Vets on the Balkans - an online journal for veterinarians from the Balkans - Vets on the Balkans

Patent Ductus Arteriosus in adult dog

July 2, 2016 Leave a Comment

Todor Kalinov, DVM, Zaravet veterinary clinic

Todor Kalinov, DVM, Zaravet veterinary clinic, city of Plovdiv, Bulgaria, e-mail drkalinov80@gmiail.com

INTRODUCTION

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Patent Ductus Arteriosus(PDA) is one of the most frequently encountered congenital heart disease in dogs , ranging in prevalence from about 25 to 32 % from reported malformations ¹ , and lest frequently in cats – about 11 % . The ductus arteriosus is normal foetal structure that shunts blood from pulmonary artery to aorta ². Before the birth , it divers approximately 80 to 90 % of the right ventricular output back to the left side of the circulation. After parturition and the onset of breathing , pulmonary vascular resistance falls, flow in the ductus reverses , and the resulting rise in arterial oxygen tension inhibits local prostaglandin release causing constriction of the vascular smooth muscle within the vessel wall and functional closure of the ductus arteriosus³.

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The ductal wall usually contains a loose branching pattern of circumferential smooth muscle in normal pups. The increasing genetic liability to PDA represents extension of the noncontractile wall structure of the aorta to an increasing segment of the ductus arteriosus, progressively impairing its capacity to undergo physiologic closure¹.

In typical cases because of the lower pressure in pulmonary circulation there is continuous flow thru the ductus arteriosus from aorta to pulmonary artery. Clinical impact from this is volume overload of the structures in the shunt pathway : the main pulmonary artery, lungs, left atrium, left ventricle, and back to the ascending aorta up to the level of the ductus⁴. In that shunt direction the dogs show signs of left-sided congestive heart failure – exercise intolerance, coughing, eventually pulmonary edema. In rare instances when the ductus still wide after birth, the flow is really enormous and this leads to increase in pulmonary vascular resistance and change in direction of the shunt, so-called Eisenmengers physiology and reversed PDA . This pattern of pulmonary hypertension and reversed (right to left) shunting usually develops within the first few weeks of life³. Clinical signs in reversed PDA are shortness of breath, differential cyanosis – pink mucous membranes in cranial part of the body and cyanosis in caudal membranes, polycythemia , pelvic limb weakness, collapse, and seizures. The changes in pulmonary vasculature are irreversible and closure of the PDA is not suggested.

Many dogs with left to right PDA do not show any clinical signs, but if left heart failure has developed in first year of life, up to 65 % would die if left untreated. In most of the dogs clinical signs are apparent before the third year of age. The appearance of signs in older dogs is unusual².

CASE PRESENTATION

Buky was 7 years old springer spaniel admitted in our clinic with severe respiratory distress. He had history of heart murmur noted on routine examination , several episodes with increasing respiratory rate, and one presyncopal event with rear limb weakness. All clinical signs were apparent past several months.

The dog breathed with open mouth, mucus membranes were cyanotic , respiration rate increased, and on auscultation we have founded continued heart murmur, and crackles on the both side of the thorax. On the X-ray there was severe generalized cardiomegaly, pulmonary overcirculation with dilation if the pulmonary arteries and veins, interstitial to alveolar lung pattern (Figure 1 – L/L projection, Figure 2 – D/V projection). We have applied initial therapy for congestive heart failure with:

Furozemide – 4mg/kg/hour i.v.

Pimobendan – 0.25mg/kg p.os.

Enalapri – 0.5mg/kg p.os.

Sodium nitroprusside – i.v. constant rate infusion

Oxygen – via mask .

After several hours there was a reduction in respiratory rate, and efforts and an ECG and echocardiography were made.

ECG findings :

Sinus tachycardia – 163 bpm

Wide and tall P wave – suggestive of left atrium enlargement

Tall R wave – suggestive of left ventricular enlargement (Figure 8)

Atrial premature complexes (Figure 3)

Ventricular premature complexes(VPC) with origin in left ventricle (Figure 4)

Fusion beats – intermediate morphology between normal complexes and VPC (Figures 5, 6, 7).

ECHOCARDIOGRAPHY

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We have made echocardiography at left and right lateral recumbency of the patient with all parasternal views according to accepted standards. From the exam we have found severe left heart volume overloud with eccentric hypertrophy of the left ventricle. Left atrium was dilated with rightward excursion of the atrial septum. Left ventricle was dilated with thin free wall and interventricular septum, dooming of the septum to the right ventricle, and reduced systolic motion of the free wall and the septum (video 1).

Left atrium and aorta was measured on right parasternal short axis view at the heart base and the ratio LA/AO was estimated with results showing at Figure 11. Normal LA/AO ratio have to be < 1,6. Main pulmonary artery was dilated compared to aortic root (video 2)

, and blowing of the pulmonary valve was noted (Figure 12).

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On Color Doppler exam there was mild mitral regurgitation with central jet , probably because the dilation of the mitral annulus (Figure 13), and in pulmonary artery was noted typical for PDA continuous flow (video 3).

With CW Doppler the aortic flow velocity was measured 2,19 m/s , with normal speed les then 2.0 m/s. In pulmonary artery CW Doppler show typical continuous bidirectional flow (Figure 14).

On the basis of this findings the dog was diagnosed with Patent Ductus Arteriousus with left to right shunt. Because of the dramatic structural and functional changes in heart, the already developed left heart failure and increased anesthetic risks the owners refused surgical ligation of the ductus. At the time of the diagnosis in our country we did not have the chance for transcatheter coil embolisation. So the only opportunity was to treat congestive heart failure with medications. We have prescribed :

Pimobendan – 0.25 mg/kg/12 h. p.os

Enalapril – 0.5 mg/kg/12 h. p.os

Furozemid – 1.0 mg/kg/12 h. p.os

Spironolacton – 1.0 mg/kg/12 h. p.os

Supplements with L carnitine, taurine, and coenzyme q10.

The dog was very well after the beginning of the therapy and had only exercise intolerance. After about 1 year he had improvement in some echocardiographyc parameters of systolic function – normal fractional shortening, normal pre ejection period, normal ejection time, but the left atrium was bigger then year ago (Figures 15, 16, 17).

Video 4 – right parasternal four and five chamber view year after diagnosis ,

video 5 – modified left parasternal short axis view of heart base with color Doppler of the pulmonary artery showing continuous flow with small turbulent jet in opposite direction.

COMMENTS

The treatments for Patent Ductus Arteriosus are surgical ligation or transcatheter device closure. Because of the technical factors and price in our country no one does make device closure but in many clinics surgical procedure can be done with great success. In this case the owners decline surgery, but mine opinion is also that the dog was not appropriate candidate for operation. Despite the fact that in most cases there is dramatic improvement in clinical status and cardiac function after surgical closure, the age ,the already developed heart failure, and concurrent heart disease, affect negatively survival period after PDA closure⁵. In adult dogs one of the major surgical complications is haemorrhage due to ductus friability². Mitral valve endocardiosis is also an important factor affecting the survival period. On video 1 and 4 we can see the slight thickening and prolapsed mitral valve leaflets, so I supposed that the dog had degeneration of the mitral valve. Conduction instability of the heart is another reason for anesthetic complications. Actually the dog has died suddenly during routine walk without any other signs, about two years after the diagnosis, so malignant arrhythmia can be the reason. Despite this facts in most of the literature, the authors suggest closure of the PDA, even in adult dogs, only important contraindication for not closing is right to left shunt.

CONCLUSION

It is not known why some animals with PDA do not show any signs until adulthood. One of the reasons could be the small diameter of the ductus. In human medicine the maintenance of normal pulmonary vascular resistance is important factor for survival of the older patients². It is certain that the adult dogs with congenital heart diseases are more then we expect, and always when we examine adult animal for some heart disease, we have to think not only for degenerative valve disease and cardiomyopathies but also for congenital and inherited problems. And of course rare things do happen everyday.

LUIGI VENCO, DVM , SCPA, Dipl EVPC, Pavia, Italy

June 15, 2016 Leave a Comment

LUIGI VENCO, DVM , SCPA, Dipl EVPC, Pavia, Italy

Graduated in Veterinary Medicine in 1987 from the University of Milan, after that obtained the Specialization in Small Animal Practice and in Veterinary cardiology . Stayed for study, research and teaching, for several months, at University Veterinary Schools in U.S.A (Athens GA, Davis, CA, Philadelphia, PA, Ft Collins CO) and in Japan (Gifu) and was invited speaker in over 100 courses and conferences in Italy, USA, Japan, Cuba, Croatia , Serbia, Bulgaria, Slovenia, Spain, Poland, Romania, Czech republic. He is author and co-author of more than 40 publications in “peer-reviewed international journals “, 2 books on Heartworm disease 3 on CVBD on one about Veterinary Cardiology. Collaborates in research projects with the University of Milan, Parma, Zagreb and Salamanca. He is member of the American Heartworm Society, Feline Heartworm International Council, SOIPA, ESSCAP and WAAP, and is vice President of the European Dirofilaria Society. He is an EVPC (European College of Veterinary Parasitology) diplomate. He deals with Parasitology, Cardiology and Cardiac Surgery both in Italian Veterinary Hospitals (Clinica Veterinaria Lago Maggiore, Ospedale veterinario Città di Pavia, Ospedale veterinario Poggio Piccolo, Istituto Veterinario di Novara) and abroad (Spain and Hungary)

Who is Luigi Venco?

He is a 27 year old vet with 28 years of experience.

Lucky enough to start working when veterinary medicine started to catch up with the human one.

Lucky of having had great teachers in Italy and around the world and being grateful to them. Lucky of having had the opportunity to work in many countries. Lucky to have found true friends and wonderful colleagues anywhere. Lucky to still have a lot of enthusiasm in his work and to have the strength to be happy for a life saved and grieve for a lost one.

Just lucky

We know you work with many vets from the Balkans. People say we are different. What do you think?

Absolutely different. Full of enthusiasm and with great sense of friendship and collaboration. As young boys in love with what they do.

Tell us more about your daily work and your problems( as well your solutions) ?

The every day work of is full of joy for the victories and sorrows for defeated. It collides with little or too much love for animals. With the economic problems of the owners. With what we would like and we can not. It ‘s a battle to fight with your heart and your mind. The solution, at the end of a tiring and stressful day, is to be able to sleep thinking: “I do not know if I was perfect. But I did the best I could. Tomorrow anyway I will do better”

Can you share with us your “golden rules” for better practice?

– Be critical of yourself, not of others, you can do better always

– Not justify your mistakes but learn from them

– Do not be afraid to teach everyone and be humble to learn from everyone

– Never think you’re the best, always think that you will become

– You are taking care of a life, not a number or a name. Always look in their eyes and listen to what they say

– Nothing is useless. Also visit a healthy dog. Only by knowing what is normal you will be able to understand what is not normal

– Never stop studying and to update you. Veterinary medicine runs in a hurry

What do you think about the level of vet medicine on the Balkans( you receive so many vets, who come to learn from you) ?

I believe that the level of veterinary medicine in the Balkans is growing every day. As in Italy a few years ago. And it runs very fast. Thank you for transmitting us this feeling

What do you think about vet online journal Vets on The Balkans?

It ‘s a wonderful Journal. Open source. Clinical cases and tips useful for the reader. Not just a display of vanity for the authors. Congratulations to the editors for strong expended effort

Surgical extraction of adult D. immitis filariae from the pulmonary arteries of a patient with stage III heartworm disease

June 10, 2016 Leave a Comment

Dr Ranko Georgiev

Ranko Georgiev¹, Hristina Shukerova², Nadezhda Petrova³(anesthetist)

^1,2,3 DVM, Central Veterinary Clinic, Sofia, Bulgaria; 2016

Introduction:

An “exotic” diagnosis for Bulgaria just 5 years ago, Heartworm Disease (HWD) is a parasitic infestation that we nowadays see regularly in our small animal practice. Due to climate change and spreading of intermediate vectors, ever more dogs are getting affected. Other major contributing factors are the infrequency of preventive measures in the country and the high number of undiagnosed and subclinical patients, leading to a reservoir of hosts in the general canine population.

The aim of this article is to report a case where the heavy worm burden of the patient warranted surgical extraction prior to adulticide therapy.

Case presentation:

Rem is a 25kg, 10 years old MC mix breed dog admitted because of ascites and exercise intolerance during the past few weeks. Most prominent of the clinical signs was the severely distended, fluid-filled abdomen – assessed as modified transudate on abdominocenthesis (more than 4 liters were drained because of the labored breathing).

Thoracic X-rays revealed right-sided cardiomegaly and severely distended tortuous and blunt-ended pulmonary arteries. On echocardiography, right heart pathology was mainly observed – including a distended right atrium and ventricle, dilated pulmonary artery and evidence of pulmonary hypertension, as well as many tubular echoic structures in the lumen of the main pulmonary artery, typically identified as adult parasites.

Serology was positive for D. immitis (IDEXX 4D snap test) and the dog was classified as stage III HWD.

Because of the high worm burden and ascites, the possibility of interventional removal of the worms, before the adulticide treatment, was suggested to the owner, who gave his informed consent.

The patient was scheduled for surgery several days after hospitalization and treatment of right congestive heart failure and pulmonary hypertension using the following therapeutic protocol:

Torasemide: 0.2mg/kg/12h, IV and PO

Sildenafil: 2mg/kg/12h, PO

Ivermectin: 6ug/kg monthly, subcutaneously

Surgical extraction of worms was routinely performed using the right jugular vein approach. The area was scrubbed aseptically and a small skin incision was made over it. The vein was dissected free from the surrounding tissue and ligated proximally. A small transverse cut in its wall was made, through which a forceps was advanced into the heart under fluoroscopic control.

Video: http://dox.bg/files/dw?a=f058367161

An Ishihara Flexible Alligator Forceps (Fujinon TypeL FK-480L) was used, which is a vet instrument designed in Japan, especially for Dirofilaria extraction.

The anesthetic protocol we used was typical for this procedure; in particular premedication with Atropine, Butorphanol and Midazolam; induction with Etomidate; and finally Isoflurane maintenance.

After nearly 20 attempts, we extracted 25 adult worms. The overall fluoroscopic time of the procedure was less than 5 minutes. The recovery of the patient was uneventful and a day later we started the adulticide protocol for HWD treatment, as recommended by the American Heart Worm Association.

Comments:

In all cases with stage III or IV HWD it is advisable to discuss the possibility of surgical extraction of some of the worms as a pre-adulticide step. This will lower the risk of fatal pulmonary thromboembolism after the injection of Immiticide and will likely improve the symptoms of existing pulmonary hypertension.

It should be noted that if a different extraction device is used (endoscopic loops and baskets, rigid or semi-rigid alligator forceps, different types of graspers, etc.), the success rate of the procedure is much lower, at least in our experience. The Ishihara forceps could be actively maneuvered into the RVOT, hence providing faster and easier access to the PA.

Conclusions:

Surgical extraction of a heavy worm burden is possible and clinically important before adulticide treatment, in patients with end-stage HWD.

Rem, the dog of our study, successfully completed the treatment protocol for HWD without any evidence of pulmonary thromboembolism; meanwhile the symptoms of RCHF have slowly abated.

Gastrointestinal linear foreign body

May 19, 2016 Leave a Comment

1 year old, Samoyed, F

History: vomiting, lack of appetite

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Findings: On plain radiographs there is a plicated appearance of some of the small intestinal loops on the middle side of the abdomen. The content of this intestinal loops it’s mixt gas-fluid, with variably sized and shaped gas bubbles.

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Fallowing contrast medium administration: Delayed gastric emptying time. The bunched and plicated pattern it’s highlighted affectind the duodenum and the jejunum.

Conclusion: Gastrointestinal linear foreign body

TTA cases , Dr Goran Tomisic from Belgrade, Serbia

May 15, 2016 Leave a Comment

Neapolitan mastiff

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) and very small dog (6kg Poodle). Furthermore, 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. Placing the cage and screws was the real challenge. The 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.

Tricuspid Valve Dysplasia (TVD) in a dog; X-ray follow-ups

May 5, 2016 Leave a Comment

Dr Ranko Georgiev

Ranko Georgiev¹, DVM, Central Veterinary Clinic, Sofia, Bulgaria

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Akira is a German shepherd dog, first presented with an ascites and exercise intolerance 4 years ago. A diagnosis of a tricuspid valve dysplasia (TVD) was made after X-rays and echocardiography. Standard therapy for a patient with a TVD and CHF was initiated and kept since. The prognosis given in 2012 was ‘guarded to poor’ concerning the severe generalized cardiomegaly, but four years later the patient is still alive and doing great with a full therapy (attached). The size of the heart is bigger at any of the control X-rays done annually; the size of the right atrium contributing with 75% to the whole heart volume!

Akira, FI GSD, 5yoa, 30kg, TVD – therapy (the patient is with an atrial fibrillation as well)

Furosemide 60mg BID

Spironolacton 25mg SID

Hydrochlorthiazide 25mg SID

Enalapril 10mg BID

Pimobendan 10mg BID

Digoxin 0.2mg BID

Cardiovet 1tabl BID (Taurin, L-Carnitin, Vit. E, Coenzim Q)

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“Sharing is Caring” . How we exchange experience on The Balkans?

April 25, 2016 Leave a Comment

Romania and Turkey!

One of the goals of the journal Vets on The Balkans is vets from that region to know each other and to find easier and cheaper way to upgrade their knowledge , experience and skills. We have so much good vets at our region and is easier to go from Bulgaria to Turkey, or from Romania to Serbia and learn what you are interested in.

We are more than happy that is already reality. Dr Onur Catar from Pet Code Veterinary Clinic in Ankara, Turkey visited Dermatology clinic of Dr Rares Capitan , resident ECVD.

Dr. Capitan graduated in 2006 from the Faculty of Veterinary Medicine Bucharest (University of Agronomic Sciences and Veterinary Medicine of Bucharest).
He is member of ESVD – European Society of Veterinary Dermatology

Dr. Capitan is passionate about all areas related to veterinary dermatology. His hope is that, in Eastern Europe, veterinary dermatology services be elevated to international standards.
In recent years Dr. Capitan has attended and graduated multiple intensive courses, seminars, and workshops, facilitated by famous dermatologists veterinarians in Europe and the United States, including:
ESAVS (European School for Advanced Veterinary Studies) – Vienna
International clerkship at Ohio State University – Dermatology and Otology

Recently he was accepted and has been participating in a veterinary dermatology residency under the guidance of Dr. Chiara NOLI DVM Diplomate of the European College of Veterinary dermatology.

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Dr Rares Capitan in Bulgaria!

He was as well guest as a consultant in 2 veterinary clinics in Sofia, Bulgaria!

When Dr onur Catar came back home in his daily job, he starts using his knowledge from Dr Rares Capitan.

This is the most important thing in our life, not only professional. “Hand by Hand” we all will be better!

Thank you guys for all! You are Vets on The Balkans!

Hemilaminectomy

April 12, 2016 Leave a Comment

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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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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– 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

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

Two portal laparoscopic ovariectomy in obese dogs

April 8, 2016 Leave a Comment

Emil Ofner, DVM

Authors : Emil Ofner, DVM

Ivica Ukić, DVM

Davor Crnogaća, DVM

Silvijo Tarasić, Eng; OLYMPUS d.o.o. Zagreb

Small Animal Veterinary Clinic More, Šibenik, Croatia

Key words : Gyrus PKS plasma SORD, Laparoscopic ovariectomy

Introduction

Since the beginning of 2012 two hundred laparoscopic ovariectomyes with two – portal method was done in veterinary clinic More. The average body weight of female dogs was 25 kg. While no surgical problems were encountered in small and medium size dogs, overweight and obese patients demonstrated to be more challenging both for the surgeon and anesthesiologist. Because of problems encountered in large and obese female dogs, especially the difficulties of removing easily ovaries with large ovarian bursa, it was necessary to find new easier and faster way for removing such ovaries through laparoscopic portals without elongation of incision. That was reason for implementation of high frequency bipolar morcellator Gyrus PKS plasma SORD for fast removal of ovaries and its adherent burse in large and obese patients.

Materials and methods

All dogs were sedated using alpha-adrenergic agonists or acepromazine. Induction of anaesthesia was done with propofol. After intubation patients were maintained on isofluran. Analgesia during surgery was provided by constant–rate infusion (CRI) of fentanyl. Most patients were breathing spontaneously and ventilatory assistance was used if needed.

To facilitate ovary visualization laparoscopic positioner was used. Ovarian fixation for resection was done with a percutaneous needle technique. Resection of ovaries was done with bipolar forceps (Grus PKS) or ultrasonic knife (Ethicon). For large and obese female dogs removal of resected ovaries was done by bipolar high frequency Gyrus PKS plasma SORD morcellator.

Results

A total of 200 laparoscopic two portal ovariectomies were done from the beginning of 2012. A body weight span of dogs was from 4.0 kg to 65 kg. The average body weight of female dogs was 25 kg. Of all dogs 29 % (58 dogs) were characterized large (above 30 kg) , overweight or obese (body condition score > 4) .

Time for ovary resection and removal in small and medium size dogs was similar like in large and obese dogs when using PKS plasma SORD morcellator. For both groups surgical time in most of the cases was under 40 minutes. For dogs under 30 kg average time was 23.45 minutes, and for large and obese dogs average surgical time was 34 minutes.

Only one dog had a postoperative wound infection which was managed with antibiotics and in one dog (8 years old Alaskan Malamute) we couldn’t establish pneumoperitoneum because of huge deposits of intra-abdominal fat tissue so we proceeded to open laparotomy.

Discussion

Veterinary laparoscopic ovaryectomy is traditionally done by three – portal method and we can call it a universal method for every type and size of the patient. But, it’s not as minimally invasive as two and single portal method.

Single portal laparoscopic ovariectomy is only method which is the not universal or ideal for every patient because of technical, intraoperative difficulties (especially in obese and large female dogs) mostly related to difficulty in viewing anatomical structures for precise surgical resection. Single portal ovariectomy in our opinion can be only ideal for small and medium size female dogs from 7 to 20 kg especially before the first heat (5-7 months old female dogs).

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Two portal method has some disadvantages, but we can also call it universal method for every type and size of dog. The main deficiency of two portal method was difficult removal of large ovaries with its adherent burse thrue laparoscopic portals in obese and large breeds of dogs. Also, using a percutaneous needle technique in two portal method for fixation of ovaries in the abdomen makes them very often hidden behind its adherent bursa and difficult for viewing in order to do a precise disection to get a smaller tissue piece for easy extraction (Picture 1).

Ovaries with adherent bursa in large and obese female dogs by our own measurements can be over 6 cm in diameter. The traditional method for removal of large ovaries was an elongation of laparoscopic portals by scalpel No. 11. Unfortunately, if you are using threaded trocars (we use endotip trocar type) this can be little challenging. Also making portal larger by incision is abandoning basic principles of minimally invasive surgery and causes more intraoperative trauma. Size of elongated incisions of laparoscopic portals is getting close to standard open laparotomy incision size and then we can’t absolutely say that we did minimally invasive surgery.

Problem of removal of large ovaries in three portal method is not so important because the surgeon can easily use scissors and forceps to divide such ovaries intra-abdominal in two or more segments and take them out separately but that also lengthens operation time.

Removing ovaries with large ovarian bursa is very often time-consuming and elevates stress on the surgeon and its assistants, also lengthens anaesthesia time and increases risk for the patient.

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Also, there are mortality risks in obese patients during and after laparoscopic surgery that are proportional to operative time which is often increased in these patients. Because of that operative time becomes very important factor (Table 1).

Taking into consideration things mentioned above, we tried to make two portal method easy and fast even in large and obese patients (> 30 kg) with large ovarian bursa making surgical time for resection and removal of both ovaries under 30 minutes.

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To achieve this we started to use human gynaecological bipolar morcellator Gyrus PKS plasma SORD (SORD – solid organ removal device) and HF generator Gyrus G400 (Picture 2, 3 , and 4).

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Main advantages when using Gyrus PKS plasma SORD are :

easy to use (Plug and play)
fast
small diameter (12 mm / 15 mm)
light (250 grams)

Main disadvantages are :

single use instrument (can be reprocessed)
smoke production (use of insufflators with the automatic smoke evacuation system resolves this problem)

Conclusion

Two portal laparoscopic ovariectomy using Gyrus PKS plasma SORD morcellator makes this method suitable for technically demanding ovariectmies especially in large and obese dogs. Difficult ovariectmies in these patients are done with minimal intraoperative trauma without elongation of laparoscopic portals and short period of time (up to 30 minutes). After 3 years using Gyrus PKS plasma SORD morcellator we can conclude that to us it’s become a crucial instrument in every two portal laparosopic ovariectomy of obese dogs. Using this instrument makes two portal laparoscopic ovariectomy universal, fast and safe especially in large and obese dogs. Only downside of using Gyrus PKS plasma SORD morcellator is its price.

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

April 3, 2016 Leave a Comment

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.

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.

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.

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.

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.

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).

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.

Post op radiographs evaluation

Excellent implants’ stability and reasonably good orientation were appreciated on the post op X- rays (Fig.9).
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.

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

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.

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.

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