Introduction
Pantarsal arthrodesis is a surgical procedure that can be performed to salvage limb function and alleviate pain in dogs with irreparable musculoskeletal abnormalities affecting the talocrural, intertarsal, and tarsometatarsal articulations. Pantarsal arthrodeses are most commonly stabilized using plates and screws. Plating confers rigid fixation and often yields favorable functional outcomes, but complication rates of 58% to 75% have been reported with these procedures.1,2 Complications associated with plated pantarsal arthrodeses include vascular compromise,1–3 pressure wounds incited by application of supplemental postoperative external coaptation that is often advocated following plate stabilization,2 implant failure, failure to obtain osseous union, and infection, which may necessitate implant removal.1,2,4,5
Circular external skeletal fixation (CESF) is an alternative stabilization modality that can be used to perform arthrodeses.6–12 Circular constructs can be 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.13–15 In addition, the use of a circular construct obviates the need for supplemental postoperative external coaptation. All fixation elements can be removed without surgical approach once union of the arthrodesis has been obtained.5–12 Circular constructs have been used to perform talocrural and tarsometatarsal arthrodesis,8–11 but there is only 1 reported dog in which CESF was used to stabilize a pantarsal arthrodesis12; that dog was reported to have an excellent return to function, although wire-skin interface inflammation developed postoperatively.12 The objective of this descriptive case series was to report the indications, surgical technique, complications, and outcomes of 8 dogs with uni- or multilevel tarsal instabilities undergoing pantarsal arthrodeses stabilized by CESF.
Methods
Medical records for dogs that had a pantarsal arthrodesis stabilized with CESF between 2010 and 2023 from the University of Florida Small Animal Hospital and between 2017 and 2023 from the Animal Referral Hospital Brisbane were reviewed (one hospital was located in the US and one in Australia). Cases were included if records could be retrieved describing the surgical technique and postoperative monitoring until fixator removal. Five cases were obtained from the University of Florida Small Animal Hospital, and 3 cases were obtained from the Animal Referral Hospital Brisbane. The clinical records were reviewed to obtain each dog’s signalment, history, physical examination findings, anesthetic and analgesic protocols, antimicrobial use, and surgical technique, and to ascertain each dog’s progress during the postoperative convalescent period, including the development of complications. Initial and follow-up postoperative radiographs were reviewed. Fixation-element tract issues requiring intervention beyond local care and systemic antibiotic administration were considered complications. Owners were contacted by phone to determine long-term clinical outcomes, which were characterized as the following: excellent (consistently fully weight-bearing with subtle gait abnormality), good (occasional weight-bearing lameness), acceptable (frequent weight-bearing lameness), or poor (intermittent or consistent non–weight-bearing lameness).
Results
The dogs’ ages ranged from 5 months to 13 years (mean, 5.5 years), and body weights ranged from 2.5 to 26.4 kg (mean, 15.1 kg; Supplementary Table S1). A unilateral pantarsal arthrodesis was performed in 8 dogs: 7 left, 1 right. Tarsal instability secondary to trauma occurred in 6 dogs (dogs 1 to 3, 5, 7, and 8) with varying severity of associated soft tissue and osseous pathology. Dog 4 previously had transection of the common calcaneal tendon to address a congenital left pelvic limb flexural contracture in an attempt to allow a functional range of motion within the left stifle and tarsus. The releases improved extension of the affected stifle and talocrural joints, but the dog was unable to effectively support weight on the limb postoperatively, necessitating a pantarsal arthrodesis. Dog 6 developed a surgical site infection from a prior tenorrhaphy to repair a transected common calcaneal tendon. The surgical site infection resulted in calcaneal osteomyelitis and secondary failure of the common calcaneal tendon. As the dog was unable to support weight effectively on the affected limb, and due to the poor tissue integrity of the calcaneus and common calcaneal tendon, a pantarsal arthrodesis was elected.
Surgery
All procedures were performed by a small animal surgical specialist. All dogs were premedicated with methadone with or without dexmedetomidine, midazolam, ketamine, and/or acepromazine at recommended doses. All dogs were induced with propofol or alfaxalone to effect. Anesthesia was maintained with isoflurane inhalant with oxygen in all dogs. Intra- and postoperative opioids with or without lidocaine and/or ketamine were given every 1 to 6 hours as needed at recommended doses for analgesia. All dogs were administered perioperative IV antibiotics, either cefazolin (dogs 1 and 3 to 8) or ampicillin/sulbactam (dog 2), at recommended doses every 90 minutes until surgical completion. Dogs 3 and 5 had calcium sulfate amikacin-impregnated beads placed in the surgical site at the time of the arthrodesis.
The talocrural, medial intertarsal, and tarsometatarsal joints were approached by a medial incision extending from just proximal to the medial malleolus to the base of the second metatarsal bone in 4 dogs (dogs 1, 2, 6, and 7) or a series of short incisions exposing each of these individual medial articulations in 3 dogs (dogs 3 to 5).16,17 The talocrural articulation in dog 1 was approached caudally through a large open wound with 2 additional medial incisions to access to the intertarsal and tarsometatarsal articulations. Dog 8 was debrided via a large medial shearing wound prior to placement of a calcaneotibial Steinmann pin and wound closure with a local transposition subdermal plexus flap (Supplementary Table S2). Articular cartilage was debrided using a pneumatic drill with a burr in all dogs except for dog 2, in which the distal articular surface of the tibia and the proximal articular surface of the talus were excised using a sagittal saw. While debridement of the talocrural articulation was extensive, debridement of the intertarsal and tarsometatarsal articulations was restricted to articular surfaces readily accessible from the medial approach. The debrided joint spaces were packed with corticocancellous bone allograft in 2 dogs (dogs 1 and 4) and autogenous cancellous bone in 3 dogs (dogs 2, 3, and 5). Bone grafting was not performed in 3 dogs (dogs 6 to 8). Small release incisions were made for fixation wire and pin placement. Intraoperative fluoroscopy was utilized in 5 dogs (dogs 4 to 8).
Intraoperative complications were not recorded in any of the operative reports. Radiographs of the distal pelvic limb were obtained in all dogs immediately following surgery to verify the arthrodesis angle and confirm proper implant placement. Additional connecting elements were added as required after postoperative radiographs, which afforded better radiographic visualization of the arthrodeses sites. Tarsi were stabilized with a flexion angle range of 111.5° to 136.5° (mean, 124.8°).
Fixator constructs
The CESF constructs (IMEX Veterinary Inc) consisted of 1 or 2 rings securing the tibia and 2 rings securing the metatarsus. An additional stretch ring was placed circumscribing the calcaneus in 2 dogs (dogs 2 and 5). Ring diameter ranged from 45 to 84 mm depending on the size of the dog. In 5 dogs (dogs 1 to 5), complete or five-eighths rings were placed circumscribing the distal metatarsus, proximal metatarsus, and distal tibia. Each ring was secured with ≥ 2 divergent olive or Kirschner wires. A 3-ring construct with proximal medial (type 1A: dogs 1 and 4) or a medial and craniolateral (type 1B: dogs 2, 3, and 5) hybrid extension was used in 5 dogs. One to 2 appropriate-diameter partially threaded half-pins (Duraface; IMEX Veterinary Inc) were placed in the tibia and fixed to the connecting rods. Transarticular olive or Kirschner wires were placed to maintain the arthrodesis angle during fixator application in 2 dogs (dogs 1 and 4), entering the palmar aspect of the talus extending into the distal tibia, as well as wires extending from the palmar aspect of the talus into the metacarpal bones. Dog 2 had a transarticular talocrural Steinmann pin placed, entering the palmar aspect of the talus extending into the distal tibia, prior to fixator application to maintain the desired angle of arthrodesis (Supplementary Table S2).
Four-ring circular constructs without hybridization were used in 3 dogs (dogs 6 to 8). Ring diameter ranged from 45 to 84 mm depending on the size of the dog. Three complete rings were placed circumscribing the proximal metatarsus, distal tibia, and mid-to-proximal tibia. A five-eighths ring was placed circumscribing the distal metatarsus. Each ring was secured with 2 divergent olive or Kirschner wires of appropriate diameter. Two dogs (dogs 7 and 8) had the talocrural joint stabilized with an appropriate-diameter transarticular talocrural intramedullary Steinmann pin, entering in the proximomedial tibia and extending into the talus, prior to fixator placement to maintain the desired arthrodesis angle. The Steinmann pin was articulated with the proximal ring on the fixator in dog 7, while the pin was cut flush with the proximal tibia in dog 8 (Supplementary Table S2).
Postoperative convalescent period
Postoperative analgesia included methadone at recommended doses every 4 to 6 hours as needed for up to 24 hours. Nonsteroidal anti-inflammatory drugs were utilized postoperatively at recommended doses in all dogs and included carprofen or meloxicam for 3 to 5 days (dogs 1 to 5) or 12 to 14 days (dogs 6 to 8). All dogs were empirically started or continued on oral antibiotics following surgery. Postoperative oral antibiotics were administered for 7 days (dog 7), 14 days (dogs 1 to 5), 28 days (dog 8), or 56 days (dog 6) based on the discretion of the attending surgeon. Oral antibiotics used included cephalexin (dogs 1 and 4), enrofloxacin (dogs 5 and 7), amoxicillin–clavulanic acid (dogs 2, 7, and 8), chloramphenicol (dog 3), and clindamycin (dog 6). Dog 6 was empirically administered oral clindamycin prior to the arthrodesis procedure due to surgical site infection and calcaneal osteomyelitis. Therapy was continued postoperatively for 56 days based on positive therapeutic response. Two dogs (dogs 3 and 5) had cultures and sensitivity performed at the time of surgery, but results did not dictate antibiotic change. Oral antibiotics used in the early postoperative period in dogs 2 and 3 (amoxicillin–clavulanic acid and chloramphenicol, respectively) were reinitiated due to wire tract drainage 6 and 12 weeks postoperatively, respectively, and continued until fixator removal.
Initially, dried chlorhexidine-impregnated sponges (E-Z Scrub 107; Becton, Dickinson and Co) were packed within the constructs for 3 to 5 days following surgery in all dogs. Five dogs (dogs 1 to 5) were discharged with a cloth shroud encompassing the fixator, entailing a thin piece of medical fabric wrapped around the fixator and secured to prevent displacement. Three dogs (dogs 6 to 8) were discharged with the construct wrapped in a soft padded bandage covered by a surgical gown sleeve. Complications ascribed to bandaging did not develop in any of the dogs. Instructions for at-home daily bandage care were provided and included cleaning around the fixation element–skin interfaces with dilute chlorhexidine solution and applying triple antibiotic ointment around the wire and pin tracts. Two dogs (dogs 1 and 5) had previously acquired external wounds that required open wound care, including repeated sharp debridement, lavage, and application of antimicrobial dressings. These wounds were managed until considered healed by the attending surgeon. All dogs returned at least once weekly for fixator care for the first 4 weeks following surgery. Sequential postoperative radiographs were obtained to gauge bone healing and evaluate implant integrity as needed until the time of fixator removal (Figure 1). Five dogs (dogs 1 to 5) returned for radiographs every 4 weeks until construct removal. Three dogs (dogs 6 to 8) had radiographs performed 12 weeks postoperatively following construct removal.
Fixator removal
Fixator removal was performed under sedation in 5 dogs (dogs 1 to 5) and under general anesthesia in 3 dogs (dogs 6 to 8). The time to fixator removal ranged from 6 to 16 weeks (mean, 11.3 weeks) postoperatively. Orthogonal-view post–fixator-removal radiographs, which appeared to show radiographic union of the debrided articulations, were obtained in all dogs (Figure 2). Dog 8 underwent subsequent radiographs 4 weeks after fixator removal, followed by Steinmann pin removal.
Complications and outcomes
All dogs developed inflammation of fixation element–skin interfaces during the recovery period, which resolved with fixation-element hygiene (including dilute chlorhexidine cleaning of the fixation element–skin interface and topical application of triple antibiotic ointment) and systemic antibiotic administration in 4 dogs (dogs 5 to 8).
Four dogs (dogs 5 to 8) did not develop postoperative complications, and the owners reported an excellent return to function when last contacted (6 months, 8 months, 2 years, and 5 years postoperatively, respectively). The other 4 dogs developed complications.
Dog 1 had palpable instability at the proximal intertarsal articulation after fixator removal despite apparent radiographic union 8 weeks postoperatively. A revision arthrodesis was performed and stabilized with a contoured 2.7-mm reconstruction plate applied along the caudoplantar aspect of the distal tibia, bridging the tarsus and engaging the fifth metatarsal. The arthrodesis subsequently obtained radiographic osseous union 14 weeks postoperatively. Dog 1 was considered to have an acceptable return to function following surgery; however, the dog developed a chronic intermittent lameness and paronychia of digits 3 and 4 of the involved limb ascribed to gait alterations associated with the arthrodesis. Excision of the third phalanx of digits 3 and 4 was performed sequentially 5 and 10 years postoperatively, respectively, which improved but did not eliminate the dog’s lameness.
Dog 2 developed lameness 6 weeks postoperatively associated with swelling of the pes. Radiographs obtained at that time revealed a fractured fixation wire, within the calcaneus, which was removed. The metatarsal swelling and lameness resolved with 2 weeks of empirical oral amoxicillin and clavulanic acid administration until the fixator was removed 15 weeks postoperatively. A weight-bearing left pelvic limb lameness and focal soft tissue swelling at the site of the remaining talocrural Steinmann pin recurred 29 weeks postoperatively. The pin was removed at that time under sedation for suspected implant loosening based on peri-implant lucency on radiographic images. The dog had already been on 2 weeks of cephalexin for a distant pyoderma unrelated to the implant at the time of removal. Bacterial cultures were not performed at that time. Following this intervention, the lameness and swelling resolved. The owner of dog 2 reported excellent limb function when contacted 6 years postoperatively.
Dog 3 had postoperative swelling of the crus and pes that persisted for 4 weeks and was primarily ascribed to the implantation of antibiotic-impregnated beads at the time of surgery. At the 12-week postoperative examination, dog 3 had developed purulent fixation-element tract drainage with digital swelling. Lucency surrounding the most proximal positive profile pin was noted on radiographs. Oral chloramphenicol administration was reinitiated, resulting in decreased swelling; however, the dog’s lameness persisted and did not resolve until the fixator was removed 16 weeks postoperatively. The owners of dog 3 reported excellent limb function when contacted 8 months postoperatively.
Dog 4 was noted to have fractures of the third through fifth metatarsal bones at the level of the distal fixation wires on radiographs obtained 4 weeks postoperatively. The dog was weight-bearing on the limb, so no intervention was initiated. The metatarsal fractures were nonpainful and palpably stable and had obtained radiographic union at the time of fixator removal 6 weeks postoperatively. The arthrodesis was palpably stable following fixator removal, and there was a column of bone bridging the talocrural arthrodesis site and loss of defined joint spaces in the intertarsal and tarsometatarsal joints. Two weeks following fixator removal (8 weeks postoperatively), the dog re-presented for an intermittent partial– to non–weight-bearing lameness and had palpable instability of the intertarsal and tarsometatarsal joints. The lameness was primarily ascribed to a restricted extension of the ipsilateral stifle. Manipulation of the pes did not evoke a pain response, but the dog’s willingness to bear weight was improved following the application of a plantar metasplint. Coaptation was discontinued after 7 days, as the dog continually soiled the splint due to congenital fecal and urinary incontinence. Nine months after surgery, the owners reported that the dog only occasionally used the affected limb for balance. Upon examination, the dog was nonpainful and the arthrodesis was stable upon palpation. The dog had reduced left stifle extension and held the pelvic limb in external rotation with abduction at the hip. Hip range of motion was normal and nonpainful. The dog had static proprioceptive deficits and increased extensor tone in both pelvic limbs. Dog 4 was considered to have a poor return to function by the attending surgeon, as the dog utilized the limb to offload weight while standing but would not use the leg while ambulating.
Discussion
Individual case reports and series have described the use of circular constructs to stabilize talocrural arthrodeses without concurrent debridement and stabilization of the intertarsal and tarsometatarsal joints.3,9–11 Isolated fusion of the talocrural articulation is associated with a high complication rate and can precipitate the development of degenerative joint disease as well as potentiate subsequent subluxation of the ipsilateral intertarsal and tarsometatarsal joints.18–20 The use of CESF for the stabilization of a pantarsal arthrodesis has only been described previously in 1 dog, which had a chronic fracture-subluxation of the right talocrural articulation. This case was part of a larger series describing early experience with the use of CESF in dogs.12 The current case series describes the use of circular constructs to stabilize pantarsal arthrodeses for pathology including distal tibial articular fractures, comminuted talar fractures, common calcaneal tendinopathies or transections, and primary tarsal instabilities.
In this series, 4 dogs (dogs 5 to 8) did not experience any complications and had excellent outcomes. Two dogs (dogs 2 and 3) experienced complications with fixator components, including wire fracture (dog 2) and implant-associated infection (dog 3). Both dogs had an excellent outcome after fixators were removed. Two dogs (dogs 1 and 4) experienced arthrodesis complication, including failed osseus union, secondary digital trauma, and/or poor limb use following fixator removal, and thus outcomes were acceptable and poor, respectively. These findings mirror complication rates in plated tarsal arthrodeses.1,2
Circular fixators are well suited for minimally invasive orthopedic procedures.6–9,21 In the current case series, the articular cartilage was debrided via limited medial approach or approaches, which resulted in reduced soft tissue morbidity in the early postoperative period. Open plating of pantarsal arthrodeses typically requires a more extensive approach and has been associated with vascular impairment resulting in ischemic necrosis of the plantar pes.1–3 While the talocrural joint was extensively debrided, debridement of the intertarsal and tarsometatarsal articulations was primarily limited to the medial articulations accessible from the limited approach with the objective of obtaining a confluent column of bone bridging the distal tibia to the metatarsus.22
Use of a circular construct allowed for open wound management following the stabilization of the osseous pathology in 2 dogs (dogs 1 and 5). The use of internal fixation would have likely required delayed intervention with a higher risk of postoperative infection. In human trauma patients, external fixation is utilized for the initial stabilization of traumatic orthopedic injuries, facilitating wound management prior to delayed wound closure and definitive internal fixation.22 This approach is not routinely performed in veterinary medicine due to the increased client costs associated with multiple procedures.
Dimensions of the constructs varied according to the size of the dog, and the rings utilized ranged from 45 to 84 mm in diameter. Ring components utilized also varied with complete, five-eighths, and stretch rings all being used as determined by the attending surgeon. Trostel and Radasch10 reported the use of a cylindrical, single–ring-block circular construct made using uniform-diameter, complete rings that were linearly aligned to perform a talocrural arthrodesis in a dog. This cylindrical construct requires using relatively large-diameter rings to accommodate angulation of the distal limb through the talocrural arthrodesis site. All the constructs in the current case series were assembled with an angulation positioned over the talocrural articulation, which allowed the fixator to be made with smaller-diameter rings. Use of smaller-diameter rings made the constructs less bulky and conferred greater construct stiffness.24,25 At least one of the hybrid rods spanned from the distal tibia ring element to the proximal tibia metaphysis, as to avoid fractures associated with spanning < 50% of the tibial length.26
Perioperative antibiotics were administered to all of the dogs in the current case series. Extended use of postoperative antibiotics was utilized following the external fixator applications in 2 dogs (dogs 2 and 3) due to the bacterial infection associated with the pin/wire-skin interface that led to draining wounds and secondary lameness, as well as in dog 6 due to the patient’s established calcaneal osteomyelitis. With the rising concern of antibiotic resistance, further studies of the benefit of oral antibiotic therapy compared to topical antimicrobial therapy alone in managing fixator element–skin interface infection are warranted.
Dog 1 had the lowest tarsal flexion angle at 111.5° (6° more acute than any other dog within the case series), which may have contributed to gait alterations and recurrent phalangeal trauma. The recommended tarsal arthrodesis flexion angle is 135° to 145° in dogs.21 It is thus recommended to avoid acute flexion angles, as phalangeal trauma may occur. Further studies of dogs with similar acute tarsal flexion angles may be warranted, as conclusions could not be drawn from 1 dog.
The time of fixator removal, abbreviated or prolonged, may be associated with an increased risk of complications. Fixator removal was performed with a mean time of 11.3 weeks postoperatively in this case series. In a previous case series,9 dogs that had circular fixators maintained for 11 or 12 weeks obtained osseous union of talocrural arthrodeses while avoiding complications associated with fixators being maintained for a prolonged duration of time; however, this study included only 2 dogs, and thus, few conclusions can be drawn. In the present case series, dog 1 failed to attain functional union of the intertarsal and metatarsal articulations and dog 4 had improved limb use with additional splint support, suggesting a degree of tarsal instability. These 2 dogs (dogs 1 and 4) had constructs removed within the shortest postoperative periods (8 and 6 weeks postoperatively, respectively). These dogs were young, and bone grafts had been placed in the debrided arthrodesis site at surgery. This failure of intertarsal and tarsometatarsal joint fusion may predispose these dogs to tarsal osteoarthritis and subsequent luxation of these joints due to the increased stress induced, similar to a talocrural arthrodesis, as previously described. Maintaining the fixators for a longer duration of time may have resulted in a more favorable outcome. In contrast, 2 other dogs (dogs 2 and 3) that developed fixator-related complications had their fixator maintained for the longest duration (16 and 15 weeks, respectively), which may potentiate the development of fixation-element complications. Due to this, it is recommended by the authors to maintain the fixators for 10 to 12 weeks to allow sufficient osseus union of all tarsal joints while avoiding complications associated with fixators being maintained for an extended length of time.
This case series substantiated that circular constructs can be used to successfully stabilize pantarsal arthrodeses. None of the dogs in this case series developed complications resulting from coaptation applied to mitigate swelling and protect incisions during the early postoperative period. Fixator element–skin interface inflammation developed in all the dogs in the current case series but has been described previously as a common morbidity associated with external skeletal fixators.27 The successful use of CESF requires daily fixator care, but inflammation may occur even with dedicated fixation-element care. This inflammation can typically be managed with additional topical care and systemic antibiotics if indicated until the time of fixator removal. Pantarsal arthrodeses stabilized with a circular construct appear to be an acceptable alternative to plate stabilization in circumstances where the risk of implant-associated infection is considered high, concomitant open wound management is required, or individual anatomical variability precludes plating.
Supplementary Materials
Supplementary materials are posted online at the journal website: avmajournals.avma.org.
Acknowledgments
None reported.
Disclosures
The authors have nothing to disclose. No AI-assisted technologies were used in the generation of this manuscript.
Funding
The authors have nothing to disclose.
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