Arthrodesis as a Treatment for Metacarpophalangeal Joint Luxation in 2 Raptors

Author(s): Arnaud J. Van WettereDMV and Patrick T. RedigDVM, PhD Source: Journal of Avian Medicine and Surgery, 18(1):23-29. 2004. Published By: Association of Avian Veterinarians DOI: http://dx.doi.org/10.1647/2003-002 URL: http://www.bioone.org/doi/full/10.1647/2003-002

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Journal of Avian Medicine and Surgery 18(1):2329, 2004 2004 by the Association of Avian Veterinarians

Case Series

Arthrodesis as a Treatment for Metacarpophalangeal Joint Luxation in 2 Raptors

Arnaud J. Van Wettere, DMV, and Patrick T. Redig, DVM, PhD
Abstract: Two raptors, a juvenile prairie falcon (Falco mexicanus) and an adult female great horned owl (Bubo virginianus), were presented with luxation of the metacarpophalangeal joint. Additionally, the falcon had a distal metacarpal articular fracture, and the owl had an open wound at the luxation site. After supportive care, both birds were treated by arthrodesis of the metacarpophalangeal joint. A Type 1 external skeletal xator was applied to stabilize the joint and to allow bony fusion to occur. Bony fusion occurred in 6 and 9 weeks in the falcon and the owl, respectively. Full ight capacity was restored, and both birds were released into the wild. Arthrodesis represents a viable option for the treatment of metacarpophalangeal joint luxations or articular fractures of the associated bone in avian species when treatment by reduction and stabilization fails. Key words: metacarpophalangeal joint, luxation, articular fracture, arthrodesis, avian, prairie falcon, great horned owl, Falco mexicanus, Bubo virginianus

Introduction Fractures and luxations of the metacarpophalangeal joint are uncommon problems in birds and generally result from trauma. In birds of prey presented to The Raptor Center at the University of Minnesota, the 2-year incidence proportion (October 2000 to October 2002) of fracture or luxation of the metacarpophalangeal joint or digits was 0.13% (2/1579; P. T. R., unpublished data, 2002). The metacarpophalangeal joint consists of the distal major and minor metacarpus, the proximal part of the minor digit, and the proximal phalange of the major digit (Fig 1). The major digit, proximal phalange, and minor digit move together, but their mobility is severely restricted by ligamentous connections. When extended or exed, they spread or fold the primary feathers. Because of the length of the primary feathers, small movements of the digits greatly affect the surface area of the wing, allowing important adjustment during ight. The major digit can also rotate and be elevated or depressed relative to the metacarpus. This very restricted movement raises or lowers the leading edge of the primaries and is important in subtle adjustment during ight.1
From The Raptor Center, Small Animal Clinical Science, College of Veterinary Medicine, University of Minnesota, St Paul, MN 55108-6108, USA.

Extension of the digits is effected by the muscles extensor longus digiti majoris, extensor digitorum communis, exor digitorum supercialis, exor digitorum profundus, abductor digiti majoris, and interosseus dorsalis. Flexion of the digits is effected by the muscles interosseus ventralis and exor digiti minoris.1 The extensor muscle mass is larger than that of the exor muscles because the forelimb ligaments draw the manus and digits into a exed position without muscular activity. The muscles extensor digitorum communis and interosseus ventralis produce a small elevation movement of the digit. The depression movement of the digit is produced by the muscles exor digitorum profundus and abductor digiti majoris.1 Repair of luxations may require reduction, immobilization, and, in some cases, stabilization.2,3 A luxation should be reduced as soon as possible after the initial injury. Although closed reduction is preferred, open reduction can be performed if necessary. After reducing the luxation, the joint should be immobilized for 14 weeks, depending on the degree of instability after reduction. If immobilizing the joint does not maintain reduction, stabilization is needed. Methods of stabilizing the joint include capsular or ligament repair, pinning across the joint, and use of a transarticular external skeletal xator.3,4 If the joint cannot be stabilized, the only 2 remaining options are amputation or arthrodesis.3 23

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To our knowledge, the management of luxation or fracture of the metacarpophalangeal joint has not been described in an avian species. The purpose of this report is to describe the successful treatment of luxation and fracture of the metacarpophalangeal joint by arthrodesis in 2 raptors. Arthrodesis of the metacarpophalangeal joints in these 2 birds restored full ight capacity. Case Reports Case 1 A juvenile female prairie falcon (Falco mexicanus) was found in a eld unable to y. On physical examination, the bird was alert and slightly underweight and had a dorsal metacarpophalangeal joint luxation of the right wing. The luxation was partially stable, and a large brous callus was present ventrally. Survey radiographs of the wing revealed a distal complete articular fracture of the major metacarpus and a distal fracture of the minor metacarpus (Fig 2). A blood sample was collected for measurement of a packed cell volume and total solids concentration, with results of 49% (reference range, 37%53%)5 and 3.2 g/L (reference range, 2.54.0 g/L)5, respectively. The wing was immobilized with silk tape (Durapore, 3M, St Paul, MN, USA) by wrapping it to the body. Supportive and antibiotic therapy was administered, consisting of lactated Ringers solution (20 ml/kg SC q12h for 2 days), vitamin B complex (1 mg/kg SC q12h for 2 days), iron dextran (10 mg/kg IM once), and amoxicillin/clavulanic acid (125 mg/kg PO q12h for 7 days; Clavamox, SmithKline Beecham Pharmaceuticals, Exton, PA, USA). Results of a fecal examination revealed the presence of ova of Serratospiculoides species and coccidial oocysts. Therefore, the falcon also received 2 doses of ivermectin (1 mg/kg SC; Ivomec, Merck & Co Inc, Whitehouse Station, NJ, USA) and toltrazuril (10 mg/kg PO;

Figure 1. Dorsoventral radiograph of the distal wing of a peregrine falcon (Falco peregrinus). The metacarpophalangeal joint consists of the distal major and minor metacarpus, the proximal part of the minor digit, and the proximal phalange of the major digit.

Previous attempts at management of metacarpophalangeal joint luxations in a bald eagle (Haliaeetus leucocephalus) and a red-tailed hawk (Buteo jamaicensis) at The Raptor Center by closed reduction and stabilization with a type 1 external skeletal xator alone or in conjunction with a splint did not restore joint stability and resulted in an unsatisfactory outcome (A. J. V. W. and P. T. R., unpublished data, January 2003).

Figure 2. Posterior-anterior radiograph of the distal right wing of a prairie falcon (case 1) with a dorsal metacarpophalangeal joint luxation and distal complete articular fracture of the major metacarpus.

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Figure 3. Dorsoventral radiograph of the distal right wing of the falcon in Figure 1 at 4 weeks after surgery. The external skeletal xator is in place, and there is a proliferation of callus at the arthrodesis site.

Baycox, Bayer Vital GmbH, Leverkusen, Germany), both given at 2-week intervals. Although the major digit and the metacarpus were not well aligned, the luxation was moderately stable. Therefore, the luxation and the fractures were managed conservatively with the wing immobilized with silk tape by wrapping it to the body. One month after the falcon was admitted for treatment, the luxation and fracture were stable and the bird was allowed free ight in a room enclosure. Fifteen days later, the joint was again luxated and the digit was refractured. After the failure of conservative treatment, we decided to surgically fuse the joint because it was the only option to return the falcon to full ight capacity. Cefazolin (100 mg/kg IM q6h; Ancef, SmithKline Beecham Pharmaceuticals, Philadelphia, PA, USA) and meloxicam (0.2 mg/kg IM q24h; Metacam, Boehringer Ingelheim Vetmedica GmbH, Ingelheim, Germany) were administered preoperatively. The falcon was induced with isourane admin-

istered by face mask and then intubated for maintenance anesthesia. The bird was monitored intraoperatively with an electrocardiograph and by direct observation of the respiratory rate and depth. The feathers were plucked on the ventral wing over the area of the distal metacarpus and digits and on the dorsal wing over the metacarpus and phalanges of the major digits. A ventral surgical approach was made over the joint.6 Some brous callus was removed with a 2-mm jaw width rongeur to allow access to the articular surfaces. The articular surfaces were removed with a 2-mm Volkman curette, and the subchondral bone was exposed. This debridement was somewhat blind because good visibility of the articular surfaces was difcult. After debridement, the skin was closed with 5-0 polyglactin (Vicryl, Ethicon, Somerville, NJ, USA) in a simple interrupted pattern. Two positive-prole threaded stainless steel pins (IMEX, Longview, TX, USA) of different sizes (0.035 in and 0.045 in) were inserted in the major digit and 2 (0.045 in) were

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Figure 4. Dorsoventral radiograph of the distal right wing of the falcon described in Figure 1 after removal of the external skeletal xator. Complete bony fusion is present.

inserted in the metacarpus. An acrylic connecting bar (Technovit, Jorgensen Lab Inc, Loveland, CO, USA) was used to link the external skeletal xator pins (Fig 3). The wing was folded against the body in anatomic position while the acrylic bar was curing. Length and rotational alignment similar to the contralateral wing were maintained with manual restraint. The wing was immobilized with silk tape (3M) by wrapping it to the body. The bird recovered from anesthesia uneventfully. Radiographs were obtained immediately after surgery and at 2, 4, and 6 weeks postoperatively. The wing was immobilized with silk tape wrap around the body during the healing process. Physical therapy was performed twice weekly with the falcon under isourane anesthesia. The physical therapy consisted of exing and extending the elbow and wrist joint through their entire range of motion for a period of 510 minutes.7 The incision and pin tracts healed uneventfully. At 2 weeks after surgery, the radiographs demonstrated increased ra-

dio-opacity at the arthrodesis site. At 4 weeks after surgery, periosteal and medullary bridging was visible. By 6 weeks after surgery (Fig 4), bridging was complete and the distal external skeletal xator pin was loose. Therefore, the external skeletal xator was removed and a splint was applied for 1 additional week. At 7 weeks after surgery, the wing wrap and the splint were removed. At this time, the falcon had full extension of the wing with good range of motion. The falcon was restricted to a hospital cage for 1 additional week before being moved to a ight room to allow increased activity. The bird was test own on a creance (a lightweight line attached to the tarsometatarsi by leather straps) at 10 weeks after surgery. Flight appeared mechanically sound.8 However, because this was a rst attempt at arthrodesis of the metacarpophalangeal joint, the effects of arthrodesis on ight capacity were unknown. Therefore, to be able to assess its ight capacity under controlled conditions, the falcon was trained using falconry techniques. After

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Figure 5. Dorsoventral radiograph of the distal left wing of a great horned owl (case 2) with a dorsal luxation of the metacarpophalangeal joint. Note the soft tissue enlargement at the luxation site.

training was completed, the falcon was own free. Flight capacity appeared fully recovered. The ight conditioning period was ended by creance ying 3 times weekly for 4 weeks. The bird was released into the wild 19 weeks after surgery. Case 2 An adult female great horned owl (Bubo virginianus) was found unable to y and brought to The Raptor Center at The University of Minnesota. On admission, the bird was depressed and very thin, and it had an open dorsal luxation of the metacarpophalangeal joint of the left wing. The luxation was unstable, and a large brous callus was present on the ventral wing. Survey radiographs conrmed the metacarpophalangeal joint luxation (Fig 5). A blood sample was collected for measurement of a packed cell volume and total solids concentration, with results of 38% (reference range, 40%46%)7 and 2.4 g/L (reference range, 4.04.5 g/L)7, respec-

tively. The luxation was stabilized with a splint (Veterinary Thermoplastic, IMEX, Longview, TX, USA), and the wing was wrapped with silk tape to the body. Supportive therapy was given as in case 1, except that treatment with lactated Ringers solution and vitamin B complex was continued for 5 days and antibiotic therapy with amoxicillin/clavulanic acid was continued for 15 days. A fecal examination revealed the presence of capillaria, ascarid, and trematode ova, and the owl received two 5-day treatments of fenbendazole (20 mg/kg PO; Panacur, Intervet Inc, Milsboro, DE, USA) at 2week intervals. Because of the poor condition of the bird and the open wound at the luxated joint, arthrodesis was delayed and a splint was applied until the time of the surgery. The open wound was managed with a wet to dry bandage for the rst 6 days. At that time, a good granulation bed was present and the wound was covered with a transparent dressing (Tegaderm, 3M, St Paul, MN, USA). Ten days after admission,

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Figure 6. Dorsoventral radiograph of the distal left wing of the owl described in Figure 5 approximately 17 weeks after arthrodesis of the metacarpophalangeal joint. The owl was released into the wild with full ight capability.

the overall condition of the bird had greatly improved and the wound was almost completely healed. Because of the excellent results obtained with the prairie falcon, surgical fusion of the joint was elected as treatment for the owl. The preparation, surgical technique, and placement of an external xator were applied as in case 1. Radiographs were obtained immediately after surgery and at 2, 4, 6, and 9 weeks postoperatively. The wing was immobilized with a silk tape wrap around the body until the fth week, and physical therapy was performed under isourane anesthesia twice weekly.7 The incision and pin tracts healed uneventfully. At 2 weeks after surgery, little change in radio-opacity was present at the arthrodesis site. At 4 weeks after surgery, a periosteal and medullary fusion was present, primarily on the ventral side. Periosteal and medullary fusion was still predominantly on the ventral side by 6 weeks after surgery, but periosteal bridging was visible dorsally. By 9

weeks after surgery, healing was complete (Fig 6), and the external skeletal xator was removed. The wing could be fully extended, with good range of motion present. The bird was restricted to a hospital cage for 1 additional week before being moved to a ight room to increase its activity. The bird was test own on a creance at 11 weeks after admission, and its ight was observed to be mechanically sound. Flight conditioning was improved by creance ying 3 times weekly for 6 weeks.8 The bird was released into the wild 17 weeks after surgery. Discussion The two raptors we describe were both presented with luxated metacarpophalangeal joints, with an additional complete articular metacarpal fracture in the rst case. Both birds were managed successfully by arthrodesis of the metacarpophalangeal joint and

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were released into the wild with full ight capability. In avian species, the very restricted movement of the metacarpophalangeal joint is important in subtle adjustment during ight.1 In these 2 cases, the birds apparently adapted very well to the small functional impairment caused by the arthrodesis of the joint. In the case of the prairie falcon, it was trained by falconry methods to allow us to evaluate it in continuous ight and in different situations: landing, turning, climbing, descending, and stooping and catching live prey. We observed no ight impairment. Conservative treatment in the prairie falcon probably failed because of spontaneous ankylosis of the joint, which rarely results in bony fusion but often results in severe periarticular brosis and contracture.3 Arthrodesis is a salvage procedure used in many situations, such as irreparable articular fracture, chronic joint instability, chronic severe degenerative joint disease, and partial paralysis of the limb caused by nerve damage.3 We believe that arthrodesis represents a viable option for the treatment of metacarpophalangeal joint luxations or articular fractures of the associated bone in birds when treatment by reduction and stabilization fails. The surgical principle of arthrodesis observed in small animal surgery as stated by Piermattei and Flo3 should also be applied in avian species: Surgery should be performed only in a non-infected joint, articular cartilage must be removed and subchondral bone exposed on what will be the fusion site, proper angle of the joint must be achieved, xation of the

bone must be rigid and long lasting, with compression of the contact surfaces preferred, and bone grafting is useful to speed the callus formation. This last point can be more difcult to achieve because the avian skeleton does not readily yield material for grafting.9,10
Acknowledgments: We thank Lori Arent for her assistance in the rehabilitation process and physical conditioning of these birds.

References
1. King AS, McLelland JM. Form and Function in Birds. Vol. 3. New York, NY: Academic Press Inc; 1985. 2. Bennett RA, Kuzma AB. Fracture management in birds. J Zoo Wildl Med. 1992;23:538. 3. Piermattei DL, Flo GL. Handbook of Small Animal Orthopedics and Fracture Repair. 3rd ed. Philadelphia, PA: WB Saunders; 1997. 4. Ackermann J, Redig P. Surgical repair of elbow luxation in raptors. J Avian Med Surg. 1997;11:247 254. 5. Jennings IB. Haematology. In: Beynon PH, ed. Manual of Raptors, Pigeons and Waterfowl. Ames, IA: Iowa State University Press; 1996:6878. 6. Orosz SE. Surgical anatomy of the avian carpometacarpus. J Assoc Avian Vet. 1994;8:179183. 7. Redig PT. Medical Management of Birds of Prey. St Paul, MN: University of Minnesota Press; 1993. 8. Chaplin S. Guidelines for exercise in rehabilitated raptors. Wildl J. 1989;12:1718. 9. Redig PT. Effective methods for management of avian fractures and other orthopaedic problems. Proc Eur Assoc Avian Vet. 2001;2642. 10. Jones R, Redig PT. Autogenous callus for repair of a humeral cortical defect in a red-tailed hawk (Buteo jamaicensis). J Avian Med Surg. 2001;15:302309.