A Novel Technique for Extracapsular Repair of the Intertarsal Joint in a Duck.
Key words: rupture, repair, intertarsal joint, extracapsular, ligament, collateral, avian, Pekin duck, Anas platyrhynchos domesticus
A 9-month-old female reproductively intact Pekin duck (Anas platyrhynchos domesticus) was examined because of acute onset lameness of the left leg. The duck and an adult drake were kept free range in a suburban backyard (approximately 10 X 5 m) and had free access to a commercial highquality chicken layer pellet and to a paddling pool (2 x 2 m). A part of the backyard was covered with grass and another part with concrete. The owner reported that in the last month the pool had been drained because she feared the drake would drown the duck while attempting to mate in the pond. Since then, the drake had been mounting the duck on the grass or concrete.
On physical examination, the duck weighed 1.78 kg and was active and alert. A mild swelling was present over the left intertarsal joint, and pain was associated with manipulation of this joint. The lameness of the left leg was graded as 1 /6, based on an extrapolation from criteria developed by Kestin et al (1) in broiler chickens. Both feet were examined and appeared normal. No other abnormalities were noted. Results of orthogonal radiographs confirmed the presence of soft tissue swelling diffusely over the medial aspect of the joint in absence of osseous lesions (Fig 1). Because of the minimal soft tissue swelling and mild degree of lameness, the owner declined bandaging and further diagnostic investigation. The duck was administered meloxicam (1 mg/kg PO q12h for 5 days) and the owner was advised to keep the duck away from the drake during this time. Additionally, the owner was to encourage paddling in the water as gentle hydrotherapy to promote motion in the joint.
The duck was represented for examination 3 days later. The owner reported that the lameness had become significantly worse and the duck was reluctant to walk. The drake had continued to access the pen where the duck was being housed. The duck remained bright and alert but the joint was now significantly swollen, painful, and warm on palpation. The owner declined further diagnostic tests (including arthrocentesis). Tramadol (10 mg/kg PO ql2h) was prescribed to provide multimodal analgesia, and the duck was discharged with instructions for the owner to continue the meloxicam and to keep the duck confined except for 15 minutes twice daily, during which time the duck was allowed to swim in a warm water tub.
Four days later the duck was reexamined because of nonweight-bearing lameness and inability to stand despite treatment with meloxicam and tramadol since it was last seen. On orthopedic examination under general anesthesia with isoflurane administered by face mask, the intertarsal joint was swollen medially, and moderate latero-medial instability with significant pain was present on manipulation. The latero-medial instability got worse when the intertarsal joint was manipulated in a flexed position. Radiographs confirmed no change in the bone or soft tissue structures when compared with those taken 7 days earlier. Differential diagnosis for the inflammatory arthropathy included septic synovitis, bacterial or fungal infectious arthropathy, and subluxation with or without concurrent ligament and meniscal damage. Based on the latero-medial instability and clinical signs, a presumptive diagnosis of left medial collateral ligament rupture was made. The owner elected surgical correction and stabilization of the joint but declined suggested further diagnostic tests including blood analysis and ultrasound or magnetic resonance imaging to assess the integrity of the ligaments.
The next day the duck was premedicated with midazolam (1 mg/kg IM) and butorphanol (2 mg/ kg IM). General anesthesia was induced with isoflurane delivered via face mask at 3% in 100% oxygen at 1.5 L/min followed by intubation with a 3.5-nm uncuffed endotracheal tube and maintenance with 2% isoflurane throughout the procedure. Supplementary heat was provided with a radiant infant warmer and a heated surgical table. During surgery, crystalloid fluids (10 mL/kg per hour) were administered through a catheter placed in the right medial metatarsal vein.
A 3.5-cm elliptical incision was made medially over the left intertarsal joint with care taken to avoid the medial metatarsal vein, which was reflected craniolaterally away from the surgical field. The incision was extended toward the caudal surface at the proximal and distal ends to form a skin flap and facilitate better exposure of the tibiotarsus and tarsometatarsus (Fig 2). A moderate amount of thickened, fibrotic tissue overlaid the ruptured medial collateral ligament, which precluded identification and primary closure of the ruptured ends of the ligament itself. Bone tunnels were made using 18-gauge needles as a drill. Tunnels were drilled through the medial condyles of the tarsometatarsus and tibiotarsus in a cranial to caudomedial direction at approximately 5 mm from the articular surface to approximate the exit points of the proximal and distal insertions of the medial collateral ligament. Size-0 nonabsorbable nylon suture (Rivermid, Riverpoint Medical, Portland, OR, USA) was passed through the needles and the needles were then removed, leaving the suture within the bone tunnels. The suture remained beneath the common calcaneal tendon and was passed beneath the medial metatarsal vein and secured to itself in a circumferential pattern. (Figs 3 and 4) The suture loop was tightened and fixed by using a self-locking surgeon's knot with half hitches while the leg was held at an angle of approximately 128[degrees]. This angle was determined radiographically before surgery as the normal standing angle for this duck by using a modification of the technique described by Bonin et alThe skin was sutured routinely using 4-0 absorbable monofilament suture (Monosyn, B. Braun Surgical, S.A, Rubi, Spain) in a simple continuous pattern. A soft-padded bandage was applied to provide semirigid immobilization after surgery.
The duck remained hospitalized for 6 days after the procedure. During this time, it was assist-fed with a mixture of 80% Roudybush hand-rearing formula (Companion Parrot Supplies, Clifton, QLD, Australia) and 20% Hills a/d (Hill's Pet Nutrition, Sydney, NSW, Australia) to try to approximate a commercial duck grower formulation. (3) Treatment with amoxicillin/clavulanic acid (125 mg/kg PO q12h) and meloxicam (1.5 mg/kg PO q12h) was started. The duck was discharged with strict instructions for cage rest, with the owner to provide passive range of motion physiotherapy to the joint in the cranio-caudal plane for 15 minutes 3 times daily. The duck was not allowed access to a water tub until day 8, when hydrotherapy was instituted and the duck was encouraged to swim for 15 minutes 3 times daily in a 2 x 2 x 2-m tub. Two weeks after surgery, the skin sutures were removed. The duck was able to walk with no appreciable lameness, and no swelling was associated with the joint. Five months after surgery, the owner reported no appreciable lameness or swelling.
This report details a simple, effective, and successful extracapsular repair for instability in the intertarsal joint associated with medial collateral ligament damage in a duck. Despite the lack of advanced imaging modalities such as computed tomography, ultrasonography, and arthroscopy, this case highlights that with a thorough physical examination, radiography, and surgical correction, a favorable outcome may still be achieved.
Ligament damage and luxations of the intertarsal joint are relatively common in the avian patient. (4) Most of these abnormalities are the result of traumatic injury or growth deformities and result in significant functional impairment. Growing birds, especially gallinaceous birds, are prone to dislocation of the intertarsal joint secondary to the medial or lateral displacement of the tendon of the gastrocnemius. (5,6) In adult birds, the intertarsal joint is usually injured as a result of severe trauma causing damage to tendons, ligaments, and the integument. (4)
The intertarsal joint consists of the tibiotarsus, composed of the fused tibia and the proximal row of tarsal bones, and its articulation with the tarsometatarsus, which is formed by the fusion of the distal row of tarsal bones and metacarpal bones II, III, and IV. The articulation consists of a synovial roll-and-glide joint, with most motion occurring in the flexion/extension plane. (6) Flexion of the intertarsal joint is automatically coupled with tarsometatarsal abduction and external rotation, (6) while the opposite occurs during extension. (7) As the degree of flexion increases, surface-to-surface contact between the 2 bones decreases.
The joint is stabilized by various ligaments and muscles that provide the primary guiding function throughout the range of motion. The medial and lateral collateral ligaments stabilize the joint mediolaterally, while the lateral tibial meniscal, lateral metatarsal meniscal, and the medial tibiometarsal ligaments act to stabilize the joint in a craniocaudal and mediolateral direction. (7) The medial and lateral menisci complete the articular surface (Fig 5). Flexion of the intertarsal joint is facilitated by the cranial tibial muscle, the tendon of which courses beneath annular tibial ligament and by the long digital extensor tendon (Fig 6). The major extensor is the gastrocnemius, which is divided into 3 separate bellies and inserts as a single tendon onto the hypotarsus. The fibularis brevis muscle enables medial rotation of the tarsometarsus and rounds out the common movements at the interarsal joint. (7) The intertarsal joint is essential for locomotion and load bearing, especially in Anatidae that rely heavily on their legs and feet for locomotion on land.
The blood vessels and nerves that cross the intertarsal joint include the deep fibular nerve and the cranial tibial artery and vein, which lie ventral to the tendon of the cranial tibial muscle. The cranial tibial artery is the major blood supply to the lower leg and digits. (6) The major venous drainage is via the caudal tibial vein and the medial metatarsal vein that lie ventromedial and medial to the tarsometatarsus respectively (Fig 7). After the artery and vein cross the tarsometatarsus, they become the dorsal metatarsal artery and vein and perfuse the digits. (7)
The diagnosis of luxation, subluxation, and joint disease in birds can be challenging. Concurrent soft tissue or skeletal damage and swelling may complicate the diagnostic process. A thorough and accurate clinical history and a thorough physical examination guide diagnostic testing. Radiography remains the mainstay of joint disease investigation, but increasingly computed tomography and magnetic resonance imaging are available to aid in the diagnosis of joint disease in avian patients. These imaging modalities will assist in ruling out bone or soft tissue injuries. In a clinical setting when advanced diagnostic imaging is not available, ultrasound will enable direct visualization of soft tissue structures (8) and assist in arthrocentesis to collect clinical pathologic samples to determine the infectious or inflammatory nature of the arthropathy.
Most reports of avian extracapsular ligament repair techniques involve the stifle. (4,8,9) A single conference abstract details successful intertarsal collateral ligament repair in 2 large birds of prey after they became entangled in aviary netting. (10) Two different techniques are described: the use of cortical screws and the use of transcondylar pins at the point of ligament attachment, with nonabsorbable suture placed in a figure-of-8 pattern between the fixators. In both cases, a transarticular type-II external fixator was placed to stabilize the joint, and good return to normal function was reported. (11) Repair of intertarsal luxations involving ligament rupture by using rigid immobilization with external skeletal fixation, arthrodesis, and extracapsular repair using suture has been suggested; however, a description of this technique has not been published. (8)
In dogs, various techniques are described to repair collateral ligaments. Bone tunnels may be used, but nonabsorbable suture material with bone screws as anchors are commonly employed. (11) The gold standard for collateral ligament repair in human medicine involves suturing the ruptured ligament ends together, where a variety of knotless suture methods are available. (13-15) Repair of collateral ligaments of the metacarpophalangeal joint in human fingers, which is anatomically similar to the intertarsal joint of the bird, involves ligament repair preferentially. When dealing with chronic rupture of the ligament, one study reports that most were repaired by a tendon graft technique, with a functional outcome of 100%. (16) In another case of chronic metacarpophalangeal collateral ligament rupture, a tendon sheath flap was used to bridge the gap left by the damaged ligament, resulting in a functional outcome. (13) A third human study describes a technique for reconstructing the collateral ligament by using a palmaris longus tendon graft; however, their method involves drilling a hole in both the metacarpal and proximal phalanx, corresponding with the proximal and distal attachments of the collateral ligaments. (15) The tendon graft was passed through these holes in a technique very similar to the suture repair method used in this case report. They report good or excellent postoperative results in 16/20 joints. The preferential use of tendon grafts in human medicine is something that may be suitable for adaption to use in avian medicine.
In a study that examined the intertarsal collateral ligaments of various strains of domestic fowl under different feeding regimes, (16) histopathologic studies reveal morphologic changes in ligaments of ad libitum-fed broilers that were less apparent or absent in other birds examined. Most notably these broilers lost the crimp pattern in the collagen bundles, which is suggested to be associated with structural derangement and tissue ischemia. The authors, along with others, concluded that despite feed restrictions, heavier strains of fowl develop structural changes to their collateral ligaments that may predispose them to weakness and rupture. (17,18) The duck we describe was being fed an ad libitum high-energy diet; therefore, some prior weakness or structural abnormality to the collateral ligament may have been present as a result of rapid growth, which may have predisposed the duck to injury.
The progressive nature of the lameness in this case suggests that the medial instability was the result of repeated trauma to the medial collateral ligament, leading to the nonweight-bearing lameness; this is consistent with findings in the human literature that report repeated traumatic injuries increase the risk of ligament damage. (19) This trauma likely was sustained during the copulation attempts on land by the drake, which was significantly larger than this female (5.8 kg versus 1.78 kg). Despite the traumatic ligament damage, this repair describes a simple technique to provide stability and full functional return to the joint.
A common complication of joint surgery in birds is soft tissue and nerve damage. (4,10) Passing the extracapsular suture beneath the common calcaneal tendon and medial metatarsal vein in this case appeared to avoid similar complications and allowed for a normal functional outcome. Similarly, prolonged external fixation leads to a decreased range of motion after surgery. (4,20,21) In this case the soft bandage allowed the duck to flex and extend the intertarsal joint while supporting the limb. Once the bandage was removed, the range of motion appeared normal when compared with the contralateral limb. Azmania et al (22) reported arthritic changes in pigeons (Columbia livia) with experimentally induced stifle luxation, independent of treatment modality and functional outcome. All pigeons recovered well and were able to bear weight normally, but 6 weeks after surgery, postmortem examination revealed mild pododermatitis affecting all birds, joint capsule fibrosis, hemorrhagic synovial fluid, and callus formation around the pins. Degenerative joint changes were evident histologically. This study highlights the fact that, despite apparently good functional outcomes, degenerative changes are possible long-term sequelae of ligament repair in birds despite not being present to date in this case.
Although considered the gold standard in the human literature, (19,23,24) ligament repair has not been reported in birds, with arthrodesis, extracapsular repair, and extraskeletal fixation being used preferentially, with mixed results. (4,20,21,25,26) The unique anatomy of birds poses significant challenges to the surgeon, especially given the minute nature of many of the ligaments. The heavy body weight and reliance of Anatidae on their legs and feet means that a rapid return to function, as well as a pain-free functional outcome, is essential to a long-term positive outcome. We hope that the technique we describe in this duck can be applied to a variety of avian species and provide an alternative to arthrodesis in birds with similar injuries.
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Hamish R. Baron, BVSc, MANZCVS (Avian Health), David N. Phalen, DVM, PhD, and Mikel Sabater Gonzalez, CertZooMed, Dipl ECZM (Avian)
From the Avian Reptile and Exotic Pet Hospital, Sydney School of Veterinary Science, Faculty of Science, University of Sydney. NSW, Australia.
Caption: Figure 1. Craniocaudal view of the left intertarsal joint of a female Pekin duck with left leg lameness showing intertarsal joint effusion (arrows). No bone abnormalities are visible.
Caption: Figure 2. Medial view of the intertarsal joint of the duck demonstrating the superficial tendons and nerves as they course over the intertarsal joint. (A) Tibiotarsus, (B) tarsometatarsus, (i) common calcaneal (gastrocnemius) tendon, (ii) cranial tibial muscle, (iii) superficial peroneal tendon, (iv) dorsal metatarsal nerve, (v) gastrocnemius muscle, (vi) annular tibial ligament.
Caption: Figure 3. Surgical sequence performed on a duck cadaver specimen demonstrating (A) the medial surgical approach and exposure of the medial collateral ligament (white arrow). (B) The origin of the medial collateral ligament (star) and the bone tunnel in the medial tibial condyle approximating this origin (needle). (C) Both bone tunnels (needles) are now in place approximating the origin and insertion (star) of the medial collateral ligament. (D) The size-0 nylon suture has been passed through the guides and needles removed from the bone tunnel to facilitate apposition of the ruptured ends of the medial collateral ligament (white arrows).
Caption: Figure 4. Schematic cranial view of the intertarsal joint of the duck demonstrating the ruptured medial collateral ligament and the nylon extracapsular repair (viii). (A) Tibiotarsus, (B) tarsometatarsus, (i) medial meniscus, (ii) lateral meniscus, (iii) distal medial collateral ligament (ruptured), (iv) lateral collateral ligament, (v) lateral metatarsal meniscal ligament not, (vi) medial tibiometarsal ligament (lateral tibial meniscal not visible), (vii) proximal medial collateral ligament (ruptured), (viii) synthetic 0-nylon suture material in situ.
Caption: Figure 5. Schematic cranial view of the intertarsal joint of the duck demonstrating ligaments and articular surfaces in a normal standing position. (A) Tibiotarsus, (B) tarsometatarsus, (i) medial meniscus, (ii) lateral meniscus, (iii) medial collateral ligament, (iv) lateral collateral ligament, (v) lateral metatarsal meniscal ligament, (vi) medial tibiometarsal ligament (lateral tibial meniscal ligament not visible).
Caption: Figure 6. Schematic cranial view of the intertarsal joint of the duck demonstrating the tendons and deep muscles (proximal) in a normal standing position. A) Tibiotarsus, (B) tarsometatarsus, (i) Long digital extensor tendon, (ii) lateral meniscus, (iii) anular tibial ligament, (iv) cranial tibial muscle, (v) superficial peroneal muscle, (vi) insertion of the cranial tibial muscle, (vii) medial tibial condyle, (viii) lateral tibial condyle.
Caption: Figure 7. Schematic craniomedial view of the intertarsal joint and tarsometatarsus showing arterial and venous blood supply to the lower leg. (A) Tibiotarsus, (B) tarsometatarsus, (i) cranial tibial artery, (ii) medial plantar artery, (iii) medial metatarsal vein, (iv, v) digital arteries.
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|Title Annotation:||Clinical Report|
|Author:||Baron, Hamish R.; Phalen, David N.; Gonzalez, Mikel Sabater|
|Publication:||Journal of Avian Medicine and Surgery|
|Article Type:||Clinical report|
|Date:||Mar 1, 2018|
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