Skalpellen Veterinær

17/06/2024

23/02/2024

Because of a very spontaneous holiday I have not been able to post the answer to the previous question. But here you are 🙃

16/01/2024

Why you should wear indicator gloves for orthopaedic surgery. Most studies show that the non-dominant hand is most prone to glove tears, so beware - and change gloves as soon as you notice, also to protect yourself against disease (rare for veterinarians, but still).
🐾

11/12/2023

Jolene the cat jumped up to see her own radiographs, and judging by the smirk she approves of the surgery. 😻

10/07/2023

The hanging limb technique. More info in the carousel.

Not doing ortho just yet? Don’t worry, this is useful also for soft tissue surgery of the limb. Save it for when you need it! 🛠️🪛🪚

29/06/2023

Today’s case:
7 months old miniature poodle with Legg-Calve-Perthes disease. More info in the carousel.
Helpful? Feel free to share or save the post for later reference 🤗

13/06/2023

This canine HD radiograph betongs to a 14 month old Cocker spaniel, and I thought I’d show you a classic example of a transitional vertebrae. This developmental defect is thought to be hereditary as one sees a clear predominance in some dog breeds. This particular dog is asymptomatic, as are many of these cases, and has 7 lumbar vertebrae where the L7 is transitional. This number can however vary, so make sure you count the lumbar vertebrae 😃
More info in the carousel 👆

01/06/2023

Some posts ago I warned against the use of Allis trauma, sorry, Allis tissue forceps on viable tissues.

Well, help is near if you have no assistant to help you grasp and hold the tissue with delicate fingers. The Doyen forceps is a good number two for use on visceral organs. They come in a variety of sizes and shapes, long, short, or curved, and feature longitudinal striations that are atraumatic to the tissues. A Doyen forceps allows you to block for example a lung leak temporarily, or close off and prevent leak from the intestines during an enterotomy or resection/anastomosis - whilst not disrupting the area.

I still prefer an assistant given the opportunity, but during night when nobody wants their beaty sleep disturbed, these guys really make your life a whole lot easier. I recommend those of you who perform emergency surgeries to always have a collection of these on the shelf.
Anybody here using these on a regular basis?

14/05/2023

Before —-> After
That certainly cleaned things up! 💨No antibiotics, just alginate for 3 days. No exudation, wound edges not swollen anymore, granulation tissue looking fresh and healthy, wound edges moving closer…are you convinced yet? 🤓

02/05/2023

Just a little info on alginate dressings for use in wounds: 👉
Some of you may recognize the H-plasty from the previous post. The little bu**er unfortunately had a partial dehiscence as well as moderate amounts of unsightly exudate. So I decided to pull an old friend from the drawer and inform you guys about this option as well. Algisite! I like it a lot, it cleans wounds like these very efficiently even though it looks rather disgusting upon removal 💩

Does anybody else have experiences using alginates that they want to share? Sharing is caring! 😁🙌

19/04/2023

The pelvis is a box-like structure and has a very rigid structure supported by both bones and heavy musculature. Hence; in order for a fragment to become displaced, there are usually at least two, most often three, associated fractures (with a few exceptions). Which bone the fracture involves and the degree of displacement are both determinants for surgical treatment, so look carefully.

Take home message? If you see one, there are likely to be more fractures +/- sacroiliac luxation. Consider CT imaging for these patients!

15/04/2023

While we are on the topic of drains; here is an example of an active one! Cheap and easy to use, the JP drain is a favourite for some scenarios, such as the one depicted; septic abdomen where drainage is required. An added benefit of these drains is that you can collect fluid for analysis from the reservoir bag and thus follow the transition from exudate to (hopefully) transudate. It is easier to maintain good hygienic conditions with this drain as it does not spill when used correctly. The large, fenestrated drain end can be placed over a large area to collect fluid from «all corners». Beware that this drain also provokes an inflammatory response and some of the fluid buildup can be ascribed to this fact. In human surgery patients are sometimes sent home with these drains for up to 5 weeks (!), for example in instances of lymphatic stasis. Our patients are harder to advice and money usually runs out fast, and so we rarely keep these drains in for more than a week or so.

Wanna share your experiences with this type of drain? Please do 🙏👇

10/04/2023

Halsted’s principle no. 7: Eliminate dead space. Sometimes this is difficult, for example if you have removed large masses of tissue or with bite injuries where surgical intervention is not indicated - or with some skin grafts where subcutaneous sutures should not be placed. In these circumstances placing a drain is very useful. The drains can be passive or active (the latter providing consistent underpressure so as to allow continous drainage). When you need short-term drainage of smaller amounts of fluids, Penrose drains are cheap and easy to use. They should however only stay for a maximum of 2-3 days to avoid becoming a nidus for infection. Rule of thumb; when the fluid produced is equal to or less than 2 mls/kg body weight/day the drain should be removed. Keep in mind that the drain itself provokes an inflammatory response and so the amount of fluid will never be zero!
Do you guys use this drain, and if so, for which cases?

29/03/2023

Thought I’d start sharing some instruments and how you (are supposed to) use them. First off; a blessing and a curse; the Allis tissue forceps.
What do YOU use this instrument for? Be honest! 😄

07/03/2023

In light of yesterday’s sad news about short ulna syndrome in labradoodles/cobberdogs I thought I would show you a case to highlight how short ulna can look on radiographs and how the elbow joint can subluxate to an almost frightening and debilitating degree.
This is an 8 month old Skye terrier that was presented to me with severe bilateral forelimb lameness (3-4/5!). It had bilateral short ulna syndrome, and this is the left side. Most of the time I would recommend surgery for these dogs, and most of the time I would go for a so-called bi-oblique proximal ulnar osteotomy where you make an oblique cut in order to elongate the ulna, release the strain on the radius and allow for the radius and ulna to realign in the elbow joint. The surgery is generally most successful if the dog has some growth potential left. This dog was unfortunately more or less fully grown and I told the owner that the prognosis for pain-free locomotion was not great. The very motivated owners wanted to give their dog a chance anyway, and so I performed a staged bilateral procedure, allowing 6 weeks between each. The last radiographs are taken 6 months later, at which point the dog was non-lame, pain-free and with a surprisingly good range of motion in the elbow joint. Most dogs with short ulna are not that lucky, which makes me extra thrilled about this tough cookie. Look how much the elbow joint improved!
Osteoarthritis? Long-term probably yes, but we can talk about that another time. 😅

24/02/2023

Suture materials vol 3.

06/02/2023

The problem with fractures of the distal radius and ulna in miniature dogs. 🥵

To experienced orthopaedic surgeons, placing an internal fixation device such as plates and screws on these types of fractures is usually quick and easy. The radiographs look nice postop and the owners are happy because the dog is placing weight on the limb the day after. So what is the problem?

The problem is exemplified by this case. 6 weeks after surgery you notice that the bone looks like in picture 1. It is dissolving underneath the plate (osteopaenia) due to reduced blood supply and a stiff implant reducing load sharing with the bone (stress protection). Invisible to the owner and the vet, but not to the X-Ray beam. Note the poor bone density underneath the plate!

So you decide to take the implant out (picture 2) in the hope that the bone quality picks up again. Then, some days later, the leg spontaneously fractures again without prior accident.

Why? Because
1) the radius and ulna have different geometric properties in miniature breeds
2) these breeds have reduced vascular density of the distal portions of the radius and the ulna.
3) A small cross-sectional area poses a challenge to adequate bone apposition
4) In order to place internal fixation you will have to disturb the soft tissues and the blood supply.
5) There is very little soft tissue coverage in this area

The end result? In many cases, stress protection and resultant osteopaenia, causing the bone to refracture.

Any ideas how we can go about this and reduce the risk of osteopaenia in our tiny canine patients?

30/01/2023

Some of you asked how I fixed the Salter Harris fracture from the previous post. Safe to say this is not my proudest fracture reduction, but it worked - and I think we should be honest in showing the less perfect cases too. We all meet them 😬

The fracture was more than two days old when I got my hands on it. In puppies, fractures stick together as if they were glued very quickly after the fracture occurs. Not only did this make repositioning difficult, but the leg was so swollen that identifying anatomical landmarks for the pins, or the tibial axis for that matter, was close to impossible. On top of that the metaphyseal bone in puppies is so soft that driving a K-wire through it feels like going through butter, and so you don’t get many chances before you can wave goodbye to bone purchase.
What is good? The repositioning is near perfect even though the tibial tuberosity is quite high, which happens a lot when these fractures are more than some hours old. The fracture reduction was rock solid when testing stability intraoperatively.
What is less good? The lateral K-wire does not cross the medial one and has much less purchase than what would be ideal. The angle of this pin should have been steeper and more in line with the angle of the medial pin.
What was the result? The puppy’s leg is reduced to half the size after the swelling subsided. It walks well with very little residual lameness, the axis is good, the fracture stable and the implants in place 1 week postoperatively. It has been in a Robert Jones bandage until now and will now spend another week with no bandasje but on cage rest.
If all goes well, the pins will be removed approximately 3 weeks post surgery pending radiographically confirmed fracture healing.
Oh, and the fibula? We rarely do anything about it. 🤷‍♀️

Any comments on this case? Scrutinisation is always welcome and makes for good learning 😉

23/01/2023

Salter Harris type I and II fractures account for 56% of proximal tibial fractures! Fortunately only 2 % of these fractures involve the stifle, but nevertheless they can cause major problems if not seen early. In this 5 months old Staffie the tibial tuberosity epiphysis was also displaced, which sometimes happens with these fractures. Since the physes suffer variable degrees of damage, this can result in growth disturbances of the tibial tuberosity and the tibial plateau as well as angular limb deformities. Thus, these dogs must be monitored for this well into their adult life, especially with regards to patellar luxation or cranial cruciate ligament disease. The most common age at which we see these fractures, is between 4 -8 months.
❓Do you know some predisposed breeds?

18/01/2023

Just to elaborate on the previous post: I realise that my pointing may have been somewhat confusing, so here is an attempt at clarifying; the angle you want to measure is where an imaginary, horizontal line from the scapula meets the humerus at its most abducted point.
Was this useful at all? Please tell me 👇

06/01/2023

FriYAY, but veterinary surgery does not care 😂
Medial shoulder instability (MSI) in dogs occurs when the medial supporting structures of the joint - namely the glenohumeral ligament, the subscapularis tendon or the joint capsule become injured, frayed or inflamed, resulting in increased laxity and sometimes subluxation of the shoulder joint, resulting in an abduction angle greater than 50 degrees. See my next post for a tutorial of how to perform this!

MSI can affect all dogs, but is most commonly seen in performance, working or active dogs. It can be difficult to diagnose as the clinical signs can range from refusing to take turns to total weight bearing lameness.

Diagnosis: abduction test +/- arthroscopy
Treatment:
Mild cases: shoulder support/(hobbles) and physiotherapy.
Moderate to severe: arthroscopy and surgical stabilisation. Several techniques have been described, the one shown here is in my opinion one of the better, albeit none can flaunt excellent scientific evidence: minimally invasive, arthroscopy-guided tightrope stabilisation on a hanging limb (see photos 2 and 3). However, the prognosis for a continued working career cannot be guaranteed and the owners should be advised accordingly.

Does any of you have experience with other types of treatment for this condition?