Developmental Orthopedic Disease - EQ

Objective

To report the evaluation, surgical planning, and outcome for

correction of a complex limb deformity in the tibia of a donkey using
computed tomographic (CT) imaging and a 3D bone model.
 Study Design

• Case report

• A 1.5-year-old, 110 kg donkey colt with an angular and

torsional deformity of the right pelvic limb.
 Clinical Report

• 83.5 kg donkey colt was admitted for evaluation of a right pelvic limb
lameness noticed on arrival of the animal at the rescue facility 2 months
prior.

• Estimated age 12-18 months, based on fully erupted deciduous incisors

• The right gluteal, semimembranosus, semitendinosus, and quadriceps

muscles were atrophied. The right distal pelvic limb was externally rotated
with a severe valgus deformity centered at the level of the tarsus
 Clinical Report – Continued

• At a walk, there was a mechanical lameness of the right pelvic

limb with a severely shortened cranial phase of the stride,
circumduction, and reduced tarsocrural joint flexion

• No joint effusion, heat, swelling, pain, or loss of passive range of

motion was noted in the right pelvic limb.
 Radiographs

• Both pelvic limbs were radiographed from the stifle distally

• There was lateral angulation of the right distal tibia, external tibial
torsion, and varus deformity of the right metatarsophalangeal region.

• The left limb was radiographically normal.

• The distal and proximal tibial physes were open bilaterally and the distal
metatarsal physes were closed bilaterally.

• The presence of tibial torsion prevented accurate quantification of the

angular deformity and CT was recommended.
Pre-op Radiographs

A – Craniocaudal

E - Lateralmedial
 CT – Pelvic Limbs

• A CT scan of both limbs was performed from the level of the pelvis to
the digits with a 64-slice helical scanner

• In addition to the bone deformity noted, there was a cortical

discontinuity in the sagittal plane of the lateral portion of the right
distal tibial epiphysis, not present in the left tibia or noted in prior
radiographs

• Differential diagnoses included a separate center of ossification, a

Salter-Harris type III fracture of the lateral epiphysis, or less likely due
to the unilateral nature of the deformity, skeletal atavism (fibular
remnant)
 CT – Planning

• Frontal, sagittal, and axial plane images derived from the CT

scan were assessed to determine limb alignment using CORA
(center of rotation of angulation) methodology.

• Landmarks described in dogs were used for assessment

• Angular correction of tibial valgus deformity was determined to

require a 238 medially based closing wedge

• Additionally, an external torsional deformity of 158 was

identified.
• CT 3D volume reconstruction

• Note the lateral angulation of the distal tibia

and the medial angulation of the metatarsus
of the right hind limb.

• Both corrections could be accomplished

through a single closing wedge ostectomy.

• Surgery was recommended to improve

locomotion and prevent future degenerative
changes in the adjacent joints.
 Bone Model

• CT data were submitted to a 3D printing service (ProtoMed,

Westminster, Colorado) for creation of a patient-specific bone
model of the right tibia.

• The model was constructed of an ultraviolet-sensitive epoxy resin

printed using stereolithography (SLA) with a solid-state laser

• A surgical rehearsal was performed using the tibial model and CT

measurements.
 Surgical Correction – Wedge

• Surgical correction of the deformity was performed 15 weeks after CT

• A routine craniomedial approach was made to expose the right tibia from
the level of the tibial tuberosity to the distal metaphysis.

• K-wires were placed across the proximal and distal tibia parallel to the
joints for assessment of tibial alignment.

• The locations of proposed cuts for the medially based wedge ostectomy
were marked on the bone using a cautery pen.

• A wedge ostectomy was performed using an oscillating bone saw and the
resected bone was morselized and preserved as autogenous graft
 Surgical Correction

• The ostectomy gap was reduced and the distal limb was rotated internally to
align the previously created marks

• Two 0.06200 Kirshner wires were placed across the ostectomy to maintain
reduction.

• The precontoured bone plates were placed on the craniolateral and medial
aspects of the tibia in neutral fashion with a combination of 3.5 mm locking
head and cortex screws.

• The surgical site was copiously lavaged, cultured, and bone graft was placed
around the ostectomy site.

• Total operating time was 330 minutes. A full limb modified Robert Jones
bandage was placed for recovery.
 Follow-up

• The donkey was examined at 4 and 10 weeks, 6 months, and 3.5 years after
surgery.

• At 4 weeks, the incision was healed and the donkey was ambulating well.
The radiographic diagnosis included stable implants, callus formation, and
a persistent radiolucent osteotomy line.

• Ten weeks postoperatively, there was progressive clinical improvement in

gait and complete radiographic healing of the ostectomy site

• Six months after surgery, the donkey’s gait had improved to straight line
tracking without lameness. Full access to paddock turnout with other
donkeys was recommended.

• Long-term follow-up was obtained 3.5 years after surgery. The donkey
weighed 195 kg and walked and trotted without lameness
Radiographic evaluation of the right
tibia before and after correction of
the deformity.

Craniocaudal (A-D) and lateromedial

(E-H) views taken preoperatively
(A/E), postoperatively (B/F), at 10
weeks (C/G), and 3.5 years
postoperatively (D/H)
 Results

• CT allowed characterization of the angular and torsional bone deformity of

the right tibia.

• A custom bone model facilitated surgical planning and rehearsal of the

procedure.

• Tibial corrective ostectomy was performed without complication.

• Postoperative management included physical rehabilitation to help restore

muscular function and pelvic limb mechanics.

• Short-term and long-term follow-up confirmed bone healing and excellent

clinical function.
 Objective

To report the outcome of horses after pancarpal or partial

carpal arthrodesis with 3 locking compression plates (LCP)
 Animals and Methods

• Six horses ranging in age from 8 months to 16 years and

weighing 227-580 kg with severe carpal pathology
including acute fractures, chronic osteoarthritis, and
chronic angular limb deformity.

• Pancarpal or partial carpal arthrodesis was performed with

3 LCP. Autologous cancellous bone grafts were used in 5 of
6 cases to facilitate joint arthrodesis.
 Case 6

• A 9-month-old, 285-kg, thoroughbred colt was presented for a severe right

carpal valgus deformity.

• The colt had sustained trauma to the limb as a 4-week-old foal

• Radiographs confirmed a right carpal valgus of approximately 30 8, with

marked physitis of the distal medial radial physis as well as widening of the
medial aspect of the antebrachiocarpal and middle carpal joints.

• A stainless steel staple over the medial distal radial physis, the result of a
much earlier attempt at correcting the deformity, was also identified, as
was a mild fetlock varus in the same limb
 Surgical Procedure

• Two days after admission, the colt was placed under general anesthesia in
dorsal recumbency for a wedge osteotomy and a pancarpal arthrodesis.

• A 20-cm incision was made over the dorsal aspect of the carpus just medial
to the extensor carpi radialis.

• By using a direct approach, all articular cartilage was debrided with a bone
curette from the radiocarpal and middle carpal joints, and a 4.5-mm drill bit
was used in different directions across the carpometacarpal joint to remove
cartilage.

• An oscillating bone saw was used to remove a 30 degree wedge of bone from
the distal medial radius.
 Surgical Procedure – Plates

• A 10-hole broad LCP was applied to the dorsal aspect of the limb with one
4.5-mm cortex screw placed in the eighth hole of the plate to hold the plate
against the bone. The remaining 9 holes were filed with 5.0-mm LHS.

• An 8-hole narrow LCP was applied dorsolaterally through the same primary
incision, and three 4.5-mm cortex screws were placed in the third, fifth, and
seventh holes. The second and third cortex screws were placed in load. The
remaining 5 holes were filled with 5.0-mm LHS.

• A 6-hole narrow LCP was placed dorsomedially through the same primary
incision, and two 4.5-mm cortex screws were placed in the second and fifth
holes of the plate, with the second screw loaded. The remaining 4 holes were
filled with 5.0-mm LHS.
 Surgery – Continued

• An autologous cancellous bone graft obtained from the right ilium was loosely
packed within the joints.

• A sterile dressing and full limb cast were applied to the limb.

• Total surgery time was 200 minutes.

• The patient was recovered with head and tail ropes and stood without
incident.

• Satisfactory implant placement was documented by postoperative

radiographs (Figure 7B).

• The colt was discharged 6 days after surgery.

 Management and Follow-up

• A full limb bandage cast was applied with instructions to have it bivalved in
5 days’ time.

• The colt remained in the bivalved cast for 3 weeks, followed by a heavy
bandage for an additional 2 weeks.

• The colt was turned out and comfortable in a paddock until 6 months
postoperatively, when he was readmitted because it was noted that the
proximal aspects of all 3 plates were exposed. Radiographic
• evaluation confirmed adequate arthrodesis of all carpal joints
 Plate Removal

• The colt was anesthetized, and all screws were removed through stab
incisions.

• The plates were removed through the proximal skin defects.

• A bandage cast was applied and the colt recovered from anesthesia
uneventfully.

• An extended course of antimicrobials (cefazolin 11mg/kg IV twice daily and

gentamicin 6.6mg/kg IV once daily for 1 day, followed by transition to
trimethoprim-sulfamethoxazole 30mg/kg orally twice daily for 10 days)
because of concern of bacterial contamination from the skin defects.
 Follow-up

• The colt remained in the cast for 2 weeks, after which it was
bivalved and maintained for an additional 4 weeks.

• At 18-month follow-up, the colt was turned out and

comfortable in the field, with only a mechanical gait deficit.
 Results

External coaptation was maintained for 4 to 6 weeks after

surgery. Radiographic follow-up was available in all 6 cases,
all of which reached arthrodesis and pasture soundness by
4-5 months postoperatively. One case required implant
removal at 6 months because of implant exposure through
the skin but returned to pasture soundness after removal
 Conclusions and Relevance

• Carpal instability due to acute fractures or chronic disease was

success fully stabilized with 3 short LCP, leading to pasture
soundness in all 6 horses.

• The use of 3 short LCP should be considered as a strategy to

facilitate pancarpal or partial carpal arthrodesis by providing
superior stability without placement of implants in the
diaphysis of the radius and third metacarpus.