pets

February 2016 – Case of the Month.
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February 2016 – Case of the Month.

I am getting this in by the “skin of my teeth” before February ends, no pun intended since it is Pet Dental Health Month! In the spirit of dental health – this case will revolve around a common oral tumor that we see in dogs. This stresses the importance of having your pet’s teeth fully evaluated which is part of the routine dental cleanings that your veterinarian can perform, especially as your furry friend ages. Countless times (including the following case), I am referred cases of oral tumors that were noted and biopsied by the family veterinarian.

There are many types of oral tumors and they can range in both their local aggressiveness and there ability to spread to other areas and significantly shorten your pets life and diminish their quality of life. The overall prevailing thought is that early detection of an oral tumor can increase the odds of a successful outcome in many cases. Any new nodules/bumps noted in the mouth or along the jaw line or nose should be brought to your veterinarians attention for further investigation.

The case for this month, involves a German Shepherd mix that presented to me for a mass that was noted in the front of the mouth – incisor 1-3 on the right side of the maxilla (upper jaw). This was noted on a routine dental examination and was biopsied before seeing me. (I love it when patients come with the oral mass already biopsied – it removes that first step for me). It is very important that oral tumors are biopsied prior to developing the final surgical plan. The size/extent of the surgery is very dependent on the tumor type – some are less aggressive and require less of an extensive surgery than others. Also, knowing what we are dealing with can help us predict the course of the disease and survival times.

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Figue 1: Picture of the oral mass on the upper jaw.

The tumor’s biopsy results revealed that it was an acanthotamous epulis/ameloblastoma. The epulid tumors come in three varieties with this type being the most common. These types of tumors can behave locally aggressive (invading into the local soft tissue and destruction of the underlying bone), however they tend to not metastasize (spread to other organs). With this type of tumor, because it doesn’t have a tendency to spread elsewhere, the next step is to perform a CT scan of the head to evaluate the extent of the tumor, which guides us in the surgical planning for tumor removal. If the patient has other concerns, a more thorough work-up may be needed (chest evaluation and abdominal ultrasound). A Complete Blood Count/Chemistry profile/Urinalysis is performed prior to an aggressive surgery and anesthetic event.

With these types of tumors, local excision is generally necessary along with removal of the underlying and surrounding bone. This is why it is so important to catch oral tumors early. I have certainly seen these tumors (among others), where they are too big to safely remove, that will still allow the pet to be comfortable and function normally. Luckily for this dog, she was able to do without the front portion of teeth and bone (incisive bone) and this left her with no visual abnormality, once her fur grew back! The last thing that we look at following surgery is our margin assessment, which tells us whether we removed it all and by how much. For this lucky girl, no further treatment was needed!

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Figure 2: Immediately following removal of mass and affected bone/teeth.

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Figure 3: Patient is visually normal following surgery.

 

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Welcome

Welcome to “A Veterinarian’s Perspective”. Thank you for taking the time to visit this site. One of the many goals is to give accurate and useful information about a wide array of veterinary medicine topics. There are many places online one can obtain information; some “good” and some “not so good”. This site is geared to both the veterinary professional and the non-veterinary trained. Another passion and new facet to this website/blog is in the realm of business management as it pertains to the practice of veterinary medicine.  Look for some fresh, useful topics in the near future. By all means, feel free to give suggestions for topics!

When to Consider a Total Hip Replacement???
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When to Consider a Total Hip Replacement???

Frankie and Ball

While the thought of a total hip replacement can conjure up thoughts of discomfort, pain and prolonged recovery, most of the time this is not the case. In dogs, total hip replacements have been performed for over 25 years and typically have great success when performed by the experienced surgeon with an experienced team. There are many reasons for total hip replacements in the dog, but the most common reason is as a treatment for canine hip dysplasia.

When considering whether a total hip replacement may be an option for your pet, a consultation with a boarded veterinary surgeon who is experienced in this procedure is the first place to start. Typically your family veterinarian can guide you in this process and make a referral to a surgical center that they trust.  When you are faced with this possible treatment option, you will be overwhelmed with questions and the biggest being, “is this the right thing to do for my pet?” My goal is to try to answer some of the commonly asked questions by owners. While I may be biased since I am a veterinary surgeon, I have also been on the owner side of the equation with my own dog with bilateral hip dysplasia (see Frankie’s Journey).

What are the common indications (reasons) why a total hip replacement would be recommended?

This is one of the biggest questions that I hear and there are actually many reasons that a total hip replacement may be recommended. The most common reason is chronic hip dysplasia. While we see hip dysplasia less than a few decades earlier, we do still see this potentially debilitating disease with some frequency. Hip dysplasia refers to a hereditary issue that induces laxity (looseness) within the hip. This looseness causes subluxation or luxation of the affected hip. Subluxation refers to movement of the femoral head partially out of the acetabulum. Think of a ball and socket joint and the ball(femoral head) is popping out of the socket(acetabulum) with movement. Luxation refers to the femoral head completely coming out of the acetabulum. This alone can cause pain and lameness in puppies and young dogs. In some dogs, they learn to navigate without much discomfort, but the joint will start to develop chronic arthritic changes and cartilage wear that go on to cause pain and discomfort. While we term a total hip replacement an end stage procedure, this just means that in dogs with chronic hip dysplasia and arthritis we always try medical/conservative management prior to surgery. There are dogs that, despite medical management and rehabilitation, are still painful and require surgical intervention; or dogs that need to be on medications continuously for the rest of their lives to be comfortable which would also qualify as a total hip replacement candidate.

Frankie's pre-operative x-rays. Bilateral hip dysplasia.

Frankie’s pre-operative x-rays. Bilateral hip dysplasia.

Other indications for a total hip replacement would include fractures associated with the hip, especially when associated with the femoral head and neck. Traumatic hip luxations are another indication. This is where the hip “pops” out of the joint due to excessive force, such as a dog that has been hit by a car. We do see congenital, chronic hip luxations and acute, non-traumatic luxations, however these cases tend to be at a heightened risk of complications with a total hip replacement. Your surgeon will review the options if your dog has this type of condition. Another indication would be for avascular necrosis of the femoral neck – this is a condition where the blood supply to the femoral neck is altered and reduced during the growth phase. Subsequently the femoral neck and head undergoes cell death (necrosis) which leads to deformation and eventual fracturing. This is more commonly seen in small breed dogs.

What types and sizes of dogs are candidates for a total hip replacement?

We generally think of total hip replacement for larger dogs, which used to be the case. The typical dogs that receive this type are surgery are the retriever and shepherd breeds, since we see hip dysplasia in these dogs more commonly. The standard weights of dogs tend to be 40 pounds and over, however that is changing. With the onset of smaller instrumentation and implants, we now can implant a total hip replacement in a dog as small as five pounds and in some cats.

Isn’t my dog too young for a total hip replacement?

While there are certain age related requirements, there aren’t any exact age requirements. Most of the requirements are based on growth plate closure associated with the femur and in particular the greater trochanter, which generally is closed at around 9-10 months of age (older in giant breed dogs). Some clients will ask, “isn’t my one year old Golden Retriever too young?” My response is “no” if the patient is painful and not responding to the conservative management. The implants themselves have a life span of >15 years, generally exceeding the life expectancy of the pet.

The converse of whether the pet is too young for a replacement is the questions as to whether the pet is too old for the procedure. With older dogs, we need to look at the entire health of the patient and ensure that the patient does not have any other related or unrelated illnesses. Total hip replacements still may be recommended in our geriatric patients.

Frankie's post operative radiographs. Left total hip replacement.

Frankie’s post operative radiographs. Left total hip replacement.

What should I expect on my initial consultation for a total hip replacement?

Every surgeon conducts their examinations differently, so here is a brief overview of a standard consultation that I would perform. Obtaining an accurate history is imperative, so be sure to be upfront with what you are seeing at home, when lameness started, what side is most affected, and ALL medications that your pet may be on or may have tried in the past related to treating lameness.

A full physical examination will be conducted looking at general health, orthopedic and neurologic health. During the general examination we are looking for any other issues that may be just as or more important than your pet’s lameness. Some examples are dental disease (potential infection source), heart murmur/cardiac disease, masses palpated on skin, abdomen or on rectal examination, and skin health. Skin infections (even mild) NEED to be treated prior to surgical consideration due to implants being used.

A full orthopedic exam is needed to rule out any other common orthopedic disease such as cranial cruciate ligament (ACL) tears, medial patella laxations, etc., which may require surgical treatment before considering a total hip replacement. A complete neurologic examination is also needed as neurologic disease would be cause for concern.

Below is a summary of the initial consultation:

– Complete examination

– Sedated X-rays. Most patients (even the best behaved patients) will require sedation for radiographs (x-rays) of the hips. We use these x-rays for measurements of implants, so they must be PERFECT. Remember that the reason your pet is seeing a surgeon is because of hip pain, and the positioning of the x-rays may cause some discomfort, so the kindest way to acquire radiographs is with sedation.

– Blood work: Complete Blood Count (CBC), Chemistry profile, and Urinalysis. This needs to be performed at the MOST 30 days prior to surgery to ensure that your pet is a good anesthetic candidate.

– In older patients, additional diagnostics may be recommended such as chest radiographs and an abdominal ultrasound to get a complete health screen.

Assuming your pet is a good candidate for a total hip replacement the procedure will be described to you in detail along with the potential complications, recovery period/rehabilitation, and overall outcome. If for some reason a total hip replacement is not a good choice or another issue is found, other treatment options will be reviewed in depth. I always mention to owners to allot enough time for the consultation since a lot is performed on that first visit.

Will both hips need a replacement?

Every surgeon may have a differing of opinions on this. My thoughts reflect the more conservative viewpoint of 20% of dogs with disease in both hips, need hip replacements in both hips. We tend to see a large amount of patients compensating very well when one hip is replaced. That being said there are some dogs that do require both be performed. The typical time frame for performing surgery on the second side is about six months (sooner in a small number of patients).

Are there other hip procedures other than a total hip replacement?

There are four main surgeries available for hip dysplasia in the dog. The first two have strict time frame/age requirements. The first is called a Juvenile Pubic Symphodesis (JPS) which is a procedure that fuses a growth plate that allows the acetabulum (cup/socket) to cover the femoral head (ball) better. This must be performed in dogs under 6 months of age, before the growth plate closes on it’s own. The second procedure is called a Double/Triple Pelvic Osteotomy (DPO). This is performed ideally in dogs under 10-12 months of age and prior to development of any arthritis. This procedure improves the coverage of the acetabulum over the femoral head and can be very effective in dogs with subluxation rather than luxations.

The two main surgical interventions for adult dogs with hip dysplasia are the Total Hip Replacement (THR), which is the scope of this article and the Femoral Head Ostectomy (FHO). The femoral head ostectomy is a procedure where the femoral head is removed and not replaced. This removes the painful source of the femoral head as it contacts the surface of the acetabulum. This is performed with a degree of frequency in small breed dogs and cats, but is considered in some cases of larger breed dogs. There are some cases where this procedure is the best option, however it has been seen that overall use and function of the limb is diminished when compared to a successful total hip replacement. In some studies, an unsatisfactory result (decreased range of motion and decreased muscle mass) has been described in as high as 40% of cases where a FHO was performed.

The total hip replacement is a procedure that replaces both the femoral side (femoral head and neck) and the acetabulum. This procedure when successfully performed allows for normal, uninhibited movement of the new hip and generally allows for a full recovery. This procedure has been done in many working dogs (police dogs, service dogs, etc.) in which the dog is able to resume its normal “job”.

Are “cementless” implants better than “cemented” implants?

There are definitely pluses and minuses to both systems. “Cementless” implants are also thought of as press fit and have a surface where the bone grows into the implant. “Cemented” implants are held in place by a polymerizing bone cement and is as strong as it will be once it solidifies and dries. We do see a slightly higher risk of infection around the implants with the cemented implants as well as what is termed “aseptic” loosening. Where the bone anatomy allows, we strive to use the “cementless” implants.

What are the potential risks and complications that could occur after a total hip replacement?

During the initial consultation we always cover potential complications. While the total hip replacement procedure has a high success rate, there are always potential complications. The first type of complication would involve implant complications, which can be exacerbated if the post-operative instructions are NOT strictly followed. Our patients, after all, are dogs and will not regulate their activity appropriately, herein lies the owner’s responsibility. If the patient is too active the more common type of complications are implant shifting, luxation of the hip, fracturing of the femur, femoral stem subsidence, and seroma formation. The first three complication would require another surgery. Other complications could include infection (short and long term), aseptic loosening of the implants, etc.

What is the outcome for my pet after a total hip replacement? 

In general, the outcome for the total hip replacement patient is quite good. Ideally the success rate of total hip replacements in the appropriate patient is around 92-95%. The return of function is typically very good and restoration of normal range of motion and improved musculature. The typical recovery/rehabilitation period is about 3 months in total, however it is a gradual ramping up of activity. As I tell my owners, if I can do it with my own dog, you can do it!!

– Frankie one day after a total hip replacement.

– Frankie (and Vinnie) 1 and 1/2 years after his total hip replacement.

Laryngeal Paralysis
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Laryngeal Paralysis

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Spring and summer bring about so many good things: the beach, warm weather, family gatherings, to name a few; and then some bad things: bugs, sweltering heat and humidity, allergies, and the list goes on. For your pets, especially your older retrievers and short nosed (brachycephalic) breeds like the pug and bulldog, the heat and humidity can spell danger due to airway conditions. For more information on the brachycephalic dog breathing issues, see my other post  http://wp.me/p2vvxS-2R . This article will focus on a condition called laryngeal paralysis which typically affects our large breed dogs, such as the Labrador Retriever and similar breeds, although it has been seen in cats (rarely) and is a defined disease process in horses.

What is laryngeal paralysis?

Laryngeal paralysis can be as bad as it sounds. The larynx is at the back of the mouth and allows the passage of air into the windpipe (trachea). In the video below, it mimics swinging doors and the cartilages (arytenoid cartilage) that form the larynx will open when breathing “in” (inspiration) and open when breathing “out” (expiration). It remains closed during other actions, like eating and swallowing, thus stopping food, water, saliva from going down the trachea. There is a muscle that controls the opening of these cartilages. The muscle (cricoarytenoideus dorsalis muscle) sits on top of the cartilages on both sides and actively contracts to open the cartilages during inspiration. The opening of the cartilages when exhaling is passive as the air blows open the cartilages. Laryngeal paralysis is a condition where the nerves that feed this muscle are not working properly and the muscle atrophies and is nonfunctional – hence the larynx is paralyzed and can’t move normally.

What causes this condition???

In most dogs, we do not know the reason for this condition. We divide the condition into two general types: 1. congenital and 2. acquired. In congenital, this condition is usually seen at an early age and is thought to be hereditary. Some common breeds affected are Siberian Huskies, Bulldogs, Rottweilers, etc. In the second form (acquired), it simply means that the disease occurs secondary from other issues. When we think of causes we have to ask ourselves, what can cause damage/changes to the nerve (recurrent laryngeal nerve) that feeds the cricoarytenoideus dorsalis muscle? Conditions that we evaluate for typically are as follows: cervical (neck) tumors, chest/lung tumors, myasthenia gravis, peripheral neuropathies, previous neck (cervical) trauma, and endocrine diseases. Most of the time, we do not find a direct cause and suspect an undiagnosed peripheral neuropathy as the underlying cause. When we do not know the actual cause we term the disease “idiopathic”. Some recent studies (Stanley, et al) have shown that most (if not all) patients with idiopathic laryngeal paralysis will begin to display some generalized neurologic signs within 1-2 years following the diagnosis.

What are the signs of acquired laryngeal paralysis???

Typically, this affects our larger breed dogs, with the Labrador Retriever being the poster child for this disease. The dogs affected are generally middle to older in age, and either male or female. The most common signs noticed is difficulty breathing, especially when exercising or excited and gagging/coughing when eating/drinking. This is a progressive disease, so signs usually begin with mild changes and become more severe, which can be over months to years. You may also notice a change in the pitch of your dogs bark (voice). Most of the time, we can arrive at a presumptive diagnosis just listening to your pet breathing. As the disease progresses, the affected dog becomes more at risk, and can have a respiratory emergency if not managed appropriately, which can be fatal. Below is a video (the audio is most important) of a dog with laryngeal paralysis:

What diagnostics are involved with laryngeal paralysis???

To begin, a thorough general and neurologic examination is needed for your pet. At minimum, a complete blood work, including a thyroid screening panel, and chest (thoracic) x-rays are needed. The importance of these is to look for other disease processes that may be going on and to ensure that the major organs are functioning appropriately. Why the thyroid panel? Hyopthyroidism (low thyroid hormone production) can cause various neuromuscular issues. With the chest x-rays we are looking for any masses, changes to the esophagus size (megaesophagus) and signs of aspiration pneumonia, which can be seen secondary with laryngeal paralysis. Because most of the patients I see with this condition are older and we are assessing for surgery, I highly recommend an abdominal ultrasound by an experienced ultrasonographer to look for any other concurrent diseases. Bear in mind, if your pet is in a respiratory crisis some of these steps may be done out of order to adequately stabilize the patient.

The best way to confirm the suspected diagnosis of laryngeal paralysis is to look directly at the larynx and assess the functioning of the laryngeal cartilages. This is typically done by inducing a light plane of anesthesia and looking at the back of the mouth. The proper assessment is sort of an art and takes practice to be comfortable making the diagnosis. In addtion to evaluating the larynx, time is taken to look at the rest of the oral cavity for other potential causes. As a surgeon, my preference is to do this examination directly prior to surgery to minimize the amount times the pet needs to undergo anesthesia.

Below is a video demonstrating laryngeal paralysis. The laryngeal opening can be seen and you will notice that it is not moving much at all during the phases of breathing.

How can I treat my pet once laryngeal paralysis is diagnosed???

Probably the better questions is when do I treat? Once a diagnosis is made, then a decision needs to be made. Since this is a progressive disease, if only one side of the larynx is affected then surgical options will most likely be delayed. The most typical treatment for idiopathic laryngeal paralysis is surgical. To date, there is no medical therapy that will restore the function of the larynx. Conservative management will typically incorporate ways to keep your pet cool (air conditioned environment), sedation possibly, and decreasing environmental allergens. If, during our pre surgical diagnostics, we find other issues, changes may be made to the treatment plan. There are some findings that may make your veterinarian reconsider your pet being a good surgical candidate, such as an enlarged esophagus (megaesophagus). The main reason to proceed forward with surgery is to improve your pets quality of life for however long that may be, as well as improve your (as the owner) life by providing more quality time together. There are risks both with surgery and without surgery.

The standard procedure to open the airway is called an arytenoid lateralization (laryngeal tie-back). This is a procedure that pulls one side of the laryngeal cartilages back, permanently opening one side of the larynx. In effect, we override the normal muscular action of the larynx. We gain access to the larynx by an incision made on the side of the neck. None of the work is done within the mouth. There are other procedures that remove the arytenoid cartilage portion of the larynx to permanently open the larynx from within the mouth, called an arytenoidectomy. This procedure, in my opinion, has not been evaluated as much as the “tie-back” procedure.

Below is a picture of an arytenoid lateralization. Notice the difference on the opening from the previous video.

Tie back

What are the risks with and without surgery and what is the typical outcome?

No procedure is without inherent risks, unfortunately. The risks and benefits of any procedure must always be weighed and discussed with your veterinarian and veterinary surgeon. The most common post-operative complication is aspiration pneumonia. Recent literature cites about a 12-15% risk of aspiration pneumonia following surgery, with the most critical time period being the actual recovery from surgery and the immediate post-operative period. Some medications can be administered that help reduce vomiting, regurgitation and increasing the tone of the lower esophageal sphincter muscle – all aimed at lowering this risk. Most of the time aspiration pneumonia, if caught early, can be treated successfully with antibiotic therapy and supportive care (depending on severity). In a small number of patients, aspiration pneumonia can be fatal. Other complications are break down of the “tie-back” suture and incisional complications such as seroma and abscess/infection. Anesthesia complications can arise with any anesthesia/surgical event, however with proper screening, this risk can be minimized. My feeling is that even dogs prior to a “tie-back” procedure have a higher risk of aspiration pneumonia because the protective mechanism of the larynx is not functioning properly.

Surgically addressing this condition can be life saving and drastically improve the quality of your pets life. Most owners (~90%) are happy they made the decision to proceed forward with surgery and are pleased with the improved quality of life for their pet. If you notice any of these changes to your pet, please plan to see your veterinarian to see if they are a candidate for surgery. While the above article is long, it does not include everything related to this disease, if you have questions, just ask!!!

Kevin Benjamino, DVM, DACVS

Copyright  2015

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Meet Faith!!!

Meet Faith!!!

Meet Faith!!!

Faith is an adult, mixed breed dog that came to Affiliated Veterinary Specialists – Orange Park from a local rescue group (SAFE Pet Rescue) in the Jacksonville, FL area. She was found and brought to a local shelter and had sustained multiple injuries. We suspect that her injuries were most likely caused by being hit by a car. Unfortunately, her injuries are chronic in nature, probably about 4 weeks old and she has learned how to scoot around and pull herself with her front end.

Left tibia/fibula fracture

Left tibia/fibula fracture

Right hip luxation

Right hip luxation

Her major injuries are a right hip luxation and left tibia/fibula fracture. She has normal neurologic function in the hind legs, however she has no support in the back legs……..until surgery. In addition to her orthopedic issues, she also is heartworm disease positive. The decision was made to address the orthopedic conditions in order to get her mobile and then focus on the heartworm disease. The heartworm disease always makes anesthesia more complicated, but with the proper precautions, she did great. Due to the chronicity of the hip luxation, a femoral head ostectomy was performed and the left tibia/fibula fracture was repaired.

Right femoral head ostectomy

Tibia/fibula fracture repair

Just two days after surgery she is starting to stand on her own and take some steps forward. She is very sweet and has determination. She will make a great addition to someone’s home when she recovered. It is exciting to know that she has been given a well deserved second chance. Please go to the SAFE Pet Rescue website:  http://www.safe-pet-rescue-fl.com or following them on Facebook: SAFE Pet Rescue to learn more about Faith and other adoptable dogs!!

Faith

Faith says “Hello”

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Pet Rehabilitation

Check out the new page on http://www.drbenjamino.com

Pet Rehabilitation.

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Top 5 List for a Safer Holiday Season

Happy Halloween!!!

As Halloween and the upcoming holidays are rapidly approaching, we are often wrapped up in family gathering, parties, and other activities and forget about the well being of our beloved pets. I tried compiling a short list to help keep our pets healthy and out of trouble this holiday season. This should ensure that everyone has a happy holiday season and may save you and your pet from needing emergency trips to veterinarian or emergency clinic.

1. Keep candy away from pets, in particular chocolate and candies made with xylitol and other sweeteners. While these taste good, they can have very harmful effects on your pet, ranging from liver failure, seizures, and as severe as death. If you suspect your pet has consumed any of these, seek veterinary care immediately.

2. Keep a close on the whereabouts of your pets. With all the excitement and increased visitors during this time, make sure your pets are accounted for and haven’t run off. Missing pets and subsequent trauma, such as being hit by a vehicle is an all to common occurrence during this time. Make sure your pets are in a safe place when company is over.

3. Keep pets out of the garbage and from grabbing food off the table. Bones and fatty meats can cause illness in our pets, especially dogs. Bones can cause a lot of irritation and in some cases puncture the gastrointestinal tracts. Fatty foods are not good for our pets and can cause pancreatitis and other gastrointestinal issues. Pancreatitis can range in severity and needs to be treated by your veterinarian.

4. Keep cords and electrical wiring away from your pets. Both cats and dogs can find wires enticing. Electrocution injury can be very severe and cause death in some cases. If you believe your pet to have be electrocuted, have them evaluated by your veterinarian immediately.

5. Keep easily ingestible objects away from your pets. Objects that can be easily swallowed can cause gastrointestinal irritation and obstruction. Some objects that can become obstructive are clothes, small toys, tinsel, etc. Gastrointestinal obstructions demand immediate veterinary care. There are times when the object can pass, but most of the time your pet will need surgery to relieve the obstruction, Surgery can range from a single incision in the stomach to removal of a segment of intestine. In extreme cases this condition can be fatal.

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October 2014 Case of the Month

October’s case of the month is an interesting one. Lucky is a young chihuahua mix that came to us with SEVERE injuries. He was attacked by a neighborhood dog about 7 days before presenting to us and was in very bad shape. His initial wounds were managed, but unfortunately infection still set in and the majority of his cervical (neck) skin started to die and needed to be removed. Not only was the infection causing a problem locally, but we had signs of it being spread systemically (through his blood stream). He needed both surgical care and care by a criticalist(board certified in Emergency and Critical Care) in order for him to have a fighting chance. Below is a picture of what he looked like when he was admitted into the hospital.

This was Lucky as he was admitted to the hospital.

This was Lucky as he was admitted to the hospital.

You can make out the extensive injuries on the photo above. He was fortunate to be alive! Whenever we get a case like this (unfortunately it happens more frequently than we like), we am always realistic with the owners, because there is a chance that their pet will not survive. Also, these cases are not quick cases, Lucky was hospitalized for 2-3 weeks and wasn’t fully healed for about 6 weeks. Our first objective is to get the systemic infection under control and get him strong enough to be able to handle surgery. While the criticalist was working on the systemic infection, we were concentrating on the neck wound.

The first phase wounds go through is the debridement phase, which is where the body gets rid of necrotic (dead) tissue and the size of the wound is established. The next phase to follow is the granulation phase. The granulation phase is very important in a large wound like this, this is when the body begins to infiltrate the wound with healthy tissue and more importantly capillary vessels, which bring blood flow. For this wound, I choose to use a wound dressing called BurnStat (Ubuntu) which is a dressing that can be used through multiple phases. It is an organic clay substrate that does an excellent job of removing toxins and necrotic tissue while promoting granulation tissue formation.

Debridement phase

Debridement phase

Applying BurnStat as the primary wound dressing

Applying BurnStat as the primary wound dressing

Following this type of bandaging, the diseased tissue begins to be replaced with more healthy, red granulation tissue. The final product, before being able to close the wound, needs to be completely covered with granulation tissue in order to increase the chance of the new skin being accepted.

Complete coverage by granulation tissue.

Complete coverage by granulation tissue.

You can see how the surface is covered with healthy looking tissue and no presence of dying tissue visible. By this time Lucky amazingly over came his battle with the widespread infection and overall was doing very well. He was making a remarkable recovery.

Our next dilemma was “how do we cover the exposed tissue”? In cases like this, we have a few options, which is beyond the scope of this post. I choose to use an advancement flap (skin freed up from a nearby location that is moved over the wound), which made the most sense due to the elasticity of the skin in this area. Below is his wound following surgery.

Advancement flap

Advancement flap

Following surgery we also utilized laser therapy to help promote uptake of the skin flap. This is Lucky in his referee uniform (it is close to Halloween) receiving his laser therapy.

Post-advancement flap therapy

Post-advancement flap therapy

Here is the finished product for Lucky!!! He overcame a lot of obstacles along the way!!

This is about 6 weeks after Lucky presented.

This is about 6 weeks after Lucky presented.

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Osteochondritis Dissecans (OCD) – Shoulder

Sometimes it can be very hard to determine which leg your pet (or patient) is limping on, let alone which joint is causing the problem. I want to take a little time to discuss a problem that we see from time to time that typically affects the juvenile (6-18 month), medium and large breed dog and is typically thought of as a congenital/hereditary issue. The most note worthy joints affected are the shoulder (proximal humerus), the elbow (distal humerus), stifle (distal femur), and hock (talus).

The underlying etiology is similar in all the joints, however this article will focus on the shoulder with subsequent articles dealing with the other joints. I think this approach is reasonable because the treatment may be different for other joints,as well as, the prognosis can vary. Again, this disease affects primarily young dogs; in the older patients we usually see the consequence of this issue, resulting in osteoarthritis of the joint.

Osteochondrosis (OC) precedes osteochondritis dissecans (OCD) and is characterized by a problem between the metaphyseal growth plates of the affected bone and the cartilage. In essence, the cartilage surface does not adhere to the underlying subchondral bone surface. When a cleft or break develops in this “soft” cartilage, this fulfills the term OCD. Once the area progresses to an OCD lesion (a break in the cartilage develops), then the patient becomes clinically lame and will exhibit a degree of lameness/limping. Once a flap/break develops there is no known healing that occurs and the abnormal area will continue to incite inflammation within the joint.

There are multiple suspected causes of this issue in the dog, with the most reasonable explanation being that of a congenital/hereditary cause. There is some support of other predisposing factors that may enhance the genetic expression of this disease such as juvenile obesity and imbalances in calcium intake.

Patients with this type of condition will usually be within 6-18 months of age and have a varying level of lameness on one or both front legs. An owner may also see more limping/lameness after strenuous activity or rising from rest.

Physical examination of the suspected patient usually will direct us in the right direction. A thorough gait evaluation is needed to identify which leg or if both front legs are affected. There are certain techniques that can be used to detect which leg is the culprit even with a mild lameness. If your dog is “off and on” lame, it is always helpful to the veterinarian for the owner to bring in video of the patient when he is limping, to help improve our chances of diagnosing your pet correctly. The next step in the evaluation is direct palpation of the leg starting from the digits, working up to the neck. It is very important that care is taken at each joint and long bone on evaluation, since shoulder OCD is not the only cause for limping in the young dog. Typically, discomfort will be elicited on manipulation of the affected shoulder(s) and especially on hyperflexion and hyperextension of the joint. The next step is diagnostic tests.

Radiographs (X-rays)

Shoulder_OCD0001 Shoulder_OCD0002

Above are x-rays of a left and right shoulder affected with OCD lesions. These are on the same patient. The images labeled with the left (L) marker has a flattened region noted by the arrow which is characteristic of OCD. The image on the right has the area highlighted in blue. While the lesion doesn’t look big, it can definitely cause a lot of pain and discomfort.

Another way to diagnostically evaluate the joint is with a computed tomography (CT) scan. This will give more detail into the region of interest. Generally this is not needed, however indications for it may be to evaluate the elbows as well.

Treatment:

For the best possible outcome do not delay treatment! At this time, the gold standard approach is arthroscopic debridement (removal) of the fragmented cartilage and the surrounding diseased cartilage and subchondral bone. Curettage may allow the now vacant cartilage bed to fill in more quickly with what is called fibrocartilage. I likened the removal of the fragment to old wallpaper removal (very much oversimplified). Once the old wallpaper bubbles and tears, you need to remove all the damaged wallpaper in the periphery or else the wallpaper will continue to peel.

If the cartilage is an osteochondrosis (OC) lesion and has not fragmented (OCD) non-surgical treatments (activity restriction, dietary restriction, etc) may be attempted and successful. Unfortunately, if OCD has not occurred then the patient will not be limping and most of these dogs go undiagnosed. It is my belief that any dog exhibiting pain/lameness with the presence of a radiographic (x-ray) OCD lesion ,should have surgery. Surgery will benefit them both in the short term and the long term.

There are older techniques of opening the joint to get access to the cartilage flap, however the recovery time on this type of procedure is significantly longer than with arthroscopy. Also, potential complications are increased with an “open” technique than with arthroscopic techniques. Arthroscopy is a minimally invasive tool that allows us to both diagnose and treat this condition. Generally speaking the patient can walk on the surgery leg (even if both legs have surgery at the same time!) following an arthroscopic procedure. Generally 2-3 small ports are placed over the shoulder (2-4mm in length) and this allows us access to the joint and work within the joint.

Recovery and Rehabilitation: 

Recovery for the arthroscopic procedure is generally 4-6 weeks. Every surgeon has a different protocol for after surgery and I am very respectful of that. I prefer controlled movement for my patients. In the first two weeks, passive range of motion is very important, followed by active icing of the joint(s). Short leash based walks are started shortly after surgery and incrementally increased as we proceed through the recovery phase. Introduction into a formal rehabilitation program is recommended, however there are times when this is not possible and rehabilitation must be performed at home. Below is a patient that had a single shoulder arthroscopy, you can see how well they can walk following surgery (this is the following day)!

Prognosis:

When diagnosed and treated early, the dog affected with OCD can have a good prognosis and resume a normal or near normal activity level and quality of life. The longer the lesion is present, the more inflammation and arthritis will develop decreasing our success with surgery. Of the OCD lesions (shoulder, versus the other sites affected) this region has the best prognosis. I do encourage all my patients to continue on joint supplementation for life and to be removed from any breeding program.

 

 

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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!!!