J Vet Clin 28(3) : 328-331 (2011)
328
Surgical Correction of an Antebrachial Deformity with Severe External Rotation in Two Dogs
Hun-Young Yoon, Mi-young Roh* and Soon-wuk Jeong1
Department of Veterinary Surgery, College of Veterinary Medicine, Konkuk University, Seoul 143-701, Korea
*Dueckso Animal Hospital, 473-2 Wabueup, Namyangjusi, Kyunggido 472-901, Korea (Accepted: June 13, 2011)
Abstract : Two dogs presented to the Dueckso Animal Hospital with a history of intermittent lameness of the left forelimb. On physical examination, a visible antebrachial deformity that resulted in gross external rotation of approximately 90o was observed in two dogs. Medial-lateral radiographic views revealed distal ulnar subluxation, cranial bowing of the radius, radial and ulnar shortening, and external rotation of the paw. A distal ulnar ostectomy and distal radial closing wedge osteotomy were performed in two dogs. A proximal ulnar osteotomy was performed, adjacent to the elbow joint in case 1. Then, the osteotomized site was supported with an intramedullary pin. A T-plate and cortical screws were applied to the proximal and distal radial segments after derotating the distal segment internally.
Postoperative radiographic view verified the correction of the angular deformity in two dogs. The follow-up was completed by physical examination 6 and 10 months after surgery respectively. There was no evidence of lameness of the left forelimb in two dogs. Gross observation of the limb revealed an apparent appropriate correction of the rotational and angular deformity in two dogs.
Key words : antebrachial deformity, external rotation, distal radial closing wedge osteotomy, dog.
Introduction
An angular limb deformity is an improper growth of antebrachium caused by premature closure of the proximal and distal radial physis, and distal ulnar physis secondary to trauma, hypertrophic osteodystrophy, chondrodysplasia, nutri- tional abnormalities, rickets, or dwarfism (6,14,15). An ante- brachial deformities can attribute to limb shortening, external rotation of the paw, joint incongruity, bowing, carpal valgus, and secondary osteoarthritis (8,11,13). Various surgical techniques, including osteotomies and internal and external fixation, have been performed to correct these deformities (1,2,12). There are few case reports of surgical correction of angular deformities with severe antebrachial external rotation (3). The purpose of this case series is to describe the successful surgical correction of angular deformities with severe antebrachial external rotation in two dogs.
Case 1
A 1-year-old intact male Maltese dog weighing 3.5 kg presented to the Dueckso Animal Hospital for evaluation of intermittent lameness of the left forelimb. On physical examina- tion, a visible antebrachial deformity that resulted in gross external rotation of approximately 90o was observed (Fig 1A).
There was evidence of pain on elbow joint palpation. Orthog- onal radiographic views of the left antebrachium including the elbow joint and carpus, were obtained. Medial-lateral radiographic views revealed distal ulnar subluxation, cranial bowing of the radius, radial and ulnar shortening, and external rotation of the paw (Fig 2A). A diagnosis of antebrachial growth deformities with severe external rotation was made.
The dog was premedicated for surgery with atropine sulfate (0.02 mg/kg subcutaneously; Atropine sulfate inj®, Je Il Pharm.
Co., Ltd, Korea), followed by anesthetic induction with propo-
1Corresponding author.
E-mail: [email protected]
Fig 1. Pre- and post-operative photographs (Case No. 1). A: Gross external rotation of approximately 90o is observed on the left fore- limb pre-operatively. B: Gross observation of the limb reveals an appropriate correction of the rotational and angular deformity post-operatively.
Surgical Correction of an Antebrachial Deformity with Severe External Rotation in Two Dogs 329
fol (6 mg/kg intravenously; Provive 1%®, Myungmoon Pharm.
Co., Ltd, Korea). The dog was intubated and anesthesia was maintained with isoflurane (Isoflurane®; Choongwae. Co., Ltd, Korea) and oxygen. Lactated Ringer’s solution was adminis- tered intravenously at a rate of 5 mL/kg/h until completion of the surgical procedure. The dog received cefazolin (20 mg/kg IV; Safdin®, Daehan Newpharm. Co., Ltd, Korea) at the time of anesthetic induction. A hanging limb preparation was performed with the dog in dorsal recumbency. Four-quarter drapes were placed to provide full access to the limb. Cranial-lateral approach to the shafts of the radius and ulna was performed. A distal ulnar ostectomy was performed by use of a sagittal saw.
Approximately 1 cm of ulna, centered on the distal physis, was removed. Then, the extensor carpi radialis and common digital extensor tendons were reflected laterally. Two Kirschner wires were placed from medial to lateral, adjacent to either side of the site of maximal radial deformity, to guide the intended osteotomy sites. The first Kirschner wire was placed through the radial epiphysis parallel to the antebrachiocarpal joint and its center of rotation. A second Kirschner wire was placed in the distal diaphysis of the radius parallel to the elbow joint and its center of rotation. The two K-wires defined the degree of deformity. A distal radial closing wedge osteotomy was per- formed. The distal osteotomy cut was performed parallel to both the preplaced distal Kirschner wire and the distal radial joint surface. The proximal osteotomy cut was performed parallel to the proximal Kirschner wire and perpendicular to the radial diaphysis; the cuts converged on the lateral surface of the radius to create a wedge for removal. The distal and proximal radial segments were apposed, and the distal segment was derotated internally approximately 90o from its original axial position. Verification of the correction of the angular deformity was assessed grossly at this time. A T-plate and 7
cortical screws were applied to the cranial surface of the radius with 4 screws in the proximal segment and 3 screws in the distal radial segment. The Kirschner wires were removed. Then, the ulna was osteotomized at the proximal level, adjacent to the elbow joint through a small caudal approach. The osteotomized site was supported with an intramedullary pin. The subcutane- ous tissues and skin were closed using 3-0 polyglycolic acid (Safil®; B/Braun) and 3-0 nylon (Nylon®; Namhae. Co., Ltd, Korea) respectively. Postoperative radiographic view verified the correction of the angular deformity (Fig 2B). The follow-up was completed by physical examination 10 months after sur- gery. There was no evidence of lameness of the left forelimb.
Gross observation of the limb revealed an apparent appropriate correction of the rotational and angular deformity (Fig 1B).
Case 2
A 3-year-old female Maltese dog weighing 3.9 kg presented to the Dueckso Animal Hospital for evaluation of intermittent lameness of the left forelimb. The owner reported that the lame- ness has been worse over the past a month. On physical exam- ination, a visible antebrachial deformity that resulted in gross external rotation of approximately 90o was observed (Fig 3A).
Orthogonal radiographic views of the left antebrachium includ- ing the elbow joint and carpus, were obtained. Medial-lateral radiographic views revealed distal ulnar subluxation, cranial bowing of the radius, radial and ulnar shortening, and exter- nal rotation of the paw (Fig 4A). A diagnosis of antebrachial growth deformities with severe external rotation was made.
Surgical preparation, distal ulnar ostectomy, and distal radial closing wedge osteotomy were performed the same as case 1.
The distal and proximal radial segments were apposed, and the distal segment was derotated internally approximately 80o from its original axial position. Verification of the correction of the angular deformity was assessed grossly at this time. A T-plate and 8 cortical screws were applied to the cranial surface of the radius with 5 screws in the proximal segment and 3 screws in the distal radial segment. The Kirschner wires were removed.
The subcutaneous tissues and skin were closed using 3-0 polyglycolic acid (Safil®; B/Braun) and 3-0 nylon (Nylon®; Fig 2. Pre- and post-operative radiographic views (Case No. 1).
A: Medial-lateral radiographic view reveals distal ulnar sublux- ation, cranial bowing of the radius, radial and ulnar shortening, and external rotation of the paw pre-operatively. B: Postoperative radiographic view verifies the correction of the deformities.
Fig 3. Pre- and post-operative photographs (Case No. 2). A: Gross external rotation of approximately 90o is observed on the left fore- limb pre-operatively. B: Gross observation of the limb reveals an appropriate correction of the rotational and angular deformity post- operatively.
330 Hun-Young Yoon, Mi-young Roh and Soon-wuk Jeon
Namhae. Co., Ltd, Korea) respectively. Postoperative radio- graphic view verified the correction of the angular deformity (Fig 4B). The follow-up was completed by physical examina- tion 6 months after surgery. There was no evidence of lame- ness of the left forelimb. No surgical complications were encountered. Gross observation of the limb revealed an appar- ent appropriate correction of the rotational and angular defor- mity (Fig 3B).
Discussion
An antebrachial deformity of the forelimb is frequently reported problems in dogs (10). Without timely surgical cor- rection, an antebrachial deformity can be attributable to elbow and carpal joint subluxation with subsequent development of degenerative joint disease in the elbow and carpal joints (7).
Many surgical techniques have been described to correct this deformity. Wedge osteotomy has been described for the correc- tion of an antebrachial deformity with valgus and mild external rotation deformities (1). In this technique, a distal radial closing wedge osteotomy is performed at the area of the greatest defor- mity using two Kirschner wires as guide wires to orient the intended osteotomy cuts, and T-plate and screws are applied to reduce osteotomy lines (1). However, this technique provides restricted correction to the dogs with severe external rotation deformities. Dome osteotomy has been described for the treat- ment of carpal valgus and varus deformities, and procurvatum deformities (5). In this technique, an osteotomy of the dome shape is created to correct the antebrachial deformities in both the frontal and sagittal planes using biradial saw blades and a specialized reciprocating saw (5). However, this technique also provides restricted correction to the dogs with severe external rotation deformities. In one report in 1998, hinged Ilizarov external fixation was applied to correct rotational deformity by rotating the distal segment around its axis (9). In another report
from 2008, osteotomies were performed at two centers of rota- tion of angulation for correction of an antebrachial deformity with severe external rotation deformities (3). In the cases reported here, wedge osteotomy, at the area of the greatest deformity, provided adequate correction to a valgus deformity and the rotational deformity was successfully corrected by internally rotating the distal segment along its axis.
Premature closure of the physis of one bone and continued growth of the other can result in limb deformity (1,4,10).
Clinical features of the deformity often depend on: where to be damaged or how severe the damage is. Asymmetric premature closure of the distal radial physis produces radial shortening with carpal joint subluxation and elbow joint subluxation, and carpal valgus deformity (1). The distal ulnar physis is cornical shaped in the dog, and cells of the physis are likely to be damaged by lateral shearing forces to the limb (1). Cessation of growth of the ulna restricts longitudinal growth of the radius.
This produces cranial bowing of the radius, radial shortening, external rotation of the paw, elbow joint subluxation, and carpal valgus deformity. To address these various deformities properly, therefore, choosing an appropriate technique for cor- rection of the deformities is very important to restore normal limb function and minimize postoperative complication. In the cases reported here, cranial bowing of the radius, valgus, and external rotation of the paw were revealed on radiography and gross assessment during surgery. A combination of closing wedge osteotomy and rotation of the distal segment around its axis was helpful in the cases, with a valgus, procurvatum, and rotational deformities, reported here.
A proximal ulnar osteotomy could be performed for correc- tion of elbow joint subluxation. In the case 1 reported here, elbow joint subluxation was suspicious. The ulna was osteoto- mized at the proximal level, adjacent to the elbow joint and the osteotomized site was supported with an intramedullary pin to prevent rotation of the ulna.
Acknowledgements
This work was supported by the National Research Founda- tion of Korea Grant funded by the Korean Government [NRF- 2009-353-E00034].
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심각한 외측 회전을 동반한 전완 기형의 외과적 교정 치료 2 증례
윤헌영·노미영*·정순욱1
건국대학교 수의과대학 수의외과학 교실, *덕소 동물병원
요 약 : 간헐적 전지 파행을 보이는 두 마리 개가 내원하였다. 신체 검사에서 약 90o외측 회전을 동반한 전완 기형
을 두 마리 모두에서 확인 하였다. 일반 방사선 사진에서 척골 원위부 아탈구, 요골 앞쪽 휨 현상, 짧아진 요골 척골, 및 앞발의 외측 회전을 확인하였다. 외측 회전을 동반한 전완 기형의 교정을 위해 척골 원위부 골절제와 요골 원위부 쐐기형 절골술 및 요골 원위부 내측 회전을 실시 하였다. 관절 부조화를 예방하기 위해 척골 근위부 절골술을 첫번째 개에서 실시 하였다. 수술 후 정기 검진은 수의사의 신체 검사를 통해 실시 되었으며 두 마리 모두에서 수술과 관련 한 합병 증상 및 파행이 없음을 확인하였다.
주요어 : 전완 기형, 외측 회전, 요골 원위부 쐐기형 절골술, 개
