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

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

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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:

Fig1FrodoPre-opValgus

Pre-op antebrachial external torsion:

Fig2Frodo Pre-opExternalTorsio

 

 

 

 

 

 

 

 

 

 

 

 

 

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:

Fig3Frodo5 MinPost-opCRCD

 

 

 

 

 

 

 

 

 

Post-op X-ray LAT:

Fig4Frodo5MinPost-opLAT

 

 

 

 

 

 

 

 

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:

Fig5MihailPre-opVarus

 

 

 

 

 

 

 

Pre-op antebrachial internal torsion right leg:

Fig6MihailPre-opInternalTorsion

 

 

 

 

 

 

 

 

 

 

 

 

Pre-op antebrachial varus left leg:

 

Fig7Pre-opVarus

 

 

 

 

 

 

 

 

 

 

Pre-op antebrachial internal torsion left leg:

Fig8Pre-opInternalTorsio8

 

 

 

 

 

 

 

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:

Fig9 5minPost-opLAT

 

 

 

 

 

 

X-ray picture 5 min post-op CrCd:

Fig10 5MinPost-opCRCD

 

 

 

 

 

 

 

 

 

 

Final result: perfect bone healing and normal leg usage

X-ray picture 6 months post-op LAT:

Fig 11 6MonthsPost-opLAT

 

 

 

 

 

 

 

 

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:

Fig 12Pre-op LAT

 

 

 

 

 

 

 

 

 

Ares X-ray piicture pre-op CrCd:

Fig 13Pre-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:

14

 

 

 

 

 

 

 

 

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

15

 

 

 

 

 

 

 

 

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

16

 

 

 

 

 

 

 

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

2

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

 

 

 

 

 

 

 

Ares CT 2 y post-op:

1

 

 

 

 

 

 

 

 

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:

Fig 19 NukyPre-OpLAT

 

 

 

 

 

 

 

 

 

Nuky X-ray piicture pre-op CrCd:

Fig 20 NukyPre-OpCRCD

 

 

 

 

 

 

 

 

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

Fig 21 NukyPre-OP

 

 

 

 

 

 

 

 

 

 

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:

Fig22 6MPost-opLAT

 

 

 

 

 

 

 

 

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

Fig 23 6MPost-opCRCD

 

 

 

 

 

 

 

 

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.

 

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

logoThis 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 1st day in clinic:pic 1

 

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: pic 2

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:

VOG? WHO ARE VOG? Meeting with 4 real orthopedic vets from The Balkans

 

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https://www.vog-vet.org/

Dr Mario Kreszinger, Croatia

Dr Vladislav Zlatinov, Bulgaria

Dr Marko Novak, Slovenia

Dr Zoran Loncar, Serbia

 

  1. Who are you?

 

 Dr Zoran Loncar:

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Dr Zoran Loncar

My name is Zoran Loncar I am a vet who dedicated his professional life to improve the knowledge and to push the borders of veterinary science.

 

 

Dr Vladislav Zlatinov:

I graduated from University of Forestry- Sofia, in 2005. I started externship attendance in a private small animal practice quite early-since my second year. Right now I am one of the chief surgeons in the Central Veterinary Clinic, Sofia- one of the busiest 24/7 practices in the region. Working already 6 years in this sophisticated facility, I had the chance to master skills and advance in the field of small animal surgery, and particularly orthopedics. I am happy to be involved in BAVOT (Bulgarian Association Veterinary Orthopedics and Traumatology)- the very first specialized guild vet organization in BG. We feel proud to be quite active and have organized some really great seminars, already.

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Dr Vladislav Zlatinov

At present, my focused interest is regional implementation of advanced care standards in the veterinary orthopedics- popularizing the routine use of minimally invasive technique (arthroscopy), Canine Total Hip Replacement and one special pioneering project- “Feline amputee prosthesis”.

 

Dr Marko Novak:

marko-poza

Dr Marko Novak

I am a vet working in a private small animal clinic Klinika Loka in the city Škofja Loka in Slovenia. I graduated in 2006 on School of Veterinary medicine in University of Ljubljana. Since than I finished multiple courses in Orthopedics and Neurology including four years of an ESAVS program, AOVet courses, ESVOT etc. Most of my today’s work are referring patients from other clinics. Concurrently I am a board member of VOG and a treasurer of VOG and active speaker and table instructor on Orthopedic courses.

Dr Mario Kreszinger:

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Dr Mario Kreszinger

Prof. Mario Kreszinger, DMV, MS, PhD
Veterinary Faculty, University of Zagreb

 

 

 

 

 

 

  1. What is VOG? What VOG means to you?

    vog

    VOG

 Dr Zoran Loncar:

VOG is a newborn that was created out of the frustration of the vets that are dealing in every day practice with neurology and orthopedic cases.

The idea was born after continuing education that we organized all around the world.

What we realized is that probably majority of orthopedics surgeries are done by general practitioners. The problem is that they don’t have guiding and possibility always to improve the skills.

This is what we found as a major frustration not only in east countries but also in developed ones. VOG role is to connect the knowledge, mentorship and to come close to the people who do orthopedics and neurosurgery in the practicesDr Zoran Loncar, Serbia.

Dr Vladislav Zlatinov:

When I joined the Veterinary Orthopedic and Neurology Group (VOG), I felt very thrilled. This newborn professional organization will face a bright future. It could not be different with so great open-minded co-founders, sharing the same sincere intentions.

The cradle of VOG may be Eastern Europe, but it is not confined geographically. It is open for all colleagues, interested in never ending process of learning and sharing. Standing for the evidence based approach, the group will encourage members to involve in clinical researches, too.

Nevertheless, the organization is focused just on veterinary orthopedics and neurology, the topics are still greatly diverse and laborious to explore. Unifying and sharing experience is the “enzyme” that fastens the growth of any vet community knowledge. Initiative like VOG may only make us better professionals and is a great chance for many new friendships to be started.

Dr Marko Novak:

A group of enthusiastic veterinarians who want to broaden the “knowhow” to other enthusiastic veterinarians in the region. By learning we evolve, by learning from those farther ahead and following “lege artis” we prosper as veterinary society.

Dr Mario Kreszinger:

VOG is regional orthopaedic Association established to promote and  organize orthopaedic, neurological and traumatological education with objective to connect the members and provide cooperation among each others. Establishing close contact and thrue friendship is one of main goal.15179126_666002020248637_6675110090243320994_nvog-1

 

  1. What means to be an orthopedic vet nowadays?

 Dr Zoran Loncar:

To be and orthopedic surgeon nowdays means that you learn and improve your knowledge and skills on a daily bases. The orthopedics is a mixture of knowledge and manual skills. That needs every day practice. On the other hand there is always a need to follow the new evidence based data in order to be updated.

Dr Vladislav Zlatinov:

The veterinary orthopedics was and still is tough field to work in, sometimes with quite ungratefully unforgiving obastcles. I have seen these: the vet staff staring at a radiograph with broken plate and shaking their heads meaningfully. Rarely you can see this with soft tissue surgeons’ work J

Indeed, the veterinary orthopedic surgeon is a person with serious proffesional responsibilties. Often, his work is not a matter of death or life. But almost always it affects the animal’s quality of life for many years. The job conatains a lot of not so obvious ethical issues behind many clinical decisions taken.

Speaking about “Nowadays”, there is a burst of companies that produce orthopedic implants and tools. Fortunately most of the products are faboulosly good and gives us a chance to help aniamls with “untreatable” conditions in the past. But for me I this also may raise a danger. Just because of a commercial emphasis, we can start easily implement new products without any evidence based justification. For me, there should be a carefull and responsible approach to the “ Fancies” in the sea of products offered to us.13245311_10206690540562329_7499136046518137278_n11986412_10153245936142960_4086193550529382361_n

Dr Marko Novak:

Well for one thing I am absolutly sure it takes a whole person ready to work, ready to work even more and finally uncompromisingly ready to work some more. :) And after you are finished working there comes a night shift… It takes a very, very loving and understanding wife. 😉
There comes a day when you want to quit but it always comes the next day when you want to get back and help some more. But I assume it is the same in any profession.

Dr Mario Kreszinger:

Being an Orthopaedist is one of the highest step in Veterinary speciality.

 

  1. What do you think about the level of veterinary orthopedic on The Balkans?

 

 Dr Zoran Loncar:

Unfortunately the level of knowledge at Balkan countries is low. The reason is old fashioned veterinary schools, the lack of continuing education at the field.

Dr Vladislav Zlatinov:

Our present status has a lot to do with the historical development of the region. I guess it is right to say that I am part of the “new generation” vets. At least in Bulgaria, this generation inherited the experience of very few small animal practitioners, working in the 90-ies. Unfortunately we cannot say that we have a long medical tradition in small animal care, as most Western Europe countries. But.. one way or another a new era has started. For me in the last ten years, the Balkan veterinarians put a hard work and did a huge development in every aspect of their work. The market was opened for Eastern Europe, the pet owners just demand and receive much better care. This includes also us- the orthopedic fellows in the region. I think that we already do quite a good job, with a real potential to shine for excellence

Dr Marko Novak:

I believe it has tremendously spiked in the last few years. There are still reserves, which is good. But what is most important is that people are more than willing to learn. Big thanks to many “good guys” who started teaching especially great orthopedic specialists like Allesandro Piras and Bruno Pierone, Massimo Petazoni etc.

Dr Mario Kreszinger:

The level is right now in extremely high learning curve, coresponds with highly developed western Countries.

 

  1. Your ” golden rules “to be professional orthoped ?

 

 Dr Zoran Loncar:

Learn, practice, learn, control your ego, learn, think out of the box and at the end, learn.
Dr Vladislav Zlatinov:

To be a good orthopedic, demands a lot. Vast stock of knowedge, skilled hands,  attention to the small details. Usually it takes so many years to develop qualities, a great determination is needed to bare the road. And the learning never stops. But this is the common knowledge. I am a believer that to become an especial orthopedic, you should be able to think “out of the box”. We should follow the great minds’ work, but there is always a place for personal contribution.  We should dare to fight paradigms; this is an essential “fuel” for medical science evolution.

Fianlly, our profession never works “good” without a sincere empathy to animals and fare etthical attitude to them and their owners15181147_10154094081597960_611406697039840077_n15181178_10154094095972960_9093230231692850684_n

Dr Marko Novak:

Be precise, train, learn, ask, always try to find mistakes and be better the next time, be objectively sharp to your work, take time for your family and for yourself. Charge your batteries regularly.

Dr Mario Kreszinger:

Be competely dedicated to your job with all efforts and breit knowledge.15181250_10154094080692960_1411178589932869639_n

 

 

  1. What do you think about  the online journal Vets on The Balkans?

Dr Zoran Loncar:

Vets on the Balkan is refreshment and result of people with good energy and wish to improve our region. We live in small countries and if we cooperate together we have better chance to improve ourselves.

 

Dr Vladislav Zlatinov:

It is so great to have such a professional forum, connecting Balkans (and not only) vets! I literally see people from different countries in the region, getting to know each other because of your journal.  The “Vets on The Balkans” deserve all the compliments for your great positive initiative and work!

Dr Marko Novak:

I came across VTB when I was scrolling down the facebook and I saw these interesting articles from guys doing great job. I think it is one of those starters that help people to become better at what they do.

Dr Mario Kreszinger:

It very usefull easy approachable source of infos we need in everyday Jobs routine.12072565_1159080807469853_2466737431594238709_n