In this picture you can see GAIA. It is a beautiful female greyhound, young adult with indeterminate age, 17.5 Kg, and she is the protagonist of this story. On the picture you can see her with Paqui, a veterinary of the Cervantes veterinary clinic team from LORCA-Murcia.
In this report I'm going to tell you some months of her life, the ones related with the treatment followed to restore her bad health.
In this report I'm going to tell you some months of her life, the ones related with the treatment followed to restore her bad health.
GAIA was picked up from the street, and came to the Veterinary Clinic thanks to an animal protection association. She had a severe trauma in her right rear extremity with multiple and splintered fracture of tibia and fibula a few months earlier. Subsequently and during her abandon this fracture strengthened abnormally, like a bad joining, provoking on her multiple deformations and a severe limp.
This picture shows GAIA’s right rear extremity. At first sight you can see the incorrect consolidation of the fracture of tibia and fibula.
The distal portion (the most distant from the trunk) of the fractured extremity had the four possible deformations in relation to the proximal portion (the closest to the trunk), the following ones:
-Translational deformation.
-Rotational deformation.
-Angular deformation.
-Deformation of longitudinal shortening.
From the measurements of both rear extremities of GAIA and her x-rays, and a comparative study between them (the healthy left one and injured right one), it was obtained the magnitude of each of these deformations and they allowed to plan thoroughly the orthopedic-surgical treatment to correct them.
The distal portion (the most distant from the trunk) of the fractured extremity had the four possible deformations in relation to the proximal portion (the closest to the trunk), the following ones:
-Translational deformation.
-Rotational deformation.
-Angular deformation.
-Deformation of longitudinal shortening.
From the measurements of both rear extremities of GAIA and her x-rays, and a comparative study between them (the healthy left one and injured right one), it was obtained the magnitude of each of these deformations and they allowed to plan thoroughly the orthopedic-surgical treatment to correct them.
In this picture you can see GAIA with Alejandro Blanco, the surgeon who treated her.
The treatment was performed in two clear different phases:
1st: The surgical implantation of an Ilizarov External Fixator.
2nd: Series of subsequent daily adjustments in the Ilizarov External Fixator for a period of roughly two months.
NOTES:
-During the surgical implant was performed an osteotomy of tibia and fibula at the level of the bad joining in order to be able to modify the relative position of the distal portion of the extremity in relation to the proximal one to solve the deformations.
-Translational and rotational deformations were resolved during the surgery and immediately after the osteotomy by means of a transversal displacement and axial rotation of the distal portion.
-Angular and longitudinal shortening deformations began to be solved five days after the surgery by a process of alignment which lasted 10 days, followed by another of lengthening which lasted 26 days.
1st: The surgical implantation of an Ilizarov External Fixator.
2nd: Series of subsequent daily adjustments in the Ilizarov External Fixator for a period of roughly two months.
NOTES:
-During the surgical implant was performed an osteotomy of tibia and fibula at the level of the bad joining in order to be able to modify the relative position of the distal portion of the extremity in relation to the proximal one to solve the deformations.
-Translational and rotational deformations were resolved during the surgery and immediately after the osteotomy by means of a transversal displacement and axial rotation of the distal portion.
-Angular and longitudinal shortening deformations began to be solved five days after the surgery by a process of alignment which lasted 10 days, followed by another of lengthening which lasted 26 days.
1.-Translational deformation.
In this craniocaudal x-ray of the fracture, the veterinarian could observe and measure a 15 mm translational deformation to one side.
2.-Rotational deformation.
This deformation was measured by calculating the angular difference between the knee an tarsus flex-extension planes of the two rear extremities. It was 20 degrees outward.
3.-Angular deformation.
This craniocaudal image clearly shows the lateral angular deformation.
3A.-Angular deformation towards lateral.
In this cranium-caudal x-ray we could observe and measure an angular deformation of 22 degrees towards lateral. (Seen in the previous picture). On the left, the injured extremity and, on the right, the healthy one which it is compared with.
3B.-Angular deformation towards caudal.
In this middle-lateral radiograph could observe and measure the angular deformation of 10 degrees towards caudal
Angular deformations (lateral and caudal ones) were combined to create both a single vector and a correction or distraction plane. This calculation was performed by three methods:
-By trigonometric calculations.
-By a drawing made with a CAD program (see picture).
-By a graphic setting out on graph paper (next picture).
The Lateral-caudal angular deformation combined angle is 24 degrees.
-By trigonometric calculations.
-By a drawing made with a CAD program (see picture).
-By a graphic setting out on graph paper (next picture).
The Lateral-caudal angular deformation combined angle is 24 degrees.
The graphic setting out was made on graph paper. Two axes were drawn: one horizontal, representing the middle-lateral direction, and other vertical, representing the craniocaudal direction.
Then it was drawn, in full-scale, the distal fixation ring of the Ilizarov External Fixator (85 and 115 mm in diameter two concentric circles), and, inside of it, a proximal-distal image of the osteotomy to be performed in the bad joining.
From the center it was drawn a 22 mm vector in the lateral semi-axis direction and a 10 mm other in the caudal semi-axis direction. The combination of these two vectors gave the direction line of placement in the distal fixation ring of the screwed rod of distraction. This rod is placed at the intersection of this line with the distal fixation ring by the lateral-caudal side.
Perpendicular to this line and tangent to the craniomedial edge of the osteotomy (the convex face of the deformation) it was drawn the line which provides the direction of placement of the cardan-hinges. Their fixations are placed at the two intersections of this line with the distal fixation ring of the Ilizarov External Fixator, one in the cranium-lateral side and the other in the middle-caudal one. The line passing by the rotations centers of the cardan-hinges is the rotation axis of correction, or hinge, the one around which the distal potion of the extremity was turning around so that its axis was aligned with the proximal portion. The turn was performed modifying slightly every day the angle between the distal and central rings up to a value equal to the total angle of correction (24 degrees).
Then it was drawn, in full-scale, the distal fixation ring of the Ilizarov External Fixator (85 and 115 mm in diameter two concentric circles), and, inside of it, a proximal-distal image of the osteotomy to be performed in the bad joining.
From the center it was drawn a 22 mm vector in the lateral semi-axis direction and a 10 mm other in the caudal semi-axis direction. The combination of these two vectors gave the direction line of placement in the distal fixation ring of the screwed rod of distraction. This rod is placed at the intersection of this line with the distal fixation ring by the lateral-caudal side.
Perpendicular to this line and tangent to the craniomedial edge of the osteotomy (the convex face of the deformation) it was drawn the line which provides the direction of placement of the cardan-hinges. Their fixations are placed at the two intersections of this line with the distal fixation ring of the Ilizarov External Fixator, one in the cranium-lateral side and the other in the middle-caudal one. The line passing by the rotations centers of the cardan-hinges is the rotation axis of correction, or hinge, the one around which the distal potion of the extremity was turning around so that its axis was aligned with the proximal portion. The turn was performed modifying slightly every day the angle between the distal and central rings up to a value equal to the total angle of correction (24 degrees).
4.-Deformation of shortening.
The longitudinal measurements got from the injured extremity were subtracted from the ones got from the healthy one to determine the deformation of shortening.
These measurements were performed by two methods:
A-Directly on the rear extremities.
B-On their radiographs.
In this picture you can see the annotations of the measurements performed directly on the extremity.
-The proximal portion measured 100 mm.
-The distal portion measured 60 mm.
It turns out a total of 160 mm when both portions are aligned.
-The healthy extremity measured 195 mm.
The difference (195-160 = 35 mm) is the deformation of shortening.
These measurements were performed by two methods:
A-Directly on the rear extremities.
B-On their radiographs.
In this picture you can see the annotations of the measurements performed directly on the extremity.
-The proximal portion measured 100 mm.
-The distal portion measured 60 mm.
It turns out a total of 160 mm when both portions are aligned.
-The healthy extremity measured 195 mm.
The difference (195-160 = 35 mm) is the deformation of shortening.
Summary of the measurements of deformation of shortening.
The first ones are the direct longitudinal measurements on GAIA’s rear extremities. This calculation has already been explained.
The next ones are the measurements form the x-rays from both extremities.
They have the following values:
-180 mm for the injured extremity.
-215 mm for the healthy extremity.
The difference (215-180 = 35 mm) is the deformation of shortening.
Note: The Anatomical points chosen to measure the longitudinal deformation on the x-rays were different from those chosen to measure directly on GAIA’s extremities; this explains why the values are different. This is irrelevant since the deformation of shortening (35 mm) is the difference between the respective measurements taken from each method.
The next ones are the measurements form the x-rays from both extremities.
They have the following values:
-180 mm for the injured extremity.
-215 mm for the healthy extremity.
The difference (215-180 = 35 mm) is the deformation of shortening.
Note: The Anatomical points chosen to measure the longitudinal deformation on the x-rays were different from those chosen to measure directly on GAIA’s extremities; this explains why the values are different. This is irrelevant since the deformation of shortening (35 mm) is the difference between the respective measurements taken from each method.
This is the Ilizarov External Fixative suited to the size of GAIA. It is formed by three rings and several structural rods.
It was mounted before its surgical implant, based on the size of the proximal and distal portions of the tibia, and on the position and magnitude of the deformations.
Two stainless steel screwed rods fasten together the proximal ring to the central one firmly. On the picture you can see that the proximal ring is 3/4. The hollow space allows that GAIA can flex her extremity normally as we will see later.
The distal ring is joined to the central one in an angle of 24 degrees by means of three rods. Two of them are articulated with cardan-hinges. The third one is the distraction one and is fastened to the rings by media oliva nuts which allow varying the distance between them by modifying the angle they form.
It was mounted before its surgical implant, based on the size of the proximal and distal portions of the tibia, and on the position and magnitude of the deformations.
Two stainless steel screwed rods fasten together the proximal ring to the central one firmly. On the picture you can see that the proximal ring is 3/4. The hollow space allows that GAIA can flex her extremity normally as we will see later.
The distal ring is joined to the central one in an angle of 24 degrees by means of three rods. Two of them are articulated with cardan-hinges. The third one is the distraction one and is fastened to the rings by media oliva nuts which allow varying the distance between them by modifying the angle they form.
On a table are arranged and classified all the pieces and instruments, properly sterilized, which are necessary for the correct implant of the Ilizarov External Fixator: rods, nuts, washers, pliers, wrenches and the dynamometric tensioner of the fixation needles.
On other tables in the operating room are available the common surgical instruments, plus the drillers to pass the fixation needles, the oscillating saw for performing the osteotomy and others.
On other tables in the operating room are available the common surgical instruments, plus the drillers to pass the fixation needles, the oscillating saw for performing the osteotomy and others.
The surgeon implanted the Ilizarov External Fixator, with two crossed needles in each ring (a needle on each side of each ring). These goes through soft tissues and the tibia leaving the extremity firmly fastened to the fixator.
He tensed the proximal and central ring needles with the dynamometric tensioner and he screwed them firmly at each end. He only tested the needles of distal ring.
The fixation was placed according to three basic conditions:
1-To fix the distal ring in a way that the perpendicular plane to the distraction rod which goes through the cardan-hinge matches with the point of the bad join which is going to perform the osteotomy in.
2-The line joining the centers of the cardans must be tangent to the convex edge of the bad join (middle-cranial edge).
3-Matching the distraction plane with the lateral-caudal angular deformation planel.
Next the surgeon performed the osteotomy, and then he moved 15 mm towards medial and turned 20 degrees inwards the distal ring needles, tensed them with the dynamometric tensioner and screwed them firmly at each end. With this operation the lateral translation and the external rotation deformations were corrected.
The implant ended up at 14:30 on July 10, 2013.
He tensed the proximal and central ring needles with the dynamometric tensioner and he screwed them firmly at each end. He only tested the needles of distal ring.
The fixation was placed according to three basic conditions:
1-To fix the distal ring in a way that the perpendicular plane to the distraction rod which goes through the cardan-hinge matches with the point of the bad join which is going to perform the osteotomy in.
2-The line joining the centers of the cardans must be tangent to the convex edge of the bad join (middle-cranial edge).
3-Matching the distraction plane with the lateral-caudal angular deformation planel.
Next the surgeon performed the osteotomy, and then he moved 15 mm towards medial and turned 20 degrees inwards the distal ring needles, tensed them with the dynamometric tensioner and screwed them firmly at each end. With this operation the lateral translation and the external rotation deformations were corrected.
The implant ended up at 14:30 on July 10, 2013.
14:34 on July 10, 2013.
In the picture you can see that the 3/4 proximal ring allows GAIA flexing her extremity. It also shows that the distal ring is forming a 24 degree angle with the central one.
The proximal and distal portions of the extremity are separate 1 mm due to the osteotomy, and they must remain like that for five days, until a certain vascularization is generated in the interstitium and it is created the properly condition so that a new bone tissue begins to be formed.
In the picture you can see that the 3/4 proximal ring allows GAIA flexing her extremity. It also shows that the distal ring is forming a 24 degree angle with the central one.
The proximal and distal portions of the extremity are separate 1 mm due to the osteotomy, and they must remain like that for five days, until a certain vascularization is generated in the interstitium and it is created the properly condition so that a new bone tissue begins to be formed.
In this picture you can see the plan that was prepared to correct the lateral-caudal angular deformation.
Five days after the implant of the fixation (July 15) began to be performed every 12 hours small adjustments on the nuts of the distraction rod according to the plan. With this method the distal ring went turning around the axis of rotation formed by the cardan-hinges, tending to place it parallel to the center ring.
The magnitude of the adjustments provoked a daily correction between 0.80 mm and 1.20 mm of the points that were more separated from the faces of the osteotomy. These are the optimal limits for the right bone regeneration.
The accumulation of daily corrections sets the total time which the correction of this deformation will take.
The plan picture shows that the corrections had to be performed over nine days. On July 23 the distal ring might have turned 24 degrees, just the necessary to align the distal portion of the tibia with the proximal one.
Five days after the implant of the fixation (July 15) began to be performed every 12 hours small adjustments on the nuts of the distraction rod according to the plan. With this method the distal ring went turning around the axis of rotation formed by the cardan-hinges, tending to place it parallel to the center ring.
The magnitude of the adjustments provoked a daily correction between 0.80 mm and 1.20 mm of the points that were more separated from the faces of the osteotomy. These are the optimal limits for the right bone regeneration.
The accumulation of daily corrections sets the total time which the correction of this deformation will take.
The plan picture shows that the corrections had to be performed over nine days. On July 23 the distal ring might have turned 24 degrees, just the necessary to align the distal portion of the tibia with the proximal one.
July 19.
Ten days after the implantation of the fixation, or five after the beginning of the distraction.
In this picture and x-ray you can see that after five days of beginning the small adjustments, every 12 hours, on the distraction rod nuts, the distal ring is becoming parallel to the central ring, and each portions of the tibia are being aligned.
Ten days after the implantation of the fixation, or five after the beginning of the distraction.
In this picture and x-ray you can see that after five days of beginning the small adjustments, every 12 hours, on the distraction rod nuts, the distal ring is becoming parallel to the central ring, and each portions of the tibia are being aligned.
July 24.
Fourteen days after the implantation of the fixation, or nine after the beginning of the distraction.
The angular deformation correction process had concluded. The articulated rods were replaced by two stiff rods of bone lengthening to correct the deformation of shortening of the injured extremity.
It is a clear thing in the picture on the left.
Fourteen days after the implantation of the fixation, or nine after the beginning of the distraction.
The angular deformation correction process had concluded. The articulated rods were replaced by two stiff rods of bone lengthening to correct the deformation of shortening of the injured extremity.
It is a clear thing in the picture on the left.
This picture shows the plan that was prepared to correct the deformation of shortening. The distal ring had to be moved away from the central one between 0.80 mm and 1.20 mm every day.
The next day after finishing with the correction of the angular deformation, it began the deformation of shortening correction.
On July 25, fifteen days after the implant of the fixation, began to be performed small adjustments every 12 hours in the nuts of lengthening rods.
The magnitude of the adjustments in the lengthening rods might have caused a daily correction between 0.80 mm and 1.20 mm between the distal and proximal portion of the tibia, since these are the optimal limits to get the right bone regeneration.
The accumulation of daily corrections sets the total time which the correction of this deformation will take.
The plan picture shows that corrections would have finished on August 18. During that period of time, the distal ring must have moved away from the central ring exactly the distance to match the lengths of both extremities.
The next day after finishing with the correction of the angular deformation, it began the deformation of shortening correction.
On July 25, fifteen days after the implant of the fixation, began to be performed small adjustments every 12 hours in the nuts of lengthening rods.
The magnitude of the adjustments in the lengthening rods might have caused a daily correction between 0.80 mm and 1.20 mm between the distal and proximal portion of the tibia, since these are the optimal limits to get the right bone regeneration.
The accumulation of daily corrections sets the total time which the correction of this deformation will take.
The plan picture shows that corrections would have finished on August 18. During that period of time, the distal ring must have moved away from the central ring exactly the distance to match the lengths of both extremities.
July 30. After five days from the beginning of the bone elongation.
On the x-ray, near the distal ring you can see the interstitium corresponding to the elongation caused in this period. The new bone tissue is being formed.
On the x-ray, near the distal ring you can see the interstitium corresponding to the elongation caused in this period. The new bone tissue is being formed.
August 7th. After twelve days from the beginning of the bone elongation.
On the x-ray, near the distal ring you can see the growth of the interstitium corresponding to the elongation produced in this period. The elongation of the extremity is clear in the picture on the left.
On the x-ray, near the distal ring you can see the growth of the interstitium corresponding to the elongation produced in this period. The elongation of the extremity is clear in the picture on the left.
August 19.
The process of bone lengthening ended the previous day, twenty-six days have passed since the beginning of bone elongation.
This process has finished by matching the length of both extremities and correcting the deformation of shortening. On the x-ray, near the distal ring you can see the growth of interstitium corresponding to the elongation. In the enlargement on the right is clearly visible the gradation of ossification from the proximal and distal edges of the osteotomy towards the central part.
The process of bone lengthening ended the previous day, twenty-six days have passed since the beginning of bone elongation.
This process has finished by matching the length of both extremities and correcting the deformation of shortening. On the x-ray, near the distal ring you can see the growth of interstitium corresponding to the elongation. In the enlargement on the right is clearly visible the gradation of ossification from the proximal and distal edges of the osteotomy towards the central part.
August 26. Eight days after the end of the bone elongation.
Forty-seven days after the implant the Ilizarov External Fixator.
The x-ray shows the progressive ossification of the elongated part.
Forty-seven days after the implant the Ilizarov External Fixator.
The x-ray shows the progressive ossification of the elongated part.
August 26. (The same day).
The previous x-ray has shown the state of ossification of the elongated part; in view of this, the surgeon can withdraw the proximal ring of the Ilizarov External Fixator.
The previous x-ray has shown the state of ossification of the elongated part; in view of this, the surgeon can withdraw the proximal ring of the Ilizarov External Fixator.
September 10.
Twenty-three days after the end of the bone elongation.
Sixty-two days after the implant the Ilizarov External Fixator.
The x-ray shows that the ossification of the elongated section is sufficiently as to replace the Ilizarov External Fixator by a Uniplanar Kirschner-Ehmer Fixator External.
Twenty-three days after the end of the bone elongation.
Sixty-two days after the implant the Ilizarov External Fixator.
The x-ray shows that the ossification of the elongated section is sufficiently as to replace the Ilizarov External Fixator by a Uniplanar Kirschner-Ehmer Fixator External.
September 10. (The same day).
The surgeon replaced the Ilizarov external fixation by an Uniplanar Kirschner-Ehmer Fixator External.
GAIA came to the Veterinary Clinic with a great loss of muscle mass and a muscular contraction of the twins of the treated extremity. Now she can complete the ossification period and an appropriate exercise of physical therapy to regain her muscle mass and especially the muscular contracture of the twins so that GAIA can support her foot properly.
The surgeon replaced the Ilizarov external fixation by an Uniplanar Kirschner-Ehmer Fixator External.
GAIA came to the Veterinary Clinic with a great loss of muscle mass and a muscular contraction of the twins of the treated extremity. Now she can complete the ossification period and an appropriate exercise of physical therapy to regain her muscle mass and especially the muscular contracture of the twins so that GAIA can support her foot properly.
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March 1, 2014.
Almost five months later, GAIA has regained her muscle mass and the atrophy of her right rear leg has disappeared and she has been adopted by a family.
Almost five months later, GAIA has regained her muscle mass and the atrophy of her right rear leg has disappeared and she has been adopted by a family.