Proceedings – Small Animals - ECVS

20th 

Annual Scientific Meeting 

University Forum UFO, Ghent University, Ghent, 

Begium, 

Proceedings – Small Animals 

Edited by: Stephen Baines 

July 7–9, 2011

Welcome to Ghent, welcome to Belgium 

A Warm Welcome to Ghent! 

Dear colleagues, 

It is a great pleasure for me and for our organising team to welcome you all to Ghent for this 

anniversary meeting of the ECVS. Yes indeed, time flies and we are already celebrating twenty years of 

ECVS! What has ever started with a small group of people with interest in veterinary surgery has now 

grown into an organisation offering education programmes, certifying specialists, promoting scientific 

progress and organising meetings. A large group of people, young and old, from resident to diplomate, 

from all over the World, but after all these years: still with a profound interest in veterinary surgery! 

We are very happy that we can celebrate this in Belgium. 

The Ghent University welcomes you in its brand new “University Forum” (UFO) building located at a 

nice 10 minutes walk from the historical centre of the city, where most of the hotels are located. At 

the UFO we have a promising scientific program for our small and large animal delegates, combined 

with a large commercial exhibition to meet with our sponsors and with your friends and colleagues. 

But as there is more than science in men’s (and women’s) life, I invite you to discover our marvellous 

city. Ghent is indeed one of the most beautiful historic cities in Europe. It is called “Medieval Manhattan” 

and combines an impressive past with a vivid present. Take this walk through history and visit the castle 

of the counts, the Cathedral, Belfry, Butchers hall and many more places. Let your beloved ones join 

the “partners program team” and they will discover many more hidden secrets of Ghent and Flanders. 

Thanks a lot to ECVS for all the support, to our sponsors to make all of this financially possible, to all 

our colleagues and friends who have worked hard for this meeting and to you all for being here! 

May Ghent be an unforgettable experience for you! 

Ann Martens 

In name of the local organising committee 

ECVS proceedings 2011 3 information section

information section 4 ECVS proceedings 2011

Platinum Sponsors 

Gold Sponsors 


We would like to thank all our sponsors and exhibitors for their support and presence 

during the 20 th Annual Scientific Meeting at the UFO University Forum Ghent University, 

Ghent Belgium 

• AdMaiora 

• AOVET 

• Arthrex 

• B. Braun Vet Care GmbH 

• City of Ghent 

• Equus Medic Line 

• Erbe 

• Dr. Fritz GmbH 

• Ghent University 

• Istrulife 

• J. Story Scientia 

• Janssen Animal Health 

• Karl Storz GmbH 

• KCI 

• Kyon AG 

• Mon & Tex Spa 

• Optomed 

• Orthomed (UK) LTd. 

• Richard Wolf GmbH 

• Royal Canin 

• SECUROS Europe GmbH 

• Smith and Nephew 

• Synthes GmbH 

• The Belgian Confederation of the Horse 

• Traumavet 

• Veterinary Instrumentation Ltd 

• Vetin-Aacofarma 

• Vétoquinol 

• VetZ Veterinär-medizinisches Dienstleistungszentrum GmbH 

• VIN Internet Cafe 

• Vlaams Paardenloket 


Scientific programme outline 



Large animals Programme outline 

Thursday July 7 

State of the art auditorium at the UFO 

Chair: D. Spreng & A. Martens 

15.30–16.15 P. Broos Pushing the boundaries in severe musculoskeletal trauma - 

what is possible? 

16.15–16.30 Coffee break 

Large animal – resident forum auditorium at the UFO 

Chair: D. Bolt 

16.30–16.45 M. Jordana Distal limb desensitization following anesthesia of the digital flexor 

Discussant: A. Fürst tendon sheath in horses: a comparison of 4 techniques 

16.45–17.00 L. Arensburg Aseptic tenosynovitis of the DFTS caused by longitudinal tears of the 

Discussant: B. Bladon flexor tendons 

17.00–17.15 T. Toth Evaluation of 1% hydrogen peroxide cream in the treatment of open 

Discussant: D. Archer wounds in healthy horses: a randomized, blinded control study 

17.15–17.30 C. Klaus Long term results of surgical correction of a deep bite class II 

Discussant: D. Verwilghen malocclusion in 7 horses 

17.30–17.45 H. Gunnarsdottir Caeco-colic intussusceptions: 10 cases over a 7 month time period 

Discussant: A. Rijkenhuizen 

17.45–18.00 T. Barnett Dynamic videoendoscopic assessment of the upper airway following 

Discussant: E. Strand laryngoplasty 

18.00–18.15 A. Fiske Jackson Evaluation of pre-operative diagnostic methods for digital sheath 

Discussant: R. Perrin pathology 

18.15–18.30 W. Schneeweiss Comparison of ultrasound-guided versus “blind” techniques for intra- 

Discussant: C. Lischer synovial injections of the shoulder area in horses: Scapulohumeral 

joint, bicipital bursa and infraspinatus bursa 

18.30–18.45 K. Benredouane Trans-arterial coil embolisation of the internal carotid artery in 

Discussant: O. Simon standing horses 

18.45–19.00 E. Lallemand Autologous nasal chondrocytes and a cellulose-based self-setting 

Discussant: P. Clegg hydrogel for the repair of articular cartilage in horses 

19.15 Transfer by boat - embarking at the pier „Muinkkaai“ 

20.00–23.00 Welcome Cocktail at Castle of the Counts 



Friday July 8 

In depth: colic 

Chair: L. Vlaminck 

08.00–08.40 G. van Loon How abdominal ultrasonography has changed our approach in colic 

surgery 

08.40–09.20 M. Mosing Perioperative intensive care of the colic patient – latest developments 

09.20–09.50 D. Archer Evidence for anastomosis technique in colic surgery 

09.50–10.20 J. Schumacher Surgeries of horses that appear difficult but are not! 

10.20–10.30 Discussion 


Short communications 

Chair: P. Clegg 

11.00–11.15 S. Brandt Equus caballus papillomavirus 2 as a possible causative agent of 

equine genital SCC 

11.15–11.30 P. Brink Uteropexy of 10 mares by laparoscopically imbricating the mesometrium 

11.30–11.45 A. Bischofberger The effect of horse age, prosthesis tension, position and number on 

the area of the rima glottidis in equine laryngeal specimens 

11.45–12.00 G. Marañon Modulation of monocyte chemotactic protein-1(mcp-1) production by 

ischaemia-reperfusion in the intestine of horses 

12.00–12.15 F. Rossignol Treatment of dorsal displacement of the soft palate by a modified tie 

forward procedure using metallic implants 

12.15–12.30 L. Hunt Comparison of thoracic ultrasound and radiography for the detection 

of small volume induced pneumothorax in the horse 


12.40–14.15 Lunch break 

13.15–13.45 Information session for our residents and supervisors as well 

as programme directors 


Chair: P. Clegg 

14.15–14.30 J. Declercq Quantitative assessment of articular cartilage degeneration of the 

metacarpal condyle using a 3D scanning system 

14.30–14.45 F. David Effect of cast immobilisation on equine SDFT lesion propagation 

14.45–15.00 M. Schramme The effect of intralesional bone marrow derived mesenchymal stem 

cells and bone marrow supernatant on collagen fibril size in a surgical 

model of equine superficial digital tendonitis 




Friday July 8 

In depth: Interactive surgical case discussion and televoting 

Chair: S. May 

Panel: A. Martens, D. Archer, J. Auer, H. Wilderjans, M. Schramme 

15.30–18.00 

J. Kümmerle A modified prosthetic capsule technique for treatment of an acute coxofemoral luxation in a pony 

B. Bladon A simple case of an incomplete non displaced sagittal fracture of P1 

U. Delling Hand-assisted laparoscopic adhesiolysis of extensive small intestinal adhesions in a mare after 

breeding injury 

G. Bodó Bilateral sinonasal cyst treated through a bone flap with nasal septum resection in a Shetland pony 

M. Meulyzer Laparoscopic mesh hernioplasty for correction of a non-strangulating scrotal hernia in a Warmblood 

breeding stallion 

L. Smith Standing removal of an ectopic, dysplastic, fourth maxillary premolar in a three-year-old 

Quarterhorse colt 

T. Levet Single transphyseal position screw for carpal valgus deviation: an unusual complication in two foals 

F. Rossignol Partial carpal arthrodesis using two 4.5 LCP plates in three horses 

18.10–19.30 ECVS Annual Business Meeting – mandatory for ECVS Diplomates 

18.10–18.40 A. Adkins Resident talk – how to examine and treat stifle OCD in the horse 

20.00–23.00 Belgian get-together at the Monastery Het Pand 



Saturday July 9 

In depth – Foal and mare 

Chair: H. Wilderjans 

08.30–09.15 J. Schumacher Foal head surgery: nose deviation, cleft palate 

09.15–09.50 J. Auer Foal physeal fractures 

09.50–10.20 A. Adkins Limb fractures in foals 


10.50–11.15 J. Auer The concept of treatment of angular limb deformities 

11.15–11.55 A. Adkins Flexural limb deformities in foals and yearlings 


12.15–14.15 Lunch 

Information session for our residents 

12.45–13.10 J. Pascoe Pitfalls to getting published in Veterinary Surgery 

Lunchtime talk 

13.20–13.40 J. Schumacher How to perform rectovaginal fistula and cervix reconstruction 

In depth: orthopaedics supported by Belgian Confederation of the Horse 

Chair: M. Schramme 

14.15–14.40 A. Fürst Should bone cysts be filled? 

14.40–15.05 B. Bladon Standing orthopaedic surgery 

15.05–15.35 F. Vandenberghe How has MRI changed our approach to the orthopaedic case: 

radiologist‘s point of view 

15.35–16.00 R. Perrin How has MRI changed our approach to the orthopaedic case: 

surgeon‘s point of view 




Large animals 


Programme outline 

Poster session 


Chair: R. Smith 

M. Chabrier Computed tomography arthrography (CTA) anatomy of the ovine stifle 

S. de la Farge Use of modified transfixation cast technique in horses 

D. Dias Standardisation of a technique for facial artery catheter implantation and maintenance in horses 

L. Gracia–Calvo Standing hand-assisted laparoscopic splenectomy: case report 

C. Hopster-Iversen Influence of mechanical manipulations on the local inflammatory reaction in the equine colon 

N. Herteman An anatomic study of the synovial cavities of the stifle in the sheep 

C. Lambert An anatomic study of ovine menisci by computed tomographic arthrography (CTA), 3D segmentation 

and magnetic resonnance imaging (MRI) 

M. Lamberts Comparison of three techniques to inject the synovial cavities of the stifle in the sheep. 

C. Méspoulhès Equine laryngeal neurostimulator: development and implantation technique 

R. Parker The in vitro effects of antibiotics on the gene expression of equine bone marrow derived 

mesenchymal stromal cells 

M. Rathmanner Comparison of the local inflammatory response in horses undergoing small intestinal resection with 

and without development of post operative ileus 

A. Salciccia Evaluation of the effect of general anaesthesia on ultrasonographic images of the small intestine in 

horses 

C. Vandecatsyne Magnetic resonance imaging anatomy of the ovine stifle described from images acquired with high- 

field magnet (3 Tesla) 

State of the art – closing session 

Chair: B. Bouvy & D. Spreng 

18.00–19.00 S. May The history of Veterinary Surgery 

20 years 

J. Auer The history of the European College of Veterinary Surgeons – the first 

20.00 Banquet and awards at the Old Fishmine – Disco night 


Small animals 


Programme outline 

State of the art auditorium at the UFO 

Chair: D. Spreng & A. Martens 

15.30–16.15 P. Broos Pushing the boundaries in severe musculoskeletal trauma - 

what is possible? 


Small animal resident forum auditorium at the UFO 

Chair: K. Pratschke 

16.30–16.45 A. Gutbrod The effects of humeral rotational osteotomy on the canine elbow 

Discussant: L. Déjardin joint. An ex vivo study 

16.45–17.00 M. Benlloch Gonzales Prospective clinical study of enterectomy with skin staplers in 9 dogs 

Discussant: D. Brockman and 9 cats 

17.00–17.15 P. Nelissen Effect of three anesthetic induction protocols on laryngeal function 

Discussant: M. Peeters during laryngoscopy in normal cats 

17.15–17.30 R. Vallefuoco Tympanic bulla osteotomy via oral approach in the dog: a descriptive 

Discussant: H. Brissot cadaveric study 

17.30–17.45 P. Buttin Removal of nephroliths by video-assisted nephrotomy: 8 cases 

Discussant: J. Ladlow 

17.45–18.00 N. Medl Intraoperative contamination of the suction tip in clean orthopedic 

Discussant: V. Lipscomb surgeries in dogs and cats 

18.00–18.15 N. Barthélémy Short- and long-term outcomes in young large breed dogs with medial 

Discussant: M. Glyde compartment disease of the elbow 

18.15–18.30 P. Rochereau Comparison of 4.0 mm partially-threaded cannulated screws and 

Discussant: D. Damur 4.0 mm partially-threaded cancellous screws in a canine humeral 

condylar fracture model 

18.30–18.45 N. Woodbrigde A retrospective study of tibial plateau translation following tibial 

Discussant: U. Reif plateau levelling osteotomy (TPLO) stabilisation using three different 

plate types 

18.45–19.00 G. Hayes Distribution and persistence of topical clotrimazole for canine sino- 

Discussant: R. Burrow nasal aspergillosis 

19.15 Transfer by boat - embarking at the pier „Muinkkaai“ 

20.00–23.00 Welcome Cocktail at the Castle of the Counts 


Small animals Programme outline 

Friday July 8 

Small animal – orthopaedics – auditorium at the UFO Small animal – soft tissues auditorium Plateau 

In depth – Shoulder arthroscopy – clinical update 

Chair: S. Langley–Hobbs 

08.00–08.30 C. Devitt Diagnosis of shoulder 

instability 

08.30–09.00 H. van Bree MRI and arthroscopy for 

evaluation of shoulder 

joint pathology 

09.00–09.30 C. Devitt Arthroscopic treatment 

of MGHL injury 

09.30–10.00 B. van Ryssen Caudal glenoid 

fragmentation 




Chair: M. Balligand 

10.45–11.00 M. Glyde Biomechanical 

comparison of plate, 

plate-rod and orthogonal 

plate locking constructs 

in an ex-vivo canine 

tibial fracture gap model 

11.00–11.15 A. Baroncelli Effect of screw 

insertional torque on 

mechanical properties of 

5 different angular stable 

systems 

11.15–11.30 B. Meij The use of pedicle 

screws in canine 

lumbosacral disease 

11.30–11.45 L. Déjardin Effect of articular design 

on mediolateral 

constraint and stability 

of two unlinked canine 

total elbow prostheses 

11.45–12.00 N. Fitzpatrick The effect of configuration 

and radiographicpositioning 

on measurements of 

deformity magnitude in a 

dog with a complex antebrachial 

growth deformity: 

comparison between 

radiographic and 3D computer 

modellingmeasurements 

In depth – Medical or surgical ? – 

Tracheal collapse 

Chair: D. Brockman 

08.00–08.30 A. Moritz Have we learnt anything in 

the last 15 years? 

Pathophysiology, medical and surgical treatment 

08.30–08.40 D. Brockman Ringing versus stenting – 

introduction 

08.40–09.10 R. White Ringing: indications, 

limitations, technique 

09.10–09.40 A. Moritz Stenting: The Giessen 

experience 




Chair: L. Findji 

10.45–11.00 J. Milgram Axial pattern flap based 

on a cutaneous branch of 

the facial artery in cats. 

11.00–11.15 O. Höglund Ligating the renal artery 

in pigs with a new 

absorbable device – 

LigaTie ® 

11.15–11.30 H. Brissot Caudal mediastinal 

para-oesophageal 

abscesses in 7 dogs. A 

retrospective study 

11.30–11.45 D. Murgia Caudal cervical 

intervertebral space 

distraction and 

stabilization using a 

distractable fusion cage 

in seven dogs 

11.45–12.00 T. Cachon Surgical treatment of 

sciatic nerve injury: 

9 cases 

12.00–12.15 L. Rancan Changes in circulating 

pro-inflammatory 

cytokines and nitric oxide 

in brachycephalic dogs 




Friday July 8 


12.00–12.15 K. Voss Association of articular 

mineralisations, cranial 

cruciate ligament pathology 

and degenerative joint 

disease in feline stifle joints 

12.15–12.30 J. Milgram The role of the antebrachiocarpal 

ligaments in the prevention 

of hyperex-tension of the 

antebrachiocarpal joint 

12.30–12.45 M. Glyde The effect of screw 

number and plate stand- 

off distance on the 

biomechanical characteristics 

of 3.5mm locking 

compression plate (LCP) 

and 3.5mm string of pearls 

(SOP) plate constructs in 

a synthetic fracture gap model 



13.15–13.45 Information session 

for our residents 

and supervisors as well 


In depth – Motion analysis and rehabilitation 

Chair: M. Owen 

14.30–14.55 M. Balligand Force plate analysis: is it 

the gold standard? 

14.55–15.20 P. Böttcher In vivo three dimensional 

motion analysis 

15.20–15.45 M. Balligand The influence of muscle 

forces on the cruciate 

deficient stifle joint 

15.45–16.15 B. Bockstahler Evidence based medicine 

in rehabilitation 




13.15–13.45 Information session 

for our residents 

and supervisors as well 


In depth – Medical or surgical ? Pyothorax in dogs 

and cats 

Chair: J.P Billet 

14.00–14.30 A. Moritz What have we learnt in the 

last 15 years? 

14.30–15.00 J. Demetriou Is surgery necessary ? 

15.00–15.15 Conclusions and 

discussion 

Pancreatitis in dogs and cats 

15.15–15.40 P. Watson What have we learnt in the 

last 15 years? 

15.40–16.00 R. White Surgical treatment: 

Necrosectomies, 

pancreatectomies, 

drainage, gall bladder 

diversion, enteral feeding 

16.00–16.20 Conclusions and 

discussion 




Friday July 8 


Chair: L. Sjöström 


A. Bernardé Retrospective study of complications following modified triple tibial osteotomy for cranial cruciate 

deficient stifles in dogs: 72 cases (2008-2010) 

B. Böhme Considerations on the pathophysiology of canine condylar fractures by finite element analysis 

L. Boland Zygomatic salivary gland diseases in the dog: 3 representative cases 

N. Fitzpatrick True spherical dome osteotomy using a novel blade design in a dog with an antebrachial growth 

deformity – planning and execution of technique 

M. Hamilton Total hip replacement with reinforced augmentation of the dorsal acetabular rim (radar) using the 

SOP implant and bone cement in seven dogs with dorsal acetabular rim deficiency 

L. Piras Effects of antebrachial torsion on the measurement of frontal plane angulation: A cadaveric 

radiographic analysis 

U. Segal Latero–distal transposition of the tibial crest for patella alta and medial luxation 

L. Souchu Morphological comparison of the middle ear between French bulldogs and non-brachycephalic dogs 

C. Tan Stabilisation of periarticular fractures and osteotomies with a notched head locking compression 

T–plate 

M. Verset Two cases of dogs with infiltrative lipomas of the thigh region 

B. Walton Owner based metrology instruments for conditions of canine chronic mobility impairment – construct 

and criterion validity of LOAD, CBPI and HCPI 

18.10–19.30 ECVS Annual Business Meeting – mandatory for ECVS 

Diplomates 

18.10–18.40 A. Adkins Resident talk – how to examine and treat stifle OCD in the horse 

20.00–23.00 Belgian get-together at the Monastery Het Pand 





In depth – Infection control in surgical practice 

Chair: G. Dupré 

08.30–09.00 S. Weese Surgical infections: Incidence, relevance, risk factors, surveillance 

09.00–09.30 L. Findji Surgical preparation: current understanding and recommendations 

09.30–10.00 P. Moissonnier Perioperative antimicrobial prophylaxis 


10.30–11.00 S. Weese Surgical site infection control programme: The Ontario experience 

11.00–11.30 All Discussion: What should we change in our practices? 

11.30–12.30 S. Weese Methicillin-resistant staphylococcal infection: Animal and public 

health consequences 


Information session for our residents 

12.45–13.10 J. Pascoe Pitfalls to getting published in Veterinary Surgery 





In depth: Bone healing for surgeons 

Chair: L. Dejardin 

14.00–14.25 O. Gauthier Stimulation of bone 

healing – latest 

developments 

14.25–14.50 D. Griffon Delayed – and non – 

unions 

14.50–15.15 O. Gauthier Stimulation of bone 

healing: commercially 

available products 

15.15–15.40 D. Griffon Stimulation of bone 

healing in clinical 

practice 


16.00–16.30 Coffee Break 

In depth: Neurosurgery: lumbosacral disease 

Chair: B. Meij 

16.30–16.55 H. van Bree Diagnostic imaging 

techniques – an 

update: MRI and CT 

16.55–17.20 C. Falzone Lumbosacral spine: 

surgical decision 

making 

17.20–17.45 C. Falzone Lumbosacral spine: 

decompression and 

stabilisation 


Small animal and large animal combined 

State of the art – closing session auditorium at the UFO 

Chair: B. Bouvy & D. Spreng 

18.00–19.00 S. May The history of Veterinary Surgery 

20 years 

In depth: VSSO – Reconstructive surgery: 

management of skin tumors - supported by KCI 

Chair: J. Kirpensteijn 

14.00–14.25 G. ter Haar Novel reconstructions of 

skin on top of the nose 

14.25–14.50 R. Sivacolundhu Reconstruction of hard 

and soft palate defects 

14.50–15.15 J. Liptak Large skin tumors and 

their resection 

15.15–15.40 S. Boston Mast cell tumors, what is 

really new? 


16.30–16.55 A. Vanlander VAC-assisted reconstruction 

in human patients 

16.55–17.20 J. Kirpensteijn Radioactive 

microbrachytherapy for 

cutaneous lesions 

17.20–17.50 Round table discussion – 

difficult skin cases 

J. Auer The history of the European College of Veterinary Surgeons – the first 

20.00 Banquet and awards at the old Fishmine – Disco night 




Contents 

Scientific programme outline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 

State of the art . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 

Pushing the boundaries in musculoskeletal trauma – what is possible in man? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 

Paul L.O. Broos, Prof. Em. Dr. 

Resident Forum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 

Effects of humeral rotational osteotomy on contact mechanism of the canine elbow joint: an ex vivo study . . . . . . . . . . . . 35 

Gutbrod A, Guerrero TG* 

Prospective clinical study of enterectomy with skin staplers in 9 dogs and 9 cats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 

M.Benlloch-Gonzalez, B.Bouvy*, E.Gomes, J.Hernandez, C.Poncet*. 

Effect of three an aesthetic induction protocols on laryngeal function during laryngoscopy in normal cat . . . . . . . . . . . . . . 37 

Nelissen P., Aprea F., Corletto F., White RAS*. 

Tympanic bulla osteotomy via oral approach in the dog: A descriptive cadaveric study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 

Vallefuoco R, Jardel N, Tessier A, Moissonnier P. 

Nephroliths and video-assisted nephrotomy in 8 cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 

Buttin P., Cachon T.*, Carozzo C*., Maitre P., Arnault A., Fau D., Genevois JP., Viguier E*. 

Intraoperative contamination of the suction tip in clean orthopaedic surgeries in dogs and cats . . . . . . . . . . . . . . . . . . . . . . 40 

Medl N 1 , Guerrero TG* 1 , Hölzle L 2 , Montavon PM 1 

Short- and long-term outcomes in young large breed dogs with medial compartment disease of the elbow . . . . . . . . . . . 41 

N. Barthélémy¹, D. Griffon* ² , G. Ragetly², I. Carrera², D. Schaeffer² 

Comparison of 4 .0 mm partially-threaded cannulated screws and 4 .0 mm partially-threaded screws in a canine 

humeral condylar fracture model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 

Rochereau P. 1 , Diop A. 2 , Maurel N. 2 , Gomez Clemente R. 2 , Gabanou P.A .3 , Bernardé A.* 1 . 

A retrospective study of tibial plateau translation following tibial plateau levelling osteotomy stabilisation using 

three different TPLO plates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 

Woodbridge N 3 , Corr S.A. 2 , Grierson J 1 , Arthurs G 1 . 

Distribution and persistence of topical clotrimazole for canine sino-nasal aspergillosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 

G. M. Hayes and J. L. Demetriou*. 

Poster session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 

A retrospective study of complications following modified triple tibial osteotomy for cranial cruciate deficient 

stifles in dogs: 72 cases (2008-2010) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 

Bernardé A., Rochereau P., Spengler E. 

Considerations on the pathophysiology of canine condylar fractures by finite element analysis . . . . . . . . . . . . . . . . . . . . . . 50 

B. Böhme 1 , V. d’Otreppe 2 , J.P. Ponthot 2 and M. Balligand 

Zygomatic salivary gland diseases in the dog: three representative cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 

Boland L, Gomes E, Payen G, Bouvy B*, Poncet C* 

True spherical dome osteotomy using a novel blade design in a dog with an antebrachial growth deformity – 

planning and execution of technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 

N. Fitzpatrick, C. Nikolaou 1 , K. Ash 1 , V. Wavreille 1 , Z. Szanto 2 

Total hip replacement with reiforced augmentation of the dorsal acetabular rim (radar) using the sop implant 

and bone cement in seven dogs with dorsal acetabular rim deficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 

N. Fitzpatrick, M. Bielecki, R Yeadon*, M. Hamilton* 

Effects of antebrachial torsion on the measurement of frontal plane angulation: a cadaveric radiographic analysis . . . . . 54 

Piras LA 1 , Peirone B 1 , Fox DB 2 



Latero-distal transposition of the tibial crest for patella alta and medial luxation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 

Segal U., Shani J* 

Morphological comparison of the middle ear between French bulldogs and non-brachycephalic dogs . . . . . . . . . . . . . . . . 56 

L.Souchu 1 , T. Chuzel 2 , C. Carozzo* 3 . 

Stabilisation of periarticular fractures or osteotomies with an LCP notched head T-plate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 

C. J. Tan, K.A. Johnson*. 

Two cases of dogs with infiltrative lipomas of the thigh region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 

M. Verset 1 , T. Cachon* 2 , D. Rémy 2 , C. Carozzo* 2 . 

Owner based metrology instruments for conditions of canine chronic mobility impairment - contruct and criterion 

validity of LOAD, HCPI and CBPI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 

Walton MB 1 , Innes JF 1 , Lascelles BDX* 2 

In depth – Infection control in surgical practice . . . . . . . . . . . . . . . . . . . . . . . . 61 

Surgical site infections: Incidence, relevance, risk factors and surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 

J Scott Weese DVM DVSc DipACVIM 

Surgical preparation: current understanding and recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 

L. Findji* 

Perioperative antimicrobial prophylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 

P. Moissonnier* 

Surgical site infection control programme . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 


Methicillin-resistant staphylococcal infections: animal and public health consequences . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 


Short communications – orthopaedics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 

Biomechanical comparison of plate, plate-rod and orthogonal plate locking constructs in an ex-vivo canine tibial 

fracture gap model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 

Glyde M *1 ., Day R. 2 , Deane B. 1 , Read R 1 . and Hosgood G * 1 . 

Effect of screw insertional torque on mechanical properties of 5 different angular stable systems . . . . . . . . . . . . . . . . . . . 89 

A Boero Baroncelli 1 , U Reif 2 , C Bignardi 3 , B Peirone 1 . 

The use of pedicle screws in canine lumbosacral disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 

Meij BP*, Smolders LA, Bergknut N, Voorhout G, Grinwis GCM, Hazewinkel HAW* 

Effect of articular design on mediolateral constraint and stability of two unlinked canine total elbow prostheses . . . . . . . 91 

Guillou RP 1 , Demianiuk RM 1 , Déjardin LM* 2 ,Beckett C 2 , Haut RC 

The effect of configuration and radiographic positioning on measurements of deformity magnitude in a dog with 

a complex antebrachial growth deformity: comparison between radiographic and 3D computer modelling 

measurements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 

N. Fitzpatrick, C. Nikolaou,JF. Isaza Saldarriaga, S. Correa Velez, V. Wavreille, K. Ash, JJ. Ochoa 

Association of articular mineralisation, cranial cruciate ligament pathology and degenerative joint disease in 

feline stifle joints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 

Voss K* 1 , Karli P 2 , Kipfer N 2 , Geyer H 3 

The role of the antebrachiocarpal ligaments in the prevention of hyperextension of the antebrachiocarpal joint . . . . . . . . 94 

Milgram J*, Milstein T, Meiner Y. 

The effect of screw number and plate stand-off distance on the biomechanical characteristics of 3 .5mm locking 

compression plate (LCP) and 3 .5mm string of pearls (SOP) plate constructs in a synthetic fracture gap model . . . . . . . 95 

Glyde M *1 , Day R 2 . and Hosgood G *1 . 

In depth – shoulder arthroscopy - clinical update . . . . . . . . . . . . . . . . . . . . . . . 97 

Dorsal recumbent shoulder arthroscopy technique, normal anatomy, & appearance of routine pathology . . . . . . . . . . . . . 99 

Chad Devitt, DVM, MS, Diplomate ACVS 

MRI and arthroscopy for evaluation of shoulder joint pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 

H. van Bree*, W. Dingemanse, I. Gielen 

Stifle arthroscopy technique, normal anatomy, & appearance of routine rathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 


Calcified bodies at the caudal rim of the glenoid cavity: diagnostic findings and results after treatment: 

retrospective study of 28 dogs and 1 cat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 

B. Van Ryssen, E. Coppieters, Y. Samoy, D. Van Vynckt, J. Saunders, H. van Bree. 



In depth – Motion analysis and rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . 109 

Force plate: gold standard? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 

M. Balligand* 

In vivo motion analysis 3D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 

P. Böttcher*, J. Rey, G. Oechtering 

Muscular forces affecting the outcome of CCL surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 

JM Ramirez Leon 1 , B Böhme 4 , C Vroomen 3 , F Farnir 2 , M Balligand 1 

Evidence based medicine in rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 

B. Bockstahler, PD, DVM, CCRP 

In depth – Bone healing for surgeons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 

Stimulation of bone healing . Latest developments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 

O. Gauthier, DVM, PhD Prof. 

Delayed union and nonunion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 

Dominique J Griffon* 

Stimulation of bone healing . Commercially available products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 

O.Gauthier, DVM, PhD Prof. 

Enhancing bone healing in practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 


In depth – Neurosurgery: lumbosacral disease . . . . . . . . . . . . . . . . . . . . . . . . 135 

Lumbosacral disease (LS): an update on diagnostic imaging techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 

I. Gielen, K. Kromhout, H. van Bree* 

Lumbosacral spine: surgical decision making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 

Christian Falzone, DVM, Dipl ECVN 

Lumbosacral spine: decompression and stabilisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 


Short communications – soft tissues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 

Axial pattern flap based on a cutaneous branch of the facial artery in cats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 

Milgram J*, Weiser M, Kelmer E*, Benzioni H 

Ligating the renal artery in pigs with a new absorbable device - LigaTie ® . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 

O V. Höglund, DVM, K. Olsson, DVM, PhD, R. Hagman, DVM, MSc, PhD, A. Lagerstedt, DVM, PhD. 

Caudal mediastinal para-oesophageal abscesses in 7 dogs . A retospective study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 

H. Brissot*, C. Burton*, R. Doyle*. 

Caudal cervical intervertebral space distraction and stabilization using a distractable fusion cage in seven dogs . . . . . 150 

Murgia D*, Gasparinetti N, Schiesaro R. 

Surgical treatment of sciatic nerve injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 

Cachon T.*, Escriou C, Arnault A., Maitre P., Fau D., Viguier E.*, Genevois JP. Carozzo C* 

Circulating proinflammatory cytokines and nitric oxide are increased in brachycephalic dogs . . . . . . . . . . . . . . . . . . . . . . 152 

Rancan L, Romussi S, Albertini M, García P, Vara E, Sánchez de la Muela M 

In depth - Medical or surgical? - Tracheal collapse . . . . . . . . . . . . . . . . . . . . 153 

Have we learnt anything in the last 15 years? Stenting: The Giessen experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 

A. Moritz, C. Paul de Melo, N. Bauer, M. Schneider, 

Tracheal collapse – ringing: indications, limitations, technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 

Robert N White* 

In depth – Medical or surgical? Pyothorax in dogs and cats . . . . . . . . . . . . . 163 

Pyothorax – have we learnt anything in the last 15 years? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 

G. Wurtinger, C. Peppler*, M. Schneider, A. Moritz, 

Pyothorax : Is surgery necessary? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 

Jackie L. Demetriou * 



In depth – Medical or surgical –Pancreatitis in dogs and cats . . . . . . . . . . . 171 

Pancreatitis in dogs and cats: what have we learnt on the last 15 years? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 

P. Watson, MA,VetMD, CertVR, DSAM, ECVIM, MRCVS 

Surgical treatment: necrosectomies, pancreatectomies, and drainage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 

Robert N White BSc (Hons) BVetMedCertVA DSAS (Soft Tissue) DiplECVS 

In depth: VSSO – Reconstructive surgery: management of skin tumors . . . . 181 

Novel reconstructions of the tip of the nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 

G. ter Haar* 

Use of local and axial pattern flaps for reconstruction of the hard and soft palate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 

Ramesh K Sivacolundhu, BVMS MVS FACVSc 

Wide excision of tumors and reconstruction of the resultant defect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 

Julius M. Liptak* 

Canine mast cell tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 

Sarah Boston* 

Closure of large abdominal wall defects using negative pressure therapy: a bridge to definitive closure . . . . . . . . . . . . . . 191 

A.Vanlander MD, F. Berrevoet MD ,PhD 

Radioactive microbrachytherapy for head and neck lesions in dogs and cats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192 

Kirpensteijn J*, Vente MAD, Nimwegen B, Nijsen JFW 

Author index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195 



combined session 26 ECVS proceedings 2011

Large and small animals combined 

State of the art 

Thursday July 7 – 15.30–16.15


Pushing the boundaries in musculoskeletal trauma – 

what is possible in man? 

Paul L.O. Broos, Prof. Em. Dr. 

Previous director of the department of surgery of the University Hospitals KU Leuven. 

Historical approach. 

Historically, surgery has always been closely linked 

to trauma care. In 2700 B.C, Imhotep taught us how to 

immobilize fractured limbs using papyrus rods. In the 

Renaissance, Heinz von Gersdorff as well as Ambroise 

Paré, were very famous army surgeons and dealt frequently 

with trauma.In the 19th century, Jean-Dominique Larrey 

reorganized the medical services of Napoleon’s army 

and introduced concepts such as triage, evacuation and 

debridement. We can go back even further, to the time 

of primitive men. Indeed, since the beginning of men’s 

inhabitancy of this planet, he has to sustain serious injuries 

as a consequence of accidents, nature disasters, attacks by 

wild animals and, last but not least, through war. Armed 

conflicts have forced men to learn how to deal with wounds, 

caused by catapulted rocks, axes or other forms of military 

armament. He had to learn how to stop a gush of blood, to 

splint broken limbs and to remove foreign objects, in other 

words: how to support threatened lives. 

In the 21st century, trauma is still a major health problem 

in the Western world. Indeed, trauma is responsible for 

about one third of all hospital admissions, with 80 % of 

all injuries occurring in individuals younger than 45 years 

of age. Trauma is the leading cause of death in this age 

group and this group accounts for 75 % of total life cost due 

to injury. And what’s even more tragic: even in our days as 

many as 40 % of trauma deaths are avoidable The care of 

multiple injured victims has now become a team approach 

with nurses, medical technicians and consulting physicians. 

Four posttraumatic periods. 

In the posttraumatic period we have to make a distinction 

between four periods: the acute or reanimation period 

the primary or stabilization period, the secondary or 

regeneration period and the tertiary or rehabilitation 

period. 

The reanimation period and the primary period 

have always been considered as the periods for “life 

saving surgery”. Trauma patients are presenting with 

a combination of problems. Advances in diagnosis and 

treatment have been greatly influenced by technology. 

Thanks to these advances, a lot of injuries can now be 

treated in a non-operative way, for example, endovascular 

procedures to stop haemorrhage. Nevertheless, the 

experienced trauma surgeons still play a vital role. 

The great majority of lesions that have to be operated 

in our countries are lesions of the musculoskeletal system. 

Adequate treatment will not only improve the quality of 

life of trauma victims but will very often be life saving. For 

instance, the lack of recognition of haemorrhage in pelvic 

fractures or severe fractures of long bones, are notorious 

pitfalls and do result in preventable deaths. The role of 

the trauma surgeon involves more than haemostatasis. 

The surgeon has to remove damaged tissues, to repair the 

injured soft tissues and to stabilize fractures. 

The reanimation period. 

During this period, decompression, or drainage, of body 

cavities (tension pneumothorax, cardiac tamponde) is 

necessary. Haemorrhage has to be localized and stopped. 

A typical example where surgical experience is 

prerequisite is in cases of complex pelvic injuries that 

still constitute common problems. Approximately 10 to 

20 % of pelvic fractures are complex injuries with a high 

likelihood of other major organ trauma or significant pelvic 

haemorrhage. Crush injuries and open pelvic fractures 

exhibit mortality rates in excess of 50% with a morbidity 

ranging from 30 to 74 %. These pelvic fractures are also 

very often associated with intra-abdominal injuries such 

as rupture of the bladder and the urethra, injuries of the 

rectum and the anus, neurological lesions and last but not 

least the pelvic compartment syndrome. Sometimes, an 

immediate urgent hemipelvectomy is the only procedure 

able to save lives. 

The primary stabilization period. 

During this period, injuries have to be treated that can 

become either life endangering or severely disabling 

without prompt treatment. In this period, the focus is on 

injuries of the musculoskeletal system especially those 

with severe soft tissue damage. 


“Early total trauma care” or “damage control” 

The most important decision now is the choice between 

the so-called “early total trauma care ”and“ damage 

control”. Until the mid-eighties delayed surgery, especially 

regarding the musculoskeletal system, was the rule in 

the polytrauma patient. The work of Bone and Bucholz 

however clearly demonstrated that delayed fixation of long 

bone fractures resulted in an increased risk of developing 

adult respiratory distress syndrome (ARDS) and multiple 

organ failure (MOF). To prevent ARDS and MOF it was 

advocated to perform early total trauma care. All injuries 

in a polytrauma patient were advised to be treated in the 

same operation. This dramatically reduced the occurrence 

of ARDS and MOSF. However in the borderline patient the 

prolonged surgery can result in profound hypothermia, 

acidosis and coagulopathy. This second (iatrogenic) hit can 

initiate the cascade of the systemic inflammatory response 

syndrome (SIRS) resulting in ARDS and MOSF. 

The experience of surgeons dealing with victims of 

shoot outs in the drugs war of Colombia or the American 

suburbs learned that if only minimal surgery was performed, 

stopping the bleeding, preventing further contamination 

and minimal lavage and debridement followed by prolonged 

resuscitation in the ICU, the likelihood of developing MOSF 

decreased significantly. They called this approach “the 

damage control approach”. 

The “damage control approach” initially was used in 

patients with multiple thoraco-abdominal shot wounds. 

However it became clear that many polytrauma patient 

could benefit from this approach. The basic principles 

“stop the bleeding and stop the contamination” nowadays 

are not only applicable for thoraco-abdominal lesions, but 

also in the treatment of vascular, urologic (shunting) and 

musculoskeletal. At the same time the approach did evolve 

from a “bail-out” procedure towards a planned and staged 

approach to the poytrauma patient. 

This choice has to be influenced by the situation of the 

patient after initial resuscitation. If the stabilization of the 

patient could be obtained easily, then the surgeon has to 

choose early total trauma care. If not, damage control has 

to be chosen. This control also has to be considered as a 

planned approach, which only has one goal: early surgical 

hemostasis and control of bacterial contamination. The socalled 

orthopaedic damage control may not be forgotten: 

debridement and lavage, revascularization, decompression 

of the compartments, stabilization of long bones, (usually 

by external fixation) and, if necessary, primary amputation. 

Prevention of infection. 

The most important step in prevention of infection is 

early lavage and debridement. “The solution to pollution is 

dilution”: initial lavage exposes wounds for inspection and 

facilitates debridement. As to the use of antibiotics: in open 

fractures with relatively limited soft tissue damage (Type I 

and II to Gustilo) , cephalosporin will be sufficient in a clean 

environment; in highly contaminated environment ampicillin 

will be added. In open factures with severe soft tissue 

damage (Gustilo Type III) a combination of Cephalosporin, 

ampicillin and aminoglycosides will be given. There is no 

advantage to use topical antibiotics or antiseptics. 

Stabilization of the fracture. 

After resucitation and debridement , the fracture will 

be stabilized. The stabilization will also improve the 

resistance to infection in facilitating capillary proliferation 

and migration of white blood cells. 

The choice of the implant depends on the soft tissue 

damage, the type of fracture, the infrastructure of the 

hospital and surgeon’s experience. 

External fixation 

In the “damage control” situation very often an external 

fixator will be chosen. Early joint motion and rehabilitation 

will then often be possible . The technique is relatively easy 

and rapidly applied, the stability is sufficient, a reasonable 

anatomical reduction is possible and there is minimal 

additional soft tissue trauma. On the other hand there are 

a lot of disadvantages: the procedure is time consuming 

in complex fractures with large wounds, the pins also 

fixate musculotendinous units, there is a high incidence 

of delayed union and pin tract infection. The device may 

also interferewith the soft tissue reconstruction . For these 

reasons the fixator is only used in cases of extreme soft 

tissue damage (Gustilo Type III b and c) or as a temporary 

stabilization before definitive internal fixation. Other 

indications are metaphyseal fractures near the joint space 

and if bridging of a joint is necessary. 

The fixator can also be used for lifting procedures in 

cases of large bone defects. 

Internal fixation. 

Historically, primary internal fixation for open fractures 

was considered a contraindication because of an increased 

risk of infection. However it has been shown that even 

reaming procedures are not associated with a higher 

infection risk. 

We now know that immediate internal fixation is NOT 

associated with a higher infection rate than external 

fixation even not in type I-II-III open fractures, if lavage and 

debridement have been thorough. Internal fixation is also 

associated with better final functional results. 

And in closed fractures? 

It has been proven that early stabilization of fractures of 

long bones, especially of the femoral shaft , in polytrauma 

patients saves lives. It improves the peripheral blood 


flow and reduces blood loss. However, severe shock and 

pulmonary contusion are contraindications for the use 

of reamed implants as reaming can activate the PMN 

Lymphocytes and create fat embolisms resulting in adjacent 

lung damage. 

Wound closure? 

Wounds may only be closed if they are very clean, if all 

tissues are viable, and there is no tension on the margins. 

If not or in case of doubt, wounds have to be left open. If 

possible, delayed closure may be performed within five 

days. Then the host is allowed to mount wound defensive 

mechanisms and risk of anaerobic infection is reduced. 

In case of impending compartment syndrome, the 

fasciotomy should not be overlooked. 

The regeneration and the rehabilitation period. 

During these periods, the interventions are focused on 

the improvement of the functional and aesthetical results; 

on the improvement of the quality of life. 

Definitive wound closure and reconstruction of the soft 

tissues will be done now as well as internal fixation of the 

fractures. If necessary delayed union will be treated with 

secondary fixation and bone grafting. 

Attention will be given to physical, psychological and 

social rehabilitation. 

Conclusions. 

In the 21st century the treatment of complex fractures 

with soft tissue lesions is much improved. There are 

much better implants and better antibiotics but last but 

not least, there is an integrated approach to care by a 

multidisciplinary team. 



Resident Forum 


16.30 – 19.00

Effects of humeral rotational osteotomy on contact 

mechanism of the canine elbow joint: an ex vivo 

study. 

Gutbrod A, Guerrero TG* 

Department of Small Animal Surgery, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland. 

Introduction 

The purpose of this study was to evaluate the effect of 

an external rotational osteotomy of the humerus on the 

forces acting in the canine elbow joint. Our hypothesis 

was that external humeral rotation of 15° would shift the 

peak pressure location and the centre of pressure laterally. 

Materials and Methods 

Eight canine forelimbs were used. A pressure sensor 

was fixed in a subchondral osteotomy distal to the elbow 

joint, and each leg was mounted in the testing apparatus. 

Measurements were taken in a neutral position and after 

15° of external rotation. The distal humerus was rotated 

by a mid-diaphyseal humeral osteotomy and stabilized with 

an internal fixator. Contact area, peak and mean contact 

pressure, peak pressure location, centre of pressure, and 

total force were acquired. Data was analyzed using paired 

T-tests. Significance was set at p≤0.05. 

Results 

After 15° of external rotation the peak pressure location 

and the centre of pressure were located 37.56 ± 15.9% 

(p=0.0001) and 21.5 ± 6.8% (p=0.0001) further laterally. 

No statistically significant differences were found between 

conditions for the contact area, peak contact pressure, 

mean pressure, and total force. 

Discussion 

The lateral shift of peak pressure and centre of pressure 

may be beneficial in dogs with medial compartment disease 

of the elbow joint. Being an ex-vivo study, care must be 

taken before extrapolating these results to a population of 

affected patients. Further studies are needed to evaluate 

the clinical effects of this osteotomy. 

ECVS proceedings 2011 35 small animal session

Prospective clinical study of enterectomy with skin 

staplers in 9 dogs and 9 cats 

M.Benlloch-Gonzalez, B.Bouvy*, E.Gomes, J.Hernandez, C.Poncet*. 

Centre Hospitalier Vétérinaire Frégis, Arcueil, France. 

Introduction 

our purpose was to conduct a prospective study to 

report the use of skin staples for intestinal anastomosis 

(as described in experimental animals by Coolman) in dogs 

and cats clinically affected with intestinal disorder to (1) 

evaluate the adaptability of the anastomotic technique 

in cats and dogs of any weight, (2) identify the type and 

frequency of operative and postoperative complications 

associated with the skin stapler technique. 

Materials and methods 

The prospective medical records included: -Preoperative 

data: signalment, history, clinical signs, physical findings, 

chemistry profile, complete blood count and abdominal 

ultrasound findings. -Intraoperative data: site and length 

of resection in the gastrointestinal tract, time to perform 

the anastomosis, number of staples used, presence of 

focal or generalized peritonitis, reasons for enterectomy 

and concurrent procedures performed. -Postoperative data: 

abdominal ultrasound examination at 3, 15 and 28 days 

postoperatively, patient follow up at 3, 6 and 12 months 

postoperatively, histopathology reports and complications 

(minor, major, short-term and long-term data). 

Results 

9 dogs and 9 cats met the inclusion criteria. Median 

body weight was 3.9 kg (range 2.8–5.7 kg) in cats and 

19.4 kg (range 6-39 kg) in dogs. Median time to perform 

the anastomosis was 4 min 22 s (range, 1 min 30 s – 7 

min 44 s). Minor complications (emesis [2], diarrhoea [1], 

anorexia [1] and hypovolaemic shock [1]) resolved with 

medical therapy and dietary manipulation. Two dogs and 

two cats died between 1 and 3 days after surgery. Necropsy 

in these cases revealed a partial obstructive ileus due to 

a stricture at the anastomotic site in the two cats and a 

partial dehiscence in one of them. Both cats had a marked 

luminal disparity oral and aboral to the site of resection 

at the moment of surgery. Increased wall thickness and 

steatitis persisted in all cases at the 28 th day ultrasound 

examination. 

Discussion/conclusion 

Too thin or too thick an intestinal wall thickness was 

not a limitation for the use of skin staples. Incidence of 

complications in this study (strictured anastomosis [11.1%] 

and dehiscence [5.5%]) was similar compared to data from 

published clinical studies (0-16%). The findings of this 

study suggest that bowel anastomosis with skin stapler 

is simple, safe in cases without marked luminal disparity 

and time efficient. 

small animal session 36 ECVS proceedings 2011

Effect of three an aesthetic induction protocols on 

laryngeal function during laryngoscopy in normal cat 

Nelissen P., Aprea F., Corletto F., White RAS*. 

Dick White Referrals, Six Mile Bottom, UK 

Objectives: 

To evaluate the effect of 3 anaesthetic induction 

protocols on laryngeal motion in normal cats. 

Study design 

Randomized prospective clinical study. 


Thirty-five client-owned cats with no previous history 

of respiratory dysfunction were randomly allocated to 

receive alfaxalone, propofol, or midazolam and ketamine 

to induce anaesthesia, after preanaesthetic medication 

with methadone. Video-laryngoscopy was performed 

and still images at maximum inspiration and expiration 

were used to measure the area and height of the rima 

glottidis. The percentage reduction of the glottic gap 

and of the normalized glottic gap area (NGGA) were 

calculated. Subjective scores for arytenoid movement 

were also obtained. Kruskal-Wallis test and ANOVA were 

used to compare reduction of normalized and percentage 

area. Pearson r-test was used to evaluate the correlation 

between subjective scores and objective measures of 

movement and between normalized and non-normalized 

area reduction. 

Results 

Reduction in glottis area and NGGA was greater in 

patients anaesthetized with midazolam and ketamine, 

compared to propofol and alfaxalone (p=0.0235 and 

p=0.0268 respectively). Significant correlations were found 

between the subjective score and percent reduction of 

area (p=0.0173), the subjective score and the reduction in 

NGGA (p=0.0023) and between percent reduction of area 

and reduction in NGGA (p=0.0006). 

Conclusions 

Induction of anaesthesia with midazolam and ketamine 

after preanaesthetic medication with methadone preserved 

arytenoid movement better during laryngoscopy. Subjective 

expert assessment supported this finding. 

Clinical relevance 

Misdiagnosis of laryngeal paralysis during laryngoscopy 

in cats can be avoided by using anaesthetic protocols with 

the least effect on laryngeal motility. 


Tympanic bulla osteotomy via oral approach in the 

dog: A descriptive cadaveric study. 

Vallefuoco R, Jardel N, Tessier A, Moissonnier P. 

ECVS Ecole Nationale Veterinaire d’Alfort, France. 

Objective 

To assess the feasibility of the oral tympanic bulla 

osteotomy and to evaluate the safety in safeguarding the 

inner ear, epitympanic recess, and neurovascular structures. 

Study Design 

Anatomic cadaveric study. 

Sample Population 

Nine fresh canine cadavers (tympanic bulla, n=17), 

different in size and skull conformation (mesocephalic, 

dolicocephalic and brachycephalic dogs). 


Cadavers were positioned in dorsal recumbency with 

the mouth open. The ventral/oral aspect of tympanic bulla 

was located through the oropharynx by palpation. An oral 

approach to the tympanic bulla was performed under 

endoscopic assistance, and a K-wire (1.5-2 mm in diameter) 

was inserted into the bulla with a maximum angle of 15° 

relative to the plane of the hard palate. The wire was then 

introduced as deep as possible in the tympanic bulla. After 

anatomical dissection, the wire’s position in the middle 

ear and its relationship to the inner ear and neurovascular 

structures were evaluated. 

Results 

In all cases, the wire was placed safely into the most 

ventral aspect of tympanic bulla and without damaging 

the epitympanic recess. In none of the cases were the 

promontory and auditory ossicles damaged. No injury to 

the carotid artery and/or hypoglossal nerve was noted. In 

mesocephalic and dolicocephalic dogs, the oral approach 

to the tympanic bulla was easier than in brachycephalic 

dogs in which the tympanic bulla was less prominent and 

covered by a more significant oro-buccal musculature. 

Discussion/Conclusions 

Bulla osteotomy via an oral approach can be performed 

without a high risk of neurovascular damage and without 

damage to the promontory and auditory ossicles. Due to 

the narrow access to the bulla, this technique could be 

considered for bacteriological and histological sampling 

from middle ear, flushing the bulla, infusion of medication 

or drainage of the tympanic cavity in cases of otitis media. 

Future studies are required to validate the effectiveness 

and usefulness of this technique in clinical cases. 


Nephroliths and video-assisted nephrotomy in 8 

cases 

Buttin P., Cachon T.*, Carozzo C*., Maitre P., Arnault A., Fau D., Genevois JP., Viguier E*. 

VetAgro-Sup Campus Vétérinaire de Lyon , France 

Introduction 

Renal and ureteral calculi are unusual clinical findings. 

Nevertheless, a recent increase in frequency has 

been observed. Medical treatment has limitations and 

nephrotomy (particularly bilateral) could have severe 

complications. 

Objectives 

The purpose of this study is to report removal of 

ureteral and renal calculi by a video-assisted nephrotomy 

(nephroscopy). 

Material and methods 

Prospective study of 3 dogs and 5 cats that presented 

with renal and/or ureteral calculi and were treated by 

removal of calculi by nephroscopy. Medical records were 

reviewed. Recorded information included breed, age, sex, 

clinical signs, complete blood analysis, RX, US, surgical 

findings and outcome. 

Results 

Eight animals were surgically treated from June 2008 

to October 2010. All animals were in a critical status 

and had renoliths with 3 affected bilaterally (1 dog, 2 

cats). Three animals had hydronephrosis and 2 had renal 

fibrosis. Nephroscopy was performed in all animals with 

3 bilateral procedures during the same anaesthesia. All 

animals but case 1had also a cystotomy. One pyelolithotomy 

had to be performed in case 2. One bilateral ureterotomy 

had to be performed. In all cases SCr and BUN levels, 

postoperatively and at follow-up showed a decrease or 

at least no worsening of the values. Four animals died of 

other complications. 

Discussion 

In all the cases, apart from one, nephroscopy allowed 

removal of renal and/or ureteral calculi with few 

complications directly related to the procedure. A 

bilateral procedure was performed in 3 cases, without 

adverse effect. Nevertheless, when severe renal function 

impairment is observed preoperatively, the prognosis is 

guarded. Nephroscopy may have several advantages over 

nephrotomy and/or ureterotomy. 


Intraoperative contamination of the suction tip in 

clean orthopaedic surgeries in dogs and cats 

Medl N 1 , Guerrero TG* 1 , Hölzle L 2 , Montavon PM 1 

1 Small Animal Clinic, Vetsuisse Faculty University of Zurich, Zurich, Switzerland. 2 Institute for Veterinary 

Bacteriology, Vetsuisse Faculty University of Zurich, Zurich, Switzerland 

Introduction 

The objectives of this study were to determine the 

frequency of contamination of the suction tip in three 

different operating modes, to assess the association of 

contamination with time, and to describe of the bacteria 

found. The hypotheses were (a) continuous suction would 

be inferior to the intermittent mode, (b) a chlorhexidine 

bath would further decrease contamination rates, and (c) 

the contamination rate would increase with prolonged 

surgical time. 

Material and Methods 

Clean surgeries (n=75) were assigned to one of three 

groups: (1) continuous suction, (2) intermittent suction or 

(3) chlorhexidine-bath intermittent suction. Samples of the 

suction tip were taken and submitted for bacterial culture 

at 0, 20, 60 minutes and at the end of surgery. A control 

suction was operated in every surgery. Samples were taken 

at the end of surgery simultaneously with a swab from the 

surgical wound. A Fisher´s exact test was used to analyze 

data. P ≤ 0.05 was considered significant. 

Results 

Aerobic contamination rate of the suction tip was 

45.3%, with significantly higher contamination rates 

for the continuous suction group (64%) compared to the 

intermittent group (24%, P=0.03). The chlorhexidine-bath 

was not proven superior. Wound contamination ranged from 

4% to 8%. The organisms cultured were identical to those 

found in the positive suction tips during the same surgery. 

In surgeries lasting longer than 60 minutes contamination 

rates doubled. Bacterial culture mainly revealed coagulasenegative 

Staphylococci. 

Conclusions 

Intermittent suction was superior to continuous suction. 

Changing the suction tip appears advisable at 60 minutes. 

Cultures revealed bacteria that are associated with the 

normal air and skin flora. 


Short- and long-term outcomes in young large breed 

dogs with medial compartment disease of the elbow 

N. Barthélémy¹, D. Griffon* ² , G. Ragetly², I. Carrera², D. Schaeffer² 

¹ Michigan State University,East Lansing,USA;² University of Illinois, Champaign,USA 

Objectives 

Prospective observational clinical study to report the 

short- (six weeks) and long-term (28 months) outcomes in 

young large breed dogs affected by medial compartment 

disease of the elbow and identify variables affecting the 

outcome. 


Fifteen large breed dogs under three years of age 

were included in the study. Medial compartment disease 

was confirmed by radiography, computed tomography, 

and arthroscopy. Dogs were treated arthroscopically by 

fragment excision or subtotal coronoidectomy, with or 

without a proximal ulnar osteotomy. Parameters recorded 

at the time of treatment included the type of medial 

coronoid disease, radio-ulnar incongruency, degree of 

cartilage erosion and surgical treatment performed. 

Parameters recorded before, 6 weeks after and at least 

23 months after surgery included the radiographic score 

of osteoarthritis (OA) and trochlear notch sclerosis ratio 

(TNS), muscle circumference, range of motion (ROM) and 

the load distribution of the vertical ground reaction forces 

between thoracic and pelvic limbs. 

Results 

The ROM and the OA were inversely correlated at 

the time of diagnosis. Dogs diagnosed with radio-ulnar 

incongruency had a higher load distribution to the pelvic 

limbs at the pre-operative evaluation. No difference in final 

outcome was observed between surgical treatments. The 

load distributions were not different at six weeks compared 

to pre-operatively but the vertical impulse distributions 

were improved at the long-term evaluation despite a 

decreased ROM and an increased OA score. Radio-ulnar 

incongruency or a high degree of cartilage erosion was 

associated with a greater improvement at the short- and 

long-term evaluations. The TNS correlated with the degree 

of cartilage erosion at the time of surgery. 

Conclusion 

Limb function was improved at the long-term follow up 

but not at six weeks after surgery. The final outcome was 

not affected by the presence of radio-ulnar incongruency, 

the surgical technique, the OA score or the degree of 

cartilage erosion. Dogs with radio-ulnar incongruency 

were more lame pre-operatively but their improvement 

was greater post-operatively. 


Comparison of 4.0 mm partially-threaded cannulated 

screws and 4.0 mm partially-threaded screws in a 

canine humeral condylar fracture model 

Rochereau P. 1 , Diop A. 2 , Maurel N. 2 , Gomez Clemente R. 2 , Gabanou P.A .3 , Bernardé A.* 1 . 

CHVSM, Saint- Martin Bellevue 1 (France). ENSAM, Laboratoire de Biomécanique et Remodelage Osseux, 

Paris (France) 2 . Synthes (France) 3 

Introduction 

The objective of this biomechanical study was to 

compare the inter-fragmentary stability of a condylar 

fracture model stabilized either with an AO 4.0 mm shortthreaded 

cancellous bone screw (Synthes) or with a 4.0 

mm self-drilling, self-tapping short-threaded cannulated 

screw (Synthes), inserted in a lag fashion. 

Materials & methods 

Ten pairs of canine humeri were harvested from dogs 

weighting 35kg to 45 kg. A lateral condylar fracture model 

was performed as previously described by Vida et al 

(2005). The fracture was stabilized using either a 4.0 mm 

cancellous screw or a 4.0 mm cannulated screw. Humeri 

were placed in a mechanical testing machine (INSTRON. 

5565). Stability of the simulated humeral fracture was 

assessed by loading the lateral condylar fragment in a 

proximal direction. Each construct was tested in a single 

ramp of constant load application at 60 mm/min until 

contact between the two margins of the gap occurs 

or until failure. Anatomic reduction, inter-fragmentary 

compression, stiffness, yield point (Y1), ultimate load at 

failure (Y2) of the bone-implant constructs and implant 

breakage, if any, were recorded. Physiologic loads at walk 

(60.1% body weight) and fast trot (131% body weight) were 

calculated. The corresponding displacement was assessed 

for both implants. 

Results 

Load at Y1 was 23.6% higher but not statistically 

different (P=.06) for the cancellous bone screws compared 

to the cannulated screws (738 ± 178 N vs 597 ± 133N, 

respectively). At Y1, the stiffness of the cancellous 

screw-bone construct (557 ± 148N/mm) was similar and 

not statistically different (P>.05) from the stiffness of the 

cannulated screw-bone construct (559 ± 142N/mm). At 

physiologic loads, no statistically significant differences 

were observed between the two implants (P>.05). Ultimate 

load at failure (Y2) was significantly higher (P= .01) for 

the cancellous bone screws compared to the cannulated 

screws (1261 ± 261N vs 1078 ± 231N, respectively). Three 

cannulated screws broke at the threaded:non-threaded 

junction during mechanical testing. None of the cancellous 

bone screws broke during the tests. 

Discussion 

At physiologic loads, stabilization of a simulated 

lateral humeral condylar fracture with a 4.0 mm partiallyshort-threaded 

cannulated screw resulted in comparable 

mechanical properties to those of a 4.0 mm cancellous 

partially-threaded screw. We chose 2 implants with 

minimal dimensional differences. At Y1, our results may 

indicate that the slight increase of the core diameter of 

the cannulated screw may balance the potential decrease 

of its mechanical properties due to the cannulation. The 

ultimate load at failure was statistically higher for the 

cancellous screws compared to the cannulated screws 

(P=.01). At Y2, three cannulated screws broke at the nonthreaded/threaded 

junction. This area may represent a zone 

of weakness because of the decrease of the shaft-to-core 

diameter. We choose self-drilling, self-tapping cannulated 

screws because their use may limit the number of the 

surgical steps, and can be less technically demanding 

and time consuming. However, we could not respect the 

insertion procedure recommended by Synthes as the 

distal threads could not engage the trans-cortex. Further 

studies are needed to refine the procedure of insertion of 

cannulated screws in the canine humeral condyle. 


A retrospective study of tibial plateau translation 

following tibial plateau levelling osteotomy 

stabilisation using three different TPLO plates 

Woodbridge N 3 , Corr S.A. 2 , Grierson J 1 , Arthurs G 1 . 

1 The Royal Veterinary College, Hertfordshire, England. School of Veterinary Medicine and Science, University 

of Nottingham, England. Dick White Referrals, Suffolk, England 

Introduction 

The objective of this study was to evaluate retrospectively 

medial to lateral translation of the proximal tibial segment 

(tibial plateau) following tibial plateau levelling osteotomy 

(TPLO), stabilised with three types of plate. 

Method 

Postoperative radiographs of 79 dogs that had TPLO 

surgery, at The Royal Veterinary College London, using 

3 different types of plates were reviewed. Two plate 

types incorporated non locking screws: Slocum (22 

cases) and Orthomed Delta (33 cases) plates and one 

plate incorporating locking screws; Synthes TPLO Locking 

Compression Plate LCP (24 cases). The radiographs were 

reviewed by three Diplomate surgeons who were blinded 

to the type of implant used. Medial or lateral translation of 

the proximal tibial plateau relative to the tibial diaphysis 

was assessed and measured at the lateral tibial cortex at 

the osteotomy site. 

Results 

Mean (+/-SD) lateral translation of the tibial plateau 

was significantly greater when using the Synthes TPLO 

LCP with locking screws (+2.06mm+/-1.79) compared to 

the non locking Slocum plate (0.37mm+/-0.96mm) or the 

Orthomed Delta plate (0.02 mm+/-1.06). 

Conclusion 

Lateral translation of the tibial plateau segment may 

occur when using the Synthes TPLO LCP during TPLO 

surgery. “Clinical significance: The use of the Synthes TPLO 

LCP will maintain a malalignment of the tibial plateau. 

Accurate alignment of the tibial plateau must be ensured 

prior to application of the Synthes TPLO LCP.” 


Distribution and persistence of topical clotrimazole 

for canine sino-nasal aspergillosis. 

G. M. Hayes and J. L. Demetriou*. 

Queen’s Veterinary School Hospital, University of Cambridge, UK. 

Introduction 

Sino-nasal aspergillosis is a common cause of chronic 

rhinitis in the dog. It is frequently treated by trephination of 

the lateral compartment of the frontal sinuses and irrigation 

with clotrimazole 1% solution before adding a depot 

preparation of clotrimazole 1% cream. The aim of this study 

was to determine the persistence of clotrimazole cream in 

the canine frontal sinus and to assess the distribution of 

clotrimazole solution over the sino-nasal mucosa using this 

treatment protocol. 


Two canine skulls were used to monitor the persistence 

of clotrimazole cream in the lateral compartment of the 

frontal sinus at 37ºC. Six canine cadaver heads were used 

to determine the distribution of clotrimazole solution around 

the frontal sinuses and nasal cavity by adding methylene 

blue stain to the irrigation solution before sectioning the 

heads sagittally. 

Results 

Clotrimazole cream persisted in the frontal sinus for a 

minimum of 96 hours. The nasal mucosa was completely 

stained in 8/12 sides and almost completely (>80%) stained 

in the remaining 4/12 sides. Flushing through the lateral 

compartment of the frontal sinus resulted in inadequate 

staining of the rostral compartment but medicating both 

the lateral and rostral compartments resulted in complete 

coating of all frontal sinus mucosa in 8/8 sides. Additional 

bony septae were present in 2/12 lateral frontal sinuses 

and 1/12 had a congenital foramen between the lateral 

compartment of the frontal sinus and the cranial cavity. 

Conclusions and Clinical Significance 

Clotrimazole cream has the potential to be retained in 

the frontal sinus for several days. The treatment protocol 

is effective at distributing medication to the entire nasal 

cavity although the success rate of the procedure could 

potentially be improved by medicating both rostral and 

lateral compartments of the frontal sinus. Variable frontal 

sinus anatomy may influence the safety and efficacy of 

topical treatments. 






Friday July 8 



A retrospective study of complications following 

modified triple tibial osteotomy for cranial cruciate 

deficient stifles in dogs: 72 cases (2008-2010) 

Bernardé A., Rochereau P., Spengler E. 

CHVSM, Saint-Martin Bellevue (France). 

Objective 

To describe the surgical technique, outcome and 

complications following modified triple tibial osteotomy 

(mTTO) for treatment of cranial cruciate ligament (CrCL)deficient 

stifle joints in dogs. 

Study Design 

Retrospective clinical study of 66 dogs with CrCL-deficient 

stifles (n=72). 

Methods 

Medical records of dogs that had mTTO over a 3 years period 

were reviewed. TTO was modified by caudal completion of 

the transverse osteotomies in order to deliberately rupture 

the caudal tibial cortices and to favorize the tibial plateau 

(TP) rotation. TP was fixed in compression using a standard 

unlocked TTO plate or a locking TPLO plate. Whenever 

possible, distal tibial tuberosity fracture (DTTF) was avoided 

and the tibial cortices at the distalmost cut of the tuberosity 

was keep intact. When it inadvertently fractured, the 

tuberosity was stabilized with 2 screws, or 1 screw and 1 

pin. Complications were recorded and separated into either 

major or minor complications based on the need for additional 

surgery. In-hospital re-evaluation of limb function and time to 

radiographic healing were reviewed. Further follow-up was 

obtained by telephone interview of owners. Influence of DTTF, 

opposite stifle status, TP plating mode, or DTTF fixation if 

any were analyzed using multivariate discriminating analysis 

(significance at p≤.05). 

Results 

Medical records of 66 dogs that had 72 mTTO were 

reviewed. Six dogs had bilateral mTTO, 1 in the same time, 

5 at 8±2.3 months interval. Sixteen had an extracapsular 

stabilization on the opposite side 11±5 months earlier. Mean 

age was 5 ±2.3 yrs, mean weight was 43±7.8 Kg and 

male/female ratio was 74% at surgery. DTTF occurred 

in 23 of 72 (31.9%) mTTO. Complications occurred 

in 11 on 72 (15.2%) procedures (6.9% major, 8.3% 

minor). All occurred within the 6 postoperative weeks. 

Major complications included plate loosening and 

subsequent tibial fracture (n=1), and tibial tuberosity 

fixation loosening (n=4). Minor complications included 

seroma formation (n=2), and incisional trauma (n=4). 

All but one major complications were treated with 

successful outcomes. All minor complications resolved. 

The mean time to documented radiographic healing 

was 12.2 weeks. Final in-hospital re-evaluation of limb 

function (mean, 13.2 weeks) was recorded for 56 dogs, 

showing no (65%), mild (31%), moderate (4%), or severe 

(0%) lameness. All but 1 owners interviewed were 

satisfied with outcome and 88.7% reported a marked 

improvement or a return to pre-injury status. DTTF and 

bilateral procedures were associated with a higher risk 

of major complications after mTTO. Short length of the 

proximal screw into the tibial tuberosity was associated 

with a higher risk of complications after DTTF. 

Conclusions 

mTTO is a procedure comparable with alternate 

methods of CrCL repair with expected good to excellent 

functional outcome. Major complications, although 

uncommon, are related to DTTF especially when 

repaired with an insufficient proximal screw purchase 

and to bilateral procedures. 

Clinical Relevance 

mTTO procedure can be successfully used to obtain 

the dynamic stability of a CrCL-deficient stifle joint in 

dogs. 


Considerations on the pathophysiology of canine 

condylar fractures by finite element analysis 

B. Böhme 1 , V. d’Otreppe 2 , J.P. Ponthot 2 and M. Balligand 

1 Kleintierklinik Bremen, Bremen, Germany; 2 Aerospace and Mechanical Department- University of Liège, 

Belgium, 3 Department of Clinical Science, University of Liège, Belgium. 

Condylar humeral fractures are classified as medial, 

lateral or bicondylar (Y-T) fractures and are believed to be 

associated with minor, indirect trauma, predominantly in 

immature dogs. It is believed that these fractures occur in 

extension of the elbow by proximal translation of the radius. 

The objective of this three-dimensional finite element 

analysis was to confirm the pathogenesis of condylar 

fractures, to determine the influence of bone positioning 

on fracture type and to evaluate the intraosseus stress 

distribution before fracturing. 

Based on computer tomographic scans (n=6; two right 

forelimbs, Beagle, 4 months of age, male, 7-7,5 kg, scans 

in -10°,0° and +10° of endo-/exorotation; 1mm sections) 

finite element analysis was performed (n=3) to create a 

three-dimensional model of the canine elbow. Bone contact, 

stress-strain distribution within the distal humerus before 

fracture and failure mode as highest intraosseus stress 

distribution were reported in 60°, 130° and 150° of flexion- 

extension angle (FEA), abduction- adduction angle (AbAdA) 

of -20°, 0° and +20° and in -10°, 0° and +10° of radioulnar 

endo-/exorotation (RA). 

In contrast to the hypothesis that the radial bone would 

be the interacting structure, the humeroulnar interaction 

is clearly dominant, less often radius and ulna are both 

interacting. Abduction/ Adduction of the elbow at the time 

of trauma seem to be an important influence on fracture 

type. Endo- and exorotation of the radioulnar bones 

additionally influences the stress-strain distribution within 

the distal humerus. 

Condylar fracture pathogenesis is more complex than 

described in the literature. They may not only occur in 

elbow extension as previously reported. The ulna may 

even play a more important role in condylar fracture 

pathogenesis then the radius. Additionally fracture type 

may be sensitive to bone positioning during trauma. The 

suspected fracture type is sensitive to abduction-adduction 

as well as radioulnar endo-/exorotation. 


Zygomatic salivary gland diseases in the dog: three 

representative cases. 

Boland L, Gomes E, Payen G, Bouvy B*, Poncet C* 

CHV Frégis, Arcueil, France 

Introduction 

Zygomatic salivary gland disease is uncommon in dogs, 

and to our knowledge, as few as 17 cases have been 

previously reported. The purpose of this report was to 

describe three additional cases of zygomatic gland diseases 

using the same diagnostic approach and treated with the 

same surgical management. 

Animals 

Three dogs : a 3-month-old male Basset Hound, a 

10-year-old male Staffordshire Terrier, and a 14-year-old 

female dalmatian. 

Methods 

Salivary gland disease were diagnosed by fine-needle 

aspiration and magnetic resonance imaging in dogs. They 

were treated surgically by a modified lateral orbitotomy and 

zygomatic glands were submit on histologic examination. 

Results 

Pathologic diagnosis were a sialocele, a malignant 

mixed salivary tumor, and a sialadenitis. The outcome 

was favourable in two cases whereas recurrence of local 

disease wartranted euthanasia 3 months following surgery 

in the neoplasctic case. 


Less of 20 cases cases of zygomatic gland diseases 

have been reported in litterature, and this paper described 

3 aditionnal cases : a sialocele, a neoplasia, and a 

sialadenitis. In our three cases, diagnosis of zygomatic 

gland disease was made with MRI and we considered MRI 

as the most valuable complementary exam to diagnose the 

zygomatic gland diseases. MRI produced detailed images 

of orbital tissues and provided more information about the 

extent of pathology than the other imaging techniques, 

giving a greater chance to make a correct diagnosis and 

allowing appropriate selection of surgical approach. The 

modified lateral surgical technique was elected because 

this approach provided an optimal exposure, with 

preservation of the palpebral nerve. 


True spherical dome osteotomy using a novel 

blade design in a dog with an antebrachial growth 

deformity – planning and execution of technique 

N. Fitzpatrick, C. Nikolaou 1 , K. Ash 1 , V. Wavreille 1 , Z. Szanto 2 

1 Fitzpatrick Referrals, Surrey, UK, 2 Twin Falls Veterinary Clinic, Avenue East. Twin Falls, Idaho, USA 

Introduction 

Dome osteotomies in literature to date have constituted 

cylindrical or crescentic cuts. We aimed to describe the 

application of a new dome blade design and trigonometric 

principles for execution of true spherical osteotomy (TSO) 

in antebrachial growth deformities. 


A dome blade was used to create osteotomies in plastic 

bone models, the surfaces of which were laser-scanned 

and trigonometric calculations were applied to align the 

epicentre (O) of the blade with the midpoint of the model 

in frontal and sagittal planes (MPfs). Complex ABGD in 

a dog was assessed using CORA methodology applied to 

radiographic images and a 3D model reconstructed from 

CT scans. Trigonometric formulas for execution of a TSO 

were applied. 

Results 

Blade orientation prevented translation at the osteotomy 

site in frontal and sagittal planes after correction of 

torsion. Preoperative FPA radiographically was 13o valgus, 

whereas FPA on the 3D model was 0o. Postoperative FPA 

radiographically was 50 varus. 

Discussion/conclusions 

Discrepancy between true FPA and that measured 

radiographically was attributable to radiographic distortion 

due to rotation. The angulation correction axis (ACA) of 

a TSO is located at O and therefore separated from the 

osteotomy by the sphere radius. To avoid translation of the 

bone axes when a TSO is employed to correct a torsional 

deformity, the ACA should pass through the CORA on the 

midline of MPfs and not any of the CORAs on the bisector 

line of the deformity. This constitutes a new rule specifically 

pertinent to dome osteotomies. 


Total hip replacement with reiforced augmentation 

of the dorsal acetabular rim (radar) using the sop 

implant and bone cement in seven dogs with dorsal 

acetabular rim deficiency 

N. Fitzpatrick, M. Bielecki, R Yeadon*, M. Hamilton* 

Fitzpatrick Referrals, Halfway Lane, Eashing, Surrey, UK 

Introduction 

Our objective was to describe a surgical technique 

for reinforced augmentation of the dorsal acetabular 

rim (RADAR) using a SOP locking plate and 

polymethylmethacrylate (PMMA) bone cement, and to 

report clinical outcome in seven dogs. 

Methods 

Medical records of seven dogs with large dorsal 

acetabular rim deficits, undergoing total hip replacement 

(THR) with RADAR using a SOP plate and PMMA were 

evaluated retrospectively. RADAR involved anchorage of 

a pre-contoured 2.0 or 2.7 mm SOP plate dorsal to the 

acetabulum followed by application of PMMA cement 

to cover the pre-prepared acetabulum and the plate. 

Cemented acetabular components were used in all cases. 

Implant associated complications were recorded. Minimum 

six month follow-up was available for all cases. 

Results 

In all dogs lameness improved at medium-term 

reassessment (median 8 months, range 6-11 months). 

Complications included transient sciatic neuropraxia in 

2/7 dogs, but this resolved by 3 months postoperatively 

in both dogs. 

Conclusions 

RADAR using a SOP TM plate and PMMA cement is viable 

and may facilitate placement of acetabular THR component 

implantation in dogs with severe DAR insufficiency. All dogs 

returned to full function at medium-term reassessment. 

In dogs with a paucity of dorsal acetabular rim, RADAR 

using SOP/PMMA may facilitate cemented acetabular THR 

component implantation. 


Effects of antebrachial torsion on the measurement 

of frontal plane angulation: a cadaveric radiographic 

analysis 

Piras LA 1 , Peirone B 1 , Fox DB 2 

1 University of Turin, Italy. 2 University of Missouri, USA. 

Objectives 

The objectives of this study were to quantify the effect of 

antebrachial torsion on the miscalculation of radial valgus 

measured radiographically and to assess a radiographic 

positioning method used to mitigate torsion-associated 

artifactual miscalculation of concurrent frontal plane 

angulation of the antebrachium. 

Methods 

A canine cadaver forelimb was used to model different 

combinations of valgus and external torsion to study 

the effects of torsion on the radiographic calcaultion of 

concurrent frontal plane angulation. 

Results 

Both 0° and 15° torsional iterations possessed mean AV 

values between 0° and 5° for every valgus increment. With 

torsion of 30° and higher, mean AV values varied widely 

and did not fall within the 0°-5° accepted range except for 

three TV iterations of the 60° torsional group (valgus 20°, 

25° and 30°). Rotationally re-positioning the limb in an 

attempt to alleviate the AV discrepancies resulted in the 

30° torsional group having acceptable AV values for valgus 

values between 0°-20°, the 45° torsional group having 

acceptable AV values for TV values between 0°-15°, and 

the 60° torsional group having acceptable AV values for 

TV values between 0°-10°. 

Clinical Significance 

Increasing antebrachial torsion interferes with accurate 

radiographic measurement of frontal plane deformities. 

Specifically, torsion in excess of 15° results in radiographic 

artifacts greater than 5° such that accurate surgical 

planning appears unreliable. 


Latero-distal transposition of the tibial crest for 

patella alta and medial luxation 

Segal U., Shani J* 

Knowledge Farm Specialist‘s Referral Center, Beit Berl, Israel 

Medial patellar luxation is a medial displacement of the 

patella from the trochlear groove. In dogs, medial luxations 

account for 75% of all patellar luxation cases, and are 

frequently associated with patella alta, i.e., an abnormally 

high (proximal) position of the patella in the femoral groove. 

The common surgical treatment of medial luxation is 

osteotomy of the tibial crest and its lateral transposition. 

This is performed in order to correct the mechanical axis, 

to neutralize the force created by the medial component 

of the quadriceps muscle, and to place the patella in the 

correct anatomical alignment. Postoperative complications 

in dogs is estimated to be 18–29% of cases, with up to 

48% involving re-luxation. 

We hypothesized that, in cases of medial luxation 

involving patella alta, addition of a distal component to the 

tibial crest transposition will distally transpose the patella 

into the patellar groove thus reducing the recurrence rates 

of luxation. We performed the procedure on 12 dogs and 

our results reveal that latero-distal transposition of the 

tibial crest produced better clinical outcome. This improved 

surgical procedure is easily preformed and may become, in 

the future, standard treatment of medial patellar luxation 

with patella alta. 


Morphological comparison of the middle ear between 

French bulldogs and non-brachycephalic dogs. 

L.Souchu 1 , T. Chuzel 2 , C. Carozzo* 3 . 

1 Clinique des Perrières, Blois, France; 2 Voxcan, Marcy l’Etoile, France ; 3 Surgery unit, VetAgroSup, Campus 

vétérinaire, Marcy l’Etoile, France. 

The objective of this study was to compare normal and 

pathological morphology of the middle ear of the French 

Bulldog with normal morphology of non-brachycephalic 

dogs using computed tomography (CT). 

CT scans from French Bulldogs (FB) (n=34) with or without 

middle ear disease and non-brachycephalic dogs(NBD) 

(n=36) without middle ear disease were reviewed. Ratios 

between inter-jugular processes distance and height of the 

Epi+Mesotympanum (rHem) and external acoustic meatus 

(rHeam) , height(rHh), width(rWh) and length(rLh) of the 

hypotymanum, percentage of tympanic bulla (TB) protrusion 

from the skull (%Hin and %Hout) were calculated from 

2D view. Relative position of TB and temporo-mandibular 

joint (TMJ) were determined with surface rendering 3D 

reconstruction. Data were compared using paired-sample 

(independent) t-test with p

Stabilisation of periarticular fractures or osteotomies 

with an LCP notched head T-plate. 

C. J. Tan, K.A. Johnson*. 

University Veterinary Teaching Hospital, University of Sydney, Australia. 

Introduction 

Fractures or osteotomies involving a small periarticular 

bone fragment can prove challenging to stabilise. The 

purpose of this study was to describe the use of a locking 

compression plate (LCP) notched head T-plate in the 

stabilisation of a variety of peri-articular and articular 

fractures or osteotomies in small dogs and cats. 


Client owned animals that had a periarticular or articular 

fracture or osteotomy stabilised with a notched head 

locking T plate were reviewed. Intraoperative complications 

and plate modification (contouring or cutting) were 

recorded. The type and size of screws used was recorded. 

Radiographs were reviewed to assess implant position 

and, when available, follow up radiographs evaluated for 

degree on bone healing. 

Results 

An LCP notched head T-plate was used in one cat and four 

dogs, resulting in a total of 6 surgeries. The mean weight 

of the animals was 3.77 +/- 1.42 kg (range 2.37-5.8kg). Of 

the 6 surgical procedures, 3 were fractures and 3 were 

osteotomies. The median number of screws used was 6 

(range 5-7) and a combination of locking and cortex screws 

were used in all constructs. The plate was modified in all 

cases. Complications encountered during surgery involved 

the direction of the locking screws towards the articular 

surface. Radiographic union was achieved at 8 weeks in 

all 4 cases with follow up radiographs 

Conclusions 

This study reports the successful use of a locking 

notched head T plate in a variety of clinical cases. Further 

investigations into the application of this plate are 

warranted. 


Two cases of dogs with infiltrative lipomas of the 

thigh region. 

M. Verset 1 , T. Cachon* 2 , D. Rémy 2 , C. Carozzo* 2 . 

1 Ecole Nationale Vétérinaire de Toulouse, France, 2 VetAgroSup, Campus Vétérinaire de Lyon, France. 

Simple lipomas are the most common adipose tissue 

tumours, whereas infiltrative lipomas (IL) are rarely 

diagnosed. 

A 8-year-old male Labrador Retriever (LR) is presented 

for a swelling of the lateral side of the right thigh and a 

7-year-old male Beauceron for recurrence of a mass in 

the caudal region of the left thigh. A CT exam concludes 

to a lipoma or liposarcoma of the thigh with muscular 

invasion. Both tumours are resected after blunt and sharp 

dissection of the surrounding sound muscles. In the LR, 

an approach of the femoral diaphysis and distal femur 

by lateral incision allows tumour and infiltrated vastus 

lateralis muscle excision. In the Beauceron, approach of 

the caudal region of the femur by caudomedial incision 

allows tumour and infiltrated semimembranosus muscle 

resection. Two Redon’s drains are placed for continuous 

suctioning, before layered closure. 

Pathology is diagnostic of IL and surgical margins 

diagnosed as tumour-free. A CT check-up at 14 weeks 

post-op shows no images of tumoral recurrence. Both 

dogs are in good condition without any thigh swelling 36 

months post-op (Beauceron) and 33 months post-op (LR). 

IL cannot be distinguished from the more common 

simple lipomas by cytology or small biopsy specimens. 

Although considered benign, they are locally aggressive 

and commonly invade adjacent tissues. CT is used to better 

delineate these tumours but differentiation from normal fat 

is a problem. MRI is the gold standard exam for adipose 

tissue tumours in humans. Aggressive treatment, including 

amputation when local complete resection is impossible, 

may be necessary for local control. Complete excision of IL 

in the thigh region is often difficult because of the large size 

of the tumour, vascular or nervous structures entrapment, 

and indistinct margins. Dead space management after 

tumour excision is necessary. Complete excision may not 

be possible without interfering with normal limb function. 

Pathologic analysis of the tumour is essential for definitive 

diagnosis and analysis of surgical margins is crucial in so far 

as it influences prognosis and may lead to surgical revision. 

Handling of infiltrative lipomas, as far as diagnosis and 

resection are concerned, may be a real challenge. 


Owner based metrology instruments for conditions 

of canine chronic mobility impairment - contruct and 

criterion validity of LOAD, HCPI and CBPI 

Walton MB 1 , Innes JF 1 , Lascelles BDX* 2 

1 Univeristy of Liverpool, Neston, UK. 2 North Carolina State University, Raleigh, USA 

Background 

Owner-based questionnaires are frequently used in 

clinical studies to assess pain and function. This study 

tests further, and compares, psychometric properties of 

three promising instruments: Liverpool Osteoarthritis in 

Dogs (LOAD, the helsinki Chronic Pain Index (HCPI) and the 

Canine Brief Pain Inventory (CBPI). 

Methods 

Dogs with conditions causing long-standing mobility 

impairment were recruited. Following clinical and 

orthopaedic examination of the dogs, their owners were 

asked to complete each of the instruments. The dogs then 

underwent force-platform analysis. An asymmetry index 

for peak vertical force for the lame limb was calculated as 

described by Fanchon (2007). Scores for each instrument, 

and asymmetry indices were then compared using 

Spearma’s Rank Correlation. 

Results 

There were significant correlations between all 

metrology instruments, including all factors of the CBPI. 

Spearman’s Rank Correlations (r s ) between the separate 

instruments varied from 0.48 (for LOAD against CBPI Pain 

Severity Score) to 0.6 (for LOAD against HCPI). 

No instrument score correlated significantly with 

asymmetry index for peak vertical force, with r s ranging 

from 0.01 for HCPI, to -0.34 for the CBPI “Overall” factor. 

Conclusions 

The significant correlation between instrument scores 

suggests that they are all influenced by common factors. 

This comparison constitutes a measure of construct 

validity. Criterion validity of a metrology instrument is 

tested by comparison with a “gold-standard” measure. 

Force platform analysis provides an objective measure of 

limb function. The poor correlation of any instrument score 

with asymmetry index may either suugest poor criterion 

valdity, or that direct comparison of total scores with this 

objective measure is an imperfect test of this feature. 

Further work is necessary to elucidate the reasons for this 

lack of correlation. 




In depth – Infection control in surgical 

practice 




Surgical site infections: Incidence, relevance, risk 

factors and surveillance 


Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada 

Introduction 

Surgical site infections (SSIs) are an inherent risk of 

any surgical procedure. By their nature, surgeries involve 

compromising the normal protective barriers that the body 

uses to prevent infections by the multitude of bacteria that 

are present on or in the body, and which are encountered 

in daily life. The advancement of veterinary medicine can 

result in a paradoxical increase in SSIs, as more aggressive 

surgical procedures are performed and procedures are 

performed on patients who are alive because of aggressive 

medical interventions, but exist in a compromised state. 

Definitions 

Prior to detailed discussion of SSIs, it is important to 

achieve consensus, or at least understanding, or what 

constitutes an SSI. Standard definitions must be used to 

allow for reasonable comparison of data from different 

locations, and to facilitate proper identification of 

SSIs. Standard criteria are also needed to differentiate 

infection from inflammation, something that is not 

always straightforward. US Centers for Disease Control 

and Prevention (CDC) has developed standard criteria 

for defining SSIs. 1 These classify SSIs into superficial 

incisional, deep incisional and organ/space SSI. It is 

reasonable to apply these criteria equally to veterinary 

medicine and it is critical to use an objective definition 

when evaluating SSIs. For example, a superficial surgical 

site infection must meet the following criteria: 

infection occurs with 30 days of the operation 

and 

involves only the skin and subcutaneous issues 

of the incision 

and 

patient has at least one of the following: 

• purulent drainage from the superficial incision 

• organisms that are isolated from a properly 

collected culture of fluid or tissue from the 

superficial infection 

• at least one of the following signs of infection: pain 

or tenderness, localized swelling, redness or heat 

and superficial incision is deliberately opened by the 

surgeon, and is culture-positive or is not cultured 

Incidence if SSIs in companion animals 

Tremendous efforts are expended in human medicine to 

collect and analyse data regarding SSIs, ranging from local 

data collection in individual hospitals to formal national 

or international surveillance programs. Comparable 

surveillance systems are lacking in veterinary medicine. 

Various reasons for the relative lack of surveillance exist. 

The overall morbidity and mortality associated with SSIs 

in veterinary patients may be less than in human patients, 

particularly given the greater number of high-risk humans 

(e.g. elderly, significant comorbidies) that undergo surgery 

and the larger number of highly invasive procedures that 

are performed in human medicine. However, other factors 

may also be involved, particularly a poorly developed 

‘culture’ of infection control in veterinary medicine, smaller 

facilities that limit the scope of studies, and the presence 

of relatively few individuals with interest and expertise for 

performing epidemiological studies. 

Despite the limitations, various studies have reported 

SSI rates in veterinary surgery, including overall infection 

rates and rates for specific surgical procedures. These have 

indicated rates of 0 – 18%, 2-9 and assessment of overall 

SSI rates is hard to do because of the different risks of SSI 

that are likely associated with different types of procedures. 

Procedure-specific rates have been reported, such as 6.6% 

(defined SSI) to 8.4% (inflammation/infection) for TPLO. 

Inherent limitations with many of these studies include 

relatively small sample sizes, the lack of use of standard 

definitions, lack of clear attempts to differentiate infection 

from inflammation and reliance on retrospective data from 

medical records. The latter limitation may be significant 

because a large percentage of infections may never be 

documented. This is particularly true for superficial SSIs 

that are treated by someone other than the original surgeon, 

combined session 63 ECVS proceedings 2011 

4, 10

as communication between veterinary hospitals is not 

always optimal. 

Impact of SSIs 

While relatively uncommon (at least for most surgical 

procedures), SSIs can have significant impacts on patients, 

owners and veterinarians. Severe illness and death are 

obvious concerns, but non-fatal SSIs can have tremendous 

impacts because of the need for ongoing treatment, revision 

surgery and sub-optimal endpoint outcome. Some effects, 

such as patient morbidity, patient mortality and increased 

treatment costs, are readily quantifiable. Others, such 

as client frustration and grief, veterinary frustration, 

potential liability, and negative public perceptions may 

be very important but difficult to quantify. While the 

population impact of post-operative infections in veterinary 

medicine may be low because of the low incidence in most 

populations (in the absence of an outbreaks), severe or fatal 

infections that develop in a small number of patients can 

be economically and emotionally draining for clients and 

veterinarians, irrespective of their low incidence. Therefore, 

even if the incidence of SSIs in veterinary medicine is low, 

the impact can be disproportionately large. 

Trends in SSIs 

Inadequate data are available to provide objective 

information about changes in SSI rates. However, anecdotal 

information suggests that SSIs may be an increasing 

concern, particularly in elective orthopedic procedures, 

perhaps largely due to the emergence and dissemination 

of multidrug resistant opportunistic pathogens such as 

methicillin-resistant Staphylococcus pseudintermedius. 

Risk Factors 

Risk factors for a variety of surgical procedures have 

been extensively evaluated in human medicine and include 

patient (diabetes, nicotine use, obesity, immunosuppressive 

therapy, malnutrition, methicillin-resistant Staphylococcus 

aureus (MRSA) colonization, prolonged hospitalization), 

procedure (wound classification, surgeon operation 

volume), pre-operative (hair removal, patient skin 

preparation, surgical team hand/forearm preparation, 

antimicrobial prophylaxis), surgical (operating room 

environment, duration, surgical instrument management, 

surgical attire and drapes, surgical aseptic technique) 

and post-operative (incision care, antimicrobial therapy) 

factors.11-13 

Many of these risk factors are probably applicable to 

veterinary medicine, yet the relative importance of each 

is unknown as risk factor data in veterinary medicine are 

limited. Care must be taken to use human data for guidance, 

but not to over-interpret the relevance of human studies 

because of the marked differences in patient populations, 

operating environments, post-operative care, duration of 

hospitalization, incidence of comorbidities, and various 

other factors. Large, well-designed risk factor analyses are 

required for veterinary procedures, yet these are rare and 

are often difficult to perform because of the large samples 

sizes that are required and the need for prospective study 

and active identification of surgical site infections (rather 

than reliance on medical record data). 

Surgical classification (clean, clean/contaminated, 

contaminated, dirty) has been associated with SSIs in 

both general small animal surgery and equine orthopedic 

surgery, 3, 14 however one study questioned its usefulness 

in small animals. 2 Duration of surgery has also been 

associated with increased SSI rates in both horses and 

small animals, 2, 3, 14, 15 as has duration of anesthesia in dogs 

and cats. 15 Number of people present in the operating room 

was also significant in a large study of dogs and cats. 3 

Clipping before anesthetic induction was associated with 

a higher SSI rate in another. 2 The use of staples versus 

suture for skin closure was associated with increased 

risk of inflammation/infection in dogs undergoing surgery 

for cranial cruciate ligament rupture. 4 Other factors that 

have been associated with SSIs in small animals include 

presence of a drain, dog size (heavier dogs at higher risk), 

gender, increasing body weight, concurrent endocrinopathy 

and the use of propofol. 3, 10, 15, 16 Data regarding the role of 

2, 4, 10 

antimicrobials in SSI prevention have been mixed. 

SSI Surveillance 

General issues regarding surveillance are discussed 

in proceedings notes for a separate presentation. 

SSI surveillance requires consideration of the goal of 

surveillance, the type of data that are available, the type 

of data that can reasonably be collected and how results 

will be used. 

Monitoring surgical site infection (SSI) rates 

One of the more common areas where surveillance 

can provide benefits is the area of SSIs. This is a readily 

identifiable problem of significant importance in veterinary 

practices and, if extrapolation from human medicine is 

accurate, an area where surveillance and other infection 

control practices can have a significant impact. 

Two important pieces of information are needed for 

accurate SSI surveillance: 

1) Number of infections (numerator) 

This requires identification of all SSI cases. To do so, a 

standard definition must be used, as is discussed above. 

Standard criteria for identification and classification of SSIs 

have been developed for human medicine and these are 

applicable to veterinary patients. Because inflammation 

or suture reaction are more common than infection, 24 

differentiating infectious from non-infectious complications 

is critical to obtain an accurate estimate of SSI rates. 

Consistent use of standard definitions is required to obtain 

adequate data. 

As discussed above, a large percentage of SSIs do 

not become apparent until after the animal has been 

discharged and capturing those cases is important. 


Many will presumably be identified at the time of suture 

removal or when presented with a clinically apparent 

SSI, however, some may be missed if the patient is not 

returned to the surgeon, a particular problem with referral 

hospitals and emergency clinics. Recent data involving 

prospective, active follow-up of surgical cases in one 

referral institution indicate that approximately 50% of SSIs 

do not end up being reported in the medical record,(Weese 

et al, unpublished data) highlighting potential problems 

with retrospective, record-based data collection. Good 

communication between practices is important. A standard 

rule is that every SSI must be reported to someone. If a 

veterinarian identifies an SSI in a patient that underwent 

surgery elsewhere, this should be reported to the original 

surgeon. 

Reporting of SSI rates should be done in real time, to 

ensure that the data actually get recorded and to facilitate 

prompt recognition of problems. Ongoing centralized data 

collection is critical, particularly in large practices where 

early stages of an outbreak may be missed if multiple 

surgeons encounter small numbers of SSIs but fail to realize 

the scope of the problem because they do not report data to 

a specific individual or communicate amongst themselves. 

2) Number of procedures (denominator) 

The number of procedures performed is required for 

determination of SSI rate. This can be calculated as overall 

SSI rate, or, preferably, SSI rates for individual procedures. 

This is greatly facilitated by electronic medical record 

systems that easily provide information about the number 

of specific and total procedures for a given time period. 

This should be taken into consideration when evaluating 

medical record systems. 

Regular (e.g. monthly) monitoring of SSI rates allows for 

an understanding of the endemic rates, differences between 

procedures and any variations that may occur. Having 

a baseline rate is critical for investigation of suspected 

SSI outbreaks, since the expected rate must be known to 

determine if an outbreak is really present. Baseline rates 

are also important to know for assessing the potential 

impact of any changes in practices or policies. Individual 

surgeon rates can be calculated if there is a means of 

collecting surgeon-specific denominators, provided there 

is a plan to only report results to the individual surgeon 

and ensure confidentiality, as is discussed further below. 

Comparing infection rates 

omparison of infection rates within and between 

facilities can provide useful information but should be 

approached with caution because of potential limitations 

of data used for comparison and the potential implications. 

Confidentially reporting SSI rates back to surgeons 

can be part of an effective SSI program by driving an 

increased awareness of the issue and leading surgeons 

to evaluate potential weaknesses or improvements 

in their practices, but broader use of the data can be 

fraught with danger. Comparison of SSI rates between 

surgeons in a hospital could identify differences in rates 

between surgeons and a surgeon with a high infection 

rate could be using inadequate or high-risk practices that 

are leading to increased infections. However, it could 

also be a reflection of the types of surgeries performed, 

the degree of post-operative follow-up and diligence 

in reporting of SSIs. Surgeon-specific SSI rates should 

never be reported or released to anyone but the individual 

surgeon. Comparison of data between facilities can also 

provide useful information but is accompanied by similar 

concerns. If comparisons are to be made, it is essential 

that standard definitions and methods be used so that the 

data are comparable. In human medicine, inter-hospital 

comparisons can be useful in lowering infection risks if 

the data collected are clearly defined (e.g. SSIs associated 

with a specific surgical procedure) and analysis is controlled 

for variations in risk factors between populations. This 

specificity of analysis would not commonly be practical 

in routine veterinary surveillance programs, particularly 

in small hospitals performing limited numbers of specific 

procedures, so inter-hospital comparisons are unlikely to 

provide much usable information. 

References 

1. Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. 

CDC definitions of nosocomial surgical site infections, 

1992: a modification of CDC definitions of surgical 

wound infections. American journal of infection control. 

1992;20(5):271-274. 

2. Brown D, Conzemius M, Shofer F, Swann H. Epidemiologic 

evaluation of postoperative wound infections in dogs and 

cats. J Am Vet Med Assoc. 1997;210(9):1302-1306. 

3. Eugster S, Schawalder P, Gaschen F, Boerlin P. A prospective 

study of postoperative surgical site infections in dogs and 

cats. Veterinary surgery : VS : the official journal of the 

American College of Veterinary Surgeons. 2004;33(5):542- 

550. 

4. Frey TN, Hoelzler MG, Scavelli TD, Fulcher RP, Bastian 

RP. Risk factors for surgical site infection-inflammation in 

dogs undergoing surgery for rupture of the cranial cruciate 

ligament: 902 cases (2005-2006). Journal of the American 

Veterinary Medical Association. 2010;236(1):88-94. 

5. Lambrechts NE, Hurter K, Picard JA, Goldin JP, Thompson 

PN. A prospective comparison between stabilized 

glutaraldehyde and chlorhexidine gluconate for preoperative 

skin antisepsis in dogs. Veterinary surgery. 2004;33(6):636- 

643. 

6. Weese J, Halling K. Perioperative administration of 

antimicrobials associated with elective surgery for cranial 

cruciate ligament rupture in dogs: 83 cases (2003-2005). J 

Am Vet Med Assoc.2006;229(1):92-95. 

7. Vasseur PB, Paul HA, Enos LR, Hirsh DC. Infection 

rates in clean surgical procedures: a comparison of 

ampicillin prophylaxis vs a placebo. J Am Vet Med Assoc. 

1985;187(8):825-827. 

8. Vasseur PB, Levy J, Dowd E, Eliot J. Surgical wound 

infection rates in dogs and cats. Data from a teaching 

hospital. Veterinary surgery 1988;17(2):60-64. 

9. Casale SA, McCarthy RJ. Complications associated 

with lateral fabellotibial suture surgery for cranial 

cruciate ligament injury in dogs: 363 cases (1997-2005). 


Journal of the American Veterinary Medical Association. 

2009;234(2):229-235. 

10. Fitzpatrick N, Solano MA. Predictive variables for 

complications after TPLO with stifle inspection by 

arthrotomy in 1000 consecutive dogs. Veterinary surgery 

2010;39(4):460-474. 

11. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis 

WR, The Hospital Infection Control Practices Advisory 

Committee. Guidelines for prevention of surgical 

site infection, 1999. Infect Control Hosp Epidemiol. 

1999;20(4):247-278. 

12. Barie PS, Eachempati SR. Surgical site infections. Surg Clin 

N Am. 2005;85:1115-1135. 

13. Muilwijk J, van den Hof S, Wille JC. Associations between 

surgical site infection risk and hospital operation volume 

and surgeon operation volume among hospitals in the Dutch 

nosocomial infection surveillance network. Infection control 

and hospital epidemiology 2007;28(5):557-563. 

14. MacDonald DG, Morley PS, Bailey JV, Barber SM, Fretz 

PB. An examination of the occurrence of surgical wound 

infection following equine orthopaedic surgery (1981-1990). 

Equine Vet J. 1994;26(4):323-326. 

15. Nicholson M, Beal M, Shofer F, Brown DC. Epidemiologic 

evaluation of postoperative wound infection in cleancontaminated 

wounds: A retrospective study of 239 dogs 

and cats. Veterinary surgery 2002;31(6):577-581. 

16. Heldmann E, Brown D, Shofer F. The association of 

propofol usage with postoperative wound infection rate 

in clean wounds: a retrospective study. Veterinary surgery 

1999;28(4):256-259. 


Surgical preparation: current understanding and 

recommendations 

L. Findji* 

VRCC, West Mayne, Bramston Way, Essex, United Kingdom 

Thanks to the works of visionary scientists and physicists 

including Semmelweis, Pasteur, Lister and Halsted, the 

basic rules of aseptic surgery were set in the early 20 th 

century, a hundred years ago. The preparation of the surgical 

team and patient for surgery then became a ritual which has 

hardly changed since. As a whole, this ritual has brought 

dramatic improvements in post-surgical infection rates, 

but most of its parts were adopted on the sole grounds of 

intellectual rationales rather than scientific evidence. 

Furthermore, it now seems that, in spite of considerable 

research and investments made to improve surgical 

preparation and environment, surgical teams struggle to 

decrease surgical site infection (SSI) rates further. As a 

result of the heavy cost of such infections and with the 

advent of evidence-based medicine, much of the dogma 

of surgical preparation has been questioned. The current 

widespread recommendations on surgical preparation are 

supported by variable levels of evidence. When considering 

the evidence from the human literature, evidence-based 

medicine (EBM) principles will be followed and highlevel 

evidence will be examined preferably examined, 

if not exclusively. As for veterinary literature, sticking 

to the strict criticism of the level of evidence applied in 

human EBM would not leave any study to examine and 

lower levels of evidence need to not be dismissed 1 . 

In view of the literature, the following recommendations 

can be made. The level of evidence supporting them will 

be ranked according to the system used by the Center for 

Disease Control and Prevention (CDC) 2 (Table 1). 

Rank Implementation of policy Support 

Preparation of the patient 

IA Strongly recommended High-level evidence (well-designed studies) 

• Skin preparation 

• Hair removal 

In one systematic review of human surgery literature, no 

differences in SSI rates were found between patients who 

had their hair removed by shaving or depilatory cream and 

those who had no hair removed 3 . Shaving was found to be 

associated with higher SSI rates than clipping or depilatory 

cream 3 . Depilatory creams are widely considered to be 

most favourable to reducing SSI risks 4 , although no highlevel 

evidence comparing depilatory cream and clipping 

exists 3 . Although some studies suggested that removing 

hair the day before surgery was associated with more SSIs 

compared to removing hair immediately before surgery 4 , 

timing of hair removal was not found to have a significant 

effect on SSI rates in a systematic review of the evidence 3 . 

In human surgery, hair removal is currently only 

recommended when the presence of hair will interfere 

with the operation 2, 5 . If hair needs to be removed, 

most organisations and authors recommend clipping, 

immediately before surgery 2, 5 . 

In veterinary surgery, no randomised controlled trial 

(RCT) could be found which investigates SSI rates with and 

without hair removal. One small study in horses found no 

significant difference in postscrub numbers of CFUs between 

clipped and unclipped areas of the skin over the carpus and 

distal interphalangeal joint 6 . Nonetheless, given the nature 

IB Strongly recommended Some scientific evidence and strong theoretical rationale 

II Suggested Suggestive scientific evidence or theoretical rationale 

NR No recommendations Insufficient evidence, absence of consensus 

Table 1: recommendation ranking according to the level of scientific support 


of the hair coat in most veterinary patients, hair removal 

is likely to be required to improve the surgeon’s comfort 

during the procedure. In the absence of evidence on its 

effect on postoperative infection rates, hair removal should 

therefore be considered necessary for practical reasons 

rather than for prevention of SSI. In areas with very short 

hair, it is unknown whether hair removal is of any benefit. 

Similarly, no RCT could be found which compares SSI 

after shaving, clipping or application of depilatory cream. 

The latter is known to be less effective on coarse animal 

hair and to induce skin reactions, especially in cats 7 . 

As in human medicine, clipping is believed to be less 

traumatic than shaving, which is not recommended. 

Lastly, there is evidence than animals clipped before the 

induction of anaesthesia are more likely to develop a SSI 8 . 

Clipping immediately prior to surgery on the anaesthetised 

animal is therefore recommended. 

In veterinary surgery, it is recommended to routinely 

remove hair from the surgical site by way of clipping, 

immediately before surgery, after induction of general 

anaesthesia (II). 

• Disinfection 

Preoperative skin disinfection is recommended on the 

basis of theoretical rationale. 

A systematic review of evidence5 found only one 

quasi-RCT investigating the effect of preoperative 

skin disinfection after soap washing compared to 

no skin disinfection after soap washing. No SSIs 

were found in either case9. There is therefore weak 

evidence of the absence of effect of any preoperative 

skin disinfection on SSI rates after clean surgeries. 

Two systematic reviews of evidence have not been 

able to draw firm conclusions as to the optimal 

preoperative skin preparation in human surgery5, 10. 

One systematic review found evidence of no difference 

in SSI rates between preoperative skin preparation 

with alcohol-based chlorhexidine spray or iodine-based 

scrubbing and painting5. It also found evidence of no 

difference between scrubbing and painting compared 

to painting only when using an aqueous solution of 

povidone-iodine (PVPI)5. Insufficient evidence was 

found comparing any other skin preparation protocols5. 

Consequently, no definitive recommendations are made 

regarding preoperative skin preparation in human 

surgery. Most organisations recommend using either 

PVPI-based or chlorhexidine based products, either in 

aqueous or alcoholic presentations. There is evidence 

that alcohol-based antiseptics may be more efficacious 

and long-lasting than their aqueous equivalents11, 12. 

Other preoperative skin preparation products are available, 

for which high-level evidence of efficacy is not available 

yet. One of them, iodine povacrylex in isopropyl alcohol 

(DuraPrep; 3M), may provide longer-lasting antisepsis as it 

forms an antiseptic film on the skin when it dries. It appeared 

to reduce SSI rates in one study13, but the study is not of 

high quality. Some other low-level evidence tends to confirm 

this efficacy12. It has been evaluated in veterinary surgery 

and no difference in efficacy, assessed by CFU counts, was 

found with PVPI14 and chlorhexidine gluconate15 scrubs. 

Another type of skin preparation product mandating 

further evaluation through RCTs is cyanoacrylate microbial 

sealants, which aims at drying and sealing skin flora under 

a breathable film. A systematic review of the evidence 

found only one small, underpowered study showing no 

difference in SSI rates whether a between film-forming, 

liquid cyanoacrylate microbial sealant was used after 

conventional PVPI preparation or not16. 

In veterinary surgery, a number of studies have 

investigated the influence of skin preparation of SSI rates 

or CFU numbers 14, 15, 17-20 . All these studies investigated 

the influence of skin preparation on CFU counts and 

only a few on SSI rates as well. However, there is no 

evidence that CFU counts are related to SSI rates. In fact, 

2 of these studies found one skin preparation superior 

to another in terms of CFU number reductions, but it 

did not translate in more postoperative infections 17, 20 . 

Overall, as in human surgery there is no good-level evidence 

of superiority of any skin preparation protocol over another 

in decreasing the risk of SSI. 

It is recommended to prepare the skin of the intended 

surgical site immediately before surgery using an aqueous 

or alcohol-based antiseptic (IB). Chlorhexidine and 

povidone-iodine are suitable (IB). 

• Mechanical bowel preparation 

In human colorectal surgery, there is no evidence 

that mechanical bowel preparation reduces SSI rates. 

Therefore, it is recommended not to use it routinely 5, 21 . 

In veterinary patients, no evidence exists investigating the 

influence of bowel preparation on SSI rates after colorectal 

surgery. Most recommendations are extrapolated from 

human literature 22 . 

No recommendation can be made regarding the benefit 

of routine mechanical bowel preparation is small animal 

colorectal surgery (NR). 

• Surgical drapes 

• Drape type 

There is little evidence investigating the influence 

of various types of surgical drapes on SSI rates. 

In a systematic review of evidence in human surgery, no 

differences were found in SSI rates between disposable 

and reusable drapes 5 . However, the wide variety of 

commercially-available drapes in terms of material and 

design, as well as the fast-paced progress made in their 

conception may rapidly render any such studies obsolete. 

Only one study examining the effect of the use of different 

types of drapes on SSI rates in veterinary surgery was 

found. This retrospective study found no differences in 

infection rates when reusable cotton muslin or disposable 

drapes were used 23 . In the absence of extensive evidence, 


the theoretical rationale of opting for drapes which have 

been shown to be impermeable to liquids and microorganisms, 

including viruses, prevails. 

No recommendations can be made as to the most 

appropriate type of drapes to use to reduce risks of SSI 

(NR). 

• Incise drapes 

In human surgery, two systematic reviews of the 

evidence showed that non-iodophor-impregnated adhesive 

incise drapes are not associated with reduced SSI rates, but 

may actually increase the risk of postoperative infection 5, 

24 . No difference in SSI rates was observed between 

iodophor-impregnated incise drape and no incise drape 5 . 

In veterinary surgery, no RCT evaluated the influence of 

adhesive incise drapes on SSI rates. Two studies evaluated 

a surrogate outcome: CFU counts. One study found that a 

1-minute alcohol scrub followed by the application of a 

iodophor-impregnated incise drape was less effective in 

decreasing CFU numbers than a conventional 3-minute 

PVPI scrub 25 . Another study compared CFU numbers 

after clean surgery 26 . No differences in CFU counts in the 

wound were found when non-impregnated adhesive incise 

drapes were compared to when they were not used 26 . No 

RCT investigating the influence of iodophor-impregnated 

adhesive incise drapes on SSI in veterinary surgery is 

available. 

It is recommended not to use adhesive incise drapes 

routinely in veterinary surgery (IB). If an adhesive incise 

drape is required, a iodophor-impregnated one should be 

used (II). 

Preparation of the surgical team 

• Scrub suits 

There is no good-level evidence regarding the influence of 

different policies (e.g. restricting the wearing of these scrubs 

to the operating suite or not, covering suits with gowns when 

out of the operating suite or not, frequency of and products 

used for laundering, etc.) regarding scrubs suits on SSI rates. 

It is however recommended to change visibly soiled or 

contaminated scrubs (IB). No recommendations can be 

made regarding restriction of these suits to the operating 

suite or to their covering when out of it (NR). 

• Theatre shoes 

Theatre-dedicated shoes have been shown to be 

less contaminated than outdoor shoes 27 . However, it is 

generally thought that SSI risk from the floor bacteria 

is low. On the other hand, the use of overshoes has 

never been shown to decrease SSI rates. Furthermore, 

no difference in theatre floor contamination was found 

when overshoes were worn compared with outdoor 

shoes. Lastly, increased bacterial contamination was 

found in the vicinity of the footware changing area 

and concerns were raised about contamination of 

hands with floor bacteria when overshoes were used. 

It is currently not recommended to wear overshoes in order 

to prevent SSI (IB). However, similarly to face masks and 

caps, the wearing of overshoes contributes to theatre 

discipline. It may therefore overall be beneficial, which 

leads some organisations to recommending it 5 . Lastly, 

overshoes can protect shoes from soiling with blood and 

body fluids and their use has been advocated to this effect 2 

• Scrubbing 

• Hand antisepsis 

Protocols of preoperative hand antisepsis can vary 

according to the type of solution (aqueous scrubs, alcohol 

rubs or alcohol rubs with addition active ingredients), 

active compound (alcohol, iodophors, biguanides, phenolic 

compounds) and timing used. Furthermore, a difference 

is most often made between the first scrub of the day 

(referred to as the initial scrub) and subsequent scrubs. 

Determination of the optimal protocol therefore involves 

considering many variables and proves very difficult. 

According to 2 comprehensive literature reviews5, 28, 

only one well-design trial investigated the influence of 2 

hand antisepsis protocols on SSI2. It showed no difference 

between a 75% alcohol rub and aqueous scrubs using 

either 4% povidone iodine (PVPI) or 4% chlorhexidine. In 

all cases, the duration of scrubbing/rubbing was 5 minutes. 

Other studies evaluated the effect of various hand antisepsis 

protocols on the number of colony-forming units (CFUs) on 

hands at various times after antisepsis. Most studies 

showed increased efficacy of chlorhexidine compared with 

PVPI. Furthermore, chlorhexidine has several advantages 

over PVPI, including a residual effect and preserved 

efficacy in presence of organic material and debris. 

It is therefore recommended to prefer a chlorhexidinebased 

rather than a PVPI-based aqueous scrub (IB). 

Some alcohol rubs containing additional active ingredients 

were shown to be more effective than aqueous scrubs in 

decreasing the number of CFUs on hands. When SSI were 

compared, no difference were found 29 . Provided hands are 

thoroughly cleaned with soap before the first rub of the day 

and when visibly dirty, alcohol rubs containing additional 

active ingredients can be considered to be acceptable 

alternatives to aqueous scrubs (IB). 

The optimal scrubbing and rubbing times are unknown. 

Several studies indicated that scrubs lasting 2 minutes or 

more are as effective as 10-minute scrubs 2 . A systematic 

review found no difference in the number of CFUs on hands 

after 2, 3 or 5-minute scrubs 28 . However, when chlorhexidine 

aqueous scrubs were used, subsequent scrubs of 30 seconds 

were found to be less effective in reducing the number of 

CFUs on hands than subsequent scrubs of 3 minutes. One 

study found that, following a 1-minute hand wash, 3-minute 

rubs were more effective in reducing the number of CFUs 

on hands than 5-minute rubs. As a result of the lack of 

definitive evidence, current precise guidelines for scrubbing 

vary greatly among organisations and authors. Surgical 


teams can therefore choose between several options 11 . 

The first scrub of the day must include a thorough cleaning 

of hands, nails and undernails. Hands are then disinfected 

with either an aqueous scrub or alcoholic rub with 

additional ingredients carried out for 2 to 5 minutes (IB). 

Subsequent scrubs can consist of shorter (2-to-3-minute) 

scrubs or rubs, provided hands are kept macroscopically 

clean (IB). 

• Rings, nail polish and nail extensions 

Although there is good evidence that the wearing of 

finger rings increase the hand microbial load, it seems that 

this is no longer the case after regular hand scrubbing or 

thorough cleaning 30 . Besides, no evidence exists linking 

the wearing of rings with SSI rates 5, 31 . It is however 

recommended that scrubbed staff do not wear hand and 

arm jewellery 2, 5 (II). 

Similarly, there is no evidence indicating that the 

wearing of nail polish or nail extensions increases SSI 

rates 2, 5, 31 . Low-level evidence of increased bacterial and 

fungal colonisation of hands in spite of adequate hand 

scrubbing when artificial nails are worn however exists 2 . 

No recommendations can be made regarding the wearing 

of nail polish and nail extensions (NR). Any type of 

manicure favouring perforation of gloves should however 

be avoided (II). 

• Attire 

There are few controlled studies investigating the 

influence of surgical attire on SSI. However, there is 

evidence of shedding of live micro-organisms from hair, 

exposed skin and mucous membranes of operating theatre 

personnel. Therefore, there is a strong theoretical rationale 

to isolate the patient from the surgical team. Although 

it is likely to be of lesser concern in veterinary surgery, 

the surgical attire also protects the surgical team from 

the patient. Sterile, impervious materials should be used 

for the parts of scrubbed personnel which may to come 

in contact with the patient or drapes (i.e. hands, arms, 

trunk). Microparticule-filtering materials should be used 

to cover body areas which are not to come in contact with 

the patient but may shed micro-organisms. 

• Gloves 

The use of sterile gloves to prevent SSI is supported by 

a strong theoretical rationale rather than actual scientific 

evidence. It is recommended that all scrubbed staff wear 

sterile gloves (IB). 

A number of options are available regarding surgical 

gloving including simple gloving, double-gloving, indicator 

gloves, orthopaedic gloves, glove-liners and knitted 

gloves. The effect of these different options on SSI rates 

has not been appropriately investigated 32 . Most studies 

have evaluated the influence of gloving options on the 

incidence of inner-glove (glove in contact with the hand, 

whether there is another pair on it or not) perforation by 

the end of surgery. However, there is no evidence that 

glove perforation increases the risk of SSI. It is however 

theoretically assumed so 32 . Double-gloving and perforationindicator 

systems are more effective than single gloving 

in avoiding inner-glove perforation (2% versus 9% in 

a meta-analysis on 9,000 gloves). Orthopaedic gloves 

(thicker gloves) were found to be as effective as doublegloving 

in reducing inner-glove perforation, and may be 

less cumbersome 32 . Indicator systems allowed surgeons 

to detect significantly more perforations than single 

or double-gloving. Except for steel weave gloves, all 

additional glove protections (triple gloving, glove liners, 

knitted-cloth gloves) reduce the incidence of inner-glove 

perforation compared to standard double gloving. They 

therefore currently provide the highest level of protection 

against inner-glove perforation. There seem to be no 

indication that any of these options reduces surgical 

dexterity, as they were not found to be associated with 

increased rates of outer-glove perforations 32 . No universal 

recommendation can be made as to gloving options (NR). 

The choice must be made by each surgical team based on 

the risk of perforation associated with the type of surgery 

(e.g. orthopaedics versus soft tissue) and cost of options. 

Double-gloving and orthopaedic gloves reduce the risk of 

inner-glove perforation compared to single gloving and can 

be used routinely, although no evidence exists to support 

that this would decrease SSI rates. 

• Masks and caps 

The wearing of disposable surgical masks by all personnel 

entering the operating theatre is commonplace. However, no 

evidence of their efficacy in preventing SSI exists and some 

authors have described ways in which they may actually 

contribute to the contamination of surgical wounds 33 . A 

systematic review of the available evidence found only 

3 well-designed studies including 2113 patients. None of 

these studies found any difference in SSI rates between 

masked and unmasked procedures, but the strength of the 

evidence was considered to be weak 33 . One study on 3,088 

patient not only found no difference in SSI rates between 

operations performed with face masks and those performed 

without, but also found that bacterial species cultured 

from SSI of both groups were similar, suggesting that 

the sources of infection were the same and therefore not 

related to the wearing or non-wearing of surgical masks 34 . 

Surrogate outcomes (e.g. room bacterial counts, 

contamination of plates placed on the operating table, 

etc.) were studied, showing that the wearing of face 

masks 35, 36 or entire head-gear 37 by unscrubbed theatre 

personnel may be unnecessary. These studies were 

however made in theatres with forced ventilation, which 

was thought to be more important than face masks in 

preventing contamination 35, 37 . Their results may therefore 

not be applicable in less modern theatres without forced 

ventilation. Bacterial counts in an empty theatre appeared 

to be unchanged by the wearing of head gear, but were 

statistically increased when the room doors were kept open 


and when people entered the room 36 . Increased traffic in 

the operating room was also found to increase the risk of 

SSI in veterinary surgery 38 . 

Overall, there is no evidence that the wearing of 

disposable surgical masks reduce the risk of SSI. It is 

unclear whether face masks contribute to the protection 

of surgical team members from the patient. 

No evidence exists that examines the influence of the 

wearing of head caps on SSI rates and SSI outbreaks have 

been traced to organisms of the hair or scalp, whether caps 

were worn or not 2, 11 . 

Like other pieces of the surgical attire, face masks 

and head caps contribute to theatre discipline and may 

therefore be beneficial in other ways than reducing SSI 

rates. 

It is recommended that scrubbed personnel wear 

disposable face masks and head caps during surgery (IB). 

No recommendations can be made based on the available 

evidence as to whether unscrubbed personnel should wear 

face masks and head caps or not (NR). 

• Gowns 

There are no well-designed studies examining whether 

the wearing of sterile gowns by the surgical team minimises 

the risk of SSI. There is however a strong theoretical 

rationale to use impervious sterile gowns.Two RCTs found 

no difference in SSI rates when disposable or reusable 

sterile gowns and drapes were used5. It is recommended 

that all scrubbed personnel wear sterile, impervious gowns 

(IB).Either reusable or disposable gowns can be used (IB). 

Conclusion 

The interpretation of the scientific literature regarding 

surgical preparation is hindered by several factors, all the 

more for veterinary surgeons. First of all, the investigation 

of certain aspects of surgical preparation is hampered by 

ethical considerations (e.g. SSI rates with or without use 

of surgical gloves) and a number of recommendations will 

remain based on theoretical rationales. Second, many 

studies do not measure SSI rates as an endpoint and 

no evidence exists supporting the relation between the 

measured surrogate outcome and SSI. For instance, most 

studies on hand preparation measure the number of colonyforming 

units (CFUs) on the surface of hands rather than 

the rate of SSI. However, there is no evidence showing that 

SSI rates are related to the number of CFUs on the hands 

of members of the surgical team. The relevance of such 

studies relies solely on assumed theoretical grounds. Third, 

many human studies are conducted within a subspecialty 

of surgery (e.g. urologic, colorectal, cardiothoracic), which 

provides data that cannot be generalised to all types of 

surgery. Lastly, the extrapolation to veterinary medicine of a 

significant part of the evidence provided by the literature in 

human medicine is not possible as the anatomy, physiology, 

microbiology and often surgical conditions are quite 

different in human and veterinary surgeries. Unfortunately, 

very little, if any, high-level evidence is available in the 

veterinary literature and much of the knowledge specific 

to veterinary surgery is based on rather weak evidence. 

The risk of developing a SSI is largely determined by 

3 factors: the type and amount of wound contamination 

during the procedure, the condition of the wound at the 

end of the operation and the host susceptibility of the 

patient. Surgical preparation, together with the class of 

surgery and surgical technique, influences the former. The 

fact that many alterations in surgical preparation appear 

to have no effect on SSI rates could mean either that they 

really have no effect, or that surgical preparation no longer 

is the limiting factor in the development of SSI. The effect 

of these alterations could therefore be masked by other 

factors such as the condition of the wound, mainly a result 

of surgical technique, and host susceptibility. This would in 

turn mean that the key to decreasing current SSI rates is 

to be searched in surgical technique and host biology and 

support (which includes sensible antimicrobial prophylaxis), 

rather than further escalation in surgical asepsis. 

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Perioperative antimicrobial prophylaxis 

P. Moissonnier* 

Ecole Veterinaire Maisons Alfort, France 


Surgical site infection control programme 



Introduction 

Infection control has been an overlooked and 

underappreciated field in veterinary medicine, particularly 

in small animal practice. The concept of ‘biosecurity’ is 

one that is well developed in some sectors of food animal 

veterinary medicine, however this differs from ‘infection 

control’. Biosecurity involves implementation of measures 

to prevent entrance and dissemination of infectious agents 

into defined groups of animals. This is not applicable to 

small animal practice because, inherently, small animal 

clinics ‘invite’ animals with infectious diseases into their 

facility. Therefore, the focus is on limiting the impact of 

infectious diseases that will enter the clinic. This is the 

practice of infection control, which attempts to control 

the impact of the inevitable entrance of infectious agents 

into a facility. Further, while we often discuss prevention 

of infections, absolute prevention of infections is not 

a realistic goal. Rather, infection control programs are 

designed to reduce the risk and incidence of infections. 

While infection control has often been ignored, there is 

increasing interest about this field in small animal practice. 

There are many possible reasons for this, but factors 

such as increased awareness of infectious disease by 

the general public, increased information about hospitalassociated 

(nosocomial) infection in human hospitals, 

occupational health and liability concerns about zoonotic 

infections and emergence of multidrug resistant pathogens 

highlight the need for a more organized approach to 

infection prevention and control. 

General principles of Infection Control 

In general terms, 3 basic areas must be considered when 

infection control is approached. These include decreasing 

exposure to pathogens, decreasing susceptibility of the host 

and increasing resistance. These categories are relevant 

for both animal diseases and zoonoses. 

The combination of these factors indicates the likelihood 

of disease. A crude representation of the risk of SSI 

development can be illustrated as: 1 

SSI risk = Microbial concentration and virulence X Tissue 

Injury X Foreign Material X Antimicrobial Resistance 

General immunity X Local Immunity X Periopeative 

Antimicrobials 

Decreasing Exposure 

Decreasing exposure is the most important aspect of 

disease control in most situations. If a pathogen is unable to 

encounter an individual, disease will not occur. Depending 

on the pathogen, preventing exposure may be easy, difficult 

or impossible. Clinically normal animals and people may 

harbour a variety of primary and opportunistic pathogens, 

and even clinical evaluation cannot rule out the possibility 

that an animal is carrying a relevant infectious agent. 

Examples of specific aspects to consider are discussed 

below. 

Decreasing susceptibility 

The pathophysiology of disease is multifactorial and in 

most cases, simple exposure of an infectious agent to an 

animal does not necessarily mean that disease will result. 

The susceptibility of the individual to an infectious agent 

plays an important role. While difficult to quantify, certain 

situations may result in increased susceptibility to disease. 

Many factors causing increased susceptibility are not 

preventable, but some are and efforts should be undertaken 

to address these issues. Identifying factors that increase 

susceptibility may be difficult and our understanding of this 

area is currently limited. 

Decreasing susceptibility is more difficult to achieve 

in a hospital setting. Surgical factors relating to patient 

susceptibility include tissue injury (pre-, intra- and post-op), 

tissue dessication, control of hemostasis, surgical time, and 

removal of blood and debris. Judicious use of antimicrobials 

and immunosuppressive agents, provision of a good quality 

diet, provision of adequate pain control, avoidance of 

dietary changes, ensuring adequate nutritional intake and 

limiting use of invasive devises should also be considered. 

For hospital personnel, an important aspect of decreasing 

susceptibility is being aware of hospital personnel that are 

more susceptible to disease. This would include people that 

are immunosuppressed (disease- or treatment-induced), 

being treated with antimicrobials, have open wounds or 

who are pregnant. Good communication between hospital 


personnel, physicians and hospital administrators is 

important to lessen the risk of zoonotic infection. 

Increasing resistance 

Vaccination is the main technique employed to increase 

resistance of animals or humans to infection. However, no 

vaccines are 100% effective and vaccination should be 

considered a 3 rd line of defense after decreasing exposure 

and decreasing susceptibility. Vaccination has little impact 

on SSI prevention, beyond trying to optimize overall health 

and decrease the risk of comorbidities. 

Infection Control Program 

An infection control program is a structured program of 

policies and practices that are designed to reduce the risk of 

infection of patients, clinical personnel and owners. Every 

veterinary clinic, regardless of size and type, should 

have at least a basic infection control program. This 

may range from a written collection of basic infection 

control practices to a formal infection control manual with 

specific training, monitoring, surveillance and compliance 

programs. Unfortunately, this is rarely the case, which may 

lead to unnecessary patient morbidity and mortality, and 

exposure of veterinarians, staff and owners to zoonotic 

pathogens. The increasingly litigious nature of society could 

be one of the driving forces towards improved infection 

control in veterinary clinics. While the potential liability 

consequences of morbidity and mortality in individual pets 

is currently limited, the potential consequences of zoonotic 

diseases in owners and staff are high and require careful 

consideration. Improved infection control is also a necessity 

as veterinary medicine evolves. Advances in veterinary 

medicine mean that animals are living longer and there 

are more animals at higher risk for infection because of 

immunosuppression and more invasive treatments. 

Selected Considerations in Infection Control 

Surveillance 

Surveillance is a key component of any infection control 

program. The Centers for Disease Control and Prevention 

(CDC) defines surveillance as ‘the ongoing, systematic 

collection, analysis, interpretation and dissemination of 

data regarding a health-related event…”. Surveillance 

can be an important part of an overall infection control 

program by providing a basis for logical infection control 

decisions, evaluating effectiveness of infection control 

practices, evaluating compliance with infection control 

procedures and stimulating efficient and economic use of 

resources. 2 However, it can also be inefficient, unrewarding 

and sometimes misleading, if improperly performed. 

There are various types of surveillance that can be 

considered, all with advantages and disadvantages. Active 

surveillance involves gathering data specifically for 

infection control purposes. As a result, it can be expensive 

and time consuming but usually provides the highest quality 

data. One exampls of this would be collection of MRSP 

screening swabs from patients upon prior to surgery as 

part of MRSP outbreak investigation. Active follow-up 

of surgical cases, beyond that normally performed (e.g. 

calling owners 30d after surgery rather than just relying 

on routine recheck appointments) is another example. 

Active surveillance is rarely needed (at least as a routine 

tool) in most veterinary clinics and is typically reserved 

for large facilities with increased infection control threats 

and personnel available to direct such testing, or during 

outbreak investigation. 

In contrast, passive surveillance is a practical, easy 

and cost-effective surveillance tool that can be easily 

performed in any clinic. It involves the use of data that are 

already available. This would include information about the 

number of surgical site infections collected through normal 

recheck visits or other standard reporting mechanisms, 

or culture results from various infections. The quality of 

passive surveillance data, however, can be limited by poor 

or incomplete record keeping. Facilitating easy access to 

passively acquired data (e.g. being able to accurately and 

easily generate a report of SSI cases or culture results) is 

critical to effective use of passive surveillance. 

Another form of surveillance that is easy to perform and 

potentially very useful is syndromic surveillance. This 

involves identification of syndromes (i.e. diarrhea, coughing) 

instead of specific diagnoses. All clinic personnel can be 

made aware of certain syndromes that indicate either 

the need for isolation or for further investigation, such 

as diarrhea, fever of unknown origin, acute neurological 

disease, wound infections and acute respiratory tract 

disease. Protocols to deal with these animals upon arrival 

should be developed. The role of lay staff (ie front office 

stall) is critical as these people are the ones that are most 

able to identify such cases before they enter the clinic and 

ensure that they are properly handled. Identification and 

proper handling of these cases can greatly decrease the 

chance of nosocomial or zoonotic transmission. 

Environmental surveillance 

Environmental surveillance is often overused and misused. 

The hospital environment is not sterile, and contamination 

of various sites with numerous opportunistic pathogens 

is fully expected. Non-targeted environmental culturing 

is a poor use of time and resources, and can result in 

useless or even misleading information. Environmental 

surveillance should be limited to circumstances where 

there is a plausible role of the environment in infection, 

when a structured sampling program can be created and 

there is a pre-determined plan to act of the results. This 

is rarely present. 

Another type of environmental surveillance, and one that 

is potentially more rewarding, is assessment of cleaning 

practices with the use of environmental marking. This 

involves application of invisible dyes to environmental 

surfaces in a manner such that they would be removed 


using normal cleaning practices. A structured program of 

‘contaminating’ surfaces followed by evaluation of those 

surfaces after a time during which cleaning should have 

been performed, can be used to assess the efficacy of 

cleaning and to act as an educational tool to personnel 

involved in cleaning. This type of method is cost-effective, 

easy to perform and can be useful, as long as it is 

approached in a non-confrontation manner designed to 

educate and improve, not assign blame. 

Handling of infectious cases 

Once an infectious or potentially infectious animal has 

been identified, it is important that established protocols 

are available and followed. Animals that are infectious or 

of uncertain risk should be housed in an isolation area. The 

isolation area should be properly identified, have restricted 

access, be away from areas of normal traffic flow and 

should never be used for storage. Isolation areas should 

have dedicated equipment (thermometers, stethoscopes) 

that is not used on different animals. Education of 

personnel regarding the reasons behind protocols and their 

importance is useful to increase compliance. 

Personal protective equipment 

All personnel in a veterinary hospital should wear 

personal protective equipment. This acts as a barrier 

between patients (as well as specimens and the patient 

environment) and the person’s body or clothing. Adequate 

personal protective equipment will reduce the risk of 

contamination of clothing or skin, and be able to be quickly 

and easily changed when contaminated. Lab coats, scrubs 

and gowns are examples of commonly used items, and 

these should be worn whenever there will be contact 

with animals or the animals’ environment. Even if obvious 

contamination is not present, they should be changed 

regularly because contamination can occur in the absence 

of obvious soiling. Protective clothing should not be worn 

home because of the risk of transmission of pathogens to 

personal pets and family members. 

Scrubs, in particular, may be misused and if personal 

protective equipment is worn home, not changed during 

the day and difficult to change after contamination, it is 

being used suboptimally. 

Enhanced precautions, which may consist of gloves, 

gowns, masks, face shields, protective footwear and other 

items, may be required when handling certain animals or 

specimens. Protocols should be in place to ensure that all 

clinic personnel are aware of their responsibilities. 

Clinic design and function 

Animal flow within the clinic should be evaluated, 

and considered as part of clinic design or renovation. It 

is important to limit potential direct and indirect animal 

contact. Sick animals should be kept away from healthy 

animals, especially high-risk animals. With the increase 

in multidrug resistant staphylococcal infection and 

colonization in some populations, particularly dermatology 

patients, consideration must be given to ways to separate 

patients at high risk for infection (e.g. surgical patients) 

from patients at high risk for shedding an impact SSI 

pathogen (e.g. dogs with pyoderma). 

Operating Room Design and Function 

Veterinary operating facilities are highly variable and 

there are few true standards. Operating rooms should be 

of adequate size for proper movement of personnel and 

equipment, with limited risk of inadvertent contamination. 

Laminar airflow is preferred but impractical for the vast 

majority of facilities, and its true role in infection prevention 

in veterinary situations is unknown. However, consideration 

and evaluation of ventilation is required to ensure that 

there is not improper airflow that could result in increased 

airborne (and subsequently patient and equipment) 

contamination. 

Operating rooms must be sole use. They should not be 

used as storage areas and should not be allowed to become 

cluttered with items. Sinks should not be present within the 

OR, or if they are present, they should not be used when a 

patient is in the room or when opened surgical items are 

present in the room. 

Patient preparation 

Patient preparation is an important aspect of surgical 

asepsis. The relative impact of patient preparation has been 

inadequately investigated, and specific details regarding 

surgical preparation are provided elsewhere. However, it 

is apparent that there are issues with compliance with 

standard practices, including the method of preparation 

and the time dedicated to this important area. Recent 

observation data has indicated marked variation in the 

time and quality of patient preparation in general small 

animal practices, with very short scrub times and improper 

scrub methods identified in some cases (Anderson et al, 

unpublished data) 

Pre-operative management of the surgical site may be an 

important factor but there has been minimal investigation of 

this area in veterinary medicine. The goal of pre-operative 

surgical site management is to eliminate potential 

pathogens while not creating a physical environment that 

is more conducive to bacterial colonization or infection 

post-operatively. Bathing of the patient pre-operatively is 

reasonable if there is significant contamination of the hair 

coat 3 and if the patient’s coat can be dried by the time of 

surgery. 

Additionally, while attention has been focused more on 

ensuring that surgical sites receive ‘adequate’ attention, 

the goals of patient preparation need to be considered. 

In essence, the goal of surgical scrubbing of patients is 

to reduce bacterial counts, reduce debris, facilitate later 

antisepsis steps and (a fact that is often overlooked) to 

do so in as atraumatic a fashion as possible. As such, 

minimizing skin damage during clipping and scrubbing 


is essential, but often overlooked. Skin damage from 

excessive attempts to clip all remaining pieces of hair or 

from forceful scrubbing of the surgical site may predispose 

to infection rather than reduce the risk. While objective 

data are lacking, there is anecdotal evidence that excessive 

preparation may be a factor in outbreaks of SSIs. Some 

indirect research data may also be present, such as a study 

that reported dogs that were clipped prior to anesthetic 

induction had higher SSI rates than those clipped after. 4 

While the true reason for this could not be determined, it 

is certainly plausible that clipping a conscious animal was 

associated with a greater likelihood of skin trauma and 

subsequent increased SSI risk. Clipping should be done 

outside of the operating environment. There is currently 

no information regarding optimal methods of cleaning 

and disinfecting clippers. Repeated use of clipper blades 

without sterilization not surprisingly results in higher levels 

of bacterial contamination of blades 5 however the clinical 

relevance of this is unclear because the surgical site would 

be cleaned and disinfected after clipping. Regular cleaning 

and disinfection are probably useful. Clippers should be 

thoroughly cleaned and disinfected after every use on an 

animal with a potentially transmissible infection (e.g. an 

animal with diarrhea), on an area where the skin is broken 

(especially if there is evidence of skin infection), or on any 

area where the skin or hair is significantly contaminated 

with feces, urine, blood or other body fluids. Only cleaned/ 

disinfected clippers should be used when clipping around 

areas with broken skin, to avoid increasing contamination 

of the abnormal area. 

Surgeon preparation 

Surgeon preparation, including surgical scrubbing and 

donning of surgical protective items, is an important area. 

Detailed discussion of surgical preparation is provided 

elsewhere in these conference proceedings. 

Compliance with standard recommendations is a concern. 

Observational data indicate that the quality of preparation 

practices can vary greatly between veterinarians, with 

some individuals used clearly inadequate practices. While 

a true standard of care has not been defined and the 

relative impact of poor practices has not been quantified, 

it is clear that there is significant room for improvement 

in compliance with typical practices amongst some 

veterinarians. Recently, application of alcohol-chlorhexidine 

combinations has been evaluated as a replacement for 

surgical scrubbing and been shown to be more effective 

than standard surgical scrub methods. 6, 7 This method is less 

time consuming and is associated with less skin irritation 

compared to repeated surgical scrubbing. Similarly, 

application of chlorhexidine (without alcohol) resulted in 

similar reduction in hand bacterial counts compared to 

surgical scrubbing in a veterinary hospital. 8 Regardless 

of the method used, a thorough handwash with careful 

cleaning under the fingernails must be performed at the 

beginning of each day. 9 Long (> 1/4”) and artificial nails are 

prohibited in many human healthcare facilities and some 

veterinary hospitals because they can harbor pathogenic 

bacteria 10 and be associated with surgical glove tears. 

Post-operative care 

Post-operative care of the incision site may be an 

important factor. The incision site is a highly susceptible 

site for opportunistic infection from the patient’s own 

microflora, from the environment or from hospital 

personnel. Contact with the surgical incision, particularly 

with bare hands, should be avoided. Covering or bandaging 

wounds for a minimum of 24 to 48 h post-operatively has 

been recommended in humans and horses 11, 12 and is a 

reasonable recommendation in small animals in most 

situations. Bandage changes should be performed using 

aseptic technique. 12 Animal owners or handlers should 

be educated on proper incision management and signs of 

SSI. There is no objective information regarding the need 

to cover incision beyond 48 hours in veterinary or human 

medicine, and arguments can be made for both sides. 

Prevention of surgical site licking or trauma by the patient 

is important as licking or scratching can damage healing 

incision site or associated skin and create a more hospitable 

site for bacterial growth. It can also result in the deposition 

of opportunistic pathogens. If surgical sites are bandaged, 

they surgical site should be inspected at least once daily to 

detect early signs of inflammation or infection. 

Cleaning and disinfection 

Cleaning and disinfection are key parts of the infection 

control process. It is important to understand why certain 

cleaners/disinfectants are being used. Improper use of 

disinfectants is widespread. Some products facilitate 

removal of debris (detergents, abrasives) while others are 

intended to kill microorganisms (disinfectants). Not all 

disinfectants are able to kill all pathogenic microorganisms, 

and there are differences in spectrum of activity, efficacy 

in organic debris, kill time, toxicity and environmental 

impact. Cleaning protocols should be reviewed to ensure 

that a relevant and acceptable level of disinfection is being 

achieved. Ability to kill specific microorganisms, human 

safety issues, cost and potential damage to surfaces 

must be considered when choosing a disinfectant. During 

outbreaks, changes in disinfection protocols may be 

required to ensure that the relevant organisms are killed. 

Periodic cleaning with certain disinfectants may also be 

useful. For example, clostridial spores are resistant to 

most disinfectants, can accumulate in the environment 

and can cause outbreaks in veterinary clinics. Unlike most 

disinfectants, bleach can kill spores and periodic cleaning 

with bleach may be useful. Non-enveloped viruses such 

as parvovirus are also difficult to kill and many routine 

disinfection protocols are inadequate to control this 

important group of pathogens. Fortunately, typical SSI 

pathogens are relatively susceptible to most commonly 

used disinfectants. 


Disinfection and sterilization of medical equipment 

Disinfection of medical equipment is also an important 

factor. All medical equipment should be designated as 

requiring cleaning, low-level disinfection, high-level 

disinfection or sterilization. Use of improper disinfection 

techniques for certain items of medical equipment has 

been identified in a number of human hospitals, particularly 

among items such as endoscopes that cannot undergo 

autoclave sterilization. “Cold-sterile” solutions are common 

in veterinary clinics, yet they are often improperly used 

and maintained. Bacterial contamination of cold-sterile 

solutions is common. 13 Problems include inadequate 

contact time, improper dilution and infrequent replacement 

of solution. 

Complete sterilization of surgical instruments and any 

items that might come in contact with the surgical field 

is a crucial procedure. Poor sterilization or inappropriate 

handling of instruments after sterilization can result in 

contamination of sterile tissues during surgery. Steam 

sterilization (i.e. autoclaving) is most commonly used in 

veterinary clinics. Quality control testing of autoclaves 

should be performed regularly and documented. Sterility 

indicator strips should be placed in every surgical pack. 

External autoclave indicator tape is not a reliable indicator 

of the sterility of a pack’s internal contents. Biological 

sterility indicators should be used periodically. These 

indicators contain bacterial spores, which are the most 

resistant form of bacteria. After being autoclaved, the 

indicator is submitted for testing to ensure that all of the 

spores have been killed by the sterilization process. In 

human healthcare facilities it is recommended that these 

indicators are used daily, or at least weekly. Weekly 

or bi-weekly use is likely adequate in most veterinary 

clinics, depending on how heavily the autoclave is used. A 

biological sterility indicator should also be used in the next 

cycle anytime the autoclave has been moved, repaired, or if 

there has been any other indication of sterilization failure. 

Flash sterilization should not be used unless absolutely 

necessary for emergencies only. Flash sterilization should 

never be used for surgical implants. 

Hand hygiene 

One of the most important facets of any infection 

control program is hand hygiene. Human hands are a 

major, if not the most important, source of infection in 

hospitals. Handwashing has been shown to decrease the 

transmission of disease in hospitals and in the community. 

A quick rinse under water, however, does not constitute 

proper hand hygiene. A 15-second scrub with a bactericidal 

soap is recommended, but rarely followed. Further, if taps 

are touched following handwashing, hands may become 

contaminated. Automatic taps can prevent this; otherwise 

a paper towel should be used to prevent direct contact with 

the taps when they are turned off. Alcohol-based hand 

disinfectants can be very useful, are now widely available 

in virtually all human hospitals and are increasingly being 

used at veterinary clinics. Superior elimination of hand 

contaminants on veterinary personnel compared to hand 

washing with antibacterial soap has been reported. 14 

These products are quick and easy to use, and because 

they include emollients, they are easier on the hands than 

frequent hand washing. Alcohol-based hand sanitizers 

should be available at multiple sites in clinics and should 

be used between every animal contact. If there is gross 

soiling of hands or suspected contamination with an 

alcohol resistant organism (i.e. non enveloped viruses, 

bacterial spores), handwashing should be performed. Nonalcohol 

based hand sanitizers are also available yet their 

role in healthcare situations is currently unclear. There is 

little evidence suggesting superiority over alcohol-based 

products at this time. 

Development of infection control protocols 

Every clinic should have a formal infection control 

program. This may involve a complex program with detailed 

policies and dedicated full-time personnel in large specialty 

hospitals, but typically only requires a modest effort with 

little to no additional resources, training and time. The 

size and scope of the infection control program needs to 

be tailored to the needs and resources of the individual 

veterinary hospital. However, some common components 

should be present in all hospitals: 

1) A written infection control manual: Written resources 

are critical. If something is not written down, there may be 

a loss of consistency as people modify practices, knowingly 

or otherwise. A central written resource allows people to 

quickly and easily determine the required practices for both 

routine (i.e. cleaning and disinfection) and uncommon (i.e. 

rabies exposure) events. Written documentation is also 

critical to demonstrate that an infection control program is 

in place, should there be issues regarding professional or 

legal liability. The adage “if it’s not written down, it doesn’t 

exist” is important to remember. 

2) Documented training of all personnel: All personnel 

working in a clinic, from owners to temporary kennel staff, 

must be trained on infection control practices. This is not 

only required for optimal patient care. It is also critical for 

protection of the clinic because failure to properly train 

and document training of individuals about how to protect 

themselves, particularly lay personnel who would not be 

expected to know anything about zoonotic diseases or 

infection control, could expose the clinic to significant 

liability risks. 

3) A designated central contact person/resource: This 

‘infection control practitioner’ (ICP) can be a veterinarian or 

technician, and should be in charge of developing protocols, 

ensure protocols are being followed, act as a resource 

for infection control questions, ensure proper training of 


new staff and direct any surveillance activities. This is not 

necessarily a cumbersome or time-consuming job, as the 

day-to-day responsibilities are typically minimal. The main 

effort involves establishing the program, and available 

resources can facilitate this. 

4) “Buy-in” from clinic management: An infection control 

program is bound to fail if people in charge of the clinic 

do not support it. Failure of senior personnel to follow 

protocols, to support the general concept and to facilitate 

with compliance of all personnel will ultimately result in 

failure of the program. In some clinics, a proper infection 

control program requires a substantial ‘culture shift’ in 

attitudes, and this can only be achieved if there is proper 

support. 

5) An ability to adapt: An infection control program 

cannot remain static. Changes in disease risks, emergence 

of new diseases, changes in clinic design and operation and 

improvement in the general knowledge of infection control 

will result in the need for an evolving program. This should 

not require extensive and frequent program modification, 

but the program needs to be designed so that it can respond 

to any changes. 

Implementation of infection control protocols 

One of the greatest obstacles to infection control is 

compliance. Many infection control practices are inherently 

cumbersome, and may conflict with other demands in a 

busy practice. For this reason, education of all personnel 

is required to facilitate compliance. If people understand 

the reasons for protocols, they are much more likely 

to comply. It is critical for owners and managers to be 

committed to the infection control program. Few things 

will adversely affect compliance more than staff observing 

senior personnel flaunting protocols. Senior personnel must 

have a commitment, demonstrate that by their actions, 

and be willing to enforce compliance among all staff. 

A combined ‘carrot and stick’ approach is often useful. 

Periodic education is useful to help maintain interest and 

compliance. Reporting infection control data from the 

practice is also useful. 

References 

1. Mandell GL, Bennett JE, Dolin R. Principles and practice of 

infectious diseases. 6th ed. Philadelphia, PA: Elsevier; 2005. 

2. Haley RW, Quade D, Freeman HE, Bennett JV. The SENIC 

Project. Study on the efficacy of nosocomial infection 

control (SENIC Project). Summary of study design. Am J 

Epidemiol. May 1 1980;111(5):472-485. 

3. Stick JA. Preparation of the surgical patient, the surgery 

facility, and the operating team. In: Auer JA, Stick JA, eds. 

Equine Surgery. 3rd ed. Philadelphia, Pa: Saunders Elsevier; 

2006:123-140. 

4. Brown D, Conzemius M, Shofer F, Swann H. Epidemiologic 

evaluation of postoperative wound infections in dogs and 

cats. J Am Vet Med Assoc. May 1 1997;210(9):1302-1306. 

5. Masterson TM, Rodeheaver GT, Morgan RF, Edlich RF. 

Bacteriologic evaluation of electric clippers for surgical hair 

removal. Am J Surg. Sep 1 1984;148(3):301-302. 

6. Mulberrry G, Snyder AT, Heilman J, Pyrek J, Stahl J. 

Evaluation of a waterless, scrubless chlorhexidine 

gluconate/ethanol surgical scrub for antimicrobial efficacy. 

American journal of infection control. Dec 1 2001;29(6):377- 

382. 

7. Hobson DW, Woller W, Anderson L, Guthery E. Development 

and evaluation of a new alcohol-based surgical hand scrub 

formulation with persistent antimicrobial characteristics 

and brushless application. Am J Infect Control. Oct 1 

1998;26(5):507-512. 

8. Corder K, Knowles T, Holt P. Factors affecting bacterial 

counts during preparation of the hands for aseptic surgery. 

Vet Rec. Jun 30 2007;160(26):897-901. 

9. Larson EL. APIC guideline for handwashing and hand 

antisepsis in health care settings. Am J Infect Control. Aug 

1 1995;23(4):251-269. 

10. Pottinger J, Burns S, Manske C. Bacterial carriage 

by artificial versus natural nails. Am J Infect Control. 

1989;17:340-344. 

11. Waguespack RW, Burba DJ, Moore RM. Surgical site 

infection and the use of antimicrobials. In: Auer JA, Stick 

JA, eds. Equine surgery. 3rd ed. Philadelphia, PA: Saunders 

Elsevier; 2006:70-87. 

12. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis 

WR, The Hospital Infection Control Practices Advisory 

Committee. Guidelines for prevention of surgical 

site infection, 1999. Infect Control Hosp Epidemiol. 

1999;20(4):247-278. 

13. Murphy CP, Weese JS, Reid-Smith RJ, McEwen SA. The 

prevalence of bacterial contamination of surgical cold 

sterile solutions from community companion animal 

veterinary practices in southern Ontario. Can Vet J. Jun 1 

2010;51(6):634-636. 

14. Traub-Dargatz J, Weese J, Rousseau J, Dunowska M, 

Morley P, Dargatz D. Pilot study to evaluate 3 hygiene 

protocols on the reduction of bacterial load on the hands 

of veterinary staff performing routine equine physical 

examinations. Can Vet J. Jul 1 2006;47(7):671-676. 


Methicillin-resistant staphylococcal infections: 

animal and public health consequences 



Introduction 

Despite being inherently susceptible to virtually every 

known antimicrobial class, staphylococci are notorious 

for antimicrobial resistance. From the first introduction 

of antimicrobials, staphylococci have demonstrated an 

impressive ability to become resistant. Penicillin-resistance 

was identified shortly after penicillin became widely used. 

New drug development outpaced resistance initially, 

but the ability of staphylococci to become resistant was 

repeatedly demonstrated as the introduction of new drugs 

was typically followed (sometimes rapidly) by emergence 

of resistance. Included in this pattern was resistance 

to methicillin, which emerged not long after the use of 

methicillin began in 1959. While resistance to methicillin 

itself is not a major concern, methicillin-resistance is 

caused by production of an altered penicillin binding 

protein (PBP2a) that has a poor affinity for beta-lactam 

antimicrobials and confers resistance not just to methicillin, 

but to virtually all beta-lactams; penicillins, cephalosporins 

and carbapenems. In addition to broad beta-lactam 

resistance, methicillin-resistant staphylococci are often 

resistant to a wide range of other antimicrobials, severely 

limiting treatment options. While methicillin-resistance 

was first noted as a problem in humans, it has emerged as 

a pressing issue in companion animals, and there have been 

striking recent changes in the epidemiology of methicillinresistant 

staphylococcal infection and colonization in dogs 

and cats. 

There is often confusion associated with staphylococci, 

particularly methicillin-resistant staphylococci. It is critical 

to remember that all staph are not created alike. The 

clinical relevance, prevalence of colonization, incidence 

of disease and potential for interspecies transmission 

vary greatly between different staphylococcal species. 

Inadequate identification practices, variable and sometimes 

improper susceptibility testing methodology, and variable 

reporting of results can lead to confusion and possibly 

suboptimal patient care. A critical aspect of dealing with 

staphylococci is knowing (with confidence) the species that 

is involved. There are two main groups of staphylococci; 

coagulase positive and coagulase negative. Coagulase 

positive species (e.g. S. aureus, S. pseudintermedius, 

S. schleiferi coagulans) are the most virulent and of 

greatest clinical relevance. Differentiation of these, or at a 

minimum, differentiation of S. aureus from other coagulase 

positive staphylococci is needed for both interpretation 

of zoonotic risks and the use of proper antimicrobial 

susceptibility testing methodology (since there are different 

recommendation for S. aureus and S. pseudintermedius). 

Coagulase negative staphylococci tend to be of limited 

virulence and after often considered together as a single 

group, although there is some evidence of variation in 

virulence and clinical relevance. 

Methicillin-resistant staphylococcus 

pseudintermedius (MRSP) 

MRSP appears to have emerged and disseminated 

internationally in companion animals at a truly amazing 

rate, with rapid development of a very high level of drug 

resistance. MRSP infections are being identified virtually 

everywhere that people are looking, and the increase in 

incidence of disease, while not objectively studied, seems 

to be dramatic, particularly among dogs with pyoderma 

and in surgical site infections. It has been called a serious 

emerging problem in small animal veterinary medicine and 

one that requires urgent action to control its spread. 1 Highly 

antimicrobial resistant strains are commonly encountered, 

and there may be few viable treatment options. Curiously, 

while MRSP appears to only have emerged as a problem 

recently, MRSP strains from dogs and cats are typically 

much more resistant than MRSA strains which have 

presumably been around much longer. 

Staphylococcus pseudintermedius is the most common 

pathogenic Staphylococcus in dogs and a common 

commensal that can be found in or on a large percentage 

of healthy dogs, and a smaller percentage of cats. As with 

methicillin-susceptible S. pseudintermedius (MSSP), MRSP 

can be found in or on healthy dogs and cats. Carriage rates 

of 0-17% in dogs and 0-1.2% in healthy cats have been 

reported,2-6 and it appears that the rate of colonization 

is increasing in many regions. Risk factors for MRSP 

colonization have not been adequately investigated, 

but there is some evidence that routine antimicrobial 


administration may be an important driving force for MRSP 

colonization in dogs. 

MRSP is an opportunistic pathogen and colonization 

does not necessarily lead to disease. Indeed, it is likely 

that the vast majority of colonized animals never develop 

a clinical infection. The risk of infection in MRSP carriers 

has not been reported, but it is reasonable to assume 

that MRSP carriers are at some increased risk of MRSP 

infection, at least in certain situations (e.g. after surgery). 

Limited study of risk factors for infection has been 

performed but antimicrobial administration, hospitalization 

or surgery within 30 days prior to the onset of infection were 

associated with MRSP versus MSSP infection in one study. 7 

Skin, ear and other soft tissue infections predominate. 7-10 

Very high rates of MRSP infection are now being identified 

among canine pyoderma patients. Likely the 2 nd most 

common presentation of MRSP infections is surgical 

site infections (SSIs), and the prevalence of MRSP SSIs 

is anecdotally increasing rapidly in many regions. Little 

comparative study has been performed, but elective 

orthopedic procedures, particularly TPLO, appear to be 

over-represented. This is of significant concern because 

of the morbidity and even mortality that can be associated 

with these infections. As highly drug resistant MRSP are 

being encountered more often, amputation is sometimes 

required to in response to uncontrollable SSI from elective 

orthopedic procedures, something that is of tremendous 

concern. 

There is no indication that MRSP infections are inherently 

more serious than infections caused by methicillinsusceptible 

strains, however they could ultimately be 

associated with increased morbidity and mortality because 

of failure of initial empirical antimicrobial therapy and 

limited treatment options. This concern is heightened by 

the continued emergence of resistance, as antimicrobials 

that were commonly effective a short time ago (e.g. 

chloramphenicol, doxycycline, trimethoprim-sulfa) are now 

often ineffective. 

Public Health Issues 

Despite the fact that exposure to S. pseudintermedius must 

be very common in pet owners (given the high prevalence of 

colonization in pets), human S. pseudintermedius infections 

are rarely reported and colonization rates in veterinary 

personnel and pet owners are rather low (1-4%),6, 11 

suggesting poor host adaptation to humans. Methicillinresistance 

simply confers antimicrobial resistance, not 

inherently increased virulence, and there is no evidence 

that MRSP is more likely to cause an infection than 

MSSP. Accordingly, the low incidence of MSSP infections 

in humans should indicate a correspondingly low risk of 

MRSP infection. Transmission of MRSP between dogs 

and people is likely based on reports of indistinguishable 

isolates from people and dogs12, 13 and isolation of MRSP 

from a small percentage of owners of dogs with MRSP 

pyoderma.14 However, there is currently limited public 

health concern regarding MRSP. However, the limited 

but increasing number of reports of MRSP infection in 

humans15, 16 should not be dismissed. Given the highly 

drug resistant nature (and associated treatment difficulty) 

of MRSP, while the risk may be very low, the consequences 

of infection could be high, so care should be taken to use 

good infection control practices around infected animals 

in households and veterinary clinics. 

The potential for under-reporting of MRSP must also 

be considered if human diagnostic laboratories are not 

adequately differentiating MRSP from the much more 

common coagulase positive Staphylococcus MRSA.17 

Methicillin-resistant staphylococcus aureus (mrsa) 

MRSA tends to receive a higher profile than MRSP 

because of its huge impact in human medicine and its 

earlier apparent emergence in companion animals (relative 

to MRSP), however it is a much less common cause of 

infection in dogs and cats. Despite the importance of 

this pathogen, the animal health implications of MRSA 

are nowhere near as large in dogs and cats compared to 

MRSP. Regardless, attention must be paid to this organism 

because of the potential for serious and difficult-to-treat 

infections and the potentially greater zoonotic implications. 

It is assumed that the emergence of MRSA in companion 

animals is directly related to MRSA in humans. As MRSA 

expanded in humans in the general population in the 1990s 

and 2000s, exposure of pets was inevitable. Humans are 

thought to be the ultimate source of infection for a large 

percentage, if not the vast majority, of infections in pets, 

and changes in the epidemiology of MRSA in humans 

can be reflected in changes in trends in pets. Virtually all 

MRSA isolates from pets are recognized human epidemic 

clones and identification of other strains in dogs and cats is 

rare. 18-22 Sequence type 398 MRSA, a livestock-associated 

strain of particular concern in Europe, has been found in a 

limited number of dogs, 23-25 however dogs were more likely 

infected by people that were exposed to livestock. 

First reported in the 1990s, MRSA infection and 

colonization have now been identified in dogs, cats and 

other companion animals across the world. Staphylococcus 

aureus can be isolated from the nares, perineum or intestinal 

tract of 12-14% of healthy dogs and 4.3-20% of healthy 

cats,3, 6, 26 and not surprisingly, MRSA can also be found in 

healthy individuals. Reported colonization rates are variable 

but tend to be 0-3.3% in healthy dogs and 0-6% in healthy 

cats.26-31 Higher rates can be encountered periodically in 

animals in veterinary facilities.32, 33 However, most MRSA 

cases are not associated with veterinary hospitals. Higher 

rates can also be found in specific dog populations such as 

households where another pet has an MRSA infection,34 or 

during outbreaks in breeding or rescue kennels.20, 25 Being 

owned by a human healthcare worker and participation in 

hospital visitation programs have been identified as risk 

factors for MRSA colonization in dogs, and are logical 

based on the increased likelihood of exposure to colonized 


people.18, 35 Contact with children has also been identified 

as a risk factor.18 While these, and potentially other, risk 

factors should be considered, MRSA can be identified in 

any animal and absence of known risk factors should not 

lead to excluding MRSA from consideration. 

As with MRSP, most animals that are colonized with 

MRSA have no signs of infection and may never develop 

a clinical infection, but opportunistic infections can 

develop. S. aureus produces a similar range of disease 

as S. pseudintermedius. The main difference between 

S. pseudintermedius and S. aureus (and therefore 

between MRSP and MRSA) is the incidence of disease, 

not disease location or severity. Clinically, MRSA 

infections are indistinguishable from those caused by 

methicillin-susceptible strains or other coagulase positive 

staphylococci, predominantly skin and ear infections, with 

smaller numbers of other opportunistic infections.3, 19, 

21, 22, 36-40 It is possible that infections more commonly 

associated with human-contact (e.g. wound and surgical 

site infections contaminated by hands of owners or 

veterinary personnel) are more likely to be caused by S. 

aureus (including MRSA) but objective data are lacking. 

Public Health Issues 

Significant attention has been given to public health 

concerns regarding pets and MRSA. Given the importance 

of MRSA in human medicine, it is perhaps not surprising 

that serious concern has accompanied identification of 

MRSA in pets. However, as knowledge regarding MRSA 

advances, it is becoming evident that while interspecies 

transmission of MRSA certainly does occur in households, 

human-to-animal transmission is probably most common. 

The role of pets in human MRSA infection is completely 

unclear. It is likely that pets play at best a very limited role 

in human MRSA infection, however zoonotic infections 

certainly cannot be dismissed and in some situations an 

infected or colonized animal could pose a reasonable risk 

to humans. 

Colonization of people in contact with infected or 

colonized dogs and cats (often with demonstration of 

the same strain in humans and animals) has been widely 

reported. 19, 22, 35, 41-44 Pets have been implicated as sources 

of infection for humans in households, 41, 43 however 

conclusions are often overstated. Virtually all studies have 

involved concurrent testing of people and pets. While 

finding the same MRSA strain in both groups strongly 

supports interspecies transmission, it cannot determine the 

direction of transmission. Further, since the MRSA strains 

found in pets are human epidemic clones, and because 

the average pet has little contact with other people or 

animals, it is most likely that a human household member 

would bring MRSA into the home, with the potential for 

subsequent dissemination to other humans and animals. 

This assessment should not be taken as an indication that 

there is no risk from pets, since regardless of how a pet is 

ultimately infected, it could still transmit MRSA to humans. 

Numerous studies of MRSA colonization in veterinary 

personnel have been performed, reporting colonization 

rates of up to 18% in small animal veterinary personnel. 45-48 

It cannot be determined with certainty that these 

colonization rates reflect acquisition of MRSA from animals 

however identification of higher rates than present in the 

general population (1.5-3%), 49, 50 and the lack of other 

explanations as to why veterinary personnel would be at 

higher risk than others provide support of occupational 

origin. Whether this constitutes a significant health risk for 

veterinary personnel is unclear. There are limited reports 

of MRSA infection in veterinary personnel that have 

worked with infected or colonization animals, 51, 52 along 

with numerous anecdotal reports. Further, the high rates 

of colonization could increase the risk of infection in some 

situations such as if colonized veterinary personnel undergo 

surgery or are admitted to hospital. Another concern is 

the potential for veterinary clinics to act as reservoirs of 

MRSA, resulting in infection or colonization of patients 

and potentially subsequent exposure of patients’ families. 

The true role of pets in human MRSA infections is 

impossible to determine at this point. Considering the 

epidemic of community-associated MRSA infections in 

people and endemic MRSA in human healthcare facilities, 

pets certainly play a minor role overall in human infections. 

Yet, with the scope of this problem, a minor role from a 

population standpoint could still represent a relevant source 

of infection. The potential role of pets in human MRSA 

infections should be considered, but in a balanced manner. 

Methicillin-resistant staphylococcus schleiferi 

(MRSS) 

Staphylococcus schleiferi consists of two subspecies, 

the coagulase positive S. schleiferi subsp coagulans and 

coagulase negative S. schleiferi subsp schleiferi. These 

are less common causes of infection compared with S. 

pseudintermedius and S. aureus, but a large percentage 

of diagnostic laboratories do not attempt to different 

S. schleiferi coagulans from S. pseudintermedius or S. 

schleiferi schleiferi from other coagulase negative species 

so there are limitations in understanding of the role of these 

species in disease. Staphylococcus schleiferi coagulans can 

be isolated in 0.8-4% of healthy dogs and 0-2% of healthy 

cats.3, 6, 26 Colonization with methicillin-resistant S. 

schleiferi (MRSS) has been identified in 0-2% of dogs3, 4, 6 

and MRSS infections are being increasingly reported.36, 53, 

54 S. schleiferi coagulans is most commonly implicated in 

pyoderma and otitis externa in dogs, but other opportunistic 

infections such as urinary tract infection and pneumonia 

have been reported.3, 36, 55-59 Less in known about S. 

schleiferi schleiferi, but it is likely present in or on a small 

percentage of healthy dogs and cats. It has been implicated 

as a cause of pyoderma and otitis,36, 56, 58 and methicillinresistant 

infections, while poorly characterized, presumably 

do the same. 


Public health concerns are currently limited. Human 

S. schleiferi coagulans infections are extremely rare. 

In one case, a dog with otitis was thought to be the 

source of S. schleiferi coagulans endocarditis in an 

immunocompromised person,60 but it was not possible to 

confirm that the dog was the source. While Staphylococcus 

schleiferi schleiferi periodically causes human infections, 

it is probably a human commensal species so pets are 

unlikely to be the source. 

Coagulase Negative Staphylococci (MR-CoNS) 

MR-CoNS are common commensals and generally 

of limited virulence. MR-CoNS infections may be 

overdiagnosed because MR-CoNS can be isolated as 

contaminants from various superficial body sites. In human 

medicine, MR-CoNS are primarily a concern in hospitalized 

individuals.61 The situation may be similar in dogs can cats, 

with most CoNS being of minimal pathogenicity and mainly 

of relevance in highly compromised patients. While CoNS 

are generally considered as a group, it is possible that there 

are differences between CoNS species. This mainly relates 

to three organisms; S. schleiferi subspecies schleiferi, S. 

epidermidis and S. felis. Staphylococcus schleiferi schleiferi 

and S. epidermidis have been implicated as a cause of 

pyoderma and otitis,36, 56, 58, 62 and may be inherently 

more pathogenic in skin and ear infections than other CoNS. 

A primary role of S. felis in urinary tract infections in cats 

has also been suggested.63 These species may, therefore, 

be relevant pathogens in community-associated disease, 

unlike most other CoNS. As with other staphylococci, 

methicillin-resistant strains are inherently no more 

pathogenic than methicillin-susceptible strains, and the 

implications of colonization with MR-CoNS are typically 

inconsequential. 

Coagulase negative staphylococci, including MR-CoNS 

are common in both animals and humans. While many of 

the same CoNS species can cause disease both people 

and pets, it is unlikely that animals are relevant sources 

of human infection. 

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Short communications – orthopaedics 

Friday July 8 


Biomechanical comparison of plate, plate-rod and 

orthogonal plate locking constructs in an ex-vivo 

canine tibial fracture gap model. 

Glyde M *1 ., Day R. 2 , Deane B. 1 , Read R 1 . and Hosgood G * 1 . 

1 Murdoch University, School of Veterinary and Biomedical Sciences, Perth, Australia. 2 Department of Medical 

Physics, Royal Perth Hospital, Perth, Australia. 

Introduction 

The purpose of this research was to compare the 

biomechanical characteristics of medial plate, plate-rod 

and orthogonal plate locking constructs in a canine ex-vivo 

comminuted tibial fracture gap model. 


Tibial pairs from six Greyhounds euthanased for reasons 

unrelated to this study were separated into two groups. 

Group MPU had a Synthes® 10 hole 3.5mm LCP (locking 

compression plate) applied to the medial tibia with 4 

unicortical screws per fracture fragment. Group MPB had 

identical plate application excepting 2 bicortical screws 

per fracture fragment. MPU and MPB constructs were 

non-destructively tested in two-plane four-point bending, 

axial compression and torsion (Instron 5566 and 8874). 

Following testing Group MPU had a 2.4mm Steinmann IM 

(intramedullary) pin added to create a plate-rod construct 

(Group PR). IM pin diameter was 30-40% of the mean 

medullary diameter at the narrowest point. Group MPB 

received a cranial 10 hole 2.7mm LCP with 2 bicortical 

screws per fracture fragment creating an orthogonal 

plate construct (Group OP). Groups PR and OP were nondestructively 

tested using the same protocols as for groups 

MPU and MPB. Subsequently Groups PR and OP were 

loaded to failure in axial compression. 

Results 

MPU and MPB construct stiffness was not significantly 

different (p>0.05) in any test mode. PR construct stiffness 

was significantly greater than MPU stiffness in lateromedial 

bending (140%, p

Effect of screw insertional torque on mechanical 

properties of 5 different angular stable systems 

A Boero Baroncelli 1 , U Reif 2 , C Bignardi 3 , B Peirone 1 . 

1 Department of Animal Pathology, University of Turin (Italy), 2 Tierklinik Dr. Reif, Böbingen (Germany), 3 

Department of Mechanics, Politecnico di Torino (Italy) 

Introduction 

The purpose of this study was to compare the screw push 

out strength and resistance to cantilever bending of five 

different angular stable systems. Our first hypothesis was 

that there is a significant difference between the systems 

regarding push out strength and cantilever bending. 

Furthermore, our second hypothesis was that screws 

insertion torque has an influence on push out strength and 

cantilever bending properties of the locking mechanism. 

Material and Methods 

Five different 3.5 mm implant systems were evaluated. 

The Synthes LCP, the Traumavet Fixin, the Securos PAX, the 

Orthomed SOP, and the Veterinary Instrumentation locking 

system. Screws were then inserted using a variable torque 

limiting device which was set to 0.8, 1.5, 2.5, and 3.5 Nm. 

To evaluate the push out strength, the constructs were 

mounted in a custom made device. A force was applied at 

the level of the screw tip acting along the long axis of the 

screw at a constant displacement rate of 1 mm/min. For 

cantilever bending a load was applied perpendicular to the 

long axis of the screw at a constant displacement rate of 1 

mm/min. Statistical analysis of the push out strength and 

cantilever bending stiffness were performed using analysis 

of variance ANOVA (p-value 0,001). 

Results 

A statistically significant influence of the insertional 

torque on push out strength was seen in the Securos 

( p = 0.00001) and the Traumavet ( p = 0.00001) system. 

A statistically significant influence of the insertional torque 

on bending stiffness was only seen in the Securos system 

(p = 0.00098). 

Conclusions 

For the Orthomed, Synthes and Veterinary Instrumentation 

systems insertional torque did not influence push out 

strength nor cantilever bending stiffness. When using 

the Traumavet and Securos angular stable systems, the 

minimum acceptable insertion torque should be 2,5 Nm, in 

order to obtain correct screw-plate coupling. In the Securos 

system insertional torque positively influence the push out 

strength and cantilever bending stiffness values. 

ECVS proceedings 2011 89 small animal orthopaedic session

The use of pedicle screws in canine lumbosacral 

disease. 

Meij BP*, Smolders LA, Bergknut N, Voorhout G, Grinwis GCM, Hazewinkel HAW* 

Department of Clinical Sciences of Companion Animals, Utrecht, The Netherlands. 

Introductio 

The use of the pedicle screw-rod fixation (PSRF) has been 

tested biomechanically in a canine cadaver study. The aim 

of the present study was to assess the pedicle screws in 

the canine lumbosacral junction (LSJ) ex vivo in an imaging 

study and to evaluate the use of PSRF in vivo in 6 dogs 

with lumbosacral disease. 


Ex vivo study: PSRF of the LSJ was performed in six 

canine cadaveric lumbosacral spinal specimens using 

predefined guidelines and was evaluated with radiography, 

computed tomography and magnetic resonance imaging. In 

vivo study: 3 Greyhound dogs diagnosed with degenerative 

lumbosacral stenosis (DLSS) and 3 dogs diagnosed 

with lumbosacral discospondylitis underwent dorsal 

laminectomy and partial discectomy combined with PSRF 

of the LSJ. Curettage of the endplates with insertion of 

an autologous cancellous bone graft was performed to 

promote spinal fusion. During the 18-month follow-up, 

the dogs were monitored by means of clinical evaluation, 

diagnostic imaging, and force plate analysis (for the dogs 

with DLSS). Post-mortem imaging and histopathological 

investigations were performed on the 3 LSJs from the dogs 

diagnosed with DLSS (euthanized for reasons unrelated 

to PSRF). 

Results 

Ex vivo study: Sixteen of 24 inserted screws had an 

acceptable placement. In vivo study: Fourteen of 16 

inserted screws had an acceptable placement. Clinical 

signs of low back pain resolved at 4 weeks after surgery 

in all 6 dogs. Force plate analysis revealed a trend toward 

improved pelvic limb function relative to the preoperative 

function for the dogs with DLSS. Diagnostic imaging and 

histopathology showed no bony spinal fusion of the LSJ 

in the dogs with DLSS 

Conclusions 

PSRF can be successfully applied to the LSJ of large 

breed dogs for DLSS and discospondylitis. Improvements 

to the surgical technique to induce spinal fusion and 

assessment in a larger sample size are required. 

Clinical Relevance: PSRF may become a valuable addition 

in the surgical treatment arsenal for dogs with DLSS and 

lumbosacal discospondylitis. 

small animal orthopaedic session 90 ECVS proceedings 2011

Effect of articular design on mediolateral constraint 

and stability of two unlinked canine total elbow 

prostheses 

Guillou RP 1 , Demianiuk RM 1 , Déjardin LM* 2 ,Beckett C 2 , Haut RC 

1 College of Veterinary Medicine and 2 Orthopedic Biomechanics Laboratories, College of Osteopathic 

Medicine, Michigan State University, East Lansing, MI, USA 

introduction 

Short and long term stability of the unlinked, semiconstrained 

IOWA and TATE prostheses is influenced 

by their articular congruity. While a less congruent 

design spares bone/implant interfaces from deleterious 

stresses, it may impair prosthetic stability. To optimize 

osteointegration, a low congruity TATE-2 profile was 

recently released; however optimal prosthesis constraint 

is unknown. Our purpose was to compare IOWA and TATE 

behavior under mediolateral translation. We hypothesized 

that constraint and stability would be greatest in IOWA and 

lowest in TATE-2 profiles. 

Materials and Method 

Four prostheses per group were tested in mediolateral 

translation. Loading conditions mimicked those of a trotting 

40kg dog in mid-stance. Stiffness (a reflection of prosthetic 

constraint) and maximum resistive force (an indication of 

prosthetic intrinsic stability) were statistically analyzed 

(p

The effect of configuration and radiographic 

positioning on measurements of deformity magnitude 

in a dog with a complex antebrachial growth 

deformity: comparison between radiographic and 3D 

computer modelling measurements 

N. Fitzpatrick, C. Nikolaou,JF. Isaza Saldarriaga, S. Correa Velez, V. Wavreille, K. Ash, JJ. Ochoa 

Fitzpatrick Referrals, Surrey, UK. 

Introduction 

Our aim was to establish the mathematical relationship 

between radiographically measured torsion and frontal 

plane antebrachial growth deformities (ABGD) and to 

compare with those derived from a 3D computer model. 


Direct digital radiographs and CT scans of the forelimbs 

of a 23kg dog with bilateral ABGD were acquired. 3D 

reconstructions were created from the CT scans and 

parametric surfaces exported to SolidWorks 2009. The 

lateral distal radial angle (LDRA) and distal caudal radial 

angle (DCRA) were measured on both. A transverse cut 

of the radius was performed at the intersection point 

of the anatomical axes and the frontal plane deformity 

was measured following: 1) rotation of the distal radial 

segment, 2) alteration of the procurvatum angle, 3) rotation 

of the limb around the humeral axis with: (a) unchanged 

procurvatum, (b) procurvatum 20 0 , (c) procurvatum 0 o , (d) 

procurvatum equal valgus angle, 4) rotation of the limb 

around the transcondylar axis. Valgus angle measurements 

were correlated using curve estimation regression analysis. 

Results 

Radiographically measured values were: valgus 8.83 o ; 

LDRA 89.81 o ; procurvatum 10.38 o ; and DCRA 86.3 o and the 

same deformities measured on the 3D model were: 29 o ; 

100.4 o ; 19.39 o ; and 96.6 o . Radial torsion and procurvatum 

did not affect measurements of valgus on the 3D model. 


Radiographic measurements of frontal plane deformity 

differed significantly from measurements on the 3D 

model and the model was more accurate for pre-operative 

planning. Rotation around the humeral axis had a significant 

and predictable effect on the measurements of valgus 

deformity. 


Association of articular mineralisation, cranial 

cruciate ligament pathology and degenerative joint 

disease in feline stifle joints 

Voss K* 1 , Karli P 2 , Kipfer N 2 , Geyer H 3 

1 University Veterinary Teaching Hospital, Sydney, Australia, 2 Clinic for Small Animal Surgery and 3 Department 

of Anatomy, Vetsuisse Faculty University of Zurich, Switzerland. 

Introduction 

The clinical significance of mineralisation in the stifle 

joint of cats is unknown despite published associations with 

cranial cruciate ligament rupture (CCLR) and degenerative 

joint disease (DJD). 


Presence and size of mineralisations were noted from 

lateral stifle radiographs of 25 cats with CCLR and an 

age-matched group of 25 cats without CCLR that had been 

euthanised for reasons unrelated to this study. Size of 

mineralisations was classified as small, medium or large, 

and the prevalence was recorded. In the second part of 

the study, stifle joints of cat cadavers were processed 

for microscopic evaluation. Degenerative changes of the 

cruciate ligaments, menisci, articular cartilage, and joint 

capsule were graded on a scale from 0 to 3. Comparison of 

stifles without, with small, and with large mineralisations 

was made. 

Results 

Mean age of both groups was 8.6 years. Prevalence of 

articular mineralisations was 0.76 in stifles with CCLR, 

and 0.64 in stifles without CCLR. Mineralisations in stifle 

joints without CCLR were predominantly small, whereas 

mineralisations in stifle joints with CCLR were medium or 

large. Small mineralisations tended to be calcifications 

located in the cranial horn of the medial meniscus. Larger 

mineralisations were ossifications commonly located in the 

cranial meniscal attachments, the joint capsule, and the fat 

pad. DJD scores of all intra-articular structures increased 

from stifles with no mineralisations to those with large 

mineralisations. 


Mineralisations in feline stifle joints were found to 

differ in size, microscopic appearance, and location. Larger 

mineralisations were mostly located cranial to the medial 

meniscus and were associated with DJD and CCLR. 


The role of the antebrachiocarpal ligaments 

in the prevention of hyperextension of the 

antebrachiocarpal joint 

Milgram J*, Milstein T, Meiner Y. 

Koret School of Veterinary Medicine, The Hebrew University of Jerusalem, Israel 

Introduction 

A normal antebrachiocarpal joint is crucial to canine 

locomotion, however, very little is known about how 

pathological changes affecting individual structures 

influences the normal kinematics of this joint. The aim of 

this study was to evaluate the role of the medial collateral 

ligament, lateral collateral ligament and the palmar carpal 

ligaments in the prevention of carpal hyperextension. 


Twenty four forelimbs were collected from 12 healthy 

mixed breed dogs of medium build. Each specimen was 

radiographed to ensure the carpal joint was free of 

abnormalities and assigned to 1 of 6 groups. The groups 

were defined by the order in which the ligaments stabilising 

the antebrachiocarpal joint were cut. The antebrachium, 

carpus and proximal metacarpal bones were stripped of 

all muscle tissue, preserving the carpal joint capsule. The 

specimens were prepared for biomechanical testing and 

placed into a custom made joint testing machine. The 

manus was loaded using a system of weights and pulleys 

resulting in the extension of the carpus. The extension was 

measured using a single motion tracking sensor fixed to the 

metacarpal bones. All specimens were tested with all the 

ligaments intact, and after cutting each of the ligaments 

in the order defined by the group. 

Results 

Cutting each of the ligaments resulted in a significant 

change in the angle of extension of the carpus when 

compared to the extension of the carpus with the ligaments 

intact. Cutting the palmar AC ligaments resulted in the 

largest change in the extension angle and this difference 

was significantly larger than that seen after cutting the 

medial and lateral collateral ligaments. 

Discussion 

Each of the AC ligaments tested contribute to the 

prevention of hyperextension of the AC joint. Improved 

understanding of the function of the AC ligaments 

may result in improved techniques for the treatment of 

hyperextension injury. 


The effect of screw number and plate stand-off 

distance on the biomechanical characteristics of 

3.5mm locking compression plate (LCP) and 3.5mm 

string of pearls (SOP) plate constructs in a synthetic 

fracture gap model. 

Glyde M *1 , Day R 2 . and Hosgood G *1 . 

1 Murdoch University, School of Veterinary and Biomedical Sciences, Perth, Australia. 2 Department of Medical 

Physics, Royal Perth Hospital, Perth, Australia. 

Introduction 

The purpose of this research was to compare the effect of 

stand-off distance and screw number on the biomechanical 

characteristics of 3.5mm LCP and 3.5mm SOP plate 

constructs in a synthetic fracture gap model. 


Stiffness of Synthes®10-hole 3.5mm LCP and 

Orthomed® 10-hole 3.5mm SOP constructs were evaluated 

in a synthetic diaphyseal bridge-plating model under axial 

compression in load control to a peak load of 120N and 

bi-planar four-point bending in displacement control with 

a peak bending moment of 6Nm (Instron 5566 and 8874, 

Bluehill v2.5.391 software sampling at 10hz). For 4-point 

bending the implant was on the construct tension side 

when load was applied parallel to the screw axis (tension 

bending) and subsequently rotated 90 degrees with 

applied load perpendicular to the screw axis (perpendicular 

bending). The central two screw holes were left vacant 

over the 10mm fracture gap. For each plate type construct 

variables included standoff distance (1 or 5mm) and 

screw number (2,3 or 4 per fracture fragment) creating 12 

treatment groups. 

Results 

There was no significant effect (p>0.05) of increasing 

screw number per fragment on SOP construct stiffness 

at 1mm or 5mm standoff with the exception in tension 

bending that 4 screws were stiffer (p0.05) on LCP constructs at 1mm with the exception 

in perpendicular bending that 4 screws were stiffer 

(p



In depth – shoulder arthroscopy - 

clinical update 

Friday July 8 



Dorsal recumbent shoulder arthroscopy technique, 

normal anatomy, & appearance of routine pathology 


Veterinary Referral Center of Colorado, Englewood, Colorado, USA 

Most descriptions of shoulder arthroscopy techniques 

position dogs in lateral recumbency with the affected limb 

up allowing for consistent establishment of lateral optical 

portal and caudolateral or craniolateral instrument. Dorsal 

recumbent positioning with distal traction of the limb is 

an alternate position allowing for additional assess to the 

joint via the craniomedial portal.1,2The main advantage 

of dorsal recumbent positioning is the view afforded via 

the craniomedial portal. This allows for the surgeon to 

change the optic port from the standard lateral portal to 

the craniomedial portal to provide an improved view of 

lateral intraarticular structures. The main disadvantage 

of dorsal recumbent positioning is accommodating for 

the inverted anatomy. While the anatomy is identical, it 

is inverted making some familiar structures completely 

unrecognizable to the naïve eye. 

To perform dorsal recumbent shoulder arthroscopy, 

patients are positioned with the aid of a vacuum-positioning 

bag to maintain dorsiflexion of the cervical spine and axial 

alignment. The limb is aseptically prepared in hanging leg 

prep and draped in a standard fashion. Distal traction on the 

limb is provided by an adjustable block and tackle secured 

in an aseptically to a sturdy ceiling anchor. Distention of 

the joint is necessary for consistent portal placement. A 

spinal needle is inserted into the joint at the depression 

between the cranial border of the acromion and dorsal 

border of the greater tubercle. Proper placement into the 

joint is confirmed by aspiration of synovial fluid. The joint 

is distended with 10 mL of sterile distension fluid (i.e., 

LRS, NaCl). Care is required to prevent over distention and 

rupture of the joint capsule. The author prefers to leave 

the spinal needle in place as an egress portal. The optical 

portal is established at the lateral location immediately 

caudal and slightly distal to the acromion. This location 

can vary dependent on the morphology of the acromion. A 

stab incision made and the sheath with a blunt obturator 

is advanced into the joint in a controlled manner. A distinct 

pop is felt as the articular space is entered. As the obturator 

is removed, the sheath is stabilized to prevent inadvertent 

displacement from the joint. Rapid egress of distention fluid 

should occur as the obturator is removed from the sheath. 

Working portals are established dependent on the 

region of interest. The location of the caudolateral 

portal is approximately 1 cm caudal and 1-2 cm distal 

to the lateral portal. Needle-localization of working 

portals facilitates proper orientation of working portals 

to identified pathology. The general location of the caudal 

lateral portal is determined by digital pressure in the 

region and observing the deflection of the joint capsule. 

Next, a nitinol needle (or a spinal needle) is inserted in the 

proposed location and the needle is observed within the 

joint. A stab incision is made at the needle puncture site 

and the cannulated obturator and cannula is inserted over 

the nitinol needle. The cannulated obturator is removed 

leaving the cannula in place as the working portal. 

Craniomedial portal can be established in lateral or 

dorsal recumbency; however, this location is difficult to 

utilize effectively in lateral recumbent positioning. Needlelocalization 

and creation from an outside-in technique 

is possible, however, the author prefers an inside-out 

technique. The craniomedial portal is established in 

a triangular region bordered by the synovium covered 

coracobrachialis tendon dorsally, subscapularis tendon 

caudally, and the biceps tendon. The arthroscope tip is 

driven to the triangular region and held securely against 

the joint capsule while the arthroscope is removed from 

the sheath. A switching stick is placed into the sheath and 

advanced through the joint capsule and skin at the site of the 

craniomedial portal from inside out. The arthroscope sheath 

was removed leaving the SS spanning across the joint from 

the lateral portal to the newly formed craniomedial portal. 

The arthroscope sheath or working cannula is advanced 

over the SS to establish the craniomedial portal. Viewing 

via the craniomedial perspective is especially useful in dogs 

with suspected shoulder instability. OCD flaps displaced 

into the medial scapular recess can be more readily 

accessed with this portal. 


References 

1. Devitt CM, Neely MR, Vanvechten BJ. Relationship 

of physical examination test of shoulder instability to 

arthroscopic findings in dogs. Veterinary surgery : VS : 

the official journal of the American College of Veterinary 

Surgeons 2007;36:661-668. 

2. Cook JL, Cook CR. Bilateral shoulder and elbow arthroscopy 

in dogs with forelimb lameness: diagnostic findings and 

treatment outcomes. Veterinary surgery : VS 2009;38:224- 

232. 


MRI and arthroscopy for evaluation of shoulder joint 

pathology 

H. van Bree*, W. Dingemanse, I. Gielen 

Department of Medical Imaging & Small Animal Orthopaedics, Veterinary Faculty, Ghent University 

The canine shoulder is a complex joint, with numerous 

passive and active soft tissue stabilizing components. 

It is a ball-and-socket joint, which allows movement in 

essentially every direction. In the dog and cat, however, 

most of the motion takes place in a direct cranial-to-caudal 

plane, resulting mainly in extension and flexion of the joint. 

The medial and lateral glenohumeral ligaments are not 

really ligaments, but rather thickenings of the respective 

surfaces of the joint capsule. They are rather weak, so it 

is the strength of the heavy musculature surrounding the 

shoulder joint that maintains its integrity. 

Shoulder lameness, although a common condition in the 

dog, can be difficult to localise, and determining the specific 

cause is often challenging. Even when the lameness has 

been localized to the shoulder, identifying the precise cause 

can be frustrating. 

Some of the indications for imaging of the shoulder 

joint are: 

• Any lameness associated with a shoulder problem: 

i.e. pain on manipulation of the joint itself or any of 

the structures in the shoulder area. 

• Swelling or deformity of the shoulder region. 

• Atrophy of the adjacent shoulder muscles. 

Possible imaging techniques 

Scintigraphy can be used to localise lameness 

originating in the shoulder region and to evaluate the 

significance of equivocal radiological findings. 

Plain radiography: standard radiographs provide 

only limited diagnostic information, and frequently there 

is a poor correlation between the radiological findings 

and clinical signs. There may be extensive changes due 

to degenerative joint disease (DJD) present, with no 

lameness but as an incidental finding in older dogs. The 

radiological assessment of the shoulder joint should include 

evaluation of alignment, subchondral bone, joint space, 

and adjacent periarticular soft tissues. Many of the joint 

tissues – such as cartilage, synovial membrane, fibrous 

capsule, and collagenous structures – are not visible on 

plain radiographs and therefore can only be evaluated 

indirectly, by (for example) calcification within tendons 

and irregularities at their attachments. Arthrography and/ 

or ultrasound can be helpful in visualizing some of these 

structures. 

Arthrography of the shoulder joint is the most common 

arthrographic procedure used in small animal orthopaedics. 

It is a useful and simple technique for imaging various 

shoulder problems in the dog. Several bursae around 

the scapulohumeral joint can be visualised. The bicipital 

tendon sheath and subscapular recess are always visible, 

whereas the infraspinatous bursa is only occasionally 

seen. Arthrography can outline the articular cartilage, 

synovial membrane, biceps tendon and associated 

synovial sheath (but cannot identify smaller lesions 

within the biceps tendon), various bursae, a cartilage 

flap in shoulder osteochondrosis (OCD) and radiolucent 

joint mice. In cases of shoulder OCD, positive-contrast 

arthrography helps to assess – with an accuracy of 80% 

– whether a non-mineralized cartilage flap is present, and 

this finding helps to determine whether a dog should be 

treated conservatively or surgically. In cases of bicipital 

pathology, positive contrast arthrography may demonstrate 

changes in the contour of the bicipital groove and tendon, 

incomplete filling of the synovial sheath, filling defects and 

irregularities. It can also aid decision making in cases of 

caudal glenoid fragmentation. With the use of positive 

arthrography, impingement of the joint capsule can be 

demonstrated, and the fragment is visible as a filling defect. 

Ultrasonography (US) can be used in the shoulder joint 

to diagnose muscle and tendon injury and to evaluate OC 

lesions. A high-frequency linear transducer is used for this 

examination, and the dog may have to be anaesthetised if 

joint manipulation is painful. The humeral head is visible as 

a hyperechoic convex curvilinear line with a strong acoustic 

shadow, and the cartilage as an anechoic layer covered 

by the joint capsule, the tendons of the infraspinatus and 

teres minor muscle and the acromial part of the deltoid 

muscle. For the evaluation of the bicipital tendon sheath, 

cross-sectional images at the level of the bicipital groove 

and longitudinal images at the level of the attachment on 


the supraglenoid tubercle are taken. Results of a recent 

study in shoulder OCD – comparing ultrasound with 

radiography, arthrography and arthroscopy – suggest that 

all radiologically diagnosed subchondral lesions in the 

humeral head can be visualised by the use of ultrasound 

as a concave deviation of the hyperechoic subchondral 

bone line with a variable length according to the extent of 

the lesion. The results also suggest that the presence of a 

second hyperechoic line at the bottom of the subchondral 

defect seen on US is a pathognomonic sign for the presence 

of a flap. It was suggested that US might present an 

alternative to positive contrast arthrography. With the 

use of ultrasound, bicipital lesions and supraspinatus 

tendinopathy can be identified. This technique is highly 

operator-dependant and requires experience. 

Computed tomography (CT): The use of CT can be 

justified in some conditions, especially in situations where 

one wants to avoid superimposition of bony structures 

when evaluating the extent of processes, or to determine 

the source of calcifications or fragments seen on plain film 

radiographs. New bone formation in the bicipital groove 

can be easily seen. Also, CT may be useful in cases with 

suspect demineralisation, as this technique can detect 

loss of bone content at an earlier stage than conventional 

radiography can. Also, arthro-CT can be performed to 

check the integrity of the biceps tendon. In the case of 

soft tissue involvement of the shoulder region, IV contrast 

can be applied with a dose of 200 mg I/kg bodyweight. CT 

guided biopsies of neoplastic processes in the shoulder 

region can be performed. 

Magnetic resonance imaging (MRI) can provide a 

more complete look at important canine soft tissue shoulder 

structures. MRI is a non-invasive diagnostic modality that 

provides a high-contrast, multi-planar depiction of joint 

associated anatomy. Superior soft tissue image resolution, 

along with the ability to image in multiple planes, has 

made MR imaging the diagnostic modality of choice for 

joint pathology in human orthopaedics. MRI relies on 

interactions between an external magnetic field, radio 

waves and hydrogen nuclei in the body. The tissue contrast 

seen with MRI is due to the differences in the magnetic 

properties of each tissue. 

MRI protocols and studies 

Several protocols for MR imaging of the shoulder have 

been proposed applying different sequences and planes 

– but essentially T1 (sometimes with contrast), T2 and 

STIR (short tau inversion recovery) images are always 

necessary (Figure 1). Depending on which structures one 

wants to visualise, images in the sagittal, transverse and 

dorsal plane are obtained. Protocols have been proposed 

with the limb in both flexion and extension. To visualise the 

joint capsule and glenohumeral ligaments, positioning of 

the shoulder in extension using intra-articular contrast has 

been described. The major periarticular anatomic structures 

of the normal canine shoulder can consistently be identified, 

but evaluation of the glenohumeral structures remains 

difficult. Cortical bone is visible on MRI as a signal void; but, 

to evaluate new bone formation, CT still is the modality of 

choice. Visualisation of canine articular cartilage remains a 

controversial issue. Even with high-field MRI, the resolution 

is not good enough to depict the thin canine cartilage. 

Figure 1: A STIR image of an inflamed shoulder joint clearly 

showing the massive joint effusion. 

Data on the use of low-field MRI in shoulder problems 

in dogs are scarce. The protocol used in our department 

is to start with a STIR sequence, imaging both elbows 

in extension in the dorsal plane to rule out brachial 

plexus pathology. Then, both shoulder joints are imaged 

in extension separately, using a T1 (plane and after 

intravenous application of a paramagnetic contrast agent, 

if indicated) sequence. Then, a T2 sequence is performed. 

Both sequences are obtained in sagittal and transverse 

planes. 

MRI has been evaluated for detecting OC lesions in 

the canine humeral head and was found to be useful in 

assessing the extent and severity of subchondral bone 

lesions. Although articular cartilage discontinuity could be 

detected, loose flaps were not always demonstrated and 

articular cartilage could not be distinguished from synovial 

fluid. In this study, MR arthrography proved to be ineffective 

in visualising canine articular cartilage. 

In one study, where surgical exploration for shoulder pain 

had been performed in 21 dogs, a high level of agreement 

and concordance between MRI and surgical findings has 

been found. However, this study was somewhat limited, 

because the radiologists were not blinded but were aware 

of the case data. Still, this study demonstrated the potential 

of MRI in the field of canine shoulder lameness. 


Another study established that MRI was a good imaging 

technique for detection of supraspinatus tendinopathy, 

where impingement or displacement of the biceps tendon 

by the enlarged supraspinatus tendon was often observed 

on imaging, contributing to development of clinical signs. 

One should be aware of artefacts produced by 

identification “chips” when imaging the shoulder region 

and the “magic angle” artefact when evaluating tendon 

integrity using a T1 sequence. 

Additional reading 

• Agnello KA, Puchalski SM, Wisner ER, Schulz KS, Kapatkin 

AS. Effect of positioning, scan plane, and arthrography 

on visibility of periarticular canine shoulder soft tissue 

structures on magnetic resonance images. Vet Radiol 

Ultrasound. 2008 Nov-Dec;49(6):529-39. 

• Fransson BA, Gavin PR, Lahmers KK. Supraspinatus 

tendinosis associated with biceps brachii tendon 

displacement in a dog. J Am Vet Med Assoc. 2005 Nov 

1;227(9):1429-33, 1416. 

• Gielen & van Bree, Chapter 38 – CT of the shoulder joint. 

In Schwarz T, Saunders J, editors: Veterinary computed 

tomography, Oxford, 2011, Wiley-Blackwell. 

• Janach KJ, Breit SM, Künzel WW. Assessment of the 

geometry of the cubital (elbow) joint of dogs by use 

of magnetic resonance imaging. Am J Vet Res. 2006 

Feb;67(2):211-8. 

• Kramer M, Gerwing M, Sheppard C, Schimke E. 

Ultrasonography for the diagnosisof diseases of the tendon 

and tendon sheath of the biceps brachii muscle. VetSurg. 

2001 Jan-Feb;30(1):64-71. 

• Lafuente MP, Fransson BA, Lincoln JD, Martinez SA, Gavin 

PR, Lahmers KK, GayJM. Surgical treatment of mineralized 

and nonmineralized supraspinatustendinopathy in twentyfour 

dogs. Vet Surg. 2009 Apr;38(3):380-7. 

• Long CD, Nyland TG. Ultrasonographic evaluation of 

the canine shoulder. Vet Radiol Ultrasound. 1999 Jul- 

Aug;40(4):372-9. 

• Murphy SE, Ballegeer EA, Forrest LJ, Schaefer SL. Magnetic 

resonance imaging findings in dogs with confirmed shoulder 

pathology. Vet Surg. 2008 Oct;37(7):631-8. 

• Schaefer SL, Forrest LJ. Magnetic resonance imaging of 

the canine shoulder: an anatomic study. Vet Surg. 2006 

Dec;35(8):721-8. 

• Schaefer SL, Baumel CA, Gerbig JR, Forrest LJ. Direct 

magnetic resonance arthrography of the canine shoulder. 

Vet Radiol Ultrasound. 2010 Jul-Aug;51(4):391-6. Sidaway 

BK, McLaughlin RM, Elder SH, Boyle CR, Silverman EB. 

Role of the tendons of the biceps brachii and infraspinatus 

muscles and the medial glenohumeral ligament in the 

maintenance of passive shoulder joint stability in dogs. Am 

J Vet Res. 2004 Sep;65(9):1216-22. 

• Vandevelde B, Van Ryssen B, Saunders JH, Kramer M, Van 

Bree H. Comparison of the ultrasonographic appearance 

of osteochondrosislesions in the canine shoulder with 

radiography, arthrography, and arthroscopy. Vet Radiol 

Ultrasound. 2006 Mar-Apr;47(2):174-84. 

• van Bree H, Van Ryssen B, Degryse H, Ramon F. Magnetic 

resonance arthrography of the scapulohumeral joint in dogs, 

using gadopentetate dimeglumine. Am J Vet Res. 1995 

Mar;56(3):286-8. 

• van Bree H. Comparison of the diagnostic accuracy of 

positive-contrast arthrography and arthrotomy in evaluation 

of osteochondrosis lesions in the scapulohumeral joint in 

dogs. J Am Vet Med Assoc. 1993 Jul 1;203(1):84-8. 

• van Bree H, Degryse H, Van Ryssen B, Ramon F, Desmidt M. 

Pathologic correlations with magnetic resonance images of 

osteochondrosis lesions in canine shoulders. J Am Vet Med 

Assoc. 1993 Apr 1;202(7):1099-105. 

• van Bree H. Comparison of the diagnostic accuracy of 

positive-contrast arthrography and arthrotomy in evaluation 

of osteochondrosis lesions in the scapulohumeral joint in 

dogs. J Am Vet Med Assoc. 1993 Jul 1;203(1):84-8. 

• van Bree H & Gielen I. The shoulder joint and scapula. 

BSAVA Manual of Canine and Feline Musculoskeletal 

Imaging, 2006, Chapter 7, p 86-102. Edited by F.J. Barr and 

R.M. Kirberger. 

• Xia, Y. Resolution ‘scaling law’ in MRI of articular cartilage. 

Osteoarthritis and Cartilage 2007, 15, 363-365. 


Stifle arthroscopy technique, normal anatomy, & 

appearance of routine rathology 


Veterinary Referral Center of Colorado, Englewood, CO, USA 

Patient Positioning 

While often an overlooked part of the procedure, proper 

patient positioning allows for consistent arthroscopic 

access without difficulty. It is important to position the 

patient in such a fashion to support the limb without the 

aid of an assistant. The author prefers to position dogs in 

dorsal recumbency, secured in a vacuum bag. The affected 

limb is placed in a self-retaining retractor to hold the limb 

in an upright position. The limb is aseptically prepared and 

draped. An adhesive iodine impregnated drape is applied 

over the surgical site to prevent wicking of arthroscopic 

distention fluid. 

Portal Placement 

Classically, Whitney described placement of the portal 

at the level of Gurdey’s tubercle. This location is effective, 

however requires extensive shaving of the infra-patellar 

fat pad to visualize the intra-articular structures. The 

optic portal has been described in the lateral parapatellar 

location and the working portal in the medial parapatellar 

location. The author prefers to place both the optic 

and working portals slightly higher allowing for rapid 

visualization of intra-articular structures of interest. 

Additionally, a suprapatellar egress portal is unnecessary 

with the use of an arthroscopic fluid pump. Frequently, 

the working portal and optic portal can be exchanged to 

improve visualization or working angle of a given structure. 

Briefly, the locations of the portals are infused with local 

anesthetic. Intra-articular injection of lidocaine or bupivicane 

is discouraged due to potential chondrocytotoxicity. 

Carbocaine, however, is an acceptable as an intra-articular 

local anesthetic. The author prefers to establish the medial 

infrapatellar portal as the optic with the stifle in moderate 

flexion, nearly equidistant from the distal pole of the patella 

and the tibial plateau due to the volume of the infrapatellar 

fat pad. In doing so, visualization of the intraarticular 

structures can occur readily in contrast to my experience 

utilizing a lateral optic portal. Close attention to a lateral 

radiograph of the stifle will facilitate localization of the 

portal in a tangent to the tibial plateau. A stab incision is 

made in the location of the portal into the joint capsule. 

The arthroscopic sheath with obturator is advanced into the 

joint. As the joint is entered, the arthroscopic sheath with 

obturator is advanced into the suprapatellar recess. Infusion 

of distention fluid is started, and the scope is assembled. 

Intra-articular Assessment 

Complete evaluation and photodocumentation of the 

stifle is performed sequentially through all compartments 

of the stifle joint. Begin by moving from the suprapatellar 

recess to the femoral trochlea. The angle of view is 

rotated as the scope is retracted to evaluate the articular 

surface of the patella. As the distal pole of the patella 

is reached, the view is directed to the medial and 

lateral femoral compartments evaluating for synovial 

proliferation and osteophytosis. The insertion of the long 

digital extensor (LDE) will come into view as the stifle is 

flexed while maintaining the position of the scope in the 

lateral infrapatellar location. As the LDE is visualized, the 

arthroscopic view is directed at the location of the lateral 

infrapatellar portal location. The portal is established with 

a #11 scalpel blade. Care is taken to maintain visualization 

of the blade to avoid iatrogenic damage to intraarticular 

structures. An arthroscopic shaver is introduced into the 

joint to resect the fat pad and synovium as needed to allow 

complete visualization and evaluation of intra-articular 

structures. A probe is inserted into the working portal 

and compents of the cranial cruciate are evaluated. The 

craniomedial and caudolateral bands are described based 

on their respective anatomic origin on the femur. The 

craniomedial band is most often injured in a partial tear 

and is tight in all ranges of motion. The caudolateral band 

is tighter in flexion as the two components wrap around 

each other during the screw-home mechanism. Evaluation 

with a probe is important to determine the competence of 

the ligament. An arthroscopic shaver is used to debride 

the torn CCL. The cutting face of the shaver is rotated to 

allow fray ligamentous ends to be pulled into the shaver, 

as the suction level is actuated. Efficiency of shaving is 

vastly improved as the area being shaved is stabilized by 

shaving toward the osseous attachment of the ligament. 

Once the CCL is debrided, evaluation of the meniscus is 

performed. While viewing the medial meniscus, a probe 

is inserted into the working portal. The stifle is placed in 


drawer by an assistant or retracting device. The femoral 

and tibial surfaces are palpated to detect early incomplete 

tears. The peripheral attachment is evaluated by direct 

palpation and attempting to displace the caudal pole 

cranially. The lateral meniscus is evaluated, by driving the 

scope view to the lateral compartment and placing a varus 

stress on the limb. Careful probing of the femoral and tibial 

surfaces is important to avoid overlooking stable tears of 

the lateral meniscus. 

Meniscal exposure can be improved by insertion of a 

retraction device such as a modified Hohmann retractor 

or chondral pick. Alternatively, a self-retaining external 

retractor can be inserted into the distal femur and proximal 

tibia. The author prefers using a reverse bend chondral 

pick inserted through a lateral parapatellar portal. The 

pick is advanced into the joint and placed at the caudal 

tibial plateau within the intercondylar notch. Retraction 

is provided in a similar manner to a Hohmann retractor, 

however the smaller instrument has a less impact on the 

visual field. Meniscal injuries are removed by use of multiple 

instruments including a hook knife, push knife, joint punch 

and arthroscopic shaver blades. Meniscal resection should 

be accomplished without any iatrogenic damage to the 

cartilage. Radiofrequency energy sources are discouraged 

due to the extraordinary risk of chondrolysis. Meniscal 

release at one time enjoyed widespread application and use 

to prevent meniscal tearing. A meniscal release, however is 

a procedure that is not without consequence to the cartilage 

surface making its use a source of debate. If a meniscal 

release is decidedly appropriate, ensuring complete release 

is of utmost importance. A caudal meniscotibial release is 

performed by applying drawer to the stifle and visualizing 

the caudal meniscotibial attachment. A hook blade is 

advanced under the meniscotibial ligament and retracted 

cutting the ligament completely. If the caudal pole of the 

medial meniscus does not retract caudally as drawer is 

applied, the ligament is not transected completely. A 

midbody release can be performed in a similar fashion with 

needle localization of the region of transetion, however its 

use is discouraged by the author due to risk of iatrogenic 

cartilage injury and medial collateral ligament injury. 


Calcified bodies at the caudal rim of the glenoid 

cavity: diagnostic findings and results after treatment: 

retrospective study of 28 dogs and 1 cat. 

B. Van Ryssen, E. Coppieters, Y. Samoy, D. Van Vynckt, J. Saunders, H. van Bree. 

University of Ghent, Salisburylaan, Merelbeke, Belgium 

Introduction 

Calcified bodies at the caudal rim of the glenoid cavity 

are commonly regarded as subclinical lesions. The origin of 

these lesions is not always clear(1). In the last decade an 

accessory caudal glenoid ossification was described as a 

possible cause of lameness in dogs (2, 3). To obtain a correct 

treatment decision, it is important to consider a calcified 

body in the differential diagnosis of shoulder lameness and 

to attribute lameness to it by a thorough diagnostic workup 

to exclude other (shoulder) problems. This retrospective 

study of 29 cases is intended to describe the signalment of 

clinically affected dogs, to describe the radiographic and 

arthroscopic findings and the results after conservative or 

arthroscopic treatment. 

Material and methods 

In a retrospective study the files of 29 cases gathered 

over 10 years were analyzed. Follow-up was performed by 

a telephone questionnaire and a clinical and radiographic 

examination. 

The files contained the signalment, history and clinical 

findings of 28 dogs and one cat. Diagnosis was based on 

plain radiographs, ultrasound and arthrogaphy. Shoulder 

arthroscopy was performed via a lateral approach with 

a 2.7 mm arthroscope (R. Wolf). During arthroscopic 

inspection the presence of a loose body was noted as 

well as the presence of cartilage lesions of the glenoid 

cavity and humeral head and lesions of the biceps tendon 

and glenohumeral ligaments. Subsequently, arthroscopic 

treatment was performed by removal via a caudal portal. 

Results 

Signalment: 

Different large breeds were affected of which seven 

were mixed breeds. The age varied between 2.5 and 11 

years, with a mean age of 6 years. 

History: 

Acute onset was noted in 50% of the cases, but related 

trauma was only reported in two dogs. Duration of 

lameness varied between 1 and 9 months. Conservative 

treatment with rest and NSAID‘s was not or only temporary 

efficacious. 

Radiographic findings 

Bilateral lesions were found in 50% of the dogs. In 

the lame shoulders, a solitary glenoid calcified body was 

found 28 dogs and 1 cat. Two dogs had an additional 

partial rupture of the biceps tendon. The size and shape 

of the fragments that caused lameness was varying: in 

15 joints the fragments were small (1-2 mm), 9 fragments 

were between 2.5 and 5 mm, and 5 were larger than 8 

mm. The fragments in the controlateral shoulder were 

also variable: some were smaller, while others were larger 

than those found in the lame shoulder. The shape of the 

calcifications was variable: round, granular (small) irregular 

shape, semi round with a gliding surface opposite to the 

humeral head. Large calcified bodies were located close 

to the humeral head while smaller ones were often closer 

to the glenoid cavity. 

Mixed breed, 2.5 y 

Schapendoes, 11 y 


Mixed breed, 5 y 

Cat, 7 y 

Osteoarthritis in the clinically affected joints was absent 

in 4 joints, light in 12 joints, moderate in 10 joints and 

severe in 3 joints. 

Arthroscopy 

All calcified bodies were visible as separate fragments 

more or less connected with the caudal rim of the glenoid 

cavity. Cartilage erosions of the humeral head varied from 

discrete to severe and were seen in 50% of the joints. 

Arthroscopic removal of the fragments was realized in 

one or several pieces using grasping forceps of 2-3.5 mm 

diameter. Control radiographs confirmed the complete 

removal of the fragment. 

Results after treatment 

The majority of the dogs recovered between 1 week and 

2 months. A residual lameness was noted in 60% of the 

dogs, after long or heavy exercise. Five dogs did not improve 

after treatment: all dogs had grade 2 tot 3 arthrosis and 

small or medium sized calcifications. 

Four joints were treated for a large fragment (+/_ 1 cm), 

3 had degree 1 and one degree 2 of OA. Results were 

very good. 

Two joints with concomitant biceps rupture had a slow 

recovery. 

Two were treated conservatively, both had bilateral 

medium sized fragments (5-7 mm) and responded well to 

a prolonged treatment. 

All non-clinical controlateral joints were treated 

conservatively and did not need a surgical treatment. 

A limited radiographic postoperative follow-up in 4 cases 

revealed the development of a ‚new‘ fragment in 2 / 4 joints. 

Arthrosis had progressed minimally in all cases. In case of 

new fragment development, one dog showed occasional 

mild lameness, the other had become more severely lame 

a few weeks before the control examination (4 years after 

treatment). 

Discussion 

Calcified bodies at the caudal rim of the glenoid cavity 

are a well known yet infrequent finding in the canine 

shoulder. Often it is classified as a clinically insignificant 

lesion, although is has been described as a possible 

cause of shoulder lameness(1-3). In the authors‘ hospital, 

the disorder was diagnosed 29 times over a period of ten 

years. This confirms that calcified bodies at the caudal 

rim of the glenoid cavity should always be included in the 

differential diagnosis for shoulder lameness, despite the 

relatively low frequency. 

In this series of 29 cases mainly large breed dogs were 

affected with the exception of a small dachshound and 

a cat. All animals were adults, in contrast to what was 

written in a study of 9 nine dogs which had an age of 

8 months to two years(3). In this series all dogs were 

older than 2 years with a mean of six years suggesting 

that the presence of these calcifications do not have a 

developmental cause. 

Bilateral calcifications were seen in 50% of the cases. 

In the four dogs that were 3 years or younger, it was 

always a unilateral problem. In young dogs, joint problems 

are often - but not necessarily - bilateral when there is 

a developmental cause. The term ununited ossification 

center of the glenoid as well as accessory caudal glenoid 

ossification center suggest that the problem would mainly 

arise in young dogs. The age of the dogs in this series argue 

against this hypothesis. 

Another cause could be a traumatic fragmentation of 

the caudal part of the glenoid cavity. However, in only one 

case radiography suggested a fragmentation of the caudal 

rim, but arthroscopic inspection demonstrated it as an 

additional fragment. 

In only 50% of the dogs lameness had an acute onset 

while only for two dogs the onset was related to a trauma. 

The cause of the calcified bodies remains unclear, but 

may be explained by an increased stress on that particular 

location, either because of traction on the insertion of the 


joint capsule or pressure exerted by the caudal part of 

the humeral head. Possibly a high activity predisposes to 

the development of these calcifications, but an individual 

predisposition might also be present. 

Since the calcified bodies are not always the cause of 

lameness(1), diagnosis should be based on the localization 

of pain in the shoulder and the exclusion of other shoulder 

problems and other frontlimb problems. It was also the 

experience of the authors that subclinical lesions may be 

clearly visible on radiographs while the cause of lameness 

was located elsewere. 

The radiographic appearance of the calcified bodies 

ranged from a small particle to a large half rounded body. 

The size and shape of the fragment was not related to the 

severity of the clinical signs. Most fragments were smaller 

than 3 mm x 2 mm, the largest was 11 mm x 6 mm. The 

size of the fragment was not correlated to the degree of 

osteoarthritis. 

Each calcification was removed successfully via 

arthroscopy. Arthroscopic treatment was technically more 

demanding than the removal of an OCD flap because of 

the location and - in some cases - the size of the fragment. 

Lipping of the glenoid cavity, as often is found in chronic 

osteoarthritis of the shoulder, should not be confused with 

this problem. In that case there is no separate fragment 

and arthroscopic removal is difficult. Removal will not 

lead to improvement of the dog (personal experience of 

the authors). 

Results after treatment were very good in most cases. 

Only when chronic arthrosis was present, the dogs did 

not improve. In those cases, the calcified body could be 

considered as a secondary sign of osteoarthritis and not 

as the primary problem. When lameness can be confined 

to this calcification and other shoulder problems can be 

excluded, arthroscopic removal is rewording. 

Only a limited number of dogs were available for 

clinical and radiographic follow-up. One dog showed a 

moderate lameness 4 years after treatment. In this dog, 

a similar fragment had developed as was removed at 

the first presentation. In one other dog a new calcified 

body had developed. This dog showed occasional light 

lameness after heavy exercise. Two other dogs were sound 

3 years after treatment and radiographs showed a minor 

progression of osteoarthritis. 

References 

1. Dennis R KR, Wrigly RH, Barr PJ. Handbook of small Animal 

Radiological Differential Diagnosis. 1ed. 2001;WB Saunders 

Company, Philadelphia, London:37-41. 

2. Van Ryssen B. Shoulder arthroscopy: a review of 47 cases 

(2002-2004): findings and current case management. . 

Proceedings 14th annual scientific meeting of the British 

Vet Orthop Assoc. 2003;Bath, UK (42). 

3. Olivieri M PA, Marcellin-Little DJ, Borghetti P, Vezzoni A. 

Accessory caudal glenoid ossification centre as possible 

cause of lameness in nine dogs. Vet Comp Orthop Traum. 

2004(3):131-5. 



In depth – Motion analysis and 

rehabilitation 

Friday July 8 



Force plate: gold standard? 

M. Balligand* 

Department of Clinical Sciences, SA Surgery, University of Liège, Belgium. 

The use of a force plate has become a standard procedure 

in the quantitative evaluation of locomotion in dogs. 

Many recent publications report ground action forces in 

various situations, from normal to pathological, and among 

different breeds of dogs. Recorded values are strongly 

influenced by parameters like velocity and acceleration, 

body weight, body size, limb length. In order to interpret 

differences between those values and be able to compare 

data, the clinician must apply specific normalization 

techniques. 

The purpose of this lecture is to review those 

normalization technique and the ways data from force plate 

analysis should be used in order to make fully appreciate 

its potentialities when its position is disputed especially 

by pressure mats. 

Needless to say, force plate gait analysis, like any other 

quantification method, is affected by several limitations, 

mainly technical. Those must be thoroughly understood 

by anyone using the system in order to fully profit of its 

performances. Some of them can be avoided by using 

concomitantly two or more force plates or an instrumented 

treadmill but this has an important impact on the overall 

cost of the system. Furthermore, ground actions forces 

reflect acceleration of the body mass of the dog, i.e. body 

and limbs, making of a comprehensive analysis of the 

locomotion a particularly complex task. Nevertheless, an 

excellent reason to use a force plate and consider it as a 

possible gold standard when evaluating gait is the fact that 

a force plate has proved to be able to diagnose locomotion 

anomalies which could pass undetected during visual 

subjective evaluation, even by experienced examiners. 

Each step of a front or a hind limb generates a unique 

pattern of characteristic forces applied by the ground on 

the foot during stance phase. The relevant questions for 

a clinician are therefore: are the recorded forces (vertical, 

horizontal fore-aft, horizontal transversal) normal or not? 

are the recorded durations of breaking and propelling 

phases during stance phase normal or not ? To answer 

those questions, the normal values of these force and 

time related parameters must be known. Yet patients 

are generally not evaluated before becoming lame. So 

the normal status of a particular patient is (almost) never 

known. Furthermore, comparing a diseased limb to its 

normal contra-lateral is unfortunately not valid as the 

dysfunction of one limb modifies the function, hence the 

recorded parameters, of the other limbs. The solution is 

therefore to compare the values of a patient with reference 

values of normal individuals after applying normalization 

techniques accounting for differences in body mass, body 

dimensions and absolute velocity (at which the dog passes 

on the force plate). So it is necessary to :1. normalize 

the recorded forces by the standing body weight (SBW) 

(Forces/SBW),2. normalize the absolute speed by the 

(functional) limb length (h), calculating a relative speed 

(Vrel=V/(gh)1/2 where “v” is the mean stride velocity, “h” 

is the functional limb length and “g” is the gravitational 

acceleration (9.81 m/sec 2); as a matter of fact, v rel= the 

square root of V2/gh” which is called the Froude number 

and is equal to the ratio of the kinetic energy (1/2mv2) and 

potential energy (mgh). Movement under gravity generally 

involves potential energy being converted to kinetic energy 

and vice versa. Therefore, dynamically similar movement 

is possible only if the systems in question have the same 

ratio of kinetic energy to potential energy. Two movements 

are dynamically similar if one could be made identical to 

the other by uniform change in the scales of length, time 

and force. One dog should not be compared to another one 

having a different Fround number;3. normalize the absolute 

values of stride period (duration of the stride in seconds 

(T)) and stride length (in cms) by the functional limb length, 

calculating a relative stride period (Trel=T/(h/g)1/2 where 

“h” is the functional limb length and “g” the gravitational 

acceleration= a constant) and a relative stride length (stride 

length/functional limb length).The stride length being 

defined as the distance between two successive foot strikes 

of the same foot, its record generally necessitates the use 

of several force plates (except for small breed individuals). 

If the effect of the body weight( or body mass) on the 

recorded forces is easy to apprehend (the gravitation force 

exerted by the earth on the body is directly proportional to 


the body mass), the effect of speed may be less evident 

to fully perceive, although it is considerable. The vertical 

force required to support an animal against gravity is 

controlled by the duration of the stance phase, when the 

foot is in contact with the ground; when the speed goes 

up, the stance phase shortens and the shorter the duration 

of the stance phase the bigger the force. Yet, for a similar 

absolute speed between two dogs, a condition which 

would appear a good condition for comparison, a larger 

dog has a longer (functional) limb length, hence a lower 

relative speed (see formula above) because the limbs are 

moving slower underneath the trunk; on the contrary, a 

smaller dog has a shorter (functional) limb length hence a 

higher relative speed. Comparisons at the same absolute 

speed deliver useful informations only if the animals are 

precisely the same size (same functional limb length). If the 

sizes between two dogs differ, comparisons can only be 

made at similar relative speeds (to be calculated). In the 

same way, the simple normalization of the forces by the 

body weight is of little practical value unless comparisons 

between individuals are made at similar relative speeds. 

Considering that each passage on the force plate 

potentially delivers a large number of numerical 

informations, force and time wise, another crucial question 

is whether the difference between normal and abnormal 

gaits can be detected, based on only one versus several 

parameters and in this latter case, what would be the 

minimal combination of parameters able to distinguish 

normal from abnormal gait? Available informations in the 

recent literature are not always consistent. Although results 

of different studies suggest that a multivariate approach 

is superior to the univariate one, for some authors, the 

combination of peak vertical forces and the falling slope 

(unloading speed of the foot) is the combination of choice to 

distinguish between healthy and affected dogs when others 

recommend the combination of the peak vertical force and 

the rising slope (loading speed of the foot). 

Finally, yet another way of detecting lameness in dogs 

based on ground actions forces is the calculation for each 

gait variable of (a)symmetry indices ((XR-XL/(XR+XL)/2) 

X100). In healthy individuals, trot is a symmetric gait in 

which the body is alternatively supported by one pair of 

diagonal limbs followed by the other pair. Although perfect 

right-to-left symmetry is generally not observed (there are 

physiological differences between sides), a threshold(cutoff 

point)can be determined to differentiate healthy from 

lame dogs. 

Conclusion 

Unlike pressure mats or pressure walkways, force 

plates are capable of recording vertical and horizontal 

action forces exerted by the feet on the ground during 

stance phase. The use of several (2 to 4) force plates 

in the same walking corridor allowing simultaneous 

recordings of different limbs together in action or their use 

in combination with instrumented treadmills makes the 

recording processes more informative, easier and quicker, 

yet much more expansive. Normalization techniques allow 

data comparison when the normal status of a diseased 

animal is unknown. Despite those advantages, available 

informations on the possible contribution of horizontal 

forces measurements in lameness detection or treatment 

evaluation are, up to now, scarce. The present situation 

likely makes the pressure walkway a serious competitor in 

the race for “gold standard method” status in locomotion 

quantitative valuation. 

References 

• Besançon MF, Conzemius MG, Derrick TR, Ritter MJ. 

Comparison of vertical forces in normal greyhounds 

between force platform and pressure walkway 

measurement systems. Vet Comp Orthop Traumatol 2003; 

3, 153-157 

• Evans RB, Gordon W, Conzemius N. The effect of velocity on 

ground reaction forces in dogs with lameness attributable 

to tearing of the cranial cruciate ligament. Am J Vet Res 

2003; 64(12): 1479-81 

• Renberg WC, Johnston SA, Ye K, et al. Comparaison of 

stance time and velocity as control variables in force plate 

analysis in dogs. Am J Vet Res 1999; 60:814-819 

• Evans R, Horstman Ch, Conzemius M. Accuracy and 

Optimization of force Platform Gait Analysis in Labradors 

with Cranial cruciate disease Evaluated at walking Gait. Vet 

Surg 2005; 34, 445-449 

• Bertram JE, Lee DV, Case HN, Todhunter RJ. Comparison of 

trotting gaits of Labradors Retrievers and Greyhounds. Am J 

vet res 2000; 61: 832-838 

• Mölsa SH, Hielm-Björkman AK, Laitinen-Vapaavuori OM. 

Force Plateform Analysis in Clinically healthy Rottweilers: 

Comparison with Labrador retrievers. Vet Surg 2010; 

39:701-707. 

• McNeillAlexander R. Elastic mechanisms in animal 

movement. Cambridge University Press, 1988 

• Conzemius N. Limitations of force platform gait 

analysis. ESVOT-VOS 3d World Vet Ortho Congres 

Proceedings,2010,87-88. 

• Viguier E, Maître P, Colin A, Poujol L, Wittman C, Le Quang. 

ESVOT-VOS 3d World Vet Ortho Congres Proceedings,2010, 

184-185. 

• Fanchon L, Grandjean D. Accuracy of asymmetry in dices of 

ground reaction forces for diagnosis of hind limb lameness I 

dogs. Am J Vet Res 2007; 68:1089-1094. 

• Quinn MM, Keuler NS, LU Y, Faria MLE, Muir P, Markel MD. 

Evaluation of Agreement Between Numerical Rating Scales, 

Visaul Analogue Scoring Scales, and Force Plate gait 

Analysis in Dogs. Vet Surg 2007;36:360-367. 


In vivo motion analysis 3D 

P. Böttcher*, J. Rey, G. Oechtering 

Department of Small Animal Medicine, University of Leipzig, Leipzig, Germany 

Traditional motion analysis involves attaching small 

retroflective markers on the skin surface of aninmals 

and recording the path of those markers in 3D with at 

least two video cameras. Precision and accuracy of 

those systems in tracking the 3D path of the markers is 

very high and data collection and processing is straight 

forward as most of the software packages available on 

the marked allow for automatic marker tracking. This is 

why video cinematography is the de facto gold standard 

in motion analysis. The theory behind skin mounted 

marker is that they represent distinct bony landmarks. 

However, due to the physiological motion between skin 

and underlying skeleton, skin based motion tracking 

is limited to “macroscopic” motion analysis, basically 

flexion and extension, acceleration and deceleration as 

well as evaluation of synchronicity. Even in humans with 

much less skin elasticity than most of our animals and 

sophisticated cluster based marker configurations, skin 

mounted markers are not accurate enough to allow precise 

estimation of 3D joint motion.1,2 Especially abduction and 

adduction, external and internal rotation as well as relative 

translation of the opposing joint surfaces are prone to 

errors, questioning the usefulness of skin marker based 

analysis of 3D joint kinematics in dogs. 

To allow for precise estimation of 3D joint kinematics 

several technical aspects have to be considered: (1) tracking 

of bone motion instead of skin motion, (2) short exposure 

time (shutter 1/2000 sec) to reduce image blurring, (3) high 

frequency data acquisition (≥ 250 Hz) to make sure not to 

miss fast movements, e.g. cranial drawer in stifles with 

cranial cruciate ligament rupture, and (4) high accuracy and 

precision (≤ 1mm of translation and ≤ 1 deg of rotation) as 

joint kinematics are a microscopic biomechanical system. 

Today only biplanar fluoroscopic kinematography using 

special hardware fulfils all these requirements. Standard 

C-arms only allow for long exposure time and small image 

sampling rates and therefore are not suitable for our 

purpose. But they can easily be “upgraded” by attaching 

a high speed video camera instead of the standard video 

camera provided by the manufacture.3 When using 

an uniplanar setup to reduce cost and x-ray exposure 

translation along the optical axis (out of plane motion; most 

of the time medio-lateraly) and in consequence internal/ 

external rotation as well as abduction/adduction are of 

suboptimal resolution.4 

The system we are currently using is a biplanar system 

with two high-power x-ray tubes and two 40 cm image 

intensifiers (fig. 1) combined with digital high speed video 

cameras for image acquisition. A third camera acquires a 

live stream of the dog while walking on the treadmill. This 

video clip is used to define start and end of stance phase. 

All cameras are synchronised at 500 fps and a shutter of 

1/2000 sec. Using custom made 2D-3D image registration 

software, which is primarily based on the work of Tasman 

and his group we can track the 3D kinematics of the canine 

stifle with a precision of 0.3 mm without any attached 

or implanted markers. Bead based tracking, using small 

spherical tantalum beads, which are “injected” into the 

bones allows for even more accurate tracking in the range 

of ≤ 0.1 mm.5 

Application of our hard- and software to dogs with 

naturally occurring cranial cruciate ligament (CCL) rupture 

has changed our understanding of 3D stifle kinematic 

dramatically. First of all, stifle instability following CCL 

rupture is not a pathological movement of the tibia, it is 

the femur which becomes instable, luxating caudally on 

heel strike. Moreover, as already suggested by Tashman 

et al.6 CCL rupture does not lead to increased internal 

rotation of the tibia, while walking. Even more controversial 

is the situation following TPLO. We observed significant 

internal rotation of the femur at heel strike, which is almost 

absent when performing a TTA. However, following both 

procedures, cranio-caudal stability is restored. Animations 

of stifles following TPLO and TTA compared to normal stifles 

can be downloaded at www.fluokin.de. 

Fluoroscopic kinematography is not limited to the stifle. 

We are currently performing a study investigating 3D 

kinematics of the canine elbow with and without elbow 

dysplasia. When the local anatomy becomes more complex 

such as in the elbow, implantation of tantalum markers 

becomes necessary. This makes the investigation more 


complex as we need the animal under full anaesthesia 

before any clinically driven invasive procedure. Implanting 

the markers is comparable to multiple bone marrow 

aspiration procedures. The tantalum markers produce no 

adverse reaction and stay in the body for the rest of the life 

of the animal.7 Big advantage when using tantalum markers 

is their good contrast in the fluoroscopic images because 

of their high x-ray absorption coefficient. This makes 

identification of the markers and subsequent automatic 

tracking a straight forward procedure. Freely distributed 

software, based o a collection of Matlab routines, for bead 

based tracking in 3D motion analysis is available at www. 

xromm.org. But even for those studies in which implantation 

of markers is not possible XROMM provides software 

tools for manual 2D-3D-registration, so called scientific 

rotoscoping, which gives very good results. 8 

Future application of fluoroscopic kinematography in 

veterinary small animal medicine will extend to shoulder 

and hip kinematics, to neurology, evaluating spine 

kinematics or to the menisci. But even pure “soft tissue” 

kinematics, such as the motion of hard valves, soft palate 

or tongue can be investigated using implanted markers. Of 

course, animals other than dogs can be investigated using 

fluoroscopy, too. In consequence we are currently setting 

up the first biplanar fluoroscopic motion analysis system 

designed for small animals such as rats, small reptiles and 

birds, up to horses and cows - including humans (www. 

fluokin.de). Once established this unique installation will 

allow for basic as well as clinical research using both 

marker less and marker based fluoroscopic motion tracking 

at high speed among all “species” 

Fig 1: Biplanar fluoroscopic setup at the Institut für Spezielle 

Zoologie und Evolutionsbiologie, Friedrich-Schiller Universität, 

Jena, Germany (Prof. Fischer) 

Bibliography 

1. Benoit D, Ramsey D, Lamontagne M, et al: Effect of skin 

movement artifact on knee kinematics during gait and 

cutting motions measured in vivo. Gait Posture 24:152-164, 

2006. 

2. Garling EH, Kaptein BL, Mertens B, et al: Soft-tissue 

artefact assessment during step-up using fluoroscopy and 

skin-mounted markers. J Biomech 40 Suppl 1:S18-24, 2007. 

3. Snelderwaard P, De Groot JH, Deban SM: Digital video 

combined with conventional radiography creates an 

excellent high-speed X-ray video system. J Biomech 

35:1007-1009, 2002. 

4. Böttcher P, Ludewig E, Oechtering G: Uniplanar fluoroscopic 

cinematography for in-vivo analysis of canine knee 

kinematics: estimation of accuracy, Proceedings, 14th 

ESVOT Congress, Munich, Germany, 10-14 September, 

2008. 

5. Brainerd EL, Baier DB, Gatesy SM, et al: X-ray 

reconstruction of moving morphology (XROMM): precision, 

accuracy and applications in comparative biomechanics 

research. J Exp Zool A Ecol Genet Physiol 313:262-279, 

2010. 

6. Tashman S, Anderst W: In-vivo measurement of dynamic 

joint motion using high speed biplane radiography and 

CT: application to canine ACL deficiency. J Biomech Eng 

125:238-245, 2003. 

7. Aronson AS, Jonsson N, Alberius P: Tantalum markers in 

radiography. An assessment of tissue reactions. Skeletal 

Radiol 14:207-211, 1985. 

8. Gatesy SM, Baier DB, Jenkins FA, et al: Scientific 

rotoscoping: a morphology-based method of 3-D motion 

analysis and visualization. J Exp Zool A Ecol Genet Physiol 

313:244-261, 2010. 


Muscular forces affecting the outcome of CCL 

surgery. 

JM Ramirez Leon 1 , B Böhme 4 , C Vroomen 3 , F Farnir 2 , M Balligand 1 

1 Department of Clinical Sciences, SA Surgery, 2 Department of Animal Productions, Biostatistics, 3 Department 

of Constructions, Materials and Structures Mechanics, University of Liège, Belgium, 4 Kleintierklinik, Bremen, 

Germany 

Introduction 

Surgical treatments, attempting to passively or 

dynamically stabilize the affected stifle joints, are carried 

out in the vast majority of cranial cruciate ligament 

ruptures (CCLR) in dogs. Indications exist that unstable 

joints following CCLR could benefit from augmentation 

of Quadriceps muscle performance, whether the joints 

are surgically treated or not. The objective of the present 

study is to evaluate the effect of the force developed by 

the Quadriceps muscle on the stability of the stifle affected 

by CCLR. 


Six hind limbs were harvested from fresh cadavers, 

weighing between 19 and 33 kilos. The dogs had been 

euthanized for reasons unrelated to this study. Pelvic 

limbs were collected by disarticulation of the coxofemoral 

joint. All muscles were dissected out, leaving intact the 

collateral and capsular ligaments of the stifle and hock 

joints. Small radio-opaque markers (segments of Kirschner 

wire) were implanted in the distal femur and proximal 

tibia. The specimens were radiographed to control the 

absence of osteoarthritis and allow calculation of the 

tibial plateau angle (TPA); they were wrapped in isotonic 

saline soaked abdominal sponges and stored in sealed 

plastic bags at -20°. Thawing occured at room temperature 

during the night preceding the tests. The day of the tests, 

a medial mini-arthrotomy of the stifle was performed and 

the infrapatellar fat pad was completely dissected out, 

exposing the cranial cruciate ligament (CCL) which was 

left intact at this moment. The joints were closed with a 

2/0 nylon interrupted suture. The Quadriceps muscle and 

the Gastrocnemius muscles/ Achilles tendon unit were 

replaced by tension bands, each of them instrumented 

with a strain gage (Sensy, 150 DN) and a turn-buckle to 

adjust the tension in the cables. The strain gages were 

conditioned in a full Wheatstone bridge by an amplifier 

(Hottinger Baldwijn Messtechnik, type MBC). Signals 

registered by the sensors were treated via a data logger 

(HP 3497 A) and an acquisition software (Scan Win).The 

limbs were placed in a press (Instron 3366, 10 KN) in a 

neutral position, between protraction (breaking phase) 

and retraction (propelling phase) a position close to the 

position of a hind limb at the time of peak vertical force 

during stance phase. The proximal femurs were securely 

fixed to a custom-made aluminum stirrup connected to the 

horizontal bar of the press via three pairs of screws and 

a 2.5 mm transfixing pin. The press was piloted in force 

during the loading phase and piloted in displacement 

during the relaxation phase. Loading was done at 30% of 

body weight at a loading rate of 2.5 mm per second until 

a plateau was reached; the target load was maintained 

during 60 seconds, allowing measurements of joint angles 

(stifle and hock) with a goniometer, recording of the force 

values and taking radiographs of the stifle. Relaxation was 

finally allowed until the initial position of the horizontal 

bar was resumed. A small pre-tension (between 2 and 

5 N) was systematically put into the Quadriceps tension 

band and the Gastrocnemius/ Achilles tension band in 

order to prevent any slack in the system and to obtain 

physiological joints angles when at peak load, ranging 

from 130° to 138°and 130° to 136° for the stifle and hock 

joint respectively. The hip joint angle was always fixed at 

a predetermined value (68° to 71°), corresponding to the 

mean value observed in physiological conditions at peak 

vertical load and reported in the literature. Measures 

were repeated two to three times, at an interval of 2 to 3 

minutes. In a second step, the CCL was transected with a 

scalpel blade, when unloaded, via the medial arthrotomy 

initially performed, which was again closed with a 2/0 

nylon single non interrupted suture. Measures were then 

repeated again two to three times at the same 30% of BW 

load, bringing no changes to the pretension initially placed 

in Quadriceps and the Gastrocnemius/Achilles bands (2 to 

5 N). Upon loading, cranial displacement of the tibia was 

documented by films and radiographs and from the load vs 

time charts delivered by the Instron press. In a third step, 

different pre-tensions were applied, from 1 to 9 kilograms 

depending on the specimen, to the Quadriceps band, 

before loading, the foot being hold in its original position 

on the ground thanks to a custom-made shoe preventing 

its cranial displacement when tightening the turn-buckle of 

the Quadriceps band. The loading processes were carried 

out like previously described and filmed again. In a fourth 


step, advancement of the tibial tuberosity was performed 

using a Modified Maquet Technique (MMT) procedure, first 

with an advancement calculated with the common tangent 

method to orthogonalize the tibial plateau and the patellar 

ligament, and then with half of this advancement but with 

different pre-tension being applied to the Quadriceps band. 

No attempt was made to keep nor the stifle nor the hock 

angles at specific values, once the CCL had been transected. 

Statistical analysis 

A multinomial logistic model with cumulative logits was 

used to assess the effect of pre-load in the quadriceps 

(PLQ) and tibial plateau angle (TPA) on the occurrence 

of a cranial drawer sign (CDS). Animals were classified 

into 3 categories with respect to CDS (absent, variable, 

present) and optimal parameters were fitted using 

GENMOD procedure of SAS. As a by-product, the used 

model also allowed to predict PLQ to be applied to have 

a given probability to avoid CDS. The effect of PLQ and 

similarly the small pre-load systematically applied in 

the Gastrocnemius/Achilles tension band(PLGA) on the 

Ultimate Load in Quadriceps (ULQ) was also investigated 

by fitting a linear model using PLQ and PLGA as covariates 

and CDS as a fixed effect. The same linear model was fitted 

for the Ultimate Load in the Gastrocnemius/Achilles tension 

band(ULGA). When testing the effect of CDS status on the 

hock angle (HA) and on ULGA, a one-way Anova was used, 

after classifying the CCLR individuals into 2 groups (group 

1: no CDS, group 2: CDS or variable CDS). 

Results 

Preload (PLQ) was found to have a significant effect 

(p=0.032) on the occurrence of CDS, with higher levels 

of preload leading to lower prevalence of CDS. TPA was 

also significantly (p=0.0016) associated to CDS, with 

higher values of TPA more likely to cause CDS. The results 

show that CDS has a significant effect (p=0.0078), with 

individuals suffering from CDS characterized by higher 

ultimate tensions (ULQ) than others. No significant relation 

could be demonstrated between PLQ and ULQ (p=0.0949), 

while a significant effect could be shown for PLGA on 

ULQ (with the 2 traits negatively correlated).HA were 

found significantly (p

especially when the stifle is more extended (high flexion 

angle) could limit or even eliminate the drawer sign. When 

ACLR is treated by advancement of the tibial tuberosity, 

pre-tension in the Quadriceps can help the procedure to 

deliver its stabilizing effect or possibly compensate for an 

insufficient advancement. It must be emphasized though 

that our model is still a very simplified anatomical model not 

taking into account the effect of cocontraction especially 

of the Hamstrings muscles. 

Bibliography 

• Ragetly ChA, Griffon DJ, Mostafa AA, Thomas JE, Hsiao- 

Wecksler ET. Inverse Dynamics Analysis of the Pelvic Limbs 

in Labrador Retrievers With and Without Cranial Cruciate 

Ligament Disease. Vet Surg, 2010, 39 (513-522) 

• Hoffmann DE, Kowaleski MP, Johnson KA, Evans RB, 

Boudrieau RJ. Ex vivo Biomechanical Evaluation of the 

Canine Cranial Cruciate Ligament-Deficient Stifle with 

Varying Angles of Stifle Joint flexion and Axial Loads after 

Tibial Tuberosity Advancement. Vet Surg, 2011, 40 (311-320) 

• Kipfer NM, Damur DM, Guerrero T, et al. Effect of tibial 

tuberosity advancement on femorotibial shear in cranial 

cruciate ligament deficient-stifles: an in vitro study. Vet 

Comp Orthop Traumatol, 2008, 21 (385-390). 

• Dennler R, Kipfer NM, Tepic S, et al. Inclination of the 

patellar ligament in relation to flexion angles in stifle joints 

of dogs without degenerative joint disease. Am J Vet Res, 

2006, 67 (1849-1854). 

• Etchepareborde S, Brunel L, Bollen G, Balligand M. 

Preliminary experience of a modified Maquet technique 

for repair of cranial cruciate ligament rupture in dogs. Vet 

Comp Orthop Traumatol, 2011, 24. 


Evidence based medicine in rehabilitation 

B. Bockstahler, PD, DVM, CCRP 

Clinic for Surgery and Ophthalmology, University of Veterinary Medicine Vienna, Vienna, Austria 

During the past decade, veterinary physical therapy 

and rehabilitation has gained popularity. ,Veterinarians 

have started focusing on several goals as the treatment 

of pain and subsequent compensatory mechanisms, the 

improvement of the joint function and a quicker return to 

function after surgery. To reach these goals the veterinarian, 

working in the field of physical therapy, must have a 

profound knowledge related not only to physical therapeutic 

modalities (like electrotherapy), but also to the etiology and 

pathophysiology of musculoskeletal disorders, conservative 

and surgical treatments and finally the biomechanics of 

the musculoskeletal system. Because of the complexity of 

musculoskeletal diseases, neither the pathophysiological 

processes related to orthopedic disorders nor the impact 

of physical therapeutic interventions like therapeutic 

exercises can be understood without a profound knowledge 

of the dog’s biomechanics 

This can only be addressed with objective and 

reproducible data on the dogs’ kinetics, kinematics and 

muscle functions. 

In contrast to human medicine where extensive 

biomechanical research has been performed and a lot of 

studies prove the efficacy of physiotherapeutic methods 

such studies are rare in veterinary medicine. This lack on 

high quality studies has brought the veterinary physical 

therapy in a zone between charlatanism and evidenced 

based medicine. 

The veterinary community is thus currently discussing 

two main questions: 

• Are the methods of physical therapy effective (e.g. 

for pain control or accelerated rehabilitation after 

surgery? 

• How can we increase our biomechanical and 

pathophysiological knowledge to improve our 

treatment options? 

Scientists all around the world are working on these 

topics, and in the field of veterinary physical therapy the 

first important steps have been done. For example, Monk et 

al.1 showed that early physiotherapy intervention prevents 

muscle atrophy, contributes to muscle mass and strength, 

and increases the stifle range of motion (ROM) after TPLO. 

Such studies using clinical outcome measurements (e.g. 

ROM) provide us with important information, but their input 

could be improved if modern motion analysis methods were 

implemented. This biomechanical research thus relies on 

both in vivo and in vitro methods. 

A common in vivo method to evaluate the influence of 

therapeutically interventions is the measurement of ground 

reaction forces (GRF). For this purpose different systems 

are available e.g. single force plates, pressure walkways or 

force plates integrated in treadmills. Each of these systems 

has its own advantages and disadvantages; nevertheless 

they can be used relatively easy to evaluate treatment 

outcomes. In the field of veterinary physical therapy 

GRF has been used relatively frequently; for example 

Marsolais et al2 showed that ground reaction forces of 

dogs after surgery for CCL rupture which underwent post 

operative rehabilitation (massage, swimming, passive 

range of motion exercises) improved compared to an 

exercises-restricted group. In a recent paper, Mueller et 

al.3 described the benefits of therapeutic ultrasound in 

the treatment of avulsion of the gastrocnemius muscle. 

Some promising results have been published for the use of 

extracorporeal shockwave therapy as a treatment modality 

in the osteoarthritic patient4,5. Important results presented 

by Mlacnik et al.6 showed that a combination of a weight 

management program with physical therapy leads to a 

better weight loss and improvement of existing lameness 

than a sole dietary program. 

Such kinetic measurements are helpful tools, but they 

only describe the forces resulting during stance; they do not 

provide us with information regarding the joint movements. 

To enable the visualization of the temporal and spatial 

characteristics of locomotion kinematic measurements 

should be used. A lot of studies have been performed to 

investigate the joints kinematics of sound and diseased 

animals. Also in the field of veterinary physical therapy first 

encourage steps have been taken. Marsolais7 compared 

coxofemoral, stifle and tarsal joint range of motion (ROM) 

and angular velocities during swimming and walking of 

healthy dogs with those of dogs after surgical treatment of 


a ruptured CCL. The authors showed that swimming leads 

to an increased ROM of the stifle compared to walking 

on normal ground. Because the ROM is considered as 

an important factor in the return to function, the authors 

concluded that swimming can contribute to a successful 

rehabilitation. Also some kinds of therapeutic exercises 

have been investigated to evaluate their impact on joint 

mobility. Richards et al.8 showed that during stair up 

ambulation, dogs show an increased flexion of stifle and 

the hock and an increased and earlier extension of the stifle 

compared to normal walk. Going the stairs down results 

in an increased flexion of all joints of the hind legs and a 

decreased extension of the hip joint. Holler et al.9 found 

in dogs crossing obstacles, a higher flexion of the hock 

and stifle as well an increased extension of the stifle joint 

compared to normal walk. During incline (11%) they found 

an increased flexion of the hip and decreased extension of 

the stifle, going decline (11%) the hock was less extended 

than during level walking and the hip was less flexed. 

This kinematic research gives a valuable insight into the 

joint mechanics and the value of therapeutic exercises, but 

the studies have failed to take into account the muscle 

function. The measurement of the muscle activity using 

needle or surface electromyography during motion 

is difficult. Nevertheless, some work has been done: 

Bockstahler et al.10 investigated the activity pattern of the 

quadriceps muscle in dogs and Lauer at al.11 investigated 

the hamstrings and the quadriceps during walking inclines/ 

declines. The activity of the hamstring muscle group if 

walking at a 5% incline is significantly increased in the 

beginning and in the end of the stance phase compared 

to a 5% decline. In contrast, the activity of the gluteal 

and quadriceps muscle groups was not affected when 

treadmill inclination was changed. The aforementioned 

studies are promising but our knowledge regarding the 

canine muscle function is still sparse. As a result, our 

pathophysiologic knowledge of some orthopedic diseases 

remains insufficient and we are thus unable to determine 

the optimal therapy. 

The scientific works quoted in this abstract show that 

veterinary physical therapy contributes to an accelerated 

rehabilitation after surgery and improves the quality of life 

of dogs suffering from chronic musculoskeletal disorders. 

However, the two questions mentioned above cannot be 

fully answered. as it is difficult to piece together the puzzle 

of external forces, morphometric data and clinical signs. 

One way to solve the problem could be to combine in 

vitro and in vivo methods. In vivo methods, describe the 

movement of the living organism but they are sometimes 

limited by ethical and methodological considerations. In 

contrast in vitro methods provide information about the 

biomechanics of a joint, without considering the influence 

of surrounding soft tissues such as muscles and tendons. 

With the help of mathematical methods it is possible to 

derive theoretical models, which can be used to assess for 

instance intraarticular forces. The combination of in vitro 

and in vivo methods permits the design of anatomically 

realistic two- and three dimensional models, which can 

provide significant insights into how the neuromuscular and 

musculoskeletal systems interact to produce movement. 

Researches based on a sound anatomic, biomechanic and 

physiologic, clinical and surgical knowledge are necessary 

to allow the physical therapists to respond fully to the 

physiological and clinical needs of our patients. 

Referenses 

1. Monk ML, Preston CA, McGowan CM: Effects of early 

intensive postoperative physiotherapy on limb function after 

tibial plateau leveling osteotomy in dogs with deficiency of 

the cranial cruciate ligament. Am J Vet Res. 2006;67:529- 

536 

2. Marsolais GS, Dvorak G, Conzemius MG: Effects of 

postoperative rehabilitation on limb function after cranial 

cruciate ligament repair in dogs. J Am Vet Med Assoc 2002; 

220:1325–1330 

3. Mueller MC, Gradner G, Hittmair KM, et al:. Conservative 

treatment of partial gastrocnemius muscle avulsions in 

dogs using therapeutic ultrasound -- A force plate study. 

V.C.O.T 2009;22: 243-248 

4. Dahlberg J, Fitch G, Evans RB, McClure SR, et al: The 

evaluation of extracorporeal shockwave therapy in naturally 

occurring osteoarthritis of the stifle joint in dogs. V.C.O.T 

2005; 18: 147-52 

5. Mueller M, Bockstahler B, Skalicky M, et al: Effects of 

radial shockwave therapy on the limb function of dogs with 

hip osteoarthritis. Vet Rec 2007;160:762-765 

6. Mlacnik E, Bockstahler B, Müller M, et al: Effects of 

caloric restriction and a moderate or intense physiotherapy 

program for treatment of lameness in overweight dogs with 

osteoarthritis. J Am Vet Med Assoc 2006;229: 1756-1760 

7. Marsolais GS, McLean S, Derrick T, et al: Kinematic 

analysis of the hind limb during swimming and walking 

in healthy dogs and dogs with surgically corrected 

cranial cruciate ligament rupture. J Am Vet Med Assoc 

2003;222:739–743 

8. Richards J, Holler P, Bockstahler B, et al: A comparison of 

human and canine kinematics during level walking , stair 

ascent , and stair descent. Wien Tierarztl Monat 2010; 

97:92 - 100 

9. Holler P, Brazda V, Dal-Bianco B, et al: Kinematic motion 

analysis of the joints of the fore- and hind limbs of 

dogs during walking exercise regimens. Am J Vet Res 

2010;71:734-740 

10. Bockstahler B, Gesky R, Mueller M, et al.: Correlation of 

surface electromyography of the vastus lateralis muscle in 

dogs at a walk with joint kinematics and ground reaction 

forces. Vet Surg 2009; 38: 754-61. 

11. Lauer SK, Hillman RB, Li L, et al: Effects of treadmill 

inclination on electromyographic activity and hind limb 

kinematics in healthy hounds at a walk. Am J Vet Res 

2009;70:658-66 




In depth – Bone healing for surgeons 




Stimulation of bone healing. Latest developments 

O. Gauthier, DVM, PhD Prof. 

Small Animal Surgery Department, ONIRIS College of Veterinary Medicine, Food Sciences and Engineering, 

Nantes, France. 

Development of synthetic bone graft substitutes 

Despite the benefits that minimally invasive 

osteosynthesis and surgery have brought to fracture 

and bone healing, there are still many circumstances 

where achieving bone healing may prove challenging. 

Autologous bone grafts are still considered the gold 

standard in bone repair and regeneration because of their 

osteogenicity, osteoinductivity and osteoconductivity. But 

in human medicine, some instances clearly demonstrated 

the advantages of synthetic bone substitutes over 

autografts which are no longer recommended as they 

are time consuming in the OR, expansive in terms of 

hospitalization, induce morbidity and chronic pain, are 

available in limited quantity and can be associated with 

unpredictable outcomes. The harvesting procedure requires 

a second surgical site, with which complications have 

been reported, and the quantity of bone graft is limited. 

In addition, autologous bone grafts may be too rapidly 

resorbable as they can be degraded before bone healing has 

been completed. Allogenic and xenogenic bone substitutes 

have also been proposed and are still used in some clinical 

applications. But viral transmission and a lack availability 

of native bone have led to the development of synthetic 

bone substitution biomaterials whose use dramatically 

increased in the last 15 years, because of their reliable 

manufacturing process and the possibility of combining 

them with bioactive molecules, therapeutic agents and 

cells for tissue engineering, cell-therapy and gene-therapy 

applications. 

The ideal bone graft substitute must combine several 

biological properties in order to favorably compare with 

an autologous graft: biocompatibility, osteoconduction, 

osteoinductivity (ostegenicity), bioactivity (interactions 

with the implantation site environment that can result 

in biodegradability, ionic release and exchange). Ideally, 

bone substitutes should be able to repair large defects, 

provide mechanical resistance and be resorbed to allow 

osteogenesis as the bone tissue is remodeled. Consequently 

the facility to release bioactive molecules incorporated in 

the synthetic graft can make such biomaterials potential 

drug delivery systems. 

Calcium phosphate ceramics 

Among ceramic-based bone graft substitutes, most of 

them are calcium (Ca) composites: Ca sulfates (plaster of 

Paris), Ca phosphates, Ca carbonates (coral), Ca silicates 

(Bioglass), Ca pyrophosphates … Calcium phosphate (CaP) 

bone substitutes are currently used for bone substitution 

in many different clinical situations such as repair of 

bone defects, bone augmentation in spinal arthrodesis, 

periodontal treatment, or as coatings for metallic implants. 

CaP ceramics are the principal raw materials used for 

bone substitutes and are available as granules or blocks. 

Among these biomaterials, biphasic calcium phosphate 

(BCP) ceramics have been used successfully in human 

surgery thanks partly to their chemical composition which 

closely resembles that of bone mineral and comprises 

a mixture of hydroxyapatite (HA) and beta tricalcium 

phosphate ß(TCP). These ceramics are biocompatible 

i.e. do not induce any adverse local tissue reaction, 

immunogenicity or systematic toxicity; osteoconductive, 

i.e. act as a scaffold for new bone formation requiring the 

presence of porosity and bioactive, i.e. degradable through 

a chemical and cellular process. Certain CaP biomaterials, 

such as HA,ß-TCP and BCP ceramics, have recently been 

shown to induce bone formation ectopically in different 

animal models and have consequently been qualified as 

osteoinductive. Macroporosity of CaP blocks facilitates 

invasion of cells and diffusion of biological growth factors 

into the implant, therefore inducing the osteogenic 

process within the inner surface of pores to achieve bone 

coalescence. 

The microarchitecture and particularly the size of the 

particles and the size and distribution of the pores are 

critical factors influencing biodegradability, fluid and 

cell penetration and the delivery modalities of bioactive 

molecules. CaP composites’ potential as drug delivery 

systems is a consequence of their bioactivity and 

biodegradability, by incorporation and subsequent release 

of active molecules or therapeutic agents, but also because 

Ca and P ions are important factors in many biochemical 

reactions in the body (enzymatic co-factors …). These 

chemical interactions together with specific architectural 


features lead to consider CaP ceramics as intrinsically 

‘osteoinductive’. 

Improvements in CaP biotechnology and new therapeutic 

approaches such as percutaneous or minimally-invasive 

techniques have allowed the development of injectable 

CaP biomaterials for bone replacement and particularly selfsetting 

CaP cements. Cementation of vertebrae or filling of 

bone cysts have already been documented. Two different 

strategies have been proposed for the development of 

injectable biomaterials: calcium phosphate cements (CPCs) 

and injectable ceramics. The setting of bone cements 

provides primary mechanical strength to compensate for 

a lack of initial or induced macroporosity. Self-setting 

CPCs were actually developed first, and many are already 

commercially available. They are based on a mixture of CaP 

mineral compounds that react together to provide a material 

that hardens in situ after injection, through a very mild 

exothermic reaction. These CPCs have variable setting and 

hardening times in situ depending on their formulations but 

a few of them are ready-to-use forms. After hardening, most 

cements provide dense biomaterials with irregular porosity, 

whereas various studies have shown that macropores are 

necessary for bone osteoconduction. Incorporating different 

kinds of polymers into CaP cements has recently been 

proposed to confer on them an induced macroporosity and 

accelerated their colonisation and remodeling. 

In human orthopaedics, numerous clinical indications 

have been investigated with injectable ceramic-based 

Ca cements, including bone void filling and fracture 

management: 

• For screw augmentation or bone void filler around 

metallic implants. 

• In calcaneal fractures and distal radial fractures 

where the use of CaP bone cements are associated 

with decreased pain, faster recovery and a higher 

range of joint motion. The level of evidence remains 

insufficient to recommend the use of CaP cements 

for trochanteric fracture augmentation and femoral 

neck fracture management; 

• Tibial plateau fractures are indications of choice 

for CaP cements in human surgery: they can 

provide immediate mechanical strength compared 

to autografts and a faster rehabilitation. A recent 

multicenter study led to strong recommendations: 

‘the use of autologous bone graft is no longer 

recommended and CaP cements can replace 

autologous bone graft for such an indication’. 

In human surgery, the association of CaP bone cements 

with bioactive molecules has been investigated for three 

major clinical purposes in the bone environment: the local 

delivery of antibiotics, the promotion of osteointegration 

or bone augmentation by the release of growth factors or 

cytokines, and the prevention of further bone resorption 

by the incorporation and subsequent in vivo release of 

antiresorptive agents such as bisphosphonates. Such 

applications have not yet been reported in veterinary 

literature except for a few isolated clinical reports mostly 

using BMPs on collagen sponges as the vehicle as opposed 

to CaP composites. 

Organic matrix and bioactive molecules 

Osteoinduction can be accomplished by devitalized 

demineralised bone matrix (DBM) due to the presence 

of preserved active protein factors that could stimulate 

bone formation, mostly identified as BMPs and TGF-�. 

DBM is an allogenic approach that is broadly applied in 

orthopaedic surgery and appeared as a viable alternative to 

autologous bone graft. Canine DBM is now currently used 

in veterinary orthopaedics. DBM does not confer primary 

mechanical strength to the grafted tissue but can promote 

angiogenesis, osteoblastic differentiation and subsequent 

extra cellular matrix production through the local release 

of these soluble factors. The extracellular matrix in DBM 

is mostly collagenic and can support osteoconduction if the 

grafted matrix is not degraded too rapidly. 

Similarly, the association of an organic matrix with 

selected growth factors tends to confer on the resulting 

biomaterial osteoinductive properties. The combination 

of BMPs and collagen sponges reproduces the concept of 

DBM without the risk of immunogenicity from an allogenic 

matrix. Such a combination has been successfully used for 

bone union induction in both human and veterinary clinical 

situations but still have some limitations. According to a 

recent review in human literature, it seems that “the use 

of BMP for spinal fusion is unlikely to be cost-effective” 

and the induced biological effects, due to the local release 

of supraphysiological doses of BMP can result in either 

deleterious ectopic bone formation, particularly in spinal 

fusion surgery, or in the unexpected absence of bone 

formation in the treatment of non-unions. 

Tissue engineering for bone graft substitutes 

Bone tissue engineering usually associates matrix 

structures or scaffolds, osteoinductive or growth factors 

and osteogenic cells. The potential use of stem cells 

for cell therapy have provoked great interest and also 

controversy over the past 10 years in all the fields of 

regenerative medicine. In bone marrow two major and 

distinct stem cell types are found: the hematopoietic 

stem cells, producing blood cells and marrow stroma 

fibroblasts, and mesenchymal stem cells that have the 

capacity to differentiate into all connective tissue types, 

including bone, cartilage, fat, fibrous tissue, muscle 

and hematopoietic stroma. The high plasticity of MSC 

differentiation suggested their potential use to augment, 

replace or repair diseased or damaged tissues. MSCs have 

also demonstrated immunomodulatory properties with antiinflammatory 

and antiproliferative effects that have been 

investigated in some cancer treatments. MSCs can also 

be easily transduced with exogenous genes via plasmidic 

or viral infection that facilitates their investigation in 


gene therapy strategies. Stem cells can be of various 

origins: MSCs from bone marrow (less than 0.01%), MSCs 

from adipose tissue (approximately 1%), MSCs from the 

embryonic chorion, circulating blood, synovium and other 

differentiated tissues. As associated growth factors, BMPs 

and angiogenic factors as VEGF have been thoroughly 

investigated. Concerning the associated cells, many clinical 

studies have now demonstrated the advantages of fresh 

harvested total bone marrow whereas many fundamental 

and animal studies focused on MSCs selected from bone 

marrow or adipose tissue and cultivated in vitro before 

being re-implanted. Unfortunately, despite promising 

results in pre-clinical animal models, such cell-based 

therapies have very limited clinical impact to date. 

Many surgeons have already experienced the efficacy 

of adding CaP bone graft substitutes to autologous blood, 

but only a few mechanisms of action have been proposed 

to explain it. In recent years, several studies went back 

to this relatively simple situation while proposing new 

mechanisms of action and biological explanations. The 

combination of autologous blood and CaP microparticles 

could bring interesting textural and biological features to 

the resulting composite that would avoid dispersion of 

the particles into the surrounding tissues. Moreover, this 

combination provides a moldable composite biomaterial 

with interconnected open porosity allowing free circulation 

of fluids and cells. A recent study has shown that the 

resulting composite exhibits osteogenic and osteoinductive 

properties. The size of the microparticles and the number 

of particles loaded into the blood clot are critical points. To 

some extent, an inflammatory reaction is required to initiate 

cell attraction and proliferation. Such an inflammatory 

reaction is part of the normal resorption-substitution 

process of CaP bone biomaterials, especially when used 

in particulate or granular forms. Osteogenic properties of 

blood clot associated to BCP particles may mostly result 

from the presence of monoculear cells, including osteoclast 

progenitors present within peripheral blood monocytic cells. 

Plasma clot/BCP microparticles composite may provide 

monocytes a favourable environment for osteoclastic 

differentiation, together with the production of proangiogenic 

and chemoattractant factors, and subsequent 

new bone apposition. 

Selected references 

1. Bajammal SS, Zlowodzki M, Lelwica A, Tornetta P 3rd, 

Einhorn TA, Buckley R, Leighton R, Russell TA, Larsson S, 

Bhandari M. The use of calcium phosphate bone cement in 

fracture treatment. A meta-analysis of randomized trials. J 

Bone Joint Surg Am 2008;90:1186-96. 

2. Balaguer T, Boukhechba F, Clavé A, Bouvet-Gerbettaz 

S, Trojani C, Michiels JF, Laugier JP, Bouler JM, Carle 

GF, Scimeca JC, Rochet N. Biphasic calcium phosphate 

microparticles for bone formation: benefits of combination 

with blood clot. Tissue Eng Part A 2010;16:3495-505. 

3. Bobyn JD, McKenzie K, Karabasz D, Krygier JJ, Tanzer 

M. Locally delivered bisphosphonate for enhancement of 

bone formation and implant fixation. J Bone Joint Surg Am 

2009;91 Suppl 6:23-31. 

4. Espitalier F, Vinatier C, Lerouxel E, Guicheux J, Pilet P, 

Moreau F, Daculsi G, Weiss P, Malard O. A comparison 

between bone reconstruction following the use of 

mesenchymal stem cells and total bone marrow in 

association with calcium phosphate scaffold in irradiated 

bone. Biomaterials 2009;30:763-9. 

5. Fellah BH, Gauthier O, Weiss P, Chappard D, Layrolle P. 

Osteogenicity of biphasic calcium phosphate ceramics and 

bone autograft in a goat model. Biomaterials 2008;29:1177- 

1188. 

6. Field JR, McGee M, Stanley R, Ruthenbeck G, 

Papadimitrakis T, Zannettino A, Gronthos S, Itescu S. The 

efficacy of allogeneic mesenchymal precursor cells for the 

repair of an ovine tibial segmental defect. Vet Comp Orthop 

Traumatol 2011;24:113-21. 

7. Garrison KR, Donell S, Ryder J, Shemilt I, Mugford 

M, Harvey I, Song F. Clinical effectiveness and costeffectiveness 

of bone morphogenetic proteins in the nonhealing 

of fractures and spinal fusion: a systematic review. 

Health Technol Assess 2007;11:1-150. 

8. Garrison KR, Shemilt I, Donell S, Ryder JJ, Mugford M, 

Harvey I, Song F, Alt V. Bone morphogenetic protein (BMP) 

for fracture healing in adults. Cochrane Database Syst Rev 

2010;(6):CD006950. 

9. Gauthier O, Bouler J-M, Aguado E, Pilet P and Daculsi 

G. Macroporous biphasic calcium phosphate ceramics: 

Influence of macropore diameter and macroporosity 

percentage on bone ingrowth. Biomaterials 1998;19:133- 

139. 

10. Gauthier O, Bouler JM, Weiss P, Bosco J, Aguado E and 

Daculsi G. Short-term effects of mineral particle sizes on 

cellular degradation activity after implantation of injectable 

calcium-phosphate biomaterials and the consequences for 

bone substitution. Bone 1999;25:71S-74S. 

11. Hoffer MJ, Griffon DJ, Schaeffer DJ, Johnson AL, Thomas 

MW. Clinical applications of demineralized bone matrix: a 

retrospective and case-matched study of seventy-five dogs. 

Vet Surg 2008;37:639-47. 

12. Han D, Sun X, Zhang X, Tang T, Dai K. Ectopic osteogenesis 

by ex vivo gene therapy using beta tricalcium phosphate as 

a carrier. Connect Tissue Res. 2008;49:343-50. 

13. Innes JF, Myint P. Demineralised bone matrix in veterinary 

orthopaedics: a review. Vet Comp Orthop Traumatol 

2010;23:393-9. 

14. Jurgens WJ, Oedayrajsingh-Varma MJ, Helder MN, 

Zandiehdoulabi B, Schouten TE, Kuik DJ, Ritt MJ, van 

Milligen FJ. Effect of tissue-harvesting site on yield of stem 

cells derived from adipose tissue: implications for cellbased 

therapies. Cell Tissue Res 2008;332:415-26. 

15. Kraus KH, Kirker-Head C. Mesenchymal stem cells and bone 

regeneration. Vet Surg 2006;35:232-42. 

16. Mouline CC, Quincey D, Laugier JP, Carle GF, Bouler JM, 

Rochet N, Scimeca JC. Osteoclastic differentiation of 

mouse and human monocytes in a plasma clot/biphasic 

calcium phosphate microparticles composite. Eur Cell Mater 

2010;20:379-92. 

17. Pioletti D, Gauthier O, Stadelmann VA, Bujoli B, Guicheux 

J, Zambelli PY, Bouler JM. Orthopedic implant used as drug 

delivery system: Clinical situation and state of the research. 

Current Drug Delivery 2008;5:59-63. 

18. Rabillard M, Grand JG, Dalibert E, Fellah B, Gauthier O, 

Niebauer GW. Effects of autologous platelet rich plasma gel 

and calcium phosphate biomaterials on bone healing in an 

ulnar ostectomy model in dogs. Vet Comp Orthop Traumatol 

2009;22:460-466. 


19. Russell TA, Leighton RK; Alpha-BSM Tibial Plateau Fracture 

Study Group. Comparison of autogenous bone graft 

and endothermic calcium phosphate cement for defect 

augmentation in tibial plateau fractures. A multicenter, 

prospective, randomized study. J Bone Joint Surg Am 

2008;90:2057-61. 

20. Spector DI, Keating JH, Boudrieau RJ. Immediate 

mandibular reconstruction of a 5 cm defect using 

rhBMP-2 after partial mandibulectomy in a dog. Vet Surg 

2007;36:752-9. 

21. Stadelmann VA, Gauthier O, Terrier A, Bouler JM and 

Pioletti DP. Implants delivery bisphosphonate locally 

increase periprosthetic bone density in an osteoporotic 

sheep model. A pilot study. Eur Cells Mater 2008;16:10-16. 

22. Tshamala M, van Bree H. Osteoinductive properties of the 

bone marrow-myth or reality. Vet Comp Orthop Traumatol. 

2006;19:133-41. 

23. Viateau V, Guillemin G, Bousson V, Oudina K, Hannouche D, 

Sedel L, Logeart-Avramoglou D, Petite H. Long-bone criticalsize 

defects treated with tissue-engineered grafts: a study 

on sheep. J Orthop Res 2007;25:741-9 

24. Wong DA, Kumar A, Jatana S, Ghiselli G, Wong K. 

Neurologic impairment from ectopic bone in the lumbar 

canal: a potential complication of off-label PLIF/TLIF 

use of bone morphogenetic protein-2 (BMP-2). Spine J 

2008;8:1011-8. 

25. Yuan H, Fernandes H, Habibovic P, de Boer J, Barradas 

AM, de Ruiter A, Walsh WR, van Blitterswijk CA, de Bruijn 

JD. Osteoinductive ceramics as a synthetic alternative 

to autologous bone grafting. Proc Natl Acad Sci U S A 

2010;107:13614-9. 


Delayed union and nonunion 


Western University of Health Sciences Michigan, USA 

Delayed union and nonunion of long bone fractures can 

lead to continued cycling of the implant, eventually leading 

to implant failure and inability for the bone to resume its 

normal roles. 

A delayed union is diagnosed when fracture healing 

is incomplete despite an adequate interval of time for 

complete healing of the fracture. In this situation, fracture 

healing is progressing, but at a much lower rate than 

expected for the given fracture configuration, type of 

fixation and age of the animal. 

A nonunion occurs when all healing repair processes 

have stopped, but osseous continuity has not been restored. 

This definition clinically implies a lack of progression 

of healing on serial radiographs. There is a fine line of 

distinction between delayed union and nonunion where 

an exact distinction cannot be made. Non-unions are 

sometimes defined as an absence of healing 6months after 

repair of the bone. 

Three main types of nonunion have been described based 

on the underlying cause: 

Vascular nonunions: These nonunions are capable of 

biologic repair and are classified according to the amount 

of callus present. 

• Hypertrophic (biologically active) usually have 

abundant hypervascular callus and are seen in an 

unstable fracture. They are often referred to as 

elephant foot and are often caused by implant 

failure, premature removal or excessive activity 

(Figure 1). 

• Mildly Hypertrophic (biologically active) 

usually have inadequate callus and mild sclerosis 

of the medullary cavity at the fracture site. They are 

often seen in association with rotational instability. 

• Oligotrophic (biologically active) have no 

visible callus, and the ends of the bone segments 

are sealed at the fracture site. Rounding of the 

ends of the long bone of the fracture is also seen. 

Unlike avascular nonunions, oligotrophic nonunions 

have fibrous tissue and blood vessels between the 

fragment edges and are still capable of a biologic 

response. Oligotrophic nonunions are usually 

seen when there is significant displacement of the 

fracture fragments. 

Avascular nonunions: These nonunions are less 

common and are associated with a disruption of the blood 

supply. 

Dystrophic: a secondary fragment has healed, but the 

main fragments are still unhealed and devoid of callous. 

It is usually characterized by poor vascularity to one or 

both sides of the fracture. A fracture gap is evident 

radiographically, and the fracture ends are rounded with 

sclerosis of the bone edges. This type of union is more 

common in geriatric patients. 

Necrotic: occurs in highly comminuted fractures in 

poorly vascularized areas (in horses, the cannon bone). 

In these cases, the major fragments eventually die or 

sequestra without becoming incorporated into the callus. 

These often occur with highly comminuted fractures, 

with disruption of the blood supply and severe soft tissue 

damage. Even though the fragments are anatomically 

reduced with no fracture gap after repair, the fragments 

are avascular and do not heal. 

Defect: result from loss of fragments at the time of injury 

or through resorption of a fragment. This causes a critical 

size defect that the callus cannot bridge. 

Atrophic nonunions: can be a result from the previous 

three types that progress through significant bone 

resorption and osteoporosis. These are characterized by 

loss of vascularity, resorption and rounding of fragment 

ends and osteoporosis (Figure 2). 

Etiology – 

Understanding the underlying cause of delayed and non 

unions is a pre-requisite to establishing an appropriate 

treatment plan. 


Local Factors 

1. Infection: This can occur from an open fracture or 

intraoperative contamination. Drainage, periosteal 

new bone formation and lucency around the 

implants are typical signs associated with infection. 

2. Inadequate immobilization. These are usually 

technical errors and involve the use of inappropriate 

implants for the fracture configuration (eg, pins 

in highly comminuted fractures, short plates or 

too short a glide hole in a lag screw placement). 

Insufficient immobilization exceeds the ability to 

form a bony bridge between fracture fragments in 

spite of excessive callus formation. Stress shielding 

leads to osteopenia and delayed formation of bone 

in the fracture gap. 

3. Lesions of adjacent soft-tissues: This issue 

has made minimally invasive fracture techniques 

popular. A large amount of soft tissue damage with 

an injury will delay fracture healing by disruption of 

peripheral blood supply. 

4. Osseous distraction: Experimental models of 

non-unions are based on the creation of a segmental 

bone defect 1.5 times the diaphyseal diameter 

(skeletally mature dog). 

5. Loss of bone stock: This factor was associated 

with the removal of avascular bone fragments 

during traditional open fracture management. The 

biological approach now recommended for the 

management of complex fractures decreases the 

likelihood of this complication. 

Host Factors 

These factors would include malnutrition, generalized 

metabolic or endocrine abnormalities, acute or chronic 

disease states, as well as concurrent treatments. 

The most common site for non-union in small 

animals is the distal radius in small breeds. 

Vascularity has been found decreased in this specific 

location and in these dogs, compared to larger breeds. 

These fractures are also frequently misconceived by 

veterinarians as simple fractures in light-weight animals, 

and treated with external coaptation. If both the radius and 

ulna are fractured, this management will inevitably lead to 

atrophic non-unions, with a high risk of cast sores and soft 

tissue injuries that may warrant amputation. 

Diagnosis 

Animals with delayed union or nonunion of fractures have 

persistent lameness with various degrees of instability. In 

cases of infected delayed union and nonunion, one or more 

draining fistulas can be seen. The true assessment of 

bone healing is obtained by serial radiographs (3 to 

6 weeks apart) using at least two views. 

The radiographic signs of delayed union include 

formation of periosteal and endosteal bridging callus with 

an open medullary cavity at the fracture site. Thus, changes 

indicative of bony union are present but are progressing at 

a slower pace than expected. 

The radiographic signs of nonunion include: 

• sclerosis of bone ends at the fracture site (evidence 

of sealing of the medullary cavity) 

• no bony progress or change over a 3-month period 

• progressive bowing at the fracture site 

• bone atrophy 

• excess callus around the fracture site with 

radiolucent lines in the callus itself 

Research focusing on new modalities for early diagnosis 

of delayed healing include focus on serum/urine markers 

of bone metabolism and nuclear scintigraphy. 

Management 

The management of delayed unions and nonunions is 

based on an understanding of the underlying cause: 

Noninfected delayed unions 

In the absence of infection, the decision making process 

is based on the assessment of implant stability and 

biological factors. Marked osteoporosis in the presence of a 

rigid implant may be a sign a stress shielding. Encouraging 

use of the limb may be enough to stimulate bone healing. 

Conversely, destabilization of the implant (for an external 

fixator for example) or replacement with an appropriately 

sized implant may be indicated. In other cases, additional 

external fixation or coaptation may be necessary. In these 

cases, increased callus typically suggests that fracture 

instability is present, justifying enforced rest. Adjunct 

fixation mau also be indicated. 

If a loose implant or malalignment is present, surgical 

revision is required. Loose implants can be removed, 

replaced or tightened, and cancellous bone graft can be 

placed around the fracture site. 

Noninfected Nonunions 

Viable nonunions are treated according to the type 

of nonunion; cases of hypertrophic nonunion should 

respond to rigid fixation. Usually, internal fixation is 

used, and just enough callus is removed to allow proper 

placement of the plate. In cases of mildly hypertrophic 

or oligotrophic nonunion, the ends of the fragment at the 

fracture can be sealed by endosteal callus. In these cases, 

opening of the medullary cavity followed by bone grafting 

and rigid fixation improve the chances of union. 

Nonviable nonunions are treated by removal of all 

necrotic and avascular bone, in conjunction with opening 

of the medullary cavity and bone grafting, followed by rigid 

fixation. A limited en bloc ostectomy and compression plate 

fixation is a viable option in cases of biologically inactive 

non-unions, as long as shortening of the limb does not 

exceed 20% of the original length of the bone. 


Selected references 

• Blaeser LL, Gallagher JG, Boudrieau RJ: Treatment of 

biologically inactive nonunions by a limited en bloc 

ostectomy and compression plate fixation: A review of 17 

cases. Vet Surg 2003;32:91-100. 

• Cabenela ME: Open cancellous bone grafting of infected 

bone defect. Orthop Clin North Am 1984; 15:427-440. 

• Kesemenli CC, Subasi M. Arslan H, Necmioglu S.Kapukaya 

A: Treatment of humeral diaphyseal nonunions by 

interlocked nailing and autologous bone grafting. Acta 

Orthop Belg 2002;68(5):471-475. 

• Muir P: Distal antebrachial fractures in toy-breed dogs. 

Comp on Cont Ed for the Pract Vet 1997;19(2):137-145. 

• Robins GM, Eaton-Wells R, Johnson K: Customized 

hook plates for metaphyseal fractures, nonunions and 

osteotomies in the dog and cat. Vet Comp Ortho Traum 

19893;6(1):56-61. 

• Zhang B, Huang FG, Yang ZM: Application of autogenous 

bone grafting with vascular anastomosis in treatment of 

nonunion of fracture and bone defect. Zhongguo Xiu Fu 

Chong Jian Wai Ke Za Zhi 2002;16(3):185-187. 


Stimulation of bone healing. Commercially available 

products. 

O.Gauthier, DVM, PhD Prof. 

Small Animal Surgery Department, ONIRIS College of Veterinary Medicine, Food Sciences and Engineering, 

Nantes, France. 

Many bone grafts substitutes are currently available 

on both human and veterinary orthopaedics, and several 

aspects must be considered before choosing one of them for 

a specific clinical application. Many of them demonstrated 

interesting properties during their development process 

that can differ from their final clinical use. Most of them 

can be qualified as osteoinductive materials, but the clinical 

interest of osteoinductivity remains controversial (why 

and how osteoinductivity could be useful for a bone graft 

substitute? How to reproduce it? What kind of currently 

available biomaterials can be qualified as ‘osteoinductive’? 

Is it clinically relevant?). 

Biological performances of bone graft substitutes can 

be related to many different factors such as: 

• Biological origin versus synthetic origin 

• Chemical composition: mineralised (Ca phosphates, 

Ca sulfates, Ca silicates, …) versus demineralised 

ou non-mineralised matrix; resorbability and 

biodegradability profile 

• Available form: granular form (what is the size 

of the particles?), massive form (can the block fit 

to the surgical site?); injectable paste or cement 

(what are the setting or hardening properties?) Is 

it ready-to-use or not (if not that implies that it may 

be prepared in the operating room)? 

• The porous architecture: what kind of porosity 

(micro and or macroporosity, interconnected, open, 

induced porosity?), what is the mean size of the 

pores, what is the percentage of porosity? 

• The recommended indications 

• The expected in vivo efficacy: what kind of biological 

properties can be expected (osteoconductivity, 

bioactivity, osteogenicity (if osteoprogenitor cells 

are present), osteoinductivity (does the biomaterial 

contain and release any growth factor?). 

This presentation will review most of the bone graft 

substitutes that are available on both human and veterinary 

markets. It will present their respective characteristics and 

biological properties and try to define their potential benefit 

for the veterinary patient. 


Enhancing bone healing in practice 


Western University of Health Sciences Michigan, USA 

The management of fractures and bone defects is aimed 

at restoring the ability of bone to support physiological 

biomechanical loads prior to fatigue failure of surgical 

implants. Stimulating bone production may be applied to 

the management of fractures, nonunions, and osteomyelitis. 

Other orthopedic indications include limb lengthening, 

reconstructive procedures following tumor resection, 

arthrodeses, and osteointegration of joint replacement 

prostheses. The clinical use of these techniques actually 

extends beyond the field of orthopaedics to include 

periodontal, maxillofacial and neurosurgery. Much 

progress has been made simultaneously with our improved 

understanding of bone healing, leading to the elaboration 

of techniques targeting various factors involved in bone 

regeneration (Figure 1). In that context, clinicians dispose 

of a wide array of strategies to create a biomechanical and 

biological environment favourable to bone formation. The 

purpose of this presentation is to provide an overview of 

the current trends in small animal orthopaedics, and their 

practical application in clinical cases. 

BONE REGENERATION 

Grafting techniques: 

Cells, Growth factors, 

Support 

Dynamisation, D.O. 

Surgical Stabilisation 

FRACTURE MOVEMENT 

FRACTURE MOVEMENT 

ANGIOGENESIS 

Healthy soft tissue bed 

Biological fixation 

Grafting techniques 

Figure 1: Diagram derived from Marsh and Li’s triad of 

interrelationships in the regenerative repair of fractures (Marsh 

& Li 1999). D.O.: Distraction osteogenesis. Support: gap filler 

and network for osteoprogenitor cells. 

The biomechanical environment was one of the first 

factors to be identified for its influence on bone healing, 

promoting the development of fracture fixation techniques. 

The concept of rigid internal fixation was first developed by 

AO to improve early return to function. Early weight bearing 

promotes biomechanical stimulation of bone healing and 

prevents disuse osteoporosis. Fracture fixation progressed 

toward semi-rigid fixation, encouraging callus formation 

and rapid gain of biomechanical strength within the fracture 

site. Semi rigid fixation is one of the most commonly applied 

strategies to accelerate normal bone healing in clinical 

cases. For example, this approach served as a rationale 

behind “elastic plating” of long bone fractures in immature 

patients. Other examples of biomechanical modifications to 

encourage bone formation include distraction osteogenesis 

and axial dynamization of long bone fractures. 

If the biomechanical environment dictates the type of 

bone repair, adequate blood supply is a prerequisite to 

bone healing. Promoting angiogenesis and preserving the 

vasculature surrounding the fracture site have become 

the center fold for encouraging bone healing in private 

practice. The concept of “biological fracture fixation” 

emphasizes the role of soft tissue integrity in fracture 

healing. In this context, surgical approach is minimized or 

eliminated, manipulation of fragments is avoided and the 

fracture hematoma is preserved. Consequently, implant 

designs have been modified to preserve extraosseous blood 

supply to the fractured bone. This approach is especially 

relevant to the management of comminuted fractures of 

the long bones, and is often combined with semi-rigid 

fixation. Plates have evolved toward a locking mechanism, 

eliminating the need for frictional contact between the 

plate and underlying cortex. The number of screws per bone 

segment is limited and the profile of these implants allow 

percutaneous placement. External fixators are designed 

to simplify frames and limit the number of pins required 

to achieve immobilization. Ring fixators limit soft tissue 

trauma through the use of tensioned wires. Closed external 

fixation is most relevant to the management of long bone 

fractures of the distal limbs. New instrumentation has been 

designed to improve interlocking nail fixation of the tibia, 


femur or humerus through percutaneous placement. Closed 

reduction and percutaneous fracture fixation techniques 

are therefore expanding in human as well as veterinary 

orthopaedics. Biophysical alternatives to enhance 

fracture repair involve the use of low-intensity pulsed 

ultrasonography, electrical stimulation and extracorporeal 

shock-waves (orthotripsy). Although their mechanisms 

of action remain somewhat unclear, these techniques 

have been used in man to obtain healing of non-unions, 

accelerate normal fracture healing and increase healing 

rates in patients considered at risk for non-union, such as 

diabetics. Some experimental data is available concerning 

the effects of these techniques in dogs and their clinical 

use is emerging in veterinary orthopedics. 

Bone grafting remains one of the most traditional 

methods to stimulate bone formation. Fresh autogenous 

grafts are still considered a “golden standard” to which 

other osteoproductive agents are compared, and remain 

the most common type of grafts in private practices 

worldwide. Indeed, autogenous bone is the most effective 

material in promoting rapid healing; compared with 

other materials, it provides viable cells while avoiding 

immune reactions and disease transmission. One of the 

shortcomings of autogenous cancellous graft consists of its 

lack of biomechanical strength, which precludes its use as a 

structural graft. Although complications have been reported 

after harvesting of autograft in dogs, their incidence has not 

been determined. In humans, the morbidity rate associated 

with the collection of augenous bone approaches 25%, 

with major complications occuring in 3 to 4 % of patients. 

Complications include pain, sepsis, stress fractures, intraoperative 

blood loss, increased surgical time and limited 

supply. Concerns with limited availability and associated 

complications have prompted the search for bone graft 

substitutes. One strategy is to identify a single purified 

molecule, which could ultimately be confirmed as the 

agent of choice for clinical promotion of bone healing 

and regeneration, for example, bone morphogenic protein 

(BMP). More than 13 BMPs have been identified. Synthetic 

agents do not carry any risk of disease but do not contain the 

optimal mixture of growth factors naturally present in bonederived 

products. Although rh-BMP2 has recently been 

clinically applied in dogs, the cost of these preparations 

remains prohibitive for the veterinary market.Another 

strategy is to identify an optimal mixture of bone growth 

agents, either concocted from purified agents, or generated 

biologically as the product of a tissue or a cultured cell, such 

as demineralized bone matrix. Demineralized bone matrix 

(DBM) is the most common source of partially purified boneinducing 

factors used in human patients. Demineralized 

bone matrix provides osteoconduction with the collagen 

network naturally present in bone, and osteoinduction by 

the inherent BMPs liberated during demineralization. The 

processing of commercial canine DBM allograft including 

removal of the periosteum, cartilage, and bone marrow, 

and freezing have been shown to reduce immune reactions. 

Frozen canine DBM has been commercialized in the United 

States in 1 and 3cc units since 1996 and is now available 

as a freeze dried product. We have previously published a 

retrospective and case-match study in which healing rate 

and complications were similar in dogs with fractures, 

arthrodesis and tibial plateau leveling osteotomy grafted 

with DBM (and cancellous allograft chips) compared 

to autogenous cancellous graft. We have since used 

demineralized bone matrix instead of autogenous grafts in 

any procedure with normal bone regenerative properties. 

The main limitations of DBM consist in its origin (risk of 

disease transmission) and lack of injectability. Numerous 

synthetic agents have become commercially available for 

clinical application in small animals. The majority consist of 

osteoconductive materials. The majority of these products 

cost a price similar to that of DBM but does not provide 

osteoinductivity. Other limitations vary with products, but 

include brittleness, slow resorption of a radio-opaque 

material (affecting the assessment of bone healing) or 

excessive degradation rate. Calcium sulfate agents can 

however be impregnated with antibiotics, acting as 

adjuncts for local therapy of infected bone defects. 

The wide therapeutic range now offered may pose a 

dilemma for clinicians: while it provides more freedom to 

optimize treatment modality for individual cases, it also 

complicates the decision-making process for orthopedic 

surgeons. A rational attitude towards solving this issue 

should be based on an assessment of the factors affecting 

bone healing (Figure 1). Understanding which factor(s) 

are deficient in a given patient determines the criteria for 

selecting a therapeutic strategy. The most popular strategy 

to stimulate healing of complex fractures in practice 

focuses on preserving surrounding soft tissues, while 

providing a biomechanical environment enhancing indirect 

bone healing. Bone grafting has become more relevant 

to the management of arthrodeses or complications of 

bone healing (large bone defects, non-unions, malunions, 

delayed unions), especially when the treatment requires 

surgical exposure of the lesion. Future research efforts 

may lead to the development of injectable agents that 

may further accelerate the healing of fractures treated 

percutaneously or allow minimally invasive treatment of 

delayed healing. 


Selected references: 

• De Long WG Jr, Einhorn TA, Koval K, et al. Bone grafts and 

bone graft substitutes in orthopaedic trauma surgery. A 

critical analysis. J.Bone Joint Surg Am 2007; 89: 649–658. 

• Drosos GI, Kazakos KI, Kouzoumpasis P, et al.Safety and 

efficacy of commercially available demineralised bone 

matrix preparations: a critical reviewof clinical studies. 

Injury 2007; 38 Suppl 4:S13–21. 

• Ferguson JF: Fracture of the humerus after cancellous bone 

graft harvesting in a dog. J Small Anim Pract 37:232-234, 

1996. 

• Griffon DJ: Fracture healing, in Johnson AJ, Houlton JE, 

Vannini R (eds): AO principles of fracture management 

in the dog and cat. Clavadelerstrasse, Switzerland, AO 

Publishing, 2005, pp73-97. 

• Ham K, Griffon DJ, Seddighi M, Johnson AL. Clinical 

application of tobramycin impregnated calcium sulfate 

beads in six dogs (2002-2004). J Am Anim Hosp Assoc 

2008, 44(6):320-326. 

• Hoffer M, Griffon D, Schaeffer D, Johnson AL, Thomas 

M. Clinical Applications of Demineralized Bone Matrix:A 

Retrospective and Case-Matched Study of 75 Dogs. 

Veterinary Surgery 2008;37(7):639-647 

• Hudson CC, Pozzi A, Lewis DD. Minimally invasive plate 

osteosynthesis: applications and techniques in dogs and 

cats. Vet Comp Orthop Traumatol 2009;22: 175–182. 

• Kraus KH, Kirker-Head C. Mesenchymal stem cells and bone 

regeneration. Vet Surg 2006; 35: 232–242. 

• Patterson TE, Kumagai K, Griffith L, et al. Cellular strategies 

for enhancement of fracture repair. JBone Joint Surg Am 

2008; 90: 111–119. 

• Pozzi A, Lewis D. Surgical approaches for minimally 

invasive plate osteosynthesis in dogs. Vet Comp Orthop 

Traumatol 2009; 22: 316–320. 

• Ragetly GR, Griffon DJ: The rationale behind novel bone 

grafting techniques in small animals. Vet Comp Orthop 

Traumatol 2011;24(1):1-8. 



In depth – Neurosurgery: lumbosacral 

disease 




Lumbosacral disease (LS): an update on diagnostic 

imaging techniques 

I. Gielen, K. Kromhout, H. van Bree* 

Department of Medical Imaging & Small Animal Orthopaedics, Veterinary Faculty, Ghent University 

What is lumbosacral (LS) disease? 

Pathological conditions of the ligaments, bony structures 

and the intervertebral disc may narrow the diameter of the 

spinal canal and the intervertebral foramina, which affect 

the spinal roots enclosed with the remnant epidural space. 

This may lead to a clinical neurological dysfunction known 

as the cauda equina syndrome. The L7-S1 disc is the largest 

disc and may undergo a fibrinoid degeneration (Hansen 

type II disc degeneration) which usually occurs in large 

breeds. Lumbosacral disease (cauda equina syndrome or 

LS syndrome) is characterised by narrowing of the vertebral 

canal and/or the intervertebral foramina in the lumbosacral 

area, with compression of the nerve roots that form the 

cauda equina and includes affections of any component 

of the LS joint (cauda equina compression): 

• Degeneration of the intervertebral disc between 

the last lumbar vertebra and the sacrum (LS disc): 

• bulging (protrusion). 

• rupture (extrusion). 

• Instability and misalignment between the last 

lumbar vertebra and the sacrum. 

• Proliferations of bony or soft tissues around the 

LS-joint. 

• Lumbosacral osteochondrosis (OCD) of the end plate 

of either the sacrum or L7 vertebra. 

• Abnormalities in the shape of the vertebrae as a 

congenital problem. 

While some dogs might have only one type of these 

diseases, many dogs will have a combination of several 

of these problems. Lumbosacral disease commonly affects 

middle aged or older large breed dogs. The precise nature of 

these problems depends on which nerves are compressed, 

and the severity and duration of compression. Working and 

sporting breeds of dogs, particularly German Shepherd 

Dogs, are predisposed. Instability is believed to play a 

major role in LS disease in dogs and humans. 

How is LS disease diagnosed? 

A detailed and thorough clinical examination is essential, 

as the symptoms can be very similar to those seen with 

other diseases, including hip dysplasia and other lower back 

problems. Clinical suspicion of lumbosacral disease can 

be confirmed with diagnostic imaging, but even the most 

advanced diagnostic imaging techniques may not always 

provide a definitive answer. 

Possible imaging techniques? 

Plain radiography: 

Lateral and ventrodorsal radiographs are the initial steps 

in evaluating lumbosacral disease. Survey radiography is 

only diagnostic in conditions that involve bony destruction 

or displacement (including discospondylitis, osseous 

neoplasia, traumatic fracture and subluxation, sacral 

endplate osteochondrosis and idiopathic lumbosacral 

stenosis), or it can identify predisposing factors to 

degenerative LS stenosis such as OCD and transitional 

vertebrae. Indirect evidence of degenerative lumbosacral 

stenosis (e.g. spondylosis deformans, disc space narrowing, 

vacuum phenomenon indicating disc rupture, end plate 

sclerosis and transitional vertebrae) is frequently present 

on survey radiographs. These findings suggest, but do not 

confirm, the diagnosis and they may occur in clinically 

normal dogs. Spondylosis may be a benign radiographic 

change and is often present in asymptomatic dogs. However, 

(non-bridging) lumbosacral spondylosis in the presence of 

the cauda equina syndrome is considered to be highly 

suggestive of degenerative lumbosacral stenosis. Dogs 

with type II disk disease may have radiographic changes 

associated with spondylosis that are more apparent 

than those in other dogs. When survey radiographs are 

suggestive for lumbosacral instability, this can be confirmed 

by stressed views including flexion and extension views. 

The greatest limitation of survey radiography is that, 

although degenerative changes involving adjacent bony 

structures are visible on radiographs, the cauda equina 

itself cannot be visualized and evaluation of the exact 

neural compression is impossible. 


Contrast radiography: 

Because clinical signs of lumbosacral disease are usually 

the result of soft tissue compression of the cauda equina, 

contrast radiography may help to give a definitive diagnosis. 

Myelography involves the injection of contrast medium 

into the subarachnoid space and allows evaluation of the 

spinal cord cranial to the LS region and thus may help rule 

out other diseases. However, it may be of limited value in 

the evaluation of the cauda equina in large dogs, whose 

dural sac usually ends before the LS junction. Stressed 

views (flexion and extension) improve the diagnostic 

sensitivity of myelography. A normal myelographic study 

does not rule out LS disease. 

Epidurography, discography and also intraosseous 

venography are probably unreliable techniques. Results 

are therefore confusing and both false positive and false 

negative conclusions can be reached. 

Epidurography involves the injection of contrast medium 

into the epidural space and is performed in patients 

under general anaesthesia and usually does not require 

fluoroscopy. Epidurography is easier to perform than 

myelography and has less morbidity but is not very reliable. 

Epidurographic findings include elevation of the epidural 

space, total obstruction to cranial flow of contrast medium, 

concomitant filling of the epidural space and vertebral 

venous sinuses as well as extravasation of contrast 

material into adjacent soft tissue adjacent to the injection 

site. The disadvantage is that filling of the epidural space 

may be incomplete, because this space is poorly defined 

and irregular. Flexed and extended views of the LS joint 

during epidurography may accentuate a compressive lesion. 

Discography involves the injection of contrast medium 

into the intervertebral disc. Normally, it is difficult or 

impossible to inject a small amount of contrast medium into 

the nucleus pulposis. When contrast medium can easily be 

injected into the disc, and lateral and ventrodorsal views 

show extensive spreading of contrast medium within the 

disc, this is indirect evidence for a Hansen type II disc 

degeneration. Discography is not often performed, as it 

can damage a normal intervertebral disc. 

Computed Tomography (CT) and Magnetic Resonance 

Imaging (MRI): 

Computed tomography (CT) and magnetic resonance 

imaging (MRI) are probably the diagnostic procedures of 

choice. Their main advantage is that they make it possible 

to evaluate structures that cannot be visualised completely 

with conventional radiography, such as the lateral recesses, 

intervertebral foramen and articular processes. These two 

imaging techniques avoid superposition of the surrounding 

bony structures, which is a major disadvantage of 

radiography. Both techniques require general anaesthesia, 

although the examination time during MRI is much longer 

than that during CT. 

CT is especially useful in patients with cauda equina 

syndrome in which radiographic findings are negative 

and in patients that demonstrate a profound unilateral 

lameness due to spinal nerve root compression. CT provides 

bone detail superior to that seen with MRI, and soft tissue 

contrast superior to that of conventional radiography. 

Specific CT findings suggestive of degenerative lumbosacral 

stenosis are obliteration of the spinal canal by disc 

protrusion (central or unilaterally left or right), dorsal 

displacement of the dorsal sac and spinal nerve roots, 

swelling of the spinal nerve roots and hypodense spots 

(vacuum phenomenon) in the intervertebral disc indicating 

disc rupture. In addition, CT allows assessment of the 

articular facets, pedicles and the intervertebral foramina 

(Figure 1). It allows visualisation of individual nerve roots 

because of the contrast provided by the epidural fat. It may 

rule out diseases producing similar symptoms, like nerve 

root tumours or discospondylitis. The use of intravenous 

contrast is always indicated. The images should be read in 

both a bone and a soft tissue window. Another advantage 

of CT versus MRI is a greater ability to discriminate 

between bone and calcified soft tissue structures versus 

gas opacities. Reconstructions in the dorsal and sagittal 

plane can be very useful, and a positional CT protocol that 

includes flexion and extension scans of L7-S1 can be used 

for quantifying dynamic changes in dogs with LS disease. 

Facet subluxation may be visible using a bone window or 

3D reconstructions. In a study evaluating canine LS stenosis 

using intravenous contrast-enhanced CT, the positive 

predictive values for compressive soft tissues involving 

the dorsal canal, ventral canal and lateral recesses were 

83%, 100%, and 81%, respectively. 

Figure 1: Transverse CT image of the lumbosacral intervertebral 

disk space in a dog with spondylosis deformans. The 

degenerative changes and spurs at the level of the left and 

right intervertebral foramina, causing compression on the 

nerve roots, can be appreciated. 


Advantages of MRI versus CT and radiography include: 

greater soft tissue contrast; excellent visualization of nerve 

roots, intervertebral discs, and ligaments; detection of disc 

degeneration (Figure 2); lack of ionizing radiation; and ability 

to acquire images in multiple planes. A disadvantage is the 

prolonged examination time requiring long anaesthesia. 

Here as well, the use of contrast medium (paramagnetic) 

may be indicated to better delineate the process. 

Figure 2: Sagittal T2-weighted, MR image, showing 

lumbosacral compression. The intervertebral disc between L7 

and is protruding into the vertebral canal, compressing the 

nerves, as they pass through. Loss of signal intensity in the 

L7-sacral disc indicates disc degeneration. 

MRI studies concluded that the predominant feature of 

the degenerative cases was disc-associated disease. The 

technique demonstrates this fact clearly, suggesting a 

sequence of disc degeneration and dehydration followed 

by nuclear fragmentation and then disc protrusion (Hansen 

type II). MRI is also sensitive for defining other disease 

processes, such as neoplastic disease, that might confound 

the diagnosis. 

However, in one study, no correlation was found between 

severity of the clinical signs and the severity of cauda 

equine compression as assessed by MRI. In humans, it 

has been proposed that MRI may lead to over-diagnosis 

of disc disease, because many people without back pain 

have disc bulges or protrusions on MR imaging. The 

results of one comparative study to assess the extent of 

agreement among CT, MRI, and surgical findings in dogs 

with degenerative LS stenosis indicate that there is a high 

degree of agreement between CT and MRI findings but 

that the degree of agreement between diagnostic imaging 

findings and surgical findings is lower. 

Inconsistency between disc abnormalities and clinical 

signs must be considered, and the diagnosis should always 

be based on clinical examination in addition to diagnostic 

imaging. 

The relevance of measuring the lumbosacral step and the 

lumbosacral canal ratio is still controversial and should be 

investigated further. 

Additional reading 

• Barthez PY, Morgan JP, Lipsitz D (1994) Discography and 

epidurography for evaluation of the lumbosacral junction 

in dogs with cauda equina syndrome. Veterinary Radiology 

and Ultrasound 35, 152-157. 

• De Risio L, Thomas WB, Sharp NJ (2000) Degenerative 

lumbosacral stenosis. Veterinary Clinics of North America 

Small Animal Practice 30, 111-132. 

• Jones JC, Cartee RE, Bartels JE. (1995) Computed 

tomographic anatomy of the canine lumbosacral spine. Vet 

Radiol Ultrasound 36, 91-99. 

• Jones JC, Shires PK, Inzana KD, et al. (1999). Evaluation of 

canine lumbosacral stenosis using intravenous contrast- 

enhanced computed tomography. Vet Radiol Ultrasound 40, 

108-114. 

• Jones JC, Davies SE, Werre SR, et al. (2008) Effects of body 

position and clinical signs on L7-S1 intervertebral foraminal 

area and lumbosacral angle in dogs with lumbosacral 

disease as measured via computed tomography. Am J Vet 

Res 69, 1446–1454. 

• Lang J, Häni H, Schawalder P (1992) A sacral lesion 

resembling osteochondrosis in the German Shepherd Dog. 

Veterinary Radiology and Ultrasound 33, 69-76. 

• Levine GJ, Levine JM, Walker MA, et al. (2006) Evaluation 

of the association between spondylosis deformans and 

clinical signs of intervertebral disk disease in dogs: 172 

cases (1999–2000). J Am Vet Med Assoc 228, 96–100. 

• Morgan JP, Bahr A, Franti CE, Bailey CS (1993) Lumbosacral 

transitional vertebrae as a predisposing cause of cauda 

equina syndrome in German shepherd dogs: 161 cases 

(1987-1990). Journal of the American Veterinary Medical 

Association 202, 1877-1882. 

• Morgan JP, Bailey CS (1990) Cauda equina syndrome in 

the dog: Radiographic evaluation. Journal of Small Animal 

Practice 31, 69-77. 

• Ramirez O, 3rd, Thrall DE. (1998) A review of imaging 

techniques for canine cauda equina syndrome. Vet Radiol 

Ultrasound 39, 283-296. 

• Schmid V, Lang J (1993) Measurements on the lumbosacral 

junction in normal dogs and those with cauda equina 

compression. Journal of Small Animal Practice 34, 437-442. 

• Selcer BA, Chambers JN, Schwensen K, Mahaffey MB 

(1988) Epidurography as a Diagnostic Aid in canine 

Lumbosacral Compressive Disease. Veterinary and 

Comparative Orthopaedics and Traumatology 2, 97-103. 

• Suwankong N, Voorhout G, Hazewinkel H, Meij B (2006) 

Agreement between computed tomography, magnetic 

resonance imaging, and surgical findings in dogs with 

degenerative lumbosacral stenosis. J Am Vet Med Assoc 

229, 1924–1929. 


Lumbosacral spine: surgical decision making 


Higham Gobion, Herts, United Kingdom 

Degenerative lumbosacral stenosis (DLSS) is a 

relatively common disorder affecting the L7-S1 joint, 

mainly in large breed and middle-aged to older dogs. 

Labrador retrievers, Border Collies and German Shepherd 

Dogs seem overrepresented, with a male to female 

ratio of approximately 2:1. DLSS is characterized by 

different degenerative changes that can occur alone or in 

combination, such as spondylosis, disc protrusion, vertebral 

instability, ligament hypertrophy etc.; those changes 

contribute in differing degrees to determine vertebral canal 

and/or foraminal stenosis and subsequent compression/ 

damage/ impingement of the conus medullaris and/or the 

cauda equina nerve roots. DLSS is sometimes wrongly 

used interchangebly with the term “cauda equina syndrome 

(CES)”: the latter describes sensory and/or motor neural 

dysfunction that results from compression, inflammation 

or destruction of the cauda equina nerve roots; therefore, 

any disease affecting the caudal lumbar and sacral 

vertebrae (less commonly the coccygeal vertebrae) can 

potentially lead to CES. On the basis of this statement, 

DLSS represents only one of the causes of CES. 

Diagnosis and treatment options are still a matter of 

debate and therefore controversy exists in the veterinary 

world. Correct clinical understanding and localization of the 

neurological problem is a critical first step in establishing 

a diagnostic protocol; moreover, most of the diseases that 

may mimic a lumbosacral (L-S) disorder such as orthopedic 

diseases (e.g., arthritis, hip dysplasia, and cranial cruciate 

ligament disease) need to be ruled out. 

Several diagnostic tools have been described in the 

past to diagnose DLSS, such as electromyography (EMG), 

x-ray, myelography, epidurography and discography; 

however, nowadays computed tomography (CT) and 

magnetic resonance imaging (MRI) seem to represent the 

best imaging modality to investigate the L-S area. The 

main goals of CT and MRI should be firstly to show the 

degenerative changes and neural structure compression/ 

damage in order to reach the correct diagnosis and 

secondly, though just as importantly, to guide the clinician 

towards the correct therapeutic decision. Finally, it is 

important to emphasise that CT and MRI should always 

be interpreted in light of the clinical findings, as clinically 

normal patients may show abnormal CT or MRI findings. 

Conservative treatment (i.e., restricted exercise and 

pain management) has been reported as an alternative to 

surgery, even though little data are available to definitively 

establish this modality and its effectiveness. In one study, 

injection of methylprednisolone sodium acetate into the 

lumbosacral epidural space resulted in clinical improvement 

in about 80% and complete resolution of signs in more 

than half of the affected dogs; nevertheless, further 

investigations are necessary to definitely establish the real 

efficacy of this therapeutic method. 

Surgical therapy represents so far the treatment of choice 

in the vast majority of patients affected by DLSS, especially 

in case of failure of conservative management, severe pain, 

and moderate to severe neurologic deficits. Quite a wide 

variety of surgical procedures have been reported to treat 

DLSS: dorsal decompression, discectomy, facetectomy, 

foraminotomy, and fixation-fusion. As previously stated, the 

choice should be based on the clinical and imaging findings. 

Survey radiography is useful to rule out other causes of 

CES (e.g., vertebral neoplasms and discospondylitis, Fig. 

1), concurrent abnormalities which include osteochondrosis 

(OCD) of the sacral end plate and transitional vertebrae 

(LSTV), but it is particularly essential (though controversy 

still exists) to assess for possible underlying instability 

of the LS junction, mainly by evaluating stress x-rays 

(extension and flexion). Instability/subluxation of the L-S 

articulation needs to be surgically addressed by dorsal 

stabilization techniques whenever it is clinically and/or 

radiographically suspected. Instability of L-S joint may 

occasionally be the only evident finding or it may represent 

a single part of a more complex DLSS, so further crosssectional 

imaging is necessary. CT, thanks to its bone 

resolution, may be complementary to radiography, to better 

define LSTV and OCD lesions for example; both these 

conditions predispose the L-S joint to degenerative changes 

and usually lead to DLSS earlier in a dog’s life. CT also 

shows spondylosis, narrowed vertebral canal, thickened 

articular processes, and osteophyte formation of articular 

processes and subsequent narrowing of the intervertebral 

foramina. Thorough evaluation of the foramina is mandatory 


in CES patients, and it may require a MRI scan. The latter, 

thanks to its superiority in soft tissue resolution and due 

to the possibility of acquiring images on multiple spatial 

planes, is commonly very helpful for assessing the foramen 

and the nerve root through the foramen itself (Fig. 2). In 

the situation of a pure foraminal stenosis, for example 

resulting from a lateralized disc protrusion, fibrous tissue 

and/or osteophyte formation, facetectomy or foraminotomy 

are the treatment of choice. Facetectomy is rarely used as 

the only decompressive procedure and it is more commonly 

associated with dorsal laminectomy instead. However, 

this association is more likely to weaken/destabilize the 

L-S joint, so foraminotomy is preferred to facetectomy. 

Degeneration and protrusion of L7-S1 intervertebral disc is 

definitely the most common finding in DLSS: when present 

it usually causes compression and dorsal displacement of 

the cauda equina nerve roots and/or the conus medullaris. 

Decompression via a dorsal laminectomy and partial 

discectomy, is the first recommended treatment to relieve 

the compression, especially when it is along the midline. 

In case of lumbosacral OCD, it is also possible to remove 

the bone fragment and to debride the nerve roots from the 

newly-formed fibrous tissue, via the same dorsal approach. 

Hypertrophy of the interarcuate ligament not uncommonly 

contributes to determine lumbosacral stenosis and 

compression of the neural structures: removal of the 

interarcuate ligament is generally performed as part of 

the dorsal laminectomy. 

Note that all the decompressive procedures, especially 

when perfomed together (e.g., dorsal laminectomy and 

facetectomy) and/or in heavy and particularly active 

dogs, might enhance or predispose to L-S instability and 

subluxation; additional dorsal stabilization should then be 

considered to prevent dramatic consequences. 

Fig. 1: Radiographic appearance of severe L7-S1 

dyscospondylitis 

Fig. 2: Transvrese T2 WI: unilateral foraminal stenosis 


Lumbosacral spine: decompression and stabilisation 


Higham Gobion, Herts, United Kingdom 

Once the correct diagnosis has been made, compression 

of the neural structures and/or instability of the L-S region 

should be surgically addressed using the most appropriate 

techniques. 

Dorsal laminectomy and discectomy 

Laminectomy at the lumbosacral junction classically 

consists of removal of the spinous processes and then 

dorsal lamina of L7 and S1: more recently a technique 

(possibly less destabilizing) consisting of removal of 

just the S1 lamina has been reported, with encouraging 

preliminary results. The articular facet joints should 

be preserved in order to prevent post-operative spinal 

instability. Dorsal laminectomy allows good visualisation 

of the cauda equina, L7-S1 dorsal annulus, articular 

processes and surrounding tissues (Fig. 3). Meticulous 

positioning of the patient is quite important, as different 

positions can modify the L-S anatomy: for example, pulling 

the back legs forward may widen the interarcuate space 

and the dorsal annulus, facilitating the visualization of the 

neural structures and relieving the compression in this 

region; however, subsequent flexion of the L-S joint might 

predispose to subluxation and should therefore be avoided 

if L-S instability is radiographically suspected or should 

otherwise be kept in mind when stabilization is perfomed. 

Discectomy (also referred to partial discectomy or dorsal 

fenestration) is usually performed in association with 

dorsal laminectomy, as it may provide additional benefit 

in all those patients in which the protruded intervertebral 

disc causes significant cauda equina compression. The 

nerve roots are gently retracted to each side in turn, to 

allow for adequate discectomy but also to visualise/asses 

the underlying structures, such as the L7 nerve root in its 

lateral recess and as it enters the intervertebral foramen. 

Finally, when other degenerative changes are present in 

association with a bulging disc (e.g. juxtafacet cysts, OCD, 

etc.), they may be properly visualized and then removed via 

a dorsal laminectomy. 

Prognosis is generally good following dorsal laminectomy, 

with a long term improvement being approximately 80%; 

the severity and duration of the clinical signs (e.g. urinary 

and/or faecal incontinence > 8 weeks) have a negative 

prognostic value, therefore surgery should be encouraged 

at an earlier stage. 

Foraminotomy and Facetectomy 

Compression/entrapment of the nerve root either due 

to soft tissue or bony enlargement at the level of the 

intervertebral foramina may occur and decompression can 

be achieved by partial removal of the pedicle cranial to the 

neuroforamen or via facetectomy. The latter is generally 

no longer recommended if bilateral decompression is 

necessary or if it is combined with other decompressive 

surgery such as a dorsal laminectomy, as spinal instability 

may be a serious post operative complication. Alternatively, 

stabilisation should be considered. 

Three different surgical techniques have been described 

to performing a foraminotomy. These include an endoscopicassisted, 

a lateral and a transiliac approach. 

1) An arthroscope placed in a caudal L7 dorsal 

laminectomy defect has been experimentally used in 

normal dogs to achieve widening of the neuroforamen: 

the technique allowed a reasonably good enlargement of 

the L-S foramina and no major/long-term complications 

have been observed; however, a 12 week post-op CT exam, 

showed that some reduction of the foraminal enlargement 

occurs due to soft tissue and/or new enchondral bone 

formation, though there was no association between 

foraminal area and clinical signs. 

2) A lateral approach was reported unilaterally or 

bilaterally, alone or in combination with dorsal laminectomy, 

with good surgical exposure/ decompression of the nerve 

root and a very good outcome. 

3) A cadaveric study has demonstrated the accessibility 

to the lumbosacral area via a transiliac approach: this 

approach allows a lateral exposure of the L7–S1 disk and 

foramen and could be used to perform a lateral corpectomy 

and foraminotomy, though further studies are necessary 

to evaluate the clinical efficacy and consequences of a 

transiliac approach in dogs with signs of lumbosacral 

disease. 


Dorsal Fusion-Fixation 

Theoretically, everytime a spinal instability is suspected, 

whether as a primary component of the CES or as a 

secondary post-operative complication, stabilization 

of the L-S joint should be performed. Considering the 

possible ventral displacement or telescoping of the 

sacrum relative to L7, a distraction-fusion technique has 

also been advocated as the sole technique for treatment 

of some cases of lumbosacral disc disease. However, 

clear indications for stabilisation are lacking. Generally 

speaking, distraction should widen both the collapsed 

intervertebral space and the neural foramina: in the case 

of facet subluxation, this must be reduced prior to fixation 

by either a meticulous positioning, by using a laminectomy 

spreader or by using towel clamps. 

Several techniques have been reported including cross 

pin fixation, transarticular screw fixation, pedicle screws 

with a bone cement bridge and pedicle screw-rod fixation; 

an external fixator might also represent an alternative 

choice. 

The transarticular screws technique is a good 

consideration in relatively heavy dogs (preferably < 25 

kg), showing only mild clinical and imaging findings 

suggestive of instability. The screws are ideally inserted 

at an angle between 30° and 45° from the sagittal plane, 

in a cranio-caudal and medio-lateral direction. Fusion is 

promoted by removing the articular cartilage from the 

facet joints and by packing them with cancellous bone, 

collected from the wing of the ilium or from the previously 

removed spinous process. Pedicle screws (usually cortical 

3.5 - depending on the dog’s size) can be inserted on L7 

and S1 and can be joined by using either bone cement 

(Polymethylmethacrylate-PMMA) or rods. Cement is usually 

malleable and suits different anatomical variations and/ 

or different pathological situations, in large breed dogs 

also (Fig. 4). Rods seem a valid alternative and also seem 

to effectively stabilize the lumbosacral spine, but further 

studies are necessary in vivo. 

The main complication is implant failure, regardless of 

the surgical technique performed. The choice among the 

different techniques varies according to many factors (e.g., 

clinical signs, underlying radiographic-CT-MRI findings, 

breed, weight, etc.) however, the surgeon’s preference 

is crucial. 

Fig. 3: L7-S1 Dorsal Laminectomy; note the cauda equina nerve 

roots retracted to one side and the underlying disc protrusion 

Fig. 4: L7-S1 Dorsal Fusion-Fixation using cortical screws and 

PMMA 


small animal soft tissue session 144 ECVS proceedings 2011

Small animals – soft tissues 

Short communications – soft tissues 

Friday July 8 – 10.45 – 12.15


Axial pattern flap based on a cutaneous branch of the 

facial artery in cats. 

Milgram J*, Weiser M, Kelmer E*, Benzioni H 

Koret School of Veterinary Medicine, The Hebrew University of Jerusalem, Israel 

Introduction 

The anatomy of the facial artery of the cat has been 

described, however, the cutaneous branches of the facial 

artery and the viability of a flap based on the cutaneous 

branches of this artery have not been described in the cat. 

The objectives of this study were to describe the anatomy 

of the facial artery, including its cutaneous portion, and 

to define the anatomic boundaries of an axial pattern flap 

based on a branch of this artery. 


The common carotid artery was identified, cannulated 

and infused with methylene blue to assist in the 

identification of the facial artery, which was subsequently 

cannulated and selectively infused with methylene blue. 

The main trunk of the artery and its branches were then 

dissected. The extent of blue coloration of the skin was 

evaluated on the contralateral side of the same specimens 

after infusing methylene blue into the facial artery. In 4 

specimens the flap was raised along previously defined 

borders and adequacy of perfusion was evaluated. 

Results 

The area of skin perfused by the facial artery extended 

from the lower eyelid dorsally, to the angularis oris cranially, 

and the wing of the atlas caudally. Borders of the skin flap 

were defined on the basis of the anatomical dissection and 

skin coloration after selective infusion of the facial artery 

with methylene blue. A skin flap of 6cm x 3.4cm, based on 

the first caudally directed cutaneous branch of the facial 

artery was shown to be well perfused. 

Discussion 

A caudally directed cutaneous artery which branches off 

the facial artery opposite to the angularis oris artery and 

continuing to the horizontal ear canal has been described 

in dogs. A cutaneous artery analogous to this artery has 

not been described in the cat. We were able to identify 

this artery as the first branch of the cutaneous part of the 

facial artery and were able to follow it to the caudal aspect 

of the wing of the atlas. This cutaneous artery is located 

more ventrally and extends further caudally than in dogs. It 

supplies a highly vascularised angiosome that can be used 

as an axial pattern flap for reconstruction of skin lesions of 

the face and was present in all of the specimens examined 

in this study. 

ECVS proceedings 2011 147 small animal soft tissue session

Ligating the renal artery in pigs with a new 

absorbable device - LigaTie ® 

O V. Höglund, DVM, K. Olsson, DVM, PhD, R. Hagman, DVM, MSc, PhD, A. Lagerstedt, DVM, PhD. 

Department of Clinical Sciences, Uppsala, Sweden 

Introduction 

An absorbable device with a self-locking loop was 

constructed for ligation purposes. It was designed for 

surgery with details enabling complete haemostasis (zero 

loop-diameter) and an enhanced tissue grip. The aim of this 

study was to test the efficiency of the device in ligating 

an artery, achiving a tight tissue grip and a complete 

haemostasis. 


The device (LigaTie ® ) was manufactured by injection 

moulding of a blend of absorbable polymers well tolerated 

by the tissue. The device was used for ligation of the 

renal arteries in three anaesthetized pigs. The vessel 

was cut between the kidney and the device. The artery 

with the attached device was inspected for haemostasis 

for a minimum of five minutes. The ability of the device 

to withstand a ligature slip-off was tested with a 

dynamometer. 

Results 

Six renal arteries were ligated with the device. The 

device was tightened and secured with one hand. Complete 

haemostasis of all arteries was obtained and verified for 

a minimum of five minutes. The devices were securely 

locked into the tissue, i.e. no sliding along the vessels 

was observed. 

Discussion/Conclusion 

This test showed that effective haemostasis and secure 

ligatures of the renal arteries can be achieved with this 

device. The device functioned as planned and may facilitate 

an easier and safer ligation of blood vessels. 


Caudal mediastinal para-oesophageal abscesses in 7 

dogs. A retospective study 

H. Brissot*, C. Burton*, R. Doyle*. 

Davies, Veterinary Specialists, Higham Gobion, UK. 

Objective 

To determine the clinical, imaging and surgical findings 

of caudal mediastinal para-esophageal abscesses (CMPA) 

and the outcome of surgical treatment in client owned dogs. 

Study design 

Case series 


Seven dogs with a CMPA. 

Methods 

Medical records between April 2005 and January 2010 

were reviewed. Retrieved data were signalment, history, 

clinical findings, diagnostic investigations, surgical 

findings, surgical procedures performed and post-operative 

recovery. Long-term follow-up information was obtained 

via telephone conversation with the owners and referring 

veterinarians 

Results 

All dogs had exploratory surgery with either a median 

sternotomy (5 dogs) or lateral thoracotomy (2 dogs). The 

abscesses were identified, opened and drained surgically. In 

5 cases omentalization of the abscess cavity was performed 

via a limited diaphragmatic incision. Foreign material was 

not identified within any of the abscesses. All dogs were 

discharged from the hospital. All dogs were alive and free 

of any clinical disorders 6 months after the surgery (range 

from 9 to 39 months). 

Clinical Significance 

These new data identifies CMPA as a new clinical 

entity that should be suspected in cases of regurgitation 

and pyrexia with a mass or enlargement of the caudal 

mediastinum. 

Trans-diaphragmatic omentalization of thoracic 

abscesses could be done successfully without postoperative 

complication and is suitable for the management 

of CMPA. 


Caudal cervical intervertebral space distraction and 

stabilization using a distractable fusion cage in seven 

dogs 

Murgia D*, Gasparinetti N, Schiesaro R. 

Diagnostica Piccoli Animali, Zugliano, Italy 

Introduction 

Goal of this retrospective study was evaluate the clinical 

and radiological 

results of the treatment of dynamic disc associated 

caudal cervical spondylomyelopathy (CCSM) using a 

purpose-designed distractable intervertebral fusion cage 

in seven dogs. 


Seven Dobermann Pinschers with neurological signs 

compatible with disc associated dynamic CCSM were 

selected. Lateral survey radiographs of the cervical spine 

were taken and suspected diagnosis confirmed by MRI 

imaging. Affected intervertebral (iv) disc spaces (C5-C6, 

C6-C7 or both) were approached ventrally, distracted and 

fenestrated.Thereafter a partial ventral slot was created. 

The cage was pressed into the slot; tightening the screw the 

wings opened 1-2 mm in cranio-caudal direction allowing 

vertebral distraction and stabilization. Lastly, 

cancellous bone allograft was packed in the surgical site. 

Clinical/radiological follow-up 

evaluations were planned at four weeks, three-six and 

twelve months postoperative. In five dogs MRI follow-up 

was performed. 

Results 

Postoperative radiographic evaluation showed good 

implants placement. No deterioration of the neurological 

status was clinically observed. At follow-up, radiographs 

revealed a slight ventral migration of ca. 2-3 mm of the 

cages, iv disc spaces collapse and new bone formation 

between the vertebrae adjacent the cages. All dogs 

showed an improvement of the neurological status and 

MRI exhibited in most of the cases resolution of spinal 

cord compression. 

Discussion 

Expansion of the wings and the toothed outer walls 

prevent dislocation of the cage. Nevertheless we observed 

a mild ventral migration and iv space collapse that were 

clinically irrelevant. If compared to other cervical spine 

distraction-stabilization techniques, the method used is 

less invasive, does not carry the risk of vertebral canal 

violation and can be used to distract and stabilize more iv 

spaces simultaneously. The titanium alloy of the implant 

results to be biocompatible and allows postoperative MRI 

evaluations of patients. Due to the lack of postoperative 

neurological deterioration, all dogs had short hospital stays. 

The described technique achieves good long-term results 

in CCSM affected dogs. Anyway further clinical cases and 

long-term follow-up visits over twelve months are needed 

to support these findings. 


Surgical treatment of sciatic nerve injury 

Cachon T.*, Escriou C, Arnault A., Maitre P., Fau D., Viguier E.*, Genevois JP. Carozzo C* 

VetAgro-Sup Campus Vétérinaire de Lyon , France 

Introduction 

Sciatic nerve injury are most frequently secondary to 

traumatic events. If neurapraxia lesion do not required 

surgical treatement in most of the cases, more severe injury 

such as axonotmesis or neurotmesis do require surgical 

exploration and treatment. 

Objectives 

The purpose of this study is to report the surgical 

treatment and outcome of traumatic sciatic nerve injury 

in 9 cases. 

Material and method 

Dogs surgicaly treated for sciatic nerve injury were 

included in this study. Medical records were reviewed 

and included signalment, duration of the clinical signs, 

neurological examination, results of diagnosis imaging, 

surgical finding, complications and follow-up. 

Results 

Of 9 dogs surgically treated, 5 resulted from hunting 

wounds. Surgical treatment was neurolysis alone in 2 cases 

and neurorraphy in 7 cases. Clinical improvement occured 

in 6 cases and there was no improvement in 3 cases. Two 

of the 3 dogs that did not recovered had a proximal lesion. 

Discussion 

Recovery after surgical treatment of sciatic nerve injury 

could be long, and incomplete. Nevertheless provided the 

use of proper surgical technique and high level of post 

operative care, improvement could be expected. A guarded 

prognostic should be give to the owner when the lesion 

is proximal. 


Circulating proinflammatory cytokines and nitric 

oxide are increased in brachycephalic dogs 

Rancan L, Romussi S, Albertini M, García P, Vara E, Sánchez de la Muela M 

Dogpital SL (Madrid);D. of Medicine and Surgery (F.Veterinary, UCM, Madrid), D of Clinical Veterinary Science 

(F. Veterinary, Milan);D of Animal Pathology (F. Veterinary, Milan); D of Biochemistry and Molecular Biology (F. 

Medicine, UCM, Madrid) 

An upper respiratory tract disease known 

as brachycephalic airways obstruction syndrome 

(BAOS) has been described in brachycephalic dogs. Signs 

of obstruction of the upper aerial ducts are consequence 

of anatomical and functional disturbances. Hypoxia also 

may increase fatigability of upper airway dilator muscle, 

and soft tissue in a manner that has the potential to 

worsen disease. inflammation as well as oxidative and 

nitrosative stress resulted from the repeated hypoxia 

and re-oxygenations could be implicated in the injury 

to these tissues. The aims of the present study was (a) 

to investigate proinflammatory mediators levels in dogs 

suffering from BAOS in order to analyse a posible role for 

these mediators in the brachycephalic syndrome, (b) to 

study the relationship between proinflammatory mediators 

levels and the severity of the clinical signs. 

Blood was collected from 17 brachycephalic dogs 

(BD) and ten control dogs (CD). BD were divided into 3 

groups depending on clinical examination (Group 1 no 

symptomatic, Group 2 moderately symptomatic and Group 

3 severely symptomatic). Comparison between results 

observed in BD requiring medical or surgical treatment was 

also performed. Proinflamatory cytokines, IL-1ß, TNF-a, IL-6 

and IL-17 plasma levels were measured by ELISA kits. NO 

levels were determinated by Griess’s test. 

The plasma concentrations of TNFa, ad IL-17, were 

significantly higher in BD compared to CD (p


In depth - Medical or surgical? - 

Tracheal collapse 



Have we learnt anything in the last 15 years? 

Stenting: The Giessen experience 

A. Moritz, C. Paul de Melo, N. Bauer, M. Schneider, 

Department of Veterinary Clinical Sciences, Small Animal Clinic, Justus-Liebig-University Giessen, Germany 

Introduction 

Collapsing trachea is a common disorder in middle-aged 

toy and miniature dogs. Two forms are described: the 

more common dorsoventral collapse and the rare lateral 

collapse. The collapse usually involves the cervical region, 

but also thoracic areas of the trachea. Affected breeds are 

Yorkshire-Terriers in first place; others are e.g. Miniature 

Poodle, Pomeranian, Chihuahua, and Maltese. 

Related to the pathophysiology of the disease it can 

be stated that there may be a failure of chondrogenesis 

or simple degeneration of hyaline cartilage with primary 

genetic influences. Lack of chondroitin sulfate and/or 

decreased glycoproteins within the cartilage matrix results 

in a reduction in bound water. Because of that, the rings 

lose their ability to remain firm and thus subsequently 

collapse. To date however, its aetiology, and most effective 

management are still controversial. 

Clinical signs 

Dogs with tracheal collapse show chronic intermittent 

coughing. The cough may vary between harsh or dry, 

often described as a “goose honk” sound. Coincidental 

chronic mitral valvular heart disease occurs and must 

be differentiated from heart failure and/or significant 

left atrial enlargement due to this condition. Excitement, 

manipulation of the tracheal, during water or eating intake 

trigger affected dogs starting to cough. 

Physical examination usually reveals a normal to 

overweighed dog. Depending on the severity of dyspnea 

the mucous membranes are normal colored up to cyanotic. 

The upper airway obstruction is combined with stridor. The 

stridor sound varies according to the anatomical localization 

of the obstruction including everted laryngeal saccules, 

laryngeal collapse and cervical/thoracic tracheal collapse. 

Varying degrees of inspiratory or expiratory dyspnea 

occur. Hyperthermia may result because of the respiratory 

distress. Cough can be triggered when palpating or pressing 

the trachea. In some dogs mild dorsoventral compression 

can lead to respiration arrest. 

Hepatomegaly is a common finding in dogs with tracheal 

collapse. Several causes for this clinical observation are 

possible, including hepatic congestion because of chronic 

right heart failure induced by a high airway resistance and 

steroid hepatopathy, as well as hepatic lipidosis in obese 

patients. In our study we described 26 dogs with tracheal 

collapse. Liver parameters where tested before and after 

stent implantation. To assess liver function gall bladder 

contraction was stimulated by intramuscular injection of 

a synthetic cholecystokinin analogue (ceruletide). Twelve 

healthy Beagle dogs and 30 dogs of various breeds 

investigated previously without evidence of hepatic, 

gastrointestinal, or respiratory diseases served as control. 

Amelioration of liver variables was assessed after stent 

implantation. Twelve of 26 (46%) dogs had increased serum 

activity of 2 or more liver enzymes. Serum basal bile acid 

concentrations were high in 24 of 26 dogs. Twenty- and 

40-minute stimulated bile acids were significantly higher in 

dogs with tracheal collapse (64.2 +130.0/243.0 mmol/L and 

82.6 +164.0/257.1 mmol/L) compared to the control dogs 

(7.0 6 3.6 mmol/L and 6.4 6 3.5 mmol/L). All twelve dogs 

reevaluated after a median of 58 days (48–219 days) had a 

normal breathing pattern and significantly decreased 20 and 

40 minutes stimulated bile acids (50.0 +92.7/232.8 mmol/L, 

52.8 +97.6/234.3 mmol/L; p = 0043), whereas plasma liver 

enzyme activities were not significantly influenced. There 

was a significant hepatic dysfunction in the majority of dogs 

with a tracheal collapse. Liver function should be routinely 

assessed in dogs with severe respiratory disease. 

Diagnosis 

Radiography is a reasonable screening test for dogs 

with tracheal collapse but underdiagnosis of the frequency 

and underestimation of the degree of tracheal collapse in 

comparison with fluoroscopy are documented. 

Endoscopy is considered to be the gold standard 

in the diagnosis of tracheal collapse and reveals a 

decreased dorsoventral diameter of the trachea with a 

pendulous dorsal tracheal membrane. The tracheal mucous 

membranes are hyperemic but usually show no exsudate. 

Occasionally catarrhal to purulent exsudate may be seen. 

Conservative treatment 

Dogs which are burdened with the anatomical change 

of the trachea may stay for a long time without clinical 


signs. Secondary factors such as cardiomegaly, heart 

failure, lung oedema, respiratory tract Infection, and 

obstruction of the upper airways, inhalation of irritants, 

adipositas or hyperadrenocortizisme may be the reason to 

develop clinical signs. Diagnostic procedures and medical 

treatment are initiated to recognize and eliminate these 

factors. Symptomatic therapy includes weight reduction, 

recommendation of a harness instead of a collar, elimination 

of irritants, nebulization/ inhaltation of bronchodilatators 

respectively saline fluids, administration of xanthine 

bronchodilators such as theophylline, aminophylline or 

propentofylline, antiinfectiva (if indicated) as well as 

steroidal anti-inflammatory therapy. Antitussiva such as 

dihydrocodein should be administered with caution, Lomotil 

(diphenoxylate hydrochloride and atropine sulfate) which is 

used in UK with good success is only with special authority 

permission available in Germany. If these secondary 

factors initiating clinical signs are not treated or cannot 

be eliminated, hypertrophy of the subepithelial glands, 

reduction of the ciliated epithelium, squamous metaplasia 

or polyp formation are the consequences. Mentioned 

chronic changes are followed by cough, increased mucus 

production and decreased mucociliar clearance ending up 

in a vicious circle. In a retrospective study, 71 of 100 dogs 

with tracheal collapse were reported to respond to medical 

therapy and management of secondary initiating causes. 

Surgical techniques 

Various surgical techniques for correcting tracheal 

collapse have been described, including plication of the 

dorsal tracheal membrane, tracheal ring chondrotomy, 

and intra- and extra-luminal stabilization using mainly 

polypropylene prosthetic devices. Stabilization of the 

trachea with intraluminal endoprostheses (stents) is of 

increasing importance. Several types of self-expanding 

elastic stents have been used. 

The Giessen experience 

In our place we treated so fare 71 client-owned dogs 

referred our Small Animal Clinic at the Justus-Liebig- 

University Giessen between August 1996 and Mai 2011. 

The main inclusion criterion for stent implantation was 

evidence of a marked reduction of the dogs’ quality of life 

due to persistence of one or more severe clinical signs 

such as dyspnoea, cyanosis, severe paroxysmal coughing, 

and syncope due to hypoxemia despite conservative 

management. All dogs received medication for at least 

3 weeks before stent implantation. Medical treatment 

included administration of xanthine bronchodilators such 

as theophylline, aminophylline (10 mg/kg PO q12h) or 

propentofylline (3 mg/kg PO q12h) as well as steroidal 

anti-inflammatory therapy (prednisolone, 0.25-0.5 mg/kg PO 

q12h). Specific therapy was used for underlying diseases 

considered to affect the respiratory tract (e.g., left heart 

failure due to mitral valve insufficiency, infection of the 

respiratory tract). Patients with only mild clinical signs 

and dogs in which with the majority of clinical signs were 

caused by diseases other than severe tracheal collapse 

were excluded from the study. 

The diagnosis of tracheal collapse was established 

by physical examination, radiography and endoscopy. 

Dogs were pre-medicated with acepromazine (0.05 mg/ 

kg IV) before radiography to avoid excitement-associated 

dyspnoea. A ruler with 1 cm radio-opaque calibration marks 

was placed beneath the patients to provide a measurement 

of the tracheal length and diameter without an additional 

correction for magnification error. Endoscopic examination 

was performed with a rigid fiberoptic bronchoscope of 600.0 

mm length and 5 mm diameter or a flexible videoscope 

600.0 mm length and 5,3 mm diameter. Endoscopy 

performed in general anaesthesia included evaluation of 

the larynx, the dorsal tracheal membrane along its entire 

length as well as the left and right mainstem bronchi. 

Using the criteria of Tangner and Hobson, 8 a configuration 

of the tracheal rings and dorsal membrane inducing a 

reduction of the tracheal lumen by 25% was regarded as 

grade 1 tracheal collapse. A 50% reduction was regarded 

as grade 2, a 75% reduction as grade 3, and a complete 

reduction (100%) as grade 4 tracheal collapse, respectively. 

If asymmetry of the tracheal cartilage rings was present 

in addition to flattening of the dorsal membrane, it was 

described as a deformation of the trachea. The location of 

the collapsed tracheal segments in the cervical, thoracal 

or entire trachea was noted. 

Implantation procedure 

Before stent implantation, the diameter of the stent 

required for intraluminal stabilization was estimated 

according to the tracheal diameter measured on the 

lateral [l/l] radiographs 1 cm distal the larynx: Stent size 

≈ (tracheal diameter [l/l] * 4 / 3.14). Example: trachea 

diameter 8 mm * 4 =32 / 3,14 = 10,2 –> selected stent: 

10-12 mm nominal diameter. The selected implanted 

(nominal) length of the stent was at least 20 mm shorter 

than the tracheal length measured on the lateral thoracic 

radiographs to keep a minimum distance of 10 mm between 

the implanted endoprosthesis and larynx or carina. The 

uncovered stent endoprosthesis consisted of the stent 

and a delivery catheter (Figure 1). The endoprosthesis 

was longitudinally stretched on the inner shaft to a smalldiameter 

configuration, spontaneously springing back to 

its original diameter after deployment. The annular space 

between the “inner shaft” and the “outer catheter” system 

was filled with contrast medium (the new Uniflex TM stent 

(Boston Scientific) with 0.9% saline) for easy deployment 

of the endoprosthesis. Furthermore, the central lumen of 

the inner shaft was flushed with saline injected through 

the proximal Luer connector to minimize resistance 

when inserted over a guide wire. The implantation of the 

self-expanding stent was performed by the authors in 

anesthetized dogs placed in left lateral recumbency 


immediately after endoscopy. Insertion, placement, 

and deployment of the stent were performed under 

fluoroscopy (Figure 2). After positioning the implant, 

the T-connector and, the rolling membrane covering the 

stent was pulled back on the outer catheter resulting in 

a deployment of the stent from the distal tip towards 

the proximal marker. Immediately after implantation, the 

delivery system was removed and the location of the stent 

was documented by endoscopy and thoracic radiography 

in lateral (Figure 3) and dorsoventral projection. 

Figure 1.: Construction of the EASY-WALLSTENT 

endoprosthesis (Boston Scientific, 890077E/07.99/05) 

composed of the stent and a delivery catheter. The figure is 

taken from the manufacturers´ instructions. 1=central lumen 

for guide wire passage; 2=streamlined tip (radio-opaque), 

3=“outer catheter”, 4=radio-opaque markers: 4a=distal, 

4b=distal expected shortening, 4c=proximal expected 

shortening, 4d=proximal, 5= WALLSTENT, 6=holder,7=“inner 

shaft”, 8=sliding T-connector, 9=stainless steel, 10 = radioopaque 

markers, showing the approximate final position of 

the stent during placement proximal, 11= Luer connector on 

the central lumen, 12=Luer connector and stopcock of the 

“inner shaft”. 

Figure 2. Lateral chest fluoroscopic view demonstrating the 

placement of the Wallstent. The stent is inserted on a 

delivery catheter with radio-opaque marker bands showing 

the expected final position of the stent (black arrows). 

Deployment of the stent is performed gradually (white arrow) 

while repositioning the delivery catheter. 

Figure 3. Lateral thoracic radiograph showing the location of the 

stent immediately after implantation 

Management after stent implantation included housing 

the dogs in small kennels for 3 days to keep them at rest. 

They received cough suppressant (dihydrocodein, 1 mg/ 

kg PO q6h) and if tracheitis was present broad spectrum 

antibiotics for 7 days. In the event of concurrent bronchial 

collapse, longterm treatment with a xanthine bronchodilator 

(theophylline, 10 mg/kg PO q12h) was recommended to the 

owners. Nebulization with saline solution (Emser Sole , 

15 min q12h) were administered if fluid accumulation was 

diagnosed endoscopically. Clinical re-evaluation included 

physical examination, radiography, and endoscopy. The 

length and the diameter of the stent were measured on 

thoracic radiographs in lateral and dorsoventral projection 

and compared with results obtained immediately after stent 

implantation. Tracheoscopy was done as described above to 

assess the stents´ location and integration in the tracheal 

mucosa. 

Results 

The Yorkshire Terrier was the most frequently represented 

breed. In the dogs considered for stent implantation no 

improvement in clinical sings such as dyspnoea, severe 

paroxysmal coughing, marked exercise intolerance, cyanosis 

and exercise-associated syncope was achieved despite 

various conservative treatments. Physical examination 

findings potentially consistent with tracheal collapse 

included tracheal stridor, marked dyspnoea and spontaneous 

paroxysmal coughing. At the time of physical examination, 

cyanosis and severe exercise intolerance were present in few 

dogs were as in the majority of dogs paroxysmal coughing 

could be elicited by tracheal palpation. Almost exclusively, 

dogs showed a combination of several clinical signs. 

Furthermore, obesity and hepatomegaly were relatively 

consistent findings. In approximately half of the patients 

endoscopy identified a severe tracheal collapse (grade 

4). In the majority of patients implantation of the (EASY-) 

WallstentTM (now called Uniflex TM, Boston Scientific) led 


to immediate improvement of clinical signs (i.e., dyspnea 

and cyanosis) seen in most dogs during anesthesia vanished 

immediately after deployment of the endoprosthesis. 

Dogs presented with severe exercise intolerance, physical 

activity increased markedly within 3 days. Mild to moderate 

dry cough due to initial irritation of the tracheal mucosa, 

was common in most patients in the first few days and up to 

3 weeks after implantation of the endoprosthesis. Coughing 

did not affect the animals´ clinical condition and responded 

well to symptomatic treatment with dihydrocodein. 

According to the owners reports regarding the long-term 

outcome about 25-30% of the dogs were asymptomatic 

after stent implantation. In 65-70% the insertion of the 

stent resulted in marked improvement of clinical signs and 

exercise tolerance, but some coughing still was present. 

The severity of the cough was reported to be markedly 

reduced after stent implantation. It was subjectively 

assessed to be mild and occurred occasionally after 

excitement in the majority of these patients. Except for the 

remaining cough, all dogs were free of clinical complaints 

including severe dyspnea, cyanosis, and syncope due to 

hypoxemia. A few dogs (< 5 %) remained symptomatic 

despite therapy. These dogs were presented with severe 

bronchial collapse or clinical signs were associated with 

left heart failure. 

A shortening of the endoprosthesis with a simultaneous 

increase in the diameter of the stent was present in the 

majority of patients. The median percentage of shortening 

was 27.3 % determined at a median of 175 days after 

stentimplantation. Shortening of the stent did not result 

in clinical signs in most of the patients. Some dogs were 

treated with a second stent because of recurrence of 

tracheal collapse mostly cranial to the first implanted stent. 

Tracheoscopic follow-up examination disclosed that 

in all animals most parts of the stent were covered with 

tracheal epithelium and several small blood vessels. The 

stent could be seen shining through the tissue. In about 

50% of the dogs bare metallic struts were visible especially 

at the lateral parts of the trachea. In these areas, the 

trachea did not touch the endoprosthesis due to a slight 

deformation of the tracheal rings. The gaps between the 

trachea and the stent (so-called “pockets”) were filled 

with mucus plugs. Symptomatic treatment of these dogs 

included administration of broad spectrum antibiotics for 10 

days and mucolytics for 21 days. Furthermore, nebulization 

with saline solution was recommended in episodes were 

coughing was present. Long-term endoscopic follow-up 

disclosed that “pocket”-formation can resolve within an 

interval up to 2 years. In some dogs parts of the stent 

were overgrown by excessive connective tissue similar to 

“granuloma formation” reported in experimental studies 

in rabbits and dogs after the implantation of metallic 

stents. This finding was primarily evident at the ends of 

the endoprosthesis. Severe, circular granuloma formation 

was apparent in 3 dogs resulting in an annular reduction 

of the tracheal lumen of 50% to 75%. “Granuloma 

formation” induced a recurrence of clinical signs 

including severe paroxysmal coughing, dyspnea, cyanosis, 

exercise intolerance, and syncope due to hypoxemia. 

All dogs responded well to conservative treatment with 

corticosteroids (prednisolone 1 mg/kg PO q12h) for 2 weeks. 

Discussion 

The results of our study demonstrate that Wallstents TM 

respectively the UNIFLEX TM stent can be used to treat 

tracheal collapse in dogs because they are available in 

a suitable size range and placement is technically easy 

via fluoroscopy. The maximal diameter of this stent type 

is 22.0 mm and the use of Wallstents for stabilization of 

the canine trachea is restricted to small to medium-sized 

dogs The initial survival rate of more than 91.7% was 

comparable with the survival rates of 96% and 94% 

respectively reported for surgical procedures. In contrast 

to surgical methods of extraluminal stabilization of the 

trachea, however, the intraluminal implantation of stents 

is much less traumatic, comparatively quick and technically 

easy to perform. With experience, the implantation of the 

stent could be performed within 20 minutes. Furthermore, 

intraluminal stabilization of the trachea could be performed 

along the entire length of the trachea whereas surgical 

placement of extraluminal stents is considered to be 

unrewarding in patients with a collapse of the thoracic 

portion of the trachea. It should be noted however that 

once expanded within the trachea Wallstents could not be 

removed or hardly repositioned. In 1 of the 2 dogs dying 

within the immediate period after stent implantation, death 

was caused by incorrect placement of the endoprosthesis 

inducing laryngeal spasm due to irritation of the larynx. 

Another severe adverse-effect reported in dogs after 

experimental implantation of stents was migration of the 

implant due to choice of too small an endoprosthesis. 16,17 

Tracheal length measured on thoracic radiographs in lateral 

projection ranged in our study from 68.0 to 175.0 mm and 

the calculated stent diameter ranged from 8.9 to 15.3 

mm. These data underline the importance of assessing 

individual tracheal measurements before implantation of 

the endoprosthesis. 

The most severe adverse effects induced by the stent 

included emphysema and pneumomediastinum resulting 

in the death of 1 dog. Another dog developed mild 

pneumomediastinum without concurrent clinical signs. 

A probable cause of the development of emphysema and 

pneumomediastinum was that the metal struts at the 

distal and proximal ends of the stent were slightly sharp. 

In contrast to surgical procedures, intensive care was 

not required after stent implantation. Clinical follow-up 

examinations in our patients showed that 25 - 30 % of 

the dogs re-evaluated within a median interval of 58 days 

after stent implantation were asymptomatic, 60 - 75% 

showed marked improvement of clinical signs and exercise 

tolerance, and 5% remained unimproved. Endoscopic 


follow-up examinations disclosed that the Wallstents 

were almost completely covered with tracheal epithelium 

within a median interval of 2 monthes after implantation. 

The most important drawback of the adaptive property of 

elastic stents however was a progressive shortening and 

concurrent increase in the diameter of the endoprosthesis 

in 83% of our patients. This finding was associated with a 

recurrence of clinical signs due to severe tracheal collapse 

cranial to the stent in about 10% of the dogs. Intraluminal 

stabilization of the entire trachea should be considered 

even in cases with a tracheal collapse restricted to the 

cervical or thoracal part of the trachea to prevent recurrence 

of clinical signs due to shortening of the stent. Another 

adverse effect of stent implantation was the formation 

of steroid-responsive granulomas. It occurred primarily at 

the ends of the stent and may have been induced by the 

mechanical effects of the endoprosthesis rather than by 

any toxic effects of the metal. A fracture of the implanted 

stent was seen only in one patient and could be managed 

by intra-stent-implantation. 

Conclusion 

In our experience intraluminal stabilization of the trachea 

with stents is an effective method of managing patients 

with severe tracheal collapse. It is a minimally-invasive, 

comparatively easy and brief alternative to surgery. Further 

studies are needed to assess if different types of stents 

(e.g. VET STENT-Trachea, Infiniti Medical) will end up with 

comparable good success and minimized side effects. 

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Tracheal collapse – ringing: indications, limitations, 

technique 

Robert N White* 

Willows Veterinary Centre & Referral Service, West Midlands UK 

The aetiology of tracheal collapse remains unknown. 

The condition is characterised by progressive weakening 

of the tracheal cartilage rings making them less able 

to resist changing intraluminal pressures resulting in 

dorsoventral collapse of the trachea. The reported average 

age at presentation is stated to be 7½ years (Padrid and 

Amis 1992), although personal experience suggests that 

cases might present at an earlier age in the UK. A juvenile 

presentation, within the first six months of life, has led 

some workers to believe that the underlying cause of the 

disease has a congenital origin (Done 1978, Bojrab and 

Renegar 1981, White and Williams 1994). The disease 

is progressive although the rate of progression varies 

between individuals (Hedlund 1987, Ettinger and Ticer 

1989, Padrid and Amis 1992). 

The severity of tracheal collapse has been graded 

endoscopically by Tangner and Hobson (1982) into 

four categories. Grade I is that in which the lumen has 

been reduced by approximately 25 per cent, grade II by 

approximately 50 per cent, grade III by approximately 75 per 

cent and in grade IV the lumen is essentially obliterated. It is 

well recognised that the collapse is dynamic in nature and, 

therefore, it is essential that the conditions under which the 

tracheal endoscopy are performed should be standardised. 

It is recommended that individuals are anaesthetised to a 

sufficient depth to abolish the cough reflex in response to 

the presence of the endoscope within the tracheal lumen 

(White 1995). The range of degrees of collapse that can be 

seen within each individual along the length of the trachea 

suggests that the site of grading should also be clearly 

stated when collapse grading is performed (White 1995). 

In general, the most severely affected area is situated at 

the level of the thoracic inlet. 

There remains considerable debate concerning the 

management of dogs suffering from tracheal collapse. 

Some reports suggest that the condition should be managed 

medically (Ettinger and Ticer 1989, Padrid and Amis 1992, 

White and Williams 1994) whilst others consider that the 

condition can be treated effectively with surgery. Medical 

management is palliative and aims to control the clinical 

signs. It may improve the quality of life of mildly affected 

individuals, but since the condition is a chronic progressive 

disorder this improvement may not last into the longer term. 

A variety of surgical procedures have been described for the 

relief of tracheal collapse including tracheal chondrotomy, 

dorsal membrane plication, intraluminal support prostheses 

(stenting), and external support devices such as total ring 

and spiral ring prostheses. Of these, intraluminal stenting 

and external ring prostheses are most extensively reported. 

Laryngeal paralysis/paresis has been documented as 

a concurrent finding is some individuals suffering from 

tracheal collapse. Although some workers suggest a 

prevalence of 30 per cent (Tangner and Hobson 1982), 

experiences in the UK would suggest that this appears to 

be an extreme finding which does not concur with the more 

general observation of an occasional case suffering from 

both conditions (White and Williams 1994, White 1995). It is 

worth noting that a number of individuals will demonstrate 

poor bilateral abductor function of the arytenoid cartilages 

at the time of evaluation endoscopy (White 1995). In fact, 

Nelissen and White (2010) recently described diagnosis 

and treatment of combined presumed laryngeal paralysis 

and larynegal collapse in six small breed dogs of which 

three also showed evidence of tracheal collapse. Personnal 

observations suggest that the laryngeal mucosa in these 

individuals is often hyperaemic and oedematous preventing 

normal arytenoid cartilage movement. Moreover, in many 

individuals the structural changes to the cartilage of the 

tracheal rings appears to be present to a greater or lesser 

degree within the cartilages of the larynx. The epiglottic 

cartilage appears to be prone to these changes and often 

takes on a shape that is significantly different from ‘normal’. 

The clinical significance of these findings remains unclear. 

Iatrogenic laryngeal paralysis (unilateral or bilateral) is 

considered a serious complication following the surgical 

placement of external support devices around the trachea. 

The paralysis occurs as a result of damage to the recurrent 

laryngeal nerves during the placement of the devices. It is 

assumed that this paralysis is either a result of neuropraxia 

during the mobilisation of the nerve in the tracheal 


adventitia or a result of long term contact of the nerve 

with the prosthetic device. It is likely, therefore, that in 

some individuals the condition will not spontaneously 

resolve. It remains the author’s preferred technique to 

always perform a unilateral arytenoid laryngoplasty 

(tieback) when undertaking ring prostheses repair of 

tracheal collapse in toy breed dogs (White 1995). 

Follow-up data are lacking in the majority of reports 

concerning the management of dogs with tracheal collapse. 

There are two reports available describing the long term 

outcomes in dogs with collapsed trachea treated with 

surgical placement of polypropylene C-shaped stents 

(White 1995, Buback and others 1996). The results for ring 

placement alone suggest the procedure has a ‘success 

rate’ (dog free of clinical signs into long term) of 22.4 

per cent at worst and 66.7 per cent at best. The ‘success 

rate’ for ring placement in combination with arytenoid 

laryngoplasty was considered to be 75 per cent. Comparison 

between studies proves difficult since the inclusion criteria 

and patient selection criteria were different for the two 

investigations. The combination procedure has now been 

performed on well over 100 cases and, although it would 

be unfair to suggest that rigid long term data is available 

for all these cases, the author remains comfortable with 

the procedure as a means of treating dogs with grade II-IV 

collapsed trachea that are not controlled with conservative 

and/or medical management. Perioperative death remains 

low (approximately 2-3 per cent) and is most commonly 

associated with what is presumed to be an avascular 

necrosis of the tracheal mucosa. Case selection has also 

changed in that many surgeries are now carried out on 

individuals that ten years ago would have been excluded 

because they were considered to either be too severely 

affected or to have serious concurrent disease. 

References 

• Bojrab MJ and Renegar WR (1981) The trachea. In: 

Pathophysiology in Small Animal Surgery. Ed Bojrab. Lea & 

Febiger, Philadelphia. Pp 359-368 

• Buback JL, Boothe HW and Hobson HP (1996) Surgical 

treatment of tracheal collapse in dogs: 90 cases (1983- 

1993). Journal of the American Veterinary Medical 

Association 208, 380-384 

• Done SH (1978) Canine tracheal collapse – aetiology, 

pathology, diagnosis and treatment. Veterinary Annual 18 

255-260 

• Ettinger SJ and Ticer JW (1989) Disease of the trachea. In: 

Textbook of Veterinary Internal Medicine. Ed Ettinger. WB 

Saunders, Philadelphia. pp 795-815 

• Hedlund CS (1987) Surgical disease of the trachea. 

Veterinary Clinics of North America: Small Animal Practice 

17, 301-332 

• Johnson L (2000) Tracheal collapse. Diagnosis and medical 

and surgical treatment. Veterinary Clinics of North America: 

Small Animal Practice 30, 1253-1266 

• Nelissen P and White RAS (2010) Ayrtenoid lateralization 

for management of combined laryngeal dysfunction in small 

dogs. Proceedings of the 19th Annual Scientific Meeting 

of the European College of Veterinary Surgeons, Helsinki, 

Finland. pp 113-116 

• Padrid P and Amis TC (1992) Chronic tracheobronchial 

disease in the dog. Veterinary Clinics of North America: 

Small Animal Practice 22, 1203-1229 

• Tangner CH and Hobson HP (1982) A retrospective study 

of 20 surgically managed cases of collapsed trachea. 

Veterinary Surgery 11, 146-149 

• White RAS and Williams JM (1994) Tracheal collapse in 

the dog – Is there really a role for surgery? A survey of 100 

cases. Journal of Small Animal Practice 35, 191-196 

• White RN (1995) Unilateral arytenoid lateralisation and 

extra-luminal polypropylene ring prostheses fro correction 

of tracheal collapse in the dog. Journal of Small Animal 

Practice 36, 151-1 



In depth – Medical or surgical? 

Pyothorax in dogs and cats 


Pyothorax – have we learnt anything in the last 15 

years? 

G. Wurtinger, C. Peppler*, M. Schneider, A. Moritz, 

Department of Veterinary Clinical Sciences, Small Animal Clinic, Justus-Liebig-University Giessen, Germany 

The etiology of pyothorax in dogs and in cats is often not 

found (1) (2) (3). Penetrating bite wounds seem to be less 

important than described in the past (2) (4). Aspirated and 

orally contaminated plant material is considered to be the 

most common route of infection in dogs. A high prevalence 

in haunting and sporting dogs supports this theory (5), yet it 

is also discussed controversially. In cats bacterial isolates in 

most cases are similar to the oropharyngeal flora. Aspiration 

of the bacteria and following pleuropneumonia seems to 

be the most likely mechanism of developing a pyothorax 

(4). Dyspnoea and Tachypnoea are the most common 

clinical signs in dogs and in cats followed by lethargy and 

pyrexia (1). Possible diagnostic procedures include thoracic 

radiographs, thoracic ultrasound and computed tomography 

of the thoracic cavity. Thoracic radiographs reveal mostly 

bilateral effusion (1). Ultrasonographic examination is 

useful to detect septated fluid and pleural masses (1), but 

differentiation between transudative and exudative pleural 

effusion is not possible (6). Computed tomography in human 

medicine is described to detect and characterize pleural 

masses, but it can be difficult to differentiate between 

loculated fluid and masses (7) (6). A recently published 

study showed that computed tomography even detects 

more pulmonary parenchymal abnormalities than surgical 

exploration of the thorax (10). We think, diagnostic imaging 

including computed tomography should regularly be used 

in dogs and cats to decide, whether surgical intervention 

should be performed or not. 

Cytological fluid examination often shows coccoid, rods 

as well as filamentous bacteria, indicating Nocardia or 

Actinomyces (8). Cultural evidence of filamentous bacteria 

seen in the cytological examination is positive only in about 

one third of cases (8). Obligate anaerobic bacteria and 

mixtures of anaerobic and aerobic isolates are frequently 

isolated in bacteriologic culture (9). Nonenteric organisms, 

especially Pasteurella spp are frequently isolated in cats, 

whereas in dogs enteric organisms are more commonly 

isolated (9). 

Anti-infective drugs recommended for initial treatment 

are ß-lactam antibiotics or metronidazol for the gram 

positive and the anaerobic bacteria. In dogs a second 

antimicrobial agent (quinolone) should be included for 

the enteric organisms. In cats a potentiated ß-lactam is 

sufficient to treat the gram positive bacteria and Pasteurella 

spp (9). 

Therapeutical approach (conservative and surgical) is 

discussed controversially in literature. In dogs surgical 

treatment is more frequently necessary compared to cats 

because of potential foreign material. On the other hand in 

many cases foreign material could not be found even after 

surgical exploration and pathohistological examination (3). 

At least after conservative therapy has failed, thoracotomy 

should be recommended (4) (2). Conservative therapy 

usually includes drainage of the thorax with indwelling 

thoracostomy tubes and lavaged with warm, sterile 

crystalloids (11) (1) (9). Current literature recommends large 

thoracostomy tubes that have to be placed either surgically 

with a forceps or over a trocar in complete anesthesia (8) 

(12). In human medicine newer studies described the use 

of small bore wire guided drains. Efficacy was even better 

than with larger drains in one study and placing and use 

was much less painful (13). Valtolina and Adamantos 

described in 2009 the use of small-bore wire-guided chest 

drains in cats and dogs as an effective alternative to larger 

drains for management of pleural space disease including 

pyothorax (14). 

In our clinic a modified seldinger technique is used to 

insert small thorax drains (6 or 8 french in dogs, 6 french in 

cats). In most cases a single catheter is placed. Therefore 

we retrospectively viewed cats with pyothorax from 2006 

to 2010 to evaluate the complications of the catheter use 

and the outcome. After catheter placement in mild sedation 

the thorax was initially lavaged at least twice daily with 

warmed sterile crystalloid infusion solution. 16 cats were 

treated with the catheter technique during the mentioned 

period. Especially domestic short hair cats (n=13) were 

represented. The median age was 5 years (range 1 to 

12 years) with no sex predisposition. The median weight 

was 3.75 kg (range 2.4 to 6.5 kg). Thoracic effusion in all 

cases was located on both sides. Cytologically, filamentous 

bacteria were evident in 11 cases. In no case Nocardia 


or Actinomyces could be cultured in bacteriological 

examination. 

There were no major complications evident due to 

catheter placement and handling. In two cats drainage 

was initially not effective. One cat underwent thoracotomy; 

the other cat got a second catheter on the other side of 

the thorax and was treated with streptokinase. Complete 

failure of the drainage did not occur. Two further cats 

got a second drain. Lavage of the thorax was performed 

over 8 days (median, range 6 to 20 days). Of the 16 cats, 

one cat underwent thoracotomy, 4 cats died and 11 cats 

were discharged. 9 of these 11 cats were still alive at the 

endpoint of the study. 

We recommend the use of small (6 french) catheters, 

inserted via modified seldinger technique for conservative 

treatment of feline pyothorax. Our results and data from 

human medicine suggest that small catheters could be a 

good technique for conservative treatment in dogs, too. 

References 

1. Demetriou J. L., Foale R. D., Ladlow J., McGrotty Y., 

Faulkner J. Canine and feline pyothorax: a retrospective 

study of 50 cases in the UK and Ireland. Journal of Small 

Animal Practice 43. 2002, S. 388-394. 

2. Waddell L. S., Brady C. A., Drobatz K. J. Risk factors, 

prognostic indicators, and outcome of pyothorax in cats: 

80 cases (1986-1999). Journal of the American Veterinary 

Medical Association 221. 2002, S. 819-824. 

3. Rooney M. B., Monnet E. Medical and surgical treatment 

of pyothorax in dogs: 26 cases (1991-2001). Journal of the 

American Veterinary Medical Association 221. 2002, S. 

86-92. 

4. Barrs V. R., Allan G. S., Beatty J. A., Malik R. Feline 

Pyothorax: a retrospective study of 27 cases in Australia. 

Journal of Feline Medicine and Surgery 7. 2005, S. 211-222. 

5. Doyle J. L., Kuipers von Lande R. G., Worth A. J. Intrathoracic 

pyogranulomatous disease in four working dogs. 

New Zealand Veterinary Journal 57(6). 2009, S. 346-351. 

6. Heffner J. E., Klein J. S., Hampson C. Diagnostic Utility and 

Clinical Application of Imaging for Pleural Space Infections. 

Chest 137. 2010, S. 467-479. 

7. Kurian J., Levin T. L., Han B. K., Taragin B. H., Weinstein 

S. Comparison of Ultrasound and CT in the Evaluation of 

Pneumonia Complicated by Parapneumonic Effusion in 

Children. American Journal of Roentgenology 193. 2009, S. 

1648-1654. 

8. Swinbourne F., Baines E. A., Baines S. J., Halfacree Z. 

J. Computed tomographic findings in canine pyothorax 

and correlation with findings at exploratory thoracotomy. 

Journal of Small Animal Practice 52. 2011, S. 203-208. 

9. Boothe H. W., Howe L. M., Boothe D. M., Reynolds L. A., 

Carpenter M. Evaluation of outcomes in dogs treated for 

pyothorax: 46 cases (1983-2001). Journal of the American 

Veterinary Medical Association 236. 2010, S. 657-663. 

10. Walker A. L., Jang S. S., Hirsh D. C. Bacteria associated 

with pyothorax of dogs and cats: 98 cases (1989-1998). 

Journal of the American Veterinary Medicalal Association 

216. 2000, S. 359-363. 

11. Barrs V. R., Beatty J. A. Feline Pyothorax - new insights into 

an old problem: Part 2. Treatment recommendations and 

prophylaxis. The Veterinary Journal 179. 2009, S. 171-178. 

12. Ottenjann M., Lübke-Becker A., Linzmann H., Brunnberg 

L., Kohn B. Pyothorax in 26 cats:Clinical signs, laboratory 

results and therapy (2000-2007). Berliner und Münchner 

Tierärztliche Wochenschrift 121. 2008, S. 365-373. 

13. Rahman N. M., Maskell N. A., Davies C. W. H., Hedley E. L., 

Nunn A. J., Gleeson F. V., Davies R. J. O. The Relationship 

Between Chest Tube Size and Clinical Outcome in Pleural 

Infection. Chest 137. 2010, S. 536-543. 

14. Valtolina C., Adamantos S. Evaluation of small-bore 

wire-guided chest drains for management of pleural space 

disease. Journal o Small Animal Practice 50. 2009, S. 

290-297. 


Pyothorax : Is surgery necessary? 

Jackie L. Demetriou * 

University of Cambridge, UK. 

Pyothorax is the accumulation of exudate in the thoracic 

cavity. In the human literature the term empyema is used 

to describe the same condition in man and is a frequent 

clinical problem in paediatric and elderly patients. In 

veterinary patients, pyothorax is an uncommon condition 

with the most likely causes being migrating foreign bodies 

in dogs and extension from pulmonary infection in cats, 

although in the majority of clinical cases an underlying 

cause is frequently not identified. Reaching a diagnosis is 

usually uncomplicated, however the treatment and timing 

of treatment of this condition is somewhat controversial. 

An accepted principle directs clinicians to drain the thoracic 

cavity early and completely. The question that remains 

unanswered in relation to treatment is: should medical 

management be the primary goal or should surgery be the 

first line of treatment for pyothorax in dogs and cats? To 

help answer this question evidence will be considered from 

both the human and veterinary literature. 

Levels of evidence for primary research questions 

have been published (University of Oxford Centre of 

Evidence Based Medicine) which can be used to evaluate 

and scrutinise available data on pyothorax and place 

information into appropriate context. In the veterinary 

literature all studies relating to pyothorax are graded at 

level III-V (retrospective comparative studies; case series 

or expert opinion). There are no randomised controlled 

trials or prospective comparative studies (levels I and II). 

Due to the complex nature of the disease and the broad 

clinical spectrum that is presented, controlled clinical 

trials are difficult to perform. Additionally, a suitable in 

vivo model is lacking. There are 6 studies in the veterinary 

literature reviewing pyothorax cases including treatment, 

which involve numbers >10, in the past 15 years; 2 feline 

studies (Waddell and others 2002, Barrs and others 2005); 

3 canine studies (Rooney and Monnet 2002, Johnson and 

Martin 2007, Boothe and others 2010) and 1 combined 

canine / feline cases (Demetriou and others 2002) . Of these 

studies, 2 concluded that surgical treatment is associated 

with better outcome than nonsurgical (Rooney and Monnet 

2002, Waddell and others 2002) although the latter study 

included untreated cases in the nonsurgical group. This 

conclusion was not supported by the remaining 3 studies 

(where medical management was deemed to be successful) 

and therefore definitive conclusions cannot be drawn. 

Success of medical management using thoracostomy tubes 

is reported in these studies as 25% (Rooney and Monnet, 

2002), 73% (Waddell and others, 2002),), 90% (Demetriou 

and others, 2002), 95% (Barrs and others, 2005), 100% 

(Johnson and Martin, 2007) and 77% (Boothe and others, 

2010). It is not entirely clear why medical management was 

not successful in the study by Rooney and Monnet (2002) 

however the presence of Actinomyces spp was suggested 

to be a reason for warranting surgical management due 

to its association with the presence of plant material (e.g. 

grass awns). All dogs in this study (8) where Actinomyces 

spp was isolated responded well to en bloc resection of 

affected tissue. Interestingly 3/6 studies reported that 

the majority of deaths occurred early on (within 48 hours) 

of presentation and start of treatment in the hospital. 

One study (Boothe, 2010) found that pleural lavage and 

the addition of heparin were two factors that positively 

influenced short-term survival rate in medical management. 

There have been no reports in the veterinary literature of 

the use of fibrinolytics (e.g. urokinase) as part of routine 

medical management of this condition. 

Due to the paucity of evidence based data in the 

veterinary literature, can we therefore learn anything from 

studies in human cases of empyema? Before examining the 

human literature it is worth mentioning that comparisons 

and correlations with veterinary species must be performed 

with caution. The majority of human cases represent a 

progression from a “simple” parapneumonic effusion. 

This aetiology is therefore perhaps more like the proposed 

aetiology in feline cases and therefore the pathophysiology 

between canine, feline and human cases appear to differ. 

This may affect the success of treatment modalities. 

Additionally, many human cases of empyema are treated 

at the fibropurulent stage. It may be the case that many 

veterinary cases are identified at the later organisational 

stage although this is not confirmed in the literature as no 

studies have attempted to grade the degree of pyothorax 

in the veterinary literature. 


There are 3 randomised prospective trials (1 adult and 2 

paediatric) examining the difference between early surgery 

using video assisted thoracoscopy (VATS) versus medical 

management using thoracostomy tubes +/- fibrinolytic 

therapy (Wait and others 1997, Sonnappa and others 

2006, St. Peter and others 2009). One study found a higher 

primary treatment success in the surgical group and surgical 

patients also had shorter drainage period and hospital stay 

(Wait and others 1997). The robustness of this trial has been 

questioned as numbers were small and had an unusually 

high clinical medical failure rate (55%) which explains the 

results. The 2 paediatric trials (UK and US), conducted 

almost simultaneously, both examined early VATS versus 

thoracostomy tube placement plus urokinase treatment 

(Sonnappa and others 2006, St. Peter and others 2009). 

Results were homogenous and concluded no difference in 

outcome between the 2 groups. Primary thoracostomy tube 

placement was recommended therefore based on cost and 

no advantage in the surgical group. With two prospective 

clinical trials demonstrating congruence the strongest level 

1 evidence is provided and the authors recommended a 

treatment algorithm: 

EMPYEMA 

Chest tube with fibrinolytics 

Drainage decreased without clinical improvement 

Ultrasound or CT 

Persistant pleural No pleural 

space disease space disease 

VATS Continue with antibiotics 

“Failure” of medical management is difficult to define. 

Should medical failure be defined as a set period after 

insertion of drainage when clinical improvement has not 

occurred or should it be defined as persistence of pleural 

space disease after drainage has decreased to the point 

of meeting chest tube removal criteria? The difficulty in 

deciding which cases would respond better to early surgery 

is impeded as different institutions and surgeons have 

varying criteria on which the decision for surgery are based. 

As an example our study demonstrated that cases were 

selected for surgery where a pulmonary or mediastinal 

mass / FB were identified by diagnostic imaging or where 

complications arose subsequent to medical management 

(Demetriou and others 2002). Other studies reported 

specific time periods of drainage after which surgery was 

selected if effusions persisted (e.g. 3-7 days). It is the 

author’s experience that successful medical management 

can still be achieved with prolonged drainage times. 

Can the need for surgery earlier in the course of the 

disease be predicted on the basis of advanced imaging? This 

question has not been fully answered yet in the veterinary 

literature however a recent study (Swinbourne and others 

2011) showed that CT and surgical findings are similar in 

most cases of canine pyothorax although how accurately it 

can guide treatment is not clear. Identification of a foreign 

body may be predictive. A recent prospective human 

study in the UK evaluated the role of CT in empyema and 

concluded that although more abnormalities were detected, 

the additional information did not alter management and 

is therefore unable to predict clinical outcome (Jaffe and 

others 2008). According to the British Thoracic Society 

guidelines CT is deemed unnecessary for most cases but 

has a role in complicated cases e.g. failure to aspirate 

fluid and failure of medical management (Balfour-Lynn and 

others 2005, Davies and others 2010). These guidelines 

also state that a lung abscess coexisting with empyema 

should not normally be surgically drained, which questions 

the decision for surgery based on identification of a focal 

disease process. Ultrasound is routinely used to guide chest 

tube placement in addition to drainage in people and there 

is an argument that as ultrasound is cost effective and 

non-invasive it should be adopted routinely with veterinary 

patients in order to improve accuracy of drain placement. In 

conclusion more evidence is required to inform the debate 

whether for example early surgery is superior to drainage 

and at which point surgery should be contemplated. If 

medical management is initiated it would be logical to 

put forward the argument that in cases of patients with 

persisting sepsis in association with persistent pleural 

collection, despite chest tube drainage and antibiotics 

then early discussion with a surgeon should be prompted. 

Cases of Actinomyces, commonly associated with foreign 

bodies may also prompt early surgery. 

Is thoracoscopic surgery preferable to open thoracotomy? 

This again is a question that cannot be answered in the 

veterinary literature. From personnel communication 

VATS has been used successfully in dogs and cats with 

pyothorax to aid chest drain placement and debridement 

/ decortication. Certainly, in other procedures, minimally 

invasive surgery is associated with reduced morbidity and 

improved clinical recovery compared with open techniques, 

however evidence directly relating to thoracoscopy and 

pyothorax is lacking. In the human literature there are a 

few studies (case series / retrospective) directly comparing 

VATS with open surgery that suggest VATS has the same 


ate of success as open thoracotomy but offers substantial 

advantages over thoracotomy in terms of resolution of 

the disease, hospital stay and cosmesis (Chambers and 

others 2010). Conversion rates vary with reports (0-86%). 

A prospective and randomized study is required to confirm 

these findings to show that this relatively new form of 

treatment is more effective and safer that the existing 

operative techniques. 

Does pulmonary decortication have a niche in the 

management of pyothorax in animals? The aims of 

decortication are to eliminate infection and achieve 

expansion of the underlying lung to improve lung function. 

Decortication carries with it a risk of mortalitily, substantial 

blood and air loss and increased surgical times. However, 

there is to date, little evidence to guide surgical decisionmaking, 

as the effectiveness of decortication in achieving 

lung re-expansion has never been fully evaluated. 

Additionally, the premise that adequate re-expansion via 

effective intrinsic fibrinolysis cannot be achieved has never 

been challenged. A recent article in “press” however has 

attempted to address this question and concluded that 

debridement alone without decortication can achieve lung 

re-expansion in patients with empyema (Kho and others 

2010). Thus the benefit of decortication in relation to its 

risks has to be questioned. 

References 

• Waddell, L.S, Brady, C.A., & Drobatz, K.J. (2002). Risk 

factors, prognostic indicators, and outcome of pyothorax 

in cats: 80 cases (1986-1999). Journal of the American 

Veterinary Medicine Association, 15, 819-824 

• Barrs, V.R., Allan, G.S., Beatty, J.A. & Malik, R. (2005). 

Feline pyothorax: a retrospective study of 27 cases in 

Australia. Journal of Feline Medicine and Surgery, 7, 

211-222 

• Rooney, M.B. & Monnet, E. (2002) Medical and surgical 

treatment of pyothorax in dogs: 26 cases (1991-2001). 

Journal of the American Veterinary Medicine Association 

221, 86-92 

• Johnson, M.S. & Martin, M.W.S. (2007) Successful medical 

treatment of 15 dogs with pyothorax. Journal of Small 

Animal Practice, 48, 12-16 

• Boothe, H.W., Howe, L.M., Boothe, D.M., Reynolds, L.A. & 

Carpenter, M. (2010). Journal of the American Veterinary 

Medicine Association, 236, 657-663 

• Demetriou, J.L., Foale, R.D., Ladlow, JJ., McGrotty, 

Y., Faulkner, J. & Kirby, B.M. (2002) Canine and feline 

pyothorax: a retrospective study of 50 cases in the UK and 

Ireland. Journal of Small Animal Practice, 43, 388-394 

• Wait, M.A., Sharma, S., Hohn, J. & Dal Nogare, A. (1997) A 

randomized trial of empyema therapy. Chest, 111, 1548- 

1551 

• Sonnappa, S., Cohen, G., Owens, C.M., van Doorn, C., 

Cairns, J., Stanojevic, S., Elliott, M.J. & Jaffe, A. (2006). 

Comparison of urokinase and Video-assisted thoracoscopic 

surgery for treatment of childhood empyema. American 

Journal of Respiratory and Critical Care Medicine, 174, 

221-227 

• St. Peter, S.D., Tsao, K., Harrison, C., Jackson, M.A., Spilde, 

T.L., Keckler, S.J., Sharp, S.W., Andrews, W.S., Holcomb III, 

G.W. & Ostlie, D.J. (2009) Thoracoscopic decortications vs 

thoracostomy with fibrinolysis for empyema in children: a 

prospective randomized trial. Journal of Pediatric Surgery, 

44, 106-111 

• Balfour-Lynn, I.M., Abrahamson, E., Cohen, G., Hartley, J., 

King, S., Parikh, D., Spencer, D., Thomson, A.H. & Urquhart, 

D. (2005). BTS guidelines for the management of pleural 

infection in children. Thorax, 60, (Suppl 1 )i1-i21 

• Davies, H.E., Davies, R.J.O. & Davies, C.W.H. (2010) 

Management of pleural infection in adults: British Thoracic 

Society pleural disease guideline 2010. Thorax, 65, (Suppl 

2) ii41-ii53 

• Swinbourne, R., Baines, E.A., Baines, S.J. & Halfacree, Z.J. 

(2011) Computed tomographic findings in canine pyothorax 

an correlation with findings at exploratory thoracotomy. 

Journal of Small Animal Practice, 52, 203-208 

• Jaffe, A., Calder, A.D., Owens, C.M., Stanojevic, S. & 

Sonnappa, S. (2008) Role of routine computed tomography 

in paediatric pleural empyema, Thorax, 63, 897-902 

• Chambers, A., Routledge, T., Dunning, J. & Scarci, M. (2010) 

Is video-assisted thoracoscopic surgical decortications 

superior to open surgery in the management of adults with 

primary empyema? Interactive Cardiovascular and Thoracic 

Surgery, 11, 171-177 

• Kho, P., Karunanantham, J., Leung. M. & Lim, E. (2010) 

Debridement alone without decortications can achieve lung 

re-expansion in patients with empyema: an observational 

study. Interactive Cardiovascular and Thoracic Surgery (in 

press). 




In depth – Medical or surgical – 

Pancreatitis in dogs and cats 


Pancreatitis in dogs and cats: what have we learnt on 

the last 15 years? 

P. Watson, MA,VetMD, CertVR, DSAM, ECVIM, MRCVS 

Queen's Veterinary School Hospital, University of Cambridge, Cambridge, United Kingdom 

Pancreatitis remains a very challenging disease in small 

animals, both to diagnose and treat. It is almost equally 

challenging in humans. There are no specific treatments 

for the disease and therapy remains supportive. It is 

frustrating for the surgeon because there are very few 

(no?) effective surgical treatments and in fact early 

surgical intervention may have a negative impact. In 

humans, necrosectomy may help some cases – but only if 

delayed. Studies have suggested that early necrosectomy 

is associated with increased mortality compared with 

necrosectomies delayed for a month 1 . Even with infected 

pancreatic necrosis, surgery does not appear to reduce 

the mortality over medical management 2 . This is largely 

because early mortality is due to SIRS and organ failure 

and surgery appears to have little impact on this. There are 

no comparable studies in dogs. 

Mortality from severe acute pancreatitis is up to 20% 

in humans 3 . The reported mortality from all cases of acute 

pancreatitis (not just severe) has reduced from 12% to 4% 

in one centre in the US 4 and from 7.4 to 1.9% in Japan 5 

over the last 10 years and the reduction in mortality has 

been attributed largely to early aggressive fluid therapy 

reducing the risk and impact of SIRS 4;6 . The true mortality 

in dogs and cats is unknown but is likely similar. Chronic 

pancreatitis is a common disease in humans and dogs 

and is a significant cause of ongoing pain and morbidity, 

resulting in total pancreatectomy in some individuals to 

control the clinical signs. 

However, there is hope on the horizon. Recent advances 

in genetics and immunology have increased understanding 

of causes in humans and very recent work in dogs suggests 

new aetiologies and potential treatments. Recent work on 

early feeding has also changed the paradigm for nutrition 

in pancreatitis in both humans and dogs. This lecture aims 

to focus on advances in a few key areas relating to causes 

and treatment. 

An update on prevalence and causes of pancreatitis 

in dogs and cats 

Acute pancreatitis is neutrophilic inflammation, necrosis 

and oedema of a previously ‘normal’ pancreas. It may 

present clinically as a mild or severe disease and there is 

normalisation of pancreatic function and structure when the 

episode resolves. Relapsing acute pancreatitis describes 

repeated bouts of acute, self-resolving inflammation. 

This is not the same as chronic pancreatitis! Chronic 

pancreatitis (CP) is defined as a continuing inflammatory 

disease characterized by the destruction of pancreatic 

parenchyma leading to progressive or permanent 

impairment of exocrine or endocrine function or both. The 

difference from true acute pancreatitis is thus histological 

and not clinical. As in other organs, true ‘acute’ pancreatitis 

is potentially reversible if the animal recovers with no 

permanent histological changes in the pancreas whereas 

chronic disease is not. The gold standard for diagnosis of 

both acute and chronic pancreatitis is histology but this is 

rarely indicated or performed in dogs or cats. Non-invasive 

diagnosis in small animals with the currently available 

diagnostic imaging and blood tests is not 100% sensitive 

and specific even in acute disease and their sensitivity is 

relatively low for chronic disease 7 . 

Traditionally, it has been assumed that cats most 

commonly suffer from CP whereas dogs suffer most from 

acute pancreatitis. However, the early literature published 

on canine pancreatic disease in the 1960’s and 1970’s 

recognized it as a common disease of clinical significance. 

It was noted that a high proportion of cases of exocrine 

pancreatic insufficiency (EPI) in dogs were caused by CP, and 

also that it might be responsible for up to 30% or more of 

cases of diabetes mellitus (DM). More recent pathological 

and clinical studies in both dogs 8, 7;9 and cats 10 have 

reconfirmed CP as a common and clinically relevant disease 

in both dogs and cats. It is frequently under-recognised 

because of difficulty in obtaining a non-invasive diagnosis. 

None of the currently available blood tests, including cPLI, 

have a high sensitivity for diagnosis and transcutaneous 

ultrasound is also not sensitive. 

In dogs, the post-mortem prevalence of CP is up to 34%, 

particularly in susceptible breeds, and even in studies 

of fatal acute pancreatitis, acute-on-chronic disease 

accounts for 40% of cases 11 . This is an important point: 

nearly half of all dogs which present for the first time 

acutely actually already have significant underlying chronic 


disease which increases their risk both of extrahepatic 

biliary obstruction and of long term sequelae. In cats, an 

even higher post-mortem prevalence of CP of 60% has 

been reported 10 . It must be noted that post-mortem studies 

tend to overestimate the prevalence of chronic diseases, 

which leave permanent architectural changes in the organ, 

whereas the prevalence of acute, totally reversible diseases 

will be underestimated, unless the animal dies during the 

episode. Nevertheless, it is clear that there are many more 

cases of CP in veterinary practice than currently recognized, 

and that a number of these are clinically relevant. 

The true prevalence of acute pancreatitis in dogs and 

cats remains unknown as the only published studies are 

either post mortem studies (which over estimate chronic 

disease, for the reasons given above) or only report fatal 

acute pancreatitis 11 , so the prevalence of resolved cases 

is unknown. 

The causes of acute and chronic pancreatitis likely overlap 

and are usually unknown in dogs. However, differences 

in pathological appearance suggest different causes in 

different breeds which we are just beginning to elucidate 9 . 

The histological appearance in terriers, and preponderance 

of acute disease, are suggestive of premature enzyme 

activation within the pancreas as a result of hereditary 

pancreatic enzyme mutations as seen in hereditary 

pancreatitis in humans. However, the only breed in which 

genetic studies have thus far been reported is the miniature 

schnauzer in which trypsinogen mutations were NOT 

found although some dogs had variants of the pancreatic 

secretory trypsin inhibitor gene of unclear significance 12;13 . 

Our studies of chronic pancreatitis showed increase 

prevalences and breed-specific histopathologies in Cavalier 

King Charles Spaniels (CKCS), Cocker Spaniels, Collies 

and Boxers in the UK 9 . An independent large study of EPI 

in the UK found an increased prevalence in older CKCS, 

supporting this breed association 14 . Chronic pancreatitis 

is extremely common in CKCS and we believe it may be 

due to an underlying systemic fibrotic disease which we 

are currently investigating. 

The particular form of chronic pancreatitis recognized 

in English Cocker Spaniels in the UK is thought to be an 

autoimmune 15 . As in human autoimmune pancreatitis, it 

typically affects middle-aged to older dogs, with a higher 

prevalence in males, and at least 50% of affected dogs 

subsequently develop DM, EPI, or both. Anecdotally, 

blue roans are most affected. Dogs also often have 

other concurrent autoimmune disease, particularly 

keratoconjunctivitis sicca and anal sacculitis may also be 

associated. There is often a mass-like lesion on ultrasound, 

and biopsies show a typical perilobular diffuse fibrotic 

and lymphocytic disease centred on perilobular ducts and 

vessels, with loss of large ducts and hyperplasia of smaller 

ducts. Immunohistochemistry shows a preponderance of 

duct and vein-centred CD3+ lymphocytes (i.e.; T-cells). The 

human disease is believed to be a duct-centred immune 

reaction and responds to steroid therapy, including a 

reduction in insulin requirement in some diabetics. There 

are not yet any controlled trials evaluating the use of 

immunosuppressive drugs in English Cocker Spaniels with 

chronic pancreatitis but there is now enough circumstantial 

evidence to justify their use in this particular breed. 

An update on feeding in acute pancreatitis 

There have been a number of recent studies and metaanalyses 

of studies of nutrition in human acute pancreatitis 

which have lead to recent changes in advice for ‘best 

practice’ for feeding these cases. There is enough evidence 

for early feed in humans now to justify commencement of 

a very large prospective randomised clinical trial of early 

feeding (less than 24 hours) compared with delayed feeding 

(3-4 days) in predicted severe acute pancreatitis 16 . 

Ten to twenty years ago, it was considered that early 

enteral nutrition was contra-indicated because it was 

likely to result in cholecystokinin and secretin release with 

consequent release of pancreatic enzymes and worsening 

of pancreatitis and associated pain. Total parenteral 

nutrition (TPN) seemed a more logical route early in the 

disease process, with jejunal tube feeding later in the 

disease aiming to bypass the areas of pancreatic enzyme 

stimulation. However, recent studies have suggested that 

early enteral nutrition is preferable to TPN and current best 

practice in human medicine is outlined below 17 . A recently 

published open-label prospective pilot study of enteral 

nutrition in dogs with pancreatitis showed a good outcome 

for dogs fed enterally proximal to the pylorus and justifies 

future larger prospective studies 18 . Note particularly that 

early enteral nutrition is PARTICULARLY indicated in severe 

disease, which is perhaps unexpected and often counter 

to our current practice in dogs. 

• A negative nitrogen balance is common in acute 

pancreatitis and is associated with a 10 fold 

increase in mortality 17 

• Iv feeding of glucose, protein or lipids do not 

stimulate pancreatic secretions. 

• Intrajejunal infusion of elemental diets in humans 17 

and experimental canine models 19 of pancreatitis 

does not stimulate pancreatic enzyme release 

significantly 

• Early ORAL feeding after acute pancreatitis in man 

IS associated with increased pain, whereas jejunal 

feeding is not 20 . 

• THIS IS IMPORTANT: EARLY INTRAJEJUNAL 

FEEDING IS PREFERRED OVER TPN IN PATIENTS 

WITH ACUTE PANCREATITIS: PARTICULARLY 

SEVERE DISEASE. Results of meta-analysis show 

that intra-jejunal feeding after 48 hours significantly 


educed incidences of infections, reduced surgical 

interventions and reduced length of hospital stay 

and cost over TPN. 17 . These findings have also 

been replicated in dogs with experimental acute 

pancreatitis 21 but not yet in clinical pancreatitis 

in dogs, although the experiences from early 

enteral feeding in other GI diseases in this species 

such as parvo virus enteritis 22 suggests the 

recommendations may be similar. Most recently, 

it has been suggested that feeding may even been 

given safely intra-gastrically in humans with acute 

pancreatitis, although more studies are needed to 

confirm this 17 . 

• Type of diet used: in humans, elemental diets have 

been used in most cases and usually by continuous 

infusion 17 . No studies have really assessed whether 

less elemental diets would also work. Recent 

studies looking at ‘immune-modulating’ micronutrients 

in the diets such as glutamine, fibre, 

arginine, omega-3 fatty acids and probiotic bacteria 

have been encouraging 17;23, but again more studies 

are needed before definite conclusions can be 

drawn. No similar studies have been undertaken 

in dogs and cats. 

• In MILD acute pancreatitis in man, current best 

practice is to withhold food in many cases for a 

little longer. Fluids, electrolytes and analgesics 

are delivered for 2-5 days and then a diet rich 

in carbohydrate and moderate in fat and protein 

is commenced with discharge on a normal diet 

within 4-7 days 17 . Again, there are no specific 

recommendations for mild acute disease in dogs 

and cats. 

• IN CATS: current anecdotal recommendations 

are to feed immediately in mild, moderate and 

severe pancreatitis, preferably via a jejunostomy 

tube, although again it has been suggested that 

gastrostromy tubes with multiple low volume feeds 

should also be safe. There is just one case report of 

using an endoscopically placed J-tube in a cat with 

acute pancreatitis 24 . The emphasis on early feeding 

in cats comes from the risk of hepatic lipidosis. 

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comparable to surgery in patients with infected pancreatic 

necrosis. Clin Gastroenterol Hepatol 2010;8:1089-94. 

3. Al M, I. Severe acute pancreatitis: pathogenetic aspects 

and prognostic factors. World J Gastroenterol 2008;14:675- 

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4. Wall I, Badalov N, Baradarian R, Iswara K, Li JJ, Tenner S. 

Decreased mortality in acute pancreatitis related to early 

aggressive hydration. Pancreas 2011;40:547-50. 

5. Satoh K, Shimosegawa T, Masamune A, Hirota M, Kikuta 

K, Kihara Y, Kuriyama S, Tsuji I, Satoh A, Hamada S. 

Nationwide epidemiological survey of acute pancreatitis in 

Japan. Pancreas 2011;40:503-7. 

6. Warndorf MG, Kurtzman JT, Bartel MJ, Cox M, Mackenzie 

T, Robinson S, Burchard PR, Gordon SR, Gardner TB. Early 

Fluid Resuscitation Reduces Morbidity Among Patients 

With Acute Pancreatitis. Clin Gastroenterol Hepatol 2011. 

7. Watson PJ, Archer J, Roulois AJA, Scase TJ, Herrtage 

ME. An observational study of 14 cases of canine chronic 

pancreatitis. Veterinary Record 2010;167:968-76. 

8. Newman S, Steiner J, Woosley K, Barton L, Ruaux C, 

Williams D. Localization of pancreatic inflammation and 

necrosis in dogs. J Vet Intern Med 2004;18:488-93. 

9. Watson PJ, Roulois A, Scase T, Johnston PEJ, Thomson H, 

Herrtage ME. Prevalence and breed distribution of chronic 

pancreatitis at post mortem in first opinion dogs. J Small 

Anim Pract 2007;609-18. 

10. De Cock HE, Forman MA, Farver TB, Marks SL. Prevalence 

and histopathologic characteristics of pancreatitis in cats. 

Vet Pathol 2007;44:39-49. 

11. Hess RS, Kass PH, Shofer FS, Van Winkle TJ, Washabau 

RJ. Evaluation of risk factors for fatal acute pancreatitis in 

dogs. J Am Vet Med Assoc 1999;214:46-51. 

12. Bishop MA, Steiner JM, Moore LE, Williams DA. Evaluation 

of the cationic trypsinogen gene for potential mutations 

in miniature schnauzers with pancreatitis. Can J Vet Res 

2004;68:315-18. 

13. Bishop MA, Xenoulis PG, Levinski MD, Suchodolski JS, 

Steiner JM. Identification of variants of the SPINK1 

gene and their association with pancreatitis in Miniature 

Schnauzers. Am J Vet Res 2010;71:527-33. 

14. Batchelor DJ, Noble PJ, Cripps PJ, Taylor RH, McLean 

L, Leibl MA, German AJ. Breed associations for canine 

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Ref Type: Abstract 

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Dejong CH, van Geenen EJ, van GH, Heisterkamp J, Houdijk 

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VB, van RB, Schaapherder AF, van der Schelling GP, Spanier 

MB, Tan A, Vecht J, Weusten BL, Witteman BJ, Akkermans 

LM, Gooszen HG. Pancreatitis, very early compared with 

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JS, Robertson ID, Hosgood G. A Pilot Study to Assess 

Tolerability of Early Enteral Nutrition via Esophagostomy 

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CG, Williams DA. Effect of early enteral nutrition on 

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in dogs with severe parvoviral enteritis. J Vet Intern Med 

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Surgical treatment: necrosectomies, 

pancreatectomies, and drainage 

Robert N White BSc (Hons) BVetMedCertVA DSAS (Soft Tissue) DiplECVS 

Willows Veterinary Centre & Referral Service, Shirley, Solihull, United Kingdom 

Acute pancreatitis is an acute inflammatory disease of 

the exocrine pancreas that ranges from mild self-limiting 

disease to severe progressive disease involving peripancreatic 

tissues and other remote organs. Cats and 

dogs with pancreatitis typically present with numerous 

clinical signs the commonest of which are abdominal pain, 

lethargy, vomiting, and anorexia (Hill and Van Winkle 1993, 

Thompson and others 2009, Son and others 2010). 

In man, definitionsfor pancreatitis wereproposed by the 

International Symposium on Acute Pancreatitis (The Atlanta 

Symposium) in 1992 (Table 1) 

Acute pancreatitis (AP) is a mild, self-limiting disease 

in the majority of affected humans. However, 10-20% of 

human patients develop a more severe form of the disease 

characterized by sepsis and multiple organ failure (MOF), 

with mortality rates approaching 30% (Holm and others 

2003). Considerable efforts have been directed toward 

early identification of patients at risk for developing severe 

AP. Several methods of severity determination have been 

developed in humans, and include clinical scoring systems, 

serum markers, and evaluation of contrast-enhanced 

computed tomography (CECT). The two most common 

causes of AP in humans are gallstones and alcohol abuse, 

Table 1 

together accounting for up to 80% of cases (Gullo and 

others 2002). 

AP is a common disease in dogs with reported mortality 

rates ranging from 27 to 42%, although most dogs that 

have mild disease recover within a few days (Cook and 

others 1993, Ruaux 1998). In dogs there are no reports as 

to the prevalence of mild acute pancreatitis (Thompson and 

others 2009). Although there are no studies evaluating the 

cause of death in dogs with AP, most dogs that develop 

systemic complications, such as respiratory distress, acute 

kidney failure, and disseminated intravascular coagulation, 

are considered to have a guarded to poor prognosis. 

Although pancreatic infection is rarely documented in dogs, 

the extent of pancreatic necrosis may be an important 

contributing prognostic factor of severity, similar to 

what has been shown in humans (Ruaux 2000). Despite 

aetiological difference between human and small animal 

AP, the pathophysiology of AP is similar. The initial event 

in AP is the intracellular activation of trypsinogen to 

trypsin, resulting in pancreatic cell destruction. Trypsin is 

also capable of activating all other pancreatic zymogens, 

causing further injury and auto-digestion of the gland. 

Because of these similarities, novel concepts used in 

Acute pancreatitis (AP) Acute inflammatory process of the pancreas with variable involvement of other regional tissues or 

remote organ systems 

Severe AP Association with multiple organ failure (MOF) and/or local complications, such as necrosis, abscess, 

or pseudocyst 

Acute fluid collection Occurs in the course of AP, located in or near the pancreas, always lacking a wall of granulation or 

fibrous tissue; bacteria variably present; occurs in 30-50% of severe AP; most acute fluid collections 

regress, but some progress to pseudocyst or abscess 

Pancreatic necrosis Diffuse or focal area(s) of non-viable pancreatic parenchyma, typically associated with peri-pancreatic 

fat necrosis, diagnosed by CT scan with intravenous contrast enhancement 

Acute pseudocyst Collection of pancreatic juice enclosed by a wall of fibrous or granulation tissue, which arises as a 

consequence of AP, pancreatic trauma, or chronic pancreatic; formation requires 4 or more weeks 

from onset of AP 

Pancreatic abscess Circumscribed intra-abdominal collection of pus usually in or near the pancreas, containing little or 

no pancreatic necrosis, arises as a consequence of AP or pancreatic trauma 


humans regarding severity assessment and therapy may 

be applicable to dogs and cats. 

Cats have different embryological development and 

anatomy of the pancreas from other species, including 

dogs. The pancreatic duct is derived from the ventral 

anlage and is the main functional pancreatic duct in cats, 

but it is of minor importance, and may be absent in dogs. 

In cats the accessory pancreatic duct generally does not 

persist, with 80% of cats having only one pancreatic 

duct. The accessory pancreatic duct enters the duodenum 

through the minor duodenal papilla. The pancreatic duct 

enters through the major duodenal papilla. In cats this is 

the main, and frequently the only, pancreatic duct opening 

into the duodenum, contiguously with the bile duct. It is 

implied that this single opening of the pancreatic duct (that 

is contiguous with the opening of the common bile duct) 

is the reason for an association between pancreatitis and 

extrabiliary tract obstruction in the species (Warman and 

Harvey 2007, Son and others 2010). 

The most appropriate therapy for acute necrotizing 

pancreatitis remains controversial. Historically, in humans, 

surgical intervention following medical stabilization was 

commonly performed to confirm the diagnosis and to treat 

acute pancreatic necrosis. In recent years, there has been a 

decreased emphasis on early surgical intervention because 

improved non-invasive imaging, therapeutic techniques, 

and intensive care have become more readily available. 

Surgical intervention in humans 

In humans, the precise indications for surgery in patients 

with pancreatitis have evolved in recent years. Whereas 

early aggressive debridement was used commonly for all 

patients with pancreatic necrosis in the past, now most 

pancreatic surgeons have adopted a more conservative 

algorithm of selective and delayed pancreatic debridement 

(Büchler and others 2000, Clancy and Ashley 2002). 

Reported indications for surgical intervention in acute 

necrotizing pancreatitis in man (Clancy and Ashley 2007) 

are, 

• Diagnostic uncertainty 

• Intra-abdominal catastrophe unrelated to necrotizing 

pancreatitis such as perforated viscus 

• Infected necrosis documented by FNA or 

extraluminal gas on CT scan 

• Severe sterile necrosis 

• Symptomatic organized pancreatic necrosis 

In man, surgical therapy for acute pancreatitis 

may address either the aetiology of pancreatitis or 

its complications. Surgery may also be indicated in 

the management of pancreatic abscessation and the 

management of certain cases of pancreatic pseudocyst. 

Operations addressing aetiology generally are limited to 

interventions to eliminate cholelithiasis and thus eliminate 

gallstone pancreatitis. Operations performed to specifically 

manage the complications of pancreatitis including the 

following. 

Resection 

Pancreatic resection for acute pancreatitis is primarily of 

historical interest only and is not recommended currently. 

In the 1960s and 1970s partial and total pancreatectomy 

for pancreatitis was performed on the basis that remaining 

diseased pancreas could be a source of persistent 

inflammation. Operative mortality was as high as 60%. 

Pancreatic debridement 

All techniques of pancreatic debridement are based on 

two principles; 1) wide removal of devitalized and necrotic 

tissue with thorough exploration and unroofing of all 

collections of solid and liquid debris, and, 2) the assurance 

of postoperative removal of the products of ongoing local 

inflammation and infection that persist after debridement. 

Techniques include debridement with closure over drains, 

debridement with open packing, and debridement with 

closure over irrigation drains and postoperative lavage are 

the three methods reported commonly. 

Pancreatic pseudocysts 

A pancreatic pseudocyst is a collection of pancreatic 

secretions and cellular debris enclosed within a fibrous 

sac that lacks an epithelial wall. Pseudocyst formation is 

a common complication of acute pancreatitis in humans 

occurring in up to 54% of pancreatitis patients (Clancy 

and Ashley 2007). The principle indications for treating 

pancreatic pseudocysts in man are to relieve symptoms 

and to prevent complications of the pseudocyst. Treatment 

approaches for pancreatic pseudocyst in man are listed 

(Table 2) as follows (Clancy and Ashley 2007). 

Approaches Examples 

Open surgical Cystogastrostomy 

Cystoduodenostomy 

Roux-en-Y cystojejunostomy 

Distal pancreatectomy +/- splenectomy 

External drainage 

Laparoscopic Cystogastrostomy 

Cystoduodenostomy 

Roux-en-Y cystojejunostomy 

Distal pancreatectomy +/- splenectomy 

External drainage 

Radiologic Percutaneous drainage 

Percutaneous transgastric drainage 

Endoscopic Transpapillary pancreatic duct stent 

Transgastric stent 

Transduodenal stent 


In recent years there has been a proliferation of reports 

describing minimally invasive approaches in necrotizing 

pancreatitis. It appears that advances in minimally invasive 

technology hold promise as adjuncts to open procedures in 

the future, particularly as a means of delaying surgery to 

facilitate debridement when the necrotic pancreas becomes 

more organized (Pamoukian and Gagner 2001). 

Surgical intervention in dogs and cats 

The previous perception that surgical management is 

unwarranted in acute pancreatitis has been questioned 

recently (Thompson and others 2009). There are no 

established specific guidelines for surgical intervention 

in dogs and cats, but in dogs accepted criteria include 

evidence of infection, local complications (abscessation or 

biliary obstruction), diagnostic confirmation (of neoplastic 

versus non-neoplastic disease), persistent distant organ 

complications, and failure to respond to aggressive medical 

management (Thompson and others 2009). 

There is similar confusion with regards to the 

management of chronic pancreatitis and its associated 

conditions including pancreatic pseudocysts and pancreatic 

abscessation. Pancreatic pseudocysts, and their treatment, 

have only rarely reported in dogs and cats (Bellenger 

and others 1989, Smith and Biller 1998, VanEnkevort 

and others 1999, Marchevsky and others 2000, Jerram 

and others 2004). Reported surgical managements 

include cystogastrostomy (Bellenger and others 1989), 

cystoduodenostomy and omentalization (Marchevsky and 

others 2000), omentalization (Jerram and others 2004), 

ultrasonographic-guided drainage (Smith and Biller 1998), 

and open external drainage (VanEnkevort and others 1999). 

The surgical management of pancreatic abscessation 

involves pancreatic necrosectomy and omentalization in 

conjunction with either closed or open peritoneal drainage 

for suspected septic peritonitis (Salisbury and others 1988, 

Johnson and Mann 2006, Anderson and others 2008). In 

a recent retrospective review of 36 dogs diagnosed with 

pancreatic abscessation despite surgical intervention 71% 

of the dogs died or were euthanized prior to discharge from 

the hospital (Anderson and others 2006). 

The role of minimally invasive approach for the surgical 

management of pancreatitis and its associated conditions 

remains to be defined in the dog and cat. 

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(2008) Pancreatic abscess in 36 dogs: a retrospective 

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• VanEnkevort BA, O’Brien RT and Young KM (1999) 

Pancreatic pseudocysts in 4 dogs and 2 cats: 

ultrasonographic and clinicopathologic findings. Journal of 

Veterinary Internal Medicine13, 309-313 

• Warman S and Harvey A (2007) Feline pancreatitis: current 

concepts and treatment guidelines. In Practice29 470-477. 




In depth: VSSO – Reconstructive 

surgery: management of skin tumors 

Saturday July 9 – 14.00 – 17.50

Novel reconstructions of the tip of the nose 

G. ter Haar* 

Utrecht University, The Netherlands 

Crescentic Nasojugal Flap 

The bridge of the nose in dogs and cats can be very 

difficult to reconstruct due to the limited availability of 

free local tissues. In addition to free skin grafts, many skin 

flaps have been described in the veterinary literature that 

allow primary closure of cutaneous lesions involving the 

facial and nasal region. Local skin flaps would be preferable 

however for closure of nasal defects because they match 

the hair length, direction and color of the recipient site and 

would have a more cosmetic result. So far, practical and 

cosmetically satisfactory techniques with local skin flaps 

for closure of rostral nasal dorsum defects in dogs and cats 

have not been reported. 

Recently, a crescentic nasojugal flap (CNJF) for nasal 

tip reconstruction after tumor removal in human patients 

was described. The donor skin is harvested from the lateral 

side of the nose and the cheek or the perialar region. 

A crescentic perialar skin excision is made to enable 

advancement of the skin of the cheek. A second, triangular 

excision is made on the contralateral side of the defect to 

prevent a dog-ear upon closure of the defect. Upon closure, 

the sutures are placed in the alar and alar-labial groove, 

yielding the excellent cosmetic appearance of the flap in 

people. The feasibility of the CNJF in dogs was studied 

by performing the technique unilaterally and bilaterally 

on canine cadavers. The applicability of the CNJF for 

reconstruction of the rostral nasal area in a dog with a 

large rostral nasal defect as a result of granulomatous 

inflammation involving the nasal plane and the nasal 

dorsum was subsequently demonstrated. 

A mixed-breed cadaver was positioned in sternal 

recumbency and the nasal and labial regions were clipped. 

The defect, the skin that was going to be excised, and the 

surgical lines were drawn onto the nose. At the rostral part 

of the round shaped defect at the tip of the nose, a line 

was drawn along the border of the tip of the nose and was 

continued laterally in an arch shape to meet the alar groove. 

To avoid dog-ears upon closure, a triangle was formed 

around the distal part of the crescent-shaped line, which 

was going to be excised. The flap area was automatically 

outlined by the caudal part of the triangle and the medial 

part of the defect. To avoid a second dog-ear upon closure, 

two converging lines were drawn on the contralateral side 

of the nose with the broadest part meeting the caudolateral 

part of the defect. The defect, the cone-shaped area and 

the triangular figure were excised. The flap area was 

undermined to facilitate advancement to the tip of the nose 

using stay sutures (absorbable monofilament 2-0). The flap 

was attached to the underlying tissue in the site of defect 

using absorbable monofilament 3-0 interrupted sutures. 

The same suture material was used to close the edges 

of the former cone-shaped area and the triangular area. 

The skin was closed using non-absorbable monofilament 

4-0 interrupted sutures. This flap could also successfully 

be performed bilaterally and can be adjusted to assist in 

reconstruction of the nasal plane as demonstrated in a 

patient. 

Modified lateral rhinotomy for removal of nasal septum 

squamous cell carcinoma in the dog 

In January 2003, a 9-year-old intact male Labrador 

retriever dog weighing 41.3 kg was referred to the 

Department of Clinical Sciences of Companion Animals, 

Utrecht University for longstanding pruritis. During the 

history taking at the dermatology receiving, the owner 

reported right-sided epistaxis and sneezing of 8 weeks 

duration as additional problems, for which the dog was 

internally referred to the ENT section. No abnormalities 

were noted on physical examination of this dog, with 

the exception of a slightly raised, ulcerated mass, only 

visible on lifting the right nostril in the right nasal 

vestibule, originating from the nasal septum of more than 

1 cm in diameter and unclear caudal borders. The right 

submandibular lymph node was not enlarged, but a FNAB 

was taken and considered to be reactive lymphoid tissue. 

Thoracic and nasal radiographs and a complete blood 

count and serum biochemical examination were normal. 

On rhinoscopy it was demonstrated that the tumor was 

well circumscribed and extended caudally for 1.5 cm and 

was confined to the nasal septum. A histological biopsy 

was taken from the cranial middle part of the tumour, 

and a histological diagnosis of a well-differentiated 

squamous cell carcinoma was made. Deforming surgery 


was absolutely unacceptable to the owner; a modified 

lateral rhinotomy procedure was therefore proposed and 

carried out as described below. 

As described by Pavletic, it is possible to elevate the 

central planum as a dorsally based flap, thereby preserving 

this tissue while gaining access to the cranial nasal septum. 

To get full access to the entire tumor, this approach was 

combined with a lateral rhinotomy, as described by Hedlund 

in analogy with the technique used in humans for surgical 

removal of nasal septum squamous cell carcinoma. The 

surgeon directs the incision dorsocaudally from the angle 

of the rhinarium toward the nasomaxillary notch between 

the dorsal and ventral parietal cartilage, transecting the 

accessory cartilage. Using this technique the tumour could 

be resected (full-thickness resection of nasal septum) 

with wide-enough margins. The lateral rhinotomy incision 

was closed in three layers (nasal mucosa, cartilage or 

subcutaneous tissue, and skin). The nasal septum flap 

was resutured into position using a simple interrupted 

suture pattern. 

No complications were encountered during surgery or 

the immediate postoperative period. Except for a slight 

ventral deviation of the dorsal cranial bridge of the nose, 

as a result of the loss of most of the cranial cartilaginous 

septum, the cosmetic appearance was excellent. Pathology 

demonstrated fully excised well-differentiated SCC, this 

dog was still free of symptoms 7 years after surgery. 

SCC of the nasal septum is an uncommon disease in 

dogs, but when diagnosed in an early stage, this tumour can 

be removed completely using the described modified lateral 

rhinotomy technique with a good long-term prognosis and 

excellent cosmesis. 


Use of local and axial pattern flaps for reconstruction 

of the hard and soft palate 

Ramesh K Sivacolundhu, BVMS MVS FACVSc 

AMC, New York, N.Y., USA 

Abstract 

There are numerous conditions which may result in 

defects of the hard and soft palate. Reconstruction of these 

defects may be difficult due to anatomical limitations and 

limited tissue availability. The majority of palate defects, 

even when large, may be closed using local and/or axial 

pattern flaps, while other more advanced techniques such 

as free tissue transfer, muscle flaps and prosthetic implants 

are required in a smaller number of cases. 

Introduction 

Defects in the hard and soft palate may result from 

congenital abnormalities, resection of neoplasms, 

traumatic injuries, severe peridontal disease, tooth 

removals, severe chronic infections, and secondary to 

surgical and radiation therapy (1-5). Reconstruction of these 

defects can be challenging. The area concerned presents 

a number of anatomical limitations, with difficulties in 

exposure and access to affected areas, and limited tissue 

available for reconstruction of defects. In addition, the 

repair must withstand mechanical stresses induced during 

mastication and deglutition (1). 

Reconstruction of palate defects requires a detailed 

knowledge of the local anatomy, and an understanding 

of the various options available to the surgeon. This may 

be particularly important in cases of large defects, or 

when radiation or previous surgeries have compromised 

local tissue (1). There are a number of general principles 

described by Harvey (1987) (3)and Luskin (2000) (4) that 

should be followed when considering surgery on a patient 

with a palate defect: 

Make flaps large compared with the size of the defect 

to minimize tension. 

Preserve the vascular supply to flaps by elevating 

adequate underlying connective tissue. For hard palate 

epithelium this means elevating the mucoperiosteum 

as one layer and avoiding the palatine artery, which 

penetrates the palatine bone approximately 1 cm medial 

to the carnassial tooth, and then runs caudally and rostrally 

parallel to the midline. 

Suture tissues to freshly incised epithelium. A flap 

sutured to an intact epithelial surface will not heal. 

Incisions should be made with a scalpel blade rather than 

scissors to minimize crushing injuries. 

Avoid the use of electrosurgery or cauterization to control 

bleeding. 

Where possible, arrange suture lines so they are situated 

over connective tissue rather than over the defect, thereby 

preventing drying and contamination of the connective 

tissue side of the flap and decreasing the risk of dehiscence. 

Suture tissue gently and with large bites of tissue to 

minimize tension and interference with blood supply at 

the wound edges. 

Suture materials used are usually 3/0, 4/0 or 5/0 

absorbable suture material, depending on the size of 

the animal, type of repair being performed, and type of 

tissue being sutured (hard palate mucosa, soft palate 

mucosa or buccal mucosa). This author generally prefers 

the use of polydioxanone although other absorbable and 

nonabsorbable suture materials have also been utilized. If 

knots are left on the epithelial surface, they will usually 

slough in three to four weeks regardless of the type of 

suture material used (3). 

There are several reports of management of palate defects 

in dogs and cats, with a variety of techniques described. 

Techniques that have been used for reconstruction or 

management of palate defects include local flaps (3,5-8), 

axial pattern flaps (1,9), distant tissue with use of a rostral 

tongue flap (10), free tissue transfer with microvascular 

anastomosis (2), temporal muscle flaps (11,12) and 

prosthetic appliances (13,14). 

References 

• Bryant KJ, Moore K, McAnulty JF: Angularis oris axial 

pattern buccal flap for reconstruction of recurrent fistulae of 

the palate. Vet Surg 32:113-119, 2003. 

• Degner DA, Lanz OI, Walshaw R: Myoperitoneal 

microvascular free flaps in dogs: an anatomical study and a 

clinical case report. Vet Surg 25:463-470, 1996. 

• Harvey CE: Palate defects in dogs and cats. Compend 

Contin Educ Pract Vet 9:404-418, 1987. 

• Luskin IR: Reconstruction of oral defects using mucogingival 

pedicle flaps. Clin Tech Small Anim Pract 15:251-259, 2000. 

• Sager M, Nefen S: Use of buccal mucosal flaps for the 

correction of congenital soft palate defects in three dogs. 

Vet Surg 27:358-363, 1998. 


• Griffiths LG, Sullivan M: Bilateral overlapping mucosal 

single-pedicle flaps for correction of soft palate defects. J 

Am Anim Hosp Assoc 37:183-186, 2001. 

• Howard DR, Davis DG, Merkley DF, et al: Mucoperiosteal 

flap technique for cleft palate repair in dogs. J Am Vet Med 

Assoc 165:352-354, 1974. 

• Knight G: Surgical closure of the cleft palate. Vet Rec 

70:680-681, 1958. 

• Dundas JM, Fowler JD, Shmon CL, et al: Modification 

of the superficial cervical axial pattern skin flap for oral 

reconstruction. Vet Surg 34:206-213, 2005. 

• Robertson JJ, Dean PW: Repair of a traumatically induced 

oronasal fistula in a cat with a rostral tongue flap. Vet Surg 

16:164-166, 1987. 

• Cheung L: An animal model for maxillary reconstruction 

using a temporalis muscle flap. J Oral Maxillofac Surg 

54:1439-1445, 1996. 

• Fahie MA, Smith BJ, Ballard JB, et al: Regional peripheral 

vascular supply based on the superficial temporal artery in 

dogs and cats. Anat Histol Embryol 27:205-208, 1998. 

• Coles BH, Underwood LC: Repair of the traumatic oronasal 

fistula in the cat with a prosthetic acrylic implant. Vet Rec 

122:359-360, 1988. 

• Hobson HP, Heller RA, Wilson JB: Use of a removable 

maxillary appliance to correct a palatal defect in a dog. Vet 

Med Small Anim Clin 66:1085-1087, 1971. 


Wide excision of tumors and reconstruction of the 

resultant defect 

Julius M. Liptak* 

Alta Vista Animal Hospital, Ottawa, Ontario, Canada 

Wide resections are considered curative-intent surgeries 

as the intention is to resect both macroscopic and 

microscopic disease, including biopsy tracts, and thus 

prevent local tumor recurrence and improve overall survival 

times. Wide excision is recommended in the management 

of the majority of solid tumors because the first surgery 

provides the best chance for a cure. 

For wide excision of tumors, a margin of normal appearing 

tissue should be excised en bloc with the gross tumor to 

account for microscopic extension of the tumor. Surgical 

margins should be determined on the basis of tumor type, 

tumor grade if appropriate (e.g., mast cell tumor), biologic 

behavior, anatomic location, and the barrier provided by 

surrounding tissues. Precise guidelines to what constitutes 

appropriate tumor margins have not been defined for most 

tumor types. The majority of surgeons use predetermined 

distances depending on tumor type; however, there is 

evidence that tumor size also influences the extent of 

microscopic tumor extension, with larger tumors of the 

same histologic type having greater microscopic extension 

and hence requiring larger margins than smaller tumors. 

Margins are three-dimensional and hence lateral and 

deep margins must be considered when planning surgical 

resections of tumors. Lateral margins are determined by 

tumor type and biologic behavior. For example, 1 cm lateral 

margins are recommended for benign tumors and most 

malignant carcinomas, whereas 3 cm lateral margins are 

required for soft tissue sarcomas. For mast cell tumors, 

lateral margins are also determined by histologic grade as 1 

cm lateral margins are sufficient for grade I mast cell tumors 

and 2 cm lateral margins for grade II mast cell tumors. 

Deep margins are determined by natural tissue barriers as 

1 to 3 cm deep margins are often not possible in regions 

such as the extremities (limbs and head) and trunk. Fat, 

subcutaneous tissue, muscle, and parenchymal tissue do 

not provide a barrier to tumor invasion and are not adequate 

for deep margins. Connective tissues, such as muscle 

fascia and bone, are resistant to neoplastic invasion and 

provide a good natural tissue barrier. Hence, deep margins 

should include a minimum of one fascial plane, while two 

fascial planes are recommended for surgical resection of 

injection site sarcomas. Lateral and deep margins should 

be greater if the tumor is invasive, recurrent, or inflamed. 

Tumors, particularly soft tissue sarcomas, should never 

be shelled out because they are often surrounded by a 

pseudocapsule of compressed, viable neoplastic cells and 

not healthy, reactive host cells. 

Primary closure of the resultant defect is preferred if 

possible. If the wound edges can be closed but tension 

is high, then tension-relieving techniques should be 

employed depending on the degree of tension. If the wound 

edges cannot be apposed, then the defect needs to be 

reconstructed. There are many different reconstructive 

options, ranging from subdermal plexus flaps (i.e., 

transposition and advancement flaps), flank fold flaps, 

axial pattern flaps (i.e., thoracodorsal, caudal superficial 

epigastric, caudal auricular, facial, tail and scrotal axial 

pattern flaps), skin grafts, and indirect flaps. 


Canine mast cell tumor 

Sarah Boston* 

University of Guelph, Dept. of Clinical Studies, Ontario Vet. College, Guelph, Ontario, Canada.. 

Initial work up of a mast cell tumor (MCT) will involve 

diagnosis by FNA and staging. The initial staging performed 

will depend on the index of suspicion that the mass is a 

grade II or III MCT and clinician’s preference. Cytology is 

generally diagnostic for MCT. However, an incisional biopsy 

to determine grade is recommended in some cases. The 

histological grade may be important to determine in some 

cases, where the surgical approach may be altered by the 

grade of the tumor. 

The World Health Organization (WHO) classification 

scheme for canine mast cell tumours divides them into 

four stages according to the clinical presentation . Stage 

I – One tumour confined to the dermis without regional 

lymph node involvement (Ia – Without systemic signs, 

Ib – With systemic signs); Stage II – One tumour confined 

to the dermis with regional lymph node involvement (IIa – 

Without systemic signs, IIb – With systemic signs); Stage 

III – Multiple dermal tumours or one large infiltrating 

tumour with or without regional lymph node involvement 

(IIIa – Without systemic signs, IIIb – With systemic signs); 

and Stage IV – Any tumour with distant metastasis or a 

recurrence with metastasis (including blood and/or bone 

marrow involvement). Locoregional staging and evaluation 

for visceral metastasis (to spleen and liver) are the areas 

that are most important to evaluate when staging canine 

patients with MCT. 

Lymph node staging will involve palpation, FNA for 

cytology and biopsy for histopathology in some cases. One 

pit fall with cytological evaluation of the lymph nodes is 

that it can be difficult to differentiate between neoplastic 

mast cells and normal mast cells that are at the site 

due to chemotaxis. Krick et al attempted to define the 

cytological staging of lymph nodes to create consistency 

in the literature. In that study they defined: 

Normal – No mast cells seen 

Reactive lymphoid hyperplasia - Reactive node +/- rare 

individual mast cells 

Possible metastasis – 2-3 mast cell aggregates of 2-3 

cells 

Probably metastasis - >3 foci of mast cell aggregates of 

2-3 cells and/or 2-5 aggregates of >3 mast cells 

Certain metastasis - Effacement of lymphoid tissue 

by mast cells and/or presence of aggregated, poorly 

differentiated MC with pleomorphism, anisocytosis, 

anisokaryosis, and/or decreased or variable granulation, 

and or >5 aggregates of >3 MC 

Although this definition is helpful and may lead to 

the ability to predict prognosis in future studies, it still 

creates a clinical problem of what to do with cases that 

are determined to have possible or probably metastasis. 

In Krick’s study, 152 dogs with MCT had lymph node 

evaluation. 63.8% of dogs were considered stage I and 

36.2% were considered stage II. In that study, stage II dogs 

had a shorter survival time and dogs with grade III MCT 

were more likely to have stage II disease. In cases with 

enlarged locoregional lymph nodes with questionable or 

certain metastasis, removal of the affected lymph node at 

the time of surgery for histopathology and cytoreduction 

is recommended. 

Abdominal ultrasound is also recommended for staging 

MCT in dogs, with ultrasound-guided FNA of the spleen 

and liver if they appear abnormal. This can also raise 

questions of true metastasis versus normal mast cells. 

Recently Stefanello et al evaluated 52 dogs with MCT that 

had ultrasound guided aspirates of the liver and spleen. 

10/52 (19%) dogs had abnormalities of the spleen or liver 

on cytology and all 10 of these cases had abnormalities 

noted on ultrasound. An additional 21/42 dogs with normal 

cytology had abnormalities on ultrasound. Although it is 

somewhat controversial, this study suggests that cytology 

should be performed in cases with ultrasound abnormalities 

of the liver or spleen. This study also found that dogs 

with cytological evidence of visceral metastasis had a 

significantly shorter survival time than dogs with normal 

cytology. (34 days vs 733 days) 

Thoracic radiographs are often taken as part of a work 

up for mast cell tumors. However, this is a low yield test. 

A recent retrospective study evaluating the prevalence of 

gross lung metastasis on three view thoracic radiographs 


in 115 dogs with mast cell tumors yielded 1/115 (0.87%) 

dog that was positive for gross metastasis. (Fung & Boston, 

unpublished data) Three-view thoracic radiographs can be 

considered as part of a base line database for older dogs, in 

cases with respiratory signs and in cases with high grade 

tumors with metastasis to other sites. 

Staging with bone marrow aspirate or biopsy has also 

been shown to be a relatively low yield test. However, some 

would argue that it is worthwhile because the prognosis is 

significantly altered with a positive bone marrow. Endicott 

et al evaluated the bone marrow of 157 dogs with MCT. In 

that study, they found that 2.8% of cases were positive at 

initial evalation, with 4.5% positive overall. 3/18 dogs were 

positive after recurrence or progression of clinical signs, 

suggesting that bone marrow is not indicated for routine 

staging, but may be considered in cases with progressive 

disease or when indicated based on CBC. Another study 

by Marconato et al evaluated the prognosis in 14 dogs 

that were positive on bone marrow evaluation. The MST 

in these cases was 43 days and most cases had concurrent 

metastasis to the lymph nodes or visceral metastasis, with 

3 cases that had evidence of pulmonary metastasis. 

Although dogs with multiple mast cell tumor are 

classified as Stage III, recent evidence suggests that these 

are separate events, with mast cells developing de novo in 

dogs that are predisposed to mast cell tumors, rather than 

metastatic events. Stage III is likely a misnomer for the 

predicted behavior of dogs with multiple mast cell tumors. 

The survival time of dogs with multiple mast cell tumors 

was not found to be significantly different than dogs with 

solitary mast cell tumors. This suggests that for dogs with 

multiple mast cell tumors, each tumor should be treated as 

a separate event. (Murphy et al 2006; Mullin et al 2006) 

Surgery remains the mainstay of treatment for canine 

mast cell tumors. The completeness of surgical excision 

has been shown to have a significant effect on prognosis 

of mast cell tumors. (Mullins et al 2006; Murphy et al 

2004). Although the dogma has been that malignant tumors 

should be removed with 3cm margins and one fascial plane 

deep, this has recently been critically evaluated. Simpson 

et al prospectively evaluated margins of grade I and II 

MCT of 1, 2 and 3cm. A total of 23 MCT were evaluated 

in this study. They found that the grade I MCT were all 

completely excised at all margins, suggesting that 1cm may 

be adequate for low grade tumors. For the grade II tumors, 

75% were considered clean at 1cm margin and 100% were 

considered clear at 2cm margins. A follow up of this study 

by Fulcher et al evaluated the margins of grade I and II 

MCT that were excised using 2cm lateral margins. They 

had 16 dogs with 23 MCT in this study. 4/23 were grade I 

MCT and all of these had clean margins. 19 of the tumors 

were grade II and 2 of these were considered to have dirty 

margins. In light of the fact that 10% of the margins were 

considered dirty for grade II MCT that were cut with 2cm 

margins, this recommendation should be considered with 

caution. The author continues to use 3cm lateral margins 

for grade II and III MCT when this is possible. 

Seguin et al evaluated the outcome of dogs with grade 

II MCT that were treated with surgery alone. 55 dogs 

with 60 tumors were evaluated retrospectively. Only one 

case had dirty histological margins. 3 cases (5%) recurred 

locally and the same number developed metastasis. 6 

cases (11%) developed a MCT at another site. 84% of 

cases were free of MCT for the duration of follow up 

(median follow up 540 days). The authors of this paper 

concluded that additional therapy may not be necessary for 

grade II MCT with complete excision and no evidence of 

metastasis. Seguin later evaluated the recurrence, outcome 

and proliferation indices in cases of MCT after incomplete 

excision. 28 dogs were evaluated with 30 MCT. 7 (23.3%) 

of the cases recurred locally and this was found to be a 

negative prognostic indicator for survival. Ki-67 and PCNA 

were also found to be prognostic for local recurrence. 

Predicting the behavior of grade I and grade III is 

straightforward. However, the common grade II MCT 

continues to be difficult to predict behavior. Indices of 

proliferation have been assessed to try to determine 

between “good” and “bad” grade II MCT. Mitotic index 

(MI) appears to be the most straightforward and promising 

method of separating out the good and bad grade II MCT. 

Recently, Romansik et al evaluated the MI for 148 MCT 

and found that MI correlated with tumor grade. As well 

the median survival time for dogs with a MI of 0-5 was 70 

months, and was significantly longer than dog with a MI 

of >5 (MST of 2 months). Similarly, a new two-tier grading 

scheme has been recently proposed by Kiupel et al. This 

scheme attempts to separate the mast cells into highgrade 

or low grade. High grade tumors were those with: 

at least 7 mitotic figures in 10 high-power fields (hpf); at 

least 3 multinucleated (3 or more nuclei) cells in 10 hpf; at 

least 3 bizarre nuclei in 10 hpf; karyomegaly. Fields with 

the highest mitotic activity or with the highest degree 

of anisokaryosis were selected to assess the different 

parameters. According to the novel grading system, highgrade 

MCTs were significantly associated with shorter 

time to metastasis or new tumor development, and with 

shorter survival time. The median survival time was less 

than 4 months for high-grade MCTs but more than 2 years 

for low-grade MCTs. This new grading scheme may help 

to guide therapy and predict behavior of mast cell tumors 

in the future. 

Although a complete excision of a mast cell tumor should 

always be the goal of surgical treatment. This is not always 

feasible or achieved. Dogs with an incompletely excised 

mast cell tumor will continue to require local control of their 

disease. If possible, a staging recut should be performed 

using 2-3 cm margins around the previous excision scar 


and one fascial plane deep. If this is not feasible, radiation 

therapy to the site is recommended. 

For tumors where complete excision is not feasible due 

to the extent of disease, the approach will depend on the 

owners treatment goals and on full staging. In these cases, 

full staging including an incisional biopsy to determine the 

tumor grade is reocommended preoperatively. In cases 

where palliation is the goal, pretreatment with either 

chemotherapy or corticosteroids can be considered prior 

to cytoreductive surgery. However, caution should be 

exercised in using corticosteroids to shrink mast cell tumors 

if a curative intent surgery is to be performed. A recent 

article by Gilson et al evaluated the use of neoadjuvant 

prednisone in cases of MCT that were treated with surgery. 

This study was a combined retrospective and prospective 

study. Dogs received 0.5-2.2mg/kg, with no control group, 

a median of 9 days prior to surgery. The overall objective 

response rate was 70% and prospectively the maximal 

diameter reduction was 42.5% and the reduction in tumor 

volume was 80%. The authors concluded that neoadjuvant 

prednisone useful for inducting reduction of MCTs and may 

facilitate resection when adequate surgical margins cannot 

be confidently attained because of mass location or size or 

both. However, despite the fact that 89% of the cases in this 

study had histologically complete margins, the overall local 

recurrent rate was 23.8% and the local recurrence rate for 

cases with “complete” excision was 17.6%. This suggests 

that pretreatment with corticosteroids may decrease the 

tumor size and facilitate resection, but that there may be 

islands of malignant mast cells that are left in the periphery 

that may be left behind after resection. Pretreatment 

corticosteroids is appropriate in some situations, such as 

when a curative intent surgery is not possible, when the 

intent is palliation and cytoreduction, or when cytoreduction 

followed by radiation is part of the treatment plan. 


References 

• Cytological lymph node evaluation in dogs with mast cell 

tumours: association with grade and survival. E. L. Krick, A. 

P. Billings, F. S. Shofer, S. Watanabe, and K. U. Sorenmo. 

VeterinaryandComparativeOncology,7, 2, 130–138; 2009 

• Ultrasound-Guided Cytology of Spleen and Liver: A 

Prognostic Tool in Canine Cutaneous Mast Cell Tumor. D. 

Stefanello, P. Valenti, S. Faverzani, V. Bronzo, V. Fiorbianco, 

N. Pinto da Cunha, S. Romussi, M. Cantatore, and M. 

Caniatti. J Vet Intern Med 2009;23:1051–1057. 

• Clinicopathological findings and results of bone marrow 

aspiration in dogs with cutaneous mast cell tumours: 157 

cases (1999–2002). M. M. Endicott, S. C. Charney, J. A. 

McKnight, A. S. Loar, A. M. Barger and P. J. Bergman. 

Veterinary and Comparative Oncology, 5 (1)31–37. 

• Clinicopathological Features and Outcome for Dogs 

with Mast CellTumors and Bone Marrow InvolvementL. 

Marconato, G. Bettini, C. Giacoboni, G. Romanelli, A. Cesari, 

A. Zatelli, and E. Zini. J Vet Intern Med 2008;22:1001–1007. 

• Evaluation of prognostic factors associated with outcome 

in dogs with multiple cutaneous mast cell tumors treated 

with surgery with and without adjuvant treatment: 54 cases 

(1998–2004)Marie N. Mullins, DVM, MS, DACVIM; William 

S. Dernell, DVM, MS, DACVS; Stephen J. Withrow, DVM, 

DACVS, DACVIM; Eugene J. Ehrhart, DVM, PhD, DACVP; 

Douglas H. Thamm, VMD, DACVIM; Susan E. Lana, DVM, 

MS, DACVIM. JAVMA, Vol 228(1), 2006 (91-95) 

• Effects of stage and number of tumours on prognosis of 

dogs with cutaneous mast cell tumours. S. Murphy, A. H. 

Sparkes, A. S. Blunden, M. J. Brearley, K. C. Smith. Vet Rec 

2006;158:287-291 

• Evaluation of surgical margins required for complete 

excision of cutaneous mast cell tumors in dogsAmelia M. 

Simpson, DVM; Lori L. Ludwig, VMD, MS, DACVS; Shelley 

J. Newman, DVM, DVSc, DACVP; Philip J. Bergman, DVM, 

PhD, DACVIM; Heidi A. Hottinger, DVM, DACVS; Amiya K. 

Patnaik, DVM, MS. J Am Vet Med Assoc 2004;224:236–240 

• Evaluation of a two-centimeter lateral surgical margin for 

excision of grade I and grade II cutaneous mast cell tumors 

in dogsRyan P. Fulcher, DVM; Lori L. Ludwig, VMD, MS, 

DACVS; Philip J. Bergman, DVM, PhD, DACVIM; Shelley J. 

Newman, DVM, DVSc, DACVP; Amelia M. Simpson, DVM, 

DACVS; Amiya K. Patnaik, DVM, MS. JAmVetMedAssoc 

2006;228:210–215 

• Relationships between the histological grade of cutaneous 

mast cell tumours in dogs, their survival and the efficacy of 

surgical resection S. Murphy, A. H. Sparkes, K. C. Smith, A. 

S. Blunden, M. J. Brearly. Vet Rec 2004;154:743-746. 

• Clinical outcome of dogs with grade-II mast cell tumors 

treated with surgery alone: 55 cases (1996–1999)Bernard 

Séguin, DVM, MS, DACVS; Nicole F. Leibman, DVM, MS, 

DACVIM; Victoria S. Bregazzi, DVM, MS, DACVIM; Gregory 

K. Ogilvie, DVM, DACVIM; Barbara E. Powers, DVM, PhD, 

DACVP; William S. Dernell, DVM, MS, DACVS; Martin J. 

Fettman, DVM, PhD, DACVP; Stephen J. Withrow, DVM, 

DACVS, DACVIM. J Am Vet Med Assoc 2001;218:1120– 

1123. 

• Recurrence Rate, Clinical Outcome, and Cellular 

Proliferation Indices as Prognostic Indicators after 

Incomplete Surgical Excision of Cutaneous Grade II Mast 

Cell Tumors: 28 Dogs (1994–2002)Bernard Se'guin, M. 

Faulkner Besancon, Jennifer L. McCallan, Loralei L. Dewe, 

Matthew C. Tenwolde, Emily K. Wong, and Michael S. Kent. 

J Vet Intern Med 2006;20:933–940. 

• Proposal of a 2-tier histologic grading system for canine 

cutaneous mast cell tumors to more accurately predict 

biological behavior. Kiupel M, Webster JD, Bailey KL, Best 

S, DeLay J, Detrisac CJ, Fitzgerald SD, Gamble D, Ginn PE, 

Goldschmidt MH, Hendrick MJ, Howerth EW, Janovitz EB, 

Langohr I et al. Vet Pathol. 2011 Jan;48(1):147-55. 

• Evaluation of neoadjuvant prednisone administration and 

surgical excision in treatment of cutaneous mast cell tumors 

in dogs. Rebecca M. Stanclift, DVM, and Stephen D. Gilson, 

DVM, DACVSJ. Am Vet Med Assoc 2008;232:53–62). 


Closure of large abdominal wall defects using 

negative pressure therapy: a bridge to definitive 

closure. 

A.Vanlander MD, F. Berrevoet MD ,PhD 

Department of General and Hepatobiliary Surgery, Ghent University Hospital, Ghent Belgium 

Benign abdominal wall tumors, lipomas, hemangiomas 

and fibromas are quite common in humans. Malignant 

tumors of the abdominal wall are less common. 

The malignant soft-tissue tumors of the abdominal wall 

consist of desmoid tumors and non-desmoid soft-tissue 

sarcomas. These neoplasms tend to invade adjacent 

musculo aponeurotic and bony structures. Extirpation with 

the full-thickness of the abdominal wall is required except 

for small, superficial lesions. A wide-margin resection offers 

the best assurance of local control. Adjuvant radiotherapy 

can be given when the margin of resection is limited. The 

effective radiation dose can be difficult to administer, due 

to the sensitivity of the underlying structures. 

The goals of the reconstruction are to restore the 

abdominal wall defects and to restore the structural and 

functional continuity of the musculofascial system. It is 

imperative to provide stable and durable wound coverage. 

A good knowledge of the anatomy and assessment 

of which structures are present, absent or distorted is 

indicated. Tissue selection for the reconstruction of the 

abdominal wall can be synthetic meshes, autologue tissue, 

regional flaps and free tissue transfer. 

However large tissue defects can often not be closed 

primarily and required, in the past, wound dressings. 

Causing increased rates of morbidity and a longer hospital 

stay. 

Negative pressure therapy will optimize the blood flow, 

decrease local oedema and remove excessive fluid from 

the wound bed, thereby supplying the wound with oxygen 

and nutrition to promote accelerated healing . The clinical 

application is the increase in cell division and the formation 

of granulation tissue. It allows preparation of the wound 

for further definitive reconstructive surgery or protection of 

vital structures to make adjuvant radiation therapy possible. 

In a RCT of Joseph et al. published in 2000, after six 

weeks , various chronic wounds treated with Negative 

Pressure Therapy had a significantly greater percent 

reduction in wound volume and depth than wounds treated 

with wet gauzes. 

NPT significantly increases the rate of re-epithelialisation 

in skin grafts compared to Opsite dressing ( Genecov 1998). 

Seven of the ten donor sites treated with NPT were noted 

to reepithelialise faster than the Opsite-treated donor sites. 

When no reconstructive surgery is possible because 

of adjuvant radiation therapy, negative pressure therapy 

is a nice alternative and healing of these wounds can be 

achieved by formation of granulation tissue and covering 

of the defect. 

When dealing with a significant loss of tissue , negative 

pressure therapy can be utilized to enhance wound healing 

by promoting granulation tissue formation and new 

blood vessels in –growth. Skin grafts or vascularized flap 

placement can then be used to secondarily close the wound. 

The black foam, polyurethane ether (PU), has large 

pores of 400-600 mm and is hydrophobic. It is ideal for the 

stimulation of granulation tissue and wound contraction. 

The white foam, polyvinylalcohol (PVA),has a pore size of 

250 mm. It is denser and hydrophilic. It is ideal to use in 

exsudative wounds. It requires , because of its density,a 

higher negative pressure. 

In a systematic review by Ubbink at al.(BJS 2008;95:685- 

692), there is little evidence to support the routinely use of 

negative pressure therapy for local wound care, however 

the clinical impression seems to be favorable. There is no 

evidence of more rapid wound healing when using negative 

pressure therapy. Is this review there are no data on cost, 

quality of life or adverse effects , such as pain. 

It is important to understand the indications for when 

and how to use negative pressure therapy. 


Radioactive microbrachytherapy for head and neck 

lesions in dogs and cats 

Kirpensteijn J*, Vente MAD, Nimwegen B, Nijsen JFW 

University of Utrecht, Faculty of Veterinary Medicine, Dep.Clinical Sciences of Companion Animals, Utrecht, 

Netherlands 

Introduction 

The worldwide annual incidence of head and neck 

cancer in man approximates 500,000 cases, making it 

the sixth most common malignancy. Surgical resection, 

chemotherapy, and external beam radiation therapy 

are the currently used treatment modalities, and are 

especially effective if the malignancies are detected in 

an early phase of disease, which is the case in 1/3 of 

all patients with head and neck cancer. However, even if 

a high portion of patients with stage I/II disease can be 

effectively treated, 10-30% of patients will develop new 

primaries in the same region. If this happens, curative 

intervention is not an option any more. For this category 

of patients as well as those who present with advanced 

disease, which is the vast majority, currently no curative 

therapies are available. Novel, effective treatment options 

are therefore urgently needed. Naturally occurring tumors 

in companion animals share many clinical and molecular 

similarities to human cancers that are difficult to replicate 

in other model systems. Cancers in these animals develop 

in the context of an intact immune system, where tumor, 

host and tumor microenvironment are syngeneic. To 

accelerate the translational to the human medical arena, 

veterinary companion animal patients (canine and feline) 

with spontaneous malignancies were treated in an early 

stage of the development of these novel and dedicated 

particulated systems. Head and neck cancers are common 

in the dog and the cat 

Microbrachytherapy 

A potentially effective treatment option for patients 

with head and neck malignancies of limited size for 

whom no treatment options are available, could consist 

of directly intratumorally injected microspheres loaded 

with the combined beta-gamma emitting radioisotope 

holmium-166 (166Ho). Next to gamma scintigraphy, both 

magnetic resonance imaging (MRI) and X-ray computed 

tomography (CT) are able to visualize the biodistribution 

of particles loaded with 166Ho in vivo. If the tumors are 

somewhat larger and the afferent vasculature is as well, 

166Ho microspheres may be delivered to the tumorous 

tissue using the intra-arterial transcatheter approach, 

in a similar fashion as the 166Ho poly(L-lactic acid) 

microspheres developed by our group which are currently 

tested in patients with metastatic liver cancer. 

This concept, the direct intratumoral injection of 166Ho- 

AcAc microspheres, has already been investigated in renal 

cell carcinoma-bearing mice and, more relevant, also in 

a series of veterinary patients, i.e., dogs and cats with 

spontaneous malignancies. It was found that extremely 

high tumor absorbed doses could be attained (in excess 

of 30 times the dose that can be achieved in external 

beam radiotherapy) with no associated side effects. 

The described results on radioactive holmium loaded 

microspheres show that the radioembolization and the 

intratumoral injection techniques are very promising for 

treatment of unresectable head and neck tumors. 

Veterinary patients 

Microspheres were administered directly into the tumors 

of 8 veterinary patients with spontaneous head and neck 

tumors; 5 cats with an oral squamous cell carcinoma and 

3 dogs with a squamous cell carcinoma in tongue and neck 

(n=1 and n=1, respectively) and one with a fibrosarcoma in 

the mandible were treated by intratumoral injections with 

166Ho microspheres. 

Results 

The injections of the radioactive microspheres were 

technically successfully performed. Generally, the 

treatment was well tolerated by the animals and the 

clinical condition of 6/8 animals improved markedly. In 

the majority of patients, partial response was achieved, 

which frequently led to downstaging to surgical resection. 

However in three of the cats with oral squamous cell 

carcinoma, outcome was complete remission. In only two 

animals progressive disease was observed. Toxicity was 

absent in most animals. In one patient a skin defect was 

observed. Most biochemical and hematological parameters 

normalized after treatment. The life of the majority of 

animals was extended whilst associated with a good 

quality of life. For the small lesions (1-15g; n=6), treatment 

often was curative whereas treatment of large lesions 

(95-150g) resulted in downstaging to surgical resection. 



Author index 

B 

C 

D 

Balligand, M . 

• Force plate: gold standard. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .111 

• Muscular forces affecting the outcome of CCL surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .115 

Barthélémy, N . 

• Short- and long-term outcomes in young large breed dogs with medial compartment disease of the elbow .41 

Benlloch-Gonzalez, M . 

• Prospective clinical study of enterectomy with skin staplers in 9 dogs and 9 cats . . . . . . . . . . . . . . . . . . . . . .36 

Bernardé, A . 

• A retrospective study of complications following modified triple tibial osteotomy for cranial cruciate 

deficient stifles in dogs: 72 cases (2008-2010) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49 

Bockstahler, B . 

• Evidence based medicine in rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .118 

Boero Baroncelli, A . 

• Effect of screw insertional torque on mechanical properties of 5 different angular stable systems . . . . . . . .89 

Böhme, B . 

• Considerations on the pathophysiology of canine condylar fractures by finite element analysis . . . . . . . . . . .50 

Boland, L . 

• Zygomatic salivary gland diseases in the dog: 3 representative cases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51 

Boston, S . 

• Canine mast cell tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .187 

Böttcher, P . 

• In vivo motion analysis 3D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .113 

Brissot, H . 

• Caudal mediastinal para-oesophageal abscesses in 7 dogs. A retospective study . . . . . . . . . . . . . . . . . . . .149 

Broos, P .L .O . 

• Pushing the boundaries in musculoskeletal trauma – what is possible in man? . . . . . . . . . . . . . . . . . . . . . . .29 

Buttin, P . 

• Nephroliths and video-assisted nephrotomy in 8 cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39 

Cachon, T . 

• Surgical treatment of sciatic nerve injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .151 

Déjardin, LM . 

• Effect of articular design on mediolateral constraint and stability of two unlinked canine total elbow 

prostheses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91 

Demetriou, J .L . 

• Pyothorax : Is surgery necessary? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .167 

Devitt, C . 

• Dorsal recumbent shoulder arthroscopy technique, normal anatomy, & appearance of routine pathology . . .99 

• Stifle arthroscopy technique, normal anatomy, & appearance of routine rathology . . . . . . . . . . . . . . . . . . . .104 


F 

G 

H 

K 

L 

Falzone, C . 

• Lumbosacral spine: decompression and stabilisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .142 

• Lumbosacral spine: surgical decision making. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .140 

Findji, L: 

• Surgical preparation: current understanding and recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67 

Fitzpatrick, N . 

• The effect of configuration and radiographic positioning on measurements of deformity magnitude 

in a dog with a complex antebrachial growth deformity: comparison between radiographic and 3D 

computer modelling measurements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .92 

• True spherical dome osteotomy using a novel blade design in a dog with an antebrachial growth 

deformity – planning and execution of technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52 

Gauthier, O . 

• Stimulation of bone healing. Commercially available products. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .130 

• Stimulation of bone healing. Latest developments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .123 

Glyde, M . 

• Biomechanical comparison of plate, plate-rod and orthogonal plate locking constructs in an ex-vivo 

canine tibial fracture gap model. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88 

• The effect of screw number and plate stand-off distance on the biomechanical characteristics 

of 3.5mm locking compression plate (LCP) and 3.5mm string of pearls (SOP) plate constructs in a 

synthetic fracture gap model. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .95 

Griffon, D .J . 

• Delayed union and nonunion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .127 

• Enhancing bone healing in practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .131 

Gutbrod, A . 

• ects of humeral rotational osteotomy on contact mechanism of the canine elbow joint: an ex vivo study. . . .35 

Hamilton, M . 

• Total hip replacement with reiforced augmentation of the dorsal acetabular rim (radar) using the sop 

implant and bone cement in seven dogs with dorsal acetabular rim deficiency . . . . . . . . . . . . . . . . . . . . . . . .53 

Hayes, G .M . 

• Distribution and persistence of topical clotrimazole for canine sino-nasal aspergillosis. . . . . . . . . . . . . . . . .44 

Höglund, O .V . 

• Ligating the renal artery in pigs with a new absorbable device - LigaTie® . . . . . . . . . . . . . . . . . . . . . . . . . .148 

Kirpensteijn, J . 

• Radioactive microbrachytherapy for head and neck lesions in dogs and cats . . . . . . . . . . . . . . . . . . . . . . . . .192 

Liptak, J .M . 

• Wide excision of tumors and reconstruction of the resultant defect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .186 


M 

N 

P 

R 

S 

T 

Medl, N . 

• Intraoperative contamination of the suction tip in clean orthopaedic surgeries in dogs and cats . . . . . . . . . .40 

Meij, B .P . 

• The use of pedicle screws in canine lumbosacral disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 

Milgram, J . 

• Axial pattern flap based on a cutaneous branch of the facial artery in cats. 

• Milgram J*, Weiser M, Kelmer E*, Benzioni H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .147 

• The role of the antebrachiocarpal ligaments in the prevention of hyperextension of the 

antebrachiocarpal joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .94 

Moissonnier, P . 

• Perioperative antimicrobial propylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73 

Moritz, A . 

• Have we learnt anything in the last 15 years? 

Stenting: The Giessen experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .155 

• Pyothorax - have we learnt anything in the last 15 years? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .165 

Murgia, D . 

• Caudal cervical intervertebral space distraction and stabilization using a distractable fusion cage in 

seven dogs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .150 

Nellissen, P . 

• Effect of three an aesthetic induction protocols on laryngeal function during laryngoscopy in normal cats . .37 

Piras, LA . 

• Effects of antebrachial torsion on the measurement of frontal plane angulation: a cadaveric 

radiographic analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54 

Rancan, L . 

• Circulating proinflammatory cytokines and nitric oxide are increased in brachycephalic dogs . . . . . . . . . . .152 

Rochereau, P . 

• Comparison of 4.0 mm partially-threaded cannulated screws and 4.0 mm partially-threaded screws in 

a canine humeral condylar fracture model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42 

Segal, U . 

• Latero-distal transposition of the tibial crest for patella alta and medial luxation . . . . . . . . . . . . . . . . . . . . . .55 

Sivacolundhu, R .K . 

• Use of local and axial pattern flaps for reconstruction of the hard and soft palate . . . . . . . . . . . . . . . . . . . .184 

Souchu, L . 

• Morphological comparison of the middle ear between French bulldogs and non-brachycephalic dogs. . . . . .56 

Tan, C .J . 

• Stabilisation of periarticular fractures or osteotomies with an LCP notched head T-plate . . . . . . . . . . . . . . . .57 

ter Haar, G . 

• Novel reconstructions of the tip of the nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .182 


V 

W 

Valander, A . 

• Closure of large abdominal wall defects using negative pressure therapy: a bridge to definitive closure. . .191 

Vallefuoco, R . 

• Tympanic bulla osteotomy via oral approach in the dog: A descriptive cadaveric study. . . . . . . . . . . . . . . . . .38 

van Bree, H . 

• Lumbosacral disease (LS): an update on diagnostic imaging techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . .137 

• MRI and arthroscopy for evaluation of shoulder joint pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101 

Verset, M . 

• Two cases of dogs with infiltrative lipomas of the thigh region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58 

Voss, K . 

• Association of articular mineralisation, cranial cruciate ligament pathology and degenerative joint 

disease in feline stifle joints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93 

Walton, M .B . 

• Owner based metrology instruments for conditions of canine chronic mobility impairment - contruct 

and criterion validity of LOAD, HCPI and CBPI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59 

Watson, P . 

• Pancreatitis in dogs and cats: what have we learnt on the last 15 years? . . . . . . . . . . . . . . . . . . . . . . . . . . .173 

Weese, J .S . 

• Methicillin-resistant staphylococcal infections: animal and public health consequences . . . . . . . . . . . . . . . .80 

• Surgical site infection control programme . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74 

• Surgical site infections: Incidence, relevance, risk factors and surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . .63 

White, R .N . 

• Surgical treatment: necrosectomies, pancreatectomies, and drainage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .177 

• Tracheal collapse - ringing: indications, limitations, technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .161 

Woodbridge, N . 

• A retrospective study of tibial plateau translation following tibial plateau levelling osteotomy 

stabilisation using three different TPLO plates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43 


Speakers 

Adkins Angus 

BVSc, FACVSc 

P.O. Box 462 

Scone 

New South Wales 1337 

Australia 

Archer Debra C 

DVM ECVS 

University of Liverpool 

Faculty of Vet. Science 

Division of Equine Studies 

Leahurst, Chester High Road 

Neston CH64 7TE South Wirral 

United Kingdom 

Arensburg Liat DVM 

Dierenklienik de Morette 

Edingsesteenweg 237 

1730 Asse 

Belgium 

Auer Jörg 

Prof. Dr.med.vet. ECVS/ACVS 

Vetsuisse Faculty University of 

Zürich 

Equine Department 

Winterthurerstrasse 260 

8057 Zürich 

Switzerland 

Balligand Marc 

Prof.DVM,DVSc, CSAO, ECVS 

Université de Liège 

Professor of SA Surgery 

Dept. of Small Animal surgery 

Bat. B44, Blv. de Colonster 20 

Sart, Tilman 

4000 Liège 

Belgium 

Barnett Tim Mr 

University of Edinburgh 

Lagre Animal Clinic 

Royal (Dick) School of Vet. 

StudiesEaster Bush 

EH25 9 RG Roslin, Midlothian 

Scotland/ United Kingdom 

Barthelemy Nicolas Dr. 

1630 Epley Road 

48895 Williamston MI 

USA 

Benlloch Gonzalez Manuel 

DVM 

Centre Hospitalier Vétérinaire Frégis 

43 Avenue Aristide Briand 

94110 Arcueil 

France 

Benredouane Kossay 

DVM 

12 Chemin des Côtes 

69210 Lentilly 

France 

Bernardé Antoine 

Dr.vét. ECVS, MS 

Centre Hospitalier Vétérinaire St. 

Martin 

Head Surgical Unit 

275 Route Impériale 

74370 St. Martin Bellevue 

France 

Bischofberger Andrea Dr. 

Biomedical Research and Clinical 

Training Unit 

Uni. Vet. Teaching Hospital Camden 

University of Sydney 

410 Werombi Road 

Camden 2570 

NSW Australia 

Bladon Bruce 

BVM&S CertEP DESTS MRCVS ECVS 

O'Gorman Slater Main and Partners 

Donnington Grove Veterinary Surgery 

Oxford Road 

Newbury, Berkshire RG14 2J 


Boaro Baroncelli Alessandro DVM 

Via Nazzario Sauro 13 

12051 Alba (CN) 

Italy 

Bockstahler Barbara 

Dr.med.vet. 

Department of Surgery and 

Ophtalmology, 

School of Veterinary Medicine 

University Vienna 

Veterinärplatz 1 

1210 Vienna 

Austria 

Böhme Beatrice 

Dr.med.vet. ECVS 

Kleintierklinik Bremen 

Schwachhauser Ring 86 

28209 Bremen 

Germany 

Boland Laetitia DMV 

Centre Hospitalier Vétérinaire Frégis 

43 Avenue Aristide Briand 

94110 Arcueil 

France 

Boston Sarah Dr. 

University of Guelph 

Department of Clinical Studies 

Ontario Veterinary College 

Guelph, Ontario, N1G 2W1 

Canada 

Böttcher Peter 


University of Leipzig 

Department of Small Animal 

Medicine 

An den Tierkliniken 23 

04103 Leipzig 

Germany 

Brandt Sabine Dr. 

University of Veterinary Medicine 

Equine Biotechnology Unit 

Equine Clinic 

Veterinärplatz 1 

1210 Vienna 

Austria 

Brink Palle 

DVM, ECVS 

Jägersro 

212 37 Malmö 

Sweden 

Brissot Hervé 

DMV, DECVS, MRCVS, ECVS 

Davies Vetspecialists 

Manor Farm Buisiness Park 

SG5 3HR Higham Gobion 


Broos Paul Dr. 

Alfons Stesselstraat 23 

3012 Leuven Wilsele 

Belgium 

ECVS proceedings 2011 199 addresses

Buttin Philippe DVM 

Chemin de la Chaux 

69210 Lentilly 

France 

Cachon Thibaut 

Dr. vét. ECVS 

VetAgro Sup 

Small animal Campus vétérinaire de 

Lyon 

1, Avenue de Bourgelat 

B.P. 83 

69280 Marcy l'Etoile 

France 

Chabrier Marion 

Veterinary Research Unit (IVRU) 

Facutly of Science, FUNDP Namur 

rue de Bruxelles 

5000 Bruxelles 

Belgium 

De la Farge Sophie 

Clinique de Grosbois 

Domaine de Grosbois 

94470 Boissy Saint Leger 

France 

Declercq Jeroen 


University of Ghent 

Faculty of Veterinary Medicine, 

Department of surgery and 

anaesthesia 

Salisburylaan 133 

9820 Merelbeke 

Belgium 

Déjardin Loïc M. 

DVM, MS, ACVS/ECVS 

Michigan State University 

College of Veterinary Medicine 

Department of Small Clinical 

Sciences 

East Lansing, MI 48824-1314 

USA 

Demetriou Jackie L. 

BvetMed. CertSAS, ECVS 

University of Cambridge 

Queen's Veterinary School Hospital 

Department of Vet. Medicine 

Madingley Road 

Cambridge, CB3 0ES 


Devitt Chad M 

DVM MS ACVS 

Veterinary Referral Center of 

Colorado 

3550 S Jason Street 

Englewood, CO 80110 

USA 

Dias Deborah Ms 

Rua 7 de setembro, 2496 

Sao Carlos-SP 

13560-181 

Brazil 

Falzone Cristian 

DVM, Dipl ECVN 

Higham Gobion 

Herts SG5 3HR 


Findji Laurent 


VRCC 1 West Mayne 

Bramston Way 

Southfields, Laindon 

Essex SS15 6TP 


Fiske-Jackson Andrew DBV 

The Royal Veterinary College 

University of London–Equine Referral 

Hospital 

Hawkshead Lane 

North Mymms 

Hatfield, Hertfordshire AL9 7TE 


Fitzpatrick Noel 

Univ, MVB, CSAO, CVR 

Fitzpatrick Referrals 

Halfway Lane, Eashing 

Godalming 

GU7 2QQ Surrey 


Fürst Anton 


Vetsuisse Faculty University of Zurich 

Large Animal Clinic 

Dept. of Veterinary Surgery 


8057 Zürich 

Switzerland 

Gauthier Olivier 

Prof.Dr.vet.PhD 

Ecole Nationale Vétérinaire de 

Nantes 

Laboratoire de Chirurgie 

Route de Gachet 

B.P. 40706 

44307 Nantes Cedex 3 

France 

Glyde Mark 

BVSc(Hons) MACVSc, MVS ECVS 

MRCVS, 

Murdoch University 

School of Veterinary and Biomedical 

Sciences 

South Street 

6150 Murdoch 

Australia 

Gracia Calvo Luis Alfonso Dr. 

C/ Juan Manuel 

Rozas 31 1B 

10004 Càceres 

Spain 

Griffon Dominique J. 

DVM, MS, PhD, ECVS/ACVS 

Western University of Health 

Sciences 


Associate Dean for Research 

309 E. 2nd Street 

Pomona 91766-1854 CA 

USA 

Gunnarsdottir Helga 

DVM, PhD 


Dept. of Large Animal Surgery 


9820 Merkelbeke 

Belgium 

Gutbrod Andreas DVM 

Vetsuisse Faculty University of Zürich 

Small animal surgery clinic 


8057 Zürich 

Switzerland 

Hamilton Michael H. 

BVM&S CertSAS MRCVS ECVS 

11 Houlton Court, Surrey 

Bagshot GU19 5QQ 


addresses 200 ECVS proceedings 2011

Hayes Graham Michael 

BVMS 

Univesity of Cambridge 


Dept. of Clinical Veterinary Medicine 


Cambridge CB3 0ES 


Herteman Nicolas 





Belgium 

Höglund Odd DVM 

Department of Clinical Sciences 

Box 7054 

750 07 Uppsala 

Sweden 

Hopster-Iversen Charlotte Dr. 

Klinik für Pferde 

Tierärzliche Hochschule Hannover 

Bünteweg 9 

30559 Hannover 

Germany 

Hunt Luanne 

BSc BVM&S ACVIM MRCVS 

Clyde Veterinary Group Equine 

Hospital New Lanark Market 

Lanark ML11 9SZ 


Jordana-Garcia Mireia DVM 


Faculty of Veterinary Medicine 

Dep. of Surgery and Anesthesiology 



Belgium 

Kirpensteijn Jolle Prof. 

DVM MS ACVS/ECVS 

University of Utrecht 


Dep. Clinical Sciences 

Yalelaan 8/ PO Box 80.154 

3508 TD Utrecht 

Netherlands 

Klaus Christoph DVM 

Free University Berlin 

Equine Clinic 

Oertzenweg 19b 

14163 Berlin 

Germany 

Kümmerle Jan M. 



Equine Department 


8057 Zürich 

Switzerland 

Lallemand Elodie DVM 


Nantes 

Equine Clinic 


BP 40706 


France 

Lambert Claire 





Belgium 

Lamberts Matthieu 





Belgium 

Liptak Julius M. 

BVSc MVet MACVSc FACVSc ACVS/ 

ECVS 

Alta Vista Animal Hospital 

2616 Bank Street 

Ottawa 

Ontario K1T 1M9 

Canada 

Marañon Gonzalo 

DVM, PhD 

Horsespital SL 

c/ Recaudacion 4 

Villanueva del Pardillo 

28229 Madrid 

Spain 

May Stephen A. 

Prof. DVR DEO ECVS 

The Royal Veterinary College 

University of London 

Equine Referral Hospital 

Hawkshead Lane, North Mymms 

Hatfield AL9 7TA Hertfordshire 


Medl Nikola 

Dr.med.vet. 




8057 Zürich 

Switzerland 

Meij Björn 

DVM, PhD, ECVS 

Utrecht University 


Dep.Clinical Sciences of Companion 




Netherlands 

Mespoulhès-Rivière Céline Isabelle 


35, Rue Alphonse Daudet 

91210 Draveil 

France 

Milgram Joshua 

BVSc ECVS 

The Hebrew University of Jerusalem 

Koret School of Veterinary Medicine 

P.O. Box 12 

Rehovot 

Israel 

Moissonnier Pierre 

Prof. MS, AEU Microsurgery, ECVS 

Ecole Nationale Vétérinaire d'Alfort 


7 Avenue du Général de Gaulle 

94704 Maisons-Alfort Cedex 

France 

Moritz Andreas Dr. 

Klinik für Kleintiere 

Klinik Pathophysiologie & Klinik 

Laboratoriumsdiagnostik 

Justus-Liebig, Frankfurterstrasse 126 

35392 Giessen 

Germany 


Mosing Martina Dr. 

Vetsuisse-Faculty University of Zürich 

Equine Department, Section 

Anaesthesiology 

Winterthurerstr. 260 

8057 Zürich 

Switzerland 

Murgia Daniela 


DPA, Diagnostica piccoli animali Srl 

Via Caldierino 14 

36030 Zugliano (Vicenza) 

Italy 

Nelissen Pieter DVM MRCVS 

East Lodge 

Bury Road 

Kentford, Newmarked CB8 7UA 


Parker Russell Alexander BVMS 

University of Edinburgh 

Large Animal Hospital 

Royal (Dick) School of Vet. Studies 

Easter Bush Vet. Centre, Roslin 

Midlothian EH25 9RG 


Perrin Roland 

Dr.vét. ECVS 

Clinque Vétérinaire 

Desbrosse/Perrin/Launois 

18 rue des Champs, La Brosse 

78470 St. Lambert des Bois 

France 

Piras Lisa Adele DVM 

Universita degli Studi di Torino 

Dept. di patologia animale 

Via Leonardo da Vinci 44 

10095 Grugliasco (Torino) 

Italy 

Rancan Lisa 

Dogspital SL, c/ Recaudacion 4 

Villanueva del Pardillo 

28229 Madrid 

Spain 

Rathmanner Magdalena DVM 

Tierärztliche Hochschule Hannover 

Klinik für Pferde 

Bünteweg 9 

30559 Hannover 

Germany 

Rochereau Philippe Dr. vét. 

Clinique VETREF 

Rue James Watt 

49070 Angers-Beaucouze 

France 

Rossignol Fabrice 


Clinique Equine de Grosbois 

Domaine de Grosbois 

94470 Boissy-St-Léger 

France 

Salciccia Alexandra 

Dr.med.vet. 

Equine Clinic 


University of Liège 

20, boulevard de Colonster, B41 

4000 Liège 

Belgium 

Schneeweiss Wilfried 

Dr.med.vet. 

27 Orpen Rise 

Stillorgan 

Dublin 

Ireland 

Schramme Michael C. 

DVM, CertEO,MRCVS,ECVS 

North Carolina State University 


4700 Hillsborough Street 

Raleigh, NC 27606 

USA 

Schumacher James 

DVM MS ACVS 

University of Tennessee 

Dept. of Large Animal Clinical 

Sciences 

2407 River Drive 

Knoxville 

Tennessee 37996-4545 

USA 

Segal Uri Dr. 

Knowledge Farm 

HaYasmin 6 

99797 Karmey Yosef 

Israel 

Sivacolundh Ramesh Dr. 

AMC 

510E 62nd Street 

New York, N.Y. 

USA 

Souchu Lawrence 


Nantes 

Laboratoire de Chirurgie 


B.P. 40706 


France 

Tan Christopher Mr. 

University Vet. Teaching Hospital 

Sydney 

The University of Sydney 

65 Parramatta Road 

Camperdown NSW 2006 

Australia 

Ter Haar Gert 

DVM Cert EP, RNVA ECVS 

University of Utrecht 


Dep. Clinical Sciences of Companion 




Netherlands 

Tóth Tamàs DVM 

Swedish University of Agricultural 

Science 

Equine Clinic 

Ulls väg 12 Box 7040 

750 07 Uppsala 

Sweden 

Van Lander Aude E.J. 

Dept. of General and Hepatobiliairy 

Surgery 

University Hospital Ghent 

De Pintelaan 185 

9000 Ghent 

Belgium 

Van Loon Gunther Prof. Dr. 

Department of large Animal Internal 

Medicine, Ghent University 

Salisbuylaan 133 


Belgium 

addresses 202 ECVS proceedings 2011

Van Ryssen Bernadette 

Prof. Dr. 




Belgium 

Vallefuoco Rosario DVM 

9 rue Eugene Renault 

94700 Maisons-Alfort 

France 

Van Bree Henri 

Prof.Dr.med.vet. ECVS 



Dept. Medical Imaging 



Belgium 

Vandecatsyne Charles 





Belgium 

Vandenberghe Filip Dr. 

Dierenkliniek De Bosdreef 

Spelonckvaart 46 B 

9180 Moerbeke-Waas 

Belgium 

Verset Michaël 


Toulouse 


23 chemin des Capelles 

31076 Toulouse Cedex 3 

France 

Voss Katja 


11 Napoleon Street 

Rozelle 2039 

Sydney, NSW 

Australia 

Walton Ben Mr. 

Small Animal Teaching Hospital 

Uni. of Liverpool 

Leahurst, Chester High Road 

CH64 7TE Neston 


Watson Penny 

MA VetMD CertVR DSAM ECVIM 

MRCVS 

Queen's Veterinary School Hospital 

University of Cambridge 


Cambridge CB3 0ES 


Weese Scott 

Dept of Pathobiology 

University of Guelph 

Guelph 

Ontario N1G2W1 

Canada 

White Robert N. 

BSc,BVetMed,CertVA,MRCVS, ECVS 

Willows Veterinary Centre & Referral 

Service 

Highlands Road 

Shirley 

Solihull 

West Midlands, B90 4NH 


Woodbridge Nicolas 

Dick White Referrals 

Six Mile Bottom 

London Road 

CB8 0UH Suffolk 



21st Annual Scientific Meeting 

Pre Announcement 

Hotel Rey Juan Carlos I and 

Palau de Congressos de Catalunya, 

Barcelona, Spain – July 5 – 7, 2012 

please visit our home page – www.ecvs.org 

Deadline for submission of abstracts is 

November 15, 2011 

Preliminary Programmes will be available 

by beginning of 2012 on our website. 

For further information please contact: 

European College of Veterinary Surgeons ECVS 

Vetsuisse Faculty University of Zurich, Equine Department 

Winterthurerstrasse 260, CH- 8057 Zürich, Switzerland 

Phone: +41-44-635 8408 / Fax: +41-44-313 0384 

email: ecvs@vetclinics.uzh.ch 

www.ecvs.org

layout: Eva–Linda Skytting, Monika Gutscher 

ECVS office Zürich, Switzerland

Call for papers and abstract submission documents and forms can be downloaded from the ECVS web site: 

www.ecvs.org 

Deadline for abstract submission is November 15. 

Please note that printed programmes will be given at the meeting in Nantes – however from the web site you will be able 

to receive all information pertaining to the Annual Meeting as soon as they are available. 

Visit our home page! 

ECVS Office Address 

European College of Veterinary Surgeons ECVS 


Winterthurerstrasse 260, 

CH- 8057 Zurich 

Switzerland 

Phone: +41-44-635 8408 / Fax: +41-44-313 0384 

email: ecvs@vetclinics.uzh.ch 

www.ecvs.org

Proceedings – Small Animals - ECVS

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