Canine Unicompartmental Elbow (CUE)

The Canine TightRope® Shoulder Stabilization technique is designed for the experienced veterinary shoulder arthroscopist for stabilization of the subscapularis, medial glenohumeral ligament (MGL) or both.
To prepare patient for hanging limb technique, place the patient in dorsal recumbency and clip, prep and drape widely around the shoulder joint for access to medial and lateral aspects of the shoulder. Establish a lateral scope portal just caudal to the acromion and fully access the joint documenting all pathology present. Determine if the main pathology (e.g. laxity and/or tearing) is in the subscapularis, MGL, or both. Make a ~2 cm incision on the medial aspect of the shoulder joint immediately cranial to the pectoralis muscles. Bluntly dissect under the pecs, retracting them caudally, to the level of the joint on the medial side.

Medial Approach with Tenotomy Option

Make a medial incision along cranial border of the medial head of the triceps over the epicondyle and then between the flexor carpi ulnaris and the superficial digital flexor – skin and fascia – ~1/4 of humerus and ~1/4 of antebrachium length.

1-1

Cut a u-shaped incision down to bone around the medial epicondyle, with tenotomy of flexor muscles at origin, near the epicondyle.

1-2

Make an incision from base of the U all the way through the joint capsule, across the joint, and distally between the flexor carpi ulnaris and the superficial digital flexor and caudal to the deep digital flexor.

1-3

Elevate the flexor muscles, joint capsule and medial collateral ligament cranially and caudally (staying on bone) to expose the cranial and caudal extents of the humeral articular cartilage, radial head and ulnar notch ("open the curtains ").

1-4

Valgus stress and internally rotate the antebrachium over a pad or block to expose and access the medial aspect of the humeral condyle (MHC) and medial coronoid process (MCP).

1-5

Gelpis can be used to retract the periarticular tissues while an assistant maintains valgus and internal rotation, so the CUE instruments can easily be placed perpendicular to the articular surfaces of the MHC and MCP.

Medial Approach with Epicondylar Osteotomy Option

2-1

Place a beath pin from the center of the medial epicondyle to the center of the lateral epicondyle, outline the cranial, proximal and caudal "edges" of medial epicondyle (~4-6 mm from drill bit in each direction). Place saw guide over the beath pin.

2-2

Use a sagittal saw with a small blade to "osteotomize" the epicondyle at its "edges". Angle the osteotomies so that you end up with a trapezoidal shaped section of bone. Cut into the humerus ~5 mm for each osteotomy.

2-3

Incise from the caudal base of the osteotomy all the way through the joint capsule, across the joint, and distally between flexor carpi ulnaris and the superficial digital flexor and caudal to the deep digital flexor.

2-4

Lever the epicondylar bone out, from proximal to distal, and elevate the flexor muscles, joint capsule and medial collateral ligament cranially and caudally (staying on bone). This will expose the cranial and caudal extents of humeral articular cartilage, radial head and ulnar notch.

2-5

Valgus stress and internally rotate the antebrachium over a pad or block to expose and access the medial aspect of the humeral condyle (MHC) and medial coronoid process (MCP).

2-6

A Gelpis can be used to retract the periarticular tissues, while an assistant maintains valgus and internal rotation, so that the CUE instruments can easily be placed perpendicular to the articular surfaces of the MHC and MCP.

Ulna Implant

3-1

Remove fragments, osteophytes and abnormal cartilage and bone to define borders of the MCP.

3-2

Center the appropriate size Ulna Drill guide on the MCP, flush to the articular surface, and place a beath pin through the Ulna Drill to exit the caudal ridge of the ulna.

3-3

When the beath pin is properly placed, use the Ulna Drill (reamer) to create the ulnar socket. Be careful to stay aligned on beath pin when reaming. Do not get off axis or wobble.

3-4

Remove the beath pin, lavage and use the Ulna Trial to determine that the ulnar socket is properly reamed.

Proceed to Humerus Implant steps before placing the Ulna Implant.

3-5

After placing the Humerus Implant, you may now place the Ulna Implant in the Ulna Implant Holder. Make sure the ridges and radiographic marker are facing out and implant it into the ulnar socket.

3-6

If necessary, the Ulna Tamp is used to fully seat the Ulna Implant.

3-7

Final view showing Humerus and Ulna Implant in place.

Humerus Implant

4-1

Place the appropriate size Humerus Drill guide on humeral articular surface so that it most fully covers the humeral lesion, making sure that it is flush to the articular surface and sagittally aligned.

4-2

When the drill guide is optimally positioned, drill the beath pins through the guide and at least 15 mm into the MHC, making sure to keep the drill guide pressed firmly and flush against the articular surface.

4-3

Cut the beath pins as flush as possible to the guide. Remove the Humerus Drill guide and insert the Humerus Drill Stop over the beath pins.

4-4

Place the Humerus Drill (reamer) in the Humerus Drill Stop and over the beath pins. Keep the Humerus Drill pressed firmly and flush against the articular surface. Use the reamer to fully ream the first humeral socket, flip the reamer and guide and ream the second humeral socket.

4-5

Place the Humerus Implant in the Humerus Implant Holder so that the bony ingrowth surface is facing out and implant into the humeral sockets.

4-6

Use the Humerus Tamp to fully seat the Humerus Implant.

Postoperative Care Recommendations

• Oral antibiotics (cephalexin, clavamox, or similar) for 10 days

• Soft-padded bandage maintained for 2 weeks minimum (can extend if sore or concerned)

• Cage rest and leash walking only for a minimum of 8 weeks

• Start rehabilitation at 8-12 weeks toward progressive return to function

• Full athletic function not expected until 6 months postoperatively

• Rechecks at 2 weeks (suture and bandage removal), 8-12 weeks (with radiographs), and 6 months (with radiographs)

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