Antebrachial Deformity Correction Combined with Osteotomized Pancarpal Arthrodesis Using Patient-Specific Guides and a Custom Printed Implant in a Dog

Abstract

This case report describes individualized treatment for a 4-year-old, 26 kg, Labrador–Springer crossbreed dog affected by chronic antebrachial growth deformity (ABGD) and recent acute carpal hyperextension injury. On the basis of a CT scan, patient-specific osteotomy guides (PSG) were designed for a diaphyseal radial ostectomy to correct the ABGD, as well as for distal radial and proximal radiocarpal and ulnar carpal bone ostectomies to arthrodese the antebrachiocarpal joint. A patient-specific 3D-printed titanium alloy implant (PSI) was applied to the dorsal aspect using the PSG pin holes as screw holes and the entire plate as a reduction device. Distally, the plate was applied to metacarpal bones II, III, and IV. At 2-month follow-up, the patient had returned to normal function, all implants were stable, and at 13 months, bone fusion was documented radiographically. When performing pancarpal arthrodesis, one might consider ostectomies (rather than burring) to increase the area of cancellous bone contact. Additional potential advantages of a PSG-PSI system include accurate limb alignment, improved distal fixation, and reduced surgical time. Carefully planned and executed single-session ABGD-correction and PCA resulted in an excellent long-term outcome in this large breed dog.

 

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Keywords

antebrachial growth deformity - pancarpal arthrodesis - patient-specific osteotomy guides - patient-specific implant - dog

Introduction

Antebrachial growth deformities (ABGD) are the most common limb malformation in dogs, with 63% caused by premature closure of the distal ulnar physis.[1] This typically results in radial external torsion, distal valgus, and increased procurvatum. These deformities then often cause secondary elbow joint incongruities and/or antebrachiocarpal joint laxity.[2] Correction of ABGD in dogs can be performed progressively using a circular external fixator,[3] or in a single surgical session using rigid internal fixation.[4] [5] Computer-aided design (CAD) now facilitates preoperative surgical planning on the basis of 3D bone data extracted from a CT scan,[6] as well as the design of both patient-specific 3D-printed surgical osteotomy guides (PSG) and patient-specific implants (PSI).[7]

Traumatic carpal hyperextension injury is a commonly encountered injury in dogs. Failure of the carpal palmar fibrocartilage is usually the result of jumping down from a height and overloading of the carpal support structures.[8] It typically manifests with palmigrade or lowered stance and carpal pain. Recommended treatment of carpal hyperextension injury is usually by salvage pancarpal arthrodesis (PCA).[9] Simultaneous ABGD correction and PCA has so far only been reported in five small breed dogs with ABGD and severe antebrachiocarpal joint collateral ligament laxity to address both these problems in a single surgery.[10] This is the first report of simultaneous ABGD correction and PCA in a large breed dog with chronic ABGD and recent traumatic carpal hyperextension injury using a 3D-printed custom-designed PSG and a 3D-printed PSI with an excellent long-term outcome.

 

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Case Report

History

A 4-year-old, male neutered, 26 kg, Labrador–Springer crossbreed dog was referred for management of a 3-week history of severe left thoracic limb lameness, which had been acute in onset following a fall in a local quarry. The owner reported that the dog had had an obvious deformity affecting that injured limb since adoption 1 year previously, but that this had not been associated with lameness or affected the dog's exercise tolerance (several hours a day on the owner's farm). Following initial presentation at the referring veterinary surgeon's clinic, NSAID medication and short leash walks were prescribed, which failed to improve the lameness.

 

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Clinical Examination and Surgical Planning

On presentation, the dog displayed a severe toe-touching lameness on the left thoracic limb. Clinical examination confirmed marked left ABGD characterized by procurvatum, carpal valgus, and external antebrachial rotation (approximately 60 degrees). Additionally, there was severe carpal hyperextension ([Fig. 1A, B]). A CT scan of both thoracic limbs was obtained to further assess the deformity and injury. In addition to the ABGD, the scan revealed a dorsal luxation of the second carpal bone. The DICOM files were exported to medical image processing software (Osirix, Pixmeo, SARL; Geneva, Switzerland) and a surface-rendered representation of both thoracic limbs was created; this was exported as a stereolithography file to computer-aided design software (Netfabb professional, Netfabb GmbH, Parsberg, Germany, and Geomagic Freeform, 3D Systems, Rock Hill, California, United States), allowing 3D virtual models of the imaged bones to be created ([Fig. 2A, B]). These models were used to plan concurrent radial deformity correction and osteotomised pancarpal arthrodesis (PCA). The radial deformity was multiapical, with mid-diaphyseal frontal and sagittal plane CORAs at similar levels, and an additional frontal plane CORA at the level of the distal metaphysis. This CORA was sufficiently distal to permit correction using an oblique distal radial articular surface osteotomy (i.e., nonparallel to the joint surface in the frontal plane) in combination with an orthogonal proximal radiocarpal and ulnar carpal bone osteotomy (i.e., perpendicular to the frontal plane). This osteotomy was planned to also achieve a 10-degree hyperextension arthrodesis angle, as well as optimized dorsal plane alignment of the manus. A radial mid-diaphyseal cuneiform closing wedge ostectomy was concurrently planned such that the combined result was optimized with regard to the orientations of both radial segments and the manus in all three planes ([Fig. 2C, D]).

Fig. 1 Clinical photograph of the patient taken preoperatively: (A) cranial and (B) lateral view.

Fig. 2 CAD representation of the preoperative left antebrachium: (A) lateral and (B) cranial view. CAD plan of the surgical correction of the left antebrachial deformity and pancarpal arthrodesis: (C) lateral and (D) cranial view.

Two PSGs were designed. The radial PSG was designed with a footprint to fit in a unique position onto the cranial aspect of the bone. It also included five 2.4 mm guide channels, allowing intraoperative placement of correspondingly sized Ellis pins to secure the PSG to the radius. The holes left by these Ellis pins would subsequently become the pilot holes for five PSI screws, and their position and orientation were planned to optimize osteosynthesis strength. The radial PSG had three osteotomy guide planes, two for the mid-diaphyseal cuneiform osteotomies and one for the distal articular surface osteotomy ([Fig. 3A, B]). The second PSG was designed to fit onto the dorso-proximal surface of the radiocarpal and ulnar carpal bones in a unique position. This PSG had a 1.6 mm guide channel for an Ellis pin, and an osteotomy guide plane ([Fig. 3C]). Once again, the hole left by the pin was planned as a pilot hole for the radiocarpal bone (RCB) screw in the PSI. The PSI was designed to extend from the proximal radius to the distal diaphyses of metacarpals III and IV, and the mid-diaphysis of metacarpal II. The PSI plate was designed as a 2.4 mm/3.5 mm hybrid, allowing for placement of one RCB and thirteen metacarpal 2.4 mm cortical screws (in three metacarpal prongs), and four 3.5 mm cortical screws in each radial segment ([Fig. 4A, B]). The thickness of the plate was based on that of 2.4 mm and 3.5 mm limited compression plates, with an additional 10% as a safety margin. The contact surface of the plate exactly matched the contours of the cranial/dorsal radial/RCB/metacarpal cortices, but was marginally offset by less than 1 mm at the levels of the reduced osteotomies and over the carpal joints ([Fig. 4A]).

Fig. 3 CAD representation of the patient-specific osteotomy guides: (A) lateral view of radius guide, (B) cranial view of the radius guide, and (C) cranio-lateral view of the radiocarpal bone guide.

Fig. 4 CAD representation of the patient-specific 3D printed titanium alloy plate: (A) caudo-cranial view and (B) medio-lateral oblique view.

PSGs and models of the antebrachium (radius/ulna and manus) were 3D-printed using Form 3B printers (Formlabs, Somerville, Massachusetts, United States). The bone models were printed in autoclavable High Temperature resin, and the PSGs in BioMed Amber resin (Formlabs, Somerville, Massachusetts, United States). This material is autoclavable and biocompatible (EN ISO 10993–1, 3, 5). The PSGs and models were washed with isopropyl alcohol and UV-cured according to the manufacturer's instructions. Prior to surgery, the PSGs and models were steam autoclaved according to the manufacturer's recommendations (134°C for 20 minutes).

The PSI was 3D-printed at an ISO13485-compliant facility in surgical-grade Ti64 alloy via direct metal laser sintering at 40 micron layer height (EOS M290 printer using EOS titanium Ti64 alloy Grade 23; ASTM F136 material standard for surgical implants: UNS R56401); EOS GmbH, Munich, Germany). The plate was heat-treated according to the printer manufacturer's instructions (ASTM F3301 compliant), micro-bead blasted, and the screw holes hand finished. Such a PSI can be produced in about 10 days.

 

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Surgical Procedure

The dog was premedicated using methadone (Comfortan, Eurovet Animal Health B.V., 0.3 mg/kg, intramuscularly [IM]) and acepromazine (AceSedate, Jurox (UK) Ltd, 0.01 mg/kg IM). Anesthesia was induced using propofol (PropoFlo, Zoetis, 4 mg/kg intravenously [IV]) and maintained with a mixture of isoflurane (IsoFlo, Zoetis) and oxygen after endotracheal intubation. A constant rate infusion of ketamine (Anesketin, Eurovet Animal Health B.V., 10 µg/kg/h IV) provided further analgesia, and cefuroxime (Zinacef, GSK, 20 mg/kg IV) was administered at induction and 90 minutes later. Paracetamol (B.Braun Melsungen AG, 10 mg/kg IV, BID) and meloxicam (Metacam, Boehringer Ingelheim, 0.2 mg/kg IV, SID) were initiated. The anesthetized patient was positioned in dorsal recumbency, and the limb was prepared aseptically in a hanging limb position.

A routine craniomedial approach to the radius was performed[11] with distal extension over the dorsal aspect of the carpus and metacarpal III. Tenotomy of the adductor pollicis longus tendon was performed. The entire cephalic vascular bundle was preserved. The soft tissues around the bony landmarks of the distal radius were elevated as required to ensure a perfect seating of the footprint of the radial PSG. Distally, this involved elevation of the proximal joint capsule as well as the extensor retinaculum and soft tissues in the extensor carpi radialis groove. Comparison of guide position and fit with the autoclaved 3D-printed antebrachial model facilitated optimal guide positioning in the patient. Five 2.4 mm Ellis pins were inserted through the guide channels into the radius. The distal radial ostectomy of the articular surface, including the ulnar styloid process, was performed first, using an oscillating bone saw ([Fig. 5]). Then, the two mid-diaphyseal radial osteotomies were performed. Thereafter, a mid-diaphyseal ulna ostectomy was performed at the level of the radial osteotomy, using a caudolateral approach. The second osteotomy guide was anchored to the RCB using a 1.6 mm Ellis pin, and the osteotomies of the proximal aspects of the RCB and ulnar carpal bone were performed using an oscillating saw. After removal of the PSGs, the radial segments were reduced and manually aligned with the plate. Cortical screws of 3.5 mm were placed into the corresponding predrilled pilot holes in the radius, and a 2.4 mm screw in the RCB, which were not yet fully tightened. Full contact between the plate and the cortex of each segment was verified before the screws were fully tightened. The additional three radial screws were placed routinely. The RCB and metacarpals were aligned with the plate, and two 2.4 mm cortical screws were placed in each metacarpal. These screws were then removed, and the cartilage in the intercarpal and carpometacarpal joints was removed using a high-speed burr. A cancellous bone graft was harvested from the ipsilateral proximal humerus and applied to the arthrodesis sites. The RCB and metacarpals were once again aligned to the plate; the previously removed 2.4 mm screws were replaced, and the remaining seven screws were placed routinely. ([Video 1]) Subcutaneous tissues were apposed, and skin closure was routine. Postoperative radiography revealed good reduction and implant positioning. ([Fig. 6A, B]) A modified Robert–Jones bandage was applied and was replaced each week for a total of 3 weeks. The dog was discharged on a 1-week course of cephalexin and a 2-week course of paracetamol and meloxicam. Radiographs were obtained 8 weeks following surgery. ([Fig. 6C, D]) These revealed that all metal implants were stable and in place. The bone healing/arthrodesis at the different osteotomy sites and joint levels was progressing appropriately, although ossification was not yet complete. The owner was advised to progressively increase the short lead exercise over the next 8 weeks, when further follow-up radiographs were recommended. The owner failed to represent the dog at 4 months postoperatively, as they felt he was sound.

Video 1 CAD animation of the CT scan-based patient-specific osteotomy surgical guide system for single-session CORA-based mid-diaphyseal antebrachial correction, osteotomised pan-carpal arthrodesis, and ulna osteotomy. The antebrachium is stabilized using a patient-specific 3D-printed titanium alloy implant extending from the proximal radius to three prongs on the metacarpal bones II, III, and IV.

Fig. 5 Intraoperative cranio-medial view of the left antebrachium (distal to the right) after application of the radial patient-specific osteotomy guide. The distal radial osteotomy has been performed, and the radiocarpal bone is retracted using a small Hohmann retractor.

Fig. 6 Radiographs of the left antebrachium: (A) immediate postoperative medio-lateral projection and (B) cranio-caudal projection; documenting appropriate axial antebrachial alignment following single-session CORA-based mid-diaphyseal antebrachial correction, osteotomised pan-carpal arthrodesis, and ulna ostectomy. The antebrachium is stabilized using a patient-specific 3D-printed titanium alloy implant extending from the proximal radius to three prongs on the metacarpal bones II, III, and IV. Radiographs of the left antebrachium: (C) 2-month postoperative medio-lateral projection and (D) cranio-caudal projection. There is no radiographic evidence of implant loosening. The bony healing and remodeling at the different levels are progressing well, but are not complete yet. Radiograph of the left antebrachium: (E) 13-month postoperative medio-lateral projection and (F) cranio-caudal projection; documenting stable implant positioning with no evidence of implant failure. The radial ostectomy, as well as the antebrachiocarpal and carpometacarpal arthrodeses, have progressed to full bone healing. The ulnar ostectomy gap has reduced in size and remodeled, although ulnar bone healing appeared incomplete.

 

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Follow-Up 13 months

The patient returned for a follow-up examination 13 months postoperatively. The owners reported that his gait and activity level had returned to normal. Clinical examination revealed a completely stable and pain-free thoracic limb with normal conformation and no lameness ([Fig. 7A] and [B]). The remainder of the orthopedic examination was normal. Radiographs documented unchanged implant positioning with no evidence of implant failure. The radial ostectomy, as well as the antebrachiocarpal and carpometacarpal arthrodeses, had progressed to full bone healing. The ulnar ostectomy gap had reduced in size and had remodeled, although ulnar bone healing appeared incomplete. ([Fig. 6E] and [F])

Fig. 7 Clinical photograph of the patient taken 13 months postoperatively (A) cranial view and (B) lateral view; displaying straightened leg conformation and full weight-bearing.

 

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Discussion

Simultaneous ABGD correction and PCA have previously only been reported in a small series of seven limbs in five dogs weighing less than 10 kg, which initially presented with concurrent ABGD and secondary chronic, severe, carpal laxity.[10] In that series, 3/7 limbs suffered complications (one major complication eventually resulting in amputation, and two minor complications). The patient described in this report differed from these previously described cases with respect to substantially greater bodyweight (26 kg) and the acute, traumatic nature of the concurrent carpal hyperextension injury, in addition to chronic ABGD.

A key advantage of the reported technique in this patient is the ability to plan and optimize the required osteotomies in the virtual CAD-based environment, and then to transfer this finalized plan to surgery via the use of PSGs and a PSI, acting as a reduction device. Without the use of PSGs, it would have been extremely challenging to judge the optimal positions and angles of both the radial and especially the articular surface osteotomies in all planes. Relative alignment of the distal radius and manus is easier to judge after a burred arthrodesis. However, in this patient, that approach would have significantly complicated the radial deformity correction since, due to the differing levels of key frontal and sagittal plane CORAs, a double-level correction would then have been necessary to achieve an optimal outcome conformation. Even in cases where oblique articular surface osteotomies are not required, there may be advantages to osteotomised rather than burred arthrodesis; in particular, the large, closely apposed surfaces of cancellous bone with potential for greater stability and more rapid bone healing. Comparative studies with a larger number of cases would be necessary to determine if these features do indeed result in better outcomes. The achieved bone healing in this case does at least demonstrate the clinical efficacy of the technique, with an excellent outcome also in the long term.[12]

The integration of the PSGs with the PSI allowed the plate to act as the reduction device for both radial segments and the metacarpals. This not only facilitates accurate transfer of the CAD-planned alignment to surgery, but also avoids the placement of reduction pins and guides typically required by non-PSI integrated guide systems. These are challenging to use for metacarpal alignment due to the lack of optimal guide placement sites, and, on the radius, add surgical time and require greater exposure as they must be positioned on a different aspect of the bone compared with the plate. The presence of the predrilled pilot holes and the accurate contour match between the contact side of the plate and the cortices allowed rapid and precise reduction of the radial segments onto the plate as the cortical screws were tightened. With the relative orientations of the radial segments and plate determined, alignment of the metacarpals with the distal plate prongs facilitated easy, fast, and accurate completion of the overall planned alignment of the manus.

A further potential advantage of the PSI design used in this case is the ability to preplan and optimize screw size, number, position, and (for screws placed into predrilled pilot holes) screw trajectory. This has the potential to improve osteosynthesis strength and load distribution when compared to traditional off-the-shelf plates. For example, off-the-shelf PCA plates applied to either one[13] or two[14] [15] metacarpals allow placement of five or six screws in positions and orientations according to the plate design. In contrast, the PSI in this report allowed placement of 13 metacarpal screws in positions determined by the bone conformation. As well as reducing the stress on each bone/screw interface, along with the greater surface area of plate/cortex contact (due to the three distal prongs, and the contour match between the plate underside and the cortex), load transfer will be distributed over a much greater surface area, and more evenly, compared with a traditional construct. This might be expected to reduce the risk of preferential screw loading, toggling, and sequential screw failure, a classic failure mode of standard nonlocked constructs.[16] It is interesting to note that despite the currently perceived superiority of locking constructs, there is evidence that their performance under cyclic loading is not necessarily superior to appropriately applied nonlocked constructs in nonosteoporotic bone.[17] Since the PSI described in this report does not generate interfragmentary compression, the appropriate bone healing demonstrated in this case must have occurred through secondary bone healing. This feature suggests that the nonlocked PSI construct was therefore able to maintain an opportune strain environment for osteogenesis within the osteotomy gaps. The biomechanical features of this type of implant may differ from conventional locked and nonlocked constructs, and warrant specific investigation.

The use of CAD-based planning, PSGs, and PSIs has several potential disadvantages. The necessary level of specific technical knowledge regarding virtual surgical planning in CAD software, guide and implant design, and their manufacture, requires outsourcing of these processes for the vast majority of surgeons. This inevitably introduces a short delay of several days before surgery can be performed, and additional expense. In our clinic, the addition of performing a CT scan and designing and producing a PSG-PSI system will add about 25% to the overall fee for the owner. However, understanding such a complex deformity, accurate planning of the correction from radiographs alone, and most importantly, surgical execution of the correction would be vastly more complex without a PSG-PSI system and using off-the-shelf implants. This is in line with previous studies highlighting improved outcomes and reduced surgical times when using PSG corrections compared with free-hand corrections.[18] [19] [20]

From a surgical perspective, close contact between the cortices, the guides, and the PSI is necessary. This necessitates soft tissue elevation from the bone in the regions corresponding to the guide footprints and plate. While the guide footprint contact area is generally quite small, the contact surface of the plate is larger, and it seems probable that periosteal blood supply will be compromised beneath the plate, albeit that no adverse effects were clinically evident in this case. Other potential disadvantages of 3D-printed patient-specific implants include the current impracticality of performing finite element analysis or biomechanical testing for every custom plate, and the possibility of variations in microstructure and surface finish that could affect mechanical strength. However, the authors speculate that the probability of rapid and complete healing of an osteotomised arthrodesis over that of a burred arthrodesis should reduce the risk of construct failure due to screw loosening or mechanical plate failure.

Considering the excellent clinical long-term outcome in this patient, the authors feel that several points in the planning and individualized treatment of this patient might be useful for other clinicians faced with a similar clinical presentation or considering the use of patient-specific guides and implants. Collating data on such patients in a multi-center case series appears warranted to assess this further and to continue to improve the clinical outcome of our patients.

 

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Conflict of Interest

B.O. is the owner of Vet3D.

Acknowledgment

The authors would like to thank Heather Goodrum and Bryony Halcrow for their expert CAD work designing the guides and implant described in this report. We thank the entire team at Whitstable Bay Veterinary Centre for their dedication to the postoperative care of this patient.

Authors' Contributions

All authors were involved with the evaluation and interpretation of the data, clinical treatment of the patient, as well as drafting of the manuscript and approval of the submitted manuscript.

• References

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Publikationsverlauf

Eingereicht: 27. April 2025

Angenommen: 15. August 2025

Artikel online veröffentlicht:
05. September 2025