Surgical correction of medial luxation of the

patella in a Miniature Horse

Mimi Arighi, James W. Wilson

Luxation of the patella has been reported in dogs,

cats, goats, llamas, horses, cows, and humans. In
dogs, medial luxations are, by far, the more common.
They are seen mainly in miniature breeds, such as the
poodle, and usually involve both legs (1). Associated
anomalies of the entire canine pelvic limb are common
with femoral and tibial shaft malformation and
ligamentous laxities. The tibia commonly develops a
medial rotation causing the axis of the quadriceps
mechanism to shift medially with a resulting tendency
of the patella to luxate medially. If medial rotation
of the tibia is severe, the patella may always reside in
a medially luxated position. Subsequent contraction
of the medial synovial and retinacular structures may
then fix its position permanently. The femoral
trochlear groove is often shallow and may essentially
be absent in dogs with severe long standing luxations
(2). These anomalies have not been described in large
animals (1,3).
In the large species, luxation of patella is uncom-
mon. In adult cattle and horses, luxations are almost
always secondary to trauma, whereas in calves and
foals, the lesion is usually congenital. The cause of
congenital luxation of the patella in large animals is
conjectural (4-10). Abnormal development or agenesis
of the medial femoropatellar ligament has been sug-
gested as a possible cause of lateral luxations (11).
However, because the medial femoropatellar ligament
normally consists of only a thin band of tissue that
is indistinct from the joint capsule, hypoplasia of the Figure 1. Caudocranial view of the right stifle of a lame
medial retinacular structures seems an unlikely cause one-month-old Miniature Horse foal. The patella is luxated
(7). Lateral luxations are seen more frequently than medially (arrow) and there is deformity of the proximal tibia
medial luxations in cattle and horses (4-10). This with medial rotation of the tibial tuberosity.
prevalence of lateral displacement is not surprising,
since the medial trochlear ridge is more prominent than femoral condyles were poorly defined, with virtually
the lateral. In foals, hypoplasia of the lateral trochlear no trochlear groove.
ridge has been found (12). This has not been found Patellar luxation can vary clinically from intermit-
in calves. Instead, lateral luxations in calves have been tent or incomplete to total and permanent displace-
attributed to the strong caudolateral pull of the ment of the patella (7). Because of the likely congenital
gluteobiceps muscle group on the patella. (12,13). etiology in the young, patellar luxations can be
There has been one reported case of unilateral con- unilateral or bilateral, but they are usually only
genital medial luxation of the patella in a llama (14). unilateral in adults due to the more likely traumatic
Although, on radiographic and clinical examination, etiology. The stifle is held in marked flexion, and the
the trochlear groove of the affected limb appeared to limb collapses when weight is supported, similar to
be comparable to that of a normal stifle, at surgery, paralysis of the quadriceps muscle. Bilaterally affected
the trochlear groove was deepened. The etiology of the calves and foals adopt a crouching stance and prefer
medial luxation was not determined. There has also to lie down. On physical examination, the patella
been only one report of patellar luxation in a Miniature forms a visible bulge on the lateral or medial aspect
Horse (3). The luxation was lateral. Radiographically, of the joint, and the trochlea is clearly palpable.
the patella was small and atypically shaped, and the Radiological studies can confirm the diagnosis (4-10).
A one-month old, 19 kg, female Miniature Horse
Can Vet J 1993; 34: 499-501 was referred for evaluation of a right hind leg
lameness. The foal had been severely lame in the right
Department of Clinical Studies, Ontario Veterinary College, hind leg since birth, and so compensatory left hind leg
University of Guelph, Guelph, Ontario N1G 2W1 (Arighi); problems were beginning to develop. Both hind
Museum of the Rockies, Montana State University, fetlocks were hyperextended and would touch the
Bozeman, Montana, USA 59717 (Wilson). ground when the foal was made to stand. The left
Can Vet J Volume 34, August 1993 499
 ...
.r .. ZeS. l_
Figure 2. Postoperative views (craniocaudal and lateral) following medial release of the retinaculum and joint capsule,
trochlear chondroplasty, and repositioning of the tibial tuberosity. The patella is correctly positioned. Pin placement has
avoided penetrating or crossing the growth plate of the proximal tibia.
fetlock was more severely affected than the right. The
right patella was luxated medially and could not be
reduced to its normal position. The left patella was
in the normal position. Radiographic examination con-
firmed a luxated right patella and also showed medial
rotation of the tibial tuberosity and malformation of
the proximal tibial physis (Figure 1). The trochlear
groove appeared nonexistent.
Ampicillin (200 mg IV) and tetanus antitoxin (IM)
were given preoperatively. Arthrotomy was performed
through a 10 cm incision, abaxial to the lateral patellar
ligament. Before the patella could be reduced, a medial
release of the retinaculum and joint capsule was per-
formed, axial to the medial patellar ligament, and the
medial patellar ligament was transected. The patella
could now be placed in the patellar groove but was still
easily luxated upon flexion and extension of the joint,
due to the shallowness of the trochlear groove. To
deepen the groove, a rectangular flap of cartilage and
subchondral bone, from the medial to the lateral
trochlear ridge, was elevated from a proximal to distal
direction and left attached distally. Enough bone was
then removed from the exposed bed, so that there was
a suitably deep trochlear groove when the cartilaginous
flap was replaced. However, because of the medially
rotated position of the tibial tuberosity, the patella
could still be luxated medially. In horses, the medial,
middle, and lateral patellar ligaments all originate on
the patella and attach to the tibial tuberosity; thus,
tibial tuberosity transplantation will reposition all three
patellar ligaments. Accordingly, the tibial tuberosity
500
was elevated with an osteotome, repositioned laterally,
and secured in its new location with three Kirschner
pins. The pins were positioned to secure the tibial
tuberosity in its new position and to counteract the pull
of the patellar ligaments, but not to interfere with the
various growth plates in the proximal tibia. As the inci-
sion was being closed, the lateral joint capsule and
fascia were imbricated using interrupted Lembert
sutures of #1 nylon.
Phenylbutazone (20 mg PO) was given post-
operatively for 10 days. The foal recovered well from
surgery and started to use the leg within a week. At
six weeks, the foal was bearing weight normally on the
right hind leg, and the hyperextension of the left hind
fetlock was improving. Radiographs revealed healing
of the tibial tuberosity at its new bed and a normal
central location of the patella within the trochlear
groove (Figure 2). Stall rest with handwalking was con-
tinued for another six weeks. At twelve weeks, the foal
was bearing weight equally on both hind legs with
some slight residual hyperextension of the left fetlock.
There were no radiographic abnormalities. Since the
foal's feet were now large enough, an extended-heel
shoe was placed on the left foot to provide support
to the tendons. Six months after surgery, the owners
reported that the extended-heel shoe had greatly helped
to reduce the left hind fetlock hyperextension and that
the foal was walking normally. She was subsequently
sold, and both the old and new owners were very
happy with the final result.
Can Vet J Volume 34, August 1993
 Corrective surgery for luxation of the patellar in all References
species falls into two categories. Stabilization proce- 1. Trotter EJ. Medial patellar luxation in the dog. Compend Contin
dures, which include reinforcement with sutures, fascia Educ Pract Vet 1980; 2: 58-66.
lata overlap, imbrication, or desmotomy, are used in 2. DeAngelis M, Hohn RB. Evaluation of surgical correction of
patients with minor or no anatomical changes. canine patellar luxation in 142 cases. J Am Vet Med Assoc 1970;
156: 587-594.
Reconstructive procedures, which include reposition- 3. Jones RD, Cantrell GW, Alexander JW. Medial imbrication
ing of the tibial tuberosity, trochleoplasty, chon- of the stifle to relieve lateral subluxation of the patella in
droplasty, trochlear wedge recession, wedge osteotomy a miniature horse. Equine Pract 1981; 3: 19-29.
of the femur and/or tibia, and derotational osteotomy 4. Greenough PR, MacCallum FJ, Weaver AD. Lameness in Cat-
tle. Edinburgh: Oliver and Boyd, 1972: 260-265.
of the tibia, are used when there are major anatomical 5. Phillip RG. Lateral luxation of the patella in a calf. Vet Rec
changes; they may be combined with stabilization tech- 1970; 86: 190-191.
niques. In large animals, reports of the use of stabiliza- 6. Meagher DM. Bilateral patellar luxation in calves. Can Vet
tion (3,4,7,8,10) exceed those of reconstruction J 1974; 15: 201-202.
(12,14). 7. Leitch M, Kotlikoff M. Surgical repair of congenital lateral
of the patella in the foal and calf. Vet Surg 1980; 9: 1-4.
The paucity of reports of reconstructive deepening 8. luxation
Nelson DR, Kneller SK. Treatment of proximal hind-limb
of the trochlear groove in large animals seems to lameness in cattle. In: Ferguson JG, ed. Bovine lameness and
indicate a reluctance by veterinary surgeons to select orthopedics. Vet Clin North Am Food Anim Pract 1985; 1:
this procedure in large animals. In this Miniature 153-173.
Horse, the procedure was performed without difficulty 9. Finocchio EJ, Guffy MM. Congenital patellar ectopia in a foal.
J Am Vet Med Assoc 1970; 156: 222-223.
and seemed to have no complications. We selected a 10. Nelson DR. Surgery of the stifle joint in cattle. Compend Contin
chondroplasty, because the subchondral bone in a foal Educ Pract Vet 1983; 5: S300-S306.
is so soft and because it provided a smooth, hyaline 11. Van Pelt RW, Keahey KK, Dalley JB. Congenital bilateral
cartilage surface within the trochlear groove. An alter- patellar ectopia in a foal. Vet Med Small Anim Clin 1971; 66:
native procedure would have been a wedge recession 12. 445-447. Rooney JR, Raker CW, Harmany KJ. Congenital lateral
(15); however, it was not selected because the width luxation of the patella in the horse. Cornell Vet 1971; 61:
of the trochlea compared to the cranial-caudal 670-673.
thickness of the femur would have made creation of 13. Baron RJ. Laterally luxating patella in a goat. J Am Vet Med
a deep and stable trochlea difficult. Trochleoplasty was 14. Assoc 1987; 191: 1471-1472.
Kaneps AJ, Riebold TW, Schmotzer WB, et al. Surgical cor-
not considered, because of the physical size of the rection of congenital medial patellar luxation in a llama. J Am
trochlear surface and the large amount of fibrocar- Vet Med Assoc 1989; 194: 547-548.
tilage that would subsequently need to be formed. 15. Slocum B, Devine T. Trochlear recession for correction of
There also seems to be a reluctance to perform tibial luxating patella in the dog. J Am Vet Assoc 1985; 186: 365-369.
tuberosity repositioning large animals. Certainly,
in
the large mechanical forces, the extremely soft
metaphyseal bone, and the postoperative problems in
large animals are points to be considered. Obtaining New Technology In Vet Scales...
sufficient bone with the tibial tuberosity at osteotomy At an Affordable Price.
is critical to securing the tuberosity at the new site.
Preparation of the site for transplantation is also
important. To ensure rapid bone healing, cortical bone
should be removed to expose the underlying trabecular
bone. Also, creating a divot or trough in which to place
the tuberosity will assist in locking the tuberosity in
place. As illustrated in the postoperative radiographs
from this case (Figure 2), the pins used to secure the
tuberosity should be placed so that they are angled
against the pull of the patellar ligaments. And, if possi-
ble, the pins should be placed so that they do not cross And Save!
the proximal tibial physis, thus decreasing the
likelihood of surgical alteration of growth. In this case,
transplantation or repositioning of the tibial tuberosity oCi Reolbo dow tl lb 0 ubr a-ncue
was easy to perform, healing was rapid, and no com-
plications occurred. Technldynec C:'oato OutsIde NJ.. 1-800-654-807
In this Miniature Horse, an excellent outcome Accu-Loce Carcuftry Accufately WVeighs
Box 46,Hwl,NwJre;73 MovAng Animals
nN.983315
0 Made for * . _' ........... :.~~~(cll ollct
vete.nna.ans
resulted from a surgical treatment focused on correc- 10 Easy to use.- push-button tare
ting the bony abnormalities existing about the stifle, 0 Animals need not be centered
rather than just reduction and stabilization of the 0 Rugged heavy gauge stainless steel
luxated patella. The above surgical procedures were O Low profile -2"H x42"L x22"W
carried out in a Miniature Horse foal where the body 0 Floor or table mounted
weight was less than it would be in full-sized breeds.
However, congenital luxations in foals or calves, if
recognized early, will be in animals much smaller than
adults; thus, we believe these procedures are certainly
worth consideration. CVJ
Can Vet J Volume 34, August 1993 501