Pets

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September 2014 Case of the Month – Meet Tido!!!

Tido two weeks after surgery!!! You can't keep him down!!!

Tido two weeks after surgery!!! You can’t keep him down!!!

Meet Tido!!! Tido is a 6 1/2 year old West Highland White Terrier that came to us (Affiliated Veterinary Specialists – Orange Park) for a lower esophageal foreign body. He started showing signs of intermittent vomiting and regurgitation after swallowing his rawhide bone. Unfortunately, it became lodged in the portion of the esophagus that goes through his chest, just past his heart. Usually we can use a scope camera and remove the object without any incisions. The piece of rawhide was wedged in this area and was unable to be moved, so surgery was his only option.

This was the piece of rawhide that was lodged in Tido's esophagus. It was nearly 5cm in length!!

This was the piece of rawhide that was lodged in Tido’s esophagus. It was nearly 4cm in length!!

An incision was made in the chest and the large piece of rawhide was found in the esophagus just past the heart. An incision was made into the esophagus and the rawhide was removed. Surgery on the esophagus is a very delicate surgery. In this area we have big vessels (aorta) above the esophagus and the vena cava below. Just in front of the esophagus is the heart. Nearby, there are very important nerves (vagus) that course over the esophagus. Also, the esophagus has a harder time healing versus other areas of the gastrointestinal tract with a higher chance of stricture (narrowing due to scar tissue) formation.

View of the esophagus just past the heart.

View of the esophagus just past the heart.

After the rawhide was removed, the esophagus was closed in two layers and then a Vetrix Extracellular Matrix (ECM) sheet was placed. This will aid in healing by providing a scaffold for the tissue to heal and incorporate the bodies own stem cells to infiltrate the area. After the esophagus was closed, Tido’s chest was closed in a standard fashion.

Vetrix Extracellular Matrix placement over the esophageal incision.

Vetrix Extracellular Matrix placement over the esophageal incision.

Tido made an excellent recovery!!! He has been on a soft diet and no rawhides for him!!! In four weeks he should be able to resume his normal activity. At his two week recheck, you could never tell he had surgery. Way to go Tido!!!

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February 2014 Case of the Month – Meet Smokey!!!

Two week recheck

Smokey at his two week recheck!

Smokey was transferred to the surgery department from the overnight emergency service after being attacked by a larger dog the night before. His injuries were multiple and severe. He sustained multiple bite wounds over his thoracic and abdominal body cavities. Thoracic radiographs revealed multiple left sided rib fractures and multiple defects (tears) into the chest wall. The bite wounds over the abdomen were superficial with no evidence of penetration in the abdomen.

Note the multiple rib fractures and the multiple thoracic wall defects.

Note the multiple rib fractures and the multiple thoracic wall defects.

Smokey was stabilized by the emergency service and prepared for surgery once transferred in the morning. Based on the injuries, Smokey had a thoracic exploratory to evaluate the thoracic wall wounds and subsequent internal injuries. Surgery revealed a large thoracic wall defect and multiple fragmented ribs, some of which needed to be removed. Interestingly, the left caudal (posterior) lung lobe had a large laceration caused by one of the rib fragments, necessitating removal of the lung lobe. The remaining thoracic wall defect was too large to close primarily.

The white arrow denotes the diaphragm, the red arrow is showing the muscle of the thoracic wall and the caudal edge of the heart and the black arrow denotes the great vessels (caudal vena cava and caudal aorta).

The white arrow denotes the diaphragm, the red arrow is showing the muscle of the thoracic wall and the caudal edge of the heart and the black arrow denotes the great vessels (caudal vena cava and caudal aorta).

The thoracic wall defect was repaired using porcine small intestinal submucosa extracellular matrix sheets (Vetrix ECM). Note the placement of the ECM in the defect. The overlying muscle was freed and placed as a muscular flap over the ECM. Following the repair a thoracic tube was placed to maintain negative pressure in the chest following surgery. Smokey recovered well from surgery and was released 48 hours following surgery. Two weeks later at his suture removal and he is doing great!

This is demonstrating the placement of the Vetrix ECM sheet for repair of the thoracic wall.

This is demonstrating the placement of the Vetrix ECM sheet for repair of the thoracic wall.

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Frankie’s Journey: Part 1

Frankie and Vinnie relaxing.

Frankie and Vinnie relaxing.

Here are some of the diagnostics  that were performed on Frankie. As mentioned before, during his first visit a thorough examination was performed, which revealed congenital issues on all limbs. Also, when he presented he was overweight (for a 6 month old puppy). We do know that too rapid growth and obesity at a young age can preferentially express the genes responsible for these issues and exacerbate signs.

Here are his physical exam findings: lameness noted in all limb, more pronounced on his left side. Pain on hyperextension and hyperflexion of both elbows and pain on palpation of the medial (inside) compartment of both elbows. Pain on hyperextension and hyperflexion of both hips. Positive Ortolani tests on both hips – this is were the femoral head portion of the hip can be pushed out of the acetabulum (socket) and then falls back in; I have downloaded a video displaying this on Frankie.

Our first steps in diagnosis was to perform radiographs (x-rays) and a CT scan of the elbows. The x-rays confirmed both elbow dysplasia and hip dysplasia. Interestingly, Frankie had bilateral Osteochondritis Dissecans lesions, which isn’t commonly seen, but can be a part of elbow dysplasia.

The CT scan demonstrates the same lesions as the x-rays, but gives a different view. A CT scan is a very sensitive diagnostic test for elbow pathology, especially in cases that have not developed normal x-rays changes yet.

Left Elbow: Osteochondritis Dissecans (OCD).

Left Elbow: Osteochondritis Dissecans (OCD).

Lateral view of the left elbow: elbow dysplasia
Lateral view of the left elbow: elbow dysplasia

Bilateral Hip Dysplasia
Bilateral Hip Dysplasia

OCD lesion seen on the humerus.
OCD lesion seen on the humerus.

Fragmented medial coronoid process.

Fragmented medial coronoid process (FCP).

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Frankie’s Journey

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I want to share this story of Frankie with everyone, as it will be an ongoing story for the next year or so as we continue to help him though this hard time. Frankie was seen by me about two months ago when he was six months old. He is a Golden Retriever that presented for lameness in all legs. He had been enrolled in a service dog program when his owners started to realize that he was having trouble walking. He was referred to me after being evaluated by a local neurologist, who couldn’t diagnose a neurologic issue.

On presentation, Frankie had lameness (limping) in all four limbs. He had pain on manipulation of both elbows, especially when pressure was placed on the inside of the elbows. He had a shortened stride to both hind limbs and was painful on hyperflexion and hyperextension of both hips. Another interesting finding, was that both hips could be felt subluxating on exam (positive ortolani test). This means that you could feel the femoral head rub and partially come out of joint.

Radiographs (x-rays) were taken of all joints and a diagnosis of bilateral elbow dysplasia (osteochondrosis dissecans (OCD) and fragmented coronoid process) and bilateral hip dysplasia was made. Unfortunately, Frankie’s career as a service dogs had to abruptly end. Because of the extensive orthopedic work that would be needed (both elbows and both hips) he was in need of a new home to care for his special needs. My wife and I may be a glutton for punishment, but we thought long and hard about this decision and decided to open our home and give this Golden puppy a second chance.

So my intention for this “Featured Article” segment is to follow the course of Frankie’s treatment including surgery, recovery, physical therapy, and final outcome. I feel that other owners may be in similar circumstances and this may help encourage some and educate others. This will also give a forum to discuss congenital issues such as elbow dysplasia and hip dysplasia. Going through these issues on our own pet, has been an eye-opening experience for us and me professionally. I can now relate to my patients and clients on a much more personal level.

In future segments (soon to follow) we will go through diagnosis, diagnostic test (radiographs and CT scan) and surgeries. So far, Frankie has had surgery on one elbow and is recovering well from that, we will go into more specifics as we go. The plan will be for the other elbow in the near future and then total hip replacements.

Also, please do not ask to donate financially to Frankie, I am not trying to raise money. I am just trying to educate others. There are so many generous people out there and there are many charitable animal organizations that can benefit from your generosity, as it is always appreciated!

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Pets and Decorations Don’t Mix

A timely discussion about some of the hazards that may be around the home during the holiday season.

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October 2013 Case of the Month

October Case of the Month

Scooter (left) enjoying the beach!!

Scooter (left) enjoying the beach!!

For October’s Case of the Month, I have selected a relatively common problem that we see in veterinary medicine – cranial cruciate ligament ruptures. Cranial cruciate ligament (CrCL) ruptures (more commonly referred to as an ACL tear after the human literature) are commonly seen in the practice of veterinary surgery, in fact they are our most common orthopedic case that we see. This disorder affects both the large and small dog, from the Great Dane to the Chihuahua and can affect dogs of any age most commonly the middle age dog. If you would like further details about this specific disorder, please see the previous posts regarding cranial cruciate ligament ruptures (click on the orthopedics tab in the menu bar).

Scooter is a  5  yr old Labrador Retriever that presented for lameness in both hind limbs. His history was such that he was lame in the left hind limb about a year ago and had a previous surgical procedure to address the CrCL performed, to which he responded well early on but became increasingly lame again in the leg and then developed a right hind limb lameness in addition. The procedure previously performed on the left stifle (knee) was not documented and no radiographic implants were used in or around the stifle. Also, Scooter has a chronic history of hip dysplasia and osteoarthritis in both hips to compound his issues.

Physical Exam:

Scooter could walk with assistance, however really struggled in both hind limbs to ambulate. Also, you could see Scooter shifting his weight to his front legs, which is a very classic feature for dogs with CrCL ruptures that affects both stifles. Our physical exam revealed that both (left and right) CrCL were ruptured and we highly suspected bilateral meniscal injuries/tears. While some discomfort could be elicited from manipulation of his hips, the majority of his discomfort and inability to walk was from his CrCL ruptures and meniscal tears.

Right knee - note the joint swelling, arthritic changes, and forward movement of the tibia in relation to the femur.

Right knee – note the joint swelling, arthritic changes, and forward movement of the tibia in relation to the femur.

Left knee - note the joint swelling, arthritic changes, and forward movement of the tibia in relation to the femur.

Left knee – note the joint swelling, arthritic changes, and forward movement of the tibia in relation to the femur.

VD pelvis x-ray - note the chronic signs associated with hip dysplasia.

VD pelvis x-ray – note the chronic signs associated with hip dysplasia.

Surgery:

Surgery was scheduled soon after his initial exam, all his pre-operative work-up was otherwise normal. Most of the time we try to stage each leg. The big reason for separating out surgery on each leg is to reduce the risk of complications such as infection and implant breakdown. Some cases, like Scooter, we chose to do both especially if they are severely affected on both legs like Scooter.

At surgery, bilateral cranial cruciate ligament ruptures were noted, along with bilateral medial meniscal tears. All those findings can be very painful for the patient. Both meniscal tears were debrided (removed) and bilateral tibial plateau leveling osteotomies (TPLOs) were performed. For more detailed information about ways we correct CrCL tears, please view that page on this website.

Right knee - following TPLO surgery.

Right knee – following TPLO surgery.

Left knee - Following TPLO surgery.

Left knee – Following TPLO surgery.

Post-operative care:

As you can image, we treat these patients very carefully. In human medicine, physical therapy and rehabilitation is started almost immediately following surgery. As soon as a patient leaves the operating room, we start icing of the surgical site. That is followed but passive range of motion exercises and short, assisted walks and frequent icing after sessions during the first two weeks. A fairly strict physical therapy program is given to owners and in some cases, organized physical therapy sessions are scheduled under the supervision of a certified canine rehabilitation therapist (CCRT). I generally tell the owners that their commitment to physical therapy is as important as the surgery performed. In Scooter’s case, his owners were very dedicated to the whole process and 16 weeks later he is back to doing his normal activity, which includes running, swimming, and of course lounging around from time to time.

Swimming at dusk.

Swimming at dusk.

Happy dog basking in the sun!!

Happy dog basking in the sun!!

Scooter and his buddy enjoying a swim!!

Scooter and his buddy enjoying a swim!!

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Fracture Management

Bone fractures in pets are a relatively common occurrence in veterinary medicine. Injuries to pets can occur many ways, with the most common being vehicular trauma (hit by car). This brief article is meant to inform owners that not all fractures should be managed the same way and that as fracture repair advances in the human orthopedic field so are the advances in the veterinary field. No longer do we need to rely on pins, wire, and a prayer. The advanced surgical techniques can be thanked due to our increasing appreciation of biomechanics and the different forces on various areas of the body. Many times I have been asked “can you cast that fracture?” The answer to the question is “sometimes”, however most fractures encountered have a much higher chance of healing with some sort of surgical fixation (internal or external). I always remind owners that with our canine or feline patients, they will be trying to use the fractured limb much sooner than we would, which means more pressure on our support. Also, be reminded that when we have a forearm (or upper arm) fracture we won’t be required to walk on it like our pet counterparts.

Our first goal with fracture fixation is how can we make this fracture stable immediately, that will last through the healing process. To do this the surgeon must have a full understanding of biomechanics to appreciate the different forces on the bone (tension, compression, etc). There is no such thing as “cookie-cutter” fracture repair. While many fractures are similar, none are exactly the same. Some may be comminuted (multiple pieces), develop fissures (splits down the long axis of the bone), exposure to the outside (open, contaminated), and be intra-articular (enter into the joint) and require special consideration. It is rare, in the day with veterinary specialists that limbs need to be amputated due to the fracture – the more common reason for amputation would be due to severe neurologic impairment (no feeling, etc). Other goals with fracture fixation include: how do we minimize trauma to soft tissue (skin,muscle, etc), minimize bleeding, minimize infection risk, and maintain blood flow and clots that initially develop around the fracture site that aid in quicker healing.

Fracture repair has evolved over the years from full exposure and full reconstruction of the bone (even with multiple fragments) to minimal reconstruction biological osteosynthesis) and soft tissue disruption (Minimally Invasive Plate Osteosynthesis (MIPO)). This articles goal is to introduce the reader to some of the newer technologies available to the veterinary surgeon and your pet. These techniques are aimed at early recovery and return to function of your pet. I would be remiss if I didn’t mention that exercise/crate restriction is needed during the post-operative phase and can be 8-12 weeks in duration, depending on the type of fracture and age of pet. Please follow the advice of your veterinarian.

Early plates that are still used today (and many times the appropriate choice) are called Dynamic Compression Plates (DCP) or Limited Contact – Dynamic Compression Plates (LC-DCP). There are many cases where this is either the most appropriate option or the only option. The plate must be placed flush against the bone after the bone is reconstructed or supported. Screws go through the plate into the bone through pre-drilled holes. Remember wood-working concepts, as the threaded holes in the bone accept the advancing screw, the screw starts to bring the bone to the plate as you tighten the screw. This bone-to-plate interface (touching/squeezing) is where this type of repair gets it strength. If there is no bone to plate contact, this becomes a very weak fixation. This also demands that the plate is precisely contoured to the bone before application. Some downsides to this fixation is that the fracture must be fully exposed and manipulated (delayed healing, increased risk of infection, soft tissue trauma to an already traumatized area) and that if not perfectly pre-contoured it could weaken the repair or offset the fracture alignment to a degree. There are advantages to this type of fracture repair as well, such as allowing the bone to accept some of the weight bearing load (if a two piece fracture), being able to compress the fracture ends and being able to compress fissures and fragments through the use of screws placed in “lag” (compression) fashion. So there is definitely a place for this type of fixation and in appropriate cases can be the best option.

DCP plate

DCP plate used to stabilize a radius fracture.

Early fracture fixation that tried to minimize soft tissue trauma while providing a strong fixation was the external skeletal fixator (ESF) which encompasses both linear and circular external fixation. These allow the surgeon to place pins of varying sizes in the bone, where the ends remain outside of the limb and connect to a bar or ring for support. Case selection is key as with any type of repair and they certainly have their place in fracture fixation. Surgeon experience and knowledge of repair mechanics is necessary. Some ideal cases may be (but not limited to): some juvenile fractures, open (infected) fractures, intra-articular (or near joint) fractures, etc. The benefit of this fixation is that once the bone is healed, all the implants are removed. Also, sequential removal of pins can be performed to destabilize the repair – which can be beneficial in fractures that are delayed in healing.

A linear external fixator used to stabilize a tibial fracture.

A linear external fixator used to stabilize a tibial fracture.

An external fixator used to stabilize a tibial fracture

An external fixator used to stabilize a tibial fracture

More recent repair options are locking plates. Many companies have began production of locking plates and this article is not meant to show favoritism to any company. The basic concept with this technology is that the screws used actually lock into the plate to provide more stabilization. Previous designs (see above) depended on the bone to plate interface. Locking plates are dependent on the strength of the screw to plate interface, which is typically much stronger. Screws “lock” into the plates by either a conical locking mechanism (Morse taper phenomenon – for all the engineers in the audience) or by threading into the plate (threads on the screw heads match the threads in the plate holes). Many hours of mechanical testing has gone into these types of plates both on the human and veterinary side and have proven their strength. A benefit of this increased strength is the need for less screws than in the earlier described plate designs. We can achieve our desired strength of fracture repair with less implants (less can be more with regards to fracture fixation). Another big benefit is that we no longer are so concerned about contouring the plate to the bone , which allows us to not touch the fracture site to aid and facilitate healing. Remember standard plates bring the bone to the plate as the screw tightens, with the locking plate design, as the screw contacts the plate and locks the bone stays stationary. This design also allows us to perform MIPO techniques with a strong fracture fixation. By in large, this type of fracture fixation is leading the way in both human and veterinary surgery. The downside is that these plating systems are usually only available at veterinary surgical centers, but again they offer a great advantage to fracture management.

Preoperative tibia/fibula fracture

Fracture repaired using a minimally invasive (MIPO) technique and locking plate.

Fracture repaired using a minimally invasive (MIPO) technique and locking plate.

Fracture repaired using a minimally invasive (MIPO) technique and locking plate.

Fracture repaired using a minimally invasive (MIPO) technique and locking plate.

Again, when deciding what type of fracture fixation is best there are many factors to consider and that decision would be made best by your veterinary surgeon. Also, not all types of fixation have been mentioned in the article. We are very fortunate to be living in this time where veterinary medicine is advancing so we can provide greater benefit for our best friend and loyal family members.

– Kevin Benjamino DVM, DACVS

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Brachycephalic Obstructive Airway Syndrome – Treatment

Elongated soft palate

Elongated soft palate

Shortened soft palate

Shortened soft palate

The mainstay of treatment for BOAS remains surgical, however some medical measures can also be taken. When considering medical management, it is important to focus on factors that can cause worsening of the signs, such as weight loss and allergies. Other factors to consider are housing the patient in a cool environment, avoiding the use of neck leads, decreased activity levels and the use of gastroprotectants for any concurrent vomiting or regurgitation. Typically medical management is used after (and in conjunction with) surgical management.

There are many questions that arise when considering surgical management and one of the biggest is when do you consider surgery? BOAS can be seen even in puppies and it is recommended that an evaluation be performed in dogs that are predisposed to this condition. Early management can halt or delay the progression that is typically seen, especially laryngeal collapse.

There are various methods to widen the nares(nostrils). The most common technique is the vertical wedge resection, where a wedge of tissue is removed with the apex of the triangle at the dorsal surface. An absorbable suture can be placed to control bleeding. It is important to make sure that the nares is wide enough to increase airflow.

An elongated soft palate is one of the most common features of BOAS. The assessment and skilled resection is key. If too much is removed, then there is a communication between the oropharynx and nasopharynx. If not enough is removed then the problem still exists.  The most common technique employed is resection with metzenbaum scissors and suture. Sharp excision of the soft palate generally ensures the least amount of inflammation. Other methods, such as CO2 laser and Ligasure, have been described and can be successful. Complications that can arise are as follows: bleeding, inflammation, chronic granulation tissue formation, and further elongation of the soft palate over time.

As mentioned previously, the presence of everted saccules characterizes the patient with stage I laryngeal collapse. There is some controversy as to whether or not everted saccules should be addressed surgically.

With patients that have grade II and III laryngeal collapse surgical correction is more difficult. When collapse is present it is always recommend to correct what is correctable, however the larynx will never be functional again. Some propose modified laryngeal tieback procedures with mixed outcomes. A permanent tracheostomy becomes a very viable option. By performing a permanent tracheostomy the entire upper airway is by-passed.

When counseling owners, generally dogs affected with BOAS have a favorable prognosis. Success is solely dependent on progression of disease. Education of owners should start when the patient is a puppy to avoid worsening. When a patient progresses to laryngeal collapse prognosis decreases greatly, as well as hospitalization time.

 

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Brachycephalic Upper Airway Syndrome (BUAS) – diagnosis

Diagnostic testing:

In addition to direct visualization of structures it is wise to evaluate both the neck and chest. This is most commonly performed with radiographs (X-rays). Structures to evaluate include the oro/nasopharynx, trachea, lungs (for pneumonia, etc), and cardiac disease. If cardiac disease is suspected due to auscultation and radiographs, an echocardiogram is recommended. A complete blood count (CBC), chemistry and urinalysis should be performed prior to anesthesia to assess total body function and if your pet is a good anesthetic and surgical candidate.

A very important part of the diagnostic workup performed just before surgery is the oral examination. One way to evaluate the upper airway is endoscopy of both the larynx and esophagus. This will provide a very thorough evaluation of the soft palate, ventricles and laryngeal function.

Direct visualization is the most common way of diagnosing the associated factors of the brachycephalic dog. The nares are narrower than a normal dog and the airflow is distorted.  For a sedated oral exam, the patient is typically anesthetized (light plane of anesthesia). Evaluating the laryngeal function in these dogs is very important in differentiating laryngeal paralysis from laryngeal collapse.

The mainstay of treatment for BUAS remains surgical, however some medical measures can also be taken. When considering medical management, it is important to focus on factors that can cause worsening of the signs, such as weight loss and allergies. Other factors to consider are housing the patient in a cool environment, avoiding the use of neck leads, decreased activity levels and the use of gastroprotectants for any concurrent vomiting or regurgitation.

 

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Brachycephalic Upper Airway Syndrome (BUAS) – physical exam

Most commonly the history of patients with BUAS are very similar. Generally, owners notice snoring and gradual progression of inspiratory stridor. Many times this will occur while the patient is a puppy and continue into adulthood. Other signs that are noted are increasing frequency of dyspnea especially during exercise or a hot environment. Another sign to look for in addition to the other is vomiting and/or regurgitation. This can be a compounding problem as it predisposes the pet to aspiration pneumonia.

On physical exam one of the first things that can be directly visualized is the nares being stenotic. The observant examiner will also note an increased upper respiratory noise with inspiratory stridor on auscultation(listening with a stethoscope. Typically the rest of the general physical examination is within normal limits.

Prior to performing a sedated oral exam various differentials should be on the list and should include neoplasia (oral/pharyngeal masses/cancer), tracheal collapse, laryngeal paralysis, lower airway disease and cardiac(heart)disease. Both lower airway diseases and cardiac disease can greatly exacerbate upper airway signs and if the patient is stable, these should be addressed first or at least concurrently.

Our next segment will be an overview of the surgical treatment and then we can wrap up this topic.