WB Saunders. In some cases. The medial saphenous vein crosses the medial surface of the distal tibia. A cancellous bone graft is unnecessary. Compression of the fracture should occur (Plate 76D). Flo GL: Brinker.2 CAUTIONS Articular reduction should be maintained during implant application. the fragment may be secured with pointed reduction forceps. with the severity depending on accuracy and maintenance of reduction. Kirschner wires. 2002. Philadelphia. reduce the fracture. Hulse DA: Management of specific fractures: Tibia and fibular metaphyseal and epiphyseal fractures. WB Saunders. convert the tensile forces resulting from the pull of the collateral ligaments to compressive forces at the fracture. Mosby. Place a transverse drill hole in the tibia. Senn retractors. Pass the figure-eight wire around the Kirschner wire and tighten it (Plate 76C). 4th ed. Degenerative joint disease may result from articular trauma. Position the animal in dorsal recumbency. manual maintenance of reduction is necessary. Hohmann retractors. 2004. OBJECTIVES • To achieve anatomic reduction of the malleoli and distal tibial articular surface.1 Approach the lateral malleolus via a lateral skin incision over the malleolus. if the fibula is too small to pass a Kirschner wire proximally. Drive a Kirschner wire into the lateral malleolar fragment. Johnson KA: An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. and tighten it. Radiographs should be repeated at 6-week intervals. and stabilize the tarsus ANATOMIC CONSIDERATIONS Tendons of the cranial tibial and long digital extensor muscles cross the cranial surface of the distal tibia. medial malleolus of the tibia or lateral malleolus of the fibula) by securing the fragment with small or mini pointed reduction forceps and placing it into alignment. St. and pass a figure-eight wire through the hole. A bivalve cast should be used to externally support the tarsus for 4 to 6 weeks. EQUIPMENT • Surgical pack.1 Reduction: Reduce the fracture (i. POSTOPERATIVE CARE The animal should be confined. pass a figure-eight wire through the hole and around the Kirschner . The long and short parts of the lateral collateral ligaments arise from the lateral malleolus of the fibula. To stabilize the fibular malleolus with a screw. Measure. in other cases. drive the Kirschner wire through the lateral malleolar fragment and into the tibia.e. across the fracture line. Stabilization: Start two Kirschner wires in the medial malleolar fragment. and proximally into the fibula. Johnson AL. In Fossum TW (ed): Small Animal Surgery. Drape the limb out from a hanging position to allow maximal manipulation during surgery. The medial malleolus of the distal tibia and the lateral malleolus of the fibula extend distal to the articulating surfaces of the distal tibia and talus. Piermattei. wire cutter. Piermattei DL. periosteal elevator. highspeed wire driver or drill PREPARATION AND POSITIONING Prepare the rear limb circumferentially from hip to below the hock.3 The cast should be destabilized as healing progresses by eliminating the cranial part of the case. treat the fibular malleolus as the fragment by drilling the gliding hole through the fibula and the tapped hole in the tibia (Plate 76E).200 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES TIBIAL FRACTURES CHAPTER 76 Malleolar Fractures wires.. tap. drill a gliding hole (equal to the diameter of the threads on the screw) in the medial malleolar fragment. 3rd ed. Implant removal may be necessary if soft tissues are irritated. 3. These ligaments are essential for hock stability. 2nd ed. Place a drill sleeve into the gliding hole. select. References 1. INDICATIONS Candidates include animals with transverse or oblique medial or lateral malleolar fractures. wire tightener. pointed reduction forceps. Louis. Piermattei D. bone screws and the instruments for screw insertion. and use blunt and sharp dissection of surrounding tissues to expose the fracture (Plate 76B). It is important to take care when manipulating and drilling the small malleolar fragments to avoid further fragmentation. 2. The long and short parts of the medial collateral ligaments arise from the medial malleolus of the tibia. To apply the lag screw. Drill a transverse hole in the fibula proximal to the fracture. Philadelphia. Drive the wires across the fracture line to lodge in the tibia. with activity limited to leash walking. EXPECTED OUTCOME Bone healing is usually seen in 6 to 12 weeks with animals experiencing a good return to function. 1997. PROCEDURE Approach: Incise the skin and subcutaneous tissue on the cranial medial surface from the distal diaphysis to the tarsus to expose the medial malleolus (Plate 76A). orthopedic wire. POSTOPERATIVE EVALUATION Radiographs should be evaluated for articular surface reduction and implant placement. Alternatively. and place a screw of the appropriate length. CHAPTER 76 MALLEOLAR FRACTURES 201 P L AT E 7 6 A B Tendon of lateral extensor digital muscle Tendon of peroneus brevis muscle Tendon of flexor hallucis longus muscle Tendon of cranial tibial muscle Tendon of caudal tibial muscle Medial collateral ligament Saphenous vein Fibula Caudal branch of lateral saphenous artery and vein Lateral extensor retinaculum Tendon of peroneus longus muscle Tendon of lateral extensor digital muscle C D E . 2nd ed. depending on fracture and signalment of the animal. Reduce long oblique fractures by dis- References 1. PREPARATION AND POSITIONING Prepare the rear limb circumferentially from mid-femur to the phalanges. The IM pin should be smaller (50–60% of the medullary canal) to accommodate the fixation pins within the medullary canal. and create soft tissue tunnels to the bone for fixator pin placement (Plate 77B). Reduce transverse and short oblique fractures by tenting the bone ends and levering the bone back into position. Drape the limb out from a hanging position. Use pointed reduction forceps to manipulate the bone segments into reduction. Johnson KA. 2002. leaving little nonarticular surface to introduce an IM pin or ILN. The range of motion of the hock should be palpated to detect pin interference in the joint. including high-speed drill).1 CAUTIONS ANATOMIC CONSIDERATIONS The tibia has a pronounced S-shaped curve in most dogs. Philadelphia. et al: Interlocking nail treatment of diaphyseal long bone fractures in dogs. it can be used for animals with medium and low fractureassessment scores.2 Perform a limited medial approach through the skin and subcutaneous tissue to the fracture site for reducible fractures (see Plate 77A). periosteal elevator. Gelpi retractors. 2. Maintain the reduction manually for transverse fractures and with pointed reduction forceps for oblique fractures. Reduction: Place an IM pin (sized to equal 60% to 70% of the medullary canal at the isthmus) in the proximal segment. In Fossum TW (ed): Small Animal Surgery. Incise the skin. Stabilization: Apply an IM pin and type Ia external fixator to the cranial medial surface of the tibia to stabilize a transverse fracture (see Plate 77B). Mosby. The ipsi-lateral proximal humerus serves as a cancellous bone graft donor site. Hulse DA: Management of specific fractures: Tibial and fibular diaphyseal fractures. The medial and lateral malleoli extend distally to the distal tibial articular surface. St. decision making in fracture management.3 Use an “open but do not disturb the fragments” technique to expose the proximal and distal bone segments with minimal disturbance of the fracture hematoma and bone fragments for nonreducible fractures. Roll the animal slightly to access the medial aspect of the limb. The IM pin should be removed when the fracture has healed. Johnson AL. J Am Vet Med Assoc 214:59. 2nd ed. Louis. Jacob pin chuck. 2004. bone curette for harvesting cancellous graft POSTOPERATIVE CARE The animal should be confined.1 The IM pin neutralizes bending forces at the fracture. wire tightener. 3. Radiographs should continue at 6-week intervals until the fracture has healed. Johnson KA: An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. Mosby. In Fossum TW (ed): Small Animal Surgery. EXPECTED OUTCOME Bone healing is usually seen in 12 to 18 weeks. The interlocking nail (ILN) neutralizes bending. PROCEDURE Approach: Insert the IM pin or the ILN from a point on the proximal medial tibial plateau midway between the tibial tuberosity and the medial tibial condyle (Plate 77A). external fixator clamps and connecting bars (or ILN equipment. Johnson AL. 4th ed. Place fixation pins in the metaphysis of each segment and about 1 cm on either side of the fracture line. Rotational alignment should be monitored during the realignment of comminuted fractures. Position the animal in dorsal recumbency. It is important to avoid the joint surfaces with the IM pin or ILN. OBJECTIVES • To achieve anatomic reduction of single fracture lines or restoration of normal bone alignment for nonreducible comminuted fractures The intramedullary (IM) pin is used in animals with high fractureassessment scores. IM pins. Radiographs should be repeated at 6-week intervals. Apply an ILN and four screws to the tibia for treatment of comminuted nonreducible fractures (Plate 77D). with activity limited to leash walking. POSTOPERATIVE EVALUATION Radiographs should be evaluated for fracture reduction or bone alignment and implant placement. Dueland RT. rotational. wire cutter.2 Retract the pin within the medullary canal of the proximal segment. and axial compressive forces at the fracture. Roe SC. Senn retractors. The cranial branch of the medial saphenous artery and vein and the saphenous nerve cross the medial aspect of the tibia. Apply an IM pin and cerclage wire to a long oblique fracture (Plate 77C). pointed reduction forceps. 1999. Piermattei DL. WB Saunders. Fixator pins should be removed after radiographic signs of bone bridging are observed. EQUIPMENT • Surgical pack. 4.4 INDICATIONS Candidates include animals with single or comminuted tibial diaphyseal fractures. . The proximal and distal tibial articular surfaces cover the ends of the long bone.202 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES TIBIAL FRACTURES CHAPTER 77 Application of an Intramedullary Pin or Interlocking Nail to the Tibia tracting the bone segments and approximating the fracture surfaces. Hulse DA: Fundamentals of orthopedic surgery and fracture management. Reduce comminuted nonreducible fractures by distracting the distal bone end with the IM pin or ILN and aligning the major segments of the bone. and is combined with cerclage wire for long oblique fractures and with external fixation for transverse or short oblique fractures to neutralize rotational and axial compressive forces. External fixator management includes daily pin care and pin packing as needed. 2002. Kern bone-holding forceps. cerclage wire. Louis. St. Hohmann retractors. 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 A Shaft of the tibia Cranial branch of medial saphenous artery and vein Saphenous nerve B C D . 204 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES TIBIAL FRACTURES CHAPTER 78 Application of a Plate to the Tibia with pointed reduction forceps for oblique fractures. Reduce comminuted nonreducible fractures by distracting and aligning the major segments of the bone. An intramedullary pin can be used to obtain axial alignment and distraction of the distal segment. Be sure to restore length and normal rotational alignment to the bone. Precontour the plate to the cranial caudal radiographic view of the contralateral tibia to prevent angular deformities. Stabilization: Apply an appropriately contoured plate to the medial surface of the tibia. The plate can function as a compression plate (Plate 78B) when used to compress transverse or short oblique fractures; as a neutralization plate to support a reconstructed fracture (Plate 78C); or as a bridging plate, with or without an intramedullary pin, spanning a nonreducible comminuted fracture (Plate 78D).4 CAUTIONS In immature dogs, it is important to avoid crossing the distal tibial physis with the plate or screws. It is also important to avoid the distal articular surface. Careful attention must be paid to bony anatomic landmarks to avoid rotation of the distal segment. Failure to contour the plate to the normal S shape of the tibia will result in a valgus angulation of the limb. Monocortical screws may be necessary to avoid interference with the intramedullary pin. POSTOPERATIVE EVALUATION Radiographs should be evaluated for fracture reduction or bone alignment and implant placement. POSTOPERATIVE CARE The animal should be confined, with activity limited to leash walking. Radiographs should be repeated at 6-week intervals until the fracture has healed. EXPECTED OUTCOME Bone healing is usually seen in 12 to 18 weeks, depending on fracture and signalment of the animal. Plate removal may be necessary after the fracture heals if soft tissue irritation or cold sensitivity occurs. References 1. Johnson AL, Hulse DA: Fundamentals of orthopedic surgery and fracture management, plates and screws. In Fossum TW (ed): Small Animal Surgery, 2nd ed. St. Louis, Mosby, 2002. 2. Piermattei DL, Johnson KA: An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WB Saunders, 2004. 3. Aron DN, Palmer RH, Johnson AL: Biologic strategies and a balanced concept for repair of highly comminuted long bone fractures. Compend Cont Educ Pract Vet 17:35, 1995. 4. Houlton JEF: Fractures of the tibia. In Brinker WO, Olmstead ML, Sumner-Smith G, et al (eds): Manual of Internal Fixation in Small Animals. New York, Springer-Verlag, 1998. INDICATIONS Candidates include animals with single or comminuted tibial diaphyseal fractures. OBJECTIVES • To achieve anatomic reduction and compression of single fracture lines or restoration of normal bone alignment for nonreducible comminuted fractures The plate is used as a compression plate for transverse or short oblique fractures, and it is combined with lag screws to compress long oblique fractures. The plate is used as a bridging plate for nonreducible comminuted fractures and may be combined with an intramedullary pin to reduce strain on the plate and to extend fatique life of the fixation. The plate neutralizes bending, rotational, and axial compressive forces. ANATOMIC CONSIDERATIONS Plates are generally placed on the medial surface of the tibia. The tibia has an S-shaped curve that must be reproduced when contouring the plate. The cranial branch of the medial saphenous artery and vein and the saphenous nerve cross the medial aspect of the tibia. The medial malleolus extends distally to the distal tibial articular surface. EQUIPMENT • Surgical pack, Senn retractors, Gelpi retractors, Hohmann retractors, periosteal elevator, pointed reduction forceps, self-centering plate-holding forceps, high-speed drill, plating equipment, bone curette for cancellous bone harvest PREPARATION AND POSITIONING Prepare the rear limb circumferentially from mid-femur to the phalanges. Position the animal in dorsal recumbency. Drape the limb out from a hanging position. Roll the animal slightly to allow access to the medial side of the bone. The ipsilateral proximal humerus serves as a cancellous bone graft donor site. PROCEDURE Approach: Incise the skin and subcutaneous tissue on the craniomedial surface of the tibia. Incise the crural fascia, and retract the cranial tibial muscle cranially and the flexor muscles caudally to expose the medial surface of the tibia (Plate 78A).2 Use an “open but do not disturb the fragments” technique to expose the proximal and distal bone segments with minimal disturbance of the fracture hematoma and bone fragments for nonreducible fractures.3 Reduction: Reduce transverse and short oblique fractures by tenting the bone ends medially and levering the bone back into position. Reduce long oblique fractures by distracting the bone segments and approximating the fracture surfaces. Use pointed reduction forceps to manipulate the bone segments into reduction. Maintain the reduction manually for transverse fractures and CHAPTER 78 A P P L I C AT I O N O F A P L AT E T O T H E T I B I A 205 P L AT E 7 8 Shaft of the tibia A Cranial branch of medial saphenous artery and vein Saphenous nerve B C D 206 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES TIBIAL FRACTURES CHAPTER 79 Application of an External Fixator to the Tibia power drill, external fixation equipment, pin cutter, bone curette for harvesting cancellous graft PREPARATION AND POSITIONING Prepare the affected rear limb circumferentially from midline to foot. Position the animal in dorsal recumbency, and suspend the affected limb from the ceiling.2 Drape the limb out in the hanging position. Prepare the ipsilateral proximal humerus for cancellous bone autograft harvest if open reduction is used. PROCEDURE Approach: Perform a limited medial approach to the fracture site for reducible fractures (Plate 79A).3 Use closed reduction techniques for nonreducible fractures (Plate 79B).4 Incise the skin, and create soft tissue tunnels to the bone for pin placement. Reduction: Lower the table to allow the animal’s weight to fatigue the muscles. For single fracture lines, lever the fragments into position through the limited surgical approach (see Plate 79A). Maintain the reduction manually for transverse fractures and with reduction forceps for oblique fractures. For closed reduction of comminuted fractures, manipulate the proximal and distal fixation pins to align the joint surfaces. Medial and lateral angular alignment is correct when the proximal and distal joint surfaces are parallel (see Plate 79B). Make sure that cranial caudal joint surfaces are also parallel. Check rotational alignment by flexing the stifle and hock after raising the table: the paw should align with the tibia. Maintain reduction by securing the connecting bars (see Plate 79B). Continued INDICATIONS Candidates include animals with single or comminuted tibial diaphyseal fractures. OBJECTIVES • To achieve anatomic reduction of single fracture lines or restoration of normal bone alignment for comminuted fractures The stiffness of the fixator can be increased in animals with low fracture-assessment scores by adding fixation pins and by using biplanar or bilateral frames.1 The fracture and fixator combination, or the fixator alone, resists axial loading, bending, and rotational forces at the fracture. ANATOMIC CONSIDERATIONS The tibia has a triangular cross section in the proximal third, with a round cross section over the rest of the bone. The proximal tibial joint surface parallels the distal tibial joint surface. The medial aspect of the tibia is covered only by skin and subcutaneous tissue. The saphenous artery vein and nerve spiral across the medial surface of the mid-diaphysis. In general, fixation pins can be applied on the medial, cranial medial, cranial lateral, and lateral surfaces of the bone. EQUIPMENT • Surgical pack, Senn retractors, small Hohmann retractors, Gelpi retractors, periosteal elevator, Kern bone-holding forceps, pointed reduction forceps, Jacob pin chuck, low-speed CHAPTER 79 A P P L I C AT I O N O F A N E X T E R N A L F I X AT O R T O T H E T I B I A 207 P L AT E 7 9 A B 3. gauze sponges should be packed around the pins. the fixator should be destabilized by removing one unilateral frame (type Ib fixator). Mosby. 4. Long oblique fractures benefit from cerclage wire or lag screw fixation in addition to the external fixator (see Plate 79D). but good return to function generally occurs after the fixator is removed. and joint surfaces with the fixation pins and to avoid the tibial crest when inserting fixation pins. J Am Vet Med Assoc 209:1445. Johnson AL. or the lateral connecting bar of the type II fixator. Animals may experience limited function while the external fixator is in place. external skeletal fixators. Johnson KA: An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. 5. Louis. External fixator management includes daily pin care and pin packing. Place additional pins when there is adequate bone (Plate 79E). Palmer RH. When bone bridging is observed. 2nd ed. 2002. In Fossum TW (ed): Small Animal Surgery. Angular malalignments should be corrected by loosening the clamps on the pins through the distal segment and repositioning the clamps attaching the fixation pins to the connecting bar. Smith CW. The external fixator should be removed when the fracture is healed. CAUTIONS It is important to avoid major nerves. At least two (and preferably three) fixation pins are placed in each bone segment. St. et al: Closed reduction and type II external fixation of severely comminuted fractures of the radius and tibia in dogs: 23 cases (1990–1994).208 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES Stabilization: Apply a type Ia external fixator to the cranial medial surface of the tibia (Plate 79C). Angular and rotational alignment should be monitored during the reduction. Johnson AL. Piermattei DL. Seitz SE. 1995. Apply a type II frame by inserting transfixation pins through the metaphyses and additional fixation pins about 1 cm from either side of the fracture. Place fixation pins in the metaphysis of each segment and about 1 cm from either side of the fracture line. Apply a type Ib frame by placing a unilateral frame on the cranial medial surface of the tibia and an additional unilateral frame on the cranial lateral surface of the tibia (Plate 79D) Connect the biplanar frames with articulating bars. St. Mosby. Louis. POSTOPERATIVE EVALUATION Radiographs should be evaluated for fracture reduction or bone alignment and implant placement. Hulse DA: Fundamentals of orthopedic surgery and fracture management: Decision making in fracture management. POSTOPERATIVE CARE To limit postoperative swelling. and the sponges should be secured References 1. The animal should be confined. 2002. Philadelphia. Use positive profile end-threaded pins to increase pin bone interface stability. depending on fracture and signalment of the animal. selected fixation pins (type Ia or type II fixator). .5 with a bandage that also incorporates the paw. Aron DN. Radiographs should be repeated at 6-week intervals to evaluate healing. Intraoperative radiographs are useful to verify joint alignment during closed reductions. WB Saunders. vessels. with activity limited to leash walking. Johnson AL. 2004. 4th ed. as needed. Johnson AL: Biologic strategies and a balanced concept for repair of highly comminuted long bone fractures. 1996. In Fossum TW (ed): Small Animal Surgery. 2. EXPECTED OUTCOME Bone healing is usually seen in 12 to 18 weeks. Compend Cont Educ Pract Vet 17:35. Hulse DA: Fundamentals of orthopedic surgery and fracture management. 2nd ed. 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 . and maintain reduction with pointed reduction forceps or Velsellum forceps.3 Countersink the proximal fragment so that the screw heads lie beneath the articular surface. Stabilize oblique fractures through the body of the radial carpal bone with a lag screw (Plate 80C). Gelpi retractors. with activity limited to leash walks until bone healing is complete. periosteal elevator. pointed reduction forceps. Hohmann retractors. padded bandage should be placed to control bleeding and swelling. Continue deep dissection between the extensor carpi radialis tendon and the common digital extensor tendon to expose the joint capsule. ulnar. Velsellum forceps. 3rd ed. Radiographs should be repeated at 6-week intervals until fracture healing is observed. . and accessory) and distal rows (II. A splint should be used for 3 weeks.4 INDICATIONS Candidates include animals with transverse or short oblique fractures of the radial carpal bone. Tomlin JL. Reduce large fragments. these conditions are more appropriately treated with carpal arthrodesis. Bennet D. depending on fracture and signalment of the animal. The radial carpal bone articulates primarily with the radius and serves as the major weight-bearing area in the joint. Johnson KA: An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. In Brinker. beginning 3 cm to 4 cm proximal to the radiocarpal joint and extending distally to the mid-metacarpus. 2. Stabilization: Stabilize dorsal slab fractures with one or two small lag screws (Plate 80B). EQUIPMENT • Surgical pack. A cancellous bone graft is not generally used. et al: Radial carpal bone fractures in dogs. Langley-Hobbs SJ.210 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES C A R P U S / TA R S U S CHAPTER 80 Radial Carpal Bone Fractures fractures. J Small Anim Pract 41:74. Piermattei DL. Gibbs C. Pead MJ. 4th ed. POSTOPERATIVE CARE A soft.1 OBJECTIVES • To achieve anatomic reduction of the articular surface and rigid fixation of the fracture to promote function and minimize degenerative changes ANATOMIC CONSIDERATIONS The carpus is composed of the proximal (radial. 2004. 1997. Philadelphia.2 Reduction: Remove fragments that are too small to handle and fragments that are associated with chronic References 1. and incise the joint capsule to expose the radial carpal bone (Plate 80A). 3. It is the most common carpal bone fractured in companion animals.3 CAUTIONS It is important to avoid articular surfaces with implants. Incise the skin and subcutaneous tissue mid-dorsally. and Flo’s Handbook of Small Animal Orthopedics and Fracture Repair. 2001. Retract the tendons. Degenerative joint disease and limited range of motion of the carpus may occur. WB Saunders. Flo GL: Fractures of the pelvis. Li A. Philadelphia. POSTOPERATIVE EVALUATION Radiographs should be evaluated for bone alignment and implant placement. Piermattei. EXPECTED OUTCOME Bone healing is usually seen in 12 to 18 weeks. PROCEDURE Approach: An Esmarch bandage or tourniquet may be used to control bleeding. III. and IV) of carpal bones. et al: Radial carpal bone fractures in 15 dogs. WB Saunders. 4. bone screws and equipment for inserting bone screws PREPARATION AND POSITIONING Prepare the forelimb circumferentially from elbow to digits. Drape the limb out from a hanging position to allow maximal manipulation during surgery. Piermattei DL. J Am Anim Hosp Assoc 37:173. 2000. Place the head of the screw through the insertion of the radial collateral ligament to avoid interfering with the joint motion. Senn retractors.1. The animal should be confined. high-speed drill. Position the animal in dorsal recumbency for greater flexibility. Dogs with radial carpal bone fractures may present with chronic lameness. 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 A Abductor pollicis longus muscle Radial carpal bone Radius Tendon of extensor carpi radialis muscle Tendon of common digital extensor tendon B C Palmar Short radial collateral ligament Dorsal . the screw may be placed as a position screw. 2004. exiting at the fracture. reduce the proximal segment by extending the hock and manipulating the fragment with pointed reduction forceps. and deep fascia from the medial malleolus to the tarsometatarsal joint. high-speed drill and wire driver. A splint should be used for 3 weeks. Stabilization: For calcaneal fractures. The medial and lateral trochleas of the talus articulate proximally with the tibia and fibula.2 CAUTIONS It is important to avoid placing implants where they will interfere with articular surfaces. subcutaneous tissue.2 For a talar neck fracture. pointed reduction forceps. place a screw from the craniomedial surface of the base of the talus into the calcaneus. 2. PROCEDURE Approach: For calcaneal fractures. subcutaneous tissue. 1997. reduce the distal fragment by manipulating the fragment with the pointed reduction forceps. and deep crural fascia along the lateral surface of the calcaneus from just proximal to the tuber calcanei distally to the tarsometatarsal joint. and Flo’s Handbook of Small Animal Orthopedics and Fracture Repair. Proximally. A cancellous bone graft is unnecessary. Place two Kirschner wires through the proximal bone segment. bone screws and instruments for inserting bone screws PREPARATION AND POSITIONING Prepare the rear limb circumferentially from hip to digits. Piermattei. Piermattei DL. incise the skin. and retract the tendon medially to expose the caudal surface of the calcaneus (Plate 81A).1 Reduction: For the calcaneal fracture. Secure the tension band wire (Plate 81C). 4th ed. Flo GL: Fractures and other orthopedic injuries of the tarsus. Johnson KA: An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. angle a lag screw from the caudal medial surface of the head of the talus into the trochlea of the talus (Plate 81D). Alternatively. Degenerative joint disease and limited range of motion of the hock may occur. orthopedic wire. WB Saunders. periosteal elevator. POSTOPERATIVE EVALUATION Radiographs should be evaluated for bone alignment and implant placement. wire cutter. Hohmann retractors. If the reduction can be maintained with forceps. Place a wire through the proximal hole. Maintain the reduction by driving the Kirschner wires. OBJECTIVES • To achieve anatomic reduction and rigid fixation of the fracture to promote function and minimize degenerative changes and to convert tension forces to compressive forces in calcaneal fractures ANATOMIC CONSIDERATIONS The calcaneus articulates with the talus to form a stable joint. it may be placed as a lag screw (Plate 81E). Gelpi retractors. depending on the fracture and signalment of the animal. In Brinker. Kirschner wires.212 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES C A R P U S / TA R S U S CHAPTER 81 Tarsal Fractures pointed reduction forceps. holding the talar body to the calcaneus. and countersink them into the calcaneus. INDICATIONS Candidates include animals with transverse or short oblique fractures of the calcaneus or the neck of the talus. Radiographs should be repeated at 6-week intervals until fracture healing is observed. wire tighteners. Drape the limb out from a hanging position to allow maximal manipulation during surgery. Retract the wires. with activity limited to leash walks. incise the skin. POSTOPERATIVE CARE A soft padded bandage should be placed to control bleeding and swelling. and drive the Kirschner wires distally. drill a transverse hole in the proximal segment and in the distal segment. Senn retractors. Position the animal in lateral recumbency for calcaneal fractures and in dorsal recumbency for greater flexibility with talar fractures. Piermattei DL. EXPECTED OUTCOME Bone healing is usually seen in 12 to 18 weeks. 3rd ed. otherwise. metatarsus and phalanges. until bone healing is complete. the orthopedic wire used in the tension band should be removed after bone healing. Drill the glide hole from inside out before reducing the fracture to center the hole and ensure purchase in the trochlea. WB Saunders. The animal should be confined. If soft tissue irritation occurs. Reduce the fracture.1 For talar fractures. For the talar neck fracture. Philadelphia. Maintain reduction manually or with . It may be necessary to pre-drill the bone for the Kirschner wires. Philadelphia. and the body articulates distally with the central tarsal bone. Incise parallel to the lateral aspect of the superficial digital flexor tendon. References 1. Elevate the fascia to expose the bones (Plate 81B). the Achilles tendon inserts on the tuber calcanei. EQUIPMENT • Surgical pack. cut. CHAPTER 81 TA R S A L F R A C T U R E S 213 P L AT E 8 1 A Lateral Tendon of flexor hallucis longus muscle Tendon of gastrocnemius muscle Calcaneus B Medial Tendon of superficial flexor muscle Tendon of abductor digiti quinti muscle Talus C D E . with activity limited to leash walking. . mini pointed reduction forceps. et al: Fixation of metacarpal and metatarsal fractures in greyhounds. Norris JL: Metacarpal and metatarsal fractures in dogs. high-speed drill and burr. Senn retractors. The extensor tendons course down the dorsal aspect of each digit. M E TATA R S A L B O N E S . Johnson KA. Philadelphia. 2004. There is minimal soft tissue coverage. and drive the pin through the slot and proxi- References 1. plating equipment. 4). Maintain reduction with the implants. Prepare the proximal humerus or proximal tibia as a donor site for cancellous bone harvest. Drape the limb out from a hanging position to allow maximal manipulation during surgery.2 For older and larger dogs. Bridge comminuted fractures with a dynamic compression plate or veterinary cuttable plate (see Plate 82D. PROCEDURE Approach: Incise the skin and subcutaneous tissue on the dorsal surface of the paw. Mosby. EXPECTED OUTCOME Bone healing is usually seen in 12 to 18 weeks. pin cutters. The flexor tendons and superficial and deep metacarpal or metatarsal artery and vein lie on the palmar or plantar aspect of the digits. 1). either on the midline (for fractures of the third and fourth bones) or directly over the fractured bone. metatarsal. bone curette for harvesting cancellous bone PREPARATION AND POSITIONING Prepare the distal limb circumferentially from elbow or stifle to the digits. The superficial dorsal metacarpal or metatarsal artery courses over the dorsal aspect of the paw.214 PA RT T W O • SURGICAL PROCEDURES FOR FRACTURES M E TA C A R PA L B O N E S . EQUIPMENT • Surgical pack. Repeat the procedure for at least the third and fourth metacarpal or metatarsal bones (Plate 82C). 1981. Use pointed reduction forceps to reduce and maintain the position of oblique fractures. J Small Anim Pract 38:344. The animal should be confined. Louis. Stabilization: Stabilize simple transverse (or very short oblique) fractures in young or small dogs and cats with intramedullary pins.1 Reduction: Lever transverse fractures into position. A plate may be used with the lag screws to support the repair. Hulse DA: Management of specific fractures: Metacarpal. Use a high-speed burr to develop a slot in the distal dorsal surface of the fractured bone (Plate 82B). 3. The extensor tendons should be protected. pin chuck. 2nd ed. phalangeal and sesamoid fractures and luxations. A N D D I G I T S CHAPTER 82 Fractures of the Metacarpal and Metatarsal Bones mally across the fracture line to seat in the proximal bone segment. Kirschner wires or small Steinmann pins. 1997. Johnson KA: An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. CAUTIONS It is important to avoid placing intramedullary pins where they will interfere with the joints. until the fracture has healed. WB Saunders. Davis PE. small Hohmann retractors. Stabilize distal metaphyseal transverse fractures with a veterinary T plate (see Plate 82D. 2002. or animals with expected athletic function. POSTOPERATIVE CARE The fixation should be protected with a splint or cast for 4 to 6 weeks. 2. 4. Bellenger CR. Radiographs should be repeated at 6-week intervals until the fracture has healed. Aust Vet J 57:205. OBJECTIVES • To realign the bones and stabilize the fractures ANATOMIC CONSIDERATIONS The primary weight-bearing bones are the third and fourth digits. 3). Blunt the tip of the pin to prevent it from penetrating the intact opposite cortex. Piermattei DL. In Fossum TW (ed): Small Animal Surgery. and the bones and joints can be easily palpated.4 INDICATIONS Candidates include animals with multiple unstable fractures of the metacarpal and metatarsal bones. Bend the distal end of the pin to prevent migration and to simplify removal. Johnson AL. POSTOPERATIVE EVALUATION Radiographs should be evaluated for fracture reduction and implant placement. Muir P. St. Position the animal in dorsal recumbency for greater flexibility. The animal should experience a good return to function if anatomic reconstruction is achieved and maintained. 4th ed. Retract the extensor tendons and ligaments of the dorsal surface of the paw to expose the fractures (Plate 82A). 2).3 Stabilize oblique or avulsion fractures with lag screws (Plate 82D. use plates or screws (or both) to achieve fracture stability. Stabilize mid-diaphyseal transverse fractures with a dynamic compression plate (see Plate 82D. CHAPTER 82 F R A C T U R E S O F T H E M E TA C A R PA L A N D M E TATA R S A L B O N E S 215 P L AT E 8 2 A Tendon of common digital extensor muscle B C D Palmar Dorsal 1 4 2 3 . the NP has a high water content. PROCEDURE Approach: Incise the skin and subcutaneous tissue on ven- INDICATIONS 1 Ventral fenestration of the cervical spine is often performed in combination with ventral decompression and surgical stabilization. elevate the longus colli muscle to expose the ventral annulus fibrosus at the affected disc space (Plate 83B). sandbags. and (3) rotation.g. Nutrition to the discs is via diffusion from the cartilaginous end-plates and is facilitated by normal vertebral movement. It is classified as an amphiarthrodial joint and collectively constitutes the largest avascular structure in the body. Reflect the skin and subcutaneous tissue medially and laterally with blunt dissection. Once it is free of its attachments. Oregon. pain) ANATOMIC CONSIDERATIONS 1. Position the animal in dorsal recumbency. resulting in the thinning of the annulus dorsally and a protrusion of the disc upon compression of the spinal cord. Fibroid metaplasia occurs in nondystrophic breeds. (2) dorsoventral. ear loop. two medium or large Gelpi retractors (depending on the size of the dog). Bluntly separate the sternohyoideus and sternomastoideus muscles along the midline. bipolar and unipolar cautery. It may be performed as a prophylactic or therapeutic measure for degenerative intervertebral disc (IVD) disease of the cervical region. The ventral and lateral portions of the annulus are 1. two Senn retractors.5 to 3 times thicker than the dorsal annulus. Age-related metaplastic degeneration results in significant changes in the biochemistry and biomechanics of the disc.2 The IVD is a complex composite of ligamentous and fibrous tissue. tartar scraper. cauterize the musculotendinous attachments of the longus colli muscle to the ventral spinous processes. and to unite the segments of the vertebral column. South Salem. The IVD is composed of two anatomically distinct regions: (1) the annulus fibrosus and (2) the nucleus pulposus (NP). It is characterized by a slow degeneration or fibrocytic change of the annulus fibrosus. OBJECTIVES • To prevent herniation of the degenerative IVD into the vertebral canal and to resolve clinical signs associated with invertebral disc disease (e.. which provides the hydroelastic qualities needed to maintain function. The NP is a gelatinous mass that arises from the embryonic notochord. It contains an intercellular mass of mesenchymal cells in a dense network of poorly arranged fibers.218 PA RT T H R E E • SURGICAL PROCEDURES FOR THE SPINE CHAPTER 83 Ventral Fenestration of Cervical Discs chondystrophic breeds of dogs. The large transverse processes of C6 and the wings of C1 are important anatomic landmarks that assist in anatomic orientation. Palpate the ventral spinous processes of the vertebral column to locate the appropriate disc space(s). to minimize and absorb shock. this explains the propensity of the nucleus to herniate dorsally. The annulus fibrosus is composed of fibrocartilaginous material arranged in woven concentric layers that allow limited vertebral motion in three directions: (1) lateral.* Secure the head by taping the mandible to the table. small bone curette PREPARATION AND POSITIONING Prepare the patient from the mid-mandible to just past the manubrium. The IVD forms a cushion between the adjacent bony vertebrae to allow movement. Once the IVD space(s) to be fenestrated have been located. and gently maneuver them out of the surgical field. suction hose and small Frazier suction tip. In the young animal. The use of cautery will reduce the amount of muscular bleeding and improve visualization. Chondroid metaplasia occurs primarily in the tral midline from the caudal aspect of the thyroid cartilage to the manubrium. crossing its forelimbs and securing them caudally. it is located at all interveterbral spaces except C1-2 and the fused sacral segments. or a vacuum-activated surgical positioning system. It is characterized by the dystrophic calcification of the NP and extrusion of the disc material into the vertebral canal. DeBakey thumb forceps. EQUIPMENT • Standard surgical pack. 11 Bard Parker scalpel blade. Adson periosteal elevator. There are two different types of metaplastic changes that have been described: (1) fibroid and (2) chondroid metaplasia. which means that the NP is always dorsally eccentric. Identify and retract the esophagus and trachea to the left with moistened laparotomy sponges and either self-retaining or Army-Navy retractors (Plate 83A). . Identify the paired carotid sheaths. Stabilize the head and neck with towels. no. Continued *Hug-U-Vac. and make every effort to ensure that the animal is straight and in true dorsal recumbency. Army-Navy retractors. Pay careful attention to patient positioning. CHAPTER 83 V E N T R A L F E N E S T R AT I O N O F C E R V I C A L D I S C S 219 P L AT E 8 3 A Sternohyoideus muscle B Longus colli muscles Trachea Sternocephalicus muscle . in vitro studies of cadaveric spines have shown that ventral fenestration produces sagittal instability of the caudal cervical spine. 11 blade. padded bedding is important for patients that are nonambulatory or weakly ambulatory. 4. recovery times may vary. Am J Vet Res 52(1):140–145. Wheeler SJ. Most animals experience a decrease in cervical pain associated with IVD disease. Urine output and quantitation should be closely monitored for the first 24 to 48 hours. Neurologic deterioration associated with ventral fenestration has been reported in the literature. Mosby.3–6 The neurologic status of the patient should be serially evaluated upon recovery from anesthesia and surgery. however. and return the trachea and esophagus to their normal positions. Dallman MJ. A clinical study evaluating the width of the IVD space and the radiographic changes before and after IVD fenestration found . In addition. J Am Anim Hosp Assoc 34(2):135–144. or small bone curette (Plates 83D and 83E). Stover SM. dry. Sharp NJH (eds): Small Animal Spinal Disorders: Diagnosis and Surgery. References 1. 1993. J Am Vet Med Assoc 187(1):76–77. 1999. Lavage the soft tissues. and therefore complete resolution of the clinical signs associated with disc herniation may not be achievable with this procedure alone. Postoperative radiographs or ancillary imaging (computed tomography or magnetic resonance imaging) of the cervical vertebrae is usually not indicated. excise a rectangular window in the ventral annulus that is large enough to allow removal of the calcified NP (Plate 83C). Lavage and close longus colli in one layer with a simple continuous suture pattern. Moon ML. Tabaru H. 6. Tomlinson J: Tetraparesis following cervical disc fenestration in two dogs. 5. J Vet Med Sci 55(5):781–784. given a sufficiently long convalescent period. Most animals will improve following surgical intervention. Burbidge HM: The canine intervertebral disc. and close the sternohyoideus and sternomastoideus with a simple continuous suture pattern. Vet Surg 28(3):171–179. and angle the instrumentation accordingly to facilitate complete disc removal.g. tartar scraper. POSTOPERATIVE CARE General supportive care and pain management are indicated in all neurosurgery patients. therapy may consist of massage. proprioceptive exercises. depending on the severity of neurologic dysfunction.220 PA RT T H R E E • SURGICAL PROCEDURES FOR THE SPINE Cervical Disc Fenestration: Using a no. Taura Y. paresis or paralysis) are candidates for ventral decompression. Giovannitti-Jensen A: Comparison of the width of the intervertebral disc space and radiographic changes before and after intervertebral disc fenestration in dogs. Bray JP. London. In Wheeler SJ. 1985. Les CM. Depending on the level of neurologic dysfunction. assisted standing. 2. POSTOPERATIVE EVALUATION 1. complete removal of disc material from the vertebral canal is not possible. Nakama S. that there was spondylosis and narrowing of the IVD space associated with the ventral fenestration procedure. which may contribute to the development of secondary instability and subsequent disc herniation (“domino lesions”) at adjacent disc sites. however.3 Ventral fenestration is a technically easier procedure to perform in comparison to ventral decompression. 1994. Sharp NJH: Cervical disc disease. soft. Clean. Animals that display more advanced dysfunction associated with spinal cord compression (e. Macy NB. Close the subcutaneous tissues and skin in a routine fashion. Remove the retractors. Part two: Degenerative changes—nonchondrodystrophoid versus chondrodystrophoid discs. 3.. Rehabilitation may be implemented as soon as the acute postoperative pain has subsided (usually after 24 hours). Neck and buckle collars should be exchanged for a harness. CAUTIONS 1. and bladder expression or catheterization (or both) should be provided in those patients not urinating on a voluntary basis. 1991. and controlled therapeutic exercise. Remove all disc material with an ear loop. EXPECTED OUTCOME 3–5 The prognosis will vary depending on the level of neurologic dysfunction. et al: Effect of disc fenestration on sagittal kinematics of the canine C5-C6 intervertebral space. et al: A retrospective study of ventral fenestration for disc diseases in dogs. 1998. Remember that the IVD space angles cranially. it is thought to be caused by residual disc material herniating into the canal. Maintenance fluid therapy is routine for the first 24 to 48 hours or until the animal is able to eat and drink without assistance. 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 . Palpate the ventral spinous processes of the vertebral column to locate the appropriate disc space(s). sandbags. that are unresponsive to previous conservative treatment. computed tomography. Once it is free of its attachments. elevate and retract the longus colli muscle to expose the ventral annulus fibrosus at the affected disc space and the adjacent vertebral bodies (Plate 84C). two medium or large Gelpi retractors (depending on the size of dog). pneumatic drill system with burr guard and a variety of sizes of round and oval burrs. Johnson & Johnson. tartar scraper. It is often performed in combination with ventral fenestration. 11 Bard Parker *Bone wax. Senn retractors and/or Army-Navy retractors.† or Avitene Sheets‡ (Microfibrillar Hemostat). Davol. † Gelfoam. The use of cautery will reduce the amount of muscular bleeding and improve visualization. bipolar and unipolar cautery. Rhode Island. Pharmacia and Upjohn. PROCEDURE Approach: Incise the skin and subcutaneous tissue on the ventral midline from the caudal aspect of the thyroid cartilage to the manubrium. double-ended curette. Surgical candidates for a ventral slot are those animals that have exhibited multiple bouts of cervical pain. To avoid damage of these vertebral sinuses and instability of the vertebral spine. Reflect the skin and subcutaneous tissue medially and laterally with blunt dissection. depending on the degree and location of spinal cord compression. PREPARATION AND POSITIONING Prepare the patient from the mid-mandible to just past the manubrium. These two thinwalled veins converge and diverge at the vertebral midbody and IVD space. Myelography or ancillary imaging of computed tomography and magnetic resonance imaging are important for both diagnostic confirmation and neuroanatomical localization of the lesion. Kerrison rongeur. or magnetic resonance imaging. Cranston. Ball burnisher. and remove the ventral spinous process with a rongeur (Plate 84D). The large transverse processes of C6 and the wings of C1 are important landmarks that assist in anatomical orientation.§ Secure the head by taping the mandible to the table. centering the slot slightly cranial to the IVD space (Plate 84A). Bluntly separate the sternohyoideus and sternomastoideous muscles along the midline. Somerville. Kalamazoo. respectively. or that are nonambulatory tetraparetic or quadriplegic and that have been diagnosed with extradural compression of the spinal cord via myelography. Additional instrumentation that is useful for removing extruded disc material from the vertebral canal includes a Buck ear curette. OBJECTIVES • To relieve compression of the cervical spine from extruded or protruded disc material ANATOMIC CONSIDERATIONS 2–4 Cervical spinal cord compression accounts for 15% of the reported cases of IVD in the dog. and gently maneuver them out of the surgical field. no. Clinical signs associated with disc disease can vary from a nerve root signature and neck pain to quadriplegia. ‡ Avitene. bone wax. Once the IVD space(s) has been located. and make every effort to ensure that the animal is straight and in true dorsal recumbency. the dimensions of the slot must be no greater than one third the width and length of the body of the vertebra. crossing its forelimbs and securing them caudally. Lempert rongeur. The head and neck can be stabilized with towels. they also determine lateralization of the disc extrusion and rule out the presence of multiple lesions. which reside on the floor of the vertebral canal. EQUIPMENT • Standard surgical pack. Michigan. Identify and retract the esophagus and trachea to the left with moistened laparotomy sponges and either self-retaining or Army-Navy retractors (Plate 84B). The internal vertebral venous plexus or sinuses comprise two valveless veins. Adson periosteal elevator.222 PA RT T H R E E • SURGICAL PROCEDURES FOR THE SPINE CHAPTER 84 Ventral Cervical Slot scalpel blade. with 80% occurring in the chondrodystrophic breeds. followed by C3-4 and C7-T1. Ethicon. The midline location of the ventral slot must be precise to avoid the internal vertebral venous plexus. Oregon.* gelfoam. . suction hose and small Frazier suction tip. Continued INDICATIONS 1 Ventral decompression of the cervical spine is performed for intervertebral disc (IVD) disease of the cervical spine. and small bone curette. cauterize the musculotendinous attachments of the longus colli muscle to the ventral spinous processes. Iris spatula. New Jersey. The most common site of disc protrusion is C2-C3. Identify the paired carotid sheaths. South Salem. or a vacuumactivated surgical positioning system. Position the animal in dorsal recumbency. § Hug-U-Vac. Pay careful attention to patient positioning. DeBakey thumb forceps. CHAPTER 84 VENTRAL CERVICAL SLOT 223 P L AT E 8 4 Slot is 1/3 the width of the vertebral body A B Sternohyoideus muscle Trachea Slot is centered slightly cranial to interspace Carotid sheath Sternocephalicus muscle C Longus colli muscles D . 2000. 1999. Generally. dry. 8. If necessary. Severe hemorrhage can occur as a result of ventral sinus laceration.5 Proper anatomic orientation is key to the identification of the correct surgical site. 4. Partington BP. recovery times may vary depending on the severity of the neurologic dysfunction and the intraoperative complications. Postoperative or intraoperative radiographs should be taken if there is any doubt about lesion location. In Small Animal Spinal Disorders. Lemarie RJ. Once the inner cortex has been removed. 1993. given a convalescence period of reasonable length (6 to 8 weeks). until the animal is able to eat and drink without assistance. however. 3. 1992. excise the dorsal longitudinal ligament with a no. Avoid damaging the venous sinuses that circumferentially surround the slot ventral to the cord. 6. Tucker R. Neurologic deterioration associated with ventral fenestration has been reported in the literature and is thought to be due to the herniation of residual disc material into the canal. Am J Vet Res 52(1):140–145. Clean. Neck and buckle collars should be exchanged for a harness. ball burnisher. J Am Anim Hosp Assoc 36(4):348–358. 5. use a probe to penetrate the site gently and create a long window to allow a Kerrison rongeur to remove any remaining bone in the oblong window. and controlled therapeutic exercise. a smaller bit can be used to remove the edges of inner cortical bone plate. Maintenance fluid therapy is routine for the first 24 to 48 hours. Remove any remaining extruded disc with a Buck ear curette.7 Most patients with cervical IVD have a fair to good prognosis. tomography or magnetic resonance imaging) of the cervical vertebrae is usually not indicated. EXPECTED OUTCOME 5. Vet Surg 28:171–179. therapy may consist of massage. Dallman MJ. POSTOPERATIVE CARE General supportive care and pain management are indicated in all neurosurgery patients. Compend Contin Educ Pract Vet 18:795–804. assisted standing. all sinus bleeding should cease. Recurrence of signs associated with IVD has been reported within the literature and should be discussed with the owner prior to surgery. Remove the retractors. however. 2. Mosby-Wolfe. Tabaru H. Wait 5 minutes for the cessation of bleeding before removing the hemostatic devices and reinitiating the exploratory surgery. Urine output and quantitation should be closely monitored for the first 24 to 48 hours. Most animals experience a decrease in cervical pain associated with IVD disease. It is important to cross-match any animal that is a candidate for a coagulopathy before surgery. and close the sternohyoideus and sternomastoideus with a simple continuous suture pattern. select a burr that is equal to the width of the slot to promote even bone removal. expected outcomes vary depending on the level of neurologic dysfunction. 7. Closure: Lavage and close the longus colli in one layer with a simple continuous suture pattern. Compend Contin Educ Pract Vet 14:1477–1488. Postoperative radiographs or ancillary imaging (computed . If a venous sinus is damaged. Giovannitti-Jensen A: Comparison of the width of the intervertebral disk space and radiographic changes before and after intervertebral disk fenestration in dogs. control the bleeding with the gelfoam or Avitene Sheets. and bladder expression or catheterization should be provided for those patients that are not urinating on a voluntary basis. Nakama S. or tartar scraper to palpate the inner bone and periosteal shelf.5–8 The neurologic status of the patient should be serially evaluated upon recovery from anesthesia and surgery. proprioceptive exercises. Slowly trickle warm saline over the burr while drilling to prevent heat transfer from the burr to the hemilaminectomy site. Depending on the level of neurologic dysfunction. Tombs JP: Cervical intervertebral disk disease in dogs.224 PA RT T H R E E • SURGICAL PROCEDURES FOR THE SPINE Ventral Cervical Slot: Drill the proposed ventral slot site with a pneumatic air drill using a burr of appropriate size (Plate 84E). When it is thin and pliable. J Am Vet Med Assoc 187(1):76–77. Most animals improve following surgical intervention. Bagley RS. or iris scapula (Plate 84F). Lavage the soft tissues. Wheeler SJ. Stover SM. 11 blade to visualize and decompress the cord. use a nerve root probe. 1996. Kass PH: Effect of disk fenestration on sagittal kinematics of the canine C5-C6 intervertebral space. Once most of the bone has been removed. Macy NB. ear loop. CAUTIONS 1. Harrington ML: Lateral and foraminal disk extrusion in dogs. Rehabilitation may be implemented as soon as the acute postoperative pain has subsided (usually after 24 hours). Once the spinal cord has been fully decompressed. and intermittently lavage the entire laminectomy site to remove bone debris and to keep the tissues moist. Tomlinson J: Tetraparesis following cervical disk fenestration in two dogs. Any bone bleeding may be controlled with bone wax. 1985. and return the trachea and esophagus to their normal position. References 1. J Vet Med Sci 55(5):781–784. London. Sharp NJH: Cervical disc disease. 1991. Yasuda M: A retrospective study of ventral fenestration for disk diseases in dogs. soft padded bedding is important for patients that are nonambulatory or weakly ambulatory. Hosgood G: Vertebral subluxation following ventral cervical decompression in the dog. POSTOPERATIVE EVALUATION 1. Close the subcutaneous tissues and skin in a routine fashion. 1994. CHAPTER 84 VENTRAL CERVICAL SLOT 225 P L AT E 8 4 E Slot is centered slightly cranial to interspace F . that are unresponsive to previous conservative treatment. Ball burnisher.4. with the operated side being most dorsal. lamina. Ethicon. and repeat the procedure. and small bone curette. Iris spatula. Retract the elevated muscles using two Gelpi selfretaining retractors (Plate 85A). South Salem. which demarcate the position of the intervertebral foramina. Each vertebra also has two sets of articular facets located on the dorsal lateral aspect of the vertebral arch. Incise the thoracodorsal fascia and supraspinous ligaments with a no. bone wax. they change direction and decrease in size at the anticlinal vertebra. further secure the animal in position with white tape to prevent malposition during surgery. deviate the incision toward the side of the hemilaminectomy at each dorsal spinous process and then return the incision back to midline. extending the incision at least two dorsal spinous processes proximal and distal to the site(s) to be decompressed. Perfect positioning and alignment assist in the approach and ensure proper orientation. DeBakey thumb forceps. PREPARATION AND POSITIONING 1. no. or that have been diagnosed with compression of the spinal cord via myelography. EQUIPMENT • Standard surgical pack.§ If needed. PROCEDURE Approach:1. where the nerve root exits the spinal canal. avoiding the nerve root coursing deep and caudoventrally under the facet. one site cranial and one site caudal to the hemilaminectomy. 15 scalpel blade. these processes are tall and slant caudally. Reposition the Gelpi retractors to improve visualization. Vertebral body anatomy varies depending on the location in the axial skeleton. Lempert rongeur.† or Avitene Sheets‡ (Microfibrillar Hemostat). the processes become more substantial. ANATOMIC CONSIDERATIONS 5 The vertebrae are key components of the axial skeleton. Dorsal spinous processes project from the lamina. 11 and dorsal midline centered from the mid-thoracic vertebra to the mid-lumbar region. Elevate the epaxial musculature (multifidus thoracis and lumborum muscles) away from the dorsal spinous process. and lamina to the level of the articular facet using an Adson or Freer periosteal elevator. Location of the proximal rib head with the vertebra is an important anatomic landmark for identification of the proper intervertebral disc space.6. some surgeons prefer that the patient be rotated slightly. Pharmacia and Upjohn. Kerrison rongeur. and prepare the back from the mid-thoracic region to the lower lumbar area. however. The incision location and length will vary somewhat depending on the lesion location(s) and the number of sites that need to be decompressed. which slopes craniolaterally from the vertebral body. pedicle. Each rib projects in a perpendicular fashion from the vertebral body. Michigan.4 • To decompress the spinal cord of the thoracolumbar spine Hemilaminectomy is often performed in combination with lateral fenestration. Using the bipolar cautery. † Gelfoam. pneumatic drill system with burr guard and a variety of sizes of round and oval burrs. Somerville. OBJECTIVES 1. Cranston. Elevate any remaining tissue attached to the exposed facet. A Freer or other small periosteal elevator may be used to palpate these landmarks to avoid excessive soft tissue dissection. Johnson & Johnson. the thoracic vertebrae also articulate with a pair of ribs just ventral and caudal to the intervertebral foramina. 15 Bard Parker scalpel blades. New Jersey.6. Support the animal with sandbags on each side of the abdomen. ‡ Avitene.* gelfoam. or magnetic resonance imaging. usually located at T10. and wider.4.7 Position the animal in sternal recumbency. In the lumbar region. In addition to articulating with each other. The articulation of the rib head with the vertebral body is easily palpated and distinguished from the transverse process of the lumbar vertebra. Rhode Island. two medium or large Gelpi retractors (depending on the size of the dog). they lie along the midline of the body. In order to minimize muscular hemorrhage. § Hug-U-Vac. Freer periosteal elevator. that exhibit loss of voluntary motor function. and pedicle. and remove the articular facets with a Lempert rongeur (Plate 85B). Senn retractors. but each has a basic structural configuration despite minor differences in morphology. suction hose and small Frazier suction tip. bipolar and unipolar cautery.7 Incise the skin and subcutaneous tissue on INDICATIONS 1–3 Surgical candidates for a hemilaminectomy are those animals that have exhibited multiple bouts of thoracolumbar pain. shorter. double-ended curette. however. The spinal cord is surrounded and protected by the lamina and pedicle. Kalamazoo. Interposed between and connecting each vertebral body is an intervertebral disc (see Chapter 83 for an in-depth discussion of disc anatomy). to provide adequate exposure. Each vertebral bone has a body that lies directly beneath the spinal cord. Davol. In the cranial thoracic vertebra. . cauterize the musculotendinous attachments of the longissimus muscles originating on the articular facets. computed tomography. Continued *Bone wax. or use a vacuum-activated surgical positioning system.226 PA RT T H R E E • SURGICAL PROCEDURES FOR THE SPINE CHAPTER 85 Hemilaminectomy no. Additional instrumentation that is useful for removing extruded disc material from the vertebral canal includes a Buck ear curette. tartar scraper. Oregon. and suture in two quarter drapes to decrease skin contamination. which collectively make up the vertebral arch. CHAPTER 85 H E M I L A M I N E C TO M Y 227 P L AT E 8 5 A B T13 L1 . Waldron DR. Maintenance fluid therapy is routine for the first 24 to 48 hours or until the animal is able to eat and drink without assistance.6 Drill the proposed hemilaminec- tomy site with a pneumatic air drill using a burr of appropriate size. . Johnson KA: Approach to the thoracolumbar vertebrae through a dorsal incision. If a venous sinus is damaged. 2003. CAUTIONS 8–11 No more than four adjacent continuous hemilaminectomy sites (or. Prior to the surgery. 2002. 1992. Recurrence of signs associated with intervertebral disc disease has been reported within the literature and should be discussed with the owner prior to surgery. WB Saunders. 1994.228 PA RT T H R E E • SURGICAL PROCEDURES FOR THE SPINE Hemilaminectomy:1. Vet Comp Orthop Traumatol 13:165–171. 2. 2004. Davis GJ. Once the spinal cord has been decompressed. Am J Vet Res 64(9):1139–1145. Wheeler SJ. select a burr that is equal to the width of the hemilaminectomy site to promote even bone removal (Plate 85C). Friis E: In vitro evaluation of biomechanical effects of multiple hemilaminectomies on the canine lumbar vertebral column. 1996. assisted standing. 5. padded bedding is important for patients that are nonambulatory or weakly ambulatory. and fenestration. and harvest a fat graft from the subcutaneous region of the back. a smaller bit can be used to remove the edges of inner cortical bone plate. Gently pass a neural probe under and dorsal to the spinal cord to ensure complete decompression. Close the subcutaneous tissues and skin in a routine fashion. POSTOPERATIVE CARE General supportive care and pain management are indicated in all neurosurgery patients. 8. Vet Clin North Am Small Anim Pract 30(1):77–110. Any bone bleeding may be controlled with bone wax. a radiograph of a sterile needle placed in a dorsal spinous process can be used to assist in vertebral body identification. Grant JW. Prognostic indicators for time to ambulation after hemilaminectomy include the presence of postoperative voluntary motor function. Sharp NJH: Thoracolumbar disc disease. Piermattei DL. Most overweight animals also benefit from a weight loss program. 9. Hill T. Sharp NJH (eds): Small Animal Spinal Disorders: Diagnosis and Surgery. and controlled therapeutic exercise. Brown DC: Prognostic indicators for time to ambulation after surgical decompression in nonambulatory dogs with acute thoracolumbar disk extrusions: 112 cases. et al: Biomechanics of the thoracolumbar vertebral column of dogs during lateral bending. use a nerve root probe. Hosgood G: Wound complications following thoracolumbar laminectomy in the dog: A retrospective study of 264 procedures. however. gently lavage the hemilaminectomy site. Urine output and quantitation should be closely monitored for the first 24 to 48 hours. 7. 11. London. Canine Practice 20(6):6–10.12 Most patients with thoracolumbar intervertebral disc disease have good to excellent prognosis. Seim HI: Dorsal decompressive laminectomy for T-L disk disease. Vet Clin North Am Small Anim Pract 22(4):899–915. Prog Vet Neuro 4(3):81–83. 4. 6. In Wheeler SJ. ear loop. Depending on the level of neurologic dysfunction. J Am Anim Hosp Assoc 28(1):47–52. Renberg W. POSTOPERATIVE EVALUATION The neurologic status of the patient should be serially evaluated upon recovery from anesthesia and surgery. References 1. Harari J. 2000. Sharp NJH (eds): Small Animal Spinal Disorders: Diagnosis and Surgery. Coates J: Intervertebral disk disease. Mosby. In Wheeler SJ. Clean. Wheeler SJ. dry. Joseph R: How do I treat? Degenerative thoracolumbar intervertebral disc disease in small breed dogs. Vet Surg 31(6):513–518. Suture the epaxial muscular fascia in a simple continuous pattern with absorbable suture. Mosby. or iris scapula (Plate 85D). Wait 5 minutes for the cessation of bleeding before removing the hemostatic devices and reinitiating the exploratory. When it is thin and pliable. use a probe to gently penetrate the site and create a long window to allow admission of a Kerrison or small Lempert rongeur to remove any remaining bone in the oblong window (see Plate 85C). depending on the level of neurologic dysfunction. 2000. EXPECTED OUTCOME 1–3. Once most of the bone has been removed. Generally. Place the fat graft over the hemilaminectomy site to prevent fibrous scarring and adhesion. because excessive weight can impair neurologic recovery. Slowly trickle warm saline over the burr while drilling to prevent heat transfer from the burr to the hemilaminectomy site.4. Remove the extruded disc with a Buck ear curette. Am J Vet Res 57:1228–1232. Lubbe A. up to two adjacent sites) should be performed to prevent destabilizing the spinal column. Guthrie A: Lumbar spine stability following hemilaminectomy. Once the inner cortex has been removed. Marks S: Surgical treatments for intervertebral disc disease. In An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. Avoid damaging the venous sinuses ventral to the cord. proprioceptive exercises. Rehabilitation may be implemented as soon as the acute postoperative pain has subsided (usually after 24 hours). Corse M. Urinary continence generally returns with the advent of voluntary ambulation. London. control the bleeding with the gelfoam or Avitene Sheets. Bailey CS. 1993. Simpson S. Kornegay J. Schulz KS. or tartar scraper to palpate the inner bone and periosteal shelf. and bladder expression or catheterization (or both) should be provided in those patients that are not urinating on a voluntary basis. Animals with intact pain sensation generally have a greater than 90% chance of full recovery. and intermittently lavage the entire laminectomy site to remove bone debris and to keep the tissues moist. Sharp NJH: Functional anatomy. bilaterally. 1995. 3. 12. Accurate anatomic identification of the hemilaminectomy site is important for the success of the surgery. ball burnisher. 10. soft. pediculectomy. 1994. 1992. Most animals improve following surgical intervention given a convalescent period of reasonable length (6 to 8 weeks). therapy may consist of massage. Philadelphia. expected outcomes will vary. 4th ed. CHAPTER 85 H E M I L A M I N E C TO M Y 229 P L AT E 8 5 C D . 11 scalpel blade. Perfect positioning and alignment assist in the approach and ensure proper orientation.§ If needed. § Hug-U-Vac. thoracolumbar fenestration has not been proven to prevent future herniation of discs. and prepare the back from the mid-thoracic region to the lower lumbar area. Support the animal with sandbags on each side of the abdomen.* gelfoam. Rhode Island. OBJECTIVES • To prevent herniation of a degenerative intervertebral disc into the vertebral canal and to resolve clinical signs associated with intervertebral disc disease (e. The intervertebral disc site of the lumbar vertebra lies just cranial to the area where the transverse process joins the vertebral body. South Salem. tartar scraper. or use a vacuum-activated surgical positioning system. suction hose and small Frazier suction tip. Somerville. resect a rectangular section of the lateral annular wall that is large enough to allow access to and removal of the calcified nucleus pulposus (see Plate 86B). In addition. Kalamazoo. two medium or large Gelpi retractors (depending on the size of the dog). Freer periosteal elevator. Ball burnisher. Discs above and below these sites are not routinely fenestrated via this approach because of technical difficulties in the approach caused by anatomic differences and to avoid inadvertent damage to the femoral nerve segments.g. and small bone curette. Retraction of the multifidus thoracis or lumborum and longissimus dorsi muscles with the blunt end of a Senn retractor reveals the spinal nerve and artery. Senn *Bone wax. † Gelfoam. bone wax. Kerrison rongeur. Suture the epaxial muscular fascia in a simple continuous pattern with absorbable suture. however. buck ear curette. or a neurologic instrument of choice. Close the subcutaneous tissues and skin in a routine fashion. Additional instrumentation that is useful for removing in situ calcified disc material from the vertebral canal includes a Buck ear curette. The intervertebral disc site of the thoracic vertebra lies just cranial and ventromedial to the tubercle of the rib and adjacent to the head of the rib. Davol. PREPARATION AND POSITIONING Position the animal in sternal recumbency.5 A dorsolateral approach (as described here) may be used to gain access to intervertebral disc sites from T10 to L5. Craniolaterally retract the spinal nerve and artery. To date. bipolar and unipolar cautery. Iris spatula. Cranston. which lie over the lateral wall of the annulus fibrosus. . 11 Bard Parker scalpel blade. Continued INDICATIONS 1–3 Dorsolateral fenestration of the thoracolumbar spine may be performed as a prophylactic or therapeutic measure for degenerative intervertebral disc disease. Ethicon. PROCEDURE Thoracolumbar Fenestration: After performing the hemilaminectomy via a dorsal approach (Plate 86A) (see Chapter 85). considerable debate exists regarding the indications and therapeutic benefit of fenestration. further secure the animal in position with white tape to prevent malposition during surgery. Lavage and remove the retractors from the epaxial musculature. remove as much of the calcified disc material as possible (Plate 86C). maintain the neurologic instrument at a perpendicular angle to the longitudinal and transverse axis of the spine. no. With a no. demarcating the intervertebral disc site to reveal the lateral aspect of the annulus fibrosis (Plate 86B). New Jersey. some surgeons prefer that the patient be rotated slightly. double-ended curette. EQUIPMENT • Standard surgical pack. Johnson & Johnson. ‡ Avitene. With a tartar scraper.. with the operated side being most dorsal.† or Avitene Sheets‡ (Microfibrillar Hemostat). however. pain) ANATOMIC CONSIDERATIONS 4. locate the intervertebral disc site(s) to be fenestrated. Lempert rongeur. most surgeons electing to perform this procedure do so in combination with a hemilaminectomy at adjacent intervertebral discs that are calcified in situ. Pharmacia and Upjohn. clinical studies have yet to prove its therapeutic benefit over the hemilaminectomy procedure. DeBakey thumb forceps.230 PA RT T H R E E • SURGICAL PROCEDURES FOR THE SPINE CHAPTER 86 Fenestration of Thoracolumbar Discs retractors. In general. To avoid damage to the peridisc neurovascular structures. Oregon. Michigan. CHAPTER 86 F E N E S T R AT I O N O F T H O R A C O L U M BA R D I S C S 231 P L AT E 8 6 B A T13 L1 C . 7. J Vet Med Sci 55(5):781–784. assisted standing. Animals that display more advanced dysfunction associated with spinal cord compression (e.6 Fenestration of the disc space alone is not an appropriate treatment in animals with neurologic deficits (e. soft. proprioceptive exercises. Burbidge HM: The canine intervertebral disc. Macy NB. J Am Vet Med Assoc 187(1):76–77. Vet Surg 28(3):171–179. and fenestration. McKee WM: A comparison of hemilaminectomy (with concomitant disc fenestration) and dorsal laminectomy for the treatment of thoracolumbar disc protrusion in dogs. et al: A retrospective study of ventral fenestration for disc diseases in dogs.5–8 The neurologic status of the patient should be serially evaluated upon recovery from anesthesia and surgery. Nakama S. Tabaru H.. Lubbe A. POSTOPERATIVE EVALUATION 3. 2.. Sharp NJH: Cervical disc disease. Dallman MJ. 1993. Urine output and quantitation should be closely monitored for the first 24 to 48 hours. Giovannitti-Jensen A: Comparison of the width of the intervertebral disc space and radiographic changes before and after intervertebral disc fenestration in dogs. . Les CM. J Am Anim Hosp Assoc 34(2):135–144. 4.g. Mosby. Sharp NJH (eds): Small Animal Spinal Disorders: Diagnosis and Surgery. 8. 6. Vet Comp Orthop Traumatol 13:165–171.g. therapy may consist of massage. Maintenance fluid therapy is routine for the first 24 to 48 hours or until the animal is able to eat and drink without assistance. EXPECTED OUTCOME 1. given an adequate convalescent period. References 1. London. 1998. Depending on the level of neurologic dysfunction. Stover SM. 2000. Taura Y. Rehabilitation may be implemented as soon as the acute postoperative pain has subsided (usually after 24 hours). Most animals improve following surgical intervention. 1991. 3. and bladder expression and catheterization (or both) should be provided in those patients not urinating on a voluntary basis. Am J Vet Res 52(1):140–145. and controlled therapeutic exercise. 1994. 1992. Moon ML. pediculectomy. padded bedding is important for patients that are nonambulatory or weakly ambulatory. Wheeler SJ. 1999.6 The prognosis varies depending on the level of neurologic dysfunction. Vet Rec 130(14):296–300. 1985. Bray JP.232 PA RT T H R E E • SURGICAL PROCEDURES FOR THE SPINE CAUTIONS 5. Clean. Part two: Degenerative changes—nonchondrodystrophoid versus chondrodystrophoid discs. dry. Postoperative radiographs or ancillary imaging (computed tomography or magnetic resonance imaging) of the thoracolumbar vertebrae is usually not indicated. significant ataxia or loss motor function) because it does not ameliorate spinal cord compression stemming from disc extrusion. Tomlinson J: Tetraparesis following cervical disc fenestration in two dogs. In Wheeler SJ. Neurologic deterioration associated with thoracolumbar fenestration has been reported in the literature and is thought to be caused by residual disc material herniating into the canal. et al: Effect of disc fenestration on sagittal kinematics of the canine C5-C6 intervertebral space. 5. paresis or paralysis) are candidates for decompression via hemilaminectomy. Guthrie A: Lumbar spine stability following hemilaminectomy. Hill T. POSTOPERATIVE CARE General supportive care and pain management are indicated in all neurosurgery patients. two medium or large Gelpi retractors (depending on the size of the dog). Kalamazoo. bone wax. with clinical signs ranging from lumbosacral pain. the spinal cord terminates between L4 and L6 in the dog. Somerville. with the hips and stifles flexed. 11 scalpel blade. Bilaterally elevate the sacrocaudalis dorsal medialis muscles away from the dorsal spinous process. have been diagnosed with compression of the cauda equina via epidurography. Freer periosteal elevator. hind end lameness. Ball burnisher. the cauda equina is composed of nerve roots from the seventh lumbar. three sacral. computed tomography. or use a vacuum-activated surgical positioning system. no. ANATOMIC CONSIDERATIONS 2 Because of the differential rate of growth between the bony vertebral column and the spinal cord. . arising from the L4-L6 spinal cord segments. South Salem. pedicle. Pharmacia and Upjohn. Oregon. Support the animal with sandbags on each side of the abdomen. and the caudal gluteal nerve (L7-S1). Degenerative lumbosacral stenosis or cauda equina is a multifactorial disease process. the disease is caused by nerve root entrapment by either hard or soft tissue. § Hug-U-Vac. pneumatic drill system with burr guard and a variety of sizes of round and oval burrs. 11 and no. Davol. and position the rear limbs forward. Johnson & Johnson. ideally. Incise the lumbosacral and gluteal fascia with a no. Perfect positioning and alignment assist in the approach and ensure proper orientation. and degenerative changes and hypertrophy of the ligamentum flavum. double-ended curette. the pudendal and pelvic nerves (which arise from the S1-S3 spinal cord segments). Specifically. DeBakey thumb forceps. Rhode Island. Senn retractors. Suture two quarter drapes to the subcutaneous tissue to decrease skin contamination. Continued *Bone wax. 15 Bard Parker scalpel blades. suction hose and small Frazier suction tip. and lamina to the articular facets of L7-S1 and the intermediate sacral crest. dorsal longitudinal ligament. Degenerative intervertebral disc disease. Excise the interarcuate ligament between the laminae of L7-S1 with a no.* gelfoam.234 PA RT T H R E E • SURGICAL PROCEDURES FOR THE SPINE CHAPTER 87 INDICATIONS 1–4 Dorsal Laminectomy of L7-S1 disease process. small bone curette. Regardless of the point of etiology. Lempert rongeur. † Gelfoam. is usually spared from lumbosacral entrapment because of its early exit from the spinal canal at the L6-L7 intervertebral disc space. bipolar and unipolar cautery. Kerrison rongeur. and prepare the lower back and sacrum from the mid-lumbar region to the tail head. congenital lumbosacral stenosis.§ If needed. or malarticulation. forming the cauda equina. The femoral nerve. and then course obliquely and caudally to their respective intervertebral foramina. Iris spatula. Ethicon. Elevate the hind end with sandbags. ‡ Avitene. New Jersey. the cranial gluteal nerves (L6-S1). or magnetic resonance imaging. Michigan. and articular facet joint capsule have all been associated with this PREPARATION AND POSITIONING 7–10 Position the animal in sternal recumbency. tartar scraper. from the L6 dorsal spinous process to the caudal median sacral crest. using an Adson or Freer periosteal elevator. and a varying number of caudal spinal segments. Nerve roots affected by degenerative lumbosacral stenosis or cauda equina syndrome include the sciatic nerve (which arises from the L6 to S1–S2 spinal cord segments). malformation. 15 blade to expose the epidural space and the cauda equina. PROCEDURE Approach:11–13 Incise the skin and subcutaneous tissue on dorsal midline from the L5 dorsal spinous process to the first or second caudal vertebrae. and nerve root retractor.† or Avitene Sheets‡ (Microfibrillar Hemostat) Additional instrumentation that is useful for removing extruded disc material from the vertebral canal includes a Buck ear curette. Cranston. EQUIPMENT • Standard surgical pack. and paraparesis and ataxia of the hind end or tail to fecal and urinary incontinence. Retract the elevated muscles using two Gelpi self-retaining retractors (Plate 87A). further secure the animal in position with white tape to prevent malpositioning during surgery. OBJECTIVES 1–6 • Lumbosacral dorsal laminectomy is performed for exposure to and is indicated for decompression of the cauda equina Lumbosacral dorsal laminectomy is often performed in combination with foraminotomy to relieve individual nerve root impingement. Surgical candidates for a lumbosacral dorsal laminectomy are those animals that have exhibited multiple bouts of lumbosacral pain and that are nonresponsive to conservative treatment of rest and nonsteroidal anti-inflammatory drugs or those animals that exhibit loss of voluntary motor function and urinary or fecal incontinence and that. At the end of the spinal cord or conus medullaris. the nerve root segments exit. S 1 235 P L AT E 8 7 A Spinous process L7 Spinous process S1 .CHAPTER 87 D O R S A L L A M I N E C TO M Y O F L 7 . using a burr of appropriate size (Plate 87C). Control any bone bleeding with bone wax. London. 16. In Wheeler SJ. EXPECTED OUTCOME 1–6. Canine Practice 20(6):6–10. et al: Predictors of outcome after dorsal decompressive laminectomy for degenerative lumbosacral stenosis in dogs: 69 cases (1987–1997). Williams & Wilkins. Schulz KS. Johnson KA: Approach to the lumbar vertebra 7 and the sacrum through a dorsal incision. depending on the level of neurologic dysfunction. Piermattei DL. J Am Vet Med Assoc 219(5):624–628. Bailey CS.12 Remove the dorsal spinous processes of L7 and S1 with a rongeur (Plate 87B). Mosby. Activity should be restricted for 4 to 6 weeks. Olby NJ. Urine output and quantitation are closely monitored for the first 24 to 48 hours. Inspect each nerve root for entrapment or compression from a bulging or extruded intervertebral disc. Slowly trickle warm saline over the burr while drilling to prevent heat transfer from the burr to the laminectomy site. and weakness have a fair to good prognosis for full recovery. proprioceptive exercises. Guthrie A: Lumbar spine stability following hemilaminectomy. 4th ed. 2. 2003. 9. Hill T. Friis E: In vitro evaluation of biomechanical effects of multiple hemilaminectomies on the canine lumbar vertebral column. 14.10. Vet Clin North Am Small Anim Pract 30(1):77–110. 2002. De Risio L. Sharp NJ: Degenerative lumbosacral stenosis. 2003. 1998. 10. In An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. has been found to be independent of disease severity and thus should not be used in prognostication. or foraminotomy. however. Marks S: Surgical treatments for intervertebral disc disease. Intermittently lavage the entire laminectomy site to remove bone debris and to keep the tissues moist. Tarvin G: Surgical treatment of cauda equina compression syndrome by laminectomy. CAUTIONS 14–17 Every effort should be made to preserve the articular facets of the lumbosacral junction to promote lumbosacral stability. given a reasonable convalescent period (4 to 6 weeks). Joseph R: How do I treat? Degenerative thoracolumbar intervertebral disc disease in small breed dogs. all lumbosacral laminectomies must be approached as exploratory operations. normal activity is then slowly reintroduced. Vet Comp Orthop Traumatol 13:165–171. Am J Vet Res 57:1228–1232. Kapatkin AS. 1995. Once the nerve root(s) has been decompressed. 4th ed. Vet Surg 28(2):91–98. 11. or stenotic intervertebral foramina or canal. Jones J. Place the fat graft over the hemilaminectomy site to prevent fibrous scarring and adhesion. Rochat MC. Owner education is very important to the success of the surgery. Degree of compression at the time of . a smaller bit can be used to remove the edges of inner cortical bone plate. Wheeler SJ. Lenehan T. as determined by magnetic resonance imaging.18–20 Most animals with degenerative lumbosacral stenosis have good to excellent prognosis. 6. Mayhew PD. facetectomy. it is often difficult to identify a compressive lesion because of the anatomic complexity of the area. 2001. Recurrence of signs has been reported at a varying rate of 15% to 67% and should be discussed with the owner before surgery. Rehabilitation may be implemented as soon as the acute postoperative pain has subsided (usually after 24 hours). 2000. Davis GJ. further decompression of a nerve root may be necessary by performing a discectomy (Plate 87F). For animals with excessive weight. 2000. Vet Clin North Am Small Anim Pract 30(1):111–132. 15. Wheeler SJ. 2004. Most animals improve after surgical intervention. Bartels KE. therapy may consist of massage. Grant JW. Once the inner cortex has been removed. peripheral nerve injury stemming from retraction is usually transient and responsive to appropriate supportive care. 17. Philadelphia. 1992. Drill the proposed laminectomy site with a pneumatic air drill. When it is thin and pliable. Gentle retraction and manipulation of the nerve roots is often necessary to access the compressive lesion.12. a weight loss program may be beneficial. 3. Lubbe A. Corse M. Harari J. Sharp NJ. 1993.236 PA RT T H R E E • SURGICAL PROCEDURES FOR THE SPINE Dorsal Laminectomy of L7-S1:4. Sharp NJH (eds): Small Animal Spinal Disorders. 13. Barring extreme paresis or ataxia. 2000. hypertrophied dorsal longitudinal ligament. ear loop. use a nerve root probe. In An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. Sharp NJH (eds): Small Animal Spinal Disorders. 18. Banfield C. Danielsson F. Sjostrom L: Surgical treatment of degenerative lumbosacral stenosis in dogs. WB Saunders. et al: Biomechanics of the thoracolumbar vertebral column of dogs during lateral bending. assisted standing. In Wheeler SJ. Ward D: Association between postoperative outcome and results of magnetic resonance imaging and computed tomography in working dogs with degenerative lumbosacral stenosis. pediculectomy. Depending on the level of neurologic dysfunction. Vet Surg 32(1):21–29. De Risio L. 1992. Once most of the bone has been removed. Young animals with mild signs of lumbosacral pain. J Am Vet Med Assoc 216(11):1769–1774. but expected outcomes vary. Close the subcutaneous tissues and skin in a routine fashion. 4th ed. Philadelphia. and bladder expression or catheterization (or both) are provided in patients not urinating voluntarily. 19. Hosgood G: Wound complications following thoracolumbar laminectomy in the dog: A retrospective study of 264 procedures. Prog Vet Neuro 4(3):81–83. presentation. and harvest a fat graft from the subcutaneous region of the back. gently lavage the laminectomy site. However. WB Saunders. Am J Vet Res 64(9):1139–1145. Therefore. padded bedding is needed for nonambulatory or weakly ambulatory patients. Vet Clin North Am Small Anim Pract 22(4):899–915. Sharp NJH: Thoracolumbar disc disease. dorsal longitudinal ligament resection. soft. emphasizing the diagnostic and therapeutic significance of the surgery. Coates J: Intervertebral disk disease. 12. The laminectomy site should extend from the cranial aspect of the dorsal spinous process of L7 to the caudal aspect of S1. Simpson S. Piermattei DL. Maintenance fluid therapy is routine for the first 24 to 48 hours or until the animal can eat and drink unaided. Thomas WB. 4. Sharp NJH: Lumbosacral disease. and controlled therapeutic exercise. London. use a probe to gently penetrate the site and create a long window to allow admission of a Kerrison or small Lempert rongeur to remove any remaining bone in the oblong window (Plate 87E). dry. Brown DC: Prognostic indicators for time to ambulation after surgical decompression in nonambulatory dogs with acute thoracolumbar disk extrusions: 112 cases. 7. Suture the epaxial muscular fascia in a simple continuous pattern using absorbable suture. References 1. Kornegay J. Linn LL. An accurate and thorough identification of each nerve root will improve the postoperative outcome. J Am Anim Hosp Assoc 38(6):555–562. Urinary or fecal incontinence and extreme age have been associated with poor or guarded recovery. Mosby 1994. Seim HI: Dorsal decompressive laminectomy for T-L disk disease. because small but significant lesions may be missed by ancillary imaging such as magnetic resonance imaging and computed tomography. 1996. Trace each nerve root with a nerve root retractor along its path toward its respective intervertebral foramina. Vet Surg 31(6):513–518. 1999. or tartar scraper to palpate the inner bone and periosteal shelf. which can impair neurological recovery. et al: Association of cauda equina compression on magnetic resonance images and clinical signs in dogs with degenerative lumbosacral stenosis. POSTOPERATIVE EVALUATION The neurologic status of the patient should be serially evaluated upon recovery from anesthesia and surgery. In Bojrab MJ (ed): Current Techniques in Small Animal Surgery. Depending on the lesion location. 1994. Renberg W. et al: Lumbosacral stenosis in 29 military working dogs: Epidemiologic findings and outcome after surgical intervention (1990–1999). Waldron DR. 2002. POSTOPERATIVE CARE Neurosurgery patients require general supportive care and pain management. Baltimore. Wortman JA. 5. 2000. J Am Anim Hosp Assoc 28(1):47–52. preserving the articular facets (Plate 87D). Johnson KA: Approach to the thoracolumbar vertebrae through a dorsal incision. Clean. 20. 2004. ataxia. 8. and fenestration. 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 . 92 in transverse derotational osteotomy stabilized with plate. 109p in stifle luxation. 129p. 2 Axillobrachial vein in forelimb amputation with scapulectomy. 205p. 144 in transverse scapular body fractures. 35p of elbow. 106. 133p femoral. 194. 205p 239 . 182. 93p in talus osteochondrosis of lateral trochlear ridge. 75p. 154. 90. 15p of stifle. 46 fractures of. 108. 101p in humeral diaphyseal fractures and external fixator. 107p at midshaft of femur. 44 in triple pelvic osteotomy. 94. 15p in shoulder luxation. 162. A Abductor digiti quinti muscle in Achilles tendon repair. 160. 202. 190. 158. 53p. 126 short oblique or transverse. 46. 103p. 159p in humeral distal fractures. 108 at midshaft of femur. 129p. 61p in medial patella luxation. 50 Brachialis muscle in humeral diaphyseal fractures and external fixator. 192. 124. 90 with intramedullary pin and wire. 142. 74 in femoral diaphyseal fractures. 77p single locking-loop method. 32 in partial carpal arthrodesis with intramedullary pins. 181p in hip luxation and extracapsular stabilization. 94. 31p Arthrodesis of carpus. 179p in hip luxation. 73p of tarsus. 132. 183p in femoral physeal fractures distal. 186. 76. 159p Brachiocephalicus muscle in forelimb amputation with scapulectomy. 100. 102 Axillary nerve in osteochondrosis of shoulder. 190. 53p in meniscectomy. 106. 107p at midshaft of femur. 108. 128. 101p of mandible. via scapulectomy. 178. 99p of rear limb at coxofemoral joint. 213p Abductor pollicis longus muscle in pancarpal arthrodesis. 109p in triple pelvic osteotomy. 68. 14. 22. 48. 93p Arthrotomy of stifle in intra-articular repair of cranial cruciate ligament. 77p Acromion process in arthrodesis of shoulder. 100. 106. 186. 65p in lateral fabellar suture repair of cranial cruciate ligament. 153p in shoulder arthrodesis. 14. 37p with plate. 96–98. 36 with plate. 122 tibial. 192. 60. 48. medial. 38. 30. 23p. 145p Axillary artery and vein in forelimb amputation with scapulectomy. 129p. 74–76. 38. 180. 55p Bone graft in carpal arthrodesis. 56. 18. 32 with intramedullary pins. 129p. 76. 14 in tarsal arthrodesis. 153p Bridging plate in diaphyseal fractures of femur. 110. 28 in shoulder arthrodesis. 77p pin and tension band method. 64. lateral. 94 with plate. 187p and plate application. 211p Acetabulum contact with femur in ostectomy of femoral head and neck with joint capsule interpolation. 191p Biceps femoris muscle (Continued) in femoral head and neck ostectomy with joint capsule interpolation. 204. 101p in forelimb salvage with scapulectomy. 14 in neck of scapula fractures. 92. 108. 19p in ununited anconeal process. 49p Amputations avoidance of. 204. 173p Anconeal muscle (Continued) in luxation of elbow. 95p with plate. 134. 103p of digit. 133p and external fixator. 52. 185p proximal. 97p. 163p and intramedullary pin or interlocking nail. 75p in intertarsal or tarsometatarsal arthrodesis with intramedullary pin and wire. 146 in supraglenoid tuberosity fractures. 104 in humeral diaphyseal fractures and plate application. 140. 187p and plate application. 159p in humeral distal fractures. 18. 193p and intramedullary pin or interlocking nail. 23p Anconeal process in lateral elbow luxation. 28. 48. 36 in radial and ulnar styloid fractures. 109p Anconeal muscle in arthrodesis of elbow. 135p comminuted. 102–104. 76. 85p in tarsal fractures. 29p of shoulder. transverse or short oblique. T or Y type. 195p long oblique. 118. 22–24. 77p three-loop pulley method. 47p in femoral neck fractures. 25p Antebrachial carpal joint in pancarpal arthrodesis. 65p medial patellar. 206 in elbow arthrodesis. 161p of radius. 128. 32. 128. 50 Achilles tendon repair. 158. 42 in rear limb amputation at coxofemoral joint. 92. 100. 34 in diaphyseal fractures. 36. 163p and intramedullary pin or interlocking nail. 162. 101p B Biceps brachii muscle in forelimb salvage with scapulectomy. 133p and external fixator. 191p of humerus. 111p of forelimb. 158. 143p Acrylic external fixation in mandibular body fractures. 141p Adductor muscles of thigh in femoral diaphyseal fractures. 144. 107p. 155p and plate application. 33p in radial carpal bone fractures. 192. 33p with intramedullary pins. T or Y type. 58 and intra-articular repair of cranial cruciate ligament. 28. 72. 155p and plate application. 19p ununited. 191p in rear limb amputation at coxofemoral joint. 106.Index Page numbers followed by p refer to plates. 100. 186. 39p and intracapsular stabilization. 120. 166. 7p Biceps femoris muscle in Achilles tendon repair. 114 in triple pelvic osteotomy. 154. 91p with intramedullary pin and wire. 167p of tibia. 29p in fracture of proximal ulna. 69p Avulsion fracture of supraglenoid tuberosity. 95p with plate. 158. 193p and intramedullary pin or interlocking nail. 34. 40. 148. 166. 131p in femoral diaphyseal fractures. 203p. 88. 157p. 161p. 214. 56. 157p. 190. 136. 18. 108 in extracapsular stabilization of hip luxation. 160. 220. 147p in shoulder arthrodesis. 16. 164 in mandibular symphyseal fractures. 59p in tarsal shearing injury and luxation. 84. 18–20. 195p humeral. 106. 34 Carpus disorders arthrodesis in. 120. 152. 162–164. 48–50. 87p in tibial malleolar fractures. 200. 63p in elbow arthrodesis. 211p radius or ulna styloid process fractures. 56. 133p intramedullary pin and bridging plate in. 211p Compression plate. 120. lateral. 159p. lateral. 26. 139p Digit amputation. 211p in stifle arthrodesis. 47p in triple pelvic osteotomy. 19p. 120. 130. 107p. 15p in shoulder luxation. in radial carpal bone fractures. 186–194. 165p intramedullary pin used with. 127p in femoral diaphyseal fractures. 78 medial in stifle luxation. 199p in tibial malleolar fractures. 118. 35p in elbow luxation. transverse. 120. 18. 218–220. 124. 151p. 219p. 151p Contracture of infraspinatus muscle. 126. 33p with intramedullary pins. 43p. 82. 4. 20. 110. 14. 2. 122. 155p. 27p Extensor hallucis longus muscle in talus osteochondrosis. 25p Extensor carpi radialis muscle in carpal arthrodesis. 215p in radial diaphyseal fractures. 58. 150. 214. 121p type Ib external fixator in. 222 Collateral ligaments lateral in cranial cruciate ligament repair with lateral fabellar suture. 209p Digastricus muscle in mandibular body fractures. 126. 188. 222–224. 150. 152. 3p Derotational osteotomy. 222. 134. 186. 188. 69p D Deltoideus muscle in forelimb amputation with scapulectomy. 95p with plate. See also Bone graft. 22–24. 63p with meniscus damage. 214. 85p in tarsal arthrodesis. 218. 166–168. 78 Calcaneus in Achilles tendon repair. 53p Dewclaw amputation. 153p in radial carpal bone fractures. 205p. 73p in stifle luxation. 210. 5p Coracobrachial muscles in medial shoulder luxation. 51p Cruciate ligaments in stifle luxation. 130. 10. 82. fragmented. 156. 107p.240 INDEX C Calcaneoquartal joint in partial tarsal arthrodesis with intramedullary pin and wire. 158. 164. 80 in tibial distal physeal fractures. 4. 195p in humeral diaphyseal fractures. 92. 45p in ostectomy of femoral head and neck with joint capsule interpolation. 30. 154–164. 208. stabilized with plate. 215p in radial carpal bone fractures. 90 with intramedullary pin and wire. 223p Carpometacarpal joint in pancarpal arthrodesis. lateral. 213p in tarsal shearing injury and luxation. 65p. 210. 193p. 29p distal ulnar ostectomy. 223p. 36 with plate. 87p External fixation in comminuted diaphyseal fractures. 127p lag screws and neutralization plate in. proximal. 169p short oblique or transverse compression plate in. 41p in intracapsular stabilization of hip luxation. 33p with intramedullary pins. 60–62. 187p. 24. 7p Coronoid process of ulna. 37p with plate. 61p. 125p Diaphyseal fractures (Continued) radial. 33p with intramedullary pins. 26. 132. 58. 38–40. 37p with plate. 36. 28. 201p radial. 123p tibial. 111p Diaphyseal fractures. 189p. 119p in femoral diaphyseal fractures. 85p of medial trochlear ridge. 203p Cervical disc disorders ventral decompression in. 205p Condylar fractures of humerus. 165p cerclage wires used with. 225p ventral fenestration in. 195p intramedullary pin used with. 93p in tarsal fractures. 111p Disarticulation. 5p in scapular neck fractures. 115p Desmotomy in medial patella luxation. 207p. 202–208. 39p. 193p. 19p in humeral fractures. 64–66. distal. 46. 192–194. 191p in humeral diaphyseal fractures. 204. distal lateral condylar. 167p. 192–194. 35p metacarpal fractures. 42–44. See Intervertebral disc disorders Dynamic proximal ulnar osteotomy in ununited anconeal process. 62. 215p radial carpal bone fractures. lateral. 68. 57p in talus osteochondrosis of medial trochlear ridge. in rear limb amputation. 126. 191p. 32 in partial carpal arthrodesis with intramedullary pins. 135p. 137p in tibial diaphyseal fractures external fixator used with. 106. 126. 163p in humeral physeal fractures. 131p femoral. 167p in tibial diaphyseal fractures. 83p. 83p. 73p in talus osteochondrosis of lateral trochlear ridge. 104 in humeral diaphyseal fractures. 49p. 6. 165p long oblique intramedullary pin and cerclage wires in. 161p in metacarpal and metatarsal fractures. intervertebral. 210. 212. 110. 80 Carotid sheath in ventral cervical decompression. 164. 21p in stifle arthrodesis. 186. 118. 59p intra-articular repair of. 119p intramedullary pin and external fixator in. coxofemoral. 17p Coxofemoral joint disarticulation in rear limb amputation. 165p intramedullary pin used with. 89p in tarsal shearing injury and luxation. 198. 150. 151p T or Y type. 151p T or Y type. 101p Cerclage wires. 114. 126 external fixator used with. 149p in infraspinatus muscle contracture. 22. 29p in elbow luxation. 34. 17p ununited anconeal process. 128. 23p. 189p. 129p type II external fixator in. 162–164. 221p. 153p in metacarpal and metatarsal fractures. 27p humeral fractures. 202. 94. distal lateral condylar. 67p lateral fabellar suture in repair of. 189p in humeral diaphyseal fractures. 126. 28. 152. 52. 201p in ulnar ostectomy with fat graft. 153p lateral luxation. 150. 78. 32. 32. See also specific bones bone grafts in. 155p. 94 with plate. in diaphyseal fractures comminuted interlocking nail in. 163p. 25p E Elbow disorders arthrodesis in. 92 in shearing injury with tarsal luxation. 36 with plate. 16. 163p. 159p. 146. 31p Cephalic vein in forelimb amputation with scapulectomy. 21p osteochondrosis and fragmented medial coronoid process. 56. 100. 101p in forelimb salvage with scapulectomy. 165p . 102. 138. 193p. 19p in humeral fractures. 75p in talus osteochondrosis of lateral trochlear ridge. 34. 211p Extensor digital muscles in carpal arthrodesis. 108 Disc disorders. 209p intramedullary pin used with. 210. 103p. 11p in shoulder osteochondrosis. 35p in elbow luxation. 196. 188. 203p in tibial oblique osteotomy. proximal. 147p of tarsus. 141p of metacarpal and metatarsal bones. 177p. 179p in extracapsular stabilization of hip luxation. 64. 176. 65p in tibial physeal fractures. 35p. 50 Gracilis muscle in rear limb amputation at coxofemoral joint. 16 in shoulder osteochondrosis. 7p. 46. 183p in femoral physeal fractures. 165p type Ib external fixator in. 166–170. 180–194. 16–28. 65p. 174–178. 108. 26. 195p of humerus. 72. 214. distal in malleolar fractures. 43p. 74. 114. 192–194. 93p in tarsal fractures. 9p Gluteal artery and vein in triple pelvic osteotomy. 16. 185p. 93p in tarsal fractures. 67p in meniscectomy. 213p of tibia. 9p. 31p in ulnar styloid fractures. 198. 185p. 56. 205p. 48. 159p. 181p. 16. 128. 122. 191p. 186. 97p. 115p Fenestration of cervical discs. 106. 38. 230–232. 106. 95p with plate. in femoral diaphyseal fractures plate application in. 189p intramedullary pin in. 219p. 139p. 132. 96–98. 13p. 3p. 137p. 43p Glenohumeral ligament in lateral shoulder luxation. 172. 61p. 107p in sacroiliac luxation. 183p. comminuted. 187p. 181p. 31p Flexor carpi ulnaris muscle in elbow arthrodesis. 106. 156. 90 with intramedullary pin and wire. 207p. 107p at midshaft of femur. 201p in talus osteochondrosis of lateral trochlear ridge. 109p proximal in acetabular fractures. 182. 108. 51p Gluteal nerve in triple pelvic osteotomy. 21p. 229p. 28. 195p interlocking nail in. 42. 173p Flexor digital muscles in Achilles tendon repair. distal ulnar ostectomy with. 5p. ventral. 202. 180. 63p Facial artery and vein in mandibular body fractures. 120. 174. 68. 109p in triple pelvic osteotomy. 13p in medial shoulder luxation. 151p. 218–220. 185p in tarsal arthrodesis with intramedullary pin and wire. 49p Grafts of bone. 155p. 167p. 164. 66. 38–40. 193p. 108. 2–14. 142–146. 227p. 47p in femoral neck fractures. 47p in femoral neck fractures. 187p. 38 in intracapsular stabilization of hip luxation. 178. 111p elbow joint disorders. 167p of styloid process. 94 in tarsal shearing injury and luxation. 178. 29p salvage with scapulectomy. 113p in short oblique or transverse diaphyseal fractures intramedullary pin used with. 25p. 45p transverse derotational osteotomy stabilized with plate. 209p intramedullary pin used with. 182. 17p. 103p shoulder joint disorders. 230 . 164. 75p in talus osteochondrosis of lateral trochlear ridge. 23p. 75p in elbow osteochondrosis and fragmented medial coronoid process. 168. 93p in tarsal fractures. 165p in mandibular body fractures. 122. 86. 42–44. 19p. 60–62. 31p. 177p in rear limb amputation with coxofemoral disarticulation. 88 in tarsal arthrodesis. 46. 10–12. 33p. 80. 120. 175p. 189p. 197p. 27p. 39p and intracapsular stabilization. 80 in tibial physeal fractures. 212. 43p in ilial body fractures. 189p. 92. 66 in physeal femoral fractures. 74. 15p Fractures of carpus. 41p Femur (Continued) in femoral head and neck ostectomy with joint capsule interpolation. 181p in intracapsular stabilization of hip luxation. 102–104. 109p Femur coxofemoral disarticulation in rear limb amputation. 110. 167p in talus osteochondrosis of medial trochlear ridge. 153p. 193p. 31p. 215p of pelvis. 75p in femoral physeal fractures. 195p midshaft level rear limb amputation. 94. 52. 139p Fascia lata graft in cranial cruciate ligament repair. 6–8. 31p. 51p Gluteal muscles in acetabular fractures. thoracolumbar. 213p in tibial malleolar fractures. 185p in intra-articular cranial cruciate ligament repair. 26. 42. 213p Flexor hallucis longus muscle in Achilles tendon repair. 106. 30. 88. 157p. 112. 163p. 37p digit amputation. 141p in radial diaphyseal fractures. 183p. 161p. 82. 169p. 53p fractures of. 122. 186–188. 165p of mandible. 143p. 199p. 169p in radial oblique osteotomy. 27p Femoral artery and vein in rear limb amputation at coxofemoral joint. 133p. 95p with plate. 206–208. 191p. See Intramedullary pins. 171p of scapula. 183p in femoral physeal fractures. 210. 17p in radial fractures diaphyseal. 231p Fibula. 89p in tarsal arthrodesis with intramedullary pin and wire. 89p in tarsal arthrodesis with intramedullary pin and wire. 7p. 190. 213p Gemellus muscle in acetabular fractures. 226–228. 84 of medial trochlear ridge. 95p with plate. 199p Flexor carpi radialis muscle in elbow osteochondrosis and fragmented medial coronoid process. 11p. 149p. 172. 203p. 179p in extracapsular stabilization of hip luxation. 181p in hip luxation and extracapsular stabilization. 197p in wedge recession trochleoplasty for medial patella luxation. 180–194. See Bone graft of fascia lata and patellar tendon in cranial cruciate ligament repair. 193p. 189p. 180. 184. 226. 107p diaphyseal fractures of external fixator in. 66 of fat. 222 of thoracolumbar discs. 145p. 185p tensor muscle of. 148–164. 191p distal in arthrodesis of stifle. distal. 112. 30. 58 and lateral suture repair of cranial cruciate ligament. distal. 70 in notchplasty for cranial cruciate ligament repair. 212. and plate application. 140. 30–36. 88. 113p F Fabella in stifle luxation and instability. 178. See Diaphyseal fractures of femur. 27p H Hemilaminectomy. 29p in ulnar fractures. 120. 179p in femoral head and neck ostectomy with joint capsule interpolation. distal ulnar ostectomy with. 211p of diaphysis. 73p in deranged stifle luxation. 157p. proximal. 65p. 179p of radius. 101p carpus disorders. 221p. 100. 85p of medial trochlear ridge. 50. 173p G Gastrocnemius muscle in Achilles tendon repair. 129p. 196–208. 17p in radial diaphyseal fracture and plate application. 201p. 200. 209p of ulna. 207p. 64. 52. 11p. 136–140. 81p in tibial diaphyseal fractures. 123p in tarsal shearing injury with luxation.INDEX 241 External fixation (Continued) type Ia external fixator in. 107p at midshaft of femur. 187p. 201p Forage procedure in elbow osteochondrosis. 2 Forelimb amputation with scapulectomy. 50. 175p in triple pelvic osteotomy. 57p in femoral physeal fractures. See Tensor fascia latae muscle Fat graft. 121p type Ib external fixator in. 65p. 242 INDEX Hemimandible in rostral hemimandibulectomy, 96, 98, 99p in transverse and oblique mandibular body fractures, 139p Hip disorders acetabular fractures, 178, 179p femoral fractures, 180, 181p, 182, 183p femoral head and neck ostectomy with joint capsule interpolation in, 46, 47p luxation and instability extracapsular stabilization in, 38–40, 39p, 41p intracapsular stabilization in, 42–44, 43p, 45p triple pelvic osteotomy in, 48–50, 49p, 51p Humerus diaphyseal fractures of cerclage wires in, 126, 156, 157p, 164, 165p external fixation in. See External fixation, in humeral diaphyseal fractures interlocking nail in, 132, 154–156, 155p, 157p intramedullary pin in. See Intramedullary pins, in humeral diaphyseal fractures plate application in, 128, 158–160, 159p, 161p distal in arthrodesis of elbow, 28, 29p in fragmented medial coronoid process and osteochondrosis, 16, 17p in intercondylar T or Y type fractures, 152, 153p in lateral condylar fractures, 150, 151p in luxation of elbow, lateral, 18–20, 19p, 21p in ununited anconeal process, 22, 25p fractures of, 148–164, 149p, 151p, 153p, 155p, 157p, 159p, 161p, 163p, 165p proximal in arthrodesis of shoulder, 14, 15p in bone grafts, as donor site, 134, 135p in forelimb amputation with scapulectomy, 100 in forelimb salvage with scapulectomy, 102 in humeral physeal fractures, 148, 149p in lateral shoulder subluxation, 10–12, 11p, 13p in medial shoulder luxation, 6–8, 7p, 9p in osteochondrosis, 2, 3p in scapular neck fractures, 146, 147p in supraglenoid tuberosity fractures, 144, 145p I Iliopsoas muscle in rear limb amputation with coxofemoral disarticulation, 106, 107p Ilium in bone grafts, as donor site, 134, 135p in extracapsular stabilization of hip luxation, 38 in femoral head and neck ostectomy with joint capsule interpolation, 46 in fractures of ilial body, 176, 177p Ilium (Continued) in intracapsular stabilization of hip luxation, 42 in sacroiliac luxation, 174, 175p in triple pelvic osteotomy, 50, 51p Imbrication in hip luxation and extracapsular stabilization, 40 and intracapsular stabilization, 44 in patella luxation, 54 Infraspinatus muscle contracture of, 4, 5p in forelimb salvage with scapulectomy, 102, 103p in humeral physeal fractures, proximal, 148, 149p in scapular body fractures, transverse, 142, 143p in scapular neck fractures, 146, 147p in shoulder arthrodesis, 14, 15p in shoulder luxation, lateral, 10, 11p, 12, 13p in supraglenoid tuberosity fractures, 145p Instability. See Luxation and instability Interlocking nail in diaphyseal fractures of femur, 132, 133p, 186–188, 187p, 189p of humerus, 132, 154–156, 155p, 157p of tibia, 132, 202, 203p Intertarsal joint in pantarsal arthrodesis, 90 in partial tarsal arthrodesis with intramedullary pin and wire, 94, 95p with plate, 92, 93p in shearing injury with tarsal luxation, 78, 80 Intervertebral disc disorders cervical ventral decompression in, 218, 220, 222–224, 223p, 225p ventral fenestration in, 218–220, 219p, 221p, 222 lumbosacral laminectomy in, 234–236, 235p, 237p thoracolumbar fenestration in, 230–232, 231p hemilaminectomy in, 226–228, 227p, 229p, 230 Intramedullary pins in carpal arthrodesis, partial, 36, 37p in comminuted diaphyseal fractures, 128, 129p in femoral diaphyseal fractures, 186–188, 187p, 189p cerclage wires used with, 126, 186, 188, 189p external fixator used with, 120, 186, 188, 189p, 192–194, 193p, 195p plate used with, 128, 129p, 190, 191p in femoral physeal fractures, distal, 184, 185p in humeral diaphyseal fractures, 154–156, 155p, 157p cerclage wires used with, 126, 156, 157p, 164 external fixator used with, 120, 162–164, 163p, 165p plate used with, 128, 158–160, 159p, 161p in long oblique diaphyseal fractures, 126, 127p Intramedullary pins (Continued) in metacarpal and metatarsal fractures, 214, 215p in radial diaphyseal fractures and plate application, 166 in short oblique or transverse diaphyseal fractures, 120, 121p in tarsal arthrodesis, partial, 94, 95p in tibial diaphyseal fractures, 202, 203p cerclage wires used with, 126, 202, 203p external fixator used with, 120, 202, 203p plate used with, 128, 204, 205p Ischium in extracapsular stabilization of hip luxation, 38 in femoral head and neck ostectomy with joint capsule interpolation, 46 in intracapsular stabilization of hip luxation, 42 in triple pelvic osteotomy, 48, 49p J Joint disorders amputations in, 96–110, 97p, 99p, 101p, 103p, 107p, 109p, 111p of carpus, 30–36, 31p, 33p, 35p, 37p of elbow, 16–28, 17p, 19p, 21p, 23p, 25p, 27p, 29p of hip, 38–50, 39p, 41p, 43p, 45p, 47p, 49p, 51p of shoulder, 2–14, 3p, 5p, 7p, 9p, 11p, 13p, 15p of stifle, 52–72, 53p, 55p, 57p, 59p, 61p, 63p, 65p, 67p, 69p, 71p, 73p of tarsus, 74–94, 75p, 77p, 79p, 81p, 83p, 85p, 87p, 89p, 91p, 93p, 95p K Kirschner wires in acetabular fractures, 178, 179p in femoral neck fractures, 182, 183p in femoral physeal fractures, proximal, 180, 181p in hip luxation and extracapsular stabilization, 40, 41p in humeral condylar fractures, 150, 151p in humeral physeal fractures, proximal, 148, 149p in radial physeal fractures, distal, 170, 171p in radial styloid fractures, 30, 31p in tarsal fractures, 212, 213p in tibial malleolar fractures, 200, 201p in tibial physeal fractures distal, 198, 199p proximal, 196, 197p in ulnar styloid fractures, 30, 31p L Lag screw fixation, 124, 125p in elbow arthrodesis, 28, 29p in femoral diaphyseal fractures, plate application with, 190, 191p in humeral fractures, distal lateral condylar, 150, 151p T or Y type, 152, 153p in metacarpal and metatarsal fractures, 214, 215p INDEX 243 Lag screw fixation (Continued) in radial carpal bone fractures, 210, 211p in radial fractures diaphyseal, plate application with, 166, 167p in styloid process, 30, 31p in sacroiliac luxation, 174, 175p in scapular neck fractures, 146, 147p in shoulder arthrodesis, 14, 15p in supraglenoid tuberosity fractures, 144, 145p in tarsal fractures, 212, 213p in tibial fractures diaphyseal, plate application with, 204, 205p malleolar, 200, 201p in ulnar fractures distal, in styloid process, 30, 31p proximal, plate application with, 172, 173p in ununited anconeal process, 22, 24, 25p Laminectomy lumbosacral dorsal, 234–236, 235p, 237p thoracolumbar hemilaminectomy, 226–228, 227p, 229p, 230 Latissimus dorsi muscle in forelimb amputation with scapulectomy, 100, 101p Longus colli muscles in ventral cervical decompression, 222, 223p, 224 in ventral cervical fenestration, 218, 219p, 220 Lumbosacral laminectomy, dorsal, 234–236, 235p, 237p Luxation and instability of elbow, lateral, 18–20, 19p, 21p of hip extracapsular stabilization in, 38–40, 39p, 41p intracapsular stabilization in, 42–44, 43p, 45p of sacroiliac joint, 174, 175p of shoulder lateral, 10–12, 11p, 13p medial, 6–8, 7p, 9p of stifle intra-articular repair of cranial cruciate ligament in, 64–66, 65p, 67p lateral fabellar suture repair of cranial cruciate ligament in, 60–62, 61p, 63p meniscectomy in, 68–70, 69p, 71p suture anchors, screws, and sutures in, 56–58, 57p, 59p wedge recession trochleoplasty, desmotomy, tibial tuberosity transposition, and retinacular imbrication in, 52–54, 53p, 55p of tarsus, in shearing injury, 78–80, 79p, 81p M Malleolar fractures of tibia or fibula, 200, 201p Mandible fractures of comminuted, acrylic external fixation in, 140, 141p mandibulectomy in, 96–98, 97p, 99p Mandible (Continued) symphyseal, cerclage wire in, 136, 137p transverse and oblique, orthopedic wire in, 138, 139p tumors of, mandibulectomy in, 96–98, 97p, 99p Mandibular artery in fractures of mandibular body, 138, 140 in mandibulectomy, 96, 98 Mandibular nerve in mandibular body fractures, 138, 140 Mandibulectomy, 96–98, 97p, 99p Maxillectomy, 98 Mayo mattress suture, modified, in medial patella luxation, 54, 55p Median artery in radial diaphyseal fractures and plate application, 167p Meniscectomy, 68–70, 69p, 71p Meniscus in stifle luxation and instability, 56, 68–70, 69p, 71p and intra-articular repair of cranial cruciate ligament, 64, 66 and lateral fabellar suture repair of cranial cruciate ligament, 60, 61p, 62 Metacarpal bones fractures of, 214, 215p in pancarpal arthrodesis, 32 in partial carpal arthrodesis with intramedullary pins, 36 with plate, 34 Metacarpophalangeal joint in digital amputation, 110, 111p Metatarsal bones fractures of, 214, 215p in pantarsal arthrodesis, 90 in partial tarsal arthrodesis with intramedullary pin and wire, 94 with plate, 92 in shearing injury with tarsal luxation, 80 Monteggia fracture, 172 Musculocutaneous nerve in humeral diaphyseal fractures and plate application, 158, 159p Mylohyoideus muscle in mandibular body fractures, 139p N Nail, interlocking. See Interlocking nail in diaphyseal fractures Neutralization plate in diaphyseal fractures, 124, 125p of femur, 190, 191p of humerus, 158, 160, 161p of radius, 166, 167p of tibia, 204, 205p Notchplasty, femoral, in intra-articular repair of cranial cruciate ligament, 64, 65p O Oblique osteotomy stabilized with type II external fixator, 112, 113p Obturator nerve in triple pelvic osteotomy, 48, 50 Olecranon of ulna in arthrodesis of elbow, 28, 29p in lateral elbow luxation, 18, 19p in ununited anconeal process, 22–24, 23p, 25p Omobrachial vein in forelimb amputation with scapulectomy, 100, 101p Omotransversarius muscle in forelimb amputation with scapulectomy, 100, 101p in forelimb salvage with scapulectomy, 102, 103p, 104 Osteochondrosis of elbow, 16, 17p of shoulder, 2, 3p of talus in lateral trochlear ridge, 82–84, 83p, 85p in medial trochlear ridge, 86–88, 87p, 89p P Pancarpal arthrodesis, 32, 33p Pantarsal arthrodesis, 90, 91p Patella in arthrodesis of stifle, 72, 73p in femoral physeal fractures, 184, 185p medial luxation of, 52–54, 53p, 55p Patellar ligament in proximal tibial physeal fractures, 197p Patellar tendon in cranial cruciate ligament repair, 66 in femoral physeal fractures, 184, 185p in medial patella luxation, 52, 54 Pectineus muscle in rear limb amputation at coxofemoral joint, 106, 107p at midshaft of femur, 108, 109p in triple pelvic osteotomy, 48, 49p Pectoral muscles in forelimb amputation with scapulectomy, 100, 101p in humeral diaphyseal fractures and external fixator, 162, 163p and intramedullary pin or interlocking nail, 154, 155p and plate application, 158, 159p in shoulder luxation, medial, 6, 7p, 8 Pelvis in acetabular fractures, 178, 179p in extracapsular stabilization of hip luxation, 38–40, 39p, 41p in femoral head and neck ostectomy with joint capsule interpolation, 46, 47p in ilial body fractures, 176, 177p in intracapsular stabilization of hip luxation, 42–44, 43p, 45p in sacroiliac luxation, 174, 175p in triple osteotomy, 48–50, 49p, 51p Peroneus muscles in talus osteochondrosis of lateral trochlear ridge, 82, 83p, 84, 85p of medial trochlear ridge, 87p in tarsal arthrodesis with intramedullary pin and wire, 95p with plate, 93p in tibial malleolar fractures, 201p Phalangeal bones in digital amputation, 110, 111p Physeal fractures of femur distal, 184, 185p proximal, 180, 181p of humerus, proximal, 148, 149p of radius, distal, 170, 171p 244 INDEX Physeal fractures (Continued) of tibia distal, 198, 199p proximal, 196, 197p Pin fixation. See also Intramedullary pins in Achilles tendon repair with tension band wire, 76, 77p in femoral physeal fractures, distal, crossed pins in, 184, 185p in hip luxation, modified toggle pin in, 42–44, 43p, 45p in humeral physeal fractures, proximal, 148, 149p in mandibular body fractures stabilized with acrylic external fixation, 140, 141p in radial diaphyseal fractures and external fixator, 168, 169p in radial styloid fractures and tension band wire, 30, 31p in ulnar styloid fractures and tension band wire, 30, 31p Plate application in acetabular fractures, 178, 179p in carpal arthrodesis pancarpal, 32, 33p partial, 34, 35p in comminuted diaphyseal fractures, 128, 129p in elbow arthrodesis, 28, 29p in femoral diaphyseal fractures, 128, 129p, 190, 191p in humeral fractures diaphyseal, 128, 158–160, 159p, 161p distal, T or Y type, 152, 153p in ilial body fractures, 176, 177p in long oblique diaphyseal fractures, 124, 125p in metacarpal and metatarsal fractures, 214, 215p in radial diaphyseal fractures, 166, 167p in scapular fractures in body of scapula, transverse, 142, 143p in neck of scapula, 146, 147p in short oblique or transverse diaphyseal fractures, 118, 119p in shoulder arthrodesis, 14, 15p in stifle arthrodesis, 72, 73p in tarsal arthrodesis pantarsal, 90, 91p partial, 92, 93p in tibial diaphyseal fractures, 128, 204, 205p in transverse derotational osteotomy, 114, 115p in triple pelvic osteotomy, 50, 51p in ulnar fractures, proximal, 172, 173p Prepubic tendon in triple pelvic osteotomy, 48, 49p Pronator teres muscle in elbow osteochondrosis and fragmented medial coronoid process, 16 in humeral distal fractures, T or Y type, 153p in radial diaphyseal fractures and plate application, 166, 167p Pubis in triple pelvic osteotomy, 48, 49p Q Quadriceps muscles in femoral physeal fractures, distal, 184, 185p in rear limb amputation at coxofemoral joint, 106, 107p at midshaft of femur, 108, 109p in stifle luxation, 52, 56 R Radial artery in diaphyseal fractures of radius and plate application, 167p Radial carpal bone fractures of, 210, 211p in pancarpal arthrodesis, 32, 33p in partial carpal arthrodesis with intramedullary pins, 36, 37p with plate, 34, 35p in physeal fractures of radius, 171p Radial nerve in diaphyseal humeral fractures and external fixator, 162, 163p, 164 and intramedullary pin or interlocking nail, 154, 155p, 156 and plate application, 158, 159p in distal humeral fractures, 150, 152 Radius diaphyseal fractures of external fixator in, 122, 168, 169p plate application in, 166, 167p distal in pancarpal arthrodesis, 32, 33p in partial carpal arthrodesis with intramedullary pins, 36, 37p in partial carpal arthrodesis with plate, 34, 35p in physeal fractures, 170, 171p in radial carpal bone fractures, 210, 211p in styloid process fractures, 30, 31p fractures of diaphyseal, 122, 166–168, 167p, 169p physeal distal, 170, 171p styloid process, 30, 31p oblique osteotomy stabilized with type II external fixator, 112, 113p proximal in arthrodesis of elbow, 28, 29p in lateral elbow luxation, 18–20, 19p, 21p in osteochondrosis of elbow and fragmented medial coronoid process, 16, 17p in ununited anconeal process, 22, 25p Rear limb coxofemoral disarticulation in amputation, 106, 107p, 108 digital amputation, 110, 111p hip joint disorders, 38–50, 39p, 41p, 43p, 45p, 47p, 49p, 51p midshaft femoral amputation, 106, 108, 109p stifle disorders, 52–72, 53p, 55p, 57p, 59p, 61p, 63p, 65p, 67p, 69p, 71p, 73p tarsus disorders, 74–93, 75p, 77p, 79p, 81p, 83p, 85p, 87p, 89p, 91p, 93p, 95p Rectus femoris muscle in medial patella luxation, 52 in rear limb amputation with coxofemoral disarticulation, 106, 107p Retinaculum extensor in lateral trochlear ridge of talus osteochondrosis, 83p in medial trochlear ridge of talus osteochondrosis, 86, 87p in tibial malleolar fractures, 201p lateral, in medial patella luxation, 52, 53p, 54 Rhomboideus muscle in forelimb amputation with scapulectomy, 100, 101p in forelimb salvage with scapulectomy, 102, 104 Rotational deformity, transverse derotational osteotomy stabilized with plate in, 114, 115p S Sacroiliac luxation, 174, 175p Saphenous artery in tibial diaphyseal fractures, 202, 203p and plate application, 204, 205p in tibial malleolar fractures, 201p Saphenous nerve in tibial diaphyseal fractures, 202, 203p and plate application, 204, 205p Saphenous vein in talus osteochondrosis of lateral trochlear ridge, 82, 84 in tibial diaphyseal fractures, 202, 203p and plate application, 204, 205p in tibial malleolar fractures, 200, 201p Sartorius muscle in rear limb amputation at coxofemoral joint, 106, 107p at midshaft of femur, 108, 109p in stifle luxation, 56, 57p Scalenus muscle in forelimb amputation with scapulectomy, 100, 101p Scapula in arthrodesis of shoulder, 14, 15p in forelimb amputation with scapulectomy, 100, 101p in forelimb salvage with scapulectomy, 102–104, 103p in luxation of shoulder lateral, 10–12, 11p, 13p medial, 6–8, 7p, 9p neck of scapula fractures, 146, 147p supraglenoid tuberosity fractures, 144, 145p transverse scapular body fractures, 142, 143p Scapulectomy in forelimb amputation, 100, 101p in forelimb salvage, 102–104, 103p Scapulohumeral joint arthrodesis of, 14 in forelimb salvage with partial scapulectomy, 102, 104 in lateral shoulder luxation, 10–12, 11p, 13p in medial shoulder luxation, 6–8, 7p, 9p Sciatic nerve in acetabular fractures, 178, 179p in femoral diaphyseal fractures, 186, 188 and plate application, 190 in ilial body fractures, 176 INDEX 245 Sciatic nerve (Continued) in intracapsular stabilization of hip luxation, 42, 43p, 44 in rear limb amputation with coxofemoral disarticulation, 107p in triple pelvic osteotomy, 50 Screw, lag. See Lag screw fixation Screw and washer combination in elbow luxation, lateral, 18, 20, 21p in hip luxation, 40, 41p in humeral condylar fractures, 150 in shoulder luxation lateral, 10, 12, 13p medial, 6, 8, 9p in stifle luxation, 56–58, 57p and intra-articular repair of cranial cruciate ligament, 66, 67p in supraglenoid tuberosity fractures, 144, 145p in tarsal luxation, 78–80, 79p Semimembranosus muscle in rear limb amputation at coxofemoral joint, 106, 107p at midshaft of femur, 108, 109p Semitendinosus muscle in rear limb amputation at coxofemoral joint, 106, 107p at midshaft of femur, 108, 109p Serratus ventralis muscle in forelimb amputation with scapulectomy, 100, 101p in forelimb salvage with scapulectomy, 102, 103p, 104 Shearing injury with tarsal luxation, 78–80, 79p, 81p Shoulder disorders arthrodesis in, 14, 15p contracture of infraspinatus muscle, 4, 5p humeral physeal fractures, 148, 149p lateral luxation, 10–12, 11p, 13p medial luxation, 6–8, 7p, 9p osteochondrosis, 2, 3p scapular fractures, 142–146, 143p, 145p, 147p Spine cervical disc disorders ventral decompression in, 218, 220, 222–224, 223p, 225p ventral fenestration in, 218–220, 219p, 221p, 222, 224 lumbosacral laminectomy, 234–236, 235p, 237p thoracolumbar disc disorders fenestration in, 226, 230–232, 231p hemilaminectomy in, 226–228, 227p, 229p, 230 Sternohyoideus muscle in ventral cervical decompression, 222, 223p, 224 in ventral cervical fenestration, 218, 219p, 220 Sternomastoideus muscle in ventral cervical decompression, 222, 224 in ventral cervical fenestration, 218, 220 Stifle disorders arthrodesis in, 72, 73p femoral physeal fractures, 184, 185p Stifle disorders (Continued) intra-articular repair of cranial cruciate ligament in, 64–66, 65p, 67p lateral fabellar suture repair of cranial cruciate ligament in, 60–62, 61p, 63p medial patella luxation, 52–54, 53p, 55p meniscectomy in, 68–70, 69p, 71p suture anchors, screws, and sutures for stabilization in, 56–58, 57p, 59p tibial physeal fractures, 196, 197p Styloid process fractures of radius and ulna, 30, 31p Subscapularis muscle in forelimb salvage with scapulectomy, 102 in medial shoulder luxation, 6, 7p, 8 Supinator muscle in radial diaphyseal fractures and plate application, 166, 167p Supraglenoid tuberosity fractures, 144, 145p Suprascapular artery in scapular neck fractures, 146 in shoulder arthrodesis, 14 Suprascapular nerve in scapular neck fractures, 146, 147p in shoulder arthrodesis, 14 in shoulder luxation, medial, 6, 8 in supraglenoid tuberosity fractures, 144, 145p Supraspinatus muscle in forelimb salvage with scapulectomy, 102, 103p in humeral physeal fractures, proximal, 149p in infraspinatus muscle contracture, 5p in scapular body fractures, transverse, 142, 143p in shoulder arthrodesis, 14, 15p in shoulder luxation lateral, 11p medial, 6, 7p, 8 Suture anchor system in elbow luxation, lateral, 18, 20 in hip luxation, 40, 41p in shoulder luxation lateral, 10, 11p medial, 6, 8, 9p in stifle luxation, 56–58, 57p, 59p Symphyseal fracture of mandible, cerclage wire in, 136, 137p T Talocalcaneocentral joint in partial tarsal arthrodesis with intramedullary pin and wire, 94 with plate, 92 in shearing injury with tarsal luxation, 78 Talocrural joint in shearing injury with tarsal luxation, 78 Talus in pantarsal arthrodesis, 90, 91p in partial tarsal arthrodesis with intramedullary pin and wire, 94 in shearing injury with tarsal luxation, 78, 80 in tarsal fractures, 212, 213p trochlear ridge osteochondrosis of lateral, 82–84, 83p, 85p medial, 86–88, 87p, 89p Tarsocrural joint in pantarsal arthrodesis, 90 in partial tarsal arthrodesis with intramedullary pin and wire, 94 in shearing injury with tarsal luxation, 78 Tarsometatarsal joint in pantarsal arthrodesis, 90 in partial tarsal arthrodesis with intramedullary pin and wire, 94, 95p with plate, 92 in shearing injury with tarsal luxation, 78 Tarsus disorders Achilles tendon rupture, 74–76, 75p, 77p arthrodesis in, 90, 91p with intramedullary pin and wire, 94, 95p with plate, 92, 93p fractures, 212, 213p metatarsal, 214, 215p tibial malleolar, 200, 201p tibial physeal, 198, 199p osteochondrosis of lateral trochlear ridge of talus, 82–84, 83p, 85p of medial trochlear ridge of talus, 86–88, 87p, 89p shearing injury with luxation, 78–80, 79p, 81p Teeth occlusion of in comminuted mandibular body fractures, 140, 141p in symphyseal mandibular fractures, 136, 137p in transverse and oblique mandibular body fractures, 138, 139p removal in mandibulectomy, 96, 97p Tension band wire in acetabular fractures, 178, 179p in Achilles tendon injuries, 76, 77p in femoral physeal fractures, proximal, 180, 181p in hip luxation and extracapsular stabilization, 40, 41p in radial styloid fractures, 30, 31p in scapular neck fractures, 146, 147p in supraglenoid tuberosity fractures, 144, 145p in tarsal fractures, 212, 213p in ulnar fractures distal, in styloid process, 30, 31p proximal, 172, 173p Tensor fascia latae muscle in acetabular fractures, 178, 179p in femoral head and neck ostectomy with joint capsule interpolation, 46, 47p in femoral neck fractures, 182, 183p in femoral physeal fractures, proximal, 180, 181p in hip luxation and extracapsular stabilization, 38, 39p and intracapsular stabilization, 42, 43p in rear limb amputation with coxofemoral disarticulation, 106, 107p in triple pelvic osteotomy, 50, 51p Teres major muscle in forelimb salvage with scapulectomy, 102, 103p 126 external fixator used with. 199p proximal. 14. 180. 3p in supraglenoid tuberosity fractures. 82. 226. 173p V Vastus intermedius muscle in femoral diaphyseal fractures. in tibial diaphyseal fractures plate application in. 193p and plate application. 45p Trachea in cervical disc decompression. 82. 63p in meniscectomy. 192. 198. 133p. 101p in forelimb salvage with scapulectomy. 29p in distal ulnar ostectomy with fat graft. 87p. 201p in tibial physeal fractures. 148. 231p hemilaminectomy in. 86–88. 42. 202. 196. 126. 126. 91p in tarsal shearing injury and luxation. proximal. 153p lateral condylar. 83p in medial patella luxation. 145p Thoracic artery and vein in forelimb amputation with scapulectomy. 134. 67p in lateral fabellar suture repair of cranial cruciate ligament. 139p . in elbow osteochondrosis and fragmented medial coronoid process. 219p Transverse derotational osteotomy stabilized with plate. 104 in humeral fractures diaphyseal. 227p. 196. 102. 129p. 208. 156. 22. 55p U Ulna distal fracture of styloid process. medial. 187p and external fixator. 86. 70 physeal fractures of. 164. 42 Trochlear ridge of talus osteochondrosis lateral. 84 in malleolar fractures. 152. 4. modified. 187p and external fixator. 201p in tibial physeal fractures. 66. 100. 173p in physeal fracture of radius. 88 in pantarsal arthrodesis. 196. 52 W Wedge recession trochleoplasty in medial patella luxation. 181p in hip luxation and extracapsular stabilization. T or Y type. 223p in cervical disc fenestration. 30. 16. 189p in femoral physeal fractures. 53p. 18–20. 78. 103p. 82–84. 5p in scapular body fractures. 64. 42–44. 2. 128. See also Kirschner wires in acetabular fractures. 180. 209p interlocking nail in. 43p. 198. 114. 53p Wire techniques. 40. 226–228. 197p proximal in arthrodesis of stifle. 23p. 102. 203p intramedullary pin in. 197p transposition in medial patella luxation. 89p in tibial malleolar fractures. 80 oblique osteotomy stabilized with type II external fixator. 34 Ulna (Continued) fractures of distal. 76. 230 Tibia diaphyseal fractures of cerclage wires in. 104 Triceps brachii muscle in forelimb amputation with scapulectomy. 197p. in styloid process. 101p in forelimb salvage with scapulectomy. 55p Tibial muscles caudal in medial trochlear ridge of talus osteochondrosis. 113p physeal fractures of distal. proximal. 73p in bone grafts. 89p Trochleoplasty of femur in medial patella luxation. 158. 16 Ulnaris lateralis muscle in arthrodesis of elbow. 52. 200. 41p in humeral diaphyseal fractures. 172. 149p in infraspinatus muscle contracture. 31p in ostectomy with fat graft. 60. 149p in infraspinatus muscle contracture. 143p in shoulder osteochondrosis. as donor site. 54. 77p in femoral diaphyseal fractures. 28. 191p in femoral head and neck ostectomy with joint capsule interpolation. 179p in Achilles tendon injuries. 200. 86. 191p in patella luxation. 38 in intracapsular stabilization of hip luxation. 21p in ostectomy for elbow arthrodesis. 178. 28. 151p proximal physeal. 68. 229p. 103p in humeral physeal fractures. 30. 188. 207p. 203p. 46. 87p in stifle arthrodesis. 27p in proximal ulnar fractures. 5p in scapular neck fractures. 172. 186. 202. 38. 11p in shoulder osteochondrosis. 230–232. 126. 138. 52. 129p. 31p proximal. lateral. 72. 26. 206–208. 73p in tarsal arthrodesis. 179p in extracapsular stabilization of hip luxation. 79p in tibial malleolar fractures. 52 Vastus lateralis muscle in femoral diaphyseal fractures. 173p in fragmented medial coronoid process. 122. 178. 39p and intracapsular stabilization. 53p Tuberosity of tibia fracture of. 209p external fixator in. 2. 22–24. 202. 186. 90. 197p tuberosity transposition in medial patella luxation. 199p Toggle pin. 101p Thoracolumbar disc disorders fenestration in. 164 in long oblique diaphyseal fractures. 204. 181p Trochanteric osteotomy of femur in acetabular fractures. 172. 103p. 107p Vastus medialis muscle in medial patella luxation. 27p in pancarpal arthrodesis. 135p in deranged stifle luxation. 90. 88. 112. 171p proximal fractures of. 157p. 65p Tibial muscles (Continued) in lateral trochlear ridge of talus osteochondrosis. 190. 36 in partial carpal arthrodesis with plate. 197p tuberosity fracture. 183p in hip luxation and extracapsular stabilization. 198. 199p cranial in intra-articular cranial cruciate ligament repair. transverse and oblique. 72. 85p medial. medial. 91p in partial tarsal arthrodesis with intramedullary pin and wire. 62. 55p in medial trochlear ridge of talus osteochondrosis. 26. 32 in partial carpal arthrodesis with intramedullary pins. 120. 47p in femoral neck fractures. 150. 54. 102. 199p in shearing injury with tarsal luxation. 3p in ununited anconeal process. distal. 52 in rear limb amputation with coxofemoral disarticulation. and plate application. 56. 126. 94 in physeal fractures. 15p in shoulder luxation. transverse. 52. 23p Trochanteric fracture of femur. 159p distal. 29p in ununited anconeal process. 57p. in intracapsular stabilization of hip luxation. 132. See Intramedullary pins. 196. 165p intramedullary pin used with. 205p distal in lateral trochlear ridge of talus osteochondrosis. 54. 17p in luxation of elbow.246 INDEX Teres minor muscle in forelimb salvage with scapulectomy. 52. 147p in shoulder arthrodesis. 101p Thoracic nerve in forelimb amputation with scapulectomy. 222. 43p in patella luxation. 182. 193p and plate application. 127p in mandibular body fractures. 115p Trapezius muscle in forelimb amputation with scapulectomy. lateral. 25p Ulnar artery and vein. 133p. 201p in medial trochlear ridge of talus osteochondrosis. 83p. 203p. 58 in intra-articular repair of cranial cruciate ligament. 19p. 65p. 200. 31p in scapular neck fractures. 172. 136.INDEX 247 Wire techniques (Continued) in mandibular symphyseal fractures. in styloid process. 30. 147p in supraglenoid tuberosity fractures. 208. 202. 137p in radial styloid fractures. 213p in tibial diaphyseal fractures external fixator used with. partial. 201p in tibial physeal fractures. 145p Wire techniques (Continued) in tarsal arthrodesis. 126. proximal. 209p intramedullary pin used with. 212. 30. 31p proximal. 196. 173p . 203p Wire techniques (Continued) in tibial malleolar fractures. 197p in ulnar fractures distal. 94. 144. 95p in tarsal fractures. 146.