Clinical and radiological evaluation of fixation technique with cerclage wires and cortical screws for elbow luxation in dogs - a retrospective studyABSTRACT
Elbow joint luxations are relatively rare and are typically associated with high -energy traumas such as traffic accidents, falls, limb compression, or altercations with other animals. This study included 14 dogs of various ages, breed, and gender, brought to the clinic with complaints of inability to use their forelimbs and diagnosed with Articulatio cubiti luxation. The cases were followed for 60 days after the operation, with follow-up on the 10th, 30th, and 60th postoperative days. In the 60-day postoperative follow-up examination, mild lameness was observed in cases 4, 9, and 12, while no signs of lameness were detected in cases 1, 2, 3, 6, 7, 8, 10, and 11. Cases 13 and 14 could not be followed up postoperatively, and case 5 was not followed up after the 30th postoperative day. The aim of this study was to evaluate the clinical and radiological outcomes of the fixation technique with cerclage wires and cortical screws used as a prosthesis for Lig. collaterale laterale and Lig. annulare in the treatment of Articulatio cubiti luxations.
Keywords:
articulatio cubiti; dog; fixation; luxation
RESUMO
Luxações da articulação do cotovelo são relativamente raras e estão tipicamente associadas a traumas de alta energia, como acidentes de trânsito, quedas, compressão de membros ou altercações com outros animais. Este estudo incluiu 14 cães de várias idades, raças e sexos, trazidos à clínica com queixas de incapacidade de usar seus membros anteriores e diagnosticados com luxação de Articulatio cubiti. Os casos foram acompanhados por 60 dias após a operação, com acompanhamento no 10º, 30º e 60º dias pós-operatórios. No exame de acompanhamento pós-operatório de 60 dias, claudicação leve foi observada nos casos 4, 9 e 12, enquanto nenhum sinal de claudicação foi detectado nos casos 1, 2, 3, 6, 7, 8, 10 e 11. Os casos 13 e 14 não puderam ser acompanhados no pós-operatório, e o caso 5 não foi acompanhado após o 30º dia pós-operatório. O objetivo deste estudo foi avaliar os resultados clínicos e radiológicos da técnica de fixação com fios de cerclagem e parafusos corticais utilizados como prótese para Lig. collaterale laterale e Lig. annulare no tratamento de luxações da Articulatio cubiti.
Palavras-chave:
Articulatio cubiti; cão; fixação; luxação
INTRODUCTION
Articulatio cubiti is a compound joint composed of the humeroradial, humeroulnar, and proximal radioulnar joints (Constantinescu and Constantinescu, 2009). The humeroulnar joint lies between the condyles of the humerus and the trochlear notch of the ulna, the humeroradial joint between the condyles of the humerus and the head of the radius, and the proximal radioulnar joint between the radial notch of the ulna and the radius (Gadallah et al., 2023). Elbow joint stability is achieved through the anatomic configuration, where the anconeal process interlocks with the Fossa olecrani, involving surrounding muscles and ligament support (Gadallah et al., 2023; Griffon, 2012). The ligamentous support of the elbow joint consists of the medial and lateral collateral ligaments, together with the annular ligament and interosseous ligaments (Gadallah et al., 2023).
Traumatic Art. cubiti luxations in dogs are not commonly encountered due to the stability of the joint's surrounding ligaments. The prevalence of peri-articular fractures is higher than luxations, given the stability provided by robust peri-articular muscle and connective tissue structures, as well as the interaction of the Processus anconeus with surrounding anatomic structures (Campbell, 1971). Luxations are commonly associated with high-energy traumas resulting from traffic accidents, fall from height, compression of the involved limb, or altercations with other animals (Campbell,1969; Schaeffer et al., 1999; Mitchell, 2011).
It is assumed that these traumas result from regional muscles and connective tissues transmitting forces directly onto the joint structures (Schaeffer et al., 1999; Farrell et al., 2009). Over 90% of Art. cubiti luxations in dogs occur in the lateral form [4,8]. Medial luxations or subluxations are rarely observed (Sasaki et al., 2020). The tendency for lateral luxation is likely due to the medial epicondyle being larger than the lateral condyle and having a steeper inclination of the joint surface (Farrell et al., 2009). The significance of damage to the Lig. collaterale laterale during luxation onset remains a debated topic. The stability of the elbow is provided by its inherent congruity, the locking mechanism of the Processus anconeus in the Fossa olecrani, and the integrity of the collateral ligaments (Campbell, 1969, 1971; Vogelsang et al., 1997; Talcott et al., 2002). The Processus anconeus in cats is smaller compared to that in dogs, and the collateral ligaments share a similar macroscopic anatomy (Andersson, 2004; Engelke et al., 2005). Reports have indicated that between 18% and 50% of patients with luxation also experience lesions in the collateral ligaments (Griffon, 2012). Recent biomechanical studies of Art. Cubiti in dogs have suggested that as long as at least the Lig. collaterale laterale remains intact, luxation may not occur. For luxation to happen in Art. Cubiti of cats, both collateral ligaments need to be damaged (Farrell et al., 2007; Saǧlam, et al., 2020; Williams, et al., 2020). However, in a previous study, it was shown that Art. cubiti luxations occurred significantly more in cats where the collateral ligaments were cut compared to dogs (Farrell et al., 2009). This finding might be attributed to the relatively stronger Lig. olecrani in the cat's relevant joint; this ligament extends from the lateral olecranon to the medial Epicondylus. The Lig. olecrani in cats, although one-third the length of that in dogs, is twice as wide and is taut in flexion of the Art. Cubiti (Engelke et al., 2005). Closed reduction can be successfully applied in cases of Art. cubiti luxations in dogs and is initially recommended for the treatment of Art. cubiti luxations (Campbell, 1969). Open reduction via surgical intervention is necessary when closed reduction cannot be performed or is unsuccessful. Several methods have been described for the stabilization of Art. cubiti luxations through open reduction. These include repairing the collateral ligaments (Campbell, 1971; Meeson and Strickland, 2021), re-suturing torn ligaments, replacing collateral ligaments with synthetic suture materials or cerclage wires (Schaeffer et al., 1999, McCartney et al., 2010), using transarticular external fixators (Griffon, 2012), and employing circular suture techniques through transcondylar drilled channels. Campbell's test is considered a non-invasive 'gold standard' for assessing the integrity of the collateral ligaments. Campbell (1969) reported that in a normal dog, at 90° rotation of both the Art. cubiti and carpus, the range of antebrachial rotation is 40 to 50° for pronation and 60 to 70° for supination. In cases of Lig. collaterale laterale damage, it has been shown that supination can reach 120° to 140°, and in cases of Lig. collaterale mediale damage, pronation can reach 90° to 100°. Assessment of antebrachial rotation following closed reduction may indicate persistent instability in the Art. cubiti, therefore advocating for an open reduction in patients showing persistent instability after closed reduction (Sajik et al., 2016).
The most common post-reduction complication of Art. cubiti luxations is recurrent dislocation. An ex-vivo study has shown that luxation is possible only after damage to the Lig. collaterale laterale, which suggests that in cases of luxation, there might be collateral ligament damage in all instances. Traumatic luxation causing damage to the collateral ligament affects the abduction, adduction, medial, and lateral rotation resistance of the Art. cubiti. In severe cases, there is an increased likelihood of significant instability and recurrent dislocation, while in milder cases, intact structures in the area assist in maintaining the joint's stability. Studies have demonstrated that the incomplete prevention of instability in traumatic elbow luxations after closed reduction has a negative impact on the success of the reduction (Sajik et al., 2016).
Reduction aids in providing post-reduction external support to allow for fibrosis and healing of the joint's internal supporting structures (Griffon, 2012). External support is applied in the extension position of the limb, aiming to facilitate the Processus anconeus settling into the Fossa olecrani on the Humerus, thus preventing recurrent dislocation (Sajik et al., 2016).
However, if significant instability persists after joint reduction, surgical repair of luxation is recommended. The most encountered types of collateral ligament damage are mid-substance ruptures, and these lesions should primarily be treated with or without the use of synthetic or autograft materials. Moreover, in cases where avulsion lesions have occurred, the aim is to re-attach the ligament to the area by creating channels passing through the bone tissue. Cortical screws can be used for this purpose (Farrell et al., 2009).
The aim of this study was to clinically and radiologically evaluate the fixation technique using cerclage wires and cortical screws as a prosthesis for Lig. collaterale laterale and Lig. annulare in the treatment of Art. cubiti luxations.
ETHICAL ASPECTS
This research was not submitted to the Ethics Committee on Animal Use”.
MATERIAL AND METHODS
The study comprised 14 dogs of various ages, breed, and gender, diagnosed with Art. cubiti luxation on presentation at the clinic with complaints of inability to use their forelimbs, as confirmed by clinical and radiological examinations (Table 1).
Comprehensive anamnesis was obtained from the owners of the cases before the clinical examination. Cases with trauma history limited to 24 hours underwent systemic examinations to evaluate their general condition regarding traumatic shock. Cases with a stable general condition were sedated, and two-way radiographs of the affected area were taken in anteroposterior (A/P) and mediolateral (M/L) positions. Preoperative evaluations of the luxation occurring in the respective joint were conducted, and surgery appointments were scheduled, providing routine preoperative information to the animal owners.
The localization and shape of the lesion were determined by evaluating the obtained radiographs. This helped in establishing the treatment approach, the surgical method, and the selection of implants to be used.
The dog owners were informed that the animal should be fasted for 12 hours before the operation and should not be given water for 6 hours before the operation.
Operation sets and implants to be used were sterilized using an autoclave.
In all cases, general anesthesia was induced with intramuscular administration of Xylazine HCl 2% (Alfazyne®, Alfasan, 20mg/mL) at a dose of 1mg/kg following premedication, followed by intramuscular administration of Ketamine HCl 10% (Ketasol®, Richterpharma, 100mg/mL) at a dose of 2mg/kg.
After general anesthesia, routine preparation of the surgical site was performed, and the area was confined with sterile drapes. When extension of anesthesia was necessary, maintenance doses were administered during the operation.
Surgical Technique: The incision of the skin and subcutaneous tissues started from the distal 1/3 of the humerus, directed cranially to the Epicondylus lateralis, and extended to the proximal 1/3 of the radius. The deep fascia at the cranial border of the M. triceps brachii was incised. The intermuscular septum between M. extensor carpi radialis and M. extensor digitalis communis was incised. The incision was extended proximally to the periosteal origin of M. extensor carpi radialis. To expose the joint capsule and Epicondylus lateralis, the cranial muscle was retracted. The joint capsule was incised in an 'L' shape, allowing access to the proximal radius by separating Epicondylus lateralis, M. extensor digitalis lateralis, and M. ulnaris lateralis.
After exposing the joint capsule, the locations of the articular surfaces of the distal humerus, proximal radius, and ulna, which constitute the Art. cubiti, were identified. Then, using an elevator, the components forming the joint were repositioned to their anatomic positions through lever movements without damaging the joint surfaces. Passive movements were then applied to the joint to assess the normalcy of joint mobility. After ensuring normal extension and flexion movements of the joint, cortical screws appropriate to the size and diameter of the bones were selected. One screw was applied transversely from Epicondylus lateralis to medialis, another screw was positioned transcortically from 1-1.5 cm below Caput radii, and a third screw was placed at the level corresponding to the trace of Art. humero-radialis, reaching the olecranon. The screws in the humerus, radius, and olecranon were then connected to each other in a figure-of-eight fashion using cerclage wires. Following this procedure, pronation, supination, extension, and flexion movements were performed on the joint to assess both the tension of the wires and the presence of instability. In cases where instability persisted, the tension of the cerclage wires was increased to a level that did not restrict joint movement but effectively resolved the instability.
After these procedures, subcutaneous tissues and skin were routinely closed, concluding the operation.
Postoperative Medical Treatment and Bandage Application: Postoperatively, analgesia was provided with meloxicam administered subcutaneously at a dose of 0.2 mg/kg (Maxicam®, Sanovel, Turkey).
All patients were administered oral amoxicillin clavulanate at a dose of 25 mg/kg (Amoksilav BID, İlsan, Turkey) for 7 days for antibiotic therapy. A soft bandage (Robert-Jones) applied to the affected limb was advised to be kept for 10 days. All the dog owners were cautioned to impose restricted movement on their animals for a minimum of 15 days.
On the 10th postoperative day, the owner and patient were called back for bandage removal. Wound healing at the surgical site was examined, and the sutures were removed. On postoperative days 30 and 60, the owners were called in for follow-up appointments to conduct clinical and radiological examinations of the dogs.
RESULTS
The study included 14 dogs of different breeds and ages, which were followed up for 60 days postoperatively. Of these 14 dogs, 6 were Kangal breed (Cases no. 1, 2, 6, 11, 12, 13), 1 was a Golden Retriever breed (Case no. 5), 1 was Rottweiler breed (Case no. 10), and 6 were mixed breed (Cases no. 3, 4, 7, 8, 9, 14). Of the dogs included in the study, 7 were male (Cases no. 2, 5, 6, 7, 9, 11, 12), and 7 were female (Cases no. 1, 3, 4, 8, 10, 13, 14). The average age of the cases was calculated as 1.83 years. Information regarding breed, age, gender, and direction of the lesion for the cases is provided in Table 1.
In the radiological examinations, it was observed that all cases had a lateral luxation. The cases were called for follow-up on postoperative days 10, 30, and 60. Cases 13 and 14 could not be followed up from postoperative day 0, and case 5 could not be observed after postoperative day 30. On the postoperative 10th day, severe lameness was observed in cases 1, 3, 4, 7, 8, 10, 11, and 12, while moderate lameness was noted in cases 2, 5, 6, and 9.
On the postoperative 30th day, moderate lameness was observed in case 4, while mild lameness was noted in cases 1, 3, 5, 7, 9, 10, 11, and 12, and no lameness was observed in cases 2, 6, and 8. On the postoperative 60th day, mild lameness was recorded in cases 4, 9, and 12, and no signs of lameness were found in cases 1, 2, 3, 6, 7, 8, 10, and 11. The lameness evaluation of the cases on the specified days is presented in Table 2.
In cases 2 and 11, it was observed that the cerclage wire between the humerus and the olecranon was disrupted, while the integrity of the wire between the humerus and the radius remained intact. In the remaining cases, it was determined that all cerclage wires remained intact.
Throughout the postoperative period, no complications such as infection, aseptic loosening, or reluxation were observed in cases that could be followed up. In cases 2 and 11, where the integrity of the cerclage wire could not be maintained, it was noted that no condition affecting the patient's comfort or hindering their daily activities occurred. The intraoperative procedural steps for case no. 6 are depicted in Fig. 1.
Preoperative and postoperative radiographs of case no. 6 are presented in Fig. 2.
Preoperative and postoperative radiographs of case no. 8 are presented in Fig. 3.
Intraoperative images related to case no. 6. a) Exposure of Art. Cubiti, b and c) Reduction of dislocated joint components, d) Transcortical screw application to the Epicondylus lateralis, e) Interconnection of screws applied to the Epicondylus lateralis and the distal end of Caput radii using a cerclage wire, f) Attachment of the 3rd cortical screw applied to the olecranon to the screw on the Radius using a cerclage wire.
Radiographs of case no. 6. a) preoperative, b) postoperative 10th day, c) and d) postoperative 60th day.
a and b) preoperative radiographs and c and d) postoperative 60th day radiographs of case no. 8.
DISCUSSION
The luxation of the Art. cubiti is relatively rare in both dogs and cats due to the naturally stabilizing structures within the joint. Strong collateral ligaments provide stability, and in the extension position, the Processus anconeus engages the Fossa olecrani to prevent luxation. It has been suggested that Art. cubiti luxation occurs because of indirect rotational forces rather than direct traumatic forces. Lateral luxation is more common than medial luxation, which is attributed to the larger size of the Epicondylus medialis compared to the Epicondylus lateralis. Some studies have suggested that the relative weakness of the Lig. collaterale mediale compared to the ligament on the lateral side might contribute to the joint's inclination for lateral luxation. In addition, the Lig. collaterale laterale is more elastic than the medial ligament and has collagen fibre bundles crossing at various angles. Studies have indicated that lateral luxation constitutes about 92-100% of Art. cubiti luxations (Mitchell, 2011).
The study consisted of 14 dogs of various breeds, age, gender, and weight. The initial clinical examinations followed by radiological assessments were conducted on all these cases, because of which, lateral luxation was observed in all the cases included in the study. This is consistent with the reported rates of lateral luxation, ranging between 92% and 100% in other studies.
Based on clinical experience gained from clinical studies, when ruptures occur in collateral ligaments during traumatic luxations of the Art. cubiti, these ligaments generally acquire a fragile character. Consequently, there is a decrease in the ligaments' suture-holding capacities. In a biomechanical study on Art. Cubiti in dogs, following a medial approach procedure involving Lig. collaterale mediale desmotomy, it was reported that only about 19% of the joint's physiological stability was preserved. Following repair of the desmotomy, it was observed that sutures applied to the ligaments failed across all joints. Based on this, external support is recommended following the primary repair of Lig. collaterale (Farrell et al., 2009).
The aim of this study was to examine the clinical and radiological outcomes of the treatment of Art. cubiti luxation in dogs using cerclage wires and cortical screws. Instead of suturing the damaged collateral ligaments, cerclage wires were used to mimic the function of the ligaments, with the aim of supporting joint stability in place of the damaged or ruptured ligament structures. The technique was applied as a single treatment procedure with a lateral approach to the joint. This eliminated the need for complex bandage care in the postoperative period or the use of an additional surgical procedure to establish and maintain joint stability.
After the reduction of Art. cubiti luxation, the most common complication encountered is reluxation. The likelihood of collateral ligament damage during traumatic luxation can significantly impact the resistance of the elbow joint to abduction, adduction, medial, and lateral rotation. Therefore, severe injuries can lead to marked instability and reluxation. In traumatic elbow luxations, it has been shown that the remaining instability in post-reduction period, negatively impacts the success of treatment. It has been reported that successful treatment outcomes are only achievable when stability is fully established (Sajik et al., 2016).
In this study, following the operative reduction of Art. cubiti luxation, to establish stability, channels were created from lateral to medial at the Epicondylus, lateromedially just distal to the Caput radii, and at points corresponding to the humeroradial joint level of the olecranon. Cortical screws were placed into these channels. In cases with Lig. annulare damage, the heads of the screws were connected from the humerus to the radius and from the radius to the olecranon, whereas in cases with intact Lig. annulare, a figure of 8 configuration of cerclage wires connected from the humerus to the olecranon and again from the humerus to the radius. After applying this technique, joint stability was assessed. In cases where stability was deemed insufficient, the tension of the cerclage wires was increased to a level that did not impede joint movement, thereby achieving joint stability. Cases no 13 and 14 could not be followed up postoperatively, while follow-up for case no 5 was not possible after the 30th postoperative day. However, all the remaining cases were followed up postoperatively until the 60th day. None of the follow-up cases exhibited any signs of reluxation. In cases no 2 and 11, it was observed that the cerclage wire connecting the screws between the humerus and olecranon was disrupted, yet the integrity of the wire between the humerus and radius was maintained. The disrupted wire did not lead to any instability, and there was no observed decrease in the comfort of the respective cases.
In a study evaluating the circumferential suture technique in dogs with Art. cubiti luxation, a reluxation occurred following the creation of a prosthetic ligament from the lateral side. However, no reluxation was observed after consecutive medial prosthetic sutures. One potential benefit of the circumferential suture prosthesis is that it addresses both medial and lateral ligamentous instabilities in a single operation. When comparing the ligament prosthesis insertion technique with bilateral sutures, the circumferential suture technique requires less soft tissue dissection as it allows incision for the passage of bone tunnel sutures into the medial elbow (Sajik et al., 2016).
In this study, cortical screws applied from the lateral side and connected by cerclage wires were used in the treatment of Art. cubiti luxations. In all cases that could be followed up, no instability or reluxation was observed. However, when evaluating the lameness of the animals, severe lameness was noted in cases 1, 3, 4, 7, 8, 10, 11, and 12 during the clinical evaluation on postoperative day 10, while moderate lameness was observed in cases 2, 5, 6, and 9. By postoperative day 60, mild lameness was detected in cases 4, 9, and 12, while no signs of lameness were seen in cases 1, 2, 3, 6, 7, 8, 10, and 11. Cases 13 and 14 could not be followed in the postoperative period, and in case 5, which was followed until postoperative day 30, mild lameness was observed on the 30th day after the operation. After applying this technique, an improvement was observed in limb usage, which increased as the postoperative period progressed. During the application of the technique, manipulation was performed only from the lateral side to minimize trauma related to the procedure. There was no manipulation from the medial side of the joint.
CONCLUSION
Elbow luxations in dogs are relatively rare injuries. Closed and open treatment methods are used for luxations of this joint. Following closed reduction of the luxation, the instability of the joint should be assessed. If instability persists, there is a high likelihood of reluxation. In such cases, surgical intervention should be considered for treatment.
Surgical treatment involves various techniques. In this study, the technique of using cerclage wires and screws for the treatment of elbow luxation in dogs was evaluated. The approach involved lateral exposure of the joint. Following the reduction of the luxation, screws were applied from lateral to medial on the humerus, radius, and olecranon, and these three bones were reconnected using cerclage wires wound around the screw heads. In addition to the clinical and radiological assessments, the presence of lameness in the extremity was followed up for 60 days in the cases comprising the study material.
Due to the subjective nature of the postoperative clinical data in this study, it can be recommended that gait analysis is assessed, or video recordings are made of the dogs constituting the study material. Furthermore, performing gait analyses using multimodal systems (kinetic, kinematic, and electromyographic) and conducting three-dimensional measurements could address the drawbacks of this study and yield more objective data. These tests could also provide significant quantitative data supporting the clinical findings.
In conclusion, the treatment of canine elbow joint luxations using screws and cerclage wires can be considered as an alternative to other surgical treatment techniques.
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The research data are available within the article itself.
