Case study: Dog - tarsal arthrodesis plate exposed
20 April 2015
Seven-year-old, female neutered, mixed breed dog. In 2013 the dog was involved in a road traffic accident. The left hock was fractured in multiple places and the joint was arthrodesed. The dog recovered well and had good use of the affected limb. In February 2015 the dog presented to the clinic for routine vaccination. A clinical examination was performed at this time and it was noted that the surgical plate used in the arthrodesis had become exposed (please see drop box folder). The owner reported that the plate had been like this for the past year and the dog seemed unbothered by it. On clinical exam the dog was sound and there appeared to be no gross discharge or infection coming from around the exposed plate. The dog didn’t resent palpation of the area and radiographs of the limb supported clinical findings of no osteomyelitis and the joint appeared to have completely arthrodesed. Due to the high risk and potentially devastating consequences of the bone becoming infected, a surgery was planned to remove the plate and close the wound via direct primary closure.
Due to the location and the scaring from the first surgery it was not going to be possible to remove the plate and close the wound left without advanced soft tissue reconstructive techniques. Soft tissue expansion was utilized in this case to expand the skin prior to removal of the plate and reconstruction. Six soft tissue expanders were placed at the very distal borders of the tibia and the skin expanded just proximal to the hock. The surgical plan was to use this expanded in as an advancement flap to help aid wound closure.
- Implantation of the soft tissue expanders proceeded well on the 17th of March 2015 (day 0)
- The dog was anaesthetised in a routine fashion and the surgical site clipped and prepped
- The devices were placed through 2 separate incision sites proximal to placement of the devices device and away from the site of expansion
- Retaining (quilting) sutures were placed in order to prevent the devices migrating either towards the wound or proximally to the incision sites
- The dog was discharged the same day of implantation, with a bandage placed
- The bandage was removed 2 days post operatively and the dog was assess weekly by the surgeon
- Device removal and reconstruction 17th April 2015 (day 30)
- All six devices expanded as expected throughout the 30 day period
- No discomfort or lameness was observed and the dog's demeanour remained normal throughout the expansion phase
- The dog was anaesthetised and prepped for surgery in a routine fashion
- The scar tissue surrounding the surgical plate was excised and the current wound extended to facilitate removal of the plate (see drop box photos)
- The plate was removed and surrounding tissues debrided
- The expanders were removed and the fibrous capsule formed from the expanders was scored with a scalpel blade to facilitate extra stretch from the expanded skin (this is routinely done in human expanded skin)
- An H plasty was utilised to advance the expanded skin over the defect
- The advancement flap closed the most proximal half of the wound with the remaining distal portion of the wound being closed with the surrounding tissues
- Sutures were removed 14 days post reconstruction, the wound healed as expected with just a small area of break down on the distal tip of the advancement flap about 0.5cm which healed fine by secondary intention
The surgeons in the case were very pleased with the expansion of the skin commenting that the skin expanded perfectly. The bandage was removed after two days of implantation and left open for the rest of the duration of expansion. The dog tolerated the expanders very well. There was no bruising over the expanded devices (post implantation bruising) and no sign of alopecia or indication that the expanders where producing a negative effect on the skin.
This was a fantastic outcome of a case fraught with difficulties. The skin expanded as required and wanted enabling the surgeons to close a wound easily and with very minor complications, which otherwise would have required extensive and advanced surgical techniques and potentially increased complications for the patient.
The surgeons would have been more aggressive with size of device used in hindsight and they would have used Expaniderm's larger devices which expand to 30mm, they would also slightly adjusted the placement of the expanders initially to better utilize expanded skin in this case
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