Ch 64 Tarsus and metatarsus Flashcards

Question

Nicholson 2012 modified repair method

Answer 1

repair of tarsocrural instability – various repair/stabilisation methods - complications: 24/26 limbs (92.3%) - prosthetic ligaments associated with major complications (5/8 required subsequent removal) - ESF-associated complications common Eight joints had internal fracture fixation and transarticular external skeletal fixator, six had external fixator alone, four had prosthetic ligaments with external fixator, and four had prosthetic ligaments with external coaptation. Two joints had pantarsal arthrodesis and two primary ligament repair Complications are common; however many are external fixator related. Regardless of technique, a degree of ongoing lameness is likely.

Answer 2

Injuries to the medial side predominate - soft tissue damage is complicated by orthopedic injury, and neural and vascular loss may be extensive - Radiography should be performed to obtain additional information about bone loss

Answer 3

- Contamination and possible infection - Loss of vital structures - Instability - Is the remaining bone sufficient to attain a function outcome? If more than 50% of the joint is intact, saving the joint is justified

Answer 4

1. open wound mgmt, tarsus splinted bandage + antibiosis 2. TA-ESF: Large proportion of cases, stability is acceptable when the fixator is removed 4 to 6 weeks later (scar tissue), in small or sedentary dogs 3. larger or more athletic animals may require artificial ligaments 4. pantarsal arthrodesis

Answer 5

91% good to excellent outcome

Answer 6

- allows dorsiflexion of the calcaneoquartal and talocalcaneocentral joints; - subluxation develops with weight bearing - not trauma, the onset of the condition is often insidious, may not be painful - animal is plantigrade

Answer 7

Middle-aged, overweight Shelties | often bilateral

Answer 8

Arthrodesis of calcaneoquartal joint - Transfixation pin and tension band - Single compression screw through cancaneus and into 4th tarsal bone - Lateral plate | poor healing capacity of the plantar ligaments.

Answer 9

- Injury is due to damage to the short dorsal ligaments spanning the joint. - dorsal aspect is not the tension side of the joint, instability may be difficult to appreciate (plantar flexion) - external coaptation, screws and orthopedic wires, external skeletal fixation, and plate fixation with or without arthrodesis. - Good results are anticipated

Answer 10

- associated pain and discomfort - Fractures of the fourth tarsal bone and of metatarsal bones II and V common - plantar luxation - Dorsiflexion occurs as a result of disruption of the plantar tarsal fibrocartilage

Answer 11

- IM pin and tension band - Cross pins +/- IM pin - Multiple pins from MTs into distal tarsal bones - Lateral plate - ESF (functional ankylosis) most reliable arthrodesis = laterally applied bone plate

Answer 12

Bernese Mt Dog Tx: correct rotational deformity and arthrodesis of proximal intertartsal joint

Answer 13

- Paired tendons of the gastrocnemius - Common tendon of gracilis, semitendinosus and biceps femoris - Superficial digital flexor tendon

Answer 14

- traumatic incident - ususally complete mid tear - hyperextension of the stifle joint and a plantigrade stance - Ultrasonography can be useful in identifying the site and nature of the tear. considerations: - Poor healing of tendon leading to lengthy convalescence - Distraction of severed tendon ends - Size and comparative fragility of the tendons after trauma

Answer 15

- remove the gap by approximating the tendon ends. A locking-loop or three-loop pulley (0, 1, or 2 polydioxanone) - appose tendon ends 3-0 PDS - immobilization of the tarsus: screw, ESF, cast - No single method has proved superior - immobilization of the tarsus does not completely eliminate strain within the common calcanean tendon during ambulation > contraction of the gastrocnemius muscle continues - calcaneotibial screw is an easy and effective (3.2 drill, 4.5mm), removed 6-8 weeks - protect with cast | halstead principles for tendon

Answer 16

- separation of the tendon of the gastrocnemius muscle from the calcaneus, leaving the superficial flexor tendon intact - lameness, and swelling may be palpable at the insertion of the tendon on the calcaneus - Knuckling of the digits may accompany this moderate plantigrade stance > tight pull caused by stretching of the superficial digital flexor tendon - cause of this condition is obscure, but it is likely a result of repetitive trauma

Answer 17

Labradors Doberman Pinschers Old, female cats

Answer 18

- surgical reattachment of the tendon to the calcaneus > using bone tunnels for suture placement - calcaneotibial screw fpr immobilation chronic disruptions - tendon must be resected and reattachment to the calcaneus is not feasible - polyethylene terephthalate prosthesis (Sutured at myotendinous junction of gastroc and attached to calcaneus with interference screw) - cast for 6 weeks - 2/10 cases developed a postoperative infection - 6/10 cases excellent pantarsal arthrodesis

Answer 19

- (67%) had tendino-osseous avulsions at the calcaneus - Complications were generally associated with the method used to maintain tarsocrural extension - consdier 2mm calcaneotibial screw (fracture risk)

Answer 20

Dogs: - Good to excellent in 72-94% - Return to work 71% Cats: - 84% good outcome

Answer 21

Shelties Collies Greyhounds - Usually occurs in a lateral direction (disruption of the medial retaining structures) - may luxate intermitently or be fixed laterally - Can test by rotating metatarsus medially while flexing the tarsus | variable presentation, ranging from very mild to severe lameness.

Answer 22

- SDFT broadens to form a fibrocartilaginous cap as it passes over the tuber calcanei - endon relocated in a central position of the groove > surgical release (i.e., desmotomy on the side toward which the tendon luxates) - medial retaining tissue is repaired - immobilized for a minimum of 4 weeks

Answer 23

indications: - Shearing injuries with critical loss of bone * Instability of the joint * Painful osteoarthritis that cannot be managed medically, usually following osteochondritis dissecans lesions * Comminuted fractures of the tarsus * Failure of the common calcanean tendon - success with various tehcniques, though plate best - plantar placement is the most biomechanically > medial and dorsal most common - High levels of complications when only the tarsocrural joint is fused - customized plates placed medially or laterally > have biomechanical advantages over dorsal

Answer 24

- Medial malleolar osteotomy - Glide hole from medial tibia to medial side of tibial cochlea - Cartilage on tibial removed at 90 degree to long axis - Cartilage on talus removed at 45 degree - Reduced (forms 135 degree angle) - Holed drilled through glide hole into talus and lag screw placed - Plate contoured for at least 4 screws in tibia and 2-3 in MT - Calcaneotibial screw placed through the plate or seperately - Cartilage removed from remaining joints and bone graft placed - Dorsal or medial 3.5/2.7mm hybrid plate

Answer 25

IM pins transarticular lag screw calcaneotibial screw external coaptation/ESF - plate dorsal aspect of the tarsus requires supplementary support during 4 to 8 weeks - plates are mechanically compromised, inability of the plate to resist the bending forces

Answer 26

Plantar necrosis with loss of soft tissue including MT pad

Answer 27

30 - 70% High complication rate mostly from attempts to arthrodese only the tarsocrural joint Good outcome expected in more than 50 - 70% complcations - failure ot fuse - failure of implant - infection - Achilles tendon pain - necrosis

Answer 28

- when the plantar ligaments are damaged, producing dorsiflexion at the level of the proximal intertarsal joints - - lagged screw placed through the calcaneus and into the fourth tarsal bone (2/35 failures) - laterally placed hybrid bone plate - plate requires contouring vs portion of the fourth tarsal bone or head of metatarsal V or both may be removed Outcome is expected to be good. complications - result of implant failure, which may be caused by technical errors, failure of arthrodesis, or inadequate protection immediately following surgery

Answer 29

cross-pins, cross-pins plus an intramedullary pin,62 external skeletal fixation,33,72 and the application of a laterally positioned plate

Answer 30

- cases with an instability of the tarsocrural joint in flexion only - The two short medial collateral ligaments (SMCLs) run deep to the long ligament, the tibiocentral ligament, and the tibiotalar ligament. Unlike the long medial collateral ligament, which stabilizes against deviation toward lateral, the SMCL stabilizes against subluxation toward medial, with the tibiotalar ligament being the major stabilizer in flexion.

Answer 31

1.9 to 6.6 kg locking External coaptation was not used in any case. Radiographic follow-up documented clinical or bony union in all cases One major complication (screw removal) and two minor complications (partial construct failure) were observed

Answer 32

Retrospective case series No major complications occurred requiring only short-term external coaptation in most patients. Time to bone union and return to normal function compared favorably to previously reported techniques Closed reduction and stabilization were achieved in 48/57 (84%) Median time to radiographic bone union in all FGNMP-treated metabones was 6 weeks

Answer 33

AN construct consisted of 3 bone anchors connected with monofilament nylon suture. The AU construct consisted of low-profile suture anchors connected with multifilament ultrahigh-molecular-weight polyethylene (UHMWPE) suture. The TN and TU constructs involved the creation of 3 bone tunnels and use of nylon or UHMWPE suture, Relative to intact tarsal joints, joint laxity was significantly increased following completion of all 4 constructs. Ultimate strength was greatest for the UHMWPE-suture constructs

Answer 34

risk factors for plantar necrosis after tarsal arthrodesis. Ex vivo + 39 retrospective. - screw placement (esp proximal 2 metatarsal screws → highest risk) - 92% of cases had 1 screw risking damage to mean intertarsal channel position - intertarsal channel located within prox 25% of metatarsal III in 95% cases - total 8% plantar necrosis (n=39), occurred mostly in lateral plate - all cases had tarsometatarsal subluxation - vascular compromise of dorsal pedal a. during surgery AND occlusion of collateral from cast/splint, tight closure low incidence of plantar necrosis is due to sustained collateral blood supply

Answer 35

- Fixator removal was performed at a mean time of 11.3 weeks - Complications developed in 4 dogs (50%) - 2 delayed arthodesis, 2 infection, 1 fracture - Six dogs had excellent outcomes. - requires rigorous postoperative care but obviates the need for supplemental postoperative coaptation applied following surgical debridement and grafting of the involved articulations through limited approaches, mitigating soft tissue and vascular disruption that is described secondary to plating techniques

Answer 36

seven tarsi of six cats veterinary cuttable plates (VCPs) without postoperative external coaptation Intraoperative complications in 2 Postoperative complications in the bilateral single-session PTA. gastrocnemius myotendinopathy (firm linear mass was palpable in the region of myotendinous region, resolved with achilles cut) protrusion of a screw head very good outcomes in all cats (FMPI score)

Answer 37

retrospective successful surgical outcome (73%) cases. Re-luxation in (15%). (13%) had a persistent lameness post-operative complications (71%), with the majority resolved medically. The risk of surgical failure higher where absorbable suture material was used compared to non-absorbable suture material. Surgical failure was more common in cases managed with non-rigid immobilisation post-operatively, howver no benefot if left on for >6wks 20/34 complications were directly related to the external coaptation Previous studies have reported success rates of 83% and 100% following surgery

Answer 38

Twenty-three procedures were performed in 19 dogs Minor complications (35%). Major complications requiring unplanned surgery (13%). reluxation (9%) All cases ultimately returned to their pre-injury level of activity treated without using post-operative immobilisation of the tarsal joint. The pins were well tolerated but in many cases the pin could be felt to scrape under the skin and caused a variable degree of soft tissue reaction which resolved on removal

Answer 39

retrospective review. 6 dogs all had no or mild lameness and evidence of fracture healing on radiography. A suspected surgical site infection occurred in one dog All dogs had concurrent fractures to the fourth tarsal bone, meatatrasal A locking compression plate > medial application without arthrodesis (neck of talus to metatarsal II Despite the bone plate bridging the talocentral, centrodistal and tarsometatarsal joints, the articular cartilage was not debrided, and a bone graft was not used. Ankylosis is expected following immobilization of the low motion joints and is associated with good function

Answer 40

retrospective multicentre case series most common fracture configuration involved the lateral trochlear ridge only (n= 9) orthogonal views, fracture was only visible in five cases

Answer 41

Retrospective case series PTA with medial plate without external coaptation, n=30 dogs, 36 PTA - adjunct CT-screw or tibiocalcaneal screw in all cases - complications: 1/36 catastrophic, 11/36 major (30.6%) requiring revision - screw breakage or loosening, metatarsal fracture, CCT pain, plate breakage - 11/36 (30.6%) classified as major II → medical management, SSI - outcome: full function 12/26 (46.2%), acceptable function 14/26 (53.8%) medial plating allows “edge” loading (compared to dorsal) > increases dorsoplantar bending stiffness 14 > gastrocnemius and common tendons were transected not to extend debridement and dissection dorsally None developed plantar necrosis > None of our dogs had a rigid cast applied (unlike Roch study)

Answer 42

successfully stabilized the luxated tarsometatarsal joint in all 16 patients. Six patients developed minor postoperative complications, which included bandage-associated dermatitis or ulceration (n = 5) and orthopedic wire failure (1). No major Prosthetic ligament placement may be an alternative to arthrodesis for tarsometatarsal joint stabilization in small patients

Answer 43

temporary calcaneotibial screw (CTS) to immobilize medial or lateral tarsocrural joint instability (TCI) in dogs. CTS + external coaptation → good-excellent outcome in 12/12 dogs - complications: 1/12 CTS breakage, 3/12 bandage-related Retrospective study. Animals: Twelve dogs (including five active working farm dogs) Surgical techniques to address TCI included primary ligamentous repair, synthetic ligament reconstruction, or malleolar fracture repair. Immobilization with a CTS was employed for 6-8 weeks postoperatively.

Answer 44

increasing loops for three-loop pulley → linear increase in strength of repair - increased yield, peak, failure loads, construct stiffness and load to gap-formation for 6LP

Answer 45

Goffart 2021 – UHMWPE suture for temporary tarsocrural stabilisation → stabilised joints at clinically relevant loads, stiffness not different to 4.5mm CTS - 4.5mm CTS → higher load to failure

Answer 46

locking loop suture, cast +/- calcaneotibial screw - 7/10 return to full/substantial work, moderate lameness in 2/7 that returned to work - 71% good-excellent functional outcome - complications: cast related 4/10, no screw-related complications

Answer 47

CCT injury in 66 cats - commonly closed (69.7%) - most common Meutstege type IIc (partial avulsion) – typically subacute/chronic - method of immobilisation → notable but not statistically significant influence on complications - more complications for TA-ESF vs CT-screw and coaptation - complications: overall 41.3%, 33.3% minor – pin tract infection - 7.9% major – ESF frame failure/breakage, SSI, re-rupture, calcaneal fracture - outcome: 86% free of lameness long term → 84.9% success - surgery → better outcome than conservative

Answer 48

complications: major 32.5%, minor 42.5% - pantarsal arthrodesis → higher major complication rate - plantar necrosis most common (15%) - more with medial plating and only with tarsometatarsal debridement - suspected due to injury to the perforating metatarsal artery

Ch 64 Tarsus and metatarsus Flashcards

(77 cards)