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Atlas of Orthopedic Surgical Procedures of the Dog and Cat

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内容提示: 11830 Westline Industrial DriveSt. Louis, Missouri 63146ATLAS OF ORTHOPEDIC SURGICAL PROCEDURES OF THE DOG AND CAT Copyright © 2005, Elsevier Inc.ISBN 0-7216-9381-4All rights reserved. No part of this publication may be reproduced or transmitted in any form or byany means, electronic or mechanical, including photocopying, recording, or any information storageand retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Health Sciences Rights...

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11830 Westline Industrial DriveSt. Louis, Missouri 63146ATLAS OF ORTHOPEDIC SURGICAL PROCEDURES OF THE DOG AND CAT Copyright © 2005, Elsevier Inc.ISBN 0-7216-9381-4All rights reserved. No part of this publication may be reproduced or transmitted in any form or byany means, electronic or mechanical, including photocopying, recording, or any information storageand retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Health Sciences Rights Department inPhiladelphia, PA, USA: phone: (+1) 215 238 7869, fax: (+1) 215 238 2239, e-mail:healthpermissions@elsevier.com. You may also complete your request on-line via the Elsevierhomepage (http://www.elsevier.com), by selecting “Customer Support” and then “ObtainingPermissions.”International Standard Book Number 0-7216-9381-4Publishing Director: Linda DuncanSenior Editor: Liz FathmanDevelopmental Editor: John DedekePublishing Services Manager: Melissa LastarriaSenior Project Manager: Joy MooreDesign Manager: Bill DronePrinted in the United States of AmericaLast digit is the print number:987654321NOTICEVeterinary Medicine is an ever-changing field. Standard safety precautions must be followed, butas new research and clinical experience broaden our knowledge, changes in treatment and drugtherapy may become necessary or appropriate. Readers are advised to check the most currentproduct information provided by the manufacturer of each drug to be administered to verify therecommended dose, the method and duration of administration, and contraindications. It is theresponsibility of the treating veterinarian, relying on experience and knowledge of the patient, todetermine dosages and the best treatment for each individual patient. Neither the publisher northe authors assume any liability for any injury and/or damage to persons or property arising fromthis publication. This book is dedicated to my family, mentors, colleagues, residents, and students, all of whom have provided input in mydevelopment as a surgeon and consequently inthe development of this book.Ann JohnsonI thank Ann Johnson for her generosity andfriendship. This book is dedicated to myamazing children, George Henry and Sydney,who generate an abundance of love, happiness,and true joy in my life.Dianne Dunning PrefaceOur goal in writing this atlas of orthopedic surgical procedureswas to create a uniquely portable, easy-to-use referenceresource for surgeons in the operating room—an atlas thatdemonstrates a wide range of procedures commonly performedin veterinary surgery. We thank Laura Duprey for helping usreach this goal by providing superb illustrations of the proce-dures.In our surgical practice at the University of Illinois, westrongly encourage our residents and students to use textbooksin the surgery suite to guide them in each surgical techniqueand to maximize their proficiency. With the constant explosionof surgical techniques and procedures, this guidance is essen-tial for those who do not have the opportunity to master eachtechnique by performing the procedures on a daily basis. The techniques selected and described are based on ouryears of experience in training surgical residents, interns, andstudents and in offering continuing education to practicing vet-erinarians. Also included are tips that we have found helpful aswe have performed these procedures in our own practice. It was a joy to compile this atlas; we hope that it is as illumi-nating to read as it was instructive to write.Ann JohnsonDianne Dunningvii SHOULDERCHAPTER 1via Caudolateral or Caudal ApproachOsteochondrosis of the Shoulder INDICATIONSCandidates include dogs with persistent lameness of theshoulder caused by osteochondrosis that is not responsive toconservative management.OBJECTIVES• To improve limb function by removal of the entire osteo-chondrosis flap, curettage of the adjacent diseased cartilage,and forage to provide blood supply to the exposed subchon-dral boneANATOMIC CONSIDERATIONSThe shoulder joint is easily located by palpating the acromialprocess of the scapula and the greater tubercle of the humerus.The acromial head of the deltoideus is bordered cranially by the omobrachial vein and caudally by the axillobrachial vein.Muscular branches of the axillary nerve and caudal circumflexvessels are located deep in the caudal aspect of the acromialhead of the deltoideus muscle, superficial to the triceps muscle.EQUIPMENT• Standard surgical pack, two medium or large Gelpi retractors(depending on the size of the dog), blunt Hohmann retractor,bone curettes, pin chuck or high-speed wire driver, Kirschnerwires or small Steinmann pin for foragePREPARATION AND POSITIONINGPrepare the leg circumferentially from dorsal midline to thecarpus. Use a hanging leg preparation with the dog in lateralrecumbency to allow for maximal manipulation of the shoulderjoint during surgery.PROCEDURECraniolateral Approach:1Incise the skin and subcuta-neous tissues in a curvilinear fashion from mid-scapula to mid-humerus. Incise the deep fascia between the acromial andspinous portions of the deltoideus muscle (Plate 1A). Further delineate this separation by blunt dissection with Mayo scissors,allowing for cranial retraction of the acromial head and caudalretraction of the spinous portion of the deltoideus muscle. Themuscle branch of the axillary nerve is visualized at this pointand preserved. Place the Gelpi retractors at 90 degrees to eachother to facilitate visualization. Incise the joint capsule parallelto the rim of the glenoid cavity and replace the Gelpi retractorswithin the joint space to facilitate visualization. Internally rotateand adduct the humerus to maximize exposure to the caudalaspect of the femoral head. Place a blunt Hohmann retractorcaudomedial to the femoral head to exteriorize the femoralhead and further facilitate lesion visualization (Plate 1C).Caudal Approach:2Incise the skin and subcutaneoustissues in a curvilinear fashion from mid-scapula to mid-humerus. Incise between the caudal border of the spinous headof the deltoideus and the long and lateral heads of the tricepsmuscle (Plate 1B). Bluntly dissect under the deltoideus muscleto visualize the axillary nerve and caudal circumflex humeralartery and vein. Use Gelpi retractors to craniodorsally retractthe teres minor muscle located deep to the spinous head of thedeltoideus muscle. Elevate and gently retract the axillary nerveoff of the joint capsule. Incise the joint capsule parallel to therim of the glenoid cavity, and replace the Gelpi retractors withinthe joint space to facilitate visualization. Internally rotate andadduct the humerus to maximize exposure to the caudal aspectof the femoral head (Plate 1D).Curettage: Remove the cartilage flap with thumb orHalstead forceps. Probe the remaining cartilage surroundingthe defect with a curette, and remove any abnormal cartilagenot adherent to the subchondral bone (Plate 1E).Forage: Using a small Kirschner wire or small Steinmannpin, penetrate the sclerotic subchondral bone in multiple sitesuntil it bleeds (Plate 1F). Explore the caudal cul-de-sac of thejoint for loose or free fragments of cartilage. Lavage the joint,and close the joint capsule and wound in a routine fashion.CAUTIONSOsteochondrosis is often bilateral (42% to 65%)3; both shouldersshould be evaluated, even if the animal exhibits a unilateral lame-ness. Accurate hemostasis should be used when approaching theshoulder, as hemorrhage will greatly impede joint visualization.POSTOPERATIVE EVALUATIONNo specific postoperative evaluation is required.POSTOPERATIVE CAREExercise should be restricted for 3 to 4 weeks to allow softtissue healing and cartilage resurfacing, and then normalactivity should be reintroduced slowly.EXPECTED OUTCOMEOutcome is good to excellent in most cases.4Note that degen-erative joint disease may develop despite the surgical removalof an osteochondrosis flap.References1. Piermattei DL, Johnson KA: Approach to the caudolateral region ofthe shoulder joint. In An Atlas of Surgical Approaches to the Bonesand Joints of the Dog and Cat, 4th ed. Philadelphia, WB Saunders,2004.2. Piermattei DL, Johnson KA: Approach to the caudal region of theshoulder joint. In An Atlas of Surgical Approaches to the Bones andJoints of the Dog and Cat, 4th ed. Philadelphia, WB Saunders, 2004.3. Whitehair J, Rudd R: Osteochondritis dissecans of the humeral headin dogs. Compend Cont Ed 12:195–203, 1990.4. Rudd R, Whitehair J, Marogolis J: Results of management of osteo-chondritis dissecans of the humeral head in dogs: 44 cases(1982–1987). J Am Anim Hosp Assoc 26:173–178, 1990.2PART ONE•SURGICAL PROCEDURES FOR JOINT DISEASES CHAPTER 1OSTEOCHONDROSIS OF THE SHOULDER 3PLATE 1ABCDEFTriceps brachii muscle:Long headLateral headDeltoideus muscle:Scapular partAcromial partCaudolateralapproachCaudalapproachDeltoideus muscle:Scapular partAcromial partDeltoideus muscleTeres minormuscle(retractedcraniodorsally)GlenoidJointcapsule SHOULDERCHAPTER 2Infraspinatus ContractureINDICATIONSCandidates are animals with infraspinatus contracture that isnot responsive to rest and management with nonsteroidal anti-inflammatory drugs. These dogs display a characteristic gaitabnormality of external rotation of the shoulder, elbow abduc-tion, and outward rotation of the pes.OBJECTIVES• To restore normal shoulder joint range of motion and fore-limb function by releasing the fibrotic infraspinatus muscleANATOMIC CONSIDERATIONSThe infraspinatus muscle is one of the cuff muscles of theshoulder joint,1lying just caudal to the scapular spine. Itstendon lies beneath the acromial head of the deltoideus muscleand crosses the joint craniolaterally, inserting on the lateralaspect of the greater tubercle of the humerus. The teres minortendon inserts just distally to the infraspinatus along the lateralaspect of the greater tubercle of the humerus.EQUIPMENT• Standard surgical pack, two medium or large Gelpi retractors(depending on the size of the dog), periosteal elevator, andformalin jar for histopathologyPREPARATION AND POSITIONINGPrepare the leg circumferentially from dorsal midline to thecarpus. Use a hanging leg preparation, with the dog in lateralrecumbency to allow for maximal manipulation of the shoulderjoint during surgery.PROCEDURE2Incise the skin and subcutaneous tissue in a curvilinear fashionfrom the mid-scapular spine to the proximal portion of thehumerus. Incise the deep fascia along the cranial border of theacromial head of the deltoideus muscle. Elevate and caudallyretract the muscle with Gelpi retractors (Plate 2A). The infra-spinous tendon should be visible as it inserts on the greatertubercle of the proximal humerus. Affected tendons will appeargrossly thickened and fibrotic and will become visibly taut andinhibit the range of motion of the shoulder when it is placed inextension or flexion. Isolate the tendon by sharp and blunt dis-section with a scalpel blade and periosteal elevator. Transectthe tendon and any associated fibrotic bands until the shouldermoves freely. Resect a portion of the tendon (approximately1 cm) to prevent recurrence and submit for histopathology(Plate 2B). Closure is routine.CAUTIONSThere are no specific cautions.POSTOPERATIVE EVALUATIONOnce released, the shoulder should resume full range of motion.A portion of the affected tendon should be biopsied and sub-mitted for histopathology for disease verification.POSTOPERATIVE CAREExcessive activity should be restricted for 10 to 14 days to pre-vent seroma formation.EXPECTED OUTCOMEOutcome is usually excellent, with a full return to functionexpected.3References1. Vasseur P, Moore D, Brown S: Stability of the canine shoulder joint:An in vitro analysis. Am J Vet Res 43:352–355, 1982.2. Piermattei DL, Johnson KA: Approach to the craniolateral region ofthe shoulder joint by tenotomy of the infraspinatus muscle. In AnAtlas of Surgical Approaches to the Bones and Joints of the Dog andCat, 4th ed. Philadelphia, WB Saunders, 2004.3. Bennet R: Contracture of the infraspinatus muscle in dogs: A reviewof 12 cases. J Am Anim Hosp Assoc 22:481–487, 1986.4PART ONE•SURGICAL PROCEDURES FOR JOINT DISEASES CHAPTER 2INFRASPINATUS CONTRACTURE5PLATE 2Deltoideus muscle:acromial partTriceps brachii muscle:lateral headInfraspinatusmuscleSupraspinatusmuscleTeres minor muscleInfraspinatusmuscleAB SHOULDERCHAPTER 3Shoulder LuxationStabilization of Medial INDICATIONSThis procedure is indicated in animals with medial shoulderluxation and instability. Open reduction and stabilization is indi-cated if a traumatic luxation is unstable enough after closedreduction that reluxation occurs, or if the luxation is chronic.Surgery is warranted in animals with congenital luxation orinstability that causes severe or persistent lameness.OBJECTIVES• To restore normal stability, congruency, mobility, and functionto the shoulder joint without altering regional anatomy1ANATOMIC CONSIDERATIONSAnatomic landmarks for the scapulohumeral joint are theacromion process of the scapular spine, the greater tubercle,and the acromial head of the deltoid muscle. Anatomic land-marks for positioning the skin incision include the acromion ofthe scapula, the greater tubercle of the humerus, and the pec-toral muscles. The suprascapular nerve is present over the cranial lateral surface of the scapula. The caudal circumflexhumeral artery and axillary nerve are present on the caudolat-eral aspect of the shoulder, and these should be avoided.EQUIPMENT• Standard surgical pack, two medium or large Gelpi retractors(depending on the size of the dog), periosteal elevator, twosmall Hohmann retractors, wire driver, intramedullary pins orKirschner wires, mallet, 20-pound nylon*or the appropriate-size nonabsorbable suture material, and a suture anchorsystem†Alternatively, if a suture anchor system is not available or ifthe animal is not large enough to accommodate the sutureanchor system, a screw and washer combination may be used.Additional instrumentation needed for this technique includes ahigh-speed drill, bone screw and washer, drill bit, tap, depthgauge, and screwdriver.PREPARATION AND POSITIONINGPrepare the leg circumferentially, from the dorsal midline to thecarpus. Use a hanging leg preparation with the dog in dorsalrecumbency to allow for maximal manipulation of the shoulderjoint during surgery. PROCEDUREApproach:2Use an approach to the craniomedial shoulderjoint to expose the luxated joint. If possible, reduce the luxationbefore the approach to reestablish normal anatomic relation-ships. Incise the skin and subcutaneous tissue from the medialaspect of the acromion over the greater tubercle to the medialaspect of the midhumeral diaphysis. Ligate the omobrachialvein if it interferes with the intended approach. Incise the fas-cial border of the brachiocephalicus muscle and retract themuscle medially. Incise the insertions of the superficial anddeep pectoral muscles from the humerus and retract themmedially. Retract the supraspinatus muscle laterally. Transectthe tendon of the coracobrachialis muscle near its origin toexpose the subscapularis muscular tendon. Incise and elevatethe subscapularis muscle tendon at its origin, exposing 0.5 to1.0 cm of the distal scapula. Place one small Hohmann retractorcranial and underneath the supraspinatus muscle and anothercaudally against the caudal scapula for good visualization of themedial glenohumeral joint (Plate 3A). Inspect the joint, andassess the condition of the humeral head and medial labrum ofthe glenoid.6PART ONE•SURGICAL PROCEDURES FOR JOINT DISEASES*Mason Nylon Leader Line, Mason Tackle Company, Otisville, Michigan.†Bone Biter Suture Anchor System, Warsaw, Indiana. Continued CHAPTER 3STABILIZATION OF MEDIAL SHOULDER LUXATION7PLATE 3SubscapularismuscleDeep pectoralmuscleCoracobrachialismuscleBiceps brachiimuscleSupraspinatusmuscleSuperficialpectoralmuscleA Stabilization with the Suture Anchor System:1,3Reduce the joint and identify the insertion and origins of themedial glenohumeral ligament in the distal scapula and prox-imal humerus. Drill three holes, one each at the cranial andcaudal components of the ligament origin on the distal scapulaand another at the ligament insertion on the proximal humerus(Plate 3B). Insert suture anchors threaded with fish leader lineor nonabsorbable suture into each of these holes. There shouldbe two independent suture loops for the cranial and caudalcomponents of the medial glenohumeral ligament. Tie thesutures with the limb held at a normal standing angle (approxi-mately 135 degrees of extension) such that the sutures are taut,but not overly tight, avoiding plication of the joint capsule(Plate 3C). Imbricate the capsule and subscapularis tendonwith nonabsorbable mattress sutures. Place the scapulo-humeral joint through a range of motion and evaluate joint sta-bility and mobility. Closure is routine.Stabilization with a Combination:1Reduce the joint and identify the origins andinsertion of the medial glenohumeral ligament in the distalscapula and proximal humerus. Drill, measure, and tap threeholes, one each at the cranial and caudal components of the lig-ament origin on the distal scapula and another at the ligamentinsertion on the proximal humerus. Use a screw and washercombination to prevent subsidence into the soft metaphysealbone and slippage of the ligature. There should be two inde-pendent suture loops for the cranial and caudal components ofthe medial glenohumeral ligament. Tie the sutures with the limbheld at a normal standing angle (approximately 135 degrees ofextension) such that the sutures are taut, but not overly tight,avoiding plication of the joint capsule (Plate 3D). Imbricate thecapsule and subscapularis tendon with nonabsorbable mattresssutures. Place the scapulohumeral joint through a range ofmotion and evaluate joint stability and mobility. Closure is routine.Screw and WasherCAUTIONSBecause the suprascapular nerve lies in close proximity to thefascial attachment between the deep pectoral and supraspinatusmuscles, care must be taken during the approach in order toavoid trauma.POSTOPERATIVE EVALUATIONJoint stability and range of motion should be evaluated at 2 and4 weeks to assess continued need for external coaptation.POSTOPERATIVE CAREA Velpeau sling is indicated to protect the repair for 2 to 4 weeks.EXPECTED OUTCOMEOutcome is good to excellent in most cases. A published caseseries noted minimal gait abnormalities following surgery andrehabilitation, even in the face of degenerative joint disease and joint malformation stemming from congenital shoulder luxation.1References1. Fitch R, Breshears L, Staatz A, et al: Clinical evaluation of prostheticmedial glenohumeral ligament repair in the dog (10 cases). VetComp Orthop Traumatol 14:222–228, 2001.2. Piermattei DL, Johnson KA: Approach to the craniomedial region ofthe shoulder joint. In An Atlas of Surgical Approaches to the Bonesand Joints of the Dog and Cat, 4th ed. Philadelphia, WB Saunders,2004.3. Ringwood P, Kerwin S, Hosgood G, et al: Medial glenohumeral liga-ment reconstruction for ex-vivo medial glenohumeral luxation in thedog. Vet Comp Orthop Traumatol 14:196–200, 2001.8PART ONE•SURGICAL PROCEDURES FOR JOINT DISEASES CHAPTER 3STABILIZATION OF MEDIAL SHOULDER LUXATION9PLATE 3Suture anchor threadedwith two suturesinserted in humerusAnchor locked beneathcorticesDCB SHOULDERCHAPTER 4Shoulder LuxationStabilization of Lateral INDICATIONSLateral shoulder luxations are usually traumatic in origin andoccur after glenohumeral ligament and infraspinatus tendonrupture. Open reduction and stabilization is indicated if the lux-ation is unstable enough after closed reduction that reluxationoccurs, or if the luxation is chronic.OBJECTIVES• To restore normal stability, congruency, mobility, and func-tion to the shoulder joint without altering regional anatomyANATOMIC CONSIDERATIONSAnatomic landmarks for the scapulohumeral joint are theacromion process of the scapular spine, the greater tubercle,and the acromial head of the deltoideus muscle. Anatomic land-marks for positioning the skin incision include the acromion ofthe scapula, the greater tubercle of the humerus, and the acro-mial head of the deltoideus muscle. EQUIPMENT• Standard surgical pack, two medium or large Gelpi retractors(depending on the size of the dog), periosteal elevator, wiredriver, intramedullary pins or Kirschner wires, mallet, 20- to60-pound nylon,* and a suture anchor system* Alternatively a bone tunnel, screw, and washer combinationmay be used, if a suture anchor system is not available or if theanimal is not large enough to accommodate the suture anchorsystem. Additional instrumentation needed for this techniqueincludes a high-speed drill, bone screw and washer, drill bit, tap,depth gauge, and screwdriver.PREPARATION AND POSITIONINGPrepare the leg circumferentially from the dorsal midline to thecarpus. Use a hanging leg preparation, with the dog in lateralrecumbency, to allow for maximal manipulation of the shoulderjoint during surgery. The animal is positioned in lateral recum-bency with the affected leg draped.PROCEDUREApproach:1,2Use an approach to the craniolateral region ofthe shoulder joint to expose the luxated joint. It may be helpfulto reestablish normal anatomic relationships by reducing thejoint before the approach is made. Incise the skin and subcuta-neous tissue in a curvilinear fashion from the mid-scapularspine to the proximal portion of the humerus. Incise the deepfascia along the cranial border of the acromial head of the del-toideus muscle. Elevate and caudally retract the muscle withGelpi retractors. If the infraspinatus tendon is not torn, eitherincise it 5 mm from its origin or perform an osteotomy of theacromial process to facilitate reattachment. Incise the joint cap-sule, inspect the joint, and assess the condition of the humeralhead and lateral labrum of the glenoid (Plate 4A). If the labrumis worn, the prognosis for successful stabilization of theshoulder is poor and arthrodesis should be considered (seeChapter 5). Reduce the joint and identify the origin and inser-tion of the lateral glenohumeral ligament. Primary apposition ofthe torn ligament, if possible, is the method of choice for repair.If greater stability is desired, reinforcement of the repaired ligament with prosthetics may be necessary.Stabilization with the Suture Anchor System:3Drill one hole in the distal scapula at the lateral glenohumeralligament origin and a second hole at the ligament insertion onthe proximal humerus. Insert suture anchors threaded withfishing leader line into each of these holes (Plate 4B). Tie thesutures with the limb held at a normal standing angle (approxi-mately 135 degrees of extension) such that the sutures are taut,but not overly tight, avoiding plication of the joint capsule.Imbricate the capsule with nonabsorbable mattress sutures.Reattach the infraspinatus tendon with a three-loop pulley orlocking loop suture pattern. Place the scapulohumeral jointthrough a range of motion and evaluate joint stability andmobility. Closure is routine.10PART ONE•SURGICAL PROCEDURES FOR JOINT DISEASES*Bone Biter Suture Anchor System, Warsaw, Indiana. Continued CHAPTER 4STABILIZATION OF LATERAL SHOULDER LUXATION11PLATE 4Deltoideus muscle:acromial partInfraspinatusmuscleSupraspinatusmuscleTeres minormuscleJoint capsuleincisedInfraspinatusmuscleASuture anchor threadedwith two suturesinserted in humerusAnchor locked beneathcorticesB Stabilization with a Bone Tunnel and Screw andWasher Combination:4Reduce the joint, and identify theorigin and insertion of the lateral glenohumeral ligament. Drillan oblique bone tunnel through the distal scapula at the originof ligament (Plate 4C). Thread the fishing leader line throughthe bone tunnel. Drill, measure, and tap a bicortical screw holein the ligament insertion on the proximal humerus. Use a screwand washer to prevent subsidence into the soft metaphysealbone and ligature slippage. Tie the sutures in a figure-eight pat-tern, with the limb held at a normal standing angle (approxi-mately 135 degrees of extension) such that the sutures are taut,but not overly tight, avoiding plication of the joint capsule(Plate 4D). Imbricate the capsule with nonabsorbable mattresssutures. Reattach the infraspinatus tendon with a three-looppulley or locking loop suture pattern (Plate 4E). Place thescapulohumeral joint through a range of motion and evaluatejoint stability and mobility. Closure is routine.CAUTIONSThere is a high potential for concurrent chest trauma with theseinjuries. Patients should be thoroughly evaluated (e.g., withelectrocardiogram, thoracic radiographs, and blood work) andstabilized before initiating surgical repair.POSTOPERATIVE EVALUATIONThe joint should be radiographed to assess implant positioningand joint congruency. Joint stability and range of motion shouldbe evaluated at 2 and 4 weeks to assess continued need forexternal coaptation.POSTOPERATIVE CAREThe limb should be supported in a spica splint for 10 to 14 days.Passive range of motion exercises should be implemented aftersplint removal for the next 2 weeks, with concurrent exerciserestriction. Over the following 2 weeks, the animal should slowlybe returned to normal activity.EXPECTED OUTCOMEOutcome is usually fair to excellent, depending on the degree oftrauma to the joint.References1. Piermattei DL, Johnson KA: Approach to the craniolateral region of theshoulder joint. In An Atlas of Surgical Approaches to the Bones andJoints of the Dog and Cat, 4th ed. Philadelphia, WB Saunders, 2004.2. Piermattei DL, Johnson KA: Approach to the lateral aspect of thehumeral condyle and epicondyle. In An Atlas of Surgical Approachesto the Bones and Joints of the Dog and Cat, 4th ed. Philadelphia, WBSaunders, 2004.3. Slocum B, Slocum TD: Suture stabilization for luxations of theshoulder. In Bojrab MJ (ed): Current Techniques in Small AnimalSurgery, 4th ed. Baltimore, Williams & Wilkins, 1998.4. Engen MH: Surgical treatment of shoulder luxations. In Bojrab MJ(ed): Current Techniques in Small Animal Surgery, 4th ed. Baltimore,Williams & Wilkins, 1998.12PART ONE•SURGICAL PROCEDURES FOR JOINT DISEASES CHAPTER 4STABILIZATION OF LATERAL SHOULDER LUXATION13PLATE 4Tendon ofinfraspinatusmuscleCDE SHOULDERCHAPTER 5Shoulder ArthrodesisINDICATIONSThis procedure is used for animals with unreconstructable jointfractures, chronic shoulder luxation, or severe osteoarthritisthat is refractory to medical treatment.1OBJECTIVES• To fuse the bones of the scapulohumeral joint in a functionalpositionANATOMIC CONSIDERATIONSThe greater tubercle of the humerus and the acromion of thescapula are palpable landmarks. Osteotomy of the acromionallows reflection of a portion of the deltoideus muscle and visu-alization of the joint. Osteotomy of the greater tubercle alsoaids joint exposure and provides a flat surface for the plate. Thesuprascapular nerve and artery course over the scapular notchand under the acromion. The axillary artery and nerve arelocated immediately caudal to the joint, but these are not usu-ally visualized with this approach.EQUIPMENT• Surgical pack, Senn retractors, Hohmann retractors, Gelpiretractors, periosteal elevator, oscillating saw, self-centeringplate-holding forceps, high-speed drill and wire driver,Kirschner wires, wire cutter, orthopedic wire, wire twister,plating equipment, and rongeursPREPARATION AND POSITIONINGPrepare the forelimb circumferentially from dorsal midline tomid-radius. Position the animal in lateral recumbency with theaffected limb up. Drape the limb out from a hanging position toallow maximal manipulation during surgery. A cancellous bonegraft can be harvested from the ostectomized humeral head.PROCEDUREApproach: Incise the skin and subcutaneous tissue over thecranial lateral aspect of the shoulder from the distal one third ofthe scapula to the proximal one third of the humerus.Osteotomize the acromion and retract the deltoideus muscledistally and caudally. Osteotomize the greater tubercle and ele-vate the supraspinatus muscle proximally. Incise the infra-spinatus, teres minor, and biceps brachii tendons and the jointcapsule to expose the articular surfaces (Plate 5A).2Alignment: Predetermine the cranial caudal angle for theshoulder arthrodesis by observing the normal standing angle ofthe shoulder in the individual patient. This angle is commonly110 degrees (Plate 5B).1,2Stabilization: Remove the articular surface of the scapulawith an oscillating saw directed perpendicular to the spine of thescapula. Flex the shoulder to the predetermined angle and performan ostectomy of the humeral head. The humeral ostectomy shouldparallel the ostectomy surface of scapula when the shoulder isflexed to the appropriate angle (see Plate 5B). Appose the distalscapular and the proximal humeral ostectomy surfaces, andtemporarily fix them with Kirschner wires (Plate 5C). Use an alu-minum template to determine the cranial contour of the junctionof the spine and body of the scapula and the cranial aspect of theproximal humerus. Use the bending pliers and the torque irons tocontour an appropriately sized bone plate (allowing at least threescrews proximally and distally to the shoulder) to match the alu-minum template. Apply the plate by first placing screws throughthe proximal and distal plate holes. Place a lag screw through theplate and across the ostectomy surfaces (see Plate 5C). Fill theremaining plate holes, directing the proximal screws into the thickbone at the junction of the spine and body of the scapula (Plate5D). Remove the Kirschner wires. Collect cancellous bone fromthe ostectomized humeral head with rongeurs and place it aroundthe ostectomy surfaces. Reattach the biceps brachii tendon to the fascia of the supraspinatus muscle. Attach the greatertubercle to the humerus lateral to the plate with a lag screw (seePlate 5D). Wire the acromion.1,2Close the wound routinely.CAUTIONSThe suprascapular nerve and artery must be protected duringthe procedure, and care must be taken not to trap the nerveunder the plate. Medial and lateral angulation of the saw bladeshould be avoided when performing the scapular and humeralarticular ostectomies. Angular and rotational alignment of thelimb should be checked carefully before the plate is secured.POSTOPERATIVE EVALUATIONThe axial alignment of the limb and the angle of the arthrodesisshould be observed critically. Radiographs for limb alignmentand implant placement should be evaluated.POSTOPERATIVE CAREA soft padded bandage should be placed around the forelimband over the scapula to control bleeding and swelling. Thearthrodesis site should be protected with a spica splint for 6weeks or until early radiographic evidence of bone bridging isobserved. Radiographs should be repeated at 6-week intervalsuntil bone healing occurs. The animal should be confined, withactivity limited to leash walks until bone healing is complete.Barring complications, the plate should not be removed.EXPECTED OUTCOMEThe bone should heal in 12 to 18 weeks. Satisfactory function ofthe treated limb can be expected as long as the elbow andcarpus are free of disease.References1. Johnson KA: Arthrodesis. In Olmstead ML (ed): Small AnimalOrthopedics. St. Louis, Mosby, 1995.2. Piermattei DL, Flo GL: The shoulder joint. In Brinker, Piermattei,and Flo’s Handbook of Small Animal Orthopedics and FractureRepair, 3rd ed. Philadelphia, WB Saunders, 1997.14PART ONE•SURGICAL PROCEDURES FOR JOINT DISEASES CHAPTER 5SHOULDER ARTHRODESIS 15PLATE 5BCD110ºInfraspinatus muscleTeres minor muscleSpinous head ofdeltoideus muscleSupraspinatus muscleJoint capsuleincisedOsteotomy siteTendon of bicepsbrachii muscle cutAcromial head ofdeltoideus muscleA ELBOWCHAPTER 6Process and Osteochondrosis of the ElbowFragmented Medial CoronoidINDICATIONS1The ideal candidates for this surgery are dogs with persistentlameness that exhibit minimal degenerative changes to the jointon radiographs. Dogs with severe degenerative joint diseaseand persistent lameness that are not responsive to conservativemanagement and nonsteroidal anti-inflammatory drugs mayalso benefit from joint exploration, loose fragment excision,and osteophyte curettage.OBJECTIVES• To improve function and limit pain stemming fromosteoarthritis and elbow incongruityANATOMIC CONSIDERATIONS2The elbow joint is exposed through a medial approach. Themedial epicondyle and the pronator teres and flexor carpi radi-alis muscles are key anatomic landmarks for this approach. Themedian nerve, brachial artery, and ulnar nerve are located justproximal to the epicondyle. The median nerve and brachialartery and vein course cranially to the medial epicondyle. Theulnar nerve courses caudally to the me...

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