M&M - 202307-202402

Question 1

Mansbridge - 2024 - JFMS - Physical examination and CT to assess thoracic injury in 137 cats presented to UK referral hospitals after trauma.pdf

Answer 1

This was a multicentre, retrospective, observational study, involving three private referral hospitals in the UK. Cats admitted to any of the participating hospitals between January 2012 and December 2022, with a history of either witnessed or suspected blunt force trauma, and that sub -sequently underwent TCT were eligible for the study.Records were reviewed and data were collected on signalment, including breed, age, sex and neutering sta -tus, as well as the nature of the trauma. The nature of the trauma was recorded in specific categories if it was either witnessed or highly suspected based on history and examination. Physical examination findings were col-lated based on clinical examination at the time of presen -tation at the participating hospital. Parameters that were not specifically commented on within the clinical notes were presumed to be within normal limits. CT scans were performed under chemical restraint; the decision to either sedate or anaesthetise patients was made on a case-by-case basis by the attending clinician or anaesthetist. For participants undergoing CT of other anatomical regions in addition to the thorax, anatomical study locations were documented. Abnormalities detected on TCT and any therapeutic interventions implemented after TCT were recorded.Ethical approval was sought from the University of Nottingham’s ethical review panel.Statistical analysisAll variables were summarised using descriptive statis -tics. Fisher’s exact tests were used to explore the asso-ciations between physical examination findings and TCT abnormalities, between physical examination findings and subsequent intervention, and between specific abnor -mal TCT findings and having abnormalities identified on thoracic physical examination. Stepwise binary logistic regression models were used to identify predictors of TCT findings based on physical examination, as well as the requirement for intervention based on TCT findings. A binary logistic regression was also used to relate the presence of abnormal CT findings and of interventions to the number of abnormalities on physical examina-tion. Statistical significance was set at P <0.05. Clinical and TCT findings identified in fewer than 10 cases were excluded from analysis.ResultsA total of 139 cats met the inclusion criteria. Of these, two cats were later excluded as no physical examination findings were recorded due to the temperament of the animals on presentation, leaving 137 cats in the analysis. Breeds comprised domestic shorthair (n = 109), domes -tic longhair (n = 6), British Shorthair (n = 5), Bengal (n = 4), Ragdoll (n = 3), British Blue (n = 2), crossbreed (n = 2) and one each of Siamese, Maine Coon, Russian Blue, Tonkinese, Norwegian Forest Cat and one was unknown. There were 83 male cats (79 neutered, four entire) and 50 female cats (48 neutered, two entire). Four cats did not have their sex recorded. The median age was 41 months (range 1–216).RTAs were the most common cause of trauma, with 94 (69%) cats presenting for this reason; 37 (27%) had an unknown history and six (4%) had experienced a fall.The most common abnormal findings on clinical examination were as follows: tachypnoea (n = 44, 32%); pale mucous membranes (n = 30, 22%); dyspnoea (n = 28, 20%); tachycardia (n = 23, 17%); altered mentation (n = 19, 14%); reduced lung sounds (n = 15, 11%); pain on abdom-inal palpation (n = 9, 7%); harsh lung sounds (n = 7, 5%); external thoracic wounds (n = 7, 5%); external abdominal wounds (n = 6, 4%); and weak pulses (n = 5, 4%). Cats were further categorised by the number of abnormalities detected on thoracic examination (Table 1).Other anatomical regions examined on CT at the same time as the thoracic study included the pelvis (n = 75), Mansbridge et al 3head (n = 66), abdomen (n = 61), regions of the appen-dicular skeleton (n = 36) and neck (n = 24).In total, 31 (23%) cats had a completely normal TCT, while 106 (77%) had abnormalities detected. The most common abnormalities identified on TCT are summa-rised in Table 2.A total of 21 (15%) cats had no abnormalities identi-fied on either thoracic physical examination or TCT; 63 (46%) had abnormalities on both examination and TCT; 45 (33%) had no physical examination abnormalities but did have abnormalities detected on TCT – six of these required an intervention. Eight cats (6%) had abnormali -ties detected on clinical examination, but a normal TCT.Fisher’s exact tests were used to identify physical examination findings associated with abnormal findings on TCT and found tachypnoea to be the only significant finding ( P = 0.004).Several TCT abnormalities were significantly associ -ated with the presence of one or more abnormalities on thoracic examination, including pneumothorax (P <0.001), subcutaneous emphysema (P <0.001), pneu-momediastinum (P = 0.006), pulmonary contusions (P = 0.006) and rib fractures (P = 0.049). Pulmonary collapse, atelectasis and pleural effusion were not significantly associated with an abnormal physical examination.An increasing number of thoracic abnormalities on examination was a significant predictor of the presence of abnormal findings on TCT (odds ratio [OR] 2.04, 95% confidence interval [CI] 1.21–3.44, P = 0.008). The results of stepwise binary logistic regressions of individual TCT findings on individual physical examination findings are displayed in Table 3.In total, 28 (20%) cats in the study required an inter -vention after TCT. A total of 17 (12%) cats required thora -cocentesis based on the TCT findings: 10 (7%) had a chest drain placed and seven (5%) required surgery – two for diaphragmatic hernia repair, three for repair of a tracheal injury and two for repair of fractured thoracic vertebrae. One cat had a bronchoalveolar lavage due to an incidental finding of suspected chronic bronchitis. In total, 109 (80%) cats did not require any kind of intervention after TCT.The presence of dyspnoea on physical examination was significantly associated with ultimately requiring an intervention (P <0.001), as was the presence of tachyp-noea (P = 0.003) and reduced lung sounds (P = 0.003). When modelled using binary logistic regression, reduced lung sounds was the only significant predictor (OR 6.29, 95% CI 2.03–19.50, P = 0.001).A highly significant association was found between an increasing number of abnormal physical examination findings and the ultimate need for intervention (OR 1.82, 95% CI 1.32–2.51, P <0.001).Table 1 Cats with differing numbers of abnormalities detected on thoracic examinationNumber of abnormalities on thoracic examinationNumber of cats (n = 137)%0 66 48.21 34 24.82 17 12.43 13 9.54 4 2.95 3 2.2Table 2 Number of cats with abnormal findings on TCT (cats could have more than one abnormality, so percentages do not add up to 100%)TCT findings Number %Atelectasis 46 33.6Pulmonary contusion 45 32.8Pneumothorax 40 29.2Pleural effusion 28 20.4Pneumomediastinum 23 16.8Rib fractures 19 13.9Subcutaneous emphysema 18 13.1Pulmonary collapse 15 10.9Tracheal tear/avulsion 4 2.9Diaphragmatic rupture 3 2.2TCT = thoracic CTTable 3 Stepwise binary logistic regression of abnormal TCT findings on physical examination findingsTCT finding Physical examination finding OR 95% CI P valuePneumothorax Tachypnoea 3.19 1.44–7.08 0.004Reduced lung sounds 3.65 1.15–11.6 0.028Contusions Dyspnoea 3.81 1.61–9.03 0.002Subcutaneous emphysemaDyspnoea 6.94 2.41–19.97 <0.001CI = confidence interval; OR = odds ratio; TCT = thoracic CT4 Journal of Feline Medicine and Surgery

Question 2

Burton - 2023 - VETSURG - Review of minimally invasive surgical procedures for assessment and treatment of medial coronoid process disease.pdf

Answer 2

NA

Question 3

Sabetti - 2024 - JSAP - Endoscopic and surgical treatment of non-neoplastic proximal duodenal ulceration in dogs, and anatomical study of proximal duodenal vascularisation.pdf

Answer 3

The study was divided into two main phases.The first phase was a post-mortem study to investigate the vas -cularisation of the proximal duodenum in dogs without gastro -intestinal diseases, while the second phase was focused on the clinical, endoscopic and therapeutic description of canine duode -nal ulcers occurring spontaneously. The second phase dogs were referral patients diagnosed by endoscopic examination that, upon failing medical therapy, then underwent surgical or endoscopic electrocautery.The study was carried out according to the Italian legislation which implemented the European Council Directive 2010/2063 regarding the protection of animals used for scientific purposes; informed consent was obtained from all dog owners before the beginning of the study.Phase 1Polyurethane foam casts of duodenal vascularisationTo investigate the role of vascularisation in ulcer persistence, poly -urethane foam casts of the gastroduodenal vessels were obtained from 5 dogs differing in sex, age, weight and breed which had died owing to causes unrelated to the gastrointestinal or cardio -vascular systems.The technique of creating polyurethane foam casts of the gastroduodenal vessels followed the method proposed by De Sordi et al. (2014 ). Briefly, the portal vein and, after opening the thoracic cavity, the first tract of the descending aorta were cath -eterised and washed with tap water to remove blood and clots. For the arterial system, an extension tube, shortened (approx. 50 cm) and cut to make the tip pointed, was inserted into the thoracic aorta and a haemostatic clamp was positioned to close the abdominal aorta after the origin of the coeliac artery. 17485827, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13680 by Vetagro Sup Aef, Wiley Online Library on [04/02/2024]. 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 LicenseNon-neoplastic duodenal ulceration in dogsJournal of Small Animal Practice • Vol 65 • February 2024 • © 2023 The Authors. Journal of Small Animal Practice published by John Wiley & Sons Ltd on behalf of British Small Animal Veterinary Association.115 For the portal system, the portal vein was used and catheterised by a similar catheter. The casts of these vessels were obtained by injecting 40 g of polyurethane foam (diphenylmethane-4, 4-diisocyanate; Soudafoam – Soudal N.V., T urnhout, Belgium), diluted with 10 mL of pure acetone into each bloodstream in order to prevent its expansion, and then adding a few drops of red, or blue nitro dye (PebeoCeramic, Gemenos Cedex, France), for the arterial and the venous systems, respectively.The abdomen was then covered with soaked absorbent paper to ensure the correct anatomical position and to avoid dehydra -tion, and each dog was cooled to 4°C for 5 hours to allow the foam to set.The stomach and the duodenum were then isolated, cut at the mesenteric edge and gently rinsed using a water jet. Finally, a morphological study was carried out; the images were acquired using a reflex digital camera (Fujifilm HS50) and were processed using Adobe Photoshop CS7®.Phase 2Subject selectionIn this observational case series study, the records from November 2016 to January 2022 were searched for dogs which were pre -sented to the Veterinary Hospital, and were diagnosed with proxi -mal duodenal ulcers. The inclusion criteria for case selection were dogs of any age, breed and sex which had clinical signs related to acute or chronic ulcers which had undergone an endoscopic examination of the digestive tract and had been diagnosed with a duodenal peptic ulcer. Dogs with gastric ulcers, with duodenal neoplastic ulcers and with ulcers associated with the concomitant presence of gastrointestinal foreign bodies were excluded. Dogs with duodenal ulcers and other comorbidities were also enrolled.All cases enrolled in the study had undergone a diagnostic investigation (complete history, clinical presentation, clinico -pathological evaluation and ultrasound examination findings) to exclude other causes of gastrointestinal bleeding before undergo -ing endoscopic examination.The following data were recorded for the dogs: signalment; history with particular attention to the presence of previous epi -sodes of vomiting, haematemesis, diarrhoea or melaena, and any possibly recent treatment with non-steroidal anti-inflammatory drugs (NSAIDs), or corticosteroids; clinical presentation; labo -ratory findings, such as blood count, biochemistry, coagulation panel and abdominal ultrasound findings, to look for increased duodenal wall thickness, periduodenal oedema, hyperechoic periduodenal fat and enlargement of pancreaticoduodenal and hepatic lymph nodes.In addition, for each dog enrolled, the gastrointestinal endo -scopic diagnosis, including the aspects of the duodenal mucosa, and the treatment (medical, endoscopic or surgical) of the ulcers were reported.Duodenal ulcer diagnosisAll the endoscopic examinations were performed by the same expert endoscopist (MP) in a standardised fashion based on the American College of Veterinary Internal Medicine (ACVIM) Consensus Statement (Washabau et al., 2010 ), using the same endoscope (Pentax EG-2970, diameter 9.8 mm).Anaesthetic protocol was based upon the patients-specific American Society of Anesthesiologists (ASA) criteria and decided at the anaesthetists discretion.The dogs were placed in left lateral recumbency to facilitate the transpyloric passage of the endoscope; the endoscopic pro -cedure was performed using duodenal dilatation with lukewarm water (Galiazzo et al., 2020 ). The pattern of the mucosal surface, the shag carpet appearance created by the villi, the major (and occasionally the minor) duodenal papilla and the Peyer’s patches were examined.All the procedures were recorded using a software package (Pinnacle Studio 22 Plus, Corel Corp., Ottawa ON, Canada) and, after the gastroenteric endoscopic procedure, the descriptive characteristics of the lesions were assessed.The following aspects were recorded for each case: (1) the affected side of the proximal duodenum (dorsal, ventral, medial-mesenteric side, lateral-antimesenteric side); (2) the presence of a single lesion or multiple ulcerating lesions and (3) the width of the ulcer. To describe the width of the lesion, the size was expressed in degrees: 90° for lesions occupying one quadrant, 180° for those occupying two quadrants, 270° for those occupy -ing three quadrants, and 360° if it extended for the entire cir -cumference of the duodenal surface ( Fig 1). The macroscopic description was obtained by evaluating four main characteristics: (1) number of lesions recorded; (2) description of the ulcer cra -ter (flat ulcer versus slightly excavated ulcer versus deep ulcer; (3) ulcer wall thickening (thickened versus non-thickened); (4) description of the margins (hyperaemic versus non-hyperaemic) FIG 1. Evaluation of the width of the ulcer. Size was expressed in degrees: 90° for lesions occupying one quadrant, 180° for lesions occupying two quadrants, 270° for lesions occupying three quadrants and 360° if it extended around the entire circumference of the duodenal surface 17485827, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13680 by Vetagro Sup Aef, Wiley Online Library on [04/02/2024]. 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 LicenseM. C. Sabetti et al.Journal of Small Animal Practice • Vol 65 • February 2024 • © 2023 The Authors. Journal of Small Animal Practice published by John Wiley & Sons Ltd on behalf of British Small Animal Veterinary Association.116and (5) presence of bleeding from the ulcer (bleeding versus no bleeding).At the time of the endoscopy, three to five biopsies were taken from the ulcer site (crater and wall) and from normal-appearing tissue and immediately placed in formalin. Biopsies were anal -ysed by the board-certified pathologist to confirm the nature of the ulcer (benign or malignant).Type of treatmentAfter the endoscopic diagnosis of a duodenal ulcer, all the dogs were started on medical treatment (omeprazole 1 mg/kg SC twice daily, sucralfate 40 mg/kg PO three times daily, and amoxi -cillin and clavulanate 12.5 mg/kg SC twice daily). In the absence of clinical/laboratory resolution within approximately 10 days (based on the disappearance of vomiting, haematemesis, melaena and/or loss of haematocrit point), the lesions were subsequently treated by endoscopic electrocauterisation or by surgery.The ulcer showing active bleeding on endoscopic examina -tion, in the absence of major areas of necrosis, underwent elec -trocoagulation (Alsa Apparecchi Medicali SRL, Castelmaggiore, Italy) using a monopolar endoscopic electric snare (Endoaccess Gmbh, Garbsen, Germany). A monopolar technique is applied with a strong thermal effect capable of producing coagulation and haemostasis in the intestinal wall, with the result of clot for -mation in the submucosal vessels.Surgery was performed if the duodenal wall involved extensive areas of necrosis, with or without active bleeding, or if the char -acteristics of the ulcer (position, duodenal diameter) prevented endoscopic treatment. Surgery included direct coagulation using bipolar electrosurgical forceps via duodenotomy or, in the case of diffuse necrosis, via duodenectomy and subsequent gastroduode -nal anastomosis (Billroth type 1).Statistical analysisAll the data were analysed using a statistical software package (MedCalc Statistical Software version 19.5.1, Ostend, Belgium). All the continuous variables were tested for their distribution using the Shapiro–Wilk normality test. Descriptive statistics included mean ±sd for normally distributed data, and median and range (minimum to maximum) for data that were not nor -mally distributed.RESULTSPhase 1Polyurethane foam castObservation of the vascular structure revealed that the blood supply to the C-shaped duodenum was shared with the head of the pancreas. The proximal segment of the duodenum was sup -plied by the gastroduodenal artery and its branches, including the cranial pancreaticoduodenal artery. Venous drainage follows the arteries and ultimately drains into the portal system.In all the specimens, a submucosal vascular network, both venous and arterial, was evident, with a prominent venous plexus seen in detail exclusively in the first half inch of the duodenum (Fig 2).Phase 2SignalmentThirty-seven cases were assessed, and 12 cases met the inclusion criteria. Four subjects were excluded due to a lack of historical and diagnostic data, while another nine were excluded due the simultaneous presence of a gastrointestinal foreign body, and FIG 2. Polyurethane foam cast (sample after foam curing and isolation). (A) Ventral view of the dog’s stomach (S) and duodenum (D). The gastroduodenal artery (gda) and vein (gdv) are clearly visible, as is the aorta (Ao). The venus plexus is on the mesenteric border of the first duodenal tract ( *). (B) The duodenum was sectioned at the antimesenteric border, at the level of the venous plexus, to better view the mucosal vascularisation. Note the vein vascularisation in blue. (C) A detail of the mucosa. Note the presence of a venous vessel (arrow) protruding from the surface of the mucosa 17485827, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13680 by Vetagro Sup Aef, Wiley Online Library on [04/02/2024]. 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 LicenseNon-neoplastic duodenal ulceration in dogsJournal of Small Animal Practice • Vol 65 • February 2024 • © 2023 The Authors. Journal of Small Animal Practice published by John Wiley & Sons Ltd on behalf of British Small Animal Veterinary Association.117 12 for a concomitant gastric ulcer. The breeds included four mixed breed dogs, two German shepherd dogs and one of each of the following breeds: Flat-coated retriever, Italian short-haired hound, Bernese mountain dog, American Staffordshire terrier, Pinscher and Labrador retriever. Sex and neuter status included five males (three neutered) and seven females (five spayed). A mean age of 7 ±4 years and a mean bodyweight of 24 ±13 kg were reported ( Table 1).History and clinical presentationAt the time of hospitalisation, the most common historical and presenting clinical signs were lethargy (9/12), dysorexia (10/12), vomiting (8/12), melaena (8/12), pale mucous membranes (7/12) and haematemesis (2/12); abdominal pain (1/12) was less frequently reported ( Table 2).All dogs had comorbidities, namely chronic enteritis, chronic pancreatitis, exocrine pancreatic insufficiency, chronic kidney disease, immune-mediated thrombocytopenia and pulmonary carcinoma. In one dog, a predisposing factor was previous treat -ment with lomustine, and then with masitinib mesylate, for cuta -neous lymphoma, ending 1 month before endoscopy, and, in a second dog, treatment, a few days before, with a drug contain -ing a non-steroidal anti-inflammatory (diclofenac diethylammo -nium). The ASA physical status classification was recorded before the anaesthesia in all patients ( Table 2).Common clinicopathological findings (8/12 dogs) were severe normochromic (MCHC 31.05 ±1.7%) normocytic (MCV 70.31 ±7.46 FI) regenerative (208,012 ±192,763 RET/mm3) anaemia (HCT 17.6 ±6.6%). All eight cases with severe anaemia had severe hypoproteinaemia (4.62 ±0.71 g/dL) and hypoalbu -minaemia (2.1 ±0.99 g/dL) ( Table 3).Abdominal ultrasound, performed on 11 of 12 cases, showed increased duodenal wall thickness (6/11), periduodenal oedema (1/11) and hyperechoic periduodenal fat (4/11) ( Table 4).Due to severe anaemia, a blood transfusion was required in seven of 12 dogs before the endoscopy.Endoscopic visualisation and histological diagnosisThe duodenal ulcers were located at the proximal part of the duo -denum before the duodenal papillae (major and, eventually if pres -ent, minor). In all cases, they involved the mesenteric portion of the wall, extending to the dorsal portion in two of 12 cases, to the dorsal and ventral portions in one case, and having an incomplete ring appearance in two of 12 cases ( Fig 3A), also involving, the dorsal side, the ventral side and part of the lateral side, in addition to the medial wall. The surface area of the proximal duodenum involved ranged from 90° to 360°. In nine of 12 cases, the lesion was single, while in two cases, there were two lesions in close prox -imity, and in the remaining case, there were multiple lesions. On endoscopic examination, the ulcers appeared flat in five of 12 dogs (Fig 3B), slightly excavated in five of 12 dogs and deep in two of 12 dogs; in seven of 12 dogs, they were associated with wall thicken -ing (Fig 3C) and in seven of 12 with hyperemic margins. Active bleeding was recorded during endoscopy in 10 of 12 patients.The full findings, treatment procedures and histological diag -nosis are summarised in Table 5.Treatments and outcomeMedical treatment was started after the first endoscopy diag -nosing the ulcer. All the dogs received proton-pump inhibitors, Table 1. Signalment and bodyweight of the dogs with proximal duodenal ulcerationBreed Sex Age Weight (kg)Case 1 Pinscher F2y 1m 5.7Case 2 Mixed breed S6y 7m 13Case 3 Mixed breed N 13y 11m 11.7Case 4 German shepherd dog M 10y 5m 36.6Case 5 Italian short-haired hound F1y 11Case 6 Mixed breed M 13y 2m 27.5Case7 German shepherd dog S6y 8m 42Case 8 American Staffordshire terrier S1y 6m 17.9Case 9 Flat-coated retriever N 9y 7m 30Case 10 Bernese mountain dog N 3y 11m 47Case 11 Labrador retriever S4y 5m 25.2Case 12 Mixed breed S5y 6m 21.5Gender: M Male, N Neutered male, F Female, S Spayed female; Age: y Year, m MonthTable 2. Historical and presenting clinical signs of the dogs with proximal duodenal ulcerationPredisposing factors/co-morbidities Lethargy Dysorexia Vomiting Hematemesis Melaena Pale mucous membranesAbdominal painASA scoreCase 1 Immune-mediated thrombocytopenia Yes Yes Yes No Yes Yes No 3Case 2 Previous treatment with masitinib mesylate and lomustine for cutaneous lymphomaYes No No No Yes Yes No 3Case 3 Chronic kidney disease Yes Yes Yes Yes Yes Yes No 3Case 4 Exocrine pancreatic insufficiency Yes Yes No No Yes Yes Yes 3Case 5 Immune-mediated thrombocytopenia Yes Yes Yes Yes Yes Yes No 3Case 6 Chronic enteritis Yes Yes No No No Yes No 3Case 7 Chronic enteritis, chronic pancreatitis No Yes No No Yes Yes No 3Case 8 / Yes Yes Yes No Yes No No 3Case 9 Pulmonary carcinoma Yes Yes Yes No Yes No No 3Case 10 Chronic enteritis No No Yes No No No No 2Case 11 Chronic enteritis Yes Yes Yes No No No No 2Case 12 NSAIDs ingestion (Diclofenac) No Yes Yes No No No No 2Total 11/12 9/12 10/12 8/12 2/12 8/12 7/12 1/12 12/12NSAIDs Non-steroidal anti-inflammatory drugs, ASA American Society of Anesthesiologists – Physical Status Classification System 17485827, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13680 by Vetagro Sup Aef, Wiley Online Library on [04/02/2024]. 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 LicenseM. C. Sabetti et al.Journal of Small Animal Practice • Vol 65 • February 2024 • © 2023 The Authors. Journal of Small Animal Practice published by John Wiley & Sons Ltd on behalf of British Small Animal Veterinary Association.118sucralfate and antibiotics. The dogs which did not respond to medical treatment in 10 days (6/12) were subsequently treated with endoscopic electrocauterisation ( Fig 4) (4/6), surgical coagulation via duodenotomy (1/6), or complete resection (enterectomy) of the proximal duodenal portion, and a gas -troduodenal anastomosis (Billroth type 1) (1/6). Surgical and endoscopic treatments successfully resolved the ulcer bleeding, without any recurrences, regardless of the predisposing factors. All the dogs survived to discharge. The median survival time [excluding cases lost to follow-up (case 4 and case 10)] was 107.5 days (10 to 1946) ( Table 5). Of the four dogs that died, case 2 died 471 days after the diagnosis of gastric ulcer due to a recurrence of cutaneous lymphoma. Case 7 died 10 days after discharge from acute pancreatitis. Case 9 died after 206 days from lung cancer. Case 11 died after 17 days from septic perito -nitis; the owners declined an autopsy.

Question 4

Looi - 2023 - VCOT - Effects of Angled Dynamic Compression Holes in a Tibial Plateau Levelling Osteotomy Plate on Cranially Directed Fragment Displacement.pdf

Answer 4

Study DesignA cadaveric, blinded study. A TPLO procedure was performedon 20 left and 20 right, non-paired ovine tibias, with either thecustom-made six-hole 3.5 mm angled compression hole plates(APlate) (n ¼20) or a standard six-hole 3.5 mm non-angledcompression hole plates (SPlate) (n ¼20) (Knight Benedikt,Seven Hills, New South Wales, Australia) in each group. Radio-graphs of the TPLO procedures were performed by a singlesurgeon (R.C.Y.L.) before and after tightening of the DC screws.The radiographs were randomized and evaluated by a secondsurgeon (D.R.J.) who was blinded to the type of plates involved.Plate DesignDifferent 3.5 mm six-hole TPLO plates consisting of left andright versions of APlate and SPlate were assessed ( ►Fig. 1 ).All plates were anatomically pre-contoured and made from316L stainless steel with the same overall size and shape.Double-thread type locking holes are situated in all proximalpositions and the middle hole of the distal cluster, as well asDC holes in positions four and six. The DC holes in SPlateswere parallel to the long axis of the plate, whereas theAPlates had DC holes angled at forty- five degrees to thelong axis of the plate, and ninety degrees to each other suchthat they would be expected to rotate the proximal part ofthe plate cranially during screw tightening.Tibial Plateau Levelling OsteotomyAll ovine tibias were obtained from a meat processing facilityand had the majority of soft tissue removed and were keptfrozen then thawed at room temperature for 6 hours prior tousage. The tibia was mounted in a timber custom-madesecurement device using two 4.5 mm negative-pro file endthreaded pins (Knight Benedikt, Seven Hills, New South Wales,Australia) connected via external skeletal fixator clamps(Knight Benedikt, Seven Hills, New South Wales, Australia).The securement device was designed to fits e c u r e l yo n t ot h eradiographic table to allow the TPLO procedure to be per-formed with minimal instability. (►Fig. 2 ) Visual inspectionconfirmed the positioning and alignment of the tibia in lateralradiographic projection. A standard Slocum-style TPLO jig(Knight Benedikt, Seven Hills, New South Wales, Australia)wasplaced using two 3.5 mm Ellis pins (Knight Benedikt, SevenHills, New South Wales, Australia), and a 30 mm TPLO saw(Aesculap, Tuttlingen, Germany) was used to make the osteot-omy in all specimens. The proximal tibial fragment was rotatedby 5 mm and a 1.1 mm Kirschner wire placed as the antirota-tional pin in all cases. There was no attempt made to compressthe osteotomy line so that a gap would be present, allowingdisplacement to be measured. The plate was initially secured tothe proximal fragment with a Kirschner wire and two 3.5 mmlocking screws (Knight Benedikt, SevenHills, New South Wales,Australia), and then secured to the distal fragment with two3.5 mm cortical screws (Knight Benedikt, Seven Hills, NewSouth Wales, Australia) in the DC holes in load position butnot fully tightened using a loading DC plate drill guide (DePuyFig. 1 TPLO plates. Left, six-hole 3.5mm standard non-angled com-pression hole plate (SPlate); Right, six-hole 3.5mm angled compres-sion hole plate (APlate)..Synthes Vet, West Chester, Pennsylvania, United States). Theplate type used was covered using a metallic object placed overthe DC holes prior to obtaining radiographs. Pins used as radio-opaque markers were secured by pre-drilling with a 0.9 mmKirschner wire(KnightBenedikt,SevenHills,New SouthWales,Australia). These markers were placed just distal to the cranialand caudal extents of the medial tibial condyles to outline thetibial plateau, aswellasalong thelong axisof thetibiaincludingthe distal tibia. Pre-tightenedradiographsweretakenwhenthehead of the cortical screws just touched the plate but had notyet engaged into the gliding holes. The proximal cortical screwwas fully tightened before the distal cortical screw. Post-tightened radiographs were taken after the cortical screwshave been engaged fully into the gliding hole, and the remain-ing locking screws were then placed.Imaging TechniqueAll radiographs were obtained using digital radiography(DuraDiagnost, Phillips, Amsterdam, Netherlands). A100 mm calibration marker (Biomedtrix, Whippany, NewJersey) was used for all the procedures, with elevation fromthe radiographic table equal to the level of the mounted tibia.The DICOM (Digital Imaging and Communications in Medi-cine) files were anonymized, converted to high de finition JPEG(Joint Photographic Experts Group) files and regroupedthrough a random number generator (Randomness and Integ-rity Services Ltd, Dublin, Ireland) before evaluation. These fileswere imported to an imaging software (OsiriX, Pixmeo, Ber-nex, Switzerland) for measurements to be made.Measurementsi)The tibial plateau was de fined by a line connecting pre-placed radio-opaque markers on the proximal tibia to avoidmeasurement irregularities associated with imprecise an-atomic landmarks and potential obstruction by the TPLO jig.ii)The mechanical axis of the tibia was de fined by the lineconnecting a marker placed on the distal tibia and onepositioned to represent the intercondylar eminences.iii)The TPA was measured as the angle between the linerepresenting the tibial plateau and a line perpendicular tothe long axis of the tibia. (►Fig. 3 )iv)The anatomic axis was de fined by a line connecting thedistal tibial marker and a further, mid tibial marker.v)Cranial displacement (CDisplacement) was de fined bythe perpendicular distance of a cranial osteotomyFig. 2 An ovine tibia was mounted on to a custom-made securementdevice and radiopaque markers were placed to aid with radiographicmeasurements. A standard TPLO procedure was performed using either acustom-made six-hole 3.5mm angled compression hole plate (APlate).Fig. 3 Measurement of Tibial Plateau Angle (TPA). The tibial plateau (blueline) was de fined by a line connecting the cranial and caudal extend of theplateau represented by radio-opaque markers αand β, whereas the tibiallong axis (green line) was represented by a line connecting a radiopaquemarker at the intercondylar eminences and mid talus gand respectively.The TPAwas measured as the angle between the tibial plateau and a lineperpendicular to the tibial long axis..fragment marker from the anatomic axis as measuredusing the perpendicular lines tool in Osirix ( ►Fig. 4 ).vi)Proximo-distal displacement (PDisplacement) wasmeasured using the perpendicular lines tool to quantifythe component of the distance between the tibial emi-nence marker and the mid tibial marker that was parallelto the anatomic axis (►Fig. 5 ).Statistical AnalysisA Wilcoxon rank sum test was performed on all cases tocompare APlate and SPlate with each measurement, with theresults reported as the median with the interquartile range(IQR: Q1-Q3).For all analyses, a value of p<0.05 was considered to besignificant.ResultsRadiographic MeasurementsCDisplacement in APlate (median 0.85, Q1-Q3: 0.575-1.325)was signi ficantly higher ( p/C200.0001, ►Table 1 ) than SPlate(median 0.00, Q1-Q3: -0.35-0.5).PDisplacement in APlate (median 0.45, Q1-Q3: 0.075-0.925) was similar to SPlate (median 0.65, Q1-Q3: 0.300-1.000) with no signi ficant difference seen ( p¼0.5066,►Table 1 ). Similarly change in TPA for APlate (median-0.25, Q1-Q3: -0.725-0.425) was not signi ficantly different(p¼0.1846, ►Table 1 ) to SPlate (median -0.75, Q1-Q3:-1.425 –0.025) ( ►Table 1 ).

Question 5

Friday - 2023 - VETSURG - Effect of metastatic calcification on complication rate and survival in 74 renal transplant cats (1998-2020).pdf

Answer 5

This was a single institution retrospective case series.Data from the medical records of 178 feline renal trans-plant candidates at the Matthew J. Ryan VeterinaryHospital of the University of Pennsylvania from 1998to 2020 were reviewed, and cats treated surgically wereincluded. Preoperative abd ominal and thoracic radio-graph reports, abdominal ul trasound reports and anyadditional follow-up imaging studies were evaluatedfor evidence of metastatic calcification for each cat. Allimages were reviewed by a board-certified radiologistat the time of report transcription. Cats with renal cal-cification alone were exclu ded from the study popula-tion as it was not possible to differentiate renalparenchymal calcification from nephroliths. Cats withonly calcification of interve rtebral disks or tracheal/bronchial rings were also excluded as these findingswere likely associated with degenerative processes anddystrophic rather than metast atic calcification. Addi-tional exclusion criteria wer ec a t sw i t hg a s t r i cc a l c i f i c a -tion that could not be dete rmined as luminal or muraland cats lacking radiographic imaging reports.In addition to imaging evaluation, age at time of renaltransplant, weight, sex, breed, and available clinicopatho-logic data —blood urea nitrogen (BUN); creatinine; totaland ionized calcium (iCa); and calcium-phosphorus solu-bility products, SP (Ca /C2P)—were recorded for each catpreoperatively and at 1 week, 1 month, 3 months,6 months, and 12 months postoperatively. The need forpreoperative hemodialysis, intraoperative complications,postoperative complications within and after 1 week ofrenal transplantation, and survival times was recorded.FRIDAY ET AL . 953 1532950x, 2023, 7, Necropsy findings were recorded when available for catsthat died during the study period.2.1 |Statistical analysisCats were stratified into two main groups based onwhether metastatic calcification was present at the timeof renal transplantation. The study’s primary endpointwas death from any cause. Survival time was calculatedfrom the date of transplantation to date of death. For catsin which the disposition was unknown, follow-up infor-mation was obtained by phone or email interview withthe owner or referring veterinarian. Descriptive data weretabulated and summarized. Normality of data was exam-ined using the Shapiro –Wilk test and visual inspection offrequency distribution histograms. Data were presentedas means (SDs) or medians (IQRs). Comparisons betweengroups were performed using unpaired t-tests, Mann –Whitney U-tests, or χ2tests. Survival was calculated usingthe Kaplan –Meier method and the difference in mediansurvival between groups calculated using the log ranktest. Right censoring was performed on cats that were lostto follow up or alive at the end of the study. Renal trans-plantation can be curative, and data sets with longfollow-up periods are characterized as highly mature.Data maturity can result in survival estimates that areunduly influenced by the diminishing number of subjectsthat remain at risk at the far right of the survivalcurves.19,20To avoid this, the presence of outliers wastested using martingale and deviance residuals and theKaplan –Meier curve was truncated at the end ofthe 5-year follow-up period. The association of demo-graphics, diagnosis, and results of diagnostic testing onsurvival was tested using univariable Cox regression. Var-iables with p< .20 on univariate analysis were consid-ered for multivariable backwards Cox regression.Collinearity of variables was examined using Pearson orSpearman correlation coefficients. Goodness of fit modelwas calculated as Harrell’s C. The proportional hazardsassumption was tested using log –log plots and a postesti-mation score test of the Schoenfeld residuals. A p< .05was considered significant. Within the cohort cats with-out mineralization at the time of transplantation, we usedunivariable logistic regression to explore variables thatpredicted subsequent development of calcification.3|RESULTS3.1 |Study cohortSeventy-nine of the 178 cats that underwent renal trans-plantation at the Matthew J. Ryan Veterinary Hospital ofthe University of Pennsylvania between 1998 and 2020met our study inclusion criteria. Ninety-nine cats wereexcluded from the study because of incomplete or miss-ing preoperative imaging reports, suspect dystrophic cal-cification of intervertebral discs, tracheal or bronchialcartilage, or inability to differentiate metastatic calcifica-tion from nephrolithiasis or luminal gastric mineral. Fiveof the 79 cats survived beyond 5 years from renal trans-plantation and were excluded as outliers as previouslyjustified. The remaining 74 cats were included in analy-sis. Median follow-up time was 472 days, with a range of0–1825 days.Fifteen of the 74 (20.3%) cats had evidence of meta-static calcification at the time of presentation for renaltransplantation. Represented breeds were domestic short-hairs (13), Persian (1), and Abyssinian (1). Ten of the fif-teen were male castrated and five were female spayed.Mean age at the time of surgery was 8.8 years. Locationof preoperative metastatic calcification included the tho-racic and/or abdominal aorta (11) (Figure 1), renal pelvis(3), adrenal gland (3), gastric wall (2), pulmonary paren-chyma (2), brachiocephalic trunk (2), aortic valve (1),renal parenchyma (1), periscapular soft tissue (1), cranialmediastinum (1), and pancreas (1). Median preoperativeSP (Ca /C2P) in cats with metastatic calcification at pre-sentation was 138.4 mg/dL (range 75.2 –176.0 mg/dL).Additional clinicopathologic results are listed in Table 1.Forty-seven of the 74 (63.5%) cats had no evidence ofmetastatic calcification during the study period. Repre-sented breeds included domestic shorthair (31), domesticlonghair (6), Siamese (4), domestic medium hair (1), Ori-ental shorthair (1), Persian (1), Himalayan (1), and Mainecoon (1). Mean age at time of surgery was 9.1 years.Median preoperative SP(Ca /C2P) in cats with no evidenceof metastatic calcification at presentation was 85.1 mg/dL(range 61.8 –113.5 mg/dL). In comparing cats with calcifi-cation at the time of presentation to cats with nocalcification, the preoperative SP(Ca /C2P) was found tobe higher in cats with calcification present ( p=.006).FIGURE 1 Left lateral radiograph of cat prior to renaltransplantation showing calcification of the entire thoracic aorta.954 FRIDAY ET AL . 1532950x, 2023, 7, Twelve of the 74 (16.2%) cats developed metastaticcalcification following renal transplantation, which wasdetected either on subsequent radiographs or at necropsy.Breeds included domestic shorthair (11) and Siamese (1).Two of the cats were female spayed and 10 were malecastrated. Mean age at the time of surgery was 7.6 years.Calcification was identified in the aorta (4), pulmonaryparenchyma (4), celiac and cranial mesenteric arteries(2), heart (interventricular septum, ventricular walls) (2),renal pelvis/parenchyma (2), renal allograft (2), tongue(2), right and left subclavian arteries (1), external iliacartery (1), intrahepatic biliary tract (1), and adrenalgland (1).3.2 |Development of calcification aftertransplantationData were analyzed to see if any variables were associ-ated with the development of calcification in the 12 catsfollowing renal transplantation. A weak positive correla-tion was identified between BUN prior to transplant (pre-BUN) and the development of posttransplant calcification.For every 10 mg/dL increase in BUN, the odds of develop-ing calcification post-transplant were 1.45 times (95% CI,1.00–1.31; p=.049) higher than those with lower pre-BUN values (Figure 2). No other bloodwork, demographic,or clinical variables, including SP(Ca /C2P) (OR, 1.01 [0.99 –1.03]; p=.28), were associated with the development ofcalcification following renal transplantation.Nine cats underwent hemodialysis prior to renaltransplantation. Two cats had aortic calcification presentprior to transplantation; one developed calcification ofthe tongue and heart (interventricular septum and rightfree wall) following transplantation that was noted onnecropsy, and one cat developed postoperative calcifica-tion of the renal allograft and required hemodialysis priorto a second renal transplant. The remaining five cats hadno evidence of calcification during the study period.There was no difference in need for hemodialysisbetween cats with evidence of metastatic calcification atthe time of renal transplantation and those without evi-dence of calcification ( p=1.000).Perioperative complications occurred in seven of74 cats (9.5%), 2/7 (28.5%) with pretransplantTABLE 1 Patient demographicsand clinical characteristics of 74 catsprior to renal transplantation.VariableNo calcification(n=59)Calcification(n=15) pSex (M/F) 41/18 10/5 >.99Age (years) 8.8 (3.5) 8.8 (3.2) .99BreedDomestic 45 13 .50Purebred 14 2BUN (mg/dL) 83 (64 –118) 114 (69 –162) .21Creat (mg/dL) 6.2 (4.4 –8.2) 6.6 (4.3 –9.0) .96SP (Ca /C2P) 85.1 (61.8 –113.5) 138.4 (75.2 –176.0) .006iCa 1.24 (1.20 –1.30)a1.23 (1.09 –1.29)b.66Hemodialysis (Y/N) 7/52 2/13 1.0Note: Data is presented as mean (standard deviation) or median (interquartile range). Significant p-valuesare in bold type.Abbreviations: BUN, blood urea nitrogen; Creat, creatinine; F, female; iCa, ionized calcium; M, male; SP(Ca/C2P), calcium-phosphorus solubility product.an=16.bn=7.FIGURE 2 Longitudinal BUN values in cats with and withoutpretransplant calcification. BUN, blood urea nitrogen; pre-, prior totransplantation.FRIDAY ET AL . 955 1532950x, 2023, 7, calcification, 2/7 (28.5%) with post-transplant calcification,and 3/7 (42.8%) with no calcification. There was no differ-ence noted between groups ( p=.624). Complicationsincluded vascular thrombosis of the allograft (3), hemoab-domen requiring exploratory laparotomy and repair (2),acute hyperkalemia and subsequent bradycardia requiringtreatment with dextrose, insulin, and bicarbonate (1), anddevelopment of a uroabdomen requiring revision of theureteral reimplantation site and cystopexy (1).Ten of 74 cats (13.5%) required a second renal trans-plantation prior to discharge from the hospital, 2 of10 (20%) with pretransplant calcification, 3 of 10 (30%)with post-transplant calcification, and 5 of 10 (50%) withno calcification. Reasons for retransplantation includedvascular thrombosis of the allograft (5), allograft rejection(2), delayed allograft function (1), allograft calcificationsuspect secondary to cyclosporine toxicity (1), and allo-graft torsion (1). No difference in need for a second renaltransplant was noted between groups ( p=1.000).3.3 |Survival of cats with calcificationCats with pretransplant metastatic calcification hadshorter median survival times than cats without calcifica-tion: Calcification, 147 days, (95% CI, 9 –520 days); no cal-cification, 646 days (95% CI, 397 –1370 days); p=.0013(Figure 3). The results of univariable Cox regression areshown in Table 2. Variables associated with survivalincluded pretransplantation metastatic calcification, allo-graft rejection, and retroperitoneal fibrosis. In multivari-able analysis after adjusting for retroperitoneal fibrosis,the presence of pretransplant calcification was associatedwith an increased risk of death by 240% (hazard ratio(HR) 2.40, 95% CI, 1.22 –4.71; p=.010) in comparisonwith cats without calcification. After adjusting for pre-transplant calcification, retroperitoneal fibrosis reducedthe risk of death by 65% (HR 0.35, 95% CI, 0.15 –0.80;p=.013) as compared with cats without fibrosis. Theproportion of cats surviving to hospital discharge follow-ing renal transplantation did not differ between groups:pretransplant calcification, 17 of 19 (90%) versus no pre-transplant calcification, 52 of 60 (87%); p=1.000.4

Question 6

Sadowitz - 2023 - VETSURG - Effect of screw insertion angle and speed on the incidence of transcortical fracture development in a canine tibial diaphyseal model.pdf

Answer 6

2.1 |Tibial diaphyseal modelA total of 66 tibiae from 39 cadaveric dogs with body-weights ranging from 20.5 to 36.9 kg, which were sourcedfrom a local humane society and were euthanized for rea-sons unrelated to the study, were collected. Only tibiaefrom skeletally mature dogs (tibiae with closed physesbased on radiographic assessment) were included andthose with any underlying orthopedic pathology (tibialfractures, synostosis of the tibia and fibula) wereexcluded from the study. The cadavers were promptlyfrozen following euthanasia and were thawed for 48 hprior to use in the study. Specimens were then preparedfor use in the study by dissecting the fibula and all softtissues from each tibia. Each individual tibia was labeledwith a unique identifier and a random number generator(Excel, Microsoft Corporation, Redmond, Washington)was used to assign each tibia randomly to one of sixgroups, which varied based on screw insertion angle indegrees (/C14) relative to the pilot hole and screw insertionspeed in revolutions per minute (rpm): Group A: 0/C14/650rpm; Group B: 5/C14/650 rpm; Group C: 10/C14/650 rpm; GroupD: 10/C14/screws placed manually with handheld screw-driver; Group E: 10/C14/1350 rpm; Group F: 0/C14/1350 rpm.The different screw insertion speeds were chosen to emu-late the speed settings found on a commercially availableorthopedic drill (DeSoutter V-Drive).10Angles of inser-tion were chosen to best reflect what we thought wouldbe a reasonable error (up to 10/C14off axis) to expect in theclinical setting.11,12For the purposes of this study, the tib-ial diaphysis was defined as the portion of bone compris-ing the middle 70% of the length of the tibia.2.2 |Tibial fixation jig application andexperimental apparatusA custom-built tibial fixation jig was used to hold the tib-iae in a fixed position for application of the bone plateand screws (Figure 1). The jig consisted of a wooden plat-form to which two pairs of “L”brackets were attached,each pair connected by a large external skeletal fixator(ESF) carbon fiber rod (IMEX Veterinary Inc., Longview,Texas). The tibia was fixed in the jig by two 3/16-inchbolts, one inserted through the proximal metaphysis andSADOWITZ ET AL . 1113 1532950x, 2023, 8, the other inserted through the distal metaphysis, both inthe sagittal plane, as well as by four 4.0 mm Duraface ESFend-threaded pins (IMEX Veterinary Inc.), two inserted inthe proximal metaphysis and two inserted in the distalmetaphysis. The bolts through the tibia were secureddirectly to the “L”brackets and the Duraface pins wereconnected to the carbon fiber rods using large SK singleclamps (IMEX Veterinary Inc.). Each tibia was oriented inthe jig with the medial aspect of the tibia facing upwards.Orthogonal radiographs, consisting of one mediolateraland one craniocaudal projection of each tibia were takenafter fixation in the jig and prior to plate and screw applica-tion using a Poskom VET 20-BT portable X-ray unit (VUEImaging, San Luis Obispo, California). The diaphysealdiameter of each tibia was measured from the craniocaudalradiograph at the level of the tibial isthmus using a digitalimage templating program (vPOP Pro, VetSOS EducationLtd., Shrewsbury, United Kingdom).The tibial fixation jig was affixed to a 7 /C210-inchmilling tilt table (Grizzly Industrial, Bellingham,Washington), which allowed for rotation of the tibiaeabout the tibial long axis. The tilt table was affixed to a6/C212-inch cross-slide XY table (Palmgren, Naperville,Illinois) allowing for horizontal translation of the tibiaeunderneath the spindle. This setup was mounted on a12-inch variable speed benchtop drill press (WEN, WestDundee, Illinois), forming the complete experimentalapparatus (Figure 1). A digital angle gauge (Klein Tools,Lincolnshire, Illinois) that was accurate to ±0.2/C14wasused to confirm the orientation of the experimental appa-ratus. The base of the tibial fixation jig was leveled to 0.0/C14and fixed in position. The spindle of the drill press waspositioned using the digital angle gauge to ensure thatthe spindle was perpendicular to the base of the tibial fix-ation jig, thereby ensuring accurate drilling and screwplacement.2.3 |Bone plate applicationA 3.5 mm combination double threaded, locking, low-contact narrow compression plate (Veterinary Orthope-dic Implants, St. Augustine, Florida) was placed on themedial aspect of the tibial diaphysis and was centered inthe cranial to caudal middle of the diaphysis. The lengthof the plate used (8 hole or 10 hole) was determinedbased on the overall length of the tibia to ensure drillingand screw application occurred in diaphyseal bone. Theplate was temporarily affixed to the bone with two0.062-inch k-wires placed through the temporary fixationholes in the plate. The position of the plate was adjustedwith the aid of a spirit level (Milwaukee Tools, Brook-field, Wisconsin) until the plate was parallel with thebase of the tibial fixation jig (Figure 2A). A bicorticallocking STS was placed in the most proximal plate holeand in the most distal plate hole to secure the plate to thebone using a standard screw insertion technique.13A random number generator (Excel) was used todetermine the order of drilling and screw insertion forthe remaining plate holes. For each plate hole, a 2.8 mmlocking drill guide was threaded into the plate hole.A 2.8 mm drill bit was mounted on the spindle of thedrill press and the drill press was set to run at 1350 rpm,the maximum drill speed of a commercially availableFIGURE 1 Testing apparatus setup. The tibial fixation jig(green arrow) was attached to a milling tilt table (white arrow),which allowed the tibia to be rotated about its long axis. This wasmounted on a cross-slide XY table (red arrow), which allowed thetibia to be moved so that the spindle (yellow arrow) could bepositioned directly over the plate hole of interest. Once assembled,this testing apparatus was mounted on a 12-inch variable speedbench top drill press (magenta arrow).1114 SADOWITZ ET AL . 1532950x, 2023, 8, veterinary orthopedic drill (DeSoutter V-DriveVMBQ-708).10The drill bit was advanced through thedrill guide and a pilot hole was drilled through both corti-ces of the tibial diaphysis (Figure 2B). This drilling proce-dure was repeated for all holes in the plate based on theorder determined by random assignment. To rule out anyiatrogenic damage to the bone associated with drillingthe pilot holes, orthogonal radiographs of the tibiamounted to the tibial fixation jig were taken prior toscrew insertion.2.4 |Screw insertion with drill press(group A –group C, group E –group F)Tibiae were rotated in the axial plane (0, 5 or 10/C14) basedon the previous randomized group assignment by rotatingthe tilt table top 0, 5 or 10/C14and using the digital anglegauge to confirm the degree of rotation (Figure 3A–C).Locking STS (3.5 mm thread diameter, 2.9 mm core diam-eter, 0.8 mm thread pitch) were applied using a T15 stard-rive driver mounted on the drill press set to run at650 rpm (Group A –Group C) or 1350 rpm (Group E andGroup F). The insertion speeds were selected to match themaximum rpm and the screw-insertion rpm found in acommonly used veterinary orthopedic drill (DeSoutterV-Drive VMBQ-708).13All screws used in this study were30 mm in length to ensure bicortical screw purchase.Screws were inserted past the transcortex until the head ofthe screw was just above the level of the plate top. A hand-held T15 screwdriver was then used to tighten the screwsmanually until the screw head fully engaged the lockingplate. Screw placement was repeated for all holes in theplate based on the order determined by random assign-ment. For each individual tibia, all screws were inserted atthe same angulation (0, 5 or 10/C14) relative to the pilot holeand at the same speed (650 rpm or 1350 rpm), based onthe previous randomized tibia group assignment.2.5 |Screw insertion by hand (Group D)The tilt table was set to an angle of 10/C14to rotate thetibia 10/C14axially around the long axis and the degreeFIGURE 2 (A) A spirit level (solid white arrow) was used to position the plate parallel to the base of the tibial fixation jig, as it wassecured to the tibia. (B) This ensured that the spindle, and thus the drill bit, were perpendicular to the plate, allowing on-axis drilling of thepilot holes through the locking drill guide (dashed white arrow).SADOWITZ ET AL . 1115 1532950x, 2023, 8, of rotation was confirmed with a digital angle gauge.A handheld T15 screwdriver was used to insert3.5 mm locking STS into the bone (Figure 3D). Thescrewdriver was first orientated so that the long axis ofthe screwdriver shaft was positioned perpendicular tothe horizontal plane and the screwdriver position wasconfirmed using a digital angle gauge. LockingSTS (3.5 mm) were then inserted sequentially intoeach plate hole following the previously determinedrandom hole assignment using the handheld T15screwdriver until the screw heads fully engaged theplate holes.2.6 |Transcortical fractureidentificationAfter screw insertion was complete for each individualtibia, the temporary fixation pins were removed. The tibiawas removed from the jig and orthogonal radiographs ofthe tibia were then taken, consisting of 1 mediolateralradiograph and 1 craniocaudal radiograph. Each tibiawas inspected radiographically for evidence of TCF(Figure 4). One observer (a board-certified surgeon) whowas blinded to the method of screw insertion (SCJ) wastasked with identifying the number of TCF for each tibia.FIGURE 3 Following thecreation of all the pilot drillholes, screws were inserted:(A) coaxial to the drill tract(groups A and F); (B) after 5/C14axial tibial rotation (group B),(C) after 10/C14axial tibial rotation(screws inserted by power:groups C and E) and (D) after10/C14axial tibial rotation (screwsinserted by hand: group D).1116 SADOWITZ ET AL . 1532950x, 2023, 8, Tibiae that developed fissure fractures during drilling orscrew placement were excluded from the study.2.7 |Statistical analysisResults of a power analysis performed on initial pilotscrew insertion of 19 specimens suggested that a mini-mum of 80 samples per group would be required todemonstrate significant differences with an alpha of .05and a beta of .8. Based on this power analysis, 80 screwswere included in each group. Specimen bodyweights andtibial diaphyseal diameters were compared betweengroups using a one-way ANOVA. The number of TCF ineach of the six groups was determined and the TCF ratewas calculated for each group. Statistical analyses wereperformed using a commercially available statisticalsoftware package (Sigmaplot 15, Inpixon, San Jose,California). For the purposes of this study, Group A(0/C14/650rpm) served as the control group against which allother groups were compared. Each study group (GroupB–Group F) was individually compared to the controlgroup (Group A) using a Fisher’s exact test to determineif a significant difference in TCF rates between groupswas present. A Bonferroni correction was performed toadjust the pvalue to account for multiple comparisons.This correction decreased the pvalue for determining sig-nificance from the initially selected value of p≤.05 to avalue of p≤.01.3|RESULTSAll data regarding dog weight and tibial diaphyseal diam-eter for tibial specimens in each group are summarizedin Table 1. No differences in mean dog bodyweight(p=.79) or mean tibial diaphyseal bone diameter(p=.63) were identified between groups (Table 1). Nocis- or transcortical fractures were identified in any tibiaafter drilling the pilot holes. No cis-cortical fractures wereidentified in any bone after the screws were placed. Onetibia from Group E developed a fissure fracture duringscrew application and was excluded from the study. AllTCF data and results are summarized in Table 2. InGroup A, no TCF were observed out of 80 screws insertedat a 0/C14screw insertion angle at 650 rpm (0% TCF rate). InGroup B, 3 TCF were observed out of 80 screws insertedat a 5/C14screw insertion angle at 650 rpm (3.75% TCF rate).In Group C, 10 TCF were observed out of 80 screwsinserted at a 10/C14screw insertion angle at 650 rpm (12.5%TCF rate). In Group D, 3 TCF were observed out of80 screws inserted at a 10/C14screw insertion angle with ahandheld screwdriver (3.75% TCF rate). In Group E,14 TCF were observed out of 80 screws inserted at a 10/C14screw insertion angle at 1350 rpm (17.5% TCF rate). InGroup F, no TCF were observed out of 80 screws insertedat a 0/C14screw insertion angle at 1350 rpm (0% TCF rate).Groups C and E had the overall highest TCF rates withsignificantly higher TCF rates observed between the con-trol group and Group C ( p=.001) and between the con-trol group and Group E ( p< .001). No difference in TCFrates was identified between Groups A and B ( p=.245),FIGURE 4 Cranio-caudal radiograph of a tibia from group E(10/C14/1350 rpm) demonstrating three transcortical fractures (whitearrows).SADOWITZ ET AL . 1117 1532950x, 2023, 8, between Groups A and D ( p=.245) or between GroupsA and F (no TCF in either group —test not performed).4

Question 7

Story - 2024 - VETSURG - Morphologic impact of four surgical techniques to correct excessive tibial plateau angle in dogs - A theoretical radiographic analysis.pdf

Answer 7

Medical records were retrospectively reviewed from 2004to 2020 searching the terms “excessive tibial slope, ”“wedgeosteotomy ”,a n d “wedge ostectomy. ”Dogs greater than15 kg in weight, diagnosed with cranial cruciate ligamentdisease based on physical and radiographic examinationfindings that possessed a TPA > 34/C14on preoperative plan-ning radiographs were included in the study. Data collectedincluded signalment, bodyweight, and affected stifle.Measurements and virtual corrections were per-formed on standardly positioned pre-TPLO mediolateralradiographs of the tibia with the stifle and tarsal jointspositioned at 90/C14of flexion. Dedicated orthopedic plan-ning software (vPOP-pro, version 2.4.3[158], VetSOS Edu-cation Ltd., veterinary preoperative orthopedic planningsoftware) was used to perform the virtual corrections oneach tibia following four previously described surgicaltechniques: Group A: combination CBLO and CCWO,7Group B: combination TPLO and CCWO,5Group C:mCCWO,8and Group D: PTNWO.9Images were calibrated to either a 25 or 30 mmmarker ball depending on the year the radiograph wasobtained. The mechanical axis of the tibia in the sagittalplane was measured from the midpoint of the intercon-dylar eminences proximally to the center of the talus dis-tally.10Tibial length was measured from the mechanicalaxis as the distal intermediate ridge utilized in other stud-ies is often obscured by the trochlear ridges of thetalus.11–13Joint orientation lines (JOL) were determinedfor the proximal and distal tibia in the sagittal planeusing previously described landmarks.10The mechanicalcranial distal tibial angle (mCrDTA) was measured as thecranioproximal angle between the mechanical axis andthe distal JOL in the sagittal plane.10TPA was measuredbetween the proximal tibial JOL and a line perpendicularto the mechanical axis.14Tibial length, mCrDTA, andTPA were measured before and after each virtual correc-tion by a single investigator (A.L.S.).2.1 |Brief description of correctivetechniquesAll techniques described in their respective originalsource documentation (abstract, manuscript or textbookchapter) including procedure-specific post-correction tar-get TPAs.5,7–92.1.1 | CBLO +CCWO7The proximal JOL was drawn (Group A, Figure 1). Aproximal caudal tibial angle (PCdTA) signifying thedesired post-correction TPA of 11/C14, was utilized to deter-mine the position of a proximal mid-diaphyseal anatomicaxis.15,16A distal, mid-diaphyseal anatomic axis wasdrawn.15,16The intersection of the proximal and distalanatomic axes determined the location and magnitude ofthe CORA. A radial saw blade template with a diameterslightly larger than that of the bone was chosen and cen-tered over the CORA.15A second radial saw blade tem-plate was drawn and translated slightly caudodistal fromthe first, converging at the caudal tibial cortex. The cra-nial aspect of the distal radial osteotomy was adjusteduntil a 15/C14cranial wedge was achieved. A 15/C14coplanarSTORY ET AL . 97 1532950x, 2024, 1, CCWO was performed in the proximal tibial metaphysis,and the proximal segment was reduced by the software.The remaining correction (CORA-15/C14) was performedalong the double radial osteotomies with the objective ofachieving a post-correction TPA of 11/C14.2.1.2 | TPLO +CCWO5A radial saw blade template was chosen per traditionalmethods: one sized to accommodate the desired plateand large enough to avoid offending the articular surfacewhile maintaining a tibial tuberosity width of at least10 mm at its narrowest point (Group B, Figure2).17,18The radial saw blade template was then centered over theintercondylar eminences. A 15/C14cranial closing wedgeostectomy was positioned at the base of the TPLO cutwith the proximal arm oriented perpendicular to the tib-ial crest and the apex at the caudal tibial cortex and exe-cuted. The remaining correction ([TPA-15/C14]/C05/C14) wasperformed by cranial rotation of the tibial plateau seg-ment along the radial osteotomy with the objective ofachieving a target TPA of 5/C14.2.1.3 | mCCWO8The distal arm of a closing wedge ostectomy was ori-ented perpendicular to the mechanical axis of the tibiain the sagittal plane (Group C, Figure3). The proximalosteotomy was positioned 3 mm distal to the patellarligament insertion on the cranial cortex, intersectingwith the distal osteotomy at a wedge angle equal tothe preoperative TPA. The distal osteotomy line wastransposed until it intersected the proximal osteotomyFIGURE 2 Group B-combination tibial plateau levelingosteotomy (TPLO) and cranial closing wedge osteotomy. A TPLOtemplate is centered at the intercondylar eminence. A 15/C14cranialclosing wedge was positioned at the base of the TPLO cut with theproximal arm oriented perpendicular to the tibial crest and theapex of the triangle at the caudal tibial cortex. Group B wasplanned to a target tibial plateau angle of 5/C14. Image created usingvPOP-pro.FIGURE 3 Group C-modified cranial closing wedgeosteotomy. The distal arm of the wedge osteotomy was orientedperpendicular to the mechanical axis of the tibia in the sagittalplane. The proximal osteotomy was positioned just distal to thepatellar ligament insertion, intersecting the distal osteotomy at awedge angle equal to the pre-operative tibial plateau angle. Thedistal osteotomy line was transposed until it intersected theproximal osteotomy at about 66% of its length from the cranialcortex of the tibia. Image created using vPOP-pro.FIGURE 1 Group A-combination center of rotation ofangulation (CORA)-based leveling osteotomy and coplanar cranialclosing wedge ostectomy. Radial saw blade templates are centeredat the CORA with a resultant 15/C14cranial wedge. Group A wasplanned to a target tibial plateau angle of 11/C14. Image created usingvPOP-pro.98 STORY ET AL . 1532950x, 2024, 1, at a point 66% of its length from the cranial cortex ofthe tibia. The wedge was excised, and the ostectomyreduced by the software. The proximal tibial segmentwas then translated caudally to align the cranial corti-ces. The described post-correction target TPA of thetechnique was 0/C14.82.1.4 | PTNWO9The proximal tibial JOL was determined (Group D,Figure4). Next, a proximal mechanical axis was drawnto pass through the intercondylar eminences and inter-sect with the JOL to reflect a mechanical caudal proxi-mal tibial angle (mCaPTA) of 83.5/C14(Figure 4A). Thiscorresponded with a target TPA of 6.5/C14.19A distal tibialmechanical axis was drawn from the center of the tibio-talar joint to maximally overlie the caudal cortex of theproximal tibial metaphysis, overlying the caudal cortexat this level. This axis was so determined by mimickingthe post-correction position of the tibial mechanical axisfollowing a standard TPLO. The CORA location andmagnitude were then determined from the inter-section of the proximal and distal mechanical axes(Figure4B). This intersection point between the twoaxes also represented the location of the angulation cor-rection axis (ACA). The ACA is the hinge axis that theangular correction is centered around. When the ACApasses through the CORA, this point can be termed theACA-CORA.20Next, a proximal osteotomy was drawnparallel to the proximal JOL and positioned 3 mm distalto the patellar ligament insertion on the cranial cortex.The distal osteotomy was drawn such that it intersectedthe proximal osteotomy at an angle equal to the magni-tude of the CORA (Figure4C). The distal osteotomy linewas then transposed proximally until the diameter ofthe tibia at that level was equal to the length of the prox-imal osteotomy from the cranial cortex to the point ofintersection. The ostectomy was performed and theproximal segment rotationally realigned pivotingaround the ACA-CORA by the software (Figure4D).2.2 |Statistical analysisFor comparison between groups, a percent change frombaseline (%CFB) was used to assess tibial length andmechanical cranial distal tibial angle (mCrDTA) whichserved as an indicator of mechanical axis shift. The TPAcorrection accuracy for each procedure was calculated bydividing the actual TPA change (preoperative TPA minuspostoperative TPA) by the intended change in TPA (pre-operative TPA minus the target TPA). After assessing fornormality, techniques were compared with a one-wayANOVA with Tukey’s multiple comparisons test. Dataanalysis was performed with statistical softwareFIGURE 4 Group D-proximal tibial neutral wedge osteotomy. (A) The proximal tibial joint orientation line (JOL) (white) and aproximal mechanical axis (black) were drawn to reflect a mechanical caudal proximal tibial angle (mCaPTA) of 83.5/C14. (B) A distal tibialmechanical axis (black) was drawn from the center of the tibiotalar joint distally as usual, but overlying the caudal cortex of the proximaltibial metaphysis proximally. The angulation correction axis (ACA)-center of rotation of angulation (CORA) (white dot) location andmagnitude were then determined from the intersection of the proximal and distal mechanical axes. (C) A proximal osteotomy was drawnparallel to the proximal JOL and positioned 3 mm distal to the patellar ligament insertion. The distal osteotomy was drawn such that itintersected the proximal osteotomy at an angle equal to the magnitude of the CORA. (D) The ostectomy was performed and reduced aroundthe ACA-CORA, resulting in translation of the segments, but maintaining collinearity.STORY ET AL . 99 1532950x, 2024, 1, (GraphPad Prism, GraphPad Software, San Diego, Cali-fornia) with significance set to p< .05.3|RESULTSSixteen dogs (27 tibias) met the inclusion criteria forthe study. Mean age at presentation was 3.1 years(range, 1.5 –6.1 years) and mean bodyweight was 35.3 kg(range, 15.3 –69 kg). There were nine castrated males andseven spayed females. Breeds represented were mixedbreed ( n=5), Golden retriever ( n=2), Great Pyrenees(n=2), Rottweiler ( n=2), and one each of GreaterSwiss mountain dog, English bulldog, Siberian husky,Australian cattle dog, and beagle. Eleven dogs were bilat-erally affected with five cases unilaterally affected basedon available imaging.The mean precorrection TPA was 42.67 ± 6.1/C14for alltibias. Mean post-correction TPA was 10.47 ± 2.1/C14forGroup A, 6.77 ± 1.6/C14for Group B, 4.76 ± 1.5/C14forGroup C, and 7.09 ± 1.3/C14for Group D (Figure 5). Therewas no difference in post-correction TPA betweenGroups B and D ( p=.895), but differences did existbetween all other groups.When assessing for TPA correction accuracy, num-bers >1.00 represented over-correction while numbers<1.00 represented under-correction of TPA. Mean TPAaccuracy was 1.02 ± 0.07 for Group A, 0.95 ± 0.04 forGroup B, 0.89 ± 0.03 for Group C, and 0.98 ± 0.04 forGroup D. Groups A and D had the least variation fromtheir respective target TPA’s and differed from each other(p=.02) (Figure6). Groups B, C and D resulted inunder-correction of TPA to varying degrees while GroupA slightly over-corrected.FIGURE 5 Post-correction tibial plateau angle (TPA) followingfour tibial osteotomy procedures. Values are depicted in degrees, asmean (95% confidence interval). Procedures with similar symbols(,†) are different from each other ( p< .05). Combination center ofrotation of angulation-based leveling osteotomy (CBLO) andcoplanar cranial closing wedge ostectomy (CCWO); combinationTPLO and CCWO; modified CCWO (mCCWO); proximal tibialneutral wedge osteotomy (PTNWO).FIGURE 6 Tibial plateau angle (TPA) correction accuracyfollowing four tibial osteotomy procedures. Values are depicted indegrees, as mean (95% confidence interval). Procedures with similarsymbols (, †) are different from each other ( p< .05). Combinationcenter of rotation of angulation-based leveling osteotomy (CBLO)and coplanar cranial closing wedge ostectomy (CCWO);combination TPLO and CCWO; modified CCWO (mCCWO);proximal tibial neutral wedge osteotomy (PTNWO).FIGURE 7 Change in tibial length following four tibialosteotomy procedures. Values are depicted in percentages, as mean(95% confidence interval). Procedures with similar symbols (*, †,‡)are different from each other ( p< .05). Combination center ofrotation of angulation-based leveling osteotomy (CBLO) andcoplanar cranial closing wedge ostectomy (CCWO); combinationTPLO and CCWO; modified CCWO (mCCWO); proximal tibialneutral wedge osteotomy (PTNWO).100 STORY ET AL . 1532950x, 2024, 1, When assessing changes in tibial length, a positivechange from baseline corresponded with tibial lengthen-ing while a negative change corresponded to tibial short-ening. Mean percent change in tibial length frombaseline was 0.48% ± 0.66% for Group A, /C00.58%± 0.58% for Group B, 0.29% ± 1.03% for Group C, and0.12% ± 0.81% for Group D. Change in tibial length wasdifferent between Group B and each of the other groups.Group B resulted in shortening of the tibia compared toeach of the other groups (Figure7).Mean percent change in mCrDTA from baseline was/C06.37% ± 0.86% for Group A, /C01.98% ± 0.36% forGroup B, /C04.59% ± 1.0% for Group C, and /C03.91%± 0.88% for Group D, with negative numbers correspond-ing to a cranial mechanical axis shift. All techniquescaused a cranial mechanical axis shift following virtualcorrection. Change in mCrDTA was different between allgroups. Group A demonstrated the greatest deviation andthus the greatest mechanical axis shift, while Group Bdemonstrated the least deviation (Figure8).4

Question 8

Thibault - 2023 - VETSURG - Poor success rates with double pelvic osteotomy for craniodorsal luxation of total hip prosthesis in 11 dogs.pdf

Answer 8

Ar e v i e ww a sp e r f o r m e do fm e d i c a lr e c o r d sf o ra l ldogs that had received a cemented or hybrid (cemen-ted cup and cementless stem) PorteVet total hip pros-thesis (PorteVet, Grosseto-Prugna, France) betweenJanuary 2010 and December 2022. Cases wereincluded only if a DPO had been performed to manageTHR craniodorsal luxation. Exclusion criteria wereincomplete medical records (age, breed, sex, weight,results of orthopedic examinations) and incompleteradiographs (absence of pre-THR, post-THR, pre-DPO,or post-DPO radiographs).2.1 |Surgical techniqueAll DPOs were performed by the same surgeon (PH).Dogs were premedicated with morphine (0.3 mg/kg IV).General anesthesia was induced with diazepam(0.25 mg/kg IV) and alfaxalone (2 mg/kg IV, titrated toeffect) and maintained with isoflurane in 100% oxygen.Perioperative antibiotics (cefazolin, 22 mg/kg IV) wereadministered just after induction and repeated every90 min until 8 h. Perioperative analgesia was maintainedby a constant rate infusion of morphine (0.2 mg/kg/h).Small doses of ketamine (0.5 –1 mg/kg) were adminis-tered during the procedure if necessary to manage painresponse.The dog was placed in lateral recumbency. An openreduction of the luxated prosthesis was performed. Astandard craniodorsal approach to the hip through a cra-niolateral incision was made.19A Hohmann retractorwas placed caudal to the cup and allowed caudal reclina-tion of the femoral shaft and visualization of the cup. Thecup was cleaned of tissue debris and flushed with saline.A reduction forceps was placed at the base of the pros-thetic femoral neck and allowed traction of the stem andfemoral head for reduction. The reduction was achievedand circumduction movements were made to ensure thatthere was no abnormality in the femoral head-cup inter-face. A standard closure was carried out. An operatingaid lifted the dog’s hind limb and a standard approach tothe ventral aspect of the pubis was used and a pubicosteotomy was performed.20The pectineus muscle wastransected. A section of the pubis medial to the ileo-pectinal eminence was achieved with an oscillating saw.A Hohmann retractor was inserted into the osteotomyline to remove adhesions and ensured a transperiostealsection. A standard flush and closure were done. Thelimb was then repositioned into lateral recumbency, simi-lar to the hip procedure. A standard approach to theilium was made through a lateral incision.21A Hohmannretractor was placed dorsal to the iliac neck and allowedfor reclination of the gluteal muscles. A periosteal inci-sion ventral to the iliac neck allowed the insertion of asecond Hohmann retractor caudal to the sacrum in thesubperiosteal region and protected the nerve structuresventromedial to the ilium. A straight oscillating sawsection of the cis-cortex and medulla was performed.Transcortex sectioning was achieved with an 8 or 10 mm1220 THIBAULT and HAUDIQUET 1532950x, 2023, 8, osteotome. A Hohmann retractor was then inserted intothe osteotomy line and allowed the caudal end to belifted craniolaterally from the cranial end. A manufactur-ing 30/C14DPO plate (PorteVet) was placed, first with thefour caudal cortical screws slightly caudally inclined andthen the four cranial cortical screws slightly craniallyinclined. This plate provided both lateralization and rota-tion of the caudal bone fragment. A flush with saline andstandard closure were then performed.2.2 |Radiographic interpretationPre-THR radiographs were assessed for coxofemoral dis-placement, and luxoid hips were defined by a completelack of dorsal acetabular coverage of the femoral head.The THR itself was evaluated on extended hip radio-graphs and oblique projections of the femur. The ALOand VA measurements were carried out on orthogonalpostoperative radiographic projections, after THR, andafter DPO.22The ALO was derived by the trigonometricformula, ALO =cos/C01(a/b), where ais the short axis andbis the long axis of the ellipsis defined by the cup on theventrodorsal radiographic projection (Figure 1). Theversion angle was the angle between the median planeand the long axis of the ellipsis on the ventrodorsal radio-graphic projection (Figure 1). Radiographs were importedinto an image analysis program (Horos software ver.3.3.6, Horos Project, Annapolis, MD, USA). Each mea-surement was repeated three times by both authors, andthe mean of six measurements was tabulated. Using apreviously described technique, the measured angleswere corrected for the degree of pelvic rotation.23Anyabnormality in follow-up radiographs was noted.2.3 |Complications and clinical outcomeIntraoperative and postoperative complications wererecorded and classified as minor, major, or catastrophicaccording to a previously established classification.24Short-term follow up consisted of a clinical and radio-graphic check at 2 months post-DPO. The medium-termfollow up consisted of a clinical and radiographic examina-tion at 6 months. Long-term follow up corresponded to thefollow up performed beyond th at period. Clinical outcomewas evaluated through a clinical examination completed byab o a r d - c e r t i f i e ds u r g e o n( P H )a n dc l a s s i f i e da saf u l l ,acceptable, or unacceptable function.242.4 |Statistical analysisAccording to the number of cases (11 dogs) and theabsence of normalcy, as detected by Shapiro –Wilk nor-mality test with an alpha set at .05, a Wilcoxon signed-rank test was used to compare ALO and VA pre- andpost-DPO. In the event of recurrent luxation, the post-DPO ALO of cases with and without recurrence was com-pared using a Wilcoxon rank-sum test. All data were pro-cessed using software R 4.0.3 (R Foundation forStatistical Computing). Statistical significance was set atp≤.05. Median and range were calculated for age, bodyweight, ALO, and VA pre- and post-DPO (Figures 2–4).3|RESULTS3.1 |SurgeryDuring the study period, 218 THRs were performedin 176 dogs. Fifteen THR luxations (6.9%) occurred in15 dogs, all of which were craniodorsal luxations. Ofthose 15 cases, 11 were treated with DPO.For the 11 cases treated with DPO (Table 1), themedian age and weight were 24.2 months (range 8.7 –117 ) and 33.5 kg (range 12.5 –54.0), respectively. Four ofFIGURE 1 Example of radiographic measurements on Horosfor case 3 with the ellipse (blue), minor axis a (pink), and majoraxis b (green), and the angle VA (red).THIBAULT and HAUDIQUET 1221 1532950x, 2023, 8, these dogs (4/11) had undergone bilateral hip replace-ments. Luxation occurred at a median of 22 days (range3–217) post-THR. The median time between THR andDPO was 30.0 days (range 7 –219). Femoral headexchange for increasing prosthetic neck length was per-formed in two dogs (cases 5 and 9) before DPO (in a sepa-rate surgery).3.2 |Radiographic interpretation(Tables 1and2)Five hips were luxoid and two femoral head and neckexcisions had been performed before THR. Two caseshad a pre-DPO ALO within the ALO recommendations(35–45/C14), and 11 cases had a pre-DPO ALO above theALO recommendations.3.3 |Luxation outcomeRecurrence of craniodorsal THR luxation followingDPO was observed in five dogs at a median of 7 days(range 5 –44). No trauma was reported for these recur-rences. These luxations were managed with closedreduction (one dog), capsulorrhaphy (one dog), orrepositioning of the same size acetabular cup (threedogs). No further luxation occurred after theseFIGURE 2 Example of craniodorsal total hip replacement (THR) luxation (case 4). Angle of lateral opening (ALO) pre-double pelvicosteotomy (DPO), and post-DPO (at 7 months) for the left prosthesis were 57.6/C14and 50.4/C14, respectively. L, left.FIGURE 3 Example of case 9 with an ALO post-DPO of 35.7/C14(within the recommended values). Note the screw loosening of thecranial screws of the DPO plate. L, left.1222 THIBAULT and HAUDIQUET 1532950x, 2023, 8, procedures. In these dogs, the median post-DPO ALOwas 58/C14versus 53/C14for dogs without recurrent luxa-tion ( p=.53).3.4 |Complications and clinical outcomeThe median clinical follow-up duration was19.7 months (range 3.4 –73.0). No intraoperative com-plications were reported. M inor postoperative compli-cations included screw loosening at 2 months (fourcases). Seven dogs required explantation (five asepticloosenings, two infections )a tam e d i a no f8 . 2m o n t h s(range 2.6 –50.6). These dogs had acceptable clinicaloutcomes after implant remo val but final results withrespect to THR outcome were considered as poor dueto explantation.4

Question 9

Sevy - 2024 - JAVMA - Abdominal computed tomography and exploratory laparotomy have high agreement in dogs with surgical disease.pdf

Answer 9

Case selectionThe electronic medical record system at Iowa State College of Veterinary Medicine Teaching Hos -pital was retrospectively reviewed for dogs that had undergone an exploratory laparotomy between October 13, 2009, and April 11, 2023. These cases were further evaluated for the completion of a pre -operative abdominal CT scan until 100 cases were identified that satisfied the criterion. For all included cases, an abdominal CT was recommended to fur -ther investigate for intra-abdominal pathology on the basis of specific presenting complaints, physical exam findings, and blood work and imaging abnor -malities and to potentially aid in surgical planning. Cases were excluded if the CT report was not read by a board-certified radiologist, the abdominal explora -tion results were not recorded in the surgery report, or any of these reports were missing.Medical record reviewMedical records were evaluated for signalment, body weight, body condition score (BCS), present -ing complaint, and physical exam findings. Contrast administration and type, official CT report, time in -terval between abdominal CT and surgery, and surgi -cal report were analyzed.Computed tomographyAll patients underwent sedation or general an -esthesia for an abdominal CT using a 16-slice or 32-slice Canon Aquilion large bore CT with postpro -cessing 3-D reconstruction capabilities (Canon Medi -cal Systems USA Inc). Forty-one participants were imaged with the 16-slice and 59 were imaged with the 32-slice CT. Patients were imaged in sternal re -cumbency from the caudal thorax through the pelvis with a CT beam pitch of 0.750 and a high pitch of 3.Positive contrast (iohexol) was administered to all participants, and imaging was completed before and after IV administration. The dose range for io -hexol was 330 to 600 mg/kg due to an international shortage occurring in May 2020 in which various pa -tients received less than a full dose. A pressure injec -tor was used to administer contrast at 2.5 mL/s. Du -al-phase studies were completed for all abdominal scans except for portosystemic shunt investigation, ureter visualization, and potential pancreatic lesions, which used a 3-phase protocol. For dual-phase stud -ies, the delay between contrast administration and image acquisition was dependent on patient size and location of the IV catheter; for example, with a catheter placed in the right thoracic limb, the de -lays for 14-, 23-, and 34-kg dogs were 22, 30, and 40 seconds, respectively. For the 3-phase protocol and specific investigation of shunting vessels, arte -rial phase imaging was acquired utilizing the auto -matic bolus tracking software. Repeated single-slice images were acquired at the level of the aortic hia -tus, with the lumen of the descending aorta as the region of interest and the threshold of starting the diagnostic scans set at 120 HU, at which time 3 se -quential scans were obtained (arterial, venous, and delayed). All shunt cases received the full dose of io -hexol (600 mg/kg). Soft tissue–reconstructed imag -es in the transverse, dorsal, and sagittal planes were available for analysis. Slice thickness for abdominal reconstructions was 1 mm for dogs < 11 kg and 2 mm for dogs > 11 kg. All images were reviewed by a diplomate of the American College of Veterinary Radiology working onsite or, when unavailable, re -motely via telemedicine services.Exploratory laparotomySurgeries were performed by a diplomate of the American College of Veterinary Surgeons or Euro -pean College of Veterinary Surgeons or a resident of the American College of Veterinary Surgeons under the supervision of a boarded surgeon. All surgeries included a full abdominal exploration in which ab -dominal organs were identified, evaluated, and re -ported in addition to specific procedures dependent on the case. Surgery reports were completed by a fourth-year veterinary student before submission by the surgeon present at the time of surgery.Data analysisWe fit a logistic regression model to character -ize the association between the outcome agreement (agreement between CT and exploratory laparotomy vs no agreement) and the predictors of BCS, time interval Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 01/27/24 05:24 PM UTC228 JAVMA | FEBRUARY 2024 | VOL 262 | NO. 2between CT and surgery, and disease process (oncologic vs nononcologic). Agreement in this study was defined as no intraoperative change in the diagnosis, surgical plan, or prognosis compared with the original CT findings. The natural log of “time” was taken prior to analysis. No inter -actions were included in the model. Confidence intervals on the outcome assumed normality of the sample coef -ficient estimates. As proportions are close to 1, the CIs are subject to some degree of error, so it is suggested that they are taken as rough estimates. The upper end of the CI was truncated at 100%, and 95% CIs are reported in parentheses following the estimate. Descriptive statistics were calculated with the use of commercially available software (Excel version 16.75; Microsoft Corp).ResultsOne hundred dogs were included in the study. Breeds included mixed-breed dogs (n = 26), Labra -dor Retrievers (13), Terriers (9), German Shepherd Dogs (6), Schnauzers (5), Bulldogs (4), Golden Re -trievers (3), and various other small- (13) and large-breed (21) dogs. Signalment included intact males (n = 12), castrated males (43), intact females (10), and spayed females (35) with a median age of 9 years (range, 5 months to 16 years). The median BCS was 5 (range, 1 to 9).The median time elapsed between CT and explor -atory laparotomy was 25 hours (range, 30 minutes to 4 months), with 97 dogs undergoing surgery within 45 days following imaging, 82 dogs undergoing surgery within 1 week following imaging, and 49 dogs under -going surgery within 24 hours following imaging. For the participants with extended time between imag -ing and surgery (> 45 days), 2 of these patients were diagnosed with single, extrahepatic portosystemic shunts that were surgically corrected and 1 patient was presented for persistent, moderate abdominal ef -fusion of unknown origin with no abnormalities on CT scan or abdominal exploration except for effusion and mild mesenteric lymphadenopathy.For the population at large, the estimated agree -ment between CT scan and exploratory laparotomy was 97% (93% to 100%). Overall, there was no evi -dence that proportion agreement differed on the basis of time elapsed between CT scan and surgery, BCS, or oncologic versus nononcologic disease.Of the 38 nononcologic cases, 41 total lesions were appreciated (Figure 1) . The estimated agree -ment between abdominal CT and exploratory laparot -omy for these cases was 98% (95% to 100%). Surgical findings disagreed with CT scan conclusions in 1 case involving a traumatic diaphragmatic hernia and pre -pubic tendon rupture. A 5-month-old male intact Jack Russell Terrier was hit by a car just prior to presenta -tion to the emergency service. While the first preoper -ative CT scan accurately diagnosed the diaphragmatic injury, the concurrent prepubic tendon avulsion was not appreciated until a second CT scan just prior to surgical intervention. This patient was given the full dose of iohexol and imaged with the 16-slice CT.There were a total of 62 oncologic cases with 81 oncologic lesions appreciated (Figure 2) . The estimated agreement between abdominal CT and exploratory lap -arotomy was 95% (90% to 100%). Surgical conclusions disagreed with imaging in 2 cases, one involving the gastrointestinal tract and the other involving the pan -creas, hepatobiliary tract, and spleen. A 16-year-old spayed female mixed-breed dog presented through the emergency department for a bleeding hepatic mass. The CT report noted a large hepatic mass most likely originating from the left lateral liver lobe in addition to a right renal nodule, multiple splenic nodules, and mild peritoneal effusion. While the exploratory laparotomy corroborated the hepatic, splenic, and renal masses, an additional pedunculated gastric mass was palpated and subsequently resected. Histopathology diagnosed the gastric mass as a pyloric mucosal inflammatory Figure 1 —Number of nononcologic surgical lesions iden -tified and not identified on abdominal CT in 100 dogs. Hernia = Diaphragmatic, prepubic, and perineal hernias. Other = Pancreatitis, peritonitis, adhesions, lymphade -nopathy. PSS = Portosystemic shunt. Urinary = Cystoliths, urinary bladder trauma, ureteral trauma. Figure 2 —Number of oncologic surgical lesions identi -fied and not identified on abdominal CT in 100 dogs. The unidentified splenic and liver lesions were both nodules and ≤ 1 cm. The splenic nodule, liver nodules, and pan -creatic tumor were all present in 1 patient. AGASACA = Apocrine gland anal sac adenocarcinoma. AGASACA-related disease = Anal gland mass and lymph node me -tastasis. GI = Gastrointestinal. Other tumors = Renal, uterine, or omental tumors.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 01/27/24 05:24 PM UTC JAVMA | FEBRUARY 2024 | VOL 262 | NO. 2 229polyp. Additionally, a 9-year-old castrated male Shih Tzu was presented through the emergency service for hypoglycemic seizures. The CT report appreciated enlargement of the right adrenal gland, mild multifo -cal mesenteric and colonic lymphadenopathy, and a normal spleen, liver, and pancreas. On surgical explo -ration, however, the spleen was noted to have a 1-cm raised nodule, a firm 3-mm nodule was appreciated at the distal aspect of the right limb of the pancreas, and multiple 3- to 5-mm nodules were noted throughout the liver. Histopathologic diagnosis reported splenic congestion with lymphoid hyperplasia, a suspect en -docrine islet cell neoplasm of the pancreas, and mild periportal lymphocytic inflammation of the liver. Both patients received the full dose of iohexol and were im -aged with the 32-slice CT.

Question 10

Onis - 2023 - VCOT - Evaluation of Surgical Technique and Clinical Results of a Procedure-Specific Fixation Method for Tibial Tuberosity Transposition in Dogs - 37 Cases.pdf

Answer 10

Study Design and Case InclusionThis was a descriptive multicenter study including twocohorts of dogs with MPL treated surgically with the RLPSTTT plating system. Cohort A was enrolled at AniCura Dier-enziekenhuis Drechtstreek between April 2020 andJuly 2021. Cohort B included all dogs treated at EvidensiaSpecialistdjursjukhuset Strömsholm between Decem-ber 2019 and August 2021. The inclusion criteria werepresence of clinically apparent MPL and age >9m o n t h s .The exclusion criteria were grade 4 MPL,15use of a patellargroove replacement or corrective osteotomy, previous sur-gery on the same sti fle, trauma, and comorbidities causingclinical signs. The owners were informed about the nature ofthe study and those that chose to participate signed aninformed consent form. Full physical and orthopaedic exami-nations were performed. Patellar luxation was gradedaccording to Roush.15Lameness was graded as reportedpreviously, with grade 0 ¼no lameness; grade 1 ¼normalat walk and mild/intermittent lameness at trot; grade 2 ¼mild/intermittent lameness at walk and increased lamenessat trot; grade 3 ¼severe lameness with regular nonweightbearing; and grade 4 ¼continuous non-weight-bearinglameness.16Lameness was also scored as grade 1 whenowners reported regular (i.e., daily) skipping lameness,which was not identi fied in the clinic. Preoperative imagingconsisted of a ventrodorsal hip-extended radiograph17extending from the pelvis to the proximal tibia plus a medio-lateral sti fle radiograph in cohort A and computed tomogra-phy (CT) in cohort B.ImplantsThe RLPS consists of titanium plates, spacers and self-tappingcortical screws, and tappet ( ►Fig. 1 ). The plates have four orsix gliding holes, depending on plate size, which accommo-date two or three screws in both the tibial metaphysis andthe tibial crest. The tappet can be locked into the holes of theplate and is rotated to gradually transpose the tibial crestlaterally using a screw mechanism. A spacer is insertedbetween the tibial crest and the plate to maintain lateraltransposition. Three sizes of plates are available for use withscrew size 1.5 or 2.0 mm (small plates) or 2.4 mm (mediumand large plates). Spacers range in width from 1 to 6 mm.Perioperative CareAnesthetic and analgesic protocols varied, based on patientcharacteristics and preference of the attending clinician. Incohort A only, cefazolin sodium (22 mg/kg) was administeredintravenously 30 to 60 minutes before surgery and repeatedevery 90 minutes until surgery was completed. All dogs weredischarged the day of or the day after surgery, receivingmethadone intravenously (0.2 –0.3 mg/kg every 4 –6h o u r sintravenously) until discharge and oral meloxicam (0.1mg/kg once daily per os) or robenacoxib (1 –2 mg/kg oncedaily per os) for 2 to 4 weeks. In cohort A only, a soft paddedbandage was applied for two weeks postoperatively. Allowners were instructed to restrict exercise until radiograph-ical follow-up showed healing of the osteotomy.Surgical ProcedureSurgery was performed by a board-certi fied or board-eligiblesurgeon. Intra-articular structures were inspected through alateral parapatellar arthrotomy. A medial release,15blockrecession trochleoplasty,18or a combination of both wasperformed as deemed necessary. Subsequently, the medialside of the proximal tibia was approached by extending theskin incision distally. The osteotomy was created using anoscillating saw, aiming just cranial to the long digital exten-sor groove proximally and ending in or directly caudal to thecranial tibial cortex at the distal end of the tibial crest, andthe RLPS was applied according to the manufacturer ’sinstructions.19After attaching the plate to the tibial shaftby placing the caudal screws, the tappet was inserted in thecranial plate holes. By rotating the tappet, the tibial crest wastransposed laterally ( ►Fig. 1C ) until appropriate alignmentwas reached, as indicated by visual assessment and a stablepatella during sti fleflexion and internal rotation of the tibia.The amount of lateralization was read from the indicator onthe tappet, the corresponding spacer was placed, and thecranial screws were inserted (►Fig. 1D ). Lateral joint capsuleimbrication and closure were routine.15Mediolateral andcraniocaudal radiographs were obtained postoperatively toconfirm correct execution of the osteotomy and placement ofthe implants. Duration of surgery, details of the surgicaltechniques and implants, and occurrence of complicationswere recorded.Follow-UpIn-clinic physical and radiological examinations were sched-uled 6 to 8 weeks postoperatively, plus, in cohort A, 3 monthsafter surgery. At the time of data acquisition, cases wereinvited for an additional in-clinic physical and radiologicalevaluation. Telephone interviews were conducted if in-clinicfollow-up was declined. Lameness grade, MPL grade, andoccurrence of complications were recorded. Complicationswere de fined as any unfavorable and unplanned event, sign,or disease related to treatment, classi fied by timeframe aseither intraoperative, immediately postoperative (betweensurgery and discharge), short term (between discharge and/C203 months postoperative) or long term ( /C213 months postop-eratively) and graded as minor when resolved spontaneouslyor with medical treatment only or as major when surgicaltreatment was indicated.6,12,13In cohort A, owners wereasked to complete the Liverpool Osteoarthritis in Dogs(LOAD) questionnaire before surgery and at 6 weeks and3 months after surgery.20Outcome was categorized asexcellent when function at last follow-up was normal,good when function was near normal with infrequent lame-ness, acceptable with grade 1 lameness and unacceptablewith higher-grade lameness or the need for analgesics..Statistical AnalysisThe data were entered in MS Excel (Microsoft, Redmond,Washington) and transferred to statistical program R version4.0.521by library readxl22for analysis. We analyzed thewithin-case difference in LOAD score between time point 0and 6 weeks and 0 and 12 weeks by Wilcoxon signed-ranktest. The level of signi ficance was set at 0.05.ResultsPatient CharacteristicsA total of 37 sti fles from 33 dogs were included, with 19 sti flesin cohort A and 18 sti fles in cohort B. No cases were excludedafter enrollment. The dogs were mixed breed dogs ( n¼8),French Bulldog ( n¼5), Maltese ( n¼3), Chihuahua ( n¼3),Pomeranian ( n¼2), Boston Terrier ( n¼2), and 1 each ofCavalier King Charles Spaniel, Cairn Terrier, Yorkshire Terrier,Staffordshire Bull Terrier, German Shepherd Dog, AustralianKelpie, Japanese Chin, Lagotto Romagnolo, Griffon Bruxellois,and Bichon Frisé. Ages ranged from 9 to 132 months (median¼36 months) and body weight was 2.5 to 36.2 kg (median¼7.8 kg). At presentation, the median lameness grade was 2(mean ¼1.9; range: 1 –4) and the MPL grade was grade 2 in 20cases, grade 3 in 16 cases, and not recorded in 1 case.Surgical ProcedureThe mean ( /C6SD) duration of surgery was 48 /C617 minutes(range: 25 –79 minutes). All available plate sizes were usedwith the small plate applied most frequently ( ►Table 1 ). Allscrew holes were filled, with enough bone stock to place thecranial screws in even the smallest patient ( ►Fig. 2 ). Inseveral cases, to allow placement of the spacer betweenthe plate and bone, the distal half of the spacer was cut off(n¼7) or a two-hole spacer was combined with a six-holeplate ( n¼3;►Fig. 3 ). Block trochleoplasty was performed in26/37 cases and medial release was performed in 4/37 cases.Lateral imbrication was performed in all cases. There were nointraoperative or immediate postoperative complications.Postoperative radiographs showed adequate positioning ofthe osteotomy and implants in 36/36 cases. The cranial tibialcortex at the distal end of the tibial crest was intact in 12/36cases; a fissure or fracture was identi fied in 24/36 cases.Postoperative radiographs were not available in one case.Follow-UpShort-term in-clinic follow-up including radiographic evalu-ation was available in 35/37 cases, at 4 to 8 weeks ( n¼35)and at approximately 3 months ( n¼18) postoperatively. Forthe remaining two cases, in-clinic follow-up was available atFig. 1 (A) Three sizes of plates accommodating 2.4-mm screws (large six-hole and medium four-hole plates) or 1.5-/2.0-mm screws (smallfour-hole plate) and ( B) corresponding spacers are available. Dimensions (length /C2width) of the large, medium, and small plates are25/C216.5 mm, 14 /C213 mm, and 13 /C28.4 mm, respectively. Available spacers have a thickness of 2, 4, and 6 mm for the large plate; 2, 3, and4 mm for the medium plate; and 1, 2, 3, and 4 mm for the small plate. ( C) The tappet locks itself in the screw holes and is used to graduallytranspose the tibial crest u sing a screw mechanism. ( D) After transposition is deemed suf ficient, the appropriate spacer is inserted, the tappet isremoved, and the remaining screws are inserted. (These images are provided courtesy of Rita Leibinger GmbH & Co. KG, Mühlheim an derDonau.) Note: The small plate is also named tiny/petite by the manufacturer.Table 1 Distribution and characteristics of the Rapid Luxation Plating System for medial patellar luxationSize plate/screws No. of cases Median bodyweight (kg) Spacer (mm)Small 4-hole/1.5 mm 7 4.2 (range: 2.8 –5.5) 2 –4Small 4-hole/2.0 mm 20 7.5 (range: 2.5 –12.3) 2 –4aMedium 4-hole/2.4 mm 6 10.6 (range: 7.8 –16.1) 3 –6Large 6-hole/2.4 mm 4 16.7 (range: 11.5 –37.4) 4 –6aOne outlier had multiple spacers with a combined thickness of 8 mm..11 months postoperatively in one case; in the other case,follow-up was by telephone interview only. Long-term fol-low-up was available in 36/37 cases, for a median of 297 days(range: 105 –693 days), either in-clinic ( n¼19) or via tele-phone interview ( n¼17). One case was lost to follow-upafter 6 weeks, at which point the patellar luxation grade andlameness grade were 0 and the osteotomy had healed.Lameness at last short-term follow-up was grade 0 for30/35, grade 1 for 2/35, and grade 3 for 1/35. The case withgrade 3 lameness had a cranial cruciate ligament rupture(CCLR) that occurred 11 weeks after surgery. As this ispresumed to have occurred unrelated to surgery, this eventwas not included as a major complication. Grade 1 lamenesswas caused by recurrent grade 2 MPL in one case. In the othercase with grade 1 lameness, a cause could not be identi fied.At physical examination, there was a normal range of motionof the sti fle without crepitation, the patella could not beluxated, the cranial drawer test was negative. There was noswelling over the implants and palpation was not painful.Orthogonal radiographs showed bridging of the osteotomy,stable implants, and no soft-tissue swelling, osteolysis, orperiosteal reaction surrounding the implants, but mild sti fleeffusion was noted (►Fig. 4 ). Additional diagnostics were notFig. 2 Postoperative radiographs of cases ( A,B)w e i g h i n g2 . 4 5 k g ,(C,D)1 0 . 8 k g ,a n d( E,F) 37.4 kg. Applied implants were the smallfour-hole plate with 2.0-mm screws in A–Dand the large six-hole platewith 2.4-mm screws in Eand F.Fig. 3 Craniocaudal and mediolateral radiographs taken 6 weekspostoperation, showing ( A–D) two cases in which the distal half of thespacer was removed and ( E,F) a case in which a two-hole spacer wasused instead of a three-hole spacer, to facilitate placement of thespacer between the tibial crest and plate.Fig. 4 Craniocaudal and mediolateral radiographs taken 7 monthsafter surgery, immediately before implant removal, in a Frenchbulldog weighing 9.2 kg with intermittent skipping lameness. Theosteotomy has healed, the implants are in the correct position, and noimplant-related complications were noted. There is mild cranialdisplacement of the fat pad, indicative of mild joint effusion..pursued, and no speci fic therapy was instituted. Sevenmonths after surgery, grade 1 lameness was still present.Since the implants could not be ruled out as a cause, theywere removed. Macroscopic signs of infection were notnoted during removal, and bacterial culture of the implantswas negative. Lameness persisted for 6 more months, afterwhich it gradually resolved. As implant removal did notresolve lameness, this was classi fied as a non-implant-relat-ed major complication. LOAD scores at 6 weeks (median¼12.5; n¼14) and 3 months (median ¼7;n¼10) weresignificantly lower compared to preoperative values (median¼22;n¼16;p<0.01). Radiographic follow-up showed heal-ing of the osteotomy in 35/35 cases.Minor and major complications were reported in 13 cases(35%) and 3 cases (8%), respectively (►Table 2 ). Two cases hadboth a minor and a major complication (minor pressure soreand implant removal, major pressure sore, and grade 1 MPL).Infection was suspected in one case, which resolved after a10-day course of antibiotics. Three cases had major compli-cations. Besides the case in which implants were removed,surgical treatment was performed for one bandage-relatedpressure sore and one case with a grade 2 MPL. Both casesrecovered uneventfully. No implant-related complications ortibial tuberosity avulsions or fractures occurred.Except for the case with the conservatively treated CCLR,lameness at long-term follow-up was scored as zero andoutcome was excellent (32/36) or good (3/36) in all cases.

Question 11

Smola - 2023 - JAVMA - Computed tomography angiography aids in predicting resectability of isolated liver tumors in dogs.pdf

Answer 11

All patients were presented to The Animal Medi -cal Center (AMC) in New York between June 2013 and November 2016. Any patient with a confirmed isolated liver tumor > 5 cm was included in the study. Patients were excluded from any surgical interven -tion for one of the following reasons: (1) the patient was not fit for major surgical intervention because of significant comorbidity, (2) CTA revealed significant concern for distant metastatic disease, and (3) the patient had a lesion < 5 cm in diameter.CTA scanEach patient was placed under general anes -thesia for the CTA procedure. Individual anesthetic protocols were similar, with minor alterations as in -dicated based on systemic health, presence of co -morbidities, and preanesthetic bloodwork. The CTA occurred a minimum of 1 day and a maximum of 21 days prior to surgery. All CTA scans were performed at The AMC, New York, using a 64-slice CT scanner (Toshiba Aquilion; Canon Medical Systems). Stan -dard kVp was 120. The mAs was calculated for each individual patient from scanogram or topogram. Pa -tient positioning was standardized. Slice thickness and interval was 1 mm with a rotation time 0.5/s. Manual bolus of IV administration of nonionic iodin -ated contrast (Omnipaque; 300 mgI/mL) was per -formed by the attending radiologist’s preference to obtain dual-phase images. To prevent bias, the at -tending radiologist supervising the CTA scan was not the radiologist who reviewed the CTA images for the purpose of this study. No reconstructed images were created or evaluated.Preoperative evaluationPrior to surgery, all images were reviewed and analyzed by the attending board-certified surgeon on a DICOM viewing system (IntelliSpace PACS system; Philips Healthcare). During review, the surgeon com -pleted the preoperative assessment (Figure 1) aimed at predicting surgical difficulty and resectability (gross and complete). The attending surgeon was instructed to predict each variable with a “yes” or “no” answer. Furthermore, a numeric value representing the pre -dicted ease of resectability was assigned on a scale of 1 to 5, with 1 representing easily resectable, 2 repre -senting mildly difficult, 3 representing moderately dif -ficult, 4 representing significantly difficult, and 5 rep -resenting nonresectable. The assessments also asked Unauthenticated | Downloaded 10/08/23 06:32 AM UTC 3the observer to describe location, size (in cm), vascular involvement, presence of effusion/rupture, multilobar involvement, abdominal lymphadenopathy, presence of adhesions, and presence of peritumoral edema. Vas -cular involvement was subdivided to include “invasion” (ie, tumor thrombus), “abutment,” and “surrounding.” Prior to surgery, each CTA scan was also reviewed by a board-certified radiologist, employed by The AMC, independent of this study.Surgery and postoperative assessmentEach animal was placed under general anesthe -sia prior to surgery. The individual anesthetic pro -tocol was tailored to each individual patient. The surgery was performed by a board-certified surgeon on faculty at The AMC. All surgeries included in this study were performed by 1 of 2 attending surgeons. An identical number of procedures were performed by each surgeon (n = 10). Surgery was performed within 21 days of CTA. The attending surgeon who performed the surgery was the same as the surgeon who reviewed the preoperative CT and completed the preoperative assessment. A standardized surgi -cal approach was used in all patients. The tumor was resected, biopsied, or debulked on the basis of the surgeon’s judgment. All samples were submitted for histopathology (H&E staining unless specific stains were required) with margin assessment. All samples were reviewed by a board-certified veterinary pa -thologist. Postoperative assessments were complet -ed by the surgeon immediately following surgery. The postoperative assessments were structured Figure 1 —Preoperative assessment form used by the surgeon and radiologist to document predetermined factors for 20 dogs with 21 isolated hepatic masses during a prospective study between June 16, 2013, and November 30, 2016, conducted to assess the accuracy of CT angiography in predicting resectability, degree of surgical difficulty, and individual factors that may impact resectability of isolated hepatic masses in dogs.Unauthenticated | Downloaded 10/08/23 06:32 AM UTC4 identically to the preoperative assessment above (Figure 1). The postoperative estimation of complete excision was later compared to the reported margins on the histopathology report.Radiologist reviewFollowing surgery, the same CTA images were independently reviewed by a blinded third-party board-certified radiologist with > 10 years of experi -ence. All images were uploaded and reviewed by the independent radiologist (Keystone Omni imaging software and Keystone viewer; Asteris Inc). The radi -ologist was blinded to the surgeon’s preoperative as -sessment, intraoperative findings, and postoperative assessment. The radiologist was also blinded to the histopathology results. An identical assessment, as compared to the surgeon (Figure 1), was completed by the radiologist. The recorded responses were then compared to the board-certified surgeon’s preopera -tive and intraoperative assessments for the purpose of statistical analysis.Statistical analysisAll analyses were performed using SAS analyt -ics software (version 9.4; SAS Institute), with the ex -ception of diagnostic accuracy indices, which were performed using the epiR software package (ver -sion 2.0.53; R Core Team). A significance threshold of 0.05 was used, and Wilson CIs were calculated for binomial proportions. Agreement was quantified with raw agreement and κ coefficients (weighted κ coefficients for ordinal data). κ coefficients were interpreted using the benchmarks previously de -scribed by Altman.21 Agreement was reported using κ value ranges as follows: ≤ 0.20, poor; 0.20 to 0.40, fair; 0.40 to 0.60, moderate; 0.60 to 0.80, good; and > 0.80, very good. McNemar tests were used to com -pare predictions between the radiologist and sur -geon. Diagnostic accuracy was quantified with sensi -tivity, specificity, and likelihood ratios. A mass being resectable or having complete margins was consid -ered a “positive” for diagnostic accuracy indices cal -culations. Fisher exact tests were used to compare presence of vascular and multilobar involvement be -tween resectable and nonresectable masses. A logis -tic regression model was used to test for an effect of mass size on odds of resectability.ResultsA total of 20 client-owned dogs with 21 isolated liver masses (> 5 cm) were included in the study. One patient had 2 isolated masses that were removed concurrently and were included in this study as in -dividual cases. Patient demographics were recorded and saved for statistical analysis (Supplementary Table S1) . There were 9 neutered males and 11 spayed females included. The mean age and body weight were 138 months (98 to 171 months) and 23.5 kg (5.79 to 40.9 kg), respectively. Mixed-breed dogs were the most represented breed (n = 8). The most common presenting complaint was elevated liver enzymes (15/20). A total of 17 patients had an abdominal ultrasound performed at The AMC prior to CTA. The remaining 3 of 20 patients were diag -nosed via abdominal radiographs or point-of-care ultrasound at their primary care facility. There was no statistical association between the age, breed, or weight of patients and the outcome of cases.The average size of all masses was calculated us -ing available surgical and histopathologic records. The average size of all masses was calculated as 9.1 X 8.9 X 11.2 cm (902 cm3). The average size of incompletely excised masses was smaller at 6.8 X 7.3 X 6.7 cm (333 cm3). However, there was no statistical significance regarding the size of the mass on probability of resec -tion (OR [95%CI], 1.3 [0.8 to 2.3]/100 cm3; P = .110).Location was predicted by both the surgeon and ra -diologist on the basis of CTA imaging. Definitive location was confirmed intraoperatively and recorded on the post -operative assessment (Figure 2; Supplementary Table S2) . Figure 2 —Intraoperatively confirmed lesion location (af -fected liver lobe) and frequency of affected liver lobe for the isolated masses of the dogs described in Figure 1.Left medial (n = 6) and left lateral (6) liver lobe masses were the most common locations recorded. Masses of the caudate lobe (n = 4) and right lateral (2), right me -dial (1), and quadrate (0) masses were less represent -ed. Multilobe involvement (n = 2) was recorded as an independent localization for the purposes of calculat -ing κ coefficients. Of the incompletely resected mass -es, 4 of 6 were primarily right sided. One additional mass was primarily right sided but did invade the left medial lobe. Only 1 of 6 incompletely excised masses was primarily left sided.All excised tissue was submitted for histopatholo -gy. Definitive diagnoses were hepatocellular carcino -ma (n = 17), hepatocellular adenoma (2), hematoma (1), and neuroendocrine carcinoma (1). The definitive diagnosis was made on the basis of histopathology as recorded by a board-certified veterinary pathologist. All nonresectable masses (n = 6) were consistent with hepatocellular carcinoma on histopathology.There was moderate interobserver agreement between the surgeon and radiologist regarding le -sion localization (κ [95% CI] = 0.59 [0.39 to 0.83]), with a raw agreement of 15 of 21 (71%; 95% CI, 50% to 86%). There was moderate agreement between the surgeon’s preoperative localization and the con -firmed intraoperative location (κ [95% CI] = 0.48 [0.23 to 0.72]), with a raw agreement of 12 of 21 (57%; 95% CI, 37% to 76%). There was very good agreement Unauthenticated | Downloaded 10/08/23 06:32 AM UTC 5between the radiologist’s preoperative localization and the confirmed intraoperative location (κ [95% CI] = 0.88 [0.72 to 1.00]), with a raw agreement of 19 of 21 (90%; 95% CI, 71% to 97%). The radiologist had a statistically higher agreement regarding location compared to the surgeon ( P = .023).At surgery, 17 of 21 masses were deemed to be grossly resectable by the attending surgeon. The 4 of 21 that were considered nonresectable at surgery were subsequently debulked/biopsied with the ex -pectation of incomplete margins. Of the masses that were deemed grossly resectable at surgery, 2 of 17 were noted to have incomplete margins following histopathologic analysis. These, combined with the 4 of 21 that were debulked/biopsied with the expecta -tion of incomplete margins, represented a total of 15 of 21 masses that were incompletely resected.There was a moderate degree of interobserver agreement between the surgeon and radiologist regarding preoperative assessment of both gross resectability (κ [95% CI] = 0.44 [0.03 to 0.85]) and complete excision (κ [95% CI] = 0.57 [0.20 to 0.94]). There was a raw agreement of 16 of 21 (76%; 95% CI, 55% to 89%) regarding gross resectability and a raw agreement of 17 of 21 (81%; 95% CI, 60% to 92%) re -garding complete excision.In this study, both the surgeon and radiologist were accurate in their preoperative predictions of resectability. The board-certified surgeon was more accurate in prediction of gross resectability when compared to the board-certified radiologist. Statisti -cally, there was good agreement between the sur -geon’s preoperative assessment and the confirmed intraoperative findings regarding gross resectability (κ [95% CI] = 0.74 [0.41 to 1.0]). There was a raw agreement of 19 of 21 (90%; 95% CI, 71% to 97%). The surgeon’s recorded sensitivity and specificity regarding gross resectability were 88% and 100%, respectively. The radiologist demonstrated only fair agreement between their preoperative assessment and the intraoperative findings regarding gross re -sectability (κ [95% CI] = 0.40 [–0.01 to 0.81]). There was a raw agreement of 16 of 21 (76%; 95% CI, 55% to 89%). Additionally, the radiologist recorded a sen -sitivity and specificity of 76% and 75%, respectively.The board-certified surgeon was also more ac -curate in prediction of complete excision. There was good agreement between the surgeon’s preoperative prediction and histopathology results (κ [95% CI] = 0.67 [0.32 to 1.0]). There was a raw agreement of 18 of 21 (86%; 95% CI, 65% to 95%). The surgeon’s record -ed sensitivity and specificity regarding complete exci -sion were 87% and 83%, respectively. The radiologist demonstrated only moderate agreement between the radiologist’s preoperative prediction and histopathol -ogy results (κ [95% CI] = 0.44 [0.03 to 0.85]). There was a raw agreement of 16 of 21 (76%; 95% CI, 55% to 89%). Additionally, the radiologist recorded a sen -sitivity and specificity of 80% and 67%, respectively. Despite the surgeon’s higher accuracy regarding both preoperative assessments of resectability, neither of these findings were determined to be statistically sig -nificant. These results are summarized (Table 1) .The surgeon’s intraoperative assessment of com -plete excision (raw agreement of 15/21 [71%]; 95% CI, 50% to 86%) was statistically less accurate than their pre -operative assessment (raw agreement of 18/21 [86%]; 95% CI, 65% to 95%), with only a moderate agreement between the values (κ [95% CI] = 0.74 [0.41 to 1.0]).The surgeon and radiologist were also instructed to predict the expected degree of surgical difficulty. The degree of difficulty was recorded on the previously described scale of 1 to 5 (Figure 1). Immediately fol -lowing surgery, the surgeon was asked to record the degree of difficulty on the same scale. While there was a moderate interobserver agreement between surgeon and radiologist (weighted κ [95% CI] = 0.43 [0.19 to 0.68]), the surgeon was significantly more accurate in their assessment of surgical difficulty (weighted κ [95% CI] = 0.50 [0.23 to 0.76]) when compared to the radi -ologist (weighted κ [95% CI] = 0.38 [0.12 to 0.64]).In grossly resectable masses, 0 of 17 (0%) had multilobar involvement, which was significantly low -er than nonresectable masses, in which 2 of 4 (50%) had multilobar involvement ( P = .029). One of the masses included portions of the right medial, left medial, and quadrate lobes. The second mass includ -ed portions of the right medial and caudate lobes. Both cases were documented as nonresectable by the surgeon at the time of surgery and debulked with the expectation of incomplete margins.Each CTA study was also evaluated for vascular involvement. Only major regional vasculature was included in this assessment. Major regional vascu -lature included the caudal vena cava, aorta, portal vein, hepatic artery and immediate lobar branches, Interobserver κ value Surgeon raw Radiologist raw Surgeon κ valueResectability (95% CI) agreement agreement (95% CI) agreement (95% CI) (95% CI) agreementGross resectability κ = 0.44 (0.03 to 0.85) 19/21 = 90% (71% to 97%) 16/21 = 76% (55% to 89%). κ = 0.74 (0.41 to 1.0) Raw agreement = 16/21 (76%) “Good”Complete excision κ = 0.57 (0.20 to 0.94) 18/21 = 86% (65% to 95%) 16/21 = 76% (55% to 89%) κ = 0.67 (0.32 to 1.0) Raw agreement = 17/21 (81%) “Good” Radiologist k value Surgeon sensitivity Radiologist sensitivity (95% CI) agreement and specificity (respective) and specificity (respective)Gross resectability κ = 0.40 (–0.01 to 0.81) 88% and 100% “Fair” 76% and 75% Complete excision κ = 0.44 (0.03 to 0.85) 87% and 83% “Moderate” 80% and 67%Table 1 —Statistical accuracy of surgeon and radiologist reported as raw agreement, weighted κ values, sensitivity, and specificity during a prospective study conducted between June 16, 2013, and November 30, 2016, to assess the accuracy of CT angiography in predicting resectability, degree of surgical difficulty, and individual factors that may impact resectability of isolated hepatic masses (n = 21) in dogs (20).Unauthenticated | Downloaded 10/08/23 06:32 AM UTC6 and hepatic veins. In grossly resectable masses, 2 of 17 (12%) had vascular involvement, which was sig -nificantly lower than nonresectable masses, in which 3 of 4 (75%) had vascular involvement ( P = .028).Abdominal effusion, lymphadenopathy, tumoral adhesions, and peritumoral edema were recorded for each case. These factors were determined to have no statistically significant impact on resectability.

Question 12

Knell - 2023 - VCOT - Outcome and Complications following Stabilization of Coxofemoral Luxations in Cats Using a Modified Hip Toggle Stabilization - A Retrospective Multicentre Study.pdf

Answer 12

Study PopulationWe searched the medical records of two veterinary hospitals(Vetsuisse Faculty Veterinary Teaching Hospital University ofZurich and Veterinary Teaching Hospital University of Bern)between November 2009 and October 2017 for cats undergo-ing hip toggle stabilization using the mini-TR. The inclusioncriteria were (1) acute ( <3 days duration from trauma) cox-ofemoral luxation without signs of OA or intra-articular frac-tures, (2) surgical treatment of coxofemoral luxation with hiptoggle stabilization using the mini-TR and (3) a completefollow-up as by the Cook and colleagues reference guidelines.5Complete follow-up was de fined as a complete medical recordand follow-up examination of the case at least 3 months aftersurgery including clinical examinationandvalidated question-naire answered by the owner. Cases were excluded from thestudy if their follow-ups were shorter than 3 months, unlessthe injured hip reluxated within that time. If available, orthog-onal preoperative, postoperative and follow-up radiographswere included in the review.We collected information about signalment, history, type ofluxation, side of luxation, uni- or bilateral condition, concur-rent injuries, surgical technique, antibiotic medication admin-istration and complications. The surgical report was reviewedfor surgical and anaesthetic time, intraoperative complica-tions, diameter of the femoral tunnel, number of suturestrands and ability to close the joint capsule. Complicationswere categorized as minor, major and catastrophic accordingto standard de finitions and criteria.5Surgical ProcedureThe surgical technique was performed as previouslydescribed in dogs and cats using a commercially availablemulti filament suture-toggle-system (Arthrex mini-TR).2,3However, modi fications of the original surgical techniquein terms of diameter of the femoral tunnel (1.5, 2.0 and2.4 mm) and use of a single or double loop suture to securethe toggle pin were used. A femoral tunnel of 1.5 mm ofdiameter was always associated with a single-strandimplant, as two loops could not be inserted through suchrelatively small bone tunnel. Single or double loop suturecould be inserted either in a 2.0 mm or 2.4 mm bone tunnel.The femoral tunnel preparation was always performed fromthe third trochanter to the fovea capitis direction, as this wasthe surgeons ’preferred technique.Pain medication was given perioperatively (opioids, e.g.,methadone 0.2mg/kg q4hrs intravenous [iv] or similar) andcontinued until suture removal (non-steroidal, e.g., melox-icam 0.05 mg/kg po).Clinical ExaminationClinical examinations were performed by the same surgeonwho performed the surgery. Limb function was subjectivelyevaluated through passive range of joint motion, evaluationof patient discomfort during joint palpation and lamenessscoring. A score from 0 to 4 (0 no lameness, 1 intermittentlameness, 2 consistent weight-bearing lameness, 3 intermit-tent non-weight-bearing lameness and 4 toe-touching lame-ness) was adopted to evaluate postoperative weight-bearingand joint function from previous studies evaluating hindlimblameness in cats.3,6Validated QuestionnaireA validated questionnaire was sent to the owners (FMPI ¼Feline Musculoskeletal Pain Index).7The owners were askedtofill a grading score form and answer 17 questionsconcerning cat behaviour, level of activity and quality oflife. Each question ranged from 0 to 4, with 0 being not at alland 4 de fined as normal. The total FMPI score is the sumof scores for each question. Higher totals indicate lessimpairment with a possible range of 0 to 68.Radiographic EvaluationOrthogonal radiographs of the pelvis were obtained pre- andpostoperatively, and at each scheduled follow-up examina-tion. The following radiographic changes of hip joint wereassessed and scored by the main author and a board-certi fiedradiologist (►Fig. 1 ): new bone formation on the femoralhead, femoral neck, acetabulum and thickness of the acetab-ular subchondral bone (bone sclerosis) were scored (normal¼0, mild ¼1, moderate ¼2, or severe ¼3). Those scores weresummed to make a total score. Th e joint space width was alsosubjectively evaluated as normal, narrow or wide. OnFig. 1 Radiographs giving differently graded hips and tunnel position as an example. Radiographic scoring of new bone formation on thefemoral head and the acetabulum in the luxated joint with subsequent stabilization with the mini-Tight Rope system ( A: normal joints, B: mild, C:moderate, D: severe). The position of the tunnel was evaluated as following: A:c e n t r a l , B:c e n t r a l , C: dorsal, D:v e n t r a l ..postoperative and follow-up ventrodorsal radiographs, theposition of the femoral tunnel within the femoral neck wasrecorded (dorsal, central, ventral). The diameter of thefemoral neck in its narrowest point was measured alongwith the diameter of the femoral tunnel at the same level. Theresulting ratio (femoral tunnel to femoral neck diameter) wascalculated to compensate for variations in body size andradiographic magni fication. Concurrent injuries or abnor-malities in the pelvic region were also recorded.Data AnalysisSpreadsheet software (Microsoft Excel for Mac) andstatistical software (Graphpad Prism) were used for sta-tistical analysis. Means, medians and standard deviationswere used to summarize the data. Fisher ’s exact test wasused to compare complications between the two surgicalmodi fications (single vs. double strand). Odds ratioswere calculated if differences between groups weredetected. Correlation between body weight and total scorein the FMPI and between surgical experience and surgicaltime were calculated using Spearman ’s correlationcoefficient.ResultsInclusion Criteria and Medical RecordsThirty-two cats met the inclusion criteria, but one catluxated bilaterally giving 33 coxofemoral luxations.The mean age of the cats was 4.1 /C63.3 years (from 0.5 to12.6 years), and their mean body weight was 4.2 /C61.1 kg(from 2.7 to 8.0 kg). The predominating breed were domesticshorthairs ( ►Table 1 ). Eighteen cats were males and 14females; none were sexually intact.Sixteen out of 32 cats had concurrent injuries affecting theappendicular skeleton: Seven cats had injuries on the sameside as the luxation, six cats on the contralateral side andthree cats had bilateral concurrent injuries. There were sixsacroiliac joint luxations, two femoral injuries and one tarsalinjury.Surgical RecordsSeven-boarded surgeons and four surgical residents per-formed the surgeries. Mean surgery duration was 90 /C642minute (from 45 to 210 minute). Longer times were associ-ated with concurrent injury repair. The correlation betweensurgeon experience (board-certi fied surgeon vs. resident)and surgical time was r¼/C00.31.Single suture strand was used in 21 hips. In four of those,the single suture strand was passed through a 1.5mm femo-ral tunnel, while in 17 cats it was inserted through a 2.0 mmfemoral tunnel. Double-stranded suture was used in 12 hips,either placed through a 2.0 mm femoral canal (11 hips) or a2.4 mm canal (1 hip).In 20 hips, the joint capsule was sutured using mono fila-ment suture material with a simple interrupted pattern(polydioxanone 2/0 to 3/0). In 13 hips, the traumatic eventseverely damaged the joint capsule and it was not sutured(►Table 2 ).All cases received perioperative cefazolin (22 mg/kg iv q90 minute). In six cases, the antibiotic treatment was contin-ued for at least 7 days due to other injuries (cefazolin22 mg/kg orally q 12 hours). Postoperative managementconsisted of pain medication and exercise restriction.Pain management typically consisted of methadone (0.2mg/kg iv q 4hrs) or buprenorphine (30 μg/kg iv q 6 hours)that was continued until discharge, typically 24 to 48 hoursafter surgery. Additionally, non-steroidal anti-in flammatorymedication was prescribed for 5 to 7 days (meloxicam 0.05mg/kg orally q 24 hours).After discharge, the owners were advised to keep the catsindoors and avoid exercise for 6 to 8 weeks.ComplicationsNo intraoperative complications were recorded. The overallmajor complication rate was 5/32, as 5 reluxations occurred.Of the five reluxation cases, four had a single loop FiberWire,and one had a double loop into a 2.0 mm femoral canaliza-tion. There was no statistical difference in the number ofreluxations between single and double strands ( p¼0.62).Two of the five cats presented 4 and 8 weeks after surgery,respectively, with an acute onset of lameness on the operatedlimb. One was the cat that was treated with the double loopmini-TR, and the other was an acute secondary traumaduring the recovery period. In both cases, the suture faileddue to bone cutout at the level of the femoral head-acetabu-lum interface. A femoral head and neck osteotomy wasperformed. In the remaining three cases, the reluxationwas observed during the planned follow-up examinations,as the owner did not notice any gross gait abnormality duringrecovery. In one case, the owner declined revision surgery.The remaining two were lost to follow-up. Neither infectionnor other implant-related complications were found in theremaining 27 cats.Clinical Examination and QuestionnaireThe two cats with reluxations within the first week were notincluded in thefollow-up examinations. The remaining 30 catsshowed a lameness grade 4/4 preoperatively. Postoperativeevaluation 24 hours after surgery revealed a lameness grade of2/4 orless in all cases. At thescheduled follow-up examination,the 30 cats showed either minimal (grade ¼) or no lamenessaccording to clinicalevaluationandowner assessment.Thelastfollow-up examinations were performed at a mean of 13 /C613months (from 4 months to 4 years).The completed questionnaire was returned in 32/32 casesat a mean of 8.5 /C614.8 months postoperatively (from 3.5 to54 months). The mean FMPI score was 0.98 /C65.9%. Therewas no correlation between FMPI score and body weight(r¼/C00.09).Questions like ‘cleaning habits ’and ‘interaction withhumans ’were consistently answered with normal. Activitieslike ‘getting up ’,‘moving down the stairs ’and ‘normal walking ’were mainly classi fied by the owner as normal or close tonormal. Scores regarding behaviour such as ‘jumping up ’or‘jumping to kitchen counter ’activities were averaged lower,but still rated within ‘normal ’or‘almost normal ’grades..Radiographic FindingsThere were 31 unilateral craniodorsal luxations, and onebilateral caudoventral luxation. Seventeen cases out of 33were affected in the right hindlimb and 16 the left hindlimb.Fourteen of 32 cats had a radiographic follow-up studylonger than 3 months, with a mean radiographic follow-upTable 1 Weight, age, breed, type of coxofemoral luxation, implant received and concomitant injury of the cases included in thestudyCaseno.Age BodyweightBreed Sex Side Type ofluxationConcurrent injuries Follow-up(months)(y) (kg) (M/F) (R/L) (CrD/V) Rads FMPI1 8 7.5 Norwegian M L CrD None 12 8.521 . 4 4 . 2 D S H ML V W o u n d 431 . 4 4 . 2 D S H MRV W o u n d 443 . 4 3 . 4 D S H F L C r D U G t r a u m a 9 85 1.4 4.3 Angora F L CrD Femur Fx contralateral, wound 86 2 4.1 DSH F R CrD None Reluxation7 8.4 8 DSH M L CrD Unknown sti fle pathology 328 9 3.5 DSH M R CrD Bilateral elbow OA 5 5.5965 . 7 D S H ML C r D W o u n d 4 4 . 510 0.4 3.2 DSH F L CrD Symphysiolysis lower jaw 811 2.5 4 Abyssinian M R CrD None 912 12.6 5.6 DSH M R CrD None 3113 4.3 3.7 DSH F R CrD Fx left ilium, ISL right, wound Reluxation14 12.3 4.7 DSH F R CrD Fx rib, Luxation Xyphoid,Amputee10 8.515 2.3 3.45 DSH M L CrD Wound 11 816 1.3 3 DSH F L CrD None 9 617 10.5 5.1 Ragdoll M R CrD Wound 718 3.1 4 DSH M R CrD Luxation left tarsus,distal left Fx fibula1219 2.5 2.7 DSH F L CrD Uroperitoneum, caudal CLR Reluxation20 3.2 3 DSH M L CrD None 22 1921 2.3 4.8 DSH M L CrD None 5422 4.3 4.5 DSH M R CrD ISL left, abdominal hernia,Fx right ilium9 Reluxation23 3 3.9 DSH F R CrD None 3324 3.5 3.5 DSH F R CrD None 3125 1.1 3.7 DSH M R CrD Fx right femur, wound 6 Reluxation26 3.5 3.9 DSH F L CrD None 15 8.527 0.9 3.9 DSH M L CrD Fx right femoral neck,greater trochanter avulsion11 1128 2 3.6 Siamese F R CrD Fx right ilium, sciatic lesion 4329 3.1 4.1 DSH F R CrD Fx right ileum, Fx pubis,ISL left, wound48 4530 0.9 3.6 DSH F R CrD Fx right ilium, ISL left 431 7.3 4.9 DSH M R CrD None 3.532 3.8 4.6 DSH M L CrD None 10 733 3 3.8 DSH M L CrD None 12 9Abbreviations: CLR, cruciate ligament rupture; CrD, craniodorsal; DSH, d omestic shorthair; Fx, fracture; ISL, iliosacral luxation; OA, osteoart hrosis;UG, urogenital; V, ventral..time of 10 /C611 months (from 4 to 48 months). Among these14 cats, eight had a left coxofemoral luxation, and six had aright coxofemoral luxation. Overall, no radiographic signs ofOA were found preoperatively, while postoperative radio-graphic OA signs were observed in the femoral head (10/14),femoral neck (2/14) and acetabulum (10/14), as seenin►Fig. 1 . Bone sclerosis was found in one case (1/14), whilejoint space widening was detected in two cats (2/14).The position of the femoral tunnel was central in eight ofthe 14 cats, distal in four and proximal in one cat. The meanfemoral tunnel to femoral neck diameter ratio was 22.5%after surgery and 22.8% at the first follow-up recheck(►Table 2 ). The size of the femoral tunnel increased betweensurgery and first radiographic recheck, with a mean value of10% (0.8 mm; range: /C00.3 to 0.7 mm). No statistical signi fi-cance was found between cat body weight and diameter ofTable 2 Cases included in the study including complications, surgica l details, follow-up and radiographic score. Time of latestfollow-up examination is mentioned in ►Table 1Caseno.No. of FWstrandsComplication Infection Drill tunnel (mm) Closure of Radiographic scoreReluxation Postoperative LatestcontrolJointcapsulePostoperative Latestcontrol1 2 No None 2.4 2.6 Y 0 42 2 No None 2 Y 03 2 No None 2 Y 04 2 No None 2 2.1 Y 0 65 2 No None 2 Y 06 2 Yes None 2 Y 0 Reluxation7 2 No None 2 Partial 08 2 No None 2 2.7 Y 0 29 2 No None 2 2.1 Y 0 110 2 No None 2 Partial 011 2 No None 2 N 012 2 No None 2 N 013 1 Yes None 1.5 Y 0 Reluxation14 1 No None 2 1.6 Y 0 115 1 No None 1.5 2.1 Partial 0 1716 1 No None 1.5 2.1 Y 0 117 1 No None 2 N 018 1 No None 2 Y 019 1 Yes None 1.5 Partial 0 Reluxation20 1 No None 2 1.9 N 0 221 1 No None 1.5 N 022 1 Yes None 2 2.5 N 0 Reluxation23 1 No None 2 Partial 024 1 No None 2 Y 025 1 Yes None 1.5 1.9 Y 0 Reluxation26 1 No None 2 N 0 427 1 No None 2 Y 028 1 No None 1.5 N 029 1 No None 2 2.1 N 0 430 1 No None 1.5 Y 031 1 No None 1.5 N 032 1 No None 1.5 1.5 Y 0 133 1 No None 1.5 1.6 N 0 2.the femoral tunnel ( p¼0.2). However, the time intervalbetween these radiographs was inconsistent.

Question 13

Stavroulaki - 2024 - JSAP - Trends in urolith composition and factors associated with different urolith types in dogs from the Republic of Ireland and Northern Ireland between 2010 and 2020.pdf

Answer 13

Medical records searchRetrospective analysis was performed on data from canine uro -liths submitted for analysis to the Minnesota Urolith Center (College of Veterinary Medicine, University of Minnesota, St Paul, MN, USA) from dogs of the ROI and RI from January 1, 2010 and December 31, 2020. In dogs with repeat sub -missions, only the first submission was included in the study. Information about patient and urolith characteristics was obtained from a standard form submitted with each urolith by the primary veterinarians. Date of submission, mineral composition of the urolith, location within the urinary tract, retrieval method and signalment of patients (age, breed, sex and neuter status), concurrent diseases, bacterial urine culture results, history of previous antibiotic therapies and recurrent urolithiasis were recorded, if available.Urolith analysisUrolith quantitative analysis was performed using polarising light microscopy and/or infrared spectroscopy. Based on the quanti -tative analysis results, uroliths were classified into distinct cat -egories. Uroliths containing >70% of a biogenic mineral were classified as that mineral type. This classification allowed for the identification of uroliths composed of a single biogenic mineral. A urolith without a nidus or shell that contained <70% of any sin -gle mineral was referred to as “mixed.” This classification denoted the presence of different minerals within the urolith structure. Uroliths that had a central core or outer layer containing ≥70% of a single mineral with an opposing outer layer or central core of a different mineral were classified as “compound.” This clas -sification highlighted the coexistence of two different minerals within the same urolith. Urate and xanthine uroliths, character -ised by their chemical composition derived from purines, were grouped together as purine uroliths. Uroliths <5% prevalent were all grouped as “other” (Cannon et al., 2007 ).Statistical analysisStatistical analyses were performed using statistical software pack -ages (SPSS version 23.0; and Prism version 9.0, GraphPad Soft -ware). Descriptive statistics included calculation of count and percentage for categorical variables while for continuous variables, the median and interquartile range (IQR) were evaluated. Chi square test for trend was used to evaluate urolith trends over time. Age was expressed as continuous variable in years or was divided into two categories based on the median: ≤7 years of age and >7 years of age to allow for an even distribution in both groups. For age, a Kolmogorov– Smirnov test was used to assess the normal -ity assumption. Age did not pass normality assumption therefore a Kruskal- Wallis test was used for between groups comparisons (struvite, CaOx and compound) followed by Dunn’s post hoc tests. Fisher’s exact test was used for univariate evaluation of asso -ciations between urolith type and categorical variables including age, breed, sex and neuter status. Multivariate logistic regression was performed to evaluate associations for the five most prevalent urolith types (struvite, CaOx, compound, purine and mixed) and age group, the five most prevalent breeds, sex and neuter status. Odds ratios (OR) with 95% confidence intervals (CI) were also calculated using the Baptista- Pike method to evaluate associations between age, breed, sex, neuter status, and different stone types. Statistical significance was set at P<0.05 ( Fig 2).RESULTSA total of 1162 canine uroliths were analysed from dogs of the ROI and RI from January 1, 2010 until December 31, 2020. One hundred forty- eight uroliths were submitted from a teach - 17485827, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13676 by Vetagro Sup Aef, Wiley Online Library on [19/01/2024]. 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 LicenseE. M. Stavroulaki et al.Journal of Small Animal Practice • Vol 65 • January 2024 • © 2023 British Small Animal Veterinary Association. 32ing veterinary referral hospital and 1014 uroliths from a total of 174 private practices (151 from the ROI and 23 from NI).Urolith prevalence and trends over timeDue to the low number of submissions from 2010 to 2013 (n=59 in total), changes in the proportions of uroliths submitted were only evaluated from 2014 onward ( Fig 1A). Of the 1162 submis -sions, 462 (39.8%) were classified as struvite uroliths ( Table 1). There was a significant decrease in the proportions of struvite uroliths submitted over time; 41.7% (15/36) in 2014 to 33.0% (57/173) in 2020 (P<0.001) ( Fig 1B). A total of 312 (26.9%) uroliths were classified as CaOx and a significant increase in CaOx urolithiasis was observed over time; from 27.8% (10/36) in 2014 to 31.2% (54/173) in 2020 (P=0.016) ( Fig 1, Table 1). Compound uroliths accounted for 126 out of 1162 submissions (10.8%) and no significant changes in their proportions occurred over time (P=0.631) ( Fig 1, Table 1). The remaining uroliths based on mineral composition and trends over time are illus -trated in Fig 1 and Table 1. Table 2 contains the mineral compo -sition of the basic anatomic layers (nidus, body, shell and surface) of compound and mixed uroliths. Uroliths with <20 submissions (brushite, calcium carbonate, calcium phosphate and silica) were classified as “other.”Sex and neuter statusData regarding sex and neutering status are listed in Table 3. Female dogs had more commonly struvite (OR 8.7, 95% CI 6.6 to 11.5, P<0.001), mixed (OR 4.5, 95% CI 2.6 to 7.9, P<0.001), FIG 1. (A) Annual number of uroliths of dogs from the ROI and NI submitted for analysis from 2010 to 2020. (B) Annual proportions of struvite- , calcium oxalate- , compound- , purine- , mixed- , cystine- and other- containing uroliths in dogs from the ROI and NI. Uroliths composed of brushite, calcium carbonate, calcium phosphate and silica are classified as “other” 17485827, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13676 by Vetagro Sup Aef, Wiley Online Library on [19/01/2024]. 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 LicenseCanine uroliths in Ireland and Northern IrelandJournal of Small Animal Practice • Vol 65 • January 2024 • © 2023 British Small Animal Veterinary Association. 33 and compound (OR 2.6, 95% CI 1.7 to 4.0, P<0.001) uroliths compared to male dogs. On the other hand, male dogs were significantly more likely to have CaOx (OR 9.6, 95% CI 6.9 to 13.3, P<0.001) and purine (OR 9.6, 95% CI 5.3 to 17.8, P<0.001) urolithiasis compared to females ( Table 4).CaOx urolithiasis was also overrepresented among male cas -trated dogs compared to male entire dogs (OR 2.0, 95% CI 1.3 to 2.9, P=0.005).AgeThe median age of dogs with urolithiasis was 7 years (IQR 5.0 to 9.0 years). Table 3 contains the distribution of submissions per age category. The proportion of purine and struvite uroliths was significantly higher in dogs ≤7 years of age compared to dogs >7 years of age (purine OR 3.0, 95% CI 1.8 to 5.0; struvite OR 2.2, 95% CI 1.7 to 2.8, both P<0.001). Dogs >7 years of age had significantly higher odds to have CaOx uroliths (OR 4.1, 95% Table 1. Summary of 1162 canine urolith submissions from the Republic of Ireland and Northern Ireland between 2010 and 2020Year Submissions Struvite CaOx Compound Purine Mixed Othern n % n % n % n % n % n %2010 12 3 25.0 3 25.0 1 8.3 3 25.0 1 7.1 1 8.32011 15 7 46.7 4 26.7 3 20.0 0 0 0 0 0 02012 17 9 52.9 3 17.6 1 5.9 3 17.7 0 0 0 02013 15 7 46.7 3 20.0 2 13.3 2 13.3 1 5.0 0 02014 36 15 41.6 10 27.8 2 5.6 3 8.3 3 6.8 3 8.32015 111 56 50.5 18 16.2 13 11.7 14 12.6 4 5.1 6 5.42016 150 64 42.7 42 28.0 12 8.0 13 8.7 9 6.7 10 6.72017 220 97 44.1 55 25.0 24 10.9 15 6.8 16 7.5 13 5.92018 228 82 36.0 62 27.2 29 12.7 23 10.1 22 9.9 10 4.42019 185 65 35.1 48 25.9 25 13.5 10 5.4 9 4.6 18 9.72020 173 57 32.9 54 30.7 14 8.1 19 11.0 18 10.2 11 6.4Total 1162 462 39.8 312 30.0 126 10.8 105 9.0 83 7.3 72 6.2Table 2. Mineral composition of the basic layers of 126 compound and 83 mixed uroliths submitted from dogs of the Republic of Ireland and Northern Ireland between 2010 and 2020Struvite CaOx Mixed Purine CAPO4CO3CAPO4AP Cystine Silica Brushite COD Unknown TotalCompound urolithsNidus 26 24 12 7 7 2 2 1 1 1 43 84Body 79 7 18 6 9 0 1 0 3 2 1 126Shell 24 6 13 4 45 0 1 0 2 9 22 104Surface 0 0 1 0 0 0 0 0 0 6 119 7Mixed urolithsNidus 8 5 16 2 5 0 0 1 0 0 46 37Body 0 0 83 0 0 0 0 0 0 0 0 83Shell 22 0 12 5 14 0 0 0 2 9 19 64Surface 0 0 0 0 0 0 0 0 0 1 82 1CaOx Calcium oxalate dihydrate, CAPO4CO3 Calcium phosphate carbonate, CAPO4AP Calcium phosphate apatite, COD Calcium oxalate dihydrateFIG 2. Age distribution of dogs from the ROI and NI with struvite- , calcium oxalate- , compound- , purine- and mixed- containing uroliths submitted for analysis from 2010 to 2020. Proportions represent the proportion of dogs with each urolith type within the different age groups 17485827, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13676 by Vetagro Sup Aef, Wiley Online Library on [19/01/2024]. 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 LicenseE. M. Stavroulaki et al.Journal of Small Animal Practice • Vol 65 • January 2024 • © 2023 British Small Animal Veterinary Association. 34CI 3.0 to 5.4, P<0.001) compared to dogs ≤7 years of age based on multivariable analysis ( Table 5).BreedUrolithiasis was reported in a total of 71 breeds. The five most frequent breeds by prevalence order were bichon frise, followed by shih- tzu, Yorkshire terrier, Jack Russell Terrier and mixed breed dogs ( Table 6). Among these breeds, Yorkshire terrier (OR 2.8, 95% CI 1.9 to 4.1, P<0.001) and bichon frise (OR 1.7, 95% CI 1.3 to 2.4, P<0.001) were significantly more likely to have uroliths composed of CaOx compared to the remaining dog breeds. Shih- tzu had higher odds for having compound uroliths (OR 1.7, 95% CI 1.1 to 2.8, P=0.015). No significant associa -tions were found between breed and struvite, purine, or mixed uroliths.Urolith locationThe most common location of the uroliths was the lower urinary tract (bladder, urethra) while small numbers were removed from the upper urinary tract (kidneys and ureters) ( Table 3). The most prevalent urolith isolated from the lower urinary tract contained struvite (n=459/1075; 42.7%) while from the upper urinary tract, the most common urolith isolated was composed of CaOx (n=11/29; 37.9%) compared to uroliths with different compo -sition. No significant changes were observed in the proportion of upper urinary tract urolith submissions over time. Statisti -cal analysis investigating changes in the proportions of uroliths based on their mineral type isolated from the upper urinary tract over time was not performed given the very low numbers of sub -missions.Urine culture resultsOf the 1162 uroliths submitted, 105 (9.0%) provided urine culture results from which 41 cultures (39.0%) came back as positive. The most common bacteria isolated were Staphylococ -cus spp. (n=22/41; 53.7%), Escherichia coli (n=14/41; 34.1%), Proteus spp. (n=2/41; 4.9%) Enterococcus spp. (n=2/41; 4.9%) and multiple non- specified microorganisms (n=1/41; 2.4%). Among dogs with a positive urine culture, 18 of 41 (43.9%) had struvite urolithiasis, and in 14 of 18 (77.8%) there was growth of a urease- producing bacterium; 14 of 41 (34.1%) had compound or mixed uroliths and seven of 41 (17.1%) had CaOx uroliths. Within the negative urine cultures, 24 of 64 (37.5%) dogs had uroliths containing CaOx, 17 of 64 (26.6%) had struvite uroliths, 12 of 64 (18.8%) had purine uroliths, six of 64 (9.3%) had compound or mixed uroliths and five of 64 (7.8%) had cystine urolithiasis. Antibiotic administration at the time of urine submission was not specified in the medical history of these dogs.Recurrent urolithiasisA history of recurrent urolithiasis was reported in a total of 137 of 944 (14.5%) dogs. Overall, from the 264 dogs with CaOx uroliths, and the 363 dogs with struvite uroliths, history of recur -rence was known in 185 and 244 dogs, respectively. A total of 43 dogs with CaOx (23.2%) and 35 dogs with struvite (14.3%) had a previous history of urolithiasis. Recurrence rates were not significantly higher in dogs with CaOx or struvite urolithiasis when each urolith type was compared with the remaining uro -lith types in dogs with recurrent urolithiasis. Within the 43 dogs with CaOx- containing uroliths and a previous history of uroli -thiasis, the previous uroliths were classified as CaOx in 23 dogs Table 3. Individual data associated with 1162 canine uroliths from the Republic of Ireland and Northern Ireland between 2010 and 2020Patient characteristics Total counts %Gender (n=1143)Female spayed 372 32.5Female entire 228 19.9Male castrated 215 18.8Male entire 328 28.7Age (n=1034)≤7 years 541 52.3>7 years 493 47.7Breed (n=1144)Bichon frise 204 17.8Shih- tzu 137 12.0Yorkshire terrier 122 10.7Jack Russell Terrier 120 10.5Mixed breed 76 6.6Retrieval method (n=1046)Surgical 1004 96.0Voided 43 4.1Catheterization 30 2.9Urolith location (n=1104)Upper urinary tract 29 2.6Lower urinary tract 1075 97.4Table 4. Distribution of sex within uroliths with different mineral composition in dogs from the Republic of Ireland and Northern Ireland and odds ratios (OR) with 95% confidence intervals (95% CI) based on multivariate analysis. Statistical significance was set at P<0.050Female Male OR (95% CI) P valuen % n %Struvite 372 80.5 86 18.6 8.7 (6.6 to 11.5) <0.001CaOx 51 16.3 256 82.1 9.6 (6.9 to 13.3) <0.001Compound 90 71.4 34 27.0 2.6 (1.7 to 4.0) <0.001Purine 12 11.4 89 84.8 9.6 (5.3 to 17.8) <0.001Mixed 68 81.9 15 18.1 4.5 (2.6 to 7.9) <0.001Table 5. Distribution of age within uroliths with different mineral composition in dogs from the Republic of Ireland and Northern Ireland and odds ratios (OR) with 95% confidence intervals (95% CI) based on multivariate analysis. Statistical significance was set at P<0.050≤7 years of age>7 years of ageOR (95% CI) P valuen % n %Struvite 263 53.3 149 27.5 2.2 (1.7 to 2.8) <0.001CaOx 82 16.6 207 38.3 4.1 (3.0 to 5.4) <0.001Compound 46 9.3 64 11.8 1.6 (1.1 to 2.4) <0.001Purine 106 21.5 36 6.7 3.0 (1.8 to 5.0) 0.004Mixed 40 8.1 29 5.4 1.3 (0.8 to 2.1) 0.383 17485827, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13676 by Vetagro Sup Aef, Wiley Online Library on [19/01/2024]. 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 LicenseCanine uroliths in Ireland and Northern IrelandJournal of Small Animal Practice • Vol 65 • January 2024 • © 2023 British Small Animal Veterinary Association. 35 (53.5%), calcium phosphate in two dogs (4.7%), struvite in two dogs (4.7%) while for the remaining 14 dogs (32.6%) the com -position of the urolith was not reported. Among the 37 dogs with struvite urolithiasis and a previous history of recurrence, the uroliths were composed of struvite in 12 dogs (32.4%), mixed in five dogs (13.5%), cystine, calcium oxalate, calcium carbonate and calcium phosphate were identified in one dog each (2.7%), while in the remaining 14 dogs (37.8%) urolith composition was unknown.Concurrent diseasesA total of 805 (69.2%) submissions provided a medical history with 780 (96.9%) dogs reported to have no significant concur -rent disease. Among the 25 dogs with concurrent pathologic conditions, 12 had portosystemic shunts and the most com -mon urolith isolated from these dogs was classified as purine (9/12; 75%). Nine dogs had seizures in which case CaOx was isolated most frequently (5/9; 55.6%). The remaining dogs were reported to have chronic kidney disease (2/25; 8%), hypercalcaemia (1/25; 4%) and leishmaniasis (1/25; 4%). Due to the low number of reports per disease category, statistical analysis for identifying urolith frequency per disease was not performed.

Question 14

Pye - 2024 - JSAP - Determining predictive metabolomic biomarkers of meniscal injury in dogs with cranial cruciate ligament rupture.pdf

Answer 14

Ethical approvalEthical approval for the collection of canine SF for use in this study was granted by the University of Liverpool Veterinary Research Ethics Committee (VREC634) as surplus clinical waste under the generic approval RETH00000553.Synovial fluid collectionCanine SF was collected from dogs undergoing surgery for CCLR, either with or without concurrent meniscal injuries, from dogs undergoing surgery for patella luxation, or as excess clinical waste from dogs undergoing arthrocentesis as part of lameness investigations from March 2018 to June 2021. Cases were divided 17485827, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13688 by Vetagro Sup Aef, Wiley Online Library on [04/02/2024]. 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 LicenseC. R. Pye et al.Journal of Small Animal Practice • Vol 65 • February 2024 • © 2023 The Authors. Journal of Small Animal Practice published by John Wiley & Sons Ltd on behalf of British Small Animal Veterinary Association.92into three groups, namely, group (1) CCLR with meniscal injury; group (2) CCLR without meniscal injury; and group (3) nei -ther CCLR nor meniscal injury (the control group). Cases were recruited with informed consent from three veterinary practices in the north- west of England. SF was collected by stifle joint arthro -centesis as per the BSAVA guide to procedures in small animal practice (Bexfield & Lee, 2014 ). A 21- gauge to 23- gauge needle attached to a 2 to 5 mL sterile syringe (depending on the size of the dog) was inserted into the stifle joint space either medially or laterally to the patella ligament after sterile preparation of the skin, before first surgical incision. After aspiration of the SF , sam -ples were placed in sterile 1.5- mL Eppendorf tubes (Eppendorf UK Ltd, Stevenage, UK), and immediately refrigerated at 4°C.Synovial fluid processingSF samples were transported on ice to the laboratory within 48 hours of collection. Samples stored for longer than 48 hours before processing were excluded from the study based on previ -ous data examining metabolomic changes in the SF with elon -gated refrigerated storage time (Pye, 2021 ). Any SF samples with a large amount of blood contamination, or that had a haemorrhagic discolouration were excluded from the study. A small number of SF samples with minor iatrogenic blood con -tamination from arthrocentesis (seen as blood “streaks” that are not completely blended with the SF sample (Clements, 2006 )) were included. Samples were centrifuged at 2540 g at 4°C for 5 minutes. The supernatant was pipetted into 200 μL aliquots, and snap frozen in liquid nitrogen before storing at −80°C (Anderson et al., 2020 ).Clinical information on the canine participantsInclusion criteria for this study were dogs undergoing surgery for either partial or complete CCLR (with or without concurrent meniscal injury), dogs undergoing surgery for patella luxation, or dogs that had stifle joint arthrocentesis as part of clinical investi -gations into hindlimb lameness. There were no exclusion criteria based on other clinical attributes of the dogs.Clinical information from the dogs used in this study was collected. This information included breed, age, sex and neuter status, bodyweight, body condition score (BCS) (Laflamme, 1997 ), presence and degree of CCLR (whether par -tial or complete CCLR), presence of meniscal injury, location and type of meniscal injury (Bennett & May, 1991 ), presence of patella luxation, length of time of lameness, co- morbidities, medication being received by the dog and radiographic level of OA using two separate scoring systems (Innes et al., 2004 ; Wessely et al., 2017 ).Orthogonal radiographs (medio- lateral view and caudo- cranial views) of the stifle joint of each dog included in the study were analysed. Radiographs were performed either as preoperative radiographs or as part of lameness investigations, less than 21 days before arthrocentesis of the SF sample. These were analysed either by a veterinary surgeon with a postgradu -ate certificate in small animal surgery, or by a veterinary stu -dent who had received training in radiographic OA scoring of the stifle joint and was overseen by the aforementioned vet -erinary surgeon. T wo separate scoring systems were initially used to assess difference between the three groups in terms of their radiographic OA score (Innes et al., 2004 , Wessely et al., 2017 ). These scoring systems use either a 10- point scale (Innes et al., 2004 ) or a 45- point scale (Wessely et al., 2017 ). A global assessment score from zero (no OA) to three (severe OA) as described by Innes et al. (2004 ) was then used when assessing metabolomic differences in the stifle joint SF based on level OA in order to group the level of OA for ANOVA test -ing (see Statistical Analysis section below).NMR metabolomicsSample preparation for NMR metabolomicsSF samples were thawed on ice immediately before sample prep -aration for NMR spectroscopy. 100 μL of each thawed SF sam -ple was diluted to a final volume containing 50% (v/v) SF , 40% (v/v) dd 1H2O (18.2 M Ω), 100 mM phosphate buffer, pH 7.4 (Na2HPO4, VWR International Ltd., Radnor, Pennsylvania, USA and NaH2PO4, Sigma- Aldrich, Gillingham, UK) in deute -rium oxide (2H2O, Sigma- Aldrich) and 0.0025% (v/v) sodium azide (NaN3, Sigma- Aldrich). Samples were vortexed for 1 min-ute, centrifuged at 13,000 g and 4 °C for 5 minutes and 180 μL transferred (taking care not to disturb any pelleted material) into 3 mm outer diameter NMR tubes using a glass Pasteur pipette.NMR metabolomics spectral acquisitionSpectra were acquired using a 700 MHz Bruker Avance III spec -trometer (Bruker Corporation, Billerica, Massachusetts, USA) with associated triple resonance inverse (TCI) cryoprobe and chilled Sample Jet auto- sampler. Software used for spectral acqui -sition and processing were Topspin 3.1 (Bruker Corporation, Billerica, Massachusetts, USA) and IconNMR 4.6.7 (Bruker Corporation).1D 1H NMR spectra were acquired using a Carr- Purcell- Meiboom- Gill (CPMG) filter to suppress background signals from proteins and other endogenous macromolecular constitu -ents, and allow acquisition specifically of small molecule metabo -lite signals (Carr & Purcell, 1954 ; Meiboom & Gill, 1958 ). A vendor- supplied standard pulse sequence was used to achieve this (cpmgpr1d) with water suppression carried out by presaturation (Hoult, 1976 ). The CPMG spectra were acquired at 37°C with a 15 ppm spectral width, a 4- second interscan delay and 32 tran -sients (Anderson et al., 2020 ).The spectra acquired in this study are available in the Metab -oLights (Haug et al., 2020 ) repository ( https://www.ebi.ac.uk/metab oligh ts/MTBLS 6050 ).NMR metabolomics spectral quality control1D 1H NMR spectra were individually assessed to ensure mini -mum reporting standards were met (Sumner et al., 2007 ). The steps for quality control included: (1) assessing the spectral baseline to ensure minimal curvatures or deviations; (2) assess -ing the quality of water suppression, to ensure the water peak 17485827, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13688 by Vetagro Sup Aef, Wiley Online Library on [04/02/2024]. 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 LicenseBiomarkers of meniscal injuryJournal of Small Animal Practice • Vol 65 • February 2024 • © 2023 The Authors. Journal of Small Animal Practice published by John Wiley & Sons Ltd on behalf of British Small Animal Veterinary Association.93 at 4.7 ppm was no more than 0.4 ppm wide; (3) aligning the spectra to the glucose beta anomeric doublet at 5.24 ppm; and (4) measurement of the line- width half height of the glucose peak at 5.24 ppm, with any spectrum where the width of this peak at half the height of the peak exceeded more than one standard deviation from the mean being regarded as a fail -ure of quality control. Any samples that were deemed to have failed quality control were re- ran on the spectrometer up to a maximum of three spectral acquisitions. Any samples that failed after the third spectral acquisition were excluded from the study.Metabolite annotation and identificationThe NMR spectra were divided into spectral regions (termed “bins”) using Topspin 3.1 (Bruker Corporation, Massachu -setts, USA), with each bin representing either single metabolite peaks or multiple metabolite peaks where peaks overlapped on the spectra. These bins were also examined using TameNMR (hosted by Github: https://github.com/PGB- LIV/tameNMR ), an “in- house” toolkit built within the galaxy framework (Afgan et al., 2018 ). Bins were altered accordingly upon visualising the fit to the overlaid spectra to ensure the area under the peak was represented by the bin.Metabolites were annotated to the spectra using Chenomx NMR Suite Profiler version 7.1 (Chenomx, Edmonton, Can -ada), a reference library of 302 mammalian metabolite NMR spectra. When metabolite peaks overlapped, multiple metabo -lites were annotated to the bin. When peaks were unable to be annotated to a metabolite, they were classed as being an “unknown” metabolite. Previous literature specifying metabo -lite chemical shifts and spectral appearance were examined to aid annotation of unknown areas. Downstream unique peak metabolite identification and in- house NMR metabolite stan -dards were examined to confirm metabolite identities where possible. Metabolites were assigned a level of identification according to the metabolite standards initiative (MSI) levels. Level 1 identified metabolites require two or more orthogonal properties of a standard component to be analysed using the same spectrometer and experimental conditions as the experi -mental spectra. Level 2a metabolite identifications are made after matching one property of a standard component analysed using the same spectrometer and experimental conditions. Level 2b are putatively identified metabolites using reference libraries of standard compounds obtained from external labo -ratories. Level 3 are putatively annotated compound classes, used when the molecule can only be annotated to a class rather than a specific metabolite (Sumner et al., 2007 ).A pattern file was created of the spectral bins and metabo -lites annotated to that bin. This is a spreadsheet outlining the bin boundaries in ppm, and the metabolites annotated to that bin. The pattern file and the Bruker spectra files were input into TameNMR, in order to create a spreadsheet of the integrals from binned spectra, with the relative intensities of each bin for each sample, which could then be used for statistical analysis of the spectra.Statistical analysisDifferences in clinical variables of the canine participantsAnalysis of the differences in clinical features between the groups in terms of age, sex and neuter status, BCS, the length of time of lameness on the affected hindlimb, and radiographic OA scores using both scoring systems and the global assessment of radiographic OA from zero to three (Innes et al., 2004 ; Wes -sely et al., 2017 ) were undertaken in the following way. Firstly, normality was tested using the Shapiro– Wilk test, as well as visualising histograms and quantile– quantile (QQ) plots of the data for each variable. Kruskal- Wallis tests were undertaken on non- parametric data, with Dunn’s post- hoc test. A Benjamini- Hochberg false discovery rate (FDR) adjustment was carried out for all tests, and significance set at P<0.05. These analyses and creation of boxplots to visualise this data was undertaken using R (R Core Team, 2020 ).Metabolomics data analysisSample size power calculations were completed using data from a previous unpublished small cohort study (n=5 with CCLR and meniscal injury and n=7 with CCLR without meniscal injury), with a specified FDR of 0.05 using MetaboAnalyst 5.0 ( https://www.metab oanal yst.ca ), a software based on a metabolomics data analysis package written in R (the MetaboAnalystR pack -age) (Pang et al., 2021 ).Metabolomics data was normalised using probabilistic quo -tient normalisation (PQN) (Dieterle et al., 2006 ), and Pareto scaled using R before statistical analysis (R Core Team, 2020 ). Unsupervised multi- variate analysis was carried out using prin -cipal component analysis (PCA) on the normalised and scaled data using R. The variance between canine phenotypes was investigated through analysis of principal components (PCs) 1 through 10 using one- way ANOVAs or linear models depend -ing on the data type. Briefly, CCLR, sex, neuter status, BCS, radiographic OA score and batch were numerically encoded and assessed against each PC using a one- way ANOVA. Age, length of time of lameness, weight, length of time of stor -age preprocessing which were already numeric variables were assessed against each PC using a linear model. All p values were corrected using FDR (Bejamini Hochberg) correction. Corre -lation matrices between phenotypes were computed using the Spearman’s correlation using the cor function in R and visual -ised using a heatmap generated with the pheatmap function in R (Kolde, 2012 ).Univariate analysis was carried out using one- way ANOVAs and one- way analysis of co- variance (ANCOVAs) using R. To account for multiple testing across all 236 metabolite bins FDR correction was applied to the F- Test p value of each metabolite, significance was accepted at P<0.05. For metabolites with an FDR <0.05 T ukey’s honest significant difference post- hoc test was applied to assess between group variances. Metabolite differences were separately analysed with respect to age, weight (divided into groups of 10 kg intervals), BCS, global assessment of radio - 17485827, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13688 by Vetagro Sup Aef, Wiley Online Library on [04/02/2024]. 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 LicenseC. R. Pye et al.Journal of Small Animal Practice • Vol 65 • February 2024 • © 2023 The Authors. Journal of Small Animal Practice published by John Wiley & Sons Ltd on behalf of British Small Animal Veterinary Association.94graphic OA score (0 to 3) (Innes et al., 2004 ), length of time of clinical lameness (divided into groups less than 1 month, 1 to 3 months, 3 to 6 months and 6 to 12 months), site of collection, partial versus complete versus no CCLR and between the three groups (group 1: CCLR with meniscal injury, group 2: CCLR without meniscal injury and group 3: control group with neither CCLR nor meniscal injury). Age adjusted one- way ANCOVAs were applied to each metabolite to assess differences between the three groups (1) CCLR with meniscal injury, (2) CCLR with -out meniscal injury and (3) control group with neither CCLR nor meniscal injury), FDR adjustment was applied as a above. Boxplots to visualise the changes in metabolite abundances were created using ggplot2 package within R.RESULTSSample size calculations revealed a sample size of n=60 per group, namely group (1) CCLR with meniscal injury, (2) CCLR with -out meniscal injury and (3) control group with neither CCLR nor meniscal injury, would give a predictive power of 0.83 when plotted on a predictive power curve.For the metabolomic study, 191 samples of canine stifle joint SF were collected and submitted for NMR spectroscopy. Of these, 14 samples had been stored for longer than 48 hours before col -lection for processing, and were subsequently excluded from the study. Four samples were from cases in which the menis -cal injury status was unknown, and were also excluded from the study. Nineteen samples were excluded as they failed to meet minimum reporting standards (Sumner et al., 2007 ) after three spectral acquisitions.In total, 154 canine stifle joint SF samples were included in the statistical analysis. These were divided into three groups, namely group (1) CCLR with meniscal injury (n=65), group (2) CCLR without meniscal injury (n=72), and group (3) control group with neither CCLR nor meniscal injury present (n=17). The two groups of CCLR cases included dogs with either partial or complete CCLR. The control group consisted of 13 cases of patella luxation, three cases from arthrocentesis of the stifle joints during lameness investigations which subsequently were found to have no pathology, and one sample from a case with fraying of the caudal cruciate ligament.Differences in signalment of the canine participants between groupsInformation regarding the signalment of the dogs in each group is shown in Table 1. There was a significant difference between the control group and both the CCLR groups with or without meniscal injury in terms of age, weight, and radiographic OA score using both the Innes et al. (2004 ) and Wessely et al. (2017 ) scoring systems. There was no significant differences between the three groups in terms of BCS of the dogs and length of time of clinical lameness ( Fig 1). There was no significant difference between groups CCLR with meniscal injury and CCLR with -out meniscal injury in terms of these clinical variables, although age was closest to reaching significance between the two groups [P=0.13, mean difference=0.86 years (0.01 to 1.73 95% CI)].Metabolite annotation and identificationSpectra were divided into 246 bins. Of these, 84 (34%) remained with an unknown metabolite identification, and 162 (66% of bins) were annotated to one or more metabolites. In Table 1. Clinical characteristics of the canine participants included in the nuclear magnetic resonance metabolomic study of biomarkers of meniscal injury in canine stifle joint synovial fluid. Canine participants were divided in three groups depending on the presence of CCLR with meniscal injury (n=65), CCLR without meniscal injury (n=72) or neither CCLR nor meniscal injury (n=17)GroupCCLR with meniscal injury CCLR without meniscal injury Control (no CCLR, no meniscal injury)Sample size, n 65 72 17 (n=13 cases of patella luxation, n=3 cases of lameness of unknown cause, n=1 case of fraying of the caudal cruciate ligament)Age, years, median (IQR) 6.9 (4.00) 7.0 (4.25) 3.2 (3.30)Weight, kg, median (IQR) 27.5 (22.32) 32.4 (20.40) 14.0 (14.76)Sex, n (%)FE 7 (11) 8 (11) 2 (12)FN 26 (40) 28 (29) 3 (18)ME 12 (19) 5 (7) 7 (41)MN 18 (28) 30 (42) 5 (29)BCS, 1 to 9, median (IQR) 6.0 (2.00) 6.0 (2.00) 5.5 (2.25)Radiographic OA score (15 to 60) (Wessely et al., 2017 ), median (IQR)22.0 (5.50) 20.0 (8.25) 16.5 (4.00)Radiographic OA score (0 to 10) (Innes et al., 2004 ), median (IQR)4 (2) 4 (2.25) 3 (1.25)Length of time of lameness, months, median (IQR)2.0 (2.88) 2.0 (2.00) 1.5 (3.25)Partial versus complete CCLR, nPartial 9 29 N/AComplete 55 42Unknown 1 1CCLR Cranial cruciate ligament rupture, FE Female entire, FN Female neutered, ME Male entire, MN Male neutered, BCS Body condition score, OA Osteoarthritis, N/A Not applicable, IQR Interquartile range 17485827, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13688 by Vetagro Sup Aef, Wiley Online Library on [04/02/2024]. 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 LicenseBiomarkers of meniscal injuryJournal of Small Animal Practice • Vol 65 • February 2024 • © 2023 The Authors. Journal of Small Animal Practice published by John Wiley & Sons Ltd on behalf of British Small Animal Veterinary Association.95 total, 65 metabolites were annotated to the spectra ( Table 2). Any bins containing ethanol peaks were excluded from the statistical analysis, due to ethanol being considered a con -taminant in NMR, usually either during the collection of the SF from the sterilisation of skin with alcohol- based solutions (Hutchinson, 2012 )or during the processing steps (Van Der Sar et al., 2015 ). Propylene glycol, a metabolite found in solvents used in pharmaceuticals (Zar et al., 2007 ) was found in one spectrum, and so those bins were excluded so as to not bias the statistical analysis.FIG 1. Clinical characteristics of the canine participants between groups. Box and whisker plots show differences in (a) age, (b) weight, (c) body condition score (BCS), (d) the length of time of clinical lameness on the affected hindlimb, (e) the radiographic osteoarthritis score using the radiographic scoring system as described by Wessely et al. (2017 ), and (f) the global assessment of radiographic osteoarthritis from 0 to 3 as described by Innes et al. (2004 ). The box indicates the interquartile range (IQR) around the median. Each whisker extends to the furthest data point that is above or below 1.5 times the IQR. Possible outliers are data points outside of this distance. Boxplot colours indicate different groups: Grey=CCLR with meniscal injury (n=65), Orange=CCLR without meniscal injury (n=72), Light blue=control group with neither CCLR nor meniscal injury (n=17). Significance testing was performed using Kruskal- Wallis testing with Dunn’s post- hoc test. CCLR Cranial cruciate ligament rupture, MI Meniscal injury, OA Osteoarthritis, ns Not significant, P<0.05, **P<0.01, **P<0.001) 17485827, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13688 by Vetagro Sup Aef, Wiley Online Library on [04/02/2024]. 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 LicenseC. R. Pye et al.Journal of Small Animal Practice • Vol 65 • February 2024 • © 2023 The Authors. Journal of Small Animal Practice published by John Wiley & Sons Ltd on behalf of British Small Animal Veterinary Association.96Metabolomic statistical analysis resultsAnalysis of canine synovial fluid metabolome with respect to weight, age, radiographic OA score, length of time of lameness, BCS, site of collection and degree of CCLR of the canine participantsAnalysis of metabolite changes with respect to clinical variables found significantly altered metabolites with differing weight (Fig S2), age (Fig S3) and radiographic OA score of the dogs using the global assessment score (0 to 3) within Innes et al. (2004 ) (Fig S4). This included an increase in glutamine with increasing weight of the dogs (Fig S2). Four mobile lipid regions on the spectra were significantly increased with increasing age of the dogs (Fig S3). There were no significant metabolite differences depending on the length of time the dog had clinical signs of lameness or due to the BCS of the dog. There were also no significant difference between dogs with a partial CCLR versus dogs with a complete CCLR.Multi- variate analysis of canine synovial fluid metabolome with respect to CCLR and meniscal injury statusMulti- variate PCA was undertaken to compare the differ -ences in the overall metabolome between the groups, namely: group (1) CCLR with meniscal injury, group (2) CCLR with -out meniscal injury and group (3) no CCLR and no meniscal injury (the control group) ( Fig 2). Over PC one and two, there were overlapping clustering of the groups, indicating little overall difference in the metabolome over these PCs ( Fig 2a). Associations between different phenotypes of the canine par -Table 2. Metabolites annotated or identified to canine stifle joint synovial fluid nuclear magnetic resonance spectra, including HMDB identification number where possible, and level of identification according to the metabolomics standard initiative (Sumner et al., 2007 )Amino acids Fatty and organic acidsMetabolite name HMDB number MSI ID level Metabolite name HMDB number MSI ID levelAcetylcysteine HMDB0001890 Level 2b 2- Hydroxyvaleric acid HMDB0001863 Level 2bAminoadipic acid HMDB0000510 Level 2b 2- Methylglutarate HMDB0000422 Level 2bAnserine HMDB0000194 Level 2b 2- Phenylpropionate HMDB0011743 Level 2bBetaine HMDB0000043 Level 2b 3 Hydroxyisovalerate HMDB0000754 Level 2bCreatine HMDB0000064 Level 2a 4- Pyridoxate HMDB0000017 Level 2bCreatine phosphate HMDB0001511 Level 2b Acetic acid HMDB0000042 Level 2bCreatinine HMDB0000562 Level 2a Acetoacetic acid HMDB0000060 Level 2bCreatinine phosphate HMDB0041624 Level 2b Azelate HMDB0000784 Level 2bGlycine HMDB0000123 Level 2b Citric acid HMDB0000094 Level 2al- Alanine HMDB0000161 Level 2a Formic acid HMDB0000142 Level 2bl- Alloisoleucine HMDB0000557 Level 2b Glycerol HMDB0000131 Level 2bl- Glutamine HMDB0000641 Level 2a Glycocholic acid HMDB0000138 Level 2bl- Histidine HMDB0000177 Level 2a Glycolate HMDB0000115 Level 2bl- Isoleucine HMDB0000172 Level 2a Glycylproline HMDB0000721 Level 2bl- Leucine HMDB0000687 Level 2a Isobutyric acid HMDB0001873 Level 2bl- Lysine HMDB0000182 Level 2a l- Carnitine HMDB0000062 Level 2bl- Methionine HMDB0000696 Level 2a l- Glutamic acid HMDB0000148 Level 2bl- Phenylalanine HMDB0000159 Level 2a l- Lactic acid HMDB0000190 Level 2al- Threonine HMDB0000167 Level 2a Methylsuccinic acid HMDB0001844 Level 2bl- Tyrosine HMDB0000158 Level 2a Mobile lipids N/A Level 3l- Valine HMDB0000883 Level 2a Pyruvic acid HMDB0000243 Level 2aSugars OthersMetabolite name HMDB number MSI ID level Metabolite name HMDB number MSI ID leveld- Galactose HMDB0000143 Level 2b 1- Methylhistidine HMDB0000001 Level 2bd- Glucose HMDB0000122 Level 2a 3- Hydroxy- 3- methylglutarate HMDB0041199 Level 2bd- Mannose HMDB0000169 Level 2a 3- Methylhistidine HMDB0000479 Level 2bFructose HMDB0000660 Level 2b Acetaminophen HMDB0001859 Level 2bGlucitol HMDB0000247 Level 2b Acetone HMDB0001659 Level 2bMannitol HMDB0000765 Level 2b Acetylcholine HMDB0000895 Level 2bCholine HMDB0000097 Level 2bDimethyl sulfone HMDB0004983 Level 2bDTTP HMDB0001342 Level 2bEthanol HMDB0000108 Level 2aHistamine HMDB0000870 Level 2bGlycerophosphocholine HMDB0000086 Level 2bO- Cresol HMDB0002055 Level 2bP- Cresol HMDB0001858 Level 2bPropylene glycol HMDB0001881 Level 2bTrigonelline HMDB0000875 Level 2bXanthine HMDB0000292 Level 2bHMDB Human metabolome database, MSI Metabolomics standards initiative 17485827, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13688 by Vetagro Sup Aef, Wiley Online Library on [04/02/2024]. 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 LicenseBiomarkers of meniscal injuryJournal of Small Animal Practice • Vol 65 • February 2024 • © 2023 The Authors. Journal of Small Animal Practice published by John Wiley & Sons Ltd on behalf of British Small Animal Veterinary Association.97 FIG 2. Principal component analysis (PCA) 2D scores plot of metabolite profiles of canine stifle joint synovial fluid by NMR. Samples grouped by CCLR and meniscal injury status. Group 1 (grey): CCLR with meniscal injury (n=65), Group 2 (orange)=CCLR without meniscal injury (n=72), Group 3 (light blue)=control group with neither CCLR nor meniscal injury (n=17). Plotted over (a) PC1 and PC2 and (b) PC3 and PC4 17485827, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13688 by Vetagro Sup Aef, Wiley Online Library on [04/02/2024]. 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 LicenseC. R. Pye et al.Journal of Small Animal Practice • Vol 65 • February 2024 • © 2023 The Authors. Journal of Small Animal Practice published by John Wiley & Sons Ltd on behalf of British Small Animal Veterinary Association.98ticipants and PC 1 to 10 found that PC three and four were primarily associated with CCLR and meniscal injury (Fig S1). PCA of the groups plotted over PC three and four showed some samples from the control group were separated from the groups CCLR with and without meniscal injury, indicating that the control group appears to have a wider variation with some samples exhibiting a differing metabolome from the other two groups ( Fig 2b).Univariate analysis of canine synovial fluid metabolome with respect to CCLR and meniscal injury statusUnivariate analysis of metabolomic differences between the three groups (1) CCLR with meniscal injury, (2) CCLR without meniscal injury and (3) control group with neither CCLR nor meniscal injury was then undertaken.Between groups (1) CCLR with meniscal injury, and group (2) CCLR without meniscal injury, there were six spectral bins that were below the threshold of significance (P<0.05), and two others that neared the threshold (P<0.06) after one- way ANOVA testing with FDR adjusted P- values and T ukey’s HSD post- hoc test ( Table 3). These included the four spectral bins related to mobile lipids.It was noted that mobile lipids were also significantly increased with increasing age of the canine participants (Fig S3), and that groups CCLR with meniscal injury and CCLR without menis -cal injury had a slight, although insignificant [P=0.13, mean dif -ference=0.86 years (0.01 to 1.73 95% CI)] difference in terms of age of the canine participants in each group with the group CCLR with meniscal injury being older ( Fig 1). There was no difference in other variables (including weight, radiographic OA score or BCS) between dogs in groups CCLR with meniscal injury and CCLR without meniscal injury ( Fig 1). ANCOVAs were therefore undertaken to control for age. The results of these ANCOVAs controlling for age are shown in Table 4. After con -trolling for age, three out of four spectral regions annotated to mobile lipids were significantly higher in the group CCLR with meniscal injury compared to the group CCLR without menis -cal injury ( Fig 3). These regions were attributed to mobile lipid - CH3 (P=0.016), mobile lipid - n(CH3)3 (P=0.017) and mobile unsaturated lipid (P=0.031). A complete list of the ANCOVA outputs is included in Table S1.After controlling for age, there were 49 spectral bins, relat -ing to 31 metabolites that were found to be significantly altered between group 1 (CCLR with meniscal injury) and group 3 (control group). Forty- eight out of these 49 bins, related to the same 31 metabolites, were also found to be significantly altered between group 2 (CCLR without meniscal injury) and group 3 (control group) ( Table S1). However, as the control group dif -fered to the other two groups in terms of other variables, such as weight and radiographic OA score, as well as it being of a smaller sample size, it was not possible to accurately assess whether these metabolomic changes were based on the presence of CCLR alone.

Question 15

Schmierer - 2023 - VETSURG - Patient specific, synthetic, partial unipolar resurfacing of a large talar osteochondritis dissecans lesion in a dog.pdf

Answer 15

A 7-month-old male intact Rhodesian Ridgeback weigh-ing 25 kg was presented to the orthopedic department ofthe small animal clinic of Posthausen (Ottersberg,Germany). The dog had a one-month history of progres-sive left hindlimb lameness. At initial presentation to thereferring veterinarian, the cause of the lameness wasunclear and a conservative trial with carprofen (4 mg/kgPO, Rimadyl, Pfizer) plus exercise restriction was startedfor 4 weeks. After an initial slight improvement, thelameness recurred and the dog was referred.The orthopedic examination at presentation revealedsevere, grade III –IV/IV. Muscle atrophy was noted in theleft hind limb compared to the contralateral side. The lefttarsal joint was severely effused and severe pain was eli-cited in extension and flexion. Range of motion wasreduced with an extension angle of 130/C14and a flexionangle of 95/C14(contralateral limb: 170/C14/45/C14). Orthogonalradiographs of the tarsal joints showed findings conclu-sive with an OC lesion of the medial trochlea of the talus(Figure 1).To better assess the extent of the lesion, axial com-puted tomography (Siemens SOMATOM go. Up, SiemensHealthcare GmbH, Erlangen, Germany) of both tarsi wasperformed with a slice thickness of 0.625 mm. CT con-firmed the diagnosis of extensive talar OCD of the lefttalus involving two-thirds of the medial talar ridge withan approximately 16 mm long osteochondral lesion and acorresponding free body located in the caudal joint com-partment (Figure 2). Due to the severity and the largeextent of the lesion, as well as the expected guardedFIGURE 1 Orthogonal radiographs of the left tarsal joint. Notethe increased soft tissue opacity centered over the medial aspect ofthe tarsal joint. A severely flattened and irregular-shaped medialtrochlear ridge of the talus with collapse of the medial jointcompartment and several small fragments with mineral opacitymedial and caudal to the medial trochlear ridge of the talus can beappreciated (white arrow).FIGURE 2 Computed tomography (CT) images of the lefttarsus. In the frontal plane (A) as well as in the sagittal plane (B) alarge defect affecting the medial trochlea of the talus can beappreciated. A corresponding free dissecate is visible (white arrow).732 SCHMIERER and BÖTTCHER 1532950x, 2023, 5, prognosis, different options were discussed with theowner, including fragment removal and debridement,pantarsal arthrodesis, osteochondral allograft, and partialunipolar synthetic resurfacing based on existingimplants.12,13Given the unavailability of a matchingdonor in a 4-week lag period, the owners opted for syn-thetic resurfacing. Owners were educated about theexperimental nature of the patient specific implant andwritten consent was obtained.Based on the available axial CT images, 3D models ofboth talar bones were created using dedicated imagingsoftware (Materialize Mimics and Materialize 3-matic,Materialize NV, Leuven, Belgium) (Figure 3). By mirror-ing the unaffected talar bone with the affected side, thephysiological subchondral bone contour was extrapolatedand the defect virtually reconstructed (Figure 3). Usingthat model, the defect area was over reamed in silicousing reamers of 6 and 15 mm diameter and an anatomi-cally fitting implant 3D modeled implant was designedwith a socket fitting in the reamed cavities (Figure 3).Because reaming resulted in an implant bed that was notconfined at the medial aspect of the talus, significantlyreducing press-fit anchorage of the implant, a transversehole for a 2.4 mm screw was added to the design, provid-ing additional implant stability. The implant itself con-sists of a PCU bearing surface and a porous titaniumsocket for secure bony anchorage. Along with theimplant, a matching patient-specific surgical guide foraccurate placement of two 2.4 mm guide pins (Drill TipGuide Pin, 2.4 mm, Arthrex VetSystem, Munich,Germany) was also constructed. These guide pins exactlymimicked the central axis and orientation of the tworeamers used during planning. Lastly, different trialimplants were also provided to allow for an intraopera-tive evaluation of the reaming depth. The surgical guide,trial implants, Implants and four models of the affectedtalus were printed on an SLA printer (Form 2, FormlabsGmbH, Berlin, Germany) using 50 /uni03BCm thick slices of For-mlabs Gray Resin. The implant socket was first printedon the Form 2 using Formlabs Castable Wax Resin andsubsequently precision-cast using the lost wax processand Grade 1 titanium under argon atmosphere. Afterdevesting, the implant was cleaned of any residual invest-ment and finally sandblasted to provide a rough surfaceallowing for bony on-growth at the implantation site. ThePCU bearing surface (Carbotane AC-4085A, The LubrizolFIGURE 3 3D models of talar bones were generated following segmentation using dedicated imaging software (Materialize Mimics v.21and Materialize 3-matic v.14, Materialize NV, Leuven, Belgium) (A). By matching the unaffected left talar bone onto the affected right side,the physiological subchondral bone contour at the defect site was extrapolated (B) and the defect virtually resurfaced (C). Based on thisplanning of the drill guide (D) the implant bed (E) and the implant socket (F) was performed.SCHMIERER and BÖTTCHER 733 1532950x, 2023, 5, Corporation, Wickliffe, Ohio, USA) was injection-moldedonto the socket using single-use molds printed on theForm 2 out of Formlabs High Temp Resin.14The equip-ment and implant were plasma sterilized prior to surgery.Before surgery, two rehearsal surgeries were performed.On the day of surgery, the dog was premedicated withmethadone (0.2 mg/kg intramuscularly [IM], Dechra)and medetomidine (10 /uni03BCg/kg IM, Vetoquinol). Anesthe-sia was induced with propofol (4 mg/kg intravenously[IV], CP-Pharma) and maintained with isoflurane in oxy-gen after endotracheal intubation. An epidural injectionof mepivacaine hydrochloride (5 mg/kg, Scandicain 1%,Aspen) was given to enhance analgesia. Cefazolin(22 mg/kg IV, Fresenius) was administered 60 minutesbefore surgery and repeated every 90 minutes. The lefttarsus was aseptically prepared. The tarsal joint wasapproached medially. After preparation of the medialmalleolus and caudal retraction of the soft tissues, includ-ing the flexor tendons, the joint capsule was opened atthe cranial aspect of the malleolus. A 20-gaugehypodermic needle was carefully placed alongside thearticular surface of the medial malleolus in order todefine landmarks for the malleolar osteotomy withoutharming the talus. A medial malleolar osteotomy wasthen performed using an oscillating saw (Acculan4, B. Braun Vetcare GmbH, saw blade thickness 0.6 mm)with constant lavage with saline solution.15The osteot-omy was performed in such a way as to ensure that thestop point was located at the transition of metaphysis todiaphysis. When this point was reached, sawing wasstopped and two 3.5 mm holes were drilled in the malleo-lar fragment serving as gliding holes for postoperative fix-ation, followed by two 2.5 mm drill holes through theremaining distal tibia and trans cortex. The osteotomywas then completed with a small transverse cut in amedial to lateral direction at the proximal end of the sag-ittal osteotomy. Soft tissues were gently dissected payingattention to not harm the medial collateral ligaments andthe musculotendinous structures. The osteotomized frag-ment was then retracted caudodistally with the attachedFIGURE 4 Images of rehearsal surgery (black box) and intraoperative images. Fitting of drill guides was confirmed (A). After reaming,the template was used to assure adequate depth (B). Finally, a trial implant was positioned confirming excellent fitting. Surgical images areshown from D –J. The large osteochondral fragment can be appreciated (D, black arrow). The drill guide was positioned, and the first guidepin was placed (E). The 6 mm cannulated reamer was used to create the plantar cavity. The drill guide was repositioned and the secondguide pin was placed to adequate depth (F). First, the 6 mm reamer was used to create the dorsal cavity and subsequently the 15 mm reamerwas used to the precalculated depth (G). The template was used to assure correct implant fit (H). Final position of the implant withsubluxated (I) and reduced Joint (J). Note the excellent fitting.734 SCHMIERER and BÖTTCHER 1532950x, 2023, 5, soft tissue structures. By applying gentle valgus stress, thearticular surface of the talus was exposed. As expectedfrom diagnostic imaging, almost all of the medial troch-lear ridge of the talus was absent and a large osteochon-dral fragment was found in the joint (Figure 4). Thearticular cartilage of the tibia looked grossly normal. Thefragment was removed, and the surgical guide was placedon the remnant of the medial talar trochlea. The properposition was verified, checking that there were no gapsbetween guide and articular surface, and the two 2.4 mmguide pins were inserted taking care not to penetrate thetrans cortex. The template was removed and the plantarcavity was reamed with copious lavage using the 6 mmcannulated reamer (Cannulated Headed Reamer, ArthrexVetSystem, Munich, Germany) (Figure 4). Reamingdepth was verified with the designated trial implant. Thedorsal cavity was then reamed, starting with the 6 mmreamer. Subsequently, the 15 mm reamer was used(Cannulated Headed Reamer, Arthrex VetSystem,Munich, Germany) and the 6 mm drill hole over-reamedto the precalculated depth (Figure 4). Both reamers had ascale on the reaming part to evaluate reaming depth.Templates were used to check for correct reaming depth.The created cavity was lavaged profusely. Gloves werechanged before touching the implant. Initial seating ofthe implant was performed by hand and the final impac-tion carried out with an impactor (Tamp Ulna, CUE,Arthrex VetSystems, Munich, Germany) and a mallet,applying gentle force. Implant to cartilage transition wascarefully checked with a Freer periosteal elevator(Figure 4).Lastly, a titanium 2.4 mm cortical screw (DePuySynthes, Umkirch, Germany) was inserted through thedesignated hole in the titanium socket from medial to lat-eral, engaging the lateral base of the talus. The joint wasreduced and taken through multiple ROM sets. The sur-gical site was again lavaged and a microbiology samplewas obtained. The osteotomized malleolus was fixatedwith two 3.5 mm self-tapping cortical screws of adequatelength. Reduction was checked and the joint was againtaken through range of motion without any friction orcrepitus occurring, followed by routine closure of subcu-taneous tissue and skin. The surgical time was 90 min.The owners were taught to fill out the Liverpool Oste-oarthritis in Dogs (LOAD) score16at the 6-week, 6-monthand 1-year follow-up appointments, by the same personand without interaction with medical staff.3|RESULTSPostoperatively, orthogonal radiographs showed goodimplant positioning with resolution of the collapse of themedial joint compartment, a radiolucent void corre-sponding to the PCU part of the implant, and anatomicalfixation of the malleolar osteotomy (Figure 5). The legwas placed in a reinforced Robert Jones Bandage extend-ing distally from the mid-tibia using a padded fiberglasssplint. Medical therapy postoperatively consisted of cefa-zolin (22 mg/kg IV twice daily), methadone (0.2 mg/kgIV every 4 h, Comfortan, Dechra), and robenacoxib(2 mg/kg IV once daily, Onsior, Novartis). At the firstbandage change 1 day after surgery, the tarsal joint wasmoderately swollen, and the wound appeared unremark-able. Careful passive range of motion was possible with-out a pain reaction. The dog was discharged 24 h aftersurgery with cefazolin (22 mg/kg PO twice daily, Cefa-septin, Vetoquinol) for 10 days and robenacoxib (1 mg/kgPO once daily, Onsior, Novartis) for 7 days. The rein-forced Robert Jones Bandage was kept for 2 weeks withbandage changes every 5 –7 days and replaced by a softFIGURE 5 Immediate postoperative radiographs (A, B) and12 months follow-up radiographs (C, D) of the operated tarsal joint.Note the only minimal progression of osteoarthritis.SCHMIERER and BÖTTCHER 735 1532950x, 2023, 5, padded bandage for another 2 weeks with the samedressing change frequency. The owners were instructedto restrict postoperative exercise and physiotherapy wasprescribed with a certified physiotherapist starting10 days after surgery and scheduled simultaneously withbandage changes for the first 4 weeks. Two weeks postop-eratively, owners reported improved limb function withgood weight bearing. Upon orthopedic examination atthat time, the dog had a grade II/IV lameness and ROMof 85/C14in flexion and 140/C14in extension (contralateral side:48/C14/165/C14). The surgical wound had healed without com-plications allowing suture removal, followed by applica-tion of a soft padded bandage. At 4 weeks, the dog hadgrade I –II/IV lameness, the tarsal joint showed mild tomoderate periarticular fibrosis, no joint effusion, andimproved ROM with a flexion angle of 60/C14and an exten-sion angle of 155/C14(contralateral side: 45/C14/165/C14). At6 weeks, the dog showed improved gait, good progresswith physiotherapy, and a LOAD score of 12. Uponorthopedic examination at that time, grade I/IV lamenesswas reported at a walk and grade II/IV lameness at a trot.Palpation detected mild to moderate medial periarticularfibrosis, but no joint effusion. ROM was unchanged witha flexion angle of 60/C14and an extension angle of 155/C14(contralateral side: 45/C14/170/C14). Orthogonal radiographswere taken and, compared with the immediate postoper-ative films, no significant radiographic changes werenoticed (Figure 5). The osteotomy showed good healingprogression. Owners were instructed to graduallyincrease exercise over the next 2 months according to apredefined rehabilitation plan and to continue physio-therapy twice weekly including underwater treadmill.At the 6-month follow-up, limb function had furtherimproved according to the owners and a LOAD score of5 was reported. Mild left hindlimb lameness was still pre-sent with a grade of I/IV lameness and mild, howeverimproved muscle atrophy compared to the contralateralside was still present. Improvement in ROM was evidentwith flexion of 60/C14and extension of 170/C14(contralaterallimb: 45/C14/175/C14). No pain could be elicited on palpation ofthe tarsal joint. In addition, there were no signs ofimplant loosening or other implant-associated complica-tions in follow-up radiographs; however, some new boneformation was recognized on the medial malleolus, thecaudal aspect of the distal tibia, and the talus.At the 12-month follow-up owners reported normallimb function with only slight stiffness after vigorousexercise resulting in a LOAD score of 4. There was nodetectable muscle atrophy compared to the contralateralside and only a mild gait alteration at the trot with agrade of I/IV lameness. No pain on palpation, and ROMof 55/C14in flexion and 170/C14in extension (contralaterallimb: 40/C14/175/C14). Radiographs were unremarkable with nofurther progression of osteoproliferation and stableimplant position (Figure 5). At the 16-month telephonefollow-up owners reported normal function with furtherimprovement.4

Question 16

Danielski - 2024 - VETSURG - Influence of oblique proximal ulnar osteotomy on humeral intracondylar fissures in 35 spaniel breed dogs.pdf

Answer 16

Dogs presenting to the authors’ institution (2019 –2022)for unilateral/bilateral thoracic limb lameness and hadHIF diagnosed by computed tomography (CT) scan wereincluded in the study. Dogs that did not undergo 6-weekfollow-up radiographs or later follow-up CT scans at alater stage were excluded from the study. Informationretrieved included age, sex, breed, uni-/bilateral lame-ness, subjective degree of discomfort on elbow extension(classified as mild, moderate and severe) preoperativelyand at the 6-week follow-up appointment, partial/complete fissure, arthroscopic findings, postoperativecomplications, time between initial surgery and follow-up CT scan, and time between initial surgery and the lasttelephonic/written follow-up. Ethical approval to performlong-term follow-up CT imaging was obtained by theRCVS Ethics review panel (2021 –2047).2.1 |Preoperative imaging and surgicalmanagementComputed tomography (GE Revolution, GE Healthcare,Chalfont St Giles, UK) of both thoracic limbs from thecarpi to the shoulders was performed with the dog underdeep sedation (3 –8 mcg/kg dexmedetomidine and0.2 mg/kg butorphanol, IV). Dogs were positioned in ster-nal recumbency, with the elbow joints parallel andextended cranially at approximately 130/C14–140/C14of exten-sion. If CT revealed changes compatible with presence ofHIF (as previously described by Carrera et al.),13elbowarthroscopy, using a 2.4 mm, 30/C14oblique arthroscope(Arthrex, Munich, Germany), was subsequently per-formed. A novel caudal portal was used to inspect theelbow joint.9The presence or absence of medial coronoiddisease, a visible HIF, the recently described focal cartilagi-nous lesion on the caudo-proximal aspect of the humeralcondyle,9and cartilage damage (using a previouslydescribed modified Outerbridge classification system)14affecting the medial compartment were recorded. If frag-mentation of the medial coronoid process was present,arthroscopic subtotal coronoid ostectomy was performed.An oblique PUO was subsequently performed as previ-ously described15with the aim to ameliorate humero-anconeal incongruity. The interosseous ligament wasreleased by placing a Freer periosteal elevator in the spacebetween the proximal radius and ulna, and by applicationof a force in a distal direction until the portion of the inter-osseous ligament of the proximal ulnar segment wascompletely transected. An intramedullary K-wire (1.25 –1.4 mm) was then placed into the ulna in a retrogradefashion to prevent excessive caudal displacement of theproximal ulnar segment. The equivalent to 0.75 mg ofdibotermin alfa of reconstituted recombinant human bonemorphogenetic protein-2 (rhBMP-2) (InductOs, MedtronicBioPharma, Heerlen, Netherlands) was uniformly distrib-uted on a collagen hemostatic matrix (Lyostypt, B. BraunMedical, Sheffield, UK) and was applied at the osteotomysite with the aim to stimulate early bone healing. If previ-ous metallic implants such as transcondylar screws or288 DANIELSKI ET AL . 1532950x, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14061 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 Licenselaterally applied plates were present, these were subse-quently removed. A compressive bandage was applied for3 days to limit postoperative swelling.2.2 |Postoperative managementPostoperative analgesia was provided by the administrationof methadone (0.2 mg/kg intramuscular, every 4 h)(Comfortan, Dechra, Skipton, UK) whilst in the hospitaland oral NSAIDs for 3 weeks whilst at home. Trazodonehydrochloride (5 –10 mg/kg, Bristol Laboratories, Ber-khamsted, UK) was also dispensed for 6 weeks to reduceanxiety and distress. Upon discharge, the recommendedpostoperative care regimen included an initial 6-weekperiod of cage rest, followed by an additional 6 weeks ofroom confinement. Throughout the entire 12-week recov-ery period, lead-only walks were instructed. Dogs wereradiographically reassessed at 6 weeks to assess the degreeof healing of the ulnar osteotomy and to screen for possiblecomplications. Complications were classified as describedby Cook et al.16A follow-up CT scan was then performedat a later date to assess the degree of healing of the HIF.2.3 |Radiographic and CT assessment ofthe effect of PUO on the ulnaGiven that the ulna would not only displace proximallybut would also tilt, two measurements (one more cranialand one more caudal) were taken to better assess the mag-nitude of proximal ulnar displacement. On the preopera-tive medio-lateral radiograph, two lines (L1, more cranialand L2, more caudal) were measured to assess the lengthof the ulna (in millimeters). To normalize these two mea-surements, the length of both these lines was divided bythe width of the radius measured at its exact half(L3) (Figure1). The same measurements were repeated onthe 6-week follow-up radiographs taking particular care inselecting the exact same landmark points that were usedon the preoperative images. An increase in ratio of thesetwo measurements was interpreted as proximal displace-ment of the proximal ulnar segment with subsequent elon-gation of the ulna as a result of the PUO.To assess if ulnar elongation corresponded to cranialdisplacement of the tip of the anconeal process in directionof the supratrochlear foramen, additional measurementswere performed on preoperative and follow-up CT images.On sagittal images, the width of the proximal radius wasmeasured in two points and a line intersecting the exactmidpoint of these two lines was drawn. A second perpen-dicular line was drawn from the tip of the anconeal pro-cess to the point where the first line intersected theanconeal process. The distance between the tip of theanconeal process and the first line was then measured(Figure2). A positive change in measurement was inter-preted as cranial displacement of the anconeal process as aresult of the tilting movement achieved by the PUO. Allmeasurements were performed by the same investigator.2.4 |Objective assessment of HIFhealing on CT imagesThe bone density of the medial and lateral humeral con-dyle was assessed on coronal planes and recorded inFIGURE 1 Radiographic measurements performed on the medio-lateral view of the affected antebrachium, prior to surgery (A) and atthe time of 6-week follow-up radiographs (B). The first line (L1) was drawn and measured from a point at the most cranial aspect of thedorsal cortex of the olecranon to an easily recognizable point at the distal end of the styloid process of the ulna. A second line (L2) was thendrawn and measured from an easily recognizable point (such as where the k-wire was engaging the cortex for example) at the caudal aspectof the dorsal cortex of the olecranon to exactly the same point at the distal end of the styloid process of the ulna where the first line ended.DANIELSKI ET AL . 289 1532950x, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14061 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 LicenseHounsfield units (HU) on the preoperative and lastfollow-up CT images. A medical image viewer (Horos,New York) and its built-in tools were used to perform themeasurements. On the preoperative images, a rectangularregion of interest (ROI) (with the area calculated inmm2) was drawn on the midline of the humeral condyleto include the entirety of the hypoattenuated humeral fis-sure. In dogs with a complete fissure, this rectangle wasextended from the caudal to the cranial aspect of thehumeral condyle whilst in dogs with partial fissures,the rectangle was extended from the caudal aspect of thehumeral condyle to a cranial direction until wherethe hypoattenuated line of the fissure ended.A free-hand ROI was then drawn to separately mea-sure the bone density of the humeral condyle, both medialand lateral to the ROI encompassing the fissure (Figure3).The selected ROIs were standardized to avoid corticalbone inside the areas of density measurements. In order tostandardize the density values as much as possible, and toreduce the dependence of the results of the spatial orienta-tion of ROIs, three different coronal planes were chosen.The density measurements of these three planes were thensummed and divided by three to obtain an average samplebone density value for each elbow. Care was taken toselect matching coronal images and the same ROI area’ssize on preoperative and follow-up CT images to ensureconsistency of measurements between time points. Allmeasurements were performed by the same investigator.For those dogs where metallic implants were already pre-sent at the time of surgery, a CT scan was repeated follow-ing surgery once the metallic implants were removed toavoid metallic artifacts and the hypoattenuated area corre-sponding to the bone tunnel was not included in the mea-sured ROIs. A decreasing mineral density of the ROIs ofFIGURE 2 The measurement of thecranial displacement of the tip of theanconeal process in direction of thesupratrochlear foramen on preoperative(A) and follow-up (B) computedtomography (CT) scans. On sagittalimages, the width of the proximal radiuswas measured in two points and a lineintersecting the exact midpoint of thesetwo lines was drawn. A secondperpendicular line was drawn from thetip of the anconeal process to the pointwhere the first line intersected theanconeal process (A1 and B1). Thedistance between the tip of the anconealprocess and the first line was thenmeasured in millimeters (A2 and B2).290 DANIELSKI ET AL . 1532950x, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14061 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 Licensethe medial and lateral regions of the humeral condyle wasinterpreted as reduction of the sclerosis of the bone whilstan increased mineral density of the rectangular ROI of theHIF was interpreted as healing of the fissure.The bone density of both the medial and lateralregions of the humeral condyle was measured in thesame way on CT images of spaniel dogs with no signs ofHIF or elbow disease. A standard rectangular area on themidline was excluded from the measurements to accountfor the possible presence of an hypothetical fissure. Thisdata was used to create a baseline for normal humeralcondyle bone density.The extent of fissure healing at the last follow-up CTscan was also evaluated subjectively, and it was catego-rized into three groups based on the condition of the HIFobserved in the pre-operative images: healed, healing,and not-healing. Dogs where complete healing/bridgingof the HIF was achieved were categorized as “healed ”whilst those where enlargement of the HIF was noticedwere classified as “not-healing. ”Dogs with documentedevidence of progressive but not complete healing of theHIF were classified as “healing. ”2.5 |Statistical analysisAll statistical analyses were performed using software(SPSS version 19, August 2010, SPSS). Results wereexpressed as mean ± SD for normally distributed vari-ables. Continuous variables in the study were normallydistributed (Kolmogorov –Smirnov test p> .05). Univari-ate statistical analyses were performed to evaluate associ-ation/correlation between postoperative complicationsand categorical/continuous variables. Fisher’s exact testwas used for discrete variables (i.e., partial/complete HIFand complications). A paired t-test was used to evaluatethe difference between means before and after surgery orat the last follow-up. Independent t-test was used to eval-uate the relationship between continuous variables andcategorical variables (i.e., bodyweight and postoperativecomplications). A Kruskal –Wallis test was used to com-pare three or more independent samples and a continu-ous variable (i.e., degree of healing of the HIF aftersurgery with variables none/partial/complete fissure andweight). Pearson’s correlation was performed to assesslinear correlation between continuous variables. Statisti-cal significance was set to p< .05 (type 1 error). For sta-tistical purposes, dogs were divided into three age groups:immature dogs (0 –14 months), adult dogs (15 –95 months), and old dogs (>96 months).3|RESULTSA total of 51 elbows (35 dogs) were included in the studyand two dogs were excluded because of the lack ofFIGURE 3 The measurement of the region of interest (ROI) of the humeral condyle on coronal computed tomographic (CT) images. Arectangular ROI (mm2) was drawn on the midline of the humeral condyle to include the entirety of the hypoattenuated humeral fissure. Indogs with a complete fissure, this rectangle was extended from the caudal to the cranial aspect of the humeral condyle (A) whilst in dogs withpartial fissures, the rectangle was extended from the caudal aspect of the humeral condyle to a cranial direction until where the hypoattenuatedline of the fissure ended (B). A free-hand ROI was then drawn to measure separately the bone density of the medial humeral condyle and ofthe lateral humeral condyle next to the ROI of the fissure. The data provided by the built-in ROI tool included area (mm2), mean HounsfieldUnits (HU) (with standard deviation and sum), minimum HU recorded, maximum HU recorded, length of the drawn line (cm).DANIELSKI ET AL . 291 1532950x, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14061 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 Licensefollow-up CT images. The breeds most commonly repre-sented were English springer spaniel (24), followed bycocker spaniel (8) and cocker /C2spaniel cross (3). A totalof 29 dogs were male and six were female. Six of thesedogs were active working dogs at the time of first consul-tation. At the time of surgery, the mean weight was18.08 ± 3.8 kg (range 7 –23.6 kg) and the mean agewas 47.6 ± 27.9 months (range 5 –101 months). Twentypercent of dogs were younger than 14 months ( n=10)and 4% were older than 96 months. On preoperative clin-ical examination, 13 elbows (25.5%) had mild discomfort,23 (45.1%) had moderate discomfort, four (7.9%) hadsevere discomfort, and 11 (21.5%) had no discomfort onelbow extension. Upon the 6-week follow-up assessment,extension of the elbows resulted in the absence of dis-comfort in 48 elbows (94%), accompanied by milddiscomfort in two elbows, and moderate discomfort inanother elbow (notably, these three latter cases coincidedwith observed cartilage damage determined througharthroscopy). The follow-up CT scan assessment was per-formed at a mean 27.21 ± 8.8 months.Surgery to treat HIF had already been performed innine elbows (four elbows had a transcondylar screw onlyand four elbows had a transcondylar screw and a plateapplied). In four of these elbows an infection was present,in two elbows the implants were poorly placed, in twodogs (two elbows) significant lameness was still presentand in one elbow the implant had become loose and wasbacking out.3.1 |Arthroscopic findingsArthroscopy confirmed presence of concomitant medialcoronoid disease in 12 elbows (23.5%). Radial incisurefragmentation of the medial coronoid process was pre-sent in seven elbows, tip fragmentation in two elbowsand a combination of tip-radial incisure fragmentation infour elbows. Concomitant cartilage damage of the medialcompartment was present in 10 elbows (ranging frommodified Outerbridge grade I to grade IV). The HIF wasvisible in all but one elbow (98%). Similarly, the focal car-tilaginous lesion recently described on the caudal aspectof the humeral condyle of spaniels with HIF was seen inall but two elbows (96%).3.2 |Objective assessment outcomesOn presentation, CT examination revealed the HIF to bepartial in 24 elbows (47.1%) and complete in 27 elbows(52.9%). Objective assessment confirmed that a differencewas found between the mean HU of the HIF’s ROI onpreoperative CT images and last-follow-up images(p=.001). The same was true for the mean HU of thelateral aspect of the humeral condyle ( p=.001),the mean HU of the medial aspect of the humeral con-dyle ( p=.001), and the total mean HU of the humeralcondyle (sum of the medial and lateral aspects of the con-dyle HUs) ( p=.001). The average HU of the humeralcondyle before surgery was 1703.7 ± 294, at the lastfollow-up CT scan was 1520.7 ± 206, and in normalelbows ( n=64) was 689.5 ± 105. Data also confirmedthat young dogs have a wider fissure (HU 481 ± 221vs. HU 675 ± 177; p=.03) and less sclerosis of thehumeral condyle (HU 1386 ± 193 vs. HU 1869 ± 271;p=.001) than older dogs.A difference was also found between anconeal tip dis-placement on pre-operative CT images versus last followup images ( p=.001), and between L1 and L2 ratios onpreoperative versus 6-week follow-up radiographs(p=.001). (Table1).Objective assessment confirmed that the age of thedog was predictor of healing of the HIF (Kruskal –WallisTABLE 1 Summary of imaging assessment.Measurements Presurgical Follow-up Paired t-test ( p-value)Radiographic assessmentRatio radio ulnar length cranial (L1) 17.60 18.14 .01Ratio radio ulnar length caudal (L2) 17.68 18.31 .01CT scan assessmentHU medial aspect humeral condyle 834.80 735.12 .01HU lateral aspect humeral condyle 852.01 785.60 .01HU total condylar region 1686.89 1520.73 .01HU fissure 640.87 835.20 .01Anconeal tip displacement (mm) 2.36 3.24 .01Abbreviations: HU, Hounsfield unit; mm, millimeters.292 DANIELSKI ET AL . 1532950x, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14061 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 Licensep=.03). Dogs in the youngest group (0 –14 months) hadthe highest mean increase in HU at the level of the fis-sure (384.54 units). Dogs in the middle group (15 –96 months) had a mean increase of 156 HU, and dogs inthe oldest group (>96 months) had a mean decrease of22.9 HU.No relationship was found between the objectivehealing assessment of the fissure on CT scan and the dif-ference in L1 length ratio between pre- and post-treatment ( p=.278, or the difference in L2 length ratio(p=.233) or anconeal tip displacement ( p=.894).3.3 |Subjective assessment outcomesSubjective assessment revealed the HIF to be healed in28 elbows (54.9%), to be healing in 13 dogs (25.4%) and toFIGURE 4 Examples of good healing of the fissure achieved byperforming an oblique proximal ulna r osteotomy (PUO) (left column:preoperative computed tomographi c( C T )i m a g e s ;r i g h tc o l u m n :l a t e s tfollow-up CT images). (A) A 6-month- old english springer spaniel (ESS)(A2: 10-month follow-up). (B) A 7-month-old ESS (B2: 10-monthfollow-up). (C) A 2-year-old ESS ( C2: 18-month follow-up). (D) A 5-year and 8-month-old Cocker x Spaniel cross (D2: 20-month follow-up).(E) A 3-year and 8-month-old ES S (E2: 16-month follow-up).FIGURE 5 Examples of progressive healing of the fissureachieved after performing an oblique proximal ulnar osteotomy(PUO) (left column: preoperative computed tomographic (CT)images; right column: latest follow-up CT images). (A) A 2-year-oldcocker spaniel (A2: 24-month follow-up). (B) A 4-year-old englishspringer spaniel (ESS) (B2: 10-month follow-up). (C) An 8-month-old ESS (C2: 18-month follow-up).DANIELSKI ET AL . 293 1532950x, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14061 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 Licensebe not-healing in seven elbows (13.7%) (two elbows thatsuffered a fracture in the postoperative period were notincluded) (Figures 4–6). A nonparametric Kruskal –Wallistest confirmed a positive association between subjectiveand the objective assessment in terms of fissure heal-ing ( p=.001).Subjective assessment confirmed that there was noassociation between the healing of the HIF and weight orage of the dogs, regardless of whether the degree of heal-ing was categorized as healed, healing or nonhealing.This was determined using t-tests ( p=.786 and 0.284)and Kruskal –Wallis tests ( p=.475 and 0.183),respectively.3.4 |ComplicationsMinor complications ( n=3, 5.8%) were experienced inthree limbs and they were due to the intramedullary pinthat migrated proximally and needed to be removedunder sedation through a stab incision of the skin at the6-week follow-up appointment. A broken intramedullarypin was noted at the level of the osteotomy at the 6-weekfollow-up radiographs ( n=4). However, due to the factthe bone healing progression at the level of the osteotomywas already considered satisfactory at that stage and thatthe outcome and the postoperative care were not changedfollowing this discovery, these cases were not classified ashaving minor complications. Major complications wereencountered in five dogs (six limbs); four of these majorcomplications were related to healing of the fissure(7.8%) whilst two were related to healing of the PUO(3.9%) (Table2).Dog 1 experienced a lateral condylar fracture follow-ing a slip on a wet surface 3 months after the initialFIGURE 6 Example of poor/lack of healing of the fissure afterperforming an oblique proximal ulnar osteotomy (PUO) (leftcolumn: pre-operative computed tomographic (CT) images; rightcolumn: latest follow-up CT images). (A) A 3-year-old cockerspaniel (A2: 23-month follow-up). (B) A 6-year 5-month-old englishspringer spaniel (B2: 24-month follow-up).TABLE 2 Dogs that sustained major complications.DogType of majorcomplication Surgical treatmentDog 1 Lateral condylarfracture4.5 mm transcondylarplate and 2.7 mmSOP appliedlaterallyDog 2LeftelbowBicondylar “Y”fracture4.5 mm transcondylarscrew, 2.7 mm SOPapplied laterallyand 2.7 mm LCPapplied mediallyRightelbowPersistent intensesclerosis of thehumeral condyle andwidening of the HIFon 2nd lookarthroscopy4.5 mm transcondylarscrew and 2.7 mmLCP appliedmediallyDog 3 Lack of healing of theHIF, increased boneproduction on lateralepicondylar crest,discomfort onmanipulation3.5 mm transcondylarscrew and 2.7 mmSOP appliedlaterallyDog 4 Broken IM pin andexcessivedisplacement of theproximal ulnarsegmentPin removal,debridement ofbone ends,realignment ofulnar segments,placement of largersize IM pin, BMPapplicationDog 5 Nonunion PUO Debridement,removal of the IMpin, application ofa 2.7 mm lockingplate, bone graftand BMPAbbreviations: BMP, bone morphogenetic proteins; HIF, humeralintracondylar fissure; IM, intramedullary pin; LCP, locking compressionplate; mm, millimeters; PUO, proximal ulnar osteotomy; SOP, string ofpearls locking plate.294 DANIELSKI ET AL . 1532950x, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14061 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 Licensesurgery. Dog 2 had a follow-up CT scan performed 1 yearand 4 months after surgery which revealed almost com-plete healing of the partial fissure previously present,bilaterally. However, the owner contacted us again2 months later reporting a certain degree of stiffness(bilaterally) that was previously not present. One monthlater the dog suddenly screamed in pain and a Y-fracturewas diagnosed on radiographs. CT scan of the contralat-eral elbow was concomitantly performed, and it revealedno improvement of the degree of sclerosis of the humeralcondyle and also that, at the most caudo-proximal aspectof the humeral condyle, the fissure was mildly visibleagain. A decision to prophylactically stabilize thehumeral condyle with a transcondylar screw and a medi-ally applied plate was taken to prevent a fracture at thesame time of performing the repair of the Y-fracture.The owner of dog 3 reported persistent lameness despitea transcondylar screw having been placed elsewhere sev-eral months earlier. The screw was removed and an obli-que PUO was performed. A CT scan performed 1 yearand 9 months after the surgery revealed that the bonetunnel left by the screw was still present. It also revealedthat new bone had formed in the center of the condyle atthe level of the HIF, but that the fissure itself was stillsurprisingly visible within the newly formed bone. Thedog did not appear lame or stiff at this stage. Six monthslater, the owner started reporting occasional lamenessand a repeat CT scan confirmed the lateral epicondylarcrest to be visibly thicker and more sclerotic than what itpreviously was, suggesting presence of persistent instabil-ity. A transcondylar screw and a locking plate wereapplied to prevent fracture development.No association could be found between the variablesassessed in this study (age: p=.420 and weight:p=.984) and the development of complications or theneed for revision surgery.At the time of writing this manuscript (median timeof 30 months from when surgery was performed), allowners were contacted again either by email or by tele-phone for an update and no additional complications orproblems were reported.4

Question 17

Mann - 2023 - JAVMA - Comparison of incisional gastropexy with and without addition of two full-thickness stomach to body wall sutures.pdf

Answer 17

Medical records from the University of Missouri VHC were searched from March 2005 through April 2019 to identify client-owned dogs in which IG was performed. Included in the study were medical re -cords for dogs that had IG performed as part of GDV correction and those that had IG performed as a pro -phylactic procedure. Prophylactic gastropexy was defined as IG performed on dogs without GDV that were presented specifically for IG or dogs that were presented for abdominal surgery and the surgeon included IG as part of the procedures after determin -ing that the dog was at risk for GDV on the basis of breed or body conformation. All prophylactic IG pro -cedures were performed via celiotomy; gastropexies performed using laparoscopy were excluded from this study.Cases were grouped on the basis of surgical method (either SIG or MIG). Surgery reports were re -viewed to determine surgical method (SIG or MIG), record the suture material used for gastropexy, identify concurrent surgical procedures other than gastropexy, and identify intraoperative and post -operative complications. All complications, includ -ing comorbidities and complications unlikely to be due to gastropexy, were recorded, but obvious co -morbidities were removed for statistical analyses. Anticipated potential complications related to gas -tropexy included right abdominal wall tenderness, hematemesis, suture-related infection or abscess, fistulous tract at gastropexy site, intestinal entrap -ment, and occurrence of GDV. Particular attention was given to search for evidence of suture-related complications. The following demographic data were also retrieved from the medical record: breed, gen -der (male, castrated male, female, spayed female), and body weight to determine whether any of these factors might influence complications. Pet owner in -formation was also recorded for the purpose of con -tacting for follow-up information.Medical record information was used to evalu -ate intraoperative, postoperative, and short-term complications. Telephone follow-up or email to pet owners and/or referring veterinarians was used to identify complications (short-term and long-term) after patient discharge from the VHC. The postop -erative follow-up period was defined as the time from completion of surgery to discharge from hospi -tal. The short-term follow-up period was defined as the time from surgery to the time the dog returned to the VHC for suture removal. If the dog was not returned to the VHC for suture removal, short-term complication information was obtained during ques -tioning about long-term complications. Long-term follow-up was defined as the time from suture re -moval to the latest medical information at the time study data collection was conducted (April 2021). To identify missing short-term complication informa -tion as well as long-term complications, an online survey was emailed and direct telephone calls were made to the pet owners or referring veterinarians. The survey was used to ascertain whether the dog was alive or deceased, whether there were complica -tions related or unrelated to the gastropexy, whether the dog had recurrent gastric distention (bloating) episodes that did not require surgery, whether the dog had additional abdominal surgeries, whether the dog had a subsequent case of GDV for which sur -gery was recommended, and whether that surgery was performed or declined.Statistical analysisData were assembled in a spreadsheet, and dogs were assigned to different groups. Dogs were matched by primary surgical intervention and wheth -er they had SIG or MIG. Six matched groupings were Figure 1 —Flow chart of case selection for dogs that had either a standard incisional gastropexy (SIG) or a modified incisional gastropexy (MIG) from March 2005 through April 2019. There were 40 cases initially exclud -ed due to insufficient data in the medical records.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 08/30/23 11:58 AM UTC JAVMA | SEPTEMBER 2023 | VOL 261 | NO. 9 1353constructed: (1) gastropexy for GDV, (2) prophy -lactic gastropexy without other procedures, (3) gastropexy with ovariohysterectomy, (4) gastro -pexy with castration, (5) gastropexy with splenec -tomy, and (6) gastropexy with celiotomy other than splenectomy. Due to the low rate of complications within groupings and the small number of compli -cations that could be potentially attributed to the gastropexy procedure, meaningful statistical compari -sons could not be made and are thus not reported. For cases with complications that could potential -ly be attributed to the gastropexy procedure, the overall complication rates between SIG and MIG were compared using the Fisher exact test with significance set at P ≤ .05. Similarly, overall rates of complications not attributed to the gastropexy procedure were compared between SIG and MIG using the χ2 test with significance set at P ≤ .05. No. of No. of Breed or type SIG cases MIG cases Complication potentially attributed to gastropexyLabrador Retriever 69 6 Fever of unknown origin (SIG) – postoperative period (1)Great Dane 55 5 German Shepherd Dog 34 5 Mixed breed 32 5 Painful (SIG) – short-term (1)Golden Retriever 14 0 Standard Poodle 11 2 Regurgitation (SIG) – long-term (1); undescribed digestive issue (SIG) – long-term (1)Unknown breed 11 1 Mastiff 6 2 Bloodhound 5 0 Boxer 5 1 Rottweiler 5 1 Regurgitation (SIG) – short-term (1)Bernese Mountain Dog 5 1 Doberman Pinscher 4 2 Celiotomy 2 mo after gastropexy unknown reason (MIG) – long-term (1)Newfoundland 4 1 Alaskan Malamute 3 0 Belgian Malinois 3 0 Golden Retriever–Poodle cross 3 0 Greyhound 3 0 Irish Wolfhound 3 0 Saint Bernard 3 2 Weimaraner 3 0 American Staffordshire Terrier 2 0 Australian Cattle Dog 2 0 Chesapeake Bay Retriever 2 0 Coonhound 2 0 German Shorthaired Pointer 2 0 Labrador mix 2 0 Great Pyrenees 2 0 Rhodesian Ridgeback 2 0 Swiss Mountain Dog 2 0 Basset Hound 1 0 Bouvier des Flandres 1 0 Cane Corso 1 0 Collie 1 1 Dalmatian 1 0 Dogue de Bordeaux 1 0 English Mastiff 1 0 English Springer Spaniel 1 0 Fila Brasileiro 1 0 French Bulldog 1 1 Great Pyrenees mix 1 0 Hovawart 1 0 Old English Sheepdog 1 0 Pointer 1 0 Pointer mix 1 0 Poodle mix 1 0 Shar Pei 1 0 Siberian Husky 1 0 Vizsla 1 0 Akita 0 1 Mild inappetence and vomiting (MIG) – long-term (1)Australian Shepherd 0 1 Bulldog 0 1 Chow 0 1 Table 1 —Dog breeds or types that had either standard incisional gastropexy (SIG) or modified incisional gastropexy (MIG), including which breeds had complications potentially attributed to gastropexy.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 08/30/23 11:58 AM UTC1354 JAVMA | SEPTEMBER 2023 | VOL 261 | NO. 9ResultsOn the basis of review of available medical re -cords, there were 388 cases that had IG performed from March 2005 to April 2019. Of these cases, 40 did not have the IG method (SIG or MIG) indicated in the medical record, 307 had SIG (polypropylene, n = 22; polydioxanone, 285) and 41 had MIG performed (polypropylene, n = 18; polydioxanone, 23). One of the MIG cases was eliminated from the study because the dog died 5 hours after surgery for GDV due to deteriorating condition, and therefore this dog had no postoperative, short-term, or long-term data for comparison. Of the remaining 347 cases, 129 owners (SIG, n = 101; MIG, 28) participated in the follow-up questionnaire by either online survey or telephone call. Intraoperative and postoperative data were avail -able for all 307 SIG and 40 MIG cases. Short-term fol -low-up (SIG median follow-up period, 12 days; range, 1 to 36 days; MIG median follow-up period, 10 days; range, 3 to 18 days) was available for 133 SIG cases and 35 MIG cases. Long-term follow-up (SIG median follow-up period, 1,161 days; range, 58 to 4,648 days; MIG median follow-up period, 1,855 days; range, 832 to 3,723 days) was available for 129 SIG cases and 29 MIG cases (Figure 1) . The median (range) body weights were 33.4 kg (5.7 to 86.6 kg) for SIG and 29.8 kg (9.6 to 75.8 kg) for MIG. There were 47 dog breeds represented (Table 1) .There were no occurrences of GDV in either group after SIG or MIG. There were 7 dogs that had complica -tions potentially attributable to the gastropexy proce -dure; 5 were in the SIG group and 2 were in the MIG group ( P = .407; power 0.131). None of these 7 dogs had more than 1 complication that could be poten -tially attributed to the gastropexy procedure. During postoperative hospitalization, 1 SIG dog had a fever of unknown origin. On short-term follow-up, one SIG dog was painful for 3 days after surgery and another SIG dog experienced regurgitation for 2 days postopera -tively; 1 MIG dog had decreased appetite and vomit -ing. On long-term follow-up, one SIG dog had frequent regurgitation and another SIG dog had an undescribed digestive issue; 1 MIG dog had an exploratory celioto -my performed 2 months after gastropexy for gastroto -my and enterotomy for unknown reasons. The median (range) body weight for the 5 SIG dogs was 26.7 kg (23.5 to 36.8 kg); the 2 MIG dogs weighed 31.2 and 31.5 kg. All dogs that had complications potentially attributed to gastropexy had gastropexy performed with polydioxanone except for the MIG dog that had inappetence and vomiting at the short-term but not the long-term follow-up. There were 38 dogs that had complications not attributed to the gastropexy proce -dure (Table 2) ; 35 were in the SIG group and 3 were in the MIG group ( P = .636; power 0.076). Complications within matched groupings were too few for statistical analysis (Supplementary Tables S1–S4) .There were 11 dogs with comorbidities. One dog in the MIG group had intraoperative atrial fi -brillation, and dilated cardiomyopathy was diag -nosed at the short-term follow-up. Among the 11 dogs with comorbidities, short-term follow-up data were available for 10 dogs and long-term follow-up data were available for 7 dogs. None of these dogs experienced gastropexy-related complications, al -though 1 dog with hypertension and kidney disease required a feeding tube for 1 to 2 months to address trouble eating.

Question 18

Adair - 2023 - VETSURG - Retrospective comparison of modified percutaneous cystolithotomy (PCCLm) and traditional open cystotomy (OC) in dogs - 218 cases (2010-2019).pdf

Answer 18

2.1 |Case selection criteriaThe medical records of dogs undergoing PCCLm and OCbetween 2010 and 2019 at an academic referral hospitalwere retrospectively reviewed. Dogs were included in thestudy if they underwent either OC or PCCLm during thestudy period and a minimum of 14 days follow-up postop-eratively was available. Dogs undergoing documentedminor surgical procedures concurrently were includedalthough statistical analyses were altered for those cases.Dogs undergoing concurrent major surgical proceduresand those with no information in anesthetic, surgical, andhospitalization records were excluded from the study.2.2 |Medical records reviewThe perioperative period was defined as the time fromadmission to the hospital until anesthetic recovery, post-operative period was defined as the time from anestheticrecovery until discharge from the hospital, and rechecktime frames were classified as short-term ( ≤14 days fromdischarge), intermediate-term (>14 days and <6 monthsfrom discharge), and long-term ( ≥6 months from dis-charge). The time of last follow-up was calculated fromthe date of surgery and was obtained from the medicalrecord or via referring veterinarian communication.Information obtained from the medical records includedhistory; signalment; physical exam findings; preoperativediagnostics (diagnostic imaging, hematology, serum bio-chemistry profile, urinalyses, urine culture); surgicaltechnique and concurrent additional procedures; anes-thetic and surgery times; conversion of PCCLm to OC(if applicable) and intraoperative complications; postop-erative diagnostics, complications, and care; and follow-up data. Azotemia was defined as creatinine values in themedical record >1.4 mg/dl and further classified as mild(1.4–2.8 mg/dl) moderate (2.9 –5.0 mg/dl), and severe(>5 mg/dl) based on the International Renal InterestSociety (IRIS) scoring system.18Clinical signs and com-plications were documented based on notation in themedical record and categorized using a standardizedcomplication scheme.19Complications were graded asfollows: grade 1: mild; asymptomatic or mild symptoms,clinical signs or diagnostic observation only, and inter-vention not indicated; grade 2: moderate; outpatient ornon-invasive intervention indicated; grade 3: severe ormedically significant but not immediately life threaten-ing; hospitalization or prolongation of hospitalizationindicated; grade 4: life-threatening consequences andurgent interventions indicated; grade 5: death related toevent defined as either euthanasia or natural death.19Duration of hospitalization was defined as the time(hours) following anesthetic recovery to discharge fromthe hospital. If patients were discharged from the hospitalimmediately after full recovery from general anesthesia,the hospitalization time was recorded as zero. Surgicalsite infection and inflammation (SSII) was identifiedfrom the medical record using previously publishedguidelines.5,20This included presence of any of the fol-lowing: purulent or seropurulent discharge, spontaneous898 ADAIR ET AL . 1532950x, 2023, 6, dehiscence or abscess of incision, microbial organismsidentified, or incision deliberately opened in combinationwith at least one of the following: localized swelling,pain, erythema or fever (>39/C14C).20The SSIIs were notfurther classified as superficial, deep or organ-related, aspreviously reported, due to the retrospective nature of thestudy, reliance of medical records from various veterinaryclinics, and concern for introduction of bias.2.3 |Surgical techniqueThe surgical team for all PCCLm procedures included anACVIM diplomate and an ACVS diplomate with respec-tive residents. The ACVIM diplomate assisted and guidedthe set-up and technique of the cystoscopic portion of theprocedure. All cystotomy procedures were performed byeither an ACVS diplomate or surgical resident. The surgi-cal procedure elected for each patient was determinedbased on clinician preference. Dogs were anesthetizedaccording to the preference of the attending anesthesiolo-gist. Following anesthetic induction, patients were placedin dorsal recumbency, and the ventral abdomen wasaseptically prepared. Depending on the sex of the patient,either the prepuce or vulva were aseptically prepared andincluded in the surgical field.2.4 |Open cystotomyThe incision for OC varied depending on clinician prefer-ence and concurrent procedures performed, but includeda ventral midline laparotomy in all cases but with a para-preputial skin and subcutaneous incision in male dogs.Although the OC procedures were not standardized dueto the retrospective nature of the study, all proceduresinvolved placement of stay sutures within the urinarybladder wall, a ventral midline cystotomy, removal ofuroliths, normograde and retrograde (also performed infemale dogs during the surgical procedure with the vulvadraped into the surgical site) saline flushing with a trans-urethral catheter to investigate for remaining uroliths,closure of the urinary bladder wall in a single layer sim-ple continuous suture pattern with monofilament absorb-able suture, subsequent testing for incisional leakage,and a standard, multilayer laparotomy closure.2.5 |Percutaneous cystolithotomy(modified)This procedure was performed similar to the PCCL pro-posed by Runge et al. with a modification of suturing thebladder to the body wall as described below.15For allPCCLm procedures, the intent was for an approximate 2 –2.5 cm skin incision made parapreputial in male dogsand ventral midline over the palpable urinary bladder infemale dogs. If the urinary bladder was not palpable, atransurethral catheter of varying sizes was placed retro-grade to allow for bladder distension. The linea alba wasincised on midline, and the urinary bladder apex wasgrasped and retracted to the body wall with tissue forcepsor a stay suture. Two simple continuous suture lines wereperformed between the urinary bladder wall and bothsides of the body wall, beginning apically and extendingtowards the bladder neck, to create a seal and preventurine contamination of the abdominal cavity. A stab inci-sion was made into the urinary bladder to allow introduc-tion of a 2.7 mm, 30-degree, 18 cm rigid cystoscope withincluded sheath (Karl Storz, Tuttlingen, Germany). Thecystoscope and sheath, to allow for ingress and egress,were introduced with or without placement of a cannulainto the stab incision depending on clinician preference.Uroliths were retrieved using an endoscopic basketinserted through the cystoscope under visualization. Theurethra was flushed with sterile saline in a retrograde (alsoperformed in female dogs during the surgical procedurewith the vulva draped into the surgical site) and normo-grade fashion, the urethra was examined normograde asfar as safely accessed by the cystoscope, and any additionaluroliths were removed. The urinary bladder was closedroutinely in a single layer simple continuous pattern withmonofilament absorbable suture, and subsequently thetwo continuous suture lines apposing bladder to body wallwere removed. Based on clinician preference, the urinarybladder was leak checked. The caudal laparotomy wasclosed in a standard multi-layer technique.2.6 |Postoperative management andfollow-upPostoperative radiographs obtained immediately after pro-cedures and prior to recovery from anesthesia werereviewed. Incomplete urolith removal was defined as uro-liths or mineralizations visualized or noted in the radiologyreport. Removal of persistent uroliths was determined bythe attending clinician based on risk of urinary obstruction.Analgesia was provided at the discretion of the attendingclinician during hospitalization and for hospital discharge.2.7 |Statistical analysisDescriptive statistics were calculated. Normally distrib-uted data are presented as mean ± SD, and non-normallyADAIR ET AL . 899 1532950x, 2023, 6, distributed data are expressed as median and range. Cate-gorical data are expressed as frequencies. Logistic regres-sion analysis was used to evaluate the effects ofpreviously noted clinical indicators (i.e., signalment; his-tory; surgical, anesthetic, and diagnostic findings andtimes; perioperative, postoperative, short-, intermediate-,and long-term follow-up clinical signs and complications)on the binary outcome variables including uroliths pre-sent on postoperative radiographs, requirement of returnto surgery to remove persistent uroliths, SSII within14 days, and urolith recurrence within both the OC andPCCLm groups. Cases which had another procedure per-formed were excluded from analysis for effects of anes-thesia and surgery time on the outcome variables withinthe PCCLm and OC groups. Urolith recurrence wasrecorded but not included in statistical analysis due toinconsistent follow-up information. Additionally, twosample t-tests and logistic regression analysis were usedto evaluate for significant differences between thePCCLm and OC groups for numeric and categoricalTABLE 1 Preoperative and historical variables in dogs ( n=218) undergoing surgical removal of uroliths via OC ( n=87) versusPCCLm ( n=131)Variable OC group PCCLm group p-valueMean age (months) 96.1 ± 43.6 108.8 ± 39.9 .045aMedian weight (kg) 7.8 (1.9 –49.8) 7.6 (2.2 –65) .593Sex <.001aCastrated male 47 (54.0%) 111 (84.7%)Intact male 14 (16.1%) 9 (6.9%)Spayed female 25 (28.7%) 11 (8.4%)Intact female 1 (1.1%) 0%Presenting clinical signsLower urinary tract signs 24 (27.6%) 71 (54.2%) <.001aUrinary obstruction 24 (27.6%) 20 (15.3%) .029aAsymptomatic 20 (23.0%) 24 (18.3%) .402Duration of clinical signs (months) 0.25 (0.03 –24) 1 (0.03 –36) <.001aPrevious history of urolithiasis 24 (27.6%) 45 (34.4%) .321Previous cystotomy for urolithiasis 29/70 (41.4%)b39/129 (30.2%)b.113Physical exam abnormalitiesTense abdomen 32 (36.8%) 17 (13.0%) <.001aLarge, firm urinary bladder 11 (12.6%) 5 (3.8%) .022aOverweight or obese 4 (4.6%) 22 (16.8%) .012aUrolith number classification Number in group out of 85bNumber in group out of 117b1–10 uroliths 35 (41.2%) 58 (49.6%) .23910–20 uroliths 12 (14.1%) 9 (7.7%) .147Too numerous to count uroliths 38 (44.7%) 51 (43.6%) .875No uroliths noted 0 (0%) 0 (0%) NAUrolith size classificationcNumber in group out of 85bNumber in group out of 117b<5 mm 56 (65.9%) 62 (53%) .011a6–15 mm 41 (47.1%) 35 (29.9%) .002a>15 mm 8 (9.4%) 4 (3.4%) .059Unable to determine 9 (10.6%) 57 (48.7%) <.001aNote: Variables that contain less than the total number of dogs are specified in the Table. p< .05 was considered statistically significant. p-values included arebased on analysis of comparison between the OC and PCCLm groups.Abbreviations: NA, not applicable; OC, open cystotomy; PCCLm, percutaneous cystolithotomy modified.aDenotes significant variables between the OC and PCCLm groups.bIf denominator is included it varies from group total; not every patient had this information known or diagnostic performed.cDenotes that stones could be classified in more than one group if varying sizes existed.900 ADAIR ET AL . 1532950x, 2023, 6, variables, respectively. Cases with additional proceduresperformed in both PCCLm and OC groups were excludedfrom the analyses to determine significant differencesbetween the PCCLm and OC groups for the followingvariables: anesthesia and surgery times, SSII within14 days, opioid administration, and hospitalizationlength. For t-tests, diagnostic analyses for linear modelassumptions were conducted on residuals and rank datatransformation was applied when non-normality andunequal variance were detected. Significance was identi-fied at ≤0.05 level. All analyses were conducted in SAS6.4for Windows 64 /C2(SAS Institute).3|RESULTS3.1 |Study populationA total of 218 dogs were enrolled in this study. Signal-ment and other group characteristics are listed inTable 1. The PCCLm procedure was performed in 60.1%(131/218) of dogs and the OC procedure was performedin 39.9% (87/218) of dogs. The most commonly repre-sented dog breeds included: mixed breed dog ( n=33),Miniature Schnauzer (26), Yorkshire terrier (25), ShihTzu (18), Bichon Frise (10), Miniature Poodle (10), Chi-huahua (10), Jack Russel Terrier (7), Pomeranian (7),Dachshund (6), and Pug (6), and multiple breeds repre-senting various small or toy breeds (32), various largebreeds (27), and a mastiff breed (1). Dogs in the PCCLmgroup were significantly more likely to be older and malecompared to the OC group (Table 1).3.2 |Preoperative dataTable 1contains preoperative information evaluated inboth the PCCLm and OC groups, including historyrelated to urolithiasis, clinical signs with duration, physi-cal exam abnormalities, and radiographic findings of uro-lith number and size. Dogs in the PCCLm group weresignificantly more likely compared to the OC group tohave lower urinary tract signs on presentation; a longerduration of clinical signs; and to be classified as obese onphysical exam; and these dogs were significantly lesslikely compared to the OC group to present with urinaryobstruction and to have a tense abdomen or large, firmurinary bladder on palpation of the abdomen (Table 1).Abdominal radiographs were performed in 89.3%(117/131) of PCCLm and 91.9% (80/87) of OC dogs, andabdominal ultrasound was performed in 28.2% (37/131)of PCCLm and 40.2% (35/87) of OC dogs. Some dogs hadboth ultrasound and abdominal radiographs diagnosticsperformed in their clinical database, and some dogs hadimaging performed at the referring veterinarian outsideof the presenting timeframe of the study so were classi-fied as no current diagnostic imaging. Uroliths werenoted within the urethra in 23.0% (20/87) of OC groupdogs, including 62.5% (15/24) of dogs presenting with uri-nary obstruction and 63.6% (7/11) of dogs with a large,firm bladder on physical examination. Uroliths werenoted within the urethra in 8.4% (11/131) of PCCLmgroup dogs, including 50.0% (10/20) of dogs presentingwith urinary obstruction and 40% (2/5) of dogs presentingwith a large, firm bladder on presentation. Dogs in thePCCLm group were significantly more likely comparedto the OC group to have urolith size that was unable tobe determined, and these dogs were significantly lesslikely compared to the OC group to have uroliths sizes<5 mm and 6 –15 mm. (Table 1).Table 2details the blood and urinalysis findings inthe PCCLm and OC groups; note that not all dogs had allanalyses performed. In the PCCLm group, azotemia waspresent and classified as mild in 6.1% (7/115) and moder-ate in 0.8% (1/115) of dogs. In the OC group, azotemiawas present and classified as mild in 2.5% (2/81), moder-ate in 1.2% (1/81), and severe in 2.5% (2/81) of dogs.3.3 |Surgical dataThe total conversion rate of PCCLm to OC was 3.8%(5/131). Four cases of conversion were due to too numer-ous stones and difficulty retrieving them with the cysto-scope. The remaining conversion was due to extensivehemorrhage of the spleen following laceration upon entryinto the abdomen. In the OC group, 12.1% (13/107) ofdogs received a lumbosacral epidural, with 3/13 of thosecases undergoing the OC procedure alone, while no casesin the PCCLm group received an epidural. Statisticalcomparison of frequency of epidurals between PCCLmand OC groups without any additional procedures per-formed, was not performed due to small case numbers ineach group. Additional procedures were performed con-current to the PCCLm or OC procedure in 13.0% (17/131)and 62.1% (54/87), respectively. More than one additionalprocedure was performed in some patients. The addi-tional procedures in the PCCLm group included: cas-tration (3), small dermal mass excision (3), normogradecystourethroscopy of the entire urethra (3), and 1 caseeach of the following: scrotal ablation, liver biopsy,gallbladder aspirate, lithotripsy, unrelated radiographs,oral mass excision, umbilical hernia removal, JacksonPratt drain placement in the subcutaneous tissue dueto infected previous cystotomy incision from 4 daysprior to PCCLm, gastropexy, episioplasty, and upperADAIR ET AL . 901 1532950x, 2023, 6, gastrointestinal endoscopy. In the OC group, additionalprocedures included: liver biopsy (20), castration (8),scrotal urethrostomy (7), episioplasty or episiotomy (5),splenectomy (5), ovariohyst erectomy (3), lipoma exci-sion (2), rhinoplasty (2), intestinal biopsy (2), gastrot-omy (2), gastropexy (2), normograde cystoscopy (2),TABLE 2 Preoperative blood analytes and urinalysis variables for the patients undergoing the PCCLm procedure ( n=131) and OCprocedure ( n=87)VariableNo. dogs documentedin PCCLm group PCCLmNo. dogs documentedin OC group Cystotomy Reference rangesBUN (mg/dl) 127 18 (2 –90) 100 20 (2 –237) 7 –37Creatinine (mg/dl) 108 0.9 (0.4 –3.5) 100 0.8 (0.4 –12) 0.3 –1.1Potassium (mEq/l) 123 4.1 (3.1 –5.7) 99 4.1 (2.9 –8.2) 2.8 –4.7Glucose (mg/dl) 139 110 (50 –507) 102 109 (44 –255) 82 –132PCV (%) 144 50 (32 –65) 105 46 (22 –65) 40.5 –59.9TS (g/dl) 127 7 (4.2 –10) 97 7.2 (3.8 –9.5) 5.6 –7.6USG 111 1.025 ± 0.0113 63 1.026 ± 0.0096 1.015 –1.045aUrine pH 114 6.88 (5 –9) 65 6.75 (5 –8.9) 5 –9Note: Values presented as median (range) due to non-normal distribution or mean ± SD due to normal distribution.Abbreviations: BUN, blood urea nitrogen; No., number; OC, open cystotomy; PCCLm, percutaneous cystolithotomy modified; PCV, packed cell volume; T S,total solids; USG, urine specific gravity.aValues obtained from IRIS scoring.TABLE 3 Surgical and postoperative hospitalization variables in dogs ( n=218) undergoing surgical removal of uroliths via OC ( n=87)versus PCCLm ( n=131)Variables OC group PCCLm group p-valueConcurrent procedure performed with eitherOC or PCCLm54/87 (62.1%) 17/131 (13.0%) <.001aAnesthesia time (min)b120 (60 –230) 97.5 (50 –255) <.001aSurgery time (min)b55 (30 –120) 60 (25 –170) .680Length of skin incision (cm) 9 (2 –30) 2.5 (0.33 –7.5) <.001aLength of hospitalization (h)b18 (0 –40) 0 (0 –29) <.001aIntraoperative complications related toprocedure3/87 (3.4%) 29/131 (22.1%) .021aIncomplete urolith removal 12/60 (20%) 14/123 (11.4%) .112Patients returned to surgery followingincomplete urolith removal1/12 (8.3%) 1/14 (7.1%) .619NSAID administration postoperatively 51/87 (58.6%) 116/131 (88.5%) <.001aLower urinary tract clinical signs immediatelypostoperative53/87 (60.9%) 17/131 (13.0%) <.001aCalcium oxalate urolith composition 45.7% (37/81) 74% (94/127) <.001aMixed or other urolith composition 28.4% (23/81) 15.7% (20/127) .031aUrate urolith composition 8.6% (7/81) 3.9% (5/127) .168Struvite urolith composition 11.1% (9/81) 3.1% (4/127) .031aCystine urolith composition 4.9% (4/81) 2.3% (3/127) .327Note: Numeric variables are presented as median (range) due to non-normal distribution. Categorical variables are presented as frequencies and percent ages.p< .05 was considered statistically significant. p-values included are based on analysis of comparison between the OC and PCCLm groups.Abbreviations: NSAID, nonsteroidal anti-inflammatory; OC, open cystotomy; PCCLm, percutaneous cystolithotomy modified.aDenotes significant variables between the OC and PCCLm groups.bIndicates that cases with additional procedures performed were excluded from analysis.902 ADAIR ET AL . 1532950x, 2023, 6, cryptorchid castration (2), and one case each of the fol-lowing: prescrotal urethrotomy, gallbladder aspiration,femoral and head and neck ostectomy, scrotal ablation,arytenoid lateralization, minor dermal mass excision,nasal planum biopsy, mandibular fracture repair, sia-loadenectomy, liver lobectomy, lip mass excision, andabdominal Jackson Pratt drain placement as precautionfor uroperitoneum follow ing cystotomy 3 days priorrequiring revision.Table 3contains surgical variables evaluated in boththe PCCLm and OC groups including anesthesia and sur-gery times (analysis of only cases in which no additionalprocedures performed), skin incision length, and fre-quency of intraoperative complications. Dogs in thePCCLm group were significantly more likely comparedto the OC group to have a shorter anesthesia time; moreintraoperative complications; and a shorter incisionlength; and these dogs were significantly less likely com-pared to the OC group to have additional proceduresperformed at the time of surgery (Table 3). When usingthe standardized complication scheme outlined previ-ously, intraoperative complications in the both groupswere graded based on severity in Table 4.3.4 |Immediate postoperative dataImmediate postoperative radiographs were performed in93.9% (123/131) and 69.0% (60/87) of dogs in the PCCLmand OC groups, respectively, at the discretion of the clini-cian. In the total of 35 dogs in both groups in which nopostoperative radiographs were performed, 45.7% (16/35)had 1 –10 uroliths preoperatively, 21.4% (11/35) had toonumerous to count uroliths, 17.1% (6/35) had uroliths>6 mm in size, and 5.7% (2/35) had 10 –20 uroliths preop-eratively. The medical records identified no definitivereason as to why eight dogs in the PCCLm group and27 dogs in the OC group did not have postoperativeTABLE 4 Intra- and postoperative complication data in dogs undergoing surgical removal of uroliths via PCCLm ( n=131) versusOC ( n=87)Grade 1 Grade 2 Grade 3 Grade 4 Grade 5Intraoperative complicationsPCCLm (29/131 dogs)Incision extended ( n=11) 1 9 1PCCLm converted to OC ( n=5) 5Damage to bladder due to approach ( n=4) 3 1Hemorrhage or vascular trauma ( n=3) 1 1 1Other organ trauma ( n=2) 1 1Stones flushed into subcutaneous tissue ( n=1) 1Stones too large to remove with cystoscope(n=1)1Anemia requiring blood transfusion ( n=1) 1Foreign material introduced into bladder ( n=1) 1OC (3/87 dogs)No stones found at surgery ( n=2) 2Other organ trauma ( n=1) 1Postoperative complicationsPCCLm (17/131 dogs)Lower urinary tract signs (stranguria, pollakiuria,hematuria) ( n=17)17aOC (53/87 dogs)Lower urinary tract signs (stranguria, pollakiuria,hematuria) ( n=53)53aNote: Complication scheme based on LeBlanc et al. 2020. Values presented as number of dogs documented in each grading group.Abbreviations: OC, open cystotomy; PCCLm, percutaneous cystolithotomy modified.aIndicates that grading was unable to be performed in these categories due to information available in medical record but can extrapolate that thesecomplications were all

Question 19

Cortina - 2023 - VETSURG - Outcomes and complications of a modified tibial tuberosity transposition technique in the treatment of medial patellar luxation in dogs.pdf

Answer 19

2.1 |Case selectionThe medical records for all cases of medial patellar luxa-tion treated by a single surgeon (RMD) from 2005 to 2018were reviewed retrospectively. Canine stifles that hadundergone m-TTT for MPL treatment, diagnosed basedon physical examination and radiographs, were includedin this study. Surgery was recommended for patients withfrequently observed lameness and pain on examination,associated with palpable patellar luxation. Procedureswere performed at the discretion of the attending sur-geon, based on radiographic examination and intraopera-tive assessment. Stifles were excluded from this study ifthe medical records were incomplete, if dogs had con-comitant cranial cruciate ligament (CCL) tear or femoraldeformity requiring corrective ostectomy, if no m-TTTwas performed, or if no follow-up data were available.2.2 |Data collected from medicalrecordsData collated from medical records included signalment,body weight, preoperative and postoperative lamenessscores, luxation grade, unilateral versus bilateral luxa-tion, and lameness duration. Surgical details, includingwhether procedures were unilateral, staged bilateral, orsingle-session bilateral, were recorded. The specific pro-cedures performed were also recorded, including troch-lear block recession, m-TTT, medial fascial release, andlateral fascial imbrication. All intraoperative and postop-erative complications were retrieved from medicalrecords and were classified as defined by Cook et al.172.3 |Surgical treatmentAll dogs were premedicated with hydromorphone, withor without the addition of dexmedetomidine, based onexamination, laboratory testing, and history. Anesthesiawas induced with a combination of diazepam and propo-fol to effect. All dogs received cefazolin sodium at least30 min before incision, and then every 90 min until skinclosure was completed. Anesthesia was maintained usingisoflurane in 100% oxygen. All dogs received epiduralanalgesia using preservative-free morphine and bupiva-caine. Orthogonal radiographs of the affected stifle wereperformed for preoperative evaluation and surgicalplanning.A single board-certified surgeon performed all surger-ies. Surgery was initiated by a lateral parapatellarapproach to the stifle. Intra-articular pathology was eval-uated by craniolateral arthrotomy. The trochlear groovewas visually assessed for patellar depth and patellar artic-ular contact with the proximal trochlea. If the groove wastoo shallow and narrow, so that more than 50% of thepatella protruded above the trochlear ridges, it wasCORTINA ET AL . 757 1532950x, 2023, 5, deepened by trochlear block recession. The TT was thennearly completely osteotomized, either by manually rock-ing the osteotome from side to side in toy breed dogs, orwith the use of a mallet, with the intention of with theintention of preserving the distal bone and soft tissueattachments. The osteotomized segment was then later-ally transposed.Once tracking was satisfactory, a single Steinman pin ofappropriate width was placed in the sagittal plane, perpen-dicular to the long axis of the tibia, entering the cut surfaceof the tibia immediately media l to the transposed tuberosity(Figure1A). This relatively large diameter pin held theosteotomized TT in the lateralized position. The pins ran-ged from 2.0 mm (5/64 in) to 2.8 mm (7/64 in) in size.Once lodged firmly in the tibia’s caudal cortex, thislarge pin was cut slightly above the cut surface of thetibia, and even with the cranial surface of the TT to mini-mize soft-tissue irritation. A single Kirschner wire wasthen placed at the most distal point of insertion of thepatellar ligament, as centrally as possible in the osteoto-mized TT. It was angled perpendicular to the tibial longaxis and was directed somewhat medially, to ensure pen-etration of the osteotomized surface of the tibia, finallylodging in the caudomedial cortex of the proximal tibia(Figure1B) near the larger transposition pin. Kirschnerwire sizes ranged from 0.9 mm (0.035 in) to 1.6 mm(0.062 in), and they were selected according to bone anddog size. All fixation pins were intended to engage deeplyin the trans(caudomedial) cortex of the tibia. They wereplaced using a hand chuck in smaller dogs and an ortho-pedic drill in larger dogs.A modified tension-band wire was placed to completethe TTT (Figure1C). Using a Kirschner wire, in either ahand chuck or an orthopedic drill, an appropriately sizedtransverse tunnel was created in the nonosteotomizedportion of the tibial crest at the proximodistal midpointof the osteotomy line. This tunnel was made 1/3 to 1/2 ofthe distance from the cut tibial surface to the caudal tibialcortical surface. An appropriately sized cerclage wire waspassed through the transverse tunnel and then proxi-mally around the Kirschner wire and Steinman pinbefore being tightened lateral to the tibial crest. The cerc-lage wire twist was rotated to be even with the craniolat-eral surface of the tibia and cut. The TT Kirschner wirewas then cut as even as possible with the cranial surfaceof the encircling wire to minimize chafing of the overly-ing soft tissues (Figure1D). It was important to seat theKirschner wire deeply into the trans(caudomedial) cor-tex, since the Kirschner wire was cut using wire cutters,without bending the kirschner wire. The cerclage wirediameter ranged from 0.6 mm (22 gauge), for small tomedium-sized dogs, to 1.2 mm (16 gauge), for giant-breeddogs. Weight categories were based on definitions byBound et al.4for small (<9 kg), medium (9.1 –18.2 kg),large (18.3 –36.4 kg), and giant breed dogs (>36.5 kg).When necessary, a medial fascial release was per-formed to allow reduction of the patella. The lateral fas-cia was partially resected and imbricated. In all cases,fascial closure was performed using a modified Mayomattress pattern, which resulted in an overlap of the jux-tapatellar fascia superficial to the caudolateral thigh fas-cia. Subcutaneous tissue and skin were closed routinely,using buried subcuticular skin sutures. Many dogs laterin the series received liposomal encapsulated bupivacainelocal anesthetic infused in layers during closure (Nocita;Elanco Animal Health, Greenfield, Indiana). Postopera-tive orthogonal stifle radiographs were obtained to docu-ment implant placement and alignment (Figure2).2.4 |Postoperative managementAfter recovery from anesthesia, dogs were monitoredovernight. They were discharged within 24 h of surgeryFIGURE 1 Intraoperative photographs of a dog treated for medial patellar luxation using a modified tibial tuberosity transpositiontechnique. The four major steps are illustrated: (A) Placement of a large pin to hold the transposed tibial tuberosity in place. (B) Placementof the Kirschner wire at the point of insertion of the patellar ligament. (C) Tension band placement. (D) Completed construct.758 CORTINA ET AL . 1532950x, 2023, 5, with instructions for administration of either tramadol orgabapentin for 14 days, in addition to an oral nonsteroi-dal anti-inflammatory drug, if not contraindicated. Thepostoperative use of oral cephalexin antibiotic was ran-domly assigned in later cases, as an ongoing, unrelated,long-term prospective clinical study, which revealed thatsurgical site infection (SSI) rates were unaffected by post-operative antibiotic prophylaxis.At discharge, owners were instructed on activityrestriction. Briefly, patients were restricted to a leash,cage, or small room, and gaits faster than a walk had tobe prevented for 6 weeks. They were restricted from play-ing or jumping onto or off of furniture. At 2 weeks post-operatively, they were allowed progressively longer leashwalks starting at 5 min and increasing to 20 min, up tothree times daily. They were re-evaluated at 6 weekspostoperatively.2.5 |Follow upData collected from re-examinations were organized intothe perioperative, short term, mid term, and long termtime frames as defined by Cook et al.17Current guide-lines state that SSIs can occur up to 90 days postopera-tively, which falls outside the scheduled recheck period.Dogs in this study were re-evaluated by a veterinarian atweeks 2 and 6 postoperatively, as part of routine postop-erative recommendations. Data collected at that timeincluded: incision healing, comfort, degree of lameness,evidence of patellar reluxation, current medications, andowner’s perception of limb function. Diagnosis of SSI wasbased on the presence of heat, swelling, erythema, orpurulent discharge around the incision. Suspected infec-tions were cultured to confirm the diagnosis, and antimicro-bials were prescribed based on culture and sensitivityresults. Veterinarians assigned lameness scores rangingfrom 0/4 to 4/4, using the lameness scoring systemdescribed by Barnhart et al.18Additional data were collectedat 6 weeks postoperatively, in cluding radiographic evalua-tion of bone healing and implan t stability, or complications.Presence of patellar desmitis was recorded and defined asthickening of the distal patellar ligament that could be sub-jectively visualized on a mediolateral radiograph.Mid-term to long-term follow up consisted of a retro-spective review of any additional orthopedic examina-tions, with or without radiographs, documented orprovided by primary care veterinarians or at our facility.Owner satisfaction surveys were also utilized and mod-eled on the Canine Brief Pain Inventory Questionnaire(CBPI) with augmented wording in the case of a deceaseddog (CBPI-D) (Appendices S1 and S2).2.6 |Statistical analysisDescriptive statistics (means) were used to evaluate thedata. Statistics were described as percentages of the num-ber of stifles operated. Outcomes were described aspercentages of occurrences of complications. Pattern rec-ognition was used to locate recurrences of signalmentdemographics within the complications data sets. Com-plication rates were compared as percentages betweensignalment groups and complication types.3|RESULTS3.1 |DemographicsThree hundred and seventeen records were reviewed.Eighty two records were excluded due to concurrent CCLtear (42), no m-TTT performed (17), lack of follow up orincomplete records (9), angular limb deformities requir-ing distal femoral ostectomy (4), or wrong species (10).Two hundred and thirty five dogs and 300 stifles met ourinclusion criteria.Breeds included mixed-breed dog (65/235, 27.6%),Yorkshire terrier (16/235, 6.8%), Chihuahua (15/235, 6.3%),Cavalier King Charles spaniel (14/235, 5.9%), Boston ter-riers, (14/235, 5.9%), Labrador retriever (12/235, 5.1%),Pomeranian (9/235, 3.8%), toy p oodle (8/235, 3.4%), pitbull( 7 / 2 3 5 ,2 . 9 % ) ,g o l d e nr e t r i e v e r( 7 / 2 3 5 ,2 . 9 % ) ,m i n i a t u r eschnauzer (6/235, 2.5%), pug (5/235, 2.1%), and one individ-ual of each of a number of other breeds (57/235, 24%).FIGURE 2 Immediate postoperative orthogonal radiographicprojections of a dog treated for medial patellar luxation using amodified tibial tuberosity transposition technique.CORTINA ET AL . 759 1532950x, 2023, 5, Body weight ranged from 1.3 kg to 72.3 kg, with amean of 14.3 kg. Weight categories4included 116 small,52 medium, 56 large, and 11 giant breeds. Ages rangedfrom 5 months to 12.6 years, with a median age of2 years. One hundred and fifteen (115/235, 48.9%) dogswere spayed females, 100 (100/235, 42.5%) were neuteredmales, 13 (13/235, 5.5%) were intact females, and seven(7/235, 2.9%) were intact males.Most (188/235, 80%) dogs were diagnosed with bilat-eral MPLs on initial orthopedic examination. The luxa-tion grade was documented during the initial orthopedicexamination for all preoperative stifles. The owner-reported lameness duration ranged from several days to3 years. Surgery was recommended, even for grades I andII MPLs, when dogs demonstrated clinical lamenessand pain.One hundred and seventy dogs (170/235) underwentunilateral repair. Nine dogs (9/235) underwent stagedbilateral repair. Fifty six dogs (56/235) underwent single-session bilateral repair. Three hundred stifles were oper-ated (155 left and 145 right stifles). Trochlear block reces-sion was performed in 282/300 stifles (94%), m-TTT wasperformed in all stifles, medial release in 227/300 cases(75%), and lateral imbrication in 299/300 stifles (99%).Only one minor intraoperative complication was docu-mented, when a small fissure occurred in the TT. No addi-tional procedures were performed to address the fissure.Two hundred and eighty six of 300 stifles were evalu-ated at 2 weeks postoperatively. Grade zero lameness(not lame) was noted in 62 stifles, grade 1 in 63 stifles,grade 2 in 88 stifles, grade 3 in 29 stifles, and grade 4 in34 stifles. Fourteen stifles were not evaluated at 2 weekspostoperatively. Lameness scores were not documentedfor 10 stifles, although they were examined. All lamenessexaminations were performed at a walk, without adefined warm-up period.Two hundred and seventy one stifles were evaluatedat 6 weeks postoperatively. Lameness was scored by vet-erinarians as previously. No lameness was noted in147 stifles, grade 1 in 53 stifles, grade 2 in 35 stifles,grade 3 in 17 stifles, and grade 4 in six stifles. Lamenessscores were not recorded for 13 hind limbs at this time-point, although the rest of the follow-up examinationwas documented. Twenty-nine stifles were not evalu-ated. Owners were instructed to have the patient re-evaluated if any residual lameness persisted past12 weeks postoperatively.This m-TTT procedure resulted in an overall com-bined short- and long-term postoperative complicationrate of 19.6% of stifles (59/300). The total major complica-tion rate was 4.3% (13/300), with a minor complicationrate of 15% (46/300). There were no catastrophic compli-cations during the reporting period.Minor complications 2 weeks postoperatively includedseroma (3, 1%), superficial SSI (2, 0.6%), pin-associateddiscomfort (1, 0.3%), reluxation grade 1/4 (1, 0.3%).Major complications noted at week 2 included SSI(2, 0.6%), and pin migration and pain (1, 0.3%). Migratedpins were removed under sedation and local anesthesiaduring the outpatient examination and infections weret r e a t e dw i t ho r a la n t i b i o t i c sb a s e do nc u l t u r ea n ds e n s i -tivity results.Minor complications at 6 weeks postoperativelyincluded the following: patellar reluxation of grades 1 or2 (10, 3.3%), pin-associated swelling and seroma forma-tion (7, 2.3%), incisional seroma (6, 2%), patellar desmitis(6, 2%), pin migration (3, 1%), TT fracture (2, 0.6%), mildsuperficial incisional infection (2, 0.6%), TT displacementresulting in patella alta (1, 0.3%), and trochlear blockfracture (1, 0.3%).Major complications affected six stifles (2.2%) 6 weekspostoperatively. These included pin migration and pain(2, 0.6%), TT fracture (2, 0.6%), reluxation to grade 3 or4 MPL (2, 0.6%). Surgical intervention was recommendedin these six stifles. Two TT fractures and both high-gradepatellar reluxations underwent successful revision sur-gery. Migrated pins were removed under sedation andlocal anesthesia at the 6 weeks postoperative outpatientevaluation.The overall short-term (up to 6 weeks postopera-tively) minor complication rate was 45/300 (15%). Short-term major complications were seen in 9/300 (3%), with atotal short-term complication rate of 54/300 (18%). Therewere too few complication cases to provide meaningfulstatistical data on whether signalment factors, such asthe dog’s age and size, and unilateral versus single-session bilateral repair could have played a role in fixa-tion failure (Table S1).Mid- to long-term follow up was available for 109/300(36.3%) of the operated stifles in 84/235 (35.7%) dogs.Orthopedic examinations alone were reviewed in 72/300(24%) stifles between 12 weeks and 10 years postopera-tively. Radiographic examinations were available for37/300 (12.3%) stifles between 16 weeks and 9 years post-operatively. The reason for follow-up radiographs atmore than 16 weeks postoperatively included newCCL rupture (16/31, 51.6%), wound at the surgical site(3/31, 9.6%), hip pain (1/31, 3.2%), forelimb lameness(1/31, 3.2%), paw injury (1/31, 3.2%), episodic lameness(4/31, 12.9%), and surgeon’s request for follow up (2/31,6.4%). Complete bone healing was noted in all stifles.No additional reluxations o r worsening of reluxationgrade were observed.The long-term minor complication rate was 1/300(0.3%). Major complications were seen in 4/300 (1.3%)accounting for a total long-term complication rate of 5/300760 CORTINA ET AL . 1532950x, 2023, 5, (1.6%). Overall, there were five pin-related complications,noted up to 9 years postoperatively, among the 109 stiflesfor which follow-up data were accessible. Three of the fivepin-related complications presented with wounds near orover the surgical site associated with pin migrationbetween 1 and 6 years postoperatively (Table1). In theremaining two patients, pin migration was noted on radio-graphs and exam for other unrelated orthopedic concerns.Forty-one owners responded to the CBPI surveys, with10 respondents replying to the CBPI-D, and 31 respondingto the CBPI, resulting in a 17% response rate. Ten partici-pants did not complete the CBPI, and three participantsdid not complete the CBPI-D. Survey results reflect 12/31(38.71%) dogs who had surgery within the past 1 –5 years,12/31 (38.71%) who had surgery within the past 5 –10 years,and 7/31 who had surgery more than 10 years prior. Ofthe respondents to the CBPI-D, 4/10 (40%) had surgery5–10 years ago, and 6/10 (60%) had surgery more than10 years ago. Most dogs (24/31, 77%) in the CBPI and inthe CBPI-D (7/10, 70%) had surgery on only one stifle.Most respondents to the CBPI (13/24; 54.17%)reported that their dog experienced no pain related toMPL surgery, and 5/10 (50%) were rated at a 3/10 orlower on the pain scale in the CBPI-D. There was 76.2%or more agreement among respondents in the CBPI thatMPL surgery did not interfere with their dogs ’ability toclimb stairs, curbs, or doorsteps; run; walk; enjoy life; orgeneral activity. Quality of life following MPL surgerywas rated as excellent in 14/20 (70%), very good 3/20(15%), and good 3/20 (15%) in the CBPI. For theTABLE 1 Long-term follow up, radiographs, and complications.Years,post-op # stifles ExaminationRadiographsavailable#yes/no RadiographImplantmigrationTX &resolution Complications16 weeks to1 year23 Stable repair (23) 6/17 MissingK-wire (1)1/6 None 1 minorHealed (6)2 9 Torn CCL (4) 4/5 Healed (4) 0 n/a 0Stable repair (9)3 14 Torn CCL (3) 5/9 Healed (5) 0 n/a 0Osteosarcoma (1)Stable repair (14)4 12 Torn CCL (3) 6/5 Healed (6) 1/6 Pin removal 1 majorOA (2) Pin migration (1)Wound (1)Stable repair (12)5 5 OA (2) 2/3 Healed (2) 0 n/a 0Paw pain (1)Stable repair (5)6 8 Torn CCL (1) 2/6 Healed (2/2) 1/6 Pin removal (3) 3 majorSuperficial Wound (1)Pin protrusion (1)Abscess (1)Stable repair (8)7 5 Stable repair (5) 0/5 n/a 0 n/a 08 3 Torn CCL (3) 3 Healed (3) 0 n/a 0Stable repair (3)9 5 Torn CCL (1) 3/2 Healed (3) 0 n/a 0Primary vet consultation (2)Stable repair (5)10 1 Stable repair (6) 0/1 n/a 0 n/a 0Abbreviations: CCL, cranial cruciate ligament; OA, osteoarthritis, TX, treatment.CORTINA ET AL . 761 1532950x, 2023, 5, CBPI-D, quality of life was described as excellent in 1/6(16.7%), very good in 3/6 (50%), and good in 2/6 (33.3%).One respondent from each group did not answer thisquestion.When surveyed about complications, 4/21 (19%) ofCBPI respondents and 2/7 (28.5%) of CBPI-D respondentsdescribed making additional veterinary visits postopera-tively, most commonly due to arthritis as described in thesurvey textbox. All respondents would choose this sur-gery again, and most CBPI respondents (20/21) and allthe CBPI-D respondents (7/7) reported that they werevery satisfied with the outcome of the MPL surgery.4

Question 20

Franklin - 2024 - VETSURG - Comparison of the effectiveness of three different rhinoplasty techniques to correct stenotic nostrils using silicone models - A case study.pdf

Answer 20

2.1 |Model fabricationA computed tomographic (CT) scan of a French bulldog’snose with moderately stenotic nares was obtained retro-spectively and used for model fabrication.15The CT wasperformed with a 16-slice multislice CT scanner(Aquilion 16; Toshiba America Medical Systems, Tustin,California). The images were acquired in helical mode,with a slice thickness of 0.5 mm. Tube rotation time was0.5 s and KVp =100, mAs =150. The images wereacquired with a bone algorithm (window width =3500Hounsfield units [HU], window level =1500HU). Theregion of interest was defined as the “nares and nasalvestibule, ”starting at the rostral most point of thenasal planum and ending at the first branch of theventral nasal conchae.16The raw multidetector CTbone algorithm datasets were imported into 3D imageprocessing software (Stradview 6.1, University ofCambridge, Cambridge, UK). The images were win-dowed, and automatic binary segmentation of thecross-sections was achieved via application of athreshold to the CT slices (window center =500 HU;window width =4000 HU; threshold =/C0500 to2500 HU), highlighting the soft tissues. A squareregion 5 mm outside the external edge of the soft tis-sue was selected manually. Using the automated func-tions within the software, maximal disc-guidedinterpolation was applied to generate surface interpo-lation between these cross-sections and triangulatesurface mesh models.17,18This created an inverse, vir-tual, 3D model of the original French bulldog nose,which would serve as a mold.This mold was then imported into 3D image-editingsoftware (Microsoft 3D builder, Redmond, Washington)and divided into three sections: a rostral section (Mold1, Figure1B,C ), a middle section (Mold 2, Figure 1D,E ),and a caudal section (Mold 3, Figure 1G). A fourthmold (Mold 2b, Figure 1F) was also created, whichwould fit the silicone model after it was removed fromFRANKLIN ET AL . 105 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14041 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 LicenseMold 1 and 2 and would allow Mold 3 to be applied toit. Connecting “arms ”were added to Mold 2 and 3 toattach the airway region of the mold to the externalstructure (Figure 1D,G ). Ten copies of each mold wereprinted using a desktop stereolithography 3D printer(Form2, Formlabs, Somerville, Massachusetts), ModelResin (V2, Formlabs) with a layer thickness of0.050 mm. The molds were washed, and the supportsremoved manually. Two millimeter holes were drilledinto the connecting “arms ”of Mold 2 and 3 to reducethe formation of air bubbles when filled with silicone.The molds were filled with silicone sequentially andallowed to set, with each mold being placed on top ofthe previously set section. This was repeated until99 remolded silicone models had been fabricated(Figure1A,H,I,J ).2.2 |Surgical techniquesAll models had one of three surgical techniques per-formed; vertical wedge resection (VW), modified horizon-tal wedge resection (MHW) or ala-vestibuloplasty (AVP)(n=33 per group).3,9–11The methods were performedsequentially in repeated groups of three, and all 99 simu-lated surgeries were performed by a single, right-handedDiplomate of the European College of Veterinary Surgeons(DECVS) familiar with all three techniques. Standarddescriptions of each technique were read by the surgeonprior to performing the surgeries and access to thesedescriptions was available throughout (VideoS1).3,9–11The VW technique involved removing a triangularbased pyramid of tissue from the ala nasi, and then sutur-ing the defect closed with simple, interrupted sutures ofFIGURE 1 (A) Virtual, 3D model created from the original CT scan of a French bulldog’s nose. (B) Mold 1. (C) Mold 1 filled with setsilicone. (D) Mold 2. (E) Model appearance from caudally once removed from Molds 1 and 2. (F) Mold 2b. (G) Mold 3. (H) Modelappearance from caudally once completed. (I) model appearance from rostrally once completed. (J) Ninety of the preoperative models.106 FRANKLIN ET AL . 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14041 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 License4–0 nylon.11The apex of the wedge was positionedslightly dorso-laterally to the dorsal limit of the nares andthe surgeon aimed for the angle of the wedge to be /C2470degrees. However, this was not physically measured sothat the clinical scenario could be simulated more accu-rately. A number 11 blade was used, and the entire cut-ting edge was inserted to standardize the depth of theincisions. The MHW involved removing a pyramid of tis-sue from the ala nasi with the base having a curvedmedial incision which followed the outer curvature of theala nasi from its dorso-medial aspect to its ventro-lateralaspect.10A 6500-pointed beaver blade was used and, onceagain, the entire cutting edge was inserted to ensure ade-quate and consistent depth. The defect was closed withsimple, interrupted sutures of 4 –0 nylon. The AVPinvolved removing the alar fold initially with a number11 blade, once again inserted to its hub.3,9The dorsal partof the alar fold was grasped with a pair of curved mos-quito forceps (Freelance Surgical, Bristol, UK) and a hori-zontal incision was made at the level of ventral edge ofthe ala nasi, medially to laterally, severing the ventralattachment of the alar fold to the floor of the nasal vesti-bule. The dorsal part of the alar fold was rotated mediallywith the forceps, followed by a dorsoventral incision withthe blade angled at 45 degrees medially, severing the lat-eral and caudal attachments of the alar fold. The ala nasiwas then grasped with a curved mosquito forceps(Freelance Surgical) at the ventromedial edge and ampu-tated by cutting across it from the dorso-medial mostpoint of the external nares to its ventro-lateral aspect(/C2445 degrees). This technique involved no suturing.2.3 |Data collectionAll 99 models underwent CT preoperatively with the samesettings as the original French bulldog, with a slice thick-ness of 0.5 mm. The raw multidetector CT bone algorithmdatasets were imported into a t hree-dimensional image pro-cessing software (Stradview 6 .1, University of Cambridge).Thresholds were applied to select the airway (windowcenter=3000 HU; window width =1000 HU; threshold =<2641 HU), and the first slice i n which the lateral slit termi-nated was identified (slice 14) . Thirteen 0.5 mm slices ros-trally and thirteen 1 mm slices caudally from this point hadthe cross-sectional area of th e airway recorded, with rightand left nasal airways being cal culated separately. Regionsof air within the model (i.e., air bubbles) that were selectedbut not connected to the main airway in each slice wereremoved manually. Where the airway was confluent withthe external airspace (i.e., the edges of the lateral slit) a verti-cal end point was drawn manually from the lateral mostpoint of the ala nasi to the floor of the nasal vestibule.Postoperatively each of the 99 models underwent repeat CTscanning, and the cross-sectional areas of the postoperativeairways were calculated in the same manner as preopera-tively. Once again, regions of air within the models thatwere not connected to the main airway within a single slicewere manually removed. In th e postoperative models, theremoved areas included and air bubbles and the regions ofexicised tissue where the edges were not completelyapposed.2.4 |Statistical analysisPreliminary power analysis was conducted using GPowerversion 3.1.9.719for sample-size estimation. The resultsindicated that the sample size required to achieve 80%power for detecting a medium to large effect ( f=0.35, theeffect size was justified from a pilot study), at a signifi-cance criterion of alpha =.05, was N=28 for a one-wayANOVA. The following statistical analyses were conductedin statistical package “R”(version 3.5.3).20Estimations of reproducibility of the remolded sili-cone models were performed using R package “rptR, ”and the reproducibility coefficients were calculated.Wilcoxon signed rank exact tests were used to com-pare the absolute postoperative CSAs of the right nasalairway to that of the left nasal airway for each techniqueand further for each slice with Bonferroni corrections.The proportional differences between the right and theleft nasal airway postoperative CSAs were calculated as100(right CSA-left CSA)/[(right CSA +left CSA)/2] (%).The proportional differences in CSAs for all slices ofpostoperative models were calculated as: 100*[(postoper-ative CSA) –(preoperative CSA)]/(preoperative CSA) (%).An average proportional difference in CSAs were thencalculated for each technique of each side. These datawere then used to assess the intrasurgon repeatability ofeach technique and side. Wilcoxon signed rank exacttests with Bonferroni corrections were used to assess thewithin-technique difference in CSAs between preopera-tive and postoperative data for the right and the left nasalairways separately.Kruskal –Wallis tests followed by Dunn’s tests(pvalue adjusted with the Bonferroni method) were usedto compare the postoperative CSAs of the three rhino-plasty techniques. Results were considered statisticallysignificant when p< .05.3|RESULTSThe preoperative models had a high reproducibility coef-ficient of 0.957 (95% confidence interval [CI]: 0.923 –FRANKLIN ET AL . 107 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14041 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 License0.973) and 0.923 (95% CI: 0.87 –0.952) for the right andleft nasal airway CSAs, respectively. The comparisonsbetween postoperative CSAs for the right and left nasalairways are as follows: for the VW technique, the abso-lute postoperative CSAs of the right nasal airway werelarger than the left for all slices ( p< .05) except forslice 16 to slice 26. The average proportional differencein CSAs was 6 ± 16%. For the MHW technique, theabsolute postoperative CSAs of the right nasal airwaywere larger than the left ( p< .01) for all slices exceptfor slice 10 and slice 11, with an average proportionaldifference of 14 ± 14%. For the AVP technique, theproportional differences in CSAs of the right nasal air-way were larger than the left ( p< .01) for all slicesexcept for slice 18 to slice 34. The average proportionaldifference was 11 ± 11% (Figure2). For assessingwithin-technique variation, the average proportionaldifference in CSA of the postoperative models withinthe VW, MHW, and AVP techniques was 7 ± 5%,7 ± 4%, and 6 ± 2% for the right nasal airways respec-tively, and 7 ± 4%, 6 ± 3%, and 5 ± 1% for the left nasalairways, respectively (Figure2).In comparison with the preoperative models, VWincreased the nasal airway CSAs from slices 1 –13, MHWfrom slices 1 –7, and AVP from slices 1 –34 (adjusted pvalue<.001 for all of these slices) (Figures 2and3). The averagepostoperative increases in absolute CSA were 12.2 mm2(range=8.7–16.8 mm2), 11.5 mm2(range=3.3–16.8 mm2)and 20.1 mm2(range=4.8–28.0 mm2)a c r o s se a c ho ft h e s eregions respectively. Average percentage increases in CSAacross all slices were 26% (maximum change =97% [slice3]) for the VW, 15% (maximum change =87%, slice 3) forthe MHW and 74% (maximum change =132%, slices 3 and16) for the AVP. For the MHW technique, the nasal airwayCSAs of slices 10 –1 4r e d u c e di nc o m p a r i s o nw i t hp r e o p e r a -tive values with an average reduction in CSA of 7%(3.1 mm2; range =1% [slice 14] –13% [slice 11]) (Figures 2and 3). This finding was further supported by a singlecadaveric study (Figure 4).When comparing the postoperative CSAs betweentechniques, AVP had larger postoperative nasal airwayCSAs than VW and MHW for all slices (adjusted pvalues<.05) except slices 36 –40, where none of the techniquescaused a postoperative change in CSA. The averageFIGURE 2 Line graphscomparing nasal airway cross-sectional areas preoperativelyand after each rhinoplastytechnique. (A) Right nasalairway. (B) Left nasal airway. Theshading surrounding each trendline illustrates the 95%confidence interval. AVP, ala-vestibuloplasty; MHW, modifiedhorizontal wedge; VW, verticalwedge.108 FRANKLIN ET AL . 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14041 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 LicenseFIGURE 3 Preoperative and postoperative silicone models for each technique, together with screenshots of CT slices 1 –40. Note thecontact points between the dorsal and ventral aspects of the midlateral slits present from slices 10 to 14 after modified horizontal wedgeresection, which is not present in the preoperative model or the other techniques.FRANKLIN ET AL . 109 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14041 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 Licensepercentage increase in the CSA for AVP was 53% greaterthan VW and 66% greater than MHW across the region ofslice 1 to slice 34 (Figure2). Vertical wedge resection hadlarger CSAs than MHW by an average of 17% from slices2–13 of the left nasal airway (adjusted pvalues <.01), and17% from slices 8 –13 of the right nasal airway (adjustedpvalues <.0001). There was no difference in CSAsbetween the VW and MHW techniques from slice 14 toslice 40 for both right and left nasal airways, from slice1 to slice 7 for the right nasal airway, and slice 1 for theleft nasal airway (adjusted pvalues ≥.05).4

Question 21

Michael - 2023 - JAVMA - Perioperative ventricular arrhythmias are increased with hemoperitoneum and are associated with increased mortality in dogs undergoing splenectomy for splenic masses.pdf

Answer 21

Case selection criteriaMedical records from the University of Georgia Vet -erinary Teaching Hospital were searched for hospital charge codes and operative reports containing the word splenectomy from January 2010 through December 2018. Only dogs that had a complete splenectomy for a splenic mass were included. Dogs were excluded if they had a concurrent condition known to cause ventricular arrhythmias (eg, gastric dilatation volvulus, arrhythmo -genic right ventricular cardiomyopathy), concurrent ad -renalectomy was performed, intraoperative euthanasia was elected, continuous ECG monitoring was not per -formed postoperatively, or incomplete records prevent -ed evaluation of the occurrence of VAs.Medical records reviewPreoperative information collected from the medi -cal record included signalment, physical examination findings on admission (age, sex, breed, body weight, heart rate, systolic arterial blood pressure, presence of hemoperitoneum), laboratory results on admission (pe -ripheral PCV/Hct, abdominal effusion PCV/Hct, platelet count, serum albumin, serum total protein, serum lac -tate), whether a transfusion was administered (packed RBCs, whole blood, or plasma), results of preoperative diagnostic imaging (thoracic radiographs, abdominal ultrasound, thoracic/abdominal CT, and echocardio -gram), and presence of VAs, type, and treatment. The time from admission to surgery was also recorded.Intraoperative information collected included dura -tion of anesthesia; presence and duration of hypotension under anesthesia; duration of surgery; surgical findings; ad -ditional surgical procedure(s) performed; whether a trans -fusion was administered; and presence of VAs, type, and treatment. Hypotension was defined as a systemic arterial blood pressure < 90 mm Hg, mean arterial blood pressure < 70 mm Hg, or diastolic arterial blood pressure < 40 mm Hg, for at least 10 minutes. For additional surgical proce -dures performed, dogs were considered to have under -gone no additional procedures if splenectomy was per -formed in addition to commonly associated procedures (gastropexy, lymph node biopsy, liver biopsy), minor additional procedures (eg, sterilization procedures, biop -sy or removal of a skin/subcutaneous mass), and major additional procedures (eg, liver lobectomy, surgery of a hollow viscus).Postoperative information collected included pres -ence of VAs, frequency (rare, occasional, frequent, con -tinuous), severity/morphology (ventricular tachycardia, R-on-T ventricular tachycardia, multiform), and time and duration of occurrence; VA treatment; length of con -tinuous ECG postoperatively; histopathologic results; whether a transfusion was administered; and survival to hospital discharge. Frequency and severity of VAs was determined from treatment sheets as ECG recordings were not available for review. For dogs that died prior to hospital discharge, cause of death was recorded.The presence of VAs was recorded for the pre-, intra-, and postoperative time points. Dogs with VAs at more than 1 time point were included in each applicable category.Statistical analysisData were analyzed using a commercially available statistics program (JMP version 17.0.0; SAS Institute). Data were tested for normality by visual inspection of the histo -gram and normal quantile plot. Descriptive statistics were generated. Normally distributed data are reported as mean ± SD and non-normally distributed data are reported as median (range). Univariable binary logistic regression was performed to compare variables of interest versus intra- and postoperative VAs and survival to discharge. Multivariable binary logistic regression with backward elimination was performed to compare significant variables from univariable analysis to the presence of postoperative VAs with a maxi -mum of 1 variable per 10 events and excluding variables un -derrepresented in the population. Significance was set at P < .05. Odds ratios and 95% CI are reported where available.ResultsThree hundred and eight dogs were included in the study. The mean age was 10.6 ± 2.2 years with 189 males (189/308 [61.4%]; 166 neutered, 23 intact) and 119 fe -males (119/308 [38.6%]; 115 spayed, 4 intact). The most commonly represented breeds were mixed-breed dogs (72/308 [23.4%]), Labrador Retrievers (40/308 [13.0%]), Golden Retrievers (22/308 [7.1%]), German Shepherd Dogs (14/308 [4.5%]), and Beagles (12/308 [3.9%]). Mean body weight was 25.0 kg ± 13.3 kg. One hundred and twenty (120/308 [39.0%]) dogs had he -moperitoneum while 188 dogs (188/308 [61.0%]) did not have hemoperitoneum. Increasing body weight was associated with the presence of hemoperitoneum ( P < .001; OR [5 kg increase], 1.22; 95% CI, 1.11 to 1.34; mean 29.1 ± 11.2 kg for 120 dogs with hemoperitoneum, mean 22.4 ± 13.9 kg for 188 dogs without hemoperitoneum).Forty-three dogs (43/308 [14.0%]) had an echocar -diogram; the most common finding was valvular disease (30/43 [69.8%]). Sixty-five dogs (65/308 [21.1%]) had a heart murmur auscultated at admission (median grade 3, range 1 to 6), 29 (29/65 [44.6%]) of which underwent echocardiographic evaluation.All dogs underwent surgery for a splenectomy. A liv -er biopsy was performed in 275 dogs (275/308 [89.3%]) and 91 dogs had a gastropexy performed (91/308 Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 12/11/23 09:45 AM UTC 3[29.5%]). Additional procedures were performed in 109 dogs (109/308 [35.4%]); these procedures were classi -fied as minor in 29 dogs (29/109 [26.6%]) and major in 80 dogs (80/109 [73.4%]). Dogs undergoing additional major procedures did not have an increased incidence of intraoperative VAs, postoperative VAs, or in-hospital mortality ( P = .245, P = .127, P = .222, respectively).Final pathological diagnosis of the spleen was malignant disease in 163 dogs (163/308 [52.9%]) and benign disease in 144 dogs (144/308 [46.8%]). In 1 dog, histopathologic findings could not differentiate between extramedullary hematopoiesis or a mono -cytic/melanocytic neoplasm; this dog was excluded from statistical analysis related to diagnosis. The most common malignancy was hemangiosarcoma (128/163 [78.5%]) with the most common other malignan -cies being lymphoma (16/163 [9.8%]) and sarcoma (13/163 [8.0%]). The most common benign conditions for all dogs were hematoma, extramedullary hemato -poiesis, and nodular hyperplasia, most often occurring in combination with each other (108/144 [75.0%]). In dogs without hemoperitoneum (187 with diagnoses), diagnoses were benign condition (118/187 [63.1%]), hemangiosarcoma (38/187 [20.3%]), or other malig -nancy (31/187 [16.6%]). In dogs with hemoperitoneum (120), the diagnoses were hemangiosarcoma (90/120 [75.0%]), benign condition (26/120 [21.7%]), or other malignancy (4/120 [3.3%]). Dogs with hemangiosar -coma were more likely to have hemoperitoneum than both dogs with benign conditions and those with other malignancies (hemangiosarcoma vs benign: P < .001 OR, 10.7; 95% CI, 6.08 to 19.00; hemangiosarcoma vs other malignancy: P < .001 OR, 18.36; 95% CI, 6.06 to 55.60). There was no difference between dogs with other malignancies and those with benign conditions. Dogs with hemangiosarcoma weighed more than those with benign conditions and those with other malignan -cies ( P < .001, mean 29.4 ± 11.8 kg for hemangiosarco -ma, mean 23.0 ± 13.7 kg for benign conditions, mean 18.1 ± 11.8 kg for other malignancies). Dogs with be -nign conditions weighed more than those with other malignancies ( P = .046).Overall, 138 dogs (138/308 [44.8%]) had VAs (pre-, intra-, or postoperative), with 126 dogs (126/138 [91.3%]) having postoperative VAs, 51 dogs (51/138 [37.0%]) having intraoperative VAs, and 26 dogs (26/138 [18.8%]) having preoperative VAs; 50 dogs (50/138 [36.2%]) had VAs at more than 1 time point. Of the 126 dogs experiencing postoperative VAs, 115 had information in the record regarding the frequency of postoperative VAs experienced, which included rare (9), occasional (94), frequent (6), or con -tinuous (6). Postoperative VAs were further described as ventricular tachycardia in 26 dogs (26/115 [22.6%]), multiform in 7 dogs (7/115 [6.1%]), and R-on-T ven -tricular tachycardia in 3 dogs (3/115 [2.6%]). Of dogs experiencing postoperative VAs, 64 (64/126 [50.8%]) received anti-arrhythmic medications postoperatively. Thirty-seven dogs received lidocaine alone, 18 dogs received lidocaine in combination with sotalol, 4 dogs received sotalol alone, and 5 dogs received 5 different combinations of anti-arrhythmic medications.Factors increasing the odds of intraoperative VAs (Table 1) and postoperative VAs (Table 2) No. Value in group with Value in group without Variable of dogs intraoperative VA intraoperative VA OR (unit) 95% CI P valueContinuous variables Body weight (kg) 308 30.8 ± 12.2 23.9 ± 13.2 1.22 (5) 1.08–1.38 < .001Heart rate (bpm) 307 146.3 ± 32.9 128.8 ± 29.0 1.46 (20) 1.19–1.79 < .001PCV/Hct (%) 293 30.7 ± 8.5 37.1 ± 10.0 0.93 0.90–0.97 < .001Platelet count (X 103/μL) 222 86.0 (9.0–416.0) 209.0 (12.0–822.0) 0.87 (20) 0.81–0.93 < .001Serum total protein (g/dL) 271 5.9 ± 1.2 6.4 ± 1.1 0.70 0.53–0.92 .010Preresuscitation serum 159 4.7 (1.0–18.5) 3.2 (0.5–15) 1.12 1.01–1.24 .027 lactate (mmol/L)Time from presentation 308 6.0 (2.0–67.0) 23.0 (1.5–168.0) 0.95 0.92–0.98 < .001 to surgery (h)Duration of hypotension 213 65.0 (10.0–180.0) 35.0 (5.0–240.0) 1.07 (5) 1.03–1.12 .001 under anesthesia (min)Time of continuous ECG (h) 308 43.0 (11.0–132.0) 25.0 (1.0–93.0) 1.04 1.02–1.05 < .001Categorical variables Hemoperitoneum 308 38/51 (74.5) 82/257 (31.9) 6.24 3.15–12.34 < .001Transfusion 308 26/51 (51.0) 65/257 (25.3) 3.07 1.66–5.69 < .001Preoperative VA 308 16/51 (31.4) 10/257 (3.9) 11.29 4.75–26.84 < .001Diagnosis 307 < .001Benign condition 17/51 (33.3) 127/256 (49.6) 2.60* 1.36–4.93 Other malignancy 1/51 (2.0) 34/256 (13.3) 11.81† 1.55–89.71 Hemangiosarcoma 33/51 (64.7) 95/256 (37.1) Continuous variables reported as mean ± SD (normally distributed data) or median (range; non-normally distributed data). Categorical variables presented as number (%). For certain factors, the unit OR was converted to an n-unit change. The n-unit used is presented in parenthesis, when no parentheses are present, the unit is 1.bpm = Beats per minute. VA = Ventricular arrhythmiaOR of hemangiosarcoma compared to benign condition.†OR of hemangiosarcoma compared to other malignancy.Table 1 —Results of univariable binary logistic regression analysis for factors significant for intraoperative ventricular arrhythmias occurring in 51 of 308 dogs undergoing splenectomy for splenic masses.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 12/11/23 09:45 AM UTC4 were identified. Two hundred and eighty-eight dogs (288/308 [93.5%]) survived to hospital discharge. Factors significant for in-hospital mortality were identified (Table 3) . Of the 14 dogs with VAs that died, the VAs occurred intra- and postoperatively (7), postoperatively only (4), preoperatively only (1), pre- and postoperatively (1), and pre-, intra-, and postoperatively (1). Frequency of postopera -tive VAs was described in 11 of the 13 dogs with postoperative VAs and was described as occasional (8) or rare (3). One of these dogs was reported to have ventricular tachycardia and another had R-on-T ventricular tachycardia with multiform complexes. Anti-arrhythmic treatment was used in 8 of the 14 dogs with VAs that died and was single agent in 6 dogs and multimodal in 2 dogs. Response to anti-arrhythmic therapy was unable to be determined from the record. Causes of death in the 14 dogs with perioperative VAs were respiratory distress leading to euthanasia or cardiac arrest (6), cardiac arrest (3), unknown (2), acute kidney injury (1), disseminated in -travascular coagulation (1), and myocardial infarction (1). Causes of death in the 6 dogs without periopera -tive VAs were cardiac arrest (4), unknown (1), and eu -thanasia due to subepidermal bullous keratopathy (1).Variables included in the multivariable analysis for intraoperative VAs were body weight and heart rate on admission, presence of hemoperitoneum, histopatho -logic diagnosis (benign condition, hemangiosarcoma, or other malignancy), and whether a transfusion was given during hospitalization. Body weight and heart rate on admission and the presence of hemoperitoneum Table 2 —Results of univariable binary logistic regression analysis for factors significant for postoperative ventricu -lar arrhythmias occurring in 126 of 308 dogs undergoing splenectomy for splenic masses. No. Value in group with Value in group without Variable of dogs postoperative VA postoperative VA OR (unit) 95% CI P valueContinuous variables Body weight (kg) 308 29.8 ± 12.0 21.7 ± 13.1 1.28 (5) 1.16–1.41 < .001Heart rate (bpm) 307 140.9 ± 30.5 125.3 ± 28.6 1.44 (20) 1.22–1.70 < .001Blood pressure (mm Hg) 168 110.9 ± 37.4 133.0 ± 33.2 0.70 (20) 0.58–0.84 < .001PCV/Hct (%) 293 33.3 ± 10.1 37.9 ± 9.6 0.95 0.93–0.98 < .001Platelet count (X 103/μL) 222 117.5 (9.0–585.0) 236.5 (28.0–822.0) 0.91 (20) 0.88–0.95 < .001Serum total protein (g/dL) 271 6.0 ± 1.1 6.5 ± 1.2 0.66 0.53–0.84 < .001Preresuscitation serum 159 4.7 (0.8–18.5) 2.7 (0.5–12.2) 1.37 1.18–1.58 < .001 lactate (mmol/L)Time from presentation 308 7.0 (2.0–96.0) 24.0 (1.5–168.0) 0.97 0.95–0.98 < .001 to surgery (h)Time of continuous ECG (h) 308 44.0 (12.0–132.0) 22.0 (1.0–72.0) 1.07 1.05–1.09 < .001Categorical variables Hemoperitoneum 308 82/126 (65.1) 38/182 (20.9) 7.06 4.23–11.78 < .001Transfusion 308 55/126 (43.7) 36/182 (19.8) 3.14 1.89–5.21 < .001Preoperative VA 308 18/126 (14.3) 8/182 (4.4) 3.62 1.52–8.62 .002Intraoperative VA 308 46/126 (36.5) 5/182 (2.7) 20.36 7.79–53.16 < .001Diagnosis 307 < .001Benign condition 43/126 (34.1) 101/181 (55.8) 3.43 2.08–5.67 Other malignancy 7/126 (5.6) 28/181 (15.5) 5.85† 2.38–14.38 Hemangiosarcoma 76/126 (60.3) 52/181 (28.7) See Table 1 for key.Table 3 —Results of univariable binary logistic regression analysis for factors significant for death prior to hospital discharge occurring in 20 of 308 dogs undergoing splenectomy for splenic masses. No. Value Value Variable of dogs in nonsurvivors in survivors OR (unit) 95% CI P valueContinuous variables Age 308 11.6 ± 2.3 10.5 ± 2.2 1.27 1.02–1.58 .031Heart rate (bpm) 307 147.7 ± 25.6 130.6 ± 30.4 1.42 (20) 1.07–1.89 .017PCV/Hct (%) 293 30.7 ± 8.7 36.4 ± 10.0 0.94 0.90–0.99 .013Preresuscitation serum 159 5.1 (0.5–18.5) 3.4 (0.5–15.0) 1.15 1.01–1.32 .050 lactate (mmol/L)Duration of hypotension 213 55.0 (30.0–175.0) 35.0 (5.0–240.0) 1.06 (5) 1.01–1.12 .022 under anesthesia (min)Categorical variables Hemoperitoneum 308 13/20 (65.0) 107/288 (37.2) 3.14 1.22–8.12 .015Intraoperative VA 308 8/20 (40.0) 43/288 (14.9) 3.80 1.47–9.84 .009Postoperative VA 308 13/20 (65.0) 113/288 (39.2) 2.89 1.11–7.43 .025Transfusion 308 15/20 (75.0) 76/288 (26.4) 8.37 2.94–23.81 < .001See Table 1 for key.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 12/11/23 09:45 AM UTC 5remained significant for intraoperative VAs. For each increase in body weight of 5 kg, the odds of intraop -erative VAs increased 16% ( P = .026; OR, 1.16; 95% CI, 1.02 to 1.33). For every 20 beats per minute increase in heart rate, the odds of intraoperative VAs increased 29% ( P = .028; OR, 1.29; 95% CI, 1.03 to 1.61). The pres -ence of hemoperitoneum increased the odds of intra -operative VAs 4.23 times ( P < .001, OR, 4.23; 95% CI, 2.05 to 8.74). Variables included in the multivariable analysis for postoperative VAs were body weight and heart rate on admission, presence of hemoperitoneum, histopathologic diagnosis (benign condition, heman -giosarcoma, or other malignancy), whether a transfu -sion was given during hospitalization, and time from presentation to surgery. Body weight, heart rate, and presence of hemoperitoneum remained significant for postoperative VAs. For each increase in the body weight of 5 kg, a 24% increase in the odds of postopera -tive VAs occurred ( P < .001; OR, 1.24; 95% CI, 1.11 to 1.37). For every 20 beats per minute increase in heart rate, a 30% increase in the odds of postoperative VAs occurred ( P = .006; OR, 1.30; 95% CI, 1.08 to 1.57). The presence of hemoperitoneum increased the odds of postoperative VAs 4.92 times ( P < .001; OR, 4.92; 95% CI, 2.85 to 8.47).

Question 22

Hixon - 2024 - JAVMA - Bupivacaine liposomal injectable suspension does not provide improved pain control in dogs undergoing abdominal surgery.pdf

Answer 22

All study procedures were approved by the Univer -sity of Georgia Clinical Research Committee, and client informed consent was obtained for each dog prior to enrollment. Dogs undergoing exploratory laparotomy were prospectively enrolled and randomly assigned to receive either BLIS or saline SII. Randomization was per -formed prior to the start of the study using a random -ization website (www.randomization.com). Exclusion criteria included dogs undergoing a caudal abdominal procedure only (eg, cystotomy) or a laparoscopic pro -cedure; dogs that were aggressive, pregnant, or lactat -ing; dogs with a portosystemic shunt; and dogs with a confirmed septic abdomen. Dogs that were enrolled but later found to have serum cortisol concentrations consistent with hyper- or hypoadrenocorticism were removed from inclusion in cortisol measurements but allowed to remain in the study.Anesthesia and surgeryPrior to anesthesia, baseline GCMPS, STT, HR, and indirect systolic BP were recorded, and whole blood was obtained for cortisol measurements and centri -fuged at 2,500 rpm for 10 minutes, with the result -ing serum saved in a –80 °C freezer until samples could be tested in batches. Serum cortisol levels were measured using a solid-phase, competitive chemi -luminescent enzyme immunoassay (Immulite 2000 XPi; Siemens Medical Solutions USA Inc). All dogs were premedicated with methadone (0.2 mg/kg) and midazolam (0.2 mg/kg) IV or IM, with administration route determined by the attending anesthesiologist. Anesthesia was induced with ketamine (2 mg/kg, IV) and propofol (4 mg/kg, IV, to effect) and main -tained with isoflurane in oxygen. No dogs received a TAP block, epidural, or NSAIDs perioperatively. At the time of closure of the abdomen, either BLIS or saline was administered peri-incisionally in 3 layers per manufacturer guidelines.23 In the BLIS group, 5.3 mg of BLIS/kg was diluted 1:1 with 0.9% sterile saline as recommended by the package insert for sufficient volume to inject the entire length of the incision.24 Dogs in the saline group received a volume of 0.9% saline equivalent to that of the diluted BLIS calculated for their weight. Prior to the beginning of the study, all surgeons (American College of Veterinary Surgeons [ACVS] diplomates and ACVS residents under the supervision of an ACVS diplomate) received instruc -tions and watched a video on proper administration of the SII to ensure consistency in treatment. After the body wall closure, 25% of the diluted volume was administered using a 1-inch, 22-gauge needle along the incision under the rectus sheath in a continuous line on both sides of the incision in a moving needle technique. Next, 50% of the volume was administered similarly within the subcutaneous tissues. The remain -ing volume was administered in a similar manner sub -cuticularly, without penetrating skin.Postoperative care and pain assessmentPostoperatively, all dogs received 0.2 mg of methadone/kg IV every 6 hours for a minimum of 3 doses with the timing of the first dose at clinician and anesthesiologist discretion, at a maximum of 6 hours after recovery from anesthesia. Additional doses of methadone after 18 hours postoperatively and any doses administered earlier than scheduled were considered rescue analgesia and administered at clinician discretion and on the basis of patient examination. Dogs receiving rescue analgesia re -mained in the study analysis. Dogs were evaluated at 4 time points postoperatively: 2 to 10 hours, 14 to 24 hours, 36 to 48 hours, and 60 to 72 hours to repre -sent days 0, 1, 2, and 3 postoperatively, respectively. At each time point, GCMPS, STT assessments, HR, and indirect systolic BP were recorded, and blood was obtained for serum cortisol measurements. The GCMPS evaluation was performed by 2 trained ob -servers (LPH and a trained independent observer: KA, SS, JSA, ED, or CC) at each time point, both of whom were blinded to the administered treatment and each other’s GCMPS score. To ensure blind -Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 01/27/24 05:24 PM UTC 3ing between observers, 1 observer performed their GCMPS evaluation without the second observer present. Then, the second observer would immedi -ately perform their GCMPS evaluation without the first observer present. Prior to the start of the study, LPH and all independent observers were given in-person instruction on the GCMPS and its use in post -operative patients with a board-certified veterinary surgeon (MLW). All parts of the GCMPS evaluation were used at each time point.Quantitative STT using an algometer was mea -sured by 1 observer (LPH) at each time point. During STT, the tip of the algometer was applied ap -proximately 2 cm lateral to the midpoint of the inci -sion. Pressure was applied until the patient reacted by showing discomfort (flinching, turning toward the tester, or vocalizing), the device was removed, and the highest pressure tolerated by the patient was recorded in Newtons. Preoperatively, STT was per -formed 3 times and averaged to establish a baseline for the patient and ensure the patient would tolerate STT throughout the study. Patients that did not tol -erate STT were removed from inclusion in the study. Thereafter, STT was performed once at each time point. Other data collected included duration of clini -cal signs associated with the dog’s condition preoper -atively, surgical procedures performed, surgical time, anesthesia time, anesthetic complications (hypoten -sion and hypothermia), time to first voluntary eating, time until discharge in days, immediate postoperative complications (ie, vomiting, regurgitation, etc), and whether rescue analgesia was required as determined by the overseeing clinician. Hypotension was defined as a mean arterial pressure < 60 mm Hg, diastolic ar -terial pressure < 40 mm Hg, and/or systolic arterial pressure < 90 mm Hg. Hypothermia was defined as a temperature < 36.67 °C . Anesthesia time was defined as the time from induction until tracheal extubation. Surgical time was defined as the time from the start of the initial incision to completion of skin closure. Pa -tients were discharged on the basis of attending clini -cian discretion, ensuring no patients were discharged when opioids were still required.Follow-up was performed at least 1 month post -operatively by means of reviewing medical records and contacting referring veterinarians and/or the owner via telephone. Complications including in -cisional site inflammation, dehiscence, or infection were recorded.Statistical analysisAll analyses were performed using SAS version 9.4 (SAS Institute Inc), except for the calculation of the intraclass correlation coefficient, which was per -formed using the irr package in R (version 0.84.1; R Core Team). A significance threshold of 0.05 was used. Two raters recorded GCMPS scores for each dog and time point. The 2 values were averaged pri -or to analysis.Linear mixed models were used to compare GCMPS, algometer readings, HR, BP, and cortisol values between groups. Histograms and Q-Q plots of conditional model residuals were examined to evaluate the assumption of normality, and plots of conditional residuals versus predicted values of as -sessments were examined to evaluate the assumption of homogeneity of variances. Pain scores, algometer readings, and cortisol values all exhibited increasing variability with increasing mean values and were log-transformed prior to analysis. A constant of 1 was added to all pain scores so there were no zero values, which cannot be log-transformed. Each linear mixed model had fixed factors of treatment, time, and a treatment by time interaction and a baseline covari -ate and a random intercept for each dog. Simple ef -fects of treatment were tested at each time. The Sat -terthwaite degrees of freedom method and restricted maximum likelihood estimation were used. Normally distributed data are presented as mean ± SD. Nonnor -mally distributed data are presented as median (IQR).ResultsForty dogs were prospectively enrolled in this study (20 BLIS and 20 saline) on the basis of previ -ous studies.13,15,25,26 One patient that received BLIS was excluded from cortisol testing due to hypoadre -nocorticism. The mean age was 8.6 ± 4.5 years. There were 20 male dogs (3 intact and 17 castrated) and 20 female dogs (3 intact and 17 spayed). The most com -mon dog breed was mixed-breed dog (n = 14 [35%]), followed by German Shepherd Dog (3 [7.5%]), Labra -dor Retriever (3 [7.5%]), Welsh Corgi (2 [5%]), Minia -ture Pinscher (2 [5%]), and 1 each of 17 other breeds. There was no difference between groups in age, sex, body condition score, or weight (Table 1) . Saline BLIS P valueAge (y) 9.1 ± 3.8 8.2 ± 5.1 .535Sex MI: 0 MI: 3 .270 MC: 10 MC: 7 FI: 1 FI: 2 FS: 9 FS: 8 Body condition 5.2 ± 1.4 5.6 ± 1.3 .420 score (1–9)Weight (kg) 24.1 ± 12.7 20.3 ± 13.8 .367FI = Female intact. FS = Female spayed. MC = Male castrated. MI = Male intact.Table 1 —Demographic data for dogs in the saline group as compared to the bupivacaine liposomal injectable so -lution (BLIS) group. Values are expressed as mean ± SD.The most common surgeries performed were splenectomy (n = 11), gastropexy (11), and liver biopsy (11). Other procedures performed included liver lobectomy (n = 4), cholecystectomy (4), enter -otomy (4), diaphragmatic herniorrhaphy (3), gas -trotomy (2), and 1 of each of prostatic omentaliza -tion, nephrectomy, partial nephrectomy, intestinal resection and anastomosis, colopexy, ovariectomy, ovariohysterectomy, and ureterotomy, with 26 of 40 (65%) dogs undergoing > 1 surgical procedure within 1 anesthetic episode. Of the baseline assessments performed at day –1, no significant differences were Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 01/27/24 05:24 PM UTC4 noted between the BLIS and saline groups. There was no difference in number of procedures, surgery time, anesthesia time, hypotension, or hypothermia intraoperatively between groups. There was no dif -ference between groups in postoperative gastroin -testinal complications including vomiting/regurgi -tation, anorexia, and diarrhea ( P = .752). Regarding time to first voluntary ingestion of food, there was no difference between groups, with saline dogs eat -ing 0.78 ± 0.81 days postoperatively as compared to BLIS dogs eating 0.81 ± 0.54 days postoperatively (P = .883). No difference was present in length of postoperative hospitalization between groups, with saline dogs hospitalized for 2.05 ± 1.35 days and BLIS patients hospitalized for 2.2 ± 0.77 days ( P = .670). Rescue analgesia was required in 6 of 40 (15%) dogs, including 4 in the BLIS group and 2 in the sa -line group, which was not different between groups (P = .661; Figure 1 ). Follow-up at 30 days postopera -tively was available in 34 of 40 (85%) dogs. One of 17 dogs in the BLIS group and 0 of 17 dogs in the saline group had surgical site infection and dehiscence of the surgical incision ( P = 1.000).Direct pain assessmentsPain assessment data were available for all dogs preoperatively and at days 0 and 1, 30 dogs (17 BLIS and 13 saline) at day 2, and 10 dogs (6 BLIS and 4 saline) at day 3. Direct pain assessment data are avail -able (Table 2) . GCMPS score was significantly lower in the BLIS group at day 3 ( P = .027; Figure 2 ). The median pain score in the saline group was 2 (2 to 3; n = 4) and in the BLIS group was 1 (0 to 3; 6). The GCMPS score was not significantly different between groups at any other time point. Additionally, the mean and median GCMPS scores at all time points in both groups were lower than the intervention threshold es -tablished in previous studies.27 The inter-rater reliabil -ity for the 159 paired scores from 2 raters was good at 0.89 (95% CI, 0.85 to 0.92). The mean difference be -tween raters was –0.16, and the limits of agreement were –2.4 to 2.1. There were no differences in STT tol -erance between groups at any time point (Figure 3) .Figure 1 —Kaplan Meier plot showing time in hours to rescue analgesia administration from the time of tracheal extubation. No difference was present between groups regarding administration of rescue analgesia ( P = .661).Table 2 —Objective pain assessment data reported as mean ± SD or median (IQR). Day –1 represents the preopera -tive time point, and days 0, 1, 2, and 3 represent 2 to 10 hours, 14 to 24 hours, 36 to 48 hours, and 60 to 72 hours postoperatively, respectively. Mean difference is given as BLIS value minus saline value. Estimated difference is given as BLIS value minus saline value and is adjusted for baseline and missing values. Time Mean difference Estimated difference Assessment point Saline BLIS (95% CI) (95% CI) P valueGCMPS –1 0 (0 to 2) 1 (0 to 1) — — — 0 2 (1 to 3) 4 (1 to 6) — 1.03 (0.68 to 1.56) .899 1 2 (1 to 4) 2 (1 to 4) — 0.87 (0.57 to 1.33) .519 2 1 (0 to 4) 1 (0 to 3) — 0.79 (0.5 to 1.26) .321 3 2 (2 to 3) 1 (0 to 3) — 0.44 (0.21–0.91) .027Sensory threshold –1 7.5 ± 4.9 5.7 ± 3.3 –1.7 (–4.4 to 0.9) — — testing (N) 0 7.0 ± 3.6 5.4 ± 2.7 –1.6 (–3.7 to 0.5) 0.83 (0.61 to 1.14) .249 1 5.5 ± 2.5 4.6 ± 2.4 –0.9 (–2.5 to 0.7) 0.90 (0.66 to 1.22) .486 2 5.5 ± 2.1 5.2 ± 3.0 –0.3 (–2.3 to 1.7) 0.94 (0.67 to 1.32) .715 3 3.8 ± 1.9 3.4 ± 1.3 –0.3 (–2.7 to 2.0) 0.81 (0.49 to 1.34) .404Blood pressure –1 144.1 ± 20.7 136.1 ± 21.5 –8.0 (–21.5 to 5.6) — — (mm Hg) 0 149.6 ± 28.1 125.8 ± 25.8 –23.9 (–41.1 to 6.6) –23 (–39 to 7) .006 1 143.9 ± 24.8 127.4 ± 28.7 –16.5 (–33.6 to 0.7) –16 (–31 to 0) .057 2 139.5 ± 16.6 128.0 ± 21.1 –11.5 (–26.1 to 3.1) –10 (–28 to 8) .272 3 125.0 ± 24.7 134.5 ± 8.9 9.5 (–15.3 to 34.3) 18 (–10 to 47) .210Heart rate –1 117.0 ± 21.1 112.5 ± 30.0 –4.5 (–21.1 to 12.1) — — (beats/min) 0 108.6 ± 21.4 99.9 ± 29.6 –8.8 (–25.3 to 7.8) –8 (–24 to 8) .327 1 111.5 ± 24.5 104.0 ± 29.7 –7.5 (–24.9 to 9.9) –7 (–23 to 9) .408 2 116.9 ± 22.0 95.5 ± 21.5 –21.5 (–37.8 to 5.1) –13 (–31 to 5) .161 3 109.0 ± 31.2 105.5 ± 26.9 –3.5 (–46.0 to 39.0) 9 (–19 to 37) .525Serum cortisol –1 4.2 ± 2.7 4.0 ± 2.1 –0.2 (–1.8 to 1.4) — — (g/dL) 0 11.4 ± 7.8 9.6 ± 7.3 –1.8 (–6.7 to 3.1) 0.79 (0.50 to 1.24) .304 1 4.2 ± 2.4 3.9 ± 2.6 –0.3 (–1.9 to 1.3) 0.85 (0.54 to 1.34) .481 2 4.0 ± 2.4 3.9 ± 2.5 –0.1 (–2.1 to 1.8) 1.03 (0.61 to 1.730 .925 3 2.9 ± 2.1 2.8 ± 1.6 –0.1 (–2.8 to 2.6) 1.44 (0.61 to 3.41) .398GCMPS = Glasgow Composite Measure Pain Scale. Bolded P values indicate significance.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 01/27/24 05:24 PM UTC 5Indirect pain assessmentsThere was no difference between the saline and BLIS groups regarding indirect assessment of pain (se -rum cortisol, BP, and HR) at any time point, except for BP on day 0 (23.9 [6.6 to 41.1] mm Hg lower in the BLIS group than the saline group; P = .006; Figure 3), which was the first assessment between 2 and 10 hours post -operatively. An increase in serum cortisol concentra -tion was identified in both the saline and BLIS groups at day 0 postoperatively, but there were no differences between groups at any time point. There was no differ -ence in HR between groups at any time point.Figure 3 —Sensory threshold testing (STT) via algometer (A), indirect systolic blood pressure (B), serum cortisol (C), and heart rate (D) values at each time point. All graphs represent mean ± SE. Day –1 represents the preoperative time point and days 0, 1, 2, and 3 are 2 to 10 hours, 14 to 24 hours, 36 to 48 hours, and 60 to 72 hours postopera -tively, respectively. Significance is notated by an asterisk ().Figure 2 —Glasgow Composite Measure Pain Scale scores at each time point. Day –1 represents the preoperative time point and days 0, 1, 2, and 3 are 2 to 10 hours, 14 to 24 hours, 36 to 48 hours, and 60 to 72 hours postop -eratively, respectively. Each box is drawn from the 25th percentile to the 75th percentile. The horizontal line in -side the box shows the location of the median, and the symbol shows the location of the mean. Whiskers extend from the upper edge of the box to the largest observed value ≤ 1.5 X IQR above the 75th percentile, and from the lower edge of the box to the smallest observed value ≥ 1.5 X IQR below the 25th percentile. Observations outside the whiskers are identified with data markers. Significance is notated by an asterisk ().Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 01/27/24 05:24 PM UTC6

Question 23

Zann - 2023 - VETSURG - Long-term outcome of dogs treated by surgical debridement of proximal humeral osteochondrosis.pdf

Answer 23

2.1 |Case selection and enrollmentThis study was approved by the Institutional AnimalCare and Use Committee of The Ohio State University(IACUC Number 2020A00000008). A medical recorddatabase search was performed to identify dogs receivingunilateral or simultaneous bilateral debridement of proxi-mal humeral OC lesions at the Ohio State University Vet-erinary Medical Center between October 1, 2009 andOctober 1, 2019. Information on age, breed, sex, spay/neuter status, diagnostic imaging performed –radio-graphs, computed tomography (CT), or both –date ofsurgery, and surgical approach (arthroscopy or arthrot-omy) were collected and reviewed.All clients were contacted via telephone. Relevantmedical history, enrollment requirements, and inclusioncriteria were discussed using a predetermined telephonescript. Dogs were excluded from enrollment if additionalorthopedic disease unrelated to the OC diagnosis, affect-ing either thoracic limb, was documented in the medicalrecord, verbalized by the owner, or detected later in theorthopedic examination or with diagnostic imaging. Writ-ten consent was obtained by each owner at the time ofcase enrollment.2.2 |Dog examinationAc o m p l e t eo r t h o p e d i ce x a m i n a t i o nw a sp e r f o r m e db yaboard-certified small animal surgeon (SCJ) in all dogs. Inchronological order, the unsedated orthopedic examinationconsisted of a subjective ga it evaluation, followed by astanding and/or recumbent ort hopedic examination, fol-lowed by an additional gait assessment after the orthopedicexamination. The gait examina tion included both a walkingand trotting examination with the subjective gait evaluationperformed using the numerical rating system defined byMarshall et al. (0 =clinically sound, 1 =subtle lameness,2=mild lameness, 3 =moderate lameness, 4 =severelameness, 5 =non–weight bearing).11Thoracic limb musclemass was measured in standing dogs utilizing the techniquepreviously described by Smith et al.12Briefly, a measure-ment of limb circumference was recorded at the midpointbetween the cranioproximal as pect of the greater tubercleand at the distalmost aspect of the lateral epicondyle using aGulick tape measure (Gulick II, Country Technology, Inc.,Gays Mills, Wisconsin). Care was taken to ensure that thetaped circumference was positioned perpendicular to thelong axis of the brachium. An average of 3 measurementswas recorded. The examiner was blinded to the lateralityand date of proximal humeral OC debridement.ZANN II ET AL . 811 1532950x, 2023, 6, 2.3 |Kinetic gait analysisDogs were allowed to acclimate to the gait laboratoryfor 10 minutes prior to being walked on a validatedpressure-sensitive walkway system (Strideway Version7.8, Tekscan Animal Walkway System, South Boston,Massachusetts). The pressure-sensitive walkway wascalibrated prior to each case. Five valid trials per dogwere averaged and used for data analysis. A trial was con-sidered valid if the dog was walked at a relaxed, steadywalk (defined as a gait pattern consisting of 3 paws onthe floor at any given time) without pulling on the leash,and with no overt turning of the head from midline, at avelocity between 0.8-1.3 m/sec and acceleration between±0.1 m/s2.13,14Peak vertical force, vertical impulse, and sym-metry indices were measured and averaged for each dog.2.4 |Sedated examination, radiography,and quantitative analysisFollowing kinetic gait analysis, dogs were sedated withdexmedetomidine hydrochloride 5 mcg/kg (Dexdomitor,Zoetis Inc., Kalamazoo, Michigan) and butorphanol tar-trate 0.2 mg/kg (Torbugesic, Zoetis Inc.) delivered intra-venously. Shoulder goniometry (flexion, extension, andabduction) was performed 3 times with the dog sedatedand in lateral recumbency. Values were recorded andthe average used for statistical analysis. Orthogonalradiographs (Canon CXDI 60G detector, Sound-Eklin,Carlsbad, California), consisting of craniocaudal andmediolateral projections of both shoulder joints wereacquired in all cases. The width and depth of articulardefects affecting the humeral head were measured by asingle observer (GJZ) utilizing the tangent line techniquedescribed by Ito et al.15In brief, lines connecting thecranial-caudal articular margins of the defect were drawnand utilized to measure defect size on the mediolateralradiographic projections (Figure 1). Osteoarthritis wasgraded using ordinal assessment screening criteria origi-nally described by Runge et al16(Table 1). Osteophyteformation of the caudal humeral head, mineralization ofthe bicipital groove, joint mice, as well as glenoid sub-chondral sclerosis and osteophytosis were subjectivelygraded based on the severity of radiographic changespresent.2.5 |Computer tomography andquantitative analysisUnder the same sedation episode, a sedated helical CTstudy (64-slice detector GE Revolution EVO, GE Health-care, Waukesha, Wisconsin) of both shoulder joints wasperformed. Dogs were positioned in sternal recumbencywith the shoulders extended. Both shoulders werescanned together and reconstructions were made using abone algorithm. Lesion localization was classified as cau-docentral or caudomedial relative to the articular surfaceof the glenoid using the methodology previouslydescribed by Oliveri et al.10Osteoarthritis was alsoassessed on the CT data using an ordinal grading schemebased on the height of the largest osteophyte as previ-ously described by Moores et al.17(Table 2).Utilizing an application of the methodologiesdescribed by Saito et al.18and Kodali et al.,19best fit cir-cles were utilized by a single observer (GJZ) to quantifythe size of the articular defect. To achieve this, circleswere superimposed over the humeral head in the dorsaland sagittal planes in a web-based image managementFIGURE 1 Right mediolateral radiograph of dog #6, 1.0 yearspostoperatively. The blue line measures lesion length, and connectsthe cranial and caudal articular margins of the osteochondrosisdefect. The black line measures lesion depth, as assessed from thedeepest aspect of the defect to the line measuring lesion lengthTABLE 1 Subjective radiographic grading of osteoarthritis asdescribed by Runge et al.13Score Subjective osteoarthritis grading0 None1 Mild2 Moderate3 Severe812 ZANN II ET AL . 1532950x, 2023, 6, program (RocketPACS, Vet Rocket, Santa Clara, CA).Circles were sized and positioned in order to match bonecontour and minimize edge-to-edge distance between thecircle and areas of healthy bone. Lesion height was mea-sured from the deepest aspect of the articular defect tothe best fit circle. Lesion width was recorded from thearticular edges of the defect (Figure 2).2.6 |Arthroscopy, arthrocentesis, andjoint fluid analysisArthroscopic assessment was performed immediately fol-lowing diagnostic imaging. If any dog required additionalsedation, dexmedetomidine hydrochloride 3 mcg/kg(Dexdomitor, Zoetis Inc.) was delivered intravenously.Arthroscopy was performed by a board-certified surgeon(SCJ) on sedated dogs positioned in lateral recumbencywith the affected limb up and held parallel to the table. A20 or 22 gauge needle was inserted distal to the acromialprocess of the scapula and advanced perpendicular to thelimb into the joint space; expected needle insertion posi-tion was predetermined based on measurements using acalibrated mediolateral radiographic projection. Jointfluid was aspirated to confirm location within theshoulder joint; this joint fluid sample was retained forlater analysis. Using the needle as a guide, a 1.9 mm 0/C14semi-rigid arthroscope (NanoScope, Arthrex Inc, Naples,Florida) offering a 120/C14field of view was advanced intra-articularly and an arthroscopic joint examination wasperformed. Video recordings of the joint examinationwere obtained in standardized fashion for each case. Thecaudal joint space, including the site of previous OCpathology, was visualized, followed by the medial jointcompartment, and finally the cranial joint space.Arthroscopic videos were later randomized and evalu-ated by the same board-certified surgeon (SCJ). Videoswere assessed at least 30 days after needle arthroscopywas performed to ensure the evaluator was blinded todog identification, signalment, and history. An ordinalgrading rubric was utilized to assess synovial hypertrophyand vascularity as described by af Klint et al. by scoringthese parameters 0-4, with 0 representing normal and4 representing severe pathology.20Subjective percentageof cartilage infilling was also quantified. Modified Outer-bridge scoring was used to grade the articular cartilage ofthe humeral head.21Evaluation of joint fluid samples was performed usingan automated chemistry analyzer (Roche DiagnosticsUSA, COBAS 6000, Indianapolis, Indiana) and micro-scopic smear assessment. White blood cell (WBC) countand percentage WBC distribution, total protein content,specific gravity, and fluid color, clarity, and viscosity wereassessed. Joint fluid cytology was performed by a board-certified clinical pathologist.2.7 |Owner assessment of lamenessAll owners completed a previously validated question-naire on dog lifestyle and current mobility status(LOAD)22at the time of case enrollment. Aggregatelameness scores were interpreted as described by Cachonet al.232.8 |Statistical analysisStatistical analysis was performed using computer soft-ware (IBM Corp. Released 2020. IBM SPSS Statistics, Ver-sion 27.0. Armonk, New York). Descriptive statistics werecalculated for signalment data, LOAD questionnaire data,and the time from surgical debridement to follow up. Allcontinuous variables were first tested for normality usingShapiro-Wilk tests. In dogs with unilateral disease, ortho-pedic examination findings (brachial circumference,shoulder abduction, shoulder extension, and shoulderflexion) and diagnostic imaging data (lesion size and oste-oarthritis) were compared using paired t-tests. Kineticdata from unilaterally affected cases and arthroscopicfindings from all shoulders were evaluated utilizing Wil-coxon signed-rank tests. In cases of unilateral disease, thecontralateral, orthopedically healthy limb was used as acontrol. Symmetry indices based on peak vertical forcewere analyzed and considered reportable in values >3.2%based on the findings of Fanchon et al.24Symmetry indi-ces were compared using a paired t-test. For all analyses,P< .05 was considered significant.3|RESULTSBased on the results of a medical records database search,and after screening for study candidates meeting inclu-sion criteria, the owners of 76 dogs were contacted.TABLE 2 Computed tomography grading of osteoarthritisbased on the height of the largest osteophyte as described byMoores et al.14Score Definition0 No osteophytes1 Osteophytes <2 mm2 Osteophytes 2 –5 mm3 Osteophytes >5 mmZANN II ET AL . 813 1532950x, 2023, 6, All dogs meeting the inclusion criteria, with consentingowners, were enrolled. Twenty dogs [17 males: 3 intact,14 castrated; 3 females: 1 intact, 2 spayed] were enrolledin the study. The mean (± standard deviation) age ofdogs enrolled in the study was 4.4 (±2.5 years). Themean (± standard deviation) duration post surgery atthe time of evaluation was 3.5 (±2.5) years. The mean(± standard deviation) dog weight was 44.3 (±5.0) kgs.Fourteen dogs with unilateral disease (9 left, 5 right)and 6 dogs with bilateral disease (for a total of 26 shoul-ders) were evaluated. Twenty-two shoulders were ini-tially treated with arthroscopic surgery (16 dogs);4s h o u l d e r sw e r es u r g i c a l l yd e b r i d e dv i ao p e na r t h r o t -omy (4 dogs). Eighteen of the 20 dogs were noted tohave forelimb lameness on subjective orthopedicexamination.The average subjective lameness score (± standarddeviation) was 1.4 (±0.75). In cases with unilateral proxi-mal humeral OC, brachial circumference ( P=.003) andshoulder extension angle ( P=.013) were decreased andshoulder flexion angle ( P=.008) was increased (ie lessflexion) in the OC limb when compared to contralateral,orthopedically healthy control limb (Tables 3and4). Inunilaterally affected dogs, there were no differences inpeak vertical force and vertical impulse between affected(37.4 /C621.7 kgs and 12.8 /C67.2 kgs, respectively) andunaffected (39.1 /C621.5 kgs and 13.1 /C67.0 kgs, respec-tively) limbs. However, dogs with unilateral disease diddemonstrate asymmetric load distribution between theforelimbs, with a mean (± standard deviation) of 4.4(±8.5%) decrease in load distributed on the operatedlimb. In dogs with bilateral OC lesions, there was no dif-ference where P>.05 in load distribution between thethoracic and pelvic limbs when compared with the uni-laterally affected study population.FIGURE 2 (A) Sagittal image ofpatient #10, 3.2 years postoperatively.(B) Dorsal image of patient #20,7.3 years postoperatively. Digitallyimposed circles were positioned andcontoured over the articular, healthysurface of the proximal humerus. Lesionheight was measured from the deepestaspect of the articular defect to thecircle. Lesion width was recorded fromthe articular edges of the defect alongthe circleTABLE 3 Mean ( +//C0standard error) values of brachialcircumference measured during standing orthopedic examination.Brachial circumference was significantly decreased ( P=.003) indogs with unilateral shoulder OC when compared with thecontralateral, healthy limbTABLE 4 Mean ( +//C0standard error) values of shoulder rangeof motion measured on sedated patients positioned in lateralrecumbency. The maximum shoulder extension angle ( P=.013)was significantly decreased and the maximum shoulder flexionangle ( P=.008) was significantly increased (ie less flexion) in dogswith unilateral shoulder OC when compared with the contralateral,healthy limb814 ZANN II ET AL . 1532950x, 2023, 6, Lesions consistently measured wider ( P=.001) anddeeper ( P=.038) when measuring on CT images whencompared with radiography (Table 5).Osteoarthritis waspresent in all shoulders with historical OC lesions.Degree of osteoarthritis in shoulders with OC lesions wasincreased when compared to the contralateral joint onboth the CT ( P=.005) and radiographic ( P=.0001) anal-ysis in unilaterally affected dogs. Based on CT imaging,17 OC lesions were caudocentrally located with theremaining 9 lesions being caudomedial.Joint fluid samples were obtained from 15 shoulders.11 samples were demonstrative of mild mononuclearinflammation; 4 samples were unremarkable. There wereno cytologic abnormalities consistent with inflammatory/infectious disease, neoplasia, or severe degenerative jointdisease detected in the sample population. Insufficientjoint fluid volume for analysis (<0.1 ml) was acquired in11 shoulders.Arthroscopic assessment was performed in 23 shoul-ders. Superficial pyoderma (n =2) and severe periarti-cular osteophytosis inhibiting safe arthroscopeinsertion (n =1) precluded joint evaluation in 3 joints(2 unilaterally affected dogs ,1b i l a t e r a l l ya f f e c t e dd o g ) .Moderate to severe synovitis was seen in all OC affectedshoulder joints. Every OC le sion was noted to have pat-chy, incomplete infilling with cartilaginous-appearingtissue (Figure 3).T h ef u l lO C Dl e s i o nw a sv i s u a l i z e di n22 joints. In the other 4 joints, due to the medial loca-tion of the OCD lesion, the most medial aspect of thelesion was not fully visualized. Of the portion of thelesions seen in all dogs, the mean ( /C6standard deviation)cartilage infilling was 37.4 ( /C612.5) %. Median (range) forordinal grading for hypertrophy was 3 (range: 2-4).Median (range) for ordinal grading for vascularity was2 (range: 1-3). Median (range) for ordinal grading forModified Outerbridge scoring was 2 (range: 2-5)(Table 6).Based on LOAD scoring, owners assessed their dog’smobility to be “very good ”(n=11),“good ”(n=7), and“fair”(n=2). Owners also graded dogs as “not at all dis-abled ”(n=13),“slightly disabled ”(n=6), and “moder-ately disabled ”(n=1) by their current level of lameness.The median of aggregate LOAD scores was6 (range: 0-20).4

Question 24

Koch - 2023 - JFMS - Outcome and quality of life after intracranial meningioma surgery in cats.pdf

Answer 24

Patient selectionThe patient database of the University of Veterinary Medicine in Vienna was searched for cats with histopatho-logically confirmed intracranial meningioma treated with craniotomy from May 2009 to March 2021. To meet the inclusion criteria, patients needed to have magnetic reso -nance imaging (MRI) performed prior to surgery.Data collectionFor each included patient, their age, cause of presenta-tion, preoperative neurological status, MRI findings, disease-related medications or therapies, and survival time were obtained.To evaluate postoperative development, a standard-ised questionnaire, adapted from the study by Weiske et al,8 was developed. The number of questions asked was reduced, and questions were designed with respect to the most common preoperative changes noticed in all patients, as well as patient-specific clinical signs.Owners of all cats receiving surgery for meningioma in the forementioned period of time and meeting the inclu -sion criteria were contacted via telephone in November 2020 to March 2021, and the time from surgery to survey was calculated. Questioning was performed to obtain information regarding the status of the first few days after discharge and the current status or the best status before death within one conversation. In the case of death, the cause and date were noted. Our questionnaire consisted of three domains, each subdivided into different items. For the first domain, physical behaviour, including gen -eral condition, food intake and mobility, was evaluated. General condition was ranked from lethargy to the cat’s normal behaviour. Food intake was screened from insuf -ficient to sufficient. For mobility, the scale ranged from an inability to walk to a normal gait with the ability to jump. Grading was possible on a range from 0, reflecting the worst condition, to 10, reflecting the best.The second domain evaluated disease-related changes and included the development of preoperative existing clinical signs, seizures and related medication. Questions regarding the improvement of preoperatively existing clinical signs were designed as closed ones and were personalised for each cat. The occurrence of postopera-tive seizures was evaluated for the period immediately after surgery and the current situation or situation before death. The necessity of medication for seizure control and the type of medication were obtained.In the last domain, the overall impression was evalu -ated by asking whether the cat had more bad days than good days, or vice versa. Again, grading was possible within a range from 0 to 10.Time until improvement in days was evaluated for every item.Finally, owners were asked, without considering financial aspects, if they would choose to have surgery for their cat again, and 0 represented a strong ‘no’, while 10 represented a strong ‘yes’.Statistical analysisStatistical analysis was performed using SPSS, version 19 (IBM Corp.). To evaluate the differences between values immediately after surgery and at the time of questioning, or before death, the Wilcoxon test was used. P <0.05 was considered statistically significant. For non-descriptive statistical analysis, only results from the first surgery were used, because taking a repetitive assessment for one cat into account would bear the risk of not being independent from the first one.ResultsMedical historyFourteen cats, all domestic shorthair, with a median (range) age of 11 (5–14) years at the time of surgery, were included in the study. The gender distribution was equal, with seven males and seven females. The most common reason for initial patient presentation was a change of behaviour, in 11 cases (79%), followed by lethargy, in eight (57%) cases. Circling was reported in 5/14 (36%) cases, followed by seizures and undefined pain, each present in four cats (29%). Further clinical signs were disorientation, problems with coordination, anorexia and blindness in Koch et al 3three cats (21%). Weakness, weight loss and anosmia were present in only two patients (14%) and the least common clinical signs were head tilt and ataxia, each in only one cat (7%).Neurological examinationComplete preoperative neurological examination was pos-sible in 13/14 cases, because one had been sedated until surgery owing to epileptic seizures. For the remaining cats, the most common clinical finding was lethargy, in six (46%) patients, followed by hopping deficiencies, in five (38%) patients. Ataxia and reduced pupillary reflex were present in four (31%) cats. Three cats (23%) showed proprioceptive deficiencies, blindness and pacing. Weakness, an exagger -ated patellar reflex, a reduced withdrawal reflex, a loss of face sensibility, head tilt and circling were each clinically present in two (15%) patients. The least common clini-cal findings were the inability to walk, an exaggerated extensor carpi radialis reflex, an exaggerated tibialis cra -nialis reflex, a reduced palpebral reflex and head turn, each present in one (8%) cat. The results of the neurological examination are listed in Table 1.T umour locationThe most commonly affected region was the parietal lobe, in eight (57%) patients. The frontal lobe was affected in five (36%) cats, and the temporal lobe was affected in four (29%). In two (14%) patients, the occipital lobe was involved, the falx cerebri was involved in one (7%), and the tentorium cerebelli was involved in another (7%). In 6/14 cases (42%), the meningioma overlapped in three regions. One (7%) cat was diagnosed with multiple men -ingiomas: one in the parietal lobe and one in the temporal lobe.Surgery and postoperative treatmentDepending on the location of the tumour, surgery was performed either by a rostrotentorial or caudotento-rial approach. It was performed by a European College of Veterinary Surgeons board-certified small-animal surgeon in all cases.Postoperatively, all patients were transferred to an intensive care unit. Three out of 14 (21%) cases died within 4 days of surgery and were excluded from fur -ther outcome evaluation. One died 24 h after surgery because this cat required ventilation owing to haemoglo -bin desaturation and was subsequently euthanased at the owner’s request. Another cat died within 48 h of surgery after cardiopulmonary arrest without the recurrence of spontaneous circulation. The third cat was euthanased on day 4 after surgery owing to lung oedema and acute renal failure.All remaining 11 cats were discharged. Gabapentin was continued after discharge in all remaining 11 (100%) patients. Nine cats (82%) received further treatment with prednisolone and an additional gastroprotec-tive. Anticonvulsive treatment with phenobarbital and levetiracetam was continued in 2/11 (18%) discharged patients. One cat (9%) needed further treatment with tramadol because of pain.Pathohistological examinationThe most common tumour type was transitional men-ingioma, in 6/14 (43%) cases. The second most common was the fibrous type, in 5/14 (36%) cases, followed by psammomatous (2/4; 14%) and meningothelial types (1/14; 7%).OutcomeThe median (range) survival time was 861 (15–2064) days. Six out of the 11 cats (55%) were still alive at the time of survey. Of the five deceased cases, two were euthanased owing to multiple seizures (one surviving 1377 days and the other 15 days after the operation). One cat was euthanased 2064 days after surgery owing to multimorbidity, apathy and anorexia. Another cat developed transitional cell car -cinoma of the urinary bladder and was euthanased 1215 days after meningioma surgery owing to problems with defecation, pollakiuria, pain and vomiting. Cause of death of the remaining cat could not be evaluated as the owner only responded with the year of death and did not answer further questions. This cat survived 474 days after surgery.Three cats (27%) had recurrence at a median (range) of 851 (133–1778) days after their first surgery and received revision surgery. One of those cats received additional radiotherapy. All of those cats were still alive at the time of questioning.Table 1 Findings according to the preoperative neurological examinationFrequency of occurrenceClinical signs46% Lethargy38% Hopping deficiencies31% AtaxiaReduced pupillary reflex23% Proprioceptive deficienciesBlindnessPacing15% WeaknessExaggerated patellar reflexReduced withdrawal reflexLoss of face sensibilityHead tiltCircling8% Inability to walkExaggerated extensor carpi radialis reflexExaggerated tibialis cranialis reflexReduced palpebral reflexHead turn4 Journal of Feline Medicine and Surgery Questionnaire resultsDescriptive analysis The owners of 11 cats discharged from hospital were surveyed within a median (range) time from surgery to telephone survey of 967 (227–4209) days after the first surgery. The owners of three cats that received revision surgery owing to tumour regrowth were asked to answer for both surgeries separately, lead-ing to a total of 14 questionnaires. Of those, one owner reported the year of death, but was not able to answer further questions. A full survey was therefore completed in 13/14 cases (93%).Postoperative behaviour was rated with a mean (SD) of 6.5/10 (± 2.9), which improved to 9.4/10 (± 1.1) at the stage of full recovery. The mean (range) time to full recovery was 17 (5–60) days. Postoperative food intake was reported with a mean (SD) of 5.8/10 (± 4.5) and improved to 10/10 ( ±0) after a mean (range) of 26 (2–60) days. Three owners needed to feed their cats with an oesophageal tube for a mean (range) time of 7 (2–28) days. The cats’ mobility after surgery was graded with an average of 6.1/10 and improved after a mean (range) of 73 (0–240) days to a mean (SD) of 8.7 ( ±2.0).Overall postoperative impression was ranked with a mean (SD) of 7.3/10 ( ±2.6) and improved to 10/10 ( ±0) (P = 0.007) at the time of full recovery.Preoperative existing clinical signs resolved in 95% of cases, with a calculated improvement of 100% for all clini -cal signs. In two patients, clinical signs improved mark -edly, but ataxia slightly persisted in both. One cat was deaf in one ear after surgery, according to the owner.Two cases (14%) suffered from postoperative epi-leptic seizures. One of them was referred to an exter -nal veterinary hospital 15 days after surgery and was euthanased. In one cat, the seizures were associated with tumour regrowth 133 days after the first surgery and resolved after revision surgery. Two cats had no clinical signs when recurrence was observed through MRI, but developed seizures after the second sur -gery and were still receiving medication at the time of questioning.Decision-making regarding the subsequent recov -ery and life quality of their cat was ranked out of 10 by all owners, including those of cats that had undergone revision surgery. The results are shown in Table 2.Pre- and postoperative comparisons Results from 10 ques-tionnaires evaluating cats after receiving one surgery were eligible for comparison with the Wilcoxon test. All evaluated items showed a statistically significant differ -ence between postoperative state and state at full recov-ery. The P value for the difference in behaviour postoperatively and at the state of full recovery was 0.011. For food intake and mobility, P values were 0.042 and 0.043, respectively. For overall impression, the P value was 0.027.Table 2 Evaluated items and results of descriptive analysis from the questionnaireFirst domainItem Score 1* Score 2†Behaviour 6.5 (±2.9) 9.4 (±1,1)Food intake 5.8 (±4.5) 10 (±0)Mobility 6.1 (±3.0) 8.7 (±2.0)Second domainPreoperative clinical sign Total Improved PercentBehaviour change 8 8 100Lethargy 7 7Circling 4 4Seizures 3 3Undefined pain 3 3Disorientation 2 2Coordination problems 3 3Anorexia 3 3Blindness 2 2Weakness 2 2Weight loss 2 2Anosmia 2 2Head tilt 1 1Ataxia 1 1 Total Resolved PercentBehaviour change 8 8 95Lethargy 7 7Circling 4 4Seizures 3 3Undefined pain 3 3Disorientation 2 2Coordination problems 3 2Anorexia 3 3Blindness 2 2Weakness 2 2Weight loss 2 2Anosmia 2 2Head tilt 1 1Ataxia 1 0Seizures Yes No PercentPostoperative 2 12 14Third domainScore 1* Score 2†Overall impression 7.3 (±2.6) 10 (±0)Decision-making owner Score Answers Percent 0–9 0/14 0 10 14/14 100Scores for pre- and postoperative evaluations are listed for the first and third domains. Values in parentheses represent the SD. Percentages are listed for the improvement or resolution of preoperative clinical signs and seizures*Score 1: average preoperative score†Score 2: average postoperative scoreKoch et al 5

Question 25

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

Answer 25

The medical records of Northwest Veterinary Specialists(United Kingdom) and of Kansas State University (UnitedStates) were searched to identify dogs diagnosed and surgi-cally treated for IVDE localized from the third thoracic (T3) tothird lumbar (L3) vertebrae between January 2016 andDecember 2020. The diagnosis was con firmed via magneticresonance (MR) and/or computed tomography (CT). Criteriafor inclusion in the study comprised availability of completemedical records, including timing of onset of clinical signs,presentation and surgery, neurological grade at examination,and neurological grade at discharge. Dogs with incompletemedical records, history of previous IVDE surgery, or diag-nosed with concurrent pathologies that could in fluence theirneurological status, were excluded from the study.Data CollectionEach dog ’s medical record was examined, and details ofsignalment, medical and surgical treatment, and durationof hospitalization were collected. The time between theinitial onset of clinical signs and presentation at the hospital(D1) and the duration from the presentation to the time ofsurgical decompression (D2)21were recorded. D2 was sub-sequently divided into three categories based on the timebetween presentation and surgical decompression: 0 to12 hours (S1), 12 to 24 hours (S2), and over 24 hours (S3).Each dog ’s neurological status was graded using a modi fiedFrankel score as shown in►Table 1 .28,29The rate of onsetwas de fined as the time from when the dog was last clinicallynormal until neurological signs developed, and it was gradedas described previously3and shown in ►Table 2 .Diagnostic ImagingAll dogs included were con firmed as having a thoracolumbarIVDE (Hansen type I) via computed tomography (CT), MR, orboth. The length of extruded disk material was measured bymultiplying the number of transverse image slices in whichthe extruded disk material was present, by the slice thick-ness. A ratio was then calculated between the length of theTable 1 Modi fied Frankel scoreNeurologicgradeClinical presentationGrade 0 Paraplegia with no deep nociceptionGrade 1 Paraplegia with no super ficial nociceptionGrade 2 Paraplegia with intact nociceptionGrade 3 Nonambulatory paraparesisGrade 4 Ambulatory paraparesisGrade 5 Spinal hyperesthesia.extruded disk material associated with the surgically oper-ated site and the length of the L2 vertebral body (DM/L2) aspreviously reported.21Surgical ProcedureAll dogs underwent a dorsolateral hemilaminectomy or mini-hemilaminectomy with the aid of surgical microscope (ZeissOPMI CS-NC-2). If the IVDE was spreading to more than oneintervertebral space, these were all approached surgically torelieve the spinal cord compression. At the surgeon ’s discretion,prophylactic fenestration was performed at the affected disksite(s). Anesthetic and surgery time were recorded for all dogs.OutcomesEvery dog was assessed at least once daily by a veterinarysurgeon and the number of days between surgery andrecovery of certain functions was recorded. For dogs pre-sented with neurological grade of 0 to 3, time to urinarycontinence (de fined as the ability of the dog to urinatevoluntarily without active or passive abdominal pressure)and ambulation (de fined for some dogs as the point at whichthe dog was first able to walk 10 or more steps unassisted)were assessed by the clinician or resident and recorded. Forsome dogs that had been discharged prior to return toambulation, owners were instructed on counting the stepsthe dog was able to make unassisted and report when thiswas 10 or more. For dogs presented with neurological gradeof 0, time between surgery and the first signs of deep painperception was assessed by the clinician or resident andrecorded. The degree of recovery was determined throughthe medical records, and it was classi fied as previouslydescribed21(►Table 3 ).Statistical AnalysisThe sample size exceeded the numbers required to detect amedium effect size at 80% power across a range of test typesaccording to Cohen.30Data are summarized as medianswith ranges. Numbers of individuals of each breed wereinsufficient to assess if breed in fluenced outcome variables.Variables of interest were age, weight, extrusion ’sr a t i o(DM/L2), an aesthetic and surgery length, D1, D2, onsetrate, fenestration, sex, and neurological grade at presenta-tion. Speci fic bivariate comparisons between continuousand/or ordinal variables were undertaken with Spearman ’srank correlation. Neurological grade at discharge was com-pared to D2 (categorized as <12, 12 –24,>24 hours) usingrank regression (using R fit in R) both without and withinclusion of neurological grade at presentation as a covari-ate. For dogs graded 0 at presentation, the in fluence of the12 variables of interest listed above on time to pain sensa-tion and on whether pain sensation returned was investi-gated in a backward elimination selection in a rankregression model and in a binary logistic regression model,respectively. Similarly for dogs graded 0 to 2, time tocontinence and whether conti nence ret urned were investi-gated. Finally for dogs graded 0 to 3, a similar approach wasused for time to ambulation and whether ambulationreturned. The threshold for statistical signi ficance wastaken as p<0.05. All analyses were performed using R4.2.2 or Minitab 19 statistical software.ResultsFour hundred and thirty-three dogs met the inclusion crite-ria. The median age was 6.25 years (range: 1 –16 years) andmedian weight was 7.8 kg (range: 2.2 –42 kg). There were 203(46.9%) Dachshunds, 31 (7.2%) Shih Tzus, 24 (5.5%) CockerSpaniels, 23 (5.4%) mixed breed dogs, 18 (4.2%) FrenchBulldogs, 12 (2.8%) Jack Russell Terriers, 10 (2.3%) LhasaApso, and 8 or less of 43 additional breeds. There were 183females (37 intact) and 250 males (50 intact).The surgical procedure involved one intervertebral spacein 334 (77.1%) dogs and two or more in 99 dogs. Fenestrationof the affected disk(s) was performed in 98 (22.6%) dogs.Table 2 The criteria for the rate of onset is illustrated in thetableRate of onset Definition of the time periodSudden <2hRapid From 2 to 48 hIntermediate >48–120 hProgressive >120 hMixed Progression of disease(over>120 h) followed by a rapiddeterioration in <48 hTable 3 T h ec r i t e r i af o rt h ed e g r e eo fr e c o v e r yi si l l u s t r a t e di nt h et a b l eDegree of recovery Clinical outcomeFull recovery Return to normal ambulation (grade 0 –4) or a resolution of pain (grade 5)Partial recovery Mild motor and proprioceptive de ficits not interfering with function (grade 0 –4)or a decrease without resolution of pain (grade 5)Incomplete Recovery An improvement in signs with residual paraparesis that does interfere with function(grade 0 –4) or an insigni ficant decrease in pain (grade 5)Poor recovery Maintenance of the preoperative neurological statusProgressive Deterioration of neurological status or development of myelomalacia.The median D1 was 2 days (range: 1 hour to 450 days). D2was available in 432 dogs. The median D2 was 5 hours (range:2–984 hours). The median length of anesthesia was165 minutes (range: 75 –380 minutes) and the median sur-gery length was 70 minutes (range: 20 –285 minutes). Post-operative treatments varied and included some combinationof opioids, nonsteroidal anti-in flammatory drugs, tramadol,glucocorticoids, gabapentin, αantagonists, diazepam, andpostoperative physical therapy.The neurological grade at presentation was 5 for 9 dogs(2.1%), 4 for 127 dogs (29.3%), 3 for 110 dogs (25.4%), 2 for23 dogs (5.3%), 1 for 91 dogs (21%), and 0 for 73 dogs(16.9%). Rate of onset was available in 432 dogs, and it wasconsidered sudden for 56 dogs (13%), rapid for 183 dogs(42.4%), intermediate for 64 dogs (14.8%), progressive for 68dogs (15.7%), and mixed for 61 dogs (14.1%).►Tables 4and 5show the median D1 and D2 for each presentingneurological grade and rate of onset. D1 and D2 changedconsistently with neurological presentation grades ( rs¼0.321 and rs¼0.471, respectively, both p<0.001), beingshorter for dogs with a worse grade at presentation. Therewere signi ficant differences between S1, S2, and S3 inneurological grade at presentation and in neurologicalgrade at discharge (both p<0.001 from rank regression);median grades were signi ficantly lower for S1 in both cases.However, if the neurological grade at presentation is in-cluded in the rank regression, no signi ficant difference isfound between the three subcategories of D2 in neurologi-cal grade at discharge ( p¼1.000). D1, D2, and rate of onsetwere not signi ficantly correlated with any outcomevariables.None of the dogs presented with a neurological grade 5underwent surgery on or within 12 hours (S1) but wereequally distributed between S2 and S3. Dogs presentedwith a neurological grade 4 were equally distributed be-tween S1, S2, and S3, and there was no signi ficant differencebetween the degree of recovery of these dogs (Kruskal –Wallis test; p¼0.744). Dogs presented with neurologicalgrade 3 underwent surgery mostly within 12 or 24 hours(65% in S1 and 25% in S2). Finally, 89% of dogs that presentedwith neurological grades 2 to 0 underwent surgery within12 hours (S1).The degree of recovery was available for 356 dogs. Amongall neurologic grades, 72.7% of the population regainedacceptable locomotor function (full or partial recovery) aftersurgical treatment. In detail, 114 (32%) had a full recovery,145 (40.7%) had a partial recovery, 49 (13.8%) had anincomplete recovery, 28 (7.9%) had a poor recovery, and 20(5.6%) had progression of disease or development of myelo-malacia. The degree of recovery related to presenting neu-rological grade is reported in►Table 6 and►Fig. 1 .A signi ficant association was found between moreacute onset of clinical signs, lower neurological grade atdischarge ( rs¼0.199; p<0.001) and worse degree of recov-ery ( rs¼–0.161; p¼0.002). Similarly, there was a signi ficantTable 4 A summary of median D1 and D2 for each presentingneurological gradeNeurologicgrade atpresentationD1 (h) D2 (h) Number51 6 8 ( 1 2 –1,008) 24 (4 –240) 941 4 4 ( 2 –5,040) 22 (2 –984) 12736 3 ( 3 –10,800) 5 (2 –360) 11024 8 ( 1 –1,440) 6 (3 –86) 2313 6 ( 2 –336) 4 (2 –46) 9104 8 ( 5 –1,440) 4 (2 –41) 73D1¼Time from the initial onset of clinical signs to presentation.D2¼Time from presentation to decompressive surgery.Table 5 A summary of median D1 and D2 for each presentingrate of onsetRate of onset D1 (h) D2 (h) NumberSudden ( <2 h) 13 (1-816) 4 (2-73) 56Rapid (2 –48 h) 26 (2-960) 4 (2-165) 183Intermediate(48–120 h)96 (54-576) 6 (2-73) 64Progressive(>120 h)336 (48-5040) 21 (2-984) 68Mixed ( >120 hfollowed by acuteworsening <48 h)168 (6-10800) 4 (2-168) 61D1¼Time from the initial onset of clinical signs to presentation.D2¼Time from presentation to decompressive surgery.Table 6 A summary of the degree of recovery for each presenting neurological grade categoryNeurologic gradeat time of surgeryFullrecoveryPartialrecoveryIncompleterecoveryPoorrecoveryProgressivediseaseTotal % of dogs that hadfull or partial recovery5 6 1 0 0 0 7 100%4 44 46 9 1 2 102 88%3 2 94 11 1 5 0 8 6 8 1 %2 4 10 3 1 2 20 70%1 2 33 41 2 2 5 7 6 7 5 %0 8 13 14 19 11 65 32%Note: Degree of recovery for each neurological grade at the time of surgery..correlation between higher grades at discharge andbetter degree of recovery ( rs¼–0.498; p<0.001).The ratio of the length of the extruded disk material to thelength of L2 vertebral body was available for 409 dogs. Themedian ratio was 1.08 (range: 0.29 –6.07) and it was signi fi-cantly correlated with more acute onset grades ( rs¼–0.150;p¼0.002), a shorter D2 ( rs¼–0.191; p<0.001) and a lowergrade at presentation ( rs¼–0.265; p<0.001) and discharge(rs¼–0.108; p¼0.032).For the 73 dogs that presented with neurological grade 0,there was no signi ficant relationship between return to painsensation or time to return of pain sensation and any othervariable.For the 187 dogs presented with a neurological grade 0to 2, there was a signi ficant relationship between a returnto urinary continence and weight (odds ratio: 0.909;95% con fidence interval [CI]: 0.847 –0.975; p¼0.008)and neurological grade at presentation (odds ratio: 5.3;95% CI: 2.4 –12.1; p<0.001); heavier dogs and more severecases were associated with longer time to regain urinarycontinence. Rank regression suggested a longer time toreturn to continence for older dogs ( p¼0.034) and forcases with lower neurological grade at presentation(p<0.001).For the 297 dogs with a preoperative grade 0 to 3, thevariables signi ficantly associated with return to ambula-tion were age (odds ratio: 0.984; 95% CI: 0.973 –0.995;p¼0.004) and the neurological grade at presentation (oddsratio: 3.2; 95% CI: 2.1 –4.8; p<0.001); lower success wasassociated with older and heavier dogs and more severecases. Rank regression identi fied fenestration duringsurgery ( p¼0.033), anesthetic length ( p¼0.012), and neu-rological grade at presentation ( p<0.001) as signi ficantlyassociated with time to return to ambulation. Dogs pre-sented with grades 1 to 3 were more likely and quicker toregain ambulation compared with grade 0, with, respec-tively, 92 and 46% of dogs that regained ambulation inthese two groups and return to ambulation was fasterwhen anesthetic length was longer and when fenestrationwas performed during surgery (median: 2 days; nonfenes-tration median: 14 days).

Question 26

Vodnarek - 2024 - VETSURG - Reliability of fluoroscopic examination of nasopharyngeal dorsoventral dimension change in pugs and French bulldogs.pdf

Answer 26

2.1 |Study designAnonymized videofluoroscopic examinations of theupper airways of pugs and French bulldogs were retro-spectively performed by four observers with differentlevels of experience (Observer 1: diplomate of theEuropean College of Veterinary Diagnostic Imaging;Observer 2: diplomate of the European College of Veter-inary Surgeons; Observer 3: surgery intern; Observer 4:resident of the European Col lege of Veterinary Diagnos-tic Imaging).2.2 |MaterialThe picture archiving and communication system(PACS) at our institution (JiveX, Visus, Essen, Germany)was searched for videofluoroscopic examinations ofclient-owned pugs and French bulldogs presenting withsymptoms of BOAS between January 2014 and JanuaryVODNAREK ET AL . 85 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13971 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 License2020. Videofluoroscopic examinations were performed aspart of the diagnostic protocol for brachycephalic airwaysyndrome established at our institution.2.3 |Inclusion and exclusion criteriaFor inclusion, the videofluoroscopic examination had torecord the nasopharynx for a minimum of two respira-tion cycles. Poor quality video examinations (e.g., due toinadequate positioning, not recording at least two respi-ration cycles due to the intolerance of patients to physicalrestraint, or because of swallowing or panting) wereexcluded.2.4 |Fluoroscopic examinationAll fluoroscopic examinations were performed using aremote-controlled X-ray diagnostic system with a fluo-roscopy table (Axiom Iconos R200, Siemens AG,Erlangen, Germany) and an X-ray tube current of200 mA and a voltage of 81 kV in the pulsed radiationmode, registering six frames per second. Patients wereplaced in right lateral recumbency using manualrestraint only, paying attention to their tolerance torestraint. Tracheal manipulation and compression werenot performed. The examination was performed in thelaterolateral view. To obtain valuable information, thetotal exposure time was determined by a radiologytechnician.2.5 |Fluoroscopic recordingsAll fluoroscopic evaluations were performed using thePACS at our institution. The recordings fulfilling theinclusion and exclusion criteria were subsequently cutinto 9 –10-s runs, focusing on the nasopharynx whileincluding at least two respiratory cycles.The studies were anonymized, exported as DICOMfiles, and duplicated. The paired recordings were codedand distributed to the observers in a random order usinga random number generator function via software avail-able under the GNU License (LibreOffice Calc, The Doc-ument Foundation, Berlin, Germany). Each observerreceived the same set of fluoroscopic studies and per-formed the measurements using their own laptop screenwith the same version of the DICOM viewer. Owing tothe duplication and randomization of the videos, eachobserver performed two measurements for each originalvideo using both methods without knowing whether andwhen they had previously evaluated the video. The mea-surements were performed one month after randomiza-tion to limit the recall bias of Observer 3, who edited andrandomized the videos.The observers received a brief video tutorial trainingthat explained the functions of the DICOM viewer usedFIGURE 1 Fluoroscopic images of the upper airway of a 1.5-year-old male neutered pug. The images were obtained in awake lateralrecumbency. (1) nasopharyngeal air column (shaded green in C +D), (2) soft palate (shaded pink in C +D), (3) epiglottis (shaded yellow inC+D). (4) dorsal nasopharyngeal wall. Note the narrowing of the nasopharyngeal air column during inspiration caused by the dorsalelevation of the soft palate with simultaneous ventral deviation (collapse) of the dorsal nasopharyngeal wall (purple arrows).86 VODNAREK ET AL . 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13971 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 Licensein the current study (Osirix_Lite software, version 12.x,Pixmeo SARL, Switzerland), described the anatomicalboundaries of the nasopharynx as seen on fluoroscopy,defined nasopharyngeal collapse, and explained bothmeasurement methods (see Figure2).2.6 |Measurement methods2.6.1 | Functional methodThe functional measurement method consists of the fol-lowing steps:1. In videofluoroscopic examination of the nasopharynxwith the dog in lateral recumbency, inspiration isdefined as the phase of the respiration cycle when thesoft palate moves caudodorsally. Conversely, the softpalate deflects rostroventrally during the expirationperiod. Observers were asked to identify the breathingcycle with the most severe dorsoventral narrowing ofthe nasopharyngeal lumen.2. The height of the narrowest nasopharyngeal lumenachieved during inspiration from the chosen breathingcycle was measured (LMin(FUNCT) ). The measurementswere performed perpendicular to the longitudinal axisof the nasopharynx. In some instances, the epiglottismay lift the soft palate dorsally. Therefore, no part ofthe nasopharynx caudal to the most rostral extremity ofthe epiglottis was considered in the measurements.Notably, similar to the actual measurement performedperpendicular to the long axis of the nasopharynx, thecaudal boundary of the rostral end of the epiglottis wasalso considered perpendicular to the longitudinal axisof the nasopharynx (blue line in Figure2).3. The height of the maximal dimension of the nasopha-ryngeal lumen achieved throughout the previous orfollowing expiration (L Max(FUNCT) ) at the same ana-tomical location as in the previous step was measured(yellow line in Figure2).2.6.2 | Anatomically adjusted method1. Inspiration and expiration of the chosen breathingcycle were identified in the same manner as in thefunctional method.2. A tangential line to the rostral-most end of the epiglot-tic cartilage (blue line in Figure 2) was placed perpen-dicular to the long axis of the nasopharynx. Theminimal (L Min(ANAT) ) and maximal (L Max(ANAT) )heights of the lumen were measured (orange line inFigure2) alongside the previously created tan-gent line.FIGURE 2 Fluoroscopic images of the upper airway of a 2.5-year-old male neutered French bulldog. The images were obtained inawake lateral recumbency. Both the B and D images are copies of their counterparts (A +C), where the measurement lines have beendrawn to explain the steps of the measurement: (1) minimum height of the nasopharyngeal air column during inspiration (L Min(FUNCT) ),(2) maximum height of the nasopharyngeal air column during expiration (L Max(FUNCT) ), (3) level of the most rostral extent of the epiglottis,(4) The maximum height of the nasopharyngeal air column (L Max(ANAT) ), (5) minimum height of the nasopharyngeal air column duringinspiration (L Min(ANAT) ).VODNAREK ET AL . 87 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13971 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 LicenseThe caliper tool of the DICOM viewer, which wasused to perform the linear measurements, allowed mea-surements with an accuracy of up to two decimal pointsper millimeter. However, the spatial resolution of thefluoroscopic units was limited. Therefore, the recordedmeasurements were rounded to the nearest whole milli-meter (i.e., ≤0.49 to 0, ≥0.50 to 1, ≤1.49 to 1, ≥1.50to 2, etc.).The observers recorded paired measurements of mini-mal and maximal nasopharyngeal dimensions for eachfluoroscopic video using both methods (LfunctMax, L funct-Min, L anatMax, and L anatMin). The randomization keywas subsequently revealed, and the observed measure-ments were assigned back to the patients, distinguishingthe first and second measurements of each observer andthe measurement method employed for future statisticalanalyses.The ratios of dynamic nasopharyngeal changes foreach pair of minimal and maximal measurements werecalculated using the following formula for both measure-ment methods:ΔL¼LMax/C0LMin ðÞ =LMaxA nasopharyngeal collapse grade was then assignedaccording to a previously published three-tier grading(no collapse: ΔL < 0.5, partial collapse: ΔL≥0.5 and <1,and complete collapse: ΔL=1).2,3Using the anonymization and randomization key, adataset of paired measurements for the first and secondattempts and the respective ratios of the dynamic naso-pharyngeal change for each animal and observer was cre-ated and prepared for statistical evaluation.2.7 |Statistical analysisUsing the icc function (R package irr, R version 4.0.2),4,5the paired measurements of the minimal and maximalnasopharyngeal dimensions of both methods (L Max,LMin) and paired ratios of the dynamic nasopharyngealchange ( ΔL) were compared for the intraobserver agree-ment for all observers com bined (global correlationcoefficient) and each observer separately. The means ofthe paired measurements and ratios were compared forinterobserver variability across all observers (global cor-relation coefficient) and for each pair of observers sepa-rately. The Bonferroni-Holm method was used formultiple testing corrections. Similarly, the assignedgrade of nasopharyngeal collapse was analyzed usingthe function kappam.fleiss (R package irr). Statisticalsignificance was set at an alpha cutoff of 5% after multi-ple testing corrections.The reliability of the observed intraclass correlationcoefficient (ICC) for intra- and interobserver agreementin the measurement of LMax,LMin, and ΔL values wasinterpreted based on previously published guidelines,where ICC values <0.5 indicate poor reliability, valuesbetween 0.5 and 0.75 indicate moderate reliability, valuesbetween 0.75 and 0.9 indicate good reliability, and valuesgreater than 0.9 indicate excellent reliability.6The strength of the intra- and interobserver agree-ment for assigning the grade of nasopharyngeal collapsewas interpreted based on previous recommendationsthat considered the kappa statistic.7Notably, κvalues<0.20 were considered poor, 0.21 –0.40 were consideredfair, 0.41 –0.60 were considered moderate, 0.61 –0.80were considered good, and 0.81 –1.00 were consideredvery good.3|RESULTSA total of 43 fluoroscopic videos of the upper airways ofFrench bulldogs and 35 videos of the upper airways ofpugs were obtained from the PACS at our institution.However, videos of only 20 French bulldogs and 16 pugsfulfilled the inclusion criteria.3.1 |Intraobserver variability for L MaxThe global correlation coefficient for intraobserver vari-ability for the measurement of L Maxwas 0.878 ( p< .01)for the functional method and 0.785 ( p<. 0 1 ) f o r t h eanatomically adjusted method and was therefore inter-preted as being good. Observer 1 achieved excellent, andthe highest, consistency between the first and secondmeasurements for both the functional (0.972, p< .01)and anatomically adjusted methods (0.973, p< .01)(Table1).3.2 |Interobserver variability for L MaxThe global correlation coefficient for interobserver vari-ability for the measurement of L Maxwas 0.857 ( p< .01)for the functional method and 0.763 ( p< .01) for the ana-tomically adjusted method and was therefore interpretedas being good (Table 2).3.3 |Intraobserver variability for L MinThe global correlation coefficient for intraobserver vari-ability for the measurement of L Minwas 0.795 ( p< .01)88 VODNAREK ET AL . 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13971 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 License(good) for the functional method and 0.676 ( p< .01)(moderate) for the anatomically adjusted method.Observer 1 achieved excellent consistency between thefirst and second measurements for both the functional(0.949, p< .01) and anatomically adjusted methods(0.961, p< .01) (Table3).3.4 |Interobserver variability for L MinThe global correlation coefficient for the interobservervariability for the measurement of L Minwas 0.7 ( p< .01)(moderate) for the functional method and 0.766 ( p< .01)(good) for the anatomically adjusted method (Table 4).TABLE 1 Intraobserver variabilityfor L Max.ObserverFunctional method Anatomically adjusted methodCorrelation coefficient p-value Correlation coefficient p-valueGlobal 0.878 <.0001 0.785 <.00011 0.972 <.0001 0.973 <.00012 0.814 <.0001 0.737 <.00013 0.870 <.0001 0.842 <.00014 0.865 <.0001 0.627 <.0001TABLE 2 Interobserver variabilityfor L Max.ObserverFunctional method Anatomically adjusted methodCorrelation coefficient p-value Correlation coefficient p-valueGlobal 0.857 <.0001 0.763 <.00011 vs. 2 0.904 <.0001 0.724 <.00011 vs. 3 0.830 <.0001 0.771 <.00011 vs. 4 0.865 <.0001 0.670 <.00012 vs. 3 0.840 <.0001 0.891 <.00012 vs. 4 0.830 <.0001 0.747 <.00013 vs. 4 0.871 <.0001 0.735 <.0001TABLE 3 Intraobserver variabilityfor L Min.ObserverFunctional method Anatomically adjusted methodCorrelation coefficient p-value Correlation coefficient p-valueGlobal 0.795 <.0001 0.676 <.00011 0.949 <.0001 0.961 <.00012 0.735 <.0001 0.452 .002283 0.716 <.0001 0.702 <.00014 0.699 <.0001 0.676 .000101TABLE 4 Interobserver variabilityfor L Min.ObserverFunctional method Anatomically adjusted methodCorrelation coefficient p-value Correlation coefficient p-valueGlobal 0.700 <.0001 0.766 <.00011 vs. 2 0.834 <.0001 0.655 <.00011 vs. 3 0.532 .000208 0.816 <.00011 vs. 4 0.706 <.0001 0.825 <.00012 vs. 3 0.606 <.0001 0.699 <.00012 vs. 4 0.816 <.0001 0.683 <.00013 vs. 4 0.666 <.0001 0.861 <.0001VODNAREK ET AL . 89 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13971 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 License3.5 |Intraobserver variability for ΔLThe global correlation coe fficient for intraobservervariability for ΔL was 0.751 ( p< .01) (good) for thefunctional method and 0.576 ( p< .01) (moderate) forthe anatomically adjusted method. Observer1 achieved excellent, and the highest, consistencybetween the first and second measurements for boththe functional (0.921, p< 0.01) and anatomicallyadjusted methods (0.94, p< 0.01) (Table5). Theintraobserver variability for ΔL is plotted in Figure 3for the anatomical method and in Figure 4for thefunctional method.3.6 |Interobserver agreement for ΔLThe global correlation coefficient for interobserver agree-ment for the measurement of ΔL was 0.621 ( p< .01)(moderate) for the functional method and 0.729 ( p< .01)TABLE 5 Intraobserver variabilityfor the ratio of the dynamic change innasopharyngeal dimensions. ObserverFunctional method Anatomically adjusted methodCorrelation coefficient p-value Correlation coefficient p-valueGlobal 0.751 <.0001 0.576 <.00011 0.921 <.0001 0.940 <.00012 0.611 <.0001 0.445 .005333 0.676 <.0001 0.558 .0004344 0.706 <.0001 0.361 .013FIGURE 3 Boxplot of intraobserver variability in measuring the ratio of the nasopharyngeal dynamic change using the functionalmethod. The boxes represent the 25th to 75th interquartile range (IQR) of intraobserver differences in the ratio of the dynamicnasopharyngeal change. The transverse line through the boxes represents the median. The upper and lower whiskers (vertical black lines)represent the 75th percentile +1.5 * IQR and 25th percentile –1.5 * IQR, respectively. The dots represent the outliers. The y-axis has a stepsize of 0.1 (10% difference in the ratio of the dynamic nasopharyngeal change). Observer (1) diplomate ECVDI, Observer (2) diplomateECVS, Observer (3) surgery intern, Observer (4) resident ECVDI. Observer 1 achieved the most consistent measurements among all theobservers and performed better in pugs than in French bulldogs (FB).90 VODNAREK ET AL . 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13971 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 License(moderate) for the anatomically adjusted method(Table 6).Of all the measured ΔLs, 234 (81.25%) and219 (76.04%) values were between 0.6 (including 0.6) and1 for the functional and anatomically adjusted methods,respectively (Figure5).3.7 |Intra- and interobserver agreementfor the grade of dynamic nasopharyngealcollapseThe global correlation coefficient for intraobserver agree-ment was 0.532 ( p< .01) for the functional method andFIGURE 4 Boxplot of intraobserver variability in measuring the ratio of the nasopharyngeal dynamic change using the functionalmethod. The boxes represent the 25th to 75th interquartile range (IQR) of intraobserver differences in the ratio of the dynamicnasopharyngeal change. The transverse line through the boxes represents the median. The upper and lower whiskers (vertical black lines)represent the 75th percentile +1.5 * IQR and 25th percentile –1.5 * IQR, respectively. The dots represent the outliers beyond this. The stepsize of the y-axis is 0.1 (10% difference in the ratio of the dynamic nasopharyngeal change). Observer (1) diplomate ECVDI, Observer(2) diplomate ECVS, Observer (3) surgery intern, Observer (4) resident ECVDI. Observer 1 achieved the most consistent measurementsamong all the observers and performed better in French bulldogs (FB) than in pugs.TABLE 6 Interobserver variabilityfor the ratio of the dynamic change innasopharyngeal dimensions. ObserverFunctional method Anatomically adjusted methodCorrelation coefficient p-value Correlation coefficient p-valueGlobal 0.621 <.0001 0.729 <.00011 vs. 2 0.812 <.0001 0.709 <.00011 vs. 3 0.437 .00314 0.795 <.00011 vs. 4 0.645 <.0001 0.747 <.00012 vs. 3 0.523 .0018 0.610 <.00012 vs. 4 0.766 <.0001 0.730 <.00013 vs. 4 0.514 .0018 0.755 <.0001VODNAREK ET AL . 91 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13971 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 License0.491 ( p< .01) for the anatomically adjusted method;therefore, it was interpreted as being moderate for bothmethods. Observer 1 achieved very good intraobserveragreement ( κ=0.887; p< .01) for the anatomicalmethod and good intraobserver agreement ( κ=0.803;p< .01) for the functional method (Tables7and8).The global correlation coefficient for interobserveragreement was 0.495 ( p< .01) (moderate) for the ana-tomically adjusted method and 0.378 ( p< .01) (fair) forthe functional method.Each nasopharynx was examined by four observerstwice, resulting in 288 diagnosed grades of nasopharyngealcollapse for each measurement method. Considering theseobservations as a population, no collapse was assigned in31 (10.76%) and 35 (12.15%) instances, and partial collapsewas assigned in 193 (67.01%) and 189 (65.63%) instancesusing functional and anatomically adjusted methods,respectively. Complete collapse was observed in64 instances (22.22%) using both the methods.However, when considering only the mean valuesfrom the first and second observations performed byFIGURE 5 Histogram of the dynamic change ratios (pooled across all observers) of the nasopharyngeal dimensions using the functional(red) and anatomically adjusted (blue) methods.TABLE 7 Intraobserver variability for assigning a grade ofdynamic nasopharyngeal collapse.ObserverFunctional methodAnatomicallyadjusted methodCorrelationcoefficient ( κ)p-valueCorrelationcoefficient ( κ)p-valueGlobal 0.491 <.0001 0.532 <.00011 0.887 <.0001 0.803 <.00012 0.214 .092 0.179 .0007753 0.408 .00369 0.499 <.00014 0.388 .00412 0.547 .159TABLE 8 Interobserver variability for assigning a grade ofdynamic nasopharyngeal collapse.ObserverFunctional methodAnatomicallyadjusted methodCorrelationcoefficient ( κ)p-valueCorrelationcoefficient ( κ)p-valueGlobal 0.495 0 0.378 <.00011 vs. 2 0.316 .026 0.659 <.00011 vs. 3 0.620 <.0001 0.310 .0421 vs. 4 0.618 <.0001 0.494 .0004372 vs. 3 0.278 .027 0.211 .1462 vs. 4 0.666 <.0001 0.397 .008523 vs. 4 0.450 .00106 0.231 .14692 VODNAREK ET AL . 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13971 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 LicenseObserver 1, 36 grades were assigned using both themethods. Of these, no collapse was assigned in six(16.76%) and five (13.88%) instances, partial collapse in27 (75%) and 23 (63.88%) instances, and complete collapsein three (8.33%) and eight (22.22%) instances using func-tional and anatomically adjusted methods, respectively.4

Question 27

Schnabel - 2023 - JAVMA - Use of mesenchymal stem cells for tendon healing in veterinary and human medicine - Getting to the "core" of the problem through a one health approach.pdf

Answer 27

NA

Question 28

McNamara - 2023 - JAVMA - Risk factors for intraoperative hemorrhage and perioperative complications and short- and long-term outcomes during surgical patent ductus arteriosus ligation in 417 dogs.pdf

Answer 28

Data collectionMedical records at 8 veterinary academic insti -tutions (University of Florida, Iowa State University, University of Missouri, University of Georgia, Oklahoma State University, Colorado State University, Cornell University, and North Carolina State University) were reviewed between the months of February and July 2021 for dogs diagnosed with a left-to-right shunt -ing PDA. Five institutions each had a single reviewer, and 3 institutions each had 2 reviewers doing differ -ent parts of the search. Surgical operative reports and patient diagnoses were searched using the key words “PDA/patent ductus arteriosus,” “PDA liga -tion,” or “PDA surgery.” Dogs that underwent surgi -cal ligation between January 2010 and January 2020 were included in the study. Dogs were excluded if surgical ligation was aborted for reasons other than hemorrhage or cardiac arrest, such as diagnosis of a right-to-left shunting PDA or anesthetic complica -tions prior to surgery that necessitated waking the patient up from anesthesia, as including these pa -tients would create a falsely high number of cases that did not experience intraoperative hemorrhage or other complications.Data recorded included patient signalment (age, breed, and sex), any reported noncardiac-related co -morbidities, presence and duration of clinical signs related to cardiac disease (exercise intolerance, dys -pnea, coughing, and lethargy), presence of other cardiac abnormalities, history of CHF, physical ex -amination parameters at presentation (weight, mur -mur timing and grade, and presence and description of arrhythmias), and echocardiogram and ECG data recorded from written reports. Acute clinical signs were defined as signs present for < 7 days. Chronic clinical signs were defined as signs present for > 7 days. Intraoperative information including dissec -tion method around the PDA, occurrence of intraop -erative hemorrhage and location of bleed, anesthetic complications, need for blood transfusion(s), ligation method of the PDA, and intraoperative death and cause was recorded. Intraoperative hemorrhage was defined as > 5% blood loss and/or acute hemorrhage from the PDA vessel that was deemed life-threat -ening by the surgeon. Intraoperative complications were divided into 4 categories: anesthetic-related complications, cardiopulmonary arrest, arrhythmias, and prolonged anesthetic recovery as noted in the anesthesia record. Immediate postoperative compli -cations, recheck cardiac auscultation, ECG and echo -cardiogram data, number of days hospitalized, sur -vival to discharge, and medications sent home were recorded. Two-week recheck information (survival to incision check, presence of a heart murmur and/or other cardiac disease, data from echocardiogram and ECG reports if performed or available, and other complications) and long-term follow-up information (recheck echocardiogram and ECG reports, presence of persistent congenital or acquired cardiac disease, need for long-term cardiac medications, date and cause of death, and other cardiac-related complica -tions such as development of arrhythmias or pres -ence of persistent changes secondary to the PDA) were recorded. Survival time for each patient was re -corded and defined as the number of days between surgery and date of death or date of last follow-up.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 07/22/23 07:43 AM UTC 3Cardiopulmonary assessmentThree-view thoracic radiographs reviewed by a board-certified radiologist were included in this study. Data recorded included evidence of cardiac silhouette enlargement along with left atrial and left ventricular enlargement, evidence of pulmonary vessel overload based on enlargement of the pulmonary arteries and veins, presence of a bulge at the main pulmonary ar -tery and/or aortic arch, and evidence of pulmonary edema consistent with left-sided CHF. Echocardio -grams reviewed by a board-certified cardiologist were included in this study. Data recorded included the following: LA:Ao ratio as reported in a 2-D right parasternal short-axis view, with results divided into 3 categories based on degree of left atrial enlarge -ment (≤ 1.54, 1.55 to 2.4, and ≥ 2.5)3,9–11; left atrial size as reported in a 2-D right parasternal view; the left ventricular size in diastole and systole, as reported in M-mode; the reported PDA description was used to divide patients into 5 groups (types 1, 2, 3a, 3b, and 4) as classified by Houghton et al12 based on the size of the PDA; murmur auscultation and presence of a palpable thrill; degree of left-sided cardiomegaly; presence and severity of mitral valve regurgitation (MR); evidence of left-sided CHF; presence and sever -ity of pulmonary hypertension; and presence of any ECG abnormalities. ECGs written by a board-certified cardiologist were included in this study, and data re -corded included the presence and description of any arrhythmias and presence of any other abnormalities within the individual wave components. Postopera -tively, the same values on thoracic radiographs, echo -cardiograms, and ECGs were recorded when available. If residual PDA flow was noted on echocardiogram, it was classified as trivial, mild, moderate, or severe as previously described by Achen et al.13Statistical analysisA univariate logistic regression model was uti -lized to evaluate preoperative and perioperative pa -tient factors and the predictive risk of intraoperative hemorrhage, perioperative mortality, and short- and long-term survival. Acute versus chronic duration of clinical signs were treated as continuous variables. A Fisher exact test was used to determine the associa -tion between preoperative and perioperative patient factors and intraoperative hemorrhage. A univariate analysis of intraoperative complications and their impact on short- and long-term survival was evalu -ated. A multivariable logistic regression model was performed to evaluate whether a combination of preoperative and perioperative patient factors im -pacted the predictive risk of intraoperative hemor -rhage. A 1-way χ2 test was used to determine sta -tistical significance with a P value < .05 considered statistically significant.ResultsHistory and physical examFour hundred twenty-one dogs were evaluated for surgical ligation of a left-to-right shunting PDA. Four dogs were excluded, with 3 dogs having anesthetic complications prior to the start of surgery necessitating abortion of the procedure and 1 dog being diagnosed with a right-to-left shunting PDA at the time of surgery. A total of 417 client-owned dogs were included in this study. A total of 60 dog breeds were represented, with Chihuahuas (12%), Maltese (9%), Pomeranians (7%), and German Shepherd Dogs (6%) overrepresented. The majority of dogs were intact females (Table 1) . Parameter ValueAge (mo) *10.3Weight (kg) *5.1Female 73.9% Intact ^83.4% Spayed ^16.6%Male 26.1% Intact ^81.7% Neutered ^18.3%Breed Chihuahua 12% Maltese 9% Pomeranian 7% German Shepherd Dog 6%Clinical signs Yes 42% Acute ^17.9% Chronic ^82.1%History Lt-CHF 10%Lt-CHF at presentation 14%Unless otherwise specified, values represent the percent -age out of total number of dogs in the study (n = 417). Acute clinical signs were defined as signs present for < 7 days. Chron -ic clinical signs were defined as signs present for > 7 days.Lt-CHF = Left-sided congestive heart failure.*Values reported as median. ^Values reported as percent -age out of total number of dogs in a specific parameter.Table 1 —Signalment and preoperative cardiac history of dogs undergoing surgical ligation of left-to-right shunting patent ductus arteriosus.The median age was 10.3 months (range, 1 to 108 months; IQR, 5 months), and the median weight was 5.1 kg (range, 0.3 to 53.7 kg; IQR, 2.75 kg). A total of 179 (42%) dogs presented with clinical signs of a PDA, including lethargy, collapse, exercise intolerance, tachypnea, and coughing. There was no association between age at the time of surgery and survival to discharge ( P = .7), 1-year survival (P = .5), or 5-year survival ( P = .3).Fifty-nine (14%) dogs had recorded comorbidi -ties, with the most common being cryptorchidism (5/59 [8.5%]), intestinal parasites (5/59 [8.5%]), or presence of an umbilical hernia (4/59 [6.8%]). Re -ported cardiac comorbidities included pulmonic ste -nosis (3/59 [5.1%]), pulmonary hypertension, (2/59 [3.4%]), subaortic stenosis (2/59 [3.4%]), atrial sep -tal defect (1/59 [1.7%]), the presence of a second pulmonary artery (1/59 [1.7%]), second-degree atrioventricular (AV) block (1/59 [1.7%]), mitral valve stenosis (1/59 [1.7%]), and mitral valve dys -plasia (1/59 [1.7%]). Sixty (14.4%) dogs had a history of a previous surgical procedure, with 15 of those being cardiac-related surgeries. Previous cardiac surgeries included previous Amplatz canine duct Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 07/22/23 07:43 AM UTC4 occluder (ACDO) placement attempts in 14 dogs and balloon valvuloplasty for pulmonic stenosis in 1 dog; 1 dog underwent ACDO placement attempt and sur -gical ligation under the same anesthetic period, and 1 dog underwent ACDO removal and surgical liga -tion under the same anesthetic period. There was no association between previous cardiac surgery and occurrence of intraoperative hemorrhage or other intraoperative complications.Of the 417 dogs, 42 (10%) had a history of left-sided CHF and 59 (14%) had evidence of left-sided CHF at the time of presentation. Eighty-six (21%) dogs were receiving cardiac medications at the time of presentation, with furosemide and pimobendan being the most common medications. Multiple logis -tic regression models were used to evaluate age and weight with a history of heart failure or the presence of heart failure at presentation and the risk of intra -operative hemorrhage. There was a significant asso -ciation of intraoperative hemorrhage in patients with evidence of heart failure at presentation, regardless of weight ( P = .04) or age ( P = .04). There was not a significant association of intraoperative hemorrhage in patients that had a history of heart failure, regard -less of weight ( P = .17) or age ( P = .12).Of the 417 dogs, 413 had a recorded heart mur -mur on presentation. The most common type of murmur was a continuous grade 5/6 heart murmur. Three out of the 417 (0.7%) dogs had only a systolic murmur. Two separate murmurs were auscultated in 19 (4.6%) dogs, all of which had a continuous mur -mur and left apical systolic murmur concurrently.Cardiopulmonary assessmentThoracic radiographs were performed in 221 (53%) dogs; 210 (95%) of those dogs had evidence of cardiomegaly per the written radiology report. An echocardiogram was performed in 407 (98%) dogs; the remaining 10 dogs were suspected to have a PDA on the basis of the presence of a continuous heart murmur and bounding femoral pulses. The LA:Ao measurement was recorded in 314 (75%) dogs. Re -sults were divided into 3 categories based on mea -surement; 165 (53%) had an LA:Ao ratio < 1.5, 138 (44%) had an LA:Ao ratio of 1.55 to 2.4, and 11 (3%) had an LA:Ao ratio of > 2.5.There was evidence of MR in 205 (65%) dogs based on echocardiogram. Based on echocardiogram reports, the MR was further classified as trace in 61 (30%) dogs, mild in 115 (56%), moderate in 26 (13%), and severe in 3 (1%). There was no association be -tween the presence or degree of MR and survival to discharge ( P = .3) or the 1-year survival rate ( P = .7).In total, 400 patients were able to be classified according to Houghton et al12 as a PDA type 1 (n = 57), type 2 (136), type 3a (43), type 3b (157), or type 4 (7) based on available records, with the majority of patients classified as type 3b and thereby indicating the presence of a palpable thrill, MR, and marked left cardiomegaly with no evidence of left-sided CHF.Overall, 37 dogs (37/417 [8.9%]) had evidence of electrocardiographic abnormalities on preopera -tive ECG, with the most common abnormalities being tall R waves (10/37) and ventricular premature com -plexes (VPCs; 10/37). Other abnormalities included first-degree AV block (n = 2), secondary degree AV block (5), atrial fibrillation (4), ventricular bigeminy (2), and accelerated idioventricular rhythm (1).Intraoperative dataThe dissection method of the PDA was classified as either a standard cranial to caudal or caudal to cranial approach (98%) or as the Jackson-Henderson approach (2%). Of the cases in which the Jackson-Henderson approach was used, 64% started with a standard approach to the PDA and then converted to the Jackson-Henderson approach when bleeding from the PDA was observed. The ligation method was reported in 395 dogs, with silk suture being most common (92%), followed by suture and hemo -clips (2%), hemoclips alone (2.5%), suture other than silk alone (3%), or umbilical tape (0.5%).Intraoperative complications were recorded in 182 patients (43.6%). Of the dogs experiencing com -plications, 146 dogs (80.2%) had anesthetic-related complications, including hypothermia, bradycardia, and hypotension. Other complications included the following: 4 (2.2%) dogs suffered cardiopulmonary arrest, 27 (14.8%) dogs had arrhythmias, and 4 (2.2%) dogs had a prolonged anesthetic recovery.Out of the 417 patients undergoing surgery, intra -operative hemorrhage occurred in 45 (11%) patients and 20 (5%) dogs required a blood transfusion during surgery (Figure 1) . Reported methods for achieving Figure 1 —Occurrence of intraoperative hemorrhage and blood transfusions in dogs undergoing surgical ligation of left-to-right shunting patent ductus arteriosus (PDA). For the 417 dogs undergoing surgery for ligation of a left-to-right shunting PDA, occurrence of intraoperative hemorrhage was recorded. The total number and per -centage of dogs experiencing intraoperative hemor -rhage is shown in the above flow chart. Of the 45 dogs experiencing intraoperative hemorrhage, the total num -ber and percentage of those receiving an intraoperative blood transfusion is shown above. Y = Yes. N = No.hemostasis included placement of hemoclips (22%), conversion to a Jackson-Henderson approach (16%), and use of Gelfoam in 1 patient. Of the 45 patients experiencing hemorrhage, 5 were euthanized or died due to persistent bleeding. Of the 40 surviving pa -tients, the procedure was aborted in 7 patients; the PDA was ligated in the remaining 33 patients. The site of hemorrhage was described as along the me -dial aspect of the PDA (49%), from the cranial aspect of the PDA (2%), from the caudal aspect of the PDA Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 07/22/23 07:43 AM UTC 5(4%), from the lateral aspect of the PDA (2%), originat -ing from a great vessel (7%), originating from a super -ficial intercostal vessel (18%), or unknown (18%). Based on this exploratory study, there was no association be -tween age at the time of surgery and risk of intraopera -tive hemorrhage ( P = .7) or between weight and risk of intraoperative hemorrhage ( P = .96). The type of PDA and risk of intraoperative hemorrhage did not have any association ( P = .28) as based on a Fisher exact test. Similarly, the type of PDA and location of intraopera -tive hemorrhage did not have any association ( P = .7) based on a Fisher exact test. There was no association between the presence or degree of MR and intraop -erative hemorrhage ( P = .3). The association between increasing LA:Ao ratio and risk of intraoperative hem -orrhage was also not significant with a P value of .08.The overall intraoperative mortality rate was 2.2% (9/417), with 4 of the 9 (44%) dogs dying from cardiac arrest and 5 (56%) dogs dying or being eu -thanized due to uncontrollable hemorrhage.Postoperative dataTen out of the 20 (50%) dogs receiving an intraop -erative blood transfusion required an additional blood transfusion following surgery. Eighty-four (21%) of the surviving 408 dogs had a recorded persistent heart murmur following surgery. Five dogs had a murmur re -corded after surgery that went away prior to discharge.Postoperative echocardiograms were performed on 129 dogs prior to discharge. Eighty-nine dogs showed complete attenuation of their PDA with no flow. Eight dogs had no flow through the PDA but had persistent MR. Twenty-two dogs had mild flow present through their PDA, and 4 dogs had mild flow through their PDA and evidence of MR.Postoperative ECG findings were reported for 46 dogs, with 8 (17.4%) having a postoperative arrhyth -mia. Recorded arrhythmias included atrial fibrillation in 7 dogs (15.2%), and persistent second-degree AV block in 1 dog that was noted preoperatively (2.2%). There was no association between the need for a blood transfusion, presence of a persistent heart murmur postoperatively, or presence of a persistent arrhythmia postoperatively with survival to discharge or long-term survival.Three dogs suffered from cardiopulmonary ar -rest postoperatively, and only 1 dog was able to be successfully resuscitated. Other postoperative com -plications included hemothorax (n = 2; 0.4%) with 1 dog requiring an autotransfusion for the hemotho -rax, pneumothorax (1; 0.2%), a chylothorax (1; 0.2%), pulmonary edema secondary to CHF (1; 0.2%), non -cardiogenic pulmonary edema and supraventricular tachycardia (1; 0.2%), atrial fibrillation (1; 0.2%), and transient Horner syndrome (1; 0.2%). The average hospitalization time for dogs surviving surgery was 2 days (range, 1 to 8 days).Survival to discharge, 2-week survival, 1-year survival, and 5-year survival were determined on the basis of available records and phone calls to the client. Of the 417 dogs undergoing surgery, 405 (97%) sur -vived to discharge. Sixty-two dogs were discharged on cardiac medications including pimobendan, furo -semide, atenolol, sildenafil, and/or enalapril.Following discharge, 100 dogs were lost to fol -low-up, 302 (99.5%) dogs survived to the 2-week re -check visit, and 1 (0.5%) dog died prior to the 2-week recheck, with the cause of death suspected to be due to an underlying arrhythmia. At the 2-week recheck, 12 (4%) dogs had documented cardiac disease as based on echocardiogram findings or thoracic ra -diograph findings, including subaortic stenosis in 2 dogs, left-sided cardiomegaly in 9 dogs, pulmonary hypertension in 1 dog, and pulmonary stenosis in 1 dog; 3 (1%) dogs had a documented arrhythmia; and 28 (9.3%) dogs had a persistent heart murmur.One-year follow-up was available for 221 dogs, with 213 (96%) alive at 1 year and 8 (4%) deceased at 1 year postoperatively. Five-year follow-up was available for 101 dogs, with 88 (87%) alive and 13 (13%) deceased. Long term, 81 (36.7%) dogs had recorded heart disease based on follow-up echocardiograms, 58 (26.2%) dogs had a recorded heart murmur, 33 (14.9%) dogs had recorded arrhythmias, and 31 (14%) dogs required cardiac medica -tion. Of the 31 dogs requiring long-term cardiac medica -tion, 20 dogs received a single medication (pimobendan, 6/20; enalapril, 9/20; benazepril, 1/20; diltiazem, 1/20; and atenolol, 3/20). Two dogs received both pimoben -dan and furosemide, and 1 dog received sotalol and mex -iletine. Eight of the 31 dogs receiving long-term cardiac medications were on 3 or more medications. Of the 81 dogs with recorded heart disease, 50 dogs had evidence of persistent changes secondary to the PDA and 31 dogs had evidence of other cardiac disease. For dogs that sur -vived to discharge but did not survive to the 1-year or 5-year time points, the cause of death was cardiac related in 38%, noncardiac related in 38%, and unknown in 24%.

Question 29

Scheuermann - 2023 - VETSURG - Minimally invasive plate osteosynthesis of femoral fractures with 3D-printed bone models and custom surgical guides - A cadaveric study in dogs.pdf

Answer 29

2.1 |Surgical planning and 3D printingSeven skeletally mature, mixed-breed dogs weighing19 to 25 kg, recently euthanized for reasons unrelated tothis study, were acquired. This study was approved bythe University of Florida institutional animal care anduse committee (study #202111344). Cadavers were frozenat/C030/C14C and thawed to room temperature prior toacquiring computed tomographic (CT) images of bothpelvic limbs. Cadavers were placed in dorsal recumbencywith both pelvic limbs extended. Both pelvic limbs ofeach cadaver were imaged using a slice thickness of0.5 mm and 0.3 mm slice overlap (Aquilion Prime S com-puted tomography scanner, Canon Medical SystemsUSA, Tustin, California). Cadavers were included if noosseous abnormalities were appreciated on the CTimages. The bone algorithm volumetric data DigitalImaging and Communications in Medicine (DICOM)files were imported into an image processing softwareprogram (Mimics, Materialize NV, Leuven, Belgium) andtransformed into 3D models. The images were segmentedusing the program's predefined bone threshold (ie,226-3071 Hounsfield units).13After segmentation, stereo-lithography (STL) files for both femurs were exported toa biomodelling software program (3-matic, MaterializeNV). Right and left femurs were randomly assigned to1 of 2 reduction groups using an online random numbergenerator ( https://www.random.org ). In one group, anIMP and precontoured plate were used for fracture reduc-tion while in the other group, a custom fracture reduc-tion system (FRS) and precontoured plate were applied.In both groups, a simulated diaphyseal femoralosteotomy was created virtually and the distal femoralsegment was angulated in the sagittal plane, reducingdistal femoral procurvatum to facilitate IMP and plateplacement. Models of the virtually aligned femurs wereprinted (White Resin or BioMed Amber Resin, Formlabs,Sommerville, Massachusetts) using a stereolithography3D printer (Form 3BL, Formlabs) and cured according tothe manufacturer's guidelines.14A 3.5 mm locking com-pression plate (LCP; DePuy Synthes, West Chester, Penn-sylvania) or a 3.5 mm limited contact dynamiccompression plate (LC-DCP; DePuy Synthes) was con-toured to conform to the lateral surface of each femoralmodel until subjectively well contoured by the primarysurgeon (SEK). Plate length was chosen at the discretionof the primary surgeon to extend from the proximalaspect of the greater trochanter to the distal femoralmetaphysis.For the FRS group, an indirect fracture reduction sys-tem was specifically designed, which consisted of reduc-tion bolts, a suture tensioner, and a suture twister.Cerclage tape threaded into the reduction bolts, posi-tioned in predrilled screw holes, could be tensioned todraw the bone segment towards the precontoured plate.The reduction bolts had a smooth shaft and a slottedcylindrical head (Figure 1A). The suture tensioner wascylindrical and tapered at the base to accept the head ofthe reduction bolts. The tensioner had 2 slots to accept828 SCHEUERMANN ET AL . 1532950x, 2023, 6, the center rod of the suture twister (Figure 1B). Thesuture twister consisted of a central rod with a transversecentral cannulation and 3 arms protruding from eachend rod (Figure 1C).Custom surgical drill guides were designed andprinted for use in the FRS group. The guides had a15 mm thick base with an undersurface that conformedto each femoral specimen's lateral trochanteric region orlateral condylar topography. The guides were printed andcured as described for the femoral bone models. The pre-contoured plate was applied to the bone model, andbicortical plate screw holes were drilled in the trochan-teric and distal metaphyseal regions of the femoralmodel. The plate was then removed from the model, andthe 3D-printed surgical guides were applied to their posi-tion of optimal fit. Corresponding holes were drilled inthe custom surgical guides by drilling through the holesin the femoral models from medial-to-lateral and throughthe custom guides (Figure 2).2.2 |Surgical techniqueAll procedures were performed by a board-certified smallanimal surgeon (SEK). Use of fluoroscopy was permittedas required at any stage of the procedure in either groupto assess femoral alignment and implant placement. Inboth groups, a medial approach was created at the levelof the mid femoral diaphysis and a comminuted mid-diaphyseal femoral fracture was created via multipleosteotomies using an oscillating saw. The incision wasclosed in a single layer. Lateral proximal and distal plateinsertional incisions were made and an epiperiosteal tun-nel was developed.15In the FRS group, the 3D-printed guides were appliedto their positions of optimal fit on the proximal and distalfemur. Using the 3D printed guides, with the predrilledholes as drill guides, a 2.5 mm twist drill bit was used tocreate 3 or 4 bicortical holes in the major proximal anddistal femoral segments. The 3D-printed guides wereremoved and the precontoured plate was insertedthrough the epiperiosteal tunnel and affixed to the proxi-mal bone segment with 3.5-mm cortical screws. Reduc-tion bolts were placed in the proximal- and distal-mostholes in the distal femoral segment. Braided suture-tape(2 mm FiberTape, Arthrex Vet Systems, Naples, Florida)was passed around the femoral diaphysis in a double-loop configuration at the level of each bolt and passedthrough the slot in the bolt head, the corresponding platehole, and secured in the suture tensioning device. Thesuture was tensioned, drawing the fracture segment tothe plate until the head of each bolt was captured intothe corresponding plate hole, thus aligning the fracture.Tension was maintained on the suture to maintain frac-ture reduction (Figure 3). A 3.5 mm cortical screw wasplaced through the empty predrilled hole in the distalfemoral segment. The reduction bolts and suture wereremoved and 3.5 mm cortical screws were placed in theremaining vacated holes.In the IMP group, a 2.8-3.2 mm Steinmann pin wasinserted in normograde fashion. Insertion of the pin intothe distal segment was performed under fluoroscopicguidance while manipulating the segment using boneholding forceps. After the fracture was aligned, the pre-contoured plate was placed within the epiperiosteal tun-nel and affixed to the major proximal and distal bonesegments with 3.5 mm cortical screws.During all procedures, the number of fluoroscopicimages acquired and surgical times were recorded. Post-operative CT scans of both pelvic limbs were obtainedusing the same technique as the preoperative images.Metal artifact was reduced using the single energy metalartifact reduction reconstruction technique (Canon Medi-cal Systems USA).16–18The bone algorithm volumetricDICOM files were imported into modeling software(Mimics, Materialize NV) for segmentation and 3D filetransformation. The STL files of both virtual femoralmodels were exported to 3-matic (Materialize NV). Thepreoperative virtually planned and postoperative femorallength, frontal plane alignment,19sagittal planealignment,20and axial plane alignment were measured.21Preoperative and postoperative length and alignmentdata were compared within and between reductiongroups. Postoperative femoral length as well as frontal,sagittal, and axial plane alignment were defined as near-anatomic, acceptable, or unacceptable based on our clini-cal experience. Near-anatomic reduction was defined asFIGURE 1 The suture tensioning system. (A) Specificallydesigned reduction bolt. (B) Suture tensioner. (C) Suture twisterSCHEUERMANN ET AL . 829 1532950x, 2023, 6, <10 mm change in femoral length, <5/C14change in frontalor sagittal alignment, and <10/C14change in axial align-ment. Acceptable reduction was defined as between10-20 mm change in length, 5/C14-15/C14change in frontal orsagittal alignment, and 10/C14-25/C14change in axial align-ment. Unacceptable reduction was defined as >20 mmchange in length, >15/C14change in frontal or sagittal align-ment, or >25/C14change in axial alignment.The number of fluoroscopic images taken per proce-dure and surgical duration were compared betweengroups using the nonparametric Mann-Whitney U-test.Differences in preoperative and postoperative length andalignment within and between reduction groups weretested using the Wilcoxon signed-rank test to accountfor the paired specimens. A P-value of <.05 was consid-ered statistically significant. An a priori power analysiswas not performed. Data are presented as median andrange.3|RESULTSFewer intraoperative fluoroscopic images were acquired(P=.001) during FRS MIPO procedures than duringIMP MIPO procedures. Surgical time, however, was lon-ger when using the FRS ( P=.01; Table 1).Femoral length was shorter postoperatively, relativeto the preoperative virtual plan, in the IMP group by amedian of 2.3 mm (range /C09.0 to 1.5 mm; P=.03;Figure 4). Reduction utilizing the FRS resulted in femorallength that was not different from the preoperative vir-tual plan with a median discrepancy of /C00.6 mm (range/C04.7 to 1.4 mm; P=.40). Postoperative femoral lengthwas deemed near-anatomic in all cases, regardless ofreduction method, as all femurs had less than a 10 mmchange in length. There was no difference in the changeof femoral length ( P=.24) from the virtual plan to post-operative length between reduction groups.Postoperative frontal plane alignment (Figure 5) wasnot different in the FRS ( P=.46) or the IMP group(P=.13) when compared to the preoperative virtual planwith median discrepancies of /C00.1/C14(range /C04.2 to 2.9/C14)and/C00.7/C14(range /C02.2 to 1.9/C14), respectively. In allfemurs, frontal plane alignment was deemed near-anatomic in both reduction groups, as all femurs had lessthan a 5/C14discrepancy in frontal plane alignment. Therewas no difference in frontal plane alignment between theFRS or IMP groups ( P=.87).FIGURE 2 Representative step-by-step images of the custom fracture reduction system preparation. (A) Lateral view of a preoperativevirtual femur model with custom guides contoured to the lateral femoral cortex. (B) A precontoured plate applied to the lateral surface of a3D-printed femoral model. (C) Lateral view of a 3D-printed femoral model with holes drilled at locations corresponding to precontouredplate holes. (D) Lateral view of 3D-printed femoral model with custom 3D-printed guides in their positions of optimal fit. (E) Proximal-to-distal view of a 3D-printed femoral model with a proximal custom drill guide placed in its position of optimal fit. A 2.7 mm twist drill bit wasused to drill holes in the drill guides corresponding to the preexisting holes in the femoral model. Holes were drilled from medial to lateralthrough predrilled holes830 SCHEUERMANN ET AL . 1532950x, 2023, 6, Femoral fracture reduction utilizing the FRSresulted in increased recurvatum relative to the pre-operative virtual plan ( P=.03) by a median of 2.9/C14(range /C00.9 to 4.6/C14;F i g u r e 6). Postoperative sagittalplane alignment was not different from the preopera-tive virtual plan in the IMP ( P=.31) with a medianchange of 2.1/C14of procurvatum (range /C04.1 to 3.7/C14).Sagittal alignment was considered near-anatomic inboth reduction groups, as all femurs had lessthan 5/C14change in angulation. Sagittal alignment wasnot different between the FRS and IMP groups(P=.06).FIGURE 3 Application of the fracture reduction system. (A-B) Using the custom surgical guide, bicortical holes in the major proximal(A) and distal (B) femoral segments that corresponded to the precontoured plate holes. (C) Specifically designed reduction bolts were placedin the proximal- and distal-most holes of the distal fracture segment. Suture-tape was passed around the femur in a double loopconfiguration and passed through the slot in the head of the bolts. (D) A plate was affixed to the proximal femoral segment and suture-tapewas passed through corresponding plate holes. (E) Suture-tape was passed through the suture tensioner and suture twister. The suture-tapewas tensioned to distract and align the distal fracture segmentSCHEUERMANN ET AL . 831 1532950x, 2023, 6, In the FRS group, postoperative axial plane alignmentwas different from the preoperative virtual plan ( P=.04)with a median change of 2.5/C14(range /C00.7 to 7.5/C14;Figure 7). Axial plane alignment was not different fromthe preoperative virtual plan after IMP application(P=.40) with a median change of 2.2/C14(range /C023.9 to7.0/C14). One femur in the IMP group had acceptable align-ment with 23.9/C14less anteversion (ie, more normoverted)postoperatively. The remainder of femurs in both groupswere near-anatomic being within 10/C14of the preoperativevirtual plan. There was no difference in the change inaxial plane alignment from the virtual plan to postopera-tive alignment between reduction groups ( P=.50).4

Question 30

Clark - 2023 - JSAP - A composite occipito-atlanto-axial joint cavity cyst in a cat.pdf

Answer 30

NA

Question 31

Hernon - 2023 - VETSURG - The effect of flushing of the common bile duct on hepatobiliary markers and short-term outcomes in dogs undergoing cholecystectomy for the management of gall bladder mucocele - A randomized controlled prospective study.pdf

Answer 31

2.1 |Population and preoperativeassessmentClient-owned dogs undergoing a cholecystectomy for aGBM were prospectively recruited for the study fromSeptember 2019 until December 2021. This study wasapproved by the University of Bristol animal welfare andethical review body (VIN/19/026). Dogs were randomlyallocated from a predetermined list into the flush groupor non-flush group using permuted block randomization(Excel; Microsoft). Owners were required to provideinformed consent for enrolment into the study.Diagnosis of a GBM was suspected on abdominalultrasound performed by a board-certified radiologist, ora resident under direct supervision. This was confirmedby histopathological assessment following surgery. Dogswere excluded if there was ultrasonographic evidence ofphysical obstruction of the CBD such as cholelithiasisand neoplasia. Only dogs that had a non-elective chole-cystectomy were included in the study. Dogs weredefined as non-elective if there was evidence of clinicalsigns attributed to hepatobiliary disease with associated698 HERNON ET AL . 1532950x, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13956 by Vetagro Sup Aef, Wiley Online Library on [22/07/2023]. 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 Licensehyperbilirubinemia, or if there was evidence of ultrasono-graphic findings associated with reactive changes/impending rupture/rupture of the GBM.19Dogs that hadan incidental GBM identified with none of the abovecriteria were deemed elective and not enrolled in thestudy. The following information was recorded for alldogs enrolled into the study: signalment, clinical signs,physical examination, and known co-morbidities andultrasonographic findings.Prior to surgery all dogs had a biochemistry panelperformed with ALP, ALT, GGT, bilirubin, cholesterol,and triglycerides, these being the parameters of interestdue to their association with hepatobiliary disease. Allsamples were analyzed using Konelab Prime 60IBiochemistry Analyz er (ThermoFisher,Massachusetts).2.2 |SurgeryDue to the variable severity of clinical signs, the anesthesiaprotocols used were left to the discretion of the lead anes-thetist. Surgery was performed by European College ofVeterinary Surgeons specialists, surgical residents whohad completed training or current surgical residents underdirect supervision. Perioperative antibiotics –cefuroxime(Zinacef; GlaxoSmithKline UK) at 20 mg/kg IV –wereprovided 30 –60 min prior to the start of surgery and wererepeated at 90-min intervals. In all cases a midline celiot-omy was performed, the gallbladder was identified, and itwas examined for evidence of rupture. The surgery thateach dog received depended on the group to which it wasrandomly allocated.The gallbladder was dissected from hepatic fossa. Astab incision using a size 11 blade was made into the apexof the gallbladder and a 6 –10 Fr rigid urinary catheterwas passed into the neck of the gallbladder. Sterile salinewas instilled through the catheter until the patency of theCBD was confirmed via palpation of the duodenum,assessing for jets of fluids from the major duodenalpapilla. Following flushing of the CBD, the cystic ductwas ligated with polydioxanone (PDS II: Ethicon) and/orappropriately sized vascular clips (soft loading systemligating clip large orange: Mediplus). The gallbladder wastransected distal to the ligatures, completing thecholecystectomy.A routine cholecystectomy was performed as abovewithout catheterization and flushing of the CBD.Following cholecystectomy, the abdomen wasclosed routinely, using appropriate sizes of polydioxa-none (PDSII; Ethicon) for the linea alba, polyglica-prone 25 (Monocryl; Ethicon) for the subcutaneoustissues followed by skin sutures using nylon (Ethilon;Ethicon) or skin staples (Manipler; Braun). The gall-bladder was submitted for histopathological and bacte-riological assessment in all cases, to confirm adiagnosis of GBM.If anorexia/hyporexia was reported preoperativelyan esophagostomy tube of appropriate size was placedand sutured in place using nylon in a finger trap suturepattern.20Correct placement was confirmed via a lat-eral thoracic radiograph. Intraoperative complicationswere recorded. Intraoperative hypotension and meansurgical time were compared between groups. Intrao-perative hypotension was defined as two consecutivemeasurements of mean arterial pressure less than60 mmHg.2.3 |Postoperative managementPostoperatively, patients were hospitalized within theintensive care unit. Patients received intravenous fluidtherapy, analgesia, antibiotics, vasopressors, and gastro-protectants as required depending on their needs. Thesewere prescribed at the lead clinician's discretion. All dogswere hospitalized for a minimum of 3 days as part of thestudy protocol. Repeat biochemistry (including ALP,ALT, GGT, total bilirubin, cholesterol, and triglycerides)was performed 3 days postoperatively and the resultswere compared with preoperative results between thegroups. Survival to discharge, complications prior to dis-charge, and duration of hospitalization were recordedand compared between the groups.2.4 |StatisticsData were reported as means +//C0standard errors oft h em e a n .D e s c r i p t i v es t a t i s t i c sw e r ec a l c u l a t e du s i n gspreadsheet software (Excel 365; Microsoft). Signal-ment, complications, duration of hospitalization, andmortality rates are presented as descriptive data. Mixedmodel analysis was performed to assess the fixedeffects of time (paired analysis) and flushing with dogb e i n gi n c l u d e di nt h em o d e la sar a n d o me f f e c t .C o n -tinuous data were assessed for normality with theKolmogorov –Smirnov test. Age of dogs and surgerytime were compared with an unpaired t-test, hospitali-zation time with a Mann –Whitney U-test, and breedand sex of dog, total complic ations, and mortality by χ2and Fisher's exact tests. The sensitivity and specificityfor the presence of free abdominal fluid and gallblad-der rupture were calculated. All statistical tests wereperformed using GraphPad Prism v.9.4. A p-value of<0.05 was considered significant.HERNON ET AL . 699 1532950x, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13956 by Vetagro Sup Aef, Wiley Online Library on [22/07/2023]. 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 License3|RESULTSThirty-two dogs were enrolled into the study (16 in eachgroup). One dog was excluded from the flush group afterbeing diagnosed with hepatic lymphoma on histopathol-ogy. Thirty-one dogs were included with a mean age of12.5+//C02.3 years at presentation. Seventeen were male(13/17 neutered) and 14 were female (13/14 neutered).Dog breeds included were border terriers (20), bichonfrisés (2), crossbreeds <10 kg (2), Shetland sheepdogs (2),toy poodles (2), pug (1), Shiba Inu (1) and shih tzu (1).There was no difference in age ( p=.41), sex ( p=.16),or breed ( p=.69) between groups.Initial recorded presenting clinical signs that werenoted were vomiting (23/31), lethargy (19/31), hyporexia/anorexia (15/31), abdominal pain (6/31), jaundice (6/31),diarrhea (4/31), polyuria/polydipsia (3/31), and regurgita-tion (2/31). Known co-morbidities were chronic enterop-athies (3/31), diabetes mellitus (1/31), long-termpsychogenic polydipsia (1/31), mitral valve disease(1/31), splenic mass (1/31), and cruciate ligament rup-ture (1/31).There were no differences in the preoperative ALT,ALP, GGT enzyme activity, total bilirubin, triglycerides,and cholesterol between the two groups (Table1).Abdominal free fluid was identified in 14/31 dogs follow-ing abdominal ultrasonography (flush group 4/15; non-flush group 10/16); there were 10/31 dogs with distensionof the CBD (flush group 4/15; non-flush group 6/16), andthere were 2/31 dogs with distension of the intrahepaticbile ducts (flush group 2/15; non-flush group 0/16). All31 dogs underwent a cholecystectomy. On examinationof the gallbladders, 2/15 (13.3%) and 2/16 (12.5%) wereconfirmed to have ruptured at the time of surgery fromthe flush and non-flush groups respectively.Free abdominal fluid was identified on abdominalultrasonography in all cases of gallbladder rupture. How-ever, it was also present in 10/27 cases without rupture.The presence of abdominal free fluid had a 29% sensitiv-ity and 73% specificity for rupture of the gallbladder.Normograde flushing was successful in 14 (93.3%)dogs. One dog was changed to retrograde flushing due tounsuccessful confirmation of patency. Mean surgical timewas 69.6 ( +//C021.7) and 68.4 ( +//C028.9) min for the flushand non-flush groups respectively ( p=.90). Intraopera-tive complications were reported in 4/31 dogs, with mildintraoperative hemorrhage noted in two dogs (one fromeach group), gastro-esophageal reflux in one case, andiatrogenic rupture of the gallbladder in one case. Intrao-perative hypotension was noted in 5/31 (16.1%) of dogs,with 4/5 occurring in the flushing group ( p=.17). Thegallbladders were submitted for histopathological exami-nation which confirmed a diagnosis of GBM in all dogs.Three-day postoperative biochemical testing was per-formed on the dogs that were alive at the time when thetests were conducted (29/31, Table1). Three dogs did notsurvive to discharge. Two (one from each group) dieddue to cardiorespiratory arrest within 24 h postopera-tively, and one (in the non-flush group) died due to a sus-pected thromboembolic event 4 days postoperatively. Ofthe dogs that did not survive to discharge 2/3 of themwere identified as having a ruptured GBM at the time ofsurgery.There was a decrease over time in ALP ( p=.020), ALT(p< .001), GGT ( p=.025), enzyme activity, total bilirubin(p=.004), and cholesterol ( p< .001) when preoperativeand postoperative values were c ompared. No difference wasidentified due to flushing in ALP ( p=.064), ALT(p=.312), GGT ( p=.235), total bilirubin ( p=.078), cho-lesterol ( p=.478) and triglycerides ( p=.368) (Figure1).Postoperative complications were common in both groupswith 8/15 (53.3%) in the flush group and 10/16 (62.5%) innonflush group but there was no difference between groups(p=.72). The most common complication was regurgita-tion, which occurred in 9/31 ( 29%) patients, 4/15 (26.7%)from the flush group and 6/16 (37.5%) from the nonflushgroup ( p=.70). Other complications included ileus(5/31;16.1%), hypoxemia requ iring oxygen supplementation(3/31; 12.9%), seroma formation (1/31; 3.2%), diabetic ketoa-cidosis in a dog with pre-existing diabetes mellitusTABLE 1 Mean (SEM) preoperative and postoperative biochemical values.Flush No flushPreoperative Postoperative Preoperative PostoperativeALP (U/L) 5325 (1247) 3759 (752) 6163 (1378) 3724 (1003)ALT (U/L) 776 (209) 365 (105) 1165 (267) 428 (60)GGT (U/L) 81.2 (16.4) 45.2 (9.5) 110.4 (26.4) 80.6 (22.2)Bilirubin ( μmol/L) 33.0 (7.6) 11.9 (1.0) 61.7 (14.4) 49.8 (24.1)Cholesterol (mmol/L) 12.6 (1.9) 8.3 (0.9) 11.0 (0.9) 7.6 (1.2)Triglycerides (mmol/L) 3.0 (1.1) 1.5 (0.4) 2.0 (0.5) 1.2 (0.3)700 HERNON ET AL . 1532950x, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13956 by Vetagro Sup Aef, Wiley Online Library on [22/07/2023]. 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(1/31;3.2%). Pancreatitis wa s suspected based on clinicalsigns in 4/31 (12.9%) dogs postoperatively, two from eachgroup. No dogs developed com plications requiring addi-tional surgery. Mean hospit alization duration for allpatients was 5.4 days (range 3 –17 days), with a survival todischarge of 90.3% (28/31 dogs ). There was no difference induration of hospitalization when the groups were com-pared ( p=.24).4

Question 32

Hynes - 2023 - JAVMA - Cranial cruciate ligament disease is perceived to be prevalent and is misunderstood in field trial sport.pdf

Answer 32

This study was reviewed and approved by the Michigan State University Institutional Review Board for human subjects (STUDY0004778). The protocol was submitted to the animal care and use commit -tee and given exempt status indicating that no re -view was needed because animals were not directly tested in this survey study.Study designA survey instrument was written (Supplementa -ry Material S1) , with some guidance from a previous study16 developed to examine the rate of return to sport postinjury in agility dogs. The purpose of the survey was to examine the knowledge and attitudes surrounding CCLD in field trial Retrievers as well as its reported occurence.16 As part of the validation process, the survey was sent out to a small group of people involved in the sport of field trials, as well as a few fellow researchers, to test for any errors within the program and gather suggested changes to ques -tion wording. The survey was refined on the basis of their feedback and submitted to our Institutional Review Board for approval before being sent out to the target population. The survey opened on July 20, 2020, and closed on September 12, 2020. Reminders were sent out at the 2- and 4-week marks.Survey audienceRetriever News , a popular publication among field sport participants, co-owns the Entry Express database, which is used for competition entry by Retriever field trial participants as well as other field sports. The survey was sent to this database, which contains individuals who are involved in the many different field sports and are handlers, judges, owners, breeders, and trainers. Our inclusion criteria limited analysis to participants involved in Retriever field trials, with no exclusion if dogs participated in other dog sports. The inclusion criteria for specific dog information (diagnosis with CCLD, age, breed, sex, etc) was limited to those who currently own an AKC-registered Retriever intended for field trial training and/or competition. All responses were col -lected from participants within the US. There was no exclusion included for multiple people answering the survey regarding the same dog.Survey detailsThis instrument was developed using the Qualtrics survey system (Qualtrics XM; Qualtrics International Inc), with access granted by our institution. The sur -vey was kept completely anonymous, and respon -dents were allowed to skip questions by choice to encourage participation. The program settings were enabled to prevent a single respondent from complet -ing the survey more than once, and the survey was organized so that the questions were tailored to each respondent, only asking them questions that applied to their background based on their responses to initial questions. All questions were multiple choice, with some questions allowing multiple answers.The number of questions in the survey varied on the basis of the respondent’s involvement in field sports and whether they currently owned an AKC-registered Retriever intended for field trial training and trialing. The survey was organized into 3 blocks of questions, the first being field trial participant de -mographics. This was used to collect information on the participants’ background and their involvement in Retriever field trials, prompting them to select in what capacity they participated in the sport (were they trainers, judges, owners, etc) and for how many years they had been involved. The second section was used to determine their background with CCLD by asking questions such as what they thought may cause the disease and how it may have affected their choices when breeding and purchasing Retrievers, as well as their opinions on its impact on the sport. The third part of the survey was used to collect informa -tion about their individual dogs to determine the re -ported occurrence and impact of this disease on the Unauthenticated | Downloaded 11/03/23 05:59 AM UTC 3population. Some examples of the questions asked included age, weight, sex, and whether they had been diagnosed with CCLD. The survey was designed so that they could enter information about multiple dogs without having to exit the survey program.Data analysisAfter the survey data were collected, descrip -tive statistics were performed and data were orga -nized using the Qualtrics analysis software (Qualtrics International Inc). All results were included, even if participants did not elect to complete every question prompted, in which case the percentage is given as well as the number of respondents in terms of total re -spondents as part of the descriptive statistics. Multi -ple logistic regression was performed looking at vari -ables of breed, sex, age (continuous), and presence of offspring (yes or no; CCLD ~ intercept + gender + age + has offspring). Other analyses included χ2 tests for evaluating return to sport given the leg(s) affected and severity of rupture. The significance for all statis -tical tests performed was set at a P value of < .05.ResultsRespondent demographicsInformation was collected from a total of 407 Re -triever field trial participants, with respondents able to skip questions as they desired, and results were calculated individually for each question on the basis of the number of responses to the question, not to the survey as a whole.Involvement in the sport —There were 401 of 407 (99%) responses; 371 of 401 (93%) considered themselves amateur handlers/trainers, 246 of 401 (61%) owned field trial Retrievers, 229 of 401 (57%) were licensed judges, 121 of 401 (30%) were breed -ers, 24 of 401 (6%) were professional handlers/train -ers, and 11 of 401 (3%) were veterinarians. For this question, respondents were allowed to choose > 1 answer (Figure 1) .Years of involvement —There were 396 of 407 (97%) responses; 16 of 396 (4%) had been involved for 3 years or less, 70 of 396 (18%) had been involved for 4 to 8 years, and 310 of 396 (78%) had been in -volved for 9 years or more.CCLD perceptionsCauses of CCLD —Out of the total 407 respon -dents, 360 of 407 (88%) chose to respond to this question. Of that number, 280 of 360 (78%) indicated that genetics were a cause of CCLD, 170 of 360 (48%) noted that weight was a cause, and 148 of 360 (41%) indicated that conformation was a cause. In addition, 34 of 360 (9%) respondents noted a relationship be -tween spay and neuter status and CCLD diagnosis. Fi -nally, 247 of 360 (69%) respondents chose trauma as a cause of CCLD and 93 of 360 (6%) noted it was a de -generative disease. For this question, all respondents were permitted to choose > 1 answer (Figure 2) .Figure 1 —Demographics of the respondents’ involve -ment in the American Kennel Club sport of field trials with 401 out of a total 407 possible. Multiple selections were allowed.Figure 2 —Distribution of answers to the question, “What do you think causes CCLD?” with 360 responses out of a total 407 possible. Multiple selections were allowed.Breeding decisions —Out of the total 407 poten -tial respondents, 323 of 407 (79%) responded to this question; 285 of 323 (88%) were less likely to breed their dog if it had been diagnosed with CCLD in both legs, and 260 of 323 (81%) were less likely to breed their dog if they only had CCLD in 1 leg. In addition, 179 of 323 (55%) indicated they would be less in -clined to breed a dog if it had produced offspring that were affected, 159 of 323 (49%) indicated they would be less likely to breed their dog if a parent was affected, and 132 of 323 (41%) indicated that they would be less likely to breed their dog if it had a sib -ling affected. Finally, 37 of 323 (11%) participants noted they would not breed their dog if it had a rela -tive that was not a parent or sibling diagnosed with CCLD. For this question, all respondents were per -mitted to choose > 1 answer.Impact on training and trialing —Out of the to -tal 407 respondents, 354 of 407 (87%) responded to this question. Of those that responded, 220 of 354 (62%) indicated that they believe CCLD has a nega -tive impact on a Retriever’s training or trialing ability, Unauthenticated | Downloaded 11/03/23 05:59 AM UTC4 102 of 354 (29%) indicated they believed this was a possibility, and 32 of 354 (9%) indicated that CCLD does not have a negative impact on the Retriever’s training and trialing ability (Figure 3) .CCLD in this population was found to be 76 of 693 (11%; Table 1). Due to the large portion of data be -ing related to Labrador Retrievers, we calculated the reported occurrence in just Labradors to be 72 of 610 (12%). There was not a significant association between breed and CCLD diagnosis ( P = .99; 95% CI, 0.8 to 1.2).Sex—Though not significant in the model (all P > .2), altered female and male dogs had a higher re -ported occurrence of CCLD than their intact counter -parts (Table 1).Age—When evaluating the dog’s age at the time of a CCLD diagnosis, we found 8 of 233 (3%) were affected in the age range < 1 to 3 years, 24 of 201 (12%) affected from 4 to 6 years of age, and 44 of 259 (17%) affected in the dogs 7 years and older. When Figure 3 —Distribution of the answers to the question, “Would you be less likely to breed your dog if … ” with 323 responses out of a total 407 possible.Is CCLD an issue in field trials? —Out of the 407 total respondents, 352 of 407 (87%) chose to respond to this question. Of the respondents, 334 of 352 (95%) believed CCLD to be an issue in this population, and 18 of 352 (5%) believed it was not an issue. Of those who believed CCLD to be an issue, 262 of 334 (78%) agreed that it was a moderate issue, whereas 72 of 334 (22%) believed it is a severe problem. Of the 321 respondents who believed CCLD to be an issue, 154 of 321 (48%) saw CCLD as a worsening problem, 129 of 321 (40%) believed it was of static prevalence in the sport, and 38 of 321 (11%) believed it was start -ing to become less of an issue.Individual dog informationGeneral questionsIndividual dog information was collected on 701 dogs, with some respondents not completing every question asked about the dog. Signalment data and presence of offspring are provided (Table 1) .CCLD-specific questionsDiagnosis as reported by client —The total num -ber of responses was 697 of 701 (99%); 77 (11%) had a positive diagnosis of CCLD, and 620 of 701 (89%) were normal. Data on leg(s) affected, severity of rup -ture, type of surgery performed, and return to sur -gery are provided (Table 2) . Overall return to sport was 44 of 74 (60%). This number does not account for duration of injury or recovery, or whether their return was successful, just if they had returned at the time of this survey.Reported occurrenceBreed —After compiling the collected data on individual dogs, the total reported occurrence of Category Has CCLD No CCLD Row totalsBreed Black Labrador Retriever 59 477 536 Chocolate Labrador 3 11 14 Retriever Yellow Labrador Retriever 10 51 61 Flat-Coated Retriever 0 4 4 Chesapeake Bay 1 15 16 Retriever Golden Retriever 3 59 62 Other 0 1 1Sex Male neutered 3 11 14 Female neutered 16 63 79 Male intact 35 335 370 Female intact 21 205 226Age (y) < 1–3 8 225 233 4–6 24 177 201 7–10+ 44 215 259Presence of offspring Has offspring 22 139 161 Has no offspring 49 427 476Table 1 —Comparison of breed, sex, age, and presence of offspring to cranial cruciate ligament deficiency (CCLD) diagnosis. Age data were a continuous vari -able, whereas presence or absence of offspring was a categorical variable.Table 2 —Comparison of leg affected, severity, and treatment on successful return to sport. Returned Not returned Category to sport to sport Row totalsLeg(s) affected Left limb 11 8 19 Right limb 12 15 27 Both limbs 21 7 28Severity of injury Partial tear 15 14 29 Full tear 28 16 44Type of surgery TTA 1 0 1 TPLO 39 21 60 ES 1 2 3 Other 1 1 2ES = Extracapsular stabilization. TPLO = Tibial plateau–lev -eling osteotomy. TTA = Tibial tuberosity advancement.Unauthenticated | Downloaded 11/03/23 05:59 AM UTC 5evaluated as a continuous variable, increasing age was statistically significant in relation to CCLD diag -nosis (Table 1; P < .001; 95% CI, 0.74 to 0.9).Offspring —Of the 71 dogs affected for which the question of whether the dog had offspring was answered (yes or no), 22 of 71 (31%) were found to have offspring, 1 (5%) dog was altered, and the rest remained intact (Table 1). There was not a significant relationship between having offspring and a CCLD diagnosis ( P = .6; 95% CI, 0.6 to 2.1).Return to competitionNumber of legs affected —Dogs with only 1 leg affected had a significantly decreased chance of re -turning to competition (Table 2; χ2 statistic of 4.51; P value of .03).Severity of rupture —The comparison of rupture severity to return to competition was not statistically significant (Table 2; χ2 statistic of 1.02; P value of .31).Type of surgery —We compared the type of sur -gery performed as a treatment with return to sport and noted that of the 66 that underwent surgery, 42 of 66 (64%) had returned to the sport at this time. Of those dogs, 39 of 42 (93%) had undergone a tibial plateau leveling osteotomy (Table 2).

Question 33

Mather - 2023 - VETSURG - Anatomical considerations for the surgical approach to the canine accessory lung lobe.pdf

Answer 33

Nine canine cadavers of dogs that had been euthanizedfor reasons unrelated to this study were obtained byowner consent (VIN/20/034). All dogs were free of dis-ease related to the thoracic cavity based on analysis oftheir medical records.All procedures were performed by a surgical resident(AM) and supervised by a diplomate surgeon (EF). Thecadaver was placed in left lateral recumbency for a rightlateral thoracotomy to be performed through the sixthintercostal space. Once the thorax had been entered, sur-gical approaches through the fifth and seventh intercostalspaces were made subsequently. The cadaver was placedin right lateral recumbency for left lateral thoracotomiesat the same intercostal spaces and in dorsal recumbencyfor a median sternotomy approach. Given that perform-ing a surgical approach affected the integrity, location,and visualization of structures during subsequentapproaches, the order in which these approaches wereperformed was randomly assigned between cadavers.Photographs were taken using a smartphone (iPhone 8with 12MP camera, Apple, Cupertino, California), andthorough voice notes were recorded during each cadaverapproach which were later transcribed. Photographs forpublication were edited and labeled (Pixelmator Pro, Vil-nius, Lithuania).3|RESULTSThe cadavers ranged in weight from 6.9 to 45.5 kg(median 20.85 kg), with a wide range of breeds repre-sented; including Bichon Frisé (1), Border collie (2),Cairn terrier (1), cross-breed (1), French bulldog (1),Labrador retriever (1), Rot tweiler (1) and Whippet (1).3.1 |Surgical anatomy3.1.1 | Location and surrounding structuresThe accessory lung lobe was located centrally withinthe caudal thorax, with the ventral process (1) extend-ing into the left hemithorax (ventrally), and the caudalaspect of all three lobes in contact with the diaphragm.It lay in contact with the right caudal lung lobe later-ally (2), the esophagus dorsomedially (3), and medias-tinum medially (4), which separated it from the leftcaudal lung lobe. The caudal vena cava (CVC) andright phrenic nerve (5) passed through a notch whichseparated the dorsal proces s( 6 )f r o mt h er i g h tl a t e r a lprocess (7). There was a thin membrane —the plicavena cava (8) which lay to the right of the right lateralprocess and spanned from the right phrenic nerve dor-sally to the pericardial ligament ventrally (Figures1–4).3.1.2 | Bronchial treeThe combined bronchus of the right caudal lung lobe andaccessory lung lobe arose from the caudal aspect of theright mainstem bronchus. Heading caudally, the accessorybronchus (9) branched ventromedially to deviate awayfrom the right caudal lung lobe bronchus, within the“apex”of pulmonary parenchyma of the ALL (Figure 2).MATHER ET AL . 1065 1532950x, 2023, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14010 by Vetagro Sup Aef, Wiley Online Library on [19/10/2023]. 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 LicenseAfter a short section within the pulmonary parenchyma ofthe apex of the ALL, this common bronchus branchedventromedially toward the ventral and right lateral pro-cesses and caudodorsally toward the dorsal process.3.1.3 | ParenchymaIn addition to the dorsal (6), ventral (1), and right lateral (7)processes, the dissections also revealed two “extensions ”which formed the tissue at th ec r a n i a la p e xo ft h eA L L ,s u r -rounding the bronchus and vasculature (Figures 2and7):•The lateral extension (10): an extension of the dorsalprocess lying ventrolaterally to the bronchus (9) andartery of the ALL (11).•The medial extension (12): an extension from theregion where the right lateral and ventral processesconverge cranially, lying ventromedially to the bron-chus and associated with the medial vein (from theventral process of the ALL –see below).3.1.4 | Vascular supply - arterialHeading caudally away from origin of the right pulmonaryartery, the artery of the accessory lung lobe (11) branchedfrom a common vessel which supplied both the right cau-dal lung lobe (2) and the accessory lobe. It then coursedcaudally, deviating ventrally and medially, always in veryclose proximity or immediately adjacent to the ALL bron-chus (9) on its ventrolateral aspect (Figure 2). When thisbronchus bifurcated (toward the dorsal and ventral/rightlateral processes), this artery also bifurcated, maintaininga close association with both of these airways.3.1.5 | Vascular supply - venousConsiderable variation of the venous drainage was observed(Table 1). Two major veins were identified: one drainingthe dorsal process —the lateral vein (13), and another drain-ing the ventral process —the medial vein (14). The lattervessel also included contribution from the right lateralFIGURE 1 Right lateral thoracotomy at the sixth intercostalspace in cadaver 9. The right caudal lung lobe has been reflectedcranially to reveal the natural position of the accessory lung lobe(ALL). Anatomical features: 2, right caudal lung lobe (RCLL);3, esophagus; 5, right phrenic nerve; 6, dorsal process of ALL; 7,right lateral process of ALL; 8, plica vena cava; 10, lateral extensionof ALL; 13, lateral vein of ALL; 15, lateral pulmonary ligament ofALL; 17, pulmonary ligament of RCLL.FIGURE 2 Right lateral thoracotomy at the sixth intercostalspace in cadaver 9. The lateral “extension ”has been removed toreveal the artery and bronchus medial to this. Anatomical features:2, right caudal lung lobe; 6, dorsal process of accessory lung lobe(ALL); 7, right lateral process of ALL; 9, bronchus of ALL;10, lateral extension of ALL; 11, artery of ALL; 13, lateral vein ofALL (variably present in this location); 16, right dorsal branch ofthe vagus nerve.1066 MATHER ET AL . 1532950x, 2023, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14010 by Vetagro Sup Aef, Wiley Online Library on [19/10/2023]. 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 LicenseFIGURE 4 Right lateral thoracotomy at the sixth intercostalspace in cadaver 9. The dorsal process has been sutured cranially,and the ventral process caudally, exposing the venous drainagevessels. Anatomical features: 1, ventral process of accessory lunglobe (ALL); 2, right caudal lung lobe (RCLL); 3, esophagus;6, dorsal process of ALL; 9, bronchus of ALL; 13, lateral vein ofALL (variably present in this location); 14, medial vein of ALL;15, lateral pulmonary ligament of ALL; 17, pulmonary ligament ofright caudal lung lobe; 18, medial pulmonary ligament of ALL;21, pulmonary vein of left caudal lung lobe.FIGURE 3 Right lateral thoracotomy at the sixth intercostal spacein cadaver 9. The ligamentous attachments of the accessory lung lobe(ALL) have been severed, and the lobe has been transposed lateral to thecaudal vena cava. The dorsal process has been reflected laterally.Anatomical features: 1, ventral process of ALL; 2, right caudal lung lobe(RCLL); 3, esophagus; 4, mediastinum; 6, dorsal process of ALL;13, lateral vein of ALL (variably pre sent in this location); 15, lateralpulmonary ligament of ALL; 16, right dorsal branch of the vagus nerve;17, pulmonary ligament of right caud al lung lobe; 18, medial pulmonaryligament of ALL; 22, combined pulmonary vein of RCLL and ALL.TABLE 1 Variation in the vascular supply to the accessory lung lobe between cadavers.Cadaver Age (Y) Sex BreedWeight(kg)Number ofarteries to ALLNumber ofveins mediallyaNumber ofveins laterallybNumber ofveins insertingc1 10 MN Bichon Frisé 8.3 1 2 0 22 13 FE Crossbreed 6.9 1 2 0 13 2 ME Frenchbulldog12.3 1 1 1 24 10 FE Bordercollie22.7 1 1 1 25 13 MN Labrador 32 1 2 0 26 8 MN Rottweiler 45.5 1 1 1 27 10 MN Bordercollie38 1 2 0 28 15 MN Cairn terrier 10.8 1 2 0 29 6 MN Whippet 20.9 1 1 1 2Abbreviations: ALL, accessory lung lobe; DP, dorsal process; FE, female entire; ME, male entire; MN, male neutered; VP, ventral process; Y, years.aEmerging from the medial aspect of the ALL.bEmerging from the lateral aspect of the ALL.cInserting on to the common venous trunk of accessory and right caudal lung lobes.MATHER ET AL . 1067 1532950x, 2023, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14010 by Vetagro Sup Aef, Wiley Online Library on [19/10/2023]. 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 Licenseprocess. The location in which the lateral vein emergedfrom the parenchyma varied considerably between thecadavers. In four dogs (cadavers 3, 4, 6, 9), this vessel exitedthe dorsal process laterally, and inserted onto the pulmo-nary vein from the right caudal lung lobe a significant dis-tance upstream from where the vein from the ventralprocess entered (Figure 5B). The medial vessel consistentlyemerged from the parenchyma medial and ventral to theaccessory lung lobe bronchus and artery. In four dogs(cadavers 1, 5, 7, 8) the lateral vein exited the paren-chyma a short distance (less than 1 cm) dorsolateral tothe medial vein on the medial aspect of the lobe. Thelateral vein then inserted onto the vein of the right cau-dal lung lobe adjacent and upstream to the medial vein(Figure 5C). In one dog (cadaver 2), the two vessels (lat-eral and medial) converged as they emerged from theparenchyma to form a single vessel which insertedinto the pulmonary vein of the right caudal lung lobe(Figure 5D).3.1.6 | Ligamentous attachmentsWe found that the right pulmonary ligament consisted ofthree parts: the lateral and medial pulmonary ligamentsof the ALL, and the pulmonary ligament of the right cau-dal lung lobe. The lateral pulmonary ligament of the ALL(15) was found to span from the dorsal aspect of the dor-sal process of the ALL, to insert on the mediastinal pleu-ral surface of the esophagus, immediately adjacent to theright dorsal branch of the vagus nerve (16). The pulmo-nary ligament of the right caudal lung lobe (17) origi-nated on the acute dorsal border of this lobe and insertedonto the lateral ligament of the ALL at the parenchymalmargin. When the lateral vein of the ALL exited from thedorsal process laterally (cadavers 3, 4, 6, 9), these liga-ments were also attached to this vessel. The medial pul-monary ligament of the ALL (18) joined the lateralpulmonary ligament of the ALL (15) at an apex on themedial surface of the dorsal process of the ALL. It spannedfrom that anatomical landmark to the mediastinum (4), asfar cranially as the hilus of the lobe, incorporating themedial vein of the ALL (Figures 1, 3, 4 ). Both ligamentswere subjectively more difficult to break down at their cra-nial aspects. The right lateral and ventral processes werenot tethered by any ligamentous attachments.3.2 |Surgical approaches for thevisualization of the accessorylung lobe3.2.1 | Right lateral thoracotomy1. A standard lateral thoracotomy approach was made atthe right sixth intercostal space, extending ventrally tothe costochondral junction.2. The right caudal lung lobe was retracted craniolater-ally, and the pulmonary ligament of the right caudallung lobe beneath (17) manually transected as far cra-nial as possible (Figure 1). Care was taken to avoidinadvertent compromise to the lateral vein of the ALL(if present in this location).3.2.2 | Median sternotomy1. The patient was placed in dorsal recumbency, and amedian sternotomy performed, transecting thexiphoid process caudally.FIGURE 5 Schematic representation of Figure 4depicting thevariations in venous drainage. (A) The natural location of thenonretracted accessory lung lobe (ALL) within the thorax. (B) Thevenous drainage configuration in cadavers 3, 4, 6, 9 (depicted in allphotographs). (C) The venous drainage configuration in cadavers1, 5, 7, 8. (D) The venous drainage configuration of cadaver2. Anatomical features: ALL, accessory lung lobe; CVC, caudal venacava; 1, ventral process of ALL; 2, right caudal lung lobe (RCLL);6, dorsal process of ALL; 7, right lateral process of ALL; 13, lateralvein of ALL; 14, medial vein of ALL; 22, combined vein of RCLL andALL; 23, right middle lung lobe; 24, right cranial lung lobe.1068 MATHER ET AL . 1532950x, 2023, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14010 by Vetagro Sup Aef, Wiley Online Library on [19/10/2023]. 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 License2. The pericardial ligament, followed by the plica venacava (8), were manually broken down to the level ofthe caudal vena cava. Care was taken at this level toavoid the inadvertent damage to the right phrenicnerve (5) which lay immediately ventrolateral to thecaudal vena cava. The untethered ventral process ofthe accessory lung lobe (1), (which had previouslybeen contained within the mediastinal recess), wasnow visible (Figure 6).3. The mediastinal membrane (4) which was consider-ably thicker than the plica vena cava, was then manu-ally broken down to the level of the heart base,adjacent to the hilus of the accessory lung lobe. Theleft phrenic nerve (19) was contained within thismembrane and care was required to not cause damageto the nerve during this maneuver. At this level themediastinal membrane became continuous with themedial pulmonary ligament of the ALL (18), whichwas attached to the medial aspect of the dorsal processof the accessory lung lobe as previously described(Figure 7).3.2.3 | Left lateral thoracotomy1. A standard lateral thoracotomy approach was made atthe left sixth intercostal space, extending ventrally tothe costochondral junction.2. The left caudal lung lobe (20) was retracted craniolat-erally and the pulmonary ligament beneath manuallytransected as far cranially as possible.3. The right hemithorax could now be visualizedthrough a roughly triangular section of mediastinumbordered by the heart cranially, the diaphragm cau-dally and the esophagus (3) dorsally. The left phrenicnerve (19) coursed from cranial to caudal over the leftlateral surface of the heart and midway across thiswindow of mediastinum. To access the accessorylung lobe, the mediastinum was perforated, takingextreme care not to compromise the left phrenic nerve(Figure 8).FIGURE 6 Median sternotomy approach. The plica vena cava hasbeen removed to reveal the accessory lung lobe (ALL) beneath. Thepericardial ligament (grasped with f orceps) and mediastinum are intact.Anatomical features: 1, ventral proc ess of ALL; 2, right caudal lung lobe;4, mediastinum; 8, plica vena cava; 23, right middle lung lobe.FIGURE 7 Median sternotomy approach. The plica vena cavaand mediastinum have been removed. The ventral process has beensutured to the ventral body wall, and the heart reflected cranially.1, ventral process of accessory lung lobe (ALL); 2, right caudal lunglobe; 4, mediastinum; 7, right lateral process of ALL; 8, plica venacava; 10, lateral extension of ALL; 12, medial extension of ALL;18, medial pulmonary ligament of ALL; 19, left phrenic nerve;20, left caudal lung lobe.MATHER ET AL . 1069 1532950x, 2023, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14010 by Vetagro Sup Aef, Wiley Online Library on [19/10/2023]. 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 License3.3 |Lung lobectomy3.3.1 | Via right lateral thoracotomy1. A right lateral thoracotomy approach was performedat the sixth intercostal space as previously described.2. The lateral and medial pulmonary ligaments of theaccessory lung lobe (15, 18) were then broken down(by a combination of sharp and blunt dissection) asfar cranially toward the hilus as possible, taking careto avoid compromising the medial vein of the ALL(14). Although the medial ligament was continuouswith the mediastinum, its transection did not rou-tinely result in perforation of the mediastinum, (Fig-ures 3and4).3. The ventral and right lateral processes of the ALL(untethered by pulmonary ligaments) were thenretracted from their natural positions and graspedalong with the dorsal process in the surgeon's lefthand to lie dorsal to the caudal vena cava. At thispoint a 30 or 60 mm surgical stapler (Proximate linearstaplers; TX60B/1, TX30B/1, Ethicon, Raritan, NewJersey) was inserted and placed across the hilus of theALL, for occlusion of the lobar artery, bronchus andvein(s).4. Alternatively, additional exposure to the bronchusand artery could be obtained by cautious swab dissec-tion caudally of the lateral extension (10) of the dorsalprocess if required. This step would not be necessaryif a surgical stapling device was used for removal;however, would be useful for identification of thesestructures if using a clamp suture technique.14Theseparate ligation of the dorsolateral hilar structures(9, 11, 13) at this point was advantageous to improveaccess to the ventromedially positioned medialvein (14), when using the clamp suture technique(Figure 2).3.3.2 | Via median sternotomy1. A median sternotomy approach was performed as pre-viously described (Figure 7).2. The medial pulmonary ligament of the ALL (18),(which was continuous with the mediastinum), andthe lateral pulmonary ligament of the ALL (15) wereblindly manually broken down, leaving the ALL freeof all ligamentous attachments. Care was taken whenbreaking down the lateral pulmonary ligament of theALL to avoid inadvertent damage to the lateral vein ofthe ALL (13).3. All three processes of the ALL were then grasped inone hand, allowing partial visualization of the apex ofthe lobe. At this point a Proximate 30 or 60 mm stapler(Ethicon) was inserted and placed across the hilus ofthe ALL, for occlusion of the lobar artery, bronchusand vein(s). The clamp and suture technique14was notattempted with this approach due to poor exposure.[Correction Notice: The citation 13 has been replacedwith 14 in the third point under section 3.3.2.]4

Question 34

Glenn - 2024 - VETSURG - Evaluation of a client questionnaire at diagnosing surgical site infections in an active surveillance system.pdf

Answer 34

2.1 |Study designAll dogs and cats undergoing surgery by the soft tissueor orthopedic services of a single university veterinaryteaching hospital between March 3, 2021 and March3, 2022 were eligible for prospective enrolment. Exclusioncriteria included surgical procedures performed by otherdepartments, and procedures not performed in an operat-ing theater. Clients were informed of the study at thetime of patient discharge and allowed to opt-out. Ethicalapproval was obtained from the institution's Human Eth-ical Review Committee (reference HERC_461_20).2.2 |Data collectionPatient data prospectively collected from hospital medicalrecords included signalment, date of surgery, use ofimplants, and alive or dead at time of follow-up. Retro-spectively collected data included date of last hospitalvisit. Wound classification was retrospectively assignedbased on the surgical procedure.282.3 |SurveillancePassive surveillance was performed at least 30 days post-operatively, or 90 days where an implant was used, where-upon the hospital medical records were reviewed forGLENN ET AL . 185 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14011by Cochrane France, Wiley Online Library on [05/01/2024]. 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 Licensediagnosis of an SSI. An implant was defined as an objectpermanently placed in the animal during a surgical proce-dure that was not suture material, vascular clips or staples.A single questionnaire was developed for use inveterinary patients (AppendixA;F i g u r e A1)b ym a k i n gminor adaptations to a questionnaire used for post-discharge surveillance of SSIs in human patients.19Activesurveillance involved emailing clients and referring veteri-narians a link to the online questionnaire (Online Surveys,JISC, Bristol, UK) automatically scheduled through prac-tice management software (Provet, Nordhealth Ltd, Hel-sinki, Finland) 30 days postoperatively, or 90 days wherean implant was used. Data were downloaded as a spread-sheet for analysis. Those with incomplete questionnaireswere sent an email reminder at least 30 days later. Whenpatients underwent multiple surgical procedures, eachprocedure was actively surveilled separately. When a sur-gical site underwent a subsequent surgical procedure(s) atthe same site within 30 days, or 90 days where an implantwas used, only the most recent surgery was included inthe active surveillance. Patients not alive at the time offollow-up were excluded from active surveillance.2.4 |SSI definitionsA gold standard diagnosis of “SSI”or“No SSI ”was madefrom hospital medical records or RV questionnaires usingan established Centers for Disease Control and Preven-tion definition (Table1).21A gold standard diagnosis of“SSI”was made if the criteria in Table 1were met. A goldstandard diagnosis of “no SSI ”was made if the criteria inTable 1were not met after a minimum of 30 days postop-eratively, or 90 days where an implant was used.Client questionnaires were analyzed using two sepa-rate criteria to identify clinical signs and prescriptionssuggestive of SSI. These criteria were used to createthree algorithms that defined SSI from client question-naires (Figure1). Criterion 1 was the presence of anywound healing problem. Criterion 2 was the presenceof (a) wound dehiscence or antibiotic prescription; and(b) purulent discharge or two or more relevant clinicalsigns of SSI (redness, pain, heat, swelling, discharge).Wound healing problems, discharge, purulent discharge,redness, pain, heat, swelling, dehiscence and antibioticprescription corresponded to questions 1, 2a, 2bii, 3i,3ii, 3iii, 3iv, 3v and 6, respectively (AppendixA;Figure A1). Algorithms were encoded as formulas inExcel (Excel 16.56, Microsoft, Redmond, Washington,United States). Returned diagnoses were compared tothe gold standard diagnoses, and classified as true posi-tive (TP), true negative (TN), false positive (FP) or falsenegative (FN).SSIs were divided into “superficial ”,“deep ”and “organspace ”where sufficient clinical information was available.212.5 |Statistical analysisDescriptive statistics were calculated in Excel. Continuousdata were assessed for normality. Normally distributeddata are presented as mean with standard deviation andnon-normally distributed data as median with range.Sensitivity, specificity, positive predictive value (PPV),negative predictive value (NPV) and accuracy were calcu-lated as previously described.293|RESULTS3.1 |Study populationPatients undergoing 754 surgical procedures met theinclusion criteria and were eligible for passive surveil-lance. Of these procedures, 666 were undertaken in dogsand 88 were in cats. Multiple surgical procedures wereperformed in 44 dogs and three cats, giving 698 uniquepatients. The median age of dogs was 63.4 months (1.8 –169) and 62.8 months (5.1 –198) for cats.Forty-four patients undergoing 45 surgical proceduresdied before 30 days (or 90 days where an implant wasused), 12 patient records did not have a valid client emailaddress, and six surgical sites were reoperated on within30 days (or 90 days where an implant was used). There-fore, 63 surgical procedures were excluded from activesurveillance, leaving 691 surgical procedures eligible foractive surveillance (Figure2).3.2 |SurveillanceMedical records for 230 surgical procedures had a follow-up consultation at least 30 days postoperatively, or 90 dayswhere an implant was used, or a recorded SSI event. Theseoccurred at a median of 116 days postoperatively (3-440)and permitted passive surveillance for these procedures.RV questionnaires were completed for 224 surgicalprocedures. A total of 25 were excluded due to early com-pletion, leaving 199 questionnaires suitable for inclusion.RV questionnaires were completed at a median of108 days postoperatively (30 –705).Hospital medical records or RV questionnaires gave agold standard diagnosis for 366 surgical procedures.Client questionnaires were completed for 309 surgicalprocedures. Fifteen were excluded due to early comple-tion, leaving 294 questionnaires suitable for inclusion.186 GLENN ET AL . 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14011 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 LicenseClient questionnaires were completed at a median of64.5 days postoperatively (30 –693). Response rate was37.9% higher for clients than RVs. Client questionnairesfrom 173 surgical procedures had a corresponding goldstandard diagnosis.The diagnoses “SSI”or“No SSI ”from each algorithmwere compared to gold standard diagnoses (Table 2) andused to calculate sensitivity, specificity, PPV, NPV andaccuracy (Table 3). Algorithm 1 was the most sensitive(87.1%) compared to algorithm 2 (61.3%) and algorithm3 (82.6%). Algorithm 2 was the most specific (97.9%) com-pared to algorithm 1 (91.5%) but very similar to algorithm3 (97.7%). Algorithm 3 was the most accurate (95.5%)compared to algorithms 1 (90.8%) and 2 (91.3%). It wasable to classify “SSI”or“No SSI ”from 156/173 (90.2%) ofresponses, leaving 17/173 (9.83%) responses as “Inconclu-sive”. Of the “Inconclusive ”responses, 9/17 (52.9%) hadan SSI and 8/17 (47.1%) did not.3.3 |SSIsA gold standard diagnosis of SSI was identified in62 of 754 surgical procedures (8.22%). Woundclassification data are shown in Table 4. Surgical pro-cedures with implants accounted for 16/62 (25.8%)SSIs. Revision surgery was undertaken in 21 of all62 SSIs (33.9%) and seven of the 16 SSIs (43.8%)involving implants.Passive surveillance identified 50/62 (80.6%) SSIs,while active surveillance identified an additional 12/62 (19.4%) SSIs that were not detected by passive surveil-lance. Active surveillance increased the SSI rate by 24%compared with passive surveillance alone. Using algo-rithm 3 to analyze the remaining client questionnairesidentified one additional likely SSI and three “inconclu-sive”responses.Clinical signs of SSI were noted by clients or referringveterinarians at a median of 8 days postoperatively (range1–201). Of the 57 SSIs with this data, 27 (47.4%) showedclinical signs within 7 days postoperatively, 46 (80.7%)within 14 days postoperatively, 52 (91.2%) within 30 dayspostoperatively and 55 (96.5%) within 90 days postopera-tively. Two SSIs occurred after 90 days, at 115 and201 days postoperatively. Both late SSIs occurred follow-ing surgical procedures with implants.Among the 45 animals that died within 30 days post-operatively, or 90 days where an implant was used, oneTABLE 1 Surgical site infection definitions.21SuperficialSSIInfection occurs within 30 days after the operative procedure and involves only skin and subcutaneous tissue of theincision and patient has at least one of the following:a. Purulent drainage from the superficial incision.b. Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision.c. At least one of the following signs of infection: pain or tenderness, localized swelling, redness, or heat, andsuperficial incision is deliberately opened by a veterinarian and is culture positive or not cultured. A culture-negativefinding does not meet this criterion.d. Diagnosis of superficial incisional SSI by the surgeon or attending veterinarian.Deep SSI Infection occurs within 30 days after the operative procedure if no implant is left in place or within 1 year if implant isin place and the infection appears to be related to the operative procedure and involves deep soft tissues (e.g., fascialand muscle layers) of the incision and patient has at least one of the following:a. Purulent drainage from the deep incision but not from the organ/space component of the surgical site.b. A deep incision spontaneously dehisces or is deliberately opened by a veterinarian and is culture-positive or notcultured when the patient has at least one of the following signs: fever or localized pain or tenderness. A culture-negative finding does not meet this criterion.c. An abscess or other evidence of infection involving the deep incision is found on direct examination, duringreoperation, or by histopathological or radiological examination.d. Diagnosis of a deep incisional SSI by a surgeon or attending veterinarian.Organ/spaceSSIInfection occurs within 30 days after the operative procedure if no implant is left in place or within 1 year if implant isin place and the infection appears to be related to the operative procedure and infection involves any part of the body,excluding the skin incision, fascia, or muscle layers, that is opened or manipulated during the operative procedureand patient has at least one of the following:a. Purulent drainage from a drain that is placed through a stab wound into the organ/space.b. Organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space.c. An abscess or other evidence of infection involving the organ/space that is found on direct examination, duringreoperation, or by histopathologic or radiologic examination.d. Diagnosis of an organ/space SSI by a surgeon or attending veterinarian.Abbreviation: SSI, surgical site infection.GLENN ET AL . 187 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14011 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 Licensedeveloped an SSI and euthanasia was elected in prefer-ence to further wound management.4

Question 35

Castejon - 2024 - JAVMA - Use of a barrier membrane to repair congenital hard palate defects and to close oronasal fistulae remaining after cleft palate repair - Seven dogs (2019-2022).pdf

Answer 35

Case selectionMedical records of dogs presented to the Matthew J. Ryan Veterinary Hospital of the Univer -sity of Pennsylvania (MJR-VHUP) and diagnosed with congenital lip and palate defects (CFL/CFP), for which a barrier membrane (autologous auricular cartilage or allogenic fascia lata) was included in the surgical repair of the hard palate, were evaluated.Medical records reviewData collected from the medical records included signalment, cause, location and size of the hard pal -ate defect, diagnostic imaging (dental radiography, CT), surgical technique utilized for repair, type and size of the barrier membrane applied, and outcome.The size of the soft tissue defect of the hard pal -ate was classified as mild if it was < 25% of the width of the palate at the same location, moderate if the relative width was between 25% and 50%, or severe if it was > 50%.Outcome was classified as completely successful if there was no residual defect (ONF) in the hard palate, functionally successful if there was resolution of clinical signs despite persistence of a small ONF, or unsuccess -ful if there were clinical signs in the presence of an ONF as detected by a periodontal probe. The presence of an ONF and clinical signs at follow-up visits were record -ed. For dogs treated with an auricular cartilage graft, complications during the healing of the pinna of the ear were also recorded. Follow-up examinations were performed under anesthesia at our institution or by the referring veterinarian. Communication via e-mail was also attempted with the dog owners.ResultsDogsSeven dogs (2019 to 2022) met the inclusion cri -teria. The barrier membrane was used in 5 dogs dur -ing their first attempt at repair of a congenital hard palate defect (auricular graft in 3 dogs and fascia lata in 2 dogs) and in 2 dogs to close an ONF re -maining after previous CFP repair (auricular graft in one dog and fascia lata in another dog). All congeni -tal defects were classified as moderate. The median age at the time of the first surgery was 5 months. The 2 dogs with ONF had their second surgery at 6 and 9 months of age (2 and 3 months after the ini -tial attempt at repair), respectively. Follow-up ex -aminations ranged from 1 to 30 months (median, 4 months). The size of the dog and the shape and size of the congenital hard palate defect at the time of the first surgery varied, with the widest area at the level of the canine and maxillary first premolar teeth (Supplementary Table S1) .Preoperatory assessment and anesthetic protocolComplete blood count, serum chemistry, and thoracic radiographs were performed within 2 weeks before the procedures. The results were unremark -able. All patients were treated with antiemetics in the perioperative period. Bilateral maxillary nerve blocks (0.1 to 0.6 mL/site [0.1 to 0.45 mg/kg], bupivacaine hydrochloride 0.5%) were performed in each patient. The nerve blocks were repeated at the end of the pro -cedures. The anesthetic protocol was tailored for each patient and adjusted during the procedure as deemed necessary by the anesthesia team. Inspection, palpa -tion with a periodontal probe, and intraoral dental radiography were performed in all patients, revealing that the bony defect was generally wider (and widest at the level of the incompletely formed palatine fis -sures caudal to the incisive papilla) compared to the soft tissue defect. Only 1 dog had a CT performed at Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 12/24/23 09:43 AM UTC 3the time of initial congenital palate repair but not at the time of the ONF repair (case 6).Surgical procedureWith the patient in dorsal recumbency, the mouth and the nasal cavity were rinsed with lactated Ringer or saline solution to remove debris, mucoid discharge, and foreign material. The oropharynx was gently packed with a lap sponge and the endotra -cheal tube cuff insufflated to avoid entry of debris, fluid, and blood into the trachea.Repair of congenital hard palate defects (cases 1 through 5)In addition to a midline defect of the soft palate, 2 dogs had a defect of the lip and hard palate, and 3 dogs a defect of the hard palate without lip involvement. All were considered to have a subjectively high risk of ONF formation caudal to the incisive papilla after surgery with traditional techniques (medially positioned flaps, overlapping flap tucked under an envelope flap, or 2-flap palatoplasty) or needed extraction of teeth 6 to 8 weeks before palate defect repair was attempted.Mucoperiosteal flaps based on each major palatine artery were elevated to close the hard palate defect with 2 medially positioned flaps (bipedicle flaps, aka Von Langenbeck technique) or 2 pedicle flaps (2-flap palatoplasty). The major palatine arteries were ligated at the most rostral aspect of the flaps before penetrat -ing the palatine fissures when pedicle flaps were used.A barrier membrane (auricular cartilage or fas -cia lata) of appropriate size was placed between the remaining bone of the hard palate and the muco -periosteal flaps. The membrane was advanced ros -trally to the palatal aspect of the incisive bones (at least 3 mm under the incisive papilla) and onto the palatine process of the maxillae labially/buccally (as close to the dental arch as possible). The most cau -dal extension of the membrane was the right and left major palatine foramen. The membrane was secured to the labial/buccal gingiva and the rostral palatal mucoperiosteum in a horizontal mattress pattern us -ing 4-0 poliglecaprone 25 or polydioxanone. Then, both mucoperiosteal flaps were apposed in the mid -line and sutured together in a 2-layer closure (inter -rupted horizontal mattress pattern in the connective tissue and simple interrupted pattern for the oral Figure 1 —Cleft palate in a 4-month-old dog repaired with auricular cartilage from the pinna (case 1). A—The hard palate defect is widest at the level of the deciduous maxillary second premolar teeth. B—Incisions are made at the defect edges and about 1 to 2 mm palatal to the teeth along the dental arch. C—Bipedicle mucoperiosteal flaps are elevated; note the major palatine artery arising from the major palatine foramen (*) and continuing rostrally within the flap (dotted arrow). The foramen marks the most caudal extension of the bone surface covered by the graft. An accessory palatine artery (^) is visible caudal to the major palatine artery. D—The cartilage graft is trial fitted over the palate and trimmed as needed. E—The graft is secured to the labial/buccal gingiva and gingiva rostral to the in -cisive papilla with absorbable sutures in a horizontal mattress pattern. F—The midline between the 2 bipedicle flaps is sutured. The soft palate defect is repaired after the hard palate defect is closed.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 12/24/23 09:43 AM UTC4 mucosa). The soft palate was closed routinely with medially positioned flaps in 3 layers without lateral releasing incisions (Figure 1) .In the 2 dogs with a congenital defect of the lip and hard palate, the hard palate defect was first re -paired as described above. Then, the alveolar cleft and most rostral aspect of the hard palate (between the incisor teeth and incisive papilla) were repaired with advancement or transposition flaps from the labial mucosa to cover the defect and barrier mem -brane. In one of the dogs (4.5 months of age), the deciduous incisor teeth that were situated in the al -veolar cleft and the unerupted right and left perma -nent canine and second and third incisor teeth were extracted just prior to palate repair because they would have erupted into the surgical site in the future (Figure 2) . The other dog had all its permanent max -illary incisor teeth extracted. The membrane was left exposed to the oral cavity at the lateral incisions and to the nasal cavity in the area of the palate defect.Closure of ONF remaining after previous CFP repair (cases 6 and 7)One of the dogs (case 6) had 2 ONF (4 X 3 mm and 1 X 2 mm) caudal to the incisive papilla. First, a partial-thickness incision was made into the oral mu -cosa 2 mm away from the defect edges. The mucosa was elevated from the periphery toward the defects to create hinge flaps that were sutured in the center of the now combined defect. Then an envelope flap with a depth of 1 cm was created in all directions around the combined defect that measured 7 X 13 mm. A 2 X 3-cm piece of auricular cartilage was har -vested from the right pinna. The graft was trimmed Figure 2 —Bilateral cleft lip and palate in a 4.5-month-old dog (case 2). A—The widest area of the palate defect (> 1/3 palate width) is located caudal to the incisive papilla. B—Dental radiograph of the rostral hard palate and maxillary teeth. C = Developing permanent maxillary canine teeth. c = Deciduous right maxillary canine tooth. I = Developing permanent right and left third maxillary incisor and supernumerary third incisor teeth. i = Deciduous incisor teeth erupted in the cleft; all these teeth were extracted. C—Two mucoperiosteal pedicle flaps are elevated from the palate; the major palatine arteries (*) are incorporated into the flaps and ligated (arrow) at the most rostral part of the flaps; the tooth extraction sites are open; the incisions to create the flaps for the extractions are made so that they can be part of the labial/buccal transposition flaps. Stay sutures (triangle) are used to handle the flaps and minimize trauma. D—Placement of the allogenic canine fascia lata; the barrier membrane is secured as in Figure 1. E—Final closure of the hard and soft palate clefts; the membrane is exposed laterally between the flaps and the gingiva; these areas heal by second intention; the labial/buccal transposition flaps close the extraction sites, part of the hard palate defect rostrally, and the alveolar cleft. F—Follow-up image 2 months later; the mucosa is healed, and permanent incisor teeth are erupted. A periodontal probe was used to rule out oronasal fistulae at the incision sites.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 12/24/23 09:43 AM UTC 5to 17 X 27 mm to fit the defect and extend under -neath the envelope flap by at least 5 mm in all di -rections. To facilitate the placement and stabilization of the graft, a full-thickness incision 1 mm palatal to the right maxillary third incisor and canine teeth was made without affecting the gingival sulcus or the periodontal tissues of the teeth. It was attached un -der the mucosal flaps to the gingiva mesial and distal to the maxillary canine teeth with horizontal mat -tress sutures (4-0 poliglecaprone 25). The graft also was sutured to the edges of the defect in a simple in -terrupted pattern (5-0 poliglecaprone 25). The area of exposed cartilage was left to heal by granulation and epithelialization (Figure 3) .The other dog (case 7) had a 1 X 2-mm ONF (3 mm palatal to the permanent first incisor teeth) remaining after previous CFP repair. Despite the small size of the defect, it caused discomfort and sneezing after drinking. To have better coverage of the barrier membrane rostral to the ONF, the right and left maxillary first and second incisor teeth were extracted. About 2 mm of the defect edge was excised in all directions. A mucoperiosteal flap from the palatal mucosa palatal to the incisor and canine teeth was elevated. The mucosa labial to the incisor region was elevated. The fascia lata was trimmed to span the rostral part of the hard palate including the alveolar bone of the extracted incisor teeth rostrally and the incompletely formed palatine fissures caudally. It was attached to the gingiva laterally and under the labial flap rostrally (5-0 poliglecaprone 25). The ONF was closed in 1 layer and the palatal flap sutured to the labial flap (5-0 poliglecaprone 25). The barrier membrane was exposed laterally between the palatal flap and the canine teeth.Harvesting the auricular cartilage graftCartilage from the pinna was harvested af -ter preparation of the mucoperiosteal flaps in the mouth (Figure 4) . The procedure was performed as described elsewhere.13OutcomeClinical signs of nasal discharge, nasal con -gestion, and sneezing after drinking resolved in all cases. Complete success was achieved in 5 (71.4%) dogs and functional success in 2 dogs (28.6%; no clinical signs despite incomplete closure of an area at the incisive papilla). Incomplete closure occurred Figure 3 —Oronasal fistula remaining after cleft palate repair in a 6-month-old dog repaired with an auricular carti -lage graft (case 6). A—Two small defects persist in the rostral hard palate (*). B—The blue line defines the incision to create a partial-thickness mucosal hinged flap combining both defects. C—The flap is elevated and sutured in the center of the defect in a simple interrupted pattern. D—The graft is placed under pockets of the envelope flap created between the first (hinge) flaps and the palatal mucosa. E—The graft remains exposed; it covers the defect and is secured to the oral mucosa at the defect edges and to gingiva next to the canine teeth. F—Follow-up image 6 months later; a defect remains with mild inflammation at the periphery; the defect is smaller than before surgery.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 12/24/23 09:43 AM UTC6 in the dog that had 2 small palate defects caudal to the incisive papilla, and an auricular graft was used. This dog had persistent chronic rhinitis that sub -sided after rinsing the nose with saline, a course of antibiotics following culture and sensitivity testing of the nasal discharge, and repair of a 1-cm dehisced area at the caudal edge of the soft palate. The other dog with incomplete closure had a pinpoint defect after congenital hard palate defect repair (medi -ally positioned flaps). The auricular incisions healed without complications. Shrinkage and folding of the ear occurred due to lack of cartilage. No other com -plications were reported during the follow-up visits (range, 1 to 30 months; median, 4 months).

Question 36

Williams - 2024 - VETSURG - Evaluation of the addition of adrenaline in a bilateral maxillary nerve block to reduce hemorrhage in dogs undergoing sharp staphylectomy for brachycephalic obstructive airway syndrome - A prospective, randomized study.pdf

Answer 36

This study was designed as a prospective, randomized,double-blinded controlled study. Informed owner con-sent, including an opt-out clause, was obtained at thetime of admission. Ethical approval for this study wasgranted by the University of Nottingham Committee forAnimals and Research Ethics (ref: 319211207 VSA).Brachycephalic dogs were recruited into the study ifthere was a clinical need for BOAS surgery, including sta-phylectomy, and they were otherwise healthy. Dogs wereexcluded if they had a previous known coagulopathy orclinical signs suggestive of a coagulopathy, cardiac diseaseor were receiving anticoagulant therapies. Pre-operativecoagulation tests were not routinely performed. Dogs thatpresented in respiratory distress and required immediatesurgery were not included, due to the difficulty in obtain-ing owner consent and ensuring the patient's health status.With the hypothesis that the addition of adrenaline toa local anesthetic would result in a 25% reduction inintraoperative hemorrhage, with a significance level of0.05 and a power of 0.8, it was calculated that a total of32 participants would be required to demonstrate a sig-nificant difference between groups.2.1 |Maxillary nerve blockA total of 32 dogs were included in the study and randomlyassigned to one of two groups: adrenaline (A) group orno-adrenaline (NA) group by random selection of anunmarked envelope. Only the anesthesiologist performingthe block was aware of the group of the patient.After induction of general anesthesia, a bilateral max-illary nerve block was performed with either lidocaine 2%and adrenaline 0.00198% (Lignol, Dechra, UK) (group A),or lidocaine only (Locaine 2%, Animalcare, UK) (group68 WILLIAMS ET AL . 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14039 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 LicenseNA) by a board-certified anesthesiologist or third yearanesthesiology resident under supervision. An intraoralapproach was performed using a 24-gage needle bilater-ally, inserted through the oral mucosa just caudal to thelast molar tooth and oriented slightly rostro-cranially andmedially.12,20The needle was advanced 3 –5 mm, depend-ing on the size of the dog, to block the branches of themaxillary nerve as they enter the pterygopalatine fossa. Astandardized volume was used regardless of patient size(0.5 mL each side) of either lidocaine only or combinedlidocaine-adrenaline formulation. After negative aspira-tion of blood, to verify no intravascular injection, thedrug was injected, at least 10 min prior to the surgicalprocedure.2.2 |Surgical procedureA total of 100 unused cotton tipped applicators (1 cmdiameter buds, Millpledge, UK) and 100 unused(10/C210 cm) surgical swabs (Medline, UK) were weighedon a set of precision scales accurate to 0.001 g, and theaverage weight of an unused cotton tip applicator andsurgical swab was calculated.A surgical swab was placed at the back of the throatbehind the soft palate to collect blood and to reduce aspi-ration of blood. If further surgical swabs were required,these could be used. The same manufacturer and size ofsurgical swabs and cotton tipped applicators were usedfor all procedures.A cut and sew sharp staphylectomy was performed ina crescent shape with Metzenbaum scissors, cutting aquarter to a third of the palate at a time and oversewnwith absorbable, monofilament suture material (4/0 poli-glecaprone 25; Monocryl, Ethicon, Inc. Somerville, NewJersey), in a continuous pattern before commencing thenext cut. The palate was resected to the level of the cra-nial pole of the tonsils.Cotton tipped applicators were applied to the hemor-rhage surface and used to absorb any blood that exudedfrom the cut surface of the palate. An assistant wasscrubbed into each procedure and was also partly respon-sible for containing the blood loss with the cotton-tippedapplicators. Surgery was performed by a board-certifiedsurgeon or surgical resident under supervision.The number of cotton tipped applicators and swabsused during the procedure was recorded and these wereweighed post-operatively on the same set of precisionscales. The total hemorrhage for the staphylectomy pro-cedure was then calculated by subtracting the averageweight of unused cotton tipped applicators and surgicalswabs (Figure1). Hemorrhage normalized for body-weight (g/kg) was calculated for each dog (normalizedhemorrhage). Electrocautery and suction were not usedfor the procedure.To ensure the amount of soft palate re-section performed was comparable between the treat-ment groups, the resected soft palate was also weighedand recorded on the precision scales and normalized forbodyweight (g/kg).The surgeon was asked at the end of the procedure togive a semi-quantitative hemorrhage score: 1 =virtuallyno hemorrhage, excellent visibility, 2 =minimal hemor-rhage, very good visibility, 3 =moderate hemorrhage,good visibility, 4 =substantial hemorrhage, poor visibil-ity, 5.=very heavy hemorrhage, very poor visibility.To evaluate any complications from administration ofthe adrenaline, heart rate and respiratory rate were moni-tored and recorded every 5 min. Oscillometric venousblood pressure was measured every 5 min, by placing acuff of appropriate size to either the metatarsus or ante-brachium of the dog. A three-lead electrocardiogram wasused continuously to monitor for any rhythm distur-bances. Heart rate, respiratory rate and blood pressurevalues that increased by 20% above the dog's baseline,were deemed tachycardia, tachypnea, or hypertension.The median mean arterial blood pressure (MAP) for eachpatient, during the intraoperative period was calculated.FIGURE 1 Image depicting set of precision scales (accurate to0.001 g) used to weigh cotton-tipped applicators and surgical swabspre- and postoperatively.WILLIAMS ET AL . 69 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14039 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 License2.3 |Statistical analysisA Fisher Exact test was used to compare the proportions ofbreeds between study groups. C ontinuous (bodyweight, pal-ate weight, total hemorrhage, normalized hemorrhage andaverage MAP) and ordinal data (hemorrhage score) werecompared between treatment groups using Mann Whitneytests adjusted for ties. Total hemorrhage and normalizedhemorrhage were compared between English Bulldogs andcombined other breeds using Mann Whitney tests adjustedfor ties. Significance of Pearson correlations between vari-ables were calculated using re sampling methods, based on1000 randomizations. Analysi s was performed using com-mercial software (Minitab 19 and R 3.6.2, State College, PA:Minitab, Inc) by an independent professional statistician. Ap-value <.05 was considered statistically significant.3|RESULTS3.1 |Study population and signalmentA total of 32 dogs underwent a sharp cut and sew staphy-lectomy at a single veterinary specialist referral center astreatment for BOAS between January and December 2022.Sixteen dogs were randomly assigned to each group:(NA) or (A). Breeds included: French bulldog ( n=16),English bulldog ( n=8), Pug ( n=4) and one each of thefollowing other brachycephalic breeds: Boston terrier,Yorkshire terrier, Cavalier King Charles Spaniel andChihuahua /C2Pug ( n=1 each). The proportions of breedsdid not differ between treatment groups ( p=.357).Median bodyweight for group A was 12.5 kg and forgroup NA was 13.6 kg (range, 5.7 –27.0) and did not differbetween treatment groups ( p=.777).3.2 |Intraoperative dataResected soft palate had a median weight of 1.70 g (range,0.95 –6.98) in group A and 1.53 g (range, 1.10 –5.30) ingroup NA. Palate weight did not differ between treatmentgroups ( p=1.000) (Table 1).The median MAP during the intraoperative perioddid not differ between the two groups ( p=.610, Table 1)and was not correlated with normalized hemorrhage(p=.521). Median total hemorrhage for group A was1.82 g (range, 0.12 –60.66) and for group NA was 7.95 g(range, 1.32 –64.09). Total hemorrhage was lower ingroup A compared to group NA ( p=.013) (Figure2)with a difference in median hemorrhage of 6.13 g and a77.1% reduction in median hemorrhage between groupA and group NA. The mean weight of 1 mL of blood is1.06 g, so this equates to a median total hemorrhage of1.71 mL for group A and 7.50 mL for group NA with adifference of 5.78 mL between the two groups.Normalized hemorrhage was also lower for group A(median, 0.15 g/kg, range, 0.01 –2.25) than group NA(median, 0.65 g/kg, range, 0.10 –3.69, p=.021).Median surgeon hemorrhage score was lower in groupA with a score of 2 (range, 1 –5) compared to group NAwith a score of 3 (range, 2 –5,p=.029). No dogs in groupNA were assigned a hemorrhage score of 1 (virtually nohemorrhage and excellent visibility) but five dogs in groupA were assigned this score. Conversely, three dogs wereassigned a hemorrhage score of 5 (very heavy hemorrhage,very poor visibility) in group NA, and only one dog ingroup A was assigned this score (Figure3,T a b l e 1).It was observed that objective total hemorrhage wasgreater in English bulldogs compared to combined otherbreeds (median, 3.09 g, range, 0.12 –25.85, p=.007).Since there were significant positive correlations betweenbodyweight and total hemorrhage ( r=0.681, p=.001),between bodyweight and palate weight ( r=0.690,p=.001), and between total hemorrhage and palateweight ( r=0.634, p=.002) it was important to comparedifferences from English bulldogs on the normalizedhemorrhage scale. This still suggested a significant differ-ence ( p=.048) between English bulldogs (median,1.24 g/kg, range, 0.08 –2.67) compared to other combinedbreeds (median, 0.28 g/kg, range, 0.01 –3.69) in normal-ized hemorrhage.TABLE 1 Median (range)bodyweight, MAP, resected palateweight, total hemorrhage, hemorrhagenormalized for bodyweight, andsurgeon bleeding score for eachtreatment group with p-value alsopresented.Group A Group NASignificance(p-value)Bodyweight (kg) 13.2 (5.7 –27.0) 13.6 (7.0 –25.0) .777MAP (mmHg) 65 (55 –85) 70 (52 –81) .610Resected palate weight (g) 1.70 (0.95 –6.98) 1.53 (1.10 –5.30) 1.000Total hemorrhage (g) 1.82 (0.12 –60.66) 7.95 (1.32 –64.09) .013Normalized hemorrhage(g/kg)0.15 (0.01 –2.25) 0.65 (0.10 –3.69) .021Surgeon bleeding score (1 –5) 2 (1 –5) 3 (2 –5) .029Abbreviations: A, adrenaline; MAP, mean arterial blood pressure; NA, no-adrenaline.70 WILLIAMS ET AL . 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14039 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 LicenseNo perioperative complications (tachycardia, arrythmias,tachypnea or hypertension) were noted as a result of theaddition of adrenaline in the bilateral maxillary nerve block.4

Question 37

Farrell - 2023 - JAVMA - Bilateral, single-session, laparoscopic adrenalectomy was associated with favorable outcomes in a cohort of dogs.pdf

Answer 37

Medical records were searched for dogs that under -went BSSLA at 4 institutions between 2017 and 2022. Data collected included patient signalment, present -ing clinical signs, physical examination findings, clini -copathologic results, diagnostic imaging results, and preoperative treatments. Operative data collected from medical records were reviewed, and surgical time, type and number of ports, order of adrenal gland re -moval, intraoperative surgical complications, need for conversion, total anesthesia time, and anesthetic com -plications were recorded where available. Postopera -tive data collected included tumor type from histopa -thology reports, postoperative adverse events, length of hospitalization, and details of short- and long-term follow-up where available in the medical records.Owner consent for surgery was obtained for all dogs. Laparoscopic adrenalectomy was performed using a 3- or 4-portal transperitoneal technique on each side with the dog positioned in an oblique lat -eral recumbent position as previously described.2,6–8 Briefly, a paramedian endoscopic portal was estab -lished lateral and caudal to the umbilicus. Depend -ing on surgeon preference, 2 or 3 instrument portals were established in a triangulating pattern around the affected adrenal gland (Figure 1) . The adrenal tumor and surrounding structures were identified (Figure 2) . A vessel-sealing device (LigaSure; Medtronic) and other endoscopic instruments were used to dissect the adrenal tumor from its retroperitoneal attach -ments, leaving its final attachment. Finally, the ves -sel-sealing device was also used to seal and divide the phrenicoabdominal vein. The adrenal gland was placed into a specimen-retrieval bag (EndoCatch; Medtronic) and extracted through an enlarged portal incision. Following resection of the first gland, dogs were repositioned into the contralateral recumbency, and the laparoscopic technique was repeated.Surgical complications and adverse events were described and classified using the definitions pro -posed by Follette et al.9ResultsSix dogs were included in this study, with 3 be -ing spayed females, 2 intact females, and 1 neutered male. Dogs included one of each of the following: Figure 1 —Port placement for laparoscopic adrenalectomy.Figure 2 —Intraoperative view of the right kidney (A; white asterisk) and right adrenal tumor (black arrows) and the left kidney (B; white asterisk) and left adrenal tumor (black arrows) in dog 1.Unauthenticated | Downloaded 10/08/23 06:32 AM UTC 3Shih Tzu, Beagle, Basset Hound, Labrador Retriev -er, West Highland White Terrier, and mixed breed. The median age was 126 months (range, 96 to 133 months). The median weight was 14.75 kg (range, 6.2 to 34.2 kg; Table 1 ).Presenting clinical signs prior to diagnosis includ -ed hyporexia (1), anxiety and restlessness (1), hyper -tension (2), polyuria and polydipsia (1), weakness and exercise intolerance (1), vomiting (1), and hyperten -sive retinopathy (1). In 1 dog, clinical signs were ab -sent, and bilateral adrenal tumors were an incidental finding during abdominal ultrasonography performed to detect whether the dog had been previously spayed.Four of 6 dogs were pretreated with phenoxy -benzamine prior to surgery. Dosages ranged from 0.2 to 0.6 mg/kg orally twice a day. Of these 4 dogs, 1 was also concurrently treated with amlodipine (0.1 mg/kg, PO, q 24 h). Two of six dogs that did not receive pretreatment with phenoxybenzamine prior to sur -gery were being treated with trilostane for manage -ment of hyperadrenocorticism.The initial diagnosis of bilateral adrenal tumors was made with abdominal ultrasound in 5 of 6 dogs and with abdominal contrast-enhanced CT (CECT) alone in 1 of 6 dogs. Other abnormalities detected at the time of abdominal ultrasonography or abdominal CECT in -cluded mild biliary sludge and mild hepatomegaly (n = 1), splenic mass (1), and cystoliths (1). Additionally, all dogs included in this study had thoracic radiographs performed as part of preoperative staging, and no evi -dence of metastasis was present in any case.All dogs included in this study underwent pre -operative CECT. Contrast-enhanced CT was used to calculate maximal tumor diameter. Median maximal tumor diameter was 2.3 cm (range, 1.6 to 6.0 cm) for the left adrenal gland and 2.6 cm (range, 1.5 to 4.0 cm) for the right adrenal gland (Table 1). BSSLA was successfully performed in 5 of 6 dogs. Of the 5 dogs that successfully underwent BSSLA, median surgical time was 158 minutes (range, 75 to 180 min -utes), and median anesthesia time was 264 minutes (range, 180 to 330 minutes). Three dogs underwent additional concurrent laparoscopic procedures (in -cluding laparoscopic liver biopsy [n = 1 dog], lapa -roscopic splenectomy [1 dog], and laparoscopic ovariectomy [1 dog]), which were included in total surgical and anesthesia times reported.Histopathological evaluation of the 11 excised tumors revealed adrenocortical adenoma (6), adre -nocortical carcinoma (2), pheochromocytoma (1), and undifferentiated tumors of adrenocortical origin (2; Table 1). In the 5 dogs that underwent BSSLA, the same tumor type was present in both adrenal glands. In the dog whose procedure was converted to open celiotomy following renal vein laceration, the single removed left-sided adrenal tumor was a pheochromo -cytoma, and a diagnosis from the contralateral tumor was not obtained, as it was left in situ.High-grade intraoperative surgical complica -tions were encountered in 2 dogs included in this study.9 Unrelenting hemorrhage was encountered in 1 dog following renal vein laceration during dis -section of the left adrenal gland, which necessitated conversion to an open approach. Left adrenalectomy and ureteronephrectomy were performed at the time of open celiotomy, as the renal vein laceration was not repairable. The right adrenal tumor was left in situ. Intraoperative cardiac arrest occurred in 1 dog at the time of repositioning for the contralateral side due to iatrogenic pneumothorax. The cause of the pneumothorax was not identified but was suspected to be due to accidental diaphragm perforation dur -ing dissection of the right adrenal gland. Resusci -tation was successful and, following owner consul -tation, a decision was made to move ahead with laparoscopic left adrenalectomy. The procedure was halted for 80 minutes for resuscitation, stabilization, and consultation with the owner. This time was not included in the total surgical time for this patient. No further anesthetic complications were encountered throughout the remainder of the procedure.All dogs in this cohort recovered from surgery and survived to discharge. Postoperative complica -tions reported included transient blindness for 18 hours in the dog that arrested during surgery (dog 6) and transient postoperative hypertension occurring 7 hours postoperatively (dog 1), which resolved with additional analgesics. The time spent in the hospital following surgery ranged from 45 to 96 hours, with a median postoperative hospital stay of 59 hours.Histopathological evaluation of adrenal tumors removed in the dogs of this report revealed that 6 of 11 (55%) were adenomas, 2 of 11 (18%) were adreno -cortical carcinoma, and 1 of 11 (9%) was a pheochro -mocytoma. Initial histopathology was inconclusive for the 2 tumors excised from dog 2 (Table 1). Im -munohistochemistry was elected, and these tumors were ultimately diagnosed as undifferentiated adre -nal cortical tumors; however, no further classification was obtained. Left maximal Right maximal Dog Weight tumor diameter tumor diameter Left side Right Surgical Anesthesia Follow-up Dead or alive at timeNo. (kg) (cm) (cm) tumor histology histology time (min) time (min) time (d) of last follow-up1 6.2 2.1 1.5 Adenoma Adenoma 180 270 305 Alive2 6.2 1.6 2.2 Adrenocortical Adrenocortical 150 240 264 Alive tumor tumor3 33.0 4.5 2.5 Pheochromocytoma NA — — — —4 34.2 6.0 3.5 Cortical Cortical 180 330 730 Alive carcinoma carcinoma5 19.0 2.5 2.7 Adenoma Adenoma 158 210 180 Dead6 10.5 2.0 4.0 Adenoma Adenoma 75 180 80 AliveTable 1 —Summary of patient weight, maximal tumor diameter, histological diagnosis, surgical time, anesthesia time, and follow-up for the dogs included in this study. Surgical, anesthesia, and follow-up times were excluded for dog 3, as bilateral, single-session, laparoscopic adrenalectomy was unsuccessful.Unauthenticated | Downloaded 10/08/23 06:32 AM UTC4 Postoperative follow-up was obtained in all 5 dogs that underwent BSSLA and ranged from 60 to 730 days, with a median follow-up time of 264 days. At the time of the last follow-up, 4 of 5 dogs were known to be alive, and no recurrence was noted. One dog was known to have been euthanized following development of aggressive mammary neoplasia 730 days postoperatively.

Question 38

Ziemann - 2023 - JFMS - Malocclusion in cats associated with mandibular soft tissue trauma - A retrospective case-control study.pdf

Answer 38

Inclusion criteriaCats that had presented for dental consultations between 2017 and 2022 and had undergone thorough clinical assessments, diagnostic imaging with whole-mouth radi-ography and cone-beam CT (CBCT) were included in the study. All cats were required to have complete perma -nent dentition, without a history of other musculoskeletal anomalies of the head.Exclusion criteriaCats that had a history of trauma to the head or max-illofacial surgery previously were excluded from the study. Cats with missing teeth relevant for the present study as well as those that had previously undergone odontoplasty or orthodontic treatment for conditions similar to those in the present study were excluded.Ethics statementThe study included client-owned cats, and all own-ers agreed to the standard-of-care treatment. Written informed consent was obtained from the owners for the participation of their animals in this study. Ethical review and approval were not required for the animal study according to Polish Regulations (Art.1 ust.2 pkt1 Dz. U.2015 poz. 266).GroupsThe cats were divided into two groups: cases and controls. The number of controls was double that of cases (case-to-control ratio: 1:2). Cases (group A) were designated as cats with clinical diagnoses of malocclusion causing trauma to the buccal mandibular soft tissues or with pyogenic granuloma secondary to the trauma. Controls (group B) were designated as cats with the absence of such diagnoses and without a history of other musculo -skeletal anomalies in the head.Medical and dental proceduresAll cats underwent thorough general and oral clinical examinations with assessments for occlusion before anaesthesia. All animals were qualified for general anaes-thesia for reasons related to oral and/or dental problems.After the induction of general anaesthesia, all cats were examined clinically. Whole-mouth radiography and CBCT (NewTom; 5G XL) were performed. For CBCT, vol-umetric assessment of the dentition was performed in the same high-resolution mode (10 × 10 cm with 0.15 mm lay-ers) and high-energy enhancement. All scans were evalu -ated by a board-certified veterinary dentist experienced in CBCT imaging (JG). The scans were analysed using NNT Viewer software (version 10.1; QR SRL).Dental treatment was performed in all cases, when indicated. The following treatments were performed: odontoplasty; extractions; excisional biopsies of any granulation or proliferative tissues; and laser ablation, if needed.2,3VariablesThe cephalometric parameters of the skull and facial indexes that were assessed and recorded were as follows: facial length; facial width; skull length; and skull width. Anatomic landmarks used for such measurements are presented in Table 1. The skull and facial indexes were calculated as previously reported.8The measurements between dental landmarks are as follows (Figure 1a–c):1. Distances (in mm) between the crown tips of 104–204, 304–404, 107–207, 108–208, 308–408 and 309–409 were calculated. In the case of 309 and 409, the distal crown tip was used for such measurements.Table 1 Dimensions and parameters of anatomic landmarks measured in each catParameter DescriptionTeeth distances Distances between the crown tips, except in the case of 309 and 409 in which the distal tip was usedTeeth angulation Angulation between the palatal plane and the tooth crown axis (the line between middle point of the crown base and the tip of the crown)Facial length Distance from the nasion (the junction on the medial plane of the left and right naso-frontal sutures) to the prosthion (the rostral end of the interincisive suture, located between the roots of the superior central incisor teeth)Facial width Distance between the left and right zygions (the most lateral point on the zygomatic arc)Skull length Distance from the inion (the rostral end of the interincisive suture, located between the roots of the superior central incisor teeth) to the prosthionSkull width The widest inter-zygomatic distanceSkull index The ratio of skull width to skull lengthFacial index The ratio of facial width to facial lengthZiemann et al 32. The space between the crown tips of 108–308, 208–408, 108–309, 208–409, 107–308 and 207–408 were determined as the difference between the previous measurements (107–207, 108–208, 308–408 and 309–409) at the point of interest, then divided by 2, to reflect the maxillomandibular dental space between each crown.3. Angulation between the palatal plane and the tooth crown axis. The tooth crown axis was defined as the line between the middle point of the crown base and the crown tip. Angulation was calculated for teeth 107, 108, 207, 208, 308, 309, 408 and 409.In the cats in group A, three grades of severity were defined for mandibular soft-tissue lesions secondary to malocclusion (Table 2 and Figure 2a–d). The number of lesions (1–4) in teeth 107, 108, 207 and 208 was recorded.Statistical analysisStatistical analysis was performed using the com-mercial data analysis software system Statistica (ver -sion 10, StatSoft) and SPSS Statistics (version 26, IBM). Quantitative data were evaluated for conformity with a normal distribution using the Shapiro–Wilk test. Differences between the case and control subgroups were determined using the Student’s t-test or the Mann–Whitney test. To evaluate the discriminatory value of the skull and facial indexes for occlusion owing to trau -matic malocclusions, a receiver operating characteristic (ROC) curve analysis was performed. A cutoff value was defined if the area under the ROC curve (AUC) was considered acceptable, and the value was determined maximising both sensitivity and specificity. P <0.05 was assumed to be statistically significant in all conducted tests.ResultsA total of 72 cats were included in the study. Their mean age was 58.74 ± 53.4 months (age range 6–236), and 39 (54.2%) were males and 33 (45.8%) were females; their mean weight was 4.57 ± 1.45 kg (range 2.35–9.0).In group A (case group; n = 24 cats), the mean age of the cats was 48.92 ± 56.53 months (age range 6–236), and 13 were males (seven intact) and 11 were females (four intact); their mean body weight was 5.15 ± 1.41 kg (range 2.82–9.0). Among the 24 cats, there were 14 British Shorthair (BSH), two domestic shorthair (DSH), five Maine Coon and one each of British Longhair (BLH), Persian and Selkirk Rex.In group B (control group; n = 48 cats), the mean age of the cats was 63.65 ± 51.67 months (age range 6–216), and 26 were males (10 intact) and 22 were females (seven intact); their mean body weight was 4.27 ± 1.4 kg (range 2.35–8.5). Among the 48 cats, there were 30 DSH, six BSH, four Maine Coon, three Ragdoll and one each of Scottish Fold, Persian, Thai, BLH and Norwegian Forest Cat.No significant differences in age were observed between both groups, except group A cats had a sig-nificantly higher body weight than those in group B (P = 0.0079).The average skull and facial indexes were 0.78 and 2.04 for group A cats and 0.71 and 1.86 for group B cats, respectively. The skull index in group A was significantly greater than that in group B (P = 0.0007), and the facial index showed significant differences (P = 0.0002) (Table 3).Figure 1 Assessment of the tooth crown axis for tooth angle determination and distances (in mm) between crown tips for (a) 104–204 and 304–404; (b) 107–207 and 108–208; and (c) 308–408 and 309–409Table 2 Categories of the malocclusion pathological consequencesPathology gradesGrade 1 Only clinical signs with gum recession and/or gingival impingement; non-visible on CBCT alveolar bone lossGrade 2 Gum recession and/or gingival impingement and visible on CBCT alveolar bone lossGrade 3 Pyogranuloma and visible on CBCT alveolar bone lossCBCT = cone-beam CT4 Journal of Feline Medicine and Surgery Figure 2 (a) Photographs, (b) clinical three-dimensional reconstructions of CBCT scans, (c) radiography and (d) coronal slice images in CBCT showing the three grades of severity of lesions in the mandibular soft tissues secondary to the malocclusion. CBCT = cone-beam CTTable 3 Association between skull and facial index (SD) with study groupsGroup A Group B P valueSkull index 0.78 (0.073) 0.71 (0.042) 0.0007Facial index 2.04 (0.31) 1.86 (0.162) 0.0002Standard deviation in bracketsThe distances and spaces between the crown tips are summarised in Table 4. The distances between the crown tips for teeth 107–207, 108–208 and 309–409 in group A were significantly greater than those in group B (P = 0.0010, <0.0010 and < 0.0010, respectively). The mean space between the crown tips of 107–308 and 207–408 was 0.39 ± 0.51 mm in group A and −0.210 ± 1.44 mm in group B, which showed significant differences (P = 0.041). The mean space between the crown tips of 108–308/208–408 was 2.04 ± 0.50 mm in group A and 2.97 ± 0.53 mm in group B, which showed significant differences (P <0.001). The mean space between the crown tips of 108–309/208–409 was 0.076 ± 0.43 mm in group A and 0.110 ± 0.60 mm in group B, which showed non-significant differences.The angulation values are presented in Table 5. All angles determined were significantly different between the groups. The angulation of teeth 108, 208, 308 and 408 in group A was significantly lower than that of group B (P = 0.0086, 0.0003, 0.0003 and 0.0010, respectively). By contrast, group A cats had a higher angulation for tooth 207 than group B cats ( P <0.0010). No significant differ -ences in angulation values were observed for teeth 309 and 409 between the groups.Traumatic impingement was mainly caused by cusps of 108 and 208, and the mean severity grade was 2.17 and 2.13, respectively. Teeth 107 and 207 caused trauma at severity grades of 1.04 and 1.20, respectively (Table 6). In group A, the mean number of lesions was 3.208 (range 2–4). Figure 3 shows the relative frequency chart of trauma grade caused by third maxillary premolars Ziemann et al 5Table 4 Axial distances (mm) and spaces between crown tips in both groups* A B C D E F (C-E)/2 (D-E)/2 (D-F)/2 104–204 304–404 107–207 108–208 308–408 309–409 Group A 18.60 ± 1.56 14.88 ± 1.68 24.73 ± 2.12 32.34 ± 2.38 24.25 ± 1.63 32.04 ± 2.39 0.39 ± 0.51 2.04 ± 0.50 0.076 ± 0.43Group B 17.80 ± 1.94 14.82 ± 1.42 22.98 ± 1.99 29.35 ± 2.24 23.90 ± 1.71 29.14 ± 2.28 −0.21 ± 1.44 2.97 ± 0.53 0.11 ± 0.60P value ns ns 0.0010 0.0000 0.1055 0.0000 0.041 0.0001 nsData are mean ± SD*(C-E)/2, (D-E)/2 and (D-F)/2 reflect the maxillomandibular dental space between each crownns = non-significantTable 5 Tooth angulation (°) to the palatal plane in both groups, assessed between the palatal plane and the tooth crown axis (defined as the line between the middle point of the crown base and the crown tip) 107 108 207 208 308 309 408 409Group A 70.95 ± 5.34 57.9 ± 7.62 72.31 ± 6.72 58.14 ± 6.67 110.2 ± 5.79 114.35 ± 5.01 112.55 ± 7.15 115.45 ± 6.84Group B 73.9 ± 5.42 63.25 ± 5.35 67.63 ± 6.31 63.57 ± 5.25 116.5 ± 7.00 115.65 ± 6.41 118.60 ± 7.13 116.15 ± 6.60P value 0.0141* 0.0086 0.0000 0.0003 0.0003† 0.2300* 0.0010* nsData are mean ± SD*Median (min –max), Mann-Whitney U test †Mean (SD), Student t testns = non-significant6 Journal of Feline Medicine and Surgery (107 and 207) and fourth maxillary premolars (108 and 208).In group A, the three-dimensional scan showed thin -ning or complete osteolysis of the palatal process of the maxillary bone at the level of mandibular molar occlusion in the palate. Among the 24 cats in group A, seven had this anomaly. Among the seven cats, one had involve-ment of four mandibular teeth (308, 408, 309 and 409) and six others had involvement of two mandibular teeth (309 and 409) (Figure 4). In group B, none of the cats had this anomaly.The ROC curve analysis showed that the skull index was a significant predictor of traumatic malocclusions in the caudal teeth (P <0.001), with an AUC of 0.773. The Table 6 Distribution and grades of trauma in the oral cavity caused by malocclusionTeeth causing trauma, pathology gradeCat 107 108 207 208 Number of lesions 1 2 2 3 3 4 4 4 5 4 6 4 7 2 8 2 9 210 211 412 413 414 415 216 417 318 419 420 321 222 423 224 4Mean 1041 2166 1208 2125 3208Colour code No trauma Grade 1 Grade 2 Grade 3 Grade 1 = 1 point; grade 2 = 2 points; grade 3 = 3 pointsFigure 3 Relative frequency chart of the severity grades of trauma caused by the third maxillary premolars (107 and 207) and fourth maxillary premolars (108 and 208)Ziemann et al 7cutoff value for the skull index was 0.7331, with a sen-sitivity of 79.2% and a specificity of 79.2% (1 – specific -ity = 0.208) (Figure 5). The ROC curve analysis showed that the facial index was a significant predictor of trau-matic malocclusions in the mandibular soft tissues (P <0.001), with an AUC of 0.772. The cut-off value for the facial index was 0.196, with a sensitivity of 83.3% and a specificity of 72.9 (1 – specificity = 0.271) (Figure 5).

Question 39

Jones - 2024 - VETSURG - Evaluation of subchondral bone cysts in canine elbows with radiographic osteoarthritis secondary to elbow dysplasia.pdf

Answer 39

2.1 |CasesMedical records of Labrador retrievers who presented foreither unilateral or bilateral forelimb lameness clinicallyassociated with the elbow joint were identified betweenJune 2018 and October 2021. A sample of conveniencewith approximately equal number of male and female,young, and old dogs (under or over 2 years of age respec-tively) were included. Dogs were excluded if their medicalrecords were incomplete. Dogs were either sedated oranesthetized at the discretion of the attending clinicianand underwent imaging using a 320-slice CT scanner(Aquilion One Genesis, Canon Medical Systems, Otawara,Japan) with the following settings: 120 kVp, 150 mAs,0.5 mm slice thickness, 25 cm field of view and 512 /C2512matrix. Elbow sequences were reconstructed using theCT scanner's associated software bone algorithm.342 JONES ET AL . 1532950x, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14047 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 License2.2 |Computed tomography analysisDigital Imaging and Communications in Medicine(DICOM) files were retrieved for the cases that wereincluded and were reconstructed using Horos v3.3.6(Horos Project, Geneva, Switzerland). Images were repo-sitioned using the three-dimensional (3D) multiplanarreconstruction (MPR) function to represent the mediolat-eral projection.Radiographic OA severity was classified using a four-point ordinal system based on the size of the largestosteophyte (Table1) previously validated against arthro-scopic cartilage condition,35,36which has also beenadapted into the International Elbow Working Groupgrading system.37The radiographic diagnosis of elbowdysplasia was based on the imaging findings reported bythe attending board certified veterinary radiologist/orthopedic surgeon responsible for the cases.Subchondral bone cysts were defined as hypoattenu-ating circular to ellipsoid structures with a hyperattenuat-ing rim with more than half of their diameter within6 mm of a subchondral bone margin (Figure1). Thedepth of subchondral bone is defined variably in differentstudies. For this study, the depth of 6 mm from the corti-cal margin was chosen, based on other work that hasexamined the subchondral bone,38and therefore SBCsgreater than 6 mm from a cortical margin or enclosedwithin an osteophyte were excluded. Sagittal plane recon-structions were reviewed slice by slice from medial to lat-eral, and SBC measurements were performed in thesagittal plane, with their frequency, size (maximumdiameter), and location recorded.2.3 |Statistical analysisData analysis was performed using SPSS (Version28, IBM, New York). Categorical variables were describedusing frequencies. Given the repeated measures design ofthis study, statistical analysis was performed using gener-alized estimating equations. Individual dogs were set asthe subject variable (repeated measure) using anexchangeable working correlation matrix. For radio-graphic OA grade and age, an ordinal logistic model wasused, with radiographic OA grade set as the dependentvariable. This was modeled with age as both a categoricaland continuous variable. Results were presented as oddsratios (OR) and 95% confidence intervals (CI). The SBCnumber was treated as count data using a Poisson countmodel, with radiographic OA severity, age and sex usedas factors. Results were presented as rate ratio (RR) and95% CI. The SBC size (maximum diameter) was rightskewed and was log-transformed to normalize the dataprior to the analysis. A linear model of the normalizedSBC size (maximum diameter) was used with radio-graphic OA severity, age and sex used as factors. Resultswere presented as OR with 95% CI. Statistical significancewas set as p≤.05.3|RESULTS3.1 |Study populationThirty-eight dogs were included in the study, with18 young dogs (mean age 1.0 years) and 20 old dogs(mean 6.7 years). The population statistics are summa-rized in Table2. There were 18 female dogs and20 male dogs.A total of 76 elbows were examined. The mostcommon radiographic diagnosis was medial coronoiddisease (67 elbows, 88%), with 25 elbows havingevidence of a fragmented coronoid process. Elbowincongruity was reported in 25 elbows (33%) andosteochondritis dissecans was reported in sevenelbows (9%). No evidence of elbow dysplasia wasreported in five elbows (7%) —all were contralateralnormal elbows other than one dog with no evidence ofdisease in either elbow.3.2 |Severity of radiographic OAOsteophytes were not identified in five elbows;these elbows did not have evidence of elbow dysplasia.In the remaining elbows, 32 elbows were OA grade1, 19 elbows were OA grade 2 and 20 elbows were OAgrade 3 (Figure2). There was a trend (although not sta-tistically significant) for i ncreasing radiographic OAseverity within the older Labrador retriever group(OR=2.969, 95% CI 0.929 –7.827 p=.068). When agewas modeled as a continuous variable, there was anincreased likelihood of increased radiographic OAseverity as age increased (OR =1.198, 95% CI 1.001 –1.433, p=.048).TABLE 1 Osteoarthritis grading system based on the size ofthe largest osteophyte.35–37OA Grade Definition0 (Normal) No osteophytes present1 (Mild) Osteophyte <2 mm present2 (Moderate) Osteophyte 2 –5 mm present3 (Severe) Osteophyte >5 mm presentAbbreviation: OA, osteoarthritis.JONES ET AL . 343 1532950x, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14047 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 License3.3 |Subchondral bone cystsSubchondral bone cysts were not identified in any nor-mal (radiographic OA grade 0) elbows. These elbowswere removed from further analysis. Subchondral bonecysts were identified in all elbows with radiographicOA. The median number of SBCs at OA grade 1 wasthree (IQR 2 –4), at OA grade 2 it was nine (IQR 7 –10),and at OA grade 3 it was 20 (IQR 15 –22) (Figure3A). Thenumber of SBCs increased as the radiographic OA sever-ity increased, with an association between the number ofSBCs and radiographic OA severity ( p< .001). Neitherage nor sex was associated with SBC number ( p=.805andp=.939 respectively). The rate at which SBC num-ber were present increased for both OA grade 2 and 3 incomparison with OA grade 1 (RR =2.46, 95% CI 2.08 –2.92, p< .001; RR =5.60, 95% CI 4.79 –6.55, p< .001).The SBC size (maximum diameter) at each radio-graphic OA grade is shown in Figure3B. Again, an asso-ciation between SBC size (maximum diameter) andradiographic OA severity was observed. ( p=.041). TheSBC size was also observed to be associated with both age(p=.013) and sex ( p=.002). As radiographic OA sever-ity increased to grade 3, there was an increased likelihoodthat the SBCs were larger than SBCs from OA grade1 (OR=1.056, 95% CI 1.012 –1.101, p=.012). A similarincreased likelihood for increasing SBC size was seen forOA grade 2 in comparison with OA grade 1; however thiswas not significant (OR =1.012, 95% CI 0.972 –1.054,p=.569). Older dogs were more likely to have largerSBCs than young dogs (OR =1.054, 95% CI 1.011 –1.098,p=.013). Female dogs were less likely to have largerSBCs compared to male dogs (OR =0.931, 95% CI 0.891 –0.973, p=.002).Most SBCs were identified in the humerus (62%), withthe remainder located in the ulna (28%) and radius (10%)FIGURE 1 Sagittal slices of threeLabrador retrievers demonstratingsubchondral bone cysts (SBCs).(A) Subchondral bone cysts with whitearrows in a 6-year, 4-month-old female,neutered Labrador retriever.(B) Subchondral bone cysts with whitearrows in a 1-year old female, neuteredLabrador retriever. (C, D) Subchondralbone cysts with white arrows in a 6-year,10-month-old male, neutered Labradorretriever.TABLE 2 Descriptive statistics of the sample population.Signalment Young dog cohort Old dog cohortMale 10 dogs (6 ME, 4 MN) 10 dogs (4 ME, 6 MN)Female 8 dogs (6 FE, 2 FS) 10 (1 FE, 9 FS)Mean weight(SD)27.4 kg (±4.4 kg) 31.9 kg (±6.2 kg)Mean age (SD) 1.0 year (±0.4) 6.7 years (±1.8)Abbreviations: FE, female entire; FS, female spayed; ME, male entire; MN,male neutered; SD, standard deviation.344 JONES ET AL . 1532950x, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14047 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 Licensesubchondral joint bone. During the scoring process, itwas observed that SBCs were predominately located inthe medial compartment of the elbow.4

Question 40

Thompson - 2024 - VETSURG - Effects of cyanoacrylate on leakage pressures of cooled canine cadaveric jejunal enterotomies.pdf

Answer 40

The research received ethical approval from The Royal(Dick) School of Veterinary Studies Institutional ReviewBoard, reference VERC 112.20.2.1 |Sample collectionThree mature male intact research Beagles, weighingbetween 10 and 15 kg, were euthanized humanely forreasons unrelated to our study. The cadavers wereobtained from the Charles River laboratories, Edinburgh.The jejunum was harvested in these dogs within 1 h ofeuthanasia, from just aborad to the caudal duodenal flex-ure to the ileum. The dogs had no history of gastrointesti-nal disease, and no gross abnormalities were presentwithin the intestinal tract or in the intestinal segmentsused for this study. The intestine was cut into 10-cm longsegments using Metzenbaum scissors next to a calibratedruler and the mesentery was excised to prevent bunchingof intestinal segments. Segments were milked to clearluminal ingesta, flushed with balanced electrolyte solu-tion until the solution ran clear, placed in a sterile salinesolution (0.9% NaCl) and stored flat at 4/C14C for 12 h beforegroup assignment and experimental testing wasperformed.2.2 |Study groupsPrior to testing, jejunal segments were randomly assignedto one of three equally sized experimental enterotomygroups using a random number generator (Research Ran-domizer; https://www.randomizer.org ). The treatmentgroups consisted of HSE, CE, or HS +CE and there werea total 15 segments per treatment group. Equal numbersof intestinal segments ( n=5) from each dog were placedin each group. Three segments from each cadaver werealso randomly assigned into a control group ( n=9),using the same random number generator.2.3 |EnterotomiesAll jejunal segments were occluded using Doyen intesti-nal forceps 1 cm from the intestinal ends. Centrally, a fullthickness antimesenteric enterotomy was made using aNo. 11 scalpel blade to make a stab incision which wasthen extended using Metzenbaum scissors to a measuredlength of 2 cm using a ruler. Once the enterotomy wascomplete, the length was remeasured using a metric rulerto ensure consistency. The HSE group was then closedconventionally with a full-thickness, single-layer continu-ous suture pattern using absorbable monofilament suture(4–0 polydioxanone; PDS, Ethicon, New Jersey), by a sin-gle residency-trained surgeon (JLT). The surgeon ensuredengagement of the submucosa on either side of the enter-otomy when closing the enterotomy and sutures wereplaced 2 –3 mm from the cut edge and 2 –3 mm apart. Thecontinuous suture line was started and terminated with asquare knot followed by three throws and suture endswere cut to a length of 3 mm using mayo scissors. TheCE group was closed using n-butyl-2-cyanoacrylate onlyapplied using the LiquiBand®FIX8™open hand piece(Advanced Medical Solutions Ltd, Plymouth, UK). Thesurgeon placed gentle pressure on either side of the jeju-nal segment, aiding apposition of the enterotomy beforeapplying 37.5 mg which is equivalent to 0.03 mL of cya-noacrylate (3 triggers at 12.5 mg per trigger) directly overthe enterotomy site. This volume allowed for applicationof a thin single layer of cyanoacrylate which covered theincision entirely and set within 1-s of deployment.The HS +CE group was closed initially as per the HSEgroup, followed by augmentation with cyanoacrylate asper the CE group.2.4 |Evaluation of leakage from theenterotomy sitesFollowing enterotomy closure, the segments were sus-pended on a clear mount to allow monitoring of leakage.Two 18-gauge, intravenous catheters were placed in anoblique direction through the jejunal wall into thelumen, 3.5 cm distal from the suture knots at both endsof the enterotomy. A 5-L bag of Hartmann's solution(Aquapharm 11; Animalcare, York, UK) containing20 mL of methylene blue (Flexipharm Austrading Ltd,Buckinghamshire, UK) was connected to a fluid line anda fluid pump and the first catheter. The second catheterwas connected to a pressure transducer and a multipara-meter monitor (Figure1). The pressure transducer waszeroed at the level of the intestinal segment at the start ofeach test. Fluid was infused through the first catheter atrate of 999 mL/h while the enterotomy closure site wasTHOMPSON ET AL . 369 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 Licensemonitored for leakage by a single study investigator(JLT). After identification of leakage, the ILP wasrecorded in mmHg by a second observer (LM) andwas defined as the intraluminal pressure at which thesolution was first observed to visibly leak extraluminally.Leakage location was recorded to occur at level of theknots (either side of the enterotomy), from suture holes(along the length of the enterotomy), or from the inci-sional line itself. After the ILP was recorded, pressuretesting was continued until there was complete failure(MIP) of the enterotomy site, determined by either asudden drop in pressure or when the intraluminalpressure plateaued and sustained for at least 5 s induration. The same experimental procedure was per-formed using the control segments (without an enter-otomy). The multiparameter monitor read a maximumof 318 mmHg.2.5 |Statistical analysisA power analysis was performed with results from an ex-vivo study performed by Duffy et al.11assessing ILP andMIP in canine intestines following enterotomy closure. Asample size of at least 11 paired intestinal segments pergroup was calculated to detect a difference of 10 mmHgleakage between study groups with a standard deviationof 8.4 mmHg by using a power of 0.8 and a confidencelevel of 95%.Continuous numerical variables were assessed fornormal distribution using a Shapiro –Wilk test. Resultsfor ILP (mmHg) and MIP (mmHg) are reported as mean± standard deviation (SD). A one-way repeated-measuresanalysis of variance accounting for cadaver as a samplesource was performed to assess for differences betweensample means from the different experimental groups. Aone-way analysis of variance was performed to assessresults among experimental groups. p-values ≤.05 wasconsidered statistically significant. Statistical analysiswas performed on a commercially available software(SPSS, v.28.9, IMB Corp, Armonk, New York). Results forILL are also reported as observed.3|RESULTSData in the control group was found not to be uniformlydistributed, all other data was uniformly distributedwhen tested with a Shapiro –Wilk test ( p< .001). Allenterotomies were successfully created, and leakage andpressure testing was performed without technical error inall specimens.3.1 |Initial leakage pressuresThe ILP in intact control segments were higher (greater than318 mmHg) than in all test groups ( p< .001). Mean ILP forthe HSE, CE and HS +CE groups were 43.8 ± 5.3 mmHg,18.6 ± 3.5 mmHg, and 83.3 ± 4.6 mmHg, respectively(Table 1, Figure 2). The CE group leaked at a lower ILPcompared with the HSE and HS +CE groups ( p< .001).The handsewn and cyanoacrylate group leaked at higherILP compared to the HSE group ( p< .001).3.2 |Maximal intraluminal pressuresThe handsewn group (HSE) revealed a mean ± SD MLPof 133.4 ± 13.0 mmHg. Mean MIP for the cyanoacrylateFIGURE 1 Photograph to show theleakage testing design. Two 18-gaugeintravenous catheters were inserted intothe lumen at either ends of theenterotomy site. One catheter wasconnected to a pressure transducer, andanother connected to the fluid infuser.370 THOMPSON ET AL . 1532950x, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14059by 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 Licensegroups (CE) was 22.7 ± 2.0 mmHg, and for the handsewnand cyanoacrylate group (HS +CE) MIP was 159.2± 6.0 mmHg (Table 1, Figure 3). The CE group leaked ata lower MIP compared with the HSE and handsewn andcyanoacrylate groups ( p< .001). There was no significantdifference in the MIP between the HSE and the hand-sewn and cyanoacrylate groups ( p=.19).3.3 |Location of leakageLeakage was observed at the suture holes in nine of15 (60%) of HSE constructs, the incisional line in fiveof 15 (33%) of HSE constructs and the knot in one of15 (7%) of HSE constructs. Leakage was observed at theincisional line in all (100%) of the CE constructs. LeakageTABLE 1 Initial leakage pressure and maximal intraluminal pressure measured of handsewn enterotomies, cyanoacrylate enterotomies,handsewn and cyanoacrylate enterotomies and the control segments.Intraluminal pressures Control HSE CE HS +CEILP, mean ± SD, mmHg 314 ± 7.5 43.8 ± 5.3 18.6 ± 3.5 83.3 ± 4.6MIP, mean ± SD, mmHg 133.4 ± 13.0 22.7 ± 2.0 159.2 ± 6.0Abbreviations: CE, cyanoacrylate enterotomy; HS +CE, handsewn and cyanoacrylate enterotomy; HSE, handsewn enterotomy; ILP, initial leakage pressure;MIP, maximal intraluminal pressure; SD, standard deviation.FIGURE 2 Outlier plot with initialleakage pressures (ILPs) of handsewnenterotomies (HSE), cyanoacrylateenterotomies (CE), handsewn andcyanoacrylate enterotomies (HS +CE)and the control segments.FIGURE 3 Outlier plot withmaximal intraluminal pressures (MIPs)of handsewn enterotomies (HSE),cyanoacrylate enterotomies (CE),handsewn and cyanoacrylateenterotomies (HS +CE) and the controlsegments.THOMPSON ET AL . 371 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 Licensewas observed at the incisional line in nine of 15 (60%) ofHS+CE constructs, the suture holes in six of 15 (40%)of HS +CE constructs. All control segments failed byserosal tearing.4

Question 41

Mayhew - 2023 - JAVMA - Laparoscopic adrenalectomy for resection of unilateral noninvasive adrenal masses in dogs is associated with excellent outcomes in experienced centers.pdf

Answer 41

AnimalsMedical records of dogs that underwent LA for resection of an adrenal mass between June 2007 and February 2022 at 1 of 7 veterinary institutions (6 academic teaching hospitals and 1 private spe -cialty practice) were included in the study. Dogs in which vascular invasion into the phrenicoabdominal vein alone had been diagnosed by preoperative di -agnostic imaging studies were retained, but dogs in which tumor thrombus extension into the vena cava or other vascular structures was present were ex -cluded from the study. Dogs that underwent an open adrenalectomy (OA) were also excluded, although data from dogs in which an LA was attempted but converted to an open approach were retained in the study. This study includes some data on small cohorts of patients for which short-term outcomes were previously published in other manuscripts.3–5Diagnostic evaluationMedical records were evaluated for signalment, history, and the results of physical examination and di -agnostic imaging. Due to the large case cohort, sum -mary data are most often reported. The presence of adrenal or pituitary-dependent hyperadrenocorticism is reported based on endocrinological evaluation us -ing urine creatinine-to-cortisol ratio, low-dose dexa -methasone suppression testing, and endogenous ad -renocorticotropic hormone assay, although results are not reported in detail. Suspicion for the presence of a pheochromocytoma was based on consistent clini -cal signs and/or the results of urine normetaneph -rine-to-creatinine and metanephrine-to-creatinine ratios where they were performed. Tumor size was measured as the maximal diameter of the tumor on either an abdominal ultrasonographic evaluation or contrast-enhanced CT (CECT). The side of the lesion (right, left) was recorded. Whether the adrenal tumor emanated principally from the cranial pole or the cau -dal pole or whether the whole gland appeared effaced was also recorded. In cases where details of mass lo -cation could not be reliably collected from recorded imaging studies, no entry was made for mass loca -tion. Vascular invasion into the phrenicoabdominal vein only was reported and these dogs were included in the study. Dogs with suspicion of vascular invasion into the vena cava or other vascular structures on pre -operative diagnostic imaging were excluded.SurgeryAll dogs in this study underwent a unilateral transperitoneal LA using a technique similar to those previously described.1–6 Dogs were positioned in lat -eral, lateral oblique, or sternal recumbency, and a 3- to 5-port technique was used. In all cases, the tele -scope port was placed 3 to 5 cm lateral to the umbili -cus on the affected side, and instrument ports were positioned in the cranial and caudal quadrants on the affected side as has been previously described.1–6 In some cases, a fourth or fifth portal was added as re -quired for placement of additional instrumentation, principally if challenges were encountered in retract -ing surrounding organs. Surgical and anesthesia time was recorded for all procedures. Anesthesia time in -cluded time for all unrelated procedures and diag -nostic imaging tests to be performed that occurred under the same anesthesia. Surgical time was re -corded as the time from the initial skin incision to the termination of the LA procedure, and every attempt was made to exclude the surgical time necessary for other nonadrenal procedures to be performed. The results of histopathological evaluation of all resected and submitted masses are reported.Complications, conversion, and recurrenceComplications were recorded for each proce -dure and classified using the Veterinary Cooperative Oncology Group—Common Terminology Criteria for Adverse Events (VCOG-CTCAE v2) scheme recently described.7 Conversion to an open approach was re -corded when it occurred along with the reason con -version was pursued. Conversions were graded from grades 1 to 4 based on a previously published clas -sification system.8 Briefly, grade 1 conversions are strategic due to anticipated surgical difficulty, grade 2 are reactive extensions of the incision or incisions due to non–life-threatening operative difficulty or er -ror, grade 3 are conversions to an open approach due to non–life-threatening operative difficulty or error, and grade 4 are conversions to an open approach due to life-threatening operative error. Periopera -tive mortality was recorded as either intraoperative or within the postoperative hospitalization period. Long-term follow-up was obtained from the medi -cal record or by email or telephone contact with the owner. Cases where recurrence of disease was di -agnosed by reemergence of clinical signs and/or by further diagnostic imaging in the postoperative pe -riod were recorded. For dogs that were discharged Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 12/11/23 09:46 AM UTC 3from the hospital, median survival time (± range) was recorded for those dogs still alive at the time of writing as well as those that had died.Statistical analysisRisk factors for complications, conversion, and perioperative mortality were evaluated statistically using both logistic (dichotomous outcomes) and lin -ear regression (continuous outcomes) analyses. Risk factors of interest were evaluated with univariate re -gression for inclusion in a main effects model, with a liberal P value of < .200. Factors with P < .200 were entered together into a main effects model, and a fi -nal model was built using backward selection with a significance level of P < .05. Before removal, risk fac -tors were tested for confounding using a 20% change in coefficients as a cut point for inclusion.9 Clinically relevant interactions were tested. Patient-specific factors including breed, age, sex, body weight, body condition score (BCS), presence of a functional tumor, and performance of additional surgical procedures at the time of LA were evaluated as potential risk factors. Tumor-specific risk factors entered into the model in -cluded tumor side (left vs right), principal tumor loca -tion within the gland (cranial pole, caudal pole, whole gland), tumor size (maximal diameter), and histologic tumor type (adrenocortical adenoma, carcinoma, pheochromocytoma). Surgeon experience with LA (dichotomized into surgeons who had performed < 10 or > 10 LA procedures) was also considered a po -tential risk factor for outcomes. Outcomes assessed included duration of surgery, conversion to an open approach, postoperative hours in the hospital, death before discharge, and local recurrence of a mass at the site of LA. Gross capsular penetration at the time of surgery was also assessed as a risk factor for local recurrence. Overall survival time was reported in a de -scriptive fashion. All analyses were conducted using Stata, version 15 (StataCorp LLC).ResultsAnimalsTwo hundred fifty-five dogs that underwent uni -lateral LA met the inclusion criteria and were enrolled in the study. The most common types represented were mixed-breed dogs (n = 62), Shih Tzu (15), Lab -rador Retriever (14), Dachshund (13), Beagle (11), Golden Retriever (11), Maltese (10), Poodle (9), Jack Russell Terrier (8), German Shepherd Dog (7), Cock -er Spaniel (6), and Yorkshire Terrier (5). Fifty other breeds were represented with < 5 dogs/breed. One hundred twenty-four dogs were spayed females, 86 were castrated males, 32 were intact males, and 13 were intact females. The median age at the time of surgery was 126 months (range, 48 to 204 months). Median body weight was 12.1 kg (range, 3 to 96 kg). The median BCS (out of 9) was 6 (range, 3 to 9).Diagnostic evaluationEndocrine evaluation was performed in most dogs but was not complete in all cases. Of dogs where there was a suspicion of an endocrinopathy present based on clinical signs, preoperative bio -chemical and endocrine function testing, and diag -nostic imaging, 141 dogs were suspected to have either pituitary- or adrenal-dependent hyperadreno -corticism, 31 were considered to be most compat -ible with having a pheochromocytoma, 3 were diag -nosed with diabetes mellitus, and 2 were considered to have an aldosterone-secreting mass. Three further dogs were diagnosed with diabetes mellitus and hy -peradrenocorticism, and 2 dogs were suspected to have hyperadrenocorticism and a pheochromocyto -ma. The remaining dogs (76) were suspected to have nonfunctional tumors.Reports from thoracic radiographs (n = 145), ab -dominal ultrasound evaluation (207), and abdominal CT (219) were reviewed. Thoracic radiographs re -vealed nonspecific pulmonary nodules that were not biopsied in 2 dogs. Findings unrelated to the adre -nal glands on abdominal diagnostic imaging are not summarized due to space limitations. One hundred fifty-five (61%) dogs had left-sided masses, and 100 (39%) dogs had right-sided masses removed. De -scriptive data of left and right-sided lesions is sum -marized (Table 1) . In 80 (37%) dogs the mass effaced the entire gland, in 99 (45%) dogs the mass primarily occupied the cranial pole, and in 39 (18%) dogs the mass emanated primarily from the caudal pole. In the remainder, medical records did not specify where the gland primarily emanated from. Phrenicoabdominal vein tumor invasion without extension into the caudal vena cava was diagnosed in 31 (12%) dogs using ul -trasonography or CECT evaluation. Of these 31 dogs, 17 had histologically confirmed pheochromocytoma, 9 had adrenocortical carcinoma, 4 had adrenocortical adenoma, and 1 had a nonspecific adrenal endocrine Variable Right-sided lesions (n = 100) Left-sided lesions (n = 155)Portion of gland affecteda Cranial pole: 34/84 (40.5%) Cranial pole: 65/134 (48.5%) Caudal pole: 10/84 (11.9%) Caudal pole: 29/134 (21.6%) Whole gland: 40/84 (47.6%) Whole gland: 40/134 (29.9%)Phrenicoabdominal vein invasion present 12/100 (12%) 19/155 (12.3%)Maximal tumor diameter (cm) 2.5 cm (range, 1.3–5.5 cm) 2.6 cm (range, 0.9–14 cm)Conversion 11/100 (11%) 13/155 (8.4%)Surgical time (min) 110 (range, 35–290) 95 (range, 40–280)aOnly cases where enough data from imaging were available to reasonably categorize into principally cranial, caudal, or whole gland effaced were included.Table 1 —Lesion variables and select outcomes based on side operated for 255 dogs undergoing unilateral laparoscopic adrenalectomy.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 12/11/23 09:46 AM UTC4 tumor diagnosis. The maximal median tumor diam -eter was 2.5 cm (range, 0.9 to 14 cm).Surgical proceduresA 3-port technique was used most commonly (n = 186), followed by a 4-port technique (54), a 2-port (sin -gle-port device plus 1 additional instrument port) tech -nique (3), a single-port technique alone (2), and a 5-port technique (1). Vessel-sealing devices were used in all cas -es. The Ligasure/ForceTriad (Medtronic Inc) line of ves -sel-sealing devices was used most frequently (n = 198), followed by the Enseal (Ethicon Endosurgery; 16), the Harmonic Scalpel (Ethicon Endosurgery Inc; 15), the RoBi Plus (Karl Storz Inc; 15), and the Sonicision (Medtronic Inc; 2). Resected adrenal tumors were placed into a spec -imen-retrieval bag or the cut thumb of a sterile surgical glove. In 55 dogs, a total of 64 additional procedures were performed at the same time as LA and included laparo -scopic liver biopsy (n = 29), laparoscopic splenectomy (10), dermal mass resection (8), castration (3), thoraco -scopic lung lobectomy (2), lap-assisted cystotomy (2), and 1 each of thyroidectomy, parathyroidectomy, tail am -putation, laparoscopic gastropexy, laparoscopic ovarian remnant resection, and partial liver lobectomy.The median surgical time for the LA procedure was 100 minutes (range, 35 to 290 minutes). The median an -esthetic time for all procedures performed at the time the LA was 210 minutes (range, 90 to 480 minutes).Surgeon experienceMedian number of LA procedures performed by 16 primary surgeons was 9 (range, 1 to 61). Eight surgeons had performed < 10 LA procedures (median number per -formed, 3; range, 1 to 7), and 8 surgeons had performed > 10 (median number performed, 21; range, 11 to 61).ConversionIn total, 24 of 255 (9.4%) procedures resulted in conversion to an open celiotomy approach. Reasons for conversion included hemorrhage that affected hemodynamic stability and/or visualization of the surgical field (n = 18), poor visualization of anatomi -cal structures (4), previously undetected vascular invasion into vena cava (1), and close adherence of tumor capsule to renal vein (1). In those that could be classified, conversions were grade 1 in 13 dogs, grade 3 in 4 dogs, and grade 4 in 6 dogs.8Intraoperative complicationsCapsular penetration during surgery occurred in 41 of 214 (19.2%) dogs in which this finding was re -ported in the surgery report. Major hemorrhage oc -curred in 14 of 255 (5.5%) dogs. The source of major hemorrhage was not noted in every case, but iatro -genic laceration of the ipsilateral renal vein occurred in 4 dogs, and laceration of the ipsilateral renal ar -tery, aorta, and vena cava occurred in 1 dog each. Of the 5 dogs where major hemorrhage emanated from either the renal vein or artery, 3 of 5 had caudal pole tumors and 1 of 5 had a tumor affecting the whole gland. In 1 dog where renal vein laceration occurred, conversion to an open approach was pursued and nephrectomy was performed. Iatrogenic injury to the diaphragm occurred in 1 dog with a right-sided tumor, which did not result in conversion. In 1 dog, an initial Veress needle approach resulted in a pneu -mothorax. Three of 255 (1.1%) dogs died intraopera -tively from hemorrhage (n = 2) and hypertension (1).Postoperative complications and long-term outcomeComplications and severity grade, occurring in the first month postoperatively in the 252 dogs that survived the surgical procedure, are listed (Table 2) . Thirteen of 255 (5.1%) dogs died before being dis -charged from the hospital, and 242 (94.9%) dogs were discharged from the hospital. Causes of death during hospitalization were as follows: unknown Table 2 —Intraoperative and postoperative complications occurring in 255 dogs undergoing laparoscopic adrenal -ectomy for resection of unilateral adrenal masses.Complication Frequency Incidence VCOG-CTCAEv2 grade7Intraoperative Capsular penetration 41/214 19.2% Grade 1 (n = 41) Major hemorrhagea 14/255 5.5% Grade 4 (n = 12) Grade 5 (n = 2) Iatrogenic injury to diaphragm 1/255 0.4% Grade 4 (n = 1) Pneumothorax 1/255 0.4% Grade 3 (n = 1) Hypertension 1/255 0.4% Grade 5 (n = 1)Postoperative Thromboembolic events 8/252 3.2% Grade 5 (n = 7) Grade N/A (n = 1) Port site wound infection 6/252 2.4% Grade 2 (n = 6) Suspected pancreatitis 5/252 2.3% N/A Regurgitation 5/252 2.3% N/A Aspiration pneumonia 5/252 2.3% Grade 2 (n = 1) Grade 3 (n = 3) Grade 5 (n = 1) Seizures 1/252 0.4% Grade 5 (n = 1) Gastric dilatation-volvulus syndrome 1/252 0.4% Grade 4 (n = 1) Severe vasculitis and skin necrosis 1/252 0.4% N/AaLower grades of hemorrhage occurred in other cases but were not ge nerally recorded and so were omitted here.N/A = Not available.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 12/11/23 09:46 AM UTC 5(n = 6), intraoperative hemorrhage (3), suspected sepsis/systemic inflammatory response syndrome (2), bleeding auricular mass (1), and suspected thromboembolism (1). The median number of days spent in the hospital was 3 (range, 1 to 18 days). The median number of postoperative hours spent in the hospital was 48 (range, 10 to 288 hours). Recurrence of an adrenal mass was detected on abdominal im -aging at the site of previous LA in 15 of 148 (10.1%) dogs that underwent subsequent abdominal imag -ing at various times postoperatively (exact timing of postoperative abdominal imaging was not noted in many cases and so is not reported). None of these dogs underwent a second adrenalectomy procedure. In 1 dog, recurrence was diagnosed at necropsy, at which time metastasis to the mediastinum was noted. Of the 242 dogs that were discharged from the hospital, 97 had died at a median of 18 months (range, 1 to 72 months) postoperatively, and 135 were still alive at a median of 12 months postopera -tively (range, 1 to 68 months) at the time of this writ -ing, with the remainder being lost to follow-up.Histopathological analysisIn dogs where histopathological evaluation of submitted samples was available, the following di -agnoses were made: adrenocortical carcinoma was diagnosed in 101 of 233 (43%) dogs, adrenocortical adenoma was diagnosed in 86 of 233 (37%) dogs, pheochromocytoma was diagnosed in 42 of 233 (18%) dogs, and both adrenocortical carcinoma and pheochromocytoma were present in the gland of 2 of 233 (1%) dogs. In 1 dog ea ch, embryonal duct remnant and adrenal hyperplasia were diagnosed.Risk factor analysisA summary of the statistically significant risk factors for the outcomes evaluated is summarized (Table 3) . Surgical time was significantly affected by side of the lesion (right-sided tumors took 16 minutes [95% CI, 3.64 to 28.18 minutes] longer to resect), part of the gland affected (caudal pole tu -mors took 27.5 minutes [95% CI, 14.11 to 40.84 min -utes] longer to resect than those effacing the entire gland), and surgeon experience (surgeons that had operated on < 10 cases took 22 minutes [95% CI, 1.89 to 41.30 minutes] longer to complete the sur -gery). Conversion to open surgery was affected by BCS (each 1/9 increase in BCS increased conversion risk by 1.7 times [95% CI, 1.06 to 2.71]), lesion size (for each 1-cm increase in lesion size, conversion risk increased 1.6 times [95% CI, 1.02 to 2.36]), and surgeon experience (surgeons who had performed < 10 procedures are 4.2 times as likely to convert Table 3 —Summary of risk factor analysis for a variety of outcomes for 255 dogs undergoing unilateral laparoscopic adrenalectomy. Only statistically significant results are listed he re. OR (for β-Coefficient dichotomous (for continuous 95% CIEffect Risk factor outcomes) outcomes) SE (LL to UL) P value InterpretationSurgical time Lesion side — 15.91 6.22 3.64 to 28.18 .011 Right-sided lesions had longer surgical time compared to left-sided lesions Part of gland affected — –27.47 6.77 –40.84 to –14.10 < .001 Cranial pole lesions had shorter surgical times compared to lesions that affected the whole gland Surgeon experience — –21.59 9.99 –41.30 to –1.89 .032 More experienced surgeons had shorter surgical timesConversion BCS 1.69 — 0.41 1.06 to 2.71 .029 Conversion rate increases with increasing BCS Lesion size 1.55 — 0.33 1.02 to 2.36 .040 Conversion rate increased as lesion size increased Surgeon experience 0.23 0.15 0.06 to 0.83 .025 Conversion rate was lower for more experienced surgeonsPostoperative Age — 0.26 0.11 0.04 to 0.47 .021 As patient age increases, hours postoperative hours in the in hospital hospital increase Endocrinopathy: — 127.70 28.68 71.08 to 184.32 < .001 Dogs with nonfunctional tumors aldosteronoma had shorter postoperative hospitalization compared to those with pheochromocytoma, aldosteronoma, or mixed tumors Endocrinopathy: — 112.17 29.56 53.80 to 170.53 < .001 hyperadrenocorticism and pheochromocytoma Endocrinopathy: hyperadrenocorticism and diabetes mellitus — 107.11 28.32 51.20 to 163.03 < .001 Surgeon experience — 19.23 9.14 1.18 to 37.28 .037 Dogs operated by more experienced surgeons had greater postoperative hours in hospitalDeath prior Lesion size 0.66 — 0.11 0.47 to 0.91 .011 As lesion size increased, to discharge risk of death prior to discharge increased Surgeon experience 6.97 — 4.49 1.97 to 24.66 .003 Increased surgeon experience decreased risk of death prior to dischargeLocal Capsular penetration 6.48 — 4.14 1.86 to 22.64 .003 Recurrence higher in group recurrence that experienced intraoperative capsular penetrationBCS = Body condition score. LL = Lower limit. UL = Upper limit.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 12/11/23 09:46 AM UTC6 [95% CI, 1.20 to 14.93]). Postoperative time in the hospital was increased by patient age (increasing age prolonged hospital stay) and surgeon experi -ence (hospital stay was longer for surgeons who had performed > 10 procedures). Risk of death prior to discharge was affected by lesion size (as lesion size increased, risk of death prior to discharge de -creased) and surgeon experience (dogs operated on by surgeons who had performed > 10 procedures were 7 times as likely to be discharged from the hos -pital [95% CI, 1.97 to 24.66]). Capsular penetration during surgery was a risk for local recurrence (odds of recurrence were 6.5 times as great in those with capsular penetration [95% CI, 1.86 to 22.64]). Of the 41 dogs with intraoperative capsular penetration, 7 experienced recurrence of a mass lesion at the oper -ated site while 19 did not, and for the remaining 15, insufficient postoperative follow-up was available to know whether recurrence occurred.

Question 42

Townsend - 2024 - VETSURG - Comparison of three-dimensional printed patient-specific guides versus freehand approach for radial osteotomies in normal dogs - Ex vivo model.pdf

Answer 42

2.1 |Study designAn ex vivo method-comparison study between 3D PSGand FH corrective osteotomy of the distal radius wasperformed.2.2 |Specimen collection and groupingTwenty-four pairs of clinically normal cadaveric fore-limbs were collected from beagle dogs euthanized for rea-sons unrelated to this study. The limb pairs wererandomly assigned using a spreadsheet function (ran-dom, roundup, rank; Microsoft Excel) to one of threegroups (n =8 per group). An a priori power analysisdetermined that eight limbs in a paired design andexpecting a clinically relevant mean paired difference of5/C14(SD=3) between freehand and guided methodswould achieve 97% power with a paired t-test at a 5% sig-nificance level. Group 1 was a uniplanar 30/C14frontal planewedge ostectomy. Group 2 was an oblique plane (30/C14frontal plane, 15/C14sagittal plane) wedge ostectomy. Group3 was a torsion-angulation osteotomy (30/C14frontal plane,15/C14sagittal plane, and 30/C14external torsion) using a singleoblique plane osteotomy12(SOO). Right or left limb pairswere randomly assigned to treatment using 3D PSG orFH approach and treated in ordinal fashion of increasingcomplexity.TOWNSEND ET AL . 235 1532950x, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13968 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 License2.3 |Three-dimensional planningLimb pairs were disarticulated and frozen with the elbowand carpus in full extension. A CT scan of both entireforelimbs was performed with a 64-slice helical scanner(GE Lightspeed VCT, Chicago, Illinois). Transverse0.625 mm slices with 50% overlap were obtained using ahigh-frequency bone algorithm. Digital imaging andcommunications in medicine (DICOM) images wereimported into 3D modeling software (Mimics version 22;Materialize, Leuven Belgium) and segmented usingthresholding (Hounsfield limits 226 –2554), region grow-ing, and editing tools to create a 3D triangular surfacemodel (mesh) of each forelimb. Models were exported to3D design software (3-Matic, version 14, Materialize, Leu-ven Belgium) for 3D planning and guide design. The neu-tral frontal, sagittal, and axial planes were individuallydefined for each limb based on humeral transcondylarorientation and used to define the object coordinate sys-tem (Figure1). These reference planes and coordinatesystem were used for standardizing guide design andpostoperative assessment.The osteotomy was located at the distal 25% of theradial length in all groups. For groups 1 and 2, a trans-verse plane was created parallel to the axial referenceplane to represent the proximal osteotomy. A duplicateosteotomy plane was created and manipulated for thedistal osteotomy. For group 1, the distal cut plane wasrotated 30/C14in the frontal plane, and moved distally alongthe object coordinate system until the two cut planes metat the lateral cortex of the radius to create a mediallybased closing wedge. For group 2, the distal osteotomyplane was rotated 30/C14in the frontal plane, followed by15/C14in the sagittal plane, then moved distally along theobject coordinate system until the two cut planes met atthe caudolateral cortex of the radius to create a craniome-dial oblique plane closing wedge. For group 3, the singleosteotomy plane was rotated 30/C14in the frontal plane,then 15/C14in the sagittal plane, and finally rotated 30/C14inthe axial plane about the object coordinate system for asingle oblique plane osteotomy. Images showing virtualosteotomy position were saved and exported for referencein surgery.2.4 |Computer-aided guide design and3D printingA region of the cranial surface of the distal radius wasmarked, and the surface extruded 3 mm to form theguide base. The base included both osteotomy planesand extended distally to include the extensor grooveapproximately 5 mm from the carpal joint. For group1 and 2 closing wedges, the osteotomy planes were con-verted to solid parts and extruded 1.5 mm thickness asFIGURE 1 Oblique view of the 3D volumetric reconstructionsof a right forelimb with the neutral frontal, sagittal, and axialplanes defined.FIGURE 2 Representative images of the osteotomy guides onthe right forelimb of group 1 (A) group 2 (B) and group 3 (C). Allguides were exported as .STL files and 3D printed on astereolithographic (SLA) printer using clear resin.236 TOWNSEND ET AL . 1532950x, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13968 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 Licensea shelf for the saw blade. Support struts were createdusing 3 mm diameter cylinders to join the proximal anddistal osteotomy planes. For group 3, the single osteot-omy plane was extruded to a thickness of 4 mm andthen hollowed in the center to create a 1 mm slot forthe saw blade. Two 1.1 mm diameter hollow cylinderswith 1.5 mm wall thickness were created to secure theguide to the radius. All components listed above werejoined into a single part and were exported as .STL filesfor 3D printing (Figure2). Guides were printed on astereolithographic (SLA) 3D printer (Form 2, FormLabs, Somerville, Massachuse tts) using clear resin witha 50 micron resolution.2.5 |OsteotomyA standard craniomedial approach was made to the distalradius. Time was recorded from start of guide applicationor measurement of the FH wedge until osteotomy com-pletion. For the limbs using 3D PSG, the guide was fittedto match the contours of the cranial of the distal radius,and secured to the bone with 1.1 mm Kirschner wires.For groups 1 and 2, the support struts were removedusing an oscillating saw (25.5 mm /C20.38 mm blade, Stry-ker TPS, Kalamazoo, Michigan) before the osteotomieswere performed. Osteotomies were performed by placingthe saw blade flat against the shelf (wedge groups) orwithin the slot (SOO group). After completion of theosteotomies, the Kirschner wires and guides wereremoved. The wedge was preserved in the surgical fieldand sutured subcutaneously for postoperative imaging,and the skin was closed.For the FH approach, the desired distance from thecarpal joint was measured (25% of radial length) for theproximal transverse cut marked on the bone. The bonediameter was measured at this location using a sterileruler. Trigonometric measurements for the desired wedgeheight were computed based on individual measured bonediameter. For example, a 30/C14wedge with bone diameter of15 mm results in a 8.7 mm wedge height (tan 30/C14/C215 mm =8.7 mm). The wedge height and proposedosteotomy locations were marked using a pencil on thebone surface as appropriate for groups 1 and 2. The proxi-mal and then distal osteotomies were completed with anobserver assisting with saw blade orientation. The wedgewas preserved and sutured subcutaneously and the skinwas sutured. For the group 3 FH approach, a 0.04500refer-ence pin was inserted from cranial to caudal on the cranialsurface of the proximal radius to indicate the true sagittalplane using the palpation of the humeral epicondyles asan anatomic reference and an observer assisting with ori-entation. Angle measurements were calculated asdescribed.12A sterile goniometer was used to measure63.5/C14from cranial to medial in the transverse plane and asecond pin was placed as a reference for the second mea-surement. A sterile goniometer was then used to measureFIGURE 3 The preoperative (yellow) and postoperative (blue)limbs were shape matched using common points of reference andautomated global registration.FIGURE 4 The intended target osteotomy (blue plane) asmeasured on the preoperative limb was compared to theachieved osteotomy plane (green plane) as measured with a fitplane to the marked surface of osteotomy on thepostoperative limb.TOWNSEND ET AL . 237 1532950x, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13968 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 License49/C14distal to align the blade to make a distomedial to prox-imolateral osteotomy. A thin piece of radiolucent gel wasplaced between the proximal and distal radial segments toseparate them for postoperative CT scan. All limbs werefrozen in extension postoperatively prior to scanning.2.6 |Postoperative analysisComputed tomography images of the postoperative limbswere obtained and 3D volumetric mesh reconstructionswere made as described above. The proximal radius,distal radius, and wedge were segmented and manu-ally separated for assessment using 3D software. Thepreoperative and postoperative proximal and distalradius 3D meshes were shape matched to one anotherusing four common prominent reference points oneach segment (aspects of radial head, radial shaft, sty-loid, extensor groove) to approximate their overlay.An automated iterative process registration tool (globalregistration, 3-Matic) was then used to optimize the over-lay between preoperative and postoperative radii(Figure3). The actual osteotomy planes were defined byfitting a plane to marked surfaces of the postoperativebone proximally and distally. Similarly, a plane was fittedto the marked cut surface of the removed wedge (groups1 and 2). The virtual target and actual osteotomy planeswere compared (Figure4). Deviance was measured sepa-rately in each frontal and sagittal plane using the previ-ously defined object coordinate system as well as in 3D(combined x,y,a n d zplanes). The actual wedge was com-pared to the target wedge size and their absolute differencewas recorded (Figure5). The actual single oblique planeosteotomy was measured relative to the target osteotomyusing the proximal surface of the osteotomy plane and dif-ferences in the frontal, sagittal, and combined 3D planeswere recorded as described above.2.7 |Data analysisData were evaluated for normality using theKolmogorov –Smirnov test and graphical visual assess-ment. Deviance from the virtual target osteotomy angleand location were determined for all osteotomies.FIGURE 5 The wedges from groups 1 and 2 were measuredand compared to their intended target wedge size. A plane was fitto each marked wedge cut surface and measured in 3 –dimensions.TABLE 1 Mean ± standard deviation angle deviation for 3D-printed patient-specific guide compared to freehand corrective osteotomiesin 32 normal ex vivo canine radii.Group Osteotomy location 3D PSG FH pFrontal uniplanar wedge osteotomy Proximal Frontal 1.5 ± 1.2* 5.7 ± 1.4 <.001Sagittal 1.9 ± 1.7 4.3 ± 3.2 .096Distal Frontal 1.5 ± 1.7* 5.8 ± 4.0 .006Sagittal 3.5 ± 1.7 5.3 ± 3.1 .161Wedge 3D 2.9 ± 2.9 2.5 ± 1.3 .061Oblique plane wedge osteotomy Proximal Frontal 2.6 ± 2.5 2.3 ± 1.4 .705Sagittal 4.3 ± 2.3 4.2 ± 2.0 .944Distal Frontal 1.6 ± 1.3* 4.1 ± 2.7 .037Sagittal 3.6 ± 2.0 3.6 ± 2.9 .955Wedge 3D 4.4 ± 2.9 2.4 ± 2.4 .563Single oblique plane osteotomy Frontal 5.3 ± 4.1* 17.8 ± 6.0 .002Sagittal 2.1 ± 1.1* 10.5 ± 9.6 .043Abbreviations: FH, freehand; PSG, patient –specific guide. *C p< .05.238 TOWNSEND ET AL . 1532950x, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13968 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 LicenseAccuracy and time using 3D PSG was compared to a FHapproach in each osteotomy group separately using apaired t-test. A clinically relevant threshold of within 5/C14of target was established as a cut point. Frequencies ofclinically acceptable angles were compared betweenapproaches using McNemar's test for paired proportions.Statistical analysis was performed using commerical soft-ware (R, version 3.0, Development Core Team, Vienna,Austria). All comparisons were considered significantatp< .05.3|RESULTSFor group 1 (single frontal plane closing wedge), the fron-tal plane deviation was increased in the FH limbs in com-parison with the 3D PSG limbs on the proximal,transverse ( p< .001) and the distal osteotomy ( p=.006)(Table 1). The sagittal plane deviation was not differentfor either proximal or distal osteotomy. The actual wedgeangle (30/C14) was not different between 3D PSG and FHgroups.In group 2 (oblique plane closing wedge), the frontalplane deviation of the distal osteotomy was increased inFH limbs compared to 3D PSG ( p=.037). No otherosteotomy or wedge measurements were differentbetween groups (Table1).In Group 3 (SOO), the FH osteotomy deviance wasincreased in comparison with the 3D PSG osteotomy inthe frontal ( p=.002) and sagittal planes ( p=.043).The combined deviance in 3D ( x,y,zplanes) was notdifferent for groups 1 and 2. The 3D deviance for group3 was increased in the FH osteotomy group relative tothe 3D PSG ( p=.001).Overall, 3D PSG osteotomies were closer to the tar-get osteotomy using a 5/C14clinically acceptable thresholdfor accuracy in ALD correction. In groups 1 and2, 32 total measurements were obtained in individualTABLE 2 Frequency of corrective osteotomies excess of 5/C14tolerance of the intended virtual target.Group Osteotomy type 3D PSG FH pvalueFrontal uniplanar osteotomy Proximal Frontal 0% 75%* .041Sagittal 13% 50% .371Distal Frontal 0% 63% .074Sagittal 25% 63% .248Pooled (n =32 osteotomies) 9% 63%* <.0013D Wedge ( x, y, z ) 0% 25% .467Oblique plane osteotomy Proximal Frontal 13% 0% .999Sagittal 38% 50% .999Distal Frontal 0% 38% .248Sagittal 25% 13% .999Pooled (n =32 osteotomies) 19% 25% .7243D Wedge ( x, y, z ) 13% 38% .467Single oblique plane osteotomy Frontal 50% 100% .134Sagittal 0% 50% .134Pooled (n =16 osteotomies) 25% 75%* .013Abbreviations: PSG, patient –specific guide; FH, freehand. * p< .05.TABLE 3 Mean ± standard deviation distance deviation (mm)from target osteotomy location.3D PSG FHGroup 1 1.0 ± 0.9 1.9 ± 1.2Group 2 2.2 ± 1.6 1.6 ± 2.2Group 3 2.9 ± 1.3 2.2 ± 1.3Abbreviations: PSG, patient –specific guide; FH, freehand. * p< .05.TABLE 4 Mean (± SD) time (s) to complete 3D PSG and FHosteotomies.3D PSG FHGroup 1 358 ± 43 372 ± 81Group 2 292 ± 48 293 ± 82Group 3 84 ± 10 162 ± 35 *Abbreviations: PSG, patient –specific guide; FH, freehand. * p< .05.TOWNSEND ET AL . 239 1532950x, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13968 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 Licenseplanes (proximal/distal sagittal/frontal for 8 limb pairs).In group 1, 63% (20/32) of measurements were greaterthan 5/C14from the target osteotomy in the FH group, incomparison with 9% (3/32) in the 3D PSG group(p< .001). In group 2, 25% (8/32) of the FH measure-ments were greater than 5/C14,i nc o m p a r i s o nw i t h1 9 %(6/32) of the 3D PSG measurements ( p=.72). Group3 had 16 measurements total in which 75% (12/16)of the FH group were greater than 5/C14from target,compared with 25% (4/16) of the 3D PSG measurements(p=.013) (Table 2).The mean deviation of osteotomy location was lessthan 3 mm from the target location in all three osteotomygroups and was not different between the 3D PSG or FHapproaches (Table 3). The maximum error across allgroups was 5.5 mm and 6.8 mm using 3D PSG and FHapproaches, respectively.The time required to perform group 1 and 2 wedgeosteotomies using the 3D PSG approach did not differfrom the FH osteotomies (Table 4). The maximum timesrequired in group 1 and group 2 were 346 and489 seconds, respectively. Time to perform group 3 osteo-tomies (SOO) using 3D PSGs was less than for FH osteo-tomies ( p< .001), and the maximum time was 106 and226 seconds.4

Question 43

Martin - 2024 - JAVMA - Computed tomography and magnetic resonance imaging are potential noninvasive methods for evaluating the cisterna chyli in cats.pdf

Answer 43

Study designThis multicenter, retrospective, observational-descriptive study includes medical and imaging re -cords from the Hospital Veterinario de Referencia UCV (Valencia, Spain) and AniCura Ars Veterinaria Hospital Veterinari (Barcelona, Spain) of cats pre -sented between January 2017 and March 2022.Client-owned cats that underwent CT or MRI of the abdomen and/or vertebral column were includ -ed. Cats were excluded if they had lymphatic system pathology or diseases associated with the develop -ment of chylothorax or chyloabdomen or if images of the entire lumbar vertebral column were not avail -able for review. CT studies were included if at least a precontrast soft tissue algorithm of the vertebral col -umn was available from T13 to S3. MRI studies were included if they contained at least the entire T13-S3 vertebral segment in 2 different planes.Clinical dataClinical data —including breed, age, sex, body weight, and clinical history—and imaging findings were retrieved from the hospitals’ database by a res -ident in veterinary diagnostic imaging (NGM). This work involved the use of nonexperimental animals only (owned animals). Established internationally recognized high standards (“best practice”) of indi -vidual veterinary clinical patient care were followed.All the studies were performed under general anesthesia. The protocol of general anesthesia was adapted for each case under the criteria of a special -ist veterinary anesthetist.Image acquisitionCT images were acquired with a 16-slice heli -cal scanner (Somatom; Siemens Medical Solutions Europe). Patients were in dorsal or sternal decubitus based on clinical criteria: for CT studies centered on the abdomen, the patients were in sternal decubitus, while for CT studies focusing on the vertebral column, they were in dorsal decubitus. If the study had a post -contrast examination, the postcontrast images were obtained after IV injection of 600 mg/kg of iodinated nonionic contrast medium using a power injector with variable injection rate (2 to 2.5 mL/s). Postcontrast se -ries were obtained between 40 and 90 seconds after contrast administration, with late contrast phases of 5 to 10 minutes to visualize the ureterovesical junction in those patients who underwent abdominal CT. Cases in which CT myelography was performed were also in -cluded, with image acquisition performed 5 to 15 min -utes after contrast injection in the subarachnoid space via lumbar puncture (0.2 to 0.3 mL/kg). CT data were acquired in helical mode with a pitch of 1.5, and slices were reconstructed at 1- to 2-mm slice thickness by means of a standard soft tissue algorithm (level, 40 HU; width, 400 HU). MRI images were obtained in dorsal decubitus with a 1.5-T unit (Vantage Elan; Canon Medi -cal Systems Europe). The protocol included pre- and postcontrast sequences (following IV administration of a dose of 0.1 mmol/kg of gadoteric acid). Standard MRI protocol varied among different cases, with repeti -tion time, echo time, and field of view adjusted on an individual basis. Slice thickness varied between 1.8 and 2 mm, with an interslice interval of 0.2 to 0.5 mm. Scans included at least 2 different planes (transverse, sagit -tal, and/or dorsal) of the vertebral column from T13 to Figure 1 —Diagram of the anatomical localization of the cisterna chyli (CC) in cats. Note the celiac artery (arrow -head) and cranial mesenteric artery (star). AO = Aorta. CVC = Caudal vena cava. LAG = Left adrenal gland. LK = Left kidney. RAG = Right adrenal gland. RK = Right kidney.Unauthenticated | Downloaded 12/24/23 09:29 AM UTC 3S3 in the following sequences: T2 weighted (T2w), T1 weighted (T1w), STIR, T2* gradient-recalled echo, T1w postcontrast, and T1w postcontrast with fat saturation.Postcontrast sequences were obtained between 4 and 10 minutes after administration of the contrast medium.Image analysisAll studies were reviewed by a single observer (NGM) under the supervision of European College of Veterinary Diagnostic Imaging board-certified vet -erinary radiologist (EDM) using a free DICOM view -ing software (Horos Project Digital Imaging; Horos Project). Readers were aware of the clinical history, imaging findings, and final diagnosis of each case.Qualitative (presence, location, shape, MRI sig -nal intensity of the CC) and quantitative (CC width, CT attenuation, and contrast enhancement) assess -ment of the CC was performed on CT and MRI.• The aorta and the cranial mesenteric artery were used as landmarks to localize the CC. The loca -tion of the central portion of the CC related to the lumbar vertebrae was also recorded.• The shape was subjectively classified as oval, crescent, or triangular in transverse images on MRI and postcontrast CT studies. Oval described cases where the CC covered between 90° and 180° of the perimeter of the aorta, and crescent was used in cases where the CC covered 180° or more of the perimeter of the aorta. In MRI, the CC shape was assessed using transverse T2w im -ages when available.• The width was measured at the site of maximum diameter in the transverse plane. In CT, the width was recorded in postcontrast images. In MRI, the width was assessed using transverse T2w images when available.• Mean CT attenuation values were determined pre- and postcontrast by measuring the HU in a manu -ally drawn region of interest placed in CC. The de -gree of contrast enhancement was classified into 3 categories depending on the HU variation between post- and precontrast studies: nonenhancing (dif -ference, < 10 HU), mild (difference, 10 to 20 HU), moderate (difference, 21 to 40 HU), and marked contrast enhancement (difference, > 40 HU).• MRI signal intensity of the CC was classified on T2w and T1w images as hypo-, hyper-, or isoin -tense compared to the regional musculature and/or CSF. Additionally, the T2w signal intensity was defined as homogeneous or heterogeneous. The presence of contrast enhancement was subjec -tively classified as nonenhancing, mild, moderate, or markedly enhancing.Statistical analysisThe mean age and body weight of the patients was calculated. The measurements of the maximum width of the CC (in CT and MRI images) and attenua -tion (CT pre- and postcontrast) were repeated 3 times, and the mean value was obtained. The results of the measurements are expressed as mean ± SD. Data were calculated using a commercially available soft -ware spreadsheet program (Excel; Microsoft Corp).ResultsNinety-four cats were included. Thirty-one had CT and 63 had MRI studies that fulfilled the inclusion criteria. Of the 31 CT cases, 19 included a postcontrast intravenous study (12 cases were CT myelography). Seventeen patients were scanned in dorsal recumbency and 14 in sternal recum -bency. Of the 63 MRIs, 35 had transverse sequences, and all the cases were scanned in dorsal decubitus. The most common breed was domestic shorthair (n = 69), and other breeds were Siamese (9), Persian (6), Sphynx (3), British Shorthair (3), Exotic (2), and Norwegian Forest Cat (2). The mean age of the patients was 8 years (range, 3 to 18 years). The mean body weight was 4.4 kg (range, 3 to 7 kg). Fifty-one of the cats were males (42 neutered, 9 in -tact) and 43 were females (34 spayed, 9 intact).Considering both imaging techniques, the CC was identified in 91 of 94 cats (96.8%). In CT, the CC was visible in 29 of 31 (93%) cats in the precontrast CT and in all the postcontrast studies (19/19 [100%]). In cases where the CC was recognized in both pre- and post -contrast CT studies, the visualization of the CC was al -ways superior in the postcontrast study. In the 2 cases where the CC was not seen in the precontrast CT, it was observed in the postcontrast images. On MRI, the CC was visible in 60 of 63 MRI studies (95%; Figure 2 ). Figure 2 —A—Sagittally reconstructed postcontrast CT image of the CC in a cat (black arrows) in soft tissue al -gorithm (window width, 300 HU; window level, 40 HU) with a 1.5-mm slice thickness, at the level of L2 show -ing the described anatomical landmarks: celiac artery (orange arrowhead), cranial mesenteric artery (purple arrowhead), and AO. B—Sagittal T2-weighted MRI se -quence (2-mm slice thickness) pointing at the CC with white arrows; note the celiac artery (orange arrow -head), cranial mesenteric artery (purple arrowhead), and AO. In these cases, the CC is slightly caudal to the cranial mesenteric artery.Unauthenticated | Downloaded 12/24/23 09:29 AM UTC4 In the 3 cases where the CC was not seen, only dorsal and sagittal sequences were available for review.The location of the CC was assessed in a total of 91 studies (31 CT and 60 MRI studies). In all cas -es but 2 (89/91 [97%]), it was found at the level of (56/91 [61%]) or caudal to the cranial mesenteric artery (33/91 [36%]). In 2 cases (2/91 [2.2%]), the CC was found cranial to the origin of the cranial mes -enteric artery at the level of L1. The central portion of the CC was ventral to L2 in 61 of 91 (67%) cases, ventral to L2-3 in 17 of 91 (18%) cases, ventral to L3 in 10 of 91(10%) cases, and ventral to L1-2 in 1 of 91 (1%) cases. The CC was dorsal to the abdominal aorta in 62 of 91 (68%) cases and dorsolateral in 29 of 91 (31%) cases, being to the right in 20 (68%) cases and to the left in 9(31%) cases (Figure 3) .The shape and width of the CC were assessed in a total of 54 cases (19 postcontrast CT studies and 35 MRI studies with transverse sequences). The shape of the CC was described as crescentic in 34 of 54 (62%) cases, oval in 18 of 54 (33%) cases, and triangular in 2 of 54 (3%) cases (Figure 4) . The mean width of the CC was 2.39 ± 0.85 mm. The width of the largest CC was 7.2 mm, and the smallest one measured 1.2 mm in width.The mean precontrast attenuation of the CC was 17.35 ± 4.82 HU (reference range, 10 to 30 HU), and Figure 3 —Transverse T2-weighted MRI images of cats (2-mm slice thickness) showing the position of the CC (white arrows) in relation to the AO (black arrows). In panel A the CC was dorsal to the AO, in panel B it was dorsolateral and to the left of the AO, and in panel C it was dorsolateral to the right of the aorta. The CC was classified as oval (A and B) or crescentic (C). In all the images, the CC was hyperintense to the regional muscles.Figure 4 —Transverse images showing different shapes of the CC of cats on postcontrast CT (A through C) using a soft tissue algorithm (window width, 300 HU; window level, 40 HU; 1-mm slice thickness) and on MRI (D through F; T2-weighted sequences; 2-mm slice thickness): oval (A, D), triangle (B, E), or crescent (C, F). For ovals, the CC covers between 90° and 180° of the AO; for crescents, the CC covers 180° or more of the perimeter of the aorta.Unauthenticated | Downloaded 12/24/23 09:29 AM UTC 5the mean postcontrast attenuation was 27.95 ± 11.01 HU (range, 12 to 44 HU). Postcontrast CT series were obtained in 19 cases. In 4 of 19 cases (21%), no con -trast enhancement was detected. Postcontrast en -hancement was observed in 15 of 19 cases (78%) and was classified as mild in all of them (Figure 5) .

Question 44

Crofts - 2023 - JAVMA - Increased incidence and shift in the location of gunshot wound injuries in dogs and cats during the COVID-19 pandemic.pdf

Answer 44

A single-center retrospective analysis was per -formed of patients presenting to an urban academic level 1 veterinary trauma center for evaluation of gunshot wound injuries. Patients were compared between 2 admission time periods: March 2018 to February 2020 (prepandemic) and March 2020 to February 2022 (pandemic). The institutional record database was searched for such patients using the following keywords: “gunshot,” “gun shot,” “pro -jectile,” “ballistic,” “gun,” “firearm,” and “bullet.” All juvenile and adult patients that were presented for evaluation or treatment of a gunshot wound injury during each time period were included in the study. Gunshot wound cases identified via the medical re -cord search were cross-referenced with Veterinary Committee on Trauma registry entries to ensure that all pertinent cases were recorded. Patients with his -torical gunshot wound injuries that were presented to the hospital for other medical reasons and pa -tients with gunshot injuries found incidentally during evaluation with no clinical significance were exclud -ed from the study.The selected dates were strategically chosen to allow comparisons of gunshot wound injuries in companion animals for the 2 years before and after the enactment of COVID-19 ordinances in the state of Pennsylvania in March 2020. A 2-year analysis pe -riod was considered appropriate, particularly for the pandemic evaluation, as social distancing guidelines and lingering effects of increased pandemic-related violence persisted through this time, even after the more stringent restrictions (ie, stay-at-home direc -tives) were lifted.Patient data were collected including species, breed, age, sex, location of injury, Animal Trauma Triage (ATT) and Modified Glasgow Coma Scale (MGCS) scores (if available), surgical procedures performed, length of hospitalization, and case outcome. Case outcome in -dicated survival to discharge or humane euthanasia, although no distinction was made between animals that were euthanized due to financial reasons and those eu -thanized due to severity of injury. Location of injury was categorized on the basis of the region of localization of associated wounds as reported in medical records, imaging studies, and surgery reports. The locations in -cluded the following: maxillofacial, cervical, thoracic, ex -tremities (ie, forelimbs and hind limbs), vertebral/spinal, and abdominal. Injuries classified as thoracic or abdomi -nal do not necessarily imply intracavitary penetration, as some injuries merely overlie the thorax or abdomen. Surgeries performed were classified into the following categories: wound exploration and debridement, oral surgery and dentistry, fracture repair, exploratory lapa -rotomy, median sternotomy/lateral thoracotomy, and amputation. With regards to both location of injury and surgeries performed, the categories were not mutually exclusive, as 1 patient could have had a multitude of wounds that localized to different body parts and there -fore required several different types of procedures.The Shapiro-Wilk test was used to assess con -tinuous variables for normality. Parametric variables were reported as the mean and SD, and nonparamet -ric variables were reported as the median and range. The count and percentage (%) were used to report frequency data. The χ2 test was used to compare proportions of the dichotomous outcome variables when the cell counts in the 2 X 2 contingency table were > 5; otherwise, a Fisher exact test was used. For all comparisons, P < .05 was considered statistically significant. All statistical calculations were conduct -ed using a commercial software package (Stata/IC version 16.1; StataCorp LLC).ResultsFrom March 2018 to February 2020 (prepan -demic), 9 patients were presented for gunshot wound injuries, whereas 16 patients were evalu -ated for gunshot wound injuries from March 2020 to February 2022 (pandemic). The total number of gunshot wound cases increased by 77.8% between the prepandemic and pandemic periods, while the total number of hospital cases decreased by 12.2% over the same time frame, from 74,262 to 65,168, re -spectively. This equates to a prepandemic gunshot wound incidence of 0.01% (9/74,262) compared to a postpandemic gunshot wound incidence of 0.02% (16/65,168; P = .084).Twenty-five animals were included in the study: 24 (96%) dogs and 1 (4%) cat. Of the 24 dogs, there were 10 (42%) pit bull-type dogs , 8 (33%) mixed-breed dogs, 2 (8%) Labrador Retrievers, and 1 each of various other breeds, including Boxer, Akita, Cane Corso, and Rottweiler. The only feline featured in this study was a domestic shorthair cat that was included within the pandemic period cohort of patients. The mean age of affected patients was 3.2 ± 2.0 years. Of the 25 ani -mals, 17 (68%) were males and 8 (32%) were females. Six patients (6/9 [66%]) in the prepandemic period had ATT and MGCS scores recorded at admission compared to only 4 patients (4/16 [25%]) in the pandemic period.Unauthenticated | Downloaded 12/04/23 07:12 AM UTC1864 JAVMA | DECEMBER 2023 | VOL 261 | NO. 12Prepandemic: March 2018 to February 2020The distribution of injuries was as follows: extremities (55%), thoracic (33%), vertebral/spinal (22%), abdominal (22%), maxillofacial (11%), and cervical (11%; Table 1 ). humanely euthanized after initial evaluation. Ten pa -tients underwent surgery, with the following procedures performed: 6 patients required wound exploration and debridement, 3 patients required oral surgery and den -tistry procedures (ie, palatal repair, teeth extraction, and mandibulectomy), 1 patient underwent an open reduc -tion and internal fixation fracture repair, and 1 patient required amputation of a disarticulated distal phalanx.

Question 45

Mullins - 2023 - VETSURG - Accuracy of pin placement in the canine thoracolumbar spine using a free-hand probing technique versus 3D-printed patient-specific drill guides - An ex-vivo study.pdf

Answer 45

2.1 |Sample populationFour skeletally mature greyhound cadavers euthanizedfor reasons unrelated to this study were included. Ethicalapproval was granted by the primary author's institution(AREC-E-20-11-Mullins). Cadavers were numbered andstored at /C020/C14C until thawed for use.2.2 |Preinstrumentation computedtomographyA 16-slice helical computed tomography (CT) scanner(SOMATOM Scope, Siemens, Germany) was used. Allscans were obtained at the primary author's institution.Transverse sections (0.75-mm thickness) were obtainedfrom T6 to sacrum. DICOM images were exported intoimage viewing software (Horosproject.org ; Annapolis,Maryland). After image acquisition, cadavers were refro-zen until instrumentation.2.3 |Randomization of technique andorder of pin insertionSeven functional spinal units (FSUs) (T7 –8t h r o u g hL 6 –7)were instrumented bilaterally in each cadaver. The order inMULLINS ET AL . 649 1532950x, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13958 by Vetagro Sup Aef, Wiley Online Library on [22/07/2023]. 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 Licensewhich FSUs was instrumented was determined a prioriusing random sequence generator ( www.random.org )(Table 1). Two 3.2/2.4-mm positive profile pins (Interfacepins, IMEX, Longview, Texas) were inserted in each verte-bra, one left and one right (4 per FSU), and then removedimmediately after placement. Method of pin insertion (FHPor 3DPG) in the first FSU of the first two cadavers to beoperated was determined a priori by coin toss and thenalternated to achieve equal group numbers (Table1). Intotal, 56 pins were placed in 28 vertebrae using eachtechnique.2.4 |Design and creation of 3DPGsDigital Imaging and Communications in Medicine (DICOM)images were imported into 3D planning software(Mimics v21, 3-Matic v15, Materialise, Belgium) and vir-tual models of preselected vertebrae and 3DPGs based onsafe pilot hole trajectories were created by a board-certified neurologist (J.G.). All guides were unilateral anddesigned as previously described,18with a 2.0-mm inter-nal diameter that matched the pilot hole for the FHPtechnique, and variable guide tube length ranging from24 to 30 mm (Figure1). The footprints of individual3DPGs were variable in dimensions but were designed insuch a way that they incorporated anatomical landmarkswith a snug fit. Guides were printed using biocompatibleresin using a stereolithography (SLA) printer (SurgicalGuide resin, Form 3B, Somerville, Massachusetts) with0.1 mm layer height (resolution).2.5 |Preoperative planning for FHPtechniqueFor the FHP technique, primary and assistant surgeonsused CT multiplanar reconstruction (MPR) images(Horos) for determination of (i) optimal pin entry andexit points, which were based on a best fit line thatbisected the pedicle and exited as close as possible tothe ventral vertebral midline in the thoracic spine, anda line that extended from the base of the accessory pro-cess (L1 –6) and crossed the ventr al vertebral midline inthe lumbar spine (Figure2); (ii) pin insertion angles(based on optimal pin entry and exit points) relative tothe sagittal plane and (iii) expected pin tract lengths.The optimal pin entry point in the thoracic spine wasbased on the location of the accessory or mammillaryprocess as previously described.6In the lumbarspine (L1 –6), the optimal pin entry point was at thelevel of the base of the acce ssory process. The optimale n t r yp o i n tf o rL 7w a si nam o r ed o r s a l l yl o c a t e dp o s i -tion at the base of its cranial articular process.5,12Allmeasurements were obtai ned from MPR images withthe dorsal plane axis parallel to the vertebral canalfloor in the sagittal plane, and the sagittal plane axisbisecting the vertebral body in the dorsal plane and theTABLE 1 Randomization of functional spinal units and method of pin insertion.Cadaver Functional spinal units and pin insertion techniques1T 9 ‐10 L2 ‐3 T11 ‐12 L4 ‐5T 7 ‐8L 6 ‐7 T13 ‐L1FHP 3DPG FHP 3DPG FHP 3DPG FHP2 T11 ‐12 T13 ‐L1 L2 ‐3T 7 ‐8L 6 ‐7L 4 ‐5T 9 ‐103DPG FHP 3DPG FHP 3DPG FHP 3DPG3T 9 ‐10 L2 ‐3 T11 ‐12 L4 ‐5T 7 ‐8L 6 ‐7 T13 ‐L13DPG FHP 3DPG FHP 3DPG FHP 3DPG4 T11 ‐12 T13 ‐L1 L2 ‐3T 7 ‐8L 6 ‐7L 4 ‐5T 9 ‐10FHP 3DPG FHP 3DPG FHP 3DPG FHPFIGURE 1 3D-printed vertebral model of T9-10 of cadaver3 with the corresponding left-sided T9 3D-printed drill guide(3DPG) in place.650 MULLINS ET AL . 1532950x, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13958 by Vetagro Sup Aef, Wiley Online Library on [22/07/2023]. 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 Licensespinous process/vertebral body in the transverse plane(Figure 2).2.6 |Spinal instrumentationThe spine was stabilized with dogs in sternal recum-bency, thoracic limbs extended cranially, and pelviclimbs flexed on either side of the abdomen. A dorsalapproach to the thoracolumbar spine was performedextending from T6-sacrum. The epaxial musculature wasreflected bilaterally, without disruption of the supraspi-nous or interspinous ligaments. Duration of pin place-ment was recorded as the time (in seconds) fromscraping the surface of the bone with a freer elevator forplacement of 3DPGs or to locate optimal pin entry pointfor the FHP technique until completed pin placement.The time taken to perform initial dissection was notrecorded. Occurrence and type of intraoperative tech-nique deviations in pin placement, defined as any unan-ticipated deviations from planned surgical technique andunrelated to postoperative modified Zdichavsky grade,15were recorded and compared between techniques.2.7 |Free-hand probing techniqueThe FHP technique (Video S1) involved: (1) creation of acortical defect (decortication) using a 2-mm drill bit atthe optimal pin entry point (based on preoperative CT)and exposure of cancellous bone; (2) palpation of the cor-tical defect with 1.1-mm Kirschner wire (k-wire) to con-firm absence of canal breach; (3) advancement of theblunted 2.0 mm Steinmann pin acting as a probe(Figure3) for/C245–10 mm at an angle guided by a goniom-eter, with as much length of pin left exiting the chuck aspossible; (4) pin removal and palpation of the initiatedtunnel with a k-wire to confirm absence of canal breach;FIGURE 2 Transverse (A, E) and sagittal (F) plane multiplanar reconstruction (MPR) images, maximum intensity projection dorsalimage (B), volume rendered 3D reconstruction images (C, G), and intraoperative images demonstrating location of ideal pin entry point inthoracic (D) and lumbar (H) vertebrae. In images (A, E), dog's left is to the right; in image (B), cranial is to the top; and in images (C, D,F, G, and H), cranial is to the left. In image (B), the blue dot represents ideal pin entry point on the left.FIGURE 3 Blunted 2.0 mm Steinmann pin acting as a probe.MULLINS ET AL . 651 1532950x, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13958 by Vetagro Sup Aef, Wiley Online Library on [22/07/2023]. 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(5) further pin advancement a distance of /C245–10 mm;(6) probe removal and palpation of the tunnel with a k-wire to confirm absence of canal breach; (7) drilling of a2.0-mm pilot hole, being careful to follow the same tra-jectory as the probe, and exiting through the ventral ver-tebral cortex; (8) palpation of the pilot hole with a k-wireto confirm absence of canal breach; (9) measurement ofthe pilot hole length; (10) marking the measured lengthon the positive profile pin; (11) insertion of 3.2/2.4 mmpositive profile pin at low speed, being careful to followthe pilot hole; and (12) removal of the positive profile pin(Figure4). The same technique was repeated on the con-tralateral side of that vertebra, before proceeding to thenext vertebra of that FSU. The probe size correspondedto/C2450% –75% the width of thoracic pedicle on pre-operative MPR transverse plane images. The angle ofSteinmann pin insertion was checked on all occasionsbefore advancement using a goniometer. Two3.2/2.4-mm pins were placed in each vertebra, with theright pin directed slightly cranially and the left pinslightly caudally. All pins were inserted by a board-certi-fied surgeon (R.A.M.) assisted by third year ECVS resi-dent-in-training (J.E.R.), over a period of 2 weeks. Theprimary surgeon had substantial experience in spinal sur-gery in dogs, had performed the FHP technique in asmall number of clinical cases, and adapted the FHPtechnique from previous descriptions6and in consulta-tion with one author (K.H.K.).6In the T7 –T10 spine, theaccessory process was identified and the pin entry pointcreated just medial thereto in the mid-to-cranial aspect ofthe transverse process (Figure2). For T10 –T13, at whichthe mammillary process typically becomes associatedwith the cranial articular process and the accessory pro-cess transitions from the transverse process to a moremedial location similar to the cranial lumbar vertebrae,an additional measurement consisting of the distanceFIGURE 4 Intraoperative images of a dissected thoracolumbar spine demonstrating creation of the cortical defect (A), palpation ofcortical defect with 1.1-mm k-wire to confirm absence of canal breach (B), advancement of 2.0 mm blunted Steinmann pin (probe) (C),palpation of initiated tunnel with k-wire to confirm absence of canal breach (D), further advancement of Steinmann pin (E), palpation oftunnel with k-wire to confirm absence of canal breach (F), drilling of pilot hole in same trajectory as probe (G), palpation of pilot hole withk-wire to confirm absence of canal breach (H), depth gauge insertion and measurement of pilot hole length (I), marking of measured pilothole length on positive profile pin (J), insertion of positive profile pin at low speed (K), removal of positive profile pin (L). In images (A –I, K,and L), cranial is to the left.652 MULLINS ET AL . 1532950x, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13958 by Vetagro Sup Aef, Wiley Online Library on [22/07/2023]. 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 Licensefrom the costovertebral junction to the ideal pin entrypoint was obtained from preoperative MPR images. Inthe lumbar spine (L1 –6), the optimal pin entry point wasat the level of the base of the accessory process(Figure2).2.8 |3DPG techniqueSoft tissues were meticulously removed over areas of boneto ensure precise and complete contact of guide footprint.3DPGs were held firmly in position by hand, and a 2.0-mmdrill bit was used to create a pilot through the guide sleeve.The guide was removed, pilot hole measured with a depthgauge, and appropriate lengt h of positive profile pininserted at low speed. The pin was then removed.2.9 |Post-instrumentation CTCT was repeated after spinal instrumentation from T6-sacrum using the previous ly described protocol andassessed in Horos. Using MPR , the dorsal and transverseplane axes were aligned with each pin tract trajectory andgraded on transverse plane images (Figure5). Grading wasperformed once by two independent observers (board-certified radiologist [S.H.] and board-certified neurologist [J.G.]) using a modification of the modified Zdichavsky classi-fication (Figure6) described by Elford and colleagues.15Dis-crepancies between observers were reviewed together onone occasion and a consensus reached.2.10 |Statistical analysisDescriptive statistics were used. Data are summarizedbyN(%) or mean ± SD. Data related to modifiedZdichavsky classification grade and duration of pin place-ment for each technique are presented for the thoracicspine, lumbar spine, and overall.3|RESULTSFour greyhound cadavers were included, two males and twofemales. Bodyweights included 25.0, 27.0, 31.0, and 34.5 kg.3.1 |Accuracy of pin placementAgreement between the two observers was present for104/112 pin tracts. Disagreeme nt was present for eight pintracts and consisted of three cases in which a discrepancybetween a grade IIa versus gr ade I was agreed by consensusas being a grade I, a further thr ee cases in which a discrep-ancy between a grade IIIa versus grade I was agreed by con-sensus as being a grade I, one case in which a discrepancybetween a grade IIa versus grade I was agreed as being agrade IIa, and a further case in which a grade IIIa versusgrade I was agreed as being a grade IIIa.Overall, 54/56 pins placed with a 3DPG were assignedgrade I compared with 49/56 pins placed using the FHPtechnique (Figure7, Table 2). Two pins placed with a3DPG were assigned grade IIa, whereas 3/56 pins placedusing the FHP technique were graded IIa (Figure 8). Fourpins placed using the FHP technique and no pins placedwith a 3DPG were assigned grade IIIa (Figure 9). No pinswere classified as grade IIb or IIIb.3.2 |Intraoperative technique deviationsIntraoperative technique deviations in pin placementoccurred during placement of 6/56 pins placed using theFIGURE 5 Sagittal (A),transverse (B) and dorsal(C) oblique plane multiplanarreconstruction (MPR) imageswith dorsal and transverse planeaxes aligned with each pin tracttrajectory and gradingperformed on transverse planeimages. In images (A and C),caudal is to the left. In image(B), the dog's left is to the right.MULLINS ET AL . 653 1532950x, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13958 by Vetagro Sup Aef, Wiley Online Library on [22/07/2023]. 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 LicenseFIGURE 6 Modified Zdichavsky classification with grade I corresponding to optimally placed pin tract fully contained within pedicle(thoracic spine) or vertebral body (lumbar spine), grade IIa denoting partial penetration of the medial pedicle wall, grade IIb correspondingto full penetration of the medial pedicle wall (whole of screw diameter within canal), and grades IIIa and IIIb denoting partial and fullpenetration of the lateral pedicle (thoracic spine) or vertebral body (lumbar spine) wall, respectively.FIGURE 7 Transverse plane multiplanar reconstructi on (MPR) images of selected examples of pin tracts (free-hand probing [FHP]: images[A–G], 3D-printed drill guide [3DPG]: images [H –N]) assigned grade I modified Zdichavsky. For all images, the dog's left is to the right.TABLE 2 Modified Zdichavsky classification grades for pins inserted by 3D-printed drill guides (3DPGs) and free-hand probing (FHP)technique in the thoracic spine, lumbar spine, and overall.Grade Thoracic Lumbar OverallFHP I 24/28 (85.7%) 25/28 (89.3%) 49/56 (87.5%)IIa 1/28 (3.6%) 2/28 (7.1%) 3/56 (5.4%)IIIa 3/28 (10.7%) 1/28 (3.6%) 4/56 (7.1%)3DPG I 26/28 (92.9%) 28/28 (100.0%) 54/56 (96.4%)IIa 2/28 (7.1%) 0/28 (0.0%) 2/56 (3.6%)654 MULLINS ET AL . 1532950x, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13958 by Vetagro Sup Aef, Wiley Online Library on [22/07/2023]. 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 LicenseFHP technique and no pins placed with a 3DPG. Incadaver 1, bilateral unintentional penetration of the ven-tral vertebral cortex of T11 occurred during advancementof the probe; however, both pin tracts were surroundedby bone and subsequently assigned grade I modified Zdi-chavsky. In the same cadaver, the left-sided corticaldefect was created in a too dorsal location at L6 and entryinto the vertebral canal was identified with initiation ofprobing. A second cortical defect was created slightlymore ventral, and the technique was completed withoutfurther complication. Grade I modified Zdichavsky wasassigned on postoperative imaging in this instance. Incadaver 2, the probe exited the dorsolateral pedicle of T13on the right and the ventrolateral body of L5 on the left.In cadaver 4, the probe exited the dorsolateral pedicle ofT7 on the left. In each of these three cases, the probe wasredirected more medially and the technique completedwithout further complication. Two of the latter 3 devia-tions were subsequently assigned modified Zdichavskygrade I, with the left-sided L5 breach assigned grade IIIa(Figure10). No intraoperative technique deviationsoccurred in cadaver 3.3.3 |Duration of pin placementPins were placed faster in the thoracic spine (mean ± SD2.8 [1.6] vs. 4.2 [1.9] min), lumbar spine (mean ± SD 2.3[0.93] vs. 4.9 [1.7] min), and overall (mean ± SD 2.6 [1.3]vs. 4.5 [1.8] min) when a 3DPG was used (Table 3).4

Question 46

Traverson - 2023 - JAVMA - Adrenal tumors treated by adrenalectomy following spontaneous rupture carry an overall favorable prognosis - Retrospective evaluation of outcomes in 59 dogs and 3 cats (2000-2021).pdf

Answer 46

Case selectionThe medical records from 10 academic institu -tions and 1 private referral institution were searched to identify dogs and cats of any age, body weight, reproductive status, sex, and breed with primary ad -renal tumors that underwent adrenalectomy between January 1, 2000, and June 1, 2021. The inclusion cri -teria consisted of dogs and cats that were taken to surgery for an adrenalectomy after presenting with a spontaneously ruptured adrenal mass as suspected by the presence of retroperitoneal effusion, perito -neal effusion or hematoma detected on preoperative imaging, and with the effusion confirmed as blood by abdominocentesis (PCV ≥ 20%) or during surgery. No minimum follow-up duration was required consider -ing the rarity of the presentation. Cases were ex -cluded from the analysis if spontaneous hemorrhagic effusion or hematoma could not be confirmed after review of the laboratory diagnostics, imaging, and/or surgery reports.Data collectionData extracted from medical records included signalment; history; clinical presentation; preopera -tive blood work; coagulation panels; adrenal function test results; abdominal fluid analysis results; blood pressure (BP) readings; electrocardiogram findings; preoperative management and response to treat -ment; diagnostic imaging; surgical, histopathologi -cal, anesthesia, and postoperative findings; adjuvant treatment; and long-term follow-up and survival.Preoperative diagnostic imaging results were reviewed to record tumor lateralization, size, pres -ence of retroperitoneal and/or peritoneal fluid, he -matoma, evidence of vascular and/or surrounding tissue tumor invasion, and suspicion for metastasis. Time-interval between initial presentation and sur -gery, gross tumor findings, active hemorrhage, caval venotomy, ureteronephrectomy, other surgical pro -cedures, intraoperative complications and manage -ment, and surgery and anesthesia durations were recorded. An emergent procedure was defined as a time interval of ≤ 1 day between presentation and surgery. Intraoperative hypotension (defined as a mean arterial pressure < 60 mm Hg or a systolic BP < 80 mm Hg for ≥ 10 minutes), hypertension (defined as a systolic BP ≥ 180 mm Hg for ≥ 10 minutes), ma -jor intraoperative hemorrhage (defined as requiring a blood transfusion and/or recorded as significant by the surgeon), blood products received, and cardiac arrhythmia and associated treatment were recorded. Information retrieved from the histopathology re -port included diagnosis and confirmed metastatic disease of any organ sampled. Postoperative com -plications and treatments associated, total duration of hospitalization, and short-term survival ( ≤ 14 days postoperatively) were recorded. Medical records from the referring veterinarian and/or referral insti -tutions were collected to gain information regarding long-term follow-up examination and diagnostics, evidence and date of local recurrence and/or me -tastasis, adjuvant treatments and potential compli -cations, and overall survival time. Owners were con -tacted as needed to confirm the dog or cat survival status or date of death, the cause of death, and nec -ropsy results if indicated.Statistical analysisAssociations between continuous variables and binary variables were examined via Wilcoxon rank sum tests. Associations between binary variables were examined via the Fisher exact test. Associa -tions of postoperative complications, short-term survival, and duration of hospitalization with preop -erative blood work abnormalities were done with a series of Bonferroni-corrected Fisher exact tests and the Wilcoxon rank sum test. Associations between continuous variables and long-term survival were examined with univariate Cox proportional hazards models. Overall and censored (excluding short-term Unauthenticated | Downloaded 12/04/23 07:18 AM UTC 3mortality) MSTs were estimated across the entire study population, including dogs and cats lost to follow-up and alive at the time of study completion, and illustrated in Prism 9 (GraphPad) using a Kaplan-Meier analysis. The cause of death was not restricted to the adrenal disease in the survival analysis due to the absence of consistent necropsy. A cutoff value of 0.05 was used for significance.ResultsClinical presentationFifty-nine dogs and 3 cats met the inclusion cri -teria. Clinical signs at presentation included lethargy (40/62 [64.5%]), abdominal pain (15/62 [24.2%]), collapse (13/62 [21.0%]), pale mucous membranes (12/62 [19.3%]), panting or tachypnea (10/62 [16.1%]), hyporexia (8/62 [12.9%]), abdominal dis -tension (7/62 [11.3%]), vomiting (6/62 [9.7%]), rest -lessness (5/62 [8.0%]), shaking or trembling (4/62 [6.5%]), and back pain (1/62 [1.6%]). Additionally, 14 of 62 (22.6%) dogs and cats were presented with uri -nary signs of varied chronicity. Cranial organomeg -aly was reported in 4 of 62 (6.5%) cases on physi -cal examination. In 4 of 62 (6.5%) cases, the adrenal mass was found incidentally via ultrasonography (n = 1 dog) or tomodensitometry (3 dogs). The popula -tion’s demographics and clinical presentation were summarized (Table 1) .Preoperative diagnostics and treatmentsComplete preoperative blood work was per -formed in 60 of 62 cases. Anemia was evident in 22 of 62 (35.5%) cases, including 2 cats, and thrombocy -topenia was reported in 7 of 60 (11.6%) canine cases, with 2 of 7 dogs that had a confirmed platelet count < 100 X 103/µL (41 and 82 X 103/µL). Overall me -dian peripheral PCV was 38% (range, 17.3% to 57%) in dogs and 30% (range, 23% to 37%) in cats. Abdomi -nocentesis was performed in 18 of 62 (29.0%) canine cases and diagnostic of hemorrhagic peritoneal ef -fusion with a median PCV value of 41% (range, 25% to 58%). There was an increased prothrombin and/or partial thromboplastin times ≥ 1.5 times the upper range limit in 7 of 48 (14.6%) canine cases. A hyper -coagulable state was suggested via thromboelastog -raphy in 4 of 4 (100%) dogs; elevated fibrinogen in 12 of 17 (70.6%) cases, including 1 cat; and elevated D-dimers in 4 of 9 (44.4%) dogs. Only 1 dog out of 45 dogs and cats for which noninvasive BP was mea -sured appeared hypotensive on presentation. Seven dogs and 2 cats (14.5%) were administrated packed RBCs (pRBCs), and 2 (3.2%) dogs received a whole blood transfusion preoperatively. Lower PCV ( P = .001) and platelet count ( P = .047) were significantly associated with preoperative blood transfusion.Adrenal function tests were performed in 26 of 62 (42.1%) cases, including a low-dose dexamethasone suppression test (n = 11 dogs and 1 cat), ACTH stimu -lation test (11 dogs), urine cortisol-to-creatinine ratio (8 dogs and 1 cat), serum or urine metanephrine (6 dogs), endogenous ACTH (4 dogs), and endogenous steroid hormone levels (1 cat). A primary cortisol- secreting adrenal tumor was suspected in 8 of 21 (38.1%) cases tested for hyperadrenocorticism, and 1 of 8 dogs received preoperative oral trilostane at 1.4 mg/kg once daily (for an unknown duration). A pheochro -mocytoma was suspected in 20 of 62 (32.2%) canine Species Variables Dogs CatsBreeds represented (n) Crossbreed 12 Labrador Retriever 8 Golden Retriever 7 German Shepherd Dogs 5 Beagle 4 Boxer 2 Yorkshire Terrier 2 Fox Terrier 1 Bichon Frise 1 Glen of Imaal Terrier 1 Labradoodle 1 Soft-Coated 1 Wheaten Terrier Basenji 1 American Eskimo 1 American Cocker Spaniel 1 Doberman Pinscher 1 Standard Poodle 1 Rhodesian Ridgeback 1 Australian Blue Heeler 1 Collie 1 Anatolian Shepherd 1 Border Terrier 1 Bassett Hound 1 Boston Terrier 1 Cavalier King 1 Charles Spaniel Pit bull–type dog 1 Domestic shorthair 3Sex status Spayed females 29 1 Castrated males 28 2 Intact female 1 Intact male 1 Median age (y) 11 (range, 8.4 5–13) (range, 8.2–12.9)Median body weight (kg) 26.8 (range, 5.6 5.1–63.9; 23/59 (range, [38.9%] ≤ 20 kg) 5.5–6.0)Clinical signs (n) Lethargy 37 3 Abdominal pain 13 2 Collapse 12 1 Pale mucous membranes 12 Panting or tachypnea 9 1 Hyporexia 6 2 Abdominal distension 7 Vomiting 5 1 Restlessness 4 1 Shaking or trembling 3 1 Back pain 1 Polyuria-polydipsia 12 Inappropriate urination 2 1Physical examination findings (n) Cranial organomegaly 3 1 Palpable fluid wave 4 Table 1 —Population demographics and clinical presentation.Unauthenticated | Downloaded 12/04/23 07:18 AM UTC4 cases based on adrenal function test (n = 8), systemic hypertension (12), vascular invasion (5), cardiac ar -rhythmia (2), and/or syncopal episode (1). α-Blockers were administrated preoperatively in 27 of 62 (43.5%) canine cases; 25 dogs received phenoxybenzamine at a mean oral dose of 0.47 mg/kg twice daily (range, 0.085 to 1.4 mg/kg) for a mean duration of 9.2 days (range, 2 to 34 days), and 2 dogs received prazosin at a mean total oral daily dose of 0.38 mg/kg for 12 and 23 days. Phenoxybenzamine use was not associated with the diagnosis of pheochromocytoma ( P = .136) but was associated with a nonemergent surgery ( P = .016). Oth -er specific preoperative medications in dogs included amlodipine (n = 2), aminocaproic acid (2), diltiazem (1), and heparin at a rate of 10/IU/kg/h (1). There was no specific pretreatment administered in cats.Fifty-nine of 62 (95.2%) dogs and cats had imag -ing with abdominal ultrasonography (n = 19 dogs and 1 cat), CT (6 dogs), or a combination of both (31 dogs and 2 cats) preoperatively. Three dogs did not have comprehensive abdominal imaging but had evidence of free fluid on FAST (focused assessment with so -nography for trauma) scan, which was confirmed as hemorrhagic on abdominocentesis in 2 of 3. Of the 62 cases that received complete abdominal imaging and/or a FAST scan, peritoneal effusion was noted in 29 dogs (46.7%), retroperitoneal effusion was noted in 39 dogs and 1 cat (64.5%), and both were noted in 16 dogs and 1 cat (27.4%). A retroperitoneal hema -toma was suspected in 34 of 59 (57.6%) cases that had complete abdominal imaging, including 1 cat. Other significant imaging findings included splenic (n = 10 dogs) and hepatic nodular lesions (8 dogs), gastric and intestinal foreign bodies (2 dogs), urocystoliths (1 dog), and diffuse small intestinal layer changes (1 cat). Three dogs of 57 (5.2%) dogs and cats that re -ceived thoracic imaging preoperatively had suspect -ed pulmonary metastasis (none sampled), and 1 dog had a right caudal lung lobe mass.Surgical procedureThe overall median time between presentation and surgery in dogs and cats was 3 days (range, 0 to 210 days), with 21 of 62 (33.9%) surgical procedures per -formed emergently (n = 20 dogs and 1 cat). No sig -nificant relationship was found between surgery timing and peripheral PCV ( P = .317), lactate ( P = .153), plate -let count ( P = .383), prothrombin time (P = .453), partial thromboplastin time (P = 1), systolic BP ( P = .169), and imaging identification of peritoneal effusion ( P = .128), retroperitoneal effusion ( P = .82), and/or hematoma (P = .053) on presentation. Surgical approach consisted of ventral midline celiotomy (n = 57 dogs and 3 cats), right paracostal approach (1 dog), or combined ap -proach (1 dog). Active adrenal hemorrhage was noted in 15 of 62 (24.1%) cases, including 1 cat. Vascular in -vasion was confirmed in 15 of 62 (24.1%) canine cases, with a tumor thrombus invading the caudal vena cava (n = 10), phrenicoabdominal (4), and renal (1) vein. Cases with right-sided tumors (n = 28 dogs) had odds of vascular or surrounding tissue invasion that were 2.8 times as high as those in left-sided tumors (30 dogs and 3 cats; OR, 3.35; 95% CI, 1.04 to 10.93; P = .047) . Retroperitoneal hematoma (n = 39 dogs and 2 cats), adrenal gland disruption (29 dogs and 1 cat), and tu -mor adhesions to the ipsilateral kidney (8 dogs) or hyp -axial musculature (1 dog) were documented at surgery.Left, right, and bilateral adrenalectomy were completed in 33 of 62 (53.2%), 28 of 62 (45.2%), and 1 of 62 (1.6%) cases, respectively. Caval venotomy was performed in 10 (16.1%) dogs to retrieve a tumor thrombus, and 12 (19.4%) dogs underwent an ipsilat -eral ureteronephrectomy. The retroperitoneal hema -toma was reportedly removed in 13 (21.3%) dogs and a nephropexy performed in 4 (6.5%) dogs. Additional procedures included liver biopsy (n = 20 dogs), sple -nectomy (9 dogs), abdominal lymph node extirpation (3 dogs and 1 cat), gastrointestinal biopsy (3 dogs and 1 cat), liver lobectomy (3 dogs), omental nod -ule excision (2 dogs), gastrotomy (3 dogs), pancre -atic nodule excision (1 dog), lung lobectomy (1 dog), typhlectomy (1 dog), renal biopsy (1 dog), cystotomy (1 dog), gastropexy (1 dog), ovariohysterectomy (1 dog), pancreatic and mesenteric nodule excision (1 dog), and excisional biopsy of skin tag (1 dog), peri -anal mass (1 dog), and facial mass (1 dog).Thirty-seven of 62 (59.6%) dogs and cats experi -enced adverse events during anesthesia, including hypo -tension in 23 dogs and 3 cats (41.9%), hypertension in 5 dogs and 1 cat (9.6%), and cardiac arrhythmia in 16 dogs (25.8%). There was no significant impact of phenoxy -benzamine pretreatment on the occurrence of hypoten -sion, hypertension, or cardiac arrhythmia, whether this was considered for the entire study population ( P = .566, P = 1, and P = .088, respectively) or pheochromocytoma cases exclusively, according to histopathology ( P = .203, P = 1, and P = 1, respectively). Intraoperative hemor -rhage upon dissection of the adrenal gland was reported in 22 of 54 (40.7%) canine cases, with major hemorrhage recorded in 8 of 22 (36.3%) dogs. Nineteen of 62 (30.6%) dogs and cats received intraoperative blood transfu -sions, including pRBCs (n = 16 dogs and 1 cat), fresh frozen plasma (2 dogs), and whole blood (1 dog). In 3 dogs and 1 cat, the transfusion was continued from be -fore the operation. Factors associated with intraopera -tive transfusion are illustrated (Table 2) .Table 2 —Predictive factors of intraoperative blood transfusion. No. Intraoperative P value, Variables of patients blood transfusion Fisher exact testTiming of surgerya Emergent 21 10/21 (47.6%) .002 Delayed 41 9/41 (21.9%) Intraoperative hemorrhage Yes 22 12/22 (54.5%) .003 No 32 5/32 (15.6%) aTime from presentation to emergent surgery of ≤ 1 day versus median time of 7 days (range, 2 to 210 days) for delayed surgery.Unauthenticated | Downloaded 12/04/23 07:18 AM UTC 5The overall median duration of the surgical pro -cedure and anesthesia was 120 minutes (range, 60 to 350 minutes) and 210 minutes (range, 113 to 480 minutes), respectively. Shorter procedures were sig -nificantly associated with emergent surgery and ab -sence of vascular invasion ( P < .001 and P = .034, respectively). Overall, 57 dogs and 3 cats (96.7%) re -covered from surgery and anesthesia. One dog was euthanized intraoperatively due to uncontrolled ad -renal hemorrhage. The second remained comatose postoperatively after an episode of cardiopulmonary arrest and was eventually euthanized. Both under -went surgery within 1 day of presentation.Postoperative periodOf the 60 cases that survived the surgical pro -cedure, 14 dogs and 2 cats (26.6%) received a blood transfusion postoperatively, including pRBCs (n = 11 dogs and 2 cats), fresh frozen plasma (4 dogs), and whole blood (1 dog); in 6 dogs and 1 cat, the trans -fusion was continued from intraoperative administra -tion. Twenty-three of 60 (38.3%) dogs and cats re -ceived glucocorticoid treatment immediately before and/or after surgery in the form of injectable dexa -methasone sodium phosphate (n = 20 dogs and 1 cat) and/or prednisone (15 dogs) or prednisolone (1 cat). For 15 dogs, hypoadrenocorticism was confirmed postoperatively, and 9 continued long-term glucocor -ticoid treatment (> 14 days postoperatively).Postoperative complications were reported in 25 of 60 (41.6%) cases, including acute kidney injury (AKI; n = 7 dogs), aspiration pneumonia (5 dogs), disseminated intravascular coagulation (5 dogs), hemoperitoneum (3 dogs), suspected pulmonary thromboembolism (2 dogs), suspected pancreatitis (2 dogs), neurologic signs including seizures (2 dogs), cardiovascular complications such as cardiac arrhythmias (3 dogs), hypo- (3 dogs) or hypertension (1 dog), and tachycardia (2 dog). Of the 7 dogs that developed an AKI, 5 of 7 had a ureterone -phrectomy and 3 of 7 developed other postoperative complications, including aspiration pneumonia (n = 2), suspected pancreatitis (1), hemoperitoneum (1), and seizure (1) leading to their death (1) or euthanasia (2). A significant association was noted between ureterone -phrectomy and postoperative AKI ( P = .003), but not with other variables, including intraoperative hypotension (P = .672). Additionally, there was no significant associa -tion between intraoperative hypotension and postopera -tive AKI within the subpopulation that underwent a ure -teronephrectomy ( P = .222).Overall, postoperative complications led to death or euthanasia in 4 and 7 dogs, respectively, with an overall short-term mortality rate of 20.9% (13/62). Me -dian duration of hospitalization was 2 days (range, 1 to 7 days), and 46 dogs and 3 cats survived the post -operative period. There was no significant impact of phenoxybenzamine pretreatment ( P = .326 for the en -tire study population, P = .347 for pheochromocytoma exclusively), ureteronephrectomy ( P = .107), postop -erative AKI ( P = .125), and overall postoperative com -plications ( P = .504) on short-term survival. Variables significantly associated with postoperative AKI and short-term mortality are reported (Tables 3 and 4) .Histopathology resultsHistopathology results were available in 60 of 62 (96.7%) cases, and diagnoses included adrenocortical carcinoma (n = 25 dogs [41.7%]), pheochromocytoma (22 dogs and 1 cat [38.3%]), adrenocortical adenoma (6 dogs and 1 cat [11.6%]), undetermined adrenocor -tical neoplasia (2 dogs and 1 cat [5.0%]), and 1 (1.7%) canine case each of adrenal fibrosis and hemorrhage and of hemangiosarcoma with metastasis to the pan -creas and kidney. Histopathology was not submitted for 1 of the 2 dogs euthanized under general anes -thesia and could not be found in the medical record system of another dog. In the second case, the sur -gery report indicated an adrenal mass associated with a 5 X 8-cm hematoma, moderate peritoneal hemor -rhagic effusion, and no other significant lesion apart Table 3 —Positive association between ureteronephrectomy and postoperative acute kidney injury ( ≤ 14 days postoperatively). No. Postoperative acute P value, Prognostic factors of patients kidney injury Fisher exact testUreteronephrectomy Yes 12 5/12 (41.6%) .003 No 48 2/48 (4.2%) Table 4 —Predictive factors of short-term mortality ( ≤ 14 days postoperatively). No. Short-term P value, Prognostic factors of patients mortality Fisher exact testTiming of surgerya Emergentb 21 6/21 (28.5%) .015 Delayed 41 7/41 (17.0%) Additional surgical procedure Yes 43 13/43 (30.2%) .006 No 19 0 (0%) Intraoperative hypotension Yes 23 9/23 (39.1%) .011 No 39 4/39 (10.3%) bWithin the subpopulation receiving an emergent surgery, there was also a significant association between hypotension and short-term mortality ( P = .012); this was not true for the subpopulation receiving nonemergent surgery ( P = 1).See Table 2 for remainder of key.Unauthenticated | Downloaded 12/04/23 07:18 AM UTC6 from a small liver nodule. Other concurrent histopath -ologic diagnoses included hepatocellular carcinoma (n = 2 dogs); splenic, hepatic, and metastatic splenic and hepatic hemangiosarcoma unassociated with a pri -mary adrenal hemangiosarcoma (1 dog each); pulmo -nary carcinoma; oral melanoma; facial carcinoma with mixed squamous and chondroid differentiation (1 dog each); and small intestinal small cell lymphoma (1 cat).Long-term follow-upThirty-nine of 49 (79.5%) dogs and cats that survived the perioperative period had follow-up examinations, with the last visit reported at a median interval of 100 days (range, 4 to 2,466 days) after surgery. Repeated diagnostics at these appointments included blood work (n = 28 dogs and 2 cats), abdominal imaging (20 dogs and 1 cat), and thoracic imaging (18 dogs and 1 cat). Local recurrence (n = 1 dog) and/or metastasis (3 dogs) of neuroendocrine carcinoma to the omentum, liver, spleen, contralateral adrenal gland, and kidney were con -firmed on histopathology in a total of 3 dogs at 314, 490, and 510 days postoperatively, including 1 dog that was initially diagnosed with adrenocortical adenoma. Non -sampled suspected metastasis and/or de novo tumors were reported in 7 other dogs and 1 cat, including sus -pected hepatic metastasis of splenic hemangiosarcoma (n = 1 dog), novel hepatic mass with liver and pulmonary nodules (1 dog), cranial abdominal mass (1 cat), mesen -teric nodules (1 dog), thyroid and pulmonary nodules (1 dog), contralateral adrenal mass with pulmonary nodules (1 dog), urothelial cell carcinoma (1 dog), and metasta -sis of oral malignant melanoma (1 dog).Seven of 49 (14.2%) dogs and cats received ad -juvant chemotherapy at a median interval of 31 days (range, 10 to 545 days) after surgery. Treatment was targeted toward the adrenal neoplasia in 2 dogs and included doxorubicin therapy for metastatic adrenal hemangiosarcoma (30 mg/m2, IV, 1 dose total) and combination therapy with docetaxel and cyclospo -rine for metastatic adrenocortical carcinoma (1.625 mg/kg and 5 mg/kg orally, respectively, 2 doses at a 1-week interval). Other adjuvant chemotherapy treat -ments included doxorubicin (n = 2 dogs), carboplatin (1 cat), vinorelbine (1 dog), and chlorambucil (1 dog) for splenic and/or hepatic hemangiosarcoma, gastro -intestinal lymphoma, suspected pulmonary carcinoma, and urothelial cell carcinoma, respectively. No dog or cat underwent adjuvant radiation therapy.Of the 49 cases that survived the perioperative pe -riod, 15 dogs and 2 cats (34.7%) were lost to long-term follow-up. Of the remaining 32 cases, 13 dogs (26.5%) were still alive at the time of data collection, and 18 dogs and 1 cat (38.8%) were deceased, leading to overall and censored MSTs of 574 days and 900 days, respectively (range, 0 to 2,466 and 8 to 2,466 days). Long-term cause of death or euthanasia was suspected related to the ad -renal neoplasia in 4 of 19 cases, including 1 cat; unrelated in 9 of 19 cases; and unknown in 6 of 19 cases. Case sum -mary and compared Kaplan-Meier survival estimates by tumor types are presented (Table 5; Figure 1) .Table 5 —Clinical summary of study population by tumor type (n = 59). Adrenocortical Adrenocortical Undetermined Adrenal tumor diagnosis carcinoma Pheochromocytoma adenoma adrenocortical neoplasm HemangiosarcomaStudy population Canine 25 22 6 2 1 Feline — 1 1 1 —Preoperative diagnostic imaging Median maximum tumor axis 5.6 (2–11.5) 5.7 (1.8–10) 5.4 (0.8–11) 6.2 (4.5–7.4) 5.2 (range [cm]) Suspected vascular invasion 5/25 (20.0%) 9/23 (40.9%) 3/7 (42.8%) 1/3 (33.3%) — Peritoneal effusion 12/25 (48.0%) 12/23 (52.1%) 2/7 (28.5%) 1/3 (25.0%) 1/1 (100%) Retroperitoneal effusion 16/25 (64.0%) 19/23 (86.0%) 2/7 (28.5%) 3/3 (100%) — Retroperitoneal hematoma 16/25 (64.0%) 8/23 (36.3%) 4/7 (57.1%) 3/3 (100%) 1/1 (100%)Preoperative treatment Phenoxybenzamine 7/25 (28.0%) 12/23 (52.1%) 4/7 (57.1%) 1/3 (33.3%) — Blood transfusion 5/25 (20.0%) 2/23 (8.6%) 1/7 (14.3%) 1/3 (33.3%) —Surgical procedure Adrenalectomy (L/R) 16/10 10/13 3/4 3 L 1 R Caval venotomy 3/25 (12.0%) 7/23 (30.4%) — — — Ureteronephrectomy 2/25 (8.0%) 7/23 (30.4%) — 1/3 (33.3%) 1/1 (100%) Additional procedures 16/25 (64.0%) 15/23 (65.2%) 5/7 (71.4%) 3/3 (100%) 1/1 (100%)Anesthesia Systemic hypotension 11/24 (45.8%) 9/21 (42.8%) 3/7 (42.8%) 1/3 (33.3%) — Systemic hypertension 2/24 (8.3%) 5/21 (23.8%) — 1/3 (33.3%) — Cardiac arrhythmias 8/24 (33.3%) 5/21 (23.8%) 1/7 (14.3%) — 1/1 (100%)Postoperative period ( ≤ 14 d) Glucocorticoid treatment 14/24 (58.3%) 7/23 (30.4%) 1/7 (14.3%) 1/3 (33.3%) — Complications 8/24 (33.3%) 14/23 (60.8%) 2/7 (28.5%) — 1/1 (100%) Short-term mortality 6/24 (25.0%) 6/23 (26.0%) — — —Long-term follow-up Local recurrence 1/19 (5.2%) — — — — Distant metastasis 2/19 (10.5%) — 1/7 (14.3%) — 1/1 (100%) Targeted adjuvant chemotherapy Docetaxel and — — — Doxorubicin (n = 1) cyclosporine (n = 1) Targeted adjuvant radiation therapy — — — — — Median or overall survival time (d) 555 (0–1,443) 580 (1–2,466) 490 (17–987) 942 (479–1,150) 190 Censoreda median or overall 855 (17–1,443) 1,471 (8–2,466) 490 (17–987) 942 (479–1,150) 190 survival time (d)aExcluding short-term mortality ( ≤ 14 days postoperatively).L = Left. R = Right.Unauthenticated | Downloaded 12/04/23 07:18 AM UTC 7

Question 47

Fontes - 2023 - JAVMA - Central and left division hepatectomies in two dogs.pdf

Answer 47

NA

Question 48

Buote - 2023 - VETSURG - 3D printed cannulas for use in laparoscopic surgery in feline patients - A cadaveric study and case series.pdf

Answer 48

2.1 |3D cannula printing design andconstruction3DPCs were designed with lengths of approximately3 cm, a length that was subjectively more appropriatefor feline patients based on the experience of a board-certified veterinary surgeon (NB). A 5 mm diametercannula was designed at a 3 cm length and an 11 mm can-nula was designed at a 3.2 cm length (Figures 1and2).The cannulas were designed using computer-aided designsoftware (Materialize 3-Matic, Plymouth, Michigan, USA).Initial prototypes were printed with a fused depositionFIGURE 1 Measurements for 5 mm shortened 3D printedcannula and trocarBUOTE ET AL . 871 1532950x, 2023, 6, modeling (FDM) 3D printer (Prusa i3 MK3S +, PrusaResearch, Czech Republic) using PLA filament material(Prusament PLA, Prusa Research, Czech Republic).Subsequent cannulas were printed with a biocompatible,autoclavable material (Dental SG print resin, FormlabsInc., Somerville, Massachusetts, USA) in a stereolithogra-phy (SLA) printer (Formlabs Form 2, Formlabs Inc)(Figure 3). Immediately after printing, post print proces-sing was performed based on manufacturer recommenda-tions for the specific resin. After post processing, the portswere sterilized in a hydrogen peroxide sterilizer (V ProMax, VHPMD 140x, Steris, Mentor, Ohio, USA). Thedesign and construction phase of this project took approxi-mately 16 h. Printing and post-print-processing of thecannulas alone required 6 –8 h. Aerobic cultures were per-formed as in Valenzano et al., to ensure appropriate steril-ity before use in the live patients. Briefly, this requiredintroducing 100 ml phosphate-buffered solution into thesterilization pouch, manually agitating it for 3 min, com-pleting centrifugation and then submitting the fluid super-natant for aerobic culture.352.2 |Sample populationTen apparently health adult (>1 year old) feline cadavericspecimens were utilized in this study. The effect of theuse of 3DPC in a laparoscopic feline surgery model wastested after difficulties were encountered during surgicalprocedure refinement on the first three cadaveric cases.The cannula type was not randomized to procedure num-ber as these cannulas were created to overcome unantici-pated specific surgical complications. The cadavericspecimens were obtained from local animal shelters afterhumane euthanasia by IV administration of pentobarbi-tal sodium for reasons unrelated to the study. An IACUCexemption was granted by the IACUC committee ofCornell University after review of the study protocol.After euthanasia, cadavers were refrigerated at 4/C14C for24 to 36 h and then stored at room temperature for 4 to6 h before performing the surgical procedure. Addition-ally, as part of a pilot project investigating laparoscopicsleeve gastrectomy, the 3DPC were utilized in twohealthy live adult felines. The surgical and postoperativeprotocol was approved for use in a live patient model bythe IACUC committee of Cornell University after review(Protocol # 2021 –0036).2.3 |Laparoscopic abdominal procedureThe cannulas were utilized during refinement of and per-formance of a laparoscopic vertical sleeve gastrectomy(LVSG) technique. The first five procedures utilizedeither all commercially available ports or commerciallyavailable ports and 3DPCs, while the last five cadavericprocedures only used 3DPCs (Table 1). The firsttechnique utilized five commercially available cannulas(Geniport Pyramidal tip trocar and cannula system,Winter Park, Florida, USA) placed in the following loca-tions: 5 mm cannulas at the umbilicus, right and leftparamedian (2 cm cranial to the umbilicus and 5 cm lat-eral), left caudal abdomen and one 11 mm cannula(Versaport Plus fixation cannula, Covidien/Medtronic,Minneapolis, Minnesota, USA) cranial to the pubis. Thesecond technique utilized a SILS (SILS port, Covidien/Medtronic) port placed in the umbilical region with addi-tional commercially available 5 mm cannulas or a 3DPCat the left and right paramedian position. The final tech-nique utilized only the 3DPCs at the umbilicus, right andleft paracostal, left caudal abdomen and cranial to theFIGURE 3 Final autoclavable 3D printed cannulas created inbiocompatible, autoclavable resin material (11 mm trocar, 11 mmcannula, 5 mm cannula with no insufflation cannula, 5 mm trocar,and 5 mm cannula with insufflation cannula from left to right)FIGURE 2 Measurements for 11 mm shortened 3D printedcannula and trocar872 BUOTE ET AL . 1532950x, 2023, 6, pubis, (Figure 4). Silicon valves from commercially avail-able cannulas (5 mm Geniport Pyramidal tip trocar andcannula system, Winter Park, Florida, USA and 11.5 mmThoracoport Covidien/Medtronic) were used for all3DPCs. All procedures were performed by one surgeon(NB) with extensive laparoscopic experience. Briefly, theLVSG procedure entails the use of laparoscopic scissorsor vessel sealing device to dissect free the greater omen-tum from the greater curvature of the stomach, the use ofan EndoGIA stapler (Endo GIA, Ultra Universal Stapler,Covidien/Medtronic) to respect the lateral aspect of thegreater curvature, and the use of multiple laparoscopicgrasping instruments.362.4 |Cadaveric procedure outcome dataThe surgical procedure time was recorded for every pro-cedure from the first cannula incision until the resectedstomach was removed from the abdomen. Instrumentcollisions were defined as a moment of intracorporealcontact between instruments that halted progress of theprocedure.37Cannula complications were defined as can-nula pullout from the body wall or CO 2leakage leadingto the necessity of an intervention (suture or towel clampplacement). This data was collected during refinement ofthe laparoscopic vertical sleeve gastrectomy procedure ina feline model. Descriptive data are presented as mean ormedian and range depending on normality. A one-tailedWilcoxan analysis was performed to assess for significantdifferences in surgery time, instrument collisions, andcannula pullout, between the first five and last five proce-dures. Significance was set to P< 0.05.2.5 |Live patient surgical outcome dataAnesthetic, surgical and postoperative data on thesepatients is reported elsewhere.36Intraoperative complica-tions including port breakage, pullout and CO 2leakageTABLE 1 Laparoscopic cannulas used in cadaver modelProcedurenumberNumber of Geniport5 mm portsNumber of5 mm 3DPCsNumber ofSILS portsNumber of Versaport11 mm portsNumber of11 mm 3DPC14 - - 1 -24 - - 1 -32 - 1 - -41 1 1 - -53 1 - - 16- 4 - - 17- 4 - - 18- 4 - - 19- 4 - - 110 - 4 - - 1Procedure number correlates with the order in which the procedures were performed.FIGURE 4 Photograph of final cannula placement forlaparoscopic partial gastrectomy. Silicon valves can be seen onthree of the ports. The yellow star indicates the umbilicusBUOTE ET AL . 873 1532950x, 2023, 6, were recorded. Postoperative complications includingskin reactions or infections at the port sites were recordedduring the 14 days until suture removal.3|RESULTSTen apparently healthy domestic shorthair adult felinecadavers were used in the study. All animals appeared tobe adults (>1 year), but exact ages were not provided.The mean weight of the cadaver specimens was 5.49 kg(median 5.45, range 3.2 –7.1 kg). The mean body condi-tion score was 6.4 (median 6, range 5 –8). The livepatients included one male and one female and wereapproximately 9 months of age at the time of the proce-dure. They were healthy with no obvious underlyinghealth concerns on preoperative testing (complete bloodcount, and serum chemistry). At the time of their proce-dure, they weighed 4.09 and 7.6 kg (a weight gain of49 and 76% their original weight, respectively).3.1 |Cadaveric outcomesThe mean surgical time for all procedures was 110.4 min(median =114.5, range 80 –145 min). The first five caseshad a mean surgical time of 125.6 min compared to the lastfive cases with a mean surgical time of 95.2 min, p=0.03.The total mean number of cannula pullout eventswas 6.1 (median 5, range 0 –14). The mean number ofcannula pullout events in the first and last five cases,respectively was 10 (median 10, range 6 –14) and 2.2(median 3, range 0 –4),p=0.03 (Figure 5).The total mean number of instrument collisions was4.7 (median 4.5, range 0 –9). The mean number of instru-ment collisions in the first and last five cases, respectivelywas 6.8 (median 8, range 4 –9) and 2.6 (median 3, range0–5),p=0.03 ( Figure 5b ).3.2 |Live surgical outcomesIntraoperative complications during case 1 included theinsufflation connection port of the 3DPC breaking in theinsufflation tubing connection during application. Thiswas avoided in case 2 by using a male luer lock connector(Injectech, For Collins, Colorado, USA) in the insuffla-tion port to connect to the tubing. None of the shaftsbroke during use or manipulation. None of the portsexperienced pullout during surgery but CO 2leakage wasevident from one of the 5 mm silicon valves and the11 mm silicon valve during case 2 requiring use of com-mercial ports. The surgeon also noted more difficulty inplacing the 3DPCs initially because the 3D printed trocarwas not as tight a fit in the lumen as is seen with com-mercially manufactured ports. To overcome this diffi-culty, the skin incision was increased 1 –2 mm andpenetrating towel clamps were used to grasp the bodywall to act as counterpressure. No postoperative compli-cations were reported during the short-term follow up. Atthe time of submission both cats are approximately3 months postoperative and are doing well.FIGURE 5 (A) Box plot of port complications pre- (without) and post (with) use of all 3DPCs in cadaver specimens. The “intervention ”is the use of 3DPC during the surgical procedure. The white line represents the median number of complication events per group. The dotsrepresent the number of complications seen in individual specimens. (B) Box plot of instrument collisions before and after use of all 3DPCsin cadaver specimens874 BUOTE ET AL . 1532950x, 2023, 6, 4

Question 49

Holroyd - 2023 - VCOT - Risk Factors Associated with Plantar Necrosis following Tarsal Arthrodesis in Dogs.pdf

Answer 49

Data CollectionAnatomic StudyThe anatomy of the intermetatarsal channel of the dorsalpedal artery and perforating metatarsal artery was evaluatedin canine cadavers (ethical approval reference 2013/R358).Dogs were euthanatized for reasons unrelated to this study.The proximal and distal extent of the intermetatarsal chan-nel was measured (►Fig. 1 ) and expressed as a percentage ofthe total length of metatarsal III, to allow comparison be-tween dogs.Clinical StudyThe medical records and postoperative radiographs for dogsthat underwent tarsal arthrodesis between 2004 and 2013 atthe Royal Veterinary College Queen Mother Hospital forAnimals and East Neuk Veterinary Clinic were reviewedretrospectively. Patients were included if they had under-gone tarsal arthrodesis with plate fixation and had a mini-mum of 6 weeks of follow-up. Signalment, surgicalindication, concurrent injuries, surgical procedure, arthrod-esis type, surgical approach, complications and duration ofpostoperative coaptation were recorded. Calibrated postop-erative radiographs were evaluated for the length of meta-tarsal III and the distance of the central axis of the metatarsalscrews from the proximal articular surface of metatarsal III,using digital callipers. If the screw did not reach metatarsal III(MTIII), the distance from the base of MTIII to the screw tipwas measured from a line that originated halfway across thejoint line, and perpendicular to MTIII mechanical axis(►Fig. 2 ). Screw position was expressed as a percentage ofthe length of metatarsal III.Fig. 1 Dissection photographs of the tarsometatarsal region. Left photograp h: Plantar view showing the perfora ting metatarsal artery exitingthe intermetatarsal channel to become the deep pl antar arch, before trifurcating into the plantar metatarsal arteries. Right photograph: Dorsalview showing the dorsal pedal artery becoming the perforating metatar sal artery as it enters the distal end of the intermetatarsal channelbetween metatarsals II and III..Postoperative complications were classi fied according toCook and colleagues as catastrophic, major and minor.5Catastrophic complications were those resulting in perma-nent unacceptable function, death or euthanasia. Majorcomplications required surgical or medical intervention toresolve, and minor complications resolved without interven-tion.5Postoperative coaptation complications werereviewed separately. The term plantar necrosis was usedfor cases with a typical distribution of skin necrosis affectingthe plantar metatarsus and the deep tissues of the metatarsalpad, as previously de fined.2In contrast to the super ficiallesions over osseous prominences that often develop withcoaptation injuries, plantar necrosis lesions were character-ized by a deep to super ficial progression, initially presentingwith skin discoloration without skin abrasions. Soft-tissuecomplications in other areas were considered coaptationrelated. In cases undergoing staged bilateral procedures,only data from the first procedure were included.Surgical ProcedureThe surgical technique was consistent with previouslyreported procedures for pan- and partial-tarsal arthrodesis(PanTA and ParTA).1,2,6,7Briefly, an open medial or lateralapproach was used for PanTA and ParTA respectively.8Artic-ular cartilage was debrided using a high-speed burr. ForPanTA, this involved the tarsocrural joint and, dependingon the injury, the intertarsal joints, the tarsometatarsal jointsor a combination of both. For ParTA, this comprised debride-ment of the intertarsal joints, the tarsometatarsal joints or acombination of both, based on the surgical indication. Fol-lowing debridement, demineralized bone matrix or autoge-nous bone graft was packed into the joint spaces. Pre-measured and contoured bone plates were applied and fixedwith screws. The proximal metatarsal screws engaged mul-tiple cortices. All plates were placed medially for PanTA andlaterally for ParTA. A calcaneotibial screw was used at thediscretion of the surgeon in PanTA cases. Routine closure wasperformed; tension-relieving techniques were utilizedwhere necessary. Postoperative orthogonal radiographswere taken. The East Neuk Veterinary Clinic applied modi fiedRobert-Jones dressings in all cases; these were routinelychanged at 48 hours postoperatively and then removed5 days later. The Queen Mother Hospital for Animals usedeither a modi fied Robert-Jones dressing for approximately6 weeks or a Robert-Jones dressing for the first 48 hours,which was replaced by rigid coaptation once swelling sub-sided, with a bivalve or half cast for between 6 and 8 weeks.Data AnalysisThe following variables were assessed for their in fluence oncomplication rates: metatarsal screw position, plate posi-tion, arthrodesis type (PanTa or ParTA), requirement for skintension-relieving techniques, coaptation, hospital, age andweight. Complications were categorized as wound compli-cations, plantar necrosis, implant loosening/breakage orsurgical site infection. Cadaveric intermetatarsal channeldata were grouped according to size or breed for comparison.Normality was assessed on continuous variables using aShapiro –Wilk test, and data were evaluated using an inde-pendent two-tailed t-test when testing between two groups,or a one-way analysis of variance when testing betweenmultiple groups. Categorical variables were analysed with aFisher ’s exact test. All proportions are expressed with 95%confidence intervals, and normally distributed data wereexpressed as mean /C6standard deviation. Statistical analysiswas performed using software (SPSS IBM Statistics version21), with signi ficance set at p-value less than 0.05.ResultsAnatomic StudyNineteen cadaveric specimens were examined, including 11Beagles, five Greyhounds, one Bulldog, one crossbreed andone unknown giant breed. Beagles, greyhounds and the giantbreed were grouped by breed, and the similarly sized Bulldogand crossbreed were grouped together.The most proximal and distal points of the intermetatar-sal channel varied between at least two breeds ( p<0.01),with the length of the intermetatarsal channel increasing inlarger breed dogs, ranging from 8.5mm /C60.7 in small breedsand up to 18.0 mm in the giant-breed dog. However, theFig. 2 Illustration showing metatarsal screw measurements on adorsoplantar tarsal radiograph. Dashed white line indicates theproximal and distal articular surface of metatarsal III (MTIII) and thelength of MTIII. The red line originates halfway across the proximalarticular surface of MTIII and is perp endicular to MTIII mechanical axis.Screw measurements were taken from the red line to the central axisof the screw (black/yellow arrows)..intermetatarsal channel length expressed as a percentage ofmetatarsal III did not vary between breeds, with a mean of18.6%/C62.8 ( p>0.05). The mean proximal and distal extentof the intermetatarsal channel was between 4.3% /C61.9(range: 1.8 –9.3) and 22.8% /C62.9 (range: 18.0 –32.4) thelength of metatarsal III respectively; however, this variedbetween breeds ( p<0.01;►Table 1 ). The intermetatarsalchannel lies within the most proximal 25% of MTIII in 95% ofcases ( n¼18; 95% con fidence interval [CI] ¼91–96).Clinical StudyThirty-nine dogs met the inclusion criteria for the clinicalstudy; 15 dogs underwent a PanTA, and 24 dogs underwent aParTA. Breeds included Labradors ( n¼7), Border Collies(n¼7), crossbreeds ( n¼4), Rough Collies ( n¼3), ShetlandSheepdogs ( n¼3), Springer Spaniels ( n¼2), Greyhounds(n¼2), Golden Retrievers ( n¼2) and nine dogs from breedsrepresented by only one dog. The median age at presentationwas 6.2 years (range: 1.0 –11.8) and the median weight was23.5kg (range: 4.5 –37.2); 22 were female and 17 were male.Cases are summarized in ►Appendix 1 (available in onlineversion only).Indications for ArthrodesisIndications for arthrodesis included luxation or subluxationof one or more of the tarsal joints ( n¼26), degenerativeAchilles tendinopathy ( n¼5), tarsal osteochondritis disse-cans ( n¼3), unspeci fied osteoarthritis ( n¼2), Achilles lac-eration ( n¼2) and tarsal fractures ( n¼1). Eleven dogs hadconcurrent fractures of the affected hock involving the tarsalbones, metatarsals, or distal tibia. Two cases had bilateralproximal intertarsal luxation and staged procedures, onlythefirst procedure was included in the study.ImplantsCommercially available implants were used from a singlemanufacturer (Veterinary Instrumentation, Shef field, Unit-ed Kingdom). A hybrid PanTA plate was used most for PanTA(n¼13), followed by a customized hybrid medial PanTAplate ( n¼2). A hybrid plate was mostly used for ParTA(n¼20), followed by a dynamic compression plate ( n¼3)and a locking compression plate ( n¼1). Plates were placedmedially for PanTA and laterally for ParTA. Adjunctivefixation with a calcaneotibial screw was used in two PanTAcases.Postoperative ComplicationsThere was no difference in complication rate or Cook Schemeclassi fication between PanTA and ParTA ( p>0.05).►Table 2details the complication types and rates unrelated to coap-tation. The overall complication rate was 36% ( n¼14; 95%CI¼21–53). Minor complications occurred in 8% of cases(n¼3; 95% CI ¼2–21), with two cases of metatarsal screwsloosening without the need for further surgery and oneminor wound complication. Major complications occurredin 26% ( n¼10; 95% CI ¼13–42) of cases, with the mostcommon major complication being surgical site infection(n¼6) followed by plantar necrosis ( n¼3). There was oneTable 1 Breed differences in intermetatarsal channel position (expressed as a percentage of the length of metatarsal III)BreedCrossbreed/BulldogBeagle Greyhound Giant breed Mean p-ValueIntermetatarsal channelposition (as % lengthof MTIII)Proximalextent8.7/C60.8 3.4 /C60.8 4.3 /C61.6 5.0 4.3 /C61.9 0.000Distal extent 28.3 /C65.9 22.8 /C61.3 20.6 /C61.9 23.0 22.8 /C62.9 0.006Intermetatarsal channellength (as % length of MTIII)19.6/C66.7 19.4 /C61.5 16.4 /C63.1 18.0 18.6 /C62.8 0.220Intermetatarsal channellength (mm)8.5/C60.7 10.8 /C60.8 12.4 /C61.7 18.0 11.4 /C62.2 0.000Abbreviation: MTIII, metatarsal III.Table 2 A summary of complication types and frequencies, excluding those related to external coaptationComplication Catastrophic Major Minor TotalImplant loosening orscrew breakage01 23Plantar necrosis 0 3 0 3Surgical site infection 1 5 0 6Wound complications 0 1 1 2Total 1 10 3 14Percentage total ofall cases ( n¼39)3% (95% CI ¼0–13) 26% (95% CI ¼13–42) 8% (95% CI ¼2–21) 36% (95% CI ¼21–53)Abbreviation: CI, con fidence interval..catastrophic complication in a dog who had undergone aParTA and suffered a recurrence of tarsal instability follow-ing plate removal for infection 1 year postoperatively; theowner opted for amputation rather than revision surgery.There was no difference in the age and weight of dogs thatexperienced complications, or whether tension-relievingtechniques were used ( p>0.05). External coaptation wasused in all 39 dogs, of which seven had a bivalve cast or halfcast placed and 32 had a modi fied Robert-Jones dressing.Coaptation type or duration had no impact on post-surgicalcomplication rates. However, the coaptation injury rate was21% ( n¼8; 95% CI ¼9–36).Screw PositionAppropriate radiographs were available for review in allcases, and 156 screw positions were measured. The meanscrew position, when grouped as PanTA and ParTA, was notdifferent between cases with or without complications. Thisalso applied to major/catastrophic complications comparedwith minor or no complications ( p>0.05).►Fig. 3 demonstrates the proximodistal screw position.Our data identi fied 34% ( n¼53; 95% CI ¼27–42) of all screwsrisked damaging the mean intermetatarsal channel, and 96%(n¼51; 95% CI ¼87–100) of these screws were metatarsalscrews 1 and 2. Metatarsal screw 1 was placed at the level ofthe mean intermetatarsal channel in 92% of cases ( n¼36;95% CI ¼79–98), and metatarsal screw 2 was placed at thelevel of the mean intermetatarsal channel in 38% of cases(n¼15; 95% CI ¼23–55). Metatarsal screw 3 was placed atthe level of the mean intermetatarsal channel in 5% of cases(n¼2; 95% CI ¼1–17), and screws 4 and 5 did not impinge onthe intermetatarsal channel in any cases. It was found thatFig. 3 Box and whisker plot showing proximodistal screw position data superimposed on an illustration of the canine pes. Image is to scale.Yellow stripes ¼mean intermetatarsal channel position. Red tube ¼dorsal pedal artery..36/39 dogs (92% [95% CI ¼79–98]) had at least one screwplaced at the level of the mean intermetatarsal channel.Due to the difference in plate types used for ParTA andPanTA, screws were positioned more proximally for ParTAthan they were for PanTA ( p<0.01), with the mean screwposition being within the mean intermetatarsal channel loca-tion for the most proximal two ParTA screws. PanTA screwswere more distal, with only the mean position of screw 1 beingwithin the intermetatarsal channel. The mean positions ofscrews 1 to 5, when grouped as ParTA and PanTA, are summa-rized in►Appendix 2 (available in online version only).Plantar NecrosisThe overall incidence of plantar necrosis was 8% ( n¼3; 95%CI¼2–21). Plantar necrosis occurred in 13% of lateral ParTAcases ( n¼3; 95% CI ¼3–32) and no medial PanTA cases. Allcases of plantar necrosis had screw 1 positioned at the level ofthe mean intermetatarsal channel. Additionally, one case hadthe second screw placed at the level of the mean intermeta-tarsal channel, and another case had the second and third.However, the mean screw position did not differ betweenParTA cases without plantar necrosis and those with plantarnecrosis ( p>0.05) (see►Fig. 4 ). Of the 36 cases with a screwpositioned at the level of the intermetatarsal channel, 8%(n¼3; 95% CI ¼2–22) went on to develop plantar necrosis.Two cases of plantar necrosis had a modi fied Robert-Jonesdressing applied for 7 days, and the third case had a modi fiedRobert-Jones dressing applied for 6 weeks. None of the caseshad a calcaneotibial screw placed. All three cases had trau-matic tarsometatarsal joint subluxation as the indication forarthrodesis. Of 11 cases with tarsometatarsaljoint subluxationor luxation, three went on to develop plantar necrosis (27%[95% CI ¼6–61]). Tension-relieving incisions were needed in7/39 cases (18% [95% CI ¼8–34]); of these 7 cases, 43% devel-oped plantar necrosis ( n¼3; 95% CI ¼10–82).

Question 50

Thibault - 2023 - JSAP - Osteochondritis dissecans of the vertebral endplate of C5 with concomitant C4-C5 disc protrusion in a French Bulldog.pdf

Answer 50

tish Small Animal Veterinary Association. 801 CASE REPORTOsteochondritis dissecans of the vertebral endplate of C5 with concomitant C4- C5 disc protrusion in a French BulldogA. T hibault *,1, M. Hamon *, R. Jossier *, B. Wyrzykowski† and P . Haudiquet **VETREF- ANICURA Clinique vétérinaire de référés, 7 Rue James Watt, Angers- Beaucouzé, 49070, France†LAPV Amboise, laboratoire d’anatomie pathologique vétérinaire, 6 Impasse de Vilvent, Nazelles- Négron, 37530, France1Corresponding author email: a.thibault17@gmail.comA 4- year- old French bulldog was presented with neck pain and left forelimb lameness. CT scan revealed a bony defect in the craniodorsal rim of the endplate of C5 with a concomitant disc protrusion leading to ventral spinal cord compression. Ventral slot at C4- C5 was performed to remove the protruding ma -terial and the fragment. Based on CT and histological findings, this bone defect was consistent with osteochondritis dissecans. Neck pain was absent immediately after the operation and the dog recov -ered without complication. Only a slight proprioceptive deficit of the left forelimb persisted during the 6- month of follow- up. Based on our search of the veterinary literature, this is the first published report of an osteochondritis dissecans of cervical endplate treated surgically.Accepted: 29 June 2023; Published online: 20 July 2023INTRODUCTIONOsteochondrosis results from abnormal endochondral ossi -fication. Four sites are primarily reported in dogs (humeral head, humeral condyle, femoral condyle and trochlea of the talus) (Breur & Lambrechts 2017 ). Numerous other sites are described but remain rare, including localization to the lum -bosacral junction or the articular process of the caudal cervi -cal vertebrae in breeds predisposed to Wobbler syndrome (Hanna 2001 , Lahunta & Glass 2009 ). Surgical treatment of a case of osteochondritis dissecans (OCD) of the C5 vertebral cranial endplate with concomitant disc protrusion in a French bulldog is reported here.CASE HISTORYA 4- year- old French bulldog was presented with a 3- day history of left forelimb lameness.Clinical examination revealed low head carriage, neck pain during manipulation, particularly in ventroflexion and moder -ate lameness of the left thoracic limb without abnormalities on orthopaedic examination.The neurological examination revealed a proprioceptive defi -cit of the left thoracic limb, with normal spinal reflexes. Exami -nation of the cranial nerves and other limbs was normal.Lateralized C1- C5 neurolocalization was suspected and CT myelography of the cervical and cervicothoracic spine was per -formed.At the C4- C5 space, there was a narrowing intervertebral space, a marked irregularity of the dorsal edge of the cranial pla -teau of C5, which was truncated in outline, with the presence of an adjacent 4.7- mm long mineralised element, the shape of which corresponds to the bony lacuna of the plateau of C5, but was not continuous with it. This bone fragment was displaced dorsally towards the spinal canal. This material was continu -ous with a dorsal deformity of the C4- C5 disc within the spinal canal, leading to the conclusion of a disc protrusion. Together, the mineralised material and the disc protrusion induced a mod -erate local deformation of the ventral portion of the spinal cord, confirmed on the myelographic sequence by the demonstration of ventral extradural compression ( Figs 1 and 2). Similar lesions, of much lesser intensity, were noted at the C2- C3 junction and on the caudal plate of C2 (reduction of the disc space, irregularity of the caudal edge of the plate of C2, minimal dorsal deforma -tion of the C2- C3 disc). These lesions do not induce any sig -A. Thibault et al.Journal of Small Animal Practice • Vol 64 • December 2023 • © 2023 British Small Animal Veterinary Association. 802nificant deformation of the cord on the myelographic sequence. Calcification of the T1- T2 intervertebral disc was also observed.It was decided to treat the spinal cord compression surgi -cally, by performing a standard ventral slot at C4- C5 (Sharp & Wheeler 2005 ).With the help of a dental tartar scraper, the dorsal part of the fibrous ring and the dorsal longitudinal ligament were broken allowing access to the spinal canal. Palpation of the caudal part of the ventral slot revealed a fragment of bony consistency adherent to the vertebral body of C5. Strong fibrous adhesions between the protruding disc, the bony fragment, and the C5 vertebral body prevented simple removal of the fragment ( Fig 3). There -fore, adhesion removal had to be carried out using a high- speed burr. After the fragment was progressively raised, it appeared yel -lowish and partially friable ( Fig 4). The fragment was removed (Fig 5) and sent for histological analysis. The rest of the protrud -ing disc material was then removed, allowing good visualisation of the spinal cord.On postoperative CT, extradural spinal cord compression was resolved and the major part of the bony fragment was resected (Figs 6 and 7).FIG 1. Sagittal section of the cervical spine. A free bony fragment is visualised on the craniodorsal endplate of C5 (green arrowhead), with a mild dorsal displacement. The bone fragment and the disc protrusion induced a moderate local deformation of the ventral portion of the spinal cord (red arrowheads). Cr Cranial, Cd Caudal, Ds Dorsal, Vt VentralFIG 2. Transverse section at the level of the cranial endplate of C5. The bone fragment is visualised in the medial plane, ventral to the spinal cord (green arrowhead) inducing a moderate deformation of the ventral, slightly lateralized on left, portion of the spinal cord. Ds Dorsal, L Left, R Right, Vt VentralFIG 3. Surgical view after completing a ventral slot at C4- C5. The bony fragment appears yellowish caudally (green arrowhead) and the protruding disc cranially (black arrowhead)FIG 4. Surgical view after completing a ventral slot at C4- C5. The bony fragment is well- visualised caudally and appears yellowish (green arrowhead). Cr Cranial, Cd Caudal, L Left, R RightFIG 5. Surgical view, removal of the bony fragment with a dental tartar scraper (green arrowhead). Cr Cranial, Ds Dorsal, L Left, R Right 17485827, 2023, 12, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13653 by Vetagro Sup Aef, Wiley Online Library on [24/12/2023]. 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 LicenseOsteochondritis dissecans of vertebral endplateJournal of Small Animal Practice • Vol 64 • December 2023 • © 2023 British Small Animal Veterinary Association. 803 Post- operative pain management with methadone (Comfor -tan; DECHRA FRANCE) constant rate infusion (0.1 mg/kg/hour) for the first 12 hours followed by subcutaneous injection of methadone (0.1 mg/kg) every 4 hours for the next 24 hours was performed. The dog was pain- free 36 hours after the pro -cedure. A subcutaneous injection of dexamethasone (Dexadre -son; MSD Santé animale) was also administered the day after the operation. The dog was discharged from the hospital 2 days after surgery. Prednisolone (Prednicortone; DECHRA FRANCE) was prescribed for 10 days (0.25 mg/kg orally twice a day) and gaba -pentin (Neurontin; VIATRIS SANTE FRANCE) for 1 month (10 mg/kg orally twice a day).Histologically, there were degenerative changes within the car -tilage characterised by variable combination of decreased baso -philia of the matrix, fibrillation, partial loss with disorientation of the chondrocytes and presence of clusters (regeneration) of hypertrophied chondrocytes ( Figs 8 and 9). Histology was con -sistent with osteochondral remodelling and was in favour of a degenerative cartilaginous process.Clinical follow- ups at 1, 2 and 6 months after surgery showed complete resolution of the neck pain and a marked improvement in the lameness of the left forelimb with persistence of a slight proprioceptive deficit.

Question 51

Gaudio - 2023 - JSAP - Short-term outcome and complications following cutaneous reconstruction using cranial superficial epigastric axial pattern flaps in dogs - Six cases (2008-2022).pdf

Answer 51

Study designThe present study was conducted in the form of a retrospective multi- centric case series by members of the Association for Veter -inary Soft Tissue Surgery (AVSTS) Research Cooperative (ARC) on dogs that were treated with a CrSE APF for the reconstruction of cutaneous defects between January 1, 2008, and December 31, 2022. This study was approved by the AVSTS ARC.Medical records searchThe medical record management system of each hospital was searched using the keyword “cranial superficial epigastric” for records of patients belonging to the canine species. Where this search function was not available, the investigator’s case log was searched instead. The search took place between June 1, 2022, and January 31, 2023. Four investigators independently con -ducted the same search for this study.Data extractionInformation obtained from the medical records included sig -nalment, location of the defect, cause of the defect, size of the defect, histological diagnosis, anatomical landmarks, length of anaesthesia and surgery, presence of hypothermia and hypo -tension during surgery, oncological outcome, drain placement, presence and type of complications, follow- up time, and out -come. Outcome was scored as previously described by Field et al. (2015 ), with the following categories: excellent (no com -plications); good (complications encountered but no second surgery required); fair (complications encountered and second surgery required); and poor (complications encountered and either multiple surgeries required and/or up to 50% necrosis of the APF).Inclusion and exclusion criteriaTo be included in the study dogs had to have undergone treat -ment where the CrSE APF was used either alone or in combi -nation with other surgical techniques for the reconstruction of cutaneous defects. The available information on flap appearance had to be sufficient to allow for reliable case follow up. Cases where essential data ( e.g. signalment, indication for surgery, outcome) were missing were excluded from the study. Patients were also excluded if a minimum of 2 weeks follow up was not available.Data reporting and statisticsUsing the above- mentioned criteria, a spreadsheet (Microsoft Excel 365, Microsoft Corporation, Redmond, WA) was created that included one row for each individual patient and one col -umn for each variable evaluated. Due to the small number of cases retrieved, only descriptive statistics were performed (Micro - 17485827, 2023, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13657 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 LicenseE. Gaudio et al.Journal of Small Animal Practice • Vol 64 • November 2023 • © 2023 British Small Animal Veterinary Association. 706soft Excel 365). Reported values are displayed as median (range) or percentages.RESULTSA total of six cases were identified with the database search. These were assessed for eligibility and inclusion criteria were met in all cases. Data were available for all patients unless otherwise stated.PatientsSix client- owned dogs were included in the study (see Table 1), with a median age of 60 months (12 to 180 months) and a median weight of 13.9 kg (7 to 21 kg). Breeds included Staffordshire bull terrier (n=1), shih- tzu (n=1), miniature schnauzer (n=1), soft- coated wheaten terrier (n=1) and cross- breed (n=2). T wo dogs were neutered males and four were neutered females.Indication for reconstructive surgery and locationAll the surgeries were performed by Diplomates of the European College of Veterinary Surgeons (ECVS). The flap was used for reconstruction of a skin defect caused by removal of a neoplas -tic mass in four (67%) dogs out of six. Histological diagnosis was available for all four dogs and included grade II soft tissue sarcoma (n=2; see Fig 1), haemangiosarcoma (n=1), and hae -mangiopericytoma (n=1). No patient with tumours received radiotherapy or pre- operative chemotherapy. Other reasons for wound closure were management of skin necrosis due to vehicu -lar trauma (n=1; 17%), and dog bite (n=1; 17%).All dogs had the defect located on the ventral aspect of the thorax, including the hypochondriac region and the sternum. The size of the defect was available in all dogs, with a median length and width of 10.5 cm (8 to 30 cm) and 9.5 cm (8 to 40 cm), respectively, and a median area of 77.8 cm2. In dog 5, the large defect (30×40 cm) was covered by other reconstruction techniques as well as a CrSE APF .Perioperative considerations and surgeryFive dogs received pre- operative antibiotics, which included amoxicillin- clavulanic acid (n=3), cefuroxime (n=1), or cefazo -lin (n=1). One dog did not receive any perioperative antibiot -ics. Only three dogs received post- operative antibiotics, namely amoxicillin- clavulanic acid (2/3 dogs) and enrofloxacin (1/3 dogs) alone, or in combination (1/3 dog). The median duration of amoxicillin- clavulanic acid post- operative treatment was 5 days (5 to 7 days), while enrofloxacin was given for 10 days. Bacterial culture and sensitivity were not performed before surgery in any of the dogs that received post- operative antibiotics.Epidural morphine alone, or in combination with lidocaine or bupivacaine was used in three dogs (50%). Regional anaesthesia with bupivacaine was used in one dog, whilst local anaesthesia was not used in one dog and data was not available from the other dog.Data on surgical and anaesthetic time was available for five dogs, with a median surgical time of 117 minutes (100 to 152 minutes) and a median anaesthetic time of 225 minutes (170 to 387 minutes). Data on hypotension and hypothermia were available in five dogs out of six. Hypotension (defined as mean arterial blood pressure <60 mmHg) was recorded in two patients for a median duration of 128 minutes (45 to 210 minutes). Of the two, only one dog developed postoperative complications (i.e. necrosis). Hypothermia (body temperature <36°C) was recorded in three dogs, with a median duration of 100 minutes (20 to 210 minutes).Five of the six dogs had specific anatomic land- mark data available. In all five, the base of the flap coincided with the third mammary gland, extending down to the fourth mammary gland.Five dogs had at least one active suction drain placed during surgery which stayed in place for a median time of 3 days (2 to 5 days). Information on the number of drains placed and location of the drain was available in three dogs out of five. One dog had a single drain located on the recipient site, whereas another dog had two drains placed both on the recipient and donor site. In one dog (dog 5; see Table 1), the CrSE APF was used together with other reconstruction techniques and had two drains placed at surgery (at the level of the CrSE APF recipient site and further cranially). In only one dog, a drain was not placed.ComplicationsComplications occurred in three dogs out of six. A seroma was documented in one dog 48 hours post- surgery as the dog had pulled out the drain. This was immediately replaced and stayed in situ for 5 days. At the same time, a light bandage to prevent further development of seroma was placed and was kept on until full healing was achieved (23 days). T wo dogs developed bruising of the flap, which was subjectively scored as Table 1. Clinical features of six dogs undergoing surgical reconstruction of cutaneous defects by means of the cranial superficial epigastric axial pattern flap. Short- term outcomes have been classified according to Field et al. (2015 )Patient numberBreed Defect region Reason for surgery Defect size (cm)Complication Short- term outcome †1 Staffordshire bull terrier Sternum Soft tissue aarcoma 9×9 None Excellent2 Cross breed Ventral thorax Haemangiosarcoma 12×8 Seroma Good3 Shih- tzu Ventral thorax Soft tissue sarcoma 10×8 Bruising, distal necrosis Fair4 Miniature schnauzer Ventral thorax Haemangiopericytoma 11×14 Distal necrosis Good5 Soft- coated wheaten terrier ‡Ventral thorax Skin necrosis due to trauma 30×40 None Excellent6 Cross breed Left hypochondrium Dog bite wound 8×10 None Excellent†Excellent: no complications; Good: complications encountered but no second surgery required; Fair: complications encountered and a second surgery required‡In dog 5, the cranial superficial epigastric axial pattern flap was used together with other reconstruction technique to close the large defect 17485827, 2023, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13657 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 LicenseCranial superficial epigastric axial pattern flapJournal of Small Animal Practice • Vol 64 • November 2023 • © 2023 British Small Animal Veterinary Association. 707 severe in one case and mild in the other ( Fig 2). In the former case, bruising progressed to the development of a small area of necrosis. In total, two dogs developed necrosis of the flap which was deemed as mild necrosis (<50% of flap; 0.50 and 1.5cm2, respectively) of the tip of the flap ( Fig 2). Of these, one dog had debridement of the necrotic area and subsequent primary closure, while the other dog was managed conserva -tively with local wound care. The latter developed hypoten -sion intraoperatively, whereas the former did not. Infection or dehiscence without necrosis of the flap was not reported in any of the dogs.OutcomeThe CrSE APF was successful in all dogs, achieving complete healing with a median of 23 days (12 to 34 days). In 5 dogs the flap healed without the need for further surgical intervention, with only one requiring open wound management. One flap required revision surgery using an advancement flap, after a short period of open wound management, due to the development of distal necrosis. In this case, clear margins had been achieved at the initial surgery. Following (Field et al. 2015 ) subjective out -come scoring system, 50% of the cases had an excellent outcome, 33% were scored as good, and 17% fair.Clear margins were achieved in two cases out of four, where a tumour was removed. Incomplete margins of excision were sus -pected in one case, and this information was not available in one case. Even though the aim of this study was to evaluate short- term outcomes and complications following CrSE APF surgery, long- term outcome was evaluated in those four patients where the reason for reconstruction was neoplasia. Data on long- term outcome were available for three dogs out of four, with a median time to recheck post- surgery of 6 weeks (3 to 12 weeks). No recur -rence was reported at last re- examination in any of these dogs.

Question 52

Warshaw - 2023 - JAVMA - Piezosurgical bone-cutting technology reduces risk of maxillectomy and mandibulectomy complications in dogs.pdf

Answer 52

Medical records of dogs that underwent man -dibulectomy or maxillectomy for the treatment of oral neoplasia at the Companion Animal Hospital at Cornell University between 2012 and 2022 were evaluated. Dogs were included if osteotomies were performed using a piezoelectric unit and complete medical records up to and through the perioperative period were available. The type of surgical procedure Figure 1 —Photographs illustrating the surgical setup of a piezosurgical unit with attached irrigation, handpiece, and cutting tips (A), closeups of the digital screen (B), handpiece with a BS1 cutting tip (C), and bone-cutting kit (D). Figure 1 was designed with the assistance of Carol Jennings, Multimedia Producer, from the College of Veterinary Medicine at Cornell University.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 08/30/23 11:59 AM UTC 3was categorized based on location of osteotomies as previously described in the literature.5,30,31 Total mandibulectomies were excluded because they do not involve an osteotomy, while extended subtotal mandibulectomy cases were excluded because the mandibular artery is ligated prior to the osteotomy.32Records were considered complete if they in -cluded preanesthetic bloodwork (CBC and serum biochemistry profile or point-of-care bloodwork for patients < 7 years of age with benign tumors con -firmed via histopathology), CT imaging of the head, histopathologic diagnosis, surgical report, anesthet -ic records, and immediate postoperative hospital monitoring/treatment records. Point-of-care blood -work included PCV, serum total protein, BUN, and blood glucose. Advanced imaging of the head was utilized to evaluate the extent of tumor invasion, de -termine whether the tumor was resectable, and de -sign the individual surgical protocol. Additional data obtained included breed, age, sex, body weight, pa -tient size, surgical time if available, and location and extent of surgery.Surgeries were performed following standard techniques5,30,31 by either an American Veterinary Dental College board-certified specialist or a closely supervised specialist in training. Anesthesia was per -formed under direct supervision of a board-certified veterinary anesthesiologist. Ethics committee ap -proval was not required for enrollment given the ret -rospective nature of the study.All records included were assessed for the pri -mary complication of interest (ie, severe intraopera -tive hemorrhage). Severe hemorrhage was differen -tiated from routine surgical bleeding by subjective documentation of nonroutine bleeding in the medi -cal record and objective signs of acute hypovolemic anemia including tachycardia, hypotension, para -doxical bradycardia, and the need for administration of blood products.Records were evaluated for intraoperative admin -istration of blood products due to severe hemorrhage, and the need for administration of blood products was compared based on whether the patient under -went maxillectomy or mandibulectomy, the location of surgery, tumor type, and size of the patient.Statistical analysisContinuous variables were assessed for normal -ity via the Shapiro-Wilk test; approximately normally distributed variables were reported as mean ± SD, while nonnormal variables were reported via median, range, and IQR. The Wilcoxon rank sum test was used to compare group medians for nonnormal variables, while Spearman rank correlation was used to exam -ine the relationship between nonnormal continuous variables. Simple logistic regression was used to de -termine the association between continuous variables and the presence or absence of complications, while relative risks (RRs) and associated 95% CIs, along with the χ2 test or Fisher’s exact test, were used to assess the relationships between categorical variables. Mul -tivariable linear regression and multivariable logistic regression were performed using stepwise backward selection with a retention threshold of P < .2, with fi -nal models checked for 2-way statistical interaction. Significance was defined as P < .05. Normality of re -siduals in linear regression was visually assessed via inspection of normal QQ plots. The linearity of the relationship between continuous predictors and the logit of the response variable in logistic regression was checked via the Box-Tidwell test. All statistical testing was performed using commercial statistical software (SAS version 9.4; SAS Institute Inc).ResultsNinety-eight cases met the inclusion criteria, representing 41 maxillectomies (41.84%) and 57 mandibulectomies (58.16%). Patient body weight ranged from 2.6 to 70.5 kg (median, 28.05; IQR, 16.80). Patient age ranged from 6 months to 15 years (mean, 7.79 ± 3.15 years). Fifty-five (56.12%) patients were male (49 castrated, 6 intact), and 43 (43.87%) patients were female (40 spayed, 3 intact). A total of 33 breeds were identified; the most com -mon were mixed-breed dogs (29 dogs [29.59%]), followed by Labrador Retrievers (14 dogs [12.28%]) and Golden Retrievers (7 dogs [7.14%]).Thirteen tumor types were represented, includ -ing canine acanthomatous ameloblastoma (31 dogs [31.63%]), oral squamous cell carcinoma (19 dogs [19.39%]), peripheral odontogenic fibroma (12 dogs [12.24%]), plasmacytoma (8 dogs [8.16%]), osteosar -coma (8 dogs [8.16%]), multilobular tumor of bone or osteochondrosarcoma (5 dogs [5.10%]), oral ma -lignant melanoma (4 dogs [4.08%]), and fibrosarco -ma (3 dogs [3.06%]). The remaining 8.19% consisted of 4 undifferentiated sarcomas, 1 amyloid-producing odontogenic tumor, 1 peripheral nerve sheath tumor, and 1 undifferentiated carcinoma.Of the patients that underwent maxillectomy procedures, 16 (39.02%) were unilateral rostral, 9 (21.95%) were bilateral rostral, 3 (7.31%) were cen -tral, and 13 (31.70%) were caudal. Of the patients that underwent mandibulectomy procedures, 11 (19.29%) were unilateral rostral, 28 (49.12%) were bilateral rostral, 6 (10.52%) were rim (marginal) exci -sions, and 12 (21.05%) were subtotal.Recorded surgical times for all 98 reported sur -geries ranged from 0.58 to 6.58 hours (median, 2.46 hours; IQR, 1.58 hours). Surgical times for maxillec -tomies ranged from 0.83 to 6.58 hours (median, 2.73 hours; IQR, 1.75 hours), and surgical times for man -dibulectomies ranged from 0.58 to 5.58 hours (medi -an, 2.41; IQR, 1.50 hours; Table 1 ). In univariable anal -yses, surgical time did not differ significantly between mandibulectomies and maxillectomies (Wilcoxon rank sum P = .6019), nor was it significantly associated with dog weight (Spearman rank correlation, 0.116; P = .2703). The surgery time for caudal procedures, including caudal maxillectomy and subtotal mandib -ulectomy (range, 2.00 to 6.58 hours; median, 3.41; IQR, 1.70), was significantly longer than that of more rostral procedures (range, 0.58 to 5.70 hours; me -dian, 2.20; IQR, 1.21; Wilcoxon rank sum P < .0001). Multivariable linear regression predicting the natural Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 08/30/23 11:59 AM UTC4 logarithm of surgical time by age, body weight, sex, neuter status, caudal vs rostral location, and mandib -ulectomy vs maxillectomy found that caudal location (P < .0001) was retained in the model and was associ -ated with a 64.33% increase in the length of surgery.When evaluating for the complication of interest, 1 of 98 (1.02%) cases received blood products due to re -ported excessive surgical bleeding with corresponding paradoxical bradycardia, premature ventricular beats, and acute drop in RBC level. Presurgical PCV was 55%, intraoperative PCV was 24%, and postoperative PCV (following a single unit of packed RBCs) was 36%. This patient was a large-breed (37.9-kg) 10-year-old spayed female Staffordshire Bull Terrier with a 5-cm-long osteochondrosarcoma that was treated with a caudal maxillectomy; surgical time was 3.58 hours.Other complications were recorded when avail -able and separated into categories for < 24 hours after surgery and 2 weeks after surgery. Within 24 hours of surgery, 33 cases (34.02%) were documented to have facial/hemifacial swelling, of which 19 (57.57%) were classified as mild, 12 (36.36%) as moderate, and 2 (6.06%) as severe. Other documented 24-hour com -plications included lip entrapment in 2 dogs (2.06%), epistaxis in 10 dogs (10.30%), inappetence in 15 dogs (15.46%), drooling in 2 dogs (2.06%), and an intraop -erative iatrogenic fracture of a marginally resected mandibular tumor that required immediate fracture repair in 1 dog (1.02%). Fifty cases (51.54%) had no reported complications at the 2-week recheck, and 19 cases (19.58%) were lost to follow-up. Eight (20%) of the maxillectomy procedures developed lip entrap -ment that required no further intervention, 2 (4.87%) had intermittent sneezing episodes, and 1 (2.43%) had mild drooling. Three (5.26%) of the mandibulectomy procedures developed lip entrapment that required no further intervention; 7 (12.28%) had mandibular drift, of which 2 (28.57%) required additional proce -dures; and 8 (14.03%) had areas of dehiscence that were managed medically. Of the 7 dogs with mandib -ular drift, 6 underwent subtotal mandibulectomies.In univariable analyses, dogs undergoing max -illectomy were more likely to experience complica -tions within 24 hours compared with mandibulec -tomy (RR, 1.86 [95% CI, 1.25 to 2.76]), but were not significantly more likely to have complications at the 2-week recheck (RR, 0.84 [95% CI, 0.46 to 1.55]); conversely, caudal location was not significantly as -sociated with complications within 24 hours (rostral vs caudal: RR, 0.77 [95% CI, 0.52 to 1.15]), but was associated with complications at the 2-week recheck (RR, 0.52 [95% CI, 0.23 to 0.90]). Location, sex, neuter status, age, and body weight were not significantly associated with either 24-hour or 2-week complica -tions. In multivariable logistic regression predicting the odds of complications within 24 hours by age, body weight, sex, neuter status, caudal versus rostral location, and mandibulectomy versus maxillectomy, the only significant predictor was mandibulectomy (OR, 0.23 vs maxillectomy [95% CI, 0.09 to 0.58]; P = .0020), with body weight also retained (OR, 1.03 [95% CI, 0.99 to 1.07]; P = .1053). For complications at the 2-week recheck, caudal location (OR, 3.32 vs rostral [95% CI, 1.07 to 10.30]; P = .0382) was the sole remaining significant predictor, with age (OR, 0.89 [95% CI, 0.76 to 1.05]; P = .1574) also retained in the model.

Question 53

Laureano - 2023 - JFMS - Feline minor salivary gland adenocarcinoma - retrospective case series and literature review.pdf

Answer 53

Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).IntroductionSalivary gland tumors in dogs and cats are uncommon and comprise < 0.2% of tumors affecting these species.1 Primary neoplasms of the salivary gland often arise from the glandular or ductular epithelium resulting in benign adenomas or carcinomas.2 There are only a few studies documenting the prevalence of primary salivary gland neoplasia of minor disseminated salivary glands in the oral cavity.3,4 There is also one report in the literature of metastatic adenocarcinoma of a minor salivary gland in a cat.5 In a study of 245 cases of salivary gland dis-ease, cats were shown to have a higher prevalence (1.6 times greater) of salivary gland tumors than dogs.4 In the study, 33 cats were diagnosed with salivary gland neoplasia. Of the cats, 31 (93.9%) had major salivary gland adenocarcinoma/carcinoma and 2 (6%) had acces-sory/minor salivary gland adenocarcinoma.4 In a more Feline minor salivary gland adenocarcinoma: retrospective case series and literature reviewMonica Morgado Laureano1, Mary Krakowski Volker2, Jennifer Tjepkema2 and Melissa D Sánchez3AbstractCase series summary Salivary gland adenocarcinoma, of major or minor salivary gland origin, is an uncommon tumor in cats. This article describes the clinical features, morbidity and survival rates of four cats with salivary gland adenocarcinoma arising from minor salivary gland tissue. Medical records from a private multicenter dentistry and oral surgery practice were reviewed for the period between 2007 and 2021. Four cats were included in this retrospective case series study, with oral masses on either the right or left caudal mandibular labial buccal mucosa. The inclusion criteria included a diagnosis of salivary gland adenocarcinoma in an anatomical location with lack of involvement of a major salivary gland, complete medical history and a follow-up of at least 6 months. The age range of the cats was 9–15 years; three of the cats were castrated males and one was a spayed female. Curative intent surgery was performed in three cats, whereas palliative surgery (debulking) owing to extensive soft tissue invasion was performed in one cat. Survival times were in the range of 210–1730 (mean 787) days. All four cats were euthanized owing to local recurrence and decreased quality of life, regardless of treatment modality.Relevance and novel information There are limited documented studies reporting the prevalence of salivary gland neoplasia affecting minor disseminated glands in the oral cavity of feline patients. Salivary gland adenocarcinoma should be a differential in cats presenting with caudal labial masses. Surgical resection has been the recommended treatment for salivary gland neoplasia of major salivary gland origin. According to this current case series, we propose that early aggressive surgical treatment with wide surgical margins should be performed for cats with salivary gland adenocarcinoma of minor salivary gland origin. Surgery increased the quality and duration of life; however, each patient was euthanized owing to local recurrence and morbidity.Keywords: Adenocarcinoma; salivary gland adenocarcinoma; minor salivary gland adenocarcinoma; salivary gland neoplasiaAccepted: 6 July 20231 Animal Specialty & Emergency Center of Brevard, Melbourne, FL, USA2Animal Dental Center, Towson, MD, USA3Antech Diagnostics, Fountain Valley, CA, USACorresponding author:Monica Morgado Laureano DVM, Animal Specialty & Emergency Center of Brevard, 2281 W Eau Gallie Boulevard, Melbourne, FL 32935, USAEmail: Dr.morgado@centralfloridaanimaler.com1189973 JFM Journal of Feline Medicine and SurgeryMorgado Laureano et alCase Series2 Journal of Feline Medicine and Surgery recent study, salivary gland tumors more frequently occurred in the mandibular salivary gland (4/6 cases, 66%).6 In the remaining two cases, one tumor arose from the left buccal cavity and the other tumor was presumed to arise from minor salivary gland tissue on the labial mucosa.Cats have four pairs of major salivary glands – parotid, sublingual, mandibular and zygomatic7 – with scattered glandular tissue present in the submucosa of the lips, cheeks and soft palate.8 In both dogs and cats, the most frequent major salivary glands to develop neoplasia are the mandibular and parotid glands, which account for approximately 75–80% of all salivary gland neoplasia.1,3 Simple adenocarcinoma (tubular or papillary) most frequently affects major salivary glands, whereas complex adenocarcinoma (ie, containing a myoepithelial component) is less common. Other tumor types, includ -ing osteosarcoma, mast cell, sebaceous carcinoma, malig -nant fibrous histiocytoma, oncocytoma, squamous cell carcinoma and adenoma, have been reported in major salivary glands.1–3,9–15 The presenting complaint in most cases of salivary gland neoplasia is halitosis and dys-phagia secondary to an oral mass.16 In cats, morbidity is frequently more advanced,4,10 and distant metastasis is more common when compared with dogs.10Historically, the long-term prognosis for patients with malignant salivary gland neoplasia has been poor. Recent reports have shown an increased survival rate (~1 year) if tumors were diagnosed early, wide surgical margins were obtained and adjuvant therapy, such as radiation, had been utilized.17,18 In a more recent case series using external beam radiotherapy for the treatment of feline major salivary gland carcinoma, it was reported that cats with large and invasive primary tumors may have locore -gional control with radiotherapy.6There are no current data on minor salivary gland neoplasia in cats. This is the first retrospective case series to document the prevalence, treatment and survival rates of cats with salivary gland adenocarcinoma of minor disseminated salivary gland origin.Case series descriptionMedical records from a private multicenter dentistry and oral surgery specialty practice were reviewed for cases of feline patients presenting with caudal mandibular oral masses using the query terms ‘oral mass,’ ‘labial mass’ or ‘oral tumor’. The inclusion criteria included biopsy-diagnosed salivary adenocarcinoma and minor salivary gland location. Specifically, the inclusion of masses was based on specific location in the caudal labial mandibu -lar buccal mucosa, caudal to the mandibular third pre -molar tooth. This anatomical location is not consistent with a known location of a major salivary gland in feline patients. A description of the presenting anatomical loca -tion of the oral masses was imperative to categorize these tumors as arising from minor salivary gland tissue vs major salivary gland tissue owing to their histological similarities. Cases without histological diagnosis or not definitively originating from minor salivary gland tissue were excluded. In addition, cats that received additional histopathology post mortem owing to recur -rence of their oral mass and were histologically con -firmed as oral minor salivary gland adenocarcinoma were also included in the study.Of the 4574 cats seen at the private multicenter spe -cialty practice between 2007 and 2021, 85 cats presented with caudal mandibular oral masses. Of these 85 cats, four (4.7%) met the inclusion criteria for the case series. Other diagnoses for the remaining 81 cats consisted of benign cysts of salivary origin, benign fibromatous gin -gival tumor, carcinoma, fibrosarcoma, chronic inflamma -tion, squamous cell carcinoma and stomatitis (Table 1).The four cats in the study included two domestic shorthairs, one Oriental Shorthair and one Russian Blue cat. Three of the cats were castrated males and one was a spayed female. The median age was 11 years (range 9–15 years).The most commonly reported clinical complaint was a notable mass associated with the caudal mandibular labial buccal mucosa (3/4). The masses had been present for a period of 1–6 months before treatment. Three of the four cats had blood-tinged saliva. One cat presented with a history of hyporexia and weight loss. Comorbidities included diabetes mellitus, seizures, hypertrophic obstructive cardiomyopathy, heart murmur (echocardio -gram declined), microphthalmia, elevated liver enzymes and inappropriate urination (Table 2).Complete blood count (CBC) and serum biochemical analyses were performed on all patients, revealing only minor non-clinically significant abnormalities. Of the four cats, three had three-view chest radiographs performed with no evidence of distant metastasis (patients 2, 3 and 4) at the time of diagnosis. One of the four cats had an evaluation of local draining lymph nodes (ipsilateral to the oral mass), revealing metastatic disease.On oral examination under anesthesia, 4/4 cats had a solitary caudal mandibular labial buccal mucosal mass with variable location within the labial mucosa (Figures 1 and 2). All masses were caudal to the mandibular third premolar tooth. All masses were greater than 1 cm, with the largest dimension being 3.4 × 4 × 4 cm in patient 3. Other descriptions of the oral masses from the medi-cal record included pedunculated (n = 1/4), ulcerated (n = 2/4), firm on palpation (n = 2/4) and active bleed-ing (n = 3/4) (Table 3).All cats underwent general anesthesia, and full mouth intraoral dental radiographs were obtained. There were no radiographic osseous changes associated with the oral masses. Advanced imaging (CT, cone-beam CT or MRI) was not performed at the time of the procedures. Only Morgado Laureano et al 3Table 1 Morphological diagnoses for 85 cats seen between 2007 and 2021 with caudal mandibular oral masses out of a total of 4574 feline patientsDiagnosis Number of cases Caudal oral masses per 85 patients (%)Prevalence per 4574 patients (%)Adenocarcinoma (major gland) 4 4.8 0.08Adenocarcinoma (minor gland) 4 4.8 0.08Benign cyst of salivary origin 2 2.3 0.04Benign fibromatous gingival tumor 1 1.2 0.02Carcinoma 1 1.2 0.02Ductal ectasia 1 1.2 0.02Fibroepithelial polyp 1 1.2 0.02Fibrogingival hyperplasia 3 3.5 0.06Fibrosarcoma 1 1.2 0.02Inflammation 16 18.8 0.34Lymphoplasmacytic osteomyelitis 5 5.9 0.10Osteoma 4 4.8 0.08Osteosarcoma 1 1.2 0.02Pyogenic granuloma 16 18.7 0.34Salivary tubulopapillary adenoma 1 1.2 0.02Squamous cell carcinoma 9 10.5 0.19Stomatitis 15 17.5 0.32Table 2 Data summary for four feline patients diagnosed with minor salivary gland adenocarcinomaPatient Breed Age Sex Weight (kg) Reason for euthanasia Comorbidity1 OrientalShorthair11 y 7 m MN 5.36 PD Cardiac murmurMicrophthalmiaLiver enzyme elevation2 DSH 12 y 6 m MN 4.27 PD Diabetes mellitusSeizuresHypertrophic obstructive cardiomyopathy3 Russian Blue 9 y 6 m FS 5.36 PD Inappropriate urination4 DSH 15 y MN 4.22 PD Cardiac murmurDSH = domestic shorthair; FS = female spayed; m = months; MN = male neutered; PD = progressive disease; y = yearsone cat had dental anomalies associated with the mass (type 3 tooth resorption).Wide soft tissue excision, including 10 mm from grossly abnormal tissue, was performed in 3/4 patients. A deep margin was not attempted. One of the four cats had marginal excision performed. All surgical sites were closed using a combination of simple interrupted and/or horizontal mattress suture patterns with 5-0 Monocryl (Figure 3).Histopathology revealed a neoplastic cellular proliferation forming acini, tubules, duct-like structures or solid sheets (Figure 4). The neoplastic cells ranged from cuboidal to polygonal, with moderate amounts of eosino-philic cytoplasm and round to oval nuclei. The mitotic index was in the range of 4–22 (number of mitotic figures in 10 400 × microscope fields). Margins were evaluated as clean, narrow or incomplete, with narrow margin status interpreted as < 1.0 mm. Clean margins > 5 mm were obtained for the three cats with wide excisional Figure 1 Patient 2 with presentation of a left mandibular buccal mucosal mass4 Journal of Feline Medicine and Surgery biopsy and incomplete margins were obtained for the patient with palliative surgical debulking. All masses were located in the mucosa; therefore, the deep margins measured did not involve bone. Bone was not sampled.All four cats were re-evaluated 2 weeks postop -eratively. In all four cases, the surgical sites had healed without complications. Owners noted increased appe-tite, increased energy and activity level, subjectively decreased pain and overall increase in quality of life. No patients underwent adjuvant chemotherapy or radiation.The patients’ follow-up data are shown in Table 4. At the time of writing this retrospective study, patient 1 was the only cat alive and additional follow-up information was provided by its primary care veterinarian. The cat was re-evaluated 60 days after the excisional biopsy owing to a pedunculated pink lesion, measuring approx -imately 4.0 mm in the area of the previous surgical site. Histopathology results from an incisional biopsy of this lesion were consistent with scar/fibrotic tissue and no evidence of neoplastic cells. At 280 days postoperatively, interstitial changes on thoracic radiographs were sugges -tive of metastatic disease, but multiple soft tissue nodules were not noted. Signs of regrowth of the oral mass at the original surgery site were noted 850 days postoperatively; the cat was asymptomatic. Patient 1 was eventually euthanized 1730 days after the excisional biopsy owing to progression of disease and decreased quality of life. The cat’s owners approved diagnostic imaging and additional histopathology of the oral mass post mortem, which had grown to surround the ventral aspect of the left mandible (Figure 5). Thoracic radiographs showed lesions compatible with metastatic nodules present within the lungs (Figure 6) and a post-mortem incisional biopsy of the mass confirmed recurrence of the adenocarcinoma.Patient 2 received multiple recheck examinations postoperatively for a period of 5 weeks, with no signs of oral mass regrowth (Table 4). Follow-up via phone call revealed that the patient was euthanized at the time of local regrowth of the mass at 910 days postoperatively.After the 2-week postoperative recheck, patients 3 and 4 were lost to follow-up. Follow-up via phone call of patient 4 revealed that the cat was alive with recur -rence of an oral mass visible at approximately 120 days postoperatively.The survival times for all four patients were in the range of 210–1730 days from surgical resection (Table 4). The three cats that had an excisional biopsy proce-dure, with 1.0 cm attempted margins, had a higher mean Figure 2 Patient 3 with presentation of a right mandibular buccal mucosal massTable 3 Oral mass inclusion criteriaPatient Tumor site Tumor size (cm) Mitotic index Tumor description1 L mandibular labial buccal mucosa1.5 × 2 × 1.5 9 per 10 hpf Oval, pale pink, firm, submucosal mass, not adhered to the mandible/mobile, buccal aspect left caudal mandible, buccal to the mandibular fourth premolar (308) and first molar (309) teeth2 L mandibular labial buccal mucosa1 × 1 × 1 22 per 10 hpf Hemorrhagic, extending deep in the subepithelial connective tissue at the level of the left mandibular first molar tooth (309)3 R mandibular buccal mucosa3.4 × 4 × 4 4 per 10 hpf Hemorrhagic, ulcerated, on the right inner cheek from the mesial aspect of the right mandibular fourth premolar tooth (408) extending to the distal aspect of the right mandibular first molar tooth (409)4 R mandibular buccal mucosa2 × 1.5 × 0.5 5 per single hpf Hemorrhagic, ulcerated, round, semi-firm and pedunculated, on the right inner cheek extending from the right mandibular fourth premolar tooth (408) to the level of the right mandibular first molar tooth (409)hpf = high power field; L = left; R = rightMorgado Laureano et al 5survival time than patient 3, which was treated with palliative surgery and lymph node removal. All four cats were eventually euthanized owing to recurrence of the oral mass regardless of surgical treatment modality. The owners of each cat perceived a decrease in quality of life when the oral tumor recurred. The most common obser -vations after oral mass recurrence included oral pain and dysphagia.

Question 54

Marks - 2024 - JSAP - Prognostic factors and outcome in cats with thymic epithelial tumours - 64 cases (1999-2021).pdf

Answer 54

Case identificationThis retrospective study used anonymised clinical data and was approved by the social science research ethical review board of the Royal Veterinary College (URN SR2020- 0228). Com -puterised clinical records database of three small animal refer -ral hospitals were searched for cats that had a cytological or histopathological diagnosis of thymoma or thymic carcinoma between January 1999 and December 2021. Cats in which a TET had been diagnosed during the study period and had comprehensive clinical records were included in the study. Cats without a subsequent definitive diagnosis, with incom -plete medical records or that presented for tumour recurrence were excluded.Data collectionInformation regarding signalment, presenting clinical signs and duration, physical examination findings, comorbidities, labora -tory tests (complete blood cell counts [CBC], serum biochem -istry and urinalysis), diagnostic findings, tumour size, staging results, cytological and histopathological reports, treatment Table 1. Masaoka- Koga staging system (Masaoka et al., 1981 )Stage DescriptionI Complete encapsulation of tumourIIa Microscopic tumour invasion through capsuleIIb Macroscopic tumour invasion into surrounding fatIII Invasion of pericardium, great vessels or lungIVa Pleural or pericardial disseminationIVb Lymphatic/haematogenous metastasis 17485827, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13675 by Vetagro Sup Aef, Wiley Online Library on [19/01/2024]. 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 LicenseThymic epithelial tumours in catsJournal 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.49 (surgery, chemotherapy or radiotherapy), documented tumour recurrences, regional or distant metastasis and date and cause of death were obtained from the medical records. Comorbidi -ties collected from medical records were defined as any chronic health condition diagnosed prior to detection of the TET.Clinical signs that occurred at sites distant from the tumour or clinical- pathological abnormalities that resolved after excision of the TET for which no other identifiable causes were documented were considered to be paraneoplastic syndromes. Cats with para -neoplastic myasthenia gravis had to have compatible clinical signs and a positive nicotinic acetylcholine receptors (AChRs) antibody testing. If this was not performed, then myasthenia gravis was classified as “suspected.” Cats with serum ionised cal -cium of >1.4 mmol/L were considered to be affected by para -neoplastic hypercalcaemia and those with a lymphocyte count of >10×109/L on peripheral blood were considered to be affected by paraneoplastic lymphocytosis.Determination of tumour size was performed by assessing the maximum tumour diameter on CT scan, thoracic ultrasound and/or thoracic radiographs. A cystic appearance was determined based on imaging if the tumour had fluid- filled cavitations. The presence or absence of a pleural effusion was also recorded.Diagnostic techniques were performed at the clinician’s dis -cretion and included ultrasound- guided fine needle aspiration, tru- cut biopsy, surgical biopsy or a combination of those. Cytol -ogy and histopathology reports for each case were retrospec -tively reviewed and information regarding mitotic count (MC), presence or absence of capsular invasion, histological subtype and margin assessment were collected. T umours were classified as thymoma or thymic carcinoma based on the final diagnosis described in the histopathology report. Reports were considered inconclusive or non- diagnostic when a diagnosis other than TET could not be excluded or when cellularity was insufficient to con -firm the diagnosis.Histological samples were examined in all cases by a board- certified pathologist or a pathology resident under supervision. Mitotic count was only recorded if calculated as the total num -ber of mitotic figures in 10 microscopic ×400 high- power fields (HPF). T umour margin assessment was described as complete if cancer cells were not present at the surgical margin or incom -plete if cancer cells were present at the cut margin or the surgical report described a marginal tumour resection with visible macro -scopic disease being left at the surgical site. Capsule invasion was recorded as present or absent as described in the histopathology report.For cats where information about microscopic capsular inva -sion based on the histopathology description, macroscopic inva -sion based on imaging or intraoperative surgical reports, and complete staging with thoracic and abdominal imaging was available, a Masaoka- Koga stage was assigned ( Table 1). For the purpose of this study, the substage classification a/b was not used.Intra- and post- operative complications were obtained from the medical records. Intraoperative complications were defined as adverse effects or complications occurring from skin incision to skin closure. Postoperative complications were defined as an adverse effects or complications occurring after skin closure.TETs were considered unresectable based on the results of the diagnostic imaging or intraoperatively based on the appearance of the TET and the experience of the surgeon.For cats that received chemotherapy, the drug type, proto -col, doses, number of treatments and whether administration was in the macroscopic or microscopic setting were recorded. Antineoplastic drugs included carboplatin (124 to 178 mg/m2 IV q3 weeks), metronomic cyclophosphamide (15 mg/m2 PO sid rounded to the nearest tablet size) and l- asparaginase (400 IU/kg SC). Chemotherapy toxicity was retrospectively graded accord -ing to the VCOG- Common Terminology Criteria for Adverse Events (VCOG- CTAE version 2, LeBlanc et al., 2021 ). Dose reductions were performed at the clinician’s discretion when tox -icity occurred.For cats treated with radiotherapy, the type of protocol (con -ventionally fractionated versus hypofractionated), the intent (pal -liative versus curative), the total dose delivered and whether this was used as sole treatment or in the neoadjuvant/adjuvant or relapse setting was recorded. For cats whose total radiotherapy dose was recorded, this ranged from 42 to 48Gy delivered in 10 to 16 fractions.Prednisolone or NSAIDs (meloxicam) were used at standard dosages alone or in association with surgery, chemotherapy, radiotherapy or in the palliative setting.Response to treatment was assessed using the Veterinary Coop -erative Oncology Group Response Criteria in Solid T umours (VCOG RECIST, version 1.0). This was classified as complete response (CR) if there was a 100% resolution of the tumour, partial response (PR) if there was >30% reduction in the over -all tumour size, stable disease (SD) if there was <30% reduction but <20% increase in tumour size, and progressive disease (PD) if there was an increase in the tumour size of >20%. (Nguyen et al., 2015 ). Restaging procedures were performed either using thoracic radiographs or CT in some cats at variable time intervals (3 to 6 months) or when clinical concerns arose, and imaging modality was based on the clinicians’ preference.To obtain follow- up information, referring veterinarians and/or owners were contacted via telephone. T umour progression was defined as recurrence of a mediastinal mass documented on imaging investigations or development of distant metastasis con -firmed to be thymoma/thymic carcinoma- related by cytology or histopathology.Statistical analysisDescriptive statistics were computed for all variables. Categori -cal variables were described as frequency and percentages. Con -tinuous variables were tested for normality using Shapiro– Wilk test. If normally distributed, data was summarised as mean and standard deviation. If non- normally distributed, data were sum -marised using median and range.Overall survival time (OST) was calculated from the day of surgery to the date of death or censorship and time to progression (TTP) was defined as the days between surgery to detection of tumour recurrence or metastasis. Cats were censored from sur -vival analysis if they were alive at the time of analysis, died for reason unrelated to the TET or were lost to follow- up. Cats that 17485827, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13675 by Vetagro Sup Aef, Wiley Online Library on [19/01/2024]. 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 LicenseT. 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.50were not operated on, were euthanased intraoperatively or died before discharge were excluded from the survival analysis.The Kaplan– Meier method and Cox proportional hazards analysis were performed to determine the possible effects of factors influencing survival time and recurrences. The explana -tory variables were those previously listed. All variables were ini -tially tested separately via univariate Cox proportional hazards analysis, and variables identified as P<0.2 were used to build a multi- variate Cox proportional hazards model. Cox proportional hazards analysis results are reported as odds ratios, 95% confi -dence intervals, and the associated P- value. For all tests, a P value <0.05 was considered statistically significant. Analyses were per -formed using Microsoft Excel 2020 and SPSS 26.0 (IBM SPSS statistics, version 26.0; IBM Corp, Armonk, New York).RESULTSDemographics and clinical presentationSixty- four cats met the study eligibility criteria. The population included 40 neutered male cats and 24 female cats (22 neutered and two entire). The most represented breed was domestic short hair (n=38, 59.4%) followed by British short hair (n=7, 10.9%), British blue (n=4, 6.3%), Burmese (n=3, 4.7%), Maine Coon (n=3, 4.7%), Abyssinian (n=3, 4.7%), Russian blue (n=2, 3.1%), domestic long hair (n=2, 3.1%), Persian (n=1, 1.6%) and Ben -gal (n=1, 1.6%). At the time of surgery, median bodyweight was 4 kg (range, 3 to 7 kg) and median age was 10 years (range, 3 to 17 years). The most common presenting clinical signs were dys -pnoea/tachypnoea (n=38, 59.4%), cough (n=11, 17%), lethargy (n=8, 12.5%), anorexia (n=5, 7.5%), weight loss (n=4, 6.3%) and vomiting (n=4, 6.3%). In most cats, a combination of clini -cal signs was reported. Median duration of clinical signs before presentation was 10 days (range, 1 to 90 days). Seven cats (11%) without TET- associated clinical signs were incidentally diag -nosed during investigations into unrelated problems.Nine cats (14.1%) presented with a paraneoplastic syndrome at diagnosis but this was the main presenting clinical sign in only four cats. The paraneoplastic syndromes included lymphocyto -sis (n=4, ranging from 10.9×109 to 19.2×109), myasthenia gravis (n=3, confirmed with AchRs antibodies in two and suspected in one), exfoliative dermatitis (n=1) and ionised hypercalcaemia (n=1). T wenty- five cats (39.1%) had co- morbidities at the time of diagnosis, the most common being: hypertrophic cardiomy -opathy (n=7, 10.9%), hyperthyroidism (n=4, 6.3%) and chronic kidney disease (n=4, 6.3%).Diagnostic investigations and Masaoka- Koga staging systemComplete blood count was available in 55 cats; the most com -mon abnormalities included lymphocytosis (n=9, 16%), anaemia (n=6, 11%) and neutrophilia (n=6, 11%). In 26 cats (47%), at least one abnormality was seen in the CBC. The remainder were within the reference limits. Serum biochemistry was available in 54 cats; the most common abnormalities included elevated creatinine kinase (n=10, 18.5%) and elevated creatinine (n=6, 11%). In 25 cats (46%), serum biochemistry was within the ref -erence limits. Feline leukaemia virus (FeLV) and feline immuno -deficiency virus (FIV) in- house ELISA tests (Idexx laboratories) were performed in 24 cats: one cat tested positive for FeLV and all cats were negative for FIV.Thoracic imaging reports were available for review in 62 cats (96.9%) including thoracic and abdominal CT in 25 cats, tho -racic CT only in seven cats, thoracic ultrasonography in 35 cats, thoracic radiographs in 20 cats, echocardiography in six cats and magnetic resonance imaging in three cats. Abdominal imaging reports were available for review in 39 cats (60.9%) including CT in 25 cats and abdominal ultrasonography in 14 cats. A combina -tion of these imaging modalities was used in 31 cats. A cranial mediastinal mass was detected in all cases with a median tumour diameter of 6 cm (measurements performed in 38 cats; range, 2 to 15 cm). Measurements of the tumour diameter were reported in all cats undergoing thoracic CT and 5 cats with thoracic ultra -sound but were not recorded in the remaining cats.A cystic appearance was reported on imaging in 25 masses, and pleural effusion was present in 21 cats. Sixteen of the 21 effusions (76%) were analysed: seven were modified transudates (43.8%), four were chylous effusions (25%), three were transu -dates (18.8%) and two were haemorrhagic (12.5%).Only one cat was suspected to have pulmonary metastases at diagnosis: multiple, nodular lung lesions were observed on CT, however, cytological or histopathological samples were not obtained ( Table 2). This cat did not undergo surgical resection but received palliative radiotherapy instead.Forty- four masses were sampled pre- operatively via fine needle aspiration, 10 masses via tru- cut biopsy and 8 masses via both methods. From the 52 cytological samples, 32 samples were con -sistent with thymoma (61.5%), one sample was consistent with Table 2. Clinical characteristics, laboratory and radiological findings in 64 cats with thymic epithelial tumoursNo. of cats affected /No. cats evaluated (%)Clinical characteristicsDyspnoea/tachypnoea 38/64 (59.4)Cough 11/64 (17.1)Lethargy 8/64 (12.5)Anorexia/inappetence 5/64 (7.5)Vomiting 4/64 (6.3)Weight loss 4/64 (6.3)Paraneoplastic disease 9/64 (14.1)Laboratory findingsIonised hypercalcaemia 1/54 (1.9)Anaemia 6/55 (10.9)Lymphocytosis 9/55 (16)Neutrophilia 6/55 (10.9)Azotaemia 6/54 (11.1)Elevated creatine kinase 10/55 (18.5)Imaging findingsPleural effusion 21/61 (34.4)Cystic thymic mass 25/60 (41.7)Metastasis 1/62 (1.6) at diagnosis and 2/62 (3%) when considering follow- up period 17485827, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13675 by Vetagro Sup Aef, Wiley Online Library on [19/01/2024]. 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 LicenseThymic epithelial tumours in catsJournal 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.51 thymic carcinoma (1.9%), 16 samples were inconclusive (30.8%) and three samples were non- diagnostic (5.8%).From the 18 masses that were sampled via tru- cut biopsy, 15 samples were consistent with thymoma (83.3%), one sample was consistent with thymic carcinoma (5.6%) and two samples were non- diagnostic (11.1%). In those cases where both cytology and histopathology were performed, results were both compatible with the diagnosis of TET.Thirty- two cats were staged using the Masaoka- Koga staging sys -tem. Sixteen had stage I (50%), four had stage II (12.5%), 10 had stage III (31.3%) and two had stage IV (6.3%) disease ( Table 3).Treatment and perioperative mortalityFifty- four (84.4%) cats underwent surgery. In 10 cats, surgical intervention was not performed. Of these, three were euthanased upon diagnosis. In two cats, surgery was not performed due to a comorbidity: one cat died at 32 days due to concomitant maxil -lary neoplasia and the other died at 30 days due to congestive heart failure. T wo cats received palliative prednisolone with survival of 7 and 365 days. One cat received palliative radiotherapy (dose unknown) and achieved a PR before being euthanased 150 days after diagnosis. The other two cats were lost to follow- up.All surgeries were performed by, or under the direct super -vision of a European College of Veterinary Surgeons (ECVS) board- certified surgeon. A median sternotomy was used as surgi -cal approach in all cats. Concomitant surgical procedures per -formed included a subtotal pericardiectomy (n=4), thoracic duct ligation (n=2), right cranial lung lobectomy due to severe adhe -sions (n=2) and sternal lymphadenectomy due to enlargement of the sternal lymph nodes observed on CT scan (n=1).Surgery was uncomplicated in 49 of 54 cats (85%). Intra- operative complications were recorded in five cats (9%) and included hypotension (n=3) and haemorrhage (n=2, one requir -ing blood- derived products). In three cats (5%) the TET was considered invasive and unresectable by the surgeon, and the cats were euthanased intraoperatively.In the postoperative period, 10 cats suffered a complication (20%), including: haemorrhage (n=2; one requiring transfu -sion of blood- derived products and one requiring a surgical reintervention), anaemia (n=2), hypotension (n=2), surgical site infection at the level of the thoracostomy tube (n=1), transient megaoesophagus (n=1), Horner’s syndrome (n=1) and aspiration pneumonia (n=1). As a result of these complications, cardiopul -monary arrest occurred in three cats leading to death. Fifty- one cats survived the surgical procedure. Three cats died in the imme -diate postoperative period resulting in an overall perioperative mortality rate of 11% (6/54). These three cats along with three other cats that died in the immediate postoperative period were excluded from survival analysis.Forty- eight (89%) cats survived to be discharged from the hospital. Masaoka- Koga stage was available for five out of six cats that did not survive the perioperative period: four cats had stage III and one stage IV.Three cats received antineoplastic drugs, with two receiv -ing adjunctive chemotherapy postoperatively. One cat with an incompletely excised, non- metastatic thymic carcinoma received carboplatin; 178 mg/m2 IV was administered initially for one dose then reduced to 124 mg/m2 due to grade II neutropenia detected 2 weeks after treatment that persisted for 32 days. The lower dose was administered every 3 weeks for four doses, before changing to metronomic cyclophosphamide (14.5 mg/m2 PO sid) and meloxicam (0.05 mg/kg PO sid) following recurrence of the pleural effusion. One cat with a completely excised thymoma received palliative metronomic cyclophosphamide (14.23 mg/m2 PO sid) and meloxicam (0.05 mg/kg PO sid) at the time of recur -rence for 60 days before being euthanased.One cat received a single dose of l- asparaginase (400 IU/kg SC) before tru- cut biopsy results confirmed a TET. This was administered empirically due to marked clinical deterioration and a suspicion of mediastinal lymphoma. Surgery was per -formed and no adjunctive chemotherapy was administered post -operatively.Three cats received radiotherapy postoperatively; two in the adjuvant setting and one at the time of recurrence. One cat with incomplete TET resection received 48 Gy over 16 fractions immediately postoperatively, achieved a PR but experienced recurrence at 300 days. A second surgery was performed, and dis -ease recurred 60 days after the second surgery. This cat was sub -sequently lost to follow- up. The second cat received 42 Gy over 10 fractions following incomplete excision. A PR was reported on first restaging with thoracic radiographs 30 days after radio -therapy and the cat remained in PR on restaging at 90, 180, 360, 540 and 720 days after radiotherapy. This cat was subsequently lost to follow- up. The third cat received 42 Gy over 15 fractions following recurrence at 417 days and experienced a CR. This cat remains alive at last follow- up, 597 days after surgical excision.Histopathological findingsA histopathological diagnosis of TET was made in all cats under -going surgery but reports were available for review in 50 (93%) Table 3. Masaoka- Koga stage and histological findings for cats with thymic epithelial tumoursNo. of cats affected/No. of cats evaluated (%)Masaoka- Koga stageStage I 16/32 (50)Stage II 4/32 (12.5)Stage III 10/32 (31.3)Stage IV 2/32 (6.3)Histological findingsThymoma 44/50 (88)Thymic carcinoma 6/50 (12)Capsular invasionPresent 8/50 (16)Absent 42/50 (84)Lymphovascular invasionPresent 1/23 (4.3)Absent 22/23 (95.7)Margin assessmentComplete 24/40 (60)Incomplete 16/40 (40)Follow upRecurrence 11/48 (22.9) 17485827, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13675 by Vetagro Sup Aef, Wiley Online Library on [19/01/2024]. 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 LicenseT. 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.52cats. Thymoma was diagnosed on histopathology in 44 cats (88%) and thymic carcinoma in six cats (12%).The median mitotic count per 10 HPF was one (range, 0 to 20) and capsular invasion was described in eight cats (16%). Eval -uation of surgical margins was available in 40 cats (74%) with complete excision reported in 24 cats (60%) and incomplete exci -sion in 16 cats (40%). Histopathology of the sternal lymph nodes excised in one cat revealed no evidence of regional metastasis.Outcome and prognostic factorsFollow- up time was available in 36 of 48 cats (75%) surviving to discharge and ranged from 31 to 3322 days (median, 897 days).Among those 48 cats, 10 cats remained alive at the time of study completion. Eight cats died or were euthanased during the follow- up period for causes directly or suspectedly related to TET between 21 and 960 days, including recurrence (n=5), pleural effusion (n=1), dyspnoea (n=1) and cranial vena cava thrombus (n=1).MST for cats surviving to hospital discharge was 897 days (range, 21 to 3322 days). Based on Kaplan– Meier estimates, the 1- , 2- and 5- year survival were 86%, 70% and 66%, respectively.T umour recurrence was identified in 11 cats at a median TTP of 564 days (range, 93 to 1095 days): six had incomplete margins and five recurred despite histological complete excision. Local recurrence developed in all cats with concurrent regional (axillary lymph node) metastasis found in one cat. T wo cats with recur -rence underwent a second surgery at 300 and 1095 days, respec -tively, from the initial surgery. The first cat experienced a second recurrence 60 days after and was subsequently lost to follow- up and the second cat was lost to follow- up immediately after the second surgery.Masaoka- Koga stage could be evaluated in seven cats with recurrence: one cat had stage I, two cats had stage II and four cats had stage III tumours. During the follow- up period, four cats were diagnosed with second tumours during restaging: one nasal adenocarcinoma, one mediastinal ectopic thyroid adenoma, one ocular tumour and one humeral osteosarcoma.Of the three cats with myasthenia gravis, two experienced res -olution after surgery. Of these, one was treated with pyridostig -mine and prednisolone and experienced resolution at 120 days and the second showed reducing anti- AChR antibody titres at 90 days and experienced resolution at 150 days. The third cat’s myasthenia gravis did not improve; this cat had tumour recur -rence at 180 days.Cats with TET classified as Masaoka- Koga stage I and II had significantly longer MST compared with TET classified as Masaoka- Koga stage III and IV (1366 days versus 454 days; P=0.002, Fig 1). There was no difference in MST between cats with complete and incomplete excision (980 days versus 730; P=0.278) and between cats with a histological diagnosis of thy -moma and thymic carcinoma (962 days versus 564; P=0.153).Logistic regression analysis was used to determine factors asso -ciated with survival and recurrence with possible confounding factors taken into account. After the initial model was refined by backward- stepwise elimination the best fit model for survival included cystic appearance, tumour diameter, Masaoka- Koga stage, pleural effusion, histological diagnosis (thymoma versus thymic carcinoma) and tumour recurrence ( Table 4). In the final multiple- regression model, the only factor associated with an increased risk of death included Masaoka- Koga stage III to IV (Table 5). No prognostic factors were found to be significantly associated with TTP ( Table 6).

Question 55

Manchester - 2024 - JAVMA - Difficult catheterization and previous urethral obstruction are associated with lower urinary tract tears in cats with urethral obstruction.pdf

Answer 55

Medical records of all male cats hospitalized at the Matthew J. Ryan Veterinary Hospital of the Uni -versity of Pennsylvania between January 2010 and December 2022 were reviewed for cases of UO and concurrent lower urinary injury. Electronic medical record keyword searches to identify cases included “bladder rupture,” “bladder tear,” “urethral tear,” “urethral injury,” “urethral rupture,” “uroperitoneum,” and “uroabdomen.” Cats were included if they were diagnosed with a UO (firm, painful, nonexpressible bladder), had urinary catheterization attempted, and had either a bladder tear or a urethral tear. Findings that were considered confirmatory of lower urinary tract injury included the following: plain radiography or abdominal ultrasonography revealing the urinary catheter within the peritoneum but outside of the uri -nary tract, the presence of peritoneal free gas and/or large volume of fluid identified in the peritoneum with the concurrent inability to pass the urinary cath -eter, contrast urethrocystogram revealing leakage of contrast outside the urinary tract, or visible ruptures during an exploratory laparotomy. All imaging stud -ies required interpretation by a board-certified ra -diologist for inclusion. In addition, if peritoneal fluid was present, fluid analysis must have been consistent with a uroperitoneum. A uroperitoneum was defined as a fluid creatinine-to-serum creatinine ratio of at least 2:1 and fluid potassium-to-serum potassium ratio of at least 1.9:113 Patients were excluded if they did not have a confirmed urinary tract rupture by one of these methods.Medical record data collected when available in -cluded signalment, year of presentation to the hos -pital, anatomic location of the tear (bladder vs ure -thra), imaging modality of confirmation of the tear, training status of the individual passing the urinary catheter (veterinary student, nurse, intern, resident, or faculty veterinarian), performance of a concurrent decompressive cystocentesis, and difficulty level of urinary catheter passage as scored with the use of a hospital-wide scoring system of a scale from 0 (easy to pass urinary catheter, no hydropropulsion with sa -line required) to 4 (unable to place urinary catheter; Supplementary Table S1 ). Additionally, information was collected on whether the cat had a previous his -tory of UO, the number of previous UOs, and how many days had elapsed since the most recent UO. Admission blood work, including blood creatinine, ionized calcium, pH, Hct, and potassium, was record -ed. Finally, the presence of cystolithiasis, the gross urine color, and the presence of visible grit in urine at the time of urinary catheterization were recorded.The therapeutic management strategies imple -mented for the urinary tract trauma were recorded for each cat and divided into the following catego -ries: (1) medical management with urinary catheter placement via standard retrograde method, (2) med -ical management following retrograde fluoroscopy-guided urinary catheter placement, (3) cystotomy, and (4) perineal urethrostomy. Finally, the length of hospitalization and survival to discharge were re -corded. Nonsurvivors included cats that were eutha -nized as well as those that suffered cardiopulmonary arrest. If the reason for euthanasia was described, it was recorded.A target number of control cases was preselect -ed at a ratio of 3:1 (controls to cases). A population of male cats hospitalized with a diagnosis of UO with -out evidence of a lower urinary tear was selected by utilizing a random number generator (Random Gen -erator; Google Workspace Marketplace) and select -ing the patient that was presented as that number in chronological order for the given calendar year. Case information recorded for the control cats was the same as the cases with the exception of therapeutic management strategies for the urinary tract trauma. Cats were excluded from the control group if they did not have attempted urinary catheter placement or they had not undergone radiography or an ultra -sonography by a radiologist to diagnose or rule out a urethral or bladder tear.Statistical analysisHospital period prevalence of cats with a urinary tear, among all cats with a UO undergoing treatment in hospital (including those without concurrent ab -dominal imaging) was calculated by dividing the number of cats with a UO and a concurrent lower urinary rupture by the number of cats diagnosed with a UO during the same time period. The distribu -tion of continuous variables was determined visually Unauthenticated | Downloaded 01/27/24 05:10 PM UTC JAVMA | FEBRUARY 2024 | VOL 262 | NO. 2 189and by the skewness and kurtosis tests for normal -ity. Normally distributed continuous variables were reported as mean ± SD, whereas median (range) was used for variables that were not normally dis -tributed. Continuous variables were compared using the 2-sample independent t test for normally distrib -uted variables, and the 2-sample Wilcoxon rank sum (Mann-Whitney) test was used for comparison of variables that were not normally distributed. The χ2 test was employed to determine whether there was a relationship between 2 categorical variables, unless 1 or more cells had a frequency of 5 or less, in which case the Fisher exact test was utilized. A P value of < .05 was considered significant for all tests. All sta -tistical evaluations were performed using a statistical software package (Stata 14.0 for Mac; Stata Corp).ResultsNineteen cats with the diagnoses of a UO and concurrent lower urinary rupture were identified af -ter a medical record search of the Ryan Veterinary Hospital’s medical record system. Four cats were excluded due to either lack of complete medical records (2 cats) or a presumptive diagnosis being made without one of the above imaging or surgi -cal modalities being performed for confirmation (2 cats). Fifteen cats (UO-R group) that met the inclu -sion criteria were included. During the years of inclu -sion, 1,631 total cats were treated in hospital for UO. This equates to a lower urinary tract rupture preva -lence of 0.92% (15/1,631). Forty-five year-matched control cases (UO-C) were also identified.The median age for the UO-R group was 3 years (range, 0.25 to 16 years) and for UO-C group was 4 years (range, 0.6 to 16 years). No significant differ -ence in median age was noted between the 2 groups (P = .7). All 15 (100%) cats in the UO-R group were classified as domestic shorthair cats. For the UO-C group, 2 (2/45 [4.4%]) cats were listed as domes -tic longhair and 1 (1/45 [2.2%]) cat was listed as a Russian Blue. The remainder (42/45 [93.3%]) were classified as domestic shorthair cats. All cats in both groups were castrated males.Lower urinary tract rupture was confirmed in the majority of cats (7/15 [47%]) with contrast urethro -cystogram. In the other 8 (8/15 [53%]) cats, it was confirmed on plain abdominal radiography (2/15 [13.3%]), abdominal ultrasonography (3/15 [20%]), or exploratory laparotomy (3/15 [20%]). The loca -tion of the tear was confirmed to be the urethra in 13 (13/15 [86.7%]) of the cases, the urinary bladder in 1 (1/15 [6.7%]) case, and in an unconfirmed location in 1 (1/15 [6.7%]) case. In the cat with the unconfirmed location of the tear, the presence of a uroperitoneum was confirmed via paired serum and fluid creatinine and potassium, and a potential sealed tear of the bladder was identified on ultrasonography. Concur -rent cystolithiasis on abdominal imaging was noted in 4 of the UO-R cases (4/15 [26.7%]) compared to 3 (3/45 [6.67%]; P = .058) cats in the UO-C group.Most cats in the UO-R group were managed medically either with a urinary catheter placed in the standard fashion (6/15 [40%]) or placed in a ret -rograde fashion via fluoroscopy (2/15 [13.3%]). Six cats were ultimately managed surgically either by a perineal urethrostomy (5/15 [33.3%]) or cystotomy (1/15 [6.67%]). One cat was euthanized prior to im -plementation of any treatment strategy once rupture was confirmed.Patients in the UO-R group were more likely to have had a history of previous UOs compared to the UO-C group (8/15 [53.3%] vs 8/45 [17.8%]; P = .007). The median number of previous UOs was 1 in both the UO-R group (range, 1 to 4) and the UO-C group (range, 1 to 2). The median number of days since last obstruction for the UO-R group was 6 days (range, 2 to 30 days) and 14 days for the UO-C group (range, 1 to 30 days).No significant differences in admission creati -nine, pH, potassium, or ionized calcium were noted between the UO-R and UO-C group. However, the Hct was significantly higher in the UO-R group than the UO-C group ( P = .0013; Table 1 ).The difficulty of catheterization score was sig -nificantly higher in the UO-R group than the UO-C group with a mean score of 3.1 (range, 0 to 4) versus 1.5 (range, 0 to 4; P = .0001), respectively. A catheter was unable to be passed in 7 cats in the UO-R group (7/15 [46.7%]) versus 1 cat in the UO-C group (1/45 [2.2%]). A decompressive cystocentesis was per -formed in 5 of the UO-C group (5/15 [33.3%]) and also in 5 of the UO-R group (5/45 [11.1%]), which was not statistically significant ( P = .06).Urine color at the time of urinary catheter place -ment was only reported in 5 (5/15 [33.3%]) cats in the UO-R group and 36 (36/45 [80%]) cats in the UO-C group, which precluded statistical analysis. The presence of grit during passage of the urinary catheter was not significantly different between the UO-R and UO-C cats ( P = .4). However, this was also less frequently recorded in the medical records and Variable UO-R group (range or mean) UO-C group (range or mean) P valueCreatinine (mg/dL) 2.55 (0.7–13) 1.5 (0.8–18.4) .5Ionized calcium (mmol/L) 1.12 ± 0.12 1.08 ± 0.16 .5pH 7.31 (7.14–7.45) 7.33 (7.06–7.46) .8Potassium (mEq/L) 4.18 (3.73–11) 4.1 (3.18–11.26) .5Hct (%) 44.43 ± 7.50 35.22 ± 9.87 .001*P < .05 considered statistically significant.*Significant finding.Table 1 —Clinicopathologic variables recorded on admission in a population of cats diagnosed with urethral ob -struction with concurrent lower urinary tear (UO-R) and a population without diagnosed lower urinary tear (UO-C) between January 2010 and December 2022.Unauthenticated | Downloaded 01/27/24 05:10 PM UTC190 JAVMA | FEBRUARY 2024 | VOL 262 | NO. 2was only available in 7 cats in the UO-R group and 28 in the UO-C group. Grit was noted in 6 (6/7 [85.7%]) cats in the UO and 17 (17/28 [60.7%]) cats in the UO-C group. The experience level of the person per -forming the unblocking procedure was infrequently recorded (3 of the UO-R group and 10 of the UO-C group), which precluded statistical evaluation.Only 10 (10/15 [66.7%]) cats in the UO-R group survived to discharge, which was significantly lower than the UO-C group in which 44 (44/45 [97.8%]) cats survived ( P = .003). In the nonsurvivor popu -lation, 1 cat in the UO-R group suffered cardiopul -monary arrest while the remainder were euthanized. One cat in the UO-R group was euthanized for a per -ceived poor prognosis and 1 for financial reasons. The remaining 2 cats euthanized in the UO-R group and the 1 individual in the UO-C group were euth -anized for reasons not recorded in the medical re -cord. The UO-R group also had a significantly longer duration of hospitalization with a median stay of 6 days (range, 1 to 11 days) as compared to the UO-C group, which had a median stay of 2 days (range, 1 to 7 days; P = .002).

Question 56

Camilletti - 2024 - JSAP - Long-term outcomes of atrophic:oligotrophic non-unions in dogs and cats treated with autologous iliac corticocancellous bone graft and circular external skeletal fixation - 19 cases (2014-2021).pdf

Answer 56

Case selectionMedical records from two referral veterinary hospitals were ret -rospectively searched by one operator for the keywords “dog,” “cat,” “non-union,” “circular external skeletal fixation,” “bone graft” between January 2014 and December 2021, using the hospitals’ database and the medical records search function integrated in the management software (CVIT). Animals were included in the study if they underwent surgery using CESF and ACBG for the treatment of viable oligotrophic or non -viable atrophic non-union fractures of radius/ulna and tibia/fibula. Patients were included if a radiographic study with a minimum of two views of the affected bone was available before revision surgery, immediately after surgery and after implant removal, and if at least one orthogonal radiographic study of the contralateral segment was available. Long-term follow-up was ≥1 year. Patients with a follow-up <1 year, patients who did not have orthogonal radiographs performed at least once every 4 weeks until bone healing was achieved, patients with radio -graphic signs of bone callus or with signs of infection at the time of diagnosis, were excluded. Non-unions were classified according to the criteria proposed by Weber and Čech ( 1976 ). Since the radiographic differentiation between viable oligotro -phic and non-viable atrophic non-union is questionable, the term atrophic/oligotrophic was used to refer to non-unions characterised by a rounded and sclerotic radiographic appear -ance of the bone ends, with bone resorption in the absence of callus. For the purposes of this study, a non-union was consid -ered to be a fracture that occurred >3.5 months previously, that was not deemed to progress to union without surgery, and in which no progression of bone healing was noted in at least 4 radiographic examinations performed 4 weeks apart.Medical record reviewMedical records were reviewed to collect information on the patients’ species, breed, sex, age, bodyweight, time from injury to non-union treatment and follow-up. Information on the surgical procedures performed on the affected and contralateral limb before the revision with CESF was recorded. The length of the affected and contralateral bone segments at the time of bone union was measured on standard orthogonal radio -graphs. The length of the bone was a straight line connecting the central point of the proximal and distal joints on the sagit -tal plane. The alignment of the bone segments was measured on both the operated and contralateral limb on radiographs obtained at the time of CESF removal, calculating the sagittal plane alignment (SPA) and the frontal plane alignment (FPA), as previously described (Dismukes et al ., 2007 ; Dismukes et al., 2008 ; Fox et al., 2006 ; Fuller et al., 2014 ). All mea -surements were performed by both authors individually, using the DICOM viewer OsiriX, and the values were compared after they were obtained. Any variability between observers was recorded. Torsional alignment was subjectively assessed by the authors on the basis of clinical comparisons between the affected and contralateral bone segments intraoperatively, in the immediate postoperative period, and at the time of CESF removal. The procedures, complications, and revision surger -ies were recorded. Complications were categorised as minor, major, and catastrophic according to the criteria proposed by James Cook et al. (2010 ); minor complications did not require further surgical or medical treatment to resolve, whereas major 17485827, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13681 by Vetagro Sup Aef, Wiley Online Library on [04/02/2024]. 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 LicenseCESF and bone graft treating non-unionJournal of Small Animal Practice • Vol 65 • February 2024 • © 2023 British Small Animal Veterinary Association. 125 complications did. The catastrophic complications caused permanent unacceptable function and were directly related to death or euthanasia.InstrumentationT wo different CESF systems (IMEX Veterinary Products, Inc., Longview, TX, USA; Small Bone Fixator: Hoffmann S.a.S., Monza, Italy) were selected on the basis of the patients’ size, according to the guidelines (Ferretti, 1991 ), and used to stabilise the fractures. The construct was composed of one full ring per main bone segment, and two K-wires for each ring connected the frame to the bone. A partially threaded half-pin was added to each ring. The rings were connected by two threaded rods and the frame was assembled before surgery on the basis of the pre -operative radiographs.Surgical procedureBefore anaesthesia, a physical examination and complete blood count and blood chemistry tests were performed. Cefazolin [Cefazolina Dorom; Teva, 25 mg/kg intravenous (IV)] was administrated 30 minutes before surgery, and the dose was repeated after 90 minutes. All cases were premedicated with methadone hydrochloride [Semfortan; Dechra, 0.2 to 0.3 mg/kg intramuscular (im)] alone or in combination with dexmedeto -midine (Dexdomitor; Vetoquinol, 5 to 10 mcg/kg im). Gen -eral anaesthesia was achieved via the administration of propofol (Propovet; Zoetis, 2 to 4 mg/kg IV) and maintained with iso -flurane (IsoFlo; Zoetis) in 100% oxygen. After obtaining x-rays of the affected and contralateral bone segments, including the proximal and distal joints, the patients were positioned in dorsal recumbency with the affected limb suspended for sterile drap -ing. A standard surgical approach to the fracture was performed, and the implants, if still present, were removed. In the case of metaphyseal/epiphyseal fractures, a traditional debridement of the bone ends was performed by removing fibrous and necrotic tissues with a rongeur and reopening the medullary canal with a smooth pin; in the case of diaphyseal fractures, debridement of the non-union site was performed by en bloc ostectomy using an oscillating saw (Blaeser et al., 2003 ). Debrided tissue and implants were collected for culture and sensitivity. The debride -ment was conducted until the bleeding bone was exposed, and this led to bone loss at the fracture site. The magnitude of this loss was estimated by measuring the length of the debrided bone intraoperatively with a Castroviejo calliper and the length of the contralateral bone on preoperative radiographs. The estimated percentage bone loss was obtained using the following formula: debrided bone (mm)/length of contralateral bone (mm)×100. After debridement, a surgical approach to the iliac wing was per -formed starting the incision over the cranial dorsal iliac spine. An incision was made on the periosteal origin of the middle gluteal muscle on the lateral edge of the ilium, near the cranial dorsal iliac spine and ending beyond the caudal dorsal spine. The mid -dle gluteal muscle was elevated to expose the gluteal surface of the wing of the ilium, and the ACBG were collected using two different techniques. One procedure involved harvesting a full-thickness portion of the cranial dorsal iliac spine en bloc with an oscillating saw, whereas the other required the collection of sev -eral portions of the iliac wing with a curved osteotome, retrieving the lateral cortex with the adjacent cancellous bone. All grafts removed en bloc were opened on the sagittal plane using no. 11 blades to obtain a longer graft ( Fig 1). The grafts were harvested such that their size, measured with a Castroviejo calliper, corre -sponded to the gap produced after debridement. Surgical time to harvest the grafts (from the skin incision to the last suture) and the length of the grafts were recorded. After lavage with sterile saline isotonic solution, the grafts were utilised to fill the gap and surround the non-union site, ensuring that they were in contact with the fracture ends ( Fig 2). The fractures were stabilised with the pre-assembled frame, and the surgical approach was routinely closed.Follow-up evaluationThe patients were divided into two groups: group A included dogs and group B included cats. Postoperative pain control was obtained by methadone hydrochloride (0.2 mg/kg im q4h) administration until the time of discharge. Patients were dis -charged 24 h after surgery, and meloxicam [Metacam; Boehringer Ingelheim, 0.1 mg/kg per os (PO) q24h in dogs and 0.05 mg/kg FIG 1. Full-thickness portion of the cranial dorsal iliac spine collected en bloc using an oscillating saw (A). Note that the bone was incised (B) using an n° 11 blade, opened (C) to obtain a longer graft and used to assure osteogenetic and osteoinductive functions and bridge a critical bone defect 17485827, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13681 by Vetagro Sup Aef, Wiley Online Library on [04/02/2024]. 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 LicenseP . Camilletti and M. d'AmatoJournal of Small Animal Practice • Vol 65 • February 2024 • © 2023 British Small Animal Veterinary Association. 126PO q24h in cats] and cephalexin (Cefaseptin; Vetoquinol, 25 mg/kg PO q12h) were administered for 7 days. The postoperative period was managed by the owner and included exercise restraint and the cleaning of pins/wires. The first clinical examination was conducted 1 week after the surgery, and postoperative clinical and radiographic assessments were conducted 4 weeks postopera -tively and every 2 weeks thereafter until radiographic evidence of bone union. Conventional orthogonal and oblique radiographs of the operated bone, including the proximal and distal joints, were obtained under sedation, and bone healing was radiograph -ically assessed applying the criteria used for the RUST score (Whelan et al., 2010 ) on the basis of the assessment of healing at each of the four cortices visible on orthogonal projections ( i.e. medial and lateral cortices on the cranio-caudal/caudo-cranial radiographs and cranial and caudal cortices on the medio-lateral radiographs). Each cortex received 1 point if it had a fracture line without a callus, 2 points if a callus was present but a fracture line was still visible and 3 points if a bridging callus was present with no evidence of a fracture line. At each radiographic check, the score of each single cortex was added, with a minimum score of 4 in the case of a non-healed fracture and a maximum score of 12 for a completely healed fracture. The CESF was removed at the time of complete bone healing. For this purpose, the patients were sedated with methadone hydrochloride (0.2 to 0.3 mg/kg im) and dexmedetomidine (5 to 10 mcg/kg im) and the pins/K-wires were removed using a hand drill. After implant removal, the owners were instructed on how to gradually increase the patient’s exercise until return to normal activity within 8 weeks. The time between the revision surgery and bone union was recorded. Bone length discrepancy and bone alignment were assessed by evaluat -ing the radiographs that were obtained after CESF removal. The percentage of length maintained in the operated bone in relation to the contralateral segment was calculated using the following formula: length of the operated bone (mm)/length of the contra -lateral bone (mm)×100. FPA and SPA were measured as previ -ously described (Dismukes et al., 2007 ; Dismukes et al., 2008 ; Fox et al., 2006 ; Fuller et al., 2014 ). Negative values represented recurvatum and varus deviations, and positive values represented procurvatum and valgus deviations. The alignment values were compared with those of the normal contralateral limb. During the clinical evaluations, information about the presence and severity of lameness, range of motion (ROM) of adjoining joints, and presence of pin/wire discharge were collected. Postoperative lameness was assessed using the following score: 0 (no observable lameness), 1 (intermittent, mild weight-bearing lameness with little if any change in gait), 2 (consistent, mild weight-bearing lameness with little change in gait), 3 (moderate weight-bearing lameness – obvious lameness with noticeable change in gait), 4 (severe weight-bearing lameness – “toe-touching” only), 5 (non-weight-bearing) (Cook et al., 1999 ). The ROM of the joints proximal and distal to the affected bone was measured using a goniometer with the animal in the lateral recumbency and the operated limb uppermost, and all measurements were recorded. A further radiographic evaluation was performed 24 weeks after surgery, during which information on the healing of the pins and K-wires holes and remodelling of the callus was recorded. Each animal was re-examined at least 1 year after surgery to assess the presence of lameness and to evaluate the ROM of the joints adjacent to the operated bone segment. The long-term outcome was assessed on the basis of a telephonic interview with the own -ers, during which they were asked to provide a subjective assess -ment of the function (Cook et al., 2010 ) and on the basis of the Canine Brief Pain Inventory (CBPI; 0 to 10 numerical rating scale, where 0=no pain and 10=extreme pain) and Feline Mus -culoskeletal Pain Index-short form (FMPI- sf; 0 to 4 numerical rating scale, where 0=activity performed normally and 4=activity was impossible to perform) scores reported by the owners (Brown et al., 2007 ; Enomoto et al., 2022 ). Subjective outcomes were FIG 2. Preoperative caudocranial (A) and mediolateral (B) radiographic images showing a mid-diaphyseal tibial atrophic nonunion fracture in a 7-years-old male domestic short-haired cat. Postoperative caudocranial (C) and mediolateral (D) views: note the corticocancellous grafts used to surround the fracture site and to fill the bone gap (white arrow). In this case, the corticancellous grafts were obtained using a curved osteotome. Caudocranial (E) and mediolateral (F) images obtained 8 weeks postoperatively, after implant removal. Note the presence of significant new bone formation and the complete incorporation of the graft into the callus (red arrow) 17485827, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13681 by Vetagro Sup Aef, Wiley Online Library on [04/02/2024]. 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 LicenseCESF and bone graft treating non-unionJournal of Small Animal Practice • Vol 65 • February 2024 • © 2023 British Small Animal Veterinary Association. 127 defined as the following: (1) full function – restoration to full level of intended activities without evidence of lameness, pain, or necessity of NSAIDs; (2) acceptable function – restoration to intended activities from pre-injury status but with intermittent pain or use of NSAIDs; and (3) unacceptable function – all other outcomes not allowing for return to intended activity.The authors confirm that the ethical policies of the journal have been adhered to. This study was exempted from ethical approval, as this is a retrospective case series in which all animals were treated for a previously occurring disease, and all owners consented to the procedures described in the study.RESULTSPatients includedT wenty-three patients (16 dogs and 7 cats) were identified through the database search. Three dogs and one cat were excluded due to the presence of callus at the fracture site. Nine -teen fractures in 13 dogs and six cats met the inclusion criteria. Patients’ signalment data are listed in Table 1. Included fractures were atrophic/oligotrophic non-unions of radius/ulna (n=12) and tibia/fibula (n=7). Seven patients had closed diaphyseal frac -tures (tibia/fibula, n=3; radius/ulna, n=4), 12 had closed distal metaphyseal/epiphyseal fractures (tibia/fibula, n=4; radius/ulna, n=8), and none had an articular fracture. All animals had never undergone surgery on the contralateral limb. The median age of the patients was 18 months in group A (range 11 to 108 months) and 66.5 months in group B (range 26 to 133 months), with a median weight of 3 kg in the group A (range 1.5 to 10 kg) and 4 kg in the group B (range 3.5 to 6.2 kg). Before the evaluation at the referral hospitals, each patient has undergone at least one pre -vious unsuccessful osteosynthesis on the affected bone segment, which in 10 cases was performed with a linear external fixator, in six cases with plate and screws, and in three cases the patients underwent a first surgery with a linear external fixator and a sec -ond surgery with plate and screws ( Table 1). The median time between the initial fracture and revision surgery was 184 days in group A (range 100 to 270 days) and 203 days in group B (range 127 to 270 days; Table 1).Surgical techniqueThe preoperative general physical examination and blood tests results were normal in all patients. At the time of the revision, 15 patients still had the previous osteosynthesis implants (linear external skeletal fixators, n=6; locking plate, n=7; dynamic com -pression plate, n=2). In seven cases, the debridement was per -formed by the en bloc technique. In the other cases, a traditional technique using a rongeur and a smooth pin was chosen (Blae -ser et al., 2003 ). A miniature CESF system (IMEX Veterinary Products, Inc., Longview, TX, USA) was used for 18 patients, applying a 35-mm diameter full ring proximally and a 35-mm diameter full ring distally, connecting bars of 4-mm diameter and four 0.8-mm transosseous wires. In one case (case 1A), a CESF (Small Bone Fixator: Hoffmann S.a.S., Monza, Italy) with a 66-mm diameter full ring proximally and a 66-mm diameter full ring distally, connecting bars of 6-mm and four 1-mm transosse -ous wires, was chosen. In case 1A, the wires were intra-operatively tensioned to 30 kg using a dynamometer wire tensioner, whereas in the other cases, K-wires tensioning was not needed owing to the small bodyweight of the patients and the small ring diam -eters (Ferretti, 1991 ). In all cases, the stability of the frame was increased by adding a partially threaded half-pin secured to the single ring. The microbiological culture results were negative for every patient. The median estimated percentage bone loss after debridement was 22.5% in group A (range 21.2% to 39.5%) and 25.4% in group B (range 22.6% to 35.3%; Table 2). In 10 cases, a full-thickness portion of the cranial dorsal iliac spine was collected en bloc, while in the other patients multiple portions of the iliac wing were withdrawn with a curved osteotome. The Table 1. Patient signalment dataCase Species Breed Sex Age (months)Weight (kg)Initial method of fracture treatmentTime from injury to non-union treatment (days)Follow-up (months)1A Dog Mixed breed ME 108 10.0 ESF, LP 123 542A Dog Yorkshire terrier FS 13 2.5 LP 270 853A Dog Mixed breed FS 12 3.1 ESF 154 634A Dog Zwergpinscher ME 27 5.0 ESF, LP 251 475A Dog Chihuahua FS 13 2.2 ESF 210 286A Dog Mixed breed FS 15 4.4 DCP 215 357A Dog Toy poodle ME 11 3.2 LP 184 408A Dog Toy poodle ME 32 3.4 ESF 165 319A Dog Mixed breed FS 18 1.5 ESF 100 3410A Dog Zwergpinscher FS 73 2.6 ESF 187 2111A Dog Bichon frisé FE 38 3.1 ESF 119 2012A Dog Pomeranian dog MC 15 2.3 LP 153 1613A Dog Chihuahua FE 37 1.9 ESF 187 171B Cat Domestic short-haired FS 48 3.5 ESF 270 922B Cat Domestic short-haired FS 26 4.1 ESF 180 873B Cat Domestic short-haired MC 84 3.6 ESF 185 514B Cat Domestic short-haired MC 49 5.0 ESF, DCP 127 235B Cat Domestic short-haired MC 108 5.2 LP 239 186B Cat Siberian MC 133 6.2 LP 221 15ME Male entire, FE Female entire, MC Male castrated, FS Female spayed, ESF Linear external skeletal fixation, LP Locking plate, DCP Dynamic compression plate 17485827, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13681 by Vetagro Sup Aef, Wiley Online Library on [04/02/2024]. 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 LicenseP . Camilletti and M. d'AmatoJournal of Small Animal Practice • Vol 65 • February 2024 • © 2023 British Small Animal Veterinary Association. 128median time required to obtain bone grafts was 8 minutes (range 7 to 9 minutes). The median length of en bloc ACBG after lon -gitudinal split was 1.8 cm (range 1.3 to 3 cm) and that of ACBG collected using an osteotome was 1.8 cm (range 1.5 to 2.5 cm).Follow-up evaluationEighteen animals (94.7%) achieved bone union while one (5.3%) did not (case 9A). All animals started to use the limb within 1 week postoperatively and showed a progressive gait improvement during the recovery period. The median time of bone union was 10 weeks in group A (range 8 to 12 weeks) and 9 weeks in group B (range 8 to 12 weeks). The limbs maintained a median bone length of 95% compared with the contralateral bone in group A (range 83.3 to 98.5%). The median bone length maintained in group B was 91% (range 75.3 to 97.2%). Among patients who achieved bone union, the difference between the FPA of the affected and contralateral bone was <3° in 94.4% of cases (n=17), while the difference in SPA was <3° in all cases. The recorded FPA and SPA values and the percentage of bone short -ening at the time of bone union are listed in the Table 2. The measurement of the length and alignment of the bone segments showed a correspondence between the observers, with minimal variations in the order of hundredths. Subjective assessment of torsional alignment showed no or minimal differences between the operated and contralateral limb. The median follow-up time was 34 months (range 15 to 92 months; Table 1). Radiographic follow-up 24 weeks post revision showed complete healing of the pin/K-wire holes and the presence of callus remodelling in every patient treated with CESF and ACBG. Five patients (26%) had minor complications in the perioperative period (<3 months), consisting of wire discharge (n=2), half-pin breakage (n=1), K-wire breakage (n=1) and valgus deviation (n=1). The pin break -age was detected at a radiographic follow-up performed 6 weeks postoperatively and replacing it was not necessary because of the presence of a radiographically evident callus on the four bone cortices, while the K-wire breakage was identified during the clinical evaluation on the day of the CESF removal. The valgus deviation occurred in the absence of rupture or bending of the implant, probably because of peri-implant bone yielding. One patient developed decreased ROM and degenerative changes in the radiocarpal joint, and two dogs developed radio-ulnar syn -ostoses without any apparent sequelae. One case (9A) did not achieve bone union and underwent further revision using an en bloc ostectomy of the bone ends, reducing the fracture to mini -mise the gap, and stabilising the site with a Micro series Fixin plate and screws (Intrauma, Rivoli, Italy). An autologous cancel -lous bone graft that was collected from the proximal humerus was applied to the fracture site, and the non-union healed in 16 weeks. The bone segment was 23% shorter than the contra -lateral side and the dog developed a moderate (3/5) lameness and slight palmigrade stance. Among the animals that achieved bone healing, 17 (94.4%) had a normal ROM of the joints adjacent to the operated bone and 18 (100%) were lameness-free at clini -cal follow-up >12 months post revision. The CBPI mean severity score was 0 (n=11), 0.25 (n=1) and 1 (n=1) while the CBPI mean interference score was 0 (n=11), 0.33 (n=1) and 1.16 (n=1). The mean FMPI- sf score was 0 (n=4), 0.22 (n=1) and 0.33 (n=1). Overall, 15 (78.9%) patients returned to full function and 3 (15.8%) returned to acceptable function, as defined by the own -er’s perception of the long-term outcome. In one (5.3%) patient, the function was classified by the owner as unacceptable, due to the persistence of lameness and slight palmigrade stance.

Question 57

Naghi - 2023 - JAVMA - Acellular fish skin may be used to facilitate wound healing following wide surgical tumor excision in dogs - A prospective case series.pdf

Answer 57

AnimalsFrom August 2020 to May 2022, client-owned dogs undergoing surgical excision of distal extremity tumors were enrolled prospectively. Cases were included if they had a locally invasive mass or tumor scar distal to the el -bow or stifle, diagnosed preoperatively with cytology or histopathology, and were undergoing wide surgical exci -sion (defined as 2- to 3-cm lateral margins and 1 fascial plane deep to the tumor and/or scar). Dogs were excluded if blood work was compatible with an endocrinopathy, they were receiving steroid treatment, or they received neoad -juvant chemotherapy or radiotherapy. This study was ap -proved by the IACUC of the University of Florida (IACUC No. 202011079). All options available at our institution for the management of distal extremity tumors were dis -cussed with pet owners, and owner consent was obtained.Anesthesia and surgeryAll dogs were anesthetized according to a pro -tocol created by the board-certified anesthesiolo -gist. Perioperative antimicrobial prophylaxis (ce -fazolin sodium, 22 mg/kg, IV) was administered to all dogs 30 minutes prior to initiation of surgery and every 90 minutes intraoperatively. General anesthesia was maintained with isoflurane in oxygen. All surgi -cal procedures were performed by a board-certified veterinary surgeon specialized in surgical oncology. A sterile ruler and marker were used to measure and mark 2-cm-wide margins around the mass prior to ex -cision. All masses were excised with 2 cm of lateral margins and 1 fascial plane deep to the tumor. Fascia was secured to the skin using intermittent interrupt -ed sutures to maintain orientation of tissues. Ink was applied to surgical margins of resected tissue, and samples were placed in neutral-buffered 10% formalin prior to histopathological analysis. Dogs undergoing MCT excision also had the sentinel lymph node removed.Unauthenticated | Downloaded 10/08/23 06:32 AM UTC JAVMA | OCTOBER 2023 | VOL 261 | NO. 10 1549Graft applicationThe acellular FSG was placed following wide surgi -cal excision of the tumor. Bandages were changed once weekly with additional FSGs placed over the wound bed once the previous graft was fully integrated. At each bandage change, wounds were gently lavaged with sterile saline (0.9% NaCl) and, prior to the placement of a new FSG, sharp debridement was performed to remove any excessive granulation tissue and initiate bleed -ing within the wound bed. Following debridement, the FSG was aseptically removed from the packaging, cut to fit the wound size, and rehydrated for 1 minute by placing it in a bowl of room-temperature sterile saline. The FSG was applied directly to the wound bed (scale pattern side up) and fixed in place with skin sutures or staples. The graft was covered with a nonadherent dressing (Adaptic; Systagenix) and bolstered with a sec -ondary dressing ideal for optimal exudate management: calcium alginate during the initial wound healing stages and hydrophilic foam dressing (silicone foam dressing; JorVet) in the later stages. The dressings also functioned to ensure graft contact with the wound bed. A soft pad -ded bandage was placed to maintain and protect dress -ing placement. All bandage changes were performed by a clinician. Sedation was used to facilitate bandage changes whenever a new FSG was applied and was ac -complished using dexmedetomidine (3 to 6 µg/kg, IV) and/or butorphanol (0.1 to 0.2 mg/kg, IV) and reversed with atipamezole volume IM equal to the administered volume of dexmedetomidine.Dogs were discharged on oral carprofen (2.2 mg/kg) or meloxicam (0.1 mg/kg) and gabapen -tin (10 mg/kg) for a minimum of 7 days and used as needed throughout the course of the treatment period. Trazodone (3 to 6 mg/kg, PO) was used as needed to aid in postoperative activity restrictions.Wound assessment and data collectedInformation regarding signalment (ie, breed, sex, age, and body weight), tumor type, surgical margins obtained, histologic margins reported, and tumor recurrence for each dog was recorded.A validated mobile platform–based 3-D wound management device (Insight; eKare Inc) was used for obtaining and tracking wound dimensions and identify -ing color of the tissues present in the wound bed.38 After placing a reference marker with a diameter of 1.90 cm, a scaled high-resolution 2-D photo with an iPhone XR na -tive 12-megapixel camera was used to obtain images of the wound at each assessment/bandage change. Using the associated mobile application, the device was used to obtain length, width, depth, and area measurements for each wound. An outline of the wound border, semi -automatically defined by the user, was used to define the region of interest. The application’s Color Classification feature was utilized to break down wound areas into 3 different categories on the basis of color analysis and ma -chine learning methods. The color of the wound bed was categorized as healing (red), devitalized (yellow), and dead (black). Quality control was performed on all wound images following each bandage change to ensure accu -rate measurements and wound bed categorization. Addi -tionally, the wounds were assessed for time to complete wound healing (defined as days from the date of surgery to complete epithelialization of the wound), percentage decrease of wound bed size at each visit, subjective as -sessment of cosmetic outcome by the overseeing clini -cian, and complications during the healing process.Statistical analysisFor descriptive analysis, categorical data was tabu -lated using an electronic spreadsheet (Sheets; Google LLC). Additionally, numbers, medians, ranges, and means were calculated using an online calculator (Mean, Median and Mode Calculator; CalculatorSoup LLC).ResultsAnimalsFive dogs (3 castrated males and 2 spayed fe -males) with distal extremity tumors undergoing wide surgical excision were enrolled in the study. Three of the 5 dogs were identified as mixed-breed dogs, and other breeds represented included an Alaskan Klee Kai and a Doberman Pinscher. Dogs had a median weight of 27.4 kg (range, 8.8 to 46.1 kg). The median age was 8 years old (range, 7 to 11 years old).Surgical resection and histologic evaluationAll masses were located over the distal limbs, in -cluding 4 right antebrachial masses and 1 left metatarsal mass. Before enrolling in this study, dog 5 had already undergone 2 incomplete excisions of an STS. In this dog, 2-cm lateral and 1 fascial plane–deep margins were ob -tained in relation to the scar and recurrent mass.Two dogs were diagnosed with a dermal mast cell tumor (MCT), both classified as Patnaik grade 2, Kiupel low grade. One dog was diagnosed with a subcutane -ous MCT, and 2 dogs were diagnosed with a grade 1, low-grade STS. Results of histological assessment of tumor specimens indicated that 3 of the 5 tumors had incomplete histological margins and 2 of the 5 were de -scribed as having clean margins (Table 1) .Graft application and wound assessmentsFour out of 5 dogs had an FSG placed immedi -ately after mass excision during the same anesthetic event. One dog underwent a reconstructive proce -dure for a wide excision of a dermal MCT on the right antebrachium. This dog initially had the surgical site closed primarily with a full-thickness skin graft and was discharged after 4 days of hospitalization fol -lowing vacuum-assisted closure. At the 1-week post -operative bandage change, the skin graft was no lon -ger viable and removed. Two days later, an FSG was placed on an otherwise healthy wound bed.The median tumor volume was 1.37 cm3 (range, 0.35 to 3.75 cm3). The initial surgical wound sites had a median surface area of 27.6 cm2 (range, 17.6 to 58.7 cm2). The median number of FSG applications was 5 (range, 4 to 9 graft applications). The median number of bandage changes was 11 (range, 9 to 23 bandage changes). The median time between each FSG application was 8 days (range, 5 to 18 days). Complete epithelialization occurred in all surgical wounds. In dogs Unauthenticated | Downloaded 10/08/23 06:32 AM UTC1550 JAVMA | OCTOBER 2023 | VOL 261 | NO. 101, 3, and 5, wounds healed without complication in 65, 52, and 64 days, respectively, after the first FSG was placed. Dog 2 had the longest time to complete wound healing (105 days) due to complications re -lated to self-trauma and repeated consumption of the bandage material. Dog 4 healed in 84 days and sustained several minor setbacks in wound healing af -ter the soft padded bandage had slipped down over the wound, traumatizing the re-epithelialized tissue, along with self-trauma to the wound bed (Figure 1) . Surgical margin Size of mass (lateral cm X Area No. of Days to Location (L X W fascial plane Histological of initial total FSG completeCase Signalment of wound Tumor type X H cm) deep) margin status wound (cm2) applications closure1 7yo MN MBD Right cranial Dermal MCT 2.0 X 1.0 X 0.5 2.0 X 1 Incomplete lateral 27.8 6 65 antebrachium Grade 2, low grade 2 8yo MN MBD Left dorsal Dermal MCT 1.0 X 1.0 X 0.7 2.0 X 1 Incomplete lateral 17.7 4 105 metatarsal Grade 2, low grade 3 11yo FS Alaskan Right cranial SC MCT 1.5 X 2.0 X 1.0 2.0 X 1 Complete 17.6 5 52 Klee Kai antebrachium 4 8yo FS MBD Right lateral STS 2.0 X 2.5 X 1.5 2.0 X 1 Incomplete deep 27.6 5 84 antebrachium Grade 1, low grade 5 7yo MN Doberman Right caudal STS 2.0 X 1.5 X 0.5 2.0 X 1 Complete 58.7 9 64 Pinscher antebrachium Grade 1, low grade with a 10-cm scar FS = Female spayed. MBD = Mixed-breed dog. MCT = Mast cell tumor. MN = Male neutered. STS = Soft tissue sarcoma. yo = Years old.Table 1 —Summary of case demographics for 5 dogs with surgically induced wounds managed with fish skin grafts (FSGs) to promote second-intention healing on the distal extremit ies following wide excision of tumors.Figure 1 —Progression of second-intention wound healing in an 8-year-old female spayed mixed-breed dog (dog 4) after wide tumor excision and immediate placement of a fish skin graft (FSG). A—A 2.0 X 2.5 X 1.5-cm soft tissue sarcoma excised with 2-cm lateral margins and 1 fascial plane deep. B—An FSG applied immediately following mass excision. C—Two weeks postoperatively, a healthy bed of granulation tissue is present. D—Five weeks postopera -tively, epithelialization along the wound margin and healthy granulation bed is present. E—Twelve weeks postopera -tively, there is complete epithelialization of the surgical wound. F—Twelve months postoperatively, mature epithelial tissue is present with no hair regrowth.Unauthenticated | Downloaded 10/08/23 06:32 AM UTC JAVMA | OCTOBER 2023 | VOL 261 | NO. 10 1551A decrease in wound area was most dramatic between the second and fourth weeks after surgery, with an average decrease of 29% ± 7%, and then between the sixth and eighth weeks postoperatively, with an aver -age decrease of 70% ± 11.1% (Figure 2) . No wounds de -veloped any clinical evidence of a surgical site infection throughout the trial. The percentage of healing (red), devitalized (yellow), and dead (black) tissue compris -ing the wound bed was measured at each bandage change. Wound beds on average had 98.3% ± 0.8%, 1.4% ± 0.5%, and 0.2% ± 0.3% evidence of healing, devi -talized, and dead tissue, respectively, over the course of treatment. Subjectively there was minimal contrac -tion of the wounds initially, which increased within the sixth to eighth weeks postoperatively. A small area of alopecia was present at the surgical site in all dogs.for removal. There were no contracture complications noted of any of the wounds.Follow up intervals ranged from 239 to 856 days. No dogs were lost to follow-up and there has been no evidence of local recurrence for any of the dogs at the time of writing this manuscript.

Question 58

Moreira - 2024 - VETSURG - Predicting tibial plateau angles following four different types of cranial closing wedge ostectomy.pdf

Answer 58

2.1 |Patient selectionComputed tomography (CT) scans of dogs presented to theorthopedic service at Highcroft Veterinary Referrals forinvestigation of hindlimb l ameness over a 3-year period(July 2016 to June 2019) were retrospectively reviewed.Dogs were selected to provid eaw i d er a n g eo fb o d y w e i g h t sand varying conformations. In formation retrieved includedbreed, age, bodyweight and presenting complaint.Owner consent for clinical data use in research andpublications was obtained as part of the standard admis-sion consent form.2.2 |Image acquisitionPatients underwent a CT scan under sedation or generalanesthesia and the images were obtained using a 16 slicemultidetector unit (GE Medical Systems LightSpeed 16 orSiemens Somatom) with a slice thickness between 0.625144 MOREIRA ET AL . 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14033 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 Licenseand 2 mm, KVP of 120 or 130 and mAs between54 and 300.2.3 |3D modeling and measuringImages were exported as DICOM files into a diagnosticimaging viewing software (Horos version 3.3.6,horosproject.org , Nimble Co LLC d/b/a Purview, Annap-olis, Maryland). A surface rendered 3D model was cre-ated as a grow region of interest with a window between200 and 4000 Hounsfield units (HU) and outside pixelsset to 0 HU. The surface rendered model was thenexported as an. STL file into an open-source 3D com-puter graphics editor (Blender version 2.82,blender.org ,Blender Foundation, Amsterdam, Netherlands). The limbwas cropped to include only the scanned area distal tothe femur. The tibias were then aligned to give a truelateral image of the tibia through precise superimpositionof the tibial condyles along the program's x- and y-axis,according to the description by Reif et al.20The position of the center of the talus, cranial andcaudal boundaries of the medial tibial condyle, apex ofthe intercondylar tubercles, tibial tuberosity and of thestart of the proximal osteotomy cut were marked with0.5 mm radius, spherical markers by one author (DO).Within the graphics editing software, the vector ofeach individual marker was recorded in the y and zplanes in mm to seven decimal places and entered intoa spreadsheet (Microsoft®Excel). The distancebetween the center of the talus and the apex of theintercondylar tubercles was designated as the mechani-c a lt i b i a ll e n g t h( m T L ) .T r i g o n o m e t r yw a su s e do nt h evectors to calculate the TPA and mTL, using the fol-lowing equations:mTLA ¼cos/C01ΔyΔx/C18/C19/C2180πwhere mTLA represented the mechanical tibial long axisangle and xandyvalues were the coordinates used to cal-culate the vector joining the talus to the intercondylareminence markers.mCdPTA ¼90/C0tan/C01ΔxΔy/C18/C19/C2180πTPA¼mCdPTA /C0mTLAwhere mCdPTA represented the mechanical caudal prox-imal tibial angle and xandyvalues were the coordinatesused to calculate the vector joining the cranial and caudalmedial tibial condyle markers.mTL¼ffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi ffiΔy2þΔx2 ðpÞwhere the xand yvalues were the coordinates used tocalculate the vector joining the talus to the intercondylareminence markers.2.4 |Surgical planningFour different CCWO techniques were investigated in thisstudy: (1)Traditional CCWO as described by Slocum andDevine,1(2) mCCWO as described by Oxley et al.,16(3) mCCWO as described by Frederick and Cross,17and(4) mCCWO as described by Christ et al.18All CCWO andmCCWO were planned with the proximal osteotomy linestarting 5 mm distal to the insertion of the patellar tendonas described in patients <25 kg by Oxley et al.16Withinthe graphics editing software, seven right angle and sevenisosceles triangular wedges were created with apex anglesvarying by 10/C14increments, ranging from 10/C14to 70/C14.T h e s ewere mapped onto the tibias as described for eachCCWO1,16 –18and a Boolean difference operation with anoverlap threshold of 1 /C210/C09mm was used to create vir-tual ostectomies in each tibia. The five proximal tibialmarkers were then parented onto the proximal tibial seg-ment so that their surface position in relation to the seg-ment was maintained, as it was manipulated. Theproximal tibial segment was then rotated and translated inthe x and y plane until the ostectomy was reduced withalignment of the cranial cortices as suggested by Baileyet al.12The new coordinate values of each marker wererecorded at axial rotation, centered at the wedge apex, andafter cranial cortical alignment in every model (Figure 1).Trigonometry of the vectors was used to calculate the newTPA and mTL, as described before. Trigonometry was alsoused to calculate the incurred TLA shift, wedge base size,cranial-caudal translation of the proximal segment andwedge apex location, using the following equations:TLA shift ¼TPAtarget/C0TPA achievedwhere TPA target represented the original TPA minus therespective wedge size for the individual tibial model.The TPAachieved was calculated as previously described.Incurred TLA shift was calculated upon axial rotationand after cranial cortical alignment.Wedge base size ¼ffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi ffiΔy2þΔx2 ðpÞMOREIRA ET AL . 145 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14033 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 Licensewhere the xand yvalues were the coordinates used tocalculate the vector joining the location of original proxi-mal osteotomy cut marker and its final position, follow-ing axial rotation and cranial-caudal translation.CrCd translation ¼Δystart/C0endwhere CrCd translation repr esented the cranial-caudaltranslation distance incurre d in the proximal segment toachieve alignment of the cran ial tibial cortices. The yvalueswere the coordinates used to ca lculate the vector joiningthe proximal osteotomy cut marker after rotation but priorto translation, and after cranial cortical alignment.PDApex¼mTL/C0ffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi ffiΔy2þΔx2 ðpÞwhere PD Apexrepresented the proximal-distal distance ofthe wedge apex in relation to the intercondylar emi-nences. The xandyvalues were the coordinates used tocalculate the vector joining the markers at the wedgeapex and talus.C h a n g ei nm T L ,w e d g eb a s es i z ea n dp r o x i m a l - d i s t a lwedge apex location were normalized as a proportion of theoriginal mTL, to allow comparison of a wide range of tibiallengths. Normalization of the proximal segment cranial-caudaltranslation distance to achieve cranial cortical alignment wasnot possible and thus simply recorded in millimeters.Both mCCWO as per Frederick and Cross17and Christet al.,18share the same proximal osteotomy line locationand orientation, parallel to the TPA. Their respectivewedge apices are then located somewhere within this cra-nioproximal to caudodistal line.17,18Cranial eccentricity ofthe wedge apex in these CCWO was then inferred from itscaudodistal distance to the proximal osteotomy cutmarker, calculated using the following formula.CdDApex¼ffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiΔy2ApexþΔx2Apex/C16rÞffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiΔy2TibiaþΔx2Tibia/C0qÞwhere, CdD Apexrepresented the caudodistal wedge apexlocation in relation to the proximal osteotomy cutmarker, normalized as the proportional distance of thefull proximal ostectomy virtual length. Numerator xApexand yApex values were the coordinates used to calculatethe vector joining the proximal osteotomy cut and wedgeapex markers. Denominator xTibiaandyTibiavalues werethe coordinates used to calculate the vector joining theproximal osteotomy cut and a 3D marker added tothe caudal tibial cortex, in line with the proximal tibialosteotomy. Wedge apices in Slocum and Devine's CCWOand Oxley's mCCWO were mapped either at the caudaltibial cortex,1or immediately cranial to it,16therefore,their cranial-caudal location was not recorded.FIGURE 1 Cranial closing wedge ostectomy in the graphics editing software, as described by Christ et al.,18in a 7-year-old maleneutered Labrador with a TPA of 29.8/C14. (A) original tibia with highlighted 3D markers placed in the center of the talus (1), cranial (2) andcaudal boundaries (3) of the medial tibial condyle, apex of the intercondylar tubercles (4), tibial tuberosity (5) and at the start of the proximalosteotomy (6), 5 mm distal to the tibial tuberosity. (B) 40/C14wedge mapped in the proximal tibia, as per Christ et al.,18transecting the 3Dmarker distal to the tibial tuberosity (6). (C) ostectomy simulated through a Boolean difference operation. (D) 40/C14axial rotation of theproximal segment, centered at the wedge apex (7). (E) caudal translation of the proximal segment, until cranial cortical alignment of theostectomy was achieved, as suggested by Bailey et al.12146 MOREIRA ET AL . 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14033 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 License2.5 |Statistical analysisMeasurements from the initial five tibias were used toestimate the sample size required to detect a differencebetween techniques of 5% in mean mTL and 1/C14in TPA ata significance level of 0.05 and power of 0.80. Estimatedsample size was n=13 and n=14, respectively. Toallow for a small increase in variability, 15 tibias wereassessed.Linear mixed models were used to test whether therelationship between (1) TLA shift, (2) TPA correction or(3) percentage change in mTL, and wedge angles variedbetween the studied CCWO techniques, that is, whetherthere was a significant technique /C2wedge angle interac-tion. Linearity in relationships for each technique wereassessed using Pearson's correlation coefficients. In thesemodels, dog was treated as a random effect, and tech-nique, wedge angle and technique /C2wedge angle as fixedeffects. Wedge angle was considered as a continuous vari-able. Visual inspection of the relationship with change in%mTL suggested a nonlinear relationship, hence itsmodel was extended to include a quadratic term forwedge angle and its interaction with each CCWO tech-nique. Wedge base size, cranio-caudal translation andTLA shift without cranial cortical alignment also sug-gested a nonlinear relationship with wedge angle andwere analyzed in similar fashion to the change in %mTL.Corrective factors for each technique were obtainedfrom linear regression equations of wedge angles (exclud-ing 0/C14) on change in TPA. Predicted TPA, mTL% changeand TLA shift for the 15 tibias were subsequently calcu-lated based on interpolations between targeted wedgeangles and the corrected wedge angle as above. Thesepredictions were then analyzed as linear mixed modelswith dog as a random effect and technique as a fixedeffect followed by Tukey's HSD multiple comparisons.Regressions of TPA correction on wedge angle werecalculated for each technique and used to estimate thevalue where the wedge angle required to achieve a post-operative TPA of 5/C14switches from a value less than theTPA, to one greater than it.Statistical significance was considered at p< .05. Allanalyses were carried out using statistical software(Minitab version19, Center County, Pennsylvania).3|RESULTS3.1 |PopulationOne tibia, randomly selected from each of the 15 differentdogs included in this study, was analyzed. Ten of the 15 tib-ias were left and five tibias were right. Twelve breeds wererepresented: crossbreed ( n=3); cockapoo ( n=2); lurcher,Bichon Frise, Rottweiler, Labrador, French Bulldog,Bernese Mountain dog, Pug, English Springer Spaniel,Staffordshire Bull Terrier and Shi Tzu ( n=1, each).Median weight at scanning was 12.6 kg (range: 4.7 –44.0 kg) and median age at scanning was 2.2 years (range:0.7–7.3 years). Six dogs were neutered males, four wereentire males, three were neutered females and two wereentire females.The reasons for pelvic limb CT scans in this populationwere: medial patella luxation ( n=7); hip dysplasia(n=2); cranial cruciate ligament disease, lateral patellaluxation, femoral angular deformity (distal varus anddecreased anteversion), intertarsal torsion, tarsal tunnelsyndrome and undiagnosed lameness ( n=1, each).Median TPA on presentation was 23.5/C14(range: 18/C14–38.7/C14).3.2 |3D modeling and measuringFrom the 15 tibias selected, 418 additional tibia modelswere generated in the graphics editing software(Figure 2). Due to the proximal tibia conformation ofpatients 10 and 14, the mCCWO as described by Christet al.,18were not possible with a 70/C14wedge, as the distalosteotomy was longer than the proximal.Within the tested range of angle corrections, the TPAvaried in a linear fashion, with increasing wedge angles(Pearson's correlation coefficient for each technique≥0.99), regardless of proximal tibia conformationFIGURE 2 Image extracted from the graphics editing softwareof a 1-year-old male neutered English Springer Spaniel with a24.15/C14TPA. From left to right: original 3D-model followed by 40/C14cranial closing wedge ostectomy as described per Slocum &Devine.,1Oxley et al.,16Frederick & Cross.,17and Christ et al.18Tibial markers in the tibial plateau and in the center of the talushighlighted.MOREIRA ET AL . 147 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14033 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 License(Figure 3). The linear mixed model indicated a difference(p< .001) between techniques in their relationshipbetween wedge angle and TPA correction (Table S1).Within the tested range of angle corrections, the finalTLA shift also varied in a linear fashion, with increasingwedge angles (Pearson's correlation coefficient for eachtechnique ≥0.95). All techniques induced a TLA shift,that increased in magnitude with higher wedge angles(TableS1) and (Table 1) and was more pronounced inthe mCCWO as described by Frederick and Cross,17aftercranial cortical alignment. The linear mixed modelassessing the final TLA shift (Figure 4) also indicated adifferent response to the wedge angle between the tech-niques ( p< .001).Tibia shortening and wedge base size were more pro-nounced in the mCCWO as per Oxley et al.16up to 40/C14and then in the Slocum and Devine1CCWO when com-pared to the more recent modified techniques (Table S1)and (Table 1). The linear mixed models for both responsesincluded significant interactions for both linear ( p<. 0 0 1 )and quadratic terms ( p< .001) indicating differencesbetween techniques in their relationship between wedgeangle and mTL%/wedge base size (Figure 5).Craniocaudal translation of the proximal segment toachieve cranial cortical alignment past 40/C14was more pro-nounced in the Slocum and Devine1CCWO when com-pared to the more recent modified techniques (Table 2).The linear mixed model included significant interactionsfor both linear ( p< .001) and quadratic terms ( p< .001)indicating differences between techniques in their rela-tionship between wedge angle and craniocaudal transla-tion of the proximal segment. The same conclusions andsignificance were also achieved for TLA shift without cra-nial cortical alignment (Table1).A regression of wedge angle on change in TPA(Figure 3) generated individual corrective equations foreach technique, as follows:Slocum and Devine1:wedge ¼desired TPA correctionðÞ /C2 1:17–0:49Oxley et al :16:wedge ¼desired TPA correctionðÞ /C2 1:19–0:87Frederick and Cross17:wedge ¼desired TPA correctionðÞ /C2 1:20–0:86Christ et al :18:wedge ¼desired TPA correctionðÞ /C2 1:20–0:80Using the above equations, the wedge angle requiredto achieve the desired TPA correction (e.g., TPA-5 toachieve a final TPA of 5/C14) can be calculated by multiply-ing the desired TPA correction by the respective CCWOslope corrective factor and subtracting the appropriateconstant.All predicted TPAs, calculated based on the obtainedcorrective equations, were within the taget range of 4-6 º(Figure6), but the mixed model identified differencesbetween technique means ( p=.005). Tukey's compari-sons indicated the mean final predicted TPA from theChrist et al.18technique was lower than those for the Slo-cum and Devine,1and Frederick and Cross techniques.17Predicted TLA shift and %mTL varied between tech-niques ( p< .001). Tukey comparisons for TLA shift indi-cated that the mean predictions for Slocum and Devine1and Oxley et al.16techniques were lower than theremaining two techniques. For %mTL only the SlocumFIGURE 3 Box plots showing tibialplateau correction (/C14)i n1 0/C14incrementsup to 70/C14, using the cranial closingwedge ostectomy techniques asdescribed by Slocum & Devine.,1Oxleyet al.,16Frederick & Cross.,17and Christet al.18The box indicates theinterquartile range with the medianvalue as the internal horizontal line,“whiskers ”extend to minima/maximaunless data are considered to be outlying(indicated by a solid symbol).148 MOREIRA ET AL . 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14033 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 Licenseand Devine1and Oxley et al.16techniques were not differ-ent from one another.4

Question 59

Griffin - 2023 - JAVMA - Modified hemipelvectomy techniques in dogs and cats appear well tolerated with good functional outcomes.pdf

Answer 59

The medical record databases of 3 academic teaching hospitals were retrospectively searched to identify dogs and cats that underwent hemipelvec -tomy for any indication. Dogs or cats that had hemi -pelvectomy procedures with any of the following components (modified techniques) were included: sacrectomy, vertebrectomy, excision crossing pelvic midline, closure technique without muscular tissue (ie, utilizing mesh, omentum, other natural or synthet -ic materials, or closure with subcutaneous tissue and skin only). Sacrectomy, vertebrectomy, and osseous excisions crossing midline are depicted (Figures 1–3) . Figure 1 —Modified hemipelvectomy with partial sacrectomy. In all images, the location of sacral osteotomy is denoted with a dashed red line, and the portion of excised sacrum has been faded. Given the variety of concurrent ipsilateral hemipelvectomy procedures, additional osteotomy locations are not demonstrated in these images. A—Excision of the sacral wing. B—Excision of the lateral third of the sacrum. C—Excision of slightly less than half the sacrum with the osteotomy just ipsilateral to midline. D—Excision of the spinous processes (median sacral crest) of the sacrum.Unauthenticated | Downloaded 10/08/23 06:32 AM UTC 3Information obtained from the medical records includ -ed signalment, history, indication for hemipelvectomy, preoperative pelvic limb function, preoperative staging, preoperative imaging of the pelvis, hemipelvectomy surgical techniques, intra- and post-operative compli -cations, survival to discharge, histopathology results, postoperative limb function and mobility, neoadjuvant and adjuvant treatments, postoperative imaging of the pelvis, and timing and cause of death. Data regarding tumor type, hemipelvectomy modification procedure, complications, mobility, and outcome for each patient are demonstrated (Supplementary Table S1) .Limb use was characterized as functional (weight-bearing with adequate orthopedic and neurologic function) or nonfunctional, and any orthopedic and neurologic deficits noted on examination were de -scribed. Preoperative lameness, prior to modified hemipelvectomy with limb amputation procedures, was graded on a scale from 0 to 5 (Supplementary Table S2) .13 Postoperatively, mobility/ambulation was described without use of a lameness score (owing to the amputated status of most patients). Neurologic deficits were also described. Complications were listed as grades 1 through 4 in accordance with the CLASSIC (Classification for Intraoperative Complications) crite -ria for intraoperative complications and the Accordion criteria for postoperative complications (Supplemen -tary Tables S3 and S4) .14Survival time was defined as days from modified hemipelvectomy to death or euthanasia. Follow-up time was defined as days from modified hemipelvectomy to last follow-up in animals that were alive at last follow-up.Figure 2 —Modified hemipelvectomy with partial ver -tebrectomy. In both images, the location of vertebral osteotomy is denoted with a dashed red line, and the portion of excised vertebra has been faded. Given the variety of concurrent ipsilateral hemipelvectomy proce -dures, additional osteotomy locations are not demon -strated in these images. A—Excision of the transverse processes of L6 (cranial osteotomy) and L7 (caudal os -teotomy). B—Excision of the spinous process of L7.Figure 3 —Modified hemipelvectomy with excision cross -ing midline. The location of contralateral pubic/ischial osteotomy was within the region demonstrated (1 [pink shading]) for cases in which the transection was within the medial third of the contralateral hemipelvis and with -in the region demonstrated (2 [blue shading]) for cases in which the transection was within the middle third of the contralateral hemipelvis. In all cases, hemipelvecto -my was classified as partial and mid-to-caudal and asso -ciated with limb amputation (external hemipelvectomy), as demonstrated by the faded portion of pelvis and red dashed line depicting the additional osteotomy location.Unauthenticated | Downloaded 10/08/23 06:32 AM UTC4 Descriptive statistics were calculated for all mea -sured variables. Continuous variables were reported as median (range), and categorical variables were reported as number with or without percentage.ResultsPreoperative findings for all animalsBetween 1996 and 2021, 20 dogs and 3 cats from 3 institutions satisfied the inclusion criteria. The median age of dogs was 9.1 years (range, 2 to 13.3 years). Dogs consisted of 10 of 20 (50%) female spayed, 8 of 20 (40%) male castrated, and 2 of 20 (10%) male intact. Dog breeds included Labrador Retriever (4/20 [20%]), mixed breed (4/20 [20%]), Golden Retriever (2/20 [10%]), Rottweiler (2/20 [10%]), and 1 each (5%) of the following breeds: Bel -gian Tervuren, Great Dane, Cocker Spaniel, Stafford -shire Terrier, German Shepherd Dog, Bernese Moun -tain Dog, Irish Setter, and Flat-Coated Retriever. The median weight of dogs at the time of surgery was 30.4 kg (range, 12.2 to 72 kg). For cats, the median age was 10.3 years (range, 5.6 to 15.3 years). Cats consisted of 2 of 3 (66.7%) female spayed and 1 of 3 (33.3%) male castrated. Cat breeds included do -mestic shorthair (2/3 [66.7%]) and Maine Coon (1/3 [33.3%]). The median weight of cats at the time of surgery was 5.2 kg (range, 5.1 to 8.2 kg).Reported comorbidities included osteoarthritis (n = 2), allergies (2), ocular disease (2), squamous cell carcinoma of the mandibular lip excised concurrently at the time of modified hemipelvectomy (1), prior mast cell tumor excision (1), prior perianal adenoma excision (1), hypothyroidism (1), proteinuria (1), hypoadreno -corticism (1), mitral valve disease (1), prior tail ampu -tation for trauma (1), liver enzyme elevation (1), chron -ic large bowel diarrhea (1), and historical seizures (1).All animals that underwent modified hemipel -vectomy had surgery performed for tumor excision. Three animals underwent modified hemipelvectomy for recurrent neoplastic disease. One cat received modified hemipelvectomy for a recurrent injection site sarcoma that was previously excised and treat -ed with adjuvant radiation therapy approximately 1 year prior to presentation. One dog had a soft tissue sarcoma (peripheral nerve sheath tumor) excised in the hip/ischial region by its primary veterinarian 4 weeks prior to presentation with rapid recurrence. Another dog previously underwent traditional ex -ternal hemipelvectomy for suspected chondroblas -tic osteosarcoma with subsequent local recurrence, prompting revision modified hemipelvectomy with partial sacrectomy; this same dog developed a pul -monary mass (osteosarcoma) that was excised 6 months prior to the modified hemipelvectomy and also received carboplatin chemotherapy prior to modified hemipelvectomy. One additional dog re -ceived 2 doses of neoadjuvant chemotherapy (ad -ministered by the primary veterinarian; agent not specified) for chondrosarcoma prior to surgery. No other animals received neoadjuvant therapy prior to modified hemipelvectomy.On preoperative staging, 21 of 23 (91.3%) ani -mals had no evidence of metastatic disease, 1 of 23 (4.3%) animals had multiple small miliary soft tissue opacities throughout the lung fields on thoracic ra -diographs with differentials including osteomas ver -sus early pulmonary metastatic disease, and 1 of 23 (4.3%) animals (dog with recurrent osteosarcoma with prior traditional hemipelvectomy and limb am -putation) had previously undergone lung lobectomy for excision of suspected metastatic osteosarcoma.Sacrectomy and vertebrectomyModified hemipelvectomy was performed with par -tial sacrectomy and/or partial vertebrectomy in 11 dogs: partial sacrectomy in 8 dogs, partial vertebrectomy in 1 dog, and both partial sacrectomy and partial vertebrec -tomy in 2 dogs. No cats underwent modified hemipel -vectomy with partial sacrectomy or vertebrectomy.Preoperatively, 1 of 11 dogs had undergone pre -vious limb amputation. Of the other 10 dogs, 2 had no apparent lameness, 1 had grade 1 lameness, 3 had grade 2 lameness, 3 had grade 4 lameness, and 1 had grade 5 lameness. No dogs were noted to have neurologic deficits preoperatively.Preoperatively, all 11 dogs had advanced imaging of the pelvis performed, with CT in 10 of 11 dogs and MRI in 1 of 11 dogs (this dog underwent partial sacrec -tomy). Abnormal pelvic and axial osseous structures on imaging involved the ilium (9/11), sacrum (8/11), L6 and/or L7 vertebrae (3/11), acetabulum (3/11), pubis (1/11), and coccygeal vertebrae (1/11), with multiple dogs having multiple osseous structures af -fected. All dogs had unilateral osseous abnormalities with no abnormalities crossing midline.For the 10 dogs that underwent modified hemi -pelvectomy with partial sacrectomy, the extent of sacrum excised was undefined in 3 of 10, lateral third in 2 of 10, slightly less than half the sacrum with the osteotomy just ipsilateral to midline in 2 of 10, sacral wing in 1 of 10, lateral 1 cm in 1 of 10, and spinous processes (median sacral crest) in 1 of 10. For the 3 dogs that underwent modified hemipelvectomy with partial vertebrectomy, the extent of vertebrae excised involved the spinous process of L7 in 1 of 3, transverse processes of L6 and L7 in 1 of 3, and transverse process of L7 in 1 of 3. All partial sacrec -tomy and partial vertebrectomy procedures were ipsilateral to the hemipelvectomy procedures or on midline in association with the spinous processes. Described osteotomy locations for dogs of this mod -ified hemipelvectomy group are depicted (Figures 1 and 2). In addition, examples of osteotomy locations on CT scans of patients in this group are provided (Supplementary Figure S1) .Modified hemipelvectomy was performed with associated limb amputation (external hemipelvec -tomy) in 9 of 11 dogs; 1 of 11 dogs underwent modi -fied hemipelvectomy with preservation of the limb (internal hemipelvectomy), and 1 of 11 dogs had prior limb amputation. The dog that had limb pres -ervation underwent excision of the cranial portion of the ilial wing (transected at the level of the sacroiliac joint) as well as the spinous processes of the sacrum Unauthenticated | Downloaded 10/08/23 06:32 AM UTC 5and L7 vertebra; amputation for wide excision was recommended and declined by the owner preopera -tively. Modified hemipelvectomy was classified as partial in 8 of 11 dogs and total in 3 of 11 dogs. For the dogs that underwent modified partial hemipel -vectomy, excised portions of the pelvis were mid-to-cranial in 5 of 8 dogs and cranial in 3 of 8 dogs. None of these dogs had hemipelvectomy excisions that crossed midline. One dog that underwent partial sa -crectomy had mesh placed for reconstruction of the abdominal wall; all other dogs had routine closure of the body wall utilizing residual muscular tissues. In -traoperative complications were reported in 2 of 11 dogs: both complications were classified as grade 1 and associated with tumor rupture intraoperatively.All 11 dogs survived to discharge with a me -dian of 2 days (range, 1 to 6 days) of hospitaliza -tion. Postoperative complications occurred in 4 of 11 (36.4%) dogs: 2 dogs had grade 1 complications (inappetence, weight loss), 1 dog had both grade 2 (blood transfusion for anemia) and grade 3 (wound dehiscence that required surgical management and antimicrobials) complications within 30 days post -operatively, and 1 dog had both grade 1 (seroma, suspect partial necrosis of skin incision) and grade 4 (L7 vertebral fracture) complications within 30 days postoperatively. The dog with the grades 2 and 3 complications had undergone partial sacrectomy and vertebrectomy with routine closure, and histo -pathology diagnosed hemangiosarcoma of the bone and muscle with metastasis in the subcutaneous tis -sues. The dog with the grades 1 and 4 complications had undergone modified total hemipelvectomy with nearly half of the sacrum excised for osteosarcoma (reported as completely excised).Overall, 7 of 11 (63.6%) dogs had no reported mobility concerns postoperatively. One of the 2 dogs that had partial sacrectomy with nearly half of the sacrum excised was noted to be ambulatory at the time of discharge, though it had difficulty rising and ambulating for long periods of time. This dog’s post -operative mobility and ambulation acutely declined to a nonambulatory status within 8 days postopera -tively, and pelvic radiographs performed 14 days postoperatively revealed a complete, displaced, oblique fracture of the body of L7; this dog was sub -sequently euthanized. Of note, the other dog that had partial sacrectomy with sacral excision near mid -line had improved mobility over the course of hospi -talization and was ambulatory with some support at the time of discharge, though this dog was ultimate -ly lost to follow-up 5 days postoperatively. A second dog with postoperative mobility concerns was re -ported to have hind end weakness both prior to and following surgery (modified cranial internal hemipel -vectomy with excision of the spinous processes of both the sacrum and L7 vertebra) and definitive ra -diation therapy. A third dog that had received modi -fied hemipelvectomy with partial sacrectomy (with excision of the lateral third of the sacrum) was con -sidered to be weakly ambulatory until death 13 days postoperatively when the dog experienced hypovo -lemic shock from a hemorrhagic event associated with residual hemangiosarcoma. A fourth dog that had received modified hemipelvectomy with partial vertebrectomy (with excision of the transverse pro -cess of L7) for osteosarcoma was reported to be am -bulating well postoperatively until developing acute and progressive apparent pain and inability to walk 47 days postoperatively; CT of the pelvis and tho -rax 52 days postoperatively revealed disease recur -rence with extension into the spinal canal as well as pulmonary nodules, and the dog was subsequently euthanized. This dog had undergone modified mid-to-cranial hemipelvectomy with partial vertebrec -tomy for osteosarcoma. No neurologic deficits were noted in any dogs postoperatively, aside from fecal incontinence in the dog that also received definitive adjuvant radiation therapy (incontinence suspected as a late radiation effect).Postoperative pelvic imaging was performed in 4 of 11 dogs (radiographs in 2, CT in 2). In addition to the dog with pelvic radiographs 14 days postopera -tively revealing an L7 vertebral fracture, pelvic radio -graphs were performed 29 days postoperatively in a dog that underwent modified mid-to-cranial hemi -pelvectomy with partial sacrectomy for osteosarco -ma and showed evidence of tumor recurrence at the site of partial sacrectomy and transverse process of L7. In addition to the dog with CT showing disease recurrence 52 days postoperatively, pelvic CT was performed for radiation planning 20 days postopera -tively in a dog that underwent modified cranial in -ternal hemipelvectomy with partial sacrectomy and vertebrectomy for chondrosarcoma and showed re -active changes in the region of the residual sacrum.Hemipelvectomy excision crossing midlineModified hemipelvectomy involving partial exci -sion of the contralateral pelvis, or bilateral hemipel -ves, was performed in 5 dogs and 2 cats.Preoperatively, 1 of 5 dogs and 2 of 2 cats had no apparent lameness, 1 of 5 dogs had grade 1 lame -ness, and 3 of 5 dogs had grade 5 lameness. Also, none of the dogs or cats undergoing modified hemi -pelvectomy excisions crossing midline were noted to have neurologic deficits preoperatively.Preoperatively, all 7 animals had advanced im -aging of the pelvis performed, with CT in 6 of 7 and MRI in 1 of 7. Abnormal pelvic structures on imaging involved the ischium (7/7), pubis (6/7), and acetab -ulum (3/7), with multiple animals having multiple osseous structures affected. Osseous abnormalities in all cases were unilateral, though the mass extend -ed near or past midline or compressed pelvic canal structures on midline in all dogs but neither cat. No dogs or cats had osseous abnormalities of the sa -crum or vertebrae.For these 7 animals, a portion of the contralat -eral (relative to tumor gross disease extent and side of amputation) pubis and ischium were excised with the ipsilateral hemipelvis in 6 of 7 cases (including both cats), and a portion of the contralateral ischium without contralateral pubis was excised with the ipsi -lateral hemipelvis in 1 of 7 case. The transected por -tions of ischium/pubis were within the medial third Unauthenticated | Downloaded 10/08/23 06:32 AM UTC6 of the contralateral hemipelvis in 5 of 7 cases (in -cluding both cats) and within the middle third of the contralateral hemipelvis in 2 of 7 cases. No concur -rent partial sacrectomy or vertebrectomy was per -formed in any case. Modified hemipelvectomy was performed with associated limb amputation (exter -nal hemipelvectomy) in all 7 cases. Modified hemi -pelvectomy was classified as partial and mid-to-caudal in all 7 cases. Described osteotomy locations for animals of this modified hemipelvectomy group are depicted (Figure 3). In addition, an example of osteotomy locations on CT scan for a patient of this group is provided (Supplementary Figure S1). All 7 animals had routine closure of the body wall utilizing residual muscular tissues. No intraoperative compli -cations were reported in any dog or cat.All 7 animals survived to discharge with a me -dian of 2 days (range, 1 to 6 days) of hospitaliza -tion. Postoperative complications occurred in 2 of 7 (28.6%) animals following hospital discharge: 1 dog and 1 cat developed grade 2 complications (surgical site infections requiring antimicrobial treatment).No animals had reported mobility issues or neu -rologic deficits postoperatively. Postoperative pelvic imaging was performed in 1 cat and no dogs: pelvic radiographs 3 days postoperatively in a cat with pel -vic osteosarcoma showed postsurgical changes with no concerning lesions.Reconstruction without native muscular tissuesModified hemipelvectomy involving closure without use of native muscular tissues (primary ap -position or flap) was performed with mesh in 1 dog and without mesh in 5 animals, including 4 dogs and 1 cat; the dog with mesh used for closure had con -current partial sacrectomy, and data for this case has been included in the previous section.Preoperatively, the 1 cat had no apparent lame -ness, 3 of 4 dogs had grade 4 lameness, and 1 of 4 dogs had grade 5 lameness. Also, 2 of 5 animals (all dogs) were noted to have neurologic deficits preop -eratively: 1 dog was weight bearing with mild neu -rologic dysfunction and severe apparent pain in the lumbar/sacral region, and the other dog was non–weight bearing with absence of proprioception and deep pain sensation.Preoperatively, 4 of 5 animals (including 3 dogs and 1 cat) had advanced imaging of the pelvis per -formed with CT; the other dog had nuclear scintigra -phy scan without CT or MRI. Abnormal pelvic struc -tures on imaging involved the acetabulum (4/5), ischium (3/5), ilium (3/5), and pubis (2/5), with multiple animals having multiple osseous structures affected. Osseous abnormalities in all cases were unilateral. No animals had osseous abnormalities of the sacrum or vertebrae.Modified hemipelvectomy was performed with associated limb amputation in all 5 cases. Modified hemipelvectomy was classified as total in 4 of 5 (in -cluding the cat) and partial (mid-to-caudal) in 1 of 5. No hemipelvectomy excisions crossed midline. No concurrent partial sacrectomy or vertebrectomy was performed in any case. For these 5 animals, the fol -lowing closure techniques were utilized: closure of subcutaneous tissues and skin only (4/5, including the cat) and mobilization of omentum from the ex -posed abdomen with apposition of the omentum to surrounding body wall and musculature followed by closure of subcutaneous tissues and skin (1/5). No prophylactic procedures (such as cystopexy or co -lopexy) were performed in any case to prevent her -niation of organs. The only reported intraoperative complication (1/5 [20.0%]) was a grade 1 complica -tion in a dog undergoing modified total hemipelvec -tomy, in which a small portion of the sacral wing was inadvertently excised during disarticulation of the sacroiliac joint.All 5 animals survived to discharge with a me -dian of 2 days (range, 1 to 4 days) of hospitaliza -tion. Postoperative complications occurred in 2 of 5 (40.0%) animals: 1 dog prior to discharge (grade 1 characterized by hypovolemia) and 1 dog within 30 days of discharge (grade 1 characterized by minor incisional dehiscence).No animals had reported mobility issues or neu -rologic deficits postoperatively. Postoperative pelvic imaging was not performed in any case.Histopathology results and long-term outcomes for all animalsModified hemipelvectomy histopathology re -sults in dogs were consistent with osteosarcoma in 10 of 20, chondrosarcoma in 3 of 20, soft tissue sar -coma in 3 of 20, hemangiosarcoma in 2 of 20, osteo -chondrosarcoma in 1 of 20, and synovial cell sarcoma in 1 of 20. The soft tissue sarcomas were reported as grade 2 in 2 dogs and grade 3 in 1 dog, and the syno -vial cell sarcoma was reported as grade 1. Modified hemipelvectomy histopathology results in cats were consistent with osteosarcoma in 1 of 3, soft tissue sarcoma (grade not reported) in 1 of 3, and injection site sarcoma (grade not reported) in 1 of 3. Excision was reportedly complete in 16 of 23, incomplete in 6 of 23, and not recorded in 1 of 23 cases.Adjuvant chemotherapy with doxorobucin, car -boplatin, and/or toceranib phosphate was admin -istered in 5 of 20 dogs. No cats received adjuvant chemotherapy. Adjuvant definitive radiation therapy was administered in 1 of 20 dog and no cats.At the time of study completion, 18 of 23 ani -mals were known to be dead and 5 of 23 were lost to follow-up (Supplementary Table S1). The medi -an time to survival or last follow-up was 251 days (range, 3 to 1,642 days). Of the animals that died, 13 of 18 were euthanized, 3 of 18 died of natural causes, and the etiology of death was unknown for 2 of 18. Death was associated with suspected metastatic dis -ease in 7 of 18 animals, primary disease progression or recurrence in 4 of 18 animals, disease not related to the neoplastic indication for modified hemipel -vectomy in 2 of 18 animals, both metastatic disease and primary disease progression in 1 of 18 animals, mobility compromise associated with postoperative vertebral fracture in 1 of 18 animals, and unknown in 3 of 18 animals. Therefore, overall, cause of death Unauthenticated | Downloaded 10/08/23 06:32 AM UTC 7was tumor-associated in 13 of 18 animals (including the dog with postoperative vertebral fracture) and either was not tumor associated or was unknown in 5 of 18 animals.

Question 60

Prabakaran - 2023 - VCOT - Kinetic and Radiographic Outcomes of Unilateral Double Pelvic Osteotomy in Six Dogs.pdf

Answer 60

Medical records were searched for patients that underwentunilateral DPO that were initially presented for hindlimb gaitabnormalities and/or coxofemoral pain between January2011 and December 2017. All surgical procedures wereperformed at a single referral institution, the Small AnimalSpecialist Hospital, North Ryde, Australia. All patientsunderwent unilateral DPO on the eligible hip with a 25- or30-degree DPO plate (DPO plate; New Generation Devices,Naples, Florida, United States; DPO/TPO plate; VeterinaryInstrumentation, Shef field, United Kingdom; DPO plate;InTrauma, Rivoli, Italy) based on surgeon preference.Initial inclusion criteria for surgical candidacy were client-owned patients with clinically apparent hindlimb lameness,positive Ortolani sign, absent or minimal radiographicallyconfirmed osteoarthritis on hip extended ventrodorsal radio-graphs and maintenance of a radiographically normal dorsalacetabular rim. Exclusion criterion for the contralateral hipwas abnormal con firmation of the dorsal acetabular rim. Inaddition, a minimum follow-up of 10 months after initialevaluation was required for inclusion. Details obtained fromthe medical record included age, breed, sex and weight at timeof initial assessment.Preoperative and postoperative hip-extended ventrodor-sal radiographs were obtained and cropped such that allosteotomies and implants were not visible to the viewer. Thecropped images were then arranged into a random sequence(Random.org, Dublin, Ireland) for hip scoring by four board-certified surgeons (A.P.B., R.G.C., S.M.F. and D.R.J.). Thesecases were included in another study evaluating radiograph-ic outcomes of DPO in dogs undergoing both unilateral andbilateral surgeries.3Each hip joint was scored out of a maximum of 53according to the British Veterinary Association Hip DysplasiaScheme (BVA-HD). Scores of 10 or less have been demon-strated to re flect changes that are unlikely to worsen overtime, whereas scores of 11 or higher re flect changes that aremore likely to progress to osteoarthritis.10The GAITRite system is a temporospatial pressurewalkway mat with embedded sensors that are triggered bymechanical pressure.11Using this temporospatial mat (GAI-TRite; CIR System Inc, Franklin, New Jersey, United States)and GAIT4Dog software (CIR System Inc, Franklin, NewJersey, United States), dogs were trotted at the time offollow-up by a single handler (P.L.J.) a minimum of five timesand the most appropriate trace was analysed. Dogs addition-ally underwent a routine orthopaedic examination by asingle examiner (P.L.J.).The preoperative and postoperative BVA-HD scores andpostoperative GAIT4 Dog Lameness Score (GLS) betweentreated and untreated hips were compared using a Wilcoxonsigned-rank test. The choice of this test was based on thesmall sample size and presence of paired data.ResultsSix juvenile dogs were eligible for inclusion in this study. Atinitial presentation, the median patient age was 8.5 months(range: 7 –13 months) and median body weight 24.1 kg(range: 7.3 –24.7 kg). Breeds included two Labradorretrievers, one Rottweiler cross, one Groodle, one Akita Inuand one Pug. Two dogs underwent follow-up examinationand kinetic gait analysis within a year of surgery, whereas theremaining four dogs had corresponding follow-up examina-tions more than 4 years after surgery (►Table 1 ).One dog (case 6) was severely lame on the limb contralat-eral to the DPO-eligible hip and hence, a non-cemented totalhip replacement (THR; BFX, Biomedtrix LLC, Whippany, NewJersey, United States) was performed 61 days after unilateralDPO. On examination, all patients apart from case 6 werepainful on hip extension on the limb contralateral to the DPOlimb and were reported to have ongoing clinical lameness.Two out of five untreated hips had a GLS less than or equal to90, whereas all surgically treated hips had a GLS more than orequal to 100. The median postoperative GLS score was lowerin untreated hips than DPO-treated hips; however, this wasnot signi ficant ( p-value ¼0.18) (►Table 1 ).There was no signi ficant difference in BVA-HD scoresbetween untreated and DPO-treated hips preoperatively(p-value ¼0.09). All untreated hips had increased BVA-HDscores at follow-up, whereas all surgically treated hipshad reduced BVA-HD scores, and five out of six surgicallytreated hips had postoperative BVA-HD scores less than 10(►Table 2 ). The disparity in radiographic scores of theTable 1 GAIT4 Dog Lameness Scores (GLS) of cases with minimum follow-up time of more than 10 monthsCase 1 Case 2 Case 3 Case 4 Case 5 Case 6 Median RangeTime of follow-up (days) 2,119 1,795 1,671 1,860 329 316 1,733 316 –2,119(monthsa) 69.5 58.9 54.8 61.0 10.8 10.4 56.8 10.8 –69.5GLS (untreated hip) 90 100 89 100 95 92b95 89 –100GLS (DPO-treated hip) 100 100 111 100 111 116 105.5 100 –116Abbreviation: DPO, double pelvic osteotomy.aCalculated by dividing the number of days by 30.5bThis score was calculated 255 days after total hip replacement in the untreated hip..untreated and DPO-treated limb is demonstrated in ►Figs. 1and2. At follow-up there was a higher median BVA-HD scorein untreated hips compared with DPO-treated hips ( ►Fig. 3 );however, this difference was not signi ficant ( p-value ¼0.06).The four cases assessed at long-term ( >4 years) follow-upremained intermittently lame in the untreated limb and THRwas recommended in three out of the four dogs. Total hipreplacement was not recommended for case 4, which wasthe only small breed dog in our population. The remainingtwo patients (cases 5 and 6) were reassessed within a shortertime-frame than that of the other four cases (►Table 1 ).Despite the owner of case 5 reporting clinical improvementat 325 days, the kinetic outcome detected a reduction in GLSand total pressure index in the untreated limb. This high-lights the poor agreeability of subjective and objectiveassessment of gait.12Total hip replacement was recom-mended for the untreated limb in this case.Case 6 underwent DPO surgery on the left hip and THR onthe right hip 61 days later. Despite the owner reporting noclinical lameness, objective gait analysis demonstrated off-loading of the THR limb to the DPO limb (►Table 1 ). Theseresults infer some degree of lameness in the limb thatunderwent THR. Radiographic assessment at follow-up(255 days following THR surgery) indicated no implantrelated complications; however, it was noted that the THRhindlimb was slightly longer than the DPO hindlimb due tothe increased angle in the femoral neck of the THR implant.

Question 61

Dallago - 2023 - VCOT - Effect of Plate Type on Tibial Plateau Levelling and Medialization Osteotomy for Treatment of Cranial Cruciate Ligament Rupture and Concomitant Medial Patellar Luxation in Small Breed Dogs - An In Vitro Study.pdf

Answer 61

Specimen SelectionHindlimb computed tomography (CT) scans were performedon both a 5 kg Yorkshire Terrier and a 10 kg MiniaturePinscher. Body condition score of dogs was 4 and 5 in the9-point scale body condition score system.11Both dogs had a normal orthopaedic examination andunderwent full body CT scan for non-orthopaedic reasons.Informed owner consent was obtained for the use of the CTdata to create tibial bone models for this study. The right tibiaof each patient was reconstruc ted as a three- dimensional(3D) model using commercially available software (Rhinoc-eros 3D, Robert McNeel & Associates, Seattle, Washington,United States, and Magic 3D Print Suite, Materialise NV,Leuven, Belgium) and 18 solid foam polylactic acid bonemodels were printed of each tibia, resulting in a total of 36tibial models (3D Printers: Delta Wasp 2040-2070).Tibial bone models were divided into two groups based onbody weight of the model patient and then each weightgroup was subdivided into three additional groups based onplate offset to be applied for a total of six groups, with eachgroup containing six tibial models. The groups were desig-nated: K5O2, K5O4, K5O6; K10O2, K10O4, K10O6 (K: Kg ofthe model patient, O: Plate offset). The two groups treatedwith the standard TPLO plate (2 mm offset plate) weredefined as ‘control groups ’since the 2 mm offset plates aredesigned for standard TPLO in small dogs without proximaltibial segment medialization. The remaining four groupswere termed ‘treated. ’Pre- and Post-Osteotomy RadiographsOrthogonal radiographic views were obtained of each tibialbone model pre- and post-osteotomy. The osteotomy wasplanned by placing a TPLO saw blade template of appropriatesize on the scaled tibial image so that the blade was centredover a pointdividing theintercondylar tubercles. Thefollowingthree reference points were recorded: D1, the distance fromthe perpendicular cranial straight edge of the tibial crestoriginating at the most cranioproximal point of the tibialtuberosity to the intended osteotomy; D2, the distance fromthe most cranioproximal point of the tibial tuberosity andextending to the point where the intended tibial osteotomytransected the cranial tibial subchondral bone; and D3, thedistance from the subchondral bone at the most caudal marginof the tibial plateau to the point where the intended tibialosteotomy transected the caudal tibial cortex.To standardize the radiographic views of each bone,custom-made positioners were fashioned for each modeltype from commercially available floral foam bricks (DesertFoamÆ Dry Floral Foam bricks: FloraCraftÆ, Ludington,Michigan, United States). A radiopaque lotion made of purepetroleum jelly mixed with barium powder, (Bario Solfatopuro A.C.E.F. Spa Fiorenzuola d ’Arda, Piacenza, ITA) wasapplied to the tibial plateau, to the medial tibial cortex ofFig. 1 Fixin 1.9-2.5 mm pre-contoure d T plates with three differentoffsets (2, 4 and 6 mm) for modi fied tibial plateau levelling osteotomyin patients weighing between 5 and 10 kg..the bone models and in the middle of the astragalus trochleato outline those portions of the models and facilitate radio-graphic measurements and positioning. Digital radiographicviews (craniocaudal and mediolateral) were obtained foreach model and each view included a magni fication correc-tion marker.Osteotomy Procedure on Bone ModelsA jig assisted TPLO was performed on all bone models asdescribed by Slocum and Slocum.12In the ‘treated groups ’theSlocum TPLO technique was modi fied as described in thesubsequent paragraph. The TPLO was performed with a12 mm blade on the 5 kg tibia models and a 15 mm blade onthe 10 kg tibial models. Screw diameters of 1.9 and 2.5 mmwere used in the 5 kg and 10 kg tibia bone models respectively.A 1.0 mm Kirschner wire was used for temporary reduction ofthe tibial segments and 1.5 mm Kirschner wires were used toattach the jig to the tibia. Pin stoppers were applied using1.5 mm Kirschner wires and 2.0 mm Steinmann pins in the 5and 10 kg tibia bone models respectively.An initial osteotomy was performed to disconnect theproximal fibula from the lateral aspect of the proximal tibiato allow caudal rotation and medialization of the proximaltibial segment. Control groups underwent a standard TPLOprocedure, without proximal tibial segment medialization.In the ‘treated groups, ’the tibial plateau was initially rotatedto level the TPA and the proximal segment was temporarilystabilized with the temporary reduction Kirschner wire. TheTPLO plate was positioned such that the top of the plate wascentred in the proximal to the distal centre of the proximalsegment while holding the distal part of the plate parallel tothe caudal cortex of the tibial diaphysis.12Temporary platefixation was achieved using pin stoppers in the most distaland cranioproximal screw holes.The plate was secured by inserting the two distal screws tothe distal tibial segment (the distal pin stopper was removed toallow screw insertion). The temporary reduction Kirschner wirewas then removed. The distal set screw in the jig was loosenedand medial translation of the proximal tibial bone segment wasobtained by sliding the distal tibia laterally. When the proximaltibial segment was in contact with the plate, the distal set screwin the jig was tightened again and the proximal screws wereinserted in the plate. At the end of the procedure, the jig andassociated Kirschner wires were removed.Study MeasurementsMeasurements were performed by two investigators, differ-ent from the investigator who performed the TPLO proce-dures on the bone models. Digital radiographic software(Horos Project Medical Imaging Viewer version 2.1.1 forMac Os X) was used for all radiographic measurementsand an electronic caliper (FERVI SPA, Vignola, Modena, ITA)was utilized for all measurements performed directly on thebone models.Electronic caliper measurements included: tibial diaphy-seal width (mm) at the level of the osteotomy (WIDTH), plateto bone distance on the proximal (PBDp) and distal (PBDd)tibial segments, plate to joint distance (PJD;►Fig. 2 ).Digital radiographic measurements included: tibial pla-teau angle (TPA), mechanical medial proximal tibial angle(mMPTA) and magnitude of proximal tibial segment medi-alization (mm) measured at the level of the osteotomy line(MED;►Fig. 3 ).13,14Using values obtained from caliper and radiographicmeasurements, two additional values were calculated. Thesevalues were: medialization index (MI), calculated asMED/WIDTH, and bone apposition at the level of the osteot-omy (APP): calculated as 1 –MI.Statistical AnalysisA statistical software package (GraphPad Prism 7, GraphPadSoftware, San Diego, California, United States) was used forall statistical calculations. Descriptive statistics includingmean and standard deviation were calculated for each mea-surement value in each group included in this study. A‘Paired sample t test ’was used to evaluate for differencesin mMPTA and TPA between control and treated groups. An‘Unpaired t test with Welch ’s correction ’was used to assessfor the presence of a signi ficant difference in MED betweengroups. A ‘Spearman test ’(p-value <0.05 was consideredsignificant with a con fidence interval of 95%) was used tocorrelate MED with plate offset, PBDp, PBDd and PJD.ResultsPre-osteotomy Measurements and PlanningThe TPA of the tibia from the 5 kg patient was 25 degreeswhile the mMPTAwas 91.1 degrees. For the 10 kg patient, theFig. 2 Cranial aspect of the proximal tibia ( A) and medial aspect ofthe proximal tibia ( B) with the distances measured using an electroniccaliper delineated. Measurements performed included: WIDTH (tibialdiaphysis width, red dotted line), PBDp (plate to bone distance on theproximal tibial segment, white double arrow line), PBDd (plate tobone distance on the distal tibial segment, yellow double arrow line),and PJD (plate to joint distance, green double arrow line)..TPA was 30 degrees and mMPTA was 92 degrees. Pre-opera-tive TPLO planning was performed using the method de-scribed by Slocum and Slocum.12The proximal tibialsegments were rotated 4.1 mm in the tibia models fromthe 5 kg dog while the proximal tibial segments were rotated6.4 mm in the tibia models from the 10 kg dog.Post-osteotomy MeasurementsMean and standard deviation values are summarizedin►Table 1 for each group.Post-osteotomy TPA values did not differ signi ficantly ( p/C210.115) between control and treated groups. Post-osteotomymMPTA values did not differ between control and treatedgroups ( p/C210.0887), except in the K5O6 treated group wheremMPTA was increased as compared to the K5O2 controlgroup ( p¼0.0204).The amount of medialization achieved with the and 6 mmplate offsets did not vary based on patient weight ( p-value /C210.232) but the amount of medialization achieved increasedin both body weight groups when the mm of plate offsetincreased from 4 to 6 mm ( p-value <0.0001). The correlationbetween mm of plate offset and MED was positive with a p-value less than 0.0001 (Graph 1 ). No correlation was identi-fied between MED and PJD ( p/C210.150). An inverse relation-ship between MED and PBDp ( p¼0.001) and a directrelationship between the MED and DBDd values(p<0.0001) were found. Medialization index and APP valuesfor each group were calculated and are reported in►Table 1 .The maximum MI value was 67% (APP ¼33%) identi fied intwo cases in group K5O6 while the minimum MI value was/C05%, identi fied in group K5O2.Magnitude of Proximal Tibial Segment MedializationBased on the absence of a signi ficant difference in MEDvalues between tibial models from different size dogswhen using the same plate offset, MED values from bothtibia sizes were pooled into 3 groups based on plate offset (2,4 or 6 mm) for ease of comparison.Theþ2mm offset plate (control group) resulted in proxi-mal segment medialization of 0.07 /C60.34 mm, withFig. 3 Craniocaudal radiographic view with the MED (proximal tibialsegment medialization) measurement at the level of the tibialosteotomy delineated by the red double arrow line. Note that radi-opaque lotion has been applied to the tibial plateau and to the medialcortex of the tibia to outline these portions of the tibia clearly.Table 1 Values are reported as mean /C6standard deviation (SD)Group TPA mMPTA MED PBDp PBDd PJD MI APPK5O2 5.9/C61.9 88.4 /C62.7 /C00.1/C60.3 2.5 /C60.8 1.8 /C60.3 3.8 /C61.3 /C01/C639 8 /C62K5O4 3.7/C61.4 91.6 /C62.8 2.8 /C60.4 1.6 /C60.4 3.7 /C60.3 4.6 /C60.5 33 /C646 7 /C64K5O6 3.4/C61.9 93.3 /C63.0 5.2 /C60.2 1.6 /C60.4 5.8 /C60.3 4.9 /C60.4 61 /C663 9 /C66K10O2 4.2/C61.1 90.5 /C61.8 0.3 /C60.3 2.6 /C60.4 2.9 /C60.2 5.9 /C60.4 3 /C639 7 /C63K10O4 5.0/C61.2 93.6 /C62.6 3.1 /C60.6 2.1 /C60.6 5.4 /C60.5 6.6 /C60.6 33 /C676 7 /C67K10O6 5.2/C63.1 93.2 /C62.8 4.9 /C60.6 2.1 /C60.3 6.8 /C60.5 6.7 /C60.4 49 /C675 1 /C67Units are mm for TPA (tibial plateau angle), mMPTA (mechanical medial pro ximal tibial angle), MED (proximal tibial segment medialization), WIDTH(tibial diaphysis width), PBDp (plate to bone distance on the proximal tibial segment), and PBDd (plate to bone distance on the distal tibial segment) .Units are % for MI (medialization index) and APP (bone apposition at the level of the osteotomy).Graph 1 Graphic illustration of the positive correlation between mmof plate offset and MED (proximal tibial segment medialization)..maximum and minimum MED values of 0.65 and /C00.50 mmrespectively. The þ4 mm offset plate resulted in proximalsegment medialization of 2.93 /C60.51 mm with maximumand minimum MED values of 3.70 and 2.35 mm respectively.Theþ6mm offset plate resulted in proximal segment medi-alization of 5.03 /C60.47 mm with maximum and minimumMED values of 5.75 and 4.25 mm respectively.

Question 62

Yair - 2023 - VCOT - Determination of Isometric Points in the Stifle of a Dog Using a 3D Model.pdf

Answer 62

Specimen PreparationThe left hindlimb of a young mixed breed adult dog (26 kg)was harvested for use in this study. The sti flew a sf r e eo fradiographic evidence of orthopaedic disease and wascollected and used for research with the informed consentof the owner. The hindlimb was stored at –20°C and thawedprior to testing. Soft tissues around the proximal femur werestripped, the femur was cut at the level of the lesser trochan-ter, and the proximal femur was potted in polymethylmethacrylate (PMMA). Four bicortical 0.5-cm-diameter tun-nels were drilled in the tibia, each through a separate 1.0-cmskin incision, for attachment of sensors.Points of InterestFive points of interest (POI) each were de fined on the femurand the tibia, and all were marked with a unicortical bonetunnel with a diameter of 0.5 mm. Three POI were marked onthe medial, lateral, and caudal cortex of the proximal femur,and two POI were marked on the distal femur at the lateraland medial femoral epicondyles. The POI on the tibia werethe tibial tuberosity, fibula head, medial condyle, and medialand lateral malleoli, and each was marked as describedearlier. The tibial POI were located at the center of theinsertion of the patellar ligament, the center of the fibularhead, the most prominent point of the medial condyle, andthe most prominent points on the lateral and medial aspectsof the lateral and medial malleoli.Computed Tomography ScanThe potted end of the proximal femur was placed into acustom-built clamp, and the sti fle was held in extension witha wooden dowel. The wooden dowel was located on thecaudal aspect of the hindlimb and was rigidly attached to thecustom-built clamp (proximally) and tuber of the calcaneus(distally). The clamp was bolted onto a perspex holder and acomputed tomography (CT) scan (Philips MX800 IDT, 16 sliceMDCT; Phillips, Cleveland, OH, United States) of the entirespecimen was acquired (MA 70 KVP 140 THK 1 window C800W2000) with a slice thickness of 0.5 mm. The CT scan wasreviewed immediately after acquisition to ensure that all thebone tunnels at the POI could be identi fied. The angle of thestifle measured with a handheld goniometer, both before andafter the CT scan, was 131 ( /C60.5) degrees.Motion TrackingThe specimen was then moved from the CT unit to a custom-built joint testing machine, which was manufactured entire-ly from nonferromagnetic materials. The joint testing ma-chine was designed to rigidly hold the bone proximal to thejoint being tested while allowing the angle of flexion/extension of the sti fle to be set in increments of 5 degrees.Joint motion was measured using the “Flock of Birds ”(FOB)electromagnetic tracking system (Ascension Technology Inc.,Burlington, Vermont, United States). The “Flock of Birds ”consists of an electronic unit, a transmitter, and four sensorsand calculated the position and orientation of the sensorswithin the generated magnetic field. The “Flock of Birds ”wasattached to a personal computer and the data were processedusing a custom script written in Matlab (R2018b, Math-works, Natick, Massachusetts, United States).The bone clamp with the specimen attached was boltedinto the joint testing machine. Prior to releasing the calca-neus, the coordinates of the POI were collected 10 timesusing a single sensor attached to a stylus and calibrated priorto the study. Four motion tracking sensors attached towooden dowels were then secured in the bone tunnelsdrilled previously and 20 repeated measures were takenfrom the sensors prior to releasing the calcaneus. Thewooden dowel holding the joint in extension was removed,and 20 repeated measures were taken from the sensorsattached to the tibia with the sti fle fully extended due tothe effect of gravity. The sti fle was then manually flexedthrough 80 degrees in increments of 5 degrees, and data (20repeated measures at each position) were collected with thecranial aspect of the tibia resting on a wooden dowel.After testing was completed, soft tissues were removed toallow access to the lateral aspect of the joint and joint space.Coordinates of five additional anatomical landmarks werecollected, using the identical technique for determination ofthe coordinates of the POI. The anatomical landmarks werecranial to the insertion of the CCL on the femur, distal to thelateral fabella on the caudolateral cortex of the femur, cranialand caudal to the extensor fossa on the lateral aspect of thetibial plateau, and the middle of the proximal aspect of thetibial plateau in line with the previous point on the lateralaspect of the tibial plateau (►Fig. 1 ).Static Sti fle ModelComputed tomography images in digital imaging and com-munications in medicine (DICOM) format were imported.into a model rendering software package (3D view, Version1.2.3, RMR Systems Ltd, East Anglia, UK), and a 3D model ofthe femur and tibia, with the sti fle extended, was generated.The origin of the system of axes used in the reconstruction ofthe 3D image was located at the top the left pixel of the firstslice, and the coordinates (x, y, and z) of the locations of allthe POI, which were all clearly visible in the model, weredefined in this system of axes. The 3D model of the entirespecimen was then saved as an Object File format (OFF) file,which is an ASCII-based format used for describing 3Dobjects.Kinematic Sti fle ModelThe kinematic model was developed by de fining the orien-tations of the femur and tibia relative to one another with thestifle extended, and then dividing the model into two solidbodies (femur and tibia) each with an embedded system ofaxes. The origin of the system of axes embedded in the femurwas de fined as the center of a line between the two POI onthe distal femur. The z-axis was de fined as a line between thispoint and the center of a circle de fined by the three POI on theproximal femur. The y-axis was de fined as a line 90 degreesto the z-axis and passing through the origin of the system ofaxes. Similarly, the x-axis was de fined as a line 90 degrees toboth the z- and y-axes and passing through the origin of thesystem of axes. The origin of the system of axes embedded inthe tibia was de fined as the center of a line between the POIon the head of the fibula and the POI on the medial condyle ofthe tibia. The z-axis was de fined as a line between this pointand the center of a line between the POI of the medial andlateral malleoli. The y-axis was de fined as a line 90 degrees tothe z-axis and passing through the origin of the system ofaxes and the x-axis was de fined as a line 90 degrees to boththe z- and y-axes and passing through the origin of thesystem of axes.In order to move the model generated from the CTaccording to the kinematic data acquired from the FOB, thetwo sets of data had to be superimposed on one another. Thetwo solid bodies (femur and tibia) were first returned to theiroriginal orientation with the sti fle in extension, and therelative orientation of the two systems of axes was recorded.The model was then imported into a system of axes contain-ing the coordinates of the POI determined using the FOB withthe sti fle in extension. The model with the sti fle in extensionwas translated and rotated until the POI on the femur andtibia of the model were aligned with the POI determined bythe FOB with the sti fle in extension. Once the location of themodel in the coordinate system generated by the FOB wasknown, the axes embedded in the femur and tibia could bedefined in the coordinate system generated by the FOB. TheFig. 1 Location of isometric areas on the distal femur and proximal tibia. ( A) On the lateral view of the femur the location of the isometricarea on the lateral aspect of the femoral condyle ( blue) can be seen proximal and cranial relative to the isometric area on the medial aspectof the femoral condyle ( red). (B) The proximal location of the lateral isometric area relative to the medial isometric area is also illustratedin the caudal view of the femur. ( C) The isometric areas on the tibia were located on the prox imal and lateral aspects of the tibial plateau (see textfor details). The locations of the five anatomical landmarks ( black dots )w e r e( D) distal to the lateral fabella on the caudolateral aspect ofthe femoral condyle, ( E) cranial to the insertion of th e CCL on the medial aspect of the lateral condyle of the femur, ( F) cranial and caudalto the extensor fossa on the lateral aspect of the tibial plateau and the middle of the proximal aspect of the tibial plateau in line with the cranialaspect of the extensor fossa. The yellow dots in (D)–(F) are the centers of mass of the isometric areas..relative positions of the system of axes were determined at15 positions, which corresponded to 80 degrees of flexion inincrements of 5 degrees.Isometric PointsIsometric points were de fined as any two points, one on thefemur and one on the tibia, where the largest difference indistance between the two points did not exceed the smallestdifference between the two points by 0.2 mm throughout therange of motion. The search for isometric points included theentire epiphysis of the femur and tibia excluding the articularsurfaces of the femur and tibia. The contours of the distalfemur and proximal tibia were converted into point cloudseach containing 1,635 (total 3,270) points. The distancebetween each point on the femur and all the points on thetibia at each of the 15 positions was repeated for each of thepoints on the femur. The difference between the maximumand minimum distances for each pair of points was calculat-ed and those less than 0.2 mm were illustrated as two reddots connected by a red line at their respective locations onthe femur and tibia. The analysis was also run with amaximum difference of less than 0.1 and less than 0.4 mm.The maximum difference was increased to see if additionalareas could be identi fied and decreased in order to decreasethe number of data points to facilitate interpretation.ResultsRunning the analysis with a maximum difference of less than0.2 mm, a total of 3,681 pairs of isometric points wereidenti fied with all points located in 4 (2 pairs) isometricareas. One pair of isometric areas was intra-articular, and theother pair was located on the lateral aspect of the sti fle(►Fig. 1A –C). The intra-articular pair of isometric areasconsisted of an area on the medial aspect of the lateralfemoral condyle, caudal to the CCL landmark ( ►Fig. 1E ),and an area on the cranial aspect of the tibial plateau. Thecenter of mass of each of the areas and the anatomicallandmarks are shown in ►Fig. 1D –F, and the distancesbetween the center of mass of the isometric and the relevantanatomical landmark are listed in ►Table 1 . When theanalysis was repeated with a maximum difference of lessthan 0.4 mm, the number of data points in the four regionsincreased; however, no additional isometric areas wereidenti fied, and the dimensions of the footprints did notchange. Running the analysis using a maximum differenceTable 1 Distances between the center of mass of the isometric area and relevant anatomical landmark(s)Center of mass of isometric area Anatomical landmark Distance (cm)Lateral aspect of the femoral condyle Distal to the lateral fabella 0.2Medial aspect of the lateral femoral condyle Cranial to the insertion of the CCL 0.3Lateral aspect of the tibial plateau Cranially and caudally to the extensor fossa 0.4 and 0.5, respectivelyProximal aspect of the tibial plateau Proximal aspect of the tibial plateau 0.6Abbreviation: CCL, cranial cruciate ligament.Fig. 2 Model of the sti fle showing the crossing over of red lines connecting pairs of isomeric points within the joint and on the lateralaspect of the sti fle. (A)O nt h el a t e r a la s p e c to ft h es t i fle, points on the proximal ( white arrow )a n dd i s t a l( black arrow ) aspects of the isometric areaon the femoral condyle were paired with points on the caudal ( white arrow )a n dc r a n i a l( black arrow ) aspects of the isometric area on thelateral aspect of the tibial plateau, respectively. ( B) Within the joint, points on the proximal ( white arrow )a n dd i s t a l( black arrow )a s p e c t so ft h eisometric area on the medial aspect of the lateral fe moral condyle were paired with points on the caudal ( white arrow ) and craniomedial(black arrow ) aspects of the isometric area on the tibial plateau, respectively..of less than 0.1 mm decreased the number of data points inall four regions, and revealed the crossing over of the lines atboth locations, but did not change the areas of the footprints(►Fig. 2 ).On the medial aspect of the lateral femoral condyle, all thepoints were located in a roughly semicircular area with amaximum diameter of 3 mm, with the convex side of thefootprint orientated caudally, and the cranial flatter sideorientated proximally/distally. On the tibial plateau, all thepoints were located in an area that started at the cranialaspect of the medial intercondylar eminence and extendedfor 9 mm through the cranial intercondylar area to the medialaspect of the tibial plateau caudal to the tibial tuberosity(►Fig. 1F ). The distance between the intra-articular femoraland tibial isometric points ranged from 8.8 to 21.3 mm, withan average percentage strain of 1.4%. The pair of isometricareas on the lateral aspect of the sti fle consisted of an area onthe lateral aspect of the lateral femoral condyle and an areaon the lateral aspect of the tibial plateau. On the lateral aspectof the lateral femoral condyle, all the points were located in aroughly circular area with a maximum diameter of 3 mm,distal to the anatomical landmark on the caudolateral femurdistal to the lateral fabella (►Fig. 1D ). On the lateral aspect ofthe tibial plateau, all the points were located cranial andcaudal to the extensor sulcus in an area that extended for7 mm. The distance between the femoral and tibial isometricpoints on the lateral aspect of the sti fle ranged from 14.3 to20.8 mm, with an average percentage strain of 1.7%.

Question 63

Murphy - 2024 - VCOT - The Prevalence and Risk Factors of Contralateral Cranial Cruciate Ligament Rupture in Medium-to-Large (≥15kg) Breed Dogs 8 Years of Age or Older.pdf

Answer 63

Case Selection Criteria –Cases were identi fied by anony-mous review of electronic medical records of dogs examinedat Dallas Veterinary Surgical Center between March 2002and December 2017 with permission from hospital admin-istration. Dogs were included if they were diagnosed withfirst-side CCLR when they were 8 years of age or older andweighed 15 kg or more. Dogs were evaluated for CCLR onphysical examination performed by a board-certi fied sur-geon during consultation (palpation of tibial thrust, cranialdrawer, joint effusion, medial buttress, meniscal click) anddiagnosis was con firmed at surgery to be included in thestudy.1–3,21Dogs were excluded from the study if they werefound to have bilateral CCLR or presence of concurrentmedial or lateral patellar luxation at the initial consultationbased on physical examination, orthopaedic malformationsor history of trauma to the hind limbs. Preoperative radio-graphs were performed on all cases for TPA measurements,evaluation of hip congruency, sti fle and hip osteoarthritisand to identify presence of joint effusion in the contralateralstifle. All dogs were re-evaluated by a board-certi fied sur-geon during a follow-up examination including radiographsof the stabilized sti fle 8 to 12 weeks postoperatively toconfirm suf ficient radiographic healing of the osteotomysite. Radiographs were unavailable for review due to theextent of the dataset range from 2002 to 2017.Data Collection –All dogs underwent a tibial plateaulevelling osteotomy (TPLO) from 2002 to 2017. Informationfrom the medical record was collected and included breed,weight, sex, intact status, age at the time of first-side CCLR andcontralateral CCLR (if applicable), date of physical examination,date of surgery, comorbidities (including history of steroids, hipdysplasia, hypothyroidism, allergies, seizures), pre-operativeTPA, surgery report, meniscus tear presence and meniscalrelease. The TPA was measured by the board-certi fied surgeonperforming the surgery as previously described.2Data collectionwas performed on 6/1/2021, signifying the end of the follow-upperiod. Follow-up period was de fined as the number of monthsfollowing the initial first-side CCLR diagnosis to the end of datacapture (6/1/2021). This allowed for a minimum follow-upperiod of 41 months (January 2018 –June 2021). Dogs werethen grouped based on unilateral CCLRor contralateral CCLR. Fordata analysis, dogs were divided into six groups for breed(German Shepherd/mix, Labrador/mix, Golden Retriever/mix,Australian Shepherd/mix, Mixed breed and Other) to simplifythe dataset for analysis.Statistical Analysis –The response variable was contra-lateral CCLR (binary). There were 17 factors that were testedfor association with contralateral CCLR including breed(German Shepherd/mix, Labrador/mix, Golden Retriever/mix, Australian Shepherd/mix, Mixed breed, other), weight,sex, intact status, age at initial CCLR, comorbidities (includinghistory of steroids, hip dysplasia, hypothyroidism, allergies,seizures), TPA (measured by a board-certi fied surgeon per-forming the surgery), meniscus tear and meniscal release.Analysis was by means of multivariate logistic regression.Multicollinearity amongst the factors was quanti fied bymeans of the variance in flation factor, where less than 2.5was considered acceptable. Linearity of the continuous fac-tors (weight and age) was assessed by means of the BoxTidwell approach and was acceptable. For continuous vari-ables the mean, SD, median and 25th/75th quartiles arereported as descriptive data. Categoric data was reportedas frequencies (%). All factors were entered in to the multi-variate equation and deleted, one at a time, according to thehighest p-value. Factors were retained in the final model if p-.value was less than 0.10, and signi ficance was claimed if p-value was less than 0.05. Odds ratios (OR) with 95% con fi-dence limits and p-values were reported.ResultsMedical records of 831 dogs were identi fied for being 8 yearsof age or older and weighing 15 kg or more with a unilateralCCLR to be included in the analysis. The most common breedswere Labrador Retriever/mix 33% (275/831), Mixed breed14.4% (120/831), Golden Retriever/mix 10.8% (90/831), Ger-man Shepherd/mix 5.5% (46/831), Australian Shepherd/mix3.3% ( n¼28) and other 32.7% (272/831). The population wascomposed of 55.5% female (461/831) and 44.5% male(370/831) dogs. This consisted of 42.4% male castrated(353/831), 2.0% male intact (17/831), 54.2% female spayed(451/831) and 1.2% female intact (10/831) dogs. The medianweight of the population was 31.8 kg (25th/75th percentile25.9/37.5). The median age at which dogs experienced a first-side CCLR was 108.0 months of age (25th/75th percentile96.2/120.0 months;►Table 1 ).A prevalence of 19.1% (159/831 dogs, 95% con fidenceinterval [CI]: 16.6 –22.0%) of dogs experienced a contralateralCCLR within the follow-up period. A median follow-up periodof over 112.7 months (25th/75th quartiles 75.4/157.7 months)from first-side CCLR diagnosis was allotted ( ►Table 2 ). Themedian time that passed from first-side CCLR to contralateralCCLR was 12.9 months (25th/75 thquartiles 6.5/24.3months; ►Table 1 ). The median age of dogs that experienceda contralateral CCLR was 119.9 months (25th/75th percentile111.7/134.2 months; ►Table 1 ).We examined breed, weight (in kg), sex, intact status, ageat initial CCLR, comorbidities (including history of steroidsn¼31, hip dysplasia n¼34, hypothyroidism n¼40, allergiesn¼45, seizures n¼13), TPA (measured by a board-certi fiedsurgeon preoperatively), meniscus tear, meniscal release todetermine the in fluence of risk on contralateral CCLR usingNCSS statistical software (2019, Kaysville, Utah, UnitedStates). Age ( p¼0.003) and breed, speci fically GoldenRetrievers ( p¼0.028) and Labrador Retrievers ( p¼0.007)were factors signi ficantly associated with contralateralCCLR. The OR for age was 0.98 (95% CI: 0.96 –0.99). Therefore,with each month increase in age, the odds of a contralateralCCLR decreased by 2% ( ►Table 3 ). For Golden Retrievers, theodds of a contralateral CCLR were found to be 53% (OR: 1 –0.47¼0.53, 95% CI: 0.24 –0.92) less compared with non-Golden Retrievers. Similarly, Labrador Retrievers were foundto have 42% (OR: 1 –0.58¼0.42, 95% CI: 0.38 –0.86) less oddsof a contralateral CCLR compared with non-LabradorRetrievers ( ►Table 3 ).

Question 64

Kazmir - 2023 - JFMS - Use of wound infusion catheters for postoperative local anaesthetic administration in cats.pdf

Answer 64

Study design and eligibility criteriaMedical records from eight veterinary referral hospitals were retrospectively searched to identify client-owned cats in which WICs were used as part of multimodal post-operative analgesic regimen between January 2010 and December 2021. Cases were excluded from the study if the records were incomplete. The data retrieved from the medical records comprised: breed, age, sex, weight, type of surgery, size and type of WIC placed, application of a filter, WIC location (subcutaneous vs intramuscular), time (h) from WIC placement to removal, type of LA, type of LA administration (continuous vs intermittent), total dose (mg) and total amount (ml) of LA delivered (< 2.5 ml vs >2.5 ml), frequency and single dose amount (ml) of LA delivered and any complications encountered until the recheck. The rechecks were performed by a veterinar -ian at the referral institution or at a referring practice at 13–15 days from the surgery or later in case of complica-tion. Complications were classified as wound-related and drug delivery complications.23 Wound-related complica -tions included fluid accumulation/drainage, localised swelling at the suture site, diffuse oedema of the surgical site, seroma, wound dehiscence and surgical site infec-tion. Postoperative surgical site infection was defined according to Centers for Disease Control and Prevention as a post-surgical infection that occurs within 30 days of the surgical procedure (or within 1 year of an implant placement) and must include at least one of the follow -ing features: purulent debris; positive bacterial culture; or pain, swelling, fever and redness at the surgical site.24,25Drug delivery complications included local (local skin reaction or pain at injection) or systemic toxicity (emergence delirium, dysphoria, neurological signs, uncontrolled pain, respiratory distress) and any techni-cal problems associated with the WIC (catheter dislodge -ment, occlusion, loss of negative pressure or resistance during injection). Emergence delirium was defined as a state of mental confusion and psychomotor agitation marked by hyperexcitability, restlessness, uncontrolled thrashing and vocalisation.26Statistical analysisAnalyses were performed using Excel 2021 (Microsoft) and SPSS, version 26.0 (IBM). Descriptive statistics were reported for all variables. The Shapiro–Wilk test confirmed that the data were not normally distributed (P <0.001) and all the data were reported as median and range. Assessed continuous explanatory variables were age, body weight, WIC size, single dose amount (ml) and frequency of LA administration, total LA dose (mg), total LA amount delivered (ml) and time (h) from WIC place -ment to removal. Assessed categorical variables were sex, neuter status, type of surgery, application of a WIC filter, WIC location (subcutaneous vs intramuscular), type of LA (bupivacaine vs ropivacaine), type of LA adminis-tration (continuous vs intermittent), use of NSAIDs and occurrence of postoperative complications.Simple and multiple logistic regression were used to determine the association of a range of variables with the Kazmir-Lysak et al 3occurrence of complications. The outcome variables were the occurrence of any type of complication associated with the WIC, and the explanatory variables were those listed above. These variables were first tested separately with simple logistic regression. A multiple logistic model was then built, which initially included the variables identi-fied as P <0.2 by simple regression. The model was then refined over multiple rounds, using backward-stepwise elimination of the least significant variable each time, and variables were only retained in the final model if they were significant in their own right (P <0.05). Logistic regression results were reported as odds ratios, 95% confidence inter -val and the associated P value. P <0.05 (two-sided) was considered statistically significant.ResultsIn total, 210 medical records of cats in which WICs were used were retrospectively evaluated. Only 166 cats met the eligibility criteria for the study after the exclusion of 44 cats, owing to the incomplete or inadequate medical records and follow-up. The most represented breeds were domestic shorthair (n = 138), followed by British Shorthair (n = 6), Maine Coon (n = 4), Bengal (n = 4), domestic long -hair (n = 2) Persian (n = 3), Norwegian Forest Cat (n = 2), Siamese (n = 2), Turkish Van (n = 2), Charteuse (n = 1), Egyptian Mau (n = 1) and Soriano (n = 1). The median (range) age was 10 (0.5–17) years and their median (range) weight was 5 (1.4–10.2) kg. There were 81 intact and three castrated males together with 80 intact and two spayed females. The most common surgical procedure was feline injection site sarcoma excision (58.4%, n = 97), followed by limb amputation (16.8%, n = 28), thoracotomy (12%, n = 20), mastectomy (7.22%, n = 12), abdominal wall resec-tion (2.4%, n = 4), other neoplasia removal (2.4%, n = 4) and joint stabilisation (0.6%, n = 1). The median (range) size of the catheter used was 4 (2–9) Fr. Mila WIC (MILA International) was used in 159 cats (95.7%), Dahlhausen WIC (Dahlhausen & Co.) was used in five cats (3%), a modified red rubber catheter (Tyco) was used in one cat (0.6%) and a modified rhinogastric catheter (Tyco) was used in one cat (0.6%). The filter (MILA International) was employed in 151 cats (90.9%).The WIC was placed within the muscular layers in 85 cases (51.2%) and in the subcutaneous tissue in 81 cases (48.8%). The WIC was left in place for a median (range) of 45 (2.5–120) h. Bupivacaine 0.25% and 0.5% were used in six (3.6%) and 105 (63.2%) cats, respectively. Ropivacaine 0.25%, 0.5% and 0.75% were used in two (1.2%), 29 (17.4%) and 24 (14.45%) cats, respectively. In all cases, the LA was administrated intermittently with a median (range) frequency of 6 (1–12) h. The administered dose of bupivacaine and ropivacaine was 1.06 (0.48–17.00) mg/kg and 1.49 (range 0.73–2.00) mg/kg, respectively. The total volume of LA was 7.7 (0.82–195.00) ml and 6.36 (0.84–17.92) ml for bupivacaine and ropivacaine, respec -tively. The volume of a single dose of LA delivered per each administration was 1.3 (0.34–15) ml for bupivacaine and 1 (0.28–2.26) ml for ropivacaine.Complications were identified in 22 cats (13.2%). Thirteen cats (7.8%) experienced wound-related compli -cations: diffuse surgical site oedema (4.2%, n = 7), seroma (1.8%, n = 3), localised swelling at level of the suture site (0.6%, n = 1) and surgical wound dehiscence (1.2%, n = 2). Wound-related complications occurred in 11 (6.6%) cats that had undergone feline injection site sarcoma excision (Table 1).Nine cats (5.4%) experienced drug-delivery complica -tions: local pain at injection of LA (0.6%, n = 1), hyper -salivation after administration of LA (0.6%, n = 1) and technical issues (4.2%, n = 7). Technical issues included: Table 1 Complications identified in 166 cats undergoing different types of surgerySurgery type Number of animals Wound-related complication Drug delivery complicationFISSexcision97 2 seroma7 oedema2 dehiscence2 dislodgement1 resistance to injectionMastectomy 12 1 swelling 1 dislodgement1 resistance to injectionLimb amputation 28 0 1 local irritation during injection1 hypersalivationThoracotomy 20 1 seroma 1 dislodgement1 resistance to injectionAbdominal wall resection 4 0 0Other neoplasia excision 4 0 0Joint stabilisation 1 0 0Total 166 13 9FISS = feline injection site sarcoma4 Journal of Feline Medicine and Surgery catheter dislodgement (2.4%, n = 4) and resistance during injection (1.8%, n = 3) (Table 1).Logistic regression analysis was used to determine factors associated with the occurrence of complications, when considering possible confounding factors (Table 2). After the initial model was refined by backward- stepwise elimination, the best-fit model was one that included three variables. In the final multiple regression model (Table 3), the only factors positively associated with an increased risk of complications was the amount of local anaesthetic delivered through the catheter (P <0.001). An amount higher than 2.5 ml of single dose of LA delivered at each administration has been found to be associated with an increased risk of complications.

Question 65

Downey - 2023 - VETSURG - Evaluation of long-term outcome after lung lobectomy for canine non-neoplastic pulmonary consolidation via thoracoscopic or thoracoscopic-assisted surgery in 12 dogs.pdf

Answer 65

2.1 |AnimalsA retrospective review of the medical records of dogs thatunderwent TL or TAL for PC at 3 veterinary institutionsbetween 2011 and 2020 was performed. All cases wereclient-owned animals, which underwent a complete lunglobectomy. Dogs of any age, sex, and weight wereincluded if a minimally invasive procedure was electedfor complete lung lobectomy and long-term follow upwas available.2.2 |Study designMedical records were reviewed to record patient demo-graphics, clinical signs, physical examination, laboratoryfindings, diagnostic imaging, anesthetic management,details of the surgical procedures, perioperative complica-tions, and long-term outcomes. Preoperative blood workusually included a complete blood count and chemistrypanel. Preoperative imaging included either 3-view tho-racic radiographs and/or thoracic computed tomography(CT) in all cases, with an abdominal ultrasound beingperformed in a subset of patients. Pulmonary consolida-tion was defined on plain radiography or CT scans asradio-opaque lung parenchyma due to fluid accumula-tion or airway collapse characterized by a loss of normalmargin between adjacent airways and blood vessels.Anesthesia data was recovered from the anestheticrecords, which included additional details regarding one-lung ventilation (OLV). Surgical data recorded includedthe number and location of lobes removed, proceduresperformed under general anesthesia, surgical equipment,approach, intraoperative/postoperative complications,conversion rates, and anesthetic and procedure times.Duration of surgery was defined as the time from the ini-tial incision until the conclusion of the closure. Patientswere divided into 2 groups according to surgical tech-nique. The TL group included patients that underwent acompletely thoracoscopic procedure and where the lungresection was performed intracorporeally with an endo-scopic stapling device. Port enlargement was performedafter lung lobectomy was complete as needed for speci-men retrieval. The TAL group included patients that hadan intercostal “assist ”thoracotomy without rib retractionto complete the procedure. Cases were considered to haveconverted to an open approach if a thoracotomy with ribretraction was performed.2.3 |AnesthesiaProtocols for premedication, induction, and maintenanceof general anesthesia were determined at the discretionof the attending veterinary anesthesiologist. The surgicalsite was widely clipped and scrubbed according to routineprotocols. One-lung ventilation was instituted in all TLgroup dogs but was not used in TAL group dogs. Toinitiate OLV either an EZ-blocker (EZB) (Teleflex Medi-cal Inc., Durham, North Carolina) or a left-sided double-910 DOWNEY ET AL . 1532950x, 2023, 6, lumen endobronchial tube (Rusch Robertshaw endobron-chial tube, Teleflex Medical Inc., Durham, North Caro-lina) was placed. In some cases, PEEP, at 2-5 cm H 2O,was used to improve oxygenation during thoracoscopy.Establishment of OLV was either performed blindly, withbronchoscopic assistance or using a fluoroscopic-assistedtechnique.16The cuffs of the (EZB) or double-lumenendobronchial tube (DLT) were inflated with air andcomplete OLV was confirmed via visual inspection thora-coscopically. Technical difficulties or failure to establishOLV were recorded. Successful OLV was defined as atel-ectasis of all the lung lobes in the corresponding hemi-thorax for the duration of the thoracoscopic procedure.2.4 |SurgeryCefazolin sodium (22 mg/kg IV) was administered atinduction and repeated every 90 minutes intraoperatively.The surgical technique for TL was similar to that previ-ously described.17Either a 3- or 4-port technique was usedin a triangulating pattern around the anticipated locationof the relevant pulmonary hilus. A combination of 6 mmnondisposable trocarless threaded cannulas (Endotip, KarlStorz Veterinary Endoscopy, Goleta, California) were usedfor the telescope and instruments, and 12 mm threadedcannulas (Thoracoport, Covidien Inc., Mansfield, Massa-chusetts) were used for placement of the endoscopic sta-plers. Port placement was dependent on the surgeon'spreference and the lung lobe of interest. A vessel-sealingdevice (Ligasure 5 mm, Medtronic Inc., Mansfield, Massa-chusetts) or hook electrode (Laparoscopic J-hook elec-trode, Medtronic Inc., Minneapolis, Minnesota) was usedto cut and seal the pulmonary ligament in dogs thatunderwent caudal or accessory lung lobectomies. A bluntprobe (Palpation probe, Karl Storz Veterinary Endoscopy,El Segundo, California) was utilized to facilitate pneumo-nolysis until the pulmonary hilus of the lung lobe to beresected could be manipulated. For transection, an articu-lating endoscopic gastrointestinal anastomosis surgical sta-pler (EndoGIA stapler, Medtronic Inc., Minneapolis,Minnesota), introduced through the 12 mm port (CovidienInc.) (Figure 1), with a 3.5 mm cartridge was used. In mostcases, a specimen retrieval bag (Monarch, Applied MedicalInc., Rancho Santa Margarita, California) was used toretrieve the lung lobe. Lung lobes were removed throughthe stapler instrument port by extending the incision with-out retraction of the ribs. At the termination of surgery,ports were closed in routine fashion.17For the TAL group, an optical trocar (VersaOne Opti-cal Trocar, Covidien Inc., Mansfield, Massachusetts) wasutilized to gain access to the thoracic cavity. A 360/C14wound retraction device (Alexis, Applied Medical Inc.,Rancho Santa Margarita, California) was placed within aminithoracotomy site to allow exteriorization of theaffected lung lobe. Lung lobectomy was performed with athoracoabdominal surgical stapler (TA stapler, MedtronicInc., Minneapolis, Minnesota) loaded with a 3.5 mm sta-ple leg-length cartridge.For dogs where a TL or TAL approach was plannedbut where conversion to an open thoracotomy was per-formed, closure of the thoracotomy incision was routinewith placement of a circumcostal appositional sutures,closure of the deep muscle and subcutaneous incision,and placement of skin sutures.An indwelling single-lumen polyurethane catheter(MILA chest tube, MILA International, Inc., Florence,Kentucky) was placed to provide thoracic drainage in thepostoperative period. Postoperative analgesia included acombination of an opioid and a nonsteroidal anti-inflammatory drug. All dogs received postoperative anal-gesics at the discretion of the attending clinician.Long-term follow up was achieved by reviewing med-ical records, documented client communications, and bytelephone conversations with owners where possible.3|RESULTS3.1 |AnimalsTwelve dogs underwent TL (9) or TAL (3) between 2011and 2020. Breeds operated included Labrador retriever(n=3), French bulldog (2), pointer (2), English bulldog(1), English setter (1), bull terrier (1), Doberman (1), andmixed breed (1). Five dogs were intact males, 4 werespayed females, 2 were intact females, and 1 was a cas-trated male. The median age was 3.5 years (range,FIGURE 1 Thoracoscopic image depicting utilization of apalpation probe for adhesiolysisDOWNEY ET AL . 911 1532950x, 2023, 6, TABLE 1 Clinicopathological data from 12 dogs that underwent thoracoscopic or thoracoscopic-assisted lung lobectomy formanagement of non-neoplastic pulmonary consolidation.Patient Group BreedAge(years)Bodyweight(kg)Lung loberesectedHistopathologicaldiagnosis Culture results Outcome1 TL LabradorRetriever7 23.7 Left cranial Severe regionalnecrotizing andsuppurativePneumoniasuspect bacterialYersiniapseudotuberculosisEuthanized at2190 daysformyastheniagravis2 TL EnglishBulldog0.5 12.3 RightcranialBronchial/alveolarmalformation andabnormal ciliaBordatellabronchisepticaAlive3851 days3 TL Caninemixedbreed2 20.6 RightmiddleBronchoalveolarPneumonia withintralesional fungiNo growth Alive 150 days4 TL LabradorRetriever1 33.3 RightcaudalInterstitialPneumoniasuspect bacterialViridans streptococci Alive 730 days5 TL LabradorRetriever1 26.3 RightmiddleBronchointerstitialpneumoniasuspect bacterialNo growth Not available6 TL Doberman 7 32 Rightcranial &middlePneumonia withnecrosis anddiffuse pleuritissuspect bacterialNo growth Alive 365 days7 TL Pointer 5 22 RightcaudalPneumonia withnecrosis suspectsecondary tomigrating foreignbody and bacterialNot available Alive 730 days8 TL FrenchBulldog3 12 Left cranial Pneumonia suspectbacterialBordatellabronchisepticaAlive 730 days9 TL EnglishSetter2 23 RightcaudalGranulomatouspleuritis andsevere lungatelectasis andneutrophilicbronchitis suspectbacterialNo growth Alive 730 days10 TAL Pointer 4 24.9 RightaccessoryBronchointerstitialpneumoniasuspect viralNo growth Alive 420 days11 TAL FrenchBulldog6 8 RightcranialBronchopneumoniawith lungabscessationsuspect bacterialNo growth Died 3 dayspost-operatively12 TAL Bullterrier 5 28 RightcaudalLeft-sided cardiacinsufficiency vspulmonarylipoproteinosisNo growth Alive at least150 days,eventuallydiagnosedwithR-CHFAbbreviations: CHF, congestive heart failure; TAL, thoracoscopic-assisted lung lobectomy; TL, thoracoscopic lung lobectomy.912 DOWNEY ET AL . 1532950x, 2023, 6, 0.5-7 years). The median body weight was 23.3 kg (range,8-33.3 kg). A categorical summary of the patient popula-tion and results can be found in Table 1.3.2 |Clinical history and physicalexaminationThe most commonly reported clinical signs includedcoughing ( n=10), vomiting (3), inappetence (2), laboredbreathing (2), and exercise intolerance (2). The medianduration of clinical signs was 30 days (range, 2-365 days).On physical examination, 2 patients had a fever>102.5/C14F and 4 had bibasilar crackles auscultated. Out-side of expected derangements associated with pneumo-nia, none of the patients had significant preoperativeblood work abnormalities; a detailed summary of theseresults was therefore not included.3.3 |Diagnostic imagingThoracic radiographs were available for review from11 dogs. Thoracic radiographs revealed a predominantlyalveolar lung pattern in 7 dogs (63.6%), a bronchial patternin 3 dogs (27.3%), or an unstructured interstitial pattern in1 (9.1%) dog in the affected lung lobe (Table 1). Onepatient's radiographs were not available for review. All thepatients ’radiographic findings fit within the authors ’definition of non-neoplastic pulmonary consolidation asan accumulation of fluid or collapse of the airway, result-ing in an increased radio opacity of lung parenchyma.Computed tomography (CT) with IV contrastadministration was performed on 10 dogs. The follow-ing patient numbers correlate with patient numberslisted in Table 1. Patient 1 had consolidation of the leftlateral cranial lung lobe with bronchial obstruction andnear complete consolidation of the caudal segment(Figure 2). Patient 2 had a diffuse saccular appearancewith diffuse patchy alveolar infiltrates in the right cra-nial lung lobe, which may represent diffuse bronchiec-tasis and/or pulmonary emphysema. Patient 3 had analveolar pattern in the right middle lung lobe with mul-tifocal cavitation/bulla formation, mild pleural effusion,and pleuritis likely secondary to migrating foreignmaterial. Patient 4 had a small linear region of soft tis-sue attenuation in the plane of a bronchus in the rightcaudal lung lobe, which extended to the level of thepleural margin at the level of the eleventh intercostalspace with a small volume pneumothorax and pneumo-mediastinum and pleural effusion, which were likelysecondary to migrating foreign material. Patient 5 hadmultilobular bronchopneumonia with right middle lunglobe atelectasis and bronchiectasis. Patient 6 had con-solidation of the right cranial and middle lung lobes.Patient 7 had consolidation of the right caudal lobe, theappearance of which was suspicious for migrating for-eign material. Patient 8 had signs consistent with aspi-ration pneumonia of the left cranial lung lobe withsevere diffuse pneumonia. Patient 9 had pleural effu-sion appreciated within the cranial thorax and pleuritisof the right caudal lung lobe. Patient 11 had an abscessof the right cranial lung lobe with severe pleural effu-sion with migrating foreign material suspected. Patients10 and 12 did not have a CT study performed. In total,CT interpretation raised concern for migration of for-eign bodies in 4 dogs (40%).Abdominal ultrasonographic examination was per-formed as part of the diagnostic evaluation on 3 dogs.One patient had splenic nodules with the remaining stud-ies unremarkable.3.4 |Anesthetic managementFor the TL group, OLV was successfully achieved in 7 of9 (78%) dogs with either an EZB (Teleflex Medical Inc.)(n=5) or DLT (Teleflex Medical Inc.) ( n=2). In 1 dog,successful OLV was only achieved after switching from aDLT (Teleflex Medical Inc.) to an EZB (Teleflex medicalInc.). In dogs where OLV was unsuccessful, the EZB (Tel-eflex Medical Inc.) and DLT (Teleflex Medical Inc.) hadFIGURE 2 Thoracic axial computed tomography imageillustrating consolidation of the left cranial lung lobeDOWNEY ET AL . 913 1532950x, 2023, 6, been used in 1 dog each, with a third dog's tube type notreported. Complications of OLV included migration ofthe tube during ventilation ( n=1), inability tocompletely occlude the bronchus ( n=1), and an inabilityto block the desired lung lobe of interest selectively(n=1). When OLV was unsuccessful, the procedure wascompleted using intermittent ventilation.3.5 |Surgical findingsThoracoscopic lobectomy and TAL were performed forthe following lobes: right caudal (4), right middle (3),right cranial (3), left cranial including both cranial andcaudal segments (2), and accessory (1). One patient had2 separate lung lobes excised (right middle, right cranial).Three patients had an additional procedure performedunder the same anesthetic event, which included bron-choscopy, bronchial alveolar lavage, and brachycephalicobstructive airway syndrome surgery (rhinoplasty, sta-phylectomy, bilateral laryngeal sacculectomy).For the TL group, specifics of portal placements werenot available for all the dogs. In 7 dogs, a 3-port tech-nique was used and in 2 dogs a 4-port technique wasused. Instrument portals were placed in the followinglocations: fourth (1), fifth (1), sixth (3), eighth (2), ninth(3), and tenth (5) intercostal spaces. In 2 dogs cannulaswere removed and the instrument port incisions wereenlarged slightly with digital pressure or by additionalincision of the tissue to allow passage of a sterile glovedfinger to aid in the manipulation of the lung lobeor to facilitate adhesiolysis. EndoGIA (MedtronicInc.) staple cartridge lengths used in TL cases were as fol-lows: 30 mm ( n=1), 45 mm (11), and 60 mm (2). Only4 out of 9 (44.4%) of the TL procedures utilized a singlecartilage. In 3 patients, 2 /C260 mm staple cartilages wereused, and 2 patients required a 60 mm and 45 mm carti-lage. In 1 dog an endoscopic clip applier (Endoclip II10 mm, Medtronic Inc., Mansfield, Massachusetts) wasused to seal a small remaining attachment of lung tissueat the termination of the staple line. A specimen retrievalbag (Applied medical Inc.) was utilized in 5 of 9 dogs(55.6%) to facilitate the removal of the resected lung lobefrom the thorax.For the TAL group access to the accessory, cranial,and caudal lung lobectomies were performed at the ninthand tenth intercostal spaces respectively. Minithoracot-omy incisions for the accessory, cranial, and caudal lunglobectomies were positioned in the sixth, fourth, and sev-enth intercostal spaces respectively. A single thoracoab-dominal stapler (Medtronic Inc.) was utilized in all TALcases. A 45 mm cartridge/stapler length was used for1 dog, and a 60 mm length cartridge was used in 2 dogs.In 1 patient in the TAL group, a plant awn was identifiedwithin the endotracheal tube after extubating.3.6 |ConversionOf the 9 dogs that underwent a TL procedure, an electiveconversion was performed in 4 out of 9 dogs. Three caseswere converted to an open intercostal thoracotomy, and1 was converted to a TAL. Conversion was performeddue to adhesions to the parietal pleura (3 cases) and poorvisualization of the surgical field (1). Intraoperative hem-orrhage was subjectively minimal in all cases. Failure ofOLV was not a reason for conversion in any dog. Conver-sion to an open approach was performed for right caudal(2), left cranial (1), and right cranial and middle (1) lunglobectomies. The median durations of clinical signs inthe dogs where a conversion was, and was not, performedwere 90 and 7 days, respectively. No cases where a TALapproach was used initially were converted to an openthoracotomy.The median anesthesia times for TL and TAL were145 minutes (range 100-315 minutes) and 160 minutes(range 154-210 minutes), respe ctively. The median surgerytimes for TL and TAL were 90 minutes (range,65-110 minutes) and 100 minutes (range, 45-150 minutes),respectively. Excluding patien ts who received an additionalprocedure under the same anesthetic event, median surgerytimes for TL were 82.5 minutes (range, 65-110 minutes) andfor TAL 125 minutes (range, 100-150 minutes).3.7 |HistopathologyHistopathologic examination was consistent with pneu-monia due to an infectious process ( n=10), bronchioal-veolar malformation with abnormal cilia (1), andleft-sided cardiac insufficiency versus pulmonary alveolarproteinosis (1). Of the infectious pneumonia group, histo-pathological analysis suggested a bacterial etiology(n=8), a viral etiology (1), or a fungal infection (1). Bac-terial culture samples (11) were positive for growth in4 of 11 dogs (36.4%) and grew the following: Bordetellabronchiseptica (n=2),Viridans streptococci (1), and Yersi-nia pseudotuberculosis (1). The dog that cultured Yersiniapseudotuberculosis was involved in a fight with a ground-hog prior to developing pneumonia.3.8 |Postoperative careAll dogs had an analgesia plan that included an opioideither as intermittent dosing or constant rate infusion914 DOWNEY ET AL . 1532950x, 2023, 6, (CRI) for at least 24 h after surgery: Fentanyl citrate (2 to10 /uni03BCg/kg/h by CRI), methadone hydrochloride(0.2-0.5 mg/kg every 4-8 h), buprenorphine hydrochloride(0.01-0.02 mg/kg IV every 6-8 h), or hydromorphonehydrochloride (0.05-0.1 mg/kg IV every 4-6 h). Allpatients had their thoracic drains evacuated every 2-4 hor as clinically indicated. The median duration ofindwelling thoracic drain time was 32.5 h (range, 4-48 h).The median time spent in the intensive care unit postop-eratively was 22 h (range, 12-102 h). The median hospitalstay was 3 days (range, 1-6 days), specifically 2 (1-3 days)and 3 days (3-6 days) for TAL and TL, respectively. Themedian hospital stays for cases that were converted andnot converted were 3 days and 4 days respectively. Peri-operative complications included a minor skin incisiondehiscence (1), self-resolving pneumothorax (2), self-limiting hemorrhage (3), and progressive pneumonialeading to euthanasia (1). Eleven of 12 (91.7%) patientssurvived to discharge. One patient had concurrent severebrachycephalic obstructive airway syndrome that was notsurgically addressed under the same anesthetic event andwas euthanized 3 days postoperatively due to severe dys-pnea. Patients were discharged on a 5-14 day supply oforal analgesic medication: carprofen (2.2 mg/kg orallyevery 12 hours; 5 cases) and tramadol hydrochloride(2-5 mg/kg orally every 8-12 hours; 2 cases).For the 11 dogs that survived the perioperative period,there was no evidence of recurrence in a median follow-up time of 24 months (range, 5-120 months) based on cli-ent phone interviews (8 cases) and/or evaluation of themedical record (3 cases). One patient had a persistentcough for up to 24 months postoperatively. The underly-ing origin of the cough was not fully defined but thepatient had evidence of biventricular heart disease.4

Question 66

Schuster - 2023 - JSAP - Physical activity measured with an accelerometer in dogs following extracapsular stabilisation to treat cranial cruciate ligament rupture.pdf

Answer 66

This study was approved by the Institutional Animal Care Committee (approval number 35932) and was performed with informed client consent. In this prospective study, conducted between September 2018 and August 2019, dogs were selected after a diagnosis of unilateral CCLR by the Veterinary Orthopae -dics and T raumatology Service of the Veterinary Teaching Hos -pital of the Universidade Federal do Rio Grande do Sul, Brazil. Inclusion criteria were: age >1 year, weight ≤20 kg and evidence of unilateral CCLR based on cranial drawer or tibial compres -sion tests. Dogs with evidence of systemic diseases or having other orthopaedic and/or neurological disorders were excluded from the study. Data collected included: age, sex, breed, affected limb, weight, reproductive status, injury time (time elapsed from rup -ture until surgery), body condition score and occurrence of com -plications. In addition, dogs underwent radiographic examination of the affected stifle preoperatively and at 6 months after surgery.The dogs were evaluated preoperatively (7 days before surgery; T0) and at 1 month (T1), 3 months (T3) and 6 months (T6) after surgery. On all occasions, a single orthopaedic surgeon was respon -sible for evaluating the lameness score and stifle pain score by use of numeric rating scales. The lameness score was determined by a scale ranging from 0 to 4, as follows: 0, no lameness; 1, mild lameness; 2, moderate lameness; 3, severe lameness and 4, non- weight- bearing lameness at all times (Barnhart et al. 2016 ). Stifle pain was evaluated by analysing stifle extension and flexion, and then assigning scores by use of a scale ranging from 1 to 4, as follows: 1, no pain; 2, mild pain; 3, moderate pain and 4, severe pain (Penha et al. 2007 ). In addition to lameness and pain scores, the same surgeon measured the thigh circumference of the affected and non- affected limbs using a measuring tape (Gulick tape) at the level of the inguinal region.The owners of the dogs were asked to respond to two non- validated questionnaires for subjective assessment of physical activity and quality of life. For the physical activity assessment, owners responded at T0 regarding how the CCLR influenced the dog’s physical activity: (1) decreased or (2) had no change. At time points T1, T3 and T6, the owners answered if physical activity: (1) decreased, (2) had no change, (3) partially returned (the dog started to partially undertake the activities it performed before the CCLR) or (4) it fully returned (it returned to fully perform the activities it used to do before the CCLR).The owners, according to their perception of the animal’s gen -eral behaviour and wellbeing, scored the quality of life of their animals. The ability and willingness of the animal to perform its normal daily activities were rated at all times on a 5- point scale: 0, poor; 1, reasonable; 2, good; 3, very good and 4, excellent.A wGT3X- BT triaxial accelerometer (ActiGraph™) was attached to the dog’s collar in order to objectively assess physical activity at T0, T1, T3 and T6. The collar was fastened so that it was very sta -ble, comfortable for the dog and did not twist around the neck. For the assessments at each time point, the dogs had the accelerometer attached for 7 days. The device was set up to register each move -ment every 15 seconds (epoch 15 ') during 24 hours of daily use. Thereafter, the data were extracted and analysed using the ActiLife 6 software (ActiGraph™), version 6.13.4, which was provided by the manufacturer of the device. Using the software, the integrated output (magnitude vector) was calculated, which is the result of the acceleration combination in the three axes. Raw data files were dis -tributed on a Microsoft Office Excel spreadsheet, being expressed as activity counts per minute (cpm) by the sum of four epochs.Four categories of physical activity were obtained: total activ -ity, expressed as average count per minute; time spent in seden - 17485827, 2023, 10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13645 by Vetagro Sup Aef, Wiley Online Library on [19/10/2023]. 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 LicensePhysical activity in dogs with CCLRJournal of Small Animal Practice • Vol 64 • October 2023 • © 2023 British Small Animal Veterinary Association. 621 tary activity (no movement of the trunk, e.g. lying or sleeping, ≤1351 cpm); time spent in light to moderate activity (slow to moderate translocation of the trunk, controlled walk on the leash, moving in an open or closed environment, 1352 to 5695 cpm); and time spent in vigorous activity (rapid translocation of the trunk, moving fast and running, ≥5696 cpm). The daily aver -age in minutes was calculated for each activity during the 7- day period with the accelerometer. Sedentary, light to moderate and vigorous activities were defined according to cutoff points based on a validation study and subsequent ActiGraph accelerometer “calibration” studies (Yam et al. 2011 , Morrison et al. 2013 ).Throughout the study, the dogs were maintained in the same environment, keeping the same routine and received the same diet in order to preserve the same everyday habits and stimuli. In addi -tion, in the periods that the accelerometer was being used, there was a washout period for chondroprotectants, analgesics and non- steroidal anti- inflammatories (15 days), and for steroids (30 days).The surgical procedure was performed by the same surgeon in all dogs and the chosen technique consisted of the standard lateral fabel -lar suture (Conzemius et al. 2005 , Au et al. 2010 , Gordon- Evans et al. 2013 ). During stifle arthrotomy, the remaining parts of the cranial cruciate ligament were removed, and a partial meniscectomy was per -formed in cases in which meniscal injury was identified. At the end of the surgical procedure, a padded comfort bandage was placed on the operated stifle (for 7 days) and postoperative analgesia consisted of meloxicam (0.1 mg/kg) every 24 hours for 5 days, dipyrone (25 mg/kg) every 8 hours for 5 days and tramadol (4 mg/kg) every 8 hours for 5 days. The restriction of activities for 3 weeks with short walks allowed with the animal always on leash was recommended.Data were analysed using the Statistical Package for Social Sci -ences (SPSS) programme (SPSS, Chicago, USA), v. 25.0. The dependent variables included in the study were sedentary activity, light to moderate activity, vigorous activity, total activity, thigh circumference, pain score, lameness score and quality of life score. The independent variables were animals’ evaluation (T0, T1, T3 and T6) and dog (individuality).Comparisons over time in the dependent variables were per -formed by generalised linear models using the Generalised Esti -mating Equations method with Bonferroni’s post hoc multiple comparisons and adjustments. A significance level of P<0.05 was used for all analyses.RESULTSSeventeen dogs were included in the study and they fully com -pleted all evaluations. Demographic data from dogs included in the study are presented in Table 1. Age and weight ranged from 4 to 11 years and from 3.5 to 20.0 kg, respectively; mean values (±sd) were 7.5±2.6 years and 12.3±5.1 kg, respec -tively. The injury time ranged from 20 to 100 days and aver -aged 41±25 days. During the arthrotomy, meniscal injury was observed in 15 (88.2%) of 17 dogs. In 12 (70.5%) of 17 dogs, the lesion was identified in the medial meniscus only whereas in three (17.7%) of 17 dogs, the lesion was detected in both the medial and lateral menisci.Subjective evaluationsThe distribution of lameness scores was as follows: T0, seven (41%) of 17 dogs with score 1, four (24%) of 17 dogs (24%) with score 2 and six (35%) of 17 dogs (35%) with score 3; T1, two (12%) of 17 dogs with score 0, 11 (65%) of 17 dogs with score 1, three (17%) of 17 dogs with score 2 and one (6%) of 17 dogs with score 3; T3, 16 (94%) of 17 dogs with score 0 and one (6%) of 17 dogs with score 1; and T6, 17 (100%) of 17 dogs with score 0.The lameness score decreased by 0.77 points from T0 to T1 [95% confidence interval (CI)=0.29 to 1.23], 1.89 points from T0 to T3 (95% CI=1.26 to 2.49) and 1.94 points from T0 to T6 (95% CI=1.38 to 2.49). The stifle pain score decreased 1.06 points from T0 to T1 (95% CI=0.79 to 1.32), 0.95 points from T0 to T3 (95% CI=0.47 to 1.40) and 1.12 points from T0 to T6 (95% CI=0.81 to 1.41) (P=0.001) for all comparisons, Table 2). At T6, 16 (94%) of 17 dogs and 1 (6%) of 17 dogs presented no pain and mild pain, respectively.The mean thigh circumference of the affected limb was 9.6% smaller (P=0.001) than the non- affected limb at T0. There was a significant increase in thigh circumference by 1.2 cm of the affected limb from T1 to T3 (95% CI=0.18 to 2.26, P=0.011) and 1.3 cm from T1 to T6 (95% CI=0.51 to 2.19, P=0.001). No significant change over time was observed in the affected limb when comparing T0 with T1, T3 and T6 ( Table 2).The average score for quality- of- life increased 1.05 points from T0 to T1 (95% CI=0.31 to 1.80), 1.94 points from T0 to T3 (95% CI=1.38 to 2.49) and 2.05 points from T0 to T6 (95% CI=1.59 to 2.52) (P=0.001) at all postoperative time points. Table 1. Demographic data for 17 dogs with cranial cruciate ligament rupture included in the studyVariable Number of dogs Percentage of dogsSexMale unneutered 1 6Male neutered 6 35Female unspayed 1 6Female spayed 9 53Age (years)4 to 5 5 296 to 8 3 189 to 11 9 53BreedsCrossbred 14 82Yorkshire 2 12Poodle 1 6Body condition score (5 points)Ideal 3 2 12Overweight 4 7 41Obese 5 8 47Injury time (days)20 to 30 10 5931 to 60 2 1260 to 100 5 29Weight (kg)0 to 5 2 125.1 to 15 9 5315.1 to 20 6 35Affected limbRight 10 59Left 7 41 17485827, 2023, 10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13645 by Vetagro Sup Aef, Wiley Online Library on [19/10/2023]. 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 LicenseL. A. H. Schuster et al.Journal of Small Animal Practice • Vol 64 • October 2023 • © 2023 British Small Animal Veterinary Association. 622Additionally, the quality- of- life score was higher at T6 and T3 than at T1 (P=0.001, Table 2). At T6, owners rated the quality of life as good (6%), very good (35%) or excellent (59%).In the physical activity questionnaire, 16 (94%) of 17 owners reported that physical activity was decreased at T0 and one (6%) of 17 owners reported that it remained unchanged. Of the owners who reported a decrease in activity at T0, 14 (88%) of 16 reported a partial return to physical activity at T1. While at T3 and T6, 13 (82%) of 16 and 16 (100%) of 16 owners, respectively, reported a total return to pre- rupture physical activity levels.Postoperative complications were considered minor and not have an impact on the individual physical activity of the dogs. One dog had moderate residual cranial drawer movement with a grade 1 lameness score at T3 and in another dog, a clicking sensa -tion was observed at T6. Its origin was thought to be related to meniscus damage or implant movement. However, this dog did not show clinical signs of lameness or pain.Objective evaluationsTable 3 summarises the daily means of physical activity variables obtained during 7 days of use of the accelerometer. There was no significant difference among time points for any variable. In the sedentary activity, the mean difference from T0 to T1 was 9 min-utes (95% CI=−26 to 42), from T0 to T3, 12 minutes (95% CI=−22 to 45) and from T0 to T6, 0 minutes (95% CI=−34 to 33). In the light to moderate activity, the mean difference from T0 to T1 was 8 minutes (95% CI=−39 to 24), from T0 to T3, 12 minutes (95% CI=−44 to 19) and from T0 to T6, 1 minute (95% CI=−33 to 30). In the vigorous activity, the mean differ -ence from T0 to T1 was 1 minute (95% CI=−6 to 5), from T0 to T3, 0 minutes (95% CI=−5 to 6) and from T0 to T6, 1 minute (95% CI=−4 to 7). The dogs spent an average time that ranged from 21.2 to 21.4 hours (approximately 89% of the day) on sed -entary behaviour, 2.3 to 2.5 hours (approximately 10% of the day) performing light to moderate activity and 13 to 15 minutes (approximately 1% of the day) performing vigorous activity.

Question 67

Kang - 2024 - VCOT - Biomechanical Comparison of Double 2.3-mm Headless Cannulated Self-Compression Screws and Single 3.5-mm Cortical Screw in Lag Fashion in a Canine Sacroiliac Luxation Model - A Small Dog Cadaveric Study.pdf

Answer 67

Specimens and PreparationTwenty-two canine cadavers weighing less than 10 kg fromvarious breeds euthanatized for reasons unrelated to the studywere included in the ex vivo study after obtaining informedowner consent. Ethics approval for the cadaveric study proto-col was not required by the Institutional Animal Care and UseCommittee of Chungnam National University. All cadaverswere stored at –20°C and thawed 24 hours before preparationof the luxation model and subsequent implantation at roomtemperature. To induce the simulated sacroiliac luxation mod-el as described previously,15hemipelvic sides were randomlyselected and the ipsilateral pubis and ischium were transectedusing an oscillating saw. Through a ventral approach to thepelvis, the ilium was separated from the sacrum using a no. 11blade and an osteotome.Preimplantation Radiographic and ComputedTomography EvaluationRadiographic and computed tomography (CT) measurementswere performed by a single radiologist (AL). Preimplantationradiographs were obtained to con firm the induction of luxa-tion and to estimate the preimplantation pelvic canal diameterratio (PCDR) and hemipelvic canal width ratio (HCWR).16,17Preimplantation CT (Alexion, Toshiba Medical System, Japan)was performed to estimate the sacral diameter and adequatescrew length. The sacral diameter was estimated by a best- fitcircle on the sacral sagittal plane, and the percentage of screwsize to the sacral diameter was calculated.18The length of theimplants was chosen to penetrate approximately 70% of thesacral width in the 3.5-mm CS group and 70% for the first and40% for the second screws in the 2.3-mm HCS group.Implantation TechniqueOne surgeon (JJ) performed all implantation procedures.Pelvic positioning and reduction of the sacroiliac jointwere evaluated under fluoroscopic guidance (Philips Health-care, Best, The Netherlands).18Total implantation time wasrecorded from con firmation of reduction to completion ofscrew placement for each cadaver. Double 2.3-mm HCSfixation ( ►Fig. 1 ) was performed by modifying a reportedsurgical technique.15An 18-gauge needle was inserted per-cutaneously as an aiming device for guidewire placement atthe center of the sacral body for primary screw placementbased on visual assessment using fluoroscopic guidance. A0.8-mm Kirschner wire was inserted into both the ilium andthe sacrum through the needle. The insertion of the Kirsch-ner wire was stopped before resistance from the far cortex ofthe sacrum was felt, and the position of the wire was assessedusing fluoroscopy. A second guidewire was inserted in thesame fashion through the percutaneous 18-gauge needleparallel to the first guidewire at the desired location forthe second screw placement, approximately 4 mm dorso-caudal to the first Kirschner wire (►Fig. 1A ), and needleswere removed. Stab incisions were made along the belly ofthe gluteal muscle adjacent to the wires, and a drill guide waspositioned over the preplaced Kirschner wire. Afterward, acannulated drill bit was driven over the preplaced Kirschnerwire through the iliac wing into the sacral body. If theKirschner wire was jammed and it pulled out during thedrill bit removal process due to bone debris, a new Kirschnerwire of the same length was manually inserted into theVeterinary and Comparative Orthopaedics and Traumatology Vol. 37 No. 1/2024 © 2023. The Author(s).Comparison of Double 2.3-mm HCS and Single 3.5-mm CS in a Canine Model Kang et al. 14corresponding position. The drilled depth was measuredusing a cannulated depth gauge over the Kirschner wire. A2.3-mm titanium HCS (thread diameter (Ø) 2.3 mm, core Ø1.8 mm, and head Ø 3.1 mm; Jeil Medical, Republic of Korea)was placed over the first guidewire (►Fig. 1B ) until com-pression was achieved. Subsequently, the second screwinsertion was performed in the same manner. Fixation ofsacroiliac luxation using 3.5-mm 316L stainless steel CS(thread Ø 3.5 mm, core Ø 2.4 mm, and head Ø 6 mm; Synthes,Switzerland) in lag fashion was performed routinely with theminimally invasive fixation technique.16,19Postimplantation Radiographic and ComputedTomography EvaluationAll medical images were reviewed using an image software(Zetta PACS, TaeYoung Soft, Republic of Korea). Postimplan-tation PCDR and HCWR were also assessed. Screw lengthwithin the sacral body was estimated as a percentage of thescrew length in the sacral width on ventrodorsal radio-graphs.1Postimplantation CT was performed to estimatethe percentage of craniocaudal reduction (CCR) and dorso-ventral reduction (DVR) of the sacroiliac joint, craniocaudalangle (CCA) and dorsoventral angle (DVA) of each screw(►Fig. 2 ), mean entry points of the screws, and cranialmargin of the first ventral sacral foramen.18,20PositiveCCA or DVA value was de fined as the angle of deviationcranially or dorsally from the transverse plane or dorsalplane, respectively. Negative values indicated caudally orventrally directed angles. Mean entry points of the screwswere evaluated on the lateral surface of the sacral body in thetransverse and dorsal planes on CT multiplanar reconstruc-tion images.20Distances of the center of the screw from thecranial end plate of the sacral body in the dorsal plane andfrom the ventral limit of the spinal canal in the transverseplane were estimated ( ►Fig. 2C, F ) and transferred to a two-dimensional plane with conversion to ratios to the sacraldiameter of each dog ( ►Fig. 3 ). Furthermore, distance of thecranial margin of the first ventral sacral foramen was esti-mated at the dorsal and ventral points in the dorsal andtransverse planes, and the measurements were transferredto a two-dimensional plane in the same manner. Y-values ofthe dorsal points were assumed to be 0. Lines connecting themean values of the dorsal and ventral points are presented asa schematic diagram ( ►Fig. 3 ).Mechanical TestTo conduct mechanical tests, pelvises of 22 cadavers wereharvested after fixation. Pelvic limbs and vertebral spineswere disarticulated at the coxofemoral joint and level of thelumbosacral and sacrocaudal junctions, respectively.Remaining soft tissues on the pelvis were dissected. Thedistance between the nearest edge of the two inserted screwheads was measured using a digital caliper in the HCS group.Specimens were then stored in sealed plastic bags at –20°Cwrapped with saline-soaked cotton gauze and thawed for12 hours before mechanical testing at room temperature. Thecontralateral intact ilium was luxated and discarded, and halfof the sacrum was potted in a designed jig with methylmethacrylate resin (Trayplast, Vertex, the Netherlands). Atest was designed to estimate the maximum rotational forceat the sacroiliac joint before failure by simulating the groundreaction force on a hindlimb by modifying a previous method(►Fig. 4 ).6The implanted sacrum was mounted on top of theload cell of the testing machine (ElectroPuls E1000, Instron.Corp., United States). A metal bar simulating the femur wasmounted and matched to the acetabulum to distribute theload. The angle between the shaft of the bar and iliac longaxis was set at 108 degrees to simulate the standing positionof a normal dog.6The hemipelvis was slowly advanceddownward, causing a rotational force to be delivered to therepaired construct, and the applied load was recorded. Thetesting machine provided a constant displacement of0.099 cm/s. A load –displacement curve was plotted foreach sample, and the maximum tolerated load of eachfixation was obtained at the point of fixation failure. Loadat failure was de fined as the point at which the first suddenFig. 1 Implantation procedures of 2.3-mm HCS placement under fluoroscopy guidance. ( A) Two guidewires are inserted parallelly through thepercutaneous needle. The second guidewire (/C3/C3) is placed dorsocaudally to the first wire (/C3). A stab incision was made along the belly of thegluteal muscle adjacent to the wires, and a drill guide was positioned o ver the preplaced Kirschner wire. Afterward, a cannulated drill bit wasdriven over the preplaced Kirschner wire through the iliac wing into the sacral body. ( B) Insertion of the first 2.3-mm HCS over the guidewire.The second wire (/C3/C3) is slightly tilted to faci litate screw insertion. ( C) Placement of double 2.3-mm HCS is assessed using fluoroscopy. HCS,headless cannulated self-compression screw.Veterinary and Comparative Orthopaedics and Tra umatology Vol. 37 No. 1/2024 © 2023. The Author(s).Comparison of Double 2.3-mm HCS and Single 3.5-mm CS in a Canine Model Kang et al. 15Fig. 2 Postimplantation computed tomography evaluation. ( A,D) CCR and DVR are calculated as the length of the sacral wing incontact with the iliac joint surface divided by the total length of the sacral wing at the level of the screw (b/a and c/d, respectively). ( B,E)C C Aa n dDVA are measured on multiplanar reconstruction views and is de fin e da st h ea n g l eb e t w e e nt h ea x i so ft h es c r e wa n dt h et r a n s v e r s ea n dd o r s a lplane, respectively, at the level of screw. Positive values of CCA or DVA are de fined as the angle of deviation cranially or dorsally from thetransverse plane or dorsal plane, respectively. Negative values indicate caudally or ventrally directed angle. ( C)X-values of the distance of thecenter of the screw from the cranial margin of th e sacral body in dorsal plane are evaluated. ( F)Y-values of the distance of the center ofthe screw from the ventral border of the neural canal in the transverse plane are estimated. CCA, craniocaudal angle of screw; CCR, craniocaudalreduction of the sacroiliac joint; DVA, dorsoventral angles of s crew; DVR, dorsoventral reduction of the sacroiliac joint.Fig. 3 Schematic diagram of the mean entry positions of the screws and mean points of the cranial edge of the first sacral ventralforamen converted to the sacral diameter ratio. The x-axis and y-axis correspond to the ventral aspect of the spinal canal and cranial end plate ofthe sacrum, respectively. The axes of the ellipse imply 95% con fidence interval of the mean entry positions on the x-axis and y-axis. A lineconnecting the mean values of dorsal and ventral points of the cranial boundary of sacral ventral foramen is drawn. The minimum x-valuesof 95% con fidence interval of the mean dorsal and ventral points are connected with an oblique line and maximum x-values of those points areconnected in the same manner. The section is marked in red.d ,s a c r a ld i a m e t e r ,S x , x-value of the mean cranial edge point of the firstsacral ventral foramen, Sy, y-value of the mean cranial edge point of the first sacral ventral foramen.Veterinary and Comparative Orthopaedics and Traumatology Vol. 37 No. 1/2024 © 2023. The Author(s).Comparison of Double 2.3-mm HCS and Single 3.5-mm CS in a Canine Model Kang et al. 16decrease in load occurred on the load –displacement curve.The moment arm estimated from the center of the acetabu-lum to the center of the fixation point was recorded tocalculate the rotational force acting on sacroiliac fixation.Mean maximum rotational force tolerated by each fixationmethod at failure was calculated as follows6:where Fis the maximum load tolerated and lis the momentarm. The failure mode of each construct was also recorded.Statistical AnalysisAnap r i o r i power analysis was performed using statisticalsoftware (G/C3Power V3.1.9.2x, Dusseldorf, Germany) to estimatethe number of pelvises required for the study. A sample size of11 pelvises for each group was estimated based on α¼0.05,power ¼0.9, and an estimated effect size (ES; d¼1.731918)when using the mean and standard deviation (SD) torsionaldisruptive forces following double versus single screw con figu-ration for repairing sacroiliac luxation model in a previouscadaveric study.6Thefinal sample size was 11 pelvises, withanticipation of 20% expected dropout. A post hoc power analysiswas conducted on maximum failure load following each groupt oc a l c u l a t eE S( d¼1.5206358) with a power of 0.91.All non-power-related statistical analyses were performedusing SPSS software version 26 (IBM Corp., Chicago, IL, UnitedStates). Assumption of normality of all continuous numericaldata was assessed using the Shapiro –Wilk test. Student ’st-testwas used to analyze and compare the mean values ( /C6SD) ofbody weight, implantation time, percentage of screws engagedin the sacrum, percentage of screw diameter per sacral diam-eter, CCR, DVR, and maximum failureload between the groups.Pre- and postimplantation values of mean /C6SD of PCDR andHCWR were also compared within each group using theWilcoxon signed-rank test. The CCA, DVA, and mean entrypoints of the screws of the 2.3-mm HCS group and 3.5-mm CSgroup were compared using one-way analysis of variance.Comparisons between the left and right maximum failureloads within each group were conducted using the Mann –Whitney Utest. Fisher ’s exact test was used to determine thedifference in failure modes between groups after the mechan-ical test. Statistical signi ficance was set at p/C200.05.ResultsDescriptive DataData were collected from the pelvises of 22 canine cadaversof various breeds. The mean body weights of the cadavers(2.3-mm HCS: 6.21 /C61.52 kg, 3.5 mm CS: 6.11 /C62.13 kg)were not signi ficantly different between the groups(p¼0.899). The mean total time required for screw place-ment was 712 /C6138 seconds in the 2.3-mm HCS group and379/C6109 seconds in the 3.5-mm CS group ( p<0.001). Themean distance between the nearest edge of two 2.3-mm HCSheads was 0.99 /C60.67 mm (range: 0.3 –2.6 mm), and therewas no impingement between the screw heads.Imaging EvaluationObjective measurements were estimated using the pre- andpostimplantation imaging modalities ( ►Table 1 ). All screwswere positioned in the sacral body without any violation ofthe spinal canal or first ventral sacral foramen in both groups.The mean percentages of screw length purchased within thesacrum reached the target value by more than 70 and 40% inthefirst and second screws in the 2.3-mm HCS group,respectively, and more than 70% in the 3.5-mm CS group.PCDR and HCWR estimated between the preimplantation(p¼0.943 and 0.491) and postimplantation ( p¼0.876 and0.949) values were not signi ficantly different between thegroups. CCR ( p¼0.245) and DVR (0.703) of the sacroiliacjoint on postimplantation CT were evaluated, and neitherwas signi ficantly different between the groups.Fig. 4 Mechanical test of fixation to rotational force. Test setup of ( A)d o u b l e2 . 3 - m mH C S fixation and ( B)s i n g l e3 . 5 - m mC S fixation. Theimplanted sacrum was mounted on top of the load cell. The testing machine slowly applied a load ( red arrow ) to the sacrum, which induced arotational force ( white arrow ) to be delivered to the repaired construct. CS, cortical screw; HCS, headless cannulated self-compression screw.Veterinary and Comparative Orthopaedics and Tra umatology Vol. 37 No. 1/2024 © 2023. The Author(s).Comparison of Double 2.3-mm HCS and Single 3.5-mm CS in a Canine Model Kang et al. 17Mean CCA ( p¼0.954) and DVA ( p¼0.992) of the firstand second 2.3-mm HCS were not signi ficantly differentbetween the screws. Neither of these angles was statisticallydifferent from the mean CCA ( p¼0.195) and DVA ( p¼0.704)of the 3.5-mm CS.A schematic diagram ( ►Fig. 3 and►Table 2 ) shows themean entry positions of the screws, which were determinedby using the centers of the screws, and the mean points of thecranial edge of the first sacral ventral foramen converted tothe sacral diameter ratio. No signi ficant differences in theposition on the transverse ( p¼0.664) and the dorsal planes(p¼0.751) of the first 2.3-mm HCS and 3.5-mm CS wereobserved. The center of the second 2.3-mm HCS was locatedat 3.93 /C60.76 mm caudal compared with the center of thefirst screw, which was approximately 12% caudal to the best-fit circle of sacral diameter. Lines connecting the mean valuesof the dorsal and ventral points of the cranial boundary of thefirst sacral ventral foramen and the 95% con fidence intervalof the x-values for each point were drawn obliquely. Two of11 second 2.3-mm HCS were located within this interval;however, none violated the first sacral foramen.Mechanical TestMaximum load tolerated by each fixation was observed in allhemipelvises, and objective measurements were tabulated(►Table 3 ). Mean /C6SD failure load ( p¼0.002) and rotationalforce ( p¼0.002) estimated at maximum failure were signi fi-cantly higher for 2.3-mm HCS than for 3.5-mm CS. The meanfailure load (kgf) was not signi ficantly different between theleft and right sides of the hemipelvis in either 2.3-mm HCS(left: 4.17 /C62.67; right: 3.69 /C62.11; p¼0.792) or 3.5-mm CSgroup (left: 0.73 /C60.30; right: 1.48 /C60.48; p¼0.052).Loss of anatomical reduction of the sacroiliac joint wasobserved visually as rotational failure in all hemipelvises ofboth experimental groups (►Fig. 5A, B ). Neither the 2.3-mmHCS nor the 3.5-mm CS head was pulled out of the iliumTable 1 Objective measurements estimated on pre- and postimplantation imagingDouble 2.3-mm HCS group Single 3.5-mm CS group p-valueSacral diameter (mm) 6.15 /C60.85 5.71 /C60.56 0.169Screw diameter/sacral diameter (%) 38.06 /C65.37a61.79 /C65.95a<0.001Screw length within sacrum (%) First Second 71.91 /C63.3673.18 /C65.58 45.39 /C63.82 0.526bPre Post Pre PostPCDR 1.31 /C60.12 1.33 /C60.11 1.31 /C60.12 1.33 /C60.10 0.859c0.422dHCWR 0.95 /C60.12 0.89 /C60.12 0.98 /C60.04 0.89 /C60.14 0.109c0.083dCCR (%) 91.04 /C67.11 87.34 /C67.41 0.245DVR (%) 86.04 /C69.34 84.36 /C610.91 0.703CCA (degrees) First Second 4.39/C64.341.19/C63.68 1.73 /C64.87 0.195DVA (degrees) –1.82/C64.30 –2.02/C63.33 –0.70/C64.21 0.704Abbreviations: CCA, craniocaudal angle of screw; CCR, craniocaudal reduc tion of the sacroiliac joint; CS, cortical screw; DVA, dorsoventral angle so fscrew; DVR, dorsoventral reduction of the sacroiliac joint; HCS, headless c annulated self-compression screw; HCWR, hemipelvic canal width ratio;PCDR, preimplantation pelvic canal diameter ratio.aStatistically signi ficant differences.bp-value between the first screw of the 2.3-mm HCS group and the 3.5-mm CS.cp-value in the 2.3-mm HCS.dp-value in the 3.5-mm CS group.Table 2 Mean entry positions of screws and mean points of cranial edge of the first sacral ventral foramen converted to the sacraldiameter ratioXYFirst Second First SecondDouble 2.3-mm HCS group ( n¼11) 0.64 /C60.15 1.12 /C60.15a–0.50/C60.17 –0.43/C60.23Single 3.5-mm CS group ( n¼11) 0.70 /C60.19 –0.44/C60.13Dorsal point of ventral sacral foramen ( n¼22) 1.25 /C60.13 0V e n t r a lp o i n to fv e n t r a ls a c r a lf o r a m e n( n¼22) 1.52 /C60.15 –0.80/C60.10Abbreviations: CS, cortical screw; HCS, headless cannulated self-compression screw.aStatistically signi ficant among the x-values of the first and second 2.3-mm HCS, and 3.5-mm CS.Veterinary and Comparative Orthopaedics and Traumatology Vol. 37 No. 1/2024 © 2023. The Author(s).Comparison of Double 2.3-mm HCS and Single 3.5-mm CS in a Canine Model Kang et al. 18surface after the test. The mode of failure was remarkablydifferent between the groups ( ►Table 4 ). In the HCS group,loss of stability occurred mainly at the sacrum while thetrailing thread engaged in the ilium, and cortical bonefracture and breakage of three screw heads (two first screwsand one second screw) were observed (►Fig. 5 ). Meanwhile,in all hemipelvises fixated with 3.5-mm CS, the head of thescrew maintained its original position, and the ilium rotatedaround the screw. None of the 3.5-mm CS had implantbending or breakage.

Question 68

Rahn - 2023 - VETSURG - Postoperative injectable opioid use and incidence of surgical site complications after use of liposomal bupivacaine in canine gastrointestinal foreign body surgery.pdf

Answer 68

The surgery case log database was searched for all casesthat underwent surgery for primary GIFB removal at asingle institution (Purdue University Veterinary Hospital)from May 2017 to August 2021. Search criteria used were:abdominal exploratory surgery and the results then nar-rowed based on presence and removal of a GIFB, andonly dogs included. No revision surgeries were included.Dogs that had a historical prior abdominal surgery for aGIFB or for other indications (such as an ovariohysterect-omy), and were fully recovered, were included. Dogs thatwere not discharged or were discharged without at least2 weeks of follow-up records postdischarge were excludedfrom the study. Preadmission clinical signs were retrievedfrom the history taken at admission. The time untilinduction of anesthesia and the time until surgical inci-sion were calculated (in minutes) based on the timestampof admission into the hospital (based on electronic medi-cal record, EMR) to induction and incision (using theanesthesia record in EMR) respectively. Liposomal bupi-vacaine use was retrieved from the charge sheet, anesthe-sia sheet and surgery report, and included method ofadministration (surgery report) and timing (anesthesiarecord). Use of LB was at the surgeon's discretion. Perhospital policy, all opened bottles were discarded at eitherend of the work day or within 12 h, whichever came first.All bottles used out of hours would be discarded immedi-ately after use and would not be stored until the next day.The surgery report was used to retrieve the followingdata: type of surgery (gastrotomy, enterotomy, enterect-omy), location, type of foreign body (linear vs. solid), anddesignation of clean-contaminated versus contaminated.13All medications given intraoperatively, in the intensivecare unit (ICU), and postoperatively were collected from acombination of anesthesia records and ICU and wardtreatment sheets. Type of opioid administration postopera-tively was recorded together with doses. Fentanyl adminis-tration was recorded as “yes”/“no”and hourly rates forCRIs were recorded every hour beginning with admittanceto the ICU postoperatively to the patient's eventualRAHN ET AL . 1025 1532950x, 2023, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13976 by Vetagro Sup Aef, Wiley Online Library on [19/10/2023]. 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 Licensedischarge. Patient ICU treatment sheets were used for this.The mean hourly fentanyl rate was calculated based on12 h time intervals (0 –12, 13 –24, 25 –36, 37 –48, 49 –60, 61 –72, and 73 +h). Dogs were checked by clinicians, ICU staffand students for pain, tenseness on abdominal palpation,and sedation level. Clinicians and students present for thesurgery were not blinded to the use of LB; however, its usewas not noted on ICU treatment sheets. The fentanyl ratewas increased or decreased based on these assessmentsand individual needs. Any findings by students and staffused to increase or decrease analgesics were doublechecked by clinicians. Dogs were rechecked /C2430 min afterany analgesic decrease or discontinuation to confirm theircontinued comfort. The time between end of anesthesia tosuccessful extubation was recorded in minutes. Postopera-tive ICU (hours) and hospital stay (hours) were calculatedbased on admittance to ICU postoperatively (ICU treat-ment sheet), discharge from ICU (ICU treatment sheet),and discharge from the hospital (EMR). Follow-up infor-mation (surgical site complications, other complications)was retrieved from the EMR for dogs that returned fortheir recheck, or by phone call (either the referring veteri-narian or client). Complications were defined as anyadverse event experienced, and then further divided aseither a surgery site complication (SSC) (i.e., seroma, infec-tion, dehiscence, and abscess), or nonsurgery site compli-cation. The SSCs were subclassified as surgery siteinfection (SSI) (infection and abscess), or other.2.1 |Statistical analysisStatistical analysis was perf ormed using commercially avail-able statistical software (SAS, Cary, North Carolina). Unlessotherwise specified, two-sam ple Wilcoxon rank-sum testswere performed for all demographic data and postoperativedata. A Fisher's exact test was performed to evaluate thepercentage of patients with regurgitation postoperatively,whereas sex and complication data were analyzed usingPearson's χ2test of independence. P ostoperative complica-tions were defined as any adverse event occurring while thepatient remained in our hospital. Due to the low percentageof surgical site infections overall, proportions with 95%binomial CI were calculated. The postoperative analgesicdata over time (mcg/kg/h) was compared using mixed-model procedures for repeat ed measures. Nonparametri-cally distributed data was presented as median (range). Thestatistical significance level was p<. 0 5 .3|RESULTSA total of 220 of dogs with GIFB were identified in thesurgery logs. Fifteen dogs were excluded due tointraoperative euthanasia ( n=4), euthanasia within48 h ( n=5) not associated with SSC or SSI or inadequatefollow up ( n=6). Data for the remaining 205 dogs wasthen analyzed and split into two groups based on the sur-geon's use of LB intraoperatively. Sixty-five dogs (31.9%)had LB administered, and 140 (68.1%) did not.3.1 |Demographic and preoperative dataDogs that received LB were heavier (median 28.5 kg,range 5.0 –82.4 kg) than those that did not (24.6 kg, range1.7–88.0 kg) ( p=.005). The median age of dogs receivingLB was 2.3 years (range 0.2 –14.4 years) and the medianage of those that did not was 3.6 years (range 0.2 –14.3 years) ( p=.080). Five breeds comprised 56.6% oftotal patients: mixed breed dog ( n=54, 26.3%), Labradorretriever ( n=24, 11.7%), golden retriever ( n=17, 8.3%),American pitbull terrier ( n=12, 5.9%), and goldendoodle(n=9, 4.4%). The sex distribution was: male intact(n=30, 14.6%14/65 and 16/140); male neutered(n=102, 49.8%); female intact ( n=20, 9.7%) and femalespayed ( n=53, 25.9%). Distribution did not differbetween the two groups ( p=.240) (Table 1). Mediantime of clinical signs prior to admission did not differbetween dogs that received LB and those that did not(p=.111). Time from hospital admission until anestheticinduction and start of surgery did not differ between thetwo groups ( p≥.449).3.2 |Perioperative and LBadministration dataAll dogs had a full midline abdominal exploratory sur-gery performed (noted as “xyphoid to caudal to the umbi-licus”), and no surgery report noted a limited incision.Seventeen surgeons had surgeries included where theywere listed as a primary surgeon, eight faculty surgeons,one locum surgeon, and eight surgery residents. Ninesurgeons had surgeries included in both groups, four onlyin the group that did not receive LB (23 dogs), and threeonly in the group that received LB (eight dogs). Seven-teen clinicians were involved in perioperative decisionmaking: nine faculty surgeons, five locum surgeons, andthree residents on a senior block. Of the 17 clinicians,10 had dogs included in both groups (59 dogs receivedLB, 105 did not), five had only dogs included that did notreceive LB (35 dogs), and two had only dogs includedthat received LB (six dogs). Of clinicians with dogsincluded in both groups, the distribution of dogs for twofaculty heavily favored dogs not receiving LB (17 vs.1 and 46 vs. 5) and the distribution for two heavilyfavored dogs receiving LB (17 vs. 9 and 10 vs. 3).1026 RAHN ET AL . 1532950x, 2023, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13976 by Vetagro Sup Aef, Wiley Online Library on [19/10/2023]. 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 LicenseForty-eight GIFBs were linear (14 out of 65 dogs thathad LB administered, 34 out of 140 dogs that did nothave LB administered), 151 solid (51 out of 65 dogsthat had LB administered; 100 out of 140 dogs thatdid not have LB administered) and six were a combi-nation of solid and linear (6 out of 140 dogs that didnot have LB administered). Four dogs had a perfora-tion at the time of surgery (3 out of 65 dogs that hadLB adminstered; 1 out of 140 dogs that did not haveLB administered). Ten dogs underwent an enterect-omy (1 out of 65 dogs that had LB administered; 9out of 140 dogs that did not have LB administered).Twenty-nine surgeries were deemed contaminated (9/65; 20/140), whereas 176 were classified as clean-con-taminated (56/65; 120/140) ( p=.933).Liposomal bupivacaine (5.3 mg/kg) was locallyinfiltrated by the surgeon at the end of surgery in65 dogs but the exact tissue layer and timing varied:“before abdominal wall closure ”(21 dogs), “afterabdominal wall closure ”(2), external rectus muscle (1),subcutaneous (11), injected within the body of theexternal rectus muscle and subcutaneous (10),TABLE 1 Patient parameters and surgical information for the dogs that received LB and those that did not.Parameter LB ( n=65) no LB ( n=140) pWeight (kg) 28.5 (5 –82.4) 24.4 (1.7 –88) .005Age (years) 2.3 (0.2 –14.4) 3.6 (0.2 –14.3) .080Sex (FI, FS, MI, MN) 5, 14, 14, 32 15, 39, 16, 70 .240Duration of clinical signs prior to admission (h) 28 (0 –3240) 48 (0 –1080) .111Blood work parametersPacked cell volume 50% (34 –81) 48.8% (22 –75) .916Total protein 7.2 g/dL (5 –12) 6.8 g/dL (4 –10.3) .024Time from admission to induction (minutes) 316 (78 –4025) 3305 (53 –7516) .449Time from admission to surgery (minutes) 356 (138 –4085) 379.5 (89 –7558) .515GIFB type 51 solid, 14 linear 100 solid, 34 linear,6 combinationn/aSurgery type .111Gastrotomy 32 (49.0%) 50 (35.6%)Gastrotomy and enterotomy 3 (4.6%) 19 (13.5%)Gastrotomy and enterectomy 1 (1.6%) 2 (1.3%)Gastrotomy, enterectomy and enterotomy - 2 (1.3%)Gastrotomy and enterotomies - 7 (5%)Single enterotomy 23 (35.4%) 48 (35.3%)Enterectomy - 2 (1.3%)Enterotomy and enterectomy - 3 (2.0%)Multiple enterotomies 2 (3.2%) 1 (0.6%)GIFB milked into colon 4 (6.2%) 6 (4.1%)(Clean)contaminated 9 contaminated,56 clean-contaminated20 contaminated,120 clean-contaminated.933Perforation at time of surgery 3 (4.6%) 1 (0.7%) n/aEnterectomy needed 1 (1.5%) 9 (6.4%) n/aTime to extubation (min) 14 (1 –54) 12 (1 –60) .300Time in ICU postoperatively (h) 40.7 (13.6 –186.9) 50.3 (19.4 –282) <.001Postoperative hospitalization (h) 50.6 (18.2; 268.3) 69.8 (24.1; 454.5) <.001Note : A Wilcoxon rank sum test was used to determine difference between groups, with median (range) stated. A Pearson χ2test was used to assess thedifference of sex of dogs between the two groups. A 10 /C22 comparison was performed on surgery type but no further statisticalanalysis was performed on the(sub)groups. Due to the small size of the individual subgroups, statistical analyses were underpowered, and the column for the pvalue for these subgroups wasleft intentionally blank.Abbreviations: FI, female intact; FS, female spayed; GIFB, gastrointestinal foreign body; LB, liposomal bupivacaine; ICU, intensive care unit; MI , male intact;MN, male neutered; n/a, not applicable.RAHN ET AL . 1027 1532950x, 2023, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13976 by Vetagro Sup Aef, Wiley Online Library on [19/10/2023]. 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 Licensesubcutaneous and skin (2), injected within the body ofthe external rectus muscle, subcutaneous, and skin(15), linea alba and subcutaneous (1), “splash ”afterabdominal wall closure (1), and “given but no knownlocation of injection ”(1). Dilution of LB prior toadministration was not recorded.3.3 |Postoperative data and analgesiarequirementPostoperative care was under the supervision of 17 clini-cians: eight faculty surgeons, five locum surgeons, andfour residents on a senior block. Three surgeons only per-formed postoperative care for dogs that received LB(5 dogs), two clinicians only for dogs not receiving LB(3 dogs). Twelve clinicians oversaw postoperative care fordogs in both groups: 60 dogs that received LB, and137 that did not.Median time to extubation was 14 min for dogsreceiving LB, and 12 min for those that did not(p=.300) (Table 1). Median postoperative time in ICUand in hospital was 40.7 and 50.6 h, respectively, fordogs receiving LB; and 50.3 h (ICU) and 69.8 h (hospi-tal) for dogs that did not ( p<. 0 0 1 ) .A l ld o g si nb o t hgroups received fentanyl in the first 12 h, but the per-centage of dogs that received fentanyl decreased there-after. Eight dogs received other opioid analgesics: threedogs received methadone (all received LB), and fivereceived hydromorphone (three received LB, two didnot); these dogs were censored from the fentanyl calcu-lations. Fewer dogs received fentanyl in the group thatreceived LB: 13 –24 h ( p=.002), 25 –36, 37 –48, 49 –60 h(p<. 0 0 1 f o r a l l t h r e e ) a n d 6 1 –72 h ( p=.006)(Figure 1). Of the dogs receiving fentanyl, the meanrate/minute required was less for dogs receiving LB ineach time interval: 1 –12 h ( p=.364), 13 –24 h(p<. 0 0 1 ) ,2 5 –36 h ( p<. 0 0 1 ) ,3 7 –48 h ( p=.010), 49 –60 h ( p=.905) and 61 –72 h ( p=.990) (Figure 2).Overall postoperative co mplications were seen in 15of dogs receiving LB (23.1%) and 22 of 140 dogs thatdid not receive LB (15.7%) ( p=.200) (Table 2). Postop-erative regurgitation was noted for nine dogs (4 out of65 that received LB and 5 out of 140 that did notreceive LB) (4/65; 5/140) ( p=.469).Follow up extended beyond 30 days in 64 out of 65dogs that had LB administered and 138 out of 140dogs that did not had LB administered (202 out of 205dogs included in the study): via written medicalrecords (17 out of 65 dogs that had LBadministered and 50 out of 140 dogs that did not hadLB administered), phone follow up with a veterinaryclinic (32 out of 65 dogs that had LB administered and53 out of 140 dogs that did not had LB administered),or phone follow up with the client (15 out of 65 dogsthat had LB administered a nd 35 out of 140 dogs thatdid not had LB administere d). Postoperative woundcomplications were seen in 7/65 dogs that received LBFIGURE 1 Administration of fentanyl during thepostoperative period for the dogs that received liposomalbupivacaine (black) and those that did not (gray). All dogs in bothgroups received fentanyl in the first 12 h, but the percentage ofdogs that received fentanyl decreased thereafter, with fewer dogsthat received liposomal bupivacaine (LB) receiving fentanyl in thefollowing time frames ( pvalues added for each interval): 13 –24 h(p=.002), 25 –36, 37 –48, 49 –60 h ( p< .001 for all three), and 61 –72 h ( p=.006). Significance is identified by an asterisk.FIGURE 2 Administration of average hourly fentanyl rate over12 h time frames for dogs that received liposomal bupivacaine(dark gray) and those that did not (light gray). The fentanyl rate inthe group of dogs receiving liposomal bupivacaine (LB) was lowerin each period ( pvalues added for each interval): 1 –12 h(p=.364), 13 –24 h ( p< .001), 25 –36 h ( p< .001), 37 –48 h(p=.010), 49 –60 h ( p=.905), and 61 –72 h ( p=.990). Significanceis identified by an asterisk.1028 RAHN ET AL . 1532950x, 2023, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13976 by Vetagro Sup Aef, Wiley Online Library on [19/10/2023]. 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(10.7% 95% CI =4.4–21.0%) and 4/140 dogs that didnot (2.9%, 95% CI =0.8–7.2%) ( p=.039). Seven clini-cians had cases with postoperative wound complica-tions: six had two dogs included and one had one dogincluded. Time to complications after surgery rangedfrom 2 to 15 days, with 10 of 11 dogs diagnosed withan SSC on or before day 5 after surgery. The 11th dogwas diagnosed with a dehiscence on the incisionalrecheck appointment. Of the dogs having postopera-tive wound complications, four dogs needed a revisionsurgery to address their surgical site complications:3/65 and 1/140.4

Question 69

Quinn - 2024 - VETSURG - Adjunctive fixation of the humeral epicondyle in a lateral condylar fracture model - Ex vivo comparison of pins and plates with a novel composite (AdhFix).pdf

Answer 69

Ethical approval for use of cadavers was obtained fromthe Uppsala Animal Ethics Committee, 15 533-2018,04682-2020. Cadavers, weighing 14 –41 kg, were donatedto the University animal hospital for teaching andresearch purposes with owners' written consent.2.1 |Specimen procurementPaired canine cadaver humeri were harvested from skele-tally mature dogs that were euthanized for reasons unre-lated to the study and the distal 120 mm cleaned of softtissues by surgical dissection. The humeri were trans-ected through the diaphysis in the transverse plane witha sagittal saw, 120 mm from the distal end and in caseswhere the humeral head was still partly intact, this wastrimmed to be the same width as the humeral diaphysis.In addition, a central hole (3.2 mm diameter) was drilledat 1 cm and another perpendicular to this at 2 cm fromthe cut end to ensure rotational stability within the resin.The accessible marrow in the proximal end was removedto maximize stability provided by infill of resin. Thehumeri were each positioned inside 60 mm lengths of50 mm diameter PVC pipe mounted on a titanium plateensuring that the bone was upright in the sagittal andfrontal planes, perpendicular to the medial-to-lateral epi-condylar axis. An epoxy resin, with low initial viscosity,was then poured into the pipe to a height of 50 mm,resulting in a 50 mm cylinder with a flat base. Specimenswere labeled, wrapped in saline-soaked gauze, sealed inbags, and placed in a refrigerated room (4/C14C) overnightprior to construction of the fracture models. All speci-mens were prepared on the same day and all modelswere wrapped in saline-soaked gauzes to keep them312 QUINN ET AL . 1532950x, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14048 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 Licensemoist between the individual steps of the constructpreparation.2.2 |Construct preparationHumeri were allowed to reach room temperature the dayof construct preparation and each pair was randomlyassigned to fixation groups (Pin vs. AdhFix and Platevs. AdhFix) and labeled with a unique consecutive num-ber. The right condyle of the first animal in each groupwas randomly assigned to a construct (e.g., AdhFix) andthe left side assigned to the other construct (i.e., Pin orPlate). The construct assignment was thereafter sequen-tially alternated from the left to the right side ensuringan equal distribution of right and left side to eachconstruct.In all humeri, a transcondylar 1.1 mm Kirschner wirewas placed and a 2.5 mm cannulated drill bit was usedonce appropriate K-wire positioning was achieved, pass-ing from lateral to medial, slightly cranial and distal tothe epicondyles. The transcondylar tunnel was thenenlarged with a 3.2 mm drill bit and the lateral part ofthe transcondylar tunnel over-drilled with a 4.5 mm drillbit to the level of the isthmus, by directly measuring thedrill against the specimen and using a drill stop. A threadwas then tapped, using a 4.5 mm cortical tap, in themedial part of the tunnel. Fractures were simulated bymaking a sagittal cut using an oscillating saw at the isth-mus extending to the level of the supratrochlear foramenwhilst secured in a vice. The bone was then repositionedin the transverse plane, to allow a 140-degree cut fromthe proximal aspect of the lateral epicondylar ridge to theproximal aspect of the supratrochlear foramen using aprotractor and laser line. The laser line was set in thedesired position and the sagittal saw blade aligned so thatthe laser line could be viewed up the length of the edgeof the blade to ensure accurate cut position and direction(Figure1). The 4.5 mm transcondylar cortical screw with-out a washer (N2, Portsmouth, UK) was then placed andtightened to 1.5 Nm with a calibrated torque limitingscrewdriver (Felo, Neustadt, Germany) to align the artic-ular surface of the humeral condyle and cortical bone ofthe lateral epicondylar crest. Overlong (32 mm) screwswere used to ensure that there was full purchase in thetrans-cortex. Adjunctive fixation was then applied.For the specimens in the pin group, a 1.6 mmKirschner wire (N2, Portsmouth, UK) was placed from thedistal aspect of the lateral epicondylar crest and advancedproximally in the medullary cavity of the epicondylar crestuntil it exited the medial cortex of the humeral diaphysis.The distal aspect of the pin was then bent over and cutshort, as would be performed in a clinical case.For the specimens in the plate group, a six-hole,2.7 mm reconstruction plate (N2, Portsmouth, UK) wascontoured to the lateral to caudolateral aspect of thedistal humerus. Plates were positioned so that threescrews were placed above the epicondylar fracture site,o n es c r e wh o l ed i r e c t l yo v e rt h ef r a c t u r es i t ea n dt w oscrews were placed distal to t h ef r a c t u r es i t e .S c r e wholes were drilled with a 2.0 mm drill bit, measured,and tapped prior to placement of 2.7 mm stainless steelcortical screws.For the AdhFix group, specimens were prepared asfollows. The same screw spacing was used as for the platespecimens and an identical six-hole reconstructionplate was used as a template to ensure the same distancebetween the screw holes, as well as the same gap over thefracture site, was achieved. Holes were drilled with a2.0 mm drill bit, measured without the plate in position,and tapped with 2.7 mm stainless steel cortical screwsplaced as for the plate group. The screws were inserted toFIGURE 1 (A) Laser line for lateralepicondylar cut. (B) Mechanical testingsetup using a linear actuator.QUINN ET AL . 313 1532950x, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14048 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 License/C2480% of their shaft length. AdhFix was supplied by Bio-medical Bonding AB (Sweden) as kits constituted of tworesin components, based on 1,3,5-triallyl-1,3,5-triazine-2,4,6(1H,3H,5H)-trione and 1,3,5-tris(3-mercaptopropyl)-1,3,5-triazinane-2,4,6-trione, respectively, as well as apowder filler component of hydroxyapatite and a photo-initiator system. First, the resin components were mixedtogether using luer lock syringes connected with astraight connector. Then the filler and initiator compo-nents were added and blended into the resin using a spat-ula. The final mixture was placed in an applicatorsyringe, ready to be used. The AdhFix composite wasthen applied around the shafts of the screws, which werethen tightened onto the bone. The composite was curedwith high energy visible light from a handheld dentalacrylic lamp (Bluephase 20, Ivoclar Vivadent AG,Liechtenstein), with wavelengths of 385 –515 nm (domi-nant wavelengths of 400 and 470 nm) and an intensity of2000 mWcm/C02. Each surface area was cured with twopulses of 5 s duration. The gap between the proximal anddistal screws was then bridged with AdhFix and cured tocreate a single patch of cured composite around thescrews. Two further layers of composite, /C241 mm in thick-ness, were applied and cured sequentially, resulting inthe screw heads being covered by the final layer of com-posite (Figure2).Specimens were then radiographed and assessed forany boney abnormalities, defects, or pre-existing condi-tions that may alter mechanical testing of the bone. Theywere then wrapped in saline-soaked gauze, sealed inlabeled bags, and placed in a refrigerated room (4/C14C)overnight prior to mechanical testing.2.3 |Mechanical testingThe mechanical performance of the constructs was evalu-ated using an Instron 5566 universal testing machine(Instron, Korea, LLC) in compression mode. The sampleswere secured to the base plate using clamps and posi-tioned so that the head of the compression press (50 mmInstron 2501 compression plate) applied a distal to proxi-mal load to the capitulum of the humeral condyle. A10 kN load cell was used with a compression speed of60 mm/min, a preload of 1 N and a preload speedof 2.5 mm/min. The samples were loaded until failure,which was determined as a sharp decrease in load or adisplacement exceeding 10 mm. All measurements wereconducted at 20/C14C with a relative humidity of 50%. Speci-mens were only removed from the saline soaked swabsimmediately prior to testing to prevent desiccation of theconstructs.FIGURE 2 Photographs of the steps involved in the AdhFix fixation procedure (specimen 25).314 QUINN ET AL . 1532950x, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14048 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 License2.4 |Data collectionLoad and displacement values were recorded at a rate of10 Hz during mechanical testing using Bluehill 3 software(version 3.63, Illinois Tool Works Inc.). These valueswere used to create load –displacement curves to deter-mine the stiffness, yield load, and maximum load foreach construct. The slope of the initial linear portion ofthe load –displacement curve was used to determine theconstruct's stiffness. Using a 0.2% offset criterion,the yield point was defined as a deviation from the initiallinear portion of the curve. The maximum load wasdefined as the highest load recorded during mechanicaltesting, immediately prior to a sudden decrease in thesustained load due to construct failure.2.5 |Statistical analysisThe quantitative mechanical data were subjected tonormality assessment via the Shapiro-Wilk test, whichdemonstrated non-normal distributions. Consequently,nonparametric statistical assessments of the mechanicalperformance (Pin vs. AdhFix and Plate vs. AdhFix) wereconducted utilizing paired Wilcoxon signed-rank tests.All statistical analyses were performed in Matlab (version2020a, Mathworks Inc., Natick, Massachusetts). Allreported p-values were two sided, and values of p< .05were considered statistically significant. Descriptive sta-tistics are summarized in tables listing the mean, stan-dard deviation, median, range and number of animals forcontinuous data or in tables listing count and percentagefor categorical data, where appropriate.3|RESULTSVisual and radiographic inspection of all fracture con-structs confirmed that the articular portion was recon-structed with no visible step or gap, as would be expectedto be achieved during surgical repair of clinical fractures.Mean weight of the dogs in the AdhFix versus Pin groupwas 30.4 kg (SD 8.75) and 25 kg (SD 5.2) in the AdhFixversus Plate group. Bodyweight of the dogs included inthe study ranged from 14 to 41 kg, with a range of bodyconditions (lean to obese) being present.All constructs repaired using pins or plates failed as aresult of the pin or plate deforming. Three of the Adhfixconstructs failed as a result of the bone of the capitulumaround the transcondylar screw splitting prior to failureof the implant construct. A total of 13 Adhfix constructsfailed due to fracture of the Adhfix composite over ascrew head and two failed due to fracture of the Adhfixcomposite between the screw heads (Table1).The mechanical results were analyzed with thefocus on three key features for a stable fixation; stiff-ness, yield load and maxim um load before constructfailure. In Figure 3,ad o tp l o tf o re a c hi n d i v i d u a lc o n -dyle measurement is presented together with compari-sons of condyle pairs in combination with a box plotfor each group.The pairwise comparison of the construct stiffness didnot show a significant difference between the pairedgroups (Pin vs. AdhFix p=.10, Plate vs. AdhFix p=.20).The yield point, where the fixation started to deformplastically, was significantly higher when AdhFix wasused to support the fractured condyle in comparison toK-wires, p=.016. No statistical significance was seen forusing AdhFix or the plate, p=.25. The yield point couldnot be adequately determined for one pin (AdhFixvs. Pin) and one AdhFix (AdhFix vs. Plate) fixation. Theinability to adequately determine the yield point for thesetwo constructs caused an overestimation of the yieldstrength and the measurements were therefore excludedfrom the yield analysis. Full details of the descriptive sta-tistics for loads are presented in Table2.At ultimate load reached by the fixations during thecompression test, the metal plate had higher load valuesthan AdhFix, p=.004. The plate group endured loadsbetween 2186 and 3635 N, while the AdhFix groupendured 1337 –2273 N. However, these values were con-siderably higher than the yield point of 516 –981 N withplate group and 385 –1147 N with AdhFix group, at whichthe construct started to deform. The maximum loadTABLE 1 Failure modes.Construct failure PinAdhFix(Pin) PlateAdhFix(Plate)Plate/pin deformed 9 0 9 0Bone of capitulum failed (prior toconstruct)02 0 1Fracture in Adhfix (over screw) 0 7 0 6Fracture in Adhfix (not over screw) 0 0 0 2Total 9 9 9 9QUINN ET AL . 315 1532950x, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14048 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 LicenseFIGURE 3 Box plot combined with a dot plot for each condyle pair with an increase marked with a blue dotted line (--) and decreasewith a red point dotted line (.-) for rigidity (A, D), yield (B, E) and maximum load (C, F) comparison of Pin versus AdhFix and Plate versusAdhFix, respectively. * p< .05, ** p< .01. ns, nonsignificant. Paired Wilcoxon signed-rank tests.TABLE 2 Descriptive statistics for loads AdhFix versus Pin group and Adhfix versus Plate group.Group Test article Load Median Range Np -valueAdhFix vs. K-wires K-wires Stiffness (N/m) 645 303 –1024 9 .10AdhFix vs. K-wires AdhFix Stiffness (N/m) 660 552 –1148 9AdhFix vs. K-wires K-wires Yield point (N) 440 220 –660 8 .016 *AdhFix vs. K-wires AdhFix Yield point (N) 631 364 –990 8AdhFix vs. K-wires K-wires Ultimate load (N) 1688 1001 –2336 9 .65AdhFix vs. K-wires AdhFix Ultimate load (N) 1407 1161 –2413 9AdhFix vs. Plate Plate Stiffness (N/m) 842 551 –1008 9 .20AdhFix vs. Plate AdhFix Stiffness (N/m) 688 601 –913 9AdhFix vs. Plate Plate Yield point (N) 707 516 –981 8 .25AdhFix vs. Plate AdhFix Yield point (N) 809 385 –1147 8AdhFix vs. Plate Plate Ultimate load (N) 2529 2186 –3635 9 .004 *AdhFix vs. K-plate AdhFix Ultimate load (N) 1751 1337 –2273 9*p< .05.316 QUINN ET AL . 1532950x, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14048 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 Licensevalues of paired constructs with AdhFix group or pingroup were not different from each other ( p=.65).4

Question 70

Shubert - 2023 - JAVMA - Outcome following elective unilateral arytenoid lateralization performed in an outpatient manner is comparable to hospitalization for dogs with laryngeal paralysis.pdf

Answer 70

Case selectionDogs were eligible for study inclusion if they were diagnosed with laryngeal paralysis and treated with an elective unilateral arytenoid lateralization. Dogs were grouped according to whether the procedure was performed on an outpatient basis (outpatient group) or they were hospitalized overnight postop -eratively (inpatient group). Dogs were excluded if they had incomplete medical records, had other con -current upper airway procedures performed, failed to have a complete 2-week follow-up medical record, or underwent emergency surgery for an upper air -way crisis. The minimum information required in the records included a sedated laryngeal examination to diagnose laryngeal paralysis, neurologic examination, preoperative thoracic radiographs to rule out the pres -ence of aspiration pneumonia and megaesophagus, a complete surgical report, and an in-person follow-up examination at 2 weeks postoperatively.Medical records reviewElectronic medical records were searched to identify all dogs that underwent unilateral aryte -noid lateralization between July 30, 2018, and July 20, 2022. The search terms included “laryngeal pa -ralysis” and “arytenoid lateralization.” Cases were included if the medical records met the inclusion cri -teria listed above. Data retrieved from the medical re -cords included signalment, clinical signs, neurologic examination, diagnostics performed preoperatively and up to the 2-week recheck, results of sedated oral examination, surgical procedure (thyroarytenoid lat -eralization or cricoarytenoid lateralization), duration of anesthesia, use of gastroprotectants, use of pro -motility agents, premedication and induction agents used, postoperative opioid use, postoperative seda -tive use, pain scores, and anxiety scores.AnesthesiaAll dogs underwent a laryngeal examination at the time of anesthetic induction to confirm the diag -nosis of laryngeal paralysis. Anesthesia was induced using propofol (4 to 6 mg/kg, IV) to effect. A diagno -sis of laryngeal paralysis was made if there was mini -mal or absent abduction of the arytenoid cartilages or if there was adduction of the arytenoid cartilages observed during inspiration. If necessary, doxapram (1.0 to 2.0 mg/kg, IV) was administered to stimu -late ventilation. Following diagnosis, patients were then premedicated with either butorphanol, hydro -morphone, methadone, or fentanyl and midazolam or diazepam. Dogs were induced with propofol that was titrated to effect and subsequently intubated. Anesthesia was maintained with isoflurane in oxygen for all patients. Lactated Ringer solution was admin -istered IV at a rate of 5 mL/kg/h. Cefazolin (22 mg/kg, IV) was administered prior to surgery and every 90 minutes during the surgical procedure.Surgical techniqueAll dogs were placed in right lateral recumbency with a towel placed under the neck in an extended po -sition. The thoracic limbs were retracted caudally. Fol -lowing aseptic preparation of the left lateral cervical region, an approximately 3- to 4-cm horizontal incision was made over the larynx just ventral to the jugular vein. Following dissection of the subcutaneous tissue and platysma muscle, the thyropharyngeus muscle was exposed and incised transversely to expose the aryte -noid and thyroid cartilages. A single stay suture of 3-0 polydioxanone was inserted through the freed thyroid cartilage to facilitate ventrolateral retraction. The crico -thyroid articulation was disarticulated at the discretion of the surgeon. The fascial membrane of the larynx was then incised. The cricoarytenoideus dorsalis muscle was freed from the caudal aspect of the muscular process using either sharp dissection or bipolar electrosurgery, with care taken to stay as close to the muscular process as possible. The cricoarytenoid articulation was then partially dissected. Two sutures of 2-0 polypropylene or polyglyconate were then used to secure the muscular process of the arytenoid cartilage to the caudodorsal aspect of the cricoid cartilage in cases of cricoarytenoid Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 08/30/23 11:58 AM UTC 3lateralization or to the caudal edge of the thyroid car -tilage in cases of thyroarytenoid lateralization, and the sutures were tightened. After lavage, routine closure with polydioxanone and monocryl was performed. The larynx was examined immediately after surgery but pri -or to anesthetic recovery to ensure that left arytenoid lateralization had been adequately abducted.Postoperative careFollowing the procedure, patients were monitored closely for respiratory distress. All dogs were main -tained on crystalloids IV (60 mL/kg/d) until discharge. Cefazolin, 22 mg/kg, IV was continued every 8 hours for 24 hours. Patients were monitored every hour for vomiting, regurgitation, pain, and anxiety. The use of postoperative metoclopramide constant rate infusion (2 mg/kg/d) was clinician dependent. Because most patients received Cerenia at induction, the periopera -tive use of ondansetron (0.5 mg/kg) every 8 hours was used if deemed necessary. Additionally, gastroprotec -tants such as famotidine (1 mg/kg) or pantoprazole (1 mg/kg) was used if directed by the attending clinician.Anxiolytic therapy was provided to patients on the basis of their anxiety score and if they displayed signs of panting, pacing, whining, and barking. Anxi -ety scores in hospital were recorded and categorized as follows: none (0), mild (1), moderate (2), and se -vere (3). For patients that were hospitalized for 24 hours after surgery (inpatient group), anxiolytic med -ications administered included dexmedetomidine (1 µg/kg, IV), dexmedetomidine constant rate infusion (0.5 to 0.75 µg/kg/h), and acepromazine (0.005 to 0.1 mg/kg, IV). The outpatient group received butor -phanol (0.15 mg/kg, IV) if painful perioperatively and dexmedetomidine (1 µg/kg) if anxiety was noted.Respiratory rate, effort, and presence of stridor was monitored and documented every hour for all patients while in hospital.Dogs in both the inpatient and outpatient group were discharged with tramadol (4 to 5 mg/kg) every 6 to 8 hours, gabapentin (5 to 10 mg/kg) every 8 hours, trazodone (3 to 5 mg/kg) every 8 to 12 hours, and carprofen (2 mg/kg) every 12 hours.Follow-upDogs returned 10 to 14 days postoperatively for suture removal and recheck. Information gathered in -cluded incisional complications, presence of vomiting or regurgitation, anxiety, pain, and respiratory effort.ComplicationsFor the purposes of the present study, compli -cations were divided into perioperative and postop -erative. Perioperative complications were those that occurred during the period following admission to the hospital and following the surgical procedure but prior to discharge from the hospital. Postoperative complications were defined as those that occurred during the period following discharge from the hos -pital up until the 2-week recheck examination. Com -plications were defined as any respiratory problem requiring hospitalization or necessitating additional surgical intervention, surgical site infection, surgical site dehiscence, and any condition that resulted in death or euthanasia. A diagnosis of aspiration pneu -monia was made on the basis of clinical signs and radiographic findings on thoracic radiographs.Continuation of mild inspiratory stridor with activity or excitement following surgery was not documented as a complication in the perioperative or postoperative period. Perioperative and postop -erative coughing and change in phonation following unilateral laryngeal tie-back were not recorded as complications, as these are common developments.Statistical analysisNormal probability plots were inspected to as -sess whether numerical variables followed a normal distribution. Subsequently, numerical variables were summarized as mean (SD). Categorical variables were summarized as counts and percentages. Inpatients were compared to outpatients using the 2-sample t test (for age, body weight, and anesthesia time) or the Fisher exact test (for the categorical variables). Statis -tical significance was set to P < .05. All analyses were performed using SAS version 9.4 (SAS Institute Inc).ResultsOne hundred five dogs met the initial criteria and were screened for study inclusion. Sixty-one cases were excluded due to lack of follow-up, incomplete medical records, or concurrent upper airway co -morbidities. The remaining 44 dogs that underwent unilateral arytenoid lateralization were included in the study. Of the 44 patients included in the study, 35 (79.5%) were Labrador Retrievers, 2 (4.5%) were Golden Retrievers, 2 (4.5%) were Labradoodles, 1 (2.3%) was a Labrador Retriever mix, 1 (2.3%) was a Shepherd mix, 1 (2.3%) was a Doberman Pin -scher, 1 (2.3%) was an American Staffordshire Ter -rier, and 1 (2.3%) was an American Pit Bull (Table 1) . Inpatient Outpatient group groupVariable n (%) n (%) P valueBreed Golden Retriever 0 (0.0) 1 (4.2) .1951 American Pit Bull 0 (0.0) 1 (4.2) American Staffordshire 1 (5.0) 0 (0.0) Terrier Doberman Pinscher 1 (5.0) 0 (0.0) Golden Retriever 0 (0.0) 1 (4.2) Labradoodle 2 (10.0) 0 (0.0) Labrador Retriever 15 (75.0) 20 (83.3) Labrador Retriever mix 0 (0.0) 1 (4.2) Shepherd mix 1 (5.0) 0 (0.0) Castration status 0 (0.0) 1 (4.2) .7490 FI FS 8 (40.0) 11 (45.8) MI 1 (5.0) 0 (0.0) MN 11 (55.0) 12 (50.0) Presence 17 (85.0) 14 (58.3) .0958 of comorbiditiesFI = Female intact. FS = Female spayed. MI = Male intact. MN = Male neutered.Table 1 —Description of the population.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 08/30/23 11:58 AM UTC4 Mean and median body weights were 36.1 and 35.2 kg, respectively (range, 23 to 51 kg). Mean and me -dian age was 11.9 and 12 years, respectively (range, 8 to 15 years). Twenty-three (52.3%) patients were male neutered, 19 (43.2%) were female spayed, 1 (2.3%) was female intact, and 1 (2.3%) was male intact. Of the 44 patients included in the study, 20 (45.4%) were hospitalized for 24 hours after surgery (inpatient group) and 24 (54.5%) were discharged the day of surgery (outpatient group). Of the surgi -cal procedures performed, 12 (27.3%) were unilat -eral thyroarytenoid lateralizations, 32 (72.7%) were unilateral cricoarytenoid lateralizations, and there was no combination of unilateral thyroarytenoid and cricoarytenoid lateralization performed. Prokinetics were used in 26 patients with 10 (50%) of those be -ing in the inpatient group and 16 (66.7%) being in the outpatient group. Antiemetic injections were used in 16 (80%) inpatients and 22 (91.7%) outpatients. Peri -operative opioids were used in 10 (50%) inpatients versus 8 (33.3%) outpatients ( P = .3588; Table 2 ). 0.3871). Radiographic evidence of aspiration pneu -monia within the 2-week postoperative period was documented in 5 (25%) dogs in the inpatient group and 1 (4.2%) dog in the outpatient group ( P = .0773). Three patients died within the 2-week postoperative period, resulting in a 6.8% mortality rate. Of those 3 patients, 2 were euthanized secondary to their dis -ease process (5.0% of inpatients and 4.2% of outpa -tients) and 1 died on the way to the hospital after having an obstructive respiratory event ( P = 1.00). The overall morbidity in the inpatient versus out -patient group was 5% versus 4.2%, respectively. The mortality rate for inpatients versus outpatients was 5.0% versus 8.3%, respectively. There was no signifi -cant difference in morbidity and mortality rates be -tween groups ( P = 1.00 and 1.00, respectively). The overall complication rate in this study was 22.7% with 35% of those being in the inpatient group and 12.5% being in the outpatient group. There was no sig -nificant difference in rate of complications between groups ( P = .1466).

Question 71

Trivino - 2024 - JSAP - Objective comparison of a sit to stand test to the walk test for the identification of unilateral lameness caused by cranial cruciate ligament disease in dogs.pdf

Answer 71

Study populationThe study was approved by the Veterinary Ethical Review Committee of the Royal (Dick) School of Veterinary Stud -ies (approval number 120.17). Non-lame dogs were recruited from staff and students working at the Hospital for Small Ani -mals at the University of Edinburgh, and dogs with CCLR were recruited from owners presenting their pet for treatment of the disease at the same institution. Owners consented for their pet to undergo the testing procedure before commencing the study. Eighteen non-lame dogs and 10 dogs with unilat -eral lameness attributed to CCLR, were recruited. Non-lame dogs were ascribed as such following a complete orthopaedic examination by an ECVS diplomate. The diagnosis of CCLR was based on history, physical exam, radiography and subse -quently confirmed by arthrotomy or arthroscopic evaluation of the joint.ProtocolAll dogs underwent the same testing procedure which com -prised visual lameness assessment and routine orthopaedic examination confirming unilateral lameness (CCLR dogs) or subjective soundness (non-lame dogs). All dogs were weighed on an electronic scale before gait analysis to allow normalisa -tion with pressure walkway data. All the patients included in the study were handled by a single operator (AT). All dogs were permitted to walk freely around the gait laboratory for 10 minutes and walked over the pressure-sensitive walkway (PSW) five times without recording data to permit habitua -tion to the laboratory conditions and the PSW, before being walked over the PSW on a loose lead, a minimum of five times for acquisition of data.A 1 m×0.5 m PSW containing 1.4 sensels per cm2 was set up as previously described (Fanchon & Grandjean, 2007 ) and the data were analysed using proprietary software (Walkway v7.02; Tekscan). The walkway was calibrated as the per manu -facturer’s guidelines, and a proprietary equilibration file (20 PSI) was used when gathering data. The data was collected at a 60 Hz sampling rate. The PSW was placed in the middle of a 13.6 m×5.3 m room and covered with a 5 m×50 cm×2 mm rubber matt as previously described (Bockstahler et al., 2009 ; Waxman et al., 2008 ).A Microsoft 1080 HD camera (Microsoft LifeCam Stu -dio Webcam, Microsoft) was used to capture video record -ings of the dogs on the PSW. The camera was synchronised with the PSW and the video recording was used to ensure the correct foot print recognition by the walkway software. The dog’s velocity and acceleration during kinetic gait data collec -tion were estimated from the video footage using five mark -ers placed 1 m apart. The mean gait velocity of each dog was recorded as the mean velocity of the 4 velocity measurements, recorded between each marker on each trial. The two gait tests were always performed in the same order: WT then STST. The time measured to undertake each test was measured with a stop -watch. Data were exported from the proprietary gait software for each of the two tests (WT, STST) for statistical analysis.The “walk” testDogs were walked on a leash, by the same handler, in a straight line across the PSW until five valid trials were achieved. Each dog was allowed to walk at its preferred velocity. A trial was considered valid when the dog walked across the full length of the PSW, in a straight line, at a gait velocity of ±0.5 m/s range, with all four paws fully contacting the plate surface as previously described (Bockstahler et al., 2009 ; Oosterlinck et al., 2011 ). T rials were excluded if the dog ran, trotted, paused, stopped or turned its head on the walkway. This was repeated until five valid trials were obtained. Peak vertical force (PVF), vertical impulse (VI), velocity and stance time (StT) were calculated. PVF and VI were expressed as a percent of bodyweight. The PVF and VI were recorded for all four limbs, and the average of the five trials was calculated for analysis.Sit to stand testDogs were sat on the PSW and then encouraged to stand up and walk away from the PSW. Each dog was allowed to stand up and walk away at its preferred velocity. A trial was considered valid when the dog stood up on the PSW, with all four paws fully contacting the plate surface at least once. This was repeated until three valid trials were obtained. PVF and VI were expressed as a percentage of bodyweight. The PVF and VI were recorded for all four limbs, and the average of the three trials calculated for statistical analysis. 17485827, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13679 by Vetagro Sup Aef, Wiley Online Library on [19/01/2024]. 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 LicenseA. Triviño 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.26The time taken to perform each data set and individual test was recorded for each dog.Statistical analysisEach dataset was assessed for the normality of distribution by visual analysis of individual value plots. The mean ± 95% con -fidence intervals (95% CI) and range were determined for fore -limbs and hindlimbs of each dog: gait velocity, StT, PVF and VI. Three measures of symmetry were calculated for each dog. The symmetry index (SI) for each variable was calculated as pre -viously described (Bockstahler et al., 2009 ; Fanchon & Grand -jean, 2007 ) as follows: SI between the hindlimb pairs (HL) was calculated {=100×[(AHL−CHL)/(AHL+CHL)], where AHL is the affected hindlimb and CHL is the contralateral hindlimb}. The SI between the diagonal limb pair (DLP) was calculated {=100×[(AHL−CFL)/(AHL+CFL)], where CFL is the contralat -eral forelimb}. The SI between ipsilateral limb pairs (ILP) was calculated {=100×[(AHL−IFL)/(AHL + IFL)]}.The age, weight and time taken to complete each test, for each group were assessed for normality by graphical representa -tion, and compared by use of independent two-sample t-tests. The kinetic and time variables for each group were assessed for normality by graphical representation, and compared by use of an independent two-sample t-test, with Bonferroni correction, to identify differences between the healthy and CCLR groups. Thus, a total of 24 test conditions were assessed (comparison of SI of PVF and VI for HL, DLP and ILP during WT and STST and comparison of SI of StT for HL, DLP and ILP during WT and STST). As an optimal diagnostic test should be able to completely discriminate between non-lame and CCLR subjects, the upper range of the SI measured in the non-lame group was selected as the cut-off value to measure the sensitivity and nega -tive predictive value of each measure (as the specificity and posi -tive predictive value will both be 100%).RESULTSThe non-lame group comprised of 18 dogs, 13 males and five females, all neutered, aged from 1 to 12 years (mean 5.1 years ±1.7 years) and weighing between 12 and 43 kg (24 kg ±4.1 kg). This group consisted of five crossbred dogs, two springer spaniels, three Border Collies, two Staffordshire bull terriers, one lurcher, one greyhound, one Labrador retriever, one cocker spaniel, one Dalmatian and one husky. The CCLR group comprised 10 dogs, six males and four females, all neutered, aged from 4 to 10 years (7.1 years ±1.3 years) and weighing between 17 and 72 kg (35 kg ±10.0 kg) and consisted of two Labrador retrievers, two Staf -fordshire bull terriers, one Border Collie, one crossbred dog, one lurcher, one rottweiler, one bullmastiff and one springer spaniel. The CCLR group was significantly heavier (P=0.03) than the non-lame group, but not significantly older (P=0.13). All dogs permitted the three trials of the STST, and five valid WT trials. The mean time taken to collect the WT dataset was 664 seconds (s) (range 449 to 1320 seconds). This was significantly longer (P=0.019) than the mean time to taken to collect the STST data (435 seconds, range 208 to 960 seconds); however, the average time to take each individual repeat was slightly longer (145 seconds per valid repeat) compared to the WT (132 seconds per valid repeat).FIG 1. Mean ± 95% confidence interval (CI) values of symmetry index (SI) comparing non-lame and CCLR groups for both tests: walk test (WT) and sit to stand test (STST), corrected to mean bodyweight. Hindlimb vertical impulse (VI HL), hindlimb peak vertical force (PVF HL), diagonal limb pair vertical impulse (VI DLP), diagonal limb pair peak vertical force (PVF DLP), ipsilateral limb pair vertical impulse (VI ILP), ipsilateral limb pair peak vertical force (PVF ILP). n=18 dogs in the non-lame group, 10 dogs in CCLR group; error bars represent 95% CIA BCDF E WT contWT CCLRSTST contSTST CCLR020406080100SI MEAN HL VI WT contWT CCLRSTST contSTST CCLR010203040SI MEAN HL PVF WTSTST WT contWT CCLRSTST contSTST CCLR020406080100SI MEAN DLP VI WT contWT CCLRSTST contSTST CCLR01020304050SI MEAN DLP PVF WT contWT CCLRSTST contSTST CCLR020406080SI MEAN ILP VI WT contWT CCLRSTST contSTST CCLR0204060SI MEAN ILP PVF 17485827, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13679 by Vetagro Sup Aef, Wiley Online Library on [19/01/2024]. 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 LicenseSit 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.27 Asymmetry in StT between the non-lame and CCLR groups did not differ significantly in either test.The mean SIs of the ground reaction forces (GRFs), HL, ILP and DLP , measured in the healthy and CCLR groups, are pre -sented in Fig 1, and sensitivity of those measures is presented in Table S2. The SI of the HL GRFs during the WT were signifi -cantly different between the non-lame and CCLR groups ( Fig 1, Table S1). The SI of the HL GRFs during the WT were 100% sensitive for classifying the non-lame and CCLR dogs ( Table S2). The SIs of the DLP GRFs during the WT were 100% sensitive (PVF) and 90% sensitive (VI) for classifying the non-lame and CCLR dogs. The SI of the ILP GRFs during the WT were 100% sensitive (PVF) and 80% sensitive (VI) for classifying the non-lame and CCLR dogs.The SI of the HL GRFs measured during the STST were 90% sensitive (PVF) and 50% sensitive (VI) for classifying non-lame and CCLR dogs. The SIs of the DLP GRFs during the STST were poorly sensitive (PVF 40%, VI 50%) for classifying the non-lame and CCLR dogs. The SIs of the ILP GRFs during the STST were 0% sensitive (PVF) and 33% sensitive (VI) for clas -sifying non-lame and CCLR dogs.

Question 72

Manzoni - 2023 - JSAP - Preoperative computed tomography, surgical treatment and long-term outcomes of dogs with abscesses on migrating vegetal foreign bodies and oropharyngeal stick injuries - 39 cases (2010-2021).pdf

Answer 72

Inclusion criteriaThe records of dogs that underwent surgery for abscesses and/or DTs of the head and neck at our institution between January 2010 and July 2021 were extracted by a single operator after a combined search in the hospital database and the surgical log of all operations in our surgery department, by using the following keywords: abscess and DTs. Only cases that were suspected to be associated with migrating VFB or OSI and that had a preopera-tive CT scan followed by surgical management with a minimum follow- up of 8 months were included.Animals with a history of bite wounds, those in which a dental abscess was the source of infection and those with incomplete medical records were excluded from the study.The collected data included the following: 1. Signalment, history (duration of the condition, previous surgical and/or medical treatments) and clinical findings: cases were classified into either acute or chronic according to whether the duration of clinical signs was less than or more than 7 days, according to previously published criteria (White & Lane 1988, Griffiths et al. 2000)2. Preoperative haematological and biochemical profiles, CT findings, cytological and histological analysis, and bacterio-logical testing3. Surgical procedures and findings4. Duration of drainage, nature of the antibiotic therapy and occurrence of minor complications (i.e. self- limited events requiring only medical treatment or superficial wound care) and major complications (i.e. events requiring intensive care therapy or additional surgery)5. Long- term follow- up assessed via telephone interviews with the owners regarding recurrence of clinical signs, medical or surgical management of episodes of recurrence: the absence of recurrence was established when no relapse of lesions or symptoms associated with the problem were observed by the owner at the time of latest follow- up.CT examination and surgical treatmentAll CT examinations were performed under general anaesthesia. Three different CT scanners were used over the study period (GE Bright Speed 16- slice™, General Electric from 2010 to 2014; Dia-mond Select Brilliance CT 64- slice™, Philips from 2014 to 2019; and Aquilion Lightning 80™, Canon Medical Systems from 2019 to 2021). Images of the head and neck regions were acquired before and after injection of iodinated contrast medium at a dose of 600 mgI/Kg (Iohexol Omnipaque® intravenously, 2 mL/kg). The slice thickness ranged from 0.625 to 1.5 mm, depending on the size of the animal and the region studied. Interpretation of CT images was performed and reviewed by diplomates of the European College of Veterinary Diagnostic Imaging. Animals were classified according to whether VFB had been identified on CT or was suspected because of the presence of cavities and/or DTs on CT examination (Bouabdallah et al. 2014).All surgical procedures were performed by experienced aca-demic surgeons, European College of Veterinary Surgeons diplo-mates or third year residents. The surgical approach and strategy were planned according to the anomalies detected on CT. The objectives of the surgical procedure were either: (1) strict removal of any VFB visualised preoperatively on CT, or (2) debridement, exploration and drainage of the abscess cavities and DTs, or 17485827, 2023, 9, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13624 by Vetagro Sup Aef, Wiley Online Library on [17/09/2023]. 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 LicenseCT for surgery of head and neck abscessesJournal of Small Animal Practice • Vol 64 • September 2023 • © 2023 British Small Animal Veterinary Association. 583 en- bloc resection of the lesions, when possible, when no VFB were identified on CT. Tissue samples and swab specimens were collected for bacteriological testing. On the basis of surgeons’ choice, excised tissues were submitted to histological analysis when no VFB were identified. The surgical wounds were man-aged by primary closure, or passive or suction drains, or were left open for second intention healing. In the immediate postopera-tive period, pain management was provided through methadone or buprenorphine administered intravenously (with dose and duration adapted according to the pain score), and meloxicam administered once daily subcutaneously for 2 to 8 days in all dogs. When broad- spectrum probabilistic postoperative antibi-otic therapy was prescribed as a first- line treatment after tissue sampling during surgery, it was adapted according to the results of antibiotic sensitivity testing.The success rate was defined as the proportion of cases with disease- free survival after CT- planned surgical treatment.Statistical analysisAll numerical data are presented as medians with ranges. Cat-egorical variables are presented as frequencies and percentages. Cases were considered “true positives” when VFB were found at surgery. Positive and negative predictive values were determined on the basis of review of CT images with knowledge of the surgi-cal findings, as reported in a former study (Blondel et al. 2021). The relative sensitivity and specificity of CT in detecting VFB were calculated according to the number of true positive cases that were correctly diagnosed preoperatively. Fisher’s exact test was used to compare success and recurrence rates between cases in which a foreign body was identified or not identified on CT. Mann– Whitney test was used to compare the identification rate of VFB at CT and at surgery in acute and chronic cases, and to compare recurrence and complication rates according to the type of surgical closure. Statistical analyses were performed in BiostatTGV™ software. A P value <0.05 was considered signifi-cant.RESULTSSignalment and clinical findingsIn total, 142 dogs were treated for head and neck abscesses and/or DTs between January 2010 and July 2021. Thirty- nine dogs (14 females and 25 males) met the inclusion criteria. The median age at the time of presentation was 48 months (7 to 168 months). Dog breeds included Labrador retriever (n=5), Staffordshire Bull Terrier (n=5), French Bulldog (n=3), Brittany Spaniel (n=3), German Shepherd (n=3), mixed breed (n=2), English Cocker Spaniel (n=2), German Shorthaired Pointer (n=2), Golden Retriever (n=2) and one of each of the following breeds: Saint Bernard, Boxer, Border Collie, Jack Russell Terrier, American Bully, Bull Terrier, Beagle, Dogue de Bordeaux, Argentine Dogo, Dachshund, West Highland White Terrier and Great Pyrenees. The median population weight was 20.9 kg (7.5 to 52 kg). In eight cases (21%), the owners reported that the lesions appeared after stick chewing.Thirty- two animals (82%) received surgical and/or medical treatment before presentation at our institution. Among them, 26 (67%) received only medical treatment (antibiotic therapy alone (n=5), non- steroidal anti- inflammatory drugs alone (n=5), a com-bination of the two (n=15), antibiotic therapy associated with cor-ticosteroids (n=2), corticosteroids alone (n=2) or a combination of the three (n=2)). The duration of medical treatment ranged from 1 to 20 days, and the median duration was 5 days. Partial response to medical treatment or transitory complete remission of clinical signs was observed in 13 cases (50%). The remaining cases (n=13, 50%) showed no response to treatment. Six animals had undergone either one (n=5) or two (n=1) surgical explorations before presentation at our institution, which consisted of drainage of the abscess and removal of two VFB in one case. No preopera-tive imaging tests had been performed in any cases.The median duration of clinical signs before admission was 15 days (0 to 365 days). Seventeen cases (44%) were classified as acute, and 22 cases were classified as chronic (56%). Thirty- three animals (85%) presented with swelling in the head or neck. DTs were observed in eight cases (21%) with an opening located intraorally (n=3), on the jaw (n=2), on the neck (n=2) or infra- orbitally (n=1). Other relevant clinical signs included hyperther-mia (n=17, 44%), chewing disorders (n=13, 33%), dysorexia (n=6, 15%), ptyalism (n=5, 13%), depression (n=4, 10%), locoregional adenomegaly (n=4, 10%) and stertor (n=1, 3%).Signs of suppurative or necrotic inflammatory processes with neutrophilic leukocytosis, associated or not associated with monocytosis, were observed in 13 of the 20 cases in which blood cell counts were obtained. Biochemistry results were within the normal ranges in all but two of the 27 cases in which these exami-nations were performed. One dog had elevated ALP [813 IU/L, range=(29 to 153 IU/L)], and another showed hyperlactataemia [4.3 mmol/L, range=(<2.5 mmol/L)].Fine needle aspiration was performed in 25 cases (64%) and revealed the presence of degenerated polynuclear neutrophils with or without the presence of macrophages in 21 cases (84%) and red blood cells in four cases (16%). Bacilli and/or cocci were identified in 15 cases (60%). No bacteria were found in the remaining cases (40%).Diagnostic imaging and surgical treatmentCT examination was limited to the head in 23 cases, and included the neck and the thorax in 12 and four cases, respectively. CT abnormalities were observed in all dogs and included isolated cavities (n=37), regional lymphadenopathy (n=19), VFB (n=11), DT (n=8) and cellulitis (n=4).At least one VFB was identified in 11 of 39 (28%) cases. Migrating VFB were suspected, on the basis of the presence of cavities and/or DTs, in the 28 (72%) other dogs. Neither acute nor chronic classification was associated with CT identification of VFB (4/17 (23%) cases and seven of 22 (32%) cases, respec-tively, P=0.06). Of the six dogs that underwent surgery before presentation at our institution, migrating VFB were identified on CT in two cases (33%).In all cases, VFB were identified as linear hyperattenuating structures (Fig 1), which were associated with gas bubbles in 17485827, 2023, 9, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13624 by Vetagro Sup Aef, Wiley Online Library on [17/09/2023]. 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 LicenseS. Manzoni et al.Journal of Small Animal Practice • Vol 64 • September 2023 • © 2023 British Small Animal Veterinary Association. 584the surrounding tissues in four cases, thus suggesting migration from the oral cavity or from the skin. The VFB ranged from 5 to 100 mm in length and were lateral to the larynx (n=5), lat-eral to the trachea (n=1), lateral to the pharynx (n=1), medial to the ramus of the mandible (n=1), in the temporal region (n=1), within the sternohyoid muscle (n=1) or in the retrobulbar space (n=1). Additional CT findings included mandibular and/or parotid glands sialadenitis (n=4), focal mandibular bone lysis (n=2), and maxillary and linguofacial venous occlusion (n=1).The median time between the CT scan and surgery was 1 day (0 to 17 days). The surgical approach was based on the location of the abscess and DTs when no VFB were identified at CT (Table 1), and consisted of removal of the VFB at the location identified on CT images in 10 of 11 dogs (Fig 2). In one case, the VFB identified on CT could not be found during surgi-cal exploration; moreover, neither histopathological analysis of the excised tissues nor postoperative CT examination identified VFB. In cases in which VFB could not be identified on CT (Fig 3), exploration and debridement of the abscess (25/28) or en- bloc excision of superficial and well- defined lesions (3/28) allowed for removal of VFB in 7 (25%) cases. All retrieved VFB were of vegetal origin, and consisted of spikelets, grass awns and pieces of wood (Fig 4). The dimensions of the VFB ranged from 2.5 to 100 mm in length. In the six cases that underwent previous surgery, VFB were found in only two cases. VFB were identified at surgery in 35% of cases with an acute history of clinical signs and in 50% of cases with a chronic history. Iden-tification of VFB at surgery did not significantly differ between dogs presenting in an acute or chronic condition (P=0.25). The CT and surgical findings are listed in Table 2. The relative sen-sitivity and specificity of CT for detecting migrating VFB were 58 and 95%, respectively; the positive and negative predictive values were 0.91 and 0.75, respectively. The odds ratio (OR) between animals in which VFB were identified or not identi-fied on CT was 28; thus, VFB were 28 times more likely to be found at surgery if VFB were identified on CT examination.In animals in which VFB were detected on CT, primary clo-sure was performed in eight dogs, delayed closure was performed in one dog at 10 days postoperatively, and second intention heal-ing was achieved in two dogs. In animals without VFB identi-fied on CT, 21 cases had primary closure, one case had delayed closure 14 days postoperatively, and second intention healing occurred in six dogs. In the 29 cases in which primary closure was performed, an active drain was placed in 26 dogs, and a pas-sive drain was placed in two dogs. The recurrence rates did not significantly differ between types of closure.Bacterial cultures were obtained at the time of surgery in 34 ani-mals and were negative in 12 (35%) of cases. The most frequently isolated bacteria were Pasteurella multocida (n=9). The rest were Gram- negative and Gram- positive anaerobic bacilli, Actimonyces, Coryneformes, Streptococcus canis, Fusobacterium, Streptococcus gal-lolyticus, Pasteurella canis, Pasteurella dagmatis, Cellulomonas, Clos-tridium perfrigens and Pasteurella pneumotropica. Among the 12 negative cultures, five animals had cocci and/or bacilli associated with phagocytosis figures visible on cytology, suggesting that, in these cases, the bacteriological results were false negatives. First- line antibiotic therapy based on amoxicillin with clavulanate was administered postoperatively in 33 of 37 animals, for durations ranging from 7 to 21 days (median 10 days). Antibiotic treatment was modified or administered according to the results of antimi-crobial susceptibility testing in 14% of cases.FIG 1. Pre contrast (A) and post contrast (B) axial CT images in soft tissue reconstruction. A rod- shaped mineral attenuating structure is present lateral to the right mandibular ramus, in agreement with a foreign body (white arrow). The foreign body is located within a small cavitary lesion with strong rim contrast- enhancement (black arrows)Table 1. Surgical approaches (39 dogs)Surgical approach Number of cases Number of VFB identified at CTNumber of VFB recovered at surgeryVentral cervical 14 8 6Oral 4 0 2Submandibular 8 0 2Retro- mandibular 5 1 4Temporal 5 1 3Retrobulbar 2 1 0Dorsal cervical 1 0 0VFB Vegetal foreign bodies 17485827, 2023, 9, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13624 by Vetagro Sup Aef, Wiley Online Library on [17/09/2023]. 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 LicenseCT for surgery of head and neck abscessesJournal of Small Animal Practice • Vol 64 • September 2023 • © 2023 British Small Animal Veterinary Association. 585 Tissues for histopathology were obtained at the time of sur-gery in 10 cases in which no VFB were found at surgery. No VFB were detected in any examined samples.OutcomeThe median hospitalisation time was 7 days (0 to 17 days). Active and passive drains were removed after a median time of 5 days (2 to 10 days) and 7 days (3 to 9 days), respectively.Minor complications were observed in four (10%) cases that developed a small fluid collection at the level of the surgical wound, 5 to 10 days after removal of the drain, which resolved unevent-fully. Major complications were observed in one dog in which no VFB were identified, where revision surgery was required to drain a large seroma that developed within 5 days of surgery. The pas-sive drain that had been placed at the time of initial surgery was replaced by an active drain that was maintained for 8 days.The median long- term follow- up was 69 months (9 to 139 months) for cases with VFB identified on CT. In these cases, no animals showed recurrence, and resolution of clinical signs was observed in 100% of cases. The median long- term follow- up of the dogs in which VFB was not identified on CT was 79 months (8 to 132 months). In 26 of 28 (93%) cases, complete resolution of clini-cal signs was achieved after a single surgery. Recurrence occurred 4 or 7 months postoperatively in two dogs in which no VFB were recovered at the time of surgery at our institution. Preoperative CT examination revealed a cervical abscess without the presence of VFB in both cases; a second surgical exploration was performed, but no VFB were identified in the two cases. No relapse was reported by the owners at 51 and 48 months after the second surgery. Because only two cases showed recurrence, no statistical analysis for risk fac-tors was performed. Outcomes are summarised in Table 3.

Question 73

De Moya - 2023 - VETSURG - Closed reduction and fluoroscopic-guided percutaneous pinning of femoral capital physeal or neck fractures - Thirteen fractures in 11 dogs.pdf

Answer 73

The medical records of dogs that underwent femoralhead or neck fracture repair via closed reduction andFGPP at two hospitals (University of Florida andACCESS Bone and Joint Center) from July 2018 to July2021 were reviewed. Cases were included if they hadcomplete medical records including surgical reports andcomplete radiographic studies. Data collected from medi-cal records included case demographics (signalment, age,weight), preoperative examination findings, fracturecharacteristics (etiology, Salter-Harris classification, timefrom injury to surgery, radiographic displacement), surgi-cal factors (surgery time, number/size of implants, reduc-tion quality) and outcomes (follow-up examinationfindings, radiographic findings, complications).Fluoroscopic-guided percutaneous pinning was per-formed using the techniqu ed e s c r i b e db yp r e v i o u sauthors.13,14Dogs were placed in lateral recumbency withthe affected side up and positio ned at the edge of the table.Before final aseptic limb preparation, orthogonal fluoro-scopic images were obtained to ensure the fracture sitecould be close reduced and im aged appropriately. The limbwas then aseptically prepared and draped in. Kirschnerwires were preplaced in normog rade fashion through smallstab incisions in the skin or through large gauge needlesused as a drill guide. The pin entry point into the femurwas located over the caudolateral aspect of the proximalmetaphysis, distal to the greate rt r o c h a n t e r .T h ef l u o r o s c o p yunit was then positioned to o btain orthogonal imagesintraoperatively to assess frac ture fixation following implan-tation. Kirschner wires were then advanced into the femo-ral neck near the fracture margin using intraoperativefluoroscopy to confirm optimization of insertion site andorientation (Orthoscan TAU 20/20, Orthoscan Inc, Scotts-dale AZ, USA). Closed reduction was then attempted byabducting and internally rota ting the femur while applyingtraction in a similar fashion than what is done to reduce acraniodorsal coxofemoral luxat ion. Intraoperative fluoros-copy was utilized to confirm fr acture reduction and Kirsch-ner wires were advanced int ot h ep r o x i m a lf r a c t u r esegment. All repairs were performed by board-certifiedACVS surgeons. All cases were hospitalized for 24 –48 hoursfollowing surgery and treated with nonsteroidal anti-inflammatory medications, injectable opioids as neededbased on regular pain score assessments (Colorado StateUniversity- Canine Acute Pain Scale) every 4 to 6 hourspostoperatively, and/or sedative medications.17Oral nonste-roidal anti-inflammatory med ications were continued for1–2w e e k s p o s t o p e r a t i v e l y a n d sedative medications wereprescribed based on the specific needs of each case. Dis-charge recommendations included passive range of motionexercises, activity restriction for 3 –6w e e k s a n d r e c h e c kappointments every 2 –4w e e k s .Orthogonal radiographs were obtained pre-, postoper-atively and at each follow-up appointment. Radiographsof the contralateral femur were obtained preoperativelyto aid in surgical planning. All dogs were sedated orunder general anesthesia for initial radiographs and allsubsequent follow-up radiographs were performed undersedation. Fracture characteristics including Salter-Harrisclassification and displacement were determined basedon preoperative radiographs of the affected femur. Preop-erative fracture displacement was defined as follows:mild (fragment overlap >2/3 bone width), moderate(fragment overlap 1/3 –2/3 bone width), or severe (frag-ment overlap <1/3 bone width). Fracture reduction wasclassified as anatomic (no fracture displacement), accept-able (<2 mm displacement), or unacceptable (>2 mmdisplacement) based on the degree of metaphyseal-physeal separation. Radiographs obtained at each follow-up appointment were assessed for evidence of fracturehealing, loss of reduction, implant migration, femoralneck resorption, and evidence of degenerative joint dis-ease. All radiographs were evaluated by one investigator(KD) using a dedicated PACS workstation using DICOMviewing software (Merge Healthcare Inc, Chicago,Illinois).de MOYA ET AL . 847 1532950x, 2023, 6, Follow-up evaluations consisted of a completephysical examination inclu ding subjective lamenessassessment, sedated orth opedic examination andorthogonal radiographs. Complications were catego-rized as major if subsequent medical or surgical treat-ments were required, or minor if they resolved withoutintervention as described b yp r e v i o u si n v e s t i g a t o r s .18Recommendations for explantation was determined bythe attending surgeon. Explantation was performed onan elective basis or due to complications associatedwith the implants. Prescheduled elective pin removalwas therefore not considered a complication. Additionaltreatment recommendations and/or complications wererecorded.3|RESULTS3.1 |Population dataEleven dogs with 13 fractures of the femoral capital phy-sis or femoral neck were included in the study. Descrip-tion of case demographics are summarized in Table 1.The study population included eight males (4 intact,4 neutered) and three females (2 intact, one spayed). Twodogs had bilateral capital femoral physeal fractures. Ofthe cases with bilateral fractures, one dog underwent asingle anesthetic episode for bilateral repair, and theother dog had staged bilateral repairs. Median age was8.5 months (range, 3 –13 months) and median body-weight was 20.3 kilograms (range, 5.9 –24.3 kg). Themedian time from injury to surgery was 5.5 days(range, 1 –42 days). Fracture etiology included vehicu-lar trauma (4), fall (1), sus pected trauma (6), and sus-pected physeal dysplasia (2). There were 10 Salter-Harris type I femoral capital physeal fractures, oneSalter-Harris type II femoral capital physeal fracture,and two femoral neck fractures. Preoperative fracturedisplacement was classified as mild (10), moderate(1) and severe (2). All dogs had a moderate to non-weight bearing lameness preoperatively.3.2 |Surgical techniqueInternal fixation was achieved using Kirschner wires forall fracture repairs. The median number of Kirschnerwires used was 2.5 (range: 2 to 4). Median Kirschner wirediameter was 0.062 inches (range: 0.045 –0.062). Kirsch-ner wires were trimmed as short as possible by eitherdepressing the surrounding skin (leaving implants rela-tively long but deep to the skin), or making a miniapproach to the pin entry site on the bone (leavingimplants relatively short). Cases with elective explant rec-ommendations had Kirschner wires that were left long inthe subcutaneous space to facilitate removal in thefuture. Median surgical time was 60 minutes (range: 45 –75 min). None of the cases required conversion to anopen approach.3.3 |OutcomeThe average time to first follow-up was 32 days (range13–58 days). At the first follow-up, 8/11 cases had mild tono lameness noted on examination. Of the seven casesthat required additional follow up (cases with incompleteradiographic union, complications, etc), five had mild toabsent lameness at the subsequent recheck appointment.Complete uneventful healing was documented in 10/13fractures at a median of 43 days postoperatively (range:25–62 days). Of the cases with uncomplicated healing,one dog had mild lameness at the final follow up exami-nation, and the remaining cases had no appreciablelameness. Prescheduled, elective explant was performedin five fractures.Quality of fracture reduction based on immediatepostoperative radiographs was deemed anatomic for10 repairs and the remaining repairs categorized asacceptable (3). Complete radiographic union was docu-mented in 10/13 fractures at a median of 43 days postop-eratively and of these 10 fractures, nine had evidence ofunion at the first follow up appointment (range 25 –62 days; Figure 1). Mild femoral neck resorption wasnoted in two of these 10 fractures. Complicationsoccurred in five dogs, and of these cases, two presentedfor initial evaluation 15 days or more from the time ofinjury and both had radiographic evidence of fractureremodeling on preoperative radiographs.Major complications occurred in five dogs andincluded intra-articular implants (1), implant failure/nonunion (1), implant migration (2), and malunion (1).Of these complications, two resolved with implantremoval, and a salvage procedure was recommended inthe remaining three cases. One dog had a chronic trans-cervical femoral neck fracture. The fracture showed pro-gressive healing at the first recheck appointment (25 dayspostoperatively); however, the dog developed progressivelameness and was diagnosed with an implant failure andnonunion. Femoral head ostectomy (FHO) was elected atthis time. One dog had persistent moderate lamenessfollowing surgery and was suspected to have an intra-articular implant (Figure 2). The dog underwent a revi-sion surgery at this time and the Kirschner wires were848 de MOYA ET AL . 1532950x, 2023, 6, TABLE 1 Case demographicsSignalmentWeight(kg) SideFractureetiologyFracturedescriptionPreoperativedisplacementTime frominjury tosurgery, daysQuality ofreductionDays tocompletehealingElectiveexplant ComplicationsFinallamenesslevel1 y, NM, mixedbreed dog21.8 L Trauma SH type 1 Mild 42 Anatomic 62 No No Mild1 y, NM, mixedbreed dog21.8 R Trauma SH type 1 Mild 42 Acceptable N/A No Implant migration Mild1 y, M, Pit bull 17.5 L Trauma SH type 1 Mild 10 Acceptable 59 No Malunion (FHO/THRrecommendedMild11 m, SF,Bernedoodle20.3 R Physeal dysplasia SH type 1 Mild 12 Anatomic 44 Yes No None1 y, NM, Chow 20.6 L Physeal dysplasia SH type 1 Mild 30 Acceptable 43 No No None3 m, M,Kooikerhondje5.98 L Trauma Basilar femoralneck fractureMild 1 Anatomic 11 Yes No None3 m, M, Pug 5.90 L Trauma Transcervicalfemoral neckfractureModerate 15 Anatomic N/A No Implant failure/nonunion (FHOperformed)Moderate7 m, F, AiredaleTerrier20.3 R Trauma SH type 1 Severe 3 Anatomic 43 Yes No None8 m, F, LabradorRetriever24.3 L Trauma SH type 1 Mild 1 Anatomic 25 Yes No None5 m, M, mixedbreed dog13.2 R Trauma SH type 2 Mild 1 Anatomic 39 Yes No None9 m, NM Blackmouth Cur23.6 L Trauma SH type 1 Mild 6 Anatomic 49 No No None9 m, NM Blackmouth Cur23.6 R Trauma SH type 1 Mild 5 Anatomic 34 No Implant migration None5 m, NM, mixedbreed dog19.3 L Trauma SH type 1 Severe 2 Anatomic N/A No Intra-articular pin(FHO performed)MildAbbreviations: F, intact female; FHO, femoral head ostectomy; HBC, hit by car; L, left; M, intact male; m, month; N/A, not applicable; NM, neutered mal e; R, right; SF, spayed female; SH, Salter-Harris; THR, totalhip replacement; y, year.deMOYA ET AL . 849 1532950x, 2023, 6, removed from the joint space. This dog had persistentlameness and pain throughout the follow-up period andsubsequent radiographs revealed progressive degenera-tive joint disease. This dog underwent a FHO at 56 dayspostoperatively. One dog developed a malunion and per-sistent lameness following surgery. FHO or total hipreplacement was recommended; however, this dog waslost to further follow-up.4

Question 74

Banks - 2024 - VETSURG - A mismatch of planning and achieved tibial plateau angle in cranial closing wedge surgery - An in silico and clinical evaluation of 100 cases.pdf

Answer 74

Electronic medical records were retrospectively reviewedto identify dogs that underwent mCCWO for the manage-ment of CCLD at a single institution between March2016 and March 2021. Radiographic inclusion criteriarequired DICOMs of diagnostic quality of pre- and post-operative straight mediolateral radiographs of the stifleincluding the distal femur and tarsus. Cases that pre-sented for the management of postoperative complica-tions or had undergone previous CCWO at otherinstitutions were excluded. Case details including signal-ment, bodyweight, and operated limb were collected.Dogs were categorized into two groups: small dogsweighing ≤25 kg and large dogs weighing >25 kg basedon previous criteria for wedge ostectomy positioning.3Radiographs were imported to orthopedic planning soft-ware (vPopPro, VetSOS Education Ltd). The TPA Prewasmeasured using the previously established methodology.13A proximal isosceles mCCWO was performed in silicoaccording to Oxley et al. (Figure1); briefly, the ostectomywas positioned at 5 and 10 mm distal to the patellar tendoninsertion on the tibial tuberosity for small ( ≤25 kg) andlarge dogs (>25 kg), respectively, and the wedge angle wascalculated according to Oxl ey's guidelines based on TPAPre(Table 1).3T h ea p e xa n g l eo ft h ei s o s c e l e sw e d g ew a sc a l c u -lated from TPA Preminus a set value dependent upon theTPA Pre. An additional group was made for dogs with aTPA Pre>3 5/C14(eTPA), extrapolating the calculation fromcases with a TPA Preof 31–35/C14, as eTPAs were not includedin the Oxley paper. After performing the mCCWO in silico,the TPAPlanwas measured. Each image was subjectivelyevaluated for plate fit by superimposing a scaled TPLOimplant based on patient weight and manufacturer guide-lines (DePuy Synthes Vet, West Chester, Pennsylvania).The TPAPostwas measured on immediate postopera-tive radiographs. The distance from the patellar tendon114 BANKS ET AL . 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13998 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 Licenseinsertion on the tibial tuberosity to the proximal aspect ofthe ostectomy line at the cranial cortex of the tibia wasmeasured to assess the position of the clinically executedostectomy (OP).To determine the effect of distalizing the ostectomyon post-planning TPA, 10 dogs per TPA category(Table1), were randomly selected. In silico ostectomieswere planned and executed at an increasing distal dis-tance from the patellar tendon insertion as follows: 5 mm(D5)—small dog recommended position, 7.5 mm (D 7.5),10 mm (D 10)—large dog recommended position, and15 mm (D 15) (Figure 2). The post-planning TPA withincreasing distal distance (TPA PlanD) was remeasured foreach ostectomy position.2.1 |Statistical analysisStatistical analyses were performed using SPSS (IBMSPSS Statistics, version 28.0. Armonk, New York: IBMCorp). Data were assessed for normality and outliersusing Shapiro –Wilk and the outlier labeling ruleFIGURE 1 An example ofin silico modified cranial closingwedge osteotomy (mCCWO)planning in a small dog ( ≤25 kg)using vPOPPro. (A) Preoperativemediolateral stifle radiograph,with a measured tibial plateauangle of 36/C14. An isosceles wedgewith an apex angle of 34/C14(TPA-2) was plotted 5 mm fromthe tibial tuberosity with thebase parallel to the cranialcortex of the tibia. (B) Plannedvirtual ostectomy reduced givinga postoperative tibial plateauangle of 7/C14.TABLE 1 Oxley et al. preoperative tibial plateau angle (TPA)category. The apex angle of the isosceles wedge was calculated frompreoperative TPA minus a set value dependent upon the preoperativeTPA. TPA5* group was created to include dogs with excessive tibialplateau angle, not previously accounted for in the Oxley publication.Preoperative TPAcategoryPreoperativeTPA (/C14)Wedge anglecalculationTPA1 ≤20 TPA –5/C14TPA2 21 –25 TPA –4/C14TPA3 26 –30 TPA –3/C14TPA4 31 –35 TPA –2/C14TPA5* >35 TPA –2/C14BANKS ET AL . 115 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13998 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 License(K=2.2). Descriptive statistics were generated accord-ingly. Mean or median TPA Pre, TPA Plan, TPA Post,and OPwere assessed overall and compared between small andlarge dogs using independent t-tests and Mann –WhitneyU for normally and non-normally distributed data respec-tively. One sample t-tests and Wilcoxon signed-rank wereused to compare the mean or median TPAPlanand TPA-Postto the target of 5/C14and to compare OP to 5 and 10 mmFIGURE 2 An example of in silico modified cranial closing wedge osteotomy (mCCWO) planning with progressive ostectomydistalization using vPOPPro. (A) The preoperative tibial plateau angle was 34/C14. An isosceles wedge with an apex angle of 32/C14(TPA-2) wasplotted 5, 7.5, 10, and 15 mm distal to the tibial tuberosity. The virtual ostectomy was executed at each level and the TPA PlanD was measured.TABLE 2 Average preoperative, post planning, and postoperative tibial plateau angle (TPA) and postoperative ostectomy position inoverall cases, small ( ≥25 kg) and large (>25 kg) dogs. p-value represents the difference between small and large dogs.TPA Pre(/C14)mean±S DTPAPlan(/C14)mean ± SDTPA Post(/C14)median (range) Ostectomy positionAll dogs 28.6 ± 6.2 7.6 ± 2.7 5.5 ( /C04–2) 8.6 mm (3.2 –20.6 mm)Smalldogs29.3 ± 6.3 7.5 ± 2.8 7.0 ( /C04–21) 8.3 mm (3.6 –20.6)Largedogs25.3 ± 4.0 7.7 ± 2.3 4.5 ( /C03–10) 12.6 (3.2 –19.0 mm)p-value .02 .84 .06 .00116 BANKS ET AL . 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13998 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 Licensefor small and large dogs, respectively. A one-wayANOVA or Kruskal –Wallis H test was performed toassess for variance in TPA Plan and TPA Post betweenwedge angle categories. A repeated measures ANOVAwas performed to assess for variance in TPA PlanD betweenostectomy positions.3|RESULTSA total of 84 small dogs and 16 large dogs were included,giving 100 stifle radiographs including 10 bilateral cases.The median (range) weight was 13.1 kg (4.1 –44.7 kg).The mean ± SD age was 7 years 1 month ± 2 years9 months. A total of 51 CCWOs were performed on righthindlimbs and 49 on left hindlimbs.The mean overall TPAPrewas 28.6 ± 6.2/C14(Table 2).The mean TPA Prewas greater in small than large dogs;29.3 ± 6.3/C14and 25.3 ± 4.0/C14, respectively ( p=.02). Whenthe mCCWO was performed in silico the mean overallTPA Planwas 7.6 ± 2.7/C14. There was no difference betweensmall and large dogs ( p=.84), and hence higher than 5/C14in both small and large dogs. Scaled TPLO plate fit wasconsidered appropriate in all cases. For clinical cases, themedian overall TPA Postwas 5.5/C14(/C04–21). The medianTPA Postfor small dogs was 7/C14(/C04–21) and 4.50(/C03–10)for large dogs. The median TPA Postwas higher than the5/C14target in small dogs only ( p=.001). The ostectomywas performed a median of 8.6 mm (3.2 –20.6 mm) fromTABLE 3 Mean post-planning and postoperative tibial plateau angle (TPA) for each preoperative TPA category ( pTPA). Asterisk (*)demonstrates a difference between categories based on one-way ANOVA and Games-Howel post hoc test. One-sample t-test resultsdemonstrating the difference between TPA outcome and 5/C14target.TPAcategory (/C14)TPA Plan(/C14)Mean ± SD5/C14targetp-valueTPA Post(/C14)Mean ± SD5/C14targetp-value<20 8.4 ± 2.5 .00 4.7 ± 5.2 .8621–25 8.2 ± 2.2 .00 4.5 ± 3.3* .5126–30 7.6 ± 2.6 .00 6.2 ± 3.3 .0331–35 7.1 ± 2.7 .01 7.5 ± 5.9 .07>35 6.4 ± 3.2 .10 10.7 ± 6.1* .00p-value .20 .01FIGURE 3 Line graphshowing post planning (in silico)and postoperative (clinical)tibial plateau angle (TPA)between preoperative TPAcategories.TABLE 4 Mean tibial plateau angle following in silico virtualostectomy performed 5, 7.5, 10, and 15 mm from the patellartendon insertion.OstectomypositionTPA PlanD (/C14)mean ± SDNumberin group5 mm 7.5 ± 2.9 107.5 mm 8.0 ± 2.5 1010 mm 8.7 ± 2.5 1015 mm 10.1 ± 2.8 10Abbreviations: TPA, tibial plateau angle.BANKS ET AL . 117 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13998 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 Licensethe patellar tendon insertion. The position was more dis-tal in large than small dogs; 12.6 mm (3.2 –19 mm) and8.3 mm (3.6 –20.6 mm), respectively. The median ostect-omy position was more distal than recommended 5 mmin small dogs and more distal than 10 mm in large dogs(p=.001 and .01, respectively). There was no differencebetween TPA Planand TPA Post(p=.05).For in silico cases, when wedge angle categories wereconsidered, there was no difference in mean TPA Planbetween categories (Table 3, Figure 3). There was a trendfor progressive under-correction as the preoperative TPAdecreased. Category 5 (eTPA) was the only group that didnot differ from the target of 5/C14(p=.10) with a TPA Planof6.4 ± 3.2/C14.For clinically executed cases, there was an inversetrend, with a progressive un der-correction as preopera-tive TPA increased (Table 3). There was a differencebetween TPA Postwhen preoperative TPA category wasaccounted for ( p=.01). Post hoc testing demonstrateda difference between categories 2 and 5 alone. Caseswith a preoperative TPA of 26 –30 and eTPA were differ-ent from the target of 5/C14(p=.03 and p=.01,respectively).The mean TPA PlanD differed between ostectomypositions (Table 4,F i g u r e 4). Post hoc analysis demon-strated that the TPA PlanD did not differ when per-formed at 5 mm or 7.5 mm from the patellar tendoninsertion ( p=.45) but was higher at increased dis-tances (10 and 15 mm). There was a progressive under-correction of the TPAPlanD as the ostectomy was dista-lized ( p=.01). The TPA PlanD was closest to the targetof 5/C14when the ostectomy was performed 5 and 7.5 mmfrom the patellar tendon insertion; however, the meanTPAPlanD for all groups was greater than 5/C14(p=.00).These findings were consistent when TPA categorieswere accounted for.4

Question 75

Clark - 2023 - JSAP - An update on mobility assessment of dogs with musculoskeletal disease.pdf

Answer 75

NA

Question 76

Adami - 2023 - JFMS - Inter-observer reliability of three feline pain scales used in clinical practice.pdf

Answer 76

Study populationThe study population was represented by client-owned cats admitted to the Queen’s Veterinary School Hospital of the University of Cambridge for routine neutering surgery (either spay or castration) between October 2022 and May 2023. The study was conducted under permission of the Ethics and Welfare Committee of the Department of Veterinary Medicine of the University of Cambridge (licence number: CR586-2022) and with signed informed owner consent.Pain assessmentsThree assessors, namely a board-certified veterinary anaesthetist (assessor A: CA), a veterinary anaesthesia nurse (assessor B: KS) and a final-year veterinary student (assessor C: CJ), assessed the study cats independently, and were blinded to the scores generated by the other assessors. They used three feline pain scales commonly used in practice: the CMPS – Feline, the CSU – FAPS and the FGS. Assessors A and B were familiar with the use of the scales, and assessor C received some basic train-ing based on two pilot cats prior to commencing data collection. The cats were assessed both preoperatively, after at least 1 h of acclimatisation in the hospital ward, and postoperatively, as soon as they were fully recovered from anaesthesia and sufficiently conscious to undergo behavioural assessment (ability to lift the head up, to respond to verbal stimulation and to eat and drink if food was offered). For each cat/assessment, the three asses-sors examined the cats within 30 mins of each other. To increase the chance that the assessors evaluated the cats while in a comparable analgesic status, care was taken to ensure that the 30-min period did not occur at a time when the previously administered analgesic drugs were expected to wear off. The order of the assessors was based on their availability at the time of the assessment and not randomised. Exclusion criteria were aggressive/defen -sive demeanour, presence of diagnosed comorbidities and administration of rescue postoperative analgesia between assessments/assessors. In case of unavailability of one of the assessors during an assessment, the cats were not excluded from the study, but pairwise evalua -tions were conducted on the available observations. Each assessor remained blinded to the scores generated by the other two until the end of data collection.Statistical analysisA sample size calculation was performed based on the hypothesis that the pairwise agreement between inde-pendent assessors would be fair to moderate. Variables were set as follows: statistical test, pairwise inter-class correlation (two-sided test); alpha ( α) value, 0.05, power, 0.8; beta ( b) value, 0.2; standard normal deviate for α (Zα), 1.960; standard normal deviate for b (Zb), 0.842; expected correlation coefficient, 0.5. This resulted in a minimum number of pairwise assessments equal to 29.Descriptive statistics was used for demographic vari -ables, and the data distribution was analysed with the Shapiro–Wilk normality test. Reliability statistics was performed with both the Cohen’s weighted kappa (k ) test and the Cronbach’s α method with calculation of the inter-class correlation coefficient (ICC).Inter-rater agreement was classified as follows: for k values below 0.01, no agreement; for k values between 0.01 and 0.20, none to slight; for k values between 0.21 and 0.40, fair; for k values between 0.41 and 0.60, moder -ate; for k values between 0.61 and 0.80, substantial; and for k values between 0.81 and 1.00, almost perfect agree -ment.20 Inter-class reliability was classified as follows: for ICC values below 0.5, poor; for ICC values between 0.5 and 0.75, moderate; for ICC values between 0.76 and 0.90, good; and for ICC values above 0.90, excellent.21To determine whether the inter-observer agreement differed between scales or between pairs of observers, the proportions of different categories of agreement were analysed with a χ2 test.Commercially available statistical software (SigmaStat 3.5 and SigmaPolt 10; Systat; SPSS, version 28; IBM Corp.) was used. P ⩽0.05 was considered statistically significant.ResultsData are presented as either the mean ± SD or median (interquartile range), depending on the data distribu-tion. Twenty client-owned cats weighing 3.2 (2.6–4) kg and aged 6 (5–24) months, of which 12 were females and eight were males, were included in the study.The cats were premedicated intramuscularly with a combination of medetomidine (0.015 [0.01–0.015] mg/kg) and methadone (0.2 [0.2–0.3] mg/kg). Following intravenous catheter placement, general anaesthe-sia was induced with either intravenous alfaxalone (2 [1–2] mg/kg) or propofol (4 [2–5] mg/kg) titrated to effect and maintained with isoflurane in oxygen delivered Adami et al 3through a modified T-piece connected to an appropri -ately sized endotracheal tube. Intra-testicular lidocaine (2 [1.5–2.0] mg/kg) was administered to the male cats before the beginning of surgery. Rescue perioperative analgesia was administered at the discretion of the anaes -thetist in charge of each case. All cats received subcutane -ous meloxicam (0.2 [0.1–0.2] mg/kg) and buprenorphine (0.02 mg/kg) postoperatively; buprenorphine was administered at 4 h from premedication or earlier if it was deemed necessary based on postoperative pain scores. All surgeries were performed by the same surgeon assisted by a final-year veterinary student.Preoperative and postoperative assessments were missing in seven and six cats, respectively, as a result of the unavailability of one of the three observers at the time of evaluation.The outcomes of each of the three scales were analysed separately per pairs of assessors (A and B, A and C and B and C) and per category (preoperative and postoperative values analysed both separately and together) (Tables 1 to 3). This resulted in a total of 27 groups of paired obser -vations (Table 4). The order of assessors was A, B, C in 10/27 (37%), A, C, B in 7/27 (26%), B, A, C in 6/27 (22%), C, A, B in 2/27 (7%) and B, C, A in 2/27 (7%) observations.Based on Cohen’s weighted k statistics, of 27 groups of observations, 16 (59%) showed fair agreement, eight (30%) showed none to slight agreement and the remain -ing three (11%) showed moderate agreement; none of the pairwise assessments showed substantial or almost perfect inter-rater reliability (Table 4). The χ2 test showed no difference in the proportions of different categories of agreement between pain scales ( P = 0.251).Based on Cronbach’s α statistics, of 27 groups of obser -vations, 12 (44%) showed moderate reliability, 12 (44%) showed poor reliability, and the remaining three (11%) showed good reliability; none of the pairwise assess-ments showed excellent inter-class reliability (Table 4). The χ2 test showed no statistically significant difference in the proportions of different categories of agreement between pain scales ( P = 0.179).The proportions of fair-to-moderate (with respect to k value) and moderate-to-good (with respect to ICC value) categories of agreement were significantly higher for the pairwise assessments B–C than for the pairwise assess-ments A–B and A–C ( P = 0.015).Table 1 Summary of reliability statistics findings of all (preoperative and postoperative) independent assessments performed by three investigators (A, B and C) using three different feline pain scalesCMPS – FelineCSU – FAPSFGSAssessors: A vs B Assessments (n) 31 31 31 ICC (average measures) 0.45 0.08 0.57 P value* 0.052 0.413 0.013 Cohen’s weighted k 0.26 0.13 0.24 P value† 0.027 0.170 0.002Assessors: A vs C Assessments (n) 30 30 30 ICC (average measures) 0.75 0.31 0.48 P value* <0.001 0.165 0.042 Cohen’s weighted k 0.46 0.27 0.17 P value† 0.001 0.009 0.140Assessors: B vs C Assessments (n) 27 27 27 ICC (average measures) 0.72 0.77 0.66 P value* <0.001 <0.001 0.004 Cohen’s weighted k 0.42 0.45 0.36 P value† 0.001 <0.001 <0.001*Significance for Cronbach’s α test†Significance for Cohen’s reliability statistics testThe numbers in bold indicate statistical significanceA = board-certified veterinary anaesthetist; B = veterinary anaesthesia nurse; C = final-year veterinary medicine student; CMPS–Feline = Glasgow Feline Composite Measure Pain Scale; CSU – FAPS = Colorado State University Feline Acute Pain Scale; FGS = Feline Grimace Scale; n = number of assessments; ICC = intra-class correlation coefficientTable 2 Summary of reliability statistics findings of preoperative independent assessments performed by three investigators (A, B and C) using three different feline pain scalesCMPS – FelineCSU – FAPSFGSAssessors: A vs B Assessments (n) 17 17 17 ICC (average measures) 0.58 0.49 0.70 P value* 0.045 0.093 0.005 Cohen’s weighted k 0.26 0.15 0.35 P value† 0.079 0.369 0.005Assessors: A vs C Assessments (n) 15 15 15 ICC (average measures) 0.76 0.12 0.49 P value* 0.006 0.404 0.110 Cohen’s weighted k 0.41 0.08 0.15 P value† 0.023 0.601 0.335Assessors: B vs C Assessments (n) 13 13 13 ICC (average measures) 0.71 0.62 0.65 P value* 0.020 0.055 0.039 Cohen’s weighted k 0.39 0.29 0.36 P value† 0.038 0.143 0.041*Significance for Cronbach’s α test†Significance for Cohen’s reliability statistics testThe numbers in bold indicate statistical significanceA = board-certified veterinary anaesthetist; B = veterinary anaesthesia nurse; C = final-year veterinary medicine student; CMPS–Feline = Glasgow Feline Composite Measure Pain Scale; CSU – FAPS = Colorado State University Feline Acute Pain Scale; FGS = Feline Grimace Scale; n = number of assessments; ICC = intra-class correlation coefficient4 Journal of Feline Medicine and Surgery Table 3 Summary of reliability statistics findings of postoperative independent assessments performed by three investigators (A, B and C) using three different feline pain scalesCMPS – FelineCSU – FAPSFGSAssessors: A vs B Assessments (n) 15 15 15 ICC (average measures) 0.49 0.05 0.49 P value* 0.110 0.763 0.118 Cohen’s weighted k 0.24 0.013 0.207 P value† 0.076 0.922 0.12Assessors: A vs C Assessments (n) 15 15 15 ICC (average measures) 0.49 0.19 0.46 P value* 0.118 0.349 0.130 Cohen’s weighted k 0.39 0.28 0.20 P value† 0.018 0.059 0.171Assessors: B vs C Assessments (n) 14 14 14 ICC (average measures) 0.69 0.78 0.66 P value* 0.022 0.005 0.030 Cohen’s weighted k 0.32 0.47 0.31 P value† 0.032 0.005 0.013*Significance for Cronbach’s α test†Significance for Cohen’s reliability statistics testThe numbers in bold indicate statistical significanceA = board-certified veterinary anaesthetist; B = veterinary anaesthesia nurse; C = final-year veterinary medicine student; CMPS–Feline = Glasgow Feline Composite Measure Pain Scale; CSU – FAPS = Colorado State university Feline Acute Pain Scale; FGS = Feline Grimace Scale; n = number of assessments; ICC = intra-class correlation coefficientTable 4 Inter-observer reliability of three different feline pain scales, used independently by three assessors, analysed with two statistical methodsPairs of assessors CMPS – Feline allCMPS – Feline preoperativelyCMPS – Feline postoperativelyCSU – FAPS allCSU – FAPS preoperativelyCSU – FAPS postoperativelyFGS all FGS preoperativelyFGS postoperativelyA vs B Assessments (n) 31 17 15 31 17 15 31 17 15 IRA Fair Fair None/slight None/slight None/slight None/slight Fair Fair Fair ICR Moderate Moderate Poor Poor Poor Poor Moderate Moderate PoorA vs C Assessments (n) 30 15 15 30 15 15 30 15 15 IRA Fair Fair Fair Fair None/slight Fair None/slight None/slight None/slight ICR Moderate Good Poor Poor Poor Poor Poor Poor PoorB vs C Assessments (n) 27 13 14 27 13 14 27 13 14 IRA Moderate Fair Fair Moderate Fair Moderate Fair Fair Fair ICR Moderate Moderate Moderate Good Moderate Good Moderate Moderate ModerateA = board-certified veterinary anaesthetist; B = veterinary anaesthesia nurse; C = final-year veterinary medicine student; CMPS–Feline = Glasgow Feline Composite Measure Pain Scale; CSU – FAPS = Colorado State University Feline Acute Pain Scale; FGS = Feline Grimace Scale; IRA = inter-rater reliability based on Cohen’s weighted k statistics; ICR = inter-class reliability based on Cronbach’s α statisticsThe preoperative and postoperative scores recorded by the three assessors are summarised in Figures 1 to 3.

Question 77

Sanders - 2024 - VETSURG - Influence of antiseptic lavage during tibial plateau leveling osteotomies on surgical site infection in 1422 dogs.pdf

Answer 77

2.1 |Preliminary dataMedical records of 333 consecutive dogs (antisepticlavage, n=138; saline irrigation, n=195) receivingTPLO procedures at three veterinary surgical referral hos-pitals in the same geographical area between December2019 and October 2021 were reviewed for preliminarydata to perform a power analysis. The TPLO SSI rateacross the entire population was 8.5%. Based on prelimi-nary population's allocation ratio of 1.4, a power (1 /C0β)=0.8 and a TPLO SSI rate of 8.4% in the preliminarypopulation, a required sample size of 1334 was estimatedif the antiseptic lavage was effective at reducing theTPLO SSI incidence to 5%. While not eliminating the riskof SSI altogether, decreasing the SSI rate from a baselineof 8% –9% down to 5% was set as clinically relevant tomonitor the efficacy of the antiseptic lavage.2.2 |Population, treatment protocol, anddata collectionMedical records at six veterinary referral hospitals werereviewed to identify dogs that had TPLO procedures per-formed between December 2019 and October 2021. Alldogs had their surgical sites irrigated with either the anti-septic lavage or 0.9% saline between implantation of theTPLO plate and screws and wound closure. All dogsreceived intraoperative antibiotics to be included in thisstudy. Relevant data were collected including signalment,surgical report, recheck exam ination and client communi-cation notes within the first 90 postoperative days to moni-tor for evidence of SSI, and intraoperative andpostoperative antibiotic prescription. All TPLO cases wereincluded whether performed as a single-session procedure,staged bilateral, or single-session bilateral procedure. Therewere no restrictions on the age, breed, or sex of the dogsincluded. Dogs had a minimum of 1-year follow-up fromthe time of surgery and dogs that were diagnosed by a sur-geon as having an SSI within the first 90-days wererecorded as either having a superficial infection, deep infec-tion, or no infection according to the guidelines outlinedby the Centers for Disease Control and Prevention (CDC)(Table1).23Dogs that had a culture and sensitivity per-formed or implant removal were recorded. Medical recordsfrom referring clinics were also reviewed in the follow-upperiod so that all wound-healing complications wereaccounted for, even for dogs that did not return to the hos-pital where the original surgery was performed.Exclusion criteria included dogs that failed to meet anyof the inclusion criteria, dogs that were not prescribedintraoperative antibiotics during the TPLO procedure, ordogs that were already being treated with antibiotics foran existing infection when the TPLO was performed. Forintraoperative antibiotics, the first dose was given/C2430 min prior to the first skin incision and subsequentdoses were administered every 90 min intraoperatively.Postoperative antibiotic type and duration of treatmentwere prescribed at the discretion of the attending surgeon.This information was recorded. The anesthetic records168 SANDERS ET AL . 1532950x, 2024, 1, were reviewed to determine which dogs received bupiva-caine liposome injectable solution and iodine-impregnatedincision drape during the TPLO procedure, though furtherdetails about the protocol for application of these productsor quantity were not investigated. Which hospital and sur-geon performed the TPLO procedure was also noted,though further information about the surgeon such as gen-der, whether they were left versus right-handed, or experi-ence level, was outside the scope of our investigation intoefficacy of antimicrobial lavage.In the antiseptic lavage group, administration of thelavage product was performed according to the manufac-turer's recommended methodology. Three to six millili-ters of antiseptic lavage (dose dependent on surface areaof wound) were aseptically withdrawn from the dosingvial with a sterile syringe and needle prior to being dosedinto the surgical wound. The antiseptic solution wasallowed to pool in the surgical wound, covering tissueand implants for 60 s prior to removal with surgical suc-tion. The site was then rinsed with an equal amount ofsaline prior to routine wound closure. In the salinegroup, a bulb syringe was used to administer copious(unrestricted) irrigation of the entire surgical site to pro-vide a mechanical scrub and dilution of bacteria from thesite. Storage of the antiseptic lavage was followed accord-ing to manufacturer guidelines.2.3 |Statistical analysisAll analyses were performed using statistical software(SAS 9.4, SAS Institute, Cary, North Carolina). Descrip-tive statistics were performed to characterize clinical fea-tures, including age, weight, sex, breed, laterality of limb,surgeon, administration of postoperative antibiotics,procedure(s) performed, use of iodine-impregnated inci-sion drape (Ioban, 3M, Saint Paul, Minnesota), use ofbupivacaine liposome injectable solution (Nocita, Elanco,Greenfield, Indiana), and use of an antiseptic lavage(Simini Protect, Simini Technologies).Aχ-square test was used to measure the cumulativeincidence of SSI in dogs with adequate follow-up. APoisson regression test was used to compare incidencerates between control and treatment groups. Multivari-able logistic and Poisson regression tests were used toadjust for any confounding factors. Exact binomialconfidence intervals were calculated. Univariable andmultivariable logistic regre ssions were utilized to testrisk factors for effects on odds of SSI and to estimateodds ratios (OR) and 95% confidence intervals (95%CI). For multivariable analysis, the initial modelincluded all risk factors except for breed (which due tothe large number of breeds caused numerical difficul-ties and the p-value was .93 upon univariable analysis).TABLE 1 Criteria for defining surgical site infection (SSI).23Variable Superficial SSI Deep SSI Organ/space SSITiming Within 30 days of theprocedureWithin 90 days of the procedureor 1 year if implantWithin 90 days of theprocedure or 1 year ifimplantLocation Involves skin and subcutaneoustissue of the incisionInvolved deep soft tissues of theincisionInvolves any part of the bodydeeper than the fascial/muscle layers that is openedor manipulated during theoperative procedure, examplejoint or bonePatient has one or more ofthe following clinical signs- Purulent drainage fromsuperficial incision- Organisms identified fromsuperficial incision orsubcutaneous tissue byculture or nonculture basedmicrobiological testing- Patient has localized pain,tenderness, swelling,erythema, or heat with orwithout culture- Diagnosis of a superficialincisional SSI by a physician- Purulent drainage from thedeep incision- Deep incision that dehisces oris opened by a surgeon andorganisms are identified fromthe deep soft tissues of theincision by culture ornonculture basedmicrobiological testing andpatient has either fever,localized pain, or tenderness- Abscess is detected or there isother evidence of deepincisional infection- Purulent drainage from adrain that is placed into theorgan/space- Organisms identified fromfluid or tissue in the organ/space by a culture ornonculture basedmicrobiological testingmethod- Abscess or other evidence ofinfection involving organ/spaceSANDERS ET AL . 169 1532950x, 2024, 1, Then iteratively the factor with the highest p-value wasremoved until all factors retained in the model hadp< .05. Log-likelihood p-values were used andreported. In all statistical analyses, a 95% confidenceinterval was used, and findings were deemed statisti-cally significant when p< .05.3|RESULTSA total of 1422 dogs met the inclusion criteria. Hospitallocations included three specialty hospitals in North Car-olina ( n=312) and three specialty hospitals in Georgia(n=1110).Data were collected from the records of 519 dogs treatedwith antiseptic lavage and 903 dogs treated with sterilesaline lavage during TPLO. Of the dogs that were treatedwith saline ( n=903), 80 (8.86%, 95% CI: 7% –11%) devel-oped an SSI. Of the dogs that were treated with antisepticlavage ( n=519), 77 (14.84%, 95% CI: 12% –18%) developedan SSI. A total of 157 dogs were positive for SSI (11.04%).Ninety-six (61.15%) were classified as superficial SSI and61 (38.85%) were classified as deep SSI. Using univariableanalysis, administration of ant iseptic lavage did not decreasethe odds of TPLO SSI (OR 1.8, 95% CI: 1.3 –2.5,p=.001).A total of 26 breeds were represented with the mostcommon being retrievers ( n=348, 24.47%), pitbulls(or pitbull crosses) ( n=175, 12.3%), and mixed breeddogs ( n=162, 11.39%). There were 24 (1.69%) intactfemales, 40 (2.81%) intact males, 591 (41.56%) neuteredmales, and 767 (53.94%) spayed females. The mean age ofenrolled dogs was 6 years, 8 months (range, 6 months –15 years, SD 2.9 years, p=.353) (Table2).Of the 157 dogs that had signs supportive of an SSI,one (0.64%) was an intact female, nine (5.73%) wereintact males, 71 (45.22%) were neutered males, and76 (48.41%) were spayed females. For intraoperative anti-biotics, 155 (98.7%) received cefazolin. Most commonly, acephalosporin was prescribed postoperatively ( n=127,80.9%). There were 23 dogs (14.6%) that did not havepostoperative antibiotics prescribed. Of dogs that devel-oped an SSI, 96 (61.15%) were classified as a superficialSSI and 61 (38.85%) were classified as a deep SSI. A totalof 59 (96.72%) of the 61 dogs with a deep SSI had implantremoval within the study period. The remaining two dogswith a deep SSI were advised to have the implantremoved, but this did not occur within the study window.Primary surgeons for the TPLO procedures reported hereincluded 12 diplomates of the American College of Veteri-nary Surgeons (ACVS) (Table3) .Ac o r r e l a t i o nb e t w e e nt h esurgeon and TPLO SSI ( p=.001) was present. In this popu-lation, heavier dogs were asso ciated with an increased riskof developing TPLO SSI ( p=.001). Dogs receiving a single-s e s s i o nb i l a t e r a lT P L Op r o c e d u r ew e r em o r el i k e l yt odevelop a TPLO SSI compared to dogs receiving unilateralTABLE 2 Descriptive statistics including age and weight of 1422 dogs that underwent tibial plateau leveling osteotomy procedure at oneof six referral hospitals between 2019 and 2021.Risk factorPositiveSSI NObs N MeanStdDev MedianLowerquartileUpperquartile Minimum MaximumAge at surgery None 1265 1265 6.7 2.9 6.8 4.3 9.0 0.0 15.8Superficial 96 96 6.5 3.1 6.6 4.1 9.0 0.9 13.0Deep 61 61 5.8 2.5 6.0 4.2 7.3 1.0 11.9Weight of dog None 1265 1181 22.8 13.7 21.0 12.4 32.0 1.0 96.2Superficial 96 92 24.6 16.5 20.2 13.2 32.8 2.0 90.9Deep 61 59 27.5 13.0 26.4 15.8 39.0 5.1 55.3Abbreviation: SSI, surgical site infection.TABLE 3 Surgeons and percentages of TPLO procedureswith SSI.SurgeonPositive SSITotal YNA 46 (11.03%) 371 (88.97%) 417B 8 (13.33%) 52 (86.67%) 60C 6 (13.33%) 39 (86.67%) 45D 11 (12.5%) 77 (87.50%) 88E 17 (12.14%) 123 (87.86%) 140F 6 (6.38%) 88 (93.62%) 94G 12 (8.7%) 126 (91.3%) 138H 11 (15.28%) 61 (84.72%) 72I 20 (18.18%) 90 (81.72%) 110J 9 (16.98%) 44 (83.02%) 53K 3 (2.24%) 131 (97.76%) 134L 8 (11.27%) 63 (88.73%) 71Total 157 1265 1422Abbreviations: SSI, surgical site infection; TPLO, tibial plateau levelingosteotomy.170 SANDERS ET AL . 1532950x, 2024, 1, TPLO ( p=.004). The dog's breed and age at the time ofTPLO, as well as performance of additional surgical proce-dures during the same anesthetic event as the TPLO, theintraoperative use of iodine-im pregnated adhesive surgicaldrapes, and local infusion of liposomal bupivacaine duringTPLO were not associated with TPLO SSI (Table4). Thedog's sex was not associated with TPLO SSI, but in pairedcomparisons, male intact dogs were 2.5 times more likely tohave an SSI than spayed female dogs (OR 2.5, 95% CI:0.98 –5.7,p=.199) and 2.4 times more likely than maleneutered dogs (OR 2.4, 95% CI: 0.9 –5.5,p=.199).A total of 119 dogs (75.80%) diagnosed with SSI had aculture and sensitivity test performed. Of those cases,97 (81.51%) had bacterial colony growth identified and22 (18.49%) had no growth. Of 97 dogs with a positiveculture, 54 (55.67%) had multidrug-resistant infections.The most common bacterial isolates from positive cul-tures are summarized in Table5.All dogs were treated with intraoperative antibioticsto be included in this study, most commonly cefazolin(West-Ward Pharmaceutical Corp., Eatontown, NewJersey) ( n=1409, 99.09%). Postoperative antibiotics wereprescribed following TPLO in 1250 dogs (87.83%). Themost common antibiotic prescribed postoperatively wascefpodoxime (Simplicef, Zoetis, Kalamzoo, Michigan)(n=1049, 83.98%). Postoperative antibiotics were shownto be protective against SSI in this study ( p=.008).4

Question 78

Aldrich - 2023 - VETSURG - Blinded, randomized, placebo-controlled study of the efficacy of bupivacaine liposomal suspension using static bodyweight distribution and subjective pain scoring in dogs after tibial plateau leveling osteotomy surgery.pdf

Answer 78

2.1 |DogsClient-owned dogs receiving TPLO between July 2019and July 2020 for confirmed unilateral cranial cruciateligament (CCL) insufficiency of any duration were eligi-ble for inclusion in the study. The study was approved byour institution's animal care and use committee. Writteninformed owner consent was obtained for all enrollees.Screening was completed on the day before surgery, andincluded physical and orthopedic examinations, tibia/fibula radiographs for surgical planning, and hematologi-cal analysis (complete blood cell count and serum bio-chemistry). Exclusion criteria were: age less than 1 year;current or historic bilateral CCL insufficiency; other clin-ically evident orthopedic disease; neurological disease;uncontrolled or clinically suspected systemic disease; any722 ALDRICH ET AL . 1532950x, 2023, 5, surgery within the previous 14 days; short-acting cortico-steroid use within the previous 7 days or repository steroiduse within the previous 2 months; NSAID use other thancarprofen within the previous 7 days; use of other analge-sics within the previous 48 h; and temperament that mightinterfere with subjective pain scoring or stance analysis.Demographic information gathered included uniquepatient identifier, age, sex, breed, bodyweight, affected hin-dlimb, and estimated duration of lameness.2.2 |Experimental designDogs were allocated into LB treatment and saline controlgroups by randomized stratification. Dogs presenting toour institution for TPLO have commonly received a recentdose of the NSAID, carprofen. To avoid a confoundingeffect on postoperative pain measurement, we stratifiedenrollees by carprofen use into “recent carprofen ”(withinthe last 40 h, representing /C245 terminal plasma half-lives)36or“no recent carprofen ”groups. Dogs within these groupswere randomly assigned to either the LB or placebo treat-ment subgroups using a computerized random selectiongenerator ( randomizer.org ).Data from pain scoring and %BW distmeasurementwere collected preoperatively (before sedation for TPLOplanning radiographs) and over the 48-h postoperativestudy duration by two investigators who were blinded totreatment assignment.2.3 |CMPS-SFThe CMPS-SF is a subjective cli nical metrology instrumentdesigned for assessment of acute postoperative pain in dogsin a clinical setting.26A total pain score is assigned between0 and 24 for ambulatory patients or between 0 and 20 forpatients who cannot walk witho ut assistance. Two investi-gators were trained together in use of the CMPS-SF for sev-eral days before the study began, to achieve subjectiveinterobserver consistency in scoring of postoperative ortho-pedic surgery patients. Pain sc ores for study participantswere assigned by one of these tw o investigators preopera-tively (baseline) and at 2, 4, 8, 12, 20, 24, 32, 40, and 48 hpostoperatively, where 0 h was time of extubation. Eachpatient may have received pain scores at different timepoints from one or a consensus of both of the assessors.2.4 |Static bodyweight distributionData from bodyweight distribution measurement werecollected by one of two investigators at baseline and at4, 12, 24 and 48 h postoperatively using a weight distribu-tion platform (PetSafe Stance Analyzer, Companion Ani-mal Health, Newark, Delaware). At the start of eachsession, the platform and associated software were cali-brated to zero weight. Based on previous studies of therepeatability of stance analysis,29,31the patient waswalked at a velocity of /C241 m/s onto the platform, led ona short neck leash by an investigator positioned to theanimal's right. The dog was abruptly stopped as theinvestigator moved in front of the animal to discourageadditional forward movement. This procedure wasrepeated as needed until the dog assumed a natural,square stance with one foot upon each of the quadrantsof the platform and its head held approximately on mid-line. After the dog maintained a square stance for /C245s ,data collection was started, with multiple measurementsof bodyweight distribution to each limb captured at/C240.5–1 s intervals, using a handheld remote control. Out-lier measurements resulting from aberrant body move-ments were discarded and six valid measurements persession were obtained, from which mean %BWdistwascalculated for the operated limb. When pain scoring and%BW distmeasurement were scheduled at concurrent timepoints, pain scoring was completed first.2.5 |Rescue analgesia, success/failuredetermination, and mean rescue opioiddosesDogs were administered a single dose of hydromorphone(0.08 mg/kg subcutaneously) as rescue analgesia if theywere assigned a CMPS-SF pain score of 6/24 or 5/20 orgreater during any of the scheduled pain assessmentsbased on previous recommendations.17After a dogreceived rescue analgesia, all subsequent pain scores and%BW distmeasurements were excluded from statisticalanalysis to avoid a confounding effect on results.2.6 |Anesthesia, analgesia and surgeryAll dogs were premedicated with IM administration ofacepromazine (0.01 –0.02 mg/kg) and hydromorphone(0.08 –0.1 mg/kg). Anesthesia was induced with intrave-nous propofol and maintained with isoflurane in oxygen;both given to effect. All dogs received cefazolin (22 mg/kg)IV and IM at induction of anesthesia, as well as intrave-nous fluid therapy during the anesthetic period. At ourinstitution it is common to give both an IV and IM dose ofcefazolin at the beginning of orthopedic surgery as thishas been shown to provide higher concentrations of thedrug for up to 5 h post administration when compared toALDRICH ET AL . 723 1532950x, 2023, 5, a single IV dose alone.37Treatments for systemic hypo-tension under anesthesia included fluid therapy, anti-muscarinics and adrenergic agonists, as needed.Routine TPLO38was performed by one of eight pri-mary surgeons, including residents, ACVS board-eligibleand ACVS board-certified surgeons. Based on surgeonpreference regarding stifle joint exploration and meniscalcartilage treatment, any of the following procedural vari-ations were permitted: craniomedial parapatellar arthrot-omy, cranial cruciate ligament debridement, meniscaldebridement, or midbody outside-to-inside medial menis-cal release.39All surgeons elevated the popliteus musclefrom the caudoproximal aspect of the tibia, but packingwith gauze was not performed. A jig was used prior toosteotomy in all cases.After stabilization of the osteotomy and closure of thejoint capsule, the surgical wound was infiltrated witheither undiluted LB (5.3 mg/kg; 0.4 mL/kg) or an equalvolume of sterile saline (0.4 mL/kg), based on thepatient's random group assignment. The infiltrate wasadministered using the moving needle technique25usinga sterile syringe fitted with a 1.0 –1.5 inch, 22-gauge nee-dle. The entire volume was distributed into three tissuelayers as described in previous LB efficacy studies25,27with/C2425%, 50% and 25% injected into the superficial tis-sues of the closed joint capsule, the closed fascial tissue,and the subcuticular tissue, respectively, before skin clo-sure. Skin closure was performed with an intradermalclosure using 3-0 Monocryl in all cases. Dilution of theLB with saline was not performed in any cases. Bothinvestigators who performed postoperative pain assess-ment remained blinded to the treatment.When skin apposition was complete, the patientreceived a single dose of IV hydromorphone (0.08 mg/kg). During the 48-h postoperative study period, all dogsreceived subcutaneous carprofen (2.2 mg/kg) every 12 h,beginning at time of extubation (0 h). When a carprofendose was scheduled concurrently with pain scoring and %BWdistmeasurement, data were collected before carpro-fen was administered. Dogs experiencing significant dys-phoria upon recovery were permitted to receive a singleIV dose of dexmedetomidine (1 mcg/kg) at the discretionof the supervising anesthesiologist. No other analgesicmodalities such as ice packing or limb compression wereused for the duration of the study.Postoperative care included leash walks every 4 h,free access to water, meals offered every 12 h, and coldcompress treatment of the incision for 10 min every 4 hbetween 7:00 a.m. and 11:00 p.m. Icing was performedonly after pain scoring/stance analysis were completed ata given time point. The surgical incision was protectedwith a bandage consisting of a nonadherent dressing withan adhesive covering until time of discharge. Dogs worean Elizabethan collar at all times. Adverse events werenoted and addressed.2.7 |Sample size calculationSufficient data are not previously reported describing staticbodyweight distribution in dogs in the acute postoperativeperiod, making a priori power analysis for sample size cal-culation a challenge. To estimate an expected effect size of%BWdistfor LB compared to placebo, we calculated aneffect size of changes in PVF ratios reported in a previousanalgesic efficacy study.40Pain intensity for the inducedsynovitis model used in that study was expected to peak at2–3 h after urate crystal injection.41At 3 h after urate crys-tal injection, PVF ratios were significantly differentbetween firocoxib and placebo groups40and the effect sizewas large (Cohen's d=1.4, effect size index for two-tailedt-test of means). Using that effect size, a priori power anal-ysis yields a sample size of 30 dogs (15 in each treatmentgroup), at a power (1- β) of .95 and significance ( α)o f. 0 5 .2.8 |Statistical analysisComparisons of treatment group variables including recentcarprofen use and frequencies of arthrotomy and meniscaldebridement were performed using a Chi-square test.Pain scores were compared between treatment groups pre-operatively and at 2, 4, 8, 12, 20, 24, 32, 40 and 48 h post-operatively with a nonparametric Mann –Whitney U-test.Treatment success for a patient was defined as not requiringany rescue analgesia within th e entire 48-h postoperativeperiod. The proportion of successes versus failures betweentreatment groups was compared with a Chi-square test. Acomparison between the number of required rescue opioiddoses relative to treatment group size was made using anonparametric Mann –Whitney U-test. Data describing %BWdistfor the operated hindlimb were determined to be nor-mally distributed ( p=.001) by use of the Anderson-Darlingtest. %BW distvalues were compared between treatmentgroups preoperatively and a t 4, 12, 24, and 48 h postopera-tively with a Student's t-test. Linear relationship betweenpain score and %BW distwas assessed using Pearson's correla-tion coefficient. Pain scores and %BW values were excludedfrom analysis after rescue analgesia as described. Statisticalsignificance was set at p<. 0 5f o ra l lt e s t s .3|RESULTSThirty-two dogs were enrolled into the study and all com-pleted the study. A total of 15 dogs were treated with LB724 ALDRICH ET AL . 1532950x, 2023, 5, and 17 with saline placebo. Carprofen was used in thepreoperative period in 11/33 (33%) dogs. Arthrotomy wasperformed in 23/33 (67%) dogs and meniscal debridementin 8/33 (24%) dogs. Frequencies of recent carprofen use(p=.39), arthrotomy ( p=.54), and meniscal debride-ment ( p=.31) (Table1) were not different betweentreatment groups.3.1 |Pain scoresMedian CMPS-SF pain scores at preoperative baselinewere 1 (range 1 –5) and 1 (range 1 –3) for the LB andsaline groups, respectively ( p=.82). Median pain scoresdid not differ between treatment groups at any postopera-tive time point (Table2).3.2 |Success/failure analysisOverall treatment success was not different between dogsthat received LB and those that received placebo (chi squarep=.27) (Table3). Two out of 15 dogs in the LB grouprequired rescue analgesia, both at 2 h postoperatively. Fiveout of 17 dogs in the placebo group required rescue analge-sia: four dogs at 2 h postoperatively, and one dog at 8 hpostoperatively.3.3 |Rescue opioid dosesThe number of rescue opioid doses did not differ betweenthe treatment groups, with the LB group receiving threetotal opioid doses and the placebo group receiving 10 totalopioid doses ( p=.41).3.4 |%BW dist%BW distdata was unable to be collected at three postop-erative time points for the 25 dogs that did not requirerescue analgesia. One dog was too sedated to stand at 4 hpostoperatively and two dogs repeatedly chose to sit orlay down upon reaching the weight distribution platformat 48 h postoperatively and could not be encouraged tostand. For the seven dogs that required rescue analgesia,concurrent and subsequent %BWdistvalues were excludedfrom statistical analyses. All remaining dogs were able toTABLE 1 Population frequencies for variable relevant to postoperative pain assessment in the LB and saline treatment groups.LB (n=15) Saline placebo ( n=17) Chi square p-valueRecent carprofen use (# of dogs) 4 7 .39Stifle arthrotomy performed (# of dogs) 10 13 .54Meniscal debridement performed (# of dogs) 5 3 .31Abbreviation: LB, liposomal bupivacaine.TABLE 2 Median (range) pain scores assigned by use of the CMPS-SF for dogs receiving LB ( n=15) or saline placebo ( n=17).LB (n=15) Saline placebo ( n=17)Time Pain score Number of dogs Pain score Number of dogs p-valuePreoperative baseline 1 (1 –5) 15 1 (1 –3) 17 .82Time after extubation (h)24 ( 1 –11) 15 3 (1 –11) 17 .7643 ( 2 –4) 13 3 (1 –5) 13 .7682 ( 1 –5) 13 2 (1 –12) 13 .4912 2 (1 –5) 13 2 (1 –4) 12 .3720 2 (1 –4) 13 1.5 (1 –4) 12 .9424 1 (1 –2) 13 1 (1 –3) 12 .4832 1 (1 –2) 13 1 (1 –3) 12 .9140 1 (1 –2) 13 1 (1 –2) 12 .9848 1 (1 –2) 13 1 (1 –2) 12 .79Note: For dogs requiring rescue analgesia, subsequent pain scores were excluded from statistical analyses.Abbreviations: CMPS-SF, Glasgow composite mean pain score, short form; LB, liposomal bupivacaine.ALDRICH ET AL . 725 1532950x, 2023, 5, have BW distribution data collected at all time points.Mean %BW distvalues for the operated hindlimb atpreoperative baseline did not differ between the LB(6.7 ± 4.0%) and placebo groups (7.5 ± 4.7%) ( p=.61) atany postoperative time point (Table 4).3.5 |Relationship between pain scoreand %BW distAnalysis of linear correlation between CMPS-SF painscores and %BW distpooled to include all study partici-pants did not demonstrate a statistically significant rela-tionship at any time point, with Pearson's rvalues of .11,.23, .02, /C0.24,/C0.19 at preoperative baseline, and 4, 12,24 and 48 h, respectively.3.6 |Adverse eventsAdverse postoperative events were observed in five dogsduring the study; three in the LB group and two in theplacebo group. Within the LB group, two dogs had inci-sional complications. One dog was noted to have bandagestrikethrough at 4, 8, and 20 h postoperatively thatresolved with placement of a soft padded compressionbandage. Another dog had focal serosanguineous dis-charge at 24 h postoperatively that resolved with place-ment of a single surgical staple to improve skinapposition. One dog in the LB group became mildly cageaggressive and less cooperative over time; however, wewere able to complete pain scoring and bodyweight dis-tribution measurements. Within the placebo group, onedog regurgitated at 42 h postoperatively and another dogwas noted to have soft but formed stools.3.7 |Post hoc sample size calculationThe size of the treatment effect observed for %BW distwassmaller than estimated before the study was initiated.Effect size (Cohen's d) for %BW distranged from 0.27 to0.75; at a power of 0.80 and significance ( α) of 0.05, atotal of 58 –436 dogs would have been needed to detectdifferences in %BW distbetween treatment groups.4

Question 79

Camarasa - 2023 - JSAP - Owner-assisted recovery and early discharge after surgical treatment in dogs with brachycephalic obstructive airway syndrome.pdf

Answer 79

Study design and inclusion criteriaThe electronic medical records (AT Veterinary Systems) at the first author’s institution were searched retrospectively to identify brachycephalic dogs who had elective surgery performed by a single European board- certified veterinary surgeon as treatment for BOAS between June 1, 2017, and May 31, 2019. Medical records were searched by a single author and searched terms included “BOAS,” “brachycephalic,” “staphylectomy,” “folded flap palatoplasty,” “tonsillectomy,” “cuneiformectomy,” “rhino -plasty,” “alaplasty” and “ala- vestibuloplasty.” Dogs with incom -plete medical records or those who had surgery performed by a different European board- certified surgeon or by a surgical resident were excluded from the study. Information collected included breed, gender, age, presenting clinical signs, upper air -way examination findings, stage of laryngeal collapse, surgical procedures performed, postoperative complications and hospi -talisation duration.The postoperative period was defined as the time from extuba -tion until 24 hours after surgery. Mild complications implied any adverse event treated medically or with minimal intervention. Major complications included those requiring general anaesthe -sia and endotracheal intubation, surgical intervention or death. During the postoperative period, the decision to induce anaes -thesia, for endotracheal reintubation or temporary tracheostomy tube placement was made after medical treatment for progressive dyspnoea was attempted and considered unsuccessful. The final population was divided into dogs that underwent standard recov -ery (from June 1, 2017, through May 31, 2018) and dogs that had owner- assisted recovery and same day discharge after BOAS surgery (from June 1, 2018, through May 31, 2019).BOAS assessmentThe severity of the presenting respiratory and gastrointestinal clinical signs was retrospectively graded according to the classifi -cation described by Poncet et al. (2005 ). Intermediate- stage cases were classified in the higher rank. Preoperative investigations included thoracic radiographs, endoscopic examination of the upper airways and laryngeal collapse staging as earlier proposed (Leonard 1960 ). Radiographs were reviewed before surgery and the surgical procedure was postponed if signs of pneumonia were observed. 17485827, 2023, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13647 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 LicenseJ. J. Camarasa et al.Journal of Small Animal Practice • Vol 64 • November 2023 • © 2023 British Small Animal Veterinary Association. 682Surgical procedureAll dogs were anaesthetised and monitored under the direct supervision of a residency trained or board- certified anaesthesi -ologist. All dogs were premedicated with a combination of a full opioid agonist and either acepromazine, midazolam or alpha- 2 agonist drug (medetomidine or dexmedetomidine) based on the anaesthetist’s judgement. Anti- emetics [maropitant 1 mg/kg intravenous (iv) or metoclopramide 0.5 mg/kg iv], proton- pump inhibitors (omeprazole 1 mg/kg iv) and broad- spectrum antibiotics (cefazolin 22 mg/kg iv) were used prior induction. Anaesthesia was induced with either propofol (2 to 4 mg/kg iv) or alfaxalone (1 to 2 mg/kg iv) and maintained with isoflurane in 100% oxygen. Decisions regarding other medications admin -istered perioperatively were clinician dependent and included steroidal (dexamethasone 0.1 mg/kg iv) and nonsteroidal anti- inflammatory drugs (meloxicam 0.2 mg/kg iv). Surgical treat -ment was elected based on individual abnormalities after clinical evaluation by a single European board- certified surgeon. Staphy -lectomy or folded flap palatoplasty was performed for shortening and thinning the soft palate. The palatine mucosa was sutured with polyglactin 910 in a simple interrupted or continuous pat -tern. Tonsillectomy was performed with monopolar electrocau -tery if the tonsils were protruded and obstructive. Laryngeal sacculectomy was accomplished at the end of the procedure by amputation at the base of the everted saccule using Metzenbaum scissors after temporary extubation. Stenotic nares were corrected by rhinoplasty either using wedge resection alaplasty technique or T rader’s alaplasty with vestibuloplasty (T rader 1949 , Huck et al. 2008 ). Xylometazoline hydrochloride was sprayed in the nares immediately before beginning the procedure to prevent nasal haemorrhage due to its local vasoconstrictor effect (Jackson & Birnbaum 1981 ). Following the completion of surgery, dogs were placed in sternal recumbency and the endotracheal tube remained in place for as long as tolerated by the dog whilst being supplemented with oxygen and monitored before being trans -ferred to an intensive care unit (ICU).Standard recoveryDogs included in this group were recovered at the ICU after extubation and they remained hospitalised for a minimum of 24 hours to allow close patient monitoring and early interven -tion if respiratory distress or other complications occurred. ICU team members were advised to consider oxygen supplementa -tion via an oxygen mask or high- flow nasal cannula and sedation of the patient if necessary. Equipment including a laryngoscope, endotracheal tube of the same and a smaller size used during anaesthesia and drugs to re- anaesthetise the patient were avail -able for emergency reintubation. Intravenous (iv) omeprazole (1 mg/kg every 12 hours) and either maropitant (1 mg/kg every 24 hours) or metoclopramide (0.5 mg/kg every 8 hours or 1 mg/kg/day iv continuous rate infusion) were continued during hos -pitalisation. After discharge, some dogs received a course of oral meloxicam (0.1 mg/kg every 24 hours) or prednisolone (0.5 mg/kg every 24 hours) for 7 to 14 days. Nutrition was provided when the dogs were fully recovered without any evidence of complications.Owner- assisted recoveryDogs included in this group were recovered in a separate quiet ICU room after extubation. An ICU team member was present in the room the entire time and the owner of the dog stayed in the kennel with the animal. ICU team members were prepared for additional interventions if required. Dogs were allowed to ambulate in the room once they were fully recovered, and water and a small amount of soft food was offered by the owner under ICU nurse or clinician supervision. The animal’s vital parameters were regularly monitored and the dogs were discharged a few hours after the surgery following clinician assessment. Dogs were discharged if they were ambulatory and demonstrated a normal respiratory rate, pattern and respiratory noise. All owners were instructed to keep the dogs in a calm environment and moni -tor for any signs of respiratory distress and contact the closest veterinary practice or the author’s institution in case of concern. The owners were contacted by telephone 24 hours after the pro -cedure and possible complications were recorded. Medications after discharge included a combination of omeprazole (1 mg/kg orally every 12 hours) and metoclopramide (0.5 mg/kg orally every 8 hours) or maropitant (2 mg/kg orally every 24 hours) for a period between 14 and 28 days. Some dogs received a course of meloxicam (0.1 mg/kg orally every 24 hours) or prednisolone (0.5 mg/kg orally every 24 hours) for 7 to 14 days.Statistical analysisData were analysed in SPSS Statistics Version 25.0 (IBM, Armonk, New York). Continuous data were assessed for normal -ity by using a Kolgomorov– Smirnov test. Shapiro– Wilk test was used for analyses of distribution in the individual groups. Non -parametric data of the two groups were compared with U- Mann Whitney. Differences between the two groups were compared using the chi- squared test of independence or Fisher’s exact test for categorical variables. Summary statistics for parametric data are presented as mean and standard deviation (sd), and for non -parametric data are presented as median and range. Values of P<0.05 were considered significant.Legal and ethical requirements with regards to the humane treatment of animals described in the study and data protec -tion have been met according to the RCVS and Pride Veterinary Referrals ethical guidelines.RESULTSA total of 105 dogs were referred for treatment of BOAS dur -ing the study period, of which 63 met the inclusion criteria previously described for the study; 21 dogs underwent standard recovery and 42 dogs underwent owner- assisted recovery. Breed, age and gender distribution is presented in Table 1. No statisti -cal difference was found between groups in mean age (P=0.28), proportion of breeds (P=0.83) and gender distribution (P=0.21). Severity of respiratory and gastrointestinal clinical sings and stage of laryngeal collapse in both groups are summarised in Table 2. There was no difference between the groups in severity of respi -ratory (P=0.37) or gastrointestinal clinical signs (P=0.49). The 17485827, 2023, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13647 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 LicenseOwner- assisted recovery after BOAS surgeryJournal of Small Animal Practice • Vol 64 • November 2023 • © 2023 British Small Animal Veterinary Association. 683 percentage of dogs with laryngeal collapse grade III was higher in dogs that underwent standard recovery (14% versus 0%. P=0.02) Surgical techniques performed in different groups are shown in Table 3. No significant difference was encountered between the groups in surgical techniques employed (palatoplasty P=1.0; ton -sillectomy P=0.27; rhinoplasty P=1.0; laryngeal sacculectomy P=1.0; cuneiformectomy P=1.0).The overall complication rate was higher in dogs that under -went standard recovery compared to dogs that received owner- assisted recovery (28% versus 2%; P=0.004). Three dogs (14%) that underwent standard recovery experienced minor com -plications consistent with respiratory dyspnoea that success -fully responded to sedation treatment with acepromazine bolus (0.005 mg/kg iv) and oxygen therapy supplementation without any further intervention. In addition to this, three other dogs (14%) experienced major complications. These included a 48- month female Pug with grade III laryngeal collapse who had cuneiformectomy in addition to the soft palate procedure and rhinoplasty. This animal was anaesthetised and a temporary tracheostomy tube was placed due to severe laryngeal oedema. T racheostomy tube removal was attempted unsuccessfully several times and due to the poor prognosis and the costs associated with a permanent tracheostomy, the dog was finally euthanased. The two other severe complications occurred in a 22- month French Bulldog and in a 70- month- old female English Bulldog with laryngeal collapse stage I and II respectively and grade III gas -trointestinal sings prior surgery. These two dogs had laryngeal sacculectomy performed in addition to the palatoplasty and rhi -noplasty. Both dogs developed severe respiratory distress postop -eratively that required placement of a temporary tracheostomy under general anaesthesia and were discharged from the hospital 3 and 6 days post- intervention, respectively.Only one dog that underwent owner- assisted recovery pre -sented a major complication on the postoperative period but this did not affect the final outcome. This dog was a 40- month male Staffordshire Bull terrier that was re- anaesthetised immediately after extubation because of a mild haemorrhage from the folded flap palatoplasty site. After intervention to control the haemor -rhage, the dog made an uneventful recovery with the owner and was discharged the same day. No other major or minor compli -cations, including the need for sedation, were reported in dogs recovered with the owners during the time of hospitalisation and no complications requiring veterinary intervention were reported by the owners during telephonic conversation 24 hours after the procedure.

Question 80

Miller - 2024 - VETSURG - Complications and outcome following staphylectomy and folded flap palatoplasty in dogs with brachycephalic obstructive airway syndrome.pdf

Answer 80

2.1 |Selection and data collectionA medical record database review for surgical cases ofS and FFP between July 2012 and December 2019 wasperformed. Dogs were included in the study if theyunderwent surgical treatment for their elongated softpalate at the University of Florida Small Animal Veteri-nary Hospital and had either a S or FFP performed.Dogs were excluded from the study if they had incom-plete medical records, laryngeal paralysis, additionalairway surgery unrelated to BOAS (i.e., cleft palate sur-gery), and/or an endoscopically performed soft palatesurgery.Medical records were retrospectively reviewed. Thedata collected and analyzed were categorized into pre-,intra-, postoperative, and fo llow-up categories. Preop-erative data collected incl uded signalment, clinicalsigns (regurgitation, vomiting ,s t e r t o r ,e x e r c i s ei n t o l e r -ance, and collapse), diagn ostic imaging (computedtomography [CT] and/or thoracic radiographs), pres-ence of specific preoperative imaging findings (aspira-tion pneumonia, hiatal hernia, and hypoplastictrachea), airway examination findings (elongated softpalate, everted tonsils, laryn geal collapse, and stenoticnares), and administration of maropitant. Clinicalsigns were reported as a resu lt of client co mmunicationand clinician interpretation. Airway examination wasperformed using subjective visual assessment; how-ever, soft palate thickness was not measured. An elon-gated soft palate was defined as extension caudal to thetip of the epiglottis or caudal to the tonsils. Grades oflaryngeal collapse were defined: Grade 1 with sacculeeversion, grade 2 with saccule eversion and arytenoidcartilage cuneiform process collapse, and grade 3 witharytenoid cartilage corniculate process collapse.Intraoperative data collected included date of sur-gery, surgeon, concurrent BOAS surgical procedures(nares surgery, sacculec tomy, and tonsillectomy),30 MILLER ET AL . 1532950x, 2024, 1, operative time, anesthetic time, other non-BOAS sur-gical procedures, and anest hetic complications (hypo-ventilation, hypoxemia, hyp ercapnia, hypothermia,and hypotension). Hypovent ilation was minute venti-lation <100 mL/kg/min or elevated arterial partialpressure of carbon dioxide (PaCO2) >50 mm of mer-cury (mmHg); Hypoxemia was <90% oxygen satura-tion as measured by pulse o ximetry; Hypercapnia wasPaCO2 or end-tidal carbon dioxide >55 mmHg; Hypo-thermia was <96 degrees Fahrenheit; Hypotensionwas <80 mmHg (systolic) or <60 mmHg (mean arte-rial pressure).Postoperative data collect ed included whether oxygenwas administered and for how long (hours), length ofpostoperative hospitalizatio n (days), medications used in-hospital and for discharge (anti-inflammatories, prokinetics,antiemetics, and GI protect ants), and incidence of re-gurgitation and aspiration pneu monia. Anti-inflammatoriesincluded steroids or non-steroidal anti-inflammatory drugs,prokinetics included metoclopr amide and/or cisapride, anti-emetics included maropitan t and/or ondansetron, and GIprotectants included famotidin e, pantoprazole, omeprazole,lansoprazole, and/or sucralfat e. Postoperative treatmentswere selected based on surgeon and/or anesthesiologist fac-ulty discretion if deemed necessary or in the best interest ofthe dog. Follow-up data includ ed persistence of a hiatal her-nia on postoperative imaging, whether an upper airwayrevision surgery was needed (staphylectomy, folded flappalatoplasty, alarplasty, and/ or sacculectomy), time to revi-sion surgery, and time to first follow-up and last knowndate of contact with associated c linical signs (regurgitation,vomiting, stertor, exercise i ntolerance, and collapse).Staphylectomies were performed using a traditionalcut-and-sew technique using long-handled Metzenbaumscissors and monofilament absorbable suture in a contin-uous pattern without the use of a vessel-sealing device,electrocautery, or laser. FFPs were performed asdescribed by Findji and Dupre (2008).8Complicationswere considered minor when dogs did not require addi-tional surgical treatment and/or did not lead to deathwithin 2 weeks of the surgery. Complications were con-sidered major when additional surgical treatment wasrequired and/or death occurred within 2 weeks of thesurgery.2.2 |Statistical analysisDescriptive statistics (median, interquartile range[IQR], and frequency) for non-parametric data wereused to report the character istics of dogs undergoingeither a S or FFP. Available information varied by casea n ds a m p l es i z ew a sa d j u s t e dt or e f l e c tt h en u m b e ro fdogs with available data for each category. For eachcategorical variable per surgery type, counts and per-centages were calculated using Excel Pivot Tables. Foreach continuous variable per surgery type, count,median, and IQR were calculated by Excel PivotTables and JMP Pro 16.TABLE 2 Preoperative clinical signs among dogs undergoing Sand FFP.S(N/64) FFP (N/60)Total(N/124)Clinical signsRegurgitation 3 4 7Vomiting 3 9 12Stertor 12 10 22Exercise intolerance 13 21 34Collapse 0 3 3Abbreviations: FFP, folded flap palatoplasty; S, staphylectomy.TABLE 1 Characteristics of 124 cases of dogs undergoingeither a S or FFP.S FFP TotalTotal surgeries64 60 124Reproductive statusFI=14;FS=17;MI=17;MC=16FI=11;FS=13;MI=15;MC=21124BreedFrench Bulldog 25 29 54English Bulldog 15 19 34Pug 11 5 16Boston Terrier 5 4 9Bulldog 2 0 2Boxer 1 0 1Affenpinscher 1 0 1Pekingese 1 0 1Pitbull 1 0 1Pomeranian 1 0 1Shih Tzu 1 0 1Cavalier King CharlesSpaniel01 1Dogue de Bordeaux 0 1 1French Bulldog/BostonTerrier mix01 1Abbreviations: FFP, folded flap palatoplasty; FI, female intact; FS, femalespayed; MC, male castrated; MI, male intact; S, staphylectomy.MILLER ET AL . 31 1532950x, 2024, 1, To test for association between procedure and cate-gorical outcome, Pearson's chi-square test was used. Inthe case where one of the variables was continuous, theWilcoxon non-parametric test was used to test for differ-ences between procedures. Values of p< .05 were consid-ered statistically significant.3|RESULTS3.1 |PreoperativeThe records of 128 dogs were reviewed, and four wereexcluded due to an endoscopic FFP (1), left lateralizingcleft soft palate surgery (1), laryngeal paralysis (1), andan incomplete medical record (1). Case characteristicinformation with sex and breed distribution betweenboth soft palate surgeries (S and FFP) are summarizedin Table1. For the three most common breeds in thisstudy, Pugs most often underwent a S (11/16; 68.75%),whereas French Bulldogs (S, 25/54, 46.3%; FFP, 29/54,53.7%) and English bulldogs (S, 15/34, 44.12%; FFP,19/34, 55.88%) were more evenly distributed betweensoft palate surgeries. Among preoperative clinical signsfor dogs undergoing surgical correction for an elongatedTABLE 3 Specific preoperative imaging findings from CT,thoracic radiographs, and the combination of CT and thoracicradiographs of dogs undergoing S and FFP.S(N/47)FFP(N/53)Total(N/100)Imaging findingsAspiration pneumonia 2 2 4Hiatal hernia 4 10 14Hypoplastic trachea 5 7 12Abbreviations: CT, computed tomography; FFP, folded flap palatoplasty; S,staphylectomy.TABLE 4 Upper airway examination findings of dogsundergoing S and FFP.S (N/62) FFP (N/58) Total (N/120)Upper airway examination findingsElongated soft palate 62 58 120Everted tonsils 6 1 7Stenotic nares 51 55 106Laryngeal collapse 34 51 85Grade 1 19 41 60Grade 2 11 10 21Grade 3 4 0 4Note: Four dogs did not have documented airway examination findings.Abbreviations: FFP, folded flap palatoplasty; S, staphylectomy.FIGURE 1 Distribution of soft palate surgery type (S and FFP)per year. FFP, folded flap palatoplasty; S, staphylectomy.TABLE 5 Distribution between different nares procedures ofdogs undergoing S and FFP.Nares procedure typeS(N/64)FFP(N/60)Total(N/124)No nares procedure 13 5 18Vertical wedge resection 36 26 62Lateral wedge resection 2 1 3Alarplasty 1 3 4Caudal wedge resection 2 23 25Circular incision with punchbiopsy of alar fold101Vertical wedge resection (R) andcaudal alarplasty (L)011Unknown nares procedure 8 1 9Unilateral procedure 1 0 1Abbreviations: FFP, folded flap palatoplasty; L, left; R, right; S,staphylectomy.TABLE 6 Median and IQR (min) of operative and anesthetictimes of dogs undergoing S and FFP.Time (N) S FFPOperative timewithout concurrentnon-airway procedure(p=.02, 63/120; S =31,FFP=32)Median =51;IQR=34–85Median =75;IQR=56.25 –94.5Anesthetic timewithout concurrentnon-airway procedure(p=.02, 63/120;S=31, FFP =32)Median =80;IQR=66–125Median =111;IQR=91–140.8Abbreviations: FFP, folded flap palatoplasty; IQR, interquartile range; S,staphylectomy.32 MILLER ET AL . 1532950x, 2024, 1, soft palate, exercise intolerance and inspiratory stertorwere the most common (Table 2).A majority of dogs received preoperative imaging(n=100) in the form of thoracic radiographs alone(92), CT alone (1), both CT and thoracic radiographs(2), or other forms of imaging (5). Among specificimaging findings for both soft palate surgeries, hiatalhernias were more common in dogs undergoing FFP(Table3).Among airway examination ( n=120) findings(Table 4), stenotic nares and varying grades of laryn-geal collapse were common c oncurrent findings indogs with elongated soft palates, whereas everted ton-sils were rarely noted. Laryngeal collapse was com-monly absent in dogs undergoing S (S, 28/35, 80%; FFP7/35, 20%), whereas grade 1 laryngeal collapse wascommonly identified in do gs undergoing FFP (S, 19/60,31.67%; FFP, 41/60, 68.33%).3.2 |IntraoperativeTotal numbers of soft palate surgeries increased acrossthe timeframe of records reviewed (2012 –2019), withmore S occurring between 2012 and 2015, more FFPbetween 2016 and 2017, and a more even distributionbetween soft palate surgeries with slightly more staphy-lectomies performed between 2018 and 2019 (Figure1).Of 16 surgeons who performed soft palate surgeries, threesurgeons performed more FFPs (Surgeon A: S, 5, FFP 30;Surgeon B: S, 3, FFP 14; Surgeon C: S, 2, FFP, 4), twosurgeons performed more S (Surgeon D: S, 18, FFP, 8;Surgeon E: S, 23, FFP, 1), and 11 of the remaining sur-geons each performed three or less soft palate surgeries.Dogs undergoing a nares procedure (106/124, 85.48%)were categorized by procedure type, with vertical andcaudal wedge resections most commonly performed(Table5). Dogs undergoing a concurrent laryngeal saccu-lectomy more frequently underwent FFP (47/74; 63.51%).The two dogs undergoing tonsillectomy underwent FFP.Of soft palate surgeries without concurrent non-airwayprocedures, total operative ( p=.02) and anesthetic(p=.02) times were longer for FFP than S (Table6).The occurrence of anesthetic complications ( p=.30;99/120) was not different for dogs undergoing either softpalate procedure (Table7). No intraoperative surgicalcomplications were noted.3.3 |PostoperativeOf 124 dogs, 64 received postoperative oxygen support.Postoperative oxygen use was similar among soft palatesurgery types; however, dogs undergoing S had a slightlylonger median duration of oxygen use (Table8). Mediandays of hospitalization did not differ ( p=.94) betweensoft palate procedures (Table 8).TABLE 7 Anesthetic complications in dogs undergoing S andFFP. For some dogs, multiple anesthetic complications wererecorded.S(N/62)FFP(N/58)Total(N/120)Anestheticcomplications p=.3049 50 99Hypoventilation 1 4 5Hypoxemia 0 1 1Hypercapnia 11 11 22Hypothermia 20 20 40Hypotension 25 19 44Abbreviations: FFP, folded flap palatoplasty; S, staphylectomy.TABLE 8 Presence of postoperative oxygen support, hospitalization, regurgitation, and aspiration pneumonia in dogs undergoing Sand FFP.S FFPPostoperative oxygen (h) S: n=30; FFP: n=34 Median =19; IQR =7.5–22.5 Median =11.5; IQR =4–21Hospitalization (days) Median =1; IQR =1–1 Median =1; IQR =1–1p=.94, S: n=64; FFP: n=60Presence of postoperative regurgitation 17 10p=.18,n=27/124Episodes of regurgitation Median =2; IQR =1–3 Median =2; IQR =1–3.25S:n=17; FFP: n=10Postoperative aspiration pneumonia n=9/124 4 5Abbreviations: FFP, folded flap palatoplasty; IQR, interquartile range; S, staphylectomy.MILLER ET AL . 33 1532950x, 2024, 1, TABLE 9 Medications prescribedfor use in-hospital and for discharge fordogs undergoing S and FFP.S (N/64) FFP (N/60) Total (N/124)MedicationsAnti-inflammatoriesAdministered in-hospital 32 27 59Prescribed for discharge 27 12 39ProkineticsAdministered in-hospital 20 27 47Prescribed for discharge 4 5 9AntiemeticsAdministered in-hospital 19 40 59Prescribed for discharge 2 4 6GI protectantsAdministered in-hospital 27 44 71Prescribed for discharge 18 31 49Abbreviations: FFP, folded flap palatoplasty; GI, gastrointestinal; S, staphylectomy.TABLE 10 Distribution of revisionsurgeries (S, FFP, nares, andsacculectomy) among dogs that initiallyunderwent a S or FFP.Initial S (N/64) Initial FFP (N/60) Total (N/124)Revision soft palate surgery 3 4 7Revision S 1 2 3Revision FFP 2 2 4Revision nares 2 2 4Revision sacculectomy 0 1 1Abbreviations: FFP, folded flap palatoplasty; S, staphylectomy.TABLE 11 Timing and clinical signs noted between discharge and first follow-up and discharge and last known date of contact for bothsoft palate procedures (S and FFP).S (N/64) FFP (N/60) Total (N/124)Time of discharge to first follow-up (74/124; S: n=37; FFP: n=37)Number of days Median =12; IQR =9.5–20 Median =14; IQR =12–113 74Regurgitation 5 3 8Vomiting 3 3 6Stertor 2 3 5Exercise intolerance 0 2 2Collapse 0 0 0Time of discharge to last known date of contact (74/124; S: n=37; FFP n=37)Number of days Median =124; IQR =14–548.5 Median =314; IQR =41–737.5 74Regurgitation 1 3 4Vomiting 0 0 0Stertor 3 2 5Exercise intolerance 0 0 0Collapse 0 0 0Abbreviations: FFP, folded flap palatoplasty; IQR, interquartile range; S, staphylectomy.34 MILLER ET AL . 1532950x, 2024, 1, Minor complications, including postoperative regurgi-tation and aspiration pneumonia, were reported in36/124 (29.03%) of dogs undergoing soft palate surgery.The occurrence of postoperative regurgitation was notdifferent ( p=.18) between soft palate procedures(Table8). The presence of postoperative aspiration pneu-monia was rare, but similar for both soft palate surgeries(Table 8).Major complications occurred in 5/124 (4.03%) dogswith a relatively even distribution among soft palate sur-gery types: Two dogs (S, 1; FFP, 1) were euthanizedwithin 2 weeks of surgery, one dog underwent a tracheos-tomy postoperatively (S, 1), and two dogs (S, 1; FFP, 1)underwent a tracheostomy postoperatively and wereeuthanized within 2 weeks. All euthanasia was due tocontinued severe airway disease. Tracheostomy was per-formed in dogs who could not be extubated or secondaryto severe respiratory effort and/or tachypnea.Variations in medications for in-hospital and dis-charge were reported for both soft palate surgery types(Table9).3.4 |Follow-upThree FFP dogs had postoperative hiatal hernias on post-operative imaging and zero S dogs had postoperative hia-tal hernias. Small numbers of dogs received a revisionsoft palate surgery or other revision upper airway surgerypostoperatively (Table10). Initial S dogs ( n=3) thatreceived a soft palate revision surgery had the surgery8, 1008, and 2522 days later and initial FFP dogs thatreceived a soft palate revision surgery ( n=4) had thesurgery 4, 231, 526, and 700 days later.Variations in time from discharge to first follow-up,discharge to last known date of contact, and prevalenceof continued regurgitation, vomiting, stertor, exerciseintolerance, and/or collapse were reported for both softpalate procedures (Table11).4

Question 81

Davini - 2024 - JSAP - Radiographic and MRI findings of a complex cervical vertebral malformation in a French bulldog.pdf

Answer 81

NA

Question 82

Menard - 2023 - JAVMA - Assessing major influences on decision-making and outcome for dogs presenting emergently with nontraumatic hemoabdomen.pdf

Answer 82

Study design and initial case identification criteriaA retrospective cohort study design was utilized for identification and evaluation of patients with nontraumatic, spontaneous hemoabdomen (NTH). Medical records of dogs that presented with NTH be -tween January 2015 and May 2022 at the Cornell Uni -versity Hospital for Animals, predominantly through the Emergency Service, were preliminarily reviewed. NTH was defined by presence of hemorrhagic peri -toneal effusion, confirmed by abdominocentesis and clinicopathologic fluid analysis. Cases were excluded if hemoperitoneum was secondary to trauma, iatro -genic causes (eg, recent surgery), coagulopathy, gas -tric dilatation-volvulus, liver lobe torsion, or splenic torsion due to a more rapidly elucidated etiology and predictable prognosis without the need for histopa -thology. Patients were included irrespective of case outcome (eg, immediate euthanasia, palliative care, surgery). Client and patient name as well as client email addresses were recorded for dogs meeting the initial inclusion criteria. Cases without a client email address on file were excluded.SurveyAn owner survey was created based on the study objectives to obtain appropriate patient follow-up and outcome. The survey was adapted from previ -ous veterinary investigations of QOL and included multiple-choice, yes-or-no, and open-ended ques -tions.12,14,15 The survey was hosted on Qualtrics, with inherent logic present allowing for a unique user experience. The study design and survey were sub -mitted to the Institutional Review Board for Human Participants, and the protocol was granted exemp -tion (protocol #IRB0145507). The complete survey (Supplementary Appendix S1) was distributed via email on July 29, 2022, and was open for 2 months following initial dissemination. Survey response was incentivized by entry into a raffle drawing. Dogs whose owners completed the survey met inclusion criteria for further clinical record review. Dogs whose owners either partially completed the survey or did not respond were excluded.Clinical records reviewA complete medical record review was per -formed for all dogs whose owners responded to the survey. Additional cases were excluded if upon deeper review previous inclusion criteria were not met. Treatment decision outcome was classified into the following categories: (1) no surgical interven -tion—natural death or humane euthanasia during initial visit or within 24 hours of discharge; (2) no surgical intervention—alive at discharge with pal -liative care elected; (3) surgical intervention—eu -thanized or died during procedure or during initial hospitalization; and (4) surgical intervention—alive at discharge.Data obtained from medical records included signalment, body weight (kg), body condition score, heart rate (tachycardia > 140 beats/min), mean arte -rial pressure, and relevant lab work (PCV, total sol -ids, platelet count, hematocrit, lactate) from initial presentation. Additional data collected consisted of admitting clinician experience (intern, resident, or faculty), thoracic focused assessment with sonogra -phy for trauma (normal or abnormal [free fluid, B-lines, absent glide sign]), thoracic radiographs (yes [nor -mal or metastatic lung pattern] or no), blood trans -fusion (yes or no), advanced abdominal imaging (ultrasound, CT, or both), surgical information (time to surgery and surgical outcome), days hospitalized, and cost and outcome of initial hospital visit.Further data obtained included reported sources of hemorrhage based on imaging and surgery, me -tastasis based on imaging and surgery, histopathol -ogy results if available, medications or supplements given following discharge (including aminocaproic acid, Yunnan Baiyao, Coriolus versicolor polysac -charopeptide [I’m-Yunity], and chemotherapy), and overall survival time. Overall survival time was defined in days from initial presentation to death. Death was verified through the medical record, owner survey response, or both. If diagnosis of hem -angiosarcoma was confirmed with histopathology, mitotic score and clinical stage were noted. Clinical Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 06/30/23 12:11 AM UTC982 JAVMA | JULY 2023 | VOL 261 | NO. 7stage was assigned based on the modified World Health Organization scheme.16 Stage I was heman -giosarcoma confined to spleen, stage II was ruptured splenic hemangiosarcoma, and stage III was clinical -ly detectable distant metastases or concurrent right atrial mass.16Statistical analysisContinuous data were assessed for normality with the Shapiro-Wilk test. Categorical data were reported as frequency (%). Normally distributed continuous data were reported as mean ± SE, and nonnormally distributed continuous data were re -ported as median and IQR. Categorical comparisons were performed utilizing a χ2 test or a Fisher exact test when cell value was ≤ 5. Comparisons between nonparametric continuous data and dichotomous variables were performed using the rank sum test. Comparisons between nonparametric continuous data and polychotomous variables were performed using the Kruskal-Wallis test. Odds ratios and 95% CI are reported where warranted. The equality of me -dians with regard to owner-reported influences on decision-making was tested using a Wilcoxon signed rank test. QOL scores were compared between pal -liative and surgery utilizing the rank sum test.Univariable Cox regression estimates were per -formed to evaluate survival time from treatment decision for all factors. Kaplan-Meier survival curves were generated for all patients and for patients un -dergoing surgery versus palliative care. Hazard ra -tios with 95% CIs and P values were reported. Pa -tients that were alive at the end of study period or known to have died from a cause unrelated to the hemoabdomen were right censored. Values of P < 0.05 were considered significant. All statistical cal -culations were performed with commercial software (Stata version 15.1; StataCorp LLC).ResultsDemographicsMedical record query revealed 710 records with a diagnosis of hemoabdomen at the Cornell University Hospital for Animals January 2015 to May 2022. Of these dogs, 503 were identified to have NTH on pre -liminary review. Email addresses were available for 436 dogs. The survey was distributed to this group, with 22 undeliverable emails. This resulted in distri -bution of 414 unique surveys. Surveys were started by 165 owners and 156 were fully completed, for a completion rate of 94.5% and overall response rate of 37.7%. Median time to complete the survey was 411 seconds (range, 312 to 758 seconds). Complete record review was performed after survey responses, resulting in exclusion of 24 cases not meeting inclu -sion criteria. A total of 132 unique responses were evaluated, for an overall survey yield of 31.9%.The most common purebred dogs represented were Golden Retriever (13/132 [9.9%]), Labrador Retriever (12/132 [9.1%]), and German Shepherd Dog (10/132 [7.6%]). Most dogs were mixed breed (45/132 [34.1%]). Median age at presentation was 10.2 years (n = 132; range, 9.0 to 11.6 years). Mean weight was 28.8 ± 1.05 kg (n = 125). Of the 132 dogs, 57 (43.2%) were male and 75 (56.8%) were female. One (1.3%) female was intact and 4 (7.0%) males were intact, while the remaining 127 (96%) dogs were spayed or neutered. Average body condition score was 5.5 ± 0.12 out of 9 (n = 77).Preoperative evaluationOn presentation, the patient was evaluated pri -marily by an intern in 64 of 132 (48.5%) cases or by a resident or faculty member in 68 of 132 (51.5%) cases. Mean presenting heart rate was 144.2 ± 2.6 beats/min (n = 128). Dogs were classified as tachycardic in 74 of 128 (57.8%) cases. Mean PCV was 32.3 ± 0.8% (n = 119). Mean total solids were 6.3 ± 0.09 g/dL (n = 118). Median platelet count was 134,200/µL (n = 43; range, 61,000 to 189,000). Average mean arterial pressure was 95.8 ± 4.0 mm Hg (n = 54). Mean serum lactate concentration was 5.0 mmol/L (n = 104; range, 2.5 to 7.6 mmol/L). A total of 41 of 132 (31.1%) patients un -derwent a packed RBC transfusion. Out of the 41 pa -tients that received a packed RBC blood transfusion, 26 (63.4%) underwent surgery, 5 (12.2%) received pal -liative care, and 10 (24.4%) were euthanized. A total of 26 of 40 (65%) dogs that underwent surgery received a blood transfusion, 5 of 22 (22.7%) dogs that under -went palliative care received a blood transfusion, and 10 of 70 (14.3%) dogs that were euthanized within 24 hours received a blood transfusion.Thoracic focused assessment with sonography for trauma was performed in 69 of 132 (52.3%) dogs, with abnormalities identified in 14 of 69 (20.3%) pa -tients. Abnormalities included pleural effusion in 6 of 14 (46.2%) patients and B-lines in 8 of 14 (61.5%) pa -tients. One patient was noted to have possible pericar -dial effusion. Thoracic radiographs were performed in 63 of 132 (47.7%) patients. Of these 63 patients, 44 (69.8%) had no significant findings, 7 (11.1%) had evi -dence of metastasis, and 7 (11.1%) had other pulmo -nary findings not suspected to be metastasis.Abdominal imaging was performed in 64 of 132 (48.5%) dogs, including abdominal ultrasound in 57 of 64 (89.1%) dogs and CT in 5 of 64 (7.8%) dogs, with 2 dogs undergoing both ultrasound and CT. The source of hemorrhage based on imaging was suspected to be spleen in 42 of 64 (65.6%) cases, liver in 19 of 64 (29.7%) cases, retroperitoneal in 1 of 64 (1.6%) cases, adrenal in 1 of 64 (0.8%) cases, and unknown/undeter -mined in 5 of 64 (3.8%) cases. Metastasis was strongly suspected on abdominal imaging in 23 of 64 (35.9%) dogs, potentially suspected in 20 of 64 (31.3%) dogs, and not identified in 21 of 64 (32.8%) dogs.When presumptive metastasis was identified during staging, 18 of 44 (40.9%) patients under -went surgery, 12 of 44 (27.3%) patients underwent palliative care, and 14 of 44 (31.8%) patients were euthanized within 24 hours. When confident metas -tasis was identified during staging, 6 of 25 (21.7%) patients underwent surgery, 6 of 25 (26.1%) patients received palliative care, and 13 of 25 (52.2%) patients were euthanized within 24 hours.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 06/30/23 12:11 AM UTC JAVMA | JULY 2023 | VOL 261 | NO. 7 983OutcomesA total of 70 of 132 (53.0%) dogs either died or were euthanized within 24 hours of presentation, 22 of 132 (16.7%) dogs were discharged for palliative care and survived > 24 hours, and 40 of 132 (30.3%) dogs underwent surgery. Of 40 dogs that underwent surgery, 4 (10%) either were euthanized or died while in the hospital perioperatively. Two dogs were eutha -nized intraoperatively, 1 dog was euthanized postop -eratively, and 1 dog died postoperatively. Median time from hospital admission until surgery was 16 hours (n = 39; range, 8 to 24 hours). Median time of hospital -ization for patients undergoing surgery was 3 days (n = 40; range, 2 to 3 days), which was longer than the median hospitalization time for patients receiving pal -liative care (n = 22; range, 0 to 1 days; P < .001).Intraoperatively, the primary source of hemor -rhage was identified as the spleen in 37 of 40 (92.5%) cases, liver in 2 of 40 (5%) cases, and kidney in 1 of 40 (2.5%) cases. When compared with surgery, lo -cation of hemorrhage on preoperative imaging was classified correctly in 97.22% of cases. Intraopera -tive metastasis was confidently identified in 11 of 40 (27.5%) patients, presumptive based on appearance in 4 of 40 (10%) patients, and not identified in 25 of 40 (62.5%) patients.Histopathology was available for 41 cases (40 surgical biopsies, 1 postmortem biopsy), of which 31 (75.6%) were considered malignant disease. Malig -nant diseases were categorized as hemangiosarco -ma in 26 of 41 (83.9%) cases, splenic leiomyosarco -ma in 2 of 41 (4.9%) cases, hepatocellular carcinoma in 1 of 41 (2.4%) cases, splenic fibrohistiocytic nodule in 1 of 41 (2.4%) cases, and splenic liposarcoma in 1 of 41 (2.4%) cases. Hemangiosarcoma was local -ized to spleen in 24 of 26 (92%) cases, liver in 1 of 26 (4%) cases, and kidney in 1 of 26 (4%) cases. Median mitotic count in 10 hpf was 11 (n = 29; range, 5 to 21). For patients with hemangiosarcoma, 10 of 24 (41.7%) patients were assigned a mitotic score of 0, 6 of 24 (25.0%) a score of 1, 4 of 24 (16.7%) a score of 2, and 4 of 24 (16.7%) a score of 3. Clinical stage was recorded in all 26 dogs, with 16 of 26 (61.5%) dogs having stage 2 and 10 of 26 (38.5%) dogs having stage 3 hemangiosarcoma. Patients were classified as having benign disease in 10 of 41 (24.4%) cases, with all cases diagnosed with splenic hematoma as the NTH cause. Seven of 10 (70%) cases had concur -rent nodular hyperplasia.Dogs were administered additional hemostatic or antifibrinolytic medications or supplements either during hospitalization or after discharge. A total of 58 of 132 (43.9%) dogs were administered aminoca -proic acid while hospitalized. Of the 58 patients that survived to discharge, 26 (44.8%) were discharged with additional medications or supplements. Fifty-six owners responded to the survey question pertaining to additional medications or supplements, with only 18 owners confidently choosing to administer them at home, with an administration rate of 69.2%. Seven out of 40 (17.5%) dogs received adjuvant chemother -apy after complete incisional healing. Four of these patients received single-agent doxorubicin, while 3 received both doxorubicin and temozolomide. Of sur -gical patients surviving to discharge, 3 of 36 (8.3%) experienced owner-reported wound complications.Median initial visit cost was $1,323.80 (range, $589.02 to $3,613.25). Median cost of surgery was $4,640.75 (range, $3,967.94 to $5,706.37). Median cost of nonsurgical visits was $716.50 (range, $518.28 to $1,497.20). Median cost to owners of patients that died or were euthanized in < 24 hours was $681.60 (range, $508.25 to $1,275.16). Median cost of pal -liative treatment was $1,143.02 (range, $600.73 to $2,199.48). Palliative treatment was more expensive than euthanasia ( P = .021), and surgery was more ex -pensive than palliative treatment ( P < .001).Influences on initial decision-makingOwners ranked QOL as the most important fac -tor influencing their decision, followed by either risk of cancer or time remaining with their pet (ie, prog -nosis), then degree of invasiveness of treatment, or age (Table 1) . Least important factors were pres -ence of concurrent diseases and finances. Age did not influence decision to pursue surgery ( P = 0.401).Clinician experience (intern with < 1 year of expe -rience vs clinician with > 1 year of experience) did not influence decision to pursue treatment (palliative care or surgery vs euthanasia; P = .305). Patients that had preoperative imaging suggesting hemorrhage from the spleen were significantly more likely to undergo surgery than those that had hemorrhage suspected from anoth -er source (OR, 29.333; CI, 7.6169 to 112.3597; P < .001). Owner Quality Risk Remaining time Invasive nature Age Concurrent ranking of lifea of cancerb with petb of treatmentc of dogc diseased Financesd1 3 (2.3%) 24 (18.2%) 20 (15.2%) 29 (22.0%) 33 (25.0%) 60 (45.5%) 52 (39.4%)2 1 (0.8%) 7 (5.3%) 13 (9.9%) 16 (12.1%) 22 (16.7%) 18 (13.6%) 30 (22.7%)3 6 (4.6%) 26 (19.7%) 25 (18.9%) 39 (29.6%) 39 (29.6%) 25 (18.9%) 29 (21.0%)4 42 (31.8%) 47 (35.6%) 43 (32.6%) 27 (20.5%) 23 (17.4%) 21 (15.9%) 18 (13.6%)5 80 (60.6%) 28 (21.2%) 31 (23.5%) 21 (15.9%) 15 (11.4%) 8 (6.1%) 3 (2.3%)≥ 4 122 (92.4%) 75 (56.8%) 74 (56.1%) 48 (36.4%) 38 (24.2%) 29 (22.0%) 21 (15.9%)Median 5 4 4 3 3 2 2IQR 4–5 3–4 2.5–4 2–4 1.5–4 1–3 1–3Owners were asked to rank the influence of the above factors on their treatment decision on a 5-point Likert scale (1 = none at all, 2 = very little, 3 = somewhat, 4 = heavily, 5 = entirely). a–dComparison of medians yielded a P value < .05 with differing superscripts.Table 1 —Summary of owner-reported (n = 132) influences on treatment decision at the time of emergent presenta -tion of dogs with nontraumatic hemoabdomen.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 06/30/23 12:11 AM UTC984 JAVMA | JULY 2023 | VOL 261 | NO. 7Patients with either presumptive ( P = .001) or confident (P < .001) imaging metastasis were less likely to undergo surgery. Patients with confident metastasis ( P < .001) were less likely to undergo any treatment option (pal -liative care or surgery). Patients that were euthanized at presentation had higher lactate values (n = 49; median, 6.54 [range, 4.03 to 9.26]) compared with those under -going any treatment (n = 55; median, 2.9 [range, 1.99 to 3.99]; P < .001). Patients that underwent surgery had lower lactate values (n = 37; median, 2.99 [range, 2.22 to 3.79]) compared with those patients undergoing either palliative treatment or euthanasia (n = 67; median, 4.73 [range, 2.9 to 8.1]; P = .002).Assessing treatment impactsThe majority of owners were satisfied with their treatment decision and would make the same decision again with the knowledge of the outcome obtained (Table 2) . Owners were more likely to be satisfied (score ≥ 4 of 5) than indifferent or unsatisfied (score < 4 of 5) when choosing surgery over either euthanasia or palliative care ( P = .039). Significance was lost when comparing any treatment versus euthanasia ( P = .122). No meaningful dif -ferences were identified when evaluating treatment select -ed and rate of second guessing, likelihood of choosing the same treatment option again, or likelihood of choosing a different specific treatment option ( P > .05). With regard to the choice between surgery or palliative care, there was no difference in frequency of owners reporting a worse-than-expected outcome ( P = .541).Four-point Likert scale scores for QOL, appetite, com -fort, and activity were evaluated for all patients prior to NTH onset, at NTH presentation, and again after treatment for those surviving to discharge, as well as for surgery and palliative care subgroups (Tables 3 and 4). No significant differences were found for any score between treatment categories either before or during the NTH event. How -ever, QOL, appetite, comfort, and activity scores were all significantly higher afterwards for patients that had under -gone surgery as compared with those that had undergone palliative care. Similar comparisons were performed for subgroup of patients that underwent surgery and were QOL score QOL score QOL score for QOL score category for all patients palliative care patients for surgery patients P valueOn average before NTH 4 (3–4) 4 (3–4) 4 (3–4) .689At the pet’s best before NTH 4 (3–4) 4 (3–4) 4 (3.5–4) .597At the pet’s worst before NTH 3 (2–4) 3 (2–4) 3 (2–4) .547On average during NTH event 1 (1–2) 2 (1–2) 1 (1–2) .268On average after treatment 3 (2–3.5) 2 (2–3) 3 (3–4) .007At the pet’s best after treatment 3 (2–4) 3 (1.5–3) 4 (3–4) .022At the pet’s worst after treatment 2 (1–3) 1 (1–2) 3 (1–3.5) .003Owners scored their pet’s QOL on a 4-point Likert scale (1 = poor, 2 = fair, 3 = good, 4 = excellent). P value is a comparison of QOL scores between palliative care versus surgery patients. Nonnormally distributed data are presented as median (range).NTH = Nontraumatic hemoabdomen.Table 3 —Summary of owner-reported quality-of-life (QOL) scores on average, at the pet’s best, and at the pet’s worst prior to onset of nontraumatic hemoabdomen; on average while suffering from nontraumatic hemoabdomen; and on average, at the pet’s best, and at the pet’s worst following treatment for those that survived to discharge. Results are categorized into scores for all patients combined and then into the subgroups of patients that received palliative care and surgery. All: n = 132 before and during, 56 after. Palliative care: n = 22 before and during, 20 after. Surgery: n = 40 before and during, 36 after.Survey question Response choice No. of responsesHow satisfied were you with the overall outcomeof your treatment choice? Extremely unsatisfied 15/132 (11.4%) Somewhat unsatisfied 9/132 (6.8%) Neither satisfied nor unsatisfied 30/132 (22.7%) Somewhat satisfied 21/132 (15.9%) Extremely satisfied 57/132 (43.2%) Did you have second thoughts about the treatment Yes (second guessed) 26/132 (19.7%)decision you made? No (did not second guess) 99/132 (75.0%) Unsure 7/132 (5.3%) If you were faced with this choice again, would you make Yes (same decision) 108/132 (81.8%)the same treatment decision? No (different decision) 11/132 (8.3%) Unsure 13/132 (9.9%) If you would make a different treatment decision or were unsure, Euthanasia 5/24 (20.8%)which treatment course would you consider instead? Palliative care 5/24 (20.8%) Surgery 5/24 (20.8%) Unsure 9/24 (37.5%) How did your pet’s outcome compare with your expectation? Better than expected 27/60 (45%) Same as expected 17/60 (28.3%) Worse than expected 16/60 (26.7%)Table 2 —Summary of owner-reported treatment choice satisfaction.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 06/30/23 12:11 AM UTC JAVMA | JULY 2023 | VOL 261 | NO. 7 985diagnosed with malignant disease, and significance was maintained for average postoperative QOL ( P = .042), best QOL after ( P = .043), and activity scores ( P = .032). The pres -ence of either presumptive or confident metastasis had no influence on any postoperative QOL parameters ( P > .05).Survival analysisOf the 58 patients that survived to discharge, 38 (65.5%) were euthanized, 9 (15.5%) died naturally at home, and 11 (17.2%) remained alive at the time of sur -vey dispersion. One patient did not have a reliable date of death. Reasons for euthanasia were often multiple in number and varied widely (Table 5) . The reason for Table 4 —Summary of owner-reported appetite, comfort, and activity scores for patients on average prior to onset of nontraumatic hemoabdomen, while suffering from nontraumatic hemoabdomen, and after treatment for those that survived to discharge. Results are categorized into scores for all patients combined and then into the sub -groups of patients that received palliative care and surgery. All: n = 132 before and during, 56 after. Palliative care: n = 2 before and during, 20 after. Surgery: n = 40 before and during, 36 after. Score for Score for palliative Score for Score category all patients care patients surgical patients P valueAppetite On average before NTH 4 (3–4) 3.5 (3–4) 4 (3–4) .124 On average during NTH event 1 (1–2) 2 (1–3) 1 (1–3) .093 On average after treatment 3 (2–4) 2 (1.5–3) 3.5 (2.5–4) .011Comfort On average before NTH 4 (3–4) 3.5 (3–4) 4 (3–4) .353 On average during NTH event 1 (1–2) 2 (1–2) 1 (1–2) .325 On average after treatment 3 (2–4) 2 (1.5–3) 3 (2.5–4) .036Activity level On average before NTH 4 (3–4) 4 (3–4) 4 (3–4) .734 On average during NTH event 1 (1–2) 1.5 (1–2) 1 (1–2) .446 On average after treatment 3 (2–4) 2 (1.5–3) 3 (3–4) .007See Table 3 for key.Table 6 —Univariable survival analysis of patients with nontraumatic hemoabdomen.Possible Presence Absence Hazard prognostic factor n (95% CI; d) (95% CI; d) ratio CI P ValueSurgery 61 213 (74–826) 39 (8–549) 0.51 0.26–1.00 .049Potential imaging metastasis 49 56 (28–155) 1243 (74–?) 4.13 1.67–10.20 .002Confident imaging metastasis 49 31 (1–64) 654 (81–1243) 4.58 2.10–9.98 < .001Potential surgical metastasis 40 31 (1–56) 654 (140–1243) 4.23 1.82–9.84 .001Confident surgical metastasis 40 31 (1–?) 304 (99–922) 2.49 1.04–5.94 .040Malignant histopathology 40 81 (50–235) 922 (213–?) 3.84 1.28–11.56 .017Mitotic rate (mitoses/10 hpf) 29 — — 1.03 1.01–1.06 .018Mitotic score 3 (vs 0–2) 24 4 (3–?) 113 (50–?) 7.79 1.87–32.42 .005PCV (%) 61 — — 0.94 0.90–0.98 .003Hct (%) 58 — — 0.93 0.89–0.97 .001Platelet count (thousand/UL) 37 — — 0.99 0.99–1.00 .008Lactate (mmol/L) 55 — — 0.96 0.83–1.11 .612TFAST fluid 34 3 (?–?) 213 (50–922) 12.25 1.08–138.86 .043TFAST B-lines 24 140 (99–?) 654 (31–1243) 1.30 0.36–4.75 .691Blood transfusion 61 155 (50–826) 94 (33–549) 0.95 0.51–1.80 .885Age (y) 61 — — 1.19 0.56–2.52 .649Weight (kg) 61 — — 1.00 0.98–1.03 .710Any supplements administered 42 — — 1.33 0.59–3.00 .487 at homeTime until surgery (h) 39 — — 1.01 0.98–1.05 .421Source of hemorrhage from spleen 40 213 (74–922) 826 (1–?) 1.13 0.26–4.90 .868Seen by an intern 40 213 (81–922) 155 (19–?) 0.81 0.37–1.77 .601Nonnormally distributed data are presented as median (range). — = Presence/absence data not available for continuous variable. ? = CI unable to be obtained due to small sample size. TFAST = Thoracic focused assessment with sonography for trauma.Table 5 —Summary of reasons why owners elected to euthanize their pet after initial hospital discharge fol -lowing surgical or medical treatment for nontraumatic hemoabdomen. Owners could select more than one reason for euthanasia if applicable.Reason for euthanasia No. of responsesStopped eating/drinking 16/38 (42.1%)Slowed down, lethargic 13/38 (34.2%)Difficulty breathing 13/38 (34.2%)Recurrent hemoabdomen 8/38 (21.1%)Presence of metastatic disease 12/38 (31.6%)Comorbidity 5/38 (13.2%)Advanced age 6/38 (15.8%)Other 18/38 (47.4%)Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 06/30/23 12:11 AM UTC986 JAVMA | JULY 2023 | VOL 261 | NO. 7euthanasia for patients that were discharged was con -fidently not related to the initial diagnosis of NTH in 9 of 38 (23.7%) cases, with 1 patient being treated pal -liatively and 8 patients treated surgically. The median survival time (MST) was 1 day when considering all patients (n = 131; 95% CI, 1 to 4 days). MST was 213 days (n = 40; 95% CI, 74 to 826 days) for patients that underwent surgery. MST of patients undergoing pallia -tive care was 39 days (n = 21; 95% CI, 8 to 549 days). Patients undergoing surgical treatment had longer sur -vival times compared with patients undergoing pallia -tive care (hazard ratio, 0.505; 95% CI, 0.256 to 0.996; P = .049). However, survival benefit of surgery was lost when considering patients with malignant histopathol -ogy (n = 30; MST, 81 days; 95% CI, 50 to 235 days) ver -sus patients undergoing palliative care (hazard ratio, 0.697; 95% CI, 0.350 to 1.389; P = .305). On univariable survival analysis, suspected or confident presence of metastasis prior to histopathological diagnosis, as well as identification of malignant histopathology, nega -tively influenced survival (Table 6) .

Question 83

Chen - 2023 - VETSURG - Detailed anatomic description of the lateral, transzygomatic approach to the middle fossa and rostral brainstem and its use in three dogs.pdf

Answer 83

2.1 |Cadaver preparationIn preparation for this procedure and for teaching pur-poses, cadaveric dissection was performed in twomedium-sized dogs (15 kg and 20 kg) euthanized for rea-sons unrelated to encephalopathy. With informed con-sent, both cadavers were donated by their owners.2.2 |Surgical procedure (cadaveric andclinical)The dogs were placed in sternal recumbency and clippedfrom the orbit to the first cervical vertebrae on theaffected side. A customized head frame designed andconstructed by one of the coauthors was secured to themaxilla. This allowed for both rotation of the head andpassive opening of the jaw. With the affected side rotatedtowards the surgeon, the surgeon's line of sight, the zygo-matic arch, and the middle fossa were in the same planeand at about a 60-degree angle to the surgery table(Figure 1). Alternatively, proper positioning was alsoachieved with a headstand, a vacuum-activated position-ing device (Hug-U-Vac positioner. Hill-Rom Holdings,Inc. Chicago, Illinois), and a mouth gag. For the clinicalcases, the surgical site was scrubbed with 5% povidone-iodine (Betadine Antiseptic Solution. Avrio HealthL.P. Stamford, Connecticut), and draped with disposable,nonabsorbent surgical drapes.6A curvilinear skin incision was made from the lateralcanthus to the tragus at the dorsal margin of the zygo-matic arch (Figure 2). The auriculotemporal branch ofthe trigeminal nerve and the auriculopalpebral branch ofthe facial nerve were identified in the same dis-section field; the auriculopalpebral nerve crossed thezygomatic arch and continued to the orbit, and the auri-culotemporal nerve ran perpendicular to the caudalaspect of the zygomatic arch and emerged between themasseter muscles (Figure 3A).7The platysma muscle,associated fascia, and the facial and trigeminal nervebranches were isolated using sharp and blunt dissection.The nerves were then retracted dorsally (Figure 3B).An incision was made into the frontalis muscle abovethe zygomatic arch, followed by blunt dissection of themusculature using Metzenbaum scissors. The superficialtemporal vein and artery along the caudal aspect of thezygomatic bone were isolated and retracted dorsocaudally.The zygomaticus and zygomaticoauricularis muscles wereFIGURE 1 The cadaver was positioned in a customized headframe secured to the maxilla, with the jaw allowed to openpassively. The surgeon's line of sight was at a 60 degree angle to thetable.FIGURE 2 Healing curvilinear skin incision in a patient14 days after lateral, post-transzygomatic craniectomy to access themiddle fossa. A skin incision was made from the lateral canthusover the zygomatic arch towards the tragus. Cosmesis wasmaintained despite the removal of the zygomatic arch fragment.CHEN ET AL . 1181 1532950x, 2023, 8, reflected ventrocaudally and dorsocaudally, respectively,using Freer periosteal elevators. The musculature was fur-ther reflected and dissected to access the zygomatic arch.Before dissecting the zygomatic arch, gentle palpationallowed the identification of three important landmarks:the zygomatic arch, lateral rim of the orbit, and temporo-mandibular joint. The temporalis muscle was incisedalong the dorsal aspect, and the masseter muscle wasincised along the ventral edge of the zygomatic arch(Figure 4). The zygomatic arch was then sectioned withtwo vertical osteotomies. The rostral osteotomy was cau-dal to the union of the zygomatic arch and zygomaticbone, and the caudal osteotomy was immediately rostralto the temporomandibular joint.The zygomatic arch could either be resectedcompletely or replaced during closure. For completeresection, the zygomatic arch was removed with a high-speed pneumatic drill (Surgairtome Two. Hall Surgical,Irvin, Texas) and variable-sized burr, a rongeur, or anosteotome, mallet, and Kerrison rongeurs (Figure 5A,B).7For zygomatic arch replacement, the temporalismuscle was incised above the zygomatic arch while leav-ing about a 1 cm margin of the temporalis muscle andfascia for suturing during closure. To facilitate archreplacement when closing, two holes were drilled oneither side of the osteotomy using a 0.35 mm Kirschnerwire (MK medical. Emmingen-Liptingen, Germany) or ahigh-speed pneumatic drill (Surgairtome Two. Hall Surgi-cal) with variable burr sizes. Two vertical osteotomieswere made using an oscillating saw (Aesculap, MK Medi-cal). The sectioned zygomatic arch was then reflectedventrally with the attached masseter muscle.(A)(B)FIGURE 3 (A) Subcutaneousexposure in a cadaver head. Importantanatomic structures include theauriculopalpebral branch of the facialnerve (solid arrow), theauriculotemporal branch of thetrigeminal nerve (dashed arrow), thezygomatic arch (dotted lines), the lateralaspect of the orbit rim (asterisk), and thetemporomandibular joint (circle). (B) Abrachycephalic cadaver head in afocused view at the same level as 3A,showing the auriculopalpebral branch ofthe facial nerve (solid arrow), theauriculotemporal branch of thetrigeminal nerve (dashed arrow), thezygomatic arch (dotted lines), the lateralaspect of the orbit rim (asterisk), and thetemporomandibular joint (circle).(A) Originally published in Color atlas ofveterinary anatomy the dog & cat,volume 3, Done et al., chapter 2 Thehead, page 2.10, Copyright Elsevier.1182 CHEN ET AL . 1532950x, 2023, 8, The deep temporalis muscle was separated with sharpand digital dissection to expose the temporal bone. Toachieve retraction and visualization, right-angle Gelpiretractors were placed in the musculature. The remainingmuscle was gently elevated from the periosteum using aFreer elevator.The frontal, parietal and temporal bones wereexposed, revealing the convergence of the frontoparietaland parietotemporal sutures (Figure 6A). A square cra-niectomy measuring approximately 1 cm2was madeusing a high-speed air drill and burrs (Surgairtome Two.Hall Surgical.) (Figure 6B). The margins of the craniect-omy were the parietotemporal suture (dorsal), the caudaldorsal margin of the temporomandibular joint (ventral),the frontotemporal suture (rostral), and the level of thecaudal margin of the zygomatic arch (caudal). The ven-tral margin was predetermined based on the measure-ments from MRI images and the ventromedial curvatureof the calvaria.The middle meningeal artery was identified andligated or skeletonized to limit hemorrhage, protectedwith an absorbable hemostatic gelatin sponge (Vetspon;Ferrosan Medical Devices, Soeborg, Denmark), andgently retracted from the surrounding tissue.Durectomy was performed with a #11 blade. Duralhemorrhage was controlled with bipolar cautery (ArronBovie, Symmetry Surgical, Nashville, Tennessee), saline,and a gelatin sponge (Vetspon; Ferrosan MedicalDevices). Once the brain was exposed, there were twoimportant landmarks. A “U”shape, in which the left armof the “U”was formed by the Sylvian gyrus, the right sideof the “U”was formed by the ectosylvian gyrus, and thelateral rhinal sulcus formed the base. An upside-down“T,”where the tall portion of the upside down “T”wasformed by the pseudosylvian fissure and the base of theupside down “T”was formed by the rostral and caudallateral rhinal sulcus. The rostral margin of the piriformlobe is ventral and medial to the upside-down “T,”whereas the caudal margin was ventral and medial to the“U.”(Figure 7A–D).7,20Kerrison rongeurs were used toextend the craniectomy window. If elevating or retractinga gyrus, relaxation was allowed every 3 –5 minutes toavoid cerebral ischemia from excessive pressure on thebrain parenchyma.8Incisional biopsy or aspirator-assisted debulking followed and is described in the casesummaries.Complete hemostasis was paramount and achievedusing a combination of bipolar cautery (Arron Bovie,Symmetry Surgical), cold saline, and hemostatic agentssuch as gelatin sponges (Vetspon; Ferrosan MedicalDevices). The craniectomy site was lavaged with salinesolution to remove blood clots, bone dust, and otherpotential contaminants. The brain parenchyma was cov-ered and protected using gel foam, the original dura, or asynthetic dural replacement such as porcine small intes-tine submucosa (SIS) (Vetric Biosis ECM. Vetrix, LLC.Dawsonville, Georgia).Protecting the brain and preserving cosmesis wasimportant when closing the incision, and typically, therewas enough muscle overlying the surgical defect toachieve these goals. However, in dolichocephalic breeds,smaller size animals, or patients with severe muscle atro-phy, it was necessary to repair the zygomatic arch byreattaching the zygomatic bone fragment with nonab-sorbable suture or MRI-compatible surgical implants,such as titanium plate or mesh and screws. If the zygo-matic arch remained attached to the masseter muscle,the fragment was replaced by suturing the temporalis fas-cia or passing a 0-PDS suture through the predrilledholes. The surgical site was closed in three layers (fascia,subcutaneous, and skin) using appositional suture pat-terns depending on the surgeon's preferences.3|CASE REPORT3.1 |Case selectionMedical records were identified from dogs with middlefossa or rostral brainstem lesions that underwent surgeryutilizing a lateral, transzygomatic approach. Three dogswere treated with their owners ’consent, and the ownerswere informed of the nature of the novel surgicalFIGURE 4 Cadaver head after ventrocaudal and dorsocaudalreflection of the zygomaticus and zygomaticoauricularis muscles,respectively. The temporalis and masseter muscles were incisedalong the dorsal and the ventral aspects of the zygomatic arch(dotted lines), respectively. Note the auriculopalpebral branch ofthe facial nerve (black arrow).CHEN ET AL . 1183 1532950x, 2023, 8, approach and associated risks. Data retrieved includedsignalment, body weight, preoperative neurological sta-tus, presurgical MRI findings, postoperative neurologicalstatus, short-term follow up (at least 4 weeks after sur-gery), outcomes, and complications. Self-limiting or self-resolving signs were classified as minor complications.Life-threatening circumstances, persistent clinical signs,conditions requiring urgent surgical or medical manage-ment, or signs affecting dogs' functional recovery weredefined as major complications.3.2 |Anesthesia, analgesia, andperioperative managementAll dogs were premedicated with an opiate, either hydro-morphone (Hospira, Inc. Lake Forest, Illinois) 0.1 mg/kg,IV or fentanyl (West-Ward, Eatontown, New Jersey,4 mcg/kg IV) and midazolam (Athenex, Schaumburg,Illinois;0.5 mg/kg IV). Anesthesia was induced with pro-pofol (Zoetis Inc, Kalamazoo, Michigan; 2 –6 mg/kg IV,titrated slowly to effect). 0.75% –1.0% of isoflurane (BaxterUS, Deerfield, Illinois) and 100% oxygen was deliveredvia an endotracheal tube and mechanical ventilator tomaintain anesthesia. The partial pressure of carbon diox-ide (PaCO 2) was maintained between 25 and 35 mmHg.Cefazolin (WG Critical Care, LLC, Paramus, New Jersey;22 mg/kg IV) was administered at induction and every90 min throughout the surgery. Mannitol 1 gm/kg, IVover 20 min, and dexamethasone sodium phosphate at0.1–0.25 mg/kg, IV were given around the time ofinduction.Intraoperative analgesia consisted of continuousintravenous infusion (CRI) of fentanyl at 10 mcg/kg/h,ketamine (MWI Animal Health, Boise, ID, USA) at5 mcg/kg/min, and lidocaine (Hospira, Lake Forest, IL,USA) at 20 mcg/kg/min. Intraoperative monitoringincluded heart rate and rhythm, respiratory rate, blood(A)(B)FIGURE 5 (A) Lateral review of acanine head after removal of themasseter muscle and temporal fascia.The dotted red line indicates an incisioninto the temporalis muscle 1 cm abovethe zygomatic arch. The solid black linesrepresent the two vertical osteotomies.The resected area is the caudal 1/3 of thecentral zygomatic arch. (B) Cadaverhead. An incision into the zygomaticarch. Two vertical osteotomies throughthe zygomatic arch (solid arrows). Therostral cut is caudal to the union of thezygomatic arch and bone, and thecaudal cut is rostral to thetemporomandibular joint. The original(A) was published in Done et al. Chapter2 The head. In: Done et al. Color atlas ofveterinary anatomy the dog & cat,volume 3. 2nd ed. Elsevier; 2009: 2.14.,Copyright Elsevier.1184 CHEN ET AL . 1532950x, 2023, 8, pressure, body temperature, end-tidal CO 2, anesthesiadepth, and oxygen saturation.Postoperative analgesia was adapted to each dog.Cases 1 and 3 received 24 h of administration of keta-mine CRI (MWI Animal Health, Boise, Idaho; at 3 –5mcg/kg/min), lidocaine CRI (Hospira, Lake Forest, IL,USA; 25 –50 mcg/kg/min), and fentanyl CRI (West-Ward,Eatontown, NJ USA; 3 –5 mcg/kg/h). The doses wereadjusted and titrated based on each dog's pain level. Alldogs were successfully transitioned to oral analgesicswithin 24 hours of surgery. The analgesics and anti-inflammatory medication included prednisone 1.0 mg/kg, once daily or divided twice daily, and as needed,gabapentin 8 –12 mg/kg three times daily orally, acet-aminophen 15 mg/kg, two to three times daily andcodeine 1 –3 mg/kg two to three times orally or tramadol2–5 mg/kg, two to three times daily orally.3.3 |Case summaries3.3.1 | Case 1A7 - y e a r - o l df e m a l es p a y e db u l l m a s t i f f - p i t b u l lm i xw a sp r e -sented for generalized seizures. Physical and neurologicalexaminations were unremarkab le. Neurolocalization was tothe forebrain. The complete bl ood count and biochemistrypanel were all within normal limits. Brain MRI(1.5 Tesla CXK4 LCC superconducting magnet; GeneralElectric Medical Systems, Milw aukee, Wisconsin) identifiedan extensive, ill-defined lesio ne x t e n d i n gf r o mt h el e f tf r o n -tal and parietal lobes to the piriform lobe (Figure 8). Thelesion was hyperintense on T2-weighted images andT2-FLAIR (fluid-attenuated inve rsion recovery), isointenseon T1-weighted and gradient echo-T2* images, and hyper-intense on both diffusion-weighted images (DWI) andapparent diffusion coefficien t( A D C )s e q u e n c e s .N oc o n t r a s tenhancement was noted with intravenous injection of theparamagnetic contrast agent Dotarem (gadpterate meglu-mine) at 0.22 mL/kg. The lesi on caused mild perilesionaledema, rightward bowing of the falx cerebri, and attenua-tion of the left lateral ventricle. A neoplastic process such asal o w - g r a d eg l i o m aw a sm o s tl i k e l y ,a n do t h e rc a u s e ss u c has ischemic stroke or encephalitis of unknown etiologywere considered less likely. After the owner was counseledregarding the nature of the surgery and associated risks, anincisional biopsy was elected.The surgical technique for incisional biopsy was per-formed as previously described in the surgical proceduresection. Once the craniectomy window was made, a dur-ectomy was performed with an #11 blade. The intendedtarget area, the lesion within the piriform lobe, wasgrossly normal. An incisional biopsy was then performedusing a sharp spatula. The samples were taken from thecranial margin of the window and the caudal marginthrough the Sylvian and caudal composite gyri, respec-tively. A small piece of SIS (Vetric Biosis ECM.Vetrix,LLC.) was used to cover the brain. The sectioned zygo-matic arch was not replaced.3.3.2 | Case 2A 5-year-old male neutered golden retriever mix pre-sented with progressive left temporalis muscle atrophyand depressed mentation for 2 weeks. Physical examina-tion was unremarkable. Neurologic examination revealed(A)(B)FIGURE 6 Craniectomy window. (A) Cadaver head. Note thezygomatic arch (asterisk); the auriculopalpebral branch of the facialnerve (black arrow), the lateral canthus (dotted arrow);frontoparietal suture (dashed white line). (B) Canine skull model.The components of the zygomatic arch (dotted lines), the zygomaticfragments (black lines), and a 1 cm /C21 cm square craniectomywindow (gray shaded box).CHEN ET AL . 1185 1532950x, 2023, 8, left temporalis muscle atrophy, absent left palpebralreflex, absent left corneal reflex, decreased sensation tothe left upper lip, and slow proprioceptive responses onthe left thoracic and pelvic limbs. A left brainstem lesionwas suspected. Complete blood count and biochemistrypanel were unremarkable.Magnetic resonance imaging (Signa 1.5 Tesla, GEHealthcare, Chicago) revealed an extra-axial ovoid mass,hyperintense on T2 weighted images, hypointense on T1weighted images, and homogenously enhancing on T1weighted images with contrast (Figure 9). The mass waslocated on the floor of the calvarium, originating at themedial border of the petrous temporal bone and extend-ing rostrally to the level of the caudal clinoid process.The lesion did not extend through the oval or rostral alarforamina. Meningioma was considered most likely, withless consideration given to a trigeminal nerve sheathtumor. After the owner was consulted regarding thenature of the surgery and associated risks, a debulkingsurgery was elected.The surgical technique for the debulking surgerywas performed as previously described in the surgicalprocedure section. The sectioned zygomatic arch wasleft connected to the masse ter muscle, the calvariumexposed, and the craniectomy window created. A mal-leable retractor was placed ventral to the horizontalportion of the upside-down “T”to retract the caudalcomposite gyrus of the temporal lobe at the floor of thecalvarium. The retraction exposed the ventral reflectionof the dura that was medial to the temporal lobe. Themedial reflection was incised with a #11 scalpel bladeto expose the mass. The mass was lateral to the caudalclinoid process and rostral to the rostral extent of thepetrous temporal bone. It was resected using a combi-nation of bipolar cautery, suction, and an ultrasonicaspirator (CUSA Excel, Valleylab, Boulder, Colorado).The zygomatic arch fragment was repositioned andsecured by opposing the fascia.3.3.3 | Case 3A 10-year-old female spayed hound mix presented forevaluation of acute generalized tonic –clonic seizures.(A)(B) (C) (D)FIGURE 7 The superimposed upside-down “T”and a “U”define surgical landmarks. (A) Schematic illustration of the lateral brain'ssulci and gyri. The upside down “T”(blue line) is formed by the intersection of the lateral rhinal sulcus and pseudosylvian fissure. The “U”(green line) was most easily noted at surgery and formed by the Sylvian and caudal composite gyri. (B) Schematic illustration of the ventraloblique view of the brain's sulci and gyri. The piriform lobe is ventral to the pseudosylvian fissure (blue line) and lateral rhinal sulcus (greenline). The lateral approach of transzygomatic craniectomy allowed access to this area. (C) Cadaver head with meninges removed from theexposed brain showing the sulci and gyri. The upside down “T”(blue line) is formed by the intersection of the lateral rhinal sulcus andpseudosylvian fissure. The Sylvian and caudal composite gyri form the “U”(green line). (D) The cadaver head showing the craniectomywindow, the upside down “T,”and the rostral half of the “U.”The original figures A and B were published in Miller and Evans Anatomy ofthe dog, 4th ed, by John W. Hermanson et al., The brain, page 678, figure 18.30. Copy right Elsevier. The original figure C was published inColor atlas of veterinary anatomy the dog & cat, volume 3, Done et al., chapter 2 The head, page 2.47, Copyright Elsevier.1186 CHEN ET AL . 1532950x, 2023, 8, Physical and neurological examinations revealed left-sided hemiparesis and right-sided menace deficit.Multifocal brain lesions were suspected. Complete bloodcount and biochemistry panel were unremarkable. BrainMRI (1.5 Tesla CXK4 LCC superconducting magnet;General Electric Medical Systems) revealed a well-demar-cated, extra-axial mass arising from the surface of the lefttemporal lobe. The mass was associated with markedperilesional edema, a rightward midline shift, and mod-erate caudal transtentorial brain herniation. After theowner was counseled regarding the nature of the surgeryand associated risks, debulking surgery was elected.The surgical technique for the debulking surgery wasperformed as previously described in the surgical proce-dure section. Prior to incising the zygomatic bone to cre-ate the reflected bone fragment, two sets of holes weredrilled on each side of the planned osteotomies for latersuturing and reconstruction of the zygomatic arch. Themasseter muscle remained attached to the sectionedzygomatic arch. A craniectomy window was createdusing a high-speed air drill and burr (Surgairtome Two.Hall Surgical, Irvin, Texas), a Kerrison rongeur, Lempertrongeur, and a House curette. The dura was incised in anX-shape and ultimately excised using a Castroviejo scis-sor. The underlying brain had an extra-axial, discoloredregion that moderately to markedly compressed thebrain. A Rhoton spatula was used to create a dis-section plane along the mass's cranial, dorsal, and caudalmargins. The mass was grasped using Yasargil tumorbiopsy forceps and was internally/centrally debulked.There was an indistinct margin between the brain andthe tumor along the deep margin. The exterior of thetumor was grasped using the Yasargil forceps and pulledinto the center, using the spatula to help separate thetumor's edges from the brain. The mass was visiblyremoved in its entirety. The normal underlying brainreturned to a normal position within the calvarium. AnSIS graft (Vetric Biosis ECM®.Vetrix, LLC.) was placedover the brain, followed by a small piece of gelatinsponge (Vetspon®; Ferrosan Medical Devices). The zygo-matic arch was repaired using a 0 PDS suture.4|RESULTS4.1 |Case 1The immediate postoperative MRI revealed that the cra-niectomy defect was centered over the lesion. The lesionvolume was subjectively smaller, and within the caudalportion of the mass, there was a 0.5 cm3T2-weighted andT2-weighted FLAIR hyperintense lesion, consistent withan incisional biopsy at the intended location. The dogrecovered uneventfully, remained seizure-free, and at48 h post-operation, was discharged on prednisone0.5 mg/kg twice daily orally and extended-release levetir-acetam 28 mg/kg every 12 hours orally. Before discharge,the neurological examination showed mild anisocoria(the left pupil was smaller than the right) and a decreasedleft palpebral reflex. Menace response testing on the leftrevealed retraction of the globe and protrusion of thethird eyelid but no palpebral response. At a 2-weekFIGURE 8 Case 1. Transverse FLAIR MR image of a suspectedlow-grade glial cell tumor. The left piriform lobe hyperintenselesion is marked with a white asterisk. The zygomatic arch ismarked with a white arrow.FIGURE 9 Case 2 MR images. Transverse T1-weightedpostcontrast MR image of a suspect brain tumor. A homogenouslycontrast-enhancing mass (black asterisk); severely atrophied lefttemporalis muscle (solid black arrow); the right temporalis muscle(dotted black arrow); the zygomatic arch (black arrowhead).CHEN ET AL . 1187 1532950x, 2023, 8, recheck, the dog was seizure free and had a normal neu-rological examination. Prednisone was tapered and elimi-nated over the following 3 months. Histopathology of thebiopsy sample was consistent with a low-grade glial celltumor. The owner declined chemotherapy and radiationtreatment. The dog was orally treated with levetiracetamextended-release (Lupin Inc, Baltimore, Maryland) at28 mg/kg every 12 hours for seizure management.At 3 months postsurgery, the dog was seizure freeand had a normal examination. A follow-up MRI wasidentical to the postoperative MRI. One year after sur-gery, although the dog remained seizure free with noneurological deficits, the recheck MRI demonstrated anincreased T2-weighted signal in the left piriform lobe.The lesion extended rostrally to the olfactory bulb anddorsally to the temporal lobe. The lesion was isointenseon T1-weighted images with slight ring contrast enhance-ment. The findings were consistent with a high-gradeglial cell tumor with a necrotic core. A month after the1-year postoperative recheck, the patient developed pro-gressive seizures despite initiating prednisone 0.5 mg/kgtwice daily and chemotherapy (temozolomide givenorally at 56 mg/kg once daily for 5 days every month).The dog was euthanized 14 months after the biopsy.4.2 |Case 2A postoperative MRI was not performed on this patient.The dog recovered without significant complications andwas discharged 1 week after surgery on prednisone 1 mg/kg every 24 hours orally. Neurological examinationrevealed decreased facial sensation, absent palpebralreflex, and proprioceptive deficits on the left. At a 2-weekrecheck, the dog had improved left-side facial sensation,proprioceptive deficits, and an absent left palpebralreflex. Histological examination of the mass found a typeII transitional meningioma. The owners declined radia-tion therapy after surgery due to financial constraints.Prednisone was tapered and eliminated over the follow-ing 3 months. By 3 months after the surgery, the palpe-bral reflex had returned. After 8 months, the dog beganhaving a recurrence of left-sided postural deficits and wasstarted on prednisone 1 mg/kg once daily orally. The dogdid not return for additional follow up and was eutha-nized by the referring veterinarian 11 months postopera-tively due to progressive weakness.4.3 |Case 3Immediate postoperative MRI documented a gross totalresection. The dog recovered uneventfully and was dis-charged the following day. Neurological examination wasunremarkable. The mass was diagnosed as an undifferen-tiated invasive neoplasia on histopathology. The exactcell type of origin could not be identified due to its ana-plastic nature. The owners elected not to pursue anyadditional therapies following surgery. The dog was dis-charged with phenobarbital (3 mg/kg every 12 h orally),diazepam 5 mg/mL injectable liquid (1 mg/kg rectally atthe onset of a seizure and up to 3 times in 24 h), levetira-cetam extended release (36.5 mg/kg every 12 h orally),and prednisone (0.5 mg/kg twice daily orally). Predni-sone was tapered and eliminated over the following3 months. The dog remained seizure free with a normalexamination 6 months after surgery. The dog then experi-enced progressive seizures and was euthanized 8 monthsafter surgery.5

Question 84

Nash - 2023 - JAVMA - Tube 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).pdf

Answer 84

Case selectionMedical records of dogs treated with tube cys -tostomy at The Animal Hospital at Murdoch Univer -sity from January 2018 to June 2022 were reviewed. Dogs were identified via database search, using the keywords tube cystostomy . Cases were included in the study if neurolocalization and MRI or CT findings supported a diagnosis of IVDE (Hansen type I or low-volume/high-velocity disk extrusion) or ischemic myelopathy cranial to the L3 spinal cord segment. No exclusion criteria were applied.Medical record reviewData collected included signalment (age, sex, neuter status, breed, and body weight); neurologic grade at presentation using the Modified Frankel Scale (MFS); neurolocalization; advanced imaging modality used (MRI or CT); decompressive surgical technique performed (if applicable); number of days from presentation until tube cystostomy placement; neurologic MFS grade at cystostomy tube placement; number of days from cystostomy tube placement to hospital discharge; number of days from cystostomy tube placement to removal and reason for removal; neurologic MFS grade at cystostomy tube removal; complications associated with tube cystostomy; and results of urine microbial culture and sensitivity.Neurologic gradingAt 3 time points (time of presentation, time of cystostomy tube placement, and time of cystostomy tube removal), dogs were assigned a neurologic grade of 1 to 5 according to the MFS by a board-certified surgeon or a surgical resident under super -vision by a board-certified surgeon.15ProceduresFemale —All surgeries were performed by a board-certified surgeon or surgical resident under supervision by a board-certified surgeon. Dogs were positioned in dorsal recumbency. The urinary blad -der was not decompressed prior to surgery, or if an indwelling catheter was present, the urinary blad -der was either closed off or infused with saline to moderately distend it. A short (approx 3 cm) ventral midline caudal celiotomy overlying the body of the urinary bladder was approached with electrosur -gery. The abdominal wall was exposed and incised along the midline (approx 2.5 cm) with an inverted No. 10 scalpel blade, and the urinary bladder was identified immediately under the incision. A horizon -tal mattress suture using 2-0 or 3-0 polydioxanone was placed either side of the abdominal wall inci -sion, with each suture incorporating abdominal wall and ventral urinary bladder wall, to isolate a small area of the ventral urinary bladder wall. A cruciform stab incision (No. 11 scalpel blade) was made into the urinary bladder lumen between the 2 mattress sutures, and a Foley catheter (with stylet) was in -serted. The bulb was then inflated and the stylet was removed. The stay sutures were tied to appose the urinary bladder with the abdominal wall to complete the cystopexy. The celiotomy was closed with inter -rupted sutures in the external rectus fascia. The sub -cutaneous tissues and skin were closed around the cystostomy tube. The Foley catheter was secured to the skin using 2-0 nylon suture in a finger trap pat -tern. The Foley catheter was secured against the dog with a compression vest, and an Elizabethan collar was placed. Urine was evacuated from the urinary bladder by continuous passive flow through connec -tion to a urine collection bag or with intermittent as -piration via a sterile syringe.Male —Dogs were positioned in dorsal recum -bency, and a short (approx 3 cm) parapreputial skin incision was performed overlying the body of the uri -nary bladder (Figure 1) . The prepuce was retracted laterally to expose the ventral midline. Thereafter, the technique was identical to that used in female dogs.Owner questionnaireFollow-up data were collected 6 to 48 months following tube cystostomy placement. Owners of dogs with cystostomy tubes placed were contacted via email and invited to participate in a question -naire distributed through an online survey platform (Institutional Ethics number 2022/213). A Likert scale (1 to 5) was used to ascertain ease of cystos -tomy tube use and daily time commitment. Own -ers were asked to record the number of times per day that the urinary bladder was aspirated. Owners were asked whether there were any difficulties in using the cystostomy tube (yes or no) and asked to list the difficulties, if applicable. ComplicationsComplications were subclassified as preopera -tive, intraoperative, and postoperative complications, by means of the classification system proposed by Follette.16 Postoperative complications were further classified via the Accordion Severity Grading System,16 whereby mild complications are defined as those which require only minor bedside procedures, moder -Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 12/11/23 09:46 AM UTC 3ate complications are defined as those which require pharmacologic treatment with drugs other than those required for minor complications, and severe complica -tions are defined as all complications requiring surgery or postoperative death. Results of urine culture and sensitivity are also reported, when performed.Data analysisCategorical response variables are summarized as frequency (%), and modes and continuous re -sponse variables were summarized as median and quartiles (Prism, version 9.0 for Mac; GraphPad Soft -ware). The risk of complications was calculated for both female and male dogs using a 2x2 table, and the risk ratio and its 95% CI were calculated with sta -tistical software (OpenEpi). If the CI of the risk ratio excluded 1.0—that is, excluded a ratio of no risk—a difference in the risk of complication between males and females was concluded.17ResultsSixty-one dogs were included in the study. The median age was 6 years (range, 2 to 13 years; Ta-ble 1 ). Twenty-five dogs were female (23 spayed, 2 intact) and 36 dogs were male (23 neutered, 13 intact). The most frequent breed was Dachshund (n = 32 dogs), with other breeds represented by 4 or less: Poodle cross (4), Heeler (4), Terrier cross (3), Maltese (2), French Bulldog (2), Staffordshire Bull Terrier (2), Cocker Spaniel (2), Labrador (1), German Shorthaired Pointer (1), Cavalier King Charles Span -iel (1), Shih Tzu (1), Beagle (1), Akita (1), Papillon (1), Basset Hound (1), Pomeranian (1), and Kelpie (1). The median body weight was 8.8 kg (range, 4.0 to 54.0 kg; Table 1).The modal neurologic grade at time of presenta -tion was 4 (range, 2 to 5; Table 2 ). Four dogs neurolo -calized to the C1-C7 spinal cord segment. Fifty-seven dogs neurolocalized to the T3-L3 spinal cord segment. Of the 57 dogs localizing to T3-L3, the most common sites were T12-13 (n = 23 dogs), T13-L1 (13 dogs) and T11-12 (6 dogs). Fifty-one dogs were diagnosed with IVDE (Hansen type I), 7 dogs were diagnosed with a low-volume/high-velocity disk extrusion, and 3 dogs were diagnosed with ischemic myelopathy.Fifty-one dogs underwent decompressive sur -gery (all IVDE Hansen type I), and 10 dogs under -went nonsurgical (conservative) management. The median number of days from presentation to cystos -tomy tube placement surgery across all dogs was 4 (range, 0 to 12 days; Table 1). For dogs that under -Figure 1 —Cystostomy tube placement in a male dog. The dog is in dorsal recumbency with its head toward the top of the images. A—A limited parapreputial incision is made through the skin and subcutaneous tissue (black dashed line). B—The penis is retracted laterally to identify the linea alba, which is incised. C—Two stay sutures are placed between the urinary bladder and the body wall to create a cystopexy. The Foley catheter is placed into the urinary bladder through a cruciform stab incision and is inflated. D—The stay sutures are tied to complete the cystopexy. The subcutaneous tissues and skin are closed. The Foley catheter is secured to the skin using a finger-trap suture.Table 1 —Quartiles describing age, body weight, days from presentation to cystostomy tube placement, days from tube placement to discharge, and days from cystostomy tube placement to removal for 61 dogs with intervertebral disk extrusion or ischemic myelopathy undergoing tube cystostomy for urinary outflow management.Variable Minimum Q1 Median Q3 MaximumAge (y) 2 4 6 8 13Body weight (kg) 4.0 6.8 8.8 14.7 54.0Days from presentation to tube placement 0 2 4 5 12Days from tube placement to discharge 0 1 1 1 3Days from tube placement to removal 3 14 19 28 74Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 12/11/23 09:46 AM UTC4 went decompressive surgery, the median number of days from decompressive surgery until cystostomy tube placement surgery was 4 (range, 0 to 12 days), day 0 being the day of decompressive surgery. The modal neurologic grade at the time of cystostomy tube placement was 4 (range, 3 to 5; Table 2). At cys -tostomy tube placement surgery, a 6F Foley catheter was placed in 2 dogs (median body weight, 4.0 kg; range, 4.0 to 4.1 kg), an 8F Foley catheter was placed in 27 dogs (median body weight, 7.3 kg; range, 4.1 to 25 kg), a 10F Foley catheter was placed in 32 dogs (median body weight, 11.4 kg; range, 5.1 to 35.0 kg), and a 12F Foley catheter was placed in 1 dog (54.0 kg). The median number of days from cystostomy tube placement surgery to discharge across all dogs was 1 (range, 0 to 3 days).Follow-up data were available for 56 of 61 dogs. The median number of days from cystostomy tube placement surgery until removal was 19 (range, 3 to 74 days; Table 1). The cystostomy tube was in place for 0 to 7 days for 3 dogs (0 representing the day of placement), 8 to 14 days for 11 dogs, 15 to 21 days for 17 dogs, 22 to 28 days for 9 dogs, and 29 to 35 days for 8 dogs. The cystostomy tube was in place for over 35 days in 3 dogs. The modal neurologic grade at the time of cystostomy tube removal was 2 (range, 2 to 3; Table 2).Complications were reported in 21 of 56 dogs with follow-up data available (38%). Fifteen dogs had minor complications (71%). Six of 15 dogs inadver -tently removed the cystostomy tube, but conscious voiding was observed, and the cystostomy tube was not replaced. Peristomal urine leakage from the stoma was reported in 6 of 15 dogs. Peristomal skin irritation was reported in 2 of 15 dogs. The finger trap suture loosened in 1 dog and the suture was replaced. Six dogs had severe complications (29%). Five of the 6 dogs inadvertently removed the cystos -tomy tube but were not able to void consciously, ne -cessitating surgical replacement of the cystostomy tube. The other severe complication was inflamma -tion and necrosis of the subcutaneous fat surround -ing the cystostomy tube stoma in 1 dog, requiring a second cystostomy tube to be placed in a new lo -cation, with successful open wound management of the original stoma. The risk of developing a compli -cation for males and females was 0.44 and 0.2, re -spectively. The risk of developing a complication was not higher for males compared with females (refer -ence range, 2.2; 95% CI, 0.9 to 5.2).Urine culture and sensitivity was performed following placement of the cystostomy tube for 13 dogs due to clinical suspicion of urinary tract infec -tion (UTI); a positive culture was confirmed in 11 of 13 dogs (85% of dogs tested, 20% of dogs with fol -low-up data available). Cultured bacteria were Esch -erichia coli (n = 3), Enterococcus (3), Staphylococcus pseudointermedius (1), Klebsiella (1), and Proteus (1). One dog yielded cultures of both E coli and En-terococcus . The bacteria cultured was not recorded in 3 dogs.Reasons for cystostomy tube removal included intentional removal after conscious urination was confirmed in 38 dogs, inadvertent dislodgement by 11 dogs (replaced in 5 dogs), cystostomy tube puncture in 1 dog, and dehiscence of the stoma site requiring subsequent indwelling urinary catheter placement in 1 dog. Five dogs were euthanized with Table 2 —Neurologic grade using the Modified Fran -kel Score (MFS) at time of presentation and cystos -tomy tube placement for 61 dogs with intervertebral disk extrusion or ischemic myelopathy undergoing tube cystostomy for urinary outflow management. Neurologic grade (MFS) at time of cystostomy tube removal is also reported for 51 dogs with long-term follow-up that were not euthanized with the cystostomy tube in place. The modal score for the cohort is bolded. At time of At time ofNeurologic At time cystostomy cystostomygrade (MFS) of presentation tube placement tube removal1 0 0 02 4 0 393 19 5 124 28 44 05 10 12 0Question 1: How would you rate the cystostomy tube in terms of: ease of use?1—Very difficult to use 2—Difficult to use 3—Neutral 4—Easy to use 5—Very easy to use0 1 4 11 11Question 2: How would you rate the cystostomy tube in terms of: daily time com mitment?1—Very large time 2—Large time commitment 3—Neutral 4—Low time commitment 5—Minimal time commitment commitment2 1 4 13 7Question 3: How many times per day did you empty your dog’s bladder?1–2 3–4 5–6 7–8 9+2 9 12 4 0Question 4: Did you have any difficulties using the tube?Yes No8 19Table 3 —Owner responses to an online-distributed questionnaire describing cystostomy tube use, for 27 client-owned dogs with intervertebral disk extrusion or ischemic myelopathy undergoing tube cystostomy for urinary outflow management.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 12/11/23 09:46 AM UTC 5the cystostomy tube in place, at days 5, 9, 11, 34, and 60. Reasons for euthanasia included clinical sus -picion of progressive myelomalacia (n = 1 dog) and lack of clinical improvement (4 dogs). No dogs were euthanized for cystostomy tube-related reasons. None of the dogs that were euthanized with the cys -tostomy tube in place had a reported complication.Twenty-seven owners responded to the ques -tionnaire (44% response rate). When questioned on the ease of cystostomy tube use, 22 of 27 (81%) own -ers reported that the cystostomy tube was easy or very easy to use (Table 3) . When questioned on daily time commitment, 20 of 27 (74%) owners reported that the daily time commitment was low or minimal. Most owners aspirated the cystostomy tube between 3 and 6 times daily (78%). Owner-reported difficul -ties in using the tube were inadvertent dislodgement by the dog (n = 4) and intermittent resistance within the cystostomy tube when aspirating urine (2).

Question 85

Lane - 2024 - JAVMA - Synthesis of surgeon and rehabilitation therapist treatment methods of bicipital tenosynovitis in dogs allows development of an initial consensus therapeutic protocol.pdf

Answer 85

A survey was developed to test these hypoth -eses. Ten individuals experienced in the treatment of bicipital tendinopathy (5 VS, 4 RTh, and 1 DB) were asked to provide feedback on a pilot survey. Based on that feedback, the survey was revised, shortened, and made available to a targeted audi -ence. Specifically, it was promoted by each of the American and European Colleges of Veterinary Surgeons and VSMR to members of the Veterinary Orthopedic Society, as well as multiple private list -serv and social media groups with specialist VS and VSMR status members, and to groups with re -habilitation certification (listserv@list.vsmr.org, or -tholistserv@groups.io, https://www.facebook.com/groups/752787724869613, https://www.facebook.com/groups/976440089198714, https://www.face -book.com/animalrehabdivision, and https://groups.io/g/VetRehab). The survey can be accessed at https://www.surveymonkey.com/r/SVHPSN3.The survey asked for respondents’ academic cre -dentials, experience treating biceps disease, and their thoughts on whether transecting the BT contributed to either shoulder joint instability or secondary mor -bidities. Further, respondents were presented with 3 case scenarios that shared a common signalment, that of a “30-kg spayed female 4-year-old field bred Labrador Retriever with whom the owner intends to hike off leash through mountainous terrain for hours at a time, as well as compete in agility with aspira -tions to make the podium at a national level. There is a 2/5 left forelimb lameness evident at all times, but minimal off-leash running will cause the lame -ness to become 3/5. It has progressively worsened over the last 6 weeks. In all cases, the owner is highly motivated to receive the best treatment possible and there are no financial or aftercare restrictions.”Case 1 illustrated a normal BT but moderate im -pingement from the supraspinatus tendon, resulting in a secondary bicipital tenosynovitis. Cases 2 and 3 illustrated a normal shoulder joint except for tenosy -novitis secondary to pathology of the BT, which dem -onstrated macroscopic tearing affecting 75% (Case 2) and 20% (Case 3) of its cross-sectional surface area.After 10 weeks, the survey was closed and the col -lected data submitted for statistical analysis. Eligible respondents were divided into 3 groups (VS, RTh, and DB). VS consisted of board-certified veterinary surgi -cal specialists and surgical residents who had not yet achieved boarded status. Members of this category may or may not also have had CCRT or CCRP certifica -tion. RTh included board-certified VSMR specialists, VSMR residents who had not yet achieved boarded status, and veterinarians who had completed CCRT or CCRP programs. Individuals who had completed board-certified designation in both surgery and VSMR were deemed DB. Furthermore, only respondents who had treated a minimum of 6 cases of biceps ten -dinopathy or tenosynovitis were included.Statistical analysisFor each of the 3 cases, tests of association of conservative versus surgical treatment and the 3 groups were by means of a Fisher exact test with Bonferroni correction for multiple comparisons of the 3 groups. Prognosis with CTx was an ordinal scale (1, 2, 3, and 4); comparisons of groups were by means of the Wilcoxon rank sum test with Bon -ferroni correction for multiple comparisons. Com -parisons of the 19 different modes of conservative therapy between the 3 groups, for each of the 3 Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 01/27/24 05:24 PM UTC 3cases and/or the 3 cases combined, were by means of the Kruskal-Wallis test with post hoc Dunn test and multiple comparisons corrected by Bonferroni. A P value < .05 was considered significant. Data were re -ported as frequencies, mean, median, SD, and 25th to 75th quartiles. The Shapiro Wilk test of normality was used to assess normality. All calculations were made by means of available software (NCSS version 2019; NCSS Statistical Software).ResultsA total of 223 individuals met the inclusion crite -ria: 140 VS, 65 RTh, and 18 DB. The survey response rate could not be calculated because the total num -ber of survey recipients was not quantifiable.Responses to the questions asking whether “transecting the BT increases the chance of second -ary shoulder region morbidities or degeneration long-term that will result in clinically relevant gait changes,” or “the BT contributes to shoulder stability in any meaningful way,” are shown (Tables 1 and 2) .For situations in which the biceps tendon is healthy but the patient is experiencing tenosynovitis secondary to supraspinatus impingement, 94.70% of respondents felt that CTx was the best initial thera -peutic approach, including 100.00% of RTh, 92.68% of VS, and 84.62% of DB (Tables 3 and 4) . RTh felt that the prognostic outcome of CTx was significantly better than that of a surgical approach, but DB and VS both felt that either approach yielded a similar prognostic outcome (Table 5) .For situations in which the majority (75%) of the biceps is torn, 68.30% of respondents felt that surgery was the best initial therapeutic approach. Only 32.76% of RTh felt surgery was the best initial therapeutic ap -proach, compared to 82.64% of the remaining groups choosing surgery (Tables 3 and 4). VS and DB both Group Don’t know Always It depends Never TotalVS Count 53 5 40 42 140 % within row 37.90% 3.60% 28.60% 30.00% 100.00%RT Count 24 16 25 0 65 % within row 36.90% 24.60% 38.50% 0.00% 100.00%DB Count 3 3 7 5 18 % within row 16.70% 16.70% 38.90% 27.80% 100.00%Total Count 80 24 72 47 223 % within row 35.90% 10.80% 32.30% 21.10% 100.00%DB = Double boarded. RTh = Sports medicine and rehabilitation therapist, either boarded specialist or DVM with additional nonspecialist certification. VS = Boarded veterinary surgeon.Table 1 —Responses when survey participants were asked whether “transecting the biceps tendon [BT] increases the chance of secondary shoulder region morbidities or degeneration long-term that will result in clinically relevant gait changes.”Table 2 —Responses when survey participants were asked, “does the BT contribute to shoulder stability in any meaningful way?”Group Don’t know Always It depends Never TotalVS Count 29 36 36 39 140 % within row 20.70% 25.70% 25.70% 27.90% 100.00%RT Count 8 35 20 2 65 % within row 12.30% 53.80% 30.80% 3.10% 100.00%DB Count 5 8 3 2 18 % within row 27.80% 44.40% 16.70% 11.10% 100.00%Total Count 42 79 59 43 223 % within row 18.80% 35.40% 26.50% 19.30% 100.00%See Table 1 for key.Table 3 —Preference by group on decision between conservative and surgical treatment for each case scenario. Case 1 Case 2 Case 3Group CTx Sx Total CTx Sx Total CTx Sx TotalVS Count 123 9 132 23 106 129 99 26 125 % within row 93.20% 6.80% 100.00% 17.80% 82.20% 100.00% 79.20% 20.80% 100.00%RT Count 61 0 61 39 19 58 54 0 54 % within row 100.00% 0.00% 100.00% 67.20% 32.80% 100.00% 100.00% 0.00% 100.00%DB Count 13 2 15 2 13 15 11 3 14 % within row 86.70% 13.30% 100.00% 13.30% 86.70% 100.00% 78.60% 21.40% 100.00%Total Count 197 11 208 64 138 202 164 29 193 % within row 94.70% 5.30% 100.00% 31.70% 68.30% 100.00% 85.00% 15.00% 100.00%CTx = Conservative therapy. Sx = Surgery.See Table 1 for remainder of key.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 01/27/24 05:24 PM UTC4 felt that the surgical prognosis was significantly bet -ter than the CTx prognosis, but RTh felt both surgery and CTx had a similar prognostic outcome (Table 5).For situations in which the minority (20%) of the BT is torn, 85.0% of respondents felt that CTx was the preferred initial therapeutic approach. RTh were unanimous in this assessment, whereas 20.8% of VS and 15.00% of DB still felt that surgery was the better initial therapeutic approach (Tables 3 and 4). RTh felt strongly ( P < .0001) that CTx had a better prognosis, but VS felt strongly ( P < .0001) that surgery had a better prognosis and DB felt both surgery and CTx yielded a similar prognostic outcome (Table 5).For all 3 cases, the decision between surgery versus CTx as an initial therapy was not affected by respondents’ experience. However, more experi -enced respondents were significantly more likely to ascribe a better prognosis for CTx in resolving Cases 1 and 3 when compared to less experienced respon -dents. This difference did not hold for Case 2. For all 3 cases, less experienced respondents tended to as -cribe a better prognosis for surgery when compared to more experienced respondents, but this differ -ence was not statistically significant.There were significant differences in selection of CTx options (modalities) between groups. Modal -ity selection between groups is listed in descend -ing order of frequency (Table 6) . Post hoc analysis determined that, compared to VS, RTh are signifi -cantly more likely to employ therapeutic exercise (rehabilitation therapy), extracorporeal shockwave (ESWT), IA platelet-rich plasma (PRP), therapeutic ultrasound, intralesional “stem cell” injections, and pulsed electromagnetic field therapy (PEMF). Com -pared to both DB and VS, RTh were significantly more likely to employ exercise restriction and pho -tobiomodulation (laser). Compared to VS, RTh were significantly less likely to prescribe NSAIDs and in -tralesional corticosteroids. Compared to both DB and VS, RTh were significantly less likely to use IA corticosteroids. Although RTh were less likely to se -lect cage rest compared to VS, this difference was not statistically significant.Intralesional hyaluronic acid and external coap -tation were infrequently employed, selected by 2% and 1% of respondents, respectively. Eleven percent of respondents provided text answers under the cat -egory of “other,” but the majority did so as a means to Table 4 —The P value for the post hoc comparisons of the 3 groups testing for preferred treatment of cases 1, 2, and 3. Since there were 3 comparisons, the type I error rate of 0.05 was protected by Bonferroni correction, where critical P = .017 (significant comparisons are bolded). Case 1 Case 2 Case 3 Group DB VS RT DB VS RT DB VS RTDB — .31 .46 — 1.00 .0001 — 1.00 .007VS — — .06 — — .0001 — — .0001RT — — — — — — — — —See Table 1 for key.Table 5 —Comparison of prognosis for CTx versus Sx by group and experience level. Case 1 Case 2 Case 3 WRST P values WRST P values WRST P values by group by group by groupVS .03 < .0001 < .0001RT < .0001 .56 < .0001DB .93 .006 .83Combined .13 < .0001 .29 WRST P values by WRST P values by WRST P values by No. of cases treated No. of cases treated No. of cases treated6–25 .29 < .0001 .00526–100 .1 < .0001 .87> 100 .003 .12 .08 Mean difference Mean difference Mean difference (CTx-Sx) by group (CTx-Sx) by group (CTx-Sx) by groupDB .05 1.18 .18VS .18 1.15 .34RT 1.26 .03 .73 Mean difference (CTx-Sx) Mean difference (CTx-Sx) Mean difference (CTx-Sx) by No. of cases treated by No. of cases treated by No. of cases treated6–25 .04 1.03 .2426–100 .29 .79 .00> 100 .95 .48 .51Bolded italics denote a negative number. WRST = Wilcoxon rank sum test.See Tables 1 and 3 for remainder of key.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 01/27/24 05:24 PM UTC 5elaborate on their treatment regimens (eg, to clarify the number of PRP injections they would employ, that underwater treadmill would be included within their therapeutic exercise program, or that the motive for injecting the biceps tendon with corticosteroids was to induce necrosis). Manual therapy and acupuncture, suggested by a few respondents, were the only addi -tional therapy options that did not already belong to the CTx modalities offered in the survey.

Question 86

Kang - 2023 - VETSURG - Accuracy of a 3-dimensionally printed custom endoscopy port for minimally invasive ventral slot decompression in dogs - A cadaveric study.pdf

Answer 86

2.1 |Cadaveric specimensFifteen mixed-breed cadaveric dogs weighing3.1-34.4 kg were included in the study. The dogs wereeuthanized for reasons unrelated to the study. Writtenconsent for use of the dogs was obtained from theowners. The study was approved by the institutionalanimal care and use committee of Jeonbuk NationalUniversity (Number: JBNU 2021 –0173). All cadaverswere initially stored at /C020/C14C. To thaw the cadaversfor the study, they were stored at /C04/C14Cf o r7 2hb e f o r esurgery.2.2 |Production of 3DEPsComputed tomography (CT) images of the cervical verte-bral column of the cadaveric dogs were acquired (1 mmslice thickness; Toshiba Alexion 16; Toshiba MedicalSystem, Tochigi, Japan). The resultant Digital Imagingand Communications in Medicine images were importedinto medical image software (3D Slicer, National Alliancefor Medical Image Computing, Boston, Massachusetts).The cervical vertebrae, including C3 and C4, were indi-vidually segmented and 3D models of the bones were cre-ated. Smoothing (median smoothing method, kernel size:10 mm) and the wrap solidify effect (region: outer sur-face, carve holes: enabled, minimum hole size: 10 mm)were applied to the 3D mesh. Stereolithography files ofthe 3D models of bones were exported to computer-aideddesign software (Fusion 360, Autodesk, San Rafael, Cali-fornia), and a virtual 3DEP was created for each speci-men. For consistency, all 3DEPs were manufactured forventral slot decompression between C3 and C4. Each3DEP consisted of a tunnel and tubes for fixation to thevertebral body (Figure 1).For the area where the tunnel came into contact withthe ventral surface of the cervical vertebral body, widthand length were set according to standard ventral slotsurgery measurements (a third of the vertebral bodylength and half of the vertebral body width);16tunnelwall thickness was set at 2 mm to ensure stability(Figure 1). To prevent the surrounding soft tissue or skinfrom entering the tunnel and interfering with the surgicalwindow, we set the tunnel height 1.5 cm higher than theskin at the incision area, based on preoperative CTimages. Each tunnel was designed based on the linebisecting the center of the dorsal spinous process and ver-tebral body in the transverse view (Figure 2A,B ). Thisline (ie, the reference line) was used as the intended drilland screw trajectory for CT evaluation after surgery.Tubes were attached to the cranial and caudal sides ofthe tunnel to facilitate screw fixation of the 3DEP to thevertebral body. The optimal screw length for screw fixa-tion without causing spinal cord damage was determinedusing the section analysis function in Fusion 360. Ahemispherical structure was designed to allow the screwhead to be seated. A cylinder that functioned as a glidinghole was then added to the tube (Figure 2C,D,I ). To limitthe risk of iatrogenic spinal cord damage during drillingthe vertebral body inner cortex, drill stoppers were manu-factured so that the drill bit could only enter the spinalcanal by 0.5 mm (Figure 2E-H ). The inner diameter ofthe tube was set at 4.5 mm to allow space for the screw-driver to enter. The wall thickness of each tube was2 mm to ensure stability (Figure 2I).KANG ET AL . 1159 1532950x, 2023, 8, To create an animal-specific endoscopy port, we usedBoolean subtraction to subtract the overlapping region ofthe 3DEP from the mesh of the vertebral surfaces of C3-C4.After this process, the base of the 3DEP was contoured thecortex in a unique position (Figure 3). To implement theMISS approach during 3DEP installation, we designed cus-tom dilators based on a tubular retractor system (Figure 4).The outer diameter of the largest dilator was designed to beequal to the internal width of the tunnel (Figure 4H). Thegap between the dilators was designed to be at least 0.5 mmto limit friction and binding between the dilators(Figure 4I). The bottom portion of each dilator was beveledto facilitate tissue dissection (Figure 4J,K).The vertebral models (Figures 2Hand 3B,D ) wereprinted using a resin 3D printer (A1, Sindoh Inc., Seoul,Korea) and a photopolymer resin (Standard +, GraphyInc., Seoul, Korea). Each 3DEP was printed using a resin3D printer (Pixel One, Zerone Inc., Gyeonggi, Korea) andFIGURE 1 Overall appearance of the 3D printed animal-specific endoscopy port (3DEP) considering the theoretically ideal slot widthand length. (A,B) The slot was created using a 3-dimensional (3D) design software after designing the slot width (transparent green coloredarea) to be less than half of the widest part of the vertebral body. (C) The slot length (green colored area) was designed to be less than a thirdof the length of each vertebral body.FIGURE 2 (A-G) Detailed components and design process of the 3D printed animal-specific endoscopy port (3DEP) for minimallyinvasive cervical ventral slot (MICVS) decompression. (H) The 3DEP and drill stopper were placed on the 3D (3-dimensional)-printedbiomodel of the vertebrae to subjectively assess fit. (I) Enlarged image of the cross-sectional shape of the tube. *, hemispherical structure;C, cylindrical structure.1160 KANG ET AL . 1532950x, 2023, 8, a photopolymer resin for dental use (ZMD-1000BCLEAR-SG, Dentis Inc., Daegu, Korea). After printing,each 3DEP was washed using 95% isopropyl alcohol,dried for 30 min, and was ultraviolet-light cured at awavelength of 405 nm for 60 min (3DP-100 S, Cubicon,Gyeonggi, Korea). This study used cadavers so the 3DEPswere not sterilized before use.2.3 |Experimental groupTo evaluate the accuracy of the 3DEP, we used randomi-zation software ( http://www.random.org/ ) to determinewhich vertebrae (C3 or C4) would have a screw insertedfirst and which of the 2 surgeons would perform that firstinsertion. We also determined the number of times eachsurgeon performed the ventral slot procedure and theanimals on which they would operate. Each screw wasinserted by an experienced surgeon (lead author, 7 yearsof specialized training in surgery after graduation from acollege of veterinary medicine, n=15) or by an inexperi-enced surgeon (2 years of specialized training in surgeryafter graduation from a college of veterinary medicine,n=15). Eight slot procedures were performed by theexperienced surgeon and 7 were performed by the inex-perienced surgeon.2.4 |Cadaveric surgeryBefore the cadaveric experiment, 2 surgeons performedrehearsal surgeries using a 3D-printed vertebrae bonemodel. All cadavers were positioned in dorsal recum-bency for the ventral approach to the cervical spine. Thisposition was maintained during the procedure using animmobilization mattress (Vaccumat, Genia, Saint-Hilairede Chaléons, France) to secure each cadaver. The MISSapproach to the surgical site was performed by the leadauthor (JSK). After identifying the C3-C4 intervertebraldisc space using intraoperative fluoroscopy (ZEN-2090Pro, Genoray Inc., Gyeonggi, Korea), a skin incision wascreated to fit the 3DEP. The length of the skin incisionwas determined based on length of the 3DEP. After thestandard median approach, dissection was performed toexpose and retract the trachea, esophagus, recurrentlaryngeal nerve, and left carotid sheath to the left. Tominimize damage to vital structures, a periosteal elevatorand digital retraction were used. Using intraoperativefluoroscopy visualization, a guide pin (1 mm Kirschnerwire) was inserted into the C3-C4 disc space parallel tothe spinous process. A periosteal elevator was used tomaintain retraction (Figure 5A). The first dilator wasplaced over the guide pin until it contacted the ventralvertebral bone. The guide pin was then removed(Figure 5B). The operative field was widened by insertingthe second and third serial dilators (Figure 5C). The3DEP was then inserted over the dilators. After the dila-tors were removed, the tendinous insertion of the longuscolli muscle was transected and elevated from the verte-bral body using a periosteal elevator through the tunnelbefore compressing the 3DEP to the bone. Fluoroscopywas used to confirm the correct position of the 3DEP overthe planned bone surface. Maintenance of the position ofthe 3DEP without substantial deviation when manualforce was applied in the craniocaudal and mediolateraldirections was also confirmed. The remaining musclesFIGURE 3 (A,C,E,F) Overall appearance of the 3-dimensional(3D) printed animal specific endoscopy port (3DEP) for minimallyinvasive cervical ventral slot (MICVS) decompression modeledusing a design software. (B,D) The 3DEP applied to a 3D-printedbiomodel of the vertebrae.KANG ET AL . 1161 1532950x, 2023, 8, and soft tissues were dissected away from the bone usinga microrongeur and periosteal elevator.Each 3DEP was held in place manually. A 1.0/1.2drill sleeve (ABLE Inc., Jeonju, Korea) was placed intothe tube, and each vertebra was drilled using a 1.0 mmdrill bit (ABLE Inc.) with a 3D printed stopper manufac-tured to ensure that the drill bit safely penetrated bothcortices. The bicortical placement of a stainless-steel self-tapping 1.2 mm cortical screw (ABLE Inc.) was then per-formed. As the screw head was seated on the hemispheri-cal structure, the 3DEP was compressed to the bone(Figure 5D,E ). After screw placement, we used intrao-perative fluoroscopy to check whether the 3DEP wasfixed in the correct position. After the remaining soft tis-sue was carefully removed using a microrongeur, theintervertebral disc space was identified and exposedthrough the tunnel. Electrocautery was then used to cutthe tendinous insertions of the longus colli muscles(Figure 5F).The remainder of the surgical procedure was per-formed via endoscopy-assisted microsurgery. The spinalendoscope (Richard Wolf GmbH, Knittlingen, Germany)had an outer diameter of 5.9 mm and a usable length of207 mm. It contained optics and a working channel(diameter: 3 mm, vision angle: 25/C14). Initially, the endo-scope was introduced in the 3DEP, the ventral tuberclewas removed using rongeurs, and the annulus fibrosuswas excised using a 2.8 mm angled slit knife (TecfenMedical, Santa Barbara, California) and a microrongeur(Richard Wolf GmbH) (Figure 6A,B ). To create the slot, aFIGURE 4 (A-G) Three-dimensional (3D)-rendered images of the design and use of dilators for the minimally invasive spine surgery(MISS) approach. The smallest dilator was placed over the guide pin; the larger dilators were inserted to expand between the soft tissues; a3D-printed animal specific endoscopy port (3DEP) was installed; and the dilators were removed. (H) The outer diameter of the largest dilatoris designed to be equal to the narrow distance of the tunnel. (I-K) Sharp-shaped dilators to facilitate tissue dissection. P, guide pin; 1, firstdilator; 2, second dilator; 3, third dilator.1162 KANG ET AL . 1532950x, 2023, 8, FIGURE 5 Implantation of 3-dimensional (3D) printed animal specific endoscopy port (3DEP). (A) Retraction of the major structureand insertion of guide pins to the disc space. (B,C) Minimally invasive spine surgery (MISS) approach using dilators. (D,E) Fixation of the3DEP and vertebral body using screws and confirmation via intraoperative fluoroscopy. (F) Surgical field after soft tissue and muscleremoval. (G) Insertion of the endoscope inside the 3DEP and suctioning of saline from the upper part of the tunnel. E, endoscope; ST,suction tip.FIGURE 6 Surgical procedure. (A,B) Excision of the annulus fibrosus using an angled slit knife (asterisk) and an microrongeur (MR).(C-F) The slot was created via high-speed surgical drilling through an intraendoscopic working channel with continuous irrigation withsaline. D, intervertebral disc; 3DEP, 3D printed animal-specific endoscopy port.KANG ET AL . 1163 1532950x, 2023, 8, high-speed surgical drill with a 2.8 mm round carbideburr (Endospine bit, ABLE Inc.) was inserted in the work-ing channel of the endoscope. The slot technique was per-formed by drilling through the i ntraendoscopic workingchannel with continuous irrigation (0.9% NaCl solution). Toavoid interference from the surgical field of view, we mainlysuctioned at the top of the tunnel. When excessive bonedebris was present, we advanced the suction tip deeper toimprove visualization (Figure 6C-F). Drilling was performedthrough the outer cortex, ca ncellous bone, and remnantdisc material until the inner cortex was identified. The dor-sal annulus and dorsal longitu dinal ligaments were resectedusing a combination of instrum ents, including a microron-geur and an angled slit knife. A 1 mm bayoneted Kerrisonrongeur and bone curettes were used to remove the innercortex (Figure 7A,B). The procedure was considered com-plete when the spinal cord was adequately visualized. Amicrorongeur and nerve root retractor were used to mimicdisc material removal and examine the spinal cord(Figure 7C-E ).2.5 |Postoperative CT and 3D softwareanalysisAll measurements were performed by a single investiga-tor (JSK). Postoperative CT images (Figure 8) wereimported into 3D Slicer (version 4.13.0) to analyze screwplacement accuracy in the 3DEP and measurement ofslot width and length. Using the 3D planning software,the screw angle in the medial and lateral directionsbetween the line for the intended screw trajectories andpostoperative screw tracts were compared using angularmeasurements. Distance deviations were compared atentry and exit points between the planned and actualpoints. For the measurement required to calculate angleand distance deviations, a line that bisected the center ofthe dorsal spinous process, and the vertebral body in thetransverse plane (previously referred to as the referenceline) was used. The length of the screw entering the spi-nal canal was also measured (Figure 9).To evaluate the safety of the slot created using the3DEP, we measured preoperative vertebral length andlength of the bone resected using the slot technique inthe sagittal plane of the 3D-rendered images of C3 andC4 (Fusion 360 section analysis function). Ventral slotlength ratio was expressed as the ratio of resected bonelength to preoperative vertebral length (Figure 10A).Ventral slot width was measured in the transverse plane.Ventral slot width ratio was expressed as the ratio of slotwidth divided by preoperative vertebral endplate width(Figure 10B). Both ratios were calculated as percentagesusing Desktop Ruler version 3.8.6498 (AVPSoft, Moscow,Russia).FIGURE 7 Surgical procedure (continued). (A,B) Removal of the inner cortex using a 1 mm bayoneted Kerrison rongeur (KR). (C-E)Mimicking removal of the disc material using a nerve root retractor (asterisk) and an microrongeur (MR). (F) Gross view of the end ofventral slot decompression. SC, spinal cord; 3DEP, 3D printed animal-specific endoscopy port.1164 KANG ET AL . 1532950x, 2023, 8, We also proposed a novel classification method to eval-uate the safety of the 3DEP by considering comprehensivelythe angle and size of slot decompression. The widest part ofthe vertebral body was divided into 4 sections (a, b, c, andd) (Figure 11A). When the slot proceeded into sections band c, which were 50% of the vertebral body width, the casewas considered safe (ie, no damage to the venous sinus, orbleeding). Otherwise, the case was classified into one of4t y p e s( F i g u r e 11B-E )( T a b l e 1).2.6 |Statistical analysisAn a priori power analysis was not performed. Descrip-tive statistics were generated for body weight, screwangle deviation, entry point deviation, exit point devia-tion, length of screw entering the spinal canal, ventralslot length ratio, and ventral slot width ratio. Continu-ous data were evaluated for a normal distribution usingthe Kolmogorov-Smirnov t est; all were found to meetFIGURE 8 Postoperative computed tomography (CT) images. (A,B,E) Transverse plane. (C,D) Sagittal plane. (F) Axial plane. T,Trachea.FIGURE 9 Postoperative 3-dimensional (3D) analysis using a 3D slicer. (A) Analysis of the screw angle deviation by measuring theangle between the RL (dashed red line) and postoperative screw tract (red line). (B) Analysis of the entry point deviation by measuring thedistance between the optimal entry point (point marked with a red dot where the RL meets the distal part of the outer cortex of the vertebralbody) and actual point. (C) Analysis of the exit point deviation by measuring the distance between the optimal exit point (point marked witha yellow dot where the reference line (RL) meets the proximal part of the inner cortex of the vertebral body) and actual point.KANG ET AL . 1165 1532950x, 2023, 8, the assumptions of a normal distribution and werereported as mean and standard deviation values. TheMann-Whitney test was u sed to compare valuesbetween experienced and inexperienced surgeons.Statistical significance was set at p<. 0 5 . S t a t i s t i c a lanalyses were performed using SPSS version 26.0 (IBM,Armonk, New York).3|RESULTS3.1 |Signalment dataFifteen cadaveric dogs met the inclusion criteria (7 mon-grels, 3 Jindo dogs, 2 shih tzus, 2 Pomeranians, 1 Mal-tese). Seven were female, and 8 were male. The medianbody weight of the cadavers was 10.25 ± 3.31 kg.3.2 |Postoperative evaluation: accuracyof the 3DEPThirty screws were inserted in 30 vertebral bodies(15 screws in C3 and 15 screws in C4). Screw angle devia-tion was 2.178 ± 0.869/C14for the experienced surgeon and2.280 ± 0.796/C14for the inexperienced surgeon ( p=.535).Entry point deviation was 1.376 ± 0.636 mm for the expe-rienced surgeon and 1.478 ± 0.733 mm for the inexperi-enced surgeon ( p=.836). Exit point deviation was 1.514± 0.754 mm for the experienced surgeon and 1.505± 0.883 mm for the inexperienced surgeon ( p=.709).Length of the screw entering the spinal canal was 0.470± 0.087 mm for the experienced surgeon and 0.560± 0.073 mm for the inexperienced surgeon ( p=.312). Nomean values (screw angle deviation, entry point devia-tion, exit point deviation, length of screw entering spinalFIGURE 10 Three-dimensional (3D) rendered images of the analysis of the ventral slot length ratio (A) and ventral slot width ratio (B).The length ratio of C3 was calculated as a/b /C2100, while that of C4 was calculated as c/d /C2100. The width ratio was calculated ase/f/C2100. The yellow-colored area represents the screw.FIGURE 11 Images of the novel classification of slot decompression. (A) If the slot proceeds inside 2 blue bars (safe zone), it isconsidered an ideal slot. (B-E) Three-dimensional (3D)-rendered images for the classification of slot decompression. The transparent greenarea indicates the passage where the slot was formed. a,b,c, and d represent the quadrants of the vertebral body width.1166 KANG ET AL . 1532950x, 2023, 8, canal) differed between experienced versus inexperiencedsurgeons (Table 2).We evaluated 15 slots and 30 vertebra (15 sections inC3 and 15 sections in C4). Ventral slot-length ratio was30.15 ± 1.86 for the experienced surgeon and 29.38± 1.61 for the inexperienced surgeon ( P=.372). Themean ventral slot width ratio was 45.60 ± 1.80 for theexperienced surgeon and 47.20 ± 1.54 for the inexperi-enced surgeon ( P=.261). The values (ventral slot lengthratio, ventral slot width ratio) did not differ between theexperienced and inexperienced surgeons (Table 3).Thirty sections were evaluated using the novel slotdecompression classification. Twenty-seven cases wereclassified as type I. However, the slots in 3 cases were cre-ated while passing through the safe zone near the innercortex but slightly deviated from the outer cortex(Figure 12). No slots were classified as type II, III, or IV.4

Question 87

MacCormick - 2023 - JAVMA - Use of a jumbo plate in dogs greater than 50 kg following tibial plateau leveling osteotomy does not prevent increase in tibial plateau angle through convalescence.pdf

Answer 87

Selection criteria and collected dataThe medical records of all canine patients from a single referral practice that had a TPLO performed by a board-certified surgeon stabilized with a lock -ing 3.5/4.0-mm jumbo TPLO plate from a single manufacturer (New Generations Devices) between January 2017 and May 2022 were retrospectively reviewed. Suspected diagnosis of CCL disease was based on physical examination and was confirmed with intra-articular evaluation. Patients that had in -complete medical records or lacked radiographic fol -low-up at the approximately 8-week postoperative period were excluded.Data collected from the medical records included signalment, physical examination findings, perioper -ative management, preoperative TPA, intraoperative joint evaluation findings, implantation chosen, and surgical technique. Lameness was scored from 0 to 5 based on physical examination findings of clinically sound, barely detectable, mild, moderate, severe, or non–weight bearing, respectively.Stifle joint evaluationIntraoperative stifle joint evaluation was per -formed via arthroscopy (n = 22) or craniomedial arthrotomy (2) allowing confirmation of a complete (17) or partial (7) CCL rupture. Meniscal pathology was diagnosed in 10 of 24 (41.6%) cases, including axial fraying of the medial meniscus (n = 1) man -aged via radiofrequency collagen shrinkage, partial meniscal tear managed via radiofrequency collagen shrinkage and meniscal release (1), or bucket handle tears or maceration of the medial meniscus (8) man -aged with partial meniscectomy. Menisci without pa -thology were either left intact (n = 10) or released via transection of the caudal meniscotibial ligament using radiofrequency ablation (4) according to the operating surgeon’s preference.Surgical techniqueFollowing a standard medial approach to the proximal tibia, all TPLOs were completed as first described by Slocum and Slocum3 with minor varia -tion. A TPLO jig was used in 13 of 24 (61.9%) cases. A TPLO saw blade with a radius of 27 mm (n = 1), 30 mm (5), or 33 mm (18) was used to produce a high tibial osteotomy with a rapidly widening cranial strut and perpendicular caudal cut within the proxi -mal tibia. The proximal segment was rotated by a mean of 12.8 mm (range, 9.5 to 17.5 mm) aiming to produce a postoperative TPA of 5°. Initial stabili -zation of the proximal segment was achieved using one or two 1.58-mm (1/16 inch) threaded k-wires placed at, or proximal to, the point of insertion of the patellar tendon on the cranial tibia and directed caudally. The k-wires were cut to the level of the tibial tuberosity and left in situ. All tibial osteoto -mies were stabilized with 8-hole locking 3.5/4.0-mm jumbo TPLO plates secured using locking self-tapping screws (Figure 1) . Screw sizes were 3.5 mm only (n = 7), 4.0 mm only (8), or a combination of both (9). An incisional block of liposomal bupiva -caine (Nocita; Elanco Animal Health) was infused in 10 of 24 cases (41.6%). The surgical site was closed routinely in 3 layers.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 12/11/23 09:44 AM UTC 3Postoperative managementPatients were administered a combination of nonsteroidal anti-inflammatories (n = 24) with gaba -pentin (21), tramadol (4), or both (1). Dogs received postoperative antibiotics (n = 9) at the discretion of the primary clinician or in a randomized fashion when concurrently enrolled in a prospective clinical study evaluating the impact of postoperative antibi -otic administration on the incidence of SSI.Rechecks and complicationsOutcome and complications were recorded from the medical records of both the institution where surgery was performed and from records of the primary care veterinarian associated with the patient. Complications were classified as pre -viously outlined into categories of catastrophic, type I major, type II major, or minor.16 Catastrophic complications included those that led to permanent unacceptable function or mortality, major compli -cations being those that required surgical treat -ment (type I) or medical treatment (type II) for res -olution, and minor complications resolving without intervention.16 The diagnosis of SSI was performed as previously described.8,17 Suspected infections were confirmed and treated on the basis of culture and susceptibility results when consented to or via empirical therapy when culture and susceptibility testing was declined. Follow-up time frames were defined as previously outlined into categories of perioperative, short term, mid term, and long term corresponding to 0 to 3 months, > 3 to 6 months, > 6 to 12 months, and > 12 months, respectively.16Radiographic evaluationThe radiographic projections obtained were me -diolateral tibial radiographs centered on the stifle joint with 90° stifle joint flexion and 90° tarsocrural joint flexion. Immediate postoperative radiographs were performed under general anesthesia. Recheck radiographs were taken approximately 8 weeks post -operatively and were performed awake or under sedation when the appropriate views could not be obtained without. TPA was measured on the imme -diate postoperative radiographs and on the follow-up radiographs using a digital radiographic viewing software by 2 individuals (1 resident in small animal surgery and 1 board-certified small animal surgeon). To calculate TPA, 1 line was drawn along the tibial axis delineated by a proximal landmark of the tibial intercondylar eminences and distal landmark of the center of the talus. A second line was drawn along the tibial plateau. Finally, the angle between a line perpendicular to the tibial axis and the tibial plateau was calculated and defined as the TPA.18 Change in TPA for each individual was calculated by subtracting the follow-up TPA from the immediate postoperative TPA. Osteotomy healing was additionally assessed on the follow-up radiographs including an orthogonal cranial-caudal tibial projection. Scores of 0 through 4 correlating to 0%, 1% to 25%, 26% to 50%, 51% to 75%, and 76% to 100% osseous bridging of the osteotomy on follow-up radiographs were assigned.19 The au -thors were blinded to patient identity by removing any patient identifiers from the digital radiographic file. The radiographs were evaluated in a randomized order to prevent influence of initial postoperative TPA value on follow-up TPA value obtained.Owner-perceived outcomesOwners of the included patients were contacted via email and telephone for participation in a ques -tionnaire. The Canine Brief Pain Inventory20 (CBPI) was performed regarding their pet’s surgical limb. Owners were asked to evaluate their overall satis -faction with their pet’s outcome and whether they would pursue the surgical intervention again in the future. Owners were questioned to ensure no further complications had been encountered that were not documented in the medical records.Statistical analysisDescriptive statistics were used to evaluate the basic properties of the data. Continuous variables were summarized by use of the mean and compared via the Student t test. Statistical software (R, version 4.3.1, The R Foundation) was used to perform sta -tistical analysis. Paired t tests were used to compare interobserver TPA. Statistical significance was set at P < .05 for all analysis.ResultsDemographics and preoperative findingsTwenty-eight stifles in 25 dogs > 50 kg un -derwent a TPLO stabilized with a locking 3.5/4.0-Figure 1 —A photograph displaying the various sizes of plates used to stabilize the proximal tibial segment fol -lowing tibial plateau leveling osteotomy (TPLO) to dem -onstrate the relative increase in size of the 3.5/4.0-mm jumbo TPLO plate used within the patients described in this report. From left to right: 3.5-mm mini TPLO plate, 3.5-mm standard TPLO plate, 3.5-mm broad TPLO plate, 3.5/4.0-mm jumbo TPLO plate.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 12/11/23 09:44 AM UTC4 mm jumbo TPLO plate between January 2017 and May 2022. Three dogs underwent staged bilat -eral TPLOs. Four cases were not presented for an 8-week radiographic recheck (inclusive of 1 stifle of a bilaterally operated patient) and therefore ex -cluded from analysis, leaving 24 stifles available to assess. The breeds of the included patients were Mastiff (n = 4), Great Dane (3), Saint Bernard (3), Old English Mastiff (3), Cane Corso (2), Great Pyr -enees (2) and one each of Newfoundland, Alas -kan Malamute, Irish Wolfhound, Mastiff mix, and Boerboel. Mean age at time of surgery was 50 months (range, 12 to 91 months). Fourteen dogs were neutered males, 8 dogs were spayed females, and 2 dogs were intact males. Mean body weight at the time of surgery was 73.2 kg (range, 52 to 93 kg) with a mean body condition score of 6.8/9 (range, 5 to 8). All dogs were noted to be lame on preoperative evaluation, with accompanying tibial thrust, stifle effusion, and medial buttress. Five patients were bilaterally lame. Lameness grades at presentation were a mean of 2.9/5 (range, 1 to 4), with a median of 3. The mean preoperative TPA was 27.38° (range, 24° to 34°).Postoperative lamenessMean immediate postoperative lameness as as -sessed the morning following surgery was 3.5/5 (range, 2 to 5), with a median of 4. Incisional re -check was performed at a mean of 14.3 days (range, 10 to 23 days) postoperatively, with mean lameness scores of 2.5/5 (range, 1 to 4), with a median of 3. Radiographic recheck was performed at a mean of 65 days (range, 51 to 96 days) postoperatively. Mean lameness score at radiographic recheck was 0.75/5 (range, 0 to 2), with a median of 1. Fur -ther recheck examinations were documented in 20 patients, with final rechecks occurring 597 days (range, 214 to 1,552) postoperatively. Thirteen pa -tients were noted to have no lameness on the surgi -cal leg at the final documented evaluation. Two pa -tients were noted to be non–weight-bearing lame at the final documented examination, one experi -encing a catastrophic complication and the other experiencing a major complication. The remaining 5 patients had no description regarding ambulation within their final documented examination.Questionnaire follow-upSeven patients were known to be deceased at the time of writing, with 1 patient euthanized as the result of a catastrophic complication. The remaining 6 patients were euthanized or passed away at a mean of 709 days (range, 214 to 1,552) postoperatively due to unrelated causes. Of the surviving patients, questionnaire data were re -trieved in 12 cases at a mean of 1,012 days (range, 388 to 2,098 days) postoperatively. The remaining 5 patients were lost to follow-up. Canine Brief Pain Inventory20 results related to the patient’s surgical limb revealed mean pain severity scores of 1.2/10 (range, 1 to 2.75), with a median of 1. Mean pain interference scores were 1.4/10 (range, 1 to 3.5), with a median of 1.08. Owners rated the patient’s quality of life as very good in 2 cases and as excel -lent in the remaining 10. Owner satisfaction with the surgical procedure was rated as satisfied in 1 case and as very satisfied in 11. Of respondents, 11 indicated they would pursue the procedure again, while the remaining respondent indicated they might consider it. Radiographic evaluationTwenty-four cases were presented for repeat radiographs at a mean of 65 days postoperatively (range, 51 to 96 days). Immediate postoperative TPA measurement obtained mean values of 5.04° (range, 3° to 8°) for observer 1 and 6.42° (range, 3° to 11°) for observer 2. Mean recheck TPAs of 5.88° (range, 4° to 8°) by observer 1 and 7.58° (range, 3° to 12°) for observer 2 were calculated. The mean change in TPA was calculated as 0.83° (range, –2° to 3°) for observer 1 and 1.17° (range, –1° to 4°) for observer 2. This increase in TPAs over time was found to be statistically significant ( P < .05) for both observers, with a P value of .02 for ob -server 1 and < .01 for observer 2. Data sets for ob -server 1 and observer 2 were statistically different, with an interobserver P value of < .01. Assessment of osteotomy healing at the radiographic recheck revealed grade 4 healing in 18 of 24 stifles (75%) and grade 3 healing in the remaining 6 of 24 (25%; Figure 2 ). Mean healing grade was 3.75, with a me -dian value of 4.ComplicationsNo intraoperative complications were recorded. The postoperative complication rate was 45.8% (n = 11/24). Perioperative complications were recorded in 7 of 24 (29%) cases and classified as minor in 1 of 24 (4.2%) cases and major in 6 of 24 (20.8%). The minor perioperative complication was diagnosis of pivot shift that resolved without intervention. Major perioperative complications were further classified into type I (n = 2/24 [8.3%]) or type II (5/24 [20.8%]). One type I major complication was a seroma overly -Figure 2 —Immediate postoperative lateromedial (A) and craniocaudal (B) and recheck lateromedial (C) and craniocaudal (D) radiographs from a 1-year-old, male neutered Saint Bernard displaying the use of the 3.5/4.0-mm jumbo TPLO plate. The recheck radio -graphs were taken 96 days postoperatively. This ra -diograph was scored as grade 4 healing. Scores of 0 through 4 were assigned correlating to 0%, 1 to 25%, 26 to 50%, 51% to 75%, and 76% to 100% osseous bridging of the osteotomy. *Two antirotation k-wires were used in this patient to provide initial stabilization of the proxi -mal segment and were left in situ.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 12/11/23 09:44 AM UTC 5ing the antirotation pin treated with a sedated pin-pull procedure, which resolved clinical signs. The second type I major complication was a persistent ulcerative lesion overlying the surgical site. Conser -vative management of a suspected lick granuloma was recommended with no improvement. Implant removal with concurrent resection of the lesion was performed 145 days postoperatively. Concurrent culture was negative. This complication occurred in one of the patients that underwent bilateral TPLO, and the contralateral implant was prophylactically removed under the same anesthetic event 201 days postoperatively. All type II major perioperative com -plications were classified as SSIs that were resolved with medical therapy.Follow-up beyond the 8-week radiographic recheck via questionnaire or clinical examination was obtained in 23 patients at a mean of 553 days (range, 145 to 2,098 days). No short-term complica -tions were encountered. One midterm type I major complication (1/24 [4.2%]) was documented 314 days postoperatively following presentation for an intermittent lameness and a draining tract. Implant removal was performed under general anesthesia, and concurrent culture confirmed Staphylococcus pseudintermedius infection. Subsequent medical management guided by susceptibility resulted in resolution of clinical signs.Three long-term complications (3/24 [12.5%]) were noted that were classified as a type I major complication, a type II major complication, and a catastrophic complication. The type I major complica -tion was diagnosed 529 days postoperatively on pre -sentation for intermittent hind limb lameness, which was unsuccessfully managed conservatively until 610 days postoperatively. Removal of the TPLO implants was then performed. The implantation was noted to be loose with moderate discharge present at the site. Cultures performed at surgery and thereafter were persistently negative. Physiotherapy and medical management of osteoarthritis were recommended, and at recheck evaluation 979 days postoperatively, the operated-upon limb had no observable lameness.The long-term type II major complication oc -curred in the same patient that experienced a peri -operative type I major complication of a suspected lick granuloma requiring surgical excision for resolu -tion. This patient had concurrent prophylactic TPLO plate construct removal of the contralateral limb and subsequently developed a new suspected lick gran -uloma on the prophylactically operated-upon limb. This was documented at the time of questionnaire 444 days postoperatively. This complication was undergoing medical management under guidance of the primary care veterinarian at the time of writ -ing with improvement described by the owner, but without resolution.The single catastrophic complication was docu -mented 1,071 days postoperatively. The patient pre -sented for severe swelling and non–weight-bearing lameness of the operated-upon limb. Removal of the TPLO implants was performed and a closed-suction drain was placed. Culture and sensitivity returned β-hemolytic Streptococcus with predictable sus -ceptibility to cephalosporins, and the patient was managed in the hospital with IV antimicrobials. The patient was released from the hospital due to over -all improvement in limb function, appetite, and de -meanor but returned 1,078 days postoperatively for general decline. Blood work revealed a severe, mod -erately regenerative anemia, azotemia, hypoalbu -minemia, severe hyperbilirubinemia, and elevation in creatine kinase. Euthanasia was elected due to over -all patient condition and financial limitation.

Question 88

Guevara - 2024 - VETSURG - Ex vivo comparison of pin placement with patient-specific drill guides or freehand technique in canine cadaveric spines.pdf

Answer 88

2.1 |Specimen collection and imagingTwenty-four medium- to large-breed canine cadaversweighing 20.9 –31.3 kg (mean 27.3 kg) were obtained forthis study through donation after euthanasia at a localanimal shelter for reasons unrelated to this study. Thestudy was approved by the University of Illinois institu-tional animal care and use committee (IACUC, protocolnumber: 18244). Computed tomographic (CT) images ofthe thoracolumbar spine were acquired for each cadaver(GE Lightspeed 16-Slice helical CT; Fairfield, Connecticut).Slice thickness was set at 0.625 mm with acquisition param-eters of 120 kVp and 12 mAs. Following confirmation ofskeletal maturity and absence of major structural abnormal-ities affecting the vertebra l column as detected by CT,cadavers were frozen at /C020/C14C until implant placement.2.2 |Drill guide design andmanufacturingDigital Imaging and Communication in Medicine(DICOM) images from each cadaveric vertebral columnGUEVARA ET AL . 255 1532950x, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14042 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 Licensewere imported into commer cial 3D modeling software(Mimics, version 19; Materialize; Plymouth, Michigan). Ver-tebral column segmentation was performed to create a vir-tual model, which was then exported to a CAD softwareprogram (3-matic version 14.0; Materialize). Planning forthe drill guides was performed with commercial 3D model-ing software (Mimics, version 19; Materialize). Using acombination of transverse a nd dorsal plane images andreconstructed CT data, paired entry and exit points wereapplied to the left and right sides of the T10-L6 vertebrae toestablish the desired pin trajectories for the 3D guides(Figure1A).52,53For each trajectory, the desired angle anddepth, in millimeters were recorded.The 3D guides were then used to plan paired entryand exit points, as well as measurements of depth. Thepins that were used were 3.2 mm and the paired pointswere then converted to virtual cylinders with an internaldiameter of 4 mm to allow for insertion of the drill sleeve.A contouring tool was used to create the base of the guidefor each vertebra of interest. The base of the guide wasdesigned so that it would conform to the caudal and lat-eral aspects of the spinous process and pertinent aspectsof the dorsal lamina and pedicle of the T11-L6 vertebra(Figure1B). For T10, the base was conformed to the cra-nial, rather than the caudal, and lateral aspects of the spi-nous process in addition to the landmarks mentionedabove. A Boolean union tool was used to merge each basewith the left and right cylinders of their respective verte-bra (Figure1C). A Boolean subtraction tool was thenused to remove each vertebra and the ventral portions ofthe left and right cylinders from their base. A label wasapplied to the left side of each guide denoting the sideand vertebra. The virtual guide data were then convertedto stereolithography (STL) files in preparation for3D printing (Figure1D). Stereolithography (STL) files forthe drill guides were then exported to a selective-sintering system for additive manufacturing (Formiga P100, EOS Gmbh; Krailling, Germany) using white poly-amide 12 powder (PA 2200, EOS Gmbh).2.3 |Implant placementFour cadavers each were randomly assigned to one of sixveterinarians with varying levels of experience(two board-certified neurologists/neurosurgeons, twoFIGURE 1 Steps in the production of the 3DP drill guides. (A) transverse Digital Imaging and Communication in Medicine (DICOM)image of the second lumbar vertebra. The paired entry and exit points for the left side (red dots) and the measured depth in millimeters, ordistance between the two points. (B) Using a contour tool, the base of the drill guide (orange area) was created on top of a virtual mesh ofthe lumbar spine. The base of the guide is a mirror image of the dorsal surface of the vertebra. (C) Drill guide cylinder on top of the virtualguide. The trajectory of the cylinder is derived directly from the paired entry and exit points determined from A. (D) the virtual guides fittedto five lumbar vertebrae prior to labeling and printing. The cylinders for each guide are seen on both the right and left sides.256 GUEVARA ET AL . 1532950x, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14042 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 Licenseboard-certified small animal surgeons, one resident insmall animal surgery, and one resident in neurology/neu-rosurgery). The right and left sides of 10 thoracolumbarvertebrae (T10-13, L1 –L6) from each cadaver were thenrandomly assigned the patient-specific drill guide (3DP)or freehand technique (FH).In preparation for implant placement, each cadaverwas thawed overnight, positioned in sternal recumbency,and secured to the surgical table. A dorsal approach tothe thoracolumbar spine was performed with bilateralelevation and reflection of the paraspinal musculature.Pins were then placed in each vertebra as randomlyassigned. Each surgeon was randomly assigned six differ-ent dogs. A Latin square method was used for each of thesix surgeons to randomize the technique (FH or 3DP),side of placement (right vs. left), and vertebrae number.For example, the vertebral order may be T13, L4, T10,and so forth. The randomization of the side would consistof T13 left then right, L4 right then left, T10 right thenleft, and so forth.), and the technique would be T13 left3DP then right FH, L4 right FH then left 3DP, T10 rightFH then left 3DP, and so forth.For the FH technique, each surgeon used the preoper-ative CT images and established safe corridor guidelinesto determine desired trajectory and depth of pin place-ment as previously described.52A pilot hole was then cre-ated using a 2.8 mm stainless steel drill bit and drillsleeve (Synthes USA; Monument, Columbia) andlithium-ion battery-powered drill (Makita; La Mirada,California). A 3.2 mm stainless steel positive-profile halfpin with a trocar point (IMEX Veterinary; Longview,Texas) was then measured and marked using a perma-nent marker to indicate the desired depth of penetrationbefore placement. A double compound steel bolt cutterwas then used to trim the exposed portion of the pin.For the 3DP technique, further removal of soft tissuesfrom the vertebral surface was performed as needed tofacilitate an optimally conforming fit for the guide. Thisincluded the removal of most of the soft tissues attachedto the vertebral lamina, vertebral body, and surroundingthe articular facets (Figure2A). After confirming an opti-mal guide-to-vertebra fit via gross and visual inspection,a pilot hole was created using the 3D-printed guide asdescribed for the FH technique. As the 3D-printed guidesdid not allow the removal of the drill bit following thecreation of the pilot hole, the guide was then removedfrom the drill bit. Following the removal of the 3D-printed guide from the drill bit, the drill was reversed outof the pilot hole. The 3D-printed guide was then replacedover the pilot hole. The pin was threaded manually intothe drill guide to create purchase with the guide itselfand then the pin was advanced to the predetermineddepth (Figure2B). For both techniques (FH or 3DP), ifresistance was met when placing the second implant dueto contact with the first, contralateral pin, the implanttrajectory was slightly adjusted to allow the plannedbicortical purchase.2.4 |Postoperative assessmentTo determine if pin placement was considered accept-able, postoperative computed tomography (CT) images ofthe thoracolumbar segments were acquired using an iter-ative metal artifact reduction (iMAR) algorithm (SiemensSOMATOM Definition 128-slice CT; Munich, Germany).Slice thickness was set at 1 mm with acquisition parame-ters of 120 kVp and 250 mAs. The iMAR algorithm wasapplied to allow improved grading of pin placement. Allimages were assessed by a single board-certifiedFIGURE 2 Printed guidesin place in a correspondingcadaveric specimen. (A), 3D-printed drill guide fitted to thethird lumbar vertebra prior topin placement. (B), caudo-dorsalaspect of lumbar spine. In thelower part of the image, the left-sided pin was placed used the3DP technique and right-sidedpin placed using the FHtechnique.GUEVARA ET AL . 257 1532950x, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14042 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 Licenseradiologist (PH). Each pin was assigned a grade usingthe modified Zdichavsky classification as follows:I—optimally placed pin fully contained within the pedi-cle and vertebral body, IIa —partial penetration of themedial pedicle wall, IIb —full penetration of the medialpedicle wall (whole of pin diameter within vertebralcanal), IIIa —partial penetration of the lateral pediclewall, and IIIb —full penetration of the lateral pedicle wall(whole of pin diameter outside the vertebral canal)(Figure3).39Grades I and IIa were considered acceptableplacement whereas grades IIb, IIIa, and IIIb were consid-ered unacceptable.2.5 |Statistical analysisAna priori power analysis was performed assuming aLatin square design balancing the independent variablesof the study, which found that a sample size of 24 wasrequired.Statistical analyses were performed in the R comput-ing environment using the base “stats ”package.54Multi-variariable logistic regression analysis was used toevaluate the effect of technique, vertebra, side, surgeon,body weight, and surgery order on whether or not a pinwas placed safely within implant corridors with grades Iand Ia defined as acceptable and grades Ib, IIIa, and IIIbdefined as unacceptable. Reduced models were evaluatedafter removing variables that were not significant byanalysis of variance (ANOVA) testing. Reduced modelswere compared with the alternative hypothesis by a χ2difference test. Significance was set at p< .05 for all tests.3|RESULTSThree pins were excluded from the analysis. Surgeon5 inadvertently placed a pin on the right of T9 ratherthan T10 for cadaver #15. Two pins could not be placedby Surgeon 6 due to meeting resistance from the previ-ously placed pin on the opposite side. This occurredwhen attempting to place a left-sided pin in L2 in cadaver#13 and attempting to place a pin on the right side of L6in cadaver #6. Thus, a total of 477 3.2 mm corticalstainless-steel pins were evaluated in 240 vertebrae. Sixsurgeons with varying levels of experience, ranging fromFIGURE 3 Representative CT images of the modified Zdichavsky classification. I —optimally placed pin fully contained within thepedicle and vertebral body. IIa —partial penetration of the medial pedicle wall. IIb —full penetration of the medial pedicle wall (whole of pindiameter within vertebral canal). IIIa —partial penetration of the lateral pedicle wall. IIIb —full penetration of the lateral pedicle wall (wholeof pin diameter outside the vertebral canal).TABLE 1 Distribution of pin placement by surgeon.Surgeon 3DP FH Total14 0 4 0 8 024 0 4 0 8 034 0 4 0 8 044 0 4 0 8 053 9 4 0 7 964 0 3 8 7 8Total implants 239 238 477Abbreviations: 3DPG, three-dimensional patient-specific guide technique;FH, freehand technique.TABLE 2 Distribution of pin placement, by grade, combiningall surgeons and locations, presented as number (percentage oftotal placed with each technique). See text for grade definitions;grades I and IIa were considered acceptable placement.Grade 3DPG ( n=239) FH ( n=238)I 152 (64) 115 (48)IIa 57 (24) 51 (21)IIb 18 (8) 30 (13)IIIa 8 (3) 27 (11)IIIb 4 (1) 15 (6)Abbreviations: 3DPG, three-dimensional patient-specific guide technique;FH, freehand technique.258 GUEVARA ET AL . 1532950x, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14042 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 License2 to 15 years, placed the implants. Table 1denotes thesurgeon, number of pins placed, and the number of pinsplaced for each technique, FH or 3DP.The 3DP and FH groups accounted for 239 and238 pins, respectively. The distribution of pin placementwith both techniques is shown in Table2.F o rt h e3 D Pgroup, 209/239 (87.5%) pins were considered acceptable(grade I or IIa), and 30/239 (12.6%) pins were unaccept-able (IIb, IIIa, or IIIb). For the FH group, 166/238(69.8%) pins were considered acceptable (grade I or IIa),and 72/238 (30.3%) pins were unacceptable (IIb, IIIa,or IIIb).Results of the logistic regression analysis are shownin Table3; the final reduced model included the predic-tor variables of technique, vertebra, and surgeon. The FHtechnique had reduced odds of acceptable pin placementcompared to the 3DP technique (OR =0.28, 95% CI0.16–0.47, p< .0001). Vertebra also affected the odds ofacceptable pin placement with both the T10 (OR =0.10,95% CI 0.03 –0.28, p< .0001) and T11 (OR =0.35, 95% CI0.12–0.96, p=.05) vertebrae having lower odds ofacceptable placement when compared to the reference,L1. Relative to surgeon 1, surgeon 2 had greater odds ofacceptable pin placement (OR =9.61, 95% CI 2.79 –45.57,p=.001). There were no other surgeon effects. Therewere no interactions between the main predictorvariables.4

Question 89

Williams - 2023 - VETSURG - Clinical outcomes of the use of unidirectional barbed sutures in gastrointestinal surgery for dogs and cats - A retrospective study.pdf

Answer 89

Medical records of dogs and cats that were presented atthe Colorado State University Veterinary Teaching Hos-pital for gastrointestinal surgery from 2015 to 2021 werereviewed. The inclusion criteria were the usage of unidi-rectional barbed sutures to close one or more gastrointes-tinal surgery sites in a client-owned dog or cat.Information collected from each animal's recordsincluded age, breed, sex, presenting complaint, physicalexamination on presentation, surgical procedures performed,surgical location, gastrointestinal perforation identifiedintraoperatively, suture type and pattern used, duration ofhospitalization, short-term complications (incisional dehis-cence, infection, seroma formation, illness due to septic peri-tonitis), and long-term compli cations (septic peritonitis,adhesion, stricture, abscessation). For any situations in whichrevision surgery was necessary, the section of the bowel thathad been removed was submi tted for histopathology.Follow-up information was collected from the medi-cal records, the owners, or the referring veterinarians.Short-term complications were defined as complicationsoccurring within 14 days after surgery. Long-term com-plications were defined as any complications occurringafter 14 days. The short-term and long-term complica-tions recorded were only complications related to gastro-intestinal surgery. Short-term complications associatedwith the gastrointestinal surgery included the develop-ment of septic peritonitis related to either leakage ordehiscence of the surgical site. Septic peritonitis had to beconfirmed with cytology and or biochemistry on theabdominal fluid collected by abdominocentesis. Vomit-ing, diarrhea, tachycardia, and tachypnea were alsorecorded, however they were not necessarily related tothe gastrointestinal surgery if septic peritonitis did notdevelop. Surgical site complications were also recorded.Long-term complications included any complications(obstruction, other foreign body located at the previoussurgical site) related to the previous gastrointestinal sur-gery. If any procedures other than gastrointestinal sur-gery were performed during the initial surgery,complications related to those other procedures were notrecorded in the short or long term.Descriptive statistics are used to describe the popula-tion and report outcomes. Data are presented as medianand range.3|RESULTSTwenty-six dogs and three cats met the entry criteria. Thesame board-certified surgeon performed all the surgeries.The median age of the dogs was 4 years (range: 0.6 –13.5 years) and 1 year for the cats (range: 0.5 –1 years).The canine population included nine spayed females, oneintact female, two intact males, and 13 castrated maledogs. In the study population there were four mixed-breed dogs, three Labrador retrievers, and one of each ofthe following breeds: American pit bull terrier,Australian heeler, Bernese mountain dog, border collie,bloodhound, boxer, Cavalier King Charles Spaniel, coon-hound, corgi, Doberman pinscher, English bulldog, Ger-man shorthair pointer, Golden retriever, Irish setter,husky, mastiff, Chinese shar-pei, and shih tzu. The felinepopulation comprised two female spayed domestic shorthairs, and one male castrated sphinx.Clinical signs at the time of presentation includedanorexia and vomiting in all three cats, with one showinglethargy. Twenty-one dogs presented with vomiting,15 with anorexia, and six with diarrhea. Abdominalradiographs, abdominal ultrasounds, or both were usedto determine indications for gastrointestinal surgery.Dogs underwent surgery for a gastric foreign body (1),intestinal foreign body (15), gastric and intestinal foreign1010 WILLIAMS and MONNET 1532950x, 2023, 7, bodies (7), intestinal mass (1), adhesion secondary to amesenteric abscess (1), intestinal mesenteric volvuluswith ischemia limited to one loop of the jejunum (1), andsmall intestinal dysmotility with biopsy of the jejunum(1). Three cats underwent surgery for foreign bodyobstruction. The foreign body was linear in six dogs andone cat. Two dogs had mild septic peritonitis due to theidentification of perforation at the time of surgery. Thesurgeries were performed laparoscopically, assisted in sixcases (one cat and five dogs), and with midline laparot-omy in 22 cases. One dog had an extrahepatic portosyste-mic shunt, attenuated at the time of gastrotomy for aforeign body.The distribution of the procedures that were per-formed with unidirectional barbed sutures in dogs andcats is reported in Table 1. Four additional gastrotomyprocedures in our animal population were closed with asimple continuous suture pattern with 4 –0 glycomer631 (Biosyn, Medtronic, Minneapolis). Gastrointestinalsurgeries were performed at multiple sites on nine dogs.A4–0 unidirectional barbed glycomer 631 (VLoc 90, Med-tronic, Minneapolis) was used for 19 enterotomies, fivegastrotomies, and nine enterectomies. Two enterotomiesand one gastrotomy were performed using 2 –0 unidirec-tional barbed glycomer 631s (VLoc 90). When unidirec-tional barbed sutures were used for a gastrotomy or anenterotomy, a simple continuous suture pattern wasstarted before the incision, and it was anchored by intro-ducing the needle through the loop. The continuoussuture pattern was completed past the end of the incisionwith two extra stitches at 180/C14as recommended by themanufacturer. When an enterectomy was performed, twostrands of unidirectional sutures were used. They werepreplaced at the mesenteric and antimesenteric bordersand anchored by placing the needle through their respec-tive loop. Each strand was used to complete half of theenterectomy. Each half of the enterectomy was com-pleted by overlapping the starting point of the otherstrand with two extra stitches at 180/C14. Simple interruptedsutures with 4 –0 glycomer 631 (Biosyn) were added inone gastrotomy, three enterectomies, and three entero-tomies that were primarily closed with unidirectionalbarbed sutures to correct any substantial gaps in the sim-ple continuous closure.Short-term follow-up information was collected on29 cases, including three cats and 26 dogs. In 12 cases,university medical records were available from our hospi-tal, in 11 cases medical records were received by the pri-mary care veterinarian, and in five cases direct contactwith an owner was made. In three cases, patient informa-tion was received from multiple sources. None of thecases were diagnosed with leakage or dehiscence at thesite of gastrointestinal surgery resulting in septic peritoni-tis before discharge. One cat became tachycardic andvomited while in the critical care unit for postoperativehospitalization. Six dogs had episodes of vomiting andregurgitation, two had episodes of tachycardia and onerequired additional opioid pain medications to controlpostoperative pain. The median postoperative hospitali-zation time was 1 day (range: 1 –3 days). After being dis-charged from the hospital, one dog developed asubcutaneous seroma at the laparotomy site. Anotherdog had a surgical site infection in the skin and subcuta-neous tissue treated with antibiotics, which ultimatelyhealed after being flushed and reapposed with sutures.One dog died before suture removal from seizure compli-cations associated with an extrahepatic portosystemicshunt attenuation at the time of surgery. There were noreports of septic peritonitis in any of the cases duringshort-term follow up.Long-term follow up was collected on one cat and18 dogs. In five cases the follow-up information was col-lected from university medical records at our institution,in 10 cases it was collected from medical records receivedfrom primary care veterinarians, and in five cases directcontact with the owner was made. In one case informa-tion was collected from multiple sources. Median long-term follow up was 1076 days (Range: 20 –2179 days)after surgery. Two out of 18 dogs (11.1%) with long-termfollow up developed strictures and adhesions requiring asecond surgery 20 and 27 days after surgery. The first sur-geries for these cases were one enterectomy and oneenterotomy. At the time of the first surgery, the enterect-omy had ischemia secondary to intestinal mesenteric vol-vulus isolated to one loop of the jejunum, and theenterotomy was a foreign body removal. Both complica-tions were corrected with an enterectomy with 4 –0 glyco-mer 631 (Biosyn). The histopathological analysis for theenterectomy case reported a chronic-active, diffuse sup-purative, lymphoplasmacytic enteritis with hemorrhageand foreign material (specific details not reported) in thesubmucosa. In the enterotomy case, a multifocal muralabscess with chronic-active dystrophic mineralizationand mild suppurative enteritis was reported. There is noreported culture for the multifocal mural abscess. Followup was available in one case after the second surgery,and no further complications were reported.TABLE 1 Distribution of surgical procedures performed withunidirectional barbed sutures.Procedures Dogs CatsEnterotomy 19 2Enterectomy 9 0Gastrotomy 5 1WILLIAMS and MONNET 1011 1532950x, 2023, 7, 4

Question 90

Potamopoulou - 2023 - VCOT - Correlation between the Insertion Side of a Transcondylar Screw for the Surgical Management of Humeral Intracondylar Fissures in Dogs and the Incidence of Postoperative Surgical Site Infection.pdf

Answer 90

DogsMedical records of canine patients that underwent surgicalmanagement of a humeral intracondylar fissure betweenJanuary 2008 and January 2020 at the Grove Referrals werereviewed retrospectively. Patients were included in the studyif a humeral intracondylar fissure diagnosis was con firmedvia a computerized tomographic (CT) study, a transcondylarscrew was placed to surgically manage the humeral intra-condylar fissure and complete records of postoperativefollow-up at least 12 weeks after surgery were available.The elbows from dogs that underwent a bilateral procedurewere recorded separately, as independent surgical proce-dures. Cases with incomplete medical records and follow-updata and cases that had sustained an intercondylar fractureon presentation due to a suspected humeral intracondylarfissure were excluded.Data CollectionA Microsoft Excel (Microsoft Corporation, Redmond, Wash-ington, United States) contingency spreadsheet with thefollowing information was generated: patients ’signalment,clinical signs upon presentation, presence of incomplete orcomplete humeral intracondylar fissure on the preoperativeCT scan images, direction of placement, type and size of theutilized transcondylar screw, surgical and anaesthetic times,other surgical procedures performed under the same generalanaesthetics (general anaesthesia), additional implants thatwere used to augment the surgical fixation, presence ofconcomitant ipsilateral and/or contralateral elbow patholo-gy, perioperative and postoperative antibiotic administra-tion, postoperative complications and diagnostic testsperformed to con firm or rule out the presence of a suspectedSSI. For cases that underwent bilateral humeral intracondy-larfissure surgery under one anaesthetic episode, the surgi-cal time for each elbow surgery was recorded separately.SurgeryAll of the surgical procedures were performed by experi-enced board-certi fied surgeons (5 in total). Prophylacticperioperative antibiotic therapy included the administrationof intravenous cefuroxime (15 mg/kg) 30 minutes prior tofirst incision and then every 90 minutes intraoperatively.Surgical preparation and draping of the patients were per-formed according to standard recommendations, in a desig-nated operated room. The selection of the transcondylarscrew insertion direction via an open medial or lateralapproach was based on the surgeon ’s preference. Whereused, transcondylar screw positioning guides and also theaugmentation of the implant construction with an additionalepicondylar plate were also at the surgeon ’s discretion.Various combinations of non-steroidal anti-in flammatorymedication and opioids were used for all patients for peri-operative and postoperative pain management. Oral cefa-lexin or potentiated amoxycillin, depending on the surgeon ’spreference, was prescribed for an average of 7.5 days (5 –10days). All patients were hospitalized until adequate levels ofcomfort were reached.Surgical Site InfectionComplications were classi fied as described by Cook andcolleagues.20Those that did not warrant any further treat-ment to achieve resolution were classi fied as minor, andthose that required medical or surgical treatment wereclassi fied as major.The World Health Organization and US Centres for DiseaseControl and Prevention de finitions were followed whenmaking a diagnosis of SSI.21,22A diagnosis of SSI was madeif one or more of the following was documented: (i) purulent.surgical wound discharge; (ii) positive culture from fluid ortissue from the surgical site; (iii) heat, pain, redness, pyrexia,localized swelling at the surgical site and/or deliberaterevision surgery due to evidence of infection; (iv) bacteriaidenti fication during an in-house microscopic cytologicalevaluation of fluid or/and tissue sample taken from thesurgical site.Clinical records, up to the latest entry, from patients thatunderwent humeral intracondylar fissure prophylactic sur-gery were reviewed to document any SSI. The diagnosticmethod that was employed, the management option chosenand the final outcome were recorded for all cases of SSI. Forpatients with less than 12 weeks postoperatively follow-uprecords, the primary/referring veterinary surgeons were con-tacted via telephone and were asked to provide information asto whether the patient had returned and was clinically exam-ined at their premises after the humeral intracondylar fissuresurgery, and if any clinical notes suggested SSI.Statistical AnalysisInformation from the contingency Microsoft Excel spread-sheet was analysed with the commercially available R statis-tical software package.23A multinomial logistic regressionwas used to assess potential predictors for the outcome ofinterest (SSI vs. no SSI). This statistical model was chosen aselbows from patients with a bilaterally performed procedurewere treated as separate cases; hence, the resultant out-comes were not completely independent. Many explanatoryvariables, such as treatment (mediolateral versus laterome-dial screw), sex, age, neutering status, weight, breed, pres-ence of lameness and/or discomfort preoperatively, screwsize, operative duration, anaesthetic duration, presence ofconcomitant ipsilateral elbow pathology, other surgical pro-cedures performed under the same anaesthetic, postopera-tive antibiotic usage and other reported chronic infections(e.g. chronic dermatitis and/or underlying atopy) were testedas predictors in the initial multivariable regression modeland with the backward elimination regression approach, areduced model that best supported the data with a pless than0.05, was obtained using Wald tests.ResultsThirty- five dogs (46 elbows) met the inclusion criteria.Among those patients, 14/35 were intact males, 7/35 werecastrated males, 7/35 were intact females and 7/35 werespayed females. The median age was 3.8 years (range: 0.4 –9)and the median weight was 20 kg (range: 2.9 –46.2). Sixteenof 35 dogs were English springer spaniels, 7/35 were cockerspaniels, 5/35 were Labrador Retrievers, 4/35 were cross-breed dogs and there was 1/35 Cavalier King Charles spaniel,1/35 labradoodle and 1/35 French bulldog. Median surgicaltime was 40 minutes (range: 18 –100) and median anaesthet-ic time was 150 minutes (range: 75 –250).Twenty-one of 35 dogs had more than one surgicalprocedure being performed under the same general anaes-thesia (►Table 1 ). During the data accrual period, 5/46elbows remained with an untreated contralateral humeralintracondylar fissure. In 1/46 cases, there was evidence ofabnormal change on the CT scan of the contralateral thoraciclimb ’s humeral intracondylar region, with osseous sclerosisin the central portion of the humeral condyle and a faintradiolucent linear shadow extending a few millimetres fromthe caudal aspect of the articulation surface of the condyle. Acomplete humeral intracondylar fissure was subsequentlyidenti fied on a CT scan study at the same level, 3 years later,when the patient presented for investigation of pain andlameness of the non-operated limb.Perioperative prophylactic intravenous antibiotic medi-cations were administered to all the cases, and 28/46 casesreceived postoperative oral antibiotic therapy.The intracondylar fissure was deemed complete in 16/46elbows and incomplete in the remainder. In all cases, post-operative radiographs were taken immediately after surgeryand in 35/46 elbows imaging (radiographs or CT scan) wasperformed at a later follow-up visit and there were no overtradiographic signs of SSI.In 11/46 elbows, following a CT scan diagnosis of humeralintracondylar fissure, surgery was performed only as aprophylactic surgical intervention, without any reportedclinical signs or/and pain.In 24/46 humeral intracondylar fissures, the transcondy-lar screws were placed in a left elbow and 22/46 trans-condylar screws in a right elbow. In 15/46 elbows, thetranscondylar screw was placed in a lateromedial directionand in 31/46 elbows in a mediolateral direction. All of theimplants were cortical trauma screws and were all but oneplaced as position screws. Only one screw was inserted in alag fashion. Thirty six of 46 4.5 mm cortical, 5/46 5.5 mmcortical, 4/46 3.5 mm cortical and 1/46 2.4mm corticalscrews were used. In two of 46 elbows, a 2.7mm lockingcompression plate (DePuy Synthes; United States) was ap-plied in addition to the transcondylar screw to augment therigidity of the implant con figuration. One plate was appliedmedially along with a medial transcondylar screw. The otherplate was applied laterally, along with a lateral transcondylarscrew and had to be removed at a later time due to an SSI thatwas refractory to medical management alone.Complications were recorded in 22/46 elbows (►Table 2 ).Nine of 22 of the described complications were seromaformation and were considered minor. Five of 15 of theTable 1 Dogs undergoing more than one surgical proceduresalong with unilateral humeral intracondylar fissure surgeryunder the same anaesthetic episodeProcedures n(number of dogs)Bilateral simultaneous humeralintracondylar fissure surgery9Ipsilateral arthroscopyand medial coronoidectomy5Ipsilateral curettage ofosteochondritis dissecans lesion1Contralateral condylar fracturerepair6.lateromedial transcondylar screws, and 4/31 of the medio-lateral transcondylar screws developed a seroma. Cultureand sensitivity analysis of fluid from the surgical site swell-ing was negative for the 2/9 cases which were tested, and inall the cases the seroma subsequently self-resolved.We identi fied 13/22 major complications. Surgical siteinfection was documented in a total of 11/46 elbows. In-housefluid cytology was indicative of SSI in all elbows, culture wasperformed in 9/11 elbows and SSI diagnosis was establishedwith positive culture in 8/11 elbows. In 1/11 elbows, withpersistent lameness and pain at the elbow joint postopera-tively, the laboratory cytology results of the identi fied elbowswelling were indicative of infection with neutrophilia andintracellular cocci. The culture results showed no overt infec-tion; however, the clinical signs resolved after a protractedantibiotic medication course. Seven of 31 elbows with amediolateral transcondylar screw and 4/15 elbows with alateromedial transcondylar screw developed SSI. In 8/11elbows that developed SSI the fissure preoperatively wasincomplete. Prophylactic postoperative oral antibiotic treat-ment was prescribed in 5/11 elbows that had developed SSI.The median time from surgery to the development of clinicalsigns of SSI was 14 days (range: 7 –49). Of the 9/35 dogs withbilateral single-stage humeral intracondylar fissure surgery,4/9 developed unilateral SSI. None developed bilateral SSI.There was no statistical difference in the rate of SSI,between mediolateral and lateromedial screw placement(p<0.05). Patient weight and general anaesthesia durationwere the only statistically signi ficant positive associationswith SSI (►Table 3 ).Screw breakage occurred in 2/31 elbows with a medio-lateral transcondylar screw. In one of them, implant failurewas detected 5 months postoperatively and in the other,31 months following surgical management of an incompletehumeral intracondylar fissure. Both cases underwent revi-sion surgery, where the broken transcondylar screw wasreplaced with a larger diameter transcondylar screw (5.5 mmand 4.5mm respectively) and in one of them, a laterallyplaced locking compression plate was also used.Median clinical follow-up time was 52 weeks (range: 12 –336). All but one case attended at least one short-termfollow-up appointment at our premises. The single casethat was not seen at our premises belonged to a veterinarian,who monitored the dog ’s recovery.

Question 91

Pappa - 2023 - VCOT - Recall Bias in Client-Reported Outcomes in Canine Orthopaedic Patients Using Clinical Metrology Instruments.pdf

Answer 91

Inclusion CriteriaClient-owned dogs that presented to the orthopaedic clinicof the Small Animal Teaching Hospital, University ofLiverpool, for investigation of lameness between April 2018and February 2020 were enrolled in the study. Dogs pre-senting with an acute traumatic injury, incomplete records,or both were excluded. The study was approved by theLiverpool Veterinary School Research Ethics Committee(VREC577) and owners were provided an information sheetoutlining the study and a written consent form prior toenrolment.LOAD and CBPI QuestionnairesThe LOAD questionnaire is a 13-item instrument. Each itemis scored from 0 to 4 and the sum of all 13 items is used togenerate a final instrument score out of a maximum of 52.8Patients were also strati fied as mildly (0 –10/52), moderately(11–20/52), severely (21 –30/52), or extremely (31 –52/52)affected based on numerical scoring.30The CBPI questionnaire is a two-part instrument.14Thefirst section calculates the Pain Severity Score (PSS)and includes four items scored on an 11-point scale(0–10). The second section calculates the Pain Interfer-ence Score (PIS) and includes six items scored on an11-point scale. The sum on each section was used togenerate a PSS out of 40 and a PIS out of 60. Overallquality of life (QOL) was rated on a 5-point categoricalscale from poor to excellent.Questionnaire Completion TimelinesEach owner was asked to complete the LOAD and CBPIquestionnaires at the time of their dog ’s initial presentationto the hospital (T 0). The LOAD and CBPI questionnaires werecompleted again at 2 (T 1), 6 (T 2), and 12 months (T 3) after theinitial presentation. At these time points, owners were askedto complete the questionnaire by trying to recall their dog ’sstatus at T 0. When dogs were reassessed at the hospital at T 1,paper copies of the CMI were completed during that visit.When dogs were not scheduled to return for posttreatmentevaluation, questionnaires were completed via telephoneinterview by the authors EP and EC.Data CollectionData collected at T 0included age, gender, breed, weight,affected limb (thoracic or pelvic limb), subjective gaitanalysis (assessed on a scale from 0 to 1031and graded asmild [0 –3], moderate [4 –7], or severe [8 –10]31), diagnosisand type of management advised (surgical or conservative).LOAD scores, CBPI PSS, and PIS scores and CBPI QOL werecollected at T 0,T1,T2,a n dT 3. A LOAD categorical score (mild,moderate, severe, and extreme) was also given at the threedifferent time points, deriving from the numerical scores.The number of days at collection of CMI scores at T 1,T2,a n dT3time points were recorded. Cases where only one of thetwo questionnaires was completed at T 0were not excluded;for these cases, owners completed the same questionnaire atT1,T2,a n dT 3.Statistical AnalysisThe enrolment of 186 dogs was calculated to provide a studypower of 80% assuming moderate agreement (0.6) asassessed by the intraclass correlation coef ficient (ICC) be-tween scores of four observations and with a lower 95%confidence interval for the ICC of no less than 0.5. Datanormality was assessed using the Kolmogorov –Smirnov.and Shapiro –Wilk tests; normally distributed data are pre-sented as mean /C6standard deviation (SD) and non-normallydistributed data as median and range. Cohen ’s weightedkappa statistic ( κw) was used to measure the agreement ofLOAD categorical scoring between T 0and T 1,T0and T 2,a n dT 0and T 3.Aκwcoefficient of less than 0.2 indicates pooragreement, 0.2 to 0.4 fair agreement, 0.41 to 0.6 moderateagreement, 0.61 to 0.8 good agreement, and greater than 0.8excellent agreement.32The agreement of LOAD, CBPI PSS,and PIS scores between T 0and T 1,T0and T 2, and T 0and T 3wasassessed using the two-way mixed effects ICC and its 95%confidence intervals (95% CI). ICC of less than 0.5 indicatespoor agreement, 0.5 to 0.75 moderate agreement, 0.75 to 0.9good agreement, and greater than 0.9 excellent agreement.33The Wilcoxon signed-rank test was used to assess thedifference between paired LOAD and CBPI scores betweenT0and T 1,T0and T 2,a n dT 0and T 3. Multilevel logisticregression was performed to identify factors associatedwith the absolute difference between initial and subsequentLOAD scores. Within dog clustering of LOAD scores wasaccounted for as a random intercept term in these two-levelmodels. Any variable with a potential association withthe difference in LOAD scores ( p-value <0.3) was consideredfor inclusion into the final multivariable model; for anycorrelated variables (correlation coef ficient >0.7), onlythe variable with the lowest p-value of the pair was included.The multivariable model was constructed with a manualbackward stepwise approach with retention of variableswith Wald ’sp-values less than 0.05. A pvalue less than0.05 was considered signi ficant. Statistical analysis wasperformed using the statistical software programs SPSS25.0 (SPSS Inc, Chicago, Illinois, United States) and MLwiNVersion 3.02 (Centre for Multilevel Modelling, Universityof Bristol, UK).ResultsAnimal and Clinical DataOf the 257 dogs initially enrolled on the study, 40 wereexcluded due to incomplete questionnaires at T 0,e u t h a n a s i a ,re-homing, or owner withdrawal at T 1. Overall, 217 dogswere included for statistical analysis. Of the 77 breedsrepresented, the most common were mixed-breed dogs(n¼54) followed by the Labrador Retriever ( n¼37), EnglishSpringer Spaniel ( n¼14), Border Collie ( n¼13), GermanShepherd dogs ( n¼9), West Highland White Terriers(n¼7), and 5 each of Cocker Spaniels, Golden Retrievers,and Staffordshire Bull Terriers. There were 101 femaledogs (84 neutered) and 126 male dogs (82 neutered). Themean age was 4.8 /C63.2 years and the dogs ’mean weight was23.7/C612.2 kg. The thoracic and pelvic limbs were affected in62 and 136 dogs, respectively, and 20 dogs were diagnosedwith multilimb lameness. Lameness was graded as mild in 92dogs, moderate in 61 dogs, severe in 27 dogs; six dogsexhibited skipping lameness. Conditions were strati fiedinto eight groups: cranial cruciate ligament disease(n¼77), elbow dysplasia ( n¼44), hip dysplasia ( n¼39),unclear ( n¼14), medial patellar luxation ( n¼13), shoulderpathology ( n¼10), angular limb deformity ( n¼4), and other(n¼23, carpal osteoarthritis, tarsal osteoarthritis, elbowosteoarthritis, elbow dysplasia and concurrent hip dysplasia,medial patellar luxation and concurrent hip dysplasia, cra-nial cruciate ligament disease and concurrent hip dysplasia,caudal cruciate ligament rupture, avascular necrosis of thefemoral head, immune-mediated polyarthritis, and multi-partite sesamoids). Surgical treatment was performed in 101dogs and 116 dogs were treated conservatively. The mediannumber of days of questionnaire completion was 70, 204, and396 at T1,T2,a n dT 3, respectively.LOAD QuestionnaireThe LOAD questionnaire was completed by the owners of 83%(n¼180), 56% ( n¼121), and 36% ( n¼79) of the dogs at T 1,T2,and T 3, respectively.Numerical ScoresThere was a signi ficant difference of the LOAD scores betweenT0and all measured time points ( p<0.001) with a medianabsolute change of 5 (0 –23), 6 (0 –23), and 7 (0 –31) at T 1,T2andT3, respectively. The recalled LOAD scores were higher in 66%(n¼115), 75% ( n¼86), and 73% ( n¼54) of cases at T 1,T2,a n dT3,r e s p e c t i v e l y( ►Fig. 1 ). Therewasmoderate agreementof theLOAD scores between T 0and T 1, moderate agreement betweenT0and T 2, and poor agreement between T 0and T 3(►Table 1 ).Fig. 1 LOAD score change between ( A)T0and T 1,(B)T0and T 2,a n d( C)T0and T 3. LOAD, Liverpool Osteoarthritis in Dogs; T 0, initial presentation;T1, 2 months from initial presentation; T 2, 6 months from initial presentation; T 3, 12 months from initial presentation..Categorical ScoresThere was moderate agreement of the LOAD categoricalscoring between T 0and T 1, fair agreement between T 0andT2, and fair agreement between T 0and T 3(►Table 2 ). TheLOAD categorical scoring at T 1remained unchanged in 52%(n¼89) of cases, changed by one category in 41% ( n¼71) ofcases, and by two categories in 7% ( n¼12) of cases(►Supplementary File S1 , available in online version only).At T 2, the LOAD categorical scoring remained unchanged in45% ( n¼52), changed by one category in 46% ( n¼53) ofcases, and by two categories in 6% ( n¼7) of cases(►Supplementary File S1 , available in online version only).At T 3, the LOAD categorical scoring remained unchanged in37.5% ( n¼27) of cases, changed by one category in 49%(n¼35) of cases, and changed by two categories in 14%(n¼10) of cases ( ►Supplementary File S1 , available in onlineversion only).CBPI QuestionnaireThe CBPI was completed by the owners of 83% ( n¼179), 56%(n¼121) and 36% ( n¼77) of the dogs at T 1,T2,a n dT 3,respectively.PSS:There was a signi ficant difference of the PSS numericalscores between T 0and all measured time points ( p<0.001)with a median absolute difference of 6 (0 –27), 19 (0 –35),and 9 (0 –24) at T 1,T2, and T 3, respectively. The recalled PSSscores were higher in 66% ( n¼118), 79% ( n¼95), and 77%(n¼59) of the dogs at T 1,T2,a n dT 3, respectively ( ►Fig. 2 ).There was poor agreement of the PSS between T 0and allsubsequent time points ( ►Table 1 ).PIS:There was a signi ficant difference of the PIS numericalscores between T 0and all measured time points ( p<0.001)with a median absolute difference of 7.5 (0 –42), 35 (0 –60),and 10 (0 –45) at T 1,T2,a n dT 3, respectively. The recalled PISscores were higher in 60% ( n¼107), 68% ( n¼82), and 68%(n¼52) of dogs at T 1,T2, and T 3, respectively ( ►Fig. 3 ).There was moderate agreement of the PIS between T 0andT1, moderate agreement between T 0and T 2, and pooragreement between T 0and T 3(►Table 1 ).QOL: The QOL score agreement was fair between T 0and allsubsequent time points ( ►Table 2 ). At T 1, 66 owners (37%)recalled accurately their dog ’s QOL; the score changed byone category for 41% of cases and by two categories for18% (►Supplementary File S2 , available in online versiononly). At T 2and T 3, the QOL remained the same for 44(36%) and 27 (35%) cases, respectively ( ►SupplementaryFile S2 , available in online version only).Factors Impacting Owners ’CMI Score RecollectionUnivariable multilevel logistic regression showed that thedog ’s age, weight, gender, breed, affected limb, grade oflameness, diagnosis, and type of management were notassociated with difference between pretreatment and sub-sequent LOAD scores. The only variable associated with thedifference was the number of days between T0and LOADcompletion at follow-up ( p¼0.0001), with weight ( p¼0.27)being the only other variable eligible for inclusion in the finalmultivariable model. Weight was excluded from the finalmultivariable logistic regression, leaving days since comple-tion as the only variable showing a signi ficant association.

Question 92

Rossanese - 2023 - JAVMA - Prevalence of malignancy and factors affecting outcome of cats undergoing splenectomy.pdf

Answer 92

This retrospective study used anonymized clini -cal data and was approved by the social science re -search ethical review board of the Royal Veterinary College, University of London (approval No. URN SR2020-024). Clinical records from 4 small animal re -ferral hospitals (The Queen Mother Hospital for Ani -mals, Royal Veterinary College; Small Animal Teach -ing Hospital, University of Liverpool, Small Animal Referral Hospital Langford Vets University of Bristol, North Downs Specialist Referrals) were searched from January 2005 to November 2022 to identify cats that had undergone splenectomy. Investigators independently searched the databases of the refer -ral institutions, using the search engine available in the practice management systems, searching for the keywords “splenectomy,” “cat,” and “feline.”Cats that underwent splenectomy during the study period that had comprehensive clinical records (medi -cal history, diagnostic procedures, treatments, and follow-up) and a histologic diagnosis were eligible for in -clusion in the study. Exclusion criteria included cats that had splenectomy for a traumatic origin, cats without a definitive diagnosis or with incomplete medical records.Information retrieved from the records included signalment, clinical history, physical examination findings and preoperative blood test results: this included preoperative PCV (if a PCV was not avail -able, hematocrit was recorded and was treated as equivalent to PCV in value) and total solids (TS). Cats were defined as anemic if PCV or Hct was < 24%.17,23 Preoperative diagnostic imaging findings (including presence of a mass, splenomegaly, or both on im -aging) and cytologic and histopathologic findings. Concordance between cytologic and histologic re -ports was assessed. Overall accuracy was defined as the ability of cytology to correctly identify neoplastic and nonneoplastic lesions and was assessed as the sum of cases in which cytology and histology agreed in diagnosing a lesion as neoplastic or nonneoplas -tic, divided by the total number of cases included in the study. Cytology examinations which showed poor cellularity or preservation and were described as nondiagnostic were excluded from this analysis.Time from presentation to surgery, time from surgery to discharge, concomitant surgical proce -dures performed under the same general anesthetic, survival to hospital discharge, postoperative treat -ments and documented local or distant metastasis were also recorded. For cats that received chemo -therapy, the drug type was recorded. The reason for splenectomy was determined based on clinical, di -agnostic, and histopathological findings.The occurrence of any intraoperative and post -operative complication was recorded as well as the requirement of additional surgical intervention or medical treatment. According with Follette et al,24 complications were classified as minor, defined as complications that did not require additional surgical or medical treatment to resolve; moderate, defined as complications that required additional medical but not surgical treatment to resolve; major, defined as complications that required additional surgical treatment to resolve; death, defined as complica -tions leading to postoperative death.25Tumor progression was defined as development of nodal or distant metastasis as confirmed by cy -tology or histopathology. Post-discharge follow-up was obtained by review of electronic patient records from the referral hospital and referring veterinary practice or by calling the owners.Survival time was defined as the time from sur -gery to euthanasia or death. When the information was available, the cause of death was described as either related or unrelated to the splenic disease.Data analysisAnalyses were performed using Microsoft Excel (version 14.00; Microsoft Corp) and SPSS 26.0 (IBM SPSS statistics, version 28.0; IBM Corp). Descriptive statistics were computed for all variables. Continu -ous explanatory variables assessed included were age, body weight, duration of clinical signs, PCV, Unauthenticated | Downloaded 11/03/23 05:53 AM UTC1648 JAVMA | NOVEMBER 2023 | VOL 261 | NO. 11survival. The Shapiro-Wilk test confirmed that none of these data were normally distributed ( P < .001 for all) so they were reported as median (IQR). Categori -cal variables assessed were sex, neuter status, body condition score (1 to 9/9), hyperbilirubinemia, blood transfusion, abdominal effusion, splenic mass, sple -nomegaly, histologic diagnosis and metastasis.For each cat, survival time was determined as the time elapsed from the date of surgery to the date of death or censorship. Cats were censored from survival analysis if they were alive at the time of analysis or lost to follow-up. The Kaplan-Meier method and Cox pro -portional hazards analysis were used to determine the association of a range of variables with the survival time. The outcome variable was survival time, and the explanatory variables were age, gender, duration of clinical signs, anemia, thrombocytopenia, need of a transfusion, weight loss, collapse, abdominal effusion, hemoabdomen, diagnosis of neoplasia, presence of metastasis, splenomegaly, splenic mass, use of che -motherapy. All the variables were initially tested sepa -rately via univariate Cox proportional hazards analysis and a multivariate Cox proportional hazards model was then built, which initially included the variables identified as P < .2 on univariate analysis. To eliminate possible confounding factors, the model was built by backward elimination approach until only significant variables ( P < .05) were retained in the model. Cox proportional hazards analysis results are reported as OR, 95% CI, and the associated P value. Fisher exact test was used to compare variables including ane -mia, hypoproteinemia, thrombocytopenia, presence of a mass on diagnostic imaging, hemoabdomen and the requirement for transfusion between cats with a diagnosis of HSA and cats with a diagnosis of MCT; between cats with a diagnosis of HSA and cats with diagnosis of other malignancies other than HSA; be -tween cats with a diagnosis of HSA and cats without a diagnosis of HSA. The level of statistical significance was set at P < .05 for 2-sided analyses.ResultsPopulation data, clinical presentation, and diagnostic investigationsIn total, 62 cats met the inclusion criteria. The most represented breed was domestic shorthair (44), followed by domestic longhair (5), British shorthair (4), Maine Coon (2), Ocicat (2), Persian (2), Burmese (1), Siamese (1), and Siberian (1).The population included 32 male neutered cats and 30 female neutered cats. At the time of surgery, the median age was 11 years (IQR, 8 to 13 years) and median weight was 4.5 kg (IQR, 3.7 to 5.2 kg). Body condition score ranged from 3/9 to 9/9 (median, 4/9) and the median duration of clinical signs was 18 days (IQR, 7 to 30 days). The most common clinical signs were summarized (Table 1) .Clinico-pathologic characteristicsComplete blood count was available for review in all cats. Median PCV was 21% (IQR, 9% to 30%). The most common hematologic abnormalities included anemia (PCV < 24%) in 30 cats with 18 cats show -ing signs of regeneration, thrombocytopenia (< 200 X 109/L) in 15 cats and neutrophilia (> 12 X 109/L) in 11 cats. In 6 cats, eventually diagnosed with MCT, circulating mast cells were reported and in 15 cats (24%) CBC was within reference limits.Coagulation parameters (prothrombin time [PT] and partial thromboplastic time [aPTT]) were assessed in 13 cats and revealed PT (> 11 seconds) and aPTT (> 20 seconds) prolongation in 5 and 3 cats, respectively.Serum biochemistry was available in 51 cats with the most common abnormalities being elevated alanine aminotransferase (> 60 U/L) in 17 cats, hyperbilirubine -mia (total bilirubin > 5.1 µmol/L) in 11 cats, hypoalbu -minemia (albumins < 25 g/L) in 10 cats and hypopro -teinemia (proteins < 60 g/L) in 8 cats. In 14 cats (27%) serum biochemistry was within normal limits.Feline leukemia virus and FIV snap tests (Idexx Laboratories) were negative in the 17 cats tested.Diagnostic imaging characteristicsAbdominal ultrasound was the most common diagnostic tool used and it was performed in 55 cats (89%), followed by CT (15 [24%]). Thoracic radiogra -phy was used in 22 cats (35%) and echocardiography was performed in 5 cats (8%).Based on imaging, 20 cats had a splenic mass, 18 cats had diffuse splenomegaly and 14 cats had both. Re -gional lymphadenopathy was described in 22 cats and peritoneal effusion was present in 27 cats. Other lesions concerning for metastatic disease found on imaging included: hepatic masses/nodules (14), hepatomegaly (9), pulmonary nodules (3) and pancreatic nodules (2).Analysis from the peritoneal effusion was avail -able in 23 cats and revealed hemoabdomen (15), protein rich transudate (6), neutrophilic exudate (1) and septic neutrophilic exudate (1). Spontaneous hemoabdomen was diagnosed in 12 cats with HSA, 2 cats with MCT, and 1 cat with leiomyosarcoma.Cytology from the splenic parenchyma was per -formed in 41 cats and results were compatible with MCT (16), malignant neoplasia (3), mesenchymal neoplasia (3), extramedullary hemopoiesis (3), round cell tumor (2), neutrophilic inflammation (1) and plas -ma cell tumor (1). Splenic cytology was reported to be normal in 3 cats, and it was not diagnostic in 9 cats.Surgical procedures and complicationsTwenty cats received at least 1 pre- or peri-oper -ative blood product transfusion including feline whole Clinical sign No. of cats (frequency [%])Lethargy 21 (34%)Weight loss 20 (32%)Hyporexia/anorexia 19 (31%)Abdominal distention 17 (27%)Abdominal mass 11(18%)Collapse 8 (13%)Vomiting 7 (11%)Polyuria-polydipsia 4 (6%)Table 1 —Most common presenting clinical signs in 62 cats undergoing splenectomy.Unauthenticated | Downloaded 11/03/23 05:53 AM UTC JAVMA | NOVEMBER 2023 | VOL 261 | NO. 11 1649blood (6), xenotransfusion (5), autotransfusion (4), bovine hemoglobin-based oxygen-carrying infusion (4, Oxyglobin; Dechra) and packed RBCs (3).All cats underwent surgery which included mid -line celiotomy and splenectomy. Median time from diagnosis to surgery was 2 days (IQR, 1 to 14 days).Seventy-six concomitant procedures were per -formed in 40 cats, with the most common ones be -ing hepatic biopsies (32), lymph node biopsies (10), pancreatic biopsies (9) and gastrointestinal biopsies (5; Supplementary Table S1 ). Antibacterial and an -algesia therapy was prescribed postoperatively at the discretion of the surgeon.Intraoperative complications were observed in 3 (5%) cats and were considered minor. During the postoperative period, 11 (18%) cats experienced complications, including 4 minor, 3 moderate and 4 causing death (Table 2) .Fifty-eight out of 62 cats survived to hospital dis -charge resulting in a perioperative mortality rate of 6%.Histopathology results and diagnostic accuracy of splenic cytologyHistopathologic evaluation revealed a diagnosis of neoplasia in 50 cases (81%) including MCT (21), HSA (20), histiocytic sarcoma (3), lymphoma (3), plasma cell tumor (1), anaplastic sarcoma (1) and leiomyosarcoma (1). In 18 cats there was evidence of tumor involvement in other organs including liver (14), lymph node (5), omentum (2), skin (2), mesen -tery (1), pancreas (1), and gastrointestinal tract (1).In 12 cats (19%) in which splenic neoplasia was not identified, splenic histopathology demonstrated: no histopathological abnormalities (5), hyperplasia with extramedullary hematopoiesis (5), neutrophilic inflammation (1) and congestion and fibrosis (1). In 4 cats with a histologically normal spleen, another pathological process was identified, including gas -tric histiocytic sarcoma (1), hepatic lymphoma (1), pancreatic adenocarcinoma (1), lymphocytic and histiocytic serositis and peritonitis compatible with feline infectious peritonitis (1).The overall diagnostic accuracy of cytology to detect malignant lesions was 73%. In 2 cats the cyto -logic diagnosis did not correlate with the histopatho -logic evaluation: 1 cat suspected to have a malignant neoplasia on cytology had a normal splenic histopa -thology and 1 cat with no cytological abnormalities in the spleen was diagnosed with a histiocytic sar -coma. Of the 9 cats with a nondiagnostic cytological result, 6 were diagnosed with an HSA and 3 had no histopathological abnormalities. The accuracy of cy -tology for the diagnosis of MCTs and mesenchymal tumors (HSA and leiomyosarcoma) was 100% and 54%, respectively.OutcomesFifty-one out of 58 (88%) cats surviving to dis -charge had available follow-up, which ranged from 5 to 1,912 days. Forty-one cats (80%) died or were eutha -nized at between 5 and 1,342 days following discharge; this was related to splenic neoplasia in 23 cats (56%).Overall median survival time (MST) for cats under -going splenectomy as estimated for all 51 cats was 159 days (IQR, 35 to 364 days). Cats diagnosed with splen -ic neoplasia had an MST of 136 days (IQR, 35 to 348 days) whereas cats with a nonneoplastic process had an MST of 715 days (IQR, 18 to 1,368 days; P < .001).No. Diagnosis Complication Treatment Time ClassificationIntraoperative complications 1 Histiocytic sarcoma Hypotension - - Minor and hypothermia 2 HSA Hypotension - - Minor 3 MCT Inability to excise None - Minor a mesenteric lymph nodePostoperative complications 1 Histiocytic sarcoma CRA CPR - Euthanasia < 24 h Death 2 MCT Unable to recover Euthanasia < 24 h Death from general anesthetic 3 HSA Hemoabdomen Blood product transfusion < 24 h Moderate 4 MCT Hemoabdomen Blood product transfusion < 24 h Moderate 5 HSA Symmetric ataxia Thiamine supplementation 1 d Minor and partial blindness, suspected thiamine deficiency 6 HSA Hypotension Blood product transfusion < 24 h Moderate 7 Nodular hyperplasia Sudden deterioration, death - 2 d Death and hematoma 8 Nodular hyperplasia Deterioration of an immune- - 5 d Death mediated hemolytic anemia, death 9 HSA Abdominal pleural port - 11 d Minor obstruction (local tumor extension around the port) 10 HSA Hyporexia None 6 d Minor 11 HSA Hyporexia None 7 d MinorCRA =Cardio-respiratory arrest. HSA = Hemangiosarcoma. MCT = Mast cell tumor. Table 2 —Surgical complications and treatment given in cats undergoing splenectomy.Unauthenticated | Downloaded 11/03/23 05:53 AM UTC1650 JAVMA | NOVEMBER 2023 | VOL 261 | NO. 11Cats with splenic mast cell tumors —Of the 21 cats with splenic MCT, 7 cats had metastatic disease at diagnosis. Chemotherapy was administered to 8 cats including lomustine (4), chlorambucil (3), ma -sitinib (1), followed by vinblastine (1), and toceranib (1). Five of the cats receiving chemotherapy were concurrently treated with prednisolone. Of the 13 cats with available follow-up, 5 died for MCT-related causes. The MST for this subgroup was of 348 days (IQR, 167 to 464 days).Cats with splenic hemangiosarcoma —Of the 20 cats with splenic HSA, 6 cats had metastatic disease at presentation. Chemotherapy was administered to 7 cats including: doxorubicin (2), metronomic cyclo -phosphamide or chlorambucil (2), thalidomide (2), and epirubicin (1). Of the 16 cats with splenic HSA and available follow-up, all died for reasons related to splenic HSA due to clinical deterioration or disease progression. The overall MST for this subgroup was 94 days (IQR, 52 to 146 days). Cats diagnosed with a splenic HSA had a shorter MST than cats with splen -ic MCT ( P < .001; Table 3 ; Figure 1 ). Cats diagnosed with HSA were more likely to present with anemia ( P < .001), a splenic mass ( P < .001), and hemoabdomen ( P < .001) compared to cats with a diagnosis of non-HSA.Risk factors associated with survival after splenectomyCox proportional hazards analysis was used to determine factors associated with survival, when considering possible confounding factors (Table 4) . Table 3 —Age, diagnostics, treatment, and survival based on final diagnosis in 62 cats undergoing splenectomy. Imaging features Anemia Other Diagnosis Median (PCV Hemo- Trans- Spleno- organ Chemo- MST †(n = 62) age* < 24%) abdomen fusion Mass megaly Combination Normal involvement therapy (d)MCT (21) 12 4 2 3 4 12 1 4 7 8 348HSA (20) 11 17 12 13 16 – 4 – 6 6 94Histiocytic 9, 8, 14 1 – 1 – 2 1 – 1 – 1, 11, 33 sarcoma (3)Lymphoma (3) 12, 9, 16 1 – 1 – 2 - 1 2 1 27, 77, 127Other 16, 13, 8 1 1 (AS) 1 – 1 2 – 2 1 194 (PCT), neoplasia (3) 35 (AS), 365 (LS)Nonneoplastic 8 4 – 3 – 1 6 1 – – 715 lesions (12)*Individual ages reported for groups less than 10 cats. †Individual survival times reported for groups < 10 cats. AS = Anaplastic sarcoma. LS - Leiomyosarcoma. MST = Median survival time. PCT = Plasma cell tumor. See Table 2 for remainder of key.Figure 1 —Kaplan–Meier survival curve for cats with splenic mast cell tumor (n = 21) and splenic hemangio -sarcoma (20) treated by splenectomy.Table 4 —Univariate Cox proportional hazards analysis results determining factors associated with survival af -ter splenectomy in cats. Survival Cox proportional hazards analysis OR 95% CI * P valueAge 1.04 0.93–1.16 .436Gender 0.95 0.39–2.32 .925Duration of clinical signs 0.98 0.95–1.02 .489Anemia 3.86 1.50–9.94 .005Thrombocytopenia 1.29 0.53–3.13 .566Transfusion 3.36 1.45–7.79 .005Weight loss 1.14 0.47–2.77 .760Collapse 1.91 0.64–5.63 .241Abdominal effusion 2.00 0.85–4.68 .111Hemoabdomen 2.84 1.21–6.63 .160Histological diagnosis 57.26 1.5–2,180.06 .029Metastasis 3.04 1.23–7.48 .150Splenic mass 1.63 0.66–4.01 .280Splenomegaly 1.12 0.5–2.51 .772Chemotherapy 1.43 0.59–3.47 .425*Reference category used in logistic regression. Variables highlighted in bold qualified for inclusion in the multiple re -gression analysis at P < .20 (Table 5).After the initial model was refined by backward-stepwise elimination, the resultant best-fit model included 6 vari -ables (preoperative anemia, transfusion required in the perioperative period, abdominal effusion at presentation, hemoabdomen at presentation, histopathological diagno -sis [neoplasia vs non neoplasia], presence of metastasis at diagnosis). In the final multiple regression model (Table 5) , the only factors associated with an increased risk of death included anemia at presentation ( P = .010) and presence of metastatic disease at diagnosis ( P = .002). Cats diagnosed with anemia at presentation had a median disease-specific survival time of 103 days (IQR, 34 to 246), compared to 278 days (IQR, 18 to 364) for cats without anemia. Cats diagnosed with metastatic disease after investigations had a median disease-specific survival time of 85 days (IQR, 27 Unauthenticated | Downloaded 11/03/23 05:53 AM UTC JAVMA | NOVEMBER 2023 | VOL 261 | NO. 11 1651to 157 days) compared to 207 days (IQR, 94 to 365 days) for cats without evidence of metastasis.

Question 93

Bounds - 2023 - VETSURG - Feasibility of feline coxofemoral arthroscopy using a supratrochanteric lateral portal - A cadaveric study.pdf

Answer 93

2.1 |Study subjectsThis was an ex vivo cadaveric descriptive study including14 hips from seven domestic cat cadavers from cats thatwere euthanized for reasons unrelated to this project. Allcadavers were sourced from Skulls Unlimited Interna-tional, Inc. (Oklahoma City, OK, USA). All hips wereassessed radiographically for evidence of degenerativejoint disease, and 12 hips were free of joint pathology.Two hips with severe DJD were also included. Specimenswere stored at /C020/C14C until thawing at room temperatureprior to the study.2.2 |Pilot catGross dissection of the hip region was performed in onefeline cadaver to evaluate regional anatomic landmarks,guide arthroscopic portal creation, and evaluate distancesbetween potential cannula insertion sites and neurovas-cular structures. Optimal limb positioning to maximizehip joint space for arthroscopy was assessed by measur-ing the space between the dorsal acetabular rim (DAR)and the femoral head with the hip at various flexionangles.2.3 |Arthroscopic procedureBased on the findings from the dissection of the pilot cat,the remaining six cadavers were positioned for arthros-copy in lateral recumbency with the hip of interest upper-most. Joint space distraction was achieved by applyingdistally directed traction to the distal femur with simulta-neous counter pressure on the ischiatic tuberosity(Figure 1).As t a bi n c i s i o nw a sc r e a t e dd o r s a lt ot h ec e n t e ro fthe greater trochanter (12 o 'clock), followed by inser-tion of a scope cannula and blunt obturator directedmedially until the tip penetrated the joint capsule(Figure 2). With the coxofemoral joint distracted, a1.9 mm, 0/C14arthroscope (NanoScope, Arthrex Inc.,Naples, Florida) was inserted through the scope portal.Fluid ingress was achieved using a 1 L bag of normalsaline placed inside a pressure bag and connected tothe fluid ingress portal on the scope cannula using IVFIGURE 1 The left hip region of a feline cadaver positioned inright lateral recumbency for left-hip arthroscopy. A radiographicprojection of the pelvis and femur is superimposed over the cadaverimage to represent limb during arthroscopy. The left femur ispositioned in neutral duction and at a 90/C14extension angle relativeto the long axis of the pelvis (represented by the dashed white line).Prior to cannula insertion, distally directed traction is applied to thedistal femur while simultaneous counterpressure is applied to theischiatic tuberosity.BOUNDS and HUDSON 1203 1532950x, 2023, 8, tubing. Fluid egress was achieved with a 22 gauge nee-dle inserted craniolaterally (at the 10 o'clock positionin left hips or 2 o'clock position in right hips)(Figure 2). Arthroscopic hip evaluation was performedusing a systematic technique to identify intra-articularstructures and all identifiable intra-articular structuresof interest were documented (Figure 3). Duringarthroscopy, the hip was placed through gentle rangeof motion while maintaining distal femoral distractionto determine the optimal limb position for assessingall intra-articular structures of interest. An instrumentportal was created by making a stab incision with a#11 blade using the egress needle as a cutting guide.The egress needle was removed once the instrumentportal was created and then a 1.5 mm right angle bluntprobe (Arthrex Inc.) was inserted and used to probeintra-articular structures (Figure 4).2.4 |Gross dissectionArthroscopic joint evaluation was followed by grossdissection of the periarticul ar coxofemoral r egion. Portallocations relative to and damage of periarticular neurovascu-lar structures and muscles was assessed visually. The arthro-scopic cannula was left in place during the dissection andthe minimal distance between the cannula and the sciaticnerve was measured using a digital caliper (Figure 5).2.5 |Postarthroscopy articular cartilageevaluationAfter gross dissection of the periarticular region, allhips were disarticulated, and an India-ink assay wasperformed to assess for femoral head and acetabularICI (Figure 6).8,26,27The femoral head and acetabulumwere divided into cranial, middle, and caudal regionsfor the purposes of localizing ICI. Cartilage lesionswere categorized by severity and location. Hips withdegenerative joint disease were excluded from ICIevaluation.3|RESULTSHip-joint working space was maximized with the femurpositioned in neutral duction and at a 90/C14extension anglerelative to the long axis of the pelvis in the sagittal plane.Additional joint space distraction was achieved by applyingdistally directed traction to the distal femur with simulta-neous counter pressure on the ischiatic tuberosity. Thislimb position resulted in 4.7 ± 0.5 mm (mean ± SD) spacefrom the DAR to the most proximal aspect of the femoralhead. The scope portal was located 4.0 ± 0.8 mm dorsal tothe center of the most dorsal aspect of the greater trochan-ter. Scope cannula insertion was consistently achieved onthe first (79%) or second (21%) attempt in all hips. Egressinsertion was always achieved on the first attempt. Theegress needle/instrument portal was positioned 3.0± 1.2 mm dorsal and 4.4 ± 0.3 mm cranial to the center ofthe most dorsal aspect of the greater trochanter.Femoral head and acetabular articular cartilage in thecranial, middle, and caudal regions, round ligament, jointcapsule, transverse acetabular ligament and DAR wereidentified and evaluated arthroscopically in all 12 hipsincluding two hips with severe DJD (Figure 3). Hipextension of 90/C14was optimal for visualization of allregions of the hip joint except for the cranial joint pouch,which was consistently better visualized with the hip in aslightly more extended position. Blunt probe insertionand palpation of articular cartilage, round ligament, anddorsal acetabular rim was achieved in all hips (Figure 4).FIGURE 2 The left hip region of a feline cadaver positioned inright lateral recumbency for left-hip arthroscopy. The lefthemipelvis and femur have been superimposed over the cadaverimage to represent the locations of the bones in the limb preparedfor arthroscopy. The ischiatic tuberosity is indicated by the whitearrow. The light blue dot demonstrates the arthroscope portallocation at the 12 o'clock position relative to the greater trochanter(green arrow). The instrument/egress portal is located at the10 o'clock position (red dot).1204 BOUNDS and HUDSON 1532950x, 2023, 8, Probe elevation of the dorsal joint capsule consistentlyimproved arthroscopic visualization of the DAR.Scope and instrument portals passed through superfi-cial, middle, and deep gluteal muscles in all hips butresulted in minimal muscle fiber disruption. Mild portalimpingement of the gemelli was noted in two hips and ofthe biceps femoris in one hip. The sciatic nerve was notdamaged during portal creation. The average shortest dis-tance between the scope cannula and the sciatic nervewas 4.3 ± 2 mm (Figure 5). The shortest measured dis-tance from scope portal to sciatic nerve in any cadaverwas 1.1 mm. The caudal gluteal artery was located caudalto the sciatic nerve in all limbs and was not damaged inany specimen.Minor partial thickness ICI consisting of 1 –3l i n e a rabrasions 1 –3m mi nl e n g t hw a so b s e r v e di na l lh i p sa tthe site of scope insertion. Focal full-thickness ICIwas noted in one hip (Figure 6). This lesion was asso-ciated with arthroscope cannula impingement onthe middle region of the femoral head. The most com-mon location of ICI was the middle region of thefemoral head.FIGURE 3 Representativearthroscopic images of the feline hipjoint. Visible structures include:1. Femoral head 2. Acetabulum3. Round ligament 4. Joint capsule/synovium 5. Transverse acetabularligament 6. Dorsal acetabular rim.FIGURE 4 Arthroscopic images ofthe feline hip joint. A blunt probeinserted through the instrument portalmay be used to probe the roundligament (A) and to lift the dorsal jointcapsule, improving visualization of thedorsal joint capsule and dorsalacetabular rim (B).BOUNDS and HUDSON 1205 1532950x, 2023, 8, 4

Question 94

Cleary - 2023 - JAVMA - Features, management, and long-term outcome in dogs with pancreatitis and bile duct obstruction treated medically and surgically - 41 dogs (2015-2021).pdf

Answer 94

Medical records of dogs treated for extrahepatic biliary obstruction due to pancreatitis at the Animal Referral Hospitals (Brisbane, Sydney, and Canberra) between January 2015 and December 2021 were evaluated retrospectively. Search terms used to iden -tify cases included pancreatitis, extrahepatic bile duct obstruction, extrahepatic biliary obstruction, EHBO, EHBDO, cholecystoduodenostomy, cholecystojeju -nostomy, cholecystoenterostomy, biliary stent, bile duct stent, and choledochal stent. To be included, dogs had to have relevant clinical signs, expected clinicopathologic abnormalities, pancreatic changes on imaging consistent with pancreatitis, and com -mon bile duct distention. The diagnosis of pancreati -tis was based on a combination of appropriate clinical signs such as hyporexia, vomiting, lethargy, abdomi -nal pain, pyrexia, and jaundice; laboratory findings including a hepatopathy, elevated ALT, and ALP; and ultrasonographic findings such as an enlarged, hypo- or hyperechoic pancreas, poor pancreatic mar -gination, hyperechoic adjacent mesentery, and local effusion. Serum snap or specific canine pancreatic li -pase (cPL) or 1,2-o-dilauryl-rac-glycero glutaric acid-(6′-methylresorufin) ester (DGGR) lipase assay results were documented, but an abnormal result wasn’t mandatory for a diagnosis of pancreatitis. The diag -nosis of EHBO was based on hyperbilirubinemia and common bile duct dilation (> 3 mm) detected sono -graphically, by CT scan or surgically. Patients were excluded if they had other causes of EHBO, such as neoplasia, cholelithiasis, foreign body, or gallbladder mucocoele. The minimum required follow-up was sur -vival to discharge, euthanasia, or death.Data extracted from the medical records in -cluded age, sex, breed, clinical signs at presentation, concurrent disease, results of clinicopathologic test -ing, and imaging findings. PLR and NLR21 were cal -culated using the first hematology profile obtained after presentation. The patients were assessed for systemic inflammatory response syndrome (SIRS) at initial presentation, with SIRS defined as ≥ 2 of the following criteria: heart rate > 120 beats/min, respi -ratory rate > 20 breaths/min, temperature < 38 °C or > 39.2 °C, WBC < 6 X 109/L or > 16 X 109/L, or > 3% bands.22 The maximum total bilirubin (TBIL) and ALT were documented, and the time from maximum TBIL until 25% reduction was assessed.The length of medical management was defined as either the number of days of medical manage -ment prior to surgery for those surgically treated or the number of days of medical management until dis -charge for those medically treated, including any days of medical management prior to referral. The surgi -cal findings and procedures performed, presence of intra- or postoperative complications, and microbiol -ogy and histopathology results were documented.Recovery was assessed by documenting the time to return to adequate function, which was de -fined as resolution or marked improvement in clini -cal signs, with patients being managed at home; approximating their preillness quality of life, pos -sibly still receiving medication1; and being counted from the first documented clinical signs and from the time of surgery. Short- and long-term survival (defined as 2 months and 1 year, respectively) were assessed. Patients were classified as nonsurvivors if they were documented to have died due to EHBO. The 2-month and 1-year survival included mortalities of any cause. The type of medical treatment, includ -ing blood product administration, was documented.Minor complications were defined as those not requiring additional medical or surgical treatments to resolve, whereas major complications were defined as those requiring additional treatment to resolve.23 Survival times and cause of death were determined by information in medical records or through com -munication with referring veterinarians or clients.Statistical analysisFor continuous variables, descriptive statistics were summarized using means, SDs, and medians. Categorical variables were summarized as frequen -cies and percentages. Analyses were conducted comparing 2 treatment groups as well as survivors versus nonsurvivors. Initial exploratory analyses showed that many of the quantitative variables used in the analyses had skewed distributions. Due to this and the relatively small sample sizes (mostly under 30 patients), a nonparametric approach for these comparisons was adopted (medians test – χ2 and P value quoted). Categorical variables were compared using a χ2 test, and when cell sizes were < 5, Fisher exact tests were used. Time-to-event analyses were summarized using Kaplan-Meier charts and tested using log rank tests. All analyses were conducted us -ing Stata (version 17; Stata Corp LLC). In accordance with the scientific standard, results that yielded as P < .05 were considered statistically significant.ResultsForty-one cases met the inclusion criteria, in -cluding 19 dogs treated surgically and 22 treated medically. There were 3 Labrador Retrievers, 3 Cocker Spaniels, 3 Border Collies, 2 Jack Russell Terriers, 2 Siberian Huskies, 2 Cavalier King Charles Spaniels, 2 Bull Terriers, 2 Poodles, 1 Pug, 1 Great Dane, 1 Pomeranian, 1 Curly Coated Retriever, 1 Whippet, 1 Fox Terrier, 1 Miniature Schnauzer, 1 Dalmatian, 1 Basenji, 1 Rhodesian Ridgeback, 1 Australian Bulldog, 1 Shih Tzu, and 10 mixed breeds. The median age was 8 years (range, 3 to 13 years) and 9 years (range, 1 to 16 years) for surgically treated and medically treated patients, respectively. There were 25 males (23 neutered) and 16 females (15 spayed).The most common presenting clinical signs were hyporexia (n = 41), vomiting (41), lethargy (39), Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 11/03/23 06:53 AM UTC1696 JAVMA | NOVEMBER 2023 | VOL 261 | NO. 11abdominal pain (32), jaundice (25), and pyrexia (15). Less common were diarrhea (n = 7) and regurgita -tion (2). Eight dogs had concurrent disease, includ -ing diabetes (n = 2), epilepsy (2), cardiac disease (2), hyperadrenocorticism (1), adrenal tumor (1), and aspiration pneumonia (2).Twenty-two of 29 (75%) dogs had abnormal snap cPLI, spec cPLI, or DGGR lipase, supporting a diag -nosis of pancreatitis. Twenty-six dogs had coagula -tion testing using prothrombin time (PT) and acti -vated partial thromboplastin time (aPTT) and 3 were abnormal, with 2 dogs having significant prolonga -tion of both PT and aPTT and 1 dog having normal PT but significantly prolonged aPTT.All dogs had an abnormal pancreas on imaging, most commonly on ultrasound (n = 39), 1 on CT scan and ultrasound and 1 on CT scan alone. Ultrasound findings reported included a pancreas that was en -larged (n = 30), hypoechoic (28), hyperechoic (3), had hyperechoic foci (4), mixed echogenicity (2), unclear margins (6), hyperechoic adjacent mesentery (26), local lymphadenomegaly (4), local effusion (6), gastroduodenopathy (8), pancreatic mass (4), dis -tended gallbladder (15), dilated intrahepatic ducts (1), and common bile duct distention (36). Twenty-two of 22 (100%) medically treated dogs had a com -mon bile duct diameter > 3 mm. Fourteen of 19 (74%) surgically treated patients had a common bile duct > 3 mm, and 1 had hepatic duct dilation documented so -nographically. This patient and the remaining 4 dogs had common bile duct distention identified surgically.There was no difference in the common bile duct diameter between the medical (mean, 7.2 mm; range, 3.4 to 11 mm) or surgical (mean, 7.1 mm; range, 3.4 to 19 mm) groups or between survivors (mean, 7 mm; range, 3.4 to 19 mm) and nonsurvivors (mean, 7.7 mm; range, 4.7 to 11 mm).All patients had hepatic enzyme elevations on biochemical analyses, and there was no significant difference in the maximum TBIL between those medically treated (mean, 155.9 umol/L; range, 28 to 366 umol/L) and those surgically treated (mean, 180 umol/L; range, 70 to 288 umol/L) or between survi -vors (mean, 166 umol/L; range, 28 to 288 umol/L) and nonsurvivors (mean, 170 umol/L; range, 63 to 366 umol/L). Similarly, there was no significant dif -ference in maximum ALT between the medically treated (mean, 1,947.5 U/L; range, 50 to 5,540 U/L) and surgically treated (mean, 1,847.6 U/L; range, 235 to 4,375 U/L) groups or between survivors (mean, 1,868 U/L; range, 50 to 4,989 U/L) and nonsurvivors (mean, 2,027 U/L; range, 132 to 5,540 U/L).NLR was not significantly different between the medically treated (mean, 9.67; range, 0.97 to 31.48) and surgically treated (mean, 7.88; range, 0.45 to 18.63) groups or between survivors (mean, 8.3; range, 0.45 to 31.38) and nonsurvivors (mean, 10.69; range, 2.1 to 22.7). There was no significant difference in the PLR between the medically treated (mean, 293.7; range, 10.5 to 939) and surgically treated (mean, 245.07; range, 27.9 to 400) groups or between survi -vors (mean, 257.39; range, 10.5 to 1,069) and nonsur -vivors (mean, 322.07; range, 93.3 to 524).Medical management entailed antimicrobial therapy in 37 cases, with a combination of antimicro -bials used in most cases (n = 31). All patients received fluids IV, antiemetics (maropitant, ondansetron, and/or metoclopramide), proton pump inhibitors (esome -prazole and omeprazole), and analgesia (various opi -oids, lignocaine, and ketamine). Other treatments in -cluded liver protectants (s-adenosylmethionine and silybin [n = 8], s-adenosylmethionine and silybin and ursodeoxycholic acid [4], ursodeoxycholic acid [4], corticosteroids [5], and blood product administra -tion [whole blood transfusion; 1]).Fifteen dogs had cholecystoenterostomies, in -cluding 12 cholecystoduodenostomies and 3 chole -cystojejunostomies. Three had exploratory surgery, 1 had a pancreatic abscess drained, a small defect in the duodenum sutured, and the common bile duct catheterized and flushed; 1 was exploratory, and the decision was made to euthanize on the basis of severity of findings; 1 had the common bile duct flushed and pancreatic mass biopsied. Only 1 dog had a choledochal stent placed. The median chole -cystoenterostomy stoma size was 3 cm, with a range of 1.2 to 5 cm.All surgical patients had visual confirmation of pancreatitis causing EHBO. The common surgical findings reported were an abnormal pancreas (n = 16), distended biliary tract (12) or gallbladder (10), pancreatic mass (8), adhesions (5), pancreatic ab -scess (1), and purulent pancreatic exudate (3). Pan -creatic biopsies were attempted in 10 patients; 7 had chronic pancreatitis, 1 had acute pancreatitis, and 2 had absent pancreatic tissue, with one showing ste -atitis and the other reactive lymph node. Nine dogs had liver biopsies, and the most common histologic finding was cholangiohepatitis with cholestasis (n = 8), followed by cholestasis with mild chronic hepatitis (1). Thirteen dogs had cultures obtained (9 bile, 3 bile and liver, and 1 pancreatic abscess), 2 of which had a positive bacterial culture. One bile sample cultured a single organism ( Enterococcus casseliflavus ), and an -other bile sample cultured 3 organisms ( Escherichia coli, Enterococcus , and Clostridium perfringens ).There was no significant difference in the time from maximum TBIL to 25% reduction between the medically treated (median, 2 days; range, 1 to 11 days) and surgically treated (median, 1 day; range, 1 to 10 days) groups. There was no difference in the number of patients meeting SIRS criteria between the medically treated (17/20 [85%]) and surgically treated (11/15 [73%]) groups or between survivors (20/22 [74%]) and nonsurvivors (7/8 [87%]).The time to return to adequate function was similar between the medical (mean, 16.3 days; 95% CI, 11.3 to 21.3 days) and surgical groups (mean, 19.9 days; 95% CI, 16.9 to 23 days; Figure 1 ). There was no difference in the length of medical management between the medically treated (mean, 10.8 days; 95% CI, 7.6 to 14.1 days) and surgically treated (mean, 10.1 days; 95% CI, 6.1 to 14.1 days) groups or the length of hospitalization between those treated medically (mean, 5.2 days; 95% CI, 3.6 to 6.9 days) and those treated surgically (mean, 5.6 days; 95% CI, 4.6 to 6.7 days; Figure 2 ).Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 11/03/23 06:53 AM UTC JAVMA | NOVEMBER 2023 | VOL 261 | NO. 11 1697The median follow-up was 26 months (range, 4 to 80 months) for surgically treated dogs and 23 months (range, 1 to 75 months) for medically treated dogs. Eighteen of 19 (94.7%) surgical patients sur -vived to discharge, 18 were alive at 2 months, and 15 were alive at 12 months. Twenty of 22 (90.9%) medi -cal patients survived to discharge, 12 were alive at 2 months, and 11 were alive at 12 months.The proportion of patients alive in the surgical versus medical treatment groups at 2 and 12 months was significantly different ( P = .009 and P = .046, re -spectively). Two dogs in the medical group were eu -thanized in hospital, one due to disseminated intra -vascular coagulation and multiple organ dysfunction and the other one due to worsening hyperbilirubine -mia, suspect disseminated intravascular coagulation and gastrointestinal hemorrhage, and anemia. One dog was discharged and reported to be improving at 2 rechecks with resolution of hyperbilirubinemia at the second recheck, then was lost to follow-up be -fore 2 months. One dog survived to discharge, was reported to be recovered at 40 days postadmission, then was euthanized 2 months postadmission for unknown reasons. One dog survived to discharge, was reported to have recovered, and then presented dead on arrival 3.5 months later. Five dogs were discharged and then euthanized due to EHBO, with persistent or worsening hyperbilirubinemia and persistent clinical signs such as hyporexia, lethargy, abdominal pain, and weight loss, 2 at 3 days postdischarge and 1 each at 11, 17, 22, and 49 days. One dog died due to con -gestive heart failure 14 months later, and 1 was eutha -nized for unknown reasons 25 months later. Four of 18 surgical patients had major complications, with 3 de -veloping a cholestatic hepatopathy 1, 2, and 4 times that resolved with antimicrobials; 1 had regurgitation due to esophagitis postoperatively; and one of the dogs that developed a cholestatic hepatopathy also had postoperative hemorrhage that did not require a blood transfusion.The mean survival time of dogs treated surgi -cally was 49.2 months (95% CI, 33.5 to 64.9 months), and the mean survival of those treated medically was 33 months (95% CI, 17.4 to 48.6 months). There was no statistical difference ( P = .09) in long-term sur -vival between the treatment groups (Figure 3) .Figure 1 —Kaplan-Meier chart documenting time to re -turn to adequate function in 41 dogs with pancreatitis causing extrahepatic biliary obstruction that were treat -ed medically (solid line) and surgically (dashed line).Figure 2 —Kaplan-Meier chart documenting hospitaliza -tion length in 41 dogs with pancreatitis causing extra -hepatic biliary obstruction that were treated medically (solid line) and surgically (dashed line).Figure 3 —Kaplan-Meier survival curve for 41 dogs with pancreatitis causing extrahepatic biliary obstruction that were treated medically (solid line) and surgically (dashed line).

Question 95

Danielski - 2023 - JAVMA - Lower body weight and increasing age are significant risk factors for complications following bi-oblique proximal ulnar osteotomy in dogs.pdf

Answer 95

The clinical records of dogs that underwent bi-oblique PUO at a single institution between January 2014 and December 2018 were reviewed. Surgeries were performed by board-certified specialists and residency-trained surgeons. Breed, gender, age, body weight, use of an intramedullary pin, release of the interosseous ligament, bilateral simultaneous sur -gery, and reason to perform the procedure were re -corded. The bi-oblique proximal ulnar osteotomy was performed as previously described with the use of a sagittal saw blade.14 Use of an intramedullary pin (to reduce excessive caudal displacement of the proximal ulnar segment or to avoid excessive varus deformity of the limb) and release of the interosseous ligament were adopted at the surgeon’s discretion. The intra -medullary pin was placed in a retrograde fashion and cut as close as possible to the cortical bone of the proximal ulna. Release of the interosseous ligament was confirmed by insertion of a Freer periosteal eleva -tor between the radius and ulna and free movement of the elevator in a proximodistal direction to the dis -tal end of the cut proximal ulnar segment.Radiographs were recovered from the hospi -tal digital archive for evaluation. As previously de -scribed,14 immediate postoperative radiographs were reviewed for proximodistal osteotomy loca -tion as a percentage of the total ulnar length, from the most proximal part of the olecranon to the most caudal point of the osteotomy line, and osteotomy angles (caudocranial and mediolateral).14 The oste -otomy angles were determined from a line perpen -dicular to the long axis of the ulna, as previously de -scribed.14 Follow-up radiographs were performed 6 weeks postoperatively. When indicated, radiographs were repeated at 12 weeks or later, until radiograph -ic union was evident. These radiographs were as -sessed for healing progression at the osteotomy site and radiographic signs of complications. Dogs that did not have 6-week follow-up radiographs or had incomplete records were excluded.Osseous union was determined by consensus of 2 board-certified surgeons. The degree of radio -graphic bone healing was classified into 4 groups based on the presence of trabecular pattern bridging at ≥ 3 of 4 cortices at the osteotomy site, presence/absence of biologic activity, and expected healing time based on the dog’s signalment: healed/healing, delayed healing, not healing but active, and not heal -ing, not active (Table 1) .For statistical purposes, dogs were classified as chondrodystrophic on the basis of breed and subjective analysis of their preoperative radio -graphs by 2 of the authors. Chondrodystrophic breeds included Basset Hound, Dachshund, Shih Tzu, Coton de Tulear, Bichon Frise, Clumber Span -iel, small terrier breeds, and cross-breed dogs known to be related to those breeds. Other breeds were defined as nonchondrodystrophic.Complications were classified as previously de -scribed by Cook et al18 as minor (not requiring ad -ditional surgical or medical treatment to resolve), major (requiring surgical or medical treatment to resolve), and catastrophic (those complications that caused permanent unacceptable function). For statistical purposes, dogs falling into catego -ries “delayed healing” and “not healing but active” were classified as having minor complications, as the degree of bone healing was delayed with respect to what we were expecting and longer confinement/rest had to be recommended. Dogs falling into the category “not healing, not active” were classified as having major complications, as these dogs were con -sidered to have oligotrophic nonunion that required additional surgery to heal.Statistical analysisAll statistical analyses were performed using software (SPSS version 19; IBM Corp). Results were expressed as mean ± SD for normally distributed Groups Degree of radiographic bone healingHealed/healing ≥ 3 of 4 cortices are bridged at 6 wkDelayed healing ≥ 3 of 4 cortices are bridged at 12 wk but not at 6 wk as expectedNot healing but active 3 of 4 cortices are not bridged as expected at 6 or 12 wk, but the osteotomy clearly showed signs of active bone activity (specifically nonbridging periosteal callus formation and/or trabecular pattern bridging < 3 cortices at the osteotomy), intimating that complete healing will be reached in the following weeksNot healing, not active 3 of 4 cortices were not bridged as expected at 6 and 12 wk, and the osteotomy site had no signs of osteogenic activityTable 1 —Group classification based on the degree of bone healing.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 11/03/23 06:54 AM UTC 3variables. When data were not normally distributed, results were expressed using median values. Univari -ate statistical analyses were performed to evaluate association/correlation between postoperative com -plications and categorical/continuous variables. A Fisher exact test was used for categorical variables (“chondrodystrophy,” “interosseous ligament re -lease,” bilateral simultaneous surgery, and use of “in -tramedullary pin”). A Mann-Whitney or independent t test was used to evaluate the relationship between continuous variables (weight, age, osteotomy loca -tion as ulna percent, craniocaudal osteotomy angle, and mediolateral osteotomy angle) and postopera -tive complications. Significant variables in univari -ate analysis ( P < .05) were included in the logistic regression model.A forward stepwise binary logistic regression model was used to test for a significant relationship between categorical/continuous dependent vari -ables and complications (categorical independent variable). The impact of the predictive variables was expressed in terms of OR: OR < 1.0 indicated a pro -tective benefit, whereas OR > 1.0 indicated a detri -mental effect. A Hosmer-Lemeshow goodness-of-fit test was performed to assess the overall fit of the lo -gistic regression. Variables with a P value < .05 with -in the log likelihood test were considered significant contributors to the model. The results of the forward stepwise logistic regression were expressed as a probability of occurrence of dependent variables by performing the appropriate mathematical modifica -tions to convert odds to a simple probability.ResultsEighty-eight dogs (102 limbs) underwent bi-oblique proximal ulnar osteotomy. Six dogs (9 limbs) were excluded because they did not meet the inclusion criteria (incomplete radiographic or clini -cal follow-up). Eighty-two dogs (93 limbs) met the inclusion criteria. Labrador Retriever was the breed most commonly represented (n = 26), followed by 8 each of German Shepherd Dog, Golden Retriever, and crossbreed and 4 each of Basset Hound and Rottweiler. Sixteen dogs (18 limbs) were chondro -dystrophic, with the other 66 dogs (75 limbs) being nonchondrodystrophic. Forty-four dogs were male (30 neutered), and 38 were female (32 spayed). Median age at the time of surgery was 9 months, with an IQR of 7 and 12.7 (first and third quartiles, respectively); 56 of 82 dogs were < 12 months old at the time of surgery, and 65 of 82 dogs were < 24 months old at the time of surgery (Figure 1) . Mean weight at the time of surgery was 28 ± 11.2 kg. Thir -teen of 16 chondrodystrophic dogs weighed < 20 kg. Seven different primary surgeons were involved (5 boarded specialists and 2 third-year residents). Six dogs underwent bilateral simultaneous surgery, while 5 dogs underwent bilateral staged surgery (median time between surgeries, 12 weeks; range, 6 to 16 weeks).Bi-oblique PUO was performed as a treatment for medial compartment disease (47 limbs), short ulna syndrome (22 limbs), fragmentation of the medial coronoid process (11 limbs), ununited anconeal pro -cess (6 limbs), osteochondritis dissecans (4 limbs), and short radius syndrome (3 limbs).An intramedullary pin (ranging in diameter from 1.2 to 1.6 mm) was placed in 14 of 79 ulnae. The interosseous ligament was released in 50 of 93 limbs. The mean ± SD caudocranial osteotomy angle was 47 ± 7° (range, 20° to 67°), and the mean lateromedial osteotomy angle was 53 ± 7° (range, 25° to 71°). The median height of the ulna osteotomy as a percentage of the total ulna length was 32.6%, and its IQRs were 30.1% and 36.8% (full range, 22.2% to 47%).On 6-week radiographic assessment, 62 of 93 os -teotomy sites were categorized as healed/healing. Thirty-nine (41.9%) limbs experienced complications (13 major and 26 minor). Major complications (13.9% of limbs) included nonunion (which was treated by revi -sion surgery; 8 limbs), excessive caudolateral displace -ment of the proximal ulnar segment without healing that required surgery to restore bone contact (2 limbs), superficial site infection (2 limbs) and, in 1 case that had surgery for ununited anconeal process , antirota -tional k-wire migration and septic arthritis (1 limb). No limbs experienced catastrophic complications.The 8 limbs in which a nonunion was diagnosed underwent revision surgery by removal of the fibrous tissue at the osteotomy site by application of rigid fixa -tion (provided by a lateral locking plate) and addition of an autologous bone marrow graft harvested from the proximal humerus and placed at the osteotomy site to encourage a biologically active environment. For the 2 limbs in which excessive caudolateral displacement of the proximal ulnar segment (with no bone contact at the osteotomy site) was noticed on radiographs 6 weeks after surgery, realignment of the 2 ulnar seg -ments was achieved by placement of an intramedullary Figure 1 —Histogram of dog age distribution in months. Notice the high frequency of dogs under 1 year of age.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 11/03/23 06:54 AM UTC4 pin, and an autologous bone marrow graft was placed at the osteotomy site to encourage healing. Lastly, in the case originally treated for ununited anconeal pro -cess, the k-wire was removed through a small skin inci -sion, a sample of the joint fluid was collected and sent for microbiology analysis (which later confirmed the presence of Staphylococcus pseudintermedius ), the joint was flushed with 2 L of sterile solution, and an -tibiotic therapy was started IV (followed by a 6-week course of oral antibiotic therapy).The most common minor complication that dogs experienced was delayed union at the oste -otomy site (n = 21 limbs [10 delayed healing and 11 not healing but active]), followed by persistent lameness (2), exaggerated kickback of the proximal ulnar segment associated with focal discomfort (2), and limb swelling (1). Three dogs that underwent bilateral staged surgery developed 1 minor com -plication each (1 swelling, 1 delayed healing, and 1 not healing but active), while 1 case that underwent bilateral simultaneous surgery sustained 1 major and 1 minor complication in each limb (1 delayed healing and 1 not healing, not active, that required surgical stabilization).The continuous variables weight, osteotomy location as ulna percent, craniocaudal osteotomy angle, and mediolateral osteotomy angle were nor -mally distributed (Kolmogorov-Smirnov test, P > .05), while age was not ( P < .05). On univariate anal -ysis, the continuous variables weight and age had a significant correlation with complications ( P = .01 and P = .04; Table 2 ). The logistic regression model was statistically significant ( χ2 [model] = 30.576; P < .001). The model explained 37.7% (Nagelkerke R2) of the variance of complications and correctly classified 75.3% of cases. While increased age was associated with an increased likelihood of develop -ing complications after PUO, an increased weight was associated with a reduction in the likelihood of complications after PUO (Table 3; Figures 2 and 3) .Table 2 —Summary univariate analysis of risk factors for complications after proximal ulnar osteotomy. Independent samples Mann-Whitney Fisher exact testVariable t test ( P value) U test ( P value) (P value)Weight (kg) .001 — —Osteotomy location as ulna (%) .260 — — Craniocaudal osteotomy angle (degrees) .231 — —Mediolateral osteotomy angle (degrees) .247 — — Age (mo) — .04 —Interosseous ligament release (yes/no) — — .833Chondrodystrophy (yes/no) — — .287Intramedullary pin (yes/no) — — .507Bilateral simultaneous surgery — — .550Table 3 —Binary logistic regression summary. Wald test 95% CI Wald Lower UpperCoefficients Estimate SE OR z statistic df P bound boundIntercept 2.423 1.161 11.277 2.088 4.358 1 .037 0.148 4.697Age (mo) 0.058 0.020 1.060 2.951 8.708 1 .003 0.019 0.097Weight (kg) –0.091 0.026 0.913 –3.468 12.027 1 < .001 –0.142 –0.039Complications Y/N level ‘2’ coded as class 1. Figure 2 —Graphic representation of the estimate “age” in our model and the probability of complications (black line) associ -ated to it. The probability of complications is represented with a confidence interval (gray area) with dog age (in months) in the horizontal axis. Notice the progressive increase of the pre -dicted probability of complications in older dogs in our model.Figure 3 —Graphic representation of the estimate “weight” in our model and the probability of complications (black line) associated to it. The probability of complications is represented with a confidence interval (gray area) with dog weight (in kg) in the horizontal axis. Notice the progressive decrease of the probability of expected complications in dogs of a higher body weight in our model.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 11/03/23 06:54 AM UTC 5

Question 96

Fracka - 2023 - VETSURG - 3D-printed, patient-specific cutting guides improve femoral and tibial cut alignment in canine total knee replacement.pdf

Answer 96

2.1 |Cadaveric specimensPelvic limbs were harvested from 16 skeletally maturemedium- to large- mixed breed dogs that wereeuthanatized for reasons unrelated to this study. The ani-mals had been donated for use in teaching and research,with the informed consent of the owners. The age andbodyweight of the cadavers were not recorded; however,they were all above 20 kg (the minimum bodyweight for aTKR candidate at our institution) to be included in thisstudy. The hindlimbs were disarticulated at the hip jointa n ds t o r e di ns e a l e db a g sa t /C020/C14Cu n t i lt h es t u d yw a sc o n -ducted. Specimens were thawed for at least 24 h andallowed to equilibrate to room temperature prior to beingused in the experiment. The specimens were randomlyallocated to one of two groups (PSG or Generic; N=8/group).2.1.1 | Preoperative planning andmeasurement of femoral and tibial cutalignment: Generic groupOrthogonal radiographs (full-length mediolateral andcaudocranial stifle series, plus a full-length caudocranialview of the femur) were obtained to confirm skeletalmaturity, rule out the presence of pre-existing orthopedicdisease, and allow for surgical templating. A 25-mm cali-bration ball was included in all radiographs for presurgi-cal templating. Femoral and tibial components of anappropriate size were positioned over caudocranial andmediolateral radiographs (Figure1A,B ). All radiographicmeasurements were made with a commercial radio-graphic planning suite (vPOPPRO; Llangollen, UK) andmeasurements were performed by the same investigatorto eliminate interobserver variability. The individualidentities of specimens within the groups were coded butit was not possible to blind the observer to group alloca-tion since the PSG measurements were made on CTrather than plain radiographs (see later).Tibial cut alignment in the frontal plane was mea-sured on caudocranial radiographs as the angle formedbetween the fixation surface of the tibial component andthe mechanical axis of the tibia (formed by a line con-necting the midpoint of the distal tibia and the intercon-dylar eminences on the proximal tibia) (Figure1C). Thetarget frontal plane alignment was at 90 degrees to themechanical axis.1Sagittal cut alignment was measuredon mediolateral radiographs as the angle between the fix-ation surface of the tibial component and the tibial axis,formed by a line connecting the midpoint of the talus dis-tally and the tibial intercondylar eminences proximally(Figure1D). The target sagittal cut alignment was with6 degrees of proximal tibial caudal slope, as per publishedguidelines for canine TKR.1Frontal plane alignment of the distal femoral cut wasdetermined as the angle formed between a line drawnFRACKA ET AL . 675 1532950x, 2023, 5, along the distal articular surface of the femoral compo-nent (line 5 in Figure 2A), and a line representing theanatomical axis of the femur (line 1 in Figure 2A). Theanatomical axis was determined with an interactive mea-suring tool ( “anatomic axis ”) within the vPOPPROsuite,which connects the midpoints of the femur at 25 and 50%of femoral length. Sagittal plane alignment of the cranialand distal femoral cuts was determined by measuring theangle formed between the anatomical axis in the sagittalplane (line 1 in Figure2B, defined using the interactivetool, as above), and lines drawn along the inside of therelevant fixation surface of the femoral component (lines2 and 3 in Figure2B). The third and final sagittal planemeasurement was the closing angle for the femoralFIGURE 1 Preoperativeplanning for the Generic guidegroup, showing optimizedpositioning of the femoral andtibial components onpreoperative caudocranial(A) and mediolateral(B) radiographs in vPOPPROplanning software. Frontal planealignment of the tibial cut wasdetermined on the caudocranialview by reference to themechanical axis of the tibia(C) and sagittal plane alignmentof tibial cut was determinedfrom the mediolateral view asthe angle between the relevantfixation surface and the axis ofthe bone (D). The angles thatwere measured are indicatedwith orange semi-circles.676 FRACKA ET AL . 1532950x, 2023, 5, component, which reflects the angle formed between thecranial fixation surface (line 2 in Figure 2B) and the cau-dal fixation surface (line 4 in Figure 2B). The target forthe closing angle was 10 degrees since this is the internalangle formed in the BioMedtrix femoral component toensure a locking fit onto the femur.2.1.2 | Preoperative planning andmeasurement of femoral and tibial cutalignment: PSG groupCT scans were used to confirm skeletal maturity, screenfor stifle joint pathology, and for surgical planning andthe design of custom PSGs. 3D computer models of thebones were created in medical imaging software(MIMICS version 24.0; Materialise BV, Belgium) andexported as STL files into surgical planning software(3-matic version 16.0; Materialise BV, Belgium). The opti-mal positions of the femoral and tibial components weredefined in three dimensions (Figure3A,B ) and their fixa-tion surfaces were used to define the cutting planes forthe femur (Figure3C,D ) and tibia. The alignment ofthese cutting planes to the anatomical axis (femur)FIGURE 2 (A) Frontal plane alignment of the femoralcomponent was determined by measuring the angle formedbetween the anatomical axis of the femur (line 1, passing betweenbest fit circles at 25 and 50% of femoral length) and the distalsurface of the femoral component (line 5). The angle is indicatedwith a black semi-circle. (B) Sagittal plane alignment of the femoralcomponent was determined by measuring the angles formedbetween the anatomical axis of the femur (line 1, passing betweenbest fit circles at 25 and 50% of femoral length) and the cranial anddistal fixation surfaces of the femoral component (lines 2 and3, respectively). The angles are indicated with black semi-circles.The locking angle of the femoral component was measured as theangle formed between lines 2 (cranial cut) and 4 (caudal cut).FIGURE 3 For the patient-specific guides (PSG) group,preoperative planning was performed on 3D models based oncomputed tomography (CT) scans. Femoral and tibial componentswere virtually implanted in the models (A and B), and thealignment of the components determined relative to the femoraland tibial axes. For the femur, the alignment of the cranial cut(C) and the distal cut (D) were measured, and the closing angle wasdetermined (E). The red circle indicates the angle that wasmeasured.FRACKA ET AL . 677 1532950x, 2023, 5, and the mechanical axis (tibia) was then determined inboth the frontal and sagittal planes. On the 3D models,the anatomical axis of the femur was defined as a linepassing through the center of the femur at 25 and 50% ofthe length of the bone. As in the Generic group, themechanical axis of the tibia was defined by a line con-necting the midpoint of the distal tibia and the intercon-dylar eminences on the proximal tibia. Alignment wasmeasured in the frontal and sagittal planes using thesame approach as described for the Generic group, lead-ing to values for frontal plane alignment of the tibial cutand the distal femoral cut, and sagittal plane alignmentof the tibial cut, and the cranial and distal femoral cuts.The locking angle was measured as the angle betweenthe cranial and caudal femoral cuts (Figure3E). All the3D measurements were made using the angle measure-ment feature of 3-matic software. Tibial and femoralmeasurements were performed by the same investigatorto eliminate interobserver variability. The individualidentities of specimens were coded but it was not possibleto blind the observer to group allocation since CT, ratherthan plain radiographs, were only used for preoperativemeasurement in the PSG group.2.2 |Design of PSGsThe cutting planes defined on the planning images weremerged with custom-designed baseplates that mirroredthe external contours of the femur or tibia, as appropri-ate. The result was a set of five femoral PSGs and one tib-ial PSG (Figure4). The definitive PSGs were designedand manufactured from an autoclavable resin by stereo-lithography (Vet3D, Staveley, Cumbria, UK). The fit ofeach guide was verified using a 3D-printed plastic modelof the femur and tibia to ensure accurate contouring, cutlocation and trajectory.2.2.1 | Surgical procedure for the GenericgroupSurgery was performed through a medial parapatellarapproach, and the joint access ed through a medial arthrot-omy. The patella was luxated laterally and the infrapatellarfat pad, cranial cruciate ligament, caudal cruciate ligamentand menisci were removed. Throughout the procedure carewas taken to preserve medial and lateral collateral liga-ments. The extramedullary tibial alignment guide (ETAG;BioMedtrix, Whippany, New J ersey) was aligned along thetibial mechanical axis by eye, then secured in place with fix-ation pins (BioMedtrix LLC, Whippany, New Jersey) in linewith current clinical guidelines.1The ETAG has a cuttingb l o c ko nt h et o p ,w h i c hg u i d e st h eo s t e c t o m yo ft h et i b i a lplateau. The oscillating saw was placed on the top of thecutting block and around 6 mm of proximal tibia (at thelevel of tibial plateau eminences) was removed. Any resid-ual irregularity in the bone surface was removed by carefultrimming with the oscillating saw or a pair of rongeurs.Next, four femoral osteotomies were made using theselected femoral cutting block (FCB). Before cuts weremade, the FCB was secured in position using three fixationpins (cranial, medial, and lateral). The cuts were madethrough the slots in the FCB, and they always followed thesame sequence: cranial, cauda l, distal then chamfer cut. Atrial femoral component was applied to the distal femurand its fit evaluated. A trial tibial component was placed onthe cut surface of the tibia and the joint was reduced toallow for assessment of joint gap symmetry, joint laxity,range of motion, femoral/tibial component position and sti-fle joint tracking. The optimal position for the tibial compo-nent was identified and a 7-m m hole was then drilled intothe tibial bone bed using a dril l guide screwed into the trialtibial component. The cavity was enlarged with a #7 flutedFIGURE 4 The use of patient-specific guides (PSGs) in caninetotal knee replacement (TKR). (A) The initial guide is designed tolocate two reference pins for the subsequent guides that are used toprepare the cranial cut, the chamfer cut (B), the distal cut, and thecaudal cut (C). On the tibia, a single guide (D) is attached to theproximal medial aspect of the tibia and used to resect the articularsurface.678 FRACKA ET AL . 1532950x, 2023, 5, reamer to provide space for the tibial keel and surroundingbone cement mantle. The trial components were thenremoved, and the bone beds cleaned and flushed. Poly-methyl methacrylate (PMMA) bone cement (Teknivet; Bio-Medtrix LLC, Whippany, New Jersey) was injected into thetibial keel hole and applied to the undersurface of an appro-priately sized 3D-printed plastic tibial component that con-tained an internal wire marker to allow for visualization onpostoperative radiographs. When the cement in the tibiahad cured, an appropriately sized cementless cobalt-chromium femoral component was impacted on the distalfemur. The patella was reduced, and stifle joint was againevaluated for laxity, implant stability and range of motion.The joint was closed routinely.2.3 |Surgical procedure for the PSGgroupThe surgical approach in the PSG group was the same asfor the Generic group, with a medial parapatellar skinincision and arthrotomy. Following stifle joint exposure, thefirst femoral PSG was positioned against the femur andsecured with two bicoretical Ellis pins (2 mm in diameter);these pins served as references for all the remaining PSGs(Figure5A). After the pins had been drilled, the first femo-ral PSG was removed, and the cranial cutting guide wasplaced over the reference pins. The cranial ostectomy wasperformed using an oscillati ng saw fitted with a 0.89-mmthick saw blade. The cranial guide was then removed, leav-ing the pins in place, and the PSG for the chamfer cut wasseated over the pins (Figure 5B). Once the chamfer cut hadbeen performed, the guide was removed and replaced withthe guide for the distal cut, then the guide for the caudalcut (Figure5C). When all femoral cuts were complete, pinswere removed from the distal femur.For the tibia, the PSG was placed on the craniomedialaspect of the proximal tibia. A small hook at the distalend of the guide was positioned so that it engaged withthe most distal part of the tibial crest (Figure5D). Theguide was secured with two parallel 2.0-mm Ellis pinsinto the tibial metaphysis, and the tibial articular surfacewas resected with the oscillating saw. Any minor imper-fections in the cut tibial surface were removed with eitherthe oscillating saw or a pair of rongeurs, as appropriate.On completion of all cuts, the tibial and femoral compo-nents were implanted in the same way as for the Genericgroup.2.4 |Postoperative assessment of tibialand femoral cut alignmentMediolateral and caudocranial radiographs were obtainedpost-operatively for each specimen. The cemented tibialcomponent was left in place for radiography. Tibial cutalignment was determined in both the frontal plane andsagittal plane (Figure6A,B ), as described previously, usingthe ostectomized surface of the proximal tibia as the refer-ence surface.One the femoral side, the femoral component wasremoved from the bone prior to imaging to improve thevisualization of the cut surfaces. Cut alignment was deter-mined using the same approach as described for preopera-tive measurement in the Generic group, resulting inangular measurements for the following cuts: frontal planealignment of the distal femoral cut (Figure7A), and sagit-tal plane alignment of the cranial cut (Figures 7B) and dis-tal femoral cut (Figure 7C). The locking angle wasmeasured (Figure 7D) and the fit of the femoral compo-nent on the cut distal femur was estimated by comparingthe cranial-caudal width of the cut femur against the inter-nal cranial-caudal dimensions of the femoral component.Tibial and femoral measurements were performed by theFIGURE 5 Intraoperative photographs illustrating the use ofpatient-specific guides (PSGs) in canine total knee replacement(TKR). An indexing guide is used for reference pin placement (A),after which there is sequential use of custom guides for the chamfercut (B) and the caudal cut (C). A separate tibial guide is applied tothe medial tibial surface (D).FRACKA ET AL . 679 1532950x, 2023, 5, same investigator to eliminate interobserver variability.The individual identities of specimens within the groupswere coded to remove identifying information.2.5 |Data handling and statisticalanalysisErrors in tibial and femoral cut alignment (in degrees)were calculated by subtracting the measured ( “actual ”)values obtained postoperatively from the values mea-sured during the planning process ( “planned ”). Errorvalues were normally distributed and comparisonsbetween the two groups were made using an unpairedStudent's t-test with significance set at p<. 0 5 .Fit of the femoral component was determined bycalculating the difference (in millimeters) between thecranial-caudal width of the cut femur and the cranial-caudal inner dimensions of the femoral component.Data from the two groups were compared using anunpaired Student's t-test, with significance setatp< .05.3|RESULTSThere were no significant technical problems with usingthe PSGs. Use of the five sequential femoral guides wasstraightforward. As seen in Figure 5A–D, the guides fitvery well onto the surface of the bone, allowing for aFIGURE 7 Measurement ofpostoperative femoral alignment.Frontal plane alignment wasdetermined relative to theanatomical axis of the femur (A).Sagittal plane measurementsincluded alignment of the cranialostectomy (B), distal ostectomy(C) and the closing angle (D). Anglesare highlighted by white quarter-circles.FIGURE 6 Measurement of postoperative tibial componentalignment was performed using the same approach as for thepreoperative measurements. Frontal plane (varus-valgus) (A) andsagittal plane (tibial slope) (B) were measured for each specimen.Angles are highlighted by black quarter-circles.680 FRACKA ET AL . 1532950x, 2023, 5, precise and definitive fit. Their lower profile and trans-parency allow greater visibility of the femur or tibia, atleast as compared with the bulkier generic guides. Noneof the guides loosened during the cutting procedure,something that has been an issue in clinical cases oper-ated with the generic guides.3.1 |Tibial component alignmentComparisons of the alignment data revealed a statisticallysignificant reduction in frontal plane alignment error inthe PSG group (2.41/C14± 1.40/C14vs. 1.03/C14± 0.96/C14) for theGeneric and PSG groups, respectively; 95% CI: /C02.674 to/C00.1011 ( p=.036) (Figure 8A). In humans, optimal tib-ial component alignment is within 3 degrees of neutral;17as shown in Figure 8A, none of the PSG knees fell out-side 3 degrees, compared with two of eight knees in theGeneric group.There was no significant difference between PSG andGeneric groups for sagittal slope (1.60/C14± 1.17/C14vs. 1.13/C14± 0.85/C14for the Generic and PSG groups, respectively;95% CI: /C01.573 to 0.6229, p=.37) (Figure 8B).3.2 |Femoral component alignmentA total of four measurements were made to assess theaccuracy of the femoral ostectomies. The use of PSGs wasnot associated with any difference in varus-valgus align-ment of the distal cut (3.02/C14± 2.14/C14vs. 2.44/C14± 1.67/C14forthe Generic and PSG groups, respectively; 95% CI: /C02.65to 1.47, p=.533) (Figure 9A). In contrast, sagittal planealignment of both the distal cut (5.93/C14± 3.33/C14vs. 2.3/C14± 1.89/C14for the Generic and PSG groups, respectively;95% CI /C06.53 to /C00.72; p=.018) (Figure 9B) and thecranial cut (6.34/C14± 4.53/C14vs. 2.5/C14± 1.82/C14for the Genericand PSG groups, respectively; 95% CI: /C07.539 to /C00.1357,p=.043) (Figure 9C) were significantly improved by theuse of PSGs. There was no statistically significant differ-ence between the accuracy of closing angle cuts in thetwo groups (3.75/C14± 2.01/C14vs 3.59/C14± 1.92/C14for the Genericand PSG groups, respectively; 95% CI: /C02.269 to 1.944)(p=.871) (Figure 9D). The fit of the femoral componenton the distal femur was also not different, with mean (±SD) under-sizing of the cranial-caudal femoral bone stockby 0.34 ± 0.38 mm for the PSG group and 0.4 ± 0.25 mmfor the generic guides ( p=.68).4

Question 97

Ullal - 2023 - JAVMA - Increasing age and severe intraoperative hypotension associated with nonsurvival in dogs with gallbladder mucocele undergoing cholecystectomy.pdf

Answer 97

Criteria for case selectionA subset of dogs with GBM enrolled in a pre -vious study37 evaluating 25(OH)D concentrations were analyzed because these dogs had sufficient serum samples available to measure CRP and hap -toglobin. Cases from 4 different academic teaching hospitals (Midwestern University College of Vet -erinary Medicine, University of Missouri Veterinary Health Center, Colorado State University James L. Voss Veterinary Teaching Hospital, and Utrecht University) were enrolled prospectively, primar -ily between July 2018 and November 2019. Four dogs were enrolled outside of the primary enroll -ment period. One dog was enrolled in 2021, 2 dogs in 2014, and 1 in 2017. This study was conducted in accordance with guidelines for clinical studies and approved by each institution’s animal care and use committee (Midwestern University College of Vet -erinary Medicine, No. 2925; University of Missouri Veterinary Health Center, No. 7334; and Colorado State University James L. Voss Veterinary Teaching Hospital, No. 2019-203). Approval from the Utrecht University Animal Care and Use Committee was not required because only dogs with serum remaining from other diagnostic testing were included. Dogs were included if they had been diagnosed with a GBM via ultrasonography, gross or histopathologi -cal examination, or both and underwent cholecys -tectomy. Ultrasound images were obtained by a board-certified veterinary radiologist, veterinary radiology resident, board-certified small animal internist, or diagnostic sonographer. An ultraso -nographic diagnosis of GBM was achieved with the identification of gravity-independent, immobile material.4,5 Two board-certified veterinary radiolo -gists reviewed all ultrasound images to reach a di -agnosis and assign a consensus GBM type between I and VI based on previously established criteria.38 Gross or histopathologic features consistent with GBM included a distended gallbladder with an ab -normal accumulation of inspissated, amorphous Unauthenticated | Downloaded 12/04/23 07:15 AM UTC 3mucus in combination with cystic mucosal hyper -plasia or hypertrophy.10Gallbladder rupture was diagnosed intraopera -tively by a board-certified surgeon when a perfo -ration in the gallbladder wall, bile leakage, or both were identified.5 Exclusion criteria included clinically relevant comorbidities that could affect prognosis such as diabetic ketoacidosis, neoplasia, congestive heart failure, or immune-mediated diseases.The following data were collected for each dog with GBM: academic hospital of admission (institu -tion), age, sex, breed, clinical signs prior to and on presentation, duration of clinical signs in days, APPLEFAST score on presentation, preoperative WBC count (/µL), ALP (IU/L), ALT (IU/L), GGT (IU/L), bilirubin (mg/dL), cholesterol (mg/dL), ul -trasonographic GBM type (I to VI), presence of in -traoperative hypotension (systolic blood pressure < 90 mm Hg), nadir intraoperative systolic blood pressure (mm Hg), gallbladder perforation (pres -ent/absent), surgery duration (minutes), gallblad -der histopathology results, anaerobic and aerobic bile culture results (positive/negative), survival in hospital (yes/no), and survival 2 weeks post–hos -pital discharge (yes/no). Nonsurvival was defined as death or euthanasia. APPLEFAST score was calcu -lated as previously described using the 5 variables of glucose (mg/dL), albumin (g/dL), mentation score, platelet count (number of platelets/µL), and lactate (mmol/L).39 Possible scores ranged from 0 to a maximum score of 50. Higher scores were indicative of more severe disease. Intraoper -ative blood pressure measurements were obtained via Doppler or oscillometric techniques according to previously established guidelines.40 Dogs were considered clinical if they had any signs of leth -argy, hyporexia to anorexia, abdominal pain, vom -iting, diarrhea, adipsia, jaundice, or fever within 7 days of presentation to the hospital. Laboratory variables such as WBC count or ALP were inter -preted as a fold change with respect to the upper limit of the reference interval (xULN) because of different analyzers and reference intervals used at different institutions.A second cohort of healthy control dogs used in a previous study37 was used as a comparison group. These dogs were selected on the basis of a review of clinical history, physical examination, CBC, se -rum biochemical profile, and urinalysis by a board-certified small animal internist (JAJ) to confirm good health. Control dogs could not have any known ill -nesses, vaccination, or medications, except monthly parasiticides within 60 days of enrollment. For each control dog, ultrasonography by a board-certified internist confirmed the absence of GBM formation on the basis of anechoic contents or small volume of gravity-dependent sludge.Blood samples were collected via venipuncture for dogs with GBM and healthy controls. Samples were centrifuged, and a minimum of 0.5 mL of se -rum was stored for each dog. Serum was stored in freezer-resistant conical microcentrifuge tubes at –80 °C for batch analysis of CRP, haptoglobin, and serum 25(OH)D concentrations. Samples were packed with dry ice and shipped overnight to VDI Laboratory LLC. Serum 25(OH)D quantification was performed on thawed samples using a competitive chemiluminescence immunoassay as previously described.41 The minimum detectable concentra -tion for serum 25(OH)D was 4.0 ng/mL. Serum CRP and haptoglobin measurements were performed as previously described using canine-specific sand -wich ELISAs.27 Precision data for each assay have been previously reported.41,42 Laboratory reference intervals for the CRP assay in dogs were normal (≤ 3.9 mg/L), mildly increased (4 to 9.9 mg/L), moderately increased (10 to 39.9 mg/L), and mark -edly increased ( ≥ 40 mg/L).27 The reference inter -val for the haptoglobin assay in dogs was 30 to 250 mg/dL.27 The minimum detectable concentration for the CRP assay was 0.5 mg/L and for the hapto -globin assay was 10 mg/dL. Laboratory technicians performing the assay were blinded to the identity of each sample.Statistical analysisStatistical analysis was performed with com -mercially available software (Stata version 17; Stata Corp). Data were assessed for normality using tests of skewness and kurtosis. Normal data were de -scribed by the mean and SD, while nonnormal data were described by the median and IQR, expressed as the first and third quartiles. Concentrations of CRP, haptoglobin, and 25(OH)D below the lower limit of detection were imputed as the lower limit of detection for statistical purposes. The association of age, sex, presence of clinical signs, CRP, haptoglo -bin, 25(OH)D, APPLEFAST score, perforation (pres -ent/absent), nadir intraoperative systolic blood pressure, xULN total bilirubin, xULN ALP, and xULN WBC with survival data in hospital and 2 weeks fol -lowing hospital discharge were determined via ex -act logistic regression. After the initial statistical analyses, lower-than-expected nadir readings for systolic blood pressure prompted a more in-depth examination via probability tables and conditional density plots generated by marginal analysis fol -lowing logistic regression. Multivariable models were built using a backward stepwise approach in -formed by prior literature and biological plausibility incorporating variables with a P value ≤ .2 in univari -able regression. Models were validated using the Pearson goodness-of-fit test to check the model’s assumptions and ensure that it fit the data appropri -ately. Proportions were compared using a 2-sided test of proportions. The Shapiro-Wilk test was used to assess for normality, after which a nonparametric Wilcoxon rank sum test was used to compare age, CRP, and haptoglobin concentrations between dogs with GBM and healthy controls. A Pearson χ2 test was used to compare sex distribution between GBM and healthy control groups. The level of significance was set at P < .05. The Strengthening the Reporting of Observational Studies in Epidemiology checklist was used to ensure all criteria were met when re -porting results. Formal power calculations were not Unauthenticated | Downloaded 12/04/23 07:15 AM UTC4 performed to estimate an ideal sample size because this was an exploratory study, but sample size was determined by enrolling cases prospectively that met the inclusion criteria during the designated study period.ResultsDemographics of the study cohort of dogs with GBMTwenty-six GBM dogs were included, of which 1 dog was excluded because sufficient serum sample was not available within 24 hours of cholecystectomy to measure CRP, haptoglobin, and 25(OH)D concen -trations. Ten cases were enrolled from Utrecht Univer -sity, 7 from University of Missouri, 5 from Midwestern University, and 3 from Colorado State University. Me -dian (IQR) age was 10.3 years (11.3 to 12.9 years). There were 13 castrated males, 10 spayed females, and 1 each of intact female and intact male dogs. Breed distribution included Chihuahua (n = 5), mixed breed (4), Beagle (3), Maltese (2), Shetland Sheep -dog (2), Labrador Retriever (1), Cavalier King Charles Spaniel (1), Pomeranian (1), West Highland White Terrier (1), Chow Chow (1), Jack Russell Terrier (1), Soft Coated Wheaten Terrier (1), Miniature Poodle (1), and Dachshund (1).Demographics of control cohort dogsTwenty healthy control dogs were included. Me -dian (IQR) age was 5.3 years (1.4 to 9.0 years), and 7 intact males, 9 spayed females, 3 intact females, and 1 intact male comprised the group. Breed in -formation regarding control dogs can be found in a previously published study.37 Age was significantly higher in GBM dogs compared to healthy controls ( P < .001), but sex distribution was not significantly dif -ferent ( P = .44; χ2 = 0.59) between the 2 groups.Clinical presentation, diagnostics, and survival outcomes of the study cohort of dogs with GBMThree of the 25 (12%) dogs were subclinical on presentation and evaluated for increased liver enzyme activity (n = 2) or for a recheck ultrasound to monitor the appearance of a previously identified GBM (1). Of the cases that presented with clinical signs, hypo -rexia to anorexia or lethargy were the most common clinical signs found in 77% (17/22) of cases followed by vomiting in 64% (14/22). Other clinical signs com -monly noted were icterus in 32% (7/22), abdominal pain in 23% (5/22), and polyuria and polydipsia in 18% (4/22). Median (IQR) number of days the dog was clinical prior to presentation was 5 (3 to 14).Median and IQR for the following laboratory vari -ables were WBC, 12,900/µL (10,580/µL to 22,610/µL); ALP, 2,198 IU/L (688 to 4,050 IU/L); ALT, 1,019 IU/L (328 to 1,506 IU/L); GGT, 67 IU/L (19 to 90 IU/L); bilirubin, 0.7 mg/dL (0.2 to 6.5 mg/dL); and cholesterol, 412 mg/dL (188 to 562 mg/dL). Of 20 dogs with available APPLEFAST scores, median (IQR) was 21 (19 to 23). There were 24 dogs with available ultrasonographic GBM type, of which there were type 1 (7/24 [29%]), type 2 (5/24 [21%]), type 3 (4/24 [17%]), and type 4 (8/24 [33%]). In 1 case, the ultrasound was performed at the referring veterinary practice and the ultrasonographic type could not be ascertained, but a GBM was later confirmed on gross and histopathological examination postoperatively.Three dogs were reported to have hyperadre -nocorticism. One dog was suspected on the basis of clinical signs and an enlarged left adrenal gland on ultrasound and the other 2 dogs were diagnosed with low-dose dexamethasone suppression testing. One dog was receiving budesonide for treatment of anorexia due to suspected, but not confirmed, in -flammatory bowel disease. One dog was reported to have diabetes mellitus.The median (IQR) duration of surgery was 110 minutes (70 to 150). During cholecystectomy, 24 of 25 underwent open laparotomy and 1 of 25 under -went laparoscopy. One dog also underwent sple -nectomy for a splenic mass later confirmed to be a benign hematoma. A different dog underwent a partial liver lobectomy because of suspicion for a hepatic mass, but histopathology revealed multifo -cal regions of hepatic necrosis and infarction with periportal neutrophilic infiltrates with no evidence of malignancy. Nadir intraoperative systolic blood pres -sure was available for 23 of 25 cases with a median (IQR) of 70 mm Hg (60 to 85 mm Hg). Four of 25 (16%) dogs had gallbladder perforation. Aerobic and anaerobic culture of bile (n = 9), swab of gallbladder content (9), swab of gallbladder wall (2), gallblad -der tissue (1), or a combination of bile or swab of gallbladder content with tissue (3) was performed in 24 of 25 cases, and results were positive in 5 of 24 (21%) cases. Bacterial species cultured included Mi-crococcus luteus and Staphylococcus spp coagulase negative (n = 1), Roseomonas mucosa (1), Lactococ -cus sp (1), Pseudomonas aeruginosa (1), and Esch -erichia coli (1). Of 25 dogs, 24 had gallbladder tis -sue submitted for histopathological examination, of which all confirmed GBM and cystic mucinous hyper -plasia. Accompanying findings included cholecystitis in 12 dogs (lymphoplasmacytic in 4, neutrophilic in 4, mixed cell in 3, and cell type not specified in the report in 1). Two of 12 (17%) cases had mucosal ne -crosis associated with the inflammatory changes.Survival to hospital discharge and 2 weeks following discharge in dogs with GBMEight of 25 (32%) dogs died or were euthanized (in hospital, n = 6; 2 weeks postdischarge, 2). Causes of death prior to discharge were due to cardiac arrest (n = 2) or unknown cause (1), and causes of eutha -nasia were concern for sepsis (2) and disseminated intravascular coagulation (1). Two cases were eutha -nized following discharge due to worsening jaundice and clinical signs (n = 1) and a bile peritonitis (1).Serum CRP and haptoglobin concentrations between dogs with GBM and controlsOf the 25 dogs with GBM, median (IQR) concen -tration for CRP was 34.2 mg/L (10.5 to 62.2 mg/L) and Unauthenticated | Downloaded 12/04/23 07:15 AM UTC 5for haptoglobin was 598 mg/dL (425 to 654 mg/dL). Of 20 healthy control dogs, median (IQR) concentra -tion for CRP was 2.0 mg/L (1.3 to 5.4 mg/L) and for haptoglobin was 156 mg/dL (62 to 369 mg/L). Serum CRP concentrations in dogs with GBM were normal (5/25 [20%]), mildly increased (1/25 [4%]), moderately increased (8/25 [32%]), or markedly increased (11/25 [44%]). Serum CRP concentrations in healthy control dogs were normal (17/20 [85%]), mildly increased (2/20 [10%]), and markedly increased (1/20 [5%]). The control dog with markedly increased serum CRP was diagnosed with coccidiomycosis 4 months after CRP measurement. Serum haptoglobin concentrations in dogs with GBM were normal (3/25 [12%]), decreased (1/25 [4%]), or increased (21/25 [84%]) above the ref -erence interval and in healthy control dogs were be -low the reference interval (3/20 [15%]), normal (8/20 [40%]), or increased above the reference interval (9/20 [45%]). Haptoglobin concentrations were increased above the reference interval in dogs with GBM that were administered exogenous corticosteroids (n = 1) or diagnosed with diabetes mellitus (1) or hyperadreno -corticism (3). In 7 of 25 (28%) dogs with GBM, concen -trations of haptoglobin or CRP were within the normal reference interval, of which 5 either had subclinical (n = 3) or very minimal clinical signs of lethargy (2).Dogs with GBM had significantly higher serum CRP ( P < .001) and haptoglobin ( P < .001) than con -trols (Figures 1 and 2) .Risk factors for nonsurvival in dogs with GBM undergoing cholecystectomyIncreasing age was associated with nonsurvival in hospital and within 2 weeks of discharge. The odds of nonsurvival in hospital and within 2 weeks of hospital discharge increased for each additional year by 2.2 ( P = .01; 95% CI, 1.2 to 5.0) and 1.7 ( P = .04; 95% CI, 1.0 to 3.2), respectively. A margins plot showed a sigmoid pattern, with the probability of nonsurvival before discharge and 2 weeks post -discharge low and insignificant (Table 1) for ages 8 to 11 and 8 to 10, respectively, then rising rapidly before leveling off at ages 15 to 16 years (Supple -mentary Figure S1) . No multivariable model was an improvement on the univariable model for age. None of the other examined clinical variables (clini -cal on presentation, gallbladder perforation, and APPLEFAST score), clinicopathologic variables (WBC count, ALP activity, or bilirubin,) nor inflammatory markers (CRP, haptoglobin, or 25[OH]D concentra -tions) were significantly associated with survival in hospital or 2 weeks post–hospital discharge (Tables 2 and 3) . While nadir intraoperative systolic blood pressure was also not associated with survival, ex -amination of the margins showed that dogs in the lowest end of the range, with systolic blood pres -sure of ≤ 65 mm Hg, had a significantly increased probability of nonsurvival in hospital (Table 4; Sup -plementary Figure S2) .Figure 1 —Comparison of serum C-reactive protein (CRP) concentrations (mg/L) in dogs with gallbladder mucocele (n = 25) prior to cholecystectomy and healthy control dogs (n = 20). Serum CRP concentrations were higher in gallbladder mucocele dogs before cholecys -tectomy compared to healthy control dogs ( P < .001). The bottom and top of the boxes represent the 25th and 75th quartiles, respectively, with the black horizontal line representing the median. The whiskers extend up to 1.5 X the IQR below and above the 25th and 75th quar -tiles, respectively. Open circles outside of the whiskers represent outlier values. Significant difference ( P < .05) between groups is marked by the asterisk.Figure 2 —Comparison of serum haptoglobin concen -trations (mg/dL) in dogs with gallbladder mucocele (n = 25) prior to cholecystectomy and healthy control dogs (20). Serum haptoglobin concentrations were higher in dogs with gallbladder mucoceles before cholecystectomy compared to healthy control dogs (P < .001). The bottom and top of the boxes repre -sent the 25th and 75th quartiles, respectively, with the black horizontal line representing the median. The whiskers extend up to 1.5 X the IQR below and above the 25th and 75th quartiles, respectively. Open circles outside of the whiskers represent outlier val -ues. Significant difference ( P < .05) between groups is marked by the asterisk.Unauthenticated | Downloaded 12/04/23 07:15 AM UTC6

Question 98

Forster - 2023 - JAVMA - Bilateral pubic and ischial osteotomy in cats offers good exposure for resection of large vaginal masses with minimal postoperative complications.pdf

Answer 98

Eleven referral clinics in the UK were invited to participate in the study. Ethical review was obtained from the University of Edinburgh ethical review com -mittee (VERC 7.21) . The surgical database of each institution was searched using the words “feline,” “cat,” “vaginal,” “neoplasia,” and “osteotomy” be -tween the dates of January 2004 and June 2022. Medical records were received from 3 institutions that met the inclusion criteria of feline patients that underwent a bilateral pubic and ischial osteotomy for surgical management of a vaginal neoplasm.Data collected included signalment, clinical his -tory, presenting clinical signs, physical examination findings, MRI or CT preoperative imaging findings, anesthesia and analgesia protocol, surgical tech -nique, histopathological diagnosis, intra- and post -operative complications, and outcome. Information regarding surgical outcome was obtained during postoperative recheck appointments, up to 12-week to 15-month postoperative follow-up telephone calls, and ongoing adjunctive chemotherapy treat -ment appointments (depending on the case).ResultsThree cases met the inclusion criteria; all cases were operated by the same surgeon (KF). There were 2 domestic shorthair cats (cases 1 and 2) and 1 Sphynx cat (case 3) reported with an age at presentation of 11.7, 5.8, and 6.3 years, respec -tively. Clinical presentation included tenesmus and constipation due to dorsal compression of the rectum in 2 cases (cases 1 and 3) and an inter -mittent mucopurulent, occasionally hemorrhagic vaginal discharge in the third (case 2). Clinical signs were reported to be noticed 30, 210, and 21 days prior to presentation, respectively, for cases 1, 2, and 3. On clinical examination, cases 1 and 3 presented with a palpable caudal abdominal mass, with a dilated colon containing feces. Case 3 also showed an externally visible perineal mass protruding from the vulva. In case 2, clinical ex -amination was unremarkable.CT imaging (thorax, abdomen, and pelvis) was performed in cases 1 and 2, while MRI and thoracic radiographs were performed in case 3. Either MRI or CT images confirmed the presence of a large mass within the pelvis, arising from the vagina. Thoracic and abdominal imaging were unremarkable in all 3 cases confirming pathology focused to the vagina, without evidence of metastatic disease. Dimensions of the vaginal tumor (height, width, and length) in relation to the largest dimension of the pelvis (height, width, and length), expressed in percent -age, was obtained by measuring multiplanar CT or MRI images. The masses measured 53% X 62% X 63% (case 1), 50% X 100% X 60% (case 2), and 150% X 120% X 120% (case 3), respectively.In case 1, in which a CT had been performed, a large volume intrapelvic mass (length 5 cm X width 4.2 cm X height 3.6 cm) occupying the majority of the pelvic canal was noted, with the mass protruding slightly cranially from the pelvic inlet. A larger pro -portion of the mass bulged caudally beyond the pel -vis into the perineal region. Postcontrast, there was a markedly enhancing vestibule/caudal vagina that was continuous with the caudal aspect of the mass. Severe secondary dorsal displacement and flattening of the rectum was noted.In case 2, in which an MRI had been performed, a large, long, bilobed mass lesion was reported in the cranial half of the pelvis with approximate dimensions of length 5 cm X width 1.5 cm. The cranial margin of the mass was just caudal to the urinary bladder neck, and caudally the mass extended to the caudal aspect of the coxofemoral joints. The mass was hyperintense on T2-weighted and STIR and isointense to the sur -rounding musculature on T1-weighted, showing mod -erate contrast enhancement. In summary, a large, bi -lobed concentric vaginal mass was reported.In case 3, in which a CT had been performed (Figure 1) , a large-volume, smoothly marginating, hy -poattenuating intrapelvic vaginal mass (length 7 cm X width 4 cm X height 4 cm) was described. The mass Figure 1 —Case 3. Sagittal and transverse contrast-enhanced CT, showing a vaginal mass occupying 150% of the length of the pelvis, with vulval protrusion, and 120% of the width of the pelvis.Unauthenticated | Downloaded 12/04/23 07:14 AM UTC 3was minimally contrast enhancing and occupied the entire pelvic canal. A significant proportion of the mass bulged beyond the pelvis into the perinium and protruded from the vulva caudally. Significant dorsal compression of the rectum within the pelvic canal was evident, with a dilation of the colon cranial to the mass, within the abdomen.Cytological evaluation of the vaginal mass in case 1 re -vealed mesenchymal cells, and a low-grade soft tissue sar -coma was reported. Cytological evaluation of case 2 con -firmed a vaginal mycetoma, and due to the extent of the vaginal mass, a combination of surgical and medical man -agement was recommended as previously described.12 Cytological evaluation of case 3 confirmed a vaginal polyp. For all 3 cases, staging investigations prior to surgery did not show any evidence of metastatic disease. In light of the size and location of all 3 of the reported vaginal masses, a bilateral pubic and ischial osteotomy was performed.Surgery time ranged from 120 to 200 minutes, and anesthesia time ranged from 200 to 265 minutes. The preoperative anesthesia and analgesia protocol was simi -lar for all 3 cases involving a premedication of methadone (0.2 mg/kg, IV) and midazolam (0.3 mg/kg, IV; cases 1 and 2) or methadone (0.2 mg/kg, IV) and acepromazine (0.05 mg/kg, IV; case 3). Anesthesia was induced with propofol (5 mg/kg, IV) and maintained with isoflurane in oxygen. In cases 1 and 3, an epidural of morphine (0.1 mg/kg) and bupivacaine (0.5 mg/kg) was given. In all 3 cases, amoxicillin–clavulanic acid (Augmentin; 20 mg/kg, IV) was administered 30 minutes prior to surgery and continued every 90 minutes during surgery.The surgical procedure was similar for all 3 cases (Figures 2–4 ; case 3). A caudal midline celiotomy was Figure 2 —Midline ap -proach to the pelvis show -ing reflection of adductor muscles bilaterally and obturator foramen. Cranial is to the top of the photo. The vaginal mass protrud -ing through the vagina is visible to the bottom of the photo. Predrilling of the pelvis (1.1 mm) bilat -erally in the pubis and is -chium prior to osteotomy cut midline to the pre -drilled holes (yellow stars). The black arrow denotes the obturator nerve.Figure 3 —Vaginal mass (yellow star) bluntly dissected following removal of pubis and ischium. The urethra is retracted laterally with a yellow vessel loop. The cer -vical stump following ovariohysterectomy is evident (black arrow).Unauthenticated | Downloaded 12/04/23 07:14 AM UTC4 performed extending from the umbilicus to the most caudal aspect of the ischium. The subcutaneous tissues and linea alba were incised to approach the caudal ab -domen. The incision extended along the midline pubis with a No. 10 scalpel blade, and the abductor longus and brevis muscles were subsequently elevated from the midline pubis with a Freer periosteal elevator (Fig -ure 2). At the cranial pelvis, the prepubic tendon was cut using a No. 11 blade as its insertion on the pubis. At the caudal pelvis, the ligamental attachment to the ischium was also cut, again using a No. 11 blade, taking care not to traumatize the urethra at this level. Any re -maining adductor and external obturator musculature attachment on the ventral pubis was elevated from the obturator foramen bilaterally, taking care to identify and carefully retract the obturator nerve bilaterally. While identification and catheterization of the urethra would be recommended prior to vaginal mass resec -tion, the distortion of the urethral orifice precluded this in all 3 patients. Avoidance of iatrogenic damage of the urethra during osteotomy was achieved through place -ment of a periosteal elevator dorsal to the osteotomy site and ventral to the urethra.Once the ventral pelvis was clearly visualized, the pubis and ischium were predrilled using a 1.1-mm drill bit. Two holes were drilled in the left pubis and left ischium. The process was repeated on the right side. The holes were drilled at a distance care -fully accounting for the width of an oscillating saw blade between them (Figure 2). An oscillating saw was then used to cut between the predrilled holes; 4 cuts were made in total. After releasing its intrapel -vic muscular attachments from the internal obtura -tor muscle, the ventral pelvis was carefully removed and placed in a saline-soaked swab.The vaginal mass and urethra were identified, and a vascular loop was placed around the urethra (Figure 3). The vaginal mass was bluntly dissected from the rectum and bladder, taking care not to damage their respective nerve supplies. In case 3, a standard ovario -hysterectomy was performed first, allowing for easier dissection of the vaginal mass around the bladder. In cases 1 and 2, ovariohysterectomy had previously been performed. Once the tumor was fully dissected, the caudal vagina was transected at the level of the ure -thral orifice and the remainder of the vestibular mucosa closed with 1.5-m polydioxanone in a simple continu -ous pattern (PDS 4/0; Ethicon Inc).Polydioxanone 3-m (PDS 2/0; Ethicon Inc) su -ture was preplaced through the predrilled holes in the pelvis, and the pubis and ischium was replaced. The sutures were tied, taking care to place equal pressure on each suture as they were tied to replace the pelvis in its precise anatomical position presur -gery (Figure 4). Overtightening of the cranial sutures before tightening of the caudal sutures would result in a gap at the osteotomy sites. In case 2, orthopedic wire was initially used to replace the pubis/ischium rather than polydioxanone. However, this resulted in a fracture of a single drill hole through to the oste -otomy site, and in all subsequent sutures, polydioxa -none was used instead.The prepubic tendon was carefully reattached to the pubis with 3-m polydioxanone (PDS 2/0; Ethicon Inc), placing each simple interrupted suture through the tendon and around the pubis/obturator foramen to allow for a firm suture anchorage and prevent any postoperative abdominal herniation. At the caudal pelvis, the tendinous attachments were also sutured in a similar fashion around the ischium/obturator fo -ramen; again, allowing for a firm suture anchorage and preventing any caudal herniation of pelvic con -tent. The adductor muscles were carefully apposed, again with 3-m polydioxanone in a simple continu -ous pattern (PDS 2/0; Ethicon Inc) and the caudal abdomen closed routinely.Postoperatively, all 3 cases showed signs of mild intermittent splaying of the pelvic limbs and 2 of the 3 cases (cases 1 and 2) presented with mild stranguria. Case 1 also presented with intermittent hematuria for 6 weeks postsurgery, with a negative urine culture on 3 separate submissions. In case 2, a urinary catheter was placed postoperatively for 3 days and the patient was discharged on prazosin hydrochloride (1 mg/kg, PO, q 12 h for 5 days) and itraconazole (10 mg/kg, PO, for 4 weeks). In case 1, the stranguria self-resolved 24 hours postsurgery and intermittent hematuria resolved 6 weeks postsurgery. The patients remained hospitalized for 3 (case 3) to 4 days (cases 1 and 2). In all 3 cases, adequate postoperative analgesia was achieved with a combination of meloxicam (0.1 mg/kg) and metha -done (0.2 mg/kg); the latter was changed to buprenor -phine (0.02 mg/kg) 24 hours postoperatively in cases 1 and 3 and 48 hours postoperatively in case 2. Patients were discharged from the hospital on meloxicam (0.05 mg/kg) for 10 days.In cases 2 and 3, full resolution of clinical signs was noted 14 days postoperatively, with no signs of splaying of the pelvic limbs. In case 1, mild pelvic limb splaying was evident for 8 weeks postsurgery. A 3-month telephone update with owners of cas -es 2 and 3 again confirmed no stranguria or pelvic gait abnormalities. This was again confirmed with a 15-month telephone update with the owner of case Figure 4 —Polydioxanone suture preplaced and then tied through predrilled holes in the pelvis for replace -ment of the pubis and ischium. Care was taken to re -suture the prepubic tendon and tendinous attachments caudal to the ischium to the pelvis.Unauthenticated | Downloaded 12/04/23 07:14 AM UTC 53. Case 1 re-presented to the oncology service at 12 weeks postsurgery, and no pelvic gait abnormalities were noted at this time.In case 1, histopathology postvaginectomy did not support the preoperative cytological diagnosis and a low-grade T-cell–rich B-cell lymphoma (Feline Hodgkin-like lymphoma) was reported following immunohisto -chemistry. Histopathology in cases 2 and 3 supported the initial cytological diagnosis of mycetoma (case 2) and vaginal polyp with the uterus reported as endome -trial hyperplasia and hydro/mucometra (case 3).In case 1, in which a T-cell–rich B-cell lymphoma was diagnosed postoperatively through histopathol -ogy and immunohistochemistry, adjunctive chemo -therapy was recommended to achieve clinical remis -sion but declined initially. The patient re-presented 12 weeks postsurgery with a pleural effusion. Ab -dominal ultrasound and thoracic radiographs identi -fied multiple enlarged mediastinal lymph nodes and a pulmonary mass. Abdominal lymphadenopathy was also confirmed. These imaging findings were absent on preoperative assessment. Cytology of the pulmonary mass revealed a mesenchymal prolifera -tion, similar to the cytological presentation docu -mented for the initial vaginal mass, and hence, while the cytology did not confirm lymphoma, this could not be excluded. Cytology of the abdominal lymph nodes was suggestive of lymphoma. The patient re -ceived L-asparaginase (400 IU/kg, SC), vincristine (0.5 mg/m2, IV), cyclophosphamide (230 mg, PO), and prednisolone (2 mg/kg, q 24 h, PO) but was eu -thanized 5 days following initiation of treatment due to failure of response to chemotherapy.

Question 99

Pacheco - 2023 - JAVMA - Cranial tibial translation measurements for radiographic diagnosis of cranial cruciate ligament rupture in dogs.pdf

Answer 99

The present study was submitted to the Ethics Com -mittee on Animal Use of the Federal University of Lavras, and approval was granted under protocol No. 052/2017.The study was conducted in the facilities of the University Veterinary Hospital, and it was divided into 2 phases of dog selection. In the first phase, a retro -spective study of radiographic images of dogs with a surgical diagnosis of complete unilateral CCL rupture was undertaken. In the second phase, a prospective study with selection of young and adult dogs without CCL rupture was performed.Initially, the inclusion criteria for the study of dogs with CCL rupture were determined and comprised ra -diographs taken under no sedation or anesthesia and with adequate positioning, the absence of other mus -culoskeletal injuries, and body weight between 15 and 40 kg, taking into consideration the epidemiology of the disorder according to one previous study,3 irrespec -tive of sex, breed, or etiology of the ligament rupture. The following radiographic positioning criteria were es -tablished: mediolateral projections of the affected pel -vic limb with the radiographic beam centered over the stifle and presence of a conventional radiograph with no TC (NTC) and a radiograph taken under joint stress by means of TC, with visibility of the talus bone to de -lineate the tibial mechanical axis, overlapping femoral condyles with a maximum gap of 2 mm between their borders, and a 135 ± 5° stifle joint angle. In both projec -tions, to obtain the radiographic image with the stifle joint positioned at approximately 135°, the joint was correctly angled with the aid of a goniometer, which allowed the uniformity of stifle joint position. In the TC radiographs, while the stifle joint was maintained in the proper position, the tibiotarsal joint was flexed to 90° to promote cranial translation of the tibia.In the retrospective phase, a search was car -ried out of all medical records of patients operated on in the service with complete unilateral rupture of the CCL between 2015 and 2018. The search subse -quently excluded data from dogs that did not fit the clinical and radiographic inclusion criteria. The re -maining medical records and surgical files were care -fully analyzed, excluding those in which there was a description of exacerbated medial buttress, advanced osteoarthritis, and partial rupture of the CCL. Initially, the radiographs of 32 dogs with the condition were selected, but 12 dogs were still excluded. Of these, 9 dogs did not have adequate overlapping of the femo -ral condyles, and 3 dogs had clinical records of previ -ous stifle joint surgery. Meniscal injury seen at surgery was not an exclusion factor. Therefore, radiographs of 20 dogs could finally be included in the study, corre -sponding to the group of adult dogs with CCL rupture.In the second phase of the study, the selection and radiographic examination of 20 healthy adult dogs and 20 healthy young dogs were undertaken prospectively. Dogs were determined to be healthy after orthopedic and radiographic examination by an experienced pro -fessional, and those exhibiting any type of musculo -skeletal disorder were excluded. The inclusion criteria for the group of healthy adult dogs were a body weight between 15 and 40 kg and an age between 18 months and 6 years. Healthy young dogs were aged between 6 and 10 months, with a body weight > 15 kg. Selec -tion was not based on sex or breed. One pelvic limb per healthy dog was randomly selected and radiographed, and no type of sedation or anesthesia was used. The radiographic positioning criteria applied were the same as those used in the group of dogs with CCL rupture, and mediolateral radiographs were also taken in 2 pro -jections: NTC and TC.Radiographs of 60 dogs were included for the study and divided into 3 groups with 20 dogs each: group 1 (G1), healthy adult dogs; group 2 (G2), adult dogs with CCL rupture; and group 3 (G3), healthy young dogs. Radiograph measurements were conducted by 2 expe -rienced radiographic interpreters blinded to the animal groups. After proper acquisition of each variable, it was measured 3 times at different time points, and the mean of each variable was used for statistical analysis.The patellar ligament angle was measured in rela -tion to the common tangent at the tibiofemoral con -tact point (Figure 1) . The patellar ligament insertion angle was measured following the recommendations of a previous study on tibial cranial angles8 (Figure 2) . Figure 1 —Radiographic image (mediolateral projec -tion) of the stifle joint of a dog, showing the patellar ligament angle (PLA).Unauthenticated | Downloaded 10/08/23 06:31 AM UTC JAVMA | OCTOBER 2023 | VOL 261 | NO. 10 1497The angle of tibial translation a (ATTa) was measured according to a method established in a 2017 study.9 The authors of the present work proposed a modifica -tion to this assessment. Specifically, the site of mea -surement was changed, and a new angle was found. Thus, ATTa stands for the angle obtained by the meth -od already described in the literature, whereas angle of tibial translation b (ATTb) indicates the modified method (Figure 3) .Conventional mediolateral radiographic images and those taken under TC were used to measure the distance between the point of origin of the CCL in the femur and the point of CCL insertion in the tibia (DPOI; Figure 4 ). Figure 2 —Radiographic image (mediolateral projec -tion) of the stifle joint of a dog, showing the patellar ligament insertion angle (PLIA).Figure 3 —Radiographic image (mediolateral projection) of the pelvic limb of a dog, showing angle of tibial trans -lation a (ATTa) and angle of tibial translation b (ATTb).Additionally, cranial tibial displacement in rela -tion to the femur was measured according to the method proposed by the authors of a previous study.3 Figure 4 —Radiographic images (mediolateral projec -tion) of the stifle joint of a dog, taken under conven -tional positioning with no tibial compression (NTC) and with tibial compression (TC), showing the distance be -tween the origin and insertion (red line) of the cranial cruciate ligament. When comparing both positioning methods, note that this animal had tibial displacement of 5.6 mm.In terms of radiography, the site considered as the CCL origin in the femur was localized at a point ad -jacent to the distal aspect of the lateral fabella on the caudal border of the proximal femoral condyle (caudal-proximal point of the Blumensaat line). The site of CCL insertion in the tibia was located at the cranial border of the medial tibial condyle. Consid -ering the variations in weight and anatomical con -formations and because this is a linear measure, the authors of the present work proposed a ratio divid -ing the DPOI value obtained from the radiograph under TC by the DPOI value from the conventional radiograph, thus generating the new variable DPOI ratio to eliminate the bias caused by dog variation.All the obtained data were tested for normal -ity (Shapiro-Wilk test) and homogeneity (Bartlett test). Parametric variables were assessed with ANOVA, and differences in the comparison of data from each variable were considered significant at P < .05. The effect of radiography performed un -der TC was tested in all assessed variables within each group with the paired t test. Subsequently, each variable (except for DPOI ratio) was tested for differences (Tukey multiple comparison test) with and without TC on radiography among the 3 dog groups. The DPOI radio was not normally distributed, and the Kruskal-Wallis and Mann-Whitney tests were chosen to assess significant differences between groups. To improve the anal -yses, each variable was identified according to radiographic positioning (ie, either conventional radiography NTC or under joint stress with TC). Intraclass correlation coefficient and CI of each variable were used for interobserver analysis. Statistical analyses were performed, and to pre -dict the diagnostic value of DPOI ratio, regression analysis was conducted with a receiver operating characteristic (ROC) curve to establish a diagnos -tic cutoff point for this variable.Unauthenticated | Downloaded 10/08/23 06:31 AM UTC1498 JAVMA | OCTOBER 2023 | VOL 261 | NO. 10ResultsMean and SD were calculated for all variables. In G1 (healthy adult dogs), images from 13 males and 7 females with a mean body weight of 33 kg (SD ± 4.6 kg) and a mean age of 4 years (SD ± 2.8 years) were selected. In G2 (CCL ruptured dogs), images were taken of dogs with a mean body weight of 37 kg (SD ± 7.1 kg) and a mean age of 6 years (SD ± 3.2 years), among which 12 were females and 8 were males. In G3 (healthy young dogs), radiographic images of 11 females and 9 males, with a mean age of 7 months (SD ± 1.8 months) and a mean body weight of 29 kg (SD ± 3.5 kg), were taken. Considering all groups, 50% of the dogs were male, and 50% were female.Statistical significance of radiographic measure -ments obtained under TC was found among most vari -ables within groups, except for the DPOI in G1. This result showed that DPOI could achieve higher precision in differentiating dogs without CCL rupture when mea -sured under TC because joint stress did not interfere with the results of these variables within G1 due to liga -ment integrity. Regarding the DPOI values under TC, the mean for the G3, both regarding the linear mea -surement for DPOI and the DPOI ratio, was between those for G1 and G2 (G1 < G3 < G2). Thus, the evalua -tion of DPOI showed that TC promoted minimal cranial tibial displacement in healthy adult dogs, moderate displacement in healthy young dogs, and pronounced displacement in dogs with CCL rupture.The results of the comparative analysis among the 3 groups are shown (Figure 5) . In the comparative analysis among the 3 groups regarding patellar ligament angle, there was no difference among them using TC. With NTC, there was no difference among the groups for patellar ligament angle, patellar ligament insertion angle, and DPOI, which showed no significant difference between the groups.The ATTa values obtained without TC were signifi -cantly different among the groups ( P = .002), and the same occurred for this variable in radiographs with TC, in which the 3 groups exhibited significant differences among each other ( P < .0001). Comparative analysis of ATTb revealed statistical results similar to those ob -tained for ATTa (ie, all groups exhibited statistically significant differences from each other in both radio -graphic positions, with and without TC).By the Tukey test, DPOI without TC was considered nonsignificant between the groups. The comparison of this variable between groups under TC showed signifi -cance, with P values < .0001. The mean distance, in mil -limeters, was higher in dogs with CCL rupture (G2), and the greatest value difference was found between healthy adult dogs (G1) and those with CCL rupture (G2). The pronounced cranial tibial translation in dogs with CCL rupture increases in a linear manner with increasing DPOI.The analysis of DPOI ratio revealed significant dif -ferences among all the groups ( P < .0001). For this variable, an ROC curve predictive analysis indicated 100% specificity and 99.9% sensitivity for this ratio in the comparison of the healthy dogs with dogs with CCL rupture. An accuracy of 1.0 for a DPOI ratio > 1.18, with no interpolation of results whatsoever be -tween dogs in G1 and in G2, was obtained. In the ROC Figure 5 —Graphs of the comparative analysis between the groups with values obtained from radiographic images taken with NTC or with TC in healthy adult dogs (G1), dogs with cranial cruciate ligament rupture (G2), and healthy young dogs (G3). [A]—PLA. [B]—PLIA. [C]—ATTa. [D]—ATTb. [E]—Distance between the origin and insertion (DPOI) of the cranial cruciate ligament. Above the bars, different letters mean statistical difference among groups. *Statisti -cally significant at P < .05.Unauthenticated | Downloaded 10/08/23 06:31 AM UTC JAVMA | OCTOBER 2023 | VOL 261 | NO. 10 1499curve analysis, a cutoff point to differentiate G3 from G1, with 100% of specificity and 85% of sensitivity, was 1.05. In radiographic imaging, young dogs should be differentiated by assessing an intermediate DPOI ratio value together with other factors, such as the detec -tion of open epiphyseal plates in radiographic images and signs of degenerative joint disease. The results showed that G3 always exhibits intermediate values, with a trend toward similarity with G1 in cumulative frequency analysis.The results obtained with the diagnostic test showed that DPOI ratio has high potential as a CCL rupture diagnostic measure, given that it exhibited high specificity and sensitivity, with better differen -tiation of healthy dogs. In the present study, DPOI ratio values above 1.18 were sufficient to accurately confirm the diagnosis of CCL rupture, completely dif -ferentiating dogs in G2 from healthy adult and young dogs (G1 and G3) (Figure 6) .because joint stress caused by TC changed the an -atomic position of the stifle. Of note, even though differences were present in some variables in all groups, these results are in agreement with the clini -cal hypothesis that joint stress caused by TC changed these variables in the following manner: increased patellar ligament angle, reduced patellar ligament insertion angle, and increased DPOI. The significance of the effect of TC for patellar ligament angle, pa -tellar ligament insertion angle, and DPOI in G2 and G3 was expected, given that the projection with con -ventional positioning of the stifle might not exhibit clear evidence of cranial tibial translation in animals with CCL rupture10 and young dogs with physiologi -cal ligament laxity, whereas TC renders cranial tibial displacement more evident.The lack of a difference between the means for G1 and G2 ( P = .3027) is in agreement with the re -sult from studies8,11 that show the variation in PLA is not significant when dogs with and without CCL rupture are compared. There is no significant differ -ence in this variable between G1 and G3 ( P = .1500) and between G2 and G3 ( P = .3000). It shows that this parameter is not useful for the evaluation of CCL rupture and was unable to differentiate tibial transla -tion in dogs with ligament rupture from healthy adult dogs and puppies.The mean radiographic ATTa in healthy dogs without TC was 61.77°, which is above the mean of 57.4° found in a previous study.9 This might be due to radiographic positioning because the present study used a 135° stifle angle and the cited study used a 90° angle. The standardization of radiograph -ic positioning is fundamental for comparisons among studies, and the difference between these studies is proof of this need. The stifle joint positioned at 135° attempts to mimic the weight-bearing position in dogs, thus rendering it more precise in the evalua -tion of cranial tibial translation parameters, as stated in some studies.9,12 Because this parameter was first established in the present study, the ATTb results cannot be compared with any data from the litera -ture; however, these data will prove useful for future comparative studies and clinical applications.The angle of cranial tibial translation has been described in only 1 study and only in healthy dogs, with no comparison whatsoever. Nevertheless, this study9 serves as a basis for future comparative stud -ies. The ATTb is a modification proposed in the pres -ent study and, according to statistical analyses, can be included in the evaluation of tibial translation and used for comparisons between patients and between radiographic positioning methods. Overall, even though its values varied according to changes in the ATTa and both variables exhibited P values < .0001, the ATTb demonstrates the advantage over the con -ventional ATTa method, as it is simpler to measure the tibial translation angle since 1 less line is needed to obtain this measurement. In general, among the assessed angles and according to statistical analysis, the ATTa, the ATTb, and the patellar ligament inser -tion angle should be considered together due to the notable differences found in G2; however, there is no Figure 6 —Multiple comparison analysis graph of the vari -able DPOI ratio in healthy adult dogs (G1), dogs with cra -nial cruciate ligament rupture (G2), and healthy young dogs (G3).For interobserver analysis, an intraclass corre -lation (ICC) above 0.75 was considered excellent, between 0.4 and 0.75 was considered satisfactory, and below 0.4 was considered poor. The results of this analysis showed that more complex measure -ments with a higher number of anatomical reference points were the most susceptible to variation when assessed by different professionals. Patellar liga -ment insertion angle and ATTa showed ICC of 0.32 and 0.25, respectively. The patellar ligament angle (ICC = 0.72), ATTb (ICC = 0.70), and DPOI (ICC = 0.88) showed values that indicate a high correlation between the measurements performed by differ -ent evaluators. These data showed that it is better to choose simpler but equally efficient radiographic measurement parameters to be used as the standard in CCL rupture diagnosis.

Question 100

Espinel - 2023 - VETSURG - Arthroscopic-assisted hip toggle stabilization in cats - An ex vivo feasibility study.pdf

Answer 100

2.1 |SpecimensFourteen pelvic limbs from 7 feline cadavers euthanizedfor reasons unrelated to this study were included. Sex,breed, and postmortem bodyweight were recorded. Ethicalapproval was obtained from the primary author's institu-tion (AREC-E-20-16-Mullins). Cadavers were stored in a/C020/C14C freezer until thawed for use. Forty-eight hoursprior to intervention, cadavers were defrosted at roomtemperature. Both pelvic limbs were clipped from the cra-nial iliac wings to stifles and dorsal to ventral midline.2.2 |Preoperative preparationAll cats underwent preoperative orthopedic examination,which included hip manipulation through a rangeof motion and palpation for crepitus, Bardens and Ortolanitests.6Cats with any abnormalities (eg, reduced range ofmotion, crepitus, abnormal anatomic landmarks) orpositive Bardens or Ortol ani tests were excluded. A16-slice helical computed tomography (CT) scanner(SOMATOM Scope, Siemens, Erlangen, Germany) wasused. Pelvic CT was performed with cadavers in dorsalrecumbency and the femurs ex tended caudally. Trans-verse sections of 0.6 mm slice thickness were obtainedfrom the sacrum to ischium. DICOM (Digital Imaging andCommunications in Medicine) images were uploaded toHoros ( Horosproject.org ;A n n a p o l i s ,M a r y l a n d )a n dreviewed by 2 authors (JER, SH) for hip dysplasia, osteoar-thritis, and/or femoral/acet abular fractures, which wereexclusion criteria. Images were reviewed for surgical plan-ning by 2 authors (JER, RAM). The ideal femoral bone tun-nel projection, consisting of a line extending from the foveacapitis to the lateral femoral cortex at the level of the thirdtrochanter, but without perforating the ventral aspect of theneck with a 2.7 mm drill bit, was drawn on CT multiplanarreconstruction (MPR) images. The distance from the idealfemoral bone tunnel entry po int to the proximal aspect ofthe greater trochanter was measured in the frontal plane(Figure 1). Following CT, ultrasound-guided LHF tran-section was performed by a board-certified radiologist (SH).Cadavers were positioned in dorsal recumbency with pelviclimbs abducted (frog leg position). A 65 beaver blade wasintroduced into the ventrocaudal aspect of the joint and theLHF was transected. The procedure was considered success-ful with a positive Bardens test.FIGURE 1 Multiplanar reconstruction computed tomographicfrontal plane image demonstrating measurement of the distancefrom the ideal femoral tunnel entry point to the most proximalaspect of the greater trochanter.854 ESPINEL RUP /C19EREZ ET AL . 1532950x, 2023, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13942 by Vetagro Sup Aef, Wiley Online Library on [30/08/2023]. 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 License2.3 |Surgical techniqueCadavers were positioned in lateral recumbency with thehip being operated uppermost. The limb was positionedin a neutral position, perpendicular to the spine. The firstside operated in each cadaver was the contralateral sideof the previous operated hip, with the first hip of cadaver1 decided by coin toss. All procedures were performedover 5 consecutive days by a third-year European Collegeof Veterinary Surgeons (ECVS) resident-in-training (JER)under the supervision of an ECVS Diplomate (RAM).Exploratory arthroscopy was performed as previouslydescribed in dogs and cats.9,13Creation of the arthroscopeportal commenced by insertion of a 20 gauge hypodermicneedle perpendicular to the skin just proximal to thegreater trochanter, with mild distal limb traction appliedby the assistant (Figure 2A). The joint was aspirated anddistended with 5 mL of saline. A /C243-5 mm stab incisionwas created in a proximodistal direction alongside thehypodermic needle using a no. 11 blade and dilated usinga straight hemostat. A 1.9 mm 30 degree oblique arthro-scope was used (Stryker, Michigan). The instrument por-tal was established using the same technique in thecraniolateral aspect of the joint. Fluid egress occurredthrough the arthroscope and instrument portals and aseparate egress portal was not placed. Mild distal limbtraction was applied throughout the procedure. Com-mencement of the arthroscopic approach was defined asintra-articular hypodermic needle insertion and comple-tion defined as intra-articular probe visualization.Difficulty of the arthroscopic approach was graded aseasy (first attempt placement of portals), mildly difficult(≤3a t t e m p t s ) ,m o d e r a t e l yd i f f i c u l t( > 3a t t e m p t s ) ,o ru n s u c -cessful (impossible to perfor m). Exploratory arthroscopywas standardized in all cases. A constant flow of fluid wasprovided using a motorized fluid pump (Arthrex Continu-ous Wave III, Arthrex Vet System s, Naples, Florida) withpressure set at 50 mmHg. Intr a-articular structuresinspected and probed included the femoral head, acetabu-lum, labrum, synovium, transverse ligament, and LHF,with each structure recorded as visualized or not. The LHFwas recorded as completely or partially transected. Anyidentified articular cartilage injury (ACI) was recorded.After exploratory arthroscopy, fibers of the LHF wereremoved using a 2 mm arthroscopic shaver (Saber Tooth2.0 mm AR-7200SR, Arthrex, Naples, Florida) introducedthrough the instrumental portal (Video S1). The tip of thearthroscopic guide (Bio-Compression Screw C-RingGuide, AR-5026G, Arthrex) was inserted through theinstrument portal and positioned on the dorsal aspect ofthe fovea capitis under arthroscopic guidance (Video S2).A/C241 cm skin incision was made over the lateral femoralcortex tunnel entry point at the third trochanter at a dis-tance from the most proximal point of the greater tro-chanter based on preoperative CT measurements(Figure 2B). The other end of the guide was secured atthis location and, following arthroscopic confirmation ofcorrect intra-articular guide positioning, a 1.1 mmKirschner wire (k-wire) was drilled from lateral to medial(Figure 2C) until interference of the k-wire with thepointed tip of the arthroscopic guide was felt. The guidewas removed and the k-wire advanced until visible intra-articularly. In the first hip of cadaver 1, the k-wire wasover drilled with a 2.7 mm cannulated drill bit, with theFIGURE 2 Series ofintraoperative images. The greatertrochanter is marked with thecurved continuous line, thearthroscopic portal with an asterisk,the instrument portal with a daggerand the mini approach to the lateralfemur with a broken line ( 2A); Thescope and the intra-articular guidehave been placed in the arthroscopicand instrumental portals,respectively, and the mini approachhas been performed. The location forthe entry point of the femoral bonetunnel is marked with an x ( 2B); TheKirschner wire has been placedthrough the intra-articular guide.For all images, dorsal is to the topand cranial is to the right ( 2C).ESPINEL RUP /C19EREZ ET AL . 855 1532950x, 2023, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13942 by Vetagro Sup Aef, Wiley Online Library on [30/08/2023]. 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 Licenseintent of exiting at the fovea capitis, manipulating limbposition, and advancing the drill bit through the fossa. Inthe subsequent 13 hips, the k -wire was advanced directlythrough the center of the acetabular fossa under arthro-scopic visualization (Video S3) and then over drilled withthe 2.7 mm cannulated drill bit (Video S4). The arthro-scopic shaver was introduced intra-articularly through thefemoral tunnel and used to remove any remaining fibers ofthe LHF that could interfere with toggle passage (VideoS5). To facilitate toggle passage, limb position was adjusteduntil there was no resistance to shaver passage throughboth tunnels. The shaver was removed and a 2.0 mm metaltoggle with 2 attached strands of 150 lb. ultrahigh molecular-weight polyethylene (Mini Tight Rope, Arthrex) was carefullymounted on the swaged end of the passing needle (Figure 3)and passed through both tunnels from lateral to medial(Video S6). Following toggle p assage, the suture was pulledon sharply, securing it on the medial acetabulum. Thearthroscope was removed, the hip put through a range ofmotion, the suture slack removed, and suture tied withhand-tied knots on the lateral femur using the metal button.The same procedure was performed on the contralateral hip.2.4 |Intraoperative complicationsIntraoperative complications were defined as any intrao-peratively recognized deviations from the planned surgi-cal course between skin incision and closure.422.5 |Postoperative CT and grossdissectionRepeat CT was performed as previously described andreviewed by one author (SH). Positioning of implants andbone tunnels was evaluated and any technique deviationsrecorded. Ideal femoral and acetabular tunnel positioningwas from the lateral femur at the level of the third tro-chanter to the fovea capitis (without breaching the con-fines of bone) and the acetabular fossa, respectively. Idealsuture button position was in direct contact with bone onthe lateral femur and that of the toggle was in direct con-tact with bone in the correct orientation medial to theacetabulum. Following postoperative CT, gross dis-section was performed by one author (JER) via a ventralapproach to the pelvic canal and craniolateral approach(with disarticulation) to the hip. All relevant neurovascu-lar structures (sciatic and obturator nerves, femoral arteryand vein) were evaluated for injury. Osteotomies of thecranial and caudal pubic rami were performed and intra-pelvic structures (urethra, colon/rectum, obturator nerve,+//C0uterus) evaluated for injury. The femoral artery andvein were evaluated by extension of the ventral approachto the medial aspect of the hip. A bilateral craniolateralapproach to the hip was performed to evaluate the posi-tion of bone tunnels, articular cartilage, periarticularmusculature, and sciatic nerve. Ideal positioning of femo-ral and acetabular bone tunnels, metal toggle and buttonwas as defined on postoperative CT. Surgical implantswere removed and the joint luxated. Articular cartilage ofthe femur and acetabulum was evaluated for injury priorto and after India ink staining (Winsor and Newton Ink,London, England).2.6 |FeasibilityThe feasibility of AA-HTS was defined as overall success-ful completion of the procedure and was divided into4 components including feasibility of (i) femoral tunnelcreation, (ii) acetabular tunnel creation, (iii) toggle pas-sage through the femoral tunnel, and (iv) toggle passagethrough the acetabular tunnel. Each component wasseparately classified as easy to perform (achieved on firstattempt), mildly difficult ( ≤3 attempts), moderatelydifficult (>3 attempts), or unsuccessful (not possible toperform).2.7 |Iatrogenic injuryAssessment of iatrogenic injury to the intra-articular/periarticular structures was performed and divided intoFIGURE 3 Metal toggle with 2 attached strands of suturemounted on the swaged end of the passing needle.856 ESPINEL RUP /C19EREZ ET AL . 1532950x, 2023, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13942 by Vetagro Sup Aef, Wiley Online Library on [30/08/2023]. 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 License5 components including injury to (i) articular cartilage,(ii) periarticular musculature (other than previouslydescribed related to arthroscopic approach in dogs9,14),(iii) neurovascular structures (sciatic and obturatornerves, femoral artery/vein), (iv) osseous structures, and(v) intrapelvic structures (urethra, colon/rectum, +//C0uterus). Articular cartilage injury (ACI) was classified aspartial (no subchondral bone exposure) or full thickness(subchondral bone exposure), assessed grossly usingIndia ink. Total dimensions (width and length) of ACIwere also measured (in mm) with a surgical ruler. Totalinjury area was calculated in mm2based on the shape ofthe lesion (rectangular area =width /C2length; circulararea =πr2). A significant ACI was defined as >10% totalcartilage area. For this calculation, total cartilage areawas determined from photographs of the coxofemoraljoint from a 3.4 kg feline cadaver using commerciallyavailable software (ImageJ version 1.53, National Insti-tutes of Health, Bethesda, Maryland), and was calculatedas 55.7 mm2for the acetabulum and 152.5 mm2for thefemoral head.2.8 |Technique deviationsDeviations were described as any modifications of ideal surgi-cal technique based on postoperative CT and gross dis-section and divided into 2 components including positioningof (i) implants (button and toggle) and (ii) femoral and acetab-ular bone tunnels. The positio no ft h el a t e r a lf e m o r a lc o r t e xtunnel entry point and femora lh e a dt u n n e le x i tp o i n tw e r efurther classified as ideal, minor deviation ( ≤2m mf r o mi d e a lposition) or major deviation (>2 mm from ideal position).2.9 |Statistical analysisContinuous variables were tested for normality usingthe Shapiro-Wilk test. Norma lly distributed continuousvariables are presented as mean (SD). Non-normallydistributed data are presented as median and range(minimum and maximum). Ca tegorical variables arepresented as frequencies. Statistical analyses wereperformed using statistica ls o f t w a r e( S P S SS t a t i s t i c sVersion 24, IBM, New York, USA).3|RESULTS3.1 |SignalmentFourteen coxofemoral joints from 7 feline cadavers wereincluded, with 6 males and 1 female. Six were domesticshorthair and 1 was British shorthair. Mean (SD) post-mortem bodyweight was 3.9 (0.8) kg.3.2 |Preoperative assessmentNo significant abnormalities were identified on preopera-tive orthopedic or CT examination. A positive Bardenstest was identified after transection of the LHF in alllimbs. Mean (SD) distance from the most proximal aspectof the greater trochanter to the lateral femoral cortex tun-nel entry point was 16.1 (1.7) mm.3.3 |Surgical techniqueThe arthroscopic approach was successful in all joints.The mean (SD) time for completion was 4 (1) minutes,with approach classified as easy in 13 joints and mildlydifficult in 1 joint in which insertion of the arthroscopiccannula required a second attempt. Identification of allintra-articular structures was possible in 12 of 14 joints.In both joints of the first operated cat, the transverse liga-ment was not identified. The femoral head, acetabularlabrum, and synovium were observed in all joints andwere normal. The LHF was observed in all joints and waspartially transected in them all. Acetabular cartilage wasobserved in all joints and was grossly normal in 9 joints.Of 5 joints with ACI, a small ( /C242-3 mm) linear, partialthickness ACI was identified on the cranial aspect of theacetabulum in 2 joints, on the cranial and caudal aspectsof the acetabulum in 2 joints, and on the caudal aspect ofthe acetabulum in 1 joint. The median time for comple-tion of exploratory arthroscopy was 3 min, with a rangeof 1-7 min. The median overall time taken for arthro-scopic approach and exploratory arthroscopy was 7 min,with a range of 3-12 min.The AA-HTS was successfully performed in all joints.Femoral bone tunnel creation was performed on firstattempt in 11 joints and on second attempt in 3 joints.Acetabular bone tunnel creation was performed on firstattempt in 14 joints. However, in 1 cat (first cadaver), thefemoral bone tunnel was inadvertently created byadvancing the cannulated drill bit over the 1.1 mm k-wire without advancement of the k-wire through the ace-tabular fossa. Toggle passage through the femoral tunnelwas performed on first attempt in 8 joints, on secondattempt in 5, and on third attempt in 1 joint. Toggle pas-sage through the acetabular tunnel was performed onfirst attempt in 11 joints, on second attempt in 2, and onthird attempt in 1 joint. The median duration of AA-HTSwas 40 min, with a range of 26-134 min. The median was41 min for the first 7 hips, with a range of 31-134 min.ESPINEL RUP /C19EREZ ET AL . 857 1532950x, 2023, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13942 by Vetagro Sup Aef, Wiley Online Library on [30/08/2023]. 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 LicenseFor the last 7 hips, the mean was 36.5 min, with a rangeof 26-49 min. The median overall surgical time for theentire arthroscopic-assisted procedure was 46.5 min witha range of 29-144 min.3.4 |Intraoperative complicationsIntraoperative complications were encountered in5j o i n t s .T h ek - w i r ee x i t e do nt h ef i r s ta t t e m p tc r a n i a land dorsal to the fovea capitis in 1 joint; it wasredrilled and exited in the ideal position on secondattempt. The acetabular tun nel was unintentionallycreated in 1 joint but it happened to be positioned inthe ideal position (acetabular fossa). The toggle passagethrough the femur was unsuccessful in 1 femur, inwhich the toggle became lodged within the femoraltunnel, just medial to the lateral cortex. The toggle wasremoved by careful manipulation to align it within thetunnel using a k-wire and it was subsequently placedsuccessfully on the second attempt. In 2 joints, the can-nulated drill bit was partially advanced by mistake overthe k-wire within the femoral tunnel without advance-ment of the k-wire through the acetabular fossa, and inboth cases the k-wire was inadvertently removed at thetime of the drill bit removal. In 1 joint, replacement ofthe k-wire through its original path was unsuccessfuland the bone tunnel had to be completed by advancingthe drill bit through the already partially drilled tunnelwithout the guide of a k-wire. In the other case, thecannulated drill bit was reintroduced into the partiallydrilled tunnel and used as a guide to reintroduce the k-wire back through its original path successfully. The k-wire was successfully placed, advanced through theacetabular fossa under arthroscopic guidance, andoverdrilled with the cannulated drill bit.3.5 |Postoperative computedtomographyAll toggles and metal buttons were correctly posi-tioned, in correct orientation, and in contact withbone on the medial aspect of acetabulum and on thelateral femur, respectively (Figure 4). The acetabularbone tunnel was positioned in the acetabular fossa inall cases. The femoral bone tunnel position was sub-optimal in 7 femurs, with 2 deviations in 6 femurs(total of 13 deviations). The l ateral femoral cortex tun-nel entry point was suboptim al (relative to preopera-tive measurements) in 7 femurs and includeddeviations of 1 mm distal in 1, 1 mm proximal andcaudal in 2, 3 mm proximal in 2, and 3 mm proximaland caudal in 2. The femoral head tunnel exit pointwas 4 mm ventrally deviated in 1, being outside thefemoral fovea and breaching the ventral aspect of thefemoral head; and 2 mm ventrally deviated in 1, beingFIGURE 4 Postoperative multiplanar reconstruction computedtomographic frontal plane image of the same hip in Figure 1demonstrating ideal position of implants and bone tunnels.FIGURE 5 Postoperative multiplanar reconstructioncomputed tomographic dorsal plane image demonstrating partialbreach of the caudal femoral cortex (black arrow) with caudaldeviation of the lateral femoral cortex tunnel entry point and idealpositioning of the femoral head tunnel exit point.858 ESPINEL RUP /C19EREZ ET AL . 1532950x, 2023, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13942 by Vetagro Sup Aef, Wiley Online Library on [30/08/2023]. 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 Licensepartially inside the femoral fovea. Partial breach ofthe caudal femoral cortex, entering the intertrochan-teric fossa, was identified in the 4 femurs with caudaldeviation (Figure 5).3.6 |Postoperative gross dissectionNo damage to intrapelvic structures was identified.All toggles were firmly positioned on the medial aspectof the acetabulum, in contact with bone, dorsal to theobturator nerve in all cases without gross evidence ofnerve injury in any case (Figure 6). No damage to eitherfemoral artery or vein was identified. Metal buttons werefirmly positioned on the lateral surface of the femur incontact with bone in all cases. The sciatic nerve was inclose proximity (within 10 mm) to the arthroscopic portalbut without injury. No significant injury to periarticularmusculature or bone was identified in any case. The ace-tabular bone tunnel was positioned in the acetabularfossa in all cases. The lateral femoral cortex tunnel entrypoint was located on the lateral femur in 10 cases(Figure 7A) and caudolateral in 4 cases. The center of thelateral femoral cortex tunnel entry point was suboptimalin 7 femurs and included deviations of 1 mm distal in1, 1 mm proximal and caudal in 2, 3 mm proximal in2, and 3 mm proximal and caudal in 2. The femoral headtunnel exit point was suboptimal in 2 and included ven-tral displacement of 2 mm in 1 (partially outside thefovea capitis) and ventral deviation of 4 mm in 1 (outsideFIGURE 6 Gross dissection following pubic ostectomy (dagger)demonstrating the toggle (x) firmly positioned on the medial aspectof the acetabulum dorsal to the obturator nerve (asterisk).FIGURE 7 Series of grossdissection images. Figure 7A: idealentry point on the lateral femur.Figure 7B; major ventral deviation ofthe exit point on femoral head.Figure 7C; partial breach of caudalfemoral cortex (asterisk) and entryinto intertrochanteric fossa.Figure 7D; cartilage damage (whitearrow) created by the misplacedKirschner wire dorsal to the foveaafter India ink application.ESPINEL RUP /C19EREZ ET AL . 859 1532950x, 2023, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13942 by Vetagro Sup Aef, Wiley Online Library on [30/08/2023]. 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 Licensethe fovea capitis) (Figure 7B), with the measurementfrom the perimeter of the fovea to the furthest point ofthe perimeter of the hole. Partial breach of the caudalfemoral cortex, entering the intertrochanteric fossa, wasidentified in 4 (Figure 7C).Articular cartilage injury was documented in 10 joints,affecting the femoral head in 9 and the acetabulumin 5. The ACI of the femoral head included 2 withsuboptimal position of the femoral tunnel exit point(as previously described), 9 with 2 mm diameter roundpartial thickness abrasion ACI on the dorsal femoralhead (in region of where the arthroscopic cannula wouldhave been positioned intraoperatively), and 1 with 1 mmdiameter round full thickness ACI (compatible withincorrect k-wire placement for creation of the femoralbone tunnel) (Figure 7D). Acetabular ACI included 2 with3 mm partial thickness linear damage in the cranioventralaspect of the acetabulum and 3 with 2 mm partial thick-ness linear damage in the cranioventral and caudoventralaspects of the acetabulum (Figure 8). Additionally, a 2 mmdiameter partial thickness ACI was identified on the dorsalaspect of 1 acetabular labrum, at the level of the arthro-scopic cannula.3.7 |FeasibilityArthroscopic-assisted hip toggle stabilization was success-fully completed in all joints. Femoral and acetabular bonetunnel creation was considered easy in 11 and 14 joints,respectively, and mildly difficult in 3 and 0 joints,respectively. Toggle passage through the femoral and ace-tabular tunnels was classified as easy in 8 and 11 jointsand mildly difficult in 6 and 3 joints, respectively.3.8 |Iatrogenic injuryNo damage to periarticular musculature, neurovascularstructures, osseous structures, or intrapelvic structures(urethra, colon/rectum, uterus) was documented in anycadaver. Articular cartilage injury was identified in10 joints on gross dissection and graded minor (<10%total cartilage area) in all cases.3.9 |Technique deviationsThirteen deviations (8 major and 5 minor) were identifiedin 7 femurs. No deviations related to the acetabular bonetunnel were identified. Deviations encountered include7 (3 minor and 4 major) related to the lateral femoral cor-tex tunnel entry point, 4 (all major) related to the femoralbone tunnel trajectory, and 2 (1 major and 1 minor)related to the femoral head tunnel exit point. No devia-tions occurred in the last 4 joints operated.4

Question 101

Knudsen - 2024 - VETSURG - Diagnosis of medial meniscal lesions in the canine stifle using multidetector computed tomographic positive-contrast arthrography.pdf

Answer 101

Client-owned dogs who presented at the first author'sclinic were recruited with informed owner consentbetween April 2017 and September 2020. Ethicalapproval was obtained from the corresponding author'sinstitution for use of obtained data but was not specifi-cally required for the first author's clinic. Inclusion cri-teria were: primary presentation with a clinical historyand examination consistent with the presence of partialor complete CCL rupture or suspicion of late meniscalinjury following prior stabilization. Specific clinical cri-teria included acute or chronic onset lameness, positivesit-test, toe-touching stance, medial stifle joint thickening(buttress sign), joint effusion, and instability and/or painwhen applying the cranial drawer and tibial compressiontests. Exclusion criteria were: gross skin pathologyaround the stifle joint, other comorbidities such as severesystemic disease, interval between scan and surgeryexceeding 2 weeks, and owner declined surgical explora-tion or stabilization. All investigative and surgical proce-dures were performed by the first author.2.1 |CTA procedureAll scans were performed with a 16-slice multidetectorcomputed tomography scanner (Brivo CT385, GE Health-care, Japan) using the axial scan mode, 100 kV, 120 mAs,and slice width of 0.625 mm. Dogs were sedated withdexmedetomidine (Dexdomitor, Orion Pharma AnimalHealth, Denmark) at 12.5 μg/kg and methadone76 KNUDSEN ET AL . 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13982 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 License(Comfortan Vet, Dechra Veterinary Products, Denmark)at 0.4 mg/kg given IM. Oxygen supplementation was pro-vided with a face mask.Dogs were positioned in dorsal recumbency withhindlimbs secured in extension and parallel to eachother, with the stifle joints centered in the gantry sothat the tibial plateau was approximately parallel to thescanning plane. The fur over the stifle joint was clippedand the skin prepared aseptically. Following a nativescan, a 21-gauge needle was inserted medial to thepatellar tendon, and joint fluid aspirated prior to injec-tion of the contrast solution until palpable joint disten-sion was noted. The contrast solution consisted of 50%iohexol (Omnipaque 350 mg/mL, GE Healthcare,Denmark), 40% sterile saline, and 10% of 1 mg/mL epi-nephrine (Takeda Pharma, Denmark), yielding a finaliodine concentration of 175 mg/mL and epinephrineconcentration of 0.1 mg/mL, based on reported iodineconcentrations in previous studies.22–24,30,31Epinephrinewas added to slow absorption of the contrast mediumthrough the synovial membrane.32Maximal injectionvolume was 5 mL per stifle.Twelve dogs with clinically normal contralateral stiflejoints underwent bilateral CTA to provide comparisonmaterial for training and control purposes. Disease-freestatus was determined by the absence of positive findingsusing the same criteria as for inclusion in the study andabsence of radiographic changes.2.2 |Joint explorationArthrotomy was performed via a standardized mini-medial approach aided by an appropriately-sized speed-lock stifle distractor in order to visualize and probe themenisci. Findings were recorded in the patient journal,and partial or total excision of the caudal horn of themedial meniscus performed as required. Unstable jointsunderwent tibial tuberosity advancement, tibial plateauleveling osteotomy or lateral suture stabilization, basedon owner preference, cost, and clinical factors such aspatient size and tibial plateau angle.2.3 |CTA evaluationTraining and CTA evaluation were performed usingopen-source DICOM viewing software (Horus 3.3.6,www.horusproject.org , accessed June 10, 2022).To finalize the examination protocol and to gain expe-rience with examination of the canine stifle joint usingcomputed tomography, the 12 normal CTA were exam-ined by all observers: these scans were excluded from thefinal evaluation. In addition, a number of examples ofmeniscal injury were also used, from patients prior to ini-tiation of this study. Two observers were considered inex-perienced, being final-year veterinary students (observers1 and 2), and observer 3 was an experienced orthopedicsurgeon with 25 years surgical experience and 8 yearsveterinary orthopedic CT experience including use ofCTA at the time of study start. Affected stifle CTA wereanonymized and randomized by observers 1 and 2 usingopen-source software (DICOM cleaner,www.dclunie.com, accessed 10 June 2022) into two collections eachcontaining all scans. Each observer, working indepen-dently, read the two collections with a one-week intervalbetween them.Using multiplanar reconstruction the scans werealigned such that the transverse plane was parallel to thetibial plateau, the dorsal (frontal) plane was perpendicu-lar to the tibial plateau and tangent to the caudal femoralcondyles, and the sagittal plane was perpendicular toboth transverse and dorsal planes (Figure1). Windowwidth and level were adjusted according to observer pref-erences for optimal viewing. A standardized scoring sheetwas used to record the results, with menisci graded aseither intact or damaged: no other interpretationwas made.FIGURE 1 Alignment of viewing planes for multiplanar reconstruction. The transverse plane (purple) was parallel to the tibial plateau(B), the dorsal (frontal) plane (blue) was perpendicular to the tibial plateau (B) and tangent to the caudal femoral condyles (A), and thesagittal plane (yellow) was perpendicular to both transverse and dorsal planes (A, C).KNUDSEN ET AL . 77 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13982 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 License2.4 |Statistical analysisAnalyses were performed using statistical software (SPSS27, IBM Software, Armonk, New Jersey; R 4.2 with EpiRpackage). The Shapiro –Wilk test was used to assess nor-mality of distribution of continuous data, which werereported as mean (standard deviation) or median (range)as appropriate. Sensitivity, specificity, positive and nega-tive predictive values, likelihood ratios, and correctlyclassified proportions were calculated by reference to therecorded arthrotomy findings. Intraobserver agreementacross the two readings was calculated using Cohen'skappa, and interobserver agreement between the threeobservers was calculated using Fleiss' kappa. Adjectivaldescriptions as defined by Altman33were used, withkappa values between 0.2 –0.4 designated fair, 0.4 –0.6 des-ignated moderate, 0.6 –0.8 designated good, and 0.8 –1.0designated very good. Changes in readings for eachobserver were assessed using McNemar's test, andbetween observers for each reading using Cochran'sQtest with post hoc Bonferroni adjustment. Significancewas set at the 5% level.3|RESULTSA total of 66 scans from 55 dogs were obtained duringthe study period: an additional five dogs were excludedfrom scanning due to comorbidities. Seven dogs did notundergo surgical exploration, four scans exceeded the2 week maximum interval from scanning to surgery, andthree scans were excluded from analysis due to missingdata and poor image quality, leaving 52 scans from44 dogs for analysis. No issues with implant-associatedartifacts were observed with the scanning protocolused here.Median age at time of surgery was 6 years 9 months(range 1 year to 11 years 3 months). There were 19 malesFIGURE 2 Examples ofmeniscal lesions seen with positivecontrast computed tomographicarthrography. Three stifles withmeniscal lesions (A –C) and oneunaffected stifle (D) seen in sagittal(i), transverse (ii) and dorsal (frontal)(iii) sections constructed with 3Dmultiplanar reconstruction with WL500 and WW 2000. A —partialthickness meniscal lesion extendingfrom the femoral surface of themeniscus distally, but not penetratingthe tibial surface (i, iii) or abaxialborder (ii) of the meniscus. B —fullthickness meniscal lesion extendingfrom the femoral to tibial meniscalsurfaces (i, iii), but not reaching theabaxial border (ii). C —damage to thecaudal horn of the medial meniscusis appreciated as hyperintenseshadowing of the meniscal tissue,without a clearly defined line ofseparation. D —normal wedgeappearance of the medial meniscuscan be appreciated (i, iii), with nocontrast penetration on thetransverse view (ii).78 KNUDSEN ET AL . 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13982 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 Licenseand 25 females with a mean body mass of 27.3 kg(SD 13.6 kg). Most common breed types were large mixedbreed ( n=9), Labrador retriever ( n=4), Old Englishbulldog ( n=3), and medium mixed breed ( n=3). Thirtystifles were operated on the day of scanning, with amedian interval of 0 days (range 0 –13 days).Suspected late meniscal injury was the indication for12/52 scans, with one prior lateral suture repair and11 tibial tuberosity advancements: meniscal lesions wereidentified in 9/12 at surgery. Lesions comprised buckethandle tears ( n=5), marked fibrillation ( n=1), radialtear ( n=1), and two unspecified lesions. In stifles with-out prior stabilization, meniscal lesions were identifiedsurgically in 19/40 scans, predominantly bucket handletears ( n=16), with one fragmented caudal horn, onedetached bucket handle, and one nonspecified lesion. Sixdogs were scanned twice due to suspected unilateral latemeniscal injury and one dog was scanned on four occa-sions due to bilateral cruciate disease and subsequentsuspicion of late meniscal injury, and these scansincluded as separate instances in this study. Surgical find-ings and observations are summarized in Table S1. Exam-ples of meniscal lesions identified in this study withcomparison normal slices are shown in Figure2: normaljoint anatomy is further detailed in Figures S1, S2 and S3.Diagnostic accuracy varied with observer experienceand between readings (Table 1). Sums of sensitivity andspecificity were approximately 1.6 for the first readingand 1.8 for the second, indicating useful diagnosticperformance.28Based on values for the second reading,identification of meniscal abnormalities on CTA had apositive predictive value of approximately 90%, whereasan absence of abnormalities had a negative predictivevalue of 91% –100%. The positive likelihood ratio follow-ing identification of meniscal abnormalities on CTA wasat least 4.6: the negative likelihood ratio was 0.08 orlower. These values may be used in a Bayes nomogram.Assuming our 75% probability of meniscal tears in a pop-ulation suspected of late meniscal injury, presence orabsence of findings on CTA would indicate >93% or<19% probabilities of meniscal lesions, respectively. Cor-respondingly, our 48% probability of meniscal injury infirst presentation cranial cruciate ligament rupturepatients would give post-test probabilities for presence orabsence of a meniscal lesion of >81% or <7%, respec-tively. Overall, the percentage of correctly classifiedmenisci was approximately 80% for reading one and 90%for reading two.For the two least-experienced observers, a change inclassification proportions was observed between readingsone and two ( p< .001, p=.02), but not for the mostexperienced observer ( p=.22).Intraobserver agreement was moderate to good, andinterobserver agreement moderate for reading one andvery good for reading two (Table2). Readings differedbetween observers for readings one and two ( Χ2[2]=13.7, p< .001; Χ2[2]=6.0, p=.05). Pairwise differ-ences were seen between observer 1 and 3 in reading oneTABLE 1 Diagnostic data. Sensitivity, specificity, positive and negative predictive values (PPV, NPV), positive and negative likelihoodratios (PLR, NLR) and correctly classified proportions (CCP), with 95% CI.Reading 1 Reading 2Observer 1 Observer 2 Observer 3 Observer 1 Observer 2 Observer 3Sensitivity 0.62 (0.42, 0.79) 0.72 (0.53, 0.87) 0.90 (0.73, 0.98) 1.00 (0.88, 1.00) 1.00 (0.88, 1.00) 0.93 (0.77, 0.99)Specificity 0.96 (0.78, 1.00) 0.87 (0.66, 0.97) 0.70 (0.47, 0.87) 0.78 (0.56, 0.93) 0.83 (0.61, 0.95) 0.91 (0.72, 0.99)PPV 0.95 (0.74, 1.00) 0.88 (0.68, 0.97) 0.79 (0.61, 0.91) 0.85 (0.69, 0.95) 0.88 (0.72, 0.97) 0.93 (0.77, 0.99)NPV 0.67 (0.48, 0.82) 0.71 (0.51, 0.87) 0.84 (0.60, 0.97) 1.00 (0.81, 1.00) 1.00 (0.82, 1.00) 0.91 (0.72, 0.99)PLR 14.28 (2.06, 99.13) 5.55 (1.89, 16.33) 2.95 (1.57, 5.53) 4.60 (2.12, 9.99) 5.75 (2.36, 14.01) 10.71 (2.84, 40.40)NLR 0.40 (0.25, 0.64) 0.32 (0.17, 0.58) 0.15 (0.05, 0.45) 0.00 0.00 0.08 (0.02, 0.29)CCP 0.77 (0.63, 0.87) 0.79 (0.65, 0.89) 0.81 (0.67, 0.90) 0.90 (0.79, 0.97) 0.92 (0.81, 0.98) 0.92 (0.81, 0.98)Abbreviations: NLR, neutrophil-to-lymphocyte ratio; NPV, negative predictive value; PLR, platelet to lymphocyte ratio.TABLE 2 Intra- and interobserver agreement. Intraobserver agreement was assessed using Cohen's kappa, and interobserver agreementwith Fleiss' kappa. Values are presented with 95% CI.Observer (intraobserver) Reading (interobserver)12312Kappa 0.50 (0.31 –0.69) 0.55 (0.34 –0.75) 0.78 (0.62 –0.95) 0.47 (0.32 –0.63) 0.83 (0.68 –0.98)KNUDSEN ET AL . 79 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13982 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 License(corrected p=.001) but not between observers 1 and2, or between 2 and 3 (corrected p=.58, correctedp=.06). No pairwise differences were found for readingtwo after correction of p-values (1 vs. 2 p=1.0; 1 vs.3p=.06; 2 vs. 3 p=.19).4

Question 102

Butts - 2023 - JFMS - Comparison of three radiographic assessment methods for detecting slipped capital femoral epiphyses in cats - Klein's line, modified Klein's line and the S-sign.pdf

Answer 102

This study was a retrospective case-control study. Ethical approval was granted by the Animal Welfare and Ethical Review Body, University of Bristol (reference VIN/20/020).Clinical records from Langford Small Animal Hospital and The Queen Mother Hospital for Animals were searched for cats with pelvic radiographs between 1 January 2010 and 14 May 2020. Cats were included in the study if they had been diagnosed with SCFE without full displacement of their FCE, and had both VD extended-leg and VD frog-leg pelvic radiographs available. A total of 20 cats met the inclusion criteria. Eight cats with unilat -eral fully displaced FCE were included as a control group, and a further five cats with normal VD extended-leg and VD frog-leg pelvic radiographs were included as an unaf-fected control group.For all 33 cases, the lateral margins of the femoral necks were identified on the VD extended-leg images. Owing to the concavity of this lateral margin, the proximal and distal aspects of the femoral neck were identified. The Klein’s line was drawn at the tangent of this curvature. A positive result occurred when the line did not intersect the epiphysis and would be indicative of a femoral capital epiphyseal slip (Figure 1).For cases without a positive result for the Klein’s line, the modified Klein’s line was performed. For these cases, the Klein’s line was drawn on both sides and the amount of femoral capital epiphyseal intersection was calculated on each side. Owing to the much smaller size of cats com -pared with humans, the difference of > 2 mm required for a positive in humans was too high; therefore, for the pur -pose of this study, a positive result was determined when the difference in epiphyseal intersection between the two sides was ⩾ 0.5 mm. The side with the least intersection was given a positive result indicative of femoral capital epiphyseal displacement (Figure 2).For the purpose of this study, the S-sign was meas-ured on both VD extended-leg and VD frog-leg images in Butts et al 3Figure 1 The Klein’s line. Ventrodorsal extended-leg view. (a) The arrowheads indicate the proximal and distal aspects of the lateral margin of the femoral neck. (b) The Klein’s line is drawn at the tangent of the curve between these two arrowheads and it intersects the femoral capital epiphysis – this is a negative result. (c) The Klein’s line does not intersect the femoral capital epiphysis on the right side and so this is a positive result indicating displacement of the epiphysis. The left side is negativeFigure 2 The modified Klein’s line. Ventrodorsal extended-leg view. In this example, 1.72 mm of the epiphysis is intersected by the Klein’s line on the left side, and 1.04 mm of the epiphysis is intersected by the Klein’s line on the right side. The difference between the two sides is 0.68 mm. In this study, we have defined that a difference of 0.5 mm or greater between the two sides is indicative of a positive result. Therefore, in this example, a positive result of epiphyseal displacement would be given to the right sideall 33 cases. For each view, a curvilinear line was 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 continu-ity, asymmetry or sharp turn was indicative of a posi-tive result for femoral capital epiphyseal displacement (Figure 3).Images were analysed using an open-source medi-cal image viewer software (Horos [Horosproject.org], sponsored by Purview). The VD extended-leg and VD frog-leg pelvic radiographs for all 33 cases were de-iden -tified and case order randomly arranged. Five observers reviewed each of the radiographs on two separate occasions 3 months apart. The observers were instructed on how to draw and interpret the Klein’s line, modified Klein’s line and the S-sign. The observers included two European specialists in veterinary diagnostic imaging and three European specialists in small animal surgery.4 Journal of Feline Medicine and Surgery The accuracy, sensitivity, specificity, positive predic-tive value and negative predictive value were reported for each parameter. For the modified Klein’s line, only unilateral cases, and those cases in which the observer determined both sides to be negative for the Klein’s line, were included in the analysis. The intra- and inter-observer reliabilities of the Klein’s line, modified Klein’s line and S-sign were measured using the Cohen’s kappa coefficient. The relative strength of agreement of the kappa statistics were evaluated according to Landis and Koch: <0.00 = poor; 0.00–0.20 = slight; 0.21–0.40 = fair; 0.41–0.60 = moderate; 0.61–0.80 = substantial; and 0.81–1.00 = almost perfect.20ResultsIn total, 20 cats (19 males, one female, all neutered) with SCFE without fully displaced FCE were included in the study. Of these affected cats, there were six DSHs, four Maine Coons, five British Shorthairs, three Bengals, one domestic longhair and one British Blue. The age range of the cats was 7–44 months (mean age 20.8 ± 8.2 months; median 20 months).Six cats presented with bilateral SCFE, seven with left-sided SCFE and seven with right-sided SCFE. Of the bilateral cases, four had moderate displacement of the femoral capital physis bilaterally, and two had one side with mild displacement and the other with moder -ate displacement. Of the remaining unilateral cases, 10 had mild displacement, one had moderate displacement and three had severe displacement. An additional eight cats with fully displaced FCE and five cats with nor -mal pelvic anatomy were included as control groups. Determination of mild, moderate and severe displace-ment was subjective and based on consensus agreement between the authors.When all 33 cases were included in the analysis (includ-ing the fully displaced FCE control group), the Klein’s line was able to identify SCFE with a mean accuracy of 69.6% (median 68.2%), sensitivity of 44.1% (median 41.2%), specificity of 96.5% (median 98.5%), positive predictive value of 92.5% (median 97.6%) and negative predictive value of 62.3% (median 60.6%).The modified Klein’s line was only performed in uni -lateral cases that did not produce a positive result for the Klein’s line. This is because this method is not to be used in bilaterally affected cases and can only be used when both sides produce a negative result for the Klein’s line. The mean number of cases for which the modified Klein’s line was applied on each round was 18 (range 14–23 for round 1 and 12–21 for round 2). Of these cases, the modified Klein’s line yielded a mean accuracy Figure 3 The S-sign. (a) Ventrodorsal (VD) extended-leg view. A curvilinear line is drawn from the lesser trochanter, along the femoral neck and around the femoral head to its midpoint. The left side on this image is normal. The right side illustrates a sharp turn and so is indicative of an abnormal result. (b) VD frog-leg view. The curvilinear line is drawn in the same way as on the VD extended-leg view. The left side on this image is normal. The right side illustrates a sharp turn and so is indicative of an abnormal resultButts et al 5Table 1 The accuracy, sensitivity, specificity, positive predictive value and negative predictive value for the Klein’s line, modified Klein’s line and S-sign in the ventrodorsal (VD) extended-leg position and the S-sign in the VD frog-leg position when the fully displaced femoral capital epiphyses control group was included in the analysisKlein’s line Modified Klein’s line S-sign VD extended-leg S-sign VD frog-legAccuracy (%)Mean 69.6 50.3 89.4 90.5Median 68.2 53.4 90.9 90.9Sensitivity (%)Mean 44.1 41.2 81.8 91.5Median 41.2 49.5 82.4 95.6Specificity (%)Mean 96.5 65.1 97.5 89.4Median 98.5 66.7 96.9 89.1Positive predictive value (%)Mean 92.5 59.6 97.2 90.1Median 97.6 66.7 96.9 90.3Negative predicitive value (%)Mean 62.3 32.1 83.9 91.2Median 60.6 35.4 84.2 94.9of 50.3% (median 53.4%), sensitivity of 41.2% (median 49.5%), specificity of 65.1% (median 66.7%), positive predictive value of 59.6% (median 66.7%) and negative predictive value of 32.1% (median 35.4%). The S-sign performed in the VD extended-leg position produced a mean accuracy of 89.4% (median 90.9%), sensitivity of 81.8% (median 82.4), specificity of 97.5% (median 96.9%), positive predictive value of 97.2% (median 96.9%) and negative predictive value of 83.9% (median 84.2%). When the S-sign was performed in the VD frog-leg position, the mean accuracy was 90.5% (median 90.9%), sensitiv -ity of 91.5% (median 95.6%), specificity of 89.4% (median 89.1%), positive predictive value of 90.1% (median 90.3%) and negative predictive value of 91.2% (median 94.9%). These results are summarised in Table 1. The mean results from each round of readings for each of the observers have also been provided in Table 2.When all 33 cases were included in the analysis, the mean Cohen’s kappa coefficient for intra-observer reli-ability for the Klein’s line was 0.611 (median 0.659), and for the modified Klein’s line, it was 0.645 (median 0.670), both showing substantial agreement. For the S-sign in the VD extended-leg position, the mean Cohen’s kappa coef -ficient for intra-observer reliability was 0.883 (median 1), and for the S-sign in the VD frog-leg position, it was 0.903 (median 0.909), both showing almost perfect agreement. The mean Cohen’s kappa coefficient for inter-observer reliability for the Klein’s line was 0.540 (median 0.551), showing moderate agreement; for the modified Klein’s line, it was 0.616 (median 0.600), showing substantial agreement; for the S-sign in the VD extended-leg position, it was 0.791 (median 0.756), showing substantial agree-ment; and for the S-sign in the VD frog-leg position, it was 0.845 (median 0.879), showing almost perfect agreement.When the fully displaced FCE control group was excluded from analysis, the Klein’s line was able to iden -tify SCFE with a mean accuracy of 60.6% (median 60.0%), sensitivity of 30.6% (median 29.7%), specificity of 97.9% (median 100.0%), positive predictive value of 93.0% (median 100.0%) and negative predictive value of 55.3% (median 54.6%). The modified Klein’s line was again only performed in unilateral cases that did not produce a posi -tive result for the Klein’s line. This yielded a mean accu -racy of 50.4% (median 53.4%), sensitivity of 40.2% (median 49.5%), specificity of 68.0% (median 66.7%), positive predictive value of 55.2% (median 66.7%) and negative predictive value of 34.0% (median 35.4%). The S-sign per -formed in the VD extended-leg position produced a mean accuracy of 88.8% (median 92.0%), sensitivity of 79.2% (median 84.6%), specificity of 99.2% (median 100.0%), positive predictive value of 99.2% (median 100.0%) and negative predictive value of 82.2% (median 85.7%). When the S-sign was performed in the VD frog-leg position, the mean accuracy was 92.4% (median 93.0%), sensitiv-ity of 93.9% (median 96.2%), specificity of 90.9% (median 91.7%), positive predictive value of 91.8% (median 92.3%) and negative predictive value of 93.5% (median 95.6%). These results are summarised in Table 3. The mean results from each round of readings for each of the observers have also been provided in Table 4.When the fully displaced FCE control group was excluded from analysis, the mean Cohen’s kappa coef-ficient for intra-observer reliability for the Klein’s line was 0.305 (median 0.336), and for the modified Klein’s line, it was 0.572 (median 0.570), showing fair and mod -erate agreement, respectively. For the S-sign in the VD extended-leg position, the mean Cohen’s kappa coef-ficient for intra-observer reliability was 0.817 (median 6 Journal of Feline Medicine and Surgery Table 3 The accuracy, sensitivity, specificity, positive predictive value and negative predictive value for the Klein’s line, modified Klein’s line, S-sign in the ventrodorsal (VD) extended-leg position and the S-sign in the VD frog-leg position when the fully displaced femoral capital epiphyses control group was excluded from the analysisKlein’s line Modified Klein’s line S-sign VD extended-leg S-sign VD frog-legAccuracy (%)Mean 60.6 50.4 88.8 92.4Median 60 53.4 92 93Sensitivity (%)Mean 30.6 40.2 79.2 93.9Median 29.7 49.5 84.6 96.2Specificity (%)Mean 97.9 68 99.2 90.9Median 100 66.7 100 91.7Positive predictive value (%)Mean 93 55.2 99.2 91.8Median 100 66.7 100 92.3Negative predictive value (%)Mean 55.3 34 82.2 93.5Median 54.6 35.4 85.7 95.6Table 2 The mean results from each round of readings from each of the observers when the fully displaced femoral capital epiphyses control group was included in analysisKlein’s line Modified Klein’s line S-sign extended S-sign frog-leg Round 1 Round 2 Round 1 Round 2 Round 1 Round 2 Round 1 Round 2AccuracyObserver 1 54.5 66.7 22.2 41.2 81.8 81.8 81.8 81.8Observer 2 83.3 77.3 64.3 53.8 93.9 86.4 95.5 90.9Observer 3 65.2 75.8 66.7 30.8 86.4 90.9 87.9 90.9Observer 4 72.7 68.2 64.7 64.7 90.9 93.9 90.9 93.9Observer 5 68.2 63.6 52.9 41.2 93.9 93.9 95.5 95.5SensitivityObserver 1 23.5 41.2 10.0 18.2 67.6 67.6 76.5 79.4Observer 2 67.6 58.8 62.5 44.4 88.2 76.5 97.1 97.1Observer 3 41.2 52.9 75.0 0.0 82.4 82.4 91.2 94.1Observer 4 47.1 38.2 60.0 54.5 82.4 88.2 88.2 97.1Observer 5 41.2 29.4 54.5 33.3 91.2 91.2 97.1 97.1SpecificityObserver 1 87.5 93.8 37.5 83.3 96.9 96.9 87.5 84.4Observer 2 100.0 96.9 66.7 75.0 100.0 96.9 93.8 84.4Observer 3 90.1 100.0 57.1 66.7 90.6 100.0 84.4 87.5Observer 4 100.0 100.0 71.4 83.3 100.0 100.0 93.8 90.6Observer 5 96.9 100.0 50.0 60.0 96.9 96.9 93.8 93.8Positive predictive valueObserver 1 66.7 87.5 16.7 66.7 95.8 95.8 86.7 84.4Observer 2 100.0 95.2 71.4 80.0 100.0 96.3 94.3 86.8Observer 3 82.4 100.0 66.7 0.0 90.3 100.0 86.1 88.9Observer 4 100.0 100.0 75.0 85.7 100.0 100.0 93.8 91.7Observer 5 93.3 100.0 66.7 66.7 96.9 96.9 94.3 94.3Negative predictive valueObserver 1 51.9 60.0 5.9 35.7 73.8 73.8 77.8 79.4Observer 2 74.4 68.9 25.0 37.5 88.9 79.5 96.8 96.4Observer 3 59.2 66.7 35.0 36.3 82.9 84.2 90.0 93.3Observer 4 64.0 60.4 30.0 50.0 84.2 88.9 88.2 96.7Observer 5 60.8 57.1 38.1 27.3 91.2 91.2 96.8 96.8Data are %Butts et al 70.839), and for the S-sign in the VD frog-leg position, it was 0.924 (median 0.920), both showing almost perfect agreement. The mean Cohen’s kappa coefficient for inter-observer reliability for the Klein’s line was 0.411 (median 0.510), and for the modified Klein’s line, it was 0.603 (median 0.584), both showing moderate agreement; for the S-sign in the VD extended-leg position, it was 0.912 (median 1.000), and for the S-sign in the VD frog-leg posi-tion, it was 0.936 (median 0.960), both showing almost perfect agreement.

Question 103

Velay - 2024 - JAVMA - Safe gastric wall closure in dogs using a single-layer full-thickness simple continuous suture pattern.pdf

Answer 103

Inclusion criteriaDogs requiring gastrotomy for foreign body re -moval were enrolled in the study between January 1, 2018, and January 1, 2023. Approval for this study was granted by the clinical research committee at VetAgro Sup, Marcy l’Etoile, France (ethics commit -tee number 2180). The initial diagnosis was based on a physical examination due to symptoms of ab -dominal discomfort, vomiting, and diarrhea, further confirmed by ultrasonography or radiography. Dogs were excluded if they presented concomitant comor -bidities that could impair the healing process, such as preoperative peritonitis, neoplasia, endocrinopa -thy, or if the owners declined surgery.Dogs were randomly assigned to 1 of 3 groups based on the gastrotomy closure pattern, using a computer-generated randomization application.5 The surgical procedures were performed randomly by one of the surgeons. Gastrotomies were closed with a double-layer inverting continuous pattern (DLI) in the DLI group: the first layer was an inverting pattern (Connell pattern) incorporating the mucosal and submucosal layers of the stomach; followed by a second inverting layer (Cushing pattern) incorporat -ing at least the serosal and muscularis layers of the stomach (Supplementary Video S1) . Gastrotomies were closed with a double-layer simple continuous pattern (DLS) in the DLS group: the first layer fea -tured a simple continuous pattern incorporating the mucosal and submucosal layers of the stomach, fol -lowed by a second simple continuous pattern that also incorporated the serosal and muscularis lay -ers (Supplementary Video S2) . Gastrotomies were closed with a full-thickness single-layer simple con -tinuous pattern (SLS), in the SLS group which en -compassed all the aforementioned layers (Supple -mentary Video S3) .Various parameters were recorded, including signalment, findings from the physical examination (temperature, heart rate, respiratory rate, respirato -ry character, abdominal palpation, blood pressure), preoperative clinical signs, preoperative bloodwork, preoperative imaging results, and preoperative man -agement (administered medications and preopera -tive intravenous fluids rate).Major complications following gastrotomy are rare, and this study had a predetermined stopping point if a major complication were to occur in the SLS group.Surgical proceduresAll surgeries were conducted either by an ex -perienced surgeon, specifically a European College of Veterinary Surgeons boarded surgeon with more than 10 years of diplomate experience, or a nationally recognized surgical specialist possessing a specialist post-graduate veterinary qualification with 20 years of post-graduate experience.Dogs were premedicated with midazolam (0.2 mg/kg, IV) and morphine (0.2 mg/kg, IV) and in -duced with propofol (4 to 6 mg/kg, IV, adjusted for effect). Anesthesia was maintained using isoflurane and oxygen. Crystalloid IV fluids were administered at a rate of 5 mL/kg/h during the surgery. Various vi -tal signs including heart rate, respiratory rate, blood pressure, end-tidal carbon dioxide, and electrocar -diogram were monitored and recorded during the surgical procedure. Gastrotomies were performed as previously described.1In brief, dogs were positioned in a dorsal recum -bent posture, and the ventral abdomen, from the xi -phoid process to the pubis, was aseptically prepared for ventral midline celiotomy. A median celiotomy was then performed. The stomach was isolated us -ing moistened laparotomy sponges, and stay sutures were placed around the gastrostomy site. The gas -trotomy was performed on the ventral surface of the stomach midway, located midway between its lesser and greater curvatures, in the area of least vascular -ity. The size and location of the incision were deter -mined by the size of the foreign body. In most cases, the incision was made in the middle of the ventral body of the stomach. The suturing of the gastros -tomy site was performed according to the group to which the dog belonged. A 4-0 absorbable mono -filament suture, made from polydioxanone (4-0 PDS) was used for all gastrotomy sites. The abdominal wall was sutured using standard techniques.Operative findings and a subjective description of the gastrointestinal tract were also recorded.Postoperative assessmentPostoperative clinical examinations, including abdominal palpation, temperature, heart rate assess -ment, and respiratory rate monitoring, were sched -uled for 2 weeks following the surgery. These exami -nations were conducted based on owner and patient availability, either at our institution or with their re -ferring veterinarians. Additionally, a phone interview was arranged 1 month postoperatively. The recorded findings included clinical examinations and gastroin -testinal signs observed. Dogs were monitored for ma -jor complications over a 1-month period. Major com -plications were defined as treatment-related adverse events requiring further treatment involving increased levels of care, such as surgical revision or a prolonged duration of hospitalization exceeding 2 days, or in ex -treme cases, euthanasia. Minor complications were defined as complications that did not require hospi -talization or additional surgical procedures.Statistical analysisSample size justification —Statisticians were un -able to determine a number of dogs per group based on power of analysis of 80%. Indeed, complication rate for gastrotomy is unreported in dogs. Complica -tions are so rare in humans that using this data would raise the number of dogs up to 5,000 dogs to reach a power of 80%. This number would make the study Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 01/27/24 05:24 PM UTC 3unrealizable in a lifetime. The inclusion of 60 subjects in the study was determined arbitrarily, with 20 sub -jects allocated to each of the gastrotomy groups.Descriptive statistics were used to analyze base -line characteristics, demographic data, minor com -plications, surgeons, and concomitant surgeries.Quantitative variables were described and sum -marized using the number of valid data inputs, the number of missing values, mean, median, SD, mini -mum, and maximum values. Qualitative parameters or variables were summarized as absolute numbers and percentages (%).For the primary endpoint, a comparative analy -sis was conducted among the 3 groups concerning the occurrence of reported minor complications us -ing Fisher exact test.A secondary comparison focused on the 2 groups: single-layer and double-layer (combining the double-layer groups together). The same tests described above were applied.The Kruskal-Wallis test was utilized to compare groups and quantitative parameters, such as the age and weight of subjects. The normality of all quantita -tive variables was assessed using the Shapiro-Wilk test.Correlations were analyzed to identify any rela -tionships among the level of minor complications, the group, the surgeons involved, and the occurrence of death after 1 month of postoperative monitoring.Correlation analysis between quantitative pa -rameters was performed using regression analysis and the calculation of the Pearson coefficient for normally distributed data. For non-Gaussian data, a nonparametric correlation analysis was applied, cal -culating the Spearman coefficient. To calculate the correlation coefficients, certain nominal variables (as surgeon and intervention type) were transformed into numerical values.No strategy for replacing or correcting missing data was applied.For all inferential analyses (comparative and ex -planatory) the significance level α was defined as 5%.All statistical analyses were performed using IBM SPSS statistics 22 software.The study’s statistical power exceeded 80%.ResultsDemographicsDuring the study period, 64 dogs were presented for gastrotomies. Four dogs were excluded from the study. The reasons for their exclusion included eutha -nasia (1 dog) due to a sarcoma diagnosis, surgery for linear foreign bodies, and preoperative peritonitis (3 dogs). Consequently, a total of 60 dogs were includ -ed, with 20 dogs allocated to each gastrotomy group.The 60 dogs represented 38 different breeds. with the most frequently encountered pure breeds were American Staffordshire (6 dogs [8.5%]), Malinois (4 dogs [5.6%]), and French bulldog (3 dogs [4.2%]). The median age of the dogs was 3 years, with a range: 6 months to 13 years. The median age for the DLI, DLS, and SLS groups were 2 years (range, 0.5 to 13 years), 3.5 years (range, 0.5 to 12 years), and 5.5 years (range, 0.5 to 13 years), respectively. In terms of weight, the median was 21.6 kg, with a range of 2.6 to 94 kg. The median weights for the DLI, DLS, and SLS groups were 29.5 kg (range, 6.3 to 67 kg), 30.75 kg (range, 3.4 to 94 kg). The median weight for the group SLS was 21.75 kg (range, 2.6 to 43 kg). There were 8 females (4 spayed, 4 intact) and 12 males (6 neutered, 6 intact) in the DLI group. There were 5 females (4 spayed, 1 intact) and 15 males (10 neutered, 5 intact) in the DLS group. There were 10 females (all spayed) and 10 males (4 neutered, 6 intact) in the SLS group. No significant difference was observed among the 3 types of groups in terms of ei -ther the dogs’ age ( P value = .348) or weight ( P value = .262). There were statistically significant differences between the types of intervention and the sex and neu -tering of dogs ( P values < .001).Gastrotomy was required due to 1 or more di -gestive foreign bodies. Concomitant surgeries were performed on 8 dogs: enterotomy (5 dogs), enter -ectomy (1 dog), hepatic lobectomy (1 dog), and cholecystectomy (1 dog). Two concomitant surger -ies were performed in the DLI group (1 enterotomy and 1 enterectomy), 3 in the DLS group (1 hepatic lobectomy, 2 enterotomies) and 3 surgeries in the SLS group (1 cholecystectomy, 2 enterotomies).All surgeries were performed by 2 surgeons. Each surgeon performed 10 gastrotomies in the DLI group, 10 in the DLS group, and 10 in the SLS group.All dogs were discharged from hospitalization without experiencing any major complications, and monitoring over 1 month confirmed a 100% survival rate with no major complications. Minor complications were recorded in 8 out of 34 dogs (for which the date was available), including skin wound dehiscence (2 dogs), cutaneous infection (2 dogs), seroma (2 dogs), vomit -ing (1 dog), and abdominal hernia (1 dog). The minor complications for each group are summarized (Table 1) . Groups DLS DLI SLSComplications (n = 20) (n = 20) (n = 20)Wound dehiscence 1 1 0Abdominal hernia 0 1 0Wound infection 0 2 0Seroma 2 0 0Vomiting 0 1 0DLI = Double-layer inverting continuous pattern. DLS = Double-layer simple continuous pattern. SLS = Single-layer simple continuous pattern.Table 1 —Repartition of dogs into 3 groups according to the gastrotomy pattern and the type of reported minor complications.For wound dehiscence and infection, treatment con -sisted of antibiotics (amoxicillin–clavulanate, 20 mg/kg, PO, q 12 h for 7 days) along with local care, and hospi -talization was not required. As for the abdominal hernia, it was very small, involving only fat tissue along the inci -sional midline. Surgery was declined by the owners due to the lack of pain and absence of clinical signs.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 01/27/24 05:24 PM UTC4 No relationship was found between the surgeon and the number of minor complications ([r = .094; P = .375] P value = .375; χ2 or Fisher tests).For animals with a known status (yes vs no) for minor complications, there was no significant different in the proportion of animals with minor complications (P = .095) among the DLS (5/20), DLI (3/20), and SLS (0/20) groups. Additionally, no correlation (r = .33; P = .095) was detected between treatment group and the number of minor complications reported.The 3 groups did not differ significantly in terms of minor complications reported ( P value = .095). When comparing complications for 2 types of suture planes (single and double layers), no minor complications were reported following single-layer sutures, com -pared to 8 cases (20%) for double-layer sutures. This difference was statistically significant ( P value = .031).Postoperative monitoringThe duration of hospitalization did not differ among the 3 groups, ranging from 1 to 2 days. No dif -ferences were observed in the survival rates among the 3 groups, either at the time of discharge or 2-months postoperatively. Furthermore, no complica -tions occurred during the 1-month monitoring period.

Question 104

Reilly - 2023 - JSAP - Surgical removal of a jugular aneurysm in a spaniel cross dog.pdf

Answer 104

NA

Question 105

Murakami - 2023 - VCOT - Examination of Proximodistal Patellar Position in Dogs with the Stifle at Full Extension.pdf

Answer 105

Privately owned dogs presented to the Nippon Veterinaryand Life Science University or Minagawa Pet Clinic to takeradiographs of the hindlimbs were included in this study ifthey weighed less than 15 kg, based on a previous study.9To avoid the in fluence of skeletal immaturity, cases wereexcluded if a dog was less than 6 months old. Informedconsent was obtained from all owners. The study wasexempted from review by our ethics committee accordingto the guidelines of the Nippon Veterinary and Life ScienceUniversity Medical Ethics Review Committee. Mediolat-eral-view radiographs were taken with the sti flej o i n ti nfull extension to examine the proximodistal patellar po-sition and then with the sti flej o i n t flexed at approximate-ly 90 degrees to measure the anatomical features, thusavoiding loosening of the patellar ligament. Full extensionof the sti fle was achieved manually by extending the sti fleto the maximum point without causing pain to the dog.Radiographs were excluded if the lateral and medialcondyles did not overlap correctly or if the patella wasnot in the trochlea; thus, no dog with grade 4 patellarluxation was included. Radiographs of the hindlimbs withMPL were included in the MPL group, and radiographs ofthose without any orthopaedic disease were included inFig. 1 Measurement de finitions of the joint angle and anatomical trochlear (AT) angle. The joint angle (white arc) is measured as the caudalangle of the anatomical axes of the femur and tibia. The distal femoral anatomical axis is de fined as the extension of the line connectingthe two points (white squares, AandB). The distal point A is the centre of the femoral width, which is one femoral condyle length (line FCL) awayfrom the proximal end of the trochlea, and the proximal point B is half the FCL away from the point A. The proximal tibial anatomical axisis de fined as the extension of the line connecting the centre of the tibial width (black square) and the notch at the front of the tibial plateau. Thetibial width is measured at the tibial cortex, which is 1.5 times the len gth of the proximal tibial width (PT W) away from the notch at the front ofthe tibial plateau. The AT angle is measured as the caudal angle mad e by the femoral anatomical axis and the femoral trochlear line..the control group. Radiographs of the hindlimbs with ahistory of any orthopaedic disease other than MPL wereexcluded from the study. Data on breed, sex, age, bodyweight, limb side and grade of MPL were obtained frompatient records. Data on whether the tibial tuberosityphysis was closed or open on the radiographs were noted.MeasurementsBased on a previously reported method, the sti fle joint anglewas de fined as the caudal angle made by the anatomical axesof the distal femur and proximal tibia ( ►Fig. 1 ).9The PLL, PL,craniocaudal size of the femoral condyle (FC), femoral troch-lear length (TL) ( ►Fig. 2 ) and anatomical trochlear (AT) angle(►Fig. 1 ) were measured as in previous studies.5,8,9Theproximodistal patellar alignment was determined by proxi-mal and distal patellar positions (PPP and DPP, respectively).These values were described as the distance from the proxi-mal trochlear margin to the distal direction, expressed as thepercentage of the TL. The lengths from the proximal end ofthe trochlea to the most proximal or distal points of thepatella were measured on the extension of the trochlear linewith the distal direction as a plus. These lengths were dividedby the TL to obtain PPP or DPP, as described in a previousstudy8,9(►Fig. 3 ). All measurements were performed by oneperson using computer-aided design software (AR_CAD v.1.6.0; SHF Co., Kyoto, Japan).Statistical AnalysisStifles with PPP or DPP exceeding the lower limit of thereference range were considered functional patella alta. Thereference range was determined as values falling withintwice the standard deviation of the mean of the PPP and DPPin the control group. Simple logistic regression was per-formed subsequently to evaluate the association betweenfunctional patella alta and sex, limb side, body weight, age,joint angle, condition of the tibial tuberosity physis, PLL/PL,TL/PL, TL/FC, or AT angle. Variables with a p-value less than0.20 were included in multivariable models.17,18Multivari-able logistic regression analysis was then performed toassess the factors associated with functional patella alta.For multivariable regression analyses, multiple regressionswith backward elimination were performed to identify amodel containing variables with coef ficients that signi fi-cantly differed from 0. The final model included any clini-cally important or signi ficant interactions. Then, thereceiver operating characteristic (ROC) curve was plotted,and the area under the curve (AUC), cut-off value, sensitivityand speci ficity were calculated for each factor included inthefinal model for functional patella alta. The cut-off valuewas determined using the Youden index. Stata (version 14,StataCorp, College Station, Texas, United States) was used forall analyses. For statistical estimation and inferences, two-sided hypothesis tests were used with a 5% signi ficance level.Fig. 2 Measurement de finitions of the patellar length (PL), patellar ligament length (PLL), femoral trochlear length (TL) and size of the femoralcondyle (FC). The PL is measured as the longest dimension of the patella. The PLL is measured from the most distal portion of the patella to thepatellar ligament insertion on the cranioproximal portion of the tibial tuberosity. The TL is measured from the proximal extent of the femoraltrochlear ridges to the origin of the long digital extensor muscle. The FC is measured from the origin of the long digital extensor muscle to thecaudal femoral cortex along the Blumensaat ’sl i n e ..ResultsOverall, radiographs of 127 sti fles from 75 dogs wereobtained. Among those 127 limbs, 44 had no patellar luxa-tion and were categorized into the control group. Otherlimbs were categorized into the MPL group; in this group,there were 11 limbs with grade I MPL, 35 limbs with grade IIMPL, and 37 limbs with grade III MPL. The control groupincluded toy poodles ( n¼11), mixed breed ( n¼5), Chihua-huas ( n¼4), French bulldogs ( n¼2), Jack Russell terriers(n¼2), Pomeranians ( n¼1), Yorkshire terriers ( n¼1), Shiba(n¼1), miniature schnauzer ( n¼1), Papillon ( n¼1) andShih Tzu ( n¼1). There were 21 males (14 neutered) andnine females (six neutered). The median age was 1661.5 days(range: 189 –4857 days), and the median body weight was4.70 kg (range: 1.70 –14.35 kg). Among the 44 limbs, 23 wereleft limbs, and 11 had an open tibial tuberosity physis. TheMPL group included toy poodles ( n¼15), mixed breed(n¼12), Chihuahuas ( n¼10), Pomeranians ( n¼7), York-shire terriers ( n¼3), Maltese ( n¼3), Shiba ( n¼2) andShetland sheep ( n¼1). There were 24 males (15 neutered)and 29 females (17 neutered). The median age was 480 days(range: 217 –4,959 days), and the median body weight was3.30 kg (range 1.15 –11.35 kg). Among the 83 limbs in theMPL group, 40 were left limbs and 34 had an open tibialtuberosity physis. Eight dogs had unilateral patellar luxa-tion; thus, they were included in both groups.The mean value ( /C6standard deviation) of the sti flej o i n tangle, PLL/PL, TL/PL, AT angle, PPP and DPP were 143 ( /C610),1.90 (/C60.22), 1.51 ( /C60.17), 138 ( /C66),/C00.24 (/C60.16) and 0.38(/C60.15) respectively for the 127 sti fles. The median value(range) of TL/FC was 1.65 (1.29 –2.13) for the 127 sti fles. Themean or median of these values for the control and MPLgroups is shown in ►Table 1 .For the control group, the reference range of PPP and DPPwere/C00.20 to /C00.12 and 0.40 to 0.49 respectively. Therefore,stifles with PPP smaller than /C00.20 or DPP smaller than 0.40were considered as functional patella alta. Eleven sti fles inthe MPL group and one sti fle in the control group met thesecriteria. Simple logistic regression showed that the limb side,body weight, age, joint angle, PLL/PL, TL/PL and TL/FC had p-values less than 0.2 ( ►Table 2 ) and thus were included in themultivariable logistic regression. The final model for func-tional patella alta is shown in ►Table 3 .T h es t i fle joint angle,TL/PL and PLL/PL were included in the final model. The ROCcurves for each value are shown in ►Fig. 4 . The AUC for thestifle joint angle was 0.89, and the cut-off value was156 degrees (sensitivity, 83.33%; speci ficity, 93.91%). TheAUC for PLL/PL was 0.70, and the cut-off value was 1.86(sensitivity, 91.67%; speci ficity, 42.61%). The AUC for TL/PLFig. 3 Measurement de finitions of the proximal patellar position (PPP) and distal patellar position (DPP). T he lines perpendicular to the trochlearwere drawn at the most proximal or distal point of the patella. X is the distance from the proximal end of the trochlear length (TL) to the proximaledge of the patella on the extension of the trochlear line. The PPP is de fined as -X/TL, as the length was measured to the distal direction. Y is thedistance from the proximal end of the TL to the distal edge of th e patella on the extension of the trochlear line. The DPP is de fined as Y/TL..was 0.70, and the cut-off value was 1.5 (sensitivity, 91.67%;speci ficity, 53.04%).

Question 106

Pawenski - 2023 - JFMS - Histopathologic diagnosis and patient characteristics in cats with small intestinal obstructions secondary to trichobezoars.pdf

Answer 106

The medical records of cats undergoing enterotomy or gastrotomy for gastrointestinal foreign body obstruc-tions between January 2016 and July 2022 at six private specialty hospitals were evaluated. The following inclu -sion criteria were applied: medical records describing a trichobezoar (‘hair’, ‘hairball,’ ‘trichobezoar’); at least one biopsy of the gastrointestinal tract obtained at time of surgery; and histopathologic evaluation by a diplomate of the American College of Veterinary Pathologists. Cats previously diagnosed with any enteropathy (based on review of available medical records) were excluded.All surgeries were performed by diplomates of the American College of Veterinary Surgeons (ACVS) or residents within an accredited ACVS residency program. Biopsies obtained at the site of obstruction were obtained via initial enterotomy with a #11 blade and excision of a variable strip of tissue from one side of the enterotomy using Metzenbaum scissors. Biopsies were submitted as formalin-fixed samples to either Antech Diagnostics or the Texas A&M Veterinary Medical Diagnostic Laboratory. Histopathology reports were completed by the attending pathologist at the time of original submission.Data obtained from the medical record included age, sex, breed, clinical history and histologic findings. Surgical reports were evaluated for location of the obstruction and site of gastrointestinal biopsy.Medical records were reviewed by the authors for histopathologic diagnosis, location within the gastro-intestinal tract and location in relation to the obstruction at the time of surgery. Histopathologic diagnosis was based on the predominant cell type. When more than one predominant cell type was noted, all predominant cell types were used to classify the sample. Gastrointestinal biopsy sites included the stomach, duodenum, jejunum and ileum. The location of the biopsy in relation to the obstruction was classified as orad to the obstruction (pre-Trichobezoar or pre-T), at the site of the obstruction (at-Trichobezoar or at-T) and aborad to the site of obstruction (post-Trichobezoar or post-T).Biopsies were categorized by the severity of inflam-mation and presence of mucosal erosion or ulceration as described on the original pathology report, in addition to patient history of acute or chronic gastrointestinal clinical signs before surgery. The severity of inflammation, docu -mented for biopsies that did not have evidence of alimen -tary small cell lymphoma, was categorized as none, mild, moderate or severe. Chronicity of clinical signs was divided into acute (less than 3 weeks) and chronic (greater than 3 weeks) as defined by the American College of Veterinary Internal Medicine (ACVIM) consensus statement.6All statistical analyses were performed using SAS 9.4 (SAS). A significance threshold of 0.05 (P <0.05) was used. Two-sided Wilson confidence intervals were calculated Pawenski et al 3for binomial proportions. An analysis of variance and Tukey-Kramer’s test were used to compare age between biopsy result groups.ResultsAn initial evaluation of medical records identified 667 cats that had undergone gastrotomy or enterotomy for foreign body obstruction between January 2016 and July 2022. Of the initial 667 cats, 44 (6.6%) met the inclusion criteria. The population consisted of 18 (41%) spayed female and 26 (59%) castrated male cats. Eight different breeds were represented in the population (Table 1), including domes-tic longhair (n = 20, 45.5%), Maine Coon (n = 9, 20.5%), domestic shorthair (n = 7, 15.9%) and domestic medium -hair (n = 4, 9.1%). The remaining breeds (Himalayan, Norwegian Forest Cat, Ragdoll, Bobtail) were all repre-sented by one (2.3%) cat.All cats were presented for acute vomiting or wors-ening of chronic vomiting. In total, 20 (45.5%) cats had only acute clinical signs, while 24 (54.5%) cats had chronic clinical signs. Additional presenting complaints included hypo-/anorexia (27/44, 61.4%), lethargy (10/44, 22.7%), acute wheezing/gagging (1/44, 2.3%) and lat-erally recumbent/obtunded (1/44, 2.3%). Chronic clini -cal signs included vomiting (23/24, 95.8%), weight loss (5/24, 20.8%) and previous trichobezoar obstruction (5/24, 20.8%).The mean age of the study cats was 14.2 ± 4.3 years (range 1.0–18.8 years) (Table 2). The mean age in cats with acute clinical signs (n = 20) was 6.4 ± 3.7 years; in cats with chronic clinical signs (n = 24), the mean age was 9.3 ± 4.3 years; and in cats with lymphoma (n = 10), the mean age was 12.5 ± 3.4 years.In total, 1–5 biopsies were collected from the cats in the study, with one (13/44) and three (13/44) biopsies being obtained most commonly (Table 3). In cats with a single biopsy, samples were most often obtained from the site of the obstruction (10/13). From the 44 study cats, a total of 100 biopsies were obtained and subsequently evaluated by various pathologists. The most common histopatho -logic diagnoses were lymphoplasmacytic inflammation (25/100), lymphoplasmacytic/eosinophilic inflammation (25/100) and small cell lymphoma (18/100) (Table 4). Of the 100 samples, eight (8%) were considered non- diagnostic as they did not contain mucosa.Table 1 Reported cat breeds and their distribution based on length of clinical signs and histologic diagnosis of alimentary small cell lymphomaBreed Acute signs Chronic signs Lymphoma TotalDomestic shorthair 2 5 4 7Domestic mediumhair 1 3 1 4Domestic longhair 11 9 5 20Maine Coon 4 5 – 9Ragdoll – 1 – 1Bobtail – 1 – 1Norwegian Forest Cat 1 – – 1Himalayan 1 – – 1Table 2 Age distribution among groups reported in yearsAge parameter Inflammation: acute signs Inflammation: chronic signs Lymphoma AllMean 6.3 9.3 12.5 7.9Range 1.0–9.4 2.0–18.8 7.0–18.8 1.0–18.8Median 8.4 9.6 12.9 8.0Table 3 Number of biopsies taken at the time of surgery per catNumber of biopsies Acute signs Chronic signs Lymphoma TotalOne site 9 3 2 13Two sites 5 5 2 10Three sites 4 9 3 13Four sites 1 7 3 7Five sites 1 – – 14 Journal of Feline Medicine and Surgery and eosinophilic inflammation was the most common finding at the site of obstruction (at-T: 11/41, 26.8%). Of the 17 biopsies with evidence of neutrophilic inflamma -tion, 14 (83.3%) were from at-T.The degree of inflammation was evaluated in 73 biop -sies (excluding non-diagnostic biopsies or those reported as alimentary lymphoma) (Table 6). Among these, 6.85% had no inflammation, 46.6% had mild inflammation, 20.5% had moderate inflammation and 26% had severe inflammation. Of the biopsies, 22 were taken pre-T, 30 were taken at-T and 21 were taken post-T. Mild inflam -mation was noted most commonly in pre-T (10/22) and post-T biopsies (13/21). Conversely, severe inflamma-tion was noted most frequently in at-T biopsies (14/30). Mucosal erosion or ulceration was noted in 14/73 biop -sies, all of which were at the site of the obstruction.For cats with multiple small intestinal biopsies (27/44), histopathology reports were evaluated for consistency between the predominant type of inflammation. In total, 11/27 cats had two small intestinal biopsies with 9/11 (81.8%) demonstrating the same type of inflammation in both biopsies. One cat (9.1%) had a sample with no mucosa, so agreement could not be evaluated.Of the 27 cats, 13 had three intestinal biopsies, with 7/13 (53.8%) demonstrating the same inflammation type within all three biopsies. Of these seven cats, three also had gastric biopsies, all of which showed a predominant inflammation type consistent with that found within the corresponding intestinal biopsies. Three of the 13 cats had one or more samples without mucosa so agreeance could not be evaluated. All of the cats with agreement between all intestinal biopsies (16/44, 36.4%) had a chronic history of gastrointestinal clinical signs.All 10 cats diagnosed with lymphoma were pre-sented with a history of chronic gastrointestinal signs, re- presenting 41.7% of cats with a chronic history. Diagnosis was based on a single small intestinal biopsy in three cats, two biopsies in three cats and three biopsies in four cats. Five cats had agreement between all small intestinal biop-sies, while five cats showed various inflammation in one Table 4 Histopathologic diagnosis distribution based on biopsy locationHistopathologic diagnosis Stomach Duodenum Jejunum Ileum TotalLymphoplasmacytic 6 4 7 8 25Lymphoplasmacytic/neutrophilic – 1 9 1 11Neutrophilic/suppurative – – 4 1 5Lymphoplasmacytic/eosinophilic 3 5 10 7 25Lymph/neutrophilic/eosinophilic – 1 1 – 2Eosinophilic – – – 1 1Small cell lymphoma – 2 7 9 18No mucosa – 4 – 4 8No noted inflammation 4 – 1 – 5Total 13 17 39 31 100Table 5 Histopathologic diagnosis based on predominant cell population in relation to trichobezoar obstruction siteHistopathology Pre-T At-T Post-TLymphoplasmacytic 10 5 10Lymph/neutrophilic 2 9 –Neutrophilic/suppurative – 5 –Lymph/eosinophilic 5 11 9Lymph/neutro/eosinophilic – 1 1Eosinophilic – – 1Small cell lymphoma 2 8 8No mucosa 2 2 4No noted inflammation 5 0 0Total 26 41 33pre-T = pre-Tricobezoar (biopsy orad to the obstruction); at-T = at-Trichobezoar (biopsy at the obstruction); post-T = post-Trichobezoar (biopsy aborad to the obstruction)Table 6 Distribution of severity of inflammation and mucosal damage within biopsy samples in relation to the trichobezoar obstruction site*Degree of inflammation Pre-T At-T Post-T TotalNone 5 0 0 5Mild 10 11 13 34Moderate 5 5 5 15Severe 2 14 3 19Erosion – 8 – 8Ulceration – 6 – 6pre-T = pre-Tricobezoar (biopsy orad to the obstruction); at-T = at-Trichobezoar (biopsy at the obstruction); post-T = post-Trichobezoar (biopsy aborad to the obstruction)*Biopsies carrying a diagnosis of lymphoma and those without mucosa were omittedOf the biopsy locations, 26% were noted to be pre-T, 41% at-T and 33% post-T (Table 5). The most common histopathologic finding orad and aborad to the obstruction was lymphoplasmacytic inflammation (10/26, 38.5% and 10/33, 30.3%, respectively). Mixed lymphoplasmacytic Pawenski et al 5or more sites. In addition, samples from five mesenteric lymph nodes were taken in these cats and lymphoma was identified in two lymph nodes.

Question 107

Griffin - 2023 - JAVMA - Short- and long-term outcomes associated with anal sacculectomy in dogs with massive apocrine gland anal sac adenocarcinoma.pdf

Answer 107

A retrospective multi-institutional study was per -formed. Dogs were included if they had a diagnosis of AGASACA > 5 cm in diameter on CT measurement and underwent anal sacculectomy. Bilateral AGASACA, disease stage, neoadjuvant radiation therapy and/or chemotherapy, and previous anal sac surgery were not considered exclusion criteria, and this information was documented. Recorded preoperative data included signalment, history, clinical signs, physical examination findings, clinical laboratory results, cytology results, diagnostic imaging and staging results, as well as neo -adjuvant treatments administered. Surgical and postop -erative outcomes recorded included intraoperative com -plications, histopathologic results, survival to discharge, postoperative complications that occurred during hos -pitalization and within 30 postoperative days, adjuvant treatments administered, disease progression, date of death or last follow-up, and cause of death. Primary tu -mor dimensions on CT were recorded, and tumor vol -ume was subsequently determined. Complications were listed as grades 1 to 4 in accordance with the Classification for Intraoperative Complications criteria for intraoperative complications and the Accordion cri -teria for postoperative complications.14Continuous variables were assessed for normality with Shapiro-Wilk tests. Summary statistics were reported as median (range) or number (percentage). Wilcoxon rank sum tests and Fisher exact tests were used for between-group comparisons. Progression-free interval (PFI) and overall survival (OS) time were modeled using product limit and Cox proportional hazard methods. Progres -sion-free interval was defined as days elapsed from sur -gery until local recurrence, new lymph node or distant metastasis, or death of any cause. Overall survival time was defined as days elapsed from surgery until death of any cause. Subjects were censored in analyses if alive or lost to follow-up without reaching the given survival end point. Univariable associations were tested, and variables with P < .15 were tested for inclusion in final multivariable models. Variables were retained in multi -variable models if P < .05 or if identified as confounders on the main effects (defined as change in hazard ratio [HR] of at least 15%). All tests were 2-sided, and P < .05 was considered statistically significant.ResultsPreoperative characteristics and stagingTwenty-eight dogs were included with 16 (57.1%) undergoing treatment at the University of California-Davis William R. Pritchard Veterinary Medical Teaching Hospital and 12 (42.9%) at the University of Guelph Ontario Veterinary College Health Sciences Centre. Baseline characteristics and presenting complaints are presented (Table 1) . Demographic No. (percent)Sex Male castrated 22 (78.6) Female spayed 6 (21.4)Breed Mixed breed 12 (42.9) Pure breed 16 (57.1)Age, years 9.9 (2.8–13.1)Weight, kg 29.8 (7.1–46.1)Body condition score (1–9) 5 (3–9)Clinical signs at referral presentation Perianal swelling 16 (57.1) Perianal discomfort 10 (35.7) Ribbon-like stools 9 (32.1) Polydipsia/polyuria 8 (28.6) Tenesmus 5 (17.7) Hyporexia 4 (14.3) Weight loss 4 (14.3) Hind limb gait abnormalities 4 (14.3) Lethargy 3 (10.7) Dyschezia 2 (7.1) Hematochezia 1 (3.6)Largest estimated mass 5.5 (3.2–10.0)dimension on PE, cmOrigin of mass Right anal sac* 18 (64.3) Left anal sac 10 (35.7)*One dog had bilateral anal sac disease, with a massive tu -mor on the right and smaller tumor on the left.Table 1 —Demographic data.Unauthenticated | Downloaded 10/08/23 06:32 AM UTC 3Two dogs had a previous history of anal sac dis -ease (fistula in 1 dog and AGASACA in 1 dog) ap -proximately 1 year prior, and one of these dogs had prior anal sac surgery at that time (excision of the AGASACA). Most (18/28 [64.3%]) dogs were diagnosed with a perianal mass by a refer -ring veterinarian before being treated; 9 were as -ymptomatic when the mass was identified on rou -tine exam. However, 8 of these 9 dogs developed clinical signs by the time they were treated at the referral institution. Among the 10 dogs diagnosed with a perianal mass by the referral institution, 5 had clinical signs and 5 did not. Overall, 14 of 28 (50.0%) dogs had clinical signs when the mass was initially identified by a veterinarian, and 22 of 28 (78.6%) had clinical signs when they were seen by the referral institution. At the time of presenta -tion to the referral hospital, the median duration of clinical signs attributable to AGASACA was 32 days (range, 0 to 281 days).Preoperative bloodwork was available for most dogs and is described (Table 2) . Fifteen (53.6%) dogs were hypercalcemic (defined for the study as ionized calcium > 1.4 mmol/L or total calcium above upper reference limit when ionized calcium was not performed). Preoperative perianal mass cytology was performed in 27 of 28 dogs, and re -sults were reported as AGASACA (n = 23), (adeno)carcinoma (3), and apocrine gland neoplasia (1).All dogs had thoracic and abdominal imaging prior to surgery. Thoracic imaging consisted of radiographs (n = 21), CT (1), or both thoracic radiographs and CT (6); evidence of thoracic metastasis was not identified in any dog. Abdominal imaging consisted of ultrasound and CT in 19 dogs and CT alone in 9 dogs. Massive tu -mors originated from the right and left anal sac in 18 of 28 (64.3%) and 10 of 28 (35.7%) dogs, respectively; 1 dog with a massive right-sided tumor also had a 2-cm-diameter left-sided tumor. On abdominal CT, median (range) tumor measurements in centimeters were 6.3 (5.0 to 10.0) X 5.3 (3.5 to 9.0) X 4.3 (2.8 to 7.7), and the median maximal tumor measurement was 6.4 cm (range, 5 to 10 cm). Median tumor volume measured on CT was 153.7 cm3 (range, 51.8 to 567.0 cm3). Me -dian tumor volume-to-body weight ratio measured on CT was 6.1 cm3/kg (range, 1.5 to 24.4 cm3/kg). CT findings included possible tumor invasion into the rec -tal wall in 15 of 28 (53.6%) dogs and enlarged ( ≥ 1 cm) or abnormal iliosacral lymph nodes in 18 of 28 (64.3%) dogs. Enlarged or abnormal iliosacral lymph nodes in -cluded medial iliac in 12 dogs, internal iliac in 8 dogs, sacral in 10 dogs, and undefined in 3 dogs; 10 dogs had multiple abnormal iliosacral lymph node sites. Enlarged or abnormal lymph nodes were ipsilateral to the mas -sive AGASACA in 6 dogs, contralateral in 1 dog, and bilateral in 5 dogs, and the laterality was not defined in 6 dogs. Two dogs with enlarged iliosacral lymph nodes also had lesions in other abdominal lymph nodes (n = 1) and adjacent vertebrae (1). The remaining 10 dogs were not considered to have lesions overtly suspi -cious for metastatic disease on CT, though metastatic disease could not be ruled out. In most cases lymph nodes were not sampled for cytology prior to surgery; in 4 dogs, cytology was performed and confirmed metastatic disease. Overall, 18 of 28 (64.3%) dogs were considered to have suspicion for metastasis at the time of surgery (all to iliosacral lymph nodes ± vertebrae) and 10 of 28 (35.7%) dogs were considered not to have definitive metastasis.Surgical treatment and complicationsAll dogs underwent closed anal sacculectomy to remove the primary tumor. Two dogs, including 1 with bilateral tumors, underwent bilateral closed anal saccu -lectomy. Rectal perforation was observed during surgery in 3 of 28 (10.7%) dogs. Nineteen (67.9%) dogs also un -derwent iliosacral lymph node extirpation, including 14 dogs with enlarged abnormal lymph nodes on CT, 3 dogs with cytology-confirmed metastatic lymph nodes, and 2 dogs with normal-appearing iliosacral lymph nodes on CT. Among the 9 dogs that did not have lymph node sur -gery, 8 were not considered to have suspicion for metas -tasis and 1 had cytology-confirmed metastatic iliosacral lymph nodes. Overall, 17 of 18 (94.4%) dogs with concern for lymph node metastasis preoperatively underwent Table 2 —Preoperative clinical laboratory results.Select preoperative CBC parameters (n = 25) Median (range)Hematocrit, % 48 (38–70)WBC, X 103/µL 9.8 (5.3–18.4)Neutrophil, X 103/µL 7.3 (3.4–15.4)Band neutrophil, X 103/µL 0.0 (0.0–0.0)Platelet, X 103/µL 300 (136–577)Select preoperative chemistry parameters No. (percent)Albumin (n = 25) Below reference range 2 (8.0) Within reference range 23 (92.0) Above reference range 0 (0.0)BUN (n = 26) Below reference range 0 (0.0) Within reference range 25 (96.2) Above reference range 1 (3.8)Creatinine (n = 26) Below reference range 5 (19.2) Within reference range 20 (76.9) Above reference range 1 (3.9)Total calcium (n = 26) Below reference range 1 (3.9) Within reference range 9 (34.6) Above reference range 16 (61.5)Ionized calcium (n = 22) ≤ 1.4 mm/L 7 (31.8) > 1.4 mmol/L 15 (68.2)Glucose (n = 23) Below reference range 1 (4.4) Within reference range 19 (82.6) Above reference range 3 (13.0)Phosphorus (n = 24) Below reference range 9 (37.5) Within reference range 15 (62.5) Above reference range 0 (0.0)Total protein (n = 24) Below reference range 1 (4.2) Within reference range 19 (79.2) Above reference range 4 (16.7)Unauthenticated | Downloaded 10/08/23 06:32 AM UTC4 lymph node extirpation at the time of anal sacculectomy. Extirpated lymph nodes included medial iliac in 10 dogs, internal iliac in 9 dogs, sacral in 5 dogs, and undefined in 7 dogs; 9 dogs had multiple iliosacral lymph nodes ex -tirpated. Extirpated lymph nodes were ipsilateral to the massive AGASACA in 10 dogs, bilateral in 3 dogs, and the laterality was not defined in 6 dogs. Lymph node ex -tirpation was performed laparoscopically in the 2 dogs with normal-appearing lymph nodes on CT and in 2 dogs with enlarged abnormal lymph nodes; no additional ab -dominal procedures were performed in dogs undergoing laparoscopic lymph node extirpation. Of the 4 dogs that underwent laparoscopic iliosacral lymph node extirpa -tion, all had extirpated medial iliac lymph nodes ipsilat -eral to the massive AGASACA. Both dogs with normal-appearing lymph nodes on CT had nonmetastatic lymph nodes on histologic evaluation; all other dogs that un -derwent lymph node extirpation had evidence of nodal metastasis on histology. Iliosacral lymph node extirpation was performed via open laparotomy in 15 dogs, and of these, 7 dogs had additional procedures: 3 dogs had liver biopsies, 1 dog had a splenectomy and liver lobectomy, 1 dog had a splenectomy alone, 1 dog had liver and omen -tal biopsies, and 1 dog had a prostatic biopsy. One dog had exploratory laparotomy and liver biopsy without ad -ditional abdominal procedures. Two dogs had additional skin masses excised.Overall, 5 dogs experienced intraoperative compli -cations. Four dogs experienced grade 2 complications during anal sacculectomy. These included 3 dogs with rectal perforation requiring surgical closure and 1 dog with hemorrhage necessitating intervention. In addi -tion, 1 dog experienced a grade 2 intraoperative com -plication during iliosacral lymph node extirpation, char -acterized by hemorrhage necessitating intervention. No other intraoperative complications were reported. Median anal sacculectomy surgical time was 105 min -utes (range, 55 to 235 minutes). Median total surgical time including anal sacculectomy plus any other pro -cedures was 198 minutes (range, 70 to 425 minutes).Histopathology was performed on all tumors, but detailed reports were not available for many dogs. Completeness of tumor excision was described in histopathology reports as complete in 2 dogs, incom -plete in 17 dogs, and was not reported in 9 dogs. Vas -cular or lymphatic invasion was described in histopa -thology reports as present in 12 dogs, not present in 7 dogs, and was not reported in 9 dogs. Invasion of tu -mor cells beyond the anal sac capsule was described in histopathology reports as present in 12 dogs, not present in 7 dogs, and was not reported in 9 dogs.Based on the criteria described by Polton and Brear -ley, at the time of surgery 10 (35.7%) dogs had stage 2 dis -ease, 11 (39.3%) dogs had stage 3a disease, and 7 (25.0%) dogs had stage 3b disease.1 Hypercalcemia occurred in 6 of 10 (60.0%) dogs with stage 2 disease, 6 of 11 (54.5%) dogs with stage 3a disease, and 3 of 7 (42.9%) dogs with stage 3b disease, which did not differ significantly ( P > .89). Neither tumor size ( P = .38) nor left/right side ( P = .63) was associated with intraoperative complications.Dogs were treated and monitored variably in the postoperative period, with 13 dogs receiving postop -erative antibiotic prophylaxis. The median duration of postsurgical hospitalization was 2 days (range, 1 to 5 days). Five dogs experienced postoperative compli -cations during the hospitalization period. Four dogs experienced grade 1 complications, as follows: 1 dog had grade 1 regurgitation and grade 1 fecal incon -tinence, 1 dog had grade 1 fecal incontinence and grade 1 tenesmus, 1 dog had grade 1 inappetence, and 1 dog experienced a grade 1 complication of hy -pocalcemia requiring pharmacologic correction. One dog experienced a grade 4 complication of acute re -spiratory distress resulting in death. All other dogs (27/28 [96.4%]) were discharged from the hospital.Follow-up of at least 10 days was obtained in all dogs, at least 30 days in 24 dogs, and at least 90 days in 22 dogs. The median duration of follow-up for all discharged dogs was 225 days (range, 10 to 1,400 days). Postoperative complications were re -ported within 30 days of hospital discharge in 7 of 27 (25.9%) dogs. Grade 1 complications were reported in 4 dogs, consisting of self-limiting fecal inconti -nence in 2 dogs; diarrhea, hematochezia, vomiting, and tenesmus in 1 dog (this dog also had intraopera -tive rectal perforation); and minor wound dehiscence in 1 dog (this dog also had intraoperative rectal per -foration). Grade 2 postoperative complications were reported in 2 dogs, consisting of a urinary tract in -fection in 1 dog and superficial surgical site infection in 1 dog. A grade 3 postoperative complication oc -curred in 1 dog 10 days postoperatively, consisting of deep surgical site infection and rectocutaneous fistula associated with dehiscence of the surgically repaired rectal wall; this dog also experienced fecal incontinence and regurgitation during hospitaliza -tion. The owner of this dog declined further treat -ment and the dog was lost to follow-up immediately following diagnosis of the complication.Overall, 10 dogs (35.7%) experienced a post -operative complication in hospital or up to 30 days postoperatively; 2 of these dogs had different com -plications within each postoperative period (during hospitalization and after discharge within 30 days postoperatively). No dog in the study had long-term fecal incontinence, tenesmus, or anal stenosis.Adjuvant therapyFollowing surgery, 19 dogs received adjuvant ther -apy, including 15 dogs that received chemotherapy, 1 dog that received radiation therapy, and 3 dogs that received both chemotherapy and radiation therapy. Nine dogs were treated with carboplatin for a median of 5 doses (range, 2 to 7 doses); 6 dogs were treated with mitoxantrone for a median of 3 doses (range, 1 to 6 doses); 1 dog was treated sequentially with mi -toxantrone, carboplatin, gemcitabine, toceranib, mel -phalan, and meloxicam; 1 dog was treated sequentially with mitoxantrone, carboplatin, and toceranib; and 1 dog was treated with toceranib. Three dogs underwent postoperative radiation therapy of the anal sac surgical site following surgery at doses of 16 X 3 Gy, 4 X 6 Gy, and 4 X 2.4 Gy. One dog had local tumor recurrence ap -proximately 60 days postoperatively and was treated with surgery followed by radiation therapy (8 X 3 Gy) to the anal sac tumor site.Unauthenticated | Downloaded 10/08/23 06:32 AM UTC 5Follow-up, disease progression, and survival outcomesAt the time of data collection, 18 dogs were lost to follow-up, including 10 dogs following document -ed disease progression, and 10 dogs had died. The median duration from anal sacculectomy to death or loss to follow-up was 222 days (range, 1 to 1,400 days). Dogs that did not receive any adjuvant ther -apy were lost to follow-up significantly sooner than dogs that did receive adjuvant therapy (median, 30 days vs 473 days; P = .013).Disease progression was evaluated in 27 dogs that survived hospital discharge. Local tumor recur -rence was reported in 10 of 27 (37.0%) dogs at a me -dian of 319 days (range, 36 to 1,100 days) postopera -tively and was not associated with disease stage at the time of surgery ( P = .27). The overall incidence of new/recurrent lymph node metastasis postoperative -ly was 10 of 27 (37.0%). New/recurrent lymph node metastasis occurred in 10 of 17 (58.8%) dogs with lymph node metastasis at the time of anal sac surgery and 0 of 10 (0.0%) dogs without lymph node metasta -sis at the time of anal sac surgery; this difference was significant ( P = .003). The median time to new/recur -rent lymph node metastasis was 183.5 days (range, 36 to 651 days) postoperatively. Seven of 27 (25.9%) dogs developed lesions that were categorized as pos -sible distant metastasis; all 7 dogs also had lymph node metastasis at the time of surgery. Distant meta -static lesions occurred in 7 of 17 (41.2%) dogs with lymph node metastasis at the time of surgery and 0 of 10 (0.0%) dogs without lymph node metastasis at the time of surgery; this difference was statistically signif -icant ( P = .026). These included 1 dog that developed an AGASACA in the contralateral anal sac, 4 dogs that developed multifocal pulmonary nodules consistent with metastasis, 1 dog that developed a cranial me -diastinal mass and subsequently pulmonary nodules, and 1 dog that developed undefined distant meta -static disease identified via abdominal ultrasound. In 2 cases, metastatic AGASACA was confirmed via his -topathology (anal sac mass in 1 dog and pulmonary metastases confirmed via necropsy in 1 dog), where -as tissue diagnosis was not obtained in the other 5 dogs such that distant metastatic AGASACA was not definitively determined.Nine dogs experienced > 1 type of disease pro -gression. Four dogs developed local recurrence, new lymph node metastasis, and distant metastasis; 3 dogs developed local recurrence and new lymph node metastasis; and 2 dogs developed new lymph node metastasis and new distant metastasis.Overall PFI was 204 days (95% CI, 145 to 392). Adjusting for sex, lymph node metastasis at the time of surgery was the only factor significantly associ -ated with PFI on multivariable analysis. Dogs with lymph node metastasis had a 12.6 times greater haz -ard of disease progression compared to dogs with -out lymph node metastasis at the time of surgery (HR, 12.60; 95% CI, 1.56 to 101.56; P = .017). Age, body weight, hypercalcemia, largest mass dimension on CT, adjuvant chemotherapy, and adjuvant radia -tion therapy were not associated with PFI nor identi -fied as confounders on the main effects (Table 3) .Table 3 —Statistical analysis findings of factors evaluated for association with progression-free interval. Univariable MultivariableVariable HR 95% CI P value HR 95% CI P valueAge, y 1.22 0.91–1.66 .18 — — —Body weight, kg 1.02 0.97–1.06 .47 — — —Male sex 12.06 1.54–94.71 .018 7.63 0.89–65.42 .06Hypercalcemia 0.85 0.33–2.18 .74 — — —Largest mass dimension, cm 1.18 0.86–1.62 .31 — — —Lymph node metastasis at surgery 20.80 2.56–168.88 .005 12.60 1.56–101.56 .017*Adjuvant chemotherapy 0.76 0.26–2.21 .62 — — —Adjuvant radiation therapy 1.32 0.43–4.04 .63 — — —*Statistically significant result.HR = Hazard ratio.Table 4 —Statistical analysis findings of factors evaluated for association with overall survival. UnivariableVariable HR 95% CI P valueAge, y 1.04 0.78–1.39 .77Body weight, kg 1.00 0.95–1.07 .89Male sex 4.18 0.53–32.99 .18Hypercalcemia 0.84 0.25–2.77 .77Largest mass dimension, cm 1.24 0.88–1.74 .22Lymph node metastasis at surgery 2.15 0.57–8.04 .2630-day postoperative complication 0.36 0.08–1.68 .19Adjuvant chemotherapy 0.35 0.09–1.32 .12Adjuvant radiation therapy 0.80 0.17–3.73 .77Local recurrence 0.36 0.10–1.29 .12Metastatic progression 1.01 0.31–3.36 .98See Table 3 for key.Unauthenticated | Downloaded 10/08/23 06:32 AM UTC6 Overall survival time was 671 days (95% CI, 225 to upper limit not reached). Age, body weight, sex, hypercalcemia, largest mass dimension on CT, lymph node metastasis, 30-day postoperative complica -tion occurrence, adjuvant chemotherapy, adjuvant radiation therapy, local recurrence, and metastatic progression were not associated with OS (Table 4) . Due to incomplete data in histopathology reports, histologic criteria (such as completeness of excision, lymphovascular invasion, and mitotic index) could not be modeled for disease outcomes.

Question 108

Vandekerckhove - 2024 - VCOT - Quantifying the Stress in Stress Radiographs to Determine Sufficient Laxity of the Coxofemoral Joint - A Canine Hip Dysplasia Cadaveric Study.pdf

Answer 108

Power CalculationAs it was uncertain whether body weight would play a roleand to allow an evaluation throughout a wide-body weightrange, it was important that suf ficient cadavers of variousbody weights were randomly selected. Based on a powercalculation, a minimum of 10 canine cadavers per weightgroup was necessary to ensure a power of at least 80%(α¼0.05, effect size ¼1, paired t-test). The goal was tosample at least 10 cadavers from each of the following threeweight groups: between 10 and 20 kg (group 1), between 20and 30 kg (group 2), and greater than 30 kg (group 3). Thiswas successful as the sample sizes per weight category were11, 11, and 12 cadavers in groups 1, 2 and 3, respectively. Thedivision into categories was purely to ensure suf ficientrepresentation across the various body weights. DuringFig. 1 Comparison between ( A) the orthogonal radiographic view(craniocaudal projection) with barium markings and ( B)as c h e m a t i coverview of the forces during stress radiography with the VMBDmDdepicted on a three-dimensional (3D) surface rendering of a caninepelvic computed tomography (CT) scan in cranial view. Position ofthe VMBDmD ( black arrowheads inA), coxofemoral joint ( black star inA), and examiner ’sh a n d( white asterisk inA). F CFJ,f o r c ea tt h el e v e lo fthe coxofemoral joint; F VMBDmD , force at the level of the Vezzonimodi fied Badertscher distension measuring device; F H,f o r c ea tt h elevel of the examiner ’sh a n d ;D CFJ-VMBDmD , distance between thecoxofemoral joint and the VMBDmD; D H-VMBDmD ’þDH-VMBDmD ’’¼DH-VMBDmD , distance between the examiner ’sh a n da n dt h eV M B D m D .Note: The distance measurements were made on the mediolateralview as the natural flexion of the sti fle causes too much distortion andmagni fication on the craniocaudal view, resulting in under- oroverestimation of the measurements..statistical analysis, the actual body weight was taken intoaccount and not the weight group.Cadaver SelectionThe cadavers were collected with a cause of death unrelatedto this study. Thus, an approval of the ethical committee wasunnecessary. Breed was not considered when cadavers wereselected. The cadavers were refrigerated at least 2 weeks andthawed at room temperature for 3 days to avoid rigor mortisduring radiography (personal experience).Acquisition of RadiographsFor each cadaver, an SVD projection, multiple stress radio-graphs, and a mediolateral barium-marked radiograph weretaken. The SVD projection was made to evaluate the pres-ence of osteoarthritis. Consecutive stress radiographs weremade with incrementing force to allow an evaluation be-tween force and laxity. Various LI results were obtained foreach cadaver. The highest LI, which is normally the valueused for reporting, is called the LImaxthroughout this articleand the other values are expressed as a proportion to thatvalue as LI%.The stress radiographs of the coxofemoral joints them-selves were obtained as described by Vezzoni and col-leagues.5The cadavers were positioned in a trough indorsal recumbency and the distension device/measuringdevice was placed in between the hindlimbs at the level ofthe pubic area. The femurs were positioned symmetricallyand in a 10-degree extension. The goal was to obtain agradual increase of around 10 N with each radiograph, untila force of 100 N was reached. At this point, it was evaluated asto whether maximum displacement had been reached. Themaximum displacement was deemed to be found when theobserved displacement did not increase visually any furtherfor two consecutive radiographs even though the force wasincreased. If this was not reached at 100 N, the force wasincreased by 10 N until maximum displacement. One finalradiograph with maximal force of the examiner was per-formed. After each radiograph, the quality was assessed,based on the criteria described by Bertal and colleagues.9If the quality was considered inferior, a retake was per-formed at a comparable force.After the stress radiographs, barium contrast medium wasapplied on the skin of the cadaver at the level of the VMBDmDand at the level of the hand of the examiner to obtainmediolateral barium-marked radiographs. From these bari-um-marked radiograph measurements were obtained thedistance between the coxofemoral joint and the VMBDmD(DCFJ-VMBDmD ) and the distance between the hand of theradiologist and the VMBDmD (D H-VMBDmD ;s e e►Fig. 1 ).These barium-marked radiographs were made to assessthe potential in fluence of the position of the device on theforce needed to quantify laxity (see ►Fig. 1 ).Assessing the Effect of Repeated Stress CyclesThe cadavers of three dogs, one from each body weightgroup, underwent the previously described radiographicprocedure five times consecutively. Each time, the dogswere repositioned on the radiography table, to mimic thevariability associated with performing the procedure entire-ly anew. This was performed in only three dogs to meet theALARA (as low as reasonably achievable) radioprotectionsafety principle for the examiner.MeasurementsAll LI measurements were performed following the measure-ment protocol previously described.12Briefly, the distancebetween the center of the circle delineating the femoral headand the center of the circle delineating the femoral head isdivided by the radius of the circle delineating the femoralhead. Image analysis software (Digimizer, MedCalc Software,Ostend, Belgium) was used. In a previous study, the accuracy ofthe LI measurements was determined by the first author(Vandekerckhove et al. 2023).11The distance measurementswereperformedwith DICOM reading software (OsiriX, Bernex,Switzerland), as previously described.Osteoarthritis ScoreTo classify the degenerative changes of the coxofemoral jointof each dog, a subjective, binary osteoarthritis score wasgiven. This was done individually and blinded by L.V. and B.B.Cases for which there was no consensus (i.e., the results didnot match between observers) were discussed together untilconsensus was reached.Statistical AnalysisAll analyses were done in R version 4.1.0. Two analyses wheremade: one using the maximum LI (LImaxobtained per animal,resulting in one value per animal as the laxity measurementsare generally used, and one using all LIs. While the formerallowed an evaluation of differences associated with theLImaxper cadaver, the latter allowed an evaluation of differ-ences throughout the entire force range and was expressed asa ratio (LI%) relative to the LI maxof each joint. Throughout allanalyses, the signi ficance threshold was set at /C200.05 and aBonferroni correction was applied to correct for multipletesting when appropriate.For the highest LI (i.e., the LI max), simple linear modelswere used to identify associations. For the LI, to compare thecurves, the LI was expressed proportionally to the LI maxofthat hip, resulting in a variable detailing how much of themaximum laxity was seen, that is, the LI%. A linear mixedmodel with a cadaver and left or right side of the cadaver asrandom effect was used in a forward selection procedure toidentify variables associated with the proportion of the LImaxvisualized.For the subset of dogs in which the procedure wasrepeated, the effect of each session on the LI maxand theforce at the LI maxwere evaluated using a mixed model withdog as random effect and session as fixed effect. To evaluatethe effect of session on the curve, first the same modelbuilding procedure as detailed earlier was used. The finalmodel allowed an evaluation of the effect of session, whilethe residual variance was a point estimate for the repeat-ability of the procedure together with the measurementvariability. Throughout the entire procedure, likelihood ratio.tests were used to evaluate the signi ficance of fixed effects inthe mixed models.ResultsGeneralA total of 563 stress radiographs were analyzed from 34cadavers. The median body weight was 25 kg (range: 10 –68 kg), while the median age was 12 years (range: 10months –16 years). Fourteen dogs were males and 20 werefemales. Seventeen dogs had osteoarthritis, while the othersdid not.Factors Associated with LI maxThe LI max(which represents the LI as it is traditionally used)ranged from 0.25 to 0.77 (median: 0.53). The forces necessaryto obtain the LI maxranged from 59 to 196 N (median: 112 N).Six variables were assessed to determine their in fluence onthe LI max. The coef ficient reported for each comparisonquanti fies the difference in LI maxand can thus range between0.00 and 1.00 in absolute values. There was no signi ficantassociation between the LI maxand the force needed to obtainthis LI max(coefficient<0.01, p¼1). Furthermore, neither theposition of the device, measured by the D H-VMBDmD /DVMBDmD-CFJratio (median value ¼2.54; range: 1.48 –5.22; coef ficient¼0.01; p-value ¼1), nor side (left/right), in terms of thefrequency on which side the LI maxwas measured (out of34 cadavers, the LI maxwas found 17 times on the right jointand 17 times on the left joint), gender (coef ficient¼0.03, p-value¼0.48), or body weight (coef ficient<0.01, p-value¼0.11), in fluenced the LI max. Finally, there was no signi ficantdifference in LI maxbetween joints with or without osteoar-thritis (coef ficient¼0.02, p-value ¼1).Factors Associated with the LI%The force –laxity relation between F VMBDmD and LI% isdepicted graphically in ►Fig. 2 . For the next comparisons,the coef ficients express the proportionate difference in LI,that is, difference in LI relative to the LI max.I nt h e finalmodel, the LI% was signi ficantly associated with force(coefficient¼0.78, p-value <0.001), quadratic force(coefficient¼–0.002; p-value <0.001), and the D H-VMBDmD /DCFJ-VMBDmD ratio (coef ficient¼–3.43; p-value ¼0.02).The presence of osteoarthritis (coef ficient¼2.81, p-value¼0.30), weight (coef ficient¼0.14, p-value ¼0.13),gender (coef ficient¼–0.89, p-value ¼0.74), and side(coefficient¼–1.98, p-value ¼0.17) were not signi ficant(as depicted graphically in ►Fig. 3B –D).Repeated Stress Cycles: Assessing whether There Is anEffect on the LI maxand the Laxity –force RelationFor three dogs, the procedure was repeated in five sessions,resulting in a mean total of 58 radiographs per dog. The LI maxdid not differ signi ficantly between the various sessions(coefficients <0.01, p-value ¼0.78). Furthermore, the LI maxwas reached at similar forces (coef ficient¼2.31, p-value¼0.31). The variability in the LI max(expressed as the stan-dard deviation of the residual variability of the random effectin the mixed model) was 0.03.The shape of the curves did not vary signi ficantly through-out the sessions (coef ficient¼0.6006, p-value ¼0.08) and thevariabilityof the LI%, expressed as thestandard deviation of theresidual variance of the mixed model, was 9% (see ►Fig. 3E ).Force Necessary to Obtain Adequate SubluxationNinety percent of the hips reach suf ficient laxity, de fined asat least 90% of the LI max, at 95.32 N (see ►Fig. 2 ).Fig. 2 Curve depicting the relation between the executed for ce (FVMBDmD) and the LI%. Two phases can be seen; the first phase is characterizedby a steep increase of the laxity until the laxity reaches a maximum and forms a plateau (second phase). The vertical line is representing a force of95.32 N at which at least 90% of the LI max(horizontal line ) is reached in 90% of the dogs. LI, laxity index; LI max, maximal LI..

Question 109

Feng - 2023 - JAVMA - Conventionally fractionated radiation therapy is associated with long-term survival in dogs with infiltrative lipomas.pdf

Answer 109

This retrospective study was performed at the University of California, Davis Veterinary Medical Teaching Hospital , using cases from January 2000 through December 2020. Animals were cared for in accordance with hospital policies. Due to the ret -rospective nature of this study, informed consent was not obtained. Electronic medical records were searched for dogs having received CFRT for an im -aging-diagnosed (via radiologist report on CT of in -filtrated connective tissue) or pathology-diagnosed lipoma infiltrating into connective tissue and were retrospectively identified by a radiation oncologist.Patient demographics, including age, weight, sex, and breed were recorded. By convention, pa -tients with a birth year, but no date, are given a January 1 birthdate. Diagnostic results (bloodwork, thoracic radiographs, abdominal ultrasound, biopsy reports, and CT imaging), clinical signs at diagno -sis, surgery performed, radiotherapy parameters, follow-up visit information, and survival times were recorded. Reported side effect data were collected, although Veterinary Radiation Therapy Oncology Group scoring was not institutionally in place for most cases. For patients without survival data in their medical records, local veterinarians and owners were contacted for date and cause of death.Radiotherapy was either manually calculated at the first treatment, or was CT-planned (CT/9800, HiSpeed, or Lightspeed 16; General Electric). For CT-planned cases, images were imported into the treat -ment planning system (TPS; Eclipse version 8-15; Var -ian Medical Systems). Relevant target volumes were contoured, including the post-operative clinical target volume (CTV) which included regions of suspected mi -croscopic involvement, planning target volume (PTV) which accounts for uncertainties in patient positioning and delivery, and organs at risk (OARs) for the treat -ment region based on clinician recommendations.3-D Conformal calculations were performed with Pencil Beam Convolution (PBC 7518 or 8118) or AAA_11031. Optimization for intensity modulated radiotherapy (IMRT) was DVO_8117 or DVO_11031, and for volumetric arc radiotherapy (VMAT) was PO_15604. Electron plans were either created manu -ally with custom cut-outs or using the TPS to assess PTV isodose-line coverage, optimize beam energy, and create a cut-out. Monitor unit calculations along the central axis were done for all electron cases. TPS-generated photon plans were evaluated based on PTV dose-volume histogram coverage and dose to OARs. When possible, 95% of the PTV was covered by prescription dose, and standardized OAR con -straints/tolerances were not in place.All inverse plans (IMRT and VMAT) were assessed by film and chamber dose measurement as previously described,17 or with a QA system (Mapcheck or Map -Phan; Sun Nuclear Corporation) using standard quality assurance techniques.17 For 3-D conformal or manually-calculated cases, a second manual check was performed by the attending physicist per institution convention.Any treatment technique was permitted: man -ual calculations (parallel-opposed photons, hand-designed en-face electron fields, TPS-designed en-face electron fields), 3-D conformal 2-field parallel-opposed photons, IMRT, and VMAT. All treatments were delivered with 6 or 10 MV photon or 6-16 MeV electron beams using a linear accelerator (Clinac 2100 or TrueBeam; Varian Medical Systems) with an 80-leaf (10 mm) or high-definition (central -ly 2.5 mm) multi-leaf collimator. For TPS-planned photon cases, daily MV-orthogonal images were ac -quired for Clinac, or CBCT scans were acquired daily and matched to the digitally reconstructed reference (DRR) or CT-simulation images for TrueBeam. Pre-delivery couch adjustments were performed as pre -viously described.18 For manually calculated photon plans, ports were imaged weekly per institution con -vention. For electron plans, visual position confirma -tion using skin markings was performed.Recheck visits were recommended 2 to 3 weeks post-radiation, then at 8 to 12 weeks for pneumoni -tis assessment if relevant, and thereafter every 3-6 months. Data from recheck examinations were col -lected, including acute effects (defined as within 3 months post-radiation), late effects (symptomatic or asymptomatic), and survival.Statistical analysisAll graphs and statistical analyses were made using software (STATA 14.2; Stata Corporation; and Microsoft Excel 2008 for Mac version 12.1; Micro -soft Corp). Due to the small sample size, nonpara -metric tests were used for continuous variables, and descriptive statistics are reported as medians/ranges. The Kaplan-Meier method was used to es -timate median overall survival times (OS). Survival time was defined as between the last treatment day and death, or date of last contact. All deaths were considered events and dogs lost to follow-up or alive at the time of analysis were scored as censored. Sex was evaluated as categorical values for survival, and to identify differences in estimated survival times, a log rank test was used. To identify differences in sur -vival times for continuous variables, a Cox regression with a Breslow method for ties was done. Due to the small sample size, only univariate testing was done. Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 11/03/23 06:54 AM UTC 3A P value < .05 was considered statistically signifi -cant. EQD2 values were retrospectively calculated for the delivered protocols.ResultsTwenty-four dogs met the inclusion criteria. The breeds represented were mixed-breed (8), Labrador Retriever (3), Golden Retriever (2), Australian Cattle Dog (2), Pomeranian (2), German Shepherd Dog (1), Rhodesian Ridgeback (1), Border Collie (1), Stan -dard Poodle (1), Boxer (1), Pug (1), and Yorkshire Terrier (1). There were 13 spayed females and 11 neutered males. The median age at treatment was 6.2 years (range, 2.2 to 14.2 years), and the median weight was 27.7 kg (range, 3.6 to 50.0 kg). All dogs had an infiltrative lipoma causing body asymmetry, and 2 cases also reported lameness at diagnosis. All tumors were surgically described as infiltrative, and diagnosis was based on a combination of CT-imaging characteristics (21) and/or pathologically confirmed normal fat invading into connective tissue (20). No tumors were described as intermuscular lipomas. Tumors were located into 3 regions: head/neck (4), trunk (13), and limbs (7).Bloodwork was available from the time of sur -gery or when starting radiotherapy for all cases, and values were unremarkable for 19/24 dogs. Two cases presented with mild lymphopenia 946 and 950 (1000-4000/mcL). There were single cases having each of the following mild changes: throm -bocytopenia 139K (150-400 103/mcL), elevated ALT 80 (21-72 IU/L), elevated GGT 6 (0-5 IU/L), elevated ALP 267 (14-91 IU/L), total bilirubinemia 0.3 (<0.2 mg/dL), and decreased bicarbonate 19 (20-29 mEq/L). Pre-surgical thoracic radiographs were available in 5/24 dogs and were unremark -able except for osteoarthrosis (2), and 1 dog had a rounded soft tissue opacity in the cranial retro -peritoneal space (further diagnostics were declined before surgery, but the dog was later found to have an adrenal mass). An unremarkable abdominal ul -trasound was recorded in 1 dog.All patients had at least 1 surgery (median: 2 surgeries, range: 1-3), and 16/24 had gross dis -ease at treatment, while 8/24 had microscopic dis -ease. The median time between the most recent surgery and radiotherapy was 45 days (range, 16 to 505 days). Prior to radiotherapy, 21/24 cases had a planning CT scan. Patients were positioned based on their tumor location, most commonly in a vacuum-lock bag (SecureVac; Bionix Development Corp) although data were incomplete on devices. Head and neck cases (4/24) were placed in ster -nal recumbency.19 Non-contrast and contrast-en -hanced series with 1.3- to 2.5-mm collimation were acquired for most cases, with larger 5- to 10-mm slices for CT/9800. Three dogs had manual calcula -tions (without CT scan) for planning (2 photon and 1 electron plans).Dogs were evenly split between Clinac 2100 (12) and TrueBeam (12). Treatment techniques were as follows: inverse-planning (IMRT [9] and VMAT [3]), manually calculated (en-face electron field [5], TPS-designed en-face electron field [3], parallel-opposed photons [2]), and 3-D conformal photon plans (2). Tissue heterogeneity correction was used for 14/17 TPS-planned cases to account for radiation deposi -tion in varying-density tissues, with the remaining 3/17 being PBC 7518 or manual calculations with -out correction. A calculation grid size of 2.5 mm was used for 14 TPS cases, and grid size was otherwise not available.Target contouring was based on clinician recom -mendation, and standard contouring protocols were not in place. For TPS-assisted cases (17/24), the gross tumor volume was contoured separately in 4 dogs (range, 44.6 to 983 cm3), but was more com -monly incorporated directly into the CTV (median CTV = 405.2 cm3; range, 46.30 to 1,910.1 cm3). CTV contouring varied, but included all grossly abnormal fat, contrast-enhancing post-surgical regions and hemoclips, and variable CTV expansions into nor -mal tissues of approximately 3 to 30 mm. The CTV did not enter the thoracic or abdominal cavity when adjacent, nor did it enter normal bone or adjacent normal luminal structures. PTV was contoured for all TPS cases as a 3- to 5-mm isometric expansion around the CTV (Figure 1) . For 2 dogs, the PTV was cropped from a 2- to 3-mm skin contour to preserve lymphatic function.20,21 A summary of TPS-planned PTV volumes for 17 cases is shown (Table 1) , and the median PTV = 503.7 cm3 (range, 31.9 to 2,070.8 cm3). OARs were contoured based on tumor location in the following frequency: spinal cord (11), trachea (8), lung (7, variably contoured as both lungs or ipsi -lateral lung), heart (6), bladder (4), colon (4), rectum (4), urethra (2), esophagus (2), eyes (1), liver (1).For manually planned cases, which were either limb tumors (2 photon plans) or flat regions ame -nable to simple electron planning (5 plans), and the PTV by convention included a 3- to 4-cm expansion around the scar, tumor bed, and any gross disease, while ensuring a minimum of 5- to 10-mm skin spar -ing for limbs to preserve lymphatic function. The decision for manual versus TPS plans was primarily based on anatomic location.Prescriptions ranged from 45 to 51 Gy total dose given in 15 to 20 fractions of 2.4-3 Gy. Radiotherapy protocols with EQD2 values are shown (Table 2) . The prescription dose covered 95% of the PTV for 11/14 TPS-planned photon cases. Prescription percent isodose lines were available for 5/8 electron cases, which ranged from 80% to 90% as is standard at this institution. Photon manual calculations were pre -scribed to midline. Normalization values could not be confirmed for the remaining 3 cases.Electron plans used single, en-face, 6-16 MeV beams (6 MeV [2], 9 MeV [1], 12 MeV [2], 16 MeV [3]), and custom cut-out blocks designed for 6- to 25-cm applicator diameters. In 1 anus-adjacent elec -tron case, a cylindrical Cerrobend block encased in a syringe cap then dipped in latex was used to push the contralateral rectal wall from the field. For the eye-adjacent electron plan, a tungsten eye-shield (2.5% to 5% transmission to lens in humans; Radiation Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 11/03/23 06:54 AM UTC4 Products Design) was placed under the dorsal eyelid to reduce dose. Dose adjustments for internal shield -ing were not performed.A single manually calculated photon case uti -lized a half-beam secondary-jaw block to spare skin. Multi-leaf collimator and wedges (15 to 30 degrees) were used for parallel-opposed TPS plans. IMRT cas -es had 5 to 8 fields, and 2 plans had carriage shifts. All VMAT plans utilized a single isocenter with 2 arcs. Bolus (0.5 to 1 cm) was used in 18/24 plans, and 2/24 did not have data reported on bolus use.The median dose to all PTVs was 50.4 Gy (range, 32.2 to 53.3 Gy), and an isodose color wash and dose-volume histogram are shown (Figure 1). Dose summaries for the PTVs22, and spinal cord and tra -chea dose (the most commonly contoured OARs) are provided (Tables 1 and 3). The contoured cord (n = 11) had maximum doses ranging from 0.6 to 44.8 Gy, with the maximum dose per fraction = 2.6 Gy (protocol, 3 Gy X 17). The trachea (n = 8) had Figure 1 —Representative planning for an infiltrative lipoma radiation case. Twenty-four dogs were treated with radiotherapy for infiltrating lipomas. A—Axial CT image of the pelvis showing gross disease (white arrow) and a post-surgical hemoclip (black arrow). B—Contours for the planning target volume (PTV) expansion (red) and dose color wash for a 50 Gray (Gy) prescription intensity-modulated radiotherapy (IMRT) plan, with 25-Gy isodose region in blue and dose gradient increasing to dose > 50 (Gy) shown in red. C—Dose-volume histogram demonstrating the dose to targets and organs at risk: PTV (red), urethra (green), and rectum (magenta). CTV (cc) PTV (cc) A) n = 15 n = 17Mean 675.2 796.2Median 405.2 503.7Range 46.3–1,910.1 31.9–2,070.8 PTV dose n = 14 Overall Overall Overall B) mean (Gy) median (Gy) range (Gy)Min* 45.3 45.6 0.0–48.9Max† 52.8 53.1 44.9–62.0Mean§ 50.1 50.2 31.5–53.9Median¶ 50.2 50.4 32.3–53.3*Min = Minimum dose to PTV. †Max = Maximum dose to PTV. §Mean = Mean dose to PTV. ¶Median = Median dose to PTV. CTV = Clinical target volume. PTV = Planning target volume.Table 1 —A) Mean, median, and range for clinical or planning target volumes in cm3 (cc). B) Dose character -istics for planning target volumes in gray (Gy).Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 11/03/23 06:54 AM UTC 5maximum doses ranging from 15.2 to 53.6 Gy, with maximum dose per fraction = 3.2 Gy (protocol, 3 Gy X 16). Lung doses (n = 7) must be interpreted care -fully with 2/7 dogs having only the ipsilateral lung contoured; however, the median total lung dose was 6.3 Gy, the mean was 13.0 Gy, and maximum point doses ranging from 40.4 to 53.9 Gy. The maximum heart dose (n = 6) had a median of 38.5 Gy (range, 22 to 50.2 Gy), and the median heart dose was 6.6 Gy with a mean of 7.9 Gy. Pelvic structures (rectum [n = 4], colon [4], bladder [4], and urethra [2]) all re -ceived less than 2.8 Gy/fraction consistent with the institutional goal of < 3 Gy/fraction for pelvic struc -tures.23 Other normal structures were only contoured in individual dogs.Patients were induced most commonly with pro -pofol (Propoflo; Zoetis) and maintained with isoflu -rane (Aerrane; Baxter), although records were not complete. Prednisone 0.5 mg/kg by mouth daily was prescribed halfway through treatment in 22/24 dogs with the aim to reduce acute radiation-related inflam -mation, 1 dog was continued on carprofen (Zoetis), and 1 did not have medications reported in the medi -cal record. Per previous convention with the aim to reduce secondary infections, Cefpodoxime (Zoetis) was prescribed in 18/24 dogs halfway through treat -ment, 4/24 were given amoxicillin trihydrate/clavula -nate potassium (Zoetis), and 2 dogs did not have any antibiotic reported. For pain medication, 6/24 were prescribed tramadol, 3/24 were prescribed gabapen -tin, and 1 dog was also prescribed amantadine.Protocol deviations included bolus not used for 4/16 fractions in one dog (with clinical assessment of appropriate skin dose by the clinician), and a 1-day treatment delay due to machine malfunction in anoth -er. Two dogs had no side effect information reported in the record, and many records were incomplete such that Veterinary Radiation Therapy Oncology Group grading could not be retrospectively applied. However, acute side effects reported in the first 3 months after CFRT were as follows: skin effects including alopecia, moist or dry desquamation (17), transient cough (2), diarrhea (1), esophagitis (1), and conjunctivitis (1). Pneumonitis, an acute-delayed effect, was noted but subclinical in 3 dogs (1 manually designed electron plan, and 2 TPS-planned cases with maximum point lung doses of 50.8 to 53.9 Gy). Late effects were also reported in some dogs: thickened and/or hyperpig -mented or alopecic skin (5), chronic joint stiffness re -ferable to the RT site (2), corneal fibrosis due to either radiation or incomplete blink (1), chronic nasal dis -charge (1), and intermittent muscle fasciculations of muscle at the CFRT site (1).The estimated median overall survival (OS) after completing radiotherapy was 4.8 years (1,760 days; 95% CI, 1,215 to 2,777 days; range, 23 to 3,499 days) for any cause of death, although no euthanasia/deaths were reported due to lipoma (Figure 2) . Eight dogs were censored, with 3/8 lost to follow-up at 62, 63, and 1,119 days (median follow-up, 63 days), and 5/8 still alive at analysis (median follow-up, 1,216 days; range, 741 to 1,870 days). For living dogs, 1/5 had static tumor size reported at their most re -cent encounter, 1/5 had progressive disease at 923 days post-CFRT, and 3/5 had incomplete records or masses that cannot be assessed without imaging. All dogs lost to follow-up (3) had gross disease at treat -ment. No significant difference in survival was found between gross and microscopic disease (gross OS, 4.8 years [1,760 days] vs microscopic OS, 3.6 years [1,322 days]; P = .45; Figure 3 ). Only 3 dogs had a delay > 2 months between surgery and radiotherapy; Table 2 —Radiation protocols and equivalent dose in 2-Gy fractions (EQD2) values for dogs (n = 24) with infiltrative lipomas. Microscopic (n = 8) Total dose in No. of cases or gross (n = 16) Gray (Gy) Protocol EQD210 EQD2317 Microscopic (7) Gross (10) 48 Gy 3.0 Gy X 16 52.0 Gy 57.6 Gy4 Microscopic (1) Gross (3) 50 Gy 2.5 Gy X 20 52.1 Gy 55.0 Gy1 Gross 45 Gy 3.0 Gy X 15 48.8 Gy 54.0 Gy1 Gross 48 Gy 2.4 Gy X 20 49.6 Gy 51.8 Gy1 Gross 51 Gy 3.0 Gy X 17 55.3 Gy 61.2 GyEQD210 = Equivalent dose in 2-Gy fractions. With an a/b = 10, this value provides an estimation of the biologically equivalent dose delivered to the tumor in 2-Gy fractions. Higher values suggest better tumor control.EQD23 = Equivalent dose in 2-Gy fractions. With an a/b = 3, this value provides an estimation of the biologically equivalent dose damage to normal tissues in 2-Gy fractions. Higher values suggest more risk of normal tissue damage.Table 3 —Dose characteristics for most commonly contoured organs at risk in Gy. Spinal cord (n = 11) Trachea (n = 8) Maximum DPF: 2.6 Gy/fraction Maximum DPF: 3.2 Gy/fraction Overall Overall Overall Overall Overall Overall mean (Gy) median (Gy) range (Gy) mean (Gy) median (Gy) range (Gy)Min 0.3 0.3 0.1–2.0 2.6 1.9 0.2–10.4Max 24.1 27.6 0.6–44.8 38.5 48.6 15.2–53.6Mean 9.9 10.1 0.6–24.3 19.4 19.2 2.5–43.4Median 9.1 8.8 0.3–26.5 15.5 14 0.7–51.0DPF = Dose per fraction. See Table 1 for remainder of key.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 11/03/23 06:54 AM UTC6 1 died at 1,665 days, and 2 are alive at 741 and 954 days. The number of surgeries before radiotherapy did not impact survival times ( P = .96).The survival difference between females (OS me -dian, 7.6 years [2,779 days]; 95% CI, 963 days to not reached) versus males (OS median, 4.6 years [1,665 days]; 95% CI, 335 to 2,245 days; P = .05) was at the cut-off for statistical significance ( P = .05; Figure 3). Additionally, the median age at death for males was slightly higher (10.8 years; range, 6.3 to 15.4 years) than for females (9.9 years; range, 6.4 to 15.3 years). The age at treatment was similar between sexes (female median, 6.2 years; male median, 6.1 years). Finally, 4/5 of the living dogs are female and were censored (living female follow-up range, 741 to 1,779 days). Therefore, the exact age at death, and differences between females and males, must be in -terpreted with caution.Records revealed limited data on objective gross tumor response: 2 had tumor reduction reported at least once in their record, and 1 had stable disease throughout follow-up. One living dog eventually had progressive disease after 923 days and received an -other surgery. One dog that died of dementia and in -continence had new masses on the irradiated leg later in life, but dates and pathology were not available; therefore, recurrence, secondary tumors, or other de novo tumors were possible. Given the limited follow-up imaging, and several cases with non-palpable regions of gross disease, further assessment regarding tumor volume response to radiotherapy was not possible.All dogs completed their radiotherapy course. Regarding other diseases and cause of death: 1 dog had a distant skin melanoma removed 14 months prior to lipoma irradiation, but was lost to follow-up. One dog developed a myxosarcoma at a distant site 2 years after lipoma irradiation, followed by surgery and definitive radiotherapy for the myxosarcoma. Contributing factors for euthanasia reported by owners, and when possible confirmed by records in -cluded: pneumonia (2), kidney failure (2), suspected brain tumor (2), primary pulmonary carcinoma with intrapulmonary metastasis, disseminated lung mass -es, soft tissue sarcoma with diffuse pulmonary me -tastasis (sarcoma was diagnosed concurrent to the lipoma), stomach cancer, gastrointestinal disease, dementia, incontinence, pancreatitis, liver failure, lethargy and inappetence, and hemoabdomen with a 4.9 cm adrenal mass found 23 days after completing radiotherapy. All radiation sites were distant to these reported diagnoses with the exception of radiologi -cally diagnosed pneumonia (CFRT in right axilla and thoracic region, survived 3.3 years and 6.2 years, respectively), and disseminated lung masses (CFRT in right axilla/thoracic wall, survived 7.6 years). Two patients had date of death in their records, but no cause of death, 4.6 years and 7.6 years post-CFRT.

Question 110

Redolfi - 2024 - VCOT - Complications and Long-Term Outcomes after Combined TPLO and TTT for Treatment of Concurrent Cranial Cruciate Ligament Rupture and Grade III or IV Medial Patellar Luxation.pdf

Answer 110

Case Selection CriteriaThe medical records database of Centre Hospitalier Vétérin-aire Anicura –Aquivet was searched to identify dogs thatunderwent TPLO-TTT for treatment of concurrent cranialcruciate ligament rupture and MPL between September 1,2016 and May 31, 2021. Dogs were included in the study ifpreoperative, immediate postoperative, and follow-up radio-graphs were available for review, and follow-up examina-tions were performed by the primary surgeon 6 to 10 weekspostoperatively (short-term follow-up) and at least 1 yearpostoperatively (long-term follow-up). Data were collected aminimum of 1 year from the time of surgery to allowsufficient time for complications to develop. For two dogsthat had staged bilateral sti fle surgery with an interval ofmore than 1 year between the two procedures, each limb wasconsidered individually. Patients with grade I or II MPL andthose that had femoral or tibial osteotomy or ostectomy forcorrecting femoral or tibial torsion, respectively, were ex-cluded. Informed consent was obtained from the pet owners.All patients were clinically managed according to contem-porary standards of care.Medical Records ReviewData obtained from the medical records included signal-ment, limb affected, lameness score (preoperative and reex-amination), MPL grade, radiographic findings, surgicalapproach, surgical findings, type of implants used forTPLO-TTT, any ancillary procedures performed, postopera-tive complications, and duration of follow-up. Lameness wasscored on a numerical rating scale from 0 to 5, as previouslydescribed: 0 (clinically sound), 1 (barely detectable), 2 (mild),3 (moderate), 4 (severe), and 5 (non-weight-bearing).11Preoperative PlanningOrthogonal preoperative radiographs of the femur and thenof the tibia were obtained to identify any frontal or sagittalplane bone deformities, size of the TPLO, TPLO location, tibialtuberosity linear osteotomy location, and for TPLO-TTT im-plant templating. Surgical planning was performed eitherusing acetate templates or digital templating (vPOP Pro;VETSOS Education Ltd, Shrewsbury, United Kingdom). TheTPLO location was planned with the osteotomy centered onthe intercondylar tubercules. Two distances (D1 and D2)were measured from the preoperative plan as previouslydescribed.12The tibial tuberosity linear osteotomy wasplanned to extend from the most proximal and cranial aspectof the radial osteotomy for the TPLO to the distal aspect of thetibial crest without cutting its distal cortex. Measurements ofD3 was determined (►Fig. 1 ). Distance D3 was measured onthe mediolateral radiographic view along a line perpendicu-lar to the cranial border of the tibia and is the distance fromthe patellar ligament attachment to the linear osteotomyline. D3 was desired to be approximately 20 to 30% of thedistance between the insertion of the patellar ligament andthe caudal tibial cortex to ensure the osteotomized tibialtuberosity was of suf ficient size to be reattached withimplants of acceptable size. These three (D1, D2, and D3)measurements were used for intraoperative reference dur-ing osteotomy positioning. Radiographs included a 10-cmlinear marker. Preoperative tibial plateau angle (TPA) wascalculated as previously described.13Surgical TechniquePreanesthetic blood tests were performed dependent onpatient's signalment and comorbidities. Dogs were anesthe-tized for surgery according to standard protocols used in ourclinic. Analgesia was provided with morphine (Morphine;Lavoisier, Paris, France) (0.2 mg/kg intravenous [IV]).Cefazolin (Céfazoline; Mylan S.A.S., Saint-Priest, France)(22 mg/kg IV) was administered 30 minutes before skinincision and every 90 minutes throughout the surgery. Allprocedures were performed by the same board-certi fiedsurgeon (JGG).After routine preparation for aseptic surgery, animalswere positioned in lateral recumbency to expose the medialsurface of the affected tibia. The surgical field was furtherprotected with a sterile, adhesive, clear plastic incisiondrape. The sti fle joint was explored by lateral arthrotomy,and adjunctive surgical techniques to correct MPL, includingtrochlear wedge recession, medial retinacular release, andlateral capsular imbrication, were performed. Meniscal inju-ries were documented and treated, if necessary.Briefly, the Slocum TPLO was centered close to the inter-condylar tubercles. The accuracy of osteotomy positioningwas assessed repeating the D1 and D2 measurements on thetibia. The TPLO was partially completed, cutting entirelythrough the cis-cortex, but not the trans-cortex in standardfashion using a radial saw blade. No jig was used. The tibial.tuberosity linear osteotomy was then partially performedusing an oscillating saw by cutting through the cis-cortex butnot the trans-cortex. The TPLO was then completed, and theproximal tibial plateau segment rotated to the desiredamount. The rotated proximal tibial plateau segment wasstabilized to the tibial tuberosity segment using one tempo-rary pin (generally 1.0- to 1.6-mm diameter depending uponthe dog's size) placed in a cranial to caudal orientation andoriginating from proximal to the patellar ligament insertion.A TPLO locking plate (DePuy Synthes (DePuy Synthes, Rayn-ham, Massachusetts, United States) Biomedtrix (Biomedtrix,Whippany, New Jersey, United States) or Veterinary Ortho-pedics Implants (Veterinary Orthopedics Implants, Orly,France)) was applied using three or four locking screws(2.0-, 2.4-, 2.7-, or 3.5-mm diameter) in the head of the plateand three or four cortical screws (2.0-, 2.4-, 2.7-, or 3.5-mmdiameter) in the body of the plate (DePuy Synthes, Biomed-trix, or Veterinary Orthopedics Implants). Then, the tempo-rary pin was removed, and the tibial tuberosity linearosteotomy was completed leaving a distal cortical and/orperiosteal attachment. The tibial tuberosity was then trans-posed laterally to visually align the patellar ligament with thetrochlea sulcus. The tibial tuberosity was secured to therotated tibial plateau segment using two or three pins(1.0 –1.6 mm) depending upon the dog's size (DePuy Syn-thes). At the surgeon's discretion, one large gauge (0.8 –1.5mm), figure-of-eight tension band wire was placed andsecured using a single twist (Aesculap Surgical Instrument,B. Braun, Hessen, Germany).After the finalfixation, intraoperative range of motion androtational and valgus/varus alignments were subjectivelyevaluated by aligning the tibial crest and the long axis ofthe metatarsus and by reestablishing the sagittal plane of thehindlimb, respectively. Indirect cranial drawer sign andpatellar stability were also assessed. Closure was routinelyperformed. After postoperative radiographs were obtained, amodi fied Robert-Jones bandage was applied.Postoperative CareAfter the first 24 hours, no additional external coaptationwas used. Morphine (0.2 mg/kg, IV, every 4 hours) wasadministered for analgesia during hospitalization. Patientswere discharged from the hospital 2 days after surgerywith anti-in flammatory (meloxicam (Metacam; Boeh-ringer Ingelheim, Ingelheim, Germany) [0.1 mg/kg orallyevery 24 hours for 10 days]) and antimicrobial medica-tions (cephalexin (Rilexine; Virbac, Carros, France) [15 –25mg/kg orally every 12 hours] for 5 days). Dogs wereconfined to a small room or cage. Short leash walks threeto four times daily was the only recommended activityduring the initial 6 to 10 weeks after surgery until clinicaland radiographic evaluation. Activities were graduallyintroduced over 1 month after the first examination bar-ring any complications or setbacks. After 10 to 14 weeks,unrestricted activities were allowed.Outcome AssessmentThe patients were reexamined at the authors ’institution bythe primary surgeon 6 to 10 weeks postoperatively forclinical and radiographic examination (short-term follow-up). Lameness was scored using the aforementioned gradingFig. 1 Preoperative mediolateral radiographic image of a 2.5-year-old, 43 kg, Labrador Retriever (case 18) with a complete rupture of thecranial cruciate ligament and a con current grade III medial patellarluxation of the right hindlimb th at has been treated with combinedtibial plateau leveling osteotomy and tibial tuberosity transposition(TPLO-TTT). This figure demonstrates precise osteotomy positioning.The TPLO location ( red circle ) was planned with the osteotomycentered on the intercondylar tubercules. Distances D1 and D2 ( yellowlines ) were measured from the preoperative plan as previously de-scribed. The tibial tuberosity linear osteotomy ( green line )w a splanned to extend from the most proximal and cranial aspect of theradial osteotomy for the TPLO to the distal aspect of the tibial crestwithout cutting its distal cortex. Measurements of D3 ( white line )w a sdetermined. Distance D3 was measured on the mediolateral radio-graphic view along a line perpendicular to the cranial border of thetibia and is the distance from the pa tellar ligament attachment to thelinear osteotomy line. D3 was desired to be /C2420 to 30% of the distancebetween the insertion of the patellar ligament and the caudal tibialcortex to ensure the osteotomized tibial tuberosity was of suf ficientsize to be reattached with implants of acceptable size. These three(D1, D2, and D3) measurements were used for intraoperative refer-ence during osteotomy positioning..system.11Signs of pain, crepitus, and range of motion onmanipulation of the sti fle were documented. Indirect cranialdrawer sign, patellar stability, patellar ligament thickening,and signs of pain on surgical site palpation were alsorecorded. Critical radiographic assessment of implant posi-tion and integrity, patellar position, and bone healing anddevelopment of osteoarthritis were evaluated. Complica-tions were reported as previously de fined as catastrophic,major, or minor.14Catastrophic complications were thosethat caused permanent unacceptable function, death, oreuthanasia; major complications were those that requiredfurther surgical treatment to resolve (e.g., surgical siteinfection, implant failure); and minor complications weredefined as those treatable through a combination of localcare and oral medication without the need for anesthesia(e.g., wound dehiscence). Patellar reluxation after surgerywas considered a major complication. Time from surgery tocomplication was recorded, and, if less than one complica-tion occurred in one patient, each was considered as aseparate data point.The primary surgeon performed long-term clinical exam-ination a minimum of 12 months postoperatively. Lamenesswas subjectively graded as previously described. Sti fle crep-itus, pain, range of motion, and patellar stability wererecorded. At the time of follow-up examination, radiographswere proposed to the owners for assessment of long-termpatellar position, evidence of implant migration, and devel-opment of sti fle osteoarthritis. On this occasion, the ownerswere asked to subjectively grade the outcome of their dog as“full, ”“acceptable, ”or“unacceptable. ”14The surgeon used acombination of clinical and radiographic assessment, inaddition to owner assessment, to determine the level ofreturn to previous activity permitted.Data AnalysisData were entered into a spreadsheet (Excel version 2006;Microsoft Corporation). Descriptive statistics were calculat-ed, with median and range reported. Data frequencies in eachcategory were reported.ResultsTwenty-two dogs met the inclusion criteria with a total of 24stifles (►Appendix Table 1 , available in the online version).The median age at presentation was 7.5 years (range: 1 –13years) and the median body weight was 23 kg (range: 3.2 –43 kg). There were 12 spayed females, 2 castrated males, 3intact females, and 4 intact males.Twenty-one sti fles had a grade III MPL and 3 sti fles had agrade IV MPL.Surgical ProcedureA TPLO-TTT was performed in all 24 sti fles. Twelve sti fles hada complete rupture of the cranial crucial ligament, and 12stifles had a partial rupture. Two sti fles (dogs 9 and 13) had amedial meniscal injury ( “bucket handle tear ”) that requiredpartial meniscectomy (caudal horn removal). Trochlearwedge recession, medial retinacular release, and lateralcapsular imbrication were performed in addition to TPLO-TTT in all 24 sti fles.Implants used for TPLO-TTT are reported in►AppendixTable 1 (available in the online version). A tension band wirewas used in 21/24 sti fles. No intraoperative complicationsoccurred. Postoperative radiographs obtained for all sti flesconfirmed appropriate postoperative TPA (median:4.4 degrees; range: 1 –6 degrees), patellar position, and posi-tioning of the implants ( ►Fig. 2 ).Short-Term OutcomeMedian time to first clinical and radiographic reexaminationwas 6.4 weeks (range: 6 –10 weeks). The median lamenessscore was 1 (range: 0 –3;►Appendix Table 2 , available in theonline version). Five of the 22 dogs were clinically sound.Eleven dogs had grade I lameness, 7 dogs had grade IIlameness, and one dog had grade III lameness. All patientswere considered to have satisfactory craniocaudal sti flestability based on indirect cranial drawer test. All sti fleshad a well-positioned and stable patella and all patellaetracked normally within the femoral sulci. Two major com-plications (cases 3 and 4) consisting of surgical site infectionwere successfully treated with initial empirical oral antibi-otic therapy (cefalexini[15–25 mg/kg PO every 12 hours])and subsequent orthopaedic implant removal 3 monthsfollowing surgery. Minor complications occurred in fivecases. Four cases (cases 19, 20, 22, and 23) had thickeningand pain on palpation of the patellar ligament and one case(case 21) developed semitendinosus and semimembranousmuscle contractures that were of undetermined origin.These five cases were successfully treated by physicalrehabilitation therapy. The remaining 17 cases had noabnormalities on orthopaedic examination. Radiographicexamination revealed adequate patellar position and stableimplants in all cases. Four dogs had marked soft-tissueswelling at the level of the patellar ligament. Radiographichealing of the TPLO-TTT osteotomy sites was reached in allcases. Overall, short-term major and minor complicationswere observed in 2/24 stifles and 5/24 stifles, respectively.Long-Term OutcomeMedian time to final clinical and radiographic reexaminationat the authors ’institution was 27 months (range: 12 –67months; ►Appendix Table 3 , available in the online version).All 22 dogs returned for long-term evaluation with 2 dogsthat had surgery on both sti fles. At the time of final clinicalexamination, all but one dog were clinically sound and 23/24stifles had satisfactory stability of the sti fle joint without anyevidence of pain or patellar luxation on orthopaedic exami-nation. One dog (case 9) had a barely detectable lameness.One dog (case 14, a 3.4-kg Yorkshire Terrier 7.7 years old atthe time of surgery) was diagnosed with a grade II MPLwithout any observed signs of lameness or pain (►AppendixTable 3 , available in the online version). The owners did notreport any trauma between the short- and long-term follow-up appointments. No revision surgery was performed as no.lameness was observed or reported by the owners. One sti fle(case 6) developed surgical site infection greater than 1 yearafter surgery and underwent orthopaedic implant removal(►Appendix Table 3 , available in the online version). Allowners of dogs elected to pursue radiographs. Radiographicexamination revealed adequate joint congruency and noevidence of implant migration in all sti fles. Development ofosteoarthritis was considered as mild in 15 cases andmoderate in 9 cases ( ►Appendix Table 3 , available in theonline version). Retrospective evaluation of preoperativeradiographs of the case with grade II MPL reluxationrevealed mild internal tibial torsion that was not addressedat the time of surgery and could be the cause of the patellarre-luxation.Fig. 2 (A,B) Preoperative, ( C,D) immediate postoperative, ( E,F)6w e e k sp o s t o p e r a t i v e ,a n d( G,H) 14 months postoperative craniocaudal andmediolateral radiographs of the case planned in Fig. 1. The tibial platea u leveling osteotomy (TPLO) was stabilized with a Biomedtrix TPLO platefor 3.5 mm in diameter screws. The tibial tuberosity transposition (TTT) was stabilized with three 1.6-mm diameter pins and a 1.25-mmdiameter figure-of-eight tension band wire. At immediate postoperative rad iographs, the tibial plateau angle (TPA) was measured at 5 degrees(C,D). At 6 weeks postoperatively, the implants were stable and both osteotomies were healed ( E,F). At 14 months postoperatively, the implantswere stable and moderate development of osteoarthritis was observed ( G,H)..The owners subjectively assessed the outcomes of theirdogs following surgery ( ►Appendix Table 3 , available in theonline version). Twenty-one of 22 dogs had full function and1 dog (case 9) had acceptable function. Overall, long-termmajor complications were observed in 2/24 sti fles.

Question 111

Holman - 2024 - VCOT - Quantification of the Field of View for Standard Lateral Arthroscopy of the Canine Shoulder.pdf

Answer 111

Arthroscopic ExaminationEleven forelimbs from seven large breed dogs (2 LabradorRetrievers, 2 German Shephard Dogs, 1 Vizsla, 1 AmericanBulldog, and 1 mixed breed dog) were included in the firstphase of the study. While body weights were not available forall specimens, the humeral length was measured to ensure asimilar body size. All the dogs had been euthanatized fornon-orthopaedic-related reasons. Institutional approval forthe use of cadavers was not required. For all owned dogs,written informed consent of the use of their dog for researchwas obtained from the owners. Shoulders with severe intra-articular pathology on initial arthroscopic evaluation wereexcluded. Intact cadavers were evaluated in lateral recum-bency. Limbs that were previously removed from the cadavertrunk were con firmed to have no gross evidence of damage tothe subscapularis on their medial aspect, and were stabilizedfor arthroscopy by securing the scapula to a wooden board ina standard lateral position. Each shoulder was examinedarthroscopically from a standard lateral portal using a 2.7-mm-long, 30-degree arthroscope.5A 38-mm 18-gauge nee-dle was inserted into the joint just cranial to the scope portalfor egress. The joints were distended using saline in a gravityflow system. All the limbs were initially evaluated in anormal standing angle with approximately 115 degrees ofjoint flexion and 0-degree abduction or adduction. Theappropriate limb positioning was con firmed via goniometry.Each joint was explored and the following landmarks wereidenti fied and marked at the outermost extent of the field ofview: (1) the cranial margin of the medial glenohumeralligament, both proximal and distal; (2) the distal most aspectof the biceps tendon with the limb held at a standing angle(115 degrees); and (3) the distal most aspect of the bicepstendon with the limb held in a 75-degree flexion (►Figs. 1and 2). The extent of field of view was marked on eachstructure with a local application of tattoo ink. The ink wasdiluted with saline, loaded into a 1-mL syringe and attachedto an 18-gauge 76-mm spinal needle. The needle was intro-duced into the joint. A small amount of ink was inserted intothe tissue at the desired location (►Figs. 3 and 4). After allmarking was done, the joint was flushed copiously withsaline. A forequarter amputation was then performed onthe limbs from intact cadavers, and all the limbs wererefrigerated until dissection could be completed.For the second phase of the study, 10 additional shouldersfrom 6 large breed dogs (4 Labrador Retrievers and 2American Staffordshire Terriers) were utilized. Arthroscopicevaluation and marking were performed under the sameconditions as previously described. The limits of the field ofview of the subscapular tendon were established by markingthe visual margins at its cranio-proximal extent and distalextent both cranially and caudally (►Fig. 1 ). The three marksformed a triangle, which delineated the portion of thesubscapular tendon within the field of view. Dissectionwas completed immediately following arthroscopic exami-nation for these samples.Fig. 1 Arthroscopic view of the media l supporting structures of theshoulder. Landmarks for the cranial edge of the medial glenohumeralligament are indicated with asterisks. Landmarks for the subscapularisare indicated with arrowheads .Fig. 2 Arthroscopic view of the biceps tendon and bicipital groove.Landmark for the distal biceps tendon (at a 115-degree standingangle) is indicated with an arrow . A second mark was made in a similarfashion, following flexion to 75 degrees..Gross EvaluationEach shoulder was dissected while preserving the medialstabilizing structures. The most distal point of the intra-articular portion of the biceps, as noted by the distal extent ofthe synovial re flection, was considered the most distal limitof the tendon for the purpose of this study. This point wasalso marked with ink at the time of dissection. The bicepstendon was then sharply removed from its origin on thesupraglenoid tubercle. The distance between the cut edgeand each mark was measured using a caliper. The medialglenohumeral ligament was sharply removed from itsattachments on the scapula and the humerus. The distancebetween the origin and insertion and each mark wasmeasured.For the shoulders in which the subscapularis tendon wasmarked, the muscle was removed from the scapula and thetendon sharply dissected from its insertion on the humerus.The overlying medial glenohumeral ligament was thendissected away to expose the entire subscapularis tendon.The three ink marks were identi fied, and a digital photo-graph of the gross specimen was taken. For the purpose ofthis study, the intra-articular portion of the subscapularistendon was de fined as the area from its insertion on thehumerus to the proximal/caudal joint capsular attachment.Using an image processing application (ImageJ), the areawithin the three marks indicating the arthroscopic field ofview was calculated digitally (►Fig. 5 ). The total area of thetendon, as de fined earlier, was also calculated from thesame image. The total humeral length of each limb was alsomeasured and recorded.StatisticsStatistical analysis was performed using commercially avail-able software (Systat version 13.2, Systat, Chicago, IL, UnitedStates). Continuous variables are reported as mean andstandard deviation. Signi ficance was set at values ofp<0.005. An unpaired T-test was performed to determinethe statistical variation in limb length between the twogroups and in the proportion (as a percentage of total length)of the biceps tendon visible by arthroscopy with the jointpositioned in standing and flexed angles.Fig. 5 Measurement of the subscapularis tendon. The area from thecapsular attachment to tendon insertion is outlined in yellow .T h ea r e aof the tendon within the arthroscopic fie l do fv i e wi so u t l i n e di n teal.Fig. 3 Arthroscopic view of the spinal needle marking thesubscapularis.Fig. 4 Arthroscopic view of the resul ting ink mark at the proximalborder of the subscapularis tendon that was placed in ►Fig. 3 ..ResultsThere was no signi ficant difference in humeral limb lengthbetween groups 1 and 2. The means for groups 1 and 2 were17.6 cm (SD /C61.5) and 17.3 cm (SD /C61.8; p¼0.685), respec-tively. The proportion of intra-articular biceps tendon visiblewithin the field of view with the limb in standing angle (48%/C60.07) and flexion (63% /C6007) was signi ficantly different(p¼0.0003;►Fig. 6 ). Fifty-eight percent (SD /C60.08) of thelength of the cranial arm of the medial glenohumeral liga-ment was within arthroscopic view. Twenty percent (SD/C60.05) of the area of the subscapularis tendon was withinthefield of view ( ►Appendix Table 1 , available in the onlineversion).

Question 112

Cinti - 2023 - VETSURG - Laparoscopic extra-abdominal transfascial suturing technique for diaphragmatic rupture repair in a cat.pdf

Answer 112

EPORTLaparoscopic extra-abdominal transfascial suturingtechnique for diaphragmatic rupture repair in a catFilippo Cinti DVM, PhD, GPCert(SASTS), Dipl. ECVS, MRCVS1|David Garcia Rubio DVM21San Marco Veterinary Clinic andLaboratory –Surgery Department,Veggiano, Italy2Hospital Veterinario AniCura SanFermín, Pamplona, SpainCorrespondenceFilippo Cinti,San Marco Veterinary Clinic andLaboratory –Surgery Department,Veggiano, Padua, Italy.Email: filippocinti@icloud.comAbstractObjective: To describe the technique, complications, and outcome of the lapa-roscopic extra-abdominal transfascial suturing method for diaphragmatic rup-ture repair in a cat.Study design: Case report.Animals: A 10 year old, female domestic shorthair cat.Methods: An acute traumatic diaphragmatic rupture was diagnosed in a cat.Following initial stabilization, 3-port laparoscopic surgery was performed.After the laparoscopic reduction of herniating organs, a circumferential dia-phragmatic tear was diagnosed, which was repaired using a multiple extra-abdominal transfascial suture technique. The total surgical time was 50 minwith no intraoperative complications encountered.Results: The successful procedure was confirmed by normalization of chestradiography, clinical signs, and blood gas analysis in the perioperative andpostoperative periods. Mild skin irritation occurred 3 weeks after surgery butwas resolved following the removal of sutures. The cat recovered well withoutmajor complications; the final reexamination was performed 3 monthspostoperatively.Conclusion: The laparoscopic extra-abdominal transfascial suturing tech-nique appears to be a feasible, and effective technique for feline diaphragmaticcircumferential rupture repair. This technique may be an alternative option tointracorporeal suturing for diaphragmatic rupture treatment in the cat.1|INTRODUCTIONDiaphragmatic hernia is a common surgical condition indogs and cats, with varying morbidity and mortality rates.Diaphragmatic rupture has a traumatic origin in 85% ofcases.1–5In most cases, trauma is caused by a motor vehi-cle accident; other causes include falls and penetratingwounds. Traditional surgical diaphragmatic rupturerepair in small animals is approached by celiotomy andthoracotomy, which are traumatic and can lead to addi-tional blood loss.6,7Laparoscopic diaphragmatic hernia repair has beendescribed in small animals, including cases with extensiveand chronic defects and large numbers of abdominalorgans displaced into the pleural space.8–11It is believedthat the benefits of laparoscopy, such as reduced tissuetrauma and less pain than conventional approaches, can beexpected for diaphragmatic hernia repair. Feline and canineminimally invasive surgery (MIS) diaphragmatic rupturerepair may be approached either through the thorax, usingthoracoscopy or video-assisted thoracoscopic surgeryReceived: 10 November 2022 Revised: 1 February 2023 Accepted: 20 March 2023DOI: 10.1111/vsu.13960864 © 2023 American College of Veterinary Surgeons. Veterinary Surgery. 2023;52:864 –869. wileyonlinelibrary.com/journal/vsu(VATS), or through the abdomen (laparoscopy or laparo-scopic assisted). The pure laparoscopic approach providesbetter working space than thoracoscopy, an importantconsideration when defects are extensive.12,13Differenttechniques for diaphragmatic rupture treatment, such asintracorporeal suturing with barbed sutures, Endostich,staples, or mesh have been described in the veterinaryliterature.8The purpose of this case report was to describe thelaparoscopic extra-abdominal transfascial suturing tech-nique and determine the success of diaphragmatic rup-ture repair in a cat.2|CASE DESCRIPTIONA 10 year old, 4.2 kg, female domestic shorthair cat wasreferred due to ataxia, lethargy, and dyspnea. Physicalexamination revealed superficial, lumbar-sacral skin inju-ries, and muffled heart sounds on thoracic auscultation.A road traffic accident was suspected. Results from hema-tology and serum biochemical analysis showed no sub-stantial abnormalities. Before further analysis the cat wastreated with oxygen flowby, analgesia (methadone0.15 mg/kg, IM) (Semfortan; Dechra Veterinary Products,Torino, Italy) and IV fluid therapy. After initial stabiliza-tion, general anesthesia was induced. Thoracic-focusedassessment with sonography for trauma, and thoracicradiography examination revealed gas-filled viscera inthe thoracic cavity, collapsed lung lobes and partial lossof the diaphragm silhouette, and a diagnosis of traumaticdiaphragmatic rupture was made.Laparoscopic surgery was carried out 24 h after thepresumed traumatic episode. The cat was premedicatedwith dexmedetomidine (3 ug/kg IM) (Dexdomitor; ZoetisItalia S.r.l, Roma, Italy) and methadone (0.15 mg/kg IM)(Semfortan; Dechra Veterinary Products, Italy). Generalanesthesia was induced with propofol (5 mg/kg IV)(Proposure; Boehringer Ingelheim Animal Health ItaliaS.p.a, Milan, Italy), maintained with isofluorane in oxy-gen (Isoflo; Ecuphar Italia, Milan, Italy) and placed on aventilator during the procedure. Under general anesthe-sia the cat was aseptically prepared for surgery andplaced in dorsal recumbency in a reverse Trendelenburgposition for gravitational assistance with the reduction ofthe hernia. Three 5 mm trocar-cannula systems (2 Kiisleeve with advanced fixation, Applied Medical, SantaMargarita, California, USA; 1 Ternamian EndoTIP can-nula Karl-Storz endoscopia Italia S.r.l, Verona, Italy)were used for laparoscopy and introduced through scal-pel blade stab incisions. The first 5 mm cannula wasintroduced on the midline 3 cm caudal to the umbilicus.The abdomen was insufflated with carbon dioxide tomaintain a pressure of 3 mm Hg. A 5 mm 30/C14telescope(Hopkins Forward-Oblique Telescope, Karl-Storz) wasintroduced through the 5 mm cannula to explore theabdomen and monitor the placement of the next 2 cannu-lae. Other cannulae were placed on either side of themidline for triangulation (Figure 1). After laparoscopicexploration, the herniated organs (liver, omentum, partof the stomach, and spleen) were reduced easily into theabdomen from the thoracic cavity using blunt probes(Karl-Storz) and Maryland forceps (atraumatic forceps)(Karl-Storz). Gentle traction and lifting of the organswere used to maneuver them over the dorsal ridge of thehernia into the abdominal cavity. Maryland forceps wereused to pull the omentum and stomach into the abdo-men. The spleen was partially reduced in the abdomenafter stomach traction and blunt probe manipulation wasthen used for complete reduction. The left liver lobeswere manipulated and reduced in the abdomen withblunt palpation probe. To improve visualization, the falci-form ligament was dissected with an advanced bipolartissue sealer device and removed from the abdominalcavity (Enseal Round Tip Tissue Sealer, Ethicon Jhonson& Jhonson, Raritan, New Jersey USA). A circumferentialtear of the diaphragm was diagnosed. A chest tube(MILA International Inc., Florence, Kentucky, USA) wasFIGURE 1 The position of the cat during the laparoscopicprocedure. The first 5 mm cannula (n.1) was introduced on themidline 3 cm caudal to the umbilicus. The other 2 cannulae wereplaced on either side of the midline for triangulation (n.2, n.3).CINTI and RUBIO 865 1532950x, 2023, 6, placed in an intercostal space before commencing thehernia closure. A laparoscopic extra-abdominal transfas-cial suturing technique was used to close the diaphrag-matic defect. The Maryland forceps were used to graspand lift the central edge of the diaphragm close to thexiphoid process during suture application. First, a 0 pro-pylene suture (Optilene B. Braun, Milan, Italy) attachedto a 1/2 circle curve taper needle was introduced, withoutskin incision, through the abdominal cavity (xiphoidarea), and was guided by intra-abdominal visualizationthrough the central part of the diaphragmatic edge. Theneedle exited the abdominal wall close to the previousingress point. External abdominal traction of the suturepermitted lifting of the abdomen and diaphragm toimprove visualization and wo rking space. Following thesame steps, 7 more sutures were placed and tied. A total of8i n t e r r u p t e ds u t u r e sw e r ep l a c e d .S i xo f8s u t u r e sw e r eanchored around the costal arch and abdominal wall(Figures 2and3). All sutures had the final knot tied extra-corporeally outside the skin. The knots of each suture wereFIGURE 2 Intraoperative laparoscopic view. Intraoperative view of herniated organs (A). Thoracic and diaphragmatic circumferentialtear of the diaphragm view after organs reduction (B). A Maryland forceps grasps and permits to lifts the diaphragm close to the abdomenand xiphoid process (C). Under telescope vision, with a standard needle holder the first suture (white arrow) attached to a 1/2 circle curvetaper needle was introduced, without skin incision, through the abdominal cavity, past the central part of the diaphragmatic edge and thenout to the abdominal wall (D, E). External abdominal traction of the suture permits to lift of the abdomen and diaphragm (F). Application ofother extra-abdominal sutures (G) (needle indicated with black arrow). Final view of diaphragm (H). Cranial (Cr).FIGURE 3 The 3 main intraoperative steps. Diaphragmatic circumferential tear of the diaphragm view after organs reduction (A).Maryland forceps handle the central edge of the diaphragm while placing sutures (B). Final view of the diaphragm after completedherniorrhaphy. All sutures had the final knot tied extracorporeally outside the skin. The knots of each suture were not buried under the skinand were visible on the exterior (C).866 CINTI and RUBIO 1532950x, 2023, 6, not buried under the skin and were visible on the exterior.After the closure of the diaphragm, the pleural space wasevacuated through the chest tube. The cannulae wereremoved, and the cannula defects were closed routinely(Figure 4). The total surgical time from the creation of thefirst port to the closure of the last port was 50 min.Postoperative radiography confirmed resolution of thehernia and the absence of pneumothorax. The cat recoveredunremarkably. Blood gas analysis was performed every 5 to8ha f t e rt h es u r g e r yw a sc o m p l e t e d .A n a l g e s i aw a sm a i n -tained intravenously methadon e0 . 2m g / k g / 4 - 6h o u r s( S e m -fortan; Dechra Veterinary Pro ducts, Italy), and through thechest tube (bupivacaine 1.5 mg/kg/6 hours until the tubewas removed, [Bupivacaina 5 mg/ml, Angelini S.p.a., Roma,Italy]). The pleural space was evacuated every 4 hours and,the chest tube was removed 12 h postoperatively. The catwas eating and drinking normally 10 h postoperatively andwas discharged 48 h after surgery with meloxicam (0.1 mL/kg OR on the first day and 0.05 mL/kg OR for 4 more days)(Meloxoral; ATI SRL, Ozzano Dell'Emilia, Italy) andamoxicillin and clavulanic acid (12.5 mg/kg OR q12h for7d a y s )( S y n u l o x ;Z o e t i s ,I t a l y )m e d i c a t i o n s .The cat was in good clinical condition 3 weeks post-operatively and the sutures were removed. The onlyminor postoperative complication at the point was skinirritation at the suture sites (Figure 5). At the 2 and3 months' postoperative reexaminations, the cat was ingood health and had no abnormality in clinical signs,blood gas analysis, or thoracic radiography.3

Question 113

Kerby - 2023 - VETSURG - Epiploic foramen entrapment in a dog.pdf

Answer 113

A 9-year-old, castrated, male shih tzu presented to theauthors' institution for a suspected abdominal mass. Thedog had a chronic, intermittent history of poor appetite,vomiting, and regurgitation of undigested food since hisadoption at 1 year of age. Results of earlier bloodworkwere normal but no radiographs were ever obtained. Noimprovement was seen with various symptomatic thera-pies. For 1 week prior to presentation at the authors'institution, the dog's signs had progressed to anorexia,lethargy, and melena. On abdominal ultrasound, thereferring veterinarian could not determine whether thedog had an abdominal mass or gastrointestinal obstruc-tion, so the dog was referred to the authors.Upon presentation, the dog was tachycardic (180 beatsper minute), hypertensive (160 mmHg), and had a tense,painful abdomen and moderate epaxial muscle wasting. Alarge, midabdominal, cavitated viscus was noted onabdominal-focused assessment with sonography fortrauma, triage, and tracking (AFAST) performed by theemergency service house officer. Hyponatremia(133.9 mmol/L; reference range: 136 –142), hyperchloremia(116 mmol/L; reference range: 95 –103), and anemia(hematocrit, 20%; reference range, 36 –50) were noted onbloodwork; lactate was normal (0.9 mmol/L; normal <2.5).On survey abdominal radiographs, abnormalitiesincluded a large, bi-lobed soft-tissue structure containingmultiple foci of mineral to metal opacity; a moderatelydilated segment of small intestine in the midventral abdo-men cranial to the bi-lobed structure, and decreased sero-sal detail. Based on radiographs, partial obstructionwas suspected (Figure 1). While the patient was sedatedfor radiographs, a nasogastric tube (NGT) (MILA,6FRx55cm, Patterson 07-890-4840, Loveland, CO) wasplaced, and appropriate gastric positioning was confirmedwith radiographs.The dog was admitted to the hospital's intensive careunit for observation and medical therapy, including IVfluids (lactated Ringers solution with potassium chloride[20 mEq/L] at 6 mLs/kg/h IV), maropitant (1 mg/kg IVevery 24 h), esomeprazole (1 mg/kg IV every 12 h),sucralfate (500 mg orally every 8 h), fentanyl (2 –5/uni03BCg/kg/h IV), lidocaine (25 /uni03BCg/kg/min IV), metoclopramide(2 mg/kg/day IV), and Proviable Forte (1 capsule orallyevery 24 h) (Nutramax Laboratories Veterinary Sciences,Inc., Lancaster, SC).Overnight, the dog's lactate, blood glucose, bloodpressure, urination, defecation, and temperatureremained normal, and it was more comfortable onabdominal palpation. The NGT was nonproductive withaspiration every 6 h. The dog was inappetent for feedingsbefore midnight and was fasted after midnight in prepa-ration for additional diagnostics.On abdominal ultrasound 14 h after presentation, thestomach was severely dilated (Figure 2), and the pyloricwall appeared thickened circumferentially (Figure 3). Por-tions of the jejunum had a stacked or tortuous course, withsome found cranial to the sto mach, and one jejunal seg-ment in the right cranial abdomen was moderately dilatedand had a markedly thickened muscularis and reduced walllayer distinction (Figure 4). Computed tomography wasrecommended to characterize the abnormal findings furtherbut the owners declined due to financial constraints. Thedog was transferred to surge ry for immediate anestheticinduction and abdominal explo ratory. At induction, cefazo-lin (22 mg/kg) was administered IV.In surgery, the stomach was severely dilated and cau-dally displaced (Figure 5A); on palpation, the pyloruswas normal, and the NGT was evident in the body of thestomach. The small intestine was stacked in loops under1238 KERBY ET AL . 1532950x, 2023, 8, a layer of omentum cranial to the gastric lesser curvatureand passed through the epiploic foramen; it was gentlypulled at its points of herniation and gradually extracted(Figure 5B). Once reduced, an eight-centimeter, necrotic,midjejunal segment was noted. The segment was resectedand anastomosed with 4 –0 polydioxanone, using aFIGURE 2 Abdominal ultrasound —Stomach. Sonographicimage of the large, cranial to midabdominal structure, whichrepresents a severely distended stomach containing a large volumeof heterogeneously hyperechoic material, interspersed withmultiple shadowing foci. (Sonographic image acquired with PhilipsEPIQ 5 microconvex 12.3 MHz transducer.)FIGURE 3 Abdominal ultrasound —Pylorus. Sonographicimage of the stomach at the level of the pylorus, showing focal,circumferential wall thickening (measuring approximately 0.7 cmin thickness; asterisk) and focal redundancy and rounding of themucosa and submucosa with resultant protrusion of the wall intothe pyloric lumen (arrows). (Sonographic image was acquired withPhilips EPIQ 5 electronic linear 18.4 MHz transducer.)FIGURE 1 Abdominal radiographs. Digital right lateral (A) and ventrodorsal (B) radiographs of the abdomen. From the lateral view,there is a large, fluid opaque structure with a bilobed shape within the midcranial abdomen (black arrows outline caudal margin),containing some ventrally dependent, stippled, mineral opaque material. This structure causes displacement of small intestines cranially(white arrows on lateral radiograph and black arrows on ventrodorsal radiograph) and of the colon to the right (white arrowheads), and isconsistent with a severely distended portion of the gastrointestinal tract with potential chronic, partial obstruction. There is focal loss ofserosal detail with fluid streaking of fat in the cranioventral abdomen (asterisk). In this same area, there is an elongated, tubular soft tissueopaque structure, suggestive of an abnormally thickened or dilated small intestinal loop. (Digital radiographs acquired with PhilipsDigitalDiagnost DR system, Philips, Koninklijke Philips, Amsterdam, Netherlands.)KERBY ET AL . 1239 1532950x, 2023, 8, combination of simple interrupted and simple continu-ous sutures. Interrupted sutures were placed at the mes-enteric and antimesenteric borders to align the intestinalends and evaluate for luminal disparity; the suture endswere left long and attached to hemostats to permitmanipulation of the intestine. One half of the circumfer-ence of the intestine was apposed with a simple continu-ous pattern. The intestine was then flipped over to exposethe unsutured side. To ensure a secure closure, two sim-ple interrupted sutures were placed at the portion of themesenteric border that was encased in fat, and then theremaining side was apposed with a simple continuouspattern. A leak test was performed with sterile saline: theintestines to either side of the anastomosis wereoccluded, and saline was injected with a 20 mL syringeand 22 gauge needle until the anastomotic site was filledwithout overdistention (volume not recorded). Both sidesof the intestine were examined, and no leaks were noted.During the test, a small amount of saline was inadver-tently injected between the mucosa and submucosa, how-ever, resulting in local bruising and a small submucosalfluid pocket. The omentum was tacked around the anas-tomotic site with three simple interrupted sutures of 3 –0poliglecaprone 25, and the abdomen was lavaged,FIGURE 4 Abdominal ultrasound —Jejunum.Sonographic image of a focally abnormal jejunalsegment, with a moderately thickened wall(measuring approximately 0.5 cm), reducedconspicuity of the wall layers and specific muscularislayer thickening (asterisk). The surroundingmesenteric fat is moderately hyperechoic. This isconsistent with either an inflammatory process, orneoplastic infiltrate, with regional peritonitis/steatitis.(Sonographic image acquired with Philips EPIQ5 electronic linear 18.4 MHz transducer.)FIGURE 5 Intraoperative images. Visceral malposition (A) and hernial reduction (B) with cranial to the left of the image and caudal tothe right of the image. The stomach (arrowhead) is located in the caudal abdomen. The intestines (asterisk) are enveloped with omentumcranial to the stomach. The hernia was reduced via manual removal of the ileum (white arrowhead) and jejunum (black arrowhead)through the epiploic foramen (oval).1240 KERBY ET AL . 1532950x, 2023, 8, suctioned, and closed routinely. The dog recovered fromanesthesia uneventfully. After surgery, the previouslyprescribed treatments were continued, with the additionof erythromycin (1 mg/kg IV every 8 h) to stimulate gas-trointestinal motility.3|RESULTSThe following morning, the dog was bright and ate boiledchicken eagerly. On bloodwork, hyperchloremia (116 mmol/L; reference range: 95 –103), anemia (hematocrit, 23%; refer-ence range: 36 –50), and hypoglycemia (60 mg/dL referencerange: 70 –110) were noted. Lactate was within normal limits.An e wg r a d e3 / 6l e f ta p i c a ls y s t o l i cm u r m u rw a sa u s c u l t e dand suspected to be secondary to anemia. The NGTremained nonproductive with aspiration, despite appropriatepositioning confirmed duri ng exploratory surgery. OnAFAST, however, the dog had persistent, severe gastric dis-tension with thick, hypoechoic gastric fluid that did not shiftwith agitation or compression. On radiographs, the NGTand stomach were appropriately positioned; however, thestomach remained severely dilated and contained radi-opaque foreign material. Because of the thickness of thematerial, the lack of productivity of NGT aspiration, and aconcern for possible persistent obstruction and for aspira-tion pneumonia if orogastric lavage was attempted, arepeat abdominal exploratory was recommended for gas-tric emptying and lavage. During exploratory, the omenta-lized intestinal anastomosis was intact, with no evidenceof leakage. The intestinal wall hematoma from the previ-ous leak test was still present. Intestinal peristalsis waspresent but there was no discernible gastric peristalsis. Agastrotomy was performed, and the gastric contents wereremoved directly with the suction hose as they were toothick to remove with a Poole suction tip. The gastriclumen was lavaged, and the previously placed NGT wasmanually advanced through the pylorus and duodenuminto the jejunum for potential nutritional support. The gas-trotomy was closed in two layers. A 20 French mushroom-tipped gastrostomy tube (GT) (20Fr /C239cm, ICU MedicalInc., Minneapolis, Minnesota) was placed through the leftlateral body wall into the body of the stomach, which wassecured to the body wall with interrupted sutures. Theabdomen was lavaged, suctioned, and closed routinely.The dog was returned to the intensive care unit, where theprevious treatments were continued. The GT was alsoaspirated every 6 h to remove, quantify, and discard gastricresidual volume (GRV).The dog recovered from anesthesia uneventfullyand, 12 h after gastrotomy, was bright, comfortable, andhad an excellent appetite for oral food. The GT produc-tion was 1.3 mL/kg/h, 0.8 mL/kg/h, and 0.2 mL/kg/h12, 24, and 48 h post gastrotomy, respectively. However,3d a y s a f t e r i n t e s t i n a l r e s e c t i o n a n d a n a s t o m o s i s a n d2d a y sa f t e rG Tp l a c e m e n t ,t h ed o gb e c a m el e t h a r g i ca n dinappetent and developed abdominal pain. Results on repeatbloodwork included a mature neutrophilic leukocytosis(WBC 28.3 /C2103//uni03BCL; reference range: 4.7 –15.2; neutrophils26.4/C2103//uni03BCL; reference range: 2.41 –10.88), regenerativeanemia (RBC 3.01 /C2106//uni03BCL; reference range: 5.74 –8.64;reticulocytes 208.5 /C2103//uni03BCL; reference range: 11.6 –92.0),thrombocytopenia (101 /C2103//uni03BCL; reference range: 147 –423),hypoproteinemia (4.8 g/dL; reference range: 5.6 –7.6),hypoalbuminemia (1.8 g/dL; reference range: 3.2 –4.3),hypomagnesemia (0.5 mmol/L; reference range: 0.65 –0.98), increased C-reactive protein (118 mg/L; referencerange: <9.99), hypoferremia (23 /uni03BCg/dL; reference range97–263), and normal lactate (0.7 mmol/L; normal <2.5).Abdominal fluid was collected during AFAST; cytologywas consistent with septic peritonitis based on neutro-philic exudate with intracellular rod bacteria. The dog wastreated with ampicillin sulbactam (30 mg/kg IV every8 h), enrofloxacin (10 mg/kg IV once daily), and fresh fro-zen plasma transfusion (20 mL/kg IV) and taken to sur-gery. During abdominal exploratory, a moderate amountof serous peritoneal fluid was removed; there was no othervisible evidence of peritonitis. No gastric peristalsis wasnoted. Omentum was removed from around the jejunalanastomosis, exposing an area of dehiscence along theantimesenteric border. The previously identified hema-toma from leak testing was static in appearance.Approximately 20 cm of jejunum, including the previ-ous anastomosis site, were resected, anastomosed, andleak tested with saline as previously described. A freshsegment of omentum was sutured around the anasto-motic site. The abdomen was lavaged, suctioned, andswabbed for aerobic and anaerobic culture. A Jackson –Pratt peritoneal drain was placed before routine abdomi-nal closure.The resected portion of jejunum was opened andinspected. Externally, an area of necrosis was present alongthe antimesenteric surface of the anastomosis, althoughthe sutures and the mucosal surface of the original anasto-motic site appeared intact. However, mucosa of the entiresegment of jejunum orad to the anastomosis was reddened,with multifocal, bleeding ulcerations approximately 3 –5cm from the anastomosis. The hematoma from the previ-ous leak test was several centimeters distal to the site anddid not extend into the mucosal surface.After surgery, previous treatments were continued,and drain fluid production was monitored. The dog con-tinued to experience pain on fentanyl (3 –5/uni03BCg/kg/h), soketamine was added (loading dose of 0.5 mg/kg IV, then2–10/uni03BCg/kg/min). Nutritional supplementation with Pera-tive (Abbott Nutrition, Abbott Laboratories, Chicago, IL),KERBY ET AL . 1241 1532950x, 2023, 8, a hydrolyzed, peptide-based protein enteral formula, wasinitiated at 25% resting energy requirement (12 kcal/kg/day) via nasojejunostomy tube (NJT). Twelve hours later,the dog appeared dull and inappetent. Bloodwork findingsincluded neutrophilic leukocytosis with regenerative leftshift (WBC 32.3 /C2103//uni03BCL; reference range: 4.7 –15.2; neu-trophils 27.13 /C2103//uni03BCL; reference range: 2.41 –10.88;bands 1.62), anemia (PCV, 18%; RBC, 2.73 /C2103//uni03BCL; refer-ence range: 5.74 –8.64; reticulocytes 187.8 /C2103/uL; refer-ence range: 11.6 –92.0), hypoproteinemia (4.9 g/dL;reference range: 5.6 –7.6), monocytosis (1.62 /C2103//uni03BCL; ref-erence range: 1.1 –3.96), hypoalbuminemia (1.7 g/dL; refer-ence range: 3.2 –4.3), and resolved thrombocytopenia(393 000 /C2103//uni03BCL; reference range: 147 –423). Progressiveanemia caused a packed red blood cell transfusion(30 mL/kg IV over 6 h) to be administered, after whichthe hematocrit increased to 35%. At 24 and 48 h followingthe second resection and anastomosis, GT production was0.04 mL/kg/h and 0.6 mL/kg/h, respectively, and perito-neal drain production was 0.5 mL/kg/h and 1.7 mL/kg/h,respectively. Hypoalbuminemia progressed (1.5 g/dL; ref-erence range: 3.2 –4.3) at 48 h, so 800 mg/kg of caninealbumin was administered IV over 6 h. No intracellularbacteria were noted on cytology of peritoneal fluid, andfluid production was static; therefore, peritoneal drain suc-tion was discontinued. Within 72 h after surgery, the dogwas bright, and bloodwork showed resolution of the leftshift, anemia, and hypoproteinemia. Nasojejunal feedingwas increased to 24 kcal/kg/day, and the peritoneal drainwas removed.Five days after the second resection and anastomosis,the dog began eating spontaneously. Chemistry panelshowed improvement in hypoalbuminemia (2.7 g/dL; ref-erence range: 3.2 –4.3). Final results from the intraopera-tive culture were negative. The GT and NJT wereremoved, and IV fluids, ampicillin sulbactam, enrofloxa-cin, metoclopramide, and erythromycin were discontin-ued. The dog was discharged 6 days after the secondresection and anastomosis on omeprazole (1 mg/kg orallyevery 12 h), gabapentin (10 mg/kg orally every 8 –12 h),erythromycin (1 mg/kg orally every 8 h), and a bland diet.When contacted by phone, the owner reported thatthe dog was clinically normal 3 days and 3 months aftersurgery, with no recurrence of gastrointestinal signs.4

Question 114

Lahiani - 2023 - VCOT - Effects of Transfixation Pin Positioning on the Biomechanical Properties of Acrylic External Skeletal Fixators in a Fracture Gap Model.pdf

Answer 114

Preparation of ESF ConstructsTwenty-four type I –uniplanar unilateral –ESF were builtusing two 19 mm diameter acetal homopolymer rods(Grainger, Thornhill, Ontario, Canada) acting as bone models,21 mm acrylic columns (APEF System, Innovative AnimalProducts, Rochester, Minnesota, United States) and 3.2 mmsmooth trans fixation pins (Intramedullary Pin Steinmann T/TSmooth, Imex Veterinary Inc., Longview, Texas, United States).Thetwo synthetic rods were 100 mm inlength and held 20 mmapart, simulating a fracture gap, and 4 pins parallel to eachother were inserted in each segment, until they protruded atleast 2 mm from the rod. Pins were initially placed 10 mm fromthe fracture gap and then spaced at 15 mm intervals. Theacrylic columns were constructed using plastic tubularmoulds supplied by the manufacturer. Plastic tubes and ace-tate rods were pre-drilled with a 1.5 mm drill bit throughcustom-made drill guides to provide an accurate and repro-ductible positioning of the pins. For half of the constructs(n¼12), pins were inserted in the centre of the plastic tubes,for the other half they were positioned eccentrically at ¼ of themoulds ’internal diameter. The acrylic was finally poured intothe tubing system, allowing it to polymerize at room temper-ature for a minimum of 10 minutes before handling (►Fig. 1 ).Mechanical TestingEach construct was evaluated using an electromechanicaltesting machine (Insight 50EL, MTS Systems Corporation,Minnesota, United States). For each group of 12 constructs –with centric or eccentric pin positioning –6 underwent axialcompression and 6 were subjected to four-point bending.Mechanical testing was done as described in the AmericanSociety for Testing and Materials F1541 –17 for standardspecification and test methods for ESF constructs.12For axialcompression, the ends of the acetal homopolymer rods wereplaced in the load cell with a preload of 12 N to preventslippage. Constructs underwent axial loading at a rate of3 mm/min, until failure, using a 1 kN maximum load cell.For the four-point bending, forces were exerted perpendicularto the pins, and the gap placed in the centre of the brackets.Constructs were submitted to a preload of 20 N and a displace-ment of 3 mm/min was applied until failure, using a 50 kNmaximum load cell (►Fig. 2 ). For constructs with eccentricpins, bending was performed with the pins closer to theFig. 1 Photographs of the two types of constructs captured from above. At the top of the image is the acrylic connecting bar (black arrow), and at thebottom, the bone model (white arrowhead). ( A) Trans fixation pins in centric position. ( B) Trans fixation pins in eccentric position..tension surface of the acrylic columns. Load/displacementcurves were generated by the manufacturer ’s software (MTSTestSuite TW Elite, Eden Prairie, Minnesota, United-States) foreach construct. The yield load was de fined as the load sup-ported by the construct before going from elastic to plasticdeformation.12Determination of the linear portion of thecurve was done visually, as many constructs had small changesin the load/displacement response at the beginning of thegraph due to pin slippage. The most obvious linear portion ofthe curve, after which the graph became obviously non-linear,was identi fied. The 0.2% offset method was then used on thisportion of the curve to determine theyield load.12The stiffnesswas calculated from the slope of the linear portion of the load/displacement curve.12The strength, or failure load, was de-fined as the maximum load supported by the ESF constructsbefore catastrophic failure occurred. The mode of failure ofeach construct was recorded.Statistical AnalysisTo control homoscedasticity criterion of dependent varia-bles, Levene tests between groups were conducted. Threelinear models were then created: one for each dependentvariable (stiffness, yield and failure loads) including the twoexplanatory variables (trans fixation pin positioning andtype of mechanical stress), and the interaction betweenthese two explanatory variables. Shapiro –Wilk tests wereused on the residuals of the models, and they followed anormal distribution ( p>0.05). To highlight which groupsdiffered from each other within signi ficant interactionsshown by the linear model, Tukey post-hoc tests wereperformed with Benjamini –Hochberg correction appliedonp-values. Parametric data were shown as mean /C6stan-dard deviation. A p-value of less than 0.05 was consideredsignificant. To estimate the goodness-of- fit of the linearregression model, namely the percentage of variance of thedependent variable explained by the explanatory variables,adjusted R-squared (from 0%: no explanation to 100%: allthe variance is explained) were estimated for each model.Statistical analyses were performed using R software, ver-sion 4.0.3.13ResultsThe 24 biomechanical tests performed were successful,resulting in interpretable load/displacement curves. Theirresults are summarized in ►Table 1 .StiffnessThere was no difference in stiffness between constructs withcentric and eccentric pins for either axial compression orfour-point bending ( p¼0.373). Stiffness was only affected bythe type of mechanical stress, being 59% higher in four-pointbending than in axial compression (154 N/mm cf. 97 N/mm;p<0.001). The explanatory variables only explained moder-ately the variance of stiffness as the adjusted R-squared of themodel was 61.4%.Fig. 2 Construct with centric trans fixation pins subjected to axial compression ( A) and four-point bending forces ( B). In bending, the gap wasplaced in the centre of the bending brackets of the electromechanica l testing machine and the force was applied perpendicular to the pins..Yield and Failure LoadsFailure load was 28% lower in constructs with eccentric pins infour-point bending ( p<0.001). Failure load in axial compres-sion ( p¼0.715) and yield load in axial compression and four-point bending were not different between groups ( p¼0.535and p¼0.135 respectively). Yield and failure loads of theconstructs were signi ficantly higher in four-point bendingthan in axial compression ( p<0.001 for both). Both modelsfor yield and failure loads were highly informative as theadjusted R-squared were 87.1 and 89.5%, respectively.Mode of FailureFor all axial compression and bending tests of ESF with centricpins, as well asfor axial compression of ESF with eccentric pins,catastrophic failure occurred at the interface between theacrylic and the pin closest to the fracture gap. In four-pointbending of the eccentric constructs, failure occurred on theacrylic column, breaking longitudinally through all the pins onone side of the gap. In both centric and eccentric constructssubmitted to axial compression, thetrans fixationpins slid off asmall distance in both the bone model and the acrylic columnbefore reaching catastrophic failure.

Question 115

McKay - 2023 - VETSURG - Biomechanical evaluation of three adjunctive methods of orthopedic tension band-wire fixation to augment simulated patella tendon repairs in dogs.pdf

Answer 115

2.1 |Specimen processing andpreparationPrior to collection, a board-certified surgeon (DanielJ. Duffy) performed a focused orthopedic examinationand confirmed lack of visible abnormalities on pairedcanine hindlimbs. Hindlimbs were harvested from32 healthy, mixed-breed adult dogs immediately follow-ing euthanasia at a local animal shelter. Dogs wereeuthanized for reasons unrelated to this study usingsodium pentobarbital (dose: 1 mL/5 kg bodyweight).Prior medical history was available but patient demo-graphics, including patient sex and weight, were notreported. Given the secondary use of specimens, an insti-tutional animal care and use committee approval was notrequired by North Carolina State University VeterinaryTeaching Hospital, Department of Clinical Sciences.Patients were excluded if they had a history of orthopedicdisease, angular limb deformity, endocrine disorders, orwere receiving any medications within 1 month ofcollection.In each respective hindlimb, the patella and its associ-ated bone-muscle-tendon unit were dissected manually.Soft tissues were removed using a combination of bluntand sharp dissection. The distal part of the quadricepsfemoris muscles, patella and parapatellar fibrocartilages,PT, tibial tuberosity with each corresponding tibia werepreserved as the construct to be repaired and tested. Thequadriceps femoris muscles were transected at a mea-sured distance of 4 cm proximal to the proximal pole ofthe patella at the musculotendinous junction to aid withspecimen fixation. Distally, respective tibiae were disarti-culated at the tibiotarsal joint by transection of the jointcapsule and supporting collateral ligaments. All other tis-sues were removed and discarded. Saline (0.9% NaCl)was used during harvest and dissection to keep speci-mens moist and prevent desiccation using a spray bottle.After collection, each specimen was labeled, wrapped insaline-soaked gauze, and stored in a thermostatically con-trolled environment at /C020/C14C using a validated tech-nique in impervious bags.19Prior to tenotomy, repair andbiochemical testing, specimens were thawed at roomtemperature (21/C14C) for 12 h.202.2 |Treatment groupsPrior to tenotomy and surgical repair, each hindlimb wasrandomly assigned to one of three treatment groups(n=18 hindlimbs/group; 54 specimens total). A fourthgroup ( n=10 hindlimbs), composed of untenotomizedspecimens, was used to assess and validate test methodol-ogy and serve as a control group representing strengthand failure mode of native tissues. Hindlimb specimensoriginating from the same cadaver were controlled frombeing placed within the same group.On the day of testing, the PT was further dissectedusing a #15 Bard-Parker scalpel blade if any residual jointcapsule and patella bursal attachments were present.Respective PTs were then uniformly transected on a flatand durable surface to provide retropatellar pressure andallow for a standardized tenotomy using a #10 scalpelblade across the midbody of the PT, at a measured dis-tance of 20 mm from the enthesis of the PT on the tibialtuberosity. All surgical repairs were performed by a board-certified small-animal surgeon (Daniel J. Duffy) experi-enced in tendon repairs both in clinical and research set-tings. Following tenotomy, photographic images wereobtained of the distal cut surface of each PT immediatelyadjacent and parallel to a calibrated millimeter ruler(iPhone XR; Apple, Cupertino, California) at a distance of10 cm. A single trained investigator (Yi-Jen Chang) mea-sured the cross-sectional area (CSA) of each distal PTstump three times using computerized software (Image J,National Institutes of Health, Bethesda, Maryland) fromwhich the mean CSA was calculated.Primary tenorrhaphy was performed in all tenoto-mized specimens using a core LL suture technique using2–0 polypropylene suture (Surgipro; Covidien Ltd, Dub-lin, Ireland), as described previously (Figure 1A).21–24Asuture was first passed through the proximal tendon endtransversely 1 cm from the transected end, a longitudinalbite was then taken 1.5 cm from the same severed proxi-mal tendon end, and finally a suture was passed from theupper surface 1 cm from the severed end in a longitudi-nal direction across the gap, through the tendon, andrepeated within the distal tendon end.24A simple contin-uous epitendinous suture (SCES) was performed using acontinuous circumferential pattern with 3 –0 polypropyl-ene suture (Surgipro; Covidien Ltd, Dublin, Ireland) withbites placed 2 mm apart and 5 mm from the transectedtendon ends.23,24Both core and epitendinous patternswere tightened to achieve close apposition of tendonends, then secured with a square knot followed by threethrows; a suture was then cut 3 mm from the knot.Suture size was elected based upon prior publishedresearch,25,26used in adherence with the manufacturer'sguidelines.Following completion of the primary tenorrhaphy,repairs were then randomized ( https://www.randomizer.org; Lancaster, Pennsylvania) to receive one of three dif-ferent augmentation techniques using 18 gauge 316 Lveterinary orthopedic wire (Imex, Longview, Texas) asdescribed with either a transpatellar, suprapatellar, or1142 MCKAY ET AL . 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 Licensecombined (transpatellar and suprapatellar) TBW tech-nique.1,5,7,14Constructs in the transpatellar group(Figure 1B) were augmented with a TBW followingdrilling using a 2.0 mm drill bit (Securos; BITE Bit,Neuhausen, Germany) to create transverse bone tunnelsin a mediolateral direction through the middle(50% width/50% height) of the patella and a mediolateralhole in the cranioproximal tibia at a measured distanceof 10 mm caudal to the tibial tuberosity. Wire was passedmanually through both drill holes to encircle the PT andthe distal limb was then mounted in a vice. The patellawas held proximally and wire tightened with wiretwisters (Securos; Wire Twister TC 700, Neuhausen,Germany) until there was removal of all slack in the wirewithout causing local deformation of the patella tendon.In the suprapatellar group (Figure 1C), constructswere augmented using an adjunctive suprapatellar TBWthat was placed through the PT immediately proximal toFIGURE 1 Lateral and craniocaudal images showing (A) The patella tendon (PT) following sharp tenotomy and tenorrhaphy using acore locking-loop pattern and simple continuous epitendinous suture (SCES) at a measured distance of 20 mm from the enthesis of the PTon the tibial tuberosity. The location of the mediolateral hole in the cranioproximal tibia can be seen at a measured distance of 10 mmcaudal to the tibial tuberosity. (B) Constructs in the transpatellar group were augmented with a tension band wire (TBW) after drilling atransverse bone tunnel in a mediolateral direction through the middle (50% width and 50% height) of the patella using a 2.0 drill bit.Orthopedic wire was passed manually through both drill holes in the patella and proximal tibia to encircle the PT using the standard AOtechnique for placement of orthopedic wire. (C) Constructs in the suprapatellar group used a TBW that was placed through the proximalpatellar tendon immediately adjacent to the dorsal aspect of the patella using the hub of an 18 gauge needle to facilitate uniform passage in amediolateral direction. Distally, the wire was placed through the cranioproximal tibia as described for the transpatellar group.(D) Constructs in the combined group were repaired using both transpatellar and suprapatellar TBW techniques as described for thosegroups above. Tendon repairs were augmented using 18 gauge 316 L veterinary orthopedic wire in all experimental groups where a tensionband was used. In the control group (not shown), native musculotendinous constructs were tested without tenotomy, tendinous repair orTBW augmentation to verify the study methodology.MCKAY ET AL . 1143 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 Licensethe dorsal aspect of the patella using the hub of an18 gauge needle to facilitate uniform passage in amediolateral direction to engage the medial and lateralparapatellar fibrocartilages, respectively. Distally, thewire was passed through the cranioproximal tibia asdescribed for the transpatellar group.In the combined group (Figure 1D), constructs wereaugmented using both transpatellar and suprapatellarTBW techniques as described for the designated groupsabove. Transosseous bone tunnels were drilled in the tib-ial tuberosity as described with both wires from thesuprapatellar and transpatellar group traversing the sin-gle bone tunnel. In all groups (transpatellar, suprapatel-lar, and combined) where TBW augmentation was used,wire was twisted using wire twisters and cut to a lengthof three twists with wire cutters (Securos; Wire Cutters,Neuhausen Eck, Germany).In the control group ( n=10), native musculotendi-nous constructs were tested without tenotomy, tendinousrepair, or TBW augmentation, to verify the study method-ology and to assess the tensile strength and stiffness ofintact specimens.2.3 |Biomechanical testingBiomechanical testing was performed using a materialstesting machine (Instron, Norwood, Massachusetts)with constructs tested at room temperature. A high-definition camera (Panasonic, Newark, New Jersey)recorded tests at 50 frames/s positioned a standardizeddistance of 30 cm, level with the tenotomy. The proxi-mal tibia, tibial tuberosity, PT, and patella were allwithin the viewing window. Calibrated software(Matlab R2018b, Mathworks, Natcik, Massachusetts)was synchronized with video recordings using an auto-mated triggering system to allow for simultaneousevaluation of both biomechanical data and frame datato allow for load calculation at both 1 and 3 mm gapformation.Following placement within the custom testing appa-ratus (SKU-1652-1; Sawbones, Vashon Island, Washing-ton), constructs were mounted on a 1000 N load cell. A5 mm bone tunnel was drilled transversely through thediaphysis of the tibia and a 4 mm stainless-steel boltpassed through the clamp and pre-drilled hole to preventrotational changes. Proximally, the remaining distal mus-culature of the quadriceps femoris muscle was securedproximal to the patella sesamoid using a servo-hydrauliccompressive pneumatic clamp (2kN, Instron, Norwood,Massachusetts) and the PT was vertically aligned. Thelong axis of the tibia was then positioned at an angle of135/C14to the PT using a medical goniometer.27Thepneumatic clamp was positioned 10 mm proximal tothe patella to prevent any possible interactionbetween the holding clamp and TBW during testing.Following positioning, specimens were preloaded to2N a n d t h e s y s t e m r e c a l i b r a t e d t o z e r o . W i r e s f o reach group were then further twisted to a load of10 N and wires cut to a length of four twists and themachine recalibrated to ach ieve a consistent restingbaseline among specimens. Constructs were distractedat 20 mm/s until the point of failure. Load and dis-placement data was collected at a frequency of100 Hz with assessment of time (seconds),displacement (millimeters), and load (newtons).Load displacement (LD) curves were created usingthe tensile-testing system and subsequently identified thebiomechanical variables of interest including yield, peak,and failure loads. Yield load was defined as the load atthe point where the first deflection in linearity of the LDcurve occurred indicating a visual change from elastic toplastic deformation of the construct. Peak load wasdefined as the highest measured load during each test.Failure load was defined as the load applied at the timeconstruct failure measured by an acute load drop of>50%. Construct stiffness (N/mm) was defined as theextent to which repaired constructs resisted deformationto an applied load that was calculated at 60% –80% ofyield load measured over the elastic region of the LDcurve. Stiffness was calculated using a coded program(Matlab version R2018b; Mathworks). Mode of failurewas recorded during testing and following review ofhigh-speed video footage. From video footage and syn-chronized load data, gap formation was calculated bymeasuring 1 and 3 mm gaps at the shortest distancebetween tendon ends. Measurements were performed fol-lowing calibration of digital calipers to a ruler of knownlength placed parallel and adjacent to the repaired con-struct (Image J, NIH, Bethesda, Maryland). The times(s) at which 1 and 3 mm gap formation occurred wascross-referenced with the recorded load data to calculateloads at which gap formation occurred between tendonends. Data were recorded as “no gapping ”if failure of theconstruct occurred prior to identification of an identifi-able gap between tendon ends.2.4 |Statistical analysisPilot testing was performed using n=9 hindlimbs torefine the study design and perform a power analysis.Pilot data was not included within the final statisticalanalysis. An a priori power analysis was performed usingpilot data and determined that ≤15 specimens/groupwould provide an 80% power to detect a mean difference1144 MCKAY ET AL . 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 Licenseof 50 ± 20 N between groups with 90% confidence.A Shapiro –Wilk test assessed the data for normality.Continuous variables were normally distributed anddescribed using means ± SDs. A mixed linear modelassessed differences in biomechanical loads and stiffnessdata, with experimental group considered a fixed effectand cadaver a random effect. A Fisher's exact test com-pared failure modes and proportional distributionof gap formation between tendon ends. All analyseswere performed using a statistical software program(v.9.4, SAS, Cary, North Carolina) and pvalues less than.05 were considered statistically significant.3|RESULTSNo specimens were rejected at the time of specimen har-vest and dissection. All construct repairs and biomechan-ical testing were performed without observed proceduralerror. Left and right hindlimbs were distributed equallyamong groups ( p=.44). Mean ± SD CSA of tendons inthe transpatellar, suprapatellar and combined group was0.26 ± 0.05, 0.26 ± 0.05, 0.23 ± 0.04 with no difference(p=.30) between groups.Combined transpatellar and suprapatellar TBW aug-mentation was superior to either transpatellar or supra-patellar groups alone (Table 1). The combined groupdiffered regarding yield ( p=.0008), peak ( p=.004),and failure loads ( p=.005). In the combined group,yield loads were 71% greater than the transpatellar(p=.0068) and 60% greater than the suprapatellargroups ( p=.02) respectively. Peak loads in the com-bined group were 23% greater than the transpatellargroup ( p=.04), and 30% greater than the suprapatellargroup ( p=.009). Similarly, the combined group failedat greater loads compared to both transpatellar (23%,p=.048) and suprapatellar groups (30%, p=.01). Con-struct stiffness was greater in the combined group(p=.04). Mean construct stiffness of suprapatellar con-structs was lower compared to other groups ( p< .002)(Table 1).There was no difference regarding the occurrence of1 or 3 mm gap formation between groups (1 mm, p=.05;3 mm, p=.06). However, the loads required to producea3 m mg a pw e r eg r e a t e rf o rt h ec o m b i n e dg r o u p(p=.036). There was no difference in loads required toproduce a 1 mm gap among groups ( p=.056); however,a1m mg a pw a so b s e r v e di n6 1 %( 1 1 / 1 8 )o ft r a n s p a t e l l a rconstructs, 39% (7/18) of sup rapatellar constructs, and22% (4/18) of combined constructs (Table 2). Followingas i m i l a rt r e n d ,3m mg a p sw e r eo b s e r v e di n3 9 %( 7 / 1 8 )of transpatellar, 22% (4/18) of suprapatellar, and 6%(1/18) of combined wire constructs respectively(Table 2).Three different failure modes were observed: tissuefailure, tenorrhaphy suture failure, or wire breakage. Insome constructs, two modes of failure were seen concur-rently. Tissue failure occurred due to patellar fracture,tibial tuberosity avulsion through the transosseous tun-nel, or proximal muscle tearing at the musculotendinousjunction of the quadriceps femoris muscle. For transpa-tellar constructs, failure occurred by core suture pullTABLE 1 Mean ± SD yield, peak, and failure loads (newtons, N) for simulated rupture of the patellar tendon (RPT) that underwenttransverse patellar tendon (PT) tenotomy and repaired using a core LL suture and SCES and augmented with either a transpatellar ( n=18),suprapatellar ( n=18), or combined technique using both a transpatellar and circumpatellar ( n=18) wire (18 gauge stainless steelorthopedic wire) alongside unaltered control tendons ( n=10).Group Yield load ( N) Peak load ( N) Failure load ( N) Stiffness ( N/mm)Transpatellar 277.9 ± 84.4 519.5 ± 78.1 517.5 ± 80.8 46.8 ± 11.6Suprapatellar 298.2 ± 116.3 491.2 ± 94.8 489.1 ± 95.7 28.5 ± 56Combined 475.7 ± 237.1 636.8 ± 154.2 634.3 ± 156.1 61.2 ± 22.5Controls 496.0 ± 189.7 583.5 ± 120.1 582.9 ± 120.0 58.8 ± 17.0TABLE 2 Proportions of theconstructs (%) and mean ± SD loads(newtons, N) in which 1 and 3 mm gapsoccurred between tendon ends duringbiochemical testing.Group1 mm gap formation 3 mm gap formationProportion (%) Force (N) Proportion (%) Force (N)Transpatellar 11/18 (61) 541.1 ± 88.1 7/18 (39) 553.6 ± 82.9Suprapatellar 7/18 (39) 380.4 ± 138.3 4/18 (22) 414.8 ± 150.0Combined 4/18 (22) 429.5 ± 255.3 1/18 (6)a228.0 ± 0.0aThe reader should note the load to cause 3 mm gap formation in a single construct in the combined grouplikely represents a single outlier within the data set.MCKAY ET AL . 1145 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 Licensethrough in 67% (12/18), repairs with failure due to wireunraveling in 50% (9/18), and avulsion of the tibial tuber-osity in 22% of repairs (4/18). In 3/12 constructs in thetranspatellar group, core suture failure occurred due towire elongation caused by the wire first cutting throughthe bone prior to complete avulsion of the tibial tuberos-ity. In the suprapatellar group, 67% (12/18) of constructsfailed by wire unraveling, 44% (8/18) by suture pullthrough, and 17% (3/18) by avulsion of the tibial tuberos-ity. Among experimental groups, fracture of thepatella was only observed in the combined wire group(2/18, 11%). In the combined group, the predominantfailure mode was by wire unraveling (39%, 7/18), withsuture pull through (17%, 3/18). Mode of failure differedbetween RPT repair techniques ( p< .001). However,mixed model analysis revealed no difference regardingthe failure mode of the TBW ( p=.29). Lastly, the pre-dominant mode of failure in the control group was mus-cle tearing and avulsion from the proximal pole of thepatella at the myotendinous junction (90%, 9/10).4

Question 116

Oyamada - 2023 - VETSURG - Extravesicular, two-layer, side-to-side ureteroneocystostomy combined with tension-relieving techniques for feline proximal ureteral obstruction - A retrospective study.pdf

Answer 116

Medical records of cats with ureteral obstruction close tothe UPJ that underwent the ETSUTT procedure at theMatsubara Animal Hospital (Osaka, Japan) betweenAugust 2018 and December 2021 were retrospectivelyreviewed. If a cat was still alive at the time of data collec-tion, a minimum of a one-year follow-up period wasrequired for inclusion in the study. Written consent wasobtained from all owners for the anesthetic, all possiblesurgical options, and a possibility of intraoperative modi-fication of the procedure.Retrieved data included signalment, pre- and post-procedural biochemical data, urinalysis and urinebacterial culture results, diagnostic imaging findings(i.e., pre- and post-operative abdominal ultrasonography,intraoperative fluoroscopy, and preoperative computedtomography [CT]), cause of obstruction, surgical proceduredetails, and clinical outcomes. Follow-up periods were clas-sified as intraoperative (from anesthesia induction to endof surgery), perioperative (aft er surgery until hospital dis-charge), short-term (from ho spital discharge to 30 daysafter surgery), and long-term (> 30 days after surgery).2.1 |Preoperative diagnostics,anesthesia, and analgesiaComplete blood count (CBC) and blood chemistry panelwere performed as a presurgical screening procedure. Inaddition, abdominal ultrasonography was performedprior to induction of anesthesia.Cefazolin (22 mg/kg IV) or cefmetazole (20 mg/kgIV) was administered 30 minutes before anesthesiainduction; administration was repeated every 90 min dur-ing surgery. Cats were premedicated using fentanyl(3/uni03BCg/kg IV) and midazolam (0.1 –0.2 mg/kg IV). Anes-thesia was induced using propofol (5 –6 mg/kg, to effect,IV) or alfaxalone (1 –2 mg/kg, to effect, IV) and wasmaintained with inhalation of isoflurane in oxygen. Fen-tanyl constant rate infusion (CRI) (10 –20/uni03BCg/kg/h IV)was used for intraoperative analgesia. Anesthetized catsOYAMADA ET AL . 973 1532950x, 2023, 7, were positioned in dorsal recumbency and nonenhancedCT was performed using a 4-row (Aquilion; Canon Medi-cal Systems, Tochigi, Japan) or 80-row (Aquilion Light-ning; Canon Medical Systems) multidetector CT scannerfor surgical planning.2.2 |Surgical procedureSurgical operating loupes ( /C23.5) were used during theprocedure. After a ventral midline celiotomy was per-formed, Balfour retractors were placed at the level ofcaudal pole of the affected kidney. Subsequently,fluoroscopic-guided antegrade pyelography (BV Pulsera;Philips Electronics Japan, Tokyo, Japan) was performedvia SUB nephrostomy tube by infusing dilute iodinatedcontrast material (Iohexol 300 injection; Fuji Pharma,Toyama, Japan, diluted 1:1 with 0.9%NaCl) in cats withSUB device when possible (Figure S1). Both CT findings(e.g., presence or absence of stones, location of obstruction,and number of stones) and gross findings (e.g., presence orabsence of stricture and distance between the kidney andbladder) during laparotomy were used for decision mak-ing. Cats were deemed as candidates for ETSUTT if theregion of ureteral obstruction involved the ureter proximalto the caudal pole of the affected kidney, including theUPJ. The obstructed ureter was isolated from the sur-rounding tissues using right-angle forceps, a bipolar elec-tric cautery, and cotton swabs (Figures 1andS2).2.2.1 | Extravesicular, two-layer, side-to-sideureteroneocystostomy combined with tension-relieving techniquesUsing a Castroviejo razor blade holder (GEUDER AG,Heidelberg, Deutschland) with an ophthalmic razorblade (Feather Safety RazorCo., Ltd., Osaka, Japan), alongitudinal incision was made at the medial aspect ofthe dilated UPJ or proximal ureter, over or just proximalto the obstruction site (Figure 2-1). Stones were removedif present, and a 3 –4 Fr soft polyvinyl chloride catheter(Atom multipurpose tube; Atom Medical Corp, Saitama,Japan) was retrogradely inserted into the renal pelvisfrom the incision site to collect a urine sample for bacte-rial culture. Once proximal patency was confirmed, a0.01800guidewire (Radifocus Guide Wire M; TerumoCorp, Tokyo, Japan) or a 24G intravenous catheter wasinserted distally through the incision site to confirm dis-tal patency, and the incision was extended to 6 –7 mmusing microscissors (Figure 3). The ventral and lateral lig-aments of the bladder were incised using bipolar electriccautery to retract the bladder as cranially as possible, anda 4-0 polydioxanone (PDS; Ethicon US LLC) stay suturewas placed at the apex of the bladder.Renal descensus and ureterocystopexyAn incision was made through the fascia of the transversusabdominis muscle just lateral to the kidney and the kidneywas freed with the peritoneum attached (Figure S3). Thekidney was then translocated as caudally as possible andwas fixed to the body wall (nephropexy) using four to fivesimple interrupted sutures (4-0 PDS) engaging the renalcapsule to complete the renal descensus (Figures 2-2andS4). Once the bladder and ureter were retracted craniallyand caudally, respectively, the ureter was fixed to the blad-der using two to three simple interrupted sutures encirclingthe ureter (4-0 PDS; Figures 2-3andS5). Once the uretero-pexy was completed, the remaining ureter distal to the fixa-tion site was resected. When pa rtial patency distal to theureteral incision site was expected, ureterocystopexy wasperformed without complete ligation of the ureter. Thebladder wall was sutured to the ureteral adventitia incorpo-rating a portion of its muscular layer.Two-layer, side-to-side ureteroneocystostomyA 1-cm incision was made at the seromuscular layer ofthe craniolateral bladder apex, and the bladder mucosawas exposed (Figures 2-4and S6). The exposed mucosawas then incised further for 6 –7 mm using microdissect-ing scissors (Figure 2-5,50).The seromuscular layer of the bladder and ureteraladventitia incorporating a portion of its muscular layerwere sutured together along the far side using a simpleFIGURE 1 Ureteral obstruction (left ureteropelvic junction).Ureteral stricture due to granulation tissue (white arrows).974 OYAMADA ET AL . 1532950x, 2023, 7, continuous pattern (7-0 PDS; Figures 2-6andS7). If therewas insufficient space in the dilated ureter for a simplecontinuous pattern, three simple interrupted sutureswere used. The bladder mucosa and the full layer of theureter were sutured together using a simple continuouspattern (7-0 PDS; Figures 2-7andS8) finishing the two-layer suture at the far side, leaving the two lumens open.A ureteral catheter was placed to drain urine fromthe renal pelvis during the early postoperative period. An18G intravenous catheter was inserted through the blad-der incision, and a 0.01800or 0.03500guidewire (TerumoCorp) was guided towards the bladder trigone andthrough the urethra out the vulva/prepuce. A 3 –4-Fr (formale) or 5-Fr soft polyvinyl chloride catheter (Atom Med-ical Corp) was inserted retrogradely over the guidewireand out the bladder incision. Scissors were used to createthree to five additional side holes on the catheter to alsoallow urine to drain from the bladder. The tip of the cath-eter was then passed through the ureteral incision to therenal pelvis (Figures 2-8andS9) and the opposite end ofthe catheter was connected to a closed collection bagfor at least 1 –2d a y s a n d u p t o 5 –7d a y s d u r i n g t h epostoperative period to monitor urine output. Insome cats with higher activity levels, the oppositeFIGURE 2 Extravesicular, two-layer, side-to-side ureteroneocystostomy combined with tension-relieving techniques (ETSUTT). (1) Alongitudinal incision is made at the medial aspect of the dilated ureteropelvic junction or proximal ureter, over or just proximal to theobstruction site. (2) Renal descensus and nephropexy: the kidney is moved caudally and fixed to the body wall. (3) Ureterocystopexy: thebladder is retracted cranially, and the ureter is retracted caudally; the ureter is fixed to the bladder using 2 –3 sutures with 4-0 polydioxanone(PDS). (4) Around the area craniolateral to the bladder apex, a 1-cm incision is made at the seromuscular layer, and the bladder mucosa isexposed. (5 and 50)A6 –7 mm incision is made at the exposed mucosa using micro-dissecting scissors. (6) Far side outer: the seromuscularlayer of the bladder is sutured on the adventitia layer of the ureter using a simple continuous pattern with 7-0 PDS. (7) Far side inner: thebladder mucosa is sutured on the full layer of the ureter using a simple continuous pattern with 7-0 PDS. (8) A 3 –4 Fr (for male) or 3 –5 Fr(for female) soft polyvinyl chloride tube with several holes is advanced retrogradely over a guidewire via the urethra. The tube is passedthrough the bladder incision. The tip of the tube is then passed through the ureter incision to the pelvis. (9) Near side inner: the bladdermucosa is sutured on the full layer of the ureter using a simple interrupted pattern with 7-0 PDS. (10) Near side outer: The seromuscularlayer isolated from the bladder mucosa is loosely sutured to the ureter adventitia using a simple interrupted pattern with 7-0 PDS.OYAMADA ET AL . 975 1532950x, 2023, 7, end of the catheter was connected to a house-madeurine bag tucked underneath postoperative pants(Elizabeth Wear; Strawhouse, Hyogo, Japan) to pre-vent catheter dislodgement.The bladder mucosa and full layer of the ureter onthe near side were sutured using a simple interruptedpattern (7-0 PDS; Figures 2-9,4,S10,a n d S11). Thetwo-layer ureteroneocystostomy was completed bysuturing the seromuscular layer isolated from thebladder mucosa loosely to the ureteral adventitiaincorporating a portion of its muscular layer using asimple interrupted pattern (7-0 PDS; Figures 2-10andS12).NephrocystopexyThe area near the bladder apex was fixed to the caudalpole of the kidney using 2 –3 cruciate pattern sutures (4-0or 5-0 PDS; Figures 5andS13) to complete the ETSUTTprocedure.Leak test and closureFluoroscopic-guided retrograde pyelography was performedvia ureteral catheter by infus ing dilute iodinated contrastmaterial (diluted 1:1 with 0.9%NaCl) in all cats. After con-firming the proximal end of the catheter being placedwithin the renal pelvis and no leakage at the ureteroneocys-tostomy site (Figure S14), a closed suction drain (SuctionDrainage Kit, Kirikan Ltd, Tokyo, Japan) was placed intothe abdominal cavity to monitor postoperative urine leak-age. Celiotomy closure was per formed using conventionalmethods, and a nasoes ophageal feeding tube (6 or 7-Fr softpolyvinyl chloride tube, Atom Medical Corp) was placed.2.3 |Postoperative careFor postoperative analgesia, fentanyl citrate (2 –3/uni03BCg/kg/h, IV CRI) was administered for 15 –24 h immedi-ately after surgery, followed by buprenorphine (0.01 –0.02 mg/kg, every 8 –12 h IV or subcutaneously) for 3 –FIGURE 3 A longitudinal ureteral incision was made at themedial aspect of a dilated ureteropelvic junction (black arrows).FIGURE 4 Near side inner layer closure. The top of thephotograph is cranial and the left side is medial. The bladdermucosa (black arrow) and full layer of the ureter (white arrow)were sutured using a simple interrupted pattern.FIGURE 5 Nephrocystopexy was performed at last to fix thearea near the bladder apex to the caudal pole of the kidney (yellowarrows).976 OYAMADA ET AL . 1532950x, 2023, 7, 4d a y s . M o n i t o r e d p a r a m e t e r s i n c l u d e d b o d y w e i g h t ,CBC, total serum protein concentrations, renal func-tion parameters (blood urea nitrogen (BUN), creati-nine, and electrolytes), the quantities of fluid collectedthrough the closed suction drain, urine output, andabdominal ultrasonography .P o s t o p e r a t i v em a n a g e -ment also included IV fluids (Lactated Ringer's solu-tion) at the rate adjusted ba sed on hydration status andurine output, IV antibiotics, and enteral feeding via anasoesophageal tube as needed (renal liquid or criticalcare liquid; Royal Canin). Antibiotics used during thepreoperative period were co ntinued for seven days. Ifurine bacterial culture tested positive, appropriate anti-biotics were prescribed for 10 –14 days. The ureteralcatheter was typically removed 5 –7d a y sa f t e rs u r g e r y .Cats were discharged when kidney function parame-ters and urine output reached a plateau.2.4 |Short- and long-term follow-upAf o l l o w - u pe x a m i n a t i o na n ds u t u r er e m o v a lw e r eperformed 10 –14 days postoperatively. Bloodwork(CBC, total serum protein concentration, BUN, creati-nine, calcium, phosphorus, sodium, potassium, andchloride) and abdominal u ltrasonography were per-formed. If the cat was clinically stable, anotherfollow-up examination (i.e. ,b l o o d w o r ka n da b d o m i n a lultrasonography) was performed at 30 days postopera-tively and every 2 –6m o n t h st h e r e a f t e r .U r i n a l y s i sa n durine bacterial culture were performed at the authors'discretion when there was clinical suspicion of bacte-rial infection.On ultrasonographic examination, the size of renalpelvis on the operated kidney was measured in the trans-verse plane and any other abnormalities were recorded ifpresent. Ureteral patency during the follow-up periodwas considered present based on the following ultrasono-graphic findings; no or mild dilation of the renal pelvis;no worsening of the dilation in cases of mildly dilatedrenal pelvis; absence of obstructing materials in theremaining ureter; and subjectively appropriate amount ofurine contained in the bladder in cases of absence of thecontralateral kidney.2.5 |Statistical analysisKaplan –Meier analysis was used to generate survivalcurves, and lognormal distributions were used to calcu-late survival rates at 1 month, 3 months, 6 months,1 year, and 2 years.3|RESULTS3.1 |SignalmentA total of 10 cats were identified after a medical recordreview. Table 1presents a summary of signalment anddetailed clinical descriptions of each case. Three wereneutered males, six were spayed females, and one was anintact female. The median age was 5.6 years (min –max:1.1–17.8 years); the median bodyweight was 3.6 kg (min –max: 2.4 –5.5 kg). The breeds were five Domestic short-hair and one each of Russian blue, Ragdoll, Americanshorthair, Scottish fold, and Maine coon. The preopera-tive clinical signs included anorexia ( n=8), lethargy(n=5), vomiting ( n=3), decreased urine output(n=1), polydipsia ( n=1), hematuria ( n=1), polla-kiuria ( n=1), weight loss ( n=1), and no clinical signs(n=1). The cat (no. 4) without clinical signs was trans-ferred to our hospital after nephrostomy tube placementat the primary care clinic and was clinically stable uponadmission.3.2 |Diagnostic findingsPre- and postoperative renal bloodwork results are shownin Table 2.Preoperative serum BUN concentrations were ele-vated in nine of 10 cats, and creatinine concentrationswere elevated in eight of 10 cats. Preoperative serumpotassium concentrations were elevated in five of 10 cats.Preoperative serum phosphorus concentrations were ele-vated in four of seven cats.The median preoperative renal pelvis diameter inthe affected kidney was 6.2 mm (min –max: 3.0 –8.7 mm, reference interval: <2 mm34n=9). In onecat, the renal pelvis diameter was not measuredbecause a nephrostomy tube was placed at the primarycare clinic and there was no measurable dilation of therenal pelvis. Nephroliths were identified in the affectedkidneys using ultrasonography and/or CT in sevencats. Imaging diagnostic fin dings of affected kidneysindicative of chronic kidney disease were found in nineof 10 cats, including small kidney, hyperechoic cortex,reduced corticomedullary distinction, and irregularshape of renal contour confirmed by ultrasonographyor CT. In addition, CT revealed distended pancreas anddilated pancreatic duct in one cat and the Dacron cuffof the cystostomy tube incorporated into the jejunumin another cat. Ultrasonography and CT findings ofnonaffected kidneys reveal ed atrophic kidneys in fivecats, no obvious abnormality in two cats, and absenceOYAMADA ET AL . 977 1532950x, 2023, 7, TABLE 1 Summary of 10 cats treated using an extravesicular, two-layer, side-to-side ureteroneocystostomy combined with tension-relieving techniques pr ocedure.BacteriuriaCatAge(years) Sex Cause of obstructionOperatedsideCondition ofcontralateralkidney Pre-surgical Post-surgicalResidualrenalcalculiSurvivaltime (days) Cause of death1 4.2 IF UreterolithiasisUreteral necrosisLeft Atrophic Yes No Yes 1130 NA2 5.2 SF Ureterolithiasis(intraoperativeureterolith migration)Left Atrophic No Yes Yes 1110 NA3 6.3 NM Occlusion of SUB deviceUreteral strictureLeft Atrophic No No Yes 1229 NA4 1.1 SF UreterolithiasisIatrogenic ureteral injuryRight Unremarkable No No No 870 NA5 2.3 SF Ureterolithiasis Left Unremarkable No No Yes 766 NA6 6.1 SF UreterolithiasisOcclusion of SUB deviceUreteral strictureRight Absent No No No 86 Unknown7 14.0 NM Ureteral stricture Left Atrophic No No No 242 Progression of CKD8 7.8 NM UreterolithiasisPyelonephritis after SUBdevice replacementLeft Absent Yes Yes Yes 530 NA9 4.4 SF UreterolithiasisOcclusion of SUB deviceUreteral strictureRight Atrophic No Yes Yes 291 Pancreatitis10 17.8 SF Occlusion of SUB deviceUreteral stricturePyelonephritisLeft Absent Yes Yes Yes 372 NAAbbreviations: IF, intact female; CKD, chronic kidney disease; NA, not applicable; NM, neutered male; SF, spayed female.978 OYAMADA ET AL . 1532950x, 2023, 7, of the contralateral kidney in three cats. Intraoperativepyelography was performed in two cats prior to theETSUTT, which revealed proximal ureteral obstructionin both cats and contrast defect suggestive of tissuegrowth in one cat (Figure S1).Urine bacterial culture were performed in four catsprior to surgery. Two of four cats had positive results; onecat started antibiotics before surgery because of pyrexia,but the remaining cat was clinically stable, so we startedantibiotics on the day of surgery. Three of 10 cats hadUTI confirmed with bacterial culture and antimicrobialsusceptibility testing of a urine sample from the renal pel-vis or urinary bladder at surgery. Identified microorgan-isms were Staphylococcus simulans and Escherichia coli(n=1),Enterococcus spp. ( n=1), and Pseudomonas aer-uginosa (n=1).All cats had unilateral ureteral obstruction; theaffected ureters were on the left in seven cats and on theright in three cats. Most cats had multiple causes ofobstruction and the majority of causes were ureterolithia-sis (n=7), ureteral structure ( n=5), and occlusion ofthe SUB device ( n=4) (Table 1).Concurrent surgical procedures were performed in sixcats (i.e., SUB device removal: n=3, SUB device removaland nephrostomy catheter exchange of the contralateralSUB device: n=1, SUB device removal, intestinalresection and anastomosis: n=1, and ovariohysterectomy:n=1). All surgical procedures were performed by one sur-geon. The median overall operation time was 204 minutes(min–max: 140 –288 min). Temporary ureteral catheterswere removed at a median of 6 days (min –max: 2 –7 days)postoperatively.3.3 |Postoperative outcomesAll 10 cats were discharged from the hospital. Themedian hospitalization duration was 8.5 days (min –max:5–16 days), but in three of 10 cats, hospitalization wasextended per each owner's request. Postoperative ultraso-nographic examinations revealed no or mild dilation ofthe renal pelvis (Video S1. Postoperative abdominal ultra-sound images). The median postoperative renal pelvisdiameter at the last visit was 2.5 mm (min –max: 0.8 –5.9 mm; n=8). Renal pelvis dilation did not progress inany of the cats during the study period (Table 2).No intraoperative procedure-related complicationswere encountered. Perioperative complications includedureteral catheter dislodgement ( n=3), pollakiuria(n=2), and dysuria ( n=1). Ureteral catheter dislodge-ment occurred 2 –3d a y sa f t e rs u r g e r yi nt h et h r e ec a t s ,but no further treatments were required. The two catswith pollakiuria and one cat with dysuria spontaneouslyrecovered within 10 to 14 days after surgery without anytreatment. During the short-term postoperative period,recurrent pyelonephritis occurred in two cats (nos.8 and 10). The infections in both cats were treated withantibiotics selected based on susceptibility testingresults, and the infections were controlled. However,after antibiotics were discontinued, the infectionsrecurred and transitioned to chronic pyelonephritis.Passage of the remaining renal stones was observed11 days postoperatively in one female cat. This cat even-tually voided three stones (3, 3.5, and 5 mm) at home.The only long-term complication in this study popula-tion was the development of UTI. Urine bacterial cultureTABLE 2 Median values for blood work and renal pelvis diameter variables of 10 cats treated using an extravesicular, two-layer, side-to-side ureteroneocystostomy combined with tension-relieving techniques.BUN (mg/dL)RI: 17.6 –32.8 nCreatinine(mg/dL)RI: 0.8 –1.8 nPotassium(mEq/L)RI: 3.4 –4.6 nPhosphorus(mg/dL)RI: 2.6 –6.0 nRenal pelvisdiameter (mm)RI: <2 nPreoperative 61.7 (27.8 –182.7) 10 3.0 (1.3 –16.6) 10 4.6 (3.7 –5.4) 10 6.6 (4.7 –15) 7 6.2 (3.0 –8.7) 10Discharge 29.6 (15.6 –48.2) 10 1.8 (1.0 –3.6) 10 4.3 (3.2 –5.6) 10 5.4 (3 –6.6) 3 3.1 (2.4 –7.8) 101 month 35.8 (29.0 –48.7) 9 1.7 (1.3 –3.5) 10 4.4 (3.6 –4.7) 9 5.2 (3.1 –5.5) 5 2.5 (1.0 –6.2) 103 months 38.7 (27.6 –85.7) 8 1.6 (1.3 –5.7) 8 4.5 (3.1 –4.9) 8 4.7 (4.2 –6.9) 5 2.2 (0.8 –6) 76 months 42.2 (27.5 –81.2) 7 2.3 (1.5 –3.2) 7 4.3 (3.9 –4.5) 6 5.0 (3.6 –7.0) 4 2.7 (0.5 –5.6) 69 months 41.7 (25.1 –129.8) 5 1.9 (1.2 –3.8) 6 4.2 (4.0 –4.9) 5 3.2 (3.2 –5.0) 3 2.5 (0.8 –6.1) 512 months 30.3 (20.9 –134.0) 7 1.9 (0.9 –7.5) 7 4.2 (3.7 –4.8) 6 3.6 (2.6 –4.1) 3 1.6 (0.8 –5.9) 6Last visitMedian: 585 days(71–1185)66.9 (23.8 –140.0) 10 1.9 (1.2 –7.8) 10 4.2 (3.6 –4.6) 9 3.9 (3.2 –7.2) 6 2.5 (0.8 –5.9) 8Note : Median values (min –max).Abbreviations: BUN, blood urea nitrogen; RI, reference interval.OYAMADA ET AL . 979 1532950x, 2023, 7, was positive in four of 10 cats at some time after surgery.Identified microorganisms were Enterococcus spp.(n=2),P. aeruginosa (n=1),S. simulans (n=1),E. coli(n=1), and Staphylococcus felis (n=1). Two of four catswith positive urine culture results were the aforemen-tioned cats with chronic pyelonephritis; the remainingtwo cats had newly identified bacteriuria after surgery.Among the two newly identified cats, clinical signs asso-ciated with bacteriuria were observed in one cat at threedifferent times, 167 days, 559 days, and 860 days, aftersurgery. This cat was successfully treated with antibioticson each occasion. In another cat, antimicrobial therapywas not prescribed because the cat had no bacteriuria-associated clinical signs.3.4 |Long-term outcomesSeven of the 10 cats were alive at the end of this retro-spective study. The median follow-up time was 648 days(min –max: 86 –1229 days). None of the seven cats devel-oped recurrent ureteral obstruction during the studyperiod. Two required regular subcutaneous fluid adminis-tration to maintain hydration; the other five remainedclinically well without any medical treatment. Three ofthe 10 cats died after surgery. The survival times of thesecats were 86 days, 242 days, and 291 days. The cause ofdeath was unknown in one cat, and progression ofchronic kidney disease and pancreatitis in the other twocats. These outcomes were considered unrelated to theETSUTT procedures. The cat that died from an unknowncause was examined by a primary care veterinarian foranorexia and vomiting right before death. However, renalpanel and urinalysis results were unremarkable, and thecat died shortly after the visit, at home.Survival rates at 1 month, 3 months, 6 months,1 year, and 2 years were 98.2% (95% CI: 59.4 –99.9%),94.0% (95% CI: 63.4 –99.3%), 88.9% (95% CI: 60.7 –97.6%),81.0% (95% CI: 52.6 –94.3%), and 70.5% (95% CI: 38.6 –90.0%), respectively (Figure 6).4

Question 117

Low - 2023 - JFMS - Surgical Management Of Feline Biliary Tract Disease - Decision-making and techniques.pdf

Answer 117

NA

Question 118

Froidefond - 2023 - VETSURG - Outcomes for 15 cats with bilateral sacroiliac luxation treated with transiliosacral toggle suture repair.pdf

Answer 118

2.1 |Medical records searchCats that were treated for a traumatic bilateral SILF bysurgical stabilization, using a transiliosacral toggle suturerepair system, were included in the study retrospectively.All cats enrolled in the study were consecutive cases pre-sented between April 2018 and April 2022, whichrequired SILF surgical treatment considering multipleclinical and radiographic criteria (degree of lameness,pain score, iliac wing displacement, pelvic canal collapse,concomitant pubic and ischial fracture and/or neurologi-cal deficits). All surgical procedures were performed bythe same boarded specialist in surgery. Cats wereincluded if at least immediate postoperative radiographswere available. Cats with unilateral SILF or bilateral SILFtreated nonsurgically or with a different surgical tech-nique were excluded. Medical records were reviewed forsignalment, history, and general physical, orthopedic andneurological evaluation findings, radiographs, concomi-tant disease, additional examinations, surgical, anesthesiaand hospitalization records, medications administered,survival to discharge, postoperative complications, andfollow up. Total hospitalization time, and time from sur-gery to discharge, were retrieved from hospitalizationrecords. Surgical times for the procedures were retrievedfrom anesthesia records.2.2 |Surgical procedureGeneral anesthesia protocols were set at the clinician's dis-cretion, depending on each cat's general medical condi-tion. Perioperative antibiotic therapy with IV amoxicillin-clavulanic acid (20 mg/kg) and locoregional analgesia withmorphine (0.2 mg/kg) and bupivacaine (0.9 mg/kg) givenepidurally were performed in all cases. Patients wereplaced in sternal recumbency in a position allowing thepelvic limbs to be hanging down, mimicking a standingposition with a straight pelvis (Figure 1). A standard bilat-eral dorsal approach to sacroiliac joints was performed foreach case with two separate skin incisions. Bone tunnelswere drilled (2.0 mm) into both iliac wings in a lateral-to-medial direction. The exit point aimed at being in thecenter of the C-shape cartilage area, constituting the artic-ular surface of the sacroiliac joint on the iliac side. Ventralretraction of both iliac wings was performed simulta-neously, with Hohmann retractors being placed just ven-tral to the sacral body, paying particular attention to L7and S1 nerve branches. A small 1 –2 mm deep mark wasperformed on each sacral articular surface at the intendedbone tunnel entry point with a 1.1 mm Kirschner wire toensure correct and maintained positioning of the C-shapeaiming device, allowing the tip to be “locked ”in one sacralmark while gentle traction is applied on the guide and aKirschner wire inserted into the appropriate sleeve on theother side. The Kirschner wire was then driven across thesacrum, and trans-sacral tunnel was generated with a984 FROIDEFOND ET AL . 1532950x, 2023, 7, 2.0 mm cannulated drill bit. Four strands of #2 UHMWPEcore with a braided polyester and UHMWPE jacket suturematerial (Fiberwire —Arthrex GmbH —Munich-Germany)attached onto the small button of a mini-TightRope systemwere passed through one iliac tunnel, trans-sacral tunnel,and contralateral iliac wing tunnel with the help of asuture passer for most cases. The suture was eventuallyput back through the four-hole button on the lateral aspectof the iliac wing. The first cases of the series had 2.7 mmtunnels performed to pass the small button of the mini-TightRope system through all tunnels directly with thehelp of the dedicated needle. Sacroiliac luxations werereduced while putting the toggle suture repair systemunder tension, using the appropriate tensioner to a forceof 20 N. Reduction was also maintained with manual pres-sure over the iliac wings and the base of the tail, respec-tively, in a craniocaudal and caudocranial direction. Bothsutures of the system were pretensioned successively. Onesuture was knotted classically with at least five squareknots while tension was maintained on the other suture.That suture was eventually tightened manually. Woundswere lavaged copiously prior to routine closure. Postopera-tive pelvic orthogonal radiographs were performed toassess for implant/tunnel positioning and for reduction ofthe luxations. Postoperative analgesia was performed withopioid administration (fentanyl, methadone, morphine, orbuprenorphine) according to the results of regular appro-priate pain scoring. Cats were discharged from hospitalonce they had been assessed as comfortable enough —asnot requiring any more opioid administration according topain scores obtained, with satisfactory ambulatory and uri-nary functions alongside a good general medical assess-ment. Strict cage rest was advocated for 2 months aftersurgery. Clinical and orthopedic examination was advisedat 2 and 6 weeks after surgery.2.3 |Measures of outcomePostoperative radiographs were reviewed for sacral tun-nel and implant positioning. Measurements were per-formed to assess satisfactory surgical reduction of bothhemipelvii, as previously reported:15,17 –19angle of devia-tion (AoD), pelvic canal width ratio (PCWR), and per-centage of reduction (PoR) (Figure 2). The PCWR wasevaluated by three operators, and means were used foreach measure. As previously described, a ratio greaterthan 1.1 is considered to be normal for PCWR.20Ap o s t -operative PoR of 100% is considered optimal. Radio-graphs available from the 6 week follow-up examinationwere reviewed for i mplant positioning, occurrence oftunnel widening, PCWR and sacroiliac reduction.Owners were also offered long-term radiographicrecheck (without sedation) for the specific purpose ofevaluating potential tunnel widening or loss of sacroil-iac reduction over time for cats that were still alive atthe time of this study.2.4 |Long-term follow upLong-term functional follow up was assessed with theuse of an owner questionnaire for each cat that was stillalive. The questionnaire was a combination of a Frenchtranslation of the Feline Musculoskeletal Pain Index21and a previously published survey.15FIGURE 1 Surgical positioning insternal recumbency. The thorax is heldin a doggy relax, and the pelvis laysdown on a bolster pillow, mimicking astanding position.FROIDEFOND ET AL . 985 1532950x, 2023, 7, 2.5 |Data analysisDescriptive statistics are reported for each variable. AShapiro –Wilk test was performed to assess for normaldistribution of AoD, PoR, and PCWR post operation, at6-week and final follow ups. A paired sample Student's t-test was performed to assess the evolution of parametersfollowing a normal distribution.3|RESULTSFifteen cats with bilateral SILF were included. Cats weredomestic shorthair ( n=14) and Siamese ( n=1). Tenwere female, half of them being entire, and five wereneutered males. Median age at surgery was 3.1 years (1 –13.9 years), with a median body weight of 4.0 kg (2.87 –5.75 kg). All cats went through a comprehensive clinicaltrauma assessment including thoracic and pelvic radio-graphs and abdominal point-of-care ultrasound examina-tion. Additional examinations were performed in somecats: Biochemistry ( n=6), complete blood count ( n=3),FeLV and FIV status ( n=2), retrograde contrast urethro-graphy ( n=1), lumbosacral and pelvic computedtomography examination ( n=1), other orthopedic radio-graphs (1), and blood typing ( n=1). Neurological exami-nation showed no clear abnormalities in 10 cats at thetime of admission, with five cats showing either moderate(n=4) or marked pelvic limb paresis with loss of motorfunction and deep pain in the tail ( n=1). This latter catwas also diagnosed with a complete and severely dis-placed sacrococcygeal luxation. Other concomitant condi-tions included pubic and/or ischial fractures ( n=8), typeI sacral fracture22(n=3), diffuse inguinal hematoma,tarsal shearing injury, tarsocrural joint luxation, pubicsymphysis separation, subcutaneous emphysema andpneumothorax, acetabular fracture, unilateral hip luxa-tion, anemia, and azotemia ( n=1 each). Overall, 14/15cats showed voluntary micturition prior to surgical treat-ment. Only three cases were identified with preoperativecraniocaudal displacement less than 50% on both sides.All three had concomitant pubic and/or ischial fractures,preoperative PCWR less than 1.1, and one also had theright ilium luxated ventrally to the sacrum. Average pre-operative displacement was 59.9% ( +//C032.8%) on theright side and 55.9% ( +//C023.1%) on the left side.All cats were treated using a mini-TightRope implantsystem. Type I sacral fracture ( n=3) did not interfereFIGURE 2 Measurement of the angle of deviation (AoD), pelvic canal width ratio (PCWR) and percentage of reduction (PoR). The AoDis defined as the angle between the sacral tunnel (T) and perpendicular line (P) to the sagittal plane (S) on ventrodorsal radiographs. ThePCWR is the ratio between pelvic width at cranial aspect of acetabuli (B) and width of caudal aspect of sacral joint surfaces (A),perpendicular to the sagittal plane (S) on ventrodorsal radiographs. The PoR is defined as (1 /C0[b/a])/C2100 where ais the length of the sacraljoint surface and bis the length of sacroiliac incongruence.986 FROIDEFOND ET AL . 1532950x, 2023, 7, with the surgical procedure, with most of the sacral artic-ular surface left intact. For cases that only underwentSILF stabilization ( n=11/15), the mean duration of thesurgical procedure was 80 minutes (50 –120 minutes).Postoperative antibiotic therapy and nonsteroidal anti-inflammatory drugs were prescribed at discharge in eachcase (amoxicillin-clavulanic acid, 12.5 mg/kg orally twicedaily for 10 days; meloxicam —0.05 mg/kg orally oncedaily for 7 days).3.1 |Short and medium-term clinicaland radiographic follow upOn immediate postoperative radiographs, mean absoluteAoD was 3.1 ± 2.8/C14(/C07.2/C14to+7/C14). Mean absolute PoRwere at 88.1 ± 11.2% and 91 ± 11.6% on the right and leftside, respectively. The PCWR was considered normal in14/15 cases, with a mean of 1.24 ± 0.08 (Table 1). Postop-erative CT-scan evaluation of the bone tunnels was per-formed on the first two cases, confirming proper tunnelplacement, without abnormal sacral cortical perforation.Median time between surgery and discharge was2 days (1 –6 days) for 13 cats. The other two cats died dur-ing hospitalization for reasons not directly related to theSILF surgical repair. All 13 cats were able to walk with-out assistance by the time of discharge without exacerba-tion of preoperative neurological signs. Of the survivingcats, 12 were presented at 2 weeks postoperative followup. One demonstrated a mild pelvic limb paresis, whichhad already improved. One postoperative complicationwas partial wound dehiscence. It eventually healed bysecondary intention uneventfully in 7 days. Major pelviclimb functional improvement was documented in theremaining cases.Ten cats were presented for first radiographic followup at a median of 44 days (39 –68 days) postoperatively.No statistical difference was found, with immediate post-operative values for AoD, PoR, or PCWR (paired sampleStudent's t-test): mean absolute AoD 2.4 ± 2.2/C14(p=.58),mean absolute PoR 84.2 ± 13.3% ( p=.17) and 87.4± 11.9% ( p=.56) on the right and left side, respectively,and mean PCWR 1.23 ± 0.12 ( p=.97), with two cats pre-senting a narrowing of the pelvic canal with PCWRbelow 1.10 (1.05 and 1.09, respectively) (Table 1). No signof sacral tunnel widening was identified. All cats werereported to have recovered good to excellent ambulatoryfunction, with no evidence of discomfort. No signs ofneurological disfunction (including urinary continence)were observed. Progressive return to normal exercise over6–8 weeks was recommended.One cat died approximately 3 months after sacroiliacstabilization at home for unknown reasons. The ownersdid not report any complications related to the surgerythat had been performed. Seven cats had a secondmedium-term radiographic follow up at a median of205 days postsurgery (71 –682 days). No signs of tunnelwidening or implant loosening were noted (Figure 3&Table 1). No significant changes in PCWR ( p=.15) orPoR ( p=.66 and 0.55 on the right and left side, respec-tively) could be identified between first and last radio-graphic follow ups (paired sample t-test).3.2 |Long-term follow upTwelve long-term follow-up questionnaires wereobtained at a median of 365 (119 –798) days postopera-tively. Anti-inflammatory or pain-killer medicationwas not required in any case. No persistent paresis wasreported, and no function al complication directlyrelated to the SILF treated could be identified. All catshad complete urinary and fecal continence. Fourowners reported that their cat had returned to a fullynormal activity. The other eight cats had returned toexcellent function, with only mild interference to per-form some activities (Table 2). Pain was evaluated as0b y9 / 1 2o w n e r s ;t h er e m a i n i n gt h r e eo w n e r ss c o r e dtheir cats ’pain at 2 ( n=2) or 3/10 ( n=1) over the2w e e k sp r i o rt oq u e s t i o n n a i r ec o m p l e t i o na n da t1 ,2 ,TABLE 1 Radiographic measurements for angle of deviation (AoD), percentage of reduction (PoR), and pelvic canal widthratio (PCWR).Immediatepostoperative(n=15)*#Firstfollow up n=10(median 44 days; 39 –68)*€Finalfollow up n=7(median 205 days; 71 –682)# € pAbsolute AoD 3.1 ± 2.8/C142.4 ± 2.2/C142.4 ± 2.7/C14*.58j#.51j€.90Absolute PoR left side 88.1 ± 11.2% 84.2 ± 13.3% 86.0 ± 13.3% *.17 j#.24j€.55Absolute PoR right side 90.1 ± 11.6% 87.4 ± 11.9% 97.0 ± 11.1% *.56 j#.46j€.66PCWR 1.24 ± 0.08 1.23 ± 0.12 1.22 ± 0.09 *.97 j#.13j€.15Note: Results are given as means ± SD. Paired sample Student's t-test showed no significant differences among these data over time.FROIDEFOND ET AL . 987 1532950x, 2023, 7, and 3/10 at the time of the survey. Overall, 11/12owners granted the maximal score of 10/10 withregards to their global satisfaction about the overalltreatment performed. The remaining owner was 9/10satisfied with the procedure.4

Question 119

Andrews - 2024 - JAVMA - 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 infections.pdf

Answer 119

Data collectionMedical records were evaluated of dogs and cats that had gastrointestinal surgery at the Matthew J. Ryan Veterinary Hospital of the University of Pennsylvania Unauthenticated | Downloaded 12/24/23 09:37 AM UTC 3and University of Florida Small Animal Hospital between July 1, 2020, and April 1, 2023. The criteria for inclusion included any animal undergoing a procedure in which a full-thickness incision was made in the stomach, small intestine, or large intestine. All subjects were hospital -ized after the procedures in either traditional patient wards or the ICU depending on their stability before and during surgery. Antibiotic choice during surgery was determined by the primary surgeon. Only subjects that were either humanely euthanized before discharge or died of natural causes before discharge or those that did not return for follow-up within 10 to 14 days of their surgery were disqualified from the study pool. Surgeries were performed by board-certified surgeons or surgical residents who were either supervised by board-certified surgeons or unsupervised. Postoperative care (appear -ance of the incision, medication administration, and continuation of antibiotics) was determined by either a board-certified surgeon or by a surgery resident under the supervision of a board-certified surgeon.Subjects were initially divided into 2 groups: those that received Nocita at the time of surgery and those that did not. Species, surgery performed, in -dication for gastrointestinal surgery, perioperative antibiotic used, presence of preoperative septic peri -tonitis, whether an antibiotic was sent home at the time of discharge, and the choice of that antibiotic were recorded. Additionally, presence of incisional infection before or at the time of routine recheck ex -amination, whether an antibiotic was prescribed at that time, and isolates after culture and sensitivity testing were recorded. Aerobic culture results were recorded for dogs and cats that developed incisional infections, when available. Aerobic cultures were ob -tained via a direct swab of the subcutaneous tissues, using aseptic technique. Routine follow-up was con -ducted 10 to 14 days following surgery. If a patient presented prior to the scheduled recheck examina -tion, due to suspicion of an incisional complication, this information was recorded. Presence of incisional infection was determined by clinicians utilizing crite -ria determined by the CDC.13 More specifically, this criteria included the presence of at least one of the following: purulent drainage from the superficial in -cision, organism(s) identified from an aseptically ob -tained specimen, and localized pain or tenderness, swelling, erythema, or heat. Deep incisional infec -tions were also identified by criteria determined by the CDC. This specifically included purulent drainage from the deep incision; a deep incision that sponta -neously dehisces or is deliberately opened or aspi -rated by a surgeon or physician and organisms iden -tified from the deep soft tissues via culture; clinical signs of fever, localized pain, or tenderness; or an abscess or other evidence of infection involving the deep incision detected grossly or via imaging.Statistical analysisFrequencies and descriptive data were determined using Excel (version 16.37; Microsoft Corp). Data were coded such that the procedures that patients under -went were divided into the following groups: gastrot -omy or gastrectomy, enterotomy, intestinal resection and anastomosis (RA), full-thickness gastrointestinal biopsies, 2 or more of the above procedures, or 2 or more of the above procedures including an RA. Indica -tions for gastrointestinal surgery were also categorized to reflect the following groups: foreign body obstruc -tion, gastrointestinal mass, intussusception, perfora -tion or ulceration, a problem at a previous surgical site (namely dehiscence or stricture), a mix of the catego -ries described above, or for a reason other than those described above (including primary medical issues, bite wounds, diaphragmatic hernia, mesenteric tor -sion, and more).ResultsStudy populationEight hundred twenty-three dogs and cats un -derwent gastrointestinal surgery during the study period. Of these, 211 dogs and 78 cats returned for reevaluation of their incision at these institutions and were included in the final study population. Of the final study population, 124 of the 211 (58%) dogs received Nocita during gastrointestinal surgery and 55 of 78 (71%) cats received Nocita during gastroin -testinal surgery. Fifty-two of 78 (66.7%) cats and 123 of 211 (58.3%) dogs underwent surgery at the Mat -thew J. Ryan Veterinary Hospital at the University of Pennsylvania, and 26 of 78 (33.3%) cats and 88 of 211 (42.7%) dogs underwent surgery at the Univer -sity of Florida Small Animal Hospital.Indications for surgery were recorded. Among dogs, 181 of 211 (85%) underwent surgery for a for -eign body obstruction, 16 (7.6%) underwent surgery for a gastrointestinal mass, 2 (0.94%) underwent surgery for an intussusception, 3 (1.4%) underwent surgery for a gastrointestinal perforation or ulcer -ation, 2 (0.94%) underwent surgery for a mix of the above categories, and 3 (1.9%) underwent surgery for another problem (primary medical issue such as inflammatory bowel disease, diaphragmatic hernia requiring gastrointestinal surgery, or mesenteric tor -sion). Among cats, 59 of 78 (75%) underwent surgery for a foreign body obstruction, 11 (14.1%) for a gas -trointestinal mass, 4 (5.1%) for an intussusception, 3 (3.8%) for a problem related to a previous surgery site (stricture or dehiscence), and 1 (1.3%) for a problem that was unrelated to those described above.Specific surgical interventions were also recorded. For dogs, 78 of 211 (36.9%) underwent a gastrotomy, 62 (29.4%) underwent an enterotomy, 31 (14.7%) un -derwent an intestinal RA, 25 (11.8%) underwent 2 or more procedures not including an RA, and 15 (7.1%) underwent 2 or more procedures including an RA. For cats, 30 of 78 (38.5%) underwent a gastrotomy, 19 (24%) underwent an enterotomy, 15 (19%) underwent an intestinal RA, 8 (10%) underwent 2 or more proce -dures not including an RA, and 6 (7.7%) underwent 2 or more procedures including an RA.Surgical site infection rateSixteen of 211 (8%) of canine patients were diag -nosed with SSI. Of the canine patients that received Unauthenticated | Downloaded 12/24/23 09:37 AM UTC4 Nocita, 7 of 124 (5.6%) were diagnosed with an SSI and 1 (0.8%) patient was diagnosed with septic peri -tonitis postoperatively. After this diagnosis, this pa -tient was lost to follow-up. Of the canine patients that did not receive Nocita, the SSI rate was 9 of 87 (10.2%; Table 1 ).Clavamox, enrofloxacin, amoxicillin, metronidazole, cefpodoxime, azithromycin, cephalexin, and merope -nem in 1 dog. Of the patients that were discharged with antibiotics, 2 of 38 (5%) were diagnosed with an SSI. One of these patients received Nocita at the time of surgery, and the other did not. The one that did not receive Nocita required additional wound de -bridement for treatment of the infection. Nine of 78 (12%) of feline patients were discharged with anti -biotics. Specific antibiotics that were prescribed in -cluded only Clavamox. No feline patient discharged with antibiotics developed an SSI.Culture and sensitivity resultsAerobic culture and antibiotic sensitivity results of those patients that were diagnosed with an incisional infection were available for 6 dogs and 1 cat. For dogs that were administered Nocita and underwent culture and susceptibility testing at the time of diagnosis of an SSI (n = 1), the isolated bacteria were MDR E coli (1) and MDR Beta streptococcus (1). For animals that did not receive Nocita and underwent culture and suscep -tibility testing at the time of diagnosis of an SSI (n = 5), the isolated bacteria included E coli (2), Pseudomonas aeruginosa (1), MDR Enterococcus faecium (1), MDR Enterobacter cloacae (1), and MDR Streptococcus equi zooepidemicus (1). Three of 5 (60%) of these patients grew MDR bacteria. All bacteria isolated from dogs were resistant to the perioperative antibiotic chosen. E coli was cultured from a feline patient that did not receive Nocita. The E coli grown was susceptible to the perioperative antibiotic chosen.

Question 120

Kuvaldina - 2023 - VETSURG - Development of a minimally invasive endoscopic technique for excisional biopsy of the axillary lymph nodes in dogs.pdf

Answer 120

2.1 |Study overviewThis study was conducted over the period of December2020 to July 2021, at Cornell University Hospital for Ani-mals. The study design was approved following ethicaland scientific review for IACUC exemption (CUVCSC,Cornell University Veterinary Clinical Studies CommitteeProtocol ID 020221-04). The first phase of the study dur-ing which the surgical techniques were refined was con-ducted on four canine cadavers; these animals wereresearch dogs that were euthanized for purposes unre-lated to this study. Following refinement, the techniquewas implemented in three clinical cases that requiredlymphadenectomy for staging purposes and the resultsreported.2.2 |Development phaseTo assist in the selection of the best surgical corridor toapproach the axillary node, a 3D reconstruction of theaxillary anatomy was created (Figure 1). A dog receivinga CT scan of the thorax for another purpose was posi-tioned in right lateral recumbency with the left thoraciclimb abducted. The thorax was scanned at 120 kVp usingautomatic MAs control (SUREExposure) in 1.0 mmtransverse slices after administration of IV contrast agentFIGURE 1 Computed tomographic 3D reconstruction ofaxillary anatomy.KUVALDINA ET AL . 889 1532950x, 2023, 6, (2 ml per kg iohexol, 350 mg/ml, Omnipaque 350, GEHealthcare, Princeton, New Jersey) using a 16-slice CTscanner (Aquilion LB, Toshiba/Canon America MedicalSystems, Tustin, California). Images were reconstructedin 1.0 mm transverse slices using a soft tissue algorithm(window level 30, window width 320).A 3D model was created from a post-contrast CT scanby anatomical segmentation of (1) the left axillary lymphnode, (2) the intrathoracic and axillary region blood ves-sels (3) the bones, and (4) the body wall and limb muscu-lature (Materialize Mimics, Plymouth, Michigan).Segmentation was performed using thresholding andregion grow techniques.17The resulting layers (masks)were modified using the split mask tool to retain only therelevant anatomy. The masks were converted to partsand exported as stereolithography (STL) files. The STLfiles were later converted to object file format in Auto-desk Meshmixer and uploaded to create a single modelusing Sketchfab.com (New York) where color and trans-parency features were subsequently applied to each layer.Following identification of a candidate surgical corri-dor that would achieve an approach to both the accessoryaxillary and axillary nodes without muscular transection,the approach was then performed on a canine cadaverusing an open technique with progressive removal andretraction of the overlying musculature to fully exposeand confirm the anatomy, as shown in Figure 2. Axillaryand accessory axillary lymphadenectomy was then per-formed on six thoracic limbs on four canine cadaversusing an endoscopic technique. Two surgeons (GH andNB) performed the procedures. Endoscopic images wereprocured and the time to complete the lymphadenectomyrecorded.2.3 |Implementation phaseOnce the authors were convinced of the feasibility andwere familiar with the anatomic details of the technique,endoscopic axillary and accessory axillary lymphadenect-omy were performed under general anesthesia on threeclinical cases by a single surgeon (GH) following the pro-vision of informed owner consent. For all cases, the clini-cal indication for lymphadenectomy was to completestaging of an oncological disease process. Perioperativeanalgesia was provided for all cases at the discretion ofthe primary clinician. Intraoperative and short-term post-operative outcomes including procedural time and com-plications, postoperative discomfort and lameness, andincidence of incisional complications (lymphedema, ser-oma) within the first three postoperative weeks wererecorded.FIGURE 2 Cadaver dissection showing key landmarks of the axillary lymphocenter. The latissimus dorsi and superficial pectoralmuscles have been separated and stay sutures placed to elevate and evert the musculature, shown in the near field. The accessory axillarylymph node is then visible on the ventral surface of the latissimus dorsi (inset, *). The thoracodorsal nerve bundle crosses thedissection avenue from caudodorsal to cranioventral. The axillary lymph node is then situated within a fat pad lying adjacent to themusculature of the chest wall, immediately dorsal to the thoracodorsal nerve bundle and immediately caudal to the axillary artery and veinwhere they exit the thoracic cavity. The first rib can be palpated just cranial to the node location.890 KUVALDINA ET AL . 1532950x, 2023, 6, 2.4 |Surgical technique descriptionThe patient was prepared for aseptic surgery and posi-tioned in lateral recumbency with operated limb posi-tioned uppermost with the limb abducted and extendedcranially. The division between the dorsal border of them. superficial pectoralis and the ventral border of them. latissimus dorsi was palpated and a 3 cm skin incisionwas made following the orientation of this division andstarting at a point approximately 6 cm caudal to the caudalborder of the m. triceps brachii (Figure 3). The muscularjunction was separated by blunt dissection and two staysutures were placed in the margins of these muscles. Thelatissimus dorsi muscle margi nw a se l e v a t e da n dr e f l e c t e dthrough the incision to expose the deep surface of the mus-cle belly. When present, the accessory axillary node waslocated adhered to the deep surface of the muscle, some-times within a fat pad, and could be excised at this location(Figure 4). The stay sutures were then used as anchors toallow the insertion of a SILS po rt (Medtronic, Minneapolis,Minnesota) between the latiss imus and m. superficial pec-toralis margins. A 5 mm 30-degree laparoscope was theninserted and CO2 insufflation to +5c mH 2O( 3 . 7m m H g )initiated. Dissection began us ing a blunt probe through theloose areolar fascia in a cranial direction (Figure 5andinset), entering the space deep to the superficial pectoraland latissimus dorsi muscles, with the thoracic wall (pector-alis profundus, serrates ventralis and scalenus m) creatingthe floor and the axillary artery and vein and first rib actingas landmarks to the cranial limit of the dissection. Early inthe dissection the thoracodorsalis n. bundle could be identi-fied crossing the near field, and care was taken to preservethis. The axillary node could be identified within a fat padlying adherent to the thoracic wall at the base of the axillaryartery and vein, which could be seen traversing the dis-section field perpendicular to t he thoracic wall. Once identi-fied, the axillary node was gras ped and dissected free of thesurrounding fat using a combination of a monopolar Lhook and a 5 mm Ligasure device (Figure 6). The node wasthen retrieved with the SILS port. The surgical site wasclosed routinely using 3/0 PDS in a simple continuous pat-tern to reappose the margins of the latissimus dorsi andsuperficial pectoralis m., and 3/0 monocryl in the subcuta-neous fat and skin.3|RESULTS3.1 |Cadaver outcomesThe mean bodyweight of the cadavers ( n=4) employedwas 10.2 kg (95% CI: 8.6 –11.8). The mean time to removalFIGURE 3 Initial patient positioning and incision location for a minimally invasive surgical (MIS) approach. Inset image shows thedivision between the superficial pectoral and latissimus muscle.KUVALDINA ET AL . 891 1532950x, 2023, 6, of the accessory axillary lymph node over six cadavericprocedure was 5.1 minutes (95% CI: 2.3 –8.0) and a singlenode was found in all six limbs. The mean time toremoval of the axillary lymph node was 33 minutes (95%CI: 18.1 –48.1), and a double node was found in one limbwith a single node in the remaining five.3.2 |Clinical case 1A 12-year-old FS mixed breed (22.6 kg) was presented forassessment and treatment of recurrence of a mass onP2/3 of the second digit of the left thoracic limb. Themass had been previously excised 6 months prior to thevisit. Histopathological diagnosis at that time wasacanthocytoma; however, the dog had persistently lickedat the area over the subsequent months, with increasingpain, swelling and inflammation unresponsive to antibi-otic therapy. FNA of the area during a recheck appoint-ment was suggestive but not definitive for a sarcoma.Thoracic radiographs were unremarkable. Ultrasound ofthe axillary lymph node revealed it to be enlarged at2.4 cm (normal <1.6 cm12) in the longest dimension how-ever ultrasound guided FNA of the node was nondiag-nostic. Digit amputation at the metacarpophalangealjoint in combination with excisional biopsy of the axillaryand accessory axillary lymph node was performed. Thesurgical time for identification, excision and closure fortwo axillary nodes and one accessory axillary node was58 minutes. No intraoperative complications occurred.Postoperatively, the dog received routine analgesic man-agement (methadone 0.1 mg/kg IV every 4 h as needed,meloxicam 0.1 mg/kg IV every 24 h). Moderate lamenesswas noted during the evening post procedure which per-sisted into the following morning, although improved.FIGURE 4 Dissection of the accessory axillary lymph nodefrom the deep surface of the everted latissimus dorsi m via theinitial SILS incision.FIGURE 5 Endoscopic dissection of the initial loose areolar fascia in the axillary space following insertion of a SILS port, inset imageshows SILS position after insufflation.892 KUVALDINA ET AL . 1532950x, 2023, 6, The patient was discharged the day following surgery. Nolymphedema was identified. There was mild bruisingwith a small seroma at the lymphadenectomy surgicalsite which resolved together with the lameness by the3-day postoperative recheck. Histopathology revealedhyperkeratosis and inflammation of the deep tissues ofthe digit, and lymph node hyperplasia. Eight months fol-lowing surgery there had been no recurrence of the origi-nal lesion and no lameness or other issues wereidentified.3.3 |Clinical case 2A 9-year-old MN Labrador mix (44.3 kg) was presentedfor treatment of a 2 /C22 cm cutaneous mast cell tumor onthe right antebrachium. Staging (thoracic radiographs,abdominal ultrasound, ultrasound guided aspirates of thespleen and axillary lymph node) was performed. Splenicaspirates were unremarkable. Lymph node aspirates wereacellular. Curative intent excision of the primary tumorand excisional biopsy of the axillary and accessory axil-lary nodes were performed. The accessory axillary nodewas identified without difficulty. The axillary space wasexplored endoscopically, and the node location identified,however excision of the node required conversion to anopen approach with muscle retraction due to difficultiesgrasping and elevating the node from the thoracic wall toallow completion of the dissection. The total surgicaltime was 58 minutes. Postoperatively, the dog receivedroutine analgesic management (methadone 0.1 mg/kg IVevery 4 h as needed). The dog showed normal limb usethe following day, with minimal to no swelling/ bruisingat the axillary incision and was discharged. No seromasor limb edema had developed by recheck 3 weeks later.Histopathology of the primary tumor and lymph nodesrevealed incomplete excision of a grade II/III (Patnaik)intermediate (Kiupel) grade mast cell tumor, and thelymph nodes were both expanded by multifocal sheets ofmast cells expanding the cortical and medullary sinuses(HN2 classification). No complications or recurrence ofthe primary tumor occurred over a 6 month follow-upperiod. Reoperation of the primary tumor was declineddue to the lymph node status. Adjunctive radiation ther-apy and chemotherapy were also discussed and declined.3.4 |Clinical case 3A 6 year old FS Labrador Retriever (33.8 kg) was pre-sented for treatment of a 2 /C23 cm diameter cutaneousmast cell tumor on the left ventral thorax. Staging (tho-racic radiographs, abdominal ultrasound, ultrasoundguided aspirates of superficial cervical and axillary lymphnodes) was performed and revealed occasional mast cellsin the axillary node. The accessory axillary node couldnot be identified on ultrasound. Curative intent excisionof the primary tumor and excisional biopsy of the axillarynode was performed. The accessory axillary node couldnot be identified intraoperatively. The axillary space wasexplored endoscopically and the axillary node retrieved.The total surgical time was 35 minutes. Postoperatively,FIGURE 6 Endoscopic retrieval of axillary node showing the location relative to the axillary artery and vein and the thoracodorsalisn. bundle.KUVALDINA ET AL . 893 1532950x, 2023, 6, the dog received routine analgesic management (metha-done 0.1 mg/kg IV every 4 h as needed). The dog showednormal limb use the following day, with minimal to noswelling/bruising at the axillary incision. Some discom-fort associated with palpation around the surgical site forthe primary tumor was noted, prompting hospitalizationfor pain management extending to 48 hours postopera-tively. No abnormalities associated with the lymphade-nectomy procedure were noted at a 3-week recheck.Histopathology of the primary tumor and lymph noderevealed complete excision of a grade II/III (Patnaik) lowgrade (Kiupel) mast cell tumor with the lymph nodeshowing early mast cell infiltration (classified as HN2).No other complications were encountered over a3-month follow-up period.4

Question 121

Horikirizono - 2024 - JSAP - Intraoperative hypertensive crisis in a dog with functional paraganglioma of the gall bladder.pdf

Answer 121

tish Small Animal Veterinary Association. 144CASE REPORTIntraoperative hypertensive crisis in a dog with functional paraganglioma of the gall bladderH. Horikirizono *†,1, M. Nakaichi *, H. Itoh *, K. Itamoto *, Y. Nemoto *, H. Sunahara * and K. Tani **Joint Faculty of Veterinary Medicine, Yamaguchi University, 1677- 1, Yoshida, Yamaguchi, 753- 8515, Japan†Animal Medical Centre, Faculty of Applied Biological Sciences, Gifu University, 1- 1, Yanagido, Gifu, 501- 1193, Japan1Corresponding author email: horikirizono.hiro.b6@f.gifu-u.ac.jp ; hiro-h@yamaguchi-u.ac.jpA 15- year- old spayed female mongrel presented with anorexia and an abdominal mass. The mass origi -nated from the gall bladder and was surgically resected along with divisionectomy of the central he -patic division. Paroxysmal hypertension and tachycardia were noted during manipulation of the mass. Following resection, arterial blood pressure decreased significantly. Histopathological analysis con -firmed a diagnosis of neuroendocrine neoplasm. Immunohistochemical staining for synaptophysin and chromogranin A yielded diffuse and strong positive results, while gastrin was positive in only 10% of the cells. The preoperative elevated concentrations of catecholamine in the urinalysis showed a marked decrease after surgery. Based on these findings, the tumour was diagnosed as a functional paraganglio -ma of the gall bladder. The patient has undergone regular thoracic radiographs and ultrasound examina -tions and, until 431 days after surgery, has shown no signs of metastases or recurrences. Based on our literature search, we report the first case of functional paraganglioma of the gall bladder in a dog.Accepted: 12 July 2023; Published online: 9 August 2023INTRODUCTIONThe occurrence of gall bladder tumours in dogs is very rare. Neu -roendocrine neoplasms, lymphomas and leiomyomas have been reported in dogs with gall bladder tumours (Willard et al. 1988 , Birettoni et al. 2008 , Nagata et al. 2015 , Lovell et al. 2019 , O’Brien et al. 2021 ). In human medicine, neuroendocrine neo -plasms are used as an umbrella term to include neuroendocrine tumours, neuroendocrine carcinomas and paragangliomas/pheochromocytomas. All these tumours usually stain posi -tive to synaptophysin and chromogranin A. Moreover, any of these neoplasms can be defined as functional or non- functional. Neuroendocrine tumours, also termed carcinoids, are a general term for tumours arising from the neuroectodermal cells and are known to arise from hepatobiliary tissue (Vail et al. 2020 ). However, there are only few reports of primary tumours of the gall bladder in dogs and consequently limited clinical informa -tion available.Pheochromocytomas of the adrenal gland are classified as neu -roendocrine neoplasms of chromophilic cell origin in the adre -nal medulla (Galac & Korpershoek 2017 ). Pheochromocytomas can cause excessive production and secretion of catecholamines in functional cases, resulting in hypertension, tachycardia and arrhythmias (Galac & Korpershoek 2017 ). These can occur in a paroxysmal, fulminant fashion, causing multi- organ damage and a potentially life- threatening hypertensive crisis. Preoperative diagnosis and careful anaesthetic management are important in cases of suspected adrenal pheochromocytoma, as a hypertensive crisis can be lethal if not appropriately managed.Hypertensive crises due to catecholamine release have also been observed in humans with paragangliomas, which are extra- adrenal pheochromocytomas. These crises are commonly observed in paragangliomas of sympathetic nervous origin in the thoracoabdominal tissue. Hypertensive crises are rarely observed in paragangliomas of parasympathetic nervous origin in the cer -vical or mediastinal tissues (Galac & Korpershoek 2017 ).The following databases (Pubmed and Web of Science) have been searched with the following keywords paraganglioma, gall bladder and canine/dog on June 4, 2023; the following textbooks have been consulted (Johnson & Tobias 2018 , Fossum 2018 , Vail et al. 2020 ). No other reports of canine functional paraganglioma of the gall bladder have been found doing these searches.Here, we report a case of functional paraganglioma of the gall bladder in a dog.Functional paraganglioma of gall bladder in a dogJournal of Small Animal Practice • Vol 65 • February 2024 • © 2023 British Small Animal Veterinary Association. 145 CASE HISTORYA spayed female mongrel, 15 years old and weighing 7.3 kg, presented with anorexia approximately 2 months before being referred to the second clinic, and an abdominal mass was noted by the referring veterinarian. While the dog’s clinical signs improved with medical treatment at the referral hospital, it was referred to the Yamaguchi University Animal Medical Centre for further examination of the abdominal mass. No obvious clinical signs were observed during the initial visit. Blood tests revealed no abnormalities, other than a mildly elevated C- reactive pro -tein (1.5 mg/dL, reference interval 0.0 to 1.0 mg/dL). Abdominal radiography revealed mild hepatomegaly and abdominal ultraso -nography revealed rich blood flow in the mass adjacent to the gall bladder. CT angiography was performed using the triple- phase helical CT technique (Kutara et al. 2014 ). The CT imaging revealed a 67×56×37 mm mass surrounding the gall bladder. The mass was contrast- enhanced in the arterial phase and drained of contrast medium in the equilibrium phase ( Fig 1). The adrenal glands were normal. Based on the imaging findings, a gall blad -der or hepatic tumour was suspected and we performed surgery to remove the mass.Pre- operatively, we administered an intravenous antibiotic injection of cefazolin (25 mg/kg; Cefamezin α; LTL Pharma Co., Ltd., Tokyo, Japan). General anaesthesia was then induced with propofol (6.6 mg/kg; Pfizer; Pfizer Japan Inc., Tokyo, Japan). After endotracheal intubation, the dog was mechanically ventilated with a mixture of sevoflurane (Sevofrane; Maruishi Pharmaceutical Co., Ltd., Osaka, Japan) and 70% oxygen. For intraoperative analgesia, we administrated intramuscular ket -amine (5 mg/kg; Ketalar; Daiichi Sankyo Propharma Co., Ltd., Tokyo, Japan) and fentanyl (5– 20 μg/kg/hour; Daiichi Sankyo Propharma Co., Ltd.).Intraoperatively, invasive arterial blood pressure monitor -ing was performed by placing an arterial catheter in the dorsal pedal artery. The dog was positioned in dorsal recumbency. A Mercedes incision was made to approach the mass for the pur -pose of obtaining extensive visibility of the anterior abdomen. The mass was severely adherent to the quadrate and right medial lobes of the liver and surrounded by the omentum ( Fig 2). We noted paroxysmal hypertension and tachycardia associated with intraoperative mass manipulation ( Fig 3). Phentolamine mesyl -ate (1 to 2 μg/kg/hour; Regitin; Novartis Pharma K. K., Tokyo, Japan) and nitroprusside sodium hydrate (2 μg/kg/hour; Nito -pro; Maruishi Pharmaceutical Co., Ltd.) were administered as intraoperative antihypertensive drugs. The central hepatic artery, common bile duct and central branch of portal vein were isolated and ligated with 3- 0 absorbable suture (PDS II; Johnson and Johnson, New Brunswick, NJ). The mass was resected en bloc by cholecystectomy with divisionectomy of the central hepatic divi -sion using 2- 0 absorbable suture ligation (PDS II). Following the mass resection, arterial blood pressure markedly decreased, and FIG 1. Triple- phase helical CT images of the mass (arrows) surrounding the gall bladder (arrowhead) contrasted in the arterial phase (A) and the equilibrium phase (B)FIG 2. Intraoperative photograph of the abdominal cavity. The mass was severely adherent to the surrounding tissue and covered by the omentum (arrows) 17485827, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13665 by Vetagro Sup Aef, Wiley Online Library on [04/02/2024]. 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 LicenseH. Horikirizono et al.Journal of Small Animal Practice • Vol 65 • February 2024 • © 2023 British Small Animal Veterinary Association. 146dopamine hydrochloride (2.5 to 5 μg/kg/minute; Inovan; Kyowa Kirin Co., Ltd., Tokyo, Japan) was initiated. ( Fig 3).Histopathological analysis revealed that polygonal and round neoplastic cells were compartmentalised into alveolar or trabecular patterns with the support of a thin fibrovascular stroma. The neoplastic cells had a medium- sized, acidophilic, granular to vacuolated cytoplasm with indistinct cell boundaries and an amorphous nucleus showing mildly anisonucleosis and FIG 3. Circulation monitoring values and drugs during operative anaesthesia. SBP systolic blood pressure, MBP mean blood pressure, HR heart rateFIG 4. Haematoxylin eosin (A), synaptophysin (B), chromogranin A (C) and gastrin (D) stainings of the gall bladder tumour (20×). Synaptophysin and Chromogranin A stains are strongly positive in the tumour cells. Gastrin is only 10% stained in the tumour cells 17485827, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13665 by Vetagro Sup Aef, Wiley Online Library on [04/02/2024]. 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 LicenseFunctional paraganglioma of gall bladder in a dogJournal of Small Animal Practice • Vol 65 • February 2024 • © 2023 British Small Animal Veterinary Association. 147 polygonal shape ( Fig 4A). The mitotic index, as observed under high- power field, was recorded as 0 to 1. Although microvascular invasion was observed in neoplastic tissue, there was no evidence of continuity with the surrounding liver tissue. The tumour was completely resected, and the surgical margins were free from neoplastic cells. Immunohistochemical staining for synaptophy -sin and chromogranin A demonstrated diffuse and strong posi -tive staining, while gastrin was positive in only 10% of the cells (Fig 4B- D ). The histopathological diagnosis was neuroendocrine neoplasm arising from the submucosal tissue of the gall bladder. Urine samples were collected on the day of the surgery, before the skin incision, as well as 3 months postoperatively. In both situa -tions, urinalysis was conducted with catheterised urine collection under anaesthesia. The concentrations of urinary catecholamines and metanephrines were measured by high- performance liquid chromatography at a commercial laboratory (RINTEC Co., Ltd., Fukuoka, Japan). Urinary catecholamine and metanephrine con -centrations in the urinalysis showed a marked decrease after sur -gery and were normal at 93 days postoperatively ( Table 1). Based on these findings, the tumour was diagnosed as a functional para -ganglioma of the gall bladder. For postoperative treatment, dopa -mine hydrochloride (2.5 μg/kg/minute; Inovan) was continued for 1 day. For postoperative analgesia, a fentanyl patch (Durotep MT Patch 4.2 mg; Janssen Pharmaceutical K. K., Tokyo, Japan) was used. There were no postoperative complications, and the dog was discharged on postoperative day eight. The patient has continued to undergo thoracic x- ray and ultrasound examina -tions and has remained free of metastases or recurrences as of postoperative day 431.

Question 122

Evans - 2024 - VCOT - Effect of Plate-Bone Distance and Working Length on 2.0-mm Locking Construct Stiffness and Plate Strain in a Diaphyseal Fracture Gap Model - A Biomechanical Study.pdf

Answer 122

A mid-diaphyseal fracture gap model was created withpolyacetal tubing (Delrin, McMaster-Carr, Elmhurst, IL, Unit-ed States) with an outer diameter of 12.7 mm and an innerdiameter of 6.35 mm. Each Delrin fragment was drilled witha computer-controlled mill using a 1.5-mm drill bit as per AOguidelines for 2.0-mm locking screws.11Each fragment hadallfive potential screw holes drilled at a distance of 7 mmbetween the center of adjacent holes, with the center of theinnermost screw hole positioned 2.5 mm from the fragment-fracture end. Each tube was also predrilled with a 4.0-mmscrew hole, 35 mm from the distal end of the tube. This holewas used for screw fixation to the loading jig to preventrelative motion during testing. The Delrin tubes were stabi-lized with a 12-hole 2.0-mm LCP (DePuy Synthes, Paolo, PA,United States), with three bicortical locking screws in eachfragment in a symmetrical con figuration with a 6-mmfracture gap centered over the sixth combination screwhole (►Fig. 1 ). To enable a change in plate working lengthwith no change in screw number and symmetrical screwplacement on either side of the fracture gap with a singlecentral vacant hole spanning the fracture gap, a 12-hole 2-mm LCP was used leaving a single unused plate hole at oneend of the plate.Construct Con figurationThree different working lengths were generated by applyingthree different screw con figurations. The screw con figura-tions were symmetrical in each fragment. The screw holeswere numbered, with “1”being the screw hole adjacent tothe slipper toe end of the plate and “11”being the screw holeadjacent to the stacked hole. The stacked hole was not filledin any construct and the fracture gap spanned the sixthhole in all constructs. All screws were 2.0-mm locking screws(20-mm length, self-tapping locking screws, DePuy Synthes)Fig. 1 Schematic showing working length con figurations. A 12-hole 2.0-mm LCP with locking holes numbered from 1 through 11, with “F”indicating the fracture gap spanning hole 6 and “S”the stacked hole, which was not used in any of the tested constructs..inserted bicortically with a standardized insertion torque of0.4 Nm (Torque limiter, 0.4 nM with AO quick coupling,DePuy Synthes), as per AO recommendations for 2.0-mmlocking screws.11The short working length constructs hadscrews in plate holes 1, 4, 5 and 7, 8, 11; the medium workinglength constructs had screws in plate holes 1, 3, 4, and 8, 9,11; and the long working length constructs had screws inplate holes 1, 2, 3, and 9, 10, 11 (►Fig. 1 ).Plate –bone distance was maintained with rigid plasticspacers (tiling spacers, Rubi, Spain, and Qep Australia) duringscrew insertion, with 1-, 1.5-, and 3-mm spacers. Prior toconstruct assembly, a sample of 20 spacers from each sizewere selected and measured with vernier callipers, con firm-ing their reported thickness (1-mm spacers: mean 1.00 mm[SD/C60 mm]; 1.5-mm spacers: mean 1.48 mm [SD /C60.06mm]; 3-mm spacers: mean 2.94 mm [SD /C60.07 mm]). Eachconstruct was assembled by a European College of VeterinarySurgeons board-certi fied surgeon (MG).A sample size of six replicates per construct con figurationwas used, for a total of 54 constructs. A sample size of sixwould detect a minimum effect size of 1.75 (power ¼0.8;α¼0.05; error variance ¼10%), which was suf ficient basedon previously reported data.8Biomechanical TestingNondestructive Four-Point BendingThe assembled constructs were fixed in a custom loading jigwith a 4.0-mm screw in the predrilled jig-positioning hole toprevent rotation during testing. Each end of the fully assem-bled construct was seated 35 mm within the custom loadingjig (►Fig. 2 ). Each construct underwent a four-point com-pression bending by a materials testing machine (Instron5566, Instron, Norwood, MA, United States) with a 100-Nload cell applied parallel to the screw axis and the platepositioned on the compression surface. A support roller with290-mm spacing supported the constructs within the load-ing jig, and a load roller with 230-mm spacing allowed auniform load and bending moment to be applied to theconstruct. Each construct was preloaded to 0.4 N, thenramp loaded for three cycles under displacement controlat 10 mm/min to a force of 40 N, as per a previously publishedprotocol.2This load protocol produced a peak bendingmoment of 0.6 Nm in compression bending which is withinthe elastic limits of the constructs based on previous testing.Eighteen complete sets of implants were used in this studyand recon figured twice to allow evaluation of 54 differentconstructs (6 replicates of 9 different con figurations). Ran-domization of construct testing order was determined byassigning each construct replicate a number between 1 and54 and determining the order of testing using a randomnumber generator.Nondestructive TorsionThe constructs were secured in a custom jig, clamped at oneend, while the opposite end of the construct was supportedwhile still allowing free rotation around the construct ’slongitudinal axis. The constructs were placed in the jighorizontally and load was applied to the distal jig screwresulting in a lever arm of 25 mm. Torque was applied to theconstruct with each construct loaded to 0.4 N before under-going three consecutive cycles of load under displacementcontrol at 10 mm/min, resulting in a torsional displacementof approximately 11 degrees. All constructs were loaded to aminimum peak load of 20 N.Stiffness and StrainAll data from the material testing were measured at a rate of10 Hz. All constructs underwent three loading cycles in eachdirection of testing (compression bending and torsion). Asper previously published protocols,2,3,8the load displace-ment measurements were recorded from the third cycle ofFig. 2 Biomechanical testing setup for four-point compression bending (left) and torsion (right)..testing. The bending and torsional stiffness for each con-struct was determined from the slope of the linear elasticportion of the load displacement curve.Strain data were collected with three-dimensional digitalimage correlation (DIC), which allowed precise measure-ment of plate strain within a speci fiedfield of view.2,12Platestrain was measured during compression bending only. Aspeckle pattern on the surface of the plates enabled correla-tion-based displacement measurements to calculate strain.The speckle pattern for strain analysis was applied using ahand speckled technique. All plates were sprayed with a basecoat of matt white spray paint and allowed to dry beforebeing speckled with a 0.05-mm black pigment marker. As perrecommendations for DIC analysis, the speckles were placedin a random distribution, with a density of approximately50%.13All speckles were applied by the same investigator(AAE) using magnifying loupes.High-de finition recordings were collected with stereo-scopic video cameras, with image capture performed usingVIC-Snap software (VIC-Snap software, Correlated SolutionsInc., Irmo, SC, United States). Given the symmetrical con fig-uration of the constructs, the field of view for image correla-tion was focused on the plate spanning holes 1 to 6 includingthe fracture gap. The region of interest for strain evaluationwas de fined as the region of the plate over the fracture gap.The von Mises strain for each construct was plotted againstload (N), and a line of best fit was used to calculate the strainat a load of 40 N.Statistical AnalysisData were evaluated for normality with a Shapiro –Wilk testand non-normal data transformed. Data were summarized asmean, SD, and 95% con fidence interval of the mean. Stiffnessand strain data were analyzed using a two-way ANOVA,including the fixed effects of working length and plate –bone distance, and the interaction. Post hoc pairwise com-parisons were made when there were signi ficant modeleffects, tested against a Tukey adjusted p/C200.05.ResultsStiffnessIn four-point compression bending, there was a signi ficantinteraction between working length and plate –bone dis-tance ( p¼0.04). All short working length constructs, regard-less of plate –bone distance, were stiffer than all mediumworking length constructs, which in turn were stiffer than alllong working length constructs. The plate –bone distance didnot affect construct stiffness in bending within any workinglength ( ►Table 1 ).In torsion, there was no signi ficant interaction betweenworking length and plate –bone distance ( p¼0.216) butsignificant main effects of working length ( p<0.0001) andplate –bone distance ( p<0.0001; ►Table 2 ). All short work-ing length constructs, regardless of plate –bone distance,were stiffer than all medium working length constructs,which in turn were stiffer than all long working lengthconstruct, except for the medium working length with the3-mm plate –bone distance, which was not different fromthe long working length with the 1 mm plate –bone distance.The effect of plate –bone distance was evident within theshort and long working lengths, with stiffness signi ficantlylower for the 3-mm plate –bone distance than the 1.5- and1.0-mm plate –bone distance ( p<0.0001 and 0.047 for shortand long working length, respectively). There was no dis-cernible effect of plate –bone distance on stiffness for themedium working length. A post hoc sample size calculationfor the medium working length group determined a sampleTable 1 M e a ns t i f f n e s s( N / m m )a c r o s sw o r k i n gl e n g t h sa n dp l a t e –bone distance in compression bendingShort working length Medium working length Long working lengthPlate –bone distance of 1 mm 33.751a(95% CI: 31.48 –36.02)25.170b(95% CI: 23.66 –26.68)19.651c(95% CI: 18.7 –20.61)Plate –bone distance of 1.5 mm 36.323a(95% CI: 33.27 –39.38)24.793b(95% CI: 23.6 –25.98)18.626c(95% CI: 17.8 –19.45)Plate –bone distance of 3 mm 33.726a(95% CI: 31.19 –36.27)25.532b(95% CI: 24.33 –26.74)18.209c(95% CI: 17.34 –19.08)Abbreviation: CI, con fidence interval.Note: Means with the same superscript are not signi ficantly different ( p/C200.05).Table 2 Mean stiffness (N/degree) across working lengths and plate –bone distance in torsionShort working length Medium working length Long working lengthPlate –bone distance of 1 mm 1.487a(95% CI: 1.41 –1.566)1.15c(95% CI: 1.072 –1.228)0.966de(95% CI: 0.881 –1.053)Plate –bone distance of 1.5 mm 1.445a(95% CI: 1.39 –1.492)1.128c(95% CI: 1.067 –1.189)0.913ef(95% C.I 0.845 –0.979)Plate –bone distance of 3 mm 1.287b(95% CI: 1.214 –1.361)1.062cd(95% CI: 1.028 –1.096)0.844f(95% CI: 0.774 –0.914)Abbreviation: CI, con fidence interval.Note: Means with the same superscript are not signi ficantly different ( p/C200.05)..size of nine replicates would be required to detect signi fi-cance, suggestive of type II error.StrainThere was a signi ficant interaction effect for working lengthand plate –bone distance ( p<0.0001) on plate strain incompression bending ( ►Table 3 ). Within the short andmedium working lengths, there was no signi ficant differencein plate strain over the fracture gap for different plate –bonedistances ( p¼0.71 –0.91 and 0.30 –0.75, respectively). Withinthe long working length group, there was signi ficantly lowerplate strain for the 1-mm plate –bone distance than both the1.5-mm ( p<0.0001) and 3-mm ( p<0.0001) plate –bonedistances, which were not different from each other(p¼0.73).Across working length groups, the plate strain was signif-icantly lower for the short working length when comparedwith the medium working length ( p<0.0001) and the longworking length ( p<0.0001 –0.0038) constructs, regardless ofthe plate –bone distance.

Question 123

Crino - 2023 - JSAP - Conservative management of metallic sharp-pointed straight gastric and intestinal foreign bodies in dogs and cats - 17 cases (2003-2021).pdf

Answer 123

Study designThe electronic medical record of the Queen Mother Hospital for Animals was searched for cases treated between March 2003 and December 2021 for sharp- pointed metallic straight foreign bod -ies using the search terms “needle foreign body”, “metallic foreign body”, “pin foreign body” and “nail foreign body”.Inclusion criteriaCases were included if a metallic sharp- pointed straight foreign body was identified within the gastrointestinal tract (stomach, small or large intestine) by means of radiography or CT scan and if conservative management was adopted either as the pri -mary therapeutic approach or following failure of endoscopic or surgical retrieval. Patients were considered to be conservatively managed if the foreign body was not removed by either surgery or endoscopy, and it was allowed to progress through the gas -trointestinal tract. Cases were excluded if the foreign body was hooked, curved or had any protuberances, if it was identified in a non- gastrointestinal location, if it was removed by endoscopy or surgery without a medical management attempt, or if evidence of excretion of the foreign body from the patient was not recorded.Data extractedData recorded included patient signalment, presenting complaint, witnessed/not witnessed ingestion, diagnostic imaging modality, foreign body location, treatment, onset/type of complications, time for transit (noted either by retrieval of the foreign body in the faeces or absence of the foreign body on repeated radiographs), length of hospitalisation (LOH) and outcome. Complications were defined as any new onset of clinical signs, deterioration of the patients’ clinical status or evidence of gastrointestinal perforation.Statistical analysisDescriptive statistic was applied for the analysis of data using a commercially available software (SPSS Statistics, IBM, New York, USA). Continuous data were assessed for normality by means of the Shapiro– Wilk test. Normally distributed data sets were reported as mean ± standard deviation (SD). Non- normally distributed data sets were reported as median and range (mini -mum and maximum). Categorical data were reported as number (n) and percentage (%).RESULTSPatient inclusionDuring the study period, metallic sharp- pointed straight foreign bodies were identified in 46 dogs and nine cats. T wenty- three cases, 21 dogs and two cats, had a foreign body identified outside of the gastrointestinal tract and were excluded leaving 32 cases (25 dogs and seven cats) where a sharp- pointed straight metallic foreign body was diagnosed within the gastrointestinal tract. Four cases (three dogs and one cat) were excluded as endoscopic retrieval of the foreign body was performed on admission; all these cases had witnessed ingestion and no clinical signs. Furthermore, five cases (three dogs and two cats) were excluded as surgery was chosen as the primary therapeutic approach on admission. [Reasons for surgery were ingestion of multiple foreign bodies in one case, the presence of an intestinal haematoma in one case and suspected gastrointestinal obstruction in another case. In the remaining two cases (both cats), a reason for surgery could not be identified in the medical record (both patients had a witnessed ingestion and no clinical signs).] Finally, six dogs managed conservatively were excluded as they were discharged before documented transit of the foreign body and were lost to follow- up.SignalmentSeventeen cases, 13 dogs and four cats, with a gastrointestinal metallic sharp- pointed straight foreign body were ultimately included. T welve cases had been referred by a primary care veteri -narian while five presented as first opinion cases. Canine breeds included four Labrador retrievers (23.5%), and one each of Bor -der collie, English bulldog, golden retriever, Jack russell terrier, Newfoundland, pug, standard poodle, Rhodesian ridgeback and crossbreed (5.9%). Cats were all domestic shorthair (100%). Most of the enrolled patients were young, with a median age of 10 months (3 to 101 months) for dogs and 17.5 months (16 to 34 months) for cats. Among the 13 dogs, three (23.1%) were females (one neutered and two entire) and 10 (76.9%) were males (four neutered and six entire). Among the four cats, three (75%) were females neutered and one (25%) was male neutered.Reason for presentation and clinical signsFourteen cases (82.3%) presented after witnessed ingestion of a metallic sharp- pointed straight foreign body. These cases had no reported clinical signs on admission. In the remaining three cases, a foreign body was noted on diagnostic imaging performed to investigate other concurrent disease processes (chronic spinal pain, immune mediated polyarthritis and pulmonic stenosis). These three dogs (17.6%) had presenting complaints on admission that could have been induced by the presence of the foreign body, vom - 17485827, 2023, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13606 by Vetagro Sup Aef, Wiley Online Library on [07/08/2023]. 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 LicenseC. Crinò et al.Journal 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.524iting and diarrhoea, vomiting, and lethargy, anorexia and abdom -inal pain. The first case had a history of chronic gastrointestinal signs and was subsequently diagnosed with chronic inflammatory enteropathy, while no concurrent diseases were identified in the remaining two cases. One dog had a gastric needle, another had a nail in the colon, and the third had a nail detected in the stomach on radiography before referral, but this had moved into the colon by the time of admission 24 hours later.Location and type of foreign bodiesA metallic gastrointestinal foreign body was found on diagnostic imaging in all cases (100%), with radiography the most com -monly used imaging modality in 15 (88.2%) cases and CT scan in two (11.8%) cases. Location of the foreign bodies on admis -sion included stomach in 14 (82.3%) cases, colon in two (11.8%) cases and jejunum in one (5.9%) case.The majority of metallic sharp- pointed straight foreign bodies were sewing needles, which were present in 11 cases (64.7%), with sewing pins in four cases (23.5%) and nails in two (11.8%) cases. [The length of the needle was noted in five (45.4%) cases with a median length of 3.5 cm (1 to 6.35 cm). Five (45.4%) of the 11 reported needles were attached to a thread; approximate length of the thread was reported in all these cases with a median estimated length of 15 cm (5 to 30 cm).]TreatmentA flow diagram of the patients recruited, excluded and treated is shown in Fig 1. Conservative management was initially attempted in 11 (64.7%) cases (seven dogs and four cats). The foreign body was in the stomach in nine (81.8%) of these cases, and in the jejunum and colon in one case (9.1%) each. Conserva -tive management was successful in 10 of 11 (90.9%) cases with no complications reported. Among these cases, the foreign body was passed in the faeces or not found on repeated radiographs in nine (90%) cases, while one dog vomited the needle after sedation for abdominal radiography. One cat had a gastrotomy performed as the needle was still present in the stomach on radio -graphs repeated 24 hours after admission.Endoscopic removal of the foreign bodies was attempted, but was unsuccessful, in three (17.6%) dogs. The reported cause for unsuccessful endoscopy in these cases was the presence of a large amount of gastric content which did not allow visualisa -tion of the foreign body in two cases. One of these dogs had an attempted endoscopy performed at the primary veterinar -ian before referral due to the presence of an oesophageal needle; the needle had moved into the stomach and a gastrotomy was attempted before referral, but the needle could not be found. On admission, conservative treatment was initially attempted, but the needle failed to progress on repeated radiographs over the follow -ing 24 hours and a further gastrotomy, with the aid of fluoroscopy, was needed to successfully retrieve the needle from the stomach. The other two dogs had a gastric needle and pin, respectively, and they were subsequently conservatively managed and the foreign body was not seen on repeated radiographs before discharge.Surgery was performed on admission in three (17.6%) dogs, all of which had their foreign body in the stomach. The reason for elective surgery was the ingestion of multiple (69) sewing pins in a dog who was witnessed to ingest a piece of meat containing FIG 1. Flow diagram describing the process of case selection 17485827, 2023, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13606 by Vetagro Sup Aef, Wiley Online Library on [07/08/2023]. 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 LicenseGastrointestinal 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.525 pins; 68 pins were removed through gastrotomy and duodenot -omy, while one could not be identified and was passed in the fae -ces following recovery from surgery. In the remaining two dogs, gastrotomy was performed by the primary veterinarian before referral and the foreign body could not be identified; these were conservatively managed following referral with no complica -tions reported. The foreign body was subsequently expelled with the faeces in one dog and was not seen on radiographs repeated 72 hours following admission in the second one.Conservative management, either primary or secondary, consisted of in- hospital monitoring in 16 of 17 (94.1%) cases; patients were assessed for onset of new clinical signs (abdominal pain, vomiting, pyrexia) suggestive of perforation, and for presence of peritoneal free fluid with bedside point- of- care ultrasonography at least once daily. Abdominal radiography was performed based on clinician discretion to determine foreign body movement. The remaining case was dis -charged home with instructions to monitor for further onset of vom -iting, lethargy, anorexia or abdominal pain and to repeat abdominal radiographs at the primary care veterinarian in 48 to 72 hours from discharge. Medical therapies administered varied. Analgesia and intravenous fluid therapy were provided to the five cases that under -went surgery. In addition, one of the cases that underwent initial unsuccessful endoscopy received intravenous fluid therapy. Omepra -zole was given to two patients and immunosuppressive steroids to the dog with immune mediated polyarthritis. The remaining eight (47%) cases did not receive any medical treatment. No mentions of specific dietary modifications were found in the medical records of any dogs or cats and animals were fed with amount and type of com -mercial diet appropriate for their size and age.Complications and transit timeWhen considering all cases, two of 17 (11.8%) cases underwent surgery following attempted medical management due to failure of the foreign body to progress on repeated radiographs 24 hours following admission. No further complications were reported. In the remaining 15 (88.2%) cases the foreign body was documented to have been expelled either by retrieval in the faeces (nine), by negative repeated radiographs (five) or was vomited (one). One case was discharged on the same day of ingestion, before repeated imaging. The primary veterinarian was contacted and the foreign body had moved in the colon 24 hours after discharge and was passed in the faeces 4 days later. The time of faecal transit was reported in 14 cases, with a mean time of 59.2 (±31.4) hours.OutcomeThe median LOH was 48 hours (24 to 144 hours). The median LOH in the five cases that underwent surgery either as a primary intervention or following initial conservative management was 72 hours (48 to 144 hours). All patients survived to discharge (100%).

Question 124

Jacobson - 2023 - JFMS - A Pandora's box in feline medicine - Presenting signs and surgical outcomes in 58 previously hoarded cats with chronic otitis media-interna.pdf

Answer 124

Animals and study designThis retrospective observational study examined the records of cats from a single institutional hoarding environment (IHE)10,23 that were transferred to Toronto Humane Society (THS) between February 2017 and April 2019. THS is a large urban shelter, with a fully equipped veterinary hospital. Routine intake procedures included core vaccination, Wood’s lamp screening retroviral screening and treatment with selamectin and pyrantel.OMI associated with Streptococcus equi suspecies zooepidemicus (SEZ) had previously been encountered in cats from another IHE. The index of suspicion was therefore high, and intake procedures included care-ful assessment for OMI. Shelter protocols for OMI and polyps were followed for suspected cases and included general anesthesia, otoscopic examination, examination of the nasopharynx for a polyp and radiographs of the tympanic bullae. CT was performed at a referral hospital on a case-by-case basis. Cultures were performed at the veterinarian’s discretion.Cats were included if they originated from the same IHE, had been diagnosed with OMI and met the following retrospective confirmatory criteria: (1) clinical findings consistent with OMI; (2) diagnosis by a shelter veterinarian; and (3) bulla disease identified by either CT scan and/or radiographs interpreted by a boarded veterinary radiologist (SM), and/or visual confirmation at the time of VBO.Case managementInitial therapy for all cases consisted of a broad- spectrum oral antibiotic and tris-EDTA-enrofloxacin- dexamethasone eardrops compounded in-house (tris-EDTA 9.8 ml, enrofloxacin [50 mg/ml]; 1.66 ml, dex -amethasone phosphate [5 mg/ml] 0.32 ml). Prednisolone was prescribed as recommended for polyps,20 and case by case at the clinician’s discretion for cats without pol -yps. Dexamethasone was administered perioperatively in selected cases. This was initially to help manage airway edema and subsequently to attempt to prevent it. There were no fixed criteria, and administration was based on the surgeon’s risk assessment. VBO surgeries were initially performed in-house, and subsequently by boarded surgeons at referral facilities. A protocolized veterinary examination (see file 1 in the supplemen-tary material) was performed, typically under sedation, to assess the result of each VBO surgery. Results were recorded for the recheck time point as close as possible to 4 weeks after the final VBO.Clinical findings and outcome measuresPreoperative findings were retrospectively classified (Table 1; see file 2 in the supplementary material for criteria). The case definition for OI/PVD was presence of head tilt/excursions and/or ataxia. Tympanic bulla wall thickening was scored by a boarded radiologist (SM). Surgical complications were classified based on a study by Smeak.21 Complications were classified as seri -ous if they were life-threatening, had functional conse-quences, and/or required intensive or prolonged care. Poor surgical outcomes were euthanasia, serious surgical complications and/or moderate/severe nasopharyngeal (NP) signs, moderate/severe OE or presence of OI at the postoperative recheck.Data analysisData analysis used Microsoft Excel and MedCalc (https://www.medcalc.org/calc/odds_ratio.php). To create dichotomous variables for statistical analysis, mild NP signs, OE and bulla wall thickening were grouped with normal findings, and other abnormal categories were grouped together (for example, moderate and severe NP signs) (see file 2 in the supplementary material). Jacobson et al 3McNemar’s test was used to test the null hypothesis that VBO did not result in resolution of clinical signs. ORs were used to quantify univariable relationships between factors relevant to clinical decision-making and out-comes/complications and were tested for significance using the Pearson c2 test. Significance was set at P <0.05.ResultsStudy populationIn total, 669 cats were transferred from the IHE during the study period. OMI was suspected in 95 (14%) cats and confirmed in 70. Nineteen cats with unconfirmed OMI were euthanized before confirmation, and six did not meet the case definition. Of the 70 cases, 59 were treated surgically and 11 medically. One was excluded because of surgical complications unrelated to OMI, leaving 58. The time from intake to surgery varied, but all cats received medical treatment before surgery.Presenting signs and clinical findingsOf the 58 cats, 18 (31%) were feline immunodefi-ciency virus (FIV)-positive on point-of-care testing. Ear mites were suspected in 20/58 (34%) because of the nature of the aural exudate. The exudate from seven cats was examined microscopically and was positive for Otodectes mites in two. Mites were visualized on otoscopic examination in one cat.Nine cats (16%) exhibited inappetence (Table 1). Half had pruritus and/or alopecia, which extended beyond the head and neck in 17 (‘generalized’). In total, 26 (45%) cats had moderate/severe NP signs. Moderate/severe OE was common (46/58, 79%), with purulent discharge in 21 (36%) cats. Polyps were found in 15 (26%) cats. The tympanic membranes (TMs) were bulging/inflamed in 13/116 (11%) ears and ruptured in 20 (17%). Radiographically, there was increased opacity in one or both compartments of the tympanic cavity in 99/108 (92%) ears. The bulla wall was thickened in 98 (91%) ears. Thickening was mild in 60 (56%) ears, moderate in 27 (25%) and severe in 11 (10%) (Figure 1). Horner’s syndrome and nystagmus were uncommon (1/58 each, 1.7%). OI was present in 23 (40%) cats, of which 22 had head tilt/excursions.A total of 81 bacterial cultures were performed for 48 cats (15 ear canal, nine nasal, two pharyngeal, 33 from the bulla at the first VBO, 20 from the bulla at the second VBO and two from the bulla at revision surgery) (manu -script in preparation). Of 48 cats, 26 (54%) had at least one Table 1 Clinical features of otitis media-interna before ventral bulla osteotomy surgery in 58 cats transferred from an institutional hoarding environmentVariable Classification n (%)Inappetence Mild/moderate 5 (8.6)Severe 4 (6.9)Pruritus/alopecia Localized 12 (21)Generalized 17 (29)Nasopharyngeal signs* Moderate 25 (43)Severe 1 (1.7)Otitis externa* Moderate 35 (60)Severe 11 (19)Aural discharge type Dark/ceruminous 30 (52)Purulent 21 (36)Tympanic membrane† Bulging, inflamed 13 (11)Ruptured 20 (17)Not visualized 35 (30)Polyp‡ Aural 6 (10)Nasopharyngeal 6 (10)Both aural and nasopharyngeal 3 (5.2)Radiographic bulla wall thickening§ Moderate 27 (25)Severe 11 (10)Horner’s syndrome 1 (1.7)Nystagmus 1 (1.7)Otitis interna (peripheral vestibular signs) Head tilt/excursions 22 (38) Ataxia 1 (1.7)Meningoencephalitis 1 (1.7)*For outcomes analysis, mild changes were grouped with normal findings for these variables†n = 116 ears‡Polyps were found in the bulla at surgery in an additional three cats§n = 108 ears (four cats had CT only)4 Journal of Feline Medicine and Surgery SEZ-positive culture and 8/48 (17%) had cultures that were exclusively positive for other species. There was no growth for 14/48 (29%) cats.Surgical complicationsTwo of three cats that underwent simultaneous bilateral VBOs developed postoperative airway obstruction. One had multiple subsequent complications (wound abscess, aspiration pneumonia and prolonged anorexia) and the other developed prolonged anorexia. Both cats ultimately recovered. All subsequent bilateral VBOs were staged and performed at least 2 weeks apart.Unilateral VBO was performed in 25/58 (43%) cats, staged bilateral in 30 (52%) cats and simultaneous bilateral in three (5.2%) cats. In total, 26 surgeries were performed by shelter veterinarians and 62 by specialist surgeons. Of the 58 cats, 40 (69%) had 65 complications after the first VBO and 19/30 (63%) had 36 complications after the sec -ond (Table 2). Of 101 complications, 56 (55%), from 27/88 surgeries (31%), were serious. The most frequent serious neurological complication was OI, in eight (14%) cats. Horner’s syndrome occurred in 41 (71%) cats and 52/88 (59%) surgeries and occurred after both VBOs in 11 cats.Life-threatening perioperative complications occurred in six cats at the first VBO and one at the second VBO (7/88 surgeries; 8%). One was euthanized after cardiac arrest. A second cat that arrested developed Horner’s syndrome and OI but improved and survived to adop-tion. One cat required an emergency tracheostomy but survived to adoption. Presumptive meningoencephalitis (ME) occurred in two cats: acutely in one cat 2 weeks after VBO; and 2 months after VBO in the other. Both were euthanized. In the first case, ME was probably present before surgery and may have been acutely exacerbated.Six cats developed prolonged anorexia postopera-tively. These cats sometimes showed interest in food, with initial prehension but subsequent dropping of the food. Three of the six cats developed brown discoloration of the tongue (Figure 2). Diagnostics were performed in one of these three, and showed neutrophilic inflammation with multiple organisms, including pigmented fungi, and a Candida-positive culture. The tongue discoloration was suspected to be secondary to xerostomia (dry mouth) and yeast overgrowth. The three affected cats were treated with oral itraconazole, topical pilocarpine and oral rinses of chlorhexidine or povidone-iodine, as well as esophago-stomy tube feeding in two cats. The tongue discoloration resolved in all three cats, but subsequently recurred in one. This cat was euthanized after a complicated and prolonged clinical course.Severe, generalized pruritus occurred in nine cats postoperatively. At the postoperative recheck, this had resolved in four cats (at intake, alopecia/pruritus was absent in three and localized in one of these four), improved in two cats (localized alopecia/pruritus was present at intake and recheck in both) and persisted in three cats (at intake, alopecia/pruritus was absent in two and localized in one of these three).In total, 53 (91%) cats were adopted, and five (8.6%) cats were euthanized for serious surgical complications (n = 3), delayed-onset ME (n = 1) and failure to improve postop -eratively, polyp regrowth and FIV-positive status (n = 1).Outcome analysisA statistically significant proportion of cats showed reso -lution of pruritus/alopecia ( P = 0.001), moderate/severe NP signs (P = 0.002), moderate/severe OE (P <0.001) and purulent aural discharge ( P = 0.002) (Table 3). At recheck, postoperative Horner’s syndrome had persisted in 26/41 (63%) affected cats (P <0.001) and resolved in 11/41 (27%) cats. Data were not available for 4/41 (10%) cats. There was no significant change for inappetence or presence of OI.OI before VBO was associated with a significantly greater risk for moderate/severe OE at recheck (OR 4.35; 95% CI 1.21–15.70; P = 0.02) (Table 4). Surgery perfomed Figure 1 Radiographic images showing otitis media in previously hoarded cats. (a) Cat 10: left dorsal-right ventral oblique radiograph of the skull, showing mild bony thickening of the left tympanic bulla (white arrow) and severe bony thickening of the right tympanic bulla (black arrow) superimposed on the skull. (b) Cat 63: left dorsal-right ventral oblique radiograph of the skull, showing moderate bony thickening of both tympanic bullae (white arrows). (c) Cat 18: left dorsal-right ventral oblique radiograph of the skull, showing severe bony thickening of both tympanic bullae (white arrows). (d) Cat 58: ventrodorsal radiograph of the skull, showing severe bony thickening of both tympanic bullae (white arrows)Jacobson et al 5by a generalist was also associated with higher risk for moderate/severe OE (OR 3.64; 95% CI 1.03–12.87; P = 0.045). No other associations with negative outcomes were identified (Tables 4 and 5).

Question 125

Biehl - 2023 - VETSURG - Influence of closed glove exchange on bacterial contamination of the hands of the surgical team.pdf

Answer 125

2.1 |Study designA prospective, experimental study was performed. Partici-pants included faculty, staff, house officers, and studentson the soft tissue, orthopedic, neurologic, oncologic, andgeneral surgery surgical services that scrubbed into a sur-gery performed in the operating rooms at the Texas A&MSmall Animal Veterinary Medical Teaching Hospital dur-ing normal business hours. Participants were able to par-ticipate each time they scrubbed into surgery; participantswere therefore included multiple times throughout thestudy. All participants were enrolled between May 21 andJune 16, 2021. The study was approved by the institutionalreview board at Texas A&M University (IRB2020-1349).2.2 |Data collectionThe traditional presurgical preparation protocol at TexasA&M Small Animal Veterinary Medical Teaching Hospitalis hand wash with nail picking prior to the first scrub ofthe day. The initial hand wash was performed using oneof three different commercially available products, chlor-hexidine gluconate 4% solution antiseptic (BD, FranklinLakes, New Jersey), Dawn dish soap (Procter & Gamble,Cincinnati, Ohio), or 0.5% providone-iodine antisepticsolution (BD). The hands were dried and a surgical handscrub preparation was performed using one of two differ-ent commercially available products, Avaguard (3 M,St. Paul, Minnesota) or Sterillium (BODE CHemie GmbH,Hamburg, Germany) according to the manufacturers ’748 BIEHL ET AL . 1532950x, 2023, 5, instructions. For subsequent scrubs during the same day,the hands were washed and nails picked at the surgeon'sdiscretion and the surgeon's scrub was performed prior tosurgery. Data pertaining to each participant was collectedprior to surgery at the time of surgeon's scrub. The partici-pants were categorized as faculty, technicians, residents,interns, or students. The participant's dominant hand wasrecorded as was level of training. The duration and sub-stance used for surgeon's scrub were recorded. The dura-tion of scrub was recorded either by direct observation or,when direct observation was not possible, from a videorecording of the scrub area.Procedural information was recorded and includedsurgical service, procedure, duration of procedure, ifglove exchange was performed during the procedure, andtime of collection of culture samples.2.3 |Sample collectionSwab samples were collected from each participant asthey were leaving the surgical procedure, similar to a pre-vious report.22One researcher (KB) collected all of thesamples. The researcher carefully removed the partici-pant's left glove, ensuring the cuff stayed in place andwas not pulled distally onto the participant's hand. Occa-sionally, this required the researcher to hold the gown atthe participant's elbow to prevent moving the cuff distallyas the gloves were removed. A swab (BBL CultureSwab,Sparks, Maryland) moistened with approximately fourdrops of sterile saline was traced five times along the fin-gers and once along the interdigital spaces of the palmarand dorsal aspects of the hand (Figure1), excluding thefingernail bed. The same procedure was repeated for theparticipant's right hand. After both hands had beenswabbed, the participants worked their hands into thecuff, so that the cuff extended just beyond the fingertips.A new swab with approximately four drops of sterilesaline was then taken from the inside of the gown's cuffs.The participants fully withdrew their hands into thegown and performed a standard closed gloving with anew pair of sterile gloves. The new pair of gloves wasremoved as described above and the previously describedhand swabbing method was repeated. The time betweenpre-CGE and post-CGE sample collection was recorded.2.4 |Bacterial analysisSwabs were streaked on Trypticase Soy Agar with 5%sheep blood (TSA II; Sparks) and plates were allowed togrow for 5 days at 35/C14C at 2.5% CO 2and the numbers ofcolony forming units (CFU) were recorded. Matrix-assisted laser desorption ionization time-of-flight massspectrometry (MALDI-TOF MS) (Microflex LT, BrukerDaltonics, Billerica, Massachusetts) was used to identifybacterial isolates. Each participant had cultures platedonto five separate blood agar plates: one plate pre-CGEnondominant hand, one plate pre-CGE dominant hand,one plate post-CGE nondominant hand, one plate postCGE dominant hand, one plate from the cuff. A positiveculture was defined by one CFU or more present on theblood agar plate after 5 days of incubation.2.5 |Statistical analysisSummary statistics were expressed as means and stan-dard deviations (for normally distributed data) or medianand interquartile range (non-normal distribution); dataFIGURE 1 Image of hand-swabbing procedure.BIEHL ET AL . 749 1532950x, 2023, 5, distribution was assessed graphically or by the D'Agostino –Pearson test. For the primary study question ( “doeshand contamination occur during closed gloveexchange? ”) we carried out two analyses: (i) using theone-sided sign test to compare incidence of positive culturebefore and after glove change ignoring the “clustering ”(i.e., repeated data collection from single individuals) thatwill occur in all “real-world ”clinics; and, (ii) using Som-ers'dstatistic to adjust for possible effects of clusteringand provide additional quantification A one-sided sign testwas used to evaluate differences in the number of CFUsbetween pre-CGE and post-CGE because it is rational toconsider only the possibility that CGE could increasecontamination.For the secondary study, we accounted for clusteringby multilevel mixed effects modeling. In this exploratorysecondary analyses, any samples that had positive handcultures pre-CGE were removed (so we could determine ifpositive hand culture on post-CGE derived from CGE).Fisher's exact test was used to test for differences betweendominant and nondominant hand contamination. Explor-atory univariable analyses of association of various possi-ble factors with positive hand culture was undertakenusing a mixed model (to account for the clustering associ-ated with repeated sampling from specific individuals)logistic regression. Finally, to adjust for effects of possibleconfounding, all variables were included in a multivariablemodel that was manipulated by stepwise forward andbackward elimination (according to the associatedpvalues) to minimize the Bayesian information criterion.Significance was set at p< .05. As there were multiplepotential interaction terms (and a relatively small numberof positive culture events) none were included in this mul-tivariable analysis. All analyses were carried out in Graph-Pad Prism (Prism 7 for Windows, San Diego, California)or Stata 17 (StataCorp, College Station, Texas).3|RESULTSSamples from 78 individuals were taken from 65 surgicalprocedures performed at the Texas A&M Small AnimalVeterinary Medical Teaching Hospital. Forty-six individ-uals participated multiple times (Table 1). For each par-ticipation, participants underwent five cultures: cultureof the dominant and nondominant hands pre-CGE, cul-ture of the cuff, and culture of the dominant and nondo-minant hands post-CGE. The total number of samplesobtained was n=1000. Categorization of the origin ofthese samples by service, and personnel position, can beseen in Table2.All participants performed an initial hand wash:186 (93%) were performed with chlorhexidine scrub,4 (2%) were performed with Dawn dish soap, and 10 (5%)were performed with povidone-iodine. All participantsperformed a preoperative surgical hand preparationscrub. 16 (8%) were performed with Avagard and184 (92%) were performed with Sterillium. The meanduration of hand scrub was 89 s (SD: 38). The mean dura-tion of participation in surgery was 129 (SD: 59) min. Themean duration of time between pre-CGE and post-CGEsample collection was 4 min (SD: 1).The total number of hand cultures (dominant and/ornondominant, pre- and/or post-CGE) (n =200) andgown cuff cultures (n =200) that returned positive bacte-rial growth is listed in Table3. The total number of bloodagar plates (n =1000) that resulted in positive bacterialgrowth after 5 days of incubation is listed in Table 4.Numbers of dominant and nondominant hands withpositive cultures pre-CGE and post-CGE are listed inTable 5. Categorization of positive cultures is summa-rized in Table 6. Our primary research objective was toassess hand contamination during closed-glove exchange.An increase in bacterial contamination associated withTABLE 1 Number of participation enrollments (total n=200)per individual ( n=78).Times enrolled Number of individuals13 222 13845546173829110 1TABLE 2 Categorization of enrollments ( n=200) by serviceand training level.Service General 32 (16%)Soft tissue 57 (28.5%)Surgical oncology 24 (12%)Neurology 25 (12.5%)Orthopedics 62 (31%)Training level Faculty 42 (21%)Student 69 (34.5%)Resident 36 (18%)Intern 39 (19.5%)Technician 14 (7%)750 BIEHL ET AL . 1532950x, 2023, 5, CGE was not apparent in raw data (i.e. without adjustingfor clustering) analysis (one-sided sign test, p=.61) norin more complex analysis that adjusted for the potentialinfluence of clustering (Somers' d;p=.27). This secondanalysis returned a point estimate increase in bacterialcontamination associated with CGE of 7% (95%CI from/C06% to 19%).One hundred and eighty seven nondominant handshad a negative hand culture pre-CGE and 14/187 (7.5%)became positive post-CGE. Similarly, 183 dominanthands had a negative hand culture pre-CGE and 11/183(6.0%) became positive post-CGE. There was no statisticalevidence to support a difference in hand contaminationbetween the participants' dominant and nondominanthands (Fisher's exact test p=.68).An exploratory univariable and multivariable mixedlogistic model (accounting for clustering within individ-uals) was performed to identify factors that might beassociated with positive culture following CGE. In theanalysis, a signficant effect was not associated with anyof the following variables: service, training level, scrubtype, time spent scrubbing, or length of surgery participa-tion. The optimal model, based on minimizing the Bayes-ian information criterion, retained service only. Theresults of statistical analyses are shown in Tables7and8.Twelve different bacterial species were isolated(Figure 2); the most commonly isolated bacterial specieswere Staphylococcus spp. There were five samples inwhich the species isolated from the cuff was the same asone of the species isolated from the hands. The speciesisolated were S. warneri (n=2),S. epidermidis (n=2),and Staphylococcus spp (n =1) (Table9). Two sampleshad the same species found only on the pre-CGE handand the cuff (samples 1 & 3). One sample had the samespecies found only on the post-CGE hand and the cuff(sample 2). The remaining ones had the same species onpre-CGE, post-CGE hands and the cuff (samples 4 and 5).Intraoperatively, prior to the planned CGE, gloveswere exchanged 16 times (16/200;8%). The gloves wereexchanged intraoperatively due to actual or perceivedbreaks in aseptic technique, adhering to the principles ofsurgical oncology, or after finishing work in a contami-nated surgical field. Three glove exchanges (3/16; 18.8%)were performed as open glove exchanges and 13 (13/16;TABLE 4 Total number of blood agar plates ( n=1000).Positive blood agar plates ( n=71)1 CFU 52>1 CFU 19Note: CFU recorded after 5 days of incubation.TABLE 5 Number of positive hand cultures (total handcultures performed, n=800).Pre-CGE Post-CGENondominant hand ( n=400) 13 15Dominant hand ( n=400) 17 14TABLE 3 Total number of hand (dominant and/ornondominant, pre- and/or post-CGE) and gown cuffcultures ( n=200).HandculturesGown cuffculturesPositive bacterial growth 45 12Negative bacterial growth 155 188TABLE 6 Categorization of positive hand cultures by service and training level. Percentages represent positive cultures/number ofenrollments per service or training level.Pre-CGEnondominantPost-CGEnondominantPre-CGEdominantPost-CGEdominant CuffService General surgery ( n=32) 1 (3.1%) 3 (9.4%) 6 (18.8%) 3 (9.4%) 1 (3.1%)Soft tissue ( n=57) 0 (0%) 2 (3.5%) 1 (1.8%) 2 (3.5%) 2 (3.5%)Surgical oncology ( n=24) 2 (8.3%) 1 (4.2%) 1 (4.2%) 3 (12.5%) 0 (0%)Neurology ( n=25) 2 (8%) 3 (12%) 1 (4%) 2 (8%) 2 (8%)Orthopedics ( n=62) 8 (12.9%) 6 (9.7%) 8 (12.9%) 4 (6.5%) 7 (11.3%)Training level Faculty ( n=42) 3 (7.1%) 4 (9.5%) 4 (9.5%) 2 (4.8%) 3 (7.1%)Student ( n=69) 1 (1.4%) 6 (8.7%) 6 (8.7%) 9 (13%) 4 (5.8%)Resident ( n=36) 3 (8.3%) 2 (5.6%) 4 (11.1%) 1 (2.8%) 3 (8.3%)Intern ( n=39) 4 (10.3%) 1 (2.6%) 1 (2.6%) 2 (5.1%) 0 (0%)Technician ( n=14) 2 (14.3%) 2 (14.3%) 2 (14.3%) 0 (0%) 2 (14.3%)BIEHL ET AL . 751 1532950x, 2023, 5, 81.3%) were performed as CGEs. Two of the 16 samplesthat had previously undergone glove exchange (2/16;12.5%) had positive hand cultures. One positive hand cul-ture was positive on the dominant hand pre-CGE, theother was on the nondominant hand post-CGE.4

Question 126

Fuchter - 2023 - VCOT - Biomechanical Comparison of Cortical Lag Screws and Cortical Position Screws for Their Generation of Interfragmentary Compression and Area of Compression in Simulated Lateral Humeral Condylar Fractures.pdf

Answer 126

Fracture ModelThirteen pairs of cadaveric humeri were obtained fromskeletally mature Merino sheep harvested at the conclusionof studies with institutional ethical approval. The glenohum-eral joint and humeroradioulnar joints were disarticulated,and soft tissue attachments were transected as close aspossible to their humeral origins and insertions. Pairedhumeri were wrapped in 7.0% phosphate buffered salinesoaked gauze, vacuum sealed and frozen at /C016°C. Speci-mens were immersed in an ambient temperature water baththe night prior to testing to thaw.Paired humeri were randomly assigned to the experimen-tal treatment groups for comparison: one to the lag screwtreatment ( n¼13) and the other to the position screwtreatment ( n¼13). The condylar width was quanti fied usingcallipers. Two osteotomies were created: one in the midsag-ittal plane from the distal humerus at the junction betweenthe trochlea and the capitulum and the other at 90 degreesangle to the first from slightly proximal to the lateralepicondyle in a medial direction to the thin bone plateequivalent to the canine supratrochlear foramen (►Fig. 1 ).Both osteotomies were created using a band saw (BAS-350C,Carbatec, Sydney, Australia). The width of the medial andlateral fragments was measured using callipers (CAL200,Knight Benedikt, Sydney, Australia). Width of the kerf wascalculated by adding the sum of the two fragments, and thensubtracting this from the condylar width.Interfragmentary Compression and Area ofCompressionCortical screws (3.5mm; KOE500S, Knight Benedikt, Sydney,Australia), 50mm in length, were used to reconstruct thesimulated fractures. Screws were tightened with a screw-driver (SWS-250, Transducer Techniques LLC, Temecula,California, United States) to a torque of 1.8Nm. A torque of1.8Nm was based on a pilot study, in which torques greaterthan 2Nm were found to cause stripping of the thread.Interfragmentary compression and area of compressionwere quanti fied using pressure mapping sensors (Model4000, Tekscan Inc, Boston, Massachusetts, United States)placed on the cranial and caudal aspects of the interfrag-mentary interface immediately adjacent to the pre-drilledFig. 1 Photograph of a simulated lateral humeral condylar fracturespecimen. The osteotomized lateral condyle has been removed fromview to facilitate visualization of the osteotomy location and angles..screw hole. A pilot study using medium (M W R270 10M 1,Fujifilm Corporation, Tokyo, Japan), low (L W R270 10M 1,Fujifilm Corporation, Tokyo, Japan) and super-low (LL WR270 5M 1, Fuji film Corporation, Tokyo, Japan) pressurepre-scale film qualitatively demonstrated the even distribu-tion of interfragmentary compression across the interfrag-mentary interface. Placement of the pressure mappingsensors on the cranial and caudal aspects minimized inter-ference during screw insertion, while placement immedi-ately adjacent to the pre-drilled screw hole ensured that thesame proportion of the interfragmentary interface in eachspecimen contacted the sensor.Insertion TechniqueIn the lag screw treatment group, a 3.5 mm orthopaedic drillbit (JBE350, Knight Benedikt, Sydney, Australia) was used tocreate a glide hole through the centre of the free lateralfragment perpendicular to the fracture (midsagittal) plane.It was drilled freehand from a retrograde ‘inside-out ’orienta-tion. The fracture was reduced using fragment forceps(PBF205, Knight Benedikt, Sydney, Australia). A 2.5mm insertdrill sleeve (SLD250, Knight Benedikt, Sydney, Australia) wasinserted into the glide hole and a 2.5mm orthopaedic drill(JBE250, Knight Benedikt, Sydney, Australia) bit was used tocreate a screw hole through the centre of the medial fragment(►Fig. 2 ). The fragment forceps were removed to facilitate theplacement of the pressure mapping sensors in the interfrag-mentary interface before the fracture was reduced.To prevent rotation of the lateral fragment during fracturefixation, an issue encountered in the pilot study, a 2mmdiameter Kirschner wire was inserted through a drill guideusing a battery powered orthopaedic handpiece with asso-ciated wire driver. It was inserted distolaterally and directedin a proximo-medial direction along the lateral epicondylarcrest. The Kirschner wire was inserted until the trocar tipemerged through the medial cortex. Following insertion andtightening of the 3.5mm cortical screw to a torque of 1.8Nm,the fragment forceps were removed (►Fig. 3 ). The real-timereadings from the pressure mapping sensors were recordedfrom 3 seconds prior to the start of screw insertion to3 seconds after the removal of the fragment forceps. Figuresfrom three standardized time points were recorded forstatistical analysis. The three time points measured weretime point 1, after fracture reduction using fragment forceps(T1), time point 2, after screw insertion with fragmentforceps remaining in position (T2) and time point 3, mea-sured after removal of the fragment forceps, leaving only thecortical screw (T3).In the position screw treatment group, the fracture wasreduced using fragment forceps. A screw hole of 2.5mm wasdrilled freehand through the centre of condyle from a lateralto medial orientation perpendicular to the fractureFig. 2 Photograph of a simulated lateral humeral condylar fracturespecimen after anatomical reduction using fragment forceps. A2.5mm insert drill sleeve is visible in the 3.5mm glide hole in thelateral fragment in preparation fo r the drilling of the 2.5mm screwhole through the medial fragment.Fig. 3 Photograph of a stimulated lateral humeral condylar fracturespecimen fixed with a Kirschner wire and a cortical screw inserted as alag screw following fragment forceps removal. Note the pressuresensitive film present in the interf ragmentary interface..(midsagittal) plane. The protocol of screw insertion andmeasurement of interfragmentary compression and area ofcompression was identical to that described above ( ►Fig. 4 ).Statistical AnalysisStripping of the thread and the resultant loss of all inter-fragmentary compression (kPa ¼0) led to the exclusion of asingle lag screw treatment and a single position screwtreatment. As these treatments were members of differentpairs, two pairs of humeri were excluded before statisticalanalysis. Therefore, the final sample sizes were as follows:lags screw treatment n¼11 and position screw treatmentn¼11.All data were analysed using IBM SPSS Statistics. Datawere assessed for normality quantitatively using a Shapiro –Wilk test and qualitatively using a histogram, normal Q-Qplot, detrended normal Q-Q plot and a boxplot. As this was apaired study, and data were not normally distributed, arelated-samples Wilcoxon signed rank test was used tocompare the two fixation methods. Data were analysed forsignificant differences between the lag screw treatment andposition screw treatment for the following variables: condy-lar width (mm), bone loss (mm), medial fragment width(mm), lateral fragment width (mm), starting interfragmen-tary compression (kPa), starting area of compression (cm2),peak interfragmentary compression (kPa), peak interfrag-mentary compression area of compression (cm2), end inter-fragmentary compression (kPa) and end area of compression(cm2). Ap-value less than 0.05 was considered signi ficant.The related-samples Hodges –Lehmann method was used toestimate median differences with 95% con fidence intervals(CI) for the two treatment groups.ResultsCondylar width, medial fragment width, lateral fragmentwidth and width of the kerf, or bone loss, did not varybetween the two treatments ( p¼1.00, 95% CI: 0.00 [0.00 –0.00], p¼0.26, 95% CI: 0.500 [0.00 –1.00], p¼0.26, 95% CI:/C00.50 ( /C01.00 –0.00) and p¼1.00, 95% CI: 0.00 (0.00 –0.00)respectively) ( ►Table 1 ).Interfragmentary CompressionNo signi ficant difference in interfragmentary compressionwas detected between the two treatments ( p¼0.72, 95% CI:11.50 [ /C0177.50 –/C0140.00]) at T1. At T2, the lag screw treat-ment generated signi ficantly greater interfragmentary com-pression compared with the position screw treatment(p¼0.003, 95% CI: /C0719.75 [ /C01876.50 –/C0383.00]). At T3,the difference in interfragmentary compression remainedsignificant between the two treatments ( p¼0.033, 95% CI:/C0436.50 [ /C01599.50 –/C016.50]). At each time point, interfrag-mentary compression was of a greater magnitude in the lagscrew treatment (►Table 2 /►Fig. 5 ).Area of CompressionAt T1, no signi ficant difference in area of compression wasdetected between the two treatments ( p¼0.197, 95% CI:/C00.047 [ /C00.13 –0.04]). At both T2 and T3, the area of compres-sion was of signi ficantly greater magnitude in the lag screwtreatment compared with the position screw treatment(p¼0.008, 95% CI: /C00.44 [ /C00.67 –/C00.19]) and ( p¼0.006, 95%CI:/C00.43 [ /C00.64 –/C00.16] respectively; ►Table 3 /►Fig. 6 ).

Question 127

Jones - 2024 - VETSURG - Comparison of mortality of brachycephalic dogs undergoing partial staphylectomy using conventional incisional, carbon dioxide laser, or bipolar vessel sealing device.pdf

Answer 127

Electronic medical records were searched at fiveOhio-based private specialty hospitals (MedVet Medical &Cancer Centers for Pets in Columbus, Cincinnati,Dayton, Hilliard, and Toledo) for all client-owned dogsthat underwent partial staphylectomy between January2011 and December 2021. For the purpose of this study,only English bulldogs, French bulldogs, and pugs wereincluded for analysis, as these breeds are commonlyconsidered in the literature when assessing treatmentsfor BOAS. Dogs were excluded if the method utilized forpartial staphylectomy was not recorded. Dogs undergoingpartial staphylectomy for reasons other than treatment ofelongated soft palate (i.e., palatal neoplastic lesions) werealso excluded. For dogs that underwent multiple partialstaphylectomy procedures over the course of the studyperiod, only the first procedure was included for statisti-cal analysis.Preoperative information recorded included age,breed, gender, reproductive status, bodyweight, body con-dition score (BCS), whether the procedure was performedon an elective or emergent basis, preoperative clinicalsigns, chronicity of clinical signs, comorbidities (includ-ing cardiac disease, lower airway disease, tracheal col-lapse, and chronic gastrointestinal disease), history ofprevious upper airway surgery, and preoperative medica-tions. Surgical information recorded included experiencelevel of the primary surgeon (ACVS diplomate or super-vised resident), upper airway examination findings, themethod utilized for partial staphylectomy, additionalupper airway procedures performed (including rhino-plasty, sacculectomy, tonsillectomy, arytenoid lateraliza-tion or arytenoidectomy, and laryngeal mass biopsy),additional nonairway procedures performed, total sur-gery time, total anesthesia time, time to extubation, theability to extubate or not, and perioperative medications.Postoperative information recorded included complica-tions, temporary tracheostomy, oxygen supplementation,mechanical ventilation, survival to discharge, cause ofdeath, and length of hospitalization.Anesthetic protocol varied by hospital and attendingclinician. Prior to surgery, a sedated upper airway exami-nation was performed by the attending clinician to docu-ment anatomical abnormalities. Cases with evidence ofJONES and KENNEDY 123 1532950x, 2024, 1, laryngeal collapse were assessed based on the scale firstdescribed by Leonard.27However, as the records oftenlacked specific detail to allow differentiation of stages IIand III, these were grouped together as higher gradelaryngeal collapse (in contrast to patients with only stageI collapse, or everted laryngeal saccules). For the upperairway procedures, patients were placed in sternal recum-bency, with the maxilla hung with medical tape and IVfluid poles. Surgical technique utilized for partial staphy-lectomy was determined by surgeon preference. For alltechniques, the planned partial staphylectomy was per-formed to shorten the soft palate to the level of the caudalaspect of the tonsillar crypts. For conventional incisionalstaphylectomy, the soft palate was sharply incised usingeither Metzenbaum or Potts scissors, and the oral andnasal mucosa apposed using either 3 –0o r4 –0 poligleca-prone 25 suture in a simple continuous pattern. For CO2laser staphylectomy, the soft palate was transected usingthe laser. For BVSD staphylectomy, a LigaSure Precisehandpiece (Medtronic, Minneapolis, Minnesota) wasused to both seal and transect the soft palate. Cases inwhich oversew of the mucosa was performed to achievehemostasis were recorded under the primary method ofstaphylectomy (e.g., CO2laser plus oversew was classifiedunder the CO 2laser treatment group). Additional upperairway procedures and nonairway procedures were per-formed at the discretion of the attending clinician andowner preference. The invasiveness of the additionalnonairway procedures was ranked based on an adapta-tion of Gruenheid et al.10(Table 1). Briefly, additionalprocedures were grouped as no additional procedures,noninvasive, minimally invasive, or invasive.2.1 |Data analysisDescriptive statistics were used to describe the study pop-ulation. The response variable was survival to discharge.Analysis was by means of multivariate logistic analysis.There were initially 41 factors that were identified aspotentially being associated with survival. Multicollinear-ity was quantified by means of the variance inflation fac-tor (VIF). A total of 28 factors with a VIF <2.5 wereretained. Each factor was then analyzed by means of Chi-square (for binary or categoric factors) and Kruskall-Wallis (for continuous factors) to determine if there wasany significant difference in distributions of each factorbetween the three staphylectomy techniques. If none,then those factors were eliminated, resulting in eight fac-tors: stage II or III laryngeal collapse, experience level ofthe primary surgeon, concurrent sacculectomy, concur-rent tonsillectomy, concurrent arytenoid lateralization orarytenoidectomy, perioperative steroid administration,perioperative NSAID administration, and perioperativeantiemetic administration. Staphylectomy technique andthose factors with a univariate p< .10 were entered intoa multivariate logistic regression model; factors with thehighest p-value were deleted one at a time, retaining allfactors with p< .05. All previously unused or deleted fac-tors were then added to the model, one at a time; all hadp> .10 and none were retained. Odds ratios, 95% confi-dence intervals (CI), and p-values were reported, withp< .05 considered statistically significant. All calcula-tions were by means of NCSS 2019 (Kaysville, Utah).3|RESULTSA total of 606 brachycephalic dogs met the inclusion cri-teria, consisting of 258 (42.6%) English bulldogs,232 (38.3%) French bulldogs, and 116 (19.1%) pugs. Themean age was 45 months (range 2 –233 months).The average weight was 16.0 kg (range 3.7 –48.6 kg). Themedian BCS was 6.0 (range 3.0 –9.0). The majority ofcases (87.5%) were performed on an elective basis,whereas the remaining (12.5%) were performed emer-gently. A total of 87 dogs (14.4%) underwent conventionalincisional technique, 385 dogs (63.5%) underwent CO2laser technique, including nine that had an additionaloversew performed, and 134 dogs (22.1%) underwentBVSD technique, including two that had an additionaloversew performed. Additional nonairway procedureswere performed under the same anesthetic event in305 dogs (50.3%), of which 13 (4.2%) were classified asnoninvasive, 250 (82.0%) as minimally invasive, and42 (13.8%) as invasive using the scale adapted by Gruen-heid et al.10(Table 1).TABLE 1 Scoring system of the invasiveness of additionalnonairway procedures, adapted from Gruenheid et al.10Types of procedures0–no additionalproceduresNA1–noninvasive Diagnostic imaging (CT or MRI)EndoscopyWound managementDental procedures2–minimallyinvasiveOphthalmic surgeriesOrthopedic surgeriesOvariohysterectomy/orchiectomyCutaneous/subcutaneous mass excisionTail or digit amputationsCardiological coiling or ballooning3–invasive Intra-abdominal surgeries other thanovariohysterectomy NeurosurgeriesAbbreviations: CT, computed tomography; MRI, magnetic resonanceimaging; NA, not applicable.124 JONES and KENNEDY 1532950x, 2024, 1, TABLE 2 Summary of cases that failed to survive to discharge.Casenumber BreedElective oremergentStaphylectomytechniqueStage of laryngealcollapseAdditional airwayproceduresAdditional non-airwayproceduresCause ofdeath Notes1 EnglishbulldogEmergent CO 2laser 2 –3 RhinoplastySacculectomyTonsillectomyn/a CPA Unknown cause2 EnglishbulldogElective CO2laser 2 –3 Sacculectomy n/a Euthanasia Suspected aspirationpneumonia3 FrenchbulldogElective BVSD 1 RhinoplastySacculectomyTonsillectomyOrchiectomy CPA Unknown cause4 EnglishbulldogElective CO 2laser 2 –3 RhinoplastySacculectomyn/a CPA Unknown cause5 EnglishbulldogEmergent BVSD 1 Sacculectomy n/a CPA Unknown cause6 EnglishbulldogElective BVSD 1 Sacculectomy Advanced imaging (CT) CPA Unknown cause7 EnglishbulldogEmergent BVSD 1 SacculectomyTonsillectomyn/a Euthanasia Concurrent broncho-pneumonia8 EnglishbulldogElective CO 2laser 1 SacculectomyTonsillectomyn/a Euthanasia Unable to discontinuemechanicalventilation9 EnglishbulldogElective BVSD 1 SacculectomyTonsillectomyPocket imbricationCryoepilationCPA Unknown cause10 EnglishbulldogEmergent BVSD 1 RhinoplastySacculectomyn/a CPA Unknown cause11 FrenchbulldogElective CO 2laser 2 –3 RhinoplastySacculectomyTonsillectomyn/a Euthanasia Euthanized 24 hoursfollowing temporarytracheostomy (detailsnot recorded)12 EnglishbulldogElective BVSD 1 RhinoplastySacculectomyTonsillectomyn/a CPA Respiratory arrest;aspiration pneumonia13 Pug Elective BVSD 1 RhinoplastySacculectomyArytenoidectomyn/a CPA Unknown cause(Continues)JONES and KENNEDY 125 1532950x, 2024, 1, TABLE 2 (Continued)Casenumber BreedElective oremergentStaphylectomytechniqueStage of laryngealcollapseAdditional airwayproceduresAdditional non-airwayproceduresCause ofdeath Notes14 EnglishbulldogElective BVSD 1 RhinoplastySacculectomyTonsillectomyn/a CPA Respiratory arrest;aspiration pneumonia15 EnglishbulldogElective BVSD 1 RhinoplastySacculectomyTonsillectomyn/a CPA Respiratory arrest;pharyngeal edema16 EnglishbulldogElective BVSD 1 RhinoplastySacculectomyTonsillectomyn/a Euthanasia Respiratory arrest;aspiration pneumonia;euthanized afterresuscitated followingCPA17 EnglishbulldogElective CO2laser 3 Sacculectomy Orchiectomy Euthanasia Unable to extubatepostoperatively18 Pug Emergent CO 2laser 1 Sacculectomy Advanced imaging (MRI)Ventral slotCPA Unknown cause19 FrenchbulldogEmergent CO 2laser 2 –3 RhinoplastySacculectomyAdvanced imaging (MRI) Euthanasia Progressive dyspnea;suspected aspirationpneumonia20 Pug Emergent CO 2laser 2 –3 RhinoplastySacculectomyArytenoidlateralizationn/a Euthanasia Unable to removetemporarytracheostomy after4 days21 Pug Emergent BVSD n/a Rhinoplasty n/a Euthanasia Tetraplegia andhypoventilationpostoperatively22 EnglishbulldogEmergent BVSD 2 –3 Sacculectomy Advanced imaging (CT)Wound debridementEuthanasia Unable to extubatepostoperatively23 EnglishbulldogElective Suture 1 RhinoplastySacculectomyn/a CPA Respiratory arrest;aspiration pneumonia24 EnglishbulldogEmergent Suture 2 –3 Sacculectomy Subcutaneous massexcisionCPA Respiratory arrest;pharyngeal edemaAbbreviations: BVSD, bipolar vessel sealing device; CO 2, carbon dioxide; CPA, cardiopulmonary arrest; n/a, nonapplicable.126 JONES and KENNEDY 1532950x, 2024, 1, Temporary tracheostomy was performed in 30 dogs(5.0%) and mechanical ventilation in 44 (7.3%). A total of24 dogs failed to survive to discharge, resulting in a 4.0%mortality rate (Table2). Of the eight potential factorsanalyzed, only staphylectomy technique and high-stagelaryngeal collapse were associated with mortality(Table3). Mortality prior to discharge was significantlyassociated with stage II or III laryngeal collapse(OR=4.6, 95% CI: 1.8 –11.8, p=.002), as well as BVSDpartial staphylectomy technique (OR =6.0, 95% CI: 1.3 –28.4, p=.023) when compared to the referent technique,conventional incisional. No significant difference wasdetected between CO2laser and conventional incisionaltechniques (OR =0.9, 95% CI: 0.2 –4.3,p=.890).4

Question 128

Klever - 2024 - VCOT - Influence of Femoral Position and Pelvic Projection on Norberg Angle Measurements.pdf

Answer 128

Material and MethodsCadavers of dogs weighing over 20 kg, euthanatized forreasons unrelated to this study, were included in the study.The dogs were placed for a ventrodorsal radiographic projec-tion with the hindlimbs extended. Three sets of radiographswith a total of 25 radiographs for each dog were taken. Afixed source to imager distance of 115 cm was used on anAxiom Luminos dRF radiography system (Siemens Healthi-neers, Erlangen, Germany). The first set was acquired duringmanual positioning, and correct positioning was initiallyproven using fluoroscopy before acquiring the final radio-graph. In the second and third sets, the dogs were positionedusing positioning devices such as foam pads, sandbags, andtape. Cadavers were aligned using the crosshair of thecollimation light, and positioning was proven using fluoros-copy. The first set with manual positioning included radio-graphs with endorotation ( /C2410–20 degrees) of the femoraand exorotation ( /C2410–20 degrees) of the femora with andwithout abduction as well as one radiograph in sternalrecumbency for a dorsoventral projection with the hipsextended. For the second and third sets of radiographs, thecadavers were positioned in dorsal recumbency in a subjec-tively perfect position and restrained using positioningdevices. To simulate rotation of the pelvis, the X-ray tubewas rotated without changing the patient position. Thisapproach was chosen to avoid in fluence of repeated posi-tioning and allowed exact adjustment of the angle of rotationusing the 1-degree step rotation facility of the X-ray tube.Radiographs in the second set were taken using eight stepsfrom 0 to 10 degrees to one side to simulate rotation of thepelvis along the long axis (sagittal plane;►Fig. 1 ). Due tobilateral symmetric anatomy of the pelvis, there was nodifference for rotation on the contralateral side; therefore,we only evaluated the unilateral tilt. During the third set,pelvic rotation from –20 degrees ( ►Fig. 2 )t oþ20 degrees(►Fig. 3 ) in 11 steps along the short axis was simulated. A fulloverview of radiographs taken during each set is depicted in►Appendix Table 2 (available in the online version).Data AnalysisEach radiograph was blinded for evaluation and numbered toguarantee assignment to the correct patient. The Norbergangles for the left and right hip joints were measured twiceby two observers (SH and ASH), and subjective assessment ofthe tilt was recorded for every image ( “tilt visible ”and “notilt visible ”). Additionally, the FCI score for each hip joint wasclassi fied. All measurements were made in the same digitalenvironment using a magni fication level of 300%. A dedicateddigital tool provided by the commercial DICOM Viewersoftware (dicomPACS, Oehm & Rehbein GmbH, Rostock,Germany) installed in our institution was used to measurethe Norberg angle. Results of the Norberg angle were storedfor each hip joint separately in an Excel spreadsheet (Of fice2010 Excel, Microsoft, Redmond, WA, United States)..Statistical analysis was performed using commercial sta-tistical software MedCalc Version 17.9.7 (MedCalc Software,Ostend, Belgium) and SPSS Version 28 (IBM Corp., Armonk,NY, United States). The Bland –Altman method of comparisonwas used to describe the variation of the Norberg anglebetween normally positioned radiographs and oblique pro-jections. A pvalue of /C200.05 was considered signi ficant.Descriptive statistic was used to describe the patient popu-lation. Diagrams were generated using Microsoft Of fice forgraphical representation of the results. Receiver operatingcharacteristic (ROC) curves were created using SPSS. TheYouden index was calculated in Excel to find the threshold ofrotation for the image to be visually perceived as tilted.ResultsCadavers of 10 large breed dogs of various breeds wereincluded. The mean body weight was 28.6 kg (ranging from21.4 to 45 kg) and the age ranged from 8 to 15 years. Themean Norberg angle value in the manually positioned hip-extended position was 102.8 degrees (ranging from 90.5 to113.8 degrees) for the right hip joint and 101.8 degrees(ranging from 86.8 to 113.1 degrees) for the left hip joint.The FCI score was “A”for 1 dog, “B”for 3 dogs, “C”for 5 dogs,and “E”for 1 dog.In the set of manually positioned radiographs ( first set),the change of the ventrodorsal projection to dorsoventralprojection showed signi ficant in fluence on the Norbergangle values. In the dorsoventral projection the mean Nor-berg angle value increased by 5.8% in the left hip joint and by3.2% in the right hip joint (►Fig. 4 ). Endorotation of thefemora leads to a mild increase of the mean Norberg angle onboth sides ( ►Fig. 4 ), while the mean Norberg angle ratherdecreases during exorotation, independent of additionalabduction ( ►Fig. 4 ).The effect of rotation of the projection in lateral direction(second set) varies between the left and right hip joints. Themean Norberg angle on one side increases, while the meanNorberg angle on the contralateral side decreases by approx-imately the same value. The change of the mean Norbergangle value is signi ficant on one side starting from a rotationof 2 degrees and on two sides starting from a rotation ofFig. 1 Set of radiographs (second set) with increasing degree of rotation alon g the long axis (ventral x degrees left lateral to dorsal right lateraloblique projection).Fig. 2 Set of radiographs (third set) with decreasing degree of rotation a long the transverse axis (ventral x degrees caudal to dorsocranialoblique projection).Fig. 3 Set of radiographs (third set) with increasing degree of rotation along t he transverse axis (ventral x degrees cranial to dorsocaudal obliqueprojection)..3 degrees ( ►Fig. 5 ). A rotation of greater than 2 degrees in alateral direction is visually perceived by the observer as tilted(sensitivity of 0.85 and speci ficity of 0.8).The effect of rotation of the projection in the dorsal plane(third set) is dependent on the direction. Rotation of theprojection in the caudoventral to craniodorsal directionleads to a mild ( /C201%) increase of the mean Norberg anglewithout signi ficance ( ►Fig. 6 ). Rotation of the projection in acranioventral to caudodorsal direction leads to a moderate(/C202%) decrease of the mean Norberg angle with unilaterallysignificant values starting from a rotation of 3 degrees(►Fig. 6 ). A rotation of less than –10 degrees (caudoventralto craniodorsal direction) or greater than 10 degrees (cra-nioventral to caudodorsal direction) is visually perceived bythe observer as obviously tilted (sensitivity of 0.76 andspeci ficity of 1).Fig. 4 Influence of different positions/projections on the mean Norberg angle ( first set). Percentage values describe the variation compared tothe normal positioned radiograph. Signi ficant values are marked with an asterisk symbol (/C3).Fig. 5 Effect of rotation of the projection in lateral direction on the mean Norberg angle (second set). Percentage values describe the variationcompared to the normal positioned radiograph. Signi fic a n tv a l u e sa r em a r k e dw i t ha na s t e r i s ks y m b o l(/C3)..

Question 129

Zuendt - 2023 - JAVMA - Centerline canine cementless total hip arthroplasty as an alternative implant system - Results in 17 dogs (2015-2020).pdf

Answer 129

Inclusion criteriaDogs free of all other orthopedic/neurologic dis -ease that received a C-THA and had complete medi -cal records (including preoperative and postopera -tive radiographs as well as at least a 6-month follow-up) were included in this study. Records of C-THA procedures performed at a single veterinary referral hospital and performed by a single board-certified surgeon (DS) during the years 2015 through 2020 were included. Dogs aged 5 years and younger with radiographic diagnoses of CHD were included. Client consent to perform the procedure and utilize medi -cal records was obtained in all cases. Institutional care and use committee review was not required for the purposes of this study.Medical recordData from the medical records (using the term “centerline” to identify cases) including age, weight, sex, indication for THA, side of hip replacement, ace -tabular cup size, stem size, femoral neck length, and femoral head prosthesis size, were obtained in all cases (Supplementary Table S1) . Range of follow-up from time of surgery to final follow-up date was recorded for all cases. Lameness score, signs of pain on palpation, and range-of-motion of the coxofemo -ral joint were recorded form orthopedic examination of the THA limb for each dog. Complications, revi -sion/explantation surgical procedure, date of proce -dure, and outcome were also recorded.Clinical evaluationPossible outcomes included excellent, good, and poor modified from Guerrero et al.2 This grad -ing scale and clinical outcome were determined by the attending board certified surgeon, as well as the need for revision surgery if warranted. An excellent outcome was defined as no overt lameness, pain, or decreased range of motion on physical exam, with no need for revision at final recheck examination (a minimum of 6 months post-operative). A good out -come was defined as a post-operative lameness, pain, or decreased range of motion which required surgical revision of the C-THA. A fair outcome was defined as a post-operative lameness, pain, or de -creased range of motion which required surgical revision with an alternative THA implant to provide resolution or mitigation of clinical signs. Finally, a poor outcome was defined as lameness, pain, or de -Figure 1 —Illustration of the components of the Biomed -trix Centerline total hip arthroplasty (THA) system. UHMWPE = Ultrahigh-molecular-weight polyethylene. Unauthenticated | Downloaded 10/08/23 06:32 AM UTC 3creased range of motion post operatively requiring full explantation to provide resolution or mitigation of clinical signs. Post-operative complications lim -ited to the stem component were defined as major if surgical revision was warranted and minor if the complication was managed medically.30Subjective lameness score which was assessed and graded at the time of presentation for surgery and upon all subsequent follow-up exams. The lameness grading scores were modified from a study by Guerrero et al2 but were modified as listed below. A 0 represented a poor score where pain was easily detected during ma -nipulation, range of motion was severely reduced, or a constant non–weight-bearing lameness was noted. A 1 represented a fair score with moderate pain during manipulation of the hip joint, reduced range of motion, or intermittent to persistent lameness. A 2 represented a good score with no pain noted on manipulation of the coxofemoral joint, mild reduced range of motion (mainly in extension), and a clinically normal gait. Fi -nally, a 3 represented an excellent score with no pain on manipulation of the coxofemoral joint, normal range of motion, and no clinically detectable lameness. All scorings were performed by board-certified veterinary surgeons or a veterinary resident supervised by board-certified surgeons prior to surgery and then evaluated at each recheck. The final score was then compared to initial scores.Radiographic measurementsAll radiographs were digital and were adjusted for magnification using a 100 mm calibration marker. Pre-operative and post-operative radiographs were performed on all cases at all time points. All preop -erative measurements were performed by the inves -tigator (DS) using Biomedtrix centerline templates and BFX acetabular cup templates.26 The normal or natural angle of inclination in the canine proximal femur intersects the axis of the femoral neck at ap -proximately 144.7 degrees.27 The proximal femoral long axis was determined by first identifying the center of the proximal femoral diaphysis at 3 points distal to the lesser trochanter, approximately 1 cm apart. The line connecting these points was drawn, defining the proximal femoral long axis.31 The center of the femoral neck was determined by identifying a single point at the center of the femoral head. A line connecting this point and the fovea capitis was created and then extended laterally until it exited the lateral cortex of the proximal femur (Figure 2) .27 The distance from the proximal, lateral aspect of the greater trochanter to where the line scribed through the center of the femoral neck is then measured. This point serves as a landmark for insertion of the drill guide at surgery and where the C-THA stem should exit the lateral cortex of the femur (Figure 2).26Radiographic evaluationRadiographs at all time points were evaluated and compared with immediate postoperative films and were calibrated with reference bars or spheres placed at the level of the region of interest. All radio -graphs were reviewed by a board-certified veterinary surgeon and radiologist, who were not blinded to the patient, for signs of loosening, infection, subsidence, fracture, and luxation. At least 2 radiographic projec -tions of each C-THA were available.Radiographs were assessed for signs of implant failure, migration, prosthesis luxation, signs of bone remodeling secondary to nondetected bone fractures or infection, and for radiolucent zones between the implant and bone. Acetabular component/prosthe -sis loosening or instability was defined as the pres -ence of a complete uneven radiolucent zone around the metallic components with or without signs of im -plant migration. Stem stability was defined by bone remodeling around the femoral component and was characterized according to the definitions proposed in a study by DeYoung and Schiller.32 These features included absence of cortical atrophy at the proximo -medial aspect of the femur, cancellous hypertrophy, periosteal proliferation, absence of lucency around the stem or any other focus of extracortical new bone formation (Figure 3) . Stem instability was character -ized by the presence of a radiolucent zone around the prothesis and the bone; in addition to a progressive increase in the gap between stem and bone as well as loss of proximal medial bone (Figure 4) .12,13,17Surgical techniqueAll patients were anesthetized and placed in lateral recumbency (Figure 5) . After shaving and Figure 2 —Measurement for lateral exit and angle of in -clination. The proximal femoral long axis and the cen -ter of the femoral neck lines were created as described above. The bisecting line of the anatomic axis of the fe -mur and the angle of inclination create a 144.7°angle. The lateral exit point (B) for the Centerline THA is then measured from this point proximally to the proximal as -pect of the greater trochanter (A).Unauthenticated | Downloaded 10/08/23 06:32 AM UTC4 sterile preparation, a standard lateral approach to the hip joint via partial tenotomy of the deep gluteal tendon was performed.33 The femoral head was exteriorized and a femoral head ostectomy was performed using a sagittal saw. The femo -ral head ostectomy was performed at the junc -tion of the femoral head and neck, preserving the entire femoral neck, along a line perpendicu -lar to the long axis of the femoral neck. Any os -teophytes along the femoral neck were removed with rongeurs to allow for better visualization of the true center of the femoral neck for proper prosthesis placement.The acetabulum was reamed and the acetabu -lar prosthesis was placed in routine fashion using a traditional BFX acetabular cup system.26 A point was measured from the greater trochanter distally along the lateral aspect of the femur. This point was obtained from preoperative radiographs as stated previously and is typically located at the level of the third trochanter. A small pilot hole was made at this point with a K-wire and the drill guide’s point was placed within this hole. The cannulated portion of the drill guide was then engaged into the center of the cut surface of the femoral head/neck between the inner surfaces of the neck cortices. A 3/32-inch pin was placed from proximal to distal. The drill guide was removed, and a cannulated drill bit was placed over the pin and a hole was drilled from the cut surface of the femoral neck out through the lat -eral cortex. In each case, the drill bit and reamer sizes used corresponded to the size of C-THA stem templated on preoperative radiographs. Next, the spherical reamer was placed in the drill hole and the femoral neck was reamed appropriately for proper fit of the C-THA stem.At this point, trial stems were placed to allow for approximately 5 mm of the stem to beyond the lateral cortex. Once a trial stem was selected, a trial head was placed. Trial reductions were then performed ensure tension, reduction and absence of impingement of the implant stem and the ac -etabulum. All trial implants were removed, and a tapered reamer was inserted through the prepared hole in the femoral neck. The depth at which the Figure 3 —Radiographic evidence of bone in-growth and stable implants as indicated by absence of lu -cency around the implants and bone growth over the collar of the implant.Figure 4 —Bone lucency around both the acetabular cup and the proximal portion of the femoral neck surround -ing the stem component, indicating unstable implants.Figure 5 —Overview of surgical technique showing step-by-step method of procedure. Figure courtesy of Biomedtrix.Unauthenticated | Downloaded 10/08/23 06:32 AM UTC 5tapered reamer was applied varied in each case based on the quality and integrity of the cancel -lous bone, such to ensure a drive distance of be -tween 8 to 10 mm for the press fit centerline stem. The appropriately sized determined from preoper -ative templating was then inserted and impacted into the femoral neck, followed by the appropri -ately sized head impacted onto the stem. Cultures were obtained and the surgical area was irrigated. The joint capsule was closed using an interrupted suture pattern. The overlying tissues were closed routinely. Postoperative lateral, open leg lateral and ventrodorsal radiographs were taken for as -sessment of prosthesis placement.Statistical analysisMicrosoft Excel was used to record all case data. Descriptive statistics were computed and analyzed to determine age, weight, and follow up times with medians and ranges being evaluated. Lameness scores were calculated as the difference from pre-operative score to final follow-up scores.ResultsAnimalsSeventeen dogs had a C-THA (3 dogs had bi -lateral C-THA at different time intervals) for a total of 20 C-THA implanted hips. C-THA was performed for hip dysplasia in all 20 cases. The median age was 1.45 years old (range, 1 to 5 years). The median body weight of dogs in this study was 34.25 kg (range, 23.6 to 50.3 kg). The median final follow-up was 621.5 days (range, 183 to 2,350 days). ComplicationsNo minor complications were noted within this study. Five (25%) cases had major complications associated with the C-THA as described below. Complications occurred between 16 and 870 days post- operatively with a median of 520 days post-opera -tive. Three of the 5 major complications occurred in dogs with bilateral THA. One dog had a major com -plication associated with both hips and the second with a single side.OutcomesOut of the 20 C-THA implants placed in 17 dogs, 15 implants had an excellent outcome (75%). All 15 implants with excellent outcomes achieved radio -graphic evidence of osteointegration of both cup and stem at 12 weeks postoperatively. The median increase in lameness scores from pre-operative to fi -nal recheck was 3 (range, 0 to 3) during a period of 183 to 2,350 days.The 2 fair outcomes, 1 patient (2 protheses), re -quired revision with bilateral Biomedtrix BFX THA due to aseptic loosening. Three out of the 20 (15%) C-THA implants had poor outcomes. Two patients acquired postoperative luxations and following re -vision surgery developed septic loosening of the implants resulting explantation and FHNE. The final patient with a poor outcome was the result of eccen -tric drilling of the femoral neck. This resulted in the implant fracturing through the caudomedial cortex of the femoral neck 2 weeks postoperatively neces -sitating explantation and FHNE.

Question 130

Sartore - 2023 - JFMS - Osteochondrodysplasia and the c.1024G>T variant of TRPV4<:em> gene in Scottish Fold cats - Genetic and radiographic evaluation.pdf

Answer 130

AnimalsA total of 17 cats from two catteries were selected: five Scottish Straight and 12 Scottish Fold. The mean age of the cats at blood sampling was 2.3 ± 1.3 years (age range 0.9–6.5). The cats were identified during routine visits at the university veterinary hospital where samples were collected in K3-EDTA blood vacutainers. Fold-eared cats were then submitted for orthopaedic examination by specialised veterinarians; the degree of lameness, pain and joint thickening were recorded and the mobility of each joint was evaluated by a ‘range of motion’ test. A CT examination was performed on 5/12 Scottish Fold cats (ie, Cat_03, Cat_06, Cat_15, Cat_16 and Cat_17) to assess whether signs of osteochondrodysplasia were pre -sent. The mean age of the cats at the first radiographical examination was 3.7 ± 1.9 years (age range 1.1–6.5) (Table 1). Thanks to the cooperative nature of the subjects, nei -ther general anaesthesia nor mild sedation was required. Manual restraint was applied for the positioning of the patients.Comparative orthogonal radiographic views of the shoulder, elbow, carpus, hip, stifle and tarsus were obtained, along with a lateral view of the thoracic and lumbar column. A second clinical and radiographic examination on 3/5 cats (ie, Cat_03, Cat_06 and Cat_15) was performed 1.5 years later with an identical approach, and the images were evaluated by the same radiologist. The mean age of the cats at follow-up was 4.2 ± 1.4 years (age range 2.6–5.0).DNA extraction and genotypingDNA was extracted using a commercial DNA extrac-tion kit (NucleoSpin Blood; Macherey Nagel) according to the manufacturer’s instructions. Genotyping for the c.1024G> T SFOCD-associated variant was performed by sequencing a 249 bp fragment on TRPV4 exon 6 using two primers (5’-TGACAGAGAACCCGCACAA-3’ and 5’-CACTCACCCCAATCTTGCC-3’), designed with Primer3 software (http://biotools.umassmed.edu/bioapps/primer3_www.cgi) to also include two other mutations, identified by Gandolfi et al.7 The PCR was per -formed in a thermal cycler (2720 Thermal Cycler; Applied Biosystems) in a total volume of 25 μ l (HotStarTaq DNA Polymerase; Qiagen). Amplification occurred at 95° for 15 mins, 35 cycles at 94° for 30 s, 54° for 30 s and 72° for 1 min, and a final extension step at 72° for 10 mins.Table 1 List of cats with phenotypes, radiographic examinations and age at the time of radiographical examinationCat ID Ear phenotypeRadiography (age in years)Follow-up radiography (age in years)Cat_01 Straight – –Cat_02 Straight – –Cat_03 Fold Yes (3.3) Yes (4.9)Cat_04 Fold – –Cat_05 Fold – –Cat_06 Fold Yes (3.5) Yes (5.0)Cat_07 Fold – –Cat_08 Straight – –Cat_09 Straight – –Cat_10 Straight – –Cat_11 Fold – –Cat_12 Fold – –Cat_13 Fold – –Cat_14 Fold – –Cat_15 Fold Yes (1.1) Yes (2.6)Cat_16 Fold Yes (3.9) –Cat_17 Fold Yes (6.5) –Sartore et al 3ResultsGenetic analysisNo Scottish Fold cats were found homozygous for the mutant allele and no mutant alleles were found in Scottish Straight cats. The DNA sequence of the 249 bp fragment of TRPV4 exon 6 investigated in all cats revealed three mutations, namely c.963A >C, c.1024G >T and c.1104C> T. As detailed in Table 2, the point mutation c.963A> C was detected in 13/17 cats. The point mutation c.1024G >T was detected only as heterozygous and only in all the Scottish Fold cats. Lastly, the point mutation c.1104C >T was detected in 16/17 cats.Both c.963A >C and c.1104C >T point mutations were labelled as silent by Gandolfi et al,7 and, consistently, were not related to either phenotype in our sample. In contrast, the c.1024G> T mutation was found in all the animals with folded ears.Clinical and radiographic evaluationOne Scottish Fold cat (Cat_17) showed clinical signs related to SFOCD. For the other cats in the study, no gait alterations, lameness or pain was reported. Only Cat_17 showed radiographical alterations attributable to SFOCD at first radiographic evaluation. Specifically, there was periarticular smooth bone remodelling with a narrow-ing of the joint spaces (both tarsometatarsal joints) with elongated osteophytes formation. Periarticular ill-defined soft tissue swelling was noted, likely indicative of syno -vial hyperplasia or non-aggressive synovitis. Mild peri -articular smooth bone remodelling was noted at the caudal aspect of the right elbow joint with two-pinpoint miner -alisation located caudal to the supratrochlear foramen and visible on the mediolateral view. This mineralisation was likely indicative of feline synovial osteochondro-mas or fractured osteophytes. The radiographic findings were indicative of multifocal bilateral degenerative joint disease and early ankylosis of the tarsometatarsal joints, associated with right elbow osteoarthrosis with possible synovial osteochondromatosis. Radiographic images of the alterations observed at this first radiographic evalua -tion are shown in Figure 1.No skeletal changes were detected at the follow-up radiographic evaluation, performed 1.5 years later on 3/5 cats.

Question 131

Husi - 2023 - VETSURG - Comparative kinetic and kinematic evaluation of TPLO and TPLO combined with extra-articular lateral augmentation - A biomechanical study.pdf

Answer 131

2.1 |Specimen preparationTen pelvic limbs of skeletally mature dogs weighing>22 kg were collected. Samples size was chosen to beconsistent with previously published studies.2,15,16Left orright limbs were randomly selected with coin flip. Alldogs were euthanized for reasons unrelated to this studyand donated for research purposes by their owners inaccordance with our institution's regulations. To excludepre-existing stifle pathology, orthogonal radiographs ofthe respective stifle joint were taken, and arthroscopic sti-fle inspection was performed. Tibia plateau angle (TPA)was measured on each limb using previously describedmethods.17The limbs were disarticulated at the coxofe-moral joint, and the proximal femur was freed from allsoft tissues. The femur was transected just distal to theminor trochanter and placed in a 3D-printed cylinder(3DGence ONE, Przyszowice, Poland) reinforced withberacryl-monomer (Swiss-Composite). After preparation,specimens were stored at /C020/C14C and thawed at roomtemperature 24 h before testing.2.2 |Testing setupThe testing setup was recently described for testing laxity indogs11and was developed based on a testing fixture usedfor knee testing in people.14The stifles were mounted to a3D printed testing fixture that was secured to a table byclamps (Figure1). To maintain the stifle at a standing angleof 135/C14throughout testing, the position of the tibia was setby an adjustable support bar fixed to the jig. A load cell(S-type load cell, range ±10 kg, repeatability 0.01%, OmegaEngineering, Manchester, UK) was inserted between the jigand the proximal femur to measure the kinetics (axial loadFIGURE 1 Testing setup.Medial (A) and cranial (B) viewshowing the set up with thefemoral load cell (▷) and themounted specimen withcoordinate systems for tracking(*) held in position by anadjustable support bar ( ►).Goniometer (C) aligned in tibiallong axis for controlling ofinternal rotation during iTPT.HUSI ET AL . 687 1532950x, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13955 by Vetagro Sup Aef, Wiley Online Library on [22/07/2023]. 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 Licenseapplied to the femur) while performing a laxity test. Acustom-made, adjustable go niometer was fixed to the jiga n dc e n t e r e do nt h el o n ga x i so f the tibia to control the rota-tional alignment of the tibia while applying iTPT. A pinwas inserted from proximal into the calcaneus serving as aclock handle (Figure1C).Stifle kinematics was measure d with a three-dimensional(3D) tracking camera system consisting of 10 motion capturecameras (Qualisys, Gothenburg, Sweden) sampling at300 Hz and collected using the QTM software (QualisysTrack Manager, Qualisys, Gothenburg, Sweden). Three2.5 mm pins each were inserted in the femur, tibia, andthird metatarsal bone. At the end of each pin, a 3D printedconnecting part was used to support four reflectivemarkers, positioned in a pattern unique for femur, tibia,and metatarsus.2.3 |Testing protocolA single experienced observer (AP) sequentially performedthe laxity tests in the different joint states for each stifle.Kinematic and kinetic measures were collected duringeach test. The study protocol included four consecutivetesting phases: (1) stifle with intact CCL (INTACT), (2)CCL-deficient stifle (CCLD), (3) CCL-deficient stifle stabi-lized with TPLO (TPLO), and (4) CCL-deficient stifles sta-bilized with TPLO and extra-articular lateral augmentation(TPLO-IB).At each testing phase, the three laxity tests wereperformed sequentially (TCT, iTPT, eTPT). To assessintraobserver repeatability for eTPT and iTPT, tests wererepeated three times in three specimens in rounds3 and 4 (TPLO and TPLO-IB). Intra- and interobserveragreement in specimens with intact and transected CCLhas been reported to be excellent in a recent study usingthe same setup.11During all rounds of testing, the kineticand 3D kinematic data were captured.2.4 |Surgical preparationAfter data collection was completed in intact stifles, theCCL was transected under arthroscopic guidance. TheCCL-deficient stifle was stabilized with a TPLO asdescribed by Slocum and Slocum17targeting a postopera-tive TPA of 6/C14. The osteotomy was stabilized using a3.5 mm standard locking TPLO plate (Arthrex, Naples,Florida), whose design allows for the application of anextra-articular lateral augmentation. After the TPLO, thepostoperative TPA was measured using radiographicimaging. The extra-articular lateral augmentation wasperformed as described previously.18,19A separate lateralstifle approach was performed. A tibial bone tunnel wasdrilled from an entry point just caudal to the long digitalextensor groove, exiting cranial to the suture hole of theTPLO plate. A 2 mm ultra-high molecular weight polyeth-ylene (UHMWPE) synthetic suture (FiberTape, Arthrex,Naples, California) was anchored to the suture hole of theTPLO plate and shuttled through the bone tunnel frommedial to lateral. The FiberTape was tensioned until theoperator determined that internal tibial rotation was ade-quately restricted. During tensioning, the stifle was heldat a standing angle and the tibia aligned with the sagittalplane. Care was taken to avoid external tibial rotation.The Fibertape was then secured to the caudal aspect ofthe lateral femoral condyle using a knotless bone anchor(3.5 mm SwiveLock Anchor, Arthrex, Naples, California).2.5 |Laxity testsThree different tests were used to assess stifle stabilityand measure kinematics and kinetics. The standard TCTwas performed as described by Henderson and Milton.20Briefly, the stifle joint was held at a standing angle of135/C14with the stifle and tarsal joints aligned in the sagittalplane. The femur was stabilized with one hand while theother hand applied axial tibial compression by flexing thetarsal joint. The iTPT was performed by rotating the tibiainternally by 15/C14before applying tibial compression. Inthis experimental setup, we used a goniometer to achievea consistent internal rotation of 15/C14in every specimen(Figure 1C). The eTPT was performed similarly to a stan-dard TCT. However, before initiating tibial compression,the tarsus was brought in external rotation until resis-tance was felt and a valgus stress was applied. Then tibialcompression was established, and external rotation wasreleased, allowing the tibia to internally rotate and even-tually subluxate11For eTPT, rotation was subjective andnot controlled by goniometer.2.6 |Data collection and analysisKinetics (N) was measured by the load cell anchored to theproximal femur and represented the axial load applied dur-ing testing. Three-dimensional kinematics was expressed astranslation and rotation of the tibia with respect to thefemur and measured by a motion capture device (Qualisys,Gothenburg, Sweden) that captures the position of reflec-tive markers at 300 Hz. The measurements from theQualisys were collected by QTM software (Qualisys TrackManager, Qualisys, Gothenburg, Sweden). The movementof the coordinate systems was recorded during the applica-tion of a load to perform the laxity tests.688 HUSI ET AL . 1532950x, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13955 by Vetagro Sup Aef, Wiley Online Library on [22/07/2023]. 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 LicenseCT scans of all specimens before and after TPLO wereobtained with specific parameters (1 mm, kVp 120, mA 152)(Brilliance CT, 16-slice, Philips AG, Zürich, Switzerland.Slice thickness 1 mm, kVp 120, mA 152). From the CT data,femur, tibia, and tarsus/meta tarsus were segmented usingan open-source software (3D Slicer, version 4.10.1, stablerelease Fedorov et al.,21)t oc r e a t e3 Dm o d e l s .T h eG e o m a g i cStudio (Geomagic Inc., Research Triangle Park, NorthCarolina) was then used to apply an anatomical coordi-nate system matching to the 3D models as describedin previous studies.22,23To represent the data in a moreclinically relevant way, rigid body transformations wereapplied to the marker data. The relative location of themarkers to the individual bones were obtained from theCT scans. The 3D kinematics of the stifle were calculatedusing custom-written programs from MATLAB (TheMathworks Inc., Natick, Massachusetts). The kinetics dataobtained by the two load cells were filtered using firstorder Butterworth filter with a cutoff frequency of 1 Hzand a sampling rate of 200 Hz (MATLAB) for analysis.2.7 |Pilot stifle testingPilot testing was carried out on three cadaveric stiflesprepared as described above. All tests were performedconsecutively by three observers and repeated threetimes, alternating between the observers. This procedurewas repeated for all four study conditions. The initialstudy protocol included TCT combined with maximuminternal rotation as allowed before soft tissue restraintwas felt. This test was excluded from the final protocolbecause excessive internal rotation led to cranial subluxa-tion of the tibia before application of tibial compressionand therefore did not allow assessment of craniocaudalinstability. The kinetic and kinematic data were analyzed toensure the feasibility of the tes ting setup and repeatabilityof the results.2.8 |StatisticsData were analyzed using SPSS (version 26.0.0.0, IBMCorp., Armonk, New York). Descriptive values arereported in mean ± standard deviation (SD) or median(range) as indicated. A Shapiro –Wilk test was used toassess normality of the data. A two-way repeated mea-sure ANOVA was conducted to examine the effect oftest and treatment on cranial tibial translation andinternal tibial rotation. If indicated, one-way repeatedmeasures ANOVA was used to investigate the differ-ences in force, cranial tibial translation, and rotationfor each clinical test after each treatment (intact,CCLD, TPLO, TPLO-IB). Greenhouse –Geisser Correc-tion was used when indicated. In the case of statisti-cally significant differences ( p≤.05), post hoc testingusing the Bonferroni correction was used for pairwisecomparisons.For tibial axial rotation, one-way repeated measuresANOVA was conducted to compare rotation during TCTbetween the four study phases. For eTPT, tibial axial rota-tion was reported as external or internal rotation in rela-tion to the starting point of the testing. For iTPT, internaltibial rotation is reported.Intraobserver reliability for eTPT and iTPT in TPLOand TPLO-IB was assessed by calculating Intraclasscorrelation coefficient and their 95% confident intervalsbased on single measures, absolute agreement, 2-waymixed-effect model by analyzing distance of cranialsubluxation. Interobserver reliability of TCT and TPTfor intact and CCL-deficient stifles has recently beenreported by Lampart (2022).113|RESULTSA total of six right and four left pelvic limbs werecollected. Mean bodyweight was 31.6 kg (range 23 –40 kg),and mean age was 8.5 years (range 2 –13 years). Mean pre-operative TPA was 24.7/C14(range 21 –26/C14), and postoperativeTPA was 5.88/C14(range 5 –7.2/C14).3.1 |Cranial tibial translationTwo-way ANOVA with repeated measurements revealed aninteraction between joint status and test effects on cranialtibial translation ( p< .001). Cranial tibial translation duringTCT was higher in CCLD compared to all other groups(p< .001) (Table1,F i g u r e 2) .T h e r ew a sn od i f f e r e n c ei ncranial tibial translation betw een CCL-deficient stifle andTPLO groups when performing eTPT and iTPT (eTPTp=1, iTPT, p=.43). Additionally, no d ifference was foundbetween the intact stifle and TPLO-IB groups (eTPT p=.16,iTPT p=1). At the same time, there was more cranial trans-lation during TPT in both CCL-deficient stifle and TPLOcompared to intact stifle and TPLO-IB.When comparing the laxity tests, cranial tibial transla-tion measured with each test was not different withinintact stifle and TPLO-IB groups. In the CCL-deficient sti-fle group, a difference could be demonstrated betweeneTPT and iTPT (13.20 mm ± 3.91 vs. 11.19 mm ± 3.58,p> .001). After TPLO, eTPT, and iTPT resulted in highercranial subluxation than TCT ( p> .001), while no differ-ence between the tests was found in the TPLO-IB group(p=.067). Intraclass correlation coefficient for bothHUSI ET AL . 689 1532950x, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13955 by Vetagro Sup Aef, Wiley Online Library on [22/07/2023]. 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 LicenseTABLE 1 Cranial tibial translationa(mm) during testing, results of one-way ANOVA and post hoc testing (if indicated).Test Intact (1) CCLD (2) TPLO (3) TPLO-IB (4) ANOVA PosthocTCT (a) 1.15 (0.94) 12.06 (3.84) 4.8 (3.7) 2.64 (1.05) p< .001 *p1-p2 < 0.001 *p1-p3=0.17p1-p4=0.13p2-p3=0.008 *p2-p4 < 0.001 *p3-p4=1eTPT (b) 1.72 (1.20) 13.20 (3.91) 12.90 (2.82) 3.20 (1.31) p< .0001 *p1-p2 < 0.001 *p1-p3 < 0.001 *p1-p4=0.16p2-p3=1p2-p4=0.001 *p3-p4 < 0.001 *iTPT (c) 2.01 (0.729) 11.19 (3.581) 12.42 (3.72) 2.27 (0.95) p< .0001 ^*p1-p2 < 0.001 *p1-p3 < 0.001 *p1-p4=1p2-p3=0.43p2-p4 < 0.001 *p3-p4 < 0.001 *ANOVA posthoc p=.103 p=.004* p< .001 * p=.067pa-pb=na pa-pb =0.23 pa-pb < 0.001 * pa-pb=napa-pc=na pa-pc =0.47 pa-pc < 0.001 * pa-pc=napb-pc=na pb-pc =0.001 * pb-pc=1 pb-pc =naAbbreviations: CCLD, cranial cruciate ligament deficient stifle; eTPT, external tibia pivot compression test; iTPT, internal tibia pivot compres sion test; TCT,tibia compression test; TPLO, tibial plateau leveling osteotomy; TPLO-IB, tibial plateau leveling osteotomy combined with extra-articular later al augmentation.aShown as means (standard deviation).*Statistically significant result ( p> .05).FIGURE 2 Mean cranial tibialtranslation (mm) in four different jointconditions while performing the manualtests. The error bars represent 95%confidence intervals. CCLD, cranialcruciate ligament deficient stifle; eTPT,external tibial pivot compression test;iTPT, internal tibial pivot compressiontest; TCT, Tibial compression test;TPLO, tibial plateau leveling osteotomy;TPLO-IB, Tibial plateau levelingcombined with extra-articular lateralaugmentation.690 HUSI ET AL . 1532950x, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13955 by Vetagro Sup Aef, Wiley Online Library on [22/07/2023]. 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 LicenseeTPT and iTPT after TPLO and TPLO-IB was excellentbeing 0.93 (0.70 –0.99) and 0.91 (0.73 –0.99), respectively.3.2 |Internal tibial rotation and flexionangleTwo-way ANOVA with repeated measurements revealedan interaction between joint status and test effects oninternal tibial rotation ( p< .001). Internal tibial rotationduring TCT was higher in the CCLD-group comparedwith all others ( p=.0003) (Table2). No difference wasfound between the other groups. When performing eTPT,the degree of internal rotation was highest in the TPLOgroup ( p< .001). Applied external tibial rotation at theinitiation of eTPT was consistent across the study(p=.419). For iTPT, where tibial rotation was con-strained to 15/C14during testing, internal tibial rotation dif-fered between TPLO and TPLO-IB groups ( p=.008).The mean change in stifle flexion angle whileperforming the tests was 5.01/C14± 3.23/C14(Table 3). Two-way ANOVA with repeated measurements revealed a sta-tistically significant interaction between the effects ofjoint status and test on stifle flexion angle ( p< .001).3.3 |KineticsTwo-way ANOVA with repeated measurements failed toreveal an interaction between joint status and test effectson the axial force ( p=.275). For TCT, forces registeredwere different between the study groups ( p=.018), andpost hoc testing revealed th at force in the CCLD group waslower than in the TPLO-IB group ( p=.017) (Table4).Comparison of forces within the study groups showed nodifference between the testing methods for the groupsINTACT, TPLO, and TPLO-IB. However, within the CCLDgroup, there was a difference between TCT and iTPTTABLE 2 External and internal tibial rotationa(degree) during testing relative to a neutral position (starting point of the tests), results ofone-way ANOVA and post hoc testing (if indicated).Test Intact CCLD (2) TPLO (3) TPLO-IB (4) ANOVA post hocTCT internal rotation 4.14 (4.89) 11.54 (4.07) 4.19 (5.61) 3.59 (2.47) p< .001 *p1-p2=0.005p1-p3=1p1-p4=1p2-p3=0.011 *p2-p4 < 0.001 *p3-p4=1eTPT external rotation 11.09 (3.78) 10.7 (3.69) 11.47 (2.83) 13 (3.67) p=.419eTPT internal rotation 15.74 (6.0) 11.75 (4.41) 27 (5.92) 12.12 (3.57) p< .001 *p1-p2=0.213p1-p3=0.002 *p1-p4=1p2-p3=0.005 *P2-p4=1P3-p4 < 0.001 *iTPT internal rotation 14.48 (2.74) 16.41 (2.0) 16.52 (1.82) 13.15 (2.1) p=.008*p1-p2=0.121p1-p3=0.657p1-p4=1p2-p3=1p2-p4=0.173p3-p4=0.002 *Abbreviations: CCLD, cranial cruciate ligament deficient stifle; eTPT, external tibial pivot compression test; iTPT, internal tibial pivot compr ession test; TCT,tibia compression test; TPLO, tibial plateau leveling osteotomy; TPLO-IB, tibial plateau leveling osteotomy combined with extra-articular later al augmentation.aShown as means (standard deviation).*Statistically significant result ( p> .05).HUSI ET AL . 691 1532950x, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13955 by Vetagro Sup Aef, Wiley Online Library on [22/07/2023]. 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(5.27 N ± 2.23 vs. 2.99 N ± 2.21, p=.013), as well asbetween eTPT (7.594 N ± 5.16) and iTPT ( p=.037).4

Question 132

Smith - 2023 - JAVMA - Number of previous surgeries and antibiotic resistance decreases the success of local administration of antibiotic-impregnated poloxamer 407 hydrogel when managing orthopedic surgical site infections in dogs.pdf

Answer 132

Study populationMedical records were searched to identify dogs that underwent intraoperative implantation of antibi -otic-impregnated 30% P407 hydrogel at the authors’ institution between March 2018 and December 2020. The medical records were reviewed of dogs with a charge code indicating dispensation of P407 hydrogel during their hospitalization. Only dogs receiving P407 hydrogel for therapeutic purposes were included, and the eluted antimicrobial was recorded. Dogs were ex -cluded if there was no evidence of a deep or organ space SSI based on CDC guidelines at the time of P407 hydrogel implantation18,19 or if the procedure was not an orthopedic procedure. Dogs that underwent to -tal hip replacement (THR) were excluded if they were not diagnosed with a periprosthetic joint infection ac -cording to published guidelines.19 Open fractures that underwent surgical treatment within 24 hours of initial trauma or that lacked a positive bacterial culture at the time of surgery were also excluded.20,21 Dogs were also excluded if follow up duration after P407 hydrogel ad -ministration was shorter than 180 days or when owners were not available for long-term telephone follow-up.Medical record data collectionData collected from medical records included sig -nalment, date of surgery, number and type of surgeries performed at the affected site before P407 hydrogel implantation, date when clinical signs of infection were noted, method of culture sample collection, bacterial culture and susceptibility results, duration of systemic antimicrobial therapy, P407 hydrogel preparation and implantation, antimicrobial eluted in the gel, dates, and findings of postprocedure evaluations. Clinical out -comes including complications, resolution of clinical signs, and radiographic findings were also recorded.DefinitionsInfections were defined as early infection when clinical signs of deep or organ space SSI were identi -fied within 8 weeks of the original surgery and delayed infection when these signs were identified > 8 weeks after the initial orthopedic surgery.22,23 Infections were defined as complex if > 1 bacterial species was iso -lated from the surgical site. Infections were classified by pathogen, methicillin resistance, and the presence of a multidrug-resistant organism, defined as a bac -terium resistant to > 1 class of antimicrobial agents.24 Initial surgeries were described as elective surgeries (TPLO, patellar luxation repair, THR, and arthrodesis for nontraumatic problems) or trauma surgeries (frac -ture repair and arthrodesis after trauma). The surgical procedure performed at the time of hydrogel implanta -tion was described as implant retaining (retention or replacement) or implant removal. Anatomic location of the procedure was defined as upper extremity (in -volving the femur or humerus and proximal) or lower extremity (involving the tibia or radius/ulna or distal).Long-term follow-upLong-term follow-up was conducted by tele -phone calls to owners by a single researcher ( JS) to determine whether additional therapy was ongoing, limb use was satisfactory, and clinical signs of persis -tent infection such as wound drainage, swelling, or pain were present. A standard list of questions was used while conducting telephone calls (Appendix) . Complications related to antibiotic-impregnated P407 hydrogel implantation were defined as minor, major, or catastrophic.25 Outcomes were deemed successful when the animal was no longer receiv -ing antimicrobial therapy and had no clinical signs of surgical site infection, no radiographic evidence of infection, and no macroscopic suppuration at the time of long-term follow-up or > 180 days from P407 hydrogel administration. Clinical signs providing evi -dence of persistent infection included discharge from the surgical site, wound dehiscence, macroscopic or microscopic suppuration, or a positive bacterial culture obtained from a tissue or implant sample. Radiographic criteria for suspected persistent infec -tion included periosteal reaction, bone lysis, implant loosening without a mechanical cause, and impaired fracture healing without an identifiable cause.Statistical analysisData from each dog’s medical record were man -aged in Excel (Microsoft Corp) and transferred to JMP Pro predictive analytics software (version 16.0.0; SAS Institute Inc) for further analysis. Descriptive statis -tics were performed to assess data distribution, and continuous data were reported as median (range). Data normality was assessed on visual inspection of histograms and confirmed by Shapiro-Wilk tests. Nominal or binomial data were tested for association using Pearson χ2 tests, and ordinal and continuous data were tested with Wilcoxon rank sum tests. Multi -variable analysis was performed to assess confound -ers using a multivariable logistic regression analysis model. Factors with a P < .20 in univariable model were included and further refined using backward stepwise model selection. Likelihood ratio tests were performed to construct the final model, retaining all factors with P < .10. Odds ratios and 95% CIs were re -ported for variables significantly associated with the outcome. Significance was set at P < .05 for all tests.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 07/22/23 07:43 AM UTC1188 JAVMA | AUGUST 2023 | VOL 261 | NO. 8ResultsEighty-four implantations of antibiotic-impreg -nated P407 hydrogel were identified in 76 dogs. For -ty-two dogs were excluded from the study because of the absence of SSI (n = 34), wound care associ -ated with soft tissue trauma (2), a soft tissue pro -cedure (1), or loss of follow-up (5). Thirty-four dogs (34 procedures) were included in the analyses.SignalmentThe median age of the 34 dogs at presentation was 59 months (range, 4 to 171 months). There were 16 castrated males, 12 spayed females, 5 sexually in -tact males, and 1 sexually intact female. The breeds included 12 mixed-breed dogs, 8 German Shepherd Dogs, 2 Labrador Retrievers, 2 Australian Shepherds, 2 Chihuahuas, 2 Saint Bernards, and of 1 each of the following breeds: Border Collie, German Wirehaired Pointer, Greyhound, Great Dane, Mastiff, Newfound -land, Pitbull Terrier, and Rottweiler. The median weight was 32.2 kg (range, 2 to 83 kg). Twenty-six dogs had an optimal or overweight body condition score (4 to 6).26 Eight dogs had a body condition score ≥ 7, and 2 dogs had a body condition score ≤ 3.Surgical history and clinical presentationThe median number of surgeries performed on the affected site before P407 hydrogel implantation was 2 (1 to 5). Nineteen initial procedures performed before P407 hydrogel implantation were elective (9 TPLO, 4 THR, 3 medial patellar luxation, 2 carpal arthrodesis, and 1 femoral head ostectomy), and 15 initial proce -dures were performed after trauma (11 fractures, 2 tarsal arthrodeses, and 2 carpal arthrodeses). Twenty-one procedures were lower extremity procedures (12 stifles, 4 carpi, 2 radii/ulnas, 2 tarsi, and 1 tibia), 11 were upper extremity procedures (4 femurs, 5 hips, and 2 humeri), and 2 involved the axial skeleton (1 ili -um and 1 lumbar vertebra). Twenty-seven dogs had 2 or more of the following clinical signs: fever, swelling, heat, drainage, joint effusion, or limited joint range of motion with no other recognized cause. Four dogs had joint fluid analysis performed, and 3 dogs had an in -creased neutrophil count (> 104/dL). Positive cultures were obtained from bone or joints in 31 dogs. Early on -set of infection was documented in 12 dogs, while 22 dogs presented with delayed onset of infection.Radiographic findingsRadiographs acquired before P407 hydrogel im -plantation were available for 32 dogs. Two dogs did not have radiographs performed. Twenty-two of 32 dogs had radiographic evidence of osteomyelitis, including periosteal proliferation, osteolysis, implant loosening/failure, and soft tissue swelling, and 10 dogs had no ra -diographic signs of osteomyelitis. Two of these dogs had the following radiographic changes consistent with an inflammatory process: joint effusion and soft tissue swelling. Two dogs only had radiographic evidence of implant loosening (n = 1) or failure (1). The remaining 6 dogs had no radiographic abnormalities.Bacterial culture and sensitivityCulture samples were collected prior to surgery and intraoperatively at the time of P407 hydrogel im -plantation in all dogs and included samples of purulent material associated with the infected site, tissue sam -pled from the infected site or implants removed from the infected site. Thirty-one dogs had a positive culture with 1 or more bacterial species. Twenty-seven dogs cultured a single bacterial species, as follows: 18 iso -lates of Staphylococcus pseudintermedius , 3 isolates of coagulase-negative Staphylococcus spp, and 1 isolate each of Pseudomonas aeruginosa , Enterococcus spp, Pasteurella spp, Staphylococcus schleiferi , Staphylo -coccus aureus , and Actinomyces spp. Four dogs had complex infections, which included 2 dogs that un -derwent open reduction internal fixation of fractures. In 1 open reduction internal fixation, P aeruginosa and Escherichia coli were isolated, and S pseudinterme -dius with Streptococcus viridians were isolated from the second fracture. Other bacteria isolated included the following: Staphylococcus spp and Enterococcus faecalis after an infected partial tarsal arthrodesis, Pro-teus mirabilis , E faecalis , and S pseudintermedius after cemented THR. Twelve isolates of S pseudintermedius and 2 isolates of coagulase-negative Staphylococcus spp were methicillin and multidrug resistant. Three dogs had no growth on the sample collected, despite evidence of clinical signs associated with bacterial in -fection (n = 3), radiographic osteomyelitis (3), or gross osteomyelitis documented in the surgical report (2).Surgical proceduresMetallic implants were present in 34 dogs before P407 hydrogel implantation. Surgical implants were re -moved at the time of P407 hydrogel implantation in 20 dogs, replaced in 12, or retained in 2. Gross osteomy -elitis was documented in the surgery report in 19 dogs.Antimicrobial-impregnated poloxamer 407 hydrogel solution implantationVancomycin was the antimicrobial eluted in the P407 hydrogel solution for all dogs included in the study. The antimicrobial choice was based on the re -sults of culture and sensitivity report and the antibio -gram at the authors’ institution. A final concentration of 20 mg/mL of vancomycin hydrochloride in P407 hydrogel was administered in all dogs.One gram of vancomycin hydrochloride that was FDA approved for IV administration was reconstituted to a concentration of 200 mg/mL by adding 5 mL of sterile water (Hospira). The antimicrobial-impregnat -ed P407 hydrogel solution was then compounded by mixing 2.5 mL of the 200 mg/mL vancomycin hydro -chloride solution with cool ( 4 °C ) liquid form of 22.5 mL of 30% P407 hydrogel solution (Medisca) that was FDA approved for use as a drug excipient. This volume ratio was selected to maintain a final concentration of P407 hydrogel ranging between 20% to 35% to main -tain ideal gelation temperatures in the perioperative period as previously reported.27 The suspension was gently mixed using two 60-mL syringes connected by a 3-way stopcock until a semiopaque, homogenous so -lution was achieved. The P407 hydrogel was prepared Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 07/22/23 07:43 AM UTC JAVMA | AUGUST 2023 | VOL 261 | NO. 8 1189the morning of surgery and refrigerated at a standard temperature of 4 °C until implantation.In all dogs, the P407 hydrogel was placed in the surgical site immediately before closure. The total vol -ume of P407 hydrogel implanted varied on the basis of available anatomic space. All incisions were closed in a routine fashion.Systemic antimicrobialsThe median duration of antimicrobial administra -tion was 40 days (10 to 138 days). For dogs in which implants were present after P407 hydrogel implanta -tion, the median duration was 46 days (10 to 138 days). Systemic antimicrobial choice was guided by the re -sults of bacterial culture susceptibility results.OutcomeThe median duration for follow-up was 363 days (15 to 1,339 days). No complications directly related to P407 hydrogel placement were identified. At final follow-up, infections were cleared in 26 of 34 (77%) dogs. These dogs had no clinical, cytologic, or radiographic evidence of osteomyelitis and reported satisfactory limb use dur -ing normal activity on phone interviews. Eight dogs had unsuccessful outcomes. One dog underwent implant ex -plantation 16 weeks after revision surgery, refractured the affected limb 2 days later, experienced severe vasculitis leading to amputation, and was euthanized 1 week later after it was presented for the following progressive neu -rologic signs: obtundation, disorientation, and nonam -bulatory tetraparesis with cervical pain. One dog under -went explantation after recurrence of SSI 20 weeks after P407 hydrogel implantation. One dog had recurrence of SSI and was euthanized. One dog reportedly had poor limb function at home and persistent drainage from the surgical site and was euthanized 1 month after gel ad -ministration. One dog underwent explantation of an im -plant 4 months after revision surgery, developed severe multilobar aspiration pneumonia, and was euthanized 1 month after explant surgery. One dog underwent fore -limb amputation secondary to nonunion, implant failure, and fracture 4 months after revision surgery. One dog was persistently lame with pain associated with a nonunion of the radius. One dog had persistent low-grade osteomyeli -tis and lameness of the operated limb, despite long-term systemic antimicrobial administration.Analysis of risk factors for unsuccessful infection treatmentDemographics, perioperative variables, diagnos -tic findings, number of clinical signs, duration of clini -cal signs, duration of systemic therapy, and treatment outcomes were evaluated using univariable analysis (Table 1) . Number of surgeries performed before Variable Infection cleared (n = 26) Recurrent infection (n = 8) P valueBody condition score (1–9) 5 (3–9) 5 (4–7) .419 Thin (1–3) 2 0 — Ideal (4–5) 17 7 — Overweight or obese (6–9) 7 1 —Body weight (kg) 30 (2–83) 31 (23–57) .542Number of surgeries before gel administration 1 (1–4) 3 (1–5) .005*Duration of clinical signs before gel 37.5 (0–581) 81 (0–422) .183 administration (d)Days from the first surgery to gel administration 212 (8–1465) 273 (11–714) .814Age at gel administration (mo) 59.5 (4–158) 57 (24–171) .919Duration of systemic antibiotic therapy (d) 34.5 (10–91) 46 (21–138) .086Breed — — .593Surgery after trauma 11 4 .702Type of procedure performed — — .367Onset of infection — — .319 Acute 8 4 Delayed 18 4 Gross osteomyelitis 17 2 .044*≥ 2 clinical signs 19 7 .400Radiographic osteomyelitis 15 7 .123Gender .756 Male 4 1 Female 1 0 Male castrated 11 5 Female spayed 10 2 Surgical location .434 Upper extremity 9 4 Lower extremity 17 4 Positive bacterial culture 26 7 .629Multidrug or methicillin resistance 9 6 .044*Complex infection 3 1 .942Implant present 8 6 .027*Infection susceptible to vancomycin 20 6 .281Median values are reported as median with range. *Statistically significant results.Table 1 —Results of univariable analysis of case demographics and variables possibly associated with treatment outcome after vancomycin-impregnated poloxamer 407 gel implantation.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 07/22/23 07:43 AM UTC1190 JAVMA | AUGUST 2023 | VOL 261 | NO. 8P407 hydrogel implantation and multidrug or methi -cillin resistance were retained in the final model for multivariate logistic regression analysis. The number of surgeries performed before P407 hydrogel implan -tation ( P = .005; unit OR, 0.25; 95% CI, 0.08 to 0.81) and presence of a multidrug- or methicillin-resistant infection ( P = .042; OR, 0.13; 95% CI, 0.01 to 1.14) were found to be significantly associated with an in -creased risk of treatment failure.

Question 133

Yu Lu - 2023 - JAVMA - Evaluation of complications and long-term outcomes associated with 101 dogs and cats discharged with and without subcutaneous active closed-suction drains (2014-2022).pdf

Answer 133

Case selection and medical records reviewMedical records from dogs and cats that had a subcutaneous closed suction drain placed at Boundary Bay Veterinary Specialty Hospital between January 1, 2014, and June 1, 2022, had medical records reviewed and were enrolled. Data collected included signalment, age, sex, reproductive status, breed, reason for drain placement, surgical procedure, location of drain, du -ration of hospitalization, whether the animal was dis -charged with or without a drain, number of days to drain removal, perioperative and postoperative anti -microbial usage, culture and sensitivity results if ap -plicable, as well as any preoperative, intraoperative, and postoperative complications reported.Animals that were discharged with a subcutane -ous drain for outpatient management were classified into Group D, while animals discharged following in-hospital drain removal were classified into Group ND. Dogs or cats that were lost to follow-up at 2 weeks, had thoracic or abdominal closed suction drains placed, or had incomplete medical records were ex -cluded from the study.Closed suction drain placement location classification and surgical techniqueThe location of drain placement was broadly characterized into 3 groups—head or neck, trunk, and limbs or tail. All wounds in which a drain was placed were classified based on the CDC surgical wound clas -sification system.14,15 For the animals that did not re -turn to the specialty hospital at the 14-day recheck, follow-up information was obtained through records from the primary referring veterinarian.All closed suction drains were placed by a board-certified veterinary surgeon using appropriate clini -cal judgment based on the animal’s reason for sur -gery as well as size and depth of the defect. Types of closed suction drains that were placed included a plastic bulb reservoir attaching to a silicone tub -ing with fenestrations at the distal end of the tube (Jackson-Pratt drain; Cardinal Health) or a modified closed suction drain involving a glass red top blood collection tube attached to an 18-gauge butterfly catheter with small fenestrations created at the dis -tal end of the plastic tubing.16All drains were placed by tunneling into the subcutaneous space, ensuring that fenestrations remained strictly within the defect. Care was taken to avoid drain placement directly under the suture line. The drains were exited at a separate incision site and secured to the skin using a finger trap suture pattern with non-absorbable monofilament suture material (nylon or polypropylene). All incisions and drain sites were covered with a sterile absorbent ad -hesive dressing. The drain reservoir was further se -cured to the animal to minimize dislodgement, either via a metallic alligator clip attaching the reservoir to the animal’s harness, using bandaging material to tie the reservoir bulb to the animal’s harness, or a single non-absorbable interrupted suture placed on the dermis of the animal to hold the reservoir. De -pending on the location of the drain, a light soft pad -ded bandage or a surgical suit using cotton tubular stockinette was also placed over the site.Postoperative drain managementDrain management was defined as the frequency of checking, cleaning, and emptying the drain. While in hospital, all drains were handled with examination gloves and the suction bulb and tubing were wiped Unauthenticated | Downloaded 10/08/23 06:32 AM UTC1512 JAVMA | OCTOBER 2023 | VOL 261 | NO. 10with alcohol-soaked gauze. The drain insertion site was covered aseptically with a sterile absorbent, breathable adhesive dressing and was replaced and recorded if strikethrough was noted. An Elizabethan collar was placed throughout the duration of hospi -talization and hourly checks were performed to en -sure that the Elizabethan collar was not dislodged. Animals received subcutaneous closed suction drain management at least every 4 hours postoperatively in hospital.For animals in Group D that were discharged with the subcutaneous closed suction drain, own -ers were instructed to wash their hands thoroughly or use disposable examination gloves and wipe the reservoir bulb or glass blood collection tube with alcohol-soaked swabs prior to emptying the drain. They were advised to empty the drain at least twice a day or as needed if the drain became full and to always have an Elizabethan collar on their pet. Owners were advised to record down the col -or, clarity, and volume of fluid obtained each time the drain as emptied.Owners were advised to return with their animal 3 to 5 days postoperatively for drain reassessment. Drains were removed when drain production dimin -ished significantly depending on the trend and volume of drain production, or were kept in place with another recheck organized at a later date for serial assessment and possible removal.6,7,17 The majority of drains were removed at the specialty hospital, with a small number of animals having their drain removed at their primary referring veterinarian due to client factors.Complications classificationComplications were classified based on guide -lines from Follette et al.18 A complication was de -fined as an unintended event that occurred from admission to hospital until reported death, euthana -sia or more than 14 days postoperatively.18 Compli -cations were further classified into its preoperative, intraoperative and postoperative time periods. In the postoperative period, complications that occurred less than 14 days were considered short-term and more than 14 days long-term.18Postoperative complications were also graded in terms of severity based on the Accordion Severity of Postoperative Complications.18 Minor complica -tions were defined as complications that were eas -ily treatable with minimally invasive procedures that can be performed bedside. Examples of minor com -plications in this study included: seroma formation, presence of discharge or swelling, drain dislodge -ment, trauma to the drain associated with chewing, acquired surgical site infections, drain malfunction. Moderate complications involved pharmaceutical treatment with drugs, major complications were de -fined as life-threatening and/or requiring another surgical procedure.2,18 Surgical site infections (SSI) were defined based on the CDC Criteria.5,14,15Statistical analysisAll analyses were performed using SAS, version 9.4 (SAS Institute Inc). A significance threshold of 0.05 was used. The primary comparison was com -plications between Group D and Group ND.Age and weight (for each species separately) were compared between groups with Student t tests. Length of hospitalization was compared be -tween groups with a Mann-Whitney test. Days until drain removed were compared between groups via zero-truncated negative binomial. Categorical risk factors were compared between groups with χ2 or Fisher exact tests.Univariable and multivariable logistic regres -sions were utilized to test risk factors for effects on odds of complication and to estimate odds ratios and 95% CI. There were 26 animals with complica -tions which would support at most 2 variables in a multivariable model following the minimum 10 events per variable rule. The 2 variables with P < .10 were included in the multivariable model for all cases. Additionally, a separate multivariable model was run for canines only adjusting for weight. The 2 variables with P < .10 were included in the multi -variable model. Log-likelihood P values were used and reported. Firth bias-reduced penalized logistic regression was used for analyses with sex as a fac -tor due to quasi-separation (ie, no complications in the sexually intact female group).ResultsStudy populationA total of 94 (93%) dogs and 7 cats (7%; n = 101) that underwent placement of a subcutane -ous closed suction drain between January 1, 2014, and June 1, 2022, met the study criteria, yielding a total study period of 3,073 days (Supplemen -tary Table S1) . The mean age and body weight of all animals were 6.2 years (SD = 3.9 years) and 24.2 kg (SD = 14.7 kg). Castrated male dogs (n = 44/94) were most common, followed by spayed females (38/94), sexually intact males (8/94), and sexually intact females (4/94). In cats, cas -trated males (n = 3/7) and spayed females (3/7) were most common. The most common breeds of dogs in the included population were Labra -dor Retrievers (n = 9/94) and German Shepherd Dog (9/94), followed by the Australian Shepherd (6/94) and Border Collie (4/94). Among cats, the most common breed represented included mixed-breed cats (n = 4/7), followed by Ragdolls (2/7) and Himalayan (1/7).Seventy-seven (76%) animals were catego -rized into Group D, including 73 dogs (95%) and 4 cats (5%). Of the 73 dogs, 35 were castrated males (48%), 8 were sexually intact males (11%), 27 were spayed females (37%), and 3 were sexually intact females (4%). The 4 cats were comprised of 2 cas -trated males (50%), 1 sexually intact male (25%), and 1 spayed female (25%). The mean age and body weight of animals in Group D was 5.9 years (SD = 4.0 years) and 26.6 kg (SD = 14.6 kg).Twenty-four animals were categorized into Group ND, including 21 (87%) dogs and 3 (13%) cats. Unauthenticated | Downloaded 10/08/23 06:32 AM UTC JAVMA | OCTOBER 2023 | VOL 261 | NO. 10 1513Of the 21 dogs, 9 were castrated males (43%), 11 were spayed females (52%), and 1 was a sexually intact female (5%). The 3 cats were comprised of 1 castrated male (33%) and 2 spayed females (67%). The mean age of animals in Group D was 7.1 years (SD = 3.4 years) and mean weight was 16.4 kg (SD = 12.4kg; Table 1 ).Dogs in Group D weighed significantly higher on average by 10.2 kg (95% CI; 4.2 to 18.3) than dogs in Group ND ( P = .002). Age was not significantly dif -ferent between the 2 groups ( P = .197). There were no significant differences in sex ( P = .199), species (P = .328 for dogs and P = 1.0 in cats) between ani -mals in Group D and Group ND (Table 1).Closed suction drain type, location of drain placement, and duration of drain placementOf 101 drains placed, 95% (n = 96/101) were Jackson Pratt closed suction drains, whereas 5% (5/101) had a modified drain using a blood collec -tion tube and a fenestrated butterfly catheter.Location of surgery and drain placement were categorized into head and neck (n = 39/101), the trunk (35/101), limbs and tail (38/101). In Group D, 39% of animals (n = 40/76) had drains placed in the region of head and neck, 28% trunk (21/76), and 38% limbs and tail (29/76). In Group ND, 38% of animals had drains placed in the head and neck (n = 9/24), 58% trunk (14/24), and 38% limbs and tail (9/24). Ani -mals in Group ND had significantly more drains placed in the trunk than did Group D ( P = .006). There was no significant difference between other drain locations (head, neck, and limbs) and groups ND and D ( P = .863 for head and neck, P = .954 for limbs and tail).The overall median number of days to drain re -moval was 4 days (lower quartile = 3 days, upper quar -tile = 6 days) range. The mean duration of days until drain removal in Group D was 5.6 days (SD = 3.3 days). In Group ND, the mean duration of days until drain removal was 3.1 days (SD = 1.8 days). Subcutaneous closed suction drains were left in place significantly longer in Group D compared to Group ND ( P = .0003).Days of hospitalizationThe overall median number of days of hospi -talization was 1.5 days (lower quartile = 0.75 days, upper quartile = 3.0 days) respectively. The median duration of days of hospitalization for Group D and Group ND were 1 day (lower quartile = 0.67 days, up -per quartile = 2 days) and 3.25 days (lower quartile = 2.5, upper quartile = 5 days), respectively. Animals in Group D had a significantly shorter hospitaliza -tion stay than animals in Group ND ( P < .0001). An increased risk of postoperative infection in animals hospitalized for a longer period was not supported in this study ( P = .254).Surgical wound classificationSurgical wounds at the time of drain placement for all animals were classified into the following cat -egories: Class I (clean; n = 22/98 [22%]), Class II (clean-contaminated; 0/98 [0%]), Class III (contami -nated; 3/98 [3%]), Class IV (dirty/ infected; 73/98 [74%]). In Group D, 20 (27%) animals were classified as Class I, none (0%) in Class II, 2 (3%) in Class III, and 52 (70%) in class IV. In Group ND, 2 (8%) animals were classified as Class I, 0 (0%) in Class II, 1 (4%) in Class III, and 21 (88%) in class IV. There was no association in surgical wound classification between Groups D and ND ( P = .141).Reasons for drain placement and concurrent proceduresSubcutaneous closed suction drains were sur -gically placed for the following reasons: wound ex -ploration (81%, n = 82/101), tumor resection (18%, 19/101) and limb amputation (1%, 1/101). Nine Table 1 —Association between patient variables examined and risk factors of complications in 101 dogs and cats that underwent surgical placement of a subcutaneous closed suction drain between January 1, 2014, and June 1, 2022.Risk factor Variable OR (95% CI) P valuea*Species Canine vs feline 2.6 (0.4 –51) .335Age Per 5 y 0.7 (0.4 –1.2) .147Weight Canine per 5 kg 1.2 (0.99 –1.4) .060 Feline Too few n = 1 complications Sex Sexually intact female vs castrated male 0.3 (0.002 –2.8) .253b Spayed female vs castrated male 0.8 (0.3 –2.3) - Sexually intact male vs castrated male 2.9 (0.7 –12.5) -Surgical category Clean vs not clean 0.6 (0.2 –2.0) .427Surgical site Neck 0.9 (0.4 –2.3) .871 Trunk 0.6 (0.2 –1.5) .285 Limbs and Tail 1.0 (0.4 –2.68) .946Presence of drain at discharge Group D vs ND** 13.4(2.6 –248) .001Duration of drain placement Per day 1.1 (0.95 –1.3) .183Length of hospitalization Per day 0.6 (0.4 –0.9) .005Type of drain Jackson Pratt vs Red Top tube 0.3 (0.03 –1.6) .140Presence of a positive bacterial Positive vs negative 0.6 (0.2 –1.9) .370 culture at time of surgeryaLog-likelihood ratio P value unless otherwise noted.bFirth bias-reduced penalized logistic regression.*Values were considered significant at P < .05.**Group D = patient was discharged with subcutaneous drain still in place; Group ND = subcutaneous drain was removed prior to patient discharge.Unauthenticated | Downloaded 10/08/23 06:32 AM UTC1514 JAVMA | OCTOBER 2023 | VOL 261 | NO. 10animals received additional procedures including lung lobectomy, caudectomy, bilateral nephropexy, lymph node extirpation.Intraoperative laboratory testingFifty-one (66.2%) animals in Group D had sam -ples collected for bacterial culture and sensitivity intraoperatively. Thirty-eight of these samples (75%) were positive for bacterial growth, with some sam -ples growing > 1 strain of bacteria. Thirteen samples (25%) were negative for bacterial growth. Bacteria cultured in Group ND included: Streptococcus canis (n = 12), Pasteurella multocida (10), Staphylococcus pseudintermedius (7), Enterococcus faecium (2), Bacillus sp (2), Escherichia coli (2), Prevotella sp (2), Acinetobacter naumannii complex (2), Staphylococ -cus aureus (1), and Actinomyces sp (1).Nineteen animals (79.1%) in Group ND had sam -ples collected for bacterial culture and sensitivity in -traoperatively. Eleven (42%) of these samples were positive for bacterial growth and 8 (58%) samples were negative. Bacteria cultured in Group ND includ -ed: Escherichia coli (n = 2), Bacillus sp (2), Proteus mirabilis (1), Pasteurella multocida (1), Staphylococ -cus warneri (1), and Actinomyces sp (1). There was no association between the rate of positive bacterial culture result at the time of drain placement surgery between Groups D and ND ( P = .013).ComplicationsOut of 101 animals, 11 animals were lost to fol -low-up. One dog from Group ND had cardiopulmo -nary arrest intraoperatively for extensive bite wound repair and was not successfully resuscitated. Postop -erative complications occurred in 26 animals (29.2%), where the majority (n = 25/26, 96.1%) were from Group D. Postoperative complications were classified as minor in 21/26 (80.8%) animals and major in 5/26 (19.2%) animals. Minor complications included drain dislodgement (n = 5/21), wound dehiscence (4/21), seroma formation (3/21), recurrent swelling (3/21), discharge around wound site (3/21), and owners’ dif -ficulty managing drain at home (3/21). Two animals (n = 2/101; 2%) that were both from Group D devel -oped postoperative infections. In both cases, repeat bacterial culture and sensitivity of the discharge from the drain isolated multi-resistant bacteria.Major complications occurred in 5 animals (5.6%), of which 4 were from Group D and 1 from Group ND. These included recurrent abscess formation neces -sitating surgical revision, surgical site dehiscence requiring surgical revision, tumor regrowth requir -ing re-excision, postoperative SIRS following wound exploration requiring euthanasia, and postoperative cervical swelling and respiratory dyspnea requiring euthanasia following cervical neck exploration for a suspected abscess (Supplementary Table S2).Upon univariable and multivariable analysis, be -ing discharged home with a subcutaneous closed suction drain in place (Group D) increased the odds of having drain-associated complications compared with having the drain removed prior to discharge ( P = .0001). The type of drain placed was not associated with risk of complications ( P = .140). There was no association between duration of drain placement and risk of complications ( P = .183). The length of hospitalization was significantly associated with the risk of complications on univariable analysis ( P = .005), however, was not significant on multivariable analysis ( P = .254). The degree of surgical site con -tamination did not increase the risk of complications (P = 0.427). The presence of a positive bacterial cul -ture was not associated with a significant increase in the risk complications ( P = .370).

Question 134

Burger - 2023 - JAVMA - Dogs with congenital extrahepatic portosystemic shunts that have persistent shunting after surgery have a higher prevalence of urolithiasis.pdf

Answer 134

A retrospective study with a prospective long-term follow-up was set up and approved by the local ethi -cal and deontological committee (EC 2018-77, DWZ/ER/19/1.15/28). Records of the clinic were searched for dogs that underwent surgical attenuation of a cEHPSS between January 2012 and December 2018. Dogs were eligible for inclusion if the postoperative PSS status was determined by transsplenic portal scintigra -phy or CT angiography a minimum of 3 months post -operatively and if the surgery was performed at least 6 months prior to study inclusion. Dogs with MAPSS (pU+/−) were only included if they developed these following surgical attenuation of a cEHPSS. As only a limited number of dogs with MAPSS were available that met the inclusion criteria, owners of all these dogs were contacted by phone and invited for a prospective follow-up visit. Subsequently, a number of dogs with closed cEHPSS with (cU+) and without urolithiasis (cU–) before or at the time of cEHPSS attenuation were list -ed. It was decided to include a similar number of dogs with closed cEHPSS with and without a history of pre -operative urolithiasis. As the minority of these dogs did not have urolithiasis before or at the time of cEHPSS attenuation, all owners of these dogs were contacted by phone and invited for a prospective follow-up visit. Finally, dogs with closed cEHPSS that had a history of preoperative urolithiasis were matched to the previous dogs included, based on the time between the cEHPSS attenuation and the prospective follow-up visit, to achieve a comparable average follow-up time between all dogs. Owners of the latter dogs were contacted by phone and invited for a prospective follow-up visit. All owners that came for the prospective follow-up visit signed an informed consent that contained all details about the study, and hence all owners gave consent to analyze all retrospectively available data and perform all prospective investigations that were part of the cur -rent study (for details, see below).Retrospective data of enrolled dogs were col -lected from medical records and included details about clinical signs before cEHPSS attenuation, sur -gical details, and postoperative follow-up. As most dogs were already included in previous prospective studies (EC2012/164 and DC211728/13_21_04; EC2014/179-27 and DC2015N03; and EC2017/49 and DC2017N06), standardized questionnaires re -garding clinical signs were available for review at diagnosis, surgery, and follow-up until 6 months postoperatively. For the prospective follow-up visit, this questionnaire was adapted by adding questions focusing on the presence and severity of urinary tract signs both preoperatively and postoperatively until the examination date at the prospective follow-up visit, diet history, and medical history between cEHPSS attenuation and the prospective follow-up visit (Supplementary Appendix S1) . Owners of dogs were invited for a prospective follow-up visit between June 2019 and January 2020, and a thor -ough history was taken by the primary author, who filled out the questionnaire together with the own -ers. If urinary tract disease occurred during the pe -riod between cEHPSS attenuation and the prospec -tive follow-up visit, the referring veterinarian was contacted to obtain the results of the investigations. To quantify the severity of urinary complaints, a urinary score (0 to 18) was calculated for each dog before cEHPSS attenuation and at time of the pro -spective follow-up visit based on answers available in the questionnaires. Urinary signs that occurred often were assigned 2 points, and those that occurred occa -sionally were assigned 1 point. Hematuria, stranguria, and dysuria were multiplied by 2, whereas polyuria, polydipsia, and periuria were not multiplied.At the prospective follow-up visit, physical ex -amination and blood analyses, including CBC, serum biochemistry, and fasting ammonia concentration, were performed. Ammonia was measured immedi -ately after blood sampling using a portable laboratory device (PocketChem BA; A Menarini Diagnostics srl). Ultrasonography of the urinary tract was performed in all dogs by a European College of Veterinary Diag -nostic Imaging diplomate (ES) to assess the presence of urolithiasis and echogenicity of urine and reassess cEHPSS closure. In case uroliths were detected, the size and location were recorded and abdominal plain radiographs were performed to assess radiopacity. Ultrasound-guided cystocentesis and in-house uri -nalyses were performed in all dogs, including urine-specific gravity, manual semiquantitative dipstick uri -nalysis and microscopic native, and diff-quick stained sediment examination, completed within 30 minutes after collection. In case uroliths were removed, they were sent for quantitative analysis.Statistical analysisDue to the small number of dogs included, it was decided to report results as nonparametric data. Sta -tistical analysis was performed using SPSS Statistics (version 26; IBM). Kruskal-Wallis tests were performed to assess differences between groups (cU+, cU–, and pU+/−) in age, body weight, body condition score, fasting ammonia concentrations, urinary scores, the pres -ence of urolithiasis at the time of surgical attenuation of Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 08/30/23 11:59 AM UTC JAVMA | SEPTEMBER 2023 | VOL 261 | NO. 9 1339the cEHPSS and the prospective follow-up visit, and the time between cEHPSS attenuation and the prospective follow-up visit. In case of statistical significance, pair -wise comparisons were performed with the Bonferroni correction. To assess urinary scores over time, Wilcoxon matched-pair signed rank tests were performed. Results with a P ≤ .05 were considered significant.ResultsSignalment, history, and clinical findingsOwners of 26 dogs were contacted. The owner of 1 dog with MAPSS elected not to participate in the study because of the anxious nature of the dog, and thus a total of 25 dogs were included, of which 17 dogs had urolithiasis before or at the time of cEHPSS attenuation (12/19 dogs in which surgical attenuation resulted in a closed cEHPSS and 5/6 dogs that developed MAPSS; Table 1 ). Breeds of dogs included the following: York -shire Terrier (n = 5); Chihuahua, Dachshund, and Mal -tese (3 each); Bichon Frise and mixed-breed dog (2 each); and Border Collie, Jack Russell Terrier, Kees -hond, Norwich Terrier, Pug, Miniature Schnauzer, and Standard Schnauzer (1 each). There was no difference between the groups in age ( P = .340), body weight ( P = .256), body condition score ( P = .900), and time be -tween cEHPSS attenuation and the prospective follow-up visit ( P = .851). In 3 of 25 (12%) dogs, uroliths were previously diagnosed and removed by the referring veterinarian, and in 10 of 25 (40%) dogs, cystotomy was performed at the time of cEHPSS attenuation. An ameroid constrictor was placed in 17 of 25 (68%) dogs, and in 8 of 25 (32%) dogs, thin film banding was used.One dog with closed cEHPSS was diagnosed with idiopathic epilepsy 7 months after cEHPSS attenuation and showed marked alopecia and a decreased mental status at the time of the prospective follow-up visit (4 years after cEHPSS attenuation). The dog was subse -quently diagnosed with hypothyroidism. None of the other dogs showed significant abnormalities on physi -cal examination at the time of the prospective follow-up visit. Irrespective of the surgical outcome, occasional gastrointestinal complaints were reported at the time of the prospective follow-up visit, mainly consisting of episodes of vomiting, diarrhea, hypersalivation, melena, and/or decreased appetite. Neurological complaints en -countered after cEHPSS attenuation were mainly peri -odically dullness and hyperactivity (Table 2) . Complete study Closed Closed cEHPSS MAPSS population cEHPSS MAPSS Variable (n = 25) (n = 19) U+ (n = 12) U– (n = 7) (n = 6) U+ (n = 5) U– (n = 1)Age (mo)a 73 (18–115) 82 (22–115) 77.5 (22–115) 83 (38–111) 51.5 (18–86) 47 (18–86) 56Body weight (kg)a 5.8 (2.2–14.9) 6.3 (2.2–14.9) 7.7 (2.4–14.9) 3.8 (2.2–7.9) 5.1 (2.5–9.2) 5.6 (3.7–9.2) 2.5BCSa 5/9 (4/9–7/9) 5/9 (4/9–7/9) 5/9 (4/9–7/9) 5/9 (4/9–6/9) 5/9 (4/9–6/9) 5/9 (4/9–6/9) 5/9Time between cEHPSS attenuation 36 (13–103) 34 (14–103) 41 (14–61) 34 (18–103) 38.5 (13–71) 36 (13–71) 41 and the prospective follow-up visit (mo)aSex (F, FN, M, MN) 0, 15, 1, 9 0, 11, 1, 7 0, 6, 0, 6 0, 5, 1, 1, 0, 4, 0, 2 0, 3, 0, 2 0, 1, 0, 0Type of cEHPSS (PA, PC, PP) 4, 17, 4 4, 12, 3 3, 6, 3 1, 6, 0 0, 5, 1 0, 4, 1 0, 1, 0Surgical attenuation method 17, 8 14, 5 9, 3 5, 2 3, 3 2, 3 1, 0 (AC, TFB)aData are reported as median and rangeAC = Ameroid ring constrictor. BCS = Body condition score. F = Female sexually intact. FN = Female neutered. M = Male sexu -ally intact. MAPSS = Multiple acquired portosystemic shunts. MN = Male neutered. PA = Portoazygos. PC = Portocaval. PP = Por -tophrenic. TFB = Thin film banding. U+ = Dogs with confirmed urolithiasis before or at the time of cEHPSS attenuation. U– = Dogs with no history of urolithiasis before or at the time of cEHPSS attenuation.Table 1 —Demographic data of included dogs in this study with a history of a surgical attenuation of congenital extrahepatic portosystemic shunts (cEHPSS). Gastrointestinal Neurological Urinary Liver-supportiveGroup n signs signs signs treatment (n)Closed cEHPSS 19 15 (79%) 9 (47%) 6 (32%) Diet (1), diet and lactulose (1), none (17) U+ 12 8 (67%) 5 (42%) 4 (33%) Diet and lactulose (1), none (11) U– 7 7 (100%) 4 (57%) 2 (29%) Diet (1), none (6)MAPSS 6 5 (83%) 4 (67%) 6 (100%) Diet (1), diet and lactulose (2), diet and metronidazole (1), lactulose (1), none (1) U+ 5 4 (80%) 3 (60%) 5 (100%) Diet (1), diet and lactulose (1), diet and metronidazole (1), lactulose (1), none (1) U– 1 1 1 1 Diet and lactuloseSee Table 1 for key.Table 2 —Number of dogs with gastrointestinal, neurological, or urinary signs a median of 36 months (13 to 103 months) after cEHPSS attenuation.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 08/30/23 11:59 AM UTC1340 JAVMA | SEPTEMBER 2023 | VOL 261 | NO. 9Seven dogs still received a liver-supportive treatment (Table 2). All dogs but one received a liver-supportive diet. One dog with MAPSS received a liver-supportive diet until 12 months after cEHPSS attenua -tion when ammonium urate cystoliths were surgically removed and after which the diet was changed to a urolithiasis-prevention diet.Urinary complaintsAt the time of cEHPSS attenuation, 23 of 25 (92%) dogs showed urinary complaints, and at the time of the prospective follow-up visit, 12 of 25 (48%) dogs had a history of urinary complaints in the period from 3 months postoperatively to the prospective follow-up visit. Six of those dogs had a closed cEHPSS (6/19 [32%]) and the other 6 had MAPSS (6/6 [100%]; Tables 2 and 3). One of the dogs with MAPSS suffered from recurrent clini -cal bacterial cystitis. At the time of cEHPSS diagnosis as well as the prospective follow-up visit, the urinary scores were not different between the different groups ( P = .347 and P = .082, respectively). However, over time, urinary scores of cU+ dogs significantly decreased ( P = .005 vs P = .223 for cU– and P = .248 for pU+/−).Blood analysesBlood examinations were performed at the time of the prospective follow-up visit (Table 4) . One (5%) dog with closed cEHPSS had hyperammonemia; nev -ertheless, neither MAPSS nor clear indications for re -canalization of the cEHPSS were found on the basis of abdominal ultrasonography. Unfortunately, further medical imaging was refused by the owner as the dog Table 3 —Number of dogs presented with urinary complaints at the time of cEHPSS diagnosis compared to the pe -riod between the time of cEHPSS attenuation and the time of the prospective follow-up visit with a median time of 36 months (13 to 103 months). Median urinary Pollakiuria Polyuria Hematuria Stranguria Dysuria Periuria score (range) cEHPSS cEHPSS cEHPSS cEHPSS cEHPSS cEHPSS cEHPSS Group n diagnosis Follow-up diagnosis Follow-up diagnosis Follow-up Diagnosis Follow-up diagnosis Follow-up diagnosis Follow-up diagnosis Follow-upClosed cEHPSS 19 15 (79%) 7 (37%) 9 (47%) 7 (37%) 7 (37%) 1 (5%) 7 (37%) 0 (0%) 6 (32%) 0 (0%) 10 (53%) 3 (16%) 4 (0–17) 0 (0–6) U+ 12 10 (83%) 2 (17%) 6 (50%) 3 (25%) 5 (42%) 1 (8%) 7 (58%) 0 (0%) 5 (42%) 0 (0%) 7 (58%) 2 (17%) 7.5 (0–17) 0 (0–4) U- 7 5 (71%) 5 (71%) 3 (43%) 4 (57%) 2 (29%) 0 (0%) 0 (0%) 0 (0%) 1 (14%) 0 (0%) 3 (43%) 1 (14%) 3 (0–11) 2 (0–6)MAPSS 6 5 (83%) 5 (83%) 4 (67%) 2 (33%) 2 (33%) 2 (33%) 1 (17%) 1 (17%) 1 (17%) 0 (0%) 5 (83%) 4 (67%) 5 (2–18) 3 (1–10) U+ 5 4 (80%) 4 (80%) 3 (60%) 2 (40%) 2 (40%) 2 (40%) 1 (20%) 1 (20%) 1 (20%) 0 (0%) 4 (80%) 3 (60%) 3 (2–18) 2 (1–10) U- 1 1 1 1 0 0 0 0 0 0 0 1 1 7 4Follow-up = At time of prospective follow-up visit.See Table 1 for remainder of key.Table 4 —Median (range) of selected blood and urine variables a median of 36 months (13 to 103 months) after cEHPSS attenuation.Variables Closed cEHPSS (range) MAPSS (range) Reference intervaln 19 6 Hematocrit (%)a 50.3 (35.8–62.1) 44.8 (29.4–49.2) 37.3–61.7Mean corpuscular volume (fL)a 65.2 (60.3–71.2) 57.2 (52.7–63.5) 61.6–73.5Albumin (g/L)a 32 (28–41) 26 (17–33) 23–40Alkaline phosphatase (U/L)a 42 (< 10–235) 99.5 (48–220) 23–212Alanine transaminase (U/L)a 51 (22–131) 66 (31–299) 10–125Urea (mmol/L)a 4.7 (2–9.6) 1.7 (0.9–3.2) 2.5–9.6Glucose (mmol/L)a 5.93 (4.58–7.19) 5.64 (4.97–7.54) 4.11–7.95Total protein (g/L)a 62 (55–72) 56 (50–70) 52–82Fasting ammonia 14 (low-84) 49.5 (20–79) < 45 concentration (µmol/L)aUrinary pH (range)a 7 (5–9) 6.75 (5–8) 7.0–7.5Urine specific gravity (range)a 1.035 (1.009–1.046) 1.022 (1.011–1.041) 1.016–1.060Urinary proteins No n = 6 (32%) n = 3 (50%) NA Trace n = 9 (47%) n = 2 (33%) NA 30 mg/dL n = 3 (16%) n = 0 (0%) NA 100 mg/dL n = 1 (5%) n = 1 (17%) NAUrinary bilirubin No n = 14 (74%) n = 3 (50%) NA 1 mg/dL n = 2 (11%) n = 2 (33%) NA 3 mg/dL n = 3 (16%) n = 1 (17%) NAMicroscopic analysis of the urinary sediment No crystals n = 16 (84%) n = 4 (67%) NA Slide artifacts n = 1 (5%) n = 0 (0%) NA Mild struvite crystalluria n = 1 (5%) n = 0 (0%) NA Moderate amorphous crystalluria n = 1 (5%) n = 0 (0%) NA Moderate amorphous crystalluria n = 0 (0%) n = 1 (17%) NA Mild amount of amorphous crystalluria n = 0 (0%) n = 1 (17%) NAaData are reported as median and range.See Table 1 for remainder of key. NA = Not applicable.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 08/30/23 11:59 AM UTC JAVMA | SEPTEMBER 2023 | VOL 261 | NO. 9 1341was clinically doing very well. Hyperammonemia was present in 4 of 6 (67%) dogs with MAPSS. A statistical -ly significant difference in fasting ammonia concen -trations was present between pU+/− and both cU+ and cU– ( P = .018 and P = .014, respectively).UrinalysisUrinalysis was performed at the time of the pro -spective follow-up visit (Table 4). Microscopic hema -turia was found in 13 of 25 (52%) dogs. Nonetheless, all dogs had an inactive sediment. Microscopic anal -ysis of the sediment revealed some artifacts in 1 dog with closed cEHPSS, most likely due to dirty slides or staining, although the presence of ammonium biu -rate crystals could not be completely ruled out. One dog with MAPSS had a previous episode of bacterial cystitis ( Escherichia coli , treated with amoxicillin–clavulanic acid) but was asymptomatic at the time of the prospective follow-up visit. Nevertheless, a moderate number of amorphous crystals and a large number of rods were present, although only a small number of erythrocytes and leukocytes were seen. Urine culture and sensitivity testing revealed the presence of multiresistent E coli . Of the 4 dogs with crystalluria at the time of the prospective follow-up visit, 2 had concomitant urolithiasis. Only in 1 dog quantitative urolith analysis was performed because the dog showed clinical signs (urinary score 10) and revealed the presence of calcium oxalate crystals, which did not match the type of crystalluria (amor -phous) at the time of the prospective follow-up visit.Ultrasonographic and radiographic assessment of the urinary tractBefore cEHPSS attenuation, uroliths were vis -ible on abdominal ultrasonography in 17 of 25 (68%) dogs, with 5 dogs having uroliths in > 1 location. In 15 of 25 (60%) dogs, echoic foci were present in the urinary bladder. In 3 dogs, echoic foci were seen in the absence of urolithiasis (Table 5) . At cEHPSS at -tenuation, the median urinary score of dogs with echoic foci was 5 (2 to 18) and the median urinary score of dogs with urolithiasis was 5.5 (0 to 18).At time of the prospective follow-up visit, uro -liths were seen in 5 of 25 (20%) dogs (Table 5), of which 4 dogs had uroliths in multiple locations. One of the 19 (5%) dogs with closed cEHPSS had uroli -thiasis, whereas 4 of 6 (67%) dogs with MAPSS had urolithiasis. In the dog with the closed cEHPSS and long-term urolithiasis, small cystoliths (up to 2.0 mm), nephroliths (< 1.0 mm), and urethral uroliths (< 1.0 mm) were detected via ultrasound. Additional plain radiographs revealed very small, faint mineral -izations (< 1.0 mm) in both kidneys and a mineral opaque structure of 2.6 mm in length at the level of the prostatic part of the urethra. In this dog, multiple nephroliths had already been reported on ultrasound 1 month before cEHPSS attenuation. However, at that time, they were ranging from 1.5 to 4.0 mm. At the time of the prospective follow-up visit, the dog had a urinary score of 4 and unremarkable blood and urinalysis. One of the dogs with MAPSS had very small cystoliths preoperatively, which were not re -moved at the time of cEHPSS attenuation because of their small size. At the prospective follow-up visit, cystoliths (1.0 to 2.0 mm) were still observed. The remaining 3 dogs with MAPSS and long-term uro -lithiasis developed new uroliths. One dog had am -monium urate cystoliths that were removed at the time of the cEHPSS attenuation and had 60 months prior to the prospective follow-up visit calcium oxa -late and struvite cystoliths removed. However, at the time of the prospective follow-up visit, new small nephroliths (1.0 to 2.0 mm), cystoliths (4.3 mm), as well as urethroliths (1.1 mm) were diagnosed by ultrasound. Based on plain radiography, only the cystoliths were radiopaque (3.5 X 2.7 mm), and uri -nalysis revealed amorphous crystalluria. The fasting ammonia concentration of that dog was normal. As the urinary score was 10, voiding urohydropropul -sion was performed, but the obtained sediment was not sufficient to allow quantitative analysis, although it revealed calcium oxalate crystals. In the second dog, only cystoliths had been present initially, and those were removed at the time of cEHPSS attenu -ation. The dog had a second cystotomy for removal Table 5 —Presence of urinary complaints, echoic foci, cystoliths, urethroliths, nephroliths, and urinary crystals in 25 dogs a median of 36 months (13 to 103 months) after cEHPSS attenuation. Echoic Ureteroliths Cystoliths, Nephroliths Crystals onGroup Dogs foci (n) (n) urethroliths (n) (n) urinary sediment (n) n cEHPSS Prospective cEHPSS Prospective cEHPSS Prospective cEHPSS Prospective Prospective diagnosis follow-up visit diagnosis follow-up visit diagnosis follow-up visit diagnosis follow-up visit follow-up visit Closed cEHPSS 19 10 3 1 0 10 1 4 1 2 U+ 12 7 1 1 0 10 1 4 1 0* AU (6) UN (1) AU with struvite (2) UN (2) U– 7 3 2 0 0 0 0 0 0 2 AM (1) Struvite (1)MAPSS 6 5 2 0 0 5 4 1 3 2 U+ 5 5 2 0 0 5 4 1 3 2 AU (2) AU (1) AM (2) UN (3) Ca-Ox and struvite (1) UN (2) U– 1 0 0 0 0 0 0 0 0 0Total 25 15 5 1 0 15 5 5 4 4*The presence of ammonium biurate crystals could not be completely ruled out in 1 dog because of the presence of artifacts.AM = Amorphous crystals. AU = Ammonia urate uroliths. Ca-Ox = Calcium oxalate uroliths. UN = unknown.See Table 1 for remainder of key.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 08/30/23 11:59 AM UTC1342 JAVMA | SEPTEMBER 2023 | VOL 261 | NO. 9of multiple newly formed ammonium urate cystoliths 15 months after cEHPSS attenuation. At the time of the prospective follow-up visit 16 months after sur -gery, the dog presented with hyperammonemia and very small mineralizations (< 1 mm) were detected in the left renal pelvis. The last dog had nephroliths (2.5 mm) and cystoliths (1.0 mm) at the time of cEHPSS attenuation that were removed. At the follow-up visit, the dog had hyperammonemia, the nephroliths (< 1.0 mm) were still present, and, additionally, new cystoliths (< 1.0 mm) had formed.Urinary bladder echoic foci were observed in 5 of 25 (20%) dogs. Three of these dogs had closed cEHPSS and no urolithiasis (one dog had struvite crystalluria, another one amorphous crystalluria, and the last one did not have crystalluria). Two dogs had MAPSS and concurrent urolithiasis (one dog without crystalluria and the other with amorphous crystalluria).In 3 of the 4 dogs with closed cEHPSS that pre -sented with nephrolithiasis at time of diagnosis, nephrolithiases were absent at the time of the pro -spective follow-up visit. In 1 dog, echoic foci were visible at the level of the renal pelvis (initial nephro -lith was 8.7 X 4.7 X 8.3 mm), whereas in the other 2 dogs (initial nephroliths were 2.0 and 3.0 mm in one dog and 4.4 and 6.0 mm in the other dog) no echoic foci were observed. The remaining dog with closed cEHPSS and preoperative nephrolithiasis developed postoperative cystolithiasis. Although there was per -sistent nephrolithiasis, at long-term the nephroliths were smaller compared to before.At the time of the prospective follow-up visit, dogs in cU+ and dogs in cU– had significantly less urolithiasis compared to dogs in pU+/− ( P = .013, and P = .010, respectively). No statistical significance in urolithiasis was present between dogs of cU+ and cU– ( P = 1.000). Dogs in cU+ had significantly less urolithiasis at the time of the prospective follow-up visit compared to the time of cEHPSS attenuation (P = .001), whereas no significant difference was present over time in dogs of pU+/− ( P = .317).

Question 135

Rivenburg - 2023 - VETSURG - Biomechanical comparison of canine median sternotomy closure using suture tape and orthopedic wire cerclage.pdf

Answer 135

2.1 |Specimen collection andpreparationThis biomechanical study was performed using 12 large-breed, skeletally mature canine cadavers. Six cadaverswere donated by shelters following euthanasia for reasonsunrelated to the study, and six canine torsos were pur-chased from an educational resources company. No insti-tutional animal care and use committee approval wasrequired for this study. The sternums were collected fromdogs ranging in weight from 25 to 35 kg to create a samplesize of six sternums per group. The musculature overlyingthe sternebrae was dissected off, similar to the surgicalapproach, and the ribs were cut using an oscillating sagit-tal saw along the dorsal aspect of the rib cage to removethe ventral thorax en bloc. Each specimen was composedof all sternebrae and at least 5 cm of ribs and intercostalmuscles. A median sternotomy was performed by a singleboard-certified surgeon (EAM) using an oscillating sagittalsaw, leaving the manubrium intact. Specimens werewrapped in saline-soaked (NaCl 0.9%) gauze and frozen at/C020/C14C until testing. All the specimens were thawed atroom temperature for 24 h before testing, maintainingconstant moisture with saline-soaked (NaCl 0.9%) gauze.The specimens were randomly assigned to one of twomedian sternotomy closure techniques: 20-gauge 316Lstainless steel orthopedic wire cerclage construct (W), orsuture tape construct (ST). The orthopedic wire was1058 RIVENBURG ET AL . 1532950x, 2023, 7, placed in a figure-of-eight pattern centered around thesternal synchondrosis by a single investigator (RER)(Figure 1A). Each sternum had seven implants. The freeends of the orthopedic wire were tensioned and twistedwith wire twisters until deemed secure, using the twist-and-lay technique. The wire was then cut with wirecutters, leaving more than three twists. Using theswaged-on passing needle of the suture tape, the suturetape was placed around the sternum in a doubled figure-of-eight pattern and knotted using the attached loaderand nitinol loop (Figure 1B). The suture tap was tight-ened to the 70-laser line (70 lbf) using the supplied ten-sioner (FiberTape) and secured with three square knots(six throws) by a single board-certified surgeon (JB).Suture ends were cut short. All reconstructed sternumswere radiographed using c-arm fluoroscopy (HologicFluoroscan Insight FD; Hologic, Marlborough, Massa-chusetts) prior to and following biomechanical testing toassess mode of failure.2.2 |Biomechanical testingA custom-made clamp with a grip was used to secureeach construct for biomechanical testing (Figure 2). Theclamps consisted of two stainless steel plates with inter-nal spikes to perforate the intercostal muscles and carti-lage and minimize tissue slippage. The clamps wereplaced on either side of the sternum /C241.5 cm from thesternotomy, compressed together using bolts, andmounted in an electrodynamic materials testing system(ElectroPuls, Instron, Norwood, Massachusetts) with a10 kN load cell and laterally distracted in a single cycle ata rate of 100 mm/min until failure, similar to othercanine sternal models.13,17The setup was designed tomaximize xiphoid process separation —consistent withclinical observations —by leaving the manubrium intactand permitting a minor rotational degree of freedom.This was achieved by allowing the bottom clamp to anglewhile testing as it rotated about the dowel pin.Load and displacement data were recorded continu-ously until failure using a materials-testing software(WaveMatrix, Instron, Norwood, Massachusetts). Thestiffness (N/mm), yield load (N), and maximum load(N) were determined. Displacements (mm) from 75 to225 N in increments of 25 N were recorded for additionalanalysis. The yield load was defined as the point at whichthere was a 10% drop in stiffness on the load –displace-ment curve. For this analysis, a linear best-fit line wasconstructed in the elastic region, and the slope wasrecorded. A second-order quadratic best fit was thenplaced in the transition region from linear to plasticdeformation. The tangential slope was used to find thepoint on the load –displacement curve where there was90% of the elastic slope (OriginPro, OriginLab Corporation,Northampton, Massachusetts). The starting point fordisplacement analysis was 75 N to account for a non-linear toe region commonly observed in biomechanicstesting and to capture a physiological load levelFIGURE 1 Median sternotomy closures using (A) orthopedicwire cerclage and (B) suture tape. Both (A) and (B) show themanubrium at the top and the xyphoid at the bottom of the figure.FIGURE 2 Biomechanical test setup with a canine sternummounted within a custom clamp. A rotational degree of freedomwas added at the caudal region to allow for xiphoid separation(black dashed arrow).RIVENBURG ET AL . 1059 1532950x, 2023, 7, representative of a cough in large animal models.38Biomechanical testing was v ideo recorded, and fluoro-scopic images were obtained before and after testing toidentify modes of failure.2.3 |Statistical analysisNormality was assessed using the Shapiro –Wilk analysis.Parametric Student's t-tests were used to compare thestiffness, yield load, maximum load, and incremental dis-placements between the suture tape cerclage andstainless-steel orthopedic wire cerclage. All data and sta-tistical analyses were performed using Microsoft Excel(Microsoft Corp, Redmond, Washington), SigmaPlot(SPSS Inc, Chicago, Illinois), and Minitab (Minitab Inc,State College, Pennsylvania) software with statistical sig-nificance set at p< .05.3|RESULTSSix sternums were included for analysis in the ST group,five sternums in the W group. One sample from the Wgroup was excluded due to an operator setup error caus-ing substantial slip in the clamps. No differences wereobserved between the ST ( n=6) and W ( n=5) groupsregarding yield load (506 ± 170/C14N vs. 626 ± 218/C14N), andmaximum load (1278 ± 265/C14N vs. 1511 ± 180/C14N)(Table 1). There was no difference regarding displace-ments (mean range: 0.58 –2.89 mm vs 0.47 –2.16 mm)(Figure 3). The ST repair was less stiff than the W repair(65 ± 13 N/mm vs 107 ± 35 N/mm, p=.01). Yield andmaximum loads did not correspond to implant failurebut instead, reflected a failure of the constructs at the cos-tal cartilage and/or sternocostal junction; no implant fail-ures occurred (Figure 4).4

Question 136

Evers - 2023 - VETSURG - Accuracy of needle arthroscopy for the diagnosis of medial meniscal tears in dogs with cranial cruciate ligament rupture.pdf

Answer 136

2.1 |Inclusion criteriaDogs presenting to the Small Animal Hospital of the Uni-versity of Florida for CCLR were considered for enrollmentinto the study. The study was approved by the institutionalanimal care and use committee (#202011242), and ownerconsent was obtained to perform NA under sedation oranesthesia, followed by SA and tibial plateau leveling osteo-tomy (TPLO). Inclusion criter ia consisted of a bodyweightbetween 20-50 kg, positive cranial drawer sign of theaffected stifle, and suitable general health for heavysedation.All arthroscopies were performed by 1 of 2 board-certified surgeons. Both surgeons were highly experi-enced with SA, having performed >100 stifle arthros-copies each. For each case, 1 surgeon performed NA andthe other surgeon performed SA; the surgeon performingthe SA was blinded to the results of the NA. The SA musthave been performed within 5 days from NA, and thenumber of days between NA and SA were noted.2.2 |Needle arthroscopyNeedle arthroscopy was attempted under either the seda-tion used for the diagnostic radiographs at initial evalua-tion or the premedication on the day of surgery. Surgeonswere permitted to palpate the stifle and the presence orabsence of a meniscal click was noted prior to the proce-dure. Needle arthroscopy was performed using a NA sys-tem (Nanoscope, Arthrex), which includes a 0/C141.9 mmarthroscope with 120/C14field of view, and a 2.2 mm can-nula with a fluid port. The camera has a resolution of400/C2400 pixels and is attached to an imaging consolewith a 13 inch screen. The dogs were sedated withdexmedetomidine (5-15 mcg/kg IM or IV) with or with-out an opioid (butorphanol, 0.1-0.2 mg/kg IM or IV,methadone, 0.2-0.5 mg/kg IM or IV, or hydromorphone,0.05-0.1 mg/kg IM or IV) with the exact protocol at thediscretion of the radiology staff or the anesthesiologistsupervising the case. Lidocaine (10 mg at each port site)was injected into the port site locations 2-5 minutes priorto the procedure.The dogs were positioned in dorsal recumbency. Thecranial stifle region was aseptically prepared for the pro-cedure, and draped with an adhesive transparent drape(Crosstex, Rush, New York). Approximately 5 ml of ster-ile saline was injected into the joint for distension. Withthe stifle held at a standing angle of ~135/C14, a ~ 1 mm stabincision through the skin only was made using ano. 11 blade at the lateral port site, which was at the levelof the mid-parapatellar tendon. The cannula with a sharptrocar was inserted into the joint at the lateral port site. A60 ml syringe with sterile isotonic saline was attached tothe cannula fluid port with an extension set, and fluidwas manually delivered intermittently by an assistant asrequested by the surgeon. An instrument port wasestablished medially at the level of the mid-parapatellartendon with a stab incision through the skin, subcutane-ous tissues, and joint capsule using a No. 11 scalpel blade.A standard meniscal probe (Vet Probe, Small Joint HookTip, Arthrex) was used to palpate the caudal horn of themedial and lateral menisci as previously described.6Nodistractors were used.The level of visibility of the caudal and cranial hornsof each meniscus was subjectively quantified. A 4 pointscale was used to describe each horn: 1: not visible, 2:minority visible, 3: majority visible, 4: completely visible.If a tear was detected, the location and configuration wasdocumented. For location, tears were classified as beingin either the caudal, mid, or cranial portion of the menis-cus. Tear patterns were classified as vertical longitudinal,horizontal longitudinal, radial, or flap.23Tears were alsoclassified as displaced or nondisplaced. NondisplacedEVERS ET AL . 821 1532950x, 2023, 6, tears were probed and considered as unstable if theycould be subjectively displaced by >2 mm. The ability toprobe the caudal horn of both menisci was documentedon a 4-point scale: 1: impossible, 2: difficult, 3: moderate,and 4: easy to probe. The time of the procedure wasrecorded, from the initiation of port establishment tocompletion of meniscal assessment.If the NA was performed during the initial evaluationand the dog completely recovered from sedation prior toTPLO, the port sites were covered in an adhesive dressing(Hypafix, BSN Medical Inc., Ch arlotte, North Carolina) anddexmedetomidine sedation was reversed with atipamezole(0.05-0.15 mg/kg IM). The de gree of lameness was subjec-tively scored before and withi n2 4h o u r sa f t e rt h ep r o c e d u r e(0: no lameness, 1: mild weight-bearing lame, 2: moderateweight-bearing lame, 3: moderate intermittently non –weight-bearing lame to 4: non –weight-bearing lame) withthe second score being obtained on the day of surgery.2.3 |Standard arthroscopyAs with NA, the surgeon performing SA was permitted topalpate the stifle and the presence or absence of ameniscal click was noted prior to the procedure. Standardarthroscopy was performed under general anesthesiaimmediately prior to TPLO using either a 2.3 mm or2.7 mm (Stryker, Kalamazoo, Michigan), a 2.4 mm(Arthrex) or a 2.4 or 2.7 mm (Karl Storz VeterinaryEndoscopy-America, Inc., Goleta, California) 30/C14foreoblique arthroscope, and a 3.2 or 4 mm trocar with ahigh-definition arthroscopy system. Standard lateralarthroscopy and medial instrument parapatellar portswere used.24Shaving was permitted throughout the pro-cedure as required (Shaver HP with 3.0 mm Dissector bit,Arthrex). As with NA, no distractors were used. Thesame parameters were collected as for the NA. As withNA, the procedural time was recorded from the initiationof port establishment to completion of meniscal assess-ment; that is, the time for meniscal treatment was notincluded.2.4 |Statistical analysisAn a priori power analysis revealed a recommended sam-ple size of 23 subjects, presuming expected sensitivity andspecificity of 0.97, disease prevalence of 0.5, precision of±0.1, with a 95% confidence level.25Sensitivity and speci-ficity were calculated for the detection of medial meniscaltears in NA. The time of both procedures was comparedusing a paired t-test. The pre-NA and post-NA lameness,the visibility score, and the probing difficulty score of themenisci between NA and SA were compared with aWilcoxon matched-pairs signed rank test. P< .05 wasconsidered statistically significant for all tests. The statis-tical analyses were performed with statistical software(Prism, GraphPad Software Inc, San Diego, Californiaand Excel, Microsoft, Redmond, Washington).3|RESULTSThirty-one dogs were enrolled in the study betweenFebruary and October 2021. Due to a subjectively per-ceived learning curve, the first 5 cases were considered apilot group and excluded from the study. Needle arthros-copy was feasible in 26 of the remaining consecutivelyenrolled dogs. The most common breeds were mixed-breed dogs (n =9), Labrador retriever (n =4), and pitbull terrier (n =3). The mean age was 5.19 years(± 2.29 years) and the mean bodyweight was 32.74 kg(± 8.12 kg). Eight dogs had a meniscal click on examinationprior to surgery, all of which h ad meniscal tears. Additionalchemical restraint was requ ired in 10 dogs who partiallyrecovered from sedation due to a prolonged period(45-117 min) between deliver yo fs e d a t i o na n dN A ;d o g sreceived either inhalational isoflurane via mask delivery(n=8), propofol IV bolus inject ion (2-4 mg/kg to effect)(n=1), or alfaxalone IV bolus injection (1-3 mg/kg toeffect) (n =1). The mean time in between the NA and SAwas 0.85 days (± 1.13 days). There were 20 medial meniscaltears and 1 lateral meniscal tear detected on SA (Table 1).The most common medial meniscal tear type was a verticallongitudinal tear (n =18).The presence of a medial meniscal tear (Figure 1) wasaccurately diagnosed with NA in 19/20 dogs, and theabsence of a medial meniscal tear (Figure 2) was accu-rately diagnosed with NA in 6/6 dogs (Table 1). Charac-terization of medial meniscal tears differed slightly in2 cases, where vertical longitudinal tears were character-ized as being displaced on SA, but nondisplaced onNA. In another case, a medial meniscus with a non-displaced but unstable vertical longitudinal tear identi-fied on SA was classified as being normal on NA. Thesingle lateral meniscal tear was not detected on NA,which was a small, nondisplaced, stable vertical longitu-dinal tear. The sensitivity, specificity, positive predictivevalue, and negative predictive value to diagnose medialmeniscal tears with NA were 95%, 100%, 100% and 85.7%,respectively. The visibility for NA was lower for all hornswhen compared to SA (Table 2), and the caudal horn ofthe lateral meniscus was more difficult to probe with NAwhen compared with SA (Table 3).Lameness score comparisons before and after NAwere possible in 14 dogs that had SA performed on a822 EVERS ET AL . 1532950x, 2023, 6, different day to NA. The median lameness grade was 2/4both before and after NA ( P=.25). The mean ± SD timefor NA (8 ± 3 minutes) was shorter than SA (15± 9 minutes) ( P=.0041).4

Question 137

Dobberstein - 2024 - VETSURG - Comparison of the diagnostic yield of 3 and 5 mm laparoscopic liver biopsy forceps in cats.pdf

Answer 137

2.1 |AnimalsThis study was conducted in accordance with theguidelines of the Canadian Council on Animal Care andwas approved by the institutional animal care committeeat the University of Guelph (approval number: AUP##4118). Twelve purpose bred male cats underwent twoseparate laparoscopic liver biopsy procedures as part ofa nutrition study assessing the effects of choline andL-carnitine supplementation on lipid metabolism once inApril 2021 and again in August 2021. Biopsies for thisstudy were collected during the laparoscopic proceduresfor the nutrition study. All cats were clinically healthy atthe time of biopsy collection; however, one cat developedurinary signs following the first biopsy event and wasremoved from the study prior to the second biopsy event.2.2 |Preoperative bloodworkThe cats were deemed to be clinically normal throughmultiple physical examinatio ns, serum biochemistry analy-sis and complete blood counts.2.3 |Anesthetic protocolCats were premedicated with hydromorphone 0.05 mg/kgIM (hydromorphone hydrochloride; Sterimax) and acepro-mazine 0.04 mg/kg IM (Acevet; Vetoquinol) then inducedwith alfaxalone 1 –3 mg/kg IV (alfaxan; Jurox Pty Ltd) toeffect and midazolam 0.3 mg/ kg IV (midazolam; Sandoz).General anesthesia was maintained with isoflurane(Fresenius Kabi Canada) in oxygen. Cats receivedintraoperative meloxicam 0.1 mg/kg subcutaneouslyDOBBERSTEIN ET AL . 303 1532950x, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14049 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 License(Metacam; Boehringer Ingelheim) as well as oneintraoperative dose of cefoxitin 22 mg/kg IV (TevaPharmaceuticals).2.4 |Surgical techniqueCats were placed in dorsal re cumbency and the ventralabdomen was clipped, aseptically prepared and draped forabdominal surgery. The surg ical procedures were per-formed by a board-certified surgeon, BB (12 cats, first biopsyevent), or one of two surgical residents –(RD) (six cats, sec-ond biopsy event) and PCL (five cats second biopsy event).A modified-Hasson technique was used to introduce a5 mm threaded trocar canula (Storz) /C241 cm caudal to theumbilicus.14The abdomen was insufflated to 6 –10 mmHgwith carbon dioxide using a pressure regulating mechani-cal insufflator (Storz) and a 5 mm 30/C14telescope (Storz)was introduced. Under visualization, an incision wasmade using a #15 blade in the left lateral abdominalquadrant a few centimeters cranial to the camera portal.A second 5 mm threaded trocar canula was introducedthrough the incision (instrument portal) and a cursoryabdominal exploration was performed; the liver wasassessed for gross abnormalities.Liver biopsies were collected from the edges of theliver lobes, avoiding previous biopsy sites during the sec-ond biopsy event. In the first biopsy event, paired biop-sies (3 and 5 mm) were collected using a TP technique,totaling two samples per cat. In the second biopsy event,paired biopsies were obtained using a P technique and aT technique, totaling four samples per cat. The order of biop-sies (3 vs. 5 mm), and the technique used first for the secondbiopsy event were determined randomly by a surgical assis-tant at the time of biopsy collection. Each cat had a total ofsix biopsies performed between the two biopsy events.Prior to closure, insufflation was terminated and the tro-car canula opened to deflate the abdomen prior to removal.All incisions were closed using interrupted cruciate patternsin two layers (rectus fascia and t he subcutaneous tissue) usinga monofilament absorbable suture (3-0 PDS; Ethicon) fol-lowed by an interrupted crucia te pattern using monofilamentnonabsorbable suture (4-0 prolene; Ethicon) for the skin.2.5 |Biopsy techniquesThree and 5 mm Storz Blakesley cup forceps purchasedfor this study were used. The biopsy instrument wasintroduced through the left paramedian trocar canula,using a 3 mm seal cap to prevent loss of pneumoperito-neum when using the 3 mm biopsy forceps. The biopsysite was identified, and the lobe was elevated gently usingthe closed biopsy forceps to isolate the site from otherabdominal organs and retracted slowly to allow the edgeof the liver lobe to fall into the jaws of the forceps. Theforceps were advanced carefully to seat the liver lobeedge fully into the jaws and the forceps were closed andheld for 3 –5 s to help with hemostasis.Three biopsy techniques were used. The TP sampleswere collected by twisting the forceps 90/C14clockwise whilegently pulling away from the liver lobe until the tissuesample released from the liver.9,15The T samples werecollected by twisting the forceps 180/C14back and forth untilthe tissue sample released from the liver. For the P sam-ples, the forceps were pulled away from the liver lobeuntil the tissue sample released from the liver.7,16Threeand 5 mm biopsies were performed consecutively andsampling sites were separated by a few millimeters ofgrossly normal liver tissue. Immediately after biopsy col-lection, the surgeon measured each sample in two dimen-sions (mm2) using a sterile stainless-steel ruler and thesamples were then weighed (Digital Portable MilligramScale 100 /C20.001 g Newacalox) and placed in a labeled10% neutral buffered formalin jar.2.6 |Postoperative careCats received postoperative buprenorphine 20 mcg/kg IV(Vetergesic) once on recovery. They were returned totheir research colony with an Elizabethan collar andmeloxicam (Metacam; Boehringer Ingelheim) 0.1 mg/kgorally once daily for 3 days with gabapentin (gabapentin;Noumed) 10 mg/kg orally every 8 –12 h for 5 days.2.7 |Microscopic analysisSamples were stored in formalin until they were all col-lected and then they were trimmed and processed rou-tinely into paraffin for sectioning and staining withhematoxylin and eosin stain by the animal health labora-tory at the University of Guelph. Samples were assigneda random identification number and were read in ablinded fashion by a board-certified veterinary patholo-gist (RF) to determine the number of portal triads andhepatic lobules available per section, to assess for thepresence/severity of crush and fragmentation artifact andto determine a morphologic diagnosis. A portal triad wasidentified by the presence of a terminal bile duct, and alobule was counted when the terminal hepatic vein andsurrounding portal triads were observed. The histologicsamples were measured in two dimensions (mm2) usinga surgical ruler as described previously. A scoring rubricadapted from Fernandez et al.12was used to assign crush304 DOBBERSTEIN ET AL . 1532950x, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14049 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 Licenseand fragmentation scores on a scale of 0 –3; 0 none,1 mild, 2 moderate, and 3 severe.2.8 |Statistical analysisFriedman test one-way ANOVA was used to assess thedifferences in scores for fragmentation and crush artifact.A general linear mixed model accounting for the blockeffect for cats as well as main effects of size and tech-nique, and their interaction, was tested for differences inthe sample size (mm2), sample weight (g), as well as thenumber of portal triads and hepatic lobules. Residualswere checked for normality using a Shapiro –Wilk test.Hepatic lobules and sample size (mm2) residuals werenot normally distributed and were log transformed tomeet the assumptions of normality. When significancewas detected in the main effect, a post hoc Tukey adjust-ment was applied for pairwise comparisons of size bytechnique interaction. A test of symmetry compared pro-portions for significant differences. All analyses were per-formed using a commercial statistical software (SASInstitute Inc. 2013. SAS/STAT®9.4. Cary, NC) and p<0.05 was considered significant. A weighted kappa testwas used to assess agreement for morphological diagno-sis, fragmentation and crush artifact for each pair of sam-ples (3 vs 5mm) for each biopsy technique in each cat.3|RESULTS3.1 |Animals and proceduresThe median age of the cats was 21 months (range15–26 months) at the time of the first biopsy event and24.8 months (range 19 –30 months) at the time of thesecond biopsy event. The median weight was 5.5 kg(range 4.3 –7.2 kg) at the time of first biopsy and 5.5 kg(range 4.3 –7.1 kg) at the second. Between the two biopsyevents there were a total of 68 samples obtained for analy-sis. Other than the cat that was excluded from the secondbiopsy event and had a total of two samples collected at thefirst event only, each cat had a total of six samples obtained.Depending on ease of access, all biopsies were obtainedfrom the left lateral and/or le ft medial liver lobes. Access tothe right liver lobes was limited in larger cats using theshorter 3 mm forceps through a l eft paramedian portal site.3.2 |Biopsy sample weightThirty-one 3 and 5 mm sample pairs were weighedimmediately following collection. Sample weights werenot collected for three sample pairs due to a scale mal-function that caused erratic measurements during thefirst biopsy event. The mean sample weight using 3 mmforceps was 0.056 g (0.02 –0.139); using 5 mm forceps itwas 0.079 g (0.016 –0.158). Forceps size affected sampleweight ( p< .01), with 5 mm biopsy forceps resulting in aheavier sample than the 3 mm forceps (Table1). No sam-ple weight difference was observed between tech-niques ( p=.32).3.3 |Tissue surface areaFour data points using the 3 mm forceps and three datapoints using the 5 mm forceps measuring tissue surfacearea were lost and unavailable from the first biopsy event.Forceps size affected tissue surface area ( p<. 0 0 0 1 )w i t hthe 5 mm biopsy forceps resulting in a larger tissue surfacearea (mm2) compared to 3 mm forceps (Table 1).3.4 |Hepatic lobules and triadsThere was a mean of 4.9 (4.1 –5.9) hepatic lobules for the3 mm forceps and a mean of 12.4 (10.7 –14.3) forthe 5 mm forceps (Table 1). The TP technique had amean of 6.6 (5.4 –8.0) hepatic lobules; the T techniquehad a mean of 9.0 (7.4 –10.9), and the P technique had amean of 8.0 (6.6 –9.8; Table 1). Five-millimeter forcepsprovided more hepatic lobules than 3 mm forceps(p< .0001). A technique (TP vs. P vs. T) effect was noted(p=.016); the T technique resulted in more hepatic lob-ules than the TP technique ( p=.005) but there was nodifference when the T technique was compared with theP technique ( p=.25), or when the TP technique wascompared with the P technique ( p=.08; Table1).There was a mean of 19.0 (16.7 –21.5) portal triads forthe 3 mm forceps and a mean of 29.6 (26.3 –33.2) for the5 mm forceps (Table 1). The TP technique had a mean of21.0 (18.3 –24.0) portal triads, the T technique had a meanof 24.8 (21.6 –28.4), and the P technique had a mean of25.6 (22.4 –29.3; Table 1). The 5 mm biopsy forcepsresulted in more portal triads than the 3 mm biopsy for-ceps ( p< .0001). There was an overall effect of biopsytechnique ( p=.007), with both P and T techniquesresulting in more portal triads than the TP technique(p=.003 and .015, respectively), but no effect wasseen when the T technique was compared with theP technique ( p=.57). There was a forceps size by biopsytechnique interaction on the number of portal triads(p=.0038; Table1), with both the 5 mm P and T tech-niques resulting in more portal triads than the 3 mmP and T techniques ( p< .0001). However, the 5 mmDOBBERSTEIN ET AL . 305 1532950x, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14049 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 LicenseTABLE 1 Mean (95% CI) sample findings for each biopsy technique and forceps size.Biopsy sample characteristicsTechnique Forceps size Size*techniqueTwist+pull Pull Twist p 3m m 5m m ppNumber of triads 21.0 (18.3 –24.0) 25.6 (22.4 –29.3) 24.8 (21.6 –28.4) Overall .007P–TP .003P–T .57TP–T .01519.0 (16.7 –21.5) 29.6 (26.3 –33.2) <.0001 Overall .00383*5 P < .00013*5 TP .143*5 T < .0001Number of lobules 6.6 (5.4 –8.0) 8.0 (6.6 –9.8) 9.0 (7.4 –10.9) Overall .016P–TP .08P–T .25TP–T .0054.9 (4.1 –5.9) 12.4 (10.7 –14.3) <.0001 Overall .113*5 P < .00013*5 TP <.00013*5 T < .0001Sample biopsy weight (g) 0.091 (0.021 –0.142) 0.137 (0.084 –0.158) 0.020 (0.016 –0.08) Overall .32P–TP .33P–T .97TP–T .440.056 (0.02 –0.139) 0.079 (0.016 –0.158) <.0001 Overall .233*5 P < .00013*5 TP <.00013*5 T < .0001Tissue area (mm2) 30.2a(25.4 –36.0) 34.5 (29.7 –40.1) 33.2 (28.6 –38.6) Overall .19P–TP .08P–T .65TP–T .1720.6a(18.1 –23.5) 51.6a(45.4-58.6) <.0001 Overall .503*5 P < .00013*5 TP <.00013*5 T < .0001Histology area (mm2) 27.7 (23.9 –32.0) 33.6 (28.9 –39.1) 32.4 (27.9 –37.7) Overall .06P-TP .03P-T .68TP-T .0720.2 (17.7 –23.0) 48.0 (42.0 –54.8) <.0001 Overall .0013*5 P < .00013*5 TP <.00013*5 T < .0001aFour missing data sets in sample area 3 mm, three missing data sets in sample area 5 mm.Abbreviations: P, pull; T, twist; TP, twist +pull.306 DOBBERSTEIN ET AL . 1532950x, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14049 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 LicenseTP technique did not result in more portal triads than the3 mm TP technique ( p=.14).3.5 |Histologic areaForceps size affected sample histologic area ( p< .0001),with the 5 mm biopsy forceps resulting in a larger histo-logic area (mm2) than the 3 mm forceps. There was nooverall effect of biopsy technique ( p=.06) on samplehistologic area (Table 1).3.6 |Crush and fragmentationThere was no effect of forceps size ( p=.67; Table 2)o ntissue crush. However, there was an effect of biopsy tech-nique ( p=.03), with the TP technique resulting ingreater tissue crush than the T technique ( p=.01), butnot the P technique ( p=.07), or when comparing theT technique with the P technique ( p=.41). Regardless ofbiopsy technique, all tissue-crush grades were moderate(grade 2) or less and did not hinder the ability to reach ahistopathologic diagnosis.3.7 |Histopathologic diagnosisGood agreement was found between the 3 and the 5 mmbiopsy samples for microscopic diagnosis using the TPtechnique ( κ=.75). However, there was poor agreementbetween the 3 and the 5 mm samples for histologic diag-nosis for both the P and T techniques ( κ=.15 andκ=.12, respectively). All samples analyzed, despite sizeor technique used to obtain them, were considered to beof sufficient diagnostic quality, and received a final histo-pathologic diagnosis. Diagnoses were distributed equallyacross biopsy forceps size and were graded as mild, andnot considered clinically relevant. Diagnoses includednodular hyperplasia (one case), reactive portal hepatitis(six cases), periportal glycogenosis (one case), periportallipidosis (six cases) and normal liver (54 cases) (Table3).4

Question 138

Hardie - 2023 - VETSURG - Evaluation of two nephrocystostomy techniques for ureteral bypass in cats.pdf

Answer 138

2.1 |Study animals and housingTwelve, healthy, adult, purpose-bred cats were includedin the study. The cats were obtained from a USDA ClassA licensed dealer (Marshall Farms, Waverly, NY) andwere scheduled for euthanasia as part of an unrelatedstudy.15Ten cats were male and two were female. Themean age was 25.7 ± 4.5 months. The mean weight was5.5 ± 1.3 kg. All cats underwent a physical examination,complete blood count, serum chemistry profile, andurinalysis to assess general health status.Cats were housed in an indoor vivarium with con-trolled environment that maintained 12 –15 air changes/h, 12 h of light/dark cycle, and room temperatures at22.2 ± 2/C14C. The cats were single, or group housed inUSDA-approved cages with food and water bowls, anelevated shelf or hammock, a litter box, and toys forenvironmental enrichment. Cats were provided waterand feline dry diet ad libitum and socialized daily. Ani-mal use was approved by the Institutional Animal Careand Use Committee.2.2 |Study designTwo different surgical tech niques were evaluated inthis study. Simple NCT was performed in three catsand bladder cuff NCT was performed in nine cats.Each technique involved two procedures. The firstprocedure involved creation of the NCT andplacement of a catheter between the renal pelvis andbladder to facilitate epithel ialization of the nephrocys-tostomy track. The catheters were in place for 41 –118 days. The second procedure involved removal ofthe catheter via a small cystostomy incision. Afterremoval of the catheters, the cats were monitored for30 or 90 days, or until signs of complete obstruction ofthe NCT via ultrasound evaluation. Postoperativemonitoring involved urine analysis, urine culture,ultrasound of the urinary tract, contrast-enhancedabdominal computed tomography (CT), and histopa-thology of the NCT and contralateral kidney.2.3 |Anesthesia and analgesiaFor all surgical procedures, a standardized anestheticprotocol was used. Cats were premedicated with keta-mine (7 mg/kg IM), acepromazine (0.01 mg/kg IM),and buprenorphine (0.03 mg/kg IM). Cats wereinduced with isoflurane to effect via facemask, endo-tracheally intubated, and maintained on isoflurane inoxygen. Intravenous crystalloid fluids (lactated Ringers3 mL/kg/h) were administered. A forced air heatingblanket was used to maintain body temperature. Moni-toring included rectal temperature, heart rate andrhythm by surface ECG, respiratory rate, and periph-eral arterial oxygen saturation. Immediately after sur-gery, a transdermal fentanyl patch (25 /uni03BCg/h) (FentanylTransdermal System; Noven Pharmaceuticals, Weston,Florida) was applied and postoperative analgesia wassupplemented for 24 h with buprenorphine(0.03 mg/kg IV, then transmucosal [TM] every 8 h).Cats were assigned a discomfort score every 12 h for5 days and supplemental analgesia was administered, ifrequired.962 HARDIE ET AL . 1532950x, 2023, 7, 2.4 |Simple NCT techniqueFor the simple NCT technique, a ventral midline celiot-omy was performed. The left kidney was mobilized, andthe ureter was ligated 2 cm from the renal pelvis. Theright kidney and ureter were not disrupted. A 1.5 cmdiameter full-thickness section of tissue was removedfrom the apex of the bladder. The dorsal aspect of thebladder defect was sutured to the capsule of the caudalpole of the kidney in two layers using 4-0 polydioxanone(Ethicon, Somerville, New Jersey). The seromusculariswas sutured in a simple-continuous pattern and themucosa was sutured in a simple-interrupted pattern. Therenal vessels were temporarily occluded with a vascularclamp. With ultrasound guidance, a 0.03 cm guidewire(MILA, Florence, Kentucky) wa sp l a c e dt h r o u g ht h ec a u d a lpole of the kidney and into the renal pelvis using modifiedSeldinger technique. An 8 F red rubber catheter (Bard,Covington, Georgia) was placed over the guidewire into therenal pelvis. The catheter was trimmed to 1 cm beyond tothe caudal pole of the kidney and sutured to the renal cap-sule adjacent to the exit site using 4-0 PDS. The remainingventral aspect of the bladder was sutured to the caudal poleof the kidney surrounding the catheter using the suture andpattern described above. The vascular clamp was removed.Ap s o a sh i t c hw a sp e r f o r m e dt or e d u c et e n s i o nb e t w e e nt h ebladder and kidney.16The kidney was evaluated with ultra-sound to verify positioning of the nephrocystostomy cathe-ter. Omentum was draped around the NCT site, and theabdomen was closed routinely.2.5 |Bladder cuff NCT techniqueFor the bladder cuff NCT technique, a ventral midlineceliotomy was performed. The right ( n=4) or left(n=5) kidney was mobilized and the ureter was ligated2 cm from the renal pelvis. The contralateral kidney andureter were not disrupted. A 1.5 cm diameter section ofFIGURE 1 Intraoperative image of protrusion of the cuff ofbladder mucosa from the defect created on the apex of the bladder.FIGURE 2 (A, B) Intraoperative image of three preplacedsutures on the edge of the bladder mucosa cuff /C24120 degrees apart.FIGURE 3 Intraoperative image of a 6 mm biopsy punchplaced into the renal pelvis from the caudal pole.HARDIE ET AL . 963 1532950x, 2023, 7, seromuscularis was removed from the apex of the bladderand the mucosa was allowed to protrude from the defect(Figure 1). The protruding bladder mucosa was incised tocreate an /C246 mm diameter defect. Three separate strandsof 3-0 or 4-0 PDS were sutured to the edge of the bladdermucosa cuff /C24120/C14apart leaving the swaged needle on thesuture (Figure 2A,B ). The renal vessels were temporarilyoccluded with a vascular clamp. With ultrasound guid-ance, a guidewire (0.03 cm) was placed through the caudalpole of the kidney and into the renal pelvis using modifiedSeldinger technique. A 6 mm biopsy punch was advancedover the guidewire creating a defect in the caudal pole(Figure 3). A 22-gauge, 2.5-inch spinal needle was insertedthrough the caudal defect exiting the cranial pole. A fourthstrand of suture (3-0 PDS) was passed through the needleexiting the defect in the caudal pole. The needle wasremoved, and the suture was tied to the tip of a 10 F redrubber catheter cut to /C244 cm in length. The catheter wasadvanced through the caudal defect into the renal pelvisand secured to the capsule using the preplaced suture onthe cranial pole (Figure 4). The preplaced sutures in thebladder mucosa cuff were passed through the caudaldefect into the renal pelvis and then out the cortex of thecaudal one-third of the kidney maintaining the 120/C14orien-tation. The nephrocystostomy catheter was positioned inthe lumen of the bladder and the mucosa cuff was pulledinto the renal pelvis using the preplaced sutures(Figure 5). The sutures were tensioned to abut the edge ofthe seromuscularis on the apex of the bladder with thecaudal pole and then tied to the renal capsule by taking asmall bite through the capsule at the site where the sutureexited and tying a knot. The seromuscularis of the bladderwas sutured to the capsule surrounding the nephrocystost-omy catheter in a simple-interrupted pattern using 4-0PDS (Figure 6). The vascular clamp was removed. A psoashitch was performed. The kidney was evaluated withultrasound to verify positioning of the nephrocystostomycatheter. Omentum was draped around the NCT site, andthe abdomen was closed routinely.2.6 |Nephrocystostomy catheterremovalFor the simple NCT group, catheters were removed at41 or 42 days. For the bladder cuff NCT group, catheterswere removed between 62 and 67 days ( n=5) and117–118 days ( n=4). Catheter removal in these four catswas delayed due to institutional COVID protocols. TheFIGURE 4 Intraoperative image of a 10F catheter placedthrough the defect in the caudal pole.FIGURE 5 Intraoperative image of three preplaced suturestensioned to pull the bladder mucosa into the renal pelvis.FIGURE 6 Intraoperative image of two of the three bladdermucosa sutures (white arrowheads) tied onto the capsule of thekidney and the simple-interrupted sutures in the seromuscularis ofthe bladder and the renal capsule in a completed bladder cuffnephrocystostomy (NCT).964 HARDIE ET AL . 1532950x, 2023, 7, same anesthetic and analgesic protocol was used asdescribed above. A caudal ventral midline celiotomy wasperformed, a 1 –2 cm ventral cystotomy was made, andthe nephrocystostomy catheter was removed. The bladderwas closed in a single layer using a simple-continuouspattern with 3-0 biosyn (Covidien, Minneapolis, Minnesota)and the abdomen was closed routinely.2.7 |Postoperative monitoringAfter the NCT procedures and nephrocystostomy cathe-ter removal, urination was monitored daily. Serum creati-nine was measured on days 1 and 2 after NCT, thenapproximately every 2 weeks, although sample timingwas disrupted in four cats in the bladder cuff NCT groupbecause of COVID protocols. Serum creatinine wasevaluated as a means of diagnosing urine leakage fromthe NCT site or other causes of azotemia. Urinalysis andculture were performed at the time of catheter removal,at necropsy examination, and periodically based on thepresence of any clinical signs suggestive of a urinary tractinfection (UTI).2.8 |Ultrasound examinationUltrasound (Aloka Noblus, Hitachi Medical Corp.,Japan) of the NCT was performed approximately every2 weeks using a 5 –18 MHz L64 linear probe. The positionof the nephrocystostomy catheter, the size and shape ofthe renal pelvis, and the patency of the nephrocystost-omy tract (after catheter removal) were subjectivelyevaluated.2.9 |Computed tomographyContrast-enhanced abdominal CT (Somatom Sensation64, Siemens Medical Solutions) was performed at theconclusion of the study: day 25 after catheter removal forthe simple NCT group and day 30 ( n=6) and day90 (n=3) for the bladder cuff NCT group. The field ofview included the urinary tract, from the cranial pole ofthe right kidney to the perineal urethra. Precontrast,arterial, venous, and delayed post-contrast phases wereperformed (iohexol 350 mg/mL, 600 mg/kg IV via pres-sure injector). Images were reformatted in 2.0 mm slices,in soft-tissue and bone algorithms. Length measurementswere performed on imaging planes optimized using mul-tiplanar reformating (OsiriX version 12.5.1, Bernex CH).Patency of the NCT track was determined based on flowof contrast to the bladder, and the length, width, and areaof the column of contrast. The length of the NCT andcontralateral kidneys were measured. All images wereevaluated by the same board-certified radiologist (KG).2.10 |Gross and histopathologicalexaminationImmediately following CT, cats were euthanized by injec-tion of pentobarbital solution (1 mL/2.5 kg IV). The NCT(kidney and bladder) and the contralateral kidney wereremoved for gross and histological examination. The sizeand shape of the NCT and contralateral kidneys were eval-uated, and the NCT track was examined from the lumenof the bladder for patency and mucosal epithelialization.The kidneys were sectioned longitudinally to allow furtherexamination of the NCT track between the renal pelvisand bladder. Samples from the cranial and caudal poles ofboth the NCT and contralateral kidneys and the NCTtrack were taken for histological evaluation. Samples werefixed in 10% neutral buffered formalin, processed routinelyfor histopathology, and stained with hematoxylin andeosin. Gross and histological examination was performedby an ACVP board-certified pathologist (DRR).2.11 |Data analysisMean length (mm) of the NCT and contralateral kidneysas determined from the CT, were compared. Continuousdata were evaluated for normality using the Kolmogorov –Smirnov test and described as mean and standard devia-tion or median and range. An unpaired student's t-test wasused to compare length of the NCT and contralateral kid-neys. Serum creatinine values were analyzed using arepeated measures ANOVA in the simple NCT group anda mixed-effects model for the bladder cuff NCT group. Acommercial software program was used for data analysis(GraphPad Prism 8.4.3, GraphPad Software, San Diego,California). Results of the serial ultrasound, CT, and histo-pathology were qualitatively described.3|RESULTS3.1 |Simple NCT techniqueThe simple NCT was successfully completed in all catswith no immediate perioperative complications. No catrequired rescue analgesia. Median surgical time was148 min (range 138 –169). The time that the vascularclamps were in place was not recorded for cats in the sim-ple NCT group but averaged /C2420 min. There was no evi-dence of urine leakage from the NCT and no statisticallysignificant change in serum creatinine occurred over time.HARDIE ET AL . 965 1532950x, 2023, 7, Gross hematuria occurred in all cats on days 1 –2 postoper-atively. No evidence of hydronephrosis was present onultrasound evaluations prior to catheter removal.At the time of catheter removal (days 41 and 42 afterNCT, Table 1), the urine appeared hematuric in two cats.On examination of the lumen of the bladder, the cathe-ters spanned the NCT site, although one had migratedcaudally /C241 cm. An aerobic urine culture was performedin all cats and was negative. Four days following catheterremoval, evidence of hydronephrosis developed in allthree cats and was progressive on subsequent ultra-sounds. The cats were asymptomatic.Contrast CT was performed on day 25 after catheterremoval in all cats. There was marked hydronephrosis ofthe NCT kidney in all cats with poor contrast enhancementof the renal parenchyma. A patent NCT track was notobserved in any cat. The contralateral kidney and ureterwere normal. Gross examination of the NCT kidneysrevealed the bladder to be firmly adhered to the caudal polewith multiple omental adhesions. Examination of the blad-der lumen revealed that the mucosa had healed over thenephrocystostomy site and there was no communicationwith the renal pelvis. Examination of the kidney and renalpelvis revealed hydronephrosis. The contralateral kidneyswere grossly normal. Histopathology was not performed.3.2 |Bladder cuff NCT techniqueThe bladder cuff NCT was successfully completed inall cats. The median surgical time was 102 min (range83–120). The mean vascular clamp time was 31.1 ± 5.5 min.No cat required rescue analgesia.After surgery, stranguria and hematuria were present inall cats. The stranguria resolved in six cats within the firstweek but was persistent until t he nephrocystostomy cathe-ter was removed in three cats. Hematuria was occasionallysevere, particularly during the first 24 h after surgery. In fivecats, hematuria resolved within the first week withoutincident. In the remaining fou rc a t s( 3m a l ea n d1f e m a l e ) ,urethral obstructions occurred on day 2 secondary toformed blood clots within the bladder. Cats were treatedwith indwelling ureth ral catheterization and intravenous orsubcutaneous fluid therapy (LRS 40 mL/kg/day) for 2 days.Two cats reobstructed 1 and 4 d ays after urethral catheterremoval, respectively. Urethral catheters were replaced foran additional 48 h in these two cats, and the obstructionsresolved. Three of the four cats with urethral obstructiondeveloped transient post-renal azotemia. No statisticallysignificant change in creatin ine concentration occurredthroughout the rest of the study.All four cats that underwent urethral catheterizationdeveloped UTIs characterized by stranguria, pollakiuria,hyperthermia, and a thickened bladder wall on ultra-sound examination. Aerobic culture of the urine was pos-itive in all four cats. All cats grew hemolytic Escherichiacoli, three cats grew Streptococcus canis , and one cat grewEnterococcus faecalis . Bacteria were sensitive to enroflox-acin, and cats were treated (22.7 mg orally every 24 h)until removal of the nephrocystostomy catheter. Repeaturine cultures were performed 7 –14 days after initiatingantibiotics and at the time of nephrocystostomy catheterTABLE 1 Surgical group, signalment, surgical details, and major outcomes in cats undergoing simple NCT or bladder cuff NCT.Cat number Group Sex (age [mon]) KidneyDuration ofcatheterization (days)Urethralobstruction Infection Outcome1 S-NCT MN (28) L 42 N N NP2 S-NCT MN (28) L 41 N N NP3 S-NCT MN (28) L 41 N N NP4 BC-NCT-30 MN (33) L 63 N N P5 BC-NCT-30 FS (24) L 62 N N P6 BC-NCT-30 MN (21) L 118 N Y P7 BC-NCT-30 MN (20) R 117 YaYP8 BC-NCT-30 MN (20) R 117 N Y P9 BC-NCT-30 MN (21) L 118 Y YbP10 BC-NCT-90 MN (30) L 67 Y Y P11 BC-NCT-90 FS (30) R 67 Y Y P12 BC-NCT-90 FS (25) R 67 YaYPAbbreviations: BC-NCT-30, bladder cuff nephrocystostomy 30-day survival; BC-NCT-90, bladder cuff nephrocystostomy 90-day survival; L, left; N, no; NP, notpatent; P, patent; R, right; S-NCT, simple nephrocystostomy; Y, yes.aObstructed urethra twice.bSuspected contamination of culture.966 HARDIE ET AL . 1532950x, 2023, 7, removal. Urine cultures taken at the time of catheterremoval in the four cats that had previous infections werenegative in three and positive in one cat which grewBacteroides sp. The Bacteroides sp. was not present on arepeat culture 1 week later and was suspected to be acontaminant. Two other cats, which had no previous evi-dence or clinical signs of infection, grew Staphylococcusepidermidis at the time of catheter removal. One of thesewas suspected to be a contaminate and was not regrownon subsequent cultures. The other was regrown on a cul-ture 1 week later; that cat was treated with cefovecinsodium (8 mg/kg subcutaneously once) and had a nega-tive culture 2 weeks later. That same cat grew a hemo-lytic E. coli from urine taken during necropsy, all othercats had a negative urine culture at necropsy.Ultrasound evaluation of the NCT kidneys revealedno evidence of hydronephrosis and the cathetersremained in place in all cats except for one, which experi-enced catheter dislodgement and migration to the proxi-mal urethra. Catheter dislodgement occurred during theprolonged (117 day) period between the NCT procedureand catheter removal. The cat was asymptomatic, andthe catheter was removed from the urethra without inci-dent using a pair of arthroscopic grasping forcepsinserted normograde from the bladder into the urethra.Following catheter removal, the NCT track between therenal pelvis and bladder appeared patent in all cats andnone had evidence of hydronephrosis (Figure 7A,B ).On CT, all NCT tracks were patent and contrastflow from the renal pelvis to the bladder was present(Figure 8A,B ). There was no evidence of hydronephro-sis or distortion of the renal pelvis beyond the NCTtrack. On arterial and venous phase images, the NCTkidneys had reduced contrast enhancement comparedto the contralateral kidneys. The contralateral kidneysFIGURE 7 (A, B) Postoperative ultrasound images of thebladder cuff nephrocystostomy (NCT). (A) Note the catheter withinthe renal pelvis. (B) Note the patent track (arrowheads) afterremoval of the catheter.FIGURE 8 Dorsal (A) and sagittal oblique (B) multiplanarreconstructions post-contrast CT images of the bladder cuffnephrocystostomy (NCT) of the left kidney (LK). Note the patenttrack between the renal pelvis and bladder (black arrowheads) andcontrast (white arrowhead) flowing into the lumen of the bladder.HARDIE ET AL . 967 1532950x, 2023, 7, were all normal. Of the 30-day NCT kidneys ( n=6),four had had irregular contours and four had wedge-shaped enhancement defects suggestive of infarction.Other than one cat which had a very small enhance-ment defect at the cranial as pect of the cranial pole,other enhancement defects were associated with thecaudal pole. Of the 90-day NCT kidneys ( n=3), onehad irregular margination and three had wedge-shapedenhancement defects.The NCT kidneys were signi ficantly shorter thanthe contralateral kidneys. In the 30-day group, themean NCT kidney length was 3.7 ± 0.45 cm, and thecontralateral kidney length was 4.5 ± 0.45 cm ( p=.016).In the 90-day group, the mean NCT kidney length was4.0 ± 0.31 cm, and the contralateral kidney length was4.7 ± 0.15 cm ( p=.021).The mean maximal length, width, and area of NCTtrack in the 30-day group was 8.2 ± 2.0, 5.1 ± 1.8 mm, and42.9 ± 17.1 mm2,r e s p e c t i v e l y .T h em ean maximal length,width, and area of the NCT track in the 90-day group was8.0 ± 4.4, 3.7 ± 0.5 mm, and 30.0 ± 17.0 mm2,r e s p e c t i v e l y .These differences were not statistically significant.On gross examination of the bladder cuff NCT, the uri-nary bladder was firmly adhered to the caudal pole thekidney with multiple omental adhesions. Examination ofthe lumen of the bladder revealed a patent nephrocystost-omy track lined by normal appearing bladder mucosa. Onlongitudinal section of the kidney and bladder, the NCTtrack was easily identified with smooth epithelializationbetween the bladder and the renal pelvis (Figure 9A,B ).The contralateral kidneys were grossly normal.Histologically, similar changes were observed in allNCT kidneys. Where the seromuscularis of the bladderwas sutured to the caudal pole, the bladder urotheliumwas hyperplastic and the bladder wall was expanded bysubmucosal fibroblasts and newly formed capillaries sur-rounded by edema. Fibrous connective tissue blendedinto the renal parenchyma and multiple clusters of epi-thelioid and foamy macrophages and multinucleatedgiant cells surrounded the suture material distributedthroughout the attachment site. The nephrocystostomytrack was lined by smooth, organized epithelium extend-ing from the apex of the bladder to the caudal aspect ofthe renal pelvis (Figure 10). In two cats in the 30-daygroup, the epithelium of the renal pelvis was hyperplas-tic. The caudal pole of the kidney was partially collapseddue to cortical and medullary tubular loss and replace-ment by lipid droplets and macrophages (consistent withtubular rupture) and fibrous connective tissue with amoderate to large number of lymphocytes and plasmaFIGURE 9 (A) Gross image of the lumen of the bladder of thebladder cuff nephrocystostomy (NCT). Note the mucosal linedtrack (arrowhead) between the bladder and the renal pelvis.(B) Longitudinal section of a bladder cuff NCT. Note the mucosallined track between the bladder and renal pelvis (asterisk).FIGURE 10 Histopathological image (stained withhematoxylin & eosin [H&E]) of the bladder cuff nephrocystostomy(NCT). Note the epithelial lined track (arrowheads) between thebladder (B) and renal pelvis (RP).968 HARDIE ET AL . 1532950x, 2023, 7, cells that occasionally formed multiple well-demarcatedclusters (consistent with regional ischemia). Periglomeru-lar fibrosis with parietal cell hypertrophy, synechia, andglomerulosclerosis was observed in four cats. The cranialpole of the kidney was normal in seven cats and had sim-ilar but minimal tubular changes in two cats. The contra-lateral kidneys were normal in all cats. The pathologicalchanges observed in the caudal pole of the kidneys werelikely associated with regional ischemia due to vascularcompromise associated with the procedure.4

Question 139

Kikuchi - 2023 - JAVMA - Vertebral fixation does not affect recovery or recurrence of cervical intervertebral disc herniation in small dogs (< 15 kg).pdf

Answer 139

Case selectionThis study included 303 dogs each weighing < 15 kg that presented to YPC Tokyo Animal Orthopedic Surgery Hospital between January 2007 and Decem -ber 2020, were diagnosed with C-IVDH, treated with VSD, and survived 30 months after surgery. All own -ers provided written informed consent for treatment before dogs underwent surgery. Diagnosis was based on each dog’s history, clinical signs, radiography, MRI, and CT. All 303 patients underwent MRI and CT. The MRI included IV paramagnetic contrast administration to identify lesions. Because CT was used as an aid to determine slot size at surgery, myelography with sub -arachnoid contrast injection was not performed.Cervical myelopathy gradeCervical myelopathy grade (CMG) severity was evaluated before and after surgery according to the methods reported by Rossmeisl et al.16 CMG was clas -sified on a 5-point scale: grade 1 (G1), no gait ataxia but neck pain, hypersensitivity, or neck contractures; grades 2 and 3 (G2 and G3), ability to walk indepen -dently without assistance with mild to moderate gait disturbance; grade 4 (G4), nonambulatory quadriple -gic or quadriplegic but without respiratory impairment; and grade 5 (G5), neuropathic respiratory impairment or complete quadriplegia with respiratory failure.Diagnostic imagingScans were performed under general anesthesia with an 80-row/160-slice CT system (Aquilion PRIME; Toshiba Medical Systems) and Brivo MR 355 Inspire 1.5 T MRI system (GE Healthcare Japan). T2-weighted sag -ittal images were taken with a slice thickness of 2.0 mm, slice spacing of 0.4 mm, repetition time of 2,800 milli -seconds, and echo time of 82 milliseconds. T2-weighted transverse images were taken with a slice thickness of 2.5 mm, slice spacing of 0.5 to 1.5 mm, repetition time of 3,400 milliseconds, and echo time of 85 milliseconds. The degree of disc degeneration between the vertebrae adjacent to the treatment area was assessed using T2-weighted midsagittal section images and classified ac -cording to the Pfirrmann classification used in human medicine.17,18 Open-source medical imaging software (OsiriX; Pixmeo) was used to analyze the images.Anesthesia and surgeryAll patients received IV atropine sulfate (0.02 mg/kg) and midazolam (0.2 mg/kg) as a preanesthetic, followed by propofol (4 to 8 mg/kg) and endotra -cheal intubation. Anesthesia was maintained using sevoflurane in oxygen (2.5% to 3%). Cefazolin (20 mg/kg, IV) was administered 20 minutes before and after surgery. Continuous IV fentanyl (1 to 10 µg/kg/min) was administered intraoperatively.VSD was performed using an operating micro -scope (X 8.5 magnification; OPMI pico S100; Carl Zeiss Meditec AG). Slot creation was performed using an ultrasonic aspirator (Sonopet UST-2001; Stryker Japan) and a round bur. At the beginning of slot creation, a shallow slot was created in the ver -tebral body using an ultrasonic aspirator until the trabecular bone was exposed to prevent the round bur from rebounding against the cortical bone and engulfing the surrounding soft tissue. After trabec -ular bone was exposed, the slot was gradually en -larged using a round bur, taking care not to narrow the dorsal side of the slot and create a conical shape. If persistent bleeding from the trabecular bone was observed, hemostatic treatment was performed us -ing an ultrasonic aspirator at key points to ensure an adequate field of view. After ventral longitudinal ligament removal, the herniated disc material was carefully removed using a nerve hook and graspers. The spinal dura mater was then visually examined. If no disc material remained around the slot, the re -moval of disc material was judged to be sufficient and the VSD was completed. The tip diameter of the ultrasonic aspirator used was 2.8 mm. Therefore, if the vertebral width was expected to be < 8.4 mm or the slot width to be created was < 2.8 mm based on the prior CT examination, the slot was created us -ing only a round rod without using an ultrasonic as -pirator. The criteria for the slot width to be created were planned approximately preoperatively based on size, location, and herniation types (disc extru -sions or protrusions), as confirmed using CT/MRI. For disc extrusions, the goal was to ensure that all herniated disc material was removed. Therefore, we decided in advance to use VF even when the trans -verse diameter of the herniated disc material was > 33% of the vertebral width, because the technique was intended to create a slot with a width equiva -lent to the transverse diameter of the herniated disc material, measured using MRI. For disc protrusions, the herniation protrusion width was measured using MRI and the same criteria were used to determine whether VF was used (Figure 1) . In other cases, even cases where it was anticipated in advance that the slot volume would not exceed 33% of the vertebral body width, priority was given to removing the disc material between the intervertebral disc space and the dorsal aspect of the slot, and the slot volume was enlarged, as necessary. VF was combined with VSD when the slot volume exceeded 33% of the vertebral body width, resulting from expansion of the slot volume. Metal implants and polymethylmethacrylate (PMMA) were used for fixation.12 Two or 3 titanium screws were used for each vertebra, with screw diameters of 1.5 mm (SophiaTech; Platon Japan), 2.0 mm, or 2.4 mm (both Matrix Mandible; DePuy Synthes Japan VET) depending on the size of the vertebra (Figure 2) . Unauthenticated | Downloaded 10/08/23 06:32 AM UTC JAVMA | OCTOBER 2023 | VOL 261 | NO. 10 1503Figure 1 —Example of slot width measurement method using MRI images and vertebral width measurement method using CT images. Transverse T2-weighted MRI images of the cervical spine obtained before contrast administration (A) and CT images (B) in a 5-year-old 4.2-kg Pekingese with disc extrusion. Transverse T2-weighted MRI images of the cervi -cal spine obtained before contrast administration (C) and CT images (D) in a 10-year-old 3.2-kg Yorkshire Terrier with disc protrusion. The transverse width (= slot width) of the herniated disc material in the Pekingese was 4.4 mm and the vertebral width was 7.0 mm, and vertebral fixation (VF) was combined because the slot width was 62.8% (> 33.3%) of the vertebral width. The transverse width (= slot width) of the herniation protrusions in the Yorkshire Terrier was 2.9 mm and the vertebral width was 6.3 mm, and VF was combined because the slot width was 46.0% (> 33.3%) of the vertebral width.Figure 2 —A postoperative radiograph (lateral and ven -trodorsal) of a stabilized slot. Postoperative radiographs of a 10-year-old 5.2-kg Toy Poodle with ventral slot de -compression and VF (lateral [A] and ventrodorsal [B]). For fixation, titanium screws with a diameter of 2.0 mm and polymethylmethacrylate were used.Unauthenticated | Downloaded 10/08/23 06:32 AM UTC1504 JAVMA | OCTOBER 2023 | VOL 261 | NO. 10A surgical loupe (X 2.5 magnification) was used dur -ing VF implant insertion. After screw insertion, VF was performed using PMMA after covering the ven -tral aspect of the slot with free fat to prevent the flow of PMMA into the slot. The amount of PMMA was ad -justed so that the inserted screw was fully embed -ded, and the longus colli muscle was sutured. To prevent damage to the surrounding soft tissue from the heat generated during PMMA polymerization, refluxing was continued in sterile saline at 4 °C for approximately 15 minutes until polymerization was complete. The surgical field was carefully cleaned, and the wound was closed.Postoperative managementAll dogs were hospitalized for approximately 1 week after surgery. The day after surgery, all ani -mals received prednisolone (1.0 mg/kg/d) subcu -taneously and continuous crystalloid infusion. From postoperative day 2, prednisolone (0.5 to 1.0 mg/kg, once daily) was administered SC or PO for 2 to 7 days, depending on the clinical signs. Cefazolin so -dium (20 mg/kg, twice daily) was administered by IV or cephalexin (20 mg/kg) PO twice a day for 2 weeks postoperatively. Patients able to walk postoperative -ly were kept on strict cage rest. In patients with tet -raplegia after surgery, a urethral catheter was placed to facilitate continuous urinary drainage to prevent dysuria or contamination of the perineum by urina -tion. To prevent pressure ulcers, the patient was re -positioned 4 times a day and actively massaged. Dai -ly neurological assessments were performed during hospitalization. After discharge, activity restriction was prescribed for 8 weeks, with regular checkups at 2 weeks; 1, 3, and 6 months; 1 year; and every year thereafter. Routine checkups included radiography of the surgical site and neurological assessments.OutcomeRecovery was defined as postoperative improve -ment in the severity of CMG. Recurrence was defined as worsening of CMG severity once recovery was achieved, and C-IVDH in another intervertebral disc space was revealed by MRI. The time to recurrence was defined as the time between the first surgery and the next visit when clinical signs reappeared. VF can cause disc degeneration and adjacent segment pathology (ASP) on the cranial or caudal side of the treated in -tervertebral region; when ASP causes clinical signs, it is termed adjacent segment disease. Because adjacent segment disease reportedly occurs between 8 months and 30 months postoperatively, we selected patients who underwent checkups at 30 months postoperative -ly. Patients without recurrence after 30 months were recorded as having no recurrence.5,8–10Statistical analysisStatistical analyses were performed using Stata version 14 (StataCorp LLC). With recovery and re -lapse as the objective variables, a single regression analysis was performed for each item, and multiple regression analysis was performed for strongly re -lated items. The study parameters included sex, age, body weight, CMG severity, surgical site, degree of disc degeneration (Pfirrmann score), concomitant VF, recovery, recurrence, site of recurrence, number of days between surgery and recovery, and number of days between recovery and recurrence. Miniature Dachshunds, Beagles, French Bulldogs, Shih Tzus, Miniature Schnauzers, and Pekingese are consid -ered CDBs.19 Other breeds were considered NCDBs. Sex was categorized as intact male, neutered male, intact female, or spayed female. Age (years) and weight (kg) were recorded at the time of the sur -gery. Multivariate logistic regression analysis was performed to examine factors associated with post -operative recovery and recurrence. Postoperative re -covery and recurrence were objective variables, and breed, sex, age, weight, affected disc, CMG severity, concomitant VF, days to recovery, and time to recur -rence were explanatory variables. ORs and their 95% CIs were calculated for each variable. Statistical sig -nificance was set at P < .05.ResultsCasesWe evaluated 303 dogs (age, 9.0 ± 3.0 years; weight, 5.9 ± 3.1 kg): 80 (26.4%) were Miniature Dachshunds, 39 (12.9%) Chihuahuas, 32 (10.6%) Toy Poodles, 29 (9.6%) Yorkshire Terriers, 25 (8.3%) French Bulldogs, 18 (5.9%) Shih Tzus, 17 (5.6%) Min -iature Pinschers, 15 (5.0%) Beagles, 14 (4.6%) mixed breeds, and 34 (11.2%) other breeds (Table 1) . VF nVFBreed n (%) Breed n (%)Chihuahua 31 (19.9) Miniature Dachshund 66 (44.9)Toy Poodle 26 (16.7) Shih Tzu 13 (8.2)Yorkshire Terrier 22 (14.1) French Bulldog 11 (7.5)French Bulldog 14 (9.0) Chihuahua 8 (5.4)Miniature Dachshund 14 (9.0) Beagle 8 (5.4)Miniature Pinscher 11 (7.1) Yorkshire Terrier 7 (4.8)Mixed 8 (5.1) Miniature Pinscher 6 (4.1)Beagle 7 (4.5) Mixed 6 (4.1)Shih Tzu 5 (3.2) Toy Poodle 6 (4.1)Other 18 (11.5) Other 16 (11.6)Total 156 (100) Total 147 (100)Table 1 —Breakdown of dog breeds in the vertebral fixation (VF) and no vertebral fixation (nVF; ventral slot decom -pression alone) groups.Unauthenticated | Downloaded 10/08/23 06:32 AM UTC JAVMA | OCTOBER 2023 | VOL 261 | NO. 10 1505There were 115 (38.0%) neutered males, 95 (31.4%) in -tact males, 61 (20.1%) spayed females, and 32 (10.6%) intact females.Of 303 dogs, 156 (51.5%) had concomitant VF (VF group) and 147 (48.5%) had VSD alone (nVF group). The breakdown of each group by breed is shown (Ta -ble 1). In the VF group, 53 (34.0%) dogs were CDBs (9 breeds) and 103 (66.0%) were NCDBs (30 breeds). In the nVF group, 99 (67.3%) dogs were CDBs (8 breeds), and 48 (32.7%) were NCDBs (15 breeds).DemographicsThe VF group included 40 intact males, 69 neu -tered males, 16 intact females, and 31 spayed females, whereas the nVF group included 54 intact males, 47 neutered males, 16 intact females, and 30 spayed fe -males. The mean age of the VF group was 8.9 ± 2.8 years (range, 1.7 to 14.8 years); the mean age of the nVF group was 9.2 ± 3.1 years (range, 2.3 to 14.2 years). Peak onset occurred at the age of 9 years (Figure 3) . at the adjacent intervertebral space (cranial side / caudal side) were as follows: 1 (25 discs, 8.7% / 30 discs, 10.5%), 2 (29 discs, 10.1% / 34 discs, 11.8%), 3 (51 discs, 17.8% / 57 discs, 19.9%), 4 (20 discs, 6.6% / 25 discs, 8.7%), and 5 (6 discs, 2.1% / 10 discs, 3.5%). In the nVF group, Pfir -rmann scores at the adjacent intervertebral space (cranial side / caudal side) were as follows: 1 (16 discs, 6.0% / 21 discs, 7.9%), 2 (24 discs, 9.1% / 30 discs, 11.3%), 3 (51 discs, 19.2% / 58 discs, 21.9%), 4 (21 discs, 7.9% / 26 discs, 9.8%), and 5 (7 discs, 2.6% / 11 discs, 4.2%). The χ2 test found that the between-group difference for degenera -tion of adjacent discs was not significant ( P = .08).Cervical myelopathy gradeIn the VF group, preoperative CMG was G1 in 57 (36.5%) cases, G2 in 51 (32.7%) cases, G3 in 27 (17.3%) cases, G4 in 20 (12.8%) cases, and G5 in 1 (0.6%) case. In the nVF group, preoperative CMG was G1 in 43 (29.3%) cases, G2 in 58 (39.5%) cases, G3 in 20 (13.6%) cases, and G4 in 26 (17.7%) cases. The χ2 test found that the between-group difference for CMG was not significant ( P = .13).In the VF group, CMG at 30 months after surgery was G0 in 146 (93.6%) cases, G1 in 3 (1.9%) cases, G2 in 5 (3.2%) cases, and G3 in 2 (1.3%) cases. In the nVF group, CMG at 30 months after surgery was G0 in 138 (93.9%) cases, G1 in 4 (2.7%) cases, G2 in 2 (1.3%) cas -es, G3 in 2 (1.3%) cases, and G4 in 1 (0.7%) case.Recovery rates were 95.5% (n = 156) in the VF group and 96.0% (147) in the nVF group. There was no significant difference between the 2 groups in terms of recovery rate ( P = .79). The median (range) time to recovery was 2.2 days (1 to 16 days) in the VF group and 2.7 days (1 to 23 days) in the nVF group. There were no significant differences between the 2 groups in terms of days to recovery ( P = .85).RecurrenceThirteen cases had recurrent signs of C-IVDH within 30 months of the initial surgery. The recur -rence rates were 4.7% (n = 7) in the VF group and 4.3% (6) in the nVF group. There was no significant difference in recurrence rate between the 2 groups (P = .79). The median (range) number of days to re -currence was 539 days (241 to 788 days) in the VF group and 562 days (266 to 792 days) in the nVF group. There was no significant difference between the 2 groups in terms of days to recurrence ( P = .75).The recurrence sites were 6 adjacent interverte -bral discs and one other intervertebral disc in the VF group and 6 adjacent intervertebral discs in the nVF group. In the VF group, 1 case was caudal to C3–C4, 1 case was cranial to C4–C5, 2 cases were caudal and 1 case was cranial to C5–C6, and 1 case was cranial to C6–C7. In another case of recurrence in nonad -jacent intervertebral discs, the C5-6 intervertebral space was treated, and recurrence was in the C3-4 intervertebral space. The nVF group had 2 cases cra -nial to C4–C5 and 3 cases caudal and 1 case cranial to C5–C6. The preoperative Pfirrmann score result was 3 in all 12 cases with recurrence in the adjacent intervertebral space and 1 case with recurrence in nonadjacent intervertebral discs. The signalment, Figure 3 —Dog age at time of surgery.The mean body weight for the VF group was 5.4 ± 3.3 kg (range, 1.6 to 14.9 kg); mean body weight of the nVF group was 6.5 ± 2.8 kg (range, 2.1 to 14.8 kg). The χ2 test and Student t test results were not signifi -cant for between-group differences for gender, age, or weight (χ2 test, P = .14 for gender; Student t test, P = .34 for age and P = .13 for weight).Affected intervertebral sitesIn the VF group, the affected intervertebral disc space was C2–C3 in 25 (16.0%) cases, C3–C4 in 45 (28.8%) cases, C4–C5 in 43 (27.6%) cases, C5–C6 in 27 (17.3%) cases, C6–C7 in 15 (9.6%) cases, and C7–T1 in 1 (0.6%) case. In the nVF group, the affected in -tervertebral disc space was C2–C3 in 29 (19.7%) cas -es, C3–C4 in 34 (23.1%) cases, C4–C5 in 36 (24.5%) cases, C5–C6 in 37 (25.2%) cases, C6–C7 in 10 (6.8%) cases, and C7–T1 in 1 (0.7%) case. A χ2 test revealed that the between-group difference for affected site was not significant ( P = .14).Degeneration of the adjacent intervertebral discsA Pfirrmann score was assigned on the basis of MRI results in all 303 cases. In the VF group, Pfirrmann scores Unauthenticated | Downloaded 10/08/23 06:32 AM UTC1506 JAVMA | OCTOBER 2023 | VOL 261 | NO. 10Table 2 —Multivariate logistic regression analysis with recovery as outcome. Estimate coefficients and OR of risk factors by logistic regression analysis for recovery Dogs with Dogs withoutVariable recovery, n (%) recovery, n (%) SE P value OR 95% CIVF No 141 (95.7) 6 (4.3) Yes 149 (94.9) 7 (5.1) 0.663 .786 1.167 0.383–3.556Sex Intact male 90 (95.7) 4 (4.3) Castrated male 109 (94.0) 7 (6.0) 0.291 .218 0.453 0.129–1.597 Intact female 32 (100) 0 (0) 0.422 .407 0.406 0.480–3.430 Spayed female 59 (96.7) 2 (3.3) 0.227 .149 0.210 0.251–1.747Age, per 1-y increase 0.119 .197 1.144 0.932–1.403Breed CDB 148 (97.4) 4 (2.6) NCDB 142 (94.0) 9 (6.0) 4.582 .023* 5.893 1.283–27.055Grade 1 97 (97.0) 3 (3.0) 2 106 (97.2) 3 (2.8) 0.543 .506 0.441 0.394–4.973 3 43 (91.5) 4 (8.5) 5.944 .019* 7.098 1.374–36.641 4 43 (93.5) 3 (6.5) 3.227 .042* 3.464 0.558–21.498 5 1 (100) 0 (0) — — — —Surgical site C2–C3 54 (100) 0 (0) C3–C4 76 (96.2) 3 (3.8) 2.250 .575 1.925 0.195–19.014 C4–C5 74 (93.7) 5 (6.3) 4.954 .168 4.521 0.528–38.717 C5–C6 60 (93.8) 4 (6.2) 2.045 .686 1.650 0.145–18.720 C6–C7 24 (96.0) 1 (4.0) 3.110 .590 2.166 0.130–36.121 C7–T1 2 (100) 0 (0) — — — —CDB = Chondrodystrophic breed. NCDB = Nonchondrodystrophic breed. *Difference is statistically significant. Statistical significance set at P < .05.Table 3 —Multivariate logistic regression analysis with recurrence as outcome. Estimate coefficients and OR of risk factors by logistic regression analysis for recurrence Dogs without Dogs with Variable recurrence, n (%) recurrence, n (%) SE P value OR 95% CIVF No 135 (95.7) 6 (4.3) Yes 142 (95.3) 7 (4.7) 0.663 .786 1.166 0.382–3.556Sex Intact male 85 (94.4) 5 (5.6) Castrated male 105 (94.6) 6 (5.4) 0.530 .757 0.818 0.230–2.914 Intact female 31 (100) 0 (0) — — — — Spayed female 56 (96.6) 2 (3.4) 0.698 .924 0.931 0.214–4.044Age, per 1-y increase 0.287 .001** 1.791 1.305–2.456Breed CDB 140 (95.9) 6 (4.1) NCDB 137 (95.1) 7 (4.9) 0.672 .768 0.627 0.388–3.605Grade 1 92 (95.8) 4 (4.2) 2 99 (95.2) 5 (4.8) 1.122 .580 1.509 0.351–6.484 3 43 (95.6) 2 (4.4) 1.825 .351 2.182 0.423–11.243 4 42 (95.5) 2 (4.5) 1.386 .669 1.488 0.240–9.231 5 1 (100) 0 (0) — — — —Surgical site C2–C3 52 (100) 0 (0) — — — — C3–C4 73 (96.1) 3 (3.9) 0.730 .667 0.585 0.509–6.737 C4–C5 71 (93.4) 5 (6.6) 1.921 .631 1.714 0.191–15.418 C5–C6 57 (93.4) 4 (6.6) 2.243 .537 2.001 0.222–18.025 C6–C7 22 (95.7) 1 (4.3) 0.978 .515 1.398 0.316–2.883 C7–T1 2 (100) 0 (0) — — — —See Table 2 for key.**Difference is statistically significant. Statistical significance set at P < .01.Unauthenticated | Downloaded 10/08/23 06:32 AM UTC JAVMA | OCTOBER 2023 | VOL 261 | NO. 10 1507neurologic grade, and recurrence time results for the 13 cases with recurrence were as follows: dogs with C-IVDH recurrence in the VF group (7 dogs) were of 5 different breeds (median age, 10.5 years; range, 7.8 to 12.3 years; median weight, 5.3 kg; range, 1.8 to 8.4 kg), with a median value of neurologic grade 2 (range, 1 to 4) and a median recurrence time of 18 months (range, 8 to 26 months). Dogs with C-IVDH recurrence in the nVF group (6 dogs) were of 4 different breeds (median age, 9.5 years; range, 6.4 to 10.4 years; median weight, 6.5 kg; range, 5.7 to 9.8 kg), with a median value of neurologic grade 3 (range, 2 to 4) and a median recurrence time of 16 months (range, 9 to 26 months).Multivariate logistic regressionNCDBs had a significantly lower recovery rate than did CDBs ( P = .023) and a significantly lower recovery rate when CMG severity was G3 ( P = .019) or G4 ( P = .042) than when CMG severity was G1. Other factors, including VF, had no significant effect on recovery rates (Table 2) . Increasing age was sig -nificantly associated with recurrence ( P = .001), but other factors, including VF, had no significant effect on recurrence rates (Table 3) .

Question 140

Liatis - 2024 - JSAP - Head tilt as a clinical sign of cervical spinal or paraspinal disease in 15 dogs (2000-2021).pdf

Answer 140

The digital medical database of the Royal Veterinary College was retrospectively searched to retrieve the records of all dogs presenting with head tilt between January 1, 2000 and Novem -ber 1, 2021. Initial search terms were “head tilt,” and then, sub search terms included “head tilt,” and “spinal cord” or “cervical” or “neck.” Inclusion criteria were (1) complete medical records, (2) head tilt clearly described and documented in the neurologi -cal examination that occurred no longer than 6 months before presentation, (3) advanced diagnostic imaging [CT or/and mag -netic resonance imaging (MRI)] of the head and cervical region and (4) presence of a lesion at the cervical region in the absence of intracranial abnormalities on advanced imaging studies. The reasoning behind including head tilts of no longer than 6 months onset was an effort to avoid recruitment of cases with histori -cal head tilt that could be attributable to previously diagnosed “idiopathic geriatric peripheral vestibular disease,” “otitis media/interna” or other previous but now resolved pathology with a residual head tilt. Cases with (1) historical head tilt, (2) pres -ence of middle ear effusion or other intracranial abnormalities on diagnostic imaging, (3) a diagnosis of Chiari- like malforma -tion and associated syringomyelia and (4) a clinical suspicion or laboratory diagnosis of metabolic disease such as hypothyroidism were excluded.Complete medical records included signalment, clinical his -tory (onset and duration of neurological signs), clinical and neu -rological examination findings and advanced diagnostic imaging findings. Advanced diagnostic imaging included CT with a 16- slice helical scanner (PQ 500, Universal Systems, Solon; GE Healthcare) under sedation or general anaesthesia or MRI with a high- field unit (1.5 T, Intera; Phillips Medical Systems) under general anaesthesia. All diagnostic imaging studies were reviewed by a board- certified neurologist. Some dogs underwent addi -tional diagnostic tests, including clinical pathology (complete blood count, serum biochemistry, thyroid profile and infectious disease tests), cerebrospinal fluid (CSF) analysis, conventional radiography or abdominal ultrasound, which were reviewed where available.Onset of neurological signs was categorised into hyperacute (<24 hours), acute (1 to 7 days), subacute (7 to 15 days) and chronic (>15 days) (Harrison et al. 2021 ). All clinical and neu -rological examinations were performed by a board- certified neu -rologist or a neurology resident under the direct supervision of a board- certified neurologist.Statistical analysis was descriptive, where median [interquar -tile range (IQR)] was used.RESULTSInitial search revealed 2881 cases with head tilt over the period 2001 to 2021. Of these, 677 cases were identified to correspond to search terms regarding spinal cord pathology. Of these, only 15 cases met the inclusion criteria ( Table 1). Duplicates, cases with concurrent hypothyroidism, middle ear effusion or Chiari- like malformation and syringomyelia, or cases identified with random use of the search terms but not associated with underly -ing pathology were excluded.Clinical presentationBreeds represented were: French Bulldog (n=4) and one of each: Staffordshire Bull Terrier, West Highland White Terrier, Lab -rador retriever, boxer, Dogue de Bordeaux, Yorkshire terrier, Chow- Chow, German shepherd dog, Lurcher, Bull Mastiff- Cross and crossbreed. T welve dogs were males (seven neutered) and three were females (one neutered). Median age at presen -tation was 6.1 years (IQR: 4.8 years, range: 2.5 to 12 years). Onset of neurological signs was chronic (9/15, 60%), acute (4/15, 26.7%) and hyperacute (post- operatively) (2/15, 13%). Mean duration of clinical signs was 30 days (IQR: 72.5 days, range: 1 to 120 days). Presenting complaints as reported by the owners included cervical hyperaesthesia (8/15, 53%), head tilt (9/15, 60%) of which two of nine reported to be episodic, incoordination (2/15, 13%), lethargy (2/15, 13%), collapse episode (2/15, 13%), neck spasms (2/15, 13%) and one of each (1/15, 7%): ambulatory tetraparesis, falling to one side, scuffing pelvic limbs, episodic pain, body turn, reluctance to exercise, episodic weakness, lameness, stiff gait, kyphosis and knuckling. One dog was referred for a witnessed road- traffic accident. T wo dogs developed head tilt immediately after undergoing a C2 modified hemilaminectomy, durotomy, rhi -zotomy (n=2) with myelotomy (n=1) for resection of a C2 spi -nal nerve root mass.On neurological examination, mentation was normal in all dogs. Posture revealed head tilt in all dogs, which was right- sided in nine dogs and left- sided in the remaining six dogs (Fig 1). Head tilt was episodic in three of 15 (20%) dogs. T wo (13%) dogs had a low- head carriage and two (13%) dogs had a head turn with pleurothotonus ipsilateral to the head tilt. Gait and postural reaction analysis revealed ambulatory tet -raparesis with generalised proprioceptive ataxia in all limbs (6/15, 40%), or non- ambulatory tetraparesis (1/15, 6%). Pro -prioceptive deficits were detected in eight of 15 (53%) dogs, which was symmetrical in three dogs and worse ipsilateral to the side of the head tilt in five dogs. Leaning towards the side of head tilt was noticed in two dogs (13%), whilst fall -ing towards the side of the head tilt was noticed in another dog (1/15, 7%%). Spinal reflexes were intact in all dogs. Ipsi -lateral ventral positional strabismus was noticed in one (7%) dog, whilst ipsilateral miosis was noticed in one (7%) dog. On palpation, cervical hyperaesthesia was observed in eight (53%) dogs, whilst symmetrical cervical muscle atrophy ventral to the nuchal ligament was noticed in one (7%) dog. The neuroana -tomical localisation was consistent with a C1- C5 myelopathy (9/15; 60%), C1- C5 or C6- T2 myelopathy (1/15, 7%), mul -tifocal with involvement of the C6- T2 spinal cord segments and central vestibular system (1/15, 7%) or central vestibu -lar system (1/15, 7%). In three dogs (20%), the neurological examination did not reveal any deficits and the observed head tilt was considered secondary to cervical hyperaesthesia. 17485827, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13674 by Vetagro Sup Aef, Wiley Online Library on [19/01/2024]. 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 LicenseT. Liatis and S. De DeckerJournal 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.58Table 1. Signalment, diagnostics, diagnosis and outcome of dog with head tilt in cervical spinal or paraspinal diseaseC Signalment Onset of signs and presenting complaintsNeurological findings Diagnostic test results Clinical diagnosis Treatment Outcome of head tilt1 7yo ME French bulldog Onset: hyperacutePresenting complaints: L head tilt after surgery for L C2 nerve root massNE: L head tilt; ambulatory tetraparesis; symmetric generalised proprioceptive ataxiaNAL: L C1- 5 SCSInfectious disease tests:IFA – Toxoplasma gondii IgG/IgM: negativeIFA – Neospora caninum IgG: negativeMRI (pre- op): intradural extramedullary mixed T2W intense and uniformly contrast enhancing mass lesion at C1- C2 affecting the L nerve root and compressing the spinal cord. Muscle atrophy of the muscles innervated by C2 spinal nerveCSF analysis (cisternal): mildly inflammatoryThoracic radiography: WNLAbdominal radiography: WNLHistopathology: malignant peripheral nerve sheath tumourPost- operative complication after C2 spinal nerve root tumour (MPNST) surgeryPrednisoloneHydroxyureaL C1- 2 modified hemilaminectomy, durotomy, rhizotomyResidual head tiltDevelopment of C3 root mass in 2 m post- op2 5.7 yo MN Staffordshire bull terrierOnset: hyperacutePresenting complaints: L head tilt after surgery for L C2 nerve root massNE: L head tilt; ambulatory tetraparesis; symmetric generalised proprioceptive ataxiaNAL: L C1- C5 SCSCoagulation profile: WNLInfectious disease tests: ELISA – Angiostrongylus vasorum : negativeMRI (pre- op): intradural extramedullary lesion on the left side causing dorsolateral compression of the spinal cord at C1- C2Thoracic radiography: WNLAbdominal ultrasound: WNLHistopathology: benign peripheral nerve sheath tumourPost- operative complication after C2 spinal nerve root tumour (BPNST) surgeryLomustineL C1- 2 modified hemilaminectomy, durotomy, myelotomy, rhizotomyResolved3 11.4 yo FE West Highland white terrierOnset: chronicPresenting complaints: scuffing thoracic limbsNE: L head tilt; ambulatory tetraparesis (left worse than right); generalised proprioceptive ataxia; postural reaction deficitsNAL: L C1- 5 SCSCBC: WNLSB: ALB: 40.9 g/L (RI: 26.3 to 38.2)MRI: left cranial cervical intradural- extramedullary masses with extension along the left C2 and C3 nerve roots into the paravertebral musculature. Secondary marked left cervical neurogenic muscle atrophyL C2 and C3 spinal nerve root massPalliative treatment (gabapentin)Lost to follow- up4 10.9 yo MN Labrador retrieverOnset: chronicPresenting complaints: head tilt, hemiparesis, neck spasms and painNE: R head tilt; R head turn; R pleurothotonus; ambulatory tetraparesis (right worse than left); generalised proprioceptive ataxia; postural reaction deficits; cervical hyperaesthesiaNAL: R C1- 5 SCSCBC: NEUT:11.89 ×10e9/L (RI: 3 to 11.5); LYMPHO: 0.51 ×10e9/L (RI: 1 to 4.8)SB: CK: 1159 U/L (RI: 67 to 446)MRI: large tubular mass- like structure which extends along the expected course of the right C2 nerve and invades intramedullary causing marked compression and infiltration of the spinal cord with contrast- enhancement. A tubular portion of the mass extends laterally into the adjacent paravertebral musculature and extends caudoventrally along the surface of C2 in multilobulated shapeR C2 spinal nerve root massPalliative treatment (prednisolone; gabapentin)Euthanasia 17485827, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13674 by Vetagro Sup Aef, Wiley Online Library on [19/01/2024]. 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 LicenseHeat 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.59 C Signalment Onset of signs and presenting complaintsNeurological findings Diagnostic test results Clinical diagnosis Treatment Outcome of head tilt5 10 yo FN Crossbreed Onset: chronicPresenting complaints: head tilt, neck painNE: L head tilt; ambulatory tetraparesis (left worse than right); generalised proprioceptive ataxia; postural reaction deficits; cervical hyperaesthesiaNAL: L C1- 5 SCSCBC: LYMPHO: 0.76109/l (RI: 1.5 to 7)SB: UREA: 2.30 mmol/O (RI: 3 to 9.1); CREA: 86 umol/L (RI: 98 to 163)MRI: extradural mass at the level of C4 vertebral body adjacent to the vertebral canal on the left severely compressing the spinal cordCSF analysis (cisternal): WNLThoracic radiography: WNLAbdominal ultrasound: multiple cystic lesions in the spleen, (DDx: myelolipomas or regenerative nodules)L C4 vertebral body massPalliative treatment (fentanyl patch)Euthanasia6 7 yo FE Dogue De BordeauxOnset: chronicPresenting complaints: head tilt, neck pain, lethargy, lameness and knuckling of one limbNE: R head tilt; postural reaction deficits; patellar hyperreflexiaNAL: C1- 5 SCSCBC: mild anaemiaMRI: right- sided extramedullary intradural mass strongly contrast enhancing causing compression to the spinal cord at the level of C1- 2Thoracic radiography: WNLAbdominal ultrasound: WNLR C1- 2 spinal cord mass (papillary meningioma)Surgical treatment (C1- 2 hemilaminectomy and removal of mass)Medical treatment (prednisolone; hydroxyurea)Resolved7 3.4 yo MN French bulldogOnset: acutePresenting complaints: head tilt, neck pain, thoracolumbar scoliosisNE: R head tilt; thoracolumbar scoliosis to the right; cervical hyperaesthesia; four limb spinal hyperreflexia; cervical hyperaesthesiaNAL: C1- 5 SCSMRI: intervertebral disc extrusion at C3- C4 and a mild bulging of the C2- C3 intervertebral disc with secondary spinal cord compressionCSF analysis (cisternal): WNLC3- 4 IVDE Surgical treatment (C3- 4 ventral slot)Medical treatment (carprofen; diazepam)Resolved8 4.5 yo MN French bulldogOnset: acutePresenting complaints: neck pain, reluctance to exerciseNE: L head tilt; non ambulatory tetraparesis; postural reaction deficitsNAL: C1- 5 SCS ±central vestibular systemVenous blood gas analysis: WNLMRI: extradural material causing moderate ventral and left sided spinal cord compression at the level of C3- 4 intervertebral disc space consistent with extrusionCSF analysis (cisternal): WNLL C3- 4 IVDE Surgical treatment (L C3- 4 dorsal hemilaminectomy)Medical treatment (gabapentin; paracetamol)Resolved9 4.6 yo ME French bulldogOnset: chronicPresenting complaints: neck painNE: low- head carriage; R head tilt; cervical hyperaesthesiaNAL: normal with cervical hyperaesthesiaMRI: right- sided extradural material compressing the spinal cord consistent with C4- 5 intervertebral disc extrusion, and syringomyelia at C2- C4 likely associated with altered CSF flow secondary to compression at C4- 5Thoracic radiography: aspiration pneumoniaR C4- 5 IVDE & C2- 4 syringomyeliaSurgical treatment (C3- 4 ventral slot)Medical treatment (meloxicam)ResolvedTable 1. (Continued) 17485827, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13674 by Vetagro Sup Aef, Wiley Online Library on [19/01/2024]. 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 LicenseT. Liatis and S. De DeckerJournal 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.60C Signalment Onset of signs and presenting complaintsNeurological findings Diagnostic test results Clinical diagnosis Treatment Outcome of head tilt10 12 yo ME Yorkshire terrierOnset: chronicPresenting complaints: episodic pain; episodic weaknessNE: R head tilt; postural reaction deficits; thoracic limb hyporeflexiaNAL: C6- T2 SCSCBC: WNLSB: WNLMRI: intervertebral disc protrusion and some compression of the spinal cord at C5- C6 and also at C6- C7 with central canal dilation (syringomyelia) at C2- C4 and C5- C6. Normal brainThoracic radiography: WNLAbdominal ultrasound: bladder calculi; prostatic cystACTH Stim Test: WNLC5- 6 and C6- 7 IVDPs & C2- 6 syringomyeliaSurgical treatment (C5- C6 ventral slot)Resolved11 3.1 yo MN boxer Onset: chronicPresenting complaints: head tilt; episode of collapse; weakness; incoordinationNE: R head tilt; ambulatory tetraparesis; generalised proprioceptive ataxia; postural reaction deficitsNAL: C1- 5 or C6- T2 SCSMRI: asymmetrical vertebral articular processes at C5/6 and C6/7 with evidence of enlargement of left one, causing impingement on dorsal and lateral aspect of dura. Multiple small fluid- containing structures associated with the synovial cysts at C4/5- C6/7 are identified. Consistent with osseous- associated cervical spondylomyelopathyC5- 7 OA- CSM Medical treatment (meloxicam)Residual12 8.7 yo ME Chow- Chow Onset: chronicPresenting complaints: episode of collapse; weakness; incoordinationNE: R head tilt; ambulatory tetraparesis; generalised proprioceptive ataxia; postural reaction deficits; ipsilateral positional ventral strabismus; ipsilateral miosisNAL: central vestibular systemCBC: WNLSB: WNLTT4/TSH: WNLMRI: focal spinal cord atrophy at C1 secondary to impingement by the densCSF analysis (cisternal): albuminocytological dissociationCervical radiography: uneven dorsal aspect of the vertebral body of C2, possible exostosis; no malalignment identifiedC2 vertebral malformation with spinal cord compressionNone Lost to follow- up13 6 yo ME cocker spanielOnset: chronicPresenting complaints: head tilt; previous road- traffic accident 2 months agoNE: R head tilt; cervical hyperaesthesiaNAL: C1- 5 SCSCT: displacement of the C2 fragments (fracture). The displacement is not causing compression/narrowing of the spinal canal and there is evidence of fibrotic fracture healingC2 vertebral fracture and displacement with associated R impingement of the spinal cordMedical treatment (gabapentin; carprofen)Residual14 6.1 yo MN Lurcher Onset: acutePresenting complaints: head tilt; neck spasms; neck pain; lethargy; stiff gaitNE: L head tilt; L head turn; cervical hyperaesthesiaNAL: normal with cervical hyperaesthesiaCBC: WNLSB: WNLInfectious disease tests:IFA – Toxoplasma gondii IgG/IgM: negativeIFA – Neospora caninum IgG: negativeMRI: T2W and STIR hyperintensity of the paravertebral musculature, ventral to C2/3, lateral to C4- T1, within the right lateral musculature at C6, longus colli muscles with diffuse paravertebral muscle contrast enhancement. R>L paravertebral myositis considered most likelyCSF analysis (cisternal): WNLCytology (FNA of epaxial muscles): WNLCervical paravertebral myositisMedical treatment (prednisolone; metronidazole; amoxyclav)ResolvedTable 1. (Continued) 17485827, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13674 by Vetagro Sup Aef, Wiley Online Library on [19/01/2024]. 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 LicenseHeat 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.61 C Signalment Onset of signs and presenting complaintsNeurological findings Diagnostic test results Clinical diagnosis Treatment Outcome of head tilt15 2.5 yo MN GSD Onset: acutePresenting complaints: neck pain; kyphosisNE: R head tilt; low- head carriage; cervical hyperaesthesiaNAL: normal with cervical hyperaesthesiaCBC: WNLSB: ALB: 25.5 g/L (RI: 28 to 39)MRI: there is an ill- defined T2W increased signal intensity with T1W post contrast enhancement within the right epaxial musculature adjacent to C4 and C5 vertebrae. The abnormal signal intensity extends along the muscular fascia to the right prescapular region where there is also T2W increased signal intensity, best seen on dorsal STIR sequence. Abnormalities of the epaxial musculature and related fascia of suspected inflammatory origin ( e.g. cellulitis, immune mediated or infectious). Mild abnormalities of the right articular facet joint at C3/4, C4/5 and C5/6, causing minimal impingement of the spinal cord at C5/6. Regional lymphadenopathy (most likely reactive)CSF analysis (cisternal & lumbar): albuminocytological dissociationCytology (FNA of epaxial muscles): WNLCervical paravertebral myositisMedical treatment (gabapentin; firocoxib)ResolvedALB Albumins, BPNST Benign peripheral nerve sheath tumour, C Case number, CBC Complete blood count, CK Creatine kinase, CSF Cerebrospinal fluid, DDx Differential diagnoses, FE Female entire, FN Female neutered, FNA Fine needle aspiration, h Hours, IFA Indirect immunofluorescence, IV Intravenous, IVDE Intervertebral disc extrusion, IVDP Intervertebral disc protrusion, L Left, m Months, ME Male entire, MN Male neutered, MPNST Malignant peripheral nerve sheath tumour, NAL Neuroanatomical localisation, NE Neurological examination, OA- CSM Osseous- associated cervical spondylomyelopathy, PL Pelvic limb, PO Per os, R Right, RI Reference intervals, SB Serum biochemistry, SC Subcutaneous, SCS Spinal cord segments, TL Thoracic limb, TNCC Total nucleated cell count, WNL Within normal limits, Y YesTable 1. (Continued) 17485827, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13674 by Vetagro Sup Aef, Wiley Online Library on [19/01/2024]. 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 LicenseT. Liatis and S. De DeckerJournal 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.62Diagnostic findingsComplete blood count was performed in nine of 15 (56%) dogs, of which three of nine (19%) had a stress leukogram and two of nine (13%) mild anaemia. Serum biochemistry was performed in eight of fifteen (50%) dogs, of which one (6%) dog had hypercholesterolemia. The remaining dogs (6/15) had complete blood count and serum biochemistry performed at the referring veterinary practice which revealed stress leuko -gram (2/6, 33%) and the remaining values were within normal limits.All dogs had MRI performed, apart from one which had a CT. MRI was performed in 14 dogs revealing a C2 spinal nerve root mass (4/15, 27%) ( Fig 1), of which one had an affected C3 spi -nal nerve root as well, a C1- C2 intradural- extramedullary mass (1/15, 7%), C4 vertebral body mass (1/15, 7%), C2 vertebral malformation (1/15, 7%) with impingement of the spinal cord by the dens and secondary spinal cord atrophy at the level of C1, C3- C4 (2/15, 13%) and C4- C5 (1/15, 7%) intervertebral disc extrusion (IVDE), concurrent C5- C6 and C6- C7 intervertebral disc protrusions (IVDP) (1/15, 7%), C5- C7 osseous- associated cervical spondylomyelopathy (1/15, 7%) and cervical paraspinal myositis (2/15, 13%). CT was performed in 1 dog revealing a C2 vertebral fracture (1/15, 7%) and displacement with associated lateral impingement of the spinal cord. No abnormalities were detected on MRI (14/15) or CT (1/15) of the head.Cisternal CSF analysis was performed in 6 dogs. Total nucle -ated cell count was within normal limits in all samples [reference intervals (RI): <6 cells/mm3], whilst increased total protein con -centration was detected in two dogs (32 and 31 mg/dL, respec -tively, RI: <25 mg/dL).Thyroid profile (total thyroxine and thyroid- stimulating hormone) was performed in one of 15 (7%) dog, whose serum biochemistry revealed hypercholesterolemia, and was normal. Serology (indirect immunofluorescence) for Toxoplasma gondii (IgG/IgM) and Neospora caninum (IgG) were performed for two of 15 (13%) dogs and was negative.Treatment and outcomeT wo dogs, one of them diagnosed with a C2 spinal nerve root mass and the other with a C4 vertebral body mass, were eutha -nased immediately after a diagnosis was made. For the remaining 13 dogs, treatment was dependent on aetiologic diagnosis. T reat -ment of two dogs diagnosed with head tilt as a post- operative complication of surgery [modified hemilaminectomy, durotomy, myelotomy (n=1), rhizotomy] for resection of C2 spinal nerve root mass included prednisolone and hydroxyurea (n=1) and FIG 1. (A) Photograph of a dog with head tilt to the right in a dog diagnosed with a C2 spinal nerve root mass. (B to H) MRI of this dog revealing a large tubular mass which extends along the expected course of the right C2 spinal nerve and invades intramedullary causing marked compression and infiltration of the spinal cord with contrast enhancement, A tubular portion of the mass extends laterally into the adjacent paravertebral musculature and extends caudoventrally along the surface of C2 in multi- lobulated shape. This portion of the mass was heterogeneous and poorly contrast enhancing. These lesions were consistent with a suspected right C2 spinal nerve root mass. Right epaxial muscle atrophy was noticed at the level of C2. There was also diffuse T2W and FLAIR intramedullary hyperintensity likely to represent syringomyelia cranial and caudal of the mass lesion. (B) T2W sagittal of the neck showing the mass (arrowhead). (C) FLAIR sagittal of the neck. (D) T1W sagittal of the neck. (E) T1W sagittal post- contrast. (F to H) T2W transverse (F), T1W transverse pre- contrast (G) and T1W transverse post- contrast (H) of the neck at the level of C2 showing the invasion of the mass to the epaxial musculature (arrowhead). (G) T1W transverse of the neck at the level of C2. (H) T1W post- contrast at the level of C2 17485827, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13674 by Vetagro Sup Aef, Wiley Online Library on [19/01/2024]. 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 LicenseHeat 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.63 lomustine (n=1). Histopathology of the C2 spinal nerve root masses was consistent with peripheral sheath tumour (PNST) (n=2; one malignant, one benign). T reatment of two other dogs, one diagnosed with a right- sided C2 and one with left- sided C2 and C3 spinal nerve root mass, was palliative including gabapen -tin 100 mg/kg PO q8h (n=2) and prednisolone 0.5 to 1 mg/kg PO q24h (n=1). T reatment of a dog diagnosed with intradural- extramedullary mass included a C1- C2 hemilaminectomy with resection of the mass, prednisolone 0.5 to 1 mg/kg PO q24h and hydroxyurea 50 mg/kg PO q48h. Histopathology of that mass was consistent with papillary meningioma (n=1). Three dogs with IVDE and one with IVDP were treated with a ventral slot surgical procedure (n=3), modified hemilaminectomy (n=1) and gabapentin 10 mg/kg PO q8h (n=1), meloxicam 0.1 mg/kg PO q24h (n=1), paracetamol 10 mg/kg PO q12h (n=1), diazepam 0.5 mg/kg PO q8h (n=1), carprofen 4.4 mg/kg PO q24h (n=1). One dog with a C2 vertebral fracture was treated medically with gabapentin, carprofen and strict rest. In one dog with a C2 ver -tebral malformation no treatment was initiated. T wo dogs with cervical paravertebral myositis were treated with prednisolone 0.5 to 1 mg/kg PO q24h (n=1), gabapentin 10 mg/kg PO q8h (n=1), firocoxib 5 mg/kg PO q24h (n=1), metronidazole 10 mg/kg PO q12h (n=1) and amoxicillin- clavulanic acid 20 mg/kg PO q12h (n=1). One dog with C5- C7 osseous- associated CSM was treated medically with meloxicam and restricted exercise.Follow- up information was available for 11 of the 13 dogs in which treatment was initiated. Median follow- up time was 60 days (IQR: 225.5 days, range: 5 to 720 days). In eight of 15 (53%) dogs head tilt resolved after initiation of treatment, whilst in three of 15 (20%) dogs it remained static. In dogs with post- operative head tilt after C2 spinal nerve root mass removal, head tilt resolved in 1 dog and remained unchanged in the other dog. One of them had a follow- up MRI immediately after surgery which revealed left- sided T2W hyperintensity of the spinal cord suggestive of oedema at the level of C1- C2. In that dog, head tilt resolved 2 months post- operatively. The other dog had a follow- up MRI 2 months later, where a C3 nerve root mass was then revealed. In that dog, head tilt remained unchanged. In all cases diagnosed with IVDE or IVDP , head tilt had resolved after sur -gery. In all cases with cervical paraspinal myositis, head tilt had resolved after treatment. In the dog with a C2 vertebral fracture, head tilt remained unchanged after medical management. The dog with C5- C7 osseous- associated CSM remained with head tilt and was euthanased 1 month after diagnosis due to owners’ inability to cope with its demanding management as per neuro -logical deterioration.

Question 141

Aldrich - 2023 - VETSURG - Blinded, randomized, placebo-controlled study of the efficacy of bupivacaine liposomal suspension using static bodyweight distribution and subjective pain scoring in dogs after tibial plateau leveling osteotomy.pdf

Answer 141

2.1 |DogsClient-owned dogs receiving TPLO between July 2019and July 2020 for confirmed unilateral cranial cruciateligament (CCL) insufficiency of any duration were eligi-ble for inclusion in the study. The study was approved byour institution's animal care and use committee. Writteninformed owner consent was obtained for all enrollees.Screening was completed on the day before surgery, andincluded physical and orthopedic examinations, tibia/fibula radiographs for surgical planning, and hematologi-cal analysis (complete blood cell count and serum bio-chemistry). Exclusion criteria were: age less than 1 year;current or historic bilateral CCL insufficiency; other clin-ically evident orthopedic disease; neurological disease;uncontrolled or clinically suspected systemic disease; any722 ALDRICH ET AL . 1532950x, 2023, 5, surgery within the previous 14 days; short-acting cortico-steroid use within the previous 7 days or repository steroiduse within the previous 2 months; NSAID use other thancarprofen within the previous 7 days; use of other analge-sics within the previous 48 h; and temperament that mightinterfere with subjective pain scoring or stance analysis.Demographic information gathered included uniquepatient identifier, age, sex, breed, bodyweight, affected hin-dlimb, and estimated duration of lameness.2.2 |Experimental designDogs were allocated into LB treatment and saline controlgroups by randomized stratification. Dogs presenting toour institution for TPLO have commonly received a recentdose of the NSAID, carprofen. To avoid a confoundingeffect on postoperative pain measurement, we stratifiedenrollees by carprofen use into “recent carprofen ”(withinthe last 40 h, representing /C245 terminal plasma half-lives)36or“no recent carprofen ”groups. Dogs within these groupswere randomly assigned to either the LB or placebo treat-ment subgroups using a computerized random selectiongenerator ( randomizer.org ).Data from pain scoring and %BW distmeasurementwere collected preoperatively (before sedation for TPLOplanning radiographs) and over the 48-h postoperativestudy duration by two investigators who were blinded totreatment assignment.2.3 |CMPS-SFThe CMPS-SF is a subjective cli nical metrology instrumentdesigned for assessment of acute postoperative pain in dogsin a clinical setting.26At o t a lp a i ns c o r ei sa s s i g n e db e t w e e n0a n d2 4f o ra m b u l a t o r yp a t i e n t so rb e t w e e n0a n d2 0f o rpatients who cannot walk witho ut assistance. Two investi-gators were trained together in use of the CMPS-SF for sev-eral days before the study began, to achieve subjectiveinterobserver consistency in scoring of postoperative ortho-pedic surgery patients. Pain sc ores for study participantswere assigned by one of these tw oi n v e s t i g a t o r sp r e o p e r a -tively (baseline) and at 2, 4, 8, 12, 20, 24, 32, 40, and 48 hpostoperatively, where 0 h was time of extubation. Eachpatient may have received pain scores at different timepoints from one or a consensus of both of the assessors.2.4 |Static bodyweight distributionData from bodyweight distribution measurement werecollected by one of two investigators at baseline and at4, 12, 24 and 48 h postoperatively using a weight distribu-tion platform (PetSafe Stance Analyzer, Companion Ani-mal Health, Newark, Delaware). At the start of eachsession, the platform and associated software were cali-brated to zero weight. Based on previous studies of therepeatability of stance analysis,29,31the patient waswalked at a velocity of /C241 m/s onto the platform, led ona short neck leash by an investigator positioned to theanimal's right. The dog was abruptly stopped as theinvestigator moved in front of the animal to discourageadditional forward movement. This procedure wasrepeated as needed until the dog assumed a natural,square stance with one foot upon each of the quadrantsof the platform and its head held approximately on mid-line. After the dog maintained a square stance for /C245 s,data collection was started, with multiple measurementsof bodyweight distribution to each limb captured at/C240.5–1 s intervals, using a handheld remote control. Out-lier measurements resulting from aberrant body move-ments were discarded and six valid measurements persession were obtained, from which mean %BW distwascalculated for the operated limb. When pain scoring and%BW distmeasurement were scheduled at concurrent timepoints, pain scoring was completed first.2.5 |Rescue analgesia, success/failuredetermination, and mean rescue opioiddosesDogs were administered a single dose of hydromorphone(0.08 mg/kg subcutaneously) as rescue analgesia if theywere assigned a CMPS-SF pain score of 6/24 or 5/20 orgreater during any of the scheduled pain assessmentsbased on previous recommendations.17After a dogreceived rescue analgesia, all subsequent pain scores and%BW distmeasurements were excluded from statisticalanalysis to avoid a confounding effect on results.2.6 |Anesthesia, analgesia and surgeryAll dogs were premedicated with IM administration ofacepromazine (0.01 –0.02 mg/kg) and hydromorphone(0.08 –0.1 mg/kg). Anesthesia was induced with intrave-nous propofol and maintained with isoflurane in oxygen;both given to effect. All dogs received cefazolin (22 mg/kg)IV and IM at induction of anesthesia, as well as intrave-nous fluid therapy during the anesthetic period. At ourinstitution it is common to give both an IV and IM dose ofcefazolin at the beginning of orthopedic surgery as thishas been shown to provide higher concentrations of thedrug for up to 5 h post administration when compared toALDRICH ET AL . 723 1532950x, 2023, 5, a single IV dose alone.37Treatments for systemic hypo-tension under anesthesia included fluid therapy, anti-muscarinics and adrenergic agonists, as needed.Routine TPLO38was performed by one of eight pri-mary surgeons, including residents, ACVS board-eligibleand ACVS board-certified surgeons. Based on surgeonpreference regarding stifle joint exploration and meniscalcartilage treatment, any of the following procedural vari-ations were permitted: craniomedial parapatellar arthrot-omy, cranial cruciate ligament debridement, meniscaldebridement, or midbody outside-to-inside medial menis-cal release.39All surgeons elevated the popliteus musclefrom the caudoproximal aspect of the tibia, but packingwith gauze was not performed. A jig was used prior toosteotomy in all cases.After stabilization of the osteotomy and closure of thejoint capsule, the surgical wound was infiltrated witheither undiluted LB (5.3 mg/kg; 0.4 mL/kg) or an equalvolume of sterile saline (0.4 mL/kg), based on thepatient's random group assignment. The infiltrate wasadministered using the moving needle technique25usinga sterile syringe fitted with a 1.0 –1.5 inch, 22-gauge nee-dle. The entire volume was distributed into three tissuelayers as described in previous LB efficacy studies25,27with /C2425%, 50% and 25% injected into the superficial tis-sues of the closed joint capsule, the closed fascial tissue,and the subcuticular tissue, respectively, before skin clo-sure. Skin closure was performed with an intradermalclosure using 3-0 Monocryl in all cases. Dilution of theLB with saline was not performed in any cases. Bothinvestigators who performed postoperative pain assess-ment remained blinded to the treatment.When skin apposition was complete, the patientreceived a single dose of IV hydromorphone (0.08 mg/kg). During the 48-h postoperative study period, all dogsreceived subcutaneous carprofen (2.2 mg/kg) every 12 h,beginning at time of extubation (0 h). When a carprofendose was scheduled concurrently with pain scoring and %BW distmeasurement, data were collected before carpro-fen was administered. Dogs experiencing significant dys-phoria upon recovery were permitted to receive a singleIV dose of dexmedetomidine (1 mcg/kg) at the discretionof the supervising anesthesiologist. No other analgesicmodalities such as ice packing or limb compression wereused for the duration of the study.Postoperative care included leash walks every 4 h,free access to water, meals offered every 12 h, and coldcompress treatment of the incision for 10 min every 4 hbetween 7:00 a.m. and 11:00 p.m. Icing was performedonly after pain scoring/stance analysis were completed ata given time point. The surgical incision was protectedwith a bandage consisting of a nonadherent dressing withan adhesive covering until time of discharge. Dogs worean Elizabethan collar at all times. Adverse events werenoted and addressed.2.7 |Sample size calculationSufficient data are not previously reported describing staticbodyweight distribution in dogs in the acute postoperativeperiod, making a priori power analysis for sample size cal-culation a challenge. To estimate an expected effect size of%BW distfor LB compared to placebo, we calculated aneffect size of changes in PVF ratios reported in a previousanalgesic efficacy study.40Pain intensity for the inducedsynovitis model used in that study was expected to peak at2–3 h after urate crystal injection.41At 3 h after urate crys-tal injection, PVF ratios were significantly differentbetween firocoxib and placebo groups40and the effect sizewas large (Cohen's d=1.4, effect size index for two-tailedt-test of means). Using that effect size, a priori power anal-ysis yields a sample size of 30 dogs (15 in each treatmentgroup), at a power (1- β) of .95 and significance ( α) of .05.2.8 |Statistical analysisComparisons of treatment group variables including recentcarprofen use and frequencies of arthrotomy and meniscaldebridement were performed using a Chi-square test.Pain scores were compared between treatment groups pre-operatively and at 2, 4, 8, 12, 20, 24, 32, 40 and 48 h post-operatively with a nonparametric Mann –Whitney U-test.Treatment success for a patient was defined as not requiringany rescue analgesia within th ee n t i r e4 8 - hp o s t o p e r a t i v eperiod. The proportion of successes versus failures betweentreatment groups was compared with a Chi-square test. Acomparison between the number of required rescue opioiddoses relative to treatment group size was made using anonparametric Mann –Whitney U-test. Data describing %BW distfor the operated hindlimb were determined to be nor-mally distributed ( p=.001) by use of the Anderson-Darlingtest. %BW distvalues were compared between treatmentgroups preoperatively and a t4 ,1 2 ,2 4 ,a n d4 8hp o s t o p e r a -tively with a Student's t-test. Linear relationship betweenpain score and %BW distwas assessed using Pearson's correla-tion coefficient. Pain scores and %BW values were excludedfrom analysis after rescue analgesia as described. Statisticalsignificance was set at p<. 0 5f o ra l lt e s t s .3|RESULTSThirty-two dogs were enrolled into the study and all com-pleted the study. A total of 15 dogs were treated with LB724 ALDRICH ET AL . 1532950x, 2023, 5, and 17 with saline placebo. Carprofen was used in thepreoperative period in 11/33 (33%) dogs. Arthrotomy wasperformed in 23/33 (67%) dogs and meniscal debridementin 8/33 (24%) dogs. Frequencies of recent carprofen use(p=.39), arthrotomy ( p=.54), and meniscal debride-ment ( p=.31) (Table 1) were not different betweentreatment groups.3.1 |Pain scoresMedian CMPS-SF pain scores at preoperative baselinewere 1 (range 1 –5) and 1 (range 1 –3) for the LB andsaline groups, respectively ( p=.82). Median pain scoresdid not differ between treatment groups at any postopera-tive time point (Table 2).3.2 |Success/failure analysisOverall treatment success was not different between dogsthat received LB and those that received placebo (chi squarep=.27) (Table 3). Two out of 15 dogs in the LB grouprequired rescue analgesia, both at 2 h postoperatively. Fiveout of 17 dogs in the placebo group required rescue analge-sia: four dogs at 2 h postoperatively, and one dog at 8 hpostoperatively.3.3 |Rescue opioid dosesThe number of rescue opioid doses did not differ betweenthe treatment groups, with the LB group receiving threetotal opioid doses and the placebo group receiving 10 totalopioid doses ( p=.41).3.4 |%BW dist%BW distdata was unable to be collected at three postop-erative time points for the 25 dogs that did not requirerescue analgesia. One dog was too sedated to stand at 4 hpostoperatively and two dogs repeatedly chose to sit orlay down upon reaching the weight distribution platformat 48 h postoperatively and could not be encouraged tostand. For the seven dogs that required rescue analgesia,concurrent and subsequent %BW distvalues were excludedfrom statistical analyses. All remaining dogs were able toTABLE 1 Population frequencies for variable relevant to postoperative pain assessment in the LB and saline treatment groups.LB (n=15) Saline placebo ( n=17) Chi square p-valueRecent carprofen use (# of dogs) 4 7 .39Stifle arthrotomy performed (# of dogs) 10 13 .54Meniscal debridement performed (# of dogs) 5 3 .31Abbreviation: LB, liposomal bupivacaine.TABLE 2 Median (range) pain scores assigned by use of the CMPS-SF for dogs receiving LB ( n=15) or saline placebo ( n=17).LB (n=15) Saline placebo ( n=17)Time Pain score Number of dogs Pain score Number of dogs p-valuePreoperative baseline 1 (1 –5) 15 1 (1 –3) 17 .82Time after extubation (h)2 4 (1 –11) 15 3 (1 –11) 17 .764 3 (2 –4) 13 3 (1 –5) 13 .768 2 (1 –5) 13 2 (1 –12) 13 .4912 2 (1 –5) 13 2 (1 –4) 12 .3720 2 (1 –4) 13 1.5 (1 –4) 12 .9424 1 (1 –2) 13 1 (1 –3) 12 .4832 1 (1 –2) 13 1 (1 –3) 12 .9140 1 (1 –2) 13 1 (1 –2) 12 .9848 1 (1 –2) 13 1 (1 –2) 12 .79Note: For dogs requiring rescue analgesia, subsequent pain scores were excluded from statistical analyses.Abbreviations: CMPS-SF, Glasgow composite mean pain score, short form; LB, liposomal bupivacaine.ALDRICH ET AL . 725 1532950x, 2023, 5, have BW distribution data collected at all time points.Mean %BW distvalues for the operated hindlimb atpreoperative baseline did not differ between the LB(6.7 ± 4.0%) and placebo groups (7.5 ± 4.7%) ( p=.61) atany postoperative time point (Table 4).3.5 |Relationship between pain scoreand %BW distAnalysis of linear correlation between CMPS-SF painscores and %BW distpooled to include all study partici-pants did not demonstrate a statistically significant rela-tionship at any time point, with Pearson's rvalues of .11,.23, .02, /C0.24,/C0.19 at preoperative baseline, and 4, 12,24 and 48 h, respectively.3.6 |Adverse eventsAdverse postoperative events were observed in five dogsduring the study; three in the LB group and two in theplacebo group. Within the LB group, two dogs had inci-sional complications. One dog was noted to have bandagestrikethrough at 4, 8, and 20 h postoperatively thatresolved with placement of a soft padded compressionbandage. Another dog had focal serosanguineous dis-charge at 24 h postoperatively that resolved with place-ment of a single surgical staple to improve skinapposition. One dog in the LB group became mildly cageaggressive and less cooperative over time; however, wewere able to complete pain scoring and bodyweight dis-tribution measurements. Within the placebo group, onedog regurgitated at 42 h postoperatively and another dogwas noted to have soft but formed stools.3.7 |Post hoc sample size calculationThe size of the treatment effect observed for %BW distwassmaller than estimated before the study was initiated.Effect size (Cohen's d) for %BW distranged from 0.27 to0.75; at a power of 0.80 and significance ( α) of 0.05, atotal of 58 –436 dogs would have been needed to detectdifferences in %BW distbetween treatment groups.4

Question 142

Bruckner - 2024 - JAVMA - Advantages of laparoscopic-assisted ovariohysterectomy versus open ovariohysterectomy for dogs with pyometra not detected in randomized clinical trial.pdf

Answer 142

Study design and animalsBetween June 1, 2016, and December 31, 2019, all dogs diagnosed with pyometra were prospectively enrolled in this study if the patients were stable and if the ultrasonographical (Logiq E9; GE) measured diameter of the uterus did fit into the following cat -egories. Uterine diameter in dogs between 5 and 15 kg should be below 2 cm, in dogs between 15 and 35 kg should be below 3 cm, and in dogs above 35 kg of body weight should be < 4 cm. Results of the general physical examination were recorded, and CBC and biochemical profile as well as CRP were analyzed. Ethical approval was provided by the Jordbruksver -ket (Swedish Authority) with the diary No. C42/16. An informed owner consent form was signed by the owners at the time of inclusion. Thereafter, all suit -able patients were randomly assigned to one of the treatment groups, LaOVH or OS, by a coin toss.Anesthetic protocolThe same standardized anesthetic protocol was used in both groups. After preoxygenation, patients were premedicated IV with 0.5 mg/kg diazepam (Di -azedor vet [5 mg/mL]) and 0.5 mg/kg methadone (Insistor vet [10 mg/mL]). Induction was performed IV with propofol (PropoVet Multidose [10 mg/mL]) to effect. Patients were endotracheally intubated, and anesthesia was maintained with isoflurane in ox -ygen using a rebreathing circuit. Meloxicam (Meta -cam för hund och katt [5 mg/mL]) was administered SC with a dose of 0.2 mg/kg shortly after induction. Intraoperative monitoring included capnography, pulse oximetry, ECG, noninvasive blood pressure, and temperature every 5 minutes. If deemed neces -sary by the attending anesthesiologist, intraopera -tive rescue analgesia could be provided in 0.1-mg/kg increments of methadone.SurgeryAll surgeries were performed by the same sur -geon, experienced in both laparoscopic and OS. Dif -ferent staff members were assisting with holding instruments in the LaOVH group, but they were not performing any active parts of the surgery. In both groups, the abdomen was aseptically prepared and patients were transferred to the surgical suite, where they were positioned in dorsal recumbency and connected to a ventilator (Care station 650; GE). Ven -tilation was set to a pressure-controlled mode, start -ing with an inspiratory pressure of 10 cm H2O. Fre -quency was adjusted to keep the end-tidal carbon dioxide between 35 and 45 mm Hg. Abdominal ac -cess was performed in the LaOVH by a visual entry technique described by Anderson and Fransson25 in the umbilicus with the help of a 6-mm Ternamian En -dotip trocar (Karl Storz) in combination with a 5-mm, 30° laparoscope (Karl Storz). Insufflation was set to a pressure of 8 mm Hg and a flow rate of 1.5 L/min. After the selected pressure was reached, a second 6- or 12-mm Ternamian Endotip trocar (Karl Storz) was placed under direct visualization with the endoscope at the level of the bladder apex.With both ports in position, patients were ro -tated manually into an about 45° right lateral recum -bency to allow visualization of the left ovary. The proper ligament was grasped with an endoscopic grasping forceps (CLICKline Dissecting and Grasp -ing Forceps; Karl Storz) and lifted toward the ven -tral abdominal wall. A needle-suture combination was percutaneously inserted under visual guidance through the bursa to allow temporary fixation of the left ovary toward the abdominal wall. The suture was fixated with a hemostat on the outside as close to the body wall as possible. The endoscopic grasping forceps was exchanged with a 5- or 10-mm Caiman handpiece (Aesculap), and the suspensory ligament, ovarian pedicle, and mesometrium were sealed and transected with the help of the vessel-sealing device (VSD). The mesometrium was transected as far cau -dally as the elevated uterus allowed. The suture was released and pulled out from the abdomen, allowing the left ovary and uterus to be free in the abdomen. The same procedure was performed on the right side after turning the patient into 45 degrees left lateral recumbency. After completing the right side, the patient was turned back into dorsal recumbency. In contrast to the left side, the ovary was still fixed to the abdominal wall with the help of the percutane -ously placed needle-suture combination. The Cai -man VSD was exchanged with the endoscopic grasp -ing forceps, and the right ovary was grasped.An Alexis wound retractor (AWR; Alexis Wound Retractor [small, 2.5 to 6.0 cm]; Applied Medi -cal) was prepared by placing a mosquito forceps through both rings. A skin incision approximately the length of the preoperatively measured diameter of the uterus was made with a No. 10 blade starting at the level of the caudal port and extending crani -ally. Thereafter, the carbon dioxide insufflation was turned off; the caudal trocar was removed from the abdomen, leaving the endoscopic grasping forceps in place; and a full-thickness incision was performed at the level of the previous skin incision with the help of Mayo scissors along the endoscopic grasping for -ceps under visual guidance. The right ovary was ex -teriorized and grasped with the mosquito forceps, preplaced through the AWR. At that time point, the needle-suture combination was pulled out, the en -doscopic grasping forceps was removed, and the green interior ring of the AWR was inserted into the Unauthenticated | Downloaded 02/25/24 04:51 PM UTC 3abdominal cavity. The remaining device was rolled down on itself to expand the abdominal incision into a round opening. The entire uterus was then exte -riorized through the AWR, and a modified Miller’s knot and 1 transfixing suture on each side were per -formed with poliglecaprone suture of appropriate size caudal to the cervix before transection of the uterine body. The abdominal incisions were routinely closed in 3 layers.Open ovariohysterectomy was performed with the same anesthesia protocol and settings of the anesthesia machine. A standard midline skin inci -sion was performed, starting slightly cranial to the umbilicus. Electrocautery was used for hemostasis of larger vessels in the subcutis, but held to a minimum. After entering the abdominal cavity, digital transec -tion of the suspensory ligament of the left ovary was performed with a caudomedially directed force. A 2-clamp technique was used on the ovarian pedicle and ligation performed with 1 sliding knot and ap -propriately sized poliglecaprone suture material. This was followed by ligation and transection of the right pedicle in the same manner. The uterine body was ligated with the same technique as described for the LaOVH group, and abdominal closure was rou -tine in 3 layers.In both groups, the following variables of inter -est were monitored: time for placement of both ports in the LaOVH group or time for surgical incision in the OS group, both starting when the scalpel blade first touched the skin. Other variables were the time for sealing and transection or ligation of the left and right ovarian pedicles (including temporary percuta -neous fixation in the LaOVH group and digital tran -section of the suspensory ligament in the OS group) and ligation and transection of the uterine stump (in -cluding placement of the AWR in the LaOVH group) as well as closure time. Total surgery time was de -fined as the time from the scalpel first touching the skin until the placement of the last suture was fin -ished. All measurements were recorded in minutes. In addition, all intraoperative complications as well as technical difficulties in the LaOVH group were re -corded. Finally, total incision length, combining both incisions in the LaOVH group, was measured in both groups with a linear ruler before protecting the sur -gical site with an absorbent dressing.Postoperative care and monitoringAt the time when the anesthesia gas was turned off, all patients received 0.1 mg/kg of methadone once IM, and the postoperative serum sample for CRP analysis was taken. Pain scoring according to a short form of the Modified University of Melbourne Pain Scale was started at 2, 4, 8, 12, 16, and 24 hours after surgery. Patients were housed in the intensive care unit during the 2 days after the surgical pro -cedure to assure continuous monitoring by nurses trained in pain scoring. Rescue analgesia with 0.2 mg/kg of methadone IM was provided in case the patients scored higher than 6.26 Meloxicam was pro -vided orally according to body weight once daily 24 and 48 hours postoperatively. Additional serum samples for CRP analysis were collected 24 and 48 hours after the initial sample, as a marker for surgical trauma and inflammation.Furthermore, the recovery period was assessed, in -cluding time to standing and time to the first water and food intake. Water and food were provided when pa -tients stood up the first time. All patients were discharged on day 2 after surgery, and a recheck examination was planned for the time of suture removal, to record for any medium-term complications postoperatively.Statistical analysisStatistical analysis was performed with Prism Windows 5 (Graph Pad Software). Normality was an -alyzed by the D’Agostino & Pearson normality test. Data are presented as median and range. Differences in results for variables of interest were compared be -tween groups using the Mann-Whitney U test, except the number of dogs requiring rescue analgesia was analyzed via the Fisher exact test, and OR and 95% CIs were presented. Values of P ≤ .05 were consid -ered statistically significant.ResultsSignalment and clinical presentationIn total, 12 female dogs could be included in the study. One dog from the LaOVH group was excluded from analysis, since there was a scant amount of free abdominal fluid leaking from the left salpinx tube and moderate peritonitis detected after insufflation was started. This patient was converted to OS to al -low adequate lavage of the abdominal cavity and ex -cluded from further analysis.Median body weight of the remaining 5 dogs was 22.0 kg (range, 7.0 to 40.0 kg) in the LaOVH group and 17.9 kg (range, 7.6 to 39.0 kg) in the OS group ( P = .792). Median age in the LaOVH group was 97.0 months (range, 90.0 to 104.0 months) and 99.5 months (range, 78.0 to 124.0 months) in the OS group ( P = 1.000). Breeds included 9 purebred dogs and 3 mixed-breed dogs.The most common clinical signs were vaginal discharge (n = 10), lethargy (8), anorexia (6), and polyuria/polydipsia (5). None of the patients pre -sented due to fever.Diagnostic evaluationResults of a CBC before surgery showed mild to moderate leukocytosis in 6 patients (median, 25.5 X 103/μL; range, 22.5 X 103 to 34.7 X 103/μL; reference interval, 6 X 103 to 17 X 103/μL), monocytosis in 4 (median, 3.6 X 103/μL; range, 2.3 X 103 to 4.3 X 103/μL; reference interval, 0.2 X 103 to 1.4 X 103/μL), and mild thrombocytopenia in 1 (110 X 103/μL; reference interval, 150 X 103 to 500 X 103/μL). Results for se -rum biochemical profiles were unremarkable for all patients, except for 1 dog with high serum alanine aminotransferase activity (180.7 U/L; reference lim -it, < 84.4 U/L).Abdominal ultrasonography confirmed a fluid-filled uterus in all dogs. Median uterine diameter was Unauthenticated | Downloaded 02/25/24 04:51 PM UTC4 2.2 cm (range, 0.9 to 3.5 cm) in the LaOVH group and 1.6 cm (range, 1.2 to 3.1 cm) in the OS group ( P = .359).Surgical timeTotal surgery time in the LaOVH group was sig -nificantly longer, with a median surgery time of 37 minutes (range, 24 to 44 minutes) compared to 22.5 minutes (range, 18 to 26 minutes) in the OS group ( P = .017). Looking into each step of surgery, there was a significant difference in the time needed for port placement in the LaOVH group (5 minutes; range, 3 to 9 minutes) compared to a median time for the surgical incision of 1 minute (range, 1 to 2 minutes) in the OS group ( P = .007). Furthermore, the time for the ligation of the uterine body was significantly lon -ger in the LaOVH group, with a median of 6 minutes (range, 4 to 8 minutes), compared to a median of 2 minutes (range, 2 to 4 minutes) in the OS group ( P = .011). There was no significant difference between the time for ligation or respective sealing and tran -section of the ovarian pedicles and mesometrium, as well as for the closure time (Table 1) .Total incision lengthTotal incision length was significantly shorter in the LaOVH group, with a median of 38 mm (range, 26 to 56 mm) compared to 106 mm (range, 85 to 142 mm) in the OS group ( P = .004).Pain scores and rescue analgesiaRescue analgesia during surgery was required by 2 dogs in the OS group at the time of digital transec -tion of the left suspensory ligament and by 1 patient in the LaOVH while lifting the left ovary ( P = .455; OR, 6.1; 95%CI, 0.2 to 162.9). Postoperative rescue analgesia due to pain scores > 6 was required for 3 dogs in the OS group at 4 time points; all of those had a pain score of 7, whereas none of the dogs in the LaOVH needed additional postoperative analgesia ( P = .1818; OR, 11; 95%CI, 0.4 to 284.5). Nevertheless, pain scores including the dogs with rescue analgesia were not statistically significantly different between the 2 groups throughout all time points (Table 2) .Recovery periodNo significant difference between any of the re -covery variables, including time to extubation, time to stand up, time to drink, and time to eat, was ob -served (Table 3) .Intra- and postoperative complications and technical difficultiesIn 1 dog in the LaOVH group, problems occurred with insertion of the cranial portal, which prolonged the procedure time by 6 minutes. In another dog of the LaOVH group, it was not possible to reach the left ovary before the patient was positioned in nearly complete right lateral recumbency. In addition, leak -age of carbon dioxide from the caudal portal was observed in 1 patient due to a defective rubber valve of the trocar. This was in the patient with the longest procedure time of 44 minutes.The only reported complication was a surgical site infection in a dog in the OS group 4 days after surgery, which resolved after empirical antimicrobial treatment until the time of suture removal.CRP—Serum CRP concentrations were initially high in all but 1 dog, with no difference between groups ( P = .464). Also, postoperative CRP concen -trations remained high without statistically signifi -cant differences between groups at the time of dis -charge (Table 4) .OutcomeAll dogs survived to discharge, and all dogs were hospitalized for an additional 2 days postoperatively according to the study protocol. Besides 2 dogs, all returned for suture removal between 10 and 14 days; the remaining 2 dogs got the sutures removed at the local veterinarian. Both veterinarians provided im -ages of the incision site at the time of suture removal for evaluation, and a telephone follow-up with the owner was undertaken a few days later.Variable LaOVH OS P valueTotal surgical time (min) 37 (24–44) 22.5 (18–26) .017Time for surgical incision (min) 5 (3–9) 1 (1–2) .007Time for left ovary removal (min) 2 (2–9) 2 (1–3) .245Time for right ovary removal (min) 3 (2–5) 3.5 (1–4) .777Time for ligation of the uterus (min) 6 (4–8) 2 (2–4) .011Time for closure (min) 8 (10–12) 11 (9–12) .497Length of incision (mm) 38 (26–56) 106 (85–142) .004Data reported as median and range.Table 1 —Comparison (Mann-Whitney U test) of results for surgical variables for 11 dogs with pyometra treated with laparoscopic-assisted ovariohysterectomy (LaOVH; n = 5) versus open-surgery (OS; 6) ovariohysterectomy between June 1, 2016, and December 31, 2019.Table 2 —Comparison (Mann-Whitney U test) of pain scores (Melbourne pain scale) after surgery for the dogs described in Table 1.Time after surgery (h) LaOVH OS P value2 2 (0–6) 0.5 (0–5) .3994 2 (0–6) 4 (0–7) .5088 2 (0–2) 2.5 (0–5) .74212 2 (0–2) 5.5 (0–7) .32416 1.5 (1–2) 3 (0–7) .32924 1.5 (0–3) 2 (0–5) .743See Table 1 for key.Unauthenticated | Downloaded 02/25/24 04:51 PM UTC 5

Question 143

Pan - 2023 - JAVMA - Addition of two full-thickness simple interrupted sutures to standard incisional gastropexy increases gastropexy biomechanical strength.pdf

Answer 143

Forty-one pigs were euthanized due to reasons unrelated to this study. The pigs were euthanized be -tween 4:00 pm and 6:00 pm on 3 different consecutive days (day 1, n = 14; day 2, 14; and day 3, 13). Their entire stomachs and right abdominal walls were har -vested and stored overnight at 5 °C in lactated Ring -er’s solution (LRS). Amounts of time in the chiller were similar across all samples (17 hours ± 30 min -utes). Each pair of stomach and body wall was placed in 1 ziplock bag (Ziploc; SC Johnson & Son Inc) and labeled with a number corresponding to the number identification of that pig. Numbers were randomized and evenly distributed into 2 groups. Four samples (2 MIG and 2 SIG) were excluded from surgery due to poor sample quality. The matched tissues in each group were assigned to receive either SIG or MIG by the same person, a board-certified small animal sur -geon, in the morning following tissue harvest. The 2 groups were labeled 1 and 2.The procedures of SIG and MIG were as follows: a 3-cm full-thickness incision in the transversus abdominis muscle was made with a No. 10 scalpel blade. Then, Metzenbaum scissors were used to make a 3-cm inci -sion in the serosa and muscularis of the stomach on the ventral surface of the pyloric antrum. This incision was extended by blunt separation of the muscularis from the submucosa with Metzenbaum scissors fol -lowed by a linear cut until the gastric seromuscular incision was the same length (3 cm) as the abdomi -nal wall incision. The measurements of these incisions were recorded (Figure 1) . The first bite of suture (0 polypropylene) was placed from the caudal portion of the abdominal wall incision to the left portion of the gastric incision and tied so that the strands were located caudally. The free end of the suture was left long enough to eventually be tied again and tagged with a hemostatic forceps. Then, the dorsally located transversus abdominis and gastric seromuscular edg -es were apposed with a simple continuous suture pat -tern. After reaching the cranial extent of the incisions, the simple continuous pattern was continued in a cau -dal direction, apposing the ventrally located transver -sus abdominis and gastric seromuscular wound edges until the free end of the original knot was reached. Figure 1 —Incisional gastropexy using porcine tissue and 0 polypropylene suture. A—The transversus abdominis muscle was incised to create a 3-cm incision, and Metzenbaum scissors were used to make an incision of the same length in the serosa and muscularis of the stomach on the ventral surface of the pyloric antrum. B—The dorsally lo -cated transversus abdominis and gastric seromuscular edges were apposed with a simple continuous suture pattern from caudal to cranial. C—The standard incisional gastropexy was completed by apposition of the ventral transversus abdominis and gastric seromuscularis incised edges. D—The modified incisional gastropexy was completed by add -ing the cranial (white arrow) and caudal (black arrow) full-thickness simple interrupted sutures. Cranial is to the top of the photos.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 08/30/23 11:58 AM UTC JAVMA | SEPTEMBER 2023 | VOL 261 | NO. 9 1347The suture line was completed by removing the he -mostatic forceps and tying (3 square knots) to the free end. For those receiving MIG, 2 additional simple interrupted sutures (0 polypropylene) were placed, 1 immediately cranial and 1 immediately caudal to the continuous suture line. These sutures were placed full thickness into the stomach (to ensure submucosa was included) and transversus abdominis muscle. A new pack of 0 polypropylene was used for each gastro -pexy specimen. The specimens were placed in indi -vidual bags containing LRS for transport to the test -ing laboratory. All specimens were tested on the same day the gastropexies were performed.For biomechanical testing, the stomach and at -tached section of abdominal wall, including the gastro -pexy site, were removed from the LRS. A tensile test machine (eXpert 2600; Admet Inc) was used to mea -sure the force change and breaking force of the suture or tearing force of the sutures when abdominal and gastric tissue were stretched away from each other. The abdominal wall tissue was secured in the top grip (surface area, 2,280 mm2/face), and the gastric tissue was secured in the bottom grip with the same surface area (Figure 2) . The top grip moved upward at a con -stant rate of 20 mm/min. The test process was stopped after the point of failure when the maximum tension was reached. Work done to reach failure, defined as area under the curve with failure load as the end point, was calculated for each sample (Figure 3) . The MTEST -Quattro software ( MTESTQuattro version 5.07.07 ; Ad-met Inc) was used to record the generated tension (N). A curve reflecting the change in tension and a corre -sponding comma-separated values file containing in -formation regarding position and load were produced by the software. The entire process was videotaped for each specimen using a smartphone (iPhone 8; Apple Inc). After each test, specimens were examined to de -termine whether the mode of failure was caused by su -ture breakage, untied knot, or tissue tearing.Statistical analysisAll collected test group data were tabulated and analyzed. Data were evaluated for normality with the Shapiro-Wilk test. The Mann-Whitney U test was used to compare body weights of SIG and MIG pigs. Figure 2 —Porcine stomach (in bottom grip) and abdominal wall (in top grip) in position on the tensile testing ap -paratus (A) before distraction and (B) after maximum tension was reached.Figure 3 —Representative tensile curve of standard in -cisional gastropexy (SIG) in sample number 4 versus modified incisional gastropexy (MIG) in sample num -ber 13. The black arrow indicates the point of failure of sample number 13. The gray shadow indicates the work of sample number 13 to reach point of failure.Figure 4 —Box plot showing body weights (in kilograms) of all sample sources. The horizontal line represents the median value, the upper and lower limits of the box repre -sent the IQR (25th to 75th percentile), and the upper and lower whiskers represent the highest and lowest values.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 08/30/23 11:58 AM UTC1348 JAVMA | SEPTEMBER 2023 | VOL 261 | NO. 9The Student t test and linear regression analysis with body weight as adjusting factors were used to com -pare the 2 groups of data with a significance value set at P ≤ .05. All statistical analysis was performed using R software.15ResultsForty-one samples were harvested. Four samples were excluded due to poor sample quality (incom -pletely harvested tissue making performing gastro -pexy impossible). Thirty-seven samples were tested mechanically, and all data (SIG, n = 19; MIG, 18) were included. There was no significant difference between body weights of sample sources between groups (SIG, 14.66 ± 2.80 kg; MIG, 12.78 ± 2.15 kg; P = .1) (Figure 4) . The maximum load (N) at failure and the work (N·mm) performed are recorded elsewhere (Supplementary Table S1) . The MIG group failed at a higher load (SIG, 52.33 ± 7.61 N; MIG, 67.16 ± 11.61; P = .00003) and required more work to fail (SIG, 19.867 ± 5.07 N·mm; MIG, 32.10 ± 10.63 N·mm; P = .00004) compared to the SIG group (Figure 5) . MIG strongly predicts higher failure load (R2 = 0.4; P = .00016) and higher work to failure (R2 = 0.4; P = .00013). All fail -ures were caused by tearing of gastric tissue. No su -ture breakage or knot untying was observed.Figure 5 —Violin plot comparing SIG (n = 18) versus MIG (19) for (A) failure load (N; P = .00007) and (B) failure work (N·mm; P = .00003). The width of shading represents the number of samples, the horizontal line represents the median value, the upper and lower limits of the box represent the IQR (25th to 75th percentile), and the upper and lower whiskers represent the highest and lowest values. Linear regression was performed using SIG or MIG as pre -dictor variable, load (C; R2 = 0.4; P = .00016) and work (D; R2 = 0.4; P = .00013) as dependent variables, and body weight as adjusting variable. Shading represents the 95% CI.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 08/30/23 11:58 AM UTC JAVMA | SEPTEMBER 2023 | VOL 261 | NO. 9 1349

Question 144

Pye - 2024 - JSAP - Current evidence for non-pharmaceutical, non-surgical treatments of canine osteoarthritis.pdf

Answer 144

NA

Question 145

Sasaki - 2023 - VCOT - Measurement of Femoral Trochlear Morphology in Dogs Using Ultrasonography.pdf

Answer 145

of measurement that can re flectthe articular cartilage surface, such as ultrasonography or MRI,would enable a more accurate evaluation of femoral trochlearm o r p h o l o g y .M R Ih a sa na d v a n t a g eo v e ru l t r a s o n o g r a p h yi nt h a tit can be used for three-dimensional analyses. However, MRIcannot be performed without general anesthesia or sedation inveterinary medicine. In addition, because MRI is costly and time-consuming, its availability as a screening test to assess femoraltrochlear morphology is low. Ultrasonography has some advan-tages in that it reduces the need for general anesthesia or sedation,is convenient, and can visualize both osseous and cartilaginousfemoral trochlear morphologies. Thus, we expect that ultraso-nography can be used as a screening test for femoral trochlearmorphology in dogs. However, there are issues regarding thereliability of the measurement method using ultrasonographybecause of the fact that measurement results can vary dependingon the angle or measurement position of the ultrasonic probe. Aprevious study in human medicine reported that reliability ofultrasonography for measuring the femoral trochlear morpholo-gy is poor.18However, there was no evidence regarding the probeangle adopted in the study. In addition, the position at which theprobe was applied was not speci fied,18which may have increasedthe measurement error. In a previous study, we found the femoraltrochlear morphology gradually deepens from the proximal partof the femoral trochlea to the deepest point, which is described inthe plane 75 degrees to the femoral axis, and then shallows againtoward the distal part of the femoral trochlea.23Therefore, weassumed it would be possible to unify the measurement positionby using the deepest position of the femoral trochlea as alandmark, leading to improved reliability. In the present study,we uni fied the measurement position and angle for the mea-surement of femoral trochlear morphology in dogs using thedeepest position of the femoral trochlea as a landmark, andexamined the reliability of the measurement method usingultrasonography. First, we evaluated the intra- and interraterreliability of ultrasonography for measuring femoral trochlearmorphology in dogs. Then, we evaluated the correlation betweenultrasonography and CT or MRI for measuring femoral trochlearmorphology in dogs. We also surveyed the SA in dogs withoutskeletal disorders using ultrasonography as the reference forfemoral trochlear morphology in dogs.Materials and MethodsValidation of the Measuring Method UsingUltrasonography to Assess Femoral TrochlearMorphology in DogsWe used 10 sti fle joints from 5 experimental beagle dogs(Institute for Animal Reproduction, Ibaraki, Japan). The meanage was 37.6 /C67.6 months, and the mean body weight was9.1/C60.9 kg. All dogs were skeletally normal on palpation andshowed normal gait. The dogs used in the current study wereeuthanatized as part of an unrelated study. The protocol foreuthanasia was approved by the Animal Committee of theGraduate School of Agricultural and Life Sciences at the Univer-sity of Tokyo (protocol number: P16-229). The dogs were placedin a lateral recumbent position, and the sti fle joint of the dogswasflexed at an angle of /C2060 degrees so that the patella wouldnot interfere in the measurement. Femoral trochlear morphol-ogy was assessed using a diagnostic ultrasound system (ARIET-TA Prologue; Hitachi, Ltd., Tokyo, Japan) with a 5.0- to 18.0-MHzlinear array probe (L64; Hitachi, Ltd.). An acoustic coupler (SF-001; Hitachi, Ltd.) was attached to the head of the probe with aplastic attachment (EZU-TEACTC2; Hitachi, Ltd.). We thenplaced the probe on the proximal part of the femoral trochleaat an angle of 75 degrees to the femoral axis and set the positionof the probe at the deepest part of the femoral trochleareviewing the ultrasonographic images. The angle of the probewas determined according to a previous study.23After making afine adjustment of the probe to the position at which we coulddescribe the contour of the osseous and cartilaginous femoraltrochlear surface most clearly, we obtained transverse images ofthe femoral trochlea ( ►Supplementary Video 1 , available inonline version). Based on the obtained images, we measured theSA as the angle formed by the lines connecting the most caudalpoint of the femoral trochlea and the most cranial points of themedial and lateral trochlear ridges. The SAwas measured for thecontour of the subchondral bone (Bony Sulcus Angle (BSA)) andthe contour of the articular cartilage (Cartilaginous Sulcus Angle(CSA);►Fig. 1 ). To evaluate intrarater reliability, one examinermeasured the BSA and CSA for 10 sti fle joints. Five measure-ments each were performed on three different days. Theexaminer started the measurement from positioning the dogson each day, and reset the sti fle joint angle on each measure-ment. The mean values of the five measurements were.calculated for each day, and they were used for calculation of theintraclass correlation coef ficient (ICC). To evaluate interraterreliability, three examiners measured the BSA and CSA for 10stifle joints. Five measurements each were performed by threedifferent examiners. Each examiner started the measurementfrom positioning the dogs and then resetting the sti flej o i n tangle on each measurement. The mean values of the fivemeasurements were calculated for each examiner, and theywere used for calculation of the ICC. As a parameter for intra-and interrater reliability, the ICC was calculated based on a studyby Shrout and colleagues.27To evaluate the intra- and interraterreliability, the ICC (1, 1) or ICC (2, 3) was calculated.Supplementary Video 1We placed the probe on the proximal part of the femoraltrochlea at an angle of 75 degrees to the femoral axisand set the position of the probe at the deepest part ofthe femoral trochlea reviewing the ultrasonographicimages. Online content including video sequences view-able at: https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0043-1770902.CT (Aquilion PRIME, 0.5-mm slice thickness, Canon MedicalSystems Corporation, Tochigi, Japan) tests and MRI (VantageGalan 3T, Canon Medical Systems Corporation) tests wereconducted for 10 sti fle joints of the same 5 dogs. Multiplanarreconstruction (MPR) was performed using the CT and MRI dataobtained. Transverse images of the femoral trochlea, which was75 degrees to the femoral axis, were obtained. The BSA wasmeasured using CT and MRI. The CSA was measured using MRI.Spearman ’s correlation coef ficient was calculated between themeasured values using ultrasonography and CT or MRI.28Survey of Femoral Trochlear Morphology UsingUltrasonography in Dogs without Skeletal DisordersAll diagnostic procedures, including palpation and ultraso-nography, were performed with the owner ’s consent. Dogsweighing less than 15 kg without skeletal disorders thatunderwent ultrasonography for both sti fle joints at twoveterinary hospitals (Veterinary Medical Center of the Uni-versity of Tokyo, Tokyo, Jap an; Kiyos umi-Shiraka wa AnimalClinic, Tokyo, Japan) between September 2017 and Octo-ber 2019 were included in this study. Dogs with lameness orskeletal disorders were excluded. The dogs were placed in alateral recumbent position, and the sti fle joint of the dogswasflexed at an angle of /C2060 degrees so that the patellawould not interfere in the measurement. We then placed theprobe on the proximal part of the femoral trochlea at anangle of 75 degrees to the femoral axis and set the position ofthe probe at the deepest part of the femoral trochlea review-ing the ultrasonographic images. After making a fine adjust-ment of the probe to the position at which we could describethe contour of the osseous and cartilaginous femoral troch-lear surface most clearly, we obtained transverse images ofthe femoral trochlea. Based on the obtained images, the BSA,CSA, and thickness of the articular cartilage of the femoraltrochlea were measured. The thickness of the articularcartilage of the femoral trochlea was measured at the mostcranial point of the medial trochlear ridge, middle of thefemoral trochlea, and most cranial point of the lateraltrochlear ridge (►Fig. 1 ). The dogs were divided by ageinto the following four age groups: under 1, 1, 2, and 3 ormore years. The data for each parameter were analyzed usingthe Kruskal –Wallis test followed by the Steel –Dwass test. Inaddition, the dogs younger 1 year were divided by age inmonths, and the measured values at each month of age werecompared to those at /C2112 months of age using the Kruskal –Wallis test followed by the Steel test.All the image analyses were conducted using an imageanalysis software (Horos ver. 3.3.6, Horos Project, Annapolis,Maryland, United States). All statistical analyses were con-ducted using EZR (Saitama Medical Center, Jichi MedicalUniversity, Saitama, Japan), a graphical user interface for R(The R Foundation for Statistical Computing, Vienna,Austria).29The results are presented as the mean /C6standarddeviation. Statistical signi ficance was set at p<0.05.ResultsValidation of the Measuring Method UsingUltrasonography to Assess Femoral TrochlearMorphology in DogsThe ICC (1, 1) calculated based on the values measured fivetimes on 3 different days for 10 sti fle joints by a single raterwas 0.97 (95% con fidence interval [95%CI]: 0.93 –0.99) for theBSA and 0.97 (95%CI: 0.94 –0.99) for the CSA. The ICC (2, 3)calculated based on the values measured five times for 10stifle joints by three raters was 0.93 (95%CI: 0.85 –0.98) forthe BSA and 0.92 (95%CI: 0.83 –0.99) for the CSA. Spearman ’scorrelation coef ficient between the BSA measured withultrasonography and CT was 0.72 ( p¼0.02). Spearman ’sFig. 1 A representative ultrasonographic image of the femoraltrochlea. The arrows indicate the most cranial points of the medial andlateral trochlear ridges and the most caudal point of the femoraltrochlea on the cartilaginous cont our of the femoral trochlea. Thearrowheads indicate the osseous contours of the femoral trochlea. Thesulcus angle (SA) was measured as the angle formed by the linesconnecting the three points. The SA was measured for the contour ofthe subchondral bone (BSA) and the contour of the articular cartilage(CSA). The thickness of the articular cartilage was measured betweenthearrow and arrowhead at the most cranial point of the medialtrochlear ridge, middle of the femo ral trochlea, and the most cranialpoint of the lateral trochlear ridge..correlation coef ficient between the BSA measured withultrasonography and MRI was 0.90 ( p¼0.001). Spearman ’scorrelation coef ficient between the CSA measured withultrasonography and MRI was 0.89 ( p¼0.001; ►Fig. 2 ).Survey of Femoral Trochlear Morphology UsingUltrasonography in Dogs without Skeletal DisordersA total of 184 sti fle joints from 92 dogs were included in thisstudy (22 males, 6 neutered males, 57 females, and 7neutered females). The number of dogs and body weightfor each age group are shown in►Table 1 . The number ofdogs under 1 year of age for each age in month is shownin►Table 2 . The breed of dogs are shown in ►SupplementaryFile 1 (available in online version).Representative ultrasonographic images of the femoraltrochlea are shown in ►Fig. 3 . The BSA and CSA for each agegroup are shown in ►Fig. 4 . The BSA and CSA were149.9 /C616.5 and 139.8 /C65.8 degrees for dogs younger than1 year, 142.7 /C64.2 and 139.0 /C65.4 degrees for 1-year-olddogs, 140.0 /C66.0 and 137.3 /C65.0 degrees for 2-year-olddogs, and 140.5 /C66.9 and 139.4 /C66.5 degrees for dogs aged3 years or older. The BSA of dogs younger than 1 year variedmore widely than the BSA of dogs that were /C211 years, and itwas signi ficantly higher than that of dogs that were 2 and /C213years old. There were not any signi ficant differences in theCSA between the age groups. The BSA and CSA at each monthof age for dogs younger than 1 year and those /C2112 months areshown in ►Fig. 5 . The BSA of dogs aged 3, 4, and 5 monthswas signi ficantly higher than that of dogs aged /C2112 months.In contrast, the CSA of dogs at each age in month did not differfrom that of dogs aged /C2112 months.The thicknesses of the articular cartilage of the femoraltrochlea for 92 dogs were 0.5 /C60.5, 0.3 /C60.2, and0.4/C60.5 mm for the medial, middle, and lateral cartilage,respectively. The cartilage thicknesses at each month of agefor dogs younger than 1 year and those of dogs aged /C2112months are shown in►Fig. 6 . The medial and middlecartilage thicknesses of dogs aged 3, 4, and 5 months weresignificantly higher than in dogs aged /C2112 months. Thelateral cartilage thickness of dogs aged 3 months was signi fi-cantly higher than in dogs aged /C2112 months.

Question 146

Larose - 2024 - VETSURG - Near-infrared fluorescence cholangiography in dogs - A pilot study.pdf

Answer 146

2.1 |Animals and ICG administrationThis study was conducted in accordance with the guide-lines of the Canadian Council on Animal Care and wasapproved by the Institutional Animal Care Committee atthe University of Guelph, AUP #4383. Eight purpose-bred beagle dogs, four neutered males and four spayedfemales, assessed to be healthy on the basis of a physicalexamination, preoperative complete blood count, bio-chemistry profile and urinalysis were used in this study.Dogs were randomized in two stages using SAS Proc Plan(SAS Institute Inc. 2015. SAS/STAT®14.1. Cary, NorthCarolina) to receive two dose/time combinations. First,each dog was randomized to a dose group (low [L] orhigh [H] dose) and then randomized to a sequence oftime of administration (0 h followed by 3 h, or 3 h fol-lowed by 0 h) in a split plot incomplete crossover design(Table1and Figure 1). Dogs received either low dose(0.05 mg/kg ICG IV) ICG at time 0 h (L0) and 3 h (L3) orhigh dose (0.25 mg/kg ICG IV) ICG at time 0 h (H0) and3 h (H3) given via an IV catheter placed in a cephalicvein. A minimum of 72 h washout period was obtainedbetween each experiment as earlier studies have shownan average of 97.3% of ICG was excreted in bile within6 h following injection with minimal enterohepatic circu-lation.27Dogs were fasted 12 h prior to their surgery.2.2 |ICG administration and histaminelevelsIndocyanine green (25 mg vials; Diagnostic GreenGmbH, Farmington Hills, Michigan) was reconstituted toa 2.5 mg/mL solution according to manufacturer instruc-tions and was given at the studied doses intravenouslywithin 6 h as per the manufacturer's recommendations.Awake animals were subjectively assessed for signs ofadverse effects. Heart rate only and HR and MAP weremonitored immediately prior to, and at 5 and 10 min fol-lowing ICG injection in conscious and anesthetized ani-mals, respectively. Peripheral blood samples werecollected immediately prior to, and within 3 min of ICGadministration, transported on ice, centrifuged to collectplasma and conserved, frozen at /C080/C14C. Plasma hista-mine levels were measured using a histamine enzymeimmunoassay (Immunotech EIA Histamine, Prague,Czech Republic) in a triplicate fashion to generate a2 LAROSE ET AL . 1532950x, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14007 by Vetagro Sup Aef, Wiley Online Library on [05/01/2024]. 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 Licensemean histamine level for each sample. Plasma histaminelevels below <0.8 ng/mL were considered normal.312.3 |ProcedureDogs were premedicated with hydromorphone (0.05 mg/kgIV), induced with propofol (IV, to effect), maintained usingisoflurane on 100% oxygen, and ventilated using intermit-tent positive pressure ventilation. A multiparametric moni-tor (Datex-Ohmeda S/5 Anesthesia Monitor; GEHealthcare, Chicago, Illinois) was used to measure directarterial blood pressure (IBP), heart rate (HR) andrhythm, end-tidal CO2, end-tidal isoflurane, pulse oxime-try, and core body temperature, every 5 min. Periopera-tive antibiotics (cefazolin 22 mg/kg IV q. 90 min) wereadministered. Dogs were instrumented for laparoscopyusing a modified Hasson technique with one 6 mm(instrument) and one 10 mm (camera) laparoscopic tro-cars (Karl Storz Veterinary Endo scopy, Goleta, California).Pneumoperitoneum was established with carbon dioxideinsufflation maintained at 8 mm Hg intraabdominal pressure.For time 0 h groups, dogs were instrumented for laparoscopyprior to injecting ICG intravenously at time 0 h allowing forpre-ICG images to be collected. For time 3 h groups, dogswere anesthetized /C242 h after ICG injection and imagesobtained starting exactly at the 3 h mark. For all dose/timecombinations, images of the biliary tree under white lightand NIRF light were collected every 10 min for 120 minthroughout the procedure. The portal sites were closed in astandard three-layer closure.Dogs were recovered and given a dose of hydromor-phone (0.05 mg/kg subcutaneously) and meloxicam(0.1 mg/kg subcutaneously followed by orally, every24 h) for 2 days. Dogs were returned to the colony after aminimum of 72 h of monitoring.2.4 |Near-infrared imaging systemand image collectionA laparoscopic NIRF imaging system (IMAGE1 S, KarlStorz Veterinary Endoscopy) was used to collect whiteand NIR light images throughout the procedures.TABLE 1 Individual patient characteristics.DogAge(years)Gender FS: female spayed MN:male neutered Weight (kg)Body conditionscore Dose groupProcedure orderrandomization(0 h;3 h or 3 h;0 h)1 5.4 MN 11.6 6/9 Low 0 h;3 h2 2.7 MN 12.2 7/9 Low 3 h;0 h3 2.7 FS 9.6 4/9 Low 0 h;3 h4 5.4 MN 11.2 6/9 Low 3 h;0 h5 2.7 FS 9.4 4/9 High 3 h;0 h6 2.7 FS 10 5/9 High 0 h;3 h7 2.7 FS 11.3 6/9 High 3 h;0 h8 2.7 MN 14.8 9/9 High 0 h;3 hFIGURE 1 Schematic of study methodology.LAROSE ET AL . 3 1532950x, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14007 by Vetagro Sup Aef, Wiley Online Library on [05/01/2024]. 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 LicenseImages were collected with the 0-degree, 10 mm laparo-scope perpendicular to the are a of interest and maintaininga5c md i s t a n c e( m e a s u r e du s i n gag r a d u a t e dl a p a r o s c o p i cprobe) from the target. Conventional and NIR images wereobtained successively by switching light modes (white lightvs. NIR) using a foot pedal while maintaining anatomicalorientation. Near-infrared i mages were recorded and dis-played in a blue overlay on a Karl Storz 4 k monitor.2.5 |Qualitative assessment ofintraoperative fluorescencePostoperative surgeon and assistant qualitative assess-ments of the intraoperative fluorescence and contrastwere performed after each procedure (AppendixA). Bothwere blinded to the dose but were aware of timing ofadministration due to methodology.2.6 |Quantitative analysis of NIRFCimagesOsiriX software ( https://www.osirix-viewer.com/ ; PixmeoSARL, Bernex, Switzerland) was used to measure fluores-cence intensities (FI) of regions of interest (ROIs), as pre-viously described.30Fluorescence images were analyzedin a blinded (to dose and time of administration as wellas order) fashion to determine cystic duct-to-liver ratio(CDLR), as previously described.7,16,32Cystic duct-to-background ratio was determined as the mean FI oftwo ROIs of the CD, divided by the mean FI of two repre-sentative background ROIs in the liver hilum; using thefollowing formula: TBR =(FI of target/FI of background)or more specifically CDLR =FI of CD/FI of liver.7,16,322.7 |Statistical analysisA general linear model (GLM) was fit to determine pre-dictive equations for the change in fluorescence intensi-ties of the liver, CD and contrast ratios over time for thefour groups. Main effects included dose, time of injectionand effect of time since injection. A post hoc pairwiset-test with Tukey adjustment was performed to comparecontrast ratios between groups at selected time points.Modeled equations were used to determine the time ofpeak and value at peak. Histamine levels, mean arterialpressure (MAP) and heart rate (HR) were comparedusing a GLM with the main effects of dose and time (pre-and post-ICG injection). The interaction of dose and timewere modeled for HR and MAP. Histamine was modeledwith dose, time of injection and time in the model.Interobserver agreement from the qualitative assess-ments was analyzed using a weighted Kappa. The indi-vidual Likert survey scores were summed (total score outof 20) and Lin's concordance correlation and a test of thebias was used to test for agreement between observers.As interobserver agreement was excellent, a singleobserver's scores were used in a GLM to test for maineffects of dose and time period as well as their interac-tions. The random effect of a dog within a group wasincluded.All data was checked for normality using a Shapiro –Wilk test and examination of the residuals. Transforma-tions were applied to meet the assumptions of normality.Log transformation was applied to the CDLR ratios, FI ofthe liver and FI of the CD. A logit transformation wasapplied to the summed Likert data. All analyses were per-formed using a commercial statistical software (SAS Insti-tute Inc. 2013. SAS/STAT®9.4) and p< .05 wasconsidered statistically significant.3|RESULTSDogs were a mean age of 3.4 years (2.7 –5.4 years), meanbodyweight of 11.26 kg (9.4 –14.8 kg) and mean body con-dition score of 6/9 (4 –9/9).Each dog successfully underw ent laparoscopic NIRFC.Only mild33adverse reactions associated with the use ofICG or the NIRF imaging system were identified. In patientsreceiving the high ICG dose pri or to anesthesia (time 3 h),rapid onset and short-lived (<60 s) signs consistent withnausea (lip licking and swallowing) were noted immediatelyafter IV injection. There was no overall effect of ICG admin-istration on HR (pre =124 bpm; post =129 bpm; p=.24),nor was there a significant change in HR between the low(130.5 bpm) and the high dose (122.5 bpm) groups ( p=0).There were no significant changes in MAP associated withICG administration (pre L: 98 mmHg; H:104 mmHg; postL : 1 0 0 m m H g ;H :9 9 m m H g )[ p=.86]), pre- or post-administration ( p=. 3 4 1 ) .T h e r ew e r en oo v e r a l ld i f f e r e n c e sin histamine levels pre-ICG administration (0.42 ng/mL)compared to post-administration (0.45 ng/mL) ( p=.64),nor was there a significant change in histamine levels post-ICG injection for low (0.59 ng/mL) compared to high dose(0.32 ng/mL) ( p=.091).Mean anesthetic time was 198 min (165 –445) andmean surgical time was 161 min (130 –405). Technical dif-ficulties with the NIRF equipment led to an exceptionallylong anesthetic time during the first procedure (at time0). After removing this outlier, mean anesthetic time was181 min (165 –210) and mean surgical time was 145 min(130 –170). All dogs recovered uneventfully from theirprocedures. A total of 16 procedures (4 trials per time/4 LAROSE ET AL . 1532950x, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14007 by Vetagro Sup Aef, Wiley Online Library on [05/01/2024]. 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 Licensedose combination) were performed. The mean washoutperiod was 113.6 h (range: 72 –139 h).3.1 |Qualitative assessmentsAll four dose/time combinations provided subjectively andobjectively improved, repeatable, and clinically usefulhepatobiliary visualization at some point throughoutthe studied times (0 –2h a n d 3 –5 h post injection).Near-infrared fluorescence was readily visible within theliver less than 30 s following IV injection in the L0 and H0groups (injection under laparoscopic NIRF visualization).For these groups, arterial fluorescence was noted to appearwithin seconds of IV ICG administration, first seen in thelungs through the diaphragm followed by the vasculatureof the diaphragm and body wall, and hepatobiliary andintestinal vasculature. Visualization of fluorescence withinthe hepatic ducts was noted at /C2410 min, whereas visuali-zation within the common bile and cystic ducts was appre-ciated between 15 and 20 min after injection of ICG andremained visible until study completion for all cases. Noevidence of hepatobiliary or other visceral abnormalitieswere noted on exploratory laparoscopy.Good to excellent agreement was obtained for the tworaters on the individual Likert scores. Weighted Kappa were0.91, 0.81, 0.51 and 0.78 for questions 1, 2, 3, and 4, respec-tively ( p< .0006). Overall agreement was excellent (0.88;0.77 –1) for the total score. No significant bias between raterswas noted with mean difference of 0.375 ( /C00.44 –1.19)(p=.35). Summed Likert data had significantly lowerscores for time of administrat ion 0 h (score 12.5; range 11 –17) compared to time of admin istration 3 h (score 19.5;range 10 –18) ( p< .0001). There was no effect of dose(p=.88), or an interaction of dose with time of administra-tion ( p=.65). Overall, superior visualization scores wereobtained at longer time poin ts from administration.3.2 |Quantitative assessments3.2.1 | Fluorescence intensitiesThe FI of the liver and CD showed a significant posi-tive linear slope for L0 and H0 until they reached theirpeak after which a significant negative quadratic slopewas present ( p< .0001) (Figures 2and 3). The FI peakof the liver for L0 and H0 occurred at 37 and 67 min,respectively whereas the FI peak of the CD were at77 min for both dose groups. The highest FI of the liverand CD were noted at 180 min for L3 and H3. The FIof the liver and cystic duct were greatest in the highFIGURE 2 Liver fluorescence intensity at given times after indocyanine green (ICG) injection. The dotted lines represent the meanfluorescence intensity of the liver hilum for each group. The 95% confidence limits for each group are represented by the solid lines.LAROSE ET AL . 5 1532950x, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14007 by Vetagro Sup Aef, Wiley Online Library on [05/01/2024]. 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 Licensedose groups. Faint residual fluorescence of the gallbladder and biliary tree and negligeable fluorescence ofthe liver was noted in two dogs that underwent H3 fol-lowed by H0 at time 0 (prior to ICG injection) duringthe second event.3.2.2 | Contrast ratios (cystic duct to liverratios)The contrast ratio was above 1 in the L0 group by time20 min and reached its peak at 100 min (Figure 4). In theH0 group, the ratio was above 1 by 60 min and reached itspeak at 90 min. Contrast ratios above 2, (i.e., fluorescencetwice as bright in the CD compared to the liver) weremaintained from 180 to 300 min for L3 and H3 and wasachieved after 80 min for L0. H3 appeared to have justreached plateau (linear slope p=.086; quadraticp=.243) at 270 min. This suggests that H3 ratioscould still increase past 280 min and is considered asignificant trend with a sample size of four dogs perdose/time group. The contrast ratios of L0 were superiorto those of H0 during the entire period of visualization(0–120 min) leading to better visualization of the biliarytree (Figures5and 7). Both doses provided the highestcontrast ratios when administered 3 h prior to surgeryand offered optimal visualization of the biliary tree(Figures 6and 8). However, the contrast ratio differ-ence between L0 (2.003; 1.63 –2.46) at 80 min was nolonger significantly different from H3 at 280 min(2.86; 2.32 –3.51) ( p=.078) which was its peak valuein this study. L0 at 120 min (2.017; 1.58 –2.56) was sig-nificantly different from L3 at 180 min (3.57; 3.12 –5.04) ( p< .0001). The highest contrast ratios wereobtained in group L3 where the CD was nearly fourtimes as bright as the surrounding liver (3.98 [3.19 –4.94]; 280 min).4

Question 147

Banks - 2023 - VETSURG - Influence of extreme brachycephalic conformation on perioperative complications associated with total ear canal ablation and lateral bulla osteotomy in 242 dogs (2010-2020).pdf

Answer 147

2.1 |Patient and clinical dataThe study was approved by the institutional EthicalReview Board at the lead institution (URN SR2019-0199)prior to commencement.Electronic medical records were reviewed to includedogs that underwent TECA-LBO at a single institutionbetween January 2010 and December 2020. Cases that pre-sented for the management of complications resulting fromTECA-LBOs performed at other institutions and cases withr e p o r t sw i t hi n a d e q u a t ed e t a i l regarding presenting signs,treatment, or perioperative outcome were excluded. Casesundergoing concurrent procedures including correctivemultilevel upper airway surgery were excluded.Case details were collected, including signalment,bodyweight, history, clinical signs, duration of presentingcomplaint, lateralization of clinical signs, and diagnostic662 BANKS ET AL . 1532950x, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13964 by Vetagro Sup Aef, Wiley Online Library on [22/07/2023]. 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 Licenseimaging findings (computed tomography, magnetic reso-nance imaging, or both). Breed data were categorizedinto two groups: EBBs (French Bulldogs, English Bull-dogs, and Pugs) or all OBs. Duration of clinical signs wascategorized into four groups: less than 2 weeks, greaterthan 2 weeks but less than 2 months, 2 to 6 months, andgreater than 6 months. The primary presenting complaintwas categorized into four groups: (1) Otitis externa with-out neurological signs, (2) otitis externa, OM, or OI withneurological signs (including peripheral vestibular syn-drome, Horner's syndrome, facial nerve paresis or paraly-sis), (3) aural mass (including those affecting the pinna,vertical and horizontal canal) and (4) other (includingmaxillary pain, facial swelling, and fistulous tract). Forthis study, facial nerve deficits were referred to as paresisrather than paralysis as not all cases had a completeinability to move the muscles of the eyelid, ears, and lips.Clinical signs of BOAS including tachypnea, dyspnea,upper respiratory stertor or stridor, exercise intolerance,or cyanotic episodes were recorded.Diagnostic imaging reports were assessed, and imag-ing modality and findings were recorded. Specific find-ings from the diagnostic imaging report included thepresence of the following: unilateral or bilateral pathol-ogy, ear canal mineralization, an aural mass affecting thepinnal base, vertical canal or horizontal canal, para-auralabscessation, middle ear soft tissue opacity, OI and evi-dence of brainstem changes. Brainstem changes weredescribed as T2-weighted ± fluid-attenuated inversionrecovery (FLAIR) interaxial hyperintensity and menin-geal enhancement on magnetic resonance imaging (MRI)and intracranial contrast enhancement on CT.The surgical records were examined for each patient.TECA-LBO surgeries were either performed uni- or bilat-erally. If bilateral surgery was performed, data for eachear were considered separately. Bilateral procedures wereclassified as single-session when left and right TECA-LBOs were performed under the same general anesthetic.Bilateral staged procedures were classified when left andright TECA-LBOs were performed separately within anytime frame. The anesthetic record was examined to deter-mine the surgical time for each operated ear. All surger-ies were performed by a board-certified specialist inSmall Animal Surgery or a resident under the directsupervision of a specialist.Intraoperative complications, defined as complica-tions occurring between skin incision to closure, wererecorded in the medical records at the time of surgery.When available, microbiology results including the loca-tion from which the sample was obtained, and the cul-ture result were recorded. If a surgical drain was placedbefore closure, the type of drain and time that itremained in place was recorded in days.Duration of hospitalization and survival to dischargewere recorded in days. Follow-up information wasincluded up to the time of discharge. Patient hospitaliza-tion records were examined and the occurrence of newpostoperative clinical examination findings includingfacial nerve paresis, vestibular signs, Horner's syndrome,hemorrhage, extensive focal swelling around the surgicalwound, and incisional dehiscence was recorded.Information regarding perioperative managementwas ascertained from detailed hospital sheets. Postopera-tive monitoring included 24-h monitoring in intensivecare or surgery ward depending on respiratory and car-diovascular stability. Opioid analgesia was provided forall cases with the drug, frequency, and dose individual-ized to the patient based on pain scoring. Where intra- andperioperative antimicrobial and nonsteroidal anti-inflam-matory drugs (NSAIDs) were prescribed, the drug andduration of treatment were recorded.2.2 |Statistical analysisAll statistical analyses were performed using commer-cially available software (IBM SPSS, Statistics, version28.0, IBM Corp, Armonk, New York). Data were assessedfor normality using Shapiro –Wilk. Descriptive statisticswere generated to report signalment; bodyweight; dura-tion of clinical signs; primary presenting complaint; diag-nostic imaging findings; surgical time; placement,duration, and type of drain; occurrence and nature ofintra- and perioperative complications; type and durationof antimicrobial and anti-inflammatory medications; hos-pitalization duration and survival to discharge.Comparison of outcomes for all variables betweengroups were assessed using independent sample t-test orMann –Whitney U test for normally and non-normallydistributed variables, respectively.Chi-square test for independence assessed the associa-tion between breed group and presenting signs, imagingfindings, intra- and postoperative complications, unilat-eral, bilateral single-session, and staged surgeries, medi-cations, and survival to discharge. Significance was set atthe 5% level and all tests were two-tailed.3|RESULTSA total of 306 TECA-LBOs performed in 242 dogs wereincluded. Eighty-one and 225 TECA-LBOs were per-formed in EBBs and OBs, respectively. Signalment data isreported in Table 1. Dogs in the EBB group were youngerat the time of surgery compared to dogs in the OB group(p=.000). No difference was detected in theBANKS ET AL . 663 1532950x, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13964 by Vetagro Sup Aef, Wiley Online Library on [22/07/2023]. 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 LicenseTABLE 1 Summary of signalment data for extreme brachycephalic and other breeds.Breed group DogsTECA-LBOsperformed(n)Mean age(years, months)Mean weightkg (range)Laterality ofoperated ear Gender categoryLeft Right FE FN ME MNTotal 242 306 6y 5 m ± 2y 10 m 15.8 (3.7 –73) 161 145Extreme Brachycephalic breeds 69 81 5y 3 m ± 2y 4 m 14.7 ± 6.7 kg 42 39 11 9 37 32French Bulldog 44 49Pug 15 19English Bulldog 10 13Other Breeds 173 225 6 year 11 m ± 2y 11 m 22.3 kg ± 13.2 kg 119 106 61 35 84 45Cocker Spaniel 27 38Cross Breed 22 25Labrador Retriever 15 18West Highland White Terrier 12 14Staffordshire Bull Terriersa11 17English Springer Spaniel 9 11Shar Peia81 3Cavalier King Charles Spaniela78Boxera67Rottweilera57Shih Tzua44German Shepherd 4 5Basset Hound 3 4Welsh Terrier 3 4Jack Russell Terrier 2 3St Bernard 2 3Bichon Frise 2 2Border Terrier 2 2Flat-Coated Retriever 2 2Hungarian Vizsla 2 2Standard Poodle 2 2Tibetan Terrier 2 4Yorkshire Terrier 2 4Afghan Hound 1 2Airedale Terrier 1 1Beagle 1 1Blood Hound 1 2Chow Chowa11Coton De Tulear 1 1Dachshund 1 2English Pointer 1 1Fox Terrier 1 2Golden Retriever 1 1Grand Basset Griffon Vendeen 1 1Irish Setter 1 1664 BANKS ET AL . 1532950x, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13964 by Vetagro Sup Aef, Wiley Online Library on [22/07/2023]. 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 Licenselateralization of the surgery between breed groups(p=.790). Thirty-eight cases were identified to be clini-cally affected by BOAS at the time of presentation, allwere EBBs (38/81, 46.9%). Twenty-two cases (22/38,57.9%) including 15 French Bulldogs, five Pugs, and twoEnglish Bulldogs had undergone previous BOAS surgery.A total of 57 EBBs (57/81 TECA-LBOs, 70.4%) under-went unilateral surgery, four EBBs (8/81 TECA-LBOs9.9%) underwent bilateral single-session surgeries, andeight EBBs (16/81 TECA-LBOs, 19.8%) underwent bilat-eral staged surgeries. A total of 121 (121/225 TECA-LBOs,53.8%) OBs underwent unilateral surgery, 37 (74/225TECA-LBOs, 32.9%) underwent bilateral single-sessionsurgeries, and 15 (30/225 TECA-LBOs, 13.3%) underwentbilateral staged surgeries. Extreme brachycephalic breedswere more likely to undergo unilateral surgery comparedto OBs ( p=.001). When bilateral surgery was performed,EBBs were more likely to have staged surgeries comparedto OBs ( p=.001). The median interval between bilateralstaged surgeries was 41 days (range 3 –1670 days). No dif-ference in surgical interval was detected betweengroups ( p=.580).The median perioperative follow-up period for allbreeds was 3 days (range 1 –18 days). The median hos-pitalization period was longer for EBBs than OBs:4d a y s ( r a n g e 1 –18) and 3 days (range 1 –15) respec-tively ( p=.026).3.1 |Presenting signsThe duration of clinical signs differed between groups(p=.001). Extreme brachycephalic breeds most com-monly presented with clinical signs <14 days duration(35/81, 43.2%) whilst OBs most commonly presented withchronic signs >6 months duration (104/225, 46.2%). Thepresenting signs are summarized in Figure1. The mostcommon presenting signs differed between EEBs andOBs ( p=.001). Extreme brachycephalic breeds mostcommonly presented with OE, OM, or OI with neurologi-cal signs (46/81, 56.8%) whereas OBs most commonlypresented with OE alone (171/224, 76.0%). Other causesincluded maxillary pain in six cases, para-aural abscessa-tion in five cases, and trauma to the ear canal in twocases. Specific preoperative neurological signs are sum-marized in Table2. Extreme brachycephalic breeds weremore likely to present with facial nerve paresis(p=.001), vestibular syndrome ( p=.001), and Horner'ssyndrome ( p=.02).3.2 |Diagnostic imaging findingsAdvanced diagnostic imaging studies were performed in281/306 (90.0%) of ears. The imaging modality performedin EBBs and OBs is demonstrated in Table 3. A higherproportion of EBBs underwent both CT and MRI andMRI alone compared to OBs ( p=.01). Specific imagingfindings between breed groups are summarized inTable4. Bilateral changes were more frequently identi-fied in OBs. Canal mineralization, ear canal mass, para-aural abscess formation, OI, and brainstem changes weremore frequently identified in EBBs (Figure2).When imaging findings were compared between pre-senting sign categories, dogs with neurological signs weremore likely to have OI and brainstem changes than dogspresenting for other reasons ( p=.001). No differencewas detected in the presence of unilateral versus bilateralchanges, middle ear effusion, or canal mineralizationbetween presenting sign categories.TABLE 1 (Continued)Breed group DogsTECA-LBOsperformed(n)Mean age(years, months)Mean weightkg (range)Laterality ofoperated ear Gender categoryLeft Right FE FN ME MNLhasa Apsoa11Mastiffa12Newfoundland 1 1Patterdale Terrier 1 1Polish Sheepdog 1 2Sussex Spaniel 1 1Toy Poodle 1 2Abbreviation: TECA-LBOs, total ear canal ablation and lateral bulla osteotomy.aRepresents breeds included that are identified as brachycephalic but do not fall within the extreme brachycephalic breed group.BANKS ET AL . 665 1532950x, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13964 by Vetagro Sup Aef, Wiley Online Library on [22/07/2023]. 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 License3.3 |Surgical details and intraoperativecomplicationsIntraoperative complications occurred during 21/306(6.9%) TECA-LBOs including 9/178 (5.1%) unilateral sur-geries, 8/82 (9.8%) bilateral single-session, and 4/46(8.7%) bilateral staged surgeries. No difference in overallintraoperative complication rate between unilateral, bilat-eral single-session, and bilateral staged surgeries wasdetected ( p=.329). Intraoperative c omplications includediatrogenic hemorrhage in 16/21 (76.2%) TECA-LBOs anddifficulty in identifying bony landmarks reported to increasesurgical time in 6/21 (28.6%) cas es. Intraoperative complica-tions were more frequent in EBBs (9/81, 11.1%) comparedto OBs (12/225, 5.3%). The apparent difference in intrao-perative complication rate did not reach statisticalsignificance ( p=.078). One French Bulldog required apacked red blood cell transfusion intraoperatively. All otherhemorrhage was managed with e ither digital pressure orFIGURE 1 Bar chart demonstrating the percentage of extreme brachycephalic (n =81) and other breeds (n =225) presenting with eachclinical sign.TABLE 2 Pre- and perioperative neurological signs in extreme brachycephalic and other breeds.Preoperative neurological signs Perioperative neurological signsExtremebrachycephalicbreeds (n =81)Other breeds(n=225) p-valueExtremebrachycephalicbreeds Other breeds p-valueFacial nerve paresis 23 (28.4%) 12 (5.3%) .001 17/58 (29.3%) 43/213 (20.2%) .138Vestibular signs 47 (58.0%) 26 (11.5%) .001 0/34 (0%) 6/199 (3.0%) .305Horner's syndrome 6 (7.4%) 2 (0.9%) .002 1/75 (1.3%) 0/223 (0%) .084Other Cranial nerve deficits 3 (3.7%) 2 (0.9%) .087 0/1 (0%) 0/1 (0%) .000Note:p-value determined via Pearson's chi-square test.TABLE 3 Imaging modality performed in extremebrachycephalic and other breeds.Imaging modalityStudy performed in each breed groupExtremebrachycephalicBreeds Other breedsCT only 58 (71.6%) 180 (80.0%)MRI only 10 (12.3%) 14 (6.2%)Both CT and MRI 12 (14.8%) 7 (3.1%)Note:p-value determined via Pearson's chi-square test =15.397. p< .001.666 BANKS ET AL . 1532950x, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13964 by Vetagro Sup Aef, Wiley Online Library on [22/07/2023]. 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 Licensetopical hemostatic agents. Ov erall median surgical time foreach ear was 100 min (30 –255). Median surgical time waslonger in EBBs than in OBs; 115 min (35 –242) versus95 min (30 –255) ( p=.011) (Figure 3).Surgical drains were placed in 113/306 (36.9%) TECA-LBOs. An active suction drain was placed in 2/113 (1.7%)and a Penrose drain was placed in the remaining111/115 (96.5%). Drains were placed in 31/81 (38.3%)TECA-LBOs in EBBs and 82/225 (36.4%) TECA-LBOsin OBs. Drains were left in place for a median of 2 daysin both EBBs and OBs with a range of 1 –3a n d1 –5 daysrespectively. No difference in drain placement orTABLE 4 Imaging findings in extreme brachycephalic and other breeds.Imaging findingsExtreme brachycephalicbreeds ( n=81) Other breeds ( n=200) p-valueBilateral changes 49 (61.3%) 95 (47.5%) .038Mineralization of the external ear canal 33 (41.3%) 101 (50.5%) .162Aural mass 8 (10.0%) 40 (20.0%) .045Para-aural abscess 13 (16.3%) 13 (6.5%) .011Middle ear effusion 60 (75.0%) 133 (68.2%) .263Otitis interna 37 (46.3%) 17 (8.5%) .001Brainstem changes 14 (17.5%) 6 (3.0%) .001Note:p-value determined via Pearson's chi-square test.FIGURE 2 Bar chart demonstrating preoperative diagnostic imaging findings between extreme brachycephalic (n =81) and otherbreeds (n =225).FIGURE 3 Box and Whisker plot demonstrating surgical timesin extreme brachycephalic and other breeds.BANKS ET AL . 667 1532950x, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13964 by Vetagro Sup Aef, Wiley Online Library on [22/07/2023]. 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 Licenseduration was detected between groups ( p=.646 andp=.535, respectively).Two EBBs (both English Bulldogs) and one OB(Staffordshire Bull Terrier) underwent an elective tem-porary tracheostomy postoperatively due to marked,pre-existing pharyngeal sw elling resulting from para-aural abscessation. No dogs required emergency tem-porary tracheostomy.Microbiology results were available for 270/306TECA-LBOs (88.2%) and culture was positive in 204/270TECA-LBOs (75.6%). Samples were taken from the tym-panic bullae in 187 cases, the external ear canal in24 cases and the site was unspecified in 15 cases. A totalof 341 microbes were isolated in total, including 15 bacte-rial isolates and one fungal isolate. The microbiologyresults are demonstrated in Table5.3.4 |Perioperative complicationsOverall perioperative complications occurred following85/306 (27.8%) TECA-LBOs including 47/178 unilateral(26.4%), 20/82 bilateral single-session (24.4%), and 18/46bilateral staged surgeries (39.1%). No difference in periop-erative complication rate was detected between unilat-eral, bilateral single-session, and bilateral stagedsurgeries ( p=.166).Facial nerve paresis occurred postoperatively in60/271 TECA-LBOs (22.1%); postoperative vestibularsyndrome occurred in 6/233 TECA-LBOs (2.6%); postop-erative Horner's syndrome occurred in 1/298 (0.3%)TECA-LBOs; postoperative hemorrhage occurred in4/306 (1.3%) TECA-LBOs; postoperative wound swellingoccurred in 10/306 (3.3%); wound dehiscence within thehospitalization period occurred in 13/306 (4.2%) surgeries(Figure4). No difference in perioperative complicationrate was detected between EBBs (19/81, 23.5%) and OBs(66/225, 29.3%) for any complication ( p=.311) (Table 6).3.5 |Perioperative medicationsBroad-spectrum intravenous antimicrobials were admin-istered intraoperatively to all cases. Postoperative antimi-crobials were prescribed in 237/306 (77.5%) TECA-LBOs(64/81, 79.0% of EBBs and 173/225, 76.9% of OBs) withno difference between breed groups ( p=.274). Amoxi-cillin clavulanate was prescribed in 125/237 (52.7%,cephalexin in 98/237) (41.4%), enrofloxacin in 12/237(5.1%), and clindamycin in 2/237 (0.01%). Antimicro-bials were prescribed for a median of 8 days postopera-tively (range 1 –56). No difference in the choice ofantimicrobial or duration of prescription was detectedbetween groups ( p=.552 and p=.271 respectively).TABLE 5 Microbiology isolates from positive middle ear or ear canal cultures in extreme brachycephalic and other breeds. Numbersrepresent individual total ear canal ablation and lateral bulla osteotomy (TECA-LBO) results.Cultured organism Extreme brachycephalic breed Other breeds Total count (all dogs)Staphylococcus pseudintermedius 34 50 84Enterococcus faecalis 22 50 72Pseudomonas aeruginosa 74 8 5 5Escherichia coli 73 2 3 9Proteus mirabilis 10 15 25Streptococcus canis 31 9 2 2Bacteroides spp. 3 6 9Staphylococcus aureus 43 7Pasteurella spp. 3 3 6Malassezia pachydermatis 06 6Corynebacterium spp. 2 3 5Staphylococcus schleiferi 22 4Methicillin-resistant Staphylococcuspseudintermedius40 4Methicillin-resistant Staphylococcus aureus 01 1Enterobacter spp. 0 1 1Streptococcus dysgalactiae 01 1Total 101 240 341668 BANKS ET AL . 1532950x, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13964 by Vetagro Sup Aef, Wiley Online Library on [22/07/2023]. 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 LicenseIntra- and perioperative complication rates did not dif-fer when antimicrobials were prescribed ( p=.796 andp=.408, respectively).NSAIDs were prescribed in 228/306 (74.5%) ofTECA-LBOs (58/81, 71.6% of EBBs and 170/225, 75.6%OBs) with no difference detected between groups(p=.484). NSAIDs were prescribed for a median of7d a y s ( 3 –14 days). No difference in NSAID courseduration was detected between groups. Intra- or peri-operative complication rates did not differ whenNSAIDs were prescribed ( p=.078 and p=.311,respectively).3.6 |Survival to dischargeReasons for prolonged hospitalization included woundmanagement following surgical site dehiscence (7), theseverity of neurological signs (2) and hospitalization forthe duration between staged surgeries (2), and manage-ment of corneal ulceration (2) and upper respiratoryobstruction (2). Prolonged hospitalization in one dog wasdue to an investigation of unrelated narcolepsy.Two dogs did not survive to discharge including oneEBB and one OB (0.70%). A 5-year 1-month-old femaleentire English Bulldog underwent bilateral single-sessionTECA-LBO for the treatment of chronic OE. The dogdeveloped postoperative aspiration pneumonia and had acardiopulmonary arrest 4 days postoperatively. The sec-ond case was a 7-year 5-month-old female neuteredBichon Frise who underwent unilateral TECA-LBO fortreatment of a para-aural abscess. The dog developed sep-sis and acute kidney injury and had a cardiopulmonaryarrest 2 days postoperatively.4

Question 148

Lampart - 2023 - VETSURG - Evaluation of the accuracy and intra- and interobserver reliability of three manual laxity tests for canine cranial cruciate ligament rupture-An ex vivo kinetic and kinematic study.pdf

Answer 148

2.1 |Specimen preparationTen pelvic limbs of skeletally mature dogs weighing >22 kgwere collected. Left or right limbs were randomly selected.All dogs were euthanized for reasons unrelated to this studyand donated for research by their owners. To exclude stiflepathologies, orthogonal radiographs of the joints wereobtained and stifle arthroscopy was performed, includinginspection and probing of the CCL, the caudal cruciate liga-ment and the menisci. The limbs were disarticulated at thecoxofemoral joint and the proximal half of the femur wasfreed from soft tissues. The proximal part of the femur wasosteotomized using a n oscillating saw and the remainder ofthe femoral diaphysis was pott ed centrally in a 3D-printedcylinder using beracryl-monomer (SCS-Beracryl D-28monomer; Swiss-Composite, Fr aubrunnen, Switzerland).Fur was clipped from the femur to distal to the stifle joint.After preparation, the specimens were stored at /C020/C14Ca n dthawed to room temperature 24 h before testing.2.2 |Setup and testing protocolThe specimens were mounted on a custom-made 3D-printed jig (3DGence ONE, 3DGence, Przyszowice, Polska)LAMPART ET AL . 705 1532950x, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13957 by Vetagro Sup Aef, Wiley Online Library on [22/07/2023]. 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 Licensereinforced with beracryl-monomer (Swiss-Composite)and clamped to a table using carpenter clamps(Figure1). To maintain the stifle joint at a standingangle (135/C14) throughout testing, limb position was setby an adjustable support bar and rechecked before eachtest with a goniometer. A load cell (S-Type Load Cell,range ±10 kgF, Omega Engineering, Manchester, UK)was inserted between the jig and the specimen to regis-ter axial load applied to the femur during the TCT andthe TPCT (Figure2). For the assessment of kineticsduring CD, a subminiature load cell (SubminiatureCompression Load Cell, ±1 0 kgF, Omega Engineering,Manchester, UK), fixed to the observer's thumb using aself-adherent wrap, registered the compressive forcea p p l i e dt ot h ef i b u l a rh e a d( F i g u r e2).To allow tracking of 3D kinematics, reflectivemarkers forming a custom-made coordinate system wereattached to the femur and tibia of each specimen(Figure1). The coordinate systems consisted of three2.5 mm pins, a 3D-printed central connecting part, andfive spherical reflective markers, a standard set up formotion capture analysis. The markers were glued to thepins and central part in a pattern unique for femur andtibia respectively to allow distinction of the bones by theFIGURE 1 Testing set up. Medial (A) and cranial (B) view showing the set up with the femoral load cell ( ▷) and the mountedspecimen with coordinate systems for tracking (*) held in position by an adjustable support bar ( ►).FIGURE 2 Load cells. (A) Medial close-up of the S-type load cell inserted between the specimen and the jig. (B –E) Image seriesshowing the fixation of the subminiature load cell used during the cranial drawer test.706 LAMPART ET AL . 1532950x, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13957 by Vetagro Sup Aef, Wiley Online Library on [22/07/2023]. 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 Licensetracking software (Qualisys Track Manager, Qualisys,Gothenburg, Sweden) (Figure 1).Ten motion capture cameras (Qualisys, Gothenburg,Sweden) sampling at 300 Hz collected kinematic data bytracking the motions of the reflective markers. Data wasrecorded and edited by QTM software (Qualisys TrackManager, Qualisys).The testing protocol included three rounds of testing(Figure3). In all rounds, all tests were performed bythree observers with different levels of experience (board-certified surgeon, [observer 1], resident [observer 2], doc-toral student [observer 3]) on each specimen. In the firstround (INTACT), the CCL was intact in all specimens. Inround 2, the accuracy of the tests was assessed and CTTwas subjectively estimated to later compare it to theobjective values obtained by kinematic assessment. Forthis round, the CCL of five randomly selected limbs wastransected arthroscopically by a board-certified surgeon.The remaining limbs underwent sham-arthroscopy. Thearthroscopy incisions were closed routinely by singleinterrupted sutures. The observers were unaware of thestate of the CCL to allow blind assessment of each speci-men. During each test, each limb was assessed qualita-tively (CCL intact/CCL transected) as well asquantitatively (estimation of CTT in mm) by palpationonly by all observers. For testing in round 3 (CCLD), theCCL was transected in all limbs and testing was repeatedas described for round 1. The order of tests, specimensand observers was chosen randomly in each round byone of the investigators. For the assessment of intraobser-ver reliability, the tests were repeated three times in threerandomly selected specimen for INTACT and CCLD.2.3 |Manual laxity testsThe three MLTs CD, TCT and TPCT were evaluated. Alltests were performed with the observer standing lateralto the specimen. For the CD, the femur was stabilizedwith one hand, while the thumb of the other hand wasplaced behind the fibular head and the index finger onthe tibial tuberosity. After applying a caudally directedforce to the tibia to reduce the joint, the observer pushedthe tibia cranially to detect excessive cranial tibial motionin the sagittal plane. The pressure applied was measuredby a subminiature load cell secured to the observer'sthumb, as described before.For the TCT, the observer's hands were placed on thetibia, as described by Henderson and Milton.5Instead ofstabilizing the femur with one hand, only the index fin-ger of this hand was placed on the tibial tuberosity todetect excessive CTT without interfering with the femoralload cell measurements. Axial tibial compression wasapplied by flexing the tarsal joint with the stifle and tar-sus aligned in the sagittal plane. The tarsus was held in aneutral position during testing.The TPCT was performed similarly to a standardTCT. However, before initiating tibial compression, theFIGURE 3 Testing procedure. Testing was conducted in three rounds. In each round of testing each observer performed each test oneach specimen. For round 1, the CCL was intact in all specimens. In round 2, the CCL was transected in five randomly selected specimen toallow blind qualitative and quantitative assessment of tibial translation. In round 3, the CCL was transected in all specimens. CCL cranialcruciate ligament.LAMPART ET AL . 707 1532950x, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13957 by Vetagro Sup Aef, Wiley Online Library on [22/07/2023]. 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 Licensetarsus was brought in external rotation until resistancewas felt and a valgus stress was applied. Then tibial com-pression was established, and external rotation wasreleased, allowing the tibia to internally rotate and even-tually subluxate (Figure4) (Video S1).2.4 |Data processingDirectly after testing, computed tomography (CT) scansof all specimens, including the associated coordinate sys-tems attached in the exact same position as during test-ing, were obtained. From the CT scans, femur and tibiaand their respective coordinate system were segmentedusing 3D Slicer software (version 4.10.1, stable release24)to create 3D models. The Geomagic WRAP software(Geomagic Inc., Research Triangle Park, North Carolina,USA) was then used to apply an anatomical coordinatesystem matching the 3D models as described in previousstudies (Figure5).25,26From these models and the motioncapture data, peak tibial translation (mm), peak tibialaxial internal or external rotation (degree) and peak stiflejoint flexion (degree) were calculated using a custom-written program in MATLAB (The Mathworks Inc.,Natick, Massachusetts, USA). Peak tibial axial rotation indegree is described as a negative (internal rotation) orpositive value (external rotation) in relation to the start-ing point of the test. The kinetic data obtained by theFIGURE 4 Testing maneuver of the tibial pivot compression test. Top row showing the cranial and bottom row showing the lateralview. (A, B) Starting position. (C,D) External rotation and valgus stress are applied. (E, F) Tibial compression is established. (G, H) Releaseof rotation and eventual subluxation in cranial cruciate ligament –deficient stifle.FIGURE 5 Three-dimensional models of femurand tibia created fromcomputed tomography scans.Mediolateral (A) andcraniocaudal (B) view of thefemur and lateromedial (C) andcraniocaudal (D) view of thetibia. A previously describedanatomical coordinate systemmatching the one used duringtesting was applied to themodels.25,26708 LAMPART ET AL . 1532950x, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13957 by Vetagro Sup Aef, Wiley Online Library on [22/07/2023]. 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 Licenseload cells as a force in N was filtered for analysis usingfirst order Butterworth filter with a cut off frequency of1 Hz and a sampling rate of 200 Hz by MATLAB (TheMathworks Inc.).2.5 |Statistical analysisThe data were analyzed using SPSS (version 25.0 IBMCorp., Armonk, New York, USA). Descriptive values arereported as mean ± standar d deviation (SD). Flexiondata were compared between INTACT and CCLD usingap a i r e d t-test. These data were not included in furtheranalysis, as stifle joint angle was a controlled variablethroughout testing (target angle =135/C14). A three-wayrepeated-measures ANOVA was conducted to investi-gate peak tibial translation and peak tibial rotation dif-ferences. Within-subject factors were CCL state( I N T A C T ,C C L D ) ,t e s t( C D ,T C T ,T P C T )a n do b s e r v e r(observer 1, 2, 3). External rotation at the start of theTPCT was not included in the ANOVA analysis, as itw a se l i c i t e db yt h eo b s e r v e ra n dn o tar e s u l to ft h et e s t .External rotation data was compared between INTACTand CCLD using a paired t-test. To account for the twodifferent sensors assessing kinetics during testing, thekinetics of the CD were evaluated separately from thekinetics of the TCT and TPCT. A two-way repeated-measures ANOVA was conducted for CD. Within-subject factors were CCL state (INTACT, CCLD) andobserver (observers 1, 2, 3). TCT and TPCT were directlycompared using a three-way repeated-measures ANOVAidentical to the analysis for translation and rotation. Iftwo- or three-way models revealed interactions betweenwithin –subject factors, the analysis was split up in two-or one-way models, respecti vely, until no more interac-tions were present.Sphericity of the data was evaluated using theMauchly test, and Greenhouse –Geisser correction wasused as indicated. In the case of statistically significantANOVA differences ( p≤.05), post hoc testing wasused for pairwise comparison, using a statistical signif-icance set by the Bonferroni correction, which controlstype I error inflation. To e valuate inter- and intraob-server reliability of kinematic and kinetic data, intra-class correlation coefficients (ICC) and corresponding95% confidence intervals were calculated using a two-way mixed, absolute agreement model.27An ICC of<0.5 was classified as poor agreement, 0.5 –0.74 asmoderate agreement, 0.75 –0.89 as good agreement,and >0.9 as excellent agreement.27Subjective quanti-tative assessment of CTT was compared to the actualtranslation values measured by the motion capturesystem using Pearson's corre lation. Median absolutedifference between subjecti ve and objective values wascalculated.3|RESULTSSix right and four left limbs were collected. Meanbodyweight ± SD of the dogs was 31.5 ± 5.4 kg and meanage ± SD was 8.6 ± 3.1 years. Mean deviation from thetarget stifle flexion angle of 135/C14during testing was/C01.86/C14± 5.03/C14. There was significantly more variation inflexion angle for CCLD than for INTACT ( p=.001).3.1 |TranslationCTT was significantly higher for CCLD than for INTACT(p< .001) (Table 1). No caudal tibial translation occurredduring testing. The highest CTT's were elicited duringTPCT for both INTACT and CCLD (Table 1). The dis-crepancy between the three tests was not significant forINTACT ( p=.30); however, for CCLD, the recordedtranslation was significantly higher for TPCT than for CD(p=.003). There was no significant difference betweenTPCT and TCT for CCLD ( p=.97). For INTACT, themost experienced observer 1 elicited significantly moretranslation during CD than the other two observers(observer 1 –observer 2: p=.014, observer 1 –observer3:p=.018). There was no significant difference in CTTfor the other observers or tests. Inter- as well as intraob-server agreement of CTT were excellent (Tables4and5).3.2 |RotationThere was significantly more rotation for CCLD than forINTACT ( p=.03) (Table 2). Ultimately, all three testsresulted in net internal rotation. The highest values ofinternal rotation were elicited by TPCT (mean CDINTACT +CCLD: 5.95/C14±7 . 3 6/C14, mean TCT INTACT +CCLD: /C06.39/C14±6 . 4 1/C14,m e a nT P C TI N T A C T +CCLD:/C09.13/C14±9 . 2 0/C14). The differences between the three testsand between observers were not significant (tests:p=.141, Observers: p=.074).Mean peak external tibial rotation applied at the startof TPCT was consistent during testing ( p=.22; meanrotation INTACT: 12.75/C14± 4.06/C14, mean rotation CCLD:14.14/C14± 5.7/C14). Interobserver agreement of tibial rotationduring CD was only moderate (ICC =0.54), while it wasgood during TPCT (ICC =0.76) and TCT (ICC =0.87)(Table 4). Intraobserver agreement was good to excellentexcept for CD and TCT performed by observer 3 (ICCCD=0.45, ICC TCT =0.58) (Table 5).LAMPART ET AL . 709 1532950x, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13957 by Vetagro Sup Aef, Wiley Online Library on [22/07/2023]. 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 License3.3 |KineticsThe force applied during CD was significantly higher forINTACT than for CCLD ( p< .001). During CD, theamount of force employed corresponded to the experi-ence level of the observer: the more experience, thehigher the applied force (Table3).For INTACT, the forces applied were significantlyhigher during TPCT than during TCT ( p=.021). DuringINTACT, the more experienced observers 1 and 2 appliedhigher forces. However, this finding only reached signifi-cance between observers 2 and 3 ( p=.005). For CCLD,there was no significant difference between the kineticsof the two tests except for the least experienced observer3, who applied more force during TPCT than during TCT(observer 1: p=.147, observer 2: p=.248, observer 3:p< .001). Overall, it was found that during all tests, theforces applied during INTACT were higher than duringCCLD (CD: p< .001, TCT: p< .001, TPCT: p=.017).Direct comparison of TCT and TPCT revealed that overallhigher forces were applied during TPCT ( p< .001).Interobserver agreement of kinetics was poor for CD(ICC=0.44), moderate for TPCT (ICC =0.51), and goodfor TCT (0.82). Intraobserver agreement for CD was mod-erate (mean ICC =0.69) while it was good for TCT andTPCT (mean ICC TCT =0.87, mean ICC TPCT =0.78).The best intraobserver agreement of kinetics was demon-strated by the most experienced observer 1 (meanICC=0.92), followed by the least experienced observer3 (mean ICC =0.89) (Tables4and5).3.4 |Subjective qualitative andquantitative assessmentThe CTT for INTACT ranged between 0.1 and 5 mm andbetween 7 and 18 mm for CCLD. The three observers'subjective qualitative assessment of CTT revealed a sensi-tivity and specificity of 100% for all tests and allobservers. Comparison of subjective quantitative assess-ment values estimated by the three observers to theobjective kinematic values revealed a strong correlationwith a correlation coefficient of 0.895 (Figure6). Medianabsolute difference between subjective and objectivevalues was 1.31 mm.4

Question 149

Makar - 2024 - JFMS - Feline radial and ulnar diaphyseal fractures - A retrospective study of 49 cases comparing single bone fixation and dual bone fixation.pdf

Answer 149

The University Veterinary Teaching Hospital Sydney, Veterinary Specialists of Sydney, Southpaws Specialty Surgery for Animals, Veterinary Specialists Aotearoa, Veterinary Specialist Services and Northside Veterinary Specialists databases were searched for cats with antebra-chial fractures that occurred between January 2004 and September 2022. The clinical, radiographic and surgical records were reviewed, in addition to telephone inter -views with owners. Only cases of cats with radial and/or ulnar diaphyseal fractures that were repaired with SBF (see Figure 1 for an example) or DBF (see Figure 2 for an example) with medical records and radiographs or owner telephone questionnaires were included in this study. Monteggia fractures, physeal fractures and fractures corrected with external skeletal fixators, or no fixation at all, were excluded from the study. The data retrieved from medical records included the following: age; weight; cause of fracture; fracture type; fracture loca-tion (proximal, middle or distal third of the bone); and use of graft (cancellous bone graft [CBG] or bone morpho-genetic protein [BMP]) and repair method – SBF or DBF. Plate types and lengths were recorded where available. Fracture types were classified as open or closed, and sim -ple or comminuted. Measures of outcome included the following: days to radiographic or clinical union; major and minor complications; and short- (< 8 weeks post-operative) and long-term ( >8 weeks postoperative) clini -cal outcomes. Complications were classified into major (when revision surgery was required) and minor (when Figure 1 Case 8: mediolateral radiographs of the right forelimb at (a) day 0 and (b) 6 weeks postoperatively showing single bone fixationMakar et al 3no surgical treatment was required). Long-term clini-cal outcomes were assessed by a veterinary surgeon as lame or not lame at follow-up appointments if recorded in the patient file, and by the clients during telephone interviews collected by the first author, which graded outcomes as excellent, good, fair, poor or very poor (see Appendix Table 1 in the supplementary material).8 At least 3/4 cortices were needed to show bony union to justify radiographic union, and this was determined by the attending veterinarian or by the first author. If the follow-up veterinary records did not include an assess -ment of lameness or a radiographic evaluation was not available, the case was designated ‘lost to follow-up’. A successful outcome was defined as either the veterinarian or the owner reporting no lameness on physical examina-tion or during telephone interview, respectively.Statistical analysisStatistical analyses were performed using a commercially available statistical package (Genstat, version 18; VSN International). Before the statistical analysis, outcomes were reduced to binary variables. For veterinarian-assessed and owner-assessed outcomes, respectively, a score of 1 indicated no lameness and 0 indicated some form of lameness; and for postoperative complications, a score of 1 indicated no complications and 0 indicated some form of complication (either minor or major). The data were analysed using logistic regression with an underlying binomial distribution. Outcomes were veterinarian-assessed score, owner-assessed score and presence of complications postoperatively. Factors assessed for an effect on the outcome variables were type of bone fixation (single/dual), other orthopaedic issues (yes/no), fracture configuration (simple/comminuted), use of bone graft (yes/no) and presence of postopera -tive complications (none/minor/major). P values, odds ratios, confidence intervals (CIs) and predicted propor -tions were calculated. Significance was defined where P <0.05.ResultsSignalmentA total of 47 cats were included in this study, includ-ing male castrated (n = 26), male entire (n = 3), female spayed (n = 15) and female entire (n = 3). Two of the cases required revision surgery and were included as separate fractures (cases 27/28 and 34/35). The mean age was 4.2 years (range 5 months to 15.5 years). The mean weight was 4.4 kg (range 2.6–7.15 kg). Breeds included the following: domestic shorthair (n = 25); Birman (n = 4), domestic mediumhair (n = 3); Bengal, British Shorthair, Siamese cross (n = 2 each); and the remainder were Ragdoll, Ragdoll cross, Scottish Fold, Russian Blue, Korat, Burmilla, Tonkinese, Ocicat and Burmese (n = 1 each).Fracture location Of all 49 fractures, 27 were confined to the left limb, 20 to the right and two were not specified. Nine of the fractures were of the radius only; there was one ulnar fracture with an intact radius and 39 combined radial/ulnar fractures, of which 26 were repaired with SBF and 13 with DBF. The cause of the fractures included the following: unknown (n = 21); falls from a height (n = 15); fight related (n = 3); caught in a trap (n = 3); hit by a car (HBC) (n = 2); inadvertent trauma by the owner (n = 2); and failed previous repair (n = 3).Figure 2 Case 49: mediolateral radiographs of the left forelimb at (a) day 0, (b) immediately postoperatively showing repair with DBF, and (c) 8 weeks postoperatively showing delayed union of the ulna4 Journal of Feline Medicine and Surgery Of the 49 diaphyseal antebrachial fractures, 24 (49%) were distal, 13 (26.5%) were proximal and 12 (24.5%) were mid-diaphyseal. Of these cases, 13 were repaired with DBF, 35 with SBF of the radius and one with SBF of the ulna. Of the 49 fractures, five were open fractures, all of which were located on the left limb.ComplicationsOf the 49 cases, 17 (34.7%) had minor complications. Of the 13 DBF cases, five (38.5%) had minor complications, compared with 12/36 (33.3%) in the SBF group. Of the 49 fractures, five (10.2%) had major complications. Major complications were found in 1/13 (7.7%) DBF cases and 4/36 (11.1%) SBF cases. Of these five fractures, two (40%) were located in the proximal third of the radius and ulna, two (40%) were located in the distal third and one (20%) was located in the middle third of the ulna. Case 6 (see Appendix Table 2 in the supplementary material, Tables 1 and 2), an open fracture in the proximal third of the antebrachium, required amputation given poor limb viability in the postoperative period. Case 18 (see Appendix Table 2 in the supplementary material, Table 1) was advised to have implants removed due to discom -fort associated with the plate on palpation and lameness. There was delayed union of the radius and the ulna at 14 weeks postoperatively; although further surgery was recommended, this case was lost to follow-up. Case 27 (see Appendix Table 2 in the supplementary material, Table 1) sustained an open fracture of the distal radius and ulna, which initially had the fracture repaired at a referring veterinarian, and radiographs taken 6 weeks postoperatively showed delayed union of the fracture site. This repair failed 9 months later, requiring revision. At the initial time of injury (HBC), the right hind paw was severed, and the tibia sustained complex trauma, resulting in the cat subsequently undergoing a hindlimb amputa -tion. Case 34 (see Appendix Table 2 in the supplementary material, Table 1) had a major complication after an initial fracture repair after a cat fight, which resulted in a long oblique fracture of the proximal radius with the ulna intact. A total of 18 months after this surgery, the bone fractured just distal to the initial implant. The cat was walking well before the second fracture. The owner reported ongoing lameness after the second surgery. Case 38 (see Appendix Table 2 in the supplementary material, Table 1) required surgical debridement of the wound due to partial dehis-cence and plate exposure 2 weeks after the original surgery of a grade 1 open mid-diaphyseal comminuted fracture of the ulna. This fracture showed delayed healing on the 8-week radiographs and there was screw loosening, neces-sitating removal of the implants at 12 weeks.The presence of postoperative complications was not significantly affected by bone fixation, presence of other orthopaedic issues or fracture type ( P = 0.952, 0.743 and 0.422, respectively) (Table 3).ComminutionThere were 21 fractures with comminution identified. Of the 21 fractures, two (9.5%) had major complications requiring surgical intervention (one amputation and one surgical wound debridement). One case (case 46; see Appendix Table 2 in the supplementary material, Table 1) had delayed union at 20 weeks but was lost to follow-up. This compares with 3/28 (10.7%) of the non-comminuted fractures sustaining major complications. Comminution had no significant effect on the final outcome (Table 3).Orthopaedic issuesOf the 49 cases, nine had other concurrent orthopaedic issues. These included major degloving injury to the frac -tured limb, puncture wounds to other limbs, fracture of the metacarpal bones of the same limb, fracture of the dis-tal metaphysis of the femur, severe arthritis, severed right hindlimb paw and trauma after an HBC accident requir -ing mid-femoral amputation, tarsal subluxation with chip fracture and a scapular fracture on the same limb as the antebrachial fracture. In total, 2/9 (22.2%) of these cases had major complications in relation to their antebrachial repair. This compares with 3/40 (7.5%) fractures with no concurrent orthopaedic issues requiring further interven-tion. Although there was a large variation between the two groups, no significant difference was identified in these results (Table 3).Fixation methodsDBF was used in 13/49 (26.5%) cases, with only 1/13 (7.7%) having major complications (Table 2). This com-pares with 4/36 (11.1%) of SBFs with major complica-tions (Figure 3). With successful veterinary assess ment outcomes, SBF was 14.25 times more likely (95% CI 2.07–97.99) to have a successful outcome (veterinary score of 0) compared with DBF ( P = 0.007) (Table 3). With owner-assessed outcomes, SBF was 9.4 times more likely (95% CI 1.4–61.96) to have a successful outcome (owner score of 0) compared with DBF ( P = 0.019) (Table 3). Of the 13 DBF cases, 9 (69.2%) cases had comminution, compared with 13/36 (36.1%) of the SBF cases.0.00%5.00%10.00%15.00%20.00%25.00%30.00%35.00%40.00%45.00%MinorM ajorDBF SBFFigure 3 Minor and major complication rates of dual bone fixation (DBF) vs single bone fixation (SBF)Makar et al 5Table 1 Cases with minor and/or major complications, including configuration, details of complications and final outcomesCase Weight (kg)Age Signalment Cause Fracture configurationSBF/DBFImplant descriptionGraft Other orthopaedic issuesTime to union Postoperative complicationFinal outcome (veterinarian lameness score)Owner response (1–5)3 4.3 5 y 11 m MN Bengal UK Left: comminuted, mid R/UDBF R: 2.0, LCPU: 1.5, LCPCancellous bone graftNone U: 13 weeksR: delayed unionMinor: delayed union0 26 4.5 6 y 7 m FS DSH Caught in a trapLeft: open, comminuted, proximal R/UDBF R: 2.0, 8-hole LC-DCPU: 1.5, 8-hole DCPBMP Concurrent damage to soft tissues of fractured limb with compromise of blood supplyN/A Major: no perfusion to the limb after 3 days. Limb was amputated0 58 3.6 9 m MN DSH UK Right: comminuted, mid RSBF R: 1.5, UK plateNone None UK (fracture still present at 6 weeks)Minor: interdigital dermatitis and decubital ulcer of the ipsilateral elbow1 212 5.7 1 y 9 m MN DSH Fall Left: comminuted distal R/USBF R: 2.0, 9-hole LCPNone Transverse fracture of the distal diaphysis of the third and fourth metacarpus with moderate craniolateral displacement6 weeks Minor: slight knuckling, weight loss, muscle atrophy of surgical limb1 LTFU13 7.15 1 y 3 m MN Bengal UK Right: comminuted mid R/USBF R: 2.0, 6- hole LCPNone None 8 weeks clinical unionMinor: digital swelling postoperatively of surgical limb1 118 3.6 4 y 2 m MN Ragdoll Non-union of previous external fixatorRight: transverse, distal R/USBF R: 2.0, 12- hole plateCBG Translation of the distal radial segment and fracture at the proximal end of the external fixator14 weeks (radius only)Minor: carpal laxity at 1 week but resolved on its own. Soft tissue infectionMajor: delayed union, implant removal required1 LTFU(Continued)6 Journal of Feline Medicine and Surgery Case Weight (kg)Age Signalment Cause Fracture configurationSBF/DBFImplant descriptionGraft Other orthopaedic issuesTime to union Postoperative complicationFinal outcome (veterinarian lameness score)Owner response (1–5)19 5 9 y MN DSH UK Left: transverse distal R/USBF R: 2.0, 8-hole LCPNone None UK None 1 120 3.2 3 y FS Birman UK Right: UK, distal R/USBF R: 2.0, 6-hole UK plateNone None UK Minor: 3/5 lameness at 3 weeks postoperativelyLTFU 121 5.1 14 y MN Birman Dog attackLeft: open, short oblique, proximal R/UDBF R: 2.0, 9-hole DCPU: 2.0, 6-hole DCPNone None 9 weeks (radius only)Minor: delayed union of the ulnar fracture, elbow incongruency0 122 5.4 7 m MN DSH Caught in doorRight: comminuted distal, R/USBF R: 2.0, 7-hole UK plateNone None 12 weeks Minor: distal screw backing out; however, bone healed at this point. No further surgery required1 123 6 3 y 7 m MN DMH Fall Left: short oblique, distal R/USBF R: 2.0, 8-hole UK plateCBG None 10 weeks (radius only)Minor: delayed union of ulna at time of final radiograph0 LTFU26 5.2 4 y 1 m ME Korat UK Right: short oblique, distal R/USBF R: 20 G cerclage wire, 2.4, 8-hole cuttable plateNone None 10 weeks Minor: seroma formation and mild dehiscence. Managed with bandage. Decubital ulcers from bandages1 127 3.3 11 m FS DSH HBC Left: open, transverse, distal R/USBF R: 2.0, 7-hole cuttable plateNone Severed right hind paw and fracture of the tibia (amputated mid-femur)6-week radiographs: delayed unionMinor: infection of woundMajor: implant loosening after 9 months0 LTFU28 3.5 1 y 8 m FS DSH Previous repair failureLeft: transverse, distal R/USBF R: 2.0, 12-hole DCPCBG on second surgerySevered right hind paw8 weeks (radius only)Minor: delayed union of ulna1 1(Continued)Table 1 (Continued)Makar et al 7Case Weight (kg)Age Signalment Cause Fracture configurationSBF/DBFImplant descriptionGraft Other orthopaedic issuesTime to union Postoperative complicationFinal outcome (veterinarian lameness score)Owner response (1–5)34 UK 2 y 11 m FS TonkineseCat fight Left: oblique, proximal RSBF R: 2.0, LCP, single positional 2.4 mm screwNone None 6 weeks Major: implant failure after 18 months1 LTFU38 7 UK MN DSH Dog attackLeft: comminuted, mid USBF U: 1.5, 10-hole LC-DCPNone None 8 weeks Major: wound breakdown requiring surgical debridementLTFU LTFU40 5.8 1 y 7 m MN DSH UK Left: transverse, distal R/USBF R: 2.0, 9-hole LCPNone None UK Minor: distal limb oedema, resolved with compressive bandageLTFU 142 4.1 2 y MN DSH UK Right: comminuted, proximal R/USBF R: 2.0, 10-hole LCPU: 2.5 mm K-wireNone None 5 weeks Minor: soft tissue infection0 LTFU46 5 11 y MN Siamese crossFall Left: comminuted, proximal R/USBF R: 2.0, 12-hole LCPNone None UK: 20 weeks delayed unionMinor: delayed union1 LTFU48 4 3 y MN DSH UK Left: comminuted short oblique, proximal R/UDBF R: 2.0, locking plateU: 2.0, locking plateNone None UK Minor: decubital ulcer at digit 1 nail bed, 4/5 lame at 1-week recheckLTFU LTFU49 4 13 y FS DSH UK Left: comminuted, proximal R/UDBF R: 2.0, 10-hole locking plateU: 1.5, 6-hole locking plateNone None 8 weeks delayed unionMinor: delayed union1 1BMP = bone morphogenetic protein; CBG = cancellous bone graft; DBF = dual bone fixation; DCP = dynamic compression plate; DMH = domestic mediumhair; DSH = domestic shorthair; FS = female spayed; HBC = hit by car; LC-DCP = limited contact dynamic compression plate; LCP = locking compression plate; LTFU = lost to follow-up; m = months; ME = male entire; MN = male neutered; R = radius; SBF = single bone fixation; U = ulna; UK = unknown; y = yearsTable 1 (Continued)8 Journal of Feline Medicine and Surgery Table 2 Cases with dual bone fixation, including configuration, details of complications and final outcomesCase Weight (kg)Age Signalment Cause Fracture configurationSBF/DBFImplant description Graft Other orthopaedic issuesTime to unionPostoperative complicationFinal outcome (veterinarian lameness score)Owner response (1–5)1 5.7 15 y 8 m MN DSH UK Right: distal R/U short oblique fractureDBF R: 2.0, locking T-plateU: 1.5, LCPNone None N/A None 0 23 4.3 5 y 11 m MN Bengal UK Left: comminuted, mid R/UDBF R: 2.0, LCPU: 1.5, LCPCBG None U: 13 weeksR: delayed unionMinor: delayed union0 25 5.2 2 y 5 m MN Ragdoll crossUK Right: comminuted, mid R/UDBF R: 2.0, LCPU: 1.5, LCPNone None UK None UK 16 4.5 6 y 7 m FS DSH Caught in a trapLeft: open, comminuted, proximal R/UDBF R: 2.0, 8-hole LC-DCPU: 1.5, 8-hole DCPBMP Concurrent damage to soft tissues of fractured limb with compromise of blood supplyN/A Major:no perfusion to the limb after 3 days. Limb was amputated0 57 3.9 2 y 11 m FS DMH Fall Right: comminuted, proximal R/UDBF R: 2.0, LCPU: 1.5, LCPNone None UK None 0 216 2.6 6 m ME BSH Fall Right: comminuted, distal R/UDBF R: 1.5/2.0, cuttable plateU: 1.5/2.0, cuttable plateNone None 4 weeks no unionNone LTFU LTFU21 5.1 14 y MN Birman Dog attackLeft: open, short oblique, proximal R/UDBF R: 2.0, 9-hole DCPU: 2.0, 6-hole DCPNone None 9 weeks (radius only)Minor: delayed union of the ulnar fracture, elbow incongruency0 131 5 2 y 11 m MN DSH UK Right: UK, mid R/UDBF R: 2.4, 8-hole locking plateU: 2.0, 6-hole locking plateNone None 6 weeks None 1 LTFU(Continued)Makar et al 9Case Weight (kg)Age Signalment Cause Fracture configurationSBF/DBFImplant description Graft Other orthopaedic issuesTime to unionPostoperative complicationFinal outcome (veterinarian lameness score)Owner response (1–5)32 4 7 y 11 m MN DSH UK Left: UK, distal R/UDBF R: 2.4, 6-hole DCPU: 2.0, 5-hole cuttable bone plateNone None 6 weeks None 1 LTFU36 4 1 y 2 m FS Ocicat UK Left: comminuted, mid R/UDBF R: 2.0, 10-hole LCPU: 2.0, 8-hole LCPNone None 6 weeks None 1 242 4.1 2 y MN DSH UK Right: comminuted, proximal R/UDBF R: 2.0, 10-hole LCPU: 2.5 mm K-wireNone None 5 weeks Minor: soft tissue infection0 LTFU48 4 3 y MN DSH UK Left: comminuted short oblique, proximal R/UDBF R: 2.0 locking plateU: 2.0 locking plateNone None UK Minor: decubital ulcer at digit 1 nail bed, 4/5 lame at 1-week recheckLTFU LTFU49 4 13 y FS DSH UK Left: comminuted, proximal R/UDBF R: 2.0, 10-hole locking plateU: 1.5, 6-hole locking plateNone None 8 weeks delayed unionMinor: delayed union1 1BMP = bone morphogenetic protein; BSH = British Shorthair; CBG = cancellous bone graft; DBF = dual bone fixation; DCP = dynamic compression plate; DMH = domestic mediumhair; DSH = domestic shorthair; FS = female spayed; LC-DCP = limited contact dynamic compression plate; LCP = locking compression plate; LTFU = lost to follow-up; m = months; ME = male entire; MN = male neutered; R = radius; SBF = single bone fixation; U = ulna; UK = unknown; y = yearsTable 2 (Continued)10 Journal of Feline Medicine and Surgery Table 3 Statistical analysis of the effects of type of fracture and bone fixation, other orthopaedic issues and postoperative complications on outcomesOutcome Variable Category OR 95% CI P value Predicted proportionStandard errorVeterinarian-assessed outcomeBone fixation DBF – 0.4 0.154 SBF 14.25 2.07–97.99 0.007 0.9 0.064Other orthopaedic issuesNo – 0.704 0.088Yes 0.4211 0.09–1.865 0.255 0.5 0.158Fracture type Comminuted – 0.563 0.124 Simple 1.426 0.35–5.775 0.619 0.647 0.116Bone graft No – 0.677 0.084 Yes 0.476 0.081–2.789 0.411 0.5 0.204Postoperative complicationMajor – 0.4 0.219Minor 2.625 0.3–22.93 0.636 0.144 None 3.75 0.49–28.3 0.438 0.714 0.098Owner-assessed outcomeBone fixation DBF – 0.375 0.17 SBF 9.4 1.4–61.96 0.019 0.85 0.08Other orthopaedic issuesNo – 0.71 0.09Yes 1.235 0.109–13.95 0.864 0.75 0.21Fracture type Comminuted – 0.583 0.142 Simple 2.381 0.424–13.36 0.324 0.769 0.117Bone graft No – 0.79 0.08 Yes 0.087 0.007–1.029 0.053 0.25 0.215Postoperative complicationMajor – 0.0005 0.013Minor 4.2 0.365–84.5 0.8 0.126 None 8.6 0.86–112.6 0.733 0.6667 0.122Postoperative complicationBone fixation DBF – 0.462 0.138 SBF 1.26 0.262–3.526 0.952 0.452 0.09Other orthopaedic issuesNo – 0.441 0.085Yes 1.649 0.309–5.2 0.743 0.5 0.16Fracture type Complicated – 0.55 0.11 Simple 0.747 0.168–2.1 0.422 0.42 0.11Reference levels for ORs were DBF, no other orthopaedic issues, complicated fracture type, no bone graft and major postoperative complicationCI = confidence interval; DBF = dual bone fixation; OR = odds ratio; SBF = single bone fixationBone grafts CBGs were used in five fractures, and BMP was used in one. Of the cases with CBG, one (20%) had major complications requiring the plate to be removed; this case was lost to follow-up (case 18). The one case in which BMP was used resulted in amputation of the frac-tured limb (case 6) within the first week.Follow-upA total of 31 cases had follow-up radiographs. Of these, 22 (71%) had healing of the fracture of the radius at a mean of 8.8 weeks (range 5–14 weeks). Seven cases were considered to have delayed union at the time of final radiographs; however, there were no further follow-up radiographs to confirm healing at a later date.Of the 49 cases, 28 were available for long-term follow-up (6 months or more) with owner questionnaires: 20/28 were excellent; 6/28 were good; 1/28 was fair; and 1/28 was poor. The one case that was poor required amputa -tion (case 6).

Question 150

Kokkinos - 2023 - VETSURG - A modified full-thickness labial:buccal rotational flap reconstruction technique following bilateral rostral maxillectomy and nasal planectomy for resection of maxillary tumors - Technique and results in two dogs.pdf

Answer 150

2.1 |Signalment and preoperativefindingsDog 1 was a 5-year-old male entire Labrador cross (bodyweight: 18 kg) referred with a 2-month history of progres-sive swelling over the right maxillary canine tooth. A com-puted tomography (CT) scan of the head with (Figure 1A)and without contrast was performed. An oral tumor ofthe right maxilla (measured length /C2height /C2width:27 mm /C224 mm /C215 mm) was present at the level ofthe right maxillary canine tooth, extending dorsally to themidline, and medially across the hard palate mucosa.Osteolysis was present in the alveolar bone (Figure 2A) ofthe right maxillary third incisor and canine tooth, sugges-tive of a neoplastic process. Tumor peripheral contrastenhancement (Figure 2C) and regional lymphadenopathy(right caudal cervical and left medial retropharyngeal)were also reported. A computed tomography scan of thethorax showed no obvious sign of pulmonary metastaticdisease. The staging was incomplete as the regional lymphnodes were not assessed cytologically. An incisional biopsyof the primary tumor was performed, and histopathologywas consistent with low-grade fibrosarcoma. However, itsclinical behavior suggested a high-grade tumor, hence adiagnosis of oral Hi-Lo FSA.Dog 2 was a 5.5-year-old male neutered Labradorretriever (body weight: 35 kg) referred with a 6-week his-tory of displacement of the maxillary incisors, and an asso-ciated swelling over the right side of the nasal planum. Alarge soft-tissue mass (measured length /C2height /C2width:34 mm /C230 mm /C228 mm) was evident on a CT scan ofthe head (Figure 1B) involving and displacing the maxil-lary incisors and right maxillary canine tooth. The masswas affecting the hard palate mucosa, nasal planum andsoft tissues present over the right rostrolateral maxilla.There were signs of osteolysis (Figure 2B) affecting theincisive bone and the alveolar bone of the right maxillarytooth, with the mass extending along its periodontal liga-ment space. Peripheral contrast enhancement of the masswas identified (Figure 2D) and there were no obvioussigns of pulmonary metastatic disease on a CT scan of thethorax. The regional head and neck lymph nodesappeared within normal limits but they were not assessedcytologically. An incisional biopsy of the primary tumor1192 KOKKINOS ET AL . 1532950x, 2023, 8, was performed, and histopathology was suggestive of alow-grade soft tissue sarcoma. However, as in the previousdog, based on its clinical behavior, a diagnosis of a Hi-LoFSA was reached.2.2 |Anesthesia and preparationPreoperative complete blood count and serum biochemi-cal analysis were within normal limits for each dog.Both dogs received similar premedication and inductionprotocols for anesthesia. Premedication consisted ofmethadone (Comfortan; Dechra Veterinary Products,Shrewsbury, UK) 0.3 mg/kg IV and medetomidine (Seda-tor; Dechra Veterinary Products) 3 /uni03BCg/kg IV. Anesthesiawas induced with propofol (PropoFlo; Zoetis UK Limited,Surrey, UK) 4 mg/kg IV given to effect and maintainedwith isoflurane (Isoflo; Zoetis UK Limited) 1.5 –2 L/minin 100% oxygen. Isotonic buffered crystalloid solution(Aquapharm 11; Animalcare Limited, York, UK) 5 mL/kg/h IV was administered during surgery as well as cefur-oxime sodium (Zinacef; Sandoz Limited, Surrey, UK) at20 mg/kg IV every 90 min intraoperatively. Bilateralmaxillary nerve blocks using a percutaneous approachwere performed using 1 mg/kg of 0.5% bupivacaine (Mar-caine 0.5%; AstraZeneca, Cambrdige, UK) in both dogs.After positioning each dog, the muzzle was clippedand prepared with chlorhexidine gluconate surgical scrub4% (Hibiscrub; Mölnlycke Health Care, Gothenburg,Sweeden) diluted to 2% with water for injection. Extracaution was taken to avoid the eyes and protect themwith copious aqueous ocular lubricant, while keeping theeyelids closed using a piece of tape. Preparation of theoral mucosa was also performed using swabs impreg-nated in chlorhexidine gluconate solution 0.12%FIGURE 1 From left to right, horizontal, transverse, and sagittal view of the multiplanar reconstruction of the computed tomographyimages showing the right maxillary masses in (A) Dog 1 (top row), and (B) in Dog 2 (bottom row).FIGURE 2 Transverse view of the computed tomographyimages showing the osteolytic changes (arrowheads) associatedwith the maxillary mass in Dog 1 (A) and Dog 2 (B). Peripheralcontrast enhancement is also shown in Dog 1 (C) and Dog 2 (D).KOKKINOS ET AL . 1193 1532950x, 2023, 8, (Hexarinse; Virbac Limited, Suffolk, UK). The pharynxwas packed with gauze sponges to minimize the risk ofaspiration of blood or lavage fluid. Each dog was initiallypositioned in sternal recumbency for the extra-oral partof the surgery.2.3 |Surgical treatment2.3.1 | Dog 1A radical bilateral rostral maxillectomy was performed.Following review of the CT scan images to evaluate theextension of the bone lesion, this was cross evaluatedwith the soft tissue extension aiming for 2 cm marginsaround this defined area. Margins were marked using asterile ruler and marker to guide the incisions. A sharpincision of the lip was initially performed using aColorado microdissection needle (Stryker Craniomaxillo-facial, Kalamazoo, Michigan) mounted on a monopolarsystem. The first cut started from, and was perpendicularto, the labial edge caudal to the right maxillary caninetooth, up to the lateral edge of the nose (Figure 3Aand4A,B ). The incision then continued caudally on thedorso-lateral aspect of the muzzle and parallel to its dor-sal line, up to the level of the right maxillary third premo-lar tooth. The incision pattern was repeated on the leftside. The width of each remaining labial tissue differedfrom right to left due to the lateralization of the neo-plasm. Finally, the two caudal incision ends wereFIGURE 3 Steps of the surgical procedure (A –D) and postoperative outcome (E –F). The two labial/buccal mucocutaneous flaps oncemaxillectomy is completed (A). The right flap is sutured on the hard palate to create a new vestibulum (B). Holes are created on the palatineprocess of the maxillary bone using a hand chuck and K-wire, to pass sutures through and reinforce tissue hold (C). The left flap is sutureddorsally in the opposite direction to ensure cutaneous continuity dorsally (D) and mucosal continuity ventrally. The nasal passages arecovered by the mucosal (buccal) aspect of the dorsal (left) flap (E). Immediate postoperative outcome (F). (The figures demonstrating theintraoperative steps correspond to Case 2 but are presented in the manuscript with the first case seen chronologically.)1194 KOKKINOS ET AL . 1532950x, 2023, 8, connected with a curvilinear incision over the muzzleand perpendicular to its long axis. The rostral skin(labial) incisions were extended to full-thickness incisionsfrom the skin to the oral mucosa through the lips. Then,intraorally, the sharp incision was extended dorsally tothe buccal vestibulum and along it caudally to the levelof the maxillary third premolar, bilaterally. The soft tis-sue bands created latero-ventrally on both sides weremeticulously undermined and separated from the maxil-lary bone resulting in two full-thickness (muco-myo-cuta-neous) labial/buccal flaps (Figures 3Aand 4C). Extracaution was taken to avoid damaging the superior labialarteries as these provided the main blood supply to theseflaps.28Once a clear bone corridor was achieved along the skinincision dorsally and laterally along the base of the labial/buccal flaps, the osteotomy was performed using a serratedtip mounted on a piezoelectric bone surgery device (OP1piezo; iM3, Northampton, United Kingdom). Firstly, osteo-tomies of the nasal and the maxillary bones were per-formed down to predetermined interdental space (betweenthe maxillary third and fourth premolar on the right andthe maxillary second and third premolar on the left).For the intraoral part of the surgery, the dog wasrepositioned into dorsal recumbency, and the mandiblewas held open using the cap of a hypodermic needlebetween the right canine teeth. A linear sharp incisionacross the hard palate connected the two maxillaryincisions. Hemorrhage was controlled by ligation of themajor palatine arteries. The rostral edge of the hard pal-ate mucosal incision was undermined to expose theunderlying maxillary bone. The latter was cut usingthe piezoelectric device. Upon completion of the osteot-omy, the mucosa, conchae and septum were dissectedsharply. The skin overlying the maxilla together with thenasal planum was resected en bloc (Figure 3A). Hemor-rhage was controlled using monopolar electrocautery.For the first part of the reconstruction, the dog remainedin dorsal recumbency. The narrow flap (right) was rotatedmedially (towards the left) by 80 –85 degrees, and the oralmucosal edge was sutured to the palatal mucosa, to create anew oral vestibulum, achieving palato-labial mucosal con-tinuation and rostral extension of the physical barrierbetween the oral and nas al cavities (Figures 3Band4E). Thecutaneous edge of the flap was sutured across the ventrallyexposed nasal structures (mucosa and conchae) using poli-glecaprone 25 (Monocryl; Ethi con) size 4/0 on a reverse cut-ting needle. Several sutures were passed through predrilledholes in the maxillary bone using a 2.0 mm K-wire mountedon a hand chuck3(Figures 3Cand4D); these holes weremade before the suturing of the oral mucosa to the palatalmucosa. The redundant skin at the tip of the flap wasresected as necessary and the fresh edge was sutured to theoral mucosa at the base of the opposite flap (Figures 3Eand4G). The wide flap (left) was su tured on the dorsal aspect ofthe defect in an opposite manner after the dog wasFIGURE 4 Illustrations of the major steps of the surgical procedure. (A) Extraoral and (B) intraoral incision lines. (C) Illustration of theintraoperative step in Figure 3A. (D) Illustration of the intraoperative step in Figure 3C. (E) Illustration of the intraoperative step inFigure 3B. (F) Illustration of the intraoperative step in Figure 3Dshowing the hand chuck creating holes with a K-wire along the nasal bone.(G,H). Illustration of the end result shown in Figure 3E,F, respectively.KOKKINOS ET AL . 1195 1532950x, 2023, 8, repositioned in sternal recumbency. Its cutaneous edge wassutured towards the right, on t he dorsal aspect of the defect,reaching the base of the contralateral flap (Figures 3Eand4G,H ). Several sutures were pass ed through predrilled holesin the maxillary and nasal bones to strengthen the attach-ment (Figure 4F).3The labial/buccal mucosal edge of theflap was sutured across the exposed nasal structures dorsally(mucosa and conchae) in the same manner as the cutaneousedge of the right flap (Figures 3Eand4G). Images of theimmediate postoperative outc ome are available in Figure 3.Illustrations of the steps of the reconstruction and outcomeare available in Figure 4.2.3.2 | Dog 2A similar approach and steps were followed for Dog 2 ,with the only difference being the osteotomy level,between the maxillary third and fourth premolar teeth onboth sides.3|RESULTS3.1 |Dog 1An Elizabethan collar was placed postoperatively to pre-vent interference with the wounds. Cefuroxime(20 mg/kg IV every 8 h) was continued for 24 h postoper-atively. Analgesia was provided with a combination of aconstant rate infusion of ketamine (Anesketin; 5 /uni03BCg/kgIV per minute), which was tapered down over the next24 h, methadone (0.1 –0.2 mg/kg IV), which was adminis-tered according to pain scoring29until discharge, andparacetamol (Paracetamol; 10 mg/kg IV every 8 h). Traz-odone hydrochloride (Trazodone; 7 mg/kg orally every8 h) was administered during the stay in the hospital, tominimize stress. Sterile saline nebulization was also per-formed every 4 h (if tolerated), to help keep the nasalmucosa hydrated, soften the blood clots and/or preventtheir formation in the nasal passages.The intraoperative blood loss was calculated at theend of the surgery at approximately 18%; a blood transfu-sion was not deemed necessary intraoperatively as thedog was otherwise cardiovascularly stable. The packedcell volume (PCV; preoperatively 48%) was repeated 4 hpostoperatively and showed a marked drop (25%).Despite this drop, there were no major or persisting car-diovascular changes. The dog remained cardiovascularlystable throughout hospitalization and further assessmentof the PCV was not deemed necessary.The patient was discharged 2 days postoperativelywith the following medications: meloxicam (Metacam;0.1 mg/kg orally every 24 h), paracetamol/codeine(Pardale-V; 10 mg/kg orally every 8 h) and gabapentin(Gabapentin; 10 mg/kg orally every 8 h) for 2 weeks. Thepatient was able to breathe through the reconstructedmaxilla, with the only persistent clinical signs being mildself-limiting epistaxis.Histopathology was definitive for soft tissue sarcoma,most likely an oral FSA. The low histological-grade desig-nation was made based on well-differentiated cells, lowmitotic count (<1 in 10 high power fields), and theabsence of substantial necrosis. Lymphovascular invasionwas not identified and surgical excision was complete. Adiagnosis of Hi-Lo FSA subtype was reached based onthe combination of histopathology findings and clinicalbehavior of the mass.The dog recovered uneventfully, without any woundcomplications, although some episodes of dyspnea/stertorwere reported but self-resolved in the first 2 weeks postop-eratively. There were no concerns over the dog's breathingthereafter. Normal activities, including unaided eating andcarrying toys, were resumed wit hin 3 weeks, despite recom-mendations to avoid playing with toys during the first4w e e k s .T h eo w n e rr e p o r t e dt h a tt h e yh a dt oi n t r o d u c eabowl raiser to help their dog with eating and drinking. Theonly complication reported at 8w e e k sp o s t o p e r a t i v e l yw a sexcessive licking of the dorsal flap resulting in acute moistdermatitis, which gradually resolved without medical inter-vention. The owner reported the need for regular trimmingof the vibrissae, as they caused irritation in the nasal pas-sages if left long. At follow-up communications, there wasno obvious tumor recurrence, with the dog remaininghealthy, resuming preoperative routine activities (video clipS1) and breathing normally (video clip S2). The latestfollow-up communication was at 15 months postopera-tively. The owners were overall very satisfied with the cos-metic outcome and quality of life (Figure 5)o ft h e i rd o g ,reporting that they would go ahead again with the proce-dure in a similar situation in the future. A previouslydescribed owner questionnaire27was used to assess theowners' perception about their pet's recovery and overalloutcome.3.2 |Dog 2Dog 2 was managed postoperatively in a similar manner toDog 1 .T h eb l o o dl o s sa tt h ee n do ft h es u r g e r yw a sc a l c u -lated at approximately 20%. The patient remained cardio-vascularly stable, so a blood transfusion was not indicatedintraoperatively. Preoperative PCV was 40%. The sequentialPCV check at 4 h postoperatively and based on clinicalassessment, thereafter, showed a marked drop (lowest22%). Cardiovascular changes, including persistent1196 KOKKINOS ET AL . 1532950x, 2023, 8, tachycardia and tachypnea nonresponsive to supportivetreatment (crystalloid fluid boluses and oxygen therapy),were noted in this dog. A blood transfusion (1 unit of250 mL packed red blood cells of compatible blood type)was administered 8 h postoperatively. Immediately post-transfusion, the PCV was 29%, and the dog became cardio-vascularly stable.The dog remained cardiovascularly stable and wasdischarged 2 days postoperatively with self-limiting epi-staxis. Meloxicam (0.1 mg/kg orally every 24 h), paraceta-mol/codeine (10 mg/kg orally every 8 h) and gabapentin(10 mg/kg orally every 8 hours) were prescribed for2 weeks.Histopathology was definitive for soft tissue sarcoma,favoring a Hi-Lo FSA based on the combination of histo-pathological and clinical features. Anisocytosis and aniso-karyosis were mild to moderate. The mitotic count was2 in 10 high power fields. Clean histologic soft tissuemargins were achieved.The dog recovered uneventfully, without any woundcomplications. Normal activities, including unaided eat-ing and carrying toys, were resumed within 4 weeks(Figure 5C,D ), despite recommendations to avoid playingwith toys during the first 4 weeks. At the last follow-upcommunication at 6 months postoperatively, the ownerreported no obvious gross tumor recurrence with no othertreatment administered since discharge from the hospital.The dog continued to perform normal activities andbreathe without any apparent difficulty according to theowner. Like Dog 1 , regular trimming of the vibrissae wasalso reported by the owner as some irritation (sneezing)was seen when left long.4

Question 151

Pierrot - 2024 - JAVMA - Presumed concurrent medial coronoid process fracture is a frequent radiographic finding in dogs and cats with humeral condylar fractures.pdf

Answer 151

Case selectionThe database of the University of Liège Veteri -nary Teaching Hospital was searched for elbow frac -tures in dogs and cats between October 2013 and March 2022. Cases of humeral condylar fractures were included if at least pre- and postoperative ra -diographs were available for review. Cases were ex -cluded if no radiographs centered on the elbow were available. Species, sex, neutered status, breed, age, weight, and the nature of the trauma, when avail -able, were noted.Images were obtained using a computed or di -rect radiography system (Musica DR 14s or CR35x; Agfa-Gevaert Group; with Flexmed 90x x-ray table; General Electric CGR). All studies in DICOM for -mat were reviewed in consensus by a second-year European College of Veterinary Diagnostic Imag -ing resident (EJP) and a European College of Vet -erinary Diagnostic Imaging diplomate (GEB) in an image viewing program (Impax version 6.5.2; Agfa HealthCare NV).Studies were evaluated for the following param -eters: (a) configuration of humeral condylar fracture (lateral, medial, or T/Y fracture; a T/Y fracture was defined as an intercondylar fracture in which both the lateral and medial supracondylar crests were fractured); (b) presence of a presumed fractured medial coronoid process on at least 1 radiograph (preoperative, postoperative, follow-up when avail -able); (c) number of medial bone fragments; (d) size of fragment(s) (measurement made on the most conspicuous, in millimeters); (e) nature of fracture (open/closed or comminuted/simple; T/Y fracture was not considered comminuted unless free bone fragments other than the separated condyle were present); (f) degree of radioulnar incongruity (ab -sent/mild/moderate/severe), measured according to the step between the articular surface of the ra -dius and ulna,7,8 when positioning of the lateral ra -diograph was considered adequate; (g) preopera -tive degree of soft tissue swelling (mild/moderate/severe); (h) associated elbow subluxation/luxation and the joint affected (humeroulnar, humeroradial, or radioulnar); and (i) chondrodystrophic configura -tion of the patient based on subjective assessment of the length and curvature of the long bones includ -ed in the study.Statistical analysisQualitative variables were reported as numbers and percentages, and quantitative variables were re -ported as median, range, and IQR. Simple logistic re -gressions were used to determine the effect of the dif -ferent assessed factors concerning the presence of a suspected fractured medial coronoid process. For each model, ORs were calculated with 95% CIs. The associa -tion between the size of the presumed fractured medi -al coronoid process and factors such as the configura -tion of the fracture, signalment of the dog or cat, type of trauma, type of fracture (open or comminuted), soft tissue swelling, and associated subluxation or luxation was evaluated using a Student test. Results were con -sidered significant at P < .05. Data analysis was con -ducted using commercial and open-source software (SAS version 9.4; SAS Institute Inc; and R version 4.1.1; The R Project for Statistical Computing).ResultsPopulationFifty-eight cases of humeral condylar frac -tures were found in the clinical database. One case was excluded from our study, because the dog was presented for a recent radius/ulna fracture and an old humeral condylar fracture was incidentally ob -served; thus, no radiographs centered on the elbow itself were available. Fifty-five patients (7 cats and 48 dogs) were therefore included in the study for a total of 57 humeral condylar fractures. The median age was 4 months (range, 2 months to 10 years), with 75% under 13 months. There were 32 males and 23 females. Dog breeds included French Bulldogs (n = 19), American Staffordshire Terrier (7), Minia -ture Doberman Pinscher (3), Bernese Mountain Dog (2), mixed-breed (3), Cocker Spaniel (2), Cavalier King Charles Spaniel (2), and 1 each of Lhasa Apso, Jack Russel Terrier, English Springer Spaniel, Ger -man Shepherd Dog, Yorkshire Terrier, Mastiff, Boer -boel, Cane Corso, Malinois, and Beagle. Cat breeds included 6 domestic shorthair and 1 Maine Coon. Twenty-four of the included dogs were considered to be chondrodystrophic.The median weight of dogs was 8.5 kg (range, 1.5 to 87 kg), with 75% of dogs weighing under 14.0 kg. The median weight of cats was 3.0 kg (range, 1.0 to 4.1 kg). Weight was not recorded for 2 animals.The most frequent type of trauma was a fall from height (n = 35), followed by collision with another animal or object (4), motor vehicle accident (2), traction (3), and dog bite (1). The type of trauma was not reported in 12 cases.Unauthenticated | Downloaded 12/24/23 09:32 AM UTC 3Forty-eight dogs and cats were treated surgically for the humeral condylar fractures. Nine owners de -clined surgery. Only postoperative radiographs were available in 1 patient, and in some cases the humeral condylar fracture was surgically treated elsewhere even though preoperative radiographs were taken at our institution. No patients were treated surgically for the suspected fractured medial coronoid process.Imaging featuresFifty-seven elbows were evaluated using radio -graphs. Twenty-nine of the humeral condylar fractures affected the right elbow, while 28 affected the left one. The humeral condylar fracture was considered commi -nuted in 35 (62.5%) cases and open in 6 (11.3%) cases. All open fractures were comminuted. A lateral condylar fracture was diagnosed in 34 of 57 cases, a T/Y fracture in 20 of 57 cases, and a medial condylar fracture in 3 of 57 cases. When preoperative radiographs were avail -able, preoperative soft tissue swelling was mild in 15 of 54 cases, moderate in 20 of 54, and severe in 19 of 54 cases. The physis of at least 1 bone of the elbow joint was still open in 41 of 57 cases. In 53 cases, a second -ary elbow joint luxation (4/53) or subluxation (49/53) was present, affecting mainly the humeroradial and humeroulnar joints simultaneously (23/47), only the humeroulnar joint in 20 of 47 of cases, and only the humeroradial joint in 4 of 47 of cases. Six cases had no craniocaudal projections preoperatively, making it impossible to accurately assess the impacted joints despite the enlarged joint spaces visible on the lateral projections. Elbow congruity was measurable in 43 dogs, and incongruity was mild in 27 cases, moderate in 1 case, and absent in 15 cases.A presumed fracture of the medial coronoid pro -cess of the ulna was detected on radiographs in 26 of 57 elbows (25 dogs and 1 cat). A suspected fracture of the medial coronoid process was seen in 1 of 3 cases of medial condylar fractures, in 14 of 34 lateral condylar fractures, and in 11 of 20 T/Y fractures of the distal humerus (Figure 1) . Other categories such as breed or size of the dog could not be tested, as the samples were too small.Figure 1 —Craniocaudal radiograph of the elbow of a dog with a humeral condyle fracture and a medial bone fragment of varying size (arrow). Lateral is on the right. A—Medial condyle fracture with humeroulnar luxation. B—Lateral condyle fracture. Note the marked humeroul -nar luxation. C—T/Y condyle fracture with blunted me -dial coronoid process (arrowhead). Humeroulnar and humeroradial subluxation.Unauthenticated | Downloaded 12/24/23 09:32 AM UTC4 The isolated bone fragment appeared as 1 or 2 small mineral opacity fragments of various shape (triangular, rectangular, or rounded) lying adjacent and medially to the ulnar articular surface. It was either directly adjacent or mildly displaced distally or proximally relative to the ulnar articular surface. The fragments were always seen on the craniocau -dal projection of the elbow or a slightly oblique view. They were never seen on the lateral view. A blunted medial coronoid process was visible in 10 cases in addition to the fragment.Out of the 26 animals with suspected fracture of the medial coronoid process, 20 cases had a single fragment and 6 cases had 2 fragments (Figure 2) . The median size of the largest fragment was 3 mm (range, 1 to 5.30 mm). When 2 fragments were pres -ent, the median size of the smallest fragment was < 1 mm and it was often adjacent to the first one.Only the comminution of the condylar fracture had a statistically significant effect on the prevalence of the suspected medial coronoid process fracture (OR, 4.27; P = .018; Table 1 ). Animals with a commi -nuted humeral condylar fracture were 4 times more likely to also have a presumed fractured medial coro -noid process. It was also more frequent in T/Y frac -Risk factor P value OR 95% CIType of fracture .56 Medial 0.41 0.03–5.28 Lateral 0.57 0.19–1.75 T/Y 1.00 Age .096 1.02 0.99–1.03Weight .094 1.05 0.99–1.11Sex .45 Male 1.00 Female 0.67 0.23–1.92Species .073 Dog 1.00 Cat 0.14 0.02–1.20Conformation .12 Nonchondrodystrophic 1.00 Chondrodystrophic 0.42 0.14–1.24Type of trauma (fall from height vs other) .29 Fall from height 0.56 0.19–1.63 Other 1.00 Type of trauma (collision or motor vehicle accident vs other) .82 Collision or motor vehicle accident 1.22 0.22–6.61 Other 1.00 Comminuted fracture .018 No comminuted 1.00 Comminuted 4.27 1.28–14.3Open fracture .17 Closed fracture 1.00 Open fracture 0.21 0.02–1.93Soft tissue swelling .27 Mild 1.00 Moderate 3.00 0.74–12.1 Severe 1.45 0.36–5.94Associated subluxation/luxation .31 Absent 1.00 Subluxation 7.98 0.29–220 Luxation 21.0 0.42-519Radioulnar incongruity in dogs .62 Absent (< 0.5 mm) 1.00 Mild (0.5–2 mm) 0.93 0.26–3.39 Moderate (2–3 mm) 3.06 0.03–326Table 1 —Risk factors for the presence of a concomitant suspected fracture of the medial coronoid process ( P values in bold are significant).Figure 2 —Craniocaudal radiograph of the elbow of a dog with a T/Y condyle fracture and 2 small medial bone fragments (arrows) with blunted medial coronoid process (arrowhead). Lateral is on the right.Unauthenticated | Downloaded 12/24/23 09:32 AM UTC 5tures, although this was not statistically significant (OR, 1; P = .56). Size of the fragment was influenced by weight of the patient, with heavier patients hav -ing larger fragments (OR, 0.41; P = .026). Fragments tended to be larger in T/Y fractures ( P = .058) and smaller in chondrodystrophic breeds ( P = .091), even though the difference was not statistically signifi -cant. No factor had an influence on the presence of multiple fragments.

Question 152

Ericksen - 2023 - JAVMA - Dome trochleoplasty for correction of patella alta and patella luxation in dogs > 20 kg.pdf

Answer 152

Client-owned large-breed dogs weighing 20 kg or more were prospectively enrolled in this study based on a history of lameness and clinical diagno -sis of patellar luxation secondary to patella alta via orthopedic and physical examinations and standard mediolateral and craniocaudal radiographic projec -tions. Patella alta was diagnosed using a patellar ligament length-to-patellar length ratio of > 1.97 as previously described.2 All owners were informed of this novel technique and were required to read and sign an informed consent agreement for dogs enrolled in the study. The breed, sex, neuter status, age, and body weight of each dog was recorded. Dogs were excluded from the study if they had con -current orthopedic and/or neurologic disease at the time of initial diagnosis. The aim was to perform the procedure on a total of 20 stifle joints before closing enrollment; 4 stifle joints were excluded due to lack of patella alta as the cause for MPL.To determine feasibility of the technique before use in clinical patients, the dome trochleoplasty procedure was first performed on canine saw bones. Following successful application of the technique to saw bones, it was performed on canine cadavers before being offered to client-owned dogs. Each dog was anesthetized using various balanced anesthetic protocols, was aseptically prepared for surgery, and received either an epidural or femoral-sciatic nerve block using 0.25% bupivacaine. A standard lateral approach to the stifle was performed10 followed by visual evaluation of the stifle joint, femoral trochlea conformation, and position of the patella. A bi -radial saw blade was sized to ensure that the entire fem -oral trochlea, including the trochlear ridges, was excised parallel to the long axis of the femur. The osteotomy was started just proximal to the origin of the long digi -tal extensor tendon into the distal femur and continued proximally up the cranial aspect of the femur until the trochlea was removed (Figure 1) .The trochlea was then translated proximally un -til 75% of the patella sat within the trochlear groove to correct patella alta (Figure 2) . Additionally, the trochlea could be translated medially or laterally or rotated 180° to ensure sufficient medial or lateral trochlear wall height to prevent patellar luxation if necessary (Figure 3) .The trochlea was secured in its new position using 2 divergent Kirschner wires (0.045 to 0.094 inches) placed just lateral to the trochlear ridges in a cranial-to-caudal direction (Figure 4) and advanced until they engaged the caudal femoral cortex. The Kirschner wires were then cut and countersunk be -low the articular cartilage. Each dog received stan -dard protocol pain management, consisting of a single injection of carprofen (2.2 mg/kg, SC) post -operatively and hydromorphone (0.2 mg/kg, IV, q 6 h) or methadone (0.2 mg/kg, IV, q 6 h) for 24 hours. Dogs were monitored in the hospital for 24 hours postoperatively until discharge. Home care included cage rest, leash walking exercise for 8 weeks, and pain management consisting of tramadol (5 mg/kg, PO, q 12 h) for 10 days and carprofen (2.2 mg/kg, PO, q 12 h) for 30 days.Postoperative clinical results were assessed us -ing subjective lameness scoring, radiographic heal -ing, and the Canine Brief Pain Inventory (CBPI) tool. Figure 1 —Osteotomy proximal to the origin of the long digital extensor tendon to remove trochlea.Figure 2 —Translation of the trochlea proximally to cor -rect patella alta.Figure 3 —Translation of the trochlea medially or later -ally to correct patellar luxation.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 11/03/23 06:54 AM UTC 3Catastrophic, major, and minor complications were recorded; catastrophic complications were defined as those leading to permanent unacceptable func -tion, major complications were defined as those re -quiring additional surgical intervention, and minor complications were defined as those that were medi -cally managed or resolved without therapy.Orthopedic examinations were performed and lameness scores were assigned by the attending sur -geon using a modified lameness scale of 0 to 5 (grade 0 = no lameness, 1 = intermittent weight bearing, 2 = consistent weight-bearing lameness, 3 = intermittent non–weight-bearing lameness, 4 = non–weight-bear -ing lameness, 5 = nonambulatory) before surgery, at 2 weeks postoperatively, and at the final recheck.11 Ra-diographs were taken immediately postoperatively to ensure proper placement of implants and at 8 weeks postoperatively to assess bone healing and identify any complications; the osteotomy was considered healed when the osteotomy line was no longer vis -ible and callus formation was present. Owners were asked to fill out the CBPI survey tool before surgery, at 2 weeks postoperatively, and at the final 8-week recheck examination.12Data were analyzed using IBM SPSS Statistics for Windows, version 28 (IBM Corp). For each surgery, the median lameness score preoperatively was com -pared with the median lameness score 2 weeks post -operatively as well as the median lameness score at a final follow-up. Additionally, for each surgery, the median pain levels preoperatively were compared with median pain levels 2 weeks postoperatively and during a final follow-up. The nonparametric related-samples Wilcoxon signed rank test (2 tailed) was used to make the comparisons, and the significance value for all analyses was set at α = 0.05.ResultsA total of 16 stifle joints (13 dogs) were included in the current study. All stifle joints were diagnosed with MPL with concurrent patella alta. The median patellar ligament length-to-patellar length ratio was 2.05 (mean, 2.1; range, 2.0 to 2.3). The left stifle was affected in 9 dogs (56.3%), and 7 dogs (43.8%) had the right stifle affected. Two stifle joints (12.5%) were diagnosed as grade 2 MPL, and 14 (87.5%) stifle joints were diagnosed as grade 3 MPL. Of the dogs included in the study, 43.8% were spayed females and 37.5% were neutered males. Ages ranged from 1 to 3 years old at the time of surgery (median, 1; mean, 1.37 years). The median body weight was 27.5 kg (mean, 30.1 kg; range, 20 to 65 kg).Following arthrotomy, all dogs were found to have intact cranial and caudal cruciate ligaments and intact medial and lateral menisci. On evaluation of the femoral trochlea, 8 of the 16 stifles (50%) showed wearing at the proximal aspect of the medial troch -lear ridge. Following the trochlear osteotomy, the trochlear segment was translated proximally in all 16 stifle joints. Additionally, the trochlear segment was translated medially in 4 stifle joints (25%), rotated 180° and translated medially in 5 stifle joints (31.3%), and rotated 180° alone in 1 stifle, and no rotation or medial translation occurred in 6 stifle joints (37.5%). The 6 stifle joints that did not have a rotation or me -dial or lateral translation of the osteotomized seg -ment required a proximal advancement of the seg -ment only. All stifle joints had proximal translation of the osteotomized segment. Concurrently performed procedures were tibial tuberosity transposition in 5 stifle joints and lateral fascial imbrication in all 16 stifle joints. No dogs in this study were identified as having femoral varus. If femoral varus was present, the dome trochleoplasty would not have been used, and a patient would have been treated with a distal femoral osteotomy instead.Eight of 16 stifle joints (50%) had reported com -plications, which were diagnosed 42 to 224 days post -operatively (mean, 101.7 days). Major complications occurred in 7 stifle joints (43.8%) due to pin migra -tion with subsequent removal (n = 4) and reluxation (3). The course of treatment for the 4 stifle joints in which pin migration occurred included pin removal under sedation followed by empirical treatment of cephalexin (22 mg/kg, PO, q 12 h) for 7 days. Of the 9 remaining stifle joints where the Kirshner wires remained in place, 8 of the osteotomized segments went on to heal without complication. One dog expe -rienced a catastrophic complication 4 months post -operatively in which the dog had progressive, severe bone resorption of the osteotomized trochlear ridge noted on radiographs (Figure 5) . The dog was subse -quently treated with a patellar groove replacement as previously described13 and recovered.Lameness scores were available for all stifle joints in this study, with a median final recheck time Figure 4 —Kirschner wire placement se -curing the trochlear segment in its new position. A—Lateral pin placement. B—Cranial-to-caudal pin placement. Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 11/03/23 06:54 AM UTC4 of 87.5 days (mean, 101.7 days; range, 42 to 224 days). The median initial, 2-week, and final recheck lameness scores were 2 (mean, 1.81 days; range, 0 to 4 days), 2 (mean, 2.63 days; range, 1 to 4 days), and 0 (mean, 0.31 days; range, 0 to 2 days). When com -paring preoperative lameness scores to lameness scores taken 2 weeks postoperatively, there were 9 instances of lameness scores increasing, 5 instances of lameness scores remaining unchanged, and 2 in -stances of lameness scores decreasing. When com -paring preoperative lameness scores to those taken during a final follow-up, there were 0 instances of lameness scores increasing, 2 instances of lameness scores remaining unchanged, and 14 instances of lameness scores decreasing.Wilcoxon signed rank tests revealed that the me -dian difference in lameness scores from preoperative levels to postoperative levels was significant. Spe -cifically, lameness scores 2 weeks postoperatively (mean, 1.81; median, 2; SD, 1.22) were higher than preoperative lameness scores (mean, 2.62; median, 2; SD, 1.09; P = .046), but lameness scores at the final follow-up were significantly lower (mean, 0.31; me -dian, 0; SD, 0.60) than preoperative levels ( P < .001).Immediate postoperative radiographs showed that proper implant placement was present in all dogs and that uncomplicated osteotomy healing was present in 15 of the 16 (94%) stifle joints at 8-week recheck radiographs. The CBPI scores were available for 8 of the 16 stifle joints (50%) with a median final recheck time of 112 days (mean, 112.8; range, 42 to 224 days). The initial 2-week and final mean CBPI scores were 45.5 (mean, 48.9; range, 32 to 74), 48 (mean, 47.4; range, 33 to 67), and 17.5 (mean, 20.5; range, 0 to 43). When comparing preoperative pain levels to pain levels taken 2 weeks postoperatively, Figure 5 —Mediolateral and craniocaudal radiographs taken of the left stifle joint preoperatively (A), immediately postoperatively (B), and 4 months postoperatively (C) demonstrating trochlear segment resorption follow dome trochleoplasty in the patient suffering a catastrophic complication. This patient went on to have a patellar groove replacement and recovered without further complications.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 11/03/23 06:54 AM UTC 5there were 3 instances of pain levels increasing, 0 in -stances of pain levels remaining unchanged, and 5 instances of pain levels decreasing. When comparing preoperative pain levels to those taken during the fi -nal follow-up, there were no instances of pain levels increasing, no instances of pain levels remaining un -changed, and 8 instances of pain levels decreasing.Wilcoxon signed rank tests revealed that pain scores were not different between preoperative levels (mean, 48.88; median, 45.50; SD, 12.90) and those recorded 2 weeks postoperatively (mean, 47.38; median, 48.00; SD, 12.32; P = .48), but pain levels during the final follow-up were significantly lower (mean, 20.50; median, 17.50; SD, 16.36) than they were preoperatively ( P = .01.)

Question 153

Kawamura - 2023 - JSAP - Percutaneous shunt vessel embolisation with Amplatzer vascular plugs II and IV in the treatment of dogs with splenophrenic shunts - Four cases (2019-2022).pdf

Answer 153

Case inclusionDogs with splenophrenic shunts treated at Kawamura Animal Hospital from January 2019 to December 2022 were identified through a medical record search for the term “splenophrenic shunt”. Dogs diagnosed with splenophrenic shunts by computed tomographic angiography and undergoing percutaneous shunting vessel embolization with Amplatzer vascular plugs were included.Data extractionData extracted from the medical records included signalment (age, breed, and sex), body weight, presenting clinical signs at diagnosis of splenophrenic shunts, diagnostic imaging findings, portal pressure before/after blockage, serum biochemistry before and after AVP placement, postprocedural complications.RESULTSPatient inclusionThrough the medical record search, 6 dogs with splenophrenic shunts were identified. T wo dogs were excluded because they were treated with laparoscopic surgery. Four dogs underwent per -cutaneous shunting vessel embolization with Amplatzer vascular plugs and were included in the case series.Clinical presentationCase 1A 17- month- old, 3.2- kg, intact male toy poodle with no relevant medical history was admitted to our hospital for a preoperative evaluation for castration. Preoperative biochemistry revealed an increase in alanine aminotransferase (126 U/L; reference range, 17 to 78 U/L). Preoperative thoracic radiographs suggested microhepatica, and follow- up abdominal radiographs con -firmed microhepatica. Preprandial bile acids were 56.6 μmol/L 17485827, 2023, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13660 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 LicenseY. Kawamura et al.Journal of Small Animal Practice • Vol 64 • November 2023 • © 2023 British Small Animal Veterinary Association. 712(reference range, <20 μmol/L) and postprandial bile acids were 155.7 μmol/L (reference range, <25 μmol/L). The presence of a CPSS was suspected, and a polyphase CT examination of the abdomen was performed. A solitary shunting blood vessel con -necting the splenic and phrenic veins was identified ( Fig 1A). The diameter of the shunting vessel distal to the junction of the left hepatic vein was 2.3×6.7 mm, and the intrahepatic portal vein branch was confirmed up to the fourth branch.The dog was diagnosed with a CPSS connecting the splenic and phrenic veins. Surgical intervention was recommended. Surgical ligation, placement of an ameroid constrictor and cel -lophane banding under laparotomy and percutaneous shunting vascular embolisation were presented as treatment options. A minimally invasive treatment protocol was requested and inter -ventional embolisation was planned.Case 2An 11- month- old, 4.2- kg, intact female mixed- breed dog (shih- tzu×Chihuahua) was admitted to our hospital for the examination of the liver. There was no relevant medical history, but a preopera -tive evaluation for ovariohysterectomy by a referring veterinarian identified increased alanine aminotransferase at 789 U/L, and ele -vated preprandial (56.6 μmol/L) and postprandial (155.7 μmol/L) bile acids. A solitary shunting blood vessel connecting the splenic and phrenic veins was identified on CT ( Fig 1B). The diameter of the shunting vessel distal to the junction of the left hepatic vein was 2.9×6.3 mm, and the liver appeared atrophied on CT images. The intrahepatic portal vein branch was identified up to the fifth branch. Due to the well- developed intrahepatic portal vein branches, closure of the shunting vessel was recommended, and embolisation of the shunting vessel was planned.Case 3A 15.8- kg intact male Welsh Corgi aged 2 years and 9 months had one seizure and was seen by a local veterinarian. The dog was referred to our hospital for investigation of elevated prepran -dial ammonia (299 μg/dL; reference range, 16 to 75 μg/dL), and preprandial (94.1 μmol/L) and postprandial (245.0 μmol/L) bile acids. The presence of a solitary shunting blood vessel connecting the splenic and phrenic veins was identified on CT ( Fig 1C). The diameter of the shunting vessel distal to the junction of the left hepatic vein was 4.7×15.8 mm, and the liver was atrophied on CT images. The intrahepatic portal vein branch was confirmed up to the third branch. Surgical intervention was recommended and embolisation of the shunting vessel was planned.Case 4A 5.2- kg intact female miniature dachshund aged 9 years and 11 months had no clinical signs other than consistently having a low body condition score of 3 (on a scale of 1 to 9). Medi -cal examination at a local veterinary clinic identified increased alanine aminotransferase (380 U/L), elevated preprandial (>150 μmol/L) and postprandial (93.1 μmol/L) bile acids, and abdominal radiography showed microhepatica. A portosystemic shunt was suspected, and the dog was referred to our hospital. The presence of a solitary shunting blood vessel connecting the splenic and phrenic veins was identified on CT ( Fig 1D). The diameter of the shunting vessel distal to the junction of the left hepatic vein was 4.0×7.7 mm, and the liver was atrophied. The intrahepatic portal vein branch was confirmed up to the third branch. Based on the above findings, the dog was diagnosed with a CPSS connecting the splenic and phrenic veins. Surgical inter -vention was recommended and embolisation of the shunting ves -sel was planned.Transcatheter shunt embolisation proceduresEmbolisation with the AVP IV (cases 1 and 2)For the transcatheter shunt embolisation procedure, cefovecin sodium (8 mg/kg) was administered subcutaneously as a preop -erative antibiotic. Atropine sulphate (0.01 mg/kg), midazolam (0.25 mg/kg) and butorphanol (0.25 mg/kg) were intravenously administered as preanaesthetic medications. Anaesthesia was induced with propofol, which was administered intravenously to effect. After induction, endotracheal intubation was performed, and anaesthesia was maintained with inhaled isoflurane (1.6% to 2.0%). Ephedrine hydrochloride (1 mg/kg, intravenous bolus as necessary) was used to maintain blood pressure. The dog was FIG 1. Maximum intensity projection CT images taken in the portal phase showing the splenophrenic shunts (arrows). (A) Case 1; (B) Case 2; (C) Case 3; (D) Case 4 17485827, 2023, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13660 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 LicenseShunt embolisation with AVP II and IV in dogsJournal of Small Animal Practice • Vol 64 • November 2023 • © 2023 British Small Animal Veterinary Association. 713 placed in a supine position, and the left side of the neck shaved and disinfected.The following procedure was performed using a flat panel- type x- ray fluoroscope (Cios fusion; Siemens, Munich, Germany). A 5- Fr sheath introducer (Radifocus Introducer IIH; Terumo, Tokyo, Japan) was placed in the left external jugular vein using the Seld -inger technique. A 5- Fr balloon catheter (Selecon MP Catheter II 9 mm; Terumo, Tokyo, Japan) was inserted under fluoroscopic guidance and advanced from the anterior vena cava to the poste -rior vena cava using a 0.038- inch angled guide wire (Radifocus Guide Wire; Terumo, Tokyo, Japan). The left phrenic vein branch -ing from the posterior vena cava at the level of the diaphragm was identified. Angiography using iohexol contrast medium (Omnip -aque 300; Daiichi Sankyo Co., Ltd., Tokyo, Japan) confirmed the shunting vessel connected the left phrenic vein to the splenic vein.The catheter tip was advanced in the left phrenic vein distal to the left hepatic vein. The balloon catheter was connected to a pressure transducer, and the portal pressure was measured. Portal pressure was 4 to 5 mmHg in Case 1 and 6 to 7 mmHg in Case 2. While injecting a 1:1 diluted solution of physiological saline (0.9% NaCl) and iohexol contrast medium (Omnipaque 300) under fluoroscopy, the balloon was inflated ( Fig 2A). Angiography confirmed that the shunting vessel was completely occluded and the portal vessels were clearly visualised ( Fig 2B). Portal pressure at this time was less than 15 mmHg and the increase did not exceed 7 mmHg ( Table 1) (Hottinger et al. 1995 , Broome et al. 2004 ).Ten minutes after balloon occlusion, there was no change in heart rate, portal vein pressure or arterial blood pressure mea -sured from the dorsalis pedis artery. In both cases, angiography confirmed the diameter of the shunting vessel and that the vessel was of sufficient length to allow placement of an AVP IV (Abbott Medical, Santa Clara, CA, USA) ( Fig 3). The outer boundary of the vessel cross- section was previously measured on CT images, and the approximate diameter was estimated by dividing the outer boundary of the vessel cross- section by the circumference ratio. The plug was selected to have a diameter 30% to 50% greater than that of the shunting vessel ( Table 1). An AVP IV with a diameter of 7 mm was used in Case 1 and an AVP IV with a diameter of 6 mm in Case 2.The AVP IV loader was flushed with saline, attached to the hub of the balloon catheter, and the pusher wire was directed into the balloon catheter until the tip of the plug reached the distal end of the catheter. The plug was unfolded by positioning the plug and pulling the balloon catheter ( Fig 2C). The pusher wire was lightly tightened in the anteroposterior direction to confirm that it was completely fixed to the vessel wall, and then the plug was released. In both cases, angiography confirmed that blood flow was completely occluded at the site where plug was placed ( Fig 2D). In Case 2, laparoscopic ovariectomy was performed after placement of the AVP .Embolisation with the AVP II (cases 3 and 4)Cefovecin sodium (8 mg/kg) was administered subcutaneously as a preoperative antibiotic. Atropine sulphate (0.01 mg/kg), midazolam (0.25 mg/kg) and butorphanol (0.25 mg/kg) were intravenously administered as preanaesthetic medications. Anaes -thesia was induced with propofol, which was slowly administered intravenously to effect. After induction, endotracheal intubation was performed, and anaesthesia was maintained with inhaled isoflurane (1.6% to 2.0%). Ephedrine hydrochloride (1 mg/kg, intravenous bolus as necessary) was used to maintain blood pres -sure. The dog was placed in a supine position, and the left side of the neck shaved and disinfected.A 7- Fr sheath introducer (Radifocus Introducer IIH; Terumo) was placed in the left external jugular vein as previously described. A 6- Fr balloon catheter (Selecon MP Catheter II 13 mm; Terumo) was inserted, and the left phrenic vein was identified. Angiog -raphy confirmed the shunting vessel connected the left phrenic vein to the splenic vein. Portal pressure was 11 mmHg in Case 3 and 1 mmHg in Case 4. The balloon was inflated and angi -ography confirmed the shunting vessel was completely occluded (Fig 4A) and portal branches were visualised ( Fig 4B). The portal pressure after balloon occlusion was 14 mmHg in Case 3 and 5 mmHg in Case 4 ( Table 1).There was no change in heart rate, portal vein pressure or arterial blood pressure measured from the dorsalis pedis artery in either dog 10 minutes after balloon occlusion. The diameter of the blood vessel at the occlusion site was measured by angiogra -FIG 2. Intraoperative fluoroscopy images of shunting vascular embolisation in Case 1. (A) The catheter is inserted into the left phrenic vein, and the portal pressure is 6 to 7 mmHg with the balloon dilated in the shunting vessel beyond the confluence of the left hepatic vein. (B) Angiography is performed from the same site to confirm the shunting blood vessel (arrow) and the intrahepatic portal vein branch (arrowhead). (C) An Amplatzer vascular plug (AVP) IV (arrow) with a diameter of 7 mm is deployed at the same site. (D) Angiography is performed to confirm complete blockage of blood flow at the location of the AVP IV (arrow) 17485827, 2023, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13660by 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 LicenseY. Kawamura et al.Journal of Small Animal Practice • Vol 64 • November 2023 • © 2023 British Small Animal Veterinary Association. 714phy. The size of the plug was determined as previously described (Table 1); for Case 3 an AVP II (Abbott Medical) ( Fig 3) with a 14 mm diameter and for Case 4 an AVP II with a 10- mm diameter. The balloon catheter was removed while leaving the guide wire in, and a 7- Fr guiding catheter (Mach 1™ Peripheral Guide Catheter; Boston Scientific, Marlborough, MA, USA) was inserted into the shunting vessel along the guide wire.The AVP II loader was flushed with saline, attached to the hub of the guiding catheter, and the pusher wire was directed into the guiding catheter until the tip of the plug reached the distal end of the guiding catheter. By pulling the guiding cath -eter, the plug expanded, and by pushing the guiding catheter, the plug was positioned so that it would not touch the junction of the left hepatic vein ( Fig 4C). The pusher wire was tightened in the anteroposterior direction to confirm that the AVP was com -pletely fixed to the vessel wall, and the plug released. In both cases, angiography confirmed that blood flow was completely occluded at the AVP site ( Fig 4D). In Case 3, surgical castration was performed after placement of the AVP .It was technically possible to place an AVP II or AVP IV in all four dogs. The diameter and circumference of the shunting vessels and the sizes of the AVPs used are shown in Table 1. In all cases, the increased portal pressure after temporary occlusion was within an acceptable range, and complete occlusion of blood flow was possible with a single plug. The total procedure times were: Case 1, 110 minutes; Case 2, 95 minutes (73 minutes for shunt embolisation, 22 minutes for laparoscopic ovariectomy); Case 3, 122 minutes (110 minutes for shunt embolisation, 12 minutes for castration); and Case 4, 115 minutes. The total anaesthetic times were: Case 1, 135 minutes; Case 2, 120 min-utes; Case 3, 148 minutes; and Case 4,153 minutes. Postopera -tively, intravenous lactated Ringer’s solution (3 mL/kg/hour) was administered until the second postoperative day. Lactulose (0.1 to 0.2 mL/kg PO 12 hours) was continued until postoperative preprandial ammonia levels normalised, but was discontinued within 2 weeks in all cases. The dog’s general condition (body temperature, heart rate, respiratory rate) and liver enzymes, ammonia, total protein, blood urea nitrogen, and glucose in plasma were monitored during the hospital stay. All dogs were in good clinical condition after surgery, Cases 1, 2, and 4 were discharged 3 days after the procedure, and Case 3 was discharged 4 days after the procedure. There were no major procedure- related complications, post- ligation seizures or signs of portal hypertension. Radiographs taken approximately 1 month after surgery (average: 32.8 days, range: 24 to 50 days) confirmed no displacement of the AVP had occurred in any of the dogs. Abdominal ultrasound performed at the same time showed no obvious colour Doppler blood flow around the plug. At the time of this report, all dogs are clinically normal, and in good general condition ( Table 1). CPSS scores (Bristow et al. 2019 ) remained at 0 in Cases 1 and 2 pre- and postoperatively, but they improved from 3 to 0 in Case 3 and 4 to 2 in Case 4. Table 2 shows serum biochemistry before and after treatment. Improvements in pre -prandial ammonia values were observed in all cases (Case 1: pre 78 μg/dL to 50 days 24 μg/dL, Case 2: pre 64 μg/dL to 138 days 42 μg/dL, Case 3: pre 294 μg/dL to 27 days 37 μg/dL, Case 4: pre 218 μg/dL to 24 days 58 μg/dL).Table 1. Summary of treatment and clinical results of four dogs with congenital splenophrenic shuntCase 1 2 3 4Age (month) 17 11 33 119Breed Toy poodle Shih Tzu×Chihuahua Welsh Corgi Miniature dachshundSex Intact male Intact female Intact male Intact femaleWeight (kg) 3.2 4.2 15.8 5.2Portal pressure before blockage (mmHg) 4 to 5 6 to 7 11 1Portal pressure at temporary blockage (mmHg)6 to 7 7 14 5Measured diameter of the shunt vessel (mm) 2.3×6.7 2.9×6.3 4.7×15.6 4.0×7.7Circumference of the shunt vessel (mm) 15.6 14.8 34.0 20.9Extrapolated diameter of the shunt vessel (mm)5.0 4.7 10.8 6.7Type of AVP IV IV II IISize of AVP (mm) 7 6 14 10Hospitalisation days (day) 3 3 4 3Total procedure time (embolisation only) (minute)110 (110) 95 (73) 122 (110) 115 (115)Follow- up (day) 590 575 120 65Complications None None None NonePreoperative CPSS score 0 0 3 4Postoperative CPSS score 0 0 0 2AVP Amplatzer vascular plug™, CPSS Congenital portosystemic shuntFIG 3. The appearances of the unfolded Amplatzer vascular plug II and Amplatzer vascular plug IV 17485827, 2023, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13660 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 LicenseShunt embolisation with AVP II and IV in dogsJournal of Small Animal Practice • Vol 64 • November 2023 • © 2023 British Small Animal Veterinary Association. 715

Question 154

Tichenor - 2024 - JAVMA - Characteristics and outcomes for 61 cats that underwent either surgery or stereotactic radiotherapy as treatment for intracranial meningioma (2005-2017).pdf

Answer 154

Case selection criteriaMedical records of client-owned cats that under -went either surgical removal or SRT for the manage -ment of intracranial tumors consistent with menin -gioma between January 2005 and March 2017 were reviewed. Inclusion criteria for this study were cats with a presumptive or definitive diagnosis of menin -gioma based on either histopathology or highly sug -gestive features on advanced imaging (MRI or CT) that underwent surgical excision or SRT. Exclusion criteria were patients that had > 2 differential diag -noses, not including meningioma.Medical record review —Information obtained from the medical records included age, sex, breed, duration of clinical signs, clinical signs present at ini -tial examination, advanced imaging findings, treat -ment (surgery vs SRT), radiation protocol, peritreat -ment complications, histologic tumor type, survival time after diagnosis, time to recurrence, and subse -quent treatment of recurrence. If date of death or follow-up was not available in the medical records, referring veterinarians and clients were contacted by telephone for additional information.DiagnosticsAll available imaging studies were initially re -viewed by a board-certified radiologist or neurolo -gist. Tumor location was classified into 3 groups on the basis of location in the brain: forebrain (cere -brum, olfactory lobes, and diencephalon), cerebel -lum, or brain stem (midbrain, medulla, pons, and cerebellomedullary angle). Multiple locations were noted when diagnosed, and the largest lesion was used for data calculations.The histopathologic diagnosis was recorded from the available histopathology report or the medical records. Diagnosis of meningioma was considered presumptive if the CT or MRI charac -teristics were consistent with previously reported lesion characteristics.1,3,11,20,21TreatmentTumor removal surgery —Surgical techniques that have been used to remove feline and canine meningi -omas have been previously detailed elsewhere.15,22 All biopsies were collected intraoperatively.Stereotactic radiotherapy —SRT performed at the Animal Specialty Center was with a Cy -berKnife Radiosurgery System (Accuray Inc). SRT consisted of either 1 or 3 daily fractions ranging from 800 to 3,000 cGy to equal 2,400 to 9,000 cGy total treatment dose.Outcomes —Peritreatment complications were defined as complications occurring during surgery or during hospitalization following treatment. Post-treatment complications were defined as complica -tions occurring after discharge from the hospital. Initial recurrence was defined as return of or new clini -cal signs consistent with the previous diagnosis and was confirmed via advanced imaging (CT or MRI).Statistical analysisContinuous data were described using median and IQR due to nonnormal distributions. Frequen -cies and percentages were used to describe cate -gorical data. Associations between treatment used and categorical variables were assessed using Fish -er exact tests. Kruskal-Wallis tests were used to test between differences in continuous variables on the basis of the treatment used. Kaplan-Meier method -ology was used to draw survival curves for time to progression or recurrence and survival time (Figure 1). Cats were censored in the time to recurrence or progression analysis if there was no documentation Unauthenticated | Downloaded 12/24/23 09:26 AM UTC 3of progression or recurrence before data collection for study, loss to follow-up, or death. In the survival time analysis, cats were censored if alive at last fol -low-up or if lost to follow-up. Log rank tests were used to compare survival distributions between treatment groups.Statistical significance was set at P = .05, and the statistical analysis was performed using a com -mercially available software package (SAS software version 9.4; SAS Institute Inc). ResultsStudy populationSixty-one cats met the criteria for inclusion in the study. Domestic shorthair was the most-repre -sented breed with 48 (79%) cats, followed by 8 (13%) pure breeds, 3 (5%) mixed breeds, and 2 (3.2%) do -mestic longhairs. Pure breeds that were represented included Persian (n = 3), Maine Coon (3), Himalayan (1), and Norwegian Forest Cat (1). The median age at diagnosis was 11 years in the surgery group and 12.5 years in the SRT group (overall range, 5 to 18 years), and there were twice as many neutered males compared to spayed females in this population (20 spayed females and 41 neutered males). No signifi -cant difference in breed, age, or neuter status was found regarding treatment group.Pretreatment evaluationOf the 56 cats that had documented clinical signs prior to diagnosis, 73% (41/56) had behavior/menta -tion changes, 68% (38/56) cranial nerve deficits, 59% (33/56) gait abnormalities, 23% (13/56) seizures, and 18% (10/56) for other changes (ie, weight loss/decreased appetite, head shaking, decreased hear -ing, urination issues, nasal discharge, and collapsing episodes). Five patients did not have documented clinical signs in the available medical records. Twen -ty-eight of 56 (50%) cats presented with 3 or more of the clinical signs listed above while 6 (11%) were pre -sented solely for seizures. Of the 38 cats that were found to have cranial nerve deficits, 26% (10/38) were found to have nystagmus; 5 cats had vertical nystagmus, 2 cats had downbeat nystagmus, and 2 cats had rotary nystagmus. Vision changes/loss were noted in 5 patients. The remainder of the cases with cranial nerve deficits were not elaborated on in the available medical records. The median duration of clinical signs was 28 days (range, 1 to 406 days) for the surgery group and 84 days (range, 13 to 730 days) for the SRT group (range, 1 day to 2 years). Thirteen (21%) cats did not have duration of clini -cal signs documented in their medical records. No significant difference was found between treatment groups related to duration of clinical signs ( P = .08).Sixty cats underwent MRI, and a single cat un -derwent CT imaging, with detailed imaging findings described in 55 of 61 (90%) cats. On the basis of ac -cessible reports, 87% (48/55) were described as fore -brain in location, 7% (4/55) were in the cerebellum, and 5% (3/55) were in the region of the brain stem (Table 1) . Lesion localization between the 2 groups nearly reached significance ( P = .07), with the only 3 lesions located in the brain stem in the SRT group. A single cat in the SRT group and 5 cats in the surgery group were noted to have 2 or more masses located within the brain at the time of diagnosis ( P = .680).TreatmentForty-six cats had surgical removal of the intra -cranial tumor initially, 14 had SRT initially, and 1 had Figure 1 —Kaplan-Meier curve to show survival prob -ability (A) and recurrence probability (B) in 61 cats with cranial meningiomas by treatment type. Treatment SRT (n = 14) Surgery (n = 46) Surgery and RT (n = 1)Variable Category n % n % n % P valueLesion localization Brain stem 3 21.4 - - - - .070 Cerebellum 0 0.0 4.0 8.7 - - Forebrain 10 71.4 37.0 80.4 1.0 100.0 Not noted 1 7.1 5.0 10.9 - - Peritreatment complications Total 1 7.1 34 73.9 - - < .0001 Anemia - - 25 54.4 - - .000 Other - - 15 44.1 - - .010Recurrence or progression 4 28.6 14 30.4 - - 1.000Time to recurrence Median (95% CI) 315 (104–NC) - 1183 (731–1,638) - - - .009Survival outcome Alive 5 35.7 21.0 45.7 - - .740 Dead 9 64.3 25.0 54.4 1.0 100.0 Survival time Median (95% CI) 339 (102–339) - 1345.0 (709–1,642) - 1,903.0* .0020*Values represent 1 cat, not median.NC = Not calculated.Table 1 —Characteristics of study population of 61 cats with cranial meningiomas that underwent surgery or stereo -tactic radiotherapy (SRT).Unauthenticated | Downloaded 12/24/23 09:26 AM UTC4 surgery followed by SRT due to incomplete surgi -cal removal. Of the 47 surgical cases, 55% (26/47) had craniotomy listed as the surgical approach, fol -lowed by a rostrotentorial approach in 38% (18/47), suboccipital approach in 4% (2/47), and transfron -tal approach in a single case. Of the 14 cats treated with SRT initially, 10 cats received an average of 3,476 cGy (range, 2,400 to 9,000 cGY) over 3 treat -ment sessions/fractions. Four cases did not have the amount of cGY received documented, including the single case that had surgery (rostrotentorial ap -proach) followed by a single fraction of SRT due to incomplete removal. The 3 cases with tumors in the brain stem location received SRT as primary treat -ment (Table 1). Histopathologic diagnosis of menin -gioma was provided in 98% of the 47 surgery cases. Twenty-five (53%) of the reports included subtypes. These subtypes included the following: psammoma -tous (11/25 [44%]), meningothelial (7/25 [28%]), transitional (4/25 [16%]), and fibroblastic/fibrous variant (3/25 [12%]).Peritreatment complicationsFor the 46 initial surgical events, 34 (74%) had peritreatment complications; the most common was anemia (25/46 [54%]), followed by inappe -tence (n = 5), hypokalemia (4), cranial nerve defi -cits (3), hyperthermia (3), ataxia (2), hyperglyce -mia (2), and seizures (2). The degree of anemia ranged from 13% to 28%, and none were noted to have received treatment in the available medical records. The specific cranial nerve deficits in the 3 initial surgical events cases were not specified. Two cats required a second surgical procedure during the peritreatment period due to cerebral/cerebel -lar herniation and hemorrhage, both of which re -covered without further issues. One cat developed seizures in the immediate postoperative period and arrested. Of the 15 total cats treated with SRT, the only immediate complication was hyperthermia and tachypnea in the same cat, both of which resolved. Significantly more cats that underwent surgery had peritreatment complications compared to the SRT group ( P < .0001; Table 1).OutcomeAt the time of data collection, 54% (n = 25) of cats in the surgery group and 64% (9) of the SRT group were either euthanized or had died ( P = .740) with a median survival time (MST) of 1,345 days (range, 708 to 1,642 days) and 339 days (range, 102 to 339 days), respectively ( P = .02). Of the surgery group, 11 (44%) cats were euthanized or died due to recur -rence or continuance of neurologic signs, 11 cats did not have a reason for death noted, and 3 cats died due to other reasons (ie, old age, weight loss, and hyporexia). Of the cats that died or were euthanized due to neurologic abnormalities, 6 had seizures (one of which expired in the peritreatment period), 1 was noted to be hiding and going into corners inappro -priately, 1 was noted to be weak and ataxic, and 1 was noted to have the same clinical signs (behavior change) as prior to treatment. One cat was noted to have neurologic deterioration and was found to have pancreatic carcinoma with pulmonary metastasis and subsequently euthanized.Death in the SRT group (9 cases) was attributed to neurologic signs in 4 (44%) cats, 4 cats did not have a reason for death noted, and 1 for other rea -sons (hiding and anorexia). Of the cats that died or were euthanized due to neurologic abnormalities, 1 cat had progressive neurologic signs and was eutha -nized after a new brain tumor was noted on MRI, 1 cat was euthanized after presenting obtunded/mini -mally responsive (suspect regrowth; no diagnostics/imaging were performed at that time), 1 cat died af -ter a subtle personality change was noted, and the final cat became nonambulatory roughly 107 days following initial SRT treatment and never regained the ability to walk.Fourteen (30%) cats in the surgery group and 4 (28%) cats in the SRT group had MRI- or CT-con -firmed tumor regrowth or new tumor growth ( P = 1.00; Tables 2 and 3 ). The median time to progres -sion was 1,183 days (range, 731 to 1,638 days) in the surgery group and 315 days (range, 104 to cen -sored) in the SRT group ( P = .009). Two (14%) cases in the SRT group and 10 (22%) cases in the surgery group had additional treatment for recurrence. Fol -lowing initial recurrence, 6 cats had a second sur -gery, 3 cases that had surgery initially had SRT, 1 cat received no treatment, 1 had surgery initially followed by conventional RT (18 treatments), and 1 had a second round of SRT.Fourteen (30%) cats that received surgery as the initial treatment had evidence of recurrence based on MRI findings (Table 3). Six cases in the initial surgery group had documented meningioma recur -Table 2 —Summary of characteristics of 4 cases with documented recurrence following SRT as initial treatment for intracranial meningioma. No. Time Tx Case of to for No. Age Sex Breed Location Clinical signs Treatment recurrences recurrence recurrence Outcome11 12 MN DSH Forebrain Behavior change, RT (3 treatment) 1 8 mo None Deceased, vision loss 1 mo15 14 FS DSH Forebrain Mentation, gait changes, RT (3 treatments) 1 10 mo RT Euthanized, CN deficits (3 treatments) 12 mo43 15 FS DSH Forebrain Behavior, gait changes, RT (1 treatment) 1 13 mo None Euthanized, CN deficits 13 mo59 12 MN DSH Brain stem Gait change, RT (3 treatments) 1 5 mo Added Deceased, CN deficits in Lomustine lost to follow-upCN = Cranial nerve. DSH = Domestic shorthair. FS = Female spayed. MN = Male neutered. RT = Radiation therapy. Tx = Treatment.Unauthenticated | Downloaded 12/24/23 09:26 AM UTC 5rence a second time and received either SRT (n = 4) or medications (2) including dexamethasone, phe -nobarbital, and Palladia as treatment. Three cases, again all in the initial surgery group, had presump -tive recurrence of meningioma based on abnormal neurologic signs but did not receive advanced im -aging to confirm recurrence. A single case (Table 3; case 38) had 3 surgeries and a final SRT treatment to treat the tumor and its recurrence. This case was eventually lost to follow-up roughly 2,700 days (7.5 years) after the last treatment.In the SRT group, 4 (26.6%) cats that received SRT initially had evidence of recurrence on repeat imaging with a median time to recurrence of 315 days (Table 2). Case 11 had recurrence after pro -gressive neurologic signs were noted 243 days post–initial treatment and was noted to be de -ceased 1 month later with no additional treatment. Case 15 had regrowth noted on MRI after 304 days, had SRT again (3 treatments), and was euthanized 1 year later due to behavioral changes. Case 43 had evidence of recurrence 395 days later and was eu -thanized with no additional treatment. Case 59 had evidence of regrowth on MRI 152 days post–initial treatment and after adding in lomustine the patient was lost to follow-up. The MST for the 5 of 7 cases that had RT for subsequent recurrence following ei -ther surgery or SRT initially was 700 days (range, 335 to 1,461 days) after the last treatment, with 2 cases lost to follow-up.Five (36%) cats in the SRT group and 21 (46%) in the surgery group were counted as alive at the time of data collection. Of these cases, 19 (73%) were lost to follow-up, 15 of the surgery group and 4 of the SRT group. Six cats that underwent surgery initially were noted to be alive and doing well at the time of data collection, whereas a single cat that received SRT initially was noted to be alive and doing well.

Question 155

Worden - 2023 - JAVMA - Geometric, landmark-guided technique reduces tissue trauma, surgery time, and subjective difficulty for canine peripheral lymphadenectomies - An educational crossover study.pdf

Answer 155

Study design and participant recruitmentAn Institutional Review Board (IRB)–approved prospective, randomized, blinded, 2-period, 2-treat -ment crossover study was performed at the University of Florida College of Veterinary Medicine between July 23, 2022, and October 12, 2022, with IRB approval ob -tained on April 26, 2022 (IRB202200416). Participants were recruited via a standardized recruitment email sent out to fourth-year veterinary students, rotating interns, and first-year small animal residents at the Uni -versity of Florida College of Veterinary Medicine. The first 12 participants who were willing to enroll in the study were selected. Randomization was used to as -sign identification numbers to participants to maintain anonymity and assign both cadavers and dissections (QuickCalcs Random Number Calculators; GraphPad Software). Six veterinary student volunteers were simi -larly recruited to assist with data collection during the study days. Volunteers received written instructions 1 week prior and verbal instructions 1 hour prior to each dissection day. Volunteers were randomly assigned to cadavers on dissection days.CadaversEighteen adult mixed-breed canine cadavers (13 males and 5 females) of medium size and similar average body condition score were obtained from a local animal shelter after euthanasia for reasons unrelated to the pres -ent study and were free of grossly apparent diseases that could result in lymphadenomegaly. Cadavers were ran -domly assigned to dissection days, and participants were randomly assigned to 1 side of each cadaver on the dis -section day. Cadavers were stored at –16 °C and thawed at room temperature for 72 hours prior to dissection. Hair was clipped bilaterally around the proposed surgical sites, ensuring that all proposed anatomical landmarks were included within the surgical field. Drapes were used to conceal the contralateral side of each cadaver while par -ticipants were performing dissections.Dissection groupsDissection days were assigned to each partici -pant on the basis of their reported availability. All participants (n = 12) performed the control, stan -dard lymphadenectomy (SL), on their first available dissection day. Each participant then performed the following 2 additional dissection days over the next several months: MBL and landmarks lymphadenec -tomy (LL). Participants were randomized to 1 of 2 sequences of surgical approaches (MBL-LL vs LL-MBL) in a 2-period, 2-sequence (2 X 2) crossover de -sign, with 6 participants/sequence. A minimum of 2 weeks between each of the 3 dissection days was en -sured for every participant. All participants received standardized instructional materials (printed copy and/or emailed) with instructions for the specific dissection day 1 week prior to each dissection day.Dissection daysOn each dissection day (SL, MBL, and LL), par -ticipants were handed an envelope containing their assigned cadaver and dissection side (right/left). The instructions for the dissection day were repeat -ed verbally to each participant. Participants then performed the 3 lymphadenectomies in the same or -der: SCLN, ALN, and SILN. The ventral approach to the SCLN was used in all cadavers.10Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 11/03/23 06:54 AM UTC 3For each lymphadenectomy, participants were allowed to palpate the lymphocentrum for as long as they desired prior to initiating their dissections. Vol -unteers assigned to each cadaver recorded palpation and dissection times as directed by the participants, as described later. A nonblinded investigator (NJW) was present to confirm identification of LNs via pal -pation and visual inspection. All participants were given a 20-minute time limit for surgical identifica -tion of the LN, as this was thought to be a reasonable amount of time allocated to LN dissection in a clini -cal setting and was extrapolated from the average surgical times reported in a previous study.2Standard lymphadenectomy —One week prior to the SL dissection day, participants were provided with a standardized educational packet contain -ing publicly available information on the regional anatomy and, if available, surgical guidelines for ex -tirpation of the superficial cervical, axillary, and su -perficial inguinal lymphocentrums.1,11 At the time of study design, no published surgical guidelines were available for lymphadenectomy of the ALN or SILN. Participants were not allowed to consult the provid -ed materials while performing dissections.Methylene blue lymphadenectomy —Cadavers as -signed to MBL dissections received a subdermal injec -tion of 1 mL of 1% MB (ProvayBlue; American Regent) at each injection site prior to the start of dissections. Injec -tion sites were chosen on the basis of established lym -phosomes and consisted of the cranial ipsilateral mid -humeral region for the SCLN, medial ipsilateral elbow for the ALN, and medial ipsilateral stifle for the SILN.12 Injec -tion sites were massaged for 5 minutes postinjection to encourage uptake and spread of MB. Participants were instructed to use the MB uptake as a guide to help them identify the 3 lymphocentrums and were asked not to reference any previously provided SL or LL materials in preparation for the MBL dissection day.Landmarks lymphadenectomy —One week prior to the dissection day, participants were provided with an informational packet containing the dissec -tion figures and landmark-guided surgical approach -es for the SCLN, ALN, and SILN described previous -ly.10 Participants were not allowed to reference the provided materials while performing dissections.Outcome measuresOutcome measures were recorded on standardized score sheets labeled with the randomly assigned par -ticipant identification numbers, cadaver information, dissection group (for nonblinded investigator score sheets only), date, and time of dissection. All outcome measures were obtained for each lymphocentrum on each dissection day unless otherwise stated.Participant data —Participant title (veterinarian/student), crossover group assignment, dissection date, time of day, cadaver assignment, cadaver sex, and cadaver side were recorded for each participant on every dissection day.Timed outcome measures —Palpation time was recorded from the moment participants verbalized the beginning of palpation until they verbalized completion. Time to LN identification (T1) was recorded from the moment participants verbalized the start of the skin inci -sion until they verbalized completion of LN identification. Time for T1 was cumulative until the LN was correctly identified by the participant, as confirmed by the super -visor (NJW). Time to LN removal (T2) was started the moment the participant verbalized continuation of dis -section after their LN identification had been confirmed and ended when the participant verbalized completion of LN removal. If participants verbalized a request for early termination of the procedure prior to the 20-minute limit, volunteers were instructed to record the time at which the request was made and participants were asked to con -tinue searching for the LN until the 20-minute time limit was reached. If a participant reached the 20-minute time limit without having correctly identified the LN, the out -come was recorded as “not identified” and participants continued to the next lymphocentrum.Dissection scoring —Descriptive scoring of the dissections was performed by a single nonblinded in -vestigator (NJW) and included incision length, incision orientation (parallel, perpendicular, or oblique to the described LL approach), and successful LN identifica -tion (yes/no). Dissection quality was scored by a single blinded investigator (JB) using a scale from 1, “very good,” to 5, “very poor,” which was a modified version of a previously published scoring system used to evaluate dissection quality in gross anatomy courses (Figure 1) .13 This assessor also recorded the number of muscles in -cised (excluding the deep pectoral muscle for the ALN), number of other structures damaged, and number of additional incisions created for each surgical site. An overall tissue trauma score (TTS) was later calculated as the sum of the dissection quality score, number of muscles incised, number of structures damaged, and number of additional incisions created, with a higher TTS indicating more tissue trauma.Participant outcome measures —At the end of each lymphadenectomy, participants were provided with a visual analog scale on which they rated the subjective difficulty of the LN identification from 1 (“extremely easy”) to 100 (“extremely difficult”), re -gardless of LN identification success. For MBL dis -sections, participants were asked whether they were able to appreciate MB uptake in the following loca -tions for each LN: skin, subcutaneous tissues/fas -cia, and LN(s). For LL dissections, participants were asked to indicate whether they found the landmarks to be helpful for LN identification (yes/no).Data analysisDescriptive statistics —Summary statistics (mean and SD, SD) for continuous variables (palpation time and incision length) were calculated with SAS proc means (version 9.4; SAS Institute Inc). TTSs were summarized by counts for each score category.Because identification times were censored, mean time to LN identification was estimated by fitting a Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 11/03/23 06:54 AM UTC4 Figure 1 —Representative images of superficial inguinal lymph node (LN) dissections performed by 7 veterinarians and 5 fourth-year veterinary students for 18 canine cadavers, presented in order of the dissection scoring system used in a cross -over study to evaluate the effect of a geometric, landmark-guided approach for peripheral lymphadenectomy between July 23 and October 12, 2022. Dissections must have met at least one of the described criteria for their assigned score.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 11/03/23 06:54 AM UTC 5right-censored linear parametric failure time model with SAS proc lifereg (version 9.4; SAS Institute Inc) and summarized as means and 95% CI.Dye versus landmark comparisons —Performance outcomes were evaluated separately for each LN type (SCLN, ALN, and SILN). The standard 2 X 2 crossover design was used to compare LL and MBL methods directly. Time to event (time to LN identification and removal) was analyzed by Cox proportional-hazards regression with method, sequence, and period as fixed effects. Continuous outcome variables were analyzed with mixed-model ANOVA (SAS proc mixed version 9.4; SAS Institute Inc) on method, sequence, and pe -riod.14 TTSs were analyzed by cumulative logit regres -sion on method, sequence, and period (SAS proc lo -gistic version 9.4; SAS Institute Inc).15 Incision lengths were compared as a 2 X 2 crossover design (SAS proc mixed version 9.4; SAS Institute Inc). Method (MB and LL), sequence, and period were modeled as fixed ef -fects, participants as random effects, and within-par -ticipant correlation modeled by unstructured variance-covariance structure.14 Model estimates are presented as means and 95% CI.ResultsParticipant dataSeven veterinarians (2 rotating interns, 2 surgical spe -cialty interns, 1 first-year medical oncology resident, and 2 first-year small animal surgery residents) and 5 fourth-year veterinary students participated in the study. All par -ticipants were assessed at each of 3 dissection days, with no dropouts. Time between dissection days averaged 18 days (SD, 6) between days 1 and 2, and 23 days (SD, 10) between days 2 and 3, with a minimum of 2 weeks (14 days) between each participant’s dissection days.Timed outcome measuresMedian palpation times were 27 seconds (IQR, 16 to 43 seconds) across all LNs; 1 participant spent 5 to 7.5 minutes palpating each LN during MB dissections.Successful LN identification was highest with LL dis -sections (30/36 [86%]) compared to SL (25/36 [69%]) and MBL (24/36 [67%]) dissections. The 4 participants who failed to identify the SCLN with the LL method did not have the incisions correctly positioned in the described anatomical location (Table 1) . Lymph node identification was similar between student and veteri -narian participants for all techniques. Students identi -fied 9 of 15 (60%) LNs with the SL method, 12 of 15 (80%) with the LL method, and 10 of 15 (67%) with the MBL method. Veterinarians identified 16 of 21 (76%) LNs with the SL method, 18 of 21 (86%) with the LL method, and 14 of 21 (67%) with the MBL method.The LL dissection method reduced T1 for the ALN by 8 to 20 minutes ( P = .03) compared to the SL and MBL dissection methods (Table 2) . Participants who successfully identified SILN and SCLN took approxi -mately 10 minutes on average. Two subjects in each of the MBL and SL trials exceeded the 20-minute limit for identification of SILN, and 4 subjects exceeded the al -lotted time for SCLN identification for all 3 dissection methods. One subject was unable to complete 7 of 9 LN identifications. The T1 for the SILN LL dissection was 2 to 8 minutes, less than half the time of SL and 1 to 4 minutes faster than MBL. Measurements for T2 were not significantly different for any LN ( P > .05); with 1 exception (1 SCLN with SL dissection), all iden -tified LNs had a T2 of ≤ 20 minutes.LN identified LL MBL SLAxillary Yes 10 5 6 No 2 7 6Superficial cervical Yes 8 9 8 No 4 3 4Superficial inguinal Yes 12 10 10 No 0 2 2Table 1 —Numbers of cadaveric canine lymph nodes (LNs; axillary LN [n = 12], superficial cervical LN [12], or superficial inguinal LN [12]) identified by 7 veterinar -ians and 5 fourth-year veterinary students in a cross -over study conducted between July 23 and October 12, 2022, to compare geometric landmark lymphad -enectomy (LL) versus standard lymphadenectomy (SL) and methylene blue–guided lymphadenectomy (MBL) performed on cadavers of 18 adult mixed-breed dogs euthanized for unrelated reasons.Table 2 —Comparisons of the mean (95% CI) time to LN identification (T1) and LN removal (T2) for LL versus SL and MBL in the study described in Table 1. P values test the overall difference between dissection methods. Significance was set at P < .05.LN and dissection group T1 (min) P value T2 (min) P valueAxillary SL 18 (11–29) .03 15 (5–42) .05 MBL 23 (14–39) 20 (7–53) LL 10 (6–15) 6 (2–13) Superficial inguinal SL 8 (5–15) .34 6 (3–11) .06 MBL 6 (3–12) 6 (3–11) LL 4 (2–8) 3 (1– 5) Superficial cervical SL 13 (7–23) .88 15 (7–29) .97 MBL 12 (7–21) 9 (4–17) LL 14 (8–26) 9 (5–17)Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 11/03/23 06:54 AM UTC6 Dissection scoringORs for the overall TTS were significant for the ALN and SILN and demonstrated reduced tissue trau -ma with the LL method compared to the SL and MBL methods (Table 3) . For the ALN, the LL method was about 7 times more likely to have a lower TTS than the SL method and 15.6 times more likely to have a lower TTS than the MBL method. For the SILN, the odds of the LL method having a lower TTS were 22.86 times greater than the SL method and 17.98 times greater than the MBL method. There was no significant differ -ence between the MBL and SL methods for any LN ( P > .05). There was no difference in TTS between any of the dissection methods for the SCLN.Incision lengths, reported as mean (SD), for the SCLN were similar between lymphadenectomy methods ( P = .86): SL, 7.5 cm (2.5 cm); LL, 7.3 cm (2.3 cm); and MBL, 7.5 cm (2.6 cm). Incision lengths increased by approximately 1.5 cm for both LL and MBL methods in the last period, although period ef -fects were not statistically significant ( P = .14). For the ALN dissections, mean incision lengths were reduced with LL (5.4 cm; SD, 0.9 cm), compared to SL (7.8 cm; SD, 3.3 cm) and MBL (8.4 cm; SD, 2.4 cm). Incision length averaged 3 cm shorter (95% CI, –4.3 to –1.6 cm) for LL compared to MBL ( P = .0002). Incision lengths increased by 1.3 cm in the last pe -riod, although period effects were not statistically significant ( P = .07). For SILN lymphadenectomy, in -cision length for SL averaged 7.0 cm (3.1 cm). The LL method resulted in the shortest incisions; incision lengths averaged 2.0 cm less for LL compared to the MBL method (95% CI, –3.4 to –0.9 cm; P = .002). Inci -sion lengths for both methods increased by 2.1 cm in the last period ( P = .002).Second incisions were made in 5 dissections: 1 SL and 1 MBL for the SCLN, 2 MBL for the ALN, and 1 SL for the SILN. No secondary incisions were made in any of the LL dissections.Participant outcome measuresSubjective difficulty of LN identification using the LL method was approximately half that of both the SL and MBL methods for the ALN ( P = .06) and SILN ( P = .008; Table 4 ). Across all methods and LNs, the mean subjective difficulty scores decreased over time. After completing their LL dissections, most participants reported that landmarks were helpful for identification of the LNs, with 8 of 12 (66.7%) re -sponding “yes” for SCLN, 10 of 12 (83.3%) for ALN, and 11 of 12 (91.7%) for SILN.For the MBL dissections, all cadavers were con -firmed by the investigators to have MB dye uptake within the dermis after injection and prior to the be -ginning of dissections. For participants, visible MB uptake into LNs was poor, with only 5 of 12 SCLN, 4 of 12 ALN, and 7 of 12 SILN having MB uptake within the LN that was appreciated by the participants. The MB was otherwise dispersed in the surrounding tis -sues and skin (Table 5) . Participants were able to ap -preciate MB dye uptake within at least 1 tissue loca -tion in 7 of 12 cadavers for the SCLN, 9 of 12 cadavers for the ALN, and 11 of 12 cadavers for the SILN.Four participants requested to end their LN dis -sections early. One participant performing SL dis -section of the SCLN requested to quit multiple times throughout the dissection starting at 9 minutes, 1 participant requested to quit after 18 minutes dur -ing MBL dissection of the SCLN, and 2 participants requested to quit after 7 minutes when performing Table 3 —Comparisons of tissue trauma scores for the SL, LL, and MBL LN dissections performed in the study de -scribed in Table 1. Number of participants in each score category by LN and method. OR (95% CI) describes likeli -hood of a lower score for each paired comparison. Larger OR indicates a higher likelihood of a lower tissue trauma score for the first method in the pair compared to the second. Sig nificance was set at P < .05. Lymphadenectomy methodLN and trauma score SL LL MBLAxillary < 4 2 5 3 4–6 7 5 5 > 6 3 2 4 LL:SL LL:MBL MBL:SLOR (95% CI) 7.03 (1.51–32.65) 15.6 (3.32–73.34) 0.45 (0.10–2.04)P value .013 .0007 .30 Superficial inguinal < 4 3 11 5 4–6 8 1 7 > 6 1 0 0 LL: SL LL: MBL MBL: SLOR (95% CI) 22.86 (4.48–116.57) 17.98 (3.55–90.96) 1.27 (0.32–5.03)P value .0003 .0007 .73 Superficial cervical < 4 3 5 3 4–6 7 5 5 > 6 1 2 4 LL: SL LL: MBL MBL: SLOR (95% CI) 1.95 (0.44–8.83) 3.96 (0.80–19.77) 0.49 (0.12–2.09)P value .38 .09 .33Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 11/03/23 06:54 AM UTC 7SL dissection of the ALN. All participants who re -quested to quit ultimately did identify the LN within the 20-minute time limit. No participants requested early termination during any of the LL dissections.

Question 156

Dumitru - 2023 - VCOT - Partial Parasagittal Patellectomy in Dogs - A Retrospective Case Series of 19 Dogs.pdf

Answer 156

CriteriaElectronic patient records at Christchurch Veterinary Refer-rals (Suffolk, United Kingdom) were searched from May 2019to December 2020 for dogs diagnosed with patellar luxationrequiring surgical treatment. Inclusion criteria for this studywere (1) unidirectional patellar luxation correction in whicha partial parasagittal patellectomy was performed and (2)follow-up examination 4 weeks or more after repair. Dogswith bidirectional luxation were excluded. The followingdata were recorded: breed, age, sex, body weight, grade ofpatellar luxation, direction of patellar luxation, single stage(unilateral or bilateral) or staged bilateral surgery, surgicaltechnique (transposition of the tibial tubercle, block reces-sion trochleoplasty), implant con figuration, intra- and post-operative complications, and clinical outcomes.Complications in this study were categorized according toCook and colleagues.19Patient PreparationAll patients were premedicated based on the attending sur-geon's preference with a combination of either medetomidine(Medetor, Virbac, United Kingdom, 1mg/mL) (2.5 µg/kg) oracepromazine (AceSedate, Jurox, 2 mg/mL) (0.02 mg/kg) andmethadone (Synthadon, Animalcare, 10 mg/mL.) (0.5 mg/kg)via an intramuscular route. All patients received meloxicam(Loxicom, Norbrook UK, 5 mg/mL) 0.1 mg/kg unless dosingwith a different nonsteroidal anti-in flammatory drug hadbeen commenced, in which case administration of the lattermedication was continued. Anesthesia was induced withalfaxalone (Alfaxan Multidose, Jurox, 10 mg/mL) (2 mg/kg)given intravenously to effect, the dog was intubated, andgeneral anesthesia was maintained with inhaled iso flurane(IsoFlo, Zoetis, United Kingdom) (1.5% in oxygen, adjusted asrequired). Cefuroxime (Zinacef, GlaxoSmithKline) 20 mg/kgwas given 30 minutes prior to first incision and repeated every90 minutes as required until completion of surgical closure.Based on surgeon preference, regional anesthesia with com-bined femoral and sciatic nerve blocks (bupivacaine (Marcain,Aspen, 0.25 or 0.5%) 1 mg/kg total dose, guided by nervestimulation (Plexygon, Vygon) ) was also used in some dogs.Intravenous fluid therapy was provided with compound sodi-um lactate (Vetivex 11, Dechra, United Kingdom) at an initialrate of 5 mL/kg/h and adjusted based on patient requirement.Surgical TechniqueThe patient was positioned in dorsal recumbency with theaffected limb(s) positioned at the end of the surgical tableprior to draping. A lateral parapatellar approach was per-formed in all cases as previously described.3The cruciateligaments were inspected to rule out concomitant cranialcruciate ligament pathology. Block recession trochleoplastywas performed in all cases using a previously describedtechnique.17Importantly, the block was created as wide aspermitted while preserving the peaks of the medial andlateral trochlear ridges. Following the block recession, thepatella was reduced and subjectively assessed for fit withinthe recessed trochlear groove. The patella was then evertedby combined internal torsion and medial luxation to exposethe retropatellar cartilage surface. Patellar width was mea-sured across its widest point before comparison to the widthof the trochlear block recession (►Figs. 1 and 2). Wherepatellar width was greater than the resultant groove, amedial, lateral, or combined parasagittal partial patellec-tomy was completed. The patella was luxated medially andeverted again to present the articular surface. A finger saw(N2 UK Ltd, Hampshire, United Kingdom) was used toremove a parasagittal section from the selected area 1 mmwider than the desired reduction (►Fig. 3 ). A scalpel blade orsmall Lempert rongeur was used to remove residual boneand the patella was reduced and assessed again for fit.Further bone removal was performed until effective reces-sion into the trochlear groove and femoropatellar contactwas achieved (►Fig. 4 ). If quadriceps mechanism realign-ment was required, tibial tuberosity transposition was thenperformed, as described previously.20Implant selection wasbased on patient signalment and surgeon preference, withone or two Kirschner ’s wires placed in the tibial tuberosity(one wire more proximally located than the other) andconnected with an appropriately size tension band wire.Medial release was performed only where patellar reductioncould not be achieved. Lateral imbrication of the joint wascompleted prior to routine closure of the subcutaneoustissues and skin. The patella was manipulated at the end ofeach surgical step to determine stability. Immediate postop-erative radiographs were performed with orthogonal cau-docranial and mediolateral sti fle projections obtained forreview (►Fig. 5 ).11Follow-UpAll patients were discharged to their owners when postsur-gical pain could be adequately managed in the home envi-ronment and received continued oral administration of a.nonsteroidal anti-in flammatory drug. All patients were reex-amined 4 weeks following surgery with the operating sur-geon. Owners were questioned on their pet ’s comfort andmobility over the previous 4 weeks, and for any relatedconcerns. Owners were also asked whether their pet hadreceived any medical or surgical intervention with anotherveterinary surgeon. Orthopaedic assessment included sub-jective static and dynamic gait assessment and surgical sitepalpation. The operated patella(e) were assessed for stabilitywith attempts to manually luxate in both the lateral andmedial directions. Sti fle range of motion was assessed instanding, with a subjective assessment of comfort. Anycrepitus or other palpable abnormalities were noted. Addi-tionally, the location of implants was palpated for evidence ofinstability or pain. Finally, the skin overlying implants andthe surgical scar were visually assessed and palpated. Radio-graphic assessment of the operated sti fle(s) was recom-mended at 8 weeks postoperatively and were completed atthe authors ’institution.All owners were contacted during the follow-up period viatelephone and asked to complete a purposely designed ques-tionnaire via e-mail, post, or in person (►Appendix 1 , availablein online version only). Each patient was offered a free-of-charge physical reassessment with a small-animal surgeon aspart of their follow-up, but this was not required for inclusion.Fig. 1 Intraoperative image showing patellar width assessment . Thesubpatellar cartilage is visible on t he under surface of the patella and ametric ruler is used to determine its maximal width.Fig. 2 Following patellar width assessment, the width of the recessedtrochlear groove is assessed in a similar fashion using a metric ruler.Fig. 4 Following trochlear block recession the patella is reduced andassessed for patellar recession.Fig. 3 Intraoperative image of partial parasagittal patellectomyperformed after width measurements. Here a finger saw is used toremove the desired amount of abaxial patella, with the osteotomyvisible as a longitudinal linear cut..ResultsA total of 93 dogs with patellar luxation were presented overa 20-month period from May 2019 to December 2020. Ofthese 93 cases, 19 cases (24 sti fles) met the inclusion criteria.Seven males and 12 females were included in the study.The median body weight was 10.3 kg (range: 3.1 –42.3 kg)and the median age was 33 months (range: 10 –133 months).Breed distribution included 3 French Bulldogs, 2 Pugs, and 1each of Pug cross, Dachshund, Patterdale Terrier, Chihuahua,Lhasa Apso, Cavalier King Charles Spaniel, English Bull Terri-er, Jack Russell cross, Labrador Retriever, Griffon, Jackapoo,Cavapoo, Cockapoo, British Bulldog. All patients were alive atthe time of follow-up and contactable via the owners orreferring veterinary surgeon.Patellar luxation distribution involved 13 right sti fles and11 left sti fles. Medial luxation was present in 21 sti fles and 3stifles had a lateral luxation. From a grading perspective, 7 ofthe 24 sti fles had a grade 3 luxation and 17 sti fles had a grade2 luxation. Unilateral surgery was performed in 14 sti fles in14 patients. Single-stage bilateral surgery was performed in10 sti fles (41.7%) in 5 patients. No patient underwent stagedbilateral interventions. The median body weight for theunilateral patellar luxation repair was 12.6 kg (range: 3.1 –42.3 kg), while the median body weight for the bilateralsingle-stage procedure was 8.3 kg (range: 3.1 –13 kg). Themedian age for dogs with unilateral patellar luxation repairwas 24.5 months (range: 10 –133 months), while the medianage for dogs with bilateral single-stage procedure was55 months (range: 13 –68 months;►Appendix Table 1 ,a v a i l -able in online version only).Tibial tuberosity transposition was performed in all sti-fles. Of the 24 sti fles that had tibial tuberosity transposition,a tension band wire was placed in 23 sti fles. In all 24 sti fleswith tibial tuberosity transposition, two Kirschner ’s wireswere implanted. A combination of two 0.9-mm Kirschner ’swires was used in three cases; the median weight of thosecases was 4.4 kg (range: 3.1 kg –5.6 kg). A combination of 0.9-and 1.1-mm Kirschner ’s wires was used in four cases; themedian weight of those cases was 7.6 kg (range: 3.1 kg –8.3 kg). A combination of two 1.1-mm Kirschner ’s wireswas used in one case with a body weight of 9 kg. A combina-tion of 1.1- and 1.4-mm Kirschner ’s wires was used in ninecases; the median weight of which was 13.5 kg (range: 9.2 –14.9 kg). A combination of 1.6- and 2.0-mm pins was used intwo cases; the median weight of which was 41.7 kg (range:41.1 –42.3 kg). The tension band wire was 0.8 mm in thick-ness in two cases; both cases had a weight of 3.1 kg. A 0.9-mm-thick wire was used in one case with a body weight of7.6 kg. A 1-mm-thick wire was used in nine cases; themedian weight of those cases was 9.7 kg (range: 4.4 –14 kg). A 1.1-mm wire was used in one case; the weight ofthe patient was 13.5 kg. A 1.2-mm-thick wire was used in fivecases; the median weight of those cases was 14.9 kg (range:11.6 –42.3 kg). Intraoperative minor complications were en-countered in four sti fles, exclusively limited to trochlearblock fracture. In all cases, block fracture was transversethrough the subchondral bone to the level of the cartilageleaving the two halves of the block attached by cartilage. Noadditional interventions were performed with the blockpress fit into the recessed trochlear (►Appendix Table 2 ,available in online version only).At postsurgical assessment, all sti fles had a palpablystable patella 4 weeks after surgery. Radiographic follow-up was available for 18 patients at 8 weeks postsurgery. Theimplants were stable in all 19 patients 8 weeks after theinitial surgery as assessed by radiography. Radiographichealing of the tibial tuberosity transposition was consideredgood in 23 sti fles. One dog developed a tibial crest fracture atthe level of the Kirschner wires; mild proximal displacementof the tibial tuberosity was subsequently noted, but thetuberosity went on to heal well in the new position andthe patella remained stable. Trochlear block healing wasconsidered good in all sti fles without any complicationsencountered. Increased soft-tissue attenuation and thicknessof the patellar tendon consistent with patellar desmitis wasnoted in 14 sti fles, but none was associated with clinicalsigns. The only postoperative minor complication noted wasthe tibial crest fracture reported earlier. No major compli-cations were encountered (►Appendix Table 3 , available inonline version only).The clinical examination median time follow-up was80 weeks (range: 28 –117 weeks), this being available in 10cases. Long-term clinical examination follow-up wasFig. 5. Caudocranial radiographic projections obtained before (left)and immediately after surgery (right ), demonstrating the typical post-operative appearance of parasagittal patellectomy. Note the minimalchange in lateral abaxial patellar contour following partial parasa-gittal patellectomy and subjective congruence with the recessedtrochlear block..available in eight cases, while medium-term clinical exami-nation follow-up was available in two cases.QuestionnairesThe median follow-up time with the questionnaire was90 weeks (range: 43 –117 weeks) and this was available for16 cases. Long-term follow-up questionnaire ( >12 months)was available in 14 cases, while medium-term follow-up (6 –12 months) was available in 2 cases. Of the patients included,none received any medications or nutraceuticals as a resultof their surgery, and no patient ’s exercise was restrictedbeyond the recommended postoperative recovery period.Regular exercise permitted ranged from unobstructed accessto the owner ’s garden to unrestricted off-lead activity. Walkdurations cited ranged from 15 to 120 minutes once or twicedaily. Limb function was considered excellent in 12, verygood in 3, and good in 1 dog. Fifteen owners would have thesurgery performed again, with one stating a “50–50”choice.A single complication was reported, being tibial tuberosityavulsion noted at radiographic follow-up.

Question 157

Welsh - 2023 - VETSURG - Biomechanical comparison of one pin versus two pin fixation in a canine tibial tuberosity avulsion fracture model.pdf

Answer 157

2.1 |AnimalsThis study was reviewed and granted exemption by theAnimal Care and Use Committee of Washington StateUniversity. Pelvic limbs were collected from 11 shelter-donated, skeletally mature, mixed-breed dogs between17 and 25 kg that were euthanized for reasons unrelatedto the study. The limbs were dissected and investigatedfor gross anatomic or pathological abnormalities by asingle individual. The stifles, including all menisci, collat-eral, and cruciate ligaments, were inspected for pathol-ogy. All soft tissues were removed except the distalportion of the quadriceps, patella, and patellar ligament.Craniocaudal and lateromedial radiographs of each limbobtained prior to dissection confirmed musculoskeletalmaturity (closed physes) and ruled out radiographic evi-dence of orthopedic abnormalities.2.2 |Cadaver preparationAs cadavers were acquired, the left or right limb wasrandomly assigned to be stabilized with one ( n=11) ortwo ( n=11) pins using a spreadsheet software (MicrosoftExcel 2016, Microsoft Corp, Redmond, Washington) withthe contralateral limb being assigned the other fixationtechnique (i.e. if the right limb was assigned for two pinfixation, then the left limb received a single pin fixation).Following collection and preparation, all tibias werewrapped in saline-soaked towels and frozen at /C020/C14C.Using a radiographic editing software (eFilm Workstation3.32010, Merge Healthcare, Milwauke, Wisconsin), mea-surements were made at 33% of the width of the tibialmetaphysis from the midpoint of the cranial aspect of thetibial crest to the proximal surface of the tibia (Figure1A).The templated measurements were then marked on thecorresponding tibia using a caliper and scalpel blade. Oncethe planned osteotomy was transposed onto the tibia, thecuts were performed free-handed with a battery-operatedhand drill and oscillating saw (Stryker 4300 CD3, USA).2.3 |Single-pin stabilizationA single pin of 0.062- ( n=1), 5/64- ( n=5), or 3/32-(n=5) inch diameter was placed perpendicular to themechanical axis of the tibia, bicortically at the enthesisby a single individual with a battery-operated hand drill(Stryker). Implant size was selected to be the largest pinsize that could be reasonably placed and was one sizelarger than the corresponding two-pin fixation size. The740 WELSH ET AL . 1532950x, 2023, 5, pin was then cut leaving an approximately 1 cm segmentremaining within the cranial cortex. Post placementradiographs were taken to measure the Kirschner wire,or pin, insertion angle (KWIA) with the same radiologysoftware (eFilm) (Figure1B).22.4 |Two-pin stabilizationTwo pins of 0.045- ( n=1), 0.062- ( n=5), or 5/64- ( n=5)inch diameter were applied by a single individual with abattery-operated hand drill (Stryker) in vertical alignmentperpendicular to the mechanical axis of the tibia on the con-tralateral limb of the single-pin fixation tibia. Pin size forthe two-pin fixation was one pin size smaller than the corre-sponding single-pin fixation. This was also found to be thelargest possible pin size that could be clinically used whenplacing two pins vertically. One pin was placed just proxi-mal to the enthesis of the patella ligament and the otherwas placed just distal to the enthesis. Each pin was placedbicortically, and the pins were cut leaving an approximately1 cm segment remaining within the cranial cortex. Postplacement radiographs were taken to measure the KWIAwith the same radiology software (eFilm) (Figure1C).22.5 |PottingFollowing fracture fixation, all tibias were cut 12.6 cmdistal to the tibial plateau (to fulfill jig design require-ments) and secured to an aluminum cup with a fiberglassepoxy resin (Bondo: Fiberglass Resin, 3 M, St. Paul, Min-nesota) as previously reported.3,13Following curing, two3/32-inch holes were drilled into the resin filled alumi-num cup and secured with two 3/32-inch diameter pinsfor additional mechanical stability.2.6 |InstrumentationA material-testing machine (Instron Model 5969, InstronCorporation, Canton, Massachusetts) was used to testeach specimen. The specimen/resin filled cups wereFIGURE 1 Radiographicanalysis of specimens.Orthogonal view radiographsruled out gross orthopedicabnormalities and were used forosteotomy planning (A).Following fixation with one ortwo pins, pin insertion angleswere measured with respect tothe mechanical axis of thetibia (B, C).FIGURE 2 Load frame unit and specimen. Tibias were pottedthen mechanically secured to a custom jig. A metric ruler wasadjacent to the jig for post hoc video analysis. A circular ring fixatorwas clamped to the patellar ligament with the patella functioningas an anchor. The ring fixator was then attached to the crown headof the load frame for load to failure testing.WELSH ET AL . 741 1532950x, 2023, 5, mechanically secured in a custom-made jig with the tibiapositioned at a normal canine standing angle of 60/C14fromthe horizontal axis, and a carbon-fiberglass ring fixatorwas used to clamp the patellar ligament distal to thepatella and quadriceps muscles as previously described.3The ring was then attached to the cross head of the loadframe via cable wire (Figure 2). Each limb was preloadedto 20 N (mean 19.8 ± 1.2 N, range: 17.3 –21.6 N), and asingle load to failure was applied at a loading rate of1 mm/s (Figure 3). Data were sampled at 10 Hzand stored in a dedicated load frame data analysis soft-ware (Bluehill®3, 2017, Instron Corporation, Norwood,Massachusetts).Clinical failure was defined as 3 mm separation of thecranial aspect of the transverse osteotomy (artificial frac-ture).3,14,15Descriptive observations for ultimate failurepatterns following clinical failure were noted. All testingwas video recorded (iPhone 11, Apple Inc., Cupertino,California) with the load display and tibias in the sameframe (Figure2). Displacement of the horizontal osteot-omy was measured using a digital video measuring soft-ware (Tracker Video Analysis and Modeling Tool,Version 6.0.6, Open Source Physics, Aptos, California).Video measurements were calibrated with a metric rulerattached to the jig adjacent to the osteotomy sites(Figure3) .G r o s sa n a l y s i so fe a c hv i d e ow a sp e r f o r m e dt odetermine ultimate failure patterns (pin bending, pull out,fracture, patellar ligament tear). A load/displacement curvewas plotted for each trial using spreadsheet software(Excel) and correlated with the determined ultimate failurepatterns (Figure4). Construct stiffness (N/mm) wasrecorded at the most linear aspect of the load/displacementcurve (Figure4) and calculated with the same spreadsheetsoftware (Excel).152.7 |Statistical analysisA sample size of 11 was chosen based on comparablebiomechanical studies of similar sample size.3,13,16Allstatistical analyses were performed using a dedicatedsoftware (GraphPad Prism 9.4.1, Dotmatics, Boston,Massachusetts). A D'Agostino-Pearson and F-test fornormality and equal variances were performed for allstrength, stiffness, and KWIA data. A one-way ANOVAtest was performed to compare KWIAs. A paired t-testwas then performed to compare the strength and stiffnessof each pair. Statistical significance was set at p< .05.FIGURE 3 Specimens priorto, during, and post load tofailure. Tibial tuberosityavulsion fractures werestabilized with one (A –C) or two(D–F) interfragmentary pins.A distraction load was applied at1 mm/s and post hoc videoanalysis identified loads atclinical failure (3 mm distractionof the horizontal osteotomy;B, E) and characterized ultimatefailure patterns (pin bending,pin pullout, fracture, or patellarligament tear; C, F).742 WELSH ET AL . 1532950x, 2023, 5, 3|RESULTSAll cadavers were skeletally mature. The mean weightwas 20.2 ± 2.2 kg (range: 17 –24 kg). There were10 females and one castrated male. All dogs were mixedbreeds with the most common dominant breed beingAmerican pit-bull terrier ( n=7) along with bordercollie mix ( n=2), golden retriever mix ( n=1), andcattle dog mix ( n=1). Specific reproductive status offemales was unknown ( n=10). All limbs were free ofgross pathological abnormalities.Mean KWIA for single-pin fixation was 82.9 ± 5.0/C14(range: 74 –93/C14). For two-pin fixation, the proximal KWIAwas 80.1 ± 4.4/C14(range: 76 –90/C14) and the distal KWIA was83.9 ± 5.2/C14(79–93/C14). No difference was noted among allKWIAs ( p=.13).The two-pin fixation technique demonstrated greaterstiffness and strength when compared to single-pin fixation(Table 1). The mean ± SD strength of the single-pin fixationwas 426.2 ± 167.4 N (range: 144 –787 N, Figure 5A). Them e a n ± S Ds t r e n g t ho ft h et w o - p i nf i x a t i o nw a s6 3 9 . 2±1 7 3 . 5N( r a n g e :3 7 5 –861 N, Figure 5A). When the single-pin fixation strengths were normalized to the two-pin fixa-tion as a ratio (%), the mean ± SD was 68.2% ± 25.8%(range: 38.4 –109.9%). All strength data were normally dis-tributed. A paired t-test showed a difference between con-struct strengths ( p=.003). The mean ± SD constructstiffness of single-pin fixation was 57.3 ± 18.7 N/mm (range:33–92.7 N/mm, Figure5B). The mean ± SD construct stiff-ness of the two-pin fixation was 71.7 ± 20.5 N/mm (range:29–110.3 N/mm Figure 5B). When the single-pin fixationstiffness was normalized to the two-pin fixation as aratio (%), the mean ± SD was 82.8% ± 24.6% (range:46.7 –116.8%). All stiffness data were normally distributed. Apaired t-test showed a difference bet ween construct stiffness(p=.029). Ultimate failure was demonstrated by a combi-nation of pin bending and pullout ( n=18), patella-patellartendon tearing ( n=2), and epiphyseal fracture ( n=2).FIGURE 4 Load/displacement curve of representative trial. Load/displacement curves graphically represented each trial and comparedstrength and stiffness of tibial tuberosity avulsion fractures when stabilized with one or two interfragmentary pins. Clinical failure pointswere plotted according to each trial (arrows). A yield load was achieved near the clinical failure point (arrows) demonstrating the conversionfrom an initial elastic region (line prior to arrow) to a plastic region (line after arrow). After clinical failure had been achieved, several otherpoints (arrowheads) were correlated with ultimate failure events such as pin bending, pin pullout, fracture, or soft tissue tearing.TABLE 1 Mean stiffness, strength, and normalized ratio data.One-pin fixation Two-pin fixation Normalized ratio one: two pins p-valueStiffness (N/mm) 57.3 ± 18.7 71.7 ± 20.5 82.8% ± 24.6% .029Strength (N) 426.2 ± 167.4 639.2 ± 173.5 68.2% ± 25.8% .003Note: Mean ± SD and p-values for stiffness and strength at clinical failure (3 mm osteotomy displacement) of ex vivo tibial tuberosity avulsion fracture modelsstabilized with one single pin or two pins placed in vertical alignment.WELSH ET AL . 743 1532950x, 2023, 5, 4

Question 158

Singh - 2024 - JAVMA - Laparoscopic surgical treatment for sliding hiatal hernia is associated with an owner-perceived improvement in clinical outcome in dogs.pdf

Answer 158

Case selection and medical record reviewMedical records were searched of dogs under -going laparoscopic treatment of SHH at the Ontario Veterinary College Health Sciences Centre between January 2019 and January 2023. Data collected in -cluded signalment, presenting clinical signs, physi -cal examination findings, preoperative diagnostic imaging results, and preoperative medical manage -ment details. Operative data collected from medical records were reviewed, and collected data included surgical and anesthesia time, type and number of laparoscopic ports, intraoperative surgical complica -tions, and need for conversion to open laparotomy.Surgical techniqueOwner consent for surgery was obtained for all dogs. The dogs were initially placed in dorsal re -cumbency, and laparoscopic treatment for SHH was performed as previously described with hiatal plica -tion, left-sided esophagopexy, and left-sided gas -tropexy.10,11 Briefly, a single-incision, multichanneled port (SILS port; Medtronic Inc) was inserted in a sub -umbilical area12 and a carbon dioxide pneumoperi -toneum was established to 8 mm Hg. An instrument portal was introduced 3 to 5 cm cranial to the single-incision port on ventral midline.10 A second instrument portal was inserted in the right paramedian region.10 If a laparoscopic-assisted gastropexy was to be per -formed, this instrument portal was placed at the loca -tion of the gastropexy, 3 to 5 cm lateral to midline and 2 to 3 cm caudal to the costal arch. If a total laparo -scopic gastropexy was performed, the second instru -ment portal was placed 3 to 5 cm lateral of midline at the same level of the single-incision port. Following port placement, the dogs were rotated into oblique right lateral recumbency to allow for visualization of the esophageal hiatus. Using a blunt probe, the left lateral hepatic lobes were manipulated axially to visu -alize the esophageal hiatus, and the left hepatic trian -gular ligament was incised using a J-hook monopolar electrosurgery probe (Medtronic Inc). An orogastric tube was inserted to reduce the hiatal hernia and provide caudal displacement of the stomach to allow for clear visualization of the left and right crus of the diaphragm during hiatal plication and esophagopexy. Hiatal plication was performed using intracorporeal suturing with either simple interrupted sutures10 of 2-0 polypropylene (PROLENE; Medtronic Inc) or a simple continuous suture pattern11 with a 2-0 unidi -rectional, barbed suture (VLOC 90, 6 inch; Medtronic Inc) to appose the right and left diaphragmatic crural muscles to reduce hiatal diameter. Plication was as -sessed subjectively and deemed adequate when the gastric cardia could not be manipulated through the hiatus. Esophagopexy was performed using intracor -poreal suturing in a simple continuous pattern with a 2-0 unidirectional, barbed suture (VLOC 90, 6 inch; Medtronic Inc). The esophagopexy began as a final hiatal plication suture between the left and right dia -phragmatic crural muscles and then continued with bites through the left crus and distal esophagus and gastric cardia. The same strand of barbed suture was used for esophagopexy if barbed suture was used for hiatal plication. Left-sided gastropexy was performed using either a total laparoscopic13 or laparoscopic-assisted14 approach, based on surgeon discretion, as previously described.Postoperative careAll dogs were recovered from anesthesia and carefully monitored in the ICU and received support -ive care in hospital postoperatively until time of dis -charge. Postoperative treatments including methods of analgesia were provided according to the discre -tion of the attending clinician.Adverse event and complication classificationSurgical complications and adverse events were described and classified using the Veterinary Coop -erative Oncology Group–Common Terminology Cri -teria for Adverse Events scheme.15 If conversion to open celiotomy occurred, the reason for conversion was recorded and it was graded (1 to 4) on the ba -sis of a previously published classification scheme.16 Summarily, grade 1 = strategic conversion to hand-assisted or open approach due to anticipated opera -tive difficulty, grade 2 = reactive extension of an inci -sion or conversion because of operative difficulty or non–life-threatening operative error, grade 3 = reac -tive conversion to open approach because of opera -tive difficulty or non–life-threatening operative error, and grade 4 = reactive conversion to open approach due to life-threatening operative error.Follow-upFollow-up information was obtained from dog owners via telephone interview or email. A standard -ized questionnaire that was previously reported to evaluate clinical outcome following surgical treat -ment for hiatal hernia was administered.10 Owners were given questions pertaining to their dog and asked for a graded response from 0 to 4, with 0 be -ing clinically normal and 4 being severe.10Statistical analysisMedian and range were reported for summary statistics. Pre- and postoperative data from the owner Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 12/24/23 09:44 AM UTC 3questionnaire were compared statistically. Question -naire scores were treated as continuous variables. Normality was tested using the Shapiro-Wilk test and appearance of histograms when necessary. Sig -nificance between pre- and postoperative values was determined using the Wilcoxon signed-rank or paired t test, dependent on normality. In instances when distributions were mixed between groups, the distri -bution of the differences was analyzed. If the distri -bution of the differences was normally distributed, a paired t test was performed to compare groups. P values of < .05 were considered statistically signifi -cant. Statistical analysis were performed using stan -dard software (RStudio version 2023.3.1.446; The R Project for Statistical Computing).ResultsStudy populationNine dogs (5 French Bulldogs and 1 each of Eng -lish Bulldog, Mudi, Boston Terrier, and mixed breed) were included in the study. Median age of dogs was 13 months (IQR, 10 to 21 months). Median weight of dogs was 13.2 kg (10 to 13.7 kg). Six dogs were intact males, 2 were spayed females, and 1 was an intact female.Preoperative evaluation and concurrent proceduresAll dogs presented for further evaluation and treatment of gastroesophageal reflux. Six dogs were treated medically with various combinations and du -rations of metoclopramide, maropitant, cisapride, omeprazole, famotidine, and ranitidine. All dogs were diagnosed with an SHH following an esophageal video -fluoroscopic swallowing study reviewed by a diplomate of the American College of Veterinary Radiology.Prior or concurrent surgery for brachy -cephalic obstructive airway syndrome Three of the 7 brachycephalic dogs included in the study had prior surgery for brachycephalic obstructive airway syndrome (BOAS; alar fold ves -tibuloplasty, 1; bilateral alar fold vestibuloplasty + folded-flap palatoplasty + bilateral tonsillectomy + bilateral laryngeal sacculectomy, 2). Four of the 7 brachycephalics had concurrent BOAS surgery (bi -lateral alar fold vestibuloplasty + folded-flap palato -plasty + bilateral tonsillectomy + bilateral laryngeal sacculectomy) and laparoscopic treatment of SHH. One brachycephalic dog had revision of the folded-flap palatoplasty at the time of laparoscopic treat -ment of SHH due to suspected chronic dehiscence.Intraoperative complications and adverse eventsGrade 3 conversions to open celiotomy occurred in 2 of 9 (22.2%) dogs in which conversion was per -formed as a result of pneumothorax.16 In 1 dog, pneumothorax occurred following iatrogenic trauma to the tendon of the diaphragm from the needle of the suture used for hiatal plication. Conversion to open celiotomy was performed and diaphragmatic repair, hiatal plication, esophagopexy, and left-sided gastropexy were performed without complication using open surgical techniques. In a second dog, progressive pneumothorax was suspected to have occurred from leakage of carbon dioxide through the suture holes of the hiatal plication, which was per -formed with barbed suture in this dog. Conversion to open celiotomy was performed, and esophagopexy and left-sided gastropexy were performed without complication using open surgical techniques.Intraoperative pneumothorax occurred in 3 addition -al dogs and were classified as grade 2 complications.16 In 2 dogs, pneumothorax was managed by the placement of a thoracic drainage catheter (MILA International Inc) to allow for continuous evacuation of the thoracic cav -ity. Following completion of all surgical procedures and withdrawal of capnoperitoneum, air accumulation within the thoracic cavity ceased. In 1 dog, pneumothorax was detected postoperatively during recovery in the ICU and thoracocentesis was performed to alleviate respiratory compromise. Intraoperative leakage of capnoperitoneum into the thoracic cavity around the suture holes of the hiatal plication was once again suspected. Following tho -racocentesis, no further episodes of pneumothorax oc -curred and this dog recovered uneventfully.Surgical procedureHiatal plication was performed using intracorpo -real, simple interrupted sutures of 2-0 polypropylene in 4 dogs and 2-0 barbed suture in 4 dogs (including 1 dog that was converted to open celiotomy after hiatal plication). In 1 dog that was converted to open celiot -omy, hiatal plication was performed with 2-0 Prolene. Esophagopexy was performed in all dogs using barbed suture. In dogs for which barbed suture was used for hiatal plication, the same strand of barbed suture was used for esophagopexy. When intracorporeal, simple interrupted sutures were used for hiatal plication, the barbed suture was used to create a final suture in the hiatal plication and then continued for esophagopexy. Left-sided gastropexy was performed using a total laparoscopic technique in 3 dogs and a laparoscopic-assisted technique in 4 dogs. Surgical times were sepa -rated for surgical treatment of BOAS and laparoscopic treatment of hiatal hernia. Median total surgical time for the BOAS surgical treatments was 60 minutes (IQR, 45 to 75 minutes) and for the laparoscopic treatment of hiatal hernia was 105 minutes (IQR, 90 to 120 minutes). Median total anesthesia time, including all procedures, was 255 minutes (IQR, 180 to 345 minutes).Follow-up and outcomeAll 9 dogs were alive at time of follow-up (me -dian, 413 days [IQR, 282 to 490 days] postopera -tively), at which time the standardized questionnaire was administered to owners.When pre- and postoperative results were com -pared, there were 2 categories/questions for which statistically significant improvement was found post -operatively: regurgitation following eating ( P < .0009) and regurgitation during excitement/increased activ -ity (P = .001). There were no questions for which clini -cal decline was reported by any owner (Table 1) .Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 12/24/23 09:44 AM UTC4

Question 159

Bilgen - 2023 - JFMS - Cardiomyopathy associated 5 (CMYA5) implicated as a genetic risk factor for radial hemimelia in Siamese cats.pdf

Answer 159

Cat ascertainmentThe study was approved by the Animal Ethics Committee of Ankara University 2018/4/33. A nuclear family of Siamese cats (n = 5) was identified, including the two normal parents, one male and one female kitten with RH, and a normal female sibling. Shortly after birth, the queen stopped nursing the affected female and male kittens. The owner noticed forelimb anomalies in two of the three kittens. The kittens were submitted to a private clinic (Kuki Veterinary Clinic, Ankara, Türkiye) for radiologi-cal examination. Lateral and ventrodorsal radiographs (70 kV , 0.3 s) were taken of the forelimbs and upper body, respectively. Oral swabs and EDTA-anticoagulated whole blood were collected by venipuncture. A complete blood count was performed using a BC-2800Vet Auto Hematology Analyzer (Mindray). An additional 13 normal cats representing the extended family were available for sampling using oral swabs.A cardiological examination of only the affected female kitten and sire was completed at a private clinic (Vet Vital VM, Ankara, Türkiye) using a Z6 ultrasound system (Mindray). CT was conducted on the female kit -ten for a better visualisation of the bones, using a paediat-ric dose (80 kV/50 mAs, 0.5 s/0.5 mm, HP 65.0, 512 × 512 pixel resolution) at the Radiology Department of Ankara University, Faculty of Medicine. A whole forearm video of the female kitten was constructed using CT images with an image-processing package (see the video in the supplementary material).21 Cross-sectional CT images were uploaded to the 3D slicer software (3D slicer, version 4.11.20; GitHub) for semi-automatic segmentation.22 During the segmentation process, the ‘segment editor’ function was used to separate bone from surrounding tissue. Intersection angle of lines drawn from the middle of the proximal and distal endpoints of the ulna were measured. Angular measurements of the ulnar bow was calculated with guidance of 3D reconstructed models as described by Ekblom et al.23 Cross-sectional CT images of the female kitten were used to measure the width of the ulna; the width of ulnar midshaft was measured at midshaft from medial-lateral and from craniocaudal.WGS and bioinformatics analysisDNA extractions were performed using a commercial kit (Qiagen) in accordance with the manufacturer’s recommendations and approximately 3 µg was submitted for WGS. Sequencing libraries and WGS was performed by BGI Sequencing Center (BGI, Hong Kong, China) using HiSeq instrumentation (Illumina). The genomic sequence data, Fastq files, were provided to the 99 Lives Consortium for variant analyses. The WGS12 workflow for processing the sequences, alignment to the Felis catus V9.0 reference sequence24,25 and variant calling was con -ducted as previously described.24 DNA variants were viewed, filtered and annotated using VarSeq (Golden Helix) with the Ensembl annotation 101.26,27 Exons and 10 bp of flanking sequences were imported for analy -ses for the WGS and whole exome sequencing (WES) data. Because both parents had normal phenotypes, an autosomal recessive mode of inheritance was assumed for the RH. Candidate variants were identified as any variants that were homozygous in the two affected cats, heterozygous in the parents and absent in 358 cats with Bilgen et al 3WGS data and 62 cats with WES data included in the 99 Lives Consortium. Sequencing data for the 99 Lives pro -ject are available at NCBI BioProject PRJNA987775. The specific cats for this study were accessions: felCat.Minti.Minti SAMN36026287; felCat.Pasa.Pasa SAMN36026288; felCat.Zivziv.Zivziv SAMN36026308; felCat.Minnos.Minnos SRX20808889.Pedigree genotypingOligonucleotides were designed using the web-based software Primer3Plus28 for the cardiomyopathy associated 5 (CMYA5 ) gene by ENSFCAG00000000223 reference. A 239 bp region in exon 1 of the CMYA5 gene harbouring the candidate causative mutation was amplified by using Forward: TGTGGAAGATGCCCATGTAA and Reverse: CGCAGCCTTCCGAAATAATA primers. A 540 bp region in exon 1 and 690 bp region in exon 9 of the JMY gene har -bouring the missense and in-frame deletion mutations were amplified using forward: TGTCTTCATTGTGGCCTGGA and reverse: CTCCTGCCCAGAATCGCA and forward: AATTTGACCAGTTACAATCACTTCT and reverse: GGGCCTTTGATTATGACTCAC primers, respectively. PCR had 1 pmol of each oligonucleotide, 200 μmol/l dNTP , 1 × buffer, 1.5 μmol/l MgCl2, 3 IU of Taq polymer -ase (MBI Fermentas) and approximately 40 ng of genomic DNA added as the template in a volume of 25 μl. PCR conditions included an initial denaturation at 95°C for 4 mins, followed by 30 cycles of denaturation at 94°C for 30 s, annealing at 60°C for 30 s, extension at 72°C for 30 s and 5 mins at 72°C for the final extension. Obtained PCR products were purified, and dideoxy chain termina -tion (Sanger) sequencing was performed using the same forward and reverse primers on an ABI310 DNA Sequencer (Applied Biosystems). Bidirectional sequence results were analysed using Molecular Evolutionary Genetics Analysis (MEGA11) software.29In silico protein sequence comparison analysis was conducted for the CMYA5 and JMY proteins using Ensembl.30 Gene ORGANizer was used to determine gene-target organ/system associations (http://geneor ganizer.huji.ac.il). Also, Sorting Intolerant From Tolerant (SIFT) analysis was conducted to assess the effects of amino acid changes in the proteins in Ensembl, Variant Effect Prediction (VEP).31ResultsAn extended pedigree was ascertained consisting of 18 Siamese cats (Figure 1). One normal (Figure 1, IV-01) and one affected female kitten (Figure 1, IV-03) and an affected male kitten (Figure 1, IV-02) were born from an unaffected queen (Figure 1, III-03) that was backcrossed to her unaffected sire to produce the litter (Figure 1, II-02), thereby suggesting an autosomal recessive mode of inheritance.Radiographs of the 1-year-old female kitten showed bilateral absence of the radii (Figure 2) with the left radius more severely affected than the right radius. The left humerus showed bowing, and the first metacarpal was dysplastic. The right radius exhibited hypoplasia of the proximal end. Additionally, the ulna appeared to be thicker than normal. The width of the left ulnar midshaft cranial- caudal was 7.56 mm, and the medial-lateral width was 3.97 mm, while the right ulnar midshaft cranial-caudal was 8.63 mm, and the medial-lateral width was 3.91 mm. The angular distortion of the ulna was measured at 170.1° on the left forearm and 87.3° on the right forearm (Figures 2 and 3; see also the video in the supplementary material). Despite these abnormalities, the female kitten was able to ambulate by supporting its contact with the ground by using its forelimbs, although it often adopted a ‘kan -garoo’ stance posture. The female kitten was consistent with a type III dysplasia on the left and type IV dysplasia on the right.Radiographs of the 1-year-old male kitten also showed a more severe presentation on the left than on the right side with hemimelia of the left radius and a partially developed right radius; presentation in the male kitten was less severe than the female (Figure 4). The left ante -brachium was dysplastic and the first metacarpal bones were absent in this cat as well. The male kitten had near-normal ambulation but was more weightbearing on the right forelimb and did not exhibit the ‘kangaroo’ stance. The male kitten’s dysplasia is consistent with a type type II on the left and type III dysplasia on the right. Both kit -tens had an extra pair of ribs, with 14 pairs each (Figure 5).The queen had a kinked half tail and the sire and male kitten had kinked tails, but the female kitten with RH did not have a tail malformation. Radiography did not show any other bone malformation in the parents.Echocardiography of the female kitten showed signs of congenital cardiac abnormality by having a large left atrium and a normal left ventricle (LA:Ao = 1.83 cm)32 (Table 1).WGS variant analysesThe 99 Lives Cat Genome Sequencing data set (n = 424) included 358 additional domestic cats with approxi-mately 15–30 × whole genome coverage and 62 cats with >50 × whole exome sequence data.26,27 The com-plete variant data set included 313,3925 variants consid -ering the exonic regions and 10 bp of flanking intronic sequence. An autosomal recessive inheritance pattern was suggested for radial hemimelia disease in cats, which is consistent with the established pedigree.9 After filtering based on inheritance and the condition being specific to the four cats, only 34 variants were identified as candi-dates for RH (Table 2; see also the video in the supple-mentary material). A majority of the variants (n = 22) were 4 Journal of Feline Medicine and Surgery Figure 1 The Siamese cat family pedigree with radial hemimelia. Circles represent females and squares represent males. Black, filled shapes are the female and male kittens with radial hemimelia. Blue connector expresses the father mating with its daughter. Genotypes are presented below each symbol. Only cats III-01, III-02 and IV-03 were unavailable. Cats with asterisks were submitted for whole genome sequencing (WGS)within nine genes and three putative transcripts clustered between 119279957 and 146045193 on cat chromosome A1. Two frameshifts were identified cardiomyopathy associated 5 (CMYA5; myospryn) with suggested loss of function effects. Eight variants were identified in junction mediating and regulatory protein, P53 cofactor (JMY), Bilgen et al 5Figure 2 Forelimb radiography of the affected female kitten. Hemimelia of radius on the left side. Hypoplasia of the proximal end of the radius on the right side. Types III and IV dysplasia in female kittenFigure 3 Three-dimensional reconstruction models of the forearm bones using CT images. (a) Sagittal, transversal and dorsal plane images of the left forearm extremity with a three-dimensional image of the left forearm bones. (b) Angular measurements of the left and right ulna with a three-dimensional image and cross-sectional imagesincluding a missense, two synonymous, an in-frame dele-tion and four 3 ′ UTR variants. However, 11 variants had lower quality scores (VQSRTranche <100), including the in-frame deletion, the missense (SIFT score = 0.14) and two 3′ UTR variants in JMY. The missense mutation in Desmoglein 1 (DSG1 ) resulted in a deleterious SIFT score of 0 and coagulation factor II thrombin receptor (F2R) was 0.17 and not suggested as deleterious.Considering information provided by GeneCards (https://www.genecards.org), CMYA5 has been shown to be involved with limb-girdle muscular dystrophy and several cardiomyopathies. JMY is stated as a cofac -tor of p53 and JMY may have an important role in p53/TP53 stress response in DNA damage. The func-tion of the CMYA5 gene in cats was defined by its similarity in humans.33 CMYA5 has two transcripts in cats: CMYA5-201 (ENSFCAT00000082556.1), which is 13,193 bp and consists of 3716 amino acid residues; and CMYA5-202 (ENSFCAT00000000223.6), which is 12,394 bp and consists of 4108 amino acids. The identified mutations (c.8856_8862delAGACACG at A1:145997464 and c.8866_8867delGT at A1:145997473) are suggested to cause a loss of function (LoF) in both transcripts, leading to p.Glu2952Aspfs*3 and p.Val2956Lysfs*3, respectively, therefore likely disrupting the terminal 20–25% of the protein. The proximity of the two variants suggested that the annotation defined two variants based on only one deletion. Bidirectional Sanger sequencing confirmed the deletions (Figure 6). Bidirectional Sanger sequencing also confirmed the missense and in-frame deletion mutations in JMY .Variant screening in extended pedigreeIn the Siamese pedigree consisting of four generations, the 7 bp deletion frameshift CMYA5 variant at position A1:145997464 was determined in the sire (II-01) (also known as the maternal sire) and the paternal queen 6 Journal of Feline Medicine and Surgery RH has been suggested as a hereditary trait in cats by Swalley and Swalley14 after observation of affected parents of one cat that produced a litter of eight kittens, and later on in Siamese and domestic shorthair cats;37 sporadic cases in random bred cats from various regions of the world have been noted and popularised on social media also. However, neither the inheritance pattern, nor the genetic background of the congenital defect has been determined. In addition to the antebrachium disruptions, each of the parental cats and the male offspring had ver -tebral abnormalities, presenting as kinked tails and an extra set of ribs. In Asian domestic cats and the Japanese and Kurilian Bobtail breeds, the HES7 gene is associated with a short and kinked tail formation due to hemiver -tebrae, as well as extra ribs and occasionally an absent thoracic or lumbar vertebrae.38 However, no variant was detected in HES7 in the parents and male kitten genome (data not shown). Therefore, the presence of the abnormal rib count and the kinked tails in the parental cats and one kitten may be incidental or potentially part of the skeletal abnormalities within these cats. If the tail and rib abnor -malities are incidental, the mode of inheritance is highly suggestive of an autosomal recessive trait with variable expression, as supported by the genotypic data, the close inbreeding and absence of the antebrachium dysplasia in the parents. However, because the maternal queen and Figure 4 Forelimb radiography of the affected male kitten. Hemimelia of radius on the left side (white dot indicates left). Hypoplasia of proximal end of the radius on the right side. Types II and III dysplasia in the male kittenFigure 5 Lateral radiography of the affected female kitten. Fourteen sets of ribs and hypoplasia of the proximal end of the radius on the right side are evident(I-01) and in the two affected kittens (Figure 1). Thus, the CMYA5 variant was concordant with phenotype and an autosomal recessive mode of inheritance. No other cats in the extended pedigree had the variant. The missense mutation in the JMY gene was determined only in the sire (II-01) and therefore did not segregate with disease or the mode of inheritance.

Question 160

Dalton - 2023 - VETSURG - Minimally invasive repair of acetabular fractures in dogs - Ex vivo feasibility study and case report.pdf

Answer 160

2.1 |Cadaveric studyAn ex vivo study to determine the feasibility of thesurgical repair of acetabular fractures using minimallyinvasive techniques in canine cadavers was performed.An unstable mid-acetabular fracture model was used,which involved pubic, ischial, and mid-acetabular osteo-tomies. The experimental protocol was approved by theInstitutional Animal Care and Use Committee (Universityof Florida IACUC Protocol #202111344).2.1.1 | Study subjectsFive adult mixed-breed dogs weighing between 19 and23 kg were used. Four of the dogs were intact males, andthe remaining dog was a female with unknown reproduc-tive status. The dogs were sourced from local animalshelters after recent euthanasia for reasons unrelated tothe study.2.1.2 | Preoperative imagingThe cadavers were stored frozen and subsequentlythawed for imaging. The pelvis and pelvic limbs of allcadavers were imaged with computed tomography(CT) (160 Slice Toshiba Aquillion CT Scanner, CannonMedical Systems, Tustin, California). The scans wereevaluated to confirm the absence of orthopedic abnor-malities such as hip dysplasia and fracture. Helical vol-ume data (slice thickness of 0.5 mm and 0.3 mm sliceoverlap) was obtained, and the bone algorithm was usedfor 3D reconstructions and analysis.2.1.3 | 3D Modeling and printingSegmentation and 3D modeling of pelvises wereperformed using Digital Imaging and Communicationsin Medicine files of bone volume imported into computersoftware (Materialize Medical Imaging Software Suite,Materialize NV, Leuven, Belgium). Three-dimensionalrenderings, referred to as masks, were created using theHounsfield unit density range for bone ( +226 to +2788).Masks were split to isolate pelvises from surroundingosseous structures by manually identifying areas of inter-est. Imperfections were corrected with wrap and hole fillalgorithms. Three-dimensional rendered models wereinverted using the mirror algorithm to mimic the clinicalscenario where a mirrored intact contralateral hemipelviscould be used to accurately precontour a bone plate; thedigital pelvic model was then transected using the trimalgorithm into hemipelves along the pelvic symphysis.Identification labels were added to the ventrolateralaspect of the iliac wings using the quick label algorithm.Hemipelvic 3D models (Figure 1) were printed usingeither a low force stereolithography printer (FormDALTON ET AL . 837 1532950x, 2023, 6, 3, Formlabs, Somerville, Massachusetts) with biocompati-ble photopolymer resin FLBMAM01 (BioMed Amberresin, Formlabs) or a fused deposition modeler additivemanufacturing printer (Fortus 450mc, Stratasys, EdenPrairie, Minnesota) with biocompatible polycarbonate-ISO (PC-ISO, Stratasys). The printer and plastic duo foreach model was chosen based on availability of materialand printer space at the time of printing.2.1.4 | SurgeryLocking compression plates (12 hole, 2.7 LCP, Synthes,Paoli, Pennsylvania) were contoured to the 3D printedmirrored hemipelves dorsally along the ischiatic tuberosityand table, curving around the lesser ischiatic notch, andlaterally to the iliac body (Figure 2). Typically, the cranialaspect of the plate was positioned in the mid-to-ventralhalf of the ilium, and the caudal aspect of the plate waspositioned centrally on the caudal margin of the ischiatictable. Of the 5 cadavers, 3 were randomly assigned to rightacetabular fracture repair, and the remaining 2 wereassigned to left acetabular fracture repair. The chosen limbwas held in abduction, and a 7-10 cm vertical incision wasmade on the ventral pelvic region 2 cm lateral of midline.The adductor, gracilis, and pectineus muscles were trans-ected at their origins and reflected. Medial ischial andpubic osteotomies were performed with an oscillating bonesaw (Colibri Saw, Synthes). The transected muscles wererepaired using monofilament suture with a cruciate inter-rupted or simple continuous pattern, and the skin wasclosed routinely.Caudal and craniolateral approaches (Figure 3) weredeveloped. The caudal approach used was a modifiedapproach to the ischium with internal obturator tenotomyand muscle elevation.8With the dog positioned in lateralrecumbency on a fluoroscopic table, a vertical incisioncentered over the ischiatic tuberosity was made. Fasciaand periosteum along the caudal border of the ischiumwere incised. The periosteum and the internal obturatormuscle were elevated from the ischium with a periostealelevator. The internal obturator tendon was partiallytransected at the lateral margin of the ischium and themuscle was elevated dorsomedially. The craniolateralapproach used was an adapted approach to the iliacbody.9An incision was made over the mid-iliac body. Sub-cutaneous tissue and gluteal fat were incised, and the ten-sor fasciae latae was separated from the middle glutealmuscle. The ventral border of the ilium was palpated andan incision was made at the ventral border of the middlegluteal muscle. The deep and middle gluteal muscles wereretracted dorsally from the lateral surface of the ilium.An epiperiosteal tunnel was created from the caudalapproach to the craniolateral approach using periostealelevators. The periosteal elevator was blindly but carefullyinserted under the internal obturator muscle craniallywhile maintaining direct contact with the underlyingbone. This also involved tunneling under the gemelli andquadratus femoris muscles although these muscles wereFIGURE 1 Three-dimensional rendering of hemipelvic modelderived from computed tomographic scans using 3D medical imageprocessing software (Materialize Medical Imaging Software Suite,Materialize NV, Leuven, Belgium)FIGURE 2 Three-dimensional printed hemipelvic model withpatient-specific contoured bone plate to allow for acetabularminimally invasive plate osteosynthesisFIGURE 3 Intraoperative photograph of the left hip regiondisplaying craniolateral (left) and caudal (right) surgical approaches838 DALTON ET AL . 1532950x, 2023, 6, not directly seen. The ipsilateral hip and stifle weremaintained in slight abduction and flexion, respectively,to limit tensioning of the sciatic nerve.To perform the acetabular osteotomy, the craniolat-eral incision was extended caudally, and a tenotomy ofthe deep gluteal muscle and craniolateral hip arthrotomywere performed to achieve direct exposure of the coxofe-moral joint. A transverse fracture was created throughthe mid acetabulum with an oscillating bone saw (ColibriSaw, Synthes). The deep gluteal tenotomy was repaired,and the caudal extension of the skin incision was closed.The fracture was medially displaced using bone-holdingforceps clamped to the ischiatic tuberosity and visualizedthrough fluoroscopic imaging (Ziehm Vision FD, ZiehmImaging, Nürnberg, Germany) (Figure 4A,B ).The fracture was reduced manually with the bone-holding forceps. The quality of reduction was assessedboth directly through the arthrotomy and indirectly withfluoroscopic images (Ziehm Vision FD). The precon-toured bone plate was applied using 2 to 3 /C22.7 mmlocking screws (2.7 mm LCP screws, Synthes) in each seg-ment. Implant placement and reduction were visualizedwith fluoroscopy (Ziehm Vision FD) (Figure 4C,D ). Carewas taken to ensure the plate position during surgery rep-licated the plate position on the 3D bone models, whereproximity to the ventral ilium (cranially) and caudalmargin of the ischiatic table (caudally) was specificallyassessed. Incision lengths and surgical times for approachesand repair were recorded.2.1.5 | Postoperative imaging, assessment,and data analysisCadavers were imaged using the same methods asdescribed for preoperative imaging. Resultant images wereimported into computer software (Materialize MedicalImaging Software Suite) for assessment of fracture gap andstep defects in the sagittal plane. Fracture gap size wasdetermined using the distance tool to quantify the largestseparation between the fracture margins (Figure 5).Stepdefect size was quantified as the largest length of unalignedarticular surface using the distance tool. For assessment ofpelvic angulation ,r e f e r e n c el i n e sw e r ed r a w nf r o mt h eischiatic tuberosity and cranioventral iliac spine that inter-sected at the caudal acetabular edge (Figure 6). Sagittal andcoronal angles were determined as the angles between the2l i n e si nt h e i rr e s p e c t i v ep l a n e su s i n gt h ea n g l et o o l .Angles were measured in both preoperative and postopera-tive 3D rendered models for each cadaver, and the differ-ences were recorded. The cadavers were then dissected(Figure 7)f o rs u b j e c t i v eg r o s sa s s e s s m e n to fs c i a t i cn e r v einjury and categorized as 0 (none), (1) (mild –no evidenceof elongation, slight disrupti on to epineurium), (2) (moder-ate–possible slight elongation and/or moderate disruptionto epineurium), or (3) (severe –obvious pronounced elon-gation or complete transection). Data were expressed asmedians and interquartile ranges for all parameters usingstatistical functions in the tabulating software (Microsoft®Excel for Mac, Microsoft, Redmond, Washington).FIGURE 4 Fluoroscopic intraoperative images. (A) Lateralview of displaced acetabular fracture. (B) Dorsoventral view ofdisplaced acetabular fracture. (C) Lateral view of acetabularfracture repaired with contoured bone plate. (D) Dorsoventral viewof acetabular fracture repaired with contoured bone plateFIGURE 5 Fracture gap measured as the largest distancebetween fractured surfaces in the sagittal plane of a postoperativecomputed tomographic scanDALTON ET AL . 839 1532950x, 2023, 6, 2.2 |Case reportAn 8 year old male castrated Chihuahua weighing 5.5 kgpresented 1 day after being hit by a car. On presentation,he was nonambulatory in both pelvic limbs but with goodvoluntary motor function and no neurologic deficits; therewas pain on manipulation of both hips. Moderate soft-tissue swelling and ecchymosis was present on the caudo-ventral abdomen and inguinal region. An apparently via-ble physiologic degloving injury was present over thedorsal pelvis. Referral radiographs indicated multiplepelvic fractures, including a right acetabular fracture;thoracic and abdominal structures were unremarkable.A CT scan of the pelvis and pelvic limbs was per-formed under dexmedetomidine sedation (10 mcg/kg IVonce), which revealed a mildly displaced right acetabularfracture resulting in separation of the ilial, ischial, andpubic components of the acetabulum (Figure 8). Therewas also a severely displaced right sacroiliac luxation anda left ischial and pubic fracture.Using the same technique as described for the cadavers,a3 Dr e n d e r e dm o d e lo ft h ef r a c t u r e dr i g h th e m i p e l v i sa n dmirrored intact left hemipelvis were created. A locking com-pression plate (12 hole, 1.5 LCP, Synthes) was precontouredagainst the mirrored intact left hemipelvis to extend dorsallyalong the ischiatic tuberosity and table, over the dorsal ace-tabulum, and laterally to the iliac body (Figure 9). The plateFIGURE 7 Dissected cadaver displaying reduced fracture andlack of sciatic nerve damage or entrapmentFIGURE 8 Three-dimensional reconstructed computedtomographic image of the right acetabular fracture (Dorsal view, A;ventral view, B)FIGURE 9 Twelve-hole locking compression plateprecontoured against the 3D rendered mirrored left hemipelvisFIGURE 6 Pelvic angulation measurements of 3D-renderedpelvic models. Angles were measured in their corresponding planesusing reference lines from the ischiatic tuberosity and cranialventral iliac spine that intersected at the caudal acetabular edge.(A) Preoperative sagittal angle. (B) Postoperative sagittal angle.(C) Preoperative coronal angle. (D) Postoperative coronal angle840 DALTON ET AL . 1532950x, 2023, 6, and 3D-rendered hemipelves were autoclaved (Steris,Mentor, Ohio).Surgery was performed 2 days following the traumaticevent. The caudal and craniolateral approaches devel-oped in the cadaveric population were performed. Anepiperiosteal tunnel was created from the caudalapproach to the craniolateral approach using a periostealelevator. The ilio-ischial segments of the acetabulumwere held in reduction with bone reduction forceps whilethe precontoured plate was secured to the ilial body andischiatic table using 4 and 3 /C21.5 mm locking screws(1.5 mm LCP screws, Synthes), respectively. Acceptablereduction was assessed both directly through a craniolat-eral hip arthrotomy and indirectly under fluoroscopicguidance, as described for the cadaveric specimens. Thecraniolateral approach was extended cranially to the ilialwing to permit stabilization of the ipsilateral sacroiliacluxation with a screw (3.0 mm cannulated partiallythreaded screw, Arthrex, Naples, Florida) and washer(6.5 mm washer, IMEX Veterinary, Longview, Texas),which were placed under fluoroscopic guidance. AJackson-Pratt drain (McKesson, Irving, Texas) was placedin the dead-space from the physiologic degloving injury.The total surgery time (including sacroiliac luxationrepair, repositioning, and acetabular fracture repair) was160 min.3|RESULTS3.1 |Cadaver studyAll cadavers underwent preoperative imaging withCT. No orthopedic abnormalities were present. Numer-ous BB-gun pellets embedded in soft tissue were observedin the CT scan of Cadaver 5, none of which invaded boneor joint structures.3.1.1 | SurgeryThe surgical technique was successfully performed in all5 cadavers. Median incision length was 5 cm (IQR,0.5 cm; Table 1) and 5 cm (IQR, 0.5 cm; Table 1) for cau-dal and craniolateral approaches, respectively. Medianprocedure time, including caudal and craniolateralapproaches, reduction, and repair, was 46 min and 15 s(IQR, 4 min and 48 s; Table 1). Variation in procedureTABLE 1 Surgical measurements and durationCadaverCaudal approach Craniolateral approachReduction andrepair time (min:s)Total approach, reduction,and repair time (min:s) Length (cm) Time (min:s) Length (cm) Time (min:s)1 5 3:35 3.5 3:02 36:27 43:042 4.5 4:45 4.5 3:00 38:30 46:153 5 3:50 5 1:52 49:00 54:424 6 4:35 5 2:02 41:15 47:525 5.5 5:40 5.5 2:03 17:50 25:33Median 5 4:35 5 2:03 38:30 46:15IQR 0.5 0:55 0.5 0:58 4:48 4:48TABLE 2 Postoperative assessmentCadaverFracturegap (mm)StepDefect (mm)Sagittal angle (/C14) Coronal angle (/C14)Sciatic nerveinjury Preoperative Postoperative Change Preoperative Postoperative Change1 0.9 0.7 154.75 155.84 1.09 138.00 135.57 2.43 02 0.4 0.9 137.33 140.32 2.99 127.01 127.81 0.8 13 1.5 0.7 145.30 147.35 2.05 136.30 133.21 3.09 04 0.8 0.9 139.49 144.06 4.57 136.11 133.98 2.13 05 0.4 0.8 151.99 156.75 4.76 133.95 133.33 0.62 0Median 0.8 0.8 145.30 147.35 2.99 136.11 133.33 2.13 0IQR 0.5 0.2 12.50 11.78 2.52 2.35 0.77 1.63 0DALTON ET AL . 841 1532950x, 2023, 6, time was attributed to difficulty of reduction andfixation due to the necessity of further repositioning andfluoroscopic imaging.3.1.2 | Postoperative assessmentFracture gaps and step defects were <2 and <1 mmfor all fracture repairs, respectively. Median fracturegap was 0.8 cm (IQR, 0.5 cm; Table 2). Mean stepdefect was 0.8 cm (IQR, 0.2 cm; Table 2). Pelvic angu-lation was <5/C14. Median change in sagittal angle was2.99/C14(IQR, 2.52/C14; Table 2). Median change in coronalangle was 2.13/C14(IQR, 1.63/C14). One mild (1) instance ofsciatic nerve injury (Table 2) was present in Cadaver2, which displayed a superficial, 2 mm long indenta-tion. Sciatic nerve injury was not detected in the othercadavers.3.2 |Case outcomeOn immediate postoperative radiographs, near anatomicreduction of the acetabular fracture with slight ( /C241 mm)medial displacement of the pubic segment was evident(Figure 10). The dog was weight bearing on the operatedlimb within 24 h of surgery.At 1 month postoperatively, no lameness was evident.On radiographs, the fracture site was stable with goodprogression of healing but the cranial-most screw in thecaudal segment was fractured. Good progression of heal-ing was evident on CT at 8 weeks following surgery(Figure 11), and complete healing of the pelvic fractures,including the acetabular fracture, was documented onradiographs at 3 months postoperatively.4

Question 161

Enright - 2023 - JFMS - Evaluation of endoscopic-assisted feline lateral bulla osteotomy - A cadaveric study.pdf

Answer 161

A total of 13 feline heads from cadavers of unowned ani -mals (Skulls Unlimited International) were acquired for use in this study. For Skulls Unlimited’s ethical sourc-ing policy, please see file 1 in the supplementaty mate-rial. Before use, each head was imaged via a GE 64-slice LightSpeed VCT scanner run in helical fashion, with images acquired at 1.0 mm and reconstructed into axial sequences at 1.25 mm. The scans were evaluated by a board-certified veterinary radiologist and assessed for any evidence of osseous changes consistent with pre-existing middle ear disease.The TECA-LBO procedure10 was performed bilat-erally on all cadavers, with the external canal ampu-tation performed by either a surgical intern or a board-certified small animal veterinary surgeon; the bulla osteotomies and ear canal ablations were per -formed exclusively by the boarded surgeon. For each cadaver, the laterality of the traditional TECA-LBO was assigned randomly via an electronic coin flip. The contralateral TECA-LBO was performed with the assistance of a 1.9 mm 30° arthroscope attached to a 4k camera system (Synergy UHD4 Imaging Platform; Arthrex) inserted intermittently into the middle ear via the lateral bulla osteotomy site to facilitate visualiza -tion of the middle ear structures and assessment of the integrity of the incomplete bony septum until entry into the hypotympanum was observed. Images of the tympanic bulla and the bony septum were captured before and after entry into the hypotympanum for all ears where endoscope assistance was utilized.After the TECA-LBO procedures, postoperative CT images were acquired as previously described. The tym -panic bullae were assessed by the board-certified radi-ologist and radiographic evidence of entry through the bony septum (yes/no) was recorded for each ear. Using the results of this assessment, a frequency table was cre -ated to compare the percentage of successful procedures (defined as those with CT evidence of entry into the hypotympanum) between the endoscope-assisted and traditional-approach TECA-LBO treatment groups. A second frequency table assessing the effect of laterality (left vs right ear) on success of the procedure by treatment group was also generated.The magnitude of the effect of endoscope assistance was determined via computation of odds ratios for both treatment groups across both ears, for the left ear only, and for the right ear only. Statistical significance was assessed using Fisher’s exact test for the resulting data, and a P value < 0.05 was considered significant. A Mantel–Haenszel procedure was performed to control for procedure laterality, along with an exact logistic regres -sion that incorporated fixed effects for both the laterality and treatment groups.ResultsBased on their dentition, all cadavers appeared to be from adult felines; the remainder of each cadaver was not available so exact age, full body weight and sex of the cats could not be determined. None of the cadaver heads exhibited any evidence of osseous pathology related to middle ear disease on initial CT imaging.Use of the endoscope during surgery did not require an additional approach or enlargement of the lateral bulla osteotomy relative to the traditional approach. The middle ear was readily observed and both osseous land -marks and neurovascular structures were able to be recognized and imaged with acceptable clarity. These structures included the malleus, incus and stapes, the chorda tympani, the external acoustic meatus, the pars flaccida and pars tensa of the tympanic membrane, the promontory, and the cochlear and vestibular win-dows. The bony septum was identified consistently and without difficulty in each cadaver, and entry into the hypotympanum was easily observed and documented. Representative images from the middle ear are shown in Figure 1.A total of 13 endoscope-assisted TECA-LBO proce-dures and 13 traditional-approach TECA-LBO proce-dures were performed. In each treatment group, 12/13 procedures resulted in entry in the hypotympanum (Figure 2). Both unsuccessful procedures were performed in the right ear. Without laterality considered, the odds of successful entry into the hypotympanum during an endoscope-assisted procedure were 1.0 (95% confidence Enright et al 3Figure 1 Images captured during endoscopic evaluation of the middle ear of feline cadavers. (a) View of the tympanic membrane before entry into the middle ear. (b) View from inside of the middle ear after penetration through the tympanic membrane. (c) View of the intact bony septum. (d) View of the bony septum after entry through the septum into the hypotympanum. (e) View of the middle ear bones. D = dorsal; V = ventral; R = rostral; Ca = caudal; CT = chorda tympani; CW = cochlear window; EAM = external acoustic meatus; I = incus; MM = manubrium of the malleus; P = promontory; S = stapes; TM = tympanic membraneFigure 2 CT images from cadaver heads before and after the total ear canal ablation and lateral bulla osteotomy (TECA-LBO) procedure. (a) Cadaver 1 with intact septa before TECA-LBO (left) and bilaterally perforated septa postoperatively (right). (b) Cadaver 11 with intact septa before TECA-LBO (left) and perforated left septum after bilateral procedure (right)4 Journal of Feline Medicine and Surgery interval [CI] 0.1–17.9) times the odds of successful entry during a traditional-approach procedure ( P = 1.0) (Table 1). An odds ratio could not be calculated for left-sided procedures owing to all procedures being successful on that side, regardless of treatment group. For right-sided TECA-LBO procedures, the odds of successful hypotym -panum entry were 1.2 (95% CI 0.1–24.5) times greater with endoscope assistance (P = 1.0) (Table 2). When adjusting for laterality, the Mantel–Haenzel odds ratio for association between hypotympanum entry and treat -ment group was 1.2 (95% CI 0.1–24.5), indicating no con -founding effect of laterality (P = 0.455). The odds ratio for successful entry into the hypotympanum with left-sided procedures (regardless of treatment group) compared with right-sided procedures was 2.4; univariable analysis revealed a lack of significance of laterality with regard to the success of the procedure ( P = 0.48).

Question 162

Frankar - 2023 - JAVMA - Video telescope operating monitor-assisted surgery is equivalent to conventional surgery in treatment of cervical intervertebral disc herniation in dogs.pdf

Answer 162

Ethical considerationThis study was approved by the ethics com -mittee of the National Veterinary School Vetagro Sup (Lyon, France; approval No. 2272). All owners involved in the study signed informed consent for a ventral decompressive surgery but were not told which technique would be chosen.Study populationAll client-owned dogs with cervical IVDD diag -nosed by CT myelography from November 2020 to January 2023 at the Centre Hospitalier Frégis in Paris, France, that required a ventral slot decompressive surgery were enrolled in this study. For population homogeneity, only dogs weighing < 20 kg were se -lected. Dogs whose surgery and postoperative scan could not be done on the same day as the preopera -tive CT myelography were excluded from the study since radiologists could not accurately perform their measurements because the myelographic contrast media was much less visible after 24 hours.The minimum number of dogs to enroll in each group for adequate statistical power was calculated considering a mean difference in decompression ratio between groups of 0.18 ± 0.1. The decompression ratio was selected because it directly assessed the effective -ness of VITOM compared to the conventional surgical method. This would be considered a better spinal cord decompression. At least 19 dogs were to be enrolled in each group to achieve an α of 0.05 and power of 90%.A complete history and the results of physical examination were recorded, including a complete preoperative neurologic examination by a board-certified neurologist (LC) or neurology resident (HF). The neurologic status was graded on the basis of the 5-point scale (0 = normal without any hyperesthesia, 1 = ambulatory, neck pain only, no deficit, 2 = am -bulatory tetraparesis with proprioceptive deficits or single thoracic limb lameness, 3 = non-ambulatory tetraparesis, 4 = tetraplegic, and 5 = tetraplegic with respiratory distress) defined by Scott.14–16Preoperative imagingAll dogs had CT myelography performed prior to decompressive spinal surgery. After premedication with morphine (0.2 mg/kg, IM) and diazepam (Va -lium; 0.2 mg/kg), anesthesia was induced with pro -pofol (titrated to effect) and maintained with isoflu -rane in 100% oxygen. Dexamethasone (Dexadreson; 0.2 mg/kg, IV) and cefazoline (Céfazoline; 15 mg/kg, IV) were administered at the time of induction.Conventional myelography was performed with lumbar injection of 0.1 mL/kg of iohexol (Omnipaque; 350 mgI/mL). CT (BRIVO CT385 16-slice helical CT scanner; GE Healthcare) of the spine extending from the base of the skull to the third thoracic vertebra was performed with the dogs in dorsal recumbency; the long axis of the cervical column was aligned perpendic -ular to the CT gantry. Positioning of all dogs in the CT scanner was performed by the neurologists. Location of the herniated material was defined as central (no ob -vious lateralization) or lateralized when the compres -sion had a lateral component in the vertebral canal.The surgical techniqueVentral slot decompression was performed by 1 of 3 board-certified surgeons and 1 of 2 senior surgery resi -dents under direct supervision of the attending special -ist. The surgical technique (ie, use of the VITOM or con -ventional surgery) was decided at the discretion of the primary surgeon on the basis of VITOM availability (ie, VITOM was unavailable if already used or not yet steril -ized from a previous surgery). Dogs were classified into the VITOM or conventional surgery group accordingly. All surgeons performed at least 1 surgery in each group.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 10/20/23 06:53 AM UTC 3Each dog was placed in dorsal recumbency with the neck slightly extended. A conventional ventral mid -line approach to the cervical spine was performed.2 The affected intervertebral disc space was identified by palpation of the anatomic landmarks. The telescope and high-definition camera system for magnifying and illuminating the surgical site (VITOM; Karl Storz) were used only in the VITOM group, and the installation was adjusted as previously described by Rossetti et al.12The autoclavable rigid lens telescope was 10 mm in diameter and 10 mm in length and capable of providing up to 16X magnification with high-definition (1080p, HD) quality resolution.17 A 300W xenon fiber optic light source (Xenon Nova 300; Karl Storz) and fiber optic cable were attached directly to the telescope. An auto -clavable high-definition digital camera (A3; Karl Storz) with optical zoom was fixed to the telescope, and the resultant image was displayed on medical-grade high-definition video monitors (52 inches) and recorded (AIDATM; Karl Storz). The telescope and camera were sterilized with ethylene oxide or autoclave and did not require a sterile drape or cover. The VITOM system was installed after patient draping, and 1 or 2 remote monitors were placed facing the primary and assistant surgeons. Video assistance was used from the begin -ning of ventral slot drilling until the end of spinal cord decompression. The occurrence of surgical and anes -thetic complications (especially sinus bleeding) were noted. Sinus bleeding severity was considered mild, moderate, or severe if bleeding was controlled in < 5 minutes, between 5 and 10 minutes, and > 10 minutes, respectively (Supplementary Video S1) .A hemostatic sponge (Pangen) was placed over the ventral slot site with an instillation of morphine on the spinal cord (0.1 mg/kg, diluted to 50%) before closure. The conventional surgical technique was performed identically except without the use of the VITOM system.Postoperative imagingAll dogs had postoperative CT myelography per -formed immediately after surgery without additional contrast media injection to assess the degree of spi -nal cord decompression, ventral slot features, and presence of residual disc material.Evaluation of images and measurements was performed by a board-certified radiologist (EG) and senior resident in radiology (CT; radiologist 1 and radiologist 2, respectively) using a DICOM viewer (Horos; Horos Project). Both radiologists were blind -ed to the surgical method performed.Spinal cord dimension measurementThe normal spinal cord area (NSCa) was mea -sured at the widest point cranial to the herniated disc site. The decompressed spinal cord area (DSCa) was measured at the level of the compressive disc site on postoperative images. The spinal cord decompres -sion ratio was calculated using the following formula: (Figure 1) .12Figure 1 continued on next page.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 10/20/23 06:53 AM UTC4 The preoperative length of the vertebral body (preLVB) caudal to the herniated disc space was measured from the cranial-to-caudal vertebral end -plate on ventrodorsal preoperative images. The postoperative length of the remaining vertebral body (postLVB) was measured at the same location on postoperative images. The vertebral body length ratio was calculated using the following formula: (Figure 1).12Figure 1 —Sagittal (above) and transverse (below) CT scan view at the level of the herniated disc (yellow arrow) before (left) and after (right) surgical decompression. The normal spinal cord area (NSCa) and decompressed spinal cord area (DSCa) are measured, and the decompression ratio is calculated using the following formula: (A). Ventrodorsal CT scan view at the level of the ventral slot before (left) and after (right) surgical decompression. The postoperative length of the remaining vertebral body (postLVB) and preoperative length vertebral body (preLVB) are measured, and the vertebral body length ratio is calculated using the following formula: (B). Transverse CT scan view at the level of the herniated disc before (left) and after (right) surgical decompression. The slot width (SW) and preoperative width vertebral body (preWVB) are measured, and the width ratio is calculated using the following formula: (C).Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 10/20/23 06:53 AM UTC 5The laterolateral width of the vertebral body (preWVB) corresponded, on transverse preoperative image, to the measurement of the space in between the 2 medial imprint of the lateral vertebral artery just cau -dally to the herniated disc space. The slot width (SW) was measured in between the remainder of the vertebral body on postsurgical images. The width ratio was calcu -lated using the following formula: (Figure 1).12 Finally, the ventral slot was defined as lateralized if its axis was not centered on the vertebral body on the transverse section.Postoperative outcomeDuring the immediate postoperative period, anal -gesia was provided through the administration of mor -phine (0.2 mg/kg, SC) or fentanyl (constant rate infu -sion, 3 µg/kg/h) as needed for 24 to 48 hours. Dogs were discharged a minimum of 3 days after surgery. A neurologic examination was performed every morning during postoperative hospitalization and at discharge. All dogs were prescribed prednisolone (Dermipred; 0.5 mg/kg, q 12 h, then decreasing dosage for 12 days), tramadol hydrochloride (Tramadol; 5 mg/kg, PO, q 12 h for 5 days), gabapentin (Neurontin; 10 mg/kg, PO, q 8 h for 15 days), and methocarbamol (Lumirelax; 20 to 25 mg/kg, PO, q 12 h for 5 days). Follow-up clinical and neurologic examinations were conducted in all dogs at suture removal 2 weeks after surgery.Statistical analysisRecorded clinical data measurements included age, body weight, breed, sex, preoperative and post -operative neurologic status (which was performed at the time of discharge), and bleeding occurrence and duration. The recorded preoperative imaging data in -cluded the location of the affected disc space and the location of the disc material within the spinal canal (ventral vs lateral). The recorded postoperative imag -ing data included the spinal cord diameter and height at the compression site, decompression ratio, ventral slot lateralization, and ventral slot dimension (length, width, and ratio compared with the vertebra).For descriptive statistics, continuous data were assessed for normal distribution by histogram eval -uation and the Shapiro-Wilk test (Gaussian if P > .2).17,18 As none of the data were normal, continuous data were presented using median (minimum–maxi -mum). Categorical data were presented as number of dogs (percentage).The VITOM and conventional surgery groups were first compared in terms of signalment, preoperative neu -rologic status, and IVDD location using a Mann-Whitney test for continuous variables (age and body weight), 2-tailed Fisher exact test for unordered categorical vari -ables (sex, breed, and IVDD location), and ordered lo -gistic regression model for ordered categorical variable (preoperative neurologic status). For the latter model, absence of significant violation of the parallel regression assumption was assessed using the Brant test.The effect of the surgical technique (ie, VITOM vs conventional surgery) on the decompression ratio, verte -bral body length ratio, ventral slot width ratio, presence of residual disc material, and postoperative neurologic status was then studied. To take into account repeat -ed measures by the 2 radiologists and the potential confounding effects of herniated disc lateralization, repeated-measures mixed-effects ANOVA models with identity covariance matrix were used, with the depen -dent variable being the decompression ratio, vertebral body length ratio, or ventral slot width ratio and the independent variables being the surgical technique, ra -diologist, first-order interaction between the two, and herniated disc lateralization. As presence of residual disc material was an unordered categorical variable, a repeated-measures mixed-effects logistic model was used, with the dependent variable being the presence of residual disc material and the independent vari -ables being the surgical technique, radiologist, first-order interaction between the two, and herniated disc lateralization. Finally, a generalized ordered logistic regression was used to assess the impact of the sur -gical approach on neurofunctional outcome, with the dependent variable being the postoperative neurologic status and the independent variables being the surgical approach and preoperative neurologic status.For mixed-effects models, only the fixed-effects results were reported. If significant differences were detected for the first-order interaction between the radiologist and surgical approach, further analyses were conducted using contrasts and predicted margin plots. For mixed-effects ANOVA models, normal dis -tribution and homoscedasticity of the residuals were assessed by graphical assessment of frequency dis -tribution histograms and residual plots, respectively.Statistical analyses were performed with commer -cially available software (Stata version 17.0; StataCorp LLC). Values of P < .05 were considered significant.ResultsStudy populationA total of 39 dogs were enrolled: 19 in the VITOM group and 20 in the conventional surgery group. De -mographic information for the dogs in each group is summarized (Table 1) .There was no significant difference between the VITOM group and conventional surgery group regard -ing age ( P = .95), body weight ( P = .41), sex ( P = .75), breed ( P = .84), and location of the affected interver -tebral spaces ( P = .22). Preoperative neurologic status was not significantly different between the 2 groups ( P = .82) and included dogs with neurologic grades from 1 to 4 in both groups (median grade 1 in both groups).Decompression ratioThe decompression ratio significantly differed between radiologists ( P = .03), although the dif -ference was not significant between the 2 surgical techniques ( P = .85) independent of the radiolo -gist and the herniated disc lateralization. A trend toward a better agreement of measurements was found between radiologists within the VITOM group rather than the conventional group (–0.005 and –0.05, respectively; Figure 2 ).Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 10/20/23 06:53 AM UTC6 Vertebral body length ratioDespite a significant difference between radiolo -gists regarding vertebral body length ratio measure -ment ( P = .02), no significant difference was found be -tween the 2 surgical techniques ( P = .13) independent of the radiologist and the herniated disc lateralization. A trend toward a significant interaction between the sur -gical techniques and radiologists was found ( P = .09), meaning that the effect of the surgical technique on the vertebral body length ratio was different depending on which radiologist reviewed the CT images. This interac -tion was explored using contrasts and predicted margins plot. Based on contrasts, the vertebral body length ratio was significantly lower in the VITOM group according to radiologist 2 ( P = .04) but not radiologist 1 ( P = .13). A trend toward a better agreement of measurements be -tween radiologists in the VITOM and conventional surgery groups was suggested by contrasts (–0.0007 and 0.03, respectively) and by predicted margins plot (Figure 2).Ventral slot width ratioWhile the ventral slot width ratio measurement differed significantly between radiologists ( P = .006), there was no significant difference between the 2 surgical techniques ( P = .39) independent of the radi -ologist and herniated disc lateralization. These results were confirmed by predicted margins plot (Figure 2).Presence of residual disc materialThere was no significant difference regarding residual disc material between the 2 surgical tech -niques ( P = .30), independent of the radiologist and disc herniation lateralization.Variable Conventional surgery (n = 20) VITOM (n = 19) P valueAge (y) 5.5 (3–11) 4.5 (2.5–13) .95Body weight (kg) 11.45 (4.9–16) 10 (2.3–20) .41Sex .75 Male 12 (60%) 10 (52.6%) Female 8 (40%) 9 (47.4%) Breed .84 French Bulldog 14 (70%) 12 (63.2%) Beagle 0 1 (5.3%) Chihuahua 0 2 (10.5%) Dachshund 1 (5%) 1 (5.3%) Jack Russel Terrier 1 (5%) 1 (5.3%) Pinscher 1 (5%) 0 Shi-Tzu 2 (10%) 2 (10.5%) Tibetan Spaniel 1 (5%) 0 Affected intervertebral spaces .22 C2-C3 2 (10%) 3 (15.8%) C3-C4 10 (50%) 5 (26.3%) C4-C5 5 (25%) 7 (36.8%) C5-C6 1 (5%) 4 (21.1%) C6-C7 2 (10%) 0 Entries represent median value (minimum–maximum) for continuous variable and number of dogs (percent of dogs) for categorical variables.Table 1 —Demographic data in conventional surgery and video telescope operating monitor (VITOM) groups.Figure 2 —Predictive margin plots of the relationship be -tween the decompression ratio (A), vertebral body length ratio (B), and ventral slot width ratio (C; on the y-axis) and the surgical approaches (on the x-axis) measured by 2 radi -ologists (radiologist 1 in blue and radiologist 2 in red). Error bars represent 95% CIs.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 10/20/23 06:53 AM UTC 7Occurrence of operative complicationsSinus bleeding was observed in only 1 (5%) dog from the conventional surgical group, whereas it was reported in 5 (26%) dogs within the VITOM group. Some dogs (n = 4) initially assigned to the conven -tional technique group had surgery stopped due to uncontrolled intraoperative bleeding prior to ad -equate spinal cord decompression. These dogs were recovered from anesthesia and underwent surgery and postoperative CT scan the next day, but due to the elimination of contrast media 24 hours postin -jection, postoperative measurements could not be obtained, resulting in exclusion of these dogs from the study. Sinus bleeding was judged to be mild in the dog in the conventional surgery group. It was considered mild, moderate, and severe in 1 (5%), 2 (10%), and 2 (10%) dogs, respectively, from the VITOM group.One dog in the conventional surgery group de -veloped discospondylitis at the surgical site and was diagnosed by MRI 3 weeks after surgery. This dog was treated successfully thereafter.Postoperative neurologic examTwo weeks after surgery, all dogs achieved a neurologic status of grade 0 to 2, regardless of the surgical technique. There was no significant difference in the postoperative neurologic status between the 2 surgical techniques ( P = .17 when comparing grade 0 to grade 1 or 2 and P = .74 when comparing grade 0 or 1 to grade 2) independent of the preoperative neurologic status. The number of dogs achieving a postoperative grade 0 were equivalent in both groups (70% in the conventional group vs 79% in the VITOM group; Supplementary Table S1 ). Despite an improvement in the neuro -logic status in dogs of both methods, the great -est neurologic improvements during our follow-up period were observed in the VITOM group (ie, from preoperative neurologic grade 4 to postoperative neurologic grade 1; Figure 3 ).

Question 163

Pavletic - 2023 - JAVMA - Successful correction of stenotic nares using combined Alar Fold Lift-Up and Sulcus Pull-Down Techniques in brachycephalic cats - 8 cases (2017-2022).pdf

Answer 163

CasesClient-owned brachycephalic cats with severe nasal stenosis and a history of progressive difficulty with na -sal breathing with increased inspiratory effort that were presented to the Angell Animal Medical Center between April 11, 2017, and July 11, 2022, were eligible for inclu -sion. Owner consent was obtained for treatment.2 Combined “Alar Fold Lift” and “Sulcus Pull Down” surgical proceduresEach cat was screened preoperatively with a CBC and serum biochemical profile. All cats under -went general anesthesia for stenotic nares correction and the anesthetic protocols were individualized for patient needs as determined by the clinical anesthe -siology service. Each cat received perioperative ce -fazolin sodium (10 mg/kg, IV) and ondansetron (0.2 mg/kg, IV). Lactated Ringer solution (5 mg/kg/h, IV) was administered through the duration of the surgical procedure.During anesthetic induction, the soft palate and larynx were examined in each cat. The skin around the perimeter of the nares was clipped of fur. The cats were placed in sternal recumbency with the Figure 1 —Illustration of the facial profile of a brachycephalic cat (left) in comparison to a domestic shorthair cat (right). Along with the flattened facial silhouette of brachycephalic cats the external nose also is smaller than other cat breeds’. Figure 2 —Sequential illustrations of the “Alar Fold Lift-Up” and “Sulcus Pull-Down” procedures performed between April 2017 and July 2022 to improve nasal breathing for 8 client-owned brachycephalic cats with stenotic nares. A 4-mm punch is used to resect a skin segment dorsolateral to the adjacent alar fold (A), followed by removal of the cu -taneous plug (B). The dorsolateral punch defect is closed with 4-0 absorbable interrupted poliglecaprone sutures (C). This is followed by skin punch placement in the slight downward curvature of the skin rostral to each nasal sulcus. The procedures are performed bilaterally for completion (D) of the “Alar Fold Lift-Up” and “Sulcus Pull-Down” procedures.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 08/30/23 11:59 AM UTC 3head elevated on folded cloth surgical towels placed along the end of the surgical table. Following surgical preparation of the skin, the facial area was draped.A surgical pen was used to mark the intended areas for skin resection in all 4 locations based on the assessment of skin tension in relation to the alar folds. An ellipse of skin, 5 to 6 mm long by 4 to 5 mm wide was created in the skin dorsolateral to the adja -cent alar fold margins using a No. 11 scalpel blade in 6 cats. In 2 cats, a 4-mm biopsy punch was used to facilitate skin resection. 4-0 absorbable interrupted poliglecaprone sutures were used to close each in -cision. Following the “Alar Fold Lift-Up” procedure, similar skin incisions were made rostral to each na -sal sulcus, over the curvature of the skin partially obstructing each nostril. Resection of the skin was followed by closure in an identical fashion. Surgi -cal closure was normally performed in sets: the left or ride side was initially completed followed by the remaining side (Figure 2) . Photographs were taken prior to and following completion of each procedure (Figures 3 and 4) .Elizabethan collars were placed on each cat dur -ing anesthetic recovery. All cats recovered from an -esthesia uneventfully and were discharged later in the afternoon with instructions to keep the collars on each cat for a minimum of 1 week. Each cat was dis -charged with a prescription of buprenorphine (0.02 mg/kg, PO) every 12 hours for 5 days.Follow-upTwo weeks after surgery, owners were called and asked about their cats’ breathing characteristics. Long-term follow-up conversations by telephone were made a minimum of 6 months postoperatively.ResultsSignalment, clinical signs, preoperative findingsClient-owned brachycephalic cats, with severe nasal stenosis and a history of progressive difficulty breathing, were presented to the Angell Animal Medi -cal Center between April 2017 to July 2022 for a total of 8 consecutive cases. Feline breeds included 4 Per -sian, 3 Himalayan, and 1 Scottish Fold. Five cats were Figure 3 —Perioperative images of a Himalayan cat from the case series described in Figure 2 before (A) and after (B) corrective surgery. In this cat, the right rostral upper margin of the lip was slightly lifted fol -lowing closure of the lower punch incision; this had no clinical consequence.Figure 4 —Perioperative images of a Persian cat from the case series described in Figure 2 before (A) and after (B) corrective surgery. Note the enlargement of each nostril opening with this simple technique.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 08/30/23 11:59 AM UTC4 neutered males, whereas 2 cats were spayed females. Cats ranged from 2 years to 9 years of age and had a mean body weight of 4.3 kg (range, 2.4 to 5.7 kg).Surgery and postoperative periodThe soft palate and laryngeal examination were within normal limits. No postoperative complica -tions were noted. Elizabethan collars were removed 1 week after surgery. The absorbable poliglecaprone sutures degraded and fell out of the skin within 4 weeks following surgery.Follow-upOwners reported their cats were breathing well at the initial follow-up call 2 weeks postoperatively. Long-term follow-up conversations by telephone were made a minimum of 6 months postoperatively. Three cats were followed over a 3- to 5-year period with 1 cat for over 18 months. All owners reported that their cats were breathing well with their nostrils maintaining their patency over the length of the follow-up reports.

Question 164

Aikawa - 2023 - JAVMA - Decompressive laminectomy with vertebral stabilization allows neurologic improvement of most Pekingese dogs with thoracolumbar vertebral instability.pdf

Answer 164

Data collectionMedical records of Pekingese presented to the Aikawa Veterinary Medical Center with thoracolum -bar spinal cord decompression and vertebral stabi -lization from 2007 to 2022 were retrospectively re -trieved and reviewed. Dogs diagnosed by dynamic myelographic study, CT myelography or MRI was included. Dogs with a conclusive diagnosis of ver -tebral fracture, luxation, or congenital vertebral ab -normality in the area of vertebral canal narrowing, with the exception of AP abnormality, were exclud -ed. Data on age, sex, body weight, preoperative and postoperative neurologic status, diagnostic findings, surgical techniques, and follow-up clinical and radio -graphic evaluations were retrieved. All clinical and radiographic evaluations were performed by the au -thors. Duration from the initial onset of clinical signs to presentation at our hospital was collected. We defined the rate of onset, established from owner observations, as the period of time from when the dog was last clinically normal until it deteriorated to the neurologic grade with which it presented to our hospital. Rate of onset was graded as follows: a sudden rate of onset was defined as < 2 hours, rapid was from 2 to 48 hours, intermediate was > 48 to 120 hours, progressive was rate of onset > 120 hours, and a mixed rate of onset was defined as a progres -sion of disease > 120 hours followed by a rapid de -terioration in < 48 hours.19 Neurologic dysfunction was graded on a scale of 0 to 5. Dogs were assigned a grade (G) of G0 to G5 based on the severity of neurologic dysfunction, in which G0 represented a clinically normal dog, G1 represented thoracolumbar paraspinal pain without neurologic deficits, and G2 represented ambulatory paraparesis. G2 was further classified as mild, moderate, or severe on the basis of subjective assessment of the severity of ataxia, as follows: mild represented ambulatory paraparesis in which the dog could walk and run, but the clini -cian could detect a slight to mild ataxia or conscious proprioception deficit; moderate represented am -bulatory paraparesis with ataxia; and severe repre -sented ambulatory paraparesis with obvious ataxia in which the dog could stand and take several steps (5 m) without support. G3 represented nonambula -tory paraparesis. G4 represented paraplegia with in -tact or positive deep nociception in the pelvic limbs and tail. G5 represented paraplegia with absent deep nociception in both the pelvic limbs and the tail.20Anesthetic protocolThe anesthetic protocol included premedication with glycopyrrolate (0.01 mg/kg, IM) and fentanyl constant rate infusion (3 µg/kg/h, IV) or morphine (0.5 mg/kg, IM). The dogs received preoxygenation for 10 minutes before induction with midazolam (0.3 mg/kg, IV) and propofol (2 mg/kg, IV, to effect). Anesthesia was maintained with isoflurane (1.5% to 2.0%) in oxygen using a ventilator. Cefazolin sodium (22 mg/kg, IV) was administered 20 minutes before surgery and 90 minutes thereafter during surgery. Postoperative analgesia was maintained using fen -tanyl constant rate infusion (3 µg/kg/h, IV) or mor -phine (0.5 mg/kg, IM) for 24 to 48 hours as needed.Imaging studySurvey radiographic projections and CT or MRI images of the spine obtained while the dogs were anesthetized were assessed. The presence of disc calcification, narrowing/collapse of the interverte -bral space, sclerosis of the endplates, spondylosis deformans, as well as the presence or absence of cranial and caudal AP abnormality were recorded. The degree of spinal cord attenuation was evaluated using static and dynamic myelographic studies.Myelography was performed using a subarach -noid injection of iohexol at L5–L6 using a fluoro -scope. A dynamic study was performed by applying manual extension and flexion to the spine, with the dog positioned in lateral recumbency. To avoid the potential risk of additional spinal cord injury by this maneuver, a gentle force that flexed and extended Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 10/20/23 06:54 AM UTC 3the spine was applied. Dynamic compression was then evaluated using lateral radiographic projections by measuring and comparing the pre- and poststress spinal cord heights at the intervertebral disc spaces.8 The spinal cord height was defined as the distance between the ventral and dorsal edges of the sub -arachnoid contrast column on the perpendicular line to the spinal cord. The percentage reduction in spinal cord height was also recorded. The primary lesion was defined as the disc(s) with the most spinal cord height reduction on stress position as compared to the other discs.8CT was performed using a 16-slice helical scan -ner (Brivo CT385; GE Healthcare), and MRI was per -formed using a 0.4 Tesla scanner (Aperto Inspire; Hitachi Medical) or 1.5 Tesla scanner (Brivo MR355 Inspire 1.5T; GE Healthcare).Surgical procedureThe dogs were placed on the surgical table with the thoracic and the pelvic legs pulled cranially and caudally, respectively. Spinal cord decompression was achieved by performing a hemilaminectomy with extension of the laminectomy, as necessary. Be -fore and after decompression, vertebral stability near the laminectomy site was assessed using intraopera -tive vertebral manipulation. The stability of multiple vertebral articulations around the decompressed site was evaluated using skin clamps placed on the base of the dorsal spinous process. The gentle dorsal-ven -tral force of the segment was applied and compared to the rest of the adjacent vertebral articulation. Loss of rigid vertebral articulation (widening/narrowing of the AP) was considered an unstable spinal seg -ment.18 This maneuver was performed with extreme caution to avoid iatrogenic spinal cord injury. Unilat -eral vertebral stabilization was performed using 4 to 6 positive-profile threaded pins (size, 1.6 to 2.4 mm) with polymethylmethacrylate (PMMA). The pins were driven into the vertebral body bicortically using the threaded portion of the pin as a guide. The extent of vertebral stabilization and the size and number of pins used were based on the number of affected disc spaces and patient size and age. Cefazolin powder (250 mg) was mixed with 20 g of the PMMA poly -mer powder before mixing with the liquid monomer. A copious saline flush was used to minimize thermal injury to the spinal cord and adjacent tissues during PMMA polymerization. The dorsal spinal fascia and subcutaneous tissue layers were closed in a continu -ous pattern using polydioxanone and the skin ap -posed with nylon.Postoperative care and follow-upNo postoperative medication was used in all dogs. Outcome was considered successful if the dog recovered deep nociception, voluntary urinary function, and the ability to walk for dogs with pre -operative grade 3 to 5; if the dog had improved in severity of ataxia after surgery for dogs with preoperative grade 2; and if there was relief of para -spinal pain for dogs with preoperative grade 1. Ra -diographs were obtained immediately after surgery to confirm proper implant placement. All dogs were hospitalized for 5 to 7 days. Postoperative neuro -logic status was evaluated daily for any evidence of neurologic deterioration compared with the preop -erative neurologic grade. All dogs were reexamined 10 to 14 days postoperatively at the time of suture removal. Routine scheduled monthly or bimonthly follow-up clinical examination and/or radiographic evaluations were conducted by the authors for 3 to 6 months postoperatively. Additionally, annual follow-up reexaminations and radiographic evalu -ations were conducted. For dogs that were not reexamined for > 12 months from the previous ex -amination, follow-up telephone interviews were conducted to assess any evidence of neurologic de -terioration compared with the previous grade with the owner or referring veterinarian.ResultsSignalmentEleven Pekingese dogs met the inclusion criteria. This included 5 males (5 neutered) and 6 females (5 spayed) with a median age of 4 years (IQR, 2.5 to 8.5 years) and a median body weight of 5.5 kg (IQR, 4.5 to 7.1 kg).Clinical historiesThe rate of onset was rapid in 5 dogs (dogs 1, 3, 6, 10, and 11), intermediate in 2 dogs (dogs 5 and 7), progressive in 3 dogs (dogs 2, 8, and 9) and mixed in 1 dog (dog 4). The neurologic grades were G2-moderate in 3 dogs (dogs 1, 6, and 8), G2-severe in 5 dogs (dogs 2 through 4, 9, and 10), G3 in 1 dog (dog 11), and G4 in 2 dogs (dogs 5 and 7). None of the dogs had urinary or fecal incontinence. Paraspi -nal pain was observed in 4 dogs (dogs 4, 6, 8, and 9).Imaging findingsAll of the dogs underwent vertebral radiography and myelography. Six dogs underwent additional CT and 1 underwent CT and MRI. On survey radio -graphs, disc calcification in 4 dogs (dogs 1, 5, 9, and 10), narrowing of the intervertebral disc space in 2 dogs (dogs 3 and 11), and spondylosis deformans in 2 dogs (dogs 3 and 7) were noted. On CT, 5 dogs had caudal AP hypoplasia and/or aplasia (dog 4: bilateral aplasia on T10, T11, and T12; dog 7: left hypoplasia on L2; dog 8: right hypoplasia on T12; dog 10: right hypoplasia on T12, bilateral hypoplasia on T13; and dog 11: right hypoplasia on T12, left aplasia on T13; Figure 1 ). Degenerative joint disease of the right L2–L3 and L3–L4 AP on dog 7 and right L1–L2 AP on dog 9 were noted.Myelography and dynamic studies were per -formed on all dogs. On myelography, spinal cord ex -tradural compression over the disc space in the neu -tral position was noted in 10 dogs (dogs 2 through 11). Dynamic study demonstrated dynamic spinal cord compressive lesions in all dogs. One dynamic spinal cord compressive lesion was identified at a site with no compression in the neutral position (dog Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 10/20/23 06:54 AM UTC4 1). Seven dogs (dogs 1, 4 through 6, and 8 through 10) had a single spinal cord compression, and 4 dogs (dogs 2, 3, 7, and 11) had multiple spinal cord com -pressions. Dynamic compressive lesions were dem -onstrated positioned in extension in 5 dogs (dogs 1, 2, and 9 through 11), in flexion in 2 dogs (dogs 4 and 7), and in both flexion and extension in 4 dogs (dogs 3, 5, 6, and 8). The reduction in poststress spinal cord height in 11 dogs at 17 disc sites was a median of 12.5% (IQR, 6.8% to 21.2%; Figures 2 and 3 ). Addi -tionally, CT myelography performed in 7 dogs (dogs 4 and 6 through 11) showed compressive lesions similar to those seen on myelography (Figure 1).Nine vertebrae in 5 dogs had caudal AP abnor -malities. Of the 28 lesions where compression in neutral position was found, 6 compressions were at the disc spaces with caudal AP abnormalities. Of the 17 lesions where dynamic compression was found, 5 dynamic compressions were at the disc spaces with caudal AP abnormalities (Table 1) .The MRI study performed in dog 7 showed se -vere ventrolateral spinal cord compression at the L1–L2 and L2–L3 disc spaces. There was an area of spinal cord hyperintensity on T2-weighted images in the center of the cord at the level of T13 through L2.SurgeryAll dogs underwent hemilaminectomy and uni -lateral vertebral stabilization, and 3 dogs (dogs 1, 2, and 5) underwent concomitant prophylactic fenes -tration. All compressive lesions consisted of fibrous ligamentous hypertrophy of the annulus fibrosus of the disc or dorsal longitudinal ligament. These com -pressive lesions were removed or incised using a No. 11 blade. All the hemilaminectomy procedures and vertebral stabilizations were performed at the site of dynamic compression, with the exception of 1 dog (dog 5) that underwent hemilaminectomy (T13–L1) and vertebral stabilization (T13–L1–L2), with L1–L2 instability confirmed by intraoperative manipulation. Six dogs had vertebral stabilization of 2 vertebrae (dogs 1, 4, 6, and 8 through 10), 3 dogs (dogs 3, 5, and 7) had vertebral stabilization of 3 vertebrae, and 2 dogs (dogs 2 and 11) had vertebral stabilization of 4 vertebrae (Figures 2 and 3).OutcomeAll but 1 dog showed successful outcomes at the last follow-up (median, 16 months; IQR, 3 to 32 Figure 1 —Dog 4. CT 3-D reconstruction view (A). Ar -rows denote bilateral caudal articular process (AP) aplasia of T10, T11, and T12. Transverse CT myelogram images at the level of T10–T11 (B), T11–T12 (C), T12–T13 (D), and T13–L1 (E) intervertebral disc space, dis -playing bilateral caudal AP aplasia of T10, T11, and T12 and normal APs of T13, respectively.Figure 2 —Dog 1. A—Neutral myelogram showing no spinal cord compression. Spinal cord height at T12–T13 was 4.5 mm. B—Dynamic myelogram on dorsal exten -sion showing attenuation of the dorsal contrast column at T12–T13. Spinal cord height at T12–T13 of 3.4 mm (24.4% reduction) was noted. C—Postoperative radio -graph, showing 4 positively threaded profile pins in -serted into the vertebral bodies of T12 and T13.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 10/20/23 06:54 AM UTC 5months). Seven dogs (dogs 1, 3, 4, and 6 through 9) showed complete neurologic recovery, 3 dogs (dogs 5, 10, and 11) improved but had residual neurologic deficits at the last follow-up. One dog (dog 2) re -mained ambulatory with no neurologic improvement at 2 months postoperatively and was lost to further follow-up. Follow-up radiographs obtained on subse -quent examinations in 10 dogs confirmed stable im -plants with unchanged stabilization alignment (me -dian, 5 months; IQR, 3 to 27 months). One dog (dog 9) had recurrent signs of acute paraparesis 3 months postoperatively and underwent a second surgery for T11–T13 decompression and stabilization. T11–T13 stabilization was combined with the previously stabi -lized site of L1–L2, resulting in T11–L2 stabilization. The dog recovered after a second surgery.

Question 165

Worden - 2023 - VCOT - Radiographic Comparison of Virtual Surgical Corrective Options for Excessive Tibial Plateau Angle in the Dog.pdf

Answer 165

Radiograph Selection and PreparationMediolateral radiographs of 30 tibias from 20 cranial cruci-ate ligament-de ficient dogs were obtained from two veteri-nary hospitals (University of Wisconsin-Madison and TuftsUniversity). The sample size was selected based on availabil-ity of eTPA tibial radiographs and to obtain equal groupnumbers. The radiographs were divided into three groups(n¼10/group) based on the measured preoperative TPA:moderate ( /C2034 degrees), severe (34.1 –44 degrees) andextreme TPA ( >44 degrees). Exclusion criteria includedother tibial deformities or bone pathologies thatimpacted the mediolateral radiographic appearance.All simulated procedures (CCWO,15mCCWO,15iCCWO,16niCCWO, TPLO/CCWO,8and coCBLO14)a n dr a d i o g r a p h i cmeasurements were performed using Veterinary Preopera-tive Orthopedic Planning Software (vPOPPRO, VETSOSEducation, Ltd. 2018, Llangollen, UK) as previously described(►Fig. 1 ). The niCCWO was a modi fication of the iCCWOused clinically by one of the investigators (JN). A standard-ized protocol for virtual correction and assessment wascompleted by two investigators (NJW, TMC) after completinga training set of images in consensus with coauthors. Eachcalibrated radiograph was saved with a pre-annotated TPAline, and measurement points on the tibial tuberosity andcentre of the intercondylar eminence to ensure consistencyin measurements.Radiographic MeasurementsThe TPA, TLA, relative tibial tuberosity width (rTTW) anddistal tibial angle/proximal tibial angle (DTA/PTA) anglemeasurements were performed as previously described(►Table 1 ).17–19The pre-simulation TLA and TTW measure-ment lines remained in position on each radiograph through-out all virtual corrections to maintain consistency withmeasurements (►Fig. 2 ). For coCBLO, osteotomy overlapwas calculated as the ratio of the arc length of bone-on-bone overlap at the ostectomy site to the arc length ofthe longer limb of the curved wedge, multiplied by 100.Osteotomy overlap for the TPLO/CCWO was calculated basedon the CCWO for the severe and extreme TPA groups. In themoderate TPA group, which did not have a CCWO compo-nent, the osteotomy overlap was calculated similarly to thecoCBLO based on the amount of overlap at the site of thecrescentic osteotomy.Virtual Proximal Tibial Ostectomy Procedures ( ►Fig. 1 )For all closing wedge and TPLO procedures, the wedge anglewas adjusted to achieve a post-simulation TPA of 5 /C60.5degrees. The wedge position was placed as described below,then adjusted to maintain a minimum distance of 25 mmfrom the intercondylar eminence to the proximal osteotomyto ensure adequate room for plate positioning post-simula-tion. For the coCBLO procedure, the wedge angle androtation were adjusted to achieve a post-simulation TPAof 10 /C60.5 degrees. After wedge removal for CCWO,mCCWO, iCCWO, niCCWO and TPLO/CCWO, the proximaland distal bone segments were aligned at the cranialcortices.Cranial Closing Wedge OstectomyThe CCWO was planned in all TPA groups as previouslydescribed by Wallace and colleagues.15Briefly, a right-angletriangle was drawn with the apex starting 10 mm distal tothe tibial tuberosity and the distal limb of the triangleperpendicular to the TLA..Modi fied Cranial Closing Wedge OstectomyThe mCCWO was planned as previously described by Fred-erick and Cross.20Briefly, a similar right triangle (CCWO) wasdrawn such that the distal limb spanned the cranial two-thirds of the total craniocaudal width of the tibia, and thenextended caudally to exit the caudal cortex.Isosceles Cranial Closing Wedge OstectomyThe iCCWO was planned as previously described by Oxleyand colleagues.16An isosceles triangle was drawn over theproximal tibia with the apex positioned at the caudal aspectof the tibia and the cranial aspect of the proximal limbpositioned 10 mm distal to the tibial tuberosity. The apexof the triangle was positioned as needed to maintain equallengths of the triangle limbs.Neutral Isosceles Cranial Closing Wedge OstectomyA similar isosceles triangle (iCCWO) was drawn over theproximal tibia such that the triangle would span approxi-mately two-thirds of the total craniocaudal width of thebone. A line was then extended caudally from the apex of thetriangle to exit the caudal cortex.Tibial Plateau Levelling Osteotomy and Cranial ClosingWedge OstectomyThe TPLO/CCWO was planned as previously described in thesevere and extreme TPA groups, with adjustments to thestandard rotation and wedge size.8Proximal segment rotationwas standardized to maintain clinically feasible wedge sizes ofmore than 10 degrees. For tibias with TPA >40 degrees, theproximal segment was rotated according a TPLO rotation chart(Synthes Vet, West Chester, PA) to correct for 30 degrees; fortibias with TPA /C2040 degrees, the proximal segment was rotatedto correct for 20 degrees. The remaining TPA was reduced to 5degrees using the CCWO. Tibias in the moderate TPA group(TPA/C2034 degrees) were treated with a TPLO (no additionalCCWO), as would be consistent with clinical management. Forthe CCWO, a right-angle triangle was drawn with the apexintersecting the caudal cortical margin of the TPLO cut, and theproximal limb of the triangle perpendicular to the TLA.Coplanar CORA-Based Levelling OsteotomyThe coCBLO was planned in the extreme and severe TPAgroups as previously described.14Briefly, two TPLO sawblades of the same size were positioned over the proximaltibia, intersecting at the caudal cortex. The proximal-mostblade was positioned 18 mm distal to the caudal aspect of theintercondylar eminence, measured along a line drawn atapproximately 80 degrees to the TPA line. After the targetwedge angle was determined, the bone wedge was removed,the ostectomy site was reduced and the proximal bonesegment was rotated cranially. Proximal segment rotationwas standardized similarly to the TPLO/CCWO. The moderateTPA group (TPA /C2034 degrees) was treated with a standardCBLO (no coplanar wedge removed) planned as previouslydescribed.21Fig. 1 The tibia has a tibial plateau angle (TPA) of 52.5 degrees in the extreme group. Pre- ( A) and post-simulation ( A'')c r a n i a lc l o s i n gw e d g eostectomy (CCWO); pre- ( B) and post-simulation (B ')m o d i fied cranial closing wedge ostectomy (mCCWO); pre- ( C) and post-simulation ( C') tibialplateau levelling osteotomy with cranial closing wedge ostectomy (TPLO/CCWO); pre- ( D) and post-simulation ( D') isosceles cranial closingwedge ostectomy (iCCWO); pre- ( E) and post-simulation (E ') neutral isosceles cranial closing wedge ostectomy (niCCWO); and pre- ( F)a n dp o s t -simulation (F ') coplanar CORA-based levelling osteotomy (coCBLO). Tibial slope ( thick green line), mechanical axis (thin green line), rotationalosteotomy (red line), virtual wedge ostectomy (green shading)..Data AnalysisPre-simulation outcome measures (TPA, tibial length, TTW,rTTW, DTA/PTA angle) were compared between the moder-ate, severe and extreme TPA groups using a one-way analysisof variance (ANOVA) and post-hoc Tukey test. Wedge anglewas compared between the different proximal tibial osteot-omies for each TPA group using a repeated measures ANOVAmodel. Distance measurements were normalized to tibiallength and comparisons were analysed on both raw andnormalized data. Outcome measures were comparedbetween the six virtual proximal tibial osteotomies for theentire group of 30 tibias, as well as for each TPA severitygroup using a two-way mixed effects ANOVA and post-hocTukey test. A linear regression analysis was performed todetermine Pearson correlation coef ficients, using preopera-tive TPA as the independent variable and cTTS, dTTS, wedgeangle, osteotomy overlap, TLAS and tibial shortening asdependent variables for each proximal tibial osteotomy. Allstatistical model assumptions were examined by analysingthe residuals and deemed to be satis fied. Results wereconsidered signi ficant at pless than 0.05. In post-hoc com-parisons, individual p-values are not reported, but the levelof magnitude is provided by lower-case or capital letters forp-values between 0.05 and 0.001 or p-values less than 0.001,respectively.ResultsRadiographs were obtained from 20 cranial cruciate liga-ment-de ficient dogs (14 right and 16 left tibias) with bodyweight from 21.9 to 59.3 kg for the study. All data presentedare based on raw data collected. Normalized data are onlypresented if normalization resulted in changes to signi fi-cance. Pre-simulation measurement data are summarizedin►Table 2 . Aside from TPLO/CCWO and coCBLO, wedgeangles needed to achieve the target TPA were not differentbetween the various closing wedges (►Table 3 ). Differencesbetween the pre-simulation TPA and wedge angles across theCCWO, mCCWO, iCCWO and niCCWO ranged from /C02.5 to5.3 degrees.Across all 30 tibias, TPLO/CCWO had the lowest TLAS, dTTSand tibial shortening ( ►Table 4 ). The coCBLO had the largestTLAS and cTTS. The CCWO had the largest dTTS and tibialshortening. The iCCWO had the second largest tibial short-ening. For the analysis between different TPA groups, largerTPA had increased TLAS, dTTS and cTTS for all proximal tibialosteotomies (►Tables 5 –7). Osteotomy overlap remainedrelatively constant across the three TPA groups and trendsfor tibial shortening were dependent upon the proximaltibial osteotomy. Speci fic differences within each outcomemeasure are detailed below.Table 1 Outcome measures and abbreviationsMeasurement DefinitionTibial plateau angle (TPA) Angle between a line drawn perpendicular to the tibial long axis and a line drawn approximatelyparallel to the slope of the tibial plateau, measured in degreesTibial length Distance from the intercondylar eminence to the center of the talus along the tibial long axis,measured in millimetresTibial long axis (TLA) Sagittal plane mechanical axis of the tibia, proximally from the intercondylar eminence, distallyto the center of the talusTibial long axisshift (TLAS)Angle formed by the distal intersection of the pre-and post-simulation TLA lines, measuredin degreesTibial tuberositywidth (TTW)Distance from the tibial tuberosity measurement point to the pre-simulation tibial long axis,measured perpendicular to the pre-simulation tibial long axis, in millimetresCranial tibial tuberosityshift (cTTS)Difference between the post- and pre-simulation TTW, in millimetres. Positive values indicate acranial shift in the tibial tuberosityDistal tibial tuberosityshift (dTTS)Distance measured from the pre-simulation TTW to the post-simulation TTW, perpendicular tothe TTW lines, measured in millimetres. Positive values indicate a distal shift in the tibialtuberosityWedge angle Angle formed by the caudal intersection of the planned proximal and distal osteotomy lines,measured in degreesOsteotomy overlap Using the craniocaudal lengths of the proximal and distal osteotomy cuts (measured inmillimetres), osteotomy overlap was the ratio of the shorter line to the longer line, multiplied by100 and expressed as a per centRelative tibial tuberositywidth (rTTW)A line was drawn from the proximal-most aspect of the tibial crest to the caudal-most aspect ofthe tibial plateau, and a circle was drawn, centred over the caudal-most aspect of the tibialplateau with a radius equal to the distance from the caudal- to cranial-most aspects of the tibialplateau. The rTTW was then calculated as the ratio between the cranial and caudal portions of theline, which were determined by the point at which the circle intersected the line18Diaphyseal tibial axis(DTA)/proximal tibialaxis (PTA) angle (degree)Acute angle formed by a line bisecting the tibial shaft at 50% and 75% of the length from theproximal to distal cortices (DTA) and a line drawn from the cranial aspect of the medial tibialcondyle to the mid-diaphysis at the level of the distal aspect of the tibial crest (PTA), in degrees19.Tibial Long Axis ShiftAcross all tibias, TPLO/CCWO had the smallest TLAS(p<0.001) and coCBLO had the largest TLAS ( p<0.001).Similarly in the moderate TPA group, TPLO alone had noeffect on TLAS and CBLO had the largest effect. The TLAS wassimilar across all CCWO variations, aside from the extremeTPA and combined TPA groups where TLAS with CCWO wasless than with niCCWO ( p<0.05). The TLAS had a strongpositive correlation with TPA for coCBLO, TPLO/CCWO,niCCWO and iCCWO, and a moderate positive correlationfor mCCWO and CCWO (►Fig. 3 ).Cranial Tibial Tuberosity Shift and Distal TibialTuberosity ShiftThe coCBLO resulted in the greatest cTTS across all TPAgroups ( p<0.001). The TPLO in the moderate TPA groupdid not impact tibial tuberosity position. The TPLO/CCWOresulted in the smallest dTTS across all TPA groups(p<0.001). The CCWO and iCCWO had the largest dTTS inall TPA groups ( p<0.001) and were only different from eachother in the extreme TPA group ( p<0.001). No changes instatistical results were found between absolute cTTS andcTTS normalized by tibial length. When all tibias wereassessed independent of TPA group, dTTS was signi ficantlydifferent between mCCWO and coCBLO only when normal-ized by tibial length. The cTTS demonstrated a strong posi-tive correlation with TPA for the TPLO/CCWO, coCBLO,mCCWO and niCCWO, and a moderate positive correlationfor the iCCWO and CCWO. The dTTS had a strong positivecorrelation with TPA for all proximal tibial osteotomies.Osteotomy OverlapThe iCCWO had the largest osteotomy overlap overall andalso in the moderate TPA group ( p<0.001). Within individualTPA groups, CCWO had the smallest osteotomy overlap withextreme TPA ( p<0.001), niCCWO had the smallest overlap withsevere TPA ( p<0.05), and niCCWO and TPLO had the smallestoverlaps with moderate TPA ( p<0.001). Osteotomy overlap hada strong negative correlation with TPA for coCBLO and CCWO; amoderately positive correlation for TPLO/CCWO, niCCWO andmCCWO; and was 100% for all iCCWO tibias.Fig. 2 (A) Pre-simulation tibia with tibial plateau angle (TPA) of52.5 degrees templated for a 53.4 degree isosceles cranial closingwedge ostectomy (iCCWO, green shading). The tibia is pre-annotatedwith markers (yellow squares) cent red over the intercondylar emi-nence and the patellar tendon insertion on the tibial tuberosity, and aline approximating the tibial slope (green line). The tibial long axis(TLA, red line) was also used to measure tibial length. The wedge angle(red angle) and pre-simulation tibial tuberosity width (TTW, blue line)are measured. The TPA is calculated as the black angle minus90 degrees. ( B) Post-simulation tibia after iCCWO. The lower portionof the image remains fixed; the upper portion shifts with theostectomy (red dotted line) to achieve a postoperative TPA of5 degrees. Pre-simulation TLA (red line) and post-simulation TLA (blueline) are used to calculate TLA shift (black angle). ( C) Post-simulationtibia after iCCWO. Pre-simulation TLA (red þpurple lines) andpre-simulation TTW (blue line) remain in place on the image.Post-simulation TTW (yellow line) and distal tibial tuberosityshift (purple line) are measured. ( D) Post-simulation tibiaafter CCWO. Distal osteotomy length (orange line) andproximal osteotomy length (light blue line) were used tocalculate osteotomy overlap.Table 2 Pre-simulation measurements. Summarized results (mean /C6standard deviation; range) for preoperative radiographicmeasurements based on TPA groupsModerate TPA Severe TPA Extreme TPA p-ValueTPA (degree) 31.9 /C61.7a29–34 38.2 /C63.3b34.5–43.7 50.4 /C63.3c45.4 to 56 <0.001Tibial length(mm)210.5 /C626.5a177–256.8 216 /C638.6a169–265.4 202.2 /C611.9a189.3 –227.8 0.546rTTW 0.50 /C60.03a0.47–0.57 0.43 /C60.07a0.33–0.56 0.32 /C60.07b0.22–0.47 <0.001DTA/PTA angle(degree)19.2/C62.7a14.8–22.3 23.4 /C62.4a20.1–28.9 30.9 /C66.0b23.2–41.2 <0.001TTW (mm) 37.3 /C65.2a32–46.7 37.4 /C66.8a30 to 47.8 35 /C63.7a30.6–45 0.550Abbreviations: DTA/PTA, diaphyseal tibial axis/proximal tibial axis; r TTW, relative tibial tuberosity width; TPA, tibial plateau angle; TTW, tib ialtuberosity width.N o t e :V a l u e sw i t h i ne a c hr o wa r es i g n i ficantly different ( p<0.05) if they do not share the same superscript letter..Tibial LengthTibial shortening was greatest for CCWO, followed by iCCWO,across all tibias and TPA groups ( p<0.05). The TPLO/CCWOhad the least effect on tibial length across all tibias and TPAgroups ( p<0.05). The mCCWO, niCCWO and coCBLO resultedin minimal lengthening of the tibias. Within individual TPAgroups, CBLO had the largest tibial lengthening ( p<0.05)with moderate TPA, but coCBLO was similar to mCCWO andniCCWO with severe and extreme TPA ( p>0.05). For CCWO,tibial shortening had a strong positive correlation with TPA.Tibial shortening had a moderate positive correlation withTPA for iCCWO and coCBLO and a moderate negative corre-lation for niCCWO. Tibial shortening was not correlated toTPA for mCCWO or TPLO/CCWO. When tibial shortening wasnormalized by tibial length, the general trends across TPAgroups were not changed.

Question 166

Goodale - 2023 - JAVMA - Lower centrifugation speed and time are positively associated with platelet concentration in a canine autologous conditioned plasma system.pdf

Answer 166

This ex vivo experimental study was performed from July to December 2022 at a single private prac -tice referral center. Thirty healthy adult dogs were recruited on a volunteer basis to participate in this study. These dogs were either employee-owned pets or patients of the sports medicine service undergo -ing elective orthopedic procedures. Owner consent for participation in the study was obtained. All ani -mals were evaluated to be free of medical problems as determined by physical examination (performed by a veterinary surgical resident), clinical history, and CBC analysis. All procedures were directly over -seen by a licensed veterinarian.The system used in this study was the Arthrex autologous conditioned plasma (ACP) double- syringe system. The blood collection for PRP prepa -ration was performed following the manufacturer’s instructions.27 The Arthrex system consists of a sin -gle centrifugation method using 13.5 mL of whole blood to produce PRP.Thirty-one milliliters of whole blood was asepti -cally collected from the jugular or cephalic vein of each patient. The whole blood was aspirated into a 35-mL syringe, while rocking the syringe carefully to allow for mixing of the blood with 4 mL of anticoagu -lant citrate dextrose solution (Solution A; ACD-A). The anticoagulant-to-blood ratio was maintained from manufacturer directions. Whole blood was evaluated with a CBC analysis for baseline hematologic analy -sis (1 to 2 mL used/CBC analysis), and the remainder was processed for PRP.Fifteen milliliters of the anticoagulated blood was transferred into 2 double syringes. Each double sy -ringe was randomly assigned to 1 of 5 groups, which varied by centrifugation force and time (Table 1) . These syringes were then placed into the cen -trifuge (Rotofix 32; Andreas Hettich GmbH and Co KG) with appropriate counterbalances, with -out the brake engaged, at the assigned speed and time. The group centrifugation speeds and times were based on those established at the authors’ institution.After the 1-step centrifugation process, double syringes were removed, with care taken to keep them in the upright position so as to not disturb the plasma layer. The total volume of PRP gener -ated was measured and recorded. PRP was then transferred into the inner syringe until the tip of the smaller syringe reached the transition layer and a flash was obtained. The smaller syringe was re -moved and agitated to distribute platelets uniform -ly in solution. An aliquot of each PRP was placed in a lavender-top (EDTA) tube and then routinely shipped with the whole blood sample to a commer -cial laboratory (IDEXX Laboratories Inc). The results were returned electronically within 24 to 48 hours of submission.Group RCF (X g) Time (min) No. of syringes1 906 5 102 906 10 113 580 5 124 580 10 125 1,304 5 11RCF = Relative centrifugal force.Table 1 —Blood from each subject was fractioned into 3 aliquots: a baseline sample and 2 double syringes to be processed into platelet-rich plasma. Each double syringe was randomly assigned to 1 of the 5 groups, which varied in centrifugation speed and time. Unauthenticated | Downloaded 11/03/23 05:59 AM UTC 3Statistical analysisBaseline descriptive statistics were calculated for all measured variables. Linear mixed models were used to estimate differences from baseline by group, with a random effect of each dog to account for correlated observation from the same animal. Linear mixed models were also used to estimate the independent effects of speed and time on the final product. These models were run separately for each measured variable, and models in which the final val -ue was the outcome were adjusted for the baseline value of that variable. P values ( P < .005 considered significant) are presented unadjusted for multiple comparisons; the a priori primary comparison was the effect of speed and time on mean platelets in the final product.ResultsA total of 90 CBCs were performed on 60 PRP and 30 peripheral whole blood samples. The aver -age amount of PRP produced was 3.5 mL (range, 0.5 to 7.5 mL) per double syringe. Data from 2 dogs were excluded from the statistical analysis of platelet fold change due to initial thrombocytope -nia (flagged in an automated CBC report and con -firmed by a clinical pathologist), raising concern for the patient’s systemic health.Blood was obtained from a total of 30 healthy adult dogs. The following breeds were represented: German Shepherd Dog (n = 6), Pit Bull–type breed (5), Husky or Husky mix (4), Labrador Retriever (3), Weimaraner (2), Border Collie (2), Boxer (1), Gold -endoodle (1), Labradoodle (1), Australian Cattle Dog (1), English Bulldog mix (1), and mixed breed (3). The patients ranged from 1.5 to 12 years of age, with a median age of 5 years. The patients ranged from 17 to 45 kg, with a median weight of 24.75 kg. Six -teen of the study participants were neutered males, 13 were spayed females, and 1 was an intact female. The samples were randomly assigned to groups, and there were no significant differences between the demographics of cohorts in each group.The only group with statistically significant platelet increase compared to whole blood baseline was group 3, which was prepared using a centrifuga -tion speed of 580 X g for 5 minutes (Figure 1) .Seventy-five percent (9/12 syringes) of PRP generated in group 3 had a fold change > 10%. In contrast, only 18% (2/11 syringes) PRP samples in group 2, which was prepared using a centrifugation speed of 906 X g for 10 minutes, had a fold change > 10% (Figure 2) .The RBC concentration was significantly de -creased from baseline in all groups, though there was not a statistically significant difference among the groups. The overall leukocyte concentration was sig -nificantly decreased in all groups, except for group 3 (Table 2) . Group 3 had a significantly decreased neutrophil concentration but significantly increased lymphocyte and monocyte concentrations, com -pared to baseline.When comparing the distribution of blood com -ponents at the 3 centrifugation forces (580, 906, and 1,304 X g), while holding the time variable constant, there was a statistically significant difference between platelet concentrations at the lowest speed compared to the 2 higher speeds (Table 3) . There were no signif -icant differences between total leukocyte, neutrophil, or monocyte concentrations among the rates. How -ever, when compared to 1,304 X g, 580 X g did yield a significantly lower lymphocyte concentration. When comparing the distribution of blood components at Figure 1 —Comparison of mean whole blood and mean platelet-rich plasma (PRP) platelet concentrations be -tween 5 groups. An asterisk (*) indicates a statistically significant difference between the mean whole blood and mean PRP product for that group. Bars repre -sent mean ± SD ( the number of syringes for groups 1 through 5 was 10, 11, 12, 12, and 11, respectively ). Figure 2 —Comparison of ratios between PRP platelet concentration and whole blood platelet concentrations. A platelet fold change of 1 means that those 2 concen -trations are equal. The mean of groups 1, 3, 4, and 5 fall above this line. Box and whisker plots represent mean ± 95% CI, with dots representing outliers. Unauthenticated | Downloaded 11/03/23 05:59 AM UTC4 the 2 centrifugation times (5 and 10 minutes), while holding the speed variable constant, there was no statistically significant difference between neutrophil concentrations. However, 5 minutes yielded a higher platelet concentration as well as higher total leuko -cyte, monocyte, and lymphocyte concentrations.

Question 167

Russell - 2024 - JAVMA - Persistent urinary incontinence in female Golden Retrievers following laser ablation of intramural ectopic ureters may be associated with the presence of historical urinary tract infection.pdf

Answer 167

Forty-two female Golden Retrievers presenting to the Queen’s Veterinary School Hospital, Univer -sity of Cambridge, undergoing CLA of uni- or bilat -eral ectopic ureters between July 2016 and July 2022 were retrospectively enrolled. All clients had con -sented to being contacted for the purpose of clinical research. One case was subsequently excluded, as not all relevant clinical data were recorded. Formal institutional approval was granted by the ethics and welfare committee at the Department of Veterinary Medicine, University of Cambridge (CR 494).Clinical records were reviewed for age at presen -tation, neuter status, weight, historical urinary tract infections prior to the procedure, and any medications being administered at the time of presentation. His -torical urinary tract infections were assessed as pres -ent or absent on the basis of review of clinical history from the referring veterinary surgeons, and all cases classified as having historical urinary tract infections had compatible urinalysis results in the history as a minimum. All patients had serum urea and creatinine (but not symmetric dimethylarginine) concentrations assessed either prior to or during referral, and all val -ues were within the reference range of the respective laboratories for all patients; thus, this information was not included in the data analysis. Diagnosis of ecto -pic ureters prior to cystoscopy was made using ab -dominal ultrasound. Reports of abdominal ultrasound scans performed by a European College of Veterinary Diagnostic Imaging (ECVDI)–certified veterinary ra -diologist, or an ECVDI resident under the supervision of an ECVDI-certified veterinary radiologist, were re -viewed, and urinary tract abnormalities were record -ed. Where ureteral dilation was subjectively described as absent but no specific measurement was recorded, a figure of 1 mm was used. Where the renal pelvis was described as normal but without a specific measure -ment, a figure of 1 mm was used for statistical analy -sis. Urinary continence was graded at the time of pre -sentation using a subjective 4-point grading system: 0, completely continent; 1, occasional dripping of urine; 2, intermittent dripping of urine with occasional pooling of urine; and 3, continuous dripping of urine with frequent pooling of urine.All cystoscopic procedures were performed by a single European College of Veterinary Surgeons (ECVS)–certified specialist in small animal surgery (LJO). Dogs were anesthetized and placed in dor -sal recumbency prior to the vulva being clipped and aseptically prepared. All dogs received IV anti -biosis at the time of the procedure with cefuroxime (Zinacef). A rigid 2.7- or 4-mm 30° cystoscope (Hopkins telescope; Karl Storz) was inserted retro -grade into the vestibule, and assessment of a per -sistent vestibulovaginal remnant (PVVR) was made prior to advancement into the urethra, with concur -rent pressurized irrigation using 0.9% saline solution. Grading of PVVRs was performed by a single opera -tor (LJO) at the time of cystoscopy as follows: grade 0, no PVVR; grade 1, thin band of tissue, commonly broken during the course of the procedure without use of the laser; grade 2, moderate band of tissue re -quiring use of the laser to transect; and grade 3, thick +/− wide band of tissue preventing access to the va -gina with the scope +/− partially dividing the vagina longitudinally. Cystoscopic examination was used to clarify the location of the openings of the ectopic ureter(s). The presence or absence of a distinct blad -der neck was assessed subjectively by a single op -erator (LJO) during cystoscopy. Bladder compliance Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 12/24/23 09:43 AM UTC 3was also assessed subjectively by the same operator (LJO) on the basis of the volume of fluid required to fill the bladder during cystoscopy. Urodynamics were not performed, and thus the exact volume of fluid required to distend the bladder was not recorded. Ureteral opening location was classified as grade 0 (trigone, nonectopic), grade 1 (bladder neck), grade 2 (proximal urethra), grade 3 (midurethra), or grade 4 (distal urethra or vestibule). For dogs from which it had not been possible to collect a cystocentesis urine sample (on the same day as or the day prior to CLA-EU), a urine sample was collected through the cystoscope operating channel soon after entry prior to administration of IV antibiotics. Urine collected via cystocentesis or cystoscopically was submitted for bacterial culture and sensitivity for all cases. Af -ter identification of the ectopic ureteral openings, a 0.025-inch guide wire (Weasel Wire; Infiniti Medical) was advanced into one or both ectopic ureteral ori -fices prior to the insertion of 4F ureteral catheter(s) (TigerTail ureteral catheter; Becton, Dickinson and Co) over the previously inserted guidewire(s). A 6-µm diode laser fiber (Ceralas Biolitec) at 8W was used through the instrument working channel to ab -late the medial wall of the iEU until the new opening was level with the normal ureter (unilateral cases) or until the openings were considered well positioned within the bladder trigone (bilateral cases). All cases were discharged with a 5-day course of amoxicillin clavulanate while awaiting the urine culture and an -timicrobial sensitivity results. Additional medication doses and duration were dispensed at the lead clini -cian’s discretion. Patients were discharged the same day, after recovery from the general anesthetic.All cases were routinely followed up by tele -phone, and owners were questioned on the degree of urinary continence achieved at 1 month postpro -cedure, as per hospital policy, using the same scor -ing system as was used at initial presentation. During this telephone call, owners were also questioned on any additional medication or antibiotic courses that had been prescribed and administered between dis -charge and the 1-month time point. Urinary conti -nence grade at this initial time point was allocated by one of the authors following a conversation with the owners to minimize variability if owners were allo -cating this grade without guidance. This information was retrieved for this study via review of the clini -cal notes and confirmed via a telephone call with the owners by the principal investigator (OLR) at a later time point. Longer term follow-up (> 10 weeks post -procedure) urinary continence scores and medica -tion history were available for all dogs but collected at nonstandardized time points by telephone, email, or follow-up appointments.Statistical analyses were performed using R ver -sion 4.3.0 for Mac (The R Project for Statistical Com -puting). Significance level was set at 0.05. Descriptive statistics were used to document findings, and non -normally distributed data were reported as median with range. Categorical variables were reported as numbers and percentages. Continuous variables (age in weeks, weight in kilograms, affected maximal ure -teral diameter in millimeters, and affected renal pelvis size in millimeters) were assessed for normality using both a frequency histogram and Shapiro-Wilk test.Continence at 1 month following the procedure was defined as achievement of grade 0. Univariate lo -gistic regression was initially performed where conti -nence (yes/no) was the dependent variable. Indepen -dent variables included for simple logistic regression were as follows: age (weeks), weight (kg), preproce -dure continence grade (0 to 3), previous history of urinary tract infections prior to the procedure (yes/no), positive urine culture at the time of the procedure (yes/no), unilateral or bilateral ectopic ureters (unilat -eral/bilateral), most severely affected ureter location (0 to 4), PVVR severity (0 to 3), presence of a distinct bladder neck (yes/no), reduced bladder compliance (yes/no), affected maximal ureteral diameter (mm), and affected renal pelvis size (mm). For bilateral ecto -pic ureters, all analysis was performed using the most severely affected ureter. Therefore, the following were used: the grade for the most severely ectopic ureter, maximal measurement of the most severely dilated ureter, and measurement of the most severely dilat -ed renal pelvis. Factors with a P value < .25 from the initial univariate logistic regression were selected for multivariant analysis. Multivariant analysis was per -formed using a backward stepwise logistic regression using Akaike information criterium to achieve the final best-fit model. The same procedure was repeated for the long-term follow-up urinary continence scores, with a continence grade of 0 again selected as repre -senting treatment success.ResultsForty-one entire female Golden Retrievers were included with a median age of 12 weeks (range, 10 to 80 weeks, with 38 dogs < 52 weeks old) and a median weight of 13.6 kg (range, 8.7 to 35.3 kg). All dogs had serum urea and creatinine measured either during or prior to referral, and the results for all dogs were within the reference range of the respective laborato -ry. Urinary continence grade at the time of the proce -dure (Table 1) was grade 0 in 0 (0%) dogs, grade 1 in 2 (4.8%) dogs, grade 2 in 23 (56.1%) dogs, and grade 3 in 16 (39.0%) dogs. Twelve (29.3%) dogs had bilateral ectopic ureters, and 29 (70.7%) had unilateral ecto -Table 1 —Total number of animals with each incontinence grade at each time point.Incontinence grade Number pre-CLA (%) Total cases 1 month post-CLA (%) Total cases long term post-CLA (%)0 0 (0%) 19 (46.3%) 26 (63.4%)1 2 (4.8%) 10 (24.3%) 9 (22.0%)2 23 (56.1%) 9 (22.0%) 4 (9.8%)3 16 (39%) 3 (7.3%) 2 (4.9%)CLA = Cystoscopic-guided laser ablation.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 12/24/23 09:43 AM UTC4 pic ureters, of which 22 (53.6%) were left sided and 7 (17.1%) were right sided. The location of the ectopic ureteral orifice was grade 1 in 2 (4.8%) dogs, grade 2 in 7 (17.1%) dogs, grade 3 in 17 (41.5%) dogs, and grade 4 in 15 (36.6%) dogs. Twenty (48.8%) dogs had a history of urinary tract infections, and 17 (41.5%) dogs had a positive urine culture at the time of the proce -dure. Eight of the 20 dogs that had a history of urinary tract infections also had a positive urine culture at the time of the procedure. Four dogs were receiving antibiotic medication at the time of presentation for CLA-EU, all of whom were classified as having a histo -ry of urinary tract infections, and urine culture results were negative in 3 of these dogs.A persistent PVVR was identified at cystoscopy in 30 (73.2%) dogs, of which 20 (48.8%) were grade 1, 7 (17.1%) were grade 2, and 3 (7.3%) were grade 3. Six (14.6%) dogs were noted as having no distinct bladder neck at surgery, and 10 (24.4%) dogs had subjectively reduced bladder compliance. Ectopic ureters had a median maximal diameter of 3.3 mm (range, 1 to 15 mm), and the renal pelvis on the side of the ectopic ureter had a median diameter of 4 mm (range, 0.6 to 25 mm).One month after CLA-EU, urinary continence grades (Table 1) were as follows: grade 0 in 19 (46.3%) dogs, grade 1 in 10 (24.4%) dogs, grade 2 in 9 (22.0%) dogs, and grade 3 in 3 (7.3%) dogs. Differ -ence between pre- and postprocedure urinary con -tinence was 0 grades in 8 dogs (19.5%), –1 grade in 14 (34.1%) dogs, –2 grades in 12 (29.2%) dogs, and –3 grades in 7 (17.1%) dogs. No dogs were receiving any form of medical management for urinary incon -tinence at this time.Age at the time of CLA, historical urinary tract infections prior to CLA, positive urine culture at the time of CLA, affected maximal ureteral diameter, presence of a discrete bladder neck, and reduced bladder compliance were carried forward into the initial multivariant analysis for short-term outcome. However, only increased age at the time of CLA ( P = .100), absence of urinary tract infections prior to CLA ( P = .018), increased maximal diameter of the affected ureter ( P = .043), and normal bladder com -pliance ( P = .054) were carried through into the final model ( P = .321; Table 2 ). Although the final best-fit model did not significantly correlate pre-/periop -erative factors and short-term urinary continence, 2 factors were individually found to be significant. Presence of urinary tract infections prior to CLA was associated with a decreased chance of achieving uri -nary continence with an estimated OR of 0.130 (95% CI, 0.020 to 0.621). Increased maximal diameter of the affected ureter was associated with an increased chance of achieving urinary continence with an esti -mated OR of 34.260 (95% CI, 1.813 to 2,143).At the time of longer term follow-up (median, 92 weeks; range, 10 to 253 weeks), 12 (29.3%) dogs were receiving phenylpropanolamine, 1 (2.5%) dog was re -ceiving oxybutynin, and 3 (7.3%) dogs had undergone surgical placement of an artificial urethral sphincter (AUS). Four (9.8%) dogs had been humanely eutha -nized, 3 dogs owing to severe recurrent urinary tract in -fections and 1 dog due to stranguria thought to be due to stricture formation secondary to AUS placement. Long-term follow-up urinary continence grades (Table 1) were as follows: grade 0 in 26 (63.4%) dogs, grade 1 in 10 (24.3%) dogs, grade 2 in 3 (7.3%) dogs, and grade 3 in 2 (4.9%) dogs. Of the 4 dogs that were euthanized, 2 were the continence grade 3 dogs and the other 2 were 2 of 3 dogs to have had an AUS placed. These latter 2 dogs had urinary continence grades of 1 and 2 prior to euthanasia. The difference from short-term to long-term urinary continence grade was as follows: +1 grade in 1 (2.4%) dog, 0 grades in 29 (70.7%) dogs, –1 grade in 7 (17.1%) dogs, –2 grades in 3 (7.3%) dogs, and –3 grades in 1 (2.4%) dog.For achievement of long-term continence, the following variables were carried into multivariant analysis: historical urinary tract infections prior to CLA ( P = .048), presence of a discrete bladder neck ( P = .125), and reduced bladder compliance ( P = .057). All were carried through into the final best-fit model (P = .765; Table 3 ). The best-fit model was not found Table 2 —Logistic regression best-fit model for short-term urinary continence.Factor Coefficient (SE) Z value Estimated OR (95% CI) P valueShort-term urinary continence –1.014 (1.022) –0.992 — .321Age at the time of CLA 0.046 (0.028) 1.647 1.047 (0.996–1.118) .100Presence of urinary tract infections –2.042 (0.861) –2.370 0.130 (0.020–0.621) .018* prior to CLAMost severely affected ureter maximal 3.534 (1.748) 2.022 34.260 (1.813–2143) .043* diameterReduced bladder compliance –1.915 (0.993) –1.929 0.147 (0.016–0.889) .054— = Not applicable.*Statistically significant.See Table 1 for remainder of key.Factor Coefficient (SE) Z value Estimated OR (95% CI) P valueLong-term continence 0.415 (1.388) 0.299 — .765Presence of urinary tract infections prior to CLA –1.752 (0.886) –1.997 0.173 (0.023–0.856) .048*Presence of a normal bladder neck 1.903 (1.240) 1.536 6.71 (0.750–151.6) .125Reduced bladder compliance –1.915 (1.006) –1.904 0.147 (0.016–0.963) .057See Tables 1 and 2 for key.Table 3 —Logistic regression best-fit model for long-term urinary continence final best-fit model.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 12/24/23 09:43 AM UTC 5to correlate significantly with the chance of achieving urinary continence. However, historical urinary tract infections prior to CLA were found to correlate with a reduced chance of achieving urinary continence with an OR of 0.173 (95% CI, 0.023 to 0.856).

Question 168

Sumner - 2023 - JSAP - Chylothorax secondary to subcutaneous cervical lipoma in a dog.pdf

Answer 168

tish Small Animal Veterinary Association. 718CASE REPORTChylothorax secondary to subcutaneous cervical lipoma in a dogS. M. Sumner1, E. J. Makrygiannis, J. Bartges and C. W. SchmiedtDepartment of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, Georgia, USA1Corresponding author email: sms0193@auburn.eduAn 8- year- old male neutered American English Coonhound was presented for a 2- day history of increased respiratory effort and rate with an occasional cough. Thoracic radiographs noted pleu -ral effusion, which was chylous based on cytological and chemical evaluation. The dog also had a 2- year history of a slow growing fatty mass in the right cervical region. A CT scan confirmed the large cervical fat attenuating mass extending from the base of the skull to the cranial thorax and right axillary region with compression of vascular structures. Severe bilateral effusion and sec -ondary pulmonary atelectasis was noted within the thoracic cavity. It was elected to surgically remove the cervical mass and place a PleuralPort within the thoracic cavity. The mass was diag -nosed as a lipoma and its removal led to rapid and complete resolution of chylothorax. Based on the literature search, this is the first case report of chylothorax secondary to a cervical mass or subcutaneous lipoma.Accepted: 21 April 2023; Published online: 26 May 2023INTRODUCTIONChylothorax is an accumulation of chylous fluid (chyle) within the pleural cavity. Commonly known causes include cardio -myopathy or cardiac structural abnormalities, mediastinal and heart base masses, heartworm disease, blastomycosis, jugular venous thrombosis, diaphragmatic hernia, pericardial effusion and trauma. However, clinically, the most common diagnosis is idiopathic chylothorax (Fossum et al. 1986 , Birchard & Fos -sum 1987 , Birchard et al. 1995 , Fossum et al. 2004 ). Databases including Medline (PubMed), Academic Search Premier, Bio -medical Index, Veterinary Source and the Institution Library Catalogue were searched using the Academic Institution Multi- Search tool and the following keywords on February 2, 2023: canine or dog, chylothorax, mass, subcutaneous and neoplasia. Textbooks consulted include Veterinary Surgery Small Animal second edition by Tobias and Johnson 2018 , Small Animal Sur -gery fourth edition by Fossum et al. (2013 ) and Textbook of Veterinary Internal Medicine eighth edition by Ettinger et al. (2017 ). No other reports of chylothorax secondary to a cervical mass or subcutaneous lipoma were found doing these searches. The purpose of this report is to describe a case of chylothorax secondary to a cervical subcutaneous lipoma.CASE HISTORYAn 8- year- old male, neutered American English Coonhound was presented to his primary care veterinarian for a 2- day his -tory of increased respiratory rate, increased respiratory effort and an occasional cough. Thoracic radiographs noted pleural effu -sion ( Fig. 1) and he was referred to a tertiary emergency service clinic. The dog had a 1- year history of an elevated ALP and a two- and- a- half- year history of a slow growing fatty mass in the right cervical region.On presentation to the emergency clinic, the dog was bright, alert and responsive. The dog was normothermic, tachycardic (heart rate 160– 180 bpm) and panting. Cardiothoracic auscul -tation revealed absent lung sounds ventrally and muffled heart sounds. Mucous membranes were injected and moist with a nor -mal capillary refill time. Femoral pulses were bounding, and the abdomen was tense. A large, firm mass was present in the right cervical area extending from the cranium to the scapula, cranial thorax and right axillary region ( Fig. 2). The remainder of the physical exam was unremarkable.Abbreviated thoracic and abdominal ultrasound noted mod -erate pleural effusion and no abdominal effusion. Pulse oxim -etry was 93% on room air and 98% with supplemental oxygen. Chylothorax secondary to a lipoma in a dogJournal of Small Animal Practice • Vol 64 • November 2023 • © 2023 British Small Animal Veterinary Association. 719 A therapeutic right sided thoracocentesis was made in which 470 mL of fluid was removed. The effusion was noted to be milk white and opaque. Fluid cytology and paired triglycerides (serum triglycerides = 62 mg/dL, reference interval 29– 133 mg/dL; pleural effusion triglycerides = 704 mg/dL, no reference inter -val) were consistent with chylous effusion, and a concomitant neutrophilic inflammation (83% non- degenerate neutrophils) was interpreted to suggest chronicity. A complete blood count and chemistry panel noted a mild neutrophilia (9.374 × 103/μL, reference interval 2.7– 8.5 × 103/μL), elevated ALP (838 U/L and reference interval 13– 103 U/L) and low BUN (6 mg/dL and ref -erence interval 9– 28 mg/dL). A fine needle aspirate of the cer -vical mass noted low cellularity with rare lipid consistent with lipoma or non- exfoliative lesion. A second right sided thoraco -centesis was made under the anaesthetic episode for CT due to respiratory compromise. A total of 600 mL of fluid was removed. A contrast CT scan of the neck, thorax and abdomen was made confirming severe bilateral pleural effusion with secondary pul -monary atelectasis and a right cervical fat attenuating mass (at least 26.0 × 24.1 cm2) extending from the base of the skull to the thoracic inlet and right axillary region with severe compres -sion of the right external jugular vein. The right internal jugular vein could not be identified. A large mass effect was present with severe leftward deviation of the cervical trachea, oesophagus, carotid arteries and adjacent midline structures. The fat mass also extended lateral and medial to the right scapula which was dis -placed laterally ( Fig. 3). The liver was moderately enlarged with rounded margins.Based on these diagnostics, the cause of chylothorax in this dog was thought to be either primary idiopathic chylothorax or secondary to the right cervical mass causing vascular and lym -phatic occlusion. It was elected to proceed with surgical removal of the right cervical mass and placement of an in dwelling tho -racostomy catheter (PleuralPort, Norfolk Vet Products). It was discussed with the owner that additional surgery (thoracic duct ligation, cysterna chyle ablation and pericardectomy) may be considered in the future if the chylothorax did not resolve fol -lowing mass removal.A mini thoracotomy was made on the right ventral thorax at the eighth intercostal space. Six hundred millilitres of pink, opaque fluid was removed from the pleural space via suction. A Pleural -Port catheter was placed within the thoracotomy site, tunnelled subcutaneously to the port site, and secured subcutaneously with FIG 1. Thoracic radiographs taken at the time of presentation to the primary care veterinarian depicting bilateral pleural effusionFIG 2. Preoperative images of an 8- year- old male, neutered American English Coonhound with a large right cervical mass extending from the base of the skull to the scapula, cranial thorax, and axillary region (A, B). The same dog postoperatively, following mass removal (C, D) 17485827, 2023, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13625 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 LicenseS. M. Sumner et al.Journal of Small Animal Practice • Vol 64 • November 2023 • © 2023 British Small Animal Veterinary Association. 720suture. Negative pressure was obtained within the thoracic cavity via aspiration of the PleuralPort. A horizontal skin incision was then made over the lipomatous cervical mass. The mass was mar -ginally excised in routine fashion and a Jackson- Pratt drain (Car -dinal Health) was placed within the subcutaneous site. Surgery was uneventful and the dog recovered smoothly. The total mass size was 31 × 27 × 16 cm with a weight of 6.8 kg (15 lbs). Histopa -thology findings included an ill- defined mass composed of mature adipocytes amidst a fine fibrovascular stroma. Multi- focally, there were large areas of eosinophilic necrotic debris that are variably mineralised admixed with haemorrhage, cholesterol clefts, small numbers of lymphocytes and plasma cells, as well as small num -bers of haemosiderin- and haematoidin- laden macrophages. These findings are consistent with a lipoma with areas of necrosis.Post- operative pain was managed with methadone (methadone hydrochloride injection, Mylan Pharmaceuticals; 0.1 mg/kg IV) administered every 4 hours during the initial 12 hours and carpro -fen (Rimadyl, Zoetis; 1.7 mg/kg PO) administered every 12 hours for 8 days. Gabapentin (Neurontin, Ascend; 14 mg/kg PO) administered every 8 hours for 14 days was prescribed for addi -tional pain control and sedation. A cold compress was applied to the incisions four times per day for 3 days. The Jackson- Pratt drain was emptied every 4 hours. Drain production was 7.4 mL/kg/day over the first 24 hours. Drain production steadily decreased to 1.7 mL/kg/day by day four and was removed. No respiratory or incisional complications were noted in the immediate post- operative period. A soft padded chest and neck bandage was placed following draining removal. The pleural effusion was mini -mal and static at the time of discharge 5 days post- postoperatively. No additional thoracocentesis was needed post- operatively based on patient respiratory status and abbreviated thoracic ultrasounds. The dog was sent home with the PleuralPort in place, gabapentin and carprofen for pain, and with instruction for 2 weeks of activ -ity restriction and respiratory watch. The owners were instructed to remove the chest and neck bandage after 5 days.At the 3- weeks follow- up appointment, the owner reported the dog was doing well at home with a stable respiratory rate under 30 breaths per minute at rest and improved energy lev -els. Vitals were normal at this visit. No free fluid was noted on abbreviated thoracic ultrasound or thoracic radiographs. A second recheck was made at 5 weeks and the dog was still doing well. No concerns were noted by the owner and no aspirations of the PleuralPort were needed. Abbreviated thoracic ultrasound and thoracic radiographs again confirmed no free fluid present. The PleuralPort was removed 9 weeks post- operatively per the owner’s preference to avoid long- term potential infection risk.

Question 169

Monnet - 2023 - VETSURG - Influence of conventional versus unidirectional barbed suture on leakage pressures in canine vesicourethral anastomosis - An ex-vivo study.pdf

Answer 169

Urinary bladder and pelvic urethra were obtained imme-diately after euthanasia from 24 fresh, intact male Walkerhound cadavers, which had been euthanatized for rea-sons unrelated to the study (Colorado State UniversityIACUC no. 17-7102A). Specimens were harvested andinspected for anatomical defects, and any residual urinewas drained. All VUA and pressure testing procedureswere conducted within 6 hours of euthanasia. Betweensample collection and pressure testing, specimens wereseparately preserved in containers filled with sterilesaline (0.9% NaCl) (0.9% sodium chloride, USP, Hospira,Inc., Lake Forest, Illinois) and stored at 2/C14C.Before VUA, careful excision of the perivesical andperiprostatic fat was performed. Both ureters were ligatedusing 3-0 Glycomer 631 (Biosyn, Medtronic, Minneapolis,Minnesota). The prostate was removed after transection ofthe urethra with Metzembaum scissors as close as possi-ble to the gland. The 24 samples were randomly dividedinto two groups for VUA according to the suturing tech-nique used: unidirectional barbed suture (UBS) group orconventional suture (C) group. All the samples wereplaced in a container and blindly pulled out of the con-tainer. The first sample was entered in the C group andthe subsequent samples were entered alternatively in theUBS or the C group. Leakage pressure, number of suturebites needed for anastomosis construction, site of leakage,and anastomotic time were recorded. All the anastomosisand pressure testing were performed by a veterinarianwith extensive experience performing VUA under thesupervision of a board-certified surgeon.2.1 |Surgical techniqueFor both groups, VUA was performed ex-vivo using stan-dard surgical instruments by a veterinarian under thesupervision of a board-certified surgeon. The veterinarianunderwent extensive training to perform VUA beforecompletion of the study. A 10 Fr. urethral catheter(Kendall Urethral Catheter; Medtronic, Minneapolis) wasinserted into the urethra and advanced into the bladder.The bladder and the urethra were stabilized on a styro-foam block with needles avoiding tension on the sutureline. An end-to-end anastomosis was performed with twohemi-circumferential simple continuous suture linesstarting at 3 and 9 o'clock. Sutures were placed 2 mmfrom the edges and 2 mm from each other.For UBS groups, VUA was completed using unidirec-tional barbed 4 –0G l y c o m e r6 3 1600(Vloc 90; Medtronic,Minneapolis) sutures with a V 20 26 mm ½circle taper nee-dle. For the C group, VUA was completed using 4-0 Glyco-mer 631 (Biosyn; Medtronic, Minneapolis) sutures with aCV 23 17 mm ½circle taper needle. A simple continuousappositional suture pattern was used for both groups tocomplete the VUA. The VUA was completed starting withthe dorsal suture line. The sutures were placed from outsideto inside in the bladder and from inside to out in the ure-thra. After the dorsal portion of the anastomosis was com-pleted, a 10 Fr. catheter was inserted in the urethra into thebladder to complete the ventral part of the anastomosis.Anastomotic time (min) and the number of suture bitesneeded for each construct were recorded.2.2 |Pressure testingSamples were immediately tested after completion ofthe anastomosis following a previously published tech-nique.14,15An 11 cm long, 8 Fr. introducer (SuperArrow-Flex Introducer Set; Arrow International, Inc.,Reading, Pennsylvania) was inserted in the urethra andsecured with two circumferential sutures using 3-0 Glyco-mer 631 (Biosyn, Medtronic, Minneapolis). A micro-tippressure transducer (Mikro-Tip Catheter Pressure Trans-ducer; Miller instrument Inc., Houston, Texas) wasinserted via the introducer into the lumen of the bladder.To record pressure, the transducer was linked to a dataacquisition system (LabChart Pro v8.1.13, ADInstrumentsPty Ltd., Australia). A colored saline solution (1:500parts) with Evans blue (Evans Blue; Fisher Scientific, FairLawns, New Jersey) was infused at a rate of 1 ml/minwith an infusion pump (Harvard Apparatus; Holliston,Massachusetts) into the injection port of the introducer.The anastomosis was visually assessed for leakage duringinjection and pressure recording.MONNET and HAFEZ 717 1532950x, 2023, 5, Leakage pressure (mmHg), as well as the site of leak-age, were recorded. Leakage pressure was defined as thepressure at which the colored-saline solution was firstnoticed to leak from the anastomosis. The leakage loca-tion was noted to be either dorsally, ventrally, or laterally(knots or loop).2.3 |Statistical analysisSuturing time, leakage pressure, and the number ofsuture bites needed to make the constructs was reportedas median and range. The Kruskal-Wallis test was usedto compare these variables between the UBS and Cgroups. The distribution of the leakage site was comparedwith a Chi-square analysis between the UBS and Cgroups. A linear regression analysis was performed toevaluate the correlation between the number of suturebites and the leakage pressure. Statistical testing wasdone with the commercially available statistical program(JMP, 15, SAS, Inc., 2016, Cary, North Carolina). Thelevel of significance was set at p< .05.3|RESULTSA total of 12 samples were entered into each group. TheVUA was successfully performed in all samples in bothgroups. On macroscopic evaluation, all constructs werepatent, and no urethral narrowing was observed in anysample after completion of the anastomosis as the intro-ducer could easily pass through the anastomotic site inboth groups. No evidence of tissue tearing, knot failure,or suture breakage was noticed during pressure testing ofthe constructs in both groups.The median leakage pressure was 8.60 mmHg (range:5.00 –17.20 mmHg) for the UBS group and 11.70 mmHg(range: 6.00 –18.50 mmHg) for the C group ( p=.236)(Figure1). The median number of suture bites was14 (range:11 –27) for the UBS group and 19 (range:17 –28)for the C group ( p=.012). Leakage occurred betweensuture bites laterally in three cases in each group andventrally in six cases in each group. The distribution ofthe leakage site was not significantly different betweenUBS and C groups ( p=1.00). The correlation coefficientbetween the number of suture bites and the leakage pres-sure was 0.06 ( p=.430) for the UBS group and 0.006(p=.810) for the C group. The median suturing timewas 12.70 minutes (range: 7.50 –16.10 min) for the UBSgroup and 17.30 minutes (range: 14.00 –21.30 min) for theC group ( p< .0002) (Figure2).4

Question 170

Buote - 2023 - VETSURG - Laparoscopic vertical sleeve gastrectomy in felines - A cadaveric feasibility study and experimental case series in two cats.pdf

Answer 170

2.1 |Sample populationThe feasibility of performing LVSG in a feline model wastested on ten apparently healthy adult (>1 year old)feline specimens. These cats were obtained from localanimal shelters after humane euthanasia by IV adminis-tration of pentobarbital sodium for reasons unrelated tothe study. An IACUC exemption was granted by theIACUC committee of after review of the cadaver studyprotocol. After euthanasia, cadavers were refrigerated at4/C14C for 24 to 36 hours and then stored at room tempera-ture for 4 to 6 hours before performing the surgicalprocedure.Following euthanasia, the animals were stored at4/C14Ca n dt h e nb r o u g h tu pt or o o mt e m p e r a t u r ef o ru s e .As part of a pilot project investigating LVSG for weightloss and glucose regulation ,t w oh e a l t h ya d u l tf e l i n e swere obtained from a commercial vendor to test thesafety of the proposed tec hnique. The surgical andpostoperative protocol was approved for use in a livepatient model by the IACUC committee of CornellUniversity College of Veterinary Medicine after review(protocol # 2021 –0036).2.2 |Phase 1: Cadaveric experimentalstudy2.2.1 | Cannula placementThree iterations of cannula placement locations evolvedduring refinement of the procedure. The first techniqueutilized four commercially available cannulas (GeniportPyramidal tip trocar and cannula system, Winter Park,FL, USA) placed in the following locations: 5 mm cannu-las at the umbilicus, right and left paramedian (2 cm cra-nial to the umbilicus and 5 cm lateral) and one 11 mmcannula cranial to the pubis. The second technique uti-lized a SILS (SILS port, Covidien/Medtronic, Minneapo-lis, MN, USA) port placed in the umbilical region with anadditional commercially available 5 mm cannula at theleft and right paramedian position. Due to difficulty withabdominal working space, instrument collisions andinadvertent cannula removal, 5 and 11 mm customized3D printed cannulas (3DPCs) with shortened shaftlengths (3 and 3.2 cm, respectively) were created andemployed in the third iteration.11,12Silicone valves fromthe 5 mm Geniport were used with 5 mm 3DPC andshrouds from Covidien Thoracoport 11.5 mm cannulas(Covidien/Medtronic, Minneapolis, MN, USA) were usedfor the 11.5 mm 3DPC. This final cannula placementtechnique utilized 5 mm cannulas at the following loca-tions: umbilicus, right and left paramedian and left cau-dal abdomen and one 11.5 mm cannula cranial to thepubis (Figure 1). A 5 mm laparoscopic Cobra liver retrac-tor (Laparoscopic Cobra liver retractor, Bariatric Solu-tions International, Switzerland) was placed through asmall incision caudal to the xiphoid without a port whennecessary for visualization of the fundus.2.2.2 | Laparoscopic vertical sleevegastrectomy procedureThe LVSG technique was developed from publishedprocedures,2and coinvestigator (GD) experience. All lap-aroscopic vertical sleeve gastrectomy (LVSG) procedureswere performed by the primary author (NB) with exten-sive experience in minimally invasive surgery, includingover 15 years of laparoscopic clinical practice. Animals wereplaced in dorsal recumbency, and 5 mm 3DPC's placed asdescribed above via Hasson technique. The abdomen wasinsufflated to 8 mm Hg with CO 2gas, and a brief exploreperformed. The 11.5 mm 3DPC was then placed cranial tothe pubis on midline for insertion of the laparoscopic stapler(Endo GIA, Ultra Universal Stapler, 60 mm cartridge length,Covidien/Medtronic, Minneapolis, MN, USA) (Figure 2).BUOTE ET AL . 879 1532950x, 2023, 6, Al i v e rr e t r a c t o rw a sp l a c e dc a u d a lt ot h ex i p h o i dt h r o u g ha5m ms t a bi n c i s i o nu n d e rv i s u a l i z a t i o ni fn e c e s s a r y .O n c ea l lcannulas were in place, a laparoscopic scissor was used todissect free the greater omentum from the greater curvatureof the stomach. Care was taken t ot r a n s e c ta l la t t a c h m e n t sbetween the stomach and spleen, and a laparoscopic mono-polar cautery instrument was used to dissect the left triangu-lar ligament attaching the left lateral liver lobe from thediaphragm. A flexible ruler was placed through a lateral can-nula and placed at the pylorus and across the antrum tomeasure the distance from the pylorus to a point beyond thevisible branches of the left gastr ic vessels on the lesser curva-ture (Figure 3). The felt stick of a sterile skin marker wasplaced through a lateral cannula and used to mark the pro-posed gastrectomy path (Figure 4).Once all attachments were di ssected, the EndoGIA sta-pler with a 60 mm purple (3 –4m m o p e n s t a p l e h e i g h t ,SKU EGIA60AMT) or blue (3.5 mm open staple height,SKU 030458) cartridge was pl aced approximately 4 cm oradto the pylorus along the greater curvature along the previ-ously marked path. Staple cartridge heights were deter-mined by known stomach thickness and previous staplingrecommendations for vert ical sleeve gastrectomy.14-16Theproposed staple line (Figure 5)w a sb a s e do f ft h eh u m a nLVSG procedure.2The first staple line was created by firingthe Endo GIA stapler from the caudal border of the greatercurvature, a 32 French orogastric tube was then placed intothe stomach, positioning it wi thin the remaining (medial)stomach near the pylorus (Figure 6). The orogastric tubewas then used as a guide for the remaining staple firesplaced cranially. One to two m ore staple cartridges werefired to remove the remaining greater curvature lateral tothe orogastric tube (Figure 7). The orogastric tube was theninjected with a methylene bl ue saline mixture (100 ml ofwater with 1 ml methylene blue) while the pylorus wasclamped with a spent Endo GIA cartridge to watch for anyleakage. The orogastric tube ac ted as the cranial barrier inthe lower esophageal sphincter to reduce loss of fluid intothe esophagus. The transected stomach was placed within alaparoscopic retrieval bag and removed through the caudalmidline abdominal cannula.2.2.3 | Cadaveric procedure outcome dataThe surgical procedure time was recorded for every pro-cedure from the first cannula incision until the resectedstomach was removed from the abdomen. The type andnumber of endoscopic staple devices was recorded. Theweight of the resected stomach was recorded. The abdo-men was then opened, and the remaining stomachremoved to acquire a weight, measure the thickness ofthe stomach and to assess the gastrectomy line and stapleplacement. The thickness of the stomach was an averageof measurements from serosa-to-serosa 1 cm medial tothe staple line in three locations with electronic calipersFIGURE 2 Photograph of the placement of the 3DPC incadaver 10. Black silicon cannula shroud indicates the 11.5 mmcannulaFIGURE 1 Diagram of final cannula placement forlaparoscopic partial gastrectomy880 BUOTE ET AL . 1532950x, 2023, 6, (Pittsburgh automotive digital caliper, Camarillo, CA,USA). The subjective appropriateness of the gastrectomyline was assessed for the following features: perceived ste-nosis from the incisura angularis to the gastrectomy line(measurement <2 cm), visual evidence of staple mala-lignment and leak test results. Regarding the perceivedstenosis this was a subjective decision based on clinicalsurgical practice of the authors. Descriptive data are pre-sented as mean or median and range depending onnormality.2.2.4 | Phase II live patient surgicalprocedureTwo cats were obtained to assess the safety and postoper-ative outcomes of LVSG before a larger study on theeffects of LVSG on weight and glucose regulation werepursued. One cat was a castrated male, and one cat was aspayed female to account for known variation inFIGURE 3 Intra-abdominalphotograph of flexible ruler placed atpylorus overlying the antrum and lessercurvature. Vascular bundle on lessercurvature is marked with yellow starFIGURE 4 Intra-abdominalphotograph of sterile marker being usedto mark proposed gastrectomy pathFIGURE 5 Diagram of proposed gastrectomy path for LVSGBUOTE ET AL . 881 1532950x, 2023, 6, metabolism between the sexes.8,17Initial physical exami-nation and baseline blood work (complete blood count,chemistry) to ensure cats' health was performed at theinitiation of the study. Cats were group housed at theCornell University East C ampus Research facility andacclimated to the research facility for two weeks. Theywere housed at a temperature of 21/C14Ca n dg i v e n12 hours of light and 12 hours of darkness. During thistime frame, the cats were given free access to waterand fed a commercial dry diet (Hill's Science DietAdult 7 +Cat Food) based on resting energy require-ments (RER) twice daily and were socialized daily dur-ing their feeding.Once cats were eligible for surgery, baseline blood workwas performed including meas urement of fasting glucose,insulin, and an oral glucose tolerance test (OGTT).16Allsamples were frozen to be run simultaneously at a later dateto decrease any variation with machine calibration.Two days before the surgical procedure, the diet waschanged to a canned version and food was withheld for12 hours prior to anesthesia. Cats were anesthetized fol-lowing all IACUC and hospital guidelines commensuratefor human care. The anesthetic protocol was determinedby the board-certified anesthesiologist on duty the day ofsurgery. The LVSG procedure was performed asdescribed above (Videos S1 –S3). Patients recovered in theintensive care unit for two days postoperatively. Postoper-ative care included intravenous isotonic crystalloid fluids(Plasma-lyte A, Baxter Healthcare Corp, Deerfield, IL,USA) at 60 ml/kg/day rate, buprenorphine (Buprenex,PAR Pharmaceutical, Chestnut Ridge, NY, USA) at0.02 mg/kg IV as needed to keep Colorado Acute FelineFIGURE 6 Intra-abdominalphotograph after first EndoGIA stapleline starting at the fundusFIGURE 7 Intra-abdominal photograph ofresected fundus after final staple line882 BUOTE ET AL . 1532950x, 2023, 6, pain scores,18below 1 (assessed every 6 h) and pantopra-zole 1 mg/kg IV (Sandoz Inc., East Hanover, NJ, USA)once daily. After two days, patients were transferred toEast Campus Research facility and continued to receiveomeprazole 1 mg/kg (compounded, Cornell UniversityHospital for Animals pharmacy) orally once daily for onemonth. The cats were housed in the same room but sepa-rated to allow for quantification of appetite. They wereallowed full access to each other and socialized multipletimes a day. Three times a day for the first 2 months andthen twice daily thereafter, the cats were assessed forany discomfort or gastrointestinal distress and weeklythey were weighed. Recheck OGTT, complete bloodcount and serum chemistries were performed at 1 monthand 6 months postoperatively.2.2.5 | Live patient surgical outcome dataThe surgical procedure time was recorded for live proce-dures from the first cannula incision until the resectedstomach was removed from the abdomen. The type andnumber of endoscopic staple devices was recorded. Theresults of the leak test and the weight of the resectedstomach was recorded. Any intraoperative or postopera-tive complications were noted. Postoperative outcomessuch as weekly weights and any gastrointestinal signswere followed for both cats for 6 months.3|RESULTS3.1 |Phase 1: Cadaveric experimentalstudyTen apparently healthy domestic shorthair felinecadavers were used in the study. All animals appeared tobe adults (>1 year), but exact ages were not provided.The mean weight was 5.49 kg (median 5.45, range 3.2 –7.1). The mean body condition score was 6.4 (median6, range 5 –8). There were six female animals and fourmale animals. No animal had grossly evident gastricdisease.3.1.1 | Cadaveric procedure outcomesThe first two cases utilized the first iteration of cannulaplacement location, the third and fourth cases utilizedthe second iteration of cannula placement location, andthe remaining six cases used the third iteration of can-nula placement location. Successful partial gastrectomywas performed in nine of 10 specimens (90%). The firstcase required more than three staple lines due to inap-propriate placement of the staple device and a fourth wasnot used to complete the procedure.The mean surgical time for all procedures was110.4 minutes (median =114.5, range 80 –145 min). Themean number of staple cartridges used to complete gas-trectomy was 2.5 (median =2.5, range 2 –3). The break-down of the different staple cartridge sizes and lengthscan be found in Table 1. Mean weight of resected stom-ach was 10 g (median =10, range 9 –11g) and the meanpercentage of the total stomach resected by weight was27.6% (median =30%, range 27% –35%). The mean stom-ach thickness measured from the in-situ stomach was2.53 mm (median =2.55 mm, range 2.0 –3.1 mm).When the appropriateness of the gastrectomy wasevaluated postoperatively, eight of 10 (80%) of the gas-trectomies appeared visually acceptable. The stomachs inthe second and fourth subjects were observed to be dis-sected too close to the lesser curvature ( ≤1.5 cm) creatinga potential stenosis. The first two cases did not utilize theorogastric tube to help with spacing from the loweresophageal sphincter and lesser curvature. Specific tech-nique refinements were made with regards to angle ofgastric resection and cannula placement after the fourthcase. Only one case (case 2) had evidence of the staplemalalignment at the point where the second and thirdstaple lines intersected but leakage was not observed atthis site. Leak testing was performed in the last 8/10 spec-imens and no obvious leaks were noted.3.1.2 | Phase II live patient surgicalprocedure outcomesMinimum database blood work performed on both catsat the beginning of the study revealed no clinicalTABLE 1 Staple number and type used during refinement oflaparoscopic vertical sleeve gastrectomy procedure. All cartridgeswere Covidien EndoGIAProcedure # Staple # Blue 60S Purple 60S Tan 30S13 3 0 023 3 0 032 2 0 043 2 0 153 2 0 163 2 0 172 2 0 082 0 1 192 0 1 110 2 0 1 1BUOTE ET AL . 883 1532950x, 2023, 6, abnormalities. Both cats underwent successful weightinduction with increases of 1.5 and 1.7 times their origi-nal weight (49% and 73% bodyweight gain) and increasesin body condition score. Both cats were approximately9 months at the time of the procedure. Patients werepremedicated and induced under the direction of board-certified anesthesiologists following standard of careprocedures. Anesthesia was maintained with isofluranein oxygen. Perioperative antibiotic consisting of cefazolin(22 mg/kg IV; Apotex, Richmond Hill, ON, Canada) wasadministered at anesthesia induction, then every90 minutes until completion of surgery. Both procedureswere successfully performed without the need for conver-sion. Slight modifications to the procedure occurred inboth procedures. Patient 1 modification included the useof the 5 mm Geniport Pyramidal tip trocar and cannulasystem for insufflation at the umbilicus when the 3DPCinsufflation attachment site broke. Patient 2 modificationsincluded the use of a Covidien Versaport 12 mm cannula(Covidien/Medtronic, Minneapolis, MN, USA) for staplermanipulation and use of the left caudal abdominal portas the site for stapler entrance instead of a prepubic port.The LigaSure (Covidien/Medtronic, Minneapolis, MN,USA) was used for dissection of omental attachments inboth patients.Neither patient required the use of the laparoscopicCobra liver retractor for appropriate visualization. Thesurgical procedure time for patient 1 was 134 minutesand for patient 2 was 96 minutes (mean =115 min). TwoCovidien EndoGIA purple staple cartridges with TriSta-ple technology were utilized to resect the fundus for eachpatient. Both patients had negative leak tests and nointraoperative surgical or anesthetic complications wereencountered. The weight of the resected stomach forpatient 1 was 9.3 g and for patient 2 was 6.7 g. Theresected stomach was placed in 10% formalin for histo-pathological review at a later date. Patients were housedin the intensive care unit for monitoring for two dayspostoperatively and provided pain medication (Buprenex0.02 mg/kg IV q. 8 h), intravenous fluids (PlasmaLyte60 ml/kg/day), cerenia (1 mg/kg IV q. 24 h) and panto-prazole (1 mg/kg IV q. 24 h). After day two patients weremoved to a step-down ward for an additional two days.Both patients were provided oral pain medication(Buprenex) as needed every 8 hours for three more daysand omeprazole daily for one month. Staff monitored thepatients for signs of abdominal pain, fever, distension ofthe abdomen, vomiting, nausea and inappetence. Neitherpatient required rescue pain medication during the post-operative period and neither exhibited any gastrointesti-nal distress (no vomiting, diarrhea, or anorexia). Noevidence of gastric dehiscence occurred during the2-week recovery period, and all incision sites healedroutinely. Both cats were closely monitored for 3 monthspostoperatively before being adopted. The cats lost 21%and 24% bodyweight in kg and BCS returned to presurgi-cal levels over the course of 3 months. At recheck6 months postoperatively both were doing clinically wellwith no gastrointestinal signs or concerns reported bytheir new owners.4

Question 171

Kalmukov - 2023 - JSAP - Internal fixation of canine coccygeal vertebral fractures - Four cases (2018-2022).pdf

Answer 171

Study design & medical record searchWe planned a retrospective case series. The medical records of dogs from a single institution were reviewed on RxWorks® Vet -erinary Software v5.9 by a single operator using keywords ‘tail fracture’, ‘caudal vertebral’ and ‘coccygeal vertebral’ between July 1, 2012 and July 1, 2022 were reviewed. A second operator inde -pendently searched the financial records on the same software using the same keywords for created invoices in the same time period.Data extractedThe recorded data included signalment, aetiology, clinical pre -sentation, location and fracture configuration, fixation method and complications. Complications were categorised as previously reported by Cook et al. (2010 ).T reatment of complications was recorded as part of the data collection.Short- term follow- up was at 6 to 8 weeks postoperatively and consisted of clinical evaluation and radiography. Bone healing was assessed by radiography on orthogonal views using a pre -viously described classification system (Hammer et al. 1985 ). Further follow- up was assessed by contacting owners over the telephone. An adapted questionnaire (Appendix S1) from the Liverpool Osteoarthritis in Dogs owner questionnaire and the Helsinki Chronic Pain Index were used.Surgical techniqueDogs were premedicated with 0.2 mg/kg of methadone (Comfor -tan®; Dechra, Skipton, UK) and 0.005 mg/kg of dexmedetomi -dine (Dexdomitor®; Vetoquinol, Espoo, Finland) intravenously (iv). Propofol (PropoFlo™; Zoetis, Leatherhead, UK) was used for anaesthetic induction, followed by endotracheal intubation for anaesthetic maintenance with isoflurane in 100% oxygen. Perioperative cefuroxime (22 mg/kg; Zinacef®, GSK, Uxbridge, UK) was administered iv 30 minutes before the first incision and repeated every 90 minutes until completion of surgery. The tail was clipped and antiseptically prepared using chlorhexidine (HiBiSCRUB®; Molnlycke Healthcare, Oldham Lancashire, UK). A four- quadrant ring block with bupivacaine (max dose 1 mg/kg; Marcain Polyamp®, AstraZeneca, Cambridge, UK) was performed at the tail base.The patient was placed in lateral recumbency. The skin was incised laterally over the fracture site extending to the adjacent vertebral bodies. Blunt dissection between dorsal and ventral lat -eral sacrocaudal muscles allowed exposure of the lateral aspect of the vertebral body. Articular surfaces were marked with 25G hypodermic needles. The fracture was reduced using bone- holding forceps and a selected plate was applied to the lateral sur -face of the vertebral body ( Fig 1). Soft tissue closure was routine with polydioxanone (PDS™II, Ethicon®, Birkenhead, UK) used FIG 1. 25G hypodermic needles are used to mark the intervertebral spaces before implant placement. Fracture reduction (a, b) and stabilisation (c)A B C 17485827, 2023, 10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13644 by Vetagro Sup Aef, Wiley Online Library on [19/10/2023]. 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 LicenseI. A. Kalmukov et al.Journal of Small Animal Practice • Vol 64 • October 2023 • © 2023 British Small Animal Veterinary Association. 644for subcutaneous tissues and nylon (Ethilon™, Ethicon®, Birken -head, UK) for the skin. Postoperative alignment, apposition and implant placement were assessed by radiography (orthogonal views).Postoperative careWooden tongue depressors (Universal®, London, UK) and adhe -sive tape (Tensoplast®, BSN Medical, Hull, UK) were used to create a splint ( Fig 2). This was applied to minimise movement and was changed every week for 4 weeks. Postoperative analge -sia included the administration of iv methadone (Comfortan®, Dechra, Skipton, UK) titrated down to the patient’s require -ments. All patients were discharged the following day with oral non- steroidal anti- inflammatory medication. Antimicrobial therapy was prescribed based on the surgeon’s preference. The exercise was restricted to controlled lead walks for 6 weeks and all dogs were discharged with an Elizabethan collar.QuestionnaireOwners were asked to complete an adapted functional question -naire regarding their dog’s activity and comfort levels. It com -prised 13 questions broadly divided into three categories to assess the function of the tail, description of pain and current medica -tion. Eight questions, each scored on a five- point scale (none, mild, moderate, severe or extreme), were used to evaluate each dog’s function and mobility of the tail (Appendix S1). Assess -ment of the dog’s comfort levels was based on the general behav -iour and activity levels and included four questions scored on a five- or six- point scale.RESULTSSearch results of the medical records identified four dogs. The same patients were identified through the search of the financial records. Signalment can be reviewed in Table 1. Three dogs were male entire and one female entire with a mean bodyweight of 25.43 kg (range 8.6 to 42.2 kg). In all cases, the cause of injury was suspected to be traumatic. In dog 2 the injury occurred after jumping over steps, in dog 3 after chasing a deer and in the remaining two dogs the trauma was unknown. The median time to presentation was 16.5 days (range 10 to 28 days). The clinical presentation is summarised in Table 1.The localisation of the fracture was in the caudal vertebral body numbers 9, 10, 17 and 15 in dogs 1, 2, 3 and 4, respectively. The fracture configuration was with comminution in dog 2 and dog 4 and simple mid- body transverse in the rest ( Fig 3). This was assessed by orthogonal radiography. In all cases, alternative treatment was sought by the owners due to ongoing abnormal tail movement, discomfort (dogs 3 and 4) and reluctance to sit (dog 2) following conservative management and a desire to avoid tail amputation that was offered at the referring veterinarian.FIG 2. Appearance of splint (a) and its application on the tail of dog 1 (b, c, d)AC DB 17485827, 2023, 10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13644 by Vetagro Sup Aef, Wiley Online Library on [19/10/2023]. 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 LicenseCaudal vertebrae fracturesJournal of Small Animal Practice • Vol 64 • October 2023 • © 2023 British Small Animal Veterinary Association. 645 In two dogs, stabilisation was performed with 1.5 of 2.0 mm veterinary cuttable plate (five holes) (Vi®, Sheffield, UK), in one dog with a 1.5 mm mini DCP plate (five holes) (Vi®, Sheffield, UK) and 1.0 mm cuttable plate (four holes) (Vi®, Sheffield, UK) in one. T wo bicortical screws were placed in the cranial and caudal fragments in all cases, except in dog 1 where three screws were placed in the cranial fragment ( Fig 4). After surgery, oral cefalexin (22 mg/kg twice daily; Therios®, Ceva, Laval, France) was prescribed in three of four dogs. Oral meloxicam (0.1 mg/kg once daily; Metacam®, Boehringer Ingelheim Vetmedica GmbH, Ingelheim/Rhein, Germany) solely was prescribed in two dogs (dogs 1 and 3) for 7 days. Dog 4 received an extended course of oral meloxicam (14 days) in combination with oral paracetamol/codeine (Pardale V™; Dechra, Skipton, UK) for 10 days. Dog 2 received oral robe -nacoxib (1 mg/kg once daily; Onsior®; Elanco, Cuxhaven, Ger -many) for 7 days. T wo of four dogs (dogs 2 and 4) tolerated a conscious change of the splinted bandage for 4 weeks. Dog 1 did not tolerate conscious bandage changes and the splint was maintained only for 10 days postoperatively. In dog 3, the original splinted bandage was removed after 3 days due to the development of surgical site infection (SSI).OutcomeFollow- up re- examinations were performed 6 to 8 weeks after sur -gery at our institution to assess fracture healing and tail function. In three of four dogs (dogs 1, 2 and 4) tail function was deemed normal. In dog 3, the tail function was deemed satisfactory (due to the presence of SSI), all based on clinical examination. Postopera -tive imaging at follow- up assessment showed satisfactory fragment alignment, no change in implant position and callus formation bridging the fracture gap at least in three of four cortices in two dogs (dogs 1 and 2) ( Fig 5). There, fracture healing was deemed sat -isfactory and due to normal tail function, no further radiographic Table 1. Summary of signalment, treatment and outcomeDog 1 Dog 2 Dog 3 Dog 4Breed Lurcher Labrador retriever Rhodesian Ridgeback Cross breedAge 3 years 7 months 4 years 5 months 7 years 1 months 2 years 2 monthsWeight 18 kg 36 kg 39 kg 8 kgDuration of clinical signs 21– 28 days 19 days 14 days 10 daysClinical symptoms Abnormal movement of tail Abnormal movement of tail, reluctance to sitAbnormal movement of tail, focal painAbnormal movement of tail, focal painPreserved motor function of tail Yes Yes Yes YesAbnormal tail carriage and wag Yes Yes Yes YesNociception Preserved Preserved Preserved PreservedFracture location and type 9th vertebrae mid- body simple transverse10th vertebrae mid- body oblique with comminution17th vertebrae mid- body simple transverse15th vertebrae mid- body transverse with comminutionFixation method 1.5 mm cuttable plate 1.5 mm mini DPC plate 1.5 mm cuttable plate 1.0 mm cuttable plateFollow- up 76 weeks 26 weeks 31 weeks 26 weeksComplications n/a n/a Major, SSI Major, pain, delayed unionTreatment of complications n/a n/a Removal of infected suture, antimicrobialsExtended course of analgesiaConservative managementFracture healing Achieved Achieved Achieved AchievedFunctional outcome Excellent Excellent Excellent ExcellentDCP Dynamic compression plate, SSI Surgical site infectionFIG 3. Dorsoventral and mediolateral views dog 1 (a, b), dog 2 (c, d), dog 3 (e, f) and dog 4 (g, h)AC EGB DF H 17485827, 2023, 10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13644 by Vetagro Sup Aef, Wiley Online Library on [19/10/2023]. 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 LicenseI. A. Kalmukov et al.Journal of Small Animal Practice • Vol 64 • October 2023 • © 2023 British Small Animal Veterinary Association. 646assessment was recommended. In dog 3, alignment, apposition and apparatus were maintained but there was no obvious activity or bone remodelling ( Fig 6). We suspected this was due to the pres -ence of an SSI. A further follow- up reassessment 31 weeks postop -eratively revealed osseous union and bone remodelling. In dog 4, there was a loosening of one screw and bone resorption with an increase in fracture gap. Due to the normal clinical function of the tail and the absence of pain, this was managed conservatively. The same dog presented again at 17 weeks postoperatively. Tail function remained excellent, with no further implant loosening and bridg -ing callus at the fracture site ( Fig 7). This outcome was deemed sat -isfactory and no further clinical reassessments were recommended.ComplicationsT wo dogs had major complications as described by Cook et al. (2010 ). Dog 3 developed SSI. Initially, an exudative pyoderma developed 3 days following surgery on the tip of the tail. Oral cefalexin (22 mg/kg; Therios™, Ceva, Amersham, UK) was pre -scribed for 10 days and then extended to 21 days. Wound dehis -cence developed at the surgical site and a course of pradofloxacin (3 mg/kg; Veraflox®, Elanco, Newbury, UK) was initiated by the primary care veterinarian. The dog presented again 6 weeks fol -lowing surgery with continuing exudation and hypergranulation at the surgical site ( Fig 8). Clindamycin (Zodon®, Ceva, Amer -sham, UK) was administered at 11 mg/kg once daily for 11 days and then further increased to 11 mg/kg twice daily for another 3 weeks. At 9 weeks postoperatively, a subcutaneous suture was exposed and removed. This led to the resolution of clinical symp -toms and the healing of the wound. At 10 weeks postoperatively, oral clindamycin was discontinued by the owner. During this time, the tail was covered by a homemade tail protector. Com -plete wound healing with normal tail function and the osseous union was achieved on radiographic examination at the final recheck 31 weeks following surgery. Dog 4 required an extended course of analgesia (14 days). The same patient had implant loos -ening and suspected delayed union (an increase of fracture gap) at 8 weeks postoperatively, however, no further implant loosening and bridging of the fracture gap was observed at 17 weeks postop.QuestionnaireAll four owners responded to the questionnaire (Appendix S2). The mean follow- up time was 40 weeks (range 26 to 75 weeks). The general function and mobility were scored as excellent, with only mild noticeable thickening of the tail at the surgical site. This was noticed in all cases when assessed by the owners. No other signs of discomfort were reported, and none of the dogs was receiving medication at the latest follow- up. Overall, all own -ers were satisfied with the outcome.Table 1 represents a summary of the cases.FIG 4. Dorsoventral and mediolateral views dog 1 (a, b), dog 2 (c, d), dog 3 (e, f) and dog 4 (g, h)AB DC EFGHFIG 5. Dorsoventral and mediolateral views dog 1 (a, b) and dog 2 (c, d)ABDCDog 1 Dog 2 17485827, 2023, 10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13644 by Vetagro Sup Aef, Wiley Online Library on [19/10/2023]. 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 LicenseCaudal vertebrae fracturesJournal of Small Animal Practice • Vol 64 • October 2023 • © 2023 British Small Animal Veterinary Association. 647

Question 172

Spies - 2024 - VETSURG - Clinical presentation and short-term outcomes of dogs > 15 kg with extrahepatic portosystemic shunts.pdf

Answer 172

Medical records of dogs diagnosed with EHPSS betweenJanuary 01, 2005 and December 31, 2020 were reviewed.Records were provided from 10 university hospitals andone private referral center. Included dogs had body-weights ≥15 kg at time of initial presentation and a singlecongenital EHPSS. Dogs with intrahepatic shunts, multi-ple congenital EHPSS, or multiple acquired portosyste-mic shunts at the time of initial presentation were notincluded. A minimum bodyweight of 15 kg was selectedbased on minimum average weights of typical large breedIHPSS dogs.8,9Shunts were diagnosed via ultrasound,computed tomography (CT) angiography, nuclear scintig-raphy, intraoperative portovenography, a combination ofthese modalities, or as a gross intraoperative finding.Dogs were required to have a physical examination,an imaging report confirming an EHPSS or intraoperativeidentification of an EHPSS, at least one preoperative bio-chemical panel, and a minimum follow-up of 90 daysthrough the reporting institution or referring veterinarianfollowing initial consultation. Information was collectedfrom the institutions' and general practitioners' medicalrecords. A follow-up time of at least 90 days was selectedas this is a commonly used time point at which dogs arereassessed for shunt patency at referral institutions.20–22Data recorded included: breed, age, sex, neuter status,concurrent diseases, clinical presentation, physical exam-ination findings, medical management, imaging findings,and anatomy of the shunt and portal vasculature if noted.Other data included the surgical procedure if performed,perioperative complications, postoperative diagnostics,and the nature of any postoperative medical manage-ment. Short-term complications were considered thosethat developed prior to the 90 day follow-up. Laboratoryvalues were characterized as low, normal, or high basedon the reference interval from a submitting institution,or, if this was not available, according to reference inter-vals provided by the Animal Health Diagnostic Center atCornell University.2.1 |Statistical analysisFor the purposes of this study, survival was classified aslonger than 90 days following surgery. Data wereassessed for normality using the Shapiro –Wilk test. Nor-mally distributed data are reported as mean ± SD, andnon-normally distributed data are reported as medianand interquartile range (IQR). Kaplan –Meier survivalanalysis curves were generated to assess the relation-ship between time, survival, and the type of EHPSSmanagement (strictly medical, or surgical attenuation)(FigureI). Dogs were censored if they were lost tofollow-up, died of a cause unrelated to the shunt, or ifthey were still alive at the time of analysis. Statisticaltests were undertaken using a statistical software pack-age (Stata SE, version 17.1).FIGURE I Kaplan –Meier survival analysis of 63 extrahepaticportosystemic shunt (EHPSS) dogs ≥15 kg: This graphdemonstrates the survival curve of large dogs that were solelymanaged medically for an EHPSS, shown by the blue curve. Thesurvival curve of dogs that received surgical attenuation is shown inred. Patients were censored (vertical black marks) at the time ofdeath or loss to follow-up.SPIES ET AL . 279 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 License3|RESULTSA total of 79 medical records were submitted for review,63 of which met the inclusion criteria. The most commonreasons for case exclusion were inadequate follow-up(<90 days) or bodyweight <15 kg at the initial visit.The median weight of dogs was 22.3 kg (IQR: 17.7 –27.05).Median age was 21.9 months (IQR: 9 –36.8). Sterilized dogsmade up the majority of the group (21 spayed females,20 neutered males). There were 13 intact male dogs andnine intact females. Cases were seen at the following insti-tutions: Purdue University Sm all Animal Hospital (11),Texas A&M Veterinary Medical Teaching Hospital(11 dogs), North Carolina State Veterinary Hospital (11),Tufts Foster Hospital for Small Animals (7), University ofMissouri Veterinary Health Center (6), Michigan State Uni-versity Veterinary Medical Center (6), Virginia-MarylandCollege of Veterinary Medicine Veterinary Teaching Hospi-tal (4), Cornell University Hospital for Animals (3), IowaState University Lloyd Veterinary Medical Center (2), Uni-versity of Georgia Veterinary Teaching Hospital (2), andV C AW e s tL o sA n g e l e sA n i m a lH o s p i t a l( 1 ) .The most common breed was the Golden retriever at18/63 (28.6%). Mixed breed dogs (13/63) made up 20.6%of the group. Other breeds included Labrador retrievers(4/64, 6.3%), German shepherds (3/63, 4.8%), Border Col-lies (2/64, 3.2%), Australian shepherds (2/63, 3.2%), IrishSetters (2/63, 3.2%), German Shorthaired pointers (2/63,3.2%), English Springer spaniels (2/63, 3.2%), and Beagles(2/63, 3.2%). Breeds included with n=1: Dutch shep-herd, Bassett Hound, Whippet, English Bulldog, Shar-pei,English pointer, Australian Cattle dog, Boxer, StandardPoodle, Airedale terrier, Great Dane, Cardigan WelshCorgi, and Clumber spaniel.3.1 |Preoperative findingsThe most common clinical signs included lethargy in39/63 (61.9%) and neurological abnormalities in 31/63(49.2%) which included ataxia, obtundation, and circlingbehaviors (Table 1). Seizures were documented in 13/63(20.6%) dogs. Polyuria and polydipsia occurred in 29/63(46%) dogs and vomiting and/or diarrhea was noted in22/63 (34.9%).Concurrent diseases (Table 2) were noted in 22/63(34.9%) of dogs and included primarily orthopedic diseasein 8/63 (12.7%), heart disease in 6/63 (9.5%), and otherdiseases in 10/63 (15.9%). Orthopedic diseases includedhip dysplasia (4/63, 6.3%), hypertrophic osteodystrophy(1/63, 1.6%), bilaterally swollen carpi (1/63, 1.6%), osteo-arthritis (1/63, 1.6%), and avascular necrosis of the femo-ral head (1/63, 1.6%). Heart disease included subaorticstenosis (3/63, 4.7%), low-grade systolic heart murmurs(2/63, 3.2%), and tricuspid and mitral valve dysplasia(1/63, 1.6%). Other concurrent diseases included the fol-lowing: immune-mediated polyarthritis (1/63, 1.6%),bilateral hyphema (1/63, 1.6%), unilateral cryptorchidism(2/63, 3.2%), ehrlichiosis (1/63, 1.6%), pyelonephritis(1/63, 1.6%), bilateral entropion (1/63, 1.6%), incidentalsitus inversus with levocardia (1/63, 1.6%), incidental gas-tric foreign body (2/63, 3.2%), and pyometra and myoto-nia congenita in the same dog. Of the 12 dogs with urinesamples submitted for culture analysis, 9/12 (75%) werediagnosed with a urinary tract infection.Of the included cases, 4/63 (6.3%) shunts were consid-ered incidental findings as dogs were not showing shunt-related clinical signs at initial evaluation. In two of thesedogs, shunt work-up was pursued following repeat find-ings of elevations in liver enzyme values (alanine amino-transferase [ALT], alkaline phosphatase [ALP]) onroutine bloodwork with the referring veterinarian. In athird dog, an EHPSS was found incidentally uponabdominal exploratory for a pyometra, and in the fourthcase, found unexpectedly on an abdominal CT scan dur-ing assessment for lipomas.Bloodwork values (Table3) were compared to institu-tional reference intervals or reference intervals outlinedby the Animal Health Diagnostic Center at Cornell Uni-versity (Cornell). Most dogs showed some degree ofTABLE 1 Clinical signs of large dogs with extrahepatic portosystemic shunts.Clinical signsNeurologicalsigns Seizures AnorecticVomiting,diarrheaPolyuria,polydipsia Underconditioned LethargicAttenuated(n=45)51.1% (23/45) 17.7% (8/45) 33.3% (15/45) 28.9% (13/45) 46.7% (21/45) 17.8% (8/45) 60% (27/45)Nonattenuated(n=18)55.6% (10/18) 27.8% (5/18) 38.9% (7/18) 38.9% (7/18) 50% (9/18) 22.2% (4/18) 66.7% (12/18)All (n=63) 52.3% (33/63) 20.6% (13/63) 34.9% (22/63) 31.7% (20/63) 47.6% (30/63) 20.6% (13/63) 61.9% (39/63)Note: The most common clinical signs reported in 63 large dogs with extrahepatic portosystemic shunts (EHPSS) at the time of their first tertiary referral visit,including dogs who were managed strictly medically without attenuation (18/63), and dogs who received surgical attenuation (45/63).280 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 Licensedecreased protein synthesis, with low total protein levelsfound in 12/18 (66.7%) medically managed dogs, and in30/45 (66.7%) dogs that went on to receive attenuation.Decreased albumin was seen in 56/63 (88.9%) total dogs,with a mean of 2.4 ± 0.53 g/dL. Decreased blood ureanitrogen (BUN) was seen in 32/63 (50.8%) dogs, with amedian of 4 mg/dL (IQR: 3 –6). Cholesterol (Chl) wasdecreased in 33/63 (52.4%) dogs, with a median of130 mg/dL (IQR: 99 –171). Elevated ALP was seen in35/63 (55.6%) dogs, with a median of 131 U/L (IQR:60–242), and elevated ALT was seen in 39/63 (61.9%)dogs with a median of 129 U/L (IQR: 67 –273). Over athird of dogs, 22/63 (34.9%), were anemic. Of the 41 dogswith documented ammonia levels, 24/40 (60%) wereelevated, with a median of 71.3 mcg/dL (IQR: 44 –167.5).Preoperative bile acids were elevated in the 45 dogswho were tested, with a preprandial median of131μmol/L (IQR: 58.3 –201) and postprandial median of221.7 μmol/L (IQR: 139.4 –333).Preoperative hypoglycemia was documented in 40/45(88.9%) attenuated dogs. Of the 18 medically manageddogs, only one was hypoglycemic at the time of referral.Most dogs (53/63, 84.3%) had some degree of initialmedical management initiated at the time of diagnosis.Shunt-specific medical management included lactulose, aliver-specific diet, an antibiotic, an antiepileptic, or somecombination of these. Lactulose was used in 45/53(84.9%) dogs, antibiotics in 45/53 (84.9%), a liver-specificdiet in 47/53 (88.7%) dogs, and anticonvulsantmedications in 27/53 (50.9%). Other medications reportedincluded hepatoprotectants in 8/53 (15.9%), and gastro-protectants in 9/53 (17%) dogs.3.2 |Diagnostic imagingImaging diagnostics for confirming shunt presenceincluded solely ultrasonography (in 15 dogs) and solelyCT angiography (in 20 dogs). In over a third of cases,modalities were used in combination, with 23/63 (36.5%)relying on a combination of ultrasound and CT angiogra-phy to assess shunt anatomy and surgical candidacy.Portovenography in addition to CT angiography wasemployed in three dogs. One dog was assessed via ultra-sonography, CT angiography, and scintigraphy. One dogtaken to surgery for a pyometra had a preoperative ultra-sound that did not identify the shunt, but a shunt wasappreciated during the abdominal exploratory surgery.The most common shunt type was splenocaval, in 16/63(25.4%) dogs. Other shunt types included splenonephricin 5/63 (7.9%), portoazygous in 3/63 (4.7%), splenoazy-gous in 5/63 (7.9%), and 16/63 (25.4%) listed as portocavalwithout further description of contributing vessels. In18 (28.6%) imaging reports, specific shunt anatomy couldnot be determined or was simply described as “a singleextrahepatic shunt ”(Table4).A total of 34 imaging reports commented on the anat-omy of the portal system in addition to the shunt. Ofthese, 18/34 (52.9%) were noted to have “a hypoplasticportal vein ”, which was either subjectively described orassessed through measurement of vein diameter. In twodogs the portal vein was enlarged caudal to the shuntingvessel. In 7/34 (20.6%) dogs the portal vein was noted tobe normal.3.3 |Surgical findingsA total of 48 dogs underwent an abdominal exploratorysurgery, with 45 ultimately receiving surgical shunt atten-uation. Attenuation methods included cellophane in21/45 (46.7%) attenuated dogs, ameroid constrictors(19/45, 42.2%), partial (2/45, 4.4%) and complete sutureligation (1/45, 2.2%), transvenous coil embolization (1/45,2.2%), and a combination of complete suture ligation andloosely placed cellophane (1/45, 2.2%).Attenuation was aborted in three of the dogs withhypoplastic portal veins due to signs of portal hyperten-sion that developed when attenuation was attempted. Noimmediate intraoperative complications were noted inthe successfully surgically attenuated group.TABLE 2 Concurrent diseases of large dogs with extrahepaticportosystemic shunts.Concurrent diseasesNumber ofpatientsPercent ofpatientsOrthopedic disease (total) 8/63 12.7%Hip dysplasia 4/63 6.3%Hypertrophicosteodystrophy1/63 1.6%Swollen carpi 1/63 1.6%Femoral head necrosis 1/63 1.6%Heart disease (total) 6/63 7.2%Subaortic stenosis 3/63 4.7%Low-grade systolicmurmurs2/63 3.2%Tricuspid, mitral valvedysplasia1/63 1.6%Urinary tract infection 9/12 75% of 12 withcultureIncidental gastricforeign body2/63 3.2%Note: Concurrent diseases reported in 63 large dogs with extrahepaticportosystemic shunts (EHPSS).SPIES ET AL . 281 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 LicenseO ft h e4 8d o g st h a tw e r et a k e nt os u r g e r y ,3 / 4 8( 6 . 2 % )h a das h u n tt h a tw a su l t i m a t e l yd e e m e dn o ta m e -nable to surgery. One dog had marked microhepaticaand a single EHPSS that was extremely large and thesurgeon elected to not occlude. Intraoperative portove-nography in a second dog revealed no overt portal vein.In the third dog, the portal vein cranial to shunt wasnoted to be diminished (3 mm in diameter), and tempo-rary occlusion of the shunt resulted in hypermotility ofthe jejunum and a rapid increase in portal pressure from0 to 35 mmHg.Concurrent surgical procedures were performed in32/48 (65.3%) dogs taken to surgery, including cystotomy(11/48, 22.9%), castration (9/48, 18.8%), prophylactic gas-tropexy (3/48, 6.3%), gastrotomy to remove incidentalgastric foreign material (2/48, 4.2%), liver biopsies (32/48,66.7%), gastrointestinal and pancreatic biopsies (1/48,2%), splenectomy due to mottled appearance of thespleen (1/49, 2%), and esophagostomy tube placement(1/49, 2%). Of these dogs, 15/32 (46.9%) had two concur-rent procedures performed. Splenic histopathology wasconsistent with lymphoid hyperplasia for the single dogwith a splenectomy. Of the 11 dogs who received cysto-tomies, seven urolith analyses were reported, all consis-tent with ammonium urate stones.A total of 32 of the 45 dogs that received attenuationhad liver biopsies performed. All histopathology reportswere consistent with hepatic hypoperfusion, with arterio-lar hyperplasia, lobular atrophy, and lymphangiectasia.One dog had grade 3/5 copper accumulation noted onhistopathology and changes consistent with a portosyste-mic shunt. This dog experienced no intraoperative orshort-term complications following cellophane attenua-tion and was maintained on all forms of medical manage-ment at the time of 90-day follow-up.3.4 |Postoperative outcomesOf the three dogs with attempted shunt attenuation, onlyone experienced a short-term complication (self-limitinghematochezia that resolved in 24 h). All were alive at thetime of 90-day follow-up, each being maintained on anti-biotics, lactulose, and a liver-specific diet. Of the 45 dogswith attenuation, 16/45 (37.8%) had short-term complica-tions, which included vomiting, diarrhea, anorexia, ane-mia, lethargy, and hyporexia. The dog who had receivedan e-tube placement at the time of surgery developedanorexia, lethargy and a multidrug resistant infection atthe e-tube site and was euthanized 51 days following sur-gery due to the extent of this infection.Three of the 45 dogs with a surgically attenuated shunt(6.7%) died as a result of shunt-related complications in thepostoperative period and did not survive to discharge fromthe hospital. One dog developed hypotension, seizures, andacute kidney injury and died within 24 h of surgery. Thisdog underwent cellophane b anding. One dog was eutha-nized after developing refractory seizures within 48 h of sur-gery. This dog had an ameroid constrictor applied. The finalTABLE 3 Biochemical abnormalities of large dogs with extrahepatic portosystemic shunts.Variable (units) (reference range) Median Number outside of normal range Percent outside of normal rangeBUN (mg/dL) (5 –26 mg/dL) 4 mg/dL 32/63 50.8% belowCrea (mg/dL) (0.6 –2.4) 0.5 mg/dL 6/63 9.5% belowTP (g/dL) (5.5 –7.2) 5 g/dL 42/63 66.7% belowAlb (g/dL) (3.2 –4.1) 2 g/dL 56/63 88.9% belowALP (U/L) (7 –115) 131 u/L 35/63 55.6% aboveALT (U/L) (17 –95) 129 u/L 39/63 61.9% aboveGlu (mg/dL) (68 –104) 85 mg/dL 41/63 65.1% belowChol (mg/dL) (136 –392) 130 mg/dL 33/63 52.4% belowNH3 (ug/dL) (0 –59) 71.3 ug/dL 24/40 60% aboveNote: Chemistry panel abnormalities of large dogs diagnosed with extrahepatic portosystemic shunts (EHPSS).Abbreviations: Alb, albumin; ALP, alkaline phosphatase; ALT, alanine aminotransferase; BUN, blood urea nitrogen; Chol, cholesterol; Crea, creat inine; Glu,glucose; NH3, ammonia; TP, total protein.TABLE 4 Anatomical descriptions of extrahepaticportosystemic shunts (EHPSS) in 63 large dogs.Imaging findingsNumber ofpatientsPercent ofpatientsSplenocaval 16/63 25.4%Portocaval 16/63 25.4%Splenonephric 5/63 7.9%Splenoazygous 5/63 7.9%Not specified 18/63 28.6%Note: This table shows the locations of shunts found in dogs ≥15 kg withEHPSS.282 SPIES ET AL . 1532950x, 2024, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14040by 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 Licensedog developed abdominal distention and became stuporouswith marked hypotension within 48 h of surgery and waseuthanized. This dog had also received an ameroid constric-tor. Two dogs (2/45) were euthanized due to reasons unre-lated to their shunts greater than 90 days following surgery.Revision surgeries were performed in four of the oper-ated dogs due to concerns for unresolved shunting in theface of persistent clinical signs. Dogs were reported tohave undergone revision for persistent clinical signs atdays 206, 230, 288, and 343 following initial surgery. Onedog, who received an ameroid constrictor at the site ofprevious cellophane band placement, was euthanizedwithin 48 h following revision surgery (208 days follow-ing initial attenuation) for refractory seizures. The otherthree revised dogs included two who had initiallyreceived cellophane banding and one dog who hadreceived an ameroid constrictor. One of the cellophane-banded dogs received an ameroid constrictor upon revi-sion surgery; the other methods of revisional attenuationwere not reported. All three were reportedly dischargedwithout complication following revision surgery andmaintained on all forms of medical management.For cases for whom long-term follow-up was available,the range was 90 –1842 days, median of 153.5 days, and IQRof 90–480.5 days. Of the 40 surviving attenuated dogs, 15/40(37.5%) were weaned completely from medical manage-ment. Six of 40 (15%) were weaned from all medicalmanagement except a liver-specific diet, while 16/40 (40%)were maintained on all initial medications long term(Table5).Only 16/63 (25.4%) of all dogs had documentedrecheck bile acid testing performed within the 90 dayfollow-up period, all of which were dogs who hadreceived attenuation. Postoperatively, these 16 dogs had amedian preprandial concentration of 34.3 μmol/L (IQR:21.9–366.7). Preprandial bile acid concentrations werenormal in 14/16 (87.5%) dogs. Post-prandial bile acid con-centrations were normal in 12/16 (75%) with a median of46.2 μmol/L (IQR: 12.3 –7) for all 16 dogs.Of the dogs who did not receive attenuation (18/63),including the three with surgical attempts, all were main-tained on their original shunt medical management regimenwithin the follow-up period (Table5). A reason for pursuingmedical management in lieu of surgical intervention was notconsistently provided in the records of these dogs. Only onedog (in which the shunt was incidentally found during emer-gency ovariohysterectomy for pyometra) was not maintainedon any form of shunt-related medical management. Six ofthese 18 dogs (33.3%) were managed with an antibiotic andlactulose, and 11/18 (61.1%) were maintained on an antibi-otic, lactulose, and a liver-specific diet. Of these 18 dogs, 4/18(22.2%) died or were euthanized related to known shunt-related complications (at 3 days, 6 days, 1 month, and9 months following the referra l visit). Within the remainingpopulation, 14/18 (77.7%) dogs were alive at the time of90 day follow-up. Four of these 18 dogs (22.2%) were eutha-n i z e do rd e c e a s e da t ≥90 days follow-up for reasons undocu-mented by their veterinarian or unrelated to shuntcomplications. Survival times of the medically managed dogscould not be assessed as many were lost to follow-up in sev-eral cases beyond the 90 day timeline as expected given theinclusion criteria. More dogs that were medically managed(4/18) had documented short-term shunt-related deathscompared to attenuated dogs (3/45) (Table6).4

Question 173

Nash - 2024 - VETSURG - Esophageal pH-monitoring in nonbrachycephalic dogs - A reference.pdf

Answer 173

2.1 |Study populationEthical approval was granted by the Murdoch UniversityAnimal Ethics Committee (permit number R3230/20).The ideal sample size was determined a priori based onprevious esophageal pH monitoring in dogs.3To capturea 95% confidence interval for mean estimates of parame-ters within +//C050% of the mean, a sample of 28 –34 dogswas required. The present cohort was selected from non-brachycephalic dogs referred for cranial cruciate ligamentdisease. Dogs were excluded if they were aggressive, ifsedation would be required for hospital-related anxiety,or they had a history of clinical signs associated with gas-trointestinal disease (such as intermittent but persistentvomiting or diarrhea, retching, lip licking or diet sensitiv-ities). Informed owner consent was obtained. The age,breed, sex, neuter status, and body weight of each dogwas recorded.2.2 |Total intravenous anesthesiaOwners were asked to withhold food from 10:00 p.-m. the evening prior to admission as per hospital proto-col. The estimated time of fasting (assuming dogs hadaccess to food until 10:00 p.m.) was calculated as thetime from 10:00 p.m. to the start of data recording.Dogs underwent total intr avenous anesthesia (TIVA)to obtain bilateral, orthogonal stifle radiographs and toplace the pH monitoring probe. Dogs were sedatedwith methadone (0.3 mg/kg) and medetomidine(5 ug/kg) IM, then anesthesia was induced with alfaxa-lone IV to effect. Orotracheal intubation was per-formed to provide oxygen supplementation; noinhalant anesthetic agents w ere used. Total intrave-nous anesthesia was maint ained with alfaxaloneboluses (0.5 –1m g / k g )t oe f f e c t .2.3 |Digitrapper placementAll dogs had a Digitrapper pH testing system placed(Digitrapper pH-Z Testing System, Medtronic, NorthRyde, Australia); this is an ambulatory pH-recordingdevice, which consists of a 70 cm long, 6-French gauge,flexible probe connected to an external reader. The probehas two sensors 15 cm apart, aligned to detect proximaland distal gastroesophageal reflux. Within 1 h prior todevice placement, the probe was calibrated in buffer solu-tions with pH 4 and pH 7, following the manufacturer'sinstructions. The probe was placed in all dogs by a singleresearcher. Lignocaine hydrochloride spray (Co-Phenylcaine Forte Spray, ENT Technologies, Hawthorn46 NASH ET AL . 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14020 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 LicenseEast, Australia) was inserted into both nostrils prior toplacement. The tip of the probe was coated in sterilelubricant and the probe was inserted via either nostrilinto the esophagus. The probe was advanced until thedistal sensor was at the level of the eighth rib and posi-tioning was confirmed based on visualization of the sen-sor on a single lateral thoracic radiograph.6The probewas sutured to the alar fold using a nonabsorbable suturein a Chinese finger trap pattern. The external reader wasplaced over the thorax under a compression vest. Atipa-mazole was administered IM at the completion of proce-dures (25 ug/kg).2.4 |HospitalizationAll dogs were hospitalized overnight as per the standardhospital protocol for the surgery ward. The proberemained in place until the dog was anesthetized prior toundergoing a tibial plateau leveling osteotomy (TPLO)the next day. Water was supplied ad libitum. Dogs werewalked four to six times per day while hospitalized. Thefeeding schedule was maintained as per the standardoperating procedure, to include twice-daily feeding ofeasily digestible dry kibble or wet food (Hills Pet Nutri-tion, Topeka, KS, USA), boiled chicken, or the dogs' ownfood. Dogs were fasted for at least 10 h prior to receivingpremedication for the TPLO. All indoor lights wereturned off overnight between treatments to allow for anatural darkness period between the hours of 10:00 p.-m. and 5:00 a.m. All dogs were under hourly supervisionby veterinary nurses and were examined at least twicedaily by a veterinarian.Adverse events associated with maintenance of theesophageal probe in situ were recorded. Device intoler-ance, which necessitated removal of the esophagealprobe, was an example of a major adverse event. The dogdemonstrating clinical signs consistent with discomfort,which resolved with minor bedside intervention, was anexample of a minor adverse event.2.5 |Data evaluationData was reviewed and analyzed using Accuview Soft-ware (Accuview pH-Z 5.2, Informer Technologies). Thefirst 45 and last 30 min of data recording was excludedfor all dogs as this coincided with anesthesia recoveryfrom probe placement and preoperative sedation forTPLO, respectively. The study period between these twotime points was called the adjusted recordingduration. A GER event occu rred when the esophagealpH recorded was less than 4. V ariables retrieved fromthe Digitrapper recording for each dog across theadjusted recording duration included total number ofGER events, the duration of each GER event, the dura-tion of the longest GER event, and the cumulative dura-tion of GER.The variables were used to generate two key parame-ters to describe reflux during the adjusted recording dura-tion. Both parameters were recorded for the distal andproximal sensor. Parameter 1 was the number of GERevents per hour, calculated by dividing the total numberof GER events by the adjusted recording duration.Parameter 2 was the cumulative esophageal acid expo-sure which reflects the duration that pH in the esophagusis less than 4, and calculated by dividing the cumulativeduration of reflux events by the adjusted recording dura-tion, expressed as a percentage.2.6 |Data analysisNumerical data describing the cohort are presented asmeans, medians, and quartiles, and categorical data arepresented as frequencies and proportions. Data pointswere rounded to one decimal place. Variables from theDigitrapper recording (number of GER events, durationof each GER event, duration of the longest GER eventand cumulative duration of GER events) and key param-eters (number of GER events per hour and cumulativeesophageal acid exposure) were plotted (GraphPad Prismversion 9.0 for Mac, GraphPad Software, San Diego,California) and the distribution visually inspected.An estimated upper reference limit was generated forthe parameters (1) number of GER events per hour andfor (2) cumulative esophageal acid exposure, at each sen-sor. The highly right-skewed nature of the data and thefrequency of zero data points prohibited the applicationof parametric generation of upper reference limits usingmean+//C02 standard deviations7of either the absoluteor transformed data. Transformation of a zero data pointis not mathematically possible using methodology suchas log transformation or reciprocal, typical for right-skewed data. An estimated upper reference limit wastherefore generated using accepted nonparametric guide-lines for probable outliers.8The median and interquartilerange (IQR) were defined, and the upper reference limitwas calculated as (median +3/C2IQR).8Thus, any resultabove this limit would be considered a probable outlierin comparison with to the referent population andthereby considered abnormal. This methodology allowsrecognition and inclusion of the zero data points. A lowerreference limit was not required because any valueNASH ET AL . 47 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14020 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 Licensecaptured below the upper limit of the data would beaccepted as consistent with the referent population.3|RESULTSThirty-five dogs were included in the study (Table 1).There were 15 neutered males, 18 spayed females, andtwo entire females. Breeds included Labrador retriever(n=10), golden retriever ( n=5), mixed breed ( n=4),Staffordshire bull terrier ( n=3), schnauzer ( n=2),bichon frise ( n=2), Maltese ( n=2), Irish wolfhound(n=1), mastiff ( n=1), miniature bull terrier ( n=1),kelpie ( n=1), Rhodesian ridgeback ( n=1), Australianterrier ( n=1), cocker spaniel ( n=1). The median agewas 7 years (range 1 –12 years). The median body weightwas 30 kg (range 5.3 –46 kg) and the median body condi-tion score was 5 (range 4 –8). At the time of presentation,22 dogs were receiving nonsteroidal anti-inflammatoriesdrugs (12 receiving carprofen, nine receiving meloxicam,one receiving firocoxib). Eight dogs were receiving gaba-pentin and one dog was receiving paracetamol. Themedian duration of fasting prior to placement ofthe esophageal pH monitoring device was estimated to be15.5 h (range 12 –18 h). All dogs were offered food onceduring the recording period.The first four dogs had a catheter with a single distalsensor only. The remaining 31 dogs had a catheter withdual sensors placed. The duration of TIVA was less than1 h for all dogs, and all dogs required 4 mg/kg or less ofalfaxalone during the procedure. Examination of theupper airway (pharynx and larynx) during placement ofthe pH monitoring probe was normal for all dogs. Thetrachea and pulmonary parenchyma were normal for alldogs on thoracic radiographs, though pathology couldnot be excluded given orthogonal views were notperformed.The esophageal probe was well tolerated in all dogsand all readers remained attached and in place, underthe vest. No major adverse events were recorded. Fourdogs had minor, intermittent sneezing due to irritationon recovery, which resolved with administration of anadditional dose of intranasal lignocaine spray. Sneezingcaused partial withdrawal of the probe from the nostril inone dog; the probe was gently reinserted easily with norequirement for sedation. The recording between thetime of partial withdrawal and reinsertion was excludedfor that dog. The median adjusted recording durationwas 21.1 h (range 13.6 –29.3 h). No dogs had expelled,productive regurgitation during the study period.Distal GER was recorded in 28/35 dogs (Table2). Thenumber of distal GER events ranged from 0 to 78 (medianTABLE 1 Cohort demographics of 35 dogs undergoing esophageal pH monitoring.Variable Minimum Q1 Median Q3 Maximum MeanAge (years) 1 4 7 9 12 7Body weight (kg) 5.3 19.5 30 37 46 26.2Body condition score (out of 9) 4 4 5 6 8 5.2Fasting duration (h) 12 13.5 15.5 16.5 18 15.3Adjusted recording duration (h) 13.6 18 21.1 22 29.3 16TABLE 2 Raw variables describing the frequency and duration of gastroesophageal reflux (GER) events in 35 dogs undergoingesophageal pH monitoring.Variable Minimum Q1 Median Q3 Maximum MeanNumber of GER eventsDistal sensor 0 1 7 21 78 14.1Proximal sensor 0 0 0 3 25 2.6Longest GER event (minutes)Distal sensor 0.1 0.6 3 5.5 14 3.6Proximal sensor 0.1 0.2 1 2.5 3 1.2Cumulative duration of GER events (minutes)Distal sensor 0 0 3 9 43 6.8Proximal sensor 0 0 0 1 13 1.448 NASH ET AL . 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14020 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 LicenseFIGURE 1 Scatter plot showing thenumber of gastroesophageal reflux(GER) events per hour recorded by thedistal and proximal sensors from 35 dogsusing esophageal pH monitoring.Horizontal line indicates upperreference limit.TABLE 3 Calculated parameters for number of GER events per hour and cumulative esophageal acid (pH <4) exposure in 35 dogsundergoing esophageal pH monitoring.Parameter Minimum Q1 Median Q3 Maximum MeanUpper referencelimitNumber of GER events per hourDistal sensor 0 0 0.3 0.7 4.3 0.7 2.4Proximal sensor 0 0 0 0.1 1 0.1 0.4Cumulative esophageal acid exposure (%)Distal sensor 0 0 0.2 0.7 3.9 0.6 2.3Proximal sensor 0 0 0 0 1 0.1 0Note: The upper reference limit is included.FIGURE 2 Scatter plot showing thecumulative esophageal acid (pH <4)exposure recorded by the distal andproximal sensors from 35 dogs usingesophageal pH monitoring. Horizontalline indicates upper reference limit.NASH ET AL . 49 1532950x, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.14020 by Cochrane France, Wiley Online Library on [05/01/2024]. 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 License7 events). The duration of the longest distal GER eventranged from 0.1 to 14 min (median 3 min). The cumula-tive duration of distal GER ranged from 0 to 43 min(median 3 min). The number of distal GER events perhour ranged from 0 to 4.3 (median 0.3 events per hour,Figure1). The upper reference limit for parameter (1) thenumber of distal GER events per hour, is 2.4 (Table 3).The cumulative distal esophageal acid exposure rangedfrom 0 to 3.9% (median 0.2%, Figure2). The upper refer-ence limit for parameter (2), the cumulative distal esoph-ageal acid exposure, was 2.3% (Table 3).Proximal GER was recorded in 12/31 dogs with dualsensoring (Table 2). The number of proximal GER eventsranged from 0 to 25 (median 0 events). The duration ofthe longest proximal GER event ranged from 0.1 to 3 min(median 1 min). The cumulative duration of proximalGER ranged from 0 to 13 min (median 0 min). The num-ber of proximal GER events per hour ranged from 0 to1 (median 0 events per hour; Figure1). The upper refer-ence limit for the number of proximal GER events perhour is 0.4 (Table 3). The cumulative proximal esopha-geal acid exposure ranged from 0 to 1% (median 0%,Figure 2). The upper reference limit for cumulative proxi-mal esophageal acid exposure was 0% (Table 3).4

Question 174

Bellamy - 2024 - JFMS - Feline ventral abdominal wall angiosarcoma - Haemangiosarcoma or lymphangiosarcoma - Clinical and pathological characteristics in nine cases.pdf

Answer 174

Inclusion criteria and data collectionHistopathology reports from two laboratories at referral centres were searched for cats with AS between January 2000 and December 2018. Cats were included if they had a histological diagnosis of AS arising from the ven-tral abdominal wall. Patients without available medical records and formalin-fixed tissue samples were excluded from the study population. Cats with no follow-up availa-ble after a histological diagnosis of AS were also included. Ethical approval was gained before starting the study as per institution guidelines (approval number 06-2019).Data retrieved from clinical records included the fol -lowing: signalment; primary tumour description; previ -ous treatments before referral; cytological or histological sampling of the primary mass; staging performed (ie, bloodwork, thoracic and abdominal imaging); and treat -ment. Where applicable for gross disease, the response to treatment was defined by the response evaluation criteria in solid tumours (RECIST) method: complete response (no residual macroscopic disease); partial response (tumour decreased by ⩾ 30%); stable disease (tumour decreased by < 30% or increased by < 20%); and progres -sive disease (tumour increased by ⩾20%).23 Follow-up information was obtained from the medical records of the referral institutes.Histology and immunohistochemistryFormalin-fixed tissue was retrieved, and histopathology samples were reviewed by a board-certified pathologist. Fresh-cut tissue sections, with a thickness of 4 µm, from formalin-fixed, paraffin-embedded tissue blocks were labelled with a mouse-monoclonal antibody against PROX-1 (Ab199359; Abcam) and a rabbit-polyclonal anti-body against factor VIII (A0082; Dako). Heat-induced antigen retrieval was performed using a pH 6 buffer (Bond ER1; Leica) for 10 mins (factor VIII) and a pH 9 buffer (Bond ER2; Leica) for 10 mins (PROX-1) at 90°C. The Bond Polymer Refine Detection kit (Leica) was used for visualisation with a haematoxylin counterstain. Normal feline skin and lymph nodes were used as posi -tive controls. When present, surrounding histologically normal blood and lymphatic vessels were used as inter -nal positive controls. Negative controls were prepared Bellamy et al 3by replacing the primary antibody with Leica Antibody Diluent (Leica) only. A positive immunolabelling was indicated by the presence of distinct brown cytoplasmic (factor VIII) or nuclear (PROX-1) staining of neoplastic cells. A diagnosis of HSA subtype was confirmed when the AS was factor VIII-positive and PROX-1-negative, and LAS subtype was confirmed when the AS was both factor VIII-positive and PROX-1-positive.Statistical analysisDescriptive statistics were applied to the data collected. In cases of complete response, the disease-free interval (DFI) was calculated from the time of surgery until local or dis-tant recurrence was documented. For patients treated in a gross disease setting, the progression-free interval (PFI) was calculated from the time of initiating treatment until documented progressive disease. Overall survival time (OST) was calculated from the date of diagnosis to the time of death (of any cause). A Kaplan–Meier survival plot was used to estimate the survival of the overall popu-lation as well as that of cases of HSA compared with cases of LAS. This statistical analysis was performed using the commercial Prism software v8.4.3 (GraphPad Software).ResultsSignalment and clinical presentationNine cats met the inclusion criteria. Eight were domes-tic shorthair cats and one was a domestic longhair cat. Six were female spayed cats and three were male cas-trated cats. The median age was 10 years and 3 months (range 5–16 years). In all cases, there was no long-term pre-existing history of diseases or medication administra -tions reported.All cats presented for a ventral abdominal wall mass. The median duration of clinical signs before presenta-tion was 20 days (range 10–76 days). Six masses (67%) had evidence of ecchymosis and five (56%) appeared ulcerated, producing a serosanguinous discharge (Figure 1). Two cats (22%) had pitting oedema of the inguinal region, one which also involved the proximal right hindlimb. Five masses (56%) were described as poorly demarcated. The median primary tumour size was 4.5 cm in maximum width (range 2.0–10.0 cm). Before tumour biopsy, six cats received empirical treat -ment with antimicrobial therapy alone, with or without non-steroidal anti-inflammatory drugs (NSAIDs) or glu-cocorticoids. None of these treatments resulted in the resolution of the presenting clinical signs.Diagnostic investigationsHaematology was performed in all nine cases. Abnormalities were identified in six cats and included a mild to moderate neutrophilia (4/9; range 14.08–27.2 ×109/l; reference interval [RI] 2.5–12.5), lymphopenia (2/9; 0.6 and 0.74 × 109/l; RI 1.5–7.0) and a mild non-regenerative anaemia (haematocrit 0.23 l/l; RI 0.29–0.46). Serum biochemistry was performed in eight cases. Three cats had mild abnormalities, including elevated alanine aminotransferase (155 IU/l; RI 5–60), hypoalbumine-mia (23 g/l; RI 24–40) and hypercalcaemia (total calcium 2.7 mmol/l; RI 2.1–2.6) with normal ionised calcium (1.37 mmol/l; RI 1.00–1.40). One cat had an assessment of prothrombin and activated partial thromboplastin clot-ting time. The former was within RI and the latter was mildly prolonged (11.4 s; RI 7.0–11.0).Eight cats had bicavitary imaging performed: five with thoracic radiographs and abdominal ultrasound and three with CT. Pulmonary nodules were detected in one cat using CT. Fine-needle aspiration (FNA) cytol -ogy of the primary mass was performed in two cases for which the interpretation of one was non-diagnostic and the other was supportive of sarcoma.Surgical biopsy of the primary tumourFive cats underwent excisional biopsies and four cats had incisional biopsies. In case 5, primary wound clo-sure was achieved with an inguinal fold advancement flap. For those undergoing excisional biopsy, histologi -cally assessed tumour-free margins were complete in one (20%) case, with the narrowest horizontal and deep mar -gins of 3 mm and 5 mm, respectively. For the remaining four cats, the margins were incomplete. Postoperative complications were described in 4/5 cats undergoing excisional surgery. Two cases had mild wound dehis-cence that required no further surgical intervention and were allowed to heal via secondary intention. In case 5, complete healing was not observed, and recurrence of a Figure 1 Appearance of feline ventral abdominal angiosarcoma on presentation (case 4). The mass was ill defined and there was accompanying ecchymosis and serosanguinous discharge4 Journal of Feline Medicine and Surgery mass lesion was grossly appreciated, followed by confir -mation with incisional biopsies 67 days postoperatively (Figure 2). Case 6 developed herniation of its abdomi -nal viscera into the subcutis, which required revision surgery. In cases 5 and 6, the wounds were swabbed for culture and sensitivity. A moderate mixed growth of beta-haemolytic Streptococcus species and coagulase positive Staphylococcus species was detected in case 5, prompting treatment with enrofloxacin at 5 mg/kg PO q24h for 7 days (Baytril; Bayer). Pseudomonas aer -uginosa was cultured in case 6; thereafter, the patient received marbofloxacin at 2 mg/kg PO q24h for 10 days (Marbocyl; Vetoquinol). Of the four cats that underwent an incisional biopsy, mild wound dehiscence requiring no further intervention was described in two cases.Histopathology and immunohistochemistryA histological diagnosis of AS and LAS was made in four and five cases, respectively. Four cases had evidence of intraluminal erythrocytes within channels lined by spin -dle-shaped neoplastic cells and five cases had anasto-mosing channels without intraluminal erythrocytes. In eight cats, the neoplastic cells had positive cytoplasmic expression for factor VIII (two strongly, five moderately and one weakly positive), while the remaining cat was negative. Four cats had strong positive nuclear staining for PROX-1 and five were negative. With the addition of IHC, five cats were assigned an HSA phenotype and four cats an LAS phenotype (Figures 3 and 4).T reatment and outcomeAfter excisional surgery, four cats received adjuvant treatment (including systemic chemotherapy or tyrosine kinase inhibitors). Of the remaining four cats that under -went incisional biopsies, one cat was lost to follow-up after diagnosis, one cat was palliated with an NSAID and two received chemotherapy. Table 1 summarises the study population.Five cats died due to local disease progression with a median survival time of 197 days (range 137–381). One cat died from cardiopulmonary arrest under anaes-thesia at the time of investigating local mass regrowth at 97 days. Of the five cats that underwent primary tumour excision, three (60%) developed local recur -rence with a median DFI of 120 days (range 53–311). Of these three cats, two with LAS phenotype experienced local recurrence at 67 and 120 days vs 311 days for the HSA phenotype. The median overall survival time for Figure 2 (a) Day 0 postoperative appearance after incomplete excision of a feline ventral abdominal wall angiosarcoma (lymphangiosarcoma-phenotype) using an inguinal fold advancement flap (case 5). (b) Local regrowth (green arrow) was subsequently confirmed on histopathology after an incisional biopsy at day 67. (c) The patient was euthanased at day 97 owing to progressive local disease and wound dehiscenceFigure 3 Haemangiosarcoma (HSA) phenotype (case 1). (a) Photomicrograph with haematoxylin and eosin stain (×200 magnification). Spindle-shaped neoplastic cells formed blood filled vascular channels. (b) Neoplastic cells demonstrated moderate positive cytoplasmic staining for factor VIII (×400 magnification) confirming endothelial cell origin. (c) Nuclei of neoplastic cells were negative for the PROX-1 (×400 magnification) consistent with an HSA phenotypeBellamy et al 5HSA cases was 166 days (range 137–381) and for LAS was 197 days (range 67–208). Two cats with HSA that underwent surgical excision were alive and disease-free at 329 and 580 days after diagnosis (Figure 5).

Question 175

Marturello - 2023 - VCOT - Post-sterilization Dimensional Accuracy of Methacrylate Monomer Biocompatible Three-Dimensionally Printed Mock Surgical Guides.pdf

Answer 175

Guide Design and 3D PrintingA mock surgical guide consisting of linear, circular as wellas positive and negative depth features was designed( F u s i o n3 6 0 ,A u t o d e s k ,S a nF r a n c i s c o ,C a l i f o r n i a ,U n i t e dStates;►Fig. 1 ). Pre-determined morphometric measure-ments, chosen to replicate standardized distances, diam-eters and thicknesses across the guide are representedin►Fig. 1 .A binary standard tessellation language file of the guidewas uploaded into image processing software (3-Matic,Materialise, Plymouth, Michigan, United States) and nameidenti fication was created for each guide (►Fig. 2 ). Fivebiocompatible resins (various compositions of methacrylatemonomers) were selected. Guides were printed using adesktop machine (Form 3B, Formlabs, Somerville, Massachu-setts, United States), which was chosen based on thereported accuracy of a similar printer6and the availableselection of biocompatible materials. Resins included surgi-cal guide (SG), biomed amber (BA), biomed clear (BC),biomed white (BW, newly released) and biomed black (BB,newly released).Files were then uploaded into printer-speci fics o f t w a r e(Preform, Formlabs, Somerville, Massachusetts, UnitedStates) and positioned with matching orientations on thebuild platform (►Fig. 3 ). Orientation was chosen to minimizepart deformation during printing and surface quality disrup-tion from support removal.6,27Automated supports werethen generated using ‘mini-rafts ’, a touchpoint density of0.5 mm and touchpoint size of 0.4 mm. Five samples in eachresin were printed for each of three sterilization methods,giving a total of n¼15 per material.Post-processingFollowing print completion, the printer platform was placedinto the automated rinse station (Form Wash, Formlabs,Somerville, Massachusetts, United States) with prints stillattached, then submerged in 99% isopropyl alcohol for20 minutes. Following rinsing, guide supports were removedwith tools provided by Formlabs. Brie fly,‘flush cutters ’wereused to snip touchpoints on the guide as close as possible tothe surface. Rafts were then removed from the print platformusing the ‘scraper ’tool. The surface of the platform wascleaned with 99% isopropyl alcohol to prepare for the nextprint.Once supports were removed, guides were placed in anultraviolet curing tank (Form Cure L, Formlabs Somerville,Massachusetts, United States). Temperature and duration ofcuring was material dependent, based on manufacturerrecommendations: SG (70°C, 30 minutes), BA (70°C,30 minutes), BC (60°C, 60 minutes), BW (60°C, 60 minutes),BB (70°C, 60 minutes). The isopropyl alcohol was changedbetween each material..Pre-sterilization MeasurementsFollowing curing, measurements were obtained using adigital caliper (Mitutoyo America, Aurora, Illinois, UnitedStates) by a single investigator (DMM). All measurementswere performed in triplicate and averaged for each sample.Measurements were taken from the following locations(►Fig. 1 , designed dimensions in parentheses): (1) A to B(12 mm), (2) A to C (21 mm), (3) B to C (11.7 mm), (4) innerdiameter of D (6.5 mm), (5) outer diameter of D (10 mm), (6)height from guide bottom to top of D (28 mm), (7) width andheight of the guide base (40 mm for both), and (8) guide basethickness (4 mm). Measurements were reported as either apositive or negative value indicating magni fication or reduc-tion of the dimensions respectively.SterilizationThree methods of sterilization were chosen –steam, ethyleneoxide and hydrogen peroxide gas. Cycle settings for eachmethod were selected based on the standard operatingprocedures for our institution. Steam cycles (single doorhinged autoclave, Consolidated Sterilizer Systems, Billerica,Massachusetts, United States) were run at 121°C for20 minutes. Ethylene oxide cycles were run at 55°C for60 minutes using a Steri-Vac GS5 –1D (3M, Maplewood, Min-nesota, United States). Hydrogen peroxide cycles were com-pleted using a Sterrad 100S (Advanced Sterilization Products,Irvine, California, United States) with temperatures notFig. 1 Mock surgical guide with designed dimensions. Each measurement has been labelled with its corresponding letter. Designed dimensionswere compared with post-print pre-sterilization dimensions to assess accuracy of each material.Fig. 2 Mock surgical guide in 3-Matic showing imprinted guide label.Each guide was created with the mate rial name, sterilization methodand model number in the upper right corner. These ‘negative ’featureswere assessed subjectively for clarity pre and post sterilization..exceeding 55°C for 48 minutes. Indicator tape or colourchange markers on packaging were used to determine ifsterility had been achieved (standard protocol for clinicalcases at our institution).Post-sterilization MeasurementsTo minimize bias, measurements were performed by a singleauthor (DMM) without viewing pre-sterilization data. Meas-urements were also made at least 1 week after pre-steriliza-tion data were collected so that the investigator could notremember previous results. Measurements were completedas described for pre-sterilization samples.Statistical AnalysisSample size ( n¼5 / material / sterilization method) wasbased on previous studies using 3D printed or machinedmodels.6,29 –31Data distribution was evaluated for normali-ty using the Shapiro –Wilk test. Mean dimensional differ-ences (absolute value) between the designed guide and pre-sterilization models were first compared using a pairedstudent t-test ( n¼15 / material). Then, pre- and post-sterilization groups were compared using a two-factorrepeated measures analysis of variance. Post-hoc Tukeytests were performed when signi ficant differences wereidenti fied. Signi ficance was set at p-value less than 0.05.Descriptions of printing time and resin volume were alsorecorded.ResultsPre-sterilization Dimensional AnalysisLinear DimensionsA-B: Differences between designed and post-print dimen-sions were identi fied in the SG ( p<0.0001), BA ( p¼0.02) andBC (p<0.0001) materials.B-C: No signi ficant differences were identi fied in anymaterial.A-C: All materials had signi ficantly different dimensions. Themost accurate mean was observed in the BA ( þ0.01/C60.01 mm,0.05%D), while the least accurate was the SG ( þ0.04/C60.04 mm,0.2%D).Width: Signi ficant differences were identi fied in SG ( /C00.02/C60.03 mm [ /C00.05% D],p¼0.009), BA ( þ0.01/C60.02 mm[0.03% D],p¼0.006) and BB ( /C00.01/C60.01 mm [ /C00.03% D],p<0.001).Height: The only difference identi fied was in the SGmaterial ( þ0.04/C60.04 mm [0.1% D],p¼0.002).Fig. 3 Orientation of the mock guides on the Form 3B build platform. Guides were all oriented similarly to ensure homogeneity among samples..Tube and Thickness DimensionsTube Inner Diameter (ID): Differences were identi fied in theBA (þ0.01/C60.01 mm [0.15% D,p¼0.03), BC ( /C00.03/C60.04mm [ /C00.47% D],p<0.0001) and BB ( /C00.01/C60.01 mm[/C00.15%], p<0.001) materials.Tube Outer Diameter (OD): The SG ( /C00.03/C60.02 mm,/C00.3%D) and BB ( /C00.02/C60.02 mm, /C00.2%D)w e r et h eonly materials with differences ( p<0.001 for both).Tube Height: The only material with signi ficantly differentdimensions was the BB ( /C00.03/C60.03 mm [ /C00.11% D],p¼0.008).Thickness: The SG ( /C00.04/C60.03 mm, /C01%D)a n dB B(/C00.02/C60.02 mm, /C00.5%D) were the only materials withdifferences noted ( p<0.001 for both).Post-sterilization Dimensional AnalysisLinear DimensionsA-B: Neither material type nor sterilization method had asignificant effect.B-C: Material type had a signi ficant effect when usingsteam sterilization only. The SG resin was the least accurate(/C00.4%D) when compared with the BA ( p¼0.02), BC(p¼0.003) and BB ( p¼0.03) resins, all of which had a 0%change. The type of sterilization did not have a signi ficanteffect.A-C: Material type had a signi ficant effect when usingethylene oxide sterilization only. The BC resin was lessaccurate ( /C00.29% D) than SG (0.05%, p¼0.04), BA (0% D,p¼0.01) and BB ( /C00.05%D,p¼0.005). Sterilization methodaffected only the BC resin, with steam more accurate thanethylene oxide ( p<0.001).Width: Material type had a signi ficant effect when usingethylene oxide sterilization. The BW resin was less accurate(0.51% D) than SG, BA, BC and BB ( p<0.001 for all, range:/C00.05% to /C00.1%D). Similarly, sterilization method had aneffect only on the BW material, with steam and hydrogenperoxide gas more accurate than ethylene oxide ( p<0.001for both).Height: Material had a signi ficant effect for ethylene oxideand peroxide gas. For ethylene oxide, BW was more accuratethan BC ( p<0.001). For peroxide, BW was less accurate thanSG and BB ( p¼0.005 and p¼0.04 respectively). Sterilizationmethod affected only BW with hydrogen peroxide gas show-ing more accuracy than ethylene oxide ( p¼0.003).Tube and Thickness DimensionsTube ID: Material had an effect for ethylene oxide only. TheBW resin was less accurate (2% D)t h a nS G( 0 % D), BA (0% D),BC (/C00.9%D) and BB ( /C00.16% D)w i t h p<0.001 for all.Sterilization method had a signi ficant effect for BC and BWresins. Steam was more accurate for BC and BW than ethyleneoxide ( p¼0.01 and p<0.0001 respectively). Peroxide gaswas more accurate than ethylene oxide for BW resin(p<0.0001).Tube OD: Similar to tube ID, the material had an effect onlywith ethylene oxide. The SG resin was less accurate ( /C00.6%D)than BA (0% D,p<0.001), BC ( /C00.1%D,p¼0.007) and BB(/C00%D,p<0.001). Only the SG material was affected bysterilization method. Similar to other measurements, steamwas more accurate than ethylene oxide ( p<0.001).Tube Height: Neither material nor sterilization methodhad a signi ficant effect.Thickness: Material type had an effect for ethylene oxideonly. The BW resin was less accurate (2.4% D)t h a nB Aa n dB B(0%D,p¼0.001 and 0.2% D,p¼0.02 respectively. The BWresin was the only one affected by sterilization method,where steam was more accurate than ethylene oxide(p¼0.02).Printing Times, Resin Use, Colour ChangePrinting time for six guides (the maximum number of guideswhich fit on the build platform each printing session) was asfollows: SG (4 hours), BA (5 hours, 15 minutes), BC (3 hours,30 minutes), BW (7 hours, 16 minutes) and BB (5 hours,20 minutes). The volume of resin used for six guides wassimilar among all materials (128.3 /C62.7 mL).Colour change following sterilization was noted for the SGand BA resins, with steam creating a lighter replica thanethylene oxide or peroxide gas when compared with initialpost-print coloration.

Question 176

Kilduff-Taylor - 2023 - JSAP - Endoscopic treatment of acute oropharyngeal stick injuries in dogs - 46 cases (2010-2020).pdf

Answer 176

Study design and inclusion criteriaMedical records and associated attachments (referral reports) for dogs examined between January 2010 and December 2020 at a UK referral centre were searched by a single operator for the pres -ence of OSI. The following keywords were used: OSI, OPSI (oro -pharyngeal stick injury), oropharyngeal and stick. Records were assessed for eligibility and only acute cases that had endoscopy of the OSI wound were included. Acute OSIs were defined as presenting less than 7 days after injury. Any records with missing or incomplete information were excluded. Information obtained from the clinical records included signalment, bodyweight, pre -senting signs, time from injury, radiographic and/or CT findings, findings at endoscopy and long- term clinical outcome.Endoscopy of OSIPremedication was determined on an individual basis but always included an opioid, such as 0.2 to 0.3 mg/kg intramuscular or intravenous methadone (Synthadon; Animalcare UK), in com -bination with a sedative such as 0.005 to 0.02 mg/kg intramus -cular or intravenous medetomidine (Sedator; Animalcare UK) or 0.005 to 0.02 mg/kg intramuscular or intravenous acepromazine (ACP; Novartis). Perioperative antibiotics were administered in some cases at the surgeon’s discretion. These included 20 mg/kg intravenous amoxicillin- clavulanate (Co- Amoxiclav; San -doz UK), 20 mg/kg intravenous amoxicillin- clavulanate (Co- Amoxiclav; Sandoz UK) combined with 15 mg/kg intravenous metronidazole (Metronidazole; B. Braun), or 20 mg/kg intrave -nous cefuroxime (Zinacef; GlaxoSmithKline UK).Induction of anaesthesia was achieved by intravenous injec -tion of 4 mg/kg propofol (Propoflo; Zoetis UK) and maintained using isoflurane (Isoflo; Zoetis) in oxygen via a cuffed endotra -cheal tube. Lactated Ringers solution [Vetivex 11 (Hartmann’s); Dechra] was administered intravenously at a rate of 5 mL/kg/h for the duration of anaesthesia.A thorough oropharyngeal examination was performed using a laryngoscope and any visible pieces of stick were removed manually. After placement of a mouth gag, 0° and 30° forward- oblique, 2.7 mm diameter, 18 cm length rigid endoscopes with a corresponding 14.5 French sheath [Karl Storz Endoscopy (UK) Ltd] were used to explore all oropharyngeal wounds and tracts. The endoscopy was performed using a gravity- fed saline irriga -tion system via an infusion port on the endoscopic sheath. Any visible foreign material was grasped using forceps fed through the sheath and removed. Further low- pressure saline lavage was then performed to eliminate any remaining foreign material. Foreign material was not submitted for culture. The endoscopic proce -dure was carried out by European board- certified surgeons or a surgical resident under direct supervision by a board- certified surgeon in all cases.In cases where oesophageal injury was suspected, a flexible endoscope or sigmoidoscope was used to visualise the oesopha -gus, and if oesophageal injury was identified, this was managed by either oesophageal bypass [using an oesophagostomy or percu -taneous endoscopic gastrostomy (PEG) tube] or ventral cervical surgical exploration was performed, with or without oesophageal bypass post- operatively. In most cases with soft palate injury, the defect was repaired using 1.5 to 3 metric polyglactin 910 (Vicryl; Ethicon) in a simple interrupted or simple continuous pattern. In cases where the extent of the oropharyngeal injury tract could not be reached with endoscopy alone, or according to individual surgeon’s discretion, open surgical exploration was performed.All dogs were discharged with oral broad- spectrum antibiot -ics, e.g. 20 mg/kg oral amoxicillin- clavulanate twice daily (Synu -lox; Zoetis UK) for 5 to 42 days. Dogs were also discharged with an oral non- steroidal anti- inflammatory analgesic, e.g. 0.1 mg/kg oral meloxicam (Metacam; Boehringer Ingelheim), once daily, 4 mg/kg oral carprofen (Carprieve; Norbrook) once daily, 17485827, 2023, 10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13642 by Vetagro Sup Aef, Wiley Online Library on [19/10/2023]. 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 LicenseEndoscopy of acute oropharyngeal stick injuriesJournal of Small Animal Practice • Vol 64 • October 2023 • © 2023 British Small Animal Veterinary Association. 637 or 10 mg/kg oral paracetamol three times daily for 5 to 14 days. Depending on whether a feeding tube had been placed and the nature of the oropharyngeal injury, patients were discharged with a nil per os (liquid tube feeds only) or soft food regime. In all cases, re- examination by the referring veterinary surgeon was rec -ommended within a few days of discharge.ComplicationsComplications were classified as minor if medical treatment was required and major if repeat endoscopy or surgical intervention was needed. Outcomes were defined as excellent if dogs had com -plete resolution of signs with no recurrence and poor if progres -sion to chronic OSI occurred.Follow- upThe long- term clinical outcome was established using a combi -nation of examination by the referring veterinary surgeon and by telephone survey of owners. Owners were asked whether the dog was still alive, general health, exercise tolerance, presence of any coughing, choking or difficulties eating or drinking, and any incidence of cervical swelling or discharge. The minimum follow- up period was 6 months after initial presentation.RESULTSOne hundred and twenty patient records were found using the search keywords. These were assessed for eligibility and 86 dogs with acute and chronic OSI were identified, of which 66 were acute. Of the 66 acute cases, 46 were managed using rigid endoscopy of the wound and associated tract. Records were excluded if they did not clearly identify an OSI either observed by the owner, assumed due to strong circumstantial evidence, or where stick foreign material was removed from the site of injury. No records were excluded due to incomplete clinical information.Signalment and clinical presentationOf the 46 dogs managed using rigid endoscopy of acute OSIs, the most commonly represented breeds were Border Collies (n=12), Springer Spaniels (n=11) Labrador Retrievers and Lab -rador crosses (n=8), Cocker Spaniels and crosses (n=3) and other crossbreeds (n=3). There were also two Staffordshire Bull Ter -riers, two Hungarian Vizslas and one each of golden retriever, Parson Russell Terrier, Pug, French Bulldog, and Cavalier King Charles Spaniel cross.The median age was 3 years old (range 0.6 to 11 years) and median bodyweight was 20.4 kg (range 7.7 to 38.4 kg). There were 27 males (58.7%) and 19 females (41.3%). T wenty patients (43.5%) presented on the same day as the injury, 15 (32.6%) presented between 24 and 48 hours after injury, and the remain -ing 11 (23.9%) presented between 72 hours and 7 days after injury. The median time from injury to presentation was 1 day (range 2 hours to 7 days). All owners recognised when the trauma occurred, although not all owners directly observed penetration of the stick into the oropharynx. Only 10 (21.7%) dogs had a visible stick removed by the owner (n=5, 10.9%) or referring vet (n=5, 10.9%). The remainder were not observed to have a grossly visible stick present at the time of injury by the owners.The presenting clinical signs are summarised in Table 1. Oral/neck pain (n=29; 63.0%), oral bleeding (n=25; 54.3%), lethargy (n=25; 54.3%), cervical swelling (n=22; 47.8%) and anorexia (n=20; 43.5%) were the most common clinical signs. Pyrexia (n=6; 13.0%) was relatively uncommon.Pre- endoscopic imagingThirty- eight out of 46 dogs (82.6%) had pre- endoscopic imag -ing consisting of radiographs, CT scan, or a combination of radiographs and CT scan. Of these 38 dogs, 30 (78.9%) had radiographs performed, with 27 (71.1%) carried out by the refer -ring veterinary surgeon, of which seven had radiographs repeated after referral, and three had radiographs performed after referral only. T wenty- one out of the 38 dogs (55.3%) had a CT scan, of which 11 (28.9%) had both radiographs and CT. Cervical emphysema was detected in 25 out of 38 dogs that had pre- endoscopy imaging (65.8%), on radiographs (n=12, 31.6%), CT (n=7, 18.4%) or both radiographs and CT (n=6, 15.8%). Fifteen of 38 (39.5%) had pneumomediastinum on radiographs (n=4, 10.5%), CT (n=7, 18.4%) or both radiographs and CT (n=4, 10.5%).Out of 21 dogs that had a CT scan, foreign material was removed from nine (42.9%) during endoscopy. Six dogs had a distinct foreign body detected on CT. Out of the three that did not have a foreign body detected on CT, all fragments of stick that were removed endoscopically were 5 mm or less in length. Interestingly, all three dogs had mineral attenuation material noted on the CT scan. One dog that had a CT scan and no for -eign material detected also had no evidence of foreign material at endoscopy. This dog developed chronic abscessation 21 days after initial presentation and a 15 mm stick fragment was recovered at open surgery. Out of 13 dogs that had foreign material removed at endoscopy and also had pre- endoscopic radiographs, only one had a foreign body detected on radiographs.One dog had cervical ultrasonography performed without further imaging and this identified a 5- cm long stick fragment lateral to the larynx.The site of stick penetration is summarised in Table 2. The most common site was the pharynx in 21 cases (45.7%). In 11 Table 1. Summary of presenting clinical signs of 46 dogs that had acute oropharyngeal stick injuryPresenting sign Number of dogs %Oral/neck pain 29 63.0Oral bleeding 25 54.3Lethargy 25 54.3Cervical swelling 22 47.8Anorexia/hyporexia 20 43.5Hypersalivation 17 37.0Retching 16 34.8Coughing 14 30.4Pyrexia 6 13.0Lameness 5 10.9Dyspnoea 5 10.9Recumbent/collapse 3 6.5 17485827, 2023, 10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13642 by Vetagro Sup Aef, Wiley Online Library on [19/10/2023]. 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 LicenseA. Kilduff- T aylor and S. J. BainesJournal of Small Animal Practice • Vol 64 • October 2023 • © 2023 British Small Animal Veterinary Association. 638cases (23.9%), both a pharyngeal and soft palate injury were present. Only four dogs (8.7%) had oesophageal injury.Injury tract lengths and presence of foreign materialAn oropharyngeal injury and associated caudally- directed tract between 1 and 20 cm in length, with a limit that could be reached with endoscopy, was present in 44 out of 46 dogs (95.7%). T wo dogs (4.3%) had tracts that were too long to appreciate a caudal limit on endoscopy: one had a tract extending into the mediasti -num and the other had a tract extending subcutaneously over the shoulder. Foreign material was retrieved endoscopically from 23 out of 46 (50.0%) OSI tracts. In the remaining 23 dogs (50.0%), no foreign material was identified and endoscopic lavage was per -formed.Of the 23 patients with foreign material present, a stick frag -ment measuring between 5 and 20 cm in length was removed via the mouth using gentle traction in four patients (17.4%). All of these required subsequent endoscopic lavage to remove small fragments of foreign material left behind after large stick frag -ment removal. T wo patients (8.7%) had small wood fragments removed endoscopically as well as removal of a 5 cm stick frag -ment in one case, and a 20- cm stick fragment in the other at subsequent open surgery. The remaining 17 dogs (73.9%) had small pieces of wood and bark measuring between 1 and 30 mm removed using endoscopic grasping forceps.Open surgeryFour dogs had open surgical exploration in conjunction with OSI tract endoscopy under the same general anaesthetic event. One dog had a 5- cm long stick fragment lateral to the lar -ynx identified using ultrasonography. During endoscopy a sublingual tract was explored and small wood fragments were retrieved. However, open surgery was required to remove the larger stick fragment. The second dog had a palpable stick in the shoulder region, confirmed on radiographs. The loca -tion of the tract was the dorsal oropharynx and a caudal limit could not be reached with endoscopy. A combined treatment approach using open surgery over the shoulder to remove the stick and endoscopic lavage of the oropharyngeal tract was uti -lised in this case.A third dog had subcutaneous emphysema and pneumo -mediastinum on radiographs, and no foreign body visible on endoscopy of the tract, the entrance of which was located dorsal to the oesophagus in the oropharynx. Ventral cervical surgical exploration was undertaken to assess for damage caudal to the extent of the oropharyngeal tract, but no further abnormalities were found. The fourth dog had a tract extending from the oro -pharynx, through the oesophagus, down to the cranial medias -tinum and laterally to the left axilla. Endoscopy identified the oropharyngeal and oesophageal injuries but surgical exploration was required to follow the full extent of the tract and to lavage and debride the defect because the tract was too long for endos -copy alone.Complications during hospitalisationFive patients (10.9%) had minor complications during hospi -talisation. These comprised gastrointestinal signs (regurgitation or vomiting) in four dogs, and neutropenia and increased liver enzymes in one dog which resolved 2 weeks post endoscopy. Supportive treatment included drugs such as maropitant and omeprazole, and use of an easily- digestible diet.Three patients (6.5%) had major complications during hospi -talisation. Of these, one dog had possible pre- existing aspiration pneumonia detected on radiography. This dog was not improv -ing as much as expected so had repeat endoscopy 3 days after the initial endoscopy, where no further foreign material was recov -ered, and a PEG tube was placed. Apart from persistent mild coughing and throat clearing after drinking this dog had no fur -ther complications.The second dog with major complications developed a cer -vical abscess 2 days after endoscopy, having been presented 2 hours after the OSI. Repeat endoscopy was performed, and grass foreign material was found in the tract. Culture of the purulent material produced Escherichia coli sensitive only to marbofloxacin and Enterococcus sp. sensitive to amoxicillin- clavulanate but not to marbofloxacin. Marbofloxacin (2 mg/kg, intravenously, once daily; Marbocyl; Vetoquinol UK) was added to the amoxicillin- clavulanate (20 mg/kg, intravenously, three times daily; Co- amoxiclav; Sandoz UK) that the dog was already receiving. This was followed by oral versions of both antibiotics for 6 weeks. The abscess was opened through the skin and subsequently a large necrotic area of skin sloughed from the ventral neck and was managed as an open wound. The dog developed azotaemia and bilirubinaemia secondary to sepsis but made a full recovery.The third dog developed cervical swelling 3 days after endos -copy and open surgical exploration of an oesophageal injury with extension into the pleural space necessitating chest drain place -ment. Further surgical exploration showed dehiscence of an oro -pharyngeal wall defect repair which was resutured. The following day inspiratory dyspnoea developed because of pharyngeal swell -ing. This dog was euthanased at this stage due to a guarded prog -nosis.The median time from admission to discharge was 1 day (range 0 to 17 days). Patients that had complications during hospitalisation had a median time to discharge of 3 days (range 1 to 17 days) and patients without complications during hos -pitalisation had a median time to discharge of 1 day (range 0 to 6 days).Table 2. Distribution of sites of oropharyngeal penetration in 46 dogs with acute oropharyngeal stick injurySite of injury Number of dogs %Pharynx † 21 45.7Soft palate ‡ 13 28.3Sublingual 11 23.9Tonsil 9 19.6Oesophagus § 4 8.7Larynx 2 4.3†Eleven cases had both a pharyngeal and soft palate injury‡Two cases had both a soft palate and oesophageal injury§One case had both an oesophageal and pharyngeal injury 17485827, 2023, 10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13642 by Vetagro Sup Aef, Wiley Online Library on [19/10/2023]. 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 LicenseEndoscopy of acute oropharyngeal stick injuriesJournal of Small Animal Practice • Vol 64 • October 2023 • © 2023 British Small Animal Veterinary Association. 639 Complications after dischargeOne patient developed major complications post discharge. This patient developed a cervical abscess 20 days after discharge which was managed initially with drainage and metronidazole antibi -otic therapy (10 mg/kg orally, twice daily, for 10 days) by the referring veterinary surgeon. Culture of the purulent fluid by the referring veterinary surgeon was negative. After lack of resolution of the cervical swelling the dog was referred again and a repeat CT scan suggested the presence of persistent foreign material. Surgical resection of chronic inflammatory material and a piece of bark resulted in resolution of the cervical abscess.Complications in the 42 patients that were managed with rigid endoscopy only without open surgery were as follows: five out of 42 patients (11.9%) had minor complications during hos -pitalisation; two out of 42 patients (4.8%) had major complica -tions during hospitalisation; one out of 37 patients (2.7%) with follow- up available had major complications post discharge. The overall outcome in patients that received endoscopy only and had follow- up available was excellent in 36 out of 37 (97.3%).OutcomesLong- term follow- up was available for 40 of 46 patients (87.0%) that had endoscopy performed. The overall outcome was excel -lent in 38 of 40 (95.0%) cases. One of these 40 patients was euthanased before discharge and one dog had major complica -tions after discharge as discussed above. The median follow- up time was 48 months (6 to 134 months). Out of 40 dogs, 33 (82.5%) were alive at the time of follow- up and no dogs were euthanased because of complications relating to OSI after dis -charge from the hospital. Owners reported transient signs of coughing, panting, voice changes or cervical swelling in the first 2 weeks post discharge in seven of 39 (17.9%) dogs. Persistent, but mild signs reported by owners include coughing or choking when drinking, change in voice, coughing or exercise intolerance when playing with a ball in eight dogs (20.5%). All owners per -ceived that these signs did not affect the dog’s quality of life.For information on patients with acute OSIs that were man -aged without the use of rigid endoscopy please see Appendix S1.

Question 177

Pearson - 2023 - JAVMA - Synovial sepsis diagnostics and antimicrobial resistance - a one-health perspective.pdf

Answer 177

NA

Question 178

Fracka - 2023 - VCOT - Three-Dimensional Morphometry of the Canine Pelvis - Implications for Total Hip Replacement Surgery.pdf

Answer 178

Study PopulationThis was a descriptive study of CT images from client-owned dogs. Dogs were included if they were skeletallymature (as determined by closed growth plates), had a CTscan of the entire pelvis and had no radiographic evidenceof hip joint disease. The CT scans of immature dogs or dogswith pelvic or hip pathology were excluded from the study.Owners provided informed consent for the use of theirdog ’s imaging data in this study. Three-dimensional data(slice thickness <1 mm) were exported in Digital Imagingand Communications in Medicine (DICOM) format tomedical engineering software (MIMICS version 24.0; Ma-terialise, Leuven, Belgium) to build the in-silico pelvicmodels. The models were segmented on a bone algorithm,smoothed (2 cycles at 0.4) and wrapped (smallest detail1 mm, gap closing 0.5 mm) to minimize artifacts from CTthat could affect measurements. The pelvic models wereexported further as Standard Tessellation Language (STL)files to a mesh-based 3D measurement and design soft-ware (3-Matic version 16.0; Materialise, Leuven, Belgium)for analysis.Anatomical Measurements from CT ScansFor the purpose of measurement, anatomical pelvic land-marks and reference planes were established. Four standard-ized landmarks were identi fied to de fine the alignment planeof the pelvis –the cranial dorsal iliac spines on the left andright sides and the ischial tuberosities on the left and rightsides (►Fig. 1A ). The dorsal plane of the pelvis was de fined bycreating a datum plane that intersected with three of the fourlandmark points (►Fig. 1B ). This plane ran along the iliois-chial line and at right angles to the median plane. The medianplane of the pelvis was de fined by creating a datum planethat bisected the line between the two ischial landmarks(►Fig. 1C ). The third pelvic plane, the transverse plane, wasdefined by creating a datum plane that intersected with thetwo ischial points and that was perpendicular to the dorsalpelvic plane. This plane was set at right angles to both themedian plane and the dorsal pelvic plane ( ►Fig. 1D ).The acetabulum was de fined by marking triangles along thelunatesurface of the acetabulum ( ►Fig. 2A ) and de fining a bestfit sphere ( ►Figs. 2B ). The centre of the acetabulum wasidenti fied by a point, representing the coordinates of thecentre of thebest- fit sphere inside the acetabulum ( ►Figs. 2C ).The orientation of the ventral acetabular rim was de fined bymarking the triangles that form the cranial and caudal rims ofthe ventral acetabulum ( ►Fig. 3A ). A plane –the ventralacetabular plane –was then de fined by best fitting to thesehighlighted triangles ( ►Fig. 3B ). The acetabular orientationplane was de fined as a plane that was perpendicular to boththe ventral acetabular plane and the dorsal pelvic plane, and thatpassed through the centre point of the acetabulum (►Fig. 3C ).The version angle was measured as the angle formedbetween the acetabular orientation plane and the transverseplane (►Fig. 4A ).The ALO, the angle formed between the ventral acetabularplane and the median plane, was measured in the transverseplane for the left and right acetabula ( ►Fig. 4B ).Data Handling and Statistical AnalysisAll data were collated and analysed using a commercialspreadsheet (Microsoft Excel for Mac version 16.62; Micro-soft Corporation, Seattle, Washington, United States). Themean and standard deviation were calculated for ALO andversion angles for each hemipelvis. Left-right differenceswere evaluated using a paired t-test, with signi ficance setatpless than 0.05, and with the symmetry index, accordingto the following formula:Symmetry index ¼100/C3(Right-Left)/(0.5/C3(Right þLeft))For the determination of intra-observer repeatability, sixhemipelves were each measured three times and the coef fi-cient of variation (%) calculated for both ALO and version. Forthe determination of inter-observer reproducibility, six hemi-pelves were measured independently by two investigators(MJA and ABF) and the coef ficient of variation (%) calculated.ResultsTwenty-seven dogs ful filled the inclusion criteria. Breeds inthis study included Boerboel ( n¼2), Leonberger,.Staffordshire Bull Terrier, Lurcher, Greyhound ( n¼3), Rho-desian Ridgeback ( n¼2), Golden Retriever ( n¼2), GreatDane, cross-breed ( n¼3), Caucasian Shepherd dog, GermanShepherd dog, Doberman, Bullmastiff, American Bulldog,Pyrenean Mountain dog, Bernese Mountain dog, Weimara-ner, Labrador Retriever ( n¼2) and Siberian Husky. Therewere 14 males (10 entire, 4 neutered) and 13 females (5entire and 8 neutered). The median age was 7 years, 5 months(range: 9 months to 12 years, 2 months) and the median bodyweight was 35.8 kg (range: 21 –79 kg).Complete data for ALO and version angles in the 27 pelvesare presented in►Table 1 .T h em e a n( /C6standard deviation)values for the ALO of left and right acetabula were42.60 /C64.15 degrees and 43.14 /C63.92 degrees, respectively.Mean version angles for the left and right acetabula were27.51 /C64.81 degrees and 26.85 /C65.82 degrees. There wereno signi ficant differences between left and right acetabulafor ALO ( p¼0.43) or version angle ( p¼0.43) and the sym-metry index was acceptable (6.8% for ALO, 11.1% for versionangle). The intra-observer coef ficient of variation was 3.5%Fig. 1 Anatomical landmarks and reference planes. (A) Four pelvic points were de fined on the left and right ilia, and the left and right ischia.These landmarks were then used to de fine the three reference planes: dorsal pelvic plane (B), median plane (C) and transverse plane (D)..for ALO and 5.2% for version angle ( ►Table 2 ). The inter-observer coef ficient of variation was 3.3% for ALO and 5.2%for version angle.

Question 179

Emilian - 2024 - VCOT - Use of Locking Plates Fixed with Cortical Screws for Pelvic Fracture Repair in 20 Cats.pdf

Answer 179

CriteriaMedical records of cats with ilial and acetabular fracturesrequiring surgical treatment between April 2015 andApril 2019 admitted at Christchurch Veterinary Referrals(Suffolk, UK) were reviewed. Inclusion criteria for this studywere the following: (1) presence of unilateral or bilateral ilialfracture, acetabular fracture, or both combined that wererepaired by open reduction and internal fixation with alaterally applied SOP locking bone plate and (2) follow-upexamination with radiographic assessment /C216 weeks afterrepair. The following data were recorded: breed, age, sex,body weight, fracture location and con figuration, fracturereduction, number and type of screws per fragment, screwloosening, any displacement of the repaired bone fragments,and intra- and postoperative complications and outcomes.Exclusion criteria included the following: patients treatedwith plating system other than SOP plates and patients thatdid not have a radiographic follow-up.Surgical TechniqueAll patients were premedicated with a combination of mede-tomidine (Medetor Virbac 1 mg/mL) at a dose of 5 µg/kgintramuscularly and methadone (Synthadone, Animalcare)at a dose of 0.5 mg/kg intramuscularly. In addition, somepatients received ketamine (Narketan, Vetoquinol) at a doseof 3 mg/kg for analgesia. Meloxicam (Loxicom, Norbrook) at adose of 0.1 mg/kg was given to all patients pre- and postoper-atively. A cephalic intravenous catheter (22 gauge) was placedand Hartmann ’s solution (Vetivex 11, Dechra) intravenousfluid therapy was administered at a rate of 5 mL/kg/h through-out anesthesia. Anesthesia was induced with alfaxalone(Alfaxan, Jurox) at a dose of 5 mg/kg. All patients were intu-bated with an endotracheal tube. Anesthesia was maintainedwith 1.5% iso flurane (Iso flo, Zoetis) in oxygen, adjusted asnecessary. Intravenous perioperative cefuroxime (Zinacef,GSK) at 15 mg/kg was given preoperatively and repeated at90-minute intervals throughout the procedure.The patients were positioned in lateral recumbency with theaffected hemipelvis uppermost. A lateral approach with glutealrollup was used in all cases to expose the ilium, with greatertrochanter osteotomy when more caudal exposure wasrequired. Greater trochanter osteotomy, together with tenot-omy and re flection of the internal obturator and gemellimuscles, was performed as needed to expose the acetabulumand ischium.24The plate was inserted ventromedially to thesciatic nerve and the gemelli and internal obturator musclesacted as a protective layer between implants and the nerve. Allprocedures were performed by three experienced surgeonsconfid e n ti nt h eu s eo fS O Pp l a t e s .I no n ec a s e ,t h eS O Pp l a t ewas applied from the ilial wing to the ischium without greatertrochanter osteotomy or gluteal tenotomy. After fracture fixa-tion, thesectioned tendonsofthe internalobturatorandgemellimuscles were sutured, followed by fixation of the greatertrochanter osteotomy with Kirschner wire/s and tension bandwire. Intraoperative techniques to reduce and immobilize thefracture fragments included the following: traction applied tothe ischium and greater trochanter or iliac wing, the use of bonereduction forceps, and permanent or temporary Kirschnerwires. A 2.0-mm SOP plate of appropriate length was used forall thefracture repairs. Plates were contoured andapplied to thelateral surface of the pelvis with a minimum of two 2.0-mmcortical screws (Orthomed, Shef field, UK) in each of the cranialand caudal fragments.Postoperatively, patients received methadone (Syntha-done, Animalcare) at a dose of 0.3 mg/kg every 8 hours forthefirst 24 hours. Oral meloxicam (Loxicom, Norbrook) at adose of 0.1 mg/kg was dispensed to be given at home for.2 weeks. The owner was advised to keep their cat in a cage for2 months. Veterinary examination was performed at 7 to10 days, and then 4 and 8 weeks after surgery for clinicalexamination and radiographic assessment of healing.Radiographic EvaluationAll the radiographic evaluations were performed by oneauthor (DEA). Preoperative radiographs of the thorax weretaken in all cases to identify thoracic injuries. Mediolateral andventrodorsal radiographic projections of the pelvis were takenpreoperatively to assess the con figuration of the fractures andwere used to calculate the normal pelvic canal width using thesacral index. The sacral index has previously been de fined asthe ratio of the width of the sacrum at the cranial border (S) tothe width of the pelvic canal at the narrowest point, betweenthe medial cortices of the acetabula (A) as measured on aventrodorsal radiograph.4The sacral index of normal cats hasbeen previously reported as 0.97 /C60.025, and 0.97 was takenas the normal value for cats in this study.4Radiographs takenimmediately after surgery were examined to assess fracturereconstruction (►Fig. 1 ). Fracture alignment and appositionwere subjectively classi fied as anatomical, near anatomical,good, fair, or poor, as described in a previous publication forthe evaluation of canine iliac fractures.25Plate length wasexpressed as a ratio of plate length in millimeters comparedwith the distance from the cranial ilial wing to the caudalaspect of the ischium, measured in millimeters and expressedin percentage. Restoration of pelvic canal width was assessedusing the sacral index.The degree of postoperative pelvic canal narrowing wascategorized as mild (within 10% of the Sacral Index (SI)),moderate (between 10 and 30% of the SI), and severe ( >30%of the SI) as described in an earlier publication.25A negativevalue indicates narrowing of the pelvic canal and a positivevalue indicates canal widening. The number of monocort-ical or bicortical screws inserted in each fragment wasrecorded. Follow-up radiographs performed between 6and 10 weeks after the initial repair were evaluated forevidence of implant failure, maintenance of fracture reduc-tion, maintenance of pelvic canal width (using the sacralindex), fracture healing, and great trochanter osteotomyhealing (►Fig. 2 ).Outcome AssessmentFollow-up clinical examination of all cases was performed at4 weeks following surgery. Earlier or later examinations werealso performed depending on the case progress as well as atthe time of radiographic follow-up.Owner-assessed outcome measures were recorded usingthe Feline Musculoskeletal Pain Index (FMPI; ComparativePain Research Laboratory, North Carolina State University,College of Veterinary Medicine). Owners were contacted viatelephone or e-mail to complete the questionnaire at 6 to12 months (mid-term follow-up) and greater than 12 months(long-term follow-up) after surgery.Function was classed as full, acceptable, or poor accordingto the FMPI responses. Complications were recorded andclassi fied as catastrophic, major, or minor.26Fig. 1 Orthogonal views of a long oblique iliac fracture repair con firming a good apposition, alignment and SOP placement following greatertrochanteric osteotomy..ResultsA total of 33 cats with iliac fractures were admitted into ourpractice over 4 years from April 2015 to April 2019. Of these,one cat was euthanatized, one received femoral head andneck excision arthroplasty, and two were treated with openreduction and internal fixation using a Veterinary CuttablePlate. The remaining 29 cats were treated with 2.0-mm SOPplate and 2.0-mm cortical screw constructs. Of these, 20patients met the inclusion criteria (►Appendix Table 1 ,available in online version only).Nine males and 11 females were included in the study. Themean body weight was 3.9 kg (range: 2.6 –6.2 kg) and the meanage was 33.7 months (range: 11 –144 months). Breed distribu-tion included 16 domestic short hair and 1 each of Bengal,British Blue, domestic medium hair, and domestic long hair.Fracture con figuration description included the follow-ing: 5 oblique iliac shaft fractures (2 right and 3 left); 2 ilialfractures with comminution of the ilial wing (1 right and 1left); 5 comminuted ilial shaft fractures (4 right and 1 left); 2short oblique ilial fractures (both located on the left side);and 2 acetabular fractures without ilial involvement (1 rightand 1 left). Finally, four cats had combined ilial and acetabu-lar fractures, of which three were right and one left.Concurrent injuries were noted in 19 cats. These includedadditional pelvic fractures (pubic 13 and ischial 12), 12 sacroiliacluxations, 8 sciatic neuropathies, 2 tibial fractures, and in 1 eachof large perineal wound, sacrococcygeal luxation, coccygealfracture, femoral capital physeal fracture, and urethral rupture.Details of surgical treatment are given in►AppendixTable 2 (available in online version only). In the chosenrepair constructs, a median of 3.1 screws were placed inthe cranial segment of the fracture (range: 2 –4). Of these, 2cats had only monocortical screws, 2 cats had a combinationof monocortical and bicortical screws, and 16 cats had onlybicortical screws. A median of 2.7 screws were placed in thecaudal segment (range: 2 –5). Of these, 1 cat had onlymonocortical screws, 2 had a combination of monocorticaland bicortical screws, and 17 had only bicortical screws. Themedian total number of screws per repair was 5.85 (range:4–9). Nine cases had additional fixation: positional screw infour cases, lag screw ion three cases, and Kirschner wires intwo cases. Plate screws engaged the sacrum in 14 cases.Immediate postoperative fracture reduction, assessed byradiography, was anatomical in 1 case, near anatomical in 9,good in 8, fair in 1, and poor in 1 case.The overall median sacral index immediately postopera-tively was 0.95 (range: 0.79 –1.24), with narrowing of thepelvic canal in 14 cases and a median reduction of –5.9%(range: –1t o –19%). This narrowing was mild in 11 cases withan average SI change of –3.7% ( –1 to -7%), and moderate in 3with an average SI change of –14% ( –11 to –19%). An increasein the width of the pelvic canal immediately after surgerywas apparent in six cases with a median increase of 7.8%(range: 1 –28%).Details of radiographic follow-up are given in►AppendixTable 3 (available in online version only). The median sacralindex at the time of follow-up radiographs was 0.91 (0.71 –1.21) with narrowing of the pelvic canal in 16 patients and amedian reduction of 5.7% (range: 1 –23%) as assessed be-tween immediate postoperative and follow-up postopera-tive radiographs. This narrowing was mild in 12 cases withan average SI change of 2.7% (1 –7%) and moderate in 4 caseswith an average SI change of 14.7% (11 –23%). Two cases hadno change in the sacral index, while further two cases hadradiographic malpositioning, which would not allow anaccurate calculation of the sacral index.String of Pearls (SOP) screw loosening occurred in threecats at follow-up. In one cat (case 18), the plate had becomedisplaced from its initial postsurgical position. This cat had ahighly comminuted acetabular fracture, which was repairedwith three monocortical screws in the ilium and two mono-cortical screws in the ischium. Case 19 developed looseningof all four monocortical ilial screws without displacement ofthe plate. In case 16, there was lysis around the most cranialilial, and the most caudal ischial screws (both bicortical), butFig. 2 Orthogonal views of the same cat as ►Fig 1 , eight weeks postoperatively. The fracture has healed in an unchanged apposition, with noimplant failure..no implant displacement. Screw fracture developed in case 8and this was noticed as an incidental finding during plateremoval for implant-related infection.Loosening of the sacroiliac screw was evident at follow-up in5 of 11 cases where the contralateral and ipsilateral (case 18)sacroiliac joints were repaired. Loss of reduction occurred inthree out of these five cases. String of Pearls (SOP) screwloosening occurred in one case (case number 18) where therewas also bilateral loss of sacroiliac reduction. In case 19, thesacroiliac luxation was not repaired and the joint displacedfurther at follow-up. Ipsilateral sacroiliac luxation was presentin cases 17 and 18, in case 17, no repair of the ipsilateralsacroiliac luxation was performed with no further displace-mentof thesacroiliac joint present at thefollow-up assessment.A dorsal approach via osteotomy of the greater trochanterwas performed in 11 cases, while in the remaining 9 cases, alateral approach was used. Complications relating to greatertrochanter osteotomy were seen in 6 of 11 cases. Partial orcomplete avulsion of the repaired greater trochanter oc-curred in three cases, breakage of one of the Kirschner wiresoccurred in one case, and implant migration occurred inthree cases, of which two cases had a delayed union.Implants used to repair the greater trochanter osteotomyrequired removal in two cases.Details of complications are given in►Appendix Table 4(available in online version only). There were 20 minor com-plications in 13 cases. Three cases had iatrogenic sciaticneuropraxia that resolved with conservative treatment. Intwo cases, SOP screws loosened, but treatment was notrequired. There were five cases where the screw used forsacroiliac luxation repair loosened and became displaced, butno treatment was required. Of these, sacroiliac alignment wasmaintained in two cases (cases 11 and 12) and lost in three(cases 1, 17, and 18). Where alignment was lost, mild tomoderate displacement was experienced and no further treat-ment was necessary. In one of the two cases (case 19) wheresacroiliac luxation was managed conservatively, further dis-placement of the luxationwas appreciated at follow-up, but nointervention was required. Minor greater trochanter osteot-omy complications included avulsion (3 cases), delayed union(2 cases), and implant failure (2 cases). Of the cats treated withSOP as the sole method of fixation, two developed majorcomplications (screw pullout) and one developed a minorcomplication (screw loosening). Of the cats treated with SOPand adjunctive fixation, one developed a major complication(infection requiring explantation) and one developed a minorcomplication (lysis around two screws).Overall, five cats had major complications. Two catsrequired removal of implants used for greater trochanterosteotomy repair (cases 14 and 19). Three cats requiredremoval of the SOP plate and screws: one for infection(case 8) —one screw and one Kirschner wire were found tobe broken; one for sciatic nerve impingement by the plate(case 9); and one for screw loosening (case 18 —all monocort-ical screws). In all cases where a major complication wasencountered, additional minor complications were also pres-ent. No catastrophic complications were seen. None of the catstreated with SOP plates in our study had any dif ficulties withurination, defecation, or developed megacolon.Owner-assessed outcome follow-up was available for 18of 20 patients, with 2 patients lost to follow-up (one killed ina road traf fic accident and one rehomed). Results are given in►Appendix Table 5 (available in online version only). Medi-um-term follow-up was available for 5 cats (range: 27 –50weeks; mean: 41.6 weeks), and long-term follow-up wasavailable for 13 cats (range: 59 –234 weeks; mean: 127.5weeks). All five cats with medium-term FMPI scores had fullfunction (range: 97 –100%; median: 98.6%). Visual analogscores revealed no pain at the time of the questionnaire norin the previous 14 days for four cases, while case 20 revealeda score of 90 out of 100 mm (low-intensity pain) for theprevious 14 days and no pain for the current day. All 13 catswith long-term FMPI scores achieved full function (range:92–100%; median: 98.3%). Of these cases, visual analogscores revealed no pain at the time of completing thequestionnaire, or during the previous 14 days, for 12 cases.Case 1 had a score of 30 out of 100 mm (moderately limitingpain) for the previous 14 days, and 70 out of 100 mm (high-intensity pain) for the current day.

Question 180

Fontes - 2023 - JAVMA - Long-term outcomes associated with a modified versus traditional closed anal sacculectomy for treatment of canine anal sac neoplasia.pdf

Answer 180

Case selection criteriaThe electronic medical records of The Ohio State University College of Veterinary Medicine and the University of Illinois College of Veterinary Medicine were searched to identify dogs with a histopatholog -ic diagnosis of AGASACA that underwent anal saccu -lectomy surgery with either the traditional closed or modified closed technique between January 1, 2016, and December 31, 2020. Search terms included anal sacculectomy, anal sac mass, and anal sac neopla -sia. To be included in the study, dogs were required to have undergone preoperative imaging (abdomi -nal ultrasound [AUS], CT, or thoracic radiographs [CXR]); complete preoperative physical examina -tion, surgery, and histological examination reports; and ≥ 250 days of clinical follow-up. Dogs that died before the minimum 250-day follow-up period were included in the study. Follow-up was performed by 2 investigators (GSF and JMT) with the referring vet -erinarian if there was no documented examination at the contributing institution ≥ 250 days following sur -gery. Owner follow-up via email or telephone was at -tempted if data were not available from the referring veterinary clinic. Dogs were excluded from the study if the anal sacculectomy surgery was performed for nonneoplastic disease, an open anal sacculectomy was performed, or the dog was lost to follow-up < 250 days following surgery.Medical records reviewData collected from the medical records includ -ed signalment and examination findings at the time of initial presentation, results of any preoperative laboratory analyses, and abnormal results of diag -nostic imaging or other diagnostic tests (eg, fine-needle aspiration and cytology) if applicable. Any perioperative treatments, antimicrobial, and neoad -juvant therapy (including radiation therapy and che -motherapy) administered were recorded.The anesthesia and surgery records were re -viewed, and the type of anal sacculectomy per -formed, traditional or modified, was classified on the basis of previously reported procedure descrip -tions.9,10 The laterality of anal sacculectomy and con -current procedures that were performed were noted. Histological examination findings of excised tissue and any postoperative treatments were recorded.A complication was defined as any adverse event associated with the preoperative time period (before surgical intervention), intraoperative time period (the time of skin incision to skin closure), or postoperative time period (after skin closure).11 Any intraoperative and postoperative complica -tions were evaluated and graded retrospectively via medical record review. Intraoperative complications were graded (from 0 [no deviations from the ideal surgical course] to IV [intraoperative death]) by use of the Classification of Intraoperative Complication System.12 Postoperative complications were graded (from 0 [minimal complications] to 4 [postoperative death]) by use of the Contracted Accordion Severity Classification system.13 Postoperative complications were categorized as short-term (from the time of hospitalization to recheck examination 10 to 14 days following surgery) or long-term (the time period fol -lowing recheck examination).Local recurrence was suspected by either physi -cal examination (digital rectal palpation) or confirmed with diagnostic testing (fine-needle aspiration and cytology, histopathology, or CT). Confirmed meta -static disease was determined with recheck of thorac -ic diagnostic imaging (CT or CXR), or abdominal di -agnostic testing (fine-needle aspiration and cytology or histopathology). Suspected metastatic disease was determined with abdominal imaging (CT or AUS) but without cytological or histopathological confirmation.Statistical analysisDescriptive statistics were calculated to summa -rize dog signalment information at the time of sur -gery. Continuous variables were assessed for normal -ity with Shapiro-Wilk tests. Normally distributed data were reported as mean ± SD, and nonnormally distrib -uted data were reported as median and IQR. Time to local recurrence was calculated as the number of days from the date of surgery to the date of detected local recurrence. Time to metastasis was calculated as the number of days from the date of surgery to the date of detected metastasis, either confirmed or suspect -ed. The median duration of follow-up was calculated as the number of days from the date of surgery to the date of death, euthanasia, or last follow-up. Survival Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 11/03/23 06:54 AM UTC 3time was calculated as the number of days from initial diagnosis to the date of death or euthanasia. Com -plication rates and recurrence proportions were com -pared using Fisher exact tests. Factors with a P value < .05 were considered significant for all comparisons. All statistical analyses were performed using statisti -cal software (SAS version 9.4; SAS Institute Inc).ResultsDogsA total of 137 dogs that underwent anal sacculecto -my were initially identified following an electronic medical record search. Of these, 47 dogs were excluded from the statistical analysis. Reasons for exclusion included the fol -lowing: incomplete medical records (n = 21), surgery was performed for nonneoplastic disease (12), loss to follow-up (6), an open anal sacculectomy was performed (4), and duplicate records (4).Thirty-five dogs were identified that had a modified closed anal sacculectomy performed and met the inclusion criteria. Of the 35 dogs, 22 (62.9%) dogs were treated at The Ohio State University College of Veterinary Medicine and 13 (37.1%) dogs were treated at the University of Il -linois College of Veterinary Medicine. Fifty-five dogs were identified that had a traditional closed anal sacculectomy and met the inclusion criteria. Of the 55 dogs, 36 (65.5%) and 19 (35.5%) dogs were treated at The Ohio State Univer -sity College of Veterinary Medicine and the University of Il -linois College of Veterinary Medicine, respectively. Dog de -mographics by procedure (modified or traditional closed anal sacculectomy) are presented (Table 1) .Clinical findingsModified closed anal sacculectomy group —Thir -ty-four dogs had unilateral, palpable anal sac masses (19 left-sided and 15 right-sided), and 1 dog had bi -lateral disease. The median maximum dimension of the anal sac mass found on physical examination was 2 cm (IQR, 5.8; range, 0.2 to 6 cm). Twenty had fine-needle aspiration and cytologic examination of the anal sac mass performed, and all but 2 had findings consistent with carcinoma. These 2 provided diagno -ses of inflammation and basilar epithelial neoplasm.All dogs had preoperative laboratory analysis (CBC, chemistry profile, or venous blood gas) performed, and 4 dogs had hypercalcemia (elevated total calcium). All dogs underwent diagnostic imaging for staging pur -poses before surgery, including CT alone (n = 14), AUS and CXR (6), CT and AUS (1), and CT and CXR (14). Six dogs had aspirates of their enlarged iliosacral lymph nodes, which confirmed metastatic disease.Six dogs had additional aspirates performed on other organs (liver and spleen), and 3 dogs had ad -ditional aspirates performed on nonregional lymph nodes (mandibular, periaortic, and popliteal). No dogs had evidence of metastatic disease identified in these organs or lymph nodes.Twelve dogs had a history of antimicrobial use (within 30 days prior to surgery), and none under -went neoadjuvant therapy before surgery (within 30 days prior to surgery).Traditional closed anal sacculectomy group —Fifty-one dogs had unilateral, palpable anal sac masses (28 left-sided and 23 right-sided), and 4 dogs had bilateral disease. The median maximum dimension of the anal sac mass found on physical ex -amination was 3 cm (IQR, 9.7; range, 0.3 to 10 cm). Thirty-five had fine-needle aspiration and cytologic examination of the anal sac mass performed, and all had findings consistent with carcinoma.All dogs had preoperative laboratory analysis (CBC, chemistry profile, or venous blood gas) performed, and 12 dogs had hypercalcemia (elevated total calcium). All dogs underwent diagnostic imaging for staging Demographic Total Modified TraditionalAge (y) Median (range) 10.2 (9.7) 11.02 (9.7) 10.1 (8.7)Weight (kg) Median (range) 24.8 (51.3) 23.2 (37.2) 25.5 (51.2)Body condition score (1–9) Median (range) 5 (6) 6 (5) 5 (6)Sex Intact female 0 0 0 Spayed female 16 9 7 Intact male 2 0 2 Neutered male 72 26 46Breed American 1 0 1 Staffordshire Terrier Australian Shepherd 2 1 1 Basset Hound 1 0 1 Beagle 2 0 2 Border Collie 3 2 1 Cavalier King 1 1 0 Charles Spaniel Cocker Spaniel 1 1 0 Coton de Tulear 1 1 0 Dachshund 2 0 2 English Bulldog 1 0 1 Flat Coated Retriever 1 0 1 German Shepherd 3 0 3 Dog Golden Retriever 3 3 0 Labrador Retriever 6 1 5 Lhasa Apso 1 0 1 Maltese 3 1 2 Miniature Dachshund 1 1 0 Miniature Schnauzer 3 1 2 Rhodesian Ridgeback 1 0 1 Sheltie 1 0 1 Shetland Sheepdog 1 1 0 Siberian Husky 1 0 1 Springer Spaniel 3 1 2 Standard Dachshund 1 0 1 Standard Poodle 1 1 0 Toy Poodle 1 0 1 Vizsla 1 0 1 Weimaraner 1 0 1 Welsh Springer 1 1 0 Spaniel Yorkshire Terrier 1 1 0 Mixed-breed dog 40 17 23Institution Illinois 32 13 19 Ohio 58 22 36Table 1 —Patient demographics including median age, weight, and body condition score; sex; and breed of dogs presenting for a closed (modified or traditional) anal sacculectomy.Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 11/03/23 06:54 AM UTC4 purposes before surgery, including AUS alone (n = 6), CT alone (19), AUS and CXR (20), CT and AUS (1), CT and CXR (6), and all 3 modalities (3). Sixteen dogs had aspirates of the iliosacral lymph nodes fol -lowing diagnostic imaging, which confirmed meta -static disease in all but 1 dog.Fourteen dogs had additional aspirates performed on other organs (liver, lung, and spleen), and 2 dogs had additional aspirates performed on nonregional lymph nodes (prescapular and popliteal). Of those 14 dogs, 3 had evidence of metastatic disease (lung, n = 1; and spleen, 2). Nine dogs had a history of antimicrobial use (within 30 days), and none underwent neoadjuvant therapy before surgery (within 30 days).Surgery —All 90 dogs underwent surgical exci -sion of the primary mass, which included anal saccu -lectomy. The choice of modified versus traditional closed method was surgeon preference. All proce -dures were performed by an American College of Veterinary Surgeons board-certified surgeon or a trainee under direct supervision.Modified closed anal sacculectomy group —Thirty-five dogs underwent the modified closed anal sacculec -tomy procedure. In 16 dogs, at least 1 additional surgical procedure was performed during the same anesthetic episode. Half of these dogs (n = 8) had iliosacral lymph node extirpation performed. Aside from lymph node ex -tirpation, other surgical procedures performed included mass removal (n = 6), liver lobectomy (1), unilateral to -tal ear canal ablation and bulla osteotomy (1), central hepatic mass microwave ablation (1), and unilateral kidney omentalization (1). Intraoperative complications were seen in 3 (8.6%) dogs. Five (14.3%) dogs had minor postoperative complications that resolved with medi -cal management. Medical management included open wound management (n = 3), physical therapy follow -ing nonambulatory paresis suspected to be secondary to epidural administration (1), discontinuation of pre -scribed nonsteroidal anti-inflammatory medication (1), and administration of an antimicrobial (1). Adjuvant treatment, chemotherapy IV or PO, was pursued in 16 (45.7%) dogs. Dog intra- and postoperative outcomes by procedure (modified or traditional closed anal sacculec -tomy) are presented (Table 2) .Traditional closed anal sacculectomy group —Fifty-five dogs underwent the traditional closed anal sacculectomy procedure. In 39 dogs, at least 1 addi -tional procedure was performed during the same an -esthetic episode. Twenty-nine of these dogs had ilio -sacral lymph node extirpation performed. Aside from lymph node extirpation, other surgical procedures performed included mass removal (n = 5), cystotomy (3), splenectomy (3), liver lobectomy or biopsy (2), castration and scrotal ablation (1), internal obturator transposition for a perineal hernia (1), hemimandibu -lectomy (1), and unilateral exenteration (1). Intraop -erative complications were seen in 7 (12.7%) dogs. Twelve (21.8%) dogs had minor postoperative com -plications that resolved with medical management. Medical management included administration of an antimicrobial (n = 3), open wound management (3), monitoring (2), administration of an anxiolytic (1), hospitalization for regulation of previously diagnosed diabetes mellitus (1), hospitalization for medical management of postoperative pancreatitis (1), and abdominal incisional closure revision following iatro -genic abdominal hernia formation (1). Adjuvant treat -ment was pursued in 33 (60%) dogs. Of these dogs, 31 received chemotherapy IV or PO and 2 received pal -liative radiation therapy treatment.Histologic diagnosisModified closed anal sacculectomy group —Thir -ty-four dogs had a histologic diagnosis of AGASACA, and 1 dog had a diagnosis of a collision tumor com -posed of AGASACA and soft tissue sarcoma. All 8 dogs that had iliosacral lymph node extirpation at the time of anal sacculectomy had evidence of metastatic disease in these tissues on histologic examination.Traditional closed anal sacculectomy group —All 55 dogs had a histologic diagnosis of AGASACA. Two dogs that received a bilateral anal sacculectomy were diagnosed with AGASACA in only 1 anal sac, with the other receiving a histological diagnosis of anal sacculitis. All 29 dogs that had iliosacral lymph node extirpation at the time of anal sacculectomy had evidence of metastatic disease in these tissues on histologic examination.Table 2 —Dogs presenting for anal sacculectomy technique, by technique performed (modified or traditional) that had intra- and postoperative complications, local recurrence, and postoperative metastatic disease. The median (range) of survival for dogs is presented as well.Variable Total Modified TraditionalIntraoperative complications (No. of dogs [%]) 10 3 (8.6%) 7 (12.7%)Postoperative complications (No. of dogs [%]) 17 5 (14.3%) 12 (21.8%)Local recurrence of tumor (No. of dogs) Confirmed 16 8 (22.9%) 8 (14.6%) Suspected 9 3 (8.6%) 6 (10.9%)Postoperative metastatic disease (No. of dogs [%]) Confirmed 22 8 (22.9%) 14 (26.4%) Suspected 11 4 (11.4%) 7 (13.2%)Survival (No. of dogs [%]) Alive 63 22 (62.9%) 41 (74.6%) Dead 27 13 (37.1%) 14 (25.5%)Survival (days) Median (range) 580 (4,224) 536 (4,183) 618 (1,628)Brought to you by Vetagro Sup Campus Vet De Lyon Biblotheque | Unauthenticated | Downloaded 11/03/23 06:54 AM UTC 5Long-term and clinical outcomes —Short-term and long-term outcomes by procedure (modified or tradi -tional closed anal sacculectomy) are presented (Table 2).Modified closed anal sacculectomy group —Tu-mor recurrence was confirmed in 8 (22.9%) dogs. Lo -cal recurrence was confirmed with fine-needle aspi -ration and cytology (n = 7) or CT (1). Local recurrence was suspected following digital rectal palpation in 3 (8.6%) dogs. Confirmed metastatic disease was re -ported in 8 (22.9%) dogs. Of these 8 dogs, thoracic metastatic disease was confirmed with CXR (n = 1) and CT (1), and abdominal metastatic disease was confirmed with fine-needle aspiration and cytology of the iliosacral lymph nodes (5) and liver and spleen (1). Suspected metastatic disease was reported in 4 (11.4%) dogs. Of these 4 dogs, abdominal metastatic disease was suspected following iliosacral lymph node enlargement visualization with AUS (n = 3) or CT (1). Twenty-two (62.9%) dogs survived to the 250-day follow-up period. The 1-, 2-, and 3-year sur -vival rates were 68%, 49%, and 21%, respectively.Traditional closed anal sacculectomy group —Tumor recurrence was confirmed in 8 (14.6%) dogs. Local recurrence was confirmed by fine-needle aspi -ration and cytology (n = 5), histopathology follow -ing surgical revision (2), or CT (1). Local recurrence was suspected following digital rectal palpation in 6 (10.9%) dogs. Confirmed metastatic disease was re -ported in 14 (26.4%) dogs. Of these 14 dogs, thoracic metastatic disease was confirmed with CXR (n = 7) and iliosacral lymph node metastatic disease was confirmed with fine-needle aspiration and cytology (5) and histopathology following surgical excision (2). Suspected metastatic disease was reported in 7 (13.2%) dogs. Of these 7 dogs, abdominal metastatic disease was suspected following iliosacral lymph node enlargement visualization with AUS (n = 5) or CT (2). Forty-one (74.6%) dogs survived to the 250-day follow-up period. The 1-, 2-, and 3-year survival rates were 81%, 49%, and 30%, respectively.Comparisons between groups —No statistically significant difference in recurrence rate was noted between groups ( P = .68).