” A neoplasia in left midbrain in dog”

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Dr Dimitar Ivanov

Dr Dimitar Ivanov,
Veterinary surgeon, Neurology specialist
Dobro hrumvane veterinary clinics
Sofia, Bulgaria

 

 

 

Case report

Dog, Bleki, toy terrier, M, 5 yo.

Came in the clinic on 11.04.2017 with left circle movements, menace deficit on the left and no reaction when stimulating the nasal mucosa.  On the right, spinal reflexes are decreased and there are no conscious proprioception.

Doubt for brainstem problem.

Differential diaggnosis:

V – vascular – it’s with peracute onset

I – inflamatory – it’s possible but no changes in blood sample

T – toxic – The dog did not take any medication, fed the same food and was not seen taking unusual things, but it’s not unpossible

A – anomalous – тhe dog is 5 years old and it is unlikely that there will be any manifestation of these diseases

M – metabolic – there is no other clinical signs or any changes in blood samples.

I – idiopathic – there is no seizures and vestibular signs

N – neoplastic – it’s more possible

D- degenerative – the dog is too young for cognitive dysfunction and too old for other degenerative diseases.

We made MRI on 12.04. and found a lesion in the left mesencephalon.

dhs dhs1 dhs2

 

 

 

 

 

 

 

 

 

 

The final diagnosis is neoplasia in left midbrain.

 

We started to prepare for surgery.

The antibiotic preoperative was Ceftriaxone 30 mg/kg i.v., Manitol 1 g/kg i.v. and Methylprednosolone 20 mg i.v.

The surgery was on 22.04.2017 and we made a left craniotomy and displacement of the temporal lobe dorsolaterally until the lesion was reached.

Bleki preoperative video:

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Pic 1

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Pic 2

The skull was open and we enlarged the hole with Kerrison rongeur (pic 1 and 2)

 

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Pic 3

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Pic 4

We aspirated the brain liquor and very slowly reverse the left temporal lobe.( Pic 3 and 4)

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Pic 5

When we found the lesion we punctured the cyst formation and drew the liquid contents.( pic 5)

 

 

 

 

 

 

 

 

 

 

The reason to do this surgery was to try to reduce the pressure in the tissue and to improve the dog’s condition.

After surgery we continued the antibiotics in the same dose and methylprednisolone in the same dose for three days. After then the dose was reduce to 2 mg /kg.  After few days the methylprednisolone was change with prednisolone and started to reduce the dose.

Until the methylprednisolone is reduced, the patient is better every day, improves motor activity, appetite, but fails to maintain a constant temperature. A corneal ulcer of the left eye appears – I guess the cause is a trauma to the left oculomotor nerve and reduced lacrimation.

On 28.04. we included one more antibiotic – amoxicillin with clavulonic acid.

On 29.04. the prednisolone was reduced to 0,5 mg/kg, the dog was with anisocoria (myosis on the right eye and mydriasis on the left). On 30.04. the circle movements on left started again.

We tried to find Lomustine for chimiotherapy but we couldn’t and increased the dose of the prednisolone to 2 mg/kg

 

Bleki 22 days after surgery:

 

 

Bleki 23 days after surgery

The dog is good, he walk normally but when he stops, he start to make circle movement on the left.

 

Tibial nerve peripheral nerve sheath tumor in dog

 

 

  1. Loncar, DVM1

    10698593_10203534440535771_1510276061084451082_n-238x300

    Dr Zoran Loncar

  2. Hadzic, DVM2

M.Dragomirov, DVM2

1,2 Department of Orthopedic Surgery and Neurology, Veterinary Clinic Novak, Belgrade, Serbia

 

INTRODUCTION

 

An 8,5 years old miniature schnauzer dog was presented at the clinic with finding of right hind limb monoparesis and grade 1 lameness. CT diagnostic study was done but it was suggested that there was no visible lesions. MRI study shoved a lesion consistent with PNST. The dog was treated surgically and the tumor was excised completely with large margins. The dog recovered completely. The purpose of the article is to suggest that a lesion consisted with PNST distal to the stifle an elbow can be treated with large margins and very good motility of the limb afterwards. This type of pathology can be often missed with orthopedic conditions.

CASE HISTORY

 

A 10 kg BW, 8,5 years old miniature schnauzer was presented at the clinic with owners complain of lameness on right hind limb for last five months.

At previous vet the dog was submitted to complete orthopedic, radiography and CT study with no diagnosis after the diagnostic workout. The dog was treated with 20 days of NSAID therapy (carprofen 2mg/kg BID 10 days and the dosage was reduced by half for the next 10 days). There was no improvement so the dog was treated with prednisolone for 20 days SID with again very little improvement.

The dog doesn’t have any important data in medical history.

At the presentation in our clinic:

During the walk dog showed grade one lameness.

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CT STUDY , Fig 1 and 2

At the clinical examination the dog showed normal proprioception but reduced withdraw reflex on right hind limb.  During palpation region of gastrocnemius muscle was markedly painful. The rest of nurology and orthopedic examination was in within normal limits.

CT Study

Figure 1. and 2.

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MRI SYUDY Fig 3

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MRY STUDY- Fig 4

There is a focal dilation of a vascular structure, presumably a vein, caudal to the medial aspect of the right stifle. The vascular dilation/aneurism has a maximal diameter of 7.7 mm and extends over a distance of approximately 4 cm. Contrast filling of the dilated area is heterogeneous with some areas lacking contrast filling. The affected vessel is an anastomosis/branch between the caudal branches of the saphenous vein and the caudal proximal femoral vein.

MRI study:

Figure 3. T1+contrast: On the right limb at the level of tibial nerve there is a lesion with heterogeneous contrast intake in long contact with blood vessel. The lesion is 3 cm long in diameter.

Figure 4. T1+contrast: Lesion at the level of tibial nerve in close contact with saphenous vein and the caudal proximal femoral vein. Heterogeneous contrast intake.

 

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Figure 5. Surgical field

The surgical approach was made from medial side at the level of proximal part of gastrocnemius muscle. The careful identification of blood supplies and nerve structure was needed. The healthy proximal and distal part of the nerve was identified and the excision with 3 cm margins has been done.

The dog was treated post operatively with antibiotics for 7 days (cephalexin 15mg/kg BID), fentanyl patch for 3 days, carprofen 2 mg/kg BID for 7 days, gabapentin since 3th day 20 days 10mg/kg TID.

Neurological exam has been done after 1,3,6 and 12 months. The only abnormal finding 6 and 12 months post op was longer ground phase during walk and reduced withdraw reflex.

 

DISCUSSION:

 

Tibial nerve is in charged for the motor function of caudal aspect of tibia and fibula. Deficit in function shows clinical signs that look similar to orthopedic conditions. Ground phase is longer, calcaneus drops distally more than in contralateral limb. Sometimes we can see plantigrade stance. Orthopedic conditions similar to these in term of signs are pathology of Achill’s tendon and tarsus and metatarsus.

PNST if at the distal part of peripheral nerves can be treated with good outcome. The reasons are fewer functions that lead in less of dysfunction of the limb, and good surgical margins.  If PNST is localized at plexus or nerve root, 78% of dogs are going to be euthanized. The prognosis depends on localization and histopathology grading.

 

CONCLUSION

 

This article shows how close sometimes can be neurology and orthopedic clinical findings. Even if advanced imaging is available the cruciate information is localization of the lesion during the clinical examination. Further a right interpretation of images is necessary to define the lesion. PNST is an important differential diagnosis in investigation of distal extremities dysfunctions.

 

Chronic lameness in a one and half year old German Boxer

marko-poza

Dr Marko Novak

Marko Novak, dvm

Department of Orthopedics and Neurology

Klinika Loka, refferal small animal clinic, Škofja Loka, Slovenia

 

Luna is a lively 1,5 year old German Boxer, weighing 28 kg. She was presented to us with chronic intermittent right front leg lameness of grade II lasting for almost a year. Her owners noticed a lump on her medial carpal site. The dog had a history of a car accident when she was only six months old. At that time Luna was treated conservatively with NSAIDs and rest. Luna became worse after time and she was reffered.

 

Anatomy

 

Carpal joint is a hinge joint. It is composed out of six carpal bones that are arranged in a proximal and distal row forming three levels of joint spaces; the antebrachiocarpal where most of the joint motion takes place, the middle and the carpometacarpal space.

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Image 1: Anatomy of carpal joint

Joint`s stability is provided by ligaments of the carpus. Carpal ligaments are very stiff and short mostly crossing only one joint level. (image 1), (1)

 

Clinical exam

 

Luna was afebrile, lame on her right front limb, grade II. Her right front limb was shaking while standing and her carpal joint was slightly flexed. Right carpal joint was obviously swollen on the medial side. Carpal range of motion was mildly decreased in flexion, distinct pain was observed on flexion of the carpal joint and by pressing on the firm medial swelling. No apparent instability could be observed while doing clinical exam but only slight valgus. The rest of physical and neurologic exam was normal.

 

Diagnostics

 

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Image 2 : orhogonal view of carpal joints

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Image 3: orhogonal view of carpal joints

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Image 4: stress view with apparent medial instability

Orthogonal and stress radiograms of both carpal joints were made and beside increased opacity of medial carpal soft tissue, extensive mineralisation near medial carpal compartment was noticed most apparently on the craniocaudal view. Stress radigraphs showed moderate instability on the medial side of all carpal joint levels. (image 2 to 4)

 

Therapy

 

Decision in making the right therapeutic approach was difficult. After taking under consideration all of the data especially chronicity of the problem, we advised the owners do a pancarpal arthrodesis. Chronic instability is by far the most common indication (in 76% of the cases) for (pan)carpal arthrodesis. (2)

We could also try to do a synthetic ligament reconstruction but since the problem was present for almost a year, the instability was present in multiple medial carpal levels and the dog did not improve, arthordesis seemed like a prudent decision.

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Image 5 : postop, with slightly suboptimal compression, but due to hybrid locking plate it healed uneventfully

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Image 6: postop, with slightly suboptimal compression, but due to hybrid locking plate it healed uneventfully

Hybride pancarpal arthodesis locking plate (Veterinary instumentation)  (2,7 – 3,5) was used for the procedure, taking care to cover 75 % of third metacrapal bone, which resulted in a strong stabile environment and rapid healing with quick return to good postoperative function. External coaptation with a splinted bandage added extra support for the first three weeks after procedure. (Image 5 and 6)

Follow up

Luna did have some problems with compensation for the first two weeks after the splint was removed, but than started to improve consistently. Follow up xrays at 4 and 8 weeks were unremarkable.

 

Discussion

 

Luna is a very active young German Boxer who was intermittently but progressively lame for the last year. A chance to reconstruct the torn medial ligaments of carpal joint was probably unknowingly lost when the instability was missed at the first veterinary visit almost a year ago.

Chronic instability is seldom succesfully solved by synthetic reconstruction which purpose is to achieve good and functionally strong stability. Unsatisfactory surgical stability again leads to pain and degenerative joint disease.

Dispite apparent instability prooved on xrays, we were not sure how much it contributed to a development of chronic tenosynoviitis but we presume that the proximity of two structures resulted in abductor pollicis longus tendinopathy as well or differentially looking could also be a sign of an old avulsion fracture.

 

Literature:

1 Fractures and Other Orthopedic Conditions of the Carpus, Metacarpus, and Phalanges, Part II: fractures and orthopedic conditions of forelimb, in BRINKER, PIERMATTEI, AND FLO’S HANDBOOK OF SMALL ANIMAL ORTHOPEDICS AND FRACTURE REPAIR, Fourth Edition, 2006, by Elsevier Inc., page 382, chapter 14

 

2 Pancarpal arthordesis in a dog: a review of forty-five cases, Robert B. Parker, DVM, S. Gary Brown, DVM and Alida P. Wind, DVM in American Collegue Of Veterinary Surgery.  

 

 

TTA cases , Dr Goran Tomisic from Belgrade, Serbia

big dog 3

Neapolitan mastiff

big dog 1

Neapolitan mastiff

In our experience most of the patients with TTA surgery are large breed dogs between 25-45kg. We heve  had experienced to work with gient dog (70kg  Neapolitan mastiff)big dog 2 and very small dog (6kg Poodle). 12966364_10209325595520597_1193906793_nFurthermore, the expectations before surgery were that the bigger dog will be a problem for setting the implants, but after both surgeries we were surprised how difficult was to set all implants into the smaller dog. Making the plane of  TTA surgery for small dog our biggest concern before the surgery of poodle was how we would cut the bone, but that part was easiest of the surgery.12966314_10209325898568173_2006959456_n12935231_10209325902128262_1630163835_n Placing the cage and screws was the real challenge. 12939598_10209325908008409_1471598489_n12966391_10209325905128337_1038654349_nThe toughest job was insert the fork into the TTA plate that took most of  the time of surgery. Overall, TTA would be the first chouse for ACL rupture in dogs.

Hemilaminectomy

timisoara

Dr. Lucian Fodor

                         Dr. Lucian Fodor (Happy Pet Timisoara, Romania)

 

    Introduction

Hemilaminectomy is a surgical tehnique of decompresion of the spinal cord wich is made by making a bone space in the lateral part of the vertebral arch.

Hemilaminectomia made a direct decompression of the spinal cord and extraction slight herniated disc. It is indicated after lateral medullary compression, lateral or ventral-dorsal side.

Case presentation

Amstaff female, 9 years old, spayed, at 2 years sufered a car crash who took to the amputation of the left anterior leg.24 hours ago she expresssed paraplegia on the posterior legs, no related to the trauma she had 7 years ago.(Fig 1,2)

   Clinical exam

Normotermia, heart and respiratory rate are phyziological, biochemical parameter of blood also in normal rates.Neurological tests are showing a flasc paralysis of the posterior legs with keeping of the deep sensitivity and lack of the superficial one.

   Complementary exam

RMN which shows a protusion of the L6-L7 intervertrebal disc.(Fig 3-8)

    Diagnosis

Right ventro-lateral disc hernia

 Treatment

Right Hemilaminectomy

Surgical  tehnique

Skin incision paramedian

Subconjunctival tissue incision until  dorsal lombar fascia

Fascia incision and supraspinos ligament(fig.10) lombar mulfifizi muscle removed from the spinous processes(fig. 11).

Highlighting mamilonat process and the process of lumbar vertebra accessory(fig. 12).

Sectioning mamilonat process using a bone pinching (fig. 13).

Highlighting the nerve root L6-L7 (fig. 14).

Milling articular surfaces L6-L7 (fig. 15).

Highlighting the spinal cord and intervertebral disc herniation(fig. 16-17).

Curettage intervertebral disc and nerve root highlighting decompressed (fig. 18).

Collagen Dressing(fig. 19).

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fig 1

Postoperative treatment was followed five days containing corticosteroids, antibiotics five days and bladder catheterization in the first 24 hours after it is no longer necessary.

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Results and discution

Hemilaminectomy indication:

Hypotonic paraplegia more than 5 days

flaccid paraplegia  with profund sensitivity and no more than 24 hours (1)

cauda equina sindrom (2)

Surgery is superior to conservative treatment (2).

In the case of a herniated disc which is manifested clinically by flaccid paraplegia but keeping deep painful sensitivity, the percentage of success and full recovery of patients is 80% (4).

 

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Conclusion

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ias

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– Postoperative evolution of the case presented was very good at 24 hours postoperatively she maintained the tripodal position and the movement is made supported by the owner(Fig 20)

– Three months after surgery the animal is completely heald, exhibiting no neurological symptoms

 

 

Bibliography

  1. Robin (Y) – Les traitements de la maladie discale du chien P.M.C.A.C. 2008 (413-424)
  2. Shores (A) – Intervertebral disc discose. Textbook of small animal ortopedics, ed. Philadelphia, J.B. Lippincot Co 2006 (739-764).

Total hip replacement after unsuccessful femoral head and neck resection in large mix breed dog

12959354_10153530931267960_1853416198_o

Dr. Vladislav Zlatinov

Corresponding author :

Dr. Vladislav Zlatinov,
Central Veterinary Clinic
Chavdar Mutafov str, 25 B, Sofia, Bulgaria
E-mail: zlatinov_vet@yahoo.com

Key words : Total hip replacement, FHNO revision, Biomedtrix universal hip system, BFX, CFX

 

Abstract

 

This a case report of successful revision of femoral head and neck ostectomy (FHNO) with hybrid BioMedtrix (Boonton, NJ) total hip replacement (THR) system, in a 7 years old mix dog. The revision indications in the case were chronic pain and functional impairment after previous excision arthroplasty for severe coxo-femoral arthritis. The weight of the patient (43kg), incomplete resection of the femoral neck and concomitant orthopaedic condition (elbow osteoarthritis) could had been contributing factors for the FHNO bad outcome. A preoperative computer tomographic (CT) study was used for underlaying cause exploration and planning the replacement arthroplasty. The time window between the two surgeries was unusually long- three years. This had caused serious morphological alterations and made the surgery of upmost technical difficulty. Nevertheless, the revision of FHNE to THR produced marked clinical improvement and return to normal activity within 3 months after surgery.

Introduction

 

THR is a salvage procedure involving replacement of a diseased pelvic acetabulum and femoral head with implants. Common diseases which necessities this advanced bionic surgery are osteoarthritis, secondary to hip dysplasia or trauma, aseptic femoral head necrosis, acute or chronic hip luxation, failed FHNO, irreparable acetabular or femoral head fracture.
Actually, the canine THR became commercially available since 1974 (Hoefle) and huge advancements in canine and feline THR have been made in the past 30 years. At the present, two cementless commercial systems are most popular, and several other under development1.
The Zurich Cementless Hip Prosthesis (Kyon, Switzerland) provides immediate fixation of the acetabular cup by a press-fit insertion (plus option for screw fixation); Locking screws are used for immediate fixation of the femoral stem, and on growth of bone provides long-term stability.
The BioMedtrix biologic fixation system (BFX) is a modular, press-fit bone ingrowth system with an unsecured acetabular component that provides the advantage of size compatibility with the components of the BioMedtrix cemented THR system (CFX). The advantages of application hybrid THR are discussed further in the case report.
Implants design and procedures in canine THR have been well reviewed in the literature. There are several studies reporting the functional outcomes and complications.2,3 Over- all excellent clinical results and reasonable (2-5%) major complications occurrence are reported by the experienced surgeons in the field.
Never mind the specific implant system used, the THR surgery should achieving the ultimate goal of relieving pain and improve the patient’s quality of life by returning normal limb function. Optimally, the functional effect and the integrity of the prosthesis should last for a lifetime. Serious complications- that could be met in the procedure should be avoided by precise surgery planning and perfect aseptic and surgical technique.
Femoral head and neck ostectomy (FHNO) is alternative low- cost salvage procedure. It intend to eliminate bone-to-bone contact of the diseased acetabulum and femoral head, through the formation of a pseudoarhrosis composed of non-painful fibrous connective tissue.
Published reports about outcome results after FHNO have been controversial. These ones based on gross veterinarian observations or client questionnaires, show encouraging improvement in clinical signs for the majority of dogs.
The more objective gait analysis data (available only recently4,5,6,7) didn’t reveal so optimistic results. Not ideal outcome in function was most evident in studies that did not rely only on owner satisfaction. Common residual dysfunctions after FHNO include: persistent lameness, restricted hip ROM , limb shortening, decreased stifle and hock angulation and muscle atrophy. The maximum functional recovery from the procedure may take up to 8 months6,7,8. Logically, the functional outcome of FHNO is affected by surgical technique, severeness of the disease, age, post op physical therapy and body weight 9. Several clinical trials suggest lack of constant results in dogs heavier than 18 kg.10,11,12 . The cause of the suboptimal outcome in larger dogs is still controversial. Some studies blame the bone-to-bone contact from inadequate excision or postoperative bone proliferation13,14; Others suggest that the bone contact is commonly found after FHNO and do not explain the different clinical outcomes15,16.
In cases of unacceptable pain relief, following FHNO, a revision osteotomy could be contemplated to correct a residual bone-to-bone contact, if present. A more aggressive ostectomy (including trochanter minor) or usage of muscle flaps “slings” modifications could be used to improve the outcome, again with unpredictable outcomes12,17. Another viable option could be conversion to THR18,19,20 . Nevertheless, revisions to THR were reported to yield good and pain-free function (Gofton, 1982; Liska et al. 2010, Fitzpatrick et al. 2012) many obstacles lay in front of successful procedure. The presence of unstructured fibrous tissue and altered anatomy at the surgery site complicates the surgery, and manipulation of a previous surgical site increases the risk of infection. After an excision, the acetabulum fills in with bone and the proximal femur remodels with bone resorption at the excision surface and sclerotic bone production in the medial proximal endoosteal surface. Complications are more likely after revision of FHNO, so dogs that are initially better candidates for a THR, should not be offered excision as an interim procedure.

 

Case report

A 7 years old female mix breed dog (43kg) was presented for consultation because of chronic left hind leg lameness. A femoral head and neck excision was accomplished 3 years ago, but the patient never show adequate pain-free recovery afterwards, despite persistent usage of anti-inflammatory medications.

 

Disease history

The patient had a history of previous surgeries (Fig.1-2)- left hip luxation was treated by toggle-pin reduction technique, five years ago. At the same traumatic incident, right intra articular ulnar fracture was diagnosed and osteosynthesis with neutralisation plate was applied. Despite the successful healing, degenerative joint changes developed gradually in the elbow afterwards.rtindex1

In the previously luxated left hip, progression of severe degenerative changes and clinical deterioration towards severe disabling lameness were demonstrated after the treatment. This why, FHNO was accomplished 18 months after the primary trauma (Fig.3). Radiographic signs of osteoarthritis progression were noticed also in the opposite, right hip joint. The primary cause was hip dysplasia, but no painful clinical consequences were confirmed.ij

 

Clinical examination

At the clinical exam we found a moderate (II/IV) left hind leg lameness. (video1). At manipulation the hip demonstrated restricted ROM, with obvious pain and crepitation feeling in extension.We found considerable limb muscle atrophy. The opposite hip also had decreased ROM but no pain was elicited through extension.

A CT imaging was used for better evaluation of the FHNO failure (Video 2). Our clinical and imaging interpretation was- residual bone-to-bone contact, caused by suboptimal FHNO and caudal- distal “under-excised” femoral neck.

 

 

Dorsal displacement of the femur could have exaggerated the residual contact. Schiatic nerve adhesions were not supposed.

A revision with hip replacement arthroplasty was planned.ik

 

 

 

 

 

 

 

 

 

Planning and templating

Preoperatively, magnification-calibrated radiographic study of the femur and pelvis was accomplished. The approximate size of the acetabular cup and femoral stem were determined using acetate template overlaid on radiographs, but with doubts considering the real bone quality of both- the acetabular and femoral components.
Actually, the CT images played a crucial role in the detailed evaluation of the abnormal morphology, present 3 years post FHNO surgery.
Appreciating the femoral component, challenging technical problem was found. A severe proximal femoral canal sclerosis (much more obvious on CT images compared to the pre op X-rays)- Fig.5. This secondary changes always interfere with the well aligned, centralised process of reaming and broaching into the femoral canal. The eccentrically dense bone structure inevitably pushes the canal instruments out of the ideal position, increasing the risk for stem malposition and iatrogenic femoral fracture. This plus the advanced age was appreciated as risk factors for femoral shaft fracture, so a decision for the safer cemented femoral stem (CFX № 7) insertion was made. Because CFX stem have collar, laying against the proximal canal opening, plan was made to correct of the previous FHNO cut, lowering it.pm

Another technical issues were met, evaluating the pelvic component. A flattened, critically shallow acetabulum was found on the CT images, not clearly visible on the radiographs (hidden by the false hoarse bone proliferation). This made the precise cup sizing challenging. The CT (including 3D reconstruction) images, were used for analysis the real bone stock present in the “pseudo acetabulum” area.
The smallest possible cup (24 mmBFX) was templated but still without adequate dorsal bone engagement.

Fortunately, the Biomedtrix THR system offers an unique clinical solution in these difficult cases. Because of the cylindrically shaped press- fit anchoring mechanism , the Biomedtrix BFX cup may offer great stability properties if just adequate cranial and caudal bone contact is achieved. A rarely applied technique of medial acetabulum wall penetration, allows deeper cup insertion , increasing the stability of the implant-Fig.6. vg

This stability is provided by the press-fit cranial and caudal cup edges flush. Logically, the technique demands ideal starting point of the acetabular reaming, because any offset may cause inadvertent dorsal bone loss or devastating acetabular fracture-Fig.7. No option for switching towards cemented cup would be present in these circumstances. So a plan for hybrid THR (BFX cup and CFX stem) was made. Excellent clinical results with hybrid Biomedtrix system were reported (Gemmill TJ, Vet surg, 2011).Untitled-7

 

Surgical protocol

Surgical approach
A standard cranio- lateral approach to the hip joint, including full tenotomy of the deep gluteal muscle, was used. The sciatic nerve was not exposed during the procedure. Advancing through the excessive fibrotic tissue formed at the previous surgical field was extremely challenging and time consuming. It included sharp and blunt tissue dissection. A serious haemorrhage was met from unrecognised arterial vessel in the caudo- distal part of the surgical area. Direct clamping was attempted but not possible, so gauze compression was applied, during the whole procedure.
The replacement arthroplasty was accomplished, following the algorithms and rules provided by the implants manufacturer (more detailed information could be found at http://biomedtrix.com). Only the important technical problems and solutions are described in the following surgery protocol.
A pelvic positioning device was placed underneath the patient, before the aseptic preparation.

Neck resection
A full external femoral rotation to 90 degrees was not possible in the case. The presence of diffuse inelastic fibrotic adhesions, restricted significantly the manipulation of the femur. Two assistants were used to improve the manipulation and retraction at the surgical site. Using a resection guide, aligned with the central axis of the femur, the remnant of the neck was resected according to the preplanned.
A blunt-tipped Hohmann retractor was used to elevate the proximal femur from the wound. Adequate but still more or less suboptimal passage to the canal was achieved.
Femoral canal preparation
Initial opening
The entry point was difficult to visualise because of the solid sclerotic bone, present in the trochanteric fossa. The femoral canal was entered with great care to the alignment, gradually starting with initial 3 mm pin and proceeding with 5 mm drill bit.
Canal preparation
The canal was opened and expanded through reaming of caudal and lateral femoral neck’s walls. Extremely hard cortical bone was found in the caudal and medial femoral neck area. It caused considerable resistance to consequent broaching process. It was physically demanding to resist the tendency of the broach to slide back into malalignment during reinsertion. Small crack fracture (about 3 mm bone fragment) was inevitably caused at the medial wall edge.

No margin of cancellous bone was preserved between the implant and the cortex in the case. Temporary gauze compression of the canal was used to restrict the bleeding, during the following procedure of acteabulum bed preparation. After the BFX cup insertion, the stem was fixed to the femoral canal, using gentamycin impregnated cement.(Biomedtrix 3 G veterinary bone cement) applied by improved pressurised technique (using cement restrictor). No stem centraliser was used in the case.

Acetabular preparation
Meyerding retractors were used to reflected fibrotic soft tissues away of the acetabulum. A Hohmann retractor tip was positioned ventro-caudally of the acetabulum, so a femoral shaft retraction was achieved through a lever arm effect. The visibility to the pelvis was quite satisfactory. An emphasis was put on NOT- starting the acetabular reaming in the dorsally migrated pseudo- acetabulum (nevertheless reliable landmarks were difficult to found). First, the reaming was started approximately 20 degrees to perpendicular, and afterwards changed to the desired cup insertion position. Sequentially larger reamers were used. Very careful and gradual medial wall penetration was accomplished, incrementally testing the acteabular depth with a trial cup. The size of the opening was reasonably big and the periosteum could not be preserved. The toggle pin from a previous surgery was retrieved during the procedure.

Аfter the BFX cup hammering, there was a feeling for solid, and good flushed cup component- Fig.8.index44

 

Post op radiographs evaluation

Excellent implants’ stability and reasonably good orientation were appreciated on the post op X- rays (Fig.9).index55
BFX cup- a mild negative inclination and moderate retroversion was noticed. There was an excellent incorporation within the acetabular bone.
CFX stem- excellently centered in the frontal plane , but caudally tipped in the saggital plane. There was good cement filling, except small cavity in near the medial femoral wall.
Comments
The caudo- distal stem deviation, was probably caused by restricted proximal femur manipulation and suboptimal canal passage availability. It had precluded good alignment broaching and stem insertion- Fig. 10. A potential negative effect of eccentrically placed stems (tip contacting the cortex) could be a creation of stress riser effect and increased risk of femoral fracture, especially if BFX stem is being inserted. The use of cement mold centraliser may had improved the stem orientation, but was unavailable in this case- Fig.11.index8

The small air defect in the cement was probably caused by leakage through the medial wall fragmentation caused intraoperatively.index9

 

Post operative care and follow up

 

Postoperative analgesia included NSAIDs for 4 weeks. The dog was discharged the next day after surgery, with owner instructions for strict cage rest: controlled leash walking only for 10 minutes, 2-3 times daily.
The patient was toe- touching for 5 days post op with gradual increase of the limb usage; real weight bearing 7 days after the surgery. Physiotherapy was restricted to passive range of motion (home exercise).
A close follow-up was performed by phone contact with the owner. Radiographs were repeated at 12 weeks post op- Fig. 12. They revealed good implants stability; a femoral cortex hypertrophy was noticed around the stem tip area. This was appreciated as physiological remodelling due to altered bone stress bearing.index10

 

Results

The patient revealed gradual , but consistent and sustained full clinical improvement. Unrestricted activity was allowed for 12 weeks, when normal (pain free) limb function was appreciated (Video 3). Increased left hind leg muscle mass was found even in this short post op period. Return to normal ROM was found at the recheck (Video 4). Very good perceived quality was reported by the owners.

 

 

CONCLUSIONS

 

Transforming of FHNO to THR is a challenging but viable treatment option, even in severely complicated cases. The Biomedtrix system offers great implants’ design advantages, including combination of hybrid elements; excellent BFX cup anchorage, even in deformed shallow acetabulums.

Difficulties and complications could be faced during the FHNO revisions. These met in this case were manageable, but a higher complication ratio could be expected in similar scenarios. The major causes are the profound morphological changes present after femoral head and neck excision, and the fibrotic adhesions restricting the optimal femoral manipulation during the procedure.

The veterinary professionals , should use FHNO technique wisely, taking into consideration its financial/clinical advantage and disadvantages. The excision arthroplasty should never be suggested as a temporary clinical relief in large breed dogs because more or less it disrupts the normal bio- mechanics, causes length discrepancy and have unpredictable pain relief, requiring prolonged rehabilitation or a revision surgery.
During initial discussions about treatment options, the owners should always be treated fare with evidence based approach and realistically expected results explained. This could protect many dogs from suboptimal functional results, following FHNO recommendation in inappropriate candidates.

REFERENCES
1. Jeffrey N. Peck, Denis J. Marcellin-Little; Advances in small animal total joint replacement ISBN 978-0-470-95961-9
2. Olmstead ML,Hohn RB,TurnerTM:A five-year study of 221 total hip replacements in the dog. J Am Vet Med Assoc 1983;183:191–194
3. Iwata D, Broun HC, Black AP, et al: Total hip arthroplasty outcomes assessment using functional and radio- graphic scores to compare canine systems. Vet Comp Orthop Traumatol 21:221, 2008.

4. BrezonJL,HowardPE,CovellSJ,etal: A retrospective study of the efficacy of femoral head and neck excisions in 94 dogs and cats. Vet Surg 1980;9:88–92
5. Dueland R, Bartel DL, Antonson E: Force-plate technique for canine gait analysis of total hip and excision arthroplasty. J Am Anim Hosp Assoc 13:547, 1977.
6. MontgomeryRD,MiltonJL,HorneRD,etal:A retrospective comparison of three techniques for femoral head and neck excision in dogs. Vet Surg 1987;16:423–426

7. GendreauC,CawleyAJ:Excision of the femoral head and neck: the long term results of 35 operations. J Am Anim Hosp Assoc 1977;13:605–608
8. Excision arthroplasty of the hip joint in dogs and cats. Clinical, radiographic, and gait analysis findings from the Department of Surgery, Veterinary Faculty of the Ludwig-Maximilians-University of Munich, Germany. 1997.
9. DuffR,CampbellJR: Effects of experimental excision arthroplasty of the hip joint. Res Vet Surg 1978;24: 174–181
10. Ganz R: A new periarticular osteotomy for the treatment of hip dysplasia: technique and preliminary results. Clin Orthop 232:26, 1988.
11. Penwick RC: The variables that influence the success of femoral head and neck excision in dogs. Vet Med 87:325, 1992.
12. Mann FA, Tangner CH, Wagner-Mann C, et al: A comparison of standard femoral head and neck excision and femoral head and neck excision using a biceps femoris muscle flap in the dog. Vet Surg 1987;16:223–230
13. Lippincott CL: Improvement of excision arthroplasty of the femoral head and neck utilizing a biceps femoris muscle sling. J Am Anim Hosp Assoc 17:688, 1981.
14. Tarvin G, Lippincott CL: Excision arthroplasty for treat- ment of canine hip dysplasia using the biceps femoris muscle sling: an evaluation of 92 cases. Semin Vet Med Surg Small Anim 2:158, 1987.
15. Duff R, Campbell JR: Effects of experimental excision arthroplasty of the hip joint. Res Vet Sci 23:174, 1978.
16. Duff R, Campbell JR: Radiographic appearance and clinical progress after excision arthroplasty. J Small Anim Pract 19:439, 1978.
17. Lewis DD, Bellah JR, McGavin MD, et al: Postoperative examination of the biceps femoris muscle sling used in excision of the femoral head and neck in dogs. Vet Surg 17:269, 1988.
18. Noel Fitzpatrick, Duniv, MVB, CertSAO, CertVR, Laura Pratola, BSc: Total Hip Replacement after Failed Femoral Head and Neck Excision in Two Dogs and Two Cats .Vet Surg 41 (2012) 136–14
19. GoftonN,Sumner-SmithG:Total hip prosthesis for revision of unsuccessful excision arthroplasty. Vet Surg 1982;11:134–139
20. LiskaWD,DoyleND,SchwartzZ: Successful revision of a femoral head ostectomy (complicated by postoperative sciatic neurapraxia) to a total hip replacement in a cat. Vet Comp Orthop Traumatol 2010;2:119–123

CHIARI-LIKE MALFORMATION AND SYRINGOMYELIA

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Dr Ates Barut, DVM, PhD

Dr Ates Barut, DVM, PhD

Owner of Small Animal Veterinary Clinic PETCODE

 

Introduction

We can describe Chiari-like Malformation as an overcrowded and narrow caudal occipital fossa and cervicomedullar junction due to a congenital developmental malformation of caudal occipital bone. Disease is similar to Chiari Type I disease in humans and therefore named as «chiari like malformation» in dogs.

Chiari-like malformation is a hereditary condition and first described in king charles cavalier spaniels and altough several other small breeds can become effected king charles cavaliers are the most common breed effected by the disease.
The other reported breeds are; Griffon, Miniature poodle, Yorkshire terrier, Maltese, Chihuahua, Bichon frise, Staffordshire terrier, Pug, Shih Tzu, Dachsund, Pincher, French bulldog, Jack Russel Terrier, Pekingese and Boston terriers.
Affected patients has a kind of cerebellar compression and narrowing around foramen magnum and cervicomeduller junction.

Patho-physiology

Bony compression, progresive meningeal hypertrophy and dural fibrosis cause; several different neurological dysfunction like cerebellovestibuler disfunction, cervical myelopathy, seizure activity, syringomyelia, ventricle dilatation and hydrocephalusPicture1Picture2Picture4

Although in humans almost all chiari malformation patients has some degree of cerebellar herniation , in dogs cerebellar herniation is not that common and this is the main difference between these 2 species. Caudal occipital malformation syndrome is a genetic deformation of the mesoderm of caudal occipital bone causing cerebellar compression and herniation.
In normal dogs CSF move from cerebral subarachnoid space to cervical spinal subarachnoid space through foramen magnum in every sistom and diastol in a pulsative manner.


Compression and partial obstruction caused by Chiari malformation disturb CSF flow in both ways but because of high systolic pressure push CSF to central canal of cervical spinal cord and produce a cavity with this hammer effect. Valsa maneuras like barking and coughing, make sudden changes in intrathorasic and intraabdominal pressure which cause epidural venous distention and fast fluid acumulation to the cavity. Because of spinal epidural vein distention and compression in cervicomedullar junction syringomyelia cavity continue to enlarge gradually.Picture5Picture6Picture7Picture9
Herniated cerebellum increase the amount of obstruction , CSF flow and fluid accumulation. CSF will flow from intrcranial cavities to cervical region easier but can not come back again.

Symptoms and clinical presentation

Presentetion of the disease is different from patient to the other. The first signs can be seen from 5-6 months to 9-10 years.Picture17Picture18Picture19
The disease can cause several different neurological signs.

We can list the possible symptoms as; cervical hyperaesthesia, scratching( air scratchig or phantom scratching)

, facial rubbing, air licking, fly catching, tail chasing, vocalization, pain reaction during atlantoxipital palpation., cervical myelopathy, fore leg paresis characterized by lower motor neurons, multifocal CNS dysfunction, torticollis, scoliosis, seizure activity.
Pain due to or seconder to syringomyelia is a very important symptom and it happens because of the damage on the dorsal horn of spinal cord.

It usually happens Because of the hypersensitivity due to the damage on spinothalamic pathways and/or dorsal horn neuronsPicture20Picture23Picture24Picture27
Abnormal sensitivity in head, shoulder, neck, axillar and sternal regions is prominent in several patients with syringomyelia but pain severity is not directly correlated with the amount of the fluid inside the spinal cord. Pain is most common in king charles cavaliers and usually more dominant in one side.
Scratching is another very common sign in king charles cavaliers and stress, excitement or a touch to the neck stimulate or increase sctraching. Some dogs has a scratch point and react to a simple touch to this point. The scratching style usually without touching the body is also unique and that is why named as air scratching or phantom scratching.


In some severe cases the patients can have cervical myelopathy, cerebellovestibüler dysfunction and multifocal central nervous system dysfunction. In these cases severe neck pain, strabismus, head tremor and nystagmus can be observed. Loss of muscle tone due to asimetric innervation of paraspinal muscles can cause opusthotonus.

Some patients with chiari-like malformation can have seizures but pathogenesis is not so clear. This rare condition can be related with impaired cerebellar functions because cerebellum has an inhibitoric effect on seizure activity.

The most common neurological and physical examination finding is atlanto-occipital pain and increased sensitivity on pin point palpation on atlanto-occipital joint.Picture28Picture29

Magnetic resonans imaging is the only way for exact and definitive diagnosis of chiari-like malformation and syringomyelia. T2 and T1 weightened midsagital and transversal images of
the foramen magnum, caudal occipital fossa and cervical spinal cord will show syringomyelia.

We can describe magnetic resonans imaging findings as a narrow subarachnoid space in cervicomedullar junction, occipital bone compression on caudal cerebellum, rostral movement of caudal cerebellum, syringomyelia, cerebellar herniation from foramen magnum and kinked appearance of caudal medulla.

Lateral vetricle dilatation is a very common sign but hydrocephalus is a possible but rare condition.

Treatment

Most of the patients with syringomyelia can spend their whole lives with mild neurological symptoms without any need for medical or surgical treatment. Life quality is the main concern for treatment decision. Patients with obvious neurological signs and pain and non-responsive to pain managment therapies are candidates for surgery. Patients with mild symptoms and pain or non-responsive to pain medication are candidates for medical treatment.

Non-steroidal antinflamatoric medications are not effective against neurologic pain. In severe cases pain can be manage just by some anticonvulsants like gabapentin( 10mg/kg tid) or pregabalin (2-4 mg/kg bid). Last researches showed that omeprazol decrease cerebrospinal fluid production and can be used in some patients but some studies done in rats showed that long term use can cause hypergastrinemia and increase the risk of stomach cancer.

The other medicatios can be used to depress the clinical signs of syringomyelia are; acetozalamide, furosemide, corticosteroids, and phenobarbital. Another promising medication for neurologic pain is palmitoylethanolamide (pea) nad can be effective in several syringomyelia patients.

Surgical treatment is indicated in patients with worsening neurological signs and unresponsive pain. Aim of the surgery is to reorganize cerebrospinal fluid flow pathways and decrease the abnormal CSF in side the central nervous system by decompressing cerebellum. For this aim “Foramen magnum decompression” is indicated by a suboccipital craniectomy and partial dorsal laminectomy of first cervical vertebra that enlarge foramen magnum .

Foramen magnum decompression window limits and borders are so important. A small window will be effectless and a large window can cause atlanto-occipital instability or excessive bleeding in a very sensitive area which can cause life treating situations. Lateral borders of the window are atlantooccipital joints and lateral vertebral foramens of atlas , rostral borders are midpoint of the distance between protuberentia occipitalis and dorsal border of foramen magnum, caudal border is ¾ of atlas. Durotomy and marsupilization of dura to the muscular structures around the foramen magnum window is the common procedure but cerebrospinal fluid leakage can cause an inflamation and this inflamation can lead severe soft tissue thickening which can cause compression in the area. Altough durameter is firmly attached to the bony structures in atlantoaccipital region carefull dissection can be done without duratomy to prevent csf leakage.

Foramen magnum decompression will reorganize cerebrospinal fluid flow but the present fluid and the syringomyelia cavity will remain which means the present symptoms will continue most of the time. Foramen magnum decompression is most effective against pain which is the most common indication of surgical treatment.

To drain the present syrinx in syringomyelia cavity “syringosubarachnoid shunt application” is the most effective and popular method. Approach to spinal cord with a dorsal laminectomy where the syrinx cavity is most prominent has to be done first. After a “T” shaped duratomy placement of a shunt in 1-1.2mm thickness from syrinx cavity to subarachnoid space has to be performed to complete the procedure.

Discussion

As a result chiari-like malformation and syringomyelia is one of the most important breed predispositions of veterinary medicine and although the disease is reported in several other breeds it creates a very important clinical problem among king charles cavalier population. Most of the patients with syringomyelia can live whole their lives with very mild symptoms within a normal life expectancies but some patients will have cervical myelopathy, cerebellovestibüler dysfunction and multifocal central nervous system dysfunction. Pain and life quality is the main concern and criteria for treatment. Patients with obvious neurological signs and pain and non-responsive to pain managment therapies are candidates for surgery. Foramen magnum decompression and syringo-subarachnoid shunt application are the two surgical procedures described to reorganize normal cerebrospinal fluid flow and drain syrinx from its cavity.

Double plated TPLO in oversized dogs

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Dr. Tsvetan Ivanov

Dr. Tsvetan Ivanov, “Dobro hrumvane!” veterinary clinics, Sofia, Bulgaria

Introduction

The most common cause of rear limb lameness in the dog is rupture of the cranial (anterior) cruciate ligament. This derangement results in degenerative changes (osteoarthritis) in the stifle (knee) joint, including cartilage damage, osteophyte (bone spur) production, and meniscal injury. The Tibial Plateau Leveling Osteotomy (TPLO) has proven effective in returning these deranged stifles to full function.

Developed by Dr. Barclay Slocum, TPLO was a radical procedure for addressing canine ACL injuries. Now in existence for over 20 years, the surgery has proven itself, time and time again, to be an extremely effective long term solution for addressing cruciate ligament injury in dogs.

Part of the positive indications for TPLO are:

  • Bodyweight:

TPLO is most frequently performed in medium to giant breeds. Greater bodyweight is a positive indicator for selection of TPLO as a treatment option. The procedure can be performed and on small dogs and even cats, but then should be make exact discretion the potential benefits and complications.

  • Age:

Cruciate ligament degeneration is seen increasingly in young large breeds, in some cases within their first year.

Minimising osteoarthritis in the long term is a priority for these young dogs. Many surgeons believe that this leads to the TPLO being the technique of choice, although long term comparative studies continue to investigate this. These cases frequently show bilateral degeneration, and partial cruciate ruptures are common.

The procedure is good option for dogs over 6 months of age, with progression of ossification of proximal tibial growth plates.

  • Partial ligament rupture.

Cases of partial ligament rupture show a very rapid iprovement following TPLO. Importantly, they typically do not progress to complete ligament failure as TPLO acts to neutralise the forces on the cranial cruciate ligament.

TPLO is widely accepted to give the best functional outcome, in the short to medium term, and has enabled working/performance animals to return to high functional standards.

  • Excessively sloping tibial plateau:

Average plateau angles range from 22°-26°, but angles from 15° are still remain a TPLO candidate with good post-operative outcome. However, in cases with an increased tibial plateau angle, TPLO has proved particularly beneficial.

Case studies have advocated TPLO as the technique of choice for even small breeds with excessive tibial plateau slopes. In some of those cases the amount of angular correction required leads to a Wedge resection technique being favoured over the Slocum(curved-cut) TPLO.

  • Cranially translocated tibial crest.

Occasionally the stifle will rest with the tibia cranially translocated following cruciate rupture the tibial crest is  palpated cranially, the patella tendon is less distinct, and the first movement during cranial drawer is backwards, often associated with a dramatic degree of movement. In some authors experience these cases may return to cranial translocation with significant recurrence of lameness weeks after extracapsular lateral fabella suture placement. In those cases, in a limited number of procedures, TPLO have shown better outcomes.

Overall, the good TPLO candidate is medium to large breed dog, from 6 months and plus, active, with need of full functional restoration of the limb.

The Case:

 

This is the case of Hades. He is oversized cane corso, 6 years old, bodyweight is 78 kg and he suffers from hip arthrosis of the right hip in result of hip dysplasia and chondroma of right carpal bones. He came with lameness on the right rear limb from few weeks, which is worsening. He had and positive “sit and drawer tests.

This is video of his walk:

The diagnosis was cranial cruciate ligament rupture.65 6My favorite procedure is TPLO, but definitely no one can be sure that, the standard procedure can give good outcome with this size dog. Furthermore, the dog have and two other problems on the right side. We were afraid from implant failure so we decided to make insurance. Instead only the TPLO plate we placed and second DCP 3.5 mm plate. The original idea was to use 3.5 screws for the 2-nd plate, but because of the risk from caudal cortex fracture the most distal three screws was 2.7 mm

 

 

 

0 post op DP

Immediately postoperator

0 post op LL

Immediately postoperator

Those are intraoperative pictures and the immediately post-op pictures:

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surgery

4

surgery

1

surgery

 

Video 14 day after the surgery:

 

X-ray pictures 45 days after the surgery:

45 dni post op - LL

45 days post op – LL

45 dni post op

45 days post operator

And this is the final result – 6 months after the surgery:

240 days post op

240 days post op

Video:

Discussion:

 

The TPLO remains one of the best surgically ways to manage CrCrLR even in oversized dogs, even with concomitant diseases of the locomotor system.

The most important thing is every surgeon to make optimal assessment of the patient’s status and to remember that every case is specific.

TTA surgery for Cranial Cruciate ligament rupture

Vet Tommy

VETERINARY CLINIC TOMMY Belgrade, Serbia

VETERINARY  CLINIC  TOMMY

Belgrade, Serbia

Surgery specialist DVM Goran Tomišić

 

 

TTA surgery for Cranial Cruciate ligament rupture

 

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TTA surgery for Cranial Cruciate ligament rupture

Medical history

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TTA surgery for Cranial Cruciate ligament rupture

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TTA surgery for Cranial Cruciate ligament rupture

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TTA surgery for Cranial Cruciate ligament rupture

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TTA surgery for Cranial Cruciate ligament rupture

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TTA surgery for Cranial Cruciate ligament rupture

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TTA surgery for Cranial Cruciate ligament rupture

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TTA surgery for Cranial Cruciate ligament rupture

Dog , Golden Retriever 4 year old,  29 kg weight, was presented to the clinic with chronic pain and lameness in his left hind limb. Beside that the dog was perfectly healthy.  During the orthopedic examination in sedation, there are persistent sign of drawers  which is the most important sing of Cranial Cruciate  Rupture. On  X- ray  was no osteoarthritis founded. During the preparation for the surgery, measures of the knee were taken from the same  X-ray. Measuring for this procedure must be precise and it’s done with help of special equipment.

 

 

Surgical treatment

 

During the surgery dog was placed in left lateral position, and approach on the knee was from medial side. After exposing the tibial  bone markers were placed  into the tibial crista. Afterwards,  precise cut was performed with special saw to cut of the tibial crista, on that  site the titanium plate was placed with fork. Next step during the surgery is placing a cage into the space between tibial crista and other part of tibial bone  screwing  it with screws. When everything was stabile it was irrigated and closed.

 

Postoperative treatment

User comments

TTA surgery for Cranial Cruciate ligament rupture

 

The dog that we operated was necessary to be under restriction  as much as possible minimum two weeks. After only 24h dog was touching ground with operated leg, but he was on restricted walks for two weeks because of his temperament. There was no postoperative complications, one month later  dog was using his leg practically normal, but he was still under the supervision  of the owner.

 

Pseudomeningocoele in dog

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Dr Zoran Loncar

Z.Loncar, DVM1

1Department of Orthopedic Surgery and Neurology, Veterinary Clinic Novak, Belgrade, Serbia

           INTRODUCTION

A 3,5 years old mixed breed dog was presented at the clinic with finding of non ambulatory paraplegia. Dog was hited by a car 25 days prior to the presentation. Since then the dog has been treated conservatively without any improvement. Radiography study showed L7 fracture. MRI study showed T13-L1 compressive myelopathy caused by disc material, and lesion L2-3 and L3-L4 consisted with the findings of pseudomeningocoele in humans. The purpose of the article is to suggest that a lesion consisted with pseudomeningocoele in humans can be find in dogs in late MRI screening after nerve root trauma.

CASE HISTORY

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Figure 1: Dorsal projection at T2 sequence shows multiple high intensity signal at the level of lumbal nerve roots L2-3, L3-4 to the right. Signal is homogenous, extradural consisted with pseudomeningocoele and CSF leakage

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Figure 2. Sagital image of lumbal spinal cord segment in T2 sequence. Shows high signal intensity at the level of nerve root. Loss of signal intensity at the disc ventral to the lesion L3-4. L1-2 complete of signal intensity. Th13-L1 compressive myelopathy caused by disc extrusion.

A 18 kg BW, 3,5 years old mixed breed dog, without significant medical history was presented at the clinic with owners complain not to be able to walk on hind limbs. The owner had not noticed voluntary movements on hind limbs of dog since had been hited by a car 25 days prior to the presentation at the clinic. There was no other abnormalities on general exam except urinary bladder enlargement and overflow pattern of voiding. Neurology exam showed normal mental status. Non ambulatory paraplegia. Cranial nerves were in normal physiological limits. Segmental reflexes in front limbs were normal. Patellar reflex on left side was increased, on right side was decreased. Withdraw reflexes were decreased bilaterally. Perineal reflex was normal. Panniculus  cut was at the level of L4 bilaterally. Deep pain was present. Hind limbs were spastic with mild muscle atrophy. The dog showed no pain during palpation of L7 fracture site and there was no crepitation  during manipulation of the region. The dog reacted painfully during deep palpation at the level of first lumbal vertebras. The lesion was localized T3 to caudal because of mixture of UMN and LMN signs, slightly lateralized to right.  Radiographs showed L7 fracture with complete dislocation of compartments. MRI findings showed :Fig 1 and 2

The dog was treated surgically right T13-L1 hemilaminectomy with disc fenestration. The owner refused to allow surgically treatment of L7 fracture. Postoperatively the dog was treated with antibiotics ( synulox 250mg BID 10 days), NSAID ( carprofen 25mg BID), and physical therapy. Dog was ambulatory 3 weeks after surgery. 1,5 month after the surgery there was no abnormalities at the neurological exam.

 

DISCUSSION

The case was analyzed for a probable etiology of L2-L3 and L3-L4 lesions visible at the MRI study considering case history, progression of signs, concurrent lesions, lesion distribution and pattern of appearance. It was also taken in count fast improvement of neurological condition immediate after decompression surgery at the level T13-L1. Most of the neurological findings were consisted with all three lesions find during MRI imaging. The lesions at the level of L2-3 and L3-4 were localized at the foramen, extradural, unilateral. Lesion were homogenous, there was no edema surrounding the lesions. Lesion showed T2 hyperintensity, T1 hypointensity. Vascular lesions at that time after the injury would show high intensity signal in both T1 and T2 sequences. Inflammatory or edema would show T2 hyper intensity and T1 hyper or iso intensity of the signal. Anomalous lesion would not be consistent with lesion pattern and neurological deficits connected to the localization without previous clinical signs. Neoplastic conditions would not fit with lesion distribution and progression of clinical signs, but would fit with signal intensity pattern. Taking all data in count lesion fits with the condition well described in human medicine as pseudomeningocoele caused by traction trauma to the nerve roots of lumbal intumescence. This hypothesis is limited by facts that MRI study is not complete. There is absence of FLAIR study wich would support theory that the T2 high signal is due to CSF accumulation. Contrast study would help to eliminate other possible lesions. One could ask question why just two nerve roots were traumatized. And the final limitation is that there is no follow up MRI study done after resolution of clinical signs. Pseudomeningocoele is condition of CSF accumulation due to dura tearing. Major causes are congenital, blunt trauma and traction trauma (1). The mechanism of traction trauma is not clear. It is suggested that can be caused by CSF pressure wave due to increased abdominal pressure (2), or flexion/abduction aggressive movement (3), or flexion/distraction movement (4). There is no correlation between severity of nerve root injury and pseudomeningocoele appearance (4). There is no definitive strategy for pseudomeningocoele treatment (4). Often nerve root injury is more distally than pseudomeningocoele site.