Stifle Disarticulation as a Pelvic Limb Amputation Technique in a Cockatiel

(Nymphicus hollandicus) and a Northern Cardinal (Cardinalis cardinalis)

Author(s): Sarah Ozawa, DVM, and Christoph Mans, Dr med Vet, Dipl ACZM
Source: Journal of Avian Medicine and Surgery, 31(1):33-38.
Published By: Association of Avian Veterinarians
DOI: http://dx.doi.org/10.1647/2015-138
URL: http://www.bioone.org/doi/full/10.1647/2015-138

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 Journal of Avian Medicine and Surgery 31(1):33–38, 2017
Ó 2017 by the Association of Avian Veterinarians

Stifle Disarticulation as a Pelvic Limb Amputation Technique

in a Cockatiel (Nymphicus hollandicus) and a Northern
Cardinal (Cardinalis cardinalis)
Sarah Ozawa, DVM, and Christoph Mans, Dr med Vet, Dipl ACZM

Abstract: This clinical report describes the use of stifle disarticulation in 2 avian patients as an
alternative to transfemoral limb amputation. A northern cardinal (Cardinalis cardinalis) was
presented for soft tissue swelling and a traumatic fracture of the third digit of the left limb, with
secondary bacterial infection and necrosis. A 25-year-old cockatiel (Nymphicus hollandicus) was
diagnosed with distal extremity necrosis after a nonunion of a closed tibiotarsal fracture. In both
cases amputation was recommended due to the poor prognosis for healing and because both
birds were poor surgical candidates for traditional methods of amputation due to patient size or
age. Therefore, stifle disarticulation surgery for amputation of the pelvic limb was performed
successfully in both cases and recovery was unremarkable. The outcomes of these 2 cases suggest
that stifle disarticulation may be used as an alternative to transfemoral amputation in birds
where prolonged surgery, anesthesia, or patient size precludes traditional amputation
techniques.
Key words: stifle disarticulation, amputation, orthopedic surgery, surgery, knee, avian

Clinical Report mg/kg PO q12h) and enrofloxacin (25 mg/kg PO

q24h, compounded suspension), and surgery was
Case 1
scheduled for the next day.
An approximately 1-year-old, 40-g captive male On the morning of surgery, the bird was
northern cardinal (Cardinalis cardinalis) with a 6- premedicated with midazolam (4 mg/kg IM) and
week history of an injured distal left tarsus was butorphanol (2 mg/kg IM; Torbugesic, Zoetis,
presented for examination. On initial presentation, Florham Park, NJ, USA) and induced and
the patient was grade 3/5 lame on the left limb with maintained with isoflurane in oxygen delivered by
edema and ulceration evident on the left foot. The mask. It was placed in dorsal recumbency and the
third digit of the left foot appeared black and surgery site was prepped aseptically. A circumfer-
necrotic (Fig 1). No other abnormalities were ential skin incision was made distal to the stifle
present on physical examination. The bird was (Fig 2a). The subcutaneous tissues and overlying
sedated with midazolam (6 mg/kg IM; Hospira muscle were bluntly dissected with tenotomy
Inc, Lake Forest, IL, USA), and radiographs were scissors and bipolar electrosurgery. A circumfer-
taken. Imaging revealed significant circumferential ential modified Miller’s knot with 4-0 polyglyco-
soft tissue swelling of the tarsus and a complete nate (Maxon, Covidien, Minneapolis, MN, USA)
fracture of the proximal phalanx of digit 3 of the was placed around the distal femur encircling the
left limb. Because of the concern for secondary muscle bellies and occluding the vasculature
bacterial infection and devitalization of the digit, running distally (Fig 2b and c). A modified Miller’s
amputation at the level of the stifle was recom- knot incorporates 2 initial loops around the tissue,
mended. The bird was started on meloxicam (0.5 with the free end of the suture placed under the
loops to produce the first throw of a knot, with the
From the Department of Surgical Sciences, School of
remainder of the knot secured by sequential square
Veterinary Medicine, University of Wisconsin-Madison, 2015 knots. A complete incision through the joint
Linden Drive, Madison, WI 53706, USA. capsule and the stifle joint was made with a #15

33
34 JOURNAL OF AVIAN MEDICINE AND SURGERY

Case 2
A 25-year-old male cockatiel (Nymphicus hol-
landicus) weighing 89 g was presented originally for
a suspected pelvic limb fracture after a traumatic
injury. On initial presentation, the bird was
nonambulatory on the left pelvic limb, and a
closed midshaft fracture of the tibiotarsus was
palpable. The bird was sedated with midazolam (2
mg/kg IM) and butorphanol (2 mg/kg IM),
radiographs were taken to confirm the left
tibiotarsal fracture, and a tape splint was applied
to stabilize the fracture. Sedation was reversed with
flumazenil (0.05 mg/kg IM), and amoxicillin/
clavulanic acid (100 mg/kg PO q12h for 7 days)
and meloxicam (1 mg/kg PO q24h for 10 days)
were prescribed. The patient was discharged after 3
Figure 1. Gross appearance of distal extremity injury in days of hospitalization with instructions to confine
a northern cardinal. Note the necrosis of the left third the bird to an enclosure that prevented climbing.
digit. At the 2-week recheck appointment, complete
devitalization of digits 1–3 of the left foot and
scalpel blade. The femorotibial joint was disartic- sloughing of the skin of the distal foot were visible
ulated, and the structures distal to the femoral (Fig 3). The fracture site remained unstable after
condyles were removed (Fig 2d). Minor hemor- removal of the splint under the same sedation
rhage was controlled with digital pressure. The protocol as described above. Amputation was
muscle tissue distal to the ligation was apposed recommended because of the compromised vascu-
with 5-0 polyglyconate in a simple continuous lar supply to the distal left limb. A blood sample
suture pattern. The skin was closed by a simple was collected for preanesthetic evaluation. The
continuous pattern with 5-0 polyglyconate (Fig results of the complete blood count and the plasma
2e). The bird recovered uneventfully. After sur- biochemical evaluation (VetScan Avian Reptilian
gery, the patient had a normal appetite and was Profile Plus, Abaxis Inc, Union City, CA, USA)
able to maintain balance properly on the remaining revealed no clinically significant abnormalities.
limb. The bird was discharged the same day, and Whole body radiographs demonstrated a non-
treatment was continued with meloxicam (0.5 mg/ union fracture of the mid-diaphysis of the left
kg PO q24h) and enrofloxacin (25 mg/kg PO q24h) tibiotarsus with mild craniodistolateral displace-
for an additional 5 days. Three weeks after surgery, ment and progressive cellulitis and edema. There
the patient was presented for examination and was also mild degenerative joint disease present in
suture removal. The incision site had healed and the right stifle. Surgical amputation of the left
sutures were removed. Developing pododermatitis pelvic limb was elected by the owner over
of the right foot was evident, with a small circular euthanasia. Before surgery, the patient received
ulceration present on the plantar surface of the meloxicam (1 mg/kg PO q24h) and trimethoprim-
fourth digit. No other physical abnormalities were sulfamethoxazole (30 mg/kg PO q12h) and was
observed. Although no further examinations were given a single vitamin K injection (2 mg/kg SC).
conducted, an interview with the owner revealed For anesthesia, the patient was premedicated
that the patient had few complications after with midazolam (3 mg/kg IM) and butorphanol (2
surgery. The bird developed mild intermittent mg/kg IM). The bird was induced with isoflurane
pododermatitis beginning a month after surgical administered by face mask then intubated with a
treatment that resolved with softer padding and 16-gauge intravenous catheter and maintained on a
alternative perches. It also developed an ulceration nonrebreathing system. Intraoperative fluid thera-
on its keel, likely from using it for balance, which py consisted of a continuous-rate infusion of a
healed well without treatment. The bird died balanced electrolyte solution (10 mL/kg per hour)
unexpectedly approximately 1 year after surgery. and bolus of hetastarch (10 mL/kg; Vetstarch,
Although a postmortem examination was not Abbott Laboratories, North Chicago, IL, USA),
performed, the cause of death was not suspected administered via an intraosseous catheter (22-
to be related to the amputation. gauge spinal needle) placed in the right distal ulna.
 OZAWA AND MANS—STIFLE DISARTICULATION TECHNIQUE 35

Figure 2. Surgical knee disarticulation procedure demonstrated in a northern cardinal cadaver. (a) Circumferential skin
incision at the level of the stifle. (b) Placement of a circumferential modified Miller’s knot around the distal femur
encircling the musculature and vasculature. (c) Appearance of the ligation (arrow) after tightening of the knot. (d)
Transection of the stifle joint and surrounding soft tissue. (e) Appearance of the amputation site after closure of the skin.
36 JOURNAL OF AVIAN MEDICINE AND SURGERY

suture removal. The incision site was healed, and

mild increased wear and hyperkeratosis were
observed on the plantar aspect of the right foot
consistent with increased weight bearing on the
affected limb. Recommendations were made to
replace perches with softer material to decrease the
probability of pressure sores and pododermatitis
developing on the weight-bearing limb. Follow-up
phone conversation with the owner 2 months after
the last recheck appointment revealed no concerns.

Discussion
To our knowledge, this is the first report of
disarticulation of the stifle joint as a method of
pelvic limb amputation in birds. Because of the
patient size (case 1) and advanced age (case 2), this
technique was selected as an alternative to
transfemoral limb amputation or euthanasia. Both
birds recovered uneventfully from surgery, and
follow-up examinations revealed adequate healing,
return to function after amputation, and a
subjectively good quality of life. These cases
suggest that stifle disarticulation may be used as
an alternative to transfemoral amputation in avian
patients in which prolonged anesthesia and surgery
or patient size precludes traditional amputation
Figure 3. Appearance of the left pelvic limb in an
approximately 25-year-old male cockatiel 2 weeks after
techniques. In both patients, amputation was
diagnosis and treatment (external cooptation) of a right recommended as the treatment of choice because
tibiotarsal fracture. Note the complete devitalization of of the poor prognosis for fracture healing, vascular
digits 1–3 of the left foot and sloughing of the skin of the compromise, necrosis, and infection of the distal
distal foot. pelvic limb.
In avian species, the most common sites for
The patient was placed in dorsal recumbency, and pelvic limb amputation are transection of the
the surgery site was prepped aseptically. The proximal tarsometatarsus and midfemur.1,2 Some
surgical procedure was repeated in a similar advocate the proximal tarsometatarsal technique,
manner described in case 1 above; however, the because the resulting stump can be used for
muscle tissue distal to the ligation was not apposed moderate weight bearing.2 However, the remaining
in this case. The subcutaneous tissue was closed stump is at risk of becoming traumatized, and
with 4-0 polyglyconate in a simple continuous most practitioners prefer the midfemoral transec-
pattern, and the skin was closed with 4 simple tion method.2,3 Because a significant portion of the
interrupted sutures with 4-0 polyglyconate. The femur is located within the body wall in avian
patient received flumazenil (0.05 mg/kg IM), and species, a midfemoral amputation results in suffi-
recovery from anesthesia was uneventful. After cient soft tissue for closure and prevents self-
surgery, the bird received another dose of butor- induced trauma to the amputated limb.4
phanol (2 mg/kg IM) and by that evening was To our knowledge, stifle disarticulation has not
consuming its regular diet and drinking water. No been used in veterinary species; however, in human
postoperative hemorrhage or discomfort was orthopedics, stifle disarticulation, or through the
observed. During hospitalization for 2 days after knee amputation, is an established technique of
surgery, the patient received meloxicam (1 mg/kg pelvic limb amputation.5,6 This method was first
PO q24h) and trimethoprim-sulfamethoxazole (30 performed in 1824 as a way to perform amputa-
mg/kg PO q12h), and medication was continued tions quickly with less blood loss.5,6 However, with
for 2 more days after discharge. the advent of modern anesthesia and aseptic
The cockatiel was re-examined 13 days after techniques, this method fell out of favor and
surgery for evaluation of the surgical site and femoral or tibial transection techniques were
 OZAWA AND MANS—STIFLE DISARTICULATION TECHNIQUE 37

preferred because of better cosmetic outcomes and muscle and the flexor cruris medialis and lateralis
easier prosthesis utilization.7,8 Recent technique muscles are responsible for flexion of the stifle.
modifications and prosthesis advances, however, In the 2 birds we describe, stifle disarticulation
have made these concerns less relevant. 7,9 was the chosen surgical technique. The advantages
Through-the-knee amputation in humans is an of this procedure are decreased surgical and
acceptable method of amputation and is performed anesthesia time, a more simple surgical procedure,
mainly in patients who are elderly, pediatric, or reduced blood loss, less trauma to soft tissue
nonambulatory or who have spinal cord injury or structures, and the lack of required bone and
vascular disease.7,9 This technique is preferred in muscle sectioning.6,7,10,11 It also may produce a
pediatric patients, because it maintains femoral longer lever arm, resulting in better proprioception
length by preserving the distal femoral epiphysis and balance, as seen in human patients.7,12 Because
necessary for growth.10 This technique also has less avian species are more similar to people in their
potential for hip or knee joint contracture com- bipedal nature compared with other species, these
pared with transfemoral or transtibial techniques.5 advantages may be applicable in the cases in this
A meta-analysis evaluating human amputation report as well.
studies over the last 10 years also found that In the 2 patients in this report, intrasurgical
through-the-knee amputation had superior physi- hemorrhage and resulting acute hypovolemia were
cal component scores, a measure of quality of life of great concern because of the small size of the
and mobility, compared with above-the-knee birds, particularly in case 1 (40-g body weight). In
amputation.11 The main disadvantage of the the case of disarticulation, risk of hemorrhage is
procedure in people is a decreased cosmetic decreased because of less muscle mass to transect
outcome, and healing complications with long and because the vasculature is ligated with a single
tissue flaps have also been reported.12,13 circumferential ligation incorporating the blood
vessels, muscle, and femur. Therefore, overall risk
Anatomically, the stifle joint of avian species is
of hemorrhage is decreased with this technique.
similar to mammals. The joint includes the distal
Another benefit of disarticulation over midfe-
articular condyles of the femur, the patella, the
moral amputation in these cases was the abbrevi-
fibular head, and the proximal tibiotarsus.14 It is
a t ed a nes t hes ia t ime r equ ir ed. B eca us e
also supported by similar soft tissue structures,
disarticulation is surgically less challenging and
including both cranial and caudal cruciate liga-
less muscle and soft tissue dissection is required,
ments, the joint capsule, the patellar ligaments, the
the procedure is significantly shorter compared
medial and lateral collateral ligaments, and 2 with traditional methods of amputation. Although
menisci with their associated ligaments.15 The knowledge of the relative anatomy is important,
caudal cruciate ligament attaches to the intercon- because of the smaller patient size selected for this
dylar groove of the femur and attaches to the procedure, specific anatomic structures are not
medial tibial condyle posteriorly. The cranial able to be individually appreciated. Dissecting out
cruciate variably attaches to the lateral femoral individual ligaments and muscles during the
condyle or in the intercondylar region, depending amputation is not recommended, because this will
on species, and inserts in the center of the tibial prolong the surgical procedure. In the trans-
plateau.15 The tibial and fibular nerves run along articular amputation technique described, we
the lateral aspect of the stifle joint and the recommended palpating the articulation between
proximal portion of the tibiotarsus and fibula. the femur and the tibiotarsus and sectioning the
The medullary cavity of the tibiotarsus is often muscle, ligaments, joint capsule, and vasculature
composed of medullary bone, whereas the femur is with a single transecting cut. Patient 2 was of
pneumatized in some avian species, connecting to geriatric age, and although preanesthetic blood
the abdominal air sacs.16 The stifle joint itself is profiles reflected adequate organ function, the
made up of 3 joints: femoropatellar, femorotibial, length of the surgical procedure was of great
and femorofibular. The femorotibial joint is the concern. In that case, disarticulation was favored
major weight-bearing joint in the stifle and because of the decreased anesthetic risk to the
functions mainly in flexion and extension.14 The patient and therefore greater chance of a successful
femorotibialis muscle is located on the dorsal recovery.
aspect of the femur and inserts on the cnemial Different species of birds have variable amounts
crest of the tibiotarsus to function in extension of of pneumatization of the appendicular skeleton. In
the stifle.14 The patella is located within the tendon most birds, the sternum, scapula, humerus, femur,
of the femorotibialis muscle. The iliofibularis pelvis, and thoracic vertebrae contain diverticula
38 JOURNAL OF AVIAN MEDICINE AND SURGERY

of the air sacs.14 When performing a transfemoral Medicine: Principles and Application. Lake Worth,
amputation, there is a risk of entering one of these FL: Wingers Publishing Inc; 1994:1096–1136.
diverticula if femurs are pneumatized. This risk is 4. Bowles HL, Odberg E, Harrison GJ, Kottwitz JJ.
not present in the case of stifle disarticulation. Surgical resolution of soft tissue disorders. In:
A complication of this procedure that is also Harrison GJ, Lightfoot TL, eds. Clinical Avian
seen in other pelvic limb amputation techniques is Medicine. Vol 2. Palm Beach, FL: Spix Publishing
pododermatitis developing in the contralateral Inc; 2006:775–829.
5. Pinzur MS, Bowker JH. Knee disarticulation. Clin
limb.16,17 This complication is less likely in smaller
Orthop Relat Res. 1999;361:23–38.
birds fed a balanced diet and provided with
6. Stark, G. Overview of knee disarticulation. J
appropriate perches.3,5 However, the bird should Prosthet Orthot. 2004;16(4):130–137.
always be monitored after surgery for development 7. Cull DL, Taylor SM, Hamontree SE, et al. A
of pododermatitis of the remaining pelvic limb. reappraisal of a modified through-knee amputation
Suggested negative prognostic indicators of pelvic in patients with peripheral vascular disease. Am J
limb amputation in birds include obesity, degener- Surg. 2001;182(1):44–48.
ative changes in the opposite limb, and disorders 8. Nellis N, Van De Water JM. Through-the-knee
affecting the wings, which are crucial for balance.4 amputation: an improved technique. Am Surg. 2002;
Although case 2 had evidence of degenerative joint 68(5):466–469.
disease in the contralateral limb at the time of 9. Behr J, Friedly J, Molton I, et al. Pain and pain-
amputation, the procedure was still elected over related interference in adults with lower-limb
euthanasia at the client’s request. Because of the amputation: comparison of knee-disarticulation,
patient’s geriatric age and the fact that no overt transtibial and transfemoral surgical sites. J Rehabil
clinical signs of osteoarthritis were present, the Res Dev. 2009;46(7):963–972.
amount of progressive degeneration to the right 10. Pinzur MS. Knee disarticulation: surgical proce-
stifle with increased weight bearing was thought to dures. In: Bowker JH, Michael JW, eds. Atlas of
be of minimal concern. Limb Prosthetics: Surgical, Prosthetic and Rehabil-
The 2 cases in this report represent successful itation Principles. Rosemont, IL: Mosby Year Book
Inc; 1992:479–486.
pelvic limb amputation using a transarticular stifle
11. Penn-Barwell JG. Outcomes in lower limb amputa-
disarticulation technique. While the current pre-
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ferred method of pelvic limb amputation in birds is meta-analysis. Injury. 2011;42(11):1474–1479.
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tation is not appropriate for all patients.1–3 Through-knee amputation in high risk patients with
Although further investigation of the postoperative vascular disease: indications, complications and
complication rate and a larger patient sample size rehabilitation. Br J Surg. 1990;77(10):1118–1120.
is needed, this surgical technique may be consid- 13. Albino FP, Seidel R, Brown BJ, et al. Through the
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amputation are contraindicated. surgical outcomes. Arch Plast Surg. 2014;41(5):
562–570.
Acknowledgment: We thank Dr Grayson Doss for 14. King AS, McLelland J. Birds: Their Structure and
taking the photographs used in Figure 2. Function. 2nd ed. Eastbourne, East Sussex, UK:
Bailiere Tindall; 1984.
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