Description and outcome of prosthetic ligament placement for stabilization of medial or dorsomedial tarsometatarsal joint luxation in dogs and cats: 16 cases (2004–2017)

Amber L. Gunstra 1Southwest Veterinary Surgical Service, Arizona Veterinary Specialty Center, 86 W Juniper Ave, Ste 4, Gilbert, AZ 85233.

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Jeffrey A. Steurer 1Southwest Veterinary Surgical Service, Arizona Veterinary Specialty Center, 86 W Juniper Ave, Ste 4, Gilbert, AZ 85233.

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Bradford C. Dixon 1Southwest Veterinary Surgical Service, Arizona Veterinary Specialty Center, 86 W Juniper Ave, Ste 4, Gilbert, AZ 85233.

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Rachel L. Siebert 2Charleston Veterinary Referral Center, 3484 Shelby Ray Ct, Charleston, SC 29414.

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Abstract

OBJECTIVE

To describe prosthetic ligament placement for reduction and stabilization of medial or dorsomedial tarsometatarsal joint luxation in dogs and cats and to report complications and postoperative outcomes for patients that underwent that procedure.

ANIMALS

14 dogs and 2 cats with medial or dorsomedial tarsometatarsal joint luxation.

PROCEDURES

The electronic database of a referral surgery practice was searched to identify records of dogs and cats with tarsometatarsal joint luxation that underwent prosthetic ligament placement between January 2004 and March 2017. For each study subject, information extracted from the medical record included signalment, a description of the tarsometatarsal joint injury, durations of anesthesia and surgery, and intraoperative and postoperative care and complications. Radiographic images were also reviewed. The long-term outcome for study subjects was assessed by administration of a standardized questionnaire to owners.

RESULTS

Prosthetic ligament placement 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 or catastrophic complications were reported. All 13 owners who completed the questionnaire perceived that the described technique resulted in satisfactory long-term function for their pets.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggested that prosthetic ligament placement was a technically simple procedure that achieved satisfactory long-term stabilization of the tarsometatarsal joint in small animal patients with medial or dorsomedial luxation of the joint. Prosthetic ligament placement may be an alternative to arthrodesis for tarsometatarsal joint stabilization in appropriate patients.

Abstract

OBJECTIVE

To describe prosthetic ligament placement for reduction and stabilization of medial or dorsomedial tarsometatarsal joint luxation in dogs and cats and to report complications and postoperative outcomes for patients that underwent that procedure.

ANIMALS

14 dogs and 2 cats with medial or dorsomedial tarsometatarsal joint luxation.

PROCEDURES

The electronic database of a referral surgery practice was searched to identify records of dogs and cats with tarsometatarsal joint luxation that underwent prosthetic ligament placement between January 2004 and March 2017. For each study subject, information extracted from the medical record included signalment, a description of the tarsometatarsal joint injury, durations of anesthesia and surgery, and intraoperative and postoperative care and complications. Radiographic images were also reviewed. The long-term outcome for study subjects was assessed by administration of a standardized questionnaire to owners.

RESULTS

Prosthetic ligament placement 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 or catastrophic complications were reported. All 13 owners who completed the questionnaire perceived that the described technique resulted in satisfactory long-term function for their pets.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggested that prosthetic ligament placement was a technically simple procedure that achieved satisfactory long-term stabilization of the tarsometatarsal joint in small animal patients with medial or dorsomedial luxation of the joint. Prosthetic ligament placement may be an alternative to arthrodesis for tarsometatarsal joint stabilization in appropriate patients.

The tarsus is a complex compound joint with multiple stabilizing ligaments.1 The primary stabilizing structures of the tarsus are the medial and lateral collateral ligaments, calcaneoquartal ligament, joint capsule and thick plantar fibrocartilage, and plantar ligaments including the long plantar ligament, calcaneocentral ligament, and plantar centrodistal ligament.1 There are also multiple intertarsal ligaments that provide support between the numerous bones of the tarsus and metatarsus.1 The intricate anatomy of the tarsus is well described in the veterinary literature.1–4 Tarsal ligaments are susceptible to both degenerative and traumatic injuries.5,6 Luxation or subluxation of the tarsometatarsal joint is reportedly uncommon and usually traumatic in nature.6,7 Trauma to the tarsometatarsal joint can result in instability in various planes depending on the anatomic structures affected by the injury.6,8 Hyperextension injuries result from trauma to the plantar stabilizing structures and consequently cause marked instability.6,8 Traumatic injuries to the tarsometatarsal joint can cause instability in the lateral, medial, or dorsal planes or any combination of those planes.6,8 However, the plantar structures generally remain intact following traumatic injuries, so there is less joint displacement observed during weight bearing than with hyperextension injuries.6,8 Small animal patients with tarsometatarsal joint luxations and intact plantar support structures often have clinical signs of pain and variable lameness referable to the affected limb and swelling of the affected tarsus.6 For such patients, stress radiography is usually necessary to diagnose the luxation and the plane of instability.9

Multiple surgical methods have been described for the treatment and stabilization of tarsometatarsal joint luxations and subluxations in small animal patients. Arthrodesis is the recommended treatment for hyperextension injuries that result in loss of plantar support to the tarsometatarsal joint.8 Techniques for arthrodesis of the tarsometatarsal joint include plate fixation, external skeletal fixation, cross pins, tarsometatarsal intramedullary pin stabilization, a pin and tension band, and lag screws.8,10–20 Arthrodesis is also a treatment option for luxations with intact plantar support structures, but other treatment alternatives such as a pin and tension band, external fixation, bone plates, and prosthetic ligaments have also been described.8,16,21–23 Use of a prosthetic ligament consisting of bone screws and orthopedic wire or nylon suture has been described as a method of arthrodesis in a veterinary orthopedic surgery textbook.8 A similar albeit modified and simpler procedure that does not result in arthrodesis has been described in a racing Greyhound with a tarsometatarsal joint luxation.23 However, to our knowledge, the long-term outcome for patients undergoing that procedure has not been evaluated. The objective of the study reported here was to describe a prosthetic ligament placement technique for treatment of medial or dorsomedial tarsometatarsal joint luxations in dogs and cats as well as the associated complications and postoperative outcomes for patients that underwent that procedure. We hypothesized that prosthetic ligament placement would adequately stabilize the tarsometatarsal joint and be a suitable alternative to arthrodesis for dogs and cats with medial or dorsomedial tarsometatarsal joint luxations.

Materials and Methods

Case selection criteria

The electronic medical record database of the Southwest Veterinary Surgical Service was searched to identify records of dogs and cats with a diagnosis of tarsometatarsal joint luxation between January 2004 and March 2017. Patients with tarsometatarsal joint luxation in the medial or dorsomedial plane that underwent prosthetic ligament placement for joint stabilization were included in the study. Patients were excluded from the study if the luxation did not involve the tarsometatarsal joint exclusively, was in a plane other than the medial or dorsomedial plane, or was repaired by a method other than prosthetic ligament placement. Patients were also excluded from the study if they had concurrent injury to the tarsus or pes, as identified on radiographic images or during surgery, that required treatment in addition to prosthetic ligament placement.

Medical records review

For each patient eligible for study inclusion, information extracted from the medical record included signalment, cause and duration of tarsometatarsal joint injury, durations of anesthesia and surgery, and description of tissue injury observed intraoperatively, implants used for joint stabilization, and postoperative care (including any supportive coaptation used) and complications. All patients underwent stress radiography prior to surgery to evaluate the severity of the tarsometatarsal joint injury and the plane of luxation (Figure 1) and postoperatively to assess surgical method, reduction, and alignment. All radiographic images were reviewed. Concurrent injuries to structures other than the tarsometatarsal joint were recorded on the basis of review of the radiographic images and surgery reports. Radiographic images and medical records were also reviewed for evidence of intraoperative or postoperative complications. Postoperative complications were defined as minor (complications that did not require additional treatment for resolution), major (complications that required additional surgical or medical treatment for resolution), or catastrophic (complications that caused permanent unacceptable function or directly contributed to the death or euthanasia of the patient) as recommended by Cook et al.24

Figure 1—
Figure 1—

Craniocaudal medial-stress (A) and mediolateral dorsal-stress (B) radiographic images of the right tarsus of a 6-year-old 6.4-kg (14-lb) spayed female Havanese with medial luxation of the tarsometatarsal joint. A large syringe case was used to apply bending force to the medial and plantar aspects of the tarsus just proximal to the tarsometatarsal joint to facilitate visualization of the extent and severity of joint luxation. R = Right.

Citation: Journal of the American Veterinary Medical Association 255, 3; 10.2460/javma.255.3.336

Surgical procedure

For each patient, a skin incision was made on the medial aspect of the tarsometatarsal joint. The surgical site was explored to evaluate ligament injury and confirm luxation. Primary repair of the damaged ligaments was not attempted. Unlike the similar arthrodesis procedure,8 the cartilage at the tarsometatarsal junction was preserved. The central tarsal bone and base of the second metatarsal bone were identified (Figure 2). Surgical debridement of fibrotic scar tissue was necessary in some patients to achieve anatomic reduction of the luxated joint. Implants were selected on the basis of patient size and surgeon preference. In general, the diameter of the cortical screw selected did not exceed 30% of the diameter of the base of the second metatarsal bone.8 A drill bit equal in size to the core diameter of the selected screw was used to drill a guide hole into the central tarsal bone as well as the fourth tarsal bone when possible. The depth of the guide hole was measured, and an appropriate self-tapping cortical bone screw with washer was placed but not completely tightened. A second screw and washer were placed into the base of the second metatarsal bone and extended into the third and fourth metatarsal bones when possible.8 Orthopedic wire or monofilament nylon suture (the size of which was selected on the basis of surgeon discretion) was wrapped around the 2 screws in a figure eight pattern and tightened to achieve and maintain joint reduction. Orthopedic wire was used in all study subjects except 1; the wire was twisted until the desired tension was achieved and then cut, leaving at least 3 wire twists. Forty-pound monofilament nylon suture was used in the remaining patient (a cat); the suture was secured with a surgeon knot with an overlapping square knot to achieve and maintain joint reduction. The screws and washers were tightened over the wire or nylon suture (Figure 3), and the surgical site was lavaged with sterile saline (0.9% NaCl) solution. The incision was closed in a routine manner with the subcutaneous tissue and skin closed in separate layers. Postoperative radiographs of the affected joint were obtained to confirm implant placement, joint reduction, and appropriate alignment (Figure 4).

Figure 2—
Figure 2—

Intraoperative photograph of the medial aspect of the left tarsometatarsal region of a 9-year-old 9.1-kg (20-lb) spayed female Chihuahua-mix dog prior to reduction and stabilization of a medial luxation of the tarsometatarsal joint by prosthetic ligament placement. Medial luxation of the tarsometatarsal joint is evident by the separation of the tarsal bones from the base of the second metatarsal bone. The distal aspect of the limb was wrapped with sterile self-adhesive bandage material, and a calibrated scalpel handle was included in the image for reference.

Citation: Journal of the American Veterinary Medical Association 255, 3; 10.2460/javma.255.3.336

Figure 3—
Figure 3—

Intraoperative photograph of the medial aspect of the left tarsometatarsal joint of the dog in Figure 2 following prosthetic ligament placement. A 2.0-mm cortical screw with a 4.5-mm washer was placed in the central tarsal bone and the base of the second metatarsus. Twenty-two–gauge orthopedic wire was wrapped around the 2 screws in a figure eight pattern and tightened to achieve and maintain joint reduction. The wire was twisted until the desired tension was achieved and then cut, leaving at least 3 wire twists. The screws and washers were tightened over the wire. See Figure 2 for remainder of key.

Citation: Journal of the American Veterinary Medical Association 255, 3; 10.2460/javma.255.3.336

Figure 4—
Figure 4—

Representative postoperative craniocaudal (A) and mediolateral (B) radiographic images of the right tarsus of a 10-year-old 37-kg (81.4-lb) male Labrador Retriever following prosthetic ligament placement for stabilization of medial luxation of the tarsometatarsal joint. A 3.5-mm cortical screw and 7-mm washer were placed in the central tarsal bone and the base of the second and third metatarsal bones, and 16-gauge orthopedic wire was wrapped around the screws in a figure eight pattern. The skin incision on the medial aspect of the tarsus was closed with staples. R = Right.

Citation: Journal of the American Veterinary Medical Association 255, 3; 10.2460/javma.255.3.336

All study subjects had external coaptation applied to the affected limb following surgery. Bandages were changed as clinically indicated (generally every 7 to 10 days) for the duration of postoperative bandaging, which ranged from 10 days to 6 weeks.

Long-term patient outcome

To ensure that uniform information was obtained for all patients, a standardized questionnaire was developed for administration to study subject owners. The owner of each study subject was contacted by telephone or email and asked to assess the function of and frequency of lameness in the affected limb of the patient following surgery as well as the patient's tolerance of the postoperative bandages. Postoperative function was classified as full, acceptable, or unacceptable as previously described.24 Owners were also asked whether they had sought care related to the affected limb at another hospital following the surgery, whether the implants had been removed, or whether they would choose to have the surgery performed again.

Results

Animals

Fourteen dogs and 2 cats were included in the study. The study population included 9 spayed females, 6 neutered males, and 1 sexually intact male and had a mean age of 6 years (range, 2 to 15 years) and body weight of 12.8 kg (28.2 lb; range, 2.6 to 37 kg [5.7 to 81.4 lb]). There was 1 domestic longhair cat (body weight, 6.6 kg [14.5 lb]), 1 domestic shorthair cat (body weight, 5.2 kg [11.4 kg]), 3 mixed-breed dogs, 2 Golden Retrievers, 2 Shih Tzus, 2 Chihuahuas, and 1 each of the following breeds: Havanese, Labrador Retriever, Maltese, Miniature Pinscher, and Vizsla.

Radiographic findings

Preoperative and postoperative radiographic images were available for all 16 study subjects. Review of the preoperative stress-view radiographs confirmed that 9 and 7 patients had medial and dorsomedial luxations of the tarsometatarsal joint, respectively. Five patients had concurrent local injuries. One had a fracture of the fourth tarsal bone. One had a fracture of both the second and fourth tarsal bones. One had a fracture at the base of the second metatarsal bone. One had a fracture at the base of the fourth metatarsal bone, and 1 had a fracture at the base of the fifth metatarsal bone. No additional surgical procedures were performed for any of those 5 patients because adequate joint stability was achieved with the prosthetic ligament and external coaptation (bandaging).

Surgical findings

All surgical procedures were performed by a board-certified veterinary surgeon. One surgeon (BCD) performed 13 of the 16 procedures, and 2 other surgeons (JAS and 1 other surgeon no longer with the institution) performed the remaining 3 procedures. Implants were selected on the basis of patient size and surgeon discretion (Supplementary Table S1, available at avmajournals.avma.org/doi/suppl/10.2460/javma.255.3.336). Implants consisted of cortical bone screws (diameter range, 1.5 to 3.5 mm), washers (diameter range, 4.5 to 7 mm; a 1.5/20-mm cuttable plate was used to fashion washers for 1 patient owing to unavailability of suitably sized washers), and orthopedic wire (size range, 16 to 24 gauge) or 40-lb monofilament nylon suture. The mean durations of anesthesia and surgery were available for 14 of the 16 patients. The mean duration of anesthesia was 98 minutes (range, 60 to 195 minutes), and the mean duration of surgery was 30 minutes (range, 20 to 57 minutes).

Postoperative management and outcome

External coaptation was applied to the affected limb of all patients following surgery and the acquisition of postoperative radiographs. Three patients had a modified Robert Jones bandage applied to the affected limb, whereas the remaining 13 patients had a modified Robert Jones bandage with an additional supportive thermoplastic splinta placed on the lateral or plantarolateral aspect of the pes. The external coaptation was left in place for a mean of 4 weeks (range, 10 days to 6 weeks).

All 16 patients had at least 1 follow-up examination performed between 10 and 14 days after surgery, which included suture removal. Fourteen patients had an additional follow-up examination performed at approximately 6 weeks after surgery (range, 3 to 8 weeks after surgery).

Follow-up radiographs were available for review for 12 patients, and those radiographs were obtained at a mean of 6 weeks after surgery (range, 4 to 10 weeks after surgery). For all 12 patients, the affected tarsometatarsal joint was palpably stable during physical examination, and the follow-up radiographs indicated that the prosthetic ligament had maintained proper joint reduction and alignment. For 2 patients, radiographs of the affected joint were obtained again when the animals were examined for lameness that was attributed to stifle joint abnormalities 10 months and 4 years after prosthetic ligament placement to stabilize the tarsometatarsal joint. In both of those patients, the tarsometatarsal joint and implants appeared stable and functional. Follow-up radiographs were not obtained for 4 patients (a 2-year-old 6.3-kg [13.9-lb] neutered male Terrier-mix dog, 3-year-old 7-kg [15.4-lb] spayed female Chihuahua-mix dog, 6-year-old 8.5-kg [18.7-lb] neutered male Shih Tzu, and 6-year-old 6.4-kg [14.1-lb] spayed female Havanese).

Intraoperative complications were reported for 2 patients. For both patients, inadequate tarsometatarsal joint stability was observed intraoperatively, and placement of a second prosthetic ligament with a more dorsal orientation resulted in appropriate joint reduction and stabilization. Thus, those 2 patients had one prosthetic ligament placed at the medial aspect and another at the dorsomedial aspect of the affected tarsometatarsal joint.

Minor postoperative complications were reported for 6 patients. Five patients developed dermatitis or superficial cutaneous ulcerations that were attributed to the bandage. In all 5 of those patients, the lesions resolved following removal of the bandage with no additional treatment. For 1 patient, the follow-up radiographs obtained 8 weeks after surgery revealed that the orthopedic wire had broken. The patient had good limb function, and the tarsometatarsal joint was palpably stable, so no further treatment was performed. No major or catastrophic complications were reported.

Owners for 13 of the 16 study subjects were successfully contacted and completed the standardized questionnaire. The mean follow-up time after surgery was 49 months (range, 6 to 126 months). Eight owners reported their pet had regained full function and 5 owners reported that their pet had regained acceptable function of the affected limb following surgery. None of the owners reported poor function of the affected limb following surgery, poor tolerance of the postoperative bandages, or the need for additional veterinary care for the affected joint or implant removal. All 13 owners stated that they would have the procedure performed again if indicated.

Discussion

In the present study, all 14 dogs and 2 cats evaluated with medial or dorsomedial luxation of a tarsometatarsal joint were successfully treated by use of a prosthetic ligament to achieve reduction and stabilization of the affected joint. The study subjects varied in size and body weight. Most of the subjects weighed < 25 kg (55 lb), although there were 4 dogs that weighed > 25 kg, with the heaviest weighing 37 kg. However, no giant-breed dogs were included in the study, and we cannot make any conclusions regarding the efficacy of the described procedure in patients that weigh > 37 kg. The implants used to create the prosthetic ligaments varied in size on the basis of patient size and surgeon preference. Orthopedic wire was used in the majority (15/16) of patients. Heavy-gauge (40-lb) monofilament nylon suture was used in 1 patient (a 5.2-kg cat) owing to its fairly small size. Few studies have compared the mechanical properties between prosthetic ligaments created with orthopedic wire and those created with monofilament nylon suture. In a study25 in which load to failure was assessed for sternotomy closures in canine cadavers, the yield, maximum load, stiffness, and displacement did not differ significantly between constructs with 20-gauge orthopedic wire and those with 80-lb monofilament nylon suture. Direct comparison of the implants used in the present study with the 80-lb monofilament nylon suture and 20-gauge orthopedic wire constructs used in the canine sternotomy study25 would not be appropriate. Nevertheless, we believe that orthopedic wire and monofilament nylon suture are both suitable for use as prosthetic ligaments but have the potential for cyclic failure even when used for a low-motion application such as stabilization of the tarsometatarsal joint, as evident by the fact that the orthopedic wire failed within 8 weeks after surgery for one of the patients of the present study.

Five of the patients evaluated in the present study had concurrent fractures of the ipsilateral tarsal bones or base of 1 or more ipsilateral metatarsal bones. However, those fractures did not affect the stability of the tarsometatarsal joint or the surgical technique performed and did not require any additional surgical stabilization. Careful evaluation of radiographs, including stress-view images, was imperative for appropriate patient assessment and successful application of the described prosthetic ligament technique.

For most patients of the present study, maintenance of tarsometatarsal joint reduction and stability by the prosthetic ligament were confirmed during follow-up examination and radiography, which were typically performed a mean of 6 weeks after surgery. A 6-week recovery time is less than that reported for other surgical methods used to stabilize the tarsometatarsal joint.14,18,21,26 In a study26 in which veterinary cuttable plates were used for carpal or tarsal arthrodesis in small dogs and cats, radiographic evidence of bone fusion was observed in only 6 of 9 patients at 2.3 months after surgery. In a case series18 of dogs and cats in which intramedullary and cross pins were used for arthrodesis of a tarsometatarsal joint, it took 6 to 11 weeks for adequate bone fusion to develop and stabilize the joint. In studies14,21 in which external fixators were used for arthrodesis of a tarsometatarsal joint, it took 11 to 28 weeks for adequate bone fusion to develop and stabilize the joint. We suspect that the tarsometatarsal joint stability achieved by the prosthetic ligament procedure described for the patients of the present study was the result of fibrous ankylosis rather than arthrodesis. Thus, joint stability was not dependent on bone fusion and was achieved more rapidly. Additionally, the prosthetic ligament technique used for the patients of the present study preserved the joint cartilage and caused less disruption of the joint's vascular supply and adjacent soft tissues than arthrodesis procedures, which facilitated rapid recovery from the procedure.

The owners of 13 of the 16 patients evaluated in the present study were successfully contacted and provided follow-up information about their pets. The mean time since surgery was 49 months (approx 4 years) at the time of follow-up. All 13 owners reported that their pet had regained full or acceptable function of the affected limb and would choose to have the procedure performed again if necessary. The questionnaire administered to the pet owners in this study was standardized but not validated; therefore, the responses were inherently subjective and need to be interpreted cautiously. Although various objective or semiobjective scoring scales, such as the Canine Brief Pain Inventory27 and Liverpool Osteoarthritis in Dogs28 score, have been validated for owner assessment of pain and mobility in dogs with arthritis, we did not believe use of those tools would adequately provide the postoperative information we were seeking for the patients of the present study. We believe that the standardized questionnaire used, although subjective, provided us a better assessment of the owner's satisfaction with the prosthetic ligament procedure and their pet's recovery.

Intraoperative and minor postoperative complications were reported for 2 and 6 patients, respectively, of the present study. No major or catastrophic complications that necessitated additional surgery or resulted in the death or euthanasia of a patient were reported. The most common postoperative complication was dermatitis or pressure sores caused by the external coaptation (bandage). The proportion of patients (5/16 [31%]) that developed complications as a result of the postoperative bandage in the present study was similar to that (range, 20% to 37.5%) reported in other studies.12,17,26,29 However, the mean duration of postoperative external coaptation (approx 4 weeks) for the patients of the present study was less than that for patients in comparable studies. External coaptation is commonly used for 4 to 24 weeks in patients that undergo plate arthrodesis techniques.13,26,29 Because prolonged bandaging is often associated with postoperative complications, limiting the duration of postoperative coaptation will likely decrease both the frequency and severity of bandage-related complications.17 For the patients of the present study, bandage-associated dermatitis and ulcerations resolved following bandage removal and did not affect joint stabilization or long-term outcome. Additionally, the surveyed owners indicated that their pets tolerated the bandages well, even those pets that developed minor bandage-associated complications.

The lack of major or catastrophic complications associated with the prosthetic ligament procedure described in the present study was in contrast to other surgical procedures for tarsometatarsal joint stabilization. In a study29 in which bone plates were used for pantarsal and partial tarsal arthrodesis, 13 of 40 (32.5%) dogs developed major complications, most commonly necrosis at the plantar aspect of the repair, which required surgical debridement. In a study30 of 14 working dogs that underwent partial tarsal arthrodesis, 3 (21%) developed major complications that necessitated implant removal. In another study,12 implant removal was necessary for 3 of 10 (30%) dogs that had a bone plate applied to the lateral aspect of the tarsometatarsal joint for arthrodesis. Implant removal was not necessary for any of the patients evaluated in the present study. Unfortunately, the definitions for major postoperative complications differed among those other studies12,29,30 and the present study; therefore, comparison of major complications between studies is challenging and should be done with caution. Nevertheless, we suspect that the discrepancy in the incidence of major complications between prosthetic ligament placement and plate arthrodesis was the result of differences in the surgical methods. Compared with prosthetic ligament placement, plate arthrodesis requires more soft tissue dissection and vascular disruption and involves the use of larger implants, which, owing to the limited soft tissue structures in the tarsometatarsal region, makes surgical closure more difficult.10 Iatrogenic vascular injury, excessive wound tension, and postoperative swelling are believed to contribute to the development of plantar necrosis in dogs that undergo plate arthrodesis.29 On the basis of our clinical experience, prosthetic ligament placement requires minimal tissue dissection and less substantial implants than plate arthrodesis. Implants used for prosthetic ligament placement have a fairly low profile, and difficulty with tissue closure over the implants was not reported for any of the patients evaluated in the present study. Moreover, the mean time required for prosthetic ligament placement was 30 minutes, which we believe is substantially less than that typically required to perform arthrodesis techniques. The fairly short surgery time required for prosthetic ligament placement likely contributed to the low complication rate reported for the patients of this study because anesthesia and surgical durations are positively associated with the risk of surgical site infections.31 However, we cannot rule out that the low number of minor complications reported in the present study was simply a reflection of the fairly small study population.

Multiple methods for stabilization of tarsometatarsal joint luxations have been described, including arthrodesis by use of bone plates, external fixation, intramedullary pins, lag screws, pins and tension bands, and cross pins.8,10,14,18–20 Compared with other stabilization methods, bone plate placement requires more soft tissue dissection and may lack a mechanical advantage because the plate is placed on the lateral aspect of the joint and it is the medial aspect of the joint that sustained injury and increased tension forces in the patients included in the current study.10,32 In a case series30 of 14 dogs that underwent partial tarsal arthrodesis, the method used to achieve arthrodesis (eg bone plate, pin and tension band, and lag screws with cross pins) did not appear to significantly affect long-term patient outcome. In dogs and cats, titanium plating systems have been used for arthrodesis and internal splints.15,22 The use of titanium plates, or any locking-plate system, requires additional specialized equipment such as screws, drill guides, and bending devices.33,34 Use of external fixation for successful arthrodesis or ankylosis of the tarsometatarsal joint has been described in dogs.14,19–21 Complications reported in those studies14,19–21 included implant loss, pin-tract discharge, poor patient tolerance of implants, and osteomyelitis. Unfortunately, descriptions of the use of internal and external fixation methods for stabilization of tarsometatarsal joint luxations in small animal patients have involved individual-animal case reports or case series with a very small number of animals (including the present study); therefore, making comparisons among methods is difficult. Additional studies comparing prosthetic ligament placement to other methods of stabilization for medial or dorsomedial instability of the tarsometatarsal joint are necessary to determine whether the method of stabilization is associated with the development of postoperative complications and healing time as we suspect. The use of external coaptation alone for stabilization of tarsometatarsal joint luxation, although not evaluated in the present study, is generally expected to be unsuccessful.8,16,17

Prosthetic ligament placement methods similar to that described in the present study have been described for stabilization of the tarsocrural, carpal, elbow, stifle, and shoulder joints of small animal patients with variable success for long-term function.7,8,35–41 The prosthetic ligament placement method described in the present study resulted in successful tarsometatarsal joint reduction and stabilization and full or acceptable long-term function in all 16 patients without any major or catastrophic postoperative complications. It is likely that the high success rate for the patients of this study was at least partially due to the low motion of the tarsometatarsal joint. Additionally, only patients with medial or dorsomedial tarsometatarsal joint luxations and intact plantar ligaments were eligible for inclusion in the present study. The tarsus of healthy dogs and cats sustains the greatest tension on its plantar aspect, and injury to the plantar stabilizing structures typically causes marked instability and requires application of a robust stabilization method.6,8,31 Thus, we believe the primary disadvantage of the prosthetic ligament technique described for tarsometatarsal joint stabilization in this study is the inability to adequately stabilize injuries that involve plantar support structures or trauma to multiple areas of the tarsus or pes.

Results of the present study indicated that prosthetic ligament placement can be used to successfully reduce and stabilize medial and dorsomedial tarsometatarsal joint luxations in dogs and cats. All owners surveyed perceived that the described technique resulted in satisfactory long-term function for their pets and would elect to have the procedure performed again if necessary. Benefits of prosthetic ligament placement for tarsometatarsal joint stabilization relative to arthrodesis with bone plates or external fixation include minimal tissue dissection and vascular disruption and manipulation, shorter surgery and anesthesia durations, fewer postoperative complications, fairly quick recovery, and no need for specialized plating systems or equipment. Limitations of the present study were those typical of any retrospective study, namely a small study population and the lack of a control or comparison population. Although the study subjects were evaluated retrospectively, potential variation was minimized by the fact that the same technique was performed by the same surgeon in 13 of the 16 patients. Further research is warranted to compare tarsometatarsal joint stabilization methods and develop guidelines for surgical case selection.

Acknowledgments

No third-party funding or support was received in connection with this study or the writing or publication of the manuscript. The authors declare that there was no conflict of interest.

Footnotes

a.

X-Lite Low-Temperature Thermoplastic, Allard USA Inc, Rockaway, NJ.

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