Dobro Hrumvane – Vets on the Balkans - an online journal for veterinarians from the Balkans

Congenital pathology of duplicated ureter from left kidney with CKD in geriatric dog Chao – Chao

February 13, 2023

Dr Mila Kisyova

Dr. Mila Kisyova

veterinary clinics “Dobro hrumvane!”- Sofia, Bulgaria

Introducion

Normal anatomy of the kidneys:

The kidneys are paired, bean-shaped structures located in the retroperitoneal space directly beneath the sublumbar muscles. The cranial pole of the right kidney lies in the renal fossa of the caudate liver lobe and is located more cranially than the left kidney. The cranial pole of the left kidney lies lateral to the ipsilateral adrenal gland, which is closely associated with the cranial aspect of the left renal vessels. The left kidney is generally more mobile than the right kidney. Each kidney has a cranial and caudal pole and a ventral and dorsal aspect .

The concave surface of the kidney is located along the medial aspect and is called the hilus. The hilus is the location where the renal artery enters the kidney and the renal vein and ureter exit. Nerves and lymphatic vessels enter at the hilus as well. Anatomically, the renal vein is located more ventrally, and the renal artery is more dorsally. In an animal of normal body condition, the kidney is typically surrounded by a substantial amount of fat; this fat is maintained even in lean animals. In obese animals, the surrounding adipose tissue can virtually hide the kidney from view, making gross evaluation difficult.

Patophysiology of duplicated ureters:

Duplicated Ureter or Duplex Collecting System is a congenital condition in which the ureteric bud, the embryological origin of the ureter, splits (or arises twice), resulting in two ureters draining a single kidney. In the case of a duplicated ureter, the ureteric bud either splits or arises twice. In most cases, the kidney is divided into two parts, an upper and lower lobe, with some overlap due to intermingling of collecting tubules. However, in some cases the division is so complete as to give rise to two separate parts, each with its own renal pelvis and ureter. Double ureters from each kidney are very rare condition in dogs. They are drain separate renal collection systems from the same kidney and open separately into the urinary or genital tract. Given the embryological migration pattern of ureters, their termination sites are often ectopic.

*) https://www.researchgate.net/figure/Classification-of-urethral-duplication-in-dogs-based-on-the-classification-in-human_fig3_250044546

Duplex kidney formation: developmental mechanisms and genetic predisposition
Vladimir M. Kozlov, Andreas Schedl, iBV, Institut de Biologie Valrose, Equipe Labellisée Ligue Contre le Cancer, Université Cote d’Azur, Centre de Biochimie, UFR Sciences, Parc Valrose, Nice Cedex 2, 06108, France

Duplex systems can have a variety of phenotypes, and multiple classification systems have been proposed to categorise this pathology. In incomplete duplication, the two poles of a duplex kidney share the same ureteral orifice of the bladder. Such duplex kidneys with a bifid pelvis or ureter arise when an initially single UB bifurcates before it reaches the ampulla. This is likely caused by a premature first branching event that occurred before the ureter has reached the metanephric mesenchyme (MM). Much more frequent are complete duplications, which occur when two UBs emerge from the nephric duct (ND). In most cases, the lower pole of the kidney is normal and the upper pole is abnormal an observation explained by the fact that the ectopic ureteric bud (UB) frequently emerges anteriorly to the position of the normal UB and drives the formation of the upper pole of a duplex kidney. Inverted Y-ureteral duplication is a rare condition in which two ureteral orifices drain from a single normal kidney. Inverted Y-ureteral duplication is believed to be caused by the merging of two independent UBs just before or as they reach the kidney anlagen. A very rare H-shaped ureter has also been reported. Although the vast majority of cases involve a simple duplication, multiplex ureters with up to six independent buds have also been described. In some cases, the additional ureter or ureters are ectopic and fail to connect to the bladder or the kidney (blind ending ureter).

Report and history of the patient

We saw Jonh (11 years old, non-castrated, cryptorchid, chao- chao) for first time in our clinic for second opinion related to chronic kidney disease (CKD). He was diagnosed with chronic renal failure by colleagues about 2 years ago. Prior to our examination, he had been taking only food supplements (Irc Vet) and Renal Food. He had polyuria and polydipsia (PU/PD). The owners said that the urine was very light in colour. Sometimes Jonny had episodes with vomiting and lose of appetite. There was data for periodic blood tests with a tendency to increase the basic renal parameters (urea and creatinine). There was no ultrasound or other type of imaging examination.

When we took Johnny’s case, we initially did a complete abdominal ultrasound and new blood tests:

1. Creatinine	456.20 mmol/L	44.30-138.40 mmol/L
2. Urea	26.32 mmol/L	3.00-8.00 mmol/L
3. ALP	272.59 U/L	10.60-109.00 U/L
4. Na	141.60 mmol/L	140.30-153.90 mmol/L
5. K	6.26 mmol/L	3.50-5.10 mmol/L
6. P	2.10 mmol/L	1.00-2.00 mmol/L
7. Albumin	31.37 g/L	25.80-39.70 g/L
8. Glucose	3.95 mmol/L	3.40-6.00 mmol/L
9. Bilirubin Total	5.07 mmol/L	0.00-5.10 mmol/L
10. Bilirubin Direct	3.05 mmol/L	0.00-3.60 mmol/L
11. ALT	31.33 U/L	8.50-109.00 U/L
12. AST	29.30 U/L	8.90-48.50 U/L

Abdominal Ultrasound:

We started a standard echo-screening and the prostatic gland was normal, the bladder too. And after that on the left abdomen near the left kidney we saw a big, elongated, strange formation with anechoic fluid with a diameter of about 3 cm. The left and right kidneys had a good ultrasound density. Three small cysts were found in the cortex of the left kidney. There was no evidence of pyeloectasis or hydronephrosis. The corticomedullary border was good. This finding may be a pathologically altered testis, cystic formation, or pathological /duplicate/ ureter. During the first ultrasound examination, the dog was fed, so we decided to repeat the examination on an empty stomach. For the next echo screening Jonny was on a 12- hour fasting diet but the ultrasound finding is the same as the previous examination – the strange formation after the left kidney was there with the same size and shape. After performing the second ultrasound examination, we had suspicion for duplicate ureter. In order to be definite in the diagnosis, it necessary to perform computed tomography (CT).

After the new blood tests we started a new supplements – Ipakitine/Rubenal 300/Renassense/IrcVet. But Jonny didn’t feel very well. After some days we made a new blood tests. Before that we had spoken with the owners about the ultrasound finding and we decided to do a CT and see what the exact cause of this strange ultrasound finding.

Rusults of the CT:

2-B

3-C

4-D

5-E

6-F

Images:

1-A – little arrows are the bought normal ureters (left and right), big arrow „А“ – duplicate/ectopic left ureter

2-B – big arrow „А“ – duplicate left ureter

3-C – little arrows are cranial and caudal renal medula, big arrow „А“ – duplicate/ectopic left ureter draining the cranial pole of the kidney

4-D – А“ – duplicate/ectopic left ureter, about 3 cm wide along entire length

5-Е – normal right kidney

6-F – Left kidney, big arrow „А“ – duplicate/ectopic left ureter

*) the photos are provided by colleagues from the CVK (Central Vet Clinic, Sofia)

Тhe conclusion of the computed tomography is the left kidney has a slightly enlarged pelvis. Two ureters originating from the left kidney are found. The ureter, originating from the left kidney, has greatly increased dimensions – a width of about 3 cm along its entire length. Before entering the bladder, it turns ventrally and then dorsally. The other ureter of the left kidney begins in the normal anatomical position and drains into the bladder in the area of the trigone. Both kidneys have no tomographic evidence of hydro/pyelonephrosis.

This kind of pathology of the urogenital system in dogs is very rare. In this case it was an incidental finding because for 11 years the patient had never previously undergone additional ultrasound examinations. Certainly, this rare pathology is directly related to the rapidly progressing renal failure.

Due to the rapidly progressing renal failure, deteriorated general condition and the age of the patient, surgical intervention could not be performed. Jonny’s prognosis is very poor.

Sourses:

„Urethral duplication in a dog: case report [Duplicação uretral em cão: relato de caso] R. Stedile, E.A. Contesini, S.T. Oliveira, C.A.C. Beck, E.C. Oliveira, M.M. Alievi, D. Driemeie, M.S. Muccillo Faculdade de Veterinária – UFRGS Av. Bento Gonçalves, 9090 91540-000 – Porto Alegre, RS „
„Duplex_kidney_formation_Developmental_mechanisms_a.pdf– in humans“
Atlas of Small Animal CT and MRI by Erik Wisner, Allison Zwingenberger ,

March 2015

Four-dimensional CT excretory urography is an accurate technique for diagnosis of canine ureteral ectopia (Tobias Schwarz, Nick Bommer, Maciej Parys, Florence Thierry, Jonathan Bouvard, Jorge Pérez-Accino, Jimmy Saunders, Maurizio Longo – onlinelibraly.wiley.com)

CORRECTIVE OSTEOTOMIES OF COMPLICATED BONE MALFORMATIONS, USING RIGID FIXATION WITH MIKROMED IMPLANTS

September 21, 2021

by the Department for orthopedic diagnostic, surgery and anesthesia in clinics “Dobro hrumvane” – dr. Kirilov, dr. D. Ivanov, dr. Ts. Ivanov, dr. Nikolov, dr. Kotsev, dr. Bochukova, technician Kirilova

Corrective osteotomies, especially the ones caused by combined and complicated malformations of the antebrachium and the crus are truly challenging surgeries, both for the surgeon, and the implants being used. Except by their design and material (steel/titanium), these implants differ also by their qualities such as elasticity, strength, long term quality of the locking mechanisms. The quality of the surgical titanium or steel, being used, along with their manufacturing technology are significantly important for the overall quality of the manufactured implants. Further below, in this abstract, we present 4 orthopedic cases, which required a maximally rigid fixation to be applied. Working on these cases, allowed us to challenge the strength and locking quality of the Mikromed implants.

Case 1: Male dog, Frodo, mixed breed, aprox. 35 kg

In its early age, the patient suffered a trauma to its elbow and antebrachium, creating a malunion, which in the long term lead to permanent elbow damage, radio-ulnar synostosis and high-grade external torsion and valgus of the distal antebrachium:

Pre-op antebrachial valgus:

Pre-op antebrachial external torsion:

Frodo pre-op video:

A double plating corrective osteotomy was performed, using a 3.5 mm locking DCP Mikromed plate and 3.5 mm locking and non-locking screws (this system also accommodates 2.7 and 4.0 mm screws) and a second, straight, non-loking Mikromed DCP plate with cortical 2.7mm screws. In this kind of surgery, it is crucial to have very strong implants and locking and to do precise calculations for the corrective angles to be achieved. Precise contouring of the medially placed non-locking implant is also very important for the successful outcome.

Post-op X-ray CrCd:

Post-op X-ray LAT:

Frodo 18H post-op video:

https://youtu.be/8wVnvzzpb-E

Final result: perfect bone healing and normal leg usage

Case 2: Male dog, Michail, mixed breed, aprox. 13 kg

The patient suffers from congenital bilateral antebtachial deformity – high-grade internal torsion and varus.

Pre-op antebrachial varus right leg:

Pre-op antebrachial internal torsion right leg:

Pre-op antebrachial varus left leg:

Pre-op antebrachial internal torsion left leg:

Video pre-op:

A single plate corrective osteotomy was performed (this was possible due to the low weight of the patient). A straight support 2.4 mm locking Mikromed plate was used, along with 2.7 mm locking and non-locking screws (the system also accommodates 2.4 mm screws). The plates was applied in an oblique fashion, instead of purely cranially, due to the need for excessive contouring, which is a serious challenge for the strength of the plate and the stability of the locking and the whole fixation in the post-op period.

X-ray picture 5 min post-op LAT:

X-ray picture 5 min post-op CrCd:

Final result: perfect bone healing and normal leg usage

X-ray picture 6 months post-op LAT:

Case 3: Male dog, Ares, GSD, aprox. 30 kg

The patient suffered a high-energy trauma to its stifle and curs in its early age, which stopped the development of the proximal portion of the tibial plateau, thus making it “sink” in relation to the tibial crest and leading to a shift of it surface in relation to the femoral condyles. Additionally a synostosis between tibia and fibula was found. The patient demonstrated intensifying lameness and more and more severe pain, especially upon limb extension. In addition, a low-grade lumbo-sacral instability was diagnosed during imaging.

Ares X-ray picture pre-op LAT:

Ares X-ray piicture pre-op CrCd:

A block resection of the tibial plateau was performed, during which the plateau was elevated and leveled. Ilial bone autografts were used to fill the gap, formed between the two tibial fragments. A straight support locking Mikromed 3.5 mm DCP plate plus 4.0 locking screws were used. The correct and adequate leveling of the tibial plateau was crucial, along with strength of the plate and the reliable locking, which were subjected to serious biological forces. In addition to that, the patient had an energetic temper.

Ares X-ray picture 24H post-op LAT:

Ares X-ray picture 24H post-op CrCd:

Ares X-ray picture 6 months post-op LAT:

Ares X-ray picture 6 months post-op CrCd:

Result: perfect healing and limb use, even years after completion of the surgery.

Ares CT 2 y post-op:

Ares video 2 y post-op:

https://youtu.be/cDpzO229GcU

Case 4: Male dog, Nuki, mixed breed,aprox 25 kg

The patient suffered from a rare congenital elbow deformation: the proximal radius and ulna exhibited “mirror view” morphology in the sagittal plane: the ulnar trochlear notch and its coronoid processes were placed at the opposite site. There was no weight baring on the limb due to this, which lead to maximal muscle atrophy. The carpal joint was in permanent flexion and extension was impossible to achieve. All soft tissues related to the elbow joint exhibited atypical morphology.

Nuky X-ray picture pre-op LAT:

Nuky X-ray piicture pre-op CrCd:

In the are moments of leg “usage” Nuky treaded in this way:

An elbow arthrodesis along with a minor (around 25 mm) limb shortening was performed. An angle of 110-130 degrees between the humerus and antebrachium was impossible to be achieved, because of the altered soft tissue morphology and due to the risk of worsening the carpal situation. Due to that, a laterally applied curved non-locking DCP Mikromed plate was used, instead of the typical caudally applied straight plate.

Medial application of the plate is usually recommended, but in this case we decided to once again challenge and trust the Mikromed implant, being laterally applied.

Nuky video 3 days post-op:

Nuky video 1 W post-op:

https://youtu.be/alVKE2AJtF0

Nuky video 2 W post-op:

Result: full bone healing and good limb use. Home carried physiotherapy helped the particular patient overcome the permanent carpal flexion and evaluate shoulder muscles.

Nuky X-ray picture 6 months post-op LAT:

Nuky X-ray picture 6 months post-op CrCd:

Nuky video 10 months post-op:

Conclusion: The corrective osteotomies require precise pre-surgical planning, regarding both the osteotomy geometry and the choice of implants to be used. The Mikromed implants possess the required strength and locking quality to withstand even excessive orthopedic challenges, especially in the area of rigid fixation.

Glioblastoma in cerebellum of the dog

August 5, 2020

Dr Dimitar Ivanov

Veterinary Clinics Dobro Hrumvane

Sofia, Bulgaria

Glioblastoma is a malignant tumor of the nervous tissue. This is the fourth degree of astrocytoma. It is more common in the frontal and temporal lobes. Good contrast enhancement in magnetic resonance imaging, edema of the surrounding tissue is often observed. Macroscopically, it has well-defined borders.

Male dog, named Jazz, 9 years old, husky, brought to the clinic on 01.07.2020

There is worsening of the condition since the day before, the animal was no longer interested in food or water, there was lack of coordination. The clinical examination reveals that the animal was obtunded, but still responsive and it was responding to commands, given by the owners, it was also consciously resisting some tests, during the examination, which it doesn’t seem to like. No evidence of seizures. Posture – head turn to the left and tilt to the right. Gait – vestibular ataxia. Cranial nerves – absent menace reaction on the left. Postural reactions – decreased proprioception of the left pelvic limb, decreased hopping reaction of the right thoracic limb. Spinal reflexes – normal. Localization – the decreased proprioception only on the left pelvic limbs cannot definitively determine the localization. Due to the left head turn, the localization is determined in the left forebrain or peripheral vestibular syndrome. Differential diagnoses: ischemia, metabolic disease, neoplasia. MRI is recommended.

On 02.07.2020 blood was taken for CBC – nothing remarkable, Biochemistry – a slight increase in glucose and AST, ALP – 455.99 (10.6-109 U / L). FT4 and TSH are normal.

On 03.07.2020, an MRI was performed. The imagining showed a mass in the left cerebellum, with mass effect on the brainstem and cerebellum, obstruction of the normal outflow of cerebrospinal fluid and for that causing hydrocephalus. Also edema in the surrounding tissue.

Preoperative preparation was started with Mannitol 1.5 g/kg/12h i.v., Methylprednisolon 15.78 mg/12h i.v. Antibiotic therapy – Ceftriaxone – 1 g/12h i.v.

On July 4, 2020, a left suboccipital craniectomy was performed for removing the mass, part of which was sent for histopathology to Laboklin, Germany. Part of the capsule of the tumor has not been removed due to adhesions with the brainstem and the risk of injury during the process of removing it. An artificial dura was placed on the defect to prevent the leakage of cerebrospinal fluid.

After the surgery Jazz was recovering very well. There was a manifestation of vertical nystagmus, which disappeared quickly by itself. Antibiotic therapy was continued, as well as mannitol and methylprednisolone therapy 24 hours after the surgery. Meloxicam was included for pain management 12 hours after the steroids were stopped

The first day after the surgery Jazz was still slightly uncoordinated and his head was still with negligible turn, but he was able to get up and walk on his own.

On July 6, 2020, 48 hours after the surgery, Jazz was more stable, progressively getting better and eating and drinking water.

On July 9, 2020, in the middle of the day Jazz’s condition got worse. He started to turn his head to the left again. On the same day, the histology result was received:

Glioblastoma with high degree of malignancy.

On 10.07.2020, steroid therapy was started, which led to a fast improvement. On the next day Jazz was sent home with home therapy of prednisolone 0.5mg/kg/12h.

Consultation with oncology department for chemotherapy was recommended

On 17.07.20 the sutures were removed from the skin incision, Jazz’s therapy with prednisolone (0.5 mg/kg /12h) was continued. There was a slight incoordination and tilt of the head.

MODIFIED PANCARPAL ARTHRODESIS “Dobro hrumvane” – new extreme challenge, new success

January 14, 2020

This year the created 5 years ago by our team new orthopedic technique for cases with radial nerve palsy in cats (see article http://balkanvets.com/index.php/2019/03/09/main-topic-a-new-approach-to-radial-nerve-palsy-in-cats-clinical-case-series-report/) met its biggest possibe challenge and led the case to unexpected 100 % success:

Cat, M, approx 3 years old, Otelo. The cat has survived after severe trauma which forced colleagues to amputate one front limb and to try saving the other one using standard surgical procedure. Weeks later the cat came to us for euthanasia: lethargic, anorhexic, with decubital wounds and with very deep and extremely inflammated and painful exhoriation at the chest area due to body dragging on the floors. The not amputated leg wasn’t functional. It was swallowed, with severe purulent inflammation and permanent fistula, with evaluating maluinon (high degree rotation and mild varus) and with radial nerve paralysis, the antebrachial bones showed all radiographic signes of osteomyelitis. The patient showed all clinical and paraclinical signs of evaluating sepsis. Additionally Otelo had also severe lungs problem. We took the risk to prepare the cat for the DH arthrodesis surgery and to test our technique in these extremest possible conditions.

Otelo’s condition 1^st day in clinic:

It took almost 3 weeks to prepare Otelo fur surgery, lungs multimodal treatment including Opti-Airwei, treatment against the systemic and local infections and lesions, chronic pain and exhaustion.

We used the technique on its standard way, we just decreased the rerotation angle from 90-95 degrees to 80-82 degrees, because cats with only one front limb move the existing one to the median body line which leads to natural 10-12 degrees carpal rerotation.

Otelo 5 min post-op X-ray:

Pre- and intra-operatively we took material for bacterial identification and antibiogram. Of course we counted as usual on VetDiaLab with their unique system for automathic identification even to subtype and for authomatic machine antibiograms. The VetDiaLab fantastic work was the key for complete solving of the chronic multi-infection.

Thanks to the precise lab results, the reliable technique and the amazing post-op care of our team (even including adoption of the patient by “fallen in love” with him team member) Otelo overcame the victim pose, the decubital wounds, the chest deep exhoriation and uses its leg with full geometrical functionality. The deep antebrachial bone infection was 100 % overcome only after removing one of the screws which kept infection – after this manipulation the operative suture finally healed 100 % and we removed the collar on Christmas!

Otelo Christmas video:

SECONDARY ALIMENTARY HYPERPARATHYROIDISM and its complications – our approach

November 11, 2019

Departments “Metabolic and endocrine disorders” and “Orthopedics” – veterinary clinics “Dobro Hrumvane”, Sofia, Bulgaria

The alimentary secondary hyperparathyroidism is not so rare as many specialists think. For period of only 9 months we diagnosed in our clinics 17 cases and had serious observations in other 9 cases (the owners didn’t agree to prove 100 % in Laboklin) in different stages of the problem evaluating. We present below our treatment protocol and two concrete complicated cases – both with healed patients but one not operated – and our consequences experience in cases with or without surgery.

The hyperparathyroidism is primary and secondary. The secondary could be renal – complication of chronic renal insufficiency, it is more often seen even in comparison to the primary – and alimentary: rarest but for sure not exotic. The alimentary variant is seen in young dogs and especially cats fed only or almost only with meat. The low calcium levels and the inadequate calcium/phosphor ratio in meat starts a multi-vector pathological process evaluating for a couple of weeks to following clinical picture: unwilling for moving, lameness, stiff walking, spontaneous fractures, face edemas, easily teeth removing or teeth loosening, spontaneous neurological deficit in different levels. The standard hematological and biochemical blood panels usually do not give any diagnose direction. It is common the right diagnose to be reached with delay because often the colleagues miss during the anamnestic phase to become well informed about the alimentary regime of the patient, X-rays are rarely made in the very beginning and usually the therapy starts with NSAIDS and general strengthening protocol.

This disease not rarely causes hind legs function insufficiency and neurological deficit, paradoxally not corresponding to and many times exceeding the found through imaging diagnostic bone (including vertebral) changes. It is not exotic OCD (even in cats) to be diagnosed later due to cartilage underlying bone and bone vessels malformation.

Most directing is the anamneses especially the alimentary regime of the young patient. Absolutely enough for 90 % sure diagnose is combination of anamneses, estimation of the bone geometry and density due to X-rays covering flat bones, spinal cord, mandibula, maxilla and blood levels of macro elements especially P. For 100 % sure diagnose we send blood hormon sample to Laboklin Germany. The differential diagnoses are not many and include some genetic or metabolic disorders.

Our newest therapeutic protocol, product of enough clinical experience and leading to fastest and completest healing includes:

Hospitalization of the patient in cage for maximal immobilization aiming to avoid pathological fractures and especially vertebral fractures.
Diet change to P-poor and Ca-rich: the variants are so many, ii is important the diet to be diverse and with enough vitamins. In most of the cases we start with renal diet combined with additional food components;
Calo-pet – zero P molecules and very adequate composition for this problem;
NEO-K9: not only because of the demonstrative bone healing stimulation but also very adequate against all cases of hyperphosphatemia – and in cases of alimentary hyperparathyroidism we have severe hyperphosphatemia as well as serious bone demineralization and decrease of their potential for resistance to physical forces and for healing;
Ipakitine – because of its ability to chelate and eliminate the phosphor
HyalOral – because of its adequate to the therapy (especially against intra-joints complications) composition and especially because of the gamma-oryzanol inside
NSAIDS – against pain and inflammation
Calciferol (Vitamin D3) in dosage 2 ng/kg/24h– please be very careful when using it because increases the resorption of calcium but also of phosphor. Should be added to the protocol only after the phosphor is already in normal blood levels or very close to them;
Sometimes after careful individual estimation – oral pure Ca human product for children or even injectable Ca vet product;
Often repeated biochemical including P and Ca blood monitoring (a big Thank you! to our trusted lab VetDiaLab for the precise and reliable work during the last 15 years), every-day neurological monitoring and checking the ability for urination, every-day check for rib and long bone fractures and regular (minimum every 8-10 days) X-ray follow-up of the geometry and healing of all fissures and fractures;
Therapy against the complications including the spontaneous fractures, eating difficulties because of jaw problems ets.

This algorithm leads to very fast and demonstrative health status improvement. Of course it is very important to estimate carefully when the patient is ready to get out of the cage. We recommend the bone fissues to be X-ray monitored every 5-10 days and all long-bone fractures to be operated especially those near the knee joints. The reason?: the long-bone fractures caused by SAHPT heal very often with malunion which is being well tolerated by young animals but many of them suffer when achieve adult/mature age. On the other hand we recommend vertebral fractures to be operated only in case of neurological deficit or pain. In all cases of eating difficulties esofageal probe and not manual assisted eating is recommendable.

Case 1: cat Darko, SAHPT complicated with two supracondylar femural fractures, operated with delay. We added Calciferol to the therapy protocol at the 7^th day when the blood phosphor decreased to normal levels. The owners asked us not to operate and to wait but as usual despide the cage rest after a couple of days the fragments geometry get worse and the healing would lead to malunion and may be to patellar luxation. The owners agreed to operate, the surgeries with implants of Mikromed were fast and simple (peri-operatively: Clavaseptin) and the case result is 100% healthy and extremely mobil cat:

Case two: cat Pisi, SAHPT complicated with fissure and fracture, not operated. The X-ray fissure (left humerus) follow up showed no need to operate and healed without problems. Unfortunately we didn’t receive permission to operate the fracture and as usual the result is serious malunion:

Conclusion: strict cage rest, strict food and therapeutical protocol, strict clinical and paraclinical monitoring and careful surgery estimation = successful outcome.

Histiocytic Ulcerative Colitis in French Bulldog

September 29, 2019

Dr Mila Kisyova,

veterinary clinics “Dobro hrumvane!”- Sofia, Bulgaria

Introduction

Histiocytic ulcerative colitis (HUC) is an inflammatory bowel disease that causes tenesmus, hematochezia, and profound weight loss. The disease is most commonly described in young Boxer Dogs but it has also been reported in other breeds of dogs, including Mastiff, Alaskan Malamute, Doberman Pinscher, French Bulldogs. One cat with HUC also has been described. HUC differs from other forms of inflammatory bowel disease in dogs because it is characterized histologically by periodic acid-Schiff (PAS)-positive macrophages; it is more likely to be associated with mucosal ulcerations; it is less responsive to therapy, and has a poorer long-term prognosis. HUC in Boxer Dogs was 1st described by Van Kruiningen et al in 1965. Since that time, the gross histopathologic and ultrastructural findings have been well characterized. The pathognomonic lesion of HUC is the accumulation of distinctive, PAS-positive macrophages (indicative of glycoprotein within the macrophages) in the lamina propria and submucosa of the colon with loss of the associated epithelial surface. The PAS-positive material may be derived from remnants of bacterial cell wall glycoprotein, and accumulation of PAS-positive material in macrophages may occur because of abnormal lysosomal activity, exhaustion of lysosomal activity, or inhibition of lysosomal activity by toxic substances. The cause of HUC has yet to be determined. Early studies proposed an infectious etiology on the basis of the presence of chlamydia-like organisms in macrophages on electron microscopy and clinical improvement after chloramphenicol therapy. In a subsequent ultrastructural study, organisms were not conclusively demonstrated. Attempts to create the disease experimentally by mycoplasma infection failed. Management of HUC consists of various combinations of the following: dietary modifications; antibiotics such as chloramphenicol, metronidazole, and tylosin and anti-inflammatory or immunosuppressive drugs such as sulfasalazine, prednisone,cyclosporine and azathioprine. Response to treatment is generally poor, frequently resulting in euthanasia of affected animals

Representative histologic images in the dog (HE, bar = 50 μm). A: Lymphocytic-plasmacytic colitis. Note the interstitial diffuse pattern of infiltrate represented by a large amount of lymphocytes mixed with plasma cells and some macrophages; B: Lymphocytic-plasmacytic colitis (follicular variant); C: Histiocytic colitis. Severe mucosal abnormalities with loss of crypts and diffuse infiltration by large macrophages (arrows) that in the insert (PAS stain) are shown as the main cells infiltrating the lamina propria; D: Eosinophilic colitis. Note the presence of a large number of eosinophils (arrows).

Report and history of the patient

We had a patient dog, named Robin, French Bulldog, male, noncastrated, 2 years old, vaccinated, with chronic diarrhea dating back about a year and a half. Everything started with minor episodes of diarrhea when the dog was about 6-7 months old, the owners also mentioned itching and licking of paws. Аll tests for infectious diseases were negative (CPV/CCV/Giardia) and blood samples were normal. The faecal sample was negative for any parasites. At that time, the patient was treated with probiotics, chemotherapeutics and sulphonamides, gastrointestinal and hypoallergenic diets without any effect. During this time, the owners refused colonoscopy or diagnostic laparotomy combined with a histopathological examination аnd a test for pancreatitis (Idexx cPL).

On April 12, 2019, the dog came to the clinic again with complaints of persistent diarrhea accompanied by blood and tennesms. Robin’s condition had become more serious since the owners had given BARF at their discretion. On the same day we did the CBC and biochemical blood tests and ultrasound of the abdomen. The ultrasound examination showed a high degree of thickening of the layers of the colon and some of the small intestine divisions, as well as enlarged mesenterial limph nodes.

We placed an intravenous catheter and included fluid therapy NaCl 55 ml/h, antiemetics (famotidine and pantoprazole), vitamins (vit C, B- complex, arginine ,ornithine, citrulline), antioxidants (duphalyte, amynoplasmal), probiotics (Fortiflora and Pro-kolin paste), painkillers (buprenorphine), haemostatic drugs (Vit K1 and etamsylate) and tylosinum 25 mg/kg/24h/p.o. Аfter 3 days we took blood tests, which again showed low-grade anemia, leukocytosis and neutrophilia. We also added injectable erythropoietin to therapy.

On April 16, 2019, we performed a diagnostic laparotomy with full thickness biopsy of thr large and small intestine. The material taken was prepared and sent for patho-histological examination in Laboklin Germany. The result was sent by email on May 24, 2019 :

” Diagnosis:
1: moderate to severe mixed cell colitis with

PAS-positive macrophages and ulceration
2: mild to moderate lymphoplasmocytic enteritis
Critical report:
The histological findings (PAS-positive macrophages) in context with the reported breed indicated a histiocytic and ulcerative colitis(HUC).This form of colitis develops especially in

boxer dogs and french bulldogs. Single cases are described forother breeds.A HUC is associated with an infection of certain strains of Escherichia coli. Clinical signs are weight loss, anorexia andpoor condition.A colitis with epithelial lesions and PAS-positive macrophages are typically found in histology.“

On the same day we started methilprednisolon 2 mg/kg/12h/i.v, ampicillin/sulbactam 15 mg/kg/8h/i.v, ceftriaxone 35 mg/kg/12h/i.v in addition to all other therapy.

On April 25, 2019 we only took complete blood count, which established increase of leukocytes and neutrophils, as well as deepening anemia. Clinically, the dog continued to have severe and watery diarrhea with tenesmus, most of which were mixed with blood. Robin began to lose weight progressively and refused to eat at his own will. He was fed by force, following a hypoallergenic diet of “Hill’s z/d cans” and “Royal Canin Hypoallergenic cans”. After a few days Robin felt better and started to eat dry hypoallergenic food.

On April 30, 2019 we took blood for a full blood count where the levels of leukocytes and neutrophils had dropped, but the levels of red blood cells were still low, so an ultrasound examination of the colon was carried out – the wall had begun to decrease in size

Robin’s condition was beginning to improve, the stools were getting better. After a few days, the patient was given home therapy (amoxicillin/clavulanic acid for 5 weeks, marbofloxacin for 6 weeks, prednisolone by scheme with start dose 3 mg/kg/12h/p.o for 7 weeks, b-complex liquit, legaphyton 200 tabl).

On May 09 2019 we took blood for a full blood count – the leukocytosis were even fewer, but still out of norm; the hematocrit, the hemoglobin and the number of red blood cells were still low. We sent another blood sample to Laboklin Germany for TLI (Tripsin-like-immunoreactivity) + Vit B12 + Folic Acid.

“Trypsin-like-Immunoreactivity (TLi) – CLA
TLI:

Result 36.8 µg/l > 5

Inretation:
TLI values < 2.5µg/l are indicative for exocrine pancreas
insufficiency (EPI).
With values of > 5.0 µg/l a EPI is most unlikely. 2.5 to 5.0 µg/l
is considered to be a questionable; a control measurement should be considered after 2 3 months time according to the clinical sings.
Reasons for questionable values are:
– acute phase of chronic pancreatitis
– sampling time within 12 hours post feeding
TLI values > 35 µg/l are indicative for pancreatitis. Renal
insufficiency can result in retention of TLI and thus falsely
elevated TLI resp.
                                               Vitamin B12 Concentration – CLA
Vitamin B12          748    pg/ml       300-800
Folic Acid Concentration – CLA
folic acid           5.73 ng/ml         3.0-10.0”

The ultrasound study showed high-grade meteorism and reactive patch plaques. No increased mesenteric lymph nodes were detected. Clinically, diarrhea was accompanied by tenesmus and fresh blood.

Based on TLI levels, we included metronidazole 7,5 mg/kg/12h/p.o for 5 weeks.

On May 23, 2019 We took blood for a full blood count – the leukocytes and neutrophils were at baseline according to the reference values. However, the hematocrit, the hemoglobin and the red blood cells levels were still low. The condition of the patient had worsen after eating food from the rubbish bin. The ultrasound study showed high-grade meteorism and reactive patch plaques; the wall of the colon had begun to decrease in size; corrugation of the colon appeared. We placed an intravenous catheter and included fluid therapy NaCl 55 ml/h, antiemetics (famotidine and pantoprazole), vitamins (vit C, B- complex, arginine ,ornithine, citrulline), antioxidants (duphalyte, amynoplasmal), probiotics (Fortiflora and Pro-kolin paste), haemostatic drugs (Vit K1 and etamsylate), metronidazole, amoxicillin/clavulanic acid, enrofloxacin 5%. We chose to stop the prednisolone and try budesonide sachet in dose 2 mg/kg/24h/p.o. The dog continued to weaken progressively.

*) abdominal ultrasound from 23.05.2019

On May 30, 2019 we took blood for a biochemical profile, which showed the following results – elevated bilirubin, elevated ALT, AST, ALP, low creatinine. On the same day, we reduced the prednisolone (1 mg/kg/12h) to include ciclosporin. Clinically the dog continued to weaken and lose muscle mass progressive. The owners started adding veterinary ciclosporin liquit in dose 5 mg/kg/24h/p.o. Three hours after the intake of cyclosporine the dog’s condition deteriorated dramatically, began to vomit and defecate only fresh blood. Unfortunately, we hospitalized the dog again.

The condition of the colon was getting worse.

*) abdominal ultrasound from 02.06.2019

We started intravenous methylprednisolone again in combination with the rest of the therapy to stabilize the patient. He didn’t want to eat alone again.

On June 04 we took blood for a biochemical profile, which showed the following results – improvement in liver enzymes as well as in pancreatic lipase levels and normal creatinine. Two days later, Robin stopped vomiting and received the rest of the therapy. We fed him three times a day with hypoallergenic food (Royal Canin Hypoallegenic cans).

On June 08 the dog felt better; body temperature was in norm; Robin started to eat with appetite again. Diarrhea continued to be abundant and watery, accompanied by blood and tenesmus. We started budesonide, and stopped methylprednisolone.

Despite the applied complex therapy, diarrhea was unaffected. Defecation continued to be extremely frequent with blood and tenesmus. The patient continued to lose weight and muscle mass progressively. On 11 June Robin was discharged from the clinic with home therapy of budesonide and cyclosporine only. The owners had been offered euthanasia.

The wall of the column progressively hyperplasia.

I apply some photos of the dog on the day of euthanasia:

Hypothyroidism- 2 case reports with different approach

July 29, 2019

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

Dr.d.ivanov.vet@gmail.com

Hypothyroidism endocrine disease that can be reason for very different neurological signs, varying from signs of polyradiculoneuritis to neurological signs from the brain and vestibular disorder.

The good news are that all of this neurological problems and deficits can be reverse with adequate treatment, good nursing and physiotherapy.

I will present 2 cases of hypothyroidism in dogs with very different neurological signs. In first case I did not believe that this disease can manifest so heavy clinical signs. In second case, I took blood sample for fT4 just to be sure that this is not hypothyroidism.

Scarlett

Signalment: Dog, F, 9 y.o., Samoyed

History: Two days ago while the dog is on a walk, the owner noticed small paresis with front legs but it was for few minutes and they went back home. The dog came in the clinic on 1^stof December in lateral recumbency, not able to stand up and not able to stay on her legs, even with help. The dog could not eat without help and holding the head and the body.

General examination: no abnormalities, the dog was not vaccinated the last year. Orthopedic examination: no abnormalities.

Neurological examination:

-Hands off exam:

Consciousness – normal
Behavior – can’t find any abnormalities in this position
Seizers – no seizers
Body posture – lateral recumbency but the dog can move head and neck
Gait – symmetrical tetraplegia

-Hands on exam:

Cranial nerves – no neurological deficits
Postural reaction – can’t be checked in this position
Spinal reflexes – absent withdrawal reflex on both front legs, reduced extensor carpi radialis on the right front leg, there are no abnormalities in hind limbs spinal reflexes. Normal tail movement, there is a perineal reflex and normal deep pain sensation.

Localization: C₆ – Th₂

Differential diagnosis: Degenerative/Neoplastic/Vascular

At this point we were unable to make CT or MRI and the decision was to use steroids in dose 2 mg/kg, famotidine 0,5 mg/kg/12 h p.o., Omeprazole 1 mg/kg/24 h p.o. and to see what will happen on the next day. On the next day the dog was in the same condition and I repeat the steroid. After second injection the dog has profuse diarrhea so we stopped the steroid and treated the GI signs.

Two days later we made CT and there are no abnormalities.

On the next day was taken blood sample for biochemistry and fT4. The biochemistry showed no specific abnormalities, but fT4 was very low.

fT4 – 0,1 pmol/L (7,7 – 47,60 pmol/L)

Creatinin – 39 mmol/L (44,3 – 138,4 mmol/L)

Glucose – 6,2 mmol/L (3,4 – 6,00 mmol/L)

Creatin kinase – 298,1 U/L (13,7 – 119,7 U/L)

LDH – 576,9 U/L (24,1 – 219,2 U/L)

Magnesium – 2,00 mmol/L (0,7 – 1,1 mmol/L)

The algorithm was to start levothyroxine and if we don’t have any results may be the reason for this condition is polyradiculoneurtis.

I didn’t believe that the reason for so hard clinical signs is only hypothyroidism.

Eight days later the dog was with total areflexion of all four limbs.

The decision was to take CSF, muscle biopsy (from M. gastrocnemius, M. triceps brachii) and nerve biopsy (from n. peroneus). The samples (the biopsies and the CSF smear) were send to Laboklin Germany. The cells count, protein, glucose and microbiology of CSF were made in laboratory department of “Dobro hrumvane!” veterinary clinics.

The results were:

Number of cells – normal (<5)

Protein total – 2.4 (<25)

Glucose – 4.6 (80% of normal blood values)

Microbiology – negative

“The smears were cell free. Only few keratin flakes were present.
Diagnosis:
1:
– striated muscle with multifocal mild degenerative and regeneative
changes
– mild multifocal purulent perivasculitis (M. gastrocnemius)

2:
– histologically normal nervous tissue

Critical report:
Mild multifocal degenerative and regenerative changes of the striated muscle was found. A specific cause was not detected. It should be kept in mind, that in muscle pathology there may not be a strong correlation between histological changes and severity of the clinical symptoms.
Considering the purulent perivasculitis in the sample of the M.
gastrocnemius an inflammatory (possibly infectious) process in other
locations should be excluded clinically.
Signs for a polyneuritis have not been observed within the examined
locations.”

I had to resign that the most likely cause of Scarlett’s condition was hypothyroidism and we started physiotherapy procedures.

Meanwhile, the patient’s condition has begun to improve. First Scarlett started to move her head better, started to lay on her chest and started eating by herself. The muscle tone start to improve.

40 days later

The day that Scarlett left the clinic.

Chata

Signalment: Dog, F, 5 y.o., German shepherd dog

History: Everything started with variable appetite. The dog came in the clinic for second opinion on 06.06.2019.

Colleague already took blood samples and there were no specific abnormalities.

Neurological examination:

-Hands off exam:

Consciousness – abnormal
Behavior – abnormal
Seizers – no seizers
Body posture – abnormal, head tilt, from time to time head turn, opisthotonus
Gait – abnormal, symmetrical, general proprioceptive ataxia

-Hands on exam:

Cranial nerves – vision, oculovestibular and menace is absent, contraction of the pupils is normal but dilatation is reduced, increased jaw tone, reduced gag reflex and reaction of the tongue.
Postural reaction – proprioception and hopping are absent
Spinal reflexes – absent withdrawal reflex on the left front legs, reduced on the right front leg.

Localization: Central vestibular

Differential diagnosis: Metabolic/Inflammatory/Neoplastic

I took blood samples to examine fT4 just to be sure that this is not hypothyroidism.

We discussed with the owner that if there is no abnormalities in thyroid hormones we will take and make some tests with CSF.

The level of fT4 was 1,60 pmol/ L (7,7 – 47,60 pmol/L)L

I started levothyroxine and after two intakes of the medication the result was:

The next few weeks the dog was not still in perfect condition, but there was improvement.

Conclusion: Hypothyroidism is often over diagnosed condition, but is also misdiagnosed metabolic disease with lots of different signs and different manifestation in every part in veterinary medicine.

Persistent right aortic arch

July 18, 2019

Tsvetan Ivanov, Dimitar Ivanov, Vladi Kirilov – veterinary clinics “Dobro hrumvane!”- Sofia, Bulgaria

Introduction:

The persistent right aortic arch (PRAA) is vascular ring which is formed by the aortic arch on the right side, with ligamentum arteriosum dorsolaterally, and pulmonary artery on the left and ventrally. This ring compresses the esophagus and trachea, which leads to swallowing difficulty. This malformation is with genetic prevalence and represents error in embryogenesis of the dog. In 95% of the cases of this vascular ring anomaly, a constricting band prevents solid foods from passing to the stomach which prevents the puppy from thriving well. In the remaining 5% of cases, a bizarre anomaly of the vessels is present (double aortic arch and aberrant subclavian artery), which may be difficult to correct and may not have a good prognosis.

Signs of this condition usually become apparent shortly after weaning, when a puppy begins eating semi-solid or solid food. While milk will slide down nicely, bulky foods will “jam up” in the esophagus, leading to a stretched structure and the inability to get food down, hence the symptom known as regurgitation. Regurgitation involves the puppy producing undigested food and mucus through the mouth with no effort; the pup tilts its head down and the food and mucus simply roll out. By contrast, vomiting is an active process, meaning there are abdominal contractions (heaving) and a retching noise when food and mucus are expelled out the mouth.

Often complication of the regurgitation is aspiration pneumonia (AP), which leads to poor prognosis for the patient.

The standart therapy is surgical and is with good prognosis if there is no signs of AP. Before the surgery CBC and blood chemistry is required – WBC is important to rule out infection and the level of blood sugar should be in the reference values. The surgery can be open thoracotomy or thoracoscopy – the goal is to ligate and resect the fibrous annulus.

Patient report

The patient is 2 months old german shepherd dog with history of vomiting after eating, according to the owners, but there is no problems with water drinking. The dog have diarrhea but is in good overall condition. When the dog sleeps there is strange noises from his neck and there is visible peristaltic waves in the level of 1-st rib.

We perform CPV/CCV/Giardia and the result was negative. The CBC and blood chemistry shows no difference from the reference values.

pic 2

Then we made x-ray of the chest: pic 2

Because of the typical sign of the chest, we performed and BaSO4 examination, and this was the result:pic 3

pic 3

So our diagnosis is PRAA with no signs of AP. We performed surgery on the next day – it was open thoracotomy with ligation of the annulus.

Differentiation of the fibrous ring:

It’s was administrated antibiotics, pain killers, sedatives and assisted feeding. We didn’t use thoracic tube after the surgery.

On the fourth day after the surgery, the dog was discharged. Three months after the surgery the owners still make assisted feeding, but the dog is not vomiting and is in good condition.

Main topic: “A new approach to radial nerve palsy in cats”. Clinical Case Series Report

March 9, 2019

by the Orthopedic department of “Dobro hrumvane!”veterinary clinics,

Sofia city, Bulgaria

Introduction

The radial nerve palsy is a pathology that is rarely seen in dogs, in comparison to cats, where it is more commonly seen, especially in young stray cats. The most commonly observed clinical picture in such patients includes paralysis of the antebrachial portion of the limb, the carpus, the manus and fingers. According to our personal observations, in about 25% of these patients the elbow’s neuro-muscular apparatus is also involved, in a different degree.

The patients demonstrate an external rotation of the antebrachial area in relation to the portion of the limb above the elbow.

The carpus and manus possess an additional and permanent external rotation in relation to the antebrachium, which causes the patients to use the rostral portion of the their carpus for stepping and weight bearing, which in turn inducts the formation of a chronical traumatic inflammatory proliferative granuloma in this area. For about a 25-45 days period, an impossible to overcome carpal hyperfelexion develops, to the point where the joint can no longer be returned to its physiological position, due to the shortening of the flexor muscle-tendon apparatus (see video 1 with cat Sonia 39 days after the trauma at https://youtu.be/SZoXfp8tMJ0 ).

A few therapeutic approaches are being advised for this pathologic condition worldwide: total limb amputation; stem cell therapy (with still controversial results); standard pancarpal arthrodesis (note that very often it is very difficult to execute procedure in the state of this disease and is almost always accompanied by a nonsatisfactory limb function end result).

None of the upper mentioned approaches for treatment of radial nerve palsy in cats, while trying to avoid limb amputation, was producing satisfying results in the patients with this problem, operated by our team. This is the reason we decided to test and implement a new “Dobro hrumvane modified pancarpal arthrodesis” procedure for the operative treatment of feline radial nerve palsy.

Report patients base

Up to this moment, this modified by our team procedure has been done in 111 patients. In the first 11 patients we tried different but very similar to each other versions of the modification, and after patient 12 up to patient 111 (meaning exactly 100 patients) we were performing always one same version of the technique.

In 87 of these patients a follow-up postoperative monitoring for over one year has been performed (in 9 of them an approximately 5 year follow up was achieved, in 33 patients the follow up period was approximately 4 years etc.), in 11 patients the follow up period was between 4 months and one year and in 2 patients the follow up period was less than 4 months. In four of the operated patients, pre- or postoperative clinically relevant paralysis of the elbow region was also observed. As was mentioned earlier, 25% of feline radial nerve palsy patients demonstrate this (according to our observations in 23% of the patients it is already observed in the preoperative period and in other 2%, it develops a few weeks after the surgical intervention, with the reasons for that still being unclear). It should be noted that the majority of owners of patients with elbow area involvement preferred amputation over the experimental procedure.

Surgical technique

The standard pancarpal arthrodesis general guidelines are being followed, but with the following modifications:

Straight 11̊ inclination non locking hybrid pancarpal arthrodesis plate has been used (produced by Medimetal or Mikromed, delivered by VetWest). The plate contouring should be modified before the surgery and the inclination should become 21-22̊. Twisting of the distal portion of the plate internally in relation to the proximal portion of the plate is not recommended! For the fixation to the metacarpus 1.5 mm non locking screws were used (produced by Mikromed, delivered by VetWest) and for the fixation to the radius 2.0 mm non locking screws were used (produced by Mikromed, delivered by VetWest);
The proximal (os carpi radiale et ulnare) and distal carpal bones are being completely removed, this being done with extreme caution not the traumatize the adjacent magistral structures (especially blood vessels), which are located on the palmar surface;
The proximal ends of the metacarpal bones are being separated from one another;
The fixation of the plate to the dorsal surface of the third metacarpal bone is achieved the same way as in the standard technique, using 1.5 mm thick and 6 mm long screws, but the fixation to the radius is not applied on its dorsal, but on its medial/mediocaudal edge/surface, using 2.0 mm screws. The screw hole on the plate which is intended for os carpi radiale (note that this bone is actually removed in the modified technique) is used for an additional 2.0 mm screw, placed in the distal radius. In other words, the whole metacarpal portion of the limb is being internally rotated around 85-95° (for the purpose of that an almost full blunt and careful separation of all soft tissues, including the magistral vessels and nerves in the distance between the carpus and the middle portion of the metacarpal bones, should be performed). After plating of the third metacarpal plate with four 1.5 mm non locking screws in neutral position the third metacarpal bone is being compressed to the radial distal This compression is easily achieved with the first screw, placed in the radius (not dorsal but medial/mediocaudal radial edge/surface – see below Xray picture Standard) thanks to the DC wholes of the plate types mentioned upper above. This screw is being inserted in the second 2.0 mm screw whole in distal to proximal direction, meaning the third plate hole in relation to the whole plate in proximal to distal direction. After that, 4 neutrally (not in compression mode) placed screws are applied to radial bone in the following order: the most distal hole, the most proximal hole, the second hole in proximal to distal direction, the third hole in proximal to distal direction. It is recommended that at least two of the screws in the distal radius engage the distal ulna too, so the distal portions of the two bones could eventually be pulled together – the screws could be numbers one and two or four and five from proximal to distal, this possibility could be estimated only intraoperativelly;
POST-OP STANDARD X-RAY PICTURE AFTER PANCARPAL ARTHRODESIS “DOBRO HRUMVANE”
- With this technique it is easy and recommendable to use a significant amount of autograft material – recommendable due to the large gap that is being created. This autograft is readily available, considering the amount of bone that is being removed in the previous stages of the surgical technique;
- The final stage of the surgery includes almost full blunt separation of the skin from the underlying soft tissues in the designated area, along with skin plastic traction modification, which is intended to place the fifth finger in a more medio-cranial position. The skin sutures and respectively the skin incision should be placed in a position that is not exactly above the plate (eventually they plate and incision could be placed in a cross manner, but should not be on top of each other for their whole lenght). It is not necessary to perform tenodesis of the digital extensors or excision of some skin on the dorsal carpal area in orther to pull the fingers in extension. It shoud be noted that the upper mentioned skin traction used to “pull” the fifth finger in a more dorsal and medial direction (meaning that the fifth finger is placed adjasent to the dorsolateral, not solely lateral, surface of the fourth finger, under subtle tension that will not allow overlapping of the fifth finger) is extremely important because in some of the first patients, which underwent the still not perfected procedure, weeks to months after the surgery pressure necrosis developped in the fifth finger, which required further revison plastic surgeries.
- In patients that have a very wild temper and where it is not possible to achieve two week long cage rest, postoperative splint could be placed. If this is done, additional amount of cotton could be used to help achieve the upper mentioned mediocranial position of the fifth metacarpus and finger;
- NEO K-9 clinical formula is prescribed for a month and a two week long cage rest is done in more calm patients.
1. C) Results – the last 100 cats (No 12 … No 111 made with identical technique) :
C1) 96 patients that did not have (according to our clinical opinion) involvement of the elbow region pre- or postoperatively:

– 95 patients with good limb geometry in stance and during walking, active involvement of the limb during walks and playing, owners completely content with the results 4 months up to 5 years after the surgery. 89 of these 95 patients had no postoperative complicatioons; 2 patients developed moderate postoperative infection that was easily treated; 2 patients demonstrated delayed healing of the surgical incision in the area above the plate (it took more than 5 weeks in both patients); 2 patients had delayed bone union, that took around 5 months to be completed;

– 1 patient demonstrated unsatisfactory to this point level of weigt bearing and limb usage during walk and play. It is understandable that the owner of this patient is not completely content with the results, but is unfortunately refusing implant removal and further diagnostic procedures;

– No cases with implant loosening, intra- or postoperative fracture, postoperative necrosis etc.;

C2) 4 patients with clinically relevant pre- or postoperative involvement and paralysis of the motor unit of the elbow joint:

– 1 patient without preoperative elbow problem, developed such around a month after the surgical intervetion and the problem was accompanied by the development of an additional low grade external rotation of the antebrachium in relation to the limb portion above the elbow. The main problem was presented by progressive loss of support of the ebow joint in extension during stance, which lead to the inability of the limb to support the body during weight bearing. The problem was resolved after a two week long active rehabilitation and machine physiotherapy and application of a light splint, which is suporrting (but not blocking) the elbow.

– 1 patient (cat named Trun) with preoperative paralysis of the elbow joint, but accompanied by almost complete ankylosis of the elbow joint (only 15% of the normal range of motion was preserved, especially the extension was blocked) – see below the post-op pictures of cat Trun

cat Trun

cat Trun

Although there was a serious accompanying problem, months after the surgery the owners are completely satisfied with the result. The patient is using the limb with no limitations during play, almost no limitations while running and with some limitations while walking – that last limitation is probably due to the constant flexed position of the elbow, which is exceeding the normal flexion angle of an elbow joint during walk, thus the animal is placing the shoulder of the affected limb under the level of the shoulder of the unaffected limb, during weight bearing (see video with cat Trun approx 3 months post-op at https://youtu.be/N9scMppZeyo ). The owners do not report signs of pain. Even though it is not right to make conclusions only on the basis of a single patient, this case gives us hope that patients with radial nerve palsy in combination with complete or partial elbow joint ankylosis have the chance to avoid amputation of the limb.

– 1 patient with partial preoperative paralysis of the elbow joint which became more severe (around 50%) month after the surgery: the bones in the arthrodesis region achieved complete healing, but the elbow joint loses support during weight bearing, thus the animal is placing the shoulder of the affected limb under the level of the shoulder of the unaffected limb, during weight bearing. Due to this the ptient is weight bearing the limb not on its pads, but rather on the carpal palmar angle surface. Because of that a chronic nonhealing skin lesion developed in this area over the time, which is intermitently bleeding. Up to this point, the owners are content with the result and do not wish to start rehabilitation or agree to a revision surgery, but for our team this result is unsatisfactory and it requires additional surgical and/or physiotrepautical intervention;

– 1 patient (Doxy) wtihout preoperative involvement and paralysis of the elbow, which developed a progressive clinically relevant paralysis of the elbow a few weeks after surgery. This led not only to loss of support of the elbow joint during weight bearing, but also to constant progressing additional rotation of the antebrachium in relation to the humeral area.

X-RAY PICTURES DOXY

X-RAY PICTURES DOXY

This rotation made the patient bear weight on the lateral surface of the carpal angle, developing a skin lesion there. This postoperative elbow joint paralysis did not resolve after a rehabilitation course. In order to correct the problem an elbow arthrodesis was performed, but not in a standard way. A “double-modified” elbow arthrodesis was performed: the boomerang plate produced by Mikromed and supplied by VetWest was placed on the lateral surface instead of the medial. Also, the antebrachial region was rotated 18 degrees internally, in relation to the humerus. We recommend very torough preoperative preparation: the execution of the technique is quite challenging, because the compression must be maintained and in the same time the “locking” of the anconeal process in the humeral fossa must be overcome, along with the congruency of the other ulnar structures and their corresponding radial structures – see below post-op X-ray pictures of cat Doxy after the second surgery, the elbow modified arthrodesis:

It can be seen that the plating is on the lateral surface of the radius distally and on the laterocranial surface of the humerus proximally.

Only a few hours after the surgery, the patient demonstrated excellent, pain free limb usage, with very good limb geometry and lack of difference in the level of the two shoulder joints during weight bearing. In the following days the patient started using the limb for playing too. At this point, 3-4 months after surgery, the patient is demonstrating completely satifying results (see video with cat Doxy approx 4 months post-op at https://youtu.be/X_rFEgrZink ). There are no signs of malunion, infection or other types of complications. The muscle mass in the shoulder area of the operated limb is similar to that of the non operated limb. Even if it is based just on one patient, the result of this case gives us some hope for surgical resolution for patients with modified or standard carpal arthrodesis, which have an acompanying or later develop severe elbow pathology of nonakylotic kind, as we know that the combination of carpal and elbow arthrodesis is not recommended in the known sources. For this patient especially we have an additional recommendation:

1) The first recommendation that is applied to all 111 operated patients – considering that it is a patient with a paralysed limb it should live on a non- smooth surface (but also not on an abrasive one). On a slippery surface patients with Dobro hrumvane arthrodesis step with mild slipping which combined with the lack of sensitivity could cause in longer period skin lesion (see Video 2 with cat Zhivka approx 5 weeks post-op at https://youtu.be/hKKjmO9yWdI ).

2) Additional recommendation especially for Doxy: the patient has two joints that underwent arthodesis, which means that a stress point is being created between the two plates, which in turn creates a significant risk for further fractures. This risk is further amplified by the fact that the arthrodesis procedures are reducing the shock absorbing function of the joints. Considering all of the mentioned above, the patient should live in an enviornment that lacks the risk of creation of serious vertical vector forces (such as jumping to or from high places). It should be noted that Doxy did exactly that, many times after surgery and no problem occured, but it is still highly not recommended.
1. Conclusion
The 100 clinical cases, with patients that underwent a similar modified pancarpal Dobro hrumvane arthrodesis procedure for the treatment of feline radial nerve palsy demonstrate a constant and satisfying result with very good return to function of the limb, pain free, with no discomfort. No following complications, including long-term ones are being observed and there is a very high level of owner satisfaction. We recommend this surgical technique and we would be glad to recieve feedback afer the completion of the procedure, either in the algorithm recommended by us, or with any additional modifications.

Hari

Even when the rotation of the metacarpal area in comparison to the antebrachial area is not 85-95 degrees the patients use the leg and the owners are satisfied but the leg geometry is in our opinion not good looking. Cat number 11, the last before the standartized 100 patients chain, named Hari is such a case, the rotation was 78-80 %, the operation was made approximately 5 years ago. As you can see at the videos made 4 years post-op the patient uses the left operated leg even during acrobatic jumping (see below picture Hari)

and active playing (see video Hari 4 years after surgery at https://youtu.be/SfhzUtLr9ig ).
1. E) Post scriptum
A few years ago we presented the technique and its results, based on a few dozens of cases, on a VOG\BAVOT event. Ever since, a few colleagues from the Balkan region have sent us feedback with very encouraging results, after using the technique. One of them was our inconsolable friend, colleague and inspirator, D-r V. Vasilev, whose memmory and collosal contribution to the development of the veterinary meidicine in Bulgaria we would like to honor in the end of this report.

Sofia The Orthopedic department of

March 2019 “Dobro hrumvane!” veterinary clinics

” A neoplasia in left midbrain in dog”

June 21, 2017

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.

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:

Pic 1

Pic 2

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

Pic 3

Pic 4

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

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.