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Partial Tarsal Arthrodesis Acknowledgments Objectives Partial Tarsal Arthrodesis David Dycus, DVM, MS, CCRP, DACVS-SA Nexus Veterinary Bone & Joint Center Nexus Veterinary Specialists Baltimore, MD Co-Founder/Co-Director Veterinary Sports Medicine and Rehabilitation Institute (VSMRI) Acknowledgments © 2020 Nexus Veterinary Specialists NEXt level veterinary medicine Objectives • Appreciate the anatomy of the tarsus • Understand diagnostic techniques to diagnose instability • Discuss surgical techniques for partial tarsal arthrodesis © 2020 Nexus Veterinary Specialists NEXt level veterinary medicine Tarsus • 3x longer in span than the carpus • Subject to propulsive forces from the pelvic limbs • Possible reason for susceptibility to over stress injuries © 2020 Nexus Veterinary Specialists NEXt level veterinary medicine Anatomy • 7 tarsal bones held together by a variety of ligaments • Fibrous component of joint capsule forms a sleeve from the distal tibia to the proximal metatarsals • All the tarsal ligaments are contained within this sleeve • Stronger on the plantar surface • Ligamentous support is complex but critical © 2020 Nexus Veterinary Specialists NEXt level veterinary medicine Anatomy • High motion • Tibiotarsal joint • Low motion • Proximal inter-tarsal joint • Distal inter-tarsal joint • Tarsometatarsal joint © 2020 Nexus Veterinary Specialists NEXt level veterinary medicine Anatomy © 2020 Nexus Veterinary Specialists NEXt level veterinary medicine Dorsal Aspect of Tarsus • Numerous intertarsal ligaments maintain stability of the tarsus © 2020 Nexus Veterinary Specialists NEXt level veterinary medicine Plantar Ligaments • Damaged in hyperextension injuries • Typically do not heal with conservative management Plantar Aspect of the Tarsus © 2020 Nexus Veterinary Specialists NEXt level veterinary medicine Tarsal Injury • Tarsocrural instability • IntertarsalAll orMay tarsometatarsal be Treated With Arthrodesis instability if Primary Repair isn’t Feasible • Tarsal fracture • Common calcanean tendon injury © 2020 Nexus Veterinary Specialists NEXt level veterinary medicine Tarsocrural Luxation • Single or bilateral collateral rupture • Assess for vascular compromise • May result in severe intra-articular damage © 2020 Nexus Veterinary Specialists NEXt level veterinary medicine Tarsocrural Luxation “Tiger” 6 yo MN DSH © 2020 Nexus Veterinary Specialists NEXt level veterinary medicine Tarsocrural Luxation “Tiger” 6 yo MN DSH © 2020 Nexus Veterinary Specialists NEXt level veterinary medicine Tarsocrural Luxation “Tiger” 6 yo MN DSH © 2020 Nexus Veterinary Specialists NEXt level veterinary medicine Tarsocrural Luxation “Tiger” 6 yo MN DSH © 2020 Nexus Veterinary Specialists NEXt level veterinary medicine Tarsocrural Luxation • Minimal intra-articular damage • Bilateral collateral reconstruction • Severe articular surface compromise • Consider arthrodesis © 2020 Nexus Veterinary Specialists NEXt level veterinary medicine Diagnosis of Tarsal Instability • Exam findings • Tarsal swelling • Tarsal instability • Pain on tarsal manipulation • Diagnostic imaging • Orthogonal radiographs • Include stressed views • Determine level of injury © 2020 Nexus Veterinary Specialists NEXt level veterinary medicine Arthrodesis Decision Making Reconstructable fracture Collateral injury, articular cartilage intact Primary Repair Acute Calcanean Tendon Injury Shearing Injury with Minimal Bone Loss Non-reconstructable Fracture Plantar ligament damage Arthrodesis Chronic calcanean tendon injury with contracture Severe articular cartilage damage © 2020 Nexus Veterinary Specialists NEXt level veterinary medicine Partial vs. Pantarsal Intertarsal or tarsometarsal joint affected Tibiotarsal joint normal Partial Tarsal Collateral ligaments intact Tibiotarsal joint affected Pantarsal Calcanean tuberosity or tendon injury © 2020 Nexus Veterinary Specialists NEXt level veterinary medicine Diagnosis of Tarsal Instability - Determine the level of Injury! Stress Views are Key!! Varus/Valgus Dorsal/Plantar © 2020 Nexus Veterinary Specialists NEXt level veterinary medicine Diagnosis of Tarsal Instability - Determine the level of Injury! Stress Views are Key!! Varus/Valgus Dorsal/Plantar © 2020 Nexus Veterinary Specialists NEXt level veterinary medicine Intertarsal & Tarsometatarsal Instability • Hyperextension injury • Varus/valgus instability • Concurrent fractures common • Primary surgical repair rarely feasible • Typically treat with partial tarsal arthrodesis © 2020 Nexus Veterinary Specialists NEXt level veterinary medicine Diagnosis of Tarsal Instability - Determine the level of Injury! • Medial plane instability or dorsomedial instability • Consider tarsal wiring • ENSURE NO PLANTAR INSTABILITY • If present then will require partial tarsal arthrodesis © 2020 Nexus Veterinary Specialists Gunstra AL, et al. JAVMA 2019;255:336-344. NEXt level veterinary medicine Diagnosis of Tarsal Instability - Determine the level of Injury! • Medial plane instability or dorsomedial instability • Consider tarsal wiring • ENSURE NO PLANTAR INSTABILITY • If present then will require partial tarsal arthrodesis © 2020 Nexus Veterinary Specialists NEXt level veterinary medicine Partial Tarsal Arthrodesis • Fusion of the intertarsal +/- tarsometatarsal joints • Individual joint fusion difficult to achieve • Small bones • Little area for implant purchase • Preserves tibiotarsal joint © 2020 Nexus Veterinary Specialists NEXt level veterinary medicine Technique for Partial Arthrodesis • Typically achieved with lateral bone plate • Plate spans calcaneus to mid- metatarsal region • Locking plate recommended • IM pin technique & tension band • Older technique • Not recommended © 2020 Nexus Veterinary Specialists NEXt level veterinary medicine Surgical Approach • Lateral approach to tarsus • Calcanean tuber to mid- metatarsals • Incise skin & fascia • Very little soft tissue coverage over lateral tarsus © 2020 Nexus Veterinary Specialists NEXt level veterinary medicine Lateral Approach to Tarsus Fascial incision dorsal to the plantar metatarsal vessels © 2020 Nexus Veterinary Specialists NEXt level veterinary medicine Pre Op Planning • Plate size • Metatarsal bone diameter • Screw diameter ≤ 40% bone diameter • Plate length • Calcanean tuber to mid-metatarsals • Plate type • Locking implants preferred © 2020 Nexus Veterinary Specialists NEXt level veterinary medicine Pre Op Planning • Screw length • Screw direction • Avoid intertarsal joints • Try to engage 2-3 metatarsals • Arch in cross section Metatarsal Cross Section © 2020 Nexus Veterinary Specialists NEXt level veterinary medicine Principles of Arthrodesis • Articular cartilage debridement • Bone grafting • Rigid stabilization • Place joint at a functional angle • +/- External Coaptation © 2020 Nexus Veterinary Specialists NEXt level veterinary medicine Surgical Technique • Open & debride intertarsal & tarsometatarsal joints • Remove articular cartilage • High speed burr • Sagittal saw • Pack bone graft in debrided joints • Autogenous Autogenous Bone Graft • Autologous © 2020 Nexus Veterinary Specialists NEXt level veterinary medicine Pre Op Post Op © 2020 Nexus Veterinary Specialists NEXt level veterinary medicine 6 Wk Post 12 Wk Post © 2020 Nexus Veterinary Specialists NEXt level veterinary medicine Gait Post Partial Tarsal Arthrodesis © 2020 Nexus Veterinary Specialists NEXt level veterinary medicine Questions Instagram: ortho_vet David Dycus, DVM, MS, CCRP Diplomate, American College of Veterinary Surgeons- Small Animal Twitter: Ortho_Vet Chief of Orthopedic Surgery, FB: Dr. David Dycus Nexus Veterinary Bone and Joint Center Medical Director, Nexus Veterinary Specialists (NVS) [email protected] Co-Founder and Co-director Veterinary Sports Medicine & Rehabilitation Institute (VSMRI) www.vsmri.com © 2020 Nexus Veterinary Specialists NEXt level veterinary medicine.
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