INTRO - 202307-202402 Flashcards

Question

Compagnone - 2023 - VCOT - Thoracolumbar Intervertebral Disk Extrusion in Dogs - Do Onset of Clinical Signs, Time of Surgery, and Neurological Grade Matter ?.pdf

Answer 1

Intervertebral disk extrusion (IVDE) is a common neurologi-cal disorder in dogs. Clinical signs can vary and range frompain to paralysis depending on the location, the degree ofspinal cord injury, and duration of the compression of thespinal cord by extruded disk material.1–6There are several reports of successful conservativemanagement in dogs affected or presumptively affectedby IVDE with minimal neurological de ﬁcits with a successrate ranging from 55.6 to 100%.6–8In dogs with markedneurological de ﬁcits, non ‐ambulatory paresis or paralysis,surgical decompression has been the recommendedtreatment option, and it has been associated with a favorable outcome compared to conservativemanagement.2,9–11Many studies have looked at prognostic variables thatinﬂuence the quality of recovery, including weight,4,12age,2,4breed,12imaging ﬁndings,13,14and severity of preoperativeneurological de ﬁcits.2,3,5,6,15 –17Presence of deep pain sensa-tion correlates de ﬁnitively with improved recovery.3,4,6,18,19Although many veterinary surgeons consider IVDE a surgi-cal emergency, the ideal timing for surgical intervention indogs has not been determined, as it has not been establishedwhether the duration of clinical signs and the outcome of dogssurgically treated for IVDE are correlated.1,4,6,9,18,20 –22Therate of onset of neurological signs has also been investigated inrelationtothetimeof recoveryand somestudies havefound nodifference on the overall outcome for cases with an acuteonset,4,21while others have found these cases having a slowerand worse recovery.3,6,9It is speculated that the rate of onsetcould in ﬂuence the recovery time6because a high-speedextrusion translates in a greater impact on the spinal cord,leading to a more severe contusion and injury.2Experimentalevidence seems to suggest that most of the damage would becaused by the primary impact and shock on the spinal cord,rather than the compression over time.23,24Should this be truein the clinical setting, the recovery of function and time torecovery could be more dependent on the severity of theprimary injury rather than the delay of surgical interven-tion.1,25,26The ideal timing of surgery remains controversial.11Upchurch and colleagues showed some evidence that adelay from the onset of clinical signs associated with IVDE tosurgery is unlikely to affect the ultimate outcome or thelength of time for a dog to regain pain sensation, urinarycontinence, or ambulation. Equally, the rapidity with whichthe onset of clinical signs develops was not shown to in ﬂu-ence the quality of the outcome.21A recent large studyanalyzed a cohort of 1,501 dogs with thoracolumbarIVDE27and the results might support the recommendationthat an early surgical intervention is warranted to improveoverall outcome. In this study, a signi ﬁcant associationbetween the time from the onset of the clinical signs untilsurgery and the overall outcome was identi ﬁed, suggestingthat a shorter delay to decompression might improve theoverall outcome. However, this correlation was not con-ﬁrmed on a bivariate analysis. Similarly, a signi ﬁcant associ-ation was found between the time from onset of the clinicalsigns until surgery and the time of recovery, which was notconﬁrmed on a multivariate regression model. Moreover,they found no signi ﬁcant association between neurologicalgrade at presentation and outcome. In another recent pro-spective study, the delay between onset of clinical signs andpresentation and time between presentation and spinalsurgery was not associated with the rapidity of recovery ofambulation in 151 dogs surgically treated for thoracolumbarIVDE.22In the same study, only duration of surgery andneurological grade at presentation were signi ﬁcantly associ-ated with rapidity of recovery of ambulation.Our study investigated the outcome and the time ofrecovery of a large population of dogs surgically treated forthoracolumbar IVDE. The purpose of this retrospective studywas to evaluate whether the overall outcome and/or time torecovery is in ﬂuenced by the delay from presentation tosurgical decompression, the rate of onset of clinical signs, andother variables of interest.

Answer 2

The nasopharynx is the nasal portion of the pharynxthat extends from the choanae to the interpharyngealostium. The rostral part of the nasopharynx is boundedby solid structures such as the hard palate ventrally,vomer dorsally, and palatine bones on both sides. Themiddle and caudal portions are bounded dorsally bymuscular constrictors (hyopharyngeus, thyropharyn-geus, cricopharyngeus, and palatopharyngeus) and dila-tors (stylopharyngeus) of the pharynx, and the ventralboundary is the mobile soft palate. The soft palate isphysiologically able to obliterate the caudal part of thenasopharynx during swallowing via the pressure of theswallowed material and the root of the tongue forcingthe soft palate dorsally.1Dynamic nasopharyngeal col-lapse is defined as the partial or complete pathologicalobliteration of the pharynx due to the dorsal displace-ment of the soft palate and/or ventral deviation of thepharyngeal wall during inspiration2,3(Figure 1). Naso-pharyngeal dynamic collapse is considered to be a partof or an important contributor to brachycephalic syn-drome.2In a recent study, the prevalence of dynamicpharyngeal collapse in brachycephalic dogs undergoingfluoroscopy was 72%.2The diagnosis and grading of theseverity of nasopharyngeal collapse were based on thevisual estimation of nasopharyngeal lumen obliterationusing fluoroscopy, which was defined as complete whena complete loss of lumen was observed and partial if thelumen diameter decreased by >50%.2,3To the best ofour knowledge, no study has compared the intra- andinterobserver variability of such estimations. However,low variability is an important prerequisite for theobjective detection of nasopharyngeal collapse as a con-tributing factor to the patient's brachycephalic airwayobstruction syndrome and for evaluation of the resultsof surgical interventions. An ideal method to objectivelycharacterize nasopharyngeal collapse using fluoroscopyis lacking. Measurements can focus on the differencebetween the maximal and minimal dorsoventral dimen-sions during one breathing cycle. However, the maximaldorsoventral dimension can appear in another part ofthe nasopharynx compared to the minimal dimension.Therefore, we have proposed a functional method tomeasure changes in the dorsoventral dimensions bydefining the points for both the maximal and minimalmeasurement using the location of the minimaldorsoventral dimension of the nasopharynx and com-paring the relative dorsoventral change at this location.Furthermore, we have proposed an anatomicallyadjusted method by defining the maximal and minimalmeasurement points according to the most rostral extentof the epiglottis.The objective of our study was to compare the intra-and interobserver agreements in assessing nasopharyn-geal collapse in a population of two brachycephalicbreeds presented for BOAS at our institution by evaluat-ing the intra- and interobserver variability in measuringchanges in the dorsoventral dimensions of the nasophar-ynx using both the functional and anatomically adjustedmethods. Our second aim was to evaluate the clinicalapplicability of the two methods by comparing the agree-ment achieved using the respective method.We hypothesized that these techniques would offerhigh intra- and interobserver agreement regardless of thebreed and the observer's specialty and expertise andwould therefore be reliable for evaluating nasopharyn-geal collapse. We further hypothesized that the anatomi-cally adjusted method would offer higher intra- andinterobserver agreements.

Answer 3

A patent ductus arteriosus (PDA) is a congenital heart anomaly characterized by the fetal duc -tus arteriosus vessel failing to close after birth.1 The ductus arteriosus functions in utero to bypass the pulmonary system and shunt blood into systemic cir -a.22.12.0541culation.1,2 Following birth, a PDA shunts blood from the aorta into the main pulmonary artery, resulting in a pathologic volume overload of the left atrium and ventricle, as well as the pulmonary system.1,3 This volume overload can eventually progress to 2 left-sided congestive heart failure (CHF) and chronic pulmonary hypertension. In patients in which the pulmonary vascular resistance exceeds that of the systemic vasculature, reverse blood flow of deoxy -genated blood from the pulmonary artery through the shunt vessel into the aorta occurs with subse -quent differential systemic cyanosis.1,4 This condi -tion is termed a “reverse PDA” or “right-to-left shunt PDA,” and surgical intervention to ligate the shunting vessel is no longer indicated.Dogs diagnosed with a left-to-right shunting PDA that undergo surgical correction have been shown to have an increased survival rate and better long-term outcome compared to dogs that do not un -dergo surgical intervention.3 Surgical intervention in -cludes either ligation of the PDA via a lateral thoracot -omy or transvascular device closure. Risks associated with both types of intervention include hemorrhage (most commonly from either the PDA or vascular ac -cess vessel), arrhythmias, and cardiac arrest, with the risk of intraoperative hemorrhage reported between 6.25% and 15%.5–7 Multiple retrospective studies have evaluated preexisting patient factors and their as -sociation with intraoperative complications, short-term outcome, and long-term prognosis and have reported a 1-year survival rate of 94%.3,5–8While there is conflicting literature in terms of prognostic variables for dogs undergoing surgi -cal ligation for a PDA, these retrospective studies span over 4 decades. There have been significant improvements in early detection of congenital heart anomalies in dogs, as well as substantial advance -ments in management for patients experiencing in -traoperative complications. To the authors’ knowl -edge, a large cohort study evaluating preoperative patient factors to identify risk factors for intraopera -tive hemorrhage and other complications, as well as the effect of intraoperative complications on short- and long-term outcomes, has not been published in recent literature. The objectives of this exploratory study were to evaluate the short- and long-term out -comes in a large cohort of dogs diagnosed with and undergoing surgical ligation for a PDA, identify risk factors for intraoperative hemorrhage, and evalu -ate intra- and postoperative complications, mortal -ity rates, and long-term survival. We hypothesized that there would be a similar survival rate for dogs undergoing surgical ligation of a PDA compared to previous studies. We further hypothesized that the presence of concurrent congenital cardiac disease or acquired cardiac disease as evidenced by the pres -ence of chamber enlargement or abnormal valvular regurgitation would increase the risk of intraopera -tive hemorrhage due to secondary structural cardiac changes, and intraoperative hemorrhage would oc -cur at a higher rate than previously reported.

Answer 4

Minimally invasive plate osteosynthesis (MIPO) is anadvancement in biologic osteosynthesis, developed tolimit iatrogenic soft tissue trauma.1By utilizing indirectfracture reduction techniques and remote plate inser-tional incisions, MIPO aims to preserve the local fractureenvironment. In dogs, MIPO has resulted in improvedpreservation of periosteal perfusion and equivalent orshorter time to union when compared to open reductionand internal fixation.2–4Obtaining acceptable alignment during MIPO appli-cations can be challenging.5Closed indirect reduction offemoral fractures is especially problematic due to theabundant surrounding musculature.6,7Several indirectfracture reduction techniques have been described tofacilitate MIPO applications.5,8–10In a retrospective caseseries, 10% of femoral fractures stabilized via MIPO per-formed without intraoperative imagining required imme-diate surgical revision.9Use of fluoroscopy to assessalignment and implant placement intraoperatively mayreduce the risk of complications during MIPO applica-tions, but exposes the surgical team to ionizing radiation.Virtual surgical planning and 3-dimensional(3D) printing are gaining interest in veterinary orthope-dic surgery and the application of custom surgical guidesto facilitate indirect fracture reduction during MIPO hasbeen described.11,12One case report described utilizingMIPO with 2 custom surgical guides and an alignment jigfor a cat with a comminuted mid-diaphyseal humeralfracture, and near-anatomic alignment was achieved.11Similarly, a custom 3D printed reduction system resultedin excellent reduction in dog cadavers with simulated tib-ial fractures.12The objectives of this study were to (1) develop anddescribe a fracture reduction system (FRS) designed tomitigate the challenges of indirect femoral fracture reduc-tion and (2) assess the efficiency and accuracy of reduc-tion using accurately precontoured plates and either theFRS or placement of an intramedullary pin (IMP). Wehypothesized that FRS would reduce the duration of sur-gery, require fewer fluoroscopic images, and producesuperior alignment when compared to IMP.

Answer 5

Gallbladder mucocele (GBM) is a common disease ofthe biliary system in dogs, with border terriers,1Shet-land sheepdogs,2miniature schnauzers, cocker span-iels, and Pomeranians being over-represented.3Gallbladder mucoceles are characterized as having cys-tic mucosal hyperplasia with increased mucus secre-tion, leading to the accumulation of thick, black,viscous bile, which can cause extrahepatic biliaryobstruction.4As the disease progresses, distension ofthe gallbladder and eventual rupture can occur, lead-ing to bile peritonitis. The underlying etiology isunknown; however, a number of studies have madeassociations with endocrinopathies,5immunologicaldiseases,6genetic defects,7idiopathic hyperlipidemia,3and administration o f particular drugs.8Gallbladder mucoceles can be an incidental finding;however, animals may present commonly with a varietyof vague clinical signs, most usually vomiting, lethargy,anorexia, and abdominal pain.9–11Biochemistry findingsgenerally show increases in alkaline phosphatase (ALP),alanine aminotransferase (ALT), gamma glutamyl-transferase (GGT) enzyme activities, total bilirubin, cho-lesterol, and triglycerides consistent with cholestatic dis-ease.1,2,12Gallbladder mucoceles are suspected fromabdominal ultrasound with varying degrees of organiza-tion within the gallbladder noted, with some cases show-ing a characteristic stellate appearance.13A diagnosis ofGBM is confirmed with histopathology.Gallbladder mucoceles are generally managed withcholecystectomy. Medical m anagement has been asso-ciated with shorter survival times than surgery; how-ever, it should be considered when surgery cannot bepursued.14A small number of cases have been reportedto have resolved successfu lly with medical manage-ment alone.15There have been sporadic reports of flushing of thecommon bile duct (CBD) at the time of cholecystec-tomy.16,17Flushing of the CBD may be performed toremove mucus accumulation and confirm patency of theduct prior to cholecystectomy. However, recent studieshave failed to demonstrate a benefit from catheterizationof the CBD11,18When comparing catheterization versusnot catheterizing the CBD retrospectively, catheterizationhas also been shown to be associated with an increasedrisk of postoperative pancreatitis.18These studies areexclusively retrospective in design and a randomized,controlled, prospective study comparing flushing and notflushing the CBD in dogs with GBM treated by cholecys-tectomy is currently lacking.The objective of this study was to identify prospectivelywhether there was a benefit to flushing the CBD comparedto not flushing the CBD when performing a cholecystec-tomy for management of GBM. Primary clinico-pathological endpoints assessed were: changes in cholestaticmarkers 3 days postoperatively compared with preopera-tively in both groups. Secon dary clinical endpoints wereused to compare the hospitalization time and survival todischarge. We hypothesized that flushing of the CBD wouldoffer no short-term clinical and/ or clinico-pathological ben-efit when compared to not flushing.

Answer 6

Cranial cruciate ligament disease (CCLD) is one of the most prevalent orthopedic problems in dogs1; however, its prevalence on field Retrievers is un -known. Retriever field trials were created in the early 1900s for the purpose of evaluating a dog’s hunting prowess in a controlled environment to better the breed.2 These competitions are primarily American Kennel Club (AKC) trials, and the dogs that are al -lowed to participate are limited to AKC-registered Retrievers and a few Spaniels.2 During these trials, the dog’s physical and mental skills are put to the test, often requiring them to retrieve birds from over 100 yards away, over varied and difficult terrains, in -cluding water, sometimes without being able to see where the bird is placed. This means they must rely on their instinct, intelligence, and strength and the owners’ commands to complete the retrieve.2,3 The Cranial cruciate ligament disease is perceived to be prevalent and is misunderstood in field trial sportJessica Hynes, BS1*; Jane M. Manfredi, DVM, PhD, DACVS-LA, DACVSMR2; Sarah A. Shull, DVM, DACVSMR11Department of Small Animal Clinical Sciences, College of Veterinary Medicine, Michigan State University, East Lansing, MI2Department of Pathobiology and Diagnostic Investigation, College of Veterinary Medicine, Michigan State University, East Lansing, MI*Corresponding author: Jessica Hynes ( hynesjes@msu.edu )Received January 5, 2023Accepted June 13, 2023doi.org/10.2460/javma.23.01.0004lifelong training for this sport is intense in order to hone their instincts into what the handler needs for both hunting and competition, including both men -tal and physical challenges,4 necessitating a well-conditioned, orthopedically sound dog.The CCL works in tandem with the medial meniscus and flexor muscles of the stifle to prevent cranial displace -ment of the tibia and limit internal rotation to maintain joint stability and proprioception.5,6 Though rupture of the CCL can be attributed to trauma in about 20% of cas -es, the majority (approx 80%) are a result of degenerative CCLD.7,8 CCLD is a progressive degeneration of the CCL’s extracellular matrix causing a predisposition to rupture, often affecting both hind limbs.9,10 The direct cause of CCLD has yet to be identified, but there is research into what might predispose a dog to CCLD. There are correla -tions with increased body weight and CCLD, with most 2 researchers agreeing that an increased body condition score leads to added weight putting more strain on the ligament and that the excess adipose with its proinflam -matory nature may increase the rate of inflammation and degeneration.9,11,12 In addition, spay/neuter status has been noted to have a correlation with an increased incidence of CCLD, with castrated dogs more often af -fected, though the precise mechanisms are unknown at this time.9,11,12 Another potentially significant cause of CCLD is a genetic factor. Prevalence of this condition has been reported to be 2.6% in the US, from a study13 look -ing at over 1,000,000 dogs between 1964 and 2003. Vari -ous studies have demonstrated an increased incidence of CCLD in breeds such as the Newfoundland, Labrador Retriever, and Rottweiler, especially when compared to other breeds such as the Greyhound that seem to be less affected.7,11 In Labrador Retrievers, the prevalence of CCLD has been shown to be 5.8%.13 The number of af -fected dogs appears to be on the rise, either because of increasing awareness or prevalence.11,13,14Labrador Retrievers make up the majority of the competitor base of field trials, though other breeds do participate, making them a perfect group to exam -ine to determine the effects of CCLD on a more ge -netically limited population of dogs. Labradors have higher instances of bilateral CCL rupture than other breeds of dogs (up to 50%) as well, making them a good population to examine.9,15 Therefore, the aim of this study was to look at a large population of primarily working field trial Labrador Retrievers and determine the perceived prevalence and impact of this disease in this community. We hypothesized that there would be a higher reported occurrence of CCLD in field trial Retrievers than what has been reported in the medical record data of the general population of Labrador Retrievers. In addition, we predicted that field trial participants would inappropriately identify causes for CCLD. Finally, we hypothesized that field trial participants would decide to breed a dog even if they have CCLD in their pedigree. Understanding the impact of this condition on the dogs in the field trial community can help guide prevention

Answer 7

The accessory lung lobe (ALL) is one of six lobes which constitutes the canine lung. It arises from the right mainstem bronchus and is located within the mediastinal recess, a space in the central thorax that exists between the diaphragm and the apex of the heart. The anatomy of the ALL parenchyma 1,2 and bronchi 3,4 have been well described previously; however, a thorough description of the vasculature and pulmonary ligamentous attachments of this lobe is currently lacking in theveterinary literature. The anatomy of these structures is of critical importance when considering the surgical removal of this lobe. Surgical approaches to cranial and caudal lung lobes in dogs are well described in surgery textbooks and the veterinary literature; however, no specific description exists for the accessory lung lobe. 5–9 Studies have shown that pathologies can be limited to this lung lobe, 10–13 so specific anatomical considerations that affect access to this lung lobe need to be considered. Of the few reported cases of accessory lung lobectomy in the literature, both median sternotomy and lateral thoracotomy approaches have been described.10–12 To the authors' knowledge, access via left lateral thoracotomy has not been reported or performed. Despite the valid anatomical reasons for this, documenting this approach may be useful to illustrate relevant surgical anatomy given the lobe's central location within the thorax. No consensus currently exists on the optimal open surgical approach to the ALL. The objectives of this study were to describe (1) the surgical anatomy of the ALL with particular emphasis on the vasculature and pulmonary ligamentous attachments and (2) the surgical removal of this lung lobe through a right lateral thoracotomy and mediansternotomy.

Answer 8

Surgical site infections (SSIs) are a major source of patient morbidity, mortality, and increased costs for clients and hospitals.1–6 Whilst SSI existence may be ineradicable,7–9 the rate is influenceable.9–13 Surveillance of SSIs is needed to estimate rate, identify outbreaks, evaluate infection control programs, and benchmark against other hospitals and surgeons. Passive surveillance is the retrospective review of data collected for reasons other than surveillance.9 It is simple to perform but is poorly sensitive and underestimates SSI rates.3,4,9,14 In a referral hospital, passive SSI surveillance is poorly sensitive because post-discharge care is often performed by the referring veterinarian (RV), who may not report back to the referral hospital.15,16 Therefore, SSI rates may be underestimated by the referral hospital because 92%–100% of SSIs are diagnosed after discharge. 3,4 Guidelines in human health care state that SSI surveillance should be active, patient-based and prospec-tive.17 Active surveillance requires scheduled, purposeful, and separate collection of postoperative data from clients or RVs.9 It has been widely and routinely used in human surgery since 1974 and is often mandatory.10,18,19 Two studies in veterinary patients have compared active and passive surveillance, finding that 27.8%–35% of SSIs were only detected through active surveillance.3,4Active surveillance is more time consuming and expensive to perform because it typically uses telephone calls, inperson appointments, or manual review of questionnaires.14,15,18 This is often undertaken by specialized infection control nurses in human hospitals, with a ratio of at least one nurse to 250 patients recommended.10,20 However, this is not possible in many veterinary hospitals due to cost and smaller case loads. Where patient-based surveillance is performed, standard definitions of SSIs 17,21 cannot be directly applied because of barriers created by medical jargon, the requirement for bacterial culture results, or interpretation of clinical signs.22,23 Examples of active surveillance in veterinary literature have involved telephone calls and questionnaires to clients and RVs, with manual review of all responses. 4,5,24,25 These methods are time consuming and expensive in personnel hours, presenting barriers to implementation.3,15,26,27 Additionally, diagnoses from client surveillance have not been compared to gold standard diagnoses, meaning the sensitivity, specificity, predictive values and accuracy of previously described methods are not known. Therefore, alternative methods utilizing automation with a client specific definition of SSI 18,19,23 and known sensitivity, specificity, predictive values and accuracy are needed if active surveillance of SSIs is to be widely implemented in veterinary hospitals as part of infection control programs.The primary objective of this study was to evaluate a dedicated client questionnaire at diagnosing SSIs compared to gold standard diagnoses made by a veterinarian. The secondary objective was to describe the impact of an active surveillance system on the detection of SSIs. Our hypotheses were that a client questionnaire would be able to accurately diagnose SSIs and that active surveillance would increase the detection of SSIs compared to passive surveillance.

Answer 9

Cleft palate (CFP) is an abnormal development of the hard and soft components of the palate that can be present with or without insufficient develop -ment of the lip and alveolar bone (cleft lip and al -veolar cleft [CFL]).1–3 Failure of the frontonasal and maxillary processes to fuse in the midline during em -bryogenesis manifests with a fissure in the palate, re -sulting in communication between the oral and nasal cavities. Crossing of water, food, and other foreign material into the nasal cavity/nasopharynx causes discomfort, sneezing, gagging, coughing, and nasal discharge. In addition, patients are at risk of aspira -tion pneumonia.1,3,4 The incidence of orofacial clefts (CFL, CFP, and CFL and CFP) in purebred dogs has been recently reported as 3%, with almost 75% of the cases presenting as CFL and CFP.5a.23.07.0393©AVMASurgical repair with mucoperiosteal flaps is the gold standard in dogs.1,3,6,7 Common techniques for closure of midline clefts of the hard palate are medially posi -tioned flaps (Von Langenbeck technique [ie, bipedicle flaps]), overlapping flap tucked under an envelope flap, and pedicle flaps (2-flap palatoplasty).1,3,6,7 For larger defects, a combination of an overlapping flap tucked under a pedicle transposition flap may be sufficient.3 In some situations, extractions of maxillary teeth 6 to 8 weeks prior to definitive palate repair may be indicated to incorporate vestibular mucosa in the flaps.6–8 Single cases of repair with a superior labial musculomucosal flap and cortico-cancellous bone graft from the tibia have been reported in client-owned dogs.9,10It is not unusual that additional surgeries may be needed to completely repair a palatal defect, as 2 oronasal fistula (ONF) formation is a relatively fre -quent complication after CFP repair.6–8 The chance of successful closure of an ONF decreases with the number of failed surgeries performed in people and dogs, and a small ONF may persist despite multiple surgical attempts at closure.6,7,11,12 A recent study6 evaluating the outcome of CFP repair reported a prevalence of ONF in 50% (of 29 dogs included) af -ter the first procedure. Common areas of failure after CFP repair are rostrally near the incisive papilla and caudally at the transition between the hard and soft palate.3,6 Other factors such as severity of the cleft, surgical technique and number of layers used in the repair, and staging versus nonstaging procedures were not associated with ONF after healing.6 Treat -ment of ONF after CFP repair often results in more complex surgeries. Furthermore, the lack of bone in the midline of the hard palate cleft may favor the de -velopment of an ONF if flaps are not raised, handled, apposed, and sutured adequately. Therefore, it has been suggested that more sophisticated techniques may be utilized to obtain complete closure of the palatal defect at the first attempt.13Repair of CFP and closure of ONF in children have been attempted with auricular grafts (tragal and con -chal cartilage) and membranes (acellular dermal ma -trix [ADM], temporal fascia, collagen membrane), re -sulting in the same or better outcome (lower rate of ONF) compared with traditional techniques.14–20 Re-ports13,21–23 about the use of auricular grafts and flex -ible bone membranes to repair traumatic ONF in cats and ONF secondary to periodontal disease in dogs have been published. The allogenic fascia lata mem -brane (Fascia lata; Veterinary Transplant Services) is a commercially available product that is biocompatible with canine tissue.24 An in vitro study24 demonstrated fibroblast attachment and proliferation in all layers of the membrane. The results of this study suggest that the membrane may be integrated in the donor site quickly due to the early cellular attachment and prolif -eration and possible mobility of the fibroblasts within the membrane.24 The aim of the study is to describe the use of autologous or allogenic barrier membranes in dogs for repair of congenital defects of the rostral aspect of the hard palate and closure of ONF caudal to the incisive papilla remaining from previo

Answer 10

Brachycephalic obstructive airway syndrome (BOAS) is acondition characterized by a flat face and shortened lengthof skull, a flat nose and secondary soft tissue abnormali-ties.1,2Surgical correction of these soft tissue malforma-tions is commonly performed to alleviate the clinical signsof upper airway obstruction when the restrictive breathingexceeds acceptable levels.3–5A“cut and sew ”sharp staphy-lectomy technique with scissors is well described and uti-lized as a method of shortening the soft palate in affectedbreeds.6,7The intraoperative complication rate is not welldescribed in the literature; however, hemorrhage canobscure the surgical site and make visualization of thenasopharyngeal mucosa and oropharyngeal mucosa diffi-cult. The bleeding comes from the palatine branches ofthe ascending pharyngeal artery and palatine muscle,which is thicker and more vascularized in brachycephalicdogs compared with mesocephalic dogs.8–10After the pal-ate has been cut with scissors it is oversewn.6,7Ensuringboth the nasal and oral mucosa are included in the sutureis essential for hemostasis during and after surgery and forappositional healing. An additional risk of excessive hem-orrhage is aspiration of blood.9,11The surgical field (soft palate, maxilla, and nose) indogs is innervated by the maxillary nerve, a branch of thetrigeminal nerve, which can be blocked peripherally withthe application of local anesthetics.12Peripheral nerveblocks are often performed in dogs undergoing surgery toreduce the requirement of inhalational anesthetic agentsand inhibit the sympathetic response to noxious stim-uli.13,14A bilateral maxillary nerve block is performed indogs undergoing surgery for BOAS and has recently beenproven to reduce intraoperative fentanyl and injectableanesthetic requirement with no cardiovascular effects.12The addition of adrenaline to local anesthetic agentsis commonly reported in the human literature to success-fully reduce intraoperative hemorrhage in cleft palateand lip surgery, sinus surgery and for tonsillectomies dueto its vasoconstrictor properties, causing spasm of themaxillary artery and decreasing blood flow to the surgicalsite.15–18Adrenaline has been found to be safe andwell-tolerated hemodynamically, with the addition oflidocaine attenuating the hypertensive response.15Theaddition of adrenaline to a local anesthetic block(mandibular nerve block) in veterinary patients has beenshown to decrease pulpal blood flow,19but there are cur-rently no veterinary scientific papers outlining the use oflidocaine with adrenaline to reduce intraoperativehemorrhage in dogs. The veterinary market already has alicensed product containing lidocaine 2% and adrenaline0.00198% (Lignol, Dechra, UK).This study aims to determine whether using acombined lidocaine/adrenaline formulation for the max-illary nerve block will reduce intraoperative hemorrhagewhilst performing a cut and sew sharp staphylectomy.We hypothesized that the addition of adrenaline to abilateral maxillary nerve block would reduce the totalhemorrhage, compared to the use of lidocaine alone.

Answer 11

Adrenalectomy is the treatment of choice for adre -nal tumors in canines.1–4 Surgical treatment of uni -lateral adrenal gland tumors has been well described in the veterinary literature, and unilateral laparoscopic adrenalectomy has been associated with favorable outcomes in selected cases of noninvasive adrenocor -tical and medullary tumors.1,2,5,6 Reported criteria for selection of dogs to undergo laparoscopic adrenalec -tomy include the absence of vascular invasion into the caudal vena cava or invasion into adjacent organs, a diameter of < 5 cm, and the absence of periadrenal hemorrhage.6 Laparoscopic adrenalectomy has been a.23.03.0132found to be associated with low conversion rates, shorter surgery time, shorter hospitalization, and lower incidence of hypotension when compared with open celiotomy in 2 studies2,6 where case characteris -tics were matched for comparison.Bilateral adrenalectomy via open celiotomy has been infrequently reported in the veterinary literature.5 A study5 evaluating outcomes in dogs that underwent open bilateral adrenalectomy concluded that bilateral adrenalectomy is a viable treatment option for dogs with bilateral adrenal disease and that mortality may be lower than previously documented. In this aforementioned 2 study,5 8 of 9 dogs that survived the perioperative peri -od had excellent long-term outcomes, ultimately dying of unrelated causes, and the resulting hypoadrenocor -ticism was routinely managed.Bilateral, single-session, laparoscopic adrenalec -tomy (BSSLA) has not previously been reported in the veterinary literature. The purpose of this report is to describe perioperative characteristics and out -comes in dogs undergoing BSSLA. The aims of the study were to document the perioperative morbidity and mortality associated with BSSLA and to report short-term and long-term outcomes.

Answer 12

Dentition is closely linked to dental occlusion in cats; therefore, malalignment of the teeth can result in sig-nificant trauma to the oral cavity and development of diseases.1 In cats, traumatic malocclusions occur secondarily to impingement of the maxillary fourth premolar teeth in mandibular soft tissues, along with the presence of pyogranuloma.2 However, the spe-cific characteristics of this condition are not yet fully understood.The potential causes of this disease include acquired or congenital malocclusion, abnormal laterolateral mobility of the mandible, occlusal drift of the premolar and molar teeth, and/or alveolar bone expansion.3Malocclusion often occurs in some breed head types wherein the normal dentition–occlusal relationship is misaligned.4 Predisposition of malocclusion has been reported in oriental and brachycephalic cats,5 especially for distal traumatic malocclusions.6 A high prevalence of malocclusions,7,8 together with maxillary premolar dis-placement, has been reported in brachycephalic cats.8The aim of the present study was to investigate whether an association existed between cephalometric measurements, maxillomandibular dental arch distances and the occurrence of traumatic malocclusions in the mandibular soft tissues of cats.

Answer 13

Osteoarthritis (OA) is the most common orthopediccondition in dogs with an estimated prevalence of2.5%–20%,1–5and it has an associated negative impact ontheir welfare and quality of life.3In dogs, the commonlyeffected joints include the hip, stifle, elbow, and shoul-der.6,7With the canine elbow, the development of OAis often secondary to elbow dysplasia,8,9a group ofheritable developmental abnormalities, including medialcoronoid process disease (with or without fragmenta-tion), ununited anconeal process, osteochondritis disse-cans, and elbow incongruity.10The prevalence of elbowdysplasia and associated OA is increased in severalbreeds, in particular the Labrador retriever, which has a5.94 times increased likelihood compared with crossbreddogs (OR =5.94, 95% CI 4.65 –7.60).11Furthermore, thepresentation of elbow disease follows a bimodal distribu-tion, with a sharp peak at 1 year of age, and a secondpeak between 6 and 10 years of age.11In clinical practice, the diagnosis of elbow OA isbased on clinical examination and diagnostic imaging,principally radiographic examination. However, com-puted tomography (CT) is becoming increasingly com-monplace due to its increased specificity and sensitivityin comparison with radiography.12–14The radiographichallmarks of OA in the dog are osteophytosis, sub-chondral sclerosis, and joint effusion,15–19and they areassessed in several clinical and experimental scoringsystems.9,20–26Interestingly, subchondral bone cysts(SBCs), which are an imaging hallmark of human,equine, and murine OA, are not a well established fea-ture of OA in dogs, with their presence only sporadicallyreported.15,27 –29In human OA, SBCs, also known aspseudocysts or geodes, are defined as small radiolucentdefects in the subchondral bone surrounded by scleroticmargins.30They have a prevalence ranging from 31% to88% in patients with end-stage knee OA,31,32and theirimportance in human OA is highlighted by their incorpo-ration into the Osteoarthritis Research Society Interna-tional (OARSI) atlas for OA diagnosis, a key OA gradingsystem used in clinical practice.33The relevance of SBCs as a diagnostic imaging featureof canine radiographic OA has not been explored previ-ously. Although SBCs are identifiable using radiographyin humans, they are typically identified in the knee joint,which does not suffer so acutely from radiographic super-imposition and is a relatively large joint compared withthe canine elbow.34The ability for CT to evaluate thestructural features of the bones without superimpositioncould allow for detection of hitherto unidentifiable struc-tural change such as SBCs. Human studies have demon-strated improved detection of SBCs using planarimaging.34The canine elbow is well suited for the investi-gation of the prevalence of SBCs in dogs with radio-graphic OA, as CT is now commonplace for the diagnosisof elbow lameness, removing the limitation of superim-position encountered with plain radiography, and provid-ing a resolution that could potentially identify suchstructures in the smaller canine joint.The aim of this study was to investigate if SBCs arepresent in radiographic canine elbow OA using CT andto investigate their relationship with radiographic OAseverity graded with CT. To mitigate potential con-founders caused by interbreed variation, only Labradorretrievers were investigated. This breed was chosen bothfor its high prevalence of elbow disease and its commonpresentation at our institution. Given the bimodaldistribution of elbow disease,11dogs were categorized aseither young ( ≤2 years old) or old (>2 years old). Wehypothesized that SBCs would be present in elbowjoints of Labrador retrievers presenting for elbow dyspla-sia with secondary radiographic OA, and that they wouldbe more frequent and larger in dogs with more severeradiographic OA.

Answer 14

Intestinal enterotomies are commonly performed withinthe companion animal population for several diagnosticand therapeutic reasons and they have a reported overalldehiscence rate of 12% –16%.1,2Dehiscence ultimatelyleads to leakage of the gastrointestinal contents into theperitoneal cavity and the subsequent development ofseptic peritonitis and potentially, systemic sepsis anddeath. This serious complication has substantial associ-ated morbidity in dogs and cats alike, with publishedmortality rates of up to 50%, even after prompt repeatsurgical interventions.3–5Leakage following intestinalsurgery can be attributable to technical error or associ-ated with risk factors including the presence ofbiochemical abnormalities preoperatively (e.g., hypoal-buminemia, hypoproteinemia) to the presence of intesti-nal foreign material.6–8Given the significance of thesequelae following intestinal leakage, ensuring properenterotomy closure is crucial. A number of closure tech-niques have been described experimentally but onlyhandsewn and stapled techniques are routinely used inclinical practice. Experimentally, leakage pressures ofcadaveric specimens are typically used to assess theintegrity of intestinal closure methods and differing abil-ities to withstand physiological and supraphysiologicalperistaltic pressures. Small intestinal intraluminal pres-sures in healthy dogs are reported to range from 15 to34 mmHg in live, conscious dogs and experimentallyintact, fresh or cooled jejunal segments can withstandpressures of approximately 50 mmHg.9–11Tissue sealants have evolved in both veterinary andhuman medicine, as an alternative or adjunct tosutures for the closure of surgical incisions. Varioussealants have been proposed for use in human surgery,divided broadly into three categories: synthetic glues,biological products, and biomimetic sealants. Syn-thetics, including the cyanoacrylate-based sealants, aremost widely used in humans for the closure of cutane-ous wounds.12They fix wound edges rapidly, favorhemostasis, and form a seal to prevent external con-tamination.13Biological sealants, such as fibrin, colla-gen or polysaccharide-based products, are inherentlybiodegradable and nonimmunogenic. They are insolu-ble in water, which lends them to be used in biomedi-cal applications, primarily for general hemostasisduring surgery. Development is still underway for bio-mimetic sealants; they are designed to mimic thenaturally occurring adhesives that are seen in marinelife and organisms (e.g., mussels, barnacles and gela-tine) and form a gel in situ which can theoreticallyserve to bond tissues or seal leaks.14The strongest sealants are the cyanoacrylate-basedadhesives but due to concerns regarding potential cyto-toxicity, they are not widely accepted for intracorporealuse.15This argument has been countered by studiesfinding no evidence of cytotoxicity and instead present-ing promising clinical properties favoring their use.16Several publications review the intracorporeal use of n-butyl-2-cyanoacrylate and fibrin adhesives in humansas a means of laparoscopic mesh fixation in abdominaland inguinal hernia repairs. Collectively, these studiesfound a shorter overall surgery time, short hospitalstays and reduced postoperative and chronic pain com-pared to traditional open methods used for herniarepair, promoting their use intracorporeally.17–20As aresult of conflicting evidence and opinion, the use ofcyanoacrylate in a medical setting continues to beresearched. Cyanoacrylates are generally low-cost andeasy to apply and consequently they are found in mostveterinary practices where they are used principally forskin closure with few reported complications and goodoverall outcome. One study using tissue adhesive only(n-butyl-2-cyanoacrylate) for the closure of 695 laparo-scopic port sites in 289 dogs found no hypersensitivityrelating to their use, nor any long-term adverse reac-tions and a second study endorsed cyanoacrylate usein reconstructive surgery.21,22Cyanoacrylates are notcurrently routinely used in clinical veterinary practicefor any other purpose and ongoing research within theveterinary field is limited.Given the potential catastrophic outcome resultingfrom intestinal leakage or dehiscence, the authors ques-tioned whether the application of cyanoacrylate to asutured enterotomy would prevent or reduce the inci-dence of intestinal leakage during the postoperativeperiod and consequently reduce the incidence of associ-ated morbidity or mortality. The first step in answeringthis question is to perform ex vivo biomechanical testingto ensure the proposed technique is deemed effectiveunder controlled conditions before piloting in vitroresearch evaluating practical technique and clinicalsafety.The primary objective of this study was to compareintestinal initial leak pressures (ILP) and maximal intra-luminal pressure (MIP) after enterotomy closure in a368 THOMPSON ET AL . 1532950x, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14059 by Cochrane France, Wiley Online Library on [14/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons Licensecooled canine cadaveric model, using three closure tech-niques; handsewn enterotomy (HSE), cyanoacrylateenterotomy (CE) or handsewn and cyanoacrylate enterot-omy (HS +CE) and to report initial leak location (ILL).It was hypothesized that the ILP would be higher in theHS+CE group compared to the HSE, CE groups andthat the ILL would differ between groups. It was alsohypothesized that the leakage pressure achieved for theHSE group would be in line with previously publishedliterature.

Answer 15

Laparoscopic adrenalectomy (LA) has been estab -lished as a safe and effective alternative to open celiotomy for resection of adrenocortical tumors and pheochromocytomas in dogs with modestly sized ad -renal masses that do not invade the vena cava.1–6 Re-sults have been published from several small cohorts a.23.03.0135of dogs that have undergone LA and have reported short-term perioperative complications and conversion rates as well as mortality.1–6 Hemorrhage and capsular penetration are cited as the most commonly encoun -tered adverse events.1–6 Conversion rates of 0% to 10% have principally been attributed to hemorrhage and 2 challenges associated with visualization of the opera -tive field.1–6 Mortality has been reported to occur in 0% to 28% of cases and is reported variably as mortality prior to discharge in some studies or mortality within 30 days of surgery in others.1–6To date, there is no report evaluating the out -comes of LA in a large cohort of dogs. Studies pub -lished to date have also not been able to evaluate risk factors for complications, conversion, and peri -operative mortality due to small case numbers. Fur -thermore, the role of surgical experience with LA has not been evaluated as a risk factor for complications or long-term outcomes. For this study, data on surgi -cal outcomes of a large cohort of dogs undergoing LA in specialized centers with considerable experi -ence in minimally invasive surgery were collected. The study aimed to document perioperative com -plications, conversion, and mortality rates as well as long-term outcomes and recurrence of adrenal tu -mors treated with LA. A secondary aim of the study was to document the effect of experience with LA on complication and conversion rates and long-term out

Answer 16

Limb deformities are complex orthopedic conditions indogs that may result in substantial pain and disability ifuntreated. The radius and ulna are the most commonbones affected in dogs, and usually manifest in asynchro-nous growth of these paired bones.1Deformity may resultin tremendous angulation and rotational malalignment,as well as carpal and elbow joint incongruency.1Surgicalcorrection requires accurate quantification of the defor-mity, and subsequent execution of this plan in theoperating room.Planning has historically been performed with acenter of rotation of angulation (CORA) methodologyusing two-dimensional radiography2and more recentlyapplied to computed tomography (CT) imaging.3Amajority of antebrachial deformity cases contain mala-lignment in the frontal, sagittal, and axial planes whichcan be quantified independently. However, currentmethods still resolve these 3D structures into 2D imagesfor quantification using 3D multiplanar and volumereconstruction approaches.2,4Transferring these detailed3D plans to guide operative surgery is an additionalfundamental obstacle.Computer-aided design (CAD) for 3D planning andprinting is an established technology in medical fields.5Widespread applications exist in human orthopedic, max-illofacial, and spinal surgery, among others, but relativelylittle comparative information in veterinary medicineand surgery is available. Orthopedics and bone deformitycorrection is an obvious target due to ease of segmenta-tion of bone from CT data due to its high Hounsfieldunits, allowing for automated and efficient thresholdingtools. Furthermore, 3D volume data can be used to printbone models for surgical rehearsal, perform computer-ized virtual correction based on the plan, and print cus-tom patient-specific guides (PSGs) for use in sterilesurgery. Accurate outcomes have been reported in defor-mity correction of the femur6and antebrachium,7,8aswell as implant placement in spine and craniomaxillofa-cial applications.9,10Despite successful clinical outcomes using 3D PSGsin clinical veterinary cases, more work is needed from anorthopedic science perspective to robustly examine thisapproach.11We lack specific indications and locations foruse to justify the time, cost, and expertise needed for 3Dplanning and guide use. A consistent workflow for 3Dplanning to include correction target magnitude fordeformity is needed. Finally, best practice guidelines fordesign approaches, materials, and manufacturing havenot been established.The primary objective of this study was to comparethe accuracy and reliability of radial osteotomies per-formed using 3D PSGs versus a freehand (FH) approach.We tested three osteotomies of increasing complexity onnormal ex vivo canine thoracic limbs. Computed tomog-raphy was performed preoperatively for planning andguide design, and postoperatively for osteotomy assess-ment. We hypothesized that 3D PSG osteotomy would bemore accurate in achieving an osteotomy within 5/C14of theintended target than a FH osteotomy in a canine antebr

Answer 17

The cisterna chyli (CC) is a dilated, bipartite por -tion of the lymph channel that lies retroperitone -ally in association with the cranial abdominal aorta. It drains the visceral and lumbar lymph trunks from the abdominal viscera and from the pelvic limbs re -spectively.1 It is dorsal to the abdominal aorta at the level of L2-4 (Figure 1) and to the renal veins. The CC is bordered by the psoas major and psoas minor muscles and diaphragmatic crura dorsally and is lat -eral to the greater splanchnic nerves, adrenal glands, caudodorsal extremities of the pleural cavity, and lumbar aortic lymph nodes. In an anatomic study1 in cats, the CC has been described as an oval sac about 2.5 cm in length that receives, caudally, the lumbar trunks and, ventrally, the visceral trunk, the intestinal Computed tomography and magnetic resonance imaging are potential noninvasive methods for evaluating the cisterna chyli in catsNoemi Gómez Martín, DVM1*, and Elisabet Domínguez Miño, DVM, PhD, DECVDI21Hospital Veterinario de Referencia UCV, Valencia, Spain2AniCura Ars Veterinaria Hospital Veterinari, Barcelona, Spain*Corresponding author: Dr. Gómez Martín (noemi.gomez@ucv.es)Received July 14, 2023Accepted September 7, 2023doi.org/10.2460/javma.23.07.0390©AVMAtrunk, or the jejunal, colic, and celiac trunks inde -pendently. The efferent lymphatic vessels from the adrenal glands and kidneys directly join the CC cau -doventral to it.1 Cranially, the CC continues through the diaphragm as the thoracic duct.Being familiar with the normal anatomic appear -ance of the CC in different imaging techniques is es -sential to distinguish it from retroperitoneal pathologic conditions, such as the accumulation of fluid pockets in inflammatory/infectious conditions.2,3 Additionally, imaging of thoracic and abdominal lymphatic vessels is useful in the diagnosis and management of chylo -thorax.4 Chylous effusion within the thoracic cavity in cats occurs secondarily because of many causes, in -cluding trauma, neoplasia, cardiac disease, lung lobe 2 torsion, or idiopathic.4 Multiple surgical techniques have been evaluated for the treatment of chylothorax in dogs and cats. The most frequently described are thoracic duct ligation, subtotal pericardiectomy, and pleural omentalization.5 CC ablation (CCA)5,6 is an -other technique, frequently combined with the other. As lymphatic hypertension has been proposed as a possible reason for the failure of thoracic duct ligation in cases of chylothorax, CCA might prevent lymphatic hypertension by allowing direct drainage of the lymph into the abdominal cavity with subsequent formation of abdominal lymphaticovenous anastomoses. There -fore, assessing the CC in cats with chylothorax is use -ful for surgical planning when thoracic duct ligation is going to be combined with CCA.CT and MRI appearance of the CC has been de -scribed in dogs without lymphatic system pathol -ogy7,8 and in CT in cats following IV administration of iodinated nonionic contrast medium.9 Ultrasound, lymphangiography, and CT lymphangiography have been used in both species to evaluate the lymphatic vessels in cases of idiopathic chylothorax.4,10The aim of this study was to describe the CT and MRI features of the CC in a group of cats without lymphatic sys

Answer 18

862 JAVMA | DECEMBER 2023 | VOL 261 | NO. 12In response to the coronavirus disease of 2019 (COVID-19) pandemic, stay-at-home orders were implemented across the US in March 2020. Fol -lowing these new guidelines, an increase in back -ground checks and firearm sales was reported, with a concomitant rise in gun violence across major US cities.1–3 Numerous human trauma cen -ters reported an increased number of individuals presenting with gunshot wounds after the start of the pandemic in comparison to prior years.4–7 Al-though these trends have been documented nation -wide, the city of Philadelphia has been particularly a.23.06.0317©AVMAimpacted by the effects of increased violence and associated firearm injuries.8–10Despite the multitude of information supporting higher rates of peripandemic gun violence and as -sociated gunshot-related injuries, there have been no reports on the consequences that this increased violence may have on companion animals. The exact incidence of gunshot injuries affecting veterinary pa -tients is not well described; however, it is estimated that projectile injuries represent 14% of reported ani -mal cruelty cases11 and up to 2% of trauma cases12 in the US. According to more recent data from the JAVMA | DECEMBER 2023 | VOL 261 | NO. 12 1863American College of Veterinary Emergency and Crit -ical Care Veterinary Committee on Trauma registry, ballistic injuries in dogs and cats constituted 0.44% of all trauma cases (109/24,845) between April 1, 2017, and December 31, 2019.13 These injuries result in high patient morbidity and mortality, expensive hospitalization and treatment costs, and consider -able emotional toll for owners.12–14The objective of this study was to investigate the incidence and patterns of gunshot wound trauma in patients that were presented to an urban level 1 veterinary trauma center before and after the start of the COVID-19 pandemic. We hypothesized that the rise in violence and gunshot wound injuries re -ported in the human medical field following the start of the COVID-19 pandemic would correlate with an increased number of gunshot wound injuries in vet -erinary patients over the same time frame. To our knowledge, this was the first evaluation of the im -pact of pandemic-related violence on companion animal healt

Answer 19

Vertebral fractures and luxations represent an importantcause of spinal cord injury in dogs.1–11The goal of sur-gery is to achieve rigid fixation while avoiding injury tosurrounding neurologic, visceral and vascular structures.6Spinal stabilization is technically challenging and associ-ated with risk of vertebral canal violation.7,12Use of pinsand polymethylmethacrylate (PMMA) offers a strong andversatile method of spinal stabilization.13A variety ofoptions exist for insertion of pins or screws in the caninespine, including a free-hand technique based on preoper-atively calculated pin entry points and angles,14apedicle-probing technique,5,6use of patient-specific3D-printed drill guides (3DPGs),7,15 –20and fluoroscopic-guided.1,21In people, robotic and image-guided spine sur-gery allow real-time intraoperative navigation, and areassociated with reduced radiation exposure, increasedaccuracy and safety of implantation, and reduced surgicaltime; however, there are no clinical reports of use of thistechnology in veterinary spine surgery.22Investigators have investigated safe corridors forinstrumentation of the canine thoracolumbar spine.23Fluoroscopic-guided pin placement has been described ina canine ex-vivo study21and a small retrospective caseseries1; however, this technique may be associated withgreater radiation exposure for the surgeon and patient.24A pedicle-probing technique has been described for pedi-cle screw placement in people and in dogs.5,6,25Itinvolves creation of a cortical defect (decortication) at thepedicle screw/pin entry site, probing of cancellous boneof the pedicle to establish a safe trajectory before drillingthe pilot hole for the definitive screw/pin.5,6Recently,use of 3DPGs has become increasingly popular in veteri-nary spine surgery.7,15 –18,20,26This technique is appealingdue to the technical challenge associated with spinalinstrumentation and the high degree of accuracy requiredfor safe implant placement. Use of 3DPGs has beendescribed for the cervical, thoracic and lumbosacral spinein dogs and is associated with a very high degree of accu-racy.7,15 –18,20,26However, spinal fractures need to be trea-ted without delay, and the hardware and softwarerequired to produce these guides are not universallyavailable. Expertise is also required in computer-assisteddesign (CAD) software and 3D printers may be expensive.Given the variety of techniques for pin placement, moreresearch is needed to compare accuracy between tech-niques and guide clinical decision making.Study objectives were to compare a free-hand probingtechnique (FHP) versus use of 3DPGs for pin placementin the canine thoracolumbar spine. We evaluated accu-racy, rate of intraoperative technique deviations, andduration of pin placement in a cadaveric model. Wehypothesized that the 3DPG technique would be associ-ated with greater accuracy, a lower rate of intraoperativetechnique deviations, and decreased duration of pinplacement compared with the

Answer 20

a.23.06.0324©AVMA2 Primary adrenal tumors account for < 2% and about 0.2% of canine and feline neoplasia, respectively.1 Adrenalectomy has been associated with an overall favorable long-term outcome regardless of the be -nign or malignant nature of the disease process,2–6 with median survival times (MSTs) ranging from 270 to 844 days and low rates of recurrence (0% to 22%)5,7–10 and metastasis (5% to 24%).9–12 Periopera -tive morbidity remains generally high, with reported mortality rates ranging from 4.2% to 43% depending on the selected population.3,6,9,11,13–15Multiple retrospective studies2–8,11–16 have de -scribed the outcome for specific tumor types, sizes, anatomic configurations, clinical presentations, or surgical approaches. However, only a few case re -ports and case series17–22 describe the outcome of dogs presenting with extracapsular adrenal gland hemorrhage secondary to spontaneous adrenal tu -mor rupture. The perioperative mortality rate has been reported as high as 50%,6,17 and studies have suggested that dogs with extracapsular adrenal gland hemorrhage are prone to developing arrhyth -mias, hypotension, and postoperative complications as well as requiring a blood transfusion and having an overall longer duration of hospitalization com -pared with nonruptured cases.6 Little information is available regarding their prognostic factors and long-term outcome.The purpose of this retrospective study was to describe the short- and long-term outcomes of dogs and cats undergoing adrenalectomy for the treatment of adrenal gland tumors with extracapsular hemor -rhage secondary to nontraumatic rupture. Particular attention was paid to the timing of the surgical proce -dure and its association with short-term survival rate. Primary variables considered for long-term outcomes were survival, rate of local recurrence, and metastasis. The authors hypothesized that initial stabilization and delayed surgical procedure would be associated with increased short-term survival over emergent surgi -cal management and that the tumor’s recurrence and metastasis rates

Answer 21

While many minimally invasive procedures have beendescribed in veterinary medicine, cats tend to beunderrepresented when compared with dogs.1–8Thesmall anatomical size of the feline thorax and abdomen,and the resulting limited working space for manipulationof instruments within the body cavity can be difficult toovercome. Even with the advent of smaller telescopesand instrumentation, manipulation in the abdominal orthoracic cavity remains challenging and various experi-mental techniques have been evaluated to address thisdifficulty for use in human patients.1,9–14While some lap-aroscopic instruments can be ordered in varying lengths,No financial support was providedThe authors have no conflict of interest to declareAbstract was presented in part at the World Veterinary Endoscopy andMinimally Invasive Surgery Meeting, June 28, 2020, Fort Collins,ColoradoReceived: 7 February 2022 Revised: 23 April 2022 Accepted: 5 May 2022DOI: 10.1111/vsu.13849870 © 2022 American College of Veterinary Surgeons. Veterinary Surgery. 2023;52:870 –877. wileyonlinelibrary.com/journal/vsuthe lengths of available cannulas remain relatively con-stant from 5 –8.3 cm. Different cannula valve types andwall security styles are available to allow for flexibility forthe wide variety of human body types.15The relativelylong length of these cannulas, when placed in a smallpatient, potentiates the challenges of limited workingspace within the abdomen of small patients.16While theshaft of the cannula could be partially exteriorized todecrease the amount within the abdomen, most cannulasdo not have the ability to be secured adequately tothe body wall if used in this capacity leading to cannulapullout, insufflation leakage and difficult instrumentexchanges. Cannulas without adjustable anchor grips andperitoneal balloons (Balloon cannula, LaproSurge Ltd,Hertfordshire, UK), especially smooth shafted cannulas,can easily move in and out of the body wall when partiallyplaced, leading to desufflation and instrument collisions.In the authors experience, even cannulas that are ribbedor screw-like that protrude from the body wall more thana few centimeters lead to awkward instrument exchangesand higher numbers of cannula pullout complications.When performing surgery on feline patients, especiallyadvanced procedures such as partial gastrectomy orpancreatectomy, if the cannula is fully inserted, it canbe difficult to open the jaws of certain instruments andmanipulate tissue as the length of the cannula within thecavity can be too great.The requirement to find creative methods to addressunique equipment needs in veterinary medicine are long-standing, however, 3D printing has more recently becomea new tool in our armamentarium.17–20In human medi-cine, 3D printing has been extensively used in cardiologyand dentistry, as well as other specialties.21–26Cardiovas-cular applications of 3D technology in human medicineinclude the use of patient-specific models, exploration ofvalve and vessel function, and procedural planning.22–24Inhuman dentistry, 3D printing has been employed for overthree decades and uses include manufacture of patientspecific surgical drill guides, temporary and permanentcrowns and bridges, orthodontic appliances, implants, andmouthguards for drug delivery.25,26Recently a group ofpediatric surgeons created a Roux retractor and infant lap-aroscopic trocar using 3D printing technology and foundthe instruments to be sterilizable and able to withstandthe force of use and pressure when tested.27The authorsconcluded that this technique was promising and couldallow for increased versatility for smaller patients. 3Dprinting has been used in veterinary surgery as well, mostcommonly to create anatomic models of angular limbdeformities, specific cutting guides, and implants for bonydefects.17,19,28 –30This technique has also been utilized inanatomic training of students and house officers.31–33In2015, del Junco et al., reported a pilot study on thedevelopment of 3D printed endoscopic (ureteral stents)and laparoscopic (trocars) instruments for porcineresearch.34They found 3D printing feasible, but the trocarsdid result in larger superficial skin defects compared tocommercially available products. As this technology hasgained popularity, newer materials have become availableincluding biocompatible implantable constituents such ascell lines.21–24The difficulty that the authors encounteredin laparoscopic manipulation during refinement of a lapa-roscopic partial gastrectomy technique in a feline model,led to the creation of customized 3D printed cannulas(3DPCs). The objectives of this study were to describe thecreation and testing of 3DPCs in a feline cadaveric modeland their use in two feline patients. We hypothesized thatthe use of customized 3DPCs would allow for reducedinstrument collisions and cannula pullout events andwould not be associated with any clinical complications.

Answer 22

Tarsal arthrodesis is a salvage procedure to fuse joints of thetarsus. Complication rates range from 58 to 75%, including a15% incidence of plantar necrosis.1,2Plantar necrosis is apotentially catastrophic complication, the aetiology of whichis not fully understood. The principal blood supply to theplantar pes is from the dorsal pedal artery, which coursesdorsally over the tarsometatarsal joint, and super ﬁcially in asulcus (the intermetatarsal channel) between proximalmetatarsals II and III, before passing interosseously in adorsoplantar direction as the perforating metatarsal arteryupply the deep plantar arch.3,4The consistent pattern ofsoft-tissue damage in cases of plantar necrosis, as describedby Roch and colleagues, suggests that vascular compromiseof the dorsal pedal artery/perforating metatarsal artery, andocclusion of the collateral blood supply is the most likelyaetiology.2Vascular compromise may occur via peripheralocclusion (e.g. preoperative or postoperative swelling, exter-nal coaptation or tight closure) and/or via direct interruptionto the principal arterial blood supply, such as metatarsalscrews causing compression/laceration or damage duringtarsometatarsal joint debridement.2Landmarks of the intermetatarsal channel have not beenpreviously reported; therefore, its vulnerability to damageduring metatarsal screw placement is unknown. This studyaims to evaluate whether the dorsal pedal artery/perforatingmetatarsal artery is at risk of damage following metatarsalscrew placement and explores the relationship betweenmetatarsal screw position, the anatomy of the intermetatar-sal channel and the development of plantar necrosis.

Answer 23

Surgical reconstruction of extensive cutaneous defects can prove very challenging. Subdermal plexus flaps and axial pattern flaps (APFs) are the most reliable techniques when seeking a tension- free reconstruction (Hunt 2012 , Wardlaw & Lanz 2012 , Field et al. 2015 ). APFs are characterised by the incorporation of a direct cutaneous artery and vein which allows for the usage of a larger flap (approximately 50% longer than a random pattern flap with a similar base) with a greater survival rate compared to random pattern subdermal plexus flaps (Pavletic 1980 , Bohling et al. 2006 , Wardlaw & Lanz 2012 ). Furthermore, APFs can be used to cover defects close to the donor site by being transposed up to 180° and do not require a staged procedure to enhance cir -culation (Bohling et al. 2006 ). These flaps can be created either in the form of a peninsula or an island, with the island having Cranial superficial epigastric axial pattern flapJournal of Small Animal Practice • Vol 64 • November 2023 • © 2023 British Small Animal Veterinary Association. 705 no cutaneous attachment to surrounding tissues. This allows for coverage of large defects with tension- free closure (Remedios & Fowler 1995 , Aper & Smeak 2003 , Wardlaw & Lanz 2012 ). Peninsular flaps tend to be rectangular in shape, but can also be modified with a right- angle extension, also called hockey- stick configuration, to cover irregular or wider defects that may not be optimally addressed using a standard peninsular flap (Pav -letic 1990 ).Although overall very successful, these flaps are not free of complications, with a complication rate up to 89% in dogs and cats (Field et al. 2015 ). Most of these complications may be deemed as minor and include mild bruising and oedema of the flap, and necrosis of its distal portion. Major complications comprise infection or necrosis of the majority of the surface of the flap (Pavletic 1981 , Kostolich & Pavletic 1987 , Henney & Pavletic 1988 , Remedios et al. 1989 , T revor et al. 1992 , Fahie & Smith 1997 , 1999 , Lascelles & White 2001 , Aper & Smeak 2003 ).Several APFs have been described in the literature and are named after the direct cutaneous artery that supplies each angio -some (Pavletic 1981 , Kostolich & Pavletic 1987 , Henney & Pavletic 1988 , Smith et al. 1991 , Degner et al. 1994 , Fahie & Smith 1997 , Anderson et al. 2004 , Saifzadeh et al. 2005 , Field et al. 2015 , Proot et al. 2019 , Forster et al. 2022 ).The cranial superficial epigastric (CrSE) APF relies upon the cutaneous branches of the CrSE artery, a blood vessel that arises from the cranial epigastric artery, a branch of the internal tho -racic (Sardinas et al. 1995 , Evans & de Lahunta 2013 ). The CrSE artery penetrates the rectus abdominis muscle, approximately 2 to 4 cm from the midline and lateral to the costal arch (Evans & de Lahunta 2013 ) Consequently, this flap can be harvested on either side of the linea alba, with its base caudal to the thoracic cage and extending up to the fifth mammary gland in female dogs. Because of the risk of the development of necrosis and the challenges associated with closure of flaps extending parallel to the prepuce, this flap should stop cranial to the prepuce in male dogs (Pavletic 2003 ).Although this flap has been used for closure of large defects on the sternum and caudal thorax, it is not commonly performed and, as a result, information on its clinical use, outcomes and com -plications is limited (Sardinas et al. 1995 , Wardlaw & Lanz 2012 , Shafiuzama et al. 2017 ). Published studies on cranial superficial APFs are limited to an experimental study in six Beagles (Sardi -nas et al. 1995 ) and a single case report of a dog, of unspecified breed, where the flap was used following tumour removal from the sternum (Shafiuzama et al. 2017 ). Mention of the successful use of the CrSE APF in one dog was made in a retrospective study of 49 dogs where APFs were used, although details on the signal -ment, indication for the flap, outcome and complications of this individual case were not reported (Field et al. 2015 ).The literature search for this study was performed using data -bases comprising MEDLINE (PubMed) and ScienceDirect, as well as several textbooks and journal articles (see References). The keywords used for the search included “axial pattern flap,” “cranial superficial epigastric,” “canine,” “cutaneous” and “recon -structive surgery.”The aim of this study was to report the indications of the CrSE APF , the short- term clinical outcome, and the complica -tions to reconstruct cutaneous defects in canine clinical patients

Answer 24

Maxillectomy and mandibulectomy are common surgical procedures for the treatment of orofacial tumors. The most common reported intraoperative complication with these procedures is hemorrhage.1–4 This is particularly true for patients undergoing caudal maxillectomy,4 as inadvertent trauma to the maxillary, infraorbital, and sphenopalatine blood vessels can occur during the osteotomy. Other complications can occur in the immediate or convalescent postoperative period, including aspiration pneumonia, surgical site dehiscence, oronasal fistula formation, and sialocele formation.1,5–7 Intraoperative hemorrhage can impede visualization of the surgical field. As a result, identification and ligation of the injured vessels is difficult, prolonging surgical times and potentially leading to life threatening blood loss. A 2018 report evaluating factors associated with intraoperative complications in 193 dogs undergoing oncologic maxillectomies found that 53.4% exhibited excessive surgical bleeding, of which 42.7% required a blood transfusion for acute hypovolemic anemia. This was consistent with prior studies 4,8,9 that reported 30% to 50% of dogs undergoing a maxillectomy required transfusion for profound intraoperative hemorrhage. In contrast to maxillectomies, however, a 2021 study found that 4 of 279 (1.4%) dogs undergoing mandibulectomy required a blood transfusion for acute hypovolemic anemia. Some authors have recommended performing osteotomies rapidly to allow more time to apply ligation to control bleeding, suggesting that excessive or profound hemorrhage is unavoidable.2,4 However, rapid identification of hemorrhage may be difficult or impossible in locations where vessels may retract into osseous recesses.10,11 Common carotid or external carotid arterial ligation has been well documented in human medicine to stop active hemorrhage during surgical procedures or to pre-emptively prevent or reduce risk for surgical procedures with a high risk of bleeding.2,10,11 Comparable approaches have been proposed in veterinary medicine including preemptive ligation of the maxillary and carotid arteries.2,11Surgical instruments used to perform osteotomies during maxillofacial surgery often include oscillating or sagittal bone saws, high-speed electrical and air-driven dental units, low-speed electrical units, and osteotomes with mallets. 2,3,5,12–24 What these instruments have in common is indiscriminate cutting of any hard or soft tissue in their path. The speed at which these instruments cut bone may be relatively quick, but secondary injury to local soft tissues is increased. 25 Another instrument that can be utilized for maxillofacial surgery is the piezoelectric unit (Figure 1). Piezoelectric surgery utilizes ultrasonic micro oscillations at a rate of 28 to 36 oscillations/s, which allows the instrument to cut mineralized tissues with precision while sparing the soft tissues. 20,26–28 There is low acoustic impact and high tactile sensitivity, allowing for less pressure for effect and enabling improved ergonomic handing of the instrument for the operator.17,29 Simultaneous sterile irrigation also rinses away blood to improve visibility and creates an environment for cavitation that has the additional benefit of cauterizing small vessels. 15,26,29 Human studies utilizing piezosurgery for maxillofacial surgery have also reported improved postoperative healing and patient comfort. 19 Due to the technically complex nature of oncologic maxillectomy and mandibulectomy and proximity to major vessels, piezosurgical units may be utilized for procedures that have high risk of hemorrhage. Few reports have systematically documented the risks or benefits of using a piezoelectric unit to perform osteotomies during maxillectomy and mandibulectomy in dogs. 3,15 The purpose of this study was to document the intraoperative complication rate in patients undergoing oncologic maxillectomy or mandibulectomy when using a piezoelectric unit to perform osteotomies.

Answer 25

Thymic epithelial tumours (TETs) are uncommon neoplasms of thymic epithelial cells that typically arise in the cranial medi -astinum and represent the second most frequent tumour in this location in cats after lymphoma (Souza, 2013 ). Less com -mon neoplastic conditions include ectopic thyroid carcinoma, heart- base tumours and metastatic neoplasia (Rogers & Walker, 1997 ; Reichle & Wisner, 2000 ). Non- neoplastic conditions causing a mediastinal mass are rare and include cysts, abscess, granuloma, benign thymic hyperplasia and haemorrhage (Malik et al., 1997 ; Rogers & Walker, 1997 ). While TETs have histori -cally been grouped together under the term “thymoma,” this nomenclature can be misleading as it often implies a benign T. A. Marks et al.Journal of Small Animal Practice • Vol 65 • January 2024 • © 2023 The Authors. Journal of Small Animal Practice published by John Wiley & Sons Ltd on behalf of British Small Animal Veterinary Association.48process despite metastasis occasionally being reported (Patnaik et al., 2003 ). Because of their variable histologic features, inva -siveness, and potential for malignant clinical behaviour, the term TET is now preferred (Garneau et al., 2014 ).TETs are most commonly diagnosed in older cats with a median age at presentation of 9 years (Garneau et al., 2014 ). Clinical signs often include dyspnoea, coughing, regurgitation, vomiting, weight loss and lethargy, which are the result of an intrathoracic space- occupying mass leading to compression or invasion of adjacent organs and tissues (Gores et al., 1994 , Zitz et al., 2008 , Garneau et al., 2014 ). Paraneoplastic syndromes have been reported in up to 22% of cats (Garneau et al., 2014 ) and include myasthenia gravis (Hague et al ., 2015 ), exfo -liative dermatitis (Rottenberg et al., 2004 ), erythema multi- forme (Godfrey, 1999 ), multi- focal non- inflammatory alopecia (Fournier et al., 2019 ), pemphigus (Hill et al., 2013 ), myocar -ditis (Carpenter & Holzworth, 1982 ), polymyositis (Carpenter & Holzworth, 1982 ) and granulocytopenia (Fidel et al., 2008 ). Interestingly, some of these syndromes are immune- mediated in nature and have been suggested to be due to abnormal mat -uration and selection of T- cells within the neoplastic thymus (Robat et al., 2013 ; Weksler et al., 2013 ). A definitive diagnosis may be achieved through ultrasound- guided cytology; however, differentiation between lymphoma and TET can be challeng -ing when a predominance of small to intermediate lympho -cytes is identified. Even though flow cytometry can aid in the diagnosis of canine TETs the high prevalence of double positive CD4/CD8 T- cells in mediastinal lymphoma in cats may limit its utility, and ultimately histopathology may be required for a definitive diagnosis (Bernardi et al., 2020 ). CT of thorax and abdomen is generally the preferred staging method although metastatic disease to hilar lymph nodes, mesothelium and lungs is uncommonly reported (3 to 14% of cases). CT scan may also help assessing the tumour invasiveness and provides valu -able information for surgical planning (Patnaik et al., 2003 , Robat et al., 2013 , Garneau et al., 2014 ). Surgical excision is the treatment of choice for TET and, although periopera -tive mortality rate for cats has been reported to be between 11 and 22%, the outcome for those surviving the post- operative period is considered fair to good with a median survival time (MST) of 2 to 5 years (Gores et al., 1994 , Zitz et al., 2008 , Garneau et al., 2014 ). For cats that are not considered surgi -cal candidates or when residual disease is present after surgery, the use of neoadjuvant and adjuvant radiotherapy, chemother -apy and electrochemotherapy has been anecdotally reported (Smith et al., 2001 , Tong et al., 2015 , Spugnini et al., 2017 ). T umour recurrence and long- term metastatic disease appear to be uncommon after excision of feline TETs. In a case series of 10 cats with long- term follow- up, none had tumour recurrence or died of thymoma- related causes (Gores et al., 1994 ) and, in another study, of 25 cats that survived the postoperative period only three cats and one cat developed recurrence and metasta -sis, respectively (Garneau et al., 2014 ).There is limited data on prognostic factors in cats. A micro -scopic cystic tumour appearance has been historically associ -ated with a favourable outcome (Patnaik et al., 2003 ) and Zitz et al. (2008 ) identified that a low lymphocyte percentage within the thymic mass was significantly associated with shorter sur -vival when data from dogs and cats were pooled. In dogs, other reported prognostic factors include lack of surgical treatment, development of a second non- thymic neoplasia, incomplete excision and presence of paraneoplastic syndromes (Garneau et al., 2014 , Yale et al., 2021 ), although some studies have not found the latter to be associated with a poor outcome (Robat et al., 2013 ). In people with TET the strongest prognostic fac -tor after surgical excision is the Masaoka- Koga stage ( Table 1). This staging system is based on the presence of local microscopic and/or macroscopic invasion and lymphatic or hematogenous metastasis (Masaoka et al., 1981 , Robat et al., 2013 ). Robat et al. (2013 ) also reported a prognostic role of this staging system in canine TET, with significantly longer survival times reported for stage I, IIA and IIB disease compared to stage III, IVa and IVb (1045 versus 224 days). The prognostic role of this system in cats is yet to be evaluated.The aims of this retrospective case series are firstly to describe the clinical presentation of a large cohort of cats diagnosed with TET and secondly to evaluate prognostic factors for recurrence and survival

Answer 26

87Feline urethral obstructions (UOs) are a common presenting reason for visits to the veterinary emergency room. Urethral obstructions may lead to clinically important life-threatening metabolic dis -turbances including hyperkalemia, acidemia, and azotemia.1,2 Although the survival to discharge with treatment is overall excellent, complications sec -ondary to deobstruction with the traditional urinary catheter approach can occur, including catheter-as -sociated bacteriuria and/or infection, urethral stric -tures, and urethral or bladder rupture.1–9 Although a reportedly rare complication of deobstruction in the current literature, urethral and bladder tears Difficult catheterization and previous urethral obstruction are associated with lower urinary tract tears in cats with urethral obstructionRachel B. Manchester, BVetMed*; Rebecka S. Hess, DVM, MSCE, DACVIM; Erica L. Reineke, VMD, DACVECCDepartment of Clinical Studies and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA*Corresponding author: Dr. Manchester ( rmanch@upenn.edu)Received July 31, 2023Accepted September 19, 2023doi.org/10.2460/javma.23.07.0419©AVMAcan lead to serious sequelae such as tissue damage from urine extravasation into subcutaneous tissues, uroperitoneum, and urethral stricture formation.7,10 These complications may lead to extended hospi -talization times and need for surgical intervention, leading to increased cost of care and, in some cases, humane euthanasia.7,8,11Based on previous literature, the urethra ap -pears to be the most common location of injury re -sulting from urinary catheterization.9 However, blad -der ruptures have also been noted following urinary catheterization, possibly secondary to the retrohy -dropulsion technique.10 It is possible that abnormal 188 JAVMA | FEBRUARY 2024 | VOL 262 | NO. 2urethral and bladder walls may lead to a more chal -lenging deobstruction as well as predispose the tis -sue to tears with normal hydropulsion techniques. Abnormal urethral and bladder tissues have been described previously in UO cases with severe meta -bolic derangements as well as in cats that have been treated for previous UOs that have been associated specifically with stricture formation.11,12 In a previous retrospective necropsy study12 of cats with UO, hy -perkalemia specifically was associated with clinically important lower urinary tract lesions including nec -rotizing cystitis and submucosal/mucosal changes consisting of edema, congestion, and hemorrhage. In addition, severe metabolic disturbances and hy -perkalemia may lead to increased urgency of the hospital staff to establish urinary patency in unstable UO cats. This may result in rougher handling tech -nique during urinary catheterization resulting in tis -sue injury and tears.To the authors’ knowledge, there is no existing literature focused on exploring the complication of lower urinary tract tears in cats presenting with UO. Therefore, the purpose of this retrospective study was to assess the incidence of iatrogenic urinary tract trauma in cats with UO and to investigate for potential risk factors that may be associated with iatrogenic urinary tract trauma. We hypothesized that a history of previous urinary catheterizations, presence of severe metabolic derangements due to the UO, and difficulty in passing the urinary catheter would be associated with an increased risk of an iat -rogenic urinary

Answer 27

Fracture healing is a complex multi-stage process that usually occurs without complications, provided an adequate mechani -cal and biological environment is ensured (Duan & Lu, 2021 ). However, despite the ability of the bone to regenerate, this process sometimes fails, and fractures may heal in inappropri -ate anatomical positions, develop a delayed-union or result in non-union (Mills & Simpson, 2012 ). In human patients, numerous studies have investigated predisposing factors and P . Camilletti and M. d'AmatoJournal of Small Animal Practice • Vol 65 • February 2024 • © 2023 British Small Animal Veterinary Association. 124the prevalence or incidence of non-unions. Zura et al. (2016 ) and Mills et al. (2017 ) reported an overall risk of developing a non-union in 1.9% and 4.9% of human patients treated for a fracture, respectively. Similarly, efforts have been made in the veterinary community to better understand the complica -tions of fracture healing and related predisposing factors. A recent retrospective study analysed complications in fracture healing in 442 dogs (461 fractures) and reported a non-union prevalence of 4.6% (Marshall et al., 2022 ). The reported pre -disposing factors for non-unions were older age, comminuted fractures, infections and implant failure; however, no correla -tion was found between the development of non-union and breed. Conversely, other studies have reported a greater risk of non-union in the distal antebrachial segment of toy breed dogs due to biomechanical and vascular reasons (Larsen et al., 1999 ; Welch et al., 1997 ). Predisposing factors for non-unions have also been investigated in cats. The authors of a study includ -ing 344 cats treated for fractures showed that 5.2% of patients developed a non-union, indicating that older, heavier cats and those with comminuted fractures were more likely to develop a non-union; bone healing furthermore appears to be more dif -ficult in distal limbs of domestic cats due to lack of soft-tissue coverage and poor vascularization (Nolte et al., 2005 ; Zurita & Craig, 2022 ). Non-unions require surgical treatment, and bone graft application is often necessary to restore an adequate biological environment (Nicholson et al., 2021 ). Autologous bone grafting is considered the gold standard, as it possesses osteogenic, osteoinductive and osteoconductive properties, as well as being safe and inexpensive (Azi et al., 2016 ). Some con -cerns related to autologous bone grafting, such as increased operative time and donor site complications, have increased interest in biosynthetic bone graft substitutes and bone tissue engineering techniques (Bigham-Sadegh et al., 2013 ; Gon -zaga et al., 2019 ; Li et al., 2022 ; Malhotra et al., 2013 ; Massie et al., 2017 ; Ragetly & Griffon, 2011 ; T rombetta et al., 2017 ; Zhang et al., 2021 ). Despite this, there are currently no mate -rials that have biological or mechanical properties superior to those of autologous bone grafts (Ferbert et al., 2023 ; Pape et al., 2010 ). Furthermore, in veterinary medicine, autologous bone graft collection appears to be well tolerated, unlike in human patients where donor site pain may persist for months or years (Calori et al., 2014 ; Kraus & Martinez, 2018 ). This retrospective study aimed to report the surgical procedure, out -comes, and complications of the treatment of radius/ulna and tibia/fibula non-unions using a free non-vascularised autolo -gous corticocancellous bone graft (ACBG) from the wing of the ilium to bridge the bone defects and circular external skel -etal fixation (CESF) for stabilisation.

Answer 28

| NO. 10 1547Definitive intent surgery to obtain histologically clean margins of locally invasive tumors often in -volves wide surgical excision with 2- to 3-cm lateral margins and 1 to 2 fascial planes deep.1–6 These mar -gins can be difficult to obtain on areas where skin is sparse (eg, distal extremities) to allow primary clo -sure. Reconstructive techniques in dogs are well rec -ognized and include axial pattern flaps,7,8 subdermal skin flaps,9 free-skin grafts,10,11 and tissue expan -sion.12 Free-skin grafts are usually preferred due to their versatility and availability; however, rate of fail -ure ranges between 0% and 50% and are complicated by infection, graft necrosis, movement, recipient site quality, and fluid accumulation under the graft.11 Sec-ond-intention healing may also be used for manage -ment of open surgical wounds in dogs.13–16 Advantages a.23.03.0157include obtaining histologically clean margins, lack of donor site morbidity, and no cross contamination of donor sites with tumor cells.14 Disadvantages in -clude frequent bandage changes, bandage morbidity, delayed healing, risk of infection, wound contracture affecting mobility, incomplete epithelialization, de -lay of adjuvant therapies, and increased costs.14–19 Some experts advise against using second-intention healing, unless the wound covers < 30% of the limb’s circumference, on the basis of personal clinical experi -ences.15 However, in a retrospective study13 looking at second-intention healing after wide resection of soft tissue sarcomas (STS) on the distal limb, most of the wounds created were > 30% of the circumference of the limb. In that study, median time to healing was 53 days (range, 25 to 179 days); however, 6.5% of dogs 1548 JAVMA | OCTOBER 2023 | VOL 261 | NO. 10required a free-skin graft to facilitate healing. Addi -tionally, there was a lack of detailed wound descrip -tions and dressing or bandaging techniques, making it challenging to determine factors that affected time to complete wound closure.Alternatively, planned marginal excision of the mass followed by primary closure may be performed with the intent to treat the surgical site with adjuvant local therapy postoperatively, such as with radiation or electrochemotherapy.20,21 Complications reported include wound dehiscence, self-trauma, osteonecrosis of the underlying bone, and local necrosis.22 Further -more, radiation therapy is often not financially feasible or available for many clients. Therefore, marginal exci -sion as a sole treatment for skin tumors is often sub -optimal, failing to achieve complete surgical margins. As a result, recurrence rates range from 11% to 80% for low-grade and high-grade sarcomas, respectively.23,24 In tumors of the extremities, amputation may be per -formed to ensure adequate margins are obtained; how -ever, this radical approach is often deemed overly ag -gressive for smaller or low-grade tumors.Recently, an acellular fish skin graft (FSG; Kerecis Omega3) has become available for treatment of com -plicated wounds in humans.25–27 Obtained from North Atlantic cod, the graft is rich in omega-3 fatty acids, col -lagen, fibrin, proteoglycans, and glycosaminoglycans and therefore serves as a good skin substitute.26,28 It is an acellular dermal matrix (ADM) that has very similar microscopic properties to the extracellular matrix (ECM) in mammalian skin. There are several other types of ADMs that have been used in both human and veteri -nary medicine, such as intestinal submucosa, peritoneal membrane, or amniotic tissue derived from porcine and bovine as well as human cadavers.29 In veterinary medicine, porcine small intestine submucosa meshes are most commonly used to recreate the natural miss -ing ECM.30 In 2015, Baldursson et al28 compared the healing rates of humans with full-thickness wounds that were treated with either fish skin ADMs or porcine small intestine submucosa and found that wounds healed sig -nificantly quicker when treated with fish skin ADMs. A study31 looking at the utilization of FSG for treatment of deep partial-thickness burn wounds in pigs found that FSG treatment resulted in faster induction of granulation tissue, vascularization, and epithelialization in compari -son to fetal bovine dermis.Additional benefits of acellular FSGs include its in -ability to incite an autoimmune response and transmit communicable diseases to mammalian species.28 FSG has been shown to accelerate wound healing, is an ef -fective antimicrobial barrier, and can be stored at room temperature with a shelf life of 3 years.32–35 The prod -uct is subjected to less rigorous tissue processing than other mammalian-derived biomaterials, which must go through “viral inactivation” by use of harsh deter -gents to remove all soluble components from the tis -sue.36 This procedure eliminates lipids, glycoproteins, glycans, elastins, hyaluronic acid, and soluble collagen, as well as other essential biological components.36 Structure and bioactive composition can be preserved through mild processing, along with antiviral, antibac -terial, and anti-inflammatory properties.30Utilization of the FSG for wound management in companion animals has been retrospectively docu -mented with resultant complete wound healing of most wounds and no attributed adverse events.19 Similarly, there has been a case report describing the success -ful use of tilapia skin graft for management of a large bite wound in a dog resulting in complete epithelializa -tion.37 Prospective analysis of wound healing outcomes in companion animals following use of the acellular FSG has not been reported. Additionally, use of the acellular FSG over oncological wound beds has not been report -ed in either the veterinary or human literature.The objective of this study was to prospectively evaluate the outcomes of dogs presenting for tu -mors of the distal extremities, managed with acel -lular FSGs following wide surgical excision of the tumor. It was hypothesized that placement of the acellular FSG following wide surgical excision of lo -cally invasive tumors in dogs would be well tolerat -ed, promote complete wound healing as compared to results from the literature, and be an acceptable treatment option for oncological wound closure.

Answer 29

The cranial cruciate ligament (CrCL) is one of the mainstabilizers of the stifle joint, acting as a restraint againstcranial tibial translation, internal rotation and hyper-extension.1–3Its rupture is amongst the most commonorthopedic conditions in dogs.4Stifle instability, follow-ing CrCL rupture, is a major contributing factor to theprogression of stifle osteoarthritis (OA) and a precursorof meniscal injuries.5,6A fundamental component of thisinstability is the cranial tibial translation that occurs dur-ing weight-bearing, through compressive and muscularforces acting on a caudally inclined tibial plateau.3Thiscranially directed tibiofemoral shear force, defined as cra-nial tibial thrust (CTT), constituted the basis for thedevelopment of the tibial plateau leveling techniques bySlocum and Devine.1,3The cranial closing wedge ostectomy (CCWO) wasoriginally described in 1984 as an adjunct technique toother procedures designed to restrain CTT.1By reducingthe tibial plateau angle (TPA), CCWO reduces or elimi-nates CTT and confers dynamic stability to the stifle jointduring the stance phase of gait.1,3However, proposed limi-tations associated with this technique include its inher-ently geometrically imprecise nature and tibial shorteningeffect with subsequent stifle hyperextension.7–10Apelt et al. demonstrated that CCWO successfullyneutralizes CTT at a TPA between 4 and 6/C14, with subse-quent shift into caudal tibial subluxation at TPA < 4/C14,similar to studies on tibial plateau leveling osteotomy(TPLO).10,11In CCWO, as the ostectomy is performed dis-tal to the joint center, the proximal tibial segment ispivoted cranially, displacing the intercondylar eminenceand causing a cranial tibial long axis (TLA) shift.12Baileyet al. further reported that, in CCWO, a causal relation-ship exists between TLA shift and the distance from thejoint center to the ostectomy and in the sagittal align-ment of the reduced ostectomy.12This TLA shift affectsthe achieved postoperative TPA10,12and is implicated asa contributing factor in the wide range of clinicallyreported postoperative TPAs.7,12 –14Residual sagittal stifle instability from inaccurate cor-rection is a disadvantage of CCWO,7,12,13,15leading to thedevelopment of several alterations to address this issue.Modified CCWO (mCCWO) techniques by Oxley et al.,16Frederick and Cross17and Christ et al.18were morerecently described adaptations that featured surgical plansto more accurately and repeatedly level the tibial plateauto the desired 4 –6/C14interval, while minimizing TLA shiftand its impact on tibial length.16–19Instead of the tradi-tional right-angle wedge ostectomy, perpendicular to theTLA, at the distal extent of the tibial crest as designed bySlocum and Devine,1Oxley et al. in 2013 described ajuxta-articular isosceles wedge ostectomy, 5 –10 mmdistal to the tibial tuberosity, leaving an intact smallcaudomedial cortex or “hinge ”.16Frederick and Cross in2017, proposed an alternative mCCWO, also based on ajuxta-articular right-angle wedge ostectomy, 3 mm distalto the tibial tuberosity, with the distal osteotomy intersect-ing the proximal osteotomy, at /C2466% of the distal osteot-omy's cranial-caudal length.17Lastly, Christ et al., in 2018also described a juxta-articular right-angle wedge ostect-omy, 2 –3 mm distal to the tibial tuberosity, but altered theapex location within the proximal osteotomy line, so as toachieve both cranial and caudal cortical alignment uponreduction.18While all of the aforementioned clinical stud-ies varied significantly, they all reported mean postopera-tive TPAs close to,16–18or within19the ideal interval of4–6/C14.10However, contrary to the traditional CCWO,10–12no studies have yet been done to calculate what the idealwedge angle should be in these modified techniques tolevel the TPA to the ideal 4 –6/C14range.The purpose of this study was to investigate how theTLA shift affects the end TPA in four different CCWO tech-niques: Slocum and Devine,1Oxley et al.,16Frederick andCross17a n dC h r i s te ta l .18We hypothesized that, in the stud-ied CCWO techniques and within the studied range of wedgeangles, the TPA varies in a linear fashion, in function ofostectomy wedge angle, indepe ndent of proximal tibial con-formation. If this hypothesis is true, then a corrective factorm a yb ea p p l i e dt ot h ep r e o p e r a t i v eT P At oc a l c u l a t et h ewedge angle required to obtain a postoperative TPA of 5/C14.

Answer 30

Multiple hemipelvectomy techniques have been described in dogs and cats, with historical clas -sifications being based on total versus partial hemi -pelvectomy (ie, removal of the entire hemipelvis vs a portion of the hemipelvis, respectively) and ex -ternal versus internal hemipelvectomy (ie, concur -rent amputation vs preservation of the limb, respec -tively).1,2 Several studies have described not only the traditional techniques used but also outcomes of dogs and cats undergoing hemipelvectomy, with the largest study to date including 84 dogs and 16 cats.3–6 In these studies, all described techniques included excision of unilateral osseous structures a.22.12.0592only (without any resections crossing midline), ap -pendicular skeletal excision only (without any con -current resections of the sacrum and/or vertebrae), and reconstruction of the abdominal wall via primary muscular closure, use of a muscle flap, or synthetic mesh. Although two recent case reports describe a dog and cat that underwent modified hemipelvecto -my with excised osseous structures crossing midline (involving both hemipelves) with reportedly good limb function postoperatively, concurrent amputa -tion (external hemipelvectomy) was not performed in either case.7,8 Additional case reports document dogs undergoing nontraditional hemipelvectomy 2 techniques, but no reports to date have documented dogs or cats undergoing modified hemipelvectomy with concurrent sacrectomy, vertebrectomy, osse -ous excisions crossing midline with concurrent limb amputation (external hemipelvectomies), or closure techniques without local muscular tissues or mesh.9–12 Also, though reported, very limited data exists on veterinary patients undergoing hemipelvectomy with mesh reconstruction of the abdominal wall or with any contralateral osseous excision.Ultimately, information on the clinical findings, techniques, complications, and short- and long-term outcomes in dogs and cats that undergo these modified hemipelvectomy procedures is lacking. Our primary objective was to describe the preoperative findings, procedural techniques, perioperative com -plications, and outcomes of dogs and cats undergo -ing modified hemipelvectomy techniques involving concurrent sacrectomy and/or vertebrectomy, osse -ous excision crossing midline, and/or reconstruction without local muscular tissues.

Answer 31

The double pelvic osteotomy (DPO) is a procedure usedfor the treatment of juvenile canine hip dysplasia.1–4Thejuvenile form of hip dysplasia presents as mild-to-severehindlimb lameness as a result of coxofemoral joint laxity.5,6Pelvic osteotomy procedures rotate the ilium to align theacetabulum such that it favours reduction in the hip joint andthus eliminates this laxity.7By restoring normal function todysplastic hips, pelvic osteotomy procedures can prevent orminimize the development of osteoarthritis.1,7The reportedbeneﬁts of DPO compared with triple pelvic osteotomyinclude increased postoperative comfort and decreasedimplant related complications.2Clinical outcomes of DPO have been examined and haveshown an increase in femoral head coverage and signi ﬁcantlyreduced joint laxity.2Medium to long-term radiographicoutcomes have also been examined,3demonstrating lowerradiographic osteoarthritis scores in DPO-treated hips com-pared with untreated hips.The clinical outcome of triple pelvic osteotomy has beenexamined with objective force plate analysis demonstratingan improvement in the peak vertical force of surgicallytreated limbs compared with untreated limbs and henceimproved weight bearing reaching or approaching the forcesexperienced in the control limb.8,9The clinical improvementfollowing triple pelvic osteotomy occurs despite the radio-graphic progression of osteoarthritis.8,9To the authors ’ledge, objective gait analysis has not been used toassess the outcome of DPO.The objective of this study is to assess the kinetic outcomeof unilateral DPO using a temporospatial pressure walkwayand to compare this outcome to the radiographic and clinicaloutcome for the patients.

Answer 32

Medial patellar luxation is a frequent cause of pelvic limblameness in small breed dogs.1–5Dogs affected by medialpatellar luxation have an increased risk of developing cranialcruciate ligament disease, with 13 to 25% of dogs diagnosedwith medial patellar luxation having concomitant cranialcruciate ligament rupture.4,6Surgical treatment ofomitant cranial cruciate ligament rupture and medialpatellar luxation has previously been achieved with a varietyof surgical techniques including tibial wedge osteotomy, mod-iﬁed tibial plateau levelling osteotomy (TPLO-M), or modi ﬁedtibial tuberosity advancement either alone or in combinationwith other procedures such as tibial tuberosity transposition,trochleoplasty, retinacular release and retinacular imbrica-tion.5–9Recently Flesher and colleagues reported on a modi-ﬁed TPLO which is referred to as ‘TPLO-M ’that simultaneouslylevels and medializes the tibial plateau using a standard radialosteotomy in the proximal tibia.10This TPLO-M technique isdesigned to negate cranial tibial thrust and improve alignmentof the quadriceps mechanism.10In Flesher ’s study, overallcomplication rates identi ﬁed were similar to complicationsreported after traditional medial patellar luxation surgicalcorrection techniques and no differences in patient outcomewere identi ﬁed between the patient group treated with TPLOand the patient group treated with TPLO-M.10Plate contouring to ﬁt the medial aspect of the proximaltibia after TPLO-M is complex and increases the surgicaltime.10Recently, 1.9 to 2.5 mm pre-contoured T plates (Intra-uma S.p.A.,Turin, Italy) designed for TPLO-M in dogs weighingbetween 5 and 10 kg with 3 different offsets (2, 4 and 6 mm) toovercome the dif ﬁculties related to plate contouring becameavailable ( ►Fig. 1 ). Plate offset, measured in mm, refers to thedistance between the axes of the proximal and distal portionsof the plate in the frontal plane. The 2 mm offset plate wasdesigned for standard TPLO in small dogs without medialpatellar luxation. The 4 and 6 mm offset plates were designedto allow medialization of the proximal tibial segment duringTPLO. The Fixin system ‘mini-implant series ’are applied using1.9 or 2.5 mm diameter screws and are indicated for thetreatment of fractures in cats and dogs up to 10 kg.The objective of this study was to determine the magnitudeof proximal tibial segment medialization achievable with Fixin1.9 to 2.5 mm pre-contoured T plates with three differentoffsets (2, 4 and 6 mm) in two different tibial model sizes.We hypothesized that different magnitudes of medializa-tion would be achieved using a plate with the same offset intibial models from a 5 versus a 10 kg dog (hypothesis 1). Wealso hypothesized that the magnitude of medializationwould not affect the degree of tibial plateau levelling inthe sagittal plane and the alignment of the tibia in the frontalplane (hypothesis 2).

Answer 33

The objective of surgical management of ruptured cranialcruciate ligament (CCL) is to reestablish a biomechanicallynormal joint with the resultant return to full function.1,2Inpeople, this is best achieved using a substitute material forintra-articular replacement of the anterior cruciate ligament,with location of the reconstruction being one of the moreimportant factors associated with a successful outcome.1–3The term isometric in cruciate ligament reconstruction refersto the constant distance between the femoral and tibialattachments of the reconstruction as the knee is extendedandﬂexed.1,3Rupture of the CCL with resultant sti ﬂe instability andlameness is common in the dog, and has been treated withboth intra-articular and extracapsular techniques.4–7Highrates of premature graft failure and poor limb function haveresulted in intra-articular techniques falling out offavor.4,6–13Similarly, extracapsular suture techniques havebeen shown to have a poorer functional outcome whenared to tibial osteotomies.7,13–15In order to improvethe functional outcome of extracapsular suture techniques,the isometric principle has been extrapolated to the lateralaspect of the joint where it is thought that placing a pros-thesis close to isometric points will result in improvedoutcome. Several studies have identi ﬁed isometric pointson the lateral aspects of the femur and tibia using a variety oftechniques.16–19However, it has been shown that although agood functional outcome can be expected using isometricpoints,13,17,18,20the techniques do not restore normal sti ﬂebiomechanics,21and the occurrence of implant failureremains high.16,17,22Signiﬁcant instability also persists indogs treated with tibial osteotomies,23,24and although thesedogs often do not show clinical lameness, failure to restorenormal sti ﬂe biomechanics results in late meniscal dam-age,25,26and progressive osteoarthritis.5,6,12,27 –30While the CCL in the dog is assumed to be, overall,isometric, as in other species,20,31 –33speci ﬁci s o m e t r i cpoints within the origin and insertion of the ligament havenot been identi ﬁed. The aims of this study were to develop athree-dimensional (3D) model to identify the isometriccomponent of the CCL in dogs and to identify any additionalisometric regions of the sti ﬂe.

Answer 34

Cranial cruciate ligament disease and subsequent ligamentrupture are one of the most common causes of pelvic limblameness in dogs.1The cranial cruciate ligament acts tostabilize the sti ﬂe, preventing cranial displacement of thetibia relative to the femur, preventing hyper extension of thestiﬂe and limiting internal rotation of the tibia.2Cranialcruciate ligament degenerative changes in dogs 8 years ofage and older have been noted to consist of calcium deposits,hyalinization, loss of wavy architecture and nesting of carti-lage cells.3–5It has been previously documented that theial cruciate ligament begins to show microscopic degen-eration in dogs weighing more than 15 kg around 5 years ofage and progresses over time.3Microscopic degenerativechanges previously reported include the loss of ligamento-cytes, metaplasia of the surviving ligamentocytes to chon-drocytes and failure to maintain collagen ﬁbres and primarycollagen bundles.3,6–11These degenerative changes havebeen linked to a higher incidence of cranial cruciate ligamentrupture (CCLR) in dogs over 5 years of age.1,3,12,13In 2003, it was estimated that dog owners in the UnitedStates spend more than one billion dollars annually formedical and surgical management of CCLR in dogs.14Asthe economic impact of medical and surgical managementof CCLR has likely grown over the past 20 years, furtherinvestigation surrounding the prevalence of contralateralCCLR in older dogs is warranted.Previous reports have found that contralateral CCLR oc-curred 11.2 months (mean, range: 5.5 –16.5 months) after ﬁrst-side CCLR diagnosis in 33.1% of dogs (mean; range: 13 –48%).13,15 –20In many of these studies, prevalence of contralat-eral CCLR was not the focus of statistical analysis and thereforedatasets consisted of a wide range of breeds, weight and agewith smaller population sizes of 166 dogs (mean; range: 94 –511 dogs).13,15 –20The most referenced contralateral CCLRstudies by Buote and colleagues are frequently utilized inconsultations with owners, stating the risk of contralateralCCLR is approximately 50% within approximately 6 monthsupon diagnosis of initial ﬁrst-side CCLR.19In this 2009 study of94 Labradors the median age was 4.8 years with a median bodyweight of 37.1 kg, concluding contralateral CCLR occurred in45/94 dogs (48%) with a median time to rupture of thecontralateral CCLR being 5.5 months.19Previous studies have failed to focus on medium andbreed dogs, 8 years of age and older, that sustain a contralat-eral CCLR for which surgical stabilization is most commonlyrecommended.2,3,5We examined multiple risk factors in-cluding breed, weight, sex, intact status, age at ﬁrst-sideCCLR, comorbidities (including history of steroids, hip dys-plasia, hypothyroidism, allergies, seizures), pre-operativetibial plateau angle (TPA, measured by a board-certi ﬁedsurgeon performing the surgery), presence or absence ofmeniscus injury and meniscal treatment (meniscal release orother) in this population to determine the in ﬂuence oncontralateral CCLR. The purpose of this study was to docu-ment the prevalence of contralateral CCLR in medium-to-large breed (15 kg and over) dogs at least 8 years of age and toevaluate risk factors that may be associated with the preva-lence of contralateral CCLR.

Answer 35

Pain is a distressful sensation after a stimulus and is usu -ally unique for each individual.1 The failure to detect and manage it adequately may lead to increased postopera -tive stress and arterial blood pressure, immunosuppres-sion, delayed wound healing, negative protein balance, decreased food intake and development of maladaptive behaviours, including self-mutilation.2,3Opioid analgesics have been the mainstay of pain management, but other medications, such as alpha2-adrenoceptor agonists, dissociative anaesthetics, tran -quilisers, non-steroidal anti-inflammatory drugs and local anaesthetics (LAs), have been used to complement opioid treatment.4,5 A multimodal approach incorporating LA administration is becoming more popular as means to provide analgesia.6–8 Local anaesthetics are unique because they can completely block the transmission of nocicep-tive signals, resulting in local anaesthesia and analgesia.9 They work by blocking the sodium influx to the nerve axon and inhibiting the action potential, which disrupts the generation and transmission of nerve impulses.10 In addition, unlike other drugs such as opioids that mod-ulate pain through receptor-binding in the central ner -vous system (CNS), LAs prevent nociceptive impulses from reaching the CNS, enabling specific and powerful control of the nociceptive pathway.11 The administration of LAs through a soaker catheter maximises their effects by allowing repeated or continu -ous administration, and facilitates blocking somatic sen -sation of the incision and surrounding muscle beds after surgical procedures.6 A soaker catheter, also known as a wound infusion catheter (WIC), has a relatively low cost and results in minimal LA systemic absorption.12,13 Placement of a WIC directly into the surgical wound is technically easy. To date, these systems have been effective in providing postoperative analgesia to human patients undergoing a wide variety of orthopaedic and soft-tissue procedures.14–16 Numerous benefits including shorter hospitalisation, decreased cost, fewer systemic side effects and a decreased need for supplemental systemic analge -sic drugs have been recognised in human patients.17–20 In the past decade, this method has been adopted as a postoperative analgesia in dogs, cats and goats.6,13,21–23 However, to our knowledge, only a few studies on the use of WICs in feline patients have been published with a limited number of cases.6,21 Furthermore, protocols and complications have not always been fully detailed.6,21The objective of this retrospective study was to evaluate the use of the WIC following a variety of surgical proce -dures in cats investigating complications and risk factors associated with WIC placement and LA administration.

Answer 36

Lower respiratory tract diseases are common diagnosesin small animal medicine. The incidence of non-neoplastic pulmonary consolidation (PC) in the generalcanine population is not well described. Pulmonary con-solidation can be associated with a variety of primary orsecondary etiologies. Causes of pulmonary consolidationinclude pneumonia, atelectasis, pulmonary edema, pul-monary hemorrhage, foreign material with underlyingpneumonia comprising the majority of the cases. Follow-ing surgical procedures such as thoracolumbar laminec-tomies, arytenoid lateralization, and intracranial surgery,the documented incidence of aspiration pneumoniaranges from 4.6% to 24%.1–5The generally recommendedtreatment for bacterial pneumonia is antimicrobial ther-apy for 4-6 weeks, however, supporting evidence is lack-ing.6For cases that have an unsatisfactory clinicalresponse or develop PC, a lung lobectomy may be consid-ered, although it is important to note that most cases ofpneumonia do not result in PC and will resolve withmedical management alone. Currently, there are no stud-ies that address long-term outcomes of non-neoplasticPC. Open pulmonary lobectomy performed for the man-agement of pneumonia in dogs resulted in 54.2% of dogsexperiencing resolution of pneumonia after lobectomy,25.4% surviving the perioperative period but failing toresolve their pneumonia, and 20.3% dying in the periop-erative period.7Minimally invasive techniques minimizeoperative trauma and optimize postoperative comfort.8–14Morbidity and mortality in dogs undergoing thoraco-scopic lung lobectomy for resection of primary or meta-static neoplasia have been reported to be low.15Thoracoscopic management of PC has not been describedin the veterinary literature. There is a need to evaluatelong-term outcomes with thoracoscopic management ofPC to help guide surgical consultation conversations withpet owners.The objective of this study was to describe periopera-tive and long-term outcomes of thoracoscopic (TL) andthoracoscopic-assisted lung lobectomy (TAL) for thetreatment of PC in dogs.

Answer 37

Cranial cruciate ligament rupture (CCLR) is a common cause of lameness in dogs that results in joint instability, discomfort, meniscal injury, osteoarthritis, chronic pain and limb functional disability when left untreated (Kowaleski et al. 2012 ). Surgi -cal correction is indicated to control pain and stifle instability (Gordon- Evans et al. 2013 , MacDonald et al. 2013 ), providing the limb with an increased likelihood of return to function (Wucherer et al. 2013 ).Dogs’ physical activity level has already been associated with CCLR development (Bennett et al. 1988 , Lampman et al. 2003 ); L. A. H. Schuster et al.Journal of Small Animal Practice • Vol 64 • October 2023 • © 2023 British Small Animal Veterinary Association. 620while in a study by Terhaar et al. (2020 ), daily physical activ -ity was not considered a risk factor. A recent study sought to assess physical activity and fitness indicators as risk factors for CCLR. Dogs that engaged in activity at higher levels of agility were shown to have less risk of CCLR than dogs that engaged in specific conditioning activities (Sellon & Marcellin- Little 2022 ). The relationship between physical activity and CCLR is still poorly understood and its evaluation is usually performed using subjective methods such as questionnaires administered to own -ers. Therefore, objective methods for the assessment of activity are important as they can overcome the limitations of subjective evaluation (Conzemius & Evans 2018 ). Measurement of physical activity levels using accelerometers is a growing methodology in veterinary medicine (Yam et al. 2011 , Morrison et al. 2013 , Helm et al. 2016 ). Accelerometry is considered a valid and objective method to quantify physical activity levels (Hansen et al. 2007 , Brown et al. 2010a ). This device registers frequency, movement intensity and how many minutes per day the animal spends mov -ing or being sedentary (Yam et al. 2011 ). The ActiGraph acceler -ometer has been validated for the measurement of spontaneous physical activity in dogs (Yam et al. 2011 ). This device was found to be portable, lightweight and non- invasive (Helm et al. 2016 ).In human beings, musculoskeletal injuries have been iden -tified as the main cause of physical activity reduction (Ardern 2015 ). Conversely, reaching adequate physical activity levels is among the most commonly discussed clinical aims during the CCLR recovery process (Filbay et al. 2015 , Ardern et al. 2016 ). Furthermore, a decrease in quality of life (Filbay et al. 2015 ) and chronic disease development (Luc et al. 2014 ) have been reported as consequences of such injury.In dogs, different from humans (Bell et al. 2017 ), no studies were found assessing the influence of CCLR on physical activity as measured by objective methods. Although accelerometry use in veterinary medicine is increasing, most research using the device is related to studies on obesity (Morrison et al. 2013 ), nutri -tion (Morrison et al. 2014a ), osteoarthritis (Brown et al. 2010b , Muller et al. 2018 ) and oncology (Helm et al. 2016 ).A search of the literature was performed on February 20, 2022 using PubMed, Science Direct and Scopus databases with the following keywords: accelerometry, dogs, accelerometer, physical activity, cruciate ligament, stifle, pain, home environment and lateral fabellar suture. No studies were found concerning the rela -tionship between physical activity and CCLR. The present study aimed to investigate, using accelerometers, the physical activity levels of dogs with CCLR before and after extracapsular stifle sta -bilisation surgery. The hypothesis was that an increase in physical activity would occur after surgical stabilisation.

Answer 38

Sacroiliac luxation is thetraumatic dislocation of the iliac wingfrom the sacrum that commonly occurs with other orthopae-dic injuries in small animals. In a retrospective study, of dogswith sacroiliac luxation, 77% had unilateral sacroiliac injuryand 85% had concurrent orthopaedic injuries.1Conservativemanagement is acceptable for minimally displaced sacroiliacluxation; however, surgical stabilizationis indicated in cases ofnarrowed pelvic canal, displacement that causes signs of painand nonambulatory state, or neurologic de ﬁcits.2,3Placement of a single cortical or cancellous screw of thelargest diameter in lag fashion is the most common surgicaltreatment for sacroiliac luxation.1,4Although postoperativeloosening rate of lag screw ﬁxation for canine sacroiliacluxation has been reported to be as high as 38%, favorableoutcomes can be obtained when the screw engages at least60% of the sacral width.1,2,4Pullout force and resistance toshear and bending forces increase as the screw diameterincreases; however, a single larger screw cannot effectivelyincrease the relative resistance to rotation forces comparedwith double smaller screws.5,6Nonetheless, placement ofdouble screws in a sacral body is challenging and requires ahigh degree of precision because of the narrow anatomicalsafe corridor in the canine sacrum.2,4,7 –9Alternatively, a headless cannulated self-compressionscrew (HCS) has an advantage in precision because the screwcan be placed over a positional guidewire under ﬂuoroscopicguidance.10Currently, the cannulated screw system is used asa surgical treatment option for internal ﬁxation in humanpelvic, articular, or periarticular small bone and joint sur-gery.11–13In veterinary medicine, constructs repaired with3.0-mm HCS in the canine humeral condylar fracture modelshowed no difference in the quality of anatomical reduction oryield loads compared with constructs with 3.5-mm cortical lagscrew ﬁxation.14However, despite the advantages of HCS andmechanical properties of double screw placement, there is alack of clinical or biomechanical studies on HCS placement forsacroiliac luxation repair in veterinary medicine.The primary objective of this study was to evaluate thefeasibility of safe positioning of double 2.3-mm HCS in asmall dog cadaveric sacroiliac luxation model. Our secondaryaim was to compare the static rotational biomechanicalproperties of ﬁxation repaired by two different screw sys-tems with a minimally invasive ﬁxation technique: double2.3-mm HCS and single 3.5-mm cortical screw (CS) placed inlag fashion. Our ﬁrst hypothesis was that safe positioning ofdouble 2.3-mm HCS in the sacral body is possible underﬂuoroscopic guidance. Our second hypothesis was thatdouble 2.3-mm HCS would show superior static mechanicalproperties to a single 3.5-mm cortical lag screw whenstanding ground reaction forces were applied.

Answer 39

Nocita (Aratana Therapeutics Inc.) is an FDA approvedproduct made up of liposomal bupivacaine (LB) and islabeled to provide up to 72 h of postoperative analgesia.1Itis currently approved as an incisional infiltration block foruse in canines undergoing cranial cruciate ligament sur-gery1and for use in feline onychectomy.2The authors haveobserved increased extra-label clinical use of LB for othersmall animal procedures. In veterinary literature, whenthe clinical efficacy of analgesia in orthopedic surgerybetween LB and bupivacaine3as well as saline4was com-pared, LB was found to have superior analgesic qualitiesthan bupivacaine or saline.3,4However, in more recentsoft-tissue studies, no additional analgesic effect of LB wasfound.5–7In addition, dogs undergoing an elective ovario-hysterectomy that received a transverse abdominis plane(TAP) block with either a mixture of bupivacaine/dexmedetomidine or with LB had lower pain scores andneeded less rescue analgesia than dogs in the controlgroup.5However, no difference was found between thegroup that received LB and the group that did not. Inanother prospective study, pain was assessed after abdomi-nal surgery by an electronic algometer and also using theGlasgow Composite Measure Pain Scale (35 dogs), and didnot differ between dogs that received LB versus those thatdid not.6No difference in need for additional intravenousopioids was reported between dogs receiving LB or placeboperi-incisionally after a variety of soft tissue surgeries.7Adverse effects described in canines from the use ofvarious formulations of LB are limited to redness at thesubcutaneous injection site,8or attributed to the creationof an inguinal hernia.9Doses used in these studies(30 mg/kg, in a 25 mg/mL formulation)8–10were higherthan the recommended dose for the commercially avail-able product (5.3 mg/kg in a 13.3 mg/mL).1,2In dogs, nodifferences in adverse events were found between use ofLB and 0.5% bupivacaine hydrochloride when used as anincisional infiltration block undergoing tibial plateauleveling osteotomy (TPLO)3or lateral suture placement.4More recently, local incisional complications have beenreported in 43/218 canine surgeries (19.7%) with localinfiltration of LB, with a higher incidence in soft tissue(32/123; 26.0%) than orthopedic (11/95; 11.6%) proce-dures.11Complications were noted more commonly incontaminated (30.8%) than in clean (18.8%), or clean-contaminated (23.1%) surgeries. In a prospective caninestudy, redness and inflammation around the laparotomyincisions treated with LB was observed in 276/321 dogsin hospital and in 80 at the 2 week recheck.12In small animal surgery, surgical gastrointestinal for-eign body (GIFB) removal is classified as a clean-contaminated or contaminated surgery. It is a commonlyperformed procedure in veterinary medicine, allowing fora larger, single-surgery-type assessment. Our objectiveswere to: (1) compare postoperative analgesic use, and(2) incidence of postoperative complications (general andsurgical site) between dogs that received LB during surgi-cal GIFB removal and those that did not in a single institu-tion. We hypothesized that: (1) dogs receiving LB wouldreceive less postoperative opioid analgesics than those thatdid not, and (2) no difference in postoperative complica-tions would be seen between the two groups

Answer 40

Humeral condylar fractures are commonly encounteredin veterinary surgery, with cocker spaniels and Frenchbulldogs being most commonly affected.1They are typi-cally divided into lateral, medial and Y-/T- condylar frac-tures.2,3Unicondylar fractures most commonly affect thelateral part of the humeral condyle.3Multiple methods of stabilizing these fractures havebeen previously described.4–8However, these fracturesare typically repaired using a transcondylar screw placedin lag fashion to provide anatomical reconstruction of thejoint surface, in combination with adjunct fixation ofthe epicondylar portion to provide both rotational stabil-ity and reduce the cyclic forces on the transcondylar fixa-tion. This is particularly important in cases wherehumeral intracondylar fissuring is the suspected underly-ing etiology of the fracture as the intracondylar portion ofthe fracture is not expected to heal normally andthe implants will likely experience mechanical strain forthe lifespan of the dog.9The benefit of adjunctive fixation with an epicondylarplate over a Kirshner wire has been shown in both theex vivo10as well as the in vivo setting.4The challengewith plating is that the topography of the lateral epicon-dyle is complex and accurate contouring of plates in thisregion can be time-consuming. In addition to this, it isimperative that screws do not breach the joint surfacecausing articular cartilage damage or penetrate the supra-trochlear foramen as this will inhibit normal elbow rangeof motion and cause ongoing lameness. Failure to accu-rately contour nonlocking plates will result in failure togenerate plate-bone friction, leading to an unstable fixa-tion. Application of a poorly contoured nonlocking platecan result in displacement of the epicondylar fragmentresulting in imperfect reduction and potentially loss ofany load sharing. This can be mitigated with the useof locking plates; however, the three-planar contouringrequired in this region can make contouring of somelocking plates challenging and the frequently fixed-anglenature of locking plates can result in screws beingdirected towards the articular surface or supratrochlearforamen.Advancing research in novel composite materials pre-sents potential new ways of stabilizing bone fragments inplace of bone plates, which have been the mainstay ofinternal fracture fixation for the last five decades.11Oneessential requirement for these novel materials is to showthat they provide adequate mechanical stability prior totheir use in clinical cases. An innovative approach ofusing composite materials is the AdhFix concept, wherea high energy visible light-cured fixator plate is con-structed in a customized fashion to fit the specificanatomical site and morphology of the fracture. Theadaptable features of an AdhFix plate is of inherent inter-est in the veterinary field, where the variation of bonesize and shape can vary a lot between patients. Earlierstudies have shown the great potential of AdhFix for frac-ture treatment,12and the material platform has compel-ling safety evidence from biological safety studies andseveral short- and long-term animal trials in accordancewith the ISO 10993 standard that is used for the approvalof medical implants in humans.12–14This ex vivo study aimed to compare adjunct epicon-dylar fixation with a novel composite material securedaround bone screws with that provided by Kirschnerwires or traditional bone plate and screws in a lateralhumeral condylar fracture model.

Answer 41

Laryngeal paralysis is a common disease process that occurs secondary to denervation atrophy of the recurrent laryngeal nerve resulting in dysfunc -tion of the cricoarytenoid dorsalis muscle and failure of the arytenoid cartilages and vocal folds to abduct during inspiration.1–3 Numerous surgical techniques have been described to treat this condition, with uni -lateral arytenoid lateralization being the most com -monly performed.1–3 Various complication rates for treatment of laryngeal paralysis have been reported in the literature, with a wide range of morbidity and mortality rates from 10% to 58% and 14% to 67%, re -spectively.3–7 Treatment with unilateral arytenoid lateralization results in the lowest complication rate, with some studies reporting as little as 10%.8 The most common postoperative complications associated with a.23.02.0121unilateral arytenoid lateralization include aspiration pneumonia, which is reported to occur in 23.6%.7 In 1 study,7 the reported mortality rate in patients > 1 year postoperatively was 14.3% and secondary to aspiration pneumonia. Other complications can in -clude coughing and recurrence of clinical signs from tearing of the suture or fracture of the arytenoid cartilage.2 Complications such as coughing after eating or drinking have also been shown to occur in 89% of dogs.4,9–11Aspiration pneumonia is a lifelong potential com -plication of the procedure and has been reported to occur in 5% to 25%3,7,12–15 of patients postoperatively, with 1 study13 reporting rates as high as 31.8% at 4-year follow-up periods. Because of the increased risk of as -piration pneumonia, numerous techniques have been 2 evaluated in the immediate postoperative period to reduce the risk of vomiting and regurgitation. A pro -spective randomized multicenter clinical trial16 evalu -ated the effect of perioperative IV constant rate infu -sion of metoclopramide on the incidence of aspiration pneumonia. This study found no significant differenc -es on the development of aspiration pneumonia be -tween the control and treated groups. A retrospective study13 evaluating 232 patient undergoing unilateral arytenoid lateralization found that postoperative ad -ministration of an opioid was a significant risk factor for the development of aspiration pneumonia in the short term (< 14 days postoperatively).Both human- and veterinary-based studies have shown that stress during hospitalization results in delayed wound healing, gastrointestinal diseases (gastric ulceration, vomiting, and nausea), and in -creased susceptibility to infections.10,11,17–19 In vet -erinary medicine, the following factors play a role in the high rate of stress seen in hospitalized patients: separation from primary caretaker, new environment and stimuli, increased noise levels, and confinement in cages.20–26 One study27 examined a less-invasive unilateral arytenoid lateralization and reported same-day discharge with no life-threatening adverse events. To the authors’ knowledge, no studies have directly compared inpatient versus outpatient treat -ment of dogs undergoing unilateral arytenoid later -alization. The objective of this study was to compare short-term outcome and complication rates be -tween outpatient management and traditional in -patient management of dogs undergoing unilateral arytenoid lateralization. An additional objective was to determine whether outpatient management is a safe alternative to the traditional inpatient postop -erative management with careful patient selection. The authors hypothesized that outpatient unilateral arytenoid lateralization would be a safe alternative to inpatient postoperative management and may be associated with less postoperative complications.

Answer 42

The visual assessment of lameness in dogs is commonly used to assess the severity of disease and response to treatment, but the correlation of such assessments with objective measures of limb function is poor (Oosterlinck et al., 2011 ; Waxman et al., 2008 ). Kinetic gait analysis of dynamic weight-bearing is considered the gold standard objective gait assessment (Ladha et al., 2017 ), and has been widely used to characterise the effect of medical and surgical interventions of musculoskeletal and neurological con -ditions in dogs (Ballagas et al., 2004 ; Borer et al., 2003 ; Buds -berg et al., 2007 ; Conzemius et al., 2005 ; Grisneaux et al., 2003 ; Karnik et al., 2006 ; Klaveren et al., 2005 ; Moreau et al., 2003 , 2007 ; Suwankong et al., 2007 ; Wilson et al., 2018 ). However, the acquisition of kinetic data from dogs during dynamic weight bearing is time consuming and thus difficult to incorporate into routine clinical practice, which has precluded its routine use.Rising from a sitting to standing position is a complex movement requiring the recruitment of multiple muscle groups (Ellis et al., 2018 ). Quantifying this movement, e.g. Sit to stand testJournal of Small Animal Practice • Vol 65 • January 2024 • © 2023 The Authors. Journal of Small Animal Practice published by John Wiley & Sons Ltd on behalf of British Small Animal Veterinary Association.25 with kinetic gait analysis, can allow the assessment of physi -cal function in the form of a sit to stand test (STST) (Caplan et al., 2014 ). In humans, the STST enables the direct quanti -fication of lower-body functional power which demonstrates a significant correlation with measurements of functional ability such as strength, speed, endurance and agility (Gray & Paul -son, 2014 ). The kinematic analysis of stifle movement in non-lame dogs during the STST demonstrates excellent intra- and inter-observer repeatability (Feeney et al., 2007 ). The range of motion of the hip joint of healthy dogs is increased when com -pared to dogs with hip dysplasia, and this difference is accen -tuated with the STST when contrasted with normal walking motion (Souza et al., 2019 ).The accuracy of kinetic parameters of the STST to identify lameness caused by cranial cruciate ligament rupture (CCLR) has not been described or compared to other methods of quantitative gait analysis in veterinary medicine to the authors’ knowledge. This study aimed to evaluate the asymmetry of weight bearing in dogs with unilateral CCLR using a simple, one stage, STST. We hypothesised that kinetic data acquired from a STST and the conventional walk test (WT) could discriminate dogs with hindlimb lameness associated with cruciate rupture from non-lame dogs, and that the STST would be quicker to complete than the WT.

Answer 43

Abscesses and draining tracts (DTs) in the head and neck regions in dogs can result from dental abscesses, bite wounds, penetrating oropharyngeal stick injuries (OSI) or migrating vegetal foreign bodies (VFB). OSI and VFB are considered to be involved in 40 to 60% of cases (Brennan & Ihrke 1983, White & Lane 1988). Surgical treatment of OSI and VFB is challenging because of dif-ficulty in localising the VFB, which often lie deep in tissues at a distance from the opening of the DTs (Lamb et al. 1994, Frendin et al. 1999, Staudte et al. 2004, Nicholson et al. 2008, Bouab-dallah et al. 2014, Jacques et al. 2022). Failure to remove or identify the infection source is a well- recognised cause of recur-rence leading to repeated and unsuccessful treatments (White & Lane 1988, Armbrust et al. 2003, Dobromylskyj et al. 2008, Bouabdallah et al. 2014). A failure rate as high as 38% has been reported when surgery is performed as a first- line procedure in dogs with VFB or OSI (Griffiths et al. 2000).Therefore, the role of preoperative imaging has been empha-sised for recurrent abscesses and DTs in VFB in multiple studies. In particular, CT is considered by many surgeons to be useful for both diagnosis and planning purposes, because it provides cross- sectional anatomical images with good spatial resolution (Nicholson et al. 2008, Bouabdallah et al. 2014, Vansteenkiste et al. 2014, Lamb et al. 2017, Griffeuille et al. 2021). When these lesions are located in thoracic or abdominal regions, a proposed strategy involves the removal of any VFB identified on CT; oth-erwise, debridement, drainage or en- bloc resection of the lesions is performed. This strategy has been reported to achieve a thera-peutic success rate of 81% after a single procedure (Bouabdallah et al. 2014).Cases in which VFB cannot be identified either on CT or at surgery are the most challenging to treat, particularly in regions such as the head and neck, where numerous anatomic structures of major functional importance limit the extent of surgical explo-ration. Apart from one report detailing the use of CT in six dogs with a known history of OSI (Nicholson et al. 2008), no retro-spective study in the veterinary literature has evaluated the value of preoperative CT imaging for surgical planning and treatment of VFB- or OSI- related abscesses and DTs located in the head and neck regions in dogs. The objectives of this study were to determine the success rate of CT- planned surgical treatment of this clinical condition in dogs, and to compare outcomes when VFB were either identified or not identified in preoperative CT examination.

Answer 44

Fractures of the proximal femur are common injuriesamong skeletally immature animals and often involvethe capital physis. Most canine femoral capital physealfractures occur via trauma and are less commonly theresult of physeal dysplasia.1–4Conservative managementof femoral head and neck fractures is associated withpoor functional outcome, therefore, surgical interventionis typically recommended.5–7Primary surgical repair via open reduction and inter-nal fixation (ORIF) with multiple pins and/or screws is aReceived: 24 March 2022 Revised: 21 June 2022 Accepted: 11 July 2022DOI: 10.1111/vsu.13867846 © 2022 American College of Veterinary Surgeons. Veterinary Surgery. 2023;52:846 –852. wileyonlinelibrary.com/journal/vsulong-established treatment option for femoral head andneck fractures.8–11Potential complications associatedwith ORIF include premature physeal closure, femoralhead/neck malformation, loss of reduction, femoral neckresorption, and the development of degenerative jointdisease.1,5,8Salvage procedures such as femoral head andneck ostectomy or total hip arthroplasty should be con-sidered for chronic fracture with evidence of remodeling,or in cases where the primary repair has failed.12,13Fluoroscopic-guided percutaneous pinning (FGPP) isa minimally invasive repair alternative to ORIF for phy-seal fracture repair in dogs and cats.14–16This techniqueutilizes intraoperative fluoroscopy to guide implant place-ment for fracture fixation. FGPP poses several advantagescompared to ORIF such as reduced surgical trauma andpostoperative morbidity.14In a retrospective study inves-tigating outcomes of closed reduction and physeal frac-tures repair with this technique in small animals,excellent functional outcome was reported in 92% ofcases, most of which had minimal fracture displacementpreoperatively.15Of the 42 physeal fracture repairsincluded in the study, only one femoral capital physealfracture repair was described. The purpose of this study isto report the short-term clinical outcome of a largercohort of dogs with femoral head or neck fracturesrepaired via closed reduction and FGPP.

Answer 45

Cranial cruciate ligament disease (CCLD) is the mostcommon cause of hindlimb lameness in dogs.1Surgicaltreatment is recommended for management, and a rangeof techniques have been described. Proximal tibial osteot-omy techniques including cranial closing wedge ostect-omy (CCWO) and tibial plateau leveling osteotomy(TPLO) aim to reduce the tibial plateau angle (TPA) to5/C14, which has been shown to dynamically stabilizethe cranial cruciate ligament deficient stifle joint.2Biomechanical studies corroborate that a reduction inTPA to 4 –6/C14will sufficiently eliminate cranial tibial thrust,and clinical investigations consistently demonstrate goodto excellent clinical outcomes for these procedures.3–5CCWO was first described by Slocum and Devine andassumed that to achieve a postoperative TPA (TPA Post)o f5/C14, the apex angle of the triangular wedge ostectomywould be equivalent to TPA minus 5/C14.6TPA is calculatedusing the tibial long-axis, and the proximal landmark forestablishing the mechanical axis of the tibia is the centerof the tibial eminences. However, as the osteotomizedwedge is reduced, the tibial eminences are displaced crani-ally resulting in a tibial long axis shift (TLAS), which ulti-mately leads to an under-correction of TPAPost. The degreeof TLAS is increased when the ostectomy is performedmore distally, and as the wedge angle is increased.6In an attempt to account for the aforementioned chal-lenges, modified ostectomy planning methods with adjustedwedge angle calculations have been described to attempt toachieve the desired TPAPost.3,7–12One of the most popularand widely adopted variations was described by Oxley et al.They reported a modified CCWO (mCCWO) which usedan isosceles wedge position ed more proximally along thetibial tuberosity. A further characteristic was the mainte-nance of a caudal “hinge ”of cortical bone to provide intrao-perative alignment and stability.3The ostectomy wedge sizerequired varied by the preoperative TPA (TPA Pre)b a s e do ngrouped ranges of increasing TPA with wedge anglesbetween TPAPreminus 5/C14and TPA Preminus 2/C14.T h ep r o x i -modistal ostectomy position was determined by body-weight, with a more distal os tectomy performed in largerdogs (>25 kg) to allow for sufficient proximal bone stockthat is appropriately sized for adequate implants. In a clini-cal case series using this method mCCWO resulted in amedian TPAPostof 6.5/C14.I nt h a ts t u d y ,a l ld o g sw e r e> 20 kg; however, mCCWO is also applied to small dogs.3The aims of this study were: (1) to determine whether theOxley mCCWO gives the desired TPA Postof 5/C14in dogs of allsizes with varying TPA Prein silico (TPA Plan) using orthopedicplanning software, (2) to compare the postoperative TPA inclinical cases executed according to the Oxley mCCWO guide-lines to the in silico planned outcome, and (3) to determinethe effect of distalizing the ostectomy in silico on TPAPlan.The hypotheses were that: (1) the TPA Plan wouldachieve the desired 5/C14TPA, (2) there would be no differ-ence between the TPA Planand TPA Post, and (3) a moredistal ostectomy would be subject to greater TLAS andthe resulting TPA would be under-corrected.

Answer 46

Pain assessment in cats is notoriously challenging for veterinarians as a result of the intrinsic characteristics of this animal species.During the past decade, a number of methods, the majority of which are based on behavioural observa-tions, have been developed, refined and validated with the purpose of quantifying pain and analgesia in feline patients.1–15 Of these, the Glasgow Feline Composite Measure Pain Scale (CMPS – Feline), the Colorado State University Feline Acute Pain Scale (CSU – FAPS) and the Feline Grimace Scale (FGS) are often regarded as user-friendly, reliable and useful in the clinical setting.15–18 The CMPS – Feline has been validated for post-surgical pain as well as for other pain syndromes, including trauma, and the findings of a recent report suggest that training may not even be necessary for the users to obtain reliable results.16,19 The FGS was initially validated in a cohort of cats mostly affected by abdominal pain, but it may be used in the clinical setting to assess acute pain resulting from various conditions.7,8 The CSU – FAPS is currently in the process of initial validation, with promising results and is particularly appreciated for its ease of use and vis -ual impact, and because it is potentially quicker to apply than other scales in a clinical setting.17 Recent research appears to support the use of these scales and suggests that they are reliable and may be used by clinical person -nel with different backgrounds.18,19Despite their clinical usefulness, one potential intrinsic limitation of behavioural pain scales is a certain degree of subjectivity depending on the individual assessor and on their level of expertise in pain assessment.The present study aimed to evaluate the inter-observer reliability of three feline pain scales commonly used in clinical practice.It was hypothesised that the three scales would show a fair to moderate level of agreement between assessors with different background and level of expertise in pain assessment, namely a board-certified veterinary anaes-thetist, a veterinary anaesthesia nurse and a final-year veterinary student.

Answer 47

Tibial plateau leveling osteotomy (TPLO) is a commonprocedure intended to neutralize cranial tibial thrust dur-ing the stance phase of gait in dogs with cranial cruciateligament (CCL) disease.1–4However, TPLO is associatedwith an increased risk of surgical site infections (SSIs)compared to other clean procedures, with incidencesAbbreviations: 95% CI, 95% confidence interval; ACVS, Americancollege of veterinary surgeons; CCL, Cranial cruciate ligament; CDC,Centers for disease control and prevention; EPS, Extracellular polymericsubstances; Kg, kilogram; MRSP, Methicillin resistant Staphylococcuspseudintermedius ; n, number; OR, Odds ratio; SSI, Surgical siteinfection; Std Dev or SD, Standard deviation; TPLO, Tibial plateauleveling osteotomy.Received: 10 July 2023 Revised: 3 October 2023 Accepted: 18 October 2023DOI: 10.1111/vsu.14050Veterinary Surgery. 2024;53:167 –174. wileyonlinelibrary.com/journal/vsu © 2023 The American College of Veterinary Surgeons. 167ranging from 0.8% to 15.8%.2–10While superficial TPLOSSIs may be successfully treated with antibiotic therapy,deep surgical site infections (implant-adjacent infections)often require implant removal for resolution due to thedevelopment of biofilms.1,4,5,8,11In addition to patientmorbidity, there is also a substantial financial cost associ-ated with treating TPLO SSIs. In 2014, Nicoll et al.reported the average cost of treating a TPLO SSI was$1559 and that $9.6 –$15.9 million were spent on the reso-lution of TPLO SSIs annually in the United States.4To reduce TPLO SSI rates, veterinary surgeons havereported the use of routine prophylactic antibiotics follow-ing TPLO. Some studies have found a decreased incidenceof SSI following TPLO surgery where prophylactic antibi-otics were used postoperatively,1–3,5,6,9,10,12 –17while othershave disputed this practice as not changing the incidence ofSSI.1,2,14,17The impact of administering prophylactic antibi-otics on bacterial resistance is of concern.18As an alterna-tive to routine antibiotic prophylaxis in human patients atrisk for implant infections, a nonantibiotic, antisepticlavage (Bactisure Wound Lavage solution, Next ScienceLtd, Jacksonville, Florida; distributed by Zimmer Biomet)consisting of acetic acid, ethanol, sodium acetate, benzalko-nium chloride, and water was developed for local adminis-tration after implant placement and before the closure ofthe surgical site with suture.19–21The antiseptic lavage iscompatible with orthopedic implants, is effective againstbiofilms and resistant bacteria, and reduces local biobur-den, with a reported 99.98% decrease in bacteria and 38%decrease in postoperative periprosthetic infection rate inpatients undergoing revision fo r total knee arthroplasty in aclinical trial.19–22The human product was adapted for vet-erinary medicine in 2019 (Simini Protect, Simini Technolo-gies, Whitby, Ontario, Canada).19The objective of this study w as to determine if the useof preclosure antiseptic lavage prior to TPLO wound closurewould decrease the cumulative TPLO SSI incidence to <5%when compared to use of traditional saline irrigation tech-niques. The hypothesis was that dogs receiving preclosureantiseptic lavage prior to TPLO wound closure would havea cumulative SSI incidence of less than 5% compared toTPLO wounds irrigated with saline prior to closure.

Answer 48

A challenge of the immediate postoperative period ismaintaining adequate analgesia as veterinary patients aretransitioned from hospital to home care. FDA-approvedoral nonsteroidal anti-inflammatory drugs (NSAIDs) arecommonly used for analgesia during this period.1For dogs that are not NSAID candidates,2–4oral narcoticsand other analgesics such as tramadol and gabapentin, aswell as lidocaine patches are available, but evidence oftheir efficacy in controlling acute postoperative pain islacking.5–13There is evidence for fentanyl patches provid-ing sustained postoperative analgesia in dogs14–16butdrawbacks include a delay of about 12 –24 h to reach ther-apeutic plasma concentrations, variability in systemicabsorption,17the possibility of overdose with oral trans-mucosal or enteral absorption,18,19and the risk of acci-dental or intentional misuse by humans.20,21The need for safe and well-tolerated analgesic prod-ucts for postoperative pain relief in humans and animalshas led to the development of FDA-approved liposomalbupivacaine (LB) products that provide extended releaseof local anesthetic into infiltrated tissues.22,23The efficacyof LB in reducing pain scores and opioid consumption inpeople recovering from surgery was evaluated in a 2021systematic review of 63 randomized clinical trials (RCTs).LB did not significantly reduce pain scores comparedwith placebo, standard bupivacaine or nonbupivacaineanalgesic agent in 74.58% of studies measuring pain. LBfailed to reduce postoperative opioid consumption in85.71% of studies evaluating opioid use.24In dogs, an FDA approved product (Nocita; ElancoAnimal Health, Greenfield, Indiana) has beenapproved for a single dose by infiltration injection atthe time of incisional closure of cranial cruciate liga-ment surgery, including tibial plateau leveling osteot-omy (TPLO) and other procedures.23The analgesicefficacy of single-dose surgical site infiltration with thisLB product has been reported in two clinical trials. Thefirst concluded that dogs rece iving a lateral retinacularsuture placement were less likely to require rescueanalgesia after LB use when the Glasgow CompositeMeasure Pain Scale (CMPS-SF) was used as a subjec-tive pain score.25,26A second study27also found that rescue analgesiaand opioid consumption were less in dogs administeredLB after receiving a TPLO. This study used the ColoradoState University Canine Acute Pain Scale (CSU-CAPS),28in addition to CMPS-SF and pressure nociceptive thresh-old measurements to assess analgesia. No differenceswere found in CMPS-SF, CSU-CAPS or nociceptivethresholds between treatment groups at any time point.27This study reported no financial conflicts of interest.Further exploration of an objective outcome measureof acute postoperative orthopedic pain is warranted. Anemerging objective measure of limb pain in dogs is %BWdist, the percentage of total bodyweight supported by agiven limb at a natural stance. Measurements of %BW disthave shown consistency over time, sensitivity to limblameness, and changes in limb use after TPLO and totalhip arthroplasty.29–35To our knowledge, no study hascompared %BW distwith subjective pain scores in dogs.As TPLO is one of the most commonly performedorthopedic procedures performed in dogs, finding a posi-tive treatment effect of LB in dogs recovering from TPLOcould benefit many animals. Conversely, finding a nega-tive treatment effect could eliminate unnecessary clientexpenses. To date, there are no reported randomized,placebo-controlled, masked clinical trials that evaluatethe efficacy of LB in dogs undergoing TPLO.The prospective study reported here was conducted tocompare pain assessments of client-owned dogs for 48 hafter undergoing TPLO between dogs receiving postopera-tive carprofen and a single-dose tissue infiltration with LB(treatment group) and those rece iving postoperative carpro-fen and infiltration with saline placebo (control group).Outcomes to be compared between groups includedCMPS-SF pain scores, the need for rescue analgesia, thenumber of rescue opioid doses, and %BWdiston the affectedlimb. A secondary objective was to describe the statisticalrelationship between CMPS-SF pain scores and %BW dist.The null hypotheses was that no significant differencewould exist between the treatment and control group forany of the outcome measures and that no meaningful sta-tistical relationship would exist between %BWdistandCMPS-SF pain scores.

Answer 49

Brachycephalic obstructive airway syndrome (BOAS) is a debili -tating and progressive disorder of the upper airways that affects brachycephalic dogs and impairs their wellbeing and life expec -tancy (Riecks et al. 2007 , Fasanella et al. 2010 , Dupré et al. 2012 ). Primary anatomical abnormalities of the skull and soft tissues of the head and secondary changes in the pharynx and larynx due to chronic negative intraluminal pressure restrict inspiration and expiration in brachycephalic dogs. In addition, a high incidence of gastrointestinal anomalies such as regurgitation and vomiting have been described in dogs affected by BOAS, both of which might contribute to an increase in the resistance to airflow and worsen upper airway disease (Poncet et al. 2005 ).Multiple surgical techniques and combinations of these have been previously described to alleviate components of upper air -way obstruction in dogs affected with BOAS and most authors report a favourable outcome and improvement of clinical signs after surgery (Poncet et al. 2006 , Riecks et al. 2007 , Fasanella et al. 2010 , Pohl et al. 2016 , Liu et al. 2017 , Seneviratne et al. 2020 ). While surgery may significantly improve the qual -ity of life of affected dogs, complications immediately follow -ing BOAS surgery have been reported in up to 29.5% of cases, including respiratory distress requiring anaesthetic induction and endotracheal re- intubation, temporary tracheostomy tube place -ment, aspiration pneumonia, respiratory arrest and death (Torrez & Hunt 2006 , Riecks et al. 2007 , Dunié- Mérigot et al. 2010 , Fasanella et al. 2010 , Lindsay et al. 2020 ).Anaesthetic recovery is a critical period after BOAS surgery since postoperative inflammation and respiratory depression result -ing from the residual effects of anaesthetic may lead to respiratory obstruction (Downing & Gibson 2018 ). In the postoperative period, anxiety and hyperthermia may be contributing factors for the devel -opment of regurgitation and respiratory distress which may aggra -vate airway collapse (Poncet et al. 2005 , Costa et al. 2020 , Fenner et al. 2020 , Debuigne & Chesnel 2021 , Appelgrein et al. 2022 ). Therefore, strategies to reduce stress and anxiety in dogs after BOAS surgery may be beneficial to minimise postoperative morbidity and reduce hospitalisation time (Downing & Gibson 2018 , Costa et al. 2020 ). Several studies have reported that the presence of the owner with the dog in hospital facilities can reduce the extent of the stress response of dogs under new situations (Mariti et al. 2013 , Lloyd 2017 , Mandese et al. 2021 ). In this context, a postoperative protocol in which the owner was present during patient recovery and the patient was discharged the same day as surgery, was estab -lished in 2018 at the author’s institution for brachycephalic dogs undergoing general anaesthesia and airway surgery.PubMed and Google Scholar and ScienceDirect databases were searched for the following keywords: “brachycephalic obstructive airway syndrome,” “brachycephalic,” “palatoplasty,” “pharyngoplasty,” “staphylectomy,” “sacculectomy,” “laryngeal collapse,” “rhinoplasty,” “alaplasty,” “ala- vestibuloplasty,” “upper airway surgery,” “soft palate” and “nares.” No reports describing the presence of the owner in the hospital after BOAS surgery were identified by these searches.The purpose of this study was to describe an owner- assisted recovery protocol and early discharge after BOAS surgery and report the outcomes and complications. The second objective was to compare the incidence of complications of this new pro -tocol with the traditional standard recovery and 24- hour hos -pitalisation after surgical correction of BOAS. We hypothesised that implementation of this protocol would be safe and would not increase the frequency of respiratory morbidity after BOAS surgery compared with the traditional recovery and 24- hour hos -pitalisation.

Answer 50

Brachycephalic obstructive airway syndrome (BOAS) iscomprised of a combination of upper respiratory ana-tomical abnormalities, prim arily including an elon-gated soft palate, stenotic n ares, hypoplastic trachea,redundant pharyngeal tissue, and aberrant nasalconchae.1–3Secondary changes associated with thissyndrome may also include everted laryngeal saccules,everted tonsils, laryngeal co llapse, pulmonary changes,and gastrointestinal (GI) signs.2–5Brachycephalicbreeds, most commonly English bulldogs, French bull-dogs, and Pugs are predisposed to these anatomicabnormalities due to their facial conformation.3,5,6Common clinical signs assoc iated with the anatomicalabnormalities of this syndrome include stertorousbreathing, stridor, exercise intolerance, collapse,and/or GI signs such as regurgitation and vomiting.1,4,5The severity of clinical signs depends on the degree ofairway obstruction due to any combination of BOASfeatures and can vary among dogs.7Elongated soft palates, wh ich can obstruct normalrespiration, have been reported as one of the morecommon BOAS features in multiple studies with aprevalence varying from 86% to 96% in brachycephalicbreeds.4,5,7As a result of breeding, brachycephaly, par-ticularly when the muzzle is less than 1/10th the cra-nial length with a subsequent lack of proportionatesoft tissue shortening, has been suggested as a primarycontributor to soft palate “elongation ”and thickness.6Staphylectomies (S) have historically been used toaddress soft palate elongat ion by shortening the cau-dal aspect of the soft palate; however, this techniqueonly addresses laryn geal obstruction.8Respiratoryobstruction can also occur due to nasopharyngeal andoropharyngeal obstruction associated with a thickersoft palate.8A folded flap palatoplasty (FFP) has beentheorized to address both shortening and thinning ofthe soft palate to provide respiratory relief within theupper respiratory tract.8This technique has been eval-u a t e di n5 5d o g sa sas a f ea n de f f i c i e n tc o r r e c t i v eoption for elongated soft palates of greater thickness.8However, the FFP has been reported to involve moretissue manipulation and longer surgical times.8No study in veterinary medicine has compared Sand FFP. Comparing S and FFP could help surgeons incase selection for each tech nique and determine if onetechnique may be superior for decreasing complica-tions and improving outcomes. The objective of thisstudy was to compare the prevalence of pre-, intra-,and postoperative variables and complications associ-ated with S and FFP.

Answer 51

| NO. 7Nontraumatic hemoabdomen or hemoperitoneum (NTH) is a common, life-threatening canine emergency. Dog owners are faced with the emotion -ally and financially demanding decision of whether to pursue urgent medical or surgical intervention despite an unknown underlying cause and often guarded prognosis.1 Common causes of NTH include benign or malignant intra-abdominal neoplasia, he -matoma, organ torsion, gastric dilatation-volvulus, and acquired or congenital coagulopathies.1–3 NTH due to organ torsion or coagulopathy is more quickly elucidated and can have a good long-term progno -sis with proper treatment; however, the majority of cases carry an uncertain diagnosis and prognosis at initial workup.1–3a.23.01.0014In the remaining cases, a bleeding abdominal mass is often suspected. Hemorrhage can originate from hepatic, renal, adrenal, prostatic, and retro -peritoneal masses, but most frequently occurs from splenic masses.3–5 Multiple studies have shown ma -lignant neoplasia is the most common cause of NTH in dogs, occurring at a rate of 68% to 87% compared with benign or nonneoplastic etiologies.2 Splenic hemangiosarcoma is identified in 63% to 70% of NTH cases and carries a poor long-term prognosis, with < 10% of dogs surviving 1 year.2,3,5A variety of point-of-care tests and advanced di -agnostics have been studied as negative prognostic indicators for NTH.5–11 Confidently reaching a diagno -sis prior to tissue acquisition is not currently feasible, JAVMA | JULY 2023 | VOL 261 | NO. 7 981and definitive diagnosis relies on histopathologic evaluation.1,2,6,12 Considering an uncertain prognosis at presentation and the prevalence of malignancy in NTH cases, ethically and clinically sound treatment remains controversial and is ultimately guided by discussions between veterinarians and clients, which may vary greatly among individuals depending on clinical experience and personal biases.1–3,5,6,13A previous study12 of dogs with suspected neo -plastic hemoperitoneum that underwent surgery ex -plored factors influencing dog owners’ decision to pursue surgery, surgical complications, and patient quality of life (QOL) following discharge. However, a limitation of this study was selection for neoplastic hemoabdomen only, as the presence of neoplasia is typically unconfirmed when the decision to pursue surgery is made.1,12 A recent study13 illustrated that the rate of euthanasia of NTH cases is significantly impacted by veterinarian experience level, highlight -ing the influential role of veterinarian-client com -munication in this pivotal decision. To the authors’ knowledge, there have been no large retrospective studies evaluating owner perception and satisfac -tion of outcome in patients with NTH of benign and malignant causes whose owners elected immediate euthanasia, palliative care, or surgery.The primary objective of this study was to evalu -ate the factors that contribute to owner decision-mak -ing at the time of emergent presentation, owner sat -isfaction in relation to the decision made, and owner perception of the pet’s QOL before, during, and after treatment of dogs with NTH. Through investigation of these factors, evidence-based recommendations and expectations can be provided to inform and facilitate discussions with clients on treatment options for dogs with NTH.

Answer 52

Intracranial surgery has become more common in veteri-nary medicine with the increased availability of magneticresonance imaging (MRI) and computed tomography(CT).1Lesions in the middle fossa, including the piriformcortex, hippocampus, and rostral brainstem, are common.2The zygomatic arch and temporal muscle impedeventral extension of a standard lateral craniectomy and,thus, optimum access to the middle fossa. TheAbbreviations: ADC, apparent diffusion coefficient; CN, cranial nerve; CO 2, carbon dioxide; CT, computed tomography; DWI, diffusion-weightedimages; FLAIR, fluid attenuated inversion recovery; Inc, incoporated; Kg, kilograms; Mcg, micrograms; MMA, middle meningeal artery; Mg,milligrams; Min, minutes; MM, millimeters; MRI, magnetic resonance image; PaCO 2, partial pressure of carbon dioxide; PDS, polydioxanone; SIS,small intestine submucosa.An abstract of this paper was presented on November 2, 2018, at the Southeastern Veterinary Neurology Group (SEVEN) meeting in Athens, Georgia.Received: 5 September 2022 Revised: 14 February 2023 Accepted: 20 March 2023DOI: 10.1111/vsu.139591180 © 2023 American College of Veterinary Surgeons. Veterinary Surgery. 2023;52:1180 –1190. wileyonlinelibrary.com/journal/vsutranszygomaticapproach to intracranial surgery has beenapplied and modified in the last three decades in humanmedicine.3This technique provides excellent access tothe middle fossa and the cavernous sinus. In veterinarymedicine, a transzygomatic craniectomy has been used toremove trigeminal nerve sheath tumors.4A dorsalapproach, modified rostrotentorial transzygomatic cra-niectomy, has also been described.5However, a detaileddescription of the anatomy, surgical technique, includinglandmarks, limits of craniectomy window, complications,and outcomes associated with these approaches has notbeen published. The objectives of this study are to pro-vide a detailed description of the lateral, transzygomaticcraniectomy to access the middle fossa and rostral brain-stem, and to report the clinical application, outcome, andcomplications in three dogs.

Answer 53

The reciprocal mechanisms involved in urine stor -age and voiding in dogs are mediated by the hy -pogastric, pelvic, and pudendal nerves.1 Interverte -bral disk extrusion (IVDE) or ischemic myelopathy occurring cranial to the L7 spinal cord segment can result in disruption of supraspinal modulation with preservation of the sacral spinal cord segments.1 In these cases, the pelvic and pudendal nerves remain functional; therefore, the external urethral sphincter remains contracted and voluntary urination is not possible.2 This condition is often referred to as upper motor neuron bladder.2Tube cystostomy is effective for urinary outflow management in dogs with intervertebral disk extrusion and ischemic myelopathy cranial to the L3 spinal cord segment: 61 dogs (2018–2022)Tesheena R. Nash, MVetSurg*, and Giselle L. Hosgood, PhD, DACVSThe Animal Hospital, Murdoch University, Perth, WA, Australia*Corresponding author: Tesheena R. Nash ( tesheena.nash@murdoch.edu.au )Received June 28, 2023Accepted July 27, 2023doi.org/10.2460/javma.23.06.0347Techniques typically employed for managing up -per motor neuron bladder dysfunction in dogs with spinal cord injury include manual urinary bladder expression, intermittent urinary catheterization, and indwelling urinary catheterization.3–6 Previous stud -ies have reported a high residual urine volume with manual expression.7 Manual expression can be diffi -cult and cause discomfort in the dog, especially after recent surgery.3 Indwelling urinary catheterization is a simple technique that permits effective urine drain -age, but does not allow for assessment of conscious urination.3,8 As such, duration of treatment may be 2 inadvertently protracted. Intermittent catheteriza -tion does allow for assessment of conscious urina -tion, but can cause repeated trauma of urethral tis -sue and is not practical for female dogs.9Tube cystostomy is an effective urinary diver -sion technique associated with minimal morbidity and has been reported for use in both short-term and long-term management of various neurologic and obstructive urinary diseases.10–14 Tube cystos -tomy offers an alternative method of managing up -per motor neuron bladder in dogs following IVDE or ischemic myelopathy.The aim of this study was to report the appli -cation and owner experience of tube cystostomy in dogs with upper motor neuron urinary bladder dysfunction caused by IVDE or ischemic myelopa -thy cranial to the L3 spinal cord segment and to re -port complications associated with cystostomy tube management. Modifications in approach for place -ment in male dogs are als

Answer 54

Pathology of the biceps tendon (BT) is a common cause of forelimb lameness in active dogs.1–4 Sy-novitis of the BT sheath (tenosynovitis) can arise from primary BT pathology or other morbidities such as supraspinatus tendinopathy or the enlargement and encroachment of this muscle into the bicipital groove, resulting in BT impingement.1,4,5a.23.08.0461©AVMAPublished treatments of BT pathology have pre -dominantly focused on transection of the tendon, with or without tenodesis.6–10 Surgical approach can be via arthrot -omy, arthroscopy, or a percutaneous or incisionless ap -proach.7,8,11,12 Although transecting the BT may improve comfort, it also alters normal anatomy and biomechanics; a transected BT no longer spans the glenohumeral joint, 2 resulting in a loss of the biceps brachii muscle’s role in shoulder extension and stabilization.1,3,4,8,9,13Many researchers recommend attempting conser -vative treatment (CTx) of the BT first, proceeding to surgery only if CTx fails.1,2,7,14 However, definitions of what constitutes appropriate CTx are absent and the CTx protocols described in some papers and textbook chapters are of questionable adequacy. For example, 1 researcher prescribed oral NSAIDs and exercise re -striction for 2 weeks before progressing to surgery.7 Other researchers simply advocate a “just cut ’em all” approach, arguing against CTx completely.15Historically, specialist treatment of orthopedic in -juries, by either conservative or surgical means, has fallen under the domain of board-certified veterinary surgeons (VS). The recognition of board-certified specialty status in sports medicine and rehabilitation (VSMR) has brought a new and potentially different perspective on whether surgery is required to treat biceps pathology and/or what constitutes an appro -priate CTx program. Some individuals possess board-certified designation in both surgery and VSMR. Such individuals are referred to as double boarded (DB).The advent of rehabilitation certification pro -grams (designations CCRT or CCRP) is also new and can be used to determine whether veterinarians possess additional rehabilitation education but not boarded specialty status. Henceforth, board-certi -fied VSMR specialists and nonspecialist veterinar -ians with CCRT or CCRP certification will herein be referred to collectively as rehabilitation therapists (RTh). Rehabilitation certification programs without the designation CCRT or CCRP are not included with -in the above RTh designation in the current study.The purpose of this research was to determine whether there is in fact a difference in therapeutic approaches between VS, RTh, and DB when treat -ing BT disease. This information can be used to de -termine whether consensus opinion exists on how to best treat this condition. Such consensus agreement can be used to accomplish the secondary goal of this paper, which was to provide a framework on how to best treat various manifestations of BT pathology.We hypothesized that, compared to RTh, VS would attribute less significance to the BT’s role in providing shoulder stability, be more likely to ad -vocate surgery as a first-line therapeutic approach, and be less optimistic when prognosticating the out -comes of CTx. Furthermore, we hypothesized that there would be significant differences between VS and RTh in the application of a CTx program. Finally, we hypothesized that DB opinions would fall some -where between those

Answer 55

Cervical disc extrusion or protrusion accounts for 14%-25% of cases of intervertebral disc disease in dogs.1,2Theventral slot procedure is the conventional surgicalmethod used for spinal cord decompression associatedwith cervical intervertebral disc disease.1,3Reduction ofiatrogenic tissue damage is an important principle in sur-gery, and minimally invasive surgery was developed forthis purpose.4In human medicine, the use of minimallyinvasive spine surgery (MISS) in cervical, thoracolumbar,and lumbosacral procedures has been increasing rapidlysince the end of the 20th century.4However, it is notwidely used for vertebral column disorders in veterinaryReceived: 19 April 2022 Revised: 9 November 2022 Accepted: 6 February 2023DOI: 10.1111/vsu.139451158 © 2023 The American College of Veterinary Surgeons. Veterinary Surgery. 2023;52:1158 –1170. wileyonlinelibrary.com/journal/vsumedicine, and experimental reports and applications arerare.5–7In the cervical region, ventral slot decompression hasbeen performed using a minimally invasive device withvideo assistance in cadaveric dogs and in 10 clinicalcases.8Spinal cord visualization using a video telescopeoperating monitor has also been improved.9Althoughthe surgical methods and approaches for MISS in smallanimals have been improved through various studies, theproblems and limitations of MISS persist for each region.In the cervical region, care must be taken not to injureimportant structures (eg, trachea, esophagus, jugularvein, carotid artery, recurrent laryngeal nerve, and vago-sympathetic trunk) when accessing the ventral aspect ofthe cervical vertebral column using intramuscular orintermuscular techniques. Instruments must be managedcarefully during placement when percutaneous equip-ment is used.5During application of MISS for ventral slot decom-pression using endoscopic instruments, drilling can dam-age the venous sinus or cause bleeding if instruments aretilted from the midsagittal plane.8Drilling at a safe anglein relation to the venous sinus can be difficult whenusing video-assisted ventral slot techniques where thesurgical field of view is limited.To overcome these limitations, we produced a3-dimensionally (3D)-printed custom endoscopy port(3DEP) using computer-aided design and 3D printingtechnology. Veterinary neurosurgery studies found thatplacement of screws and implants in the spine can beperformed safely using various 3D-printed guides.10–15Toour knowledge, there are no studies of the use of a 3DEPfor minimally invasive cervical ventral slot (MICVS)decompression in dogs. This study aimed to evaluate theaccuracy of a 3DEP used for MICVS decompression incadaveric dogs.

Answer 56

Cranial cruciate ligament (CCL) disease is one of the most common etiologies of pelvic limb lameness in canines.1 Cranial cruciate ligament disease can be surgically managed in a variety of ways; however, a recent survey2 of veterinary surgeons suggests tib -ial plateau leveling osteotomy (TPLO) to be the fa -vored technique.2 This procedure, as first outlined by Slocum and Slocum,3 has the goal of neutralizing cranial tibial thrust experienced during pelvic limb weight bearing by leveling the tibial plateau via a ra -dial osteotomy. The segments are subsequently sta -a.23.07.0379©AVMAbilized to maintain the new tibial plateau angle (TPA) via a TPLO plate and screws.Correlation between increasing patient body weight and increased complication rates of TPLOs has been reported.4,5 One report4 described that for every 4.5-kg increase in body weight, the OR of postoperative complications increased by 1.10. The mean weight of the 9 dogs in the cited study that experienced implant failure or tibial fracture was greater than the cohort as a whole. Correlation be -tween patient body weight and the risk of surgical 2 site infection (SSI) following TPLO has also been in -vestigated in numerous retrospective studies5–7 with conflicting results; however, a prospective study8 comparing postoperative antibiotic use with use of a placebo showed a significant association between risk of SSI and increasing patient size.Change in TPA during the convalescent period following TPLO has been reported in dogs.9 The clini -cal consequences of change in TPA during convales -cence following TPLO have not been rigorously de -scribed in the literature; however, an increase in TPA at recheck evaluation has been associated with an increased risk of tibial tuberosity fracture following TPLO.10 Different stabilization systems for manage -ment of TPLO patients > 50 kg have been described in the literature, including double plating. Double plating involves the addition of a second plate on the proximal tibia, caudal to the TPLO plate, to pro -mote rigid fixation of the osteotomy and decrease the risks of increasing TPA and micromotion at the osteotomy.4,11,12 An abstract13 on the use of a single locking 3.5-mm jumbo TPLO plate for stabilization following TPLO reports a major complication rate of 20% (approx 3/14) and minor complication rate of 6% (1/14). There was no statistical change in TPA when comparing immediate postoperative and 6 week postoperative values.Kowaleski et al14 evaluated the short-term clini -cal performance of an anatomically precontoured locking plate in dogs undergoing TPLO. In that case series, intraoperative complications were reported in 4 of 56 (7.1%) patients, minor postoperative compli -cations were reported in 3 of 56 (5.4%) patients, and no major or catastrophic postoperative complica -tions were noted. Their patient population addition -ally showed a median bone healing score of 4/4 (a qualification of 4 describing excellent union with > 75% healing). The mean change in TPA throughout the convalescent period within the series was 0.15 ± 1.32°. This led the authors to conclude that the investigated plate revealed reliably excellent bone union, minimal change in TPA, and a relatively lower complication rate than previously reported.14The objective of the present study was to evalu -ate the effectiveness of a single locking 3.5/4.0-mm jumbo TPLO plate in maintaining the postoperative TPA in dogs weighing > 50 kg. A secondary objective was to evaluate the postoperative bone healing scores and complication rates associated with the use of this implant in comparison with the recent literature.4,14,15 It was hypothesized that the implementation of this sys -tem in TPLO patients > 50 kg would prevent secondary loss of reduction and therefore preserve postoperative TPA. It was additionally hypothesized that the bone healing scores and complication rates would be com -parable to those of the published liter

Answer 57

Spinal instability is a common cause of neurologicdysfunction and pain in the canine population and canoccur secondary to a variety of conditions.1–8Surgical stabi-lization of the spine is indicated in dogs with evidence ofvertebral column instabilit y with or without spinal cordcompression, severe and/or progressive pain, and progres-sive neurologic dysfunction d uring conservative manage-ment efforts. Several surgical techniques for spinal columnstabilization have been described, with pin or screw andpolymethyl methacrylate (PMMA) constructs being themost common.1,9–15When performing sp inal stabilization,t h eu n i q u ea n a t o m i c a ln a t u r eo fv e r t e b r a ea n dt h e i ri n t i -mate association with the neurovascular structures presentsignificant surgical challeng es and introduce the potentialfor life-threatening complications.16Considering the anatomical differences betweenhumans and canines, the extrapolation of these standardsto canine patients may be grossly inaccurate and warrantsfurther investigation. The implementation of intraoperativenavigation techniques, such as computer-assisted surgery(CAS), and computed-tomography- (CT)-based computer-assisted design (CAD) and manufacturing (CAM) technolo-gies in human spinal surgery has seen considerable growthover the years.17–34Computer-based CAD/CAM technol-ogy, such as three-dimensional printing (3DP), as it per-tains to spinal surgery is a multistep process by whichadvanced diagnostic imaging (e.g., CT) files from an indi-vidual patient are used to manufacture a patient-specificdrill guide template, which is then used intraoperativelyfor placement of implants within predetermined areas.34–38Computed-tomography-based CAD/CAM technology forthe development of patient-specific drill guides has beenshown to have increased accuracy and safety during verte-bral implant placement in humans when compared to theconventional freehand technique.25,35,38The use of 3D-printed guides in a variety of applicationsto the canine spine has been previously reported, both in aclinical setting and in cadavers , and is associated with a veryhigh degree of accuracy39–51However, in many of thesestudies, implant placement was performed by only one ortwo surgeons with experience in spinal stabilization. Theo b j e c t i v eo ft h i ss t u d yw a st oc o m p a r et h ep l a c e m e n to fv e r -tebral implants between patient-specific drill guides and thefreehand technique in surgeons with varying levels of expe-rience. We hypothesized that the use of CT-based patient-specific vertebral drill guides would result in a higher pro-portion of bicortical implants with acceptable placement int h ec a n i n ec a d a v e r i cs p i n ei nc o m p a r i s o nw i t ht h ec o n v e n -tional freehand technique, regardless of skill set.

Answer 58

Gastrointestinal surgery in s mall animals is very common.1Gastrointestinal obstruction with foreign material is themost common indication for a gastrotomy, an enterotomy,an enterectomy, or a combination of those procedures.Those surgeries are traditionally performed with conven-tional absorbable sutures.1,2The most devastating complica-tion of full-thickness gastroint estinal surgery is incisionaldehiscence resulting in septic peritonitis.Received: 22 November 2022 Revised: 26 April 2023 Accepted: 29 May 2023DOI: 10.1111/vsu.13978Veterinary Surgery. 2023;52:1009 –1014. wileyonlinelibrary.com/journal/vsu © 2023 American College of Veterinary Surgeons. 1009Surgical techniques have been improved, leading todecreased risk of leakage and dehiscence, and risk fac-tors have been identified for a more informed case prog-nosis in the postoperative period.3–8In the last decade,stapling equipment has been used with or without over-sewing the staple line to accomplish a side-to-side anas-tomosis of the intestine.9–14Stapling equipment hasbeen associated with lower rates of postoperative dehis-cence, and lower rates of dehiscence when septic perito-nitis is present before surgery.11Unidirectional barbed sutures are self-anchoringsutures that do not require knot tying at the end of anysimple continuous pattern. These sutures have mostlybeen used during minimally invasive surgery in humansand dogs.15–25Bautista et al.25reported the successful uti-lization of unidirectional barbed sutures during laparo-scopic gastrointestinal surgeries in 50 human patientswith a 1.6% rate of postoperative leakage on 62 anasto-motic sites. In an ex vivo study using a canine cadavericintestine, a higher leakage pressure after enterectomyoccurred when compared with a traditional smoothsuture.26Ehrhart et al.27have demonstrated that unidi-rectional barbed sutures were not associated with anincreased risk of leakage and dehiscence in the intestineof dogs without pathology present. Unidirectional barbedsutures have been shown to reduce surgical and anesthe-sia time and have no knot-related complications.28–31The purpose of this study is to report the clinical out-come of gastrointestinal surgeries completed with unidi-rectional barbed sutures for client-owned dogs and cats.

Answer 59

Surgical site infection (SSI) is the most commonly reportedcomplication following humeral intracondylar ﬁssure surgi-cal management.1–6Despite the high prevalence of SSIfollowing humeral intracondylar ﬁssure surgery, a notablevariability between studies has been observed, with someauthors documenting no postoperative SSI7–9and othersrecording SSI rates ranging between 5 and 42%.1–6,10,11Insome of these studies, the incidence of SSI considerablyexceeds the average reported SSI rates associated with othercommonly performed clean, elective orthopaedic surgeriesin the dog (1.3 –11%).12–15Possible risk factors for the higher incidence of SSI follow-ing prophylactic transcondylar bone screw placement for theical management of humeral intracondylar ﬁssure indogs include the direction of placement of the transcondylarscrew (medial-to-lateral vs. lateral-to-medial),2the inser-tion of a transcondylar screw in lag or position fashion andthe body weight of the patient.1The possibility that thesurgical approach might in ﬂuence the incidence of postop-erative SSI was highlighted by Moores and colleagues2whoreported a lower incidence of infection when the trans-condylar screw was placed from medial to lateral. Thisidea has since been adopted and described by otherauthors,4–6but the reason(s) for this apparent differencehave only been assumed. Possible explanations include (1)the sparse soft tissue coverage of the lateral aspect of theelbow and (2) the constant direct contact with the ground ofthe lateral elbow when the patient is recumbent.3,16Con-versely, fracture repair of the lateral portion of the humeralcondyle is commonly performed using a surgical incisionthat closely matches that used for humeral intracondylarﬁssure screw placement. If the above proposed mechanismshold true, then surgical infection rates following lateral distalhumeral condylar fracture repair might be expected to besimilar to those of lateromedial transcondylar screw place-ment for humeral intracondylar ﬁssure. This is not supportedby our experience nor the outcomes of previously publisheddata, which document 617and 13%18SSI rates followingﬁxation of an overall number of 201 lateral humeral condylarfractures.Although several studies have reported a lower complica-tion rate when placing a screw in a mediolateral direction(including lower SSI),4–6,10there have been no studies di-rectly comparing SSI between mediolaterally and laterome-dially placed screws for humeral intracondylar ﬁssure since2014. In addition, Moores and colleagues2had low casenumbers of each (8 cases lateromedial transcondylar screwand 6 cases mediolateral transcondylar screw). Drilling thehumeral condyle from a mediolateral direction has beenlinked, in a previous cadaveric study, with a higher chance ofinadvertently entering the elbow joint,19and this risk needsto be balanced by bene ﬁt. Our study aimed to document andcompare the postoperative SSI rates between placement of alateromedial and a mediolateral transcondylar screw for thesurgical management of canine humeral intracondylar ﬁs-sure. The hypothesis of the study was that the direction inwhich the transcondylar screw was inserted would notinﬂuence the incidence of postoperative SSI.

Answer 60

Clinical metrology instruments (CMI), also called owner-reported outcome measures, are a sequence of questionsthat are scored based on owners ’observations regardingtheir pets ’health status. The cumulative score provides theclinician with information on limb function, pain, and theirquality of life. Repeated use can be used to monitor diseaseprogression and assess response to medical and surgicalinterventions.1–3While kinetic and kinematic gait analysesare considered by many as the gold standard of quantitatingne limb function,4–6use of validated CMI is cost-effec-tive, reliable, less time-consuming, and does not requirespecialized equipment. In addition, CMI aim to capture theoverall clinical picture as perceived by the observer and canbe used for cases that present with single- or multilimblameness. On the contrary, objective gait analysis is best usedfor assessment of single-limb lameness as symmetry indexvalues may be unreliable when both of the thoracic or pelviclimbs of a dog are abnormal.7Several CMI have been reported for evaluation of canineosteoarthritis,1,3,8 –12with the Liverpool Osteoarthritis in Dogs(LOAD) and the Canine Brief Pain Inventory (CBPI) question-naires being among the most frequently used. Although theCBPI is a validated CMI, a study has shown that its two-factorstructure is not ideally suited to measure owner-perceivedpain related to osteoarthritis.13Both the aforementioned CMIhave only been validated for contemporaneous use.11,14Forretrospective studies, contemporaneous CMI data may not beavailable, so retrospective collection of CMI data may provide asolution to complete missing datasets. In such a scenario,owners would be asked to complete a CMI recalling theirdog ’s preintervention status. CMIs have been used to retro-spectively complete preoperative datasets for total hipreplacement, total elbow replacement, cruciate disease, andsurgical correction of angular limb deformity in dogs.15–19Astudy using this methodology may be susceptible to recallbias.20Recall bias is a particular concern in studies where dataare collected retrospectively and is de ﬁned as a systematicerror in the accuracy or completeness of the recollections by astudy participant regarding events or experiences from thepast.21,22This bias could lead to either overestimation orunderestimation of the preintervention status.23–29In compa-rable human research, questionnaires that were completedretrospectively by patients following lumbar spinal or totaljoint replacement surgery showed that patients overestimatetheir preoperative status.23,24Overestimation of preoperativestatus could inaccurately improve intervention success ratesand reduce the accuracy and even the validity of the conclu-sions made.23,25The susceptibilityof the LOAD and CBPI CMI torecall bias is unknown. Therefore, the primary objective of thisstudy was to determine if owners can accurately recall theirdog ’s pretreatment status using the LOAD and CBPI question-naires at prede ﬁned time points following their ﬁrst consulta-tion. A secondary objective of the study was to identify factorsimpacting owners ’recollection of their dogs ’pretreatmentstatus. We hypothesized that the agreement between theactual and recalled pretreatment scores would be poor, basedon previous human data.

Answer 61

646 JAVMA | NOVEMBER 2023 | VOL 261 | NO. 11Splenopathies in cats are uncommonly diag -nosed, with a prevalence estimated at 5%, and include primary and metastatic neoplasia, nodu -lar hyperplasia, hematomas, ischemic obstruction and splenitis, among others.1–4 Splenic diseases are typically identified by abdominal palpation and diagnosed with abdominal imaging followed by ultrasound-guided cytology or biopsy.5,6 Even though cytologic and histopathologic agreement for splenic lesions is reported to be between 59% to 100% in dogs and cats, those studies contained Prevalence of malignancy and factors affecting outcome of cats undergoing splenectomyMatteo Rossanese, MSc, DVM, DECVS, MRCVS1; Heather Williams, BVSc, MSc, MVetMed, MRCVS2; Benito de la Puerta, DVM, DECVS, MRCVS3; Peter Scott, BVSc, MRCVS4; Guillaume Chanoit, DEDV, PhD, DECVS, DACVS, FRCVS4; Alexandra Guillén, DVM, DECVIM-CA, MRCVS1*1The Royal Veterinary College Department of Clinical Science and Services, Hatfield, England2Small Animal Teaching Hospital of the University of Liverpool, Neston, England3North Down Specialist Referrals, Bletchingley, England4Small Animal Referral Hospital Langford Vets, University of Bristol, Bristol, England*Corresponding author: Dr. Guillén ( aguillen@rvc.ac.uk )Received May 23, 2023Accepted July 12, 2023doi.org/10.2460/javma.23.05.0258very small numbers of cats. This, together with the different prevalence of splenic diseases between these species, makes the true accuracy of cytol -ogy to diagnose feline splenopathies unknown.6–8The ultrasonographic appearance of the feline spleen is generally considered nonspecific9,10; how -ever, presence of a splenic mass > 1 cm in cats was suggestive of malignancy.7 In addition to these chal -lenges, changes in the splenic size and parenchyma can be incidental, associated with nonspecific clini -cal signs or due to systemic disease.7,9,10 JAVMA | NOVEMBER 2023 | VOL 261 | NO. 11 1647In dogs, splenic masses with or without associ -ated hemoabdomen, are the most common reason for splenectomy, with malignant lesions being diag -nosed in 48% to 76% of cases.5,11,12 Hemangiosarcoma (HSA) is the most common splenic tumor reported in dogs, but it appears to be less common in cats with a reported prevalence of 2% to 21%.4,10 Nevertheless, it accounts for 60% of all neoplasms of cats presenting with spontaneous hemoabdomen suggesting a link between malignancy and clinical presentation.13Splenic mast cell tumors (MCTs) were more prev -alent in a small group of cats undergoing splenec -tomy with or without hemoabdomen and accounted for 53% of all diagnosis followed by HSA (21%) and lymphoma (11%).4 When diagnosis was solely based on cytology lymphoproliferative diseases (ie, lym -phoma) were found to be the most common neo -plasm affecting the spleen,2,4 likely as part of multi -organ infiltration.10 Less often, histiocytic sarcoma, other sarcomas, myeloproliferative diseases and my -elolipomas can also be found.2,14–16In dogs undergoing splenectomy, anemia (PCV < 24%) and intraoperative arrythmias have been as -sociated with increased risk of perioperative death.17 Dogs with splenic HSA were significantly more likely to have preoperative anemia, lower mass to splenic volume ratio, lower splenic weight, hemoabdomen, thrombocytopenia, and to have received a blood transfusion, compared to dogs with other malignan -cies or benign lesions.18,19Risk factors for cats undergoing splenectomy have not been clearly defined. Weight loss, anorexia, mastocytemia, administration of a blood product, metastasis to regional lymph nodes and a concur -rent or historical neoplasia have inconsistently been reported as negative prognostic factors in cats un -dergoing splenectomy for MCTs.4,20–22The objectives of this study were: 1) to assess the prevalence of malignancy in cats undergoing splenectomy, and 2) to identify prognostic factors associated with outcome i

Answer 62

Coxofemoral injury and degenerative joint disease (DJD)are frequently diagnosed in cats.1–5Surgical treatment offeline hip disease, if indicated, is typically performed usingan open surgical approach. Arthroscopic surgery can offermultiple advantages over open surgery, including improvedvisualization of intra-articular structures,6–8decreased surgi-cal morbidity, and decreased postoperative pain.9–11The useof arthroscopy for diagnosis or treatment of intra-articularpathology has been reported in feline elbow,12shoulder,13and stifle joints14but a technique for arthroscopic examina-tion of the feline hip joint has yet to be described.Abbreviations: DAR, dorsal acetabular rim; DJD, degenerative jointdisease; ICI, iatrogenic cartilage injury; ROM, range of motion.Received: 10 June 2023 Accepted: 13 August 2023DOI: 10.1111/vsu.140191202 © 2023 The American College of Veterinary Surgeons. Veterinary Surgery. 2023;52:1202 –1208. wileyonlinelibrary.com/journal/vsuHip arthroscopy is used in dogs as a diagnostic toolto assess joint pathology, to assist with collection of rep-resentative intraarticular tissue samples, to assist withtoggle rod stabilization,15–17and to assist with fracturerepair5,10,18 –22Hip arthroscopy may have similar utilityin cats; however, small patient and joint size in compari-son to traditional arthroscope size makes arthroscopychallenging and may be associated with an increasedrisk of iatrogenic articular cartilage injury (ICI). Utiliza-tion of needle scopes in veterinary patients is becomingmore common and may increase feasibility and safety ofarthroscopy in small patien ts. Needle scopes are smallarthroscopes, typically between 1.0 –1.9 mm in diameterare often more flexible than traditional arthroscopesand are often disposable (but can typically be reusedmultiple times in veterinary patients). Needle arthros-copy for evaluation of the canine stifle,11shoulder23,24and elbow25joints has been described but, to date, hasnot been described for cats.The purpose of this study was to evaluate the feasibil-ity of feline diagnostic coxofemoral arthroscopy using aneedle scope, including determination of optimal limbposition for arthroscopy, determination of safe arthros-copy portal locations, documentation of visible intra-articular structures, assessment of periarticular tissueinjury associated with portal creation, and evaluation ofiatrogenic cartilage injury (ICI) associated witharthroscopy.

Answer 63

Extrahepatic biliary tract obstruction (EHBO) is a common problem in dogs. Causes can be divided into extraluminal (eg, pancreatitis, adjacent neoplasia), intraluminal (eg, cholelithiasis, inspissated bile), and intramural (eg, cholangitis, mucinous gallbladder, neoplasia) obstructions.1 EHBO due to pancreatitis is a well-recognized and serious complication in dogs, with variable recommendations made for either medical stabilization or surgical decompression.2–9 Obstructive jaundice has potentially multiple harmful effects both locally, with increased risk of bacterial cholangitis and hepatic injury, and systemically, secondary to the impact of endotoxemia on the cardiovascular, pulmonary, and coagulation systems; gastrointestinal integrity; and renal function.10–12 Surgical decompression of EHBO has historically been associated with increased mortality risk, with the largest case series showing a mortality rate of 28% and 53% for dogs undergoing extrahepatic biliary tract surgery irrespective of cause. A recent publication also suggested that some dogs do not require surgical decompression, with 79% of dogs surviving with medical management of EHBO due to pancreatitis. Treatment of EHBO in people varies according to cause and includes endoscopic retrograde cholangiopancreatography, endoscopic stent placement, and sphincterotomy,13–16 many of which are not readily available in veterinary medicine.6,17–20 The authors’ observations have been that while some dogs only require medical monitoring with EHBO due to pancreatitis, there is a subset that require surgical decompression and that this subset improves quickly postoperatively with few complications. With this in mind, the primary objective of this study was to describe the morbidity and mortality of dogs with EHBO due to pancreatitis treated medically or by surgical decompression. Additional objectives were to assess for markers, including the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) that may help with prognostication.

Answer 64

Elbow dysplasia is a common cause of thoracic limb lameness in dogs.1,2 Medial coronoid process dis -ease and elbow incongruity are 2 of the most frequent -ly diagnosed pathologies involved in this syndrome.1,3,4 These diseases are most commonly diagnosed in young, large-breed dogs. However, elbow incongru -ity can also affect small-breed dogs, particularly those that are chondrodystrophic.5Dynamic proximal ulnar osteotomy leads to rota -tion of the proximal segment that results in an improved radioulnar congruency and reduced focal contact at the level of the medial coronoid process.6–8 Proximal ulnar a.23.05.0232osteotomies have been recommended as a treatment for medial coronoid process disease in dogs with radial short -ening and in skeletally immature dogs and as a treatment for dogs with an ununited anconeal process.6,9–11 Use of a bi-oblique proximal ulnar osteotomy (PUO) has also been described in conjunction with osteochondral autograft transfer procedures of the medial humeral condyle and subtotal coronoid ostectomy to treat young dogs pre -senting with medial coronoid disease and concomitant osteochondritis dissecans lesions.12,13One of the challenges of a bi-oblique PUO is the propensity for excessive migration of the proximal 2 ulnar segment, which can lead to the development of several postoperative complications.9,14–17 Recent studies have focused on attempting to identify the po -sition and trajectory of the bi-oblique PUO that would reduce the risk of excessive migration of the proximal ulnar segment.7,8,14 One of these studies, to our knowl -edge, is the only study in the veterinary literature to analyze the effect of a bi-oblique PUO (as a treatment for medial compartment disease) performed by a sin -gle surgeon in a large cohort of dogs (120 elbows).14 This study reported an overall complication rate of 12% (all minor complications),14 with other studies report -ing similar findings in smaller cohorts of dogs.9,15–17 However, none of these studies analyzed the risk fac -tors involved in the development of complications fol -lowing proximal ulnar osteotomy. The objective of our study was to describe the complications experienced by different surgeons (at a single institution) after per -forming bi-oblique PUO in 82 dogs and to evaluate the risk factors associated with t

Answer 65

Total knee replacement (TKR) is recognized as an effec-tive treatment option for dogs with end-stage stifle dis-ease.1As in total hip replacement (THR), long-termclinical success in TKR depends on optimal implantpositioning and alignment to ensure appropriate boneingrowth –bone ongrowth and load transfer. Conven-tional planning for canine TKR is based on plain radio-graphs and the surgery is performed with the aid ofAbbreviations: 3D, 3-dimensional; CT, computed tomography; ETAG, extramedullary tibial alignment guide; FCB, femoral cutting block; PMMA,polymethyl methacrylate; PSG, patient-specific guide; STL, Standard Tessellation Language; THR, total hip replacement; TKR, total kneereplacement.Presented in part at the American College of Veterinary Surgeons Congress; October 12-15, 2022; Portland, Oregon.Received: 18 October 2022 Revised: 18 February 2023 Accepted: 2 April 2023DOI: 10.1111/vsu.13963674 © 2023 American College of Veterinary Surgeons. Veterinary Surgery. 2023;52:674 –685. wileyonlinelibrary.com/journal/vsugeneric cutting blocks/guides. This is the same approachas is used in human TKR, but questions remain as tohow accurate these generic TKR instruments are,2partic-ularly with respect to accurate alignment with themechanical axes of the femur and tibia.3It is widely rec-ognized in human TKR that component alignment is akey determinant of long-term implant survival,4and ithas been reported that up to 22% of primary TKR casesperformed using standard instrumentation have axialmalalignment of greater than 3 degrees.5Generic instru-mentation is also more challenging to use in knees withdeformities.5There is growing interest in the use of patient-specificguides (PSGs), designed from computed tomography(CT) scans of the patient's anatomy. Proposed advantagesof PSGs include greater accuracy in the bone cuts,reduced operative time and the ability to account forunique pathologies (especially deformity) that can com-plicate the use of generic cutting guides.3,6PSGs arebecoming more common in human orthopedics, includ-ing TKR surgery. PSGs simplify pin placement and thecreation of individualized bone cuts that correspond tothe patient's unique mechanical axis, in contrast withgeneric cutting guides that rely on average values fordetermining the mechanical axes of the femur and tibia.On the tibial side, PSGs can also avoid the need for place-ment of an intramedullary alignment rod, making theapproach less invasive for the patient.In veterinary medicine, the use of PSGs has garneredsignificant attention in the last few years, with potentialapplication in the correction of antebrachial growthdeformities,7–9the drilling of transcondylar screws inhumeral fractures and humeral intracondylar fissures,10atlanto-axial stabilization,11,12pedicle screw placement,13and femoral osteotomy.14There have been isolatedreports on the use of PSGs with custom canine and felineTKR implants,15,16but their utility and accuracy have notbeen evaluated in a systematic manner to date. Wehypothesized that PSGs would improve the surgeon'saccuracy in delivering the planned implant alignment inTKR surgery. The objective of this canine cadaveric studywas therefore to determine whether the use of PSGs incanine TKR increases the accuracy of femoral and tibialcut alignment, as compared with results obtained withthe use of generic cutting guides.

Answer 66

Gallbladder mucocele (GBM) is an increasingly rec -ognized biliary disease in dogs1–8 and is charac -terized by an accumulation of thick amorphous mu -cus in the gallbladder, possibly due to biliary stasis a.23.06.0305©The authorsand hypersecretion.9,10 Risk factors associated with GBM include hyperlipidemia,11 endocrinopathies such as hyperadrenocorticism and hypothyroid -ism,6,12,13 breeds such as the Shetland Sheepdog6,14,15 2 and Border Terrier,15,16 and hyperleptinemia.17 Dogs with GBM can present with a spectrum of illness ranging from subclinical to critically ill because of extrahepatic biliary obstruction, bile peritonitis, and systemic inflammatory response syndrome.1–5,7,8,14,18 Gallbladder mucocele and perforation can be diag -nosed with imaging methods such as abdominal ul -trasonography or CT and addressed surgically with a cholecystectomy. However, the average rate of postoperative mortality is approximately 20% (range, 7% to 45%).1–5,7,8,14,18,19 Given the high risk of mortal -ity and costs of surgery, it is important to identify prognostic indicators and predictors of postsurgical survival outcomes. Identification of such predictors could help triage patients, counsel pet owners, and strategize treatment approach.Dogs that survive 2 weeks postcholecystectomy have a good prognosis for long-term survival,2,3,19 and therefore identifying prognostic indicators of short-term survival is valuable. Attempts in vari -ous studies to identify such predictors have yielded conflicting results for clinical variables such as gall -bladder rupture,1,3,5,7,18,19 age,1,4,18,20 and presence of clinical signs20; laboratory variables such as serum creatinine, phosphorous, ALP activity, hyperbiliru -binemia, and postoperative lactate3,4,19,20; and in -traoperative nadir systolic blood pressure.4,21 These contradicting results justify further investigation of prognostic indicators of nonsurvival postcholecys -tectomy in dogs with GBM.Because the sequelae of GBM include complica -tions such as cholecystitis, gallbladder perforation, bile peritonitis, pancreatitis, acute kidney injury, extrahepatic biliary duct obstruction, and systemic inflammatory response syndrome,1–5,7,8,14,18,19 iden -tification of serum markers of inflammation might improve patient management and prediction of postsurgical complications and survival. Examples of such markers include C-reactive protein (CRP), hap -toglobin, and 25-hydroxyvitamin(OH)D (25[OH]D).CRP and haptoglobin are nonspecific positive acute phase proteins that increase in response to inflammatory stimuli22,23 and diseases such as acute pancreatitis,24,25 parvovirus,26 immune-mediated diseases,27 and neoplasia in dogs.28,29 CRP is a highly sensitive and moderately specific marker for gallbladder rupture in dogs with GBM undergoing cholecystectomy.30 Furthermore, in humans, higher CRP is an independent predictor of more advanced acute cholecystitis31 and surgical complexity.32 Thus, CRP and haptoglobin have the potential to be valuable markers of disease and surgical outcomes in dogs with GBM.Vitamin D is a steroid hormone that regulates calcium homeostasis but is also an indirect marker of inflammation.33,34 Decreased serum 25(OH)D con -centrations have been found in dogs with critical ill -ness,35 sepsis,35 and acute pancreatitis,36 and serum 25(OH)D concentrations have been correlated with illness severity (measured using acute patient physi -ologic and laboratory evaluation [APPLEFAST] scores)35 and nonsurvival.36 Decreased 25(OH)D concentrations have also been found in dogs with GBM,37 but the asso -ciation between 25(OH)D and survival postcholecys -tectomy has not yet been examined.The primary objective of this study was to exam -ine the association of several variables (APPLEFAST scores and serum concentrations of CRP, haptoglo -bin, and 25[OH]D) with survival to discharge and 2 weeks post–hospital discharge in dogs with GBM undergoing cholecystectomy. A secondary objec -tive was to determine whether dogs with GBM have higher serum CRP and haptoglobin concentrations compared to healthy control dogs. We hypothesized that variables such as gallbladder perforation, high -er APPLEFAST scores, higher CRP and haptoglobin concentrations, and lower 25(OH)D concentrations would be associated with nonsurvival in hospital and 2 weeks post–hospital discharge and that serum CRP and haptoglobin concentrations would be higher in dogs with GBM compared to

Answer 67

Feline vaginal neoplasia, either benign or malig -nant, is infrequently reported in the veterinary literature.1–4 Such reports include vaginal leio -myoma,1 vaginal adenocarcinoma,3 and vaginal polyp.4 Complete and subtotal vaginectomy are recognized surgical techniques for management of vaginal neoplasia in canine and feline patients.4–8 To date, there is limited literature describing and assessing the surgical approach for these pro -cedures. In dogs, reported techniques include a combined abdominal and vestibular approach,7 sagittal pubic osteotomy,9 and a combination of perineal, abdominal, and perivaginal approach.10 In conjunction with these approaches, and while not currently reported for resection of vaginal tu -a.23.05.0260©AVMAmors in dogs, a bilateral pubic and ischial osteoto -my for surgical management of caudal colonic and rectal masses has also been described.11 This tech -nique was reported to provide sufficient exposure for resection of intrapelvic tumors, with minimal complications. In feline patients, only a single case report4 of the use of a bilateral pubic and ischial osteotomy for resection of a benign vaginal tumor has been described.Due to the lack of reports in the literature, the aim of this case series was to describe the clinical signs, diagnostic findings, surgical treatment, and outcomes of 3 cats diagnosed with extensive vagi -nal masses. A second aim was to provide a detailed description of the surgical technique of a bilateral 2 pubic and ischial osteotomy, including documentation of intraoperative and postoperative

Answer 68

| NO. 10 1495The function of the cranial cruciate ligament (CCL) is to restrict cranial displacement of the tibia in relation to the femur, to limit internal tibial rotation during flexion, to counteract joint hyperextension, and to ensure the stability of the varus and valgus motion of the stifle joint.1 CCL rupture is among the most common orthopedic injuries in dogs, and it is the main cause of pelvic limb lameness in these patients.2 The etiopathogenesis of ligament insuf -ficiency or rupture can be traumatic, but in most cases, it is degenerative, and anatomical factors, in -cluding the tibial plateau angle and bone rotational deviations, are related to the condition.3 CCL rupture causes joint instability and changes the biomechani -cal mechanism of the stifle due to cranial tibial trans -lation, which triggers progressive osteoarthritis.4a.22.11.0528In dogs, CCL rupture is most commonly diag -nosed by means of specific orthopedic tests, such as the drawer test and the tibial compression (TC) test, both of which assess joint stability and promote crani -al tibial translation in relation to the femur if ligament insufficiency or rupture is present.5 Complementary imaging-based tests may prove helpful for diagnosis and are, in general, useful in preoperative planning, the evaluation of osteoarthritis, and the identification of concomitant affections.6 Cranial tibial translation detected by radiography is indicative of CCL rupture; however, it must be interpreted in association with clinical findings. Radiography performed under joint stress by means of TC might be more accurate in indi -cating CCL insufficiency or rupture.3,7 In mediolateral radiographic projections of the stifle, conventional 1496 JAVMA | OCTOBER 2023 | VOL 261 | NO. 10joint positioning and positioning under TC are strong indicators in the diagnosis of CCL rupture, which can also be used to assess the efficacy of treatment.3The aim of this study was to assess the specific quantitative parameters of cranial tibial translation that allow for a radiographic diagnosis of CCL rupture in dogs. A comparative analysis was conducted to assess the effect of TC in radiographs of the stifles of healthy adult dogs, adult dogs with CCL rupture, and healthy young dogs. The hypothesis was that dogs with liga -ment rupture exhibit significantly different values com -pared with those for healthy dogs in the analyses of radiographic images taken under TC. Furthermore, a novel variable was proposed for the quantitative diag -nosis of rupture: the ratio of the distance between the points of CCL origin and insertion, obtained from radio -graphs taken under TC and without TC.

Answer 69

Hip toggle stabilization (HTS) is one of the mostcommonly performed open techniques for managementof coxofemoral luxation in cats.1–5The goal of HTS isto maintain coxofemoral reduction until joint capsularhealing and periarticular fibrosis occur.6Long-term(>6 months) reluxation rates in retrospective studiesinvolving 48 and 14 cats treated with HTS was 11.1% and14.3%, respectively.1,5Excellent outcomes (no reluxationwith lameness resolution) of arthroscopic-assisted HTS(AA-HTS) were reported in 2 canine case reports with6 months follow-up.7,8As far as to the authors' knowledge,there are no descriptions of AA-HTS in cats.No peer-reviewed studies describe feline hip arthros-copy. In dogs, coxofemoral arthroscopy offers numerousadvantages over traditional open surgical techniques,including decreased postoperative pain and morbidity,increased visibility, and increased precision.9–12In catswith coxofemoral luxation, arthroscopy offers the poten-tial to assess damage to intra-articular structures anddebride the ligament of the head of the femur (LHF).13Study objectives were to (1) describe the technique ofAA-HTS in feline cadavers, (2) evaluate its feasibility andassociated rate of iatrogenic injury, and (3) evaluate forrate of deviations from preoperative planned surgical tech-nique. We hypothesized that AA-HTS would be (1) possibleto perform in all hips, (2) associated with no substantialdamage to intra-articular or extra-articular structures, and(3) associated with a low rate of techniq

Answer 70

Cranial cruciate ligament (CCL) disease is one of themost common causes of hindlimb lameness in dogs.1–3Acommon sequela to joint instability after CCL rupture ismedial meniscal injury.4–6Tears of the caudal horn of themedial meniscus exacerbate pain and loss of functionassociated with CCL rupture, making it essential for thesurgeon to accurately diagnose meniscal lesions to ensurethe best possible outcome of surgery.6,7Meniscal injuriesmay be present at the time of diagnosis or surgery, ordevelop subsequently (late meniscal injury). Rates varyfrom 20% –77% for concurrent meniscal lesions,7–11andlate meniscal injury is reported in 2% –22% of dogs follow-ing stabilization surgery.12–14Diagnosis of meniscal lesions typically relies on directinvasive visualization with either arthrotomy or arthros-copy, with associated morbidity.15,16A canine cadaverstudy identified iatrogenic cartilage lesions in 13/14 sti-fles following arthroscopy and 4/14 following mini-medial arthrotomy, with larger lesions in the arthro-scopic cases.17A review of human arthroscopic videosfound an incidence of iatrogenic lesions of 74%, and sig-nificant cartilage cell death in a bovine model simulatingthese lesions.18These authors found it plausible that iat-rogenic lesions could contribute to pain, inflammationand osteoarthritis progression, especially in prediseasedjoints in which the cartilage may be more sensitive todamage.18Noninvasive alternatives currently describedinclude ultrasonography, MRI and positive-contrast com-puted tomographic arthrography (CTA), predominantlyusing single-detector technology.10,19 –25Definition ofsoft-tissue structures of the canine stifle, including themenisci, is possible using single-detector CTA, eventhough single-detector technology limits image resolu-tion, especially for multiplanar reconstruction, whichnegatively impacts diagnostic accuracy.22–24In humans,multidetector CTA has been shown to have excellentdiagnostic value in evaluating menisci,26and similartechnology is now available in veterinary referral centersand larger hospitals.Where test sensitivity for CTA represents the abilityof screening to correctly identify dogs with meniscallesions from the population of dogs known to have ameniscal lesion, the positive likelihood ratio reflectschange in odds of a dog having a meniscal lesion given apositive CTA result. Conversely, specificity for CTA rep-resents the ability of screening to correctly identify dogswithout meniscal lesions from the population of dogsknown to be disease-free: the negative likelihood ratioindicates the change in odds of a dog having a meniscallesion given a negative CTA result.27For a test to be use-ful, the sum of sensitivity and specificity should exceed1.5.28How informative a test is, depends on how far thelikelihood ratios are from 1.0, indicating no change inodds. A positive value ≥10 or a negative value ≤0.1 pro-duce large and likely conclusive changes in pretest proba-bility of disease, whereas values ≥5o r≤0.2 generatemoderate shifts in pretest probabilities.29Single-detector positive-contrast CTA has reportedsensitivity and specificity of 13.3% –73.3% and 57.1% –100%, respectively,24with no observer's values exceedingthe 1.5 sum threshold. A similar study reported sensitiv-ity and specificity of 57% –64% and 71% –100%, respec-tively.22While the first study concluded that CTA hadlimited potential for meniscal lesion diagnosis, the sec-ond was more positive in this regard.22,24We hypothesized that multidetector CTA wouldenable combined sensitivity and specificity exceedingthreshold values for clinical usefulness ( ≥1.5) and likeli-hood ratios with a strong evidence level ( ≥10;≤0.1) in aclinical population of dogs affected by CCL rupture.

Answer 71

Slipped capital femoral epiphysis (SCFE) has previously been described in cats as a progressive condition resulting in displacement of the proximal femoral epiphysis, which occurs due to abnormalities of the proximal femoral physis.1–5 Histologically, characteristic changes include a widened physis with irregular clusters of chondrocytes within an abundant extracellular matrix.1–4 Affected cats present with either a unilateral or bilateral hindlimb lameness in the absence of trauma1,5 and may suffer spontaneous femoral capital physeal fracture.2,6 A strong male predisposition has been identified and almost all affected cats are neutered.1–5 It has been suggested that delayed physeal closure may be a predisposing factor.1,2,4 Prepubertal neutering in cats has been associated with delayed physeal closure.7,8 Although frequently reported in domestic shorthairs (DSHs), it also appears that Maine Coon and Siamese cats are predisposed to the condi-tion.1–3 Typical radiographic features include an open proximal femoral physis, osteolysis and sclerosis of the femoral neck, and displacement of the proximal femo-ral epiphysis.1,2,6,9 Previous reports have also labelled the condition femoral neck metaphyseal osteopathy and spontaneous capital femoral physeal fracture,5,6 but it is believed these are in fact the same condition and SCFE has become the accepted terminology for the disease. In previous literature, the most commonly reported treat-ment option for cats with SCFE is a femoral head and neck ostectomy.1,2,5 Surgical reduction and stabilisation with K-wires has also been reported, with one study high -lighting a short recovery and good prognosis for return to normal function in these cats.1,2,10 More recently, treat -ment with a total hip replacement has been reported.1 Although rarely described, conservative management is a further option.2SCFE is the most common hip abnormality in adoles -cent humans.11,12 Early diagnosis is extremely important to allow prompt treatment to optimise long-term func -tional outcome.11,13 However, subtle and early abnormal -ities are often missed on radiographs.11,14,15 Because of the difficulties in early diagnosis in humans, a variety of radiographic assessment methods have been developed to aid in its identification. These include the Klein’s line, modified Klein’s line and the S-sign.11,16–19The Klein’s line is a tangent drawn on the lateral mar -gin of the femoral neck on an anteroposterior (AP) pelvic radiograph (equivalent to a ventrodorsal [VD] extended-leg pelvic view). A positive result is when the line does not intersect the epiphysis.11,16,17Owing to poor sensitivity of the Klein’s line in cases of mild epiphyseal displacement, the modified Klein’s line method was developed. This involves a Klein’s line being drawn bilaterally and the amount of epiphyseal intersec -tion measured. A positive result is one where the affected side has reduction in epiphyseal intersection > 2 mm in comparison to the unaffected limb.16–18A further method to improve diagnostic sensitivity is the S-sign. This is measured on a frog-leg lateral pelvic radiograph and is a curvilinear line drawn from the lesser trochanter, continuing along the femoral neck, across the line of the physis and wrapping around the femoral head to the midpoint. A broken continuity, asymmetry or sharp turn is a positive result.19Although advanced stages of SCFE in cats are typically easy to identify on radiographs, subtle changes early in the course of the disease are harder to detect,9 especially in cases of acute fracture with minimal displacement or in those with chronic fractures.2 Early diagnosis of subtle SCFE could lead to earlier surgical treatment9 and avoid the need for salvage surgery, such as femoral head and neck excision or total hip replacement.Application of these human radiographic assessment methods to the radiographs of cats with SCFE has not been published. The objectives of this study were to apply the Klein’s line, modified Klein’s line and the S-sign to the radiographs of cats with SCFE. We aimed to investi-gate whether these methods can be used successfully to aid in the diagnosis of cats with SCFE. We hypothesised that the anatomical differences between humans and cats would reduce the effectiveness of the Klein’s line and the modified Klein’s line, and that the S-sign would be the most effective of these methods for the detection of SCFE in cats.

Answer 72

Gastric foreign bodies are the most common indi -cations for gastrotomies in veterinary medicine, accounting for 16% of digestive foreign body cases.1,2 Traditionally, the gastric incision is closed in 2 layers using a synthetic, monofilament, absorbable suture.1 The first layer typically employs a simple continuous appositional pattern or an inverting pattern, such as the Connell pattern, which incorporates both the mucosa and submucosa. A second inverting layer is added to the first, incorporating at least the serosal and muscularis layers of the stomach.3Interest in single-layer closure has been growing, both in clinical practice and in literature.4 In an ex -perimental study involving canine stomachs without a.23.06.0344©AVMABrought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 01/27/24 05:24 PM UTC2 a full-thickness single-layer simple continuous pat -tern would not adversely affect survival time or the incidence of major

Answer 73

The proximodistal patellar position along the femoral troch-lea has been discussed in relation to patellar luxation indogs.1–9A proximally positioned patella (patella alta) hasbeen believed to be related to medial patellar luxation (MPL),which causes the patella to exceed the trochlear grooveproximally and lose support from the trochlear ridge.4,5,7,10However, measuring the absolute position of the patella isdifﬁcult because it slides over the femoral trochlea with sti ﬂeﬂexion and extension.8Therefore, the ratio of the patellarligament length to patellar length (PLL/PL) has been used as adiagnostic indicator for abnormality of the proximodistalpatellar position,1–8adopted from the Insall-Salvati indexused in human medicine.11–13A study in humans showed aweak correlation between the Insall-Salvati index andpatellofemoral joint congruency measured on magnetic res-onance imaging.12Similarly, it is recognized that the prox-imodistal patellar position of dogs depends on multiplefactors, including PLL/PL, and that the diagnosis of patellaralta by PLL/PL alone might be inappropriate.9Although some studies on large dogs reported that PLL/PLwas greater in dogs with MPL than PLL/PL in normal dogs,5,7studies on small dogs reported no differences in PLL/PLrelated to MPL.4,10,14It was also reported that small dogs MPL do not have a more proximally positioned patellathan those without MPL, at approximately 90 degrees ofstiﬂe angle.9These studies refuted the theory that smalldogs with MPL had patella alta, in which the patella wasplaced more proximally than normal throughout the entirestiﬂe angle. However, none of these studies considered thedifference in the range of extension of the sti ﬂej o i n t .T h erange of motion of joints is affected by breed,15age,15sex16and other factors. Variation in the range of extension in sti ﬂejoints could cause a discrepancy in the range of proximo-distal patellar position because the patella moves proximallyas the sti ﬂe extends.8,9A previous study proposed a condi-tion described as ‘functional patella alta ’, in which the patellaexceeds the trochlea during hyperextension of the sti ﬂej o i n tdespite its position not being more proximal than normal attheﬁxed sti ﬂe angle.10Though the study described ‘func-tional patella alta ’as a cause of bidirectional patella luxation,it could also be a cause of MPL. To the best of our knowledge,no study has evaluated the association between MPL andpatella alta considering the range of motion of the sti ﬂe joint.This study aimed to determine the reference range of theproximodistal patellar position in healthy small dogs whenthe sti ﬂe is at full extension and identify the factors relatedto proximodistal patella position exceeding this referencerange proximally.

Answer 74

‘Bezoar’ refers to concretions in the gastrointestinal tract that increase in size by continuous accumulation of non-absorbable food or fibers.1 In cats, grooming can result in ingestion of copious amounts of hair forming ‘tricho -bezoars’ or ‘hairballs’. This hair usually passes through the intestinal tract and is then expelled in the feces. If hair accumulates in the stomach, vomiting may occur to eliminate the trichobezoar. Some sources consider this a normal physiologic process, though frequent elimination has been cited as evidence of pathologic overgrooming or underlying gastrointestinal pathology.2,3 This lack of consensus regarding normalcy of trichobezoar formation and elimination further contributes to the uncertainty regarding the cause of trichobezoar obstruction. While many veterinarians tend to accept the formation of an obstructive trichobezoar as an unusual, yet inescapable, nuisance (reminiscent of other types of foreign body obstructions), others feel these obstructions are often secondary to gastrointestinal pathology.3 In the authors’ experience, conservative management with fluid therapy and supportive care may allow passage of trichobezoar obstructions, but a portion of these cats ultimately require surgical intervention. Owing to the paucity of published literature regarding trichobezoar obstructions, the clini-cal utility of obtaining gastrointestinal biopsies at the time of surgery for relief of trichobezoar obstructions is unknown.2,3The underlying pathology may result in abnormal intestinal structure and motility, potentially predispos-ing to trichobezoar obstruction. Many gastrointestinal diseases in cats, including inflammatory bowel disease, diffuse alimentary lymphoma and food-responsive enteropathy, are generally categorized as feline chronic enteropathies (FCE). This term encompasses any gas-trointestinal disease causing clinical signs with a dura-tion of more than 3 weeks that cannot be attributed to infectious disease, obstruction or localized neoplasia causing a mass effect.4 A definitive diagnosis of specific FCE commonly requires advanced diagnostics, includ-ing gastrointestinal histopathology, as well as a clinical response to the therapy. However, a recent study suggests that histopathologic results do not always correlate with clinical disease, which complicates a diagnosis strictly from biopsy results.5 Histopathology results presenting diagnostic ambiguity may benefit from additional testing, such as when PCR for antigen receptor rearrangement (PARR) or immunohistochemistry (IHC) are used to dis -tinguish severe lymphoplasmacytic inflammation from alimentary small cell lymphoma.4,5The potential for underlying gastrointestinal disease as a precipitating factor for trichobezoar obstructions has led some to the conclusion that cats presenting for surgical intervention should have gastrointestinal biop-sies obtained concurrently. However, the decision to take biopsies is not standardized and leads to significant vari -ation in the number and location of biopsies. Some sur -geons obtain gastric, duodenal, jejunal and ileal biopsies, while others take just a single biopsy of intestine associ -ated with the obstruction to limit the number of enteroto -mies performed. Lastly, some surgeons will only obtain biopsies aborad to the obstruction owing to the perceived difficulty of interpreting orad inflammation, which may occur secondarily to trichobezoar passage or a primary enteropathy. To the authors’ knowledge, a distribution of histopathologic findings in gastrointestinal biopsies performed at the time of surgery to relieve mechanical obstructions due to trichobezoars has not been reported.The objective of the present study was to report histo -pathological findings in surgically obtained gastrointes -tinal biopsies from cats with an obstructive trichobezoar. The second aim of the study was to report the location of the changes relative to the obstruction and clinical char -acteristics of the study cats.

Answer 75

Multiple prognostic indicators have been reported for dogs with apocrine gland anal sac adenocarcinoma (AGASACA), including disease stage, hypercalcemia, his -topathologic features, and treatment performed.1–6 Pri-mary AGASACA tumor size is an important component of disease stage that has been associated with outcome. Reports suggest that dogs with larger tumors have worse prognoses and may be more likely to present with meta -static disease.1,3,7–9 One study demonstrated a reduced mean survival time of 9.4 months in dogs with primary tu -mor diameter > 5 cm compared to 18.8 months for dogs a.23.02.0102with primary tumor diameter < 5 cm.7 In that study, 86% of dogs with tumor diameter > 5 cm had locoregional lymph node metastases at the time of diagnosis.7 However, data were lacking with regard to staging diagnostics and treat -ments performed for these dogs.7Surgery is generally considered the first-line ther -apy for dogs with primary AGASACA. A recent study reported the overall intraoperative and postoperative complication rates for anal sacculectomy in 161 dogs with AGASACA to be 7% and 17%, respectively; self-limiting diarrhea/hematochezia, tenesmus, 2 surgical site erythema/swelling not related to infec -tion, transient fecal incontinence, urinary retention or difficulty ambulating after epidural injection, and inappetence during hospitalization were consid -ered sequelae and not complications.10 The most common intraoperative complication was anorectal perforation (5%), and the most common postopera -tive complication was surgical site infection (12%); no dogs developed permanent fecal incontinence.10 In that study, the median primary tumor diameter was 2.4 cm and 60% of tumors were < 2.5 cm in diame -ter.10 The authors found no association between pri -mary tumor size and development of complications, though the majority of tumors were relatively small.10Data on dogs with massive (> 5 cm) primary AGASACA that undergo anal sacculectomy is gener -ally lacking, likely given the potential for poor prog -nosis, as previously reported, as well as a subjectively greater risk for perioperative complications (eg, rec -tal perforation, fecal incontinence, and infection).1,3,7 Although larger primary tumor size has previously been correlated with an increased risk of metastatic disease, several studies have demonstrated potential for prolonged outcomes (up to several years) with lymph node extirpation in dogs with nodal metasta -sis.1,5,11–13 Therefore, the potentially increased risk of metastatic disease in dogs with massive AGASACA does not necessarily result in guarded prognoses for owners that elect treatment.The aims of our study were to evaluate the short- and long-term outcomes of dogs that undergo surgi -cal excision of massive (> 5 cm) AGASACA. We hy -pothesized that dogs undergoing anal sacculectomy for massive AGASACA would have low perioperative morbidity rates and the long-term outcomes for these dogs would be comparable to those found for nonmassive AGASACA cases of similar metastatic stage at the time of surgery.

Answer 76

Canine hip dysplasia (CHD) has been de ﬁned as “a varyingdegree of laxity of the hip joint permitting subluxationduring early life, giving rise to varying degrees of shallowacetabulum and ﬂattening of the femoral head, ﬁnally,leading to osteoarthritis. ”1As laxity of the coxofemoral joint is the primary reasonfor secondary osteoarthritis, four techniques to measure thelaxity of the coxofemoral joint have been described: thePennHIP method,2the subluxation index,3the dorsolateraluxation index,4and the Vezzoni modi ﬁed Badertscherdistension device (VMBDD)5technique. For the dorsolateralsubluxation index technique, both the body weight alone anda combination of body weight and additional weights can beused to (sub)luxate the coxofemoral joints.4,6The other threetechniques can be described as passive stress radiographsbecause the operator is putting stress (i.e., force) on thecoxofemoral joint.2,7Both the VMBDD and PennHIP areroutinely used in veterinary practice and measure the laxityof both hips and identify the hip with the highest laxity forreporting. Although both techniques are equivalent andwell documented,8literature on the force required on thelimbs of the dog to demonstrate the (sub)luxation isscarce. However, the technical repeatability and reproduc-ibility of the VMBDD is good when performed by trainedclinicians.9For the VMBDD, the measurement of laxity iscalled the laxity index (LI), while for PennHIP, it is termed thedistraction index . The LI correlates well with the FédérationCynologique Internationale (FCI) score on a standard ventro-dorsal (SVD) projection, but in FCI-normal dogs a wide range ofpassivehipjoint laxity persists.10However, thelackofobjectiveforce guidelines is confusing during the training of cliniciansand may leave room for fraud during screening programs.Additionally, it is currently unknown what the minimal forcethreshold required for the laxity to be suf ﬁciently evident isand whether this is in ﬂuenced by patient-speci ﬁc character-isticssuch as body weight, age, and degenerative changes in thehip joint. For an in-depth assessment of this, we recentlydeveloped and validated the Vezzoni modi ﬁed Badertscherdistension measuring device (VMBDmD). With this device, theforce applied at the level of the device (i.e., FVMBDmD as depictedin►Fig. 1 , referred to as the force throughout this article) canbe monitored in real time to acquire the radiograph at thedesired force, and during the acquisition of the radiograph, theforce was registered and saved (Vandekerckhove et al. 2023).11This can aid in the further understanding and standardizationof this technique.The aims of this study are the following:To evaluate the force-laxity association and potentialinﬂuencing factors. Only the highest value of the two LI(one per hip) measured in a dog was retained, this wascalled the maximum LI (LImax; traditional use of LI). Ina second analysis the LI was expressed proportionately tothe LImaxmeasured per hip (so retaining all values per hipand expressing them relative to the highest LI of that hip).The latter value is called the LI%.To evaluate how the joint reacts under repeated cycles ofstress and to determine the variability of the procedurethroughout the force range.To measure the force necessary to cause suf ﬁcient visuali-zation of the laxity present in the hip joints, with suf ﬁcientlaxity being de ﬁned as at least 90% of the maximum laxity.

Answer 77

Infiltrative lipomas are uncommon tumors report -ed in a variety of species, with dogs and humans comprising the most reported cases.1–9 Clinically, infiltrative lipomas present as poorly delineated masses that can interfere with range of motion or cause discomfort.1 They are distinct from the more common, classic lipomas because they infiltrate sur -rounding tissues (eg, muscle and fascia).10 Despite behaving aggressively, they lack histological criteria of malignancy seen in liposarcomas and are instead comprised of well-differentiated adipocytes. There -fore, diagnosis is based on combination of surgical impression, tissue infiltration on histopathology,11 or unique appearance on 3-D imaging showing invasion a.23.05.0288into muscle or other tissues.12 Infiltrative lipomas are commonly suspected only after attempted resec -tion, and CT is recommended to assess tumor extent before further treatment.10 Metastatic infiltrative li -poma has not been reported in dogs.4Limited information is available on treatments. Surgery is reported, with local recurrence ranging from 36% to 50%.1,4 In 2 published cases, dogs with spinal infiltration received surgery alone, with improved am -bulation for 6 and 24 months after surgery.13,14 There is also a single canine case report describing a partial response at 6 weeks with doxorubicin treatment.15Conventionally fractionated radiotherapy (CFRT) involves multiple radiation treatments, necessitating 2 larger treatment volumes to account for daily target uncertainties. Fractionating dose also allows normal tissues to better recover, thereby limiting late radiation damage while achieving high target dose. Therefore, extensive areas of normal tissue (with suspected micro -scopic disease) can be included and treated appropriate -ly. Radiotherapy has been reported in 13 dogs with gross or microscopic infiltrative lipomas, with a subset also re -ceiving hyperthermia treatment, with a reported median survival of 40 months.11 However, in another combined surgery and radiation report,16 a dog with spinal canal infiltration had a short survival of 6.6 months. Limited radiotherapy planning data are available in these stud -ies. To better define the role of CFRT in canine infiltrative lipomas, this study describes survival outcomes for 24 infiltrative lipoma cases treated at a single institution, with contemporary dosime

Answer 78

Cranial cruciate ligament rupture and medial patellar luxa-tion (MPL) are common causes of lameness in dogs and mayoccur concurrently.1In dogs with MPL, cranial cruciateligament rupture is recognized in up to 25% of cases.2As aresult, a combination procedure to stabilize the sti ﬂea n dtreat the patellar luxation is often necessary.Several surgical methods for treating concomitantly cra-nial cruciate ligament rupture and MPL have been reported,uding extracapsular stabilization and tibial tuberositytransposition (TTT),3tibial plateau leveling osteotomy(TPLO) and TTT (TPLO-TTT),4TPLO with lateral translationof the distal tibial segment,5,6TPLO and additional trans-verse osteotomy,7TTT advancement,8,9and modi ﬁed tripletibial osteotomy.10These techniques have been describedeither alone or in combination with additional proceduressuch as trochleoplasty or soft-tissue (retinacular) release orimbrication. To date, only one report has documented clinicaloutcomes of TPLO-TTT surgery for treatment of concurrentcranial cruciate ligament rupture and MPL in dogs.4In thatstudy, all 11 dogs (15 sti ﬂes) were reported to have mild orno lameness at their last follow-up 8 to 10 weeks aftersurgery. No catastrophic or major complications occurredthat required additional surgery and patellar re-luxation didnot develop in any of the 13 sti ﬂes available for in-hospitalfollow-up. However, data regarding long-term complicationsand outcomes associated with TPLO-TTT technique were notreported.Our objective was to report complications and long-termclinical and radiographic outcomes of TPLO-TTT surgery inconjunction with ancillary procedures (e.g., trochlear blockrecession, lateral capsulorrhaphy, and lateral parapatellarfascial imbrication) in dogs concomitantly affected by cranialcruciate ligament rupture and MPL.

Answer 79

Pathology of the shoulder joint is a common cause offorelimb lameness in dogs, often resulting in pain and poorlimb function.1Orthopaedic examination, radiography,ultrasonography, and cross-sectional imaging have all beenused to evaluate the shoulder joint; however, for evaluationof intra-articular structures arthroscopy remains the “goldstandard. ”2–4Structures commonly evaluated through stan-dard lateral arthroscopy include the medial glenohumeralligament, subscapularis tendon, biceps tendon, humeralhead, glenoid, supraglenoid tubercle, joint capsule, andcaudal joint pouch.5While arthroscopy of the shoulder joint has many diag-nostic and therapeutic applications, only portions of vitalintra-articular structures are visible, and the limits are notwell de ﬁned. To our knowledge, no reports have been pub-lished mapping the extent of the stabilizing structures thatare within the ﬁeld of view during standard arthroscopicevaluation of the canine shoulder. The aim of this study wasto de ﬁne the extent of the biceps tendon, subscapularistendon, and cranial border of the medial glenohumeralment that are within the ﬁeld of view during standardlateral shoulder arthroscopy. In addition, the effect of jointﬂexion on the ﬁeld of view of the biceps tendon was exam-ined. Based on our clinical experience, we speculated thatless than 75% of each supporting structure would be withinthe arthroscopic ﬁeld of view. We hypothesized that theproportion of biceps tendon visible by arthroscopy would besigniﬁcantly greater with the shoulder positioned in ﬂexion.

Answer 80

An internal abdominal hernia is a protrusion of a viscusthrough a peritoneal or mesenteric aperture.1The aperturecan either be a natural opening, such as the epiploicAbbreviations: AFAST, abdominal-focused assessment withsonography for trauma, triage, and tracking; EFE, epiploic foramenentrapment; FWH, foramen of Winslow hernia; GRV, gastric residualvolume; GT, gastrostomy tube; NGT, nasogastric tube; NJT,nasojejunostomy tube.Received: 27 December 2022 Revised: 7 April 2023 Accepted: 20 May 2023DOI: 10.1111/vsu.13975Veterinary Surgery. 2023;52:1237 –1244. wileyonlinelibrary.com/journal/vsu© 2023 American College of Veterinary Surgeons. 1237foramen, or it may be an unnatural congenital or acquiredopening, such as an enlarged esophageal hiatus or a mes-enteric defect from intestinal surgery.1,2The epiploic fora-men is the opening to the omental bursa, a virtual cavityformed by the greater and lesser omentum.2,3The foramenis situated in the right dorsomedial abdomen caudal to thecaudate liver lobe, cranial to the celiac artery, dorsal to theportal vein and hepatic artery, and ventral to the caudalvena cava.2,4,5Intraoperatively, it is most easily visualizedby retracting the duodenum ventrally and to the left.4Epiploic foramen entrapment (EFE) has been welldocumented in horses and in humans, in whom it iscalled a foramen of Winslow hernia (FWH).2,5–8Risk fac-tors for FWH in humans include an enlarged foramen,abnormally long small intestine mesentery, persistentascending mesocolon, elongated right liver lobe, lack offusion between the cecum or mesocolon to parietal peri-toneum, a gastrohepatic ligament defect, or intestinalmalrotation.6,7,9Changes in intra-abdominal pressure,such as those associated with parturition, straining, or ameal, may also increase the risk.5,8,9Most affectedhumans have acute, severe, intermittent, or progressivepain and signs of small bowel obstruction.5,9In horses,risk factors for EFE include warmblood breeds, wind-sucking, cribbing, and previous colic.6,7In affectedhumans and horses, resection of herniated intestine isoften required, although some horses may be treated byintestinal reduction and decompression alone.2,7–10Inboth species, mortality rates are often over 30%.7–10As far as the authors are aware, there are no reportsof canine EFE in veterinary literature. The purpose ofthis article is to describe the historical and clinical find-ings, treatment, and outcome of a dog with EFE.

Answer 81

External skeletal ﬁxators (ESF) are commonly used in smallanimal veterinary surgery and the use of acrylic connecting barsoffers several advantages, including versatility, malleability,lightweight, ease of use, radiolucency, availability and afford-ability.1–4Strength and stiffness of these constructs are affectedby several factors associated with the frame con ﬁguration,connecting columns and trans ﬁxationpins.1,5–8Failure of acryl-ic ESF occurs at the pin-acrylic interface, even though thisinterfacehas been shown to be structurally stiffer andwithstandgreater loads than that of similarly sized Kirschner-Ehmerstainless steel ﬁxators.2,8–11The mechanical properties of thisinterface are in ﬂuenced by the thickness of the acrylic sur-rounding the pin, thus the diameter of the acrylic column, andt h ec e n t r i n go ft h ep i ni nt h ec o l u m n .T h ei n ﬂuence of pinpositioning –centric versus eccentric –in acrylic connectingcolumns was recently studied, and revealed a decrease in thestiffness of acrylic columns with eccentric pins.6However, onlythe acrylic columns themselves were subjected to axial com-pression. No previous study has evaluated the effects of trans-ﬁxation pin positioning on the biomechanical properties ofacrylic ESF constructs.The objective of this in vitro study was to evaluate theinﬂuence of trans ﬁxation pin positioning in acrylic columnson the biomechanical properties –in axial compression andfour-point bending –of ESF constructs in a fracture gap model.We hypothesized that pin positioning would not affect theechanical properties –stiffness, yield and failure loads –ofthe constructs.

Answer 82

The patellar tendon (PT) is the tendinous insertion of thequadriceps femoris muscle extending from the patellasesamoid to the tibial tuberosity, which functions to facil-itate femorotibial extension and both stifle and patellastabilization.1,2In dogs, rupture of the patellar tendon(RPT) is an infrequently reported injury caused by directlaceration and trauma, or secondary to forceful simul-taneous stifle flexion and quadriceps femoris musclecontraction.1,3,4However, endocrine disorders andcollagenous connective ti ssue abnormalities havebeen described.1,5–7In humans, RPT has beenreported due to systemic inflammatory disorders orcorticosteroid-associated tendinous deterioration.5,7Current techniques for the repair of RPT in dogsinclude primary tendinous repair using core suture pat-terns, including the locking loop (LL), three-loop pulley(3LP), Bunnell –Mayer, mattress suture, Krackow, andvarious repair modifications.6,8–12Previous reports sup-port the use of concurrent augmentation of primarytenorrhaphy techniques using adjunctive stabilizationprocedures to reduce the risk of repair failure and tocounteract the considerable forces applied to the PT dur-ing active quadriceps contraction.1,4,7,13,14Use of transpa-tellar or suprapatellar (also known as circumpatellar)augmentation using monofilament nylon or 316 L stain-less steel wire has been described.1,3–7,14Distally, ortho-pedic wire is anchored through the tibial tuberosity usingtransosseous tunnels and functions as an internal splintto aid in the apposition of tendon ends prior to primaryrepair, and subsequently provide secondary dynamic sta-bilization to the tendinous anastomosis.1,3–7,14Use ofautogenous fascia lata grafts,1,13,15,16and PT plating hasbeen described.1Further stifle stabilization using eitherexternal coaptation3,5or transarticular external skeletalfixation3–5,7has also been advocated by surgeons to fur-ther promote postoperative joint immobilization andreduce tensile loads placed directly on the repair.Current methods of RPT repair protection are prob-lematic for several reasons. Use of external coaptation forimmobilizing the stifle joint postoperatively may aid inprotecting the primary repair; however, soft-tissue mor-bidity has been reported in 63% of dogs.4,8,17Most nota-bly, concerns exist regarding failure of the primarytenorrhaphy, resulting in the need for either revision sur-gery or secondary intervention.4,5Postulated reasons forRPT repair failure relate to the initial strength of primaryrepair, with several studies focused on optimization ofsuture repair techniques.6,11In a study by Biskup et al.the biomechanical properties of cadaveric canine patella-tibia-ligament segments were evaluated.18Failure loadsfor tested segments ranged from 811 to 3451 N dependingon the size of the dogs used.18A common sequela tousing either transpatellar or suprapatellar tension bandwire (TBW) includes the need for implant removal post-operatively due to subsequent lameness, seroma forma-tion, or excoriation of overlying soft tissues due to wirebreakage.3,4,15Given that TBW augmentation followingRPT repair is a widely adopted practice among surgeons,there is a paucity of information within the veterinary lit-erature to support a superior method for wire place-ment.4,11This information is of use to veterinarysurgeons in efforts to reduce the occurrence of repair fail-ures and increase the tensile strength of RPT repairs.Although use of transpate llar and suprapatellarTBW have been reported following RPT repair withinthe veterinary literature,1,3–7,14there are infrequentreports of the combined use of transpatellar and supra-patellar wire-fixation techniques,4,13and biochemicaltesting focused on these methods of augmentation iswarranted.The objective of this study was to evaluate the effectof three different techniques for TBW augmentation fol-lowing primary PT repair using 316 L 18 gauge orthope-dic wire (transpatellar, suprapatellar, or combinedtranspatellar and suprapatellar) on the biomechanicalproperties and failure mode in a canine RPT model. Ourhypothesis was that the use of combined transpatellarand suprapatellar TBW augmentation would be biochem-ically superior, exhibiting greater yield, peak, and failureloads than other techniques. Our secondary hypothesiswas that there would be no difference in failure mode orgap formation among groups.MCKAY ET AL . 1141 1532950x, 2023, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14000 by Vetagro Sup Aef, Wiley Online Library on [15/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

Answer 83

Feline ureteral obstruction due to uroliths or stricturescommonly occurs in the proximal ureter.1,2Ureterolith-associated proximal ureteral obstruction involving theproximal third of the ureter can be treated using ureter-otomy. However, when it results from other causes(e.g., ureteral strictures, trauma, iatrogenic ligation,neoplasia), ureterotomy is not indicated and surgicaltreatment can be technically challenging. In these situ-ations, surgical options include traditional surgery(e.g., ureteroneocystostomy or ureteroureterostomy)3–10or implant placement (e.g., ureteral stent1,11–18or sub-cutaneous ureteral bypass [SUB]).11,13,16,19 –29Ureteroneocystostomy in ca ts is associated with majorpostoperative complications, such as uroabdomen (15% –17%)5,10and persistent ureteral obstruction (11%).5Uretero-neocystostomy performed within the proximal third of theureter, including the uretero pelvic junction (UPJ), cancause anastomotic leakage and stenosis due to excessivetension. Thus, use of ureteroneocystostomy is generally notconsidered for very proximal ureteral obstructions.5,9,30Ureteroureterostomy is technically more difficult andhas a higher risk of postoperative ureteral obstructionthan ureteroneocystostomy.4,9Ureteral stenting is associ-ated with frequent postoperative complications in cats,including dysuria (37% –64%),12,14,18urinary tract infec-tion (UTI) (9% –67%),1,12,15,18and it requires stent exchangeor removal (22% –36%).12,14,15Although SUB device place-ment is considered effective for feline proximal ureteralobstruction, postoperative complications, such as dysuria(8%–45%),16,20,22,27,28UTI (8% –36%),20–23,26,28,29and deviceocclusion (5% –33%),16,21,22,27occur.One option for treatment of very proximal ureteralobstruction includes the use of a Boari flap,25,30 –32whichinvolves the extension of a tubularized bladder to theremaining ureteral orifice. Another option is the use ofan ileal graft33that replaces the obstructed ureter with avascularized segment of ileum. Both techniques weredeveloped to minimize tension at the ureteroneocystost-omy site. Three successful30–32and one failed25cases ofureteroneocystostomy with a Boari flap in cats with prox-imal ureteral obstruction have been reported. There isone case report of an ileal graft technique (ileal-ureteralsubstitution), but the length of the ureter proximal to thestricture site was not included in the report.33An alternative procedure that can be performed safelyand provide better outcomes is needed for feline proximalureteral obstruction including UPJ, especially for nonure-terolith obstruction. Thus, we developed a novel form ofureteroneocystostomy without a Boari flap, called extra-vesicular, two-layer, side-to-side ureteroneocystostomycombined with tension-relieving techniques (ETSUTT),which consists of a modified extravesicular technique andthree different tension-relieving techniques (i.e., renaldescensus,8,9ureterocystopexy, and nephrocystopexy9). Wehypothesized that ETSUTT would be feasible, safe, andprovide good clinical outcomes in cats with proximal ure-teral obstruction. The objectives of this study were todescribe the surgical techniques used with the ETSUTTprocedure and report the clinical outcomes of its use incats with proximal ureteral obstruction.

Answer 84

Sacroiliac luxation/fracture (SILF) is a common conditionin dogs and cats undergoing a blunt trauma such as roadtraffic accident (RTA) or fall. Sacroiliac luxation has beenreported in 12.4% of all dogs undergoing RTA,1andaccounts for 27% –36% of all pelvic injuries.1,2Sacroiliac lux-ations have been reported in 60% of cats with pelvic traumaand are reported to be bilateral in 33% –46% of felinecases.3,4This condition is often associated with other pelvicinjuries.2Surgical management of bilateral SILF consists ofstabilization with implants that can either be transiliosa-cral, transilial craniodorsally to the sacrum, or bilateral ilio-sacral. Drilling through the sacral body is technicallychallenging, with a limited safe corridor, especially for lessexperienced surgeons and without intraoperative fluoro-scopic guidance.5–12When the condition is bilateral, thesimultaneous approach of both the sacroiliac joint and,especially, the sacral wings and the use of an aiming devicecan enable this technical challenge to be overcome. Previ-ous studies reported the use of a single transiliosacralscrew, pin, rod, or screw and nut as treatment of bilateralsacroiliac luxation.4,13–15All these internal stabilizationtechniques aim at avoiding any motion of both sacroiliacjoints (severe ankylosis or fibrous arthrodesis). A dynamicisometric technique could potentially be used with a systemplaced at the center of rotation of both sacroiliac joints andtightened between iliac wings, onto or into which it wouldbe anchored but still allowing motion (rotation and transla-tion) in the sagittal plane.16This would allow anatomicalrestoration alongside the preservation of at least some ofthe sacroiliac motion, bilaterally, which could have apotentially beneficial clinical outcome.As far as the authors are aware, the use of the transi-liosacral toggle suture repair (mini-TightRope —ArthrexGmbH, Munich, Germany) has not been described as asurgical treatment for bilateral SILF in small animals.Here, we report the surgical technique as well as the clin-ical and radiographic outcomes of 15 cats treated forbilateral sacroiliac luxation with a transiliosacral togglesuture repair. The hypotheses were that bilateral SILFstabilization with a toggle suture repair would lead togood to excellent functional clinical outcomes, and that agood anatomic restoration could be achieved and main-tained in the medium term.

Answer 85

Gastrointestinal surgery in dogs and cats is ex -tremely common in both elective and nonelec -tive scenarios. Gastrointestinal surgery is most commonly classified as a clean-contaminated pro -cedure (surgery under normal conditions involving entry into the respiratory, gastrointestinal, or geni -tourinary tracts), based on the wound classification system developed by the National Academy of Sci -ences National Research Council.1 However, in the presence of septic peritonitis, these procedures are considered to be dirty.1 Common indications in vet -erinary medicine for gastrointestinal surgery are for Use of liposomal bupivacaine in dogs and cats undergoing gastrointestinal surgery is not associated with a higher rate of surgical site infections or multidrug-resistant infectionsCamille Andrews, VMD1; Rachel Williams, DVM, DACVS1*; Marie Burneko, VMD, DACVS21College of Veterinary Medicine, University of Florida, Gainesville, FL2School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA*Corresponding author: Dr. Williams ( rwwilliams@ufl.edu )Received August 18, 2023Accepted September 30, 2023doi.org/10.2460/javma.23.08.0463©AVMAthe removal of obstructive foreign bodies, gastroin -testinal masses, intussusceptions, and obtaining full-thickness gastrointestinal biopsies for diagnosis of common medical problems like inflammatory bowel disease, and more. Gastrointestinal surgery may in -volve entering the stomach or small or large intestine and may involve the resection and subsequent anas -tomosis of viscera.A major consideration in the postoperative pe -riod for animals undergoing gastrointestinal surgery is surgical site infections (SSIs). Antibiotics are com -monly used perioperatively, but antibiotics are not 2 routinely prescribed postoperatively. Indications for postoperative antibiotic administration include the degree of contamination or presence of infection before surgery (as with a diagnosis of septic perito -nitis), degree of contamination or break in sterility during surgery, presence of infection in the imme -diate postoperative period, or certain individual risk factors (degree of immunocompromise, age, and more).2 High mortality rates (17%) and excessive cost are associated with SSIs.3 It has been shown that SSIs cost hospitals $1.6 billion annually and may accumu -late an extra 1 million days of stay in hospital.3 The rate of SSI after gastrointestinal surgery in humans is especially high, with studies finding that the rate is between 15% and 20%, depending on the segment of the gastrointestinal tract involved.3 It has been well documented that clean-contaminated SSI rates are between 4.5% and 5% in veterinary medicine.4 A re -cent veterinary study3 identified an incisional infec -tion rate of 7% for gastrointestinal surgery specifical -ly, but infection rates were not reported for specific regions of the gastrointestinal tract. Risk factors of SSIs, specifically pertaining to clean-contaminated surgery, include length of anesthesia, length of sur -gery, and incidence of underlying disease, specifi -cally endocrinopathies in intact males.2 Other stud -ies have shown that density, virulence, synergism of bacterial inoculum, local environment, hypothermia under anesthesia, and other host factors contrib -ute to the incidence of SSI.3 The most common flora from an SSI, cultured 10 to 14 days after gastrointes -tinal surgery, are normal gastrointestinal flora includ -ing Escherichia coli , Enterobacter , and more.3 Many of these commonly cultured bacteria are multidrug resistant (MDR), or resistant to > 1 class of antibiotic agents and therefore not susceptible to commonly administered perioperative antibiotics, necessitating either the use of second- or third-line antibiotics, ex -tended hospital stays, or repeat surgery.5The use of injectable liposomal bupivacaine has increased in veterinary medicine since its develop -ment in 2011 and FDA approval in dogs and cats. The FDA-approved product Nocita has been approved for a single dose by infiltration injection at the time of in -cisional closure of cranial cruciate ligament surgery and for feline declaw procedures.6,7 The off-label use of incisional infiltration of Nocita at the time of inci -sional closure for gastrointestinal surgery, however, is common at the authors’ institutions. In a recent study,8 the incisional complication rate (infection, seroma, and dehiscence) was 10.8% in 65 dogs that received Nocita during foreign body surgery, higher than reported for dogs that did not receive Nocita (n = 140) during for -eign body surgery. The SSI rate was also higher in dogs that received Nocita, as 1.5% of the 65 dogs developed an SSI, compared to 0.7% of 140 dogs that did not re -ceive Nocita.8 This study did not report the bacterium isolated, nor did it indicate whether dogs diagnosed with SSI had surgeries performed under clean-contam -inated or dirty conditions. Another study9 found that the incidence of wound complications after infiltration of liposomal bupivacaine in dogs did not vary signifi -cantly between clean, clean-contaminated, and dirty surgeries but that the overall wound complication rate was 19.7%, with contaminated and clean-contaminated surgeries having high complication rates of 30.8% and 23.1%, respectively. The overall rate of SSI reported was 5%, but the rate of SSI for clean, clean-contaminated, or contaminated surgeries was not reported.9In human medicine, SSI is listed as a potential complication of liposomal bupivacaine administra -tion. Some reports support an increased risk of SSI with use of liposomal bupivacaine, particularly in skin graft donor sites and after arthroplasty.10,11 Howev -er, 1 study12 found no significant difference in SSIs rates between a group receiving liposomal bupiva -caine and a control group during abdominal surgery. In a laboratory setting, 1 study10 inoculated 6 common bacterial isolates of SSIs in humans (methicillin-resistant Staphylococcus aureus , methicillin-sensitive S aureus , coagulase-negative staphylococci, E coli , and Entero -coccus ) into liposomal bupivacaine, finding that the an -tibacterial effects seen with traditional local anesthetic agents (bupivacaine) are not seen with liposomal bupivacaine. They concluded that an animal model would be a critical next step.10 This study suggests that MDR bacteria may more easily grow in incisions after incisional infiltration with Nocita compared to a typical line block of bupivacaine.Considering the morbidity, mortality, and cost as -sociated with SSIs in a veterinary setting, it is important to document whether incisional infiltration of Nocita at the time of closure of gastrointestinal surgery is a risk factor for incisional infections. No studies in vet -erinary medicine have assessed the SSI rate in cats that have received Nocita for gastrointestinal surgery, the SSI rate of dogs that received Nocita undergoing gastrointestinal surgery for indications other than for -eign body retrieval, or whether the presence of septic peritonitis or dirty abdominal surgery affects SSI rate in dogs and cats receiving Nocita. Additionally, no paper in veterinary medicine has discussed specific isolates of SSIs in animals that received Nocita for gastrointes -tinal surgery and compared them to animals that did not receive Nocita. Our objectives were to (1) report the incidence of SSI rate after gastrointestinal surgery in dogs and cats that received Nocita and (2) report the aerobic bacteria isolated from cultures obtained of those patients with incisional infections. We hypothe -sized that the rate of incisional infection would be simi -lar between patients receiving Nocita and those that did not. We also hypothesized that similar species of causative bacteria isolated would be similar to those that have been reported previously for incisional infec -tions following gastrointestinal surgery. However, we also hypothesized that MDR bacteria would be isolated more frequently from SSIs in patients receiving Nocita than those

Answer 86

Neoplastic disease with metastatic potential requires stag-ing to determine prognosis and appropriate treatmentoptions. This process frequently involves cytological orhistological assessment of lymph nodes for neoplasticinfiltration.1,2,3Excisional biopsy and histology of lymphnodes has been shown to be more sensitive than cytologyfor the detection of metastatic disease and may be electedover cytological assessment in select cases.2,3Surgicalexcision and histology may also be elected over aspirationand cytology due to the survival advantage conferred byexcision if the node is infiltrated. Multiple studies con-ducted on human patients have identified reduced risk ofneoplastic recurrence4,5and extended median survivalAbbreviations: MIS, minimally invasive surgical; STL,stereolithography.Received: 2 February 2022 Revised: 31 July 2022 Accepted: 1 September 2022DOI: 10.1111/vsu.13901888 © 2022 American College of Veterinary Surgeons. Veterinary Surgery. 2023;52:888 –896. wileyonlinelibrary.com/journal/vsutimes6,7when lymph nodes carrying metastasizing cellsare surgically excised. A study investigating dogs withstage II cutaneous mast cell tumors also identified thera-peutic value and improved prognosis with regionallymphadenectomy.8The axillary lymphocenter consists of the axillarynode and the accessory axillary node,9,10and may pose aparticular challenge to lymphadenectomy by traditionalopen techniques11due to its location deep to the muscu-lature of the thoracic limb a nd immediately adjacent tothe axillary vasculature. The axillary lymph node con-sists of a single node in 91% of dogs, with two or eventhree nodes detected in the remainder,12and is situatedmedial and caudal to the shoulder joint, adjacent to theaxillary artery and vein. The accessory axillary lymphnode is reported as variably present, and lies caudal tothe axillary node on the deep aspect of the ventral bor-der of the latissimus dorsi muscle - this node has alsobeen reported as a double node.12The axillary lympho-center drainage area consists of the mammary glands,thoracic and cranioventral abdominal walls, and thedeep structures of the thoracic limb.10Axillary lympha-denectomy may be indicated for neoplasia in any ofthese areas.Reports of axillary lymph node identification andlymphadenectomy techniques in dogs are relativelysparse with one study reporting three cases in which onlytwo procedures were successful in locating the nodes.13As the size of the dog increases, an open procedure maybecome progressively more challenging due to the loca-tion of the node medial to the shoulder and the limita-tions to retraction set by the thoracic limb musculature.A minimally invasive surgical (MIS) technique may offeradvantages including improved visualization of the nodefor identification and dissection, reduced incision sizeand no need for aggressive retraction. Studies investigat-ing minimally invasive lymphadenectomy techniquesconducted in human patient populations have identifiedequivalent or better lymph node retrieval rates withreduced blood loss and scarring compared with openapproaches.14,15Recognized complications includelymphedema, wound infection, hemorrhage and ser-oma.15Randomized controlled trials comparing openwith minimally invasive approaches for lymphadenect-omy in human patient populations have proven to bechallenging due to the reluctance of patients to beassigned into the open surgery arm of these studies.16The objectives of this study were to describe (1) devel-opment of an MIS technique for lymphadenectomy of theaxillary and accessory axillary lymph nodes in caninecadavers, and (2) the outcomes following pilot implemen-tation of the technique in live dogs in a clinical setting.

Answer 87

Adequate understanding of the biomechanical requirementsfor repair of a particular fracture is necessary to ensure thatthe chosen repair will remain biomechanically effective forthe time required for fracture healing. Construct stiffness hasbeen shown to be a determinant of the type and rate offracture healing, with inadequate stiffness contributing todelayed healing or nonunion,1or implant-fatigue failure.1–4Implants with lower stiffness will undergo higher stress,h has been shown to increase the risk of fatiguefailure.5,6Plate working length signi ﬁcantly affects the stiffness of aconstruct; however, con ﬂicting interpretations of investiga-tions are cited.1–4,7Stoffel and colleagues4reported that alonger plate working length resulted in less constructstiffness in a 4.5-mm locking compression plate (LCP)fracture gap model with a 6-mm fracture gap. However, ina 1-mm gap model, longer working lengths had higherconstruct stiffness due to deformation of the constructresulting in transcortical contact and load sharing. Whetherthein vivo increase in stiffness in the 1-mm gap model wouldbe sustainable in a clinical case due to the resultant highinterfragmentary strain produced on transcortical contact isquestionable. Similar discrepancies have been cited regard-ing the effects of working length on plate strain; however,recent biomechanical studies2,3,8showed that a short work-ing length had lower plate strain than a long working length.Plate –bone distance, or standoff , can also affect constructstiffness. Ahmad and colleagues9reported plastic deforma-tion and failure at lower loads in 4.5-mm LCP constructs witha 5-mm plate –bone distance compared with a 2-mm plate –bone distance. Other studies in human orthopaedics haveshown that greater plate –bone distance results in less con-struct stiffness in both axial compression and torsion.4,10Nopublished studies have evaluated the effect of plate –bonedistance in small locking constructs such as those used insmall animal orthopaedics. Furthermore, no studies haveexamined the interaction between working length andplate –bone distance in locking constructs, nor plate strainassociated with varying plate –bone distance.The objectives of this study were to determine the effect ofthree working lengths in combination with three plate –bonedistances on 2.0-mm locking construct stiffness and strain ina diaphyseal fracture gap model. It was hypothesized that along working length or greater plate –bone distance wouldresult in low construct stiffness in compression bending andtorsion, and high plate strain in compression bending. Wealso hypothesized that there would be an interactionbetween plate –bone distance and working length for bothstiffness and strain.

Answer 88

Gastrointestinal foreign bodies are a common reason for presen -tation to veterinary emergency departments (Pratt et al. 2014) and account for roughly 4% of urgent endoscopic procedures in humans (Becq et al. 2021). In human medicine, most ingested foreign bodies are managed conservatively, but endoscopic retrieval is necessary in 10% to 20% cases (if the foreign body induces complete oesophageal obstruction or for sharp- pointed foreign bodies, magnets and batteries) and surgery in less than 1% of cases (Becq et al. 2021). For sharp- pointed foreign bod -ies, the European Society of Gastrointestinal Endoscopy (ESGE) recommends emergent (preferably within 2 hours) endoscopic removal of objects within the oesophagus, and urgent (within 24 hours) endoscopic removal of gastric objects, as the risk of complications is reported to be as high as 35% (Birk et al. 2016). Gastrointestinal metallic sharp foreign bodiesJournal of Small Animal Practice • Vol 64 • August 2023 • © 2023 The Authors. Journal of Small Animal Practice published by John Wiley & Sons Ltd on behalf of British Small Animal Veterinary Association.523 No consensus guidelines exist in veterinary medicine on the management of straight sharp- pointed metallic gastrointestinal foreign body such as sewing needles.The databases Medline (Pubmed), Scholar and Science direct were searched with the following keywords “ingested needle AND dogs”, “ingested needle AND cats”, “gastrointestinal nee -dle AND dogs”, “gastrointestinal needle AND cats”, “metallic foreign body AND dogs” and “metallic foreign body AND cats” (authors’ last search on 09/07/2022). This revealed only two ret -rospective studies describing the clinical signs, complications, treatment and outcome of dogs and cats following ingestion of sewing needles (Felts et al. 1984, Pratt et al. 2014) and conserva -tive management is not described in either study in detail.The aims of this study were to describe the conservative man -agement of gastrointestinal metallic sharp- pointed straight foreign bodies (e.g. sewing needles, pins, nails) in dogs and cats, to assess the onset and type of complications seen and patient outcome.

Answer 89

Feline otitis media (OM) can be a challenging diagnosis because it lacks specific clinical signs and often manifests as upper respiratory disease or otitis externa (OE).1,2 It is most often associated with ascending infection from the nasopharynx through the auditory (Eustachian) tube1,3 and may extend to cause otitis interna (OI).1,4,5 This causes A Pandora’s box in feline medicine: presenting signs and surgical outcomes in 58 previously hoarded cats with chronic otitis media-internaLinda S Jacobson1, Kyrsten J Janke1, Sasha K Kennedy1, Gina A Lockwood2, Shawn D Mackenzie3, Carl D Porter3 and Patrick B Ringwood4AbstractObjectives The aim of the present study was to report clinical findings, surgical complications and outcomes for previously hoarded cats treated surgically for otitis media-interna (OMI) and to investigate the risk factors for complications and poor outcomes.Methods A retrospective study was conducted of 58 cats from an institutional hoarding environment that underwent ventral bulla osteotomy (VBO).Results Inappetence was uncommon at presentation (9/58, 16%) compared with pruritus/alopecia (50%), nasopharyngeal signs (45%), otitis externa (OE) (79%) and otitis interna (OI) (ataxia ± head tilt/head excursions) in 40%. Purulent aural discharge occurred in 36% and polyps in 26%. The tympanic bulla wall was moderately or severely thickened radiographically in 38/108 (35%) ears. Cultures were positive for Streptococcus equi subspecies zooepidemicus in 26/48 (54%) cats. Of the 58 cats, 40 (69%) had complications after the first VBO and 19/30 (63%) after the second. Of 101 complications, 56 (55%), from 27/88 (31%) surgeries, were considered serious, including life-threatening perioperative complications in seven, OI in eight, prolonged anorexia in six and worsening of pruritus/alopecia in nine cases. Three cats developed xerostomia (dry mouth) after the second VBO. Pruritus/alopecia, nasopharyngeal signs, OE and purulent aural discharge resolved in a statistically significant proportion of cats but persisted in some. Full resolution of OI was uncommon. OI preoperatively, and surgery performed by a generalist (vs specialist) surgeon, were risk factors for OE at recheck (OI: odds ratio [OR] 4.35; 95% confidence interval [CI] 1.21–15.70; P = 0.02; surgery: OR 3.64; 95% CI 1.03–12.87; P = 0.045). No other prognostic indicators were identified. No variables tested were significantly associated with risk of serious complications or euthanasia.Conclusions and relevance Surgical management of chronic OMI was successful in most cases but was not benign and not always beneficial. The analysis was unable to identify clinically helpful outcome predictors. Optimal management of chronic feline OMI remains a challenge, particularly for animal shelters. Less invasive approaches and chronic medical management require further investigation.Keywords: Otitis media; otitis interna; ventral bulla osteotomy; surgery; animal hoarding; complications; outcomes; Streptococcus equi subspecies zooepidemicusAccepted: 2 August 20231Toronto Humane Society, Toronto, ON, Canada2Biostatistical Consultant, Toronto, ON, Canada3Toronto Veterinary Emergency Hospital, Toronto, ON, Canada4Veterinary Emergency Clinic, Toronto, ON, CanadaCorresponding author:Linda Jacobson BVSc, MMedVet(Med), PhD, Toronto Humane Society, 11 River Street, Toronto, Ontario, M5A 4C2, Canada Email: ljacobson@torontohumanesociety.com1197089 JFM Journal of Feline Medicine and SurgeryJacobson et alOriginal Article2 Journal of Feline Medicine and Surgery the classic signs of peripheral vestibular disease (PVD) (nystagmus, head tilt/excursions and ataxia)2,4 that are likely to trigger suspicion of OM.Stress and overcrowding predispose to upper respira -tory infection (URI) in cats.6,7 Hoarding environments are high risk for chronic upper respiratory disease complex,8–10 which can involve the nasal passages, naso -pharynx, auditory tubes, paranasal sinuses and middle ear (for reference, see https://fankhauserblog.files.word-press.com/1993/04/cat_head_xs_p4183384lbd.jpg and https://teachmeanatomy.info/head/organs/the-nose/paranasal-sinuses/).11 Undiagnosed otitis media-interna (OMI) is common in cats with rhinitis,11,12 and concurrent sinonasal disease1,11,13,14 complicates the management of chronic OMI.Surgical management has been reported for pol-yps,15,16 failed medical therapy,17,18 opacity in the tym-panic cavity, thickening of the bulla wall and chronic OM.5,19 When surgery is deemed necessary, ventral bulla osteotomy (VBO) is the surgery of choice in cats. This requires advanced surgical expertise, is expensive and time-consuming, and can be associated with significant complications.15–17,19–22Chronic feline OMI is a Pandora’s box (‘a source of great and unexpected troubles’) for animal shelters. Failure to identify OMI has implications for both cats and adopters, but overdiagnosis is also a risk, and clinical management is problematic. There are no evidence-based guidelines for feline case management, nor are reliable prognostic indicators available.It was the authors’ hope that this study would help resolve some of the decision-making dilemmas associated with chronic OMI. The aims of the present study were to report presenting signs, postoperative complications and outcomes in 58 previously hoarded cats treated surgically for OMI, and to identify the risk factors for complications and poor outcomes.

Answer 90

Surgical site infections (SSI) are a risk in any surgery.The incidence of SSIs varies following small animal surgi-cal procedures but ranges from 0.8% to 18.1%.1–3Surgicalsite infections result in increased morbidity, increasedtreatment costs, and can be fatal in some patients.3,4Surgical preparation, including hand hygiene and don-ning sterile surgical gloves, is an important part of preventingSSI. Glove puncture during surgery can result in higher ratesof SSI.5Glove punctures occur in 6% –66% of surgeries6–10butgo unnoticed by the surgical team 78% –86% of thetime.6,9,11,12When a glove perforation occurs, a path betweenthe surgeon's hand and the surgical site opens, allowingAbbreviations: CFU, colony forming unit; CGE, closed gloveexchange; MALDI-TOF MS, matrix-assisted laser desorption ionizationtime-of-flight mass spectrometry; SSI, surgical site infection.Received: 28 July 2022 Revised: 9 February 2023 Accepted: 2 April 2023DOI: 10.1111/vsu.13962Veterinary Surgery. 2023;52:747 –755. wileyonlinelibrary.com/journal/vsu © 2023 American College of Veterinary Surgeons. 747bacteria to move from inside the glove into the surgical site.13When assessing intraoperative bacterial contamination,Andrade et al. found that the most common source ofwound contamination was the hands of the surgical staff.6For a variety of reasons, surgeons change gloves intrao-peratively. In human patients, glove exchange prior towound closure has been shown to reduce the risk of SSI.14,15Similarly, in veterinary medi cine, intraoperative gloveexchange may be performed for glove perforation, glove con-tamination, prior to wound clo sure following a clean/con-taminated, contaminated or dirty surgical procedure, or aftera tumor has been manipulated intraoperatively.In veterinary medicine, glove exchange can be per-formed as a closed glove exchange (CGE).16An assistantwill pull the surgeon's gloves off, simultaneously pullingthe gown sleeve so that the sleeve of the gown covers theentirety of the surgeon's hands and fingers as the glovesare removed. The surgeon will then work through theirgown sleeves to reglove using a closed gloving technique.This method ensures that the hand never comes in contactwith the outside of the gown or glove.16Although thismethod is used, there are no published studies that exam-ine the potential contamination of the surgeon's handswhile using this technique. When performing the firstgloving when donning a new sterile gown, a closed glovingmethod is acceptable because the gown sleeves are sterile,therefore working through the sterile gown sleeves willnot result in depositing bacteria on the hands. However,when performing a glove exchange, the surgeon has beenwearing the gown for some period of time. The gown-gloveinterface is prone to contamination, which makes it apotential source for contamination.17When performing aCGE, the gown sleeve is pulled from proximal to distal onthe arm, a practice that is avoided when preparing oneselffor surgery. When the sleeve is pulled distally and thehands are manipulated to reglove during the CGE, bacte-rial contamination of the hands may therefore occur fromthe inside of the gown sleeves. In human medicine, chang-ing sterile gloves during a procedure is frequently per-formed as an assisted glove exchange.18The gown cuff isnot altered when the glove is removed. The sterile glovebeing donned is held open by a scrubbed team member,and the person regloving inserts his hand into the glove,only touching the inside of the glove.Newman et al. found that assisted glove exchangeresulted in gown contamination 0% of the time, whileboth open and closed glove donning resulted in gowncontamination 100% of the time.19Duxbury et al. foundthat the open gloving technique caused less outer glovecontamination when compared with closed gloving.20Newsom et al. found that the closed gloving techniquecaused less bacterial hand contamination than open glov-ing.21A veterinary study assessing glove exchange wasrecently published and evaluated CGE and bacterial con-tamination of the outside of gloves and gowns.22Thisgroup showed that performing CGE did not result in bac-terial contamination of the outside of gloves;22however,the study did not evaluate the hands of the surgical team.Glove puncture is common, so detection of hand contam-ination during glove exchange is necessary.As there is a potential for hand contamination from con-tact with the gown cuff and sleeve, the primary objective ofthis study was to determine if CGE increases hand contami-nation. A secondary objective was to explore whether therewas an association between hand contamination post-CGEand surgical service, participant training level, scrub type,time spent scrubbing, and leng th of surgery participation.We hypothesized that a greater number of positivebacterial cultures would be detected from swabs per-formed post-CGE when compared to baseline (bacterialcultures performed pre-CGE).

Answer 91

al Comparison of Cortical LagScrews and Cortical Position Screws for TheirGeneration of Interfragmentary Compressionand Area of Compression in Simulated LateralHumeral Condylar FracturesLucy M. Fuchter1Dan Wills2William R. Walsh2Mark Newman3Chris Tan21Small Animal Specialist Hospital (SASH), Sydney, Australia2Surgical and Orthopaedic Research Laboratories (SORL), UNSWSydney, Price of Wales Clinical School, Prince of Wales Hospital,Sydney, Australia3Western Australia Veterinary Eme rgency and Speciality (WAVES),Perth, AustraliaVet Comp Orthop Traumatol 2023;36:250 –256.Address for correspondence Lucy M. Fuchter, BVetBiol, DVM, SmallAnimal Specialist Hospital, Level 1/1 Richardson Place, North Ryde,NSW, 2113, Sydney, Australia (e-mail: lfuchter@sashvets.com).oductionSuccessful treatment of intra-articular fractures relies uponatraumatic surgical technique, articular cartilage protectionand preservation, accurate anatomical fracture reduction andrigid internal ﬁxation, which may be assisted through thegeneration of interfragmentary compression.1As compressionpromotes bone healing through gap reduction and increasedstability, the generation of interfragmentary compression isarguably the most important component, although the idealmagnitude of compression is not known or measured.2Lateral humeral condylar fractures (LHCF) are a commonintra-articular fracture seen in small animal practice. Vari-ous methods of LHCF ﬁxation are reported in the scienti ﬁcliterature: cortical, cancellous, cannulated, mini, Shermanand headless compression screws, self-compressing Ortho ﬁxpins, Kirschner wires and wiring.3–14Adjunctive stabilizingimplants such as Kirshner wires, supracondylar screws,washers and lateral epicondylar plates are often added toaugment stabilization, prevent fragment rotation or a com-bination of both.8,11,13Bone screws are preferred by manysurgeons due to their versatility, as they have potential foruse as a lag screw, position screw or plate screw dependingon insertion technique.15Cortical screws are preferable tocancellous screws for the ﬁxation of LHCF due to theirincreased resistance to both bending and shear loads..They have been shown to provide stiffer ﬁxation comparedwith headless compression screws and a greater area ofcompression, compression and compressive force comparedwith self-compressing Ortho ﬁxp i n s .6,16Cortical screws canbe inserted as a lag screw, generating interfragmentarycompression during tightening or as a positional screw,which serves to maintain any interfragmentary compressionthat was generated by the application of reduction forceps.The aim of this study was to compare the interfragmen-tary compression and area of compression achieved usingcortical screws inserted as lag screws and cortical screwsinserted as a positional screw. To achieve this, we developeda simulated LHCF model in cadaveric ovine humeri. Our nullhypothesis was that there would be no signi ﬁcant differencein both the magnitude of interfragmentary compression andarea of compression between the two groups.

Answer 92

Brachycephalic obstructive airway syndrome (BOAS) is acommon cause of dyspnea in dogs.1–3The developmentof BOAS is a multifactorial process involving both primaryand secondary anatomical abnormalities, such as elon-gated and/or thickened soft palate, stenotic nares, hypo-plastic trachea, aberrant nasal turbinates, macroglossia,Data from this study were presented as an abstract in oral form at the American College of Veterinary Surgery Summit, Portland, Oregon, October13, 2022.Received: 7 November 2022 Revised: 29 June 2023 Accepted: 5 July 2023DOI: 10.1111/vsu.14002122 © 2023 American College of Veterinary Surgeons. Veterinary Surgery. 2024;53:122 –130. wileyonlinelibrary.com/journal/vsuevertedlaryngeal saccules, laryngeal collapse, and evertedtonsils.1–7Multilevel upper airway surgery is commonlyperformed to address the variety of abnormalities thatmay be present in a single patient, including rhinoplasty,laryngeal sacculectomy, and partial staphylectomy.1–3Risks of surgery include minor complications, such aspersistent stertor, stridor, and coughing, to more seriouscomplications requiring intervention, such as hemorrhage,dehiscence, dyspnea, regurgitation, vomiting, aspirationpneumonia, and in severe cases, death.1–3,8–11Pharyngealedema as a result of surgical trauma is thought to contrib-ute to the development of postoperative dyspnea and mayrequire intervention such as anti-inflammatory adminis-tration, supplemental oxygen therapy, and upper airwaydiversion via temporary tracheostomy.1,2,8,9,11 –14Factorsshown to be associated with the requirement for tempo-rary tracheostomy postoperatively include increasingage, development of postoperative aspiration pneumonia,concurrent airway pathology, emergent presentation priorto surgery, and increased surgical duration.11–13Elongation of the soft palate has been reported as themost common abnormality observed in dogs undergoingsurgical correction for BOAS.1–3,11,13Evaluation of softpalate length is commonly performed during sedatedupper airway examination; however, this technique doesnot allow for accurate assessment of palatal thickness.Studies investigating the soft palate by means of com-puted tomography (CT) and histology in brachycephalicbreeds have demonstrated that excessive thickness maybe an important contributing factor to BOAS.15,16Despitethese findings, many surgeons only address excessive softpalate length when addressing dogs with BOAS in multi-level upper airway surgery.Numerous methods have been described to effectivelyshorten the soft palate, including conventional incisionaltechnique, monopolar cautery, diode laser, carbon diox-ide (CO2) laser, bipolar vessel sealing device (BVSD),harmonic scalpel, and plasma-mediated bipolar radiofre-quency ablation.17–26Several studies have sought to eval-uate differences between various partial staphylectomytechniques. Previous studies comparing conventionalincisional with CO2laser techniques have found no sig-nificant differences in clinical outcome.13,18Studies com-paring CO 2laser with BVSD techniques in both normaland clinically affected dogs have yielded similar histo-pathological findings and no significant difference in theincidence of complications; however, these studies wereperformed with relatively low numbers of dogs in eachtreatment group.19,24No studies have been performed comparing conven-tional incisional with BVSD techniques, nor have anystudies directly compared conventional incisional, CO2laser, and BVSD partial staphylectomy techniques in aclinical setting. The objective of this study was to retro-spectively compare these techniques in regard to risk ofmortality in a large number of dogs undergoing partialstaphylectomy for the treatment of BOAS. Our hypothesiswas that no significant difference in odds of mortalitywould be apparent between the techniq

Answer 93

Canine hip dysplasia is one of the most common orthopaedicdiseases in dogs.1The prevalence varies between breedsfrom 2 to 80%.2Canine hip dysplasia is a multifactorialcondition with polygenetic component. Heritabilities of0.15 to 0.43 are reported for the disease.3,4Increased hipjoint laxity is one of the most important factors of canine hipdysplasia and results in subsequent in ﬂammation and oste-oarthritis in later life. To reduce the incidence of canine hipdysplasia in the population, breeding selection programshave been established. Most methods rely on radiographicassessment of the hip joints. There are different methods forthe radiographic detection of canine hip dysplasia. TheFédération Cynologique Internationale (FCI) scoring schemewith ﬁve descriptively de ﬁned grades (A-E) is a commonlyused method in Europe.5The FCI scoring scheme is based onevaluation of a hip-extended ventrodorsal radiograph of theis. Dogs scored using the FCI method are required to havea minimum age of 12 to 18 months, and general anesthesia isstrictly required to avoid in ﬂuence of muscle tone. It hasbeen reported that the Norberg angle increases by up to2.65 degrees in unsedated animals.6In Germany, radio-graphs can be taken by any veterinarian and scoring isusually made by a certi ﬁed scrutineer. Hip joints are evalu-ated for congruence, shape, bone structure, osteophyte for-mation, and measurement of the Norberg angle. The ﬁnalgrade of a dog is based on the grade of the worse hip joint.7The Norberg angle is a measure of hip joint laxity and isinﬂuenced by the depth and shape of the acetabulum. TheNorberg angle is the angle between a line from the center ofthe femoral head of the left hip joint to the center of thefemoral head of the right hip joint and a line from the centerof the femoral head of each side to the dissecting point of thecranial acetabular joint surface and the femoral head jointsurface. The descriptions of the grades A to E in the FCIsystem include suggestions for the Norberg angle cutoffvalues (►Appendix Table 1 , available in the online version).Although the radiographic technique is precisely described,images submitted for scoring are often tilted (cranial/caudal orleft/right) or with the femora rotated too far inward oroutward.8In human medicine, it is known that pelvic rotationand tilt in ﬂuences the measurement of the acetabular index.9While a recent study showed no effect of pelvic tilt in thecoronal plane in a bone model, a thesis in veterinary medicineusing dissected pelves suggests dorsal and ventral tilt of thepelvis in ﬂuences the Norberg angle by up to 10 degrees.10,11Therefore, malpositioning may potentially in ﬂuence the FCIscore of the dog.12Obviously tilted radiographs are usuallyrejected from evaluation. It has been reported that interob-server agreement increases with radiographs evaluated asassessable.13,14Correct positioning for a hip-extended ven-trodorsal radiograph of the pelvis can be evaluated usingvarious anatomical landmarks.7,15–17In the cases with asym-metrical lumbosacral transitional vertebrae, incorrect posi-tioning of the dog during radiographic examination canoccur.18Femora should be parallel to each other and parallelto the caudal lumbar spine. Dorsal spinous processes of thecaudal lumbar spine should be in the middle of the vertebralbody. The wings of the ilium as well as the obturator foramenshould be bilateral symmetrical. The patella should be pro-jected centrally between the medial and lateral femoral con-dyle, and both the medial and lateral sesamoid bone of thegastrocnemius muscle should intersect with the femoralcortical bone. There are reports suggesting iliac horizontaldiameter and obturator foramen width are best to evaluate thelateral tilt of pelvic radiographs.19,20To the best of the authors ’knowledge, there is no study assessing the in ﬂuence of mal-positioning in various directions on the Norberg angle in aclinical scenario. The aim of the study was to quantifythe degree of long and short axis rotation, which is necessaryto subjectively recognize the radiograph as tilted or inade-quately positioned and to determine the in ﬂuence of position-ing on the Norberg angle to avoid false i

Answer 94

IntroductionCanine Hip Dysplasia (CHD) is the most common inherited orthopedic coxofemoral disease with a reported prevalence in 19.7% of purebred dogs and 17.7% of mixed breed dogs.1 Loss of function and pain associated with the coxofemoral joint is the most common reason for total hip arthroplasty (THA).2 THA has been used as a treatment for a va -riety of coxofemoral pathologies, including osteoar -thritis (OA), congenital and traumatic hip luxation, proximal femoral head and neck fractures, proximal femoral tumor excision, and CHD.3 CHD and associat -ed OA are commonly diagnosed on physical exam in addition to ventrodorsal hip-extended radiographs. Additional radiographic techniques can be utilized to add diagnostic information regarding hip laxity and overall conformation.4 CHD is commonly managed a.23.02.0082conservatively via weight loss, activity modification, physical therapy, anti-inflammatory medications and/or supplements.5,6 For patients that fail conser -vative management or have severe disease affecting quality of life, surgical intervention with either fem -oral head and neck excision (FHNE) or THA is rec -ommended. FHNE has incurred inconsistent results regarding outcomes following the procedure.7–9 THA has become the gold standard with upwards of a 95% success rate.2,10–12Currently, there are 2 main categories of THA: ce -mented and cementless, with a hybrid combination available. Reported complications of all THA systems include infection, septic and aseptic implant loosen -ing, coxofemoral luxation, femoral fracture, femoral implant subsidence, femoral medullary infarction, pulmonary embolism, metallosis, and sciatic neura -praxia. Complication rates range from 5% to 30% de -2 pending on the THA system employed and duration of study follow-up.2,12–21 Femoral fracture, which can be created during the reaming process of the femoral ca -nal is a risk factor/complication of both cemented and cementless THA with a reported incidence of 2.9%.22 Aseptic loosening is another possible complication that can occur with THA.23 Finally, a complication of cementless THA includes subsidence which is the set -tling or distal migration of the femoral component with respect to surrounding bone.24,25The Centerline THA (C-THA; Biomedtrix) sys -tem (Figure 1) is a cementless system that was initially developed to specifically treat dogs with proximal femoral deformities, where access to the femoral medullary canal for reaming associated with traditional THA was not possible.26 While most THA systems create a coxofemoral angle around of 135 degrees, the C-THA replicates the angle of the femoral neck (144.7 degrees)27,28 The C-THA has been shown to be biomechanically stiffer than comparative THA procedures in an ex-vivo study. Within this study, the C-THA showed significantly greater compressive stiffness and less displace -ment at peak load compared to the collared, col -larless and lateral bolt THA (Biomedtrix) systems. Also, the C-THA had a significantly higher torque when compared to a collarless THA.29 To the best of the authors’ knowledge, there has been no re -port of the long-term clinical results and complica -tions associated with the C-THA system in a clinical series. The objective of this study was to evaluate the long-term clinical and radiographic outcome associated with the C-THA implant in a population of client owned dogs that would be candidates for traditional THA. Our hypothesis was that the C-THA would have similar clinical outcomes as traditional THA systems, while avoiding complications such as subsidence and femoral fracture.

Answer 95

Scottish Fold is a purebred cat breed characterised by typical ears folded forward on the head. This trait devel -ops from 3–4 weeks of age and usually is set by the age of 3–4 months.1 The breed was developed in 1961 by mat -ing a Fold queen (carrying a de novo mutation) with a British Shorthair stud.2 The first deformities were men-tioned in 1971, when progressive bone abnormalities and crippling lameness were described.3 The breed was no longer recognised in England from 1974, while in the USA, imported cats from the UK were outcrossed with normal eared breeds, and in later generations, fold-to-fold mating was carefully avoided. Thus, only 50% of kittens will have folded ears, while kittens with normal ears are known as Scottish Straight.4Scottish Fold osteochondrodysplasia (SFOCD) is an inheritable disorder (dominant trait displaying incom-plete dominance)5 characterised by skeletal deformities.2 In homozygous individuals, joint lesions progress until Osteochondrodysplasia and the c.1024G>T variant of TRPV4 gene in Scottish Fold cats: genetic and radiographic evaluationStefano Sartore1*, Riccardo Moretti1*, Lisa Adele Piras1, Maurizio Longo2, Stefania Chessa1 and Paola Sacchi1AbstractObjectives The objectives of this study were to investigate the c.1024G>T SNP in the TRPV4 gene in Scottish Straight and Fold cats, and to evaluate the pattern of skeletal phenotype and the evolution of radiological signs of Scottish Fold osteochondrodysplasia (SFOCD) over time in heterozygous subjects.Methods DNA was obtained from blood samples of 17 cats (Scottish Fold: n = 12; Scottish Straight: n = 5) and subsequently genotyped by sequencing in a 249 bp region of the TRPV4 gene (exon 6), including the known c.1024G>T causative mutation for osteochondrodysplasia. Orthopaedic and radiographic analyses were performed on animals carrying the mutant allele.Results Genotyping by sequencing confirmed that all and only the Scottish Fold cats carried the mutant allele in a heterozygous asset. Furthermore, two other exon variants, already described in the literature as silent variants, were found in some of the sampled cats. Comparative orthogonal radiographic views of the shoulder, elbow, carpus, hip, stifle and tarsus were obtained. A mediolateral projection of the thoracic and lumbar column was also performed. Three out of four cats were clinically and radiographically examined again 1.5 years later.Conclusions and relevance Although the presence of the mutant allele in all the tested Scottish Fold cats was confirmed, only 1/12 showed clinical signs of SFOCD. Furthermore, no cats in the 1.5-year follow-up showed skeletal changes. Although significant, the c.1024G>T mutation in the TRPV4 gene, supposedly, is not the only cause or risk of developing SFOCD.Keywords: Osteochondrodysplasia; Scottish Fold; TRPV4 genotyping; radiological examinationAccepted: 17 October 20231Department of Veterinary Science, University of Turin, Grugliasco, Turin, Italy2Department of Veterinary Medicine and Animal Science, University of Milan, Lodi, Italy*Stefano Sartore and Riccardo Moretti contributed equally to this workCorresponding author:Stefania Chessa PhD, Department of Veterinary Sciences, University of Turin, 10095, Grugliasco, Turin, Italy Email: stefania.chessa@unito.it 1211763 JFM Journal of Feline Medicine and SurgerySartore et alShort Communication2 Journal of Feline Medicine and Surgery the cats are unable to walk. On radiography, distorted metaphyses of metatarsal and metacarpal bones are evi -dent. This results in the decreased length and abnormal shape of bones and distal limbs. Shorter caudal vertebrae, widened endplates and gross plantar exostoses of tarsal and metatarsal bones are clinically and radiographically evident.6In 2016, a genome-wide association study revealed a significant association between fold phenotype, osteo-chondrodysplasia and a missense variant in TRPV4 .7 Located on chromosome D3, TRPV4 encodes for the Transient Receptor Potential Vanilloid family member 4 protein, is expressed in a wide range of tissues and is considered the strongest candidate marker due to its mechanosensory action on chondrocytes.8 In total, 11 variants were detected in TRPV4 : five were responsi -ble for a change in the amino acidic sequence, but only one was associated with the folded ear phenotype (exon 6, c.1024G> T). In 2008, Masuyama et al demonstrated that the lack of TRPV4 expression in mice increases bone mass by impairing bone resorption.9 Furthermore, a genome-wide screening carried out on two murine cell lines showed that TRPV4 is involved in the regulation pathway of SRY-Box Transcription Factor 9 ( SOX9 ), a transcription factor for chondrocyte differentiation.10 Lastly, the skeletal phenotypes reported in the literature in heterozygous cats for the c.1024G> T ranged from mild to severe, with a high variability of the severity of skeletal abnormalities among affected cats,11 although the age of onset of clinical signs, as well as the severity and the progression of the secondary bone formation, are highly variable. So far, no information is available about the evolution of the SFOCD over time. The aim of the present study was to investigate the c.1024G> T variation in TRPV4 in Scottish Straight and Fold cats, to evaluate the pattern of skeletal phenotype in heterozygous sub-jects and to determine the progression of SFOCD radio -logical signs over time.

Answer 96

Tibia plateau leveling osteoto my (TPLO) aims to neutralizecranial tibial thrust during t he weightbearing phase of thestride by rotating the tibial plateau and reducing the caudalslope.1,2A negative TCT performed intra- or postoperativelyResults from this study were presented at the virtual 30th AnnualScientific Meeting of the European College of Veterinary Surgery;July 8 –10, 2021.Received: 18 September 2022 Revised: 26 January 2023 Accepted: 15 February 2023DOI: 10.1111/vsu.13955This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in anymedium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.© 2023 The Authors. Veterinary Surgery published by Wiley Periodicals LLC on behalf of American College of Veterinary Surgeons.686 Veterinary Surgery. 2023;52:686 –696. wileyonlinelibrary.com/journal/vsuisinterpreted as an i ndication for a stable stifle after TPLO.However, persistent cranial t ibial subluxation has beenreported in 30% of dogs after TPLO,3–5suggesting that TCThas limitations for evaluatin g stifle stability post-TPLO.Pivot shift, a phenomenon de scribing rotational andtranslational stifle instability, has been reported to causeongoing lameness after TPLO,6–8encouraging some sur-geons to combine TPLO with an extra-articular lateral aug-mentation in selected cases.9,10To the authors'knowledge, there are no reports of joint kinematics of TPLOcombined with extra-articular lateral augmentation. In addi-tion, there are no investigations on laxity tests assessing rota-tional stability after TPLO . Such a test could guide thesurgeon intraoperatively when to perform an extra-articularlateral augmentation in combination with TPLO. Earlierdetection of rotational instab ility and treatment may preventpersistent instability and lameness after TPLO.The aim of this study was to analyze biomechanicallyCCL-deficient stifles treated with TPLO and TPLOcombined with an extra-articular lateral augmentation.Craniocaudal and rotatory instability were assessed whileperforming traditional TCT as well as the novel tibial pivotcompression test (TPT). The TPT has been described andvalidated as a tool to assess craniocaudal and rotationalinstability in CCL-intact and -deficient stifle.11It combinest i b i a lc o m p r e s s i o ne i t h e rw i t ha ni n t e r n a l( i T P T )o ra nexternal rotational moment (eTPT). These tests were per-formed in intact, CCL-deficie nt, TPLO-stabilized stifles,and after combined TPLO and extra-articular lateral aug-mentation. A testing set-up, previously described by Lam-part et al.11and used in several biomechanical studies inpeople for evaluating anterior c ruciate ligament reconstruc-tion techniques, was utilized.12–14We hypothesized that:(1) a combined TPLO and extra-articular lateral augmenta-tion would more effectively restore the native kinematics,especially for rotational instability, than TPLO alone;(2) the TPT would detect more laxity after TPLO than TCT.

Answer 97

186 JAVMA | AUGUST 2023 | VOL 261 | NO. 8Surgical site infection (SSI) is a challenging postop -erative complication that negatively impacts patient recovery and increases the cost of care.1 Treatment of orthopedic SSI includes local decontamination of the af -fected site, administration of systemic antibiotics, and the removal of metallic implants after adequate healing of the surgical site.2,3 Successful clearance of orthopedic SSI with systemic antibiotics alone can be challenging due to several factors, including inability of the drug to penetrate the biofilm on metallic implants or bone and poor compliance.4,5 The presence of a multidrug-resis -tant pathogen complicates the management of an SSI and can require a prolonged treatment with systemic an -timicrobials, increasing the risk of adverse drug events.6a.23.02.0058Local antimicrobial administration is often consid -ered an adjunct therapy, as it allows the sustained release of the antimicrobial at a high concentration with de -creased systemic toxicity.7 Optimal vehicles for antimicro -bial delivery should be sterile, biodegradable, and easy to administer; have a small volume; and provide controlled drug release.8,9 Calcium sulfate beads are commonly used in veterinary medicine for local antimicrobial delivery be -cause they are bioresorbable and have osteoconductive properties.10–14 The use of a dextran polymer hydrogel vehicle for delivery of local antimicrobials has also been described for the management of dogs with infected tibial plateau leveling osteotomies (TPLO) and septic ar -thritis.9,15 Thirty percent poloxamer 407 (P407) hydrogel JAVMA | AUGUST 2023 | VOL 261 | NO. 8 1187(Pluronic F-127 hydrogel) is a temperature-responsive poloxamer aqueous solution that is a versatile vehicle for local antimicrobial therapy and simple to administer, allowing delivery to infected sites with limited space or access.8 Antimicrobial elution using P407 hydrogel as a delivery vehicle has been reported for multiple drugs.16,17 Results for clindamycin, amikacin,16 and vancomycin17 showed local concentrations above minimal inhibitory concentrations against Staphylococcus for at least 4 to 8 days. Little is known about the outcome of orthopedic SSI treated with local antibiotic therapy using P407 hydrogel. The aims of the study were to report the outcomes of sur -gical implantation of antibiotic-impregnated P407 hydro -gel in a population of client-owned dogs as part of the management of orthopedic SSI and to identify risk factors for treatment failure.

Answer 98

510 JAVMA | OCTOBER 2023 | VOL 261 | NO. 10Subcutaneous closed suction drains are wide -ly used in human and veterinary medicine for wound and postoperative surgical site manage -ment.1,2 Closed suction drains allow evacuation of necrotic tissue, bacteria, inflammatory mediators or serous fluid from an enclosed space which may help prevent infection, delayed healing and discomfort.2Closed suction drains comprise a plastic or glass reservoir to store fluid produced from the cavity and a silicone drainage tube with fenestrations at the distal end.1,3 Active closed suction drains employ a suction generating reservoir to actively pull fluid a.23.03.0180through the drainage tube.1 These are reported to be superior to passive drains because the suction effect results in better apposition between tissue surfaces for healing and carries a lower risk of introducing nosocomial infection.3,4Closed suction subcutaneous drains are com -monly used in human medicine for procedures such as radical mastectomy, and total hip and knee ar -throplasty.5–7 It is common practice for patients to be discharged with continued postoperative drain management at home prior to removal.6 In prosthet -ic breast reconstruction procedures, closed suction JAVMA | OCTOBER 2023 | VOL 261 | NO. 10 1511drains are removed at day 7 postoperatively or if the drain fluid is less than 30 mL within a 24-hour pe -riod.6,7 In total knee and hip arthroplasty procedures, drains are removed as early as 24 hours postopera -tively; most (91%) drain production occurs within the first 24 hours, and drain placement > 24 hours is associated with an increased degree of contami -nation.4,7 In human medicine, additional reported benefits of early drain removal include decreased dressing-associated costs, lower risk of scar-forma -tion, decreased drain-associated discomfort and ac -cumulative anxiety leading up to drain removal.6Animals in veterinary medicine are typically not discharged from hospital until removal of closed suction drains due to the risk of premature dislodge -ment or removal, inaccurate drain production quan -tification, as well as owner difficulty managing drains at home.2,8 Despite drain removal being a require -ment for discharge in many veterinary facilities as reflective of current literature,9,10 the timing of drain removal is still highly debatable and is dependent on practitioner experience and preference, drain pro -duction trends, type of drain, size of cavity and the weight of the animal.2,8 There is a reported reduced incidence of seromas when drains are removed at a production rate of less than 0.2 ml/kg/h.9As a result, animals are often hospitalized for long periods of time solely due to the presence of a subcutaneous drain.2,10 Prolonged hospitalization is associated with increased cost11 and increased risk of nosocomial infection,12 therefore, discharging an animal with ongoing drain management at home may expedite hospital discharge and help to miti -gate such risks. In human medicine, outpatient drain management is commonplace to reduce the duration of hospitalization.13 To date, there is little informa -tion in veterinary medicine regarding postoperative management of subcutaneous drains in the outpa -tient setting and associated complications.The objective of this study was to retrospectively describe and compare intraoperative and postopera -tive complications reported in a cohort of dogs and cats that had an active closed suction subcutaneous drain surgically placed and were either managed completely in the hospital setting (drain removed prior to discharge) or discharged home for ongoing outpatient care (drain in place at time of discharge). We hypothesized that the risk of complications as -sociated with being discharged home with a closed suction drain in place would be minimal and not sig -nificantly different compared with animals having drains removed prior to discharge from hospital.

Answer 99

| NO. 9 1337Urate uroliths are a common urolith type in the canine population,1,2 associated with 2 distinct disease en -tities. The first is a mutation of the urate transporter, which is commonly seen in breeds such as Dalma -tians.3,4 Secondly, ammonium urate uroliths are seen in dogs with a portosystemic shunt (PSS), or sporadically other liver disorders, due to reduced hepatic conver -sion of ammonia to urea and uric acid to allantoin.3 PSS are vascular anomalies that connect the portal vein to the systemic venous circulation, bypassing the hepatic circulation.5 Clinical signs involve the central nervous system and gastrointestinal and urinary tracts.5 Urolith a.23.02.0087formation is seen in 20% to 70% of dogs with a congeni -tal extrahepatic PSS (cEHPSS), with ammonium urate reported in 36% to 100% of those cases.5–7 Surgical treatment of cEHPSS accounts for longer survival and is preferred over medical treatment,8 but the incidence of ammonium urate urolithiasis in dogs following com -plete closure of cEHPSS without the development of multiple acquired PSS (MAPSS) is currently unknown. Only 1 study9 describes the presence of ammonium urate cystoliths in a cat, 3 years after surgical attenua -tion of a cEHPSS using thin film banding. In this study, the cEHPSS was presumed to be closed on the basis of 1338 JAVMA | SEPTEMBER 2023 | VOL 261 | NO. 9the presence of within-reference-interval postprandial serum bile acid concentrations 1 and 3 months postop -eratively, yet absence of portosystemic shunting was not confirmed using medical imaging. Although uroli -thiasis can be asymptomatic, lower urinary tract signs such as hematuria, stranguria, and pollakiuria can oc -cur, especially in the presence of a concurrent urinary tract infection.5,7,10 Besides, obstructive disease can be life-threatening.10 Urinary tract signs related to uroli -thiasis have been documented in 21% to 45% of dogs diagnosed with cEHPSS.6,7,11Currently, it is unclear whether dogs are still vul -nerable to developing ammonium urate uroliths fol -lowing successful cEHPSS surgery and whether neph -roliths remain or dissolve over time in the absence of portosystemic shunting. Furthermore, it is unclear whether dogs that develop MAPSS after cEHPSS at -tenuation are at greater risk of recurrent urolithiasis. Our study aimed to document the presence of uro -lithiasis in dogs long-term after cEHPSS attenuation.

Answer 100

Median sternotomy is the approach of choice in dogsrequiring surgical exploration of both hemithoraces.1Ahigh rate of postoperative complications, reported to bebetween 14% and 78%, has led to investigation of variousmethods of surgical closure.2–5Postoperative complicationsreported include pain, lameness, seroma formation,infection, dehiscence, drainin gt r a c t s ,p e r f o r a t e di n t e r n a lthoracic artery, osteo myelitis, sternal fr acture, and implantfailure.2–4,6In human medicine, adequate reduction andstabilization of the median sternotomy site are imperativeto avoid complications related to instability, such as pain,incisional dehiscence, and implant failure.7–10Clinicalresearch supports rigid fixation for sternotomy closures inpeople using plates and screws11,12but sternal plate fixationis not currently possible in ve terinary medicine due to lackof optimized available implants.Traditionally, orthopedic wire in a figure-of-eight pat-tern has been the recommended closure material andResults of this study were presented in part at the American College ofVeterinary Surgeons Annual Surgery Summit, virtual, October7–9, 2021.Received: 13 May 2022 Revised: 7 June 2023 Accepted: 25 July 2023DOI: 10.1111/vsu.14015Veterinary Surgery. 2023;52:1057 –1063. wileyonlinelibrary.com/journal/vsu © 2023 American College of Veterinary Surgeons. 1057pattern for dogs weighing more than 10 kg.1,6Despite itswidely accepted use, orthopedic wire presents severallimitations, including uneven tension distribution,increased time for placement in comparison with sutures,and potential glove perforation. It has been demonstratedthat pushing the twisted wire over to rest flat against abone surface substantially reduces the tension.13,14Morerecently, monofilament suture and crimped leader linehave been proposed as alternative closure devices toorthopedic wire.4,5,15 –17Suture has been proven to bemechanically inferior to orthopedic wire in a distractionmodel,15but it is frequently used as a primary closuretechnique in dogs.5The results of one study comparingmedian sternotomies closed with suture or orthopedicwire in dogs were that implant failure following distrac-tion was greater in the suture closure group.4This led togreater radiographic displacement and increased instabil-ity at 28 days, and histopathologically, there was nochondral or osteochondral healing in comparison withthe wire closure groups.4In humans, it is reported thatsternal instability can lead to a nonunion more than6 weeks postoperatively and is characterized by chronicdiscomfort and a sensation of abnormal motion.7,8Arecent, multi-institutional study of median sternotomyclosures in dogs reported comparable closure-relatedcomplication rates between orthopedic wire and suture.5The authors also reported a 14.1% closure-related compli-cation rate with a 2.3% reduction of closure-related com-plications associated with using suture versus wire,challenging the use of orthopedic wire as a primary clo-sure method for median sternotomies.Suture tape is an alternative fixation technique used inhumans for median sternotomy closure.18,19Suture tape iscomprised of a 2 mm wide nonabsorbable multistrand,long-chain, ultrahigh-molecular-weight polyethylene corewith a braided jacket of polyester. Advantages of suturetape versus metallic cerclage include ease of handling withthe elimination of wire-stick injuries, less regional trauma,and radiolucency.20In vitro studies in dogs also demon-strated good mechanical properties and predictability, withsuture tape being stronger, stiffer, and resisting morecycles than nylon.21–23A recent publication reporting onthe clinical use of suture tape for sternal closure inhumans reported no complications when compared withclosure with wire, which had a complication rate of 28.6%requiring surgical intervention.24In humans, suture tapeapplications include rotator cuff repair, anterior cruciateligament reconstruction, ulnar collateral ligament repair,olecranon fracture repair, and patellar fracture repair,among others.25–29Suture tape is most commonly used inveterinary medicine as a lateral suture at the stifle and intoggle rod procedures for repair of coxofemoralluxation.30–32Based on a review of the literature at thetime of writing, suture tape has not been reported formedian sternotomy closure in companion animals.The suture tape system (FiberTape cerclage; Arthrex,Naples, Florida) employs a loading device with a pretiedknot and two suture tails, resulting in two strands ofsuture tape placed with each pass of the conjoined sutureends. It has a preplaced half-racking knot, permittingcontrolled tensioning via a tensioner. Complicationsreported with the use of high-tensile-strength multifila-ment sutures in dogs include implant failure/breakageand infection.32–34In vitro, multifilament sutures havegreater bacterial adherence than monofilamentsutures.35,36However, clinical infection rates reportedwith multifilament sutures are low, and similar to com-parable fixation techniques.19,33,34,37The purpose of this study was to compare themechanical properties of suture tape with orthopedicwire cerclage in an ex vivo canine median sternotomymodel. We hypothesized that the suture tape would bemechanically similar to orthopedic wire when applied toa median sternotomy stabilization model in the dog.

Answer 101

Meniscal tears secondary to cr anial cruciate ligament rup-ture (CCLR) are common in dogs,1–4and often contributeto pain and lameness.5Thorough evaluation of the menisciis therefore recommended when treating CCLR,6which isusually performed at the time of surgical stabilization withan arthrotomy or arthroscopy. This can lead to prolongedanesthesia time and additiona ls u r g i c a lt r a u m a .P r e o p e r a -tive diagnosis of medial meniscal tears in dogs can beachieved with imaging modalities such as computed tomog-raphy, magnetic resonance im aging, and ultrasound; how-ever, these tests are infrequently performed for a variety ofreasons including cost and limited accuracy.7–9Received: 22 November 2021 Revised: 25 January 2022 Accepted: 11 April 2022DOI: 10.1111/vsu.13828820 © 2022 American College of Veterinary Surgeons. Veterinary Surgery. 2023;52:820 –826. wileyonlinelibrary.com/journal/vsuNeedle arthroscopy (NA) refers to the use of portablearthroscopic systems with small-bore arthroscopes that canbe performed outside the operating theater under localanesthesia. It is considered as a cost-effective diagnostic toolfor many orthopedic conditions in humans,10,11althoughtherapeutic procedures such a sp a r t i a lm e n i s c e c t o m yu n d e rNA have also been reported.12,13In a clinical study ofhumans with knee pain, NA had equivalent accuracy fordetecting meniscal tears when compared with standardarthroscopy (SA).14Multiple systems are commerciallyavailable, such as the Nanoscope (Arthrex, Naples, Florida),Mi-Eye (Trice Medical, Malvern, Pennsylvania), MIDASVuSystem (IntraVu, Redwood City, California), and Need-leView (Biovision, Milpitas, California), and to date no sin-gle NA system is considered superior to another. Needlearthroscopy is relatively new in veterinary medicine,15–22and may be a clinically useful tool for assessing menisciprior to any definitive surgery.The objective of this study was to determine the accu-racy of NA for the diagnosis of medial meniscal tears indogs with CCLR. Secondarily, we also aimed to deter-mine whether the procedure could be performed undersedation only, and to quantify the morbidity associatedwith NA. We hypothesized that NA would be a fast andaccurate diagnostic test that can be performed undersedation with minimal morbidity for detecting medialmeniscal tears in dogs with CCLR when using SA as thegold standard

Answer 102

Hepatic lipidosis and inflammatory liver diseases arereported as the most common ( 49.7% of all such diseases),and second most common (25.7% ) hepatic diseases identi-fied histopathologically in feline livers.1Liver biopsy is thesingle most informative diagnostic test for definitive diagno-sis of feline liver disease.2Larger liver biopsies obtainedduring surgery or necropsy, such as the guillotine or wedgeliver biopsy, are generally considered the gold standardtechniques for histo logic diagnosis.3–5One of the mainadvantages of these techniques is that the larger sample sizeallows enhanced diagnostic testing.6However, these tech-niques require a laparotomy or a minilaparotomy, whichhas disadvantages, namely a larger abdominal incisionand longer postoperative recovery times.5Vasanjee et al.7compared five intraoperative liver biopsy methods in dogs,including the 5 mm laparoscopic cup biopsy forceps andfound that all methods produced minimal complicationsand, aside from the needle biopsy sample, all yieldedadequate tissue samples for histology. Current researchsupports laparoscopy as a safe, minimally invasive proce-dure that allows abdominal organ visualization and biopsycollection.8,9Five millimeter cup biopsy forceps are regarded as thestandard method for laparoscopic tissue sampling in dogsbut there are no data specific to cats.8Subjectively, thelength (36 cm) and cup size of the 5 mm biopsy forceps islarge when working in smaller patients with less workingspace, and results in relatively large tissue samplesrelative to the organ from which it is retrieved. Newerpediatric laparoscopy equipment, such as the miniature3 mm biopsy forceps (20 cm long), has the potential toobtain samples of a similar diagnostic quality while mini-mizing the amount of tissue that is biopsied and can beperformed through smaller laparoscopic incisions/portals. Ina study utilizing canine cadavers, Kimbrell et al.10reportedthat there was no significant difference in morphologic diag-nosis between the 3 and the 5 mm laparoscopic biopsy for-ceps. As far as the authors are aware, liver biopsytechniques have not been investigated for feline patients.Several laparoscopic liver biopsy collection techniqueshave been reported.8,9,11,12Anecdotally, a twisting motionwhile obtaining a laparoscopic liver biopsy is thought toassist with hemostasis and was the primary techniqueused in several studies.8,13Most recently, Buote et al.11determined that a 360/C14twist technique resulted in largerliver biopsy samples and fewer histologic artifacts incanine cadavers when compared to a pull technique andpull through a cannula technique. However, there is lim-ited research in both cats and dogs that directly assessesdiffering laparoscopic liver biopsy techniques and thequality of samples obtained.As such, the primary objective of this study was todetermine if 3 mm miniature laparoscopic liver biopsyforceps would provide samples of equivalent diagnosticquality in cats compared to standard 5 mm laparoscopicbiopsy forceps. A secondary objective was to compare theeffect of a twist (T), pull (P), and twist +pull (TP) biopsycollection technique on sample size and quality. Theauthors hypothesized that liver biopsies collected usingthe 3 mm miniature laparoscopy biopsy forceps wouldprovide samples of equivalent diagnostic quality forhistopathologic analysis compared to standard 5 mmbiopsy forceps and that the 3 mm biopsy forceps, and theT technique, would result in equivalent or more tissuefragmentation and crush artifact.

Answer 103

Lesions of the proximal ureter in cats can be challengingto treat. Options for surgical management include directrepair or ureterotomy, ureteral resection and anastomo-sis, ureteral resection and neoureterocystostomy, ureteralresection and neoureterocystostomy with creation of aBoari flap, or pelvicocystostomy.1–3Surgical managementof ureteral obstruction in cats has a relatively high morbidityand mortality rate ranging from 3% to 31% and 8% to 18%,respectively.2,4Because of challenges associated with surgi-cal treatment, palliative interventional approaches usingsubcutaneous ureteral bypass devices (SUBs) and stentshave gained favor.5–7The use of these devices eliminates theneed for microsurgical skill or instrumentation, avoids someof the acute complications, and are generally faster and eas-ier to perform. However, interventional approaches havetheir own set of long-term complications.5–8Pyelovesicostomy and vesicocalicostomy, with or with-out a Baori flap, are established techniques for completeureteral bypass in humans when the renal pelvis and prox-imal ureter cannot be safely accessed due to severe pathol-ogy or following failure of endoscopic repair.9–14This study was prompted by the lack of a techniquefor bypassing the ureter for management of proximal ure-teral lesions in cats that provides continuous drainage ofthe renal pelvis, uses native tissues, is technically feasiblefor most surgeons, and does not require microvascularskill or instrumentation.The objectives of this study were to describe the surgi-cal techniques and evaluate the outcomes of two differentnephrocystostomy (NCT) techniques for complete ure-teral bypass in normal cats. Our hypothesis was that theNCT techniques would be successful and result in a pat-ent stoma between the renal pelvis and urinary bladderfor at least 90 days.

Answer 104

| NO. 10 1501Cervical intervertebral disc herniation (C-IVDH) ac -counts for approximately 15% of disc herniations, and ventral slot decompression (VSD) is the surgical procedure most commonly performed to remove the disc material on the ventral side of the spinal cord in C-IVDH.1–4 This technique decompresses the spinal cord by removing the herniated disc material (nu -cleus pulposus), which often allows for rapid reso -lution of clinical signs.5 The presence of a large slot width after VSD (slot size larger than 33% to 50% of vertebral body width) can increase the risk for seri -ous complications, such as postoperative instability, vertebral body subluxation, and fracture; vertebral fixation (VF) can prevent these complications.6,7 De-pending on the amount and direction of disc material extrusion, in small dogs with a corresponding small vertebral body size, the limited slot width may be insufficient to allow complete retrieval of extruded a.23.01.0038disc material. However, C-IVDH might recur in the adjacent intervertebral region after VF in large dogs because it creates an abnormal mechanical environ -ment between adjacent vertebrae and contributes to instability.8–10 The effect of combined VSD and VF on the mobility of the adjacent intervertebral region in large dogs has been reported in biomechanical stud -ies and clinical cases, but there are few reports on their effect in small dogs.8,9,11,12 To our knowledge, whether use of VF combined with VSD in small dogs that undergo VSD affects recovery of initial neuro -logic signs and is associated with recurrence at ad -jacent sites after surgery, compared with dogs that undergo VSD alone, has not been evaluated using sufficient numbers of cases. In addition, with respect to C-IVDH in small dogs, there are 2 known types of chondrodystrophic breeds (CDBs) that commonly develop type 1 hernias and non-CDBs (NCDBs) that 1502 JAVMA | OCTOBER 2023 | VOL 261 | NO. 10commonly develop type 2 hernias.13–15 However, it is not known whether there is a difference between outcomes of CDBs and NCDBs undergoing VF com -bined with VSD . To investigate the prognosis of C-IVDH in small dogs (< 15 kg) that underwent VSD with or without concomitant VF and test our hypoth -esis that concomitant VF might predispose to recur -rence in adjacent vertebral segments in small dogs, we conducted a retrospective study of data extract -ed from medical records.

Answer 105

Head tilt ( later torticollis or laterocollis ) is described as a rotation of the head around the first cervical vertebra or atlas, such that one of the ears is held lower than the other. This is known to be a clinical sign indicative of unilateral vestibular syndrome (Ferreira et al. 2007 , Muñana 2014 ).Although head tilt in the veterinary literature remains strongly associated with vestibular dysfunction, this clinical sign has been associated with a wider aetiological variety in human medi -cine. Underlying causes of head tilt in human medicine include congenital muscular ( e.g. sternomastoid “tumour” of infancy), osseous ( e.g. atlanto- axial subluxation), central/peripheral ner -vous system (brain – posterior fossa or basal nuclei, cervical spinal cord or spinal nerve root), ocular ( e.g. strabismus) and soft tissue ( e.g. retropharyngeal abscess; cervical muscle abscess) disease; whilst there is also a paroxysmal phenotype ( i.e. Sandi -fer’s syndrome, benign paroxysmal torticollis, spasmodic cervical dystonia etc.) (Tomczak & Rosman 2012 , Beasley 2021 ).There is currently little known about head tilt in cervical spi -nal and paraspinal disease in dogs (Harris et al. 2011 , Fernandes et al. 2019 , De Lahunta et al. 2021a , De Lahunta et al. 2021b ). The aim of this study is to characterise head tilt as a clinical sign of dogs with cervical spinal or paraspinal disease.Heat tilt in cervical spinal or paraspinal diseaseJournal of Small Animal Practice • Vol 65 • January 2024 • © 2023 The Authors. Journal of Small Animal Practice published by John Wiley & Sons Ltd on behalf of British Small Animal Veterinary Association.57

Answer 106

A challenge of the immediate postoperative period ismaintaining adequate analgesia as veterinary patients aretransitioned from hospital to home care. FDA-approvedoral nonsteroidal anti-inflammatory drugs (NSAIDs) arecommonly used for analgesia during this period.1For dogs that are not NSAID candidates,2–4oral narcoticsand other analgesics such as tramadol and gabapentin, aswell as lidocaine patches are available, but evidence oftheir efficacy in controlling acute postoperative pain islacking.5–13There is evidence for fentanyl patches provid-ing sustained postoperative analgesia in dogs14–16butdrawbacks include a delay of about 12 –24 h to reach ther-apeutic plasma concentrations, variability in systemicabsorption,17the possibility of overdose with oral trans-mucosal or enteral absorption,18,19and the risk of acci-dental or intentional misuse by humans.20,21The need for safe and well-tolerated analgesic prod-ucts for postoperative pain relief in humans and animalshas led to the development of FDA-approved liposomalbupivacaine (LB) products that provide extended releaseof local anesthetic into infiltrated tissues.22,23The efficacyof LB in reducing pain scores and opioid consumption inpeople recovering from surgery was evaluated in a 2021systematic review of 63 randomized clinical trials (RCTs).LB did not significantly reduce pain scores comparedwith placebo, standard bupivacaine or nonbupivacaineanalgesic agent in 74.58% of studies measuring pain. LBfailed to reduce postoperative opioid consumption in85.71% of studies evaluating opioid use.24In dogs, an FDA approved product (Nocita; ElancoAnimal Health, Greenfield, Indiana) has beenapproved for a single dose by infiltration injection atthe time of incisional closure of cranial cruciate liga-ment surgery, including tibial plateau leveling osteot-omy (TPLO) and other procedures.23The analgesicefficacy of single-dose surgical site infiltration with thisLB product has been reported in two clinical trials. Thefirst concluded that dogs rece iving a lateral retinacularsuture placement were less likely to require rescueanalgesia after LB use when the Glasgow CompositeMeasure Pain Scale (CMPS-SF) was used as a subjec-tive pain score.25,26A second study27also found that rescue analgesiaand opioid consumption were less in dogs administeredLB after receiving a TPLO. This study used the ColoradoState University Canine Acute Pain Scale (CSU-CAPS),28in addition to CMPS-SF and pressure nociceptive thresh-old measurements to assess analgesia. No differenceswere found in CMPS-SF, CSU-CAPS or nociceptivethresholds between treatment groups at any time point.27This study reported no financial conflicts of interest.Further exploration of an objective outcome measureof acute postoperative orthopedic pain is warranted. Anemerging objective measure of limb pain in dogs is %BW dist, the percentage of total bodyweight supported by agiven limb at a natural stance. Measurements of %BW disthave shown consistency over time, sensitivity to limblameness, and changes in limb use after TPLO and totalhip arthroplasty.29–35To our knowledge, no study hascompared %BW distwith subjective pain scores in dogs.As TPLO is one of the most commonly performedorthopedic procedures performed in dogs, finding a posi-tive treatment effect of LB in dogs recovering from TPLOcould benefit many animals. Conversely, finding a nega-tive treatment effect could eliminate unnecessary clientexpenses. To date, there are no reported randomized,placebo-controlled, masked clinical trials that evaluatethe efficacy of LB in dogs undergoing TPLO.The prospective study reported here was conducted tocompare pain assessments of client-owned dogs for 48 hafter undergoing TPLO between dogs receiving postopera-tive carprofen and a single-dose tissue infiltration with LB(treatment group) and those rece iving postoperative carpro-fen and infiltration with saline placebo (control group).Outcomes to be compared between groups includedCMPS-SF pain scores, the need for rescue analgesia, thenumber of rescue opioid doses, and %BW diston the affectedlimb. A secondary objective was to describe the statisticalrelationship between CMPS-SF pain scores and %BW dist.The null hypotheses was that no significant differencewould exist between the treatment and control group forany of the outcome measures and that no meaningful sta-tistical relationship would exist between %BW distandCMPS-SF pain scores.

Answer 107

Laparoscopic sterilization has become the stan -dard of care in dogs,1 which is due to all the re -ported benefits, including improved visualization, less soft tissue trauma, less pain, shorter hospitaliza -tion times, and fewer postoperative complications compared to open surgery.2–6 Techniques in laparo -scopic sterilization have been continuously modified in recent decades, starting with 3-port techniques and more recently description of several single-port techniques.3,7–12 Although laparoscopic-assisted ovariohysterectomy (LaOVH) has been described in a.23.08.0467©AVMAseveral studies,5,10,11,13–16 ovariectomy is still the pre -ferred technique and has been recommended to be the technique of choice, even in open surgery.15,17–20 Laparoscopic-assisted treatment of pyometra was first described in 1997 by Minami et al.21 Over the last 10 years, 3 additional reports were published on that topic. The publication by Adamovich-Rippe et al22 describes safe diameters for the enlarged uterus in dogs with pyometra and guidelines for selecting possible cases for LaOVH. According to their results, a diameter of < 2 cm was safe in dogs below 10 kg 2 of body weight, and in larger dogs, the uterine di -ameter should be below 4 cm. Two more recent pa -pers23,24 describe different single-port techniques, but so far, none of those studies did compare the minimally invasive approach to a standard open ovariohysterectomy in dogs with pyometra. There -fore, the objective of this study was to evaluate the effects of LaOVH in dogs presented with pyometra on surgery time, perioperative pain, need for rescue analgesia, recovery, C-reactive protein (CRP), and postoperative complications, compared to conven -tional surgery (ie, open

Answer 108

| NO. 9 1345Gastric dilatation-volvulus (GDV) is a commonly encountered condition in large-breed dogs and has a recorded mortality rate of 4.3% to 26.8%.1–5 Treatment involves rapid medical stabilization, surgi -cal gastric repositioning, and gastropexy to prevent recurrence. Among various gastropexy techniques, incisional gastropexy (IG) is one of the most easily performed and commonly used methods.6–8 While gastropexy is typically effective in preventing GDV,7–9 failure of IG has been reported. Hammel et al10 re-ported recurrence of GDV after IG in a Rottweiler. Hoogzand11 and Theisens12 reported failure rates of 6.9% and 9% in 2016 and 2017, respectively.Since IG can fail, a more secure method may be helpful to avoid future GDV. In 1 case, failure was proposed to have resulted from chronic stretch of the original gastropexy site, resulting in ineffective adhesion formation.10 In a report of circumcostal a.23.03.0141gastropexy, security was improved by engagement of gastric submucosa.13 Similarly, a modification of incisional gastropexy was developed whereby 2 sim -ple interrupted full-thickness sutures, 1 cranial and 1 caudal to the primary gastropexy incision, are add -ed. These 2 sutures penetrate into the gastric lumen to ensure engagement of the gastric submucosa, the strongest layer of the stomach.13,14 Adding these 2 sutures may improve the strength of gastropexy and potentially minimize the failure of IG.The objective of this study was to use tensile testing to compare the acute strength of standard incisional gastropexy (SIG) and modified incisional gastropexy (MIG) as described above. It was hypoth -esized that (1) MIG would fail at higher force than SIG and (2) failure would be manifested as stretching or tearing of gastric tissue rather than stretching or tearing of abdominal wall muscle or suture breakage.1346 JAVMA | SEPTEMBER 2023 | VOL 261 | NO. 9

Answer 109

Medial patellar luxation is one of the most common ortho-paedic diseases in dogs.1–4There are several surgical optionsfor the treatment of medial patellar luxation, includingtrochleoplasty. Trochleoplasty has been conducted in manycases with the aim to manage medial patellar luxation bydeepening the femoral trochlea.5–7However, the currentguidelines on when to perform trochleoplasty in dogs arevague. The general recommendation is to perform trochleo-plasty when the femoral trochlea is ﬂattened. However, themorphology of the femoral trochlea has not been accuratelydescribed in skeletally normal dogs or in dogs with luxatingpatella.2,8The morphology of the femoral trochlea is gener-ally estimated by palpation, and the decision regarding thenecessity of trochleoplasty has been made on the basis of thesurgeons ’subjective judgment.2,8Therefore, a method formeasuring femoral trochlear morphology in dogs is required. reports have described the measurement of trochleardepth in dogs.9–11As the trochlear depth is affected by bodysize, the ratio of the trochlear depth to the thickness of thepatella is used as the parameter for trochlear morphology indogs.9–11However, it has been reported that patellar morphol-ogy can change in association with induced patellar instabilityin rabbits.12In addition, the ratio of the trochlear depth to thethickness of the patella isknown todiffer depending on the dogbreed.11Thus, femoral trochlear morphology may not beappropriately evaluated in a manner connected to patellarmorphology. In human medicine, the sulcus angle (SA) hasbeen used as a parameter to assess femoral trochlear mor-phology in patients with patellar instability.13–15The SA is theangle formed by lines connecting the most posterior point ofthefemoral trochlea and the most anterior points of the medialand lateral trochlear ridges.13–15The SA is independent ofphotographic enlargement and is less susceptible to differ-ences in body size.16As the body size of dogs varies widely bybreed, it is worth utilizing the SA as the parameter of femoraltrochlear morphology in dogs.The SA can be measured in humans using radiography,computed tomography (CT), magnetic resonance imaging(MRI), or ultrasonography.16–22In a previous study, we investi-gated trochlear morphology in dogs utilizing the SA measured byCT.23The deepest point of the femoral trochlea was found in thetransverse images perpendicular to the tangent of the femoraltrochlea, which was 15 degrees to the anatomical axis of thefemur.23However, radiography and CT have critical disadvan-t a g e si nt h a tt h e yc a no n l yr e ﬂect osseous structures.24In humanmedicine, differences between the SA measured for the articularcartilage surface and the contour of the subchondral bone havebeen rep

Answer 110

Laparoscopic cholecystectomy (LC) has widely replacedopen cholecystectomy in humans. However, LC is stillvery new to veterinary medicine with only 165 casesreported.1–6Laparoscopic cholecystectomy is currentlyrecommended for more elective procedures for benignconditions such as mucocele, cholelithiasis and cholecys-titis without evidence of rupture, extrahepatic bile ductdistension or obstruction (EHBO).3,6Recently, Kanaiet al. also reported on 76 dogs that underwent LC withsigns of jaundice, gall bladder rupture, abdominal effu-sion, or EHBO.Complication rates associated with LC in humans arelow (0.5% –6%), with bile duct injury (BDI) occurring in0.18% –1.5% of cases.7–16Bile duct injury typically resultsfrom misidentification of the common bile duct (CBD) orcystic duct (CD) anatomy.12,17 –19Such complications canhave devastating consequences and are associated with amortality rate of up to 21%.20Conversion rates of 0% –30%and BDI rates of 0% –5% have been reported in dogs.1,3,5,6Intraoperative cholangiography (IOC) allows visuali-zation of the intra- and extra-hepatic bile ducts, aids inidentification of cholelithiasis and has been shown toreduce the incidence of, and increase identification ofBDI.21–23However, in humans, bile duct (BD) catheteri-zation for IOC poses a risk for BDI, it increases surgicaland anesthetic times, it exposes the patient and personnelto unnecessary radiation and the ensuing images can bedifficult to interpret.7,21,24Near-infrared fluorescence(NIRF) imaging has recently been used in both open andlaparoscopic procedures. It is recommended for its easeof use, lack of ionizing radiation, excellent imaging prop-erties, and has been shown to increase the identificationrate of BDI in people undergoing LC.24Following intravenous administration, ICG is rapidlycleared from the plasma and exclusively excreted, unal-tered by the liver into the bile which allows visualization ofthe biliary tree anatomy using a NIRF laparoscope.16,25 –28The near-infrared (NIR) light emitted is invisible to thehuman eye and does not alter the appearance of the surgi-cal field in white light.16Dose and timing of administrationare most important to optimize the target-to-background(bile duct-to-liver) contrast ratio and therefore enhancevisualization of the biliary tree.7,16,19,27,29,30The exact doseand timing of administration for identification of the BD indogs is unknown.The objective of this study was to determine the effectof ICG dose and timing of administration on NIRFimaging of the biliary tree in dogs to help guide clinicaluse of this technique during LC in dogs. It was hypo-thesized that all dose/time combinations would providefluorescence of the CD in dogs and that a longer timebetween injection and surgery would lead to improvedvisualization and contrast of the CD.

Answer 111

Total ear canal ablation with lateral bulla osteotomy(TECA-LBO) is a salvage surgery performed to treat end-stage otitis externa (OE), otitis media (OM), otitis interna(OI), auricular neoplasia or tympanokeratoma (cholestea-toma) in dogs.1–3TECA-LBO is technically challengingdue to the anatomic complexity of the region. Poor accessand visualization of critical neurovascular structuresincluding the facial nerve, retroarticular vein, externalcarotid artery, and maxillary vein may lead to iatrogenicdamage resulting in perioperative complications.4,5Incomplete debridement of the epithelial lining of theexternal acoustic meatus may result in latent para-auralabscessation, which typically manifests 5.5 –10 monthspostoperatively.1,6The most commonly encountered major intraopera-tive complication is severe hemorrhage from the retroar-ticular vein, maxillary vein, or external carotid arteryduring dissection around the external acoustic meatus.1Significant hemorrhage requiring a blood transfusion hasbeen reported in 5.5% –15.6% of cases.7,8Overall postoper-ative complication rates range from 21% to 53%.4,8–10Wound-related complications include surgical site infec-tion, fistulation, para-aural abscessation, and persistentdrainage tracts (2% –50%).1,7Neurological complicationsinclude facial nerve paresis or paralysis (13% –36%),Horner's syndrome (3.3%), vestibular disease (1% –8%),and hypoglossal nerve dysfunction (3% –8%).11–14French Bulldogs, English Bulldogs, and Pugs havebeen referred to as extreme brachycephalic breeds(EBBs).15Recent studies have demonstrated significantdivergence of EBBs from other brachycephalic and non-brachycephalic breeds in terms of overall health and spe-cific disease predispositions including stenotic nares,brachycephalic obstructive airway syndrome (BOAS),aural discharge, and lower respiratory disease.16–18Com-puted tomographic conformational studies carried out inthese breeds have demonstrated distinct differences inthe anatomy of the tympanic bullae in EBBs includingbulla volume, wall thickness, and position in relation tothe temporomandibular joint compared with all otherbreeds (OB).19Furthermore, stenotic malformation of theporous proximal external auditory canal resulting in a50% reduction in the lumen compared with normocepha-lic dogs has been demonstrated on computed tomography(CT) examination.20This malformation may predisposeto or complicate the treatment of OE and OM.20In theprimary author's institution, the number of EBBs, pri-marily French Bulldogs, presenting for TECA-LBO hasincreased in recent years. Subjectively, otic surgery inEBBs is considered more technically challenging com-pared to OBs.To the authors' knowledge, the complication rate fol-lowing TECA-LBO in EBBs has not been reported. Thepurpose of our study was to investigate and compare pre-senting clinical signs and diagnostic imaging findings ina cohort of EBBs and OBs and to determine intraopera-tive and perioperative complication rates followingTECA-LBO. The hypothesis was that EBBs would havehigher complication rates than OBs.

Answer 112

Cranial cruciate ligament rupture (CCLR) is a commondisease in canine orthopedics.1,2Most CCLR cases aretreated surgically, although subclassifying CCLR basedon clinical presentation may help defining more specifictreatment recommendations.3,4CCLR is diagnosed primar-ily by physical examination, often by manual laxity tests(MLT) such as the cranial drawer test (CD) and the tibialcompression test (TCT).5,6Excessive cranial tibial transla-tion (CTT) during testing suggests CCLR.6Although theTCT and CD are routinely used, they were never validatedusing objective kinetic or kinematic measures.7Further-more, a recent study reported a surprisingly low accuracyfor the CD and TCT.7This could be caused by interobser-ver variability of the testing maneuver, as shown for someMLTs in humans.8,9To reduce interobserver variabilityand increase accuracy of MLTs for human anterior cruciateligament rupture (ACLR), standardized testing maneuvershave been successfully established.10With the same pur-pose, quantitative measurement methods for human MLTshave been developed.9,11–14So far, there are no veterinarystudies investigating strategies to standardize the CD orTCT or to establish methods for subjective and objectivequantification of CTT during MLTs.In addition to limiting CTT, the cranial cruciate liga-ment (CCL) restrains internal tibial rotation.15Rotationalinstability after CCLR has become increasingly recog-nized in dogs.16–19So far, there is no veterinary test toassess for this type of instability, although it would bevaluable to better characterize stifle instability and toidentify dogs that might be prone to complications aftersurgical treatment of CCLR.16,19In humans, rotationalinstability in addition to anterior laxity is a well-knownproblem after ACLR and is evaluated by the pivot shifttest.20–23For this test, the patient lies in dorsal recum-bency, legs extended. The examiner picks up the affectedleg at the ankle and applies internal rotation with onehand. The other hand is placed proximolateral on thetibia and applies a valgus stress. Then, the knee is slowlyflexed. In ACLR, a sudden reduction of the anteriorlysubluxated lateral tibial plateau can be palpated.21Basedon the pivot shift test, the authors developed a new testnamed tibial pivot compression test (TPCT) to detectrotational and craniocaudal instability in canine patients.The TPCT can be performed with the dog in dorsal or lat-eral recumbency and consists of a standard TCT com-bined with a rotational and a valgus stress.Considering all the above, this study had four objec-tives. First, we wanted to describe and compare the kinet-ics and kinematics of the canine stifle joint during theCD, TCT and the new TPCT when performed by threedifferent observers in an experimental set up includingintact and transected CCLs. Second, we used kinematicand kinetic data to assess the intra- and interobserverreliability of the three MLTs. Third, to assess the accuracyof subjective quantification of CCT, we compared thesubjectively estimated CTT to the objective CTT valuemeasured during the tests. Our fourth objective was toevaluate the new TPCT for assessing rotational instabil-ity. Based on our clinical experience and preliminarydata, we hypothesized (1) that the TPCT would elicitmore CTT and internal tibial rotation than the othertests, (2) that the intraobserver reliability of kinetics andkinematics of the tests is better than the interobserverreliability, and (3) that all tests are accurate at detectingCTT but unreliable for quantifying it.

Answer 113

Radial and ulnar fractures are infrequent in cats, repre-senting 3–8% of all fractures.1,2 Cats have a highly flex-ible and extensive interosseous membrane, which allows twice the range of pronation (40–50°) and supination (90–128°) of the antebrachium compared with dogs.1 It has been suggested that the repair process in radial and ulnar fractures can be more challenging due to a greater chance of movement at the fracture site, which increases the interfragmentary strain and hence the risk of potential complications.3 In one study, the distribution of weight in the forelimbs of a cat was 48.2% at a walk, which increased to 148.2% when jumping down from 1 m.4 This would rapidly increase as height increased.4 This finding confirms that forelimb stability is of utmost importance for cats, particularly during everyday activities such as jumping and climbing.The majority of previous studies assessing complica -tions associated with antebrachial fractures have been based on dogs or have a mixed population of predomi -nantly dogs and fewer cats.5–7 To the authors’ knowledge, the largest study of feline antebrachial fractures is that of 28 cats; however, this included multiple methods of repair, including bone plates, external skeletal fixators and external coaptation.8 Currently, internal fixation is more commonly used to treat feline antebrachial frac-tures, and its advantages include low morbidity, minimal maintenance and allowing cats to weight bear immedi-ately after surgery.5 Reported complications related to bone plates include implant failure, bone re-fracture, surgical site infection, non-union, malunion and delayed union.1,3,9,10 One study suggested that single bone fixation (SBF) in cats (stabilising the radius or ulna alone) may be inadequate due to an insufficient splinting effect on the other bone, and the incidence of major complications was as high as 12.5–31%.8 Based on previous ex vivo bio -mechanical studies, dual bone fixation (DBF; plating the radius in conjunction with an intramedullary [IM] pin in the ulna, or plating both the radius and ulna) has been proposed to provide additional stability and significantly reduce the incidence of complications and surgical revi -sion rate.1,3To date, no study has been performed to exclusively compare the complications and clinical outcomes of SBF and DBF in the management of feline antebrachial fractures. The aim of the present study was to report the incidence of complications after internal fixation of antebrachial fractures, and to compare the incidence of postoperative complications and the short- and long-term outcomes of DBF compared with SBF. The authors hypothesise that the use of DBF will have a lower com -plication rate and improved clinical outcomes compared with SBF.

Answer 114

Nasal and facial reconstruction in dogs has beendescribed, generally following maxillectomies andnasal planectomies for maxillofacial neoplasms,1–4or incases of severe maxillofacial trauma.5–7Oral fibrosarcoma(FSA), osteosarcoma, squamous cell carcinoma, and mel-anoma are among the most frequent neoplasms involvingthe maxilla and the nasal planum.4,8–10Of the FSA, a dis-tinct subtype of biologically high-grade histologicallylow-grade fibrosarcoma (Hi-Lo FSA) affecting the rostralmaxilla, frequently seen in retriever breeds, has beendescribed.11–13Tumor-free margins are associated with amore favorable prognosis.3,12,14 –16As such, a combinedresection of the nasal planum and rostral maxilla, offer-ing wider surgical margins,2has been described.17–23Wound dehiscence, stenosis of the reconstructednares, and poor cosmetic outcome are among the mainpostoperative concerns.3,4,20,24Stenosis of the nares is acommon complication when utilizing the purse-stringtechnique for nasal reconstruction following the com-bined resection of the nasal planum and incisive bone,2or for radical bilateral rostral maxillectomy.3Novel25andcorrective26reconstructive techniques have been devel-oped aiming to minimize these postoperative complica-tions. Gallegos et al. described the reconstruction of anasal planum facsimile using the nonhaired pigmentedmargins of bilateral labial mucocutaneous rotation-advancement flaps in two dogs, achieving better cosmeticresults.25Recently, a larger case series was publishedusing the same technique; however, narrowing of thenasal orifice still occurred in 19% (5/26) of dogs, resultingin mouth breathing in two dogs.27The cosmetic result in dogs undergoing radical maxil-lectomy remains a challenging issue for surgeons toaddress and for the owners to familiarize themselveswith. This is especially important when a radical changein the dog's facial appearance is anticipated. Most dogswill return to almost normal routine, reporting goodquality of life postoperatively.3,25,27However, a dramaticchange in the patient's appearance can be a barrier forowners to consent to a potentially curative surgeryfor their pet.25In some cases, the final cosmetic outcomemay take several weeks to achieve, especially if wounddehiscence and healing by secondary intention occur. Insuch cases, the direct exposure of the nasal mucosa, nasalconchae and altered nasal orifices can be unsightly forsome owners.The purpose of this small case series was to describe anovel technique for nasal reconstruction and its use intwo dogs. Bilateral full-thickness labial/buccal rotationalflaps were used for nasal reconstruction after combinedradical resection of the nasal planum and rostral maxilla.We hypothesized that this technique would allowprimary wound healing after direct mucosal appositionand enhanced soft-tissue coverage of the exposed nasalmucosa and conchae to achieve a functional and accept-able cosmetic outcome.

Answer 115

Fractures of the medial coronoid process have been described as a separate entity from the most frequent developmental abnormality affecting the canine elbow in elbow dysplasia (ie, fragmented medial coronoid process). Isolated medial coronoid fractures are secondary to a traumatic event and re -sponsible for acute non–weight-bearing lameness of the thoracic limb.1–3 These fractures have also been observed in association with distal humeral frac -tures, some of which were intra-articular, with the a.23.08.0448©AVMAothers being supracondylar.4 Humeral condylar frac -tures tend to affect young dogs between the age of 3 to 6 months,5 and breeds such as French Bulldogs and Spaniels are at increased risk.5,6 In a study by Weigel,4 an intra-articular fragment medial to the proximal ulna was observed in 7 out of 18 condylar fractures. The described fragments were triangular in shape, and their size was a few millimeters.4 These fractures were attributed to concussive trauma to the elbow joint, and in all cases the fragments were re -2 moved arthroscopically.4 The dogs all showed post -operative satisfactory improvement of the lameness. If untreated, these fractures could potentially have consequences similar to medial coronoid process disease. However, as all fragments were removed in this study, it is unclear whether leaving the fractured fragment would have consequences on the animal’s recovery and future function.We observed in our institution that several pa -tients affected by a humeral condylar fracture also presented a possible fractured medial coronoid process. The aims of this study were to (1) report a series of cases of humeral condylar fractures with and without concomitant suspected medial coronoid process fracture and determine the prevalence of this affection and (2) evaluate the influence of the condylar fracture configuration and nature, patient signalment, elbow incongruity, and subluxation or luxation on the prevalence of concomitant suspected medial coronoid pro

Answer 116

Patellar luxation is a commonly diagnosed orthopedic condition in dogs.1 Dogs can present with varying signs ranging from mild instability of the patella within the trochlear groove with no clinical signs to constant luxation with skeletal deformity, gait abnormalities, and pain. This condition can also be accompanied by proximal displacement of the patella in the trochlear groove, known as patella alta, which may be associated with development of medial patellar luxation (MPL).2Higher grades of patellar luxation are associated with greater anatomical abnormality and severity of lameness in large-breed dogs.3 In cases of high-grade luxation, severe skeletal deformation and lameness a.23.06.0307can occur, and surgical treatment is warranted. The goal of corrective surgery is the realignment of the stifle extensor apparatus using both soft tissue and/or bone reconstructive techniques, including various types of trochleoplasty techniques to deepen the trochlear groove.4–6 While deepening the trochlear groove would allow the normally located patella to sit in a deeper groove, dogs with patella alta have a patella that sits proximal to the femoral trochlea and can luxate due to the absence of the trochlear ridges limiting medial or lateral displacement.Reported complications following surgical cor -rection of MPL include delayed union of osteotomy 2 sites, fixation failure, recurrence of patellar luxation, and lameness, with complication rates of 18.5% to 37%.3,6–9 In comparison with small-breed dogs, large-breed dogs can pose greater surgical challenges, as they have increased risk of postoperative complica -tions and may require more extensive combinations of corrective procedures.3The objectives of this study were to describe the dome trochleoplasty procedure and to report short-term outcomes and complications associated with a novel surgical technique to correct MPL secondary to patellar alta in larger-breed dogs. We hypothesized that the procedure would have a favorable outcome in correcting patellar luxation secondary to patella alta with minimal major complications compared with previous reports using oth

Answer 117

Extrahepatic splenophrenic shunts are common in dogs, and frequently identified in small breed dogs, such as miniature dachshund, Yorkshire terrier and toy poodle (Nelson & Nelson 2011 , Fukushima et al. 2014 ). The shunting vessel originates from the splenic vein, adjacent to the lesser curvature of the stomach, and connects to the phrenic vein at the ventral or dorsal cardia. During inspiration, the lumen of the shunt vessel narrows, reducing shunt blood flow and increasing portal vein blood flow. Thus, the intrahepatic portal branches are relatively well developed. For dogs with extrahepatic portosystemic shunts, occlusion of the shunting vessel is necessary for curative treatment. In veterinary medicine, occlusion of extrahepatic portosystemic shunts can be accomplished by surgical ligation, or placement of an ameroid constrictor or cellophane band (Vogt et al. 1996 , Youmans & Hunt 1998 , Hunt & Hughes 1999 , Hunt et al. 2004 , Frankel et al. 2006 , Falls et al. 2013 , Zwingenberger et al. 2014 , Bristow et al. 2017 , T raverson et al. 2018 , Joffe et al. 2019 , Serrano et al. 2019 , Matiasovic et al. 2020 , Otomo et al. 2020 , Glenn et al. 2022 ). Poggi et al. (2022) reported laparoscopic extrahepatic portosystemic shunt attenuation using a thin film in 20 client owned dogs. Although laparoscopic attenuation of extrahepatic portosystemic shunts can be performed in dogs with satisfactory clinical results, especially for shunts in the epiploic foramen, open surgery is more often performed. In human infants, if portal vein pressure under balloon occlusion is less than 32 mmHg, transcatheter embolisation using a coil is the treatment of choice for congenital portosystemic shunts (CPSSs) (Franchi- Abella et al. 2010 , Bernard et al. 2012 , Johansen et al. 2018 , DiPaola et al. 2020 ). This is a minimally invasive treatment; however, if portal vein pressure under balloon occlusion is 32 mmHg or more, it is recommended that patients are converted to open surgery, and performed partial ligation of the vessel. After treatment, CT and abdominal ultrasound are performed to identify the placement of the embolic device and observe the development of the intrahepatic portal vein branches. To monitor hepatic function, ammonia and bile acids should be measured (Franchi- Abella et al. 2010 , Bernard et al. 2012 ). In veterinary medicine, intrahepatic portosystemic shunts have been treated with central venous catheter stents and coils (Gonzalo- Orden et al. 2000 , Asano et al. 2003 , Bussadori et al. 2008 , Weisse et al. 2014 , Cook et al. 2015 , Knapp et al. 2015 , Case et al. 2018 , Culp et al. 2018 , Johansen et al. 2018 ). On the other hand, catheter treatment for extrahepatic portosystemic shunts has used coils as embolic devices (Léveillé et al. 2000 , Léveillé et al. 2003 , Bussadori et al. 2008 ). Léveillé et al. (2003 ) reported seven dogs with extrahepatic portosystemic shunts and showed that three to six coils were required to occlude or attenuate shunt blood flow. Four dogs had complete resolution of clinical signs, two dogs died from coil migration, one dog developed a second shunting vessel and ameroid constrictor was placed during laparotomy. Bussadori et al. (2008 ) reported that one dog with extrahepatic portosystemic shunts underwent coil embolization with four coils, but was euthanased 6 months later due to severe liver failure. The Amplatzer vascular plug™ (AVP) is used in human medicine for peripheral vascular embolisation of high flow medium to large blood vessels. The AVP is a self expanding device made of nitinol wire mesh. Upon release, the AVP assumes prespecified shape due to thermal memory. The AVP II is a multilayered mesh with six planes of cross- sectional coverage designed to increase density and flow disturbance and result in rapid occlusion.The AVP II has a central lobe and a disc both proximally and distally to this. The AVP IV can be delivered through a 0.038 compatible diagnostic catheter (5F diagnostic catheters), eliminating the need for catheter exchange. The multilayered, double lobed design of the AVP IV enables rapid embolization, can accommodate tortuous vessels, and is available up to 8 mm (Ramakrishnan 2015 ). Although there are reports of AVP used in cardiovascular veterinary medicine (Bagardi et al. 2022 , Belach -sen et al. 2022 , Hildebrandt et al. 2022 , Ostenkamp et al. 2022 ), there are only two reports of AVP treatment of CPSSs (Weisse et al. 2005 , Hogan et al. 2010 ). To date, there are no reports of using AVP for splenophrenic shunts. Pubmed and Google Scholar were searched using the keywords “canine,” “portosystemic shunt” and “Amplatzer vascular plug” on November 30, 2022. With the exception of the two studies (Weisse et al. 2005 , Hogan et al. 2010 ), no other reports of canine portosystemic shunts treated with AVP were identified. The aim of this study was to describe the AVP procedure and document clinical outcomes in dogs with splenophrenic shunt.

Answer 118

Primary brain tumors occur with a reported inci -dence of 2.2% in cats, and meningioma is the most reported primary brain tumor in cats,1–6 accounting for 56% to 58% of all intracranial tumors.1,7 Cats with meningiomas are significantly older than cats with other types of intracranial tumors,1,8,9 and no sex predilection has been consistently demonstrated.Feline meningiomas are considered benign, slow-growing, and mostly solitary tumors that are typically well circumscribed and delineated from the surround -ing brain tissue.10,11 Median survival times following surgical excision of meningiomas range from 693 to a.23.02.0083©The authors1,125 days (22.8 to 37 months),1,9,12,13 with a 2-year survival rate of 50%.13 Due to these characteristics, the recommendations for treatment of intracranial meningiomas in cats is primarily surgery. However, surgery is not without risks and complications, and occasionally the location and size of the tumor, or pa -tient comorbidities, may preclude surgery as a treat -ment option.14 Morbidity associated with brain sur -gery can be quite high, and reported complications include hemorrhage, anemia, central blindness, acute renal failure, pneumocephalus, increased intracranial pressure, seizures, brain herniation, infections, and 2 aspiration pneumonia.10–13,15 An immediate postop -erative mortality rate of 6% to 19% has been described in cats.9,12,13 Recurrence following surgical excision ranges from 12% to 21.4%.1,12,13 The median postop -erative time to recurrence in 6 cats was noted to be 285 days (range, 123 to 683 days).1Radiation therapy has become a mainstay of treatment for intracranial neoplasia in both hu -mans and animals as both a primary and adjunctive treatment.3 Stereotactic radiotherapy (SRT) deliv -ers a curative dose of radiation from numerous dif -ferent angles to focus the radiation while sparing the surrounding normal tissue from damage.16 The large number of beams allows for highly confor -mal target treatment with a steep dose gradient, while the nonintersecting arcs minimize exposure of normal overlying tissue, allowing a larger single treatment dose and, therefore, a lower total dose to be applied. SRT involves fewer treatments, typi -cally 1 to 3, called “fractions,” with a larger amount of radiation applied at each administration as com -pared to the traditional or conventional RT, which typically involves multiple, smaller-dose fractions delivered 3 to 5 times weekly over 3 to 4 weeks.17 Advantages of this noninvasive, single-dose to hy -pofractionated form of treatment of brain tumors in animals are that only a few episodes of general anesthesia are required and radiation exposure of normal brain tissue is substantially reduced, thereby avoiding complications associated with conventional RT.18,19 The CyberKnife system is an RT device manufactured by Accuray Inc and is 1 type of SRT system that can facilitate SRT through a linear accelerator placed on a robotic arm, giv -ing it many degrees of freedom. This freedom al -lows for increased accuracy in the delivered radia -tion to the area of interest and for the sparing of normal surrounding tissue. To our knowledge, no literature regarding SRT involving 1 to 3 high-dose fractions or the use of a CyberKnife system for the specific treatment of feline meningiomas is avail -able and no prior studies have evaluated whether SRT alone significantly prolongs survival time. The purpose of this retrospective study was to report clinical features, outcomes, and survival times of cats undergoing either SRT or surgical excision for the treatment of intracrani

Answer 119

Lymphadenectomy is known to be an important surgical procedure for the identification and treatment of metastatic lymph nodes (LNs) in vet -erinary medicine.1,2 In addition to guiding progno -sis and treatment plans, excisional LN biopsy for histopathology is the gold standard for detection of metastatic disease, and removal of metastatic LNs can improve survival rates in dogs with certain neoplasms.1–4 Despite the high clinical importance Geometric, landmark-guided technique reduces tissue trauma, surgery time, and subjective difficulty for canine peripheral lymphadenectomies: an educational crossover studyNatalie J. Worden, DVM1; Judith Bertran, DVM, MS, DACVS1*; Penny S. Reynolds, PhD1,2; Ellis C. Chase, BS1; Chiquitha D. Crews, MS1; Kathleen Ham, DVM, MS, DACVS1; Carlos H. de Mello Souza, DVM, DACVS, DACVIM1; Penny J. Regier, DVM, MS, DACVS1; Christopher A. Adin, DVM, DACVS1; Elizabeth A. Maxwell, DVM, MS, DACVS11Department of Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL2Department of Anesthesiology, College of Medicine, University of Florida, Gainesville, FL*Corresponding author: Dr. Bertran ( bertran.judith@ufl.edu )Received April 26, 2023Accepted July 5, 2023doi.org/10.2460/javma.23.04.0206of lymphadenectomies, surgical approaches to the peripheral lymphocentrums, such as the superficial cervical LN (SCLN), axillary LN (ALN), and superfi -cial inguinal LN (SILN), are infrequently described or absent within the veterinary literature.1,5Peripheral LN identification is known to be time consuming and difficult, with 1 study2 demonstrating that 40% (± 27%) of the total surgical time for mass removal and LN extirpation was dedicated solely to 2 LN identification and removal. In the same study, surgeons’ subjective difficulty scores for LN identifi -cation were as high as 85/100 for more challenging LNs, such as the ALN.2 The lack of described surgi -cal approaches to these peripheral lymphocentrums likely increases the risk of prolonged operative times and excessive tissue trauma due to the challenge of identifying the LNs. Additionally, changes in patient positioning may alter the necessary incisional orien -tation and location due to shifting of anatomy, sup -porting a demand for alternative surgical approach -es to the peripheral lymphocentrums to prevent the need for intraoperative patient repositioning.Previously, these challenges have been addressed through the use of intraoperative LN mapping tech -niques, most commonly injection of methylene blue (MB) dye.6–9 MB injection is a readily available method of intraoperative LN identification that does not re -quire any specialized equipment and therefore is suit -able for use in both specialty and general practice. However, blue dye injection may have inconsistent tissue uptake, can be challenging to discern from nor -mal tissue coloration, and can reduce visualization of fascial planes.8,9 These limitations are important to consider when selecting intraoperative methods for LN identification.In a previous study, we proposed novel, geo -metric, landmark-guided, surgical approaches to the SCLN, ALN, and SILN in canine cadavers with the goal of reducing dissection times, tissue trauma, and subjective difficulty of these lymphadenectomies.10 These approaches were based on superficial ana -tomical landmarks expected to be readily identifiable in most dogs, which could be used to triangulate the expected locations of these peripheral lymphocen -trums. The advantages of the geometric technique include the following: (1) its applicability in a range of clinical settings, as it does not require specialized dye or equipment; (2) its descriptions of deep ana -tomical landmarks, which can be referenced even when identifying lymphocentrums from alternative approaches; and (3) the definitive guidelines regard -ing patient positioning and incisional orientation.The objectives of the present study were to evaluate the previously described landmark-guided surgical approaches (SCLN ventral approach, ALN, and SILN) compared to standard and MB-guided lymphadenectomies (MBL) performed by novice surgeons in canine cadavers. The outcome measures were surgical time, successful LN identification, de -gree of tissue trauma, and subjective difficulty. The null hypothesis was that there would be no differ -ences in successful LN identification, surgical times, tissue trauma scores, or subjective difficulty scores between the 3 lymphadenecto

Answer 120

Patellar luxation is one of the most common orthopaedicconditions in dogs, with a high prevalence in small-breeddogs.1Traumatic or developmental etiologies are recog-nized, with most cases secondary to skeletal malformationsof the femur, tibia, or both.2In dogs, atraumatic patellarluxation leads to progressive femoropatellar cartilage oste-oarthritis and pain.3In a study by Daems and colleagues,4two-thirds of 145 dogs demonstrated cartilage erosion atthe time of surgery. While medial patellar luxation is mostcommon,5lateral and bidirectional luxations are also rec-ognized, with proposed differing aetiopathogenesis.6Surgi-cal management is routinely recommended for patientsdiagnosed with grade II to IV patellar luxation5with theaim of realigning the sti ﬂe extensor mechanism and im-proving femoropatellar contact within the femoral trochleargroove.7Tibial tuberosity transposition, femoral trochleo-plasty, medial retinacular release, and lateral imbricationare the most common techniques used in combination forthe treatment of patellar luxation in dogs8with reportedoverall complication rates following surgery ranging from21 to 43%.9–13k recession trochleoplasty provides more uniform in-crease in trochlear depth, especially proximally, in comparisonto wedge recession trochleoplasty, reducing the risk of patellarre-luxation with the sti ﬂe in extension.14Failure to realign thestiﬂe extensor mechanism at the time of femoral trochleo-plasty has been proposed as a risk factor for recurrence ofpatellar luxation.3The use of a combination of block recessiontrochleoplasty and tibial tuberosity techniques has beenshown to reduce postoperative reluxation rates.15It is the authors ’impression that it is not uncommon toencounter patella –trochlear groove mismatch intraopera-tively, similar to that described in cats.16This prevents thepatella from being effectively recessed following trochleo-plasty when the medial and lateral trochlear ridges arepreserved as previously described for trochlear block reces-sion.17To counter this, partial parasagittal patellectomy hasbeen performed using a technique previously described byVezzoni18to reduce patella –trochlear groove width mis-match, improve patellar recession and resultant femoropa-tellar contact. This retrospective study aims to describe thesurgical technique and complications in a cohort of dogs.

Answer 121

Tibial tuberosity avulsion fractures (TTAF) are commoninjuries in skeletally immature dogs. They are often asso-ciated with minimal trauma, such as a fall or jumpinginjury.1–3Traditionally, these fractures have been treatedwith open reduction and internal fixation using a pin andtension band technique. However, recent studies haveadvocated for fluoroscopic-guided percutaneous pinningrather than traditional open approaches.1,2,4,5There are limited studies directly comparing openreduction and internal fixation to fluoroscopic-guidedpercutaneous pinning in animals. The current literaturesuggests that fluoroscopic-guided percutaneous pinningresults in decreased morbidity, expedited return to func-tion, and decreased infection rates.1,2,4,5Furthermore,Received: 22 December 2022 Revised: 23 February 2023 Accepted: 2 April 2023DOI: 10.1111/vsu.13961Veterinary Surgery. 2023;52:739 –746. wileyonlinelibrary.com/journal/vsu © 2023 American College of Veterinary Surgeons. 739percutaneous pinning for pediatric fracture repair inpeople has shown a variety of advantages includingdecreased surgical time, increased patient/guardiansatisfaction, decreased tissue trauma, and reduced periop-erative pain.6,7The use of Kirschner wires or Steinmann pins (bothreferred to as pins in this study) alone for repairing TTAFcontinues to grow.1,4,5Moyer et al. found a 50% complica-tion rate when pins were used alone without tensionband wire in the fixation.8All complications in this studywere from pin migration that required pin removal fol-lowing healing. This high rate of complication has notbeen shown in other studies and is not the authors ’clinical experience.1,2,4,9,10The use of a single pin forTTAF fixation has been suggested and may provide amore technically simple repair, especially for smallerpatients.1,2,5However, one retrospective study found thatutilization of a single pin for tibial tuberosity transposi-tion for surgical correction of medial patella luxation insmall breed dogs was 11 times more likely to haveimplant failure when compared to two pins.11In contrast,percutaneous pinning of TTAF has been shown to haveonly minor complications while simultaneously offeringthe aforementioned benefits.1,2,5,8To the authors' knowl-edge, no study has evaluated the effect of the number ofpins on the failure rate for TTAF stabilization.A recent ex vivo study looked at strength and stiffnessof three different fixation techniques for TTAF.3Thisstudy showed that while both pin and tension band wireand external fixators provided the superior fixation stiff-ness and strength, pin fixation alone resisted forcesgreater than those demonstrated by normal dogs at awalk while also being the least technically challengingimplant to apply.3,12An advantage of using pin fixationalone for TTAF is that it can be performed percutane-ously without the need for soft tissue dissection and dis-ruption of the fracture hematoma. It would be of benefitto know the properties of using one versus two pins forTTAF stabilization.To the authors' knowledge, no studies have investi-gated fixation load to failure (strength) and stiffness com-paring one pin versus two for TTAF stabilization.Limitations of implant selection are often based on thesize of the avulsion fracture, and a single pin of largerdiameter may be more technically feasible whencompared to placing two pins of smaller diameter.The objective of this study was to determine whetherone larger diameter or two smaller diameter pins used forTTAF stabilization would provide greater axial tensilestrength and stiffness when subjected to monotonicmechanical load to failure testing. Our hypothesis wasthat a two-pin fixation would provide greater strength andgreater stiffness when compared to a single-pin fixation.

Answer 122

Sliding hiatal hernia (SHH) occurs when the lower esophageal sphincter moves cranially through the esophageal hiatus and into the thoracic cavity, resulting in gastroesophageal reflux.1–5 While gas -troesophageal reflux disease is likely the result of a complex, multifactorial disease process, an asso -ciation between upper airway obstruction and SHH has been suggested in brachycephalic dogs.3,4,6 In-creased upper airway resistance and negative intra -thoracic pressure is suspected to create a physiologic Laparoscopic surgical treatment for sliding hiatal hernia is associated with an owner-perceived improvement in clinical outcome in dogsAmeet Singh, DVM, DVSc, DACVS*; William Hawker, BVMS; Krista Mitchell, DVM, DACVAA; Ryan Appleby, DVM, DACVR; Alexa Bersenas, DVM, DVSc, DACVECC; Allison Collier, DVM, DVSc, DACVIMDepartment of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada*Corresponding author: Dr. Singh ( amsingh@uoguelph.ca )Received September 5, 2023Accepted October 7, 2023doi.org/10.2460/javma.23.08.0479©AVMApressure gradient that predisposes to cranial transla -tion of the lower esophageal sphincter into the tho -racic cavity through the esophageal hiatus.3,4,6 Sur-gical treatment of SHH in dogs was first reported by Prymak et al,1 who described a combination of open surgical techniques consisting of hiatal plica -tion, esophagopexy, and left-sided gastropexy in an attempt to prevent cranial translation of the lower esophageal sphincter into the thoracic cavity and prevent gastrointestinal reflux.2 Minimally invasive surgery is the standard of care in people for the treatment of refractory gastroesoph -ageal reflux disease and hiatal hernia with a variety of described surgical techniques.7–9 In dogs, 2 studies have reported laparoscopic surgical techniques and resultant clinical outcomes following laparoscopic treatment of SHH with intracorporeal suturing for hiatal plication, esophagopexy, and left-sided gas -tropexy.10,11 The objective of this study was to report on perioperative complications and owner-perceived outcome using a standardized questionnaire follow -ing laparoscopic surgical treatment for SHH in dogs. We hypothesized that owner-perceived clinical out -come related to SHH would improve po

Answer 123

Radial hemimelia (RH) (intercalary longitudinal hemimelia of the radius; OMIA 002225-9685) is a con-genital absence of the radius characterised by partial or total absence of the bone. RH has been documented in various domesticated species;1–7 however, opportunities for genetic studies have been limited in diverse and non- traditional biomedical models. Limb patterning and development is highly conserved across vertebrate species8 and animals with rare diseases are important resources for assigning new functions to genes and deci -phering syndromic conditions.RH is suggested as one of the most common dysos-toses affecting the forelimbs in cats9 and several sporadic, rare cases of RH are reported in randomly bred, domestic shorthairs10–16 where cases are often combined with other anomalies, including vertebral abnormalities, anal atresia and cardiovascular defects.17 The RH phenotype is also known as ‘Squitten’, ‘Kangaroo cats’ or ‘Twisty cats’ by the lay public; however, scientific evaluations and docu -mentation are not available in peer-reviewed literature for most presentations described on social media.18In humans, RH is rare, occurring in 1 in 5000–30,000 live births, but is slightly more common in males than in females (sex ratio of 3:2), and is observed in more than 200 genetic syndromes as isolated cases, as part of chro -mosomal aneuploidies and owing to exposure to tera-togenic chemicals during embryonal development.19 In accordance with the phenotypic severity, RH is classi-fied into four categories: type I – mild shortening of the distal radius; type II – more severe radial shortening, where ulna shortening and bowing may also be present; type III – severe radial shortening and radial deviation of the hand and wrist; and type IV – complete absence of the radius with severe radial deviation of the hand and wrist.20 More severe phenotypes (II, III, IV) generally are accompanied with absence of the first metacarpal bones.Presentations of RH are heterogeneous and therefore likely to be genetically heterogeneous as well. Heritable forms of RH are caused by different gene variants in humans, including X-linked (OMIM: 312190), autoso-mal recessive as part of Baller–Gerold syndrome (BGS; OMIM: 218600) and Rothmund–Thomson syndrome type 2 (OMIM: 268400) and an autosomal dominant form as part of Duane-radial ray syndrome (OMIM: 607323). In cattle, tetra-amelia has been associated with a r-spondin 2 (RSPO2 ) disruption.2The present study aimed to identify the genetic vari -ants responsible for the rare RH malformation observed in a Siamese cat family. The researchers conducted whole genome sequencing (WGS) on the parents and two affected kittens to identify potential candidate variants that may be linked to the RH phenotype. To validate the findings, the genomic data obtained were compared with the 99 Lives Cat Genome data set, which included 420 other domestic cats with both whole genome and whole exome sequencing data.

Answer 124

Surgical repair of acetabular fractures in dogs is oftenindicated to restore joint function and reduce the progres-sion of osteoarthritis.1Current surgical approaches toThis study was presented at the sixth Annual World OrthopaedicCongress in conjunction with the 49th Annual Conference of theVeterinary Orthopedic Society; February 5-12, 2022, Snowmass,Colorado.Received: 25 July 2022 Revised: 19 December 2022 Accepted: 8 January 2023DOI: 10.1111/vsu.13937836 © 2023 American College of Veterinary Surgeons. Veterinary Surgery. 2023;52:836 –845. wileyonlinelibrary.com/journal/vsuexpose the acetabulum for fracture repair are invasiveand typically require trochanteric osteotomy or glutealtenotomy.2An additional disadvantage of conventionalrepair is iatrogenic damage to the sciatic nerve, as it isvulnerable during fracture fragment manipulation,retraction, and implant placement.2,3Irreversible injuriesto the sciatic nerve have been reported due to entrapmentin fracture gaps or the jaws of reduction forceps, andimpingement from implants.3In human medicine, standard approaches for therepair of acetabular fractures include the Kocher-Langenbeck and ilioinguinal approaches, which allowfor direct access to the posterior and anterior aspects ofthe pelvis, respectively.4Modified approaches to reducesurgical trauma based on the ilioinguinal approach weredescribed, with promising results.5–7In a clinical caseseries of 12 human subjects with acetabular fractures, a2-incision minimally invasive approach with minimallyinvasive plate osteosynthesi su s i n gp r e s h a p e dp l a t e sw a sperceived as having decreased soft tissue injury, reducedbleeding, and rapid recovery in comparison with con-ventional repair.6The application of 3D surgical plan-ning and patient-specific osteosynthesis plates producedaccurate operative reconstruction of complex acetabularfractures and good functional patient recovery inhumans.5–7Assessment of acetabular fracture morphol-ogy with 3D printed models allowed for preoperativecontouring of plates, formulating the fracture reductionsequence, and ascertaining the ideal positioning ofimplants.6,7As far as the authors are aware, minimally invasivetechniques for acetabular fracture repair in dogs, with orwithout 3D printing, have not been reported. The pur-pose of this study was to develop and describe a mini-mally invasive approach for acetabular fracture repair indogs using plates contoured to 3D printed hemipelvicmodels, to assess the accuracy and feasibility of the tech-nique in cadaver testing, and to report the successfulmanagement of an acetabular fracture in a dog with thismethodology. We hypothesized that minimally invasiveacetabular fracture repair is feasible in dogs and wouldresult in small fracture gaps (<2 mm) and step defects(<1 mm), low (<5/C14) pelvic angulation, and the absence ofsciatic nerve injury.

Answer 125

Total ear canal ablation and lateral bulla osteotomy (TECA-LBO) is commonly performed in both dogs and cats and involves complete resection of the external ear canal and ablation of the epithelial lining of the tym-panic bulla. While it is typically performed to treat septic otitis media in dogs, in cats, both neoplasia and inflam -matory disease are the leading causes for TECA-LBO.1–3 Significant differences exist in the structural anatomy of the middle ear between these species; namely, the pres -ence of an incomplete bony septum within the feline tympanic bulla that divides it into a smaller dorsolat -eral component, composed of the epitympanum and mesotympanum, and a larger ventromedial hypotympa -num.4,5 In combination with the relatively deep tympanic chamber of the cat, this septum can impede complete penetration into the deeper portion of the tympanic bulla, limiting the surgeon’s ability to fully ablate the epithe-lium of the bulla. In fact, previous research has shown that even experienced surgeons may fail to completely enter the hypotympanum through the septum up to 25% of the time during feline TECA-LBO procedures.6One strategy for increasing success in entering the hypotympanum may involve more direct visualization of the structures of the middle ear than is achievable with current surgical approaches. In human otolaryngol -ogy, endoscopy has gained popularity in the diagnostic assessment of the middle ear, as well as visualization during surgery, and is acknowledged as an effective means of identifying ear anatomy and adequately illu-minating the middle ear during surgical procedures.7,8 A recent veterinary study has illustrated that an endoscope can be used to effectively identify the structures of the canine middle ear after lateral and ventral bulla osteot-omy,9 but so far, no attempts have been documented to assess endoscopic evaluation of middle ear structures in cats. In addition, there is no existing literature evaluating the use of scope assistance for increasing effective hypo -tympanum entry during feline TECA-LBO.The aims of the present study were to investigate whether the unique anatomy of the feline middle ear can be adequately visualized using endoscopy via a lateral bulla approach and to determine if endoscopy is helpful in ensuring appropriate entry into the hypotympanum during feline TECA-LBO. We hypothesized that the ease of successful visualization of middle ear structures would be comparable to that in dogs, and that direct endoscopic visualization of the septum during surgery would facili -tate higher rates of successful bony septum penetration than previously reported.

Answer 126

Chondrodystrophic dogs and other small breeds are at a higher risk for intervertebral disc herniation (IVDH).1,2 Medical treatment is usually appropriate for dogs with a first episode of neck pain, whereas surgi -cal treatment is recommended for dogs with recur -rent pain or those presenting with neurologic deficits.3 Ventral slot decompression is the surgical method of choice for most cervical IVDH and is often considered more challenging than thoracolumbar hemilaminec -tomy due to reduced visualization of the spinal cord.2Conventional ventral slot is the most commonly used technique to remove herniated disc material compressing the cervical spinal cord; however, ventral slot decompression is usually inadequate for removing lateral or foraminal disc extrusions.2,4 In 1 study,5 the Video telescope operating monitor–assisted surgery is equivalent to conventional surgery in treatment of cervical intervertebral disc herniation in dogsHadrien Frankar, DMV1*; Kevin Le Boedec, DMV, MS, DACVIM, ECVIM2; Laurent Cauzinille, DMV, DACVIM, ECVN1; Eymeric Gomes, DMV, DECVDI3; Chloé Touzet, DMV, DECVDI3; Diego Rossetti, DMV, DECVS4; Cyrill M. Poncet, DMV, DECVS51Neurology Department, Centre Hospitalier Vétérinaire Frégis, Arcueil, France2Internal Medicine Department, Centre Hospitalier Vétérinaire Frégis, Arcueil, France3Radiology Department, Centre Hospitalier Vétérinaire Frégis, Arcueil, France4Surgery Department, Centre Hospitalier Vétérinaire Advetia, Vélizy-Villacoublay, France5Surgery Department, Centre Hospitalier Vétérinaire Frégis, Arcueil, France*Corresponding author: Dr. Frankar ( hadrien.frankar@live.be)Received February 24, 2023Accepted June 13, 2023doi.org/10.2460/javma.23.02.0114incidence of serious immediate surgical complications has been reported to be around 9.9% and include blood loss, ventilatory failure, and cardiac dysrhythmias. Ad -ditional postoperative complications, such as infection, vertebral instability, subluxation, and neurologic status worsening, have also been reported. Alternative treat -ments have therefore been developed in an attempt to improve the intraoperative challenges associated with ventral slot decompression, as well as to improve the postoperative patient. Among these, magnification methods have gained interest in human and veterinary neurosurgery. The use of magnifying binocular lenses, operative microscopes (OMs), and endoscopes has historically been employed in an attempt to improve surgical technique and patient outcomes. These tools 2 have been shown to have several advantages in people as follows: they improve delicate anatomic structure vi -sualization, allow for smaller incisions, reduce soft-tis -sue damage and operative complications, and shorten hospitalization times.6 An OM occupies a large space in the operating room, limiting the movements of the surgical team; is an expensive piece of equipment; and needs consumable supplies. It also provides an un -comfortable surgical position and a small field of view with a short focal length.6 Because of these limitations and a difficult sterilization protocol, the OM is usually brought into position after spine dissection. The endo -scope also has a small field of view, and it is commonly obstructed by surgical instruments. Reports of the use of video-assisted neurosurgery in the veterinary litera -ture is scarce, except for 1 clinical study describing the use of an endoscope-assisted minimally invasive ven -tral slot technique and 2 cadaveric studies on minimally invasive thoracolumbar neurosurgery in dogs.7–9The exoscope is a novel alternative to OM and en -doscopy, allowing an enhanced visualization with eas -ier access to the operative field and improved ergon -omy.10,11 The exoscope is a rigid 0° or 90° scope that sits outside the body cavity (focal distance of 250 to 300 mm) and is held by a mechanical arm that allows for the scope position to be adjusted during surgery.6The video telescope operating monitor (VITOM) is a recently developed exoscope first described in 2012 to assist human neurosurgeons.6 The VITOM provides high-quality video images, reduces surgeon discomfort, costs less, is easier to use and removable, provides teaching opportunities, and is less obstruc -tive than the OM.6 Use of VITOM recently has been described for cervical IVDH and pituitary adenoma re -moval in dogs.12,13 In these cases, this system allowed better magnification and illumination while maximiz -ing the comfort of the surgeon and reducing fatigue.13 Despite the great interest in these techniques, little is known about the potential benefits that video-assist -ed neurosurgery can provide in a veterinary setting.This prospective study was designed to evaluate the efficacy of the VITOM for ventral slot decompres -sion in dogs with cervical IVDD and compare video-assisted surgery with conventional surgery in terms of spinal cord decompression, ventral slot dimensions, residual disc material, surgical bleeding and compli -cations, and postoperative neurofunct

Answer 127

Stenotic nares in the cat is almost exclusively noted in the brachycephalic breeds, including the Per -sian, Himalayan, Exotic Shorthair, Scottish Fold, and Burmese cats.1 These cats have smaller nostrils and a flattened facial profile when compared to other fe -line breeds (Figure 1). In some brachycephalic cats, the small nasal opening can increase their respira -tory effort to breathe.2–4 Any nasal discharge more easily obstructs the nares of these cats, further com -promising air excursion through each nostril.Surgical procedures used to treat stenotic na -res in brachycephalic cats include punch resection alaplasty,5 the use of a single advancement flap,6 ala vestibuloplasty (resection of the ala nasi or alar wings),2,7 small wedge resection,8 and the use of the carbon dioxide laser to remove the lower portion of each alar fold.9 All these techniques were reported to improve nasal breathing.The authors had previously noted that the up -ward curvature of the skin, rostral to the nasal sulcus of brachycephalic cats, partially obstructs the na -sal opening. This, combined with the downward or partially collapsed position of the alar folds contrib -a.23.01.0054ute to nasal stenosis. The small, lower alar folds in brachycephalic cats, have the flexibility to be easily elevated in a dorsolateral direction with thumb for -ceps. Based on these clinical observations, this study describes the use of small elliptical or punch resec -tions of skin dorsolateral to the alar folds (Alar Fold Lift-Up) and small elliptical or punch skin resection rostral to the sulcus (Sulcus Pull-Down) for treating nasal stenosis in brachycephalic cats. Used in com -bination, both techniques were used to enlarge the nostrils of brachycephalic cats with the expectation of facilitating nasal breathing postoperatively.

Answer 128

Thoracolumbar intervertebral disc extrusion (IVDE) is the most common neurologic disease in dogs. Pekingese dogs are one of the chondrodystrophic (CD) breeds that frequently suffer from IVDE.1 Several risk factors and unique characteristics of Pekingese with IVDE have been identified.2 The characteristically low frequency of FGF4 expression in Pekingese dogs among the CD breeds with accelerated intervertebral disc disease suggests that Pekingese dogs are more likely to have other causes of IVDE.3The concept of vertebral instability as the cause of the spinal cord injury has been controversial and sparsely investigated in veterinary medicine. Panjabi4 defined vertebral instability as “the loss of the spine’s a.23.01.0041ability to maintain its patterns of displacement un -der physiologic loads.” Any degenerative lesion of the spinal column (vertebrae, facet joints, interver -tebral disc, spinal ligaments, and joint capsules), spi -nal muscles, and tendons results in some degree of vertebral instability.5 In the present study, vertebral instability is defined as having dynamic compression confirmed by dynamic myelographic study and/or unstable spinal segment confirmed by intraoperative vertebral manipulation.The stability of the adjacent thoracolumbar ver -tebrae is supported by the intervertebral disc, articu -lar process (AP) joints, ligaments, and surrounding muscles.6 Disc degeneration causes loss of stiffness 2 in the disc, resulting in vertebral instability and disc protrusion/extrusion.6–8 APs contribute up to 30% of the stability of the vertebral column in normal dogs, and abnormalities of APs have been suggested to compromise vertebral stability.9–11 These abnormali -ties have been reported to be associated with inter -vertebral disc herniation, spinal arachnoid diverticula, and constrictive myelopathy causing various degrees of spinal cord injury.12–14 Neurologic dysfunction sec -ondary to congenital AP anomalies has been reported in Pugs.13–18 Histopathological analyses of extradural compressive lesions of Pugs with presumptive con -strictive myelopathy are consistent with fibrotic mate -rial and chondroid metaplasia, which is suggestive of a consequence of suspected chronic micromotion.15 Compromised vertebral stability due to caudal AP ab -normality is likely to inflict direct spinal cord trauma by chronic micromotion, spinal canal stenosis as a conse -quence of vertebral instability, or indirect trauma by negatively interfering with vascular supply of the spi -nal cord and thus limiting its resistance to injury.16 In a recent report18 on Pug dogs, dynamic myelographic study was used to confirm single or multiple dynamic thoracolumbar spinal cord compressive lesions asso -ciated with or without AP anomalies. The decompres -sion and stabilization of these segments resulted in good outcomes.18There has been no information regarding the diagnostic methods, surgical treatments, and out -comes in Pekingese with spinal cord injury associ -ated with vertebral instability. We hypothesized that vertebral instability is a potential cause of thoracolumbar spinal cord injury in Pekingese. The objective of the present study was to describe the clinical signs, diagnostic and surgical findings, and outcomes of 11 Pekingese with thoracolumbar my -elopathy diagnosed through dynamic myelographic studies and intraoperative spinal manipulation and treated by decompressive laminectomy and verte -bral stabilization.

Answer 129

c Comparison of Virtual Surgical CorrectiveOptions for Excessive Tibial Plateau Angle in the DogNatalie J. Worden1,2Bill Oxley3Jaron Naiman4William Michael Karlin5Tiffany M. Chen1Scott J. Hetzel6Jason Bleedorn1,71Department of Surgical Sciences, School of Veterinary Medicine,University of Wisconsin-Madison, Madison, Wisconsin, United States2Department of Clinical Sciences, College of Veterinary Medicine,University of Florida, Gainesville, Florida, United States3Vet3D, Coventry, West Midlands, United Kingdom4Department of Small Animal Surgery, ACCESS Specialty AnimalHospital –Pasadena, Pasadena, California, United States5Department of Clinical Sciences, Cummings School of VeterinaryMedicine, Tufts University North Grafton, Massachusetts,United StatesVet Comp Orthop Traumatol 2023;36:225 –235.Address for correspondence Jason Bleedorn, DVM, MS, DACVS-SA,Department of Clinical Sciences, Colorado State University, 200 WestLake Street, Fort Collins, CO 80523, United States(e-mail: J.bleedorn@colostate.edu).6Department of Biostatistics and Medical Informatics, School ofMedicine and Public Health, University of Wisconsin-Madison,Madison, Wisconsin, United States7Department of Veterinary Clinical Sciences, Colorado StateUniversity, Fort Collins, Colorado, United StatesoductionCranial cruciate ligament rupture is one of the most commonorthopaedic conditions in dogs, often treated by tibialplateau levelling osteotomy (TPLO).1–4The goal of TPLO isto eliminate cranial tibial thrust instability by reducing thetibial plateau angle (TPA) to a target of approximately5 degrees. The mean TPA ranges from 23 to 28 degrees;however, a small subset of dogs with cranial cruciate liga-ment ruptures has excessive TPA (eTPA) de ﬁned as a TPAmore than 34 degrees.5,6The exact cause of the eTPA defor-mity is unknown, but premature closure of the caudal aspectof the proximal tibial physis has been proposed as a possiblemechanism, and an underlying genetic component islikely.6,7Performance of traditional tibial osteotomies for routinecranial cruciate ligament rupture, such as TPLO, can beproblematic in dogs with eTPA. Correction requires exces-sive proximal tibial segment rotation, potentially increasingthe risk of complications and resulting in inadequate neu-tralization of cranial tibial thrust.5,8–11A theoretical ‘safepoint ’of rotation of the plateau to the level of the tibialtuberosity has been proposed, but not rigorously tested. Incontrast, several studies have reported successful outcomesusing TPLO alone with eTPA in small-breed dogs.12,13Tomitigate these challenges, many alternative proximal tibialosteotomies have been proposed: cranial closing wedgeostectomy (CCWO) and various modi ﬁcations, centre ofrotation of angulation (CORA)-based levelling osteotomy(CBLO), and combined TPLO/CCWO or coplanar CBLO (coC-BLO).8,14–16These approaches allow for the achievement ofideal postoperative TPA and correction of concurrent planardeformities when present.5,15However, several of thewedge procedures have been associated with higher com-plication rates and delayed healing times.5,6,8Despite therange of available options, little comparison data exists andwe lack consensus among surgeons on which correctionmay best improve tibial alignment in the spectrum of dogswith eTPA.The purpose of our study was to compare the impact of sixvirtual proximal tibial osteotomy procedures on radiographictibial alignment in dogs with a range of TPA for management ofcranial cruciate ligament rupture. We hypothesized thatseverity of TPA would impact the magnitude of tibial align-ment alteration among various tibial wedge and levellingosteotomy procedures. Speci ﬁcally, TPLO would have the leasteffect on tibial long axis (TLA) shift, and CCWO would have thegreatest effect on tibial tuberosity alignment.

Answer 130

Platelet-rich plasma (PRP) continues to increase in popularity as a biologic regenerative therapy op -tion and is applied to an ever-expanding array of con -ditions across numerous species.1,2 PRP originated in human medicine and was then adopted in veterinary medicine, initially with equine patients.3–8 It is now in -creasingly common in canine medicine for the treat -ment of soft tissue injuries, wound healing, bone heal -ing, the treatment of tendon and ligament injuries, and patients experiencing clinical signs of osteoarthri -tis.9–13 The benefit of PRP administration is attributed to the high concentration of growth factors contained a.23.04.0218within the alpha granules released when platelets are activated. These alpha granules release a variety of growth factors, including but not limited to platelet-derived growth factor, insulin-like growth factor, transforming growth factor-β1 and β2, vascular endo -thelial growth factor, basic fibroblastic growth factor, and epidermal growth factor.14–16 These growth fac -tors have been shown to mitigate inflammation, initi -ate anabolic processes, and regenerate tissue.17,18 In contrast, other components of PRP, particularly leu -kocytes, are thought to release proinflammatory cyto -kines that can exacerbate or perpetuate inflammation 2 and potentially impede tissue healing.19 As shown by Sundman et al,20 growth factor and catabolic cytokine concentrations are influenced by the cellular compo -sition of PRP. Therefore, the cell distribution created through the use of commercial PRP systems will likely ultimately impact patients’ clinical outcomes.The therapeutic use of PRP has faced substan -tial criticism over the years due to gaps in the under -standing of the best methods for generating a con -sistent, effective final product. The systems used to generate PRP vary by blood volume, use of antico -agulant, number of spins, and centrifugation speed, resulting in drastically different cell distributions.21,22 The variation in clinical outcomes is further com -pounded by administration variables such as dose volume, timing of treatment, and redosing inter -vals. Because of these variables, some studies have concluded that there is no clinical benefit of PRP.23 However, these conclusions can often be traced to the generation of PRP that is inconsistent in quality. The makeup of an ideal PRP product (concentration of platelets, neutrophils, macrophages, total leuko -cytes, and erythrocytes) remains unknown.24,25 Ex-tensive clinical trials are necessary to determine the makeup of an ideal canine PRP product. This study examined a specific widely used commercial system to optimize variables in the canine patient for that specific system.The objective of this study was to evaluate the cellular composition of the final product of a double-syringe system when subjected to different centrifu -gation speeds and times. This system requires 13.5 mL of whole blood, substantially less than any other system on the market, making it ideal for small-ani -mal patients.26 It is also straightforward to use, with relatively short spin times (5 to 10 minutes), while still generating a clinically useful volume of PRP. Through quantifying the platelet concentrations and fold changes achieved and assessing leukocyte and erythrocyte concentrations or reductions in the PRP products, an optimal protocol for PRP genera -tion with this system can be established. This study aimed to answer a necessary question along the path to generating consistent and effective PRP in canine patients. We hypothesized that manufacturer direction settings would produce PRP with platelet concentrations greater than that of whole blood. We further hypothesized that increasing centrifugation force and time would negatively impact the concen -tration

Answer 131

Ureteral ectopia is the most common cause of canine juvenile incontinence in female dogs and is a congenital abnormality whereby one or both ureteral orifices are located distal to the bladder trigone. Ectopic ureters can be either extramural or intramural (iEU), with 87% to 99% of canine ureteral ectopia reported to be intramural. 1–4 Numerous breeds have been found to be at higher risk of ureteral ectopia, including the Golden Retriever, Labrador Retriever, Siberian Husky, West Highland White Terrier, New-foundland, Miniature and Toy Poodle, Entlebucher Mountain Dog, and Soft Coated Wheaten Terrier. 4–9 In these breeds, there is thought to be a heritable basis for the condition. Female dogs commonly present with clinical signs of intermittent or continuous urinary incontinence from a young age, but some dogs may present with clinical signs later in life. 10,11 Numerous diagnostic imaging modalities have been used to assess ectopic ureters in dogs. 11–13 Abdominal ultrasonography has recently been shown to have a diagnostic accuracy of 95% 12 while also allowing evaluation of the upper urinary tract for the presence of other common concurrent abnormalities such as hydroureter, hydronephrosis, renal hypoplasia, and renal aplasia. 3,11 Cystoscopy has been found to have a 100% sensitivity for diagnosing ureteral ectopia 13,14 and allows for concurrent assessment of the lower urinary tract and treatment of iEU with cystoscopic-guided laser ablation of iEU (CLA-EU), which is the treatment of choice for iEU.15–18 The success rate (defined broadly as urinary continence) for female dogs undergoing CLA-EU is reported to range from 31% to 80% without additional therapies and 67.7% to 81% with the addition of adjunctive medical or surgical procedures.15–18 Previous studies evaluating CLA-EU in female dogs have failed to identify any positive or negative preoperative prognostic factors. These studies have also been limited by variation in breed and age of the dogs at presentation, diagnostic approach, and surgeon performing the procedure, which may have led in part to the lack of identification of any prognostic factors. 3,17,19 Factors proposed for poor outcomes following CLA-EU include other factors related to urinary incontinence in female dogs such as urethral sphincter mechanism incompetence 20,21; an intrapelvic bladder 22; a short urethra, lack of a defined bladder neck, and paramesonephric remnants 9,23 ; and poor bladder compliance.19,24 Other factors such as ureteral or renal pelvic dilatation, age at surgery, or preoperative urinary tract infections have been suggested as positive prognostic factors for surgical correction but not CLA of ectopic ureters.1,25 Our primary aim was to identify prognostic factors that affect short and long-term continence scores in female Golden Retrievers undergoing CLA-EU. Our objective was to evaluate a homogenous sample of female Golden Retrievers younger than 24 months, all diagnosed with ectopic ureters using a standard protocol and all treated via cystoscopic laser ablation by the same surgeon to assess for pre and perioperative prognostic factors associated with short-term (1 month) and long-term urinary continence following cystoscopic laser ablation of ectopic ureters. We hypothesized that both the lack of a defined bladder neck and subjectively reduced bladder compliance would be associated with a lower likelihood of achieving urinary continence following CLA-EU due to the relation of these factors with urinary incontinence in female dogs. The secondary aim was to add to the literature on the efficacy of CLA of ectopic ureters in female Golden Retrievers — FRANCAIS L'ectopie urétérale est la cause la plus courante de l'incontinence juvénile chez les chiens femelles et est une anomalie congénitale où un ou les deux orifices urétéraux sont situés distaux au trigone de la vessie. Les uretères ectopiques peuvent être soit extramuraux soit intramuraux (iEU), avec 87 % à 99 % des cas d'ectopie urétérale canine rapportés comme étant intramuraux. De nombreuses races sont plus exposées à l'ectopie urétérale, notamment le Golden Retriever, le Labrador Retriever, le Husky Sibérien, le West Highland White Terrier, le Terre-Neuve, le Caniche miniature et toy, le Bouvier de l'Entlebuch, et le Terrier à poil doux. Dans ces races, il est supposé qu'il existe une base héréditaire pour la condition. Les chiennes présentent généralement des signes cliniques d'incontinence urinaire intermittente ou continue dès un jeune âge, mais certains chiens peuvent présenter des signes cliniques plus tard dans leur vie. De nombreuses modalités d'imagerie diagnostique ont été utilisées pour évaluer les uretères ectopiques chez les chiens. L'échographie abdominale a récemment été démontrée avoir une précision diagnostique de 95 % tout en permettant également l'évaluation de la partie supérieure des voies urinaires pour la présence d'autres anomalies concomitantes courantes telles que l'hydrouretère, l'hydronephrose, l'hypoplasie rénale et l'aplasie rénale. La cystoscopie a été trouvée avoir une sensibilité de 100 % pour le diagnostic de l'ectopie urétérale et permet une évaluation concomitante de la partie inférieure des voies urinaires et le traitement de l'iEU avec l'ablation laser guidée par cystoscopie de l'iEU (CLA-EU), qui est le traitement de choix pour l'iEU. Le taux de réussite (défini de manière large comme la continence urinaire) pour les chiennes subissant un CLA-EU est rapporté varier de 31 % à 80 % sans thérapies supplémentaires et de 67,7 % à 81 % avec l'ajout de procédures médicales ou chirurgicales adjuvantes. Des études antérieures évaluant le CLA-EU chez les chiennes n'ont pas réussi à identifier des facteurs pronostiques positifs ou négatifs préopératoires. Ces études ont également été limitées par la variation de race et d'âge des chiens à la présentation, l'approche diagnostique et le chirurgien effectuant la procédure, ce qui a peut-être en partie conduit au manque d'identification de facteurs pronostiques. Des facteurs proposés pour de mauvais résultats après le CLA-EU incluent d'autres facteurs liés à l'incontinence urinaire chez les chiennes tels que l'incompétence du mécanisme du sphincter urétral ; une vessie intrapelvienne ; un urètre court, l'absence de col vésical défini et des restes paramesonephriques ; et une mauvaise compliance vésicale. D'autres facteurs tels que la dilatation urétérale ou pelvienne, l'âge au moment de la chirurgie ou les infections urinaires préopératoires ont été suggérés comme des facteurs pronostiques positifs pour la correction chirurgicale mais pas pour le CLA des uretères ectopiques. Notre objectif principal était d'identifier les facteurs pronostiques qui affectent les scores de continence à court et à long terme chez les Golden Retrievers femelles subissant un CLA-EU. Notre objectif était d'évaluer un échantillon homogène de Golden Retrievers femelles âgées de moins de 24 mois, toutes diagnostiquées avec des uretères ectopiques en utilisant un protocole standard et toutes traitées par ablation laser cystoscopique par le même chirurgien pour évaluer les facteurs pronostiques pré et périopératoires associés à la continence urinaire à court terme (1 mois) et à long terme après ablation laser cystoscopique des uretères ectopiques. Nous avons émis l'hypothèse que le manque d'un col vésical défini et une compliance vésicale réduite de manière subjective seraient associés à une probabilité plus faible d'atteindre la continence urinaire après CLA-EU en raison de la relation de ces facteurs avec l'incontinence urinaire chez les chiennes. L'objectif secondaire était de contribuer à la littérature sur l'efficacité du CLA des uretères ectopiques chez les Golden Retrievers femelles.

Answer 132

Vesicourethral anastomosis (VUA) is an essential compo-nent of radical prostatectomy (RP).1–3It requires anappropriate tissue apposition to minimize leakage in thepostoperative period, to reduce morbidity, and to improvelong-term outcomes.4,5Unsecured VUA can lead touroabdomen and prolonged urinary catheterization.6It isstandard procedure to maintain a urinary catheter for10 days after radical prostatectomy in human patients toprevent urine extravasation.3,4,6 –13Since unidirectional barbed sutures do not requireknot tying, it has been used during laparoscopic orrobotic radical prostatectomy in human patients.3,6–13Received: 29 June 2022 Revised: 23 December 2022 Accepted: 15 February 2023DOI: 10.1111/vsu.13950716 © 2023 American College of Veterinary Surgeons. Veterinary Surgery. 2023;52:716 –720. wileyonlinelibrary.com/journal/vsuWaiter et al.3reported less anastomotic leakage after radicalprostatectomy in human patien ts with the unidirectionalbarbed suture. However, a urinary catheter is still main-tained for 7 to 10 days after rad ical prostatectomy and VUAcompleted with unidirectional barbed sutures.3,6–13To the best of our knowledge, the leakage pressureafter completion of the VUA with unidirectional barbedsutures has not been reported or compared to conven-tional sutures in human patients or dogs. If unidirec-tional barbed suture can provide a better seal after VUA,it might reduce the need for a urinary catheter in thepostoperative period after radical prostatectomy.Therefore, the objective of our study was to compareleakage pressures of VUA performed with unidirectionalbarbed and conventional sutures in an ex-vivo modelusing canine cadaveric bladder and urethra. We hypothe-sized that VUA performed with unidirectional barbedsutures and conventional sutures would leak at a similarpressure.

Answer 133

Laparoscopic surgery has grown in popularity over the pre-ceding decades due to reported decreases in postoperativepain and infection rates, howe ver, limitations to advancedlaparoscopic gastrointestinal p rocedures in veterinary medi-cine still exist. In human medicine, a wide variety of laparo-scopic procedures are performed,1,2with the most commonincluding cholecystectomy, her nia repair, colorectal resec-tions and bariatric procedures. Laparoscopic vertical sleevegastrectomy (LVSG) has become the most commonlyAbstract was presented in part at the World Veterinary Endoscopy andMinimally Invasive Surg ery Meeting, June 28, 2020, Fort Collins, Colorado.Received: 7 February 2022 Revised: 10 May 2022 Accepted: 20 June 2022DOI: 10.1111/vsu.13862878 © 2022 American College of Veterinary Surgeons. Veterinary Surgery. 2023;52:878 –887. wileyonlinelibrary.com/journal/vsuperformed bariatric surgery in the U.S. due to its surgicalsimplicity, low complication r ates, and exceptional effi-cacy in producing weight loss and remission of type2d i a b e t e sm e l l i t u s .2While this treatment has beentested in murine and swine animal models,3–7exten-sively there have been no s tudies investigating itspotential use in feline populations.While an open approach is us ed for partial gastrec-tomy currently, a minimally invasive approach incor-porates the benefits of decreased discomfort andreduced infection rate. Man ym i n i m a l l yi n v a s i v ep r o -cedures have been reported in both dogs and cats;however, cats are underrepresented.9The small ana-tomical size of the feline thorax and abdomen, and theresulting limited working s pace for manipulation ofinstruments within the body cavity can be difficult toovercome. Because of this difficulty the authors per-formed a feasibility study in feline cadavers to refinethe LVSG technique before performing the procedurein a live feline research model. The objectives of thisstudy were to describe a laparoscopic gastrectomytechnique in a feline cadaveric model and to reportshort-term outcomes in two live subjects as an initialstep for future clinical applications.

Answer 134

The tail is a natural continuation of the vertebral column in dogs and consists of six to 23 caudal (coccygeal) vertebrae with varia -tion in different dog breeds (Evans et al. 2020 ). The cranial verte -brae are composed of the typical vertebral structures (spinous and transverse processes, etc.), while the caudal coccygeal vertebrae are described as rods consisting only of a vertebral body with cranial and caudal articular surfaces (Evans et al. 2020 ).The tail is used as a counterbalance during jumping, swimming and climbing. Moreover, it is a relevant structure for interspecies signalling and non- verbal communication. (Wansbrough 1996 , Bennett & Perini 2003 , Leaver & Reimchen 2008 ).A recent study conducted in 2010 by Diesel et al. reported a weighted risk of sustaining a tail injury of 0.23% per year for dogs in Great Britain. Dogs kept in kennels and with a wide range of wag were reported to be at an increased risk. Later, Cameron et al. (2014 ) described that 0.59% of the population of dogs in Scotland suffered a tail injury between 2002 and 2012. The most frequently reported conditions of the tail include lacerations and open wounds (Houl -ton 2008 , Diesel et al. 2010 , Simons et al. 2014 ). Others consist of fractures, dislocations, self- trauma and neoplasia.Caudal vertebrae fracturesJournal of Small Animal Practice • Vol 64 • October 2023 • © 2023 British Small Animal Veterinary Association. 643 T reatment of coccygeal vertebral fractures may be conservative or involve partial or complete caudectomy. Partial or complete tail amputation is a common procedure in dogs performed for therapeutic and non- therapeutic reasons (Schoen & Sweet 2009 , Knight et al. 2013 , Cameron et al. 2014 ). Indications for caudec -tomy include traumatic injuries, neoplasia, paralysis, tail fold pyoderma or adjunctive treatment for perianal fistulas (Van Fe & Palminteri 1987 , Schoen & Sweet 2009 , Knight et al. 2013 ). Tail docking may reduce the risk of tail injuries in working dogs and is done for cosmetic purposes in puppies to meet certain breed standards (Bennett & Perini 2003 ). However, in early 2007, non- therapeutic tail docking was banned in Great Britain with exemptions for certain types of working dogs in England and Wales (Anon 2006 , Defra 2007 ).Journal databases (PubMed, Science Direct, Openathens and Wiley Online Library) and individual journals (Veterinary and Comparative Orthopaedics and T raumatology, Veteri -nary Surgery) have been searched with the following keywords (tail, tail fractures, caudal vertebral fractures and coccygeal fractures) on February 28, 2023; veterinary surgery textbooks (Veterinary Surgery Small Animal. 2nd edn. S. Johnston and K. Tobias. Elsevier, St. Louis, Missouri, 2017; Brinker, Piermat -tei, Flo’s Handbook of Small Animal Orthopaedics and Fracture Repair. 5th edn. Ch. Decamp, Sp. Johnston, L. Dejardin, S. Schaefer. Elsevier, St. Louis, Missouri, 2016) have been con -sulted. A second author independently performed the same search on March 4, 2023. Only one report about tail frac -ture treatment (Robertson & Miller 1986 ) was found doing these searches.The purpose of our study was to describe the surgical tech -nique, complications, and outcome in four dogs with coccygeal vertebral fractures treated with internal fixation.

Answer 135

Canine congenital hepatic portosystemic shunts (PSS) resultfrom disruption of normal embryonic development.1–3Canine congenital extrahepatic portosystemic shunts(EHPSS) result from aberrant vasculature between the fetalcardinal and vitelline systems.1,3Most often, shuntingoccurs via anomalous flow through the left gastric vein.4EHPSS is thought to develop as a result of genetic and envi-ronmental influences.4,5The relationship between small breed dogs and con-genital EHPSS has been well-documented.6–9Breeds likethe Yorkshire terrier, Havanese, and Maltese are over-represented in cases of EHPSS.1,7–10In a study byBostwick and Twedt, large breed dogs had a 90% chanceof having an intrahepatic portosystemic shunt (IHPSS)within one study population, whereas small-breed dogshad a 93% chance of having an extrahepatic shunt.8The anatomy associated with typical EHPSS in smallbreed dogs has been described, with the majority beingsplenocaval, left gastrophrenic, left gastroazygous, or rightgastric shunts.4Characteristics of common breed andshunt combinations are addressed in several large EHPSSstudies.8,11Documented clinical trends and outcomes arelargely reflective of common congenital shunt patterns —that is, small breed dogs with EHPSS, or large breed dogswith IHPSS. Under-represented breeds have been found tohave greater odds (29%) of having unusual or inoperableshunts when compared to typical breeds (7.6%).9Treatment options for single congenital extrahepaticshunts include surgical attenuation or medical manage-ment. In study populations consisting of primarily smallbreed dogs, mortality for surgically treated dogs ranges from2% to 27%.3,9,12 –14Most common surgical options includeameroid ring constrictors and thin film banding, both ofwhich cause gradual occlusion , or complete suture ligationwhich causes acute shunt closu re. Coil embolization usinginterventional radiology has also resulted in complete occlu-sion of intrahepatic and extrahepatic shunts over an averageperiod of 1 –2m o n t h s .15,16Gradual occlusion allows adjust-ment to increased hepatic portal blood flow over time.Medical management, whether to stabilize a case preop-eratively or in cases where surgery is not pursued, is targetedat reducing plasma concentrations of toxic hepatic wasteproducts, like ammonia. Liver-s pecific diets, antibiotics, andsoluble fiber products are associated with reduced levels ofammonia.1,17Increased median survival times long term areseen in surgically managed dogs with congenital EHPSScompared to those who are medically managed in severalstudies reflective of common shunt demographics.3,5,11,18278 SPIES ET AL . 1532950x, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14040 by Cochrane France, Wiley Online Library on [14/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons LicenseUnusual extrahepatic shunt morphology has been shownto occur in breeds without an established predisposition forEHPSS,1,9but whether this influences clinical outcomes isunknown. There is minimal info rmation published describ-ing the demographics, clinica l presentation, vascular anat-omy, outcomes or complications specific to EHPSS inlarger dogs.These authors have found that larger dogs makeup a small, but nonetheless present, proportion ofcongenital shunt cases at tertiary institutions across theUnited States. However, there is little information inthe present body of literature to help guide case selectionfor surgery and inform owner expectations, leaving clini-cians in a place of uncertainty when faced with thesecases. Surgical management has consistently been shownto be more successful compared to medical interventionsalone in the management of EHPSS in smallerdogs3,5,11,19but whether this applies to larger dogs isunknown. The aim of this study was to describe demo-graphics, clinical presentation, vascular anatomy, short-term outcomes, and complications of EHPSS in dogs≥15 kg treated with or wi

Answer 136

Gastroesophageal reflux (GER) with regurgitation is fre-quently identified in brachycephalic dogs and can neces-sitate surgical or medical management.1,2Identifyingdogs with excessive GER requires a comparison to theexpected frequency and duration of GER in healthy,nonbrachycephalic dogs.Esophageal pH monitoring offers a minimally inva-sive, objective means to identify the frequency andduration of GER events. Using this modality, an acidicGER event is defined as a reduction in esophageal pHto less than 4.1,3–5Based on three previous studiesusing esophageal pH monitoring, it appears that infre-quent, small volumes of GER may be a normal featurein healthy, nonbrachycephalic, nonanesthetized dogs,under experimental conditions.3–5Although minimalexposure of the esophagus to acidic GER is oftenreported, there is variabilit y in the frequency and dura-tion of GER.3–5As these three studies are under experi-mental conditions and restricted to small sample size,and certain breeds, body weights, and by sex ofdogs,3–5it is unclear whether the results translate todogs in a clinical setting. Additionally, prior studieshave used highly morbid surgical device placementtechniques,3or expensive equipment that is not readilyaccessible for clinicians.4All prior studies have exam-ined the frequency of GER in the distal esophagus; theexpected proximal extent of GER in dogs is notreported.The objective of the current study was to establishparameters that describe GER events in nonbrachycepha-lic, hospitalized dogs with no known history of gastroin-testinal disease, using prolonged esophageal pHmonitoring following short total intravenous anesthesia.Data were collected to establish upper reference limits forparameters that describe reflux

Answer 137

Angiosarcoma (AS) is a rare malignant mesenchymal neoplasm of endothelial cell origin.1 For ASs that dem-onstrate features of lymphatic differentiation, subclas-sification with the term lymphangiosarcoma (LAS) is favoured, whereas those of blood vessel origin are termed haemangiosarcoma (HSA).2 With histopathology alone, the subclassification of AS phenotypes may be challeng -ing.3 Both have the overlapping characteristic feature of irregular anastomosing vascular channels lined by spindle-shaped mesenchymal neoplastic cells; however, the absence of intraluminal erythrocytes, hobnail cell appearance, kaposiform architecture and lymphocytic infiltrates would favour a diagnosis of LAS.3 In humans, confirmation of vascular endothelial origin for AS is achieved with immunohistochemical markers, such as factor VIII-related antigen, also known as von Willebrand factor, CD31, CD34, FLI1, ERG and Ki67.3 Differentiation between HSA and LAS relies on immunohistochemis-try, and for this, a number of antigens that are preferen -tially expressed by lymphatic endothelial cells, including podoplanin, prospero homeobox protein 1 (PROX-1), vascular endothelial growth factor receptor (VEGFR)-3 and lymphatic vessel hyaluronan receptor (LYVE)-1, are available.2In cats, AS is rare; however, cutaneous and visceral locations are the most commonly reported primary sites.4–18 Metastasis at the time of presentation appears uncom-mon but has been documented in the lungs, liver, spleen, myocardium, pericardium, diaphragm, omentum, mes-entery, mediastinum and regional lymph nodes.6–9 Within the feline AS population, a predilection for the subcutis of the caudal ventral abdominal wall is reported and this has subsequently been termed feline ventral abdominal wall angiosarcoma (FVAA).10 Affected animals typically present with solitary, poorly circumscribed, locally infil -trative masses with ecchymosis, lymphoedema with or without serosanguinous discharge.10–18 Of these, an LAS phenotype appears favoured and from 18 cases previ-ously reported in the literature, the perceived prognosis is guarded, with the majority of cats being euthanased due to disease progression within a period of days to months (range 3 days to 13 months), irrespective of treatment modalities pursued.10–18 For cases of FVAA that favour a HSA phenotype, there is a comparative paucity of infor -mation available in the literature, often admixed among cutaneous and subcutaneous HSAs. Based on a limited number of cases that have experienced prolonged sur -vival times with surgery alone or in combination with chemotherapy, it is possible that phenotypic subclassi-fication may provide additional prognostication for AS in this location.19–21 In cats, a diagnosis of neoplasia of endothelial cell origin is usually achieved based on histo -logical features, as described above in humans, alongside immunohistochemistry (IHC) for CD34, CD31 and factor VIII.22 Diagnostic tools previously described for confir -mation of an LAS phenotype in cases of feline FVAA include PROX-1,17,18 LYVE-114 or a demonstration of a discontinuous basement membrane with methenamine silver–Periodic acid–Schiff stain (Jones’ stain)11 or elec-tron microscopy.12,14The aim of this study was to collate the largest set of data on FVAA to date and thereby describe clinical pres -entation, tumour staging, diagnostic tests, potential treat-ment options and outcomes.

Answer 138

Three-dimensionally (3D) printed patient-speci ﬁc guides arebecoming increasingly popular in veterinary medicine.1–6Indeed, as the availability and affordability of desktop print-ers have improved, veterinary surgeons ’interest in thesetools is gaining momentum.7–9From a clinical standpoint,since desktop printers have been shown to produce highlyaccurate replicas with only sub-millimetric dimensionalerrors,6surgeons should feel con ﬁdent utilizing such print-ers in clinical cases.In human medicine, patient-speci ﬁc instrumentation hasbeen shown to improve procedural precision, as well as toreduce both patient morbidity and operating times.10,11How-ever, since patient-speci ﬁc instrumentation contacts patienttissues, they are subject to the same safety standards as othermedical devices, including sterilization practices.12–15Com-mon methods of sterilization for medical devices includem, ethylene oxide or chemical germicides such as hydro-gen peroxide gas.15Steam sterilization, which has been used for over acentury, has three critical components to ensure ef ﬁcacy:time, temperature and pressure. General recommendationsto achieve 10/C04remaining organisms are 121°C for morethan or equal to 20 minutes, requiring 103 to 117 kPa ofpressure.16However, the ubiquitous use of heat or moisture-sensitive medical prostheses requiring sterilization has ledto an increasing desire for alternative methods.15Ethylene oxide is a direct alkylating agent, reacting withcellular components of organisms (e.g. nucleic acids orfunctional proteins), resulting in denaturation.17One bene ﬁtis the option for cycle parameter adjustments to account formaterial sensitivities, thereby preserving device integrity.However, concerns about ethylene toxicity have resulted inmany jurisdictions restricting the use of this process.18Unlike ethylene oxide, hydrogen peroxide gas is non-toxicand has the added bene ﬁt of leaving sterilized instrumentswith a residue-free surface.19Hydrogen peroxide steriliza-tion is achieved by injecting liquid hydrogen peroxide into avacuum chamber. Following radiofrequency wave applica-tion, free radicals are produced which invade the bacterialcell wall, and kill the bacteria.19While effective sterilization is critical for patient-spe-ciﬁc instrumentation, there are concerns regarding thepossibility of dimensional changes during the process,which could have a deleterious impact on the accuracyof implant placement and, therefore, on surgical out-come.20Yet, only a few studies have evaluated the post-sterilization effects on patient guides,21–26the majority ofwhich focus on steam methods using polymers such aspolylactic acid and acrylonitrile butadiene styrene.21–25However, these polymers are not always considered bio-compatible and the long-term effects of contact withpatient tissues are unknown.While biocompatible 3D printed materials are available,few reports exist evaluating their accuracy following sterili-zation.26–28One group of investigators reported dimensionalchanges less than 0.2 mm, but used only one resin andsterilization method.27Another group of researchers simi-larly evaluated steam sterilization effects on surgical guidepolymer replicas created by industrial printers not readilyavailable in veterinary medicine.26Finally, while one studyevaluated absorbable stents, such devices are not used inorthopaedic surgery.28Unfortunately, due to variations inmethodology and types of polymers, these studies cannot bedirectly compared. Additionally, they do not provide sub-stantial information for surgeons regarding the safety andreliability of orthopaedic PSIs created from biocompatiblematerials, intended for use in clinical patients. Furthermore,new materials have been introduced since the publication ofthese prior studies, and further investigation of their accu-racy is warranted.Therefore, the purpose of this study was to evaluate post-sterilization dimensional accuracy of biocompatible 3Dprinted resins using a standardized guide, and to assessthe effect of three sterilization methods. The null hypothesiswas that sterilization methods would have no signi ﬁcanteffect on dimensional accuracy of 3D printed guides regard-less of resin type.

Answer 139

Oropharyngeal stick injuries (OSIs) occur when dogs that are retrieving, carrying or chewing sticks become impaled (Hallstrom 1970 , White & Lane 1988 , Doran et al. 2008 ). Cases have been described as either acute (less than 7 days) or chronic (more than 7 days) at presentation (White & Lane 1988 , Griffiths et al. 2000 ). Earlier reports primarily describe the presentation of patients with chronic OSI as a cervical swelling with or without a discharging sinus tract (White & Lane 1988 , Griffiths et al. 2000 , Nicholson et al. 2008 ). However, more recent reports have focused on acute OSI (Doran et al. 2008 , Robinson et al. 2014 ). Most studies recommend early intervention in acute OSIs in order to avoid long- term complications (Baker 1972 , White & Lane 1988 , Griffiths et al. 2000 , Doran et al. 2008 , Nicholson et al. 2008 , Robinson et al. 2014 ). Clinical signs of acute OSI have been reported as oral pain, oral bleeding, hypersalivation, lethargy, dysphagia, anorexia, pyrexia, cervical swelling, retching, subcutaneous emphysema, coughing or choking, and less commonly, dyspnoea, exophthalmos and tetraparesis. (Baker 1972 , White & Lane 1988 , Griffiths et al. 2000 , Rayward 2002 , Robinson et al. 2014 ). Over- representation of middle to large breed dogs (White & Lane 1988 , Griffiths et al. 2000 , Robinson et al. 2014 ) and male dogs (Nicholson et al. 2008 , Robinson et al. 2014 ) has been reported, although in other papers the gender balance was equal, or females were more commonly represented (White & Lane 1988 , Doran et al. 2008 ). The prognosis for acute OSI has been reported to be good with survival rates of 73.3% (White & Lane 1988 ) and 87.8% (Doran et al. 2008 ), and resolution of signs in up to 100% of dogs in smaller studies (Griffiths et al. 2000 , Robinson et al. 2014 ). The prognosis is reported to be less favourable when oesophageal injury is involved, compared to patients where the injury is confined to the oropharynx, with all fatalities having oesophageal tears (White & Lane 1988 , Doran et al. 2008 ). Retention of foreign material within the tract is associated with the development of an abscess and for this reason a primary aim of treatment is to ensure that there is no retained foreign material (Baker 1972 , White & Lane 1988 , Griffiths et al. 2000 , Doran et al. 2008 , Nicholson et al. 2008 , Robinson et al. 2014 ). A variety of imaging techniques may be used for the initial assessment of dogs with OSI. Radiography is a simple and relatively cheap screening technique that can detect cervical emphysema, pneumomediastinum, pneumothorax, pleural effusion and mediastinal effusion, and occasionally the presence of foreign material (Doran et al. 2008 ). However, false negative results are possible, so this cannot be relied upon for decision making regarding surgery (Robinson et al. 2014 ). Magnetic resonance imaging (MRI) and CT have been shown to be useful for detecting the presence of foreign material in chronic OSI cases (Dobro -mylskyj et al. 2008 , Nicholson et al. 2008 ), but there is little information on the use of these modalities in acute OSIs. Flexible endoscopy has previously been described in the management of acute OSI in a cat (Bright et al. 2002 ). The most commonly recommended treatment for patients with OSI is surgical exploration via a ventral midline cervical approach to examine the site of injury, debride any sinus tracts, and remove all foreign material (Baker 1972 , White & Lane 1988 , Griffiths et al. 2000 , Doran et al. 2008 , Nicholson et al. 2008 ). However, the use of rigid endoscopy to investigate and treat acute OSI has been described in a small number of dogs with excellent outcomes (Robinson et al. 2014 ). The aim of this study is to evaluate whether the management of acute OSIs with rigid endoscopy results in favourable longterm outcomes and a low recurrence rate in a larger cohort of dogs.

Answer 140

Total hip replacement (THR) is a highly effective technique forthe management of hip dysplasia and other diseases of thecoxofemoral joint in dogs.1However, several potentiallychallenging complications have been reported followingthe procedure, including luxation, implant loosening, infec-tion and femoral fracture.2–5Luxation has been described asthe most common complication,3,4,6 –8with a reported inci-dence of between 1.1 and 15.8%.1,4,5,7A variety of patient-related and technical factors havebeen postulated as determinants of the risk of luxation indogs, including breed, conformation, implant sizing andimplant positioning.4,6,9Of these, the most attention hasbeen paid to the role of acetabular cup positioning (angles oflateral opening [ALO] and cup version).4,6Manufacturer ’srecommendations for acetabular positioning range from 35to 45 degrees for ALO4and 15 to 25 degrees for versionangle.10,11However, these angles are not intended to bebreed-speci ﬁc. Given the variation in pelvic size andormation seen in dogs that are candidates for THR, it isunlikely that population-based average values will be appro-priate for all dogs. Additionally, the published guidance doesnot take into consideration any pelvic pathology that mayaffect acetabular conformation and orientation. Based on thecurrent state of knowledge, it is apparent that a morecomplete description of normal reference values for acetab-ular orientation across different breeds and over a range ofpathologies could be helpful in better de ﬁning optimalimplant position and reducing the risk of postoperativecomplications following THR.Two-dimensional measurements have been widelyused to describe acetabular geometry.12–14However,plain radiographs do not account for pelvic rotation ortilting, and perfect projections are necessary for accurateand repeatable measurements.15Measurements of ace-tabular morphometry utilizing computed tomography(CT) have also been reported.16With CT becoming moreaccessible and accepted as a routine diagnostic modalityin veterinary medicine, there is potential to obtain moreaccurate and precise measurements. Three-dimensional(3D), CT-derived bone models give detailed informationon acetabular morphometry and are relatively insensitiveto variation in patient positioning during the CT scanprocedure.17The speci ﬁc aim of this study was to determine ALO andversion angles of the native canine acetabulum in a hetero-geneous population of dogs to establish reference values fordogs using 3D in-silico models derived from CT scans, and tovalidate this method by determining intra-observer coef ﬁ-cient of variation. We hypothesized that measurementsmade on 3D models are repeatable and that ALO and versionangles are more variable than the range recommended byimplant manufacturers.

Answer 141

Pelvic fractures are a common traumatic injury in cats, repre-senting between 20 and 34% of the fractures seen in thisspecies.1–3Historically, many feline pelvic fractures havebeen treated conservatively, and while most heal, malunionis expected.1,2Complications of conservative treatment in-clude narrowing of the pelvic canal, obstipation, hip osteoar-thritis and pain (for articular fractures), and neurologicaldeﬁcits.4The small size of cats compared with dogs and theirdemeanor make cage rest a viable option in many cases, but theabove complications can be avoided with surgical intervention.Many different techniques have been described for therepair of ilial and acetabular fractures in cats. These includeboth lateral4and dorsal plating5with a wide variety ofdifferent types of plate. The use of dynamic compressionplates,6veterinary cuttable plates,7T-plates,8Y-shaped tibialplateau leveling osteotomy (TPLO) plates,9and TPLO lockingcompression plates10has been reported. Orthogonal (dorsaland lateral)11plating has also been described. Other reportedﬁxation techniques include screws with a ﬁgure-of-eightwire, screws and pins augmented with polymethyl methac-rylate (PMMA),12intramedullary pinning, and intramedul-lary pin in combination with a lateral plate.13mmonly reported complication associated with non-locking plate ﬁxation of ilial and acetabular fractures is screwloosening. The incidence of screw loosening has beenreported to be as high as 62% in one study4and 50% inanother.14The incidence of screw loosening is lower withlocking plate ﬁxation (1 case out of 13 fracture repairs) andno cases of screw loosening were seen in 11 ilial fracturesrepaired with double locking plates.14Plate failure leading topelvic collapse and malunion was reported in one retrospec-tive study of feline pelvic fracture repairs at an incidence of3/18,15and in this same study, delayed union was reported in1/18 cats. Short-term sciatic neuropraxia has been reportedin 13% of cats with pelvic fractures.16In dogs, the combina-tion of a lag screw and neutralization plate reduced theincidence of screw loosening for nonlocking implants.17The high incidence of screw loosening in cats can beexplained by the poor quality and thickness of bone of thefeline ilial wing, which provides limited screw purchase for alaterally applied plate. In addition, the potential for ﬁxationfailure is increased when there is limited screw purchasecaudal to the fracture site,18which can be the case for caudalilial or acetabular fracture repair. The use of locking platesand screws ameliorates these problems to a large extent.Locking plates do not rely on generating friction between theplate/bone interface,19but rather lock the screws to theplate, so that the system acts as a single-beam construct.This can increase the construct strength by up to four timeswhen compared with nonlocking plates where micromotioncan occur between the plate and screws.19Angular stableinternal ﬁxators such as the locking compression plate havebeen advocated for osteoporotic or poor-quality bone wherethey improve screw pullout20and minimize the negativeimpact on local vascularity during fracture healing.21The “String of Pearls ”(SOP) is a strong and versatilelocking plate system (Orthomed, Shef ﬁeld, UK) that usesconventional cortical screws.22The SOP plate consists of aseries of cylindrical sections ( “internodes ”) and sphericalcomponents ( “pearls ”) and can be contoured in three planesto suit almost every fracture or bone con ﬁguration withoutcompromising its locking ability.22Each pearl can engage astandard cortical bone screw in a locking fashion by allowingthe screw threads to engage with a thread within the pearl.The use of the SOP plate for the repair of pelvic fractures inﬁve cats was previously reported.23This study describes theuse of the SOP in a larger series of cats and reports medium-and long-term complications and outcomes.

Answer 142

Apocrine gland anal sac adenocarcinoma (AGASACA) is the result of the neoplastic transformation of glandular epithelial cells of the apocrine gland of the anal sac.1–3 AGASACA is considered a locally invasive and highly metastatic disease.1–4 The presence of me -tastasis is often detected at the time of initial anal sac mass diagnosis, and it is most commonly detected at Long-term outcomes associated with a modified versus traditional closed anal sacculectomy for treatment of canine anal sac neoplasiaGabrielle S. Fontes, DVM1; Alysha M. McGrath, DVM2; Carolyn L. Chen, DVM3; Jennifer M. Truong, BS4; Hadley E. Gleason, DVM, MS, DACVS4; Janis M. Lapsley, DVM, DACVS1; Laura E. Selmic, BVetMed, MPH, DACVS, DECVS, MRCVS1*1Department of Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus, OH2Department of Small Animal Surgery, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA3Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA4Department of Veterinary Clinical Medicine, College of Veterinary Medicine, University of Illinois, Urbana, IL*Corresponding author: Dr. Selmic ( selmic.1@osu.edu )Received May 25, 2023Accepted July 20, 2023doi.org/10.2460/javma.23.05.0239the iliosacral lymph center before reaching distant sites like abdominal organs or the lungs.1,5,6The definitive treatment for AGASACA often involves anal sacculectomy and extirpation of any metastatic iliosacral lymph nodes.3 Both chemo -therapy and radiation therapy are recommended adjunct treatments, and closed and open techniques 2 for anal sacculectomy have been described.3 The open approach, which involves making a direct inci -sion into the anal gland to expose the lining of the anal sac, is considered faster and simpler to perform but inappropriate for anal sacs affected by tumors.7 The closed technique keeps the anal sac completely intact, therefore decreasing contamination of sur -rounding tissue and the potential for postoperative infection.7,8 The closed technique is recommended for anal sacculectomy for neoplasia.8 A potential drawback to the use of the traditional closed tech -nique is that the anal sac duct is not fully excised but only ligated. A modified approach to the closed anal sacculectomy has been described to facilitate full anal sac duct excision with minimal surround -ing soft tissue trauma by use of a hemostat to assist with intraoperative manipulation and traction of the anal sac.9 Minimal short-term complications were re -ported with the procedure.9 No long-term outcomes, including recurrence or metastasis rates, have been reported following the use of this modified closed technique for dogs with anal sac neoplasia.The objective of this study was to report the short-term and long-term outcomes, recurrence, and metastasis rates of dogs that underwent the modified closed anal sacculectomy or traditional closed anal sacculectomy for treatment of anal sac neoplasia. The authors hypothesized that dogs that received the modified closed approach would have lower recur -rence rates and fewer short-term and long-term com -plications than the traditional cl

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