Clinical comparison between two stabilization methods in distal tibial angular deviation corrected by the CORA method
Background: Angular deformity is characterized by the deviation of part of the bone that can occur in three different planes, frontal, sagittal and transverse. Trauma on physeal plates is the most common cause of angular deviations of the limbs in dogs. Currently the CORA (Center of Rotation of Angulation) methodology is the best way to evaluate and surgically correct these deformities. The objective of this study is to describe the surgical procedures performed
to treat the uniapical valgus deviation affecting both tibial bones in a dog, comparing the outcomes of hybrid external skeletal fixator used in the right pelvic limb in relation to the locking plate used in the left pelvic limb.
Case: A 10-month old Border Collie dog was attended at the University Veterinary Hospital with history of lameness and deviation of both pelvic limbs. In the orthopedic examination, it was possible to identify bilateral valgus deviation in the region of the tibio-tarsal joints and moderate lameness, with absence of pain or joint crepitation. Radiographic examination showed that the deformity was only uniapical in the frontal plane, affecting both tibial bones of the dog. Signs of osteoarthrosis were not observed and the preoperative examinations were within the normal limits for the species. The deformities were corrected in two surgical times starting with the procedure in the right tibia, which appeared to be clinically worse. Due to the fact that it was a bilateral affection and there was not a healthy pelvic limb to obtain the normal angles values of this dog, for planning according to the CORA methodology, the values of the tibial mechanical angles for dogs of similar size were taken from the literature. For surgical correction of the right tibia, a closed wedge osteotomy was performed following the second rule of Paley, with bone stabilization using type IB hybrid external skeletal fixator (ESF). The radiographic follow-up was done every 30 days postoperatively, however at 60 days the dog presented with severe lameness and the ESF had to be removed due to the breaking of one of the wires that composed the ring of the hybrid system. The limb continued to be treated by external bandages and total bone healing occurred at 210 days after surgery. Only after the complete recovery of the right limb, the left pelvic limb was operated and was also corrected by closed wedge osteotomy from the second Paley's rule. However, the bone stabilization was achieved with the use of a T-shaped locking plate. Radiographic follow-up was performed every 30 days postoperatively and at 60 days the osteotomy gap was already consolidated and the dog showed good weight bearing in the pelvic limbs without signs of lameness or pain.
Discussion: Currently, it is indicated that bone deformities in small animals should be corrected using the CORA methodology. The hybrid ESF is one of the most commonly used fixation systems for bone stabilization after corrective osteotomies due to great versatility, however, the reported complication rates are relatively high. The locking plates with special shapes, such as the "T" plate used in this study, provide the stable fixation of osteotomies with limited bone stock, as they allow the introduction of larger number of screws per area. Thus, this latter type of implant becomes advantageous for the correction of bone deformities close to the joints. It is concluded that CORA methodology is really effective in the planning of corrective surgeries of angular deviations in dogs. In this case report, the resulting tibial angles after the surgical corrections were within the normal range for healthy dogs of similar size. However, the use of locking plate provided better results with early bone healing and fewer complications than the type IB hybrid ESF.
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Figura 1. Radiografia craniocaudal dos membros pélvicos de um cão demonstrando a deformidade uniapical distal das tíbias direita (D) e esquerda (E) (Fonte: Hospital Veterinário da Universidade Federal de Lavras [HV-UFLA]).
Figura 2. Imagens radiográficas da tíbia direita em projeção craniocaudal. A- Mensuração da amplitude do desvio angular da tíbia (32,7°) a partir da determinação dos ângulos considerados normais para raças de porte similar, com mMPTA de 90,1° e mMPTA de 101,0°. B- Determinação do ângulo suplementar da tíbia (147,2°). C- Determinação da linha de bissecção transversal (tBL) com amplitude correspondente à metade do ângulo suplementar (73,5°). D- Esboço da cunha óssea com amplitude de 32,7° proximal à linha tBL, seguindo a segunda regra de Paley (Fonte: HV-UFLA).
Figura 3. A- Radiografia craniocaudal da tíbia direita imediatamente após o procedimento cirúrgico para correção do desvio ósseo e implantação do fixador esquelético externo (FEE) híbrido do tipo IB. B- Radiografia craniocaudal da tíbia direita aos 30 dias após o procedimento cirúrgico com implantação do F.E.E. Observa-se início de formação de calo ósseo. C- Radiografia craniocaudal da tíbia direita após 210 dias de recuperação pós-operatória. Observa-se consolidação total da osteotomia. D- Determinação dos ângulos mecânicos da tíbia direita após consolidação da osteotomia (mMPTA = 90,0° e mMDTA = 90,7°). Notar que os ângulos mensurados estão dentro da variação aceitável para cães porte grande (Fonte: HV-UFLA).
Figura 4. Imagens radiográficas da tíbia esquerda em projeção craniocaudal. A- Determinação da amplitude do desvio angular da tíbia (26,1°) a partir da determinação dos ângulos considerados normais para raças de porte similar, com mMPTA de 90,1° e mMPTA de 101,0°. B- Determinação do ângulo suplementar da tíbia (153,2°). C- Determinação da linha de bissecção transversal (tBL) com amplitude correspondente à metade do ângulo suplementar (76,6°). D- Esboço da cunha óssea com amplitude de 26,1° proximal à linha tBL, seguindo a segunda regra de Paley (Fonte: HV-UFLA).
Figura 5. A- Radiografia craniocaudal oblíqua da tíbia esquerda imediatamente após o procedimento cirúrgico para correção do desvio ósseo e implantação da placa bloqueada em formato de “T”. B- Radiografia craniocaudal oblíqua da tíbia esquerda aos 30 dias após o procedimento cirúrgico demonstrando integridade dos implantes e pequena atividade de reparação óssea. C- Radiografia craniocaudal da tíbia esquerda após 60 dias de recuperação pós-operatória. Observa-se consolidação da osteotomia. D- Determinação dos ângulos mecânicos da tíbia esquerda após consolidação da osteotomia (mMPTA = 90,3° e mMDTA = 101,4°). Notar que os ângulos mensurados estão dentro da variação aceitável para cães de porte grande (Fonte: HV-UFLA).
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